Science OF ACUPUNCTURE 2011

1. Science OF ACUPUNCTURE2011 RM Clemmons, DVM, PhD, CVA, CVFT University of Florida http://dog2doc.com/IVAS/

3. J Pain Symptom Manage. 2009 Apr;37(4):709-14. Epub 2008 Sep 11. Acupuncture: what does the most reliable evidence tell us? Many trials of acupuncture and numerous systematic reviews have recently become available. Their conclusions are far from uniform. In an attempt to find the most reliable type of evidence, this article provides an overview of Cochrane reviews of acupuncture. Such reviews were studied, their details extracted, and they were categorized as: reviews with a negative conclusion (no evidence that acupuncture is effective); reviews that were inconclusive; and reviews with a positive or tentatively positive conclusion. Thirty-two reviews were found, covering a wide range of conditions. Twenty-five of them failed to demonstrate the effectiveness of acupuncture. Five reviews arrived at positive or tentatively positive conclusions and two were inconclusive. The conditions that are most solidly backed up by evidence are chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. It is concluded that Cochrane reviews of acupuncture do not suggest that this treatment is effective for a wide range of conditions.

4. What does the literature say? • Total 17414 • Human 13244 • Animal 3223 • Scientific (clinical trials, meta-analysis, randomized control trials) • Human 2987 • Animal 53 435/year 75/year

5. Cites by species • Dog 231 • Cat 238 • Horse 68 • Cow 39 • Pig 37 • Bird 12 • Chicken 3 • Rodent 2044 • Human 13244

6. Feb-2011 to Feb-2012 • Total 1146 • Human 711 • Animal 112 • Scientific (Clinical trials, meta-analysis, random control trials) • Human 229 • English 123 • Chinese 108 • Animal 1

7. Animal Scientific Articles • Effect of acupuncture on allergen-induced basophil activation in patients with atopic eczema: a pilot trial. • The study design was a unicenter, single-blinded (observer), prospective, randomized clinical pilot trial with an additional experimental part. • Mean itch intensity in a visual analog scale was rated significantly lower in the acupuncture group (-25% +/- 26% [day 15-day 0]; -24% +/- 31% [day 33-day 0]) than in the control group (15% +/- 6% [day 15-day 0]; 29% +/- 9% [day 33-day 0]). The acupuncture group showed less CD63 positive basophils than the control group regarding stimulation with house dust mite and grass pollen allergen at various concentrations. • Results show a reduction of itch intensity and of in vitro allergen-induced basophil activation in patients with atopic eczema after acupuncture treatment.

8. Animal Scientific Articles • Survey of colleges and schools of veterinary medicine regarding education in complementary and alternative veterinary medicine. • Responses were received from 34 of 41 schools: 26 in the United States, 2 in Canada, 3 in Australia and New Zealand, and 3 in Europe. Sixteen schools indicated that they offered a CAVM course. Nutritional therapy, acupuncture, and rehabilitation or physical therapy were topics most commonly included in the curriculum. • The consensus among survey respondents was that CAVM is an important topic that should be addressed in veterinary medical education, but opinions varied as to the appropriate framework. The most common comment reflected strong opinions that inclusion of CAVM in veterinary medical curricula must be evidence-based.

9. Animal Scientific Articles • Effectiveness of electroacupuncture analgesia compared with opioid administration in a dog model: a pilot study. • Twelve dogs were randomly allocated into two groups. Dogs received either electroacupuncture stimulation (16 and 43 Hz) at Shen Shu, Chang Shu, He Gu, Tai Yuan, Zu San Li, Yang Ling Quan, and BaiHuiacupoints, while control dogs were treated with butorphanol. • Plasma β-endorphin levels in dogs receiving electroacupuncture increased significantly against baseline values after 1 and 3 h after surgery. Moreover, the end-tidal isoflurane concentration needed for second ovary traction was significantly lower in acupuncture-treated dogs than control animals. All animals having electroacupuncture experienced prolonged analgesia. • The results obtained from the present investigation showed some evidence for electroacupuncture as an alternative technique to provide postoperative analgesia in dogs.

