Abstract
The present study attempts to critically evaluate previously published research articles on the efficiency of acupuncture in the treatment of diseases. First, 35 systematic reviews or meta-analysis were found in the Cochrane database. Second, 54 related articles were selected by searching important scientific databases. Based on the results obtained regarding the efficacy of acupuncture for the treatment of various diseases, the articles were divided into 3 groups. The first group of articles confirmed the efficacy of treatment by acupuncture. In the second group of articles, the therapeutic effect of acupuncture was shown; however, further research is required to verify the results. In the third group of articles there is no evidence regarding the therapeutic effect of acupuncture till now. There is an urgent need to design and conduct double-blinded randomized clinical trials with high-quality methodologies. This provides a more careful evaluation of acupuncture efficiency in relation to the treatment of a vast array of diseases, based on scientific evidence.
Acupuncture is one of the various kinds of traditional complementary and alternative medicines. The word acupuncture is derived from 2 Latin words: “acus,” meaning “needle,” and “puncture,” meaning “to penetrate.” The traditional treatment process is the insertion of needles at specific points into the body of patients. In addition to traditional and common methods of using needles, acupuncture includes acupressure, electro-acupuncture, and laser acupuncture. Although the ancient Greeks postulated that health requires a balance of vital humors, Asian cultures considered that health depends on the balance and flow of vital energies through the body. The latter theory underlies the practice of acupuncture, that is, vital energy flow can be restored by placing needles at critical body points. 1,2 The review and study of historical documents demonstrates that acupuncture originated in China. However, the remaining parts of tattoos in the bodies of the Icemen living about 3300 years BC show that acupuncture may have originated in other parts of the world 3 ; also, stones and bones related to 6000 years BC show that this method had been used in the ancient era. 4,5
To date, acupuncture is one of the most comprehensive traditional complementary and alternative approaches to medicine. Physicians and healers in various countries are using acupuncture to treat diseases. Universities and institutions not only in China but also in other parts of the world are attempting to train experts in acupuncture. 6 The number of studies done on acupuncture is considerable compared with other types of traditional complementary and alternative medicine. The expansions in the use of acupuncture within the field of training and treatment have led to the growing importance of studying and evaluating the effectiveness of acupuncture in the treatment of diseases based on scientific findings. Considering the increasing use of acupuncture in the treatment of various diseases, physicians, experts, and healers from different countries attended a symposium held by the World Health Organization (WHO) in June 1979. At this meeting, the participants drew up a list of 43 diseases amenable to treatment by acupuncture. In 2003, the WHO published a book introducing clinical trials in the field of acupuncture. 7
The importance and necessity of the evaluation of prevention methods, diagnosis, and treatment of diseases led to the establishment of special databases dealing with evidence-based medicine. 8,9 The Cochrane database is one of the most important and authoritative databases. The Cochrane database of scientific research contains a systematic review of clinical trials conducted on prevention, treatment, and rehabilitation of different diseases. By using standard tools, it evaluates interventional studies and measures their effectiveness. We evaluated the effectiveness of acupuncture in the treatment of diseases through studying systematic reviews with or without meta-analysis in the Cochrane database and other systematic reviews. Over the past 10 years, there have been very few systematic reviews appraising the efficacy of acupuncture in the treatment of diseases. In addition, there are limited studies that evaluate the quality of the systematic reviews and disregard the clinical aspects. 10,11
Methods
There is a general consensus among researchers that the Cochrane systematic reviews serve as the gold standard of systematic reviews. First, all systematic reviews with or without meta-analysis found in Cochrane database, comprising 35 articles on the effectiveness of acupuncture in the treatment of 33 diseases, were carefully studied. Subsequently, we searched MEDLINE, EMBASE, Google Scholar, ISI Web of Knowledge, National Center for Complementary and Alternative Medicine (NCCAM), Journals@Ovid, and Books@Ovid for relevant studies performed from 1997 to 2011. A combination of Medical Subject Heading (MeSH) and text words was then used to generate 2 subsets of citations comprising studies on acupuncture encompassing “acupuncture,” “ acupressure,” “ moxibustion,” “electro-acupuncture,” “auricular acupuncture,” “laser acupuncture,” “dry needling acupuncture,” “acupunc*” and “systematic reviews or reviews or Meta-analysis” with the disease keyword that was found in the Cochran library that was systematically reviewed by this center. Hence, the main inclusion criterion is the availability of disease in Cochrane database.
It should be noted that regardless of publication dates, the selection of articles was restricted to English language.
