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Acupuncture and Back Pain – Part II

Last week I discussed a clinical trial comparing standardized acupuncture, individualized acupuncture, placebo-acupuncture, and usual care. In that discussion I emphasized the comparison between the three acupuncture groups, which did not show any difference in outcome. These results are consistent with the overall acupuncture literature, which shows in the better controlled trials that it does not matter where you stick the needles or even if you stick them through the skin. Therefore the scientific evidence fails to reject the null hypothesis (that acupuncture does not work). This did not stop the press from declaring, almost uniformly, that acupuncture works for back pain, contributing to the public misunderstanding of clinical science.

This week I am going to focus on the other aspect of the trial – the one the researchers and the press chose to focus on – the comparison of the two real and one placebo acupuncture arms to “usual care.” This too was misrepresented by the press, encouraged by the overinterpretation of the evidence by the researchers.

In the comments to Part I of this discussion David Gorski correctly pointed out that the study in fact did not even constitute a comparison of acupuncture to standard medical treatment. He is absolutely correct, and the many reasons for this are worth explaining in detail. Understanding the technology of clinical trials is central to science-based medicine, including all of their pitfalls and limitations. For practical and logistical reasons there is almost never a perfect clinical trial, but mischief only ensues when limitations are not understood, leading to a misinterpretation (and almost always an overinterpretation in the direction of the researcher’s bias) of the evidence.

The primary reason why this study did not constitute a direct comparison of standard medical care to acupuncture for chronic lower back pain is (again, as David pointed out) because this was not a variable among the treatment groups.  In the methods to this study it is explained that patients were chosen for having chronic low back pain, among other entry criteria. All patients in the study were allowed to continue their “usual” care – which means whatever they were doing to treat their back pain prior to entry into the trial.

Although it is not explicitly stated in the methods, the acupuncture groups also continued whatever care they were receiving for back pain. There is no indication that they were made to stop. Further, one of the secondary outcomes tracked in the trial was the use of anti-inflammatory pain medications. The study reports:

The use of medications for back pain in the past week (mostly nonsteroidal anti-inflammatory drugs) was similar across groups at baseline (ie, 62% to 65%), but by 8 weeks, it had decreased to 47% in the real and simulated acupuncture groups vs 59% in the usual care group (P=.01). This difference persisted at 26 and 52 weeks.

So clearly those receiving acupuncture were allowed to continue to take pain medication – their usual care.  Therefore what the trial compared was usual care + a new intervention vs usual care. The group not receiving any new intervention was not blinded at all to that fact. The author’s acknowledge that a weakness of their trial was the “exclusion of a medical attention control group.”

The press, and the majority of the public (which I estimate based upon my copious feedback on this issue and from reading blog and article comments) seems to have completely missed the distinction between “medical attention” (standard care) as a control, and “usual care”, which essentially means doing nothing at all.

Given the unblinded nature of this comparison it is to be expected that there would be a significant placebo effect associated with introducing a novel treatment for subjective symptoms, especially one that involves personal attention and direct physical contact. Therefore this study only demonstrated a previously documented placebo effect from adding such a new intervention. This data cannot be used to conclude that acupuncture or placebo-acupuncture had any specific physiological effects. Any attempt to draw such a conclusion from this data, or to compare acupuncture to standard medical treatment, is misleading.

It also must be pointed out that study participants were included because they had chronic low back pain (more than three months) of a certain severity or greater despite their usual care.  Therefore these subjects constitute a group that has already failed usual care, and it is not surprising that the usual care group showed little improvement.

Further, this means that this study was not a prospective study of usual care, or any specific medical intervention.

The study authors also introduced another variable into the mix. They report:

All participants received a self-care book with information on managing flare-ups, exercise, and lifestyle modifications.

So really the comparison was between real or fake acupuncture + usual care + self-care education compared to usual care + self-care education.The data on education for back pain indicates that it is as effective as medical interventions for acute and subacute low back pain, and effective but not as effective as medical intervention for chronic low back pain. While its overall effectiveness is still unclear, the contribution of this intervention in this trial should not be overlooked. It is likely responsible for some of the improvement reported in all the groups.

