A Systematic Review: Evidence Map of Acupuncture

Many Veterans desire complementary and alternative medicine or integrative medicine modalities such as acupuncture, both for treatment and for the promotion of wellness. However, the effectiveness and adverse events associated with acupuncture are not firmly established. The VA Evidence-Based Synthesis Program located in West Los Angeles conducted a systematic review of systematic reviews that were published from January 2005 to March 2013 in order to provide an overview of the existing literature on acupuncture. This was then used to produce:

• An evidence map (see bubble plots below) that provides a visual overview of the distribution of evidence (both what is known and where there is little or no evidence base) for acupuncture. Evidence maps are only meant as a broad overview of the evidence base, indicating in which areas research has been conducted.
• A set of executive summaries that would help stakeholders interpret the state of the evidence to inform policy and clinical decision-making.

This review of systematic reviews focused on three areas in which acupuncture therapy is used, and which are of importance to Veterans and the VA healthcare system: 1) Pain (59 systematic reviews), 2) Mental Health (20 systematic reviews), and 3) Wellness (44 systematic reviews). Investigators also examined other clinical areas for which at least three reviews and/or recent large randomized clinical trials (RCTs) exist (48 systematic reviews). A summary of the evidence on the three priority areas follows.

Acupuncture and Pain
There were a number of clinical indications under Pain that were examined in this review, as indicated in this bubble plot:

The bubble plot shows an estimate of the evidence base for pain-related indications judging from systematic reviews and recent large RCTs. The plot depicts the estimated size of the literature (y-axis, number of RCTs included in largest review), the estimated effect (x-axis), and the confidence in the estimate (bubble size).

Acupuncture and Mental Health
There were a number of clinical indications under Mental Health that were examined in this review, as indicated in the bubble plot:

The bubble plot shows an estimate of the evidence base for mental health-related indications judging from systematic reviews and recent large trials. The plot depicts the estimated size of the literature (y-axis, number of RCTs included in the largest review), estimated effect (x-axis), and the confidence of the estimate (bubble size).

Acupuncture and Wellness
There were a number of clinical indications under Wellness that were examined in this review, as indicated in the bubble plot:

The bubble plot shows an estimate of the evidence base for wellness-related indications judging from systematic reviews and recent large trials. The plot shows the estimated size of the literature (y-axis, number of RCTs in largest review), estimated effect (x-axis), and confidence of the estimate (bubble size).

Future Research

Pain
Although chronic pain was classified as one of the conditions for which acupuncture has evidence of a positive effect and high confidence, this conclusion is limited by the lack of consistent evidence of positive effect in the individual pain categories that must make up any "chronic pain" population.

Mental Health
The effect of acupuncture on chronic fatigue syndrome and its role in the treatment of addiction, in particular opiate addiction, remained unclear. Systematic reviews should be conducted to differentiate effects on relapse rates and effects on drug withdrawal symptoms.

Wellness
The therapeutic effectiveness of acupuncture is unclear and further research is needed regarding a substantial number of specific clinical indications related to wellness. For some of the clinical indications, the evidence base appeared to be unclear due to the lack of research studies. However, the evidence base for physical symptoms of cancer treatment-associated adverse events was unclear despite a large number of research studies. Future systematic reviews and/or future individual studies may determine whether acupuncture has a role in these clinical indications, and for which clinical outcome.

Other Indications
There were a number of clinical indications (i.e., brain injury, spinal cord injury, Alzheimer's disease) with only one or two reviews published in recent years. A couple of systematic reviews on broad topics, such as sham acupuncture compared to true acupuncture, exist but could not be considered in this review of systematic reviews due to an insufficient number of relevant systematic reviews.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers — and to disseminate these reports throughout VA.

Reference

Hempel S, Taylor SL, Solloway M, Miake-Lye IM, Beroes JM, Shanman R, Booth MJ, Siroka AM, and Shekelle PG. Evidence Map of Acupuncture. VA-ESP Project #05-226; 2013.

View the full report.

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Read past HSR&D Management e-Briefs on the HSR&D website.

This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

See all reports online.