Prospective studies of the safety of acupuncture: a systematic review

Acupuncture as a complementary therapy in chemotherapy-induced nausea and vomiting

The effect of acupuncture on chemotherapy-induced nausea and vomiting has been studied over the past 20 years, and clinical evidence gathered to date has been favorable. Current practice guidelines recommend acupuncture as a complementary therapy for uncontrolled nausea and vomiting induced by chemotherapy. Nevertheless, a placebo effect may have been present in studies that had no control group, and unanswered questions remain-particularly since newer and more effective antiemetic medications have become available. A research study employing adjunctive electroacupuncture for both acute and delayed chemotherapy-induced nausea and vomiting is proposed to address some of the unanswered questions.

Complementary medicine and safety: a systematic investigation of design and reporting of systematic reviews

OBJECTIVES

The objective of this study was to examine the methods used in systematic reviews of safety across a range of complementary therapies to assess the variation in approach and the potential for developing guidance on conduct and reporting.

DESIGN

Systematic reviews focusing on safety were retrieved from NHS Evidence and searches of major databases. A pre-prepared template was used for data extraction. Information extracted included details of search strategies, sources, participants, interventions, reported adverse event/effect(s) and causality assessment. Data extraction was carried out by one researcher and a check for accuracy by a second researcher. Methods were assessed against criteria based on guidance provided by the Cochrane Adverse Effects Methods Group.

RESULTS

A total of 2563 citations were screened and 88 systematic reviews were selected for inclusion. The majority focused on the safety of herbs and nutritional supplements. Approximately half the reviews covered all aspects of safety; other reviews addressed specific adverse effects or interactions. Types of data included in the reviews did not always reflect the focus of the review. Search strategies, sources used, quality assessment and assessment of causality also varied.

CONCLUSIONS

Detailed examination and comparison of the methods has highlighted several areas in which there is potential for development of guidelines and consensus on standards. These include search strategies, sources of information, data extraction and assessment of causality. The value of systematic reviews in relation to large outcome studies requires further consideration.

Referrals and shared or collaborative care: managing relationships with complementary and alternative medicine practitioners

In this article we discuss steps that clinicians should take after deciding to include a complementary and alternative medicine (CAM) treatment that is beyond the clinician's expertise in a patient's treatment plan. We use the example of an adolescent patient with chronic recurrent headaches that have not been relieved by medication or other therapies and whose physician refers her to an acupuncturist for treatment. We focus on (1) circumstances under which referral is appropriate, (2) the nature of the relationship between the referring clinician and the practitioner to whom the referral is made (considering conventional health care and CAM, regulated and unregulated practitioners), and (3) considerations when undertaking shared or collaborative care with other health care practitioners (conventional health care or CAM). We also suggest best practices in managing such relationships.

Acupuncture for autism spectrum disorders (ASD)

BACKGROUND

Autism spectrum disorders (ASD) are characterized by impairment in social interaction, impairment in communication and lack of flexibility of thought and behavior. Acupuncture, which involves the use of needles or pressure to specific points on the body, is used widely in Traditional Chinese Medicine and increasingly within a western medical paradigm. It has sometimes been used as a treatment aimed at improving ASD symptoms and outcomes, but its clinical effectiveness and safety has not been rigorously reviewed.

OBJECTIVES

To determine the effectiveness of acupuncture for people with ASD in improving core autistic features, as well as communication, cognition, overall functioning and quality of life, and to establish if it has any adverse effects.

SEARCH STRATEGY

We searched the following databases on 30 September 2010: CENTRAL (The Cochrane Library, 2010, Issue 3), MEDLINE (1950 to September 2010 Week 2), EMBASE (1980 to 2010 Week 38), PsycINFO, CINAHL, China Journal Full-text Database, China Master Theses Full-text Database, China Doctor Dissertation Full-text Database, China Proceedings of Conference Database, Index to Taiwan Periodical Literature System, metaRegister of Controlled Trials and the Chinese Clinical Trials Registry. We also searched AMED (26 February 2009) and Dissertation Abstracts International (3 March 2009), but these were no longer available to the authors or editorial base at the date of the most recent search. TCMLARS (Traditional Chinese Medical Literature Analysis and Retrieval System) was last searched on 3 March 2009.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials. We included studies comparing an acupuncture group with at least one control group that used no treatment, placebo or sham acupuncture treatment in people with ASD. We excluded trials that compared different forms of acupuncture or compared acupuncture with another treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted trial data and assessed the risk of bias in the trials. We used relative risk (RR) for dichotomous data and mean difference (MD) for continuous data.

