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Regular readers will know the Editor's fixation with acupuncture's specific effects: acupuncture has shown itself to be effective enough overall to be useful in care of some conditions but, arguably, public funds should not be spent on treatments that are entirely psychological (unless they are entirely psychological!). A recent update of NICE guidelines (http://guidance.nice.org.uk/CG177) has moved the goalposts further away: no therapy will be recommended for osteoarthritis unless its effect size compared with placebo/sham is 0.5 (half a standard deviation, SD). This is not the place to argue the rights and wrongs of this threshold, but it puts our first paper into dramatic context.
Postoperative pain is a great scenario for testing acupuncture, with possibilities for blinding and objective measurement using patient-controlled analgesia. Ntritsou and colleagues used a sound design for a sham-controlled study in major surgery where postoperative pain is severe for 48 hours. They found significant effects of acupuncture on primary pain scores, supported by several secondary outcomes—other pain scores, pain threshold, analgesic requirement, and serum cortisol levels. Figure 1 shows the pain scores on deep breath and on relaxation, and readers will calculate that the effect size of pain reduction was about two SD at 45 minutes, and more than one SD at every time point up to 24 hours. Acupuncture is clearly a significant benefit for patients and for their hospitals. This paper is followed by an RCT by Zhang et al which reinforces one of the secondary findings—that acupuncture reduces the need for opioids and therefore their side effects.
In their linked editorial, Usichenko and Streitberger put these studies in the context of the whole literature on the subject. The technique is simple, the points are easily accessed, the process interferes little with the progress of the operation, and the benefits are clear. Their title says it all: ‘Perioperative acupuncture: why are we not using it?’ The answer seems to be some combination of prejudice and ignorance. Usichenko finds indwelling needles particularly useful in theatre, and this issue also has his letter describing his wife's positive experience after childbirth.
Acupuncture is more widely used for chronic pain, for which acute pain research may not be applicable. The novel study by Plaster and colleagues is all the more important—for its concept more than its results. The authors measured acupuncture's short-term effects on pain and function in osteoarthritis. The effect size was about 0.24 in favour of electroacupuncture, though the sample size for this Master's project was too small to be definitive for comparing two active treatments. Because of the opportunities for blinding and control of variables, laboratory studies are an interesting option for future research.
Our next report is another rigorous, sham controlled RCT from that productive clinical trials centre run by Vas and his colleagues. This time they find that auriculo-acupressure leads to a difference of 10 points on the VAS for back pain compared with sham – an effect recognised as clinically significant, even though its effect size of 0.3 is nowhere near that demanded of NICE for osteoarthritis.
This issue has plenty of other clinical interest: diabetic neuropathy, emergency care, pregnancy, schizophrenia—and pneumothorax; and basic research on heart rate variability and needle rotation—Benham and Johnson showing that rotation increases the pain threshold.
And finally, for something completely different, Vivien Shaw argues that at least one of the ancient meridians simply describes human anatomy. Tell everyone acupuncture is based in science, not metaphysics: prejudice and ignorance, be gone!
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
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