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Acupuncture Does Not Work for Back Pain

ResearchBlogging.orgA new study which randomized 638 adults to either standard acupuncture, individualized acupuncture, placebo acupuncture using tooth picks that did not penetrate the skin, and standard therapy found exactly what previous evidence has also suggested – it does not seem to matter where you stick the needles or even if you stick the needles through the skin. The only reasonable scientific conclusion to draw from this is that acupuncture does not work.

But let me back up a minute. Imagine if we were evaluating the efficacy of a new pain drug. This drug, when tested in open trials (no blinding or control) has an effect on reducing pain – it is superior to no treatment. When compared to a placebo, however, the drug is no more effective than the placebo, although both are more effective than no treatment.

Now imagine that the pharmaceutical company who manufactures this drug sends out a press release declaring that their drug is effective for pain, but that their research shows that a placebo of their drug is also effective (FDA applications are pending). Therefore more research is needed to determine how their drug works.  Would you buy it?

That is the exact situation we are facing with acupuncture research.

Acupuncture is the traditional Chinese medicine practice of placing thin needles to a specific depth through the skin in specific acupuncture points in order to treat illness and relieve symptoms. Claims for acupuncture, including the number and location of acupuncture points, have changed greatly over the centuries, but there is no scientific evidence base for any of these claims. Acupuncture is philosophy-based medicine, not science-based medicine. The presumed mechanism for acupuncture, according to TCM, is that the needles unblock the flow of chi (life energy) through the body. Acupuncture points are supposed to corresponds to the pathways through which chi flow, correlating to specific organs or functions in the body.

Modern proponents of acupuncture come in two basic flavors – those who promote so-called medical acupuncture, and those who restrict their claims to symptomatic relief of pain, nausea, and other symptoms. Medical acupuncture is the claim that acupuncture can actually treat real medical diseases, like cancer. It is dependent entirely on the TCM philosophy of acupuncture, including the flow of chi. Medical acupuncture is pure pseudoscience without any basis in science or evidence and does not require further consideration.

Some proponents of symptomatic acupuncture have divorced their claims from the original philosophy of acupuncture, claiming that the needling works through more prosaic mechanisms, such as the release of pain-relieving endorphins or through nerve stimulation. While these explanations are plausible, they are post-hoc speculations and have not been demonstrated to occur to a clinically relevant degree.

But before we speculate about possible mechanism, we need to establish that acupuncture has an effect – that it works for some specific indication. This has not been established, despite rather robust clinical research efforts. If there were not a cultural inertia to the notion of acupuncture the existing research would have been sufficient to abandon this modality as a dead end.

To understand the clinical research into acupuncture we need to understand how clinical scientific studies work. Typically they are designed to isolate specific variables to measure the effect, if any, of those specific variable. That is the purpose of using controls – comparing an active treatment to an inactive treatment or some other intervention. Subjects are randomized to control or treatment so that other variables will, on average, cancel each other out. Larger numbers are required for randomization to work, so larger trials are better. And subjects and evaluators are blinded to treatment so that psychological biases will be factored out.

A well-designed trial, therefore, isolates the specific treatment variable to see what effect it has.

There are two treatment variables when it comes to acupuncture. (Actually, there can be more if we include other treatments that use acupuncture, such as giving electrical stimulation through acupuncture needles – but those variables should be considered separately and they are not acupuncture itself.) The two variables specific to acupuncture are sticking needles through the skin, and the locations on the body where the needles are placed.

Here is the key to understanding acupuncture research – when these two variables are properly isolated the evidence shows that there is no measurable effect from either.  It does not matter where you stick the needles, or even if you stick them through the skin. Since these two variables are specific to acupuncture it is safe to conclude that acupuncture does not work.

This latest study, one of the largest to date, supports this conclusion. The three acupuncture arms – placing needles in a standard pattern, placing needles in an individualized pattern according to acupuncture philosophy, and touching the skin with tooth picks without penetrating the skin – showed almost exactly the same degree of symptom relief both short and long term. However, all three treatments were more effective than standard therapy. The authors conclude:

Although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appear to be unimportant in eliciting therapeutic benefits. These findings raise questions about acupuncture’s purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.

The first sentence is misleading, that acupuncture was found to be effective. This is based entirely on the fact that the three acupuncture arms showed more effect than the standard treatment arm. However, this was not a blinded comparison, and did not control for al the nonspecific aspects of acupuncture treatment.

