Western Medical Acupuncture
Western medical acupuncture is a complementary therapy involving the insertion of fine, sterile, disposable needles for the relief of health complaints such as musculoskeletal pain, trapped nerves, irritable bowel, menstrual and menopausal symptoms. It is based in scientific research, and the modern and evolving concepts of anatomy and physiology. In the West research by Melzack and Wall discovered that the body has the ability to produce its own painkillers. By inserting acupuncture needles in human voluntaries it was proved that the body releases endorphins and enkephalines these substances are able to suppress pain.
Through research and the wisdom of observation, it is believed that acupuncture works through the vast network of nerve endings near the surface of the skin. When an organ is diseased or working below par, the sufferer may feel a tender spot. During assessment with the practitioner, the patient may become aware of those painful areas when the skilled practitioner uses manual palpation to search for the root of the problem. For example for headaches, the problem may be identified in the neck, and for relieving childbirth pain at the bottom of the spine.
The treatment itself consists of inserting fine single use sterile needles on specific points, with the aim as to improve activity at the point and at the same time to improve function in other areas of the body.
Acupuncture treats pain and other conditions by stimulating the body's own defense mechanisms and in doing so calms painful sensations, improves health and vitality.
For the management of pain there is a vast amount of evidence , to manage such conditions as musculo skeletal pain, trapped nerves, pain from arthritis.
For visceral complaints such as irritable bowel, constipation, menstrual problems, fertility issues, acupuncture is often a complementary therapy to be used along with conventional treatments.
Evidence for Acupuncture.
A Cochrane review by Furlan et al of acupuncture and dry needling for low back pain, which included 35 RCTs, concluded that ‘for chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short term only’. A systematic review published in the same year by Manheimer et al also found acupuncture to be significantly more effective than sham acupuncture in chronic low back pain. More recent systematic reviews have not included meta-analysis. The Cochrane review (including meta-analysis) is being updated under the new title Acupuncture for (sub)acute non-specific low-back pain, and will be published in due course.
Since these reviews there have been several relevant studies published. The ART (Acupuncture Randomised Trial) study (n=298) from the Charité University Medical Center in Berlin of acupuncture for chronic low back pain shows a trend in favour of verum over minimal (superficial non-point) acupuncture, but a significant difference between verum and the no (additional) treatment control group. The standard deviation in the primary outcome measure in this trial exceeded the estimate in the sample size calculation by 50%, which reduced the intended statistical power of the trial considerably.
Thomas et al reported positive results in their pragmatic trial of acupuncture in chronic low back pain in primary care (n=241). They demonstrated effectiveness and cost-utility at 24 months – the cost per additional QALY was £4241.[5,6] The primary outcome for additional acupuncture over routine GP care was significant at 24 months but not at 12 months. This is a surprising result following a short course of acupuncture, since the systematic reviews demonstrate a short term effect only.
An individual patient data meta-analysis reported by Vickeer et al in 2012 includes pooled data from five of the best quality trials of acupuncture in low back pain in a sensitive analysis. This includes data from the ART& GERAC trials described above. Acupuncture was significantly superior to sham and to no acupuncture with pooled effect sizes os 0.20 and 0.46 respectively.
The NICE clinical guideline for the early management of persistent non specific low back pain ( between 6 months and 1 year), include consideration of 12 sessions of acupuncture over three months.
The first Cochrane review on acupuncture for idiopathic headache was tentatively positive.
Vickers and Wonderling show definite effectiveness ( not efficasy) and cost effectiveness- the cost per additional QALY was £9180 .
Efficasy was still on some doubt following the result of the German ART studies in migraine. Responder rates were good for needling but rates in the minimal sham needling groups were also high.. Responder rate were confirmed in a large epidemiological study ( n=2022).
The GERAC trial on migraine (n=960) showed that outcomes do not differ between acupuncture, minimal (sham) needling and
standard therapy (1st beta-blocker; 2nd flunarizine; 3rd valproic acid). The responder rates at 26 weeks after randomisation were 47%, 39% and 40% respectively. When reanalysed in the IPDM by Vickers et al, the difference between acupuncture and minimal (sham) acupuncture became statistically significant.
