1. General consideratio 1. 4 Safet Generally speaking, acupuncture treatment is safe if it is performed properly by a well-trained practitioner. Unlike many drugs, it is non-toxic, and adverse reactions are minimal. This is probably one of the chief reasons why acupuncture is so popular in the treatment of chronic pain in many countries. As mentioned previously, acupuncture is comparable with morphine preparations in it ffectiveness against chronic pain but without the adverse effects of morphine, such as dependency Even if the effect of acupuncture therapy is less potent than that of conventional treatments, acupuncture may still be worth considering because of the toxicity or Adverse effects of conventional treatments. For example, there are reports of controlled clinical trials showing that acupuncture is effective in the treatment of rheumatoid arthritis (4-6), although not as potent as corticosteroids. Because unlike corticosteroids, acupuncture treatment, does not cause serious side-effects, it seems reasonable to use acupuncture for treating this condition, despite the difference in effectiveness 1.5 Availability and practicability The availability and practicability of acupuncture are also important factors to consider. The advantages of acupuncture are that it is simple, convenient and has few contraindications. Although the success rate of acupuncture therapy in treating kidney stones, for example, is confirmed by comparative studies with other therapies(7), it is by no means as high as that of surgical intervention. However, acupuncture treatment of kidney stones is still worth recommending because of its simplicity, which makes it more acceptable to patients There are also instances where acupuncture is not more practicable than conventional therapy. For example, the effectiveness of acupuncture treatment of acute bacillary dysentery has been shown to be comparable with that of furazolidone(8-10), but this is of rather academic significance because oral administration of furazolidone or other antidysenteric drugs is more convenient The conditions of the health service in a given country or area should also be considered in evaluating acupuncture practice. In developing countries, where medical personnel and medicines are still lacking, the need for acupuncture may be considerable and urgent; proper use of this simple and economic therapy could benefit a large number of patients. On the other hand, in developed countries, where the health system is well established, with sophisticated technology, adequate personnel and a well-equipped infrastructure, acupuncture might be considered to be of great value in only a limited number of conditions It could still serve as a valuable alternative treatment for many diseases or conditions for which modern conventional treatments are unsuccessful. It is also valuable in situations where the patient is frightened of the potential risks or dverse effects of modern conventional treatments. In fact, in some developed countries, the diseases for which patients seek help from acupuncturists tend to be beyond the scope of orthodox medicine
1. General considerations 1.4 Safety Generally speaking, acupuncture treatment is safe if it is performed properly by a well-trained practitioner. Unlike many drugs, it is non-toxic, and adverse reactions are minimal. This is probably one of the chief reasons why acupuncture is so popular in the treatment of chronic pain in many countries. As mentioned previously, acupuncture is comparable with morphine preparations in its effectiveness against chronic pain, but without the adverse effects of morphine, such as dependency. Even if the effect of acupuncture therapy is less potent than that of conventional treatments, acupuncture may still be worth considering because of the toxicity or adverse effects of conventional treatments. For example, there are reports of controlled clinical trials showing that acupuncture is effective in the treatment of rheumatoid arthritis (4–6), although not as potent as corticosteroids. Because, unlike corticosteroids, acupuncture treatment, does not cause serious side-effects, it seems reasonable to use acupuncture for treating this condition, despite the difference in effectiveness. 1.5 Availability and practicability The availability and practicability of acupuncture are also important factors to consider. The advantages of acupuncture are that it is simple, convenient and has few contraindications. Although the success rate of acupuncture therapy in treating kidney stones, for example, is confirmed by comparative studies with other therapies (7), it is by no means as high as that of surgical intervention. However, acupuncture treatment of kidney stones is still worth recommending because of its simplicity, which makes it more acceptable to patients. There are also instances where acupuncture is not more practicable than conventional therapy. For example, the effectiveness of acupuncture treatment of acute bacillary dysentery has been shown to be comparable with that of furazolidone (8–10), but this is of rather academic significance because oral administration of furazolidone or other antidysenteric drugs is more convenient. The conditions of the health service in a given country or area should also be considered in evaluating acupuncture practice. In developing countries, where medical personnel and medicines are still lacking, the need for acupuncture may be considerable and urgent; proper use of this simple and economic therapy could benefit a large number of patients. On the other hand, in developed countries, where the health system is well established, with sophisticated technology, adequate personnel and a well-equipped infrastructure, acupuncture might be considered to be of great value in only a limited number of conditions. It could still serve as a valuable alternative treatment for many diseases or conditions for which modern conventional treatments are unsuccessful. It is also valuable in situations where the patient is frightened of the potential risks or adverse effects of modern conventional treatments. In fact, in some developed countries, the diseases for which patients seek help from acupuncturists tend to be beyond the scope of orthodox medicine. 5
