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Acupuncture for Migraine

A recent study looking at acupuncture for the prevention of migraine attacks demonstrates all of the problems with acupuncture and acupuncture research that we have touched on over the years at SBM. Migraine is one indication for which there seems to be some support among mainstream practitioners. In fact the American Headache Society recently recommended acupuncture for migraines. Yet, the evidence is simply not there to support this recommendation, which, in my opinion, is a failure to understand a science-based assessment of the clinical evidence.

The recent study, like many acupuncture studies, was problematic, and was also negative. It showed that acupuncture does not work for migraines, but of course also contains the seeds of denial for those who want to believe in acupuncture. From the abstract:

METHODS:
We performed a multicentre, single-blind randomized controlled trial. In total, 480 patients with migraine were randomly assigned to one of four groups (Shaoyang-specific acupuncture, Shaoyang-nonspecific acupuncture, Yangming-specific acupuncture or sham acupuncture [control]). All groups received 20 treatments, which included electrical stimulation, over a period of four weeks. The primary outcome was the number of days with a migraine experienced during weeks 5-8 after randomization. Our secondary outcomes included the frequency of migraine attack, migraine intensity and migraine-specific quality of life.
RESULTS:
Compared with patients in the control group, patients in the acupuncture groups reported fewer days with a migraine during weeks 5-8, however the differences between treatments were not significant (p > 0.05). There was a significant reduction in the number of days with a migraine during weeks 13-16 in all acupuncture groups compared with control (Shaoyang-specific acupuncture v. control: difference -1.06 [95% confidence interval (CI) -1.77 to -0.5], p = 0.003; Shaoyang-nonspecific acupuncture v. control: difference -1.22 [95% CI -1.92 to -0.52], p < 0.001; Yangming-specific acupuncture v. control: difference -0.91 [95% CI -1.61 to -0.21], p = 0.011). We found that there was a significant, but not clinically relevant, benefit for almost all secondary outcomes in the three acupuncture groups compared with the control group. We found no relevant differences between the three acupuncture groups.

There are multiple methodological problems with this study. The first is that it is single-blind, which means the acupuncturists knew what type of acupuncture they were giving, including sham acupuncture, which was their control. Previous studies have shown that the perceived empathy of the practitioner affects the outcome, and so unblinded acupuncturists who are giving “real” acupuncture may just be a bit more enthusiastic than those who know they are giving sham acupuncture. This would tend to result in a false positive outcome.

Second, the acupuncture treatments used electrical stimulation. This is very problematic because it mixes modalities – acupuncture and transcutaneous electrical stimulation – therefore we cannot say which component is responsible for the outcome. Mixing variables is sloppy research, and I wonder why, with three acupuncture arms, they did not include one without electrical stimulation to control for that variable.

Also, the number of treatments given was very aggressive, and not practical. Some have noted that perhaps this is a difference between Chinese and Western application of acupuncture, and that in the US doing 20 treatments over 4 weeks is expensive and not practical. This is a good way to maximize placebo effects, however.

Despite all of these shortcomings, all of which would bias the study in the direction of being positive, the study was negative. For the primary outcome measure there was no statistically significant difference between any of the acupuncture groups and the sham acupuncture group. Once again we see that it does not matter where you stick the needles. Since acupuncture is the practice of stimulating acupuncture points with needles, we can conclude that acupuncture does not work for migraines.

Some of the secondary outcome measures were significantly different, but clinically irrelevant. You always have to be cautious about secondary outcome measures. It is easy to look at many secondary outcomes and choose the ones (even subconsciously) that show the biggest effect. Also, researchers often forget to control for multiple comparisons when doing the statistics. Simmons et al recently pointed out that exploiting researcher “degrees of freedom” can easily result in a false positive result. What this means is that researchers make many decisions about how to look at the data and which data points to look at, and can innocently bias those decisions in the direction of seeing a positive outcome. The degrees of freedom are greater when you have lots of secondary outcome measures to choose from. Picking a primary outcome at the beginning of a study, however, is more constraining.

The study also did not include a placebo acupuncture group – one in which there is no needle penetration, or tooth picks are used instead of needles. Studies using blinded placebo acupuncture generally show no difference in outcome, leading us to conclude that not only does it not matter where you stick the needles, it doesn’t matter if you stick the needles. In short – the needles don’t matter. The training of the acupuncturists doesn’t matter. All of the cultural beliefs about meridians, acupuncture points, and chi do not matter. All that matters is the kind and amount of attention given by the acupuncturist to the patient. In other words – acupuncture is entirely a non-specific placebo intervention. It is the irrelevant magical ritual surrounding the attention from an empathic practitioner. This study is further confirmation of that basic conclusion.

The most recent Cochrane review of acupuncture for migraine reflects the above difficulties, and is also another great example of the difference between evidence-based medicine and science-based medicine. The authors conclude:

 There is no evidence for an effect of ‘true’ acupuncture over sham interventions, though this is difficult to interpret, as exact point location could be of limited importance. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.

The authors find it difficult to interpret the fact that there is no evidence for a difference beetween “true” acupuncture and sham acupuncture. Let me help them. The key point that acupuncture supporters miss when reviewing the evidence is the difference between blinded and unblinded comparisons. In general blinded comparisons are much more reliable than unblinded comparisons, in any area of science. In medicine, and with acupuncture specifically, we have evidence for a large placebo effect, which is strongly affected by practitioner empathy and the attention that goes with the ritual of acupuncture.

What the evidence essentially shows is that blinded comparisons with acupuncture are negative, and unblinded comparisons are positive. This is not hard to interpret at all – it means acupuncture does not work. Whenever we see a phenomenon disappear with the application of proper blinding, we conclude the phenomenon is not real. A phenomenon that depends upon not being blinded is an illusion. Acupuncture is the N-rays of medicine.

Until acupuncture researchers can show a consistent, statistically significant, and clinically relevant effect from blinded comparisons of acupuncture to sham or placebo acupuncture, there is no reason to think that there is any underlying reality to acupuncture as a specific intervention. The best conclusion we can make today, based on all available evidence, is that acupuncture adds nothing to the non-specific effects of the attention from the practitioner. Acupuncture does not work for migraine, and recommendations to use acupuncture are misguided and unscientific.

I generally do not see this confusion in non-CAM areas of medicine. CAM, it appears, has an anti-science field around it that confuses researchers and prevents them from properly interpreting negative outcomes.

Posted in: Acupuncture

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56 thoughts on “Acupuncture for Migraine

  1. wilibrord says:

    How do you blind the practitioner in an acupuncture trial?

  2. trrll says:

    I don’t agree that it is “sloppy science” to study “electroacupuncture.” This is a treatment modality that is used, and it is reasonable to examine its efficacy. Of course, if you wanted to figure out why it works, it would make sense to do a mechanistic study that included treatment groups with and without electrical stimulation, etc. But considering that it does not appear to work significantly better than placebo (and an incompletely blinded placebo, at that), that seems very much a moot question. It would not be surprising if the “electro” version is a more effective placebo than traditional acupuncture simply because it is more of a production (hooking up wires to the needles, additional equipment, and perhaps some additional sensation) and more impressive to patients, but that would not be very meaningful.