In 2009 the Cochrane review was updated and split into acupuncture for migraine prophylaxis, and acupuncture for tension-type headache. A significant effect over sham was noted in the latter but not the former. Acupuncture appeared to be at least as good (statistically superior) as prophylactic medication in migraine.
The NICE clinical guideline (CG150) on diagnosis and management of headaches in young people and adults recommends the use of acupuncture for prophylaxis of tension type headache and migraine, although there is some debate over the network meta-analysis that showed acupuncture to be only half as good as topiramate, when the same data seems to show that sham acupuncture is marginally better than real topiramate.
An update to CG150 was published in November 2015, and the recommendations for acupuncture remain.
Subsequently the Cochrane reviews have been updated,[27,28] and the conclusions remain positive. Data from the IDPM was used, and for the first time acupuncture has been shown to be marginally superior to sham, as well as medication in migraine prophylaxis.
KNEE OSTEOARHRITIS (OA knee)
The largest sham controlled trial to date is the GERAC OA knee trial (n=1007). This trial used off-point superficial acupuncture in the sham, and a third arm of conservative treatment only (physiotherapy and NSAIDs). Both acupuncture groups (traditional Chinese acupuncture and sham acupuncture) were significantly better than conservative treatment alone. The improvement in WOMAC index in the real acupuncture group was very similar to that in the ART OA knee trial around 20% reduction at 26 weeks .
The key difference between ART and GERAC appears to be the effect size in the minimal acupuncture group (it was markedly higher in the GERAC trial than in the ART trial). An SR by White et al included 13 RCTs.  The results from the five high quality trials (n=1334) were pooled in meta-analysis for the primary outcome, and demonstrated a significant effect of acupuncture versus sham in short term pain.
A subsequent SR by Manheimer et al found very similar results in their meta-analysis, although their interpretation differed in terms of clinical relevance. The pragmatic ARC study on acupuncture for OA in the hip and knee (n=712 randomised; 3633 total cohort) has demonstrated marked clinical improvement, which is maintained at six months, from a 15 session course of treatment. The economic analysis performed alongside the ARC study (n=421) demonstrated cost effectiveness of €17 845 per additional QALY. 
A further health economic assessment in the UK, that formed part of the APEX trial, provides a more favourable figure of £3889 per additional QALY for an intervention including advice, exercise and acupuncture. The most recent Cochrane review of acupuncture for peripheral joint OA (lead by Manheimer) included 16 trials and 3498 participants.
Twelve trials were on OA knee, three on OA hip and one included both. The authors concluded: Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding. Waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects.
We (White & Cummings) argue that you can only test the biological plausibility of acupuncture against sham acupuncture, not its clinical relevance
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144 – The NICE clinical guideline (CG59) on osteoarthritis recommends that electroacupuncture should not be used on the basis of the perceived cost derived from health economic modelling. This guideline was much debated,[40–42] and an alternative economic analysis seemed to favour acupuncture, however, the updated guideline did not recommend acupuncture, despite evidence of efficacy over sham, effectiveness and cost effectiveness within threshold.
The difference beyond sham is the sticking point, and the wording of the Cochrane review above is repeated as the excuse. Acupuncture did not achieve a standardised mean difference (SMD) of 0.5 over sham acupuncture; however, few interventions if any in osteoarthritis do achieve this. Further evidence that suggests acupuncture can play a useful role in osteoarthritis comes from a network meta-analysis (NMA). This was a comprehensive NMA of physical treatments for pain relief in osteoarthritis of the knee (OA knee). A total of 114 trials including 22 different interventions in 9709 patients provided data suitable for NMA.
The higher quality trials were of acupuncture (11 trials) and muscle strengthening exercises (9 trials). The latter is recommended in national clinical guidelines as a core treatment in OA knee. Acupuncture was significantly better than muscle strengthening exercises with an effect size of 0.49 (SMD). This seems to raise questions about why acupuncture is not recommended as a treatment in OA. A further small but rigorous study published in JAMA again raised the question of MCID over sham. There was a significant difference for needle acupuncture over a no treatment control who were not aware of the trial (Zelen design), and therefore not disappointed. The paper has raised some debate over interpretation of the results.[47