Acupuncture Research Evidence

When looking at data from acupuncture clinical research trials, evidence summaries and evidence-based guidelines it is important to have some understanding both of acupuncture practice/theory and research methodology.  Unfortunately many of the researchers themselves have not been well versed in both of these aspects.  The acupuncture intervention may have been inadequate or inappropriate; the randomization procedures can be absent or unreliable; the control intervention has often undermined the ability of the research to deliver a credible answer (see below). A good place to start in understanding these, often controversial, issues is the book edited by MacPherson et al (2007) but they have also been discussed repeatedly in many journal articles.

• Nowdays most research information is accessed online – anything from blogs to whole books, but most importantly journal articles – and the best gateway is usually through an electronic database such as Medline http://www.ncbi.nlm.nih.gov/pubmed, that can be systematically searched for publications of interest. General purpose search engines such as Google are inadequate.

For keeping up with current research books take too long to produce and date too quickly. Nevertheless they are useful for:

• Reviewing existing research up to a point about two years before publication date
• Providing comprehensive information on research methods
• Giving more detailed exploration of a subject than is possible within the length of a journal article
• Information on areas scarcely covered by journal articles, which could include substantial descriptions and thinking on acupuncture practice. This may not in itself be research but could certainly inform research

Here is a selection of general research books for acupuncture/Chinese medicine/CAM:

Journal articles make up the bulk of the research literature for acupuncture, as with any other subject. Here is a list of the main journals that have a high frequency of acupuncture articles. Note though that occasional articles appear in a large number of medical journals, as well as others in public health, psychology, social science and science publications. The journals listed are almost entirely English language publications, though important titles in many other European languages are indexed in Western databases. More significant still is the huge output from China, along with Taiwan, Korea, Japan and other East Asian countries. A few of these journals are in English and some others in their own languages are indexed in English language databases (with English abstracts). However, the bulk of this literature is not generally available without expensive subscriptions and knowledge of the language.

Medical databases should usually be the starting point for acupuncture research literature searches. There is a comprehensive list of relevant databases, together with links to them, in this document:

• ‘Complementary medicine resources for health professionals and researchers’, available from this website  www.compmed.umm.edu

This article reviews the characteristics of all accessible CAM databases in 2008/9:

• Boehm K, Raak C, Vollmar HC, Ostermann T. An overview of 45 published database resources for complementary and alternative medicine. Health Information & Libraries Journal 2010; 27(2):93-105.

Databases differ in various important respects:

BAcC Fact Sheets and Research Papers: these are summaries of the research on the effectiveness and mechanisms of acupuncture for a given medical condition

NIHR Centre for Reviews and Dissemination (CRD) www.york.ac.uk/inst/crd: you can freely search their databases of systematic reviews, economic evaluations and health technology assessments

Cochrane Library www.thecochranelibrary.com: you can freely (in the UK and many other countries) search the database of their own (highly regarded) systematic reviews

Complementary and Alternative Medicine Evidence Online (CAMEOL): the database can be viewed on the Research Council for Complementary Medicine website (www.rccm.org.uk) by members. It contains reviews of research evidence for CAM therapies for a few conditions that were identified as NHS priorities, but only up to 2009 (funding was withdrawn then).

University of Maryland Medical School’s Center for Integrative Medicine www.compmed.umm.edu: you can download a copy of their document ‘Complementary medicine resources for health professionals and researchers’, which includes an extensive list of evidence resources for CAM

BMJ Grouphttp://clinicalevidence.bmj.com/ceweb/about/index.jsp: up to date summaries of the clinical evidence for different interventions

Society for Acupuncture Research (SAR) www.acupunctureresearch.org : some useful bits and pieces though much of it is restricted to members only (such as their evidence summaries for a few conditions)

Foundation for Research into Traditional Chinese Medicine www.frtcm.org.uk : a charity that promotes research into TCM, and has been the foremost organization for clinical acupuncture research in the UK. The website provides some information about these studies.

Good Practice in TCM Research Association (GP-TCM) www.gp-tcm.org: promotes research following on from a 3-year EC funded project with European-Chinese collaboration on establishing best practice in TCM

Research Council for Complementary Medicine (RCCM) www.rccm.org.uk: a comprehensive site with much useful information. Membership is not expensive and gives access to more resources

CAMbrella www.cambrella.eu: a European CAM research network. It has reported on CAM use, perspectives of patients and providers, and legal and regulation issues in a series of documents available on the site

Complementary and Alternative medicine Library and Information Service (CAMLIS) www.cam.nhs.uk: this is based at the Royal London Hospital for Integrated Medicine www.uclh.org/OURSERVICES/OURHOSPITALS/RLHIM and contains a large collection of CAM books and journals. Anyone is free to visit, read and photocopy, though only members can also access the electronic resources.