In addition, another source was acupuncture, review and analysis of reports on controlled clinical trials, published by the WHO, assessed 293 clinical trials on the effectiveness of acupuncture in different diseases. The effectiveness of acupuncture was divided into 4 categories and/or groups in this book only based on clinical trials. 7 The information in this source was carefully investigated and compared with disease that our systematic review or meta-analysis found in the Cochrane database or other sources. Also, the characteristics of the systematic review or meta-analysis articles were investigated based on the criteria of methodological issues like the number of participants in the systematic reviews, randomization, the number of articles indicating the inclusion or exclusion into the study, and blindness, allocation concealments, with or without meta-analysis. It is worth noting that in some articles the authors might have used randomization, blinding, or allocation concealment. However, as it is unclear in the articles, we consider the assumption of zero (Table 1) disease was chosen based on the Cochrane database.
The Aspects of Agreement and Disagreement With Acupuncture Efficiency in Classification of Diseases in Both the World Health Organization (WHO) and the Cochrane Study Group.
The diseases were categorized into 3 groups based on the degree of curative efficiency of acupuncture. The first category included 6 diseases, which according to studies showed significant responses to acupuncture treatment. The second category refers to the following 6 diseases that respond to the therapeutic effect of acupuncture, which need verification by further studies. The third category contained twice as many diseases as the first and second groups combined, including diseases for which there were no compelling evidence of the effectiveness of acupuncture treatment. The criteria for this classification were based on Cochrane database results as well as the published systematic reviews with or without meta-analysis in the same area.
Results
The study evaluated 88 systematic reviews exploring the efficiency of acupuncture in 33 diseases. The number of articles is shown in an ascending trend with regard to their publication dates in Figure 1. These articles included 28 studies about the effect of acupuncture on pain relief, 23 articles on the effectiveness of acupuncture in various disorders in the area of psychiatry and neurology, 17 articles about the effectiveness of acupuncture in the field of obstetrics and gynecology and infertility, 7 in joint diseases, 5 articles relating to the treatment of nausea and vomiting, and 2 reports on eye diseases. Then, based on the systematic review on the curative potential of acupuncture, the diseases treated with this procedure were divided into 3 groups. The first group consisted of 6 diseases (back pain, neck pain, headaches, migraine, nausea and vomiting, labor pain) in which the effectiveness of acupuncture has been proved by systematic reviews. The second group included 6 reviews on induction of labor, primary dysmenorrhea, rheumatoid arthritis, joints osteoarthritis, which need verification by further investigation. The third group involved 21 diseases for which the therapeutic effect of acupuncture has not yet been substantiated (Table 2).
Distribution of articles about systematic review with or with out meta analysis of acupuncture during the period 1997 until to 2011.
The Summary of Review Articles Related to Acupuncture.
Abbreviation: NR, not reported.
There are few agreements between viewpoints of the WHO and the Cochrane Study Groups about classification of diseases based on the efficacy of acupuncture. Only in 4 diseases did we see concordance between them (Table 1).
Discussion
First Category
Low Back Pain
The efficacy of acupuncture in treating back pain was evaluated in 10 systematic reviews. 12 –15 Earlier studies have not reported sufficient evidence to confirm the effectiveness of acupuncture in treating low back pain (LBP). 15 A systematic review has not provided compelling evidence of the successful treatment of LBP with transcutaneous electrical nerve stimulation. 16 But recent studies with larger sample sizes showed therapeutic effect of acupuncture in LBP. For example, Furlan et al, 16 based on a systematic review, performed in the Cochrane Study Group, demonstrated that acupuncture was more effective in the treatment of LBP than sham acupuncture (standard mean difference [SMD] = −0.78, 95% confidence interval [CI] = −1.52 to −0.04; relative risk [RR] = 2.62, 95% CI = 1.59 to 4.32). Lewis and Abdi 17 and Yuan et al 18 recommended the use of acupuncture for chronic LBP according to the European guideline for the treatment of chronic LBP. Recent studies also confirmed the effectiveness of acupuncture in the treatment of LBP. 19,20
Neck Pain
In their systematic review, White and Ernst 21 did not report the efficacy of acupuncture in treating neck pain. But Trinh et al, 22 in a meta-analysis in the Cochrane Study Group, showed that acupuncture was more effective in relieving neck pain compared to the control group, especially in the short term (SMD = −0.37, 95% CI = −0.61 to −0.12).
