Intended for healthcare professionals

Rapid response to:


Acupuncture in mainstream health care

BMJ 2006; 333 doi: (Published 21 September 2006) Cite this as: BMJ 2006;333:611

Rapid Response:

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

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

Competing interests: No competing interests

06 October 2006
Richard G Richards
Consultant in Public Health
Nottinghamshire County tPCT, Mansfield, NG21 0ER