The Cochrane Reviews of Acupuncture Doris Hubbs, MD, FACP April 26, 2013

 No financial conflicts of interest  No intention of discussion off-label use  I would like to recognize and thank several important people…

 Dr. Suarez—AMAZING TEACHER!  Dr. Chris Kwasigroch– volunteer coordinator  Dr. Bob McKay—course instructor  Dr. Marian Chamberlin--sponsor  Dr. Beth Fox—CME course director  Pat Myrick—CME planner  Barbara Sucher and the CME Office  All our course participants!  All our volunteers!

 7:30 AM in B-04/5/6, Blgd. 1  Bring your Pictorial Atlas for reference  Wear comfortable clothes  Download power point slides from CME website  Join us for dinner at Café Pacific at 6:30 if you wish

Acupuncture has been practiced for thousands of years!

 We know that acupuncture has been effective in treating many people all over the world for millennia  But what about evidenced-based medicine? Placebo-controlled,  double-blinded randomized trials????

 Systematic reviews of primary research in human health care  Internationally recognized as the highest standard in evidenced-based health care

 Eight Cochrane reviews evaluating effectiveness of acupuncture for pain  Four reviews concluded that acupuncture is effective for: migraines neck disorders tension HA’s peripheral joint OA

To investigate whether acupuncture is  a) more effective than no treatment  b) more effective than “sham” (placebo) acupuncture  c) as effective as other interventions in reducing HA frequency in migraine pts.

 Selection criteria:  Randomized trials with observation period of at least 8 weeks, comparing clinical effects of acupuncture treatment with: No treatment or routine care only Sham acupuncture Another intervention for migraine

 22 trials with 4419 participants met the inclusion criteria.  There is consistent evidence that acupuncture provides additional benefit to routine care for migraine  Acupuncture is at least as effective as (possibly more) prophylactic drug tx  And has fewer adverse effects.

 To investigate whether acupuncture is a) more effective than no tx or routine care only b) more effective than ‘sham’ acupuncture c) as effective as other interventions in reducing HA frequency in patients with chronic tension HA

 11 trials with 2317 participants met inclusion criteria  2 large trials showed statistically significant benefits of acupuncture over control for response, number of HA days, and pain intensity for the length of f/u (3 months)

 5 trials comparing acupuncture with sham tx showed small but statistically significant benefits of acupuncture over sham treatment

 Acupuncture can be a valuable non- pharmacological treatment in patients with frequent episodic or chronic tension-type headaches

 Neck pain is one of the three most frequently reported complaints of the musculoskeletal system.

 Objective:  To determine the effects of acupuncture for individuals with neck pain.  RCT’s or quasi-RCT’s included.  10 trials using acupuncture for chronic neck pain.

 No trials examined the effects of acupuncture for acute or subacute pain  Methodological quality had a mean of 2.3/5 on the Jadad Scale.  For chronic mechanical neck pain, there was moderate evidence that acupuncture was more effective than sham controls, massage, or a wait-list control.

 Peripheral joint osteoarthritis is a major cause of pain and disability.  Objective: To assess the effects of acupuncture for treating peripheral joint osteoarthritis

 Inclusion criteria: RCT’s comparing acupuncture with sham, another active tx, or a waiting list control group in people with OA of the knee, hip, or hand.

 16 trials involving 3498 people were included:  12 RCT’s with only OA knee  3 trials with only OA hip  1 trial with OA of the hip and/or knee

 Sham-controlled trials showed statistically significant benefits;  However, did not meet pre-defined thresholds for clinical relevance  Waiting list-controlled trials suggested statistically significant and clinically relevant benefits of acupuncture for pain from peripheral joint OA

 4 reviews concluded that acupuncture is effective for migraines, neck disorders, tension HA’s, and peripheral joint OA  3 reviews were inconclusive for shoulder pain, lateral elbow pain, and LBP  One review failed to demonstrate the effectiveness of acupuncture for RA

 Acupuncture for conditions other than pain: Asthma, glaucoma, depression, schizophrenia, irritable bowel syndrome, nausea due to CHT or post-op, Bell’s palsy, RLS, epilepsy, vascular dementia, stroke, insomnia, cocaine dependence, conception, induction of labor, uterine fibroids

 Cost  Difficult to find a credible placebo  Unable to keep practitioners blinded  Many different acupuncture methods  Controlling the skill of the practitioner  Guerra de Hoyos et al., Medical Acupuncture: A Journal for Physicians By Physicians, Vol. 14, #2, 2001

 Acupuncture for Chronic Pain (back, neck, OA, headache, shoulder)  Individual Patient Data Meta-analysis  Systematic review of 29 RTC’s with total of 17,922 patients.

 Conclusions: Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo.

 Acupuncture has been shown in RCT’s to be safe and effective for certain types of pain, include HA, neck pain, OA pain  Many financial and technical difficulties limit the availability of acupuncture RCT’s  More studies are needed to better understand the benefits of acupuncture.

“Absence of Evidence is Not Evidence of Absence” Altman, Douglas, and Bland, Martin, “Absence of evidence is not evidence of absence,” BMJ vol.311:485, 1995.

Questions?