ALBERTA Re Scanned Acupuncture Evidence 2002

8/2/2019 ALBERTA Re Scanned Acupuncture Evidence 2002

1/67

IEAl berta Heritage Foundationfor Medical Research

Acupuncture: Evidencefrom Systematic Reviewsand Meta-analyses

Patricia Leggett Tait, Laurie Brooks,Christa Harstall

March 2OO2

HT A 27: Series A Health Technology Assessment


2/67

@ Cop).right Alberta Herltage Foundation for Medical Research, 2002

This Health Technolosr Report has been prepared on the basis of available informationof whtch the Foundatlon ls aware from public literatue and expert opinion andattempts to be curent to the date of publication. It has been externally reviewed.Additional information and comments relatlve to the report are welcome and should besent to:

Director, Health Technology AssessmentAlberta Heritage Foundation for Medical Research1500, 10104 - 103 AvenueEdmontonAlberta TsJ 4A7CANADATeI:. 780-423-5?27, F ax 780-429-3509

ISBN l-896956-56-4

Alberta's health technolory assessment program has been established under the HealthResearch Collaboration Agreement between tie Alberta Heritage Foundation forMedical Research and the Alberta Health Ministry.


3/67

AcKNowLEDGMENTSThe Alberta Heritage Foundation for Medical Research is most grateful to the followingpeFons for provision of information and comments on the draft report. The viewsexpressed in the final report are those ofthe Foundation.Dr. Brian Berman, MD, Complementary Medicine Prog.am, Baltimore, MDD!. Stephen Birch, Stichting (Foundation) for the Study for Traditional East AsianMedicine (STEAM), Amsterdam NetherlandsDr. Andrew Vickers, Memorial Sloan-Kettering Cancer Center, New York, New YorkDr. Harald Walach, Universitatsklinikum Freiburg, Institute fur Umweltmedizln undKrankenhaushygiene, Fdeburg, I.BRDr. Adrian R. White, Department of Complementary Medicine, Unlversity of Exeter,Exeter, UK

Alberta He.itage Foundation for Medical ResearchHeahh Technology Assessment


4/67

SUMMARYThis report's objective is to provide an overview ofevidence from systemaricreviews and meta-analyses on the effectiveness ofacupunctule for any conditionthat has been assessed in this manner.Two-thirds ofCanadians used some form ofalternative or complementary medicinein 2000, and l-27o reported seeing an acupuncture practitioner in 1998/99.Acupuncture, in the stdctest sense refers to "insertion of dry needles, at speciallychosen sites, for the treatment or prcvention of symptoms and conditions." It is arelatively safe procedure, but it can lead to both minor (fainting, exacerbation ofsymptoms) and se ous (hepatitis, traumatic injury of body tissue) adverse events.Twenty-three reviews were included: two on dental and temperomaldibulardysfunction (TMD) pain; one on headaches; one on tinnitus; three on asthma; one onstroke rehabilitation; two on antiemesis; ftve on neck/back pain; two on chronicpain; one on fibromyalgia: one on induction oflabour; one on addictions; two onsmoking cessation; and one on weight reduction. Unanimously these reviews callfor higher quality research with greater sample size.Among the studies included in the review there are wide variatlon oftreatmentssuch as manual or electrical stimuladon, number of needles per treatment, techniqueofneedle insertion, and fuequency oftreatment. All ofthese factors may influencethe outcome.Acupuncture was found to be effective for the treatment of dental and TMD painand antiemesis (nausea/vomiting) in comparison to other chosen interventions. Theresults for idiopathic headaches and fibromyalgia were reported as encouraging.The evidence was inclusive for the treatment ofback pain, chronic pain, smokingcessation. and asthma. Effectiveness was not supported by the evidence for tinnitus,stroke rehabilitation, neck pain, addictions, and weight reduction.Dental and TMD pain and antiemesis appear to be two areas in which acupunctureis reproducibly effective. Fo. all other indications the methodology design andquality is either too weak to dmw conclusions, the studies have not been done, or, instudies of better quality, acupuncture does not appear to be more effective thanstandard ofcare or control chosen.Clearly, more research of higher mefiodological quality is called for. Issues ofblinding, the use ofa credible control, varying diagnosis amongst differingphilosophical approaches, and the diversity oftreatment points chosen andtechniques used challenge this particular area olcomplementary medicine.

Alberta Herila8e Foundation for lledical ResearchHeahh Technology Assessment


5/67

Alberta Heritage Foundation for Medical ResearchHealth Technology Assessment l


6/67

Acupuncture Evidence from Systematic Reviews and Meta,analyses

Appendix A: Methodology....................... ....................-.......................24Appendix B: Data Extraction and Quality Assessment oflncluded Studies....................29Appendix C: Quality Assessment Tools.... .......,,,,,,,,.....................,,,..51Appendix D: Crite a for Evaluating Systematic Reviews.,.....,...........................................56Appendix E: Checklist of Data Required in a Complete Report of AcupunctureTreatment......,,,........ .................. 56References................. ................,,,........................ 57Tables:Table 1: Conclusions and quality rating ofthe systematic reviews.................................... 13Table 2: Data extraction and qualitv assessment ofincluded studies ,,,..................,,,,,,,....2g

Alberta Heritage Foundation for Medical ResearchHealth Technology Assessment


7/67

lNTRoDUcTtoNTwo-thirds ofCanadians used some form ofcomplementary or alternative medicine in2000, mostly vitamins 1. Sixteen percent of Canadians saw an altemative health careprovider in 1998/99, and of those people , 160/o (or l-Za/. ol t}Le total population) saw anacupuncturist. In Canada, the incorporation of complementary or alternative medicineinto one's health care regime is more common in the western provinces, in women agedbetween 25 and 44 years, and in those living with chronic conditions 2. Medical schoolsare incorporating complementary and alternative medicine training in their cufficula,with ten out ofsixteen Canadian medical schools providing some exposure toacupuncture 3.A large body of research exists in acupuncture, covedng viftually every symptom a. Inthe 1950's the Central Committee in China was interested in this question andthousands of studies were performed. The results led the Committee to bestow equalrecognition to Traditional Chinese Medicine (TCM) and Western Medicine 5.This project is Part II ofa request from several Regional Health Authorities and AlbertaHealth and Wellness, regarding two key objectives: to present information on theregulation ofacupuncture in Alberta, including the scope ofpractice and coverage ofservices: and to conduct a systematic review of currcnt scientiffc evidence to determinethe effectiveness ofacupuncture, and the conditions lor which it has been found to beeffective. Objective two is addressed in this report.Part I, titled "Overview of the Regulation of Acupuncture in,4lrerra ", addressed the firctobjective and was completed in May 2001 6. In Part I, three categories ofcertification orgovernance were found to be in place: those who are members ofa professional collegeor association (eg. physical therapists) prior to their study ofacupuncture; those whohave completed training in an acupuncture program and have passed a provincialexam; and those who have knowledge ofacupuncture (eg. from another country), butare practicing without a governing body. Acupuncture is usually performed in aclinical setting, and is not covered by the Alberta Health Care Insurance plan. As theinsertion ofneedles will be considered a 'restricted activity' under the new HealthProfessionals Act, these activities will only be allowed to be practiced by thosegoverned by a regulating body.Growing demands on the health care system for provision ofcomplementary medicine,the evolution oflegislation regarding the regulation ofhealth professionals, inconjunction with requests fiom the community for funding coverage for acupuncturetreatment illustrate the importance and timeliness ofthis review.

Alberta Heritage Foundation for Medical ResearchHealth Technology Assessment


8/67

Acupuncture: Evjdence ftom Systematic Revlews and Meta-analyses

ScoPE oF THE REPoRTDue to tlle breadth ofthis topic and the challenge ofreviewing the extensive body ofresearch on acupuncture, the approach of systematically assessing the available reviewswas chosen to evaluate the current evidence for the efficacy ofacupuncture. Inchoosing this approach, it is acknowledged that there are areas in which acupuncture isused that have not been assessed and reported as a systematic review.Though the scope for this report did not limit the search ofscientific evidence to speciffcmedical conditions, systematic reviews meeting methodological inclusion crite a a.rereviewed on the following topics; dentistry, headaches, tinnitus, asthma, strokerehabilitation, nausea/vomiting, neck,/back pain, chronic pain, fibromyalgia, labourinduction, addiction, smoking cessation, and weight/appetite reduction.This assessment will not be comprehensive including all ofthe primary acupunctureresearch, and all the conditions currently heated by acupuncture, but for the systematicreviews and meta-analyses published in English between 1990 and 2001 that met theinclusion criteria (see Appendix A). Primary studies published since the reviews havenot been included; the results from these primary studies may change some oftheconclusions derived at in this systematic review.The findings from this review are summarized by medical condition and the overallresults compared with those from the United States'National Institute of HealthConsensus statements and other systematic reviews of rcviews.There are many issues in acupuncture research that need to be explored and addressedin future studies which a.e pointed out briefly in this report. These issues range fromthe quality and assessment ofmethodology to the appropdate acupuncture treatmentregimen.DEFINITIONAcupuncture. in the stdctest sense, refers to "inseftion of dry needles, at speciallychosen sites for the treatment or prevention of symptoms and conditions" i. TheChinese term "zhenjiu" references both acupuncture and moxibustion. The latter is theuse of a herb, fienrbJa yulgan3 (mugwort) which is burned over the acupuncture site forpurposes of warming L9.Acupuncture is performed with solid needles ranging in length from I cm to l0 cm r0.They are made ofgold, silver, copper, stainless steel, or a combination of metals 10 andmay be inserted under the skin no more than 8 cm deep. As technology evolved it wasapplied to traditional forms ofhealing. Electroacupuncture refers to the technique ofintroducing an electrical curent to the inserted needles at various frequencies. A laserbeam, directed at the acupuncture site and stimulated, has developed into a technique