10. Animal Scientific Articles • Acupuncture ameliorated skeletal muscle atrophy induced by hindlimb suspension in mice. • EA and MA reduced the HS-induced upregulation of atrogin-1 (p<0.01 in EA and MA) and MuRF1 (p<0.01 in EA) mRNAs. • Acupuncture partially prevented skeletal muscle atrophy. This effect might be due to an increase in protein synthesis and a decrease in protein degradation.

11. Animal Scientific Articles • Acupuncture-like stimulation at auricular point Heart evokes cardiovascular inhibition via activating the cardiac-related neurons in the nucleus tractussolitarius. • Acupuncture at auricular point Heart showed a more significant inhibitory effect on arterial pressure (-22.1±2.4mm Hg; P<0.001) and heart rate (-12.7±1.7 bpm; P<0.001) than that at ST36 and PC6. • Acupuncture at the auricular point Heart regulates cardiovascular function by activating baroreceptor sensitive neurons in the NTS in a similar manner as the baroreceptor reflex in cardiovascular inhibition.

12. Animal Scientific Articles • Electroacupuncture improves rectal distension-induced delay in solid gastric emptying in dogs. • EA is able to attenuate RD-induced delay in gastric emptying of solids, and this ameliorating effect may be mediated via the opioid pathway. EA may have a therapeutic potential for treating delayed gastric emptying attributed to lower gut distension.

13. Animal Scientific Articles • Synchrotron radiation phase-contrast X-ray CT imaging of acupuncture points. • Three-dimensional (3D) topographic structures of acupuncture points were investigated by using synchrotron radiation in-line X-ray phase contrast computerized tomography. Two acupuncture points, named Zhongji (RN3) and Zusanli (ST36), were studied. We found an accumulation of microvessels at each acupuncture point region. Images of the tissues surrounding the acupuncture points do not show such kinds of structure. This is the first time that 3D images have revealed the specific structures of acupuncture points.

14. Animal Scientific Articles • TRPV1 expression in acupuncture points: response to electroacupuncture stimulation. • Study was to examine the distribution of transient receptor potential vanilloid type-1 (TRPV1) receptor immunoreactivity in the acupuncture points. • The expression of TRPV1 in nerve fibers is significantly increased by EA stimulation in acupoints. • A high expression of TRPV1 endowed with nNOS in subepidermal nerve fibers exists in the acupoints and the expression is increased by EA.

15. Animal Scientific Articles • Acupuncture prevents relapses of recurrent otitis in dogs: a 1-year follow-up of a randomised controlled trial. • One-year follow-up of a randomised controlled trial. 31 dogs with a history of recurring otitis were randomised into two groups. • The main outcome for the follow-up was the rate of acute otitis episodes in each group over 1 year, with blinded evaluation. • Acupuncture seems effective for preventing relapses in cases of recurrent canine otitis.

16. Animal Scientific Articles • Electroacupuncture at ST-36 relieves visceral hypersensitivity and decreases 5-HT(3) receptor level in the colon in chronic visceral hypersensitivity rats. • The abdominal electromyogram (EMG) in response to colorectal distension was selected as the index for measurement of visceral hypersensitivity. 5-HT(3) receptors were analyzed through reverse transcription-polymerase chain reaction and western blot. • EA at ST-36 significantly decreased evoked EMG. • EA at acupoint ST-36 attenuates CVH in rats and decreases 5-HT(3) receptor level in the colon.

