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238 thoughts on “Acupuncture Revisited

  1. tanha says:

    Harriet, how’s this:

    “Acupuncture might help –we don’t know why but it could simply be placebo. Are you ok with that?”

  2. Harriet Hall says:

    @ tanha,

    That’s better than claiming it works, but I still wouldn’t feel right about recommending acupuncture just as I wouldn’t feel right about recommending homeopathy or prayer or therapeutic touch. I wish there was a way to elicit the placebo response while offering the best available evidence-based medicine or while acknowledging that evidence-based medicine had nothing to offer but still finding a way to offer comfort.

  3. nybgrus says:

    If a method like acupuncture has distractant, and counter-irritant potential, along with enabling periods of enforced relaxation, and opportunities for ongoing socio-medical interactions, as well as perhaps being a good provoker of endorphin release, why would it be dismissed as “only ” a placebo? WTF does that mean for practical medicine?

    Because, pmoran, once it is identified as placebo, regardless of whether you want to quibble over whether that means it “works” or not, it is unethical to recommend or use it! If we had no clue that acupuncture was almost certainly only a placebo effect then your arguments would hold water. However, in using the best and most current data, we can say that most likely acupuncture is only a placebo effect ergo WTF that means for practical medicine is we cannot in good consience use it. Pretty simple.

    Why would a cotton wool plug in the left ear (an example I provided previously) not distract some people from their sea sickness, and quicker than any pill?

    Because you would know that the purpose is a distraction device and tell the patient that. And, also importantly, you would also know the level of risk with that is very low. If you told the patient that the cotton wool would channel chakras into the ear and heighten the vestibulocochlear acuity to compensate better for motion sickness and that this was based on “ancient wisdom” that would be employing a placebo effect under false pretenses and be unethical. If you further went on to claim that cotton wool rubbed on your knee would active the CW-6 point and change the chakras there to decrease knee pain, well… then you’d have cotton wool acupuncture! And that is the point that people seem to be willfully missing here.

  4. daedalus2u says:

    Harriet, you raise someone’s NO/NOx level and you will trigger the placebo effect pharmacologically. You have to raise the NO/NOx level via physological means, and I know of only two ways to do that, meditation (which not everyone can do and so it can’t work on everyone) and my bacteria applied topically.

    I appreciate I don’t have any “data” to show it yet, just “theory”, but it is a lot of “theory”.

  5. Ed Whitney says:

    Sorry squire, I’ve had a look ’round the back of the shop, and uh, we’re right out of parrots.

    I was careless again, and Karl caught me dead to rights; I should have said that “ethanol” and “methanol” differ by one letter, and that ethanol and methanol differ by a carbon and two hydrogens. “The use-mention distinction” isn’t “all that important most of the time,” but sometimes, as in the present example, it does matter.

    When I see phrases such as “people like you,” followed by allusions to “a belief system amounting to a religion,” with quotes from Jonathan Swift about the futility of reasoning a man out of a thing he was never reasoned into, I have to be very careful not to read too much into the thing, and not to infer that anyone thinks that I have a belief in acupuncture amounting to a religion. We all depend greatly in these websites, where we do not know one another, on the ability of supposedly educated people to read. We may not have the chance to have a beer together in the Rose Garden at the White House. So we have to read one another carefully.

    The only reference I have knowingly made as to my personal convictions in the matter was when I confessed I had never tried acupuncture, not much believing in it. Thanks to pmoran for disagreeing with my interpretation of the literature, which is what this is all about. Much appreciated!

    The studies comparing acupuncture, sham acupuncture, and no acupuncture have consistently shown small differences between the first two and appreciable, clinically relevant differences between the last two. If this had happened only once or twice, it would not be of interest, but when it happens repeatedly, I get fascinated and see it as an opportunity to learn something new.

    Having the “no acupuncture” arm in the RCT helps one to separate out many factors that usually get lumped together under the term “placebo effect.” These include the natural history of the condition, regression to the mean, the effect of being under observation in a clinical trial, and, if the follow-up assessments are done correctly, the potential for reporting and other biases. Having that third arm in the trial clarifies things that may otherwise be mixed in together.

    Some of the literature on “placebos” distinguishes the effects of an intervention into two components: the specific effects, attributable to the theoretical mechanism of action of the supposed active agent, and the nonspecific effects, which are triggered by expectations, interactions between provider and patient, the context in which the intervention takes place (pending personal injury litigation is different from anticipation of an upcoming vacation), and similar vaguely characterized factors. In this setting, they can be approximately calculated by taking the difference between the sham acupuncture and usual care. The nonspecific effects repeatedly turn out to be a majority of the total effects (calculated by the difference between real acupuncture and usual care). If you do not care to tell patients that acupuncture is a “placebo” (which is a nonspecific term, when you get right down to it), you can tell them that its effects are nonspecific. It is just as accurate and less pejorative to some ears.

    The size of these nonspecific effects in relation to specific effects is greatly annoying to some observers, and greatly fascinating to other observers. In general, patients, their families, and their clinicians want to observe the total effects, and are only mildly inconvenienced if the bulk of those are nonspecific. The persistence of acupuncture in the health care system will depend on the total effects, not on the specific effects, which means it is likely here to stay. Whether to be fascinated or vexed by the phenomenon is a matter of individual choice.

  6. JMB says:

    There seems to be an assumption that you cannot tell a patient that they are receiving a placebo, if you wish to observe a placebo effect. While ritual and deception may increase the placebo effect, telling a patient that they are receiving a placebo will not eliminate observed placebo effects.

  7. pmoran says:

    Harriet pmoran,

    I agree that placebos have plausible medical potential. I’d love to find a way to take advantage of that potential without lying to patients. Can you suggest a way to do that?

    I would be lying to a patient if I said that Laetrile would cure their cancer. Characterizing the use of placebo medicines in other contexts as always involving ” lying to the patient” is a “loaded language” way of bolstering a case that could often go either way and probably depends very much on the individual case. What doctor has not had some simple soul ask, at the end of a long explanation as to why no treatment is needed: “so you are not going to give me anything for it?”.

    But independently of this, the issue with acupuncture is whether it is quite accurate to regard it as placebo. For a long time now I have been referring to it as “mainly placebo”, in deference to the range of likely physiological responses it may provoke or enable.

    One could go further than that and ask who makes the decision that something with those potentials is “only” a placebo (other than nybgrus, of course), and on what basis? The evidence allows us to say that it does not posses any unique therapeutic activity, also that it does not work as TCM theorists claim. But it is a complex intervention with some plausible potential above and beyond the expectancy responses that are generally regarded as underlying the placebo “effects” of a sugar pill.

    So one answer to your question is to be more discriminatory as to what kinds of treatment we classify as purely placebo. Otherwise we may be trying to practice medicine with one hand tied behind our back.

  8. GLaDOS says:

    “Placebo” is just another word for “ignorance.” Prove me wrong.

  9. Scott says:

    Even if we were to provide placebos, surely we’re obliged to use the placebos with the least risk of adverse events. That will certainly not be acupuncture. Reiki and other “energy healing” would probably be the safest placebo of all.

    So even the “ethical placebo” argument can’t justify acupuncture.

  10. GLaDOS says:

    Placebo research means sifting apart the variables in the treatment setting associated with symptom improvement.

    So, for example, we can give one group red sugar pills and another group blue sugar pills, to see if pill color has an effect.

    Once we know the effect of pill color, pill color is no longer part of what we mean by “placebo.”

    So what remains? All the variables with uncertain effect upon symptoms. In other words: ignorance.

    Ignorance surrounds us. There’s nothing really wrong with ignorance. But it is a mistake to *value* ignorance. It’s a mistake to build social structure that depend upon ignorance as their raison d’etre. Example: the intelligent design movement.

    CAM is analogous to ID in its commercial exploitation of gaps in understanding.

  11. GLaDOS says:

    But it [acupuncture] is a complex intervention with some plausible potential above and beyond the expectancy responses that are generally regarded as underlying the placebo “effects” of a sugar pill.

    As the person making the positive claim, the onus is on you to name the variable associated with acupuncture that is having an effect beyond patient expectation.

  12. “But it [acupuncture] is a complex intervention with some plausible potential above and beyond the expectancy responses that are generally regarded as underlying the placebo “effects” of a sugar pill.”