The second sentence is correct but understated. This study (and others with similar results) does not just call into question the purported mechanisms of action of acupuncture – it blows them out of the water.

The final sentence is the meat of the conclusion, but again is trying to tip toe over the obvious scientific conclusion. The authors recognize that the results of their study are consistent with placebo or nonspecific effects, without the need to invoke any specific effects from acupuncture itself. But I would say that this study, combined with other studies, does not leave the question “unclear” – it makes is very clear that there are no specific effects from acupuncture, and any effects are either due to placebo effects or are a response to the therapeutic ritual surrounding the delivery of acupuncture.

These nonspecific effects may derive from the attention of the acupuncturist, the relaxing atmosphere in which the treatment is given, and the expectations derived from introducing a novel modality into treatment. These are variables known to have a symptomatic effect. Therefore if you give treatment X plus these nonspecific effects you will measure a symptomatic benefit. Treatment X can only be said to work if it provides symptomatic benefit in excess of these other variables – which acupuncture does not.

And yet the news reports of this study almost invariably declare that “Tooth pick acupuncture works” or that “Acupuncture, real or fake, helps aching back.”  They are all buying the deceptive press release. This study was not designed and is not capable of showing that “fake acupuncture works” any more than a negative drug trial shows that “sugar pills relieve pain.” This is because, as the authors admit, you cannot separate out the nonspecific and placebo effects from the acupuncture treatment.

The spin that acupuncture proponents are placing on this type of evidence turns scientific logic onto its head. In the scientific literature the authors need to be more circumspect, probably to get past peer-review. But then to the lay press the spin begins. Study author, Dr. Daniel Cherkin, is quoted as saying:

“We found that simulated acupuncture, without penetrating the skin, produced as much benefit as needle acupuncture – and that raises some new questions about how acupuncture works.”

This is wrong – these results call into question if acupuncture works.

Conclusion

Once again we see that the best acupuncture clinical trials show that it does not matter where or if you place the needles. Since these are the two interventions specific to acpuncture, we can conclude (confidently, at this point) that acupuncture does not work and that any perceived benefit from acupucture is due to placebo or nonspecific effects.

The acupuncture industry needs to be called on their continued promotion of a medical modality which has already been shown to be ineffective by clinical research. The mainstream media needs to be criticized for uncritically accepting the propaganda of the acupuncture industry.

 

See also: Acupuncture and Back Pain — Part II.

Posted in: Acupuncture, Science and Medicine

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46 thoughts on “Acupuncture Does Not Work for Back Pain

  1. superdave says:

    Great post Dr. N. I have a question though. Could you design a study in which the control for acupuncture was just a sugar pill? I understand why the sham acpuncture is better scientifically, but it seems like the sugar pill method is the only way to fight this whole reporting nonsense that fake acupuncture works.

    Also, (and this is just to play devils advocate) I know people researching possible cell signalling methods that occur when you twist an acupuncture needle. If the toothpick is twisted but does not penetrate the skin, I don’t think you can rule out this mechanism as there might be sufficient friction between the surface of the toothpick and the surface of the skin.

  2. David Gorski says:

    Actually, this study is an even better piece of evidence that any effect from acupuncture is due to nonspecific placebo effects than Steve argues. The reason? There was no restriction on “usual care” among the acupuncture groups. Thus, the three acupuncture groups were getting their version of acupuncture or sham acupuncture added to their usual care, the same usual care given to the “usual care” group. Given such an experimental design, I would have been shocked if the acupuncture groups didn’t show superiority to the “usual treatment” arm. Such a result was exactly expected based on the expected placebo effect from being in one of the acupuncture arms of the study.

  3. Tim Kreider says:

    This trial really sounds like a win. Big size, and the four groups allow several interesting comparisons.

    1. Real acupuncture is no better than sham acupuncture, obviously the most important conclusion.

    2. Individualized acupuncture is no better than “cookbook” acupuncture, weakening the CAM argument that their interventions are too personalized to be studied properly.

    3. Any novel kind of acupuncture-like intervention (lay down and relax, provider’s hands on patient’s body, sensation of slightly painful and invasive procedure), even a goofy charade with toothpicks, results in improved subjective outcomes.

