Acupuncture for Chronic Pain
Vickers, AJ m.fl: Acupuncture for Chronic Pain. Individual Patient Data Meta-analysis. JAMA. 22. oktober 2012
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Methods: We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17 922 patients analyzed.
Results: In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias.
Conclusions: Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.
Acupuncture is the insertion and stimulation of needles at specific points on the body to facilitate recovery of health. Although initially developed as part of traditional Chinese medicine, some contemporary acupuncturists, particularly those with medical qualifications, understand acupuncture in physiologic terms, without reference to premodern concepts.1
An estimated 3 million American adults receive acupuncture treatment each year,2 and chronic pain is the most common presentation.3 Acupuncture is known to have physiologic effects relevant to analgesia,4 - 5 but there is no accepted mechanism by which it could have persisting effects on chronic pain. This lack of biological plausibility, and its provenance in theories lying outside of biomedicine, makes acupuncture a highly controversial therapy.
A large number of randomized controlled trials (RCTs) of acupuncture for chronic pain have been conducted. Most have been of low methodologic quality, and, accordingly, meta-analyses based on these RCTs are of questionable interpretability and value.6 Herein, we present an individual patient data meta-analysis of RCTs of acupuncture for chronic pain, in which only high-quality RCTs were eligible for inclusion. Individual patient data meta-analysis are superior to the use of summary data in meta-analysis because they enhance data quality, enable different forms of outcome to be combined, and allow use of statistical techniques of increased precision.