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Acupuncture Doesn’t Work

About a year ago the editors of Anesthesia & Analgesia solicited a written debate on whether or not acupuncture is effective or simply an elaborate placebo. Four experienced acupuncture researchers agreed to write the pro-acupuncture article, Wang, Harris, Lin and Gan. They asked David Colquhoun to write the con position, and David asked me to write it with him (which, of course, I enthusiastically agreed to do).

The article is fortunately published in open access, and so I can reprint it here (full article is below). What I think David and I convincingly demonstrated is that, according to the usual standards of medicine, acupuncture does not work.

Let me explain what I mean by that. Clinical research can never prove that an intervention has an effect size of zero. Rather, clinical research assumes the null hypothesis, that the treatment does not work, and the burden of proof lies with demonstrating adequate evidence to reject the null hypothesis. So, when being technical, researchers will conclude that a negative study “fails to reject the null hypothesis.”

Further, negative studies do not demonstrate an effect size of zero, but rather that any possible effect is likely to be smaller than the power of existing research to detect. The greater the number and power of such studies, however, the closer this remaining possible effect size gets to zero. At some point the remaining possible effect becomes clinically insignificant.

In other words, clinical research may not be able to detect the difference between zero effect and a tiny effect, but at some point it becomes irrelevant.

What David and I have convincingly argued, in my opinion, is that after decades of research and more than 3000 trials, acupuncture researchers have failed to reject the null hypothesis, and any remaining possible specific effect from acupuncture is so tiny as to be clinically insignificant.

In layman’s terms, acupuncture does not work – for anything.

This has profound clinical, ethical, scientific, and practical implications. In my opinion humanity should not waste another penny, another moment, another patient – any further resources on this dead end. We should consider this a lesson learned, cut our losses, and move on.

I suspect, however, human nature being what it is, that this will not happen anytime soon.

________________

Full article reprinted from Anesthesia & Analgesia

Acupuncture Is Theatrical Placebo

  1. Steven P. Novella, MD

Introduction

Pain is a big problem. If you read about pain management centers, you might think it had been solved. It has not. And when no effective treatment exists for a medical problem, it leads to a tendency to clutch at straws. Research has shown that acupuncture is little more than such a straw.

Although it is commonly claimed that acupuncture has been around for thousands of years, it has not always been popular, even in China. For almost 1000 years, it was in decline, and in 1822, Emperor Dao Guang issued an imperial edict stating that acupuncture and moxibustion should be banned forever from the Imperial Medical Academy.1

Acupuncture continued as a minor fringe activity in the 1950s. After the Chinese Civil War, the Chinese Communist Party ridiculed Traditional Chinese Medicine, including acupuncture, as superstitious. Chairman Mao Zedong later revived Traditional Chinese Medicine as part of the Great Proletarian Cultural Revolution of 1966.2 The revival was a convenient response to the dearth of medically trained people in postwar China and a useful way to increase Chinese nationalism. It is said that Chairman Mao himself preferred Western medicine. His personal physician quotes him as saying “Even though I believe we should promote Chinese medicine, I personally do not believe in it. I do not take Chinese medicine.”3

The political, or perhaps commercial, bias seems to still exist. It has been reported (by authors who are sympathetic to alternative medicine) that “all trials [of acupuncture] originating in China, Japan, Hong Kong, and Taiwan were positive.”4

Acupuncture was essentially defunct in the West until President Nixon visited China in 1972. Its revival in the West was largely a result of a single anecdote promulgated by journalist James Reston in the New York Times5 after he had acupuncture in Beijing for postoperative pain in 1971. Despite his eminence as a political journalist, Reston had no scientific background and evidently did not appreciate the post hoc ergo propter hoc fallacy, or the idea of regression to the mean.

After Reston’s report, acupuncture quickly became popular in the West. Stories circulated that patients in China had open heart surgery using only acupuncture.6The Medical Research Council (UK) sent a delegation, which included Alan Hodgkin, to China in 1972 to investigate these claims, about which they were skeptical. The claims were repeated in 2006 in a British Broadcasting Corporation TV program, but Simon Singh (author of Fermat’s Last Theorem) discovered that the patient had been given a combination of 3 very powerful sedatives (midazolam, droperidol, fentanyl) and large volumes of local anesthetic injected into the chest. The acupuncture needles were purely cosmetic.

Curiously, given that its alleged principles are as bizarre as those on any other sort of prescientific medicine, acupuncture seemed to gain somewhat more plausibility than other forms of alternative medicine. As a result, more research has been done on acupuncture than on just about any other fringe practice.

The outcome of this research, we propose, is that the benefits of acupuncture are likely nonexistent, or at best are too small and too transient to be of any clinical significance. It seems that acupuncture is little or no more than a theatrical placebo. The evidence for this conclusion will now be discussed.

THREE THINGS THAT ARE NOT RELEVANT TO THE ARGUMENT

We see no point in discussing surrogate outcomes, such as functional magnetic resonance imaging studies or endorphine release studies, until such time as it has been shown that patients get a useful degree of relief. It is now clear that they do not.

We also see little point in invoking individual studies. Inconsistency is a prominent characteristic of acupuncture research: the heterogeneity of results poses a problem for meta-analysis. Consequently, it is very easy to pick trials that show any outcome whatsoever. Therefore, we shall consider only meta-analyses.

The argument that acupuncture is somehow more holistic, or more patient-centered, than medicine seems to us to be a red herring. All good doctors are empathetic and patient-centered. The idea that empathy is restricted to those who practice unscientific medicine seems both condescending to doctors, and it verges on an admission that empathy is all that alternative treatments have to offer.

There is now unanimity that the benefits, if any, of acupuncture for analgesia, are too small to be helpful to patients.

Large multicenter clinical trials conducted in Germany710 and the United States11 consistently revealed that verum (or true) acupuncture and sham acupuncture treatments are no different in decreasing pain levels across multiple chronic pain disorders: migraine, tension headache, low back pain, and osteoarthritis of the knee.

If, indeed, sham acupuncture is no different from real acupuncture, the apparent improvement that may be seen after acupuncture is merely a placebo effect. Furthermore, it shows that the idea of meridians is purely imaginary. All that remains to be discussed is whether or not the placebo effect is big enough to be useful, and whether it is ethical to prescribe placebos.

Some meta-analyses have found that there may be a small difference between sham and real acupuncture. Madsen et al.12 looked at 13 trials with 3025 patients, in which acupuncture was used to treat a variety of painful conditions. There was a small difference between “real” and sham acupuncture (it did not matter which sort of sham was used), and a somewhat bigger difference between the acupuncture group and the no-acupuncture group. The crucial result was that even this bigger difference corresponded to only a 10-point improvement on a 100-point pain scale. A consensus report13 concluded that a change of this sort should be described as a “minimal” change or “little change.” It is not big enough for the patient to notice much effect.

The acupuncture and no-acupuncture groups were, of course, neither blind to the patients nor blind to the practitioner giving the treatment. It is not possible to say whether the observed difference is a real physiological action or whether it is a placebo effect of a rather dramatic intervention. Though it would be interesting to know this, it matters not a jot, because the effect just is not big enough to produce any tangible benefit.

Publication bias is likely to be an even greater problem for alternative medicine than it is for real medicine, so it is particularly interesting that the result just described has been confirmed by authors who practice, or sympathize with, acupuncture. Vickers et al.14 did a meta-analysis for 29 randomized controlled trials, with 17,922 patients. The patients were being treated for a variety of chronic pain conditions. The results were very similar to those of Madsen et al.12Real acupuncture was better than sham but by a tiny amount that lacked any clinical significance. Again there was a somewhat larger difference in the nonblind comparison of acupuncture and no-acupuncture, but again it was so small that patients would barely notice it.

Comparison of these 2 meta-analyses shows how important it is to read the results, not just the summaries. Although the outcomes were similar for both, the spin on the results in the abstracts (and consequently the tone of media reports) was very different.

An even more extreme example occurred in the CACTUS trial of acupuncture for “frequent attenders” with medically unexplained symptoms.15 In this case, the results showed very little difference even between acupuncture and no-acupuncture groups, despite the lack of blinding and lack of proper controls. But, by ignoring the problems of multiple comparisons, the authors were able to pick out a few results that were statistically significant, though trivial in size. Despite this unusually negative outcome, the result was trumpeted as a success for acupuncture. Not only the authors, but also their university’s public relations department and even the journal editor issued highly misleading statements. This gave rise to a flood of letters to the British Journal of General Practice16 and much criticism on the Internet.17

From the intellectual point of view, it would be interesting to know whether the small difference between real and sham acupuncture found in some recent studies is a genuine effect of acupuncture or whether it is a result of the fact that the practitioners are never blinded, or of publication bias. However, that knowledge is irrelevant for patients. All that matters for them is whether or not they get a useful degree of relief. It seems that they do not.

There is now unanimity between acupuncturists and nonacupuncturists that any benefits that may exist are too small to provide any noticeable benefit to patients. That being the case, it is hard to see why acupuncture is still used. Certainly, such an accumulation of negative results would result in the withdrawal of any conventional treatment.

SPECIFIC CONDITIONS

Acupuncture should, ideally, be tested separately for effectiveness for each individual condition for which it has been proposed (like so many other forms of alternative medicine, that is a very large number). Good quality trials have not been done for all of them, but results suggest strongly that it is unlikely that acupuncture works for rheumatoid arthritis, stopping smoking, irritable bowel syndrome, or for losing weight. There is also no good reason to think it works for addictions, asthma, chronic pain, depression, insomnia, neck pain, shoulder pain or frozen shoulder, osteoarthritis of the knee, sciatica, stroke or tinnitus, and many other conditions.18

In 2009, the United Kingdom’s National Institute for Clinical Excellence did recommend acupuncture for back pain.19 This exercise in clutching at straws caused something of a furore.20 In the light of National Institute for Clinical Excellence’s judgment, the Oxford Centre for Evidence-Based Medicine updated its analysis of acupuncture for back pain. Their verdict21 was

“Clinical bottom line. Acupuncture is no better than a toothpick for treating back pain.”

The article by Artus et al.22 is of particular interest for the problem of back pain. Their Figure 2 shows that there is a modest improvement in pain scores after treatment, but much the same effect, with the same time course is found regardless of what treatment is given, and even with no treatment at all. They say

“we found evidence that these responses seem to follow a common trend of early rapid improvement in symptoms that slows down and reaches a plateau 6 months after the start of treatment, although the size of response varied widely. We found a similar pattern of improvement in symptoms following any treatment, regardless of whether it was index, active comparator, usual care, or placebo treatment.”

It seems that most of what is being seen is regression to the mean, which is very likely to be the main reason why acupuncture sometimes appears to work when it does not.

Although the article by Wang et al.23 is written to defend the continued use of acupuncture, the only condition for which they claim that there is any reasonably strong evidence is for postoperative nausea and vomiting (PONV). It would certainly be odd if a treatment that had been advocated for such a wide variety of conditions turned out to work only for PONV. Nevertheless, let us look at the evidence.

The main papers that are cited to support the efficacy of acupuncture in alleviation of PONV are all from the same author: Lee and Done (1999)24 and 2 Cochrane reviews, Lee and Done (2004),25 updated in Lee and Fan (2009).26 We need to deal only with the latest updated meta-analysis26.

Although the authors conclude “P6 acupoint stimulation prevented PONV,” closer examination shows that this conclusion is very far from certain. Even taken at face value, a relative risk of 0.7 cannot be described as “prevention.” The trials that were included were not all tests of acupuncture but included several other more or less bizarre treatments (“acupuncture, electroacupuncture, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, an acu-stimulation device, and acupressure”). The number needed to treat varied from a disastrous 34 to 5 for patients with control rates of PONV of 10% and 70%, respectively.

The meta-analysis showed, on average, similar effectiveness for acupuncture and antiemetic drugs. The problem is that the effectiveness of drugs is itself in doubt because an update to the Cochrane review has been delayed27 by the discovery of major fraud by a Japanese anesthetist, Yoshitaka Fujii.28 It has been suggested that metoclopramide barely works at all.29,30

Of the 40 trials (4858 participants) that were included in Lee and Fan,26 only 4 trials reported adequate allocation concealment. Ninety percent of trials were open to bias from this source. Twelve trials did not report all outcomes. The opportunities for bias are obvious. The authors themselves describe all estimates as being of “moderate quality” which is defined thus: “Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.” That being the case, perhaps the conclusion should have been “more research needed.” The conclusions of Lee and Fan26 are nowhere near as secure as the abstract implies. In fact, almost all trials of alternative medicines seem to end up with the conclusion that more research is needed. After more than 3000 trials, that is dubious.

CONCLUSIONS

It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions. After thousands of trials of acupuncture and hundreds of systematic reviews,18 arguments continue unabated. In 2011,Pain published an editorial31 that summed up the present situation well.

“Is there really any need for more studies? Ernst et al.18 point out that the positive studies conclude that acupuncture relieves pain in some conditions but not in other very similar conditions. What would you think if a new pain pill was shown to relieve musculoskeletal pain in the arms but not in the legs? The most parsimonious explanation is that the positive studies are false positives. In his seminal article on why most published research findings are false, Ioannidis32 points out that when a popular but ineffective treatment is studied, false positive results are common for multiple reasons, including bias and low prior probability.”

Since it has proved impossible to find consistent evidence after more than 3000 trials, it is time to give up. It seems very unlikely that the money that it would cost to do another 3000 trials would be well-spent.

A small excess of positive results after thousands of trials is most consistent with an inactive intervention. The small excess is predicted by poor study design and publication bias. Furthermore, Simmons et al.33 demonstrated that exploitation of “undisclosed flexibility in data collection and analysis” can produce statistically positive results even from a completely nonexistent effect. They say this is “… not driven by a willingness to deceive but by the self-serving interpretation of ambiguity, which enables us to convince ourselves that whichever decisions produced the most publishable outcome must have also been the most appropriate.”

With acupuncture, in particular, there is documented profound bias among proponents.4 Existing studies are also contaminated by variables other than acupuncture, such as the frequent inclusion of “electroacupuncture” which is essentially transdermal electrical nerve stimulation masquerading as acupuncture.

The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research. The most parsimonious conclusion is that with acupuncture there is no signal, only noise.

The interests of medicine would be best-served if we emulated the Chinese Emperor Dao Guang and issued an edict stating that acupuncture and moxibustion should no longer be used in clinical practice.

No doubt acupuncture will continue to exist on the “High Streets” where they can be tolerated as a voluntary self-imposed tax on the gullible (as long as they do not make unjustified claims).

DISCLOSURES

Name: David Colquhoun, PhD.

Contribution: Professor Colquhoun coauthored the manuscript.

Attestation: Professor Colquhoun approved the final manuscript.

Conflicts of Interest: Professor Colquhoun has no financial conflicts of interest. Professor Colquhoun writes the “DC’s Improbable Science” blog (http://dcscience.net/), devoted to scientific fraud and medical quackery and education policy. Many postings to Dr. Colquhoun’s blog address the lack of scientific evidence for alternative medicine.

Name: Steven P. Novella, MD.

Contribution: Professor Novella coauthored the manuscript.

Attestation: Professor Novella approved the final manuscript.

Conflicts of Interest: Professor Novella has no financial conflicts of interest. Professor Novella maintains the “Neurologica blog”, described as “your daily fix of neuroscience, skepticism, and critical thinking.” The Neurologica blog occasionally addresses the lack of scientific evidence for alternative medicine.

This manuscript was handled by: Steven L. Shafer, MD.

Footnotes
  • Accepted for publication February 1, 2013.

  • Funding: None.

  • Conflict of Interest: See Disclosures at the end of the article.

  • Reprints will not be available from the authors.

REFERENCES

1. Acupuncture Centre. . About Acupuncture. Available at: http://www.acupuncturecentre.org/aboutacupuncture.html. Accessed March 30, 2013

2. Atwood K. “Acupuncture Anesthesia”: a Proclamation from Chairman Mao (Part IV). Available at: http://www.sciencebasedmedicine.org/index.php/acupuncture-anesthesia-a-proclamation-from-chairman-mao-part-iv/. Accessed September 2, 2012

3. Li Z Private Life of Chairman Mao: The Memoirs of Mao’s Personal Physician. 1996 New York: Random House

4. Vickers A, Goyal N, Harland R, Rees R. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials. 1998;19:159–66 Available at: http://bit.ly/WqVGWN. Accessed September 2, 2012

5. Reston J. Now, About My Operation in Peking; Now, Let Me Tell You About My Appendectomy in Peking … The New York Times. 1971 Available at: http://select.nytimes.com/gst/abstract.html?res=FB0D11FA395C1A7493C4AB178CD85F458785F9. Accessed March 30, 2013

6. Atwood K. “Acupuncture anesthesia”: a proclamation from chairman Mao (part I). Available at: http://www.sciencebasedmedicine.org/index.php/acupuncture-anesthesia-a-proclamation-of-chairman-mao-part-i/. Accessed September 2, 2012

7. Linde K, Streng A, Jürgens S, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes MG, Weidenhammer W, Willich SN, Melchart D. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005;293:2118–25

8. Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes M, Hummelsberger J, Irnich D, Weidenhammer W, Willich SN, Linde K. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ. 2005;331:376–82

9. Haake M, Müller HH, Schade-Brittinger C, Basler HD, Schäfer H, Maier C, Endres HG, Trampisch HJ, Molsberger A. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007;167:1892–8

10. Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S, Hummelsberger J, Walther HU, Melchart D, Willich SN. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet. 2005;366:136–43

11. Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009;169:858–66

12. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009;338:a3115

13. Dworkin RH, Turk DC, McDermott MP, Peirce-Sandner S, Burke LB, Cowan P, Farrar JT, Hertz S, Raja SN, Rappaport BA, Rauschkolb C, Sampaio C. Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations. Pain. 2009;146:238–44

14. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, Sherman KJ, Witt CM, Linde K. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172:1444–53

15. Paterson C, Taylor RS, Griffiths P, Britten N, Rugg S, Bridges J, McCallum B, Kite G. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms: a randomised controlled trial (CACTUS study). Br J Gen Pract. 2011;61:e295–e305

16. . Letters in response to Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract. 2011;61 Available at: http://www.ingentaconnect.com/content/rcgp/bjgp/2011/00000061/00000589. Accessed March 30, 2013

17. Colquhoun D. Acupuncturists show that acupuncture doesn’t work, but conclude the opposite: journal fails. 2011 Available at: http://www.dcscience.net/?p=4439. Accessed September 2, 2012

18. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011;152:755–64

19. Colquhoun D. NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself. 2009 Available at: http://www.dcscience.net/?p=1516. Accessed September 2, 2012

20. Colquhoun D. The NICE fiasco, part 3. Too many vested interests, not enough honesty. 2009 Available at: http://www.dcscience.net/?p=1593. Accessed September 2, 2012

21. Bandolier. . Acupuncture for back pain—2009 update. Available at: http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Chronrev/Other/acuback.html. Accessed March 30, 2013

22. Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology (Oxford). 2010;49:2346–56

23. Wang S-M, Harris RE., Lin Y-C, Gan TJ. Acupuncture in 21st century anesthesia: is there a needle in the haystack? Anesth Analg. 2013;116:1356–9

24. Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg. 1999;88:1362–9

25. Lee A, Done ML. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2004:CD003281

26. Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2009:CD003281

27. Carlisle JB. A meta-analysis of prevention of postoperative nausea and vomiting: randomised controlled trials by Fujii etal. compared with other authors. Anaesthesia. 2012;67:1076–90

28. Sumikawa K. The results of investigation into Dr.Yoshitaka Fujii’s papers. Report of the Japanese Society of Anesthesiologists Special Investigation Committee. http://www.anesth.or.jp/english/pdf/news20120629.pdf

29. Bandolier. . Metoclopramide is ineffective in preventing postoperative nausea and vomiting. Available at: http://www.medicine.ox.ac.uk/bandolier/band71/b71-8.html. Accessed March 30, 2013

30. Henzi I, Walder B, Tramèr MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies. Br J Anaesth. 1999;83:761–71

31. Hall H. Acupuncture’s claims punctured: not proven effective for pain, not harmless. Pain. 2011;152:711–2

32. Ioannidis JP. Why most published research findings are false. PLoS Med. 2005;2:e124

33. Simmons JP, Leif DN, Simonsohn U. False-positive psychology: undisclosed flexibility in data collection and analysis allows presenting anything as significant. Psychol Sci. 2011;22:1359–66

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Leave a Comment (566) ↓

566 thoughts on “Acupuncture Doesn’t Work

  1. Bob says:

    Whenever I bring up the proven lack of efficacy of things like acupuncture, I have a friend who responds by saying the place effect is still an effect. How do you respond to that?

    1. Bob says:

      placebo, not place

    2. DugganSC says:

      To be perfectly honest, if a very small brief respite from pain is all that they want, and the price is acceptable, I’m not certain if there’s an issue. It’s not like we clamp down on parents who use distraction to make their kid forget that they were crying over a skinned knee. That said, over and over again, it’s been shown that placebo works only on pain and nausea, it doesn’t fix any underlying problems, and pretty much any placebo works the same. It’s not a cure, and I balk at the idea of subsidizing it through my insurance premiums as if it were actual medical treatment.

      1. egstra says:

        I agree… if people want to pay for temporary pain relief out of their own pockets, that’s their choice. Ask me to help pay for it, and that’s another story.

      2. mho says:

        Acupuncture costs us all when our insurance companies build coverage into our premiums, and when hospitals devote premium sq. footage to practitioner’s offices.

        1. DugganSC says:

          ^_^ Thus why I added my caveat that since it doesn’t actually cure anything, I balk at the idea of my insurance premiums going into it. I have friends who deal with pain by knitting, but I don’t think insurance should cover that form of needle therapy either.

    3. Jan Willem Nienhuys says:

      In the first place, the “placebo effect” is a tangle of natural course (aka regression to the mean), and all kinds or research errors. Due to the ‘placebo’-effect a patient may be subjectively convinced that s/he is much better, even though in reality nothing has changed. But maybe there is a genuine effect caused by the interaction between the doctor (or the mother who kisses away the pain) and the patient and the whole therapeutic setting.

      The main reason why a physician may not rely on the placebo effect, i.e. consciously prescribing an ineffective pill, is simply that it is a lie. Suppose the patient asks for more? If the physician has to confess that the treatment was fake, this may have serious repercussions for the trust of the patient in this person.

    4. What I say to that is that the interesting recent development is that the placebo effect is usually too small to be of much value to the patient (e give references for that assertion). It is becoming increasingly apparent that most of what we are seeing is the get-better-anyway effect (regression to the mean), You get treatment when you are at your worst. The next day you are better, and would have been even if you hadn’t had the treatment.

      1. windriven says:

        Wang mentioned a Duke study published in BJA that showed acupuncture as an adjunct to conventional pain management resulted in (a little) less opioid consumption and a pretty significant reduction in anti-emetics and anti-prurients. I haven’t read the BJA paper, only the abstract. But I’d be interested in hearing your thoughts if you’re familiar with the study.

        1. Tom says:

          yes Windriven. and there are numerous additional studies to include its use in palliative care. Not sure of the efficacy of what was written here other than a biased historical review. I can actually feel that this was an emotion attack on this field behind the writings, not based on fact alone, a problem with qualitative studies is the susceptibility to bias as we have seen here. Thanks, I look forward to using this with my statistics and research students to show how bias can come out in semi-professional writings. Apparent and sad! Dr. Tom

      2. Gypsy Rose says:

        I do not understand what qualifies you to make a decision for humanity on acupuncture. Do you mean to disqualify 2,000 years of TCM?

        1. WilliamLawrenceUtridge says:

          Acupuncture either works, or it doesn’t. Age has nothing to do with it. If age truly impresses you, why not instead pray to the Egyptian god Thoth, a practice that is at least a good 3,000 years older. If age had anything to do with effectiveness, it would be far more potent a treatment than antibiotics or vaccination, but Thoth was powerless in the face of smallpox, which arose in Egypt itself. Not to mention, it is extremely unlikely that acupuncture is 2,000 years old (see here, the entire series on modern acupuncture by Kimball Atwood, starting here and the any post by Ben Kavoussi, who “specializes” in acupuncture here on SBM). China lacked the technology to create the kind of high-grade steel necessary to forge filiform needles such as those used today. The earliest tools of acupuncture suggest bloodletting rather than the relatively bloodless variant used today, with a heavy dose of astrology.

          Of course, none of that really matters. The history of a treatment, even its prior probability, is far less important than the results of clinical trials. Those results fail to find any meaningful effects bar the temporary reduction of pain and nausea (both of which are symptoms, not diseases, and both of which are extremely subject to the placebo effect). Further, the placebo effect is not unitary, it varies according to conditions and circumstances. It is enhanced by form (injections are better than pills, sham surgery better than injections), by theatrics (dramatic interventions are better than banal interventions, exotic are better than familiar), by contact with practitioners (lengthy consultations are better than brief ones, empathetic practitioners better than brusque, and even the act of discussing a health issue can make one feel better), and technical are better than simple. Acupuncture has all of these features – a lengthy consultation involving extensive technical (but meaningless) TCM babble with a caring practitioner who asserts the age and foreign origins of acupuncture to set the stage for a dramatic intervention in which multiple needles are inserted into the skin. It’s frankly custom-made to enhance the placebo effect.

          Not to mention, one must ask – what kind of acupuncture? Chinese? Japanese? Korean? Tibetan? German? Acupuncture has repeatedly splintered as it encountered new cultures. It behaves more like a religion, with adherents and dogma, than it does a science, which converges on a set of meaningful treatments and results.

          It doesn’t matter where you put the needle. It doesn’t matter if you penetrate the skin. It does matter if the practitioner is enthusiastic. Despite the existence of TCM for thousands of years, Chinese people still died, and died far younger than even a poor citizen of America, of diseases they were helpless against – once modern medicine was introduced to China, life expectancy rose, despite the existence of extremely old medical practice.

        2. MadisonMD says:

          “Do you mean to disqualify 2,000 years of TCM?”
          Yes–right on. Did you read figure it out by reading the post or by reading our tongues?

          1. Jo says:

            Actually, it’s closer to 3,000 years…and no one with any real intelligence takes this blog seriously. It’s pretty funny, as the writers and editors here often blatantly do what they accuse others of: cherry picking, using the slippery slope, straw man, etc…Always good for a laugh, this blog.

          2. WilliamLawrenceUtridge says:

            Well surely you can point to a meta-analysis to support your point? Like, oh, I don’t know, the one discussed in this post?

            As far back as five thousand years ago the Mesopotamian people were using haruspex, liver divination, to treat disease. You should go with that, since it’s even older than acupuncture!

            Well, I say acupuncture, but if you look at the tools, it’s more like “gouging and puncturing the flesh”. The earliest tools were rather vicious and far, far larger than the thin needles we use today. I assume, given the importance you place on its apparent age, that you use these tools – stone bodkins or iron fleams, big enough to perform surgery with.

          3. @williamlawut. “acupuncture, but if you look at the tools, it’s more like “gouging and puncturing the flesh”. The earliest tools were rather vicious and far, far larger than the thin needles we use today.”

            Have you seen some of the tools used on the orthopedic surgical suites? Barbaric!

            You are correct in the needle has been perfected over the centuries and now with stainless steel they are absolutely the perfect tool.
            You can make a more perfect gouge at the best point to activate the healing cascade! And the steel will depolarize the muscle to release the contractive forces so the muscle will relax.

            That’s all the needles do!

            How the questions we should be asking are;
            1. Why do we need to accomplish those 2 events simultaneously?
            2. Why doing one or the other is not as good as the 2 events together.
            3. What is going on in the tissues that disrupt natural healing?
            4. What perpetuates this disrupted tissue?

            Did y’all know that today microscopically we can see this disrupted tissues!

          4. WilliamLawrenceUtridge says:

            What does orthopedic surgery have to do with acupuncture? I thought we were discussing acupuncture, specifically its consistent failure upon scientific testing. Why are you bringing up utterly irrelevant issues? I mean, I know why – you hope that people will be distracted from the substantive issue which is acupuncture’s lack of efficacy.

            You pose a series of “why” questions, skipping quite over the fact that we haven’t even answered the “if” questions. Specifically, if acupuncture even does anything. As the meta-analysis discussed in the article says – it doesn’t. 3,000 studies, and it doesn’t matter where you needle, it doesn’t matter if you use a needle, and it doesn’t do anything but relieve pain and nausea.