MAIN RESULTS

We included 10 trials that involved 390 children with ASD. The age range was three to 18 years and the treatment duration ranged from four weeks to nine months. The studies were carried out in Hong Kong, mainland China and Egypt.Two trials compared needle acupuncture with sham acupuncture and found no difference in the primary outcome of core autistic features (RFRLRS total score: MD 0.09; 95% CI -0.03 to 0.21, P = 0.16), although results suggested needle acupuncture might be associated with improvement in some aspects of the secondary outcomes of communication and linguistic ability, cognitive function and global functioning.Six trials compared needle acupuncture plus conventional treatment with conventional treatment alone. The trials used different primary outcome measures and most could not demonstrate effectiveness of acupuncture in improving core autistic features in general, though one trial reported patients in the acupuncture group were more likely to have improvement on the Autism Behavior Checklist (RR 1.53; 95% CI 1.09 to 2.16, P = 0.02) and had slightly better post-treatment total scores (MD -5.53; 95% CI -10.76 to -0.31, P = 0.04). There was no evidence that acupuncture was effective for the secondary outcome of communication and linguistic ability, though there seemed to be some benefit for the secondary outcomes of cognitive function and global functioning.Two trials compared acupressure plus conventional treatment with conventional treatment alone and did not report on the primary outcome. Individual study results suggested there may be some benefit from acupressure for certain aspects of the secondary outcomes of communication and linguistic ability, cognitive function and global functioning.Four trials reported some adverse effects, though there was little quantitative information, and at times both intervention and control groups experienced them. Adverse effects noted included bleeding, crying due to fear or pain, irritability, sleep disturbance and increased hyperactivity. None of the trials reported on quality of life.There are a number of problems with the evidence base: the trials were few in number and included only children; six of the trials were at high risk of bias; they were heterogeneous in terms of participants and intervention; they were of short duration and follow-up; they reported inconsistent and imprecise results, and, due to carrying out large numbers of analyses, they were at risk of false positivity.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of acupuncture for treatment of ASD. There is no conclusive evidence that acupuncture is effective for treatment of ASD in children and no RCTs have been carried out with adults. Further high quality trials of larger size and longer follow-up are needed.

Acupuncture: does it alleviate pain and are there serious risks? A review of reviews

Acupuncture is commonly used for pain control, but doubts about its effectiveness and safety remain. This review was aimed at critically evaluating systematic reviews of acupuncture as a treatment of pain and at summarizing reports of serious adverse effects published since 2000. Literature searches were carried out in 11 databases without language restrictions. Systematic reviews were considered for the evaluation of effectiveness and case series or case reports for summarizing adverse events. Data were extracted according to predefined criteria. Fifty-seven systematic reviews met the inclusion criteria. Four were of excellent methodological quality. Numerous contradictions and caveats emerged. Unanimously positive conclusions from more than one high-quality systematic review existed only for neck pain. Ninety-five cases of severe adverse effects including 5 fatalities were included. Pneumothorax and infections were the most frequently reported adverse effects. In conclusion, numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse effects continue to be reported. Numerous reviews have produced little convincing evidence that acupuncture is effective in reducing pain. Serious adverse events, including deaths, continue to be reported.

Acupuncture for attention deficit hyperactivity disorder (ADHD): study protocol for a randomised controlled trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common neuro-psychiatric problem, affecting 7-9% of children. Pharmacological interventions are widely used with behavioral treatments in ADHD. Still, the origin of ADHD is unclear, limiting pharmacological effectiveness and making adverse effects common. The use of complementary and alternative medicine (CAM) has increased, especially for developmental and behavioral disorders, such as ADHD. CAM is used by 60-65% of parents of children with ADHD to relieve ADHD-associated symptoms and to avoid the side effects of conventional medication. Acupuncture has been widely used to treat patients with ADHD, but the available evidence of its effectiveness is insufficient. Our aim was to evaluate the effectiveness and safety of acupuncture in patients (both and each treatment naive and conventional therapy children) with ADHD (any subtype) compared to the waitlist control.

METHODS/DESIGN

This study is a waitlist controlled open trial. We used a computer generated randomization scheme. This randomised, controlled trial had two parallel arms (acupuncture, and waitlist group). Each arm consisted of 40 participants. The acupuncture group received acupuncture treatment two times per week for a total of 12 sessions over 6 weeks. Post-treatment follow-up was performed 3 weeks later to complement the 12 acupuncture sessions. Participants in the waitlist group did not receive acupuncture treatments during the first six weeks but were only required to be assessed. After 6 weeks, the same treatments given to the acupuncture group were provided to the waitlist group. The primary outcome of this trial included differences in Korean version of ADHD-Rating Scale (K-ADHD-RS) before randomization, 3 weeks and 6 weeks after randomization, and 3 weeks after completing the treatment.

DISCUSSION

Subjective measurements, like K-ADHD-RS, are commonly used in ADHD. Although these measurements have adequate reliability and validity, lack of objective assessment in ADHD may lead to some disputes, like parental placebo effects. More objective measurements, like Computerized Neurocognitive function Test (CNT) in this study, are needed in ADHD trials. Furthermore, this trial will provide evidence for the effectiveness of acupuncture as a treatment for ADHD.

TRIAL REGISTRATION

Clinical Research Information Service (CRiS) KCT0000019.

Acupuncture for infertility: is it an effective therapy?

Acupuncture has been used to treat infertility extensively, including ovulatory dysfunction, in vitro fertilization and embryo transfer (IVF-ET), and male infertility. This review summarizes the recent studies which investigated the role of acupuncture in infertility. In conclusion, most of the existing studies suggest a positive effect of acupuncture in infertility treatment. Firstly, acupuncture may improve ovulation by modulating the central and peripheral nervous systems, the neuroendocrine and endocrine systems, the ovarian blood flow, and metabolism. Secondly, acupuncture can improve the outcome of IVF-ET, and the mechanisms may be related to the increased uterine blood flow, inhibited uterine motility, and the anesis of depression, anxiety and stress. Its effect on modulating immune function also suggests helpfulness in improving the outcome of IVF-ET. Finally, the studies suggest that acupuncture plays a positive role in male infertility, the mechanism of which is not yet clear. Even though a positive effect of acupuncture in infertility has been found, well-designed multi-center, prospective randomized controlled studies are still needed to provide more reliable and valid scientific evidence. Furthermore, it is urgent and necessary to clarify the mechanism of acupuncture for infertility.

