ALBERTA Re Scanned Acupuncture Evidence 2002

Alberta Heritage Foundation
for Medical Research

IE
Acupuncture: Evidence
from Systematic Reviews
and Meta-analyses
Patricia Leggett Tait, Laurie Brooks,

Christa Harstall
March 2OO2
HT A 27: Series A Health Technology Assessment

@ Cop).right Alberta Herltage Foundation for Medical Research, 2002
This Health Technolosr Report has been prepared on the basis of available information
of whtch the Foundatlon ls aware from public literatue and expert opinion and
attempts to be curent to the date of publication. It has been externally reviewed.
Additional information and comments relatlve to the report are welcome and should be
sent to:
Director, Health Technology Assessment

Alberta Heritage Foundation for Medical Research
1500, 10104 - 103 Avenue
Edmonton
Alberta TsJ 4A7
CANADA
TeI:. 780-423-5?27, F ax 780-429-3509
ISBN l-896956-56-4
Alberta's health technolory assessment program has been established under the Health
Research Collaboration Agreement between tie Alberta Heritage Foundation for
Medical Research and the Alberta Health Ministry.
AcKNowLEDGMENTS
The Alberta Heritage Foundation for Medical Research is most grateful to the following
peFons for provision of information and comments on the draft report. The views
expressed in the final report are those ofthe Foundation.
Dr. Brian Berman, MD, Complementary Medicine Prog.am, Baltimore, MD
D!. Stephen Birch, Stichting (Foundation) for the Study for Traditional East Asian
Medicine (STEAM), Amsterdam Netherlands
Dr. Andrew Vickers, Memorial Sloan-Kettering Cancer Center, New York, New York
Dr. Harald Walach, Universitatsklinikum Freiburg, Institute fur Umweltmedizln und
Krankenhaushygiene, Fdeburg, I.BR
Dr. Adrian R. White, Department of Complementary Medicine, Unlversity of Exeter,
Exeter, UK
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Heahh Technology Assessment
SUMMARY
This report's objective is to provide an overview ofevidence from systemaric

reviews and meta-analyses on the effectiveness ofacupunctule for any condition
that has been assessed in this manner.
Two-thirds ofCanadians used some form ofalternative or complementary medicine
in 2000, and l-27o reported seeing an acupuncture practitioner in 1998/99.
Acupuncture, in the stdctest sense refers to "insertion of dry needles, at specially
chosen sites, for the treatment or prcvention of symptoms and conditions." It is a
relatively safe procedure, but it can lead to both minor (fainting, exacerbation of
symptoms) and se ous (hepatitis, traumatic injury of body tissue) adverse events.
Twenty-three reviews were included: two on dental and temperomaldibular
dysfunction (TMD) pain; one on headaches; one on tinnitus; three on asthma; one on
stroke rehabilitation; two on antiemesis; ftve on neck/back pain; two on chronic
pain; one on fibromyalgia: one on induction oflabour; one on addictions; two on
smoking cessation; and one on weight reduction. Unanimously these reviews call
for higher quality research with greater sample size.
Among the studies included in the review there are wide variatlon oftreatments
such as manual or electrical stimuladon, number of needles per treatment, technique
ofneedle insertion, and fuequency oftreatment. All ofthese factors may influence
the outcome.
Acupuncture was found to be effective for the treatment of dental and TMD pain
and antiemesis (nausea/vomiting) in comparison to other chosen interventions. The
results for idiopathic headaches and fibromyalgia were reported as encouraging.
The evidence was inclusive for the treatment ofback pain, chronic pain, smoking
cessation. and asthma. Effectiveness was not supported by the evidence for tinnitus,
stroke rehabilitation, neck pain, addictions, and weight reduction.
Dental and TMD pain and antiemesis appear to be two areas in which acupuncture
is reproducibly effective. Fo. all other indications the methodology design and
quality is either too weak to dmw conclusions, the studies have not been done, or, in
studies of better quality, acupuncture does not appear to be more effective than
standard ofcare or control chosen.
Clearly, more research of higher mefiodological quality is called for. Issues of
blinding, the use ofa credible control, varying diagnosis amongst differing
philosophical approaches, and the diversity oftreatment points chosen and
techniques used challenge this particular area olcomplementary medicine.
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Acupuncture Evidence from Systematic Reviews and Meta,analyses
Appendix A: Methodology....................... ....................-.......................24

Appendix B: Data Extraction and Quality Assessment oflncluded Studies....................29
Appendix C: Quality Assessment Tools.... .......,,,,,,,,.....................,,,..51
Appendix D: Crite a for Evaluating Systematic Reviews.,.....,...........................................56
Appendix E: Checklist of Data Required in a Complete Report of Acupuncture
Treatment......,,,........ .................. 56
References................. ................,,,........................ 57
Tables:
Table 1: Conclusions and quality rating ofthe systematic reviews.................................... 13
Table 2: Data extraction and qualitv assessment ofincluded studies ,,,..................,,,,,,,....2g

lNTRoDUcTtoN
Two-thirds ofCanadians used some form ofcomplementary or alternative medicine in
2000, mostly vitamins 1. Sixteen percent of Canadians saw an altemative health care
provider in 1998/99, and of those people , 160/o (or l-Za/. ol t}Le total population) saw an
acupuncturist. In Canada, the incorporation of complementary or alternative medicine
into one's health care regime is more common in the western provinces, in women aged
between 25 and 44 years, and in those living with chronic conditions 2. Medical schools
are incorporating complementary and alternative medicine training in their cufficula,
with ten out ofsixteen Canadian medical schools providing some exposure to
acupuncture 3.
A large body of research exists in acupuncture, covedng viftually every symptom a. In
the 1950's the Central Committee in China was interested in this question and
thousands of studies were performed. The results led the Committee to bestow equal
recognition to Traditional Chinese Medicine (TCM) and Western Medicine 5.
This project is Part II ofa request from several Regional Health Authorities and Alberta
Health and Wellness, regarding two key objectives: to present information on the
regulation ofacupuncture in Alberta, including the scope ofpractice and coverage of
services: and to conduct a systematic review of currcnt scientiffc evidence to determine
the effectiveness ofacupuncture, and the conditions lor which it has been found to be
effective. Objective two is addressed in this report.
Part I, titled "Overview of the Regulation of Acupuncture in,4lrerra ", addressed the firct
objective and was completed in May 2001 6. In Part I, three categories ofcertification or
governance were found to be in place: those who are members ofa professional college
or association (eg. physical therapists) prior to their study ofacupuncture; those who
have completed training in an acupuncture program and have passed a provincial
exam; and those who have knowledge ofacupuncture (eg. from another country), but
are practicing without a governing body. Acupuncture is usually performed in a
clinical setting, and is not covered by the Alberta Health Care Insurance plan. As the
insertion ofneedles will be considered a 'restricted activity' under the new Health
Professionals Act, these activities will only be allowed to be practiced by those
governed by a regulating body.
Growing demands on the health care system for provision ofcomplementary medicine,
the evolution oflegislation regarding the regulation ofhealth professionals, in
conjunction with requests fiom the community for funding coverage for acupuncture
treatment illustrate the importance and timeliness ofthis review.

Acupuncture: Evjdence ftom Systematic Revlews and Meta-analyses
ScoPE oF THE REPoRT

Due to tlle breadth ofthis topic and the challenge ofreviewing the extensive body of
research on acupuncture, the approach of systematically assessing the available reviews
was chosen to evaluate the current evidence for the efficacy ofacupuncture. In
choosing this approach, it is acknowledged that there are areas in which acupuncture is
used that have not been assessed and reported as a systematic review.
Though the scope for this report did not limit the search ofscientific evidence to speciffc
medical conditions, systematic reviews meeting methodological inclusion crite a a.re
reviewed on the following topics; dentistry, headaches, tinnitus, asthma, stroke
rehabilitation, nausea/vomiting, neck,/back pain, chronic pain, fibromyalgia, labour
induction, addiction, smoking cessation, and weight/appetite reduction.
This assessment will not be comprehensive including all ofthe primary acupuncture
research, and all the conditions currently heated by acupuncture, but for the systematic
reviews and meta-analyses published in English between 1990 and 2001 that met the
inclusion criteria (see Appendix A). Primary studies published since the reviews have
not been included; the results from these primary studies may change some ofthe
conclusions derived at in this systematic review.
The findings from this review are summarized by medical condition and the overall
results compared with those from the United States'National Institute of Health
Consensus statements and other systematic reviews of rcviews.
There are many issues in acupuncture research that need to be explored and addressed
in future studies which a.e pointed out briefly in this report. These issues range from
the quality and assessment ofmethodology to the appropdate acupuncture treatment
regimen.
DEFINITION
Acupuncture. in the stdctest sense, refers to "inseftion of dry needles, at specially

chosen sites for the treatment or prevention of symptoms and conditions" i. The
Chinese term "zhenjiu" references both acupuncture and moxibustion. The latter is the
use of a herb, fienrbJa yulgan3 (mugwort) which is burned over the acupuncture site for
purposes of warming L9.
Acupuncture is performed with solid needles ranging in length from I cm to l0 cm r0.
They are made ofgold, silver, copper, stainless steel, or a combination of metals 10 and
may be inserted under the skin no more than 8 cm deep. As technology evolved it was
applied to traditional forms ofhealing. Electroacupuncture refers to the technique of
introducing an electrical curent to the inserted needles at various frequencies. A laser
beam, directed at the acupuncture site and stimulated, has developed into a technique

Acupuncture: Evidence from Syslematic Reviews and Meta-anaryses
called laser acupuncture, Techniques of fire needles involve inserting red-hot needles
at an acupuncture point.
Staple puncture is the application ofa metal staple to an acupuncture point where it
remains lor a prolonged period of time. Cupping is a technique by which a vacuum
force is applied to acupuncture sites, Bloodletting refers to tie pricking ofthe skin for
the purpose of releasing blood. This may be aided with the application of a cup over
the site. A less lnvasive procedure is acupressure which refers to the stimulation ofa
point manually with pressure with the intention ofstimulating Qi flow. Intramuscular
stimulation is a technique of applying needles to areas of tenderness. There is debate in
the acupuncture community over which ofthese techniques fall under the classification
ofacupuncture.
'De qi' is the sensation ofnumbness, tingling, electrical sensation, fullness, distension.
soreness, warmth, and itching which may be felt subjectively around the acupuncture
point 8. The practitioner may have a sensation of tenseness or dragging to the needle 11.
This sensation may be sought by some practitioners through twirling, plucking, or
thrusting ofthe needles. In Western terms these are signs that A-delta fibers are
activated r0. In TCM this indicates that the Qi has affived. There is controversy
amongst practitioners ofacupuncture as to whether it is necessary to elicit this sensation
ro render the rreatment effective 8.
CoMPLICATIoNS oF AcUPUNCTURE
Acupuncture is a relatively safe procedure, but it can also lead to both minor and
se.ious adverse events. There is an increasing amount ofliterature on adverse effects of
acupuncture; however, there is still a concem about under reporting in the studies of
the more minor adverse effects ofacupuncture.
Norheim's study ofthe literature from 1981 to 1994 examined 78 case reports (N= 193
treatments) of adverse effects with needle acupuncture 12. He classified the
complications as mechanical organ injuries such as pneumothorax (n=23) and medulla
spinalis injury (n=13); infections such as hepatitis (n=100) and auricular chondritis
(n=16); and other effects such as argyria (n=5) and problems with implanted needles
(n=5). Many ofthe effects seem to be linked to practitioner competence, or patients'
ongoing health conditions.
White et al. and MacPherson et al. both examined the adverse events occurring with
acupuncturists in the U.K., in over 32,000 and 34,000 consultations respectively 13,1r. In
MacPherson et al, no serious adverse effects were reported, as defined as requiring
hospitalization, or leading to permanent disability or death. and there was a rate of
1.3/1000 consultation of minor adveEe events such as severe nausea and fainting.
White et al. also found no serious adverse events in theb study. Significant minor
events such as fainting, lost needles, and exacerbation of symptoms were reported at a
rate of l4l10,000 consultations. In addition, both studies reported on'minor events'or
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Acupuncture: Evidence from Systematic Revieu,s and Meta,analyses
'mild transient reactions' occurdng in

