SYSTEMATIC REVIEW
Acupuncture for surgical conditions: an overview of systematic reviews M. S. Lee,1 E. Ernst2
1
SUMMARY
Review criteria
Aim: Several systematic reviews (SRs) of acupuncture for surgical conditions have recently been published with sometimes contradicting results. The aim of this overview was to summarise recent SRs of acupuncture for surgical conditions. Method: Thirteen electronic databases were searched for relevant reviews published since 2000. Data were extracted by two independent reviewers according to predefined criteria. Results: Twelve SRs met our inclusion criteria. They related to the prevention or treatment of postoperative nausea and vomiting as well as to surgical or postoperative pain. Their results were far from uniform, and several caveats need to be considered. Conclusion: The evidence is insufficient to suggest that acupuncture is an effective intervention in surgical settings. More rigorous research seems warranted. This protocol was registered with PROSPERO database (registration number: CRD42013004817).
Introduction The current fascination which Western scientists seem to have with acupuncture started when James Reston, a journalist accompanying Henry Kissinger to China in 1971, had to have an appendectomy in the ‘Anti-Imperialist Hospital’ and was subsequently treated with acupuncture for his postoperative pain (1). He reported his experience in the New York Times on 26 July 1971, and his account triggered a flurry of interest and research. As a consequence, we now have hundreds of clinical trials of acupuncture (2) and several reasonable hypotheses regarding its mode of action (3). Yet many surgeons remain sceptical about the value of acupuncture, often arguing that the evidence is far from convincing (4). The aim of this article was to summarise and critically evaluate all systematic reviews (SRs) of acupuncture as a treatment of conditions relevant to surgery.
Methods Search methods for identification of studies Electronic literature searches, without language restrictions, were conducted in Pubmed, Embase, Amed, CINHAL, Health Technology Assessments,
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789. doi: 10.1111/ijcp.12372
We included all systematic reviews (SRs) of acupuncture surgical conditions after searching 13 databases from January 2000 to June 2013, without language restrictions.
Message to the clinic Acupuncture is one of the most popular types of CAM. It is sometimes used as a treatment for surgical conditions. The results of our overview of SR failed to provide reliable evidence for acupuncture in the treatment or prevention of surgical problems including postoperative nausea and vomiting or postoperative pain.
DARE, the Cochrane Library, five Korean Medical Database (Korean Studies Information, DBPIA, Korea Institute of Science and Technology Information, KoreaMed, and Research Information Service System), and one Chinese Database (CNKI). In addition, our departmental files were hand-searched. The time window for these searches was from 2000 to June 2013; older SRs were not considered because they would now be out of date. The search terms were ‘acupuncture OR acupressure OR moxibustion OR electroacupuncture OR auricular acupuncture’ AND ‘surgical OR operation OR surgery OR postoperative OR preoperative OR PONV’ AND ‘review OR meta-analysis’. Abstracts of reviews thus located were inspected by both authors and those appearing to meet the inclusion criteria were retrieved and read in full by the two authors. Reviews were defined as systematic if they included an explicit and repeatable method section with details on searching the scientific literature, and if they had explicit and repeatable inclusion and exclusion criteria.
Medical Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea 2 Complementary Medicine, Peninsula Medical School, University of Exeter, Exeter, UK Correspondence to: Edzard Ernst, Complementary Medicine, Peninsula Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK Tel.: + 44 (0)1392 726029 Fax: + 44 (0)1392 421009 Email: [email protected]
Disclosure None.
Type of studies Systematic review had to be concerned specifically with the therapeutic effectiveness of acupuncture in surgical settings and to include evidence from at least two controlled clinical trials.
783
Acupuncture for surgical conditions
Identification
Records identified through database searching (n = 901) Pubmed (n = 376), EMBASE (n = 397), Cochrane Library (n = 85) DARE (n = 28), HTA (n = 3), AMED (n = 6), CNKI (n = 6), Korean DBs (n = 0)
Records screened (n = 852)
Records excluded (n = 793)
Eligibility
Screening
Records after duplicates removed (n = 852)
Full-text articles assessed for eligibility (n = 59)
Full-text articles excluded, with reasons (n = 47) - Not related to AT (n = 6) - Not related to surgery (n = 28) - Not SR (n = 13)
Included
784
Studies included in qualitative synthesis (n = 12)
Figure 1 Flow chart of the publication-selection process. AT, acupuncture; SR, systematic review
Type of participants Systematic reviews were considered regardless of patients’ age and gender.
Type of intervention No limitation on the type of acupuncture stimulating techniques, e.g. body acupuncture, ear, electroacupuncture, laser, moxibustion or acupressure.
Data extraction and assessment of quality of SRs Hard copies of all articles were obtained and read in full by two independent reviewers. The data from articles were validated and abstracted according to predefined criteria that included the author information, the country of origin of the SRs, the treatment, condition, quality of primary studies, conclusion and result.