Headache
Eight studies have been conducted to explore the therapeutic effect of acupuncture in headache. Davis et al 23 showed that acupuncture had limited efficacy in comparison with sham acupuncture in reducing the frequency of tension headache. However, 7 studies including investigation conducted by the Cochrane group revealed the efficacy of acupuncture in the treatment of this disease. The researchers have considered the use of acupuncture as a nonmedication tool in the treatment of tension headache, and chronic recurrent headache compared with drug therapy. 24 –30
Migraine
Two systematic reviews were consulted regarding the effectiveness of acupuncture in the treatment of migraine headaches. In this context, a systematic review conducted in 2006 by Griggs and Jensen 31 did not reach a clear-cut conclusion. A systematic review and meta-analysis done by the Cochrane Study Group in 2009, and revised in 2011, indicated a beneficial effect of acupuncture on treating acute migraine attacks, alone or in combination with conventional treatment. This study showed that acupuncture was comparable to, or more effective than, preventive medications with fewer side effects. 32
Nausea and Vomiting
With regard to the efficacy of acupuncture in relieving nausea and vomiting, 5 systematic reviews were studied. Lee et al 33 attempted to determine the effect of acupuncture, electro-acupuncture, and acupressure in preventing vomiting after surgery. The results showed that their effects were similar to antivomiting drugs. They found that these methods are more effective in the treatment of nausea and vomiting 6 hours after surgery than placebo in adults, but not in children. A systematic review conducted by Ezzo et al 34 confirmed the curative efficacy of electro-acupuncture in the treatment of acute and delayed chemotherapy-induced nausea and vomiting in cancer patients. Streitberger et al 35 summarized the existing knowledge about the impact of acupuncture point stimulation on nausea and vomiting. To this end, they reviewed 26 trials. The results revealed that acupuncture point stimulation was effective for both postsurgical nausea and vomiting. Two meta-analyses were carried out by the Cochrane Study Group on this subject. In the first study, Lee and Fan 36 reviewed 40 trials by using acupuncture. P6 accupoint stimulation significantly reduced nausea (RR = 0.71, 95% CI = 0.61 to 0.83) and vomiting (RR = 0.70, 95% CI = 0.59 to 0.83). Ezzo et al 37 reviewed 11 studies about electro-acupuncture on acute vomiting, and the authors found that electro-acupuncture decreased acute vomiting.
Labor Pain
In a systematic review, Cho et al 38 found no evidence to support the use of acupuncture in controlling labor pain in randomized clinical trials, due to inconsistency and diversity of primary studies. Lee and Ernst 39 concluded that the evidence for acupuncture as adjunct to conventional pain control during labor is promising although they emphasized the need for further researches on the subject. The Cochrane group reviewed 9 trials reporting on acupuncture and 4 reporting on acupressure, where acupuncture was associated with less pain compared with the no intervention approach (SMD = −1.00, 95% CI = −1.33 to −0.67). One trial increased satisfaction with pain relief compared with placebo control (RR = 2.38, 95% CI = 1.78 to 3.99). Reduced application of pharmacological analgesia was found in one trial of acupuncture compared with placebo (RR = 0.72, 95% CI = 0.58 to 0.88). 40
Second Category
Induction of Labor
There were 2 systematic reviews on the effectiveness of acupuncture in inducing labor. One systematic review was conducted by the Cochrane pregnancy and childbirth group, where acupuncture was shown to be more effective compared with the induction of labor by standard methods using oxytocin and prostaglandins (RR = 1.45, 95% CI = 1.08 to 1.95). 41 Another systematic review undertaken by Lim and colleagues 42 indicated that the existing studies referred to the possible benefit of acupuncture in inducing labor. However, researchers in both studies suggested carrying out randomized clinical trials to substantiate the efficacy of acupuncture in labor induction.
Breech Presentation
We analyzed the results of 4 studies on the effects of acupuncture treatment in correcting breech position. In a systematic review, the Cochrane Group studied the safety and effectiveness of moxibustion to correct the breech presentation, based on criteria including the need to ECV (external cephalic version), delivery techniques, mortality, and complications around delivery. According to the results, the evidence supporting the effect of moxibustion to correct the breech presentation was inadequate, but proved to reduce the need of applying ECV (RR = 0.47, 95% CI = 0.33 to 0.66) and oxytocin (RR = 0.28, 95% CI = 0.13 to 0.60). 43 Li et al, 44 in a systematic review with meta-analysis, reported the effectiveness of moxibustion to correct the breech presentation in comparison with no treatment (RR = 1.35, 95% CI = 1.20 to 1.51) and other treatment methods (RR = 1.36, 95% CI = 1.31 to 1.54). Laser stimulation was more efficient than knee chest post and pelvic rotating (RR = 1.45, 95% CI = 1.22 to 1.72). 44 A systematic review and meta-analysis conducted by Vas et al 45 showed that moxibustion improved the status of breech and other unusual situations (nonvertex) compared with no treatment or other treatments (RR = 1.36, 95% CI = 1.17 to 1.58). Based on the systematic review of van den Berg et al, 46 in 2008 of 9 studies, including 3 cohort studies and 6 randomized clinical trials, it has been shown that BL67 acupuncture point in the correct position on abortion is more effective than conventional therapies. Overall, studies indicate the efficiency of moxibustion to correct breech position, but because of inconsistencies of the results, further comprehensive studies are needed to reach a definitive conclusion.
