Characteristics of acupuncture treatment associated with outcome: an individual patient meta-analysis of 17,922 patients with chronic pain in randomised controlled trials

Hugh MacPherson, Alexandra C Maschino, George Lewith, Nadine E Foster, Claudia M Witt, Andrew J Vickers, Acupuncture Trialists' Collaboration, Claire Allen, Mac Beckner, Brian Berman, Benno Brinkhaus, Remy Coeytaux, Angel M Cronin, Hans-Christoph Diener, Heinz G Endres, Nadine Foster, Juan Antonio Guerra de Hoyos, Michael Haake, Richard Hammerschlag, Dominik Irnich, Wayne B Jonas, Kai Kronfeld, Lixing Lao, George Lewith, Klaus Linde, Hugh MacPherson, Eric Manheimer, Alexandra Maschino, Dieter Melchart, Albrecht Molsberger, Karen J Sherman, Hans Trampisch, Jorge Vas, Andrew J Norbert Victor, Peter White, Lyn Williamson, Stefan N Willich, Claudia M Witt, Hugh MacPherson, Alexandra C Maschino, George Lewith, Nadine E Foster, Claudia M Witt, Andrew J Vickers, Acupuncture Trialists' Collaboration, Claire Allen, Mac Beckner, Brian Berman, Benno Brinkhaus, Remy Coeytaux, Angel M Cronin, Hans-Christoph Diener, Heinz G Endres, Nadine Foster, Juan Antonio Guerra de Hoyos, Michael Haake, Richard Hammerschlag, Dominik Irnich, Wayne B Jonas, Kai Kronfeld, Lixing Lao, George Lewith, Klaus Linde, Hugh MacPherson, Eric Manheimer, Alexandra Maschino, Dieter Melchart, Albrecht Molsberger, Karen J Sherman, Hans Trampisch, Jorge Vas, Andrew J Norbert Victor, Peter White, Lyn Williamson, Stefan N Willich, Claudia M Witt

Abstract

Background: Recent evidence shows that acupuncture is effective for chronic pain. However we do not know whether there are characteristics of acupuncture or acupuncturists that are associated with better or worse outcomes.

Methods: An existing dataset, developed by the Acupuncture Trialists' Collaboration, included 29 trials of acupuncture for chronic pain with individual data involving 17,922 patients. The available data on characteristics of acupuncture included style of acupuncture, point prescription, location of needles, use of electrical stimulation and moxibustion, number, frequency and duration of sessions, number of needles used and acupuncturist experience. We used random-effects meta-regression to test the effect of each characteristic on the main effect estimate of pain. Where sufficient patient-level data were available, we conducted patient-level analyses.

Results: When comparing acupuncture to sham controls, there was little evidence that the effects of acupuncture on pain were modified by any of the acupuncture characteristics evaluated, including style of acupuncture, the number or placement of needles, the number, frequency or duration of sessions, patient-practitioner interactions and the experience of the acupuncturist. When comparing acupuncture to non-acupuncture controls, there was little evidence that these characteristics modified the effect of acupuncture, except better pain outcomes were observed when more needles were used (p=0.010) and, from patient level analysis involving a sub-set of five trials, when a higher number of acupuncture treatment sessions were provided (p<0.001).

Conclusion: There was little evidence that different characteristics of acupuncture or acupuncturists modified the effect of treatment on pain outcomes. Increased number of needles and more sessions appear to be associated with better outcomes when comparing acupuncture to non-acupuncture controls, suggesting that dose is important. Potential confounders include differences in control group and sample size between trials. Trials to evaluate potentially small differences in outcome associated with different acupuncture characteristics are likely to require large sample sizes.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