Acupuncture: review and analysis of controlled clinical trials 1.6 Studies on therapeutic mechanisms Clinical evaluations indicate whether the therapy works; research on the mechanisms involved indicates how it works and can also provide important information on efficacy. Knowing that acupuncture is effective and why makes the practitioner confident in its use, and also allows the technique to be used in a more appropriate way. The clinical evaluation may precede studies on the mechanisms, or vice versa For acupuncture, in most instances the clinical effect has been tested first. Use of the technique may then be further expanded on the basis of the results of research on the mechanisms. For example, experimental studies of the effect of white blood cells led to a successful trial of th leukopenia caused by chemotherap To date, modern scientific research studies have revealed the following actions of acupuncture regulating various physiological functions. n reality, the first two actions can also be attributed to the regulation of physiological functions. The therapeutic effects of acupuncture are thus brought about through its regulatory actions on various systems, so that it can be regarded as a nonspecific therapy with a broad spectrum of indications, particularly helpful in functional disorders. Although it is often used as a symptomatic treatment(for pain, for instance), in many cases it actually acts on one of the pathogenic links of a diseas Although different acupuncture points and manipulations may have an effect through different actions, the most important factor that influences the direction of action is the condition of the patient. Numerous examples reveal that the regulatory action of acupuncture is bi-directional. Acupuncture lowers the blood pressure in patients with hypertension and elevates it in patients with hypotension; increases gastric secretion in patients with hypoacidity, and decreases it in patients with hyperacidity; and normalizes intestinal motility under X-ray observation in patients with either spastic colitis or intestinal hypotonia(11). Therefore, acupuncture itself seldom makes the condition worse In most instances, the main danger of its inappropriate application is neglecting the proper conventional treatment Since its therapeutic actions are achieved by mobilization of the organisms own potential, acupuncture does not produce adverse effects, as do many drug therapies. For example, when release of hydrocortisone plays an important role the production of a therapeutic effect, the doses of this substance released by cupuncture are small and finely regulated thereby avoiding the side-effects of hydrocortisone chemotherapy (12). On the other hand -and for the same reason-acupuncture has limitations. Even under conditions where acupuncture is indicated, it may not work if the mobilization of the individuals potential is not adequate for recovery
Acupuncture: review and analysis of controlled clinical trials 1.6 Studies on therapeutic mechanisms Clinical evaluations indicate whether the therapy works; research on the mechanisms involved indicates how it works and can also provide important information on efficacy. Knowing that acupuncture is effective and why makes the practitioner confident in its use, and also allows the technique to be used in a more appropriate way. The clinical evaluation may precede studies on the mechanisms, or vice versa. For acupuncture, in most instances the clinical effect has been tested first. Use of the technique may then be further expanded on the basis of the results of research on the mechanisms. For example, experimental studies of the effect of acupuncture on white blood cells led to a successful trial of the treatment of leukopenia caused by chemotherapy. To date, modern scientific research studies have revealed the following actions of acupuncture: • inducing analgesia • protecting the body against infections • regulating various physiological functions. In reality, the first two actions can also be attributed to the regulation of physiological functions. The therapeutic effects of acupuncture are thus brought about through its regulatory actions on various systems, so that it can be regarded as a nonspecific therapy with a broad spectrum of indications, particularly helpful in functional disorders. Although it is often used as a symptomatic treatment (for pain, for instance), in many cases it actually acts on one of the pathogenic links of a disease. Although different acupuncture points and manipulations may have an effect through different actions, the most important factor that influences the direction of action is the condition of the patient. Numerous examples reveal that the