A pilot study of acupuncture augmentation therapy in antidepressant partial and non-responders with major depressive disorder

BACKGROUND

Acupuncture is widely used for treating major depressive disorder (MDD). There is evidence supporting acupuncture as an antidepressant monotherapy, but its efficacy as augmentation in antidepressant partial and non-responders has not been well-investigated.

METHODS

Thirty subjects (47% female, mean age 48±11 years) with a history of SCID-diagnosed MDD and partial or non-response after ≥8 weeks of antidepressant therapy were assigned 8 weeks of standardized 30-min open acupuncture augmentation sessions on a weekly (n=24) or twice-weekly (n=6) basis. Change in the Hamilton-D-17 score was the primary outcome measure, and response rates (based on HAM-D-17 score improvement of ≥50%) the secondary outcome.

RESULTS

Twenty subjects (40% female; 18 in weekly and 2 in twice-weekly treatment) completed the study. In the intent-to-treat (ITT) sample (N=30), HAM-D-17 scores decreased from 18.5±3.8 to 11.2±5.3 in the weekly group (p<0.001), and from 18.5±3.3 to 11.8±4.8 in the twice-weekly group (p=0.03). Improvement did not differ significantly between treatment arms (p=0.76). Response rates were 47% for all ITT subjects, 50% for the weekly group and 33% for the twice-weekly group (p=0.66). The most common side effects included soreness/pain (n=7), bruising (n=4), and mild bleeding (n=1) at the needle site. One subject discontinued because of side effects (pain).

LIMITATIONS

Open design, small sample, polypharmacy with antidepressants.

CONCLUSIONS

Once or twice-weekly acupuncture augmentation was safe, well-tolerated and effective in antidepressant partial and non-responders, suggesting good feasibility in outpatient settings. Replication in controlled trials is warranted.

Adverse events associated with acupuncture: a prospective survey

OBJECTIVE

The objective of this study was to investigate the adverse events associated with acupuncture using a standard record form in order to identify the risks of acupuncture therapy and assess their causes.

METHODS

Thirteen (13) Oriental medicine doctors volunteered to report the number of acupuncture treatment sessions administered and patients encountered every week. When adverse events occurred, these doctors reported it using a record form that we created. The record form contained six major items to be filled out: patient, acupuncture treatment, adverse event, causality, person reporting the incident, and acupuncturist.

RESULTS

In 5 weeks, the 13 Oriental medicine doctors in our study conducted 3071 acupuncture treatment sessions on 2226 patients. A total of 99 adverse events were reported, which is a rate of 3.2 events per 100 treatments. Common adverse events were hemorrhage (32%), hematoma (28%), and needle site pain (13%). Of the 99 treatments during which an adverse events occurred, 64 treatments were ended, and 62 of the adverse events diminished or disappeared. Of the 35 remaining cases of adverse events in which treatment was continued, 28 patients had their adverse events diminish or disappear. Causality assessment suggested that 47% of adverse events were certainly caused by acupuncture, 45% were probably/likely caused by acupuncture, 7% were possibly caused by acupuncture, and only 1% of events were unassessable/unclassifiable.

CONCLUSIONS

Although acupuncture was associated with adverse events, there were no serious adverse events experienced by patients this study. If acupuncture treatment is administered by a practitioner with enough experience and is conducted in accordance with established guidelines, it is a safe treatment method.

Cardiac tamponade caused by acupuncture: a review of the literature

This systematic review aims to summarize all reported cases of cardiac tamponade after acupuncture. Five electronic databases and our own files were searched for reports of cardiac tamponade after acupuncture. No restrictions in time or language were imposed. Data were extracted by two independent reviewers according to predefined criteria. We found a total of 26 cases. In 14 patients, the complications were fatal. In most instances, there is little doubt about causality. We conclude that cardiac tamponade is a serious, often fatal complication after acupuncture. As it is theoretically avoidable, acupuncturists should be trained to minimize the risk.

Acupuncture in Reproductive Medicine

Acupuncture is increasingly being used in reproductive medicine. This review summarizes the evidence of acupuncture in pain relief for oocyte retrieval, improving pregnancy outcomes of in vitro fertilization treatment, management of ovulation disorders, male subfertility, primary dysmenorrhea, endometriosis and menopausal symptoms. However, most of the studies are nonrandomized uncontrolled trials, case reports or case series. For randomized controlled trials, the sample size is underpowered and blinding of assessors is lacking. Different acupuncture protocols and controls are used. These heterogeneities make it difficult to compare studies and draw any firm conclusions. Further studies should also evaluate the cost-effectiveness of acupuncture and investigate the underlying mechanism of acupuncture treatment.

Electroacupuncture for cervical ripening prior to labor induction: a randomized clinical trial

PURPOSE

The present study was aimed to compare the effects of the use of electroacupuncture and misoprostol in inducing labor in patients with Bishop score < 7 and to observe the characteristics of labor in both methods.

METHODS

As much as 67 pregnant women with Bishop score < 7, single cephalic presentation with gestational age confirmed by first-trimester ultrasound, reactive cardiotocography, and amniotic fluid volume and estimated fetal weight within the respective normal ranges for gestational age were selected. They were randomized into 2 groups: electroacupuncture (AC) or misoprostol (M).

RESULTS

There were no significant differences regarding age, gestational age, fetal weight, parity, Bishop score, or indication for induction. Labor was the main outcome, which was obtained in both groups without significant difference regarding frequency (p = 0.07) and time of induction (p = 0.29). Absence of obstetric complication, higher duration of labor (p = 0.036), and tendency to a higher satisfaction of the patients (p = 0.046) were observed among patients of group AC. Higher frequency of cesarean sections (p = 0.014) and obstetric complications (9.3%) were observed among patients of group M.