References

    1. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H et al. (2012) Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med 172(19): 1444-1453. doi:10.1001/archinternmed.2012.3654. PubMed: .
    1. Hopton AK, Curnoe S, Kanaan M, MacPherson H (2012) Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey. BMJ Open. 2: e000456. doi:10.1136/bmjopen-2011-000456. PubMed: .
    1. Klaber Moffett JA, Carr J, Howarth E (2004) High fear-avoiders of physical activity benefit from an exercise program for patients with back pain. Spine. 29(11): 1167-1172. doi:10.1097/00007632-200406010-00002. PubMed: .
    1. Underwood MR, Morton V, Farrin A (2007) Do baseline characteristics predict response to treatment for low back pain? Secondary analysis of the UK BEAM dataset [ISRCTN32683578]. Rheumatology (Oxf). 46(8): 1297-1302. doi:10.1093/rheumatology/kem113.
    1. Brookes ST, Whitely E, Egger M, Smith GD, Mulheran PA, Peters TJ (2004) Subgroup analyses in randomized trials: risks of subgroup-specific analyses; power and sample size for the interaction test. J Clin Epidemiol 57(3): 229-236. doi:10.1016/j.jclinepi.2003.08.009. PubMed: .
    1. Stewart LA, Tierney JF (2002) To IPD or not to IPD? Advantages and disadvantages of systematic reviews using individual patient data. Eval Health Prof 25(1): 76-97. doi:10.1177/0163278702025001006. PubMed: .
    1. Brinkhaus B, Witt CM, Jena S, Linde K, Streng A et al. (2006) Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 166: 450-457. doi:10.1001/archinte.166.4.450. PubMed: .
    1. Witt C, Brinkhaus B, Jena S, Linde K, Streng A et al. (2005) Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet 366: 136-143. doi:10.1016/S0140-6736(05)66871-7. PubMed: .
    1. Foster NE, Thomas E, Barlas P, Hill JC, Young J et al. (2007) Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ. 335(7617): 436. doi:10.1136/. PubMed: .
    1. National Institute for Health and Clinical Excellence (2009) Low back pain: Early management of persistent non-specific low back pain National Institute for Health and Clinical Excellence. Available: . Accessed 16th September 2013.
    1. Hughes JG, Goldbart J, Fairhurst E, Knowles K (2007) Exploring acupuncturists' perceptions of treating patients with rheumatoid arthritis. Complement Ther Med. 15(2): 101-108. doi:10.1016/j.ctim.2006.09.008. PubMed: .
    1. Paterson C, Britten N (2004) Acupuncture as a complex intervention: a holistic model. J Altern Complement Med 10(5): 791-801. doi:10.1089/1075553042476669. PubMed: .
    1. Witt CM, Lüdtke R, Wegscheider K, Willich SN (2010) Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture? J Pain. 11(5): 431-435. doi:10.1016/j.jpain.2009.08.010. PubMed: .
    1. Birch S (2007) Reflections on the German Acupuncture Studies. Journal of Chinese Medicine.83: 12-17.
    1. Hanfileti L (2013) Medical acupuncture and traditional Chinese medicine: What licensed acupuncturists need to know about the training and qualifications of physicians providing medical acupuncture. Retrieved onpublished at whilst December year 1111 from . Accessed 16th September 2013.
    1. Wampold BE, Brown GS (2005) Estimating variability in outcomes attributable to therapists: a naturalistic study of outcomes in managed care. J Consult Clin Psychol 73(5): 914-923. doi:10.1037/0022-006X.73.5.914. PubMed: .
    1. Lewis M, Morley S, van der Windt DA, Hay E, Jellema P et al. (2010) Measuring practitioner/therapist effects in randomised trials of low back pain and neck pain interventions in primary care settings. Eur J Pain. 14(10): 1033-1039. doi:10.1016/j.ejpain.2010.04.002. PubMed: .
    1. Price S, Mercer SW, MacPherson H (2006) Practitioner empathy, patient enablement and health outcomes: a prospective study of acupuncture patients. Patient Educ Couns 63(1-2): 239-245. doi:10.1016/j.pec.2005.11.006. PubMed: .
    1. Scheid V (2012) Defining best practice or cultivating the best practitioner. In: Scheid V, MacPherson H. Integrating East Asian Medicine into Contemporary Healthcare.Edinburgh: Churchill Livingstone; pp. 13-38.

Source: PubMed

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