MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

placebo

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Shiatsu is a (mostly) manual therapy that was popularised by Japanese Tokujiro Namikoshi (1905–2000). It developed out of the Chinese massage therapy, ‘tui na’. The word shiatsu means finger pressure in Japanese; however, a range of devices is also being promoted for shiatsu. The evidence that shiatsu is effective for any condition is close to non-existent.

This study aimed to investigate the effect of Shiatsu massage on agitation in mechanically ventilated patients.

A total of 68 mechanically ventilated patients were randomly assigned to two groups. Patients in the intervention group received three 5-minute periods of Shiatsu massage with a 2-minute break between them, while patients in the control group only received a touch on the area considered for the message. Data were collected before and after the intervention using the Richmond Agitation-Sedation Scale (RASS) and then analyzed.

The results showed that the level of agitation significantly decreased in the intervention group compared to the control group (p=.001).

The authors concluded that the application of shiatsu massage seems to be effective in managing agitation in mechanically ventilated patients. Further studies with greater sample size and longer follow-up period are needed to confirm the current findings.

It is good to see that, as far as I know for the first time, an attempt was made to control for placebo and other non-specific effects in a trial of shiatsu. However, in itself, the attempt is not convincing. What we need to know is whether the attempt was successful or not. Were the patients fully blinded and unable to tell the difference between verum and sham? From reading not just the abstract but the full paper, I do not get the impression that patients were successfully blinded. This means that the results might be entirely due to the effect of deblinding.

 

Tai chi is a meditative exercise therapy based on Traditional Chinese Medicine. On this blog, we have repeatedly discussed this so-called alternative medicine (SCAM). It involves meditative movements rooted in both Traditional Chinese Medicine and the martial arts. Tai chi was originally aimed at enhancing mental and physical health; today it has become a popular alternative therapy.

This systematic review assessed the efficiency of tai chi (TC) in different populations’ cognitive function improvement.  Randomized controlled trials (RCTs) published from the beginning of coverage through October 17, 2020 in English and Chinese were retrieved from many indexing databases. Selected studies were graded according to the Cochrane Handbook for Systematic Reviews of Intervention 5.1.0. The outcome measures of cognitive function due to traditional TC intervention were obtained. Meta-analysis was conducted by using RevMan 5.4 software. We follow the PRISMA 2020 guidelines.

Thirty-three RCTs, with a total of 1808 participants, were included. The results showed that TC can progress global cognition when assessed in middle-aged as well as elderly patients suffering from cognitive and executive function impairment. The findings are as follows:

  • Montreal Cognitive Assessment Scale: mean difference (MD) = 3.23, 95% CI = 1.88-4.58, p < 0.00001,
  • Mini-Mental State Exam: MD = 3.69, 95% CI = 0.31-7.08, p = 0.03,
  • Trail Making Test-Part B: MD = -13.69, 95% CI = -21.64 to -5.74, p = 0.0007.

The memory function of older adults assessed by the Wechsler Memory Scale was as follows: MD = 23.32, 95% CI = 17.93-28.71, p < 0.00001. The executive function of college students evaluated by E-prime software through the Flanker test was as follows: MD = -16.32, 95% CI = -22.71 to -9.94, p < 0.00001.

The authors concluded that TC might have a positive effect on the improvement of cognitive function in middle-aged and elderly people with cognitive impairment as well as older adults and college students.

These days, I easily get irritated with such conclusions. That TC might improve cognitive function is obvious. If not, there would be no reason to do a review! But does it?

This paper does not provide an answer. All it shows is that TC trials are of lousy quality and that the observed effects might well be due not to TC itself by to non-specific effects.

Cupping is a so-called alternative medicine (SCAM) that has been around for millennia in many cultures. We have discussed it repeatedly on this blog (see, for instance, here, here, and here). This new study tested the effects of dry cupping on pain intensity, physical function, functional mobility, trunk range of motion, perceived overall effect, quality of life, psychological symptoms, and medication use in individuals with chronic non-specific low back pain.

Ninety participants with chronic non-specific low back pain were randomized. The experimental group (n = 45) received dry cupping therapy, with cups bilaterally positioned parallel to the L1 to L5 vertebrae. The control group (n = 45) received sham cupping therapy. The interventions were applied once a week for 8 weeks.

