NIHR Signal Acupuncture shown to have benefits for treatment of some chronic pain

Published on 20 June 2017

Acupuncture is not a placebo for treatment of chronic pain. This NIHR-funded systematic review shows that acupuncture is better than usual care and sham acupuncture for pain from musculoskeletal conditions, knee osteoarthritis and chronic headache.

This NIHR review was large with over 140 trials overall, and the direct comparison with sham acupuncture helps to address uncertainty around whether acupuncture gives clinical benefit above a “placebo effect.” Acupuncture had a smaller effect on pain when compared with sham acupuncture than when compared with no acupuncture, but both comparisons showed statistically significant differences. Acupuncture also improved quality of life compared with standard care and was assessed to be a good use of NHS resources.

Acupuncture is currently recommended for the prevention of chronic headaches, but not for musculoskeletal pain or osteoarthritis pain. The findings may inform forthcoming guideline updates.

The availability of accredited acupuncturists varies across the UK. Though some are currently funded in NHS clinics, additional NHS funding for providers managing chronic pain conditions may be indicated.

Acupuncture shown to have benefits for treatment of some chronic pain

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Why was this study needed?

Around four million acupuncture treatments are provided each year in the UK with approximately two-thirds of this provision outside the National Health Service. Acupuncture is often used in circumstances when other treatments have not fully helped patients, especially as treatment for joint pain and long-term headaches. The NHS reportedly funds around one-third of treatments given in the UK through providers such as doctor’s physiotherapists and nurses, but access to acupuncture varies around the country.

Studies to date have suggested that acupuncture is safe when delivered by experienced professionals. However, whether it actually gives any clinical benefit, or whether any effects might be down to the “placebo effect” of delivering an intervention, has often been debated. Some argue that the placebo effect itself is useful.

Using a robust systematic review methodology, this project aimed to shed light on the clinical benefits and costs of acupuncture, comparing it to sham acupuncture, placebo, usual care and other interventions. The researchers wanted to provide information for patients and decision-makers to guide the NHS in better understanding the role of acupuncture in chronic pain and to settle the question of whether it was acting as a complex placebo.

What did this study do?

This systematic review was conducted in two parts. The first included 29 randomised controlled trials comparing acupuncture with sham acupuncture or non-acupuncture controls in 17,922 adults with osteoarthritis, chronic headache or musculoskeletal pain (back, neck or shoulder).

Researchers looked at effect on pain and whether acupuncture improved quality of life on the EuroQol-5 Dimensions (EQ-5D) scale and gave value for money.

The studies came from UK, US, Germany, Spain and Sweden. Most had high follow-up rates and participants were unaware of treatment given. However, individual trial results differed, likely due to differences in the controls used and method for assessing pain outcomes.

The second part included 114 trials in 9,709 people with knee osteoarthritis. Researchers included the higher quality trials in a network meta-analysis, comparing acupuncture with other physical therapies directly within trials and indirectly across trials.

What did it find?

  • Acupuncture was more effective than control for all pain conditions. It had moderate effect compared with non-acupuncture care for musculoskeletal pain (standardised mean difference [SMD] 0.55, 95% confidence interval [CI] 0.51 to 0.58), osteoarthritis (SMD 0.57, 95% CI 0.50 to 0.64) and headache (SMD 0.42, 95% CI 0.37 to 0.46).
  • It had smaller effect compared with sham acupuncture for musculoskeletal (SMD 0.37, 95% CI 0.27 to 0.46), osteoarthritis (SMD 0.26, 95% CI 0.17 to 0.34) and headache pain (SMD 0.15, 95% CI 0.07 to 0.24).
  • When excluding smaller, lower quality trials, patients receiving acupuncture still had less pain than people receiving sham acupuncture.
  • Acupuncture was better than standard care for osteoarthritis knee pain (SMD 1.01, 95% credible interval [CrI] 0.61 to 1.43). It outperformed exercise and weight loss interventions, and had similar success to balneotherapy, which consists in bathing in water rich in minerals (data from only one small trial). Sham acupuncture was also better than standard care for knee pain (SMD 0.68, 95% CrI 0.19 to 1.17), but had smaller effect when compared with acupuncture (SMD 0.34, 95% CrI 0.03 to 0.66).
  • Acupuncture improved quality of life compared with usual care in people with musculoskeletal pain (EQ-5D score improvement 0.082, 95% CrI 0.047 to 0.116), knee osteoarthritis (0.079, 95% CrI 0.042 to 0.114) and chronic headache pain (0.056, 95% CrI 0.021 to 0.092). There was no significant effect compared with sham acupuncture.
  • Acupuncture has a cost of £9,000 to £13,000 per quality-adjusted year of life gained (QALY) for musculoskeletal, osteoarthritis or chronic headache pain. This is below the NHS willingness-to-pay threshold of £20,000 to £30,000.

What does current guidance say on this issue?

The NICE guideline on headaches in young people and adults, reviewed in 2016, recommends up to ten sessions of acupuncture delivered over five to eight weeks for the prevention of tension-type headaches and migraines.

