|Randomized clinical trials on acupuncture in Korean literature: a systematic review
|Kong J C, Lee M S, Shin B C
The authors found that no definitive conclusions could be drawn from Korean randomised controlled trials, concerning the use of acupuncture for the treatment of premenstrual syndrome, shoulder pain and low back pain, given the limited evidence included in this review. These cautious conclusions appropriately reflect this limitation.
To assess the effectiveness of acupuncture using randomised controlled trials published in Korean literature.
The following Korean databases were searched from inception to May 2007: National Assembly Library (of the Republic of Korea), Research Information Service System (RISS), Oriental Medicine Information System (OMIS), Korean Medical Database (KMBase), DBPIA, Koreanstudies Information Service System (KISS), and Research Information Centre for Health (RICH). Several libraries of the Oriental Medical School were also searched. Search terms were reported. Eight specialised Korean journals were handsearched.
Randomised controlled trials (RCTs) comparing the efficacy of needle acupuncture with or without electrical stimulation, with another active intervention, no intervention or placebo/sham acupuncture, were eligible for inclusion. Trials of any form of auricular acupuncture were also eligible for inclusion. However, the following types of trials were excluded: those evaluating two forms of acupuncture; other forms of acupuncture, such as laser acupuncture or acupuncture using moxibustion or transcutaneous electrical nerve stimulator (TENS); adjuvant acupuncture; bee-venom therapy; herbal acupuncture; trials of healthy participants; and trials with insufficient data or where only outcomes related to immunological or biological parameters were reported.
Included trials assessed the treatment of insomnia, post-operative nausea and vomiting, temporomandibular disorder, allergic rhinitis, premenstrual syndrome, frozen shoulder, chronic low back pain, chronic headache, post-thoracotomy pain and dysmenorrhoea. The majority of included trials assessed classic acupuncture techniques, but auricular acupuncture and electroacupuncture were also assessed. Comparators included placebo, other treatments and no treatment. A variety of condition specific outcomes were included, although a number of studies assessed pain, usually using a visual analogue scale.
The authors did not state how studies were selected for inclusion or how many reviewers carried out the assessment.
Assessment of study quality
Validity was assessed independently by two reviewers, using a modified version of the 5 point Jadad scale, which assessed the following criteria: randomisation, blinding of patient and/or outcome assessor, and withdrawals. Concealment of allocation was assessed using the Cochrane Collaboration criteria.
Any discrepancies were resolved through discussion or consultation with a third reviewer. The quality of the acupuncture intervention was also assessed by two experienced practitioners.
Two reviewers independently extracted the study data. The overall effects and p values for each outcome were recorded.
Methods of synthesis
Studies were grouped according to comparator (placebo, no treatment or other treatment) and combined in a narrative synthesis with summary data tables.
Results of the review
Ten randomised controlled trials (RCTs) including 597 randomised patients (sample size range from 20 to 101 patients), were included in the review. The methodological quality of the trials was poor, with seven trials reporting a Jadad score of less than 3 out of possible 5 points. The degree of confidence that acupuncture was applied appropriately ranged from 15 to 95%, with the authors reporting that they would have applied the intervention differently in two trials.
Acupuncture versus placebo: Acupuncture reduced the pain associated with premenstrual syndrome (p<0.05, one RCT), but failed to do so in frozen shoulder pain (one RCT) and chronic low back pain (one RCT), in comparison to placebo. One RCT of allergic rhinitis reported mixed treatment effects in comparison with placebo.
Auricular acupuncture versus no treatment: One RCT reported that sleep quality was improved in insomnia patients treated with auricular acupuncture, in comparison to no treatment (p<0.001). Another RCT reported that auricular acupuncture was significantly superior to no treatment in terms of the incidence of post-operative vomiting, retching, and nausea (p<0.01).
Electroacupuncture versus no treatment: One RCT reported that electroacupuncture improved pain (p<0.05) and the limitation of motion (not significant) in temporomandibular disorder patients compared to no treatment.
Acupuncture versus other treatments: None of the trials comparing acupuncture to other treatments reported a significant difference in pain between the treatment groups. These trials included treatments for the following different chronic pain conditions: stellate-ganglion block therapy for headaches (one RCT); analgesic treatment for post-thoracotomy pain (one RCT) and herbal medicine for dysmenorrhoea (one RCT). One RCT did report that acupuncture reduced the need for analgesics in comparison with analgesic treatment.
No definitive conclusions could be drawn from Korean randomised controlled trials, concerning the use of acupuncture for the treatment of premenstrual syndrome, shoulder pain and low back pain, given the limited evidence included in this review.
This review assessed a clear research question, which was limited by study design and location. A number of local Korean databases were searched, as appropriate to the review inclusion criteria, but relevant data concerning the effectiveness of acupuncture from other countries also practicing oriental medicine may have been missed. This limitation, in terms of geographical focus, should be borne in mind when interpreting the review findings. The authors also acknowledged that relevant Korean evidence may have been missed, due to the inherent risk of publication and location bias associated with this type of literature. However, steps were taken to reduce the risk of reviewer error and bias throughout the review process. Two reviewers independently assessed trials for both inclusion and data extraction. Two reviewers also independently assessed the quality of the trials using a validated assessment tool. However, the quality of the trials was found to be poor, so the data are unlikely to be reliable. Given the small number of trials included in the review and the differences in intervention, comparator, population and outcomes, the trials were appropriately combined in a narrative synthesis. Overall, the authors' cautious conclusions appropriately reflect the limitations of the included evidence.
Implications of the review for practice and research
Practice: The authors did not state any implication for practice.
Research: The authors stated that further randomised controlled trials (RCTs) are currently underway in Korea to assess the efficacy of acupuncture. Future RCTs need to be well-designed and rigorous and, in particular, should use comparable controls, treatment blinding (sham acupuncture) and assess the effectiveness of blinding.
Wonkwang University, Korea.
Kong J C, Lee M S, Shin B C. Randomized clinical trials on acupuncture in Korean literature: a systematic review. Evidence-Based Complementary and Alternative Medicine 2009; 6(1): 41-48
Subject indexing assigned by CRD
Acupuncture; Humans; Korea
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.