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NIHR systematic review

Why was this study needed?

Around four million acupuncture treatments are provided each year in the UK with approximately two-thirds of this provision outside the National Health Service. Acupuncture is often used in circumstances when other treatments have not fully helped patients, especially as treatment for joint pain and long-term headaches. The NHS reportedly funds around one-third of treatments given in the UK through providers such as doctor’s physiotherapists and nurses, but access to acupuncture varies around the country.

Studies to date have suggested that acupuncture is safe when delivered by experienced professionals. However, whether it actually gives any clinical benefit, or whether any effects might be down to the “placebo effect” of delivering an intervention, has often been debated. Some argue that the placebo effect itself is useful.

Using a robust systematic review methodology, this project aimed to shed light on the clinical benefits and costs of acupuncture, comparing it to sham acupuncture, placebo, usual care and other interventions. The researchers wanted to provide information for patients and decision-makers to guide the NHS in better understanding the role of acupuncture in chronic pain and to settle the question of whether it was acting as a complex placebo.

What did this study do?

This systematic review was conducted in two parts. The first included 29 randomised controlled trials comparing acupuncture with sham acupuncture or non-acupuncture controls in 17,922 adults with osteoarthritis, chronic headache or musculoskeletal pain (back, neck or shoulder).

Researchers looked at effect on pain and whether acupuncture improved quality of life on the EuroQol-5 Dimensions (EQ-5D) scale and gave value for money.

The studies came from UK, US, Germany, Spain and Sweden. Most had high follow-up rates and participants were unaware of treatment given. However, individual trial results differed, likely due to differences in the controls used and method for assessing pain outcomes.

The second part included 114 trials in 9,709 people with knee osteoarthritis. Researchers included the higher quality trials in a network meta-analysis, comparing acupuncture with other physical therapies directly within trials and indirectly across trials.

Abstract

Acupuncture for chronic pain and depression in primary care: a programme of research
Published on 23 January 2017

MacPherson H, Vickers A, Bland M, Torgerson D, Corbett M, Spackman E

Programme Grants for Applied Research Volume 5 Issue 3 , 2017
Background There has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money. Aim Our aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression. Methods and results We synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective. Conclusion We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence. Funding The National Institute for Health Research Programme Grants for Applied Research programme.

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