Rheumatology 2003; 42: 1272-1273
© 2003 British Society for Rheumatology
Letter to the Editor |
Reply
Complementary Medicine Research Unit, University of Southampton, Southampton, UK
Correspondence to:
P. White, Complementary Medicine Research Unit, Mail Point OPH, Royal South Hants Hospital, Brintons Terrace, Southampton, UK. E-mail: pjw1{at}soton.ac.uk
We very much appreciate the thoughtful comments made in relation to our previous paper, but would like to comment on some of the points raised by Dr White and Professor Ernst.
We most definitely agree that systematic reviews do need to be read carefully, as indeed do all papers. Whilst we did produce a table of ‘sound-bite summaries’ [1], this was intended to give the flavour of the state of play at the time. The paragraph in which our table was included was in fact commenting on studies relating to efficacy rather than effectiveness, as detailed in the first line. We thought that this was clear, but if this was confusing we would like to make it unmistakable that efficacy was indeed the issue and not effectiveness.
With regard to the issue of the inclusion of laser acupuncture in a study of acupuncture efficacy, here we must agree to differ. Implicit in the word ‘acupuncture’ is the notion of skin puncture. If a study is intended to include such therapies as laser, perhaps the title should reflect this: for example, with the wording ‘acupuncture and other associated therapies’. The fact that a study describes itself as relating to acupuncture does not make it so, and we firmly believe that this is quite fundamental in an efficacy study. As researchers and clinicians with a good knowledge of acupuncture, we as a profession have the responsibility to present the clearest possible evidence, and we do not believe that it is in the consumer’s best interest to further propagate more confusion if such confusion already exists.
We would also like to make it clear that we have not at any point accused White and Ernst (or indeed anyone else) of misrepresenting the truth and, as pointed out in the letter by White and Ernst, pulling out a ‘sound-bite’ such as this can be a risky business. The paragraph in which this phrase was used in our paper related to the general use of scoring mechanisms and the inherent problems thereof. White and Ernst’s letter then draws attention to a neck pain trial that we have conducted ourselves. This trial is not the focus of our attention and indeed the finished paper is in submission and therefore cannot be commented upon. We would agree, however, with the comment that the placebo effect of sham TENS (transcutaneous electrical nerve stimulation) could indeed be different from that of sham acupuncture. This is a very valuable point and suggests that more research into acupuncture controls is vital. We are ourselves planning such research. The advantage of sham TENS, however, is that, in terms of efficacy, it is inert whereas sham acupuncture may not be. The use of sham TENS as a control has been well validated [2–5] and there is no evidence to show that, when used in conjunction with the proper outcome measures, it is inferior to any other currently used acupuncture control.
Lastly, White and Ernst have drawn attention to their use of the Jadad scoring mechanism. Whilst we would in no way doubt the calculations made by White and Ernst, our point was that the system has poor intertester reliability and sensitivity, as explained in our paper [1], and it is therefore not surprising that our scoring of the same trials was different from theirs.
We would like to thank Dr White and Professor Ernst for pointing out and highlighting two valuable papers that have been published since our own review was written [6, 7]. The more debate we can have around the issue of adequate methodology in acupuncture research the better, and it is only through these types of forum that the profile of such research and developments can be raised and improved upon.
References
- White P, Lewith G, Berman BM, Birch S. Reviews of acupuncture for chronic neck pain: pitfalls in conducting systematic reviews. Rheumatology 2002;41:1224–31
[Abstract/Free Full Text] - Lewith GT, Machin D. On the evaluation of the clinical effects of acupuncture. Pain 1983;16:111–27[CrossRef][Web of Science][Medline]
- Vincent C, Lewith G. Placebo controls for acupuncture studies. J R Soc Med 1995;88:199–202[Abstract]
- Petrie J, Hazleman B. Credibility of placebo transcutaneous nerve stimulation and acupuncture. Clin Exp Rheumatol 1985;3:151–3[Medline]
- Wood R, Lewith G. The credibility of placebo controls in acupuncture studies. Complement Ther Med 1998;6:79–82[CrossRef]
- White A, Filshie J, Cummings M. Clinical trials of acupuncture: consensus recommendations for optimal treatment, sham controls and blinding. Complement Ther Med 2001;9:237–45[CrossRef][Web of Science][Medline]
- MacPherson H, White A, Cummings M, Jobst K, Rose K, Niemtzow R. Standards for reporting interventions in controlled trials of acupuncture: The STRICTA recommendations. Acupunct Med 2002;20:22–5[Medline]
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