Earlier this month the National Institute for Health and Care Excellence (NICE) released a draft of their new guideline on chronic pain and one of the treatment recommendations was acupuncture. Although acupuncture is commonly used to treat pain, recent research found that the evidence is conflicting and inconclusive. NICE usually takes a rigorous approach to developing guidelines, so how did they end up recommending a treatment that does not have good evidence of effectiveness? This is a complex issue that deserves further investigation.
Summary of conclusions:
1. The evidence in favour of acupuncture for chronic pain is weak and in many cases conflicting.
2. Traditional Chinese acupuncture is based on entirely false beliefs in qi, meridians and other pre-scientific concepts. It shouldn’t be included in any health guidelines.
3. NICE seem to have made a mistake in recommending acupuncture in their draft guidelines for chronic pain. Hopefully they will correct this mistake in the final guidelines.
What is acupuncture?
There are many different types of acupuncture, with all of them being based in some way on placing needles in various parts of the body. There are two main ideas that underpin acupuncture: (i) Traditional Chinese acupuncture based on qi (or chi) and meridians and (ii) Modern acupuncture based on a neurophysiological model (that acupuncture needles stimulate nerve endings and alter brain function). Qi and meridians are based on pre-scientific beliefs and should have no place in modern healthcare.
What do the NICE guidelines for chronic pain say about acupuncture?
The NICE guidelines state:
Consider a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:
- is delivered in a community setting, and
- is delivered by a band 7 (or lower) healthcare professional, and
- is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries).
Besides the recommendation for acupuncture itself, it’s concerning that NICE refer to “a traditional Chinese or Western acupuncture system” (emphasis mine). As previously stated, traditional Chinese acupuncture is based on Qi and meridians. These are concepts that conflict with modern science and have never been shown to actually exist.
Looking in the more detailed Evidence review for acupuncture, things get even worse. In that section, NICE refer directly to the concept of Qi and talk about this as if it’s a real thing. Here is what they say:
“Therapists trained in traditional Chinese medicine operate under the assumption of optimising the flow of the vital energy “Qi” in the body.”
Now there is no such thing as “vital energy” but, for some reason that I’m struggling to understand, NICE appears not to know this. They also go on to say:
“protagonists of traditional Chinese medicine (TCM) choose distant points in their attempts to harmonise the perceived misbalance of body functions and emotions.”
This is complete nonsense, yet here is the organisation that is responsible for producing evidence-based health and social care guidance in the UK taking about it in their guideline for chronic pain.
I have written previously on this blog about other guidelines produced by NICE such as this post about acupuncture for low back pain. Their approach to developing guidelines is usually extremely rigorous. I have also personally worked with them on other topics and seen the same thorough approach there too. I am staggered, and I don’t use this word lightly, that an organisation that is usually so careful and thorough is referring to traditional Chinese acupuncture, Qi and related concepts in the evidence used to develop their guideline on chronic pain.
What does the actual evidence say?
Within NICE’s Evidence review for acupuncture they include a series of “Clinical evidence statements”. For acupuncture versus sham acupuncture they have a large number of these statements. In almost all cases the evidence is labelled as low or very low quality. Is evidence of such low quality sufficient to make a recommendation in favour of a treatment? I would argue that it is not. When you take into account that several of the papers used to prepare these evidence statements are based on traditional Chinese acupuncture, I would suggest that the argument in favour of acupuncture looks even more dubious.
I have looked more closely at some of the papers that NICE refer to in their Evidence review for acupuncture. I have focused on those papers that a) compare acupuncture to sham and b) have a reasonably large sample size. A detailed explanation of why I have done this is beyond the scope of this article but in short: a) comparison with sham is important to control for non-specific treatment effects such as placebo and b) studies with larger sample sizes are more likely to provide accurate results than those with smaller sample sizes. Overall the quality of papers is poor with numerous methodological flaws in most of them, ranging from problems with blinding to issues with the statistical analysis. Even where these poor quality papers found a benefit the improvement was actually pretty small and unlikely to be clinically significant. Importantly, several of the studies are also based on the use of traditional Chinese acupuncture. Here is an example quote from one of the papers:
“The most frequently diagnosed TCM syndromes were Liver Qi stagnation (44.4%), followed by Spleen and Kidney Yang deficiency (21%) and Yin deficiency (13.6%).”
None of these things is recognised or accepted as a medical diagnosis and they are based on an outdated and incorrect approach to carrying out such a diagnosis. Taking all of this into account, it is hard to understand why NICE think acupuncture is a viable treatment for chronic pain.
Why did NICE include acupuncture as a recommendation for chronic pain?
The evidence for acupuncture as a treatment for chronic pain is pretty thin on the ground and in a recent review has been described as conflicting and inconclusive. The traditional Chinese medicine approach to acupuncture is based on things that do not exist and makes no logical sense. Why then did NICE include it as a recommendation in their guidelines for chronic pain? I had given this significant thought and not come up with a good answer. I did wonder if they were just short of interventions to include as a treatment for chronic pain and had concluded that acupuncture is the best of a bad bunch. However, I think that on balance there are two better explanations:
- As described in the post from Steve Novella on Science Based Medicine, NICE have failed to consider Science Based Medicine altogether. This is a serious failing for an organisation that has such an important role in creating guidelines for health and social care.
- One of the members of the NICE committee is Jens Foell, a GP who makes use of acupuncture in his practice and has even authored papers supporting acupuncture. In the Declaration of Interests register for the committee members he declares “I have been a member of the council of BMAS, the British Medical Acupuncture Society and member of the editorial board of “Acupuncture in Medicine” in the 12 months preceding joining the advisory I stood down from these posts in the last weeks”. This is someone who is clearly a strong supporter of acupuncture and provides a potential explanation for the inclusion of acupuncture within the guideline. The DoI was handled by having him “Declare and withdraw from drafting recommendations on acupuncture.” However, it also states that “The committee member will remain in the room for presentation of the evidence and may be asked to respond to specific questions from the committee regarding this topic.” Is having a fellow member of the committee who could speak confidently and strongly in favour of acupuncture likely to influence the committee’s decision? Absolutely! My thanks to David Colquhoun for highlighting this issue.
The other important point raised in the Science Based Medicine post is the risk of legitimising acupuncture and the potential for acupuncturists to use this NICE recommendation to market acupuncture for other conditions. Quoting from the SBM article “By recommending acupuncture for pain, based upon very weak evidence of a clinically tiny effect in the face of a lack of a plausible mechanism, you are throwing patients to the wolves.”
To conclude, it is a serious concern that NICE has failed to apply any sort of science-based approach when selecting treatments to include in their guideline. This has resulted in them recommending a treatment based on Qi, meridians and other nonsensical concepts. Even putting the lack of plausible scientific basis to one side, the evidence supporting acupuncture as a treatment for chronic pain is very weak. I am not the only one to have these concerns. Besides the article by Steve Novella on SBM, Edzard Ernst has also written about this and reaches similar conclusions. I think that NICE have made a serious mistake here and hope that they correct this error when they produce the final version of the guideline.
Last updated 06/09/20