a much larger percentage ofthe beatments,
though these were not considered significant.
Using combined data from published literature, Ernst rs found that the most commonly
reported adveme events were drowsiness and fainting, increased pain, nausea/
vomiting, and infections. Infections, including Hepatitis C, were usually due to
using,/reusing unstedle needles, or practitioner error. In a 2001 systematic review by
Emst and White on tie safety of acupuncture they reviewed nine studies, which
included almost 250,000 treatments 16. Thirty-eight percent of all patients experienced
bleeding and 45% experienced an aggmvation of pain symptoms. Overall 28% of
patients expe enced some adverse effect, serious effects were rare, as supported by
their systematic review of life threatening adveme effects in 1997 r?.
Across the studies common mild or 'non-significant' adverse effects included pain at
the needling site, nausea, bleeding, aggravation ofsome symptoms and faintness or
fatigue 1315 17 r8. Infections, such as hepatitis. were often due to poor hygiene technique
such as reusing unsterilized needles. Some cases oftraumatic injury ofbody tissue
including pneumothorax, cardiac tamponade, spinal trauma, and hematoma re have
also occurred usually due to practitioner eror.
Some key challenges identified in consistent reporting ofadverse effects are
summarized by Emst and White 10. The method of defining adverse events and of
collecting/reporting ofthese events diflers across the studies. As well, the style of
acupuncture differs across cultures and practitioner groups, which have differing risk
levels for adverse events. Finally, the rate ofadverse events may vary according to the
condition being treated, and the body part being stimulated during that treatment.
Yamashita et al. suggest that a distinction should be made between the reporting of
results due to negligence and those due to adverse events ofthe acupuncture technique
itself r8.
The studies' conclusions are consistent in that they found that the mte or incidence of
serious adverse events due to acupuncture treatment is low but that they do
occur 12 13 15 18. Acupuncture is not free of risk. it is important to track and report minor
side eflects as they may progress into a more serious event. Ifthere is not a consistent
and thorough process for reporting these events, the evidence on adverse effects
remains limited and incomplete. MacPherson and colleagues ra stated that the adverse
event mte, when compared with primary care drugs, suggests that acupuncture is a
relatively safe treatment. and many researchers concur that it is a relatively safe
technique 12.15.16.
FtNDtNGS
Of the thirty three studies selected, twenty-three systematic reviews met the inclusion
criteria, including five Cochrane Reviews (see Appendix A). A table of data extraction
and quality assessment ofincluded systematic reviews can be found in Appendix B.
Though there is growing debate as to whether the Cochrane Reviews should continue
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to be a 'gold standard' for systematic review methodology, they curently have the
most rigorous methodology, and therefore, a quality assessment ofthese reviews was
not undertaken 20. The other reviews were assessed using criteria based on those set out
in Greenhalgh 21 (see Appendix D). Though this quality assessment may not be as
rigorous as initially intended by its authors, it has been consistent across the reviews.
Once agreed upon criteria have been developed for the assessment ofthe
methodological quality ofprimary studies in acupuncture, the same approach should
be taken for the assessment ofsystematic reviews.
The methodology of a review was considered to be satisfactory if it contained a concise

research question(s) and inclusion criteria, an adequate search strate$/, and included a
quality assessment evaluation 22 28. If a review also attempted to integrate andlor
statistically analyze the data, it was considered to be of good quality 2e-36. The rest of the
reviews were considered to be ofpoor methodological quality 37 3e.
Dental and temperomandibular pain

Two reviews focused on dental pain, temperomandibular dysfunction (TMD) and facial
pain. Eight ofthe l6 studies reviewed by Ernst and Pittler 24 regarding dental pain were
also included in Rosted's review 22. In Emst and Pittler, eleven studies examined pain
due to dental surgery and five studies evaluated pain induced in an experiment.
Methodological quality was assessed using the Jadad Scale 40 (Appendix C). Though
the authors state that the heterogeneity oftreatments and low quality ofmany ofthe
studies reviewed limit the conclusions that can be drawn, the data suggest that
acupuncture can be effective in the treatment ofdental pain. The method and regimen
ofacupuncture that most eflectively rclieves dental pain. however, remains unclea..
Rosted's review 22 examined seven studies on pain associated with tooth extraction and
eight studies on TMD/facial pain. Overall the review's methodology was fairly
dgorous. Descriptions ofthe treatment and practitioner's qualifications were assessed
as part ofthe quality assessment, but these details were not presented.
Eleven studies indicated that acupuncture was effective and seven ofthese studies were
rated at a high level due to their methodological quality. Rosted concluded that most of
the studies suggest that acupuncture is effective in controlling dental and TMD,/facial
pain. He stated concerns, however, about the clinical relevancy ofthis treatment as a
surgical analgesic, as the time needed for acupuncture to take effect was much longer
than other analgesics.
Headache
Only one review met the inclusion criteria.al. This Cochrane Review addressed the
question whether acupuncture was more effective than no treatment. sham or other
treatments used for headache ol three types: mig.aine, tension. and mixed. The Jadad
Scale 40 was used to assess study quality (Appendix C) ofthe 26 RCTs (16 RCTs for
migraine headaches, six RCTS for tension type headaches, and four RCTs for various

Acupuncture: Evidence from Systematic Reviews and Meta-analyses
headache types). Evaluation ofthe appropriateness ofacupuncture point selection was

undertaken by someone trained in both Western and TCM acupuncture.
Sham'controlled studies for migraine and tension type headaches, reported favourable
results for acupuncture, though the methodological quality ofmany ofthe studies was
rated as weak. There were a small number of studies for all types of headaches
indicating mixed results for acupuncture compared with each of physiotherapy, drugs,
and massage/relaxation.
Four out of 16 studies evaluating the effectiveness of acupuncture for the treatment of
migraines were rated at a high level in relation to their methodological quality. Of these
four studies, two studies showed a benefit from acupuncture, one study showed no
difference in comparison to sham acupuncture, and one study noted that acupuncture
was less effective when compared to standard care.
For tension-type headaches, two out ofthe six RCTS were rated as high for
methodological quality. These two studies indicated that acupuncture was effective for
the treatment of tension type headaches.
The authors stated that acupuncture appears relatively safe when administercd by
qualified providers- Although the type of acupuncture used and whether it should be
widely recommended could not be answered by the evaluators, and patients wishing to
try it should not be discouraged.
Tinnitus
One systematic review focused on acupuncture as a tleatment for tinnitus. Park et al. 23
identified six RCTS which compared electro or manual acupuncture in the treatment of
tinnitus to sham, physiotherapy, biofeedback, or medication. Park and colleagues
evaluated methodological quality using the Jadad Scale {0 (Appendix C). The type of
acupuncture stimulation and number ofsessions were described but not the
appropriateness ofthe acupuncture treatment. Four studies found no effect of
acupuncture on tinnitus; three ofthese studies achieved passable methodological
quality scoring by the Jadad criteria. Due to the low methodological quality overall, the
heterogeneity of the samples. and the ffndings of'no effect', the conclusion of the
rcviewerc was that evidence did not support the use ofacupuncture for the trcatment of
tinnitus.
Asthma
Two systematic reviews assessed the effectiveness of acupuncture in the treatment of
asthma, in addition to a Cochrane Review. Kleijnen and colleagues 28 reviewed 13 RCTs
that were based on needle acupuncture. They reported on the style ofacupuncture (all
but one were based on formula acupuncture) but did not evaluate the appropriateness
ofpoints chosen. The methodological quality of the 13 studies was rated on the
Kleijnen scoring system (see Appendix C). No studies of high enough quality were
found to conclude ifacupuncture was effective in the treatment ofasthma.
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In 1996 Linde and his colleagues published a review 2e of 15 tials including all but two
ofthe studies included in the Kleijnen et al. review. These excluded studies were not
.andomized trials. They were concemed that there had been no evaluation as to the
appropriateness of point selection; therefore four physicians who also taught and
practiced acupuncture evaluated the appropriateness ofthe acupuncture points chosen.
There was vadability in the assessment of adequacy oftreatment choice, but none ofthe
studies were evaluated as being totally inadequate. Jadad's scale a0 was used as well as
Linde's own scale to assess methodological quality ratings and were compared to the
ratings obtained in the Kleijnen scoring system (Appendix C). More similarity was
found between the Linde and Kleijnen ratings than those of Jadad. They concluded that
there was insufficient research ofhigh enough quality to recommend to acupuncturists
to stop treating asthma patients, nor to recommend to non-acupuncturists to start its
use,
A Cochrane Review by Linde, Jobst and Patton {2 using similar inclusion criteria was
published in 2000. Seven studies matched the criteria and were evaluated using the
Jadad Scale. One ofthe authors was experienced in acupuncture and evaluated the
adequacy ofthe sham-acupuncture, but not the appropriateness ofthe acupuncture
treatment. Objective measurements for lung function were included as well as drug
use. Subjective results were also accounted for in these studies. They concluded that
the efficacy of acupuncture for asthma can not yet be determined.
Although there were avariety ofcriteria used to evaluate the methodological quality of
the studies, the results obtained were consistent in stating that the evidence did not
support or refute the use ofacupuncture in the treatment of asthma.
Stroke rehabilitation
A review by Park and colleagues 2s included nine RCTS comparing needle acupuncture
to standard medical and rehabilitative treatments or sham electro-acupuncture, The
search included more than one complementary database, and study quality was
assessed usingJadad's Scale {0 (Appendix C). They identified variability in treatment
schedules, types ofstimulation, time ofinitiation ofacupuncture, acupuncture sites, and
use of quality of life measures. Numerous different stroke assessment scales were used
in the primary studies to measure the outcome, challenging the ability to make
comparisons between the studies. No mention was made of the evaluation of the
appropriateness ofteatment, although the duration ofheatment and whether it was
manual or electroacupuncture was documented. The authors found the quality of
studies to be poor (only two studies obtained a Jadad score of 3 or more) and stated that
the evidence does not support the use ofacupuncture for stroke rehabilitation, though
the findings show some promise.
Nausea and emesis

Peiicardium 6 (P6) is used in the treatment of post-operative nausea and vomiting
(PONV). Two systematic reviews evaluated the effectiveness ofP6. TheLeeandDone
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meta analysis 30 included 19 studies that evaluated post-operative nausea and vomiting
by comparing acupuncture andlor TENS to a control group receiving eitier sham
acupressure or treatment or a pharmacological intervention. No specific
complementary database rvas searched to locate primary studies nor was there a stated
search ofthe grey literature. Eleven ofthe 19 studies scored three or better onJadad's
Scale a0 (Appendix C). though there were many issues noted that hindered comparison,
including diversity of techniques used for stimulation of the point. Acupuncture was
not deemed effective in the control ofnausea and vomiting in the pediatric population.
P6 stimulations fo. early or late PONV compared to pharmaceutical treatments was
reported to have an equal effect, and when compared to sham or no treatment was
supedor in 20% to 25% ofadults within 6 hours oflaparoscopic and gynecological
procedures. There was inadequate data to determine effects oftreatment versus sham
for late PONV.
Vickers' review 31, which included a complementary database in the search strategy,
identified 33 studies and evaluated the methodological quality using the Vickerc Scale a0
(Appendix C). They divided the studies into nausea and vomiting post-operatively,
following cancer chemothe.apy, and morning sickness. A diveNity of treatments were
assessed in the primary studies such as acupressure, electroacupuncture. needle
acupuncture, TENS, and acupoint injections. Using acupuncture while under
anaesthesia was found to be ineffective at controlling emesis, in four studies. All but
two ofthe remaining 29 studies reported a positive effect for acupuncture in P6
anti-emesis. The author concluded that PO stimulation seems to be effective except
when it was administered under anaesthesia.
Back and neck pain

Five systematic reviews, including a Cochrane Review, examined the efncacy of
acupuncture for the treatment ofneck or back pain. White and Ernst 33 reviewed the
methodological quality of 14 RCTS on the treatment of acupuncture in neck pain usjng a
modified Jadad Scale. The initial diagnosis varied, including ankylosing spondylitis,
myofascial pain, osteoarthritis, and pain ofundefined etiology. The method of
acupuncture treatment varied, although most studies used formula acupuncture. The
control groups varied. including sham needling, TENS or laser, physiotherapy, waiting
Iists, and medication. These reviewers were ofthe opinion that there was no evidence
f.om sound clinical trials to support the use ofacupuncture for neck pain.
The Smith et al. review 32 examined the use ofacupuncture on traditional and
non-traditional points for chronic neck and back pain in l3 RCTs. Eleven RCTs
evaluated the effectiveness ofacupuncture in chronic neck or back pain and two studies
assessed acupuncture lor acute low back pain. They used theJadad Scale a0 to assess
methodological quality and also tested their own tool, the Oxford Pain Validity Scale
(OPVS) in the review (see Appendix C). There was no assessment as to appropriateness
ofacupuncture site selection. Nine out of II studies used multiple treatments for
chronic neck and back pain. Acupuncture, electro acupuncture or laser acupuncture
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was compared to sham, needling. laser, or TENS, waiting lists, or standard clinical
therapy. Most of the studies on chronic neck and back pain found either no difference
between acupuncture and control treatments, or found an initial positive effect for
acupuncture, but often after 24 hours there was no significant difference between the
treatments. The two studies examining acute low back pain after a single treatment
were evaluated to have no benefit over sham or acupressure with anaesthetic spray.
The conclusion ofthe reviewerc was that there was no evidence to support the
treatment ofback or neck pain by acupuncture.
Using methodological cdteria adapted from Koes (see Appendix C), Strauss 26 reviewed
results from four controlled clinical trials for chronic low back pain (LBp). There was
no evaluation olthe appropriateness of the acupuncture treatment, although the
discussion did address many ofthe problems associated with the assessment of
acupuncture including the skill of the acupuncture provider. Three of the studies
reported positive results for acupuncture, however these were ofpoor methodological
quality. The heterogeneity of patients and treatment methods, and practitioner
qualifications, made drawing any conclusion regarding the effectiveness ofacupuncture
in chronic LBP difficult. Though the author believed that acupuncture was a safe and
popular treatment for LBP, he recommended that rigorous research was needed to
determine the most appropriate treatment methods for specific conditions ofLBp.
Ernst and White 36 included 12 RCTs (9 into the meta-analysis) on back pain.
Methodologically this review was rigorous, with good data integration and assessment
of trcatment adequacy. Acupuncture was shown to be superior to waiting list and
physiotherapy but was not found to be superior to placebo except in one study on
severe pain. Odds ratios for unblinded studies suggested a strong placebo effect. They
recommended that further studies explore the specific and non-specific effects of
acupuncture, as well as the adveme elfects and cost-effectiveness ofthe various
treatments for back pain. to assist in determining the usefulness ofthese therapies.
The Cochrane Review by van Tulder 8 examined l1 RCTS on the effect of acupuncture
in chronic and acute lower back pain. This review followed the Cochrane Back Review
Croup's rules for assessing methodological quality (see Appendix C). No assessment as
to appropriateness of trcatment was made. There was conflicting evidence from low
quality trials comparing acupuncture to no treatment, moderate evidence that
acupuncture was not more effective than TENS or trigger point injections. and limited
evidence that acupuncture was not more effective than sham for the treatment of
chronic LBP. Overall this review reports that the ellectiveness ofacupuncture in t1-re
treatment ofLBP was unclear and, since there are effective altematives, the authors do
not.ecommend acupuncture as a regular treatment for LBp.
Chronic pain
Two reviews focused on the effectiveness ofacupuncture for the treatment ofchronic
pain. The appropriateness of treatment was not evaluated in either review.