Alberta Heritage Foundation for Medical ResearchHeahh Technology Assessment


9/67

Acupuncture: Evidence from Syslematic Reviews and Meta-anaryses

called laser acupuncture, Techniques of fire needles involve inserting red-hot needlesat an acupuncture point.Staple puncture is the application ofa metal staple to an acupuncture point where itremains lor a prolonged period of time. Cupping is a technique by which a vacuumforce is applied to acupuncture sites, Bloodletting refers to tie pricking ofthe skin forthe purpose of releasing blood. This may be aided with the application of a cup overthe site. A less lnvasive procedure is acupressure which refers to the stimulation ofapoint manually with pressure with the intention ofstimulating Qi flow. Intramuscularstimulation is a technique of applying needles to areas of tenderness. There is debate inthe acupuncture community over which ofthese techniques fall under the classificationofacupuncture.'De qi' is the sensation ofnumbness, tingling, electrical sensation, fullness, distension.soreness, warmth, and itching which may be felt subjectively around the acupuncturepoint 8. The practitioner may have a sensation of tenseness or dragging to the needle 11.This sensation may be sought by some practitioners through twirling, plucking, orthrusting ofthe needles. In Western terms these are signs that A-delta fibers areactivated r0. In TCM this indicates that the Qi has affived. There is controversyamongst practitioners ofacupuncture as to whether it is necessary to elicit this sensationro render the rreatment effective 8.CoMPLICATIoNS oF AcUPUNCTUREAcupuncture is a relatively safe procedure, but it can also lead to both minor andse.ious adverse events. There is an increasing amount ofliterature on adverse effects ofacupuncture; however, there is still a concem about under reporting in the studies ofthe more minor adverse effects ofacupuncture.Norheim's study ofthe literature from 1981 to 1994 examined 78 case reports (N= 193treatments) of adverse effects with needle acupuncture 12. He classified thecomplications as mechanical organ injuries such as pneumothorax (n=23) and medullaspinalis injury (n=13); infections such as hepatitis (n=100) and auricular chondritis(n=16); and other effects such as argyria (n=5) and problems with implanted needles(n=5). Many ofthe effects seem to be linked to practitioner competence, or patients'ongoing health conditions.White et al. and MacPherson et al. both examined the adverse events occurring withacupuncturists in the U.K., in over 32,000 and 34,000 consultations respectively 13,1r. InMacPherson et al, no serious adverse effects were reported, as defined as requiringhospitalization, or leading to permanent disability or death. and there was a rate of1.3/1000 consultation of minor adveEe events such as severe nausea and fainting.White et al. also found no serious adverse events in theb study. Significant minorevents such as fainting, lost needles, and exacerbation of symptoms were reported at arate of l4l10,000 consultations. In addition, both studies reported on'minor events'orAlbena Heritage Foundation for Medical ResearchHealth Technology Assessment


10/67

Acupuncture: Evidence from Systematic Revieu,s and Meta,analyses

'mild transient reactions' occurdng in a much larger percentage ofthe beatments,though these were not considered significant.Using combined data from published literature, Ernst rs found that the most commonlyreported adveme events were drowsiness and fainting, increased pain, nausea/vomiting, and infections. Infections, including Hepatitis C, were usually due tousing,/reusing unstedle needles, or practitioner error. In a 2001 systematic review byEmst and White on tie safety of acupuncture they reviewed nine studies, whichincluded almost 250,000 treatments 16. Thirty-eight percent of all patients experiencedbleeding and 45% experienced an aggmvation of pain symptoms. Overall 28% ofpatients expe enced some adverse effect, serious effects were rare, as supported bytheir systematic review of life threatening adveme effects in 1997 r?.Across the studies common mild or 'non-significant' adverse effects included pain atthe needling site, nausea, bleeding, aggravation ofsome symptoms and faintness orfatigue 1315 17 r8. Infections, such as hepatitis. were often due to poor hygiene techniquesuch as reusing unsterilized needles. Some cases oftraumatic injury ofbody tissueincluding pneumothorax, cardiac tamponade, spinal trauma, and hematoma re havealso occurred usually due to practitioner eror.Some key challenges identified in consistent reporting ofadverse effects aresummarized by Emst and White 10. The method of defining adverse events and ofcollecting/reporting ofthese events diflers across the studies. As well, the style ofacupuncture differs across cultures and practitioner groups, which have differing risklevels for adverse events. Finally, the rate ofadverse events may vary according to thecondition being treated, and the body part being stimulated during that treatment.Yamashita et al. suggest that a distinction should be made between the reporting ofresults due to negligence and those due to adverse events ofthe acupuncture techniqueitself r8.The studies' conclusions are consistent in that they found that the mte or incidence ofserious adverse events due to acupuncture treatment is low but that they dooccur 12 13 15 18. Acupuncture is not free of risk. it is important to track and report minorside eflects as they may progress into a more serious event. Ifthere is not a consistentand thorough process for reporting these events, the evidence on adverse effectsremains limited and incomplete. MacPherson and colleagues ra stated that the adverseevent mte, when compared with primary care drugs, suggests that acupuncture is arelatively safe treatment. and many researchers concur that it is a relatively safetechnique 12.15.16.FtNDtNGSOf the thirty three studies selected, twenty-three systematic reviews met the inclusioncriteria, including five Cochrane Reviews (see Appendix A). A table of data extractionand quality assessment ofincluded systematic reviews can be found in Appendix B.Though there is growing debate as to whether the Cochrane Reviews should continueAlbefta Heritage Foundation for Medical ResearchHealth Technolo&y Assessment


11/67

Acupuncturet Evidence from Systematic Reviews and Mera-analyses

to be a 'gold standard' for systematic review methodology, they curently have themost rigorous methodology, and therefore, a quality assessment ofthese reviews wasnot undertaken 20. The other reviews were assessed using criteria based on those set outin Greenhalgh 21 (see Appendix D). Though this quality assessment may not be asrigorous as initially intended by its authors, it has been consistent across the reviews.Once agreed upon criteria have been developed for the assessment ofthemethodological quality ofprimary studies in acupuncture, the same approach shouldbe taken for the assessment ofsystematic reviews.The methodology of a review was considered to be satisfactory if it contained a conciseresearch question(s) and inclusion criteria, an adequate search strate$/, and included aquality assessment evaluation 22 28. If a review also attempted to integrate andlorstatistically analyze the data, it was considered to be of good quality 2e-36. The rest of thereviews were considered to be ofpoor methodological quality 37 3e.Dental and temperomandibular painTwo reviews focused on dental pain, temperomandibular dysfunction (TMD) and facialpain. Eight ofthe l6 studies reviewed by Ernst and Pittler 24 regarding dental pain werealso included in Rosted's review 22. In Emst and Pittler, eleven studies examined paindue to dental surgery and five studies evaluated pain induced in an experiment.Methodological quality was assessed using the Jadad Scale 40 (Appendix C). Thoughthe authors state that the heterogeneity oftreatments and low quality ofmany ofthestudies reviewed limit the conclusions that can be drawn, the data suggest thatacupuncture can be effective in the treatment ofdental pain. The method and regimenofacupuncture that most eflectively rclieves dental pain. however, remains unclea..Rosted's review 22 examined seven studies on pain associated with tooth extraction andeight studies on TMD/facial pain. Overall the review's methodology was fairlydgorous. Descriptions ofthe treatment and practitioner's qualifications were assessedas part ofthe quality assessment, but these details were not presented.Eleven studies indicated that acupuncture was effective and seven ofthese studies wererated at a high level due to their methodological quality. Rosted concluded that most ofthe studies suggest that acupuncture is effective in controlling dental and TMD,/facialpain. He stated concerns, however, about the clinical relevancy ofthis treatment as asurgical analgesic, as the time needed for acupuncture to take effect was much longerthan other analgesics.HeadacheOnly one review met the inclusion criteria.al. This Cochrane Review addressed thequestion whether acupuncture was more effective than no treatment. sham or othertreatments used for headache ol three types: mig.aine, tension. and mixed. The JadadScale 40 was used to assess study quality (Appendix C) ofthe 26 RCTs (16 RCTs formigraine headaches, six RCTS for tension type headaches, and four RCTs for variousAlberta Heritage Foundation for Medical ResearchHealth Technology Assessment


12/67

Acupuncture: Evidence from Systematic Reviews and Meta-analyses

headache types). Evaluation ofthe appropriateness ofacupuncture point selection wasundertaken by someone trained in both Western and TCM acupuncture.Sham'controlled studies for migraine and tension type headaches, reported favourableresults for acupuncture, though the methodological quality ofmany ofthe studies wasrated as weak. There were a small number of studies for all types of headachesindicating mixed results for acupuncture compared with each of physiotherapy, drugs,and massage/relaxation.Four out of 16 studies evaluating the effectiveness of acupuncture for the treatment ofmigraines were rated at a high level in relation to their methodological quality. Of thesefour studies, two studies showed a benefit from acupuncture, one study showed nodifference in comparison to sham acupuncture, and one study noted that acupuncturewas less effective when compared to standard care.For tension-type headaches, two out ofthe six RCTS were rated as high formethodological quality. These two studies indicated that acupuncture was effective forthe treatment of tension type headaches.The authors stated that acupuncture appears relatively safe when administercd byqualified providers- Although the type of acupuncture used and whether it should bewidely recommended could not be answered by the evaluators, and patients wishing totry it should not be discouraged.TinnitusOne systematic review focused on acupuncture as a tleatment for tinnitus. Park et al. 23identified six RCTS which compared electro or manual acupuncture in the treatment oftinnitus to sham, physiotherapy, biofeedback, or medication. Park and colleaguesevaluated methodological quality using the Jadad Scale {0 (Appendix C). The type ofacupuncture stimulation and number ofsessions were described but not theappropriateness ofthe acupuncture treatment. Four studies found no effect ofacupuncture on tinnitus; three ofthese studies achieved passable methodologicalquality scoring by the Jadad criteria. Due to the low methodological quality overall, theheterogeneity of the samples. and the ffndings of'no effect', the conclusion of thercviewerc was that evidence did not support the use ofacupuncture for the trcatment oftinnitus.AsthmaTwo systematic reviews assessed the effectiveness of acupuncture in the treatment ofasthma, in addition to a Cochrane Review. Kleijnen and colleagues 28 reviewed 13 RCTsthat were based on needle acupuncture. They reported on the style ofacupuncture (allbut one were based on formula acupuncture) but did not evaluate the appropriatenessofpoints chosen. The methodological quality of the 13 studies was rated on theKleijnen scoring system (see Appendix C). No studies of high enough quality werefound to conclude ifacupuncture was effective in the treatment ofasthma.Alberta Heritage Foundation for Medical RsearchHealth Technology Assessment