17. Animal Scientific Articles • The effects of stimulation at acupoint ST36 points against hemorrhagic shock in dogs. • Thirty healthy dogs were randomly divided into 5 groups: sham hemorrhagic shocked group, hemorrhagic shocked group, EA group, nonacupuncturing group, and EA after vagotomy group. Zusanli points were electroacupunctured with constant voltage (10-15 V, 30 Hz) for 30 minutes immediately after the shock models were established. • In the EA group, the levels of MAP, cardiac output, cardiac index, central venous pressure, and pulmonary arterial wedge pressure gradually increased, but the content of serum TNF-α and lactate obviously decreased. • The results suggested that EA zusanli points produce a protective effect on hemorrhagic shock in dogs.

18. Science by system (Highlights) • GI 3 • Perioperative acupuncture and postoperative acupressure can prevent postoperative vomiting following paediatric tonsillectomy or adenoidectomy: a pragmatic randomisedcontrolled trial. • Heart 4 • Acupuncture to Danzhong(CV17) increases the cardiac vagal component of heart rate variability. Provides strong evidence for the presence of a specific acupunctural point that causes the modulation of cardiac autonomic function. • Blood Pressure 1 • Acupuncture treatment (PC6, Shen Men, BL15) prevents arrhythmic recurrences after cardioversion in patients with persistent AF. This minimally invasive procedure was safe and well tolerated.

19. Science by system (Highlights) • Vomiting 3 • Fentanyl requirement of 116 patients were available for the final analysis. Patients from AA group required 15% less fentanyl during surgery than the controls. • Tetanic stimulation applied to the P6 acupuncture point can reduce PONV after laparoscopic hysterectomy, resulting in a greater degree of patient satisfaction. • Hearing 1 • Acupuncture and moxibustion therapy of excitation-focus transfer presents superior therapeutic effect on sudden deafness as compared with the routine western therapy. • Cancer 10 • Magnetic acupressure at the LI4 acupoint requires minimal training and expense and is well tolerated. Although its use did not significantly reduce median pain scores in patients undergoing BMAB, it does appear to reduce the proportion of patients with severe pain associated with this invasive procedure.

20. Science by system (Highlights) • Pain 91 • Acupuncture and acupressure may have a role with reducing pain during labor, increasing satisfaction with pain management and reduced use of pharmacological management. • EA could effectively lower the contents of TNF-alpha and VEGF in peripheral blood and joint synovia to improve the internal environment for genesis and development of RA, so as to enhance the clinical therapeutic effectiveness. • Applying S-Mox(SP6) could markedly shorten the active phase of the first stage of labor and lower the VAS score of uterine contractive pain, which means alleviating the pain caused by vaginal delivery. • The results suggested that acupuncture was more effective than flunarizine in decreasing days of migraine attacks, whereas no significantly differences were found between acupuncture and flunarizine in reduction of pain intensity and improvement of the quality of life. • Arthritis 11 • Showed significant effects of moxibustion on the Relative Risk compared with drug therapy in patients with knee osteoarthritis, whereas it failed to do so in rheumatoid arthritis.

21. Science by system (Highlights) • Asthma 6 • In children and adolescents with bronchial asthma, acupuncture ameliorated peak expiratory flow variability and anxiety. • Stroke 14 • The data suggest that GV20 acupuncture treatment increases cerebral blood flow. • Electroacupuncture therapy combined with rehabilitation program is effective for the spasticity status of lower-extremity in post-stroke. The therapeutic effect of EA in the frequencies of 100 Hz or 50 Hz is superior to that of 2 Hz stimulation and parameter of 100 Hz may be optimal.

22. Science by system (Highlights) • Stem Cells • Our results indicate that acupuncture for SCI can mobilize human CD133(+)34(-) cells. • Depression 7 • Once or twice-weekly acupuncture augmentation was safe, well-tolerated and effective in antidepressant partial and non-responders, suggesting good feasibility in outpatient settings improvement in depressive mood status. • The relevance between symptoms and magnetic resonance imaging analysis of the hippocampus of depressed patients given electro-acupuncture combined with Fluoxetine intervention - A randomized, controlled trial. There was a significant improvement in the hippocampal metabolites in depressed patients who treated by EA combined with Fluoxetine.