    Although the inclusion of the “standard therapy alone” group may be a net downside because it helps apologists avoid acknowledging conclusion 1, it allows more honest readers to be very confident about conclusion 3.

  4. Scott says:

    superdave,

    A sugar pill would be a very poor control – it would make blinding impossible, and the degree of the placebo effect would vary. Seems to me that it would be only marginally more informative than a no-control study, i.e. effectively useless.

  5. Harriet Hall says:

    There’s another reason the sugar pill would be a poor control. There is a hierarchy of placebos: injections work better than pills, etc. Bausell elaborates in Snake Oil Science. Pills are at the bottom of the hierarchy – they elicit the least response.

  6. Scott says:

    That’s what I was trying to get at by mentioning “the degree of the placebo effect.” Thanks for saying it so much more clearly!

  7. daedalus2u says:

    What I would like to do is use my NO producing bacteria as a placebo control. My hypothesis is that it would work better than any of the acupuncture placebos because NO invokes the placebo effect pharmacologically.

    I also think that there would be no added improvement to adding an acupuncture placebo to a nitric oxide bacteria placebo. The placebo effect isn’t in the placebo, it is in the physiology of the person experiencing it. Once the placebo effect is maximally invoked, there is nothing more that any placebo can do.

  8. melospiza says:

    I have learned a tremendous amount on this website, and I was able to read the morning paper–”Acupuncture, even faked with toothpicks, may relieve back pain”–with enough knowledge and skepticism to explain it to someone else.

    My question is, do science and medicine understand the placebo effect? Exactly what is going on in the brain? Something is happening. Is the placebo effect measurable in any way that is not subjective self-reporting? It’s my opinion that belief not only affects pain but actual healing, though I can’t back it up.

  9. superdave says:

    Thanks for the explanation for placebo. I was just trying to think of somewya to combat the whole “fake acupuncture works!” headline.

    That statement is just mind boggling. Imagine a headline that read, “Fake computer still runs windows XP”. It would inherently not make sense. However, as per the other part of my comment, I read the paper and they did infact twist the toothpicks, meaning that some sort of small scale mechanotransduction mechanism of action still cannot be out ruled, however small are chances of it existing.

  10. hatch_xanadu says:

    “Acupuncture Does Not Work for Back Pain”: Now that’s an honest headline.

  11. daedalus2u says:

    I have a discussion of my understanding of the placebo effect on my blog.

    http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html

    I see it as the completely normal allocation of metabolic resources, primarily ATP between the various tasks that all organisms must carry out. These include mounting an immune response, healing, growing, food digestion, reproduction, food gathering, escaping from predators.

    The relative need for resources to accomplish these various tasks is not constant over time, the organism that can allocate resources as they are needed will have more resources to devote to reproduction and will out reproduce those that cannot.

    I see the placebo effect as the physiological shifting of metabolism from the “fight or flight” state (where resources are diverted away from healing) to a physiological state where resources are allocated to healing.

    These different physiological states are quite complex (there are many hundreds of thousands of pathways that are differentially controlled), so it is not surprising that they cannot be precisely characterized. Many of the mechanisms behind the physiology of how ATP and other resources are allocated remain not fully understood.

    A major final common pathway in triggering the placebo effect is raising the NO level. If you can do that pharmacologically (which is actually extremely difficult to do), then you will trigger the placebo effect. Once you have fully switched physiology into the mode where maximum resources are allocated to healing, there is nothing that any other placebo can do.

  12. jonny_eh says:

    This stuff is so infuriating. They’re controlling the outcome so they always win. It’s like flipping a coin: “Heads I win, tails you lose”. If the real acupuncture has a bigger effect than the control (matchsticks in this study) then it’s proof that acupuncture works. If the real acupuncture has the same effect as the control, then it just means the control works too!

    You cannot just elevate the control to treatment status like this when you don’t get the desired results. That’s why you have to specify at the start of the study what is being studied. At first they’re studying real acupuncture, then all of a sudden the real acupuncture becomes the control, and the original control becomes the treatment being tested. Anything to maintain the illusion that acupuncture works. Bait and switch!

  13. randyextry says:

    NEXT STUDY:

    Repeat that study exactly, except tell the toothpick group that they are getting toothpicks. The “benefit” will disappear and the placebo effect will be the only possible explanation left.

