a systematic review of reviews of systematic reviews of acupuncture
TRANSCRIPT
R E V I E W
Focus on Alternative andComplementary Therapies
Volume 18(1) March 2013 8–18© 2013 The Authors
FACT © 2013Royal Pharmaceutical Society
DOI 10.1111/fct.12004ISSN 1465-3753
A systematic review of reviews of systematicreviews of acupuncture
Andrew Gilbey, Edzard Ernst, Kawtar Tani
AbstractBackground Acupuncture is one of the more popular forms of complementary and alternative medicine. Whilst thetherapy has been the subject of many published trials, systematic reviews and reviews of reviews, the conclusions of thesepublications often have been inconsistent.Objectives To systematically review reviews of reviews of acupuncture in an attempt to better understand existingcontradictions in the literature.Methods The databases MEDLINE, Scopus and EbscoHost were searched using the keywords (systematic review) AND(acupuncture OR acupressure) for the period January 1991 to December 2011. The methodological quality of includedreviews was assessed using a nine-item measure developed by the authors.Results Eighteen reviews of reviews met the inclusion criteria; two reviews did not assess the methodological quality of theincluded reviews and only two rigorously assessed the quality of the primary studies included in the reviews. Quality of thereviews of reviews ranged from poor to excellent. Conclusions were positive for nausea and vomiting and some types of pain,but negative for smoking cessation.Conclusions Only two reviews of reviews allowed definitive conclusions to be drawn; that is, there is insufficient evidenceto make positive recommendations. Further reviews, or reviews of reviews, are unlikely to break this impasse, owing to thecombination of new and existing reviews or primary studies upon which they can draw. We therefore recommend thathigh-quality RCTs should be conducted in the areas where most promise has already been shown.
KeywordsAcupuncture • randomised controlled trial • review of reviews • systematic review
Background
Acupuncture is a popular form of CAM that isincreasingly being integrated into mainstream care.1
It has also been the subject of much research; forexample, a search of the database MEDLINE (viaOvid) from 1970 to October 2011, using the keyword‘acupuncture’, returned more than 17 000 publishedarticles. However, as the number of primary studieshas increased, a situation has arisen where there havebecome ‘too many studies for people involved in
healthcare to identify and consider when makingdecisions’.2 Moreover, significant variation in thequality and contradictions in the conclusions of acu-puncture trials further adds to the difficulty of inter-preting research findings for the purpose of guidingclinical practice.3
In order to make sense of the numerous studies ofacupuncture, many primary studies have been sub-jected to systematic review (SR). However, in recentyears ‘decision makers who were once overwhelmedby the number of individual studies have become
bs_bs_banner
8
faced by a plethora of (systematic) reviews’.2 In anattempt to synthesise the findings of the growingbody of SRs, there have also been SRs (and criticalreviews, overviews, reviews and summaries) of SRs,which in principle may help to make the evidencemore accessible for general readership. Differencesbetween the types of reviews of SRs appear minimal;for example, although SRs of SRs require criticalappraisal,4 and specific inclusion and exclusion crite-ria,2 at least two overviews and one review of SRshave systematic inclusion and exclusion criteria andstate that their aim is to critically evaluate the studiesunder review.5,6 So much is the overlap, a well-knowntext on medical research defines a SR as an overview.7
Given the increasing number of reviews of reviewsnow available, a logical progression was to criticallyevaluate the conclusions reached by any type ofreview of SRs of acupuncture for any condition.Recently published guidelines for conducting SRswere used as a guiding framework.2
Method
A literature search was carried out using the databasesMEDLINE (via Ovid), Scopus and EbscoHost. Thesearch terms used were (systematic review) AND (acu-puncture OR acupressure). The search was limited tothe period January 1991 to December 2011. No lan-guage restrictions were applied.
The results of the search were assessed for relevanceby two authors (AG and KT), and any disagreementswere resolved by discussion. The following inclusioncriteria were specified: (1) the article must be a review(i.e. critical overview, critical review, overview,review, summary or SR) of SRs; (2) acupuncture (e.g.electro-acupuncture, acupressure or auricular acu-puncture, but not exclusively moxibustion) must bethe primary intervention for one or more conditions,or one of several interventions for one or more con-ditions; and (3) where acupuncture was one of severalinterventions investigated, reviews of reviews wereonly included if three or more primary reviews ofacupuncture or acupressure were included (three waschosen as the cut-off point as preliminary investiga-tion revealed that it was the smallest number ofprimary reviews included in a review of reviewswhere acupuncture or acupressure was the primaryintervention).8 No limit was placed on conditionexamined or participant. Articles were excluded iftheir only purpose was to investigate safety or adversereactions, rather than efficacy or effectiveness.
There are presently two known validated toolsavailable for assessing the quality of SRs [i.e. AMSTAR(an acronym for: ‘a measurement tool to assess sys-tematic reviews’),9 and an overview quality assess-ment questionnaire (OQAQ)10]; a number of authorshave also devised their own measures.3 As the currentarticle is the first to review reviews of reviews, there
was no existing measure of quality to assess reviewsof reviews. Accordingly, we devised the followingnine-item measure of methodological quality ofreviews of reviews based on recently published guide-lines for conducting SRs of SRs:2
1 Was the objective and reason for the SR of reviewsexplained?
2 Were inclusion criteria reported?3 Were exclusion criteria reported?4 Were the search methods reported?5 Was the way in which reviews were selected
reported?6 Was the quality of the SR explicitly assessed?
(Score ‘partly’ if no assessment rationale provided)7 Was the quality of the primary studies explicitly
assessed?(Score ‘partly’ if no assessment rationale provided)
8 Was a summary of findings of included reviewsprovided?
9 Were implications for practice and/or researchgiven?
By scoring each of the nine items as yes = two,partly = one, or no = zero, the total score for each ofthe reviewed studies would provide an indication ofmethodological quality. Studies were rated as highmethodological quality (i.e. had few or no minorflaws) if the total score was �14, as low methodologi-cal quality (i.e. had numerous flaws) if total scoreswere greater than or equal to seven, and as moderatequality if total scores ranged from eight to 13. Twoauthors (AG and KT) independently assessed thequality of the included reviews of reviews, with anydiscrepancies settled by discussion. (EE did notparticipate in this process as he had authored orco-authored some of the included studies and couldtherefore be susceptible to bias.)
Results and discussion
The search identified 1360 studies; the title andabstract of each of these studies was examined by twoauthors (AG and KT). Following discussion, it wasdetermined that 1337 articles were not reviews of SRsof acupuncture on humans and thus were excluded.The remaining 23 articles were retrieved and read infull text. For eight of these articles, acupuncture oracupressure were not the primary interventions; fivearticles were subsequently excluded as they includedless than three primary studies where acupunctureor acupressure were the primary interventions.Although one review stated that it was not a reviewof the efficacy of acupuncture per se,3 it was includedas it did draw conclusions about the effectivenessof acupuncture. A summary of the study selectionprocess is illustrated in Figure 1.