Acupuncture: Evidence from Systematic Reviews and Meta analyses
The review by Ezzo et al. 3a used the Jadad Scale (see Appendix C) to evaluate 51 RCTS
in which patients with pain longer than 3 months were treated with needle
acupuncture. The review assessed the number offieatments, number ofpoints needled,
eliciting of'de qi', and type of acupuncture (whether formula or individualized). On$
'number oftreatments' seemed to be co.related with a positive outcome. The authors
found that the control group participants in studies using sham acupuncture (needles
were inserted) as the control had a proportionally higher improvement rate compared
to the control group participants in studies using inert controls such as, TENS, sugar
pills, and mock acupuncture (in which needles were not inserted), This led the authors
to propose, amongst other possibilities, that sham acupuncture was not physiologically
inert. They stated that they found limited evidence that acupuncture was more
effective than waiting lists and the evidence was inconclusive on whether acupuncture
was more effective than physiologically inert controls, sham acupuncture, or standard
The ter Riet. Kleijnen and Knipschild's meta-analysis 3e also evaluated 51 studies using
needle acupuncture (excluded surlace electrodes or laser acupuncture). but these
studies included patients with chronic pain of at least 6 months duration. They
assessed methodological quality based on criteria developed by ter Riet and colleagues
(see Appendix C) and found that further research needed to be conducted with more
homogeneous study groups, and better methodological design. The reviewers stated
that there are no published studies ofhigh enough quality and that the efficacy of
acupuncture lor this condition remains inconclusive.
Fibromyalgia
One review addressed the use of acupuncture for the trcatment of fibromyalgia 27. The
reviewers used the Jadad Scale to rate the methodological quality ofthe studies (see
Appendix C). They did not, however, identify the style (eg. classical TCM or formula
acupuncture), appropriateness of treatment, or the qualifications of the acupuncture
practitioner. The authors based their conclusions on one high quality RCT, which
found signiffcant improvement in both subjective and objective pain measures
compared to sham acupuncture but the duration of benefit was unknown. A lew
patients had woNening of symptoms during the treatment with acupuncture. They
state that their review may provide some practical information for practitioners on
possible benefits and risks ofacupuncture. Based on limited evidence, acupuncture is
more effective than sham acupuncture for improving symptoms (pain relief. reducing
morning stiffness, increasing pain threshold, and improving global ratings) in patients
with fibromyalgia syndrome.
Obstetrics
A Cochrane Review was conducted by Smith and Crowther a3 to determine the effects
of acupuncture lor the induction of labour. The authors noted that there were limited
observation studies published that suggested acupuncture appeared safe and effective.
Alberta Heritage Foundaljon for Medical Research 10

H€alth Technology Assessm€ni
Acupuncture: Evidence from Systemalic Reviews and Meta-analvses
None ofthe published trials, however, met the inclusion c teria and the authors
suggest the need for a well-designed RCT.
Addictions
Ter Riet and colleagues 38 conducted a meta-analysis that included 2Z studies.
euality
of studies was assessed using criteria developed by the authors (see Appendix C). The
outcomes assessed, however, were not clearly defined in terms ofaddiction treatments,
as they were only stated as the cessation of smoking. use of heroin, or use of alcohol. In
addition, no biochemical vedfication of cessation,/abstinence was included.
Fifteen ofthe 22 studies examined the use ofacupuncture (excluded surface electrodes
or laser acupuncture) in smoking cessation and reported acupuncture as not effective in
comparison to placebo; however placebo treatment was not identified. Five studies
reviewed the use of acupuncture in hercin addiction. The methodological quality of all
five studies was rated as low and therefore it was difficult to draw any conclusions.
Two studies using acupuncture for the treatment ofalcohol addiction reported a
positive effect for acupuncture reatment but these studies suffered from high drop-out
rates. No mention was made ofthe appropriateness ofthe acupuncture points used in
any ofthese studies. though the practitioner and treatment description were assessed as
part of the quality assessment. The conclusion lrom this review was that the evidence
does not support the use ofacupuncture in the treatment ofaddictions.
Smoking cessation
Two reviews examined acupuncture in the treatment ofsmoking addiction; the
Cochrane Review by White and colleagues aa and a meta analyses by White et al. 35. The
Cochrane Review included 18 RCTs in which smoking cessation was the outcome.
Acupuncture was compared to sham acupuncture or an alternative form ofcessation
intervention or to no inteNention. There was no assessment of appropdateness of
acupuncture sites chosen, but the treatment regimen was descdbed in the primary
studies. Only four studies reported any form of biochemical validation of smoking
cessation. Three studies indicated strong positive results for acupuncture in the
treatment olsmoking addiction. In two ofthese studies prolonged auricular
acupuncture was applied. The authors proposed that perhaps more rigourous study
into the effects ofintensive and continuous treatment was warranted. As \a,ell. they
suggested the importance olstudying acupuncture effects during acute nicotine
withdmwal. The review concludes that acupuncture was not superior to sham
acupuncture. Compared with other anti-smoking interventions there was no difference
but early results indicated it was superior to no intervention.
The meta analysis 35of 14 RCTs (12 RCTs sham-controlled) was thorough and methods.
as well as limitations, were clearly stated. The authors came to the same conclusions as
the Cochrane Review that there was no evidence that acupuncture was more or less
effective than sham acupuncture or other smoking cessation interventions.
Alberta Heritage Foundation for Medical Research 11

Health Technology Assessmenr
Acupuncture: Evidence from Systematic Revie$,s and Meta analyses
Weight loss
One systematic review on the eflectiveness of acupuncture and acupressure in weight
loss and hunger suppression was identified 37, Four sham-controlled clinical trials were
assessed by an "accepted instrument" used by Kleijnen, Knipschild, ter Riet (see
Appendix C), One study used an acupressure device. while all other studies used
varying auricular points. The conclusion of the reviewers was that fufther, well
designed research needs to be conducted to provide sufficient evidence regarding the
effectiveness ofacupuncture in appetite or weight reduction, but that there curently
was no convincing evidence to support the effectiveness of acupuncture for weight loss
or hunger suppression.
Summary
For the various conditions listed in Table 1, the respective reviews found that the
evidence supports acupuncture as an ellective treatment for dental pain, and
nausea./vomiting. Though the evidence for the other conditions such as idiopathic
headaches, back pain, chronic pain, and fibromyalgia was often inconclusive due to
methodological weaknesses, andlor conflicting results reported by the primary studies
included in the reviews, the results look promising. These reviews. the majority with a
good quality rating, found acupuncture to be as effective in the short term as the
conventional interventions or no t.eatment for these conditions. Many of the authon
noted that better quality studies provided negative results while poorer quality studies
tended to report positive results. Furthermore. they agreed that there appeared to be
insufficient evidence and that better quality research was needed.
Alberta Heritage Foundation for Medical Research t2

H€alth Technology Assessment
Acupuncturc: compilalnxt ofsystonralic ft:vicws ancl mcra analyscs
Table 1: Conclusions and quality rating of the systematic reviews
Condition Review Conclusions Quality Rating

Dental and TMD Ernst E, Piltler MH'?a Acupuncture can be effective in alleviating dentalpain Salisfactory
1998
Rostad P " 1998 Acupuncture was more effeclive than sham and had a similar SaLisfactory
effect as conventional lreatment
a1
Headache Lindc K, et al. Evidence supported the value of acupuncture for the treatmenl Cochrane Review
2001 of idiopalhjc headaches bul1he quality and amount of evidence is
not convirlcing
Tinnitus Park J, et al.'z3 Evidence of efficacy does not suppod acupuncture for the Satisfaclory
2000 trealmenl of chronic tinnilus
Kleilnen J, et al. Efficacy not supported by the resulls ofwellperlormed cljnical Satisfactory
1991
Linde K, et al.'zs lnsufficaent evidence to draw reliable conclusions
1996
a'z
Linde K, et al. Not enough evidence to make recommendations aboutlhe value
2000 of acupuncture
Slroke Park J, et aI. 'z5 Evidence does not support acupuncture in stroke rehabilitation Satisfactory
2001
Nausea and Emesis Evidence indicates signjficanl reduction in adults ve6us no Good
1999 qss
-te3!!9!!q9rp{?!lqr99q!!!lqgqsi!!t9
Acupuncture seems to be effective exceptwhen it is administered Good
1C96
Back and Neck Pain White AR, Ernst E 3l Evidence from clinicaltrials does not suppot the {realment of Good
1999 .neck pain
36
Ernst E, While AR Combined results indicaled lhat acupuncture for back pain was Good
1C98 glp-e,ILoIlg SqlllgLlllgrvenlions but not to sham
Smith LA, et a|.32 Evidence from valid trials indicates no analgesic efficacy for neck Good
2000 and back pain
26
Strauss AJ Efficacyfor chronic low back pain has not been demonstrated by Satisfactory
1S9S good clinicalstudies
Van Tulder I\,4W, et al. Evidence indicates that acupunclure is not proven effective for
u
2oo1 the treatmenl ot low back Dain
Albcrla Ilcrilagc Irou'rda(ion for M{{iical ltcsearch

l3
Hcalth Tcchnology Asscssmcnt
Acupu cturci Ividdrcc trom Syslomatic Rcvi{}ws and Mcta anatysos
Table l: Conclusions and quality rating of the systemaiic reviews (cont,d)

Condition Review Conclusions Quality Rating
Chronic Pain Ezzo J, et at. 3a
Limited evidence indicates that acupuncture is more effective Good
2000 than no lreatmenl; inconclusive that it is more effective than
sham, standard care or inerl conlrols
3'g
ter Riel G, el al. Efficacy of acupuncture in chronic pain (at leasl6 monlhs)
1990 remains doubtlul
Fibromyalqia Berman BM, et al. 27
Based on one good quality triatthe evidence jndicated significant Satisfactory
1999 symptom improvement compared to sham but duration of benefit
wtl4!9!!
Obstetrics Smith CA. Crowlher Observalional studies provided promising findings but no
43 Cochrane Review
cA 2oo1 randomired controlled studtes were lo.ated
Addictions ter Riet c, et al- 33
Efficacy for smoking, heroin and alcohotaddiclions are not
1990 suppotled bv evidence lrom qood chnicdl studies
Evidence indicates that acupunclure does not appear to be Cochrane Review
2000 effeclive for smokinq cessalion
Evidence indicates that acupuncture appears to be better in Good
lreatino smokino a.l.liclions c6mnarp.i
1^ thnaa riclc
^n 'lrifinn
Weight Reduction Ernst E 37
Based on two rigorous sludies there was no elfcct on body
1997
Albcrta Ilcritage Foundation for Modical Rcsoarch

