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Effectiveness bulletin
Acupuncture
Free
  1. A Vickers1,
  2. P Wilson2,
  3. J Kleijnen2
  1. 1Memorial Sloan-Kettering Cancer Center, New York, USA
  2. 2NHS Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK
  1. Correspondence to:
 Dr P Wilson, NHS Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK;
 pmw7{at}york.ac.uk

Abstract

The research evidence on the effectiveness of acupuncture for the treatment of pain presented in a recent issue of Effective Health Care is reviewed.

  • effectiveness bulletin
  • acupuncture
  • pain

https://doi.org/10.1136/qhc.11.1.92

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    This paper summarises the research evidence presented in a recent issue of Effective Health Care on the effectiveness of acupuncture.1

    BACKGROUND

    In the UK, acupuncture is widely used in both private and NHS practice. In surveys of the use of complementary medicine, acupuncture is consistently cited among the most commonly used.2 Approximately 7% of the adult population in England have received acupuncture.3 Most acupuncture sessions are provided by specialist practitioners without other medical qualifications, of whom there are over 2200 in the UK.4 In addition, the British Medical Acupuncture Society has among its members over 2000 doctors who use acupuncture in hospital or general practice,5 and there are over 1200 physiotherapists who are members of the Acupuncture Association of Chartered Physiotherapists.6 In 1995, the last year for which there are data, approximately 10% of GPs in England either referred patients for acupuncture or administered it themselves.7 A more recent survey estimated that, in 1998, the NHS provided one million acupuncture treatments in England. The current estimated total cost to the NHS of nearly £26 million is equivalent to all other complementary therapies combined.3 In the private sector it is estimated that patients receive around two million acupuncture treatments a year.8

    WHAT IS ACUPUNCTURE?

    Acupuncture involves the stimulation of specific points on the skin, usually by the insertion of needles. In its original form acupuncture was based on the principles of traditional Chinese medicine. Traditional acupuncturists understand health in terms of a vital force or energy called “Qi” (pronounced “chee”) which circulates between the organs along channels called meridians. Qi energy must flow in the correct strength and quality through each of these meridians and organs for health to be maintained. The acupuncture points are located along the meridians and provide one means of altering the flow of Qi. Traditional acupuncturists use an Oriental medicine framework for referring to disturbances thought to cause symptoms, such as “kidney yang vacuity, water overflowing” or “damp heat in the bladder”.

    Many conventional healthcare professionals who practise acupuncture have dispensed with such concepts. Acupuncture points are thought to correspond to physiological and anatomical features such as peripheral nerve junctions, and diagnosis is made in purely conventional terms. One concept thought important by some practitioners is that of “trigger points” which they believe often correspond to acupuncture points.9 This is an area of increased sensitivity within a muscle which is said to cause a characteristic pattern of referred pain in a related segment of the body. An example might be tender areas in the muscles of the neck and shoulder that relate to various patterns of headache.9

    It is often implied that a clear distinction exists between traditional and western acupuncture, but the two approaches overlap considerably.10 Moreover, traditional acupuncture is not a single historically stable therapy11 and there is considerable variation between different “schools” of acupuncture practice.10 Two acupuncturists treating the same patient may vary in the particular points chosen, the depth and duration of needling, the method and intensity of needle stimulation, and the use of adjunctive techniques such as massage or herbal medicines.

    NATURE OF THE CLINICAL EVIDENCE

    Most of the conditions that acupuncturists treat are either self-limiting (such as low back pain and morning sickness) or have a relapsing and remitting course (such as migraine and asthma) and, almost without exception, the presenting complaint is a subjective symptom such as pain, fatigue, or breathlessness. Accordingly, it is hard to justify types of evidence other than randomised controlled trials (RCTs) in the evaluation of the effectiveness of acupuncture.

    This paper is based predominantly on a review of systematic reviews conducted by the Complementary and Alternative Medicine Field of the Cochrane Collaboration.12 Individual RCTs published subsequent to the reviews are also included.

    EFFECTIVENESS

    Acute pain

    Pain after dental surgery provides a good model of acupuncture analgesia due to its limited and predictable course. In a typical RCT, patients undergoing third molar extraction were randomised to receive acupuncture or placebo on a double blind basis. The mean duration of the pain-free interval following surgery was 181 minutes in acupuncture patients and 71 minutes in controls, a statistically significant difference.13 A systematic review of 16 such studies concluded that acupuncture was probably effective for pain after dental surgery and that future research should concentrate on defining “the optimal acupuncture technique”.14 While this research does seem to demonstrate an effect of acupuncture not attributable to placebo, its clinical importance is not fully clear. Two additional RCTs found similar results.15, 16

    Studies investigating acupuncture for other forms of postoperative pain used widely diverse treatment techniques, studied small samples of patients, and have had inconsistent findings.17–25

    Chronic pain

    Several systematic reviews have evaluated the effectiveness of acupuncture for the treatment of chronic pain (table 1).26–44 Some systematic reviews have examined particular diagnoses, such as headache or back pain, whereas others have included studies across a range of chronic pain conditions. Although reviews vary in their conclusions, acupuncture was found to be superior to no treatment or waiting list control in most studies. RCTs comparing acupuncture to a sham technique were more evenly balanced between those that did and those that did not find statistically significant differences between groups. Meta-analysis was not generally attempted. Quality was related to study outcome with lower quality studies being more likely to favour acupuncture.