13/67

Acupuncturer Evidence from Systematic Reviews and Meta analyses

In 1996 Linde and his colleagues published a review 2e of 15 tials including all but twoofthe studies included in the Kleijnen et al. review. These excluded studies were not.andomized trials. They were concemed that there had been no evaluation as to theappropriateness of point selection; therefore four physicians who also taught andpracticed acupuncture evaluated the appropriateness ofthe acupuncture points chosen.There was vadability in the assessment of adequacy oftreatment choice, but none ofthestudies were evaluated as being totally inadequate. Jadad's scale a0 was used as well asLinde's own scale to assess methodological quality ratings and were compared to theratings obtained in the Kleijnen scoring system (Appendix C). More similarity wasfound between the Linde and Kleijnen ratings than those of Jadad. They concluded thatthere was insufficient research ofhigh enough quality to recommend to acupuncturiststo stop treating asthma patients, nor to recommend to non-acupuncturists to start itsuse,A Cochrane Review by Linde, Jobst and Patton {2 using similar inclusion criteria waspublished in 2000. Seven studies matched the criteria and were evaluated using theJadad Scale. One ofthe authors was experienced in acupuncture and evaluated theadequacy ofthe sham-acupuncture, but not the appropriateness ofthe acupuncturetreatment. Objective measurements for lung function were included as well as druguse. Subjective results were also accounted for in these studies. They concluded thatthe efficacy of acupuncture for asthma can not yet be determined.Although there were a variety ofcriteria used to evaluate the methodological quality ofthe studies, the results obtained were consistent in stating that the evidence did notsupport or refute the use ofacupuncture in the treatment of asthma.Stroke rehabilitationA review by Park and colleagues 2s included nine RCTS comparing needle acupunctureto standard medical and rehabilitative treatments or sham electro-acupuncture, Thesearch included more than one complementary database, and study quality wasassessed usingJadad's Scale {0 (Appendix C). They identified variability in treatmentschedules, types ofstimulation, time ofinitiation ofacupuncture, acupuncture sites, anduse of quality of life measures. Numerous different stroke assessment scales were usedin the primary studies to measure the outcome, challenging the ability to makecomparisons between the studies. No mention was made of the evaluation of theappropriateness ofteatment, although the duration ofheatment and whether it wasmanual or electroacupuncture was documented. The authors found the quality ofstudies to be poor (only two studies obtained a Jadad score of 3 or more) and stated thatthe evidence does not support the use ofacupuncture for stroke rehabilitation, thoughthe findings show some promise.Nausea and emesisPeiicardium 6 (P6) is used in the treatment of post-operative nausea and vomiting(PONV). Two systematic reviews evaluated the effectiveness ofP6. TheLeeandDoneAlberla Herilage Foundation for Vedical ResearchHealth Technology Assessmnt


14/67

Acupuncture: Evidence from Systematic Reviews and Meta'analyses

meta analysis 30 included 19 studies that evaluated post-operative nausea and vomitingby comparing acupuncture andlor TENS to a control group receiving eitier shamacupressure or treatment or a pharmacological intervention. No specificcomplementary database rvas searched to locate primary studies nor was there a statedsearch ofthe grey literature. Eleven ofthe 19 studies scored three or better onJadad'sScale a0 (Appendix C). though there were many issues noted that hindered comparison,including diversity of techniques used for stimulation of the point. Acupuncture wasnot deemed effective in the control ofnausea and vomiting in the pediatric population.P6 stimulations fo. early or late PONV compared to pharmaceutical treatments wasreported to have an equal effect, and when compared to sham or no treatment wassupedor in 20% to 25% ofadults within 6 hours oflaparoscopic and gynecologicalprocedures. There was inadequate data to determine effects oftreatment versus shamfor late PONV.Vickers' review 31, which included a complementary database in the search strategy,identified 33 studies and evaluated the methodological quality using the Vickerc Scale a0(Appendix C). They divided the studies into nausea and vomiting post-operatively,following cancer chemothe.apy, and morning sickness. A diveNity of treatments wereassessed in the primary studies such as acupressure, electroacupuncture. needleacupuncture, TENS, and acupoint injections. Using acupuncture while underanaesthesia was found to be ineffective at controlling emesis, in four studies. All buttwo ofthe remaining 29 studies reported a positive effect for acupuncture in P6anti-emesis. The author concluded that PO stimulation seems to be effective exceptwhen it was administered under anaesthesia.Back and neck painFive systematic reviews, including a Cochrane Review, examined the efncacy ofacupuncture for the treatment ofneck or back pain. White and Ernst 33 reviewed themethodological quality of 14 RCTS on the treatment of acupuncture in neck pain usjng amodified Jadad Scale. The initial diagnosis varied, including ankylosing spondylitis,myofascial pain, osteoarthritis, and pain ofundefined etiology. The method ofacupuncture treatment varied, although most studies used formula acupuncture. Thecontrol groups varied. including sham needling, TENS or laser, physiotherapy, waitingIists, and medication. These reviewers were ofthe opinion that there was no evidencef.om sound clinical trials to support the use ofacupuncture for neck pain.The Smith et al. review 32 examined the use ofacupuncture on traditional andnon-traditional points for chronic neck and back pain in l3 RCTs. Eleven RCTsevaluated the effectiveness ofacupuncture in chronic neck or back pain and two studiesassessed acupuncture lor acute low back pain. They used theJadad Scale a0 to assessmethodological quality and also tested their own tool, the Oxford Pain Validity Scale(OPVS) in the review (see Appendix C). There was no assessment as to appropriatenessofacupuncture site selection. Nine out of II studies used multiple treatments forchronic neck and back pain. Acupuncture, electro acupuncture or laser acupunctureAiberta Heritage Foundation for Medical ResearchHeal!h Technology Assessmenr


15/67

Acupuncture: Evidence from Systematic Reviews and Mera-analyses

was compared to sham, needling. laser, or TENS, waiting lists, or standard clinicaltherapy. Most of the studies on chronic neck and back pain found either no differencebetween acupuncture and control treatments, or found an initial positive effect foracupuncture, but often after 24 hours there was no significant difference between thetreatments. The two studies examining acute low back pain after a single treatmentwere evaluated to have no benefit over sham or acupressure with anaesthetic spray.The conclusion ofthe reviewerc was that there was no evidence to support thetreatment ofback or neck pain by acupuncture.Using methodological cdteria adapted from Koes (see Appendix C), Strauss 26 reviewedresults from four controlled clinical trials for chronic low back pain (LBp). There wasno evaluation olthe appropriateness of the acupuncture treatment, although thediscussion did address many ofthe problems associated with the assessment ofacupuncture including the skill of the acupuncture provider. Three of the studiesreported positive results for acupuncture, however these were ofpoor methodologicalquality. The heterogeneity of patients and treatment methods, and practitionerqualifications, made drawing any conclusion regarding the effectiveness ofacupuncturein chronic LBP difficult. Though the author believed that acupuncture was a safe andpopular treatment for LBP, he recommended that rigorous research was needed todetermine the most appropriate treatment methods for specific conditions ofLBp.Ernst and White 36 included 12 RCTs (9 into the meta-analysis) on back pain.Methodologically this review was rigorous, with good data integration and assessmentof trcatment adequacy. Acupuncture was shown to be superior to waiting list andphysiotherapy but was not found to be superior to placebo except in one study onsevere pain. Odds ratios for unblinded studies suggested a strong placebo effect. Theyrecommended that further studies explore the specific and non-specific effects ofacupuncture, as well as the adveme elfects and cost-effectiveness ofthe varioustreatments for back pain. to assist in determining the usefulness ofthese therapies.The Cochrane Review by van Tulder 8 examined l1 RCTS on the effect of acupuncturein chronic and acute lower back pain. This review followed the Cochrane Back ReviewCroup's rules for assessing methodological quality (see Appendix C). No assessment asto appropriateness of trcatment was made. There was conflicting evidence from lowquality trials comparing acupuncture to no treatment, moderate evidence thatacupuncture was not more effective than TENS or trigger point injections. and limitedevidence that acupuncture was not more effective than sham for the treatment ofchronic LBP. Overall this review reports that the ellectiveness ofacupuncture in t1-retreatment ofLBP was unclear and, since there are effective altematives, the authors donot.ecommend acupuncture as a regular treatment for LBp.Chronic painTwo reviews focused on the effectiveness ofacupuncture for the treatment ofchronicpain. The appropriateness of treatment was not evaluated in either review.Alberta Heritage Foundation for Medical ResearchHealth Technology Assessment


