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EDITORIALS: David Wonderling Acupuncture in mainstream health care BMJ 2006; 333: 611-612 [Full text]

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Acupuncture is safe

Tony Thick   (22 September 2006)

A biased editorial.

Richard G Richards   (6 October 2006)

Acupuncture is safe 22 September 2006
Tony Thick, Sessional GP Welbeck Medical Centre NE6 2PB Send response to journal: Re: Acupuncture is safe	Acupuncture is not only cost-effective for low back pain (1,2) it is safe too. In his editorial (3), David Wonderling emphasises the importance of taking adverse effects into account in economic evaluations. Unfortunately, in stating that acupuncture ‘sometimes has serious side effects’ he seems to have misread his reference (Vincent) (4). This was also a BMJ editorial introducing two articles about acupuncture, being prospective studies of adverse events. Both found no serious adverse events, the first after 34 407 acupuncture treatments (5) and the second after 31 822 treatments (6). Vincent himself concluded in 2001 that acupuncture is safe in the hands of competent practitioners and referred to the inadequacy of anecdotal reports of serious adverse effects in the early literature. (1) K J Thomas et al BMJ 2006 333: 623 (2) J Ratcliffe et al BMJ 2006 333: 626. (3) D Wonderling BMJ.2006 333: 611-612 (4) C Vincent BMJ 2001 323: 467-468 (5) H MacPherson et al BMJ 2001 323: 486-487 (6) A White et al BMJ 2001 323: 485-486. Competing interests: None declared
A biased editorial. 6 October 2006
Richard G Richards, Consultant in Public Health Nottinghamshire County tPCT, Mansfield, NG21 0ER Send response to journal: Re: A biased editorial.	Wonderling states that the case is made for acupuncture in the treatment of migraine1. The primary research by Wonderling and Vickers2 is cited as evidence for this, though Wonderling drawns attention to the lack of difference in outcomes between real and sham acupuncture in tension- type headaches demonstrated by Melchart and Linde3. Wonderling's outcomes were replicated by Linde and Melcart4 in similar research which showed an even greater benefit from acupuncture compared to usual care. However this latter paper, not cited by Wonderling, also had a sham acupuncture arm which had outcomes identical to the acupuncture arm: acupuncture in this case worked by the placebo affect. The Wonderling study2 had main outcomes based on measures unique to the study whilst the Linde study4 used internationally recognised outcomes. Furthermore the outcomes of the Wonderling study2 were highly subjective continuous and ordinal variables whilst in the Linde study4 the outcomes were binary. Subjective outcomes are much more susceptible to the placebo effect and the biased misreporting of unblinded participants who would also have been selected in a biased manner in favour of acupuncture. Vickers, Melchart and Linde collaborated on the Cochrane Library review of acupuncture for idiopathic headache5 which attempted "to determine whether acupuncture is more effective than no treatment and/or more effective than 'sham' (placebo) acupuncture" and concluded that "There is an urgent need for well-planned, large-scale studies". Of the two studies only Linde's4 meets the desired obectives. Furthermore if the use of sham acupuncture demonstrated that acupuncture achieved its benefits through the placebo affect in migraine, that might also be the case in low back pain casting doubt on the conclusions of the cited study on acupuncture low back pain6 as there was no 'sham' arm, only usual care for comparison. This editorial may well be cited as justification for the use of acupuncture. A peer reviewed journal such as the BMJ should take more care when it publishes such a biased editorial based on incomplete analysis. 1 Wonderling D.Acupuncture in mainstream health care.BMJ 2006;333:611 -612 2 Wonderling D, Vickers AJ, Grieve R, McCartney R. Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care. BMJ 2004;328: 747-52. 3 Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, et al. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ 2005;331: 376-82. 4 Linde K, Streng A, Jurgens S, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes MG, Weidenhammer W, Willich SN, Melchart D. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005 May 4;293(17):2118-25. 5 Melchart D, Linde K, Berman B, White A, Vickers A, Allais G, Brinkhaus B. Acupuncture for idiopathic headache. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD001218. 6 Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ, et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ 2006; 333:623-6 Competing interests: None declared