            If there is histological proof of acupuncture being effective, surely you can link to the relevant studies? Because you keep claiming things but never manage to back them up with pubmed-indexed journal articles. Just your own website, some blog, a random webpage. Sadly, anyone can have a webpage, or upload a youtube video, and they can be deceptive. Science is fortunately transparent – if it is to be taken seriously, it is discussed and replicated. So, studies please, no more worthless webpages.

        3. “Do you mean to disqualify 2,000 years of TCM?”

          Should I disqualify (or at least be extremely skeptical of)….

          Medicine which….was developed with a disease model which is so far off what is observed to happen that calling it “completely wrong” is being generous.

          Medicine which….was developed with poor controls and poor blinding?

          Medicine which…analysis was done without statistical tools. Chinese math historically shows some knowledge of probability but nothing like Europe int he 1800′s or 1900′s.

          So if we’re talking about medicine which is 2000-3000 years old then yeah I feel pretty confident that it would be only capable of detecting strong effects which were capable of overcoming all the biases in the system. Since no strong effects for acupuncture have been found I think it likely that it’s bunk.

          1. Hmmm no strong evidence in my office using these tools to help hundreds of patients ??? Who paid you to hold this stance against these clinical results??

            Modern medicine has accomplish some great feats of medicine fails at caring for a lot of illness. Because modern medicine is looking for a pill or machine to take advantage of the sick. Discounting the natural healing power we were born with. Greed … who is paying you?

          2. WilliamLawrenceUtridge says:

            What kind of doctor are you?

            Nobody pays us to hold these opinions. You bring up alleged conflict of interest because you are unable to deal with our substantive points and hope to distract from the real issue – the lack of scientific support for acupuncture. Also, by pretending we have conflicts of interest, you can rationalize discounting our opinions and not thinking about them. As in, instead of saying “Wow, I can’t reply to these points, I should rethink my clinical practices”, you say “Wow, I can’t reply to these points, so they must be bad people.” You are projecting your own failure to reconcile our criticisms onto an imagined motive you have no evidence for.

            Why do you think there is such a disconnect between your clinical impressions, and the scientific literature and randomized controlled trials, which consistently find that acupuncture is essentially ineffective for anything but pain and nausea, and only effective for those two symptoms over the short term?

          3. “no strong evidence in my office using these tools to help hundreds of patients”

            Actually what I said was “no strong effects”. In other words when you actually measure these things in a useful way the effect size is always small compared to the biases. This probably doesn’t happen in your office simply because you don’t measure anything in a useful way (well randomized, controlled, blinded, etc…)

            “Who paid you to hold this stance against these clinical results??”

            Your claims are simply unimpressive when looked at rationally.

  2. adenacb says:

    it worked for me. sorry.

    1. windriven says:

      When I was a child I had a wart on my left hand. My grandmother had me take a bite out of an apple, rub the apple on the wart and bury it. Some weeks later the wart was gone.

      If you think that implies that the apple ceremony cures warts you may not find this an hospitable environment.

    2. Tony Ingram says:

      No it didn’t.

      You got better anyway. Or slight placebo effect.

      Did you not read anything above?

      I like how people say things like “it worked for me. sorry.” and drop the mic and walk off the stage. As if it shatters everything else discussed here.

      1. Jo says:

        No, they leave because they know what works for them and what doesn’t. They don’t need some self-righteous prig telling them “they are wrong”. I love statements like this: “You got better anyway. Or slight placebo effect.” Yeah, real scientific there. Without knowing what the issue was, or what was performed, you know the score. Must be nice to have magic powers.

        1. weing says:

          No magical powers needed. Someone tells you that Santa gave them something. Tells you a lot about the person and what actually happened.

          1. Weing are you discounting that we are a miraculous force. NO magic. Take away the force and you are on the bottom side of grass. Gee … who has to care for a simple cut from a knife … no one(human) except the miraculous force.

          2. WilliamLawrenceUtridge says:

            We’re not a “miraculous force”, we are the usual “just enough” adapted product of evolution of every other animal and plant on the planet. There’s no miracle, just a whole bunch of make-do and biochemistry. Richard Dawkins once noted that humans, in fact all animals, are only apparently impressive from the very outside. Once you dig beneath the skin, you see the signs of our evolutionary history. The vagus nerve wanders, the appendix is prone to infection, the recurrent laryngeal nerve takes a torturous path around the chest before returning to the larynx, humans are prone to back aches and death in childbirth.

            No miracle, only just enough to keep us breeding, in aggregate.

        2. WilliamLawrenceUtridge says:

          You’re right, these comments aren’t scientific. Scientific are the investigations undertaken of acupuncture that consistently show it doesn’t matter where you put the needle or if you use a needle. Science shows that acupuncture doesn’t cure any specific diseases, just improves two symptoms, both of which are extremely susceptible to placebo. Science shows us that anecdotes are useless for determining causality. Science tells us that humans are excellent at confirming what they know and ignoring what they don’t.

          There’s no magic, merely critical thinking. If acupuncture actually worked, science would demonstrate this – as it did for chemotherapy, ulcers, vaccination and so forth. 3,000 studies, with no convergence on a coherent set of findings? As the title to the article says – acupuncture doesn’t work.

          1. “Scientific are the investigations undertaken of acupuncture that consistently show it doesn’t matter where you put the needle or if you use a needle.”
            To be scientific you have to have defined standards, controls, contestants … none in any studies related to Acupuncture. Again define Acupuncture? Remember there are a few types. Conclusion; worthless data and thus worthless results.

            “Science shows that acupuncture does not cure any specific diseases,”
            Gee where is the scientific evidence that medicine cure any specific disease?? (remember … medication actually help the human body fight disease and infection, thus they do not cure!)

            “Science shows us that anecdotes are useless for determining causality. Science tells us that humans are excellent at confirming what they know and ignoring what they don’t.”
            How would you define a surgeon exploring the belly of a kid who is having pain and finding nothing … just adenopathy. OR actually finding an inflamed appendix and removing it?
            So do all surgeon have to prove that removing an inflamed appendix was warranted?

            “There’s no magic, merely critical thinking.” Who proved that eating tree leave would not lead to a healthier life?

            “ If acupuncture actually worked, science would demonstrate this” How do you demonstrate that sleep is require for wellness or cholesterol medicine actually helps folks to live longer?

            “– as it did for chemotherapy, ulcers, vaccination and so forth. “”
            OMG, you think chemotherapy is curative?
            Ulcer used to be treated with vagotomy …. thousands and thousands … oop them we found out why freezing the stomach in the 60’s cured ulcers … a bacterial infection.

          2. WilliamLawrenceUtridge says:

            Yes, I do think that in aggregate, chemotherapy saves lives. Not everyone’s life, they are not a certainty.

            Also, you are distracting from the issue, as you often do. We are not discussing whether other types of medicine are perfect. We are discussing acupuncture and its consistent failure during scientific testing to be distinguished from placebo.

        3. @Tony how did we find out that people were allergic to PCN? WE killed a lot of them!

          It is not placebo when a patient has been treated by a few doctors without improvement and they leaves your office stating “I feel better already” Are they liars? or Are you the naysayer?

          1. weing says:

            They are trying to please you by saying that. That’s why it’s called placebo.

          2. WilliamLawrenceUtridge says:

            First of all, we aren’t discussing penicillin, we are discussing acupuncture and specifically its failure to demonstrate objective improvements upon scientific testing. Please stop changing the subject, whether penicillin works or not, whether people are allergic to it or not, has nothing to do with whether acupuncture works or not.

            Second, at best you could say yes, we should have tested penicillin for allergenicity before using it widely. Of course, as the first antibiotic, and the only effective treatment of bacterial infection, we had no real choice at the time, it was penicillin or nothing. Sidebar – does acupuncture cure infection? But anyway, that does speak to a valid point – interventions should be tested for risks and benefits before being used. Of course, acupuncture wasn’t, it’s used by millions throughout the world, despite lacking any evidence of efficacy.

            Third, there is no arguing that people can feel better after acupuncture. That’s what placebo means (and I bet there are people who also exhibit nocebo responses as well). I have no doubt people feel less pain, but that this sensation could be blocked with naloxone, which blocks endogenous opioid receptors (the biochemical part of the placebo effect). The real question is – does that patient return? Are they still pain-free? Must they keep returning for treatment? If the answers are Yes, No, Yes, then you’ve got a fair amount of evidence to suggest placebo.

    3. weing says:

      @Stephen,

      “Modern medicine has accomplish some great feats of medicine fails at caring for a lot of illness.”

      Give it time and research dollars and it will accomplish even more. Where did you get the idea that we have reached the end in medical research? We’ve only just begun.

      “Because modern medicine is looking for a pill or machine to take advantage of the sick.”

      WTF did you come up with that?

  3. Daevid says:

    Just quickly, is there any practical difference between acupuncture and dry needling?

    1. eva says:

      I ask the same question, not quite so quickly! I was “sent” by my physiotherapist for dry needling as an adjunct to exercises for shoulder muscle pain. I was told that the needles penetrate the “knots” and somehow realign the fibres. Is this true? I didn’t find it a very satisfactory explanation. I didn’t continue with it as I became convinced after a few times that even if it would work it would take many, many sessions. However, I am loathe to be too quick to judge some alt med as I have had 2 mysterious experiences.

      The first was when young I took someone to an osteopath who did iridology. Just for fun, I asked him to look into my eye to see what he could see. He told me I have a retroverted uterus. No big deal, but turned out to be true. I haven’t studied iridology so there may be some perfectly simple explanation.

      The other was years later after diagnosis with occupational overuse injury, I had a full body massage and the masseuse, without knowing anything about my medical history, ran her finger across the base of one of my big toes and said “Your neck and shoulders are shocking”. True, but no news to me. An interesting diagnostic technique though. I haven’t studied reflexology either so there may be some perfectly simple explanation. Weird though.

      However, I’m left wondering if there is something to be said for empirical evidence of efficacy built up over aeons.

      1. “However, I’m left wondering if there is something to be said for empirical evidence of efficacy built up over aeons.”

        Aeons of poor evidence is more likely to be wrong than right.

        In order to actually detect effects usefully medical science has had to come up with a sophisticated set of tools to come up with a useful expression of the probability that an observed effect is a true effect

        Much of this has come from math developed in the last 200 years. People without a number system, without a decimal number system, without probability theory, without parametric methods, t-statistics and without regression. Are working at such a profound disadvantage it’s not funny.

    2. WilliamLawrenceUtridge says:

      Depends on the type, but generally dry needling occurs at the site of pain and doesn’t involve any handwaving about magic, ancient wisdom or energy. I’ve also seen it referred to as puncturing a tendon repeatedly (not a muscle) in order to stimulate healing. Don’t know if it works.

      I think it’s supposed to involve a sold hypodermic needle too, but I could be wrong.

  4. windriven says:

    Wang et al did a pretty good job of defending acupuncture in their paper – if one is willing to ignore the absence of any scientific plausibility. They trot out a number of the old pro-acupuncture tropes but they also discuss, among other technological support (fMRI studies, etc.) a Duke University study published in the British Journal of Anaesthesia* that demonstrated (what appears to be modest) reduction in post-operative opioid consumption and a fairly significant reduction in opioid related side effects such as nausea and pruritus.

    Scientific purists won’t be swayed by Wang but pragmatists might. From a public policy perspective if, as Wang argues, acupuncture is a cost-effective adjunct to routine medical care that leads to patients’ perception of better well-being it is likely to find increased use.

    *http://www.ncbi.nlm.nih.gov/pubmed/18522936?dopt=Abstract

    1. calliarcale says:

      Well, that is basically why Mao supported it; it’s an inexpensive way to give patients the impression of better well-being, and when you’re a politician, impressions are what matter.

      1. windriven says:

        “[W]hen you’re a politician, impressions are what matter.”

        And unfortunately, it is politicians who set policy. That is why we have to be very careful to clearly disprove the efficacy of sCAMs in each and every particular. Otherwise, we are just another interest group trying to feather our own bed.

    2. Tony Ingram says:

      If it results in less opiate use, it’s only cost effective *IF* the cost of the acupuncture is less than the savings in opiates.

      Also factor in side-effects, I suppose.

  5. Booker says:

    The media should be interested in this piece, right? After all, they print every claim for acupuncture’s efficacy. A definitive statement that “acupuncture does not work” should create some buzz. I’m not holding my breath, but I hope this gets some attention.

    1. windriven says:

      It isn’t as straightforward as “acupuncture does not work.” A&A published a piece defending and a piece challenging acupuncture. Neither piece, at least in my opinion, scored a knock-out.

  6. dogmaphobe says:

    I was recently discussing Acupuncture with my Dad, who himself was both a GP and an Acupuncturist. I think of myself as a skeptic and my personal viewpoint is that there’s no evidence that it is effective, and I think I was doing OK explaining my position to him, and discussing the latest evidence in regards to acupuncture when he hit me this one:

    He said (and I’ve no reason to think he would make this up) that he has on numerous occasions been administering acupuncture for immediate pain relief – he gave a specific example of on my brother for tooth ache – whereby he would insert a needle and the pain would stop instantly, he would then remove the needle and the pain would start again immediately – and that he could continue to repeat this – the needle goes in and the pain stops, it comes out and the pain starts.

    At this point in the discussion I was a bit stumped – short of calling him a liar I had to accept that this would seem to show that there is certainly something happening. I’d be very interested to get some advice as to how best I could have countered his point.

    1. Newcoaster says:

      There would probably be the same effect if your father had pinched one of your brothers fingers in some pliers…the toothache would “go away”, and then return once the pliers were removed.

      In any case, his evidence is anecdotal. Even if repeated, each trial is still an N=1, lacking proper controls and blinding.

    2. BillyJoe says:

      Your dad is either a liar or he misremembered, probably a bit of both.
      You can still love him though.

  7. WilliamLawrenceUtridge says:

    @Daevid

    From my understanding, dry needling is essentially the practice of acupuncture, for purely musculoskeletal complaints, in the absence of any claims of energy, qi, meridians or points, done by physicians drawing up on the scientific evidence for what parts of acupuncture works. It’s the physiotherapists’ attempt to make acupuncture scientific. Solid needles are pushed into painful muscles or other areas of the body.

    Essentially, a group of doctors went “well this magic and ancient knowledge stuff is nonsense, but it does seem to help with pain; let’s drop the crap and just use needles”. It is perhaps merely placebo, like acupuncture itself, but a safer (because it’s not used around organs) and more rational, less corrosive approach (because it doesn’t invoke imaginary energies or nonexistent anatomical structures).

  8. Kudos to Novella and Colquhoun. Excellent, science-based article.

  9. @ dogmaphobe:
    I recently finished a book, “On Being Certain – Believing You’re Right Even When You’re Not,” which details a study on the pitfalls of memory. Students who watched the explosion of the space shuttle Challenger were asked to write down an account of their reaction to this event immediately after it happened. Years later, they re-read their accounts. Many students disputed their own observations, saying, “Yes that’s what I wrote, but that’s not what happened.”

    Memory is fallible and exquisitely subject to confirmation bias. Think of the “false memory” tragedy of the 80s, where people going for psychotherapy were convinced they had been sexually abused, even in Satanic rituals, by their parents or caregivers.

    Your brother probably was experiencing some placebo effect from being reassured by your dad. And your dad’s memory is exaggerating the effects of your brother’s reaction.

    Part of our pain response is our emotional reaction to that pain. I think of my experience with childbirth, where a gifted nurse consolled me, and though I was still suffering, I felt better, the pain slightly assuaged by relief from anxiety, knowing my baby and I were doing fine, everything was progressing normally, and we were not in any danger.

    If your dad was able to relieve dental pain by a placebo, you and your brother must love and respect him a lot. He sounds like a good dad.

  10. Newcoaster says:

    Great review article, Steve. It’s going up in the doctors lounge in my rural hospital. We have a few GP-acupuncturists on staff.

    I particularly enjoyed the section on PONV, as I had a vigorous email debate with one of the GP’s a few years ago about acupuncture and Therapeutic Touch…which he also believes in (sigh). One of the articles he sent me as “proof” that acupuncture has a biological basis were those same ones by Lee and Done. It was pretty clear he hadn’t actually read them, so I took the time, and pointed out the numerous flaws similar to the points you raised. I thought I did a great job of deconstructing the articles and debunking what he thought was rock solid evidence.

    Unfortunately, after that, what had started out as a polite discussion on the scientific evidence for acupuncture soon degenerated into ad hominems from him, and accusations of me of being “uncaring and angry”, and he hasn’t spoken to me since.

  11. WilliamLawrenceUtridge says:

    @dogmaphobe

    I had a longer post written up, but the website ate it. The guts of it was, pain is a symptom, not a disease. It’s extremely liable. There are myriad examples of pain disappearing in circumstances that indicate placebo effect (traumatic amputation, religious ceremonies, pills that are effective as soon as you swallow them) without clearing up the underlying condition. Placebo effects are enhanced by drama, exoticness, authority and form (injections are better than pills). Acupuncture is a dramatic, exotic, injection-based intervention, in the specific example you give, delivered by an authority figure (a doctor who was also the patient’s father). Acupuncture does “work” in that it makes pain (and only the pain, not the underlying condition) go away in certain circumstances. It’s not reliable, and it’s not curative. Acupuncture is also “effective” for one other symptom – nausea – which is also intensely subjective and liable to placebo. The very fact that the pain disappeared immediately is more an indication of placebo effect than effective intervention. Most interventions take time to be effective, placebos don’t. So yes, it can be said to “work” – due to placebo effects, not due to qi, meridians or other such hypothetical constructs. I bet many of your father’s patients feel better immediately after talking to him (I know I do when I talk to a doctor), but he still probably writes a prescription, schedules a test or conducts the surgery. And I’m betting your brother still went to the dentist and got novocaine.

    The debate really isn’t over whether acupuncture is an effective placebo (it is), or whether placebo effects can alleviate pain (they can), it’s whether it’s anything more than that, and more substantively, whether its pain-relieving effects are predictable, consistent and repeatable.

    1. dogmaphobe says:

      @WLU

      Thanks for the reply – that’s very helpful. I think I’d already managed to make a decent case against Acupuncture as having any curative effects (and to be fair to my Dad, also as to why the evidence might not have been so clear cut when he chose Acupuncture as a speciality during medical school), but it didn’t occur to me that this type of effect could be put down to Placebo response. I think the examples you give – “traumatic amputation, religious ceremonies, pills that are effective as soon as you swallow them” – as other mechanisms that can provide immediate pain relief are very instructive.

      1. WilliamLawrenceUtridge says:

        How do you choose acupuncture as a specialty in medical school? Perhaps get training in acupuncture, yes, but specialize in real medical school? Weird!

  12. Roz says:

    Interesting paper until the end, when they suggest we embrace as our role model one of the most corrupt, traitorous & incompetent emperors China ever had!

    1. Artoo45 says:

      Yeah, Mao was a bastard . . .

  13. Tudor Vi says:

    I have severe myopia (-11 and -8). I reached these levels from the age of 3 to the age of 6. At 5 and 6 I spent two summers doing acupuncture. The myopia stopped growing. I should have been blind by 9 or 10, yet I am still at -11 and -8 at age 27. There were no other treatments applied during those two years. So, while I agree that physical evidences may be lacking from a modern scientific perspective, I cannot ignore the living example that I am.

    1. DugganSC says:

      The problem, as noted before, is that there is no control group in this experiment. Yes, you had someone saying that, if the myopia progressed, you’d go blind. You had acupuncture sessions in those two years. Within those two years, hundreds of factors, ranging from choices you made to random environmental factors, could have resulted in the myopia halting. :) I’m glad to know that your vision ceased to get worse. We’re just saying that cases such as yours are outliers where the same acupuncturist probably applied that treatment to a few thousand other people with absolutely no effect. If the acupuncturist you were working with got consistent results, well, it’s like the old joke about how if psychics were real, we’d never hear about them because they’d buy a winning lotto ticket and then disappear.

    2. windriven says:

      Myopia just means nearsighted. It is self limiting.

      1. Jo says:

        Lol. Another psychic. I love it! You can diagnose and give a prognosis over the internet. Amazing!

  14. Jesse says:

    Worst response ever. People use “it worked for me” all of the time. Praying to Jesus cured my cancer, magnets fixed my back, homepathy cured my headache are all examples where people use “it worked for me”. Can you honestly state that your ailment would not have gone away natually or that a placebo effect did not happen?

  15. What is the difference, according to its proponents, between “acupuncture” on one hand, and “sticking needles in people” on the other?

    It is in that difference, if there is any, that acupuncture is a reality or a fiction.

  16. Kov says:

    “Conflicts of Interest: Professor Novella has no financial conflicts of interest. Professor Novella maintains the “Neurologica blog”, described as “your daily fix of neuroscience, skepticism, and critical thinking.” The Neurologica blog occasionally addresses the lack of scientific evidence for alternative medicine.”

    Steve, I’m a frequent reader and a fan of the SGU., and this strikes me as…hmm…I think “disingenuous” is maybe too non-charitable a word, but I guess it’s odd that Neurologica is mentioned (and that it “occasionally addresses the lack of scientific evidence for alternative medicine.”), but not SBM or the SGU, the raison d’etre of each being to pretty much eviscerate alt med with its own acupuncture needles. It’s not that I have an issue with alt med being taken to task for its evidentiary shortcomings, and I’m not sure to what extent your other media presences comprise a conflict of interest, but it strikes me as odd that these would be left out. I worry when I notice this kind of thing, because I know if someone came to me with a study claiming to support acupuncture or whatever, and I noticed what seemed to be a lack of transparency on the part of one of the authors, I would raise that as a red flag as to the credibility of the author. I think it does a potential disservice to the skeptical viewpoint when “we” appear less than forthcoming.

    Hopefully that didn’t come across as too lambasting; just wonder if you have any thoughts on that, or context or perspective you could offer.

    Cheers.

  17. Kov – I did not write that statement. I don’t know why they chose to include NeuroLogica and not SBM or SGU. I certainly would not have done that.

    The fact is – I have no financial conflict of interest. I have no research or grants on the line. My livelihood is in no way tied to acupuncture. Mention of NeuroLogica was not required, and I guess was added for context.

    I also think mentioning multiple outlets is redundant. The fact is – I write critical articles about acupuncture. Does it really matter how many outlets they are spread across? I don’t think so.

  18. Andrey Pavlov says:

    I’ve had acupuncture as a kid to remove a piece of glass that was embedded in my foot. I was absolutely amazed at how well it worked to completely block the pain. It was during my martial arts class that I got glass stuck in my foot and then the headmaster came and did the acupuncture. It was definitely a pretty theatrical production. Later in life I got acupuncture for my chronic joint pain (prior to my diagnosis of Ehlers-Danlos which is a minor variant, but enough to cause some hyperlaxity in my joints and leading to pain) and it worked amazingly. I felt downright euphoria. Of course, I believed in it, it was done by an MD, and there was electricity coursing through the needles. I stopped doing it when the effect wore off after 3-4 sessions. Funny how that is – a placebo effect wears off when the novelty of my interest in it wanes and making appointments and paying for them predominate the effect I experienced.

    I’m waiting for Peter Moran to come around and demonstrate us all wrong with his effect sizes of 0.5+ and the myriad studies Dr. Novella and Dr. Colquhoun forgot to include which demonstrate this.

  19. MAC says:

    It seems to me the growth in SCAM providers and treatments is related to shorter visit times with PCPs. I hear regular complaints from patients that their PCPs don’t listen, they are scuttled in and out, only one issue is addressed etc. This is a systemic problem due to the physician reimbursement process (read insurance companies, capitation etc). Instead of insurance companies covering acupuncture, as many folks have worried about here, they should reimburse PCPs at a higher rate. This way, PCPs will have more time with each patient, i.e. more time to hand hold and “kiss the boo boos better.”

  20. Ian says:

    If you set this up as an east vs west with acupuncture being from the east I would choose acupuncture first for pain management. The risks and side effects of so called western medicine is only worth it of all else fails. Western pain management is really just a mask. So unless we are talking surgery I will avoid pills and chemical solution as much as possible. My HMO md has ineffective solutions for my shoulder and neck problems but my chiropractor and acupuncturist offer real and lasting relief.

    1. Newcoaster says:

      East vs West is a false dichotomy. The distinction should be between that which is safe, proven and effective and that which is not. Any medication or treatment that works…that is, has an effect, may also have side effects. A significant part of the patient encounter is counselling about possible side effects of recommended treatments. I have never heard of acupuncturists, or any SCAMsters giving informed consent , or explaining possible side effects. For the most part, that is because there are no effects, either.

      The overwhelming evidence in properly controlled trials is that acupuncture does nothing at all, or that its effects are clinically insignificant and only “effective” for subjective symptoms such as pain or nausea, not for the treatment of any actual disease process. You really should re-read Dr Novellas article, and the many many other articles on acupuncture on this site.

      Even if acupuncture worked..it doesn’t…then wouldn’t it really just be “a mask” as well? Pain is a symptom. Patients seek relief from symptoms. If you keep going back to your acupuncurist and chiropractor…as most people do, then I am not sure what you mean by “real and lasting relief”.

      1. Ian says:

        I can not address every study cited in this article but there are numerous studies that counter this one. I suspect it is a case of finding what you are looking for. Or, perhaps introducing a cultural bias of some sort. The Mail UK phrased it well: “In order to determine whether acupuncture is an effective treatment, trials have to be conducted under certain strict clinical conditions. However, acupuncture is far more difficult to test in this way than, say, drugs.
        One of the reasons for this is that it is hard for scientists to find a suitable placebo – a test treatment which has no effect but may help to relieve a condition because a patient has faith in it. Dr Mike Cummings of the British Medical Acupuncture Association points out that unlike drug trials, where patients are given a false tablet, it is more difficult to administer a false needle.
        ‘Placebo needles often do not penetrate the skin and it’s hard to get them to stay in place without the patient realising that the needle is not actually being inserted into their body,’ he says.
        ‘Another problem is that scientists often do not understand how acupuncture works and tend to make inadequate comparisons.’
        But to your basic question, no it would not be a mask such as an opiate would be. Real and lasting relief: pain is gone no more treatment needed. (return visits are for new conditions: I practice martial arts and injuries happen)
        Can acupuncture be proved to work? For me yes. No side effects, no withdrawal, inexpensive, relatively quick. Is it all in my mind? Maybe, but so what. The power of the mind is much more of a worthwhile investigation than feeding people pills that don’t really work either. Although opium is a lot of fun….

        1. Andrey Pavlov says:

          You are still completely missing the point Ian. Firstly, a very, very good sham acupuncture method has been developed. Read through the posts on this site about it. So your first point is completely moot.

          Second, the entire point of this article is exactly that any individual study can demonstrate anything you want it to. That is why met analysis is a powerful tool – it evens out the variance in individual studies. You cannot counter a meta analysis with a handful of studies. In fact, that would be “finding what you are looking for” as you yourself say. Please try and realize the irony of you claiming that a meta-analysis of thousands of studies is “finding what you are looking for” while simultaneously claiming “there are numerous studies that counter this one.”

          Furthermore, any treatment of pain is, by definition, a mask. Unless you are now wishing to claim that acupuncture treats the cause of the pain rather than the symptom of pain itself, which is not claimed by anyone except the farthest reaches of quacks. All the studies you have discuss treating the symptom of pain which is, indeed, a mask entirely the same as an opiate. However one blocks the neural impulses from pain the mechanism and end result are the same. And indeed, the strongest argument for acupuncture is that it activates endogenous opioid production. But of course, so does any placebo.

          Lastly, “scientists often do not understand how acupuncture works” – sorry Ian, nobody “understands how acupuncture works.” Look at the literature – there are as many purported mechanisms of action as there are practitioners, ranging from “unblocking chi” to “endogenous opioid production” to “counter irritant” effects to “distraction.” The only commonality between them all is the placebo response and placebo effects (yes, they are different things).

          It is completely naive to think that something that has an effect cannot have a side effect. Even the placebo effect has a “side effect” – the nocebo. And inexpensive is a highly relative term. Personally I find the 5 cents per pill of hydrocodone to be much less expensive than an acupuncture treatment. Admitting that it may be all in your mind and you don’t care if that is the case is the last cop-out. The authors here – and myself as well – are exactly making the point that it is only in your head… with a helping of study artifact and bias to help boost what we think is the effect.