14
Hcallh l cchnology Asscssrncnt
Acupuncture: compilation of systematic reviews and meta-analyses
OTHER REVIEwS
Systematic reviews are a synthesis and critical appraisal of p mary studies and
therefore play an important role in evidence-based decision making. Many of the
primary studies included in a systematic review may not be easily accessible to a
number ofpmctitione$ or busy practitioners may not have time to read all the
published research, hence the value of systematic reviews. A main limitation of this
systematic review ofsystematic reviews is that it did not take into account the evidence
from new research that may add to or change the conclusions. For example, since the
publication ofthe systematic review by Park and colleagues 25 on the eflectiveness of
acupuncture for stroke, a sham controlled study considered ofgood quality, indicated
negative results. The addition of this study to the systematic review would strengthen
the evidence to recommend against the use ofacupuncture for this indication.
In 1997 the National lnstitute of Health held a2 d,ay conference on acupuncture
^nd,1/2
specifically to evaluate the scientific data on the conditions, sks, and benefits. They
stated that there seemed to be potential usefulness based on the studies but, due to
flaws in design, sample size, and other factors, the results ofthe research were often
equivocal. The role of acupuncture in nausea and vomiting resulting f.om
chemotherapy as well as post-operative surgical and dental pain appeared to have some
of the best evidence. They also acknowledged that there are many other conditions for
which acupuncture may be useful as an alternative or adjunct treatment. Their
concluding comments focused on the issues oftraining and licensure, summadzing that
there was sufficient evidence to support further research and integration into
conventional medicine a5. Based on these results Medicare does not cover acupuncture
services. The coverage and analysis group, however, a.e open to receiving furthe.
evidence on the efficacy ofacupuncture (informed placement ofneedles with or
lvithout twirling, but not with electrical stimulation or moxibustion) for post operative
chemotherapy pain and nausea in adults and post-operative dental pain for dental
conditions covered by Medicare 46.
Ernst and White { reviewed seven systematic reviews on the effectiveness of
acupuncture for dental pain, low back pain, neck pain, osteoarthritis, stroke, smoking
cessation and weight loss. They concluded that there was strong evidence on the
efficacy of acupunctu.e for dental pain, low back pain, and nausea/vomiting. In
addition, they stated the need for .igorous research by experts in the field, and lunding
support to allow for the expansion of acupuncture .esearch.
Linde et al. a7 published a bibliography ofsystematic reviews in acupuncture. The
reviews they included were on the lollowing topicsr chronic pain, headaches,
dental/TMD pain, rheumatic diseases, addiction, nausea, asthma, tinnitus,
weight,/appetite reduction. and stroke rehabilitation. They only found convincing
evidence in support of acupuncture for postoperative nausea and against acupuncture
for smoking cessation. They also concluded that there were key issues around

methodological problems, lack ofresearch infrastructure and funding for research and
pointed to the complexities ofacupuncture as a group oftreatments for many and
vadous medical conditions.
A final review by Vickers as published in the fall of200I looked ar effectiveness in the
treatment ofacute pain. chronic pain, addiction, astima, nausea/vomiting, obesity,
stroke rehabilitation, tinnitus, and various other conditions. They found acupuncture to
be effective for postoperative and chemotherapy nausea/vomiting. and postoperative
dental pain. They also found that the evidence for acupuncture in obesity, sm;king
cessation and tinnitus suggested it is 'unlikely to be of benefit'. For the other
conditions, the evidence was insufficient to support any conclusions.
Comparison ofthese reviews with this report finds consistent support for the
effectiveness of acupuncture in the treatment ofpostoperative nausea,/vomiting, and
dental pain.
lssuEs tN AcupuNcruRE TREATMENT AND REsEARGH

Many issues have arisen with regards to developing a study model for acupuncture
research. Three key areas will be discussed:
. selection ofcontrol groups;
. complexities of acupuncture; and
. study design and assessment of methodological quality.
Selection of control groups

The use ofa control group is a key part ofclinical trials. It is the comparator group for
the experimental group receiving the treatment being investigated. The selection of
'credible' controls a.26, ae,50 poses a challenge for acupuncture research as controls can
range from placebo or 'sham' controls, to standard care, to no treatment at all. The use
ofstandard care or no treatment versus placebo or sham, and the effects of some .sham'
techniques on outcomes. are issues ofdebate in the literature 51.52.
Vickers and de Craen reviewed methodological literature and provided a summary of
arguments for and against the use ofplacebo controls in acupuncture 52. placebo use
enables blinding and potentially decreases drop out rates ofpa.ticipants in ,known
control groups'. Non-placebo control groups can have a higher drop-out rate, because
participants know they are not receiving treatment. Vincent and Lewith suggest
routine assessment of control g.oup members' perceptions oftheir treatments through a
'credibility scale' 53. The aim is to reflect patient perceptions olefficacy oftheir
treatment, and therefore the credibility ofthe placebo control.
Streitberger and Kleinhenz have developed a 'placebo needle', which mimics the visual
and tactile sensations ofacupuncture with a needle that does not break the skin, but
disappea$ into the handle 5a. Irnich et al. used'sham' laser acupuncture with visual
Alberta Heritage Foundation for Medical R€search 16

Acupuncture: Evidence from Syslematic Reviews and Meta-analyses
and acoustic signals similar to those found during active laser acupuncture ss. These
placebo or sham controls increase the patient's perception ofactually receiving
acupuncture treatment, and also enables double-blinding.
Placebo or 'sham' were defined in the studies included in the systematic reviews as
using non-traditional acupuncture points, superficial puncturing ofthe skin without
stimulation, introduction ofa sensation without puncturing (eg. acupresssure), or, in
the case of elechoacupuncture, the use ofelectro stimulators without connecting the
cables s. 'Sham' acupuncture, the most commonly used control in acupuncture studies,
is where needling is done at theoretically irelevant sites t3.50. It was initially believed
that acupuncture at these sites would have no effect, but many people now believe that
inserting a needle anywhere in the body or applying pressure to any site evokes a
response s2. s3, 57. This evocation of response can also be found with other placebo
controls mentioned. Others believe that there is a strict process to ensuring that'sham'
is truly placebo. based on where the needling is done in relation to the treatment
aCuPuncture 56.
The specific and nonspecific effects ofsham techniques are unclear. For example, ifthe
sham control group also shows benefits, the acupuncture featment may be deemed
ineffective in comparison to the 'control' group; however, this may be misleading ifthe
'sham' featment was actually evoking a physiological response similar to the
acupunctu.e treatment group. Though this does not clarify the issue around placebo
controls, it does illustrate the complexity, and the impact ofindividual trcatment styles.
Though the effects, both specific and non-specific, of acupuncture at various sites need
to be determined, the value ofsham acupuncture as a control is clear: the patients can
then be blinded to treatment, 'improving' the quality ofthe research study 58. The
choice ofcontrol group in acupuncture research. Iike in conventional medicine research,
needs to be guided by the research question. and the objectives ofthe research 52.
Complexities of acupuncture
Acupuncture is a complex 'umbrella' oftreatment apprcaches. Acupuncture includes
such a diverse constellation ofphilosophies and treatment styles. This means the most
accurate determination ofeffectiveness of acupuncture should include the evaluation of
each single, well-defined approach, versus evaluating the 'umbrella' oftreatments as a
single approach 58. However, the many types and methods of acupuncture are often
combined and compared in the systematic reviews. For example, manual stimulation
and electrostimulation have seldom been compared to each other as to their
effectiveness, but are considered the same in many systematic reviews.
As well, many microsystems are used in treating varying conditions. Ear acupuncture
is perhaps the most widely used, although other systems such as scalp, hand, foot, nose,
and abdominal acupuncture are also considered specialties. Formula and TCM
acupuncture are two diiferent styles. which are also often grouped together in reviews.
TCM focuses on a balanced system. It uses point selection based on symptoms, pulse,
and tongue diagnoses, and the choice of points used may vary from day to day as the
Alberla Heritage Foundation for Medicai Research 17

Acupuncturet Evidence from Sysrematic Reviews and Meta analyses
balance shifts. The "formula" or standardized approach in which the same prescription
ofpoints are used for each patient repeatedly is better suited for research, but perhaps
not reflective ofactual experience 5.7.
The individualization of diagnosis and treatment may be more similar to
psychotherapy or physiotherapy where the skill ofthe therapist and the bond with the
patient are as important in producing an elfect as the treatment strategies 7.ae. Thempy
is adjusted according to the subtle shifLs as they occur rather than continuing with a
standard pattern. There have not been studies to elucidate the effectiveness ofany one
ofthese acupuncture approaches over the other or whether they are equal in their effect.
yet they are compared against placebo or sham in studies.
There is also variability in the technique ofneedle insertion and manipulation that may
influence the efficacy but are often not reported in studies. Electrical or manual
stimulation may alter the outcome. Diameter. length, depth of insertion, duration of
retention, the number of needles pe. treatment, tempemture ofthe needles, the number
oftreatments, and materials ofthe needles may all be factors which influence the
OUtCOme 7,49.
Linde et al. 2e included four expert opinions in acupuncture to evaluate the adequacy of
the acupuncture treatments from a clinician's percpective. They were given a
questionnaire to evaluate the choice ofacupuncture points used in the studies. Linde et
al. found a low level olagreement bet$,een the four experts and posed questions of
clinical relevance.
Few researchers have investigated what adequate acupuncture treatment is, due to the
complexity described above, and little agreement has been reached for the various
conditions treated with acupuncture. Birch broke this challenge down into the
administration ofadequate treatments, and the adequacy ofthe repo.ting ofthe
treatments 5r. The difnculties in determining adequate treatment can be captured by the
following: Which sources,/evidence does one use? Can the treatments from a study be
standardized to a broader population, or is it specific to those individuals? How many
treatment points and sessions are the correct number for certain conditions? Is the
condition used alone or in conjunction with any other modes oftreatment? sr. The issue
ofinadequate reporting makes assessment ofthe research difftcult and makes the
gene.alizability impossible. The inclusion ofkey information is necessary to be able to
determine the adequacy ofthe treatment used.
Study design and assessment of quality

The issue ofstudy design is a challenge for acupuncture research. Some ofthe
systematic reviews. and the primary studies reviewed within. either lacked a st.ong
research design, and,/or an adequate description ofthe design on which a reader could
base an opinion 5s. For example, Linde points to the problem of small sample size in
many studies, leading to underpowering of the results 47. In addition, some of the
reviews found a positive co elation between low methodological study quality and
Alberta Heritage Foundation for Medical Research l8

positive outcomes 28 32 34 37. 38. This makes the determination of efficacy very difficult, as
it is hard to differentiate between true positive effects, and false positive effects due to
poor study quality, leading to inconclusive results.
There is also the issue ofassessing methodological quality ofstudies, not only for
acupuncture specifically, but for complementa.y medicine overall. Acupuncture is
based on differing philosophical models 4. 4e than Western Medicine. Using
methodological c te.ia validated in conventional clinical tdals, to evaluate acupuncture
trials may not be appropriate 4e. As in the determination of adequate treatment, one
needs to attempt to separate the quality ofthe research from the quality ofthe
reporting 60.
Many systematic reviews examined in this report used the Jadad Scale 40.61 as their
quality assessment tool, as it is 'the'validated tool among the assessment scales
available 61. This scale includes five criteria (see Appendix C), four ofwhich look at
randomization and blinding. Therefore, if a study does l1ot describe the randomization
process or blinding methodology, the quality is deemed to be poor, without considering
other criteria 5e. It also does not evaluate specifics important in acupuncture elficacy
research, such as the appropriateness oftreatment, the skill ofthe the.apist, and the
type and duration of treatment. Difficulties in blinding both practitioner and
patient a ae are intrinsic to acupuncture, and some criticism ofthe Jadad Scale has been
based on this 5e. Double blinding can, however, also be ofthe patient and the assessor
ofthe results, which means that acupuncture research could meet this c terion after all
6t. 62. This latter inclusion for double blinding is not known or understood by some
researchers. so studies may meet that criterion and be underscored in the quality
assessment.
Any quality scale should explore the clinical relevance ofthe question, the intemal and
extemal validity, the appropdateness ofthe methodologies, and the ethical
implications. There are many scales presently being used. though the key criteria to be
assessed have not been agreed upon. Experts debate whether five criteria, such as the
Jadad Scale, are enough to effectively determine quality of any research 5e and. on the
other hand, whether longer lists of criteda may be too unwieldy. There is also some
discussion whethe. scoring studies using set criteria is a useful tool for determining the
quality olthe research 60 61. The criteria are often used solely to present the study data
(10 trials were randomized. 12 were not) in a standard format, rather than to use it as a
tool to analyze the study. These issues also extend to the systematic reviews, as the
quality ofreviews varied f.om poor to good, and the review details provided were
minimal in some cases 28. 37, 3e. Associated with this is the lack of agreement on an
appropriate tool to assess the quality ofstudies in complementary medicine.
The continuing goal is the development ofstandardized and accepted criteria that are
effective in evaluating the quality ofstudies in complementary and alternative
mediajne 26,39,59.

