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Hempel S, Taylor SL, Solloway MR, et al. Evidence Map of Acupuncture [Internet]. Washington (DC): Department of Veterans Affairs; 2014 Jan.

EVIDENCE MAP OF ACUPUNCTURE FOR WELLNESS

The results for Wellness-relevant indications and outcomes are presented in the bubble plot and text summary below. The bubble plot represents 43 systematic reviews and 3 recent large RCTs not yet incorporated in existing reviews summarizing effects for 20 distinct clinical indications relevant to Wellness [search date: March 2013].

Legend: The bubble plot shows an estimate of the evidence base for wellness-related indications judging from systematic reviews and recent large trials

Legend: The bubble plot shows an estimate of the evidence base for wellness-related indications judging from systematic reviews and recent large trials. The plot shows the estimated size of the literature (y-axis, number of RCTs included in largest review), the estimated effect (x-axis), and the confidence in the estimate (bubble size).

The figure provides a visual overview of the evidence base of acupuncture for wellness indications. The bubble plot depicts the estimated research volume based on the number of acupuncture RCTs included in the largest review for each of the differentiated clinical areas, the estimated treatment effect compared to passive control, and the confidence in the effect estimate, judging from published systematic reviews. Effect size estimates of the treatment effect based on specific individual reviews, as well as reason for classifying the evidence base as inconclusive, are reported in the narrative synthesis. The evidence map used the clinical topics as addressed in existing reviews and individual research studies may have contributed to a number of included reviews and clinical indications. All 3 depicted dimensions (literature size, effect, and confidence) are estimates and can only provide a broad overview of the evidence base.

EXECUTIVE SUMMARY: WELLNESS

As shown in the bubble plot, the largest research area was the indication insomnia. We identified 7 recent systematic reviews by independent author groups; the largest review, published in 2009, included 46 acupuncture RCTs.24 A 2012 Cochrane review reported that compared with other treatment alone, acupuncture as an adjunct might marginally increase the proportion of people with improved sleep quality (OR 3.1, 95% CI: 1.9, 4.9) but concluded that the current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia. The role of acupuncture in obesity has also been evaluated in a large number of studies; a 2012 review included 44 primarily non-PubMed indexed acupuncture RCTs.60 The review reported a risk ratio of 2.14 (95% CI: 1.58, 2.90) in favor of body weight reduction with a mean difference in body weight reduction of 2.76kg (95% CI: 1.61, 3.83) but noted that the majority of included studies was of low quality. A competing review including 31 acupuncture RCTs concluded that results suggested 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.122 Smoking cessation has also been addressed in a large number of studies; a 2011 Cochrane review included 31 acupuncture RCTs. The review reported that compared with sham acupuncture the risk ratio for short-term effects was 1.18 (95% CI: 1.03, 1.34) and 1.05 (CI: 0.82, 1.35) for long-term effects74 but concluded there is no consistent, bias-free evidence that acupuncture, acupressure, laser therapy, or electro-stimulation are effective for smoking cessation and no firm conclusions can be drawn. A 2012 review reported positive effects of acupoint stimulation at immediate, 3- and 6-month follow-up but did not differentiate effects of acupuncture, acupressure, electro-acupuncture, or percutaneous electrical nerve stimulation.53 Nausea and vomiting was addressed in a number of publications for a variety of indications and results appear to depend on the underlying condition causing the symptom. A 2009 Cochrane review included 11 acupuncture RCTs evaluating the effect of wrist acupuncture point P6 stimulation (acupressure, acupuncture, electro-acupuncture, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, acustimulation device) for preventing postoperative nausea and vomiting (PONV).111 The review reported a pooled effect size of 0.65 (95% CI: 0.48, 0.89) for acupuncture trials compared to sham for nausea and 0.60 (95% CI: 0.43, 0.84) for vomiting. The review concluded that P6 acupoint stimulation prevents post-operative nausea and vomiting; however the majority of included studies evaluated acupressure or other treatments and no conclusions specific to acupuncture were presented.

Positive effects were also reported for other clinical indications; however, the effects are based on only a small number of primary research studies. A Cochrane review on acupuncture for restless legs syndrome reported dermal needle therapy in combination with medications and massage was more effective than medications and massage alone in terms of remission of unpleasant sensation in the legs (RR 1.36, 95% CI: 1.06 to 1.75). However, the result was based on a single RCT and the review concluded that the evidence is insufficient.130 A systematic review on the efficacy of TCM for the management of constipation included 3 acupuncture RCTs.99 The RCTs comparing acupuncture treatment with patients taking lactulose or Folium Sennae reported statistically significant benefits in favor of acupuncture but no pooled effect was reported to estimate the size of the acupuncture treatment effect.