The assessments of the quality of the primary studies were adopted from the respective SRs. The Overview Quality Assessment Questionnaire (OQAQ) was used to evaluate the methodological quality of all of the included SRs (5,6). The OQAQ score ranges from 1 to 7; a score of 3 or less indicated extensive or major flaws, and a score of 5 or more suggested minor or minimal flaws. The two authors independently assessed the OQAQ and extracted the data using predefined criteria (Table 2), and discrepancies were settled by discussion.
Results Our searches produced 901 hits and 12 articles met our inclusion criteria (Figure 1, Table 1). The included reviews had been published between 2005 and 2012 (7–18). Their first authors originated from ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
P6 point stimulation (AT, EA, Laser AT, TENS, AP and related)
P6 point stimulation (AT, EA, AP, wristband, Laser AT, injection, and related)
AT, AP wristband
AP wristband
AP wristband
AT, AP
AT, AP, Laser AT, EA, AP wristband
Zhu (2010) (8)
Abraham(2008) (9)
Zhou (2011) (10)
Doran (2010) (11)
Holmer Pettersson (2012) (12)
Dune (2006) (13)
Treatment
Lee (2009) (7)
First author Year (Ref)
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
21
PONV
PONV
PONV in children
PONV
PONV
PONV
12
3
13
9
10
40
Condition
PONV
No. primary studies
Table 1 Systematic reviews of acupuncture for surgical conditions
Variable
Variables
Variable
Variable
Mostly poor
Variable
Variable
Quality of primary studies
AT-related vs. various controls Nausea (two studies): RR, 0.59 (0.46, 0.76) Vomiting (12 studies): RR, 0.69 (0.59, 0.80)
No
AP vs. placebo Nausea (nine studies): RR, 0.85 (0.72, 1.00); Vomiting (nine studies): RR, 0.50 (0.37, 0.66) No
AT-related vs. sham AT Nausea (27 studies): RR, 0.71 (0.61, 0.83); Vomiting (32 studies): RR, 0.7 (0.59, 0.83) AT-related vs. antiemetic Nausea (nine studies): RR, 0.82 (0.6, 1.13); Vomiting (14 studies): RR, 1.01 (0.77, 1.31) AT-related vs. sham AT Nausea (13 studies): RR, 0.71 (0.62, 0.80); Vomiting (13 studies): RR, 0.71 (0.60, 0.84) AT-related vs. antiemetic Nausea (five studies): RR, 1.19 (0.86, 1.66); Vomiting (four studies): RR, 0.75 (0.51, 1.11) No
Meta-analysis
1
Nausea:+ Vomiting: +
Nausea:+ Vomiting: +
1
3
Nausea:+ Vomiting: +
5 Usage of AP… can ease postoperative vomiting, but it cannot reduce PO nausea ‘class -definitely recommended’ evidence exists … … all kinds of AP stimulation,…, seem to prevent PONV with minimal side effects AT is as effective as medications
Nausea: Vomiting: Nausea: Vomiting: +
1
Nausea:+ Vomiting: +
7
Compared with sham stimulation, P6 stimulation can be effective in preventing PONV …
AT and AP are ineffective…
Nausea:+ Vomiting: +
Result
7
Quality of SR (OQAQ)
P6 acupoint stimulation prevented PONV
Conclusion (quote)
USA
Sweden
USA
China
UK
China
China
Country
Acupuncture for surgical conditions 785
AT-related vs. various control (four studies) OR, 6.39 (4.03, 10.15) Variable 6 PO ileus AT, EA, AP Chen (2012) (18)
AA, auricular acupuncture; AP, acupressure; AT, acupuncture; EA, electroacupuncture; Moxa, Moxibustion (stimulation of acupoints by heat); OR, odd ratio; PO, postoperative; PONV, postoperative nausea and vomiting; P6 point stimulation, stimulation at point ‘pericardium 6’; RR, risk ratio; TENS, transcutaneous electrical nerve stimulation; WMD, weight mean difference; +, overall positive; , fails to show effectiveness; +/ , unclear.