    Plausible in that it is not doing absolutely nothing? Is acupuncture really much more biologically plausible than sugar pill? Sugar pill increase blood sugar levels and caloric intake shortly after consumption, so it has some biological action, it’s not completely inert either. What is the plausible biologic model for the supposed action of acupuncture? To be biologically plausible, it needs to have a plausible method of action relative to the claimed effect, not just some demonstrable biological effect.

    Really, if we can accept that the wise, old, ancient practitioners of acupuncture were wrong about the meridian/chi concept underlying acupuncture, and that they were probably wrong about the requirement of needling, why do many people assume they were right about the effectiveness of acupuncture itself?

    Did the ancients use a different way of knowings for determining the various different aspects of the practice of acupuncture? Did they not use rigorous methods to determine these mythical chi points? Presumably those points were the points they determined to be most effective for needling, through trial and error, right? I mean the way they determined chi points couldn’t be more akin to astrology, could it? And if the way they determined those chi points was less scientifically rigorous and more akin to astrology, then surely they used more rigorous, scientific methods to at least determine the effectiveness of acupuncture, right? It wasn’t all just mysticism and mythology, right?

  13. daedalus2u says:

    Lactose probably is one of the better placebos because it mimics one of the archetypal placebos, being nursed.

    When an infant is nursed, it knows that all is right with the world. It is being held by its mom, and she is calm enough to lactate, meaning that she feels safe. If you are an infant and your mom feels safe and is holding you, you are as safe as you are ever going to be.

  14. pmoran says:

    Karl: Plausible in that it is not doing absolutely nothing? Is acupuncture really much more biologically plausible than sugar pill?

    Of course it is. I have listed several ways in which it may have added effects over a sugar pill. They are all ways that are accepted as having limited medical value in other contexts, yet EBM princesses can still only feel the “P” under all the mattresses.

    In any rigorous scientific approach, the toothpick and random puncture point studies don’t actually show that acupuncture-like activities (to be precise) “don’t work better than placebo” (they actually beg the question “what placebo?) — they merely show that certain elements of TCM theory are not necessary to any medical activity that such treatment programs may possess.

    (For GlaDOs and nybgrus — the “medical activity” is suggested by patient and practitioner testimonials and thousands of comparative studies that skeptics have often chosen to dismiss as “just showing placebo effects”. We can explain away a lot of those observations as mere illusion, but it is going well beyond the available science to claim that there is nothing else. )

    It would not even be surprising if inserting needles into more sensitive parts of the body, such as the tip of the nose, elicited stronger therapeutic responses, and such confounding may explain some of the scatter in the results of RCTs that compare real and sham versions both of which are capable of delifvering much the same generic medical activity.

    We have referred to EBM’s overemphasis on RCTs as an evidence base as “methodolatry”.

    There may be another version of EBM that is over-preoccupied with mechanisms, having an unreasoning prejudice against methods that don’t have simple, unique physical or chemical effects on human physiology or pathology.

  15. daedalus2u says:

    PM, would you consider applying a culture of ammonia oxidizing bacteria? There is some plausibility associated with that as a treatment for non-specific symptoms. I think more plausibility than is associated with acupuncture, and certainly more than is associated with reiki or homeopathy.

  16. pmoran says:

    AS we have discussed before, Daedalus2, I don’t accept your (very cute) hypothesis as a yet tenable explanation for placebo-related phenomena. The latter clearly require the mediation of higher cerebral centres, and they don’t involve “healing” in the sense in which you seem to want to use the term.

  17. GLaDOS says:

    For GlaDOs and nybgrus — the “medical activity” is suggested by patient and practitioner testimonials and thousands of comparative studies that skeptics have often chosen to dismiss as “just showing placebo effects”. We can explain away a lot of those observations as mere illusion, but it is going well beyond the available science to claim that there is nothing else.

    You’ve lost me.

    t would not even be surprising if inserting needles into more sensitive parts of the body, such as the tip of the nose, elicited stronger therapeutic responses, and such confounding may explain some of the scatter in the results of RCTs that compare real and sham versions both of which are capable of delifvering much the same generic medical activity.

    Ok so if acupuncture hurts more it might provoke a greater sense of benefit in the patient, for a period of time.

    Seems a reasonable idea. But not an awesome idea. I’d rather spend my research dollars on something else.

  18. daedalus2u says:

    PM, I appreciate that you don’t accept my cute NO hypothesis. But I presume you also don’t accept the disproven “hypotheses” of homeopathy, reiki, or acupuncture, yet you seem willing to accept their use because of a placebo effect. A placebo effect you are unwilling to consider might be triggered by my bacteria, either via my cute NO hypothesis or via the physiology of the “real” placebo effect which you do not have an explanation for.

    Could you explain why you have a double standard that favors traditional CAM over scientific CAM? (scientific CAM is a term I have just coined to to label science based treatments that have not been shown to be Medicine in clinical trials (Medicine being all treatments that have been shown to work better than placebo, CAM being all treatments that lack clinical trial evidence that they work better than placebo)).

  19. GLaDOS says:

    Y’know Freud was all over this placebo thing like white on rice. He played around with hypnosis, suggestion, and ritual. Initially he was keen to find a few tricks to speed up his talking cure. But later he abandoned the effort.

    D’you know why? Because he came to understand something he termed the transference.

    We cannot see the mind of another. We have to hallucinate it. Mother nature gives us a basic template for agency –friend or foe. Upon that template we add enough details to give us a feeling of what the other person is thinking.

    Turns out this placebo thing can work both ways. It can provoke trust and symptom relief in patients. But it can also provoke mistrust, anxiety, abandonment fears, and resistance to getting better.

    Freud witnessed many patients initially benefitting from placebo interventions only to become terribly stuck later on. He wasn’t interested in filling his practice with neurotics coming regularly for their mental subluxation adjustments. He wanted people to get better. He wanted patients to become partners with him in the work of understanding their own feelings. That work requires being awake and thinking.

    tl;dr: If you make heavy use of the power of suggestion with your patients, you risk fostering a dependency that you cannot cure.

  20. nybgrus says:

    GLaDOS: I lost him a long while ago.

  21. GLaDOS says:

    nybgrus, I’d much rather argue with pmoran that the little group of chiropractors that visits this site.

    We can explain away a lot of those observations as mere illusion, but it is going well beyond the available science to claim that there is nothing else.

    Yes but we have the onus rule for a reason.

    Claims can be proven, unproven, or disproven. Sadly the set of unproven claims is infinitely large. But thanks to the labor saving power of the onus rule, we get to lump “unproven” with “disproven,” as “stuff we can ignore for now,” and so carry on with our lives.

  22. daedalus2u says:

    GLaDOS, that onus rule is only a heuristic. It is not always lead to correct results.

  23. GLaDOS says:

    Ed Whitney:

    In general, patients, their families, and their clinicians want to observe the total effects, and are only mildly inconvenienced if the bulk of those are nonspecific.

    Yes but patients also expect MDs to base their opinions on sound scientific evidence.

    Thinking rationally is difficult. Individuals can’t think clearly over long periods of time apart from an entire culture around them that is vigilant of the rules of organized thought. The introduction of dissonant values and language games into medicine by wealthy and politically motivated theocrats is presently disrupting that culture.

    The persistence of acupuncture in the health care system will depend on the total effects, not on the specific effects, which means it is likely here to stay. Whether to be fascinated or vexed by the phenomenon is a matter of individual choice.

    No, acupuncture is merely a symptom of a much larger problem within the house of medicine. Either rules of evidence matter or they do not.

  24. GLaDOS says:

    GLaDOS, that onus rule is only a heuristic. It is not always lead to correct results.

    I don’t know what you mean. The onus rule dictates who bears the burden of proof. It doesn’t lead to any “result.”

  25. heretix says:

    In the same way as practitioners of acupuncture want very much acupuncture to be proven right, some of you behave like a bunch of denialists, because you want acupuncture to be proven wrong.
    An example of that is the link proposed by Peter Deadman was quiet interested, but dismissed because of were it was coming from
    If you had taken the time to read the article and argument presented by Marc Bowey, you could have seen that using Ernst as the only valued reference in scientific evaluation of CAM may not be such a good idea.

