Strategies to maintain the credibility of sham acupuncture used as a control treatment in clinical trials

Effect of electroacupuncture at Zusanli (ST36) and Sanyinjiao (SP6) acupoints on adrenocortical function in etomidate anesthesia patients

Background

We aimed to investigate the effect of electroacupuncture at Zusanli (ST36) and Sanyinjiao (SP6) on adrenocortical function in patients with etomidate anesthesia.

Material/Methods

We randomly divided 80 patients who underwent elective surgery into 4 groups: group etomidate (ETO), group etomidate + electroacupuncture (ETO+EA), group etomidate + sham acupuncture (ETO+SEA), and group propofol (PRO). The patients in group ETO, ETO+EA, and ETO+SEA were induced with etomidate and sufentanil and maintained with intravenous infusion of etomidate and remifentanil. Group PRO was induced with propofol and sufentanil and maintained with propofol and remifentanil. Group ETO+EA received electro-acupuncture stimulation at Zusanli and Sanyinjiao throughout the operation, while group ETO+SEA received electro-acupuncture stimulation at non-acupoints. We recorded the values of MAP, HR, BIS, CVP, cortisol, ACTH, epinephrine, norepinephrine, and arterial blood gas during the perioperative period.

Results

Cortisol concentrations were significantly higher at all times except T0 in group ETO+EA compared with group ETO. The ACTH concentrations were lower in group ETO+EA than that in group ETO at point T3.

Conclusions

Electroacupuncture at ST 36 and SP 6 can mitigate the adrenal cortical inhibition induced by etomidate and can reduce the secretion of catecholamines during surgery.

Acupuncture for acute non-specific low back pain: a randomised, controlled, double-blind, placebo trial

OBJECTIVE

To assess the efficacy of Yamamoto's acupuncture method on pain, drug intake, functional capacity and quality of life for the treatment of acute non-specific low back pain (ANLBP).

METHODS

A prospective, randomised, parallel-group, double-blind, placebo-controlled trial was performed in 80 men and women with ANLBP who were randomly assigned to five acupuncture sessions (intervention group (IG), n=40) and to five non-penetrating acupuncture sessions (sham group (SG), n=40). Patients were evaluated at baseline and at 3, 7, 14, 21 and 28 days. The measurements used were: visual analogue scale (VAS) for cumulative pain (before intervention, VAS1) and immediate pain (after intervention, VAS2); function (Roland-Morris Disability Questionnaire (RM)); quality of life (SF-36); improvement rating; and number of anti-inflammatory tablets taken. The primary endpoint was a decrease of at least 2 cm in VAS1.

RESULTS

Pain VAS improved significantly in the IG from day 14 onwards compared with the SG, but the difference did not reach the prespecified clinically relevant value of 2 cm. The IG was significantly superior to the SG in the following outcomes: cumulative pain, function, pain (SF-36) and vitality (SF-36) at days 14, 21 and 28 (p<0.05); limitation in physical aspects (SF-36) at all times (p=0.007 and p=0.02); and functional capacity (SF-36) at days 21 and 28 (p<0.05). The IG also took significantly fewer anti-inflammatory tablets than the SG (p=0.004) at all evaluation times and the improvement rating was better than the SG (p<0.001).

CONCLUSIONS

Yamamoto's new scalp acupuncture was more effective than sham treatment with regard to decrease in pain and anti-inflammatory intake as well as improving functional status and quality of life for patients with ANLBP.

CLINICALTRIALSGOV

NCT 01124955.

Blinding measured: a systematic review of randomized controlled trials of acupuncture

Background. There is no agreement among researchers on viable controls for acupuncture treatment, and the assessment of the effectiveness of blinding and its interpretation is rare. Purpose. To systematically assess the effectiveness of blinding (EOB) in reported acupuncture trials; to explore results of RCTs using a quantitative measure of EOB. Data Sources. A systematic review of published sham RCTs that assessed blinding. Study Selection. Five hundred and ninety studies were reviewed, and 54 studies (4783 subjects) were included. Data Extraction. The number of patients who guessed their treatment identity was extracted from each study. Variables with possible influence on blinding were identified. Data Synthesis. The blinding index was calculated for each study. Based on blinding indexes, studies were congregated into one of the nine blinding scenarios. Individual study characteristics were explored for potential association with EOB. Limitations. There is a possibility of publication or reporting bias. Conclusions. The most common scenario was that the subjects believed they received verum acupuncture regardless of the actual treatment received, and overall the subject blinding in the acupuncture studies was satisfactory, with 61% of study participants maintaining ideal blinding. Objectively calculated blinding data may offer meaningful and systematic ways to further interpret the findings of RCTs.

The optimized acupuncture treatment for neck pain caused by cervical spondylosis: a study protocol of a multicentre randomized controlled trial

BACKGROUND

Neck pain is one of the chief symptoms of cervical spondylosis (CS). Acupuncture is a well-accepted and widely used complementary therapy for the management of neck pain caused by CS. In this paper, we present a randomized controlled trial protocol evaluating the use of acupuncture for CS neck pain, comparing the effects of the optimized acupuncture therapy in real practice compared with sham and shallow acupuncture.

METHODS/DESIGN

This trial uses a multicentre, parallel-group, randomized, sham acupuncture and shallow acupuncture, controlled single-blind design. Nine hospitals are involved as trial centres. 945 patients who meet inclusion criteria are randomly assigned to receive optimized acupuncture therapy, sham acupuncture or shallow acupuncture by a computerized central randomization system. The interventions past for 4 weeks with eight to ten treatments in total. The group allocations and interventions are concealed to patients and statisticians. The Northwick Park Neck Pain Questionnaire (NPQ) is used as the primary outcome measure, and the McGill Pain Questionnaire (MPQ) and The Short Form (36) Health Survey (SF-36) are applied as secondary outcome measures. The evaluation is performed at baseline, at the end of the intervention, and at the end of the first month and the third month during follow-up. The statistical analyses will include baseline data comparison and repeated measures of analysis of variance (ANOVA) for primary and secondary outcomes of group and time differences. Adverse events (AEs) will be reported if they occur.

DISCUSSION

This trial is a multicentre randomized control trial (RCT) on the efficacy of acupuncture for CS neck pain and has a large sample size and central randomization in China. It will strictly follow the CONSORT statement and STRICTA extension guideline to report high-quality study results. By setting the control groups as sham and shallow acupuncture, this study attempts to reveal the effects of real acupuncture versus placebo or non-classic acupuncture treatment and evaluate whether classic Chinese medical acupuncture is effective on CS neck pain. This study will provide evidence for the effects of acupuncture on CS neck pain.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR-TRC-00000184.

Deqi sensations without cutaneous sensory input: results of an RCT

Background

Deqi is defined in relation to acupuncture needling as a sensory perception of varying character. In a recently published sham laser validation study, we found that subjects in the verum and the sham laser group experienced deqi sensations. Therefore, we aim to further analyze whether the perceptions reported in the two study arms were distinguishable and whether expectancy effects exhibited considerable impact on our results.

Methods

A detailed re-analysis focusing on deqi sensations was performed from data collected in a previously published placebo-controlled, double-blind, clinical cross-over trial for a sham laser evaluation. Thirty-four healthy volunteers (28 ± 10.7 years; 16 women, 18 men) received two laser acupuncture treatments at three acupuncture points LI4 (hégu), LU7 (liéque), and LR3 (táichong); once by verum laser and once using a sham device containing an inactive laser in randomized order. Outcome measures were frequency, intensity (evaluated by visual analogue scale; VAS), and quality of the subjects' sensations perceived during treatments (assessed with the "acupuncture sensation scale").

Results

Both, verum and the sham laser acupuncture result in similar deqi sensations with regard to frequency (p-value = 0.67), intensity (p-value = 0.71) and quality (p-values between 0.15 - 0.98). In both groups the most frequently used adjectives to describe these perceptions were "spreading", "radiating", "tingling", "tugging", "pulsing", "warm", "dull", and "electric". Sensations reported were consistent with the perception of deqi as previously defined in literature. Subjects' conviction regarding the effectiveness of laser acupuncture or the history of having received acupuncture treatments before did not correlate with the frequency or intensity of sensations reported.

Conclusions

Since deqi sensations, described as sensory perceptions, were elicited without any cutaneous sensory input, we assume that they are a product of non-specific effects from the overall treatment procedure. Expectancy-effects due to previous acupuncture experience and belief in laser acupuncture do not seem to play a major role in elicitation of deqi sensations. Our results give hints that deqi might be a central phenomenon of awareness and consciousness, and that its relevance should be taken into account, even in clinical trials. However, further research is required to understand mechanisms underlying deqi.

Recent developments of acupuncture in Australia and the way forward

Almost one in ten Australians has received acupuncture treatment by acupuncturists and/or medical doctors in private clinics. The majority of Australian health insurance funds offer rebates for acupuncture. Statutory regulations for acupuncture have been implemented in the State of Victoria, Australia. Six acupuncture degree courses have been approved by the Chinese Medicine Registration Board of Victoria and/or accredited by the Australian Acupuncture and Chinese Medicine Association. Furthermore, a number of clinical trials of acupuncture on allergic rhinitis, pain and women's health were carried out in Australia. Recent developments of acupuncture in Australia indicate that through adequate and appropriate evaluation, acupuncture begins to integrate into mainstream health care in Australia.

The effect of electroacupuncture on opioid-like medication consumption by chronic pain patients: a pilot randomized controlled clinical trial

Opioid-like medications (OLM) are commonly used by patients with various types of chronic pain, but their long-term benefit is questionable. Electroacupuncture (EA) has been previously shown beneficial in reducing post-operative acute OLM consumption. In this pilot randomized controlled trial, the effect of EA on OLM usage and associated side effects in chronic pain patients was evaluated. After a two-week baseline assessment, participants using OLM for their non-malignant chronic pain were randomly assigned to receive either real EA (REA, n=17) or sham EA (SEA, n=18) treatment twice weekly for 6 weeks before entering a 12-week follow-up. Pain, OLM consumption and their side effects were recorded daily. Participants also completed the McGill Pain Questionnaire (MPQ), SF-36 and Beck Depression Inventory (BDI) at baseline, and at the 5th, 8th, 12th, 16th and 20th week. Nine participants withdrew during the treatment period with another three during the follow-up period. Intention to treat analysis was applied. At the end of treatment period, reductions of OLM consumption in REA and SEA were 39% and 25%, respectively (p=0.056), but this effect did not last more than 8 weeks after treatment. There was no difference between the two groups with respect to reduction of side effects and pain and the improvement of depression and quality of life. In conclusion, REA demonstrates promising short-term reduction of OLM for participants with chronic non-malignant pain, but such effect needs to be confirmed by trials with adequate sample sizes.

Acupuncture for Perimenopausal Symptoms in Women who Underwent Oophorectomy – a Comparative Study

OBJECTIVE

To explore the effects of acupuncture on perimenopausal symptoms in women who underwent oophorectomy.

METHODS

67 women who had undergone oophorectomy were divided into an acupuncture group (n = 36) and a comparison group (n = 31) according to their wishes. The first group was treated by acupuncture and the latter group by Livial. Clinical symptoms were assessed by the modified Kupperman index. The levels of venous blood serum beta-endorphin (beta-EP), follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2) and the maturation index (MI) of vaginal epithelial cells were assessed.

RESULTS

There were no significant group differences for the MI of vaginal exfoliative cells nor for the levels of FSH, LH and E2 after treatment (p > 0.05), but Kupperman scoring and the levels of beta-EP differed significantly between the acupuncture and the Livial group (p < 0.05). No side-effects were reported in either group.

CONCLUSION

Acupuncture results in a significant improvement in perimenopausal symptoms in women who have had an oophorectomy. Acupuncture performs as well or better than Livial. Yet, this result may have been influenced by a potential bias and the small sample size.

Acupuncture and moxibustion in the treatment of ulcerative colitis: a randomized controlled study

OBJECTIVE

Acupuncture has traditionally been used in the treatment of inflammatory bowel disease in China and is increasingly applied in Western countries. The objective of this study was to investigate the efficacy of acupuncture and moxibustion in the treatment of active ulcerative colitis (UC).

MATERIAL AND METHODS

In a prospective, randomized, controlled clinical trial 29 patients with mild to moderately active UC (mean age 37.8 +/- 12.0 years) were randomly assigned to receive either traditional acupuncture and moxa (TCM group, n = 15), or sham acupuncture consisting of superficial needling at non-acupuncture points (control group, CG, n = 14). All patients were treated in 10 sessions over a period of 5 weeks and followed-up for 16 weeks. The main outcome measure was the change in the Colitis Activity Index (CAI) after treatment; secondary outcome measures were changes in quality of life, general well-being and serum markers of inflammation.

RESULTS

In the TCM group, the CAI decreased from 8.0 (+/- 3.7) to 4.2 (+/- 2.4) points and in the control group from 6.5 (+/- 3.4) to 4.8 (+/- 3.9) points (TCM versus CG: p = 0.048). In both groups these changes were associated with significant improvements in general well-being (TCM group: from 3.0 (+/- 1.8) to 1.8 (+/- 1.0); CG: from 3.2 (+/- 1.9) to 2.2 (+/- 1.7)) and quality of life (TCM group: from 146 (+/- 23) to 182 (+/- 18); CG: from 157 (+/- 20) to 183 (+/- 23)). No significant differences between the TCM and CG were found regarding these secondary outcome measures.

CONCLUSIONS

Differences in efficacy between traditional acupuncture and sham acupuncture were small and significant only for CAI as the main outcome measure. Both traditional and sham acupuncture seem to offer an additional therapeutic benefit in patients with mild to moderately active UC.

Does acupuncture or Chinese herbal medicine have a role in the treatment of allergic rhinitis?

PURPOSE OF REVIEW

Complementary medicines, including acupuncture and Chinese herbal medicine, are being used increasingly for the management of allergies such as allergic rhinitis. Until relatively recently, however, evidence for the efficacy and safety of these therapies in allergic conditions has been lacking.

RECENT FINDINGS

A limited number of well conducted studies, all with small sample sizes, have demonstrated the promising therapeutic potential of acupuncture and Chinese herbal medicine for allergic rhinitis. The possible additional benefit of combining the two therapies, however, is yet to be confirmed. There are concerns about the appropriateness of the sham/placebo controls that have been used in acupuncture studies and also about the safety evaluation of individual herbs and herbal formulations. In addition to well established symptom scores and specific quality of life questionnaires, the concurrent use of conventional anti-allergy medications has been utilized as an outcome measure in a number of trials that have evaluated the effectiveness of acupuncture and Chinese herbal medicine for allergic rhinitis.

SUMMARY

Tentatively, it appears that acupuncture and Chinese herbal medicine can be effective treatments for allergic rhinitis. Confirmatory evidence, however, is needed from large and, ideally, multi-centre trials.

Methodological concerns when designing trials for the efficacy of acupuncture for the treatment of pain

The aim of all clinical research must surely be to assess an intervention or process or relationship between variables, ultimately in order to be able to improve clinical practice and healthcare for patients/consumers. As such, evidence gathered must have external validity (generalisability) and it must be relevant to clinical practice. It can be seen therefore that research into acupuncture for pain relief is an inherently difficult task, which requires much sensitivity and careful planning in order to minimise error when drawing conclusions. The researcher needs to adequately address problems such as sample size, blinding, randomisation and appropriate use of control and treatment. It is also most important to be able to clarify that the placebo (if used) is credible to the patient. The field of acupuncture has been overwhelmed with hundreds of sub-standard trials and much doubt still surrounds the issue of efficacy. Few good quality rigorous trials exist to support the use of acupuncture for pain relief in general. It has also been noted that the question of long-term efficacy has not been assessed by the many trials and this needs to be addressed prior to its acceptance. Further well conducted rigorous trials are therefore needed, utilising the lessons learnt through the substantial number of previous trials, in order to adequately assess the efficacy of acupuncture for painful conditions. Such trials must therefore: Utilise a placebo control. Be randomised and stratified. Ensure patient blinding. Use self completed outcome measures and blinded assessors. Have sufficient and well validated outcome measures. Check credibility of treatment. Have a well defined entry criteria which includes a single condition only. Have a long term follow up. Enrol sufficient subjects, the number to be determined by a power calculation. Provide adequate acupuncture treatment as would be found in clinical practice. Be group comparative so as to negate any carry-over effects. In this way good quality trials can be undertaken which will yield reliable results and therefore add meaningful data to the body of knowledge appertaining to the effectiveness of acupuncture.

A parametric study of electroacupuncture on persistent hyperalgesia and Fos protein expression in rats

We previously reported the anti-hyperalgesia of electroacupuncture (EA) on persistent inflammatory pain in an unrestrained, unsedated, and conscious rat model. Using this model, induced by injecting complete Freund's adjuvant (CFA) into one hind paw, we systematically evaluated the anti-hyperalgesia of EA stimulation parameters (frequency, intensity, treatment duration, and pulse width). We assessed hyperalgesia by paw withdrawal latency (PWL) to a noxious thermal stimulus and found that 10- and 100-Hz EA frequencies at a current intensity of 3 mA produced the greatest anti-hyperalgesia, when compared to other parameters. Both frequencies significantly increased PWL in the early phases of hyperalgesia (2.5 and 24 h; p < 0.05), and 10 Hz EA also significantly increased PWL in later phases (5 to 7 days; p < 0.05). A sufficient but tolerable intensity of 3 mA was more effective than lower intensities (1-2 mA). A 20-min treatment produced better anti-hyperalgesia than longer and shorter (10 and 30 min) treatments. Acupoint specificity study demonstrated that GB30 produced significant EA anti-hyperalgesia, while Waiguan (TE5) and sham points, an abdominal point and a point at the opposite aspect of GB30, did not. The spinal Fos protein expression study demonstrated that the optimal EA selectively suppressed Fos expression in superficial laminae (I/II) and activated it in deeper laminae (III/IV) of the spinal dorsal horn. The results suggest that the EA anti-hyperalgesia is parameter-dependent and point-specific, and they provide important information for designing further clinical acupuncture research on persistent inflammatory pain.

Clinical Research on Acupuncture: Part 2. Controlled Clinical Trials, an Overview of Their Methods

There is almost universal agreement that the quality of clinical trials of acupuncture is poor. There is an urgent need to improve their quality. The author develops here a list of 45 criteria important in the design, implementation, and writing up of controlled clinical acupuncture trials. This list has been compiled after examining the quality assessment criteria used in meta-analyses and systematic reviews of acupuncture, general publications on clinical trial designs and methodological considerations specific to acupuncture trials. Each criterion is discussed with recommendations about use and implementation. Additionally, each criterion is discussed relative to their importance in three types of acupuncture trial, acupuncture versus sham acupuncture, acupuncture versus standard therapy and acupuncture versus no treatment or wait-list. It is hoped that this exploration and systematic presentation of the 45 criteria will contribute to improving the quality of clinical trials of acupuncture. Improved trial quality will lead to greater ease interpreting the results of trials, especially in systematic reviews.

Electroacupuncture for Tension-type Headache on Distal Acupoints Only: A Randomized, Controlled, Crossover Trial

OBJECTIVE

To investigate the efficacy of electroacupuncture, applied to distal acupoints only, for tension-type headache.

BACKGROUND

Electroacupuncture is commonly used for tension-type headache, but when applied to distal acupoints only, evidence of its efficacy is lacking.

DESIGN

A randomized, single-blinded, sham-controlled, crossover clinical trial. Methods.-The trial had 5 stages: baseline (2 weeks), phases I and II (each 4 weeks), washout period (2 weeks), and follow-up (3 months after phase II). Forty patients were randomly assigned to either group A or group B. Group A received real electroacupuncture during phase I, then sham electroacupuncture in phase II. Group B received the treatments in reverse order. Outcome measures were headache frequency and duration, pain intensity using a visual analog scale, mechanical pain threshold, headache disability, and sickness impact. Data were analyzed by univariate 2-way analysis of variance.

RESULTS

Thirty-seven patients completed the trial. There were no significant differences between the 2 groups at baseline. At the end of phase I, group A, but not group B, demonstrated significant improvement in mean (standard error of the mean [SEM]) headache frequency (3.0 per month [0.3] versus 12.0 per month [1.7]), duration (13.3 hours [3.5] versus 32.0 hours [6.2]), pain intensity (32.8 mm [4.1] versus 47.5 mm [2.7]), pain threshold (right side, 2.9 kg/second [0.1] versus 0.9 kg/second [0.1]; left side, 2.4 kg/second [0.1] versus 1.1 kg/second [0.1]), headache disability score (6.0 [1.0] versus 16.3 [1.6]), and sickness impact score (288.7 [48.0] versus 687.1 [77.2]). For each parameter, significant differences also were demonstrated for both groups between baseline and phase II, and baseline and follow-up. There were no significant differences between the groups at the end of follow-up (P >.05).

CONCLUSION

Electroacupuncture to distal points alone is effective for short-term symptomatic relief of tension-type headache.

Acupuncture and arthroscopic acromioplasty

BACKGROUND

Acupuncture alleviates acute and chronic shoulder pain. Yet it has not been determined whether acupuncture is useful following musculoskeletal surgery.

HYPOTHESIS

Compared to sham acupuncture, arthroscopic acromioplasty subjects who received real acupuncture would manifest significantly better recovery as demonstrated by: UCLA shoulder scale, improved range of motion, diminished pain, decreased need and duration of analgesic use, and enhanced patient satisfaction.

METHODS

Forty arthroscopic acromioplasty patients were randomized to real or sham acupuncture. UCLA shoulder scale scores, pain intensity, analgesic use, range of motion, and quality of life were monitored for four months. Data were analyzed with the general linear model ANOVA for repeated measures.

RESULTS

Thirty-five subjects completed the study. Real acupuncture subjects scored significantly better on UCLA shoulder scale (p<0.000); pain intensity (p<0.022); self-reported analgesic use (p<0.008); angles of abduction (p<0.046); and in six of eight health status questionnaire components.

CONCLUSIONS

Following arthroscopic acromioplasty, real acupuncture compared to sham acupuncture offered significantly greater improvement via: (1) lower pain level, (2) less analgesic use, (3) range of motion, and (4) patient satisfaction.

A controlled trial on acupuncture for chronic neck pain

To evaluate the efficacy of Chinese medicine (CM) acupuncture for chronic neck pain (CNP), a single blind, controlled, crossover, clinical trial was undertaken. Twenty-nine volunteers with CNP were randomly recruited into two groups. Both groups received two phases of treatment with a washout period between the two phases. Group A (14 volunteers) received CM acupuncture in the first phase and sham acupuncture in the second, while Group B (15 volunteers) received sham in the first and real in the second. CM acupuncture was individualized and consisted of nine sessions on both local and distal points. Manual twisting of the needle was applied on all points plus strong electrical stimulation of distal points in CM acupuncture. Sham acupoints (lateral to the real) and sham (weak) electrical stimulation was used in the control group. Comparison of subjective and objective measures between the two groups was made at different periods, including baseline, after each phase of treatment, after washout, and after the 16th week follow-up. The subjective measures included pain intensity, duration per day, analgesic medication count, visual analogue scales (VAS) and neck disability index (NDI). The objective measures consisted of neck range of motion (ROM) and pain threshold (PT). Both the real and sham treatments significantly reduced subjective pain, without significant differences between groups for most subjective measures. Objective measures showed no significant change for either group before and after each period or by inter-groups analysis. A minimum 16-week effect of both real and sham acupuncture was found for subjective measures in the follow-up periods. Further study is recommended with an increased sample size, a longer washout period, and a longer baseline period.

The placebo response and effect of time in a trial of acupuncture to treat nausea and vomiting in early pregnancy

OBJECTIVES

The sham control is widely used in acupuncture research, and its adequacy may be assessed by exploring the 'credibility' of the intervention. We aimed to examine the credibility of the study intervention, to quantify the size of the placebo response and effect of time in reducing nausea in early pregnancy.

DESIGN

Five hundred and ninety-three women with nausea or vomiting in early pregnancy volunteered to participate in a randomised controlled trial, conducted at the Women's and Children's Hospital, South Australia.

OUTCOME MEASURES

Women completed the Rhodes Index of Nausea and Vomiting and the Credibility Rating Scale.

RESULTS

The credibility of the acupuncture and sham acupuncture interventions were not different. The relative change in nausea at the end of the first week of the study was estimated to be 28% attributed to a time effect and 7% to the placebo response. At the end of the third week, there was a further small increase in time effect (32%) and the placebo response (17%).

CONCLUSION

Sham acupuncture is a credible control and allows assessment of the size of the placebo response.

Clinical trials of acupuncture: consensus recommendations for optimal treatment, sham controls and blinding

Evidence of effectiveness is increasingly used to determine which health technologies are incorporated into public health provision. Acupuncture is a popular therapy that has been shown to be superior to placebo in the treatment of nausea and dental pain, and promising for migraine and osteoarthritis of the knee. For many other conditions, such as chronic pain, in which acupuncture is often used, the evidence is either insufficient or negative. Misleading results may occur for a number of reasons. False negative results may arise from inadequate treatment schedules and inappropriate control interventions. This consensus document considers these issues with the aim of improving the design of efficacy trials of acupuncture in order that they are more likely to be conclusive and more meaningfully interpreted. Clinical trials of acupuncture must use an optimal form of treatment; this can be defined by examining standard texts, by surveying and consulting experts. There are a great many variables in treatment (such as point selection, form of stimulation) all of which need to be addressed in designing and reporting clinical trials. The control procedure is determined by the precise research question that is being addressed. For efficacy studies, in which the question is whether acupuncture has specific effects (i.e. is superior to placebo), sham forms of acupuncture appear the most appropriate method of controlling for needle penetration. A recent development of blunted, telescopic needles may represent a major advance. Such procedures may produce a therapeutic response so should preferably be recorded as 'sham' procedures rather than true 'placebo' controls. Blinding in clinical trials is an accepted means of reducing bias. Patient blinding in acupuncture studies can be achieved by sham procedures and its success should be measured. While practitioner blinding is difficult, though not impossible, blinding of the observer and the analyst should be considered as the ideal for all studies. A number of recommendations are made which aim to improve the quality of sham-controlled acupuncture studies.

Non-specific effects of traditional Chinese acupuncture in osteoarthritis of the hip

OBJECTIVES

The effectiveness of acupuncture treatment in patients with osteoarthritis of the hip was tested.

DESIGN

This is a prospective, randomized, controlled, patient- and investigator-blinded clinical trial.

PATIENTS AND SETTING

The study was performed at a university department for physical medicine and rehabilitation. Sixty-seven patients were separated into two treatment groups.

INTERVENTIONS

Group 1 (treatment) had traditional needle placement and manipulation, whereas in group 2 (control) needles were placed away from classic positions and not manipulated. In both groups needles were placed within the L2 to L5 dermatomes. Outcome parameters were: pain (VAS), functional impairment (hip score), activity in daily life (ADL) and overall satisfaction before treatment, and 2 weeks and 2 months after treatment.

RESULTS

For all parameters there was a significant improvement versus baseline in both groups 2 weeks and 2 months following treatment, but no significant difference between the two treatment groups.

CONCLUSIONS

We conclude from these results that needle placement in the area of the affected hip is associated with improvement in the symptoms of osteoarthritis. It appears to be less important to follow the rules of traditional acupuncture techniques.