Acupuncture for ‘frequent attenders’ with medically unexplained symptoms

Paterson et al¹ conclude from their randomised controlled trial (CACTUS study) that an addition of 12 sessions of five-element acupuncture to usual care resulted in improved health status and wellbeing. We were immediately attracted to their article by the clinical relevance of investigating treatment in patients with medically unexplained physical symptoms (MUPS). MUPS are an interesting and relevant problem in primary health care, because these patients are often ‘frequent attenders’ and this leads to high medical costs, frustrated doctors, and patients who feel misunderstood. The authors recommend in their study the use of five-element acupuncture for patients with MUPS as a safe and potentially effective intervention. However, we have some questions and comments about the outcome measures applied and the selection of patients in their study.

The conclusion of the study is only based on the outcomes of two questionnaires, that is to say, the Measure Yourself Medical Outcome Profile (MYMOP) and the Wellbeing Questionnaire (W-BQ12). At 26 weeks’ follow-up, when adjusted for missing values and baseline scores, a significant difference in the between-group analysis is only seen on the W-BQ12. Moreover, the medical and clinical relevance of the outcome measures of these, for clinicians, relatively-unknown questionnaires are not described. Although acupuncture in people with MUPS may lead to improved wellbeing, there was no evidence that the GP consultation rate or medication use was decreased. The Patient Enablement Instrument was omitted because it did not perform well as a repeated measure. The authors state that many control group patients checked ‘not applicable’ because they thought the questions related only to the acupuncture treatment. What is this statement based on and how bad did it perform as a repeated measure?

Because patients were selected by their own GPs, selection bias is likely. Besides, inclusion criteria are not clear enough. Four inclusion criteria are stated in Box 1, however, the authors also report ‘other inclusion criteria (from electronic record search).’ What is meant with this? Is this an additional criterion or a new criterion for inclusion? One of the inclusion criteria of this study was the existence of the symptom for at least 3 months, but the table of participant characteristics shows two patients with a duration of the complaint of 4 to 12 weeks. Why were these patients included in the study?

With these comments, it is hard for us to estimate the clinical relevance of this study.