DrscussroN
This project was undertaken to provide a critical appraisal ofthe scientific literature and
determine the status ofacupuncture as a treatment option for various conditions, to
assist health care decision-makers in Alberta, both rcgionally and provincially
regarding acupuncture services. Acupuncture has become increasingly popular,
especially for conditions of a chronic or recurring nature. Though the determination of
effectiveness of trcatment for each condition is the primary objective ofthe report, much
ofthe discussion has focused on the quality ofthe evidence and the issues in
acupuncturc treatment and research.
Just as there are methodological limitations ofthe prima.y research studies, there are
methodological limitations ofsystematic reviews, The quality ofthe systematic review
is impacted by the quality of the reporting of the studies included in the review. This is
even more ofan issue when critically appraising systematic reviews, which is further
removed lrom the primary rcsearch.
Overall. the systematic reviews examined (10 out of 18, excluding Cochrane Reviews,
had ratings ofpoor to satisfactor, were oflow quality methodologically, and reported
mixed findings with inconclusive results. Dental pain, and nausea,/vomiting are the
two conditions for which evidence supported the efficacy ofacupuncture as a
treatment.
For dental and TMD pain. two reviews both found that acupuncture can be effective as
a treatment, though there was no discussion as to the specific type and method of
acupuncture that would be the most appropriate 2?. 24. Rosted, finding most studies in
favour ofacupuncture, had concerns with the clinical relevancy ofsuch findings, as
there are other analgesics available, with simpler procedures 22.
A Cochrane Review oa headaches found that though the procedures seemed safe, there
were mixed results, and therefore the authoN made no statements regarding the
efficacy ofacupuncture for migraine or tension headaches a1.
The one review on tinnitus found that there was no difference between acupuncture
and sham, and that the evidence did not support ofthe use ofacupuncture 23.
Three reviews including a Cochrane Review on asthma reported inconclusive results,
and that claims of efficacy \ /ere not supported. One difference with the study by
Kleijnen et al. 28. however, is that they used only relative effectiveness as their
outcomes, meaning that acupuncture would have to be more, not equally effective to
the controls, to show results. Though the evidence was not strong enough to support
claims of efficacy. Linde et al. 2e concluded that the evidence was also not shong enough
to recommend to those using it, to discontinue. Overall, however, the use of
acupuncture was not supported for the treatment ofasthma.
The one review on st.oke rehabilitation found that though the evidence did not
support acupuncture effectiveness, the findings were promising enough to warrant

Acupuncture: Evidence from Sysremaric Revie$,s and Meta analyses
further and better research to determine the actual effectiveness ofacupuncture as a

treatment option 2.. However, two recently published blinded, placebo conbolled trials
showed no effect of acupuncture (personal communication, Vickers, White).
In the two reviews on nausea and vomiting 30.3r, acupuncture was found to be effective,
except for children and when acupuncture was administered under anaesthesia. The
positive effects were better than sham acupuncture or no treatment, and equivalent to
antiemetics.
Four ofthe five reviews focused on back or neck pain, found that the effectiveness of
acupuncturc for these types ofconditions was not supported by strong
evidence 8 26 32 33. A rigorous meta-analysis36 by Ernst and White found that
acupuncture was an effective treatment relative to other types oftreatment, and that
thei. rclative usefulness needs to be investigated. Though Strauss 26 believes that
acupuncture is safe and should be evaluated in more rigorous studies, the Cochrane
Review Group concluded that since there were effective altematives, that acupuncture
not be recommended as a regular treatment 8. These conflicting conclusions add to the
uncertainty in the interpretation ofthe research to date.
The two reviews on chronic pain 3l rs found that the evidence was inconclusive overall.
Ezzo et al. 3r also concluded that acupuncture for patients with chronic pain was more
effective than the waiting list control group. Ezzo and colleagues also questioned
whether sham acupuncture is inert, and what impact that may have.
The review on fibromyalgia discussed adverse reactions to the acupuncture treatment,
and even questioned whether this was an appropriate treatment for fibromyalgia 27,
Though their findings were based on one quality RCT with positive results. they still
felt that their review provided information on the benefits and risks, and raised
questions on efficacy that required further research.
Two reviews on addictions to alcohol or heroin; smoking addiction; and
weight/appetite reduction 38 3i indicated that the evidence was ofpoor quality and
found little support for the effectiveness ofacupuncture. Acupuncture appea-red to be
better than doing nothing for smoking addiction according to the results ofthe
Cochrane Review aa and another systematic review 3t with a good quality rating. The
review on weight and appetite reduction provided little information on which to
evaluate the quality, and the treatments being reviewed together were very
heterogeneous, both of which made the evaluation extremely difficult 37. Currently the
evidence does not support the use ofacupuncture in addiction treatment or
weight/appetite reduction.
Alberta Heritage Foundation for Medical Research 2t

Acupunctur€: Evidence from Systematic Reviews and Meta analyses
CoNcLUSIoNS
Growing demands on the health care system for public funding ofcomplementary
health seryices, the changes in legislation regarding the regulation ofhealth care
professionals, in conjunction with demand from the community for funding coverage
for acupuncture treatment underline the importance and timeliness of this review.
A large body of primary research exists in acupuncture, covering virtually every
symptom. Due to the breadth of this topic and the challenge of reviewing the extensive
body ofresearch on acupuncture, the approach of systematically assessing the available
reviews was chosen to evaluate the current evidence for the efficacy ofacupuncture. In
choosing this approach, it is acknowledged that there are limitations.
There are many issues in acupuncture research which are highlighted briefly in this
report that need to be explored and addressed in future studies. These issues range
from the assessment ofstudy methodology to the appropriateness ofan acupunctu.e
treatment regimen. The studies included in the reviews had many limitations and
variations. Variability among the studies included the technique of needle insertion
and manipulation, grouping of range ofacupuncture techniques, the number ofneedles
per treatment, temperature ofthe needles, material composition ofthe needles, and
selection ofconhol comparatoF. All ofthese factors may influence the study's
outcomes and the overall conclusions ofthe systematic reviews,
Many researchers concur that acupuncture is a relatively safe procedure howevet. it is
not without risk. Acupuncture can lead to both minor (drowsiness. nausea and
fainting) and serious (traumatic injury ofbody tissue) adverse events. There is an
increasing amount of literature published on adverse effects ofacupuncture, but there is
still a concern about under reporting.
Twenty-three systematic reviews on conditions such as dental pain/TMD, headaches,
tinnitus, asthma, stroke, nausea/vomiting. neck/back pain, chronic pain, ftbromyalgia,
labour, addictions, and obesity, were included in this appraisal ofsystematic reviews.
This systematic review confirms the findings from other reviews which indicate
consistent support for the effectiveness of acupuncture in the treatment ofpostoperative
nausea/vomiting. and dental pain. For other indicators the robustness ofthe effect of
acupuncture is debatable and its clinical value questionable for conditions such as
idiopathic headaches, chronic pain, smoking and fibromyalgia, ho'"'i,ever some reviews
indicated promising results. The results from these reviews 27 3136 ar, the majority of
which had a good quality rating, found acupuncture to be as effective as the alternative
interventions or no treatment in the short term.
Alberta Heriiag€ Foundalion for \,ledical Research 22

Acupuncture: Evidence hom Systenatic Reviews and Meta analj.ses
Overall, in terms of the volume ofresearch that has been created in studying
acupuncture there is a paucity of good quality research with large sampie sizes,
randomization, and control for placebo effects. There was a lack of study detail
provided in the reviews in regards to descriptions ofthe practitioners inirolved, Hence
it was not possible to relate treatment effect or no effect to service provider.

23
Health Te€hnology Assessment
Acupuncture: Evidence from Systematic Revie$6 andMeta analyses
APPENDx A: METHoDoloGy
Two searches were performed inJanuary andJuly 2001. The following outlines the
search strategy and the databases used. Effort was made to find criteri; accepted by the
acupuncture community as well as the scientific community for use in the critical
appraisal ofthe quality ofsystematic reviews for acupuncture. No quality assessment
tool specific to acupuncture was found.
Two ofthe co-authors (LB and CH) selected the arlicles based on the inclusion and
exclusion criteria while two co-authors (LB and pLT) extracted data lrom the re\,iews
and evaluated their methodological quality using criteria by Greenhalgh 2r as outlined
in Appendix B, The authors of the reviews were not contacted for misiing information.
Search Strategy
Databases Searched Subject headings (Bolded) and Textwords combinations
IVEDLiNE (Ovid) Acupuncture (exploded) OR acupuncture
1990-May2001 acupressure OR Electroacupuncture OR
and PTeMEDLINE electro-acupuncture OR staple acupuncture OR
to Ju v 21. 2001 staple-acupuncture OR stapleacupuncture OR staple puncture OR
HeahhSTAR (Ovrd) staple-puncture OR slaplepuncture OR moxibusiion
1991- Jan 2000 - database
disconlinued
Best evidence (Ovid)
Jan/Feb 2001
CINAHL (ovid)
1990-March 2001
EMBASE (Ovid)
199 2AA1
AMED (Ovid)
l\4av 2001
Cochaane Database of Acupunctur' OR acupressure OR eleciroacupuncture OR
Syslematic Reviews e ectro-acupuncture OR staple acupunct!re OR
1st Ouarter 2001
staple-acupuncture OR stapleacupuncture OR staple puncture OR
slap e-punciure OR stapleouncture OR nroxibusiion
CMA praclice guide lnes- acupuncture OR moxibustion
CPG lniobase
June 22,2aA1
National guide ine acupunclure OR moxibLtstiof
cearinghouse
June 22 2AA1
DARE HTA, EED AcLrp OR moxibustion
June.2001
Aiberta Heritage Foundation for Medicat Research 24

Subiect headings (Bolded) and Tgxtwords combinations

WWW| ECRI, Bandolier, and acupuncture OR acupressLrre OR electroacupuncture OR
other HTA agencies electro-acupuncture OR stap e acupuncture OR
websites
staple-acupuncture OR stapleacupuncture OR staple punciure OR
cture OR staDleounciure OR moxibustion
Two other databases, ISTAHC. Psyclnfo (February 2001), were searched but there were
no relevant studies found. Articles were submitted by various people interested in
acupuncture. and access was gmnted to a private collection ofjournals ofacupuncture.
This 'grey literature'was hand searched for articles that complied with rhe inclusion
cdte.ia. Reference lists of retrieved reviews were search for systematic reviews and
meta analyses.
Publlcation type limirs (where available): meta-analysis, systematic review
"A systematic review is an oveNiew olprimary studies that use explicit and
reproducible methods" 21.
"A meta analysis is a mathematical synthesis ofthe results of two or more primary
studies that addressed the same hypothesis in the same way" 2r.
These publication types were searched as textwords and where publication type
Iimiting was not available by using this search stringr (Subject headings OR Textwords)
AND (systematic review OR meta analysis OR critical appraisal OR metaanaly$ OR
meta-analy$ OR metanalys OR critical$ apprais$ OR systematic$ review$)
Inclusion diteria: Articles were selected if they were systematic leviews, which
includes but is not limited to meta-analyses. The study must have human participants,
but with no restriction ofage group or nationality. Reviews were requi.ed to have an
intervention of acupuncture as being the primary treatment intervention in the study.
Studies addressing any medical indication were included if they were published within
the past ll years (1990 - 2001). Only reviervs available in English were evaluated.
Exclusion criteria: Reviews were excluded if the use ofa tool to evaluate the
methodological quality of the primary studies rvas not apparent. If reviews used the
same methodological c.iteda and had the majority of primary studies in common, the
older publications were excluded.
lncluded studies:
. Ernst E, Pitder MH. The elfectiveness ofacupuncture in treating acute dentalpain: a
systematic review 21
. Rosted P. The use of acupuncturc in dentistry: a review of the scientilic validity of

published papers22
. ParkJ, White AR,EtnstE. Ellicacy ofacupuncture as a trcatment fot Tinnitus23
Atberta Heritage Foundation for Medical Res€arch 25

Acupuncturei Evidence from Systematic Reviews and Meta-analyses
. KleijnenJ, ter Riet G, Knipschild P. Acupuncture andasthma:a review ofcontrclled

trials2s
. Linde K, Worku F, Stor W, Wiesner-Zechmeister M, Pothmann R, Weinschutz T, et
al. Randomized clinical trials of acupuncture lor asthma - a systematic rcview 2s
. ParkJ, Hopwood V, White AR, Ernst E. Ellectiveness ofacupuncture fot stmke: a
systematic review2s
. Lee A, Done ML. The use of nonphamacologic techniques to prevent postoperative nausea
and vomiting: a mek-analysis 30
. Vickers A. Can acupuncture have specific etects on health? A systematic review of
ac upu nc ture antiemes is tri als 3l
. White AR, Ernst E. A systematic reuiew ofrandomized controlled trials ofacupuncturc for
neck Pain33
. Smith LA, Oldman AD, McQuay Hj, Moorc RA. Teasing apart quality and validity in
systematic feviews: an example from acupuncture trials in chnnic neck and back pain 32
. Strauss AJ. Acupuncture and the treatment of chronic low-back pain: a review of the
Iiterature26
. Berman BM, EzzoJ, Hadhazy V, SwyerslP. Is acupuncture ellective in the treatmert of
fibromyalgia? 27
. Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB . Is acupuncture ellective
f1r the treatment ofchronic pain? A systematic review3a
r ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteia-based meta
analysis 3s
. White AR, Resch KL, Ernst E. A meta-analysis of acupuncture techniques for smoking
cessation 3i
. ter Riet G, KleijnenJ, Knipschild P. A meta-analysis ofstudies into the ellect of
ac up u ncture on addic tio n 38
. Ernst E. Acupuncturc/acupressure for weight rcduction? A systematic review3r