16/67

Acupuncture: Evidence from Systematic Reviews and Meta analyses

The review by Ezzo et al. 3a used the Jadad Scale (see Appendix C) to evaluate 51 RCTSin which patients with pain longer than 3 months were treated with needleacupuncture. The review assessed the number offieatments, number ofpoints needled,eliciting of'de qi', and type of acupuncture (whether formula or individualized). On$'number oftreatments' seemed to be co.related with a positive outcome. The authorsfound that the control group participants in studies using sham acupuncture (needleswere inserted) as the control had a proportionally higher improvement rate comparedto the control group participants in studies using inert controls such as, TENS, sugarpills, and mock acupuncture (in which needles were not inserted), This led the authorsto propose, amongst other possibilities, that sham acupuncture was not physiologicallyinert. They stated that they found limited evidence that acupuncture was moreeffective than waiting lists and the evidence was inconclusive on whether acupuncturewas more effective than physiologically inert controls, sham acupuncture, or standardThe ter Riet. Kleijnen and Knipschild's meta-analysis 3e also evaluated 51 studies usingneedle acupuncture (excluded surlace electrodes or laser acupuncture). but thesestudies included patients with chronic pain of at least 6 months duration. Theyassessed methodological quality based on criteria developed by ter Riet and colleagues(see Appendix C) and found that further research needed to be conducted with morehomogeneous study groups, and better methodological design. The reviewers statedthat there are no published studies ofhigh enough quality and that the efficacy ofacupuncture lor this condition remains inconclusive.FibromyalgiaOne review addressed the use of acupuncture for the trcatment of fibromyalgia 27. Thereviewers used the Jadad Scale to rate the methodological quality ofthe studies (seeAppendix C). They did not, however, identify the style (eg. classical TCM or formulaacupuncture), appropriateness of treatment, or the qualifications of the acupuncturepractitioner. The authors based their conclusions on one high quality RCT, whichfound signiffcant improvement in both subjective and objective pain measurescompared to sham acupuncture but the duration of benefit was unknown. A lewpatients had woNening of symptoms during the treatment with acupuncture. Theystate that their review may provide some practical information for practitioners onpossible benefits and risks ofacupuncture. Based on limited evidence, acupuncture ismore effective than sham acupuncture for improving symptoms (pain relief. reducingmorning stiffness, increasing pain threshold, and improving global ratings) in patientswith fibromyalgia syndrome.ObstetricsA Cochrane Review was conducted by Smith and Crowther a3 to determine the effectsof acupuncture lor the induction of labour. The authors noted that there were limitedobservation studies published that suggested acupuncture appeared safe and effective.Alberta Heritage Foundaljon for Medical ResearchHalth Technology Assessmni 10


17/67

Acupuncture: Evidence from Systemalic Reviews and Meta-analvses

None ofthe published trials, however, met the inclusion c teria and the authorssuggest the need for a well-designed RCT.AddictionsTer Riet and colleagues 38 conducted a meta-analysis that included 2Z studies. eualityof studies was assessed using criteria developed by the authors (see Appendix C). Theoutcomes assessed, however, were not clearly defined in terms ofaddiction treatments,as they were only stated as the cessation of smoking. use of heroin, or use of alcohol. Inaddition, no biochemical vedfication of cessation,/abstinence was included.Fifteen ofthe 22 studies examined the use ofacupuncture (excluded surface electrodesor laser acupuncture) in smoking cessation and reported acupuncture as not effective incomparison to placebo; however placebo treatment was not identified. Five studiesreviewed the use of acupuncture in hercin addiction. The methodological quality of allfive studies was rated as low and therefore it was difficult to draw any conclusions.Two studies using acupuncture for the treatment ofalcohol addiction reported apositive effect for acupuncture reatment but these studies suffered from high drop-outrates. No mention was made ofthe appropriateness ofthe acupuncture points used inany ofthese studies. though the practitioner and treatment description were assessed aspart of the quality assessment. The conclusion lrom this review was that the evidencedoes not support the use ofacupuncture in the treatment ofaddictions.Smoking cessationTwo reviews examined acupuncture in the treatment ofsmoking addiction; theCochrane Review by White and colleagues aa and a meta analyses by White et al. 35. TheCochrane Review included 18 RCTs in which smoking cessation was the outcome.Acupuncture was compared to sham acupuncture or an alternative form ofcessationintervention or to no inteNention. There was no assessment of appropdateness ofacupuncture sites chosen, but the treatment regimen was descdbed in the primarystudies. Only four studies reported any form of biochemical validation of smokingcessation. Three studies indicated strong positive results for acupuncture in thetreatment olsmoking addiction. In two ofthese studies prolonged auricularacupuncture was applied. The authors proposed that perhaps more rigourous studyinto the effects ofintensive and continuous treatment was warranted. As \a,ell. theysuggested the importance olstudying acupuncture effects during acute nicotinewithdmwal. The review concludes that acupuncture was not superior to shamacupuncture. Compared with other anti-smoking interventions there was no differencebut early results indicated it was superior to no intervention.The meta analysis 35 of 14 RCTs (12 RCTs sham-controlled) was thorough and methods.as well as limitations, were clearly stated. The authors came to the same conclusions asthe Cochrane Review that there was no evidence that acupuncture was more or lesseffective than sham acupuncture or other smoking cessation interventions.

Alberta Heritage Foundation for Medical ResearchHealth Technology Assessmenr 11


18/67

Acupuncture: Evidence from Systematic Revie$,s and Meta analyses

Weight lossOne systematic review on the eflectiveness of acupuncture and acupressure in weightloss and hunger suppression was identified 37, Four sham-controlled clinical trials wereassessed by an "accepted instrument" used by Kleijnen, Knipschild, ter Riet (seeAppendix C), One study used an acupressure device. while all other studies usedvarying auricular points. The conclusion of the reviewers was that fufther, welldesigned research needs to be conducted to provide sufficient evidence regarding theeffectiveness ofacupuncture in appetite or weight reduction, but that there curentlywas no convincing evidence to support the effectiveness of acupuncture for weight lossor hunger suppression.SummaryFor the various conditions listed in Table 1, the respective reviews found that theevidence supports acupuncture as an ellective treatment for dental pain, andnausea./vomiting. Though the evidence for the other conditions such as idiopathicheadaches, back pain, chronic pain, and fibromyalgia was often inconclusive due tomethodological weaknesses, andlor conflicting results reported by the primary studiesincluded in the reviews, the results look promising. These reviews. the majority with agood quality rating, found acupuncture to be as effective in the short term as theconventional interventions or no t.eatment for these conditions. Many of the authonnoted that better quality studies provided negative results while poorer quality studiestended to report positive results. Furthermore. they agreed that there appeared to beinsufficient evidence and that better quality research was needed.

Alberta Heritage Foundation for Medical ResearchHalth Technology Assessment t2


19/67

Acupuncturc: compilalnxt ofsystonralic ft:vicws ancl mcra analyscs

Table 1: Conclusions and quality rating of the systematic reviewsCondition Review Conclusions Quality Rating

Dental and TMD Ernst E, Piltler MH'?a1998 Acupuncture can be effective in alleviating dentalpain SalisfactoryRostad P " 1998 Acupuncture was more effeclive than sham and had a similareffect as conventional lreatment SaLisfactoryHeadache Lindc K, et al. a12001

Evidence supported the value of acupuncture for the treatmenlof idiopalhjc headaches bul1he quality and amount of evidence isnot convirlcing

Cochrane Review

Tinnitus Park J, et al.'z32000 Evidence of efficacy does not suppod acupuncture for thetrealmenl of chronic tinnilus SatisfacloryKleilnen J, et al.1991 Efficacy not supported by the resulls ofwellperlormed cljnical SatisfactoryLinde K, et al.'zs1996Linde K, et al. a'z2000

lnsufficaent evidence to draw reliable conclusionsNot enough evidence to make recommendations aboutlhe valueof acupunctureSlroke Park J, et aI. 'z52001 Evidence does not support acupuncture in stroke rehabilitation Satisfactory

Nausea and Emesis19991C96

Evidence indicates signjficanl reduction in adults ve6us no-te3!!9!!q9rp{?!lqr99q!!!lqgqsi!!t9 qssAcupuncture seems to be effective exceptwhen it is administeredGoodGood

Back and Neck Pain White AR, Ernst E 3l1999Ernst E, While AR 361C98

Evidence from clinicaltrials does not suppot the {realment of.neck painCombined results indicaled lhat acupuncture for back pain wasglp-e,ILoIlg SqlllgLlllgrvenlions but not to sham

GoodGood

Smith LA, et a|.322000 Evidence from valid trials indicates no analgesic efficacy for neckand back pain GoodStrauss AJ 261S9S Efficacyfor chronic low back pain has not been demonstrated bygood clinicalstudies SatisfactoryVan Tulder I\,4W, et al.u 2oo1 Evidence indicates that acupunclure is not proven effective forthe treatmenl ot low back Dain

Albcrla Ilcrilagc Irou'rda(ion for M{{iical ltcsearchHcalth Tcchnology Asscssmcnt l3


20/67

Acupu cturci Ividdrcc trom Syslomatic Rcvi{}ws and Mcta anatysos

Table l: Conclusions and quality rating of the systemaiic reviews (cont,d)Condition Review Conclusions Quality Rating

Chronic Pain Ezzo J, et at. 3a2000 Limited evidence indicates that acupuncture is more effectivethan no lreatmenl; inconclusive that it is more effective thansham, standard care or inerl conlrolsGood

ter Riel G, el al. 3'g1990 Efficacy of acupuncture in chronic pain (at leasl6 monlhs)remains doubtlulBased on one good quality triatthe evidence jndicated significantsymptom improvement compared to sham but duration of benefitwtl4!9!!Observalional studies provided promising findings but norandomired controlled studtes were lo.atedEfficacy for smoking, heroin and alcohotaddiclions are notsuppotled bv evidence lrom qood chnicdl studies

Fibromyalqia Berman BM, et al. 271999 SatisfactoryObstetrics Smith CA. CrowlhercA 43 2oo1 Cochrane ReviewAddictions ter Riet c, et al- 331990

