studies where acupuncture is compared with no treatment, waitlist or usual care, there is a significantly larger treatment effect than when acupuncture is compared with some form of sham, placebo or minimal acupuncture (23-27). The Society for Acupuncture Research has dubbed this phenomenon a paradox in acupuncture The Acupuncture Evidence Project © AACMA 4 research (25). There is evidence that many, if not all, the forms of sham/placebo acupuncture treatment protocols used in acupuncture trials to date are not inert, and exert physiological, and possibly also placebo effects, making it extremely difficult (if not impossible) to accurately measure how much of the observed non-specific effects may be attributable to placebo and/or nocebo effects, and how much is due to the placebo not being inert (23, 26-29). Hence a comparison of the effect size of acupuncture when compared to that of placebo acupuncture may result in consistent underestimation of the true effect size (23, 28). Some acupuncture researchers are now suggesting that clinical decisions regarding whether or not acupuncture should be recommended as a treatment option would be more accurately based on comparisons of acupuncture with usual care or acupuncture with other interventions (headto-head studies and network meta-analyses) (25, 29). This trend of increased focus on pragmatic trials over explanatory trials is not limited to research into acupuncture, but has been identified as an issue in health research more generally (30). Further research on acupuncture mechanisms has also been recommended by both the Society for Acupuncture Research and the National Institutes for Health (NIH) in the USA which, at the Society for Acupuncture Research’s biannual conference in Boston in October 2015, announced a new funding pool dedicated to acupuncture mechanism research (25). NIH have identified limited value in true versus sham acupuncture trials when investigating pain and have consigned such trials to a low programmatic priority (31). NIH has given high priority instead to pragmatic studies investigating acupuncture and pain management along with further research into the mechanisms of acupuncture (31). The use of exit-debrief questionnaires in published sham/placebo-controlled acupuncture trials, which show no significant differences between the real and sham acupuncture groups in belief about which treatment they had received, suggests that in these trials placebo/nocebo effects are not an adequate explanation for any effects produced in the sham acupuncture group (32). 1.5 Acupuncture recommendations in clinical practice guidelines In Australia, acupuncture has been included in clinical practice guidelines for various types of acute pain including post-operative pain, and for rotator cuff syndrome (33, 34). In ‘Acute Pain Management: Scientific Evidence’ published by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine in 2015, NHMRC Level I evidence was identified from Cochrane reviews for acupuncture for labour pain, oocyte retrieval pain, primary dysmenorrhoea, tension-type headaches and migraine, and from PRISMA reviews for postoperative pain, back pain and acute burns pain (33). In ‘Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace’, published by The University of New South Wales in 2013, Recommendation 23 states that ‘Clinicians may consider acupuncture in conjunction with exercise; both modalities should be provided by suitably qualified health care providers’ (Grade C: ‘Body of evidence provides some support for recommendation but care should be taken in its application to individual clinical and organisational circumstances’) (34). In ‘Consensus Guidelines for the Management of Postoperative Nausea and Vomiting’ published in USA by the Society for Ambulatory Anesthesia in 2014, acupuncture and point stimulation of The development of guidelines requires quality levels of evidence adequate to support a given recommendation, even though they may fall below the highest level in some cases, and requires consideration of other factors including cost, clinical judgement, and patient preference. The Acupuncture Evidence Project © AACMA 5 PC6 were recommended as both prophylactic and treatment strategies [Category A recommendation: based on supportive literature which contains multiple randomised controlled trials which report statistically significant (P < 0.01) differences between clinical interventions for a clinical outcome, and aggregated findings are supported by meta-analysis] (35). Between 2012 and 2015 four International Symposia of Evidence-Based Clinical Practice Guideline in Traditional Medicine have been held in Daejon, South Korea hosted by the Korean Institute of Oriental Medicine (KIOM), bringing together participants from Korea, China, Japan, UK, Norway, Holland and Australia (36). By November 2015, over 870 recommendations for acupuncture were identified for over 100 conditions from multiple international groups and over 30 countries (36). Examples include: the Otolaryngology Head Neck Surgery Foundation’s clinical practice guidelines for allergic rhinitis in 2015 (37); the National Institute for Health and Care Excellence (NICE), UK inclusion of migraine and tension type