  26. heretix

    “…you could have seen that using Ernst as the only valued reference in scientific evaluation of CAM may not be such a good idea.”

    If you think any of the blogers (or any of the serious commenters) on this site are doing anything remotely close to relying on Ernst as a sole source of scientific evaluation of CAM, you cannot have read very many other posts besides this one.

    Ernst and everything he has done could be wiped from history by a causality violation, and it wouldn’t significantly change the scientific evaluation of CAM or acupuncture specifically by the bloggers here. Ernst just adds the the plethora of evidence and information we already have.

  27. Harriet Hall says:

    I read Bovey’s response to Ernst’s article. I was not impressed. Among other things he complains that the method is not defined in the paper – although it is defined in a footnoted reference. He criticizes it for not including an Australian meta-analysis – but meta-analyses are not the same as systematic reviews and do not belong in a review of systematic reviews.
    He misattributes an argument in Ernst’s article (any risk is too great) as coming from me.
    It struck me as little more than a biased attempt at damage control from a true believer.

    I don’t rely solely on Ernst, but I value his conclusions because he has revised them over the years in response to the evidence. He has a strong track record of rigorously following the evidence wherever it leads and being willing to change his mind, rather than consistently trying to support a preconceived conclusion like the acupuncture advocates do.

  28. Ed Whitney says:

    I was a bit more impressed with Bovey than was Harriet, but not enormously more impressed. I must defend him from one implied criticism, though.

    “He criticizes it [Ernst] for not including an Australian meta-analysis – but meta-analyses are not the same as systematic reviews and do not belong in a review of systematic reviews.”

    Actually, Ernst did include some meta-analyses (Madsen 2009, Reference #89), but he did not attempt to pool effect sizes himself. All meta-analyses are SRs but not the converse. Bovey correctly identified Hopton as having clearer methods, and I concur. Hopton (way up in this thread) used the same framework for evaluating SRs as Ernst (Oxman and Guyatt 1991), but supplements that reference with the AMSTAR tool, which spells out in more detail what an SR has to do to satisfy the Oxman and Guyatt criteria.

    Bovey, though, is focused narrowly on defending acupuncture rather than looking at the broader question of how to create comparison groups for complex interventions, of which acupuncture is only one example. Free access to one article by Paterson and Dieppe at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC558023/?tool=pubmed .

    These authors suggest that the randomized placebo controlled trial, invaluable for the testing of the efficacy of new drugs, has been used to evaluate complex non-pharmacological interventions, using physiotherapy, psychotherapy, and acupuncture as illustrative examples. As was suggested above, effects can be divided into “specific” and “nonspecific” effects, which they call “characteristic” and “incidental” effects. They further suggest that elements which are incidental to drug trials may be integral to non-pharmacological trials. These include the process of interaction with the practitioner, the type of talking and listening which is permissible, and the way that a consultation indicates to patients that everything about them is relevant to the diagnosis and treatment plan. Using acupuncture as an example, they assert that needling, talking, listening, and the attention to physical, emotional, and social concerns, are all part of the characteristic factors, rather than incidental.

    If Paterson and Dieppe are right, then sham controlled acupuncture trials, which include most of the same complex interpersonal interactions as true acupuncture, are controlling for only one of the characteristic factors of acupuncture. The sham acupuncture session, under this way of looking at it, is like a partial agonist of a drug, producing some or even most of the effects of the test drug. Both compounds are more effective than a placebo pill or no treatment, but they may differ from one another less than both differ from the dummy pill. They could look very much like RCTs with true and sham acupuncture and with a usual care group.

    Some comments on this thread have spoken of sham needling as “random”, as if ” needles in random places activate it and that activation occurs in ways that are indistinguishable from the activation by acupuncture.” However, none of the sham studies have done this. The placement of the needles has in each case been systematic in some fashion. “Random” would mean, by definition, that every square centimeter of the body had an equal likelihood of being needled. I have seen no sham controlled trial that has done this.

    Much of the debate over the “implausibility” of acupuncture has arisen from its classically described model of the human body, with “meridians” and “qi” flowing along them. If, however, these were surrogates for factors that have physiological existence (connective tissue planes, cutaneous nociceptors, and other sensory receptors), then the plausibility of acupuncture changes.

    There is good evidence that yoga is effective for many kinds of back pain and other musculoskeletal conditions. There is no comparable scientific evidence for chakras and prana, at least not as described in classical yoga. However, the way that yoga strives to align and integrate these entities could have biomechanical effects of which chakra and prana are surrogate descriptors. If yoga is to chakra what acupuncture is to meridian, there may be two active interventions whose classical explanatory principles are pre-scientific, but partly corresponding to normal physiologic variables. Quaint and obsolete language to describe them both should not directly affect our estimates of biological plausibility.

    There is one pervasive kind of bias that seems to permeate almost all acupuncture RCTs and warrants mention here. Randomization, while protecting threats to internal validity by preventing biased comparisons of treatment groups, leaves itself open to other kinds of bias. Notably, participants in acupuncture trials are generally interested in acupuncture in some way, are often recruited through public announcements, and are enticed to participate in the RCT by assurances that they may cross over to the acupuncture treatment at the end of the trial if they are assigned to one of the control groups. They are, in short, more likely to be placebo responders, at least to sham acupuncture, and to expect good results from it. An RCT composed entirely of subscribers to the Skeptical Inquirer would have an unbiased comparison of treatment groups, but the effects of sham acupuncture would be much less, and much closer to usual care. Then leave it to Cochrane to combine them all in a meta-analysis, calculate that the heterogeneity was high, and choose a random effects model to estimate the overall effect, giving its readers one more damn mess to try to make sense of.

  29. Harriet Hall says:

    @ Ed Whitney,

    “they assert that needling, talking, listening, and the attention to physical, emotional, and social concerns, are all part of the characteristic factors” only emphasizes that it is these factors that induce a placebo response that are characteristic of acupuncture.

    The plausibility of how specific effects might be caused is not even an issue while the existence of specific physiologic effects has not been convincingly demonstrated.

    The hypothesis that acupuncture is a complex suite of placebo and other nonspecific effects fits all the published data.

  30. heretix says:

    “If you think any of the blogers (or any of the serious commenters) on this site are doing anything remotely close to relying on Ernst as a sole source of scientific evaluation of CAM, you cannot have read very many other posts besides this one. ”

    Although Ernst is not the only reference, he is the one that is the most frequently referred to.
    It seems to me that the skeptics are out to “prove acupuncture wrong” rather than give it a chance and a proper evaluation;they dismiss it as a placebo rather than considering the psychosomatic impact of such a treatment; it is also because of this psychosomatic impact that it is difficult to evaluate this kind of treatment with RCTs set up in the same way as they would be for testing drugs.

    The skeptic movement seems to be a predominantly anglosaxon thing with no real equivalent in non-english speaking part of the world; thus there is a tendancy to let research done in the english language predominate and ignore good research from other non-english speaking countries.

  31. daedalus2u says:

    heretix, what experiment would you propose to distinguish between a psychosomatic effect of a treatment like acupuncture and the psychosomatic effect of a placebo?

    If there is no experiment that can distinguish them, how is it useful to think about them as different things?

  32. Scott says:

    It seems to me that the skeptics are out to “prove acupuncture wrong” rather than give it a chance and a proper evaluation

    More that it has already been given a chance and a proper evaluation, proven wrong, and we don’t close our eyes to the evidence.

    they dismiss it as a placebo rather than considering the psychosomatic impact of such a treatment

    That IS what makes it a placebo.

    it is also because of this psychosomatic impact that it is difficult to evaluate this kind of treatment with RCTs set up in the same way as they would be for testing drugs.

    False. The exact form of the control is different (sham acupuncture instead of a sugar pill) but RCTs are absolutely applicable.

  33. “It seems to me that the skeptics are out to “prove acupuncture wrong” rather than give it a chance and a proper evaluation”

    Actually, if you’d been reading this blog for a while, you’d know that acupuncture was one form of CAM the Dr. Gorski once considered plausible, not because he believed in the chi model, but because it was an active, invasive biological intervention. Only after rigorous research and review of scientific studies did he come to the conclusion he now holds.