    View this table:
    Table 1

    Systematic reviews of clinical RCTs of acupuncture for chronic pain

    A number of additional RCTs have been published subsequently and have yet to be reviewed systematically.45–69 These RCTs are of variable quality and also provide conflicting evidence for the effectiveness of acupuncture across a range of chronic pain conditions. Tables providing more detail on each of these trials are available via the Centres for Reviews and Dissemination (CRD) website (www.york.ac.uk/inst/crd/ehcb.htm).

    Advocates of acupuncture have pointed to the findings of several high quality studies that have shown statistically and clinically significant differences between acupuncture and sham.53, 70, 71 However, each of these findings should not be viewed in isolation from the more extensive body of evidence on chronic pain.

    Addiction

    Acupuncture is widely promoted as an aid to smoking cessation. A systematic review of 21 trials suggested that, at best, acupuncture may have a small benefit over a sham acupuncture procedure for short term abstinence rates.72 Acupuncture is not more effective than placebo techniques for long term abstinence.72 Quit rates for acupuncture appear slightly lower than those for nicotine replacement.73

    Acupuncture has been used to treat cocaine addiction in several hundred drug treatment programmes in the United States.74 Several RCTs have been conducted75–79 but these have not been subjected to systematic review. Acupuncture is favoured in some analyses, but some RCTs were complicated by multiple statistical comparisons: this increases the likelihood of a false positive result. The most rigorous RCT reported that patients assigned to acupuncture were significantly more likely to provide cocaine negative urine samples, the prespecified primary outcome measure, than those in both the control and sham acupuncture groups.79

    No systematic reviews evaluating the use of acupuncture to treat alcoholism or opiate addiction were identified. The number, size, quality, and strength of findings of RCTs studying acupuncture for alcoholism and opiate addiction is insufficient to guide clinical decisions.80–86

    Asthma

    Systematic reviews of acupuncture for asthma have concluded that there is little evidence on which to base clinical decisions.87, 88 A number of the included RCTs have examined acupuncture for asthma and chronic obstructive pulmonary disease. The RCTs are heterogenous with respect to patients, acupuncture techniques, outcome measures, and controls. They have also been small with a median sample size of 25; the largest RCT accrued only 39 patients. Some RCTs have used models of induced asthma to allow good experimental control.89, 90 While appearing to show a physiological benefit of acupuncture on lung function, these studies have not been replicated and provide limited insight into the clinical usefulness of acupuncture for asthma. Two small RCTs have recently been published which also provide limited insight into the clinical effectiveness of acupuncture for asthma.91, 92

    Nausea and vomiting

    Two systematic reviews have examined acupuncture for nausea and vomiting.93, 94 The first included RCTs on nausea related to surgery, pregnancy, and chemotherapy.93 Although acupuncture was not an effective technique when administered under anaesthetic, it was superior to a sham technique in 11 of the 12 studies rated as high quality. The reviewed RCTs showed consistent results across different investigators, different groups of patients, and different forms of acupuncture point stimulation. Allocation concealment was not included in the quality assessment and two studies with unconcealed allocation were included in the principal analysis. The second review, which concentrated on postoperative emesis, improved on the original review by excluding studies with unconcealed allocation and reported a meta-analysis.94 Data from 19 studies including 1679 patients were analysed. Acupuncture reduced both nausea (relative risk compared with placebo control 0.4; 95% CI 0.2 to 0.7; five RCTs) and vomiting (relative risk compared with placebo control 0.5; 95% CI 0.35 to 0.65; eight RCTs) in adults in the immediate postoperative period. These findings were reasonably robust to sensitivity analyses of study size and quality. Of four additional RCTs on postoperative emesis, two reported less nausea and vomiting95, 96 and two reported no differences between acupuncture, acupressure, and sham treatment.97, 98

    In the case of nausea related to chemotherapy, one of the findings of the early review was that the data were weaker for this indication than for postoperative vomiting.93 A subsequent high quality RCT (n=104) which included concealed allocation, sham control, and careful blinding found clinically and statistically significant differences in vomiting between acupuncture and control.99 An additional small trial of 17 women undergoing chemotherapy for breast cancer found significantly less nausea in the group receiving acupressure.100

    In pregnancy related nausea the early review indicated that acupuncture might have a prophylactic effect but there were no data on acupuncture for the treatment of severe vomiting.93 More recently a randomised, blinded, crossover trial of 33 pregnant women with hyperemesis reported large clinical improvements from acupuncture and statistically significant differences between acupuncture and sham.101 One other RCT (n=55) found no effect of acupuncture on pregnancy related nausea.102

    A small number of paediatric studies reported in the later review did not find differences between acupuncture and control.94 Two subsequent double blind, sham controlled RCTs used acupuncture points specially chosen for the paediatric population.103, 104 The two RCTs included a combined total of 115 children and had similar results; rates of vomiting in the first 24 hours after surgery were approximately 20% in the acupuncture treated patients compared with about 60% in controls. Three additional RCTs (including a combined total of 224 children) involved stimulation of the acupuncture point P6. Two of the three trials found no effect for acupuncture on postoperative vomiting.105, 106 The third trial found significantly less vomiting in the children receiving laser acupuncture.107

    Obesity

    A systematic review of four RCTs of acupuncture for weight loss concluded that there was no clear evidence for its effectiveness.108 Two RCTs have been published subsequently: one reported that active acupuncture suppressed appetite and led to greater weight loss than a placebo device109; the second reported no effect on weight loss.110

    Stroke rehabilitation

    One poorly reported systematic review of acupuncture for stroke rehabilitation has been conducted.111 Four RCTs have been published subsequent to the review.112–115 Of these, the two more recent studies both with good methodology failed to find effectiveness of acupuncture.114, 115 There is currently insufficient evidence of good quality for the use of acupuncture in stroke rehabilitation.

