Abstract

Objective. Several systematic reviews (SRs) have assessed the effectiveness of acupuncture for rheumatic conditions, often with contradictory conclusions. Our aim is to provide a critical evaluation and summary of these data.

Methods. Electronic searches were conducted in 15 databases to locate all SRs on acupuncture for rheumatic conditions published since 2000. Data were extracted by the authors according to pre-defined criteria.

Results. We found 30 SRs that met our inclusion criteria. They related to the following rheumatic conditions: FM, low back pain, lateral elbow pain, musculoskeletal pain, orthopaedic diseases, OA, RA, shoulder pain, frozen shoulder, neck disorder, AS and sciatica. Their conclusions were in several instances contradictory. Relatively clear evidence emerged to suggest that acupuncture is effective for OA, low back pain and lateral elbow pain and ineffective for FM and RA.

Conclusion. Many SRs have recently been done. Only for OA, low back pain and lateral elbow pain is the evidence sufficiently sound to warrant positive recommendations of this therapy in routine care of rheumatic patients.

Introduction

Acupuncture is frequently promoted for rheumatic conditions. One detailed text, for instance, provides the following ‘indications for acupuncture in rheumatology: muscle strain, acute and chronic osteoarthritis, enthesopathy, acute and chronic shoulder pain, acute and chronic neck and low back pain, post-laminectomy pain, scar pain, inflammatory polyarthritis, fibromyalgia, soft tissue rheumatism’ [1]. Rheumatic conditions are, according to survey data, amongst other diseases most frequently treated by acupuncturists amongst diseases [2–4].

Many rheumatologists, however, have remained sceptical and argue that the evidence for acupuncture is not convincing. Numerous clinical trials and a multitude of systematic reviews (SRs) with sometimes contradictory conclusions have been published. Clinicians might not always find it easy to make sense of this confusing plethora of evidence.

This overview is aimed at summarizing and critically evaluating the evidence from SRs published between 2000 and 2010 on the subject. Our objective was to provide clinicians with a manageable assessment of the therapeutic value of acupuncture for rheumatic conditions.

Methods

The following databases were searched in February 2010 without any language restrictions: Medline, Embase, Amed, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Health Technology Assessments, Database of Abstracts of Reviews of Effects (DARE), the Cochrane Library, six Korean medical databases [Korean Studies Information; DBPIA (available at www.dbpia.com); Korea Institute of Science and Technology Information; Korea Education and Research Information Service; KoreaMed; and Korean National Assembly Library] and two Chinese Databases [China National Knowledge Infrastructure (CNKI)]. In addition, we searched our departmental files by hand. Key words were (systematic review OR meta-analysis) AND (acupuncture OR electro-acupuncture OR auricular acupuncture OR moxibustion OR acupressure) AND (rheumatism OR rheumatoid arthritis OR osteoarthritis OR arthritis OR spondylitis OR gout OR systemic lupus OR osteopathic OR musculoskeletal OR osteoporosis OR back pain OR rheumatology). Only articles published after 2000 were included because older reviews would now be out of date.

Articles were included if they related to a formal SR or meta-analysis on any type of acupuncture as a treatment for any type of rheumatic condition. Reviews, comments and overviews without a formal methods section were excluded. Key data were extracted independently by both authors according to pre-defined criteria (Table 1).

Table 1

SRs of acupuncture for rheumatic conditions

Study Condition No. of primary studies Quality of primary studiesa Conclusion (quote) Quality of SR OQAQb Result 
Langhorst et al. [7FM Variable Acupuncture cannot be recommended for the management of FMS − 
Martin-Sanchez et al. [8FM Mostly poor Found no evidence of benefit − 
Mayhew and Ernst [9FM Mostly poor Not supported by the results from rigorous clinical trials − 
Yuan et al. [10Low back pain 23 Variable There is strong evidence that acupuncture can be a useful supplement to other forms therapy 
Furlan et al. [11Low back pain 35 Variable The data do not allow firm conclusions ± 
Manheimer et al. [12Low back pain 33 Variable Acupuncture effectively relives back pain ± 
Henderson [13Low back pain Poor Did not provide definitive evidence ± 
Ernst et al. [14Low back pain 12 Variable Acupuncture is superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo ± 
Zhu et al. [15Low back pain Variable Might be effective to lower 
Trinh et al. [16Lateral elbow pain Good There is strong evidence 
Green et al. [17Lateral elbow pain Variable There is insufficient data ± 
Lee et al. [18Musculoskeletal pain 11 Poor The total number and sample sizes were too small to draw definite conclusions ± 
Schuller et al. [19Orthopaedic diseases Variable Better trials are mandatory ± 
Manheimer et al. [20OA (peripheral joint) 16 Variable Sham-controlled trials show statistically significant benefit 
Selfe et al. [21OA 10 Good Acupuncture is an effective treatment 
Manheimer et al. [22OA (knee) 11 Variable Sham-controlled trials show clinically irrelevant short-term benefits ± 
White et al. [23OA (knee) 13 Variable Acupuncture is significantly superior to sham-acupuncture 
Kwon et al. [24OA 18 Variable Acupuncture seems an option worthy of consideration 
Ferrández Infante et al. [25OA (knee) Mostly poor Insufficient evidence ± 
Ezzo et al. [26OA (knee) Variable Play a role in the treatment 
Wang et al. [27RA Variable Conflicting evidence exists ± 
Lee et al. [28RA Variable Failed to show specific effects of acupuncture − 
Li et al. [29RA Mostly poor Acupuncture combined drug therapy more effective than pure RA drug 
Casimiro [30RA Poor Poor quality precluded its recommendation − 
Green et al. [31Shoulder pain Variable There is little evidence − 
Peng et al. [32Frozen shoulder Good Effective 
Trinh et al. [33Neck pain 10 Variable Moderate evidence 
Fu et al. [34Neck pain 14 Variable Short-term effectiveness and efficacy 
Gong and Ren [35AS Poor Effective 
Wang et al. [36Sciatica Mostly poor Effective 
Study Condition No. of primary studies Quality of primary studiesa Conclusion (quote) Quality of SR OQAQb Result 
Langhorst et al. [7FM Variable Acupuncture cannot be recommended for the management of FMS − 
Martin-Sanchez et al. [8FM Mostly poor Found no evidence of benefit − 
Mayhew and Ernst [9FM Mostly poor Not supported by the results from rigorous clinical trials − 
Yuan et al. [10Low back pain 23 Variable There is strong evidence that acupuncture can be a useful supplement to other forms therapy 
Furlan et al. [11Low back pain 35 Variable The data do not allow firm conclusions ± 
Manheimer et al. [12Low back pain 33 Variable Acupuncture effectively relives back pain ± 
Henderson [13Low back pain Poor Did not provide definitive evidence ± 
Ernst et al. [14Low back pain 12 Variable Acupuncture is superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo ± 
Zhu et al. [15Low back pain Variable Might be effective to lower 
Trinh et al. [16Lateral elbow pain Good There is strong evidence 
Green et al. [17Lateral elbow pain Variable There is insufficient data ± 
Lee et al. [18Musculoskeletal pain 11 Poor The total number and sample sizes were too small to draw definite conclusions ± 
Schuller et al. [19Orthopaedic diseases Variable Better trials are mandatory ± 
Manheimer et al. [20OA (peripheral joint) 16 Variable Sham-controlled trials show statistically significant benefit 
Selfe et al. [21OA 10 Good Acupuncture is an effective treatment 
Manheimer et al. [22OA (knee) 11 Variable Sham-controlled trials show clinically irrelevant short-term benefits ± 
White et al. [23OA (knee) 13 Variable Acupuncture is significantly superior to sham-acupuncture 
Kwon et al. [24OA 18 Variable Acupuncture seems an option worthy of consideration 
Ferrández Infante et al. [25OA (knee) Mostly poor Insufficient evidence ± 
Ezzo et al. [26OA (knee) Variable Play a role in the treatment 
Wang et al. [27RA Variable Conflicting evidence exists ± 
Lee et al. [28RA Variable Failed to show specific effects of acupuncture − 
Li et al. [29RA Mostly poor Acupuncture combined drug therapy more effective than pure RA drug 
Casimiro [30RA Poor Poor quality precluded its recommendation − 
Green et al. [31Shoulder pain Variable There is little evidence − 
Peng et al. [32Frozen shoulder Good Effective 
Trinh et al. [33Neck pain 10 Variable Moderate evidence 
Fu et al. [34Neck pain 14 Variable Short-term effectiveness and efficacy 
Gong and Ren [35AS Poor Effective 
Wang et al. [36Sciatica Mostly poor Effective 

The overall score is from 1 to 7. OQAQ ≤ 3: extensive or major flaws; OQAQ⩾5: minor or minimal flaws. aAs judged by the authors of the respective SRs. bOQAQ. +: overall positive; −: fail to show effectiveness; ±: unclear. FMS: fibromyalgia syndrome.

Judgements on the quality of the primary studies were taken from the respective SRs. The Overview Quality Assessment Questionnaire (OQAQ) was used to evaluate the methodological quality of all included SRs [5, 6]. The scores ranged from 1 to 7; a score of ≤3 was considered as indicative of extensive or major flaws and a score of ≥5 as suggesting only minor or minimal flaws. The authors assessed the OQAQ independently and discrepancies were settled by discussion.

The direction of the result of each SR was estimated according to the conclusions of each SR. Statements such as ‘no evidence of benefit’ were categorized as negative (i.e. fail to show effectiveness); statements such as ‘acupuncture effectively relieves pain’ were categorized as positive; and statements that were neither clearly positive nor clearly negative were categorized as unclear. Disagreements were resolved by discussion between the authors.

Results

Our searches generated 238 hits, and 30 SRs met our inclusion criteria (Fig. 1 and Table 1; [7–36]). They related to a range of rheumatological conditions: FM, low back pain, lateral elbow pain, musculoskeletal pain, orthopaedic diseases, OA, RA, shoulder pain, frozen shoulder, neck disorders, AS and sciatica. About half of the SRs arrived at a clearly positive conclusion [10, 12, 15, 16, 20, 21, 23, 24, 26, 29, 32–36].

Fig. 1

Flow chart of publication selection process.

Fig. 1

Flow chart of publication selection process.

Relatively clear consensus exists among the SRs that acupuncture is effective for OA. Of the seven SRs [20–26] on this topic, five are clearly positive [20, 21, 23, 24, 26], while two [22, 25] cast doubt on the clinical relevance of the small effect size. For FM, the evidence seems to be clearly negative with all three available SRs drawing negative conclusions [7–9]. Of the six SRs on lower back pain [10–15] three are clearly positive [10, 12, 15], while three draw unequivocal conclusions [11, 13, 14]. More overt contradictions exist for two indications: lateral elbow pain [16, 17] and RA [27–30]. For lateral elbow pain, one SR concluded that ‘there is insufficient data’ [17], whereas 2 years later, Trinh et al. [16] conclude that ‘there is strong evidence’. In the case of RA, there are four SRs that span the entire spectrum from negative to positive.

Discussion

Our analysis shows that 30 SRs of acupuncture for rheumatic conditions have been done within the past decade. This is considerably more than the five SRs that were published between 1989 and 2000 [37], indicating that the interest in this subject has grown considerably. The conclusions of the new SRs are by no means always uniform. The evidence for OA, FM and back pain is relatively clear. The contradictions exist, however, for lateral elbow pain and RA. In the case of lateral elbow pain, this can be explained by the time difference between the two SRs [16, 17]. The more up-to-date SR [16] includes two further rigorous and positive studies that had emerged meanwhile. Thus, the totality of the current best evidence seems to suggest acupuncture to be effective for this indication [16]. In the case of RA, the situation might be more complex. The only clearly positive SR [29] is of poor methodological quality, which renders its conclusions unreliable. Thus, the current best evidence is not strong and tends to indicate that the effectiveness of acupuncture as a treatment of RA is unproved. Two SRs exist for neck pain [33, 34]. Both are rigorous and based on a sufficiently large number of primary studies, some of which are of high quality. Therefore, its positive conclusion is likely to be reliable.

By contrast, the SRs relating to frozen shoulder [32], AS [35] and sciatica [36] are all of poor quality and based on relatively small numbers of primary studies. Thus, their positive conclusions may be less than reliable. This indicates that, in these areas, more high-quality studies are required.

Collectively, these data suggest that the evidence from SRs is conclusively or tentatively positive for low back pain, lateral elbow pain, OA and neck pain. For all other rheumatic conditions, this is not the case.

SRs of acupuncture have been noted to be limited by the often poor quality of the primary data [37, 38]. Our analysis confirms this view. It also suggests that some of the recent SRs are of poor quality (Table 1). Many of the primary acupuncture trials originate from China (data not shown); Vickers et al. [39] have demonstrated that virtually 100% of Chinese acupuncture trials are positive. This casts considerable doubt on their reliability. Collectively, these facts limit the conclusiveness of SRs of acupuncture. A level of uncertainty thus remains, and SRs in general have been criticized for being often unable to provide specific guidance [40]. Yet, even if uncertainty prevails, SRs have the important function of mapping areas of doubt [40]. Thus, as pointed out above, our overview highlights areas of research where investment in further clinical trials would be fruitful. In conclusion, this overview of recent SRs suggests that acupuncture is effective for low back pain, lateral elbow pain, OA and neck pain, whereas for RA and FM the evidence is negative.

graphic

Acknowledgements

The authors thank Tae-Young Choi, MD, PhD and Tae-Hoon Kim, OMD of KIOM for extracting data from Chinese and Japanese literature, respectively. M.S.L. was supported by KIOM (K10251).

Disclosure statement: The authors have declared no conflicts of interest.

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