The number of clinical trials investigating acupuncture’s effectiveness and efficacy have now surpassed 9,000 in the Cochrane Register of Clinical Trials. This compares favourably with the number of trials for other Allied Health professions such as physiotherapy and chiropractic, but is unsurprisingly exceeded by nursing research.

There are also now 115 Cochrane systematic reviews which include acupuncture among other interventions, of which 45 are dedicated solely to acupuncture. There are also an additional 381 systematic reviews on acupuncture published by other reviewers.

The Acupuncture Evidence Project: New review finds mounting evidence

In a new review of acupuncture research, Australian researchers have found that the quality of evidence and the number of conditions for which acupuncture has been shown to be effective has increased significantly since the last major review published by the US Veterans Affairs Department in 2014.

In a project funded by the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA), researcher Dr John McDonald PhD and Stephen Janz reviewed all the systematic reviews of acupuncture published between March 2013, the cut-off date for the US Veterans Affairs ‘Evidence Map of Acupuncture’, and September 2016. A total of 136 systematic reviews, including 27 Cochrane systematic reviews, were included in this review, along with three network meta-analyses, nine reviews of reviews and 20 other reviews. In total over 8,000 randomised controlled trials of acupuncture have now been published and over 1,000 of these were included in the systematic reviews examined. In all, 122 conditions were reviewed.

In the Evidence Map of Acupuncture only three conditions reached the highest level of evidence – ‘Evidence of Positive Effect’. However, that number has risen to eight conditions in the new review: allergic rhinitis; chronic low back pain; migraine prevention; chronic tension-type headache; knee osteoarthritis; post-operative nausea and vomiting; post-operative pain; and chemotherapy-induced nausea and vomiting (CINV).

A further 38 conditions are now graded as ‘Evidence of Potential Positive Effect’ compared to 20 conditions in the 2014 Evidence Map. There was either low quality evidence or conflicting evidence for 71 more conditions categorised as ‘Unclear/ Insufficient evidence’. Only five conditions were found to have ‘No evidence of effect’. In total positive results were found at various levels of evidence for 117 conditions. It is clear that the research effort in acupuncture is accelerating and that many new conditions are now being studied for the first time. The other emerging trend is that researchers are becoming more specific in their research focus. What was once reviewed as just ‘cancer adverse effects’ has now been separated into a dozen different conditions including cancer pain, cancer-related insomnia, cancer-related fatigue, chemotherapy-induced nausea and vomiting.

Where studies on safety or cost-effectiveness of acupuncture were available, these results have been included in the review. Overall, acupuncture was found to safe in the hands of well-trained practitioners, and acupuncture was specifically shown to be safe in treatment of low back pain, migraine, osteoarthritis of the knee, depression, allergic rhinitis, prostatitis pain/chronic pelvic pain syndrome, ambulatory anaesthesia, Alzheimer’s disease and cancer-related psychological symptoms. Studies also showed acupuncture to be cost-effective for low back pain, migraine, headache, chronic pain, neck pain, post-operative nausea and vomiting, osteoarthritis, allergic rhinitis, depression, dysmenorrhoea, ambulatory anaesthesia.

Acupuncture is now recommended by many clinical practice guidelines. By November 2015, over 870 recommendations for acupuncture were identified for over 100 conditions from multiple international groups and over 30 countries. Examples include:

• Acute Pain Management: Scientific Evidence published by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine in 2015
• Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace published by The University of New South Wales in 2013
• Consensus Guidelines for the Management of Postoperative Nausea and Vomiting published in USA by the Society for Ambulatory Anesthesia in 2014
• Clinical Practice Guidelines For Allergic Rhinitis published by the Otolaryngology Head Neck Surgery Foundation’s in 2015
• The National Institute for Health and Care Excellence (NICE), UK for migraine and tension type headache in 2012
• Guideline for the Management of Chronic Pain published by The Scottish Intercollegiate Guidelines Network in 2013
• Clinical Practice Guidelines for Breast Cancer Treatment published by The National German Gynaecologic Oncology Association’s (Arbeitsgemeinschaft Gynakologische Onkologie) in 2015.

This review reflects the current state of evidence from research, but is not a definition of acupuncture’s scope of practice. When research attempts to validate traditional medical practices which have a history of over two millennia, it takes a great deal of time, research effort and funding to fully explore acupuncture’s scope of practice as it is described anecdotally in the historical literature, which includes thousands of clinical acupuncture books dating from the pre-Christian era to the present day.

What is clear is that the evidence for the effectiveness, safety and cost-effectiveness of acupuncture is growing rapidly.

The Acupuncture Evidence Project by Dr John McDonald, PhD and Stephen Janz was commissioned and funded by the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA).

A plain language summary and the full document (81 pages) is available from the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA): http://www.acupuncture.org.au.

McDonald J, Janz S. The Acupuncture Evidence Project: A Comparative Literature Review (Revised edition). Brisbane: Australian Acupuncture and Chinese Medicine Association Ltd; 2017.

The full results of our study have finally been published this week in the Annals of Allergy, Asthma and Immunology and Australian Doctor has also reported on our paper.

The purpose of the study, which was conducted at Southport Acupuncture Clinic, Queensland Allergy Services Allergy and Griffith University, was to investigate how the immune system changes in response to acupuncture when treating allergic rhinitis.

The study was funded by the National Health and Medical Research Council and all acupuncture needles for the study were generously donated by Helio Supply Company (Sydney).

I would like to thank all of the 151 allergic and 20 non-allergic volunteers who participated in the study, and all of the research team. Prof Allan Cripps (Pro-Vice-Chancellor Health at Griffith University), Prof Pete Smith (Allergy Specialist and Griffith Professor) and Prof Charlie Xue (Head of Health Sciences at RMIT) were my three supervisors and Associate Professor Caroline Smith (Western Sydney University) and Associate Professor Brenda Golianu (Stanford University) completed our team. I have been most fortunate to have the opportunity, as a first-time researcher, to work with such a wonderful team of people, and to be able to investigate how acupuncture works, a question which has always fascinated me. This study formed the basis of my thesis for Doctor of Philosophy which was awarded on 16^th April 2105.

So what did we learn from this study? Firstly, we did see clear evidence that the immune system changes in response to acupuncture and that symptoms continued to improve four weeks after the treatment ceased. In other studies, this improvement has been shown to last for 3 months, and but even at 6 months, although symptoms were starting to deteriorate slightly, they were still much better than before treatment. In clinical practice, a “top up” short course of treatment is therefore recommended if symptoms begin to recur after 3 months.

The symptoms which improved most were nasal congestion, runny nose, sneezing, nasal itch, eye itch and unrefreshed sleep. Post-nasal drip and sinus pain did not improve.

Based on the observation from past studies that all of the studies which used less than 12 treatments and treated less than twice weekly had produced poor or mixed results, whereas all of the studies providing 12 treatments or more, at least twice weekly had been very successful, our study treated twice weekly for 8 weeks. A previous study at RMIT in Melbourne by Prof Charlie Xue and colleagues used twice weekly treatments for 8 weeks rather than 6 weeks so we decided to use the same regimen.

Of those who received real acupuncture in the study, 86.1% of participants showed significant improvements in symptoms and quality of life. Other studies have reported responder rates between 84.6% and 95.8%. Acupuncture treatment has been shown to be very safe with total minor adverse events rate in this study (such as transitory pain on needle insertion or slight bruising) of 3%. Other studies have reported adverse events rates from 0.15% to 4.2%.

In April 2015, the American Academy of Otolaryngology Head and Neck Surgery Foundation updated their Clinical Practice Guidelines for allergic rhinitis in which they recommended acupuncture as a treatment option for patients preferring a non-pharmacologic therapy.

A study in Germany found acupuncture is also cost-effective as a treatment for allergic rhinitis (Witt et al, 2009).

So, in a nutshell, acupuncture is a safe, effective and cost-effective treatment for allergic rhinitis which produces lasting changes in the immune system and hence improvements in symptoms and quality of life.

Dr John McDonald

Click on “Publications” tab for links to the two reviews and final study results

The Centres for Disease Control (CDC) in the USA recently called for submissions on their draft revised prescribing guidelines for opioid medications. This was in response to what has been described by the Journal of the American Medical Association as “The Opioid Epidemic” with prescribed opioid medications accounting for more deaths in the US than any illegal drug. The Acupuncture Now Foundation joined with the American Society of Acupuncturists to form the Joint Acupuncture Opioid Task Force which lodged a submission in the CDC process. The main points in the submission were:

1. Acupuncture is an effective, safe and cost-effective treatment for various types of pain. Acupuncture should be recommended for the treatment of pain before opiates are prescribed.

2. Acupuncture analgesic mechanisms have been extensively researched and include the production and release of endogenous opioids.

3. Acupuncture is effective for the treatment of chronic pain involving adverse neuroplasticity.

4. Acupuncture is a useful adjunctive therapy in opiate dependency and rehabilitation.

The full text of the submission can be found at:

https://acupuncturenowfoundation.org/opioid-epidemic-campaign

Two White Papers regarding the potential role of acupuncture in the opioid crisis have recently been sent to the FDA (Food and Drug Administration) in the US. One was written for the Acupuncture Now Foundation (ANF) by Matthew Bauer and John McDonald, and the second White Paper was a collaboration between ANF and several acupuncture organisations including the American Society of Acupuncturists.

ANF White paper on Acupuncture’s role in solving the opioid epidemic

The second White Paper has recently been published in the Journal of Integrative Medicine.

The potential role of acupuncture in the opioid crisis

The original version can also be downloaded free from the American Society of Acupuncturists website