    Tinnitus

    Two systematic reviews have included RCTs of acupuncture for tinnitus.116, 117 With one possible exception of an RCT that found a significant but short term benefit,118 results have been broadly negative. Although it is possible that the RCTs have been underpowered and/or the acupuncture administered inadequately, current evidence suggests that the effectiveness of acupuncture in tinnitus is doubtful.

    Other conditions

    RCTs of acupuncture and related techniques have been conducted in a wide variety of other conditions including depression,119 urinary incontinence,120 induction of uterine contractions,121 breech presentation,122 hot flushes,123 xerostomia,124 irritable bowel syndrome,125 hyperactivity,126 male subfertility,127 urinary tract infection,128 and hay fever.129 Although generally tending to support the effectiveness of acupuncture or the related technique for the condition concerned, such RCTs have rarely been reproduced and therefore do not constitute a sufficient basis for clinical recommendations.

    SAFETY OF ACUPUNCTURE

    Serious adverse effects including pneumothorax, spinal lesions, and hepatitis B transmission have been reported in the literature, but these are rare and are generally associated with poorly trained unlicensed acupuncturists.130. A systematic review of prospective studies of acupuncture safety found only two cases of pneumothorax and two cases of broken needles in a quarter of a million treatments.131 A prospective survey of Japanese acupuncture practitioners recorded only 94 minor adverse events, the most common being forgotten needles and faintness, but no serious adverse events across 65 000 treatments.132 A study of Swedish physiotherapists practising acupuncture prospectively recorded side effects during more than 9000 episodes of care. Although minor bleeding or haematoma were reported following nearly one in five treatments, other minor adverse effects such as fatigue or sweating were rare. There were no serious complications.133 More recently, a UK study involving 574 acupuncturists has reported adverse events and treatment reactions associated with 34 407 treatments. No serious adverse events were reported although there were 43 minor adverse events, about a quarter of which were for severe nausea and fainting.8 In addition, a recent prospective UK survey of 31 822 consultations with 78 doctors and physiotherapists who performed acupuncture reported a rate of 14 minor but significant adverse events (such as headache or fainting) per 10 000 acupuncture consultations.134

    IMPLICATIONS

    Acupuncture appears to be effective for postoperative nausea and vomiting, chemotherapy related nausea and vomiting, and for postoperative dental pain. Current evidence suggests that acupuncture is unlikely to be of benefit for obesity, smoking cessation, and tinnitus. For most other areas the available evidence is clearly insufficient to guide clinical decisions. The most problematic area is chronic pain, where there is a large body of data open to conflicting interpretations.

    Where evidence is not compelling and is open to differing interpretations, it can be instructive to link levels of evidence to practical decisions. For example, stronger levels of evidence are needed for interventions that involve considerable cost or risk of harm than for less expensive and safer treatments. Similarly, it could be argued that more evidence is required to recommend an intervention as a regular first line treatment than as adjunctive treatment for refractory patients.

    Acupuncture is most often used in the NHS as a second or third line treatment for chronic pain. A typical patient has arthritis, back pain, or headache and is not responding to conventional management, is not tolerating medication, or is experiencing recurrent pain. Current levels of evidence from RCTs of acupuncture for chronic pain are probably sufficient to justify this practice. However, there is insufficient evidence to warrant first line treatment of chronic pain; similarly, there is enough evidence to suggest that attempts to curtail acupuncture would be unjustified.

    The evidence cited in this bulletin provides an overview of the methodological limitations of previous research conducted in this area. Any future research evaluating acupuncture should be carried out with appropriate methodology in order to improve the quality of the existing evidence base.

