Acupuncture for migraine prophylaxis.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR.
Source
Centre for Complementary Medicine Research, Department of Internal Medicine II, Technische Universitaet Muenchen, Wolfgangstr. 8, Munich, Germany, 81667. Klaus.Linde@lrz.tu-muenchen.de
Abstract
BACKGROUND:
Acupuncture is often used for migraine prophylaxis but its effectiveness is still controversial. This review (along with a companion review on 'Acupuncture for tension-type headache') represents an updated version of a Cochrane review originally published in Issue 1, 2001, of The Cochrane Library.
OBJECTIVES:
To investigate whether acupuncture is a) more effective than no prophylactic treatment/routine care only; b) more effective than 'sham' (placebo) acupuncture; and c) as effective as other interventions in reducing headache frequency in patients with migraine.
SELECTION CRITERIA:
We included randomized trials with a post-randomization observation period of at least 8 weeks that compared the clinical effects of an acupuncture intervention with a control (no prophylactic treatment or routine care only), a sham acupuncture intervention or another intervention in patients with migraine.
DATA COLLECTION AND ANALYSIS:
Two reviewers checked eligibility; extracted information on patients, interventions, methods and results; and assessed risk of bias and quality of the acupuncture intervention. Outcomes extracted included response (outcome of primary interest), migraine attacks, migraine days, headache days and analgesic use. Pooled effect size estimates were calculated using a random-effects model.
MAIN RESULTS:
Twenty-two trials with 4419 participants (mean 201, median 42, range 27 to 1715) met the inclusion criteria. Six trials (including two large trials with 401 and 1715 patients) compared acupuncture to no prophylactic treatment or routine care only. After 3 to 4 months patients receiving acupuncture had higher response rates and fewer headaches. The only study with long-term follow up saw no evidence that effects dissipated up to 9 months after cessation of treatment. Fourteen trials compared a 'true' acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any outcome in any of the time windows, but the results of single trials varied considerably. Four trials compared acupuncture to proven prophylactic drug treatment. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment. Two small low-quality trials comparing acupuncture with relaxation (alone or in combination with massage) could not be interpreted reliably.
AUTHORS' CONCLUSIONS:
In the previous version of this review, evidence in support of acupuncture for migraine prophylaxis was considered promising but insufficient. Now, with 12 additional trials, there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. There is no evidence for an effect of 'true' acupuncture over sham interventions, though this is difficult to interpret, as exact point location could be of limited importance. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.

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Acupuncture for tension-type headache.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR.
Source
Centre for Complementary Medicine Research, Department of Internal Medicine II, Technische Universitaet Muenchen, Wolfgangstr. 8, Munich, Germany, 81667. Klaus.Linde@lrz.tu-muenchen.de
Abstract
BACKGROUND:
Acupuncture is often used for tension-type headache prophylaxis but its effectiveness is still controversial. This review (along with a companion review on 'Acupuncture for migraine prophylaxis') represents an updated version of a Cochrane review originally published in Issue 1, 2001, of The Cochrane Library.
OBJECTIVES:
To investigate whether acupuncture is a) more effective than no prophylactic treatment/routine care only; b) more effective than 'sham' (placebo) acupuncture; and c) as effective as other interventions in reducing headache frequency in patients with episodic or chronic tension-type headache.
SELECTION CRITERIA:
We included randomized trials with a post-randomization observation period of at least 8 weeks that compared the clinical effects of an acupuncture intervention with a control (treatment of acute headaches only or routine care), a sham acupuncture intervention or another intervention in patients with episodic or chronic tension-type headache.
DATA COLLECTION AND ANALYSIS:
Two reviewers checked eligibility; extracted information on patients, interventions, methods and results; and assessed risk of bias and quality of the acupuncture intervention. Outcomes extracted included response (at least 50% reduction of headache frequency; outcome of primary interest), headache days, pain intensity and analgesic use.
MAIN RESULTS:
Eleven trials with 2317 participants (median 62, range 10 to 1265) met the inclusion criteria. Two large trials compared acupuncture to treatment of acute headaches or routine care only. Both found statistically significant and clinically relevant short-term (up to 3 months) benefits of acupuncture over control for response, number of headache days and pain intensity. Long-term effects (beyond 3 months) were not investigated. Six trials compared acupuncture with a sham acupuncture intervention, and five of the six provided data for meta-analyses. Small but statistically significant benefits of acupuncture over sham were found for response as well as for several other outcomes. Three of the four trials comparing acupuncture with physiotherapy, massage or relaxation had important methodological or reporting shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes in the control groups.
AUTHORS' CONCLUSIONS:
In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.