    Acupuncture has been given a fair chance already and has had numerous proper evaluations. The strongest positive spin that anyone can possibly reasonably make at this time is that the evidence is, at best, still inconclusive and contradictory, which at this point in the game means it’s really time to move on.

    In spite of that, it is my understanding that the bloggers here are more than willing to give any new evidence objective consideration. Nothing so far has withstood the crucible of scientific scrutiny.

  34. nybgrus says:

    heretix and Ed Whitney seem to think that acupuncture is the green jelly bean.

  35. pmoran says:

    Karl: “In spite of that, it is my understanding that the bloggers here are more than willing to give any new evidence objective consideration. Nothing so far has withstood the crucible of scientific scrutiny.

    I also cannot see obsolete TCM hypotheses ever being seriously resuscitated.

    Nevertheless, a fresh problem looms. I predict that we will now see a lot of “pragmatic”, real-world studies comparing acupuncture and other CAM methods with drugs for various common conditions wherever the drug treatment is of “proven”, but limited benefit.

    I further predict that this will be a close-run thing. There are already a smattering of such studies about, most notably studies showing a similar prophylactic effect for acupuncture as drugs on migraine*, using the fairly objective measure of a migraine diary, with considerably more side effects and drop-outs in the subjects allotted to the drugs.

    Such studies have the potential to seriously challenge the mainstream’s scientific and ethical positions on treatments having mainly placebo/non-specific ‘effects’ and I don’t know why we are not seeing any discussion of them.

    If the results proved consistent in quality studies, we might have to either admit that both methods are actually placebos, or allow them similar status within practical medicine, deciding between them on cost/risk/benefit grounds.

    * http://www.ncbi.nlm.nih.gov/pubmed/19160193

  36. Ed Whitney says:

    “The hypothesis that acupuncture is a complex suite of placebo and other nonspecific effects fits all the published data”

    If this means that all nonspecific/incidental effects of acupuncture (interaction with a practitioner who takes the time to listen to the patient, who touches the patient in a therapeutic manner prior to placing the first needle, who pays attention to how the patient is responding during the session and adjusts the treatment approach accordingly, and creates an atmosphere of participation in which the burden of illness can be shared and partly relieved) are counted as “placebo,” that is consistent with the data. Paterson and Dieppe suggest that they be counted as an inextricable part of the entire encounter with the acupuncturist, and thereby count as specific/characteristic effects, but their suggestion need not be taken. It is just one way of looking at how to analyze a complex intervention.

    The key word is “complex.” We appear to be in agreement that it is not likely that you can get the same outcome by giving the patient a sugar pill and saying, “Here, swallow this.” And the methods for investigating the effectiveness of complex interventions ought to be of interest to us all. Physiotherapy, psychotherapy, cognitive-behavioral therapy (CBT), multidisciplinary rehabilitation, all are complex and lend themselves poorly to the kind of placebo control which works so well for new drugs. If CBT is as effective as instrumented fusion for patients with chronic disc degeneration, that is a big deal, but the simple inert placebo control cannot be used in its evaluation.

    I realize that for the most part, this web site is not mainly about general problems in research methodology. It is focused on one particular kind of problem facing the science-based medical community, to wit, “woo.”

    Trouble is figuring out exactly what criteria an intervention has to meet before qualifying for classification as “woo.” I am working on that. It seems that the intervention has to purport to be a form of medical practice, no? Yoga does not count, in spite of the chakras, tai chi does not count, and chai tea does not count. Fair enough. Astrology for deciding when to propose to your beloved, no; astrology to guide decisions about surgery for a herniated disc, yes. Foot reflexology to delay the onset of labor so that the newborn child will be a Sagittarius instead of a Scorpio, most probably.

    A biologically ludicrous proposed mechanism of action? Sufficient but not necessary—homeopathy qualifies on this criterion alone, but not acupuncture. Potential adverse effects—helpful, but neither necessary nor sufficient. Unanimous, categorical rejection by all responsible medical professional organizations—works for homeopathy but not for acupuncture.

    Will keep working on it. Honest.

  37. Ed Whitney says:

    “heretix and Ed Whitney seem to think that acupuncture is the green jelly bean.”

    If I were to come to the defense of the green jelly bean or any other kind of pseudoscience, I would follow the postmodern pseudoscience advocacy guidelines of the American College of Charlatans and Snake Oil Salesmen (ACCSOS). This would take the form of a series of posts in roughly this form and sequence:

    1. Rambling diatribe about paradigm shifts, Cartesian dualism, the holographic brain, quarks and/or whale songs, supported by mangled, out-of-context quotes from Thomas Kuhn, Paul Feyerabend, and Michel Foucault, plus reminders that Isaac Newton dabbled extensively in alchemy, followed by links to websites dedicated to the postmodern philosophy of Deleuze and Guattari

    2. Something about the Heisenberg Uncertainty Principle, chaos theory, the butterfly effect, Bell’s inequality, nonlocality, and Schroedinger’s cat, accompanied by quotes from Rupert Sheldrake, David Bohm, Ilya Prigogine, and the Flower Garland Sutra, with self-congratulatory comment about refusing to be grounded or compromised by referentiality, plus additional diatribe against Western Science since the time of Francis Bacon for inciting man’s violent gang rape of nature

    3. Non-sequitur fart joke in response to criticism of post #2

    4. Follow-up post four days after #1, to the effect that since no one responded to the cryptic but devastating quote from Foucault, no one was capable of responding, and therefore the contributors to this thread must be mentally myopic, morally dishonest, or both. Then make a petulant resolution to start a new blog to promote own point of view; only to die while jaywalking across Sepulveda Boulevard in order to purchase homeopathic Cadmium iodatum in lieu of potassium iodide to ward off effects of radiation coming from Japanese earthquake.

  38. Scott says:

    If this means that all nonspecific/incidental effects of acupuncture (interaction with a practitioner who takes the time to listen to the patient, who touches the patient in a therapeutic manner prior to placing the first needle, who pays attention to how the patient is responding during the session and adjusts the treatment approach accordingly, and creates an atmosphere of participation in which the burden of illness can be shared and partly relieved) are counted as “placebo,” that is consistent with the data.

    I fail to see how anyone can acknowledge this, yet not then conclude that the acupuncture part of acupuncture (you know, the needles bit) provides no demonstrated benefit, carries risks, and therefore cannot be justifiably practiced.

    Nobody disputes that a soothing interaction with a helpful person in a relaxing environment can help people feel better. But it’s a gargantuan leap from there to the claim that sticking needles into people, and charging them money to do so, is a good idea.

  39. nybgrus says:

    If this means that all nonspecific/incidental effects of acupuncture (interaction with a practitioner who takes the time to listen to the patient, who touches the patient in a therapeutic manner prior to placing the first needle, who pays attention to how the patient is responding during the session and adjusts the treatment approach accordingly, and creates an atmosphere of participation in which the burden of illness can be shared and partly relieved) are counted as “placebo,” that is consistent with the data.

    Take out the acupuncture bit, substitute efficacious medicine, and you have what I would call a good patient-physician encounter. The fact that the current levels of physician engagement with their patient in this regard are sub-par at best does not advocate the substitution of acupuncture for efficacious medicine in order to capture and deliver those missing aspects the patient-physician encounter. No, I see it as a call to improve ourselves as physicians. When you have a scenario in which all of those aspects are present in both an acupuncture setting and an SBM setting then it is clear to me who will win out. Trying to divine some sort of place for acupuncture and rationale for its usage in light of the data and this knowledge is akin to saying that because a particular town has a lot of bad interventional cardiologists we should do away with PTCA and stenting for MI and have someone take the time to listen carefully to the person having a heart attack, touch them in a therapeutic manner, pay attention to how much their chest hurts and adjust the treatment approach, and create an atmosphere of sharing the pain of the MI with the patient, all whilst waving crystals or giving extremely dilute and succussed epinephrine.

    No, I think I would simply rather train those cardiologists to do their job better and not give in to the woo in the meantime.

  40. nybgrus says:

    Trouble is figuring out exactly what criteria an intervention has to meet before qualifying for classification as “woo.”

    Not so difficult really. You are missing a key point here – the distinction is one made between individual free choice and something being a medically accepted fact.

    Yoga does not count, in spite of the chakras, tai chi does not count, and chai tea does not count.