    REFERENCES

    1. ↵
      NHS Centre for Reviews and Dissemination. Acupuncture. Effective Health Care2001;7:1–12.
      OpenUrl
    2. ↵
      Zollman C, Vickers A. ABC of complementary medicine. Users and practitioners of complementary medicine. BMJ1999;319:836–8.
      OpenUrlFREE Full Text
    3. ↵
      Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complementary Therapies in Medicine2001;9:2–11.
      OpenUrlCrossRefPubMedWeb of Science
    4. ↵
      British Acupuncture Council. www.acupuncture.org.uk (accessed 19 June 2001).
    5. ↵
      British Medical Acupuncture Society. www.medical-acupuncture.co.uk (accessed 19 June 2001).
    6. ↵
      Acupuncture Association of Chartered Physiotherapists. www.aacp.uk.com (accessed 19 June 2001).
    7. ↵
      Thomas K, Fall M, Parry G, et al. National survey of access to complementary health care via general practice. Sheffield: Medical Care Research Unit, SCHARR, 1995.
    8. ↵
      MacPherson H, Thomas K, Walters S, et al. The York acupuncture safety study: a prospective survey of 34,000 treatments by traditional acupuncturists. BMJ2001;323:486–7.
      OpenUrlFREE Full Text
    9. ↵
      Baldry PE. Acupuncture, trigger points and musculoskeletal pain. London: Churchill Livingstone, 1993.
    10. ↵
      Birch S. Diversity and acupuncture. In: Vickers AJ, ed. Examining complementary medicine. Cheltenham: Stanley Thornes, 1998.
    11. ↵
      Ergil KV. China's traditional medicine. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. London: Churchill Livingstone, 1996.
    12. ↵
      Linde K, Vickers A, Hondras M, et al. Systematic reviews of complementary therapies - an annotated bibliography. Part 1: Acupuncture. BMC Complementary and Alternative Medicine2001;1(3).
    13. ↵
      Lao L, Bergman S, Langenberg P, et al. Efficacy of Chinese acupuncture on postoperative oral surgery pain. Oral Surg Oral Med Oral Path Oral Radiol Endod1995;79:423–8.
    14. ↵
      Ernst E, Pittler MH. The effectiveness of acupuncture in treating acute dental pain: a systematic review. Br Dent J1998;184:443–7.
      OpenUrlCrossRefPubMedWeb of Science
    15. ↵
      Lao L, Bergman S, Hamilton G, et al. Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial. Arch Otolaryngol Head Neck Surg1999;125:567–72.
    16. ↵
      Kitade T, Ohyabu H. Analgesic effects of acupuncture on pain after mandibular wisdom tooth extraction. Acupunct Electrother Res2000;25:109–15.
      OpenUrlPubMed
    17. ↵
      Ceccherelli F, Ambrosio F, Adami MG, et al. Failure of high frequency auricular electrical stimulation to relieve postoperative pain after cholecystectomy. Results not improved by administration of aprotinin. Dtsch Z Akupunktur1985;28:87–92.
    18. Chen L, Tang J, White PF, et al. The effect of location of transcutaneous electrical nerve stimulation on postoperative opioid analgesic requirement: acupoint versus nonacupoint stimulation. Anaesth Analg1998;87:1129–34.
      OpenUrlPubMedWeb of Science
    19. Christensen PA, Noreng M, Andersen PE, et al. Electroacupuncture and postoperative pain. Br J Anaesth1989;62:258–62.
      OpenUrlAbstract/FREE Full Text
    20. Christensen PA, Rotne M, Vedelsdal R, et al. Electroacupuncture in anaesthesia for hysterectomy. Br J Anaesth1993;71:835–8.
      OpenUrlAbstract/FREE Full Text
    21. Felhendler D, Lisander B. Pressure on acupoints decreases postoperative pain. Clin J Pain1996;12:326–9.
      OpenUrlCrossRefPubMedWeb of Science
    22. Wang B, Tang J, White PF, et al. Effect of the intensity of transcutaneous acupoint electrical stimulation on the postoperative analgesic requirement. Anaesth Analg1997;85:406–13.
      OpenUrlCrossRefPubMedWeb of Science
    23. Wigram JR, Lewith GT, Machin D, et al. Electroacupuncture for postoperative pain. Physiother Pract1986;2:83–8.
    24. Facco E, Manani G, Angel A, et al. Comparison study between acupuncture and pentazocine analgesic and respiratory post-operative effects. Am J Chin Med1981;9:225–35.
    25. ↵
      Martelete M, Fiori AM. Comparative study of the analgesic effect of transcutaneous nerve stimulation (TNS); electroacupuncture (EA) and meperidine in the treatment of postoperative pain. Acupunct Electrother Res1985;10:183–93.
      OpenUrlPubMed
    26. ↵
      Ezzo J, Berman B, Hadhazy V, et al. Is acupuncture effective for the treatment of chronic pain? A systematic review. Pain2000;86:217–25.
      OpenUrlCrossRefPubMedWeb of Science
    27. ↵
      Patel M, Gutzwiller F, Paccaud F, et al. A meta-analysis of a acupuncture for chronic pain. Int J Epidemiol1989;18:900–6.
      OpenUrlAbstract/FREE Full Text
    28. ↵
      ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol1990;43:1191–9.
      OpenUrlCrossRefPubMedWeb of Science
    29. ↵
      van Tulder M, Cherkin D, Berman B, et al Acupuncture for low back pain (Cochrane Review). In: The Cochrane Library. Issue 2. Oxford: Update Software, 2001.
    30. ↵
      Smith LA, Oldman AD, McQuay HJ, et al. Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. Pain2000;86:119–31.