CONCLUSIONS

Our results showed that electroacupuncture can be used to obtain cervical ripening, with similar results as compared with misoprostol, with a significantly higher frequency of vaginal deliveries and without occurrence of obstetric complications.

Short-term reactions to acupuncture treatment and adverse events following acupuncture: a cross-sectional survey of patient reports in Korea

OBJECTIVES

The objective of this study was to explore the type and frequency of short-term reactions, de qi associated with acupuncture treatment, and to determine the incidence of adverse events following acupuncture treatment in Korea.

SUBJECTS AND METHODS

This study is a retrospective and cross-sectional survey of patient reports using 1095 subjects; 585 subjects are outpatients of the East-West NEO Medical Center and the remaining 510 subjects are outpatients of the Kyung Hee Medical Center. In the period of June to November 2006, the participating subjects, who had all received acupuncture, consented and completed a single survey form. On this form, patients were asked to report their short-term reactions to the acupuncture, de qi, a patient satisfaction score (using the Visual Analogue Scale [VAS]) and any adverse events related to the acupuncture treatment. The 8 acupuncturists involved in this study were Korean medicine doctors who had more than 10 years' experience working as practitioners.

RESULTS

The average age of the 1095 subjects was 58 years old. Positive short-term acupuncture reactions were reported by 878 (80.2%) of the 1095 subjects. Seventy-five (75) (6.8%) subjects described negative short-term acupuncture reactions. The most common positive short-term acupuncture reaction was that of a "relaxed" feeling in 472 (43.1%), followed by 90 (8.2%) who acknowledged a feeling of "less pain"; 16 (1.5%) felt "energized"; 16 (1.5%) experienced "tingling" and a sensation of "Heat" or "Coldness" was reported by 10 (0.9%). Negative short-term acupuncture reactions included feelings of "pain" 37 (3.4%), tiredness 24 (2.2%), and dizziness 9 (0.8%). Traditionally, the needling sensations of de qi refer to a patient's response to treatment, such as distension, pulling, soreness, heaviness, and numbness. Some (39.7%) subjects reported de qi during needling. A number experienced "distension" 333 (30.4%), "soreness" 52(4.7%), "pulling" 22(2.0%), "heaviness" 18(1.6%), and "numbness" 10 (0.9%). Positive short-term acupuncture reactions and de qi ratings were highest in those less than 40 years of age (83/96 86.5%, 50/96 52.1%). No reaction responses to acupuncture were the highest frequency in subjects over 70 years of age (31/187, 16.6%). Patient satisfaction level using VAS was comparatively high: 72.9 +/- 19.9. The only adverse events reported were bleeding in 92 (8.4%) of the participants. The majority of patients treated with acupuncture had suffered from stroke (430; 16.9%), headache (185; 16.9%), hypertension (97; 8.9%), or dizziness (85; 7.8%).

CONCLUSIONS

Short-term acupuncture reactions and de qi were related to the age group. With the exception of bleeding, there were no adverse events related to the acupuncture treatment in this study. We consider acupuncture treatment to be very safe if the practitioners are well educated, trained and experienced. The number of post-treatment positive short-term acupuncture reactions was 12 times higher than that of the negative short-term reactions. Overall, subjects were comparatively satisfied with the acupuncture treatment.

Efficacy of acupuncture in management of premenstrual syndrome: a systematic review

BACKGROUND

The effectiveness of acupuncture in the case of premenstrual syndrome (PMS) is not fully understood.

OBJECTIVES

To assess the effectiveness and adverse effects of acupuncture for the symptomatic treatment of PMS from randomised controlled trials (RCTs).

SEARCH STRATEGY

Electronic databases, including English, Korean, Japanese and Chinese, were systematically searched up to January 2009 with no language restrictions.

SELECTION CRITERIA

RCTs comparing acupuncture with control investigating acupuncture for PMS were considered.

DATA COLLECTION AND ANALYSIS

Study collection and quality assessment were performed by two reviewers using the criteria described in the Cochrane Handbook.

MAIN RESULTS

Nine studies were systematically reviewed. Only two of the nine trials reported details regarding sequence generation and allocation concealment. Four studies reported a significant difference in reduction of PMS symptoms for acupuncture treatment compared with pharmacological treatment. Two studies reported the improvements in primary symptoms within the acupuncture and herbal medications groups compared with baseline. Only two RCTs reported information regarding acupuncture-related adverse events, which included one case of a small subcutaneous haematoma.

CONCLUSIONS

Although the included trials showed that acupuncture may be beneficial to patients with PMS, there is insufficient evidence to support this conclusion due to methodological flaws in the studies, including unknowns in sequence generation, concealment of allocation, blinding and outcome measures.

Adverse event reporting in acupuncture clinical trials focusing on pain

OBJECTIVES

To review the quality of adverse event reporting for published randomized controlled trials (RCTs) focusing on acupuncture for pain reduction. With the release of the Consolidated Standards of Reporting Trials (CONSORT) in 2001, the quality of published RCTs has improved. To improve reporting on adverse events, CONSORT expanded the section on harms (adverse events) in 2004. This paper evaluates whether the updated harms guidelines have been implemented in RCTs evaluating acupuncture for pain relief.

METHODS

Systematic searches were conducted using the following databases: MEDLINE, Allied & Complementary Medicine, Cumulative Index to Nursing & Allied Health Literature, and All EBM Reviews. Each database was searched from 2005 through 2008, corresponding to the availability of the updated harms guideline.