. Linde K, Melchart D, Fischer P, Berman B, White A, Vickers A, et al. Acupuncturc fot
idiopathic headache (Cochnne review) !1
. Linde K,JobstK, Panton J. Acupuncture for chronic asthmaa2

r van Tulder MW. Cherkin DC, Berman B, Lao L. Koes BW. Acupuncture for low back
pains
. White AR, Rampes H, Ernst E. Acupuncture for smoking cessation44
. Smith CA. Croq,ther CA. Acupuncture for induction of laboura3
Albena Heritage Foundation for Vedical Research 26

Heaith Technology Assessment
Acupuncture: Evidence from Sysrcmatic Reviews and Meta analyses
. Ernst E, White AR, Acupuncturc for back pain: a meta-analysis of nndomized contt,lled
trials 36
Excluded Studies:
. Ernst E, White AR. Acupuncturc as a treatment for temporomandibularjoint dydunction:
a systematic review of randomind trials63 - methodological quality was not discussed
. Ernst E. Acupuncture as a symptomatic tftatment of osteoarth tis. A systematic revlew ia -

did not use a 'tool' to evaluate methodological quality
. Ernst E. Acupuncturc as an adjuvant thetapy in stroke rchabilitation? 6a ' does nol
discuss methodological quality
. Hopwood V. Acupuncture in stroke recovery: a litetature tevlew 65 - methodological
quality was not discussed
. Rosted P. Survey of recent clnical studies on the treatment of skin diseases with
acupuncture 66
. Melenger A, Borg steir\J. Acupuncturc and sports medicine. A review ofpublished
studies6T
. South NA. Acupuncture for the treatment of trithdrawa] sruptoms in detoxilication

processei 68 - did not review methodological quality olthe studies,
. Ashenden R, Silagy CA, Lodge M, Fowler G. A meta-analysis of the ellectiveness of

acupuncturc in smoking cessalrbr 6e - included in the review by white and Rampes
. Green CJ; Kazanjian A; Rothon DA. Acupuncturc in the management of alcohol and
dMg dependence 7a report in dmft stage
. Baillie AJ, Mattick RP, Hall W, Webster P. Meta-analytic rcview of the elficacy of
smoking cessation interventionsTt - no clear systematic review of the literature is
outlined. Databases used are not identified.
. Melcha D, Linde K, Fischer P, White A, Allais G, Vickers A, Berman B.
Acupuncture fot recurent headaches: a systematic review of tundomized controlled trials 72
- included in Cochrane reviews

Three 'reviews' were identified by the search that are currently in the form ofprotocols,
not reviews, with the Cochrane group. They are as follows:
. HeL,ZhouD,WuB,LiN. Acupuncture fot Bell's palsy (Protoco, n
. Green S, Buchbinder R, Hall S, Barnsley L, Forbes A, SmidrN,elal. Acupuncture for
laterul elbow pain in adults (Protocol for a Cochrane Review)73
r Richardson MA, Allen C, ExxoJ, Lao L, Ramirez G, RamirezT,etal. Acupuncture for
chemothenpy-induced nausea or vomiting among cancet patients (Protocol for Cochrane
Review) 7a

Health Technology Assessm€nt
AcupuncLurc: coDrpila&rn ofsysrcmatic rcviows and mola anatyscs
AppENDrx B: DATA ExrRAcIoN AND euaLtry AssEssMENT oF INCLuDED STUD|ES

Table 2: Data extraction and quality assessment of included studies
Study Design lype Endpoini Oata inregEtion
(Ouality Ratins) Reviewers assessment
Dentalan d TMD Pain
Jff*""""-, svsr"."t" I lo *rtu - Dala reviewed suggest Clear question, search
l"=," eiJeclive in allevjating extraction was delailed,

L, *,'n,".
Ihe conclusions lhat can
and quality assessment
lhe olher s be drawn are limiled, Results interprcted in a

Emsr E. P,(er I
I
werc ccrs I methodological qualily of Comparisons of sludies
setting.
tsarisracroryt I
lu"ot,n.. I !ii,ff'-."" using variouslechniques
and duration. and for
I r'o,",v. I sludies.lrials
methods of lhe sludy
Difficuli lo glean the
l."uo".
lctscotr rr'.t
I
acupuncture techniques. praclical implications.
o'" rr*. o,scurs.n Sham acupunclure had

posilive eflects as well.
lnadequale description
I
acupuncture treaiment
] No conclusive evidence
I
l",pu,r"in tn" I I acupunclure that is best
for denlal analgesia, and
I
I
I I oL,orrsrreo ano I I
I
wdl I
l _l
AIbc{a Ilcritagc loundalion for Mcdical Rcscarch

Hcalth 'l cchnology Asscssmcnr 28
Ampuncturri: Ilvidcn{l) liom Systc )alic Rcvicws and Mrta-anatyscs
Table 2: Data extraction and quality assessment of included studies (cont,d)

Design type Endpoint ReYiewers assessnent
Sample size
Search sir.teqy
Dala inlegralion Objeclive is clear, search

exlraction studaes, three stElegy was adequale
lisr ol 24 and inclusion/erclusion
N= 15-all
RCTs resulls. This linding
musl be intefpreled with
Outcomes descibed in a
ol 92 poinls, simplislic way of positive
Biological or negalive. Makes il
Rosled P 1998" diffacull to determine lhe
lSatisractoryl
questionable, as the time relaled to lhe effcacy of
Science needed for acupuncture
before a procedure is
much longer than other
methods ot aneslhetic. assessmenl of method
ctscoM tanguages - qualily was more lhan
English, For facialpai. and TMO,
Gelman, Danish. appropriale compadsons
and conclusions drawn on
resulls, and could be
This is nol a lreatment
60%. effecliveness study, as
TENS or laser Eleven of 1 5 RCTS lv€re much as a melhodoloqy
in favour of acupunctue
and shown ir ro be befler
lhan sham, or similar lo Dala was grouped to
convenlional treatmenls. illuslrate if lhere w€re
pailems between lho
methodolog ical score and
highest melhodologically
Albcrla Ileritagc lroundalion for Mcdi0al Research 29

Hcallh l cchnology Asscssmcnt
A(upunclurc: Ilvidorcc fro Systcmalic Itcvicws and Mota nnalyscs
Table 2: Dala extraction and quality assessment of included studies (cont'd)

Study Endpoinl Data integration
(Quality Ratins) Reviewers assessment
N=26 trealmenl of rccurrenl

headaches, but most
[,IEDLINE, werc melhodoloqically

Oualily of
(15)
(6)
- mixed (1)
(1)
Albcda Ilcritagc loundalio lbr Mcdicat Itcscarch

30
I Icalth Tcchnology Asscssmcnl
Acupuncturc: Iividcncc liom Systcmalic Iicvicws an(l Mcla analyscs

Study Design type Endpoint Data inlegration Reviewers assessmerr
(Oualily Ratinq)
The objeclive was clear,

positive eflecl and four and the search stralegy
sludies thai we.e sham adequale. Theinclusion
Tinnilus N= 6 all RCTS
differcnce belreen lhe
23 Ouality assessmenl was
20oo adequale according lo the
suggesting non-specifl c
etrects oI acupuncture. Jadad scoring, lhough the
lSalisfacloryl
sample was quile small.
[,lelhodological quallty
crscoi/ was Poor, with only lhree
adequate, excepi for the
AMED and
Brilish Library
Studies reviewed provide

little information, as lhe
acuPunclurc may have oulcome measures varied
across sludies, and there
was no inlegralion of dala
Diflicull to inlerprel rcsult
as lhe grcups were very result lhatwould be useful
as a practical applicalion.
supported by evidence.
Albcrta Flcritagc Foundation for Medical ltcscarch 3l

Hcalth Tcchnology AsscssDlcDt
Acupundurc: Ilviclcncc liom Syslcmalic Rcvicws and Mcra rnatysos

Study Oesiqn type Endpoinl Data int€gration Reviewers assessment
(auality Rating)
Qualily Data integmtion: The objective is faidy

arcund whelher sham clear, bul the search was
N 13
acupuncture is an aclive not comprehensive. The
regading placebo or not, and lhe inclusion/exclusion crile.ia
Kleijnen J, elal
19C1
_ lradiiional and Weslern
thal [ledline CD- Quality was assessed
lsalisfactoryl RON4s, of 100. usang standad criteria
Concerns wilh the use of
mela-analysjs and the
Bolh lhe Study oulcomes we€
only listed as positive or
Though eight of lhe 13 prcsenlation in lhe inilial
results, only lhree had

quality scores above 50
in English and lhe five negative
result studies had scores
Claims ofthe eflicacy of

English studies.
lrealment of aslhma are
not suppoded by well
peformed clinical lials.
Albc(a Ilcritagc loundation for Mcdical Rcscarch

Hcalth Tcchnology Asscssnrcrl
Acupuncturc: Iividcnc{} liom Sysl{}malic Itcvicws aDCl Mc1:r analvscs
Study Design lype En.lpoint Data inteqration RevieweB arsessment
(Ouality Ratins)
From a clinical standpoint The obleclive is clear. The

comparabilily of the tr ats
N = 15 RCTS
inlerprelation and clinical
applicalion is very difticutt.
Qualily assessment was
1996,e Difficull io interp.el the low
l',ledline CD' rateFagreemeni f indings comprehensive manner
IGoodl ROMS (1983 using two scaies separalety
assessing ac!puncture
quality. May bedue toa
lack of agreement otwhat Quanlitalive measures of
good qualily acupuncture lhe studies results were
AMED, is, a poorly designed tool, incllded fo. readers lo see
clscor\4). or an inabilily lo interpret
for clinical applications, compared on key variables.
(1991). Their conclusions were
delailed and supported by
the.evlew of the trials in
moslly on the beliefs and

allitudes of lhe.eviewers.
Due lo lhe hete.ogeneity
insufficient data, the highly

Dulch) conlradictory resulls are
Can neilher recommend

to acupuncturists to cease
lreating aslhma Dalienls
nor recommend io start its
Albcrla Ucritagc loundalion fbr Mcdicat ltcsca.ch

Hcallh Tcchnology Asscssmcnl
Acupunc(urci lividunr liot) Systcma(ic llcvicws and Mcla analyscs
Table 2: Data extraction and quality assessment ot included studies (cont'd)

Study Design type Endpoinl Reviewe.e assessment
(Quality Ratins) Sample size
Search strategy
Did not find acupuncture
N=7RCTS needed. Poinls ofsome

of lhe sham lreatmenls
would be considered for
global lrcatment of asthma by
Albcrla Hcritagc F'oundation for Modi(al Rcscarch 34

Hcalth l echnology Asscssrncnt
Acupuncturc: Evidencc fi.om Systonaric R{}vicws and Mcra analyscs
Design type Endpoint
Stroke Rehabilitation
Lack of homogeneity of The objellive or the siudy

iniervenlions and outcohe was clear. Search slrategy
N= 9 RCTS was suflicient and inctusion
syslematic review very
P5ark J, el al.2001 difiicult
Qualrty assessmenl was
done using a validated toot,
improvement when using and dal8 en.acliob was
Chinese scales, and no
ctscoM Daily Living signiticant improvement
(including when using a Weslem
AMED), olher
integralion, so the overatt
findings, though rcbust.
sufiicienlly promising to were based on summary
The authors state that lhe

Overall evidence does not poor melhodologicat q!atity
supporl ihe effeciiveness impacls on lhe cerialnly of
of acupuncture tor shoke the inlerpretalions of ihe
resulls This indicales the
Albcrla Hcritagc F-oundation Ibr Mcdicat Rcsoarch

I lcalr l1 Tcchnology Asscssmcnt 35
Acupuncturc: Iavidcncc tr$D Sysrcmaric ltcvicws and Mcta anatyscs
Nausea and Emesis
Well designed pedialric

siudies tailed to show a rnclusion criteria were
signilicant benelit using clear. The seamh strategy
complementary dalabases
There was a siqnficant The qualily assessmenl
lale (G48 reducl on in early onset
PONV in adults versus supported by reliability
30 placebo or drugs, and in
1999
PONV late onset PONV versus
Clear oulcome measures
IGoodl
and strong quanlitative
Data was integraied well,

variaiion in lhe length of
trealmenl trom 5 minules descriplion or assessmenl
Lale oulcomes results Findings are rcbust and

were based on studics should be generalizable lo
PONV wilh small samples, so the larger population due io
lhe strength of melhods
The aulhors .ecognized

and staled limilations and
the potenliat impact on lhe
ihose who have adverse

reactions lo anliemelic
drogs or wish to reduce
Albcrta IIcrilagc Foundation for Mcdical Rcscarch

36
I Icallh Tcchnology Asscssncnt
Acupuncluro: tividorcc fr.orD Sysrcnraljc ltcvicws and Mcra anatyscs
Table 2: Data extraction and qualily assessment of included studies (cont,d)
Design type Endpoinl
Sludy quality Pe6 slimulalion is an objeclive was clear, as

were the inclusion criteia.
N = 33 CCTS, lechnique,lhough not Search was inadequale,
RCTs oppodunily lo find srey
clscoM, found lillle difference Assessment of sludy

between groups, which quality was adequate. bur
lhe scorinq was quile
vomiling subjeclive, and there was
IGoodl weighling not slandard weighting of
Ieading ilself, in lrealmeni and
Outcome measures were

rcporled wilh staiislical
conclusions up to lhe data,lhough there was
liltle inlegralion of lhe
data, and no mention of
27 of29 studies lbal did
showed acupuncture as
lhough lhe
Summary of lhe quality
and the resulls. minimal
dala inlegration of the
Based on lhe number of

posilive versus negalive
findings, the authols
feasible; however. wilh
(includins
TENS, acupoint
Albcrta Hcritagc lounrlatton tor. vca icai ncscarch

llcalth Tcchnology Asscssmcnt 37
-
Acupuncturc: Ividcncc fr.oln Sysrcmarj(j Rcvicws and Mcta anatyscs
Table 2: Data extraction and quality assessment of included studies (cont'd)

Study Design type Endpoint Data integration
(Quality Ratino) Reviewers assessment
search 6tralegy
Data integralion Sludies werc balanced Search adequale, the

belween posilive and
N 14 inclusion andexclusion
belweeo a better quality
of5. [4otion (RO[4) Qualily was assessed

using a standard tool.
33
E 19SS The endpoints werc well
language
clinical lrials needs to be described with p,values
IGoodl ClSCO14, lheir included. but lillle data
Though the adequacy ol

felt that it
Some studies suggest
that precise techniques
assessed. the rcview's
lisling no
authors rccognized this
limitalion and lhe need in
future studies for lhis
vaiable ro be included.
equipoise in the resulls
of lhe .eview ro justifyTheir conclusions alrd
recommendations make
assuming acupuncture is sense and arc supported
by the lindings in lheir
treaiment of neck pain is

not suppoded by curent
Albcrta Hcrilagc Foundalion for Mcdical Rcscarch

38
I lcalth lcchnology Asscssmcnt
Acupun{1urci Itvidorrcc lionr Svsrcnlatic R(:vn}ws and Mcr:l anatvscs
Table 2: Data extraction and quality assessment ot included studies (cont'd)
The high odds mtio of Objeclive is clear, search

inleglaled using unblinded studies may sitategy was adequale,
N = 12 RCTS
suggesf an association and inclusion/exclusion
between acupuncture
ralng Qualily assessment used

36 Acupuncture has been
1998 shown lo be superior to Endpoinis were slaled,
tGoodl CISCO[,'1, gray Spanish,llalian
interuentions. but it was
not shown lo be superior
Dala was analyzed well.

and integ.aled thoroughly.
Further studies rcquired
effects as well as non- lreatment adequacy was

rigorous,lhough only I of
lrial the 12 included sludies
were incorpomred jnlo the
The limitaiions of lhe
descibed, and next sleps

for research suggesled.
The findings were clear
Albc[a llcritago loundation Ibr Mcdical Rcscarch 39

Heallh'f cchnolouy Assossmcnt
Acupunclurc: l-vidcnco fmm Systoomtic licvicws all.l Mota-analvscs
Table 2: Dala extraction and quality assessment of included studies (cont'd)
Sludy Design type
(Quality Ratinq)
Endpoint Data inlegmtion lnt .ptul"lion,.d RevieweIs assessment
Though the lrial objeclives and inclusions

conclusions lead to no criteria werc clear. and
validily in global
N= 13 RCTS rclationship belween the search was faifly
(11 in chrcnic sludy validity and lial thorough, no search on a
findings,lhis review s complementary medicine
aulhols found that ther€ dalabase. Dataexlracted
24 hours) or
Large discrepancy in
negalive findings. melhods of lrealmenl
which.educed the degree
There was insufficienl of analysis lhat could be
2000 ' data io answer many
tcoodl lhe OPVS, (oPVS score) Qualily/validily
OPVS may be a useful assessment Iool was
findings acco.ding to validlly in added a lurther degrce of

groups, <10 qualilalive rcviews. One slrength lo their findings
benelil oflhis melhod
liallindings inclusion citeria can be

used melhodologically,
validity wilhout decreasing llle Dala was inlegraled jn the
analysis of validity and
study outcomes, but was
No convincing evidence minjmalregarding lhe
aclualoutcomes and
acupunclule in lreating
Their ovemll conclusions
were robust. and rculdn l
be significantly allercd if
inclusion c teria were
adjusted lo include or
exclude cerlain sludies
Alberta Horitage loundation for Mcdical Rcscarch

Ilcalth Tcch olo&y Asscssmcnr 40
Acupuncturc: tsvidcncc from Syslcl alic Rcvicws and Mclr .rnalyscs

Study Design lype Endpoint Reviewers ass€ssment
(Otlality Ratins)
Three studies showed Search slrategy was not
This rcview shows some

complemenlary medicine
Slrauss AJ 1999 N=4CCIS literalure. The objeclives

and inclusion crileia were
weighling,
ISalislacloryl [,EDLINE,
Aulhors {lsed a sel of
CINAHL, =100
English future research design. craleia lhat assessed lhe
t!1ANTtS,
ne@ssary items lo be
AIIIED, AIVII, lmponant thal singte-
blind sham conlrolled
RCTS a€ completed to lreatmenf s efticacy. No
show lhe validily of this
menlion of who did the
Lillle dala inlegration

:onclusions regarding the
rcupunclurc, from lhese

)oorly designed kials. acupunclure trcatmenl
and the practitioner were
Very few details, outside

of the lable of quality
sludies. Difticull lo check

or duplicate the review's
melhods and findings.
Albcrta llcritage loundalion for Mcdiml Rcscarch 4l

Hcallh Tcchnok)sy Asscssmcnt
Acupundurc: Ividcncc fr.om Systcnr.rtic ltovjcws and Mola,analyscs

Study Design type Endpoint Data inlegration
(Qualily Ratinq)
proven effective fo. lhe

N.11 RCTS lrcatment of back pain
accordlng ro rhe siudies
idenlitred in lhis review
Disability Scale,
Albofla rlcritagc IroLndalion ibr Mcdicat Roscarctr

Hcallh 't cchnology Asscssmcnt 42
Acupuncturc: Lvi(lcnce fron) Systonatir Itcvicws artd Mela analyscs
Table 2: Data extmction and quality assessment of included studies (cont'd)

Sludy Design type Endpoint RevieweB assessment
(Ouality Raling)
Search slralegy
Chn
Obje.tives and inclusion
con t rol qroup lype makes lhe

resulls more comparable lo
outcomes assessmenl l.
deiine signficance but we€
not pEsented in lhe Ev eu
Dala Ms well Jnlegraled
across studies 5nd rhe use
oi stalislical melhodologies
makes lhe lindinqs more
tEatment examined. lhe
Auihors reporled lhe €sulls
unknowns (eg. Possible
Review lindings are robusl

and lhe removal of one or
Alberta Heritagc Foundation for Mcdical ltesearch 43

Acupuncluro: Evidcncc from Syslcmalic Rcviows and Mcla analyscs

Study Q!estion/ Desiqn type Endpoint Dala integration Reviewe6 assessment
(Ouality Rating)
No def initive conclusions

on lhe efficacy can be comprehensive, but their
N=51 objeclives and inclusion
alleviating melhodolog ical quality of
3e Used a veified lool to

1990 Some rcviewer bias may
lvledline cD- 100
ROI\,1S, be involved as lhey were
nol blinded to lhe sludy Data was integraled well
methodological scores.
More research needs lo
be conducted wilh more Study oulcomes were
only lisled as positive or
English abslract melhodological qualily slatislical data presented.

(ifan existing
The aulhors examined lhe
Results arc conlmdictory rclalionships betw€en
English was
between positive and varaables well, but lhe
chronic pain condilions included studies are not
Albcrta Hcritage Foundalion for Mcdical Rosearch

44
Acupunclurc: Ividcncc from Systcnratic Revicws and Mora-analyscs

Srudy Oesign type Endpoint Dala integ.ation Revi€weB assessm6nt
(Quality Ralins) Samplesiz€
Fibromyalgia
Objectives and inciusion
cnleda we€ clear, and the
acupuncture, which may be
claled to lhe etiology ol ihe
disease. Physicians should
Only three studies had any
MANTIS, number ofFMS palienls follow 0p per ods, and iew
used any endpoint measues
lhal we€n t self-repo.led.
Qua ily assessment uses lwo
aulhors dont report the

This revrew may provide
c{scoM, NtH praclilioners some practical summary of data extraciion
infomation on lhe beneiits (even lhough a sludy s'high
and risk s of acuponctu re, s@p is mentioned in the
raisinq questions for lulure
Eseatuh, nol addressing Evidence is based on only 1
slody. and lhe.efore would
be considered sensiliee
Then .onclusron lhat this
review en be used lor some
acu P u nclue experienced
sign icant improvehenls in .aisi.g reseaah quesiions,
subjective and objelive
Albcrla Hcritage loundattonforMcdical Rcs€arch 45

Hcalth Tcchnology Asscssnrnt
Acupuncturc: Ividcnce from Systcmalic llcvicws and Mcla anatysos

Design type Endpoinl Data integralion Reviewers assessmert
Search slrategy
lnduction of Labour
Need for a welldesigned
RCT lo evaluate the mle
N=0RCTS
Smalh CA,
a3
Review 2001
childbinh
Group lrials
bibliogmphies
Albcrla Hcriragc [oundarion for Medical Rcsoarch 46

Acuplrn(xurci lividoncc li.om Systcnratic Rcvicws and Mirla analyscs

Study Design type Endpoint Reviewers assessment
lQuality Rating)
A lisr oI 18 Trcnd between quality

of studies and resull, in broadt it could be mo.e
N = 22 CCTS - ihal higherqualiiy specif ically slaled. Their
literalure search was
100. Points
RCTs
inclusion craleia were
36 There is no evidence
1990
tPoorl Medline CD No iesults other th.n +/-

RO[,{, Excerpta lreatment of addiction
The ulility of
acuPunclurc in heroin robust in that they saw a
common Pattern across
sludies. which wouldn t
have changed dmstically
ifa study was removed.
alcohol addiclion needs
drop out rales seen in
English was
when the sludies are of
involving
significantly Acupunclure has not
prcven lo be efficacious
as a trealmenl for these
Albcfia Hcrilagcloundatio'1 lbrMcdicalRoscarch 47

Hcalth l cchnology Asscssmcnt
Acupundulc: lividcmc lionl Syslcrrlalic Rovbws and Mota analysos

Sludy Desisn type Endpoint Data integration Reviewers assessm€nl
(O!al'ty Rating) Tool
Search strategy
Majority of studies did
randomizalion prccess
N = 18 RCTS
R€view 2000 " ofskill.

acupuncturc incrcases
Group lrials
smoking compared Io
sham, bul appeared lo
(less than 6
rclhing
12 monlhs. lf
Social
poinls (including
Smoking&
Heallh.
Biological
DRUG.
bibliographies.
Alhcrta Hcrilagc Found:rlion for Mcdical Rcscarch 4lr

rlcall h 'l cchnology Asscssmcnt
Acupunclurc: Ividcnco from Systcmalic llcvicws and Mda anatyscs
Table 2: Data extraciion and quality assessment of included studies (cont,d)

Design lype Reviewers assessment
Subgroups Acupuncl{r.e did seem lo Though it was stated that

be more efleclive than lhey contacted oiginal
authols for additional
study details, lhey then
English, Frcnch smoking at3 effecl, lhougtt short{erm stated lhal lack ofdelall in
E[,IBASE,
15 in smoking Brilish Libmry, righl afier Acupunclurisl should be
1999
ctscot\,1,
quality oi lhe lechnique
IGoodl defl ciency across sludies.
lhe This review reflecls thal
This meta-analysis was
lack oi clear hypoiheses
lhorouqh. ll clearly staled
re:role of acupuncture an
its melhods, limilations of
up lo 100 smoking cessalion bolh
findings.
Future research needs

Fairly robust - removing
melhodological aspecls,
biochemical validation of
cessaiion, longer follow scenarios ifa study was
rcmoved, or some sludies
delails, werc grouped rogether
and analyzed, rcsulls
efiective lhan sham. or
lhal one acupuncture
efieclive lhan another
I igour.
Alberta Hcritagc loundation for Medical Rcsoarch

49
I Ioallh Tcchnology Asscssmcnt
Acupuncturc: lvidcnco trom Syslomalic Rcvicws and Mcla analysos

Study Design type Endpoint Data intesration Reviewers assessment
(Ouality Ratins)
Objectives and inclusion

crite a are not specific.
and the search stralegy
trealment peiod, sl'rdy

Qualily assessmenl was
Ernsl E 1997
37 ctscoM, = 100 design.
lPoorl Due lo lhe heterogeneity

methodological qualily
of lhe slsdy melhods, and
results. whlle the 2 morc findings, in conjunclion
igoro'rs sl'rdies did not. wilh lhe small sample of
Future studies should be nndings of no evidence

arc sound. However, the
including search slralegy,

Therc is no convincing
stalement of objectives,
and claily of inclusion
using acupunclure/acupressur
crileria. are weak. These
reaknesses likely played
rcducing body weighl or
a .ole in lhe inconclusive
lindings.
Albcrla Ilcrilagc Foundalion forMcdicalRoscarch 50