2000 Evidence indicates that acupunclure does not appear to beeffeclive for smokinq cessalion Cochrane ReviewEvidence indicates that acupuncture appears to be better inlreatino smokino a.l.liclions c6mnarp.i 1^ thnaa ^n 'lrifinn riclc GoodWeight Reduction Ernst E 371997 Based on two rigorous sludies there was no elfcct on body

Albcrta Ilcritage Foundation for Modical RcsoarchHcallh l cchnology Asscssrncnt 14


21/67

Acupuncture: compilation of systematic reviews and meta-analyses

OTHER REVIEwSSystematic reviews are a synthesis and critical appraisal of p mary studies andtherefore play an important role in evidence-based decision making. Many of theprimary studies included in a systematic review may not be easily accessible to anumber ofpmctitione$ or busy practitioners may not have time to read all thepublished research, hence the value of systematic reviews. A main limitation of thissystematic review ofsystematic reviews is that it did not take into account the evidencefrom new research that may add to or change the conclusions. For example, since thepublication ofthe systematic review by Park and colleagues 25 on the eflectiveness ofacupuncture for stroke, a sham controlled study considered ofgood quality, indicatednegative results. The addition of this study to the systematic review would strengthenthe evidence to recommend against the use ofacupuncture for this indication.In 1997 the National lnstitute of Health held a2 ^nd,1/2 d,ay conference on acupuncturespecifically to evaluate the scientific data on the conditions, sks, and benefits. Theystated that there seemed to be potential usefulness based on the studies but, due toflaws in design, sample size, and other factors, the results ofthe research were oftenequivocal. The role of acupuncture in nausea and vomiting resulting f.omchemotherapy as well as post-operative surgical and dental pain appeared to have someof the best evidence. They also acknowledged that there are many other conditions forwhich acupuncture may be useful as an alternative or adjunct treatment. Theirconcluding comments focused on the issues oftraining and licensure, summadzing thatthere was sufficient evidence to support further research and integration intoconventional medicine a5. Based on these results Medicare does not cover acupunctureservices. The coverage and analysis group, however, a.e open to receiving furthe.evidence on the efficacy ofacupuncture (informed placement ofneedles with orlvithout twirling, but not with electrical stimulation or moxibustion) for post operativechemotherapy pain and nausea in adults and post-operative dental pain for dentalconditions covered by Medicare 46.Ernst and White { reviewed seven systematic reviews on the effectiveness ofacupuncture for dental pain, low back pain, neck pain, osteoarthritis, stroke, smokingcessation and weight loss. They concluded that there was strong evidence on theefficacy of acupunctu.e for dental pain, low back pain, and nausea/vomiting. Inaddition, they stated the need for .igorous research by experts in the field, and lundingsupport to allow for the expansion of acupuncture .esearch.Linde et al. a7 published a bibliography ofsystematic reviews in acupuncture. Thereviews they included were on the lollowing topicsr chronic pain, headaches,dental/TMD pain, rheumatic diseases, addiction, nausea, asthma, tinnitus,weight,/appetite reduction. and stroke rehabilitation. They only found convincingevidence in support of acupuncture for postoperative nausea and against acupuncturefor smoking cessation. They also concluded that there were key issues aroundAlberta Heritage Foundation for Medical ResearchHealth Technology Assessment 15


22/67


methodological problems, lack ofresearch infrastructure and funding for research andpointed to the complexities ofacupuncture as a group oftreatments for many andvadous medical conditions.A final review by Vickers as published in the fall of200I looked ar effectiveness in thetreatment ofacute pain. chronic pain, addiction, astima, nausea/vomiting, obesity,stroke rehabilitation, tinnitus, and various other conditions. They found acupuncture tobe effective for postoperative and chemotherapy nausea/vomiting. and postoperativedental pain. They also found that the evidence for acupuncture in obesity, sm;kingcessation and tinnitus suggested it is 'unlikely to be of benefit'. For the otherconditions, the evidence was insufficient to support any conclusions.Comparison ofthese reviews with this report finds consistent support for theeffectiveness of acupuncture in the treatment ofpostoperative nausea,/vomiting, anddental pain.lssuEs tN AcupuNcruRE TREATMENT AND REsEARGHMany issues have arisen with regards to developing a study model for acupunctureresearch. Three key areas will be discussed:. selection ofcontrol groups;. complexities of acupuncture; and. study design and assessment of methodological quality.Selection of control groupsThe use ofa control group is a key part ofclinical trials. It is the comparator group forthe experimental group receiving the treatment being investigated. The selection of'credible' controls a.26, ae,50 poses a challenge for acupuncture research as controls canrange from placebo or 'sham' controls, to standard care, to no treatment at all. The useofstandard care or no treatment versus placebo or sham, and the effects of some .sham'techniques on outcomes. are issues ofdebate in the literature 51.52.Vickers and de Craen reviewed methodological literature and provided a summary ofarguments for and against the use ofplacebo controls in acupuncture 52. placebo useenables blinding and potentially decreases drop out rates ofpa.ticipants in ,knowncontrol groups'. Non-placebo control groups can have a higher drop-out rate, becauseparticipants know they are not receiving treatment. Vincent and Lewith suggestroutine assessment of control g.oup members' perceptions oftheir treatments through a'credibility scale' 53. The aim is to reflect patient perceptions olefficacy oftheirtreatment, and therefore the credibility ofthe placebo control.Streitberger and Kleinhenz have developed a 'placebo needle', which mimics the visualand tactile sensations ofacupuncture with a needle that does not break the skin, butdisappea$ into the handle 5a. Irnich et al. used'sham' laser acupuncture with visualAlberta Heritage Foundation for Medical RsearchHealth Technology Assessment 16


23/67

Acupuncture: Evidence from Syslematic Reviews and Meta-analyses

and acoustic signals similar to those found during active laser acupuncture ss. Theseplacebo or sham controls increase the patient's perception ofactually receivingacupuncture treatment, and also enables double-blinding.Placebo or 'sham' were defined in the studies included in the systematic reviews asusing non-traditional acupuncture points, superficial puncturing ofthe skin withoutstimulation, introduction ofa sensation without puncturing (eg. acupresssure), or, inthe case of elechoacupuncture, the use ofelectro stimulators without connecting thecables s. 'Sham' acupuncture, the most commonly used control in acupuncture studies,is where needling is done at theoretically irelevant sites t3.50. It was initially believedthat acupuncture at these sites would have no effect, but many people now believe thatinserting a needle anywhere in the body or applying pressure to any site evokes aresponse s2. s3, 57. This evocation of response can also be found with other placebocontrols mentioned. Others believe that there is a strict process to ensuring that'sham'is truly placebo. based on where the needling is done in relation to the treatmentaCuPuncture 56.The specific and nonspecific effects ofsham techniques are unclear. For example, ifthesham control group also shows benefits, the acupuncture featment may be deemedineffective in comparison to the 'control' group; however, this may be misleading ifthe'sham' featment was actually evoking a physiological response similar to theacupunctu.e treatment group. Though this does not clarify the issue around placebocontrols, it does illustrate the complexity, and the impact ofindividual trcatment styles.Though the effects, both specific and non-specific, of acupuncture at various sites needto be determined, the value ofsham acupuncture as a control is clear: the patients canthen be blinded to treatment, 'improving' the quality ofthe research study 58. Thechoice ofcontrol group in acupuncture research. Iike in conventional medicine research,needs to be guided by the research question. and the objectives ofthe research 52.Complexities of acupunctureAcupuncture is a complex 'umbrella' oftreatment apprcaches. Acupuncture includessuch a diverse constellation ofphilosophies and treatment styles. This means the mostaccurate determination ofeffectiveness of acupuncture should include the evaluation ofeach single, well-defined approach, versus evaluating the 'umbrella' oftreatments as asingle approach 58. However, the many types and methods of acupuncture are oftencombined and compared in the systematic reviews. For example, manual stimulationand electrostimulation have seldom been compared to each other as to theireffectiveness, but are considered the same in many systematic reviews.As well, many microsystems are used in treating varying conditions. Ear acupunctureis perhaps the most widely used, although other systems such as scalp, hand, foot, nose,and abdominal acupuncture are also considered specialties. Formula and TCMacupuncture are two diiferent styles. which are also often grouped together in reviews.TCM focuses on a balanced system. It uses point selection based on symptoms, pulse,and tongue diagnoses, and the choice of points used may vary from day to day as theAlberla Heritage Foundation for Medicai ResearchHealth Technology Assessment 17


24/67

Acupuncturet Evidence from Sysrematic Reviews and Meta analyses

balance shifts. The "formula" or standardized approach in which the same prescriptionofpoints are used for each patient repeatedly is better suited for research, but perhapsnot reflective ofactual experience 5.7.The individualization of diagnosis and treatment may be more similar topsychotherapy or physiotherapy where the skill ofthe therapist and the bond with thepatient are as important in producing an elfect as the treatment strategies 7.ae. Thempyis adjusted according to the subtle shifLs as they occur rather than continuing with astandard pattern. There have not been studies to elucidate the effectiveness ofany oneofthese acupuncture approaches over the other or whether they are equal in their effect.yet they are compared against placebo or sham in studies.There is also variability in the technique ofneedle insertion and manipulation that mayinfluence the efficacy but are often not reported in studies. Electrical or manualstimulation may alter the outcome. Diameter. length, depth of insertion, duration ofretention, the number of needles pe. treatment, tempemture ofthe needles, the numberoftreatments, and materials ofthe needles may all be factors which influence theOUtCOme 7,49.Linde et al. 2e included four expert opinions in acupuncture to evaluate the adequacy ofthe acupuncture treatments from a clinician's percpective. They were given aquestionnaire to evaluate the choice ofacupuncture points used in the studies. Linde etal. found a low level olagreement bet$,een the four experts and posed questions ofclinical relevance.Few researchers have investigated what adequate acupuncture treatment is, due to thecomplexity described above, and little agreement has been reached for the variousconditions treated with acupuncture. Birch broke this challenge down into theadministration ofadequate treatments, and the adequacy ofthe repo.ting ofthetreatments 5r. The difnculties in determining adequate treatment can be captured by thefollowing: Which sources,/evidence does one use? Can the treatments from a study bestandardized to a broader population, or is it specific to those individuals? How manytreatment points and sessions are the correct number for certain conditions? Is thecondition used alone or in conjunction with any other modes oftreatment? sr. The issueofinadequate reporting makes assessment ofthe research difftcult and makes thegene.alizability impossible. The inclusion ofkey information is necessary to be able todetermine the adequacy ofthe treatment used.Study design and assessment of qualityThe issue ofstudy design is a challenge for acupuncture research. Some ofthesystematic reviews. and the primary studies reviewed within. either lacked a st.ongresearch design, and,/or an adequate description ofthe design on which a reader couldbase an opinion 5s. For example, Linde points to the problem of small sample size inmany studies, leading to underpowering of the results 47. In addition, some of thereviews found a positive co elation between low methodological study quality andAlberta Heritage Foundation for Medical ResearchHealth Technology Assessment l8


25/67


positive outcomes 28 32 34 37. 38. This makes the determination of efficacy very difficult, asit is hard to differentiate between true positive effects, and false positive effects due topoor study quality, leading to inconclusive results.There is also the issue ofassessing methodological quality ofstudies, not only foracupuncture specifically, but for complementa.y medicine overall. Acupuncture isbased on differing philosophical models 4. 4e than Western Medicine. Usingmethodological c te.ia validated in conventional clinical tdals, to evaluate acupuncturetrials may not be appropriate 4e. As in the determination of adequate treatment, oneneeds to attempt to separate the quality ofthe research from the quality ofthereporting 60.Many systematic reviews examined in this report used the Jadad Scale 40.61 as theirquality assessment tool, as it is 'the'validated tool among the assessment scalesavailable 61. This scale includes five criteria (see Appendix C), four ofwhich look atrandomization and blinding. Therefore, if a study does l1ot describe the randomizationprocess or blinding methodology, the quality is deemed to be poor, without consideringother criteria 5e. It also does not evaluate specifics important in acupuncture elficacyresearch, such as the appropriateness oftreatment, the skill ofthe the.apist, and thetype and duration of treatment. Difficulties in blinding both practitioner andpatient a ae are intrinsic to acupuncture, and some criticism ofthe Jadad Scale has beenbased on this 5e. Double blinding can, however, also be ofthe patient and the assessorofthe results, which means that acupuncture research could meet this c terion after all6t. 62. This latter inclusion for double blinding is not known or understood by someresearchers. so studies may meet that criterion and be underscored in the qualityassessment.Any quality scale should explore the clinical relevance ofthe question, the intemal andextemal validity, the appropdateness ofthe methodologies, and the ethicalimplications. There are many scales presently being used. though the key criteria to beassessed have not been agreed upon. Experts debate whether five criteria, such as theJadad Scale, are enough to effectively determine quality of any research 5e and. on theother hand, whether longer lists of criteda may be too unwieldy. There is also somediscussion whethe. scoring studies using set criteria is a useful tool for determining thequality olthe research 60 61. The criteria are often used solely to present the study data(10 trials were randomized. 12 were not) in a standard format, rather than to use it as atool to analyze the study. These issues also extend to the systematic reviews, as thequality ofreviews varied f.om poor to good, and the review details provided wereminimal in some cases 28. 37, 3e. Associated with this is the lack of agreement on anappropriate tool to assess the quality ofstudies in complementary medicine.The continuing goal is the development ofstandardized and accepted criteria that areeffective in evaluating the quality ofstudies in complementary and alternativemediajne 26,39,59.

Alberta Heritage Foundation for Medical ResearchHealth Technology Assessment 19


26/67


DrscussroNThis project was undertaken to provide a critical appraisal ofthe scientific literature anddetermine the status ofacupuncture as a treatment option for various conditions, toassist health care decision-makers in Alberta, both rcgionally and provinciallyregarding acupuncture services. Acupuncture has become increasingly popular,especially for conditions of a chronic or recurring nature. Though the determination ofeffectiveness of trcatment for each condition is the primary objective ofthe report, muchofthe discussion has focused on the quality ofthe evidence and the issues inacupuncturc treatment and research.Just as there are methodological limitations ofthe prima.y research studies, there aremethodological limitations ofsystematic reviews, The quality ofthe systematic reviewis impacted by the quality of the reporting of the studies included in the review. This iseven more ofan issue when critically appraising systematic reviews, which is furtherremoved lrom the primary rcsearch.Overall. the systematic reviews examined (10 out of 18, excluding Cochrane Reviews,had ratings ofpoor to satisfactor, were oflow quality methodologically, and reportedmixed findings with inconclusive results. Dental pain, and nausea,/vomiting are thetwo conditions for which evidence supported the efficacy ofacupuncture as atreatment.For dental and TMD pain. two reviews both found that acupuncture can be effective asa treatment, though there was no discussion as to the specific type and method ofacupuncture that would be the most appropriate 2?. 24. Rosted, finding most studies infavour ofacupuncture, had concerns with the clinical relevancy ofsuch findings, asthere are other analgesics available, with simpler procedures 22.A Cochrane Review oa headaches found that though the procedures seemed safe, therewere mixed results, and therefore the authoN made no statements regarding theefficacy ofacupuncture for migraine or tension headaches a1.The one review on tinnitus found that there was no difference between acupunctureand sham, and that the evidence did not support ofthe use ofacupuncture 23.Three reviews including a Cochrane Review on asthma reported inconclusive results,and that claims of efficacy \ /ere not supported. One difference with the study byKleijnen et al. 28. however, is that they used only relative effectiveness as theiroutcomes, meaning that acupuncture would have to be more, not equally effective tothe controls, to show results. Though the evidence was not strong enough to supportclaims of efficacy. Linde et al. 2e concluded that the evidence was also not shong enoughto recommend to those using it, to discontinue. Overall, however, the use ofacupuncture was not supported for the treatment ofasthma.The one review on st.oke rehabilitation found that though the evidence did notsupport acupuncture effectiveness, the findings were promising enough to warrantAlberta Heritage Foundation for Medical ResearchHealth Technology Assessment 20


27/67

Acupuncture: Evidence from Sysremaric Revie$,s and Meta analyses

further and better research to determine the actual effectiveness ofacupuncture as atreatment option 2.. However, two recently published blinded, placebo conbolled trialsshowed no effect of acupuncture (personal communication, Vickers, White).In the two reviews on nausea and vomiting 30.3r, acupuncture was found to be effective,except for children and when acupuncture was administered under anaesthesia. Thepositive effects were better than sham acupuncture or no treatment, and equivalent toantiemetics.Four ofthe five reviews focused on back or neck pain, found that the effectiveness ofacupuncturc for these types ofconditions was not supported by strongevidence 8 26 32 33. A rigorous meta-analysis36 by Ernst and White found thatacupuncture was an effective treatment relative to other types oftreatment, and thatthei. rclative usefulness needs to be investigated. Though Strauss 26 believes thatacupuncture is safe and should be evaluated in more rigorous studies, the CochraneReview Group concluded that since there were effective altematives, that acupuncturenot be recommended as a regular treatment 8. These conflicting conclusions add to theuncertainty in the interpretation ofthe research to date.The two reviews on chronic pain 3l rs found that the evidence was inconclusive overall.Ezzo et al. 3r also concluded that acupuncture for patients with chronic pain was moreeffective than the waiting list control group. Ezzo and colleagues also questionedwhether sham acupuncture is inert, and what impact that may have.The review on fibromyalgia discussed adverse reactions to the acupuncture treatment,and even questioned whether this was an appropriate treatment for fibromyalgia 27,Though their findings were based on one quality RCT with positive results. they stillfelt that their review provided information on the benefits and risks, and raisedquestions on efficacy that required further research.Two reviews on addictions to alcohol or heroin; smoking addiction; andweight/appetite reduction 38 3i indicated that the evidence was ofpoor quality andfound little support for the effectiveness ofacupuncture. Acupuncture appea-red to bebetter than doing nothing for smoking addiction according to the results oftheCochrane Review aa and another systematic review 3t with a good quality rating. Thereview on weight and appetite reduction provided little information on which toevaluate the quality, and the treatments being reviewed together were veryheterogeneous, both of which made the evaluation extremely difficult 37. Currently theevidence does not support the use ofacupuncture in addiction treatment orweight/appetite reduction.

Alberta Heritage Foundation for Medical ResearchHealth Technology Assessment 2t


28/67

Acupunctur: Evidence from Systematic Reviews and Meta analyses

CoNcLUSIoNSGrowing demands on the health care system for public funding ofcomplementaryhealth seryices, the changes in legislation regarding the regulation ofhealth careprofessionals, in conjunction with demand from the community for funding coveragefor acupuncture treatment underline the importance and timeliness of this review.A large body of primary research exists in acupuncture, covering virtually everysymptom. Due to the breadth of this topic and the challenge of reviewing the extensivebody ofresearch on acupuncture, the approach of systematically assessing the availablereviews was chosen to evaluate the current evidence for the efficacy ofacupuncture. Inchoosing this approach, it is acknowledged that there are limitations.There are many issues in acupuncture research which are highlighted briefly in thisreport that need to be explored and addressed in future studies. These issues rangefrom the assessment ofstudy methodology to the appropriateness ofan acupunctu.etreatment regimen. The studies included in the reviews had many limitations andvariations. Variability among the studies included the technique of needle insertionand manipulation, grouping of range ofacupuncture techniques, the number ofneedlesper treatment, temperature ofthe needles, material composition ofthe needles, andselection ofconhol comparatoF. All ofthese factors may influence the study'soutcomes and the overall conclusions ofthe systematic reviews,Many researchers concur that acupuncture is a relatively safe procedure howevet. it isnot without risk. Acupuncture can lead to both minor (drowsiness. nausea andfainting) and serious (traumatic injury ofbody tissue) adverse events. There is anincreasing amount of literature published on adverse effects ofacupuncture, but there isstill a concern about under reporting.Twenty-three systematic reviews on conditions such as dental pain/TMD, headaches,tinnitus, asthma, stroke, nausea/vomiting. neck/back pain, chronic pain, ftbromyalgia,labour, addictions, and obesity, were included in this appraisal ofsystematic reviews.This systematic review confirms the findings from other reviews which indicateconsistent support for the effectiveness of acupuncture in the treatment ofpostoperativenausea/vomiting. and dental pain. For other indicators the robustness ofthe effect ofacupuncture is debatable and its clinical value questionable for conditions such asidiopathic headaches, chronic pain, smoking and fibromyalgia, ho'"'i,ever some reviewsindicated promising results. The results from these reviews 27 3136 ar, the majority ofwhich had a good quality rating, found acupuncture to be as effective as the alternativeinterventions or no treatment in the short term.

Alberta Heriiag Foundalion for \,ledical ResearchHeahh Technology Assessment22


29/67

Acupuncture: Evidence hom Systenatic Reviews and Meta analj.ses

Overall, in terms of the volume ofresearch that has been created in studyingacupuncture there is a paucity of good quality research with large sampie sizes,randomization, and control for placebo effects. There was a lack of study detailprovided in the reviews in regards to descriptions ofthe practitioners inirolved,it was not possible to relate treatment effect or no effect to service provider. Hence

Alberta Heritage Foundation for Medical ResearchHealth Tehnology Assessment 23


30/67

Acupuncture: Evidence from Systematic Revie$6 andMeta analyses

APPENDx A: METHoDoloGyTwo searches were performed inJanuary andJuly 2001. The following outlines thesearch strategy and the databases used. Effort was made to find criteri; accepted by theacupuncture community as well as the scientific community for use in the criticalappraisal ofthe quality ofsystematic reviews for acupuncture. No quality assessmenttool specific to acupuncture was found.Two ofthe co-authors (LB and CH) selected the arlicles based on the inclusion andexclusion criteria while two co-authors (LB and pLT) extracted data lrom the re\,iewsand evaluated their methodological quality using criteria by Greenhalgh 2r as outlinedin Appendix B, The authors of the reviews were not contacted for misiing information.Search Strategy

HeahhSTAR (Ovrd)1991- Jan 2000 - databasedisconlinuedto Ju v 21. 2001

Best evidence (Ovid)Jan/Feb 2001CINAHL (ovid)1990-March 2001

and PTeMEDLINE

EMBASE (Ovid)199 2AA1AMED (Ovid)

IVEDLiNE (Ovid)1990-May2001

l\4av 2001

June 22,2aA1National guide inecearinghouseJune 22 2AA1

CMA praclice guide lnes-CPG lniobase

Subject headings (Bolded) and Textwords combinationsAcupuncture (exploded) OR acupunctureacupressure OR Electroacupuncture ORelectro-acupuncture OR staple acupuncture ORstaple-acupuncture OR stapleacupuncture OR staple puncture ORstaple-puncture OR slaplepuncture OR moxibusiion

acupuncture OR moxibustion

DARE HTA, EED

acupunclure OR moxibLtstiof

AcLrp OR moxibustionJune.2001

Databases Searched

Cochaane Database ofSyslematic Reviews1st Ouarter 2001Acupunctur' OR acupressure OR eleciroacupuncture ORe ectro-acupuncture OR staple acupunct!re ORstaple-acupuncture OR stapleacupuncture OR staple puncture ORslap e-punciure OR stapleouncture OR nroxibusiion

Aiberta Heritage Foundation for Medicat ResearchHealth Technology Assessment 24


31/67


WWW| ECRI, Bandolier, andother HTA agencieswebsitesacupuncture OR acupressLrre OR electroacupuncture ORelectro-acupuncture OR stap e acupuncture ORstaple-acupuncture OR stapleacupuncture OR staple punciure ORcture OR staDleounciure OR moxibustion

Two other databases, ISTAHC. Psyclnfo (February 2001), were searched but there wereno relevant studies found. Articles were submitted by various people interested inacupuncture. and access was gmnted to a private collection ofjournals ofacupuncture.This 'grey literature'was hand searched for articles that complied with rhe inclusioncdte.ia. Reference lists of retrieved reviews were search for systematic reviews andmeta analyses.Publlcation type limirs (where available): meta-analysis, systematic review"A systematic review is an oveNiew olprimary studies that use explicit andreproducible methods" 21."A meta analysis is a mathematical synthesis ofthe results of two or more primarystudies that addressed the same hypothesis in the same way" 2r.These publication types were searched as textwords and where publication typeIimiting was not available by using this search stringr (Subject headings OR Textwords)AND (systematic review OR meta analysis OR critical appraisal OR metaanaly$ ORmeta-analy$ OR metanalys OR critical$ apprais$ OR systematic$ review$)Inclusion diteria: Articles were selected if they were systematic leviews, whichincludes but is not limited to meta-analyses. The study must have human participants,but with no restriction ofage group or nationality. Reviews were requi.ed to have anintervention of acupuncture as being the primary treatment intervention in the study.Studies addressing any medical indication were included if they were published withinthe past ll years (1990 - 2001). Only reviervs available in English were evaluated.Exclusion criteria: Reviews were excluded if the use ofa tool to evaluate themethodological quality of the primary studies rvas not apparent. If reviews used thesame methodological c.iteda and had the majority of primary studies in common, theolder publications were excluded.lncluded studies:. Ernst E, Pitder MH. The elfectiveness ofacupuncture in treating acute dentalpain: asystematic review 21. Rosted P. The use of acupuncturc in dentistry: a review of the scientilic validity ofpublished papers22. ParkJ, White AR,EtnstE. Ellicacy ofacupuncture as a trcatment fot Tinnitus23Atberta Heritage Foundation for Medical ResarchHealth Technology Assessment

Subiect headings (Bolded) and Tgxtwords combinations

25


32/67

Acupuncturei Evidence from Systematic Reviews and Meta-analyses

. KleijnenJ, ter Riet G, Knipschild P. Acupuncture andasthma:a review ofcontrclledtrials2s. Linde K, Worku F, Stor W, Wiesner-Zechmeister M, Pothmann R, Weinschutz T, etal. Randomized clinical trials of acupuncture lor asthma - a systematic rcview 2s. ParkJ, Hopwood V, White AR, Ernst E. Ellectiveness ofacupuncture fot stmke: asystematic review2s. Lee A, Done ML. The use of nonphamacologic techniques to prevent postoperative nauseaand vomiting: a mek-analysis 30. Vickers A. Can acupuncture have specific etects on health? A systematic review ofac upu nc ture antiemes is trials 3l. White AR, Ernst E. A systematic reuiew ofrandomized controlled trials ofacupuncturc forneck Pain33

. Smith LA, Oldman AD, McQuay Hj, Moorc RA. Teasing apart quality and validity insystematic feviews: an example from acupuncture trials in chnnic neck and back pain 32. Strauss AJ. Acupuncture and the treatment of chronic low-back pain: a review of theIiterature26. Berman BM, EzzoJ, Hadhazy V, SwyerslP. Is acupuncture ellective in the treatmert offibromyalgia? 27. Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB . Is acupuncture ellectivef1r the treatment ofchronic pain? A systematic review3ar ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteia-based metaanalysis 3s. White AR, Resch KL, Ernst E. A meta-analysis of acupuncture techniques for smokingcessation 3i. ter Riet G, KleijnenJ, Knipschild P. A meta-analysis ofstudies into the ellect ofac up u ncture on addic tio n 38. Ernst E. Acupuncturc/acupressure for weight rcduction? A systematic review3r. Linde K, Melchart D, Fischer P, Berman B, White A, Vickers A, et al. Acupuncturc fotidiopathic headache (Cochnne review) !1. Linde K,JobstK, Panton J. Acupuncture for chronic asthmaa2r van Tulder MW. Cherkin DC, Berman B, Lao L. Koes BW. Acupuncture for low backpains. White AR, Rampes H, Ernst E. Acupuncture for smoking cessation44. Smith CA. Croq,ther CA. Acupuncture for induction of laboura3

Albena Heritage Foundation for Vedical ResearchHeaith Technology Assessment 26


33/67

Acupuncture: Evidence from Sysrcmatic Reviews and Meta analyses

. Ernst E, White AR, Acupuncturc for back pain: a meta-analysis of nndomized contt,lledtrials 36

Excluded Studies:. Ernst E, White AR. Acupuncturc as a treatment for temporomandibularjoint dydunction:a systematic review of randomind trials63 - methodological quality was not discussed. Ernst E. Acupuncture as a symptomatic tftatment of osteoarth tis. A systematic revlew ia -did not use a 'tool' to evaluate methodological quality. Ernst E. Acupuncturc as an adjuvant thetapy in stroke rchabilitation? 6a ' does noldiscuss methodological quality. Hopwood V. Acupuncture in stroke recovery: a litetature tevlew 65 - methodologicalquality was not discussed. Rosted P. Survey of recent clnical studies on the treatment of skin diseases with

acupuncture 66. Melenger A, Borg steir\J. Acupuncturc and sports medicine. A review ofpublishedstudies6T. South NA. Acupuncture for the treatment of trithdrawa] sruptoms in detoxilicationprocessei 68 - did not review methodological quality olthe studies,. Ashenden R, Silagy CA, Lodge M, Fowler G. A meta-analysis of the ellectiveness ofacupuncturc in smoking cessalrbr 6e - included in the review by white and Rampes. Green CJ; Kazanjian A; Rothon DA. Acupuncturc in the management of alcohol anddMg dependence 7a report in dmft stage. Baillie AJ, Mattick RP, Hall W, Webster P. Meta-analytic rcview of the elficacy ofsmoking cessation interventionsTt - no clear systematic review of the literature isoutlined. Databases used are not identified.. Melcha D, Linde K, Fischer P, White A, Allais G, Vickers A, Berman B.Acupuncture fot recurent headaches: a systematic review of tundomized controlled trials 72- included in Cochrane reviews

