Inspired by number 8 in the BMJ acupuncture research series.[1–8]
SR – systematic reviewkey to acronyms
ICU – intensive care unit
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
MSK – musculoskeletal
ES – effect size
SMD – standardised mean difference
TMJD – temporomandibular joint dysfunction
We now have number 8 in the series of 9 papers, but it is not the one with the FAMOUS acronym. I guess that will be number 9.
This paper is an overview of 120 SRs of acupuncture that identifies promising areas where better evidence is required and those areas where the evidence is already good, but it remains underutilised in practice. They do not appear to measure utilisation in this paper, but that topic is addressed in another paper in the series. The process of selection was restricted to a period of just under 6 years from January 2015 to November 2020.
Another rather important aspect to this mapping exercise is the exclusion of studies where acupuncture was used as an adjunct therapy. There is no further detail on this aspect apart from the usual description of two reviewers separately selecting papers and then resolving differences with a third reviewer. I wondered how they classified acupuncture plus usual care versus usual care alone. In this design you could say it was acupuncture versus no additional treatment or you could say it was an adjunct to usual care compared with usual care alone. If the context is sepsis in ICU, then usual care is by definition intensive, and acupuncture is certainly adjunctive, but if the context is of benign neglect of chronic MSK pain in the community then it seems more like acupuncture is a primary intervention.
To resolve this query, I thought I would see whether the ARC trials from the Modellvorhaben Akupunktur were included somewhere in the map. I am pleased to say that I found them in the online matrices for back pain, knee pain, headache, dysmenorrhoea and allergic rhinitis.
Searches were carried out in 4 Chinese databases and the Epistemonikos database. The latter was initiated in 2009 by a physician and a computer scientist in Chile and launched as a database in 2012. It is now run by a non-profit organisation called the Epistemonikos Foundation. It is a database of SRs relevant to health decisions and all the RCTs contained within those SRs. The foundation runs a number of other related projects including one called LOVE (as in the lyric: Love is all you need – with reference to health data… cute) and a GRADE guidelines repository.
Of the 120 SRs included I was surprised to see that only 1 came from the UK. I had the impression that we had done a lot of the early SRs of acupuncture, because I grew up in that era then I remembered that the earliest date of the search was January 2015. The majority of SRs came from China (n=98), and the greatest volume of evidence in terms of the number of RCTs included and the total number of patients was in neurological conditions. Now that is definitely something that is way more prevalent in the Far East.
There were 3 conditions with large or moderate effects (ES) and high or moderate certainty (GRADE):
- Post-stroke aphasia
- Myofascial pain
- Postpartum lactation.
We have covered post-stroke aphasia on here before (Acupuncture for PSA) and I have heard from my colleague Taras that acupuncture appears to have a noticeable effect in stimulating postpartum lactation, particularly following caesarean section.[10,11] But I was a little surprised to see myofascial pain in the list, because, whilst my clinical experience suggests very good effects of acupuncture in myofascial pain, I didn’t think the research reflected that. So, I tracked down the SR concerned.
It is quite a big SR from 2016 of acupuncture in MSK pain including both meta-analyses and meta-regression. The latter is used to explore sources of heterogeneity within the individual meta-analyses. Eight conditions were included with a total of 63 trials and 6382 patients. The pooled effect size (ES) over all 8 conditions gave an SMD of -0.61 for pain and -0.77 for disability. The ES for the myofascial pain category was -1.00 for pain from 13 trials and 414 patients. That is the best result I have seen for myofascial pain to date. I suspect that may be a result of mixing myofascial pain related to TMJD with pain from other areas, which is fine, but I have not seen that done before.
Most interesting is that the meta-regression identified sham needle location and depth as the principal factors causing heterogeneity in the result for myofascial pain – 99.52% of it for both factors combined. For most of the other categories with significant heterogeneity, these were not the critical factors involved apart from sham needle location in shoulder pain (100%) and sham needle depth in back pain (62.69%).
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 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
3 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
4 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
5 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
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 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
8 Lu L, Zhang Y, Ge S, et al. Evidence mapping and overview of systematic reviews of the effects of acupuncture therapies. BMJ Open 2022;12:e056803. doi:10.1136/bmjopen-2021-056803
9 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
10 Pierdant G, Westphal K, Lange A, et al. Stimulation of Lactation Using Acupuncture: A Case Study. J Hum Lact Published Online First: 21 February 2022. doi:10.1177/08903344221078802
11 Usichenko TI, Henkel BJ, Klausenitz C, et al. Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial. JAMA Netw Open 2022;5:e220517. doi:10.1001/jamanetworkopen.2022.0517
12 Yuan Q-L, Wang P, Liu L, et al. Acupuncture for musculoskeletal pain: A meta-analysis and meta-regression of sham-controlled randomized clinical trials. Sci Rep 2016;6:30675. doi:10.1038/srep30675