      OpenUrlCrossRefPubMedWeb of Science
    31. ↵
      White AR, Ernst E. A systematic review of randomized controlled trials of acupuncture for neck pain. Rheumatology1999;38:43–7.
      OpenUrlFREE Full Text
    32. ↵
      van Tulder MW, Cherkin DC, Berman B, et al. The effectiveness of acupuncture in the management of acute and chronic low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine1999;24:1113–23.
      OpenUrlCrossRefPubMedWeb of Science
    33. ↵
      Ernst E, White AR. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch Intern Med1998;158:2235–41.
      OpenUrlCrossRefPubMedWeb of Science
    34. ↵
      Longworth W, McCarthy PW. A review of research on acupuncture for the treatment of lumbar disk protusions and associated neurological symptomatology. J Altern Complement Med1997;3:55–76.
      OpenUrlPubMed
    35. ↵
      ter Riet G, Kleijnen J, Knipschild P. Acupunctuur en nekpijn/rugpijn. Huisarts Wet1989;32:223–7.
    36. ↵
      Linde K, Melchart D, Fischer P, et al. Acupuncture for idiopathic headache (Cochrane Review). In: The Cochrane Library. Issue 2. Oxford: Update Software, 2001.
    37. ↵
      Melchart D, Linde K, Fischer P, et al. Acupuncture for recurrent headackes: a systematic review of randomized controlled trials. Cephalalgia1999;19:779–86.
      OpenUrlAbstract/FREE Full Text
    38. ↵
      ter Riet G, Kleijnen J, Knipschild P. [Acupuncture and facial pain.] Huisarts Wet1989;32:264–6.
      OpenUrl
    39. ↵
      ter Riet G, Kleijnen J, Knipschild P. Acupunctuur bij migraine en spanningshoofdpijn. Huisarts Wet1989;32:258–63.
      OpenUrl
    40. ↵
      Ezzo J, Hadhazy V, Birch S, et al. Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis Rheum2001;44:819–25.
      OpenUrlCrossRefPubMedWeb of Science
    41. ↵
      Berman B, Ezzo J, Hadhazy V, et al. Is acupuncture effective in the treatment of fibromyalgia? J Fam Pract1999;48:213–8.
      OpenUrlPubMedWeb of Science
    42. ↵
      Ernst E. Acupuncture as a symptomatic treatment of osteoarthritis. A systematic review. Scand J Rheumatol1997;26:444–7.
      OpenUrlPubMedWeb of Science
    43. ↵
      Lautenschlager J. Acupuncture in treatment of inflammatory rheumatic diseases. Zeitschr Rhemuatol1997;56:8–20.
    44. ↵
      ter Riet G, Kleijnen J, Knipschild P. Acupunctuur en reumatoide artritis. Huisarts Wet1989;326:228–9.
      OpenUrl
    45. ↵
      Cherkin D, Eisenberg D, Sherman K, et al. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Arch Intern Med2001;161:1081–8.
      OpenUrlCrossRefPubMedWeb of Science
    46. Franke A, Gebauer S, Franke K, et al. Acupuncture massage vs Swedish massage and individual exercise vs group exercise in low back pain sufferers: a randomized controlled clinical trial in a 2 × 2 factorial design. Forsch Komplementarmed Klass Naturheilkd 2000;7:286–93.
      OpenUrlCrossRefPubMed
    47. White A, Resch K, Chan J, et al. Acupuncture for episodic tension-type headache: a multicentre randomized controlled trial. Cephalalgia2000;20:632–7.
      OpenUrlCrossRefPubMedWeb of Science
    48. Karst M, Rollnik J, Fink M, et al. Pressure pain threshold and needle acupuncture in chronic tension-type headache: a double-blind placebo-controlled study. Pain2000;88:199–203.
      OpenUrlCrossRefPubMedWeb of Science
    49. Liguori A, Petti F, Bangrazi A, et al. Comparison of pharmacological treatment versus acupuncture treatment for migraine without aura: analysis of socio-medical parameters. J Tradit Chin Med2000;20:231–40.
      OpenUrlPubMed
    50. Heikkila H, Johansson M, Wenngren B. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Man Ther2000;5:151–7.
      OpenUrlCrossRefPubMedWeb of Science
    51. Wedenberg K, Moen B, Norling A. A prospective randomized study comparing acupuncture with physiotherapy for low-back and pelvic pain in pregnancy. Acta Obstet Gynecol Scand2000;79:331–5.
      OpenUrlCrossRefPubMedWeb of Science
    52. Jensen R, Gothesen O, Liseth K, et al. Acupuncture treatment of patellofemoral pain syndrome. J Altern Complement Med1999;5:521–7.
      OpenUrlPubMedWeb of Science
    53. ↵
      Kleinhenz J, Streitberger K, Windeler J, et al. Randomised clinical trial comparing the effects of acupuncture and a newly designed placebo needle in rotator cuff tendinitis. Pain1999;83:235–41.
      OpenUrlCrossRefPubMedWeb of Science
    54. David J, Townsend S, Sathanathan R, et al. The effect of acupuncture on patients with rheumatoid arthritis: a randomized, placebo-controlled cross-over study. Rheumatology (Oxford)1999;38:864–9.
      OpenUrlAbstract/FREE Full Text
    55. Gao S, Zhao D, Xie Y. A comparative study on the treatment of migraine headache with combined distant and local acupuncture points versus conventional drug therapy. Am J Acupunct1999;27:27–30.
      OpenUrlPubMed
    56. Giles L, Muller R. Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. J Manipulative Physiol Ther1999;22:376–81.
      OpenUrlCrossRefPubMedWeb of Science
