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This issue of the Acupuncture in Medicine marks an important milestone. After 27 years of independent publication, the journal will now be published by BMJ Publishing Group, thus adding the resources and global reach that are essential in modern medical publishing. In some circles, acupuncture still has a negative ‘image’ – implausible mechanisms and overenthusiastic claims for effectiveness in a whole range of conditions. The British Medical Acupuncture Society aims to encourage the use and scientific understanding of acupuncture, and will continue to own the journal. But the journal remains editorially independent: it shares the aim of understanding acupuncture through scientifically plausible mechanisms, but its main aim is to provide evidence of where acupuncture is safe and effective and where it is not, so as to help define the place of acupuncture in mainstream medicine.
There is evidence from systematic reviews that acupuncture is superior to placebo for treating nausea, chronic back and knee pain, tension headache and postoperative pain; it is equally important to know where acupuncture is not helpful and the journal will continue to publish, without bias, any studies that meet the required standard, whatever their results.
Acupuncture involves minimal technology; but even the most cursory inspection will reveal infinite complexities and uncertainties – even about the right ‘dose’ of acupuncture. These make meaningful research a nightmare, and a number of these difficulties are well illustrated by the papers in this issue.
Acupuncture research is under-developed. This journal champions ‘phase II’ studies to determine the optimal acupuncture treatment, and to identify the best responders. Our three clinical studies can be regarded as throwing some light on particular problems in acupuncture research.
Taechaarpornkul and colleagues compared treatments with two and six needles, a rare but important study that warrants publication even though the conclusions are limited by the small sample size. So it should be read with the caution that ‘no difference found’ is not the same as ‘the treatments are equivalent’.
Secondly, El-Rakshy and colleagues wanted to test the ability of acupuncture to reduce postoperative discomfort and minimise the discomfort of acupuncture by giving it during surgery under general anaesthesia. Unfortunately, there is already some evidence that anaesthesia depresses the parts of the central nervous system that respond to acupuncture – so it looks as if their study was doomed from the start. Their findings are mitigated by the fact that there is evidence from elsewhere that acupuncture given before or after surgery is known to reduce postoperative pain.
Thirdly, we still do not know which is the best device to use as sham control. Whale and colleagues want to use a novel blunt needle in a clinical trial, and wisely tested its credibility compared with standard needling in a pilot study.
Acupuncture is safe. But traditional acupuncturists use smouldering moxa to heat the needles, and Wheeler and colleagues have analysed the constituents of moxa smoke, to assess its safety.
Acupuncture is satisfying. The views of clinicians who refer to the Gateway clinic, surveyed by Unwin and Peters, show acupuncture as a valued resource within primary care. Patients whom nothing else has helped have benefitted from acupuncture and told their GPs, who are increasingly referring patients. Here the GPs rely less on formal evidence from clinical trials, and more on perceived benefit reported in informal discussions and feedback. Two GPs added their own case histories of personal benefit – one of the strongest drivers of all!
Acupuncture is effective and cost-effective. Most studies have now been published from the large programme of research instigated by the German insurance companies, with the aim of providing evidence for deciding whether to provide acupuncture. They are summarised by Cummings. Acupuncture was superior to usual care for several conditions, though not superior to needling in the ‘wrong’ site which is increasingly considered as an active treatment. The figure shows the results of the one series of studies, though the larger studies were less positive. The bottom line outcome of the research programme is that the German health service will fund acupuncture for chronic back pain and osteoarthritis of the hip and knee.
Acupuncture is complex. Lundeberg and Lund comment that individuals respond differently to acupuncture, for reasons that are not yet clear. Acupuncture is generally used to treat symptoms rather than their cause, so clinical trials have to use subjective measures. These authors make the case that interpreting the results on a group basis will underestimate the benefit of acupuncture, since improvement in some subgroups of patients will be masked by lack of improvement in other groups. This has implications for both the design and analysis of clinical trials.
Acupuncture is plausible. The Editorial board have taken the opportunity of this milestone issue to include a paper that defines Western Medical Acupuncture. It is perhaps surprising that no clear statement has been made in the journal before, considering the significance of this fundamental shift in ideology away from the traditional approach.
And acupuncture remains fascinating. It is also used in veterinary medicine, and here Crouch describes using it for pain relief in a disabled penguin. It is obvious that acupuncture can have an effect even to a bird brain.
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