It is also plausible that the impact of exercise and lifestyle education on symptoms differed between the intervention groups (real or fake acupuncture) and the non-intervention group (usual care).  While there was no difference reported in the percentage of subjects who read more than two-thirds of the self-education booklet, motivation to comply with exercise and lifestyle changes was not measured. Therefore one of the nonspecific effects of being in an intervention group could have been increased motivation to comply with exercise and lifestyle changes.

Conclusion

In part I of my analysis of this study I demonstrated that the results fail to reject the null hypothesis of a lack of effect from acupuncture for chronic low back pain – which is scientific jargon for “acupuncture does not work.” This depends upon a meaningful definition of “acupuncture” (scientific questions depend upon unambiguous definitions). Acupuncture is placing needles at specified acupuncture points through the skin to a specific depth. This study, and previous evidence, clearly shows that these two variables (placing needles through the skin at acupuncture points) have no clinical effects.

Acupuncture proponents have engaged in misdirection from this unavoidable conclusion of their own research. They have done this largely by playing with the definition of “acupuncture.” One such method of misdirection (not involved in this latest study) is to mix acupuncture with another intervention, such as electrical stimulation, and then ascribe effects which are likely due to the other intervention to acupuncture. (Even calling it “acupuncture” is misleading.)

In this and other placebo-controlled acupuncture studies, proponents have attempted to expand the definition of acupuncture to include placebo or fake acupuncture. This allows them to use nonspecific and placebo effects from the ritual of receiving a novel intervention from a caring practitioner to promote the notion that “acupuncture works.”

In this study we also see the confusion of unblinded comparison to no intervention (other than usual care and self-education) with standard medical treatment. While the study authors did not make this false comparison in the paper itself, their misinterpretation of the implications of their data and the promotion of the study results to the media has resulted in widespread misreporting of this study.

In fact this study was not designed to compare acupuncture to standard medical care. Such a study would involve randomizing patients to a new medical intervention they have not already been receiving without effect and acupuncture vs placebo acupuncture. In order to be reliable such a study should also be blinded as much as possible.

The inclusion of a usual care arm in this study was appropriate, however. This is standard practice and serves the purpose of demonstrating that the study design and power were adequate to detect an effect.  In other words, the presence of a usual care group helps calibrate the study so that the difference between the acupuncture and placebo groups can be properly interpreted. If there were no difference between the usual care and the real or placebo acupuncture groups then one might conclude that the study was simply not able to detect a difference between acupuncture and placebo-acupuncture.

Therefore, ironically, the fact that the acupuncture and placebo acupuncture groups performed better than usual care allows us to more strongly interpret the lack of difference between acupuncture and placebo-acupuncture as being due to a lack of effectiveness of acupuncture – because if an effect existed this study was powerful enough to detect it.

There remains no compelling evidence for any of the claims made for acupuncture. When the variables specific to acupuncture are properly isolated there is consistently no demonstrable effect. This study adds to previous studies to allow the confident conclusion at this point that acupuncture is a failed medical hypothesis. There is also a complete lack of scientific support for the underlying claims of acupuncture – for the presence of “chi” or life energy that flows through meridians that can be manipulated to influence health and illness.

Posted in: Acupuncture, Science and Medicine

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20 thoughts on “Acupuncture and Back Pain – Part II

  1. Wholly Father says:

    Per Dr. Novella:

    “The inclusion of a usual care arm in this study was appropriate, however. This is standard practice and serves the purpose of demonstrating that the study design and power were adequate to detect an effect.”

    Studies are powered based on the following factors: 1. The expected outcome in the control (placebo group); 2. A definition of the size of a treatment effect the designers wish to be able to detect; And 3. With what confidence (power) they wish to be able to detect it. Thus the power is usually expressed as “The study was designed with a XX% power to detect a difference of X between group “Experimental” and group “Placebo”, assuming an outcome of Y in group “Placebo”.

    If the metric used to measure the endpoint is validated, and well characterized in the study population, an internal validation should not be necessary, and I would argue is not standard practice.

    The designers of this study even had a pilot study as a guide for design of this one. I don’t think the unmasked, usual care group was at all necessary in the design. It did not contribute to answering the primary question of the study, and post-hoc, is being used as a point of obfuscation. Might this have been included as a “fail safe” strategy in anticipation of what turned out to be the findings of the study?

    A related and equally interesting thing about the study is the statistical analysis plan. The primary statistical analysis was an analysis of the differences among ALL the treatment groups. If the among group comparison was statistically significant, then pair-wise comparisons between the individual groups were to be performed.

