Acupuncture where is the evidence?

Acupuncture:where is the evidence?The Cochrane Reviews of AcupunctureDoris Hubbs, MD, FACPApril 26, 2013DisclosuresNo financial conflicts of interest

No intention of discussion off-label use

I would like to recognize and thank several important people

The Cochrane ReviewsSystematic reviews of primary research in human health care

Internationally recognized as the highest standard in evidenced-based health care

Theyinvestigate the effects of interventions for prevention, treatment and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting. They are published online inThe Cochrane Library.

3Acupuncture for Painan overview of Cochrane reviewsEight Cochrane reviews evaluating effectiveness of acupuncture for pain

Four reviews concluded that acupuncture is effective for:

migrainesneck disorderstension HAsperipheral joint OAThe Cochrane reviews were all of high methodological quality.4Acupuncture for Migraine Prophylaxis: Cochrane ReviewTo investigate whether acupuncture is

a) more effective than no treatmentb) more effective than sham (placebo) acupuncturec) as effective as other interventions in reducing HA frequency in migraine pts.

Acupuncture for Migraine Prophylaxis: Cochrane ReviewSelection criteria:

Randomized trials with observation period of at least 8 weeks, comparing clinical effects of acupuncture treatment with:No treatment or routine care onlySham acupunctureAnother intervention for migraineSearch methods: The Cochrane Pain, Palliative & Supportive Care Trials Register, CENTRAL, MEDLINE, EMBASE and the Cochrane Complementary Medicine Field Trials Register were search to Jan. 2008.At least 8 weeks post-randomization observation.Two reviewers check eligibility; extracted information on patients, interventions, methods and results; and assessed risk of bias and quality of the acupuncture intervention. Outcomes extracted included response (outcome of primary interest), migraine attacks, migraine days, headache days and analgesic use. Pooled effect size estimates were calculated using a random-effects model.

6Migraine Results22 trials with 4419 participants met the inclusion criteria.

There is consistent evidence that acupuncture provides additional benefit to routine care for migraine

Acupuncture is at least as effective as (possibly more) prophylactic drug txAnd has fewer adverse effects.6 trials (including two large trials with 401 and 1715 patients) compared acupuncture to no prophylactic tx or routine care only.After 3-4 months patients receiving acupuncture had higher response rates and fewer HAs.The only study with long-term follow up saw no evidence that effects dissipated up to 9 months after cessation of treatment.14 trials compared a true acupuncture tx with a sham tx. Pooled analyses did not show a statistically significant superiority for trye acupuncture, but the results of single trials varied considerable.4 trials compared acupuncture to proven prophylactic drug tx. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than drug tx. Acupuncture should be considered a tx option for patients williing to undergo this tx.7Acupuncture for Tension HAsCochrane ReviewsTo investigate whether acupuncture is

a) more effective than no tx or routine care only

b) more effective than sham acupuncture

c) as effective as other interventions in reducing HA frequency in patients with chronic tension HASearched data bases to Jan. 2008.Included randomized trials with a post-randomiztion observation period of at least 8 weeks that compared the clinical effects of an acupuncture intervention with a control tx or routine care. Outcomes extracted included response (at least 50% reduction of HA freq.; outcome of primary interest), HA days, pain intensity and analgesic use.8Acupuncture for Tension HAsMain Results11 trials with 2317 participants met inclusion criteria

2 large trials showed statistically significant benefits of acupuncture over control for response, number of HA days, and pain intensity for the length of f/u (3 months)Acupuncture for Tension HAs Cochrane Review Results5 trials comparing acupuncture with sham tx showed small but statistically significant benefits of acupuncture over sham treatmentAcupuncture for Tension HAs Cochrane Review ConclusionAcupuncture can be a valuable non-pharmacological treatment in patients with frequent episodic or chronic tension-type headachesAcupuncture for Neck PainCochrane Reviews 2008Neck pain is one of the three most frequently reported complaints of the musculoskeletal system.

Acupuncture for Neck PainCochrane Reviews 2008Objective:

To determine the effects of acupuncture for individuals with neck pain.

RCTs or quasi-RCTs included.

10 trials using acupuncture for chronic neck pain.Acupuncture for Neck PainCochrane Reviews 2008No trials examined the effects of acupuncture for acute or subacute pain

Methodological quality had a mean of 2.3/5 on the Jadad Scale.

For chronic mechanical neck pain, there was moderate evidence that acupuncture was more effective than sham controls, massage, or a wait-list control.Acupuncture for OsteoarthritisCochrane Review 2008Peripheral joint osteoarthritis is a major cause of pain and disability.

Objective:

To assess the effects of acupuncture for treating peripheral joint osteoarthritisFew treatments are safe and effective for pain due to peripheral joint OA.15Acupuncture for OsteoarthritisCochrane Review 2008Inclusion criteria:

RCTs comparing acupuncture with sham, another active tx, or a waiting list control group in people with OA of the knee, hip, or hand.

Searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE (both through Dec. 2007) and scanned reference lists of articles.Two authors independently assessed trial quality and extracted data and calculated standardized mean differences using the differences in improvements between groups.16Acupuncture for OsteoarthritisCochrane Review Results16 trials involving 3498 people were included:

12 RCTs with only OA knee

3 trials with only OA hip

1 trial with OA of the hip and/or kneeAcupuncture for OsteoarthritisCochrane Review ConclusionsSham-controlled trials showed statistically significant benefits;However, did not meet pre-defined thresholds for clinical relevance

Waiting list-controlled trials suggested statistically significant and clinically relevant benefits of acupuncture for pain from peripheral joint OAAcupuncture for PainCochrane Reviews 20084 reviews concluded that acupuncture is effective for migraines, neck disorders, tension HAs, and peripheral joint OA

3 reviews were inconclusive for shoulder pain, lateral elbow pain, and LBP

One review failed to demonstrate the effectiveness of acupuncture for RAAll were of high methodological quality.19Cochrane Reviews2008Acupuncture for conditions other than pain:

Asthma, glaucoma, depression, schizophrenia, irritable bowel syndrome, nausea due to CHT or post-op, Bells palsy, RLS, epilepsy, vascular dementia, stroke, insomnia, cocaine dependence, conception, induction of labor, uterine fibroidsLimitations to RCTs for AcupunctureCost

Difficult to find a credible placebo

Unable to keep practitioners blinded

Many different acupuncture methods

Controlling the skill of the practitioner

Guerra de Hoyos et al., Medical Acupuncture: A Journal for Physicians By Physicians, Vol. 14, #2, 2001

Problems with sham acupunctureProblems with selecting suitable end point and traditional diagnosis.Using standardized vs. individualized points.Difficulty quantifying pain, etc.

Guerra de Hoyos et al., Medical Acupuncture: A Journal for Physicians By Physicians, Vol. 14, #2, 2001:Much of the research on acupuncture has lacked quality, producing heterogeneous and conflicting results. Poor application of general research procedures, and specific difficulties related to adapting research designs to acupuncture, have contributed to this problem.

21Arch. Intern. Med: 2012Acupuncture for Chronic Pain (back, neck, OA, headache, shoulder)

Individual Patient Data Meta-analysis

Systematic review of 29 RTCs with total of 17,922 patients.RCTs in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs with a toltal of 17, 922 patients analyzed.22Arch. Intern. Med. 2012Conclusions:

Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option.

Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo.However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.23SummaryAcupuncture has been shown in RCTs to be safe and effective for certain types of pain, include HA, neck pain, OA pain

Many financial and technical difficulties limit the availability of acupuncture RCTs

More studies are needed to better understand the benefits of acupuncture.

Thank You!Questions?