  14. tmac57 says:

    I wonder what the outcome would be if the patients were told that their acupuncturist was somebody they just pulled off the street with no expertise, and that they would just be using toothpicks?

  15. Harriet Hall says:

    In Snake Oil Science, Bausell describes an experiment where only those who believed they got “real” acupuncture responded, regardless of whether they actually got “real” or “sham.”

  16. wertys says:

    This is just *another* study showing that it’s time to give up on acupuncture and spend the limited research dollars we have on something that might actually be worthwhile. I’m sick of acupuncturists and their special pleading. They want more research, they’ve had it in buckets. We’re still waiting for a single convincing line of treatment effect research and it’s now 30 years or more since the studies began.

    While people may criticize the Pharma companies for some of their misbehaviour (and rightly so may I say) the SCAM industry spends virtually nothing on researching their own treatments and millions of times more money on marketing them. At least pharma compoanies have to spend lots of money doing fairly rigorous research to demonstrate that what they are selling is capable of producing a treatment effect. Who is being more intellectually dishonest ?

  17. Tim Kreider says:

    wertys, interesting point. I would love to see data to that effect if it exists.

    Does anyone know if the ratio of marketing dollars to research dollars has been calculated or estimated for herbal/supplement/homeopathic firms?

    Is there much serious research in CAM that is privately funded, or is it primarily NCCAM and NCI?

  18. wertys says:

    Some figures I have picked up with a little browsing (currently at work so a bit rushed )

    Pfizer – R&D spend of $7 billion in 2008

    Janssen Cilag – R&D spend of $3.8 billion

    Eli Lilly – R&D 19% of sales income translating to around $8 billion

    Compare with Blackmores (Australian SCAM company) which had their 2008 annual report balance sheet reading as follows

    Total income AUD$180 million R&D zero. presumably it is accounted for under marketing expenses.

    Similar information for Airborne Health is unavailable asit is a private company.

    I think you will find that while SCAM companies are happy to fund ‘lifestyle symposia’ which are after all just marketing exercises, they do not fund any independent research into their products before they begin making claims about them.

    I’d be happy to see what other information people can find about this issue !

  19. wertys says:

    search update…Pharmacare laboratories which produces 2 of the most popular supplement brands in Australia (Nature’s Way and Bioglan) has no information available for perusal about their balance sheets or research activities, nor does Brauer Natural Medicines, a commercial homeopathic business in South Australia. Those companies which are not already subsidiaries of pharma companies seem to be privately owned, and therefore do not have annual reports available for analysis….

  20. Wholly Father says:

    So now “simulated acupuncture” works as well as the venerable ancient art itself.

    Another finding was that there were fewer adverse events in the “simulated” group. (statistically significant) than in the 2 other treatment groups.

    If one accepts the conclusions as the authors have reported, acupuncturists treating back pain are morally obligated to abandon their needles and adopt the safer, equally effective treatment. Do I need a license or a degree to poke people with toothpicks?

  21. tmac57 says:

    Hey podna! Backache gotcha down!? Scared of needles!? Then get on down to Dale Darlin’s ‘Pick N Poke’ back clinic! We use only the finest ‘All Natural’ lumbar lumber for our back picks! We can end yer backache for less, cause we save money on overhead! No need fer stair-l-za-shun! No fancy Chi charts! No need fer anti-septic,cause we don’t break yer skin! Hell, we don’t even train our ‘pokers’, cause guess what; it don’t matter!!! So get on down to ‘Pick N Poke’ now! You don’t gotta suffer no more, cause at Dale Darlin’s, “We gotcha Back!

  22. Jayhox says:

    I have a backache today after doing too much heavy lifting yesterday. I’m planning on putting 4 or 5 straight pins into a sugar cube and swallowing it. This “double placebo” should give me twice the relief as a regular placebo. All in the new “time release” formula. I’ll report back on my results, and if successful, I’ll put them on the market soon.

  23. sanjiva86 says:

    tmac: I lol’ed.

  24. tmac57 says:

    sanjiva86- Glad you liked it. Thanks!

  25. boyhayden says:

    Today in the UK it has been announced that, the NHS will provide acupuncture for lower back pain free of charge.

    The BBC interviewed a doctor about the plan, she explained that this form of treatment was a new kind of acupuncture, because it was applied into the muscles, which are the cause of the lower back pain.

    Having already been made to look stupid in front of the wife, for suggesting that acupuncture was all rubbish, not what I called it, who do I believe the skeptics or a large body of trained doctors?

    Is it any wonder people believe all sorts of strange and odd ideas, if you can’t trust your doctors who can you trust.

  26. benguela says:

    Fantastic article.

    Have you investigate Dry Needling? My physiotherapist says that it’s not the same as acupuncture and that it has a sound theoretical base and an increasing number of good, peer reviewed academic papers to support it.

    I am yet to be convinced of this. Any comments?

  27. alabere says:

    I think it is rather funny, when somebody tries to neglect the fact, that accupuncture is used since hundred of years and even used as anästhesia in surgery since long time until now.
    I know people who had very successful treatment with accupuncture.

    Let me guess.
    Mr. Novella never read on of the standard books of accupuncture.
    He never tried a treatment.
    And he never talked to a learned one who was able to perform treatments.

    Is that science. No that is bullshit.

  28. alabere says:

    I think somme million people in the world (mostly in china)
    know that accupuncture works. Just Mr. Novella does not know it. Is that important?

  29. Chris says:

    alabere, you have used both an argument of antiquity and one of popularity. Neither is real evidence on acupuncture. To quote:

    Is that science. No that is bullshit.

    Here is some reading for you: Snake Oil Science by R. Barker Bausell Ph.D.

  30. Chris says:

    Well, that comment went to some spam bucket. In the mean time, alabere, look up these two terms:

    Argument from Antiquity
    Argument from Popularity

    (when my comment is retrieved, you can just click on them to find links where they are explained)

    Also, go to your local library and check out the book Snake Oil Science> by R. Barker Bausell Ph.D.

  31. Karl Withakay says:

    alabere said,

    “I think it is rather funny, when somebody tries to neglect the fact, that accupuncture is used since hundred of years and even used as anästhesia in surgery since long time until now.”

    I reply,

    How is it you stumbled across this site and this particular post, and yet somehow managed to miss all the other posts about acupuncture that cover and debunk those claims, including a very recent one by Kimball Atwood?”

    To bring up an old favorite response, bloodletting was practiced for hundreds of years as well, but that doesn’t provide any support for its efficacy.

    Go to the top of this page and click on the Acupuncture link under CATEGORIES for more information.

    I especially recommend the following posts that deal directly with your comment.

    Puncturing the Acupuncture Myth
    http://www.sciencebasedmedicine.org/?p=252

    “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part I)
    http://www.sciencebasedmedicine.org/?p=131

    “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part II)
    http://www.sciencebasedmedicine.org/?p=494

    If you have have support to counter anything in these posts, I encourage you to post a reply with your arguments, but you will be expected to make logical, scientifically supported arguments rather than logical fallacies.

  32. wertys says:

    @benguela

    Dry needling is indeed different in both rationale and technique from acupuncture, though often the same needles are used. Dry needling refers to the insertion of either acupuncture needles or even a regular medical type needle into muscle. The technique if properly done can be an effective way of reducing pain and muscle overactivity from myofascial trigger points. Trigger points have been a source of controversy in musculoskeletal medicine for decades, but in the eight years I have been following the literature there has been a definite improvement in both the basic science and clinical research on the topic. Regrettably for such a common and disabling condition, there is a massive void of well-conducted clinical trial data.

    It would be reasonably uncontroversial to make the following statements about myofascial pain and dry needling:
    1. Myofascial pain originates in the soft tissues (muscle, connective tissue) but is maintained by an interaction between the muscle and the nerves which supply it.
    2. It tends to occur in predictable locations and have a definable pattern, though it is variable
    3. Dry needling directed to ‘active’ trigger points ie those which are spontaneously painful at rest can result in short-term reductions in pain and tightness in the affected muscle.
    4. Dry needling and trigger point injections are superior to injected saline or no-treatment controls in reducing myofascial pain.

    Trigger point injections with local anaesthetic are a less painful and (I think) more reliable way to diagnose and potentially treat severe myofascial pain. The injections or needlign are only as good as the stretching and retraining of the muscle that they allow, in other words they are not the be-all and end-all of treatment. In about 5% of cases they make the myofascial pain worse.

    hope this information helps. references can be provided upon request but I’m trying not to bore everyone too much.

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