Acupuncture for surgical conditions: an overview of systematic reviews

Authors

  • M. S. Lee,

    1. Medical Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
    Search for more papers by this author
  • E. Ernst

    Corresponding author
    1. 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: E.Ernst@exeter.ac.uk

    Search for more papers by this author

  • Disclosure

    None.

Summary

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).

Review criteria

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.

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, 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.

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.

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 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).

Figure 1.

Flow chart of the publication-selection process. AT, acupuncture; SR, systematic review

Table 1. Systematic reviews of acupuncture for surgical conditions
First author Year (Ref) Treatment Condition No. primary studies Quality of primary studies Meta-analysis Conclusion (quote) Quality of SR (OQAQ) Result Country
  1. 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.

Lee (2009) [7]P6 point stimulation (AT, EA, Laser AT, TENS, AP and related)PONV40Variable

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)

P6 acupoint stimulation prevented PONV7

Nausea:+

Vomiting: +

China
Zhu (2010) [8]P6 point stimulation (AT, EA, AP, wristband, Laser AT, injection, and related)PONV21Variable

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)

Compared with sham stimulation, P6 stimulation can be effective in preventing PONV …7

Nausea:+

Vomiting: +

China
Abraham(2008) [9]AT, AP wristbandPONV10Mostly poorNoAT and AP are ineffective…1

Nausea:

Vomiting:

UK
Zhou (2011) [10]AP wristbandPONV9Variable

AP vs. placebo

Nausea (nine studies): RR, 0.85 (0.72, 1.00); Vomiting (nine studies): RR, 0.50 (0.37, 0.66)

Usage of AP… can ease postoperative vomiting, but it cannot reduce PO nausea5

Nausea:

Vomiting: +

China
Doran (2010) [11]AP wristbandPONV13VariableNo‘class -definitely recommended’ evidence exists …1

Nausea:+

Vomiting: +

USA
Holmer Pettersson (2012) [12]AT, APPONV3VariablesNo… all kinds of AP stimulation,…, seem to prevent PONV with minimal side effects1

Nausea:+

Vomiting: +

Sweden
Dune (2006) [13]AT, AP, Laser AT, EA, AP wristbandPONV in children12Variable

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)

AT is as effective as medications3

Nausea:+

Vomiting: +

USA
Chen (2006) [14]AT + moxaPONV20VariableNoEfficacy has not been confirmed1 +/ China
Usichenko (2008) [15]AAPO pain9VariableNoAA reduces postop pain is promising but not compelling6 +/− German
Sun (2008) [16]AT, EA, AA, relatedPO pain15Good

AT-related vs. sham AT

(three studies) WMD, −14.57 (−23.02, −6.13)

PO AT may be a useful adjunct …7 +/− USA
Lee (2005) [17]AT, EASurgical pain19VariableAT vs. No-treatment (two studies) WMD, 5.60 (−0.48, 11.68),Strong evidence exists that real AT is not significantly different for placebo AT7 Korea
Chen (2012) [18]AT, EA, APPO ileus6VariableAT-related vs. various control (four studies) OR, 6.39 (4.03, 10.15)No conclusive evidence AT for PO ileus5 +/− China
Table 2. The Overview Quality Assessment Questionnaire (OQAQ) of included systematic reviews
First author Year (Ref) 1 Were the search methods reported? 2 Was the search comprehensive? 3 Were the inclusion criteria reported? 4 Was selection bias avoided? 5 Were the validity criteria reported? 6 Was validity assessed appropriately? 7 Were the methods used to combine studies reported? 8 Were the findings combined appropriately? 9 Were the conclusions supported by the reported data? 10 Overall score
  1. 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]1111111117
Zhu (2010) [8]1111111117
Abraham (2008) [9]110000−1−1−11
Zhou (2011) [10]111−1110115
Doran (2010) [11]11−1−1−1−1−1−111
Holmer Pettersson (2012) [12]1100−1−1−1−111
Dune (2006) [13]110−111−1−113
Chen (2006) [14]1−100−1−1−1−101
Usichenko (2008) [15]1111111016
Sun (2008) [16]1111111117
Lee (2005) [17]1111111117
Chen (2012) [18]1110110115

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 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.

Table 3. Indications evaluated by multiple SRs
Condition Number of SRs Direction of results Comments
+ +/−
  1. +, positive conclusion; +/−, conclusion neither positive nor negative; −, negative conclusion.

Nausea8512

Cochrane review is positive but probably clinically not relevant

High quality SRs show positive results

Vomiting8611

Cochrane review is positive but probably clinically not relevant

High quality SRs show positive results

Pain3021SR with sham-controlled RCTs
Ileus1010High heterogeneity exists in meta-analysis

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 available. 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.

Ancillary