Fall Newsletter - October 2011

Ernst et al. claimed “acupuncture is neither a safe procedure nor superior to placebo.”
One of the last review articles on acupuncture research from Professor Edzard Ernst, prior to the announcement of his retirement, was met with broad dissatisfaction from the acupuncture research community, with concerns raised that he had presented a biased picture of the state of the science.  A summary of the published letters rebutting Professor Ernst’s conclusions is presented below.  We urge acupuncture researchers and practitioners to read Professor Ernst’s article in Pain (as well as the full complement of letters to the editor published in a subsequent issue of the journal (Witt et al.; Manheimer and Berman; Karst;  Baumler; Usichenko; Henke 2011). For the sake of brevity, we summarize the letters to the editors.

A letter by Witt and colleagues found the article “highly misleading” and criticized the authors’ choice of evidence from different levels within the evidence hierarchy for different parts of the paper. In particular, the writers of the letter criticize the use of case studies to determine the safety of acupuncture and cite several larger-scale studies that had different results.

A letter by Manheimer and colleagues criticized Ernst et al.’s methods of data analysis and evaluation as neither systematic, reproducible, nor transparent and found Ernst et al.’s evaluation criteria for assessing the quality and results of systematic reviews to be poorly defined. The writers of the letter also suggest that Ernst et al. succumbed to presentation bias, presenting data in the Discussion section which were not included in the review.

A letter by Matthias Karst notes that the paper misinterprets one of the cited cases, and suggests that the paper’s other conclusions should be suspect, and also warns of a possible “efficacy paradox” which can lead to false positives when testing complex interventions by means of randomized controlled trials.
A letter by Baumler and colleagues pointed out several inconsistencies and accuses the authors of failing to incorporate basic scientific methodology. Specifically, the writers of the letter find the paper’s aim vague, study eligibility criteria absent, and (like Witt et al.) the choice of case reports in the assessment of acupuncture risk questionable. Like Manheimer et al., the letter-writers found Ernst et al.’s methods of determining the quality and outcome of each review unclear. The letter-writers determine that the paper is “not … based on a careful and scientific analysis of the literature.”

A letter by Usichenko and colleagues, like Witt et al. and Baumler et al., criticized the authors’ use of case studies to determine the adverse effects of acupuncture.
A letter by Christian Henke points out the relatively high instance of drug-related adverse events compared to acupuncture-related adverse events and criticizes Ernst et al.’s choice to include the conclusions of various acupuncture experiments in their discussion, despite the fact that conclusions of papers do not reflect statistical outcomes. The letter-writers also note that some important studies were overlooked.

Finally, a letter by James Mooney criticizes the authors’ addressing of the broad spectrum of acupuncture as little more than a single treatment. The letter-writers note that if only the highest-quality reviews are examined, the results are no longer condemning of acupuncture. Mooney also dismisses the authors’ conclusion that acupuncture should be questioned since it reduces pain in “some conditions while failing to work in many others,” noting that the same can be said about acetaminophen.

The authors’ response ran in the same issue of PAIN: Ernst E. Response from Author. Letters to the Editor / PAIN 152 (2011) 2184–2186. As of Oct 13, it is noted this is withdrawn at authors’ request. 
Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011 Apr;152(4):755-64.

Karst M. Comment on ''Acupuncture: does it alleviate pain and are there serious risks? A review of reviews" Ernst et al. [Pain 2011;152:755-764]. Pain. 2011 Sep;152(9):2181
Bäumler P, Irnich D. Pain. 2011 Sep;152(9):2181-2
Henke C. Pain. 2011 Sep;152(9):2183-4.
Manheimer E, Berman BM. Pain. 2011 Sep;152(9):2179-80

Sufferers of medically unexplained physical symptoms report improved health status with acupuncture
In a pragmatic randomized trial, study participants with medically unexplained physical symptoms (MUPS) seeking frequent consultations with their medical provider appear to benefit from acupuncture. Adding at least twelve Five-Element acupuncture sessions to usual care improved their self-reported health status and wellbeing measures. 

Patterson et al randomized 80 participants with MUPS into two groups. The treatment group received weekly acupuncture immediately and the control group was wait-listed to start acupuncture in six months. Acupuncture was individualized in the Five Element style and privately administered. The participants in this trial were predominately female (N= 64, 80%), white (N=57, 71%) and the median age was 51 years old. The primary problems reported were predominantly musculoskeletal (N=47, 60%), followed by psychological/emotional (N=10, 12.5%) and headache and neurological issues (N=10, 12.5%). At the end of the study, 48 participants were included in the final analysis. The Measure Yourself Medical Outcome Profile (MYMOP) was the primary outcome measure at 26 weeks. There was an 89% response rate for the 26-week questionnaire.

Between the acupuncture and control group, there was a -0.6 adjusted MYMOP mean difference (95% CI -1.1. to 0, p=0.05) of the mean 26-week MYMOP when compared to baseline, favoring acupuncture. This improvement was sustained for twelve months but there was no change in the consultation rate.

Patterson C, Taylor RS, Griffiths P, Britten N, et al. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms: a randomized controlled trial (CACTUS study). Br J Gen Pract 2011; DOI:10.3399/bjgp11X57s689.

