Acupuncture for post-tonsillectomy pain: evidence from a recent randomized clinical trial
Editorial

Acupuncture for post-tonsillectomy pain: evidence from a recent randomized clinical trial

Byung-Cheul Shin

Department of Rehabilitation Medicine of Korean Medicine and Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan 50612, Republic of Korea

Correspondence to: Byung-Cheul Shin, MD (DKM), PhD. Department of Rehabilitation Medicine and Division of Clinical Medicine, School of Korean Medicine, Pusan National University, 49 Busandaehak-Ro, Yangsan 50612, Republic of Korea. Email: drshinbc@pusan.ac.kr; drshinbc@gmail.com.

Provenance: This is an Editorial commissioned by the Editor-in-Chief, Zhen Xiao, MD, MPA (Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China).

Comment on: Dingemann J, Plewig B, Baumann I, et al. Acupuncture in posttonsillectomy pain: A prospective, double-blinded, randomized, controlled trial. HNO 2017;65:73-9.


Received: 27 August 2018; Accepted: 11 September 2018; Published: 17 September 2018.

doi: 10.21037/lcm.2018.09.02


The French Society of Otorhinolaryngology (SFORL) published a guideline on the nonpharmacological treatment of post-tonsillectomy pain in 2014 (1). The guideline states that acupuncture for post-tonsillectomy pain remains controversial (level of evidence: 2); additionally, the guideline notes that moderate side effects are found in 11.8% of pediatric acupuncture cases (level of evidence: 2) (1,2).

A prospective, double-blinded, randomized controlled trial of acupuncture for post-tonsillectomy pain was published in 2017 (3). The authors concluded that acupuncture is clinically effective in reducing post-tonsillectomy swallowing pain and may be performed in addition to the administration of standard medications without any relevant side effects (3). There are conflicts between the two reports (1,3); therefore, further trials on acupuncture use in post-tonsillectomy pain are warranted.

In 2009, Sertel et al. (4) reported on a patient-assessor-blinded randomized, controlled trial of patients with post-tonsillectomy aged ≥16 years. The trial randomized the subjects (n=123) into three groups [nonsteroidal anti-inflammatory drug (NSAID) plus verum acupuncture, n=41; NSAID plus control acupuncture (non-specific control points on the body), n=41; and NSAID only, n=41]. Verum acupuncture demonstrated pain reduction without side effects (4).

A 2-armed, randomized controlled trial (2015) of conventional postoperative analgesia plus acupuncture (n=30) versus only conventional postoperative analgesia (n=30) (5) and a retrospective review of pediatric acupuncture for postoperative pain in tonsillectomy (2013) (6) both reported positive effects on pain reduction when acupuncture was added to conventional analgesia. A double-blind, placebo-controlled, randomized trial published in 2015 (7) allocated pediatric tonsillectomy patients undergoing standard surgery into a real acupuncture group (n=30) and a Streitberger sham acupuncture group (n=29) to investigate whether pain was reduced by acupuncture treatment. The researchers concluded that intraoperative acupuncture demonstrated analgesic effects and was well tolerated (7). Although these studies (4-7) generally showed positive results for pain reduction with acupuncture use and safety of the technique, there are conflicts within the total body of evidence (1). Why is there a gap between the 2014 evidence and other results?

A recent randomized controlled trial (3) presented moderate risk of bias when assessed by the Cochran risk of bias tool (Table 1). In addition, the effect size (ES) and power of the trial had less of an impact on the evidence regarding acupuncture analgesia for post-tonsillectomy pain. Recalculation of results of ES and power (G*Power Version 3.1.9.2 statistical software; Franz Faul, Universität Kiel, Germany) between the verum acupuncture group (n=16) and the sham acupuncture group (n=15) yielded T0/20 [ES: 0.35; estimated sample size: 260 (130+130), σ=0.05, β=0.2, 1:1 group allocation ratio, compared means between two independent groups; post hoc recalculated power: 0.16]; T0/60 [ES: 0.46; estimated sample size: 148 (74+74); post hoc power: 0.24]; T0/120 [ES: 0.27; estimated sample size: 430 (215+215); post hoc recalculated power: 0.11]; and T0/180 [ES: 0.25; estimated sample size: 518 (259+259); post hoc recalculated power: 0.10]. Therefore, the trial seemed to be underpowered with insufficient sample size. Clearly, a powered trial with low risk of bias would impact the evidence regarding analgesic effects of acupuncture for post-tonsillectomy patients or postoperative pain management (8,9).