          1. Ian says:

            It is clear from your post that you actually no nothing of acupuncture, how it works (or claims too) or how it is applied. You have only read claims of how some have theorized how they think it works. Perhaps I am wrong and you have experienced it yourself or have interviewed a qualified practitioner. I find your thinking a little unnerving quite frankly. First that you say treatment of pain by definition is just masking the symptoms. Are we parsing words and saying treating inflammation causing pain is treating the inflammation and not the pain? Chicken and the egg? Second to suggest the met analysis is fail safe and that it invalidates any other study to the contrary is false.
            I will summarize based solely on personal experience: My wife and three year old daughter accompanied me to an acupuncturist for a treatment of ‘tennis elbow’. After my treatment the Dr. noticed my daughter had fever and asked if we minded if she could quickly examine and possibly treat her. We said yes. As I held my daughter the Dr. placed a few needles and I felt her body temperature drop. In a few moments her temp. went from 102 to 98 (ish). Obviously the story is condensed for illustration purposes and is not scientific. However, my story is not unique, the study you defend here is not the final word.
            There is clearly more to the story of acupuncture that has yet to be addressed.

    2. It’s quite true that analgesic drugs are quite often ineffective. That does not mean that acupuncture or chiropractic work, It just means, sadly, that chronic pain is one of the many problems for which there are not yet good treatments. See, for example, http://www.dcscience.net/?p=6083#030613

      1. calliarcale says:

        One of the big problems I find with analgesic drugs is that when I’m in a lot of pain, particularly if it’s a headache, I become quite nauseated. Most drugs are acidic, and analgesics are notorious for irritating the stomach, so put those things together, and when I’m in pain it is quite common for the pills to do nothing because they end up in the toilet in short order anyway. I have half a mind to start looking for them in suppository form, because at least then they might accomplish something useful before getting ejected….

  21. pmoran says:

    ISteve says—

    If, indeed, sham acupuncture is no different from real acupuncture, the apparent improvement that may be seen after acupuncture is merely a placebo effect. Furthermore, it shows that the idea of meridians is purely imaginary. All that remains to be discussed is whether or not the placebo effect is big enough to be useful, and whether it is ethical to prescribe placebos.

    Some meta-analyses have found that there may be a small difference between sham and real acupuncture. Madsen et al.12 looked at 13 trials with 3025 patients, in which acupuncture was used to treat a variety of painful conditions. There was a small difference between “real” and sham acupuncture (it did not matter which sort of sham was used), and a somewhat bigger difference between the acupuncture group and the no-acupuncture group. The crucial result was that even this bigger difference corresponded to only a 10-point improvement on a 100-point pain scale. A consensus report13 concluded that a change of this sort should be described as a “minimal” change or “little change.” It is not big enough for the patient to notice much effect.

    ———-

    From the intellectual point of view, it would be interesting to know whether the small difference between real and sham acupuncture found in some recent studies is a genuine effect of acupuncture or whether it is a result of the fact that the practitioners are never blinded, or of publication bias. However, that knowledge is irrelevant for patients. All that matters for them is whether or not they get a useful degree of relief. It seems that they do not.
    —————————————————————————————————-
    I say —

    Steve, re-think this. Sham vs real” comparisons are deliberate attempts to cancel out all non-specific influences including placebo between the two groups. They tell us nothing about the overall impact of the “acupuncture variants” versus “no acupuncture” yet that is what you are going on to claim.

    All such comparisons show is that certain aspects of ancient Chinese medical theory are likely to be invalid. We did not need studies to suspect that.

    Look, the reason I am asking for a re-examination of customary lines of thought on these matters is that it is almost certain that head-to-head comparisons of weakly active pharmaceuticals against elaborate programs of psycho-socio-sensory interventions like acupuncture in some populations will not reflect overwhelmingly favourably on the former. especially when side effects are also taken into consideration.

    Studies like this

    http://www.bmj.com/content/329/7478/1317.abstract?ijkey=221648facec2262caf301dc57002822a0ddc9c7b&keytype2=tf_ipsecsha

    make such study outcomes likely even with the NSAIDs recently “strongly recommended” by the AAOS for osteoarthritis. Indeed, if you apply an equally strict “null hypothesis” approach to NSAIDs for that condition, and take into account the possibility of Ionnadis-type bandwagon effects and the influence of drug company bias on study outcomes, how sure are we that they are much more than a credible placebo for some common uses?

    As I have said, there are many reasons why the mainstream might choose not to endorse acupuncture for routine patient care. Certainty that they do not “work” for anyone and in any sense is not one of them. Medicine is complicated and I did not make it so.

    1. pmoran says:

      Sorry, I am in error, in that Steve did refer to the “somewhat bigger difference between the acupuncture group and the no-acupuncture group” in the middle paragraph but I missed that sentence.

      He argues that even those benefits are small enough to be disregarded, although I suspect the same effect would be considered adequate for pharmaceutical use.

      This stance has other weaknesses. It is a rather arbitrary way of disposing of a source of potential patient benefit. NSAIDs may not be that much better while having higher potential for ill-effects. There is no allowance for the fact that the kind of influences that are involved (non-specific, placebo, ongoing practitioner support, relaxation, distraction) may be more dependent upon individual patient characteristics than are pharmaceuticals.

      As I say, we may choose not to employ acupuncture ourselves, and one of the reasons for that is uncertainty as to its true effectiveness, or the consistency thereof, as WLU says.

      We may merely not be ethically justified in bad-mouthing it to the extent that we do on present evidence. “Acupuncture does not work” is saying a lot more than the science actually permits.

      1. Andrey Pavlov says:

        Interesting reflex response pmoran. It is, to me at least, telling that you wrote your response, copy-pasting large quotes from the article, and yet missed something that is repeated a few times throughout the piece. Of course, you do have the intellectual honesty to admit it and I would expect no less.

        However, you seem to continue to berate us for not sticking diligently enough to the science, yet you continually stick to a purely frequentist interpretation and hide steadfastly in the protective shadow of the p-value when the whole point of this blog is to consider a Bayesian framework.

        And now you are further grasping tenuously at straws by invoking what you suppose might be the true effect sizes of NSAIDs as a justification for the utility of acupuncture. Quite disingenuous, I think, to say that by your specific interpretation of what science can say we can’t say “acupuncture doesn’t work” and then simultaneously justify that by conjecturing something science hasn’t had a chance to say. At least the Bayesian prior for an NSAID is vastly larger than that of acupuncture which is something you conveniently ignore.

      2. Andrey Pavlov says:

        Wow, I even gave you the benefit of the doubt but I am in error as well. An error that makes yours even more glaring – you actually quoted the part of the article you didn’t know existed in your initial response.

        Tell me Peter – how is it that you can formulate a response based on a quotation you yourself selected to respond to and completely miss the key sentence within that same quote? To the point where it necessitated an apology and clarification? It is clear you didn’t even read the article, you merely skimmed it and proceeded to respond with whatever your predetermined conclusion about acupuncture was.

      3. windriven says:

        Peter, I share your concern that the case against acupuncture may be overstated here.

        Acupuncture is devilishly difficult to blind and therefore difficult to study. But results like those referenced by Wang regarding post-op reductions in opioid consumption and opioid related side effects (presuming they are replicated) suggest that something is going on. It may be – and probably is – nothing more than placebo. But from a public policy standpoint, who cares? If drawing sunflowers around the navels of post-op patients (low cost and low risk) improves their sense of well-being, lowers their perception of pain and reduces their consumption of anti-emetics, I for one am good to go.

  22. Booker says:

    It is remarkable that people are still trying to defend acupuncture, even stating that it might be useful as a placebo, in light of the lack of evidence of efficacy. They seem to be saying “don’t count acupuncture out yet, because there is still a slight chance that it may have a barely measurable positive effect”. Why is acupuncture being given such a benefit of the doubt? I like that Steve’s paper states simply that “it doesn’t work”. That’s a reasonable conclusion, and its the same conclusion that would be applied to any pharmaceutical medication or surgical procedure. The double-standard being applied here is stunning.

  23. WilliamLawrenceUtridge says:

    Ian, if you still have a chiropractor and acupuncturist, that suggests you’re still seeing them, in turn suggesting the “real and lasting relief” has obvious limits.

    Also note that there is no such thing as “Western” pain management. There is pharmacological, surgical, cognitive and placebo pain management, but none of these forms start or stop working upon passing a particular line of longitude. Acupuncture is quite popular in Europe and the Americas, though the practice of it differs (acupuncturists in China see many more patients per hour and day, for much shorter periods of time, compared to American acupuncturists; they also use it for more neurological conditions, compared to musculoskeletal conditions in Germany, the UK, Australia and the US, PMID 15253864). Morphine works in China and on people whose ancestors come from China just as well as in humans in and from other parts of the world. That’s why it’s superior to acupuncture.

    1. Ian says:

      New injuries do occur that is why the return. Get it? If my leg snaps in half, give me morphine. If my knee is swollen give me acupuncture.

      1. GShelley says:

        Yes, you could be a rare example of someone for whom Acupuncture has an actual physical effect. No clinical trial will show something doesn’t work, just that if it does, the effect was too small to differentiate it from no effect given the sample size. However, we can say that there have been sufficient trials that we can be confident for the vast majority of people, there is no acupuncture effect, even for those that think there is. We can also say that the traditional explanations, such as chi and ancient eastern ideas of how the body, disease and the universe works are false and that the effect is so small that it could not have been detected by the people who developed acupuncture and it was developed because of placebo effect and other mistaken beliefs about its efficacy.

  24. I completely disagree with the notion that “who cares if it works by placebo, as long as patients feel better. The point of science-based medicine is to find what actually works, and to separate specific from non-specific effects. If acupuncture does not work, then further investment in it is counterproductive. Convincing patients that acupuncture works because the ritual surrounding acupuncture has a non-specific placebo effect does harm and is a disservice to the patient and to society. It results in resources wasted on needless research, and it leads to a parasitic and harmful system of using acupuncture for things other than placebo pain treatment.

    Saying that acupuncture does not work is absolutely justified, as I painstakingly pointed out in my introduction – after more than 3,000 trials researchers still cannot reject the null hypothesis. Effect sizes range from indistinguishable from zero, to so small that it does not rise above the noise level in clinical research (and there are good reasons to conclude that the noise level is higher than average in acupuncture research).

    Enough is enough.

    1. windriven says:

      Dr. Novella said:

      “The acupuncture and no-acupuncture groups were, of course, neither blind to the patients nor blind to the practitioner giving the treatment”

      “We see no point in discussing surrogate outcomes,”

      As difficult as it is to subject acupuncture to traditional, well-blinded RCTs, it seems to me that surrogate outcomes will have to be part of any balanced evaluation of acupuncture. The validity of fMRI or endorphin release studies may well be moot until a more-or-less direct relationship between those studies and patient well-being is demonstrated.

      But the Duke study that I keep harping about (and yes, this is a single study and needs to be replicated) seems to show that acupuncture as an adjunct to conventional pain management reduces opioid consumption and the consumption of drugs used to manage opioid side-effects.

      If these results are repeatable then this is not a simple case of subjectively feeling better. Opiates are powerful drugs with powerful side effects and very real dangers. If acupuncture demonstrably reduces consumption of those drugs, understanding the precise mechanism of action is an important but still secondary concern.

      That does not suggest that acupuncture should be accepted broadly. As you noted in your article:

      “Acupuncture should, ideally, be tested separately for effectiveness for each individual condition for which it has been proposed…”

      Adjunctive perioperative acupuncture should be fairly easy to evaluate along the lines of the Duke study. Again, from a public policy standpoint, that a modality works is more important than why a modality works.

      1. MadisonMD says:

        Windriven:
        Use of opiates is, like many endpoints, a flawed one. I could reduce opiate use in patients by any of the following:
        (a) Not prescribing, or prescribing fewer tablets
        (b) change the sig. to every 8 hours instead of 4 hours, telling the patient it lasts longer than it does pharmacologically
        (c) adding other non-opiate effective analgesics
        (d) precribing an ineffective analgesic or placibo pill to be used in to be taken every other time s/he has pain
        (e) spend extra time warning a patient the dangers and addictive power of opiates
        So, if reducing opiate use is a valid end in itself, which of the above is justified?

        You also state that if rubbing a sunflower around a navel reduces pain, you would use it. I have two questions about this sentiment. Is it ethical to tell your patient that this maneuver relieves pain when in fact you know it is placebo? Is it useful for humanity to spend research dollars on thousands of studies trying to investigate the effectiveness and potential mechanisms of rubbing sunflowers against navels?

        MadisonMD

        1. windriven says:

          Thank you for your thoughtful and thought-provoking response. I should make clear that I am a physicist, not a physician. My interest is in public policy surrounding health care.

          I would propose a trial with both the experimental and reference groups on PCA pumps programmed following a uniform protocol. Basal dose plus self administered dosages plus anti-emetic consumption would be compared. The trial would not be blinded and great care would need to be taken in phrasing the disclosure for informed consent to avoid poisoning the well. Perhaps the reference group would receive a bogus adjunct to ‘balance the equation’ if you will. I do not pretend to be an expert in the design of clinical trials. But it seems that a protocol along these lines could yield meaningful results.

          My thinking on the ethics of placebos has changed over the years. One of the important end points of any therapy is patient ‘satisfaction.’ Medicine cannot cure all ills and sometimes patients have to accept that palliation is as good as it gets. If a patient believes that a therapy that is inexpensive to administer and that does not carry substantial risk in its deployment makes him more comfortable, I question the ethics of withholding that therapy even if the mode of action is purely placebo.

          But I hasten to add that I see this in a very limited way and only as an adjunct to conventional medical care.

        2. windriven says:

          “Is it ethical to tell your patient that this maneuver relieves pain when in fact you know it is placebo?”

          No. But in response to a patient request I would argue that it is ethical to state that the preponderance of evidence shows no therapeutic benefit beyond placebo yet some patients claim subjective benefit.

          1. MadisonMD says:

            I partially agree. I have no issue with patients seeking out placebo treatments that lack physical harm. But I feel obligated to be completely honest and tell them it is placebo. I gather this is what Dr. Novella is saying in this blog post.

            Research is the second issue that arises. As scientists, if what we are trying to accomplish is to study and apply the placebo effect in a completely honest, ethical, and aboveboard manner, I think it would be most parsimonious to start from scratch rather than start with acupunture/TCM. After all, we already know there is no need for needle placement, or skin penetration. If equally effective, wouldn’t it be better to use a $.01 sugar pill rather than require the patient to spend an hour or two traveling to and seeing an acupuncturist and pay, what $80 per visit ? I wonder if the public would support such research into ‘optimizing placebo’ if we honestly tell them this is what it’s about. I wonder if the patients would participate if the consent form for the study actually tells the truth–that the intervention is a placebo.

            I think your proposed clinical trial is not a worthwhile endeavor. I would grant you that if you give a patient any non-opiate placebo, s/he will use fewer opiates… at least for a little while. After all s/he trusts your advice and has the expectation that the placebo you provide will work. S/he will hold off on opiates to give your other intervention a chance. But in this case, would you not expect your patient to ultimately experience more pain? And wasn’t the real goal of the opiates to actually alleviate suffering?

            Finally, you say you are more open to placebo because the goal is patient satisfaction. The goal of medicine is not patient satisfaction. The goal is to optimize the health, alleviate suffering and to provide honest medical advice. I could improve a patient’s satisfaction by not telling him/her to quit smoking, avoid fast food, avoid alcohol. I could improve a patient’s satisfaction by lying about his/her disease state (“this cancer won’t kill you.”). I could tell her that wishful thinking, vitamins, and a changed diet would cure what ails her. Patient satisfaction would be high, but then I would be a charlatan, not a physician.

        3. windriven says:

          “Research is the second issue that arises”

          I am suggesting that acupuncture be put to the test as a specific therapy or adjunct therapy for very specific conditions. If we are to run quackery out of medicine we will have to do it methodically, leaving no wiggle room.

          Using the notion so acupuncture as an adjunct to conventional post-op pain management as the example, it should be easy enough to demonstrate whether acupuncture is simply placebo or something more in that specific situation. In the unlikely circumstance that a real effect is suggested, that points to a specific area for further research.

          My overarching point here is that acupuncture (or its more troubling cousins) will not be driven from medicine by us calling it quackery. Those efforts have flatly failed as evidenced by the appearance of ‘integrative’ medical programs at the nation’s premier medical schools and medical centers.

          “I think your proposed clinical trial is not a worthwhile endeavor. I would grant you that if you give a patient any non-opiate placebo, s/he will use fewer opiates…”

          Clearly, I have done a poor job of describing the proposed trial. The idea was to simply measure consumption of opiate by patients who are (within limits) controlling their own consumption with PCA pumps. While not a physician, I have considerable experience with PCA from its earliest days and am frankly resistant to the notion that a physician’s suggestion or an ineffective placebo are going to have a meaningful effect on how many times the button gets pushed.

          Returning to the issue of placebos, I am not suggesting that patient satisfaction is the only – or even primary – goal of medical care. As you point out, a patient may be satisfied not having you advise him to quit smoking. But patient satisfaction is nonetheless an important goal if you don’t want the patient wandering off into the weeds of homeopathy and ear-candling and whatnot.

          If placebo is a useful adjunct to pain management, fine. Whether a patient experiences less pain – or just believes he feels less pain – is immaterial except in cases where the illusion of pain relief results in reluctant mobility, shallow breathing, etc.

          That is not to argue that the same ethics apply to the use of placebo as a therapy for heart disease or cancer.

          1. MadisonMD says:

            “I am suggesting that acupuncture be put to the test as a specific therapy or adjunct therapy for very specific conditions. If we are to run quackery out of medicine we will have to do it methodically, leaving no wiggle room.”

            It is not possible to prove a negative. No number of studies will ‘prove’ acupunture is useless. True believers will not be dissuaded by any evidence. Nor will it be driven by negative clinical trials. After thousands of studies, acupuncture is actually one demonstrable field where this is true.

            Moreover, if acupuncture were to be scientifically investigated, clinical studies are the worst way to start. These are powered to use the minimal number of subjects to detect a statistical difference. Thus 1/20 can be expected to be wrong by statistical chance. When this is exacerbated by researcher degrees of freedom and publication bias (covered in this blog), you end up with a number of false positive studies. We start practicing medicine that does not improve health or treat a symptoms (Note; this issue is not limited to alt med). This is why SBM requires prior plausibility. Thus, the lack of demonstrable meridians and qi should be enough to reject acupuncture. Scientific review panels should reject human studies based on this alone. It is crazy that thousands of studies have been done already, when the effort could have been invested in true treatments of deadly diseases– heart disease and cancer as you mention.

            If what we are doing here is studying the placebo effect, this is potentially of scientific and medical value, but then we need to be honest with ourselves, our patients, and funding sources that this is what we are doing. Acupuncture-placebo is probably not the best way to start.

            “But patient satisfaction is nonetheless an important goal if you don’t want the patient wandering off into the weeds of homeopathy and ear-candling and whatnot.”

            Most patients already reject these and acupuncture alike. Recommending acupuncture, I would promote magical thinking not critical thought. I am not yet cynical enough to recommend magical thinking of one sort to prevent a fraction of patients seek out another sort (even if this does work). In fact, I carefully try to inculcate the value of critical thinking into my patients by telling them not only what I recommend, but what the evidence is that the intervention is worthwhile. I even allow them to reject it when their values rationally lead them to conclude taht the risk does not warrant the potential benefit.

            You are a physicist. What would your opinion be if the NSF spent 10% of its budget researching N-rays, cold fusion, and the flight dynamics of Santa’s sleigh? If the research was done, should it be limited to showing the effect of these on living matter with multiple endpoints and the minimal number of replicates to have a false positive rate of 5%? This is what we continue to do with acupuncture.

          2. windriven says:

            “Most patients already reject these and acupuncture alike”

            Dr. Madison, if I believed that, we’d be sharing a bottle of a fine Barolo instead of debating this issue.

            “The report from a Consensus Development Conference on Acupuncture held at the National Institutes of Health (NIH) in 1997 stated that acupuncture is being “widely” practiced—by thousands of physicians, dentists, acupuncturists, and other practitioners—for relief or prevention of pain and for various other health conditions. According to the 2007 National Health Interview Survey, which included a comprehensive survey of CAM use by Americans, an estimated 3.1 million U.S. adults and 150,000 children had used acupuncture in the previous year. Between the 2002 and 2007 NHIS, acupuncture use among adults increased by approximately 1 million people.”

            You are perfectly correct in saying that it is difficult to prove that, say, acupuncture doesn’t work. Yet we have acupuncture – and even more egregious sCAMs – being taught at first rank medical schools and practiced at first rank hospitals.

            We seem to be losing this battle. How then to turn the tide?

            *http://nccam.nih.gov/health/acupuncture/introduction.htm

          3. MadisonMD says:

            Says I: “Most patients already reject these and acupuncture alike”

            Says you: “Dr. Madison, if I believed that, we’d be sharing a bottle of a fine Barolo instead of debating this issue.”

            Lets drink. You make my case. Since the population of the U.S. is 315 million and, as you point out, 3.1 million use acupuncture only 1% use it. I stand by my assertion. Perhaps you would like to visit Madison where I reside.

            Says you: “We seem to be losing this battle. How then to turn the tide?

            Magical thinking is natural human behavior. When this popular delusion blows over, the next will blow in. We cannot really change human nature or eliminate magical thinking. However, I would suggest that we don’t help by promoting irrational belief. The best we can do is be totally honest with ourselves, patients and colleagues and promote critical thinking. And, we can invest solely in plausible science to supplant ‘grasping at straws’ with more effectual medicine.

          4. windriven says:

            Agreed! If I find myself headed to Madison I’ll bring a bottle of a 98 that I’m particularly fond of.

    2. Ray Zich says:

      You should seriously have ‘Like’ buttons for the comments.

  25. WilliamLawrenceUtridge says:

    Honestly, I have little problem with acupuncture under the following conditions:
    - needles inserted superficially into areas with thick muscle layers
    - sterile needles, sterile skin
    - training consists of “avoid the organs, keep it clean” with no magic
    - cheap, less than $10 per session
    - pain and nausea only
    - treat it as one option among many, not a magical cure-all
    - explain to patients that it’s unclear if it has a specific effect, or if it works purely through cognitive means (definitely don’t use the word “qi” in your discussion)
    - stop it if it doesn’t work
    - don’t bundle it with all the nonsense that usually accompanies SCAMs
    - only use it after a proper differential diagnosis, to be sure the pain isn’t caused by something serious
    - more if I think of more

    If this was how acupuncture was practiced, I wonder – would it become more popular? Less popular? Would it be like pain pills, used everywhere but not on everyone? Would it disappear? Would the placebo effect weaken to the point of disappearance? Would the very familiarity breed contempt? Would the lack of exoticness and drama undermine the effects?

    Sadly, that’s not how acupuncture is practiced, it’s still “energy, ancient wisdom, East vs. West” and all-too-often, “Big Pharma wants to kill you”.

    Hah, what a stupid idea. If you’re dead, they can’t sell you any drugs!

    1. NotTheEnemy says:

      “Honestly, I have little problem with acupuncture under the following conditions:
      - needles inserted superficially into areas with thick muscle layers
      - sterile needles, sterile skin
      - training consists of “avoid the organs, keep it clean” with no magic
      - cheap, less than $10 per session
      - pain and nausea only
      - treat it as one option among many, not a magical cure-all
      - explain to patients that it’s unclear if it has a specific effect, or if it works purely through cognitive means (definitely don’t use the word “qi” in your discussion)
      - stop it if it doesn’t work
      - don’t bundle it with all the nonsense that usually accompanies SCAMs
      - only use it after a proper differential diagnosis, to be sure the pain isn’t caused by something serious- more if I think of more”

      I for one can’t imagine that you have ever had an acupuncture treatment because nearly everything you listed is already mainstream protocol upon visiting your acupuncturist.

      How can one even begin making value judgements on the efficacy of a modality if they have never experienced it in the first place? Sounds like bad science to me.

      “Definitely don’t use the word “qi” in your discussion”

      -Why can’t I use the word Qi?
      -Why can’t I talk about meridians?

      Is there literally a thick red line that says “THE EQUATOR” that separates Columbia from Ecuador?. Isn’t The Equator just a useful concept to demonstrate that the earth CAN be separated into two unique halves?

      Isn’t the existence of meridians, like The Equator, just the compilation of USEFUL symbols, concepts, metaphors, and tools that a physician may use?

      Why are we so stuck in this reductionist viewpoint that OUR view is the only way?

      How can you be so sure that “placebo” treatments cannot cure underlying disease?

      I for one believe that acupuncture is just on the cusp of psychosomatic research and by not addressing its or “placebos” importance in the healthcare field we are throwing the baby out with the bathwater.

      I look forward to working with you in Hospitals over the next couple of years,

      Sincerely,

      The Acupuncturist

      1. MadisonMD says:

        The Acupuncturist says:
        “Is there literally a thick red line that says “THE EQUATOR” that separates Columbia from Ecuador?. Isn’t The Equator just a useful concept to demonstrate that the earth CAN be separated into two unique halves?”

        I would not propose to unblock human peace and freedom by sticking needles in the equator. I now hear you saying that meridians are not physical entities through which qi flows. Do you have a plausible mechanism by which acupuncture works?

        “I for one believe that acupuncture is just on the cusp of psychosomatic research and by not addressing its or “placebos” importance in the healthcare field we are throwing the baby out with the bathwater.”

        Ah, if we agree that the mechanism of acupuncture is the placebo effect, then we can incorporate this within scientific framework. This is, in fact, a very plausible mechanism for the effect of acupuncture. It could be investigated scientifically and rationally. However, would not ethics require us to be honest that this is what we are doing?

        1. NotTheEnemy says:

          MadisonMD,

          “I would not propose to unblock human peace and freedom by sticking needles in the equator. I now hear you saying that meridians are not physical entities through which qi flows. Do you have a plausible mechanism by which acupuncture works?”

          I would also not propose sticking needles in the ground to unblock peace or freedom, but I would suggest sticking a metal pole in the ground to attract lightning.

          Acupuncture theory is an art and a systems science. Its systems approach of looking at the whole body as “energy’ patterns is its biggest advantage and disadvantage concurrently. In talking about concepts like meridians, qi, heat, cold, you run the risk of over generalizing and diagnostically losing specificity of the problem. However, under generalizing as has been the mechanistic view of western medicine these last few centuries can lead to a rather myopic, and unnatural view of nature. I’m not arguing that one is better than the other, but rather that they are both unique systems of thinking with advantages and disadvantages. Shrugging off two millenia of observations because they didn’t teach this stuff in the dogma of medical school is ignorant at best.

          “Ah, if we agree that the mechanism of acupuncture is the placebo effect, then we can incorporate this within scientific framework”

          The problem I have with calling acupuncture the “placebo” effect is in the semantics. The word placebo in its modern usage can connote deception and trickery which I feel is a misnomer and takes away from the real meaning of the word. If we look at the placebo effect as a variable, generative, physiological force that exists within an organism then the term changes.

          Kindly,

          The Acupuncturist

          1. MadisonMD says:

            “Shrugging off two millenia of observations because they didn’t teach this stuff in the dogma of medical school is ignorant at best.”

            My clinical practice hardly reflects “dogma” in medical school. In fact I remember several times in my post-MD training when the physicians called a meeting based on the latest evidence. Thenceforth, we changed our routine practice and a new practice (not taught in medical school) was implemented. This has continued to occur during every year in clinical practice. Dogma can be upset. However, for the most revolutionary ideas, extraordinary evidence is required (A good example– General Relativity which was tested by light deflection in 1919 with results that were inconsistent with prior models).

            But, I am not sure how you propose to distinguish truth from fantasy? If I am to accept acupuncture into practice because of two millenia of observations, I need to be fair and consistent– I’ll need to use this method to assess other truths. It seems I would then be required to then accept bloodletting and humoral medicine; moving beyond medicine I have to accept astrology. I am forced to reconcile two-millenia old religions that seem incompatible. Do I need to reject newer ideas that don’t conform to this evidence of truthfulness? I’m afraid this general method that you propose to distinguish truth from fantasy is just not viable. A good history can easily display the irrationality of humans which seems adequate to explain two millenia of observations (I’d suggest my favorite if you haven’t read it– Gibbon’s Decline and Fall).

            “The problem I have with calling acupuncture the “placebo” effect is in the semantics. The word placebo in its modern usage can connote deception and trickery which I feel is a misnomer and takes away from the real meaning of the word.”

            It’s funny you say this. To me, not using the word placebo seems to be deceptive. Perhaps you would prefer psychological? Psychosomatic? I think these would be equally accurate. In any case, are we not required to be totally honest with ourselves, patients, and research sponsors? If they choose not to participate in or support placebo/psychological interventions/psychosomatic interventions, then this is their right. Isn’t it somehow dishonest to tell them it is something different?