Primary Dysmenorrhea
There are 3 systematic reviews and meta-analysis on the effect of acupuncture treatment with regard to primary dysmenorrhea. In this context, a systematic review and meta-analysis conducted by the Cochrane Study Group, through assessment of 10 clinical trials, showed that acupuncture was effective in alleviating pain compared with placebo, nonsteroidal anti-inflammatory drugs, and Chinese herbal medicine (Yueyueshu). Also, treatment by acupuncture was more effective in reducing menstrual symptoms, such as nausea and back pain, than drug treatment (odds ratio [OR] = 7.2, 95% CI = 3.1 to 16.5). In one of the examined clinical trials in this systematic review, acupuncture was found to improve the quality of life compared with conventional medical cares. Based on the results, the Cochrane Study Group confirmed the effectiveness of acupressure in reducing menstrual pain and alleviating the symptoms compared with placebo. 47 Systematic reviews and meta-analyses conducted by Cho and Hwang 48 and Yang et al 49 confirmed the efficacy of acupuncture in the treatment of primary dysmenorrhea. However, they also emphasized doing further research with more participants and high-quality methodology.
Rheumatoid Arthritis
Four review articles studied the effects of acupuncture in the treatment of rheumatoid arthritis (RA). The study of Wang et al 50 reported positive results of active control trials, but suggested to carry out further high-quality randomized clinical trials. In a systematic review and meta-analysis conducted by Lee et al, 51 8 controlled randomized trials, including penetrating and nonpenetrating sham acupuncture, no specific effect of acupuncture on pain control was observed in these patients with RA, but emphasized to perform precise clinical studies on acupuncture treatment of RA. Choi et al, 52 in a systematic review and meta-analysis, could not confirm the efficacy of moxibustion compared with conventional therapy of RA patients, which was attributed to the lack of appropriate methodologies. Based on a systematic review and meta-analysis conducted in 2005 by Casimiro et al, 53 which was completed and updated in 2010, some clinical trials showed the efficacy of acupuncture in reducing knee pain in patients with RA (weighted mean difference [WMD] = −0.2, 95% CI = −0.36 to −0.04), but found little evidence regarding the effectiveness of acupuncture in reducing the other symptoms of this disease.
Joints Osteoarthritis
Peripheral joint osteoarthritis (OA) is one of the major causes of pain and restriction of motion, with limited effective treatments. A systematic review and meta-analysis was conducted by Manhiemer et al, 54 which comprised 12 clinical trials of knee OA, 3 series of hip joint OA, and a clinical trial including a combination of both diseases. They found a significant but little difference between the effect of acupuncture and control group, including sham acupuncture and waiting list, in reducing pain and improving motion limitation due to peripheral OA (RR = −0.29, 95% CI = −0.46 to −0.09). They also observed no significant difference between acupuncture combined with exercise-based rehabilitation program, as a complementary therapy, and the rehabilitation program alone. Know et al, 55 in a systematic review and meta-analysis, investigated the effectiveness of acupuncture, manual and electrical acupuncture, compared with control groups. Contrary to the effect of electric acupuncture, the results showed a significant difference between overall efficacy of acupuncture in reducing knee pain in patients with OA compared with the control group (RR = −0.89, 95% CI = −1.18 to −0.60). Overall, studies indicated a limited efficacy of acupuncture in reducing pain and improving motion limitation in peripheral joint OA. However, more comprehensive studies are needed to compare the efficacy of acupuncture with physical therapy techniques in such patients.
Cancer Pain
With regard to early and intermediate stages of cancer 40% of patients and with respect to advanced stages of cancer 90% of patients suffer from moderate to severe pain, and 70% of those who experience cancer pain do not receive appropriate treatment. Thus, efficacy of traditional medicine and complementary approaches, including acupuncture in controlling pain in cancer patients, has been considered by researchers. The efficiency of acupuncture in the treatment of cancer pain has been assessed in 5 systematic reviews, of which 3 studies involved a meta-analysis. A systematic review and meta-analysis by the Cochrane Groups confirmed the effectiveness of acupuncture compared with a placebo and conventional medical therapy (Western medicine analgesic drug) in the treatment of pain in clinical trials with high-quality methodology (SMD = −1.06, 95% CI = −0.51 to −1.61). 56 A systematic review and meta-analysis conducted by Choi et al 57 demonstrated the effectiveness of acupuncture combined with medication versus medication alone in the treatment of cancer pain. However, no significant difference was observed between the efficacy of acupuncture alone and medication. A systematic review conducted by Robb et al 58 investigated the effectiveness of the treatment of cancer pain with transcutaneous electrical nerve stimulation. Lee et al 59 carried out a systematic review of 7 carefully designed clinical trials on the efficacy of acupuncture in reducing pain from cancer, of which only one showed significant effectiveness for acupuncture compared with a placebo. Peng et al 60 studied 7 clinical trials on the effectiveness of acupuncture in the treatment of cancer pain in comparison with placebo, Western medications, Chinese medications, and combination of acupuncture with medication therapy. The results confirmed the efficiency of auricular acupuncture in reducing pain in cancer patients. The results of the above-mentioned studies prove the considerable efficacy of auricular acupuncture in alleviating cancer pain, a condition deserving further studies.
