Issues in study design
One of the major challenges in acupuncture research is in the design of an appropriate placebo control group. In trials of new drugs, double blinding is the accepted standard, but since acupuncture is a procedure rather than a pill, it is difficult to design studies in which both the acupuncturist and patient are blinded as to the treatment being given. The same problem arises in double-blinding procedures used in biomedicine, including virtually all surgical procedures, dentistry, physical therapy, ''etc.'' As the Institute of Medicine states:
Blinding of the practitioner in acupuncture remains challenging. One proposed solution to blinding patients has been the development of "sham acupuncture", ''i.e.'', needling performed superficially or at non-acupuncture sites. Controversy remains over whether, and under what conditions, sham acupuncture may function as a true placebo, particularly in studies on pain, in which insertion of needles anywhere near painful regions may elicit a beneficial response. A review in 2007 noted several issues confounding sham acupuncture:
An analysis of 13 studies of pain treatment with acupuncture, published in January 2009 in the journal ''BMJ'', concluded there was little difference in the effect of real, sham and no acupuncture.
Evidence-based medicine
There is scientific agreement that an evidence-based medicine (EBM) framework should be used to assess health outcomes and that systematic reviews with strict protocols are essential. Organizations such as the Cochrane Collaboration and Bandolier publish such reviews. In practice, EBM is "about integrating individual clinical expertise and the best external evidence" and thus does not demand that doctors ignore research outside its "top-tier" criteria.
The development of the evidence base for acupuncture was summarized in a review by researcher Edzard Ernst and colleagues in 2007. They compared systematic reviews conducted (with similar methodology) in 2000 and 2005:
The effectiveness of acupuncture remains a controversial issue. ... The results indicate that the evidence base has increased for 13 of the 26 conditions included in this comparison. For 7 indications it has become more positive (''i.e.'' favoring acupuncture) and for 6 it had changed in the opposite direction. It is concluded, that acupuncture research is active. The emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions.
For acute low back pain there is insufficient evidence to recommend for or against either acupuncture or dry needling, though for chronic low back pain acupuncture is more effective than sham treatment but no more effective than conventional and alternative treatments for short-term pain relief and improving function. However, when combined with other conventional therapies, the combination is slightly better than conventional therapy alone. A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.
There are both positive and negative reviews regarding the effectiveness of acupuncture when combined with in vitro fertilisation.
A Cochrane Review concluded that acupuncture was effective in reducing the risk of post-operative nausea and vomiting with minimal side effects, though it was less than or equal to the effectiveness of preventive antiemetic medications. A 2006 review initially concluded that acupuncture appeared to be more effective than antiemetic drugs, but the authors subsequently retracted this conclusion due to a publication bias in Asian countries that had skewed their results; their ultimate conclusion was in line with the Cochrane Review - acupuncture was approximately equal to, but not better than preventive antiemetic drugs in treating nausea. Another Cochrane Review concluded that electroacupuncture can be helpful in the treatment of vomiting after the start of chemotherapy, but more trials were needed to test their effectiveness versus modern antivomiting medication.
There is moderate evidence that for neck pain, acupuncture is more likely to be effective than sham treatment and offers short-term improvement compared to those on a waiting list.
There is evidence to support the use of acupuncture to treat headaches that are idiopathic, though the evidence is not conclusive and more studies need to be conducted. Several trials have indicated that migraine patients benefit from acupuncture, although the correct placement of needles seems to be less relevant than is usually thought by acupuncturists. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.
There is conflicting evidence that acupuncture may be useful for osteoarthritis of the knee, with both positive, and negative results. The Osteoarthritis Research Society International released a set of consensus recommendations in 2008 that concluded acupuncture may be useful for treating the symptoms of osteoarthritis of the knee.
A systematic review of the best five randomized controlled trials available concluded there was insufficient evidence to support the use of acupuncture in the treatment of the symptoms of fibromyalgia.
For the following conditions, the Cochrane Collaboration has concluded there is insufficient evidence to determine whether acupuncture is beneficial, often because of the paucity and poor quality of the research, and that further research is needed:
Positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias. Edzard Ernst and Simon Singh state that as the quality of experimental tests of acupuncture have increased over the course of several decades (through better blinding, the use of sham needling as a form of placebo control, etc.) the results have demonstrated less and less evidence that acupuncture is better than placebo at treating most conditions.
Evidence from neuroimaging studies
Acupuncture appears to have effects on cortical activity, as demonstrated by magnetic resonance imaging and positron emission tomography. A 2005 literature review concluded that neuroimaging data to date show some promise for being able to distinguish the effects of expectation, placebo, and real acupuncture. The studies reviewed were mostly small and pain-related, and more research is needed to determine the specificity of neural substrate activation in non-painful indications.
NIH consensus statement
In 1997, the United States National Institutes of Health (NIH) issued a consensus statement on acupuncture that concluded that despite research on acupuncture being difficult to conduct, there is sufficient evidence to expand its use and encourage further studies of the phenomenon. The statement was not a policy statement of the NIH but is the considered assessment of a panel convened by the NIH. The consensus group also noted the relative safety of acupuncture compared to certain other medical interventions. They stated that deciding when to use it in clinical practice depends on multiple factors, including the experience of the clinician, the information available on the treatment, and the individual patient's characteristics.
In 2006 the NIH's National Center for Complementary and Alternative Medicine continues to abide by the recommendations of the NIH Consensus Statement the effects of acupuncture have been documented, even if research is still unable to explain its mechanism and relationship to Western medicine.
- Acute bacillary dysentery
- Adverse reactions to radiotherapy and/or chemotherapy
- Allergic rhinitis
- Biliary colic
- Depression
- Essential hypertension
- Headache
- Induction of childbirth and correction of the malposition of fetus
- Inflammation of the tissues surrounding the shoulder
- Leukopenia
- Nausea and vomiting including morning sickness
- Pain in the epigastrium, face, neck, tennis elbow, lower back, knee, during dentistry and after operations
- Primary dysmenorrhea
- Primary hypotension
- Renal colic
- Rheumatoid arthritis
- Sciatica
- Sprains
- Strokes
The report also listed other conditions for which acupuncture may be effective.
The WHO explained the report's purpose:
- "In order to promote the appropriate use of acupuncture in those Member States where acupuncture has not been widely used, this document is annexed with a brief abstract of each relevant reference for the assessment of acupuncture practice. The clinical conditions covered in the existing data are also included. It must be emphasized that the list of diseases, symptoms or conditions covered in this publication is based on collected reports of clinical trials and, so, can serve only as a reference. Only national health authorities can determine the diseases, symptoms and conditions for which acupuncture treatment can be recommended."
The report was controversial; critics say it is cited by supporters as an endorsement of the practice by the WHO. Several scientists also expressed concern that the evidence supporting acupuncture was weak, and that the WHO had been biased by the involvement of practitioners of alternative medicine.
Further Reading
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