    57. Korpan M, Dezu Y, Schneider B, et al. Acupuncture in the treatment of posttraumatic pain syndrome. Acta Orthop Belg1999;65:197–201.
      OpenUrlPubMed
    58. Grant D, Bishop-Miller J, Winchester D, et al. A randomized comparative trial of acupuncture versus transcutaneous electrical nerve stimulation for chronic back pain in the elderly. Pain1999;82:9–13.
      OpenUrlCrossRefPubMedWeb of Science
    59. Berman B, Singh B, Lao L, et al. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology (Oxford)1999;38:346–54.
      OpenUrlAbstract/FREE Full Text
    60. David J, Modi S, Aluko A, et al. Chronic neck pain: a comparison of acupuncture treatment and physiotherapy. Br J Rheumatol1998;37:1118–22.
      OpenUrlAbstract/FREE Full Text
    61. Birch S, Jamison R. Controlled trial of Japanese acupuncture for chronic myofascial neck pain: assessment of specific and nonspecific effects of treatment. Clin J Pain1998;14:248–55.
      OpenUrlCrossRefPubMedWeb of Science
    62. McMillan A, Nolan A, Kelly P. The efficacy of dry needling and procaine in the treatment of myofascial pain in the jaw muscles. J Orofac Pain1997;11:307–14.
      OpenUrlPubMed
    63. Dyrehag L, Widerstrom-Noga E, Carlsson S, et al. Effects of repeated sensory stimulation sessions (electro-acupuncture) on skin temperature in chronic pain patients. Scand J Rehabil Med1997;29:243–50.
      OpenUrlPubMedWeb of Science
    64. Pintov S, Lahat E, Alstein M, et al. Acupuncture and the opioid system: implications in management of migraine. Pediatr Neurol1997;17:129–33.
      OpenUrlCrossRefPubMedWeb of Science
    65. Fink M, Wipperman B, Gehrke A. Non-specific effects of traditional Chinese acupuncture in osteoarthritis of the hip. Complement Ther Med2001;9:82–9.
      OpenUrlCrossRefPubMedWeb of Science
    66. Irnich D, Behrens N, Molzen H, et al. Randomised trial of acupuncture compared with conventional massage and “sham” laser acupuncture for treatment of chronic neck pain. BMJ 2001;322:1574–8.
      OpenUrlAbstract/FREE Full Text
    67. Haslam R. A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip: a randomised controlled trial. Acupunct Med2001;19:19–26.
      OpenUrlPubMed
    68. Tillu A, Roberts C, Tillu S. Unilateral versus bilateral acupuncture on knee function in advanced osteoarthritis of the knee: a prospective randomised trial. Acupunct Med2001;19:15–8.
      OpenUrlPubMed
    69. ↵
      Wang R, Tronnier V. Effect of acupuncture on pain management in patients before and after lumbar disc protrusion surgery: a randomized control study. Am J Chin Med2000;28:25–33.
    70. ↵
      Deluze C, Bosia L, Zirbs A, et al. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ1992;305:1249–52.
    71. ↵
      Vincent CA. A controlled trial of the treatment of migraine by acupuncture. Clin J Pain1989;5:305–12.
      OpenUrlPubMedWeb of Science
    72. ↵
      White AR, Rampes H, Ernst E. Acupuncture for smoking cessation (Cochrane Review). In: The Cochrane Library. Issue 2. Oxford: Update Software, 2001.
    73. ↵
      Silagy C, Mant D, Fowler G, et al. Nicotine replacement therapy for smoking cessation (Cochrane Review). In: The Cochrane Library. Issue 2. Oxford: Update Software, 2001.
    74. ↵
      Kolenda J. A brief history of acupuncture for detoxification in the United States. Acupuncture Today 2000. Available from www.acupuncturetoday.com/archives/2000/sep/09kolenda.html (accessed 28 February 2001).
    75. ↵
      Lipton DS, Brewington V, Smith M. Acupuncture for crack-cocaine detoxification: experimental evaluation of efficacy. J Subst Abuse Treat1994;11:205–15.
      OpenUrlCrossRefPubMedWeb of Science
    76. Avants SK, Margolin A, Chang P, et al. Acupuncture for the treatment of cocaine addiction. Investigation of a needle puncture control. J Subst Abuse Treat1995;12:195–205.
      OpenUrlCrossRefPubMedWeb of Science
    77. Otto KC, Quinn C, Sung YF. Auricular acupuncture as an adjunctive treatment for cocaine addiction. A pilot study. Am J Addict1998;7:164–70.
      OpenUrlPubMedWeb of Science
    78. Bullock ML, Kiresuk TJ, Pheley AM, et al. Auricular acupuncture in the treatment of cocaine abuse. A study of efficacy and dosing. J Subst Abuse Treat1999;16:31–8.
      OpenUrlCrossRefPubMedWeb of Science
    79. ↵
      Avants SK, Margolin A, Holford TR, et al. A randomized controlled trial of auricular acupuncture for cocaine dependence. Arch Intern Med2000;160:2305–12.
      OpenUrlCrossRefPubMedWeb of Science
    80. ↵
      Rampes H, Pereira S, Mortimer A et al. Does electroacupuncture reduce craving for alcohol? A randomised controlled study. Complement Ther Med1997;5:19–26.
    81. Worner TM, Zeller B, Schwarz H, et al. Acupuncture fails to improve the treatment outcome in alcoholics. Drug Alcohol Depend1992;30:169–73.
      OpenUrlCrossRefPubMedWeb of Science
    82. Bullock ML, Umen AJ, Culliton PD, et al. Acupuncture treatment of alcoholic recidivism: a pilot study. Alcohol Clin Exp Res1987;11:292–5.
      OpenUrlCrossRefPubMedWeb of Science
