6017/37 BMAS vol 20(4) 12/2002

Introduction Acupuncture is increasingly popular with the public, and more general practitioners (GPs) are using acupuncture as another therapeutic option. The BMA report on acupuncture highlights its effectiveness in certain conditions and relative safety compared to the widespread use of NSAIDs, which are responsible for over 2000 deaths a year from gastrointestinal bleeds. The report comments that previous trials were often of poor design and calls for high quality research to help establish the appropriate place for acupuncture in modern medical practice. Tennis elbow is a common troublesome condition that affects about four adults per 1000 annually. ‘Tennis elbow’ is a pragmatic term that refers to pain in the lateral elbow (‘lateral epicondylalgia’), increased with pressure on the lateral epicondyle and during resisted dorsiflexion of the wrist. Although it is usually self-limiting eventually, it causes much morbidity until it resolves. A recent trial demonstrated that a two week course of an NSAID was no better than placebo, and that although steroid injection provided superior pain relief at four weeks this effect was no longer seen at twelve months. Some patients receiving steroid injection had worse symptoms at six months. A systematic review of 13 studies found insufficient evidence to draw firm conclusions, but suggested a superior shortterm effect of steroid injection over periods of less than six weeks, but no beneficial effects over intermediate or long terms. In addition, steroids are unpopular with some patients. Since the optimum treatment for tennis elbow in primary care is still unclear, acupuncture is a safe alternative, which, if shown to be effective, could provide an alternative choice for both clinicians and patients. Therefore, a pragmatic randomised trial of acupuncture for tennis elbow compared with steroid injection and conservative treatment has been proposed. In order to allow the study to be replicated and to optimise the chance of successful treatment, we wanted to develop a standardised treatment protocol. Therefore a consensus study was performed and is described here. A modified Delphi process was seen as the most practical way to overcome the barriers of distance between experts and to minimise the inconvenience to them. The Delphi process takes its name from the Delphic oracle’s skills of interpretation and foresight. One purpose of this method is to determine the extent to which experts agree on issues – overcoming the disadvantages normally found in decision making in groups, Philip Webster-Harrison general practitioner Port View Surgery Saltash Cornwall, UK