regulatory action of acupuncture is bi-directional. Acupuncture lowers the blood pressure in patients with hypertension and elevates it in patients with hypotension; increases gastric secretion in patients with hypoacidity, and decreases it in patients with hyperacidity; and normalizes intestinal motility under X-ray observation in patients with either spastic colitis or intestinal hypotonia (11). Therefore, acupuncture itself seldom makes the condition worse. In most instances, the main danger of its inappropriate application is neglecting the proper conventional treatment. Since its therapeutic actions are achieved by mobilization of the organism’s own potential, acupuncture does not produce adverse effects, as do many drug therapies. For example, when release of hydrocortisone plays an important role in the production of a therapeutic effect, the doses of this substance released by acupuncture are small and finely regulated, thereby avoiding the side-effects of hydrocortisone chemotherapy (12). On the other hand—and for the same reason—acupuncture has limitations. Even under conditions where acupuncture is indicated, it may not work if the mobilization of the individual’s potential is not adequate for recovery. 6
1. General consideratio 1.7 Selection of clinical trial reports In recent decades, numerous clinical trials have been reported; however, only formally published articles that meet one of the following criteria are included in eview randomized controlled trials(mostly with sham acupuncture or conventional therapy as control) with an adequate number of patients observed nonrandomized controlled clinical trials(mostly group comparisons) with an adequate number of patients observed and comparable conditions in the various groups prior to treatment In many published placebo-controlled trials, sham acupuncture was carried out y needling at incorrect, theoretically irrelevant sites. Such a control really only offers information about the most effective sites of needling, not about the specific effects of acupuncture(13). Positive results from such trials, which revealed that genuine acupuncture is superior to sham acupuncture with statistical significance, provide evidence showing the effectiveness of acupuncture treatment On the other hand, negative results from such trials, in which both the genuine and sham acupuncture showed considerable therapeutic effects with no significant difference between them, can hardly be taken as evidence negating the effectiveness of acupuncture In the latter case, especially in treatment of pain, most authors could only draw the conclusion that additional control studies were needed. Therefore, these reports are generally not included In this review The reports are first reviewed by groups of conditions for which acupuncture herapy is given(section 2). The clinical conditions covered have then been classified into four categories(section 3) 1. Diseases, symptoms or conditions for which acupuncture has been proved-through controlled trials-to be an effective treatment 2. Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown, but for which further proof is needed 3. Diseases, symptoms or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which acupuncture is worth trying because treatment by conventional and other therapies is difficult 4. Diseases, symptoms or conditions in which acupuncture may be tried provided the practitioner has special modern medical knowledge and adequate monitoring equipment Section 4 provides a tabulated summary of the controlled clinical trials reviewed giving information on the number of subjects, the study design, the type of acupuncture applied, the controls used and the results obtained
1. General considerations 1.7 Selection of clinical trial reports In recent decades, numerous clinical trials have been reported; however, only formally published articles that meet one of the following criteria are included in this review: • randomized controlled trials (mostly with sham acupuncture or conventional therapy as control) with an adequate number of patients observed; • nonrandomized controlled clinical trials (mostly group comparisons) with an adequate number of patients observed and comparable conditions in the various groups prior to treatment. In many published placebo-controlled trials, sham acupuncture was carried out by needling at incorrect, theoretically irrelevant sites. Such a control really only offers information about the most effective sites of needling, not about the specific effects of acupuncture (13). Positive results from such trials, which revealed that genuine acupuncture is superior to sham acupuncture with statistical significance, provide evidence showing the effectiveness of acupuncture treatment. On the other hand, negative results from such trials, in which both the genuine and sham acupuncture showed considerable therapeutic effects with no significant difference between them, can hardly be taken as evidence negating the effectiveness of acupuncture. In the latter case, especially in treatment of pain, most authors could only draw the conclusion that additional control studies were needed. Therefore, these reports are generally not included in this review. The reports are first reviewed by groups of conditions for which acupuncture therapy is given (section 2). The clinical conditions covered have then been classified into four categories (section 3): 1. Diseases, symptoms or conditions for which acupuncture has been proved—through controlled trials—to be an effective treatment. 2. Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown, but for which further proof is needed. 3. Diseases, symptoms or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which acupuncture is worth trying because treatment by conventional and other therapies is difficult. 4. Diseases, symptoms or conditions in which acupuncture may be tried provided the practitioner has special modern medical knowledge and adequate monitoring equipment. Section 4 provides a tabulated summary of the controlled clinical trials reviewed, giving information on the number of subjects, the study design, the type of acupuncture applied, the controls used and the results obtained. 7
