Volume 8, Number 1 | Spring 2013

Editorial
Clinical Practice Guidelines including Acupuncture
The NICE Guidelines (UK) for low back pains and headaches provide information aboutacupuncture, as is well known, but evidence-based clinical practice guidelines published in Japan havealso begun to contain such information in recent years. As of 2013 at least, seven guidelines in Japan
provide information about acupuncture. Among these, a grade of recommendation of A or B is given toacupuncture for low back pain, fibromyalgia, chronic headache (excluding tension-type headache, which
is given a C grade of recommendation), and tennis elbow. A grade of recommendation of C is given to
facial paresis and non-odontogenic toothache, and D is given to alopecia areata (acupuncture should notbe performed). Such information about acupuncture is supposedly based on systematic reviews or metaanalyses of randomized controlled trials (RCTs), but in reality,there are some guidelines in which
judgments have not been properly drawn out. For example, compared to the NICE guidelines, Japaneseguidelines for tennis elbow overestimates acupuncture, as the grade of recommendation is based on theold Cochrane systematic review, while the guidelines for tension-type headache underestimates
acupuncture. With respect to alopecia areata, its grade of recommendation goes against the guidelines’
definition of recommendation grade to begin with, and is self-contradictory.
Thus, although clinical practice guidelines that deal with acupuncture treatment also exist in Japan,
they are not yet sufficiently reliable. Why is this so? One reason is perhaps the absence of any committeethat is well-versed in acupuncture treatment and aptly suited to preparing guidelines on the treatment ofvarious diseases. Unlike drug therapy, clinical practice and RCT for acupuncture is complex and unique,so it is difficult for those who are not familiar with this difference to determine the grade ofrecommendation of acupuncture treatment. Sham acupuncture is frequently regarded as a control inrelation to acupuncture treatment, but it actually differs from a placebo in an RCT of a drug, as it hascertain specific effects. Another problem is that clinical practice guidelines in Japan mostly refer to RCTsof TCM acupuncture, due to the lack of sufficiently examined and publishedevidence of Japanese
acupuncture treatment.
The fair evaluation of acupuncture treatment in clinical practice guidelines requires the participationof specialists who have knowledge of the characteristics of acupuncture practice and research. Whencompiling guidelines on diseases for which evidence of acupuncture treatment is gradually being
accumulated, an open framework that invites the participation not only of physicians but also
acupuncturists is thought to be instrumental to producing even fairer guidelines. Toward this end, it isimportant that acupuncture clinicians and researchers make greater efforts to more widely disseminate
and raise awareness of the differences between acupuncture studies and pharmaceutical studies.

Hitoshi Yamashita, Lic. Ac., Ph.D.
Professor, Graduate School of Health Sciences
Morinomiya University of Medical Sciences, Osaka, JapanThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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