RESULTS

Ten studies met the inclusion criteria of this review. Six of the 10 studies mentioned or discussed adverse events. Four of the 6 studies did not detail how adverse events were collected. Only 2 studies discussed how adverse events were assessed.

DISCUSSION

On the basis of our findings, acupuncture clinical trials for pain reduction have yet to comprehensively meet CONSORT's guidelines for adverse event reporting. Acupuncture is commonly used by patients experiencing pain and although typically viewed as a benign and minimally invasive therapy, serious adverse events have been reported in the literature. To effectively and comprehensively document and understand these events, routine reporting according to CONSORT's harms guidelines should become the norm. Both science and patients are served by accurately evaluating the safety of acupuncture for patient populations experiencing pain.

Randomized, Blinded, Sham-Controlled Trial of Acupuncture for the Management of Aromatase Inhibitor–Associated Joint Symptoms in Women With Early-Stage Breast Cancer

Purpose

Women with breast cancer (BC) treated with aromatase inhibitors (AIs) may experience joint symptoms that can lead to discontinuation of effective therapy. We examined whether acupuncture improves AI-induced arthralgias in women with early-stage BC.

Methods

We conducted a randomized, controlled, blinded study comparing true acupuncture (TA) versus sham acupuncture (SA) twice weekly for 6 weeks in postmenopuasal women with BC who had self-reported musculoskeletal pain related to AIs. TA included full body/auricular acupuncture and joint-specific point prescriptions, whereas SA involved superficial needle insertion at nonacupoint locations. Outcome measures included the Brief Pain Inventory–Short Form (BPI-SF), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Modified Score for the Assessment of Chronic Rheumatoid Affections of the Hands (M-SACRAH) obtained at baseline and at 3 and 6 weeks.

Results

Of 51 women enrolled, 43 women were randomly assigned and 38 were evaluable. Baseline characteristics were comparable between the two groups. Our primary end point was the difference in mean BPI-SF worst pain scores at 6 weeks, which was lower for TA compared with SA (3.0 v 5.5; P < .001). We also found differences between TA and SA in pain severity (2.6 v 4.5; P = .003) and pain-related interference (2.5 v 4.5; P = .002) at 6 weeks. Similar findings were seen for the WOMAC and M-SACRAH scores. The acupuncture intervention was well-tolerated.

Conclusion

Women with AI-induced arthralgias treated with TA had significant improvement of joint pain and stiffness, which was not seen with SA. Acupuncture is an effective and well-tolerated strategy for managing this common treatment-related side effect.

Acupuncture for vasomotor menopausal symptoms: a systematic review

OBJECTIVE

The aim of this study was to critically assess whether acupuncture therapy reduces vasomotor menopausal symptoms and to evaluate the adverse effects of acupuncture therapy on the basis of the results of randomized controlled trials (RCTs).

METHODS

Nineteen electronic databases, including English, Korean, Japanese, and Chinese databases, were systematically searched for RCTs in which acupuncture was used to reduce vasomotor menopausal symptoms before July 2008. There were no language restrictions. The methodological quality of the eligible studies was assessed using the categories provided by the Menstrual Disorders and Subfertility Review Group.

RESULTS

Eleven studies, which included a total of 764 individual cases, were systematically reviewed. The methodological quality of the trials varied substantially. Six trials compared acupuncture treatment to sham or placebo acupuncture. Only one study using a nonpenetrating placebo needle found a significant difference in the severity outcomes of hot flashes between groups (mean difference, 0.48; 95% CI, 0.05-0.91). Five studies reported a reduced frequency of hot flashes within groups; however, none found a significant difference between groups. An analysis of the outcomes of the trials that compared acupuncture with hormone therapy or oryzanol for reducing vasomotor symptoms showed that acupuncture was superior. Three RCTs reported minimal acupuncture-related adverse events.

CONCLUSIONS

There is no evidence from RCTs that acupuncture is an effective treatment in comparison to sham acupuncture for reducing menopausal hot flashes. Some studies have shown that acupuncture therapies are better than hormone therapy for reducing vasomotor symptoms. However, the number of RCTs compared with a nonpenetrating placebo control needle or hormone therapy was too small, and the methodological quality of some of the RCTs was poor. Further evaluation of the effects of acupuncture on vasomotor menopausal symptoms based on a well-controlled placebo trial is therefore warranted.

Acupuncture: Complications are preventable not adverse events

If adverse effects are understood as "something that happened unexpectedly" while receiving drug treatment, there is no difference between adverse effects and complications. However, acupuncture is a process different from the use of drugs. While acupuncture procedures should not be taken for granted as safe, complications causing harm are usually, according to the authors, the result of negligence, and should be differentiated from other adverse effects. Harmful complications noted consisted of bleeding and damage to the tissues and organs under the puncture sites. Adverse effects consisted of symptomatology like fainting and other systemic disturbances difficult to explain. In a study of acupuncture complications and adverse effects in 2000 procedures conducted by experienced professional acupuncturists in a research institution, it was found that complications did not occur, and adverse events happened infrequently. Attempts were made to explain the causes of adverse effects. Now that acupuncture is being widely incorporated into medical practice, a good understanding of adverse effects and complications would be necessary and helpful.

Acupuncture for alcohol dependence: a systematic review

BACKGROUND

Acupuncture has been used in the treatment of substance-related disorders for the past 30 years. However, a systematic review to assess the effect of various types of acupuncture for alcohol dependence has not yet been performed. The present systematic review assessed the results of randomized controlled trials (RCTs).