The 2016 NICE guideline recommends against acupuncture for managing low back pain with or without nerve pain (sciatica). The 2014 NICE guideline on the management of osteoarthritis also advises against acupuncture and also considered the evidence presented in this review.

All three guidelines are planned for review in 2018.

What are the implications?

This study shows that acupuncture is not just a placebo and is effective for treatment of musculoskeletal, osteoarthritis and chronic headache pain.

This study supports the UK practice for considering acupuncture in the preventative management of chronic headache pain. It could also point to a possible change in future treatment recommendations for musculoskeletal and osteoarthritis pain.

However the treatment benefit might be considered small. The practical issues of workforce development and the total costs that arise from changing referral practices for common long-term conditions, will also need consideration.

It is difficult to find properly accredited acupuncturists in the UK and appropriate training would be needed if the provision of acupuncture was increased nationally.

Citation and Funding

MacPherson H, Vickers A, Bland M, et al. Acupuncture for chronic pain and depression in primary care: a programme of research. Programme Grants Appl Res 2017;5(3).

This project was funded by the National Institute for Health Research [Programme Grants for Applied Research programme] (project number RP-PG-0707-10186).

Bibliography

Claxton K, Martin SSoares M, et al. Methods for the Estimation of the NICE Cost Effectiveness Threshold. Health Technol Assess. 2015;19(14):1-503.

Hopton AK, Curnoe S, Kanaan M, Macpherson H. Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey. BMJ Open. 2012;2(1):e000456.

NHS Choices.  Acupuncture. London: Department of Health; reviewed 2016.

NICE. Headaches in over 12s: diagnosis and management. CG150. London: National Institute for Health and Clinical Excellence; 2015.

NICE. Low back pain and sciatica in over 16s: assessment and management. NG59. London: National Institute for Health and Clinical Excellence; 2016.

NICE. Osteoarthritis: care and management. CG177. London: National Institute for Health and Clinical Excellence; 2014.

Vogel S. NICE clinical guidelines. Low back pain: The early management of persistent non-specific back pain. Int J Osteopath Med. 2009;12:113-4.

Why was this study needed?

Around four million acupuncture treatments are provided each year in the UK with approximately two-thirds of this provision outside the National Health Service. Acupuncture is often used in circumstances when other treatments have not fully helped patients, especially as treatment for joint pain and long-term headaches. The NHS reportedly funds around one-third of treatments given in the UK through providers such as doctor’s physiotherapists and nurses, but access to acupuncture varies around the country.

Studies to date have suggested that acupuncture is safe when delivered by experienced professionals. However, whether it actually gives any clinical benefit, or whether any effects might be down to the “placebo effect” of delivering an intervention, has often been debated. Some argue that the placebo effect itself is useful.

Using a robust systematic review methodology, this project aimed to shed light on the clinical benefits and costs of acupuncture, comparing it to sham acupuncture, placebo, usual care and other interventions. The researchers wanted to provide information for patients and decision-makers to guide the NHS in better understanding the role of acupuncture in chronic pain and to settle the question of whether it was acting as a complex placebo.

What did this study do?

This systematic review was conducted in two parts. The first included 29 randomised controlled trials comparing acupuncture with sham acupuncture or non-acupuncture controls in 17,922 adults with osteoarthritis, chronic headache or musculoskeletal pain (back, neck or shoulder).

Researchers looked at effect on pain and whether acupuncture improved quality of life on the EuroQol-5 Dimensions (EQ-5D) scale and gave value for money.

The studies came from UK, US, Germany, Spain and Sweden. Most had high follow-up rates and participants were unaware of treatment given. However, individual trial results differed, likely due to differences in the controls used and method for assessing pain outcomes.

The second part included 114 trials in 9,709 people with knee osteoarthritis. Researchers included the higher quality trials in a network meta-analysis, comparing acupuncture with other physical therapies directly within trials and indirectly across trials.

What did it find?

  • Acupuncture was more effective than control for all pain conditions. It had moderate effect compared with non-acupuncture care for musculoskeletal pain (standardised mean difference [SMD] 0.55, 95% confidence interval [CI] 0.51 to 0.58), osteoarthritis (SMD 0.57, 95% CI 0.50 to 0.64) and headache (SMD 0.42, 95% CI 0.37 to 0.46).
  • It had smaller effect compared with sham acupuncture for musculoskeletal (SMD 0.37, 95% CI 0.27 to 0.46), osteoarthritis (SMD 0.26, 95% CI 0.17 to 0.34) and headache pain (SMD 0.15, 95% CI 0.07 to 0.24).
  • When excluding smaller, lower quality trials, patients receiving acupuncture still had less pain than people receiving sham acupuncture.
  • Acupuncture was better than standard care for osteoarthritis knee pain (SMD 1.01, 95% credible interval [CrI] 0.61 to 1.43). It outperformed exercise and weight loss interventions, and had similar success to balneotherapy, which consists in bathing in water rich in minerals (data from only one small trial). Sham acupuncture was also better than standard care for knee pain (SMD 0.68, 95% CrI 0.19 to 1.17), but had smaller effect when compared with acupuncture (SMD 0.34, 95% CrI 0.03 to 0.66).
  • Acupuncture improved quality of life compared with usual care in people with musculoskeletal pain (EQ-5D score improvement 0.082, 95% CrI 0.047 to 0.116), knee osteoarthritis (0.079, 95% CrI 0.042 to 0.114) and chronic headache pain (0.056, 95% CrI 0.021 to 0.092). There was no significant effect compared with sham acupuncture.
  • Acupuncture has a cost of £9,000 to £13,000 per quality-adjusted year of life gained (QALY) for musculoskeletal, osteoarthritis or chronic headache pain. This is below the NHS willingness-to-pay threshold of £20,000 to £30,000.