23. Science by system (Highlights) • Nausea 7 • Patients treated with verum or sham acupuncture experienced less nausea and vomiting compared to patients receiving standard care, possibly through a general care effect or due to the high level of patient expectancy. • Catgut implantation at BL 57 can effectively relieve the postoperative pain, reduce postoperative adverse reactions and complications in mixed hemorrhoids patients. • Obesity 4 • Analgesia 28

24. Hauer K, Wendt I, Schwenk M, Rohr C, Oster P, Greten J. Stimulation of acupoint ST-34 acutely improves gait performance in geriatric patients during rehabilitation: A randomized controlled trial. Arch Phys Med Rehabil. 2011 Jan;92(1):7-14. • DESIGN: Multiple-blinded, randomized, controlled intervention trial. • SETTING: Geriatric ward rehabilitation. • PARTICIPANTS: 60 geriatric patients during rehabilitation. • INTERVENTIONS: Both groups received a 1-time acupoint stimulation according to randomization. Stimulation of a verumacupoint (verum treatment) according to principles of traditional Chinese medicine was compared with a technically identical needle application on a nonacupoint (control treatment) in the control group. • CONCLUSIONS: Study results showed that a 1-time administration of a specific acupoint stimulation regimen statistically significantly improved gait performance during geriatric ward rehabilitation.

25. Landgren K, Kvorning N, Hallström I. Acupuncture reduces crying in infants with infantile colic: a randomised, controlled, blind clinical study. Acupunct Med. 2010 Dec;28(4):174-9. Epub 2010 Oct 18. • OBJECTIVE: To investigate whether acupuncture reduces the duration and intensity of crying in infants with colic. Patients and methods 90 otherwise healthy infants, 2-8 weeks old, with infantile colic were randomised in this controlled blind study. 81 completed a structured programme consisting of six visits during 3 weeks to an acupuncture clinic in Sweden. Parents blinded to the allocation of their children met a blinded nurse. The infant was subsequently given to another nurse in a separate room, who handled all infants similarly except that infants allocated to receive acupuncture were given minimal, standardised acupuncture for 2 s in LI4. • CONCLUSIONS: Minimal acupuncture shortened the duration and reduced the intensity of crying in infants with colic.

26. Kong JC, Lee MS, Shin BC, Song YS, Ernst E. Acupuncture for functional recovery after stroke: a systematic review of sham-controlled randomized clinical trials.CMAJ. 2010 Nov 9;182(16):1723-9. Epub 2010 Sep 27. • BACKGROUND: Acupuncture is frequently advocated as an adjunct treatment during stroke rehabilitation. The aim of this review was to assess its effectiveness in this setting. • METHODS: We searched 25 databases and 12 major Korean traditional medicine journals from their inception to October 2009. We included randomized controlled trials, with no language restrictions, that compared the effects of acupuncture (with or without electrical stimulation) with sham acupuncture. We assessed the methodologic quality of the trials using the Cochrane risk-of-bias criteria and the PEDro (Physiotherapy Evidence Database) scale. • CONCLUSIONS: Our meta-analyses of data from rigorous randomized sham-controlled trials did not show a positive effect of acupuncture as a treatment for functional recovery after stroke.

27. Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, Donovan D, Katovic N, Reeder C, Eilers K. Acupuncture for hot flashes in patients with prostate cancer. Urology. 2010 Nov;76(5):1182-8. Epub 2010 May 21. • OBJECTIVES: To determine the effect of acupuncture on hot flash frequency and intensity, quality of life, and sleep quality in patients undergoing hormonal therapy for prostate cancer. Hot flashes are a common adverse effect of hormonal therapy for prostate cancer. • METHODS: Men who had a hot flash score > 4 who were receiving androgen deprivation therapy for prostate cancer underwent acupuncture with electrostimulation biweekly for 4 weeks, then weekly for 6 weeks, using a predefined treatment plan. The primary endpoint was a 50% reduction in the hot flash score after 4 weeks of therapy, calculated from the patients' daily hot flash diaries. The hot flash-related quality of life and sleep quality and biomarkers potentially related to hot flashes, including serotonin, calcitonin gene-related peptide, and urinary 5-hydroxyindoleacetic acid, were examined. • CONCLUSIONS: Multiple placebo-controlled trials have demonstrated a 25% response rate to placebo treatment for hot flashes. Of the 22 patients, 41% had responded by week 4 and 55% overall in the present pilot study, providing evidence of a potentially meaningful benefit.

28. Hübscher M, Vogt L, Ziebart T, Banzer W. Immediate effects of acupuncture on strength performance: a randomized, controlled crossover trial. Eur J Appl Physiol. 2010 Sep;110(2):353-8. Epub 2010 May 25. • The present study investigated the immediate efficacy of acupuncture compared to sham acupuncture and placebo laser acupuncture on strength performance. A total of 33 recreational athletes (25.2 +/- 2.8 years; 13 women) were randomized to receive acupuncture, sham acupuncture (needling at non-acupuncture points) and placebo laser acupuncture (deactivated laser device) in a double-blind crossover fashion with 1 week between trials. Assessment included bipedal drop jumps for maximum rebound height and quadriceps maximum isometric voluntary force (MIVF). Furthermore, surface electromyography (EMG) was used to measure the EMG activity of the rectus femoris muscle during a 30-s sustained MIVF of the knee extensors. Mean power frequency (MPF) analysis was applied to characterize muscular endurance. Measurements were performed at baseline and immediately after treatment by a blinded investigator. Repeated measures ANOVA and post hoc paired-sample t test with Bonferroni-Holm correction were used for statistical analysis. • CONCLUSIONS: Study shows that a single acupuncture treatment was efficacious for improving isometric quadriceps strength in recreational athletes.

29. Wu MX, Li XH, Lin MN, Jia XR, Mu R, Wan WR, Chen RH, Chen LH, Lin WQ, Huang CY, Zhang XR, Hong KD, Li L, Liu XX. Clinical study on the treatment of knee osteoarthritis of Shen-Sui insufficiency syndrome type by electroacupuncture. Chin J Integr Med. 2010 Aug;16(4):291-7. Epub 2010 Aug 10. • OBJECTIVE: To study the clinical effificacy of electroacupuncture (EA) on treating knee osteoarthritis (KOA) of Shen ()-Sui () insuffificiency (SSI) syndrome type. • METHODS: A total of 245 patients (279 knees) of KOA-SSI were randomly assigned to two groups by lottery: 141 knees in the treatment group and 138 knees in the control group. The treatment group was managed with EA at the dominant points of Neixiyan (Ex-LE4) and Waixiyan (Ex-LE5) as well as the conjugate points of Xuanzhong (GB39) and Taixi (KI3) for 30 min, once a day, with 15 days as one course; 2 courses were applied with a 5-day interval in between. The control group was treated with intra-articular injection of 2 mLhyaluronic acid into the affected joint every 7 days for 5 times in total. The clinical effects on the patients in different stages were observed, and their symptom scores of knee and contents of cytokines, including interleukin-1 (IL-1), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), prostaglandin E(2alpha) (PGE(2alpha)) and matrix metalloproteinases-3 (MMP-3), in the knee joint fluid were measured before and after treatment. • CONCLUSIONS: EA could effectively alleviate the clinical symptoms in KOA patients of stage III, showing an effect superior to that of hyaluronic acid. EA also shows action in suppressing the secretion of IL-1, IL-6, TNF-alpha, PGE(2alpha) and MMP-3 in the knee fluid.