    Because yoga is great exercise and people can exercise their chakras whenever and howver they like on their own time. If you were to start claiming that yoga cured cancer, then we would have woo. Ergo, when you start claiming that acupuncture can cure this, alleviate that, etc… you have woo. If all you claimed was “Sticking needles in you is a fun way to relax and make you feel better” then I hardly think anyone here would care to say much about it. Massage is relaxing (and I am way overdo for one) but my girlfriend can’t stand them. It is literally torture for her. Some may find the arbitrary sticking of needles in them quite relaxing and enjoyable, others not so much. Inasmuch as it stays in that realm, there is no problem. But if massage suddenly is claimed to cure disease, or if needles in your skin is claimed to reduce pain and increase function then it becomes a matter of scrutiny. When the claims do not match the results, and the claim continues to persist, then we have woo. Simple enough.

  41. Ed Whitney says:

    “…yoga is great exercise and people can exercise their chakras whenever and however they like on their own time. If you were to start claiming that yoga cured cancer, then we would have woo. Ergo, when you start claiming that acupuncture can cure this, alleviate that, etc… you have woo. “

    So here is the thing: Yoga has been claimed to alleviate chronic low back pain.
    See Williams K, Abildso C, et al. Evaluation of the Effectiveness of Iyengar Yoga Therapy on Chronic Low Back Pain. Spine 2009;34(19):2066-2-76.

    90 patients (69 women, 21 men, mean age 48) treated for chronic nonspecific low back pain in the orthopedics department of the University of West Virginia. Eligibility criteria included age 18-70, BMI<37, low back pain at least 3 months, Oswestry Disability Index (ODI) score between 10 and 60, pain VAS between 3 and 8 cm (30 to 80 mm), and ability to get up and down from the floor without assistance. There were lots of exclusion criteria: spinal stenosis, tumor, infection, osteoporotic fracture, ankylosing spondylitis, spondylolisthesis with radiculopathy, kyphosis, scoliosis, radicular pain with weakness, failed back syndrome, pregnancy, fibromyalgia, major depression, substance abuse, current litigation, having practiced yoga in the previous year, or an open workers compensation for low back pain.

    They were randomized to yoga (n=43) or control (n=47). The yoga group got 24 weeks of twice-weekly classes of 90 minutes duration, a yoga DVD, and was asked to practice yoga 30 minutes per day. The control group continued with self-directed standard medical care. The yoga group did poses like Supta urdhva hastasana and Parsva pavanamuktasana. There were about 30 such postures listed in the article. (Aside: what do you get when you cross the Godfather with a yoga instructor? Someone who makes you an offer you can’t pronounce).

    ITT analysis for ODI showed a mean decrease of 7.3 points (29%) in the yoga group at 24 weeks, with a decrease of only 2.3 points (10%) in the control group; for pain VAS, the corresponding decreases were 17.6 mm (42%) and 4.4 mm (10.7%). At 6 months the yoga group continued to have lower ODI and VAS scores than the usual care group.
    About 63% of the participants had previous experience with “CAM” but the nature of the woo was not further described. The research assistant who collected the outcome data was blinded to group assignment. The method of randomization was not as clear as you would like, since the participants were given envelopes with group assignment but allocation concealment was not clearly described.

    Overall, the article was adequate for evidence that yoga can improve nonspecific chronic low back pain. And there you have it: a study claiming that yoga can treat a common back disorder.

    I asked specifically if yoga was “woo” precisely because the claim made in this study is no different from that made in most of the acupuncture literature I read. Nonspecific neck pain, nonspecific back pain, and peripheral joint osteoarthritis are alleviated by both true and sham acupuncture. I have seen no claims that acupuncture cures cancer; if I did, I would approach them with the assumption that the studies were not credible, and that the methods were unsound. Most acupuncture studies exclude specific pathologies from inclusion; far from claiming to cure cancer, they exclude tumors and the other diseases that were excluded from the yoga study.

    Acupuncture makes the same low-key claims that yoga makes. Acupuncture probably works by stimulating nociceptors in a particular pattern (hence toothpicks can reproduce most of the effects of needles). This is a perfectly reasonable mechanism of action, and piercing the skin may not be required. After all, no one chastises medical students on their neurological examinations if they failed to puncture the skin during the sensory exam.

    No chakras, no prana, no meridians, no qi, just modest claims to alleviate symptoms of some common musculoskeletal conditions. No grandiose claims to rid the world of all known diseases, just moderately effective adjuncts to reasonable treatment plans for some forms of chronic pain.

    So I am still stuck: acupuncture is “woo” but yoga is not. I do not get it.

  42. Ed Whitney,

    Discussion of tai chi and fibromyalgia here:
    http://www.sciencebasedmedicine.org/?p=6617

    My take on the acupuncture ruckus is:

    1) Actually, it’s not clearly that good for anything in particular. It might help some people but it doesn’t seem to help much; otherwise, clinical results would be less equivocal.

    2) I thought the nocioception hypothesis hadn’t been sustained, perhaps I’m wrong. If it hasn’t been sustained then it really just is the attention and deliberate relaxation and the poking itself is not part of any beneficial effect. If poking is not required — even with toothpicks — then it’s unethical to pretend that it is and any risks associated with poking are unjustifiable.

    3) Even if acupuncture does offer significant pain relief, does that make it medicine? Massages and sex can often provide pain relief as well but are not considered medical procedures or therapies and are not routinely offered in medical clinics. People can obtain these things outside the clinic in a non-medical context and get at least as much benefit from them there.

    But I think it’s mostly 1). IF it doesn’t actually do much, THEN there’s no point in discussing how it works.

    *** *** ***
    I do find the area of nonspecific effects troublesome. In ngybrus’ ideal of medical practice, nonspecific effects are leveraged by practitioners of scientific medicine. One of the major contributors to nonspecific benefits is human physical touch, such as happens during a routine physical exam or when blood pressure is measured.

    From the comments in this post on the usefulness of the routine pelvic exam:
    http://www.sciencebasedmedicine.org/?p=11218

    OP:
    “Hands-on interactions and the perception of “doing something” can be reassuring and can enhance the doctor/patient relationship. But can’t a caring clinician attain those same benefits within the realm of science-based medicine?”

    Alison Cummins:
    “What hands-on interactions do you recommend for routine visits? Blood pressure?”

    Harriet Hall:
    “It is more cost-effective for BP to be taken by others with lower salaries. The MD’s time is better used in activities requiring more education. It would be presumptuous of me to recommend any hands-on interactions that have not been studied and are not evidence-based; but things like shaking hands and touching/examining areas of concern to the patient would seem to be appropriate. Human interactions will vary with culture and custom and with individual styles.”

    If blood pressure is taken by a nurse who uses a special chair and doesn’t need to actually touch the patient, then physical contact between doctor and patient may be limited to a handshake.

    Most doctors do not offer a handshake.

  43. “I realize that for the most part, this web site is not mainly about general problems in research methodology. It is focused on one particular kind of problem facing the science-based medical community, to wit, “woo.”"

    This site deals with science based medicine and non-science based medicine. Although the major focus is what is often called woo, it also deals with more mainstream, conventional medicine, like the recommended schedule for mammography, etc.

    “So here is the thing: Yoga has been claimed to alleviate chronic low back pain.”

    It’s a form of light exercise, so that’s not implausible. It’s reasonable to study that. The practice of yoga is not woo; it’s light exercise. However the traditional underlying philosophy and understanding of yoga is indeed woo.

    Likewise the traditional underlying philosophy and understanding of acupuncture is clearly also woo. The actual practice of acupuncture has been studied and been found to be no more effective than the controls of needling in “wrong” locations and no needling at all. It has so far failed to be scientifically validated.

    It is another question entirely if any certain aspects of, or similar to, the practice of acupuncture may have some scientific validity, such as needling. The studies show that poking works just as well as needling, so we don’t even have an aspect of acupuncture that may be valid. At best, what we have is some possible practice derived from/inspired by acupuncture, such as poking in random locations, that could potentially be valid, but the plausibility doesn’t seem to great for that either.

    “Acupuncture probably works by stimulating nociceptors in a particular pattern (hence toothpicks can reproduce most of the effects of needles).”