2011 Contextualizing DongUiBoGam in Traditional Eastern Medicine

The 2011 DongUiBoGam International Symposium, "Contexualizing DongUiBoGam in Traditional Eastern Medicine" was held on Sep 25, 2011 at Coex, Seoul, which was sponsored by the Ministry of Health and Welfare and co-hosted by the Korean Institute of Oriental Medicine and the Korean Society of The Medical History.

This international symposium was to shed light on, and to promote worldwide academic exchange of DongUiBoGam, the first ever medical book to be selected as the UNESCO's World Documentary Heritage in the field of medicine in 2009. The symposium will also offer a variety of lectures from traditional medicines around the world,  such as Ayurveda and Tibetan Medicine and is expected to contribute greatly on expanding international exchanges in the field of traditional eastern medicine. More detail on DongUIBoGam can be seen at http://unesdoc.unesco.org/images/0018/001897/189770e.pdf.

Chinese herbal medicine for anovulatory infertile women

In this meta-analysis, the authors identified 1,009 randomized controlled trials that employed Chinese herbal medicine (CHM) with clomiphene citrate (CC) to treat anovulatory infertile women. Fourteen trials that compared CC and CHM combination treatment to CC alone in 1316 patients met their inclusion criteria, despite poor methodology and small sample sizes. [read more] When compared to CC alone, CC and CHM improved basal body temperature charts (n=315, RR=1.14; 95% CI 1.00-1.29), improved endometrial lining (n= 138, RR=1.78; 95% CI 1.22-2.60), and improved pregnancy rates (n=1202, RR=1.50; 95% CI 1.23-1.84).

See CJ, McCullough M, Smikle C, Gao J. Chinese herbal medicine and clomiphene citrate for anovulation: a meta-analysis of randomized controlled trials. J Alt Complement Med 2011; 17(5):397-405.

Acupuncture and acupressure may be an effective treatment to manage primary dysmenorrhea

Despite the limited number of studies, a recent Cochrane meta-analysis reported acupuncture and acupressure may be an effective treatment to manage primary dysmenorrhea. Ten trials (n=944) were included in this meta-analysis; of which six (n=673) were acupuncture trials and four (n=271) were acupressure trials. Of the acupuncture trials, acupuncture significantly improved pain when compared to a placebo control (OR=9.5, 95% CI 21.17 – 51.8), as well as NSAIDs (SMD -0.70, 95% CI CI -1.08 to -0.32) and Chinese herbs (SMD -1.34, 95% CI -1.74 to -0.95). [read more] Acupressure also provided pain relief when compared to a placebo (SMD -0.99, 95% CI -1.48 - -0.49). Acupuncture also strongly reduced menstrual symptoms when compared with medication in one trial (OR 3.25, 95% CI 1.53 – 6.86) and when compared to Chinese herbs in another trial (OR 7.0, 95% CI 2.22 – 22.06). Acupressure also reduced menstrual symptoms when compared with a placebo control (SMD -0.58, 95% CI, -1.06 to -0.10).

Smith CA, Zhu X, He L, Song J. Acupuncture for primary dysmenorrhoea. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD007854. DOI: 10.1002/14651858.CD007854.pub2

The Patient-Centered Outcomes Research Institute (PCORI) Announces a New Pilot Projects Grant Program

Patient-Centered Outcomes Research Institute (PCORI) recently announced the Pilot Projects Grant Program, the organization's first major funding opportunity.  PCORI is an independent organization created to help people make informed health care decisions and improve health care delivery, and commissions research that is guided by patients, caregivers and the broader health care community and will produce high integrity, evidence-based information.   The purpose of the Pilot Projects Grant Program is to inform PCORI's ongoing development and enhancement of national priorities for patient-centered outcomes research (PCOR), support the collection of preliminary data that can provide a platform for an evolving research agenda, and support the identification of research methodology to advance PCOR.  All application materials can be downloaded from the "Funding Opportunities" section of PCORI's website www.pcori.org <http://researchlist.partners.org/t/28617/19061/9035/11/>

Job Opportunity Announcement
Clinical Research Assistant (UNC-CH) -- Asian Medicine and Acupuncture Research, Dept. of Physical Medicine and Rehabilitation, University of Chapel Hill NC (UNC-CH), School of Medicine seeks a part time Research Assistant. This is an opportunity to work with clinical researchers in developing and carrying out clinical studies including observational studies and clinical trials to evaluate various treatment modalities.

Duties include: Literature search and acquisition, writing up reports, assisting researchers to write up study protocols and grant proposals, manuscripts for publication. In addition, multi-tasking nature of academic assistance will be included.

Qualifications: Master in a health related sciences discipline, or its equivalents; experiences with health and medical research; reasonable knowledge of statistics, and epidemiology; participation in publications related to health research.

Duration: At .5 FTE (possibility of renewal contingent upon fund availability).

Salary: Commensurate with qualifications and experience.

Application Deadline: November 1, 2011

Anticipated start date: January 2, 2012.

To apply:  Email CV and statement of your motivation to apply for the job to Hiring Committee, Asian Medicine & Acupuncture Research, Department of Physical Medicine and Rehabilitation, UNC School of Medicine, Campus Box 7200, Chapel Hill, NC 27599-7200; Fax: 919 843 0164; Email: acupuncture@med.unc.edu

** UNC hires on the basis of merit and is committed to employment equity. We encourage all qualified persons to apply.

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