Rédacteur : Johan Nguyen

Sommaire

1. Overviews of Systematic Reviews
2. Overviews of Clinical Practice Guidelines
- 2.1. Birch 2018
- 2.2. Guo 2017

Effectiveness of acupuncture: all conditions

Évaluation de l'acupuncture : toutes pathologies

1. Overviews of Systematic Reviews

1.1. Lu 2022

Lu L, Zhang Y, Ge S, Wen H, Tang X, Zeng JC, Wang L, Zeng Z, Rada G, Ávila C, Vergara C, Chen R, Dong Y, Wei X, Luo W, Wang L, Guyatt G, Tang CZ, Xu NG. Evidence mapping and overview of systematic reviews of the effects of acupuncture therapies. BMJ Open. 2022 Jun 6;12(6):e056803. https://doi.org/10.1136/bmjopen-2021-056803

Objective	To provide a route map regarding systematic reviews (SRs) of acupuncture therapies that will meet two goals: (1) to identify areas in which more or better evidence is required and (2) to identify acupuncture applications that, although proven effective, remain underused in practice, and thus warrant more effective knowledge dissemination.
Eligibility criteria	We included SRs that conducted meta-analyses (MAs) of randomised controlled trials (RCTs) for this overview.
Information sources	We searched for SRs without language restrictions from January 2015 to November 2020 in four Chinese electronic databases and Epistemonikos database. And we also searched for newly published RCTs that were eligible for selected best SRs in PubMed, Medline, Cochrane Central Register of Controlled Trials, Embase and four Chinese electronic databases from its lasted search dates to November 2020.
Synthesis of results	We reanalysed the selected MAs if new primary studies were added. We used random-effect model to calculate the overall effect.
Results	Our search identified 120 SRs published in the last 5 years addressing acupuncture therapies across 12 therapeutic areas and 77 diseases and conditions. The SRs included 205 outcomes and involved 138 995 participants from 1402 RCTs. We constructed 77 evidence matrices, including 120 SRs and their included RCTs in the Epistemonikos database. Seventy-seven SRs represented the effect estimate of acupuncture therapies. Finally, we system summarised the areas of possible underutilisation of acupuncture therapies (high or moderate certainty evidence of large or moderate effects), and the areas of warranting additional investigation of acupuncture therapies (low or very low certainty evidence of moderate or large effects).
Conclusion	The evidence maps and overview of SRs on acupuncture therapies identified both therapies with substantial benefits that may require more assertive evidence dissemination and promising acupuncture therapies that require further investigation.

1.2. Salehi 2016

Salehi A, Marzban M, Imanieh MH. The Evaluation of Curative Effect of Acupuncture: A Review of Systematic and Meta-Analysis Studies. J Evid Based Complementary Altern Med. 2016;21(3):202-14. [173828].

The present study attempts to critically evaluate previously published research articles on the efficiency of acupuncture in the treatment of diseases. First, 35 systematic reviews or meta-analysis were found in the Cochrane database. Second, 54 related articles were selected by searching important scientific databases. Based on the results obtained regarding the efficacy of acupuncture for the treatment of various diseases, the articles were divided into 3 groups. The first group of articles confirmed the efficacy of treatment by acupuncture. In the second group of articles, the therapeutic effect of acupuncture was shown; however, further research is required to verify the results. In the third group of articles there is no evidence regarding the therapeutic effect of acupuncture till now. There is an urgent need to design and conduct double-blinded randomized clinical trials with high-quality methodologies. This provides a more careful evaluation of acupuncture efficiency in relation to the treatment of a vast array of diseases, based on scientific evidence.

1.3. Salehi 2015

Salehi A, Marzban M, Imanieh MH. the evaluation of curative effect of acupuncture: a review of systematic and meta-analysis studies. J Evid Based Complementary Altern Med. 2015. [183430].

1.4. Hempel 2014

Hempel S, Taylor Sl, Solloway MR, Miake-Lye IM, Beroes JM, Shanman R, Booth MI, Siroka AM, Shekelle PG. Evidence map of acupuncture. VA evidence-based synthesis program reports.2014. 170098.