Third Category
Insomnia
Although medical and nonmedical treatments for insomnia bring about improvement in many patients in conventional medicine such as sedative, antidepressant, tranquilizer, and narcotic analgesics, using a variety of traditional and complementary medicine is common in this patient group. Therefore, it is necessary to assess the efficacy and safety of these methods. The systematic review and meta-analysis study conducted by the Cochrane Study Group on conventional acupuncture and acupressure, compared with placebo and no treatment, demonstrated an improvement in sleep quality score, but the result was not statistically significant (RR = 1.66, 95% CI = 0.68 to 4.03); therefore, sufficient evidence to confirm the efficacy of acupuncture in the treatment of such patients is not available, 61 In 4 systematic reviews, the efficacy of traditional acupuncture alone or in combination with drugs was compared to placebo auricular acupuncture, conventional drugs, and herbal therapy. Although some significant results have been reported, all of them have problems such as low quality of data, low quality of research methodology, and inadequate sample size; thus, scientific evidence is not conclusive and the need for quality design, including double-blind studies with placebo groups, has been emphasized. 62 –65
Epilepsy
In a systematic review and meta-analysis conducted by Cheuk and Wond, 66 which was first carried out in 2006 and updated in 2011, the effectiveness of acupuncture was compared with phenytoin, valproate, and other drugs with measurable outcomes such as seizure frequency, impact on quality of life of patients, reduced frequency of dizziness or impaired concentration, and improved Epilepsy Score. Clinical trials of this systematic review reported different results. In 5 clinical trials acupuncture treatment was not effective in reducing seizure frequency. In 2 clinical trials comparing traditional acupuncture (needle acupuncture) with phenytoin, seizure frequency decreased by 25% to 75%. Traditional acupuncture, compared with valproate, was effective in improving the quality of life, reduced impaired concentration and decreased frequency of defects, and at least 70% improvement in Epilepsy Score. Cat gut implantation at accupoint, in comparison with conventional drugs, showed similar effects in improving epilepsy. However, due to high risk of bias, short follow-up periods, and other limitations of clinical trials, there is still no evidence to prove the efficacy of acupuncture in the treatment of epilepsy. 66
Dementia
Dementia is a disease characterized by progressive deterioration of cognitive functions without a reduction in consciousness. As yet, there is no definite cure for vascular dementia. Different types of acupuncture methods are used for treating vascular dementia in hospitals in China. In the systematic review carried out by the Cochrane Group, 18 clinical trials on the issue of effectiveness of acupuncture in the treatment of vascular dementia were examined. None of the studies included randomized clinical trials or used an appropriate placebo control group; thus, the efficacy of acupuncture in the treatment of vascular dementia is still unclear. 67
Depression
In the study conducted by Cochrane Group, a systematic review of acupuncture in the treatment of depression showed that different types of acupuncture were compared with sham acupuncture treatment, drug treatment, psychiatric treatment, and no treatment. The effectiveness of acupuncture was not observed in most studies. Currently, there is insufficient evidence to recommend the use of acupuncture for the treatment of depression. 68 In 4 systematic reviews of which 3 included meta-analysis, the effectiveness of acupuncture in the treatment of major depressive disorder was evaluated, and the results were similar to the findings obtained by the Cochrane Group. This emphasized that there was no conclusive scientific evidence regarding effectiveness of acupuncture in the treatment of depression. 69 –72
Schizophrenia
Acupuncture is a relatively safe therapy with limited side effects compared to antipsychotic drugs, and for this reason researchers are encouraged to investigate the efficacy of this method in the treatment of patients with schizophrenia. In a meta-analysis conducted by the Cochrane Group, the results support the short-term effectiveness of antipsychotic drugs combined with acupuncture in comparison with antipsychotic drugs alone, and measuring Brief Psychiatric Rating Scale (WMD = −4.31, 95% CI = −7 to −1.6). Because these findings were based on the results of few studies and there was a lack of blinding and short follow-up period, at present, adequate evidence is not available to confirm the therapeutic effect of acupuncture in the treatment of schizophrenia. 73 The systematic review and meta-analysis study conducted by Lee et al 74 was similar to the results reported by the Cochrane Group. By and large, the available evidences are not sufficiently convincing.
Cocaine Dependence
Auricular acupuncture is widely used in the treatment of cocaine dependence. In the systematic review and meta-analysis conducted by the Cochrane Group, no significant differences were found between the effectiveness of auricular acupuncture and sham acupuncture and no treatment in reducing cocaine use (RR = 1.05, 95% CI = 0.89 to 1.23; RR = 1.06, 95% CI = 0.90 to 1.26). 75 The findings of Mills and colleagues 76 were in line of the Cochrane Group (RR = 0.76, 95% CI = 0.45 to 1.27). At present there is no scientific evidence regarding the effectiveness of acupuncture in treating cocaine addiction.