  3. You can (and people have) blinded practitioners with sheathed needles – they don’t know if they penetrate or not.

    Just because the study came out negative, does not mean it wasn’t sloppy. It is sloppy to do two treatments at once, call it acupuncture, and not control for the variables.

    It’s moot, in this study, because the results are still negative. But it’s still sloppy.

  4. Janet Camp says:

    And yet, at least once per week, I run into someone (most recently at a volunteer stint) who is doing acupuncture for something or other–usually a neck problem or allergies. When I say (very gently) it doesn’t do anything beyond placebo, they become instantly defensive and say it “helps” them. I say it helps them be relieved of their money. The most recent victim only countered with, “I have a coupon”. She is doing the acupuncture because the chiropractor has already failed to help her. After a few minutes of conversation, she simply said that nothing I could say would deter her from “holistic medicine”, that she “believes” in it.

    Another woman at the same event announced that she has celiac disease, although being wheat free for some time now has not really helped her due to “all the previous damage”. Over the course of a few days she mentioned other things the doctor had “taken her off of” such as artificial sweetener and MSG. I asked if she was seeing a MEDICAL doctor and she said yes, so I can only conclude we have another quack with an MD on the loose diagnosing celiac disease the same way they were diagnosing whatever it was they were treating with “probiotics” a while back.

    My point is–I run into this absolutely everywhere I go and with almost anyone I interact with. I don’t ask about these things or instigate the conversation. It simply comes up in almost any situation that involves small talk of any kind. These people are completely in thrall to anything “alternative” whether or not they are actively religious (I used to think it was just a religion substitute). Along with their “holistic” medicine, they harbor an insane fear of GMO’s and various conspiracy-type theories such as fear of cell phone and microwave oven emanations.

    I’m afraid that the internet is complicit in this. I’ve tried entering almost any chronic ailment and honestly, you have to go through several pages to even get to anything vaguely “mainstream”. I propose that skeptics set up “spas” where people can be “seen” by “practitioners”, for a fee–there MUST be a fee–who will teach them the very basics of critical thinking in a very supportive and touch-feely environment. We must swamp the internet with airy-fairy sites full of smiling, white-garbed “gurus” who offer the “truth” of–well, we must come up with a name for critical thinking that doesn’t sound threatening or complex, something that just sounds “spiritual”. I’m sorry, but simply setting forth the facts does not make a dent in the spread of woo. You get a fence-sitter here and there, but the multitudes are unaffected.

    I am becoming a recluse as a result of these interactions. Even some of my very best (and very well-educated) friends flirt with woo, believing it to be supported by “science” (as they have little knowledge of science, it hardly matters). Whenever they bring out the “ancient wisdom” gambit, I counter by asking them when they are getting their feet bound.

  5. David Gorski says:

    Oy, vey. A Facebook friend showed up on my wall after my providing a link to Steve’s excellent post:

    https://www.facebook.com/dhgorski/posts/10150740399274744

    Quote:

    Look, I understand his argument completely and he’s right — up to a point. But he doesn’t consider other possible mechanisms by which acupuncture might be effective. And he also seems to just gloss right over the Cochrane Review conclusion that acupuncture is at least as effective as prophylaxis.

    I would never EVER suggest someone throw aside traditional medicine for CAM for any disease or condition. It is NOT an alternative, but it can be a complement, and for a variety of conditions, acupuncture has real effects, at least on a qualitative basis.

    If I had migraines and someone told me to carry around a turnip for a week to feel better and it worked, I’d carry around a turnip. I’d also take Imitrex.

    Sigh….

  6. Scott says:

    I am firmly convinced that acupuncture would work better for my migranes than triptans do.

    Of course, that’s because for some reason, triptans make it worse in my case, so “does nothing” ends up being a superior treatment.

  7. I love it when there is free, public access to the actual study paper and not just the abstract.

    “The primary outcome was the number of days with a migraine experienced during weeks 5–8 after randomization.”

    No mention is made in the methods section of weeks 13-16 being a target for evaluation, but here it is without explanation for why they chose this interval for evaluation. Why single out weeks 13-16 post hoc? It may not be, but this sounds like cherry picking of a subset of favorable data.

    “The goal was to elicit a de qi sensation (a range of sensations typically generated by the insertion of a needle into an acupuncture point and the manipulation of the needle) in the three acupuncture groups but not in the sham-acupuncture group. ”

    How is this good blinding? It’s certainly not a good control when the application of treatment is fundamentally different between your groups.

    “However, patients were unaware of their treatment group, and all had been informed that they would receive “real” acupuncture in order to reduce the chance of unblinding.”

    No mention is made of any testing for blinding effectiveness, and they admit to lying to their subjects in an attempt to control for a placebo responses.

    “According to our results, nonspecific effects (e.g., expectations and patient–practitioner interaction) may have had a more prominent role and been increased by the use of electrostimulation in all groups. However, the use of electrostimulation is typical in China and was used in the control group to ensure blinding.”

    No reference is given to support the assertion that the use of electrostimiulation is typical in China or anywhere else. Note: they did not say common or frequent; they said typical.

    Also, while I’m not a fan of throwing out too many arms, in addition to there being no acupuncture w/o estim, there was no estim w/o acupuncture either. It’s also interesting that they did not do any kind of crossover in this study.

  8. But Dave,

    Your Facebook friend was raised by a forensic economist and statistician, and he’s “been working in EBM for six years now”.

    He has the power of argument from (questionable) authority! He doesn’t need logic or reason to support his position.

  9. chaos4zap says:

    What exactly does it mean to be “working in EBM”? Unless you are conducting studies or research, I’m just not sure how it makes much sense. It sounds more like something people say to give the illusion of knowing what they are talking about, when they really don’t “get it”. You know, like how Alex Tsakiris calls himself a skeptic, even though he clearly is not even capable of grasping some very fundamental concepts of logic, bias and critical thinking.

  10. actinomyces says:

    I have a very severe chronic headache condition, chronic daily headache with migraineous features. I’ve been this way for 13 years. When someone learns about my condition they say “have you tried….” I have tried every treatment supported by good science to have some efficacy and have had some success, although not enough to resume the career in science I had to leave behind due to this disabling condition.

    I get SO sick of people suggesting CAM crap I should try, it happens several times a month. The last person, a neighbor, asked if I had tried acupuncture and since I was already pissy that day after a 8 day migraine, I retorted “I only try treatments that actually have scientific evidence of working”, which was rude and I apologized for later. I know people who suggest these things are only trying to help but I find the vast knowledge gulf I would have to navigate with them to explain why their suggestions are crap frankly exhausting. I often refer people here.

    I also get very tired of going to new doctors who have less knowledge than I do. The last doctor I went to prescribed gabapentin which has a nasty side effect profile. I went home and read all the most recent studies regarding the efficacy of this drug for migraine, including negative studies that were unpublished by the drug’s manufacturer but forced to be released in a class action lawsuit regarding off label use of the drug for migraine. The overall picture: no good support for gabapentin’s efficacy for migraine. I was pissed. I didn’t go to medical school, that’s what I’m paying the doctor for–his supposed expertise–but I find most of the doctors I have visited have no idea how to evaluate scientific research (except one, he was great–I picked him becaused he published his own research studies in reputable journals, but he sadly moved from my area). Is how to integrate scientific research into everyday practice not taught in medical school? I can’t believe that is the case (or maybe I can with the CAM infection in medical schools), but it’s been my personal experience.

  11. Jan Willem Nienhuys says:

    How do you blind the practitioner in an acupuncture trial?

    One way of doing it might be that an acupuncturist who claims he or she knows where to put the needles, marks a couple of verum spots and a couple of control spots on either (A) points that are not acupuncture points at all, or (B) recognized acupuncture poinrs that are definitely (according to the acupuncture theory) not appropriate for the complaint. Marking measn write a little circle with the acupoint in its center. Marking should be done in a random predetermined order.

    Then the ‘expert’ leaves, and someone without knowledge of the ‘correct’ points enters and is given instruction to put needles in some of the marked spots.

    In this way the interaction of the acupuncturist with the patient is minimal, moreover, the acupuncturist is blinded w.r.t. which patient is verum or control. The person putting in the needles also doesn’t know which locations are verum and which ones are control.

    In this manner you cannot distinguish between acupuncture yes /no. But the acupuncturists claim that one has to know exactly where to put the needles. and also that one needs to study a lot before becoming an acupuncturist. The contrary opinion is that it really doesn’t matter where you put the needles and that all it takes is a course of one afternoon (and that the fees for this kind of help should not be higher than, say, the wages of a parking lot attendant).

    All this advanced studying is just as useful as memorizing the telephone book.

  12. RedBear says:

    @Janet Camp

    YES! How do we package critical thinking so that it appeals to the masses?! I feel the same way, that I am becoming a recluse because I am weary of beating my head against the wall of CAM and delusional thinking so prevalent in my friends and acquaintances. Here is the 16 ton weight that broke the camel’s back for me:

    I have a friend completing a PhD in science education. I lamented to her about a mutual friend’s belief in psychics. Our PhD candidate then stated, “Well, I think I’m actually somewhat psychic.” I waited hopefully for a punch line that never came. She was serious. I knocked myself over with the resulting facepalm. I haven’t spoken with her since. It’s just too painful.

    If I don’t make it to TAM or CSICON or something similar this year, I’m afraid I might succumb to peer pressure and sit on a quartz crystal just so I can relate to the people around me. Throw me a rope!

  13. Eugenie Mielczarek says:

    A study of all acupuncture awards by NCCAM from 1998 to present, 488 grants totaling $144 million for 10 different medical conditions, included not only standard acupuncture but also acupuncture combined with ultrasound, electric shock, moxibustion , herbs. We , Engler and Mielczarek, found no positive results. Nothing ever dies but vivid imaginations persist.

  14. agitato says:

    Janet Camp:

    You wrote: “I run into this absolutely everywhere I go and with almost anyone I interact with. I don’t ask about these things or instigate the conversation. It simply comes up in almost any situation that involves small talk of any kind. These people are completely in thrall to anything “alternative” whether or not they are actively religious (I used to think it was just a religion substitute). Along with their “holistic” medicine, they harbor an insane fear of GMO’s and various conspiracy-type theories such as fear of cell phone and microwave oven emanations.”

    I share your feelings completely and feel pretty pessimistic about controlling the horrible tsunami of snake oil we are currently engulfed in. I’m absolutely convinced the #1 reason people claim benefits from CAM is related entirely to the experience of visiting a CAM “practitioner” namely a whole lot of attention, a huge wad of false hope, soothing smells and music. It has nothing to do with whatever the kooky treatment is (unless some of the recommendations include basic public health advice.)

    Since the belief that CAM works is entirely experiential, I’m wondering if we should adopt a few of its practices and make the experience to a medical doctor more pleasant. I am not advocating false hope of course, but what if there was a separate waiting room where the chairs reclined and pan-pipes played and the air was pleasantly scented? What if massage therapy students circulated and offered hand and head/neck massages like they do at the salon where I get my hair cut. How about some iPads? (same salon).

    Am I totally off-base here? ie thin edge of the wedge…caving in to the dark side etc.

  15. windriven says:

    @RedBear

    “How do we package critical thinking so that it appeals to the masses?!”

    I don’t think that we can. I once believed it was possible but repeated negative results have convinced me otherwise. I’ve come to believe that quitting woo is harder than quitting smoking.

    Like smoking, the individual first has to want to quit woo. There are many clear reasons to quit smoking, not the least of which is peer pressure. The reasons for quitting woo are less obvious and then there is the happy embrace of a community of new-agey, spiritual, sciency-sounding proponents of woo to make it all seem wonderful, magical even. Harry Potter will make you better if you just wish for it hard enough.

    If you want the masses to embrace critical thinking over woo you will have to convince them that woo is the idiotic fantasy of knuckle-dragging morons: “you don’t want to be a knuckle-dragging moron, do you???” That or you can convince them that critical thinking will make them more likely to spend a sweaty evening with Brad Pitt or Christina Aguillara.

    Good luck with that.

  16. trrll says:

    “Just because the study came out negative, does not mean it wasn’t sloppy. It is sloppy to do two treatments at once, call it acupuncture, and not control for the variables.”

    In general, it is impossible to control for all of the variables in a study. A drug trial cannot try every dose, every dosing interval, every type of formulation. How far do you go to separate patient variables: women, or men or both? what age range? what specific diagnosis? weight, height, etc. etc.? Moreover, there will be a “placebo component” that could potentially confound the outcome of a treatment: whether the person administering the treatment is a nurse or a doctor, and whether that person wears a white coat, a suit, or bluejeans; whether there are diplomas displayed on the wall and whether those diplomas are from Harvard Medical School or New York College of Osteopathic Medicine, etc.

    How many of the potential variables you will be able to separate will ultimately be limited substantially by practical considerations. Dividing up your study population into smaller treatment groups reduces the power of the study, and/or increases the cost.

    Inevitably, you are compelled make a “best guess” as to which variables are most likely to most strongly influence your study, based upon common sense and knowledge of pharmacokinetics and physiology, and which variables you are most interested in. You do your best keep the others either pretty much constant or you randomize them. In an initial study (such as this one), you will probably choose the treatment conditions that you expect will maximize your chances of observing a significant effect, with the expectation that if a significant effect is observed, you will then carry out follow-up studies to disentangle the factors that you were unable to separate in your initial study. Of course, if you don’t observe a significant effect in your initial study, people are far less likely to care about further separation of variables, and those follow-up studies may never be done.

    It is always a judgment call, and of course there is always a risk. Guess wrong in your initial study and you may never get the support to do a follow-up. What if conventional acupuncture has a genuine effect, but it is somehow “cancelled out” by electrical stimulation? But this is the case in any study, because no study can test every single variable that could conceivably be important. Indeed, this is the most rationalization one hears from those who are convinced of the efficacy of “alternative” therapies–you must not have done it right. If the nutritional supplement has no benefit or causes harm, it must be because you used synthetic active ingredient instead of natural, or because you did not combine it with other natural ingredients in the same way as might possibly have been done by the ancient practitioners of the art, etc., etc.

  17. BKsea says:

    Another distinction between CAM researchers and real medicine researchers is that the latter generally defer to the less invasive procedure when two techniques are shown to be equivalent. If you want to try to argue that acupuncture can not be distinguished from sham acupuncture because both “work”, you should at least argue that henceforth all practitioners should use the less invasive sham technique.

  18. BKsea says:

    To trrll: Perhaps this will clarify the situation regarding controlling the variables. Imagine a drug trial of drugs A, B, and C. The trial has 3 arms: arm 1 gets drugs A&B, arm 2 gets drugs A&C, arm 3 gets placebos. The result is that arms 1 and 2 both do better than placebo but are not different from each other. Conclusion: Drugs B&C are both effective.

    Do you see anything wrong here? Because of a poor trial design, it is impossible to conclude anything about what combination of drugs should be recommended. This is essentially the same as the accupuncture study design discussed here.

  19. RedBear says:

    @windriven

    Say it isn’t so! Don’t give up. Quitting woo may be more difficult than quitting smoking, probably because it is more enmeshed with one’s world-view/sense-of-self than smoking. It is no less of a health threat, however.

    I have friends who have postponed, or completely avoided, medical treatment for serious illnesses because of their belief in woo and fear of authority. At least one has paid the ultimate price (and now may at least have an answer to the question of life after death). I want to be a shruggy and let them live their own lives, but when those lives are cut unnecessarily short I can’t just stand by and watch.

    I also have two wonderful high school age kids young adults, learning to navigate life in the internet age. They will be an interesting test case, as my ex-wife is deep in woo belief and the kids spend equal time with each of us. This has not become an overt tug-of-war, but the potential is there. Both my kids are considering studying medicine, by the way, and we live within dowsing distance of Bastyr University!

    If we cannot turn many believers from delusional thinking, than hope must lie in young, more flexible minds. I understand the challenge. Believe me I appreciate the work of Steven Novella, Harriet Hall, James Randi, and the like… but HOW do we get a former Playboy bunny to jump on the bandwagon as a spokesperson? (No offense, Novella.)

  20. annappaa says:

    @RedBear: Didn’t Penn & Teller’s Bullshit have an episode on vaccines in which they were able to find a Playboy bunny to rebut McCarthy’s statements?

  21. actinomyces says:

    It occurred to me I should have provided links to the evidence supporting my assertation that the most recent evidence for the use of gabapentin (Neurontin) for migraines does not support its efficacy. Especially in light of the fact that a 2004 Cochrane review says its use “may be beneficial” for migraine prevention. I mean, not providing evidence may fly in the comments section of say, the HuffPo, but certainly won’t fly here at SBM. It’s a bit of an involved, somewhat sordid tale, but I’ll summarize.

    Normally tales involving nefarious plots by Big Pharma ding my skeptidar, but in this case, there is good evidence to support wrongdoing on the part of Neurontin’s manufacturer, Pfizer, in its promotion of the off label use of this drug for several different conditions, including migraine. In 2011, Pfizer lost a lawsuit claiming it illegally promoted and marketed the use of Neurontin for conditions where the research doesn’t support its use:

    http://www.nytimes.com/2011/01/29/business/29pfizer.html

    Furthermore, good evidence was found during this lawsuit that Pfizer selectively published positive studies on the efficacy of Neurontin for off label uses such as migraine while not doing so–or actively suppressing–research showing lack of efficacy.

    http://www.nytimes.com/2008/10/08/health/research/08drug.html

    A well conducted review of the research regarding the efficacy of Neurontin for migraine which was done for this lawsuit included both published and unpublished studies and is available here:

    http://www.prescriptionaccess.org/docs/neurontin_exh_M.pdf

    This review found the following: “In summary, the randomized double-blind, placebo-controlled trials of gabapentin versus placebo, considered together, fail to consistently or convincingly demonstrate that gabapentin is effective for migraine prophylaxis.”

    The above review is the first search return for the terms “Neurontin efficacy migraine” in Google which I was able to find in ten seconds or less (judging if it was good evidence took more time however). My question was, if I could find this information so easily, why couldn’t my doctor? Who instead prescribed a medication that has a strong side effect profile in exchange for no benefit for my condition.

  22. Ed Whitney says:

    The Cochrane review included Linde 2005 which appears (ungated) in JAMA at http://jama.ama-assn.org/content/293/17/2118.full.pdf+html . This had three randomization arms, acupuncture, sham acupuncture, and a waiting list (no acupuncture) control in which treatment was confined to medication for acute attacks only. The response rate (50% reduction in headache frequency) for the two acupuncture arms was not significantly different. For sham acupuncture, the response rate was 53%; the waiting list response rate was 14.5%.

    The sham response rate of 53% (and the large difference from the wait group) is likely to reflect an expectation from acupuncture; the study, done in Germany, recruited patients through local newspapers and word of mouth, with the expectation of receiving acupuncture at some point during the study.

    What is rather interesting is that the placebo response of 53% is greater than the placebo response for any drug trial reviewed in 2002 by Van der Kuy and Lohman (A quantification of the placebo response in migraine prophylaxis, Cephalalgia 2002;22:265-270). This article reviewed 22 studies of a variety of medications; a reduction of 50% or more (responders) averaged 23.5% of the placebo groups and 45.5% of the active groups; the largest placebo response was 34.4%.

    This would support the conjecture of the Cochrane reviewers that a more complex intervention (sham acupuncture) has a larger placebo response than a simple intervention (an inert pill). If all placebos are equal, some appear to be more equal than others. There seems to be a difference between a placebo and “just a placebo.”

  23. EricG says:

    @ windriven and Redbear

    honestly, its just because we are so damn human. we are the centers of our own world, want to live forever, be special, believe we do no wrong, that the world has a unique wonderful purpose for us, that we can fly if we try hard enough, believe in perfect distributive justice (heaven and hell), that the world is cosmically fair (karma)…

    we all know (*sigh* have no evidence for…) these things to be patently false. we persist in believing. it is systemic to all groups of humans. call it nihilistic…i guess. I think Louis C.K. put it quite well, “but they are my believies! they make me feel good. i like to hold them! I don’t care if they aren’t true…they make me feel good!”

    and, to top it all off, humans love drama, love being self-righteous, revel in indignation, leap to point the finger to prevent fingers inching in their own direction. its a recipe to keep mystical irrationality around for another 10,000 years.

    but this isn’t me being a cynic, i just look at the glass somewhat full of stuff and say, “haha, look at that silly glass!” then shrug my shoulders and go live my life the way I see fit. what else can you do?

    /rant-gent

  24. EricG says:

    *call me nihilistic

  25. pmoran says:

    This is a good way to maximize placebo effects, however.

    Until acupuncture researchers can show a consistent, statistically significant, and clinically relevant effect from blinded comparisons of acupuncture to sham or placebo acupuncture, there is no reason to think that there is any underlying reality to acupuncture as a specific intervention.

    Time for a bit of “what was the question, again?”

    1. If the question is : “does acupuncture have mysterious healing ability?” the answer is clear : “not established, , very unlikely on other grounds, and now proven to be, at best, weak in comparison to the effects of the non-specific influences (presumably placebo, counter-irritation, relaxation, etc) operative within acupuncture studies”.

    This study follows the usual pattern. Figure 2 shows that the incidence of migraine was HALVED in ALL groups including sham when compared to baseline. The results were presumably established using a migraine diary, a reasonably objective method. They show a dramatic reduction from almost daily migraine. (Reversion to the mean could, of course, account for some of that).

    2. So, what if a patient asks a less focused question : “will ‘acupuncture’ help my migraine?”? . I would feel rather obliged to say “well, it certainly seems to help some people” and only give further information about what I know if the patient seems to want it . I would not go beyond the information outlined above. I would not say “it doesn’t work!” but I might say “it doesn’t work that way”, if prodded. I am not sure that I have the right to poison this well while there is a chance that this patient may derive significant benefit from it, especially if there are factors favoring that, such as cultural heritage or a past history of satisfaction with CAM methods.

    3. The third question that arises is : “should the mainstream advocate acupuncture programs, if they can reduce migraine to this degree?” The answer to that can quite reasonably be “no, at least not without further study into its cost/risk/effectiveness within the specific environment within which it is to be used”. The benefits shown are likely to be specific to the population concerned and the enthusiasm of the practitioners. They are not necessarily reproducible under the conditions that will apply within the mainstream and especially with a population getting mixed messages as to the method’s worth and practitioners whose instinct is to reject it..

    4. An allied question is “who should pay for it”. But I have said enough.

  26. Harriet Hall says:

    @pmoran
    “well, it certainly seems to help some people”

    When you say that, the patient will hear “The doctor said acupuncture works.”
    I consider such an un-nuanced answer to be a significant misrepresentation of the truth: lying by omission.

    I think the minimum honest answer is “Some people think acupuncture helps, but then some people think sugar pills help, too.”

  27. Janet Camp says:

    @RedBear

    Thanks for the response! Hey, maybe we should start a support group for people who have lost most of their friends due to woo?

    It is getting lonely out here as I stop calling people back who want to share the dangers of GM dog food or tell me how much “better” they feel since they started mega-dosing with Vitamin D (on their “doctor’s” advice). Whenever I hear “doctor” anymore, I don’t even ask–they could mean anything from chiro to naturopath to deluded MD.

    I have even taken to “interviewing” any new MD that I see to make it clear that I’m not interested in any Dr. Woo (no offense to any good doctor who happens to be named Woo)—and if the response is anything other than an enthusiastic smackdown, I look elsewhere. One gyn I saw had boxes of herbal menopause “treatments” all over the exam table when I came in. I expressed alarm and her reply was, “so many people want it these days, I had to include it”. I have dozens of stories like this.

    More than one person I have known or lived next door to has either forgone standard treatment or spent buckets of money “complementing” that treatment–often with a perhaps dangerous delay before finally seeing a real doctor.

    I used to live “dowsing distance” from Bastyr as well, but thought I would escape a lot of it when I came to the Midwest–uh-uh! It’s as bad or worse here. At least in the Northwest they kind of form little cliques and stay within those groups, but here they seem to be all over the place. Also, in the NW, they tend to look the part more so you can see it coming (and run), but here they blend in and you have no idea until they suddenly pop off about something utterly ridiculous. I know this sounds nuts–like I’m talking about aliens or something, but SCAM really does touch my life all too often and it’s beginning to feel creepy.

    I think that Windriven is probably right and it’s very depressing. I go to Skeptics meetings, but even there, people are otherwise, well–skeptical, will go on a rant about how yoga cured their whatever and how it’s far superior to “just stretching”, or they will outright attack a speaker who does GMO work at a major university. Luckily, I am very comfortable being pretty much on my own. The chickens and the dog are at least safe to talk to.

  28. windriven says:

    @ RedBear

    “Don’t give up. ”

    I won’t, even though I believe it to be essentially Sisyphean. Bottom line: on some level (some would argue on many levels) I’m an a$$hole and aggravating the wooies is a cheap thrill.

  29. windriven says:

    @EricG

    “what else can you do?”

    You can get in their vapid little faces and make them squirm. It really doesn’t accomplish anything but it feels great.

  30. windriven says:

    @Janet Camp

    “I think that Windriven is probably right and it’s very depressing.”

    Don’t be depressed. Adults are generally beyond hope. But children are wide open territory. Teach a child some critical thinking skills. Show one how interesting it is to break down widely held superstitions and how empowering it is to understand how things really work.

  31. pmoran says:

    Harriet:@pmoran
    “well, it certainly seems to help some people”

    When you say that, the patient will hear “The doctor said acupuncture works.”

    Possibly, although the “seems to” surely conveys some reservation that the patient can explore further if wished.

    I consider such an un-nuanced answer to be a significant misrepresentation of the truth: lying by omission.

    So ignoring the most striking finding in such studies, i.e. that ALL the ‘treatments’ “seemed to work”, is NOT “lying by omission”.

    I think the minimum honest answer is “Some people think acupuncture helps, but then some people think sugar pills help, too.”

    Thus poisoning the well, while omitting to say that sugar pills can also “seem to work” under the right conditions, just not as well as acupuncture much more commonly “seems to”.

    However, I do understand and respect your ethical approach. I just don’t see it as clear-cut as skeptics like to make it out to be and it has always felt to me like a suspiciously convenient and bias-serving answer to what many see as a serious ethical dilemma .

    The ethical argument will especially wear a little thin if other well-performed studies show that acupuncture can perform as well as commonly used pharmaceuticals as per the Cochrane report. You will then surely need my argument, that acupuncture almost certainly not work as well (and not cost effectively, as Steve says) if we tried to use it in an atmosphere of skepticism.

  32. kathy says:

    Janet Camp wrote, “These people are completely in thrall to anything “alternative” whether or not they are actively religious (I used to think it was just a religion substitute).”

    It IS a religion, complete with the urge to spread the gospel. They mean oh-so-well, but so do young men in suits that ring my doorbell and want to preach to me about the end of the world.

    I am terminally irritated with friends who email wide-eyed alarmist-woo (or any other urban myths) to me and their 457 other contacts. Likewise with those who post pseudo-medical stuff on Facebook. A relative (a qualified nurse) had been posting religion-based “medical” woo on fb, that is, those bits of woo that were in keeping with her (formal) religion. Like, abortion causes cancer. I took her on a few times, also on fb, and now she doesn’t post it any more, but I doubt that she’s “renounced” it. Come to think of it, I’d better check up if she’s still on my list of Friends … maybe she’s “Unfriended” me …

    Another characteristic true-woo-believers share with some forms of religion is the lager mentality, “We are the one true faith and the whole world is in the power of the devil and therefore is against us”, or in woo-speak, “The whole orthodox medical world is in the power of Big Pharm and therefore is against us”. Cults are especially prone to using this tactic to keep their members from straying. Their leaders know the value of an external threat (real or just percieved) to keeping the sheep nervously huddled in the kraal.

    The more we tell them they are wrong, misguided, irresponsible, etc., the tighter they hold on to their belief. On the other hand, if you don’t tell them how are they going to find out? It’s a lose-lose situation on the face of it … I feel, along with others on this site, the down-drag of “It’s hopeless, I’m wasting my time, why try any more?”

    … from RentaRanta … no more I promise.

  33. papertrail says:

    I could have written several of these posts! I keep asking what can be done and feel exasperated but then I remember that the good doctors here are doing it with this blog. I swear I would have gone insane by now if not for this and similar blogs. When I reach an impasse or just don’t want to get into a fight, I refer the person to SBM. I first started to feel skeptical of many claims (homeopathy, to start) about 12 years ago. I wrote to Quackwatch to ask why there are so many studies showing positive results with homeopathy. I got back a one line answer: “one out of 20 studies will be positive just by chance based on p value alone” (or something like that). My eyes were opened. I asked if someone there could specifically analyze some of he studies touted by Dana U. and got a reply: “we don’t have the staff to handle that”. Fast forward: CSICOP, SBM, Skeptic Dictionary, on and on. Whew! Even I wrote a few blog articles and newspaper opinion pieces. So, what can be done? I think we’re doing it right now!

  34. WilliamLawrenceUtridge says:

    I would actually recommend acupuncture to people who were using it as a form of symptom control (i.e. pain and nausea only) but with the following caveats:

    - nonpenetrating (best) or shallow-penetrating (acceptable) needles fresh from a package
    - acupuncture sites far from nerves or blood vessels
    - no TCM diagnosis, just a lengthy conventional history
    - practitioner emphasizes empathy, excellent listening, attention to detail and is alert for the possibility of other diagnoses
    - no discussion of qi, meridians or acupuncture points
    - emphasis of the safety and evidence for the modified, modern technique

    Even if acupuncture is just a placebo, it’s a truly effective one. Since TCM theory, point selection and penetration are all worthless (sham controls for all these are equivalent to placebo) they can be discarded. The safety of the procedure is enhanced significantly and there is no erosion of critical thinking or science.

  35. DugganSC says:

    Now if only we could get some good studies with sham chiropractry… I suspect we’d come out to the same result, subjective and equal improvement in symptoms with all methods compared to the control group. Avoid neck-cracking, of course (not letting a tyro get around my neck…), but the whole back-cracking aspect of it.

  36. trrll says:

    @BKSea [I]To trrll: Perhaps this will clarify the situation regarding controlling the variables. Imagine a drug trial of drugs A, B, and C. The trial has 3 arms: arm 1 gets drugs A&B, arm 2 gets drugs A&C, arm 3 gets placebos. The result is that arms 1 and 2 both do better than placebo but are not different from each other. Conclusion: Drugs B&C are both effective.
    Do you see anything wrong here? Because of a poor trial design, it is impossible to conclude anything about what combination of drugs should be recommended. This is essentially the same as the accupuncture study design discussed here.[/I]

    Actually, the only thing really wrong is your conclusion. The correct conclusion is that combinations A+C and B+C are both effective compared to placebo. This is useful information: you now have two effective therapies that you did not have before. And you also have a reason to do follow-up studies to disentangle the contributions of the individual drugs in the combination.

    We can contrast to a study that examines placebo, drug A alone, drug B alone, drug C alone, and the combinations A+C, B+C, A+B. In the ideal situation, this would give you the most information. Unfortunately, because you now have 7 treatment groups instead of 3, so the treatment groups have to be smaller. You observe the same magnitude of therapeutic effect, but because the individual groups are smaller, the standard error is larger, and you also have to make an adjustment for multiple comparisons. The result is that none of the treatment groups are significantly different from placebo. The result is inconclusive. All the journals you submit it to reject it, because it is clear that the study was insufficiently powered to detect a therapeutically important treatment effect. You have wasted your money and potential placed treatment subjects at risk, and added nothing at all to medical knowledge.

    A more realistic situation is when a drug is known to affect two biological targets potentially relevant to therapeutic outcome. Do you do an initial efficacy study at a dose (known to be safe from Phase I studies) at a dose that affects both targets, or do you use a lower dose that affects only one of those targets? Or subdivide your treatment population to test multiple doses at the cost of reducing the power of the study to detect a real effect? How about if you know that funding for the project will likely be withdrawn if your study fails to yield a significant effect?

  37. papertrail says:

    These acupuncture studies are attracting volunteers who I imagine are biased to believe acupuncture works, and I suspect are more suggestible than the general population. I don’t imagine you’d see as high of a placebo response with the general patient population.

  38. Alia says:

    As for kids – I’m a teacher. And as part of my curriculum I also need to talk about CAM (if only to teach my students English names for various practices – don’t ask me why our authorities decided that all kids learning English at the secondary school level should know words “chiropractor” or “faith healer”). I usually seize this opportunity to discuss the problem with them – and I must say I feel heartened by their response, which is usually closer to “Reflexology and foot detox, WTF?” than “Reflexology and foot detox, what a great idea!”

  39. trrll says:

    papertrail, There is not much evidence to support the hypothesis that the population can be meaningfully stratified into “suggestible” people who show a strong placebo response and “less suggestible” people who do not. Drug companies sometimes try to weed out placebo responders by beginning a drug trial with a “placebo lead-in” in which everybody gets a placebo to begin with, and those who “respond” are dismissed from the study, but this does not seem to appreciably reduce the fraction responding to placebo.

    Part of the problem is likely that not all of “responding” to placebo is going to be due to power of suggestion. There is also the phenomenon of “regression to the mean,” which tells you that on the average, people who seek medical intervention because they feel bad are likely to feel better at some time in the future (simply because virtually all conditions show some fluctuation in severity of symptoms, and people are more likely to seek care when they feel particularly bad). But if you do get a treatment and then (purely by random chance) happen to feel better shortly afterwards, this may increase your belief in the the efficacy of the treatment and enhance any suggestion effect. So power of suggestion (to the extent that it is really a factor in the placebo response) may interact strongly with random factors.

  40. papertrail says:

    Thanks trrll. I am familiar with regression to the mean (familiar as opposed to knowledgeable). I am assuming that that’s the point of a non-treatment group, among other things.

    I didn’t know that eliminating placebo responders hasn’t shown to make much difference, and it really surprises me.

    I’m not sure if that means that people who expect acupuncture to reduce their pain wouldn’t respond more favorably to both “real” and sham acupuncture than the general public/patient or those who are more skeptical.

    The argument I keep hearing is that acupuncture studies show a much higher rate of placebo response than other treatments. More and more people are saying they don’t care if a treatment is a placebo as long as it works. Migraines are very hard to treat and the meds have serious side-effects. This becomes a rationale for anything from shrugging over someone’s decision to use acupuncture for migraines (and other conditions), to physicians recommending it, to including it in their own practice and in hospital program as science-based medicine (in other words, the science is showing it to be effective reasons if nothing else).

    The study mentioned above http://jama.ama-assn.org/content/293/17/2118.full.pdf+html which showed a dramatic difference between the non-treatment group improvement (about 15%) and the acupuncture arms (sham and “real” – about 50%).

    I just have to wonder if something else was going on with that study.

    At what point does it become science-based medicine to use acupuncture for let’s say migraines if science shows a dramatic improvement as compared to standard or no treatment?

  41. papertrail says:

    Ugh, jumbled my words. Ignore this: “(in other words, the science is showing it to be effective reasons if nothing else).”

    And then I meant to say: I’m thinking about the study mentioned above http://jama.ama-assn.org/content/293/17/2118.full.pdf+html which showed a dramatic difference between the non-treatment group improvement (about 15%) and the acupuncture arms (sham and “real” – about 50%).

    Sorry.

  42. papertrail says:

    I should add too that I’m asking about sham acupuncture becoming science-based medicine, not “real” acupuncture, because the evidence seems overwhelming that sham is just as effective as a placebo and is less invasive.

  43. windriven says:

    @Alia

    “I usually seize this opportunity to discuss the problem with them”

    May Thor shower blessings on you and yours. The world is changed through the minds of its children.

  44. tmac57 says:

    BKsea-

    If you want to try to argue that acupuncture can not be distinguished from sham acupuncture because both “work”, you should at least argue that henceforth all practitioners should use the less invasive sham technique.

    Your wish is my command:

    http://youtu.be/IS9EwFE-hJo

  45. trrll says:

    A non-treatment group is not always used, and comparing the non-treatment and placebo groups to separate regression to the mean from suggestion effects will work only if these are independent effect. But if a random improvement can synergize with suggestion, they become very hard to disentangle. This could explain why it has not in practice been possible to eliminate placebo responders. An individual may be a responder or a non-responder depending upon random factors.

    The question of whether placebos of any type should be used as evidence-based therapies runs into problems that are partially ethical and partially due to the fact that understanding of the placebo effect is still quite imperfect. Surveys have shown that in practice it is not uncommon for physicians to prescribe treatments that they at least suspect function as placebos, and it was probably even more common in the past when physicians took a more paternalistic attitude toward their patients. However, a modern view of medical ethics precludes the physician from being dishonest with his patient. Of course, there there are ways of skating close to the edge of dishonesty. Is it a violation of medical ethics to tell a patient, “There is no known medical basis for pain relief from acupuncture, but some patients report that it makes them feel better?” This is not actually false, but it falls far short of full disclosure. If a friend tells me how much his pain is relieved by acupuncture treatments, I don’t normally go out of my way to tell him that it is almost certainly a placebo effect. But I would feel differently if he were to specifically ask me for information about acupuncture, or if I thought that his acupuncture treatments were seriously straining his finances. Moreover, we don’t know how much telling a patient that acupuncture is a placebo impairs its efficacy. Some studies suggest that part of the perceived benefit of a placebo may be conditioned response to intervention, and that at least a portion of the perceived benefit remains even when the subjects are informed that the treatment is a placebo. Dr. Gorski has criticized one such study on the grounds that the investigators primed the subjects with the meta-belief that placebos work even if you know that they are placebos.

    http://www.sciencebasedmedicine.org/index.php/placebo-effects-without-deception-well-not-exactly/

  46. DKlein says:

    @Janet Camp – Yes – I agree with your entire post. The skeptics’ spa is particularly intriguing. I, too, am feeling a bit like a recluse, losing friends left and right. Just lost another one this weekend over a conversation about BPA. And it is true that you cannot get away from it. Last year in a small painting class, I mentioned migraine and 4 out of 6 students turned out to be Reiki Masters. It used to be the eccentric old lady up the street was a Reiki Master and everyone thought she was crazy but now these types seem to get respect. My 4 Masters lost their blissful smiles when I declined their offers and they weren’t very nice after that.

    Just when I was starting to see that the alternative medicine modalities I had been dabbling in, and even studying, was hooey, my neurologist suggested acupuncture. There was never, ever anything to suggest this doctor in a big neuro group was into anything alternative. I was satisfied taking Frova as needed for migraines, so I second-guessed my DOUBTS about acupuncture and found a practitioner who told me my liver was the culprit (it usually is with these types). She suggested 3 sessions. During the 3rd, it just really hit me that I was paying for a nice nap in a nice setting, for $80. I really wanted it to “work” because it seems like with meridians you can kill a lot of birds with one needle so maybe it would help my eczema and knee pain too.

    What really grinds my gears is that my rabbit vet has gone alternative and offered acupuncture for my blind rabbit at our last visit. These poor creatures. I just don’t get this at all.

  47. papertrail says:

    Thanks, again, trrll.
    “Dr. Gorski has criticized one such study on the grounds that the investigators primed the subjects…”
    I thought the same thing when I read about that study. He should have told them that the pill they were taking was completely inert with nothing in it other than fillers. Anymore, the word “placebo” itself is interpreted by many as “powerful mind-body medicine.”

    @DKlein
    Ugh, like a nightmare where you try to use the phone to call for help but keep pressing the wrong numbers.

  48. mousethatroared says:

    regarding losing friends over alternative medicine.

    I completely understand folks unhappiness over previously trusted doctors or vets making poor recommendations based on CAM.

    I don’t understand losing a friend over their belief in CAM or woo, anymore than I understand losing a friend over their being a smoker, bad with money or incredibly bad with mechanical things (there are people who actually can’t change an automotive lightbulb). As long as a friend isn’t making my health care decisions, why can’t one remain friends with someone who is mistaken about the medical advice they are pursuing? I have a friend who has been into alternative medicine for as long as we have know each other (20+ years) I think that our continued friendship (as well as her friendship or other more conventional minded folks) has moderated her medical decisions.

    The key is that we both understand that we have a difference here, but we are both willing to focus on other interests and respect the others right to make the medical decisions that they feel comfortable with.

    If one can not respect a friends right to make mistakes (that aren’t endangering you) and still appreciate the positive attributes of that person, then it will be very difficult to find any friends at all, I would think.

    Sorry, I realize that’s a lecture, obviously, it’s only my opinion and there are many ways to approach friendship.

  49. Newcoaster says:

    I just got my copy of the CMAJ this week and read the study. I mentally checked off all the problems and biases, and noted what a terrible study it was. I was thinking of writing a letter to the CMAJ to point it out, then thought about forwarding it to the guys at SBM, only to find that Dr Novella has already seen it, dissected it and shown it for the worthless bit of fluff that it is ! Thanks, I’ll just send them the link to this blog!

    Other notable problems include patient selection bias, and publication bias, given that acupuncture studies from China tend to be overwhelmingly more positive than those done in the rest of the world. The odd thing was off course that it wasn’t actually a “positive” study at all.

