The Acupuncture Evidence Project
The most thorough and detailed review of the evidence supporting the effectiveness of acupuncture is The Acupuncture Evidence Project: A Comparative Literature Review. Here is the Summary of the findings, followed by the project’s Preface. (For a fully referenced copy of the Preface, please select the link above for the complete 81 page version of the Project.)
The Acupuncture Evidence Project: Plain English Summary
The following is a plain English summary of the findings of the Acupuncture Evidence Project (McDonald J, and Janz S, 2017). The full document (81 pages) is available from the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA) http://www.acupuncture.org.au.
Our study found evidence for the effectiveness of acupuncture for 117 conditions, with stronger evidence for acupuncture’s effectiveness for some conditions than others. Acupuncture is considered safe in the hands of a well-trained practitioner and has been found to be cost effective for some conditions. The quality and quantity of research into acupuncture’s effectiveness is increasing.
Acupuncture originated in China and is now practised throughout the world. Although acupuncture has been practised for thousands of years, evidence of its effectiveness is still controversial. The Australian Acupuncture and Chinese Medicine Association Ltd (AACMA) identified the need for an updated review of the evidence with greater rigour than was possible in the past and commissioned The Acupuncture Evidence Project.
We searched the literature with a focus on systematic reviews and meta analyses (the highest form of evidence available). We sorted the evidence to identify which conditions acupuncture has been found to be most effective for. We also looked for evidence of acupuncture’s safety and cost-effectiveness, and we reported how the evidence for acupuncture’s effectiveness has changed over an eleven-year time-frame.
Of the 122 conditions identified, strong evidence supported the effectiveness of acupuncture for 8 conditions, moderate evidence supported the use of acupuncture for a further 38 conditions, weak positive/unclear evidence supported the use of acupuncture for 71 conditions, and little or no evidence was found for the effectiveness of acupuncture for five conditions (meaning that further research is needed to clarify the effectiveness of acupuncture in these last two categories).
In addition, research showed that acupuncture was cost effective for 10 conditions, and is safe in the hands of a well-trained practitioner. The level of evidence has increased over the 11-year period of this study for 24 conditions. Placebo-controlled clinical trials consistently underestimate the true effect size of acupuncture (which means that acupuncture is more effective than the type of trials used in this review show), yet they have still demonstrated National Health and Medical Research Council (NHMRC) Level I evidence for the effectiveness of acupuncture for 117 conditions.
Table 1. Conditions with strong evidence supporting the effectiveness of acupuncture
Reviews with consistent statistically significant positive effects and where authors have recommended the intervention. The quality of evidence is rated as moderate or high quality.
- Allergic rhinitis (perennial & seasonal)
- Chemotherapy-induced nausea and vomiting (with anti-emetics)
- Chronic low back pain
- Headache (tension-type and chronic)
- Knee osteoarthritis
- Migraine prophylaxis
- Postoperative nausea & vomiting
Table 2. Conditions with moderate evidence supporting the effectiveness of acupuncture
Reviews reporting all individual RCTs or pooled effects across RCTs as positive, but the reviewers deeming the evidence insufficient to draw firm conclusions. The quality of evidence is rated as moderate or high quality.
- Acute low back pain
- Acute stroke
- Ambulatory anaesthesia
- Aromatase-inhibitor-induced arthralgia
- Asthma in adults
- Back or pelvic pain during pregnancy
- Cancer pain
- Cancer-related fatigue
- Craniotomy anaesthesia
- Depression (with antidepressants)
- Dry eye
- Hypertension (high blood pressure) (with medication)
- Irritable bowel syndrome (IBS)
- Labour pain
- Lateral elbow pain
- Menopausal hot flushes
- Modulating sensory perception thresholds
- Neck pain
- Peri-menopausal & post-menopausal insomnia
- Plantar heel pain
- Post-stroke insomnia
- Post-stroke shoulder pain
- Post-stroke spasticity (muscular rigidity)
- Post-traumatic stress disorder (PTSD)
- Prostatitis pain/chronic pelvic pain syndrome
- Recovery after colorectal cancer resection
- Restless leg syndrome
- Schizophrenia (with antipsychotics)
- Shoulder impingement syndrome (early stage) (with exercise)
- Shoulder pain
- Smoking cessation (up to 3 months)
- Stroke rehabilitation
- Temporomandibular pain (TMJ pain)
Table 3. Conditions with weak positive/unclear evidence supporting the effectiveness of acupuncture
Reviews consisted mostly of weak positive evidence or conflicting evidence between reviews or between authors within a review, with reviewers summarising the evidence as inconclusive. Reviews are of low or very low quality; or there is conflicting levels of evidence within or between reviews.
