Dokumentation for effekt af akupunktur Danske Akupunktører 24.november 2012

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1 Dokumentation for effekten af akupunktur I dette dokument er abstrakts for meta-analyser af kliniske forsøg med akupunktur samt abstrakts fra undersøgelser, der dokumenterer akupunkturs omkostnings-effektivitet. Bemærk venligst, at listen er et prioriteret uddrag af den dokumentation, der foreligger på effekten af akupunktur og er således ikke fuldt udtømmende. Såfremt yderligere dokumentation ønskes, bedes man rette henvendelse til Danske Akupunktører. Alle abstrakts er i det efterfølgende gengivet i det sprog, de er publiceret i, nemlig på engelsk. Til hvert abstrakt er der lavet en kort opsummering øverst i en boks på dansk. Indhold Dokumentation for effekten af akupunktur... 1 Kroniske non-maligne smerter... 2 Migræne... 3 Spændingshovedpine... 4 Post-operativ kvalme... 5 Kemoterapi-induceret kvalme og opkastninger... 6 Nakkesmerter... 7 Lændesmerter... 8 Menstruationssmerter... 9 Fødselssmerter Omkostning-effektanalyser Generel omkostnings-effektanalyse af akupunktur Omkostnings-effektanalyse af akupunktur ved kroniske smerter

2 Kroniske non-maligne smerter REFERENCE: Vickers AJ, Cronin AM, Maschino AC, Lewith G, Macpherson H, Foster NE, Sherman KJ, Witt CM, Linde K; for the Acupuncture Trialists' Collaboration. Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med Sep 10:1-10. doi: /archinternmed [Epub ahead of print] Denne meta-analyse omfatter patienter i 29 kliniske forsøg med akupunkturbehandling af nakkesmerter, slidgigt, kronisk hovedpine og skuldersmerter. Forfatterne konkluderer, at akupunktur har effekt på kroniske smerter og derfor bør indgå som en behandlingsmulighed. BACKGROUND Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain. METHODS We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of patients analyzed. RESULTS In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P <.001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, ), 0.16 (95% CI, ), and 0.15 (95% CI, ) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, ), 0.57 (95% CI, ), and 0.42 (95% CI, ) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias. CONCLUSIONS Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture. 2

3 Migræne REFERENCE: Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD DOI: / CD pub2. Published October 7, Denne Cochrane meta-analyse omfatter 4419 patienter i 22 kliniske forsøg med akupunkturs effekt på migræne og forebyggelse heraf. Forfatterne konkluderer at akupunktur er gavnlig alene eller i tillæg til rutine behandling af akutte anfald, samt har bedre effekt med færre bivirkninger end konventionel forebyggende behandling af migræne. BACKGROUND Acupuncture is often used for migraine prophylaxis but its effectiveness is still controversial. This review (along with a companion review on 'Acupuncture for tension-type headache') represents an updated version of a Cochrane review originally published in Issue 1, 2001, of The Cochrane Library. OBJECTIVES To investigate whether acupuncture is a) more effective than no prophylactic treatment/routine care only; b) more effective than 'sham' (placebo) acupuncture; and c) as effective as other interventions in reducing headache frequency in patients with migraine. SEARCH STRATEGY The Cochrane Pain, Palliative & Supportive Care Trials Register, CENTRAL, MEDLINE, EMBASE and the Cochrane Complementary Medicine Field Trials Register were searched to January SELECTION CRITERIA We included randomized trials with a post-randomization observation period of at least 8 weeks that compared the clinical effects of an acupuncture intervention with a control (no prophylactic treatment or routine care only), a sham acupuncture intervention or another intervention in patients with migraine. DATA COLLECTION AND ANALYSIS Two reviewers checked eligibility; extracted information on patients, interventions, methods and results; and assessed risk of bias and quality of the acupuncture intervention. Outcomes extracted included response (outcome of primary interest), migraine attacks, migraine days, headache days and analgesic use. Pooled effect size estimates were calculated using a random-effects model. MAIN RESULTS Twenty-two trials with 4419 participants (mean 201, median 42, range 27 to 1715) met the inclusion criteria. Six trials (including two large trials with 401 and 1715 patients) compared acupuncture to no prophylactic treatment or routine care only. After 3 to 4 months patients receiving acupuncture had higher response rates and fewer headaches. The only study with long-term follow up saw no evidence that effects dissipated up to 9 months after cessation of treatment. Fourteen trials compared a 'true' acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any outcome in any of the time windows, but the results of single trials varied considerably. Four trials compared acupuncture to proven prophylactic drug treatment. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment. Two small low-quality trials comparing acupuncture with relaxation (alone or in combination with massage) could not be interpreted reliably. AUTHORS' CONCLUSIONS In the previous version of this review, evidence in support of acupuncture for migraine prophylaxis was considered promising but insufficient. Now, with 12 additional trials, there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. There is no evidence for an effect of 'true' acupuncture over sham interventions, though this is difficult to interpret, as exact point location could be of limited importance. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment. 3

4 Spændingshovedpine REFERENCE: Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tensiontype headache. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD DOI: / CD Denne Cochrane meta-analyse omfatter 2317 patienter i 11 kliniske forsøg med akupunkturs effekt på spændingshovedpine. Forfatterne konkluderer at akupunktur kan være en værdifuld nonfarmakologisk behandling af episodisk eller kronisk spændingshovedpine. BACKGROUND Acupuncture is often used for tension-type headache prophylaxis but its effectiveness is still controversial. This review (along with a companion review on 'Acupuncture for migraine prophylaxis') represents an updated version of a Cochrane review originally published in Issue 1, 2001, of The Cochrane Library. OBJECTIVES To investigate whether acupuncture is a) more effective than no prophylactic treatment/routine care only; b) more effective than 'sham' (placebo) acupuncture; and c) as effective as other interventions in reducing headache frequency in patients with episodic or chronic tension-type headache. SEARCH STRATEGY The Cochrane Pain, Palliative & Supportive Care Trials Register, CENTRAL, MEDLINE, EMBASE and the Cochrane Complementary Medicine Field Trials Register were searched to January SELECTION CRITERIA We included randomized trials with a post-randomization observation period of at least 8 weeks that compared the clinical effects of an acupuncture intervention with a control (treatment of acute headaches only or routine care), a sham acupuncture intervention or another intervention in patients with episodic or chronic tension-type headache. DATA COLLECTION AND ANALYSIS Two reviewers checked eligibility; extracted information on patients, interventions, methods and results; and assessed risk of bias and quality of the acupuncture intervention. Outcomes extracted included response (at least 50% reduction of headache frequency; outcome of primary interest), headache days, pain intensity and analgesic use. MAIN RESULTS Eleven trials with 2317 participants (median 62, range 10 to 1265) met the inclusion criteria. Two large trials compared acupuncture to treatment of acute headaches or routine care only. Both found statistically significant and clinically relevant short-term (up to 3 months) benefits of acupuncture over control for response, number of headache days and pain intensity. Long-term effects (beyond 3 months) were not investigated. Six trials compared acupuncture with a sham acupuncture intervention, and five of the six provided data for meta-analyses. Small but statistically significant benefits of acupuncture over sham were found for response as well as for several other outcomes. Three of the four trials comparing acupuncture with physiotherapy, massage or relaxation had important methodological or reporting shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes in the control groups. AUTHORS' CONCLUSIONS In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches. 4

