NICE, electroacupuncture, and osteoarthritis

Background I was surprised to come across a senior colleague using acupuncture in the British military when I started my general practice training. I had joined the Royal Air Force (RAF) rather than a civilian vocational training scheme, because I was interested in musculoskeletal pain and sports medicine. I trained in Western medical acupuncture with the British Medical Acupuncture Society and found dry needling appeared to be a very useful intervention in soft tissue pain, particularly muscle pain. After 7 years in the RAF as a general duties medical officer, I retired to pursue a career in orthopaedic medicine, but having taken over an established medical acupuncture practice, I found myself mostly in demand for acupuncture services. It was the early 1990s and systematic reviews (SRs) had just been developed, and Adrian White, one of my former acupuncture tutors, got me involved in both performing and reviewing SRs. The first meta-analysis of acupuncture was performed by Ernst and White in 1998, and this reported that acupuncture was superior to non-acupuncture controls. A subsequent SR by the Cochrane Collaboration Back Group (van Tulder et al.) opted to avoid data pooling in meta-analysis, and instead performed a best evidence synthesis within a qualitative review. Van Tulder et al. concluded that there was no evidence for an effect of acupuncture in back pain. This conclusion was a shock to me after the positive meta-analysis by Ernst and White, so I read the entire review. The conclusions were influenced by one of the two trials that were judged to be ‘high quality’. I knew this trial well, as it had been included in my first SR – Garvey et al. It was with some consternation that I realized the conclusions of an SR of acupuncture could be influenced by reviewers opinions over a trial that had not actually used acupuncture needles at all – Garvey et al. used insertion of a hypodermic needle at a single point and referred to it as acupuncture. So this was the start of my evolving understanding of the limitations, within the review process, of championing the avoidance of bias over the judgement of clinicians.