30. Pfab F, Huss-Marp J, Gatti A, Fuqin J, Athanasiadis GI, Irnich D, Raap U, Schober W, Behrendt H, Ring J, Darsow U. Influence of acupuncture on type I hypersensitivity itch and the wheal and flare response in adults with atopic eczema - a blinded, randomized, placebo-controlled, crossover trial. Allergy. 2010 Jul;65(7):903-10. Epub 2009 Dec 11. • BACKGROUND: Itch is a major symptom of allergic skin disease. Acupuncture has been shown to exhibit a significant effect on histamine-induced itch in healthy volunteers. We investigated the effect of acupuncture on type I hypersensitivity itch and skin reaction in a double-blind, randomized, placebo-controlled, crossover trial. • METHODS: An allergen stimulus (house dust mite or grass pollen skin prick) was applied to 30 patients with atopic eczema before (direct effect) and after (preventive effect) two experimental approaches or control observation: acupuncture at points Quchi and Xuehai [verum acupuncture (VA), dominant side], 'placebo-point' acupuncture (PA, dominant side), no acupuncture (NA). Itch intensity was recorded on a visual analogue scale. After 10 min, wheal and flare size and skin perfusion (via LASER-Doppler) were measured at the stimulus site, and the validated Eppendorf Itch Questionnaire (EIQ) was answered. • CONCLUSIONS: Acupuncture at the correct points showed a significant reduction in type I hypersensitivity itch in patients with atopic eczema.

31. Sherman KJ, Cherkin DC, Ichikawa L, Avins AL, Delaney K, Barlow WE, Khalsa PS, Deyo RA. Treatment expectations and preferences as predictors of outcome of acupuncture for chronic back pain. Spine (Phila Pa 1976). 2010 Jul 1;35(15):1471-7. • STUDY DESIGN: Preplanned secondary analysis of data from participants receiving acupuncture in a randomized clinical trial. • OBJECTIVE: To determine whether patients' expectations of and preferences for acupuncture predict short and long-term treatment outcomes for persons with chronic back pain. • SUMMARY OF BACKGROUND DATA: Although accumulating evidence suggests that patient expectations and treatment preferences may predict treatment outcomes, few studies have examined this relationship for acupuncture. • METHODS: Four hundred seventy-seven acupuncture-naïve participants with chronic low back pain who were randomized to 1 of 3 acupuncture or simulated acupuncture treatments were the focus of this analysis. Ten treatments were provided during a 7-week period, and participants were masked to treatment assignment. Before randomization, participants provided expectations regarding treatment success, impressions, and knowledge about acupuncture and treatment preferences. Outcomes of interest were functional status (Roland score) and symptom bothersomeness at 8 and 52 weeks postrandomization, obtained by telephone interviewers masked to treatment assignment. • CONCLUSIONS: Pretreatment expectations and preferences for acupuncture were not found predictive of treatment outcomes for patients with chronic back pain.

32. Wong CL, Lai KY, Tse HM.Effects of SP6 acupressure on pain and menstrual distress in young women with dysmenorrhea. Complement TherClinPract. 2010 May;16(2):64-9. Epub 2009 Nov 14. • OBJECTIVES: This study aims to evaluate the effects of Sanyinjiao (SP6) acupressure in reducing the pain level and menstrual distress resulting from dysmenorrhea. • METHODS: Forty participants with dysmenorrhea were assigned to either the acupressure group (n = 19) or the control group (n = 21). The acupressure group received 20 min of SP6 acupressure during the initial intervention session and was taught to perform the technique for them to do twice a day from the first to third days of their menstrual cycle, 3 months subsequent to the first session. In contrast, the control group was only told to rest. Outcomes were measured through (1) the Pain Visual Analogue Scale (PVAS), (2) the Short-Form McGill Pain Questionnaire (SF-MPQ), and (3) the Short-Form Menstrual Distress Questionnaire (SF-MDQ). • CONCLUSIONS: SP6 acupressure has an immediate pain-relieving effect for dysmenorrhea. Moreover, acupressure applied to the SP6 acupoint for 3 consecutive months was effective in relieving both the pain and menstrual distress level resulting from dysmenorrhea.