Many Veterans desire complementary and alternative medicine or integrative medicine modalities such as acupuncture, both for treatment and for the promotion of wellness. However, the effectiveness and adverse events associated with acupuncture are not firmly established. Given the VA's desire to promote evidence-based practice, this evidence mapping project will help provide guidance to VA leadership about the distribution of evidence to inform policy and clinical decision making. In general, acupuncture is the stimulation of specific acupuncture points through penetration of the skin with needles, which aims to correct imbalances in the flow of qi, a concept of energy in traditional Chinese medicine (TCM), through meridians (ie, energy channels). The available published literature on acupuncture is extensive. PubMed searches in 2013 identified almost 20,000 citations with the term “acupuncture” and almost 1,500 randomized controlled trials (RCTs) with “acupuncture” in the title. Not surprisingly, a large number of systematic reviews and meta-analyses have been published to-date, and even a number of “reviews of reviews” are available in the published literature on acupuncture in general or for a specific clinical condition. Results from existing reviews of reviews about the effectiveness of acupuncture are non-conclusive. A systematic review of systematic reviews of acupuncture published between 1996 and 2005 included 35 reviews. The overview noted that 12 reviews reported support for acupuncture and 6 reported strong support; however, when applying strict inclusion criteria, such as randomized and double blind studies, good evidence of no benefit was shown. In 2007, Adams compiled a “Brief Overview - A summary of the evidence for use of acupuncture from systematic reviews and meta-analyses” for the Veterans Health Administration Office of Patient Care Services Technology Assessment Program. The report included 42 systematic reviews published since 2002 and concluded that higher quality studies are only beginning to emerge, the evidence base is heterogeneous, and the review results highlight the overall poor quality of studies and reporting. Thus, it is timely to assess the current state of reviews of acupuncture.

1.5. Piso 2014

Piso B, Breuer J, Reinsperger I et al. Akupunktur. Einsatzgebiete, Evidenzlage und gesicherte Indikationen. Wien: Ludwig Boltzmann Institut für Health Technology Assessment (LBI-HTA). 2014;:114P. [10217].

Background and aim Acupuncture is a native of traditional Chinese medicine therapy method that is often used in addition or exclusively for the treatment of diseases. This report deals with the questions in which indications acupuncture is recommended and for which indications evidence exists on the effectiveness of acupuncture in form of (Cochrane) reviews. These results are then compared with 25 approved indications from the Austrian Health Council (Oberster Sanitätsrat, OSR), an advisory committee for the Ministry of Health. Methods We identified WHO recommendations or recommendations from professional associations for the use of acupuncture through a web-based hand search. We conducted a systematic literature search in the Cochrane Database of Systematic Reviews for the „Overview of Cochrane Reviews“. Additionally, we carried out a hand-search on recent review articles in PubMed. Results The WHO poses recommendations for the use of acupuncture for a total of 108 indications. The professional associations recommend acupuncture in a wide range of applications. The results of the overview of Cochrane Reviews (a total of 55 Cochrane Reviews were included) show the effectiveness of acupuncture for 2 indications (migraine prophylaxis as well as pelvic and back pain during pregnancy). In 7 indications effectiveness could be given. For 4 indications (epilepsy, irritable bowel syndrome, nausea and vomiting in early pregnancy and assisted reproductive technology) the results of the overview of Cochrane Reviews indicate the ineffectiveness of acupuncture. For 42 indications no statement can be made regarding (in)effectiveness due to missing or inconclusive evidence. Conclusion and recommendation Regarding the 25 OSR indications, the comparison of the available evidence shows that effectiveness of acupuncture has been proven for some areas (headaches and migraines, degenerative arthritis, back pain, diseases of the cervical spine, dysmenorrhoea, chronic pain). For allergic rhinitis, vomiting in pregnancy, irritable bowel syndrome and fibromyalgia one systematic review concluded, that acupuncture was ineffective. Concerning the other OSR-indications no statements on the effectiveness or ineffectiveness of acupuncture can be made.

1.6. Gilbey 2013

Gilbey A, Ernst E and Tani K. A systematic review of reviews of systematic reviews of acupuncture. Focus on Alternative and Complementary Therapies. 2013;18:8-18. [165907].