British Library www.bl.uk: can supply copies of almost any article, generally quite quickly, in electronic or paper form. Alternatively it is possible to visit in person and read and copy articles there. Material can be ordered beforehand to ensure it is there when you visit.

Undergraduate acupuncture dissertations

The BAcC maintains a database of dissertations from BAAB approved teaching institutions which is available on its member and student member websites.

Doctoral theses

The British Library operates a service for 300,000+ dissertations from UK universities: EThOS - Electronic theses online service http://ethos.bl.uk/. Once registered, you can search online for free, and order full text copies (presumably not free).

The Index to Theses http://www.theses.com/ covers all theses accepted for higher degrees by universities in Great Britain and Ireland since 1716, almost 600,000. However, it is now a commercial subscription service

In most countries there are no formal, generally-agreed, guidelines to cover the specific details of how to diagnose and treat particular groups of patients. Different styles, schools and individuals have different ideas and there is little evidence to favour one above another. The BAcC have produced Standards of Practice for Acupuncture, which lay down the bases of good practice in general terms. The BAcC Codes of Safe Practice provide more detailed guidance in this area. These are available on the codes page of the BAcC website.

Evidence-based TCM clinical practice guidelines have been developed recently in China for some conditions, though their implementation amongst acupuncture practitioners appears to be poor (Zhou L, Chen Y, Liu J, Liu ZL,  Gao Y.  Evaluating the implementation of evidenced-based TCM clinical practice guidelines for cerebral infarction. European Journal of Integrative Medicine, 6 (2) (2014), pp. 147–155).

This comprises all literature that is not accessible through conventional channels, because it is not published publicly, or only in a very limited way. It could include technical or research reports, progress reports, dissertations, conference papers, committee proceedings, internal memoranda, newsletters and many other types. There is no organized repository for acupuncture grey literature.

Conference proceedings make up a large and valuable resource. They often signpost research in early or pre-publication stages but also research that will never be published. It is less constrained and wider in scope than published data, but also less critically scrutinized and not formally peer reviewed. Some is available in journal supplements (for example the proceedings of the Society for Acupuncture Research conference are published in the Journal of Alternative and Complementary Medicine), some is available on conference websites (e.g. ARRC’s symposia) and some by subscription, but much can be accessed only in person(e.g. proceedings of the scientific meeting at the Rothenburg TCM Kongress http://www.tcm-kongress.de).

Various useful articles may be found in the newsletters of acupuncture professional bodies, e.g. the BAcC’s ‘The Acupuncturist’.

Miscellaneous reports may surface only through personal contacts or trawling through relevant websites.

System for Information on Grey Literature in Europe (SIGLE) www.opengrey.eu: contains 700,000 references accumulated since 1980; unfortunately only 25 of these mention acupuncture (accessed September 2013).

Coad et al (2006) provide a simple guide for nurses on searching the grey literature http://www.nursingtimes.net/searching-for-and-using-grey-literature/201505.article

Given their pre-eminent position in the evidence hierarchy (see ‘Understanding acupuncture clinical research: the evidence base and the problem of placebo acupuncture’) it is important that controlled trials are registered at their outset, so that negative results cannot conveniently be swept under the carpet. Various national and international organizations maintain such registers and their websites can be searched to locate research (in some cases not just restricted to controlled trials) involving particular interventions (such as acupuncture) and/or medical conditions. The information available usually includes status (e.g. recruiting, completed), timetable, principle researcher and a brief description of the aims and approach. Note that not all registers are as up to date, or as easy to search, as they should be. Some of the more important are listed here (others can be found by searching the internet for clinical trials registers).

Research on the safety of acupuncture can largely be found by database searching for the keyword ‘adverse’ or ‘adverse events’. There are several different types of study

• Individual case reports of adverse events
• Systematic reviews of numbers/types of case reports in the literature (Xu et al 2013)
• Prospective surveys of adverse events recorded in normal practice. These may be practitioner reports (MacPherson 2001) or patient reports (MacPherson 2004; Witt 2010). While the former tend to underestimate, the latter may record spurious incidents that are either not adverse or not related to the acupuncture treatment
• Experimental studies; for example, anatomical information about safe needling depths at different points
• Reports of any adverse events seen in trials, especially those comparing acupuncture to other interventions or to no treatment.

Many of the top medical journals are now becoming freely available online in full text: http://www.freemedicaljournals.com/. They may, individually, have acupuncture articles only once in a blue moon but taken altogether this will provide a substantial resource

Bandolier http://www.medicine.ox.ac.uk/bandolier/: articles on healthcare evidence, including a few on acupuncture. Little published since 2007, though the back issues are all freely available

CAM-Cancer www.cam-cancer.org: evidence-based articles synthesizing the best available research on CAM interventions.

Evidence-based medicine toolkit http://www.ebm.med.ualberta.ca/ebm.html: from the University of Alberta; provides links to various useful sites for identifying, assessing and applying evidence