Participants were assessed before and after the first treatment session, and after 4 and 8 weeks of intervention. The primary outcome was pain intensity, measured with the numerical pain scale at rest, during fast walking, and during trunk flexion. Secondary outcomes were physical function, functional mobility, trunk range of motion, perceived overall effect, quality of life, psychological symptoms, and medication use.

On a 0-to-10 scale, the between-group difference in pain severity at rest was negligible: MD 0.0 (95% CI -0.9 to 1.0) immediately after the first treatment, 0.4 (95% CI -0.5 to 1.5) at 4 weeks and 0.6 (95% CI -0.4 to 1.6) at 8 weeks. Similar negligible effects were observed on pain severity during fast walking or trunk flexion. Negligible effects were also found on physical function, functional mobility, and perceived overall effect, where mean estimates and their confidence intervals all excluded worthwhile effects. No worthwhile benefits could be confirmed for any of the remaining secondary outcomes.

The authors concluded that dry cupping therapy was not superior to sham cupping for improving pain, physical function, mobility, quality of life, psychological symptoms or medication use in people with non-specific chronic low back pain.

These results will not surprise many of us; they certainly don’t baffle me. What I found interesting in this paper was the concept of sham cupping therapy. How did they do it? Here is their explanation:

For the experimental group, a manual suction pump and four acrylic cups size one (internal diameter = 4.5 cm) were used for the interventions. The cups were applied to the lower back, parallel to L1 to L5 vertebrae, with a 3-cm distance between them, bilaterally. The dry cupping application consisted of a negative pressure of 300 millibars (two suctions in the manual suction pump) sustained for 10 minutes once a week for 8 weeks.

In the control group, the exact same procedures were used except that the cups were prepared with small holes < 2 mm in diameter to release the negative pressure in approximately 3 seconds. Double-sided adhesive tape was applied to the border of the cups in order to keep them in contact with the participants’ skin.

So, sham-controlled trials of cupping are doable. Future trialists might now consider the inclusion of testing the success of patient-blinding when conducting trials of cupping therapy.

Open-label placebos (OLPs) are placebos without deception in the sense that patients know that they are receiving an inert sugar pill with no activity of its own. Intuitively, we think that such treatments must be ineffective. Yet, there have been several studies that seemed to show otherwise.

The objective of this paper was to systematically review and analyze the effect of OLPs in comparison to no treatment in clinical trials. A systematic literature search was carried out in February 2020. Randomized controlled trials of any medical condition or mental disorder comparing OLPs to no treatment were included. Data extraction and risk of bias rating were independently assessed. 1246 records were screened and 13 studies were included in the systematic review. Eleven trials were eligible for meta-analysis.

These trials assessed the effects of OLPs on

  • back pain,
  • cancer-related fatigue,
  • attention deficit hyperactivity disorder,
  • allergic rhinitis,
  • major depression,
  • irritable bowel syndrome,
  • menopausal hot flushes.

The risk of bias was moderate among all studies.

Click to enlarge.

A significant overall effect (standardized mean difference = 0.72, 95% Cl 0.39–1.05, p < 0.0001, I2 = 76%) of OLP. Thus, OLPs appear to be a promising treatment in different conditions. Yet, the researchers spotted several caveats and discuss them in some detail.

First, we detected hints of a publication bias in the study sample, but the respective test was not significant. The quantitative basis of the meta-analysis is based on a small number of studies, reflecting the early state of research in this field. Moreover, the set of studies showed some heterogeneity. Finally, four studies were rated to have a high risk of bias, and nine to have some concerns.

In order to assess the impact of these high-risk studies we performed an exploratory best-evidence synthesis. We excluded the four studies with a high risk of bias. In this analysis, the heterogeneity could be reduced to a non-critical value and almost all variance in the set of studies could be explained by a sampling error (I2 = 4%). With the exclusion of these four studies the mean effect size was reduced to a more conservative SMD = 0.49.

Regardless of this reduction of the overall effect, the same conclusions about the treatment-effect of OLPs can be drawn, although the lack of robustness means that interpretations require some caution. The decrease of heterogeneity shows that methodological impairments might be responsible for the considerable unexplained variance in our results. We abstained from carrying out a further sensitivity analysis for explaining heterogeneity because of the small number of studies.

This is certainly an interesting subject. And the above findings are certainly counter-intuitive.