Background Acupuncture is one of the more popular forms of complementary and alternative medicine. Whilst the therapy has been the subject of many published trials, systematic reviews and reviews of reviews, the conclusions of these publications often have been inconsistent. Objectives To systematically review reviews of reviews of acupuncture in an attempt to better understand existing contradictions in the literature. Methods The databases MEDLINE, Scopus and EbscoHost were searched using the keywords (systematic review) AND (acupuncture OR acupressure) for the period January 1991 to December 2011. The methodological quality of included reviews was assessed using a nine-item measure developed by the authors. Results Eighteen reviews of reviews met the inclusion criteria; two reviews did not assess the methodological quality of the included reviews and only two rigorously assessed the quality of the primary studies included in the reviews. Quality of the reviews of reviews ranged from poor to excellent. Conclusions were positive for nausea and vomiting and some types of pain, but negative for smoking cessation. Conclusions Only two reviews of reviews allowed definitive conclusions to be drawn; that is, there is insufficient evidence to make positive recommendations. Further reviews, or reviews of reviews, are unlikely to break this impasse, owing to the combination of new and existing reviews or primary studies upon which they can draw. We therefore recommend that high-quality RCTs should be conducted in the areas where most promise has already been shown

1.7. Ernst 2008

Ernst E. Acupuncture: what does the most reliable evidence tell us?. J Pain Symptom Manage. 2008;sept 11. [150368].

Many trials of acupuncture and numerous systematic reviews have recently become available. Their conclusions are far from uniform. In an attempt to find the most reliable type of evidence, this article provides an overview of Cochrane reviews of acupuncture. Such reviews were studied, their details extracted, and they were categorized as: reviews with a negative conclusion (no evidence that acupuncture is effective); reviews that were inconclusive; and reviews with a positive or tentatively positive conclusion. Thirty-two reviews were found, covering a wide range of conditions. Twenty-five of them failed to demonstrate the effectiveness of acupuncture. Five reviews arrived at positive or tentatively positive conclusions and two were inconclusive. The conditions that are most solidly backed up by evidence are chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. It is concluded that Cochrane reviews of acupuncture do not suggest that this treatment is effective for a wide range of conditions.

1.8. Derry 2006

Derry CJ, Derry S, Mcquay HJ, Moore RA. Systematic review of systematic reviews of acupuncture published 1996-2005. Clin Med. 2006;6(4):381-6. [141392].

Systematic reviews of acupuncture have tended to support its use, but few applied rigorous inclusion criteria. We tested the credibility of conclusions of systematic reviews of acupuncture published since 1996 by applying rigorous inclusion criteria. Reinterpretation used randomised and double blind trials with valid outcomes or design, and with information available from at least four trials or from 200 patients. Qualified support for acupuncture was originally reported in 12 out of 35 systematic reviews, and strong support was found in another six. Applying stricter inclusion criteria, however, showed that none of the 35 reviews supported acupuncture, predominantly because there were too few patients in the randomised, double blind studies. Six reviews with more than 200 patients in randomised, double blind studies had good evidence of no benefit. Systematic reviews of acupuncture have overstated effectiveness by including studies likely to be biased. They provide no robust evidence that acupuncture works for any indication.

1.9. Linde 2001

Linde K, Vickers A, Hondras M, Ter Riet G, Thormahlen J, Berman B, Melchart D. Systematic reviews of complementary therapies - an annotated bibliography. Part 1: Acupuncture. BMC Complement Altern Med. 2001. [141252].

Background	Complementary therapies are widespread but controversial. We aim to provide a comprehensive collection and a summary of systematic reviews of clinical trials in three major complementary therapies (acupuncture, herbal medicine, homeopathy). This article is dealing with acupuncture.
Methods	Potentially relevant reviews were searched through the register of the Cochrane Complementary Medicine Field, the Cochrane Library, Medline, and bibliographies of articles and books. To be included articles had to review prospective clinical trials of acupuncture; had to describe review methods explicitly; had to be published; and had to focus on treatment effects. Information on conditions, interventions, methods, results and conclusions was extracted using a pretested form and summarized descriptively.
Results	From a total of 48 potentially relevant reviews preselected in a screening process 39 met the inclusion criteria. 22 were on various pain syndromes or rheumatic diseases. Other topics addressed by more than one review were addiction, nausea, asthma and tinnitus. Almost unanimously the reviews state that acupuncture trials include too few patients. Often included trials are heterogeneous regarding patients, interventions and outcome measures, are considered to have insufficient quality and contradictory results. Convincing evidence is available only for postoperative nausea, for which acupuncture appears to be of benefit, and smoking cessation, where acupuncture is no more effective than sham acupuncture.
Conclusions	A large number of systematic reviews on acupuncture exists. What is most obvious from these reviews is the need for (the funding of) well-designed, larger clinical trials