Acupuncturei compilation ofsystematic reviews and meta analyses
AppENDrx C: QuAlrry ASSESSMENT TooLS
Jadad Scale for Evaluating Randomized Controlled Trials 23 25 27 2s 30 32-34.4t 42
Add a point for a "yes" and give no points for a "no"

1. Was the study described as randomized (this includes the use of words such as
random, randomly and randomization)?
2. Was the study described as double-blind?
3. Was there a description of withdmwals and dropouts?
4. Was the method to generate the sequence of randomization described and was it
appropriate (table of random numbers, computer-genemted etc.)
5. Was the method of double-blinding described and was it appropriate (identical
placebo. active placebo, dummy, etc?)
Deduct one point it
6. The method to genemte the sequence of randomization was described and it was
inappropriate (table of random numbers, computer generated etc)?
7. The method ol double-blinding described and was it appropriate (identical placebo,
active, dummy, etc)?
Vickers Scale for Evaluating Randomized Controlled Trials 3r.s7.75
l. Adequate desc ption ofthe population from which the participants are drawn.
2. Sample size adequate.
3. Random allocation to the treatment arms.
4. P.ognostic vadables adequately assessed.
5. Full description oftest inteNention.
6. Where possible a credible, inactive placebo should be used. If no placebo is
available. standard care may be used (but should have been compared previously to
placebo).
7. The use ofappropriate outcome measures for the condition and the therapy.
8. Patients blind to treatment allocation and researchers blinded when assessing
outcome,
9. Withdrawal and no-respondents less than 20% of initial sample.
10. Appropriate use ofinference statistics.
A ranking of very good receives 4 points, good - 3, fair - 2, not satislactory - 1 and
poor 0.
Ve.y good reflects a study which has adequately met the criteria and the results may be
considered valid-

Acupuncture: Evid€nc€ from Systematic Reviews and Meta analyses
Good reflects that the major crite a were met and the results have not been affected
Fair reflects the criteria have not been met fully and that the results have probably not
been affected
Poor reflects that the criteria have not been met adequately and that the outcome ofthe
study has probably been influenced by this.
List of Methodological criteria: ter Riet G, Kleijnen J, Knipschild 28.v-3s
Criteria Weight
C omp arab ility of prognosis
A. Homogeneity (1) 3
B. Prestratification (2) 3
C. Randomization 12
D. Comparability of relevant baseline characteristics shown 2
E. U 50 patients per group l0
F. < 20% loss to follow-up (3) 5
Adequate interyention
G. Avoidance ofDNIC (4) 2
H. Adequate description ofacupuncture procedure (5) 10
L Mentioning good quality ofthe acupuncturist 15
J. Existing treatment modality in reference group 3
Adequate EIfect Measurctuent

K. Patients blinded 10
L. Evaluator blinded 5
M. Follow-up alter treatment > 3 months (6) 5
N. Pain (7) 3
C)- Use ofmedication 2
P. Activities oldaily living 3
Q. Remark of side-effects 2
Data presentation
R, Reader is given opportunity to do inferential statistics 5
Methodological criteria: Lincle 2e,ar
1 Method ofallocation to groups

2. Concealment of allocation
3. Baseline comparability
4. Blinding olpatients
5. Blinding of evaluators
6. Likelihood olselection bias after allocation to groups by drop outs

Acupuncture: Evidence from Syslematic Reviews and Meta-analyses
Each item is scored as follows

o=criterion not met or insufffcient information
1=critedon met
Maximum score is 6
An adaptation ofthis scale is used in 2e, where the 6!h and 7ih critefa include the
handling of withdrawals, and the handling of inferential statistics.
Maximum score is 7
Methodological Criteria: Cochrane Collaboration Back Review Group 8
Patient selection
a. were the eligibility criteria specified
b. treatmentallocation
i. was the method of mndomization described and adequate
ii. was the treatment allocation concealed
c. were the groups similar at baseline regarding the most important prognostic
indicato$
lntervention
a. were therapeutic and control interventions operationalized
b. was the care provider blinded
c. was controlled for co-interventions which could explain the results
d. was the compliance mte (in each group) unlikely to cause bias
e. was the patient blinded
Outcome measurement
a. was the outcome assessor blinded
b. was at least one ofthe primary outcome measures applied
c. was there a description ofadverse effects
d. was the withdrawal/drop-out rate unlikely to cause bias
e. timing of follow-up measurement perfomed
i. was a short-term follow-up measurement performed
ii. was a long-term follow-up measurement pe.formed
f. was the timing of the outcome assessment in both groups comparable

Statistics
a. was the sample size for each group described
b. did the analysis include an intention-to treat analysis
c. were the point estimates and measures ofvadability presented for the pdmary
outcome measures
Methodological criteria: Strauss adapted from Koes 26
Study Population
a. Description ofinclusion and exclusion criteria (l point)
b. Similarity ofrelevant baseline characteristics: the duration olcomplaints, value of
outcome measures, age, recurence status, radiating complaints (1 point)
Adequate validity, accuracy, and reliability of diagnosis point)
(1
c. Randomisation procedure adequate: randomisation procedu.e described (2 points).

Randomisation prccedure which excludes bias (2 points)
d. Dropouts described for each study group sepa.ately: information from which group
and with reason for withdrawal (3 points)
e. Loss to follow'up: <20% loss to follow-up (2 points), <10% loss to follow-up (2
points)
f. Smallest group immediately after randomisation: >50 subjects in the smallest group
(6 points), > 100 subjects in the smallest group (6 point).
Interventions
g. Interventions included in protocol and described adequately: acupuncturc treatment
described (5 points)
h. Pragmatic study: comparison with an existing treatment modality (5 points)
i. Co-interventions avoided: other physical therapy modalities or medical
interventions are avoided in the design ofthe study except analgesics (5 points)
j. Placebo (or sham) contrclled: comparison with a placebo or sham therapy (3 points).
Adequate description and use ofan appropriate placebo or sham (2 points).
k. Good qualification of acupuncturist: mentioning of qualified education and work
expedence ofthe acupuncturist (5 points).
Measurement of Effect
i. Patients blinded: placebo controlled: Attempts for blinding (3 points), blinding
evaluated and fully successful (2 points).
Alberta Herirage Foundation for Medical Research 54

Acupuncture: Evidence from Systematic R€vi€ws and Meta analyses
m. Outcome measures relevant: use (measured and reported) of: pain. global measure
of improvement, functional status (activities of daily living). spinal mobility,
medicine consumption (1 point each). Validity and reliability olinstruments (1
Poin0.
n. Blinded outcome assessments: each blinded measurement mentioned under point
M. Earns 2 points. Control of observer and subject bias (1 point).
o. Follow-up period adequate: moment of measurement during orjust after trcatment
(2 points). Moment of measurement 3 months or longer (2 points)
Data Presentation and Analysis

p. Intention to treat analysis: when loss to follow up is less than 10%: all randomised
patients for most important outcome measures and on the most important moments
of effect measurement minus missing values, irrespective of non-compliance and co-
interventions. When loss to follow-up is greater than 10o%: intention to treat as well
as an alternative analysis which accounts for missing values (5 points).
q. Frequencies ofmost important outcomes presented for each treatment group. For
most important outcome measufes, and on the most important moments ofeffect
measu.ement. In the case of (semi-) continuous va ablesr presentation ofthe main
or median with standard error or percentiles (5 points). Use ofdescriptive as well as
inferential statistics. Literature review (1 point), good use ofreferences (1 point)
Methodological Criteria: Oxford Pain Validity Scale 32
This Scale is to be used with trials that are randomized and have an N ) 10. There are
five main categories with a possible score being between 0 and 16.
1 Blinding maximum 6 points)
2. Size oftrial groups (maximum 3 points)
3. Outcomes (maximum 2 points)
4. Baseline pain and internal sensitivity (maximum 1 point)
5. Data Analysis (maximum 4 points)
. Definition of outcomes
. Data presentation: location and dispersion
. Statistical testing
. Handling oldropouts

Health Technology Assessmen!
Acupunclure: compiiation of systematic reviews and meta-analyses
APPENDIX D: CRITERIA FoR EVALUATNG SYSTEMATIc REVIEWS
Papers that summarise other papers (systematic reviews and meta-analyses) by Trisha
Greenhalgh 2r:
L Can you find an important clinical question which the review addressed?
2. Was a thorough search done ofthe appropriate databases and were other potentially
important sources explored?
3. Was methodological quality assessed and the trials weighted accordingly?
4. How sensitive are the results to the way the review has been done?
5. Have the numerical results been interpreted with common sense and due regard to
the broader aspects ofthe problem?
AppENDtx E: CHEcKlrsr oF DATA REoUTRED rN A CoMpLETE REpoRT oF

ACUPUNCTURE TREATMENT 76
l. Patient's posture
2. Number ofneedles*
3. Needle size, manufacturer
4. Rationale and justification for point selection (traditional, tenderness, formulae)
5. Points used (international nomenclature), nonstandard points carefully described
6. Laterality
7. Depth*
8. Stimulation (eg manipulation, electrical, omoxabustion) strength and duration
9. Needle sensation induced
10. Duration of needling*
11. Frequency and number of repetitions**
12. Other simultaneous interventions
13. Subsequent changes to treatment
* where values vary. the median and range should be quoted
** where electrical stimulation is used. details of device, pulse width, waveform,

frequency, and strength ofstimulation (eg. presence olmuscle cont.actions) should be
included.

Acupuncture: compilation of systematic reviews and meta,analyses
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Alberta Heritage Foundation

for Medical Research

Patricia Leggett Tait, Laurie Brooks,

HT A 27: Series A Health Technology Assessment

Director, Health Technology Assessment

TeI:. 780-423-5?27, F ax 780-429-3509

Alberta He.itage Foundation for Medical Research

This report's objective is to provide an overview ofevidence from systemaric

Alberta Herila8e Foundation for lledical Research

Appendix A: Methodology....................... ....................-.......................24

Alberta Heritage Foundation for Medical Research

Alberta Heritage Foundation for Medical Research

ScoPE oF THE REPoRT

Acupuncture. in the stdctest sense, refers to "inseftion of dry needles, at specially

Alberta Heritage Foundation for Medical Research

Albena Heritage Foundation for Medical Research

'mild transient reactions' occurdng in

Albefta Heritage Foundation for Medical Research

The methodology of a review was considered to be satisfactory if it contained a concise

Dental and temperomandibular pain

Alberta Heritage Foundation for Medical Research

headache types). Evaluation ofthe appropriateness ofacupuncture point selection was

Alberta Heritage Foundation for Medical R€search

Nausea and emesis

Alberla Herilage Foundation for Vedical Research

Back and neck pain

Aiberta Heritage Foundation for Medical Research

Alberta Heritage Foundation for Medical Research

Alberta Heritage Foundaljon for Medical Research 10

Alberta Heritage Foundation for Medical Research 11

Alberta Heritage Foundation for Medical Research t2

Table 1: Conclusions and quality rating of the systematic reviews

Condition Review Conclusions Quality Rating

Albcrla Ilcrilagc Irou'rda(ion for M{{iical ltcsearch

Table l: Conclusions and quality rating of the systemaiic reviews (cont,d)

Albcrta Ilcritage Foundation for Modical Rcsoarch

Alberta Heritage Foundation for Medical Research 15

lssuEs tN AcupuNcruRE TREATMENT AND REsEARGH

Selection of control groups

Alberta Heritage Foundation for Medical R€search 16

Alberla Heritage Foundation for Medicai Research 17

Study design and assessment of quality

Alberta Heritage Foundation for Medical Research l8

Alberta Heritage Foundation for Medical Research 19

Alberta Heritage Foundation for Medical Research 20

further and better research to determine the actual effectiveness ofacupuncture as a

Alberta Heritage Foundation for Medical Research 2t

Alberta Heriiag€ Foundalion for \,ledical Research 22

Alberta Heritage Foundation for Medical Research

Aiberta Heritage Foundation for Medicat Research 24

Subiect headings (Bolded) and Tgxtwords combinations

. Rosted P. The use of acupuncturc in dentistry: a review of the scientilic validity of

Atberta Heritage Foundation for Medical Res€arch 25

. KleijnenJ, ter Riet G, Knipschild P. Acupuncture andasthma:a review ofcontrclled

. Ernst E. Acupuncturc/acupressure for weight rcduction? A systematic review3r

. Linde K,JobstK, Panton J. Acupuncture for chronic asthmaa2

Albena Heritage Foundation for Vedical Research 26

. Ernst E. Acupuncture as a symptomatic tftatment of osteoarth tis. A systematic revlew ia -

. South NA. Acupuncture for the treatment of trithdrawa] sruptoms in detoxilication

Jff""""-, svsr"."t" I lo rtu - Dala reviewed suggest Clear question, search