- Acupuncture in Emergency Department
- Acute ankle sprain in adults
- Alzheimer’s disease
- Angina pectoris
- Assisted conception in ART
- Asthma in children
- Atopic dermatitis
- Attention Deficit Hyperactivity Disorder (ADHD)
- Autism spectrum disorder (ASD)
- Bell’s palsy
- Bladder pain syndrome
- Cancer-related insomnia
- Cancer-related psychological symptoms
- Carpal tunnel syndrome
- Chemotherapy-induced peripheral neuropathy
- Chronic fatigue syndrome
- Chronic kidney disease
- Chronic obstructive pulmonary disease (COPD)
- Chronic urinary retention due to spinal cord injury
- Chronic urticaria
- Dysmenorrhoea (period pain)
- Dyspepsia (indigestion) in diabetic gastroparesis (DGP)
- Erectile dysfunction
- Exercise performance & post-exercise recovery
- Fatigue in systemic lupus erythematosus
- Functional dyspepsia (indigestion)
- Gag reflex in dentistry
- Heart failure
- Hot flushes in breast cancer
- Hyperemesis gravidarum (severe nausea and vomiting during pregnancy)
- Hypoxic ischemic encephalopathy (brain disease) in neonates
- Induction of labour
- Inflammatory bowel disease
- Lumbar spinal stenosis
- Melasma (brown patches on the skin)
- Meniere’s disease/syndrome
- Menopausal syndrome
- Multiple sclerosis
- Mumps in children
- Myelosuppression after chemotherapy
- Oocyte retrieval (IVF egg collection) pain relief
- Opiate addiction
- Opioid detoxification
- Parkinson’s disease
- Polycystic ovarian syndrome (PCOS)
- Poor sperm quality
- Postnatal depression
- Postoperative gastroparesis syndrome (PGS)
- Postoperative ileus (bowels not moving)
- Post-stroke hiccoughs
- Premenstrual syndrome (PMS)
- Primary ovarian insufficiency (lack of eggs)
- Primary Sjogren’s syndrome (immune disorder characterised by dry eyes and dry mouth)
- Psoriasis vulgaris
- Rheumatoid arthritis
- Slowing progression of myopia (nearsightedness)
- Spinal cord injury
- Stress urinary incontinence in adults
- Sudden sensorineural hearing loss
- Surgery analgesia
- Traumatic brain injury
- Urinary incontinence
- Uterine fibroids
- Vascular cognitive impairment without dementia
- Vascular dementia
- Whiplash associated disorder (WAD)
- Xerostomia in cancer (dry mouth)
Table 4. Conditions with little or no evidence supporting the effectiveness of acupuncture
Reviews have consistently found little support for acupuncture. The quality of the evidence is consistently low or very low. Further research required.
- Alcohol dependence
- Cocaine addiction
- Nausea in pregnancy
- Smoking cessation (more than 6 months)
Summary of Findings 2: Conditions with evidence of cost-effectiveness.
Table 5. Conditions with evidence of cost effectiveness
- Allergic Rhinitis
- Ambulatory Anaesthesia
- Chronic Pain
- Dysmenorrhoea (period pain)
- Low back pain
- Neck Pain (plus usual medical care)
- Post-operative nausea and vomiting
Summary of Findings 3: Conditions with evidence of safety.
Table 6. Conditions with evidence of safety
|Acupuncture generally prior to this review||Acupuncture can be considered inherently safe in the hands of well-trained practitioners.|
|Allergic Rhinitis||Safe and cost-effective|
|Ambulatory Anaesthesia||Acupuncture safe, cost-effective and effective as an adjunctive therapy.|
|Alzheimers disease||Acupuncture is Safe.|
|Cancer-related psychological symptoms||Strong evidence for safety.|
|Depression||Strong evidence for safety. Effective and safe for major depressive disorder.|
|Low back pain||Safe and well tolerated.|
|Migraine||Moderate to high quality evidence Cost effective. Promise in safety and effectiveness. Serious adverse events were not reported in any trial.|
|Osteoarthritis of the Knee||Promise in safety and effectiveness.|
|Prostatitis pain/chronic pelvic pain syndrome||Acupuncture superior to both sham and to usual care and safe.|
Summary of Findings 4: Changes in evidence levels over the eleven-year period covered by this review
Table 7. Statistical summary of findings of this review
|Evidence Level||Number of Conditions||Changes in Level of Evidence||Number of Conditions|
|Strong Evidence of effect||8||Increase to strong evidence||5|
|Moderate Evidence effect||38||Increase to moderate evidence||18|
|Unclear/mixed evidence||71||Increase to weak positive/unclear evidence||1|
|Little of no evidence of effect||5||Decreased evidence level||2|
|Total conditions with some evidence of effect (any level)||117|
|Total conditions reviewed||122||Total increases in evidence level since prior reviews||24|
Evidence of effectiveness underpins the validity of all health care interventions. Acupuncture has been practised for thousands of years; however, research into its effectiveness and cost effectiveness is in its relative infancy. The first significant attempt to identify the evidence validating the role of acupuncture was undertaken by the World Health Organization (WHO) in 1979 (1). WHO conducted a Delphi-like symposium in Beijing in 1979 where physicians from around the world identified 43 diseases which they believed acupuncture may benefit (1). The 1979 report was criticised because it was not based on clinical trials, rather the clinical experience of the participants (2).
The US Department of Health and Human Services National Institutes of Health (NIH) released a consensus statement on acupuncture in 1997 (3). The statement identified the efficacy of acupuncture for adult postoperative and chemotherapy nausea and vomiting, and for postoperative dental pain. In addition, the statement found support for the use of acupuncture for a range other conditions and identified the need for further research (3).
In 1996, WHO held a consultation on acupuncture in Cervia, Italy. At this meeting it was decided to review acupuncture again, this time focusing on the now-numerous controlled clinical trials. The result was a review of clinical trials up until early 1999 and culminated in ‘Acupuncture: review and analysis of controlled clinical trials’ published by WHO in 2002 (4). The report identified 28 conditions for which acupuncture was found to be effective, and nearly 100 others where there was a therapeutic effect (4). It was acknowledged at the time that there were problems with the methodology in some of the trials included in the review (4). Notwithstanding these limitations, the WHO report indicated a growing and convincing body of evidence indicating that there was more to acupuncture than the placebo effect (4).
The Acupuncture Evidence Project
Fourteen years after the WHO publication on acupuncture evidence there has been further refinement in the conduct of clinical trials, not just for acupuncture, but in health-care generally, with clearer guidelines on how to rate the quality of the evidence. The Australian Acupuncture and Chinese Medicine Association Ltd (AACMA) identified the need for an updated review of the literature with greater rigour than was possible in the past, and commissioned the acupuncture evidence project. AACMA engaged experienced clinician and researcher, Dr John McDonald PhD, to conduct the research and analysis for the project.
This review draws on two prior comprehensive literature reviews, one conducted for the Australian Department of Veterans’ Affairs (DVA) in 2010 and another conducted for the United States Department of Veterans Affairs (USVA) in 2013 (5, 6). The research identified by these reviews was pooled, then a search of further literature from 2013 to 2016 was conducted. Trials were assessed using the National Health and Medical Research Council (NHMRC) levels of evidence, with risk of bias assessed using the Cochrane GRADE system (7, 8). Results have been tabulated to indicate not just the current state of the evidence, but to indicate how the quality and quantity of evidence has changed from 2005 to 2016. In this review, 122 conditions across 14 broad clinical areas were identified and, of these, only five conditions found ‘no evidence of effect’ for acupuncture. The level of evidence was found by this review to have increased for 24 conditions.
How to use this review
This project sets a new benchmark to inform acupuncturists, the public, researchers, health departments, governments, and other health providers that acupuncture has a valuable contribution to make to global healthcare and to assist in reducing the global burden of disease.
Acupuncturists should also take confidence from this report that their clinical expertise has been validated, and to confidently offer their services alongside other health professionals. Students and clinicians can use this report to identify areas of clinical interest which they may have overlooked. Researchers can find inspiration for areas of future investigation where the evidence is currently unclear. This review should also encourage educational institutions to maintain robust programs of study in acupuncture to continue to produce graduates capable of the broad scope of practice that this report indicates. It is no longer possible to say that the effectiveness of acupuncture can be attributed to the placebo effect or that it is useful only for musculoskeletal pain.
The realisation that pharmacological and surgical interventions are not without their limitations has increased interest in drug-free treatments such as acupuncture (9-13). This review found eight conditions where acupuncture may be used to reduce reliance on pharmacological or surgical options. Migraine and tension headaches lead to loss of productivity and quality of life; a drug- free therapy has a major health impact and potential cost savings as well as maintaining participation in the workforce (14). Medication is not always an effective or acceptable therapy for allergic rhinitis and acupuncture improves the range of interventions available to improve quality of life (15). Post-operative nausea and vomiting and post-operative pain complicate post- operative management, with acupuncture offering another avenue to enhance care in the post- operative period and reduce reliance on medication alone (16, 17).
Knee osteoarthritis is on the increase globally and contributes not just to disability adjusted life years (DALYs), but is an increasing burden on health budgets (18, 19). The option of a safe, drug- free treatment that may improve quality of life and potentially delay surgical intervention has significant potential to control these spiralling costs and DALYs. Low back pain is a WHO priority disease, and is the single largest contributor to disability worldwide (20). The finding that acupuncture benefits chronic low back pain is arguably the most important finding from this report. Finally, chemotherapy induced nausea and vomiting is an unwanted complication of cancer treatment and is often not fully controlled even with state-of-the-art antiemetics. Acupuncture can assist in improving quality of life for these cancer patients (21).
It has been estimated that there is a 17-year time lag in translating clinical research into clinical practice (22). During this time patients are being deprived of the benefit of a proven therapy. Health policy makers now have eight clear conditions associated with a significant burden of disease where acupuncture should be integrated into current clinical guidelines without further delay. Placebo controlled clinical trials consistently underestimate the true effect size of acupuncture (as discussed in section 1.4), yet they have still demonstrated NHMRC Level 1 evidence for the effectiveness of acupuncture for a further 109 conditions. This review has found a significant improvement in both the quality of studies and the levels of evidence supporting acupuncture since the most recent reviews conducted by the Australian and US Departments of Veterans Affairs.