Acupuncture for pain no better than placebo and not without harm

Although acupuncture is commonly used for pain control, doubts about its effectiveness and safety remain. Investigators from the Universities of Exeter and Plymouth (Exeter, UK) and the Korea Institute of Oriental Medicine (Daejeon, South Korea) critically evaluated systematic reviews of acupuncture as a treatment of pain in order to explore this question. Reporting in the April 2011 issue of PAIN(R), they conclude that numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain, and serious adverse effects continue to be reported.

'Many systematic reviews of acupuncture for pain management are available, yet they only support few indications, and contradictions abound,' commented lead investigator Professor Edzard Ernst, MD, PhD, Laing Chair in Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, UK. 'Acupuncture remains associated with serious adverse effects. One might argue that, in view of the popularity of acupuncture, the number of serious adverse effects is minute. We would counter, however, that even one avoidable adverse event is one too many. The key to making progress would be to train all acupuncturists to a high level of competency.'

Researchers carefully identified and critically examined systematic reviews of acupuncture studies for pain relief and case reviews reporting adverse effects. Reviews were defined as systematic if they included an explicit Methods section describing the search strategy and inclusion/exclusion criteria. Systematic reviews had to focus on the effectiveness of any type of acupuncture for pain. Of the 266 articles found, 56 were categorised as acceptable systematic reviews.

The authors observe that recent results from high-quality randomised controlled trials have shown that various forms of acupuncture, including so-called 'sham acupuncture,' during which no needles actually penetrate the skin, are equally effective for chronic low back pain, and more effective than standard care. In these and other studies, the effects were attributed to such factors as therapist conviction, patient enthusiasm or the acupuncturist's communication style.

If even sham acupuncture is as good as or better than standard care, then what is the harm? The answer lies in the adverse effect case studies. These studies were grouped into three categories: Infection (38 cases), trauma (42 cases) and other adverse effects (13 cases). Many of these adverse side effects are not intrinsic to acupuncture, but rather result from malpractice of acupuncturists. The most frequently reported complications included pneumothorax, (penetration of the thorax) and bacterial and viral infections. Five patients died after their treatment.

In an accompanying commentary, Harriet Hall, MD, states her position forcefully: 'Importantly, when a treatment is truly effective, studies tend to produce more convincing results as time passes and the weight of evidence accumulates. When a treatment is extensively studied for decades and the evidence continues to be inconsistent, it becomes more and more likely that the treatment is not truly effective. This appears to be the case for acupuncture. In fact, taken as a whole, the published (and scientifically rigourous) evidence leads to the conclusion that acupuncture is no more effective than placebo.'