    It was not pre-defined what conclusions would be drawn from the various possible outcomes of the pair-wise comparisons. This omission gave the authors freedom to create the definition of a successful study after the results were known.

    Since the conclusions from these post hoc comparisons was not defined, we can only do a thought experiment to consider all the possible permutations which might have been declared a “win’ for acupuncture.

  2. tgobbi says:

    Dr. Novella — Your articles say nothing about acupuncture and neck pain. Is it safe to assume that it’s equally ineffective for treating necks? Or would other studies be necessary to reach that conclusion?

    tgobbi

  3. Karl Withakay says:

    If we accept the abstract’s statement of purpose:

    “This trial addresses the importance of needle placement and skin penetration in eliciting acupuncture effects for patients with chronic low back pain.”

    and accept the implication of this statement that acupuncture’s effectiveness is established, then the usual care arm could seem relevant to ensuring the ‘real’ acupuncture methodology used was done correctly and producing an effect, if the usual care arm could be blinded or you had some previously established accepted basis for estimating the strength of placebo response, to filter out that effect from the various acupuncture groups.

    Without the blinding, you don’t have any idea what you have detected, just the idea that you have detected something.

    The way the abstracts states the purpose, this study was philosophically flawed in the first place. It doesn’t set out to disprove that acupuncture does not work. A strict reading of the abstract tells me that the study does not even address if acupuncture is effective at all. It says basically that acupuncture is popular, and recent studies have shown similar short term benefit from real and sham treatment, without explicitly stating the nature (or source) of those benefits. (Though I do infer the researchers not to believe that it does not work.)

    The way I read the abstract, I kind of interpret the real acupuncture group as the control (the known), and the sham and toothpick groups the experimental groups (the groups they want to see if there is any difference from the known), and the usual treatment group as a hedge against unexpected results.

    The the firm conclusions I can draw from this study are:

    1 Needle placement and penetration do not make a difference in acupuncture when used with usual care.
    2 Real, sham, and placebo acupuncture with usual care all equally produce an effect beyond usual care when the usual care group is not blinded
    3 Real, sham and placebo acupuncture are either equally effective or equally ineffective when used with usual care.
    4 Based on 1, individualized chi and meridian points are meaningless in the practice of acupuncture (and acutoothpicking) when used with usual care.
    5 Nobody ever seems to test acupuncture for anything but pain management, even though it is claimed to be effective for many more conditions.

    The conclusions I feel safe drawing from this study, but which may not be 100% correct or are not strictly supported by the experiment are:

    1 Chi/ Meridian points are bunk
    2 Real, sham and placebo acupuncture are equally ineffective.
    3 Acupuncture is nothing but a powerful placebo

    I might get more out of the full paper, but the abstract seems to be carefully reverse engineered to put the best possible spin on the outcome of the experiment, and likely doesn’t reflect the original purpose of the study.

  4. Wholly Father says:

    To Karl Withakay,

    Your analysis is right on target. The authors published Study Design paper

    http://www.trialsjournal.com/content/9/1/10

    appropriately cited in the current paper, and which, mea culpa, I had not read yet. This gives more details about the aims of the study. They list three hypotheses:

    “We hypothesize that acupuncture needling (both
    standardized and individualized) will be more effective
    than usual medical care.”

    “We hypothesize that standardized acupuncture needling
    will be more effective than non-insertive simulated
    needling.”

    “We hypothesize that individualized acupuncture needling
    will be more effective than standardized acupuncture
    needling.”

    There was no hypothesis relevant to the effectiveness of simulated acupuncture to usual care. They fail to acknowledge throughout the document that the acupuncture groups are actually acupuncture plus usual care. So the comment that the study is “philosophically flawed” is correct.

    So the only hypothesis which was confirmed, is the one based on an unblinded treatment added to usual care.

    Based on the study design, about the only way the study could have failed (from the authors point of view) was if the placebo effect took a holiday.

  5. Karl Withakay says:

    Wholly Father,

    Wow, that study design reads VERY differently from the post study abstract.

    Some observations on the study design paper:

    “1) Is acupuncture needling more effective than usual medical care for reducing dysfunction or symptom bothersomeness due to chronic low back pain?
    We hypothesize that acupuncture needling (both standardized and individualized) will be more effective than usual medical care.”