Acupuncture: review and analysis of controlled clinical trials
Acupuncture: review and analysis of controlled clinical trials 8
eview of clinical trial re 2. Review of clinical trial reports P The effectiveness of acupuncture analgesia has already been established controlled clinical studies. As mentioned previously, acupuncture analgesia works better than a placebo for most kinds of pain, and its effective rate in the treatment of chronic pain is comparable with that of morphine. In addition, numerous laboratory studies have provided further evidence of the efficacy of acupunctures analgesic action as well as an explanation of the mechanism involved. In fact, the excellent analgesic effects of acupuncture have stimulated research on pain. Because of the side-effects of long-term drug therapy for pain and the risks of dependence, acupuncture analgesia can be regarded as the method of choice for treating many chronically painful conditions The analgesic effect of acupuncture has also been reported for the relief of eye pain due to subconjunctival injection(14), local pain after extubation in children (15), and pain in thromboangiitis obliterans(16) 2.1.1 Head and face The use of acupuncture for treating chronic pain of the head and face has been studied extensively For tension headache, migraine and other kinds of headache due to a variety of causes, acupuncture has performed favourably in trials comparing it with standard therapy, sham acupuncture, or mock transcutaneous electrical nerve stimulation(TENS)(17-27). The results suggest that acupuncture could play a significant role in treating such conditions Chronic facial pain, including craniomandibular disorders of muscular origin, lso responds well to acupuncture treatments(28-31). The effect of acupuncture is comparable with that of stomatognathic treatments for temporomandibular joint pain and dysfunction. Acupuncture may b seful as complementary erapy for this condition, as the two treatments probably have a different basis of action(2, 32) 2.1.2 Locomotor system Chronically painful conditions of the locomotor system accompanied by restricted movements of the joints are often treated with acupuncture if surgical intervention is not necessary. Acupuncture not only alleviates pain, it also reduces muscle spasm, thereby increasing mobility. Joint damage often results from muscle malfunction, and many patients complain of arthralgia before any
2. Review of clinical trial reports 2. Review of clinical trial reports 2.1 Pain The effectiveness of acupuncture analgesia has already been established in controlled clinical studies. As mentioned previously, acupuncture analgesia works better than a placebo for most kinds of pain, and its effective rate in the treatment of chronic pain is comparable with that of morphine. In addition, numerous laboratory studies have provided further evidence of the efficacy of acupuncture’s analgesic action as well as an explanation of the mechanism involved. In fact, the excellent analgesic effects of acupuncture have stimulated research on pain. Because of the side-effects of long-term drug therapy for pain and the risks of dependence, acupuncture analgesia can be regarded as the method of choice for treating many chronically painful conditions. The analgesic effect of acupuncture has also been reported for the relief of eye pain due to subconjunctival injection (14), local pain after extubation in children (15), and pain in thromboangiitis obliterans (16). 2.1.1 Head and face The use of acupuncture for treating chronic pain of the head and face has been studied extensively. For tension headache, migraine and other kinds of headache due to a variety of causes, acupuncture has performed favourably in trials comparing it with standard therapy, sham acupuncture, or mock transcutaneous electrical nerve stimulation (TENS) (17–27). The results suggest that acupuncture could play a significant role in treating such conditions. Chronic facial pain, including craniomandibular disorders of muscular origin, also responds well to acupuncture treatments (28–31). The effect of acupuncture is comparable with that of stomatognathic treatments for temporomandibular joint pain and dysfunction. Acupuncture may be useful as complementary therapy for this condition, as the two treatments probably have a different basis of action (2, 32). 2.1.2 Locomotor system Chronically painful conditions of the locomotor system accompanied by restricted movements of the joints are often treated with acupuncture if surgical intervention is not necessary. Acupuncture not only alleviates pain, it also reduces muscle spasm, thereby increasing mobility. Joint damage often results from muscle malfunction, and many patients complain of arthralgia before any 9