Smoking Relinquishment
According to the systematic review and meta-analysis on smoking relinquishment, there were no significant results in the long term (RR = 1.05, 95% CI = 0.82 to 1.35). Acupuncture was less effective than nicotine replacement therapy. Also, acupuncture was not found to be superior in comparison with psychotherapy interventions or waiting list in cessation of smoking. Laser therapy and electro-acupuncture were not found to have a significant impact. Overall, there was no scientific evidence of acupuncture efficacy and related techniques to combat the smoking habit. 77 In this context, the systematic review and meta-analysis study undertaken by Ashenden et al 78 were in agreement with the study of the Cochrane Group.
Bell’s Palsy
In the Cochrane Group’s systematic review, no significant difference was found between the effect of acupuncture combined with drug therapy including vitamin B1, B12, dexamethasone, steroids, and so on, and drug therapy alone. These studies did not report on associated side effects and had problems related to the quality of research and random sampling. 79 The results of systematic reviews conducted by He et al 79 and Zhou et al 80 were consistent with those of the Cochrane Group. Thus, compelling scientific evidence is needed to clarify the efficacy of acupuncture in the treatment of Bell’s palsy.
Autism Spectrum Disorder
Autism spectrum disorders (ASD) are characterized by impairment in social interaction and communication and lack of flexibility of thought and behavior. Acupuncture is widely used in traditional Chinese medicine and increasingly as a Western medical paradigm. But so far, clinical efficacy and safety of acupuncture in the treatment of ASD has not been studied. The Cochrane Group conducted a review and meta-analysis of 6 clinical trials including traditional acupuncture combined with conventional treatment and conventional therapy alone in the treatment of ASD. Significant effects were not found in 2 clinical trials that compared the effectiveness of acupuncture, traditional acupuncture with sham acupuncture. Some adverse effects of treatment such as increased irritability and sleep disorders and hyperactivity were associated with 4 clinical trials. Although some clinical trials have positive results, the low-quality studies, their heterogeneity, borderline and inconsistent results of the studies provided no convincing evidence of the efficacy of acupuncture in treatment of ASD. 81 These findings were in agreement with the result of the systematic review undertaken by Lee and colleagues. 82
Dysphagia After Stroke
Dysphagia after stroke, especially if it is prolonged, indicates poor prognosis of disease. Acupuncture is widely used in China for the treatment of swallowing dysfunction after stroke. The Cochrane Group evaluated the effectiveness of acupuncture in the treatment of dysphagia after acute stroke. In this study, 28 clinical trials were excluded due to lack of necessary criteria and only one single-blind randomized controlled clinical trial had the inclusion criteria. This clinical trial compared the effectiveness of acupuncture and electro-acupuncture in the scalp, and neck, along with placebo, sham acupuncture, or no acupuncture. Normal eating was observed in 35.5% and 21.9% of the patients treated with acupuncture and the control group, respectively, with no statistically significant difference between the groups (RR = 1.61, 95% CI = 0.73 to 3.58). There was no scientific evidence of therapeutic effects of acupuncture in improving dysphasia after acute stroke, a condition requiring further studies including high-quality clinical trials with appropriate sample size and a randomized group. 83 In this context, the systematic review and meta-analysis by Wong and colleagues 84 as well as the systematic review by Wang and colleagues 85 found no scientific evidence to support the efficacy of acupuncture, because their sample sizes were insufficient and their clinical trials were evaluated with a short follow-up period and had no coherence in assessing their patients’ outcomes.
Chronic Asthma
The Cochrane Study Group, in a systematic review and meta-analysis study, compared the efficacy of different types of traditional acupuncture, laser acupuncture, and so on, with control groups including sham acupuncture and conventional asthma treatment. Most trials showed no significant results regarding the efficacy of acupuncture in the treatment of chronic asthma. It is not possible to sum up the studies due to the heterogeneity and various methods of measuring the outcome variables. Overall, there is no evidence of the efficacy of acupuncture in the treatment of chronic asthma. 86 The results of a similar study performed by Martin and colleagues 87 were comparable to those of Cochrane Groups, which provided no evidence of the efficacy of acupuncture in asthma treatment.