China 5
+/
Korea 7 AT, EA Lee (2005) (17)
Surgical pain
19
Variable
AT-related vs. sham AT (three studies) WMD, 14.57 ( 23.02, 6.13) AT vs. No-treatment (two studies) WMD, 5.60 ( 0.48, 11.68), Good PO pain AT, EA, AA, related Sun (2008) (16)
15
No Variable AA Usichenko (2008) (15)
PO pain
PONV AT + moxa Chen (2006) (14)
9
Strong evidence exists that real AT is not significantly different for placebo AT No conclusive evidence AT for PO ileus
+/ 7
USA
+/ 6
German
+/ 1
Efficacy has not been confirmed AA reduces postop pain is promising but not compelling PO AT may be a useful adjunct … No Variable
Condition Treatment
20
Result Quality of SR (OQAQ) Conclusion (quote) Meta-analysis Quality of primary studies No. primary studies First author Year (Ref)
Table 1 Continued
China
Acupuncture for surgical conditions
Country
786
the China (7,8,10,14,18), USA (11,13,16), UK (9), Korea (17), German (15) and Sweden (12). Seven reviews incorporated a meta-analytic approach (7,8,10,13,16–18). The reviews were based on 3–40 primary studies. They related to the following conditions: postoperative nausea/vomiting (PONV) (7– 14), postoperative pain or surgical pain (15–17) and postoperative ileus (18). Based on the OQAQ scores, the quality of the SRs varied; seven SRs had minimal bias (7,8,10,15–18), four SRs had major limitations (9,11,12,14) and the remaining SR had moderate flaws (13) (Table 2). Six SRs arrived at a clearly positive conclusion (7,8,10–13) and five referred to postoperative nausea (7,8,11–13) and six SRs referred to vomiting (7,8,10– 13) (Table 3). In four SRs (14–16,18), the conclusions were neither positive nor negative but unclear; one of these articles referred to PONV (14), two SRs related with surgical pain (15,16) and one SR was on postoperative ileus (18) (Table 3). Three SRs drew clearly negative conclusions (9,10,17); two referred to postoperative nausea (9,10), one to vomiting (9) and the other to surgical pain (17).
Discussion This overview shows that numerous SRs have recently addressed the question whether acupuncture and related techniques are effective in surgical settings. A similar overview of SRs published between 1989 and 2000 included only two articles related to surgery (19). This shows that the research interest in this area has increased considerably. The included SRs (Table 1) are not free of contradictions. The fact that SRs often fail to provide clear guidance for clinicians is well-known. In such instances, their main value may lie in directing more research towards areas of uncertainty. The current best evidence from SRs suggests that acupuncture might be effective for the prevention of PONV. The results of a meta-analysis (7,8) indicate that the effect size is small and probably not clinically relevant. The results of meta-analysis (7,8) concluded that acupuncture was as effective (or ineffective) as antiemetic drugs. Many of the trials that were included in the SRs did not test acupuncture per se, but electroacupuncture, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, an acupoint stimulation device and acupressure wristbands. This seems to indicate that we need more and better clinical trials to determine whether any of these treatments works and which, if any, is the most effective. Even if acupuncture turns out to be effective for PONV, the question remains whether and in what way it is superior to drug treatment. We therefore ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1
1 1 1
1 1 1
2 Was the search comprehensive?
1 1 1
0 0 1
1 1 0 1 1 0
3 Were the inclusion criteria reported?
1 1 0
1 0 1
1 1 0 1 1 0
4 Was selection bias avoided?
1 1 1
1 1 1
1 1 0 1 1 1
5 Were the validity criteria reported?
1 1 1
1 1 1
1 1 0 1 1 1
6 Was validity assessed appropriately?
The overall score is from 1 to 7. OQAQ ≤ 3, having extensive or major flaws; 5 ≤ OQAQ, having minor or minimal flaws.
Lee (2009) (7) Zhu (2010) (8) Abraham (2008) (9) Zhou (2011) (10) Doran (2010) (11) Holmer Pettersson (2012) (12) Dune (2006) (13) Chen (2006) (14) Usichenko (2008) (15) Sun (2008) (16) Lee (2005) (17) Chen (2012) (18)
First author Year (Ref)
1 Were the search methods reported?
Table 2 The Overview Quality Assessment Questionnaire (OQAQ) of included systematic reviews