    That’s an interesting speculation, but I wouldn’t even call it a hypothesis at this point. For one thing, you’re working backwards from the assumption that acupuncture works and speculating on remotely biologically plausible mechanisms whereby it could act. I can try to determine where the Loch Ness Monster and Bigfoot came from, what kind of animals they are, and how they live, but I really need to establish that they exist first.

    If you accept that needling is not required, I don’t see why you’re even discussing acupuncture anymore rather than advocating randopoking. Needling is unnecessarily invasive compared to poking. Even if you think that poking only reproduces MOST of the effects of needling, I would think that we need to determine when poking is sufficient and when the added risk of needling is warranted. Such needling, if scientifically valid, would be medical needling, not acupuncture as key aspects of the practice of acupuncture, such as chi points, would be absent.

  44. Alison Cummins – “Massages and sex can often provide pain relief as well but are not considered medical procedures or therapies and are not routinely offered in medical clinics. ”

    As part of my physical therapy for two conditions (Plantar fasciitis and hip/leg pain related to SI joint issues) was deep tissue massage. Both of the therapists also showed me how to do some form of at home massage (a tennis ball is your friend), for when I noticed the condition flaring up. Paid for by insurance, so I will assume that some targeted massage for tendon inflammation can be considered a medical therapy, at least here in the states.

  45. Yes, and presumably that was a specific effect of that form of touch on that part of the body for that problem.

    I’m thinking more of the kind of massage that you get at a spa which feels really good and has you walking on air afterwards. That kind of massage can help all kinds of aches and pains (though not for long).

  46. Regarding handshakes. Recently (say in the last five or eight years) I’ve noticed that doctors are offering handshakes more. Particularly upon first meeting, but often at the end of an appointment too.

    I’m not a big handshaker myself. But in this case, I do think it’s a nice touch. It sort of puts the appointment in a more respectful, professional light.

  47. Actually, massage is a topic I would love to see covered here, from a science based medicine perspective, of course. It’s a topic in need of some separating of wheat from chaff. I think it is a practice (or numerous practices) that stretches from reasonably scientifically base (or at least not un/pseudo-scientific base) all the way to uber-woo including Reiki and Craniosacral therapy.

    Any skeptical/ Science Based massage experts out there? (Do I hear crickets chirping, or is that the minor narrow frequency hearing loss ringing in my right ear?)

  48. On massage, specific vs general. Agreed.

    Also, I would say that a 45 minute spa type deep tissue massage offers some relief and increased mobility for back muscle spasms. It was often enough take the hard edge of the worst first day of a three or four day muscle spasm cycle. For me, the relief offered was about the same as that of gentle exercise that raises the heart rate (say walking on a treadmill). Although the massage is more pleasant, the walking is cheaper and possibly more accessible (driving with muscle spasms is not fun).

    Never tried acupuncture, though. Can’t compare the non-specific results.

  49. pmoran says:

    Karl:”If you accept that needling is not required, I don’t see why you’re even discussing acupuncture anymore rather than advocating randopoking.

    It’s tricky. Remember poking with toothpicks (or retracting needles) only works as well as “real” acupuncture if the patients think they are being needled.

    I agree the word acupuncture has lost any clear meaning once we divorce it from TCM.

  50. nybgrus says:

    @karl: exactly what I was to say. Yoga is not woo for back pain because yoga actually is exercise and actually specifically stretches the back, ergo very plausible and likely mechanism. If you claimed that it was the chakras re-aligning that fixed your back pain, now we are back to woo. Also I would like to add that yoga can be a very intense workout – I do the P90X version and it kicks my butt!

    pmoran: that is exactly the point, isn’t it? When you divorce acupuncture from its TCM roots it suddenly just becomes a complex human interaction that has non-specific effects. Arguing for the efficacy and utility of such a method is akin to saying we should have shamanistic voodoo dances in our waiting rooms since those will have non-specific effects as well.

  51. pmoran says:

    Intriguingly enough, Nybgrus, when challenged, nearly everyone agrees that it would be OK to recruit the services of the local shaman should a member of an isolated tribe want him to participate in their hospital treatment.

    We merely deny a similar courtesy to our own culture, even when there are clearer placebo/non-specific/??specific benefits to be had from treatment programs like acupuncture in some settings (see Ed’s effect-sizes of 0.45).

    I also, by training and bent, approve of medicine trying to confine itself to EBM -endorsed methods. But let’s be absolutely clear as to why and how we draw certain lines, and consider how we should deal with certain inevitable consequences (which happen to include wider use of CAM).

  52. nybgrus says:

    I respectfully disagree. I think I know what you are referring to, but I also think that was more of a tolerance for practices deeply imbued in a person under your care, not an endorsement of their use. The idea being that denying what would otherwise be a non-harmful (but non-beneficial) “treatment” from the family would cause undue mental and emotional stress. That is a tolerance on a individual basis and things like that are indeed denied to the patient if there is evidence of likely harm or other problems (like burning sage in an ICU room or something). The lines you speak of seem reasonably clear to me, but muddied to you for some reason.

    If a patient came into my care who was in hospital and adamantly demanded acupuncture, I would state that to my knowledge I think it would do nothing, that the patient should procure and pay for the acupuncturist, and that I would examine the patient afterward to ensure no deleterious effects, but I would not deny the acupuncture. That is wholesale different from actually endorsing acupuncture as a viable treatment modality and offering it to the patient.

  53. daedalus2u says:

    nybgrus, it turns out that the external skin has the highest nitrite level of any tissue compartment. At least in rats. I think that is true for all mammals and relates to reduction of nitrite to NO in the region of skin that is most hypoxic.

    The skin is the tissue compartment that is among the most hypoxic in the body. The external skin gets O2 from the external air, and there is a minimum O2 concentration where O2 diffusion from the internal blood supplies the O2.

    I think massage is a way to increase lymph flow and increase the transport of nitrite in the skin into the blood stream. I think that cupping is a way to put that lymph and blood containing nitrite in an even more hypoxic state so that the nitrite is reduced to NO. Reduction of nitrite to NO is inhibited by O2. That is probably the source of hyperemia when skin is pressed on and blood flow is prevented. Blocking blood flow causes local hypoxia, nitrite is reduced to NO, the NO causes vasodilatation until the hyperemia restores the local O2 level.

  54. Ed Whitney says:

    “you’re working backwards from the assumption that acupuncture works and speculating on remotely biologically plausible mechanisms whereby it could act.”

    Well, I said “nociceptors” when I should say “cutaneous afferents.”

    I was basing my assumption that it worked based upon a number of studies, the best of which in my opinion was Haake (Arch Intern Med. 2007;167(17):1892-1898). This was one of the largest studies, and gives the best support for the equal effectiveness of true and sham acupuncture. They randomized 1162 patients to true acupuncture (n=387), sham acupuncture (n=387) or standard therapy (n=388). Patients in the conventional therapy group “received a multimodal treatment program according to German guidelines.” The guidelines provide “the treating physician with recommendations about the treatment algorithm and assess the various therapy forms according to the degree of evidence based on a literature search and recommendations of the specialist associations.” The no acupuncture group is getting good evidence-based treatment in this study, and is therefore a suitable comparison group for the two acupuncture groups.

    The acupuncture was done by physicians of various specializations who had at least 140 hours of acupuncture training: 55% had undergone basic training (mean, 213 hours) and 45% had advanced training (mean, 376 hours). The study physicians had practiced acupuncture for 2 to 36 years (median, 8.0 years). “Sham acupuncture on either side of the lateral part of the back and on the lower limbs was also standardized, avoiding all known verum points or meridians. As with verum acupuncture, 14 to 20 needles were inserted, but superficially (1-3 mm) and without stimulation.”

    The primary outcome was treatment response 6 months after randomization, defined as 33% improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale or12% improvement or better on back-specific functional status measured by the Hanover Functional Ability Questionnaire. Patients who had recourse to additional treatments other than rescue medication were classified as nonresponders, as were unblinded patients. The interviewers were blinded to the treatment group of the study participants.

