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A very special issue of Medical Acupuncture

Every so often, our “friends” on the other side of the science aisle (i.e., the supporters of “complementary and alternative medicine”—otherwise known as CAM or “integrative medicine”) give me a present when I’m looking for a topic for my weekly bit of brain droppings about medicine, science, and/or why CAM is neither. It’s also been a while since I’ve written about this particular subject; so it’s a win-win for all sides! I get a topic. A certain CAM journal gets extra traffic. And you get the benefit of my usually brilliant deconstruction of dubious science. What could go wrong? I mean, I might not be Mark Crislip, but I do enjoy a good dive into a pile of pseudoscience every now and then. It’s just a weird trait of mine.

In any case, there is a journal called Medical Acupuncture. Sadly, it’s published by a real scientific publisher, Mary Ann Liebert, Inc., a publisher that has a stable of decent, if not top tier, journals. Unfortunately, it also has a stable of CAM journals, including, of course, the aforementioned journal Medical Acupuncture. Because I happen to be on the mailing list for Mary Ann Liebert, Inc., I recently got an e-mail with an announcement:

How Does Acupuncture Work? The Science behind the Therapy Is Explored in a Special Issue of Medical Acupuncture

New Rochelle, NY, April 16, 2013—Even as medical acupuncture is increasingly being validated as an effective treatment for a broad range of medical conditions, what has been missing is an understanding of the basic science and mechanisms of action of this age-old method of healing. A special issue of Medical Acupuncture, a peer-reviewed journal published by Mary Ann Liebert, Inc., publishers presents a series of articles by authors from around the world who provide diverse and insightful perspectives on the science and physiologic responses underlying medical acupuncture. The issue is available free on the Medical Acupuncture website.

“Understanding acupuncture in the same manner that we understand the mechanism of action and pharmacokinetics of a particular drug will, similarly, enable us to match treatments better with conditions,” states Guest Editor Richard F. Hobbs, III, MD. “The net effect will be improved outcomes,” he writes in his editorial “Basic Science Matters.”


The beauty of this gift to me is that not only can I write about the contents of this issue, but the articles are available for free; so you can read them too. No paywalls! One wonders what possessed the editors of this particular journal to provide such an awesome gift to both me and you, our readers.

In any case, I would certainly agree that basic science matters. After all, that’s the whole point of science-based medicine (SBM), isn’t it? That evidence-based medicine (EBM) in its current incarnation relegates basic science considerations to the lowest rung of evidence on its hierarchy of clinical evidence. Indeed, I spent quite some time talking about just that in my talk to the National Capital Area Skeptics a month and a half ago. Basically, EBM suffers from what I like to refer to as “methodolatry,” which an epidemiologist fellow blogger defined as the “profane worship of the randomized clinical trial as the only valid method of investigation. Indeed, the gods of EBM, namely the reviewers for the Cochrane Collaborative, are particularly prone to methodolatry. Indeed, one of the key points we at SBM try to make is that this sort of methodolatry provides and opening for pseudoscientific treatment modalities like acupuncture to gain the appearance of efficacy in some parts of the medical literature. Basic science considerations are, in essence, ignored in determining whether there is sufficient prior scientific plausibility of acupuncture to treat, for instance, infertility or depression, and equivocal, bias-prone clinical trials are ranked much higher than the basic science considerations that make the hypothesis that acupuncture can do anything for infertility so implausible as to border on impossible, barring new evidence speaking to its plausibility.

Of course, in a way acupuncture is a special case. I’ve said it before, and I’ll say it again (at the risk of boring my readers): I actually used to think that maybe there was something to acupuncture, for the simple reason that it involves an actual physical act on the human body, namely sticking needles into it. On a strictly conceptual level, one can speculate that maybe sticking needles into the skin does something. However, the more I read about acupuncture, the more I delved into the actual scientific literature purporting to support acupuncture, the more I realized that there’s no “there” there, even from studies done by advocates, in which negative or equivocal results are almost uniformly spun to be supportive of acupuncture, and mechanisms that probably have little to do with any purported effects of acupuncture. The “adenosine” mechanism I wrote about three years ago comes to mind. The bottom line when it comes to acupuncture is that it’s almost certainly all placebo. It doesn’t matter where you stick the needles. In other words, acupuncture “meridians” are nonsense, which is not surprising, given that attempts to associate any real anatomical structures to meridians have uniformly failed. It doesn’t even matter if the needles are stuck in; twirling toothpicks against the skin does just as well, dubious systematic reviews of acupuncture not withstanding.

So let’s see what Dr. Hobbes, who is based at Plum Blossom Acupuncture and Integrative Medicine, a clinic that offers woo ranging from acupuncture to cupping to moxibustion, has to say about how “basic science matters“:

Medical acupuncture is a part of medicine and is being validated, increasingly, as an effective treatment for a wide range of conditions.1 However, for the most part, we are missing the foundation, the basic science piece. This is a deficiency which, in my view, we must correct. Understanding acupuncture in the same manner that we understand the mechanism of action and pharmacokinetics of a particular drug will, similarly, enable us to match treatments better with conditions. The net effect will be improved outcomes.

How does one define “basic science” in the field of acupuncture? There are traditional paradigms that many of us use every day in treating patients, and then there are views that are informed by those subjects we studied in medical school. So far, efforts to “connect the dots” have not been completely successful. However, progress is being made, and once that goal is achieved, the sharp lines of demarcation between Western and Oriental medicine will disappear.

For this special issue, we encouraged the submission of exemplary studies or comprehensive review articles dealing with research methodologies, physical properties of points and channels, signaling mechanisms, and mechanisms of acupuncture effects.

Apparently, Dr. Hobbes has a different definition of what constitutes “exemplary studies” or “comprehensive review articles” than I do. For instance, the article he cites to support his claim that acupuncture is being increasingly “validated as an effective treatment” for a wide range of (I note, unrelated) conditions is Vickers et al, a systematic review that has been a chew toy of various SBM bloggers, including Steve Novella, Mark Crislip, and myself. Basically, Vickers et al was an article that found a “statistically significant” but clearly clinically insignificant difference between pain scores in sham control versus acupuncture-treated patients with chronic pain syndromes, as I discussed in inordinate detail. If this is “clinical validation,” then we should cease all acupuncture studies right now as a pointless waste of money that unethically subject patients to risk with no likelihood of benefit! Amusingly, just a month and a half ago Andrew J. Vickers, the first author of the review, published a followup rebuttal in (of course!) a CAM journal in which he whined about how those nasty, nasty “skeptics” (he even used the term “sceptics movement” in full U.K. spelling) were so unfair in their criticisms, singling out Steve Novella, a blogger who also wrote about the study under the ‘nym askeptic, and my alter-ego for particular opprobrium.

But let’s look at the rest of what Dr. Hobbes wrote. Truly, it could very well have qualified for Kimball Atwood’s much missed feature, the Weekly Waluation of the Weasel Words of Woo. I particularly like the part where he contrasts the “traditional paradigms that many of us use every day in treating patients” versus the “views that are informed by those subjects we studied in medical school.” Notice how he refers to his beliefs about “acupuncture” as “paradigms” and what he was taught in medical school about the science that says that acupuncture is pseudoscience as “views.” It’s a simultaneously subtle (if you’re not familiar with CAM weasel words) and not-so-subtle (if you are) denigration of scientific medicine. I also like how he uses what I consider to be the racist distinction between “Western” medicine (i.e., evidence- and science-based medicine) and “Oriental” medicine (i.e., traditional Chinese medicine). Seriously, does he even realize the implication he’s making, namely that “Western” medicine is scientific and “Oriental medicine” is touchy-feeling and “holistic”? Doesn’t he realize that there are some damned good “Oriental” scientists, every bit on par with “Western” scientists, and that they have come to the same conclusion, namely that acupuncture is placebo?

So let’s take a look at some of these studies and review articles. The first one that caught my eye was one by John Longhurst, MD, PhD of the Samueli Center for Integrative Medicine at the University of California, Irvine, entitled Acupuncture’s Cardiovascular Actions: A Mechanistic Perspective. Dr. Longhurst begins:

The practice of acupuncture began 2000–3000 years ago. Until the last 50 years, acupuncture developed empirically and its art was passed on from teacher to student through practical application. More recently, practitioners began to find that acupuncture had a rightful place in mainstream medicine and could be used to treat a number of conditions and symptoms. The public outside the Orient has accepted acupuncture because of a perception that it reduces pain effectively and successfully reverses a number of other medical problems. Western medical and scientific communities have been more reluctant to accept this practice because of the absence of controlled clinical trials and scant scientific evidence for its mechanisms of action. However, there may be reason for this skepticism to change. The number of articles published on acupuncture research (451 articles worldwide in 2009) has been increasing almost exponentially over the last several decades, with the United States and China both taking lead roles in advancing understanding of this ancient therapy.1

Don’t you just love the argumentum ad populum (appeal to popularity)? The point is that, because there are now lots of articles on acupuncture and the number has been increasing, it must mean there is something to acupuncture. Never mind that the vast majority of articles are of low quality and that the higher the quality of the research the more likely the findings are to be negative, just like homeopathy. Then there’s also the “appeal to antiquity,” which argues or implies that, just because people have been doing something for a long time, there must be something to it. I like to point out that bloodletting was viewed as an excellent treatment for almost any ailment for hundreds, if not thousands of years, before the late 19th century, when the rise of scientific medicine showed that it was not.

One thing I noticed about this review article right away is that nearly all the studies it discussed were about electroacupuncture (EA). This is, in my mind, a classic “bait and switch,” in which therapy is described as acupuncture but is in reality nothing more than electrical nerve stimulation clumsily grafted onto acupuncture. One might reasonably expect that electrical stimulation of certain nerves might have physiological effects. For instance, anyone who’s ever undergone a nerve conduction study, as I have, know this. (It’s a study that could easily be used as torture, let me tell you.) The very basis of nerve conduction is electrochemical, and it can be influenced by electrical currents. That doesn’t make it acupuncture. Worse, the insistence of using acupuncture points, instead of nerves that might actually have physiological relevance, only muddies the waters, making it less likely that an actual, useful therapy might be derived from the mix of electricity and the vitalism of traditional Chinese medicine that is “electroacupuncture.” Basically, it’s nothing more than a “rebranding” of acupuncture, which doesn’t work, by disguising something that might work (electrical nerve stimulation) as somehow being acupuncture. After all, the Chinese of hundreds (or thousands) of years ago who supposedly invented acupuncture did not have knowledge of electricity, nor did they have the technology to construct batteries or generators. Personally, I think that it’s telling that in many places I saw references to “acupuncture,” but when I clicked on the citations to support the claim I found papers on EA. Indeed, the authors even point out that they focus on EA because “this form of acupuncture is easy to standardize.” No kidding. And they should stop calling EA “acupuncture,” because it’s not.

Next up is an amusing little study from the New England School of Acupuncture, led by a naturopath named Keith Spaulding, entitled Acupuncture Needle Stimulation Induces Changes in Bioelectric Potential. It’s a study of 14 healthy volunteers from ages 24 to 52 in which the investigators tried to tell if there were differences in electrical potential attributable to acupuncture based on needle positioning on “real” acupuncture sites and “sham” acupuncture sites:

Randomized clinical trials (RCTs) of acupuncture often include stimulating verum acupoints and nearby so-called “sham” acupoints. Clinical effectiveness has been reported with both verum and sham stimulation. The verum acupuncture is often only marginally better than the sham acupuncture.6–8 This leads researchers to question if sham acupuncture is indeed a physiologically inactive control placebo.9 An electrophysiological correlate of these clinical findings would be eliciting from the sham acupuncture at a nonacupoint a bioelectrical response that is nearly as strong as the bioelectrical response from stimulating a verum acupoint.

The aim of this study was to document changes in the bioelectric potential that occur in response to needling Pericardium 4 (PC 4) and PC 4cont (control) at four sites on the forearm PC 4, a nearby nonacupuncture point (PC4cont) and two distal points (PC 6 and a nearby nonacupoint (PC 6cont) It was hypothesized that a greater bioelectric potential amplitude was induced distal to the point of stimulation only when the needling site was on the acupuncture point and the distal measured site was on the meridian.

One notes that this was not a blinded study, which pretty much sinks it right there. The acupuncturists knew who was getting what, and they decided the depth of insertion of the needles. They could easily have unconsciously inserted needles into the “true” sites in a systematically different way than they did for the “control” sites. Moreover, the placement of the reference electrode in the umbilicus, by the authors’ own admission, produced a “noise floor” acting as an artifact. Even with the lack of blinding, the results of this study are completely underwhelming. Basically, the investigators found that when the PC4 site was stimulated there was a greater response compared to when a control site (a non-accupoint) was stimulated, leading the authors to observe, “A translation phenomenon (an induced polarization) was seen at the distal site when the proximal site was stimulated. At PC 6 with PC 4 stimulated there was a larger amplitude (p<0.05), compared to the control response.” One notes that out of three sets of comparisons, only one was statistically significantly different, and then only with p=0.02. Also, since multiple comparisons were being made (in reality, six sets, rather than three sets of two) one could argue that an adjustment for multiple comparisons should have been made, which might have made the single result obtained no longer statistically significant. Be that as it may, this is hardly a “highly rigorous” study and basically demonstrates nothing.

The remaining studies were even less “interesting.” For instance, there was a study of “laser acupuncture” in depression. (Whenever I hear the term “laser” attached to acupuncture, I can’t help but think of Dr. Evil demanding to have “sharks with frickin’ laser beams attached to their heads,” but that’s just me.) This study looked at functional MRI imaging of patients with and without depression subjected to laser acupuncture on four putative antidepressant acupoints, and concluded:

Laser acupuncture on LR 8, LR 14, and CV 14 stimulated both the anterior and posterior DMN in both the nondepressed and depressed participants. However, in the nondepressed participants, there was consistently outstanding modulation of the anterior DMN at the medial frontal gyrus across all three acupoints. In the depressed participants, there was wider posterior DMN modulation at the parieto–temporal–limbic cortices. This is part of the antidepressant effect of laser acupuncture.

There’s one problem. (Well, there are a lot of problems, but this is the most glaring.) Nowhere could I find out whether the analysis of the fMRI images was blinded; i.e., nowhere does it say whether the radiologists analyzing the images knew which patients were depressed or not or which image series represented patients receiving “real” acupuncture versus sham. Given how finicky interpreting fMRI studies can be and how easily they can show something where there is nothing, blinding of the radiologists analyzing an fMRI study is essential. That’s at a minimum, not even including whether the patients or the practitioners were blinded or not. One would think that if the fMRIs were analyzed in a blinded fashion that the investigators would have mentioned it; so I have to assume that they were not.

Perhaps the most hilariously pointless study in the group was done by a group in Germany and entitled Transcontinental High-Tech Teleacupuncture Studies and Integrative Laser Medicine. Wow. That sure sounds science-y, doesn’t it. Very impressive. But what the heck does it mean? Basically, the investigators studied subjects in China undergoing laser acupuncture therapy and “integrative laser therapy” (whatever that means), as well as EA and regular acupuncture, and had the subjects’ electrocardiogram readings transmitted to their facility in Germany at the Medical University of Graz, where they were analyzed. Quite honestly, this is about as pointless a use of telemedicine as I can imagine, and it’s not even that sophisticated. I mean, really. We’re doing telesurgery over thousands of miles now, and all these investigators could do is to transmit ECG data from China to Germany?

I’m not impressed.

There are other articles, of course, all of about the same level of scientific rigor or less. None of them validate acupuncture in any way or provide any compelling evidence for a physiologically plausible mechanism, all of which makes the introduction by Richard C. Niemtzow, MD, PhD, MPH (yes, that Richard C. Niemtzow, the one who has promoted “battlefield acupuncture” for our troops in combat), entitled Basic Science: Mysteries and Mechanisms of Acupuncture, all the more cringe-inducing. First of all, it’s quite telling that Niemtzow begins with a quote from Hamlet (Act 1, Scene V), “There are more things in heaven and earth, Horatio,than are dreamt of in your philosophy.” It’s a Shakespeare quote that quacks love as a means of claiming that science can’t study their quackery. Ironically enough, Niemtzow uses it to introduce a short article in which he tries to paint himself as a hopeless dinosaur dedicated to science:

Every day, acupuncturists insert tiny metal needles into acupuncture points located on meridians, hoping to combat a myriad of clinical pathologies. For the most part, we practitioners are witness to a clinical benefit. Otherwise, physicians would have stopped performing this technique several thousand years ago, and we would not be using it today. However, while we witness healing, none of us has ever seen an acupuncture point let alone a meridian. Modern investigational technology, at its best, fails to provide evidence of these two very basic structures.

One notes that the obvious conclusion from this summary of the existing evidence regarding acupuncture meridians and points is that they do not exist. Somehow, Niemtzow fails to take the logical next step to that conclusion. Instead, he writes:

With this in mind, I know that many of us have asked: “How does acupuncture work?” Perhaps we depended, somewhat, on mythical explanations influenced by the classic readings. When I hypothesized Western mechanisms that might offer an explanation, I was told, by one of my esteemed colleagues, that acupuncture does not follow Newtonian physics. I thought, perhaps, that was an excuse to avoid “drilling” deeper to uncover the same mechanisms that enriched our understanding of allopathic medicine. My wife, who was trained in acupuncture in China, told me that exploring acupuncture on a molecular level to seek an explanation as to “how it works” is, somewhat, a fallacy. She posited that, to understand acupuncture, one most [sic] explore its relationships to the environment, animal and plant life, weather, seasons, and the universe. However, I have to admit that I am an “old die hard”; for me, natural events do have scientific explanations and placing a needle in an acupuncture point on a meridian and producing a physiological effect could be understood by using the scientific technology used to understand allopathic medicine.

Good for you, Dr. Niemtzow! Maybe there’s hope for you yet! Or maybe not. In a way, Dr. Niemtzow reminds me of one of the past presidents of the American Association of Naturopathic Physicians, Carl Hangee-Bauer, ND, LAc (note that he’s an acupuncturist as well), taking umbrage at criticisms of naturopathy as unscientific and then declaring his allegiance to rigorous science, even though his practice is rife with what I consider to be pseudoscience, such as traditional Chinese medicine, “biotherapeutic drainage,” detoxification, and others, as well as unproven modalities such as breast thermography. “Science,” Dr. Niemtzow. You keep using that word. I do not think it means what you think it means. (Hint: It does not mean acupuncture.)

Amusingly, in that same editorial, Dr. Niemtzow admits that “a collection of high-quality basic science articles is very difficult to obtain, given the fact that, over the years, we have received and only published a few articles on this topic.” One wonders why not. Could it be because we’re dealing with acupuncture? Sure it could. In any case, it’s hard not to feel a little bit sorry for Dr. Niemtzow. He thinks he’s scientific, while his wife in reality provides a closer approximation of what real acupuncturists think. He also thinks he’s scientifically studying acupuncture, when in fact what he is doing is curating articles designed to validate the treatment rather than to see if there really is anything to it from a scientific standpoint. That fundamental tension makes me wonder when he’ll just give up and let his true proclivities rule.

Posted in: Acupuncture

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74 thoughts on “A very special issue of Medical Acupuncture

  1. I never tried acupuncture, but several friends swear it works for some conditions like motion sickness and sciatica. They are fairly skeptical and are aware of the placebo effect, so its worth considering if conventional medical treatments are not working for you.

  2. rork says:

    Niemtzow’s “Otherwise, physicians would have stopped performing this technique several thousand years ago, and we would not be using it today” might have bothered me the most. Red osier dogwood has probably been used for thousands of years to treat all kinds of things by North American natives (search “Cornus sericea” at an ethnobotany site like http://herb.umd.umich.edu/). Like acupuncture, what it might be good for varies, and it probably doesn’t actually work for any of them. But the bark sure is red.

  3. Scott says:

    @ FBA:

    Various people also swore that bloodletting worked. Your friends are apparently not skeptical in this regard or they wouldn’t be holding up anecdotes as trumping real science. And awareness of the placebo effect does not ensure that one’s anecdotes are good evidence.

    So no, acupuncture is in no way worth considering for any condition for any person.

    1. Sarah says:

      bloodletting does work

      1. WilliamLawrenceUtridge says:

        For HFE hereditary haemochromatosis? Yes, absolutely.

  4. weing says:

    “so its worth considering if conventional medical treatments are not working for you.”
    Here goes. In my experience, when conventional medical treatments aren’t working it is usually because the diagnosis is wrong.

  5. qetzal says:

    I don’t know about motion sickness, but I can imagine that the overall acupuncture ‘experience’ could relieve sciatica symptoms. Not due to the acupuncture per se, but perhaps due to the relaxation effects, provider’s attention, patient’s expectation, etc. So sure, FBA, acupuncture may “work” in some overall sense, especially compared to doing nothing, but that doesn’t mean it works through insertion of needles (regardless of where or even if they’re inserted).

  6. Eugenie Mielczarek says:

    NCCAM has expended $156 million for acupuncture studies and funded 65 clinical trials . No concept was missed –trials covered every problem from irritable to impacted tooth. A colleague who filed using turbo tax noticed the software provided information so its customers would not miss claiming it as a medical deduction.
    NIH spreadsheets show total federal funding ( including NCCAM ) was $162 million. Is paying for mythology a new federal initiative?
    Eugenie Mielczarek

  7. windriven says:

    ” No paywalls! One wonders what possessed the editors of this particular journal to provide such an awesome gift to both me and you, our readers.”

    One supposes that they did extensive market research and set the price point at the highest level they could while maintaining readership greater than 1.

  8. ste5e says:

    Acupuncture has no scientific model of its effect that is better than the cognitive neuroscience view that the brain outputs an experience that is appropriate to its inputs.
    There are two small studies which look at acupuncture done to a prosthetic hand whilst the subject is experiencing a ‘rubber hand illusion’ – a significant number in both studies experienced ‘Deqi’. In Bulley A., Thacker M., Moseley L. eS1226 Physiotherapy 12 out of 14 subjects experienced Deqi. In Hui et al 2007 24 out of 28 acupuncture naive subjects picked 3 out of ten deqi describing words to describe their experience which was not mirrored by the rubber hand illusion experience alone Fischer’s p<0.01.
    Acupuncture is an illusion or voodoo has as good a scientific model of effectiveness. Take your pick.

  9. goodnightirene says:

    “…a systematic review that has been a chew toy of various SBM bloggers…”

    Thanks for that hilarious image–made my day, even without all the rest of this superb takedown. :-))

  10. booker says:

    It’s interesting that you bring up racism in the article — it’s a very important point that is made too infrequently. I think that much of the support for Acupuncture and TCM in the “west” is nothing more than Orientalism, a form of racism. The Orientalist romanticizes all things “eastern” and applies quite different standards to ideas and practices that originate in Asia compared to those that originate in their own “western” culture. Asserting that other ethnic groups have special powers is just as much racism as asserting that they lack certain abilities.

    Faith-healing is faith-healing regardless of where it originates, and regardless of the racial or ethic background of its practitioner. Enough of the “mysterious East”.

  11. windriven says:

    “Modern investigational technology, at its best, fails to provide evidence of [acupuncture points or meridians]. ”
    –Richard C. Niemtzow, MD, PhD, MPH, MOUSE

    We can pick up the thermal signature of a bomber under a tarp from a helicopter, we can track changes in blood flow in the brain as subjects pass in and out of REM sleep, we can find astronomically tiny planets circling stars light years distant, but we can’t find evidence of acupuncture points or meridians.

    So, Dr. Dr. Niemtzow, do you suppose these supposed structures to be composed of dark matter or the thin tissue of delusional fantasies?

  12. goodnightirene says:

    @booker

    Whenever I get the “ancient Chinese practice” trope, I mention that these are the same people who bound women’s feet to the point of completely crippling them. This usually brings at least a temporary halt to the woo–followed by a look that asks why I had to spoil all the fun.

  13. So sure, FBA, acupuncture may “work” in some overall sense, especially compared to doing nothing, but that doesn’t mean it works through insertion of needles

    One possible explanation is the needles interfere with neural transmission of pain. I dont know, but even if the needles do nothing, and the patient is feeling pain relief from relaxation or other reasons, then the experience has some benefit no?

  14. Davdoodles says:

    “Medical Accupuncture”

    Medical bicycling
    Medical opera
    Medical speliology
    Medical baking
    Medical dancing
    Medical millinery…
    .

  15. norrisL says:

    FBA

    “even if the needles do nothing, and the patient is feeling pain relief from relaxation or other reasons, then the” reason is that what is happening is just placebo. Nothing more, nothing less.

    Additionally, it is bordering on malpractice for a doctor to dispense what he/she knows to be pure placebo.

    just my thoughts

  16. egstra says:

    I don’t mind if people go in for acupuncture; that’s their choice, after all. But why MDs prescribe it and insurance pays for it is beyond me.

  17. BillyJoe7 says:

    FBA,

    “even if the needles do nothing, and the patient is feeling pain relief from relaxation or other reasons, then the experience has some benefit no?”

    But why not link the placebo effect to a treatment that works instead of one that doesn’t work.

    In any case, the patient may only report that he feels better without actually feeling better, or he may feel subjectively better but all objective measures suggest that he is, in fact, not better.
    (See the commentary of a recent trial of acupuncture in the treatment of asthma where patients said they felt better and reported that they felt better, but objective measures of their airway showed they were not better)

  18. BillyJoe7 says:

    egstra,

    “I don’t mind if people go in for acupuncture”

    I do. Because it means critical thinking has not been applied. And there goes another victim into the arms of pseudoscience where they are often persuaded to avoid mainstream or science-based medicine and introduced to other more harmfull practices.

  19. Narad says:

    Niemtzow’s “Otherwise, physicians would have stopped performing this technique several thousand years ago, and we would not be using it today” might have bothered me the most.

    One might also note that his favored “battlefield acupuncture” is auricular, which was invented out of whole (homuncular) cloth in France a mere 60 or 70 years ago.

  20. norrisL: Additionally, it is bordering on malpractice for a doctor to dispense what he/she knows to be pure placebo.

    Malpractice? Prescribing placebos is perfectly legal. Its better to get a placebo than patient taking something actively harmful (like, say, an antibiotic, or narcotic painkiller). Doctors dish out placebos daily. There was a post here on this blog with a survey where 90% of doctors admitted to prescribing placebos.

    Acupuncturists do not consider their work to be dishing out placebos by the way.

  21. Scott says:

    @ FBA:

    Prescribing placebos is perfectly legal.

    But considered profoundly unethical.

    There was a post here on this blog with a survey where 90% of doctors admitted to prescribing placebos.

    No, there was a post about a survey where the people doing it manufactured a completely false definition of “placebo” in order to make up that number.

    Acupuncturists do not consider their work to be dishing out placebos by the way.

    Which proves nothing other than that they are wrong about what they do.

  22. weing says:

    “There was a post here on this blog with a survey where 90% of doctors admitted to prescribing placebos.”

    The post was about how wrong that survey was. Homeopaths, acupuncturists, dish them out daily as that is all they got. The placebo effect is inherent in the doctor patient relationship but with SBM we go above and beyond the placebo effect.

  23. WilliamLawrenceUtridge says:

    One possible explanation is the needles interfere with neural transmission of pain. I dont know, but even if the needles do nothing, and the patient is feeling pain relief from relaxation or other reasons, then the experience has some benefit no?

    I’ve an inkling the counter-irritant explanation had been tested and failed, but I’ve no source. But there are lots of potential counter-irritants which don’t rely on explanations that corrode rationalism, that don’t act as a foot in the door for a host of other even more unscientific interventions, that don’t penetrate the skin, that don’t have the potential to puncture the lung, that don’t rely on conspiracy theories and arguments from authority and that are science-based. If one considered acupuncture purely as a physical intervention, it still bears risks. If one considers it purely from an economic perspecitve, it’s tremendously wasteful as currently taught (all the nonsense about qi, meridians, points and other such nonsense take up too much time for zero benefit, while taking time away from things like sterility and anatomy) not to mention you are significantly over-paying for your placebo. If one considers it purely from a scientific perspective, it is part of a constelation of nonsense, it is a bait-and-switch, it is a waste of scarce research resources like money and time.

    Malpractice? Prescribing placebos is perfectly legal.

    And it took significant effort and time for the medical community to abandon its practice of paternalism to get away from head-patting placebo prescribing in order to enable patients to participate with full consent in their own care. What is legal is a bare-minimum standard that it would be good to exceed. Acupuncture benefits practitioners far more than it benefits patients.

    Its better to get a placebo than patient taking something actively harmful (like, say, an antibiotic, or narcotic painkiller).

    That really depends. Medicines carry risks and benefits. A pure placebo where there is an effective treatment that will address a genuine need is probably not better for the patient. A narcotic painkiller carries risks, but in cases of acute or chronic genuine pain, their long-lasting, unequivocal analgesic benefits are far more effective than acupuncture’s transitory and unreliable effects. Whether it’s better to get or give a placebo than a real medication is probably a decision that should be made by the individual patient, as advised by their doctor. Mainstream medicine attempts to enter a dialogue with patients, fully informing them of the risks and benefits then allowing them to make an informed choice. It’s the rare acupuncturist who says “this could be total placebo; there’s a risk I could damage your nerves or puncture a lung; meridians have never been proven to exist, and the points I chose aren’t real”. That kind of genuine informed consent would erode the placebo benefits of acupuncture (possibly eliminating any benefits of acupuncture in the process), and most acupuncturists are probably uninformed of the true scientific debate and uninterested in learning. Instead, we get a lot of what you’re saying here – non sequiters and false dilemmas about the flaws in mainstream medicine.

    In cases where there are no effective medications or the illness is self-limiting, I would agree – a placebo is better than a risky dose of drugs. Even better would be an informed patient who is willing to accept there is nothing to be done or that it might be better to just suffer. But it’s a false choice to say it’s either drugs or acupuncture. It can be neither, it can be both.

    Doctors dish out placebos daily. There was a post here on this blog with a survey where 90% of doctors admitted to prescribing placebos.

    Yes, doctors (collectively) do dish placebos. That doesn’t make it right, nor does it justify the fact that most, possibly all CAM, including acupuncture, is solely placebo. Rather than dragging everything down to a bare minimum level, woudln’t a better option be trying to identify more effective treatments, interventions that can be enhanced through placebo while also genuinely healing patients, ensuring patients can have more time with their doctors to be better educated consumers, healthcare costs are used more efficiently and research time and energy can be spent where it is most fruitful?

    Acupuncturists do not consider their work to be dishing out placebos by the way.

    Then perhaps they should begin examining their discipline more self-critically. There is considerable evidence that acupuncture is not a particularly good treatment, offering only minimal short-term symptom relief for pain and nausea. Perhaps acupuncturists could learn from doctors (rather than their usual rhetoric for doctors to be open minded) and start dropping from their practice those things that are not useful (meridians, needling specific points, Traditional Chinese Medicine practices in general) while adding to their practice harm-reduction strategies like a better appreciation of anatomy and sterility.

    The road to hell is paved with good intentions, and the road to medical harm is as well. Good intentions should not be used as an excuse to preserve worthless and ineffective treatments from scrutiny or change. Doctors are forced to spend considerable time and money ensuring their medical knowledge changes to keep up to date with current best practices. Don’t you think this is laudable and worth imitating? Why is “it’s 2,000 years old” held up as if it were something good? Change is inevitable, and when science is involved, nearly always positive.

  24. Xplodyncow says:

    Spaulding:

    This leads researchers to question if sham acupuncture is indeed a physiologically inactive control placebo.

    Instead of questioning whether the placebo is really a placebo, the researchers never thought that maybe acupuncture is a placebo?

  25. @WilliamLawrenceUtridge

    I wouldnt dismiss acupuncture as pure placebo or a complete waste of money as a subject for scientific investigation. Besides the anecdotal success stories I cited for pain relief and nausea relief, there are scientific studies as well. Here is one review of trials conducted on acupuncture: http://cat.inist.fr/?aModele=afficheN&cpsidt=18229166

    Conclusion: There is good clinical evidence from more than 40 randomised controlled trials that acupuncture has some effect in preventing or attenuating nausea and vomiting.

    Do we know why it works? No. That doesnt make it a placebo.

  26. Davdoodles says:

    “Do we know why it works? No. That doesnt make it a placebo.”

    While techically correct (not knowing “why it works” does not equal “it’s a placebo”), it is irrelevant and misleading.

    Because, we do know it’s a placebo. And we also know it doesn’t work.

    We know it’s a placebo because trials have been performed that show that needle placement (ie random as opposed to “meridian-based” or whatever, or even non-insertion of needles, makes no difference to the effect.)

    We also know it doesn’t work, because it’s effects are indistinguishable from the effect of any other placebo.

    Where there is a physical process at work, placebos are always demonstrably ineffective. Brokenones do not knit faster. Tumors do not diminish in size, woulds do not close faster or scar less.

    Where there is a subjective or psychological component, as is often the case (and is certainly the case with nausea and vomiting, pain and asthma), a placebo (something which a trusted person says will “help”), will often be reported as “helping”, or may in fact be linked to a reduced rate of vomiting, for example.

    But that’s not the same as this-or-that placebo, incantation, or cuddle “working”.

    At the risk of sounding cynical, I would wager that that is precisely why woo plays in the placebo space. Because they can’t demonstrate any result peculiar to their particular woo but at least when they wave their hands or release their Chakras or whatever, someone will hopefully agree they feel better or is demonstrably calmer.
    .

  27. pmoran says:

    I was disappointed to see Vickers being treated in such a dismissive and condescending manner and I am not surprised to see him react. He is no fool. He has written a very good article on alternative cancer treatments in which he said that most of them should be regarded as disproved rather than unproven (Andrew Vickers, PhD.  CA Cancer J Clin 2004; 54:110-118)
     
    Along with Linde, he has had considerable experience at meta-analyses and its relevant statistics (probably more than Drs Gorski or Crislip ) , and he would be well aware of the opprobrium that would attach to anyone going to the trouble of (yet again!) analysing the extant data, but doing so in an obviously defective way.

    This is why they concentrated on studies where allocation concealment (single blinding, at any rate) was certain and why they actually went so far as to exclude a set of unusually positive studies. This is why their conclusions are modest, allowing that any specific effect of acupuncture is small and that most of its apparent clinical activity must be due to placebo and other influences. They make no reference to ancient Chinese superstitions. They are simply stating what the studies seem to show and it would be perversely unscientific to claim that any different, unbiased survey of the data would show anything different. Too many studies have now supplied much the same results.

    So we are not arguing about what the data reveals, we are arguing about what it means. I agree with those who say that the differences between sham and real acupuncture are probably small enough to be explained by expectancy effects and other practitioner influences leaking through onto patient responses. So probably acupuncture has no unique or mysterious properties that need exploring.

    It is an entirely different question as to whether patients are deriving genuine symptomatic benefits from such elaborate protocol, even from twiddling toothpicks against the skin under the right conditions. This relates to the only challengeable statement in Vickers et AL’s conclusions i.e. that “acupuncture is effective”. Yet this may well be true for the studied conditions if the broadest meaning is applied to the word “acupuncture”. To challenge it we have to show either that we know better than our patients how they are feeling at any point in time, or that they are fibbing to us about that all the time. Go for it!

    We need to know these things if we are to fully understand the practice of medicine in all its manifestations. It is a valid scientific hypothesis to suggest that procedures like acupuncture can be good at exerting and enforcing a combination of mundane, plausible but limited therapeutic influences such as relaxation, meditation, ongoing encouragement and psychosocial interaction, distraction and counter-irritation. Once again, for science, this is either true or not true. It does not matter what awkwardness its truth might create for certain circles, such as those adopting an extremely aggressive stance towards anyone who expresses the least tolerance for the procedure.. The level of their aggression and especially the ad hominem towards perceived opponents earns them the onus of proof. Science is normally more cautious.

  28. WilliamLawrenceUtridge says:

    I wouldnt dismiss acupuncture as pure placebo or a complete waste of money as a subject for scientific investigation. Besides the anecdotal success stories I cited for pain relief and nausea relief, there are scientific studies as well. Here is one review of trials conducted on acupuncture

    Yes, one of the two indications for which acupuncture has some evidence are pain relief and nausea. However, those are symptoms, they are not causes. Further, their effectiveness is transitory, unreliable, and clinically of borderline significance. Pain and nausea are the two symptoms for which placebo effects are most potent and reliable, as well as being most vulnerable to contamination in a research study – they are purely subjective, there is no way to measure them objectively, they are often not uniform, and if you think about them long enough, they can often temporarily abate.

    http://cat.inist.fr/?aModele=afficheN&cpsidt=18229166Here is a Cochrane review for post-operative nausea and vomiting which I suggest you refer to. It is from 2011 (your study is from 2006), and its results are far more equivocal (in particular, noting it was not clear if acupuncture offerred any benefits compared to next-generation antinausea drugs). Here is another review in which acupuressure reduced nausea (again a subjective symptom) but not vomiting (an objective act) in pregnant women.

    Results are extremely equivocal, and there are still so many questions about it – what were the controls? Were they “anything but acupuncture”? Were they “different spots” (as still there is evidence that there is nary a single point that is different from any other)? Were they retracting needles, the best form of control since it is essentially indistinguishable from actual skin penetration, and also the one that indicates actual skin penetration doesn’t seem to add anything but risk?

    Conclusion: There is good clinical evidence from more than 40 randomised controlled trials that acupuncture has some effect in preventing or attenuating nausea and vomiting.

    All that effort for “some effect”, not to mention I would question how good a quality those 40 trials were. But actually, I support acupuncture use for pain and nausea. I just question all the crap that tends to accompany it – qi should be discarded, meridians are nonsense, needling of specific points adds nothing, its great age is anything but, and so it goes on. If acupuncture training consisted of a weekend course focusing on anatomy (specifically where to not needle due to risks of bleeding, lung puncture, nerve and tendon damage) and sterility, with none of the antiscientific rhetoric that so often accompanies CAM modalities, no discussion of Traditional Chinese Medicine, no discussion of “diagnosis” and use of acupuncture solely for adjuvant treatment of pain and nausea, I would have little problem with it. But it’s not. People can get Masters of Science in acupuncture, still babble about qi, points, ancient wisdom, the evil of “Western science” (a fundamentally racist and inaccurate claim), pulse “diagnosis”, tongue “diagnosis” and other nonsense.

    Plus, just give up researching it. At this point, we know it offers some minor benefits, essentially indistinguishable from effective placebos, for two symptoms. But millions of precious research dollars are thrown at this, chasing down an effect that just keeps getting smaller (and was never that impressive to begin with).

    Do we know why it works? No. That doesnt make it a placebo.

    You should read the acupuncture chapter in Trick or Treatment, as it does an excellent job of explaining why the scientific controls to date have been rather poor, as well as why older trials can’t be relied on as much.

    Equivocal, unreliable, transitory effects, intensive, worthless training, antiscientific rhetoric, often racist presentation and a foot-in-the-door for other nonsense. The flaws of acupuncture are myriad, practitioners often fail to recognize them. Again, compare this to medicine which learns and changes in the face of new evidence. I refuse to condemn acupuncture outright, but I am disgusted at how actual acupuncturists selectively cite the scientific research for their own benefit and never recognize the flaws and dangers of the “treatment” they provide.

  29. @WilliamLawrenceUtridge Yes, one of the two indications for which acupuncture has some evidence are pain relief and nausea. However, those are symptoms, they are not causes.

    There is a whole class of drugs that does nothing but symptom relief. In pain relief especially. You mention risks of acupuncture, how about the risks of oxycodone that conventional medicine dishes out? How many people drive while doped on painkillers? There is a public health epidemic of deaths from prescription pain symptom relief drugs: http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/

    The military is turning to acupuncture as SAFE pain relief cause they dont want pilots and drivers to go on missions doped up on Vicodin: http://www.stripes.com/military-turns-to-acupuncture-as-alternative-to-prescription-painkillers-1.116167

  30. Scott says:

    If acupuncture provided pain relief anywhere vaguely comparable to narcotics, you might have the beginnings of an argument there.

    But it doesn’t, so you don’t.

  31. Ed Haines says:

    goodnightirene. Your referral to foot binding is very apropos. However, should you look at a lateral xray of a woman’s foot in a high heel, you will be struck by the closeness of appearance to that ancient form of torture. The difference, of course is that foot binding was left in place for years whereas modern women “only” torture their feet for a few hours at a time. To the best of my knowledge, acupuncture is unlikely to benefit either group.

  32. WilliamLawrenceUtridge says:

    There is a whole class of drugs that does nothing but symptom relief. In pain relief especially. You mention risks of acupuncture, how about the risks of oxycodone that conventional medicine dishes out? How many people drive while doped on painkillers? There is a public health epidemic of deaths from prescription pain symptom relief drugs

    Those drugs work reliably, far beyond placebo, for all humans, do not violate any scientific principles, do not require hundreds of trials to establish an effect, do not require an essentially racist approach to scientific results, are not accompanied by a corrosive, antiscientific paradigm, and unequivocally work. Scientifically, in terms of results to investment, the results are unambiguous interpretable, and the investment relatively negligible. It would be interesting to total up the cost of all the acupuncture trials compared to the overall clinical benefit in terms of pain relief, versus the equivalent number of trials, subjects, money and number of drugs produced that result in unequivocal pain relief.

    Not to mention, if drugs are proven to have a questionable safety to efficacy ratio, they are pulled. If drugs are found to be barely better than a placebo, they probably aren’t approved. If they aren’t found better than placebo, they are not approved. If drugs can be reformulated to provide greater benefits with fewer side effects, that change occurs. If new treatments are developed that are superior to old treatments, practice changes. Last I checked, acupuncture practitioners still rely on things like “ancient wisdom”, qi, meridians, acupuncture points, tongue diagnosis, pulse diagnosis and needling of the torso where it is relatively easy to puncture a lung (or pericardium, or hit another organ). These aspects of acupuncture are not necessary, add risk and expense, and ultimately are little more than lies told to patients.

    And finally, the two are completely different issues – if drugs have side effects, that doesn’t mean acupuncture works. If a drug trial had equivalent result, it would receive rabid criticisms. You’re asking for a double standard. This is more false dilemma so beloved of CAM practitioners – failing to justify the effectiveness of their prefered CAM intervention, they turn instead to criticisms of drugs.

    If you really want to apply the lessons of science regarding acupuncture, you should look at it as identifying ways to enhance placebo effects while providing real medicine. Practitioner enthusiasm, care paid to packaging and form, emphasis on quality and science of intervention, and above all a lengthy consultation where the patient feels valued. Of course, we knew that before we started examining acupuncture.

    The military is turning to acupuncture as SAFE pain relief cause they dont want pilots and drivers to go on missions doped up on Vicodin

    During WWII, they found that saline injections provided pain relief when they ran out of morphine. Personally, I think that if someone is risking their life for a country, they deserve real medicine.

    Also, your point doesn’t really register the fact that scientific support for acupuncture is still equivocal and flawed. Acupuncture may be safer than Vicodin, but that doesn’t make it effective (not to mention, what happens when the short-term effects of acupuncture wear off mid-mission? We know how long Vicodin lasts, acupuncture is far less predictable since it’s not really based on a chemical effect; I’d rather teach pilots and soldiers biofeedback or something that is at least controllable).

  33. cloudskimmer says:

    Years ago I accompanied someone I cared very much about to an acupuncture treatment for pain. I remained silent because it was a referral by an internist I respected, and this person suffered for years from severe chronic pain. My hope was that, even as a placebo, if the patient felt better, that would be great. Instead, the needles caused severe pain. In addition, after the procedure, the patient experienced dizziness, nausea, and later vomited. So, my conclusion is that acupuncture causes pain, nausea and vomiting. The acupuncturist of course maintained that the procedure could only making things better, never worse. She also recommended enzymes and other dietary supplements–conveniently for sale in their office! I couldn’t get out of there quickly enough, and after the education I’ve had on this website (and reading R. Barker Bausell’s book,) try to discourage people from spending any time or money on this useless, idiotic, possibly dangerous procedure. I also told the referring doctor about our experience and tried to encourage him not to refer anyone else.

  34. pmoran says:

    If acupuncture provided pain relief anywhere vaguely comparable to narcotics, you might have the beginnings of an argument there.

    I am not sure who this was directed at, but don’t forget that the apparently beneficial effects of acupuncture can be demonstrated over and above those of regular medical care and in otherwise difficult and disabling conditions such as chronic pain. They are also only small (e.g. effect sizes of about 0.2 to 0.25) when you consider comparisons with sham, not when you compare what might be described as “acupuncture variants” with usual care (effect sizes of 0.4-0.5).

    Also, who is to say that even small gains are not worthwhile to some? If we are to attack the paternalistic judgements of others, we should be careful. The most we can do is advise on their likely cost-effectiveness to those for whom that is a major consideration. But we might need a lot more data for that, also more certainty as to either the actuality or illusoriness of the apparent benefits.

    This is also before considering that those “small gains” derive from averaging out in an artificial clinical environment. Many matters are by no means as settled as common discourse suggests.

  35. Scott says:

    @ pmoran:

    It was directed at FBA, who was trying to imply that acupuncture provides pain relief as effective as oxycodone.

  36. WilliamLawrenceUtridge says:

    don’t forget that the apparently beneficial effects of acupuncture can be demonstrated over and above those of regular medical care and in otherwise difficult and disabling conditions such as chronic pain.

    Those benefits tend to be equivocal, and often those difficult and disabling conditions like chronic pain have relatively poor controls. To compare acupuncture to something like a pill, waiting list or usual care isn’t a fair comparison. Research on placebos indicates that lengthy consultations, injections or needles rather than pills, dramatic and exotic interventions and a demeanor of caring all enhance the effectiveness of nonspecific symptom relief. Acupuncture has all of these things – but that doesn’t make these placebo effects any less of a nonspecific effect. If acupuncture has a specific effect beyond placebo, it is not very strong and is quite hard to demonstrate with adequate controls. We know it doesn’t matter if you penetrate the skin or where you needle, but practitioner characteristics do matter. If acupuncturists took these lessons and dropped all the worthless nonsense like TCM diagnosis, unjustified criticisms of science and years of training, I would have little issue with acupuncture. If training consisted of a weekend course emphasizing anatomy and sterility, and it were one of many adjuvants in the armenture of medicine, fine. That is science-based practice. But that’s not how CAM practitioners use it – it is bundled with herbs, moxibustion, homeopathy, supplements, and above all an ignorant, unjustified criticism of science.

    The greatest benefit of medicine is that it changes in the face of new evidence. The worst crime of CAM is that it does not. Acupuncture is an incredibly obvious example of this.

    They are also only small (e.g. effect sizes of about 0.2 to 0.25) when you consider comparisons with sham, not when you compare what might be described as “acupuncture variants” with usual care (effect sizes of 0.4-0.5).

    Again, unsurprising. I know for studies of back pain, most patients have been through “usual care” for a while. The whole reason we try to account for placebo effects is because they enhance both real and sham medical interventions. Real medicine should be focused on enhancing nonspecific effects as part of usual care, not on adopting the worthless, time-consuming, antiscientific nonsense aspects of usual care that we know as CAM. Again I see a double-standard – if drug companies got to use “no care” as a comparison rather than placebo-controlled trials, the effectiveness of their medications would also be unfairly enhanced. It’s bad science, bad medicine and bad patient care.

    Also, who is to say that even small gains are not worthwhile to some? If we are to attack the paternalistic judgements of others, we should be careful. The most we can do is advise on their likely cost-effectiveness to those for whom that is a major consideration. But we might need a lot more data for that, also more certainty as to either the actuality or illusoriness of the apparent benefits.

    This is also before considering that those “small gains” derive from averaging out in an artificial clinical environment. Many matters are by no means as settled as common discourse suggests.

    Those small gains are worthwhile – again, as part of usual care that genuinely helps patients. As soon as you try to justify scientifically questionable medical procedures (particularly ones that basically can’t work) you stop helping the patient in any meaningful way. There are ways to provide usual care that are reassuring and symptom-alleviating that don’t involve breaking Occam’s razor. Your claim of averaging of small gains also ignores people who simply won’t benefit from placebo interventions (see for example cloudskimmer’s post), and by providing acupuncture to these groups, it is all risk with no benefit, accompanied by a healthy dose of patronizing deceit (and in many cases, unwarranted rhetoric about the completely irrelevant failings of real medicine).

    As is said so often – if any CAM practice works, it can and should be adopted by regular practice. To that I will add that it should be stripped of the useless, time-wasting, expensive accretions as well as the dishonest criticisms of conventional medicine. The bundling and bait-and-switch that so often accompany placebo care can be passively or actively harmful, but beyond that I have this to say to you specifically Pete. As an oncologist, do you really think it is justified that patients spend what may well be their final days pissing away time, spending money and experiencing anguish over placebos? Are false hope and transitory symptom relief really worth lying that much to your patients? I can see how it may be tempting, and how in clinical practice you might apply it to specific patients. But to support this sort of equivocal, expensive, risk-including practice in the abstract in the comments section of a blog is still a genuine surprise to me.

  37. pmoran says:

    WLU, your first paragraph suggests that you have missed my statement that “I agree with those who say that the differences between sham and real acupuncture are probably small enough to be explained by expectancy effects and other practitioner influences leaking through onto patient responses. So probably acupuncture has no unique or mysterious properties that need exploring.”

    I have also stated elsewhere that even if acupuncture can help some patients in other ways, there remain a number of reasons why doctors might choose not to endorse it for routine medical care. These include the likelihood that acupuncture, if cost-effective in some populations, might not be in others. Also most of those consulting regular Western medical practitioners will come long with certain expectations as to how they will be treated. It would be quite inappropriate to refer them all to an acupuncturist and silly to expect similar outcomes to that possible with a group of mainland Chinese. .

    So, can you forget all about all that for a minute and accept that even so, CAM, and especially procedures like acupuncture, pose important questions for the science of medical practice? Also that scientific rigor should be permitted to cut all ways, meaning that we who pretend to be at its very edge should not be resorting to weak arguments (such as ” its only a small effect”) as though they are strong, and committing ourselves too far into positions that you yourself are allowing to be equivocal?

    I am especially opposed to creating a battleground with our endeavours wherein anyone who does not think exactly as we do becomes an object of derision. Those interested in acupuncture, for example, are a very mixed bag that includes reasonable scientists as well as nutty extremists. SBM sometimes seems to be doing its best to create mortal enemies out of people who I would like to sit down with and say “look, you have interpreted that this way, but would you agree this other way is as likely an explanation?” What could be productive dialogue is being eschewed in favour of the addictive thrills of the put-down. I once suggested that some of the more reasonable people should be invited to participate on these pages, and still think that we have nothing to fear from that.

    It would be very desirable if Vickers and Linde could be persuaded to publicly qualify their “acupuncture is effective” statement (as indeed the conclusion of their abstract does, to a degree, but probably without hitting the press) as their study is likely to be extremely influential. It is most unlikely that any other analysis of the data , or future studies of the same kind, would provide different results.

  38. Narad says:

    The military is turning to acupuncture as SAFE pain relief cause they dont want pilots and drivers to go on missions doped up on Vicodin

    Once again, auricular acupuncture was created out of whole cloth in France in the late 1940s. It is even sillier than “real” acupuncture.

  39. @Narad.. you might want to look at this study http://www.ncbi.nlm.nih.gov/pubmed/7402685
    the idea that musculoskeletal pain is related to auricular acupuncture has some merit.

  40. Narad says:

    you might want to look at this study http://www.ncbi.nlm.nih.gov/pubmed/7402685
    the idea that musculoskeletal pain is related to auricular acupuncture has some merit.

    Given that I can only see the abstract, no, it doesn’t, unless you’re now making the claim that (outlandish) diagnostic methods now correspond to treatment modalities.

  41. weing says:

    I wonder what happens when the patient has no ear, or missing parts? Do the corresponding organs wither?

  42. Harriet Hall says:

    @FastBuckArtist

    That study is 33 years old and has not be replicated. In fact, it has been refuted by a much more recent double blind study:http://www.ncbi.nlm.nih.gov/pubmed/17906600

  43. @Harriet I am not specialist of acupuncture, but dont they use electric skin resistance to measure tenderness of ear rather than poking the patient with a stylus as is done in the study you presented?

    Here is a study on electric stimulation of the ear to reduce chronic back pain:
    http://www.ncbi.nlm.nih.gov/pubmed/15105215
    they believe it works

  44. Narad says:

    I am not specialist of acupuncture, but dont they use electric skin resistance to measure tenderness of ear rather than poking the patient with a stylus as is done in the study you presented?

    Allow me to rephrase my previous comment, which doesn’t seem to have sunk in: If one has a patient who presents with yellow sclerae, one does not, to the best of my understanding, treat the eyes.

  45. WilliamLawrenceUtridge says:

    @Pete – you’re right, I did, my apologies for not reading your comments more carefully. It was discourteous. You may also note that I have frequently said I have no issue with acupuncture being used given certain realistic restrictions (sterility, anatomy and stripped of nonsense TCM/CAM concepts). I disagree that CAM has anything to teach real medicine that real medicine can’t learn for itself, better, faster and propagated much more effectively. They are profoundly unscientific, by nature and by rhetoric (the most pernicious aspect of CAM), and can’t think of any treatment modalities that have entered mainstream practice that couldn’t have gotten there through ongoing research. Specifically for acupuncture, even those “reasonable scientists” who research it refuse to drop the unscientific and antiscientific aspects in their research, for some reason perseverating over concepts such as qi, meridians and needling of specific points. Keep the meaningful aspects of acupuncture, drop the irrational (and worthless) parts.

    @FBA
    Medical practice based on 33-year-old information these days would be referred to as “malpractice”. Science has advanced, and medicine changed much in that time and the subsequent decades to research the topic have produced only equivocal results, not clarity. I’m also not sure what we would get out of examining the ear homonculous for body pain when we could simply ask the patient where it hurts. I’m also curious why you are referring to electrifying the ear as “acupuncture”, as I do not believe the Yellow Emperor had the means to reliably connect the needles to an electricity source.

  46. David Gorski says:

    I am especially opposed to creating a battleground with our endeavours wherein anyone who does not think exactly as we do becomes an object of derision. Those interested in acupuncture, for example, are a very mixed bag that includes reasonable scientists as well as nutty extremists. SBM sometimes seems to be doing its best to create mortal enemies out of people who I would like to sit down with and say “look, you have interpreted that this way, but would you agree this other way is as likely an explanation?” What could be productive dialogue is being eschewed in favour of the addictive thrills of the put-down. I once suggested that some of the more reasonable people should be invited to participate on these pages, and still think that we have nothing to fear from that.

    Once again, Peter represents himself and those like him as paragons of reason, practicality, and civility compared to those who actually do take a hard look at the actual evidence, who are portrayed as being dogmatic, harsh, and hateful ideologues who drive away all reasonable conversation. It’s a straw man argument at best, and I’m tired of it given how often Peter trots it out. It seems to serve, more than anything else, to let Peter frame the discussion in the way he wants: Presenting himself as oh-so-much-more-reasonable than the rest of us, who, not being as enamored of being liked as he apparently is, are portrayed as nasty and uncaring skeptical brutes who revel in chasing away “reasonable” people like him who don’t see things our way.

    Much more importantly (and having nothing to do with my renewed exasperation with Peter), I would also point out that anyone who wants to do so is quite free to participate on these pages. Anyone. All it takes is registering an account, and we only require that to cut down on comment spam and drive-by trolls. Many have been the commenters who have disagreed with what SBM is saying, including, I might add, Peter. Anyone is welcome to submit a guest post, which just has to convince a large enough proportion of the core SBMers that it’s worth publishing. That includes you Peter. You are free to submit a post arguing your point, and I would very likely post it. In fact, I do believe I’ve publicly made this offer to you before on multiple occasions, but you have never taken me up on it. I make it again.

    I also predict that you will once again fail to take me up on it. Now that’s something you could easily prove me wrong about!

  47. pmoran says:

    Ah, so what I say is not worthy of consideration, if I only choose to say it in the comments? And do you really want me to dissect out examples of the ad hominem in a major piece? I am content for what I have said to have whatever influence it will and don’t expect a lot.

    I am well aware that some of the material I have been discussing in relation to acupuncture variants and the practice of medicine is arguable, but that is the whole point. It IS arguable, and moreover in somewhat different ways to that being considered by the main protagonists — which IS worthy of a major piece but I am still evolving the vocabulary needed to clearly describe it.

    While there is ANY uncertainty as to medical outcomes we have proportionately less right to be despising those who see things a little differently, and who may be mistaken only in small ways and for easily understandable reasons. It is an excess of dogmatism, even if in part justified by a privileged and sophisticated informational background, that spawns the ad hominem and also sets those who cannot easily follow our reasoning to asking “how can these arrogant pricks be so sure?”.

    I was just now trying to find Steve Novella’s recent piece on the standards that are desirable in our dialogue with different-thinking persons, but can’t locate it. Some sound advice there, I think. .

  48. WilliamLawrenceUtridge says:

    It’s really more of a “put up or shut up” kinda thing. Put forth your argument and evidence in a single article, with no interruptions and not as a response to someone else’s work. You can construct it, beginning to end, in the most coherent fashion possible, so we can all stop playing “guess what Pete Moran is trying to say”. Make your own coherent argument for acupuncture, where it can, can’t and should be used, in the most rigorous fashion. Quite obviously, either you aren’t expressing it very well here, or the nature of a comments thread isn’t the correct venue to make yourself understood.

    It’s not dogmatic to expect ostensibly-medical practitioners to change practice in the face of new evidence that maintains or improves efficacy while reducing adverse effects. I have nothing but contempt for acupuncturists and their cheerleaders who ignore the evidence that their practice could be better, and instead resort to false dilemmas and conspiracy theories. Of course, right off the get-go, since CAM practitioners aren’t starting from an evidence-based position in the first place, you’re already speaking two different languages. One that makes sense, and one that does little more than enrich liars. They may be well-intentioned liars, at best they are ignorant liars, but they still don’t tell the truth about their practices or their opponents.

    It really is like trying to nail jelly to a wall, you really do spend a lot of time talking about what you don’t mean. It’d be nice if you were a little more rigorous and clear.

  49. Harriet Hall says:

    @FastBuck Artist,

    “@Harriet I am not specialist of acupuncture, but dont they use electric skin resistance to measure tenderness of ear rather than poking the patient with a stylus as is done in the study you presented?”

    Ear acupuncture is being taught for battlefield medicine. They don’t have any instruments to measure electric skin resistance on the battlefield. Measuring skin resistance is not part of the usual practice of either acupuncture or ear acupuncture.

    And even if a tender spot is found on the ear, there are no connections between the ear and the rest of the body. Stimulating a tender point might serve as a distraction from pain elsewhere, but there’s no way that stimulating a specific point on the ear could treat pain in a specific location.

  50. David Gorski says:

    It’s really more of a “put up or shut up” kinda thing. Put forth your argument and evidence in a single article, with no interruptions and not as a response to someone else’s work. You can construct it, beginning to end, in the most coherent fashion possible, so we can all stop playing “guess what Pete Moran is trying to say”. Make your own coherent argument for acupuncture, where it can, can’t and should be used, in the most rigorous fashion. Quite obviously, either you aren’t expressing it very well here, or the nature of a comments thread isn’t the correct venue to make yourself understood.

    I couldn’t have said it better myself. Trying to get Peter to make his point really is like trying to nail jello (or jelly, or whatever example you want to use) to the wall. Here’s his chance to make his best case uninterrupted. He has but to take it. We’ll even edit for style, grammar, spelling, etc. if he wants. We’ll insert links where he wants them if he doesn’t want to figure out HTML. We’ll insert pictures or illustrations. You know, all that annoying detail work that detracts from focusing on content.

    It doesn’t even have to be about acupuncture specifically, although it might be better if it were restricted to one example of alternative medicine, as making it about all CAM might be too daunting. However, I’d look at it either way. I know Peter can write coherently when he wants to. Just read some of his articles at http://www.cancerwatcher.com on cancer quackery, which, as I’ve pointed out several times, inspired me years ago, and you’ll see. That makes it puzzling why Peter can’t seem to make his case regarding CAM that isn’t cancer quackery.

  51. Harriet Hall says:

    I think he’s saying that placebos “might” actually help patients in some obscure ways, so we shouldn’t discourage them until we learn more about it. Also that we shouldn’t be so critical of people who disagree with us because they might just have some access to a truth we can’t appreciate, and because making fun of silly ideas only alienates people so they are not receptive to our messages about good science. Basically, we should be humble and play nice.

    I wish instead of telling us what we are doing wrong, he would tell us how to do it right. He has made a lot of general statements but has not provided any specific practical guidelines. Perhaps he could provide an example by re-writing one of our posts about acupuncture to comply with his standards.

  52. @Harriet And even if a tender spot is found on the ear, there are no connections between the ear and the rest of the body.

    The ear is connected via the auricular nerve to the cervical plexus, where it joins the other nerves coming from the spine. Yes, its connected to the body!

    Pain in seemingly unrelated body parts can often show up elsewhere. When I had epigastric pain, it showed up in upper back muscles for example. This is the likely origin of acupuncture – patients with musculoskeletal ills complaining of side effect feelings in ears, feet, hands.. the “chi life force and yinyang meridians” theories were ancient attempts at neurology.

    there’s no way that stimulating a specific point on the ear could treat pain in a specific location.

    There are ways nerve stimulation numbs pain in other areas. Please see the research in this area: http://www.ncbi.nlm.nih.gov/pubmed/15135942 . The body has natural mechanisms for producing opioid peptides, which act as painkillers. Neuropeptides release can be stimulated.

    Again I am no acupuncture expert but the real experts believe endorphin release is the leading explanation for acupuncture’s therapeutic effects.

  53. Harriet Hall says:

    @FastBuckArtist,

    Obviously there are sensory nerves FROM the ear. Otherwise we couldn’t feel it when our ear is touched. But there are no sensory nerves from painful body parts TO the ear. The foot is connected to the body, but that doesn’t mean pain from a foot fracture can be experienced as coming from the hand, and it doesn’t mean stimulating a sensory nerve in the ear could have any influence on pain from the foot fracture, other than possibly by distraction.

    Referred pain is a phenomenon where pain in one part of a dermatome is felt in another part of the same dermatome. It does not explain how pain in the extremities could have any relation to a totally different dermatome like the ear.

    And endorphin release has been shown to occur when patients take placebos. A veterinarian tells me endorphin release can also be produced by trailering horses and throwing a stick for a dog. Finding endorphin release with acupuncture supports the hypothesis that acupuncture is a placebo treatment.

    The nervous system has been carefully mapped and is well understood by anatomists and physiologists, and there is nothing there to explain ear acupuncture.

  54. @Harriet

    Endorphin is released during normal body activities, acupuncture stimulates this function, a therapeutic effect in pain relief.

    More evidence of efficiency of acupuncture is in regulation of dopamine, as shown in this study of 100+ rehabilitation patients: http://www.ncbi.nlm.nih.gov/pubmed/11789190 with clear therapeutic benefit. You cannot write this off as placebo effect, since the control group in the study got placebo and did not experience same benefits.

    Acupuncture experts who have much better understanding of neurochemistry than I do wrote an in depth review on acupuncture effect in cerebral opioid system here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2529396/

  55. pmoran says:

    Everyone, — now come on!, — it is absurd to suggest that I should be required to present a comprehensive world view before I can comment on the amount of ad hominem in certain writings, or point out certain weaknesses in a commonly expressed viewpoint regarding the “small” benefits to be expected from acupuncture. These points can stand in their own right, independently of all else. You must see this. I have given my reasons.

    If I have drifted off into more general considerations that are difficult to follow, I apologise.

    Harriet: I think he’s saying that placebos “might” actually help patients in some obscure ways, so we shouldn’t discourage them until we learn more about it.

    What I have in fact said above is this: It is a valid scientific hypothesis to suggest that procedures like acupuncture can be good at exerting and enforcing a combination of mundane, plausible but limited therapeutic influences such as relaxation, meditation, ongoing encouragement and psychosocial interaction, distraction and counter-irritation.

    Enhanced placebo influences from the intervention would add to my reasons for advising caution when having any urge to dismiss acupuncture as totally worthless.

    I am of course well aware of the usual counter — why risk seeming to tolerate pseudoscience when the same influences can be harnessed within the mainstream alongside more evidence-based treatment? Why open that can of worms?

    Well, it should be enough that it is the job of science to understand these things, even if beneficial patient outcomes were not at stake.

    But I also ask how exactly is the mainstream going to exploit these influences? I know of no evidence-based form of medical care that can keep a patient coming back so that a comparable spectrum of influences can be brought repeatedly to bear. If we are to be ruthlessly realistic and scientific while also prizing optimal individual patient care I don’t see how we can not at least stop and think for a bit about what we want to achieve here.

    As I have said, there are additional considerations which make it possible for us doctors to choose not to endorse acupuncture for routine medical care. One of those is that the evidence is not totally clear, but that that in itself warrants a somewhat moderate or provisional stance.

  56. Narad says:

    The ear is connected via the auricular nerve to the cervical plexus, where it joins the other nerves coming from the spine. Yes, its connected to the body!

    You are contending, on the basis of a 1980 paper in Pain that you haven’t read beyond the abstract, that there is a “mapping” between the musculoskeletal system and the ear. What kind of mapping is it? Injective, surjective, both, or neither?

  57. DevoutCatalyst says:

    An acupuncturist cannot be the person to deliver acupuncture. An acupuncturist wants a middle class lifestyle, and that cannot be achieved without being dishonest to customers about the things that acupuncture can do (if it can do anything at all). One side-effect of acupuncture is the distrust it instills towards medicine, the painting of the average physician as an allopathic buffoon. Seems to me ‘acupuncture’ as a name is totally worthless, and whatever needly thing that might prove beneficial in some small way to some fraction of humanity will want be called something else and dispensed by someone other than an acupuncturist.

  58. Harriet Hall says:

    @FastBuckArtist,

    The links you provided are not convincing. One is a Chinese study that says nothing about dopamine and doesn’t even say whether it was double-blinded (so we can assume it wasn’t) and doesn’t even do an “exit poll” to determine whether patients could tell whether the electric stimulator was turned on. In fact, it wasn’t even about acupuncture, but about electrical stimulation.

    The other is a review that amounts to speculation based on a review of the literature by authors who believe in acupuncture.

    Neither was published in a major journal.

    Many hypothetical mechanisms have been proposed, from the gate theory of pain on. There is no consensus about “how acupuncture works” or even “what acupuncture is” among acupuncturists, much less among non-acupuncturist scientists.

    The adenosine release hypothesis was addressed by Dr. Gorski at http://www.sciencebasedmedicine.org/?s=adenosine

  59. WilliamLawrenceUtridge says:

    @Dr. Gorski – very similar thoughts. I can’t understand the apparent double-standard: quackery for cancer – bad; quackery for anything else – hey, there might be something here!

    Well, it should be enough that it is the job of science to understand these things, even if beneficial patient outcomes were not at stake.

    The problem is, we do understand acupuncture – it’s placebo. It fits very neatly into our understand of what an effective placebo should look like – drama, exoticness, intrusive, lengthy and caring consultation. Bar the latter, which is more a function of resources than science, these things are ethically problematic and deceptive. Further, there is the waste of resources spent chasing down illusory benefits. We know enough about acupuncture that the meaningful parts could be used as adjunct therapy, that’s probably the best we’re going to get. Wouldn’t you rather the research funding go towards cancer? I would.

    The ear is connected via the auricular nerve to the cervical plexus, where it joins the other nerves coming from the spine. Yes, its connected to the body!

    Trivially true, certainly not meaningfully true. There’s no reason to believe in an ear homunculus, such an extraordinary claim requires extraordinary evidence. Evolution provides for no reason to create a tiny fetus in the ear, though given acupuncture is based on magic, not reason, this is only a barrier for the rational.

    When I had epigastric pain, it showed up in upper back muscles for example.

    Yep, this is the reliably re-created, readily observable referred pain. Like most widely-accepted concepts in biology, it can be verified by nigh-anyone and has several readily logical explanations (connections of nerves, confusion between physically-distant but neurologically-close areas, organs within the torso don’t have specific innervation so their pain generalizes). They also tend to be 1:1 – heart attacks cause pectoral pain, pancreatic pain causes back pain. At no point is it “this one part of the body accepts referral pain for the rest of the body”.

    This is the likely origin of acupuncture – patients with musculoskeletal ills complaining of side effect feelings in ears, feet, hands.. the “chi life force and yinyang meridians” theories were ancient attempts at neurology.

    …except they had no idea what nerves were. Even if your assertion is correct, like all ancient attempts at anything – they were wrong. There is no invisible energy, but there is conductance. There are no meridians, but there are blood vessels. If acupuncturists were genuinely committed to updating their knowledge so it reflects modern science, they would have abandoned these concepts. Instead, apologists attempt to co-opt science to avoid having to update their knowledge, vocabulary or practice. They are pseudoscientists, they wish to capitalize on the justified social status that science holds without contributing to it or honestly engaging with it. Like all CAM practitioners, they are parasitic pretenders who only learn to mouth the words but never truly dig into what the words mean. If they did, they wouldn’t be CAM practitioners.

  60. nickmPT says:

    Is acupuncture better than just needling (sticking in needles in non-meridian points)?

    Is needling better than aggressive, non-invasive manual therapy (manipulation, deep tissue massage)?

    Is aggressive, non-invasive manual therapy better than gentle manual therapy?

    I believe the answers to these are no, as we move treatment for non-specific “musculoskeletal” pain down the continuum from aggressive to gentle, we help reduce threat on the nervous system and shift the locus of control toward the patient.

    Pain neuroscience is telling us these things. Manual contact is good (usually the more gentle the better) and modern pain education is very important.

    Why would you want to stick a needle in someone with some bogus explanation (and the inherent risks of sticking a needle in someone) when it is really not required?

    TL;DR: Modern pain science tells us we need to be empathic caregivers that empower and educate the patient via pain education (more factually correct metaphors the better), reducing the threat, possible hands-on treatment (more gentle the better), and gradual increase in activity.

  61. pmoran says:

    WLU:@Dr. Gorski – very similar thoughts. I can’t understand the apparent double-standard: quackery for cancer – bad; quackery for anything else – hey, there might be something here!

    (Me): Well, it should be enough that it is the job of science to understand these things, even if beneficial patient outcomes were not at stake.

    The problem is, we do understand acupuncture – it’s placebo. It fits very neatly into our understand of what an effective placebo should look like – drama, exoticness, intrusive, lengthy and caring consultation.

    I remind WLU and everyone else that “quackery” is not a property of any particular kind of medicine, it pertains to certain claims that are made for them. I do not see myself as supporting or defending quackery in any way, shape or form.

    Harriet and WLU have completely missed a crucial point, that I now realise I should have spelt out earlier. So perhaps it IS all my fault. I’ll try again. (This is why I am not yet ready for the “grand opus”)

    My hypothesis, that I will now state for the fourth time, is that the various variants of acupuncture that seem able to produce hard-to-ignore outcomes in certain kinds of clinical study (as well as in anecdote) are not clearly one thing (i.e. placebo as normally understood) or the other (i.e. evoking a single plausible therapeutic influence).

    The hypothesis was this: — that procedures like acupuncture can be good at exerting and enforcing a combination of mundane, plausible but limited therapeutic influences such as relaxation, meditation, ongoing encouragement and psychosocial interaction, distraction and counter-irritation.

    If this is true, we may have to, for at least the theoretical purposes of medical science, regard such methods as a kind of accidentally compounded hybrid of various authentic therapeutic influences. It does not fit the simple “working better than placebo” model of medicine that dominates the medical world and which assumes that any efficacious medical intervention will work in one consistent way. It is not even easily investigated under that model because most of its influences will operate upon both randomised groups in any normal pattern of RCT, and they are extremely difficult to adequately control for individually in any other.

    Some of our acupuncture-supporting “opponents” seem to be approaching a similar position, but like me they have difficulty finding the vocabulary to explain this rather novel concept. We can thus appear to be mounting an apology for “quackery”, and that triggers a dialogue-aborting snapping down of the shutters in most sceptical minds. I understand that deeply ingrained modes of thought, that I partially share, do make it a difficult thing to grasp. Yet it is entirely consistent with the science. Indeed it would help explain much of it.

  62. pmoran says:

    Curses! — Attribution fixed, I hope.

    WLU: @Dr. Gorski – very similar thoughts. I can’t understand the apparent double-standard: quackery for cancer – bad; quackery for anything else – hey, there might be something here!

    (Me): Well, it should be enough that it is the job of science to understand these things, even if beneficial patient outcomes were not at stake.

    WLU: The problem is, we do understand acupuncture – it’s placebo. It fits very neatly into our understand of what an effective placebo should look like – drama, exoticness, intrusive, lengthy and caring consultation.

    Firstly, I remind WLU and everyone else that “quackery” is not a fixed property of any particular kind of medicine. It pertains to certain claims that are made for them. I do not see myself as supporting or defending quackery in any way, although I think I understand better than some here why it can thrive.

    Secondly, Harriet and WLU have completely missed a crucial point, that I now realise I should have spelt out earlier. So perhaps it IS all my fault. I’ll try again. (This is why I am not yet ready for the “grand opus”).

    My hypothesis, that I will now state for the fourth time in this thread, is that the various variants of acupuncture that seem able to produce hard-to-ignore outcomes in certain kinds of clinical study are not clearly one thing (i.e. placebo as normally understood) or the other (i.e. evoking a single plausible therapeutic influence).

    The hypothesis was this: — that procedures like acupuncture can be good at exerting and enforcing a combination of mundane, plausible but limited therapeutic influences such as relaxation, meditation, ongoing encouragement and psychosocial interaction, distraction and counter-irritation.

    If this is true we may have to, for at least the theoretical purposes of medical science, regard such methods as a kind of “third case”, an accidentally compounded hybrid of various authentic therapeutic influences. It does not fit the simple “working better than placebo” model of medicine which dominates the medical mind and which assumes that any efficacious medical intervention will work via one consistent physiological means. It is not even easily investigated under that model because most of its influences will operate upon both randomised groups in any normal pattern of RCT, and they will be extremely difficult to adequately control for individually in any other.

    Some of our acupuncture-supporting “opponents” seem to be approaching a similar concept, but like me they have difficulty finding the vocabulary to explain it. We can thus appear to be mounting an apology for “quackery”.

    I understand that deeply ingrained modes of thought, that I partially share, do make it a difficult thing to grasp and there remains the problem of how to justify tolerance of something so bound up with pseudoscientific medical practices (that seems able to work. mostly, in Canada and Australia). Yet it is entirely consistent with the science. Indeed, it would help explain much of it.

  63. WilliamLawrenceUtridge says:

    Firstly, I remind WLU and everyone else that “quackery” is not a fixed property of any particular kind of medicine. It pertains to certain claims that are made for them. I do not see myself as supporting or defending quackery in any way, although I think I understand better than some here why it can thrive.

    First, “quackery” has a fixed property in my mind – it is unproven medicine sold direct to consumers. Often, it is also impossible medicine. Often will new theories be integrated into medicine. Rarely will CAM provide conventional medicine anything of use. Second, I think I understand pretty well why quackery thrives. I just object to it as immoral, and often practiced by greedy hypocrites (or well-intentioned fools). Quackery is false hope. It’s easy to sell, but that doesn’t make it right.

    My hypothesis, that I will now state for the fourth time in this thread, is that the various variants of acupuncture that seem able to produce hard-to-ignore outcomes in certain kinds of clinical study are not clearly one thing (i.e. placebo as normally understood) or the other (i.e. evoking a single plausible therapeutic influence).

    Yes, that’s fine. I disagree with you, I think acupuncture is easily explained as placebo, given what we know about it. If there is any actual effect, it seems to be minor and transitory, and so equivocal that it’s hardly worth the time and effort put into researching and promoting it. And certainly the effects are not so powerful or dramatic that it is worth pretending it is unarguably effective sufficient to sell directly to consumers or consumed uncritically by doctors, consumers and reporters.

    Your hypothesis, “that procedures like acupuncture can be good at exerting and enforcing a combination of mundane, plausible but limited therapeutic influences such as relaxation, meditation, ongoing encouragement and psychosocial interaction, distraction and counter-irritation“, certainly doesn’t account for a “third thing”, since each aspect of this hypothetical situation is already recognized as a components of the “placebo effect”, which itself is not a unitary, simple thing. The rest of your argument looks like a “you can’t measure my woo” when for me it’s more of a “your woo doesn’t really justify deception to patients or the abandonment of science”. If all you’re measuring is a variant or combination of nonspecific effects, that’s all well and good – but it’s not medicine. Learning about nonspecific effects so they can be enhanced while giving real treatment is a laudatory goal. At this point, further research on acupuncture as if it taught us anything new serves little purpose bar wasting money. Acupuncture shouldn’t be a first-line form of treatment. It shouldn’t be used in isolation. It shouldn’t be accompanied by nonsterile practice. It shouldn’t involve TCM or spurious criticisms of real medicine. It shouldn’t take years to learn. It shouldn’t be expensive. It shouldn’t be used near organs, blood vessels or nerves. Ideally, it shouldn’t penetrate the skin.

    Rather than continuing to research acupuncture, why don’t we put resources into more training for doctors, more time between doctors and patients, and more tools to enhance the safety, uptake and effectiveness of relaxation, meditation, ongoing encouragement, distraction and counter-irritation? Makes more sense to me than pretending acupuncture is some sort of magical, poorly-understood wisdom of the exotic Orient.

  64. pmoran says:

    WLU: First, “quackery” has a fixed property in my mind – it is unproven medicine sold direct to consumers.

    Sometimes, but quackery is better characterised by “overblown or poorly supported medical claims”. Lupron is a proven pharmaceutical; it is quackery when recommended for autism. Quackery often involves a diagnosis, or a diagnostic method, and not the selling of anything.

    I have commented above about the shakiness of supposedly “minor” effects from acupuncture variants. Some studies do in fact show small enduring effects and we do not condemn other symptomatic treatments simply because their effects are transitory.

    Also, if you are going to class all the non-specific therapeutic influences that acupuncture variants might exert as placebo, what is it that makes their employment reprehensible when described as “acupuncture” but not when applied as part of “normal” medical care?

    And are support groups also to be classed as “placebo”? Meditation? I agree distraction from symptoms might reasonably be regarded (or equally not) as one of the ways placebos might work, but find it hard to see what is reprehensible about trying to achieve that. The humble liniment might be another remedy that is difficult to place in a clear category but which seems quite capable of producing temporary symptom relief.

    I have also asked how those influences could be exerted to the same degree within normal medical practice. I know no one will answer that because there is no answer. We can do a bit better, but realistically not a whole lot better.

  65. @Harriet

    The rehabilitation study was on electroacupuncture, it’s a variant of acupuncture. The lack of “exit poll” is a minor flaw that reviewer did not find critical. I chose this study to present as skeptics usually dismiss acupuncture studies for not having convincing placebo controls. This is one study where controls were convincing, and the patient didnt know what treatment they were receiving.

    The dopamine release is key mechanism of substance addiction and rehabilitation. There is evidence in animal models that acupuncture normalises dopamine release : http://www.ncbi.nlm.nih.gov/pubmed/16289320/

    There is extensive scientific study on acupuncture, I am just scratching a surface (being a non-expert in the field). It’s well accepted in the scientific community. The National Institute Of Health has recognised acupuncture as effective treatment already 15 years ago: http://www.nih.gov/news/pr/nov97/od-05.htm

    A consensus panel convened by the National Institutes of Health (NIH) today concluded there is clear evidence that needle acupuncture treatment is effective for postoperative and chemotherapy nausea and vomiting, nausea of pregnancy, and postoperative dental pain.

    The 12-member panel also concluded in their consensus statement that there are a number of other pain-related conditions for which acupuncture may be effective as an adjunct therapy, an acceptable alternative, or as part of a comprehensive treatment program. but for which there is less convincing scientific data. These conditions include but are not limited to addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia (general muscle pain), low back pain, carpal tunnel syndrome, and asthma.

  66. Narad says:

    The dopamine release is key mechanism of substance addiction and rehabilitation.

    Granting this massive oversimplification arguendo, why then would the purported DA effects of needling be expected to do any better than the spotty results already found from direct dopaminergic agents? If you want to talk about EtOH dependence, it seems as though your problem is still going to be GABA-A dysregulation regardless of the downstream effect on DA.

  67. WilliamLawrenceUtridge says:

    I’m not sure why anyone is pretending electroacupuncture is acupuncture. Seems like the “electro” part rather separates it from any of the Ancient Chinese Wisdom acupuncture is so famed for. Did the Yellow Emperor’s Inner Canon include a diagram of the Baghdad Batteries?

    Also, if you are going to class all the non-specific therapeutic influences that acupuncture variants might exert as placebo, what is it that makes their employment reprehensible when described as “acupuncture” but not when applied as part of “normal” medical care?

    The underlined part. For some reason I object to time and resources being spent merely to provoke placebo responses.

    Groups and meditation are not sold as “magical interventions from Ancient China”, do not come accompanied by unwarranted criticisms and conspiracy-mongering over real medicine and do not have the potential to drive MRSA into the skin or puncture a lung. They are explicitly framed and sold as purely psychological interventions, though meditation can have physiological effects of course. Meditation is also free once learned.

    And as I have said before – no problem with acupuncture if practiced with sterile techniques, not accompanied by disingenuous criticisms of real medicine, cheap, superficial (or ideally non-penetrating), not accompanied by TCM diagnosis, not requiring years of learning and described as an investigatory treatment that might temporarily alleviate some symptoms. For someone who spends so much time lamenting being misunderstood here, you’re not doing a great job of keeping track of what I’ve said.

  68. pmoran says:

    For someone who spends so much time lamenting being misunderstood here, you’re not doing a great job of keeping track of what I’ve said.

    Not really, because I am sensitive to all those elements as you are. I am not coming from a supportive position of CAM, I am coming from a probably much more hostile position than yours, starting with being appalled by cancer quackery.

    But I now see that the key to all this is the gaining of public trust and that obligates us to be seen to be prepared to go wherever the science may lead us, actually doing it rather than merely saying that we do it. Nearly every interjection I make relates to overstatement or assumptions in disputable matters.

    That is why, if we cannot fully explain, with proof, effect sizes of 0.5 over normal medical care when applying acupuncture variants to difficult conditions, or explain what evidence-based protocol could reproduce such e effects within mainstream medical practice, it can be unwise to sustain too violent an opposition to “acupuncture” in some guise or other (as you also seem to accept in your last paragraph). Otherwise we could be accused of manipulating the science to support preferred attitudes rather than letting the science lead us where it will.

    There is also no law that says that the science of medical practice has to be tidy, with everything fitting into neat compartments of our own devising. You are doing this when you class all those things as “placebo”. Most people would refer to “placebo and other non-specific influences” or “non-specific influences including placebo” . That gets around the need to make some nigh-impossible distinctions, but it leaves you the problem of having to decide what constitutes a “proper”, respectable, medical influence and what is not. We are claiming to be the arbiters of that. Hmmmh —-.

    I may be away for a bit.

  69. WilliamLawrenceUtridge says:

    Not really, because I am sensitive to all those elements as you are. I am not coming from a supportive position of CAM, I am coming from a probably much more hostile position than yours, starting with being appalled by cancer quackery.

    …and that’s what’s frustrating. Cancer quackery – bad. All other types of quackery – good! It just seems like a double-standard. Yes, cancer kills. But other forms of morbidity also kill, and even if they don’t – it doesn’t seem to justify lying to patients.

    But I now see that the key to all this is the gaining of public trust and that obligates us to be seen to be prepared to go wherever the science may lead us, actually doing it rather than merely saying that we do it. Nearly every interjection I make relates to overstatement or assumptions in disputable matters.

    You may gain the public trust for the short term, but you lose it over the long as the effects of CAM and quackery become obvious. Not to mention, you aren’t taking them anywhere science may lead us. Quite the opposite – science tells us these quackeries don’t work. Science tells us that virtually every tenet of acupuncture is untrue – points and meridians don’t exist and don’t matter. Needling location don’t matter. Needles don’t matter. Traditional diagnosis doesn’t matter. Qi doesn’t exist and doesn’t matter. Acupuncture doesn’t treat anything but two symptoms, and those are relatively indistinguishable from placebo. I don’t see how pretending there is merit where there isn’t helps anyone. I don’t see how indulging CAM’s penchant for dishonestly, logical fallacies and lies helps the public.

    That is why, if we cannot fully explain, with proof, effect sizes of 0.5 over normal medical care when applying acupuncture variants to difficult conditions, or explain what evidence-based protocol could reproduce such e effects within mainstream medical practice, it can be unwise to sustain too violent an opposition to “acupuncture” in some guise or other (as you also seem to accept in your last paragraph). Otherwise we could be accused of manipulating the science to support preferred attitudes rather than letting the science lead us where it will.

    …except we usually can explain these things. Many are due to improper controls (waiting list, pills and usual care don’t compare to the dramatic, exotic, lengthy and attention-filled diagnosis and treatment process of TCM acupuncture; control for those factors and much of the apparent effectiveness of acupuncture disappears). And it doesn’t really work on difficult conditions – just pain and nausea, symptoms that are incredibly responsive to the placebo effect.

    I’m not being violent to acupuncture, I’m pointing out why it’s not as effective as it is often portrayed. I’m pointing to alternative explanations that don’t require whole new tissues, new neurological or biological processes or (FSM forbid) new, hitherto-undiscovered forms of energy. It’s the kind of routine skepticism that exists in nearly every branch of science, the application of Occam’s razor and high-quality controls, that is absent in CAM and acupuncture.

    There is also no law that says that the science of medical practice has to be tidy, with everything fitting into neat compartments of our own devising. You are doing this when you class all those things as “placebo”. Most people would refer to “placebo and other non-specific influences” or “non-specific influences including placebo” . That gets around the need to make some nigh-impossible distinctions, but it leaves you the problem of having to decide what constitutes a “proper”, respectable, medical influence and what is not. We are claiming to be the arbiters of that.

    Medicine is recognized as not tidy, consistently the distinction between the science and art of medicine is made (Dr. Novella in particular makes this distinction routinely). However, one should establish the best and ideal science to guide and base practice on, then adapt that in the real world. For instance, we know ways of enhancing nonspecific effects and can incorporate them into regular practice (though in many cases structural changes to the reimbursement process are required to do so). In the abstract, dealing with the pure science as we are on this blog, we can indeed make these distinctions. In the case of specific patients, yes this will be adapted or even discarded outright – but we’re not discussing specific patients, we’re talking about the abstract science.

  70. BrewandFerment says:

    do people who believe that auricular acupuncture works have pierced ears?

  71. Chris says:

    What about those who garden near cactus? I swear the prickly pear in my dad’s front garden actually shoots out little needles. Is there such thing as prickly pear acupuncture?

    The prickly pear just has tiny needles. The major damage I get much further north are the rose thorns of my Polka Climbing roses. Those very sharp things are almost two centimeters wide and more than one centimeter long. Who cares about acupuncture, I just make sure my tetanus boosters are up to date (lately with a Tdap).

  72. Joerg Reiher says:

    Only a short correction:
    The paper “Transcontinental High-Tech Teleacupuncture Studies and Integrative Laser Medicine” is not from a group in Germany, but from a group at the medical university of Graz, Austria.

    …though I’m sure you’ll find similar high quality studies at some German universities :-)
    Greetings from Southern Germany,
    joerg reiher


    “Stronach Research Unit for Complementary and Integrative Laser Medicine, TCM Research Center, Graz, and Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Graz, Austria.”
    [http://online.liebertpub.com/doi/abs/10.1089/acu.2012.0944]

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