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As highlighted in this issue by Xiao-Qian Li et al., in their review of risk of bias within acupuncture trials, it is accepted that patient and practitioner blinding is needed to separate specific from non-specific effects of an acupuncture intervention. To date, however, there is still no perfect comparator as ‘sham’ acupuncture is never completely inert. Consequently, often the net difference between ‘verum’ and sham treatment groups in research studies is merely one of location (ie, classical acupuncture point versus non-acupuncture point, local versus distant and/or segmental versus non-segmental needling) and/or neurophysiological ‘dose’, as determined by the number of needles, retention time and degree of stimulation (eg, minimal, de qi, manual manipulation, electroacupuncture). Accordingly, the effect size of acupuncture compared with sham is usually less than that compared with standard care or no treatment (eg, 0.26 and 0.55, respectively, in back and neck pain based on a recent individual patient meta-analysis.1 This differential appears to vary by clinical condition. For example, verum acupuncture was found to outperform sham in the latest Cochrane review of osteoarthritis2 but not migraine.3 In the current issue, Yang et al., present the results of an up-to-date systematic review and meta-analysis of acupuncture for migraine demonstrating statistically significant benefits of verum acupuncture for the first time relative to sham. Nevertheless, acupuncture for migraine prophylaxis is already widely accepted and even recommended by the UK's National Institute for Health and Care Excellence (NICE) as a second-line therapy after topiramate or propranolol. Although the precise contribution of various mechanism of acupuncture analgesia remains unknown for migraine, it is likely that it mainly involves central/general effects, which may explain the smaller differences between verum and sham acupuncture in this condition. This hypothesis is further supported by the preclinical work of Cui et al., reported in this issue, which strongly implicates the descending pain inhibitory and facilitatory pathways in both the pathogenesis of migraine and effects of acupuncture.
This month's cover image is an extreme close-up of a smoker's lung. Congratulations to any readers who managed to work that out without reading the caption; I personally was never that hot on Histology. One might imagine this is how Jia Li et al.,'s rats' lungs may have looked by the end of their highly novel preclinical experiment, in which chronic exposure to cigarette smoke was used to model chronic obstructive pulmonary disease (COPD). Although the effectiveness of acupuncture for smoking cessation remains unclear,4 it is possible that it could exert a protective effect on the lung through both immunomodulatory and epigenetic mechanisms, however its efficacy in established COPD will need to be assessed by future clinical research.
This month's editor's choice is a unique observational study of acupuncture for pre-eclampsia by Zeng et al. Pre-eclampsia, a placental disorder characterised by new-onset hypertension and proteinuria during the second half of pregnancy, is a challenging condition to manage. Whilst conventional anti-hypertensive medication can be used to prevent severe hypertension, and thereby haemorrhagic stroke, it does not influence the underlying disease process, for which there is no specific treatment except for delivery. Although not a randomised controlled trial, this novel report suggests that acupuncture may be an effective adjunctive treatment in pre-eclampsia; affected women between 21 and 34 weeks gestation receiving acupuncture plus usual care demonstrated a greater reduction in blood pressure than matched controls receiving usual care alone. Although small, the size of the effect was comparable with a recent trial in primary hypertension.5 Although the study was too small to evaluate perinatal outcomes, treatment appeared safe. An adequately powered clinical trial looking at clinically relevant outcome measures is now needed.
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