My impression is that the effect of OLPs is small and of doubtful value in clinical practice. My prediction is that, as more and better research emerges, it will diminish further, if not vanish totally. I think that there are several reasons for this:

  • The number of trials is still quite small.
  • The studies obviously lack patient blinding.
  • Positive messages can be included alongside open-label placebos.
  • The “time lag bias” is high.

This type of bias means that, due to initial enthusiasm in a new subject, negative results are published with some delay. I have observed this bias repeatedly in the past. A new treatment initially tends to generate nothing but positive results, and only after a while, when the researchers’ euphoria has subsided, more realistic findings emerge.

This review summarized the available evidence on so-called alternative medicine (SCAM) used with radiotherapy. Systematic literature searches identified studies on the use of SCAM during radiotherapy. Inclusion required the following criteria: the study was interventional, SCAM was for human patients with cancer, and SCAM was administered concurrently with radiotherapy. Data points of interest were collected from included studies. A subset was identified as high-quality using the Jadad scale. Fisher’s exact test was used to assess the association between study results, outcome measured, and type of SCAM.

Overall, 163 articles met inclusion. Of these, 68 (41.7%) were considered high-quality trials. Articles published per year increased over time. Frequently identified therapies were biologically based therapies (47.9%), mind-body therapies (23.3%), and alternative medical systems (13.5%). Within the subset of high-quality trials, 60.0% of studies reported a favorable change with SCAM while 40.0% reported no change. No studies reported an unfavorable change. Commonly assessed outcome types were patient-reported (41.1%) and provider-reported (21.5%). The rate of favorable change did not differ based on the type of SCAM or outcome measured.

The authors concluded that concurrent SCAM may reduce radiotherapy-induced toxicities and improve quality of life, suggesting that physicians should discuss SCAM with patients receiving radiotherapy. This review provides a broad overview of investigations on SCAM use during radiotherapy and can inform how radiation oncologists advise their patients about SCAM.

In my recent book, I have reviewed the somewhat broader issue of SCAM for palliative and supportive care. My conclusions are broadly in agreement with the above review:

… some forms of SCAM—by no means all— benefit cancer patients in multiple ways… four important points:
• The volume of the evidence for SCAM in palliative and supportive cancer care is currently by no means large.
• The primary studies are often methodologically weak and their findings are contradictory.
• Several forms of SCAM have the potential to be useful in palliative and supportive cancer care.
• Therefore, generalisations are problematic, and it is wise to go by the current best evidence …

One particular finding of the new review struck me as intriguing: The rate of favorable change did not differ based on the type of SCAM. Combined with the fact that most studies are less than rigorous and fail to control for non-specific effects, this indicates to me that, in cancer palliation (and perhaps in other areas as well), SCAM works mostly via non-specific effects. In other words, patients feel better not because the treatment per se was effective but because they needed the extra care, attention, and empathy.

If this is true, it carries an important reminder for oncology: cancer patients are very vulnerable and need all the empathy and compassion they can get. Seen from this perspective, the popularity of SCAM would be a criticism of conventional medicine for not providing enough of it.

The effectiveness of manipulation versus mobilization for the management of spinal conditions, including cervicogenic headache, is conflicting, and a pragmatic approach comparing manipulation to mobilization has not been examined in a patient population with cervicogenic headache.

This study evaluated the effectiveness of manipulation compared to mobilization applied in a pragmatic fashion for patients with cervicogenic headache.

Forty-five (26 females) patients with cervicogenic headache were randomly assigned to receive either pragmatically selected manipulation or mobilization. Outcomes were measured at baseline, the second visit, discharge, and 1-month follow-up. The endpoints of the study included the Neck Disability Index (NDI), Numeric Pain Rating Scale (NPRS), the Headache Impact Test (HIT-6), the Global Rating of Change (GRC), the Patient Acceptable Symptoms Scale (PASS). The primary outcome measures were the effects of treatment on disability and pain. They were examined with a mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization) as the between-subjects variable and time (baseline, 48 hours, discharge, and follow-up) as the within-subjects variable.

The interaction for the mixed model ANOVA was not statistically significant for NDI (p = 0.91), NPRS (p = 0.81), or HIT (p = 0.89). There was no significant difference between groups for the GRC or PASS.