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Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S120-30.
Comparative effectiveness of exercise, acupuncture, and spinal manipulation for low back pain.
Standaert CJ, Friedly J, Erwin MW, Lee MJ, Rechtine G, Henrikson NB, Norvell DC.
Source
Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98104, USA. cjs1@uw.edu
Abstract
STUDY DESIGN:
Systematic review.
OBJECTIVE:
We sought to answer the following clinical questions: (1) Is structured exercise more effective in the treatment of chronic low back pain (LBP) than spinal manipulative therapy (SMT)? (2) Is structured exercise more effective in the treatment of chronic LBP than acupuncture? (3) Is SMT more effective in the treatment of chronic LBP than acupuncture? (4) Do certain subgroups respond more favorably to specific treatments? (5) Are any of these treatments more cost-effective than the others?
SUMMARY OF BACKGROUND DATA:
Exercise, SMT, and acupuncture are widely used interventions in the treatment of chronic LBP. There is evidence that all of these approaches may offer some benefit for patients with chronic LBP when compared with usual care or no treatment. The relative benefits or cost-effectiveness of any one of these treatments when compared with the others are less well-defined, and it is difficult to identify specific subgroups of those with chronic LBP who may preferentially respond to a particular treatment modality.
METHODS:
A systematic review of the literature was performed to identify randomized controlled trials comparing a structured exercise program, SMT, or acupuncture with one another in patients with chronic LBP.
RESULTS:
Two studies were identified comparing the use of structured exercise with SMT that met our inclusion criteria. Although these studies utilized different approaches for the exercise and SMT treatment groups, patients in both groups improved in terms of pain and function in both studies. Using random-effects modeling, there was no difference between the exercise and SMT groups when the data from these studies were pooled. We identified no studies meeting our inclusion criteria that compared acupuncture with either structured exercise or SMT or that addressed the relative cost-effectiveness of these approaches in the treatment of patients with chronic LBP.
CONCLUSION:
The studies identified indicate that structured exercise and SMT appear to offer equivalent benefits in terms of pain and functional improvement for those with chronic LBP with clinical benefits evident within 8 weeks of care
. However, the level of evidence is low. There is insufficient evidence to comment on the relative benefit of acupuncture compared with either structured exercise or SMT or to address the differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is also insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP. CLINICAL RECOMMENDATIONS: Structured exercise and SMT appear to offer equivalent benefits in the management of pain and function for patients with nonspecific chronic LBP. If no clinical benefit is appreciated after using one of these approaches for 8 weeks, then the treatment plan should be reevaluated and consideration should be given to modifying the treatment approach or using alternate forms of care. Strength of recommendation: Weak.There is insufficient evidence regarding the relative benefits of the acupuncture compared with either structured exercise or SMT in the treatment of chronic LBP.There is insufficient evidence to address differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP.

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Ann Intern Med. 2005 Apr 19;142(8):651-63.
Meta-analysis: acupuncture for low back pain.
Manheimer E, White A, Berman B, Forys K, Ernst E.
Source
University of Maryland School of Medicine, Center for Integrative Medicine, Baltimore, Maryland 21207, USA.
Erratum in
  • Ann Intern Med. 2005 Jun 7;142(11):950-1.
Abstract
BACKGROUND:
Low back pain limits activity and is the second most frequent reason for physician visits. Previous research shows widespread use of acupuncture for low back pain.
PURPOSE:
To assess acupuncture's effectiveness for treating low back pain.
DATA SOURCES:
Randomized, controlled trials were identified through searches of MEDLINE, Cochrane Central, EMBASE, AMED, CINAHL, CISCOM, and GERA databases through August 2004. Additional data sources included previous reviews and personal contacts with colleagues.
STUDY SELECTION:
Randomized, controlled trials comparing needle acupuncture with sham acupuncture, other sham treatments, no additional treatment, or another active treatment for patients with low back pain.
DATA EXTRACTION:
Data were dually extracted for the outcomes of pain, functional status, overall improvement, return to work, and analgesic consumption. In addition, study quality was assessed.
DATA SYNTHESIS:
The 33 randomized, controlled trials that met inclusion criteria were subgrouped according to acute or chronic pain, style of acupuncture, and type of control group used. The principal [correction] measure of effect size was the standardized mean difference, since the trials assessed the same outcome but measured it in various ways. For the primary outcome of short-term relief of chronic pain, the meta-analyses showed that acupuncture is significantly more effective than sham treatment (standardized mean difference, 0.54 [95% CI, 0.35 to 0.73]; 7 trials) and no additional treatment (standardized mean difference, 0.69 [CI, 0.40 to 0.98]; 8 trials). For patients with acute low back pain, data are sparse and inconclusive. Data are also insufficient for drawing conclusions about acupuncture's short-term effectiveness compared with most other therapies.
LIMITATIONS:
The quantity and quality of the included trials varied.
CONCLUSIONS:
Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.

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Top Stroke Rehabil. 2007 Jul-Aug;14(4):40-58.
Does acupuncture work for stroke rehabilitation: what do recent clinical trials really show?
Shiflett SC.
Source
Department of Psychology, University of Arizona, Tucson, AZ, USA.
Abstract
A number of randomized controlled trials of acupuncture for stroke recovery were critically reviewed, beginning with an existing systematic review and meta-analysis. A number of these clinical studies suffered from methodological flaws that tended to obscure and reduce the reported effect size. These flaws included inadequate statistical analysis, failure to adequately account for differences in baseline stroke severity, and the use of an inadequate posttreatment assessment period. These three flaws, taken individually or in combination, resulted in the underreporting of acupuncture effects in 5 of the randomized controlled trials reviewed. By informally adjusting study results for these limitations, it was possible to demonstrate that acupuncture is probably much more effective in assisting stroke recovery than has generally been reported, especially when the stroke is in the moderately severe range. The negative impact of well-intended but inappropriate exclusion criteria in the meta-analysis was also illustrated. The importance of giving more attention to ancillary results, such as walking speed and mortality, was illustrated as a way to gain a deeper understanding of the true impact of a still poorly understood therapy such as acupuncture. The general conclusion of the reanalysis presented here is that there is in fact substantial evidence that acupuncture is effective as an adjunctive treatment for facilitating stroke recovery.