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expert reaction to study looking at acupuncture as an added treatment for angina

Research, published in JAMA Internal Medicine, reports that use of acupuncture in the reduction of angina attacks. 

 

Prof Edzard Ernst, Emeritus Professor of Complementary Medicine, University of Exeter, said:

“This study is in many ways odd.  It was concluded 4 years ago; why is it published only now?  The primary outcome measure was entirely subjective; an objective endpoint would have been valuable.  The success of patient blinding was not checked, but would have been important.  The discussion lacks critical input; this is perhaps best seen by looking at the reference list which contains not a single critical analyses of acupuncture.

“The therapists were not blinded (when using electroacupuncture, this would have been achievable).  Therefore, one explanation for the outcome lies in the verbal and non-verbal communication between therapists and patients.

“Acupuncture was used as an adjuvant therapy, meaning it was given alongside normal drug treatment, and it is conceivable that patients in the acupuncture group were more motivated to take their prescribed medications.  The costs for 12 sessions of acupuncture would be much higher (in the UK) than those for an additional medication.  The practicality of consulting an acupuncturist three times a week is questionable.  The long-term effects of acupuncture on angina pectoris are unknown.

“These new findings alone are not enough to be translated into clinical use without robust, independent replication first.  The wider context of previous research on acupuncture is also important.  At least three independent analyses have shown that previous studies from China on Traditional Chinese Medicine rarely show negative results.  Therefore, there is not a firm and robust body of previous evidence backing acupuncture.”

 

Prof Kevin McConway, Emeritus Professor of Applied Statistics, The Open University, said:

“This study generally seems to have been conducted and analysed pretty well.  But there’s a well-known aphorism that ‘extraordinary claims require extraordinary evidence’.  The theory behind acupuncture in traditional Chinese medicine isn’t accepted in conventional scientific medicine, so perhaps we should be particularly careful in looking at what might be going on in this study.  It’s important to note, though, that what was studied here was not acupuncture on its own, but acupuncture in combination with the sort of conventional treatments for angina that might be used anywhere.  And even if acupuncture doesn’t have an effect through the mechanisms described in traditional Chinese medicine, that doesn’t mean it can’t have an effect on disease in some other way.  There are several other conditions where acupuncture is generally accepted to be beneficial even from the point of view of Western scientific medicine.

“So, is there an alternative explanation for these new findings, beyond the possibility that adding acupuncture to other angina treatments might really reduce the number of angina attacks, on average?  There is one fairly obvious alternative.  The researchers were careful to ensure that the patients who received one of the three types of acupuncture were not told which type they received, and that the people recording and analysing the patients’ changes in health did not know what treatment each patient had received until after their work was done.  That’s good practice for avoiding biases in clinical trials.  But obviously the acupuncturists themselves did have to know what sort of acupuncture to perform.  Although the patients receiving acupuncture on the disease-affected meridian (the appropriate places for this condition according to traditional Chinese medicine) were supposed to be treated in exactly the same way as those having acupuncture on the non-affected meridian (the ‘wrong places’), it’s possible that the acupuncturists might have behaved slightly differently (probably unconsciously) in these two cases.  If so, that could have affected the treatment itself, directly, or it could have somehow communicated something to the patients that affected the outcomes.  It’s perhaps more likely that some of the patients who had sham acupuncture might have noticed that the treatment might not be ‘normal’ acupuncture, since the sham acupuncture did not produce a sensation known as ‘deqi’ that is considered to indicate effective needling.  Patients who had had acupuncture before for some reason might be aware of this.  So, I’d say, we can’t exclude the possibility that the results are due, in part at least, to something other than a real benefit of real acupuncture.

“The researchers do also point out that their research excluded people who previously had had a heart attack or several other types of heart disease, or indeed other serious diseases.  Thus the research can’t tell use anything direct about how acupuncture might help with angina in patients who do have these conditions.  Also, they point out that the research tells us nothing about long-term effects beyond the 16 week length of the trial.  And I do wonder what the results might have been in a different population in which acupuncture plays a different cultural role.  In this study, 94% of the patients had an expectation, before the study began, that acupuncture might have some success.  In a Western country, the level of scepticism about acupuncture might well be higher, and that might matter.”

 

Prof Tim Chico, Professor of Cardiovascular Medicine and Honorary Consultant Cardiologist, University of Sheffield, said:

“This study reported that treatment with acupuncture (in addition to prescription medication) improved the symptoms of angina.  The reasons for this are unclear, but even so-called ‘sham’ acupuncture or acupuncture where the needles were placed in the ‘wrong’ place had an effect compared with no treatment at all.  This suggests the placebo effect may account for some of the benefits seen.  However, the placebo effect alone would not explain why the ‘right’ type of acupuncture was more effective than the sham treatment.

“Although this study does provide some evidence of possible benefit, it would need larger studies to be certain the benefit seen in this study are not due to issues such as differences in the patients or their other treatments.  NICE guidance recommends that acupuncture should not be offered for angina, which is a reasonable position given the cost and time implications of acupuncture.”

 

Prof Hugh Montgomery, UCL Professor of Intensive Care Medicine, and Head of the Centre for Human Health and Performance, UCL, said:

“These data are interesting, but must be viewed with some caution.

“Patients were recruited in part from inpatient cardiology units.  This would be odd for a stable cardiac patient.  They were also recruited from departments of acupuncture- suggesting that they had prior treatment (and belief?) for some other diseases (as they were not meant to be receiving acupuncture therapy for angina).  Certainly, there is a risk that they would know which was a real meridian and which a sham, and also would culturally know what ‘sham acupuncture’ was given that they’d experienced ‘real’ acupuncture.

“Further,  the behaviour of a practitioner can communicate to a patient whether or not they are receiving a placebo treatment or one which the practitioner expects to work.  Indeed, if a person hands two syringes of placebo to a practitioner and tells them that syringe ‘A’ is the active treatment (when it isn’t), and the second person then administers each solution without telling the patient anything, pain relief is still more with placebo A than B.  It is thus really hard to allow for TRUE placebo in trials such as this.”

 

‘Acupuncture as Adjunctive Therapy for Chronic Stable Angina: A Randomized Clinical Trial’ by Ling Zhao et al. was published in JAMA Internal Medicine at 16:00 UK time on Monday 29 July 2019.

DOI: 10.1001/jamainternmed.2019.2407

 

Declared interests

Prof Edzard Ernst: “No conflicts of interest.”

Prof Kevin McConway: “Prof McConway is a member of the SMC Advisory Committee, but his quote above is in his capacity as a professional statistician.”

None others received.

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