The authors concluded that manipulation has similar effects on disability, pain, GRC, and cervical range of motion as mobilization when applied in a pragmatic fashion for patients with cervicogenic headaches.

Essentially, this study is an equivalence trial comparing one treatment to another. As such it would need a much larger sample size than the 45 patients enrolled by the investigators. If, however, we ignored this major flaw and assumed the results are valid, they would be consistent with both manipulation and mobilization being pure placebos.

I can imagine that many chiropractors find this conclusion unacceptable. Therefore, let me offer an alternative: both approaches were equally effective. Therefore, mobilization, which is associated with far fewer risks, is preferable. This means that patients suffering from cervicogenic headache should see an osteopath who is less likely to use manipulation than a chiropractor.

And again, I can imagine that many chiropractors find this conclusion unacceptable.

Well-conducted systematic reviews (SRs) should in principle provide the most reliable evidence on the effectiveness of acupuncture. However, limitations on the methodological rigour of SRs may impact the trustworthiness of their conclusions. This cross-sectional study was aimed at evaluating the methodological quality of recent SRs of acupuncture.

The Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE were searched for SRs focusing on manual acupuncture or electro-acupuncture published during January 2018 and March 2020. Eligible SRs needed to contain at least one meta-analysis and be published in the English language. Two independent reviewers extracted the bibliographical characteristics of the included SRs with a pre-designed questionnaire and appraised the methodological quality of the reviews with the validated AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2). The associations between bibliographical characteristics and methodological quality ratings were explored using Kruskal-Wallis rank tests and Spearman’s rank correlation coefficients.

A total of 106 SRs were appraised. The results were as follows:

  • one (0.9%) SR was of high methodological quality,
  • no review (0%) was of moderate quality,
  • six (5.7%) were of low quality,
  • 99 (93.4%) were of critically low quality.

Only ten (9.4%) provided an a priori protocol, only four (3.8%) conducted a comprehensive literature search, only five (4.7%) provided a list of excluded studies, and only six (5.7%) performed a meta-analysis appropriately. Cochrane SRs, updated SRs, and SRs that did not search non-English databases had relatively higher overall quality. The vast majority (87.7%) of the 106 reviews included in this analysis originated from Asia. Conflicts of interest of the review authors were declared in only 2 of the 106 reviews.

The authors concluded that the methodological quality of SRs on acupuncture is unsatisfactory. Future reviewers should improve critical methodological aspects of publishing protocols, performing comprehensive search, providing a list of excluded studies with justifications for exclusion, and conducting appropriate meta-analyses. These recommendations can be implemented via enhancing the technical competency of reviewers in SR methodology through established education approaches as well as quality gatekeeping by journal editors and reviewers. Finally, for evidence users, skills in SR critical appraisal remain to be essential as relevant evidence may not be available in pre-appraised formats.

On this blog, I have often complained about the lack of critical input and the poor quality of systematic reviews of so-called alternative medicine (SCAM), particularly of acupuncture, and especially of Chinese reviews, and even more especially Chinese reviews of (mostly) Chinese studies. This new paper is a valuable confirmation of this fast-growing deficit.

One does not need to be a prophet to predict that this pollution of the literature with complete rubbish will have detrimental effects. Because poor reviews almost always draw an over-optimistic picture of the value of acupuncture, this phenomenon must seriously mislead the public. The end result will be that the public believes acupuncture to be effective.

I cannot help thinking that this is, in fact, the intended aim of the authors of such poor, false-positive reviews. Moreover, a glance at the subject areas of the reviews in the list below gives the impression that China is heavily promoting the idea that acupuncture is a panacea. Yet there is good evidence to show that acupuncture is little more than placebo therapy.

In my last post, I have reported that I am an author of many of the frequently-cited systematic acupuncture reviews. You might thus assume that I am a significant part of this pollution by rubbish reviews. This would, however, be an entirely wrong conclusion. The above analysis covers a period when my unit had already been closed, and I am thus not responsible for a single of the papers included in the above analysis.

