placebo
Auriculotherapy (or ear acupuncture) is the use of electrical, mechanical, or other stimuli at specific points on the outer ear for therapeutic purposes. It was invented by the French neurologist Paul Nogier (1908–1996) who published his “Treatise of Auriculotherapy” in 1961. Auriculotherapy is based on the idea that the human outer ear is an area that reflects the entire body. Proponents of auriculotherapy refer to maps where our inner organs and body parts are depicted on the outer ear. These maps are not in line with our knowledge of anatomy and physiology. Auriculotherapy thus lacks plausibility.
This single-blind randomized, placebo-controlled study aimed to investigate the effect of auriculotherapy on the intensity of Premenstrual Syndrome (PMS) symptoms.
Ninety-one women were randomly assigned to
- Auriculotherapy (AG),
- Placebo (PG),
- Control (CG) groups.
The intervention was 8 weeks long, done once per week. At each session in AG the microneedles were placed in seven points related to PMS symptoms (Anxiety; Endocrine; Muscle relaxation; Analgesia; Kidney; Shen Men; and Sympathetic). At PG the microneedles also were placed in seven points but unrelated to PMS symptoms (Tonsils; Vocal cords; Teeth; Eyes; Allergy; Mouth; and External nose). The women allocate in the CG received o intervention during the evaluation period.
Assessments of PMS symptoms (Premenstrual Syndrome Screening Tool), musculoskeletal pain (Nordic Musculoskeletal Questionnaire), anxiety (Beck Anxiety Inventory), and quality of life (WHOQOL-Bref) were done at baseline, before the 5th session, after program completion, and a month follow-up.
The AG and PG showed significantly lower scores of PMS symptoms, musculoskeletal pain, and anxiety. On the quality of life and follow-up analysis, the significance was observed only in PG.
The authors concluded that auriculotherapy can be used as adjunctive therapy to reduce the physical and mood PMS symptoms.
If I understand it correctly (the paper is unclear), verum and placebo were both better than no intervention but showed no significant differences when compared to each other. This is strong evidence that auriculotherapy is, in fact, a placebo. To make matters worse, in the follow-up analysis placebo seems to be superior to auriculotherapy.
Another issue might be adverse effects. Microneedle implants can cause severe complications. Thus it is mandatory to monitor adverse effects in clinical trials. This does not seem to have happened in this case.
The mind boggles!
How on earth could the authors conclude that auriculotherapy can be used as adjunctive therapy to reduce the physical and mood PMS symptoms.
The answer: a case of scientific misconduct?
This systematic review examined the efficacy of acupressure on depression. Literature searches were performed on PubMed, PsycINFO, Scopus, Embase, MEDLINE, and China National Knowledge (CNKI). Randomized clinical trials (RCTs) or single-group trials in which acupressure was compared with various control methods or baseline (i.e. no treatment) in people with depression were included. Data were synthesized using a random-effects or a fixed-effects model to analyze the impacts of acupressure treatment on depression and anxiety in people with depression. The primary outcome measures were depression symptoms quantified by various means. Subgroups were created, and meta-regression analyses were performed to explore which factors are relevant to the greater or lesser effects of treating symptoms. 
A total of 14 RCTs (1439 participants) were identified. Analysis of the between-group showed that acupressure was effective in reducing depression [Standardized mean differences (SMDs) = -0.58, 95%CI: -0.85 to -0.32, P < 0.0001] and anxiety (SMD = -0.67, 95%CI: -0.99 to -0.36, P < 0.0001) in participants with mild-to-moderate primary and secondary depression. Subgroup analyses suggested that acupressure significantly reduced depressive symptoms compared with different controlled conditions and in participants with different ages, clinical conditions, and duration of intervention. Adverse events, including hypotension, dizziness, palpitation, and headache, were reported in only one study.
The authors concluded that the evidence of acupressure for mild-to-moderate depressive symptoms was significant. Importantly, the findings should be interpreted with caution due to study limitations. Future research with a well-designed mixed method is required to consolidate the conclusion and provide an in-depth understanding of potential mechanisms underlying the effects.
I think that more than caution is warranted when interpreting these data. In fact, it would have been surprising if the meta-analyses had NOT generated an overall positive result. This is because in several studies there was no attempt to control for the extra attention or the placebo effect of administering acupressure. In most of the trials where this had been taken care of (i.e. patient-blinded, sham-controlled studies), there were no checks for the success of blinding. Thus it is possible, even likely that many patients correctly guessed what treatment they received. In turn, this means that the outcomes of these trials were also largely due to placebo effects.
Overall, this paper is therefore a prime example of a biased review of biased primary studies. The phenomenon can be aptly described by the slogan:
RUBBISH IN, RUBBISH OUT!
Bach Flower Remedies are often mistaken for homeopathy. Yet they are quite different. They were invented about 100 years ago by Dr. Edward Bach (1886–1936), a doctor homeopath who had previously worked in the London Homeopathic Hospital. His remedies are clearly inspired by homeopathy; however, they are by no means the same because they do not follow the ‘like cures like’ principle and neither are they potentised. They are manufactured by placing freshly picked specific flowers or parts of plants in water which is subsequently mixed with alcohol, bottled, and sold. Like most homeopathic remedies, they are highly dilute and thus do not contain therapeutic concentrations of the plant printed on the bottle. In other words, flower remedies (or essences) are placebos. This does not stop enthusiasts to continue submitting them to clinical trials.
This study tested the effects of flower essence bouquets on the signs and symptoms of stress in nursing students. The study was designed as a randomized clinical trial, triple blind, with two groups (flower essence group and placebo group), carried out with 101 nursing students. Bach’s flower essences Cerato (Ceratostigma wilimottianum), Cherry Plum (Prunus cerasifera), Elm (Ulmus procera), Impatients (Impatiens glandulifera), Larch (Larix decidua), Olive (Olea europaea) and White Chestnut (Aesculus hippocastanum) were selected by the researcher based on the experience of attending nursing students on flower essence therapy. The formulas were prepared in a 30 ml amber glass bottle with a perforated cap with a white seal and bulbs, and labeled according to randomization (Group 1 or Group 2). The groups applied the treatments for 60 days at a dosage of 4 drops 4 times a day. The outcome was evaluated using the Baccaro Test and the Perceived Stress Scale applied at the beginning and at the end of the intervention.
The results demonstrated no significant difference between the groups in stress reduction (p > 0.05). Both groups showed a reduction in scale scores (p < 0.001) with a large effect size. There was an influence of the COVID-19 pandemic in the reduction of Baccaro Test scores.
The authors (who seem to have been advocates of Bach Flower Remedies) concluded that the intervention with flower essence therapy was not more effective than placebo in reducing stress signs and symptoms.
Is anyone surprised?
I am not!
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 |