    83. Bullock ML, Culliton PD, et al. Controlled trial of acupuncture for severe recidivist alcoholism. Lancet1989;i:1435–9.
    84. Sapir Weise R, Berglund M, Frank A, et al. Acupuncture in alcoholism treatment: a randomized outpatient study. Alcohol Alcohol1999;34:629–35.
      OpenUrlAbstract/FREE Full Text
    85. Washburn AM, Fullilove RE, Fullilove MT, et al. Acupuncture heroin detoxification: a single-blind clinical trial. J Subst Abuse Treat1993;10:345–51.
      OpenUrlCrossRefPubMedWeb of Science
    86. ↵
      Wells EA, Jackson R, Diaz OR, et al. Acupuncture as an adjunct to methadone treatment services. Am J Addict1995;4:198–214.
      OpenUrlCrossRefWeb of Science
    87. ↵
      Kleijnen J, ter Riet G, Knipschild P. Acupuncture and asthma: a review of controlled trials. Thorax1991;46:799–802.
      OpenUrlAbstract/FREE Full Text
    88. ↵
      Linde K, Jobst K, Panton J. Acupuncture for chronic asthma. (Cochrane Review). In: The Cochrane Library. Issue 2. Oxford: Update Software, 2001.
    89. ↵
      Fung KP, Chow OK, So SY. Attenuation of exercise-induced asthma by acupuncture. Lancet1986;ii:1419–22.
      OpenUrl
    90. ↵
      Tashkin DP, Bresler DE, Kroening RJ, et al. Comparison of real and simulated acupuncture and isoproterenol in methacholine-induced asthma. Ann Allergy1977;39:379–87.
      OpenUrlPubMedWeb of Science
    91. ↵
      Medici T. Acupuncture and bronchial asthma. Forsch Komplementarmed1999;6:26–8.
      OpenUrl
    92. ↵
      Joos S, Schott C, Zou H, et al. Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study. J Altern Complement Med2000;6:519–25.
      OpenUrlCrossRefPubMedWeb of Science
    93. ↵
      Vickers AJ. Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis RCTs. J R Soc Med1996;89:303–11.
      OpenUrlAbstract/FREE Full Text
    94. ↵
      Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg1999;88:1362–9.
      OpenUrlCrossRefPubMedWeb of Science
    95. ↵
      Alkaissi A, Stalnert M, Kalman S. Effect and placebo effect of acupressure (P6) on nausea and vomiting after outpatient gynaecological surgery. Acta Anaesthesiol Scand1999;43:270–4.
      OpenUrlCrossRefPubMedWeb of Science
    96. ↵
      Ho C, Hseu S, Tsai S, et al. Effect of P-6 acupressure on prevention of nausea and vomiting after epidural morphine for post-cesarean section pain relief. Acta Anaesthesiol Scand1996;40:372–5.
      OpenUrlPubMedWeb of Science
    97. ↵
      Yentis S, Vashisht S. The effect of timing of PC.6 acupuncture on post-operative vomiting following major gynaecological surgery. Acupuncture Med1998;16:10–3.
    98. ↵
      Windle P, Borromeo A, Robles H, et al. The effects of acupressure on the incidence of postoperative nausea and vomiting in postsurgical patients. J Perianesth Nurs2001;16:158–62.
      OpenUrlCrossRefPubMed
    99. ↵
      Shen J, Wenger N, Glaspy J, et al. Electroacupuncture for control of myeloblative chemotherapy-induced emesis: a randomised controlled trial. JAMA2000;284:2755–61.
      OpenUrlCrossRefPubMedWeb of Science
    100. ↵
      Dibble S, Chapman J, Mack K, et al. Acupressure for nausea: results of a pilot study. Oncol Nurs Forum2000;27:41–7.
      OpenUrlPubMed
    101. ↵
      Carlsson CP, Axemo P, Bodin A, et al. Manual acupuncture reduced hyperemesis gravidarum. A placebo-controlled, randomized, single-blind, crossover study. J Pain Symptom Manage2000;20:273–9.
      OpenUrlCrossRefPubMedWeb of Science
    102. ↵
      Knight B, Mudge C, Openshaw S, et al. Effect of acupuncture on nausea of pregnancy: a randomized, controlled trial. Obstet Gynecol2001;97:184–8.
      OpenUrlCrossRefPubMedWeb of Science
    103. ↵
      Chu YC, Lin SM, Hsieh YC, et al. Effect of BL-10 (tianzhu), BL-11 (dazhu) and GB-34 (yanglinquan) acuplaster for prevention of vomiting after strabismus surgery in children. Acta Anaesthesiologica Sinica1998;36:11–6.
      OpenUrlPubMed
    104. ↵
      Schlager A, Boehler M, Puhringer F. Korean hand acupressure reduces postoperative vomiting in children after strabismus surgery. Br J Anaesth2000;85:267–70.
      OpenUrlAbstract/FREE Full Text
    105. ↵
      Schwager K, Baines D, Meyer R. Acupuncture and postoperative vomiting in day-stay paediatric patients. Anaesth Intensive Care1996;24:674–7.
      OpenUrlPubMedWeb of Science
    106. ↵
      Shenkman Z, Holzman R, Kim C, et al.Acupressure-acupuncture antiemetic prophylaxis in children undergoing tonsillectomy. Anesthesiology1999;90:1311–6.
      OpenUrlCrossRefPubMedWeb of Science
    107. ↵
      Schlager A, Offer T, Baldissera I. Laser stimulation of acupuncture point P6 reduces postoperative vomiting in children undergoing strabismus surgery. Br J Anaesth1998;81:529–32.
      OpenUrlAbstract/FREE Full Text
    108. ↵
      Ernst E. Acupuncture/acupressure for weight reduction? A systematic review. Wien Klin Wochenschr1997;109:60–2.
      OpenUrlPubMedWeb of Science
    109. ↵
      Mazzoni R, Mannucci E, Rizzello SM, et al. Failure of acupuncture in the treatment of obesity: a pilot study. Eat Weight Disord1999;4:198–202.
