Intended for healthcare professionals

Rapid response to:

Head To Head

Should doctors recommend acupuncture for pain?

BMJ 2018; 360 doi: (Published 07 March 2018) Cite this as: BMJ 2018;360:k970

Rapid Response:

Author’s response IV: Needling is superior to conventional care in chronic low back pain

Let me start with a definition of acupuncture:[1]
“Acupuncture refers to the insertion of a solid needle into any part of the human body for disease prevention, therapy or maintenance of health.”

Note that this definition from the Acupuncture Regulatory Working Group set up by the Department of Health does not refer to specific points. Acupuncture is about needling the soma with solid filiform needles, wherever they go. The fact that many practitioners like to use certain places to insert their needles is unlikely to be the most important aspect of the process.

I will follow up with the selected quotes from Sackett et al in my previous RR:[2]
“The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
“By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine…”
“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough.”
“Without clinical expertise, practice risks becoming tyrannised by evidence…”
“Evidence based medicine is not restricted to randomised trials and meta-analyses.”

Cochrane reviews never conclude that an intervention does not work. They simply present the evidence that an intervention does work, or that there is insufficient evidence to tell if it works.

The current Cochrane review listed for acupuncture in low back pain concludes:[3]
“For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only.”

This review is now quite old, and more recent meta-analyses have been heavily influenced by the largest study of acupuncture in low back pain, which included 1162 patients.[4] This study randomised patients to three groups. Two groups had forms of acupuncture needling: verum manual acupuncture and superficial off-point needling as a control; the third group received a conventional multimodal treatment programme according to German guidelines. The conclusion of the paper reads thus:
“Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.”

So when focussing on the efficacy question, the size of the apparent effect of acupuncture (over sham) principally varies with the size of the effect in the sham acupuncture group. Acupuncture appears to have a lesser effect in low back pain than in neck pain or shoulder pain; however, the within group changes in the huge cohorts of the Modellvorhaben Akupunktur that received acupuncture are all rather similar.[5] The more marked differences appear in the within group changes of the sham acupuncture performed in the GERAC and ART trials of the same research programme.

Can a placebo treatment outperform guideline based (the best) conventional care by more than 50%? Really?

In the ethereal world of academia, “placebos effects have been measured up to… blah blah… well very high percentage effects”. But here I refer to over 300 patients with chronic low back pain and an outcome measured at 6 months. Seriously, do you think that should be casually dismissed as theatrical placebo? Pull the other one!

1 The statutory regulation of the acupuncture profession - the report of the Acupuncture Regulatory Working Group. London: The Prince of Wales’s Foundation for Integrated Health 2003.
2 Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71–2.
3 Furlan AD, van Tulder MW, Cherkin D, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev Published Online First: 24 January 2005. doi:10.1002/14651858.CD001351.pub2
4 Haake M, Müller H-H, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med 2007;167:1892–8. doi:10.1001/archinte.167.17.1892
5 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

Competing interests: I am the salaried medical director of the British Medical Acupuncture Society (BMAS), a membership organisation and charity established to stimulate and promote the use and scientific understanding of acupuncture as part of the practice of medicine for the public benefit. I am an associate editor for Acupuncture in Medicine. I have a very modest private income from lecturing outside the UK, royalties from textbooks and a partnership teaching veterinary surgeons in Western veterinary acupuncture. I have no private income from clinical practice in acupuncture. My income is not directly affected by whether or not I recommend the intervention to patients or colleagues, or by whether or not it is recommended in national guidelines. I have not chaired any NICE guideline development group with undeclared private income directly associated with the interventions under discussion. I have participated in a NICE GDG as an expert advisor discussing acupuncture. I have used Western medical acupuncture in clinical practice following a chance observation as a medical officer in the Royal Air Force in 1989. My opinions are formed by data that spans the range of quality and reliability, much of which is in the public domain. I have a logical mistrust of the motives of anyone who advertises an interest or hobby in being a ‘Skeptic’, as opposed to using appropriate scepticism within their primary profession, or indeed organisations that claim to promote generic ‘science’ as opposed to actually engaging in it.

05 April 2018
Mike Cummings
Medical Director
British Medical Acupuncture Society
BMAS London, Royal London Hospital for Integrated Medicine, 60 Great Ormond Street, London WC1N 3HR