5 Post-operativ kvalme REFERENCE: Lee A, Fan LTY. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD DOI: / CD pub3 Denne Cochrane meta-analyse omfatter 4858 patienter i 40 kliniske forsøg med akupunkturs effekt på post-operativ kvalme. Forfatterne konkluderer, at akupunktur af punktet P6 forebygger postoperativ kvalme. BACKGROUND Postoperative nausea and vomiting (PONV) are common complications following surgery and anaesthesia. Drugs to prevent PONV are only partially effective. An alternative approach is to stimulate the P6 acupoint on the wrist. This is an update of a Cochrane review first published in OBJECTIVES To determine the efficacy and safety of P6 acupoint stimulation in preventing PONV. SEARCH STRATEGY We searched CENTRAL (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966 to September 2008), EMBASE (January 1988 to September 2008), ISI Web of Science (January 1965 to September 2008), the National Library of Medicine publication list of acupuncture studies, and reference lists of articles. SELECTION CRITERIA All randomized trials of techniques that stimulated the P6 acupoint compared with sham treatment or drug therapy for the prevention of PONV. Interventions used in these trials included acupuncture, electro-acupuncture, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, an acu-stimulation device, and acupressure in patients undergoing surgery. Primary outcomes were the risks of nausea and vomiting. Secondary outcomes were the need for rescue antiemetic therapy and adverse effects. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted the data. We collected adverse effect information from the trials. We used a random-effects model and reported relative risk (RR) with associated 95% confidence intervals (95% CI). MAIN RESULTS We included 40 trials involving 4858 participants; four trials reported adequate allocation concealment. Twelve trials did not report all outcomes. Compared with sham treatment P6 acupoint stimulation significantly reduced: nausea (RR 0.71, 95% CI 0.61 to 0.83); vomiting (RR 0.70, 95% CI 0.59 to 0.83), and the need for rescue antiemetics (RR 0.69, 95% CI 0.57 to 0.83). Heterogeneity among trials was moderate. There was no clear difference in the effectiveness of P6 acupoint stimulation for adults and children; or for invasive and noninvasive acupoint stimulation. There was no evidence of difference between P6 acupoint stimulation and antiemetic drugs in the risk of nausea (RR 0.82, 95% CI 0.60 to 1.13), vomiting (RR 1.01, 95% CI 0.77 to 1.31), or the need for rescue antiemetics (RR 0.82, 95% CI 0.59 to 1.13). The side effects associated with P6 acupoint stimulation were minor. There was no evidence of publication bias from contour-enhanced funnel plots. AUTHORS' CONCLUSIONS P6 acupoint stimulation prevented PONV. There was no reliable evidence for differences in risks of postoperative nausea or vomiting after P6 acupoint stimulation compared to antiemetic drugs. 5

6 Kemoterapi-induceret kvalme og opkastninger REFERENCE: Ezzo J, Richardson MA, Vickers A, Allen C, Dibble S, Issell BF, Lao L, Pearl M, Ramirez G, Roscoe JA, Shen J, Shivnan JC, Streitberger K, Treish I, Zhang G. Acupuncture-point stimulation for chemotherapyinduced nausea or vomiting. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD DOI: / CD pub2 Denne Cochrane meta-analyse omfatter 1247 patienter i 11 kliniske forsøg med akupunkturs effekt på kvalme og opkastninger i forbindelse med kemoterapi. Forfatterne konkluderer at akupunktur har en biologisk effekt på kvalme og at disse data komplementerer konklusionerne i tidligere forsøg med akupunktur post-operativ kvalme. BACKGROUND There have been recent advances in chemotherapy-induced nausea and vomiting using 5- HT3 inhibitors and dexamethasone. However, many still experience these symptoms, and expert panels encourage additional methods to reduce these symptoms. OBJECTIVES The objective was to assess the effectiveness of acupuncture-point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients. SEARCH STRATEGY We searched MEDLINE, EMBASE, PsycLIT, MANTIS, Science Citation Index, CCTR (Cochrane Controlled Trials Registry), Cochrane Complementary Medicine Field Trials Register, Cochrane Pain, Palliative Care and Supportive Care Specialized Register, Cochrane Cancer Specialized Register, and conference abstracts. SELECTION CRITERIA Randomized trials of acupuncturepoint stimulation by any method (needles, electrical stimulation, magnets, or acupressure) and assessing chemotherapy-induced nausea or vomiting, or both. DATA COLLECTION AND ANALYSIS Data were provided by investigators of the original trials and pooled using a fixed effect model. Relative risks were calculated on dichotomous data. Standardized mean differences were calculated for nausea severity. Weighted mean differences were calculated for number of emetic episodes. MAIN RESULTS Eleven studies (N = 1247) were pooled. Overall, acupuncture-point stimulation of all methods combined reduced the incidence of acute vomiting (RR = 0.82; 95% confidence interval (CI) 0.69 to 0.99; P = 0.04), but not acute or delayed nausea severity compared to control. By modality, stimulation with needles reduced proportion of acute vomiting (RR = 0.74; 95% CI 0.58 to 0.94; P = 0.01), but not acute nausea severity. Electroacupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% CI 0.60 to 0.97; P = 0.02), but manual acupuncture did not; delayed symptoms for acupuncture were not reported. Acupressure reduced mean acute nausea severity (SMD = -0.19; 95% CI to -0.01; P = 0.04) but not acute vomiting or delayed symptoms. Noninvasive electrostimulation showed no benefit for any outcome. All trials used concomitant pharmacologic antiemetics, and all, except electroacupuncture trials, used state-of-the-art antiemetics. AUTHORS' CONCLUSIONS This review complements data on post-operative nausea and vomiting suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies combining electroacupuncture with state-ofthe-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance. Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control. Noninvasive electrostimulation appears unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy. 6

7 Nakkesmerter REFERENCE: Trinh K, Graham N, Gross A, Goldsmith CH, Wang E, Cameron ID, Kay TM, Cervical Overview Group. Acupuncture for neck disorders. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD DOI: / CD pub3 Denne Cochrane meta-analyse omfatter 10 kliniske forsøg med akupunkturs effekt på kroniske nakkesmerter. Studiernes kvalitet rent metodologisk var moderat. Forfatterne konkluderer at akupunktur har en moderat effekt på nakkesmerter, der overgår inaktive behandlinger og sham akupunktur ved korttidsopfølgning. BACKGROUND Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied, as are the perceptions of benefits. Acupuncture has been used as an alternative to more traditional treatments for musculoskeletal pain. This review summarizes the most current scientific evidence on the effectiveness of acupuncture for acute, subacute and chronic neck pain. OBJECTIVES To determine the effects of acupuncture for individuals with neck pain. SEARCH STRATEGY We searched CENTRAL (2006, issue 1) and MEDLINE, EMBASE, MANTIS, CINAHL from their beginning to February We searched reference lists and the acupuncture database TCMLARS in China. SELECTION CRITERIA Any published trial using randomized (RCT) or quasi-randomized (quasi-rct) assignment to the intervention groups, either in full text or abstract form, were included. DATA COLLECTION AND ANALYSIS Two reviewers made independent decisions for each step of the review: article inclusion, data abstraction and assessment of trial methodological quality. Study quality was assessed using the Jadad criteria. Consensus was used to resolve disagreements. When clinical heterogeneity was absent, we combined studies using random-effects meta-analysis models. MAIN RESULTS We did not find any trials that examined the effects of acupuncture for acute or subacute pain, but we found 10 trials that examined acupuncture treatments for chronic neck pain. Overall, methodological quality had a mean of 2.3/5 on the Jadad Scale. For chronic mechanical neck disorders, there was moderate evidence that acupuncture was more effective for pain relief than some types of sham controls, measured immediately post-treatment. There was moderate evidence that acupuncture was more effective than inactive, sham treatments measured immediately post-treatment and at short-term follow-up (pooled standardized mean difference (SMD) -0.37, 95% confidence interval (CI) to -0.12). There was limited evidence that acupuncture was more effective than massage at short-term follow-up. For chronic neck disorders with radicular symptoms, there was moderate evidence that acupuncture was more effective than a wait-list control at short-term follow-up. AUTHORS' CONCLUSIONS There is moderate evidence that acupuncture relieves pain better than some sham treatments, measured at the end of the treatment. There is moderate evidence that those who received acupuncture reported less pain at short term follow-up than those on a waiting list. There is also moderate evidence that acupuncture is more effective than inactive treatments for relieving pain posttreatment and this is maintained at short-term follow-up. 7

8 Lændesmerter REFERENCE: Furlan AD, van Tulder MW, Cherkin D, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD DOI: / CD pub2 Denne Cochrane meta-analyse omfatter 35 kliniske forsøg med akupunkturs effekt på akutte og kroniske lændesmerter. Der var utilstrækkeligt med data til at konkludere på akupunkturs effekt på akutte lændesmerter. Forfatterne konkluderer, akupunktur på kort sigt har effekt på smertelindring og nedsat funktion ved kroniske lændesmerter og data supporterer akupunktur som en anvendelig tillægsbehandling af kroniske lændesmerter. BACKGROUND Although low-back pain is usually a self-limiting and benign disease that tends to improve spontaneously over time, a large variety of therapeutic interventions are available for its treatment. OBJECTIVES To assess the effects of acupuncture for the treatment of non-specific low-back pain and dryneedling for myofascial pain syndrome in the low-back region. SEARCH STRATEGY We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February SELECTION CRITERIA Randomized trials of acupuncture (that involves needling) for adults with non-specific (sub)acute or chronic low-back pain, or dry-needling for myofascial pain syndrome in the low-back region. DATA COLLECTION AND ANALYSIS Two authors independently assessed methodological quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analyses methods or levels of evidence when the data reported did not allow statistical pooling. MAIN RESULTS Thirty-five RCTs were included; 20 were published in English, seven in Japanese, five in Chinese and one each in Norwegian, Polish and German. There were only three trials of acupuncture for acute low-back pain. They did not justify firm conclusions, because of small sample sizes and low methodological quality of the studies. For chronic low-back pain there is evidence of pain relief and functional improvement for acupuncture, compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and at short-term follow-up. There is evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain. No clear recommendations could be made about the most effective acupuncture technique. AUTHORS' CONCLUSIONS The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain. For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain. Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area. 8

9 Menstruationssmerter REFERENCE: Smith CA, Zhu X, He L, Song J. Acupuncture for dysmenorrhoea. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD DOI: / CD pub2 Denne Cochrane meta-analyse omfatter 944 patienter i 10 kliniske forsøg med akupunkturs effekt på akutte menstruationssmerter. Metodologiske forskelle i studierne (fx anvendelse af akupressur eller akupunktur) vanskeliggør tolkningen af data. Forfatterne konkluderer, akupunktur formentlig har en effekt på smertelindring i forbindelse med menstruation og efterlyser flere veldesignede kliniske forsøg til at underbygge konklusionen yderligere. BACKGROUND This review examined the currently available evidence supporting the use of acupuncture to treat primary dysmenorrhoea. OBJECTIVES To determine the efficacy and safety of acupuncture in the treatment of primary dysmenorrhoea when compared with a placebo, no treatment, or conventional medical treatment (for example oral contraceptives and non-steroidal anti-inflammatory medication (NSAIDs)). SEARCH STRATEGY The following databases were searched (from inception until March 2010): the Cochrane Menstrual Disorders and Subfertillity Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), PubMed, CINAHL, PsycINFO, Chinese Biomedical Literature Database (CBM), Chinese Medical Current Content (CMCC), China National Knowledge Infrastructure (CNKI), VIP database, Dissertation Abstracts International, BIOSIS, AMED (The Allied and Complementary Medicine Database), Acubriefs, and Acubase. SELECTION CRITERIA Inclusion criteria included all published and unpublished randomised controlled trials comparing acupuncture with placebo control, usual care, and pharmacological treatment. The following modes of treatment were included: acupuncture, electro-acupuncture, and acupressure. Participants were women of reproductive age with primary dysmenorrhoea during the majority of the menstrual cycles or for three consecutive menstrual cycles, and moderate to severe symptoms. DATA COLLECTION AND ANALYSIS Meta-analyses were performed using odds ratios (OR) for dichotomous outcomes and mean differences or standard mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CI). Primary outcomes were pain relief and improved menstrual symptoms, measured by self-rating scales. Other outcomes included use of analgesics, quality of life, and absence from school or work. MAIN RESULTS Ten trials were included in the review with data reporting on 944 participants. Six trials reported on acupuncture (n = 673) and four trials (n = 271) reported on acupressure. There was an improvement in pain relief from acupuncture compared with a placebo control (OR 9.5, 95% CI to 51.8), NSAIDs (SMD -0.70, 95% CI to -0.32) and Chinese herbs (SMD -1.34, 95% CI to -0.95). One trial found a reduction in pain intensity compared with usual care (MD -2.09, 95% CI -2.99, -1.19). In two trials acupuncture reduced menstrual symptoms (for example nausea, back pain) compared with medication (OR 3.25, 95% CI 1.53 to 6.86); in one trial acupuncture reduced menstrual symptoms compared with Chinese herbs (OR 7.0, 95% CI 2.22, 22.06); and in one trial acupuncture improved quality of life compared with usual care. There was an improvement in pain relief from acupressure compared with a placebo control (SMD -0.99, 95% CI to ), and in one trial acupressure reduced menstrual symptoms compared with a placebo control (SMD , 95% CI to -0.10). The risk of bias was low in 50% of trials. AUTHORS' CONCLUSIONS Acupuncture may reduce period pain however there is a need for further well-designed randomised controlled trials. 9

10 Fødselssmerter REFERENCE: Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD DOI: / CD Denne Cochrane meta-analyse omfatter 1986 patienter i 13 kliniske forsøg med akupunkturs effekt på smerter i forbindelse med fødsel. Forfatterne konkluderer, akupunktur og akupressur kan spille en rolle som smertelindring i forbindelse med fødsler, øge tilfredsheden med smertebehandling og reducere medicinsk behandling og efterlyser desuden yderligere forskning på området. BACKGROUND Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined evidence supporting the use of acupuncture and acupressure for pain management in labour. OBJECTIVES To examine the effects of acupuncture and acupressure for pain management in labour. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and The Cochrane Complementary Medicine Field's Trials Register (October 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4), MEDLINE (1966 to October 2010), and CINAHL (1980 to October 2010). SELECTION CRITERIA Published and unpublished randomised controlled trials comparing acupuncture and acupressure with placebo, no treatment or other non-pharmacological forms of pain management in labour. We included all women whether primiparous or multiparous, and in spontaneous or induced labour. DATA COLLECTION AND ANALYSIS We performed meta-analysis using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. The outcome measures included pain intensity, satisfaction with pain relief, use of pharmacological pain relief, relaxation, caesarean section rate, augmentation with oxytocin, length of labour and anxiety. MAIN RESULTS We included 13 trials with data reporting on 1986 women. Nine trials reported on acupuncture and four trials reported on acupressure. Less intense pain was found from acupuncture compared with no intervention (standardised mean difference (SMD) -1.00, 95% confidence interval (CI) to -0.67, one trial, 163 women). One trial increased satisfaction with pain relief compared with placebo control (RR 2.38, 95% CI 1.78 to 3.19, 150 women). Reduced use of pharmacological analgesia was found in one trial of acupuncture compared with placebo (RR 0.72, 95% CI 0.58 to 0.88, 136 women), and compared with standard care, however, there was significant heterogeneity (RR 0.68, 95% CI 0.56 to 0.83, three trials, 704 women). Fewer instrumental deliveries from acupuncture were found compared with standard care (RR 0.67, 95% CI 0.46, 0.98, three trials, 704 women). Pain intensity was reduced in the acupressure group compared with a placebo control (SMD -0.55, 95% CI to -0.19, one trial, 120 women), and a combined control (SMD -0.42, 95% CI to -0.18, two trials, 322 women). No trial was assessed as being at a low risk of bias for all of the quality domains. AUTHORS' CONCLUSIONS Acupuncture and acupressure may have a role with reducing pain, increasing satisfaction with pain management and reduced use of pharmacological management. However, there is a need for further research. 10

11 Omkostning-effektanalyser Generel omkostnings-effektanalyse af akupunktur REFEERENCE: Kim SY, Lee H, Chae Y, Park HJ, Lee H. A systematic review of cost-effectiveness analyses alongside randomised controlled trials of acupuncture. Acupunct Med Oct 25. [Epub ahead of print] Denne omkostnings-effektanalyse omfatter 17 internationale studier med akupunkturs effekt på en lang række kroniske eller akutte tilstande. Forfatterne konkluderer, at akupunktur er en omkostnings-effektiv behandling og anfører, at en generalisering af disse resultater begrænses af variabiliteten af de undersøgte sygdomme samt geografiske forskelle i akupunkturs status. OBJECTIVE To summarise the evidence on the cost-effectiveness of acupuncture.methods: We identified full economic evaluations such as cost-effectiveness analysis (CEA), cost-utility analysis (CUA) and cost-benefit analysis (CBA) alongside randomised controlled trials (RCTs) that assessed the consequences and costs of acupuncture for any medical condition. Eleven electronic databases were searched up to March 2011 without language restrictions. Eligible RCTs were assessed using the Cochrane criteria for risk of bias and a modified version of the checklist for economic evaluation. The general characteristics and the results of each economic analysis such as incremental cost-effectiveness ratios (ICERs) were extracted. RESULTS Of 17 included studies, nine were CUAs that measured quality-adjusted life years (QALYs) and eight were CEAs that assessed effectiveness of acupuncture based on improvements in clinical symptoms. All CUAs showed that acupuncture with or without usual care was cost-effective compared with waiting list control or usual care alone, with ICERs ranging from 3011/QALY (dysmenorrhoea) to /QALY (allergic rhinitis) in German studies, and from 3855/QALY (osteoarthritis) to 9951/QALY (headache) in UK studies. In the CEAs, acupuncture was beneficial at a relatively low cost in six European and Asian studies. All CUAs were well-designed with a low risk of bias, but this was not the case for CEAs. CONCLUSIONS Overall, this review demonstrates the cost-effectiveness of acupuncture. Despite such promising results, any generalisation of these results needs to be made with caution given the diversity of diseases and the different status of acupuncture in the various countries. 11

12 Omkostnings-effektanalyse af akupunktur ved kroniske smerter REFERENCE: Ambrósio EM, Bloor K, MacPherson H. Costs and consequences of acupuncture as a treatment for chronic pain: a systematic review of economic evaluations conducted alongside randomised controlled trials. Complement Ther Med Oct;20(5): Epub 2012 Jun 6. Denne oversigtsartikel omfatter 8 økonomiske evalueringer af akupunkturs cost-effectiveness og cost-utility på en lang række kroniske eller akutte tilstande, herunder menstruationssmerter, nakkesmerter, migræne og hovedpine, lændesmerter og slidgigt. Forfatterne konkluderer, at akupunktur er en omkostnings-effektiv behandling ved visse kroniske smertetilstande. BACKGROUND The economic burden that chronic pain conditions impose on individuals and society is significant. Acupuncture appears to be a clinically effective treatment for some chronic pain conditions. Given the need for policy decisions to be informed by economic evaluations, the objective of this systematic review was to synthesise data from economic evaluations to determine whether acupuncture for the treatment of chronic pain conditions is good value for money. METHODS A literature search was conducted using health and economics databases, with additional hand-searching. Economic evaluations conducted alongside randomised controlled trials were eligible. RESULTS Eight economic evaluations were included in this review, seven cost-utility analyses and one cost-effectiveness analysis. Conditions treated included low back pain, neck pain, dysmenorrhoea, migraine and headache, and osteoarthritis. From the seven cost-utility analyses, acupuncture was found to be clinically effective but cost more. The cost per quality adjusted life year (QALY) gained ranged from 2527 to 14,976 per QALY, below the commonly quoted threshold used by the UK National Institute for Health and Clinical Excellence of 20,000 to 30,000. The one cost-effectiveness study indicated that there might be both clinical benefits and cost savings associated with acupuncture for migraine. There was heterogeneity across the eight trials in terms of professional who provided the acupuncture, style of acupuncture, and country of origin. CONCLUSION The cost per QALY gained in all seven cost-utility studies was found to be below typical thresholds of willingness to pay. Acupuncture appears to be a cost-effective intervention for some chronic pain conditions. 12