1 1 0
1 1 1
1 1 1 0 1 1
7 Were the methods used to combine studies reported?
1 1 1
1 1 0
1 1 1 1 1 1
8 Were the findings combined appropriately?
1 1 1
1 0 1
1 1 1 1 1 1
9 Were the conclusions supported by the reported data?
7 7 5
3 1 6
7 7 1 5 1 1
10 Overall score
Acupuncture for surgical conditions 787
788
Acupuncture for surgical conditions
Table 3 Indications evaluated by multiple SRs
Direction of results Condition
Number of SRs
+
+/
Comments
Nausea
8
5
1
2
Vomiting
8
6
1
1
Pain Ileus
3 1
0 0
2 1
1 0
+, positive conclusion; +/ , conclusion neither positive nor negative;
need to consider conducting rigorous equivalence studies to find the answer. Our review thus points to areas where more research might be fruitful. The evidence relating to acupuncture’s value for pain control is similarly contradictory. Although one SR (16) concluded acupuncture-related treatment is effective in reducing pain compared with sham control, the other SR (17) failed to show benefit compared with no-treatment. Considering that highly effective mainstream treatments are available for this important indication (Table 3), we would require convincing data to consider acupuncture as a realistic option for clinical routine. It therefore seems unlikely that acupuncture might become an alternative to conventional pain control. However, future studies should be directed towards exploring its value as an adjunctive therapy for the management of postoperative pain. Our review has important limitations. Even though our search strategy was thorough, we cannot be sure that all relevant articles were located. Searching the literature in this area is often less than straight forward. The variable and often poor quality of the primary data limits the conclusiveness of the SRs and thus our analysis. Our approach of evaluating the evidence on the level of SRs risks disregarding many of the subtleties of the primary data. It also neglects subject areas for which no SRs are avail-
References 1 Singh S, Ernst E. Trick or Treatment? Alternative Medicine on Trial. London: Bantam Press, 2008. 2 Ernst E, Pittler MH, Wider B, Boddy K. The Desktop Guide to Complementary and Alternative Medicine, 2nd edn. Edinburgh: Elsevier Mosby, 2006. 3 Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008; 85(4): 355–75. 4 Wu C, Weber W, Kozak L et al. A survey of complementary and alternative medicine (CAM) awareness among neurosurgeons in Washington State. J Altern Complement Med 2009; 15(5): 551–5.
Cochrane review is positive but probably clinically not relevant High quality SRs show positive results Cochrane review is positive but probably clinically not relevant High quality SRs show positive results SR with sham-controlled RCTs High heterogeneity exists in meta-analysis , negative conclusion.
able. Some primary studies that might nevertheless be relevant for acupuncture’s role in surgery were therefore not considered in our assessment. We recommend that researchers follow the CONSORT guidelines when designing and reporting clinical trials (20). Our overview of SRs adhered to the PRISMA guidelines (21), and we recommend that future SRs do so as well to produce high quality SRs. In conclusion, even though several SRs have recently become available, the result of our overview failed to determine whether there are beneficial effects of acupuncture in the treatment or prevention of surgical conditions. Further rigorous RCTs seem warranted but need to overcome the many limitations of the current evidence.
Acknowledgement EE and MSL had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. MSL was supported by KIOM (K13281).
Funding No external funding.
5 Jadad AR, McQuay HJ. Meta-analyses to evaluate analgesic interventions: a systematic qualitative review of their methodology. J Clin Epidemiol 1996; 49(2): 235–43. 6 Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin Epidemiol 1991; 44(11): 1271–8. 7 Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev; 2009 (2): CD003281. 8 Zhu D, Lv HW. Effectiveness of p6 stimulation on postoperative nausea and vomiting: a meta-analysis. Chin J Evid Based Med 2010; 10(8): 923–31.
9 Abraham J. Acupressure and acupuncture in preventing and managing postoperative nausea and vomiting in adults. J Perioper Pract 2008; 18(12): 543–51. 10 Zhou X, Wang Q. Acupressure wristbands prevent postoperative nausea and vomiting: a meta-analysis. J Nutr Sci 2011; 26(6): 81–4. 11 Doran K, Halm MA. Integrating acupressure to alleviate postoperative nausea and vomiting. Am J Crit Care 2010; 19(6): 553–6. 12 Holmer Pettersson P, Wengstrom Y. Acupuncture prior to surgery to minimise postoperative nausea and vomiting: a systematic review. J Clin Nurs 2012; 14: 1799–805.
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
Acupuncture for surgical conditions
13 Dune LS, Shiao SY. Metaanalysis of acustimulation effects on postoperative nausea and vomiting in children. Explore 2006; 2(4): 314–20. 14 Chen M, Li S-T, Zheng H. Progress in acupuncture for treatment of postoperative nausea and vomiting in foreign countries. Chin J Clin Rehabil 2006; 10 (47): 112–4. 15 Usichenko TI, Lehmann C, Ernst E. Auricular acupuncture for postoperative pain control: a systematic review of randomised clinical trials. Anaesthesia 2008; 63(12): 1343–8. 16 Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain:
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
a systematic review of randomized controlled trials. Br J Anaesth 2008; 101(2): 151–60. 17 Lee H, Ernst E. Acupuncture analgesia during surgery: a systematic review. Pain 2005; 114(3): 511–7. 18 Chen Y, Huang JL, Gong X, Wu DR. Acupuncture treatment for postoperative ileus of systematic review of the literature. Shaanxi J Tradit Chin Med 2012; 33(3): 301–13. 19 Linde K, Vickers A, Hondras M et al. Systematic reviews of complementary therapies – an annotated bibliography. Part 1: acupuncture. BMC Complement Altern Med 2001; 1: 3.
789
20 Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Int J Surg 2011; 9(8): 672–7. 21 Moher D. Corrigendum to: Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. Int J Surg 2010; 8: 336–41.
Paper received September 2013, accepted November 2013
Acupuncture for surgical conditions: an overview of systematic reviews M. S. Lee,1 E. Ernst2
1
SUMMARY
Review criteria
Aim: Several systematic reviews (SRs) of acupuncture for surgical conditions have recently been published with sometimes contradicting results. The aim of this overview was to summarise recent SRs of acupuncture for surgical conditions. Method: Thirteen electronic databases were searched for relevant reviews published since 2000. Data were extracted by two independent reviewers according to predefined criteria. Results: Twelve SRs met our inclusion criteria. They related to the prevention or treatment of postoperative nausea and vomiting as well as to surgical or postoperative pain. Their results were far from uniform, and several caveats need to be considered. Conclusion: The evidence is insufficient to suggest that acupuncture is an effective intervention in surgical settings. More rigorous research seems warranted. This protocol was registered with PROSPERO database (registration number: CRD42013004817).
Introduction The current fascination which Western scientists seem to have with acupuncture started when James Reston, a journalist accompanying Henry Kissinger to China in 1971, had to have an appendectomy in the ‘Anti-Imperialist Hospital’ and was subsequently treated with acupuncture for his postoperative pain (1). He reported his experience in the New York Times on 26 July 1971, and his account triggered a flurry of interest and research. As a consequence, we now have hundreds of clinical trials of acupuncture (2) and several reasonable hypotheses regarding its mode of action (3). Yet many surgeons remain sceptical about the value of acupuncture, often arguing that the evidence is far from convincing (4). The aim of this article was to summarise and critically evaluate all systematic reviews (SRs) of acupuncture as a treatment of conditions relevant to surgery.
Methods Search methods for identification of studies Electronic literature searches, without language restrictions, were conducted in Pubmed, Embase, Amed, CINHAL, Health Technology Assessments,
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789. doi: 10.1111/ijcp.12372
We included all systematic reviews (SRs) of acupuncture surgical conditions after searching 13 databases from January 2000 to June 2013, without language restrictions.
Message to the clinic Acupuncture is one of the most popular types of CAM. It is sometimes used as a treatment for surgical conditions. The results of our overview of SR failed to provide reliable evidence for acupuncture in the treatment or prevention of surgical problems including postoperative nausea and vomiting or postoperative pain.
DARE, the Cochrane Library, five Korean Medical Database (Korean Studies Information, DBPIA, Korea Institute of Science and Technology Information, KoreaMed, and Research Information Service System), and one Chinese Database (CNKI). In addition, our departmental files were hand-searched. The time window for these searches was from 2000 to June 2013; older SRs were not considered because they would now be out of date. The search terms were ‘acupuncture OR acupressure OR moxibustion OR electroacupuncture OR auricular acupuncture’ AND ‘surgical OR operation OR surgery OR postoperative OR preoperative OR PONV’ AND ‘review OR meta-analysis’. Abstracts of reviews thus located were inspected by both authors and those appearing to meet the inclusion criteria were retrieved and read in full by the two authors. Reviews were defined as systematic if they included an explicit and repeatable method section with details on searching the scientific literature, and if they had explicit and repeatable inclusion and exclusion criteria.
Medical Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea 2 Complementary Medicine, Peninsula Medical School, University of Exeter, Exeter, UK Correspondence to: Edzard Ernst, Complementary Medicine, Peninsula Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK Tel.: + 44 (0)1392 726029 Fax: + 44 (0)1392 421009 Email: [email protected]
Disclosure None.
Type of studies Systematic review had to be concerned specifically with the therapeutic effectiveness of acupuncture in surgical settings and to include evidence from at least two controlled clinical trials.
783
Acupuncture for surgical conditions
Identification
Records identified through database searching (n = 901) Pubmed (n = 376), EMBASE (n = 397), Cochrane Library (n = 85) DARE (n = 28), HTA (n = 3), AMED (n = 6), CNKI (n = 6), Korean DBs (n = 0)
Records screened (n = 852)
Records excluded (n = 793)
Eligibility
Screening
Records after duplicates removed (n = 852)
Full-text articles assessed for eligibility (n = 59)
Full-text articles excluded, with reasons (n = 47) - Not related to AT (n = 6) - Not related to surgery (n = 28) - Not SR (n = 13)
Included
784
Studies included in qualitative synthesis (n = 12)
Figure 1 Flow chart of the publication-selection process. AT, acupuncture; SR, systematic review
Type of participants Systematic reviews were considered regardless of patients’ age and gender.
Type of intervention No limitation on the type of acupuncture stimulating techniques, e.g. body acupuncture, ear, electroacupuncture, laser, moxibustion or acupressure.
Data extraction and assessment of quality of SRs Hard copies of all articles were obtained and read in full by two independent reviewers. The data from articles were validated and abstracted according to predefined criteria that included the author information, the country of origin of the SRs, the treatment, condition, quality of primary studies, conclusion and result.