    * The study was unable to determine this as the usual care only group was not blinded.

    “2) Is acupuncture needling more effective that non-insertive simulated acupuncture for reducing dysfunction or symptom bothersomeness due to chronic low back pain?
    We hypothesize that standardized acupuncture needling will be more effective than non-insertive simulated needling.”

    * They found out otherwise.

    “3) Is individualized acupuncture needling more effective than standardized acupuncture needling for reducing dysfunction or symptom bothersomeness due to chronic low back pain?
    We hypothesize that individualized acupuncture needling will be more effective than standardized acupuncture needling.”

    * They found out otherwise.

    “In addition to the assigned treatments, all participants will receive a high-quality book about self-management of back pain and will retain access to the health care services to which they are entitled by their insurance coverage.”
    &
    “primary and secondary outcomes will be assessed by telephone interviewers”

    * It’s not hard to imagine that the group not receiving attentive care beyond a phone call would be less motivated to read the book.

    “This study will focus on patients between 18 and 70 years of age with non-radicular chronic low back pain of mechanical origin (as opposed to infectious, neoplastic, or inflammatory causes). There are many potential causes of low back pain, but in most cases, a precise pathoanatomic diagnosis is unattainable because of the weak associations among symptoms, pathoanatomic changes, and imaging results.”
    &
    “Entry inclusion and exclusion criteria (Table 1) were developed with the goal of maximizing enrollment of appropriate participants while excluding patients who have low back pain of a specific (e.g., spinal stenosis) or complicated (e.g., due to a medical condition) nature…”
    &
    “These criteria are intended to exclude patients with medical conditions that might contribute to an increased risk of a severe adverse event, would not allow for fully informed consent, or might lead to misinterpretation of the outcomes (e.g., multiple sclerosis or diabetes whose neurological symptoms might interfere with pain sensation).”

    * The did everything they could to limit the trial to mild back pain that would be most likely to see the most benefit from a placebo effect. I don’t remember too many acupuncture advocates so strictly qualifying their recommendation of their favorite alternative to medicine.

    “We have included a usual care treatment arm to permit us to determine if individualized or standardized acupuncture offers advantages over standard care for chronic low back pain.”

    * But since the group wasn’t blinded, they can’t determine that.

    “There will be no physical assessments or laboratory tests because these have not been found to be useful for assessments of outcomes in studies of mechanical back pain.”

    * I find that a very interesting statement. It tells me that back pain can be very subjective, and that people’s perception of their pain can be more important than physical measurables, and therefore back pain relief may be especially subject to a placebo response.

  6. wertys says:

    @Karl Withakay

    The exclusion of prospective trial subjects who have LBP due to fractures, nerve root compression and other potentially remediable causes is fairly standard for trials of any intervention in LBP. What makes many of these studies virtually uninterpretable is that they lump together a large group of ‘non-red flag’ back pain types into a seemingly homogenous population, when we already know that about 30-40% will have discogenic pain, 20-40% will have some degree of facet joint pain and a similar number will have sacroiliac joint pain. Most of them will have soft tissue pain such as myofascial pain as well. These diagnoses are very well known and recognized in the interventional pain community, and the statement
    “but in most cases, a precise pathoanatomic diagnosis is unattainable because of the weak associations among symptoms, pathoanatomic changes, and imaging results”

    is not really an acceptable statement if all available means of diagnosing the source of the back pain are not used.

    Acupuncture will have dry-needling-like effects on the soft tissue components of the pain, and no discernible effect on any other type of pain.

    in addition we already have known for around 20 years that the primary determinants of progression to chronic back pain from an acute incident are mostly psychosocial. Intersetingly there appears to be a significant genetic influence as well, but it’s early days for this technology. Helping people with chronic back pain has to include a significant psychosocial intervention, but this is absolutely not the same thing as writing it off to a placebo effect.

    Studies like this are useless and insulting to back pain sufferers as they are at cross purposes to the main lines of 30 years of evidence based treatment for chronic back pain, and they seek to reduce a complex psychosocial issue to a trivial ailment which can be be wished away by imaginary interventions.

  7. Versus says:

    If you look up all the studies Cherkin has authored in PubMed, you’ll see he’s made a cottage industry out of studying chiropractic and acupuncture and reaching the conclusion that more studies are needed.

  8. pmoran says:

    Yes, as most of us predicted long ago, acupuncture works no better than a placebo treatment of equivalent mystique, theatricality and attentiveness.

    There is one remaining question: “Are such placebo treatments nevertheless of significant medical value to some sufferers?” This is why the authors and the press can with some legitimately continue to interpret the study as showing that (some element of acupuncture) “works”. We need to deal with this directly.

    SBM (of which I like to regard myself as a member) tends to gloss over this question. Steve Novella suggests that “working no better than placebo” means the same thing as “does not work”, which is clearly true for many medical questions but not at all well-established for others.

    Other skeptics accept that placebo “effects” occur, but use certain ethical objections to the conscious use of placebo treatments by doctors as an excuse for not exploring what functions they may serve for more scientifically naive populations, or when there are no satisfactory EBM-validated treatment methods available. Surveys suggest that these negative views of placebo medicine are by no means generally held by the medical profession and for that reason alone the question is worthy of more serious *science-based* analysis.

    Steve has cannily chosen to discuss a study of chronic low back pain in which the “acupuncture” elements produced only very limited (but ?worthwhile to some patients) apparent benefits on average over “usual care”. But chronic LBP resists most kinds of treatment. “Usual care” itself probably has little effect beyond placebo in terms of terminating the complaint; this study is probably comparing a range of placebos.

    Look at similarly designed studies of acupuncture for migraine and the above question becomes clearer. Many permit sizable benefits for placebo-”treated” patients over “usual care” or sitting on a waiting list. E.g. http://www.medscape.com/viewarticle/549905?rss.

    A third reason for paying more attention to this question is the frustration I share with Val concerning how “being right” (by our own lights) does not automatically translate into having influence over public opinion. What if we are not even wholly right? What if there is an all-pervasive baseline generic medicine that our “working better than placebo” model explicitly excludes but which should be providing the rational starting point for any understanding of, and any dealings with alternative medicine and its users, rather than something to be reluctantly acknowledged only when pushed?

    We are understandably repelled by stupidity of most “alternative sciences” and the self-serving, pretentious vocabularies that alternative supporters use to try to validate their roles in this quirky domain: “holism”, “healing energies”, “everyone is an individual”, “different ways of knowing”, “believe and it will be true” etc.

    We SBM doctors have the explanation for it all within our grasp, but we may be unnecessarily alienating ourselves from our own constituency by an elitist, supposedly science-based judgmentalism that can be justified in many medical contexts (e.g. cancer cures), but not necessarily everywhere else (e.g. cancer pain). We perhaps should be trying to develop our own conceptual vocabulary and a rhetoric that facilitates communication rather than hampers it, that understands, rather than reflexly condemns.

    This is what the so-called “shruggies” may sense, but, like me, have difficulty articulating.

  9. Harriet Hall says:

    pmoran has a point. Placebos “work” – and we need to learn how to elicit the placebo response without lying to patients. There is also a placebo response with treatments that are proven effective, so when effective treatments are available we ought to be able to use those effective treatments and get the placebo response there.

    I recently saw a flyer from a cancer center advertising a briefing on alternative treatments like aromatherapy, but they called it “comfort therapy.” I like that approach. No claims of efficacy, just the idea that some patients might feel better subjectively.

    Instead of just treating the disease we must remember to treat the person who has the disease. Can’t we find ways to increase patients’ comfort without lying?

  10. pmoran – You seem to have missed my core point that acupuncture is defined (if it has any meaning at all) as placing needles through the skin at acupuncture points. Therefore, if it doesn’t matter where and if we stick the needles, the elements that comprise acupuncture have no effect, which is equivalent to – acupuncture does not work. I did not gloss over this point – I spelled it out in detail.

    I acknowledge there are placebo effects here. But we do not know if they constitute anything useful, or are just an artifact of the study (such as confirmation bias, expense justification, etc). If there are any placebo effects that are useful, this study showed they have nothing to do with the acupuncture.

    None of what I said is incompatible with understanding the non-specific effects of therapeutic attention, relaxation, etc. and then exploiting those factors in a science-based context. As Harriet said – we don’t have to lie and pretend that there is chi flowing through the body in order to benefit from the non-specific elements of this intervention.

  11. daedalus2u says:

    I have mentioned this before, but there is pretty good evidence that the physiological placebo effect (to distinguish it from error) is due to neurogenic release of NO triggering the “standing down” of physiology from a high stress state to a low stress state. Under high stress, metabolic resources will be diverted from non-time urgent pathways and held at the ready for immediate consumption to deal with what ever the stressor is.

    There is pretty good evidence that migraine is an inflammatory state, similar (if not identical to) ischemic preconditioning. Ischemic preconditioning is a temporary state of reduced ATP demand characterized by reduced ATP concentration. It can be induced in just about every tissue compartment and is significantly protective against ischemia. Non-time urgent pathways are shut down to reduce ATP consumption. Those non-time urgent pathways have to include things that tissues can do without for a few minutes or even longer, things like repair, growth and cell division, the immune system, axonal transport, things that take a long time and/or consume ATP. It makes a lot of sense that many states of “stress” would trigger the same pathways and reduce ATP consumption by the same pathways turned off during ischemic preconditioning.

    A well recognized trigger for ischemic preconditioning is low nitric oxide, often brought about by oxidative stress due to superoxide formation during hypoxia. That state has hysteresis due to the ongoing oxidative stress. To terminate the ischemic preconditioned state requires an NO stimulus. That NO combines with the superoxide, forms peroxynitrite which inhibits the sites of superoxide production. If there isn’t enough NO to overcome that threshold, then the ongoing oxidative stress state continues.

    Increasing the basal NO level reduces the neurogenic NO needed to terminate the ischemic preconditioned state.

    Since many of the SBM doctors will be at TAM 7 and in fine skeptic form, I wonder if I might arrange a meeting where I could talk about nitric oxide and the placebo effect?

  12. AppealToAuthority says:

    “Instead of just treating the disease we must remember to treat the person who has the disease.”

    This is obviously true anyway, but as part of a propaganda war, it is doubly important: “treating the person” is the main claim for many non-scientific treatments, which are competing with scientific care for people’s beliefs.

    People generally want to be well, and to feel well. They usually approach a medical practitioner because they _feel_ ill.

    It is pretty reasonable that the _patient’s_ goal is to feel better.

    For many people, their most common interactions with medical practice are with a general practitioner. And a large proportion of GP time is spent with people who have non-specific, self-limiting, relatively minor, or chronic and untreatable complaints. A good GP leaves these people feeling better through placebo effects, even when there is insufficient evidence for any more specific treatment, or where none is available.

    The impressions and attitudes formed in patients from these experiences are then carried with them if or when they need more specialist or intensive medical treatment.

    If they walk away with “I felt better, the doctor helped me”, or even “the doctor was honest with me about not being able to help”, then they are more likely to remain well-disposed to scientific medicine.
    If the treatment is going to mean the person feels worse for some period of time, they need to be convinced that this is worthwhile, otherwise the doctor loses not just the patient’s trust (and hence compliance with this treatment), but also their long-term belief in medical practice.

    If they walk away with “the doctor didn’t believe I was sick” or “they rushed through and didn’t take any notice of me” or “they just prescribed some stuff that I can’t afford and I don’t know why” or even “the doctor wouldn’t give me anything for the pain, they just saw me for 2 minutes and sent me away” well, the door to the homeopath with time on their hands is wide open.

    Depending on which country you are in, these problems are as much due to the attitudes of individual doctors as they are to constraints set by the medical system in which they work.

    To get past the false dichotomy of Being Right Versus Being Influential, GPs need to be enlisted to the cause: not just educating patients (within their 7 minute visit!) but also taking the patient seriously as a person who feels ill and wants to feel better.

    If people feel better after seeing the doctor, they are likely to feel better about medicine. And then they will continue to seek proven treatments.

  13. daedalus2u says:

    Unfortunately “feeling better” is not always a good sign that proper and appropriate care was given. The old patent medicines that combined cocaine, opium and alcohol would always make the patient feel better at least temporarily, no matter what was wrong with them.

  14. wertys says:

    I believe this study to be the definitive work on treating all types of back pain. It is thorough and comprehensive and deserves to be much more widely known outside of France.

    Oenotherapy appears to be very promising, probably better than acupuncture.

    http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/100_oeno/oenous.shtml

  15. pmoran says:

    I dunno, Wertys. A really rough young cleanskin would have provided for fairer comparisons.

  16. AppealToAuthority says:

    daedalus2u:

    I know “feeling better” is not always a good sign that proper and appropriate care was given.

    But by default, it is what the patient will measure, especially in the short term.

    If we want to convince people to believe in scientific treatment, I think we have to deal with that fact.

  17. daedalus2u says:

    I know you didn’t mean that literally, but the patent medicines that did make people feel better (while making them less healthy) did a fabulous business until they were banned.

    There is no shortage of people willing to sell dangerous, harmful, addictive drugs to people. Tobacco killed about 100 million in the 20th century, and if trends continue will kill a billion in the 21st.

  18. cloudskimmer says:

    Why did the study only run for 8 weeks? In trying to help my mother with her back pain we tried practically everything. Initially she would be optimistic, and the practitioner would assure her that they could help her. Mostly we sought help from medical doctors, primarily those who said they treated chronic pain (including Cedars Sinai in Los Angeles.) Best response seemed to occur about two months into whatever was being tried (exercise, TENS, anaesthetic injections, trigger-point injections,) followed by diminished response, lessened interest by the Doctor, then blaming the patient. Most of the time we would have an appointment where my mother would say that the therapy was no longer helping; the response from the doctor would be to come back in a month. My mother would ask, “What should I do until then?” And there would be no reply. Of course, she stopped going. The only quacks she visited was one chiropractor (who “helped” for a couple of months,) and one acupuncturist who, in one session tried needling in her back and legs, needling in the ear, applying electrical current to the needles, homeopathic skin cream, and finished up by recommending that my mother buy and take some expensive enzyme supplement. Following the session, my mother experienced extreme dizziness, and vomited repeatedly; when I called the acupuncturist, she didn’t believe that her “treatment” had anything to do with my mother’s problems; you can bet if the “treatment” had been successful, she would’ve had no hesitation in claiming credit.

    My point: 8 weeks is too short. Placebo effect, since it is illusory, will stop “working” over time. Had the study progressed for 16 weeks instead, I’ll bet that the results would’ve been clearer: that is improvement would be lower, and dropout rate higher.

    Probably most of the doctors and quacks we went to forgot all about the fact that they had a patient who wasn’t helped and stopped going to see them. No one seems interested in any long-term follow-up to learn if the treatments they prescribe actually help their patients. And I really don’t think that current medical–or quack–treatment can help back pain. Some people get better, some don’t; patients and practitioners think that if they get better, then the last “treatment” “worked.”

    My one-time acquaintance with acupuncture showed very clearly that it is a quack therapy. While the acupuncturist said some words, they didn’t make sense: she couldn’t define qi, thought the ear was a perfect map of the human body, when one needle fell out she said that didn’t matter; when needles in the back caused pain, she said that shouldn’t happen, but couldn’t deal with it. If acupuncture helps with nausea when the needles are inserted correctly, why couldn’t improperly inserted needles cause nausea and vomiting? Can’t qi be blocked as well as enhanced?

    Consumer Reports Health newsletter often supports acupuncture as an effective treatment. They claim to be a good source of information: accurate and impartial. I’m disapointed that they endorse garbage like acupuncture. And I’m equally disappointed at the medical doctors who take money from patients they can’t help.

  19. wertys says:

    Has anyone seen the new NICE guidelines for treating subacute LBP ? They are mentioned in the current BMJ, and they recommend acupuncture and manual therapy as the FIRST LINE TREATMENTS.

    AAARRRGGGGHHHH

    The ‘expert’ committee has clearly been hijacked by propagandists with an agenda to push. They discount evidence supporting actual, useful treatments such as structured CBT and some interventional techniques, while placing huge emphasis on the rubbish evidence for their pet therapies. Unsurprisingly there was woo in evidence on the ‘expert’ committee which drafted the guidelines, and according to a comment posted on the BMJ website by a group of Pain Physicians, supporting evidence contradicting the claims of inefficacy of interventional modalities was abindantly provided to the committee but ignored in favour of their own biases.

    This is a clear abuse of the evidence-based guideline process, and probably this is the biggest win for healthcare woo in a long time. Comments directed to the NICE website would be encouraged !

    BTW cloudskimmer, I agree with your comments about 8 weeks being too short. That’s just about long enough for most placebo responders to begin to show the placebo sag phenomenon so it’s a good cutoff point if your therapy is essentially placebo-based

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