    The primary outcome was attained by 47.6% of the true acupuncture group, by 44.2% of the sham acupuncture group, and by 27.4% of the conventional therapy group at 6 months after randomization. This analysis included all patient on an intention-to-treat basis. The differences between true and sham acupuncture were not significant; the differences between both acupuncture and conventional treatment were. In terms of the success rate, sham acupuncture was 1.6 times as successful as the evidence-based guideline multimodal care. True or sham, that damn acupuncture is doing something that can be measured by a blinded observer using a conservative method of analysis.

    “I don’t see why you’re even discussing acupuncture anymore rather than advocating randopoking. Needling is unnecessarily invasive compared to poking. Even if you think that poking only reproduces MOST of the effects of needling, I would think that we need to determine when poking is sufficient and when the added risk of needling is warranted.”

    Assuming that randopoking means “random poking,” we have no data about it and cannot speculate on it. This assertion of random needle placement has been made before. Random has a formal definition; it means that every element in a population is equally likely to be selected in a sample. The eyeball is just as likely to be selected for needling as the T11-T12 intercostal space on the right or the tip of the index finger.

    The “sham” acupuncture in the Haake study was done by the same trained physician acupuncturists that did the true acupuncture. They may have chosen points that are not identified as acupuncture points, but the points were chosen deliberately, and they did not operate haphazardly or randomly. For one thing, they are physicians, bound by the Hippocratic Oath, sworn to do no harm and to seek the well being of all who come to them. Even when conducting a study, they are not just poking around. In order for the RCT to be valid, this has to be the case. If you had the control group get poked by Larry the cable guy when he came to install the cable TV setup, and gave him 14 needles and told him to go poke that lady over there, you would have an invalid study; there would be two variables to account for instead of one: the provider and the technique.

    If this can be done non-invasively, and produce a 60% increase in the success rate of treatment of chronic low back pain, that would be a very good thing. Hell, I might even sign up to have it done when my back bothers me.

    A while back Harriet quoted Carl Sagan’s great skeptic’s motto: “Extraordinary claims require extraordinary evidence.” True enough; it is also true that mundane claims require mundane evidence. We are not talking about cancer or HIV or Alzheimer’s disease here: these studies are done on low back pain after serious pathology has been ruled out. A non-specific modality alleviates symptoms of a non-disease more effectively than conventional standard care. Not by a miraculous amount, either, but by enough to matter. A mundane claim has been made, and mundane evidence has been supplied in support of it. No wu, no mu (well, maybe endogenous ligands of mu receptors are involved), no mysticism. A pretty boring condition responds to a pretty boring treatment. The treatment is not represented as good for spinal cord compression from multiple myeloma, but for garden variety mechanical back pain. You can use yoga or you can use acupuncture; if you choose the latter, you can choose true or sham acupuncture, whichever is cheaper. Just make sure you are treated by a trained acupuncturist!

  55. GLaDOS says:

    Intriguingly enough, Nybgrus, when challenged, nearly everyone agrees that it would be OK to recruit the services of the local shaman should a member of an isolated tribe want him to participate in their hospital treatment.

    We merely deny a similar courtesy to our own culture, even when there are clearer placebo/non-specific/??specific benefits to be had from treatment programs like acupuncture in some settings (see Ed’s effect-sizes of 0.45).

    How about yourself? Do you see an acupuncturist for pain?

  56. pmoran says:

    nybgrus The lines you speak of seem reasonably clear to me, but muddied to you for some reason.

    They once seemed quite clear to me, too. Yet if complex interventions are proving to have similar or better outcomes to normal EBM-endorsed medical care, possibly even with fewer ill effects than commonly employed drugs, I am required by the same standards of evidence to look at the “lines” more closely.

    Although, I wish that in studies like the one Ed has just described they would place more emphasis on more objective outcomes, such as analgesic consumption and how long off work? Those results will be less contaminated by reporting biases– patients supplying what they think are the expected answers.

  57. pmoran says:

    GLados: How about yourself? Do you see an acupuncturist for pain?</i?

    No. There may first need to be a special series of studies using hardened skeptics as subjects.

    I have allowed that acupuncture is "mainly placebo".

  58. Scott says:

    Random has a formal definition; it means that every element in a population is equally likely to be selected in a sample.

    No, it does not. Random means that there is a distribution. It most certainly does NOT mean that the distribution is uniform. The sum of two dice rolls is random, but non-uniform. A Gaussian is random but non-uniform. And so on. Not a key part of your point, but sufficiently wrong that it needs correcting.

  59. Ed Whitney says:

    Man, you just can’t get away with carelessness on this blog! I should have specified that I meant a simple random sample of the body surface. If the average 70 kg man has a body surface area of 2800 square inches, then each square inch in a simple random sample is equally likely to be selected for a random needling. Scott is correct to point out that the essential thing about a random variable is that it is described by a probability distribution.

    Main point is that the so-called sham acupunctures in RCTs are done in a way that makes them comparable to drugs with similar mechanisms of action. A carefully planned sham acupuncture done by a trained practitioner is like a partial agonist of a drug receptor. That is what makes the selection of suitable controls for acupuncture so controversial.

  60. @Ed Whitney

    “Random has a formal definition; it means that every element in a population is equally likely to be selected in a sample. The eyeball is just as likely to be selected for needling as the T11-T12 intercostal space on the right or the tip of the index finger. ”

    Did you really think I meant truly random poking at any location on the body, including the eyeballs and not understand that I used the term randopoking simply to differentiate from the chi point based needling of acupuncture?

    If so, let me just clarify for you that the term “rando” was indeed derived from the word random, but was not intended to imply chaotic randomness in point of application, but was only meant to imply the use of non traditional application points (in other words, the non-use of traditional points of acupuncture).

    Perhaps it was my fault that I left some straw, clothing and matches laying around. /endsnark :)

  61. “They may have chosen points that are not identified as acupuncture points, but the points were chosen deliberately, and they did not operate haphazardly or randomly. ”

    I’m curious then, what was the basis for the selection of the points?

    I would think that for the control, you would define acceptable application regions, but that the specific points used within those regions should indeed be assigned randomly, possibly even different for each test subject to minimize the possibility that you might discover a new, unknown chi point.

  62. Ed Whitney says:

    @ Karl
    If you want me to go on arguing, you have to pay for another five minutes.

    Seriously, folks, the sham acupuncture is being done systematically by trained practitioners in a systematic, planned fashion, and that makes the true/sham comparison more subtle than is the case in placebo-controlled drug trials. It is a bit like telling a trained gymnast to go out on the mat and do the routines in a clumsy manner; they will depart from their usual routine, but do it gracefully. An attentive observer can immediately tell the difference between a trained gymnast acting like a klutz and an actual klutz.

    Main soapbox is that the interpretation of studies is not standardized or completely straightforward. Imagine the horror you would feel if a nominee for Chief Justice of the United States sat in front of the Senate Judiciary Committee and said that judging Constitutional law was just like an umpire calling balls and strikes. What a nightmare that would be! Just hypothetical, of course.

    Oh, wait…

  63. Ed Whitney,

    “If you want me to go on arguing, you have to pay for another five minutes.”

    Awesome response!

  64. GLaDOS says:

    No. There may first need to be a special series of studies using hardened skeptics as subjects.

    Thanks to this web site there’s a chance anyone Googling “acupuncture” will learn that the procedure works about as well as a kindly doctor offering reassurance, the tincture of time, chicken soup, back rubs, etc. –i.e., stuff a lot cheaper than a $1000 series of acupuncture visits.

    So when you say “skeptic,” do you mean someone who has been exposed to this kind of information?

  65. Ed Whitney says:

    “Although, I wish that in studies like the one Ed has just described they would place more emphasis on more objective outcomes, such as analgesic consumption and how long off work? Those results will be less contaminated by reporting biases– patients supplying what they think are the expected answers”

    That is true of a lot of studies out there; something like analgesic refills and return to work are reported less often than the self-rated stuff. The Hanover Functional Ability Questionnaire was used as a functional outcome, and looks similar to Oswestry and Roland-Morris scales that turn up a lot in the US literature—can you reach up and get a book off a high shelf, pick up a light object from the floor, wash your hair over a washbasin, etc. I can only find it in German on the internet. In Googling it I ran across something just made for the SBM website:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004618/pdf/jpr-2-075.pdf is free access. Anthroposophic therapy for low back pain, from the Institute for Applied Epistemology and Medical Methodology in Freiburg. Gotta love those Germans—an Institute for Applied Epistemology!