            You sign off as an acupuncturist. I am sorry if this discussion is causing any cognitive dissidence. I mean to be honest, not hurtful.

      2. WilliamLawrenceUtridge says:

        The equator is used as a geographic landmark to determine positions on the planet. It’s not an explanation for anything. And it’s acknowledge as a convenient fiction. Qi is treated as an explanation, acupuncture is explained as the manipulation of qi (at least in traditional schools of thought). If qi is actually a metaphor for some other process – why not explain it in terms of that other process instead of a form of energy that can’t be measured? And meridians don’t seem to be relevant considering the selection of points varies by school and seems to be rather irrelevant anyway. If you don’t think acupuncture works by manipulating qi, then I assume you don’t explain it as such during your practice. Good for you.

        Incidentally, pneumothorax is a recognized adverse effect of acupuncture, so while where you practice it might be standard treatment to avoid the torso bar perhaps above the thick pectoral muscles, it’s obviously not the case elsewhere. Real medicine is aspirational towards an improved and consistent standard of practice, hence the emphasis on continuing education and standards of care. I don’t believe there is a similar movement in acupuncture, particularly given various national divergent and mutually-contradictory types of acupuncture.

        Science isn’t “stuck” in a reductionist viewpoint – it reduces and isolates the components of a system, then resynthesizes and tests the system in an iterative fashion. It doesn’t use metaphors, they explain things in terms of molecular pathways. They might use metaphors as an illustrative device, but they quite clearly state things as part of real biology. When explaining a fever with reference to a thermometer and set point, they are clear that there’s no real thermometer involved.

  26. Go Quietly says:

    glad I didn’t read this before I went to the acupuncturist. should have gotten pain pills and stayed in bed until I healed naturally…oooops, what are the ‘natural’ pain pills? it’s not cheap but why is it ok to ‘group pay’ for pain pills but not for another type of help? And which pain pill ‘cures’ the cause of the problem. why isn’t ‘it works for me’ valid for alternative medicine whereas ‘masking’ a symptom is OK? so many have expressed their opinion that it doesn’t work but haven’t experienced the process. while I was being ‘needled’ I commented that I have no feeling in my upper arm because my lymph nodes were ‘harvested’ 25 years ago when I had breast cancer surgery. I have feeling there now and had been led to believe that it would forever be numb. the original problem was taken care of and I will go back whenever I have something that it might ‘fix’. ..or I might try poisoning my body with pain pills first because that is what is acceptable.

    1. windriven says:

      It is OK to group pay for proven therapies and not OK to pay for frauds. There is precious little evidence supporting acupuncture. That, to my mind, is not the same as declaring acupuncture worthless. But it’s worth needs to be demonstrated before it is adopted and paid for whether by government or private insurance pools.

      Dr. Novella argues above, in essence, that enough is enough and that further research on acupuncture is redundant. But many top medical schools, medical centers and garden variety hospitals now have “integrative” medicine programs that include acupuncture. We will find no success separating SBM wheat from sCAM chaff by simply announcing to the SBM echo chamber that the matter of acupuncture has been settled.

    2. Artoo45 says:

      Why the scare quotes around harvested? It makes the people who saved your life sound sinister.

  27. And where are you going to practice this type of acupuncture?
    “How about fantasy land.”
    The criteria you outline would reduce the harm, but even still I could not support it as it’s simply unnecessary, and inserting needles without benefit is unethical, in my opinion.

    Also – it’s never going to happen. You can contain magical thinking like that.

  28. WilliamLawrenceUtridge says:

    @Ian

    If your knee is swollen, how do you know acupuncture made it go away? Does the swelling subside immediately after acupuncture? Would it have gone away without the acupuncture?

    It is clear from your post that you actually no nothing of acupuncture, how it works (or claims too) or how it is applied. You have only read claims of how some have theorized how they think it works.

    How does it work then? There are myraid suggestions of how it might work, all the way from straight-up magic to biochemical explanations (adenosine release, see here) to neurological claims (counter-irritation) to straight-up placebo (the position taken by the authors of this blog, and yours truly). Which is the true explanation, and what is your reasoning for believing it to be the actual explanation? Why do you find it so convincing when the scientific community does not agree?

    Perhaps I am wrong and you have experienced it yourself or have interviewed a qualified practitioner.

    If I interviewed a qualified bloodletter two centuries ago, or a homeopath now, or a Traditional Chinese bloodletter now, or any of their patients, all would earnestly attest to the efficacy of their practices. So would orthopedic surgeons who practiced tissue debridement, or Ancient Egyptian doctor-priests 3,000 years ago insisting on prayers to Thoth being the most efficacious cure. So, given doctors and patients in years past all assert these are effective cures, will you be praying to Thoth while having your knee cartilage scraped away without any medications or heat treatment to promote clotting?

    I find your thinking a little unnerving quite frankly. First that you say treatment of pain by definition is just masking the symptoms. Are we parsing words and saying treating inflammation causing pain is treating the inflammation and not the pain? Chicken and the egg?

    Pain and inflammation are both symptoms. They used to categorize disease by symptoms rather than by causes. It was rather unsuccessful. Doctors now treat diseases according to cause – treat the cause and the symptoms go away (and treat the symptoms for comfort). I don’t believe there is any evidence that acupuncture reduces inflammation, though it stands to reason it might cause it through tissue trauma.

    Second to suggest the met analysis is fail safe and that it invalidates any other study to the contrary is false.

    It’s “meta analysis”, with an “a”. Do you know what one is? Do you understand why it permits firmer conclusions than individual studies?

    I will summarize based solely on personal experience: My wife and three year old daughter accompanied me to an acupuncturist for a treatment of ‘tennis elbow’. After my treatment the Dr. noticed my daughter had fever and asked if we minded if she could quickly examine and possibly treat her. We said yes. As I held my daughter the Dr. placed a few needles and I felt her body temperature drop. In a few moments her temp. went from 102 to 98 (ish). Obviously the story is condensed for illustration purposes and is not scientific. However, my story is not unique, the study you defend here is not the final word.

    You might be interested in this article by Clay Jones regarding childhood fever.

    You also appear to not understand why human perceptions of causality, though emotionally compelling, are rather worthless. You should read Snake Oil Science, which discusses acupuncture specifically, as well as scientific testing in general. It’s quite good. You might also consider the following thought experiments. I never wear a seatbelt. I’ve never been in an accident. Therefore, not wearing seatbelts protects me from accidents. The sun clearly orbits the earth. I can see it going around. Every year I catch a cold. I drink chicken soup, and a week later, my cold goes away. Therefore chicken soup cures the cold. I used to see a chiropractor regularly. My neck frequently hurt. A day or so after visiting the chiropractor, my neck pain subsided. I stopped going to the chiropractor. My neck frequently hurt. A day or so after my neck hurting, my neck pain subsided.
    Personal experience is unreliable.

    There is clearly more to the story of acupuncture that has yet to be addressed.

    I have no doubt about that, I think it’s a fascinating research tool, an investigative modality into human experiences of medicine and how perception affects symptoms and diseases. It’s also a great story, full of exotic locales, drama and heroes. It’s just not a good way to predictably relieve pain. It’s certainly not magic. It’s current practice, which is often accompanied by claims of magic (vis. qi) and blatant criticism of real medicine, is pernicious and corrosive in a society and culture heavily reliant on science and technology to feed, clothe, warm and entertain us.

    1. Ian says:

      Your statement of ‘truth’ is not a truth but an opinion. The study you cite as absolute proof does not offer absolute proof and even says so. Your claim of proof is an interpretation of statistical data which does not rule out acupuncture as being valid but that acupuncture, according to the sample studies, had a low probability of working according to a preconceived notion that it won’t work regardless. Read these: http://m.huffpost.com/us/entry/1982479 and http://m.theatlantic.com/health/archive/2012/09/biological-implausibility-aside-acupuncture-works/262224/ and http://www.livescience.com/29494-acupuncture.html The article from where this debate originated has some sound science and is pretty convincing but also a huge bias built into it even though they claim it is just numbers. There was a lot of data collected but much of it (as I read it) before suitable controls where developed which would seem to invalidate much of the studies.All done it seems with the intent of proving acupuncture doesn’t work. Seek and you shall find. The authors claim bias for the studies that contradict there studies, hello pot meet kettle. I am only speaking from personal experience, I came to this article looking to broaden my horizons but it seems to be dominated by zealots that can’t see past the end of their own nose. It is like the studies claiming chiropractors are quaks because a neurosurgeon went a to a weekend seminar and the next day paralyzed a patient. It is like saying don’t go to a hospital because statistically you might catch a disease. The qualification for approval of new drugs only have prove they are a percentage point more effective than placebo. This is desperation science because it did not come from a lab. This is a significant study yes, but by no means final.
      To Your questions: we don’t bleed for bad humors any more but after an absence of several hundred years leeches came back in medicine. So perhaps if you had interviewed a qualified surgeon four hundred years ago you could have learned something and brought leeches back sooner.
      Thoth? Really? Ok, any studies out there suggesting that if a person with a critical illness has someone praying for them tat they are statistically more likely to recover? I don’t know, check it out, I suspect so. Zoroastrian beliefs making a come back ? Fire good!
      Yes, relief is immediate and lasting with my experience with acupuncture. I don’t think it help stop smoking or lose weight but it can be very effective for certain conditions.
      Tissue trauma? You really have no idea what acupuncture is do you? It is not like a syringe or a knitting needle.
      Pardon my typo, iPads are a little trick to type on: Met A. Please check my grammar next. Or perhaps proof read your own text. Actually do ok.
      Read the ‘fever’ article. Um, so? The first child is hard but helps prepare you for the next two.
      Granted personal experience as well as anecdotal evidence is unreliable. But if it works for me and so many other people I know I am going to go with it. If I need surgery or have a serious illness then I go to an MD. Muscle aches etc. that I want rid, acupuncture; It works.
      By the way, if your neck pain takes a week to heal with no treatment, but goes away in a day after treatment then you shouldn’t wait so long next time.
      You should always where your seat belt when driving it will save your life one day.
      And last but not least, allow me to introduce you to the dragon in my garage; its name is Chi. Don’t you feel it?

  29. mobiletechie says:

    Please can someone explain why this trial http://www.lamsam-casalotti.org.uk/Journal%20Club/pdf%20files/20110316TianJun.pdf does not deserve it’s conclusion “The pragmatic GRASP trial showed that Chinese acupuncture is
    an effective alternative to conventional standard therapy in
    chronic shoulder pain. Fifteen Chinese acupuncture treatments
    over 6 weeks are more effective than conventional standard therapy with NSAIDs and physiotherapy. After the end of treatment, the therapeutic effect of acupuncture lasts for 3 months. The pragmatic trial shows that verum acupuncture is more effective than
    sham acupuncture at non-verum points located far away from the verum acupuncture points.”

    1. WilliamLawrenceUtridge says:

      Have a look at the methods section – note the “true” acupuncture points are all on the arm and shoulder (close to the site of pain) and the “sham” acupuncture points are all in the leg. The key point in the section you quote above could be “located far away from the verum acupuncture points”, which were at the site of pain. In addition, the doctors knew who was getting real and who was getting sham acupuncture, leaving the possibility for “leakage” to patients (the doctors must know who is getting verum and who is getting sham acupuncture, the same doctor delivers both). Also note the large drop-out rate from the sham group in table 3 (61 vs. 26 in verum and 29 in conventional treatment). I also find it weird that the last patient was recruited in 1999 but they’re reporting out 10 years later. But I’m not a researcher, perhaps that’s perfectly normal.

      Others might be able to see more (I didn’t read much, just jumped to the results tables), but those facts jumped out at me. It’s very hard to control for point location and practitioner enthusiasm (the most interesting trial to me was the one that used the latter as a specific experimental arm, low vs. high enthusiasm).

      But again, it’s not about this trial, it’s about the whole arc of trials and the building towards better and better, more and more specific methods and tests. For the next one, for instance, they should use acupuncture points solely in the shoulder.

      But at least the trial design was very good, the kind that you can confidently make a specific prediction for your subsequent test.

  30. WilliamLawrenceUtridge says:

    @Dr. Novella,

    If regulated and enforced as I suggest, it might actually be the death knell of acupuncture because of the low cost. It demystifies the topic, would reduce the human tendency to justify their decisions (easy to say “that was $10 wasted”; hard to say “that was $1,500 wasted”). The strictures would also probably reduce a lot of the factors that enhance the placebo effect (and thence the effectiveness of acupuncture itself).

    But yeah, good luck enforcing it, good luck getting the government to adopt such restrictions.

    Part of my equivocation is because I’m also torn on the idea of doctors using placebos (particularly effective ones). For the worried well and self-limiting conditions, it might increase patient satisfaction and reduce the number going to quacks willing to tell them whatever they want to hear in exchange for cash. For all that paternal medicine had its flaws, in some cases there were benefits. Were they worth the costs? Don’t know, I’m not a doctor. Probably not the extreme taken during the heights of paternalism. And it’s quote possible if I were a doctor, I wouldn’t be an ethical one given apparent my propensity for lying to (imaginary) patients.

    I’ve always had a soft spot for harm reduction over absolutes, given we don’t live in a world in which I rule as an iron-fisted dictator. Were I such a ruler, things would be different. Definitely more cackling, and zero patient choice. Everyone would be involved in a clinical trial. All would love me and despair!

  31. bill t. says:

    Hence, the placebo effect.

  32. bill t. says:

    No one is 100% right or 100% wrong. The point was that even though Mao was promoting traditional treatment, he had no faith in them.

  33. Andrey Pavlov says:

    You make some very bold assertions with much hubris which you are clearly not in a position to make.

    Indeed I do know about acupuncture and I have had it myself – with great effect. That doesn’t negate my comment.

    Furthermore, you need to realize that you are in a veritable den of scientists. Myself included. To try and assert that you somehow know more than the entirety of science by saying that meta-analysis can simply be overturned by a single study belies your undeserved hubris. You have a conclusion that you like – acupuncture works since it worked for me – and when meta-analysis demonstrates you wrong you merely ignore the established rules and hierarchies of evidence to suit your needs. Sorry Ian, but it simply doesn’t work that way.

    And of course I say that treating pain is merely masking something. Pain is, by definition, a symptom. It is a marker of something else that is going on. If you treat pain, you are merely masking whatever is causing that pain. Acupuncture does not treat any underlying condition – it is purported to treat pain which is precisely what an opiate does. If you have back pain and I give you hydrocodone or acupuncture, both are merely masking the symptom of your actual problem. It is clear that you have a muddied understanding of what you are talking about, further making your hubris worse.

    There is more to the story of acupuncture? Really? The 3,000 studies we have had so far haven’t managed to settle it? Yet your couple of anecdotes can just go ahead and trump everything else demonstrating acupuncture doesn’t do much, if anything. Which is the entire point of this post. Don’t you think if there was an actual effect that wasn’t miniscule the 3,000 studies would have demonstrated it? Don’t you think that if the effect was there I, as a physician, would want to use it? Why on earth would I want to turn down something that is relatively harmless, has few side effects, little risk, no withdrawals, and yet actually helps alleviate pain? That is utterly illogical. I reject acupuncture not because I have some particular bias against it. As I said, I’ve used it myself before and experienced perceived benefit from it. I reject it because if after 3,000 studies we can’t find a clear cut benefit from it it simply isn’t worth my time at best and is a lying placebo at worst. But you have a particular bias for it, and thus ignore reality to preserve that.

    1. Ian says:

      True, true, true to your criticisms of my opinions. For the ‘proof’ that acupuncture doesn’t work, I recognize snake oil when I see it. You are selling something to the public, me in this case, but I am not buying it. Why, is because it comes across as hypocritical. The standards you are applying would knock most medications off the shelves. I am very pleased you are a scientist ( I’m guessing a geologist?) because as we know all scientist think and act and our educated in exactly the same way. Everyone bow there is a scientist entering the room. I do not pretend to know more than ‘SCIENTISTS’ but I am an avowed skeptic and I am not convinced. And no, your 3000 studies do not offer definitive proof. In a search that took .25 seconds I found reports and numerous scientific studies from reputable institutions and sited in publications far and wide that refute the claim the acupuncture is bunk. It worked for you you say and yet you are willing to give your self over to a king you have anointed to be the bearer of truth. I have a bridge I am willing to sell, cheap, ask my friends we are designers, we know it is the right bridge for you. I will order a study that will prove it. Sorry to be so snarky but as a scientist! you should have seen it coming.

      1. WilliamLawrenceUtridge says:

        It’s funny that you claim you recognize snake oil when you see it, but don’t recognize the profound flaws in acupuncture research. And this site is free, you’re buying from your acupuncturist, who might have a bit of an incentive to keep you happy. Intrapsychically, you have a huge incentive to keep chugging down the road and prevent yourself from admitting you are wrong (see Mistakes were Made (but not by me) by Carol Tavris – you’re in good company, the entire human race has an inborn tendency to avoid changing its mind, no matter how stupid the decision or bad the results; witness the Vietnam, Iraq and Afghan wars). The standards applied to medications, if applied to acupuncture, would prevent it from being approved because it’s so hard to tell if there’s a real effect. If a new drug had 3,000 trials of equivalent results, there’s no way it would be in the market. The real problem is that these standards aren’t being applied, and by you special-pleading away the results, you are being hypocritical. You keep claiming you are “skeptical” without applying any of the standards of skepticism. For instance, you look 0.25 seconds to find those studies, but zero time to evaluate their quality. A skeptic would realize that there is a difference in quality and methodology of studies, and recognize the importance of giving greater weight to the better-designed studies – which show that it doesn’t matter where you put the needles, it doesn’t matter whether you penetrate the skin, but it does matter if your practitioner is enthusiastic or not.

        Andrey is a medical student, see here, bottom of the page.

        1. Ian says:

          If you are trying to sell somebody something, which you are, your technique is terrible. I will explain in a second.
          First what is said in this article is basically stated in every other article I have ever read and that is this: trust us, not them our study (data) is superior to theirs.
          If you are trying sell (i use the word sell because it has a certain immediacy and illustrative quality) you can’t make the claim that your product is better because we say so. In other words trust us, WE know better. EVERY other study you claim (or the authors here do) is flawed or biased. But not us you say we are better. A skeptic looks at all the available information and evaluates the data, with out bias or personal interest in the outcome. This is supposed to be the safetynet inheritant of the scientific method and yet you still need someone to point out that the emperor has no clothes.
          I will re state my position: My personal experiences with acupuncture have been positive. But I do not think it does as many things as it claims to do. I have read and will continue to read articles like this in order to deepen my understanding. I don’t read scientific journals (generally) but I do read extensively on a wide variety of subjects including health and medicine. My mind has been change on certain treatments, and I have learned a great deal about others that was surprising, intriguing and made me want to dig deeper. I read this article (actually because of the push back here I have reread it 4 times now) and I am not convinced. The basic underlying concept of the article is this: Trust us we did it right this time.

      2. Andrey Pavlov says:

        I’ve not much to add to WLU, but I should point out that you need to have a bit of introspection about your own hubris. We do things in a certain way for very good reasons. And your ability to write such self aggrandizing posts on this thing we call the internet is a direct result of that.

        To think that you can know better than 3,000 studies analyzed by folks expert in the relevant fields after a .25 second search just skimming a few titles without any deeper understanding is quite a statement. And not one you should be particularly proud of.

        And yes, I am indeed willing to recognize when I have been wrong and understand how our own mind can trick us into believing untruths. Unlike yourself, when I actually studied the topic and understood these facts about neuropsychology I changed my mind rather than clinging endlessly to what I used to think worked from my own personal experience. After all, if personal experience trumps actual scientific endeavor, what use is science? And we would live in a world where cold fusion and N-rays worked for some but not others. I suppose the universe could work that way, but everything we know so far indicates it doesn’t (and thankfully we now know a lot). I reject the notion that the universe is inconsistent and bubbles of “works for me but not for you” exist.

        1. Ian says:

          No. The point of my search was this: I found numerous articles from prestigious and respected institutions and universities studying 10′s of thousands of cases and they came to a different conclusion then what is offered here. Distill the information down and it comes down to this: We are right, they are wrong. Jump up and down all you want and claim this the end but I can (practically) guarantee within two years this study will be just another foot note. My personal opinion is that brute force, which is how most medicines seem to work now, is never the answer. Just as a great way to releave stress is through meditation the next break through in drugs, and non surgical healing will come from with in as well. The answer to agriculture and health seems to be taking the same approach, blast the problem with chemicals and your problems are solved. I sorry you find my approach abrasive to your reasoning but you are not entitled to your own facts. Opinions, “In my opinion humanity should not waste another penny, another moment, another patient – any further resources on this dead end.” in the end are just that.

  34. Andrey Pavlov says:

    One more realization as I have been mulling it over. You do realize that your argument distills down to “NSAIDs may not work and acupuncture doesn’t work any better than the NSAIDs that don’t work. Since we use NSAIDs and say they work we should do the same for acupuncture.”

    Wouldn’t it make sense instead to stop using NSAIDs and acupuncture? I fail to see how indicting two things as not working validates the use of either, let alone both. No matter how you slice it the argument fails.

    1. pmoran says:

      Andrey, let’s work out the science and then tune policy to the results and their level of certainty.

      Part of my argument is that we don’t always fully understand our own science and its limitations.

      I have been in this game a very long time. I recall the days when we were saying to homeopaths. and chiropractors ” You must do controlled studies –otherwise you cannot know what you are really achieving with your patients.”

      I recall some minor misgivings about this, knowing how clinical studies often gave conflicting results, but everyone else was saying so and it seemed a doddle to perform a double-blinded randomised controlled trial of homeopathic preparations. Surely a few decent clinical studies would sort this whole “alternative medicine” business out, — or so we thought, long before the days of Ionnadis and his “most published research is wrong” .

      Well it didn’t happen that way, of course. I won’t say that it was an entirely humiliating backtrack to have to modify our erstwhile “Gold Standard” of medicine by trumping it, whenever necessary, with the new-found superior standard of prior plausibility, but to those having any doubts about the much-vaunted intellectual superiority of medical scepticism it must look a bit like the shifting of some rather unstable goalposts.

      You are very right to ask what the new goalposts will be, should studies emerge showing what I suspect they will. Having locked ourselves solidly into certain positions some backtracking will probably be in order.

      1. WilliamLawrenceUtridge says:

        3,000 studies without an answer seems pretty certain to me. If there’s something there, it doesn’t seem like it’s worth spending more public money on, or insurance either.

  35. Jan Willem Nienhuys says:

    Chairman Mao Zedong later revived Traditional Chinese Medicine as part of the Great Proletarian Cultural Revolution of 1966.

    More specifically, acupuncture was ‘recommended’ from 1971 on for anaesthesia during operations. Doctors, hospitals and patients all had to cooperate or else. An estimated two million patients were operated on without general anesthesia. If they screamed, they shouted “Long live Chairman Mao!” rather than “aow!”. This is one of the major frauds of the Maoist regime.

  36. pmoran says:

    Yes, I did notice my error but found the site was not responding when I tried to send this last night — .

    Sorry, I am in error, in that Steve did refer to the “somewhat bigger difference between the acupuncture group and the no-acupuncture group” in the middle paragraph quoted. I thought at the time this would be uncharacteristic for Steve. Many apologies.

    However, Steve’s argument then becomes that even these greater benefits are small enough to be disregarded.

    This stance has another set of weaknesses, including its arbitrariness when used to support a completely destructive stance towards a source of potential patient benefit, the possibility that NSAIDs and may not be that much better while having higher potential for ill-effects, and that similar benefits, if as consistent, would almost certainly enable the marketing of a pharmaceutical for the same conditions.

    Pooled results also do not allow for the fact that the therapeutic influences that are plausibly exerted during acupuncture programs are likely to be more dependent upon individual patient characteristics, also incidental events such as the extent of the distraction and counterirritation experienced during and after acupuncture sessions, and other circumstances specific to each case than applies in drug studies.

    So I think it is reasonably sound to say that “acupuncture does not work” when qualified by “as a manifestation of ancient Chinese medical theory”. But it is only in that very narrow sense that such a statement is well supported by scientific study and reasoning.

    More general application of that statement involves interpreting the evidence according to certain selected protocols and conjectures when other interpretations and conjectures are just (or very nearly?) as valid. We also don’t like to admit that our methods of clinical study cannot yet conclusively answer some questions so we have the urge to find definite answers even when none yet exist..

    One reason for the difference of opinion: the question I (and Windriven?) am asking is a different one to that which Steve is primarily considering.

    He is clearly asking whether “acupuncture” (in some unspecified sense) has proved to be of sufficient medical value to become part of the (hopefully) solid knowledge that medical science passes down from generation to generation. He thus wants near-absolute truth, and that does require evidence that cannot reasonably be argued against.

    I agree with that approach for that purpose, yet must point out that we probably don’t have that level of certainty with NSAIDs for knee osteoarthritis. (No, I don’t like the “pot, kettle, black,” line of argument much, either, but if we are going to influence the behaviour of people in more important respects than this we need to be seen to be capable of even-handed and irreproachable scientific rigor and also to have individual patient welfare at the very top of our list of imperatives).

    So, in short, I am saying that we have conflicting obligations. Set against the duty of medical science to “find and uphold Medical Truth” is an ethical one which requires us not to be too obstructive in relation to measures we cannot be too sure about.

    1. Andrey Pavlov says:

      You’ve still missed the point Peter. And you are still arguing with bad form and bad logic.

      This stance has another set of weaknesses, including its arbitrariness when used to support a completely destructive stance towards a source of potential patient benefit, the possibility that NSAIDs and may not be that much better while having higher potential for ill-effects, and that similar benefits, if as consistent, would almost certainly enable the marketing of a pharmaceutical for the same conditions.

      Where in this do Novella or Colquhoun support NSAIDs for osteoarthritis. More to the point, where do they do anything except state that the evidence base supporting the use of acupuncture is not sufficient for any other conclusion except “it either doesn’t work or has such a small effect size as to be clinically useless”?

      Furthermore, you may have noticed that accepted medical standards not considered alternative are skewered here from time to time as well. But that is, by in large, not the primary focus of the site nor the primary interest of the authors. So you are claiming that Novella and Colquhoun’s arguments fall flat because they don’t sufficiently address a completely different topic that you feel should be addressed prior to even discussing acupuncture. Sorry but it simply doesn’t work that way. We needn’t address every problem of legitimate medical practice before even attempting to address the problems of so-called alternative medicine. And that is why the premise of your argument is fallacious.

      Pooled results also do not allow for the fact that the therapeutic influences that are plausibly exerted during acupuncture programs are likely to be more dependent upon individual patient characteristics, also incidental events such as the extent of the distraction and counterirritation experienced during and after acupuncture sessions, and other circumstances specific to each case than applies in drug studies.

      Then we move to special pleading.

      “But, but pooled results don’t take into account that maybe, sometimes, some people have more effects than others because they are more believing and/or because some practitioners put on a better show. So “it worked for me” should be entirely good enough and stop trying to say that acupuncture doesn’t work.”

      You do realize that this line of argument can be applied to literally anything don’t you? I could do a world-wide genome wide assay and segregate out the tiniest populations based on haplotypes and then try 1 million interventions on them all and I promise you that at least 1 will have some sort of effect that would be drowned out by pooled studies. But until we get to that level of testing and sophistication it is asinine to assert that “maybe it may have some sort of effect” and use that as an argument that “it doesn’t work” is not supported by the science. Within the limits of our current methodology “it doesn’t work or it works so insignificantly as to not matter” is a perfectly reasonable conclusion.

      He is clearly asking whether “acupuncture” (in some unspecified sense) has proved to be of sufficient medical value to become part of the (hopefully) solid knowledge that medical science passes down from generation to generation. He thus wants near-absolute truth, and that does require evidence that cannot reasonably be argued against.

      Near absolute truth? On what planet are you reading these posts? To within the limits of our current abilities to discern effect. Which, btw, is robust enough to determine that if an effect is present it is small enough that use on a population level is not reasonable. We don’t need absolute truths to find that. But hiding in the tiny remaining shadows of uncertainty in effect size is very near in style to the “god of the gaps” argumentation. And our friend Bayes gives us a light that slinks those shadows back even further. Any putative mechanism or biological plausibility for acupuncture is either based in magic or reveals that any effect size cannot be large. And yes, that has been discussed and demonstrated quite sufficiently despite your protestations.

      I agree with that approach for that purpose, yet must point out that we probably don’t have that level of certainty with NSAIDs for knee osteoarthritis.

      Why must you point that out? What bearing does that have on the discussion at all? For illustrative purposes I will completely agree with you. NSAIDs do not work at all. Not even in the slightest by any standard I have. So how does that affect how I must look at acupuncture and what my conclusion about it must be? Does my agreement as to the lack of efficacy of NSAIDs for knee OA suddenly make acupuncture work? Does the lack of effect size of NSAIDs magically increase the effect size of acupuncture? Of course not. Your only argument here is that we must lower our standards to accept acupuncture. The correct argument would be that neither work and we should reject both.

      Of course the fundamental difference is that the Bayesian prior for NSAIDs is much higher than for acupuncture. Which brings me to my last point:

      …backtrack to have to modify our erstwhile “Gold Standard” of medicine by trumping it, whenever necessary, with the new-found superior standard of prior plausibility

      New found? Perhaps you weren’t aware that Thomas Bayes lived in the 17th century and that he wasn’t even the first to formulate the concept of prior probability? The fact that we have been lazy and not applied it does not invalidate it nor make it new found. So if the best argument you can come up with is to hide in the frequentist p-value because Bayesian frameworks are too new-fangled and we look like we are backtracking, you are in a weak position indeed.

      1. pmoran says:

        Andrey, I am not taking any position other than that we don’t know as much as we think we know about the science of medical practice.

        The simple fact is that the next likely challenge for us is to explain to the world why we are so violently opposed to alternative methods when they will be found able to perform as well as supposedly well-validated conventional methods in many head-to-head comparisons. (This is fairly predictable, if only because of the known influence of various biases upon study outcomes with subjective complaints. The difficulty is in knowing how much genuine patient benefit exists. We assume that is minimal in the case of the alternatives, but not the conventional methods, yet we have as yet no secure scientific basis for that judgment. The importance of certain neurophysiological studies — sidestepped by Steve and Colqhoun — is that they are increasing the likelihood that the benefits are “real” to the patient — from placebo and other incidental therapeutic influences — even with treatment rituals that we judge have no right to “work”, according to the standard conventional intellectual framework. ).

        I would be interested to hear your opinion upon on how we approach that, also that of anyone else.

        PS Drs Novella and Colqhoun did not protest at Harriet’s endorsement of the AAOS’s strong recommendations of NSAIDs and strong recommendation against acupuncture for knee osteoarthritis so it reasonable to assume they concur with that.

        PPS I am not advocating that the mainstream plunges into CAM. There are many reasons why that would be wrong. We simply need to be able justify the total dismissal of it, even when we lack very safe and effective treatments. That is the implication of most sceptical rhetoric.

        1. Andrey Pavlov says:

          You have a penchant for coloring your responses with as many hyperbolic adjectives as possible. There is a small gray in which you reside and to make it seem as wide as possible you distract and deflect by throwing in references to NSAIDs – which have absolutely nothing to do with the conversation at hand – and words like “so violently opposed.” I’m impressed you could find Dr. Novella’s writing to be “violent.” I have visions of Dr. Novella’s anti-CAM army of minions descending on Chinatowns around the country with machine guns in one hand and meta-analyses on the other.

          The next likely challenge? How’s about we focus on this current challenge? Do you not feel like your argument is weak when every point you make is about something else besides the argument at hand? And when you consistently use such hyperbolic language?

          We assume that is minimal in the case of the alternatives, but not the conventional methods, yet we have as yet no secure scientific basis for that judgment

          Nobody here assumes that. I believe you have just accused Dr. Novella and folks like myself of being utterly biased and blinkered by our own desire for “conventional” medicine to work and “alternative” medicine to fail. I can’t even begin to explain how wrong that is and wouldn’t waste my time since I know you read the blog here constantly. Perhaps Dr. Gorski pointing out why gamma scintigraphy of breasts is not feasible and also not effective is an example of the bias you are accusing us of? I’m sure that he wrote that piece because using radioactive glucose with multi-positional gamma detectors is “alternative.” I could go on but what’s the point? You’ve read all those as well and yet still see fit to argue as if you hadn’t.

          The importance of certain neurophysiological studies — sidestepped by Steve and Colqhoun — is that they are increasing the likelihood that the benefits are “real” to the patient — from placebo and other incidental therapeutic influences — even with treatment rituals that we judge have no right to “work”, according to the standard conventional intellectual framework.

          Finally an actual argument. Yes, I agree wholly that there is actual effect from placebos. However now you are far, far beyond the science here in trying to assert that means anything clinically or practically useful. Because that same data demonstrates it is difficult to implement, typically ephemeral, and – except in certain extremely contrived cases – absolutely requires lying to the patient for even the chance of working. So once again, an attempt to defend a practice that is wholly based on placebo effects and responses by hiding in the highly speculative position of placebo science… whilst simultaneously chiding us for going beyond what the science says. I suppose it is merely a matter of who is going beyond which science and whether you like what the implication is or not.

          But the deeper point is that even if I take you at face value here it is still fair to say that acupuncture doesn’t work. Because the acupuncture isn’t doing anything – the ritual and the non-specific effects are. So what shall I tell the patient? I’m doing this specific intervention because it works just as well as any other random thing I may do as long as I do it theatrically and at least pretend needles are involved?

          The point is that if you disclose and fully explain to the patient what the science does tell us about acupuncture do you think they would still gobble it up? I certainly don’t.

          How do we approach that? Simple. Tell them the truth. It is what I do in the patients that ask me. And guess what? Most of them are surprised to hear it, and then decide against whatever “alternative” it is they were considering. Because they don’t like the idea of wasting their money on a small effect size that is mostly, if not wholly, a placebo. But then again I typically deal with lower SES urban populations who don’t have much money to throw around.

          As for how we justify our total dismissal of CAM? Simple – it is a non-category. It doesn’t make sense. The NCCAM itself has admitted that even they can’t actually define what it is. And Dr. Killen has admitted to me – when I pressed him hard on the NCCAM blog – that it “doesn’t matter” and they just press on anyways. But really, the justification is simple – anything proven to sufficient standards is simply medicine and we should use it. Anything used and found to be insufficient should be discarded. Period. Regardless of whether somebody finds a way to call it “alternative” or “conventional.” That is what this site and I advocate.

          1. windriven says:

            Andrey, there is a difference between ‘a small grey (area)’ and what I, for one, perceive as a subtle and nuanced position that Peter is defending. I begin from the assumption that all of us want some variant of the same good: high quality, cost-effective, science and evidence based practice that leaves patients both healthy and satisfied with the quality of their care.

            We aren’t going to banish woo – acupuncture in this case – by declaring victory and telling people, ‘move along, nothing to see here.’ Too many people claim anecdotal ‘evidence’ and too many first rank medical schools and facilities have integrated woo into their programs. Winning the battle among a minority of physicians is losing the war.

            If what we want is really science-based medicine then we are going to have to be honest with ourselves and with the patient population about the limits as well as the strengths of the state of the art.

            We would all like to see scarce research dollars spent on projects that best advance the state of the art. But if we ignore sCAM it will grow like weeds in an untended garden. We are going to have to study it to death and demonstrate that it doesn’t work for a or b or c or d or… And who knows, we may learn something truly useful along the way.

            1. Andrey Pavlov says:

              I have always respected what you have to say windriven, and in fact Peter as well. However, I disagree here. Peter certainly appears to be trying to proffer a subtle and nuanced position but from all my interactions over the years with him it is actually just a waffling about and high-level rhetoric with no true substance. If it were just me having this opinion I would have less certainty in it, but Drs. Hall and Gorski clearly have agreed as well as have other commenters here.

              The reality is anything could be. And acupuncture could help people. Perhaps everyone and not just some people. As you know we cannot prove a negative in that it can’t help anyone. But clearly the effect size is small enough, capricious enough, that we can move on to better things.

              One of the premises of the authors here – which I share – is that chasing down something like the true effect of acupuncture is an exercise in diminishing returns and that part of good science is learning when to move on. We can’t just keep researching and using anything we want willy nilly. I seem to recall you said you were a physicist. What would you think about someone subtly and in a nuanced way defending the idea that phlogiston may still play a role in understanding the universe, although it is certainly small, but we should keep researching it and doing some things as if it existed and had an effect? I mean, can you really prove that phlogiston doesn’t in any way, shape, form, or effect size exist at all? No. So would you countenance spending millions of potential research dollars on it? Would you advise undergrads and young postdocs to research it and use it in their models? The only difference between phlogiston and acupuncture is that in physics you have the luxury of being able to confirm things to 7-sigma, so you can be really damned sure of something not being there. As sure as we can possibly hope to be anyways. Well there must be a lower bound in medical sciences as well and obviously that must be bigger than for physics. Peter is hiding in the gray area of phlogiston, it is just that the gray area for us is much, much larger and can be more convincingly argued that something is there.

              So yes, we must be honest about the limits and strengths of our abilities. But within that framework we should also explain why something that still has room to be argued is still something we can discard and move on. Because room to argue in and of itself is not sufficient to say it is worthwhile.

              (sorry if this is not particularly clear – it is 5:30am and I am in a rush to get out the door)

  37. Newcoaster says:

    The very bottom line is quite clear.

    If we had the same equivocal results for let’s say Penicillin, 40 years, thousands of studies, and still no definitive proof it worked, and repeated calls for “more study needed”, the AltMed crowd would be justified in laughing at us for clinging to something that clearly didn’t work for ideological reasons.

    It is useless. Get over it.

  38. ghostcow says:

    Thank you thank you thank you. As an Anesthesiologist I can’t count the number of times I have had to bite my tongue as the the pain Anesthesiologist have gone around the OR throwing needles in residents, nurses, surgeons for any number of reasons or complaints. I even endured a M&M conference given by one of these preachers of the CAM faith stating throughout the power point how proven all the acupuncture research has been. At the end I said my peace about the lack of consensus within the medical and scientific community was, and how the presentation wasn’t exactly a balanced presentation of the research. I was greeted with shear astonishment that I would question the validity of the presentation given by one of the nicest MDs in our group. I continue to try to be the first to address acupuncture with residents so that might learn to question what the will be taught to them in later portions of their training.
    Sigh, so much wu here in the Pacific NW.
    Thank you for the continued research on the research.

  39. Jan Willem Nienhuys says:

    May I point out that reference 31 (a commentary by Harriet Hall) was reproduced here?
    http://www.sciencebasedmedicine.org/acupuncture-revisited/

  40. WilliamLawrenceUtridge says:

    @Eva and Daevid

    My apologies, Eva’s comment jogged my memory. I’m aware of two types of “dry needling”. One is simply “acupuncture without the magic” as I described above, also known as “medical acupuncture”. The other is used by physiotherapists for specific indications regarding (I believe, I could be wrong) tendons and ligaments. It consists of repeatedly puncturing the connective tissue. I believe the rationale is that it stimulates the healing process in some way. I know essentially nothing beyond that. I suggest looking on pubmed or google scholar for more (pubmed has the advantage of having clinical trial and – more importantly – meta analysis/systematic review filters). Paul Ingraham might know more than I, his site is http://www.saveyourself.ca and is great reading.
    @Eva

    I didn’t continue with it as I became convinced after a few times that even if it would work it would take many, many sessions.

    That’s why clinical trials are important – to tell the difference between “it would take many, many sessions” and “it’ got better on its own”.

    The first was when young I took someone to an osteopath who did iridology. Just for fun, I asked him to look into my eye to see what he could see. He told me I have a retroverted uterus. No big deal, but turned out to be true. I haven’t studied iridology so there may be some perfectly simple explanation.

    You may be interested in this article regarding iridology. You may also want to read or think about cold reading, or even hot reading. If you hadn’t had an retroverted uterus, would you remember the anecdote? Did he make any other predictions? Did you have back pain? Did you have pelvic pain? Had he performed a pelvic exam? Also note that a retroverted uterus is a pretty common thing, about 20% of women have it. If you are still seeing this osteopath, maybe think about switching doctors; as the quackwatch article discusses, there’s no anatomical reason, nor method, by which the iris can become a homunculus for the body. For an osteopath, who should be a conventionally trained doctor, to fail to realize such basic anatomy is distressing. Though perhaps he was a legacy doc left over from before osteopaths became real doctors with an embarrassing history.

    For me, part of skepticism is realizing that the weird experiences might, probably do, have rationale explanations (or if they don’t, then we’re still better off going with science). I vividly remember my mother (a massage therapist who practices energy work) doing energy work on a friend’s thumb. I remember touching her hand while she was doing so. I vividly remember the buzzing, vibrating sensation in my fingers. I vividly remember removing my hand in astonishment, at which point the buzzing went away, then replacing my hand and feeling the buzzing return. I have no explanation for this.

    I still don’t believe in energy work. I do think my mother is a good massage therapist (which she charges for) who doesn’t need to practice energy work to do good (which she throws in for free). Again I’ll link to Paul Ingraham’s site, this time for a personal story about changing your mind.

    The other was years later after diagnosis with occupational overuse injury, I had a full body massage and the masseuse, without knowing anything about my medical history, ran her finger across the base of one of my big toes and said “Your neck and shoulders are shocking”. True, but no news to me. An interesting diagnostic technique though. I haven’t studied reflexology either so there may be some perfectly simple explanation. Weird though.

    I like to say, “a massage therapist will give you a massage, a masseuse will give you a handjob”. It’s a terrible joke, but with a mother who is an RMT, the distinction was made clear to me (not in anything close to these words, she rather left out the last part).
    Again, contemplate cold reading – humans are pattern-recognition machines. She sees your posture, she sees you adjusting your shoulders, she had just given you a massage (I believe, from your story) so it’s hardly surprising if she recognized the muscles of your neck and shoulders were tight. I’m not saying she’s scamming you – she could be attributing knowledge gained through other pathways to the more rewarding, nigh-magical belief that she can diagnose and treat illness through a method doctors don’t use or know about. She could simply be fooling herself into using post hoc ergo propter hoc in the sense that she did the reflexology “assessment” last, and attributed her knowledge to that rather than to other sources of information. When you test reflexologsits blindly, without those other sources of information, their success rate drops. Considerably. Regards reflexology, I’m back to quackwatch.

    However, I’m left wondering if there is something to be said for empirical evidence of efficacy built up over aeons.

    First, acupuncture isn’t necessarily that old – the technology for thin steel needles didn’t exist until a couple hundred years ago. The oldest acupuncture instruments, which are used to claim an old age for the practice, look a lot more like knives and bodkins – bloodletting instruments.

    Second, for aeons people believed in bloodletting, magic and demons to treat illnesses. Old doesn’t mean it’s right.

    Third, if it were aeons of correct observation leading to valid empirical evidence – why does science consistently fail to replicate these results? When we tested the aeons-old use of willow bark to relieve pain, we found out it works. Ditto for the aeons-old use of St. John’s Wort for depression. Why wouldn’t these same methods work for acupuncture? If complementary and alternative medicine treatments are as effective as their proponents claim, shouldn’t we be able to demonstrate it? If we can detect a single photon landing on a sensor, or the effects of quantum foam at scales literally unimaginable, why can’t we detect qi? If acupuncture points are so important, why do we get the same results irrespective where we needle? If acupuncture abandoned all the things proven not to work, I would have much less of a problem with it, but it doesn’t change in the face of new evidence – practitioners still speak of ancient wisdom, magical energy, the importance of specific points and lines, and worst of all – the ability to treat disease.

    If it’s so effective, why can’t we prove it?

  41. WilliamLawrenceUtridge says:

    @Ian

    If you are trying to sell somebody something, which you are, your technique is terrible. I will explain in a second.

    I’m not trying to sell you something, this website is free as are my comments. I’m explaining why the scientific support for acupuncture is lacking, why your own experience can be deceptive, and why the assertions made for acupuncture are usually factually incorrect. If you are unwilling to put in the time to familiarize yourself with the data and make an evidence-based, I’m not going to convince you. If you want to make an emotional decision, you are in good company – that’s what most of the world does. It’s just a bad idea in terms of choosing safe and effective health care.

    First what is said in this article is basically stated in every other article I have ever read and that is this: trust us, not them our study (data) is superior to theirs.

    Sure, but it’s a matter of why. Why is one set of data better than another? Why are control groups necessary? Why are appropriate control groups vital? What is the Hawthorne effect? Why is randomization important? Why are large numbers needed? When we say “placebo effect”, what do we mean? What is the relationship between placebo effects (symptom improvement) and real effects?

    If you are trying sell (i use the word sell because it has a certain immediacy and illustrative quality) you can’t make the claim that your product is better because we say so. In other words trust us, WE know better. EVERY other study you claim (or the authors here do) is flawed or biased. But not us you say we are better. A skeptic looks at all the available information and evaluates the data, with out bias or personal interest in the outcome. This is supposed to be the safetynet inheritant of the scientific method and yet you still need someone to point out that the emperor has no clothes.

    I’m not really asking you to trust me (though I should probably include weblinks, even though they’re a pain in the ass). I’m pointing to flaws in the data which make other conclusions less solid. If you really want to learn, you have to look at both sides of the issue. Good science advances by building on previous science – addressing flaws, isolating elements, refining methods. There are many posts on acupuncture on this blog, probably in excess of 150. They go deeply into individual studies, explaining why the data is flawed, and what the true implications of many of the studies are (or, at minimum an alternative explanation).

    If you want all skepticism about acupuncture distilled into a convincing soundbite, I can’t give it to you. The best I can manage is:
    - It doesn’t matter where you put the needles
    - It doesn’t matter if the needles penetrate the skin
    - It doesn’t matter if you use toothpicks versus needles
    - It only works on two symptoms, both of which respond very strongly to placebos
    - It does matter if the practitioner is enthusiastic or not, to the point that practitioner enthusiasm washes out all of the remaining factors

    I will re state my position: My personal experiences with acupuncture have been positive.

    Yes, but personal experience is unreliable. The exact same statement could be said about myriad ineffective medical interventions. Knee tissue debridement for osteoarthritis. Bloodletting for everything. Emetics for everything. Antioxidants for heart attacks. Positive thinking for cancer. It depends on what the acupuncture is for (has it ever helped you for anything but pain or nausea?) and what you mean by “positive”. If you mean “I felt good about it afterwards”, that’s patient satisfaction. Patient satisfaction doesn’t cure cancer, or asthma, or heart attacks, or strokes, or infertility. Not to mention, all humans have an inborn cognitive bias to justify their past actions, it’s extremely hard to admit that you made a mistake or were wrong in the past. Again, read Mistakes Were Made by Carol Tavris and that other guy.

    But I do not think it does as many things as it claims to do.

    Why is your skepticism selective? Does part of your thinking process involve a starting point of either of the following?
    - My personal experience may be misleading
    - Acupuncture may be a placebo
    If you’re unwilling to entertain either of those thoughts, you’re probably a lot closer to confirmation bias, and a lot further from skepticism, than you realize.

    I have read and will continue to read articles like this in order to deepen my understanding. I don’t read scientific journals (generally) but I do read extensively on a wide variety of subjects including health and medicine.

    You should read:
    - Mistakes Were Made by Carol Tavris
    - Bad Science by Ben Goldacre
    - Trick or Treatment by Edzard Ernst & Simon Singh
    - Snake Oil Science by R. Barker Bausell
    All are popular, and all do a very good job of debunking CAM, including acupuncture. I’ve heard good things about Michael Shermer’s Why People Believe Weird Things as well, but I haven’t read it.

    The basic underlying concept of the article is this: Trust us we did it right this time.

    And your basic response is “trust me, I experienced it”. That’s not a skeptical response, that’s a credulous one that places too much faith in your ability to correctly understand and contextualize your own experience, and shows too little awareness of your own cognitive biases.

    Acupuncture is particularly a difficult aspect of CAM to appreciate because it is accompanied by a very strong placebo (assuming it’s even effective) and there’s so many aspects to it (practitioner characteristics, needle position, needle depth, needle manipulation, it’s lack of link to a specific mechanism which allows it to be proclaimed a treatment for any disease, diagnosis, needle material, difficulty blinding and probably more I’m missing). And are you aware that there’s no such thing as “acupuncture”? It’s actually a myriad of mutually-contradictory diagnostic and interventionist systems. Chinese, Korean, Japanese, Tibetan and “Western” are all applied in different ways, using different instruments, for different parts of the body, selecting different points via different standards. That sounds more like religious schisms than science. Science converges over time, it doesn’t splinter. The signal rises out of the noise, particularly after 3,000 trials. Can you name any other medical discipline that has conducted 3,000 trials and not reached a consensus? I wager you can’t. Apply the same numbers and concepts to any mainstream intervention – would you take a pill that has had 3,000 studies applied to it, but they still don’t know if it works? If so, why the double-standard?

  42. WilliamLawrenceUtridge says:

    No. The point of my search was this: I found numerous articles from prestigious and respected institutions and universities studying 10′s of thousands of cases and they came to a different conclusion then what is offered here.

    What do the most recent meta-analyses and Cochrane reviews say? Recency is particularly important since the development of retracting needles in the early 2000s, which finally permitted a better degree of scientific control since they were much more convincing to patients.

    Distill the information down and it comes down to this: We are right, they are wrong. Jump up and down all you want and claim this the end but I can (practically) guarantee within two years this study will be just another foot note.

    It’s not a study, it’s an editorial.

    The meta-analysis is an empirical, structured way of distilling large volumes of research into single conclusions. Bad Science goes into them in detail, and I believe so does Snake Oil Science. What do the meta analyses say? Here’s one, acupuncture doesn’t work for irritable bowel syndrome. Here’s another saying it doesn’t work for depression.

    My personal opinion is that brute force, which is how most medicines seem to work now, is never the answer.

    Ah, yes, that’s a common trope among CAM promoters – their treatments are natural and gentle, drugs are nasty and harsh. The reality is, if a medicine has an effect, it’s likely to have a side effect. The human body reuses receptors and proteins, so if it does something in the brain, the gut probably gets a kick too. Often “gentle” natural approaches are merely ineffective (you’re healing yourself, take the credit, to paraphrase Dara O’Briain). When they are effective, it turns out they have have side effects – witness St. John’s Wort, or black salve, which ate a woman’s face. Even vitamins have adverse effects – just ask Gary Null, or have some polar bear liver for dinner (don’t, it’ll kill you).

    Just as a great way to releave stress is through meditation the next break through in drugs, and non surgical healing will come from with in as well.

    Meditation might work but more studies are needed. And if self-healing is so effective, why didn’t it work before modern medicine? Why did death rates drop and lifespans increase quite steadily over the past 150 years? Has the human body changed such that we have new internal healing mechanisms now that we didn’t have before?

    The answer to agriculture and health seems to be taking the same approach, blast the problem with chemicals and your problems are solved.

    That’s a bit of a straw man. Doctors try to prevent as many diseases as possible through vaccination. Proper nutrition as recommended by the USDA is used to prevent malnutrition. Sanitation reduces the danger of drinking water. Medicine is strongly preventive. What does medicine not have preventive recommendations for? It sounds like you have been well-schooled in a lot of talking points from CAM providers, though be aware of the fact that much of alternative medicine involves not positive statements but rather disparagement of real medicine. Yes, real medicine isn’t perfect, but it is self-correcting and self-critical. It changes. Meanwhile SCAMs rarely change. Homeopathy is much the same as it was 200 years ago, I challenge you to find an equivalent medical treatment that hasn’t changed in that time period.

    I sorry you find my approach abrasive to your reasoning but you are not entitled to your own facts.

    Ha, that’s amusing.

    Opinions, “In my opinion humanity should not waste another penny, another moment, another patient – any further resources on this dead end.” in the end are just that.

    What opinions? So you’re criticizing Dr. Novella and Colquhoun for clearly labelling their opinions as such? What an odd thing to do.

    1. Ian says:

      “That’s a bit of a straw man. Doctors try to prevent as many diseases as possible through vaccination. Proper nutrition as recommended by the USDA is used to prevent malnutrition. Sanitation reduces the danger of drinking water. Medicine is strongly preventive. What does medicine not have preventive recommendations for? It sounds like you have been well-schooled in a lot of talking points from CAM providers, though be aware of the fact that much of alternative medicine involves not positive statements but rather disparagement of real medicine. Yes, real medicine isn’t perfect, but it is self-correcting and self-critical. It changes. Meanwhile SCAMs rarely change. Homeopathy is much the same as it was 200 years ago, I challenge you to find an equivalent medical treatment that hasn’t changed in that time period.”
      First, don’t know what CAM stands for and I don’t care. I am guessing the A is for acupuncture? I don’t ‘do’ talking points.
      Second, straw man argument? read your second sentence. How is that possibly relevant to the discussion at hand. Has anyone advocate that acupuncture works as a preventative? If you want to discuss USDA guidelines for nutrition that is a whole other conversation that I don’t wish to get into although it does make for an interesting conversation. I made an analogy comparing pesticides with pain meds, and that is what that was. We could bring in Statins and cholesterol too if you want, although you would be taking with yourself as I have grown tired of your circular arguments.
      “The meta-analysis is an empirical, structured way of distilling large volumes of research into single conclusions. Bad Science goes into them in detail, and I believe so does Snake Oil Science. What do the meta analyses say? Here’s one, acupuncture doesn’t work for irritable bowel syndrome. Here’s another saying it doesn’t work for depression.” What? So? Again not relevant to the discussion. Never brought up by me, or this article. Dude you are freaking out. I am sorry for you that this article did not persuade me that acupuncture is complete bunk. You are advocating a point of view not science. You call all the other reports irrelevant and flawed but this one is the best! please, pull the other one.

    2. Ian says:

      Hopefully my last reply made into the forum, went thru a tunnel with out wifi… sorry if it didn’t.

  43. WilliamLawrenceUtridge says:

    CAM stands for complementary and altenrnative medicine, also known as “things people will sell you as medicine but don’t have any proof”. Yes, acupuncture is a type of CAM.

    You said “The answer to agriculture and health seems to be taking the same approach, blast the problem with chemicals and your problems are solved.” CAM proponents like to pretend that our soils are depleted and there’s something evil about applying fertilizer, herbicides and pesticides – never mind that fertilizers make things grow, herbicides and pesticides are safety-tested, and all three are responsible for ensuring we don’t starve to death. CAM proponents also like to pretend that proper diet, regular exercise and disease prevention are somehow “alternative”, when they’re just mainstream care, along with vaccination – all are preventive of morbidity and mortality. So pretending doctors do nothing but presecribe drugs is nonsense, though when patients don’t follow the advice of their doctors and mainstream medicine, doctors are often required to prescribe drugs to prevent death. Medicine is very far from “blasting things with chemicals”. And chemophobia is dumb anyway. Statins reduce cholesterol and prevent heart attacks. They’re used for patients who are either unable or unwilling to get their cholesterol under control through other means. Can’t blame the doctor if the patient doesn’t lose weight, or their genese don’t permit their cholesterol to drop below a risk threshold.

    There’s no “one report” for acupuncture. There are myriad studies. Asking for “one study”, one magic bullet proof-or-disproof study is fallacious, that’s not how science works. This opinion piece written by Drs. Novella & Colquhoun summarizes the literature in a critical way, drawing heavily upon meta-analyses either in specific or general terms. I’m not surpirsed you’re unconvinced by the article – you came here convinced that your own experience trumps any science because “it worked for you”. That’s not science, and you don’t seem particularly aware of the history, context or practice of acupuncture, let alone the research base, let alone how science works. So unsurprisingly, we disagree. We’re barely speaking the same langauge. So there’s not much I can do to convince you until you read up on why science beats your individual experience. Have a look at the books I suggested, then you might understand.

    1. Ian says:

      No, no and no again. I run into people like you all the time: all hat and no cattle. Your diatribe is so reactionary. You make assumptions about who I am and what standards I applying in my decision making processs. How do I evaluate material ? You are so far off base as to align me with a group I have never heard of.
      I am not anti science or anti medicine. However I am skeptical on every new bit of science I come across and as general practice I have learned that when it comes to issues of health and medicine there needs to be long incubation period before acceptance or rejection. I have NEVER said my experience trumps science. I have said your lovely meta analysis is not beyond reproach. Because that data is still open for debate and reevaluation. You are condescending blow hard that has prejudge me to such an extent I am forced to conclude you are just an Internet troll.
      Ps as person that has worked as a soils engineer I can state unequivocally that if we keep blasting our soils with pesticides and petroleum based fertilizers we will ruin the soils And this conversation won’t matte one jot.

      1. WilliamLawrenceUtridge says:

        Actually, medical practice can change incredibly quickly in the face of sufficiently convincing evidence. Look up the effects of the Women’s Health Initiative on the use of hormone replacement therapy to control the symptoms of menopause. Look how quickly the treatment of ulcers changed. I still can’t believe you’re defending acupuncture, after 3,000 studies, with “it worked for me”. Which shows me that your experience does indeed trump science.