What does current guidance say on this issue?

The NICE guideline on headaches in young people and adults, reviewed in 2016, recommends up to ten sessions of acupuncture delivered over five to eight weeks for the prevention of tension-type headaches and migraines.

The 2016 NICE guideline recommends against acupuncture for managing low back pain with or without nerve pain (sciatica). The 2014 NICE guideline on the management of osteoarthritis also advises against acupuncture and also considered the evidence presented in this review.

All three guidelines are planned for review in 2018.

What are the implications?

This study shows that acupuncture is not just a placebo and is effective for treatment of musculoskeletal, osteoarthritis and chronic headache pain.

This study supports the UK practice for considering acupuncture in the preventative management of chronic headache pain. It could also point to a possible change in future treatment recommendations for musculoskeletal and osteoarthritis pain.

However the treatment benefit might be considered small. The practical issues of workforce development and the total costs that arise from changing referral practices for common long-term conditions, will also need consideration.

It is difficult to find properly accredited acupuncturists in the UK and appropriate training would be needed if the provision of acupuncture was increased nationally.

Citation and Funding

MacPherson H, Vickers A, Bland M, et al. Acupuncture for chronic pain and depression in primary care: a programme of research. Programme Grants Appl Res 2017;5(3).

This project was funded by the National Institute for Health Research [Programme Grants for Applied Research programme] (project number RP-PG-0707-10186).

Bibliography

Claxton K, Martin SSoares M, et al. Methods for the Estimation of the NICE Cost Effectiveness Threshold. Health Technol Assess. 2015;19(14):1-503.

Hopton AK, Curnoe S, Kanaan M, Macpherson H. Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey. BMJ Open. 2012;2(1):e000456.

NHS Choices.  Acupuncture. London: Department of Health; reviewed 2016.

NICE. Headaches in over 12s: diagnosis and management. CG150. London: National Institute for Health and Clinical Excellence; 2015.

NICE. Low back pain and sciatica in over 16s: assessment and management. NG59. London: National Institute for Health and Clinical Excellence; 2016.

NICE. Osteoarthritis: care and management. CG177. London: National Institute for Health and Clinical Excellence; 2014.

Vogel S. NICE clinical guidelines. Low back pain: The early management of persistent non-specific back pain. Int J Osteopath Med. 2009;12:113-4.

Acupuncture for chronic pain and depression in primary care: a programme of research

Published on 23 January 2017

MacPherson H, Vickers A, Bland M, Torgerson D, Corbett M, Spackman E

Programme Grants for Applied Research Volume 5 Issue 3 , 2017

Background There has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money. Aim Our aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression. Methods and results We synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (pā€‰<ā€‰0.001) and usual care (pā€‰<ā€‰0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective. Conclusion We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence. Funding The National Institute for Health Research Programme Grants for Applied Research programme.

Acupuncture is a treatment derived from ancient Chinese medicine where fine needles are inserted in specific sites in the body for therapeutic or preventative purposes. Sham acupuncture involves using needles that do not penetrate the skin or performing acupuncture at the wrong sites. Sham acupuncture is designed not to have clinical effect and is solely an experimental control of acupuncture.

Statistical analyses sometimes report credible intervals [CrI]; these intervals summarise the level of certainty of the results. This study reports 95% CrI, which means there is a 95% probability that the value of interest lies in the interval.

Expert commentary

Acupuncture is widely used in the NHS. It is particularly used by physiotherapists for musculoskeletal conditions. Its advantage is that it’s not a drug – many drugs have unpleasant side effects and are often poorly tolerated. Most recent guidance suggests that acupuncture is ineffective as a treatment. Yet proponents stubbornly refuse to give up on it. Transcutaneous nerve stimulation (TNS) has had a similar bad press. The greatest problems have been with the design of an appropriate placebo to test it.

This research has developed rigorous methods to investigate both treatments. The outcomes are positive and seem to chime with clinical impressions that acupuncture and TNS can be effective for the right people. Is this the beginning of the turn of the tide?

Dr Cathy Price, Consultant in Pain Management, Southampton University Hospitals