Review 9
Key characteristics of each of the 18 reviews of SRs,and the methodological quality of each review, areshown in Table 1. Of the 18 included reviews, fourwere ‘SRs of SRs’, seven were ‘overviews of SRs’, andthere was one each of the following: ‘critical reviewof SRs’, ‘evidence from SRs and meta-analyses’,‘summary of Cochrane SRs’, ‘overview of Cochranereviews’, ‘review of RCTs and SRs’, ‘review of reviews’and ‘review of SRs and meta-analyses’.
Thirteen reviews of reviews described the interven-tion as acupuncture, one as acupressure and oneas acupuncture or acupressure. In the remainingthree reviews of reviews, acupuncture was oneof various interventions that were described as‘non-pharmacological’,4 ‘CAM’,18 or ‘any method’.19
Although interventions were described as acupunc-ture, they included a number of different styles ofacupuncture; for example, auricular acupuncture21
and P6 acupuncture.20
All primary studies were of research conducted onhumans. Participants in the primary studies mayhave been further categorised; for example, as chil-dren,18 healthy,11 patients,11 smokers11 or volunteers.11
No reviews of reviews had inclusion or exclusioncriteria that specified the type of comparative treat-ments in the primary studies. Hence, the reviewsincluded trials using a range of comparative treat-ments, including sham acupuncture,11 placebo,12 notreatment,12 physiotherapy,12 standard treatment,12
other12 or unclear.12
Reviews of reviews were for a broad range of con-ditions. Five reviews evaluated acupuncture for anycondition,3,5,11,12,19 while the remaining studies werefor specific conditions, such as addiction,12 depres-sion,16 gynaecologic conditions,13,20,23 insomnia,4,21
nausea and vomiting,8 pain,22,24 palliative and sup-portive cancer care,15 rheumatic conditions14 andtemporomandibular disorders.19
According to our nine-item measure of methodo-logical quality, one review of reviews was rated as lowquality,8 two were of moderate quality,3,16 and 14 wereof high quality (of which two scored a maximum
possible score of 18). One review11 could not be evalu-ated as its stated aim was to review ‘in-house’ studies;thus, the items relating to the search strategy, and theinclusion and exclusion criteria, were not applicable.
Of the 16 studies where the quality of the includedreviews was evaluated, eight used the OQAQ (a vali-dated nine-item tool),10 seven used the authors’ ownmeasures3 and one used the AMSTAR.9 Two reviews ofSRs8,11 did not evaluate the quality of the includedSRs, which is potentially a serious flaw.
Ernst11 conducted the first review (overview) ofseven (in-house) SRs of acupuncture, each for differ-ent conditions. Neither the quality of the includedreview nor the primary studies were assessed formethodological quality. It was not possible to assessthe quality of this review using our nine-itemmeasure of methodological quality as three itemswere not applicable. Ernst concluded that acupunc-ture can alleviate dental pain; however, it is impor-tant to note that the author also stated that ‘with fewexceptions, the (primary studies) were burdenedwith significant methodological flaws’. It was alsoconcluded that acupuncture for low back pain issupported by reasonably good evidence, althoughassessment of the review and its primary studies wasnot reported. Evidence for five other conditions waseither inconclusive (i.e. for neck pain, osteoarthritisand stroke) or negative (i.e. for smoking cessationand weight loss), although in each case the reviewwas not assessed for methodological quality and,with the exception of those for smoking cessation,the primary studies were generally of low quality. Onthis basis, the positive findings should be treatedwith some caution.
Linde et al.12 conducted an overview of 39 SRs ofacupuncture for any condition. The authors devisedtheir own five-item measure for reviewing the meth-odological quality of the included review; only threeof the 39 SRs scored below the mid-point of five. Theauthors concluded that there is convincing evidencethat acupuncture appears to benefit postoperativenausea. However, as the quality of the primary
Potentially relevant articles including
duplicates (n = 1360) Excluded (n = 1337) Reason: not a review of a review of acupuncture
Articles read in full (n = 23)
Final articles for full review (n = 18)
Excluded (n = 5) Reasons: reviews where acupuncture was not the primary intervention contained less than three primary studies where acupuncture was the primary intervention
Figure 1 Flowchart of review of reviews selection.
Focus on Alternative and Complementary Therapies March 2013 18(1)10
Table
1Su
mm
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clud
edre
view
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view
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Con
dit
ion
(s)
trea
ted
Nu
mbe
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revi
ews
incl
ud
eda
Qu
alit
y(0
–18)
Ern
st(1
999)
11A
cup
un
ctu
refo
rva
riou
sco
nd
itio
ns.
Ove
rvie
wof
SRs.
Den
tal
pai
n,
low
back
pai
n,
nec
kp
ain
,os
teoa
rth
riti
s,st
roke
,sm
okin
gce
ssat
ion
,w
eigh
tlo
ss.
Seve
nn
/ab
Lin
de
(200
1)12
Acu
pu
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ure
for
vari
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con
dit
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verv
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ofSR
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nic
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ease
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ause
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thm
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ilit
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n,
den
tist
ry.
3914
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ry(2
006)
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nd
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ns.
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SRs.
Pain
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roke
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ause
aan
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mit
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dep
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ion
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som
nia
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eigh
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ss,
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ma.
3513
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(200
6)8
Acu
pu
nct
ure
and
acu
pre
ssu
refo
rn
ause
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dvo
mit
ing.
Sum
mar
yof
Coc
hra
ne
SRs.
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sea
and
vom
itin
g.T
hre
eSi
x
de
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t(2
009)
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har
mac
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ical
inte
rven
tion
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rin
som
nia
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Rev
iew
ofSR
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anal
yses
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16
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ancy
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ght
18
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ure
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vari
ous
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verv
iew
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s.N
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ause
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orrh
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ine
17
Ern
st(2
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14A
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refo
rrh
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atic
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verv
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ofSR
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mat
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nd
itio
ns
(low
back
pai
n,
late
ral
elbo
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ain
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brom
yalg
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oste
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hri
tis,
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ould
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eck
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1113
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18
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back
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men
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stru
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1616
Lee
(201
1)24
Acu
pu
nct
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for
pai
n.
Ove
rvie
wof
Coc
hra
ne
revi
ews.
Pain
,os
teoa
rth
riti
s,m
igra
ine,
hea
dac
he,
nec
kp
ain
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eum
atoi
dar
thri
tis,
shou
lder
pai
n,
low
back
pai
n,
late
ral
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wp
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ght
14
a In
revi
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ofre
view
sw
her
eac
up
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terv
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teri
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ree
and
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ed.
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MD
,te
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and
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lar
dis
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er.
Review 11
studies was not assessed, it is difficult to ascertain thevalidity of this or any other conclusions. Our nine-item measure of methodological quality revealed ascore of 14. Overall, Linde et al. rightly err on the sideof caution when suggesting that there is a need formore high-quality primary research.
Derry et al.3 conducted a SR of 35 SRs of acupunc-ture for any condition. Included reviews were judgedfor methodological quality using the authors’ ownmeasure, although the details of the assessmentwere not explicitly reported. Partial assessment ofthe primary studies was carried out. Our nine-itemmeasure of methodological quality revealed a score of16. On this basis, the authors rightly concluded thatnone of the included reviews were of rigorous quality,as they all included studies likely to be biasedand, as a result, none provided robust evidence ofeffectiveness.
Ezzo et al.8 summarised three Cochrane SRs of P6acupuncture for nausea and vomiting, but did notassess the quality of the included reviews or theprimary studies. This review scored six on our nine-item measure, suggesting that it may not be ofhigh methodological quality. The authors’ conclu-sion that P6 acupuncture may be beneficial fornausea and vomiting should therefore be treatedwith caution.
De Niet et al.4 reviewed 16 reviews of non-pharmacological interventions for insomnia, three ofwhich were for acupuncture. The OQAQ was used toassess the methodological quality of the includedreviews, although the quality of the primary studieswas not assessed. One included review of acupunc-ture was of high quality and the remaining two hadmajor methodological flaws. The high-quality reviewconcluded that there was not enough evidence tosupport the use of acupuncture for insomnia, whilethe two low quality reviews suggested that acupunc-ture may be effective. The study scored 16 on ournine-item measure of methodological quality. Theauthors rightly conclude that there is insufficientdata to draw a conclusion.
Smith and Cochrane13 conducted a review of eightSRs of acupuncture as an adjunct treatment duringpregnancy. The authors assessed the methodologicalquality of reviews using the OQAQ, and judged sevenreviews to be of high quality and one to have majorflaws. The quality of the primary studies was assessedon four criteria, and was found to be of variablequality. The study scored 18 on our nine-itemmeasure of methodological quality. The authorsrightly err on the side of caution when concludingthat further research is justified before any definitiveconclusions can be reached.
Ernst and Lee5 conducted an overview of nine SRsof acupressure for any condition. The OQAQ wasused to assess the methodological quality of reviews.Eight included reviews were found to have major
flaws, while one had minor flaws. The quality of theprimary studies was assessed – although the means ofassessment was not explained – and all except onereview were deemed to have included studies of pooror variable quality. The study scored 17 on our nine-item measure of methodological quality. On thisbasis, we agree with the authors’ interpretationthat no definitive conclusions could be reached andfurther research is recommended.
Ernst and Lee14 conducted an overview of 30 SRs ofacupuncture for rheumatic conditions. The OQAQwas used to assess the methodological quality ofreviews. Eleven reviews achieved the maximumscore, but 10 were deemed to have extensive or majorflaws. The quality of the primary studies was assessed,and of the 30 reviews, only three were deemed tohave included primary studies that were of goodquality, with the remainder being variable (18),mostly poor (five) or poor (four); although the meansof assessment was not made explicit. The studyscored 17 on our nine-item measure of methodologi-cal quality. On this basis, the authors concluded thatevidence from SRs was only strong enough for posi-tive recommendations for osteoarthritis, low backpain and lateral elbow pain. We suggest this conclu-sion be viewed with some caution as the method ofevaluating the primary studies was not explicitlyreported.
Ernst and Lee15 conducted a SR of seven SRs ofacupuncture for palliative and supportive cancercare. The methodological quality of the includedreviews was rated as excellent (one), good (five) andpoor (one), although the method of assessment wasnot reported. The quality of the primary studies inone review was good, but in the remaining reviewswere variable (one), mostly poor (four) or poor (one);again, the method of assessment was not reported.The authors concluded that the use of acupuncture inpalliative and supportive cancer care is supportedonly for chemotherapy-induced nausea and vomit-ing, on the basis of the review that was rigorous andincluded primary studies of high quality. The studyscored 14 on our nine-item measure of methodologi-cal quality. We suggest this conclusion be viewedwith some caution because the means used for evalu-ating the primary studies and the reviews was notexplicitly reported.
Ernst, Lee and Choi16 conducted a SR of 11 SRsof acupuncture for addiction. The methodologicalquality of the included reviews did not appear to beassessed, although the quality of the primary studieswas assessed; in five of the studies the quality wasrated as ‘variable’, with the remainder being ‘mostlypoor’ (four) or ‘poor’ (two). The review scored 13on our nine-item measure of methodological quality.The authors rightly concluded that none of thereviews provide strong evidence for the use of acu-puncture for addiction.
Focus on Alternative and Complementary Therapies March 2013 18(1)12
Ernst, Lee and Choi17 conducted a SR of nine SRs ofacupuncture for depression. The OQAQ was used toassess the methodological quality of reviews, withsix reviews having only ‘minor or minimal flaws’and three reviews receiving the maximum score forquality. The quality of the primary studies was alsoreported, using the Jadad score; only in two of thereviews were more than half of the primary studiesdeemed to be of high quality. It was observed thatreviews of primary studies originating from Chinamay be ‘less than reliable’. This review of reviewsreceived a maximum score of 18 on our nine-itemmeasure of methodological quality. We agree withthe authors’ conclusion that the evidence for the useof acupuncture for depression is unconvincing andmost likely indistinguishable from placebo effects.
Hunt and Ernst18 critically reviewed 17 SRs of CAMfor children, where acupuncture or acupressure wasone of the interventions in four of the includedreviews. The methodological quality of the includedreviews was assessed and all four included reviewswere deemed to have limitations, although themethod of assessment was not reported in detail. Thequality of the primary studies was assessed for onlytwo of the four reviews of acupuncture. The reviewscored 16 on our nine-item measure of methodologi-cal quality. On this basis, we suggest that the authors’conclusion that there is some evidence to suggestthat acupuncture may be effective for nausea andvomiting be viewed with some caution.
List and Axelson19 systematically reviewed 30 SRsof interventions for temporomandibular disorders, ofwhich acupuncture was the intervention in sevenof the reviews. The AMSTAR was used to assessthe methodological quality of reviews. Out of amaximum possible score of 11, two reviews scoredseven, one each scored six, five and four and twoscored three. The quality of the primary studies wasnot reported, although item seven in the AMSTARconcerns whether the quality of the primary studieswas assessed. The review scored 16 on our nine-itemmeasure of methodological quality. The authorsrightly concluded that there is some evidence thatacupuncture can be effective in alleviating pain inpatients with temporomandibular disorders, but con-siderable variation in the methodology betweenthe primary studies made definitive conclusionsimpossible.
Ernst, Lee and Choi20 conducted an overview of 24SRs of acupuncture for gynaecological conditions.The methodological quality of the reviews was cat-egorised as good (17) or poor (seven), but the criteriaused to form these judgements were not explicit. Thequality of the primary studies was assessed, of whichthree were mostly poor, 17 variable, two poor, onemostly good and one not reported; but again, themethod of assessment was not explicit. This studyscored 14 on our nine-item measure of methodologi-
cal quality. On this basis, the authors rightlyconcluded that the evidence of effectiveness for acu-puncture for any type for gynaecological conditionsis limited.
Ernst, Lee and Choi21 conducted an overview of 10SRs of any type of acupuncture for insomnia. Themethodological quality of the reviews was assessedusing the OQAQ; two reviews scored seven, onescored six, two scored four, two scored three andthree scored one. The quality of the primary studiesin each review was also assessed; two were variable,three were mostly poor, and five were poor, althoughthe criteria were not explicit. This study scored 17 onour nine-item measure of methodological quality. Onthis basis, the authors rightly concluded that reviewsof acupuncture for insomnia that considered thelimitations of the primary studies fail to arrive at apositive verdict.
Ernst, Lee and Choi22 conducted a review of 57reviews of acupuncture for pain. The methodologicalquality of reviews was assessed using the OQAQ.Reviews were rated as excellent (four), good (32),moderate (three) and poor (19); however, numericalscores were not reported. The quality of the primarystudies in the reviews was good (10), variable (31),mostly poor (nine) or poor (seven), although theassessment criteria were not explicit. Positive conclu-sions from more than one good quality SR existedonly for neck pain; however, it should be noted thatthe quality of the primary studies was variable. Onthis basis, the authors rightly concluded that therewas no convincing evidence of effectiveness for acu-puncture for any other type of pain. This study scored17 on our nine-item measure of methodologicalquality.
Kang, Jeong, Kim and Lee23 conducted an overviewof 16 SRs of acupuncture for gynaecologic conditions.The methodological quality of reviews was assessedusing the OQAQ; six reviews achieved a maximumscore of seven, two scored six, three scored five, onescored four, one scored two and three scored one. Thequality of the primary studies was not assessed.Overall, it was concluded that there is sufficientevidence for the use of acupuncture to treatchemotherapy-induced nausea and vomiting, and toimprove pregnancy rates in in-vitro fertilisation (IVF).This study scored 16 on our nine-item measure ofmethodological quality. The conclusions of thisreview of reviews should be treated with caution asthe quality of the primary studies was not assessed.
Lee and Ernst24 conducted an overview of eightCochrane reviews of acupuncture for pain. Themethodological quality of all reviews was reportedas excellent, although the means of assessing thequality was not reported. However, in seven reviewsthe primary studies were of variable quality and inone they were poor. This review of reviews scored 14on our nine-item measure of methodological quality.
Review 13
Table
2C
hara
cter
istic
sof
incl
uded
revi
ews
Firs
tau
thor
(yea
r)M
ain
fin
din
g(s)
Wer
ep
rim
ary
stu
die
sas
sess
ed?
Eval
uat
ion
ofq
ual
ity
ofin
clu
ded
revi
ews
(in
stru
men
t)A
uth
or(s
)’m
ain
con
clu
sion
Rev
iew
ers’
con
clu
sion
s
Ern
st(1
999)
11R
easo
nabl
ygo
odev
iden
cefo
r:al
levi
atin
gd
enta
lan
dlo
wba
ckp
ain
.Po
siti
vebu
tun
conv
inci
ngfo
r:st
roke
.C
ontr
adic
tory
for:
nec
kp
ain
.N
egat
ive
but
unco
nvin
cing
for:
oste
oart
hri
tis.
Con
vinc
ingl
yne
gati
vefo
r:sm
okin
gce
ssat
ion
.N
otsu
ppor
ted
bygo
odev
iden
ce:
wei
ght
loss
.
No
No
Con
clu
sive
lyp
osit
ive
for
den
tal
and
low
back
pai
n.
Mor
eri
goro
us
tria
lsre
qu
ired
ifd
efin
itiv
eco
ncl
usi
ons
are
tobe
dra
wn
rega
rdin
got
her
con
dit
ion
s.
Lack
ofev
alu
atio
nof
eith
erre
view
sor
pri
mar
yst
ud
ies
mea
ns
all
con
clu
sion
ssh
ould
betr
eate
dw
ith
som
eca
uti
on.
Lin
de
(200
1)12
Posi
tive
:p
osto
per
ativ
en
ause
a.N
egat
ive:
smok
ing
cess
atio
n.
Inco
nclu
sive
:ch
ron
icp
ain
,n
eck
pai
n,
faci
alp
ain
,‘o
ther
’rh
eum
atoi
dd
isea
ses,
back
pai
n,
mig
rain
e,te
nsi
onh
ead
ach
es,
den
tal
pai
n,
tem
por
oman
dib
ula
rd
ysfu
nct
ion
,ch
emot
her
apy
ind
uce
dst
roke
reh
abil
itat
ion
oste
oart
hri
tis,
fibr
omya
lgia
,m
orn
ing
sick
nes
s,ti
nn
itu
s,w
eigh
tre
du
ctio
n,
asth
ma
and
alco
hol
and
her
oin
add
icti
on.
No
Yes
(au
thor
s’ow
nm
easu
re,
com
pri
sin
gfi
veit
ems,
scor
edye
s,n
oor
par
tly)
.A
ssu
min
gth
atye
s=
two,
par
tly
=on
ean
dn
o=
zero
,th
em
ean
scor
efo
rq
ual
ity
was
6.85
(SD
=1.
99)
(on
asc
ale
of0–
10).
Con
vin
cin
gev
iden
ceth
atac
up
un
ctu
reap
pea
rsto
ben
efit
pos
top
erat
ive
nau
sea.
Hig
h-q
ual
ity
larg
erp
rim
ary
rese
arch
stu
die
sre
qu
ired
.
Lack
ofev
alu
atio
nof
pri
mar
yst
ud
ies
mea
ns
all
con
clu
sion
ssh
ould
betr
eate
dw
ith
som
eca
uti
on.
Der
ry(2
006)
3N
oro
bust
evid
ence
for:
pai
n,
stro
ke,
nau
sea
and
vom
itin
g,d
epre
ssio
n,
inso
mn
ia,
smok
ing
cess
atio
n,
wei
ght
loss
and
asth
ma.
Part
lyYe
s(a
uth
ors’
own
mea
sure
).D
etai
lsn
otex
pli
citl
yre
por
ted
.T
he
lack
ofev
iden
cem
akes
for
pro
blem
sfo
rth
ose
pro
vid
ing
acu
pu
nct
ure
serv
ices
and
for
regu
lato
rs.
Th
eau
thor
sri
ghtl
yco
ncl
ud
eth
atn
ost
ud
ies
pro
vid
ero
bust
evid
ence
ofef
fect
iven
ess.
Ezzo
(200
6)8
P6ac
upun
ctur
e-po
int
stim
ulat
ion
may
bebe
nefi
cial
for:
vari
ous
con
dit
ion
sin
volv
ing
nau
sea
and
vom
itin
g.
No
No
Effe
ctof
ind
ivid
ual
ised
trea
tmen
tba
sed
onT
CM
shou
ldbe
exp
lore
d.
Th
est
ud
yis
not
ofh
igh
qu
alit
yan
dal
lco
ncl
usi
ons
shou
ldbe
trea
ted
wit
hca
uti
on.
de
Nie
t(2
009)
4In
suff
icie
ntda
tafo
rfi
rmco
nclu
sion
sfo
r:in
som
nia
.N
oYe
s(O
QA
Q).
Scor
esof
zero
to<f
ive
=m
ajor
flaw
s;sc
ores
�fi
ve=
min
orfl
aws.
On
eSR
scor
edse
ven
,on
esc
ored
six
and
two
scor
edtw
o(m
ean
scor
e=
4.25
).
Dif
ficu
lty
ind
raw
ing
firm
con
clu
sion
sow
ing
toth
ep
oor
qu
alit
yof
incl
ud
edp
rim
ary
revi
ews.
Th
eau
thor
sri
ghtl
yco
ncl
ud
eth
atn
ost
ud
ies
pro
vid
ero
bust
evid
ence
ofef
fect
iven
ess.
Smit
h(2
009)
13So
me
evid
ence
begi
nnin
gto
cons
olid
ate
sugg
esti
nga
bene
fit
from
acup
unct
ure
for:
trea
tmen
tof
nau
sea
inp
regn
ancy
.En
cour
agin
gbu
tsm
all
amou
ntof
evid
ence
for:
trea
tin
gba
ckp
ain
,p
ain
man
agem
ent
inla
bou
r.M
ixed
find
ings
for:
stim
ula
tin
gth
eon
set
ofla
bou
r.
Yes
Yes
(OQ
AQ
).T
he
nin
eit
ems
ofth
eO
QA
Qw
ere
scor
edze
ro,
one
ortw
o,ra
ther
than
the
nor
mal
min
us-
one,
zero
and
one.
Th
era
nge
ofsc
ores
was
ther
efor
e0–
18(h
owev
er,
ast
ud
ysc
orin
gze
roto
item
stw
o,fo
ur,
six
orei
ght
was
con
sid
ered
toh
ave
am
ajor
flaw
).Si
xre
view
ssc
ored
17,
one
scor
ed18
and
one
scor
ed14
(th
ela
tter
was
con
sid
ered
toh
ave
am
ajor
flaw
).
Insu
ffic
ien
tev
iden
ceto
mak
ecl
inic
alre
com
men
dat
ion
sfo
rp
ract
ice,
and
the
nee
dco
nti
nu
esfo
rfu
rth
erh
igh
-qu
alit
yR
CTs
.
Th
eau
thor
sar
eri
ghtl
yca
uti
ous
rega
rdin
gco
ncl
usi
ons
that
can
bed
raw
n,
owin
gto
the
vari
able
qu
alit
yof
the
pri
mar
yst
ud
ies.
Focus on Alternative and Complementary Therapies March 2013 18(1)14
Ern
st(2
010)
5Po
siti
vebu
tpo
orqu
alit
yev
iden
cefo
r:tr
eatm
ent
ofn
ause
aan
dvo
mit
ing
and
dys
men
orrh
oea.
Con
trad
icto
ryev
iden
cefo
r:p
reve
nti
onof
nau
sea
and
vom
itin
g.C
ontr
adic
tory
but
poor
evid
ence
for:
alle
rgic
rhin
itis
.
Part
lyYe
s(O
QA
Q).
Scor
esof
�th
ree
=m
ajor
flaw
san
d�
five
=m
inor
flaw
s.O
ne
revi
ewsc
ored
five
,fo
ur
scor
edth
ree
and
fou
rsc
ored
one
(mea
nsc
ore
=2.
33).
Giv
enth
ela
ckof
sou
nd
evid
ence
,cl
aim
sof
effe
ctiv
enes
sm
ade
byp
ract
itio
ner
sm
igh
tn
otbe
resp
onsi
ble.
Th
eau
thor
sar
eri
ghtl
yca
uti
ous
rega
rdin
gco
ncl
usi
ons
that
can
bed
raw
n,
owin
gto
the
vari
able
qu
alit
yof
the
pri
mar
yst
ud
ies
and
the
incl
ud
edre
view
s.
Ern
st(2
010)
14Ef
fect
ive
for:
oste
oart
hri
tis,
low
back
pai
n,
and
late
ral
elbo
wp
ain
.N
egat
ive
for:
fibr
omya
lgia
and
rheu
mat
oid
arth
riti
s.
Part
lyYe
s(O
QA
Q).
Scor
esof
�th
ree
=m
ajor
flaw
san
d�
five
=m
inor
flaw
s.El
even
revi
ews
scor
edse
ven
,fo
ur
scor
edsi
x,fi
vesc
ored
five
,th
ree
scor
edth
ree,
one
scor
edtw
oan
dsi
xsc
ored
one
(mea
nsc
ore
=4.
77).
On
lyfo
ros
teoa
rth
riti
s,lo
wba
ckp
ain
and
late
ral
elbo
wp
ain
isth
eev
iden
cesu
ffic
ien
tly
sou
nd
tow
arra
nt
pos
itiv
ere
com
men
dat
ion
sof
acu
pu
nct
ure
ther
apy
inro
uti
ne
care
ofrh
eum
atic
pat
ien
ts.
Ow
ing
toth
eva
riab
leq
ual
ity
ofal
mos
tal
lp
rim
ary
stu
die
s,al
lco
ncl
usi
ons
(in
clu
din
gth
ose
for
oste
oart
hri
tis,
low
back
pai
nan
dla
tera
lel
bow
pai
n)
shou
ldbe
trea
ted
wit
hso
me
cau
tion
.
Ern
st(2
010)
15G
ood
evid
ence
for:
chem
oth
erap
y-in
du
ced
nau
sea
and
vom
itin
g.
Part
lyYe
s(m
eth
odn
otd
efin
ed).
On
ew
asra
ted
asex
cell
ent,
five
good
and
one
poo
r.
Acu
pu
nct
ure
shou
ldbe
con
sid
ered
asa
trea
tmen
tfo
rch
emot
her
apy-
ind
uce
dn
ause
aan
dvo
mit
ing,
but
its
use
for
oth
erco
nd
itio
ns
isn
otsu
pp
orte
dby
rigo
rou
sSR
s.
Th
eq
ual
ity
ofth
ep
rim
ary
stu
die
sin
the
revi
ewof
nau
sea
and
vom
itin
gw
ere
vari
able
(alt
hou
ghth
eq
ual
ity
ofth
ere
view
was
exce
llen
t);
ther
efor
eso
me
cau
tion
may
bere
qu
ired
rega
rdin
gth
eco
ncl
usi
onof
good
evid
ence
for
nau
sea
and
vom
itin
g.Er
nst
(201
0)16
Can
not
conc
lude
effe
ctiv
enes
sfo
r:op
iate
san
dob
esit
y.In
conc
lusi
vefo
r:n
icot
ine.
Pred
omin
atel
yne
gati
vefo
r:co
cain
ead
dic
tion
.N
egat
ive
for:
alco
hol
.
Part
lyYe
s(m
eth
odn
otd
efin
ed).
Six
wer
era
ted
asp
oor
orm
ostl
yp
oor,
five
wer
eva
riab
le.
Tota
lity
ofev
iden
ced
oes
not
sup
por
tac
up
un
ctu
reas
effe
ctiv
efo
rad
dic
tion
.
Th
eau
thor
sar
eri
ghtl
yca
uti
ous
rega
rdin
gco
ncl
usi
ons
that
can
bed
raw
n,
owin
gto
the
vari
able
qu
alit
yof
the
pri
mar
yst
ud
ies.
Ern
st(2
010)
17N
otef
fect
ive
(i.e
.ac
upun
ctur
eno
diff
eren
tfr
ompl
aceb
o)fo
r:d
epre
ssio
n.
Yes
Yes
(OQ
AQ
).Sc
ores
of�
thre
e=
maj
orfl
aws
and
�fi
ve=
min
orfl
aws.
Th
ree
revi
ews
scor
edse
ven
,fi
vesc
ored
six
and
one
scor
edfi
ve(m
ean
scor
e=
6.22
).
Acu
pu
nct
ure
for
dep
ress
ion
rem
ain
su
np
rove
n.
Stu
die
sor
igin
atin
gin
Ch
ina
ten
dto
bem
ore
pos
itiv
eth
anot
her
stu
die
s.
Th
eau
thor
sar
eri
ghtl
yca
uti
ous
rega
rdin
gco
ncl
usi
ons
that
can
bed
raw
n,
owin
gto
the
vari
able
qu
alit
yof
the
pri
mar
yst
ud
ies.
Hu
nt
(201
0)18
Enco
urag
ing
posi
tive
for:
pos
t-op
erat
ive
nau
sea
and
vom
itin
g.Po
ssib
lyde
trim
enta
lfo
r:st
rid
or.
Inco
nsis
tent
for:
noc
turn
alen
ure
sis,
pai
nre
lief
,ch
emot
her
apy-
ind
uce
dn
ause
a,la
yngo
spas
man
drh
init
is.
Part
lyYe
s(a
uth
ors’
subj
ecti
veev
alu
atio
nn
otre
por
ted
bySR
).In
suff
icie
nt
evid
ence
tosu
gges
tth
atC
AM
sar
eef
fect
ive
for
the
trea
tmen
tof
pae
dia
tric
con
dit
ion
s.
Th
eau
thor
sar
eri
ghtl
yca
uti
ous
rega
rdin
gco
ncl
usi
ons
that
can
bed
raw
n,
owin
gto
the
vari
able
qu
alit
yof
the
pri
mar
yst
ud
ies.
List
(201
0)19
Mos
tly
posi
tive
for:
tem
por
oman
dib
ula
rd
isor
der
s.N
oYe
s(A
MST
AR
).O
ut
ofa
max
imu
msc
ore
of11
,tw
ore
view
ssc
ored
seve
n,
one
each
scor
edsi
x,fi
vean
dfo
ur,
and
two
scor
edth
ree
(mea
nsc
ore
=fi
ve).
Som
eev
iden
ceth
atac
up
un
ctu
reca
nbe
effe
ctiv
ein
alle
viat
ing
pai
nin
pat
ien
tsw
ith
TM
D,
but
con
sid
erab
leva
riat
ion
inth
em
eth
odol
ogy
betw
een
the
pri
mar
yst
ud
ies
mad
ed
efin
itiv
eco
ncl
usi
onim
pos
sibl
e.
Th
eau
thor
sar
eri
ghtl
yca
uti
ous
rega
rdin
gco
ncl
usi
ons
that
can
bed
raw
n,
owin
gto
the
lack
ofas
sess
men
tof
qu
alit
yof
the
pri
mar
yst
ud
ies.
Ern
st(2
011)
20Po
siti
vefo
r:n
on-v
erte
xp
rese
nta
tion
.Po
siti
vebu
tpo
orqu
alit
yev
iden
cefo
r:p
rem
enst
rual
syn
dro
me
and
back
pai
nd
uri
ng
pre
gnan
cy.
Con
trad
icto
ryfo
r:d
ysm
enor
rhoe
a,ad
vers
eef
fect
sbe
cau
seof
can
cer
ther
apy,
nau
sea
and
vom
itin
g(f
oran
yre
ason
),p
regn
ancy
,lo
wba
ckp
ain
du
rin
gp
regn
ancy
and
sub-
fert
ilit
y.N
egat
ive
for:
men
opau
sal
hot
flu
shes
(in
clu
din
gin
brea
stca
nce
r).
Part
lyYe
s(w
her
eap
pli
cabl
e,re
view
sw
ere
jud
ged
agai
nst
PRIS
MA
guid
elin
es25
).Se
ven
teen
revi
ews
wer
era
ted
asgo
odan
dse
ven
asp
oor.
Nu
mer
ous
SRs
hav
ere
cen
tly
beco
me
avai
labl
e,bu
tth
eth
erap
euti
cva
lue
ofac
up
un
ctu
refo
rob
stet
rica
lan
dgy
nae
colo
gica
lco
nd
itio
ns
rem
ain
sli
mit
ed.
Th
eau
thor
sar
eri
ghtl
yca
uti
ous
rega
rdin
gco
ncl
usi
ons
that
can
bed
raw
n,
owin
gto
the
vari
able
qu
alit
yof
the
pri
mar
yst
ud
ies.
Review 15
Table
2C
ontin
ued
Firs
tau
thor
(yea
r)M
ain
fin
din
g(s)
Wer
ep
rim
ary
stu
die
sas
sess
ed?
Eval
uat
ion
ofq
ual
ity
ofin
clu
ded
revi
ews
(in
stru
men
t)A
uth
or(s
)’m
ain
con
clu
sion
Rev
iew
ers’
con
clu
sion
s
Ern
st(2
011)
21Li
mit
atio
nsof
prim
ary
stud
ies
prev
ent
firm
conc
lusi
ons
for:
inso
mn
ia.
Part
lyYe
s(O
QA
Q).
Scor
esof
�th
ree
=m
ajor
flaw
san
d�
five
=m
inor
flaw
s.Tw
ore
view
ssc
ored
seve
n,
one
scor
edsi
x,tw
osc
ored
fou
r,tw
osc
ored
thre
ean
dth
ree
scor
edon
e(m
ean
scor
e=
3.7)
.
Mor
ere
sear
chre
qu
ired
.T
he
auth
ors
are
righ
tly
cau
tiou
sre
gard
ing
con
clu
sion
sth
atca
nbe
dra
wn
,ow
ing
toth
eva
riab
leq
ual
ity
ofth
ep
rim
ary
stu
die
s.
Ern
st(2
011)
22Ef
fect
ive
for:
nec
kp
ain
.M
ostl
ypo
siti
vefo
r:lo
wba
ckp
ain
and
oste
oart
hri
tis.
One
SRsu
gges
ted
effe
ctiv
enes
sfo
r:ch
ron
ich
ead
ach
e.N
ode
fini
tive
conc
lusi
onow
ing
topo
orqu
alit
yof
prim
ary
stud
yor
revi
ewfo
r:an
kylo
sin
gsp
ond
ylit
is,
cerv
ical
spon
dyl
osis
,fr
ozen
shou
lder
,in
terv
erte
bral
dis
kd
isp
lace
men
t,lu
mba
rin
terv
erte
bral
dis
kh
ern
iati
on,
orth
opae
dic
dis
ease
s,p
ain
du
rin
goo
cyte
retr
ieva
lan
dsc
iati
ca.
Con
trad
icto
ryfo
r:d
ysm
enor
rhoe
a,te
mp
orom
and
ibu
lar
join
tp
ain
and
myo
fasc
ial
trig
ger-
poi
nt
pai
n.
Faile
dto
show
effe
ctiv
enes
sfo
r:ca
nce
rp
ain
,m
igra
ine
pro
ph
ylax
is,
mu
scu
losk
elet
alp
ain
,sh
ould
erp
ain
,an
dsu
rgic
alp
ain
.M
ostl
yne
gati
vefo
r:tr
eatm
ent
ofm
igra
ine,
rheu
mat
oid
arth
riti
s,an
dte
nsi
onh
ead
ach
e.
Part
lyYe
s(O
QA
Q).
Rev
iew
sw
ere
rate
das
exce
llen
t,go
od,
mod
erat
ean
dp
oor
(nu
mer
ical
scor
esw
ere
not
rep
orte
d).
Nin
etee
nre
view
sw
ere
rate
das
poo
r,th
ree
wer
em
oder
ate,
32w
ere
good
and
fou
rw
ere
exce
llen
t.
Acu
pu
nct
ure
seem
edto
beef
fect
ive
for
nec
kp
ain
.O
vera
ll,
agre
emen
tfo
rco
nd
itio
ns
was
low
.
Ove
rall
,th
eau
thor
sar
eri
ghtl
yca
uti
ous
rega
rdin
gco
ncl
usi
ons
that
can
bed
raw
n,
owin
gto
the
vari
able
qu
alit
yof
the
pri
mar
yst
ud
ies.
Giv
enth
eva
riab
leq
ual
ity
ofth
ep
rim
ary
stu
die
sin
the
two
revi
ews
ofn
eck
pai
n,
the
con
clu
sion
rega
rdin
gn
eck
pai
nsh
ould
betr
eate
dw
ith
cau
tion
(wh
ich
we
susp
ect
the
auth
ors
imp
ly).
Kan
g(2
011)
23C
onvi
ncin
gev
iden
cefo
r:im
pro
vin
gra
teof
pre
gnan
cyan
dli
vebi
rth
sat
the
tim
eof
embr
yotr
ansf
erd
uri
ng
in-v
itro
fert
ilis
atio
nan
dth
em
anag
emen
tof
chem
oth
erap
y-in
du
ced
nau
sea.
No
conv
inci
ngev
iden
ceal
thou
ghth
eda
tapo
int
topo
tent
ial
bene
fits
for:
trea
tin
gp
rim
ary
dys
men
orrh
oea,
men
opau
sal
hot
flu
shes
and
pol
ycys
tic
ovar
ysy
nd
rom
e.
No
Yes
(OQ
AQ
).Sc
ores
of�
thre
e=
maj
orfl
aws
and
�fi
ve=
min
orfl
aws.
Six
revi
ews
scor
edse
ven
,tw
osc
ored
six,
thre
esc
ored
five
,on
esc
ored
fou
r,on
esc
ored
two
and
thre
esc
ored
one
(mea
nsc
ore
=4.
88).
Ove
rall
,th
ere
issu
ffic
ien
tev
iden
cefo
rth
eu
seof
acu
pu
nct
ure
totr
eat
chem
oth
erap
y-in
du
ced
nau
sea
and
vom
itin
gan
dto
imp
rove
pre
gnan
cyra
tes
inIV
F.
Som
eca
uti
onsh
ould
besh
own
rega
rdin
gth
eau
thor
s’co
ncl
usi
ons,
asth
eq
ual
ity
ofth
ep
rim
ary
stu
die
sw
asn
otas
sess
ed.
Lee
(201
1)24
Posi
tive
for:
nec
kd
isor
der
s,te
nsi
on-t
ype
hea
dac
hes
and
per
iph
eral
join
tos
teoa
rth
riti
s.In
conc
lusi
vefo
r:sh
ould
erp
ain
,la
tera
lel
bow
pai
nan
dlo
wba
ckp
ain
.N
egat
ive
for:
rheu
mat
oid
arth
riti
s.
Part
lyYe
s(n
otd
efin
ed).
All
eigh
tre
view
sw
ere
dee
med
tobe
ofex
cell
ent
qu
alit
y.
Acu
pu
nct
ure
isef
fect
ive
for
som
ety
pes
ofp
ain
(i.e
.m
igra
ines
,n
eck
dis
ord
ers,
ten
sion
-typ
eh
ead
ach
esan
dp
erip
her
aljo
int
arth
riti
s)bu
tn
otal
lty
pes
(i.e
.rh
eum
atoi
dar
thri
tis)
.
Som
eca
uti
onsh
ould
besh
own
rega
rdin
gth
eau
thor
s’co
ncl
usi
ons,
owin
gto
the
vari
able
qu
alit
yof
the
pri
mar
yst
ud
ies.
AM
STA
R,a
mea
sure
men
tto
olto
asse
sssy
stem
atic
revi
ews;
IVF,
in-v
itro
fert
ilis
atio
n;O
QA
Q,o
verv
iew
qu
alit
yas
sess
men
tq
ues
tion
nai
re;P
RIS
MA
=Pr
efer
red
Rep
orti
ng
Item
sfo
rSy
stem
atic
Rev
iew
san
dM
eta-
anal
yses
;SD
,st
and
ard
dev
iati
on;
SR,
syst
emat
icre
view
;T
MD
,te
mp
orom
and
ibu
lar
dis
ord
er.
Focus on Alternative and Complementary Therapies March 2013 18(1)16
Although it was concluded that acupuncture is effec-tive for some types of pain, it is important to notethat the quality of the primary studies was, at best,variable and, therefore, this conclusion should betreated with some caution.
The main findings reported in the 18 reviews ofreviews tended to fall into one of two ranges(Table 2): positive to inconsistent (or inconclusive),or inconsistent (or inconclusive) to negative. Thefindings were mostly positive for some types of painrelief12,14 and for nausea and vomiting.8,12,15,18,23 Con-trarily, the findings were generally negative for rheu-matic arthritis13,14,23 and inconclusive to conclusivelynegative for smoking cessation.3,11,12,16
Many of the conclusions reached by the authors ofthe 18 reviews of reviews were that there is insuffi-cient evidence to draw firm conclusions.3,4,13 Someexceptions to this were: the evidence for dental andlow-back pain is conclusively positive;11 there is con-vincing evidence that acupuncture appears to benefitpostoperative nausea;12,18 acupuncture is effective forsome but not all types of pain;24 and there is suffi-cient evidence to warrant positive recommendationsfor acupuncture for chemotherapy-induced nauseaand vomiting15,23 and for the pain of migraines, neckdisorders, tension-type headaches and peripheraljoint arthritis.14
This SR of reviews of SRs suggests that no definitiveconclusions regarding the effectiveness of acupunc-ture are currently available, although some indi-vidual primary studies show promise. Although notconvincing in isolation, the combined weight of evi-dence from reviews of SRs of acupuncture appearshighly promising for nausea and vomiting.8,12,15,18,23 Itis our opinion that new SRs or reviews of SRs are notlikely to improve upon this situation, as each willinclude some different and some similar primarystudies or SRs.
Accordingly, we suggest that the best way to answerthe question of ‘does acupuncture work and, if so, forwhat conditions?’, is to conduct more high-qualityRCTs. Owing to the limited funding available forclinical trials of CAM, we advise that further trialsshould first be in the areas where there is greaterevidence of effectiveness or promise (e.g. for nauseaand vomiting). The design of new primary studiesshould take into account the weaknesses identified inSRs, and should also be recorded to reduce the like-lihood of publication bias in the case of negativefindings, which may prove harder to publish. Futureprimary studies should also attempt to measure notjust whether acupuncture is effective, but how effec-tive it is compared to other interventions.
Conclusion
Our SR of reviews of SRs has shown that there issome consensus, both positive and negative, for a
small number of treatments provided by acupunc-turists. However, in most cases, some caution shouldbe shown owing to the lack of consideration ofthe quality of the primary studies. We suggestthat further high-quality RCTs should be conducted,but only in the areas where promise has alreadybeen shown (e.g. nausea and vomiting). Wewould find it hard to justify further studies ofacupuncture for rheumatic arthritis or smokingcessation.
Conflict of interest None declared.
References1 Witt CM, Pach D, Brinkhaus B et al. Safety of acupunc-
ture: results of a prospective observational study with229,230 patients and introduction of a medical infor-mation and consent form. Forsch Komplementmed 2009;16: 91–7.
2 Smith V, Devane D, Begley C, Clarke M. Methodologyin conducting a systematic review of systematicreviews of healthcare interventions. BMC Med ResMethodol 2011; 11: 15.
3 Derry CJ, Derry S, McQuay HJ, Moore RA. Systematicreview of systematic reviews of acupuncture published1996–2005. Clin Med 2006; 6: 381–6.
4 de Niet GJ, Tiemens BG, Kloos MW, HutschemaekersGJM. Review of systematic reviews about the efficacy ofnon-pharmacological interventions to improve sleepquality in insomnia. Int J Evid Based Health 2009; 7:233–42.
5 Ernst E, Lee MS. Acupressure: an overview of systematicreviews. J Pain Symptom Manage 2010; 40: e3–e7.
6 Ernst E, Posadzki P, Lee MS. Complementary and alter-native medicine (CAM) for sexual dysfunction anderectile dysfunction in older men and women: an over-view of systematic reviews. Maturitas 2011; 70: 37–41.
7 Greenhalgh T. How to read a paper: papers that reportdrug trials. BMJ 1997; 315: 480–3.
8 Ezzo J, Streitberger K, Schneider A. Cochrane system-atic reviews examine P6 acupuncture-point stimula-tion for nausea and vomiting. J Altern Complement Med2006; 12: 489–95.
9 Shea BJ, Grimshaw JM, Wells GA et al. Development ofAMSTAR: a measurement tool to assess the methodo-logical quality of systematic reviews. BMC Med ResMethodol 2007; 7: 10.
10 Oxman AD, Guyatt GH. Validation of an index of thequality of review articles. J Clin Epidemiol 1991; 44:1271–8.
11 Ernst E. Clinical effectiveness of acupuncture: an over-view of systematic reviews. In: White A, Ernst E (Eds).Acupuncture: A Scientific Appraisal. Oxford: ButterworthHeinemann, 1999. pp. 107–27.
Review 17
12 Linde K, Vickers A, Hondras M et al. Systematic reviewsof complementary therapies – an annotated bibliogra-phy. Part 1: acupuncture. BMC Complement Altern Med2001; 1: 3.
13 Smith CA, Cochrane S. Does acupuncture have a placeas an adjunct treatment during pregnancy? A review ofrandomized controlled trials and systematic reviews.Birth 2009; 36: 246–53.
14 Ernst E, Lee MS. Acupuncture for rheumatic condi-tions: an overview of systematic reviews. Rheumatology(Oxford) 2010; 49: 1957–61.
15 Ernst E, Lee MS. Acupuncture for palliative and sup-portive cancer care: a systematic review of systematicreviews. J Pain Symptom Manage 2010; 40: e3–5.
16 Ernst E, Lee MS, Choi TY. Acupuncture for addictions:a systematic review of systematic reviews. Focus AlternComplement Ther 2010; 15: 97–100.
17 Ernst E, Lee MS, Choi TY. Acupuncture for depression?A systematic review of systematic reviews. Eval HealthProf 2010; 34: 403–12.
18 Hunt K, Ernst E. The evidence-base for complementarymedicine in children: a critical overview of systematicreviews. Arch Dis Child 2011; 96: 769–76.
19 List T, Axelsson S. Management of TMD: evidence fromsystematic reviews and meta-analyses. J Oral Rehabil2010; 37: 430–51.
20 Ernst E, Lee MS, Choi TY. Acupuncture in obstetricsand gynecology: an overview of systematic reviews. AmJ Chin Med 2011; 39: 423–31.
21 Ernst E, Lee MS, Choi TY. Acupuncture for insomnia?An overview of systematic reviews. Eur J Gen Pract2011; 17: 116–23.
22 Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviatepain and are there serious risks? A review of reviews.Pain 2011; 152: 755–64.
23 Kang HS, Jeong D, Kim D, Lee MS. The use of acupunc-ture for managing gynaecologic conditions: an over-view of systematic reviews. Maturitas 2011; 68: 346–54.
24 Lee MS, Ernst E. Acupuncture for pain: an overview ofCochrane reviews. Chin J Integr Med 2011; 17: 187–9.
25 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferredreporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6:e1000097.
Andrew Gilbey, BSc, PhD, Senior Lecturer, Massey Uni-versity, Turitea Campus, Palmerston North 4442, NewZealand.E-mail: [email protected] Ernst, MD, PhD, FMedSci, FSB, FRCP, FRCPEd,Editor-in-Chief of FACT, Emeritus Professor, PeninsulaMedical School, Veysey Building, Salmon Pool Lane, ExeterEX2 4SG, UK.E-mail: [email protected] Tani, MSc, PhD (previously doctoral candidate),c/o Massey University, Palmerston North 4442, NewZealand.E-mail: [email protected]
Focus on Alternative and Complementary Therapies March 2013 18(1)18