Mike Cummings

Acupuncture for anxiety and anxiety disorders - a systematic literature review

Introduction The aim of this study was to evaluate the evidence for the efficacy of acupuncture in the treatment of anxiety and anxiety disorders by systematic review of the relevant research. Methods Searches of the major biomedical databases (MEDLINE, EMBASE, ClNAHL, PsycINFO, Cochrane Library) were conducted between February and July 2004. Specialist complementary medicine databases were also searched and efforts made to identify unpublished research. No language restrictions were imposed and translations were obtained where necessary. Study methodology was appraised and clinical commentaries obtained for studies reporting clinical outcomes. Results Twelve controlled trials were located, of which 10 were randomised controlled trials (RCTs). Four RCTs focused on acupuncture in generalised anxiety disorder or anxiety neurosis, while six focused on anxiety in the perioperative period. No studies were located on the use of acupuncture specifically for panic disorder, phobias or obsessive-compulsive disorder. In generalised anxiety disorder or anxiety neurosis, it is difficult to interpret the findings of the studies of acupuncture because of the range of interventions against which acupuncture was compared. All trials reported positive findings but the reports lacked many basic methodological details. Reporting of the studies of perioperative anxiety was generally better and the initial indications are that acupuncture, specifically auricular acupuncture, is more effective than acupuncture at sham points and may be as effective as drug therapy in this situation. The results were, however, based on subjective measures and blinding could not be guaranteed. Conclusions Positive findings are reported for acupuncture in the treatment of generalised anxiety disorder or anxiety neurosis but there is currently insufficient research evidence for firm conclusions to be drawn. No trials of acupuncture for other anxiety disorders were located. There is some limited evidence in favour of auricular acupuncture in perioperative anxiety. Overall, the promising findings indicate that further research is warranted in the form of well designed, adequately powered studies.

Defining an adequate dose of acupuncture using a neurophysiological approach – a narrative review of the literature

Many different styles of acupuncture practice exist, and lack of agreement on the optimal acupuncture treatment for any particular condition may mean that some patients do not receive the best treatment. This uncertainty also makes the negative results of sham controlled trials difficult to interpret. Unless we can be sure that both adequate acupuncture and an inactive sham were used in a particular trial, then that trial should not be interpreted as dismissing acupuncture for that condition. Acupuncture practice clearly involves much more than needling procedures, but there is a strong argument for elucidating the role of those needling procedure first. The components of acupuncture needling procedures have been described in the STRICTA document, but it is also clear that the patients perception of needling is relevant for the outcome of treatment. We therefore recommend the concept of ‘dose’ of acupuncture needling, which should include both the stimulus given to the patient, and certain aspects of the patients perceptions and response that are known to be linked to the subsequent therapeutic response. We propose the following definition of dose: the physical procedures applied in each session, using one or more needles, taking account of the patients resulting perception (sensory, affective and cognitive) and other responses (including motor). The dose may be affected by the state of the patient (eg nervous, immune and endocrine systems); different doses may be required for different conditions. The constituents of an adequate dose can be established initially by clinical opinion and subsequently by empirical evidence from experimental studies, which may be either clinical or basic research studies. Systematic reviews which do not consider the adequacy of the acupuncture treatment may have unreliable conclusions. Out of 47 recent systematic reviews, only six have applied some criteria for adequacy. Five used a rating system or conducted a subgroup analysis, and one excluded studies from the analysis altogether if they did not meet criteria for adequacy. Research into what constitutes an adequate dose of acupuncture has long been neglected and is now urgent. Clinical studies that compare the effects of different treatment protocols are probably the most reliable source of evidence, and may also demonstrate a dose-response relationship.

Modellvorhaben Akupunktur - a summary of the ART, ARC and GERAC trials

In October 2000 the German Federal Committee of Physicians and Health Insurers recommended that special Model Projects on Acupuncture (“Modellvorhaben Akupunktur”) be developed in order to determine the evidence-based role of acupuncture in the treatment of certain illnesses. This paper presents a summary of the main randomised controlled trials performed as part of these projects, and the associated economic analyses. Overall the results show that acupuncture is effective in practice for a range of chronic conditions, and it seems likely to have acceptable cost utility (at least at a rate of ¢35 per session). Sham acupuncture, in the form of minimal off-point needling in a therapeutic context, also appears to be effective, being no different to prophylactic medication in migraine, and superior to guideline-based standard care in chronic low back pain. In patients recruited to acupuncture trials, the response to treatment does not differ between those that agree to be randomised and those that do not. This suggests that the results of the pragmatic Acupuncture in Routine Care studies are applicable to patients from the general population who express a preference for acupuncture. In conclusion, acupuncture appears to be effective in a range of chronic conditions and it seems to have acceptable cost-effectiveness in Western health economic terms. These programmes of research do not confirm the hypothesis that needling at specific points is essential to achieve satisfactory clinical effects of acupuncture. Sham acupuncture, in the form of minimal off-point needling in a therapeutic context, is unlikely to be an inactive placebo. In April 2006, the German health authorities decided that acupuncture would be included into routine reimbursement by social health insurance funds for chronic low back pain and chronic osteoarthritis of the knee.

Acupuncture in the treatment of obesity: a narrative review of the literature

Obesity is one of the leading health risk factors worldwide and is associated with several other risk factors and health problems including type 2 diabetes mellitus, cardiovascular disease and malignancies. Current conventional therapeutic strategies for obesity cannot achieve adequate weight control in all patients, so complementary types of treatment are also performed. Acupuncture, one of the oldest healing practices, represents the most rapidly growing complementary therapy which is recognised by both the National Institutes of Health and the WHO. A previous review concluded that acupuncture was superior to lifestyle advice, to sham acupuncture and to conventional medication. In this narrative review, the possible mechanisms of actions and the results of recent experimental and clinical studies with different forms of acupuncture (eg, body, auricular, manual and electroacupuncture) are presented. In particular, the effects of acupuncture on anorexigenic and orexigenic peptides, insulin resistance, lipid metabolism and inflammatory markers are discussed. Both experimental and clinical current data suggest that acupuncture exerts beneficial effects on the mechanisms of obesity. Some data suggest that electroacupuncture may be more effective than manual acupuncture; however, the most effective frequency remains controversial. Combination of different forms of acupuncture with diet and exercise seems to be necessary for achieving and maintaining weight loss. Further prospective clinical trials are needed to establish the effectiveness of this complementary method for obesity treatment.

The effectiveness of acupuncture for osteoarthritis of the knee - a systematic review

Objective To determine the effectiveness of acupuncture treatment for pain and function of patients with osteoarthritis of the knee. Methods A systematic review of randomised controlled trials was performed, including a meta-analysis which combined the results of trials that used adequate acupuncture treatment and used WOMAC scores to measure the effect. The internal validity (quality) and heterogeneity of studies were taken into account. Results Thirteen studies were available, of which eight, involving 2362 patients, could be combined. For both reduction of pain and improvement of function, acupuncture was significantly superior to sham acupuncture (P<0.05 for all comparisons) in both the short term and the long term. Compared with no additional intervention (usual care), acupuncture was again significantly superior for pain and function. The treatment effects were maintained after taking account of quality and heterogeneity in sensitivity analyses. Conclusion Acupuncture is an effective treatment for osteoarthritis of the knee. Its overall effect size is 0.8, and it can be considered instead of non-steroidal anti-inflammatory drugs for patients whose symptoms are not controlled by education, exercise, weight loss if appropriate and simple analgesics. Further research is necessary into the most efficient way of delivering acupuncture, and its longer term benefits.

‘Forbidden points’ in pregnancy: no plausible mechanism for risk

It has been suggested that acupuncture may pose particular risks during pregnancy: by enhancing oxygenation to the developing embryo (presumably via increasing blood flow to the uterus); by affecting the level of maternal progesterone in early pregnancy; or by stimulating uterine contractions. This article examines the proposed risks and fails to find any plausible physiological mechanism for them.

High volume acupuncture clinic (HVAC) for chronic knee pain – audit of a possible model for delivery of acupuncture in the National Health Service

Recent research has established the efficacy, effectiveness and cost effectiveness of acupuncture for some forms of chronic musculoskeletal pain. However, there are practical problems with delivery which currently prevent its large scale implementation in the National Health Service. We have developed a delivery model at our hospital, a ‘high volume’ acupuncture clinic (HVAC) in which patients are treated in a group setting for single conditions using standardised or semi-standardised electroacupuncture protocols by practitioners with basic training. We discuss our experiences using this model for chronic knee pain and present an outcome audit for the first 77 patients, demonstrating satisfactory initial (eight week) clinical results. Longer term (one year) data are currently being collected and the model should next be tested in primary care to confirm its feasibility.

Acupuncture for knee osteoarthritis: study by Hinman et al represents missed opportunities

We believe AiM readers will be interested to learn of the factors that led to negative reporting of the positive study by Hinman et al on acupuncture for knee osteoarthritis (OA) pain.1 The study showed the effects of acupuncture to be significantly superior to no acupuncture and consistent with the best current evidence, but the authors actually reported: ‘Our findings do not support acupuncture for these patients’. Patients with OA knee pain are suffering the commonest cause of pain and disability in elderly people. More than half have inadequate pain relief.2 They face ‘a choice between ineffective paracetamol, non-steroidal drugs that can harm the heart, (kidneys) and gastrointestinal tract, gels that scarcely work, physiotherapy, opioids that cause dependency and lose effectiveness, arthroscopic washouts that do nothing or surgery’.3 They deserve a fuller, more considered answer to their question: should they try acupuncture? The neat part of the Zelen design that Hinman et al used was that the control group, who were not given acupuncture, were not even aware that their pain scores were used in a trial of acupuncture so disappointment could not influence their scores, as was claimed for other studies. This ‘no acupuncture’ group was compared with acupuncture (manual) and with sham laser (and with real laser, …

Myofascial pain from pectoralis major following trans-axillary surgery.

This is the first reported description, to the authors knowledge, of myofascial pain occurring at a surgical drain site. The patient consulted a medical acupuncturist after suffering five months of continuous chest and arm pain associated with ‘tingling’ in the forearm and hand. She had undergone trans-axillary resection of the first left rib following a left axillary vein thrombosis 18 months previously. Her symptoms had been principally attributed to nerve traction at surgery or nerve root entrapment from scar tissue. However, the drain passed through the free border of pectoralis major, and the myofascial trigger point that appeared to develop as a result of the muscle trauma, or the pain at that site, presented as a chronic and complex post-surgical pain problem. The pain and tingling resolved completely after two sessions of dry needling at a single myofascial trigger point in the free border of the left pectoralis major muscle.

Why recommend acupuncture for low back pain but not for osteoarthritis? A commentary on recent NICE guidelines

I attended a dinner in November 2005 with Sir Michael Rawlins (chairman of the National Institute for Health and Clinical Excellence (NICE)) organised by the King’s Fund to explore some of the issues around the assessment of complementary interventions in the NHS. It was a valuable opportunity to gain an insight into policy making processes and principles, and I specifically remember Sir Michael’s mantra: “Does it work? Is it safe? How much does it cost?” I realised that “Does it work?” referred to specific efficacy confirmed in systematic review of randomised controlled trials (RCTs), rather than pragmatic data on effectiveness in clinical practice. He indicated that there was a growing quantity of suitable evidence (systematic reviews) in the complementary medicine field, and when referring specifically to acupuncture I’m sure he said “We will probably buy acupuncture for back pain, but definitely not for migraine”. At this point I spluttered on my glass of water, and was subsequently invited to comment. I briefly described the issues surrounding sham acupuncture,1 “missing the point”2 and the extraordinary effectiveness of these procedures in the prophylaxis of migraine.3 Sir Michael’s response was simply to comment: “That is your ( viz the acupuncture profession’s) problem!” Around the same time I had a detailed discussion of the research issues of acupuncture for headaches with one of the leading academics in field of migraine. He took a similar approach to the chairman of NICE, in that he would not consider the data on effectiveness or cost effectiveness until the question over specific efficacy (“Does it work?”) was answered satisfactorily. These interactions with leading academics who had (and still …