METHODS

Nineteen electronic databases, including English, Korean, Japanese, and Chinese databases, were systematically searched for RCTs of acupuncture for alcohol dependence up to June 2008 with no language restrictions. The methodological qualities of eligible studies were assessed using the criteria described in the Cochrane Handbook.

RESULTS

Eleven studies, which comprised a total of 1,110 individual cases, were systematically reviewed. Only 2 of 11 trials reported satisfactorily all quality criteria. Four trials comparing acupuncture treatment and sham treatments reported data for alcohol craving. Three studies reported that there were no significant differences. Among 4 trials comparing acupuncture and no acupuncture with conventional therapies, 3 reported significant reductions. No differences between acupuncture and sham treatments were found for completion rates (Risk Ratio = 1.07, 95% confidence interval, CI = 0.91 to 1.25) or acupuncture and no acupuncture (Risk Ratio = 1.15, 95% CI = 0.79 to 1.67). Only 3 RCTs reported acupuncture-related adverse events, which were mostly minimal.

CONCLUSIONS

The results of the included studies were equivocal, and the poor methodological quality and the limited number of the trials do not allow any conclusion about the efficacy of acupuncture for treatment of alcohol dependence. More research and well-designed, rigorous, and large clinical trials are necessary to address these issues.

Alternative treatments in pediatric bipolar disorder

There has been growing interest in the use of complementary and alternative treatments in pediatric bipolar disorder (BPD). There are limited data, however, regarding the safety and efficacy of these treatments. This article discusses select complementary and alternative treatments that have been considered for use in pediatric BPD and/or depression, including omega-3-fatty acids, inositol, St. John's wort, SAMe, melatonin, lecithin, and acupuncture. Background information, reference to available adult and pediatric data, proposed mechanisms of action, dosing, side effects, and precautions of these treatments are included. Across the board, more research is necessary and warranted regarding the long-term safety and efficacy of available complementary and alternative treatments for the management of pediatric BPD.

Acupuncture for obesity: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Acupuncture is widely used in complementary and alternative medicine to reduce body weight. However, a systematic review and meta-analysis to assess an effect of acupuncture has not yet been performed. Aim of this study is to critically assess evidence for reduction of body weight and to evaluate adverse events of acupuncture therapy based on the results of randomized controlled trials (RCTs) that evaluate the effect of various types of acupuncture therapies.

DATA SOURCES

A total of 19 electronic databases, including English, Korean, Japanese and Chinese databases, were systematically searched for RCTs of acupuncture for reduction of body weight or improvement in obesity up to March 2008 with no language restrictions.

METHODS

RCTs for acupuncture compared either with placebo controlled or with comparator intervention were considered. Studies' methodological qualities were assessed using the Jadad scale. If no evidence of heterogeneity existed across study results, statistical pooling of data was performed using a fixed effects model; otherwise, a random effects model was used. Publication bias was assessed using funnel plots. Subgroup analyses were performed according to types of acupuncture.

RESULTS

A total of 31 studies, which comprised a total of 3013 individual cases, were systematically reviewed. Owing to insufficient data in 2 RCTs, 29 RCTs were used for meta-analysis. About two-thirds of the trials (20 out of 31) showed the lowest score of the Jadad. Compared to control of lifestyle, acupuncture was associated with a significant reduction of average body weight (95% confidence interval, CI) of 1.72 kg (0.50-2.93 kg) and associated with an improvement in obesity (relative risk=2.57; 95% CI, 1.98-3.34). Acupuncture significantly reduced a body weight of 1.56 kg (0.74-2.38 kg), on average, compared to placebo or sham treatments. Acupuncture also showed more improved outcomes for body weight (mean difference=1.90 kg; 1.66-2.13 kg), as well as for obesity (relative risk=1.13; 1.04-1.22), than conventional medication. Only four RCTs reported acupuncture-related adverse events, which were mostly minimal.

CONCLUSIONS

Our review suggests that acupuncture is an effective treatment for obesity. However, the amount of evidence is not fully convincing because of the poor methodological quality of trials reviewed. In conclusion, there is an urgent need for well-planned, long-term studies to address the effectiveness of acupuncture for treating obesity.

Outbreak of invasive methicillin-resistant Staphylococcus aureus infection associated with acupuncture and joint injection

OBJECTIVE

To describe an outbreak of invasive methicillin-resistant Staphylococcus aureus (MRSA) infection after percutaneous needle procedures (acupuncture and joint injection) performed by a single medical practitioner.

SETTING

A medical practitioner's office and 4 hospitals in Perth, Western Australia.

PATIENTS

Eight individuals who developed invasive MRSA infection after acupuncture or joint injection performed by the medical practitioner.

METHODS

We performed a prospective and retrospective outbreak investigation, including MRSA colonization surveillance, environmental sampling for MRSA, and detailed molecular typing of MRSA isolates. We performed an infection control audit of the medical practitioner's premises and practices and administered MRSA decolonization therapy to the medical practitioner.

RESULTS

Eight cases of invasive MRSA infection were identified. Seven cases occurred as a cluster in May 2004; another case (identified retrospectively) occurred approximately 15 months earlier in February 2003. The primary sites of infection were the neck, shoulder, lower back, and hip: 5 patients had septic arthritis and bursitis, and 3 had pyomyositis; 3 patients had bacteremia, including 1 patient with possible endocarditis. The medical practitioner was found to be colonized with the same MRSA clone [ST22-MRSA-IV (EMRSA-15)] at 2 time points: shortly after the first case of infection in March 2003 and again in May 2004. After the medical practitioner's premises and practices were audited and he himself received MRSA decolonization therapy, no further cases were identified.