  66. nybgrus says:

    This is honestly very interesting, intelligent, and detailed analysis about these sorts of things. Ed is very much applying thoughtful detailed analysis at a level much higher than your average Bear. (And no, that is not at all a snark).

    However, the main problem here is that it is tooth fairy science. Missing the forest for the trees. Assuming something and working very intelligent discourse around it.

    And pmoran:

    Yet if complex interventions are proving to have similar or better outcomes to normal EBM-endorsed medical care, possibly even with fewer ill effects than commonly employed drugs, I am required by the same standards of evidence to look at the “lines” more closely.

    Indeed. But medical ethics keep those lines quite nicely in place.

  67. pmoran says:

    GlaDos:Thanks to this web site there’s a chance anyone Googling “acupuncture” will learn that the procedure works about as well as a kindly doctor offering reassurance, the tincture of time, chicken soup, back rubs, etc. –i.e., stuff a lot cheaper than a $1000 series of acupuncture visits.

    That may be said, but is it an entirely accurate reflection of the available evidence? What do relevant studies actually show?

    So when you say “skeptic,” do you mean someone who has been exposed to this kind of information?

    Not really.

  68. GLaDOS says:

    What do relevant studies actually show?

    Harriet Hall summarized the acupuncture studies like this:

    Overall the evidence is inconsistent, and the results tend to be negative among those studies judged to be of the highest quality. Where the results are positive, the reported benefits can be explained by the surrounding ritual, the beliefs and expectations of patient and practitioner, and other nonspecific effects of treatment.

    You said acupuncture probably won’t work on skeptics. So to clarify I asked if by “skeptic” you mean people who accept Dr. Hall as a qualified expert and who happen to read her article above, for example.

    So help me out here. What do you mean by skeptic in this case, with respect to acupuncture?

  69. nybgrus says:

    that is exactly my point glados… considering that I view the evidence as not supporting the inherent efficacy of acupuncture, that I think the mysticism surrounding it is BS, and that all the is there is the ritual… would the ritual stil have an effect on me? Do you think that if I, personally, went to an acupuncturist I would experience any sort of positive effect from it? If not, then how can you be arguing for its use on patients? When the entire “effect” of a treatment evaporates the moment you no longer believe in the ritual what do you have left?

    Nothing. And nothing you can recommend to patients. And nothing you can feel good knowing people are paying for. That is the definition of placebo I like. And “works.” If something stops “working” because you have become educated as to exactly how it works, then it never “worked” in the first place. And I would be willing to bet that it wouldn’t “work” on me if I were to get it tomorrow.

    Of course, you can then claim that I don’t have the proper condition, or mindset, or whatever you can come up with and thus it would work in a certain subset of the population, of which I am not a member. And thus you could liken it to, say an antidepressant, of which any given agent only “works” in about 60% of the population. But that would be disingenious – the key difference here is that once the antidepressant does work you cannot suddenly make the effect go away by teaching the patient about the mecahnism of SSRI and norepi in the brain. But if you do have a person on whom acupuncture “works” and you educate them to it, I am willing to bet it will suddenly stop working. That is the key difference.

    I may honestly go out and get some acupuncture soon just to try and prove the point.

  70. Ed Whitney says:

    “You said acupuncture probably won’t work on skeptics. So to clarify I asked if by ‘skeptic’ you mean people who accept Dr. Hall as a qualified expert and who happen to read her article above, for example.

    So help me out here. What do you mean by skeptic in this case, with respect to acupuncture?”

    Well, I was going on the basis of the fact that expectations of benefit are an important component of the placebo response, and that the placebo response would be less in skeptics insofar as that component was less. Because a high placebo response is one factor that can obscure a true treatment effect, a specific effect of acupuncture, if there is one at all, would be easier to detect in a population with a low placebo response rate. This would be a good study to do. You could not use the usual incentives for enrollment, that whatever group assignment the participant receives, he or she will be eligible to receive real acupuncture at the end of the trial. Maybe offer tickets to Penn and Teller; I don’t know.

    Ralph Horwitz at Yale once estimated that one third to one half of RCTs in medicine are negative, even when the intervention is known to be clinically effective. I don’t know how he came up with that figure (it does not seem to apply to published RCTs), but sometimes it certainly does happen. R. Buynak et al (Expert Opin Pharmacother 2010;11(11)1787-1804) randomized 965 patients with chronic low back pain to tapentadol, oxycodone controlled release, or placebo. The attrition rate was high, but tapentadol and oxycodone were both superior to placebo in the average reduction on the Numerical Rating Scale from baseline to 12 weeks (2.9 for tapentadol, 2.9 for oxycodone, and 2.1 for placebo). When responder rates were compared (defined as either 30% or 50% reduction in pain), the rates were higher in tapentadol than in placebo groups, but oxycodone did not differ significantly from placebo: for 30% response the rates were: placebo, 27.1%, tapentadol, 39.7%, oxycodone, 30.4%; for 50% response, the rates were: placebo, 18.9%, tapentadol, 27.0%, oxycodone, 23.3%. Because many researchers consider it better to report response rates rather than mean pain reductions (due to the distribution of pain scores), this large RCT could be interpreted to mean that OxyContin is no different from placebo.

    When first reading this, my heart leapt and I was excited: I could start my own Broward County, Florida type “pain clinic.” You know, the ones on the OxyContin express, visited by people from several neighboring states, located in strip malls between a pawn shop and a tattoo parlor, where you can go and stock up on hundreds of pills in an unregulated and unmonitored fashion. I could go and rent a place in a strip mall right next to the Skin Cabaret and dispense gelatin capsules for $25 a pop! Then I remembered what Ralph Horwitz said and my heart sank again. That damn thing that happens when placebo response rates are high: the efficacy of known valid treatments is obscured. Of course, OxyContin is much more effective an analgesic than gelatin capsules, and it was the conditions of the RCT and the high attrition and the high placebo response rate that made the difference between them “non-significant.”

  71. Ed Whitney says:

    Funny word, “sham” acupuncture…

    All the talk of “sham” acupuncture for RCTs in which the sham group had superficial or alternative needle placement, or toothpicks instead of needles, has rested on one critical, and from my observation, unexamined assumption. That “acupuncture” refers to an exact set of procedures done in accordance with a manual of some kind, such that superficial needle placement, rather than being called a variant procedure, is called a “sham” procedure. This is rather odd. It is as if you were listening to spine surgeons talking among themselves, and finding that some of them routinely used pedicle screws in certain situations and others did not. You might not think that they were discussing variations on a single kind of operation, and might think that some were doing real and some were doing sham fusions. After all, if they do not do them all exactly the same way, then what else are you to think? The guys who use pedicle screws are doing “true” fusion and the others are doing “sham” fusion, right? Wrong! These are variations of fusion, not qualitatively different procedures!

    The Ernst paper mentioned Cherkin (who used toothpicks for the sham acupuncture procedure); Cherkin had three acupuncture groups, one individualized, one standardized, and one sham; the fourth group had usual care. The three acupuncture groups were all superior to usual care, and the percentages of patients with 3 point improvements on the Roland-Morris disability scale at the end of 6 months for the four groups were 62%, 58%, 58%, and 44%; usual care was significantly different from the three acupuncture groups, but those three groups did not differ from one another. With Cherkin, the usual care group “received no study-related care—just the care, if any, they and their physicians chose (mostly medications, primary care, and physical therapy visits).” Cherkin mentions Haake 2007 and Brinkhaus 2006, notes that they are all coming up with similar results, and ponders on the meaning of it all.

    Sham acupuncture better than usual care, and about as good as true acupuncture–strong evidence, as Cherkin sees it, that this pattern points to a real phenomenon. All three authors discuss the small clinical significance of the details of needle placement. Most interesting of all, Cherkin says that the use of blunt needles was discussed in a classical Chinese book on acupuncture needling. Because penetrating the skin has been construed as something essential to acupuncture (otherwise you couldn’t call it “puncture”), the equal effectiveness of the toothpick sham procedure has been interpreted as devastating to the hypothesis that acupuncture is an effective treatment. If Cherkin’s history is correct, this finding need not prove anything dismaying to the practice of acupