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The Journal of Alternative and Complementary Medicine Vol. 24, No. 8 pp. 752-769 (2018)

Overview of Treatment Guidelines and Clinical Practical Guidelines That Recommend the Use of Acupuncture: A Bibliometric Analysis

Stephen Birch (1), Myeong Soo Lee (2), Terje Alraek (1,3), and Tae-Hun Kim (4)

1 Department of Health Sciences, Kristiania University College, Oslo, Norway.
2 Clinical Medicine Division, Korea Institute of Oriental Medicine, Daejeon, Republic of South Korea.
3 Department of Community Medicine, Faculty of Medicine, National Research Centre in Complementary and Alternative Medicine, UiT The Arctic University of Norway, Tromso, Norway.
4 Korean Medicine Clinical Trial Center, Korean Medicine Hospital, Kyung Hee University, Seoul, Republic of Korea.

Abstract

Introduction:
As positive evidence emerges for the use of an intervention to treat a health problem, the intervention gradually becomes incorporated into treatment guidelines (TGs) or clinical practice guidelines (CPGs) that are related to that health problem. To assess whether this general hypothesis can apply to acupuncture, 96 health problems were identified for which positive conclusions in systematic reviews and meta-analyses regarding the effectiveness of acupuncture have been made and then searched for TGs or CPGs that have recommended the use of acupuncture.

Methods:
Through August 31, 2017, searches were performed in relevant medical databases and Google using “treatment guideline,” “clinical practice guideline,” and the names of the 96 medical conditions as search terms. A “snow-balling” search approach was adopted. All positive recommendations were added into the registry.

Results:
A total of 1311 publications were found that recommended using acupuncture published between 1991 and 2017. The number per year reached 50 in 2005 and 100 in 2009. In addition, 2189 positive recommendations were found for the use of acupuncture. Of these, 1486 were related to 107 pain indications and 703 were related to 97 nonpain indications. These recommendations were made by a wide range of groups, such as government health institutions, national guideline, and medical specialty groups. The recommendations came from around the world but were especially abundant in North America, Europe, and Australasia.

Discussion and Conclusion:
Considerably more recommendations were found for the use of acupuncture than are known within the acupuncture or medical communities. A trend by year was also found; a rise in the number of positive statements about acupuncture was typically followed by a rise in the number of recommendations of acupuncture. Thus, the recommendations followed the emergent evidence for acupuncture. Better implementation plans need to be developed for the CPG/TG recommendations about acupuncture to be more effective/efficient.

Free full text:
https://www.liebertpub.com/doi/full/10.1089/acm.2018.0092

Excerpts:

“When evidence of the effectiveness of a therapy emerges with evidence of the safety and cost-effectiveness of the therapy, medical treatment guidelines (TGs) or clinical practice guidelines (CPGs) should start to begin recommending the therapy, even when the evidence is not yet strong.1 Acupuncture has been tested in many clinical trials since the mid-1970s. In 2010, the Australian Department of Veterans Affairs found acupuncture to be effective for four conditions and trending toward effectiveness for one condition.2 A 2012 review of acupuncture for chronic pain conditions found it to be effective for a number of chronic pain conditions.3 In their 2014 synthesis of evidence for the U.S. Department of Veterans Affairs, Hempel et al. found that acupuncture was effective for three conditions, trending toward effectiveness for 20 conditions and was mixed positive for another 23 conditions.4 In their 2017 review, McDonald and Janz found that acupuncture was effective for 8 conditions, trending toward effectiveness for another 38 conditions and was mixed positive for another 70 conditions.5 Acupuncture has also been found cost-effective for several pain conditions6–11 and several nonpain conditions.12–15 Over the past 30 years, researchers have consistently shown that acupuncture is a safe therapy, when administered by properly trained practitioners.10,16–18 However, little has been known about the number of CPGs and TGs that include acupuncture.

“CPGs are defined as ‘systematically developed statements to assist practitioners and patients' decisions about appropriate health care for specific clinical circumstances.’19 CPGs tend to be more scientific and involve much time and work to complete. TGs in contrast tend to be less scientific and focus on providing clinical recommendations directly to healthcare practitioners often using nonacademic media for dissemination such as Medical Society websites, medical journals, and medical expert websites.”

“In 2012, Hughes and White briefly searched PubMed to determine how many clinical guidelines could be found that recommended acupuncture, these authors found 14 publications that recommended acupuncture for 10 different medical conditions.20 A recent article on acupuncture and pain suggested that the number of guidelines for acupuncture was underestimated.21 In a recent study, Cho et al. examined the extent to which CPGs reflected the actual evidence found in SRs and MAs for lower back pain. This review found six CPGs that recommended acupuncture and further concluded that current CPGs did not fully reflect the levels of evidence for acupuncture.22

“Given the emergent evidence base for the effectiveness, safety, and cost-effectiveness of acupuncture and contradictory claims about acupuncture and CPGs, the primary aim of this study is to explore the extent to which acupuncture has been recommended as a treatment option in TGs or CPGs. As a secondary aim, the timeline was examined for the CPGs/TGs that were found to explore whether they are related to the emerging evidence of effectiveness.”

“The term ‘acupuncture’ was used to include the use of acupuncture needles applied manually or with electrical stimulation anywhere on the body and regardless of theoretical framework.”

“To the authors' surprise, a considerable number of recommendations were found for the use of acupuncture. This search identified 1311 publications covering a 27-year period that have made 2189 positive recommendations for acupuncture for 204 health problems. Hence, the authors' findings are not in line with previous claims that the number of recommendations for acupuncture is less than the evidence suggests they should be21,22 and far exceed the earlier search the authors found.20

“Claims of publication bias in acupuncture-related research have been made, especially in Asia.23 It was found that only a small percentage of the guideline recommendations were published in Asia. The conventional medical communities that write CPGs in Korea and China, for example, do not generally include acupuncture in their considerations,1 and thus, the authors do not see this publication bias in the CPG/TG recommendations.

“In this article, the authors have addressed the question of the extent to which medical groups have recommended the use of acupuncture. The authors did not include or specifically search for publications that recommend not to use acupuncture because it was not found effective or had insufficient evidence. This issue will be dealt with in later publications.

“Moreover, the medical, research, and acupuncture communities are not aware of the extent to which acupuncture is recommended as a treatment in clinical guidelines, as evidenced by the few recommendations found in the 2012 search.20"

“If the acupuncture community as a stakeholder is not included in the guideline development group, implementation will obviously be hampered. Many guidelines were apparently written with insufficient acupuncture expert consultation such that acupuncture practitioners and their organizations did not know about them and could not act on them.”

“This search has found a surprisingly large number of recommendations (2189) for the use of acupuncture for over 200 health problems. These recommendations are mostly related to the emergent evidence of the effectiveness of acupuncture (87%).

“Considerably more recommendations for the use of acupuncture were found than is known within the acupuncture community or medical community. This suggests that medical healthcare providers around the world have begun incorporating or are seeking to incorporate acupuncture widely into healthcare but have not sought sufficient collaboration with the acupuncture community to enable the effectiveness of acupuncture. Thus, medical authorities need to develop better implementation plans to make the CPG/TG recommendations more effective.”