CONCLUSIONS

This outbreak most likely resulted from a breakdown in sterile technique during percutaneous needle procedures, resulting in the transmission of MRSA from the medical practitioner to the patients. This report demonstrates the importance of surveillance and molecular typing in the identification and control of outbreaks of MRSA infection.

Complementary and alternative medicine in the treatment of bipolar disorder--a review of the evidence

A growing number of patients with mood disorders are using complementary and alternative medicine (CAM) interventions. In this paper, we review the published scientific evidence on the benefits and risks of CAM for the treatment of patients with bipolar disorder. Since very few studies of CAM have involved patients with bipolar disorder, most available evidence is derived from trials conducted in patients with major depressive disorder. The use of omega-3 fatty acids has been studied in two controlled studies in bipolar disorder while St. John's wort (Hypericum perforatum), S-adenosyl-l-methionine (SAMe), and acupuncture have been studied in a series of randomized controlled trials in patients with major depression. Overall, the best evidence supports the use of St. John's wort for the treatment of mild to moderate depression. SAMe may also be effective for depression. However, both of these products have the potential to induce mania; the extent of this risk needs to be quantified. St. John's wort can also interact with a variety of medications. Evidence regarding the benefits of omega-3 fatty acids or acupuncture is inconsistent. Data regarding other CAM interventions (e.g., aromatherapy massage, massage therapy, yoga) are almost entirely lacking. In conclusion, better studies are needed before CAM interventions can be recommended to patients with bipolar disorder. In the meantime, patients need to be informed about the possible risks associated with the use of these interventions.

Acupuncture Is Underutilized in Hospice and Palliative Medicine

Acupuncture is a complementary and alternative medical modality. A considerable body of acupuncture research has accumulated since 1998. Acupuncture has been integrated into palliative care settings in the United Kingdom but is yet to be widely offered in the United States. The literature was searched to identify clinical trials involving acupuncture, palliative care, hospice, chronic obstructive pulmonary disease, bone marrow, and cancer. Twenty-seven randomized controlled clinical trials of acupuncture were found that reported on conditions common to the hospice and palliative care setting, including dyspnea, nausea and vomiting, pain, and xerostomia, and 23 reported statistically significant results favoring acupuncture use for the conditions investigated. Acupuncture is safe and clinically cost-effective for management of common symptoms in palliative care and hospice patients. Acupuncture has potential as adjunctive care in palliative and end-of-life care, and the evidence warrants its inclusion in reimbursed palliative and end-of-life care in the United States.

Vascular injuries caused by acupuncture

AIM

To systematically review the literature on vascular injuries caused by acupuncture.

METHOD

Systematic literature search in Medline and PubMed.

RESULTS

Twentyone cases were identified and the majority developed symptoms in direct connection with the acupuncture treatment. Three patients died, two from pericardial tamponade and one from an aortoduodenal fistula. There were five more tamponades, seven pseudoaneurysms, two with ischaemia, two with venous thrombosis, one with compartment syndrome and one with bleeding. The two patients with ischaemia had remaining sequeleae. Information on follow-up was suboptimal with no information in nine patients.

CONCLUSION

Vascular injuries are rare, bleeding and pseudoaneurysm dominating. Follow-up is insufficient in the hitherto published papers.

The role of acupuncture in the management of subfertility

OBJECTIVE

To review systematically the use of acupuncture in the management of subfertility.

DESIGN

A computer search was performed via several English and Chinese databases to identify journals relevant to the subject.

RESULT(S)

The positive effect of acupuncture in the treatment of subfertility may be related to the central sympathetic inhibition by the endorphin system, the change in uterine blood flow and motility, and stress reduction. Acupuncture may help restore ovulation in patients with polycystic ovary syndrome, although there are not enough randomized studies to validate this. There is also no sufficient evidence supporting the role of acupuncture in male subfertility, as most of the studies are uncontrolled case reports or case series in which the sample sizes were small. Despite these deficiencies, acupuncture can be considered as an effective alternative for pain relief during oocyte retrieval in patients who cannot tolerate side effects of conscious sedation. The pregnancy rate of IVF treatment is significantly increased, especially when acupuncture is administered on the day of embryo transfer.

CONCLUSION(S)

Although acupuncture has gained increasing popularity in the management of subfertility, its effectiveness has remained controversial.

Acupuncture needles causing lumbar cerebrospinal fluid fistula

✓Acupuncture is a frequently used adjuvant treatment for chronic pain conditions. The authors report the case of a patient in whom the delayed migration of embedded acupuncture needles into the lumbar spinal canal caused the formation of a cerebrospinal fluid fistula and spine-related headache. The needles were safely removed surgically and the patient improved clinically.

Effectiveness and tolerability of acupuncture compared with metoprolol in migraine prophylaxis

OBJECTIVES

In a randomized controlled multicenter trial extending over 24 weeks, we investigated whether acupuncture is as effective and safe as metoprolol in the prophylactic treatment of migraine under conditions similar to routine care.

METHODS

One hundred fourteen migraine patients could be randomized to treatment over 12 weeks either with acupuncture (8 to 15 sessions) or metoprolol (100 to 200 mg daily). Main outcome measure was the difference in the number of migraine days between baseline and the weeks 9 to 12 after randomization (derived from a headache diary).

