The report of the CACTUS study1 and the accompanying editorial2 are flawed by several biases and errors. The Editor's review gave the study an unjustified commendation by stating, ‘A series of five-element acupuncture treatments has significant and sustained benefit in patients who frequently attend with medically unexplained symptoms’.3 In fact, the flaws and biases are so many that we can expose only the most important ones: failure to consider clinical relevance and measurement precision, and failure to consider the risk of bias in unblinded pragmatic trials such as CACTUS.
The differences in outcome measures are small and imprecise and therefore unlikely to be relevant to patients. For …