The clinical effectiveness is unclear for a number of wellness-relevant indications. Several primary studies and systematic reviews have been published on cancer treatment-associated physical adverse events; a 2013 review included 41 RCTs addressing a variety of adverse events such as pain, nausea, hot flashes, fatigue, xerostomia, prolonged postoperative ileus, anxiety / mood disorders, and sleep disturbance.38 The review concluded that acupuncture is an appropriate adjunctive treatment for chemotherapy-induced nausea / vomiting but additional studies are needed, and for other symptoms efficacy remains undetermined due to the high risk of bias of existing studies. A Cochrane review specific to chemotherapy-induced nausea or vomiting reported that stimulation with needles reduced the proportion of acute vomiting (RR 0.74, 95% CI: 0.58, 0.94) but not acute nausea severity. Results were inconsistent for elector-acupuncture and manual acupuncture, and studies combining electro-acupuncture with state-of-the-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance.161 The evidence base across and within 5 additional reviews on cancer and cancer-treatment related adverse events or specific conditions such as cancer-related fatigue, hot flashes in breast cancer survivors, and hiccups in cancer patients was judged to be insufficient to draw firm conclusions by the review authors. A Cochrane review on irritable bowel syndrome (IBS) included 17 RCTs57. The review indicated that acupuncture was more effective than no specific therapy (RR 2.11, 95% CI: 1.18, 3.79) and Chinese medicine treatment alone (RR 1.17, 95% CI: 1.02, 1.33), but not sham acupuncture for symptom severity (SMD -0.11, 95% CI: -0.35, 0.013) or quality of life (SMD -0.03, 95% CI: -0.27, 0.22). Results of effects of acupuncture on rhinitis were judged to be inconsistent in 3 systematic reviews; the largest review included 12 acupuncture RCTs. A recent, large RCT, commissioned by German health insurance companies as part of the “Acupuncture in Routine Care” study and not yet included in existing reviews, included 981 randomized participants with allergic rhinitis. The study reported a mean improvement of 1.48 (SE 0.06) on a rhinitis quality of life questionnaire in the acupuncture group and 0.50 (SE 0.06) in the control group (p<0.001).208 The existing reviews did not report sufficient data to allow a reanalysis of all available RCTs. A 2006 systematic review on acupuncture treatment in gastrointestinal diseases included 10 RCTs covering a wide range of indications and reported that quality of life improved independently from the treatment, real or sham acupuncture, while a recent large RCT on functional dyspepsia and a trial on gastroesophageal reflux disease reported superior effects of true acupuncture, and a meta-analytic reanalysis for the purpose of this review of reviews was not possible.209,210 Two reviews on acupuncture effects on blood pressure and one review on tinnitus concluded that the evidence is inconclusive. Reviews on menopausal symptoms, premenstrual syndrome, and xerostomia showed conflicting results across reviews; each topic was targeted in 2 to 3 reviews by independent researcher groups. Reviews on dry eye, exercise performance, rrectile dysfunction and quality of life found conflicting results across included studies, did not pool results, and provided insufficient details for a reanalysis without obtaining original trials data. The reviews indicate that only a limited number of individual studies are available, ranging from 2 to 6 included acupuncture RCTs.

A review on acustimulation effects on nausea and vomiting in pregnant women (nausea-pregnancy) included 4 acupuncture RCTs and reported no effect in reducing nausea and vomiting.154

In addition, a small number of reviews were identified that could not be incorporated in the bubble plots. They primarily addressed the comparative effectiveness of acupuncture in comparison to other active treatments. One review concluded, based on individual RCTs and existing meta-analyses, that acupuncture was as effective as pharmacological therapies or acupressure in addressing postoperative nausea but not vomiting.54 A review of the effects of acupuncture on hot flushes in men with prostate cancer117 and reviews of auriculotherapy (either acupuncture or auricular taping) for managing constipation87, 211 concluded most studies were too methodologically flawed to reach a conclusion. A recent Chinese-language RCT (N=577 participants) not yet included in existing reviews on acupuncture for pulmonary function concluded that the effect of acupuncture is equal to salbutamol aerosol inhalation.211 A systematic review on acupuncture for respiratory disease in Japan 197 included 2 relevant RCTs, and the evidence tables indicated that acupuncture was superior to waiting list controls for cold prevention. However, no numerical values were reported and the statistical significance is not known.

Cover of Evidence Map of Acupuncture
Evidence Map of Acupuncture [Internet].
Hempel S, Taylor SL, Solloway MR, et al.
Washington (DC): Department of Veterans Affairs; 2014 Jan.

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