Three 'reviews' were identified by the search that are currently in the form ofprotocols,not reviews, with the Cochrane group. They are as follows:. HeL,ZhouD,WuB,LiN. Acupuncture fot Bell's palsy (Protoco, n. Green S, Buchbinder R, Hall S, Barnsley L, Forbes A, SmidrN,elal. Acupuncture forlaterul elbow pain in adults (Protocol for a Cochrane Review)73r Richardson MA, Allen C, ExxoJ, Lao L, Ramirez G, RamirezT,etal. Acupuncture forchemothenpy-induced nausea or vomiting among cancet patients (Protocol for CochraneReview) 7a

Alberta Heritage Foundation for Medical ResearchHealth Technology Assessmnt 27


34/67

AcupuncLurc: coDrpila&rn ofsysrcmatic rcviows and mola anatyscsAppENDrx B: DATA ExrRAcIoN AND euaLtry AssEssMENT oF INCLuDED STUD|ESTable 2: Data extraction and quality assessment of included studies

Study(Ouality Ratins) Design lype Endpoini Oata inregEtion Reviewers assessment

Jff*""""-,

Emsr E. P,(er Itsarisracroryt I

I

I

l

svsr"."t" Il"=,"L, *,'n,".I lhe olher swerc ccrs Ilu"ot,n.. II r'o,",v. Il."uo". Ilctscotr rr'.tI o'" rr*.l",pu,r"in tn" II oL,orrsrreo ano Iwdl

sludies.lrials

III_l

Dentalan

!ii,ff'-.""o,scurs.n

]

II

I

d TMD Painlo *rtu -

setting.

Dala reviewed suggesteiJeclive in allevjatingIhe conclusions lhat canbe drawn are limiled,methodological qualily ofmethods of lhe sludyacupuncture techniques.Sham acupunclure hadposilive eflects as well.No conclusive evidenceacupunclure that is bestfor denlal analgesia, and

Clear question, searchextraction was delailed,and quality assessmentResults interprcted in aComparisons of sludiesusing variouslechniquesand duration. and forDifficuli lo glean thepraclical implications.lnadequale descriptionacupuncture treaiment

AIbc{a Ilcritagc loundalion for Mcdical RcscarchHcalth 'l cchnology Asscssmcnr 28


35/67

Table 2: Data extraction and quality assessment of included studies (cont,d)Design typeSample sizeSearch sir.teqy

Ampuncturri: Ilvidcn{l) liom Systc )alic Rcvicws and Mrta-anatyscs

Endpoint ReYiewers assessnent

Rosled P 1998"lSatisractoryl

N= 15-allRCTs

Biological

Science

ctscoM tanguages -English,Gelman, Danish.

TENS or laser

lisr ol 24

ol 92 poinls,

60%.

Dala inlegralion exlraction studaes, threeresulls. This lindingmusl be intefpreled with

questionable, as the timeneeded for acupuncturebefore a procedure ismuch longer than othermethods ot aneslhetic.For facialpai. and TMO,resulls, and could be

Eleven of 1 5 RCTS lvrein favour of acupunctueand shown ir ro be beflerlhan sham, or similar loconvenlional treatmenls.highest melhodologically

Objeclive is clear, searchstElegy was adequaleand inclusion/erclusionOutcomes descibed in asimplislic way of positiveor negalive. Makes ildiffacull to determine lherelaled to lhe effcacy of

assessmenl of methodqualily was more lhanappropriale compadsonsand conclusions drawn onThis is nol a lreatmenteffecliveness study, asmuch as a melhodoloqyDala was grouped toilluslrate if lhere wrepailems between lhomethodolog ical score and

Albcrla Ileritagc lroundalion for Mcdi0al ResearchHcallh l cchnology Asscssmcnt 29


36/67

A(upunclurc: Ilvidorcc fro Systcmalic Itcvicws and Mota nnalyscsTable 2: Dala extraction and quality assessment of included studies (cont'd)

Study(Quality Ratins) Endpoinl Data integration Reviewers assessment

N=26[,IEDLINE, Oualily of

Albcda Ilcritagc loundalio lbr Mcdicat ItcscarchI Icalth Tcchnology Asscssmcnl 30

(15)(6)- mixed (1)

(1)

trealmenl of rccurrenlheadaches, but mostwerc melhodoloqically


37/67

Acupuncturc: Iividcncc liom Systcmalic Iicvicws an(l Mcla analyscs

Table 2: Data extraction and quality assessment of included studies (cont,d)Study(Oualily Ratinq) Design type Endpoint Data inlegration Reviewers assessmerr

Tinnilus20oo 23lSalisfacloryl

N= 6 all RCTS

crscoi/AMED andBrilish Library

positive eflecl and foursludies thai we.e shamdiffercnce belreen lhesuggesting non-specifl cetrects oI acupuncture.[,lelhodological qualltywas Poor, with only lhree

acuPunclurc may haveDiflicull to inlerprel rcsultas lhe grcups were very

supported by evidence.

The objeclive was clear,and the search stralegyadequale. TheinclusionOuality assessmenl wasadequale according lo theJadad scoring, lhough thesample was quile small.adequate, excepi for the

Studies reviewed providelittle information, as lheoulcome measures variedacross sludies, and therewas no inlegralion of dalaresult lhatwould be usefulas a practical applicalion.

Albcrta Flcritagc Foundation for Medical ltcscarchHcalth Tcchnology AsscssDlcDt 3l


38/67

Acupundurc: Ilviclcncc liom Syslcmalic Rcvicws and Mcra rnatysos

Table 2: Data extraction and quality assessment of included studies (cont,d)Study(auality Rating) Oesiqn type Endpoinl Data intgration Reviewers assessment

Kleijnen J, elal19C1 _lsalisfactoryl

thal

N

[ledline CD-RON4s,

English studies.

13

in English

Qualily

of 100.

regadingData integmtion:

Bolh lhe

arcund whelher shamacupuncture is an acliveplacebo or not, and lhelradiiional and WeslernConcerns wilh the use ofmela-analysjs and the

Though eight of lhe 13results, only lhree hadquality scores above 50and lhe five negativeresult studies had scoresClaims ofthe eflicacy oflrealment of aslhma arenot suppoded by wellpeformed clinical lials.

The objective is faidyclear, bul the search wasnot comprehensive. Theinclusion/exclusion crile.iaQuality was assessedusang standad criteriaStudy oulcomes weonly listed as positive or

prcsenlation in lhe inilial

Albc(a Ilcritagc loundation for Mcdical RcscarchHcalth Tcchnology Asscssnrcrl


39/67

Acupuncturc: Iividcnc{} liom Sysl{}malic Itcvicws aDCl Mc1:r analvscsTable 2: Data extraction and quality assessment of included studies (cont,d)Study(Ouality Ratins) Design lype En.lpoint Data inteqration RevieweB arsessment

N = 15 RCTS

l',ledline CD'ROMS (1983

AMED,clscor\4).(1991).

Albcrla Ucritagc loundalion fbr Mcdicat ltcsca.chHcallh Tcchnology Asscssmcnl

1996,eIGoodl

Dulch)

From a clinical standpointcomparabilily of the tr atsinlerprelation and clinicalapplicalion is very difticutt.Difficull io interp.el the lowrateFagreemeni f indingsassessing ac!puncturequality. May bedue toalack of agreement otwhatgood qualily acupunctureis, a poorly designed tool,or an inabilily lo interpretfor clinical applications,

moslly on the beliefs andallitudes of lhe.eviewers.Due lo lhe hete.ogeneityinsufficient data, the highlyconlradictory resulls areCan neilher recommendto acupuncturists to ceaselreating aslhma Dalienlsnor recommend io start its

The obleclive is clear. The

Qualily assessment wascomprehensive mannerusing two scaies separaletyQuanlitalive measures oflhe studies results wereincllded fo. readers lo seecompared on key variables.Their conclusions weredelailed and supported bythe.evlew of the trials in


40/67

Acupunc(urci lividunr liot) Systcma(ic llcvicws and Mcla analyscsTable 2: Data extraction and quality assessment ot included studies (cont'd)

Study(Quality Ratins) Design typeSample sizeSearch strategyEndpoinl Reviewe.e assessment

N=7RCTS

global

Did not find acupuncture

needed. Poinls ofsomeof lhe sham lreatmenlswould be considered forlrcatment of asthma by

Albcrla Hcritagc F'oundation for Modi(al RcscarchHcalth l echnology Asscssrncnt34


41/67

Table 2: Data extraction and quality assessment of included studies (cont,d)Endpoint

Lack of homogeneity ofiniervenlions and outcohesyslematic review verydifiicultimprovement when usingChinese scales, and nosigniticant improvementwhen using a Weslem

sufiicienlly promising to

Overall evidence does notsupporl ihe effeciivenessof acupuncture tor shoke

Acupuncturc: Evidencc fi.om Systonaric R{}vicws and Mcra analyscs

Design type

Stroke Rehabilit

Documents

ALBERTA Re Scanned Acupuncture Evidence 2002