      OpenUrlPubMed
    110. ↵
      Richards D, Marley J. Stimulation of auricular acupuncture points in weight loss. Aust Fam Physician1998;27:73–7.
      OpenUrl
    111. ↵
      Ernst E, White AR. Acupuncture as an adjuvant therapy in stroke rehabilitation? Wien Med Wochenschr1996;146:556–8.
      OpenUrlPubMed
    112. ↵
      Kjendahl A, Sallstrom S, Osten PE, et al. A one year follow-up on the effects of acupuncture in the treatment of stroke patients in the subacute stage: a randomized, controlled study. Clin Rehabil1997;11:192–200.
      OpenUrlAbstract/FREE Full Text
    113. Wong AM, Su TY, Tang FT, et al. Clinical trial of electrical acupuncture on hemiplegic stroke patients. Am J Phys Med Rehabil1999;78:117–22.
      OpenUrlCrossRefPubMedWeb of Science
    114. ↵
      Johansson BB, Haker E, von Arbin M, et al. Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation. A randomized controlled trial. Stroke2001;32:707–13.
      OpenUrlAbstract/FREE Full Text
    115. ↵
      Gosman Hedstrom G, Claesson L, Klingenstierna U, et al. Effects of acupuncture treatment on daily life activities and quality of life: a controlled, prospective, and randomized study of acute stroke patients. Stroke1998;29:2100–8.
      OpenUrlAbstract/FREE Full Text
    116. ↵
      Dobie RA. A review of randomized clinical RCTs in tinnitus. Laryngoscope1999;109:1202–11.
      OpenUrlCrossRefPubMedWeb of Science
    117. ↵
      Park J, White AR, Ernst E. Efficacy of acupuncture as a treatment for tinnitus: a systematic review. Arch Otolaryngol Head Neck Surg2000;126:489–92.
    118. ↵
      Furugard S, Hedin PJ, Eggertz A, et al. Acupuncture worth trying in severe tinnitus. Lakartidningen1998;95:1922–8.
      OpenUrlPubMed
    119. ↵
      Eich H, Agelink MW, Lehmann E, et al. Acupuncture in patients with minor depressive episodes and generalized anxiety. Results of an experimental study. Fortschr Neurol Psychiatr2000;68:137–44.
      OpenUrlCrossRefPubMedWeb of Science
    120. ↵
      Ellis N, Briggs R, Dowson D. The effect of acupuncture on nocturnal urinary frequency and incontinence in the elderly. Complement Med Res1990;4:16–7.
      OpenUrl
    121. ↵
      Dunn PA, Rogers D, Halford K. Transcutaneous electrical nerve stimulation at acupuncture points in the induction of uterine contractions. Obstet Gynecol1989;73:286–90.
      OpenUrlPubMedWeb of Science
    122. ↵
      Cardini F, Weixin H. Moxibustion for correction of breech presentation: a randomized controlled trial. JAMA1998;280:1580–4.
      OpenUrlCrossRefPubMedWeb of Science
    123. ↵
      Wyon Y, Lindgren R, Lundeberg T, et al. Effects of acupuncture on climacteric vasomotor symptoms, quality of life and urinary excretion of neuropeptides among post menopausal women. Menopause1995;3:3–12.
    124. ↵
      Blom M, Dawidson I, Angmar Mansson B. The effect of acupuncture on salivary flow rates in patients with zerostomia. Oral Surg Oral Med, Oral Path Oral Radiol Endod1992;73:293–8.
      OpenUrl
    125. ↵
      Kunze M, Seidel HJ, Stuebe G. Comparative studies of the effectiveness of brief psychotherapy, acupuncture and papaverin therapy in patients with irritable bowel syndrome. Zeitschrift für die Gesamte Innere Medizin und ihre Grenzgebiete1990;45:625–7.
    126. ↵
      Matsumoto K, Tsujimoto T, Morishita H, et al. A variation of acupuncture used in the sedation of hyperactive children. Am J Acupunct1990;18:359–61.
      OpenUrl
    127. ↵
      Siterman S, Eltes F, Wolfson V, et al. Effect of acupuncture on sperm parameters of males suffering from subfertility related to low sperm quality. Arch Androl1997;39:155–61.
      OpenUrlPubMedWeb of Science
    128. ↵
      Aune A, Alraek T, LiHua H, et al. Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women. Scand J Prim Health Care1998;16:37–9.
      OpenUrlCrossRefPubMedWeb of Science
    129. ↵
      Williamson L, Yudkin P, Livingstone R, et al. Hay fever treatment in general practice: a randomised controlled RCT comparing standardised Western acupuncture with Sham acupuncture. Acupuncture in Medicine1996;14:6–10.
      OpenUrl
    130. ↵
      Vickers A, Zollman C. ABC of complementary medicine. Acupuncture. BMJ1999;319:973–6.
      OpenUrlFREE Full Text
    131. ↵
      Ernst E, White A. Prospective studies of the safety of acupuncture: a systematic review. Am J Med2001;110:481–5.
      OpenUrlCrossRefPubMedWeb of Science
    132. ↵
      Yamashita H, Tsukayama H, Tanno Y, et al. Adverse events in acupuncture and moxibustion treatment: a six-year survey at a national clinic in Japan. J Altern Complement Med1999;5:229–36.
      OpenUrlPubMedWeb of Science
    133. ↵
      Odsberg A, Schill U, Haker E. Acupuncture treatment: side effects and complications reported by Swedish physiotherapists. Complement Ther Med2001;9:17–20.
      OpenUrlCrossRefPubMedWeb of Science
    134. ↵
      White A, Hayhoe S, Hart A, et al. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ2001;323:485–6.
      OpenUrlFREE Full Text