Long term benefits of acupuncture  for chronic pain: what makes a difference? Hugh MacPherson www.hughmacpherson.com 1 Outline Acupuncture for chronic pain – the 1. Acupuncture Trialists Collaboration, and long-term effects Longer-term effects of acupuncture from 2. trials conducted in the UK Exploring explanation of longer term 3. effects in the ATLAS chronic neck pain trial 2 J.-S. Han, Y.-S. Ho / Neuroscience and Biobehavioral Reviews 35 (2011) 680–687 1.1. Members of the Acupuncture Trialists Collaboration www.acupuncturetrialistscollaboration.org 4 Acupuncture trialists’ collaboration Methods: We combined 29 high quality acupuncture  trials in a single database with 17,922 patients with chronic pain: Osteoarthritis  Headache/migraine  Low back and neck pain  Aims:  Establish effect of acupuncture vs. usual/standard care 1. Establish effect of acupuncture vs. sham 2. Establish long term trajectory of benefit 3. www.acupuncturetrialistscollaboration.org 5 Individual patient data meta-analysis Single database with raw data obtained  from 29 trials with 17,922 patients: 20 trials with sham controls (5,230  patients) 18 trials with usual/standard care controls  (14,597 patients) NB: some trials had three arms  Is acupuncture better than sham  Acupuncture, varies across trials  Sham acupuncture controls vary: Non-needle sham (e.g. inactive TENS)  Needle-based sham  Penetrating needles  Non-penetrating needle  At acupuncture points  At non-acupuncture points  Individual patient data meta-analysis Acupuncture vs. Sham controls (n= 5,230) Indication Effect size (Fixed effects) Acupuncture vs. Sham controls (excluding outliers) Migraine/headache -0.15 (-0.24, -0.07) P<0.001 Osteoarthritis -0.16 (-0.25, -0.07) P<0.001 LBP & Neck Pain -0.23 (-0.33, -0.13) P<0.001 Interpretation of effect sizes: 0.8 = LARGE 0.5 = MODERATE 0.3 = SMALL Negative values represent better outcomes Values in parentheses are 95% confidence intervals  Is acupuncture better than non- acupuncture controls  Acupuncture, varies across trials  Non-acupuncture controls vary: No treatment  Wait list  Attention control  Rescue medication  Usual care  Other standard treatment  Individual patient data meta-analysis Acupuncture vs. Sham controls, and Acupuncture vs. Non-acupuncture controls (n= 14,597 ) Effect sizes: 0.8 = LARGE Indication Effect size 0.5 = MODERATE (Fixed effects) 0.3 = SMALL Acupuncture vs. Sham controls (excluding outliers) Migraine/headache -0.15 (-0.24, -0.07) P<0.001 Osteoarthritis -0.16 (-0.25, -0.07) P<0.001 Back & Neck Pain -0.23 (-0.33, -0.13) P<0.001 Acupuncture vs. Non-acupuncture controls Migraine/headache -0.42 (-0.46, -0.37) P<0.001 Osteoarthritis -0.57 (-0.64, -0.50) P<0.001 Back & Neck Pain -0.55 (-0.58, -0.51) P<0.001 Negative values represent better outcomes Values in parentheses are 95% confidence intervals