        What’s your solution to pesticides and herbicides in order to grow enough foods to feed the world?

        How does fertilizer ruin the soil?

        How do you evaluate scientific material?

        If you worked with soil in a scientific fashion, you should be able to point to a recent review article in the peer-reviewed literature that supports your assertion that our current farming practices will lead to the collapse of our ability to feed ourselves.

        You may not realize that you align with SCAM promoters, but you use the same arguments they do. Even if you don’t consider yourself aligned with them, your tactics, arguments and above all assumptions quite neatly align with other SCAM promoters to the point that they’re quite close to indistinguishable.

        1. Ian says:

          I am surprised you haven’t heard of the soils thing. It is a much bigger issue, with far greater implications for the overall health and well being of the people of this planet than this acupuncture silliness. Highly recommend you look into this story line. I can’t recall specific publications or articles but search with titles like: Synthetic fertilizers deplete soil …. or effect on soil; long term effects of petroleum based agricultural products and/or fertilizers, Synthetic Nitrogen Fertilizers Deplete Soil. Something along those lines should give you a path to follow. If you are really into it than find issues of (probably have to pay for them) Journal of Environmental Quality, Soil Ecology or Applied soil Ecology, Science direct I think is publisher, Cambridge press? I think. Google has a search function for peer reviewed papers, I suggest you start there. Long running story, interesting parallels with the acceptance/rejection of acupuncture. The dust bowl in part was created by over reliance on synthetic fertilizers. The issue keeps coming up and getting and the getting swept a the sideignored. Interesting history Wait…..http://grist.org/ they had a go summary of the history, gotta search tho.
          cheers

          1. WilliamLawrenceUtridge says:

            The fact that you are citing a pro-environmentalist news organization (and really, you’re actually saying “search here, you’ll find it”) rather than the scientific literature kinda undercuts your credibility. Science is iconoclastic, not self-confirming.

    2. Ian says:

      No, it just means you are an insufferable bore that would rather remain ignorant than expend an iota of energy learning something new. It also means that I have more to do than dig up articles on subject that while still interesting, not one that I am still involved in. You clearly can not help but to prejudge others and can only relate to ideas by defining them as liberal or conservative or with you or against you. You are good typist but your thinking clearly lacks the dexterity of your fingers.
      Cheers

      1. Andrey Pavlov says:

        Wow. Project much? You do realize that we actually have done the hard work and have looked at the evidence and that is why we dismiss acupuncture? You haven’t even bothered to look and continue to claim it doesn’t even interest you, and yet feel like we are being flippantly dismissive.

        Expending one iota of energy learning more? Perhaps you should look at the archives of this site for the articles and the comments from myself and WLU and see who is not spending “one iota of energy learning more.”

        What is really happening is that you are an insufferable narcissist who thinks your uninformed and non-expert opinion is more or at least equally valid as those of experts in the field who actually are informed. And you don’t like someone telling you that a random idea you believe may have merit doesn’t. Perhaps you should try expending “one iota” of energy to read the literature and demonstrate you point of view? Of course not.

  44. Pau Coyne says:

    A propos of the difficulty of double blinding (and conveniently ignoring the ethical question for the sake of simplicity) might it be feasible to “dope” with real anaesthetic the needles used on a subject group and leave them clean for a control group. Theoretically that would allow full double-blind comparison, albeit that both groups would have the acupuncture with the difference being the presence or not of proven anaesthetic. If acupuncture were effective the difference between the groups in reported levels of pain should be low; if not then I’d expect a greater difference. Also rather than using self-reported experience of pain levels, a more psychological experimental approach could be taken, for example a (deliberate) minor mishap could cause the patient/subject to have to move and their response times objectively measured. Like I say…. I’m kind of sidestepping the ethical question, but surely the truly ethical thing is to get the evidence and base our medical decisions on the facts, not conjectures.

    1. sally says:

      it works for me.

      1. WilliamLawrenceUtridge says:

        What do you mean by “works”? It reduces pain? It reduces nausea? It sets broken bones? It cures infectious diseases?

  45. I’d like to enquire about the figure of 3000 trials mentioned in the paper. I couldn’t find a reference to it. What is “3000″ referring to, is it the total number of trials included in the meta-analyses that were discussed?

    Wang’s paper at least mentioned that a PubMed search for “acupuncture clinical trials” resulted in 3833 results. In talking about 3000 trials, were you referring to a PubMed or other database search also?

  46. Bryan White says:

    I had a positive needle experience. Definitely not acupuncture though.

    My hand surgeon performed needle aponeurotomy on my small finger that is particularly afflicted with Dupuytren’s contracture (and Boutonniere deformity) under local anesthetic. The condition is regressing slowly but I can still get it in a glove several years later.

    Interestingly the technique was developed by French surgeons due to the high frequency of occurrence in males of Northern European origin and low rates of pay for surgeons. It’s much faster than a traditional fasciotomy and doesn’t require an operating room.

    Needles do have their uses.

  47. Badly Shaved Monkey says:

    I’ve come to the party a bit late, but to pick up this from Windriven;

    As difficult as it is to subject acupuncture to traditional, well-blinded RCTs, it seems to me that surrogate outcomes will have to be part of any balanced evaluation of acupuncture.

    I don’t think so. Acupuncture doesn’t work, at least not in any meaningful clinically significant way, although I am prepared to set aside ‘dry needling’ for the moment as something rather different not quite addressed adequately by trial as far as I am aware (thought happy to be corrected on that point).

    So, what’s the best that can come out of examining surrogate outcomes for real and sham needling?

    Because there are no meaningful clinical effects, any differences in surrogate outcomes would only represent a very expensive and complicated assay for saying which trial arm had the real needles. Looking at the needles or the coding sheet would be, I hazard to suggest, both cheaper and simpler.

    Having to apply the medical technological equivalent of spotting a candle against the glare of the Sun is impressive but not very useful. It might be feasible, but why bother.

    Nonetheless, if anyone is currently planning a trial of acupuncture I would be pleased to offer, for a modest fee, my services in looking at needles and spotting toothpicks among metal needles.

    I hope I can be of help.

  48. pmoran says:

    BSM, It goes without saying that there is no point to further study of acupuncture of the kind that can only keep on producing the same results.

    There is however a lot of presumption behind the assertion that benefits from placebo and other incidental influences of CAM methods are always spurious, or always trivial enough to be ignored. The evidence suggests that their strength will depend upon many factors.

    So we need more proof if we are to go around bad-mouthing those methods (rather than their risks) to the extent that we do, regardless of whether we choose not to employ them within our own practices on arcane (to the public) “null hypothesis not disproven” grounds.

    Our mandate from the public does not extend to denying them potential medical benefits, as, I think, the very phenomenon of CAM demonstrates. (Everyone now springs to their feet saying, disingenuously, “we are not denying anyone anything” Humbug! — when the title of this post is the bald “Acupuncture” doesn’t work ! )

    It is only by devising objective surrogates for true symptom relief that we get such proof. Mainly we need to be able to distinguish true symptomatic benefits from reporting bias. I think this will eventually happen, although it may take some time.

    We should be careful until then, or this will add to the already long list of things that we in the mainstream were very wrong about even when sure we were right.

    1. Badly Shaved Monkey says:

      Peter

      I acknowledge the point you make, but I don’t agree with it. Sure there are some grey areas, but I think there’s plenty where we can confidently say “doesn’t work” and I think we do our patients a disservice if we keep the door open on busted therapies. Even in this world of collaborative decision-making we are supposed to know enough to give clear advice where the evidence is good enough. Mealy-mouthed vagueness from us also does little to erode the effect created by Tru Bleevers who are heavily vested, personally and financially, in SCAM offerings.

  49. Tim says:

    This article sheds light on something that was already known: that Acupuncture has little affect on CHRONIC pain. But Chronic pain is just one claimed benefit of Acupuncture. If Hypnosis was shown to not help people stop smoking, would that mean it has no use and should be banned? …while hypnosis may be quite effective at solving other problems? No, I don’t think so. The title of this article should be “Acupuncture appears to have little affect on Chronic pain”. But alas, the “unbiased” author decided to instead go with the title “Acupuncture Doesn’t Work”.

    Although Anecdotal, I’ve personally experienced profound improvements to 2 different acute injuries immediately following Acupuncture therapy. A 2 month old neck injury that wouldn’t allow me to turn my head to the left without excruciating pain and a nagging month-old knee injury -both gone within 2 days after receiving acupuncture therapy.

    Although I know these are purely anecdotal and by no means a viable study, it’s difficult for me to dismiss Acupuncture as ‘quackery’ simply because somebody points out that studies show only minor gains over placebo when tested on chronic pain. Maybe it was the heat combined with the massage she would do after, or the ‘cupping’ which is more than just needles. Maybe there is an explanation and this guy has it right, but I highly doubt the placebo effect alone could fix a neck injury that prevents you from turning your head to the left without major pain….in only 1 day.

  50. WilliamLawrenceUtridge says:

    Depending on how you define acupuncture, it doesn’t really work for chronic or acute pain. Depending on your fishing expedition, it can be said to work for both. The point is, lots of things are claimed for acupuncture, the evidence is null for all but pain and nausea, and for pain and nausea, the results are questionable. It’s been tested for myriad things, the only thing it seems to work for are two symptoms which are incredibly susceptible to placebo effects.

    The fact that you are citing personal experience, anecdote, means you don’t understand the scientific process. As I’ve recommended before, Snake Oil Science is a good book to explain why, you should read it. For instance, you may have visited the acupuncturist when the symptoms were at their worst, and thus due to regression to the mean, likely to reduce anyway. Yes, indeed, intense personal narrative and confirmation bias are extremely difficult for humans to overcome, which is why science took so long to develop. But surely you can see that when it arrived, when a process developed that deliberately worked at challenging, testing and disproving our biases took hold, the resulting improvements in every aspect of human life were dramatic.

    Keep in mind, the term “placebo” is a complicated one. You don’t avoid placebo effects by being smart, or knowing about it. Placebo effects can be quite dramatic, but they’re nonspecific – a similar, even less intrusive intervention, could have exactly the same benefits, which might not produce any objective improvement.

    Also, you’re describing not just acupuncture, but also heat, massage and cupping. Which improved your neck pain? You’re describing a spaghetti effect – you could equally attribute your improvement to any one of these interventions, why pick acupuncture? How do you know it wasn’t the much safer, far less intrusive, far more sterile massage? This is why adequate controls and isolation are needed.

    1. Tim says:

      If you read my comment you should know that I stressed repeatedly that my neck/knee injuries were purely anecdotal and that the results could very well have been due to one of the other treatments. Perhaps I shouldn’t have even brought it up, but just fyi, I had tried plenty of massage + hot/cold therapy first, and we’re talking about a 2 month injury that was fixed with one treatment.

      Could you point me to the study that shows conclusively that Acupuncture doesn’t work for Acute injuries? All I see mentioned in this article are studies on ‘chronic’ pain. And these studies actually concluded that Acupuncture DOES work, although not that profoundly. What isn’t clear to me is how the author translates this into “Acupuncture does not work”. It doesn’t sound very scientific to me to jump to conclusions like this when in fact the study results seem to say the opposite but are not very clear. Furthermore, chronic pain is only one application of Acupuncture. But the author’s statement seems to lump all applications of Acupuncture into the ‘quackery’ category.

      Yes, until proven effective, I’ll be skeptical of Acupuncture, but I don’t think it’s fair nor scientific to pretend to have settled the debate yet.

      This study suggests that it works better than medication for Acute lower back pain:
      http://www.ncbi.nlm.nih.gov/pubmed/23269281

      1. Andrey Pavlov says:

        “Could you point me to the study that shows conclusively that Acupuncture doesn’t work for Acute injuries?”

        That’s the point you are missing. There is no such thing as A single study to “prove” anything. That is impossible. That is why we do meta analyses in the first place. We look at multiple lines of converging evidence to bolster our conclusions.

        In uncommon cases we get really as close to certain as we can be. The Standard Model of physics for example. There is no one paper that proves the Standard Model is correct. But we have do much evidence to support it of such high quality it would be perverse to deny its veracity.

        After thousands of trials we are arguing over whether an effect of acupuncture exists at all. The better done the trial, the smaller the eeffect size. And nearly all the trials that are positive are weakly so with a small effect size. Only really bad studies have the largest effect size. And we certainly can agree some are very bad and obviously done with a conclusion in mind twisting the data to fit.

        The fact of this alone is serious reason to consider the complete disutility of acupuncture. The evidence looked at as A whole completes the picture, with no reasonable mechanism of action that would salvage utility.

        So at what point can we finally say it is time to move on? How small must the potential effect be, how implausible that it will be any use clinically, how much ideological baggage must it carry before you are willing to say it is time to move on and declare acupuncture dead? I’m sure there are claims you feel this way about. Are you applying the same standard in judging all claims? Or us acupuncture getting a special bye? Or perhaps no claim is so ridiculous for you to feel that way. Do you think homeopathy has some potential benefit and more research is needed?

        1. weing says:

          From my understanding of statistics, which is little, the “p” has no relationship to the size or importance of the effect. Very small effects can have a very impressive “p” if you have a large enough population studied. If acupuncture had even a small effect, I would then expect a very impressive “p” with larger studies. Because the “p”s barely meet statistical significance, I am very skeptical of any effect. If anyone with better knowledge of statistics wants to correct me, please do.

          1. Andrey Pavlov says:

            Weing:

            You are correct. The p-value has nothing to do with an effect size and things cannot be “more statistically significant.” Statistical significance is an arbitrary cutoff of 0.05. Thus, 0.04 or 0.000001 tells us the exact same thing about the claim, except that we can be more reasonably sure that the null hypothesis is safe to reject in the latter (all else being equal, of course).

            Where this fails is if the study is underpowered or otherwise tweaked in some way to produce a lower p-value by manipulating input parameters. There was a study that demonstrated a sharp rise in reported p-values at just below the 0.05 mark indicating that it is likely there is some sort of manipulation (likely throwing out cases post-hoc deemed to be reasonable to remove from the study for some reason) going on.

            Which is why I am not impressed with p-values beyond saying if they cross significance. The entirety of the study needs to be looked at as a whole in order to determine what that p-value is really conveying, especially in the context of a Bayesian framework. But people – even “smart” people – really like simple things. P<0.05 = good, p<0.05 = bad. Good = study prove something. Bad = …. well… manipulate the data and make excuses, in the CAM world. LOL.

            It is, of course, much more complicated than that. Which is why meta analysis is a very useful tool. However, anyone who has taken (and understood) basic sciences should understand about significant figures and the rules for reporting results of calculations – you cannot have a result more accurate than your least accurate measurement. Similar in meta analysis – garbage in, garbage out.

            The fact that larger and more robust studies of acupuncture demonstrate smaller and smaller (or non-existent) effect sizes is not indicative that we need more studies to "find" the effect as Peter Moran would seem to have us believe. It indicates a trend which, when coupled with everything else we know about acupuncture, leads us to reasonably conclude that it doesn't work in the same way we can conclude that a lead balloon will not float. Except in the extremely contrived circumstance the Mythbusters did, it really won't float, and the exception is of no practical use.

  51. Mia Taylor says:

    It all depends on the perception of the patient whether acupuncture work or not.

    1. Egstra says:

      “It all depends on the perception of the patient whether acupuncture work or not.”

      And that’s exactly why acupuncture is bogus.

  52. WilliamLawrenceUtridge says:

    Tim, if you know anecdotal experiences are scientifically unconvincing, why bring them up? All you’re proving is that you’re falling for a well-recognized fallacy of allowing personal experience to be more compelling than science. We already know that, and we know why personally compelling evidence is extremely untrustworthy. Have you ever looked into Elizabeth Loftus’ research on eyewitness testimony? Or false memories?

    As for magic bullet studies, Andrey has discussed that. In addition, if acupuncture works for acute pain, that’s not particularly interesting. Acute pain goes away on its own. It’s still just pain, it’s a symptom, not an etiology. But if you’re looking for reviews, you should learn to use the search feature of the Cochrane Collaboration’s website. It turned up this review (“There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain” – if it is as effective as you say, shouldn’t we be able to demonstrate this?). But really, isn’t it up to you? You’re the one making the dramatic claim, that acupuncture works for acute pain. Surely if this is true, you can muster some evidence for it, can’t you? If acupuncture is effective, dramatically so, shouldn’t this appear somewhere in the scientific literature?

    Note as well that back pain is a difficult topic. Most comparisons are to “usual care”. Usual care for back pain is terrible, we honestly don’t have much that works well for back pain. Doing anything new tends to have some effect compared to usual care because back pain tends to be chronic, and most patients are used to being disappointed by usual care. I believe Trick or Treatment goes into this in greater detail.

    Please stop discussing how acupuncture worked for you as if it were evidence, unless you are using it as evidence that you don’t really understand the scientific process. It’s simply not evidence for acupuncture being effective.

  53. cloudskimmer says:

    My experience of N=1 is that of my mother, with a long-term chronic back pain problem. Everything “worked” for 2-3 months–which means that nothing really worked. Her well-meaning primary care physician provided a referral to an acupuncturist, and I said nothing, hoping for a bit of relief for her. My observations:
    Needle insertion is not sterile. The acupuncturist uses bare fingers and slides the needles along them, rendering their sterility useless. (Dr. Crislip has commented on this.). Neither did she clean the skin prior to needle placement. The needles are sterile, the procedure is not.
    The needles were very painful. In fact, the procedure caused a lot more pain, and relieved none. In response, the acupuncturist told her to just “relax and get into the experience. That was no help at all.
    Because initial needle placement did nothing but cause extreme distress, the acupuncturist tried placed more needles into her ear, which caused even more pain.
    Because neither procedure helped, she hooked up an electrical device to the needles, and the pain continued.
    Finally the needles were withdrawn, and recommendations were made for more treatments, as well as oral enzyme tablets–very expensive and conveniently sold in her office. We left.
    My mother complained of dizziness as we made our way down the steep staircase from the acupuncturists office. When we returned home, she threw up. In a phone call, the acupuncturist denied that her procedure could be responsible for these adverse effects.
    From my observations, acupuncture causes pain, nausea, dizziness and vomiting. Needless to say, we never went back. I doubt that acupuncture is effective even for chronic pain and/or nausea, outside of the placebo effect. Acupuncturists are simply quacks, and all my subsequent research seems to point to that conclusion.
    For those who disagree and think the decision is simply that of choosing between anecdotes, you ought to admit that viewpoints contrary to your own are equally valid. If you admit to the possibility that science may lead us to true conclusions, you ought to develop the ability to evaluate the research, and try to eliminate confirmation bias. Otherwise you occupy a space where all views are equally valid, which may be true when judging if a work of art is pretty or not, but of no use when choosing between science based medical treatments and SCAM.

    1. WilliamLawrenceUtridge says:

      Your first point about everything “working” is pretty much the first point of R. Barker Bausell’s Snake Oil Science.

      And it sounds like your mother may have experienced nocebo effects; I believe all the symptoms you describe are mentioned by Edzard Ernst in his “review of reviews” of acupuncture.

  54. hippiehunter says:

    I have found acupuncture very helpful in treating my fear of needles.
    My doctor suggested exposure therapy but after a year of regular visits to my acupuncturist I dont need it anymore.

  55. Artoo45 says:

    I love the passive/aggressive “it works for me” drive-bys. They have nothing but anecdote, so they stick the flounce on the first post. Reminds me of me back in my altie, worried-well days . . .

  56. P. Axelsen says:

    This study seems quite conclusive. Yet, “is there really any need for more studies”. Yes, because this study had focused on pain, which is not a disease in itself. A meta analysis should be conducted assuming the null hypothesis for a variety of diseases.

    1. Andrey Pavlov says:

      That is kind of the point of this site – to demonstrate that using a Bayesian framework will allow you to safely stop wasting money on research in many cases. We do not need more studies (or meta analyses) of acupuncture (or homeopathy or reiki or therapeutic touch) for each indication. The premise of these treatments is flawed, there is no reason to believe that they would have efficacy for any other indications, and ergo we can stop wasting our resources on finding no worthwhile effects.

      By extending your logic just a little bit we should also do studies to demonstrate that jumping on one leg while singing your favorite song doesn’t provide benefit for toothache. And then do another study to see if it provides benefit for diarrhea. And so on

      1. P. Axelsen says:

        I understand your point, and thank you for your rely. I still think that, unfortunately, to stop people from wasting millions on bad treatment, we will have to spend more money on research to debunk acupuncture (and all clinically irrelevant therapies for that matter). The argument that pain is not a disease was the answer I was given by a acupuncturist when confronted to the conclusion of this study. Not knowing what to say, I turned to you for an answer. Thanks.

  57. WilliamLawrenceUtridge says:

    We’ll never be able to stop people from wasting their money on this. I think the best things we can do are a) ensure that publicly-funded health care plans do not reimburse and b) lobby insurance companies not to reimburse them (as it drives up premiums, though perhaps they could offer tiered plans with and without nonsense as a way of offering more customer choice). If people want to pay out of pocket for this sort of nonsense, there’s little we can do – and chances are they wont’ be convinced by the evidence no matter what. People should have the freedom to spend their money on harmless nonsense so long as it is indeed harmless (or close to it) and doesn’t make false claims. For me, that’s the lines – no public reimbursement, I don’t want to have to pay for it out of my insurance premiums, and (here is where most of the government effort should go) prosecute those who promise what they can’t deliver.

  58. pmoran2013 says:

    BSM, re “Mealy-mouthed vagueness — “. (answer delayed by technical problems with this blog)

    Well, I understand the wish to send a strong message, but sound science is characterized by BOTH cautious pronouncements and precision of language. Loose language encourages an over-simplifying, “near enough is good enough” approach to medical science. The message gets muddled. Studies get misinterpreted. “Lot’s of people are saying it, so it must be true.”

    Surely you are aware how some prominent skeptics are explaining how some testimonials suggest a placebo response, while others (mainly on SBM) are expressing some certainty that placebo responses either don’t exist or are too trivial to be of any use at all (a conclusion that will be noted by the more cynical to have surfaced only AFTER it was thought — wrongly in my opinion — that CAM practitioners might want to use them to justify their activities. ). Which is closer to the truth?

    Note also: that when the above data was presented to a cloistered scientific audience it’s title was “Acupuncture Is Theatrical Placebo”, whereas when presented to a mostly lay audience on this site, the title becomes an unqualified “Acupuncture doesn’t work”.

    There are vastly different scientific implications to those two titles. The first is likely to prove the more scientifically accurate, although it does tend to lump a sizable spectrum of possible mundane therapeutic influences under the heading of “placebo”, rather than as “placebo and other non-specific influences”, as some of us would prefer with such complex interventions. Also, if “it doesn’t work”, even as placebo, as per the drift of it all, what does it matter how theatrical it is?

    So, yes, we have the secondary objective of hoping to persuade the public regarding certain matters (– the primary one being to be quite sure that we understand the science of medical practice in all its variants and complexities). But first we must have their trust, which is one good reason for showing restraint where that is what the science calls for, but firmness wherever . the science permits. .

    1. Andrey Pavlov says:

      Peter – once again hiding in that gray. The discussion needn’t even progress to the level of scientific pedantry you are espousing. Deep discussions about the objective validity of placebo responses that effect objective and repeatable physiological changes are neither here nor there. The effect size in aggregate is still small enough to be clinically insignificant. Whether or not placebo can be rightfully dismissed entirely or not is absolutely irrelevant. Only poorly conducted studies and a very, very small smattering of better conducted studies demonstrate a meaningful effect size for acupuncture. Good studies have small ,if any, effect sizes and most all the rest snuggle up nicely around a clinically insignificant effect size.

      So whatever your inclinations and arguments for the placebo are matters not one jot.

      We didn’t think to consider placebo responses as clinically insignificant until after CAM began to try on the robe of “placebo medicine?” Something you don’t believe has happened anyway? Quite an accusation, and one that doesn’t really stand up. No doubt the old school thought is that it is a complete fabrication. But even I have never thought it was a complete artifact of study. And even then the temporality of it doesn’t inherently dismiss the concept as false. The same as COI on a study doesn’t mean it is a bad study – just that you should look more closely at it. So a simple and ominous “well maybe they just decided to take this tack as purely a reactionary outcry to CAM… wink wink” is simply bad rhetoric and a dirty tactic.

      So titles in a “cloistered scientific community” mean… what? They must be more accurate and reflect the science in an unbiased manner? I’m not sure what literature you read, but it must be rather narrow. And so what if the title here is different? Different doesn’t mean inaccurate and, once again, needs more follow up than just an attempt at guilt by shady implication.

      Also, if “it doesn’t work”, even as placebo, as per the drift of it all, what does it matter how theatrical it is?

      And this is when I just feel as if you must be disingenuous. Really? You can’t imagine what role theatrics would play in a completely and utterly useless thing that doesn’t even pretend to do something? Ever heard of a snake oil salesman? And how they would ply their wares? Ever consider going to pay money to see a boring show? Ever tried to make an expensive night at the theatre seem better because you paid good money for it and it turned out to be a disappointing show?

      Of course theatrics is important regardless of the validity of the placebo response!

      And indeed, the firmness is permitted by science. It is a question of where to draw that line of firmness. The argument here is that we feel the line of firmness need not be so incredibly far off. You are arguing that we haven’t met your requirements for the line of firmness. We are having different conversations – we understand we haven’t met your line. We are arguing that your line is wrong. (amongst a few other more minor points)

  59. pmoran2013 says:

    Andrey, you yourself describe above how acupuncture “worked for you” as an analgesic under quite dramatic circumstances. You describe the intense euphoria that you experienced after acupuncture sessions for another condition.

    Why would you now dismiss such psycho-sensory experiences as of no medical value under any circumstances, especially when that inevitably requires us to adopt a dismissive and alienating attitude to anyone who recounts similar experiences?

    This is not only a matter of a risky scientific interpretation through a focus upon studies in which if anything placebo responses may be inclined to be suppressed, to the exclusion of other highly suggestive evidence, There is a form of methodolatry in this to the exclusion of plausibility and other data.

    Over-simplifying the science is also risky so far as persuasion is concerned. I have found that when talked to reasonably, most CAM sympathizers can entertain the possibility that the benefits they observe might be due to placebo or incidental influences. What they won’t accept is being made to look like fools who cannot even know how they are really feeling.

    1. Andrey Pavlov says:

      Yes, indeed I have had such experiences. People also have near death experiences and are convinced that they can talk to Jesus and speak in tongues. These are completely psychogenic effects with no objectively real benefits.

      It is completely akin to chopping off your foot and then repeating over and over “I still have a foot, it isn’t bleeding, I am OK” and believing it. Sure, you can convince yourself that you really are fine and the pain can “go away” and you can even convince yourself that the bloody stump your are staring at isn’t yours or isn’t even there, but this is not anything more than tricking yourself into denying reality.

      The whole time I had acupuncture (also NB that my euphoria experience was electroacupuncture which is a whole different ballgame – like saying that Reiki works for pain whilst simultaneously injecting hydromorphone into your patient) I still had the pain. I kept going back over and over until finally the time and money commitment proved onerous enough that I didn’t want to waste my time. I tricked myself into ignoring my pain – it wasn’t actually treated.

      Hence why I can dismiss the experience as useless and a waste of my time and money. I can understand how your own mind can trick you without any lasting, objective, or worthwhile benefit. Just like Beethoven in clockwork orange.

      The attitude is not to dismiss the other person’s experience but to clarify that it was a false experience – a trick of the mind. Just like someone staring at an optical illusion should not be told that it is truly happening but merely a trick to confuse the optical system. Such “tricks” are not limited to optics but can – and are – indeed much more profound. Using such tricks as a clinical adjunct is not only unethical, but entirely useless. A band-aid over an arterial bleed that will only work as long as everyone agrees to pretend it is working (or the patient bleeds to death).

      There is no methodolatry involved in this. It is a fair and reasonable assessment of the current state of knowledge and ability. Yes, placebo responses (true, objective, physiologically altering processes) do exist. No, there are not currently clinically significant nor can we reliably use them in a clinical setting. When you show me data to demonstrate we can reliably use placebo responses in clinically significant ways I am happy to add that to my armamentarium. The rub will be doing it ethically (i.e. without lying to the patient). That evidence is not only not there, but so far has been shown to not exist. I leave it open that it may in the future, but for now placebo must be relegated as an adjunct to actual medicine which we call “bedside manner.”

      And of course – tack with individual people is different. We’ve been over this before. You seamlessly slip between speaking to the audience writ large and the individual patient in my consultation room. They are fundamentally different and it would be wrong to treat them otherwise. I would not speak to my patient in the manner of Dr. Novella’s article nor would I ever write an article in the manner I speak to my patients. But that is true for any scientific or medical article.

  60. pmoran2013 says:

    Andrey “These are completely psychogenic effects with no objectively real benefits.”

    We are talking about human suffering which is real despite being subjective.

    Part of our message should be that “mind-body” effects have limited potential so far as medical outcomes are concerned. We don’t even get that message across when we try to damn all use of CAM to hell by making sometimes problems into global ones, even when we have no entirely satisfactory and safe answers ourselves, and we thereby induce some to think that we are about to get stuck into their freedoms for unclear, but presumably base reasons.

    And why should your attitude towards CAM with your own patients be very different to your public one? That also suggests a muddled perspective.

    The science is not as clear as we are being told. Note that “high quality studies” in general means that action has been taken to minimise the influence of placebo and non-specific influences. That can include patients not knowing whether they are supposed to get better or not. Then we claim to have shown something about these medical influences.

    This is why “the better the quality the less the effect ” is not so clear in relation to acupuncture variants. It applied more so to double-blinded studies of homeopathy, a simpler matter for clinical study. There the null hypothesis can relate closely to the intrinsic activity of the method.

    .

    1. Andrey Pavlov says:

      “We are talking about human suffering which is real despite being subjective”

      Yes. And the reduction in said human suffering through acupuncture is transient at best and more likely non-existent. Either a flimsy bandage ready to fall off at the slightest draft or a shared delusion of practitioner and patient, each merely agreeing that the incantation worked despite having no actual relief.

      “And why should your attitude towards CAM with your own patients be very different to your public one? That also suggests a muddled perspective.”

      My attitude is the same. My tack for approaching it is different. And if yours isn’t then I either pity your patients or pity you for being so blinkered. My perspective is not muddled in the slightest. Changing your rhetoric to reflect the audience you are speaking to is not a sign of muddled thought or wishy washiness – it is how one should conduct themselves. I can have the same attitude, same convictions, and convey the same message in multiple very different ways. If you can’t, then I suggest you practice at it.

      So far I have had great success in telling my patients exactly what I think of CAM in a kind, respectful manner that acknowledges that it does seem to help them but that likely the effect is not worth the cost (financial, time, risk, some combination thereof) and have even told them flat out that the existence of certain effects (homeopathy, reiki) are non-existent. I’ve been universally thanked for my candor and kindness and had many patients decide to stop wasting their time and money. I am certain that over the course of my career this will not hold universally true as I will undoubtedly encounter some true believers. But so far so good.

      And I have brought up the concept of smoking cessation with you before and, as usual, you ignore such lessons and continue your holier than thou attitude and stick to your conclusions.

      When I counsel patients on smoking cessation I do not say “Smoking is bad, it will kill you, you will die a horrible death, and you should stop otherwise you are stupid.” Scare tactics do not work on an individual level. There is good data to show that. In fact, the first tack to take is asking if the patient is ready to discuss smoking cessation. Then to ask them what benefits they receive from smoking and acknowledging that there are indeed benefits. Then what the negatives are and weighing them against their values and ultimately pushing them towards the correct decision of smoking cessation. The same exact tack can be taken for CAM.

      On the flipside public messages and ads have also been shown to be quite effective in reducing smoking on a population level. And those are nasty, unequivocal, often garish (graphic photos of strokes and lung cancer), and do not acknowledge any benefits to smoking and focus entirely on the universally negative nature of smoking.

      Boy what a muddled message and thought process we must have on smoking! How could we possibly have such two completely different tacks depending on our audience? One of them simply must be wrong! Clearly we should make smoking cessation ads include bunnies and joyful messages to match our cloistered patient interactions.

      Please. You are intelligent enough that you should not be making such asinine arguments anymore.

      “The science is not as clear as we are being told. Note that “high quality studies” in general means that action has been taken to minimise the influence of placebo and non-specific influences. That can include patients not knowing whether they are supposed to get better or not. Then we claim to have shown something about these medical influences.”

      Exactly. And what it shows is that there is nothing unique or intrinsic to acupuncture. Which is exactly why acupuncture doesn’t fracking work. The same can – and is – said for homeopathy. Why aren’t you on your high horse over on those threads touting how the wonderful ritual of homeopathic nostrums shouldn’t be so maligned? Why don’t you have the same standard regardless of the BS placebo theatrical delivery system?

      And that is the point – you admit (tacitly) that acupuncture is nothing but placebo, but then you try and admonish us not to damn acupuncture and yet don’t do the same for homeopathy, reiki, therapeutic touch, reflexology, iridology, applied kinesiology, etc etc. Those invoke your “non-specific” effects and genuine placebo responses too Peter.

      And even then, it has been demonstrated over and over that placebo alone is not only not ethical but not particularly effective. Yet. There is potential, I agree. But until it is realized and can be ethically applied in a clinical setting it is only useful as an adjunct to actual patient care – “bedside manner.”

      But I have no illusion you will actually get off your acupuncture hobby horse and apply a consistent standard to your argumentation. You have a penchant for seamlessly blending and switching from one specific to another to prevent anyone from pinning you down. No doubt it’s effective, but also disingenuous.

      1. WilliamLawrenceUtridge says:

        For me the real question is – is the effect reliable? Can it alleviate suffering in the same way analgesics and anesthetics can, or real medications? Particularly for the latter, the answer is “no”, because acupuncture has no specific effects. For the former, the question seems to be – unreliably, over the short term, for some patients, and completely unrelated to any of the magical nonsense used to explain it. No matter what, it is not on par with genuine medications in terms of reliability, though perhaps it might have fewer adverse effects.

        I don’t have a problem with it being an option available to patients, given the restrictions I listed back on June 20th, in particular divorced from nonsense and magical “how it works”. I don’t think it should be a front-line or first-choice option, but I do think that the best and safest way to deliver it is as an option in mainstream care (it’d be safer, it’d be more sterile, it’d be cheaper and it’d be more scientific). And it would probably result in acupuncture becoming mainstream and eventually abandoned as the impact of placebo wither in the absence of mysticism.

        1. Andrey Pavlov says:

          Indeed. It has fewer adverse effects because it has fewer effects.

          However we are at an impasse here when it comes to making it available to patients. I agree it shouldn’t be made illegal, but neither should physicians be using it. On what basis would we be taught to use it?

          And that is the entire problem with acupuncture – and all placebo medicine – is that we can’t be ethically trained to use let alone actually use it. Because once we are aware of it being a placebo with absolutely minimal actual effects it becomes our professional onus to not use it. Any actual medical intervention that is discovered to have minimal positive effects we work hard to stop using – particularly if it has significant negative effects. So if we teach acupuncture honestly then it is a horse that can’t get out of the barn.

          1. WilliamLawrenceUtridge says:

            Having thought about it a bit, were I a doctor (and thankfully I am not, I’d be awful), I think I would approach it as:

            There is some evidence behind it, we’re not sure how it works, the most probable to me in terms of physiology is that it may be a counter-irritant, but it may help your pain and nausea. I don’t think it is a cure, but it might make you feel better while your body heals. If you are interested, we will use sterile instruments and clean your skin beforehand, and will only insert the needles superficially, well-away from organs, blood vessels and nerves. The side effects are minimal when performed in this way, and if it works for you we can keep doing it. If it does not, I will continue to work with you to try to find an alternative.

            It skirts rather close to the edge of outright deception (in particular, while “counter-irritant might be the best physiological explanation, I would say “placebo” is probably the best explanation overall – but some placebo accompanies even merely taking a history, it can’t and shouldn’t be avoided, so it’s on the border of ethical. In some cases, I think there’s merit in using placebos in medicine for patients who might otherwise go to a fake doctor who could do real harm. But that’s such a huge, slippery, paternalistic slope, I am afraid where me-as-a-hypothetical-doctor would end up.

  61. mihai says:

    3 questions for you all:
    1. If acupuncture is a scam, why doesn’t work if the needles are not inserted in the right locations? The studies are done like, we have a point, LI4, let’s see if it does what they claim. WRONG
    2. if it’s a placebo, why can’t u gain some relief doing something else and not acupuncture? such as standing in one foot, believe in it and your pain will be gone. Can u do something like this?
    3. Even if it’s a placebo, the patient will be very happy as long as he is cured, why does it matters? The ultimate goal of a patient would be to get healthy.

    1. Andrey Pavlov says:

      1) This is false. There is no well designed study that demonstrates the needle needs to be in a specific spot and plenty to demonstrate that not only does the spot not matter, but that it doesn’t even matter if you insert the needles.

      2) This works as well. Distraction from pain is a well documented technique and this is another distraction technique and nothing more.

      3) Because lying to patients and knowingly giving them a placebo is ethically wrong and practically not a good idea either. Can you imagine if a pharmaceutical company was selling a pill that they made up a story about how it worked, saying it was a monoclonal antibody that blocked the pain receptors and thus decreased pain with no risk of dependence, and then we found out that they were completely lying about it and just giving you a sugar pill? Wouldn’t you be pretty upset? What if you found out that your doctor knew that it was just a sugar pill and went along with the lie? Would you trust your doctor?

    2. davdoodles says:

      “If acupuncture is a scam, why doesn’t work if the needles are not inserted in the right locations?”

      For the same reasons it doesn’t work when the needles ARE inserted in the “right” locations?

      Do I get a prize?
      .

  62. WilliamLawrenceUtridge says:

    Acupuncture isn’t a scam, it’s almost certainly an extremely convincing placebo. The only point I’m aware of with asserted specific effects is the P6 point on the wrist for nausea (which isn’t actually a specific effect), and I’m not sure about the quality of those trials.

    Acupuncture being placebo neither proves nor disproves the effectiveness of other interventions, either as placebo or as specific effect. You can indeed obviate pain with non-acupuncture placebos. For instance, participants in the Native American Sun Dance will pierce their chest muscles with hooks and experience no pain, despite essentially dangling from them. It’s quite gruesome, but it’s basically your example of “standing on one foot”. Then there is the Phuket vegetarian festival featuring extreme cheek piercings, which are experienced as ecstatic rather than painful (warning, gross pictures in that link).

    And as for “the powerful placebo”, it’s a waste of money compared to actual treatments, which done properly are accompanied by their own placebo effects. The goal of medicine isn’t happy patients (who might not get real treatment in time, leading to unhappy patients who die gruesome, painful and unnecessary deaths), it is to cure disease. The goal of patients should indeed be to get healthy, but acupuncture won’t help with that. At best it delivers short-term pain and nausea relief for a subset of patients for whom it is effective, with a (small) risk of lung collapse or even death. I’m not sure why you are pretending or claiming that the goal of real medicine isn’t “to get healthy”. It is. Acupuncture just isn’t part of that process.

    1. Bold statements about what we do as physicians! We don’t usually cure, we assist in the healing of the human body.

      Have you performed Acupuncture or used needling?
      Have you had it done on yourself?

      Acupuncture is safe and non-toxic with no drug to drug interaction!

      Can you truly define what Acupuncture is–you have an opinion on–that is just a placebo?

      1. WilliamLawrenceUtridge says:

        Acupuncturists aren’t physicians. Antibiotics are pretty curative, so is surgery to remove sold tumors, chemotherapy for blood cancers is curative, vaccines are preventive, even better, and you can’t cure cystic fibrosis, you can just stave off death.

        My doctor has never had cancer, can he still diagnose it? I’ve never treated someone with chemotherapy, can I still get it if I develop cancer?

        How safe was acupuncture for Kim Ribble-Orr? And if you say “safer than medicine”, well, a collapsed lung is probably less safe than Tylenol. Plus, the lack of safety of drugs or surgery has no bearing on how safe acupuncture is.

        Can you point to specific, high-quality evidence that acupuncture is not a placebo? Any specific, and in particular recent studies?

  63. Hello all, I have a problem with this article! The design and the outcomes are invalid.

    1. What is Acupuncture? There are many types and many philosophies related to Acupuncture. I did not see a definition or a description of the techniques used and for what it was being used for??

    I been using Acupuncture in my family practice for 15yrs and it is not what I was taught! It is a powerful tool and that is all it is. It does what it is supposed to do and does it very effectively.

    I will be commenting on a few statements, please ask questions!!

    1. WilliamLawrenceUtridge says:

      There are many types of acupuncture because it has no underlying mechanism besides placebo. As long as it’s dramatic, it works, so it’s very easy to splinter into many different forms – Korean, Chinese, Thai, Japanese, Tibetan and more. It’s very much like a religion – when you have no real phenomenon to pin your theories and observations to, randomly flailing in any direction gives you just as good an answer as any other direction. It may have an internal logical consistency – but it has no external validity.

      I’m not really asking questions, but you should look into the many articles here to see why there’s good reason to believe it doesn’t “work” beyond placebo. It doesn’t matter where you put the needles. It doesn’t matter whether you penetrate the skin. It doesn’t matter if you use needles. But what does matter is emphasis on the foreigness and exoticness of the treatment, the drama of using all those needles, the long consultation, the lengthy discussion of symptoms, the caring dialogue with the practitioner.

      You are giving your patients an extremely effective placebo which transitorily reduces some of their symptoms for a short time but does nothing objective to genuinely help them.

      I hope you use sterile needles and gloves.

  64. I posted earlier because I was excited and nervous about most of the chatter. This entire study is erroneous–as are all the studies done in the past decade. I am certain most here have very little experience with Acupuncture and it modern versions. The whos whats whys of this most powerful tool. This has to be clarified as soon as possible.

    1. Harriet Hall says:

      You are making a very bold claim when you call all the studies done in the past decade erroneous. How do you know this? Why do you claim it is a “most powerful tool”? Do you expect us to disregard science and believe you simply because you say so?

    2. WilliamLawrenceUtridge says:

      Please start a dialogue about exactly what specifics you think support your points. Please note that “it worked for me” or “it worked for my patients” is not a meaningful specific thing to say.

  65. Define Acupuncture and we can compare apples. It is not what you think.

    1. weing says:

      “Define Acupuncture and we can compare apples.”
      Placebo. Mumbo-jumbo placebo? A shamanistic ritual? All variants on placebo.

      1. Easy to deny and hide behind studies. There are aspects to the discipline that need study. It is like the differencebetween .3 mg of clonidine and .9.
        Do you really want to know ?

        1. WilliamLawrenceUtridge says:

          The onus is always on the claimant though. If you think there are specific uses for acupuncture, what are they? What is your evidence? Why haven’t they been identified? As best we can tell, using the best research methodologies we have, it doesn’t matter where you put the needles, it doesn’t matter whether you penetrate the skin, chi doesn’t exist, and it’s only useful for two limited symptoms that are both highly liable to the placebo effect (the acute relief of pain and nausea). Meanwhile, acupuncture is enhanced by practitioner confidence, lengthy consultations and elaborate explanations that emphasize its alleged ancientness, and some mystic rigmarole (which are essentially lies, or at least untruths).

          You may be dealing with an elaborate placebo, and if no evidence will ever convince you of this, then you shouldn’t bother discussing it. I simply can’t see any reason why there would be a real effect that we’re somehow missing whenever good-quality studies are completed.

    2. G.Shelley says:

      I suppose a rough definition would be “The insertion of needles at specific points in the body to manipulate the flow of chi and this reduce or prevent illness or symptoms”
      Do you have a different definitions? If it isn’t needles, it isn’t acupuncture. You might be able to argue that the placing of the needles isn’t important and still get to call it acupuncture, but that would be a struggle. You might also be able to get away with a non chi based form, but you would then need an alternate mechanism (preferable one that is science based rather than superstition based)
      Non of which would change the fact that as tested, it doesn’t work. Of course, you might be able to claim that your own personal definition of acupuncture hasn’t been tested, but the tests have been so varied I am not sure if there is any space left for something that is still acupuncture to not have been covered.

  66. It is easy to compare a chemical to another but Acupuncture is not so simple to define. TCM includes the use of substances plus needles… Still you have to define Acupuncture. I use French Energetic, Chinese and variations of Japanese. Then there periosteal, Mark Seems, and the CraigPENS.

    So your definition is inadequate.

    The above article did not give a defined method.

    1. WilliamLawrenceUtridge says:

      You aren’t really helping your own point though. There are many different kinds of acupuncture, and none appear materially superior to any others. There is no single definition of acupuncture, and when the individual components are tested (location, manipulation, use of needles, skin penetration and in particular effectiveness for specific conditions) none of them seem to matter. Do you have any evidence to the contrary?

      You should read Edzard Ernst and Simon Singh’s Trick or Treatment, it has a section on the scientific testing of it. The definition normally given for acupuncture, an ancient practice of inserting needles to manipulate chi, is actually wrong – it’s not particularly old, and chi doesn’t exist. My personal definition would be along the lines of “the shallow insertion of sterile, filiform needles to cause a short-term placebo reduction in pain and nausea.”

      PENS isn’t really acupuncture, unless you believe the Chinese had generators that the archaeological record has missed somehow. I mean, they were more advanced than probably any other civilization on the planet – but they weren’t that advanced. It’s just TENS using needles instead of pads, which is a distinct disadvantage since the pads don’t penetrate the skin.

      1. Actually not true. If you are interested the needles are bimetallic or material and as such generate a minute electrical current with manipulation.

    2. WilliamLawrenceUtridge says:

      And actually in follow-up to that, your point then suggests acupuncture should at best be an investigational treatment. How would you feel if Pfizer said “we’ve got this new drug, we’re not really sure what it does, it’s hard to compare to other drugs, but we’d like to sell it anyway; also, it’s super safe, and effective. I know, because I’ve used it on people and they tell me they like it.”

      If you find those statements objectionable, even though the compound could be perfectly safe and have a powerful placebo effect, then why is acupuncture less objectionable? Why a double-standard?

      1. I will use “Acupuncture” to denote a procedure we have no idea what it is — YET. “Acupuncture” can do no harm … none. As with … the distorted data we get from pharma; http://en.wikipedia.org/wiki/List_of_withdrawn_drugs

        1. MadisonMD says:

          Stephen S. Rodrigues: Your statement is one of the oddest I’ve seen. You say we have no idea what acupuncture is yet. If we don’t know what it this future panacea is, then how is it possible you use it? Your statement that acupuncture can do no harm is simple to disprove. (e.g. Wheway et al.).

    3. windriven says:

      Mr. or Dr. Rodrigues, whatever, look at this statement:

      “Acupuncture is not so simple to define. TCM includes the use of substances plus needles… Still you have to define Acupuncture. I use French Energetic, Chinese and variations of Japanese. Then there periosteal, Mark Seems, and the CraigPENS.”

      What you are doing is blowing smoke. There are enough studies showing acupuncture to offer no benefit beyond placebo. So now your claim is – “no, not that acupuncture, this other acupuncture.” It is a game of shifting targets. Outside medicine the game is called Three Card Monte and only suckers play it.

      I call bullshit.

  67. WilliamLawrenceUtridge says:

    @Stephen S. Rodrigues says:

    http://apps.who.int/medicinedocs/en/d/Js4926e/5.html

    First of all, that’s from 2003; most science changes rather dramatically in a decade. Actually, the evidence base for acupuncture has changed rather significantly – it has eroded, particularly with the development of a reasonable placebo for skin penetration in the form of retracting needles. See here as well for a criticism of the WHO report. Please take the time to delve into the sources that section cites, Trick or Treatment in particular should be one you should focus your attention on. It is very readable and provides a large number of very, very basic reasons to question the WHO report specifically as well as the overall research base.

    Actually not true. If you are interested the needles are bimetallic or material and as such generate a minute electrical current with manipulation.

    Is that electrical current significant, or is it overwhelmed by the electrical current of contracting muscles and firing nerves? Or the electrical activity of the heart, which can be measured throughout the body? “Minute” effects are often of little interest since they rarely result in meaningful cures. Now that you have claimed there is such an effect, it is incumbent on you to a) demonstrate this through a citation of scientific evidence and b) more importantly, demonstrate this alleged tiny current has some sort of clinically significant effect. What happens if you reduce a TENS unit to deliver an equivalent current for instance?

    I will use “Acupuncture” to denote a procedure we have no idea what it is — YET.

    If you don’t know what acupuncture is, how can you claim it is effective?

    I think what you might mean is “we don’t know how acupuncture works”. This is somewhat trivially true, but is really the wrong question. We don’t know if acupuncture works beyond mere placebo. We know acupuncture has a powerful placebo effect, the question is whether there are any specific effects beyond that, particularly for specific indications. Certainly it’s effective, over the short-term, for reducing the two symptoms most strongly affected by placebo effects – pain and nausea – in some patients. Whether it does anything else is an open question, but there definitely isn’t a lot of evidence to suggest this.

    “Acupuncture” can do no harm … none.

    Actually, that’s wrong – risks are rare, but they are present. And do you know who Kim Ribble-Orr is? Have you ever seen the website What’s the Harm? Before you claim some sort of “No True Scotsman” argument like those acupuncturists were doing it wrong, or they weren’t acupuncturists, keep in mind that many CAM practitioners are quite willing to cite medical error in criticisms of real medicine. It seems only fair that acupuncturists similarly acknowledge, at minimum, that acupuncturists may make mistakes or be incompetent. Acupuncture can quite easily do harm, you could get bumped, or sneeze, or trip, or have an attack of narcolepsy and drive the needle into someone’s heart.

    But yes, overall acupuncture has few adverse effects, particularly in the hands of trained acupuncturists.

    Do you use sterile needles? Do you clean the needling site before using them? Do you wear gloves?

    As with … the distorted data we get from pharma; http://en.wikipedia.org/wiki/List_of_withdrawn_drugs

    What does this have to do with acupuncture? Even if every single drug in the world was actually rat poison (which, by the way, is warfarin, an effective blood thinner though its therapeutic index is narrow) that would make harmless acupuncture better by comparison – but it doesn’t mean it’s actually effective. Homeopathy had a similar issue back when it was devised – medicine was actively harmful, so taking some useless sugar pills and doing nothing else actually resulted in real survival. Of course, now that medicine is tested to be safe and effective, it’s seen as worthless and actively harmful because it tends to have a pernicious effect on patient trust in real medicine. Treat cancer with homeopathy (or acupuncture) and what you have is a patient dead of cancer.

    You are using a logical fallacy known as a “false dilemma” – you are pretending that we have to choose between acupuncture or drugs. If one works, the other doesn’t, and if you can prove drugs are harmful, that means acupuncture is effective.

    The reality is of course totally different. Acupuncture can be effective, or useless, and this is completely unrelated to any fact about the effectiveness or safety of drugs. So please don’t keep invoking “but medicine can hurt patients” as if it were a valid argument, please restrict yourself to making positive claims for acupuncture specifically. This is not a game of heads or tails.

  68. I know and my patient know beyond a doubt that Acupuncture and needles therapy works!!
    http://en.wikipedia.org/wiki/Validity

    An inquisitive mind would ask — Why?
    A naysayer and provocateurs would say — Prove it? But really can not be swayed.
    Y’all already know there is no way I can prove how this works beyond a shadow of a doubt!!

    Can any study be designed to find the truth of “Acupuncture”?
    These are the parameter I would want to include: A general description of the the term Acupuncture, the intensity of the procedure, needle type, depth of penetration, time spend doing the procedure, number of procedures, frequency of procedures, were the patients naive to needles, co-morbid issues, overall health and wellbeing of the subjects etc.

    Well it is not really about “Acupuncture” per se but the needles thanks to C. Chan Gunn.
    http://www.istop.org/research.html
    Gunn’s philosophy went beyond traditional acupuncture for a new vision of what was truly happening within the muscle tissues. Gunn believed that using the acupuncture needles in IMS created the following benefits:
    1. Inserting the thin flexible solid stainless steel needle into the skin and muscle caused microscopic tissue injury. That injury triggered a healing cascade of repair which repaired the tissue injury and any local secondary injury. Muscle stem cells proliferate to restore muscle health and power.
    http://en.wikipedia.org/wiki/Healing
    http://en.wikipedia.org/wiki/Wound_healing
    2. The stainless steel needle, once it entered the muscle, triggered a muscular re-polarization creating a muscle twitch. After the twitch, the muscle would relax. The relaxed muscle would be a little longer, less tense and tight. Better able to fit and correctly realign a joint. [↵Cannon WB, Rosenblueth A. The supersensitivity of denervated structures: a law of denervation. New York, NY: MacMillan; 1949. ]http://www.istop.org/papers/radiculopathicpain.htm

    In my practice I see 15-20 patients per day of various types of pain syndromes, most are referred by word of mouth. They all tell me that it works … that’s all I need.

    1. Harriet Hall says:

      “They all tell me that it works … that’s all I need.”

      That may be all you need, but it’s not all we need. Patients treated with Perkins’ tractors all said that they worked, too. There are plenty of testimonials for every quack remedy, from bloodletting to Hulda Clark’s zappers.

      1. Treating colds with an antibiotic is another example of quack remedy. Try not doing this and the patient will curse you out for wasting their time and effort getting to the office visit.

        Another is the therapeutic MRI … the patient will remain sick until the mri shows that they do not have a life threatening illness. Treatment my Scans … expensive Huh.

        And the ‘look-see” arthroscope …

        And the minimally invasive back surgery … there are now > 11 in the Dallas/FT Worth area. They are popular too. This is no more than myofascial release therapy with a steel device.

        1. Badly Shaved Monkey says:

          Treating colds with an antibiotic is another example of quack remedy.

          And responsible authorities in medicine around the world agree with you. But here you are heading off on another tangent while missing the central point. Quack remedies can be popular because people and their therapists mistakenly think that they work. You have again missed this point. You need to answer my Question 5.

          Here again is the list of questions that you should be answering and said you would answer;

          1. What’s the objective evidence that supports each of the specific therapeutic claims on your website?
          2a. What’s the objective evidence that supports the claim that acupuncture works in animals?
2b. On what conditions does it work?
          3. What would be the effect of a single instance of morbidity or death from acupuncture on your claim that acupuncture is “not dangerous at all”?
          4. Have you ever seen the articular surfaces of a severely arthritic joint?
          5. What is the purpose of control groups in scientific trials?

        2. Harriet Hall says:

          You contradict yourself. You said the patient’s report of feeling better was all you needed. If you were consistent, you would accept a patient’s word that antibiotics made his cold better, but you obviously believe the science that says antibiotics don’t work for colds. We know antibiotics are ineffective for colds because we have tested them; we don’t know that your treatments are effective, only that your patients are grateful, as are the recipients of any quack remedy.

          1. Badly Shaved Monkey says:

            Brilliant! I think that gets a “Bazinga!!”

        3. Badly Shaved Monkey says:

          Dr R.

          That feeling you got when you read Dr Hall’s post? Well, in the interweb language of young people, you just got pwned.

    2. WilliamLawrenceUtridge says:

      I know and my patient know beyond a doubt that Acupuncture and needles therapy works!!

      Sure, they may be convinced of it, but that doesn’t mean they are right. Humanity was convinced for millennia that the universe was geocentric, made up of four elements and populated with animate spirits of trees, rocks and streams. And don’t get me started on their perceptions regards the efficacy of prayer and bloodletting! Much like patient satisfaction, patient certainty is not evidence.

      An inquisitive mind would ask — Why?

      A well-read mind would realize there are a variety of reasons for patients to be convinced of this, that aren’t actually true. Confirmation bias would be one, face-saving would be another. An inquisitive mind would wonder “what happens if I give one group real acupuncture, the other fake, but in all other ways treat them the same”. This has been done, and the results are:

      - it doesn’t matter where you put the needle
      - it doesn’t matter if you break the skin
      - it doesn’t matter if you manipulate the needle
      - it doesn’t do anything specific
      - it does matter if you exhibit a caring and charismatic mannerism.

      A naysayer and provocateurs would say — Prove it? But really can not be swayed.

      Right back at ya, champ! You see, you claim acupuncture is real, but there are hundreds of studies that demonstrate very little of it matters. Wouldn’t you say the onus is on you to explain why this is?

      Y’all already know there is no way I can prove how this works beyond a shadow of a doubt!!

      Sure you could (well, except one doesn’t prove a scientific hypothesis, one tests it; hypotheses that fail to be falsified go on to become theories). Isolate each part of your practice, and control for it. Do them one at a time, then do them in combination. It’s not easy, it’s not cheap, and it’s going to take a while, but you can, in principle, test all the parameters of acupuncture. In fact, they have and it turns out none of them really matter.

      Can any study be designed to find the truth of “Acupuncture”?

      The question for me is “can a study be designed to convince you that acupuncture’s claims are false?”