The assessments of the quality of the primary studies were adopted from the respective SRs. The Overview Quality Assessment Questionnaire (OQAQ) was used to evaluate the methodological quality of all of the included SRs (5,6). The OQAQ score ranges from 1 to 7; a score of 3 or less indicated extensive or major flaws, and a score of 5 or more suggested minor or minimal flaws. The two authors independently assessed the OQAQ and extracted the data using predefined criteria (Table 2), and discrepancies were settled by discussion.
Results Our searches produced 901 hits and 12 articles met our inclusion criteria (Figure 1, Table 1). The included reviews had been published between 2005 and 2012 (7–18). Their first authors originated from ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
P6 point stimulation (AT, EA, Laser AT, TENS, AP and related)
P6 point stimulation (AT, EA, AP, wristband, Laser AT, injection, and related)
AT, AP wristband
AP wristband
AP wristband
AT, AP
AT, AP, Laser AT, EA, AP wristband
Zhu (2010) (8)
Abraham(2008) (9)
Zhou (2011) (10)
Doran (2010) (11)
Holmer Pettersson (2012) (12)
Dune (2006) (13)
Treatment
Lee (2009) (7)
First author Year (Ref)
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
21
PONV
PONV
PONV in children
PONV
PONV
PONV
12
3
13
9
10
40
Condition
PONV
No. primary studies
Table 1 Systematic reviews of acupuncture for surgical conditions
Variable
Variables
Variable
Variable
Mostly poor
Variable
Variable
Quality of primary studies
AT-related vs. various controls Nausea (two studies): RR, 0.59 (0.46, 0.76) Vomiting (12 studies): RR, 0.69 (0.59, 0.80)
No
AP vs. placebo Nausea (nine studies): RR, 0.85 (0.72, 1.00); Vomiting (nine studies): RR, 0.50 (0.37, 0.66) No
AT-related vs. sham AT Nausea (27 studies): RR, 0.71 (0.61, 0.83); Vomiting (32 studies): RR, 0.7 (0.59, 0.83) AT-related vs. antiemetic Nausea (nine studies): RR, 0.82 (0.6, 1.13); Vomiting (14 studies): RR, 1.01 (0.77, 1.31) AT-related vs. sham AT Nausea (13 studies): RR, 0.71 (0.62, 0.80); Vomiting (13 studies): RR, 0.71 (0.60, 0.84) AT-related vs. antiemetic Nausea (five studies): RR, 1.19 (0.86, 1.66); Vomiting (four studies): RR, 0.75 (0.51, 1.11) No
Meta-analysis
1
Nausea:+ Vomiting: +
Nausea:+ Vomiting: +
1
3
Nausea:+ Vomiting: +
5 Usage of AP… can ease postoperative vomiting, but it cannot reduce PO nausea ‘class -definitely recommended’ evidence exists … … all kinds of AP stimulation,…, seem to prevent PONV with minimal side effects AT is as effective as medications
Nausea: Vomiting: Nausea: Vomiting: +
1
Nausea:+ Vomiting: +
7
Compared with sham stimulation, P6 stimulation can be effective in preventing PONV …
AT and AP are ineffective…
Nausea:+ Vomiting: +
Result
7
Quality of SR (OQAQ)
P6 acupoint stimulation prevented PONV
Conclusion (quote)
USA
Sweden
USA
China
UK
China
China
Country
Acupuncture for surgical conditions 785
AT-related vs. various control (four studies) OR, 6.39 (4.03, 10.15) Variable 6 PO ileus AT, EA, AP Chen (2012) (18)
AA, auricular acupuncture; AP, acupressure; AT, acupuncture; EA, electroacupuncture; Moxa, Moxibustion (stimulation of acupoints by heat); OR, odd ratio; PO, postoperative; PONV, postoperative nausea and vomiting; P6 point stimulation, stimulation at point ‘pericardium 6’; RR, risk ratio; TENS, transcutaneous electrical nerve stimulation; WMD, weight mean difference; +, overall positive; , fails to show effectiveness; +/ , unclear.