Shoulder Pain
The traditional and complementary medicines have been increasingly used for the treatment of shoulder pain, which calls for further studies providing scientific evidences to prove the efficiency of these methods. A systematic review and meta-analysis study by the Cochrane Study Group investigated the effect of acupuncture compared with placebo, drug therapy, physical therapy, and other techniques in the treatment of shoulder pain due to adhesive capsulitis (frozen shoulder) and osteoarthritis. Totally inadequate sample size and heterogeneity of methodology led to little scientific evidences supporting the efficacy of acupuncture for treatment of shoulder pain, demanding designing and performing clinical trials with adequate sample size and appropriate methodology for determining the outcomes in a longer follow-up period. 88
Lateral Elbow Pain
Lateral elbow pain (tennis elbow) is a common disorder that causes elbow pain in the elbow and wrist that limits power and performance. Different types of acupuncture in China and Western countries have long been used in treating this disease. In the study by the Cochrane Group, a significant reduction in pain was found in acupuncture-treated subjects compared with placebo group in a short-term follow-up (RR = 0.09, 95% CI = 0.01 to 0.64). But in the long term (3-12 months), the results were not significant. The meta-analysis was not performed because of the low number of participants, lack of random assignment by using the correct methods, and the heterogeneity between studies. In general, there was no scientific evidence of confirming the efficacy and safety of acupuncture in treating lateral elbow pain. Therefore, clinical trials with adequate sample size and long-term follow-up period are required to reach a definitive conclusion. 89
Restless Legs Syndrome
Restless legs syndrome is a kind of motor disorder in which patients abundantly use complementary and traditional medicine. In the systematic review conducted by the Cochrane Group, acupuncture versus drug treatment in improving symptoms of diseases did not provide significant results (RR = 0.97, 95% CI = 0.76 to 1.2). Due to the small number of clinical trials, the results cannot confirm the adequacy of the effectiveness of acupuncture in treating restless leg syndrome, thus requiring further trials with larger sample sizes. 90
Glaucoma
In the systematic review conducted by the Cochrane Group, the effect of acupuncture in the treatment of glaucoma was evaluated. In this systematic review there were only 2 nonrandomized clinical trials, which were not adequately convincing due to lack of quality. Therefore, at present no scientific evidence confirms the efficacy of acupuncture in the treatment of glaucoma. 91
Progressive Myopia
Worldwide, 25% of people, with highest prevalence in Asia, are afflicted with some degree of progressive myopia, so-called refractive focusing errors. Women are more affected than men. In this context, the systematic review by the Cochrane Study Group included only 2 of 32 clinical trials. Based on this systematic review, acupuncture compared with placebo in improving myopia had no significant effect, and carrying out a meta-analysis was not possible because of differences in the outcomes of various studies. Thus, there is as yet no evidence of the effectiveness of acupuncture in slowing the progress of myopia. 92
Irritable Bowel Syndrome
Irritable bowel syndrome is a disorder of the gastrointestinal tract that is associated with chronic or recurrent abdominal pain. In a systematic review and meta-analysis study conducted by Lim et al, 93 no significant difference was observed between acupuncture and sham-treated groups according to the Global Symptom Score (RR = 1.28, 95% CI = 0.83 to 1.98). But 2 studies showed significant improvements in symptoms in patients treated with acupuncture combined with Chinese herbal medication “Tong Xie Yao Fang” (RR = 1.14, 95% CI = 1.00 to 1.31) and acupuncture along with psychotherapy, compared to psychotherapy alone (RR = 1.20, 95% CI = 1.03 to 1.39). However, no significant effect was found in patients receiving acupuncture compared with those treated with conventional methods (RR = 1.49, 95% CI = 0.94 to 2.34). 93 Therefore, due to the limited number of studies, lack of consistencies, and poor quality of the results of some researches, there was no conclusive evidence regarding the effect of acupuncture in the treatment of irritable bowel syndrome.
Uterine Fibroid
Uterine fibroids are muscular tumors that grow in the wall of the uterus. About 25% to 30% of women in the reproductive age are suffering from symptoms of uterine fibroids. There is no medical or surgical treatment for this disease other than hysterectomy. With regard to acupuncture treatment of uterine fibroid disease, 2 systematic reviews conducted by the Cochrane Group evaluated the efficacy and safety of acupuncture compared with sham acupuncture, waiting list, Chinese medicines, Western medicines, and other methods. However, no clinical trial was eligible for inclusion and the issue has remained unresolved up until now. Therefore, further studies including randomized controlled clinical trials with adequate sample sizes and longer follow-up periods are necessary to establish the efficacy of acupuncture treatment of uterine fibroid disease. 94
Polycystic Ovarian Syndrome
Polycystic ovarian syndrome presents with oligo-menorrhea and hirsutism. The most common treatments are medical therapy, surgery, and lifestyle modification. The conventional therapeutic approaches have problems such as high cost, increased risk of multiple pregnancies, undesirable side effects, and inconsistent effectiveness. Given that acupuncture has an impact on β-endorphin production, which may affect gonadotropin-releasing hormone secretion, it is postulated that acupuncture may have a role in ovulation induction and fertility. The Cochrane Group’s systematic review in 2011 showed no randomized controlled clinical trial to evaluate the efficiency of acupuncture in the treatment of this disorder. Thus, there are no sufficient evidences of acupuncture efficacy for treating this disease as yet. 95
Endometriosis