      These are the parameter I would want to include: A general description of the the term Acupuncture, the intensity of the procedure, needle type, depth of penetration, time spend doing the procedure, number of procedures, frequency of procedures, were the patients naive to needles, co-morbid issues, overall health and wellbeing of the subjects etc.

      Sure, but many of those have been tested, and failed to support many of the specific claims. Also, I still don’t think you have provided a definition or description of what acupuncture means to you. Does needling location matter?

      Gunn’s philosophy went beyond traditional acupuncture for a new vision of what was truly happening within the muscle tissues. Gunn believed . . . [snip] . . . [↵Cannon WB, Rosenblueth A. The supersensitivity of denervated structures: a law of denervation. New York, NY: MacMillan; 1949.

      Wow, 1949. That’s an old reference. The actual paper is from 1997, I will point out that this is an assertion, a hypothesis. One doesn’t merely propose an hypothesis then claim it is correct. One must test. Has Dr. Gunn conducted such testing? If not, then this is not proof of anything, it’s merely an interesting idea. You don’t know it’s right, and it is no more a valid way justification of your practice than the assertion that acupuncture works because it’s old. If acupuncture worked along these lines, you could test it to see if it was correct and finally have a valid mechanism by which acupuncture could have specific effects. It would be of tremendous help to the scientific and acupuncture practitioner community if someone (such as you) undertook such tests. Please feel free to spend your time on this far more fruitful avenue than continuing to assert your opinion here.

      In my practice I see 15-20 patients per day of various types of pain syndromes, most are referred by word of mouth. They all tell me that it works … that’s all I need.

      Do you treat anything other than pain? If you do not, then good – you are actually restricting your practice to something reasonable. Of course, that doesn’t change the fact that you may still be delivering no more than a placebo treatment. Do your patients return? Frequently? As if you were doing little more than treating an acute symptom? It’s one of the few practices of acupuncture I would endorse, so kudos to you, sir.

  69. Badly Shaved Monkey says:

    “They all tell me that it works … that’s all I need.”

    Any doctor who says that and really does not understand why it is a fundamentally misguided basis for medical practice scares me deeply.

    Dr Rodrigues, do you have any understanding of why your experience is a poor guide to the efficacy of your methods? Please remember you are talking to other doctors here and they have no problem with making their personal experience subordinate to objective evidence. We are not your patents, but physicians and scientists, please do not talk as if we are fools.

  70. I have to admit it is not all about “Acupuncture” in the traditional view although it is still a powerful adjunct to a provider who wishes to treat patients out of the box. When I get a complex case and I have run out of chemicals to push out of the vending machine, I reach for my needles. Placebo is a power ally and I use it wisely.

    From placebo to miraculous; This is the kicker … I noticed a decade ago that acupuncture was a “weak” therapy maybe because of my inexperience. But then something happened, I ran out of my short favorite 15mm needles. I only had longer 30 mm needles. Because they were longer I inserted them in deeper. That is when patients started to respond favorably on that particular visit with slightly less pain and better range of motion. So I had stumbled on to The Gunn technique.

    Then intramuscular stimulation was my best choice for many years. Gunn-IMS has it’s downsides and not tolerate in a lot of patients.

    Then Travell/Simons trigger points injection, to Prolo-therapy, Botox and Platelet rich plasma.

    I am absolutely certain, that one this health care system implodes, what will rise out of the rubble are the needles. No matter what your thought process or biases … Needles will save the day.

    Myofascial release therapy will change the paradigm of healthcare and why needles are the most powerful tools in medicine.

    http://americannewsreport.com/nationalpainreport/acupuncture-the-most-powerful-therapy-in-medicine-8820052.html

    http://americannewsreport.com/nationalpainreport/chronic-pain-is-manageable-with-the-right-therapy-8819887.html

    http://americannewsreport.com/nationalpainreport/can-chronic-pain-be-cured-8820366.html

    http://americannewsreport.com/nationalpainreport/steroid-shots-for-back-pain-raise-risk-of-bone-fractures-8820306.html

    1. WLU romotely says:

      Another explanation is that as your confidence increased so did the placebo effect (which includes demand characteristics, when patients tell you it got better just to please you).

  71. This is what comes into my office. I guess you can say, I am not for these surgeries … ever! They usually respond to a combo of all the tools in the toolbox, plus you have to treat them for PTSD, social issues, job issues etc. (can y’all gather up the data to dispel these surgeries?)

    https://plus.google.com/photos/110826061508916566142/albums/5914999798990372033?authkey=CPP2tIa5wayzgAE

    1. WilliamLawrenceUtridge says:

      What do failed surgeries have to do with the effectiveness of acupuncture?

  72. Badly Shaved Monkey says:

    Dr R
    I find it curious that you have splurged two more posts neither of which respond to the detailed critique present by WilliamLawrenceUtridge several hours previously.

    http://www.sciencebasedmedicine.org/acupuncture-doesnt-work/comment-page-1/#comment-138278

    I think it it be good if you replied quietly and coherently to the specific arguments and refrain from your breathless tangential scribbling.

    1. Thanks for the spurges!!!

  73. Badly Shaved Monkey says:

    I am forced to conclude that you have no answers.

    That is typical for enthusiasts for alternative medicine.

    Goodbye.

  74. Badly Shaved Monkey says:

    Actually, I’m forced to conclude that you don’t even understand the questions, which, in a doctor, is worrying.

  75. Dang … I am seeing, jabbing and poking patients plus doing paper work now … give me a fricken break. Splurges not spurges. I can only do a couple things at once! And I am planning my wife’s murder … that’s from Princess Bride.

    1. WilliamLawrenceUtridge says:

      What kind of doctor are you?

  76. Badly Shaved Monkey says:

    My suggestion, Dr Rodrigues, was that you should already have answered the points made by WLU. Frankly, if you had half a clue you would have done so at the time and not require repeated prodding. I truly doubt that you are going to come up with any meaningful data to advance the case that acupuncture has any non-trivial clinical benefits (Clue: none exists).

    And it does still appear that you do not comprehend why personal clinical experience is a very poor guide to objective efficacy of any therapy. Not good.

  77. Y’all know that I am a big fan of integrative medicine … anything reasonable that works which will help and not harm my patients.

    Naysayers and provocateurs are interfering with the advancement of the powerful tool in modern medicine … my Acupuncture. In 2013, I’m convenience it will be adopted in a form that will highlight the tremendous benefits and comprehend it’s deep mysterious aspects. I was shocked that intelligent minds would want to find fault with such a profound therapy. Well I have. As I began to try to have a reasonable converse the biases were exposed and I was the oddball stupid practitioner. (Granted i am biased too but my biases have been learned over 2 decades of primary care medicine)

    Be Careful of what you believe! http://www.sciencebasedmedicine.org

    “Acupuncture doesn’t work” and they call this Science-Based Medicine???

    “Sure, they may be convinced of it, but that doesn’t mean they are right. “
    This is the most profound insult to a patient or human suffering in pain … not to believe what they are saying in response to the treatment?? Why believe them in the first place?

    IMO this is the disconnect and the most corrupting force in modern medicine and that is what to believe. You guys apparently do not see patients on a face to face basis and have no idea how to manage a primary care office with any success seeing the most complex pain and emotional cases. In an office based practice the only outcomes that matters are how the patient feels and the traditional elements of an encounter ie Vital Signs.

    What the patient states in the subjective is where you uncovered the diagnosis. It should trump all other average data points. How it’s stated and the nuances of this face to face encounter is vital. It is very difficult to put into words such an encounter so a video would be the only way to document this exchange.

    I have to believe what the patient is saying is true so that we can uncover the truth. What I believe or don’t … what you believe or don’t … what anyone else believes or doesn’t has diddly to do with what a patient feels.

    So if you guys can’t bring yourselves to believing what a patient feels that is a big error in your investigative model.

    So … Why are you here?

    And don’t get me started on their perceptions regards the efficacy of prayer and bloodletting!
    The past is catching up to the future;

    http://www.nytimes.com/2006/03/31/health/31pray.html?pagewanted=all&_r=0

    http://www.leeches.biz/leech-approval.htm

    http://www.nytimes.com/2006/03/31/health/31pray.html?pagewanted=all&_r=0

    - it doesn’t matter where you put the needle
    Yes it matters and the only person who can tell you this is the patient not an ancient model.
    This is a very good point and I instruct my patients on this when they use home needles. If the point they chose is void of any sensations, that is ok. The needle has to seek and find to stir up the healing cascade and to allow for a better distribution of blood flow and healing elements. This I call blending or mixing the sick with the well so the healing can be more thorough and complete.

    - it doesn’t matter if you break the skin
    Yes it does … there are 2 levels of ouch associated with the use of needles; the skin level and the deep ache a patient will tell you they feel. The skin level feels like a snap from a rubber band or a simple light touch. This aspect can be shamed. I would not begin to figure out how to sham the deep aching feeling.

    - it doesn’t matter if you manipulate the needle
    Yes it does! You don’t have to manipulate but you will get a better “bang” for the encounter if you do. Why waste a patient’s time and effort if you don’t do as much to help per unit visit. Some patients love the sensation, others will feel nauseated, while others will punch the crap out of you.

    - it doesn’t do anything specific
    We already answered this … igniting the healing cascade and rebooting the muscle.

    - it does matter if you exhibit a caring and charismatic mannerism.
    Hell yes it does!! You can make a patient sick just with the nocebo effect … so be nice.

    My patient and millions of others all believers ,,, we don’t think the world is flat anymore. NO one can cause us to be isolated in a patch of the earth now that we know the true story. Once you see that the earth is round–you can’t go back to the flat paradigm … unless you have a vested interest in keeping some people ignorance.

    For me to believe any study with needles I would have to see via video the intent of the therapist or provider. I can tell just my how the use the needles.

    Do you use sterile needles?
    You must have got this notion from an old reference. Needles are so cheap 1-2 pennies each, there is no need to do this any more. Where have you been in the past few decades?

    Do you clean the needling site before using them?
    Yes and no … depending on how dirty the patient is or where they work. I usually will wipe down the feet, but in general solid needles use is a clean procedure and not a sterile. With wet injections or use of a hypodermic needle an alcohol wipe is standard. I like Hibiclens on the feet.

    Do you wear gloves?
    Yes and no … depending on the patient and what I am doing etc. There is a Gunn technique where I use gloves because it reuse the same needle until it get dull.

    Treat cancer with homeopathy (or acupuncture) and what you have is a patient died of cancer.
    You must think that since Acupuncturist are stuck on needles that we can’t see clearly. We are not stupid and blinded by our powerful tools. Any modern provider in his right mind using common sense (having ambulance chasers at the ready) would want the best medicine and therapy possible. Cancer require cancer treatment protocols. I have a few dozen patients, with have mostly breast cancer, who come in to help with the side effects from the caustic chemicals like nausea, myalgias, neuropathy, insomnia etc. I have to admit this tool does make me feel a little more confident. I can actually help patient feel at peace that I can help them. Being a MD who uses needles puts me in best vantage point possible.

    Another explanation is that as your confidence increased so did the placebo effect (which includes demand characteristics, when patients tell you it got better just to please you).
    In my office this is not allowed … this only way for the therapy to really be effective it to focus on how the patient feels (I know a bad word in y’all vocabulary). Raw data from the patient, unfiltered by logic, is the best subjective info.

    This was a great exercise … I will post this on my web page, blog and FB site. I hope this helps.
    If you truly have any more questions–just ask.

    1. “What the patient states in the subjective is where you uncovered the diagnosis. It should trump all other average data points”

      So if a patient says they believe they have cancer (or feel they have cancer). That should trump all other risk factors right?

    2. WilliamLawrenceUtridge says:

      This is the most profound insult to a patient or human suffering in pain … not to believe what they are saying in response to the treatment?? Why believe them in the first place?

      Patients often reported improvements after bloodletting. Patients report improvement after sham surgery. I felt better about my shoulder pain after merely talking to my doctor about it. As a doctor, it’s your obligation, your job in fact, to provide your patients with more than placebo effects, it’s your job to offer genuine improvements in their health. Most doctors feel it unethical to give their patients sugar pills. Would you do so if they reported improvement? It’s OK to lie to your patients as long as they report subjective improvements? I wouldn’t want you as my doctor.

      And don’t get me started on their perceptions regards the efficacy of prayer and bloodletting!

      To this you append two articles. One is about leeches. I’m not sure what you’re trying to say with it – my point is that the use of bloodletting as a cure for any and all diseases is absurd nonsense not based on anything but fanciful nonsense, you reply with an article demonstrating how leeches have an evidence-based use for specific indications. Your second article is about how intercessory prayer doesn’t work. Based on your earlier comments, I assume you’re saying “hey, as long as they help patients feel better, as a doctor it’s my job to use them”. So now you will substitute leeches for antibiotics and prayer for surgery?

      We already answered this … igniting the healing cascade and rebooting the muscle.

      You provided an assertion that acupuncture does this based on some theoretical work from the 1940s. I pointed out this was not proof, it was a theory, proof requires more than merely theory. If acupuncture actually has this effect, it can be tested empirically – and it should be. In fact, you would be adding a new and valid treatment modality to medicine. However, if you haven’t done the work, you haven’t got anything. Consider, for example, that you might simply be wrong. Or, you might be introducing scars into the skin and muscles that interfere with functioning over the short or long term. Scars prevent contraction, so eventually you might end up immobilizing your patients. I mean, theoretically it could happen, right? Are you helping your patients, or paralyzing them slowly?

      Any modern provider in his right mind using common sense (having ambulance chasers at the ready) would want the best medicine and therapy possible.

      But you aren’t. You’re using acupuncture, which has a terrible evidence base. You seem to believe your personal opinion and experience is superior to the scientific evidence. Put simply, you’re wrong.

      In my office this is not allowed … this only way for the therapy to really be effective it to focus on how the patient feels (I know a bad word in y’all vocabulary). Raw data from the patient, unfiltered by logic, is the best subjective info.

      The mind doesn’t take in “raw data” though. It filters information. Memories are not recorded, they are recreated, informed by context, bias and prior beliefs. The patient’s symptoms are shaped by your stated and unstated opinions. The patients of a crass, indifferent or hostile doctor will experience their symptoms differently than a caring practitioner – this is known. The objective condition is not effected, merely the patient’s perception of it. They may feel better, or worse, but the tumor is still gnawing its way through their colon. Also, by stating “In my office this is not allowed” you are forcing your patient to adjust how they report symptoms. They are more likely to minimize them, to exagerrate their recovery, to not mention the nagging twinge they feel, with an attitude like that. This is what I mean by “demand characteristics”, you couldn’t have given me a better example. And I would argue that a clean x-ray is far, far better than a patient who reports no symptoms. Perhaps that’s just me.

      If you truly have any more questions–just ask.

      Why do you think your experience is superior to the scientific model and evidence, despite history showing just how terrible humans are at understanding how wrong they can be? Think about it – doctors who bled their patients on the advice of Galen; what they were doing was objectively harmful. Do you think they knew this and just pretended it wasn’t? I think they must have been like you – arrogantly convinced of their own efficacy, even as they hastened their patients to their graves.

  78. moderator the text did not come out well … I can fix or let it ride??

  79. Badly Shaved Monkey says:

    “Sure, they may be convinced of it, but that doesn’t mean they are right. “
    This is the most profound insult to a patient or human suffering in pain … not to believe what they are saying in response to the treatment?? Why believe them in the first place”

    Um, you have got this profoundly wrong.

    No one is accusing your patients of lying.

    Unfortunately, what you utterly fail to understand is that people saying truthfully how they feel can be completely wrong about the objective state of their health. And using their assertions about their status leads you to make utterly fallacious causal inferences about your therapy. And you don’t understand this. How is it possible for someone to pass through medical school in a developed country and not understand this fundamental principle? I spend my clinical days explaining to people how they can confuse these things. Other doctors who write here can do the same. Why can’t you?

    If you want an example of how a patient’s subjective account of their health can be dangerously at odds with their objective status read this;

    http://www.sciencebasedmedicine.org/spin-city-placebos-and-asthma/

    It is a perfect example of why fools believing in useless therapies should be kept away from real patients.

  80. Badly Shaved Monkey says:

    By the way;

    “- it doesn’t matter if you break the skin
    Yes it does … there are 2 levels of ouch associated with the use of needles; the skin level and the deep ache a patient will tell you they feel. The skin level feels like a snap from a rubber band or a simple light touch. This aspect can be shamed. I would not begin to figure out how to sham the deep aching feeling.”

    If your point was valid, then the studies showing no meaningful difference between ‘real’ and sham acupuncture would constitute even more damning evidence against it. Want to shoot yourself in the foot any more?

  81. @B. S. Monkey, I think I understand your logic which is not to believe. That is the most powerful observation I have learned too. So … the only entity to believe is the force that holds us up and allow us to be aware that every human is a liar and can be fooled or deceived by his or her own thoughts or the ideas and actions of others.

    Hmmmm … just like in the Matrix!!! We are all being guided and controlled by a game master!!! Except YOU who can see the 1’s and 0’s … I am amazed at your intellect.

    Are you God incarnate ….. no because you are too cynical, you must the the opposite of the loving force.

    1. Badly Shaved Monkey says:

      You used the word “liar” again, which continues to suggest that you do not comprehend the sources of bias that disable the accurate inference of causal links from observations.

      The rest of your post is another sequence of worrying non sequiturs.

      The Aztecs slaughtered humans in the belief that it was necessary to keep the Sun rising. They slaughtered humans and the Sun surely did rise. Were they correct in their causal inference? If not, why not?

  82. jenny says:

    I had accupuncture two days ago. I went in for just relaxation. Told accupuncturist about my asthma and irritable bowel. She put in the needles. I don’t know….I usually take ventolin about 3 times a day. None since. (about 2 1/2 days). No irritable bowel pain. And I had one night of very good sleep. So maybe it just relaxed me. But how do you explain these things? I didn’t even go for these reasons….

    1. WilliamLawrenceUtridge says:

      I know someone with irritable bowel. They can swing from normal, to diarrhea, to constipation within days. The symptoms are extremely liable. Does anxiety or tension make your IB worse? Did you go to the acupuncturist when your tension or anxiety, or your IB was at a peak? In which case, your recovery could be regression to the mean. Do you ever have pain-free days? If so, then was this pain-free day caused by the acupuncture? How do you know?

      To better understand why you need controls and record keeping to make firmer judgments, you could read Snake Oil Science by R. Barker Bausell, he goes into these sorts of issues.

  83. Badly Shaved Monkey says:

    Dr R, have you read that paper on subjective and objective observations in asthma patients treated with acupuncture?

    A simple yes/no answer will suffice.

  84. Badly Shaved Monkey says:

    Dr R,

    Some quotes from your website. And some questions. Concise specific answers would be much appreciated.

    Here is a list of all the things acupuncture can treat:
    Allergies/Asthma
    Anxiety/Depression
    Back/Neck/Shoulder/Knee Pain
    Arthritis
    Bladder/Kidney Problems
    Cough/Bronchitis
    Gynecological Disorders
    Headache/Migraine
    Fatigue
    High Blood Pressure
    Sexual Dysfunction
    Stress/Tension
    Drug Addiction/Smoking
    Vision Problems

    Your site emphasises fibromyalgia and trigger points. You then switch (one might call it “bait and switch”) to a much wider range of medical problems.

    1. What’s the objective evidence that supports each of those specific claims?

    Acupuncture is used successfully to treat animals that cannot understand the process or “believe” that it will make them better.

    Many people here know I am a vet, so will be especially interested in this.
    2a. What’s the objective evidence that supports the claim that acupuncture works in animals?
    2b. On what conditions does it work?

    How dangerous is Acupuncture?
    It is not dangerous at all.

    3. What would be the effect of a single instance of morbidity or death from acupuncture on your claim?

    My orthopedic doctor tells me I will need to get my knee or hip replaced because it is bone on bone. What is this bone on bone arthritis?

    The “bone on bone” statement is use by some doctors to interpretation an X-ray meaning that the bones of a joint are rubbing together and thus the joint will require replacement.

    In my opinion I consider that a myth. I have not been able to find a corresponding pathologic diagnosis in a search of the literature.

    4. Have you ever seen the articular surfaces of a severely arthritic joint?

    I look forward to your answers.

    1. Thanks for your service!!
      Your suspicions are correct … healthcare is a mess.
      Don’t believe most of the pain articles written in the past decade because they neglect to include a vital error in-which the human flesh will stall in the healing process or the flesh will collect errors of repair[My words]

      Myofascial pain and dysfunction will explain or not explain a lot of the inconsistencies in medicine.

      There is not such thing as bone on bone … it is a deception to make money.
      Most of the words, descriptions and terms used to describe a diagnosis are invalid.

      YOU found the perfect skeptic … me.

      1. Badly Shaved Monkey says:

        Dr R.

        I asked you a set of questions. You have answered none.

        You have alluded to question 4, relating to arthritis, in a manner that suggests you have never seen the interior of a severely arthritic joint. I have.

        I shall ask the question again. Please give a straight answer this time.

        4. Have you ever seen the articular surfaces of a severely arthritic joint?

        Then answer the others.

    2. WilliamLawrenceUtridge says:

      That list of “conditions acupuncture is effective for” looks to be drawn from the flawed WHO report from eight years ago. I doubt you’d find any meta analyses from the past five years for anything but pain (which is, again, a symptom, highly liable and susceptible to placebo).

  85. Jenny says:

    Hi…I went for acupuncture just to look good for a night out. Acupuncturist asked me health questions. Well, all I can say is that three days post treatment, I don’t have irritable bowel pain , nor have I needed ventolin for my asthma. Hmmm…and I had one really good night sleep. I’m not political on this. Just amazed…

    1. I am still shocked by these statements. I spend the fist half of my career giving out pill and was programmed to do so.

      The shock is I guess the shock a person who has Post-Traumatic Stress Disorder. Imprisoned in an idea so long and them to SEE and witness something so profound.

      Natural healing is a function of our DNA given to us from God. (I know I put God into the mix … blasphemy to the AMA).

      The WHO published a list of problem acupuncture can help.
      http://apps.who.int/medicinedocs/en/d/Js4926e/5.html

      I also use needles in the office to treat a type of blindness called Macular Degeneration.
      http://reverseamd.com/santafeprotocol.html

      Can you imagine when a going blind patient comes into the office and leaves being able to see a little clearer. The smiles and excitement is overwhelming. And his eye doctor never told him or her that this therapy was available … that makes me ill just thinking about it.

      1. Badly Shaved Monkey says:

        I also use needles in the office to treat a type of blindness called Macular Degeneration.
        http://reverseamd.com/santafeprotocol.html

        OK. I’ve followed the link and read the results.

        You need another question.

        5. What is the purpose of control groups in scientific trials?

        It’s not a hard question. I’d expect a child at elementary school to be able to give a good answer. Mine could. You have an MD, so I’m sure you will be able to do it.

        1. windriven says:

          @BadlyShavedMonkey

          “5. What is the purpose of control groups in scientific trials?

          It’s not a hard question. I’d expect a child at elementary school to be able to give a good answer. Mine could. You have an MD, so I’m sure you will be able to do it.”

          I have a crisp clean $20 that says he can’t.

      2. cloudskimmer says:

        Let me see… what was wrong with the Santa Fe Protocol?
        The patients were only followed for one year.
        There was no control group.
        Study size was small.
        Measures were subjective–people learn how to read the eye chart and no doubt improve with practice. Squinting alone can improve vision by 1-2 lines, so 1-2 letters is hardly earth-shaking.
        I’m not a Doctor, but can still see that this study is only preliminary, was conducted by true believers, and probably was not replicated.
        Nor was the study blinded.
        So, the study really has no validity and is not a reason to believe in the powers of acupuncture. Sorry. Try again. And at $250 per treatment, I hope not many people suffering from this disease are scammed by the Santa Fe Protocol.

        1. Research all the cost associated with mac deg and then see if 250/visit is reasonable. He does offer a refund.

          That statement also raises more issues related to healthcare and that is the care and feeding of deep pocket. 2. making money off the sick and ill. 3. conflict of interest.

          A tooth implant cost 4 grand!!

          What would you pay to be able to see better? OH!!! Mag Deg is basically a degenerative illness that ends in blindness. Are you saying let the old people go blind because to the cost?

          I my office since I don’t charge for acupuncture the procedure is just of part of an office visit = complementary.

          1. Badly Shaved Monkey says:

            What is the cost:benefit ratio when Cost = $250 and Benefit = Illusory?

            What is the net profit on $250 when the overheads are a few needles and a nice white coat? And maybe a coffee machine. And maybe a potted plant. And certainly a smart website.

          2. WilliamLawrenceUtridge says:

            Does he offer you a new eye if the old one gets infected after you stick it with a needle?

      3. WilliamLawrenceUtridge says:

        I addressed that link to the WHO list last week, please see this comment. Your trivial use of “PTSD” is rather irritating. I don’t know if someone who has been through multiple tours in Iraq or Afghanistan, or has been repeatedly raped, or tortured, or has seen people die in fires and shootings, are comparable to someone with IBS.

        Can you imagine when a going blind patient comes into the office and leaves being able to see a little clearer.

        At $250 per treatment, how many treatments are needed to achieve a clinically-meaningful improvement? Are there other treatments for this condition that are cheaper and/or more effective that could be used instead? I mean, you are jabbing a needle in the patient’s eye, then electrifying it. That seems awfully intrusive for a “little clearer” vision.

  86. Get me your email and i will let you see a few dozen questions and answers I’ve put together so you can SEE thru my eyes and experiences.

    Be careful once you read them you will not be able to see the way you now see ever again.

    1. Badly Shaved Monkey says:

      No, I will not give you my e-mail address. You have taken part in this exchange in a public forum. You have made a range of claims in a public forum. Your website places a number of quite specific claims in the public realm.

      I think I can reasonably expect you to answer my set of really quite simple questions in this same public forum, so that the quality of your answers can be assessed by other readers.

      1. Gee just trying to help …

        1. Why do I feel like you want me to do all your due diligence?

          I can tell you for sure this site is not the place to get valid data about your issues.

          Track all my prior post, on my web page, FB pages and the links I provided.

          The list was a condense version of all of these issues that have been asked over a few yrs. I can post the question list here but they are evolving and unedited. I was going to let you see them as a favor.

          1. Badly Shaved Monkey says:

            My due diligence?

            It’s not me making money from poking needles in people and making claims about the supposed therapeutic benefits and then dodging some simple questions.

          2. Badly Shaved Monkey says:

            The comments have now spilled over on to a second page. Please make sure you click on “Newer Comments” to find the latest;

            http://www.sciencebasedmedicine.org/acupuncture-doesnt-work/comment-page-2/#comments

          3. Badly Shaved Monkey says:

            This is a duplicate post, because I’d hate for you to miss it;

            Dr. R.

            Please understand that I have interacted with people like you on the internet for many years now and it is remarkable how consistently the purveyors of alt.med. practices wriggle and dodge when faced with even the simplest of direct questions. You are conforming to a familiar pattern. I think we’ve seen enough of your blustering rhetoric. Please make you next post some answers to the following questions.

            1. What’s the objective evidence that supports each of the specific therapeutic claims on your website?
            2a. What’s the objective evidence that supports the claim that acupuncture works in animals?
2b. On what conditions does it work?
            3. What would be the effect of a single instance of morbidity or death from acupuncture on your claim that acupuncture is “not dangerous at all”?
            4. Have you ever seen the articular surfaces of a severely arthritic joint?
            5. What is the purpose of control groups in scientific trials?

            Thank you.

        2. Badly Shaved Monkey says:

          No, I don’t think you really are. I think you are trying to dodge the public challenges that your opinions have met here.

          Now, please get on with answering those questions…

          1. You don’t have to coerce, me just ask. Maybe tonight or in the morn. In the mean while google DIY needles. I think that needles are the best tools-super safe and effective … I have begun teaching my patients to help themselves. Can you imagine going to the Walmart pharm to get an RX for needles and an instruction booklet to use for your own knee pain or a headache. (With oversight obviously)

          2. WilliamLawrenceUtridge says:

            Stephen, were needles safe for Kim Ribbles-Orr? That’s a “trained” professional delivering the needling, I shudder to think of DIY approach.

    2. WilliamLawrenceUtridge says:

      Get me your email and i will let you see a few dozen questions and answers I’ve put together so you can SEE thru my eyes and experiences.

      Yes, but we’re uninterested in your testimonials. Why do you think your experience with acupuncture is so at odds with the experimental base for acupuncture, which consistently finds that acupuncture is good for little beyond pain and nausea, and only over the short term?

      What kind of doctor are you?

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