    However, worse than the study itself, was a guest commentary from a Dr. Albrecht Molsberger. Unfortunately you need to be a paid subscriber to read this but CMAJ helpfully points out he “has received payment for lectures on acupuncture at scientific meetings, providing continuing medical education for the Forschungsgruppe Akupupunktur and is president of the Forschungsgruppe Akupupunktur”

    It also mentions his article “was solicited and has not been peer reviewed”. The latter is clearly an understatement! Dr Molsberger starts off by stating that “In general, the harder a medical problem is to treat, the more treatment strategies exist” He then documents a selection of the various pharmacological and non-pharmacological things that have been tried for migraine including avoiding known triggers, keeping a headache diary, various lifestyle changes, the use of vitamins etc. He finishes that summary by stating “…there is no clear evidence to support or refute homeopathy” (No comment.)

    He then goes on to say that while “most studies for these types of treatments are small and of low methodologic quality…this is no longer the case for acupuncture”. That is, I think, true, but what follows is a lesson in how to cherry pick positive trials, and spin the results of neutral studies. He favours German studies, (which similar to Chinese ones tend to be far positive than those done in the rest of the world, as has been discussed at SBM in the past.) He cites the exact same Cochrane review that Dr Novella did, but instead claims “there is consistent evidence that acupuncture is beneficial in the treatment of acute migraine attacks and that ….(it) is at least as effective as prophylactic drug treatments and has fewer side effects”

    Finally he goes on to comment that “another finding common in acupuncture studies: there is no evidence of additional effect of “true” acupuncture over “sham” acupuncture” He seems to miss the significance of this. He mentions that there was no difference between sham and true acupuncture for the entire study…except at the 8 week mark. He conceeds they found “small but not clinically relevant” differences in the frequency, severity and intensity of migraines. He also conceeds there were no differences between the various styles of acupuncture. However, he then goes on to suggest the future meta-analyses should “ask whether acupuncture is clinically effective without there being much difference between specific and non-specific acupuncture points” (Huh??) He comments that acupuncture textbooks describe the points as being small and difficult to localize and he is not sure how precisely practitioners locate the points or whether they are larger fields.

    Two people looking at the same data and coming to opposite conclusions.

  50. Alia says:

    @mousethatroared
    I think that the problem is that some people who are into CAM are also highly proselytic. So you cannot have a normal talk with them about I don’t know, the latest movie or anything because if you just happen to mention the new cafe in the mall, they start talking about how you should change your diet, avoid carbohydrates and eat only protein and if you happen to say that you feel under the weather, they will tell you about the new supplement that you really must try.
    That’s one of the reasons why my contacts with my mother-in-law are rather limited these days – every time we meet, she comes up with some other woo my husband should try for his chronic illness (well managed with the help of registered pharmaceuticals, thank you very much).

  51. Hinterlander says:

    @ WilliamLawrenceUtridge

    I would actually recommend acupuncture to people who were using it as a form of symptom control (i.e. pain and nausea only) but with the following caveats:
    - nonpenetrating (best) or shallow-penetrating (acceptable) needles fresh from a package
    - acupuncture sites far from nerves or blood vessels
    - no TCM diagnosis, just a lengthy conventional history
    - practitioner emphasizes empathy, excellent listening, attention to detail and is alert for the possibility of other diagnoses
    - no discussion of qi, meridians or acupuncture points
    - emphasis of the safety and evidence for the modified, modern technique

    Even if acupuncture is just a placebo, it’s a truly effective one. Since TCM theory, point selection and penetration are all worthless (sham controls for all these are equivalent to placebo) they can be discarded. The safety of the procedure is enhanced significantly and there is no erosion of critical thinking or science.

    Interesting idea, but how would this work in practice? A treatment following this model would require a practitioner knowingly providing (and being paid for) a placebo treatment, is this ethical?

  52. pmoran says:

    Newcoaster: Two people looking at the same data and coming to opposite conclusions.

    They are actually reflecting the different questions that can be asked of the data. Here they muddle them up so as to try and preserve some credibility for TCM theory, when the obvious conclusion from dozens of similar studies and other relevant research is that placebo and other non-specific influences are by far the dominant force.

    See my first comment above.

  53. papertrail says:

    @mousethatroared

    Yes, agreeing to disagree or just avoiding that topic, that can work with some relationships; I have lots of those going on among friends and family members. I think the problem of skeptics losing (or not gaining in the first place) friendships is more analagous to atheists trying to have conversations and friendships with creationists or people who relentlessly give a religious answer for everything. When my mother started to give an astrological answer for every single issue, among other annoying things on her road to dementia, it was pretty hard to take.

    I’m glad I developed some tolerance and understanding of how hard it is to know what to believe and who to trust. I do a fair amount of tongue biting or self-belittling, especially when I realize there’s no point in pursuing the topic. I have said things like “Oh, I’m just on this scientific skeptic kick.”

    Still, discussing medical treatment efficacy and safety ought to be a matter of intellectually analyzing facts and evidence. Many times I’m talking to someone, and we’re both happily on the same rational, science-based, anti-sCAM page, and suddenly BAM! we hit on something that they believe in that I find very dubious (“Oh, but acupuncture really does work.” Or, “but consciousness after death has been proven by science”. Or, “Hey, I’m looking for a chicken pox party for my unvaccinated son.”) There are few pure skeptics or rational thinkers, I suspect, including myself (but I’m trying).

    The closer I feel to a family member or friend, the harder it is to just watch them waste their time and money or risk their own health or that of their kids due to dubious notions. But rather than pounce on them, I try (and often don’t succeed) to approach the subject by asking their permission first, like I might say: “I’ve been working on sorting fact from fiction on this issue for myself for a long time now. Do you want to know what I think about *fill in the blank*?” With my sister, sometimes I say: WTF are you thinking?!

    Right now I have a new friend who doesn’t vaccinate her children because she doesn’t trust government (which does impact community-immunity), and although I can see there’s no point in talking about it further than we already did (she knows I’m pro-vaccine), I have been posting more vaccine info on my Facebook page. If she brings it up or if it comes up, I’ll have to risk our friendship to speak up. We like each other in other ways, so let’s see how long this will last. Thank reason (let’s spread that one!), my best friend and I are like-minded on this topic, my spouse. That’s all I need. That and SBM :-)

    Here’s a funny/poignant video for skeptics about this topic, “The Skeptic in the Room” by Eddie Scott: http://www.youtube.com/watch?v=OPs_j1EEplI Here’s his blog: http://www.theskepticintheroom.blogspot.com/

  54. Gordon20 says:

    I know a few acupuncturists and have asked about how they come up with treatment points, etc. They have responded in various ways, from historical, observational indications, to numerology based on significant dates of trauma/stress (unrelated to the patient’s complaint), to “esoteric” patterning (basically making pretty geometric pictures on a patient’s back with needles), to basing it on the “pulse diagnosis”. Wil Morris (there have been previous posts on this guy), a real “guru” and president of AOMA: Graduate School of Integrative Medicine (Traditional Chinese Medicine school) teaches advanced “pulse diagnosis” classes for around $500 a pop and includes numerology in his clinical decision making as well. The sad thing is that this program is being incorporated into the Seton Hospital network in Austin, TX (the biggest regional hospital network) and it is offered to medical patients. Another example of the blurring between science and numerology-witch craft. Patients see this as offered through the hospital so it must be researched, approved, etc.

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