33. Cho SY, Jahng GH, Park SU, Jung WS, Moon SK, Park JM.fMRI study of effect on brain activity according to stimulation method at LI11, ST36: painful pressure and acupuncture stimulation of same acupoints. J Altern Complement Med. 2010 Apr;16(4):489-95. • OBJECTIVES: The objective of this study was to assess differences in brain responses between pressure and acupuncture stimulation at the same acupoint using functional magnetic resonance imaging (fMRI). • SUBJECTS: A total of 10 healthy right-handed volunteers were studied. • DESIGN: fMRI was performed with two different paradigms; namely, pressure and acupuncture stimulation at acupuncture points LI11 and ST36 on the left. fMRI data were analyzed using SPM2. • CONCLUSIONS: Brain signal activation patterns according to the stimulation methods and acupoints were observed to differ. Acupuncture stimulation activated more regions than pressure at the same acupoint. In particular, acupuncture stimulation activated the limbic system, such as the parahippocampalgyrus and anterior cingulate cortex.

34. Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Pain Pract. 2010 Mar-Apr;10(2):94-102. Epub 2010 Jan 8. • OBJECTIVES: There is controversy as to whether or not acupuncture is more effective than placebo. To help clarify this debate, we synthesized the evidence gathered from systematic reviews on the pooled data of high-quality randomized controlled trials comparing acupuncture to sham acupuncture for chronic pain. • METHOD: Systematic reviews of acupuncture for the most commonly occurring forms of chronic pain (back, knee, and head) published between 2003 and 2008 were sourced from Ovid databases: Medline, Allied and Complementary Medicine database, Cochrane Library and Web of Science during December 2008. Eight systematic reviews with meta-analyses of pooled data were eligible for inclusion. Data were extracted for short- and longer-term outcomes for the most commonly occurring forms of pain. Two independent reviewers assessed methodological quality. • CONCLUSIONS: The accumulating evidence from recent reviews suggests that acupuncture is more than a placebo for commonly occurring chronic pain conditions. If this conclusion is correct, then we ask the question: is it now time to shift research priorities away from asking placebo-related questions and shift toward asking more practical questions about whether the overall benefit is clinically meaningful and cost-effective?

35. Witt CM, Lüdtke R, Wegscheider K, Willich SN.E Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture? J Pain. 2010 May;11(5):431-5. • The aim of this paper was to quantify the influence of the physician's training and experience in the field of acupuncture on the outcome in patients with chronic pain. Patients visiting their physician because of chronic low back pain, headache, pain due to osteoarthritis of the knee or hip, or neck pain, were included in 4 multicenter, randomized, controlled studies. All patients received routine care; patients in the acupuncture groups received additional acupuncture treatment (on average 10 sessions). The data was pooled, and the 3-month change from baseline of the SF-36 bodily pain subscale as the main outcome defined. A total of 9,990 patients (mean age 49.6 +/- 13.6 years, 68% female) treated by 2,781 physicians (mean age 46.3 +/- 7 years, 37% female) were analyzed. The physicians had 7.3 +/- 5.2 (mean +/- sd) years of experience in acupuncture and their mean duration of formal acupuncture training had been 287 +/- 321 hours. The outcome was markedly improved in the acupuncture group. • CONCLUSIONS: We identified only 1 physician characteristic with a significant influence on the outcome: Internists performed better and orthopedists worse than the average physician. Neither the duration of training nor the duration of experience had any impact on the extent of the acupuncture effect.

37. Conclusion • Science supports the use of acupuncture for many conditions that affect man and animals. • We will have work to do to provide better evidence for where acupuncture can be applied best for the treatment and prevention of disease.