Endometriosis is a common disease among women, which is either symptomless or associated with severe pelvic pain. Control of pain in endometriosis is very difficult. Acupuncture has been studied in the treatment of gynecologic disorders, but its effectiveness in the treatment of endometriosis pain is unclear. A systematic review by the Cochrane Group only referred to a clinical trial with 67 participants. This review highlights the necessity for conducting well-designed, double-blind, and randomized controlled trials that assess various types of acupuncture compared with conventional therapies. 96
The Process of Embryo Transfer
For the first time about 55 years ago, embryo transfer was successfully performed on cattle, with embryo transfer by in vitro fertilization being the last step. In the study of the Cochrane Group, acupuncture was compared with controls in the process of embryo transfer, and the result showed significant effect on the live birth rate (OR = 1.86, 95% CI = 1.29 to 2.77). According to researchers, this result may be due to placebo effect and the low number of trials. Larger studies are necessary to confirm the results. 97 The systematic review and meta-analysis study conducted by El-Toukhy et al showed similar results. 98
Comparison of the Results of This Study With the World Health Organization Book
In the modern field of medicine, a great number of studies have been conducted regarding the therapeutic effects of acupuncture. The systematic review studies in acupuncture began in the 1960s. Numerous studies have been systematically reviewed ever since. Most systematic reviews tend to report the positive therapeutic effects of acupuncture. However, a critical review of these researches reveals that many studies are flawed in some way. 7 Randomized clinical trials that follow the Standard for Reporting Interventions in Controlled Trials of Acupuncture are necessary to accurately establish the therapeutic effect of acupuncture. This clarifies the authenticity of published reports and provides a better understanding and interpretation of the results. Also, the researchers are urged to elaborate on the kind of blinding, and inclusion or exclusion criteria considered in their studies. A comparison between the results of this study and those of WHO book are shown in Table 1. However, this book has been strongly criticized by the authors. The first criticism is that it did not take into consideration clinical trials that employ high-quality research methods. The second censure is that 20% of its articles on acupuncture trials were taken from a Chinese journal having reputation for bias. Chinese trials investigating the same intervention always yielded positive results. However, the results of Western trials of acupuncture contained a mix of mildly positive or negative effects. 8 On the other hand, it was amazing why no mention is made about evaluation of therapeutic effect of acupuncture in some diseases like epilepsy or ASD, which have been subjected to many clinical trials. On the other hand, we emphasize carrying out further studies on the curative effect of acupuncture in several diseases like biliary colic, acute infectious diarrhea, and leucopenia, which have been the subject of limited investigations. Also, the WHO book categorized disease into 4 grades, However, it has not been mentioned how they categorize these diseases.
The gold standard of our investigation was the Cochrane database. Cochrane reviews are systematic reviews of primary research in human health care and health policy and are internationally recognized as the highest standard in evidence-based health care. Each Cochrane review is a peer-reviewed systematic review that has been prepared by a team of authors and supported by a Cochrane Review Group editorial team in the collaboration. Therefore, we are sure the selected diseases have suitable inclusion of epidemiological parameters in each diagnosis. In addition, the remaining meta-analysis or systematic reviews were selected from popular databases, most of which consider some important parameter like randomization or blinding. Furthermore, these parameters are depicted in Table 1. The current study also found the landmark randomized trials with sham acupuncture as readers would avail of the extent of good trials. For example, in the studies by Furlean et al 16 with 2861 participants, Lewis and Abdi 17 with 6359 participants, and Yuan et al 18 with 6359 participant for LBP and studies by Melchart et al 25 with 1042 participants and Manias et al 26 with 1088 participant for head ache, there was demonstrable effectiveness of acupuncture compared with sham acupuncture.
Conclusion
By and large, there is a lack of proportion between compelling evidences supporting the extent of curative efficiency of acupuncture and managing a broad spectrum of diseases in connection with acupuncture application. Therefore, it is logical to confine acupuncture therapy to diseases responsive to this mode of treatment. In this context, comprehensive studies are needed to assess the efficiency of acupuncture in relation to other diseases.
Limitation
Because of the large numbers of studies conducted to assess the efficiency of acupuncture therapy in relation to the broad spectrum of diseases, a structured review of the systematic review and meta-analysis of such investigations was not undertaken, and the present study was that of a narrative review. However, the classification of systematic reviews was based on the structured review and meta-analysis of Cochrane, which is a gold standard for such studies and has considerable methodological quality and consistent with experts’ perspectives.
There were some difficulties in relation to categorizing diseases, for example, if we look at the 3 criteria for qualitative evaluation (randomization, random allocation, and blinding) in the third category, we have seen that most of them do not have good status for these criteria. This is one of the limitations of our study. Hence, further study is required.
Footnotes
Acknowledgment
We thank the Research Center for Traditional Medicine and History of Medicine. In addition, we express our appreciation to Shiraz University of Medical Sciences for its support.
Author Contributions
Alireza Salehi: primary idea and final approve writing and design of the manuscript. Maryam Marzban: revision and data collection and writing the manuscript. Mohammad Hadi Imanieh: revision and final approval.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Shiraz University of Medical Sciences supported this study.
Ethical Approval
This is a systematic review and does not need permission from the ethical committee.