The Acupuncture Evidence Project: A Comparative Literature Review is the most comprehensive review of the evidence supporting the effectiveness of acupuncture available. This project has been led and co-authored by former AACMA president and Clinic Director Stephen Janz, with Dr John McDonald PhD the principal researcher and first author. The preface, written by Stephen Janz, is reproduced here. For a referenced version of the preface refer to the full 81 page The Acupuncture Evidence Project: A Comparative Literature Review on the Australian Acupuncture and Chinese Medicine Association website.
Evidence of effectiveness underpins the validity of all health care interventions. Acupuncture has been practised for thousands of years; however, research into its effectiveness and cost effectiveness is in its relative infancy. The first significant attempt to identify the evidence validating the role of acupuncture was undertaken by the World Health Organization (WHO) in 1979. WHO conducted a Delphi-like symposium in Beijing in 1979 where physicians from around the world identified 43 diseases which they believed acupuncture may benefit. The 1979 report was criticised because it was not based on clinical trials, rather the clinical experience of the participants.
The US Department of Health and Human Services National Institutes of Health (NIH) released a consensus statement on acupuncture in 1997. The statement identified the efficacy of acupuncture for adult postoperative and chemotherapy nausea and vomiting, and for postoperative dental pain. In addition, the statement found support for the use of acupuncture for a range other conditions and identified the need for further research.
In 1996, WHO held a consultation on acupuncture in Cervia, Italy. At this meeting it was decided to review acupuncture again, this time focusing on the now-numerous controlled clinical trials. The result was a review of clinical trials up until early 1999 and culminated in ‘Acupuncture: review and analysis of controlled clinical trials’ published by WHO in 2002. The report identified 28 conditions for which acupuncture was found to be effective, and nearly 100 others where there was a therapeutic effect. It was acknowledged at the time that there were problems with the methodology in some of the trials included in the review. Notwithstanding these limitations, the WHO report indicated a growing and convincing body of evidence indicating that there was more to acupuncture than the placebo effect.
The Acupuncture Evidence Project
Fourteen years after the WHO publication on acupuncture evidence there has been further refinement in the conduct of clinical trials, not just for acupuncture, but in health-care generally, with clearer guidelines on how to rate the quality of the evidence. The Australian Acupuncture and Chinese Medicine Association Ltd (AACMA) identified the need for an updated review of the literature with greater rigour than was possible in the past, and commissioned the acupuncture evidence project. AACMA engaged experienced clinician and researcher, Dr John McDonald PhD, to conduct the research and analysis for the project.
This review draws on two prior comprehensive literature reviews, one conducted for the Australian Department of Veterans’ Affairs (DVA) in 2010 and another conducted for the United States Department of Veterans Affairs (USVA) in 2013. The research identified by these reviews was pooled, then a search of further literature from 2013 to 2016 was conducted. Trials were assessed using the National Health and Medical Research Council (NHMRC) levels of evidence, with risk of bias assessed using the Cochrane GRADE system. Results have been tabulated to indicate not just the current state of the evidence, but to indicate how the quality and quantity of evidence has changed from 2005 to 2016. In this review, 122 conditions across 14 broad clinical areas were identified and, of these, only five conditions found ‘no evidence of effect’ for acupuncture. The level of evidence was found by this review to have increased for 24 conditions.
How to use this review
This project sets a new benchmark to inform acupuncturists, the public, researchers, health departments, governments, and other health providers that acupuncture has a valuable contribution to make to global healthcare and to assist in reducing the global burden of disease. Acupuncturists should also take confidence from this report that their clinical expertise has been validated, and to confidently offer their services alongside other health professionals. Students and clinicians can use this report to identify areas of clinical interest which they may have overlooked. Researchers can find inspiration for areas of future investigation where the evidence is currently unclear. This review should also encourage educational institutions to maintain robust programs of study in acupuncture to continue to produce graduates capable of the broad scope of practice that this report indicates. It is no longer possible to say that the effectiveness of acupuncture can be attributed to the placebo effect or that it is useful only for musculoskeletal pain.
The realisation that pharmacological and surgical interventions are not without their limitations has increased interest in drug-free treatments such as acupuncture. This review found eight conditions where acupuncture may be used to reduce reliance on pharmacological or surgical options. Migraine and tension headaches lead to loss of productivity and quality of life; a drug-free therapy has a major health impact and potential cost savings as well as maintaining participation in the workforce. Medication is not always an effective or acceptable therapy for allergic rhinitis and acupuncture improves the range of interventions available to improve quality of life. Post-operative nausea and vomiting and post-operative pain complicate post-operative management, with acupuncture offering another avenue to enhance care in the post-operative period and reduce reliance on medication alone.
Knee osteoarthritis is on the increase globally and contributes not just to disability adjusted life years (DALYs), but is an increasing burden on health budgets. The option of a safe, drug-free treatment that may improve quality of life and potentially delay surgical intervention has significant potential to control these spiralling costs and DALYs. Low back pain is a WHO priority disease, and is the single largest contributor to disability worldwide. The finding that acupuncture benefits chronic low back pain is arguably the most important finding from this report. Finally, chemotherapy induced nausea and vomiting is an unwanted complication of cancer treatment and is often not fully controlled even with state-of-the-art antiemetics. Acupuncture can assist in improving quality of life for these cancer patients.
It has been estimated that there is a 17-year time lag in translating clinical research into clinical practice. During this time patients are being deprived of the benefit of a proven therapy. Health policy makers now have eight clear conditions associated with a significant burden of disease where acupuncture should be integrated into current clinical guidelines without further delay. Placebo controlled clinical trials consistently underestimate the true effect size of acupuncture (as discussed in section 1.4), yet they have still demonstrated NHMRC Level 1 evidence for the effectiveness of acupuncture for a further 109 conditions. This review has found a significant improvement in both the quality of studies and the levels of evidence supporting acupuncture since the most recent reviews conducted by the Australian and US Departments of Veterans Affairs.
Stephen Janz MPH
The AACMA Acupuncture Evidence Project