In the linked systematic review (doi:10.1136/bmj.a3115), Madsen and colleagues assess the analgesic effect of acupuncture and “placebo acupuncture” compared with usual care in 13 three arm studies.1 Acupuncture has been used virtually unchanged for about 2000 years, although in contemporary practice needles are often stimulated electrically (electroacupuncture). Traditional concepts of the mode of action have not been scientifically substantiated. Acupuncture is currently explained by neurophysiological mechanisms that are well established in research into experimental pain,2 although the precise mechanisms of effects seen in clinical practice are more elusive.

The clinical effectiveness and cost effectiveness of acupuncture versus conventional treatment for chronic pain have been confirmed in large trials over the past 10 years. In particular, Germany’s Modellvorhaben Akupunktur (health insurance funded trials on acupuncture) provide evidence of effectiveness that has led to the integration of acupuncture into the management of osteoarthritis of the knee3 and back pain.4 In contrast, the evidence was insufficient to support such a policy for tension headache and migraine.

However, the nature of classic “acupuncture points” is …