2. Overviews of Clinical Practice Guidelines

2.1. Birch 2018

Birch S, Lee MS, Alraek T, Kim TH. Overview of Treatment Guidelines and Clinical Practical Guidelines That Recommend the Use of Acupuncture: A Bibliometric Analysis. Journal of Alternative and Complementary Medicine. 2018;24(8):752-769. [174019].

Introduction	As positive evidence emerges for the use of an intervention to treat a health problem, the intervention gradually becomes incorporated into treatment guidelines (TGs) or clinical practice guidelines (CPGs) that are related to that health problem. To assess whether this general hypothesis can apply to acupuncture, 96 health problems were identified for which positive conclusions in systematic reviews and meta-analyses regarding the effectiveness of acupuncture have been made and then searched for TGs or CPGs that have recommended the use of acupuncture.
Methods	hrough August 31, 2017, searches were performed in relevant medical databases and Google using “treatment guideline,” “clinical practice guideline,” and the names of the 96 medical conditions as search terms. A “snow-balling” search approach was adopted. All positive recommendations were added into the registry.
Results	A total of 1311 publications were found that recommended using acupuncture published between 1991 and 2017. The number per year reached 50 in 2005 and 100 in 2009. In addition, 2189 positive recommendations were found for the use of acupuncture. Of these, 1486 were related to 107 pain indications and 703 were related to 97 nonpain indications. These recommendations were made by a wide range of groups, such as government health institutions, national guideline, and medical specialty groups. The recommendations came from around the world but were especially abundant in North America, Europe, and Australasia.
Discussion and conclusion	Considerably more recommendations were found for the use of acupuncture than are known within the acupuncture or medical communities. A trend by year was also found; a rise in the number of positive statements about acupuncture was typically followed by a rise in the number of recommendations of acupuncture. Thus, the recommendations followed the emergent evidence for acupuncture. Better implementation plans need to be developed for the CPG/TG recommendations about acupuncture to be more effective/efficient.

2.2. Guo 2017

Guo Y, Zhao H, Wang F, Li SN, Sun YX, Han MJ, Liu BY. Recommendations for acupuncture in clinical practice guidelines of the national guideline clearinghouse. Chinese Journal of Integrative Medicine. 2017;23(11):864-870. [166775].

Objective	To organize the clinical practice guidelines (CPGs) related to acupuncture included in the National Guideline Clearinghouse (NGC) to systematically summarize the diseases and disorders most commonly treated with acupuncture, the strength of recommendations for acupuncture and the quality of evidence.
Methods	The NGC database was systematically searched for guidelines that included acupuncture as an intervention. Two independent reviewers studied the summaries and the full texts of the guidelines and included guidelines based on the inclusion and exclusion criteria. Thirty-nine guidelines were collected with 80 recommendations. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used to assess the quality of these guidelines.
Results	Of the 80 recommendations on acupuncture, 49 recommendations were clearly for acupuncture, 25 recommendations were against acupuncture and 6 recommendations did not indicate any clear recommendations, 37 recommendations were for painful diseases/disorders, and 12 recommendations were for non-painful diseases/disorders. Locomotor system disorders were the most common in the painful diseases/disorders category. Out of all the recommendations for acupuncture, most recommendations (87.76%) were weak in strength, and most of the evidence (40.84%) was of low quality.
Conclusions	In the National Guideline Clearinghouse, the recommendations for acupuncture focus on painful diseases/disorders. The recommendations in the guidelines are not high in strength, and most of the evidence is moderate or low in quality.