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Acupuncture for elbow pain

The review

Bandolier is always attracted to systematic reviews claiming to find strong evidence about a treatment effect. Strong evidence is not easy to find, but one expects a rock on which good practice can be built. When strong evidence and acupuncture are used in the same sentence, though, Bandolier begins to smell a rat. Not because of any bias, but because good evidence indicates that acupuncture does not work.

It should be an educational experience, then, to see how a review of acupuncture for elbow pain [1] stacks up against the requirements of quality, validity, and size (QVS). What does this mean?

These are the criteria on which we should judge evidence. For it to be strong evidence, it has to meet all three criteria.

The review

The review sought randomised studies of patients with pain resulting from tennis elbow, with other descriptions, but essentially with pain originating from the common origin of the extensor tendon, and with needle acupuncture as the primary intervention. Excluded were other elbow problems, and patients concurrently receiving other treatments.


Of 53 articles screened, the authors chose to include six. Results from all these six trials were combined in a qualitative 'best evidence synthesis'.

Of these six included trials, one was not properly randomised.

Of the remaining five trials, two were not double blind.

Of the remaining three, one had results only immediately after treatment (not much use in a chronic condition, and duration of the condition was about 10 months in some of the trials).

That left two randomised, double-blind trials, both of which reported results two or three months after treatment. Both compared real acupuncture with sham acupuncture (using different needle points, for instance). Both reported outcomes roughly equivalent to half pain relief, and the rates were similar (Figure 1).

Figure 1: Valid, randomised trials of acupuncture versus sham acupuncture for tennis elbow

There was no significant difference between real and sham acupuncture. The relative benefit was 1.2 (0.96 to 1.6).


This review failed QVS criteria. Six original trials soon became two small and useful trials, with valid outcomes, but no different from control. Even if there were an effect, it is so small that we would need large trials to be confident that it was there: our information is from only 123 patients.

And that is the best one might say. Reading the original trials is interesting. One included trial was published twice (without acknowledging the other), quoted odds ratios to six significant figures (52.2888 seemed slightly over-precise based on 48 patients), and used NNTs when results were not statistically significant. That does not give much confidence in the quality of trial reporting.

So is there strong evidence for acupuncture in tennis elbow? No. Actually there is no evidence that it works, and what evidence we have suggests it does not work in any meaningful way. A pity, then, that this will be seized upon as a way of extracting money from wallets.


  1. KV Trinh et al. Acupuncture for the alleviation of lateral epicondyle pain: a review. Rheumatology 2004 (advance access 22 June, doi: 10.1093/rheumatology/keh247).

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