Val Hopwood

Effectiveness of acupuncture for stroke: a systematic review.

Background Acupuncture has been suggested as a treatment for stroke rehabilitation, but the question whether it is effective has not been answered satisfactorily. Purpose To summarise and critically review all randomised controlled trials of the effectiveness of acupuncture as a treatment for stroke. Methods Four independent computerised literature searches (in MEDLINE, Cochrane Controlled Trials Register, Embase, and CISCOM data bases) were conducted in June 1999. All randomised-controlled trials that compared any form of needle insertion acupuncture to any form of non-acupuncture control intervention in the treatment of human stroke patients were included. Data were extracted independently by two authors and arbitrated by a third. The methodological quality of the included studies was assessed using the Jadad score. Results Nine randomised controlled trials with a total sample size of 538 patients were included. Two studies were assessor blind, one was subject blind, and one was assessor and subject blind. Two studies exclusively used manual acupuncture, five only electro-acupuncture, and two used both. Outcome measures used were Scandinavian Stroke Scale, Chinese Stroke Scale or Recovery Scale, Barthel index, Nottingham Health Profile, Motor function, balance, and days in hospital. Of the nine studies, six yielded a positive result suggesting that acupuncture is effective, and three produced a negative finding implying that acupuncture is not superior to control treatment. Only two studies obtained a Jadad score of more than 3. These methodologically best trials showed no significant effect of acupuncture. Conclusion Based on the evidence of rigorous randomised controlled trials, there is no compelling evidence to show that acupuncture is effective in stroke rehabilitation. Further, better-designed studies are warranted.

Evaluating the efficacy of acupuncture in defined aspects of stroke recovery : A randomised, placebo controlled single blind study

ObjectiveTo investigate the efficacy of acupuncture on stroke recovery compared to an inert placebo.DesignPlacebo-controlled, randomised, clinical trial.SettingPost-stroke rehabilitation wards in five NHS hospitals in the UK.SubjectsPatients between 4 and 10 days after their first stroke.Interventions and outcome measuresThe patients received 12 acupuncture or placebo treatments over four weeks. Acupuncture with electrical stimulation was compared with mock TENS, and assessments continued for 12 months after entry. Primary outcome was the Barthel Index (BI). Secondary outcomes were muscle power, Motricity Index (MI), mood, Nottingham Health Profile (NHP) and treatment credibility.Results92 patients completed data sets. Data were analysed using both t tests and a structural equation based on longitudinal analysis of both BI and MI, using generalised estimating equations with an exchangeable correlation structure. While both acupuncture and placebo (mock TENS) appeared to have had an equal effect on stroke recovery, there is no significant difference between the two interventions at 12 (p = 0.737, 95 % CI –2.00 to 2.81) and 52 weeks (p = 0.371, 95 % CI –3.48 to1.32). An apparently accelerated improvement in the MI scores in the acupuncture group at 3 weeks (p = 0.009, 95 % CI 1.55 to 10.77) is interesting.ConclusionsAcupuncture did not demonstrate specific efficacy over placebo and both groups did as well as normally expected with this condition.

The Context and Meaning of Placebos for Complementary Medicine

Calls for placebo-controlled randomised trials in complementary and alternative medicine (CAM) are entirely reasonable. However, they present major methodological problems, particularly when we understand so little about the underlying biological mechanisms involved for many of these therapies. Designing a placebo in CAM is frequently dependent on unsubstantiated assumptions about the specificity of a particular CAM intervention. In this paper we address the development and application of placebos to clinical trials of homeopathy, acupuncture, kinesiology, Chinese herbal medicine and healing. Each therapy-based vignette is authored by a researcher from the Complementary and Integrated Medicine Research Unit at the University of Southampton who has specific expertise in the field. The essential research question within this review is; can we legitimately claim to have placebos for these particular CAM interventions? In some areas of CAM the debate has become very involved and sophisticated, for instance in acupuncture but for other areas, such as healing, our understanding of placebos is currently limited and very naïve. For instance, if acupuncture is not point specific, then many so-called ‘placebo-controlled’ acupuncture trials are both misconceived and misleading. We have addressed this debate in what we hope is a thoughtful and rigorous manner with a view to developing realistic, reliable and credible placebos for randomised controlled studies when and where possible. However, our conclusions suggest that we are some way from developing valid, credible and reliable placebos for most CAM therapies.

The effect of acupuncture on the motor recovery of the upper limb after stroke

Summary The aim of this study was to investigate the effect of acupuncture on recovery of upper limb function in stroke patients. A single case study design was used. Upper limb motor function was assessed using the Rivermead Motor Assessment, the Motricity Index and the Nine-hole Peg Test. Since pain might inhibit motor function, the presence and severity of pain was evaluated with a visual analogue scale. Six patients were all given daily treatment for two months, alternating between two weeks of the acupuncture treatment and two of placebo intervention. Then four assessments followed at two-week intervals. Since these were performed by the investigator, an attempt was made to eliminate bias by videoing the assessments for verification by an impartial group of professional colleagues. The results are most striking in the Motricity Index, a mean increase of 17.96 points over all six patients with a high of 26 and a low of 10. When shown graphically, the rate of change indicated by the slope of the graph varies clearly with the acupuncture and placebo interventions, being most often steeper with the former. A similar pattern is seen with the Rivermead Motor Assessment. The other two measures were not easy to interpret, nor did they apply to all the patients.

The Meaning of Evidence: Can Practitioners Be Researchers?

Our research group at Southampton contains a combination of non-clinical researchers as well as CAM and conventional clinicians who have become researchers. The transition from practitioner to practitioner-researcher has led us to question, challenge and re-consider the paradigmatic differences in our practices compared to conventional medicine and how we might understand and interpret evidence derived from both quantitative and qualitative research. We very much value the randomised controlled trial (RCT) but have all come to understand its limitations and constraints when trying to encapsulate a complete, rigorous, and honest understanding of our complex interventions and how they are delivered in practice. Equally, our expertise in qualitative research leads us to understand the patient’s perspective and to value a more individual agenda. We believe that we share these tensions with clinicians working in primary care. We appreciate that we need to understand contextual effects so we can better utilise and research them appropriately, rather than dismiss them as mere placebo. These issues represent both personal and transcendent conflicts that we have expressed as a series of vignettes each written by a practitioner/researcher working in that filed. Our principle aim in writing this essay is to offer our practical experience and insight as issues for thoughtful debate for those clinicians and academics involved in clinical research in controversial areas such as CAM.

Poor Reviews May Not Give a True Reflection of the Evidence

Summary The predominance of poor systematic reviews in the current research literature is an unfortunate development, particularly in the light of the undoubtedly excellent work of the Cochrane Collaboration. The quality of any review depends entirely on the quality of the research work included. A common dismissive comment about this type of review is ‘Garbage in, garbage out. It is therefore the responsibility of all researchers to make sure that this cannot apply to their own work. A literature review of the effectiveness of four modalities commonly used to relieve pain was published in the August 2001 issue of Physiotherapy . That paper originated as part of an informal workshop held at the World Confederation for Physical Therapy Congress in Japan in May 2000. This should have been made clear in the published format, as several aspects of it, particularly with regard to acupuncture, may cause concern. This opinion piece was originally written as a letter in response to publication of the WCPT report. Unfortunately the shortcomings evident in it are quite common and should lead us to consider very carefully any claims as to clinical efficacy, or lack ot it, in the acupuncture field.

Acupuncture Research: Strategies for Clinical Evaluation: Workshop Report, York, July 5–8, 2006

This report summarizes a ground-breaking workshop on the strategic direction of acupuncture research which was held in York in early July 2006. Three days were spent discussing the history, the philosophy and the practicalities of researching acupuncture. Attending the workshop were an international group of researchers with varied backgrounds, including acupuncturists, physicians, physiotherapists, sociologists and anthropologists. Supported by the Medical Research Councils Health Services Research Collaboration, Elsevier and others, this workshop was an opportunity to brainstorm the issues and to the concerns in the field and set out directions for research that would tackle some of the major challenges facing the acupuncture research community.