China 5
+/
Korea 7 AT, EA Lee (2005) (17)
Surgical pain
19
Variable
AT-related vs. sham AT (three studies) WMD, 14.57 ( 23.02, 6.13) AT vs. No-treatment (two studies) WMD, 5.60 ( 0.48, 11.68), Good PO pain AT, EA, AA, related Sun (2008) (16)
15
No Variable AA Usichenko (2008) (15)
PO pain
PONV AT + moxa Chen (2006) (14)
9
Strong evidence exists that real AT is not significantly different for placebo AT No conclusive evidence AT for PO ileus
+/ 7
USA
+/ 6
German
+/ 1
Efficacy has not been confirmed AA reduces postop pain is promising but not compelling PO AT may be a useful adjunct … No Variable
Condition Treatment
20
Result Quality of SR (OQAQ) Conclusion (quote) Meta-analysis Quality of primary studies No. primary studies First author Year (Ref)
Table 1 Continued
China
Acupuncture for surgical conditions
Country
786
the China (7,8,10,14,18), USA (11,13,16), UK (9), Korea (17), German (15) and Sweden (12). Seven reviews incorporated a meta-analytic approach (7,8,10,13,16–18). The reviews were based on 3–40 primary studies. They related to the following conditions: postoperative nausea/vomiting (PONV) (7– 14), postoperative pain or surgical pain (15–17) and postoperative ileus (18). Based on the OQAQ scores, the quality of the SRs varied; seven SRs had minimal bias (7,8,10,15–18), four SRs had major limitations (9,11,12,14) and the remaining SR had moderate flaws (13) (Table 2). Six SRs arrived at a clearly positive conclusion (7,8,10–13) and five referred to postoperative nausea (7,8,11–13) and six SRs referred to vomiting (7,8,10– 13) (Table 3). In four SRs (14–16,18), the conclusions were neither positive nor negative but unclear; one of these articles referred to PONV (14), two SRs related with surgical pain (15,16) and one SR was on postoperative ileus (18) (Table 3). Three SRs drew clearly negative conclusions (9,10,17); two referred to postoperative nausea (9,10), one to vomiting (9) and the other to surgical pain (17).
Discussion This overview shows that numerous SRs have recently addressed the question whether acupuncture and related techniques are effective in surgical settings. A similar overview of SRs published between 1989 and 2000 included only two articles related to surgery (19). This shows that the research interest in this area has increased considerably. The included SRs (Table 1) are not free of contradictions. The fact that SRs often fail to provide clear guidance for clinicians is well-known. In such instances, their main value may lie in directing more research towards areas of uncertainty. The current best evidence from SRs suggests that acupuncture might be effective for the prevention of PONV. The results of a meta-analysis (7,8) indicate that the effect size is small and probably not clinically relevant. The results of meta-analysis (7,8) concluded that acupuncture was as effective (or ineffective) as antiemetic drugs. Many of the trials that were included in the SRs did not test acupuncture per se, but electroacupuncture, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, an acupoint stimulation device and acupressure wristbands. This seems to indicate that we need more and better clinical trials to determine whether any of these treatments works and which, if any, is the most effective. Even if acupuncture turns out to be effective for PONV, the question remains whether and in what way it is superior to drug treatment. We therefore ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 783–789
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1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1
1 1 1
1 1 1
2 Was the search comprehensive?
1 1 1
0 0 1
1 1 0 1 1 0
3 Were the inclusion criteria reported?
1 1 0
1 0 1
1 1 0 1 1 0
4 Was selection bias avoided?
1 1 1
1 1 1
1 1 0 1 1 1
5 Were the validity criteria reported?
1 1 1
1 1 1
1 1 0 1 1 1
6 Was validity assessed appropriately?
The overall score is from 1 to 7. OQAQ ≤ 3, having extensive or major flaws; 5 ≤ OQAQ, having minor or minimal flaws.
Lee (2009) (7) Zhu (2010) (8) Abraham (2008) (9) Zhou (2011) (10) Doran (2010) (11) Holmer Pettersson (2012) (12) Dune (2006) (13) Chen (2006) (14) Usichenko (2008) (15) Sun (2008) (16) Lee (2005) (17) Chen (2012) (18)
First author Year (Ref)
1 Were the search methods reported?
Table 2 The Overview Quality Assessment Questionnaire (OQAQ) of included systematic reviews