RESULTS

Two of 59 patients randomized to acupuncture withdrew prematurely from the study compared to 18 of 55 randomized to metoprolol. The number of migraine days decreased by 2.5 +/- 2.9 days (baseline 5.8 +/- 2.5 days) in the acupuncture group compared to 2.2 +/- 2.7 days (baseline 5.8 +/- 2.9 days) in the metoprolol group (P= .721). The proportion of responders (reduction of migraine attacks by > or =50%) was 61% for acupuncture and 49% for metoprolol. Both physicians and patients reported fewer adverse effects in the acupuncture group.

CONCLUSIONS

Due to missing the recruitment target (480 patients) and the high drop-out in the metoprolol group the results must be interpreted with caution. Still, they suggest that acupuncture might be an effective and safe treatment option for patients unwilling or unable to use drug prophylaxis.

An audit of self acupuncture for chronic musculoskeletal pain

BACKGROUND

Acupuncture is increasingly offered as a treatment for chronic pain, but continued treatment is expensive. Self acupuncture might offer a cost effective alternative. The aim of this project was to investigate the effectiveness and safety of self acupuncture in a pain clinic.

METHODS

A retrospective audit was conducted by postal questionnaire of all patients with chronic pain who were taught self acupuncture as a home pain management strategy in the previous three years. The study was conducted by a researcher not involved in the patient's treatment. The patients selected for self acupuncture were those who had responded to acupuncture previously, met certain criteria, and had been taught self acupuncture successfully. Patients were taught self acupuncture using three acupuncture points (LI4, ST44, LR3).

RESULTS

Of 52 eligible patients (70% female) who were approached, 38 valid questionnaires were returned, giving a response rate of 73.1% . Of these, 76.3% were female; 86.8% (33) still used self acupuncture and 13.3% (5) had stopped; 86.8% of the patients continued to experience pain reduction with self acupuncture. The reported pain relief gained was 5.7 (SD 2.6) measured on a visual analogue scale, improvement in quality of life was reported by 73.7% and no serious adverse effects were reported.

CONCLUSION

This audit suggests that self acupuncture is effective for pain relief and improves quality of life in this selected group of patients. Safety can be maintained provided that pre-selection is done with care, and appropriate training is carried out. Self acupuncture has considerable potential to reduce clinic waiting lists and appointment times for patients. Further research is required to determine the cost effectiveness of this approach.

Potential synergism between hypnosis and acupuncture—is the whole more than the sum of its parts?

Both hypnosis and acupuncture have gained credibility over the years in their effectiveness for treating various health conditions. Currently, each of these treatments is administered in distinct settings and separate times. That is, even if patients receive both treatments as part of a multidimensional therapeutic program, they would typically receive them separately rather than simultaneously at the same session. This separation however might be undesirable since, at least theoretically, hypnosis and acupuncture could potentially augment each other if administered concomitantly. In this article we outline the rationale for this hypothesis and discuss the potential ramifications of its implementation.

Acupuncture treatment for opiate addiction: A systematic review

A review of the efficacy of acupuncture as treatment for opiate addiction, covering 33 years of reported literature in western scientific journals, was systematically undertaken. Some abstracts from Chinese language journals were also briefly reviewed. Supportive evidence often came from non-controlled nonblinded methodologies. When well-designed clinical trials (randomized, controlled, single-blind methodologies) were used, there was no significant evidence for acupuncture being a more effective treatment than controls. Some of the current supportive evidence for efficacy came from Chinese journals that have not been translated into English yet.

Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting

BACKGROUND

There have been recent advances in chemotherapy-induced nausea and vomiting using 5-HT(3) inhibitors and dexamethasone. However, many still experience these symptoms, and expert panels encourage additional methods to reduce these symptoms.

OBJECTIVES

The objective was to assess the effectiveness of acupuncture-point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, PsycLIT, MANTIS, Science Citation Index, CCTR (Cochrane Controlled Trials Registry), Cochrane Complementary Medicine Field Trials Register, Cochrane Pain, Palliative Care and Supportive Care Specialized Register, Cochrane Cancer Specialized Register, and conference abstracts.

SELECTION CRITERIA

Randomized trials of acupuncture-point stimulation by any method (needles, electrical stimulation, magnets, or acupressure) and assessing chemotherapy-induced nausea or vomiting, or both.

DATA COLLECTION AND ANALYSIS

Data were provided by investigators of the original trials and pooled using a fixed effect model. Relative risks were calculated on dichotomous data. Standardized mean differences were calculated for nausea severity. Weighted mean differences were calculated for number of emetic episodes.

MAIN RESULTS

Eleven trials (N = 1247) were pooled. Overall, acupuncture-point stimulation of all methods combined reduced the incidence of acute vomiting (RR = 0.82; 95% confidence interval 0.69 to 0.99; P = 0.04), but not acute or delayed nausea severity compared to control. By modality, stimulation with needles reduced proportion of acute vomiting (RR = 0.74; 95% confidence interval 0.58 to 0.94; P = 0.01), but not acute nausea severity. Electroacupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% confidence interval 0.60 to 0.97; P = 0.02), but manual acupuncture did not; delayed symptoms for acupuncture were not reported. Acupressure reduced mean acute nausea severity (SMD = -0.19; 95% confidence interval -0.37 to -0.01; P = 0.04) but not acute vomiting or delayed symptoms. Noninvasive electrostimulation showed no benefit for any outcome. All trials used concomitant pharmacologic antiemetics, and all, except electroacupuncture trials, used state-of-the-art antiemetics.

AUTHORS' CONCLUSIONS

This review complements data on post-operative nausea and vomiting suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies combining electroacupuncture with state-of-the-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance. Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control. Noninvasive electrostimulation appears unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy.