Inspired by a series of recent on access articles in the BMJ online.[1–6]
CACMS – China Academy of Chinese Medical Scienceskey to acronyms
BUCM – Beijing University of Chinese Medicine
EBM – evidence-based medicine
SR – systematic review
RCT – randomised controlled trial
GRADE – Grading of Recommendations, Assessment, Development and Evaluation (a method of grading the quality or ‘certainty’ and strength or ‘effect size’ of evidence in healthcare)
ARC – Acupuncture in Routine Care (trials that were part of the large health insurance funded research program on acupuncture in Germany in the 90’s and 00’s)
A series of articles on acupuncture research was published online in the BMJ towards the end of February this year, and the 6th of the series was published at the end of March.
This set of articles was commissioned by the BMJ and funded by a number of centres in China, including the China Academy of Chinese Medical Sciences (CACMS).
The key author is Yu-Qing (‘Madison’) Zhang, who qualified from Beijing University of Chinese Medicine (BUCM) in 2009. She went on to do a master’s degree at BUCM before moving to McMaster University to do her PhD from 2011 to 2015. She was at the Department of Clinical Epidemiology and Biostatistics under Gordon Guyatt, a famous name in the world of EBM, and she still works part-time in the same department as an assistant professor. Gordon’s name is also on this series of papers, which give them considerable clout. I should note that the department has changed its name to the Department of Health Research Methods, Evidence and Impact – HEI for short.
I got a welcome email from Madison in July 2020 after being invited to join the project for one of the 7 papers by Prof Jing from CACMS. We went through a series of 3 sequential online questionnaires over a number of months, and I had a certain growing unease about what I perceived to be the unquestioned status of acupuncture points and meridians.
The opening opinion piece authored by Zhang (‘Madison’), Jing and Guyatt is quite positive:
In our view, the emerging evidence base on the use of acupuncture warrants further integration and application of acupuncture into conventional medicine.
I’m not sure what order the rest are supposed to be in, since I was invited to number 3 and it was number 6 to be published. Anyway, the one that caught my eye first had an implication in the title that acupuncture was underused, although that is not exactly what it said. It said that the evidence is underused, but I took that as meaning that if the evidence was used we would have more positive indications in health policy. One of the key examples they cite in this paper is the use of acupuncture in post-stroke aphasia, where they say a high-quality SR of 8 RCTs including 481 patients demonstrated a substantial effect over language rehabilitation (best conventional care). The forest plot in the paper looked odd so I tried to track down the original reference. I could not get hold of the full text, but the abstract indicated that the review included 28 RCTs including 1747 patients. Hmmm, that’s a bit odd.
Moving quickly on, paper 3 in my list is on clinical practice guidelines and tells us that it typically takes 17 years for an evidence based intervention to be implemented into usual care. The authors go on to list 15 conditions with moderate or large effect sizes from acupuncture treatment (but with low or very low certainty – GRADE terminology) that have not been included in any clinical practice guidelines. But before you get excited about these potential new areas, you should know that they include Meniere’s disease, autism, and postpartum lactation, as well as depression and sleep quality in chronic kidney disease. I will not be a surprise that the vast majority of the research comes from China, and as I have already said, comes with a GRADE label of low or very low certainty.
As a short aside on the GRADE approach, acupuncture research is at a particular disadvantage over assessment of blinding and heterogeneity, so it is vanishingly rare for the certainty of evidence to reach the levels moderate or high using this approach.
The next paper up in my list is on economic evaluations. I was expecting some positive comments about those performed as part of the ARC studies in the Modellvorhaben Akupunktur – huge studies with rigorous evaluation of direct healthcare costs as well as societal costs. But no, this was a sober account of the deficiencies so far, including a lack of long term outcomes and the failure to address contextual effects. Of course, the main reason for these deficiencies is almost certainly related to inadequate funding as well as the inadequate infrastructure for wide scale provision of acupuncture in the West, where the demands for evidence of cost-effectiveness are most prominent.
The next paper is about methodological challenges, and as I read it, I realised that this was the paper I should have contributed to! The authors list complexity (of the intervention), expertise (of the practitioner), and prominent contextual effects before mentioning the fact that sham acupuncture may not be inactive. The authors are not keen on the non-penetrating techniques and argue that just touching the skin could be therapeutic. The reference here is to the 2021 Nobel prize in Physiology or Medicine which was shared by the researchers who discovered the receptors related to transduction of heat (TRPV1) and mechanical stimulation (Piezo1 & Piezo2). They miss the crucial point that most of the serious adverse events associated with acupuncture are related to skin penetration, so if you cannot show a difference between touch and needling, you should not be needling at all.
Of course, there are other prominent problems with the ancillary non-penetrating gadgets – they make the real needling techniques quite limited. And don’t get me started on the double blinded devices that only penetrate 5mm in the real version!
The slightly alarming aspect of this paper, from my perspective, is the mention of relevant and irrelevant meridians rather than a distinction between sites of needling based on neurophysiology.
Finally, we come to the paper for which I contributed to the consensus process. I have nothing much to say about it. It is a guide to designing acupuncture trials, but it is very broad in scope and necessarily limited in detail – you could write a whole textbook on the subject. It was hard to know where to start when commenting on the first draft, it was broad and lacking obvious structure or importantly any description of the method of consensus. I am relieved to say that the final version is actually very good. If I was to be allowed one small gripe it would be that there was relatively too much consideration of practitioner expertise (without supporting evidence) and too little attention to the physiological aspects of the stimulus. Plus there was an excess of references to a yet unpublished paper with the less than self-deprecating acronym FAMOUS – Factors Associated with the Magnitude Of acUpuncture treatment effectS.
I asked Madison about the 7th paper, and she sent it to me, and let me know that there were a further 2 in the series. I’m not sure how I missed this one in BMJ Open, which was published online at the same time as the first batch in late February. I guess the title is not super exciting in itself, and I probably did not scrutinise the author list.
Perhaps I’ll update this reference list when the last two come out, or perhaps the FAMOUS paper will deserve a blog of its own!
1 Zhang Y-Q, Jing X, Guyatt G. Improving acupuncture research: progress, guidance, and future directions. BMJ 2022;376:o487. doi:10.1136/bmj.o487
2 Lu L, Zhang Y, Tang X, et al. Evidence on acupuncture therapies is underused in clinical practice and health policy. BMJ 2022;376:e067475. doi:10.1136/bmj-2021-067475
3 Zhang Y-Q, Lu L, Xu N, et al. Increasing the usefulness of acupuncture guideline recommendations. BMJ 2022;376:e070533. doi:10.1136/bmj-2022-070533
4 Li H, Jin X, Herman PM, et al. Using economic evaluations to support acupuncture reimbursement decisions: current evidence and gaps. BMJ 2022;376:e067477. doi:10.1136/bmj-2021-067477
5 Fei Y-T, Cao H-J, Xia R-Y, et al. Methodological challenges in design and conduct of randomised controlled trials in acupuncture. BMJ 2022;376:e064345. doi:10.1136/bmj-2021-064345
6 Zhang Y-Q, Jiao R-M, Witt CM, et al. How to design high quality acupuncture trials-a consensus informed by evidence. BMJ 2022;376:e067476. doi:10.1136/bmj-2021-067476
7 Zhang B, Han Y, Huang X, et al. Acupuncture is effective in improving functional communication in post-stroke aphasia : A systematic review and meta-analysis of randomized controlled trials. Wien Klin Wochenschr 2019;131:221–32. doi:10.1007/s00508-019-1478-5
8 Cummings M. Modellvorhaben Akupunktur–a summary of the ART, ARC and GERAC trials. Acupunct Med 2009;27:26–30. doi:10.1136/aim.2008.000281
9 Tang X, Shi X, Zhao H, et al. Characteristics and quality of clinical practice guidelines addressing acupuncture interventions: a systematic survey of 133 guidelines and 433 acupuncture recommendations. BMJ Open 2022;12:e058834. doi:10.1136/bmjopen-2021-058834