1 1 0
1 1 1
1 1 1 0 1 1
7 Were the methods used to combine studies reported?
1 1 1
1 1 0
1 1 1 1 1 1
8 Were the findings combined appropriately?
1 1 1
1 0 1
1 1 1 1 1 1
9 Were the conclusions supported by the reported data?
7 7 5
3 1 6
7 7 1 5 1 1
10 Overall score
Acupuncture for surgical conditions 787
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Acupuncture for surgical conditions
Table 3 Indications evaluated by multiple SRs
Direction of results Condition
Number of SRs
+
+/
Comments
Nausea
8
5
1
2
Vomiting
8
6
1
1
Pain Ileus
3 1
0 0
2 1
1 0
+, positive conclusion; +/ , conclusion neither positive nor negative;
need to consider conducting rigorous equivalence studies to find the answer. Our review thus points to areas where more research might be fruitful. The evidence relating to acupuncture’s value for pain control is similarly contradictory. Although one SR (16) concluded acupuncture-related treatment is effective in reducing pain compared with sham control, the other SR (17) failed to show benefit compared with no-treatment. Considering that highly effective mainstream treatments are available for this important indication (Table 3), we would require convincing data to consider acupuncture as a realistic option for clinical routine. It therefore seems unlikely that acupuncture might become an alternative to conventional pain control. However, future studies should be directed towards exploring its value as an adjunctive therapy for the management of postoperative pain. Our review has important limitations. Even though our search strategy was thorough, we cannot be sure that all relevant articles were located. Searching the literature in this area is often less than straight forward. The variable and often poor quality of the primary data limits the conclusiveness of the SRs and thus our analysis. Our approach of evaluating the evidence on the level of SRs risks disregarding many of the subtleties of the primary data. It also neglects subject areas for which no SRs are avail-
References 1 Singh S, Ernst E. Trick or Treatment? Alternative Medicine on Trial. London: Bantam Press, 2008. 2 Ernst E, Pittler MH, Wider B, Boddy K. The Desktop Guide to Complementary and Alternative Medicine, 2nd edn. Edinburgh: Elsevier Mosby, 2006. 3 Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008; 85(4): 355–75. 4 Wu C, Weber W, Kozak L et al. A survey of complementary and alternative medicine (CAM) awareness among neurosurgeons in Washington State. J Altern Complement Med 2009; 15(5): 551–5.
Cochrane review is positive but probably clinically not relevant High quality SRs show positive results Cochrane review is positive but probably clinically not relevant High quality SRs show positive results SR with sham-controlled RCTs High heterogeneity exists in meta-analysis , negative conclusion.
able. Some primary studies that might nevertheless be relevant for acupuncture’s role in surgery were therefore not considered in our assessment. We recommend that researchers follow the CONSORT guidelines when designing and reporting clinical trials (20). Our overview of SRs adhered to the PRISMA guidelines (21), and we recommend that future SRs do so as well to produce high quality SRs. In conclusion, even though several SRs have recently become available, the result of our overview failed to determine whether there are beneficial effects of acupuncture in the treatment or prevention of surgical conditions. Further rigorous RCTs seem warranted but need to overcome the many limitations of the current evidence.
Acknowledgement EE and MSL had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. MSL was supported by KIOM (K13281).
Funding No external funding.
5 Jadad AR, McQuay HJ. Meta-analyses to evaluate analgesic interventions: a systematic qualitative review of their methodology. J Clin Epidemiol 1996; 49(2): 235–43. 6 Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin Epidemiol 1991; 44(11): 1271–8. 7 Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev; 2009 (2): CD003281. 8 Zhu D, Lv HW. Effectiveness of p6 stimulation on postoperative nausea and vomiting: a meta-analysis. Chin J Evid Based Med 2010; 10(8): 923–31.
9 Abraham J. Acupressure and acupuncture in preventing and managing postoperative nausea and vomiting in adults. J Perioper Pract 2008; 18(12): 543–51. 10 Zhou X, Wang Q. Acupressure wristbands prevent postoperative nausea and vomiting: a meta-analysis. J Nutr Sci 2011; 26(6): 81–4. 11 Doran K, Halm MA. Integrating acupressure to alleviate postoperative nausea and vomiting. Am J Crit Care 2010; 19(6): 553–6. 12 Holmer Pettersson P, Wengstrom Y. Acupuncture prior to surgery to minimise postoperative nausea and vomiting: a systematic review. J Clin Nurs 2012; 14: 1799–805.
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Acupuncture for surgical conditions
13 Dune LS, Shiao SY. Metaanalysis of acustimulation effects on postoperative nausea and vomiting in children. Explore 2006; 2(4): 314–20. 14 Chen M, Li S-T, Zheng H. Progress in acupuncture for treatment of postoperative nausea and vomiting in foreign countries. Chin J Clin Rehabil 2006; 10 (47): 112–4. 15 Usichenko TI, Lehmann C, Ernst E. Auricular acupuncture for postoperative pain control: a systematic review of randomised clinical trials. Anaesthesia 2008; 63(12): 1343–8. 16 Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain:
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a systematic review of randomized controlled trials. Br J Anaesth 2008; 101(2): 151–60. 17 Lee H, Ernst E. Acupuncture analgesia during surgery: a systematic review. Pain 2005; 114(3): 511–7. 18 Chen Y, Huang JL, Gong X, Wu DR. Acupuncture treatment for postoperative ileus of systematic review of the literature. Shaanxi J Tradit Chin Med 2012; 33(3): 301–13. 19 Linde K, Vickers A, Hondras M et al. Systematic reviews of complementary therapies – an annotated bibliography. Part 1: acupuncture. BMC Complement Altern Med 2001; 1: 3.
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20 Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Int J Surg 2011; 9(8): 672–7. 21 Moher D. Corrigendum to: Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. Int J Surg 2010; 8: 336–41.
Paper received September 2013, accepted November 2013