List of included systematic reviews

ID Included systematic reviews
1 Acupuncture for primary insomnia: An updated systematic review of randomized controlled trials
2 Efficacy and safety of acupuncture for essential hypertension: A meta-analysis
3 Acupuncture for the treatment of sudden sensorineural hearing loss: A systematic review and meta-analysis: Acupuncture for SSNHL
4 Effectiveness of Acupuncturing at the Sphenopalatine Ganglion Acupoint Alone for Treatment of Allergic Rhinitis: A Systematic Review and Meta-Analysis
5 Acupuncture and clomiphene citrate for anovulatory infertility: a systematic review and meta-analysis
6 Acupuncture for primary trigeminal neuralgia: A systematic review and PRISMA-compliant meta-analysis
7 Acupuncture as an adjunctive treatment for angina due to coronary artery disease: A meta-analysis
8 Conventional treatments plus acupuncture for asthma in adults and adolescent: A systematic review and meta-analysis
9 Optimizing acupuncture treatment for dry eye syndrome: A systematic review
10 Acupuncture using pattern-identification for the treatment of insomnia disorder: a systematic review and meta-analysis of randomized controlled trials
11 Efficacy and Safety of Auricular Acupuncture for Cognitive Impairment and Dementia: A Systematic Review
12 Acupuncture for cognitive impairment in vascular dementia, alzheimer’s disease and mild cognitive impairment: A systematic review and meta-analysis
13 Effectiveness of pharmacopuncture for cervical spondylosis: A systematic review and meta-analysis
14 Acupuncture combined with swallowing training for poststroke dysphagia: a meta-analysis of randomised controlled trials
15 Scalp acupuncture treatment for children’s autism spectrum disorders: A systematic review and meta-analysis
16 Acupuncture for Post-stroke Shoulder-Hand Syndrome: A systematic review and meta-analysis
17 Systematic review of acupuncture for the treatment of alcohol withdrawal syndrome
18 Acupuncture for hip osteoarthritis
19 Clinical Benefits of Acupuncture for the Reduction of Hormone Therapy-Related Side Effects in Breast Cancer Patients: A Systematic Review
20 Combination therapy of scalp electro-acupuncture and medication for the treatment of Parkinson’s disease: A systematic review and meta-analysis
21 Acupuncture for migraine: A systematic review and meta-analysis
22 Acupuncture to Promote Recovery of Disorder of Consciousness after Traumatic Brain Injury: A Systematic Review and Meta-Analysis
23 Acupuncture Compared with Intramuscular Injection of Neostigmine for Postpartum Urinary Retention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
24 Acupuncture for the relief of hot flashes in breast cancer patients: A systematic review and meta-analysis of randomized controlled trials and observational studies
25 Effectiveness and Safety of Acupuncture for Perimenopausal Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
26 Acupuncture plus Chinese Herbal Medicine for Irritable Bowel Syndrome with Diarrhea: A Systematic Review and Meta-Analysis
27 Electroacupuncture as an adjunctive therapy for motor dysfunction in acute stroke survivors: A systematic review and meta-analyses
28 Acupuncture for Acute Pancreatitis: A Systematic Review and Meta-analysis
29 Acupuncture for chronic fatigue syndrome: a systematic review and meta-analysis
30 Compare the efficacy of acupuncture with drugs in the treatment of Bell’s palsy: A systematic review and meta-analysis of RCTs
31 The effectiveness and safety of acupuncture for the treatment of myasthenia gravis: a systematic review and meta-analysis of randomized controlled trials
32 Acupuncture therapy for fibromyalgia: A systematic review and meta-analysis of randomized controlled trials
33 The effectiveness of acupuncture therapy in patients with post-stroke depression: An updated meta-analysis of randomized controlled trials
34 Fire needling for herpes zoster: A systematic review and meta-analysis of randomized clinical trials
35 Comparison between the Effects of Acupuncture Relative to Other Controls on Irritable Bowel Syndrome: A Meta-Analysis
36 Manual Acupuncture for Optic Atrophy: A Systematic Review and Meta-Analysis
37 Effect of warm needling therapy and acupuncture in the treatment of peripheral facial paralysis: A systematic review and meta-analysis
38 The Effect of Acupuncture in Breast Cancer-Related Lymphoedema (BCRL): A Systematic Review and Meta-Analysis
39 The Efficacy of Acupuncture in Chemotherapy-Induced Peripheral Neuropathy: Systematic Review and Meta-Analysis
40 The maintenance effect of acupuncture on breast cancer-related menopause symptoms: a systematic review
41 The effectiveness of acupuncture in the management of persistent regional myofascial head and neck pain: A systematic review and meta-analysis
42 Acupuncture for the Treatment of Adults with Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis
43 The effectiveness of superficial versus deep dry needling or acupuncture for reducing pain and disability in individuals with spine-related painful conditions: a systematic review with meta-analysis
44 Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis
45 Is dry needling effective for low back pain?: A systematic review and PRISMA-compliant meta-analysis
46 The effectiveness and safety of acupuncture for patients with atopic eczema: a systematic review and meta-analysis
47 Comparing verum and sham acupuncture in fibromyalgia syndrome: a systematic review and meta-analysis
48 Acupuncture for symptomatic gastroparesis
49 The Efficacy and Safety of Acupuncture for the Treatment of Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis
50 Acupuncture Versus Sham-acupuncture: A Meta-analysis on Evidence for Non-immediate Effects of Acupuncture in Musculoskeletal Disorders
51 Acupuncture Treatment for Post-Stroke Dysphagia: An Update Meta-Analysis of Randomized Controlled Trials
52 Effectiveness of Acupuncture Used for the Management of Postpartum Depression: A Systematic Review and Meta-Analysis
53 Clinical effects and safety of electroacupuncture for the treatment of post-stroke depression: a systematic review and meta-analysis of randomised controlled trials
54 Placebo effect of acupuncture on insomnia: a systematic review and meta-analysis
55 Acupuncture for Chronic Pain-Related Insomnia: A Systematic Review and Meta-Analysis
56 Evidence for Dry Needling in the Management of Myofascial Trigger Points Associated With Low Back Pain: A Systematic Review and Meta-Analysis
57 Warm needle acupuncture in primary osteoporosis management: a systematic review and meta-analysis
58 Acupuncture for overactive bladder in adults: a systematic review and meta-analysis
59 Traditional acupuncture for menopausal hot flashes: A systematic review and meta-analysis of randomized controlled trials
60 The effectiveness of acupuncture for osteoporosis: A systematic review and meta-analysis
61 Long-term effects of acupuncture for chronic prostatitis/chronic pelvic pain syndrome: Systematic review and single-Arm meta-Analyses
62 Does acupuncture the day of embryo transfer affect the clinical pregnancy rate? Systematic review and meta-analysis
63 Acupuncture treatments for infantile colic: a systematic review and individual patient data meta-analysis of blinding test validated randomised controlled trials
64 Acupuncture performed around the time of embryo transfer: a systematic review and meta-analysis
65 Is Acupuncture Effective for Improving Insulin Resistance? A Systematic Review and Meta-analysis
66 Efficacy of acupuncture in the management of post-apoplectic aphasia: A systematic review and meta-analysis of randomized controlled trials
67 Acupuncture for lumbar disc herniation: a systematic review and meta-analysis
68 Traditional Chinese acupuncture and postpartum depression: A systematic review and meta-analysis
69 Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis
70 Acupuncture Therapy for Functional Effects and Quality of Life in COPD Patients: A Systematic Review and Meta-Analysis
71 Electroacupuncture for Reflex Sympathetic Dystrophy after Stroke: A Meta-Analysis
72 The Effect of Patient Characteristics on Acupuncture Treatment Outcomes
73 The efficacy and safety of acupuncture in women with primary dysmenorrhea: A systematic review and meta-analysis
74 Role of acupuncture in the treatment of insulin resistance: A systematic review and meta-analysis
75 Appropriateness of sham or placebo acupuncture for randomized controlled trials of acupuncture for nonspecific low back pain: A systematic review and meta-analysis
76 Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomised placebo- or sham-controlled trials
77 The effects of acupuncture on pregnancy outcomes of in vitro fertilization: A systematic review and meta-analysis
78 Acupuncture for migraine without aura: a systematic review and meta-analysis
79 Acupuncture for acute stroke
80 Acupuncture at Tiaokou (ST38) for Shoulder Adhesive Capsulitis: What Strengths Does It Have? A Systematic Review and Meta-Analysis of Randomized Controlled Trials
81 Acupuncture for hypertension
82 The effect of acupuncture on Bell’s palsy: An overall and cumulative meta-analysis of randomized controlled trials
83 Effects of acupuncture on cancer-related fatigue: a meta-analysis
84 Acupuncture for adults with overactive bladder
85 Electroacupuncture for Postoperative Urinary Retention: A Systematic Review and Meta-Analysis
86 Meta-Analysis of Electroacupuncture in Cardiac Anesthesia and Intensive Care
87 Acupuncture therapy improves health-related quality of life in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis
88 The effect of acupuncture on the quality of life in patients with migraine: A systematic review and meta-analysis
89 Cognitive improvement effects of electro-acupuncture for the treatment of MCI compared with Western medications: A systematic review and Meta-analysis 11 Medical and Health Sciences 1103 Clinical Sciences
90 Oriental herbal medicine and moxibustion for polycystic ovary syndrome: A meta-analysis
91 The Effect of Acupuncture and Moxibustion on Heart Function in Heart Failure Patients: A Systematic Review and Meta-Analysis
92 Acupuncture therapy for the treatment of stable angina pectoris: An updated meta-analysis of randomized controlled trials
93 Traditional manual acupuncture combined with rehabilitation therapy for shoulder hand syndrome after stroke within the Chinese healthcare system: a systematic review and meta-analysis
94 Effects of moxibustion on pain behaviors in patients with rheumatoid arthritis: A meta-analysis
95 Acupuncture Treatment for Chronic Pelvic Pain in Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
96 The effectiveness of dry needling for patients with orofacial pain associated with temporomandibular dysfunction: a systematic review and meta-analysis
97 Acupuncture for postherpetic neuralgia systematic review and meta-analysis
98 Acupoint selection for the treatment of dry eye: A systematic review and meta-analysis of randomized controlled trials
99 Warm-needle moxibustion for spasticity after stroke: A systematic review of randomized controlled trials
100 Acupuncture for menstrual migraine: a systematic review
101 The efficacy of acupuncture for stable angina pectoris: A systematic review and meta-analysis
102 Acupuncture and weight loss in Asians: A PRISMA-compliant systematic review and meta-analysis
103 Effects of Acupuncture on Breast Cancer-Related lymphoedema: A Systematic Review and Meta-Analysis
104 Acupuncture for infertile women without undergoing assisted reproductive techniques (ART): A systematic review and meta-analysis
105 Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer
106 Acupuncture for stable angina pectoris: A systematic review and meta-analysis

It was only when I came across this recent paper that I realized that, apparently, I am THE WORLD CHAMPION in acupuncture reviews. The aim of this paper was to analyze the 100 most-cited systematic reviews or meta-analyses in the field of acupuncture research.

The Web of Science Core Collection was used to retrieve lists of 100 most-cited systematic reviews or meta-analyses in the field of acupuncture research. Two authors screened literature, extracted data, and analyzed the results.

The citation number of the 100 most-cited systematic reviews or meta-analyses varied from 65 to 577; they were published between 1989 and 2018. Fourteen authors published more than 1 study as the corresponding author and 10 authors published more than 1 study as the first author.

In terms of the corresponding authors, Edzard Ernst and Linde Klaus published the most systematic reviews/meta-analyses (n = 7). The USA published most of the systematic reviews or meta-analyses (n = 24), followed by England (n = 23) and China (n = 14). Most institutions with more than 1 study were from England (4/13). The institutions with the largest numbers of most-cited systematic reviews or meta-analyses were the Technical University of Munich in Germany, the University of Maryland School of Medicine in the USA (n = 8), the Universities of Exeter and Plymouth in England (n = 6), and the University of Exeter in England (n = 6). The journal with the largest number of most-cited systematic reviews or meta-analyses was the Cochrane Database of Systematic Reviews (n = 20), followed by Pain (n = 6). The majority of the 100 most-cited reviews are on pain or pain-related conditions. Only 4 of them focus on safety issues, and all of these are by my team.

The authors concluded that the 100 most-cited systematic reviews or meta-analyses in the acupuncture research field are mostly from high impact factor journals and developed countries. It will help researchers follow research hot spots, broaden their research scope, expand their academic horizons, and explore new research ideas, thereby improving the quality of acupuncture research.

The authors show that, both in the list of corresponding as well as first authors, I am in place number one! Not only that, they furthermore reveal that my department is also in place number 1 (as Universities of Exeter and Plymouth in England (n = 6), and the University of Exeter in England (n = 6) both refer to my unit [in the 19 years it existed the Exeter medical school changed affiliation twice]). This is remarkable, particularly because acupuncture was only one of several research foci of my team (the other 3 being herbal medicine, homeopathy, and spinal manipulation), and my department was closed almost 10 years ago.

When I write about acupuncture these days (mostly on this blog), I often get the impression that the true believers in this therapy don’t especially like what I have to say. I, therefore, fear that the concept of me being the WORLD CHAMPION of acupuncture reviews might cause some degree of displeasure to them.

What can I say?

Sorry guys!

The non-specific effects constitute part of the overall effect of acupuncture. It is unclear whether responders and non-responders of acupuncture experience non-specific effects differently. This analysis aimed to compare their experiences in a nested qualitative study embedded in an acupuncture trial on functional dyspepsia.

Purposive sampling was used to capture the experience of responders (n=15) and non-responders (n=15) to acupuncture via individual in-depth interviews. Design and analysis followed a framework analysis approach, with reference to an existing model on acupuncture non-specific effects. Themes emerging outside of this model were purposefully explored.

The findings suggest that responders had a more trusting relationship with the acupuncturist in response to their expression of empathy. In turn, they were more actively engaged in lifestyle modifications and dietary advice offered by acupuncturists. Non-responders were not satisfied with the level of reassurance regarding acupuncture safety. They were also expecting more peer support from fellow participants, regarded that as an empowerment process for initiating and sustaining lifestyle changes.

The authors concluded that our results highlighted key differences in acupuncture non-specific effect components experienced by responders and non-responders. Positive non-specific effects contributing to overall benefits could be enhanced by emphasizing on empathy expression from acupuncturists, trust-building, offering appropriate explanations on safety, and organizing patient support groups. Further research on the relative importance of each component is warranted.

I doubt that this tiny study lends itself to drawing any firm conclusions. However, what they seem to imply and what the authors (proponents of acupuncture) ignore totally is the following: acupuncture responders are those people who respond to the context of the treatment situation. Thus their positive result is not due to the specific effects of acupuncture itself but to non-specific effects. In other words, acupuncture operates predominantly or entirely via non-specific effects. Or, to put it bluntly: this analysis confirms what we have discussed many times before (see for instance here, here, and here), namely that

acupuncture is a placebo therapy.

The authors of this review start their paper with the following statement:

Acupuncture has demonstrated effectiveness for symptom management among breast cancer survivors.

This, I think, begs the following question: if they already know that, why do they conduct a systematic review of the subject?

The answer becomes clear as we read thier article: they want to add another paper to the literature that shows they are correct in their assumption.

So, they do the searches and found 26 trials (2055 patients), of which 20 (1709 patients) could be included in the meta-analysis. Unsurprisingly, their results show that acupuncture was more effective than control groups in improving pain intensity [standardized mean difference (SMD) = -0.60, 95% confidence intervals (CI) -1.06 to -0.15], fatigue [SMD = -0.62, 95% CI -1.03 to -0.20], and hot flash severity [SMD = -0.52, 95% CI -0.82 to -0.22].  Compared with waitlist control and usual care groups, the acupuncture groups showed significant reductions in pain intensity, fatigue, depression, hot flash severity, and neuropathy. No serious adverse events were reported related to acupuncture intervention. Mild adverse events (i.e., bruising, pain, swelling, skin infection, hematoma, headache, menstrual bleeding) were reported in 11 studies.

The authors concluded that this systematic review and meta-analysis suggest that acupuncture significantly reduces multiple treatment-related symptoms compared with the usual care or waitlist control group among breast cancer survivors. The safety of acupuncture was inadequately reported in the included studies. Based on the available data, acupuncture seems to be generally a safe treatment with some mild adverse events. These findings provide evidence-based recommendations for incorporating acupuncture into clinical breast cancer symptom management. Due to the high risk of bias and blinding issues in some RCTs, more rigorous trials are needed to confirm the efficacy of acupuncture in reducing multiple treatment-related symptoms among breast cancer survivors.

Yes, I agree: this is an uncritical white-wash of the evidence. So, why do I bother to discuss this paper? After all, the acupuncture literature is littered with such nonsense.

Well, to my surprise, the results did contain a little gem after all.

A subgroup analysis of the data indicated that acupuncture showed no significant effects on any of the treatment-related symptoms compared with the sham acupuncture groups.

In other words, this paper confirms what has been discussed repeatedly on this blog (see for instance here, here, and here):

Acupuncture seems to be a placebo therapy!

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