Table 1
Table 1 Cochrane risk of bias of the randomized clinical trial
Full table

Debates regarding sham acupuncture are ongoing (10). Dingemann et al. (3) adopted control acupuncture for practitioner-patient-blinding to acupuncture at nonspecific acupuncture points in the midaxillary line. A validation questionnaire could have been administered to blinded subjects to determine whether blinding was successful (11). Another issue in acupuncture studies is use of the Standards for Reporting Interventions in Controlled Trails of Acupuncture (STRICTA) reporting guideline to improve transparent reporting of acupuncture trials (12). The Dingemann et al. study (3) showed scant reporting on items regarding acupuncture rationale, details of needling, other components of treatment, and practitioner background (Table S1).

Table S1
Table S1 Checklist for items in STRICTA 2010 of the randomized clinical trial
Full table

A last issue in acupuncture trials is safety reporting. Dingemann et al. (3) noted no significant side effects, but more detailed reporting is required. In contrast, the SFORL guideline reported moderate side effects in 11.8% of pediatric acupuncture patients (2). Future trials should focus on risk of bias, ES, power, use of sham acupuncture controls, use of STRICTA reporting guidelines, and safety.


Acknowledgements

None.


Footnote

Conflicts of Interest: The author has no conflicts of interest to declare.


References

  1. Fayoux P, Wood C. Non-pharmacological treatment of post-tonsillectomy pain. Eur Ann Otorhinolaryngol Head Neck Dis 2014;131:239-41. [Crossref] [PubMed]
  2. Adams D, Cheng F, Jou H, et al. The safety of pediatric acupuncture: a systematic review. Pediatrics 2011;128:e1575-87. [Crossref] [PubMed]
  3. Dingemann J, Plewig B, Baumann I, et al. Acupuncture in posttonsillectomy pain: A prospective, double-blinded, randomized, controlled trial. HNO 2017;65:73-9. [Crossref] [PubMed]
  4. Sertel S, Herrmann S, Greten HJ, et al. Additional use of acupuncture to NSAID effectively reduces post-tonsillectomy pain. Eur Arch Otorhinolaryngol 2009;266:919-25. [Crossref] [PubMed]
  5. Gilbey P, Bretler S, Avraham Y, et al. Acupuncture for posttonsillectomy pain in children: a randomized, controlled study. Paediatr Anaesth 2015;25:603-9. [Crossref] [PubMed]
  6. Ochi JW. Acupuncture instead of codeine for tonsillectomy pain in children. Int J Pediatr Otorhinolaryngol 2013;77:2058-62. [Crossref] [PubMed]
  7. Tsao GJ, Messner AH, Seybold J, et al. Intraoperative acupuncture for posttonsillectomy pain: a randomized, double-blind, placebo-controlled trial. Laryngoscope 2015;125:1972-8. [Crossref] [PubMed]
  8. Liu XL, Tan JY, Molassiotis A, et al. Acupuncture-Point Stimulation for Postoperative Pain Control: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med 2015;2015. [Crossref] [PubMed]
  9. Wu MS, Chen KH, Chen IF, et al. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One 2016;11. [Crossref] [PubMed]
  10. MacPherson H, Hammerschlag R. Acupuncture and the emerging evidence base: contrived controversy and rational debate. J Acupunct Meridian Stud 2012;5:141-7. [Crossref] [PubMed]
  11. Hróbjartsson A, Forfang E, Haahr MT, et al. Blinded trials taken to the test: an analysis of randomized clinical trials that report tests for the success of blinding. Int J Epidemiol 2007;36:654-63. [Crossref] [PubMed]
  12. MacPherson H, Altman DG, Hammerschlag R, et al. Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): extending the CONSORT statement. PLoS Med 2010;7. [Crossref] [PubMed]
doi: 10.21037/lcm.2018.09.02
Cite this article as: Shin BC. Acupuncture for post-tonsillectomy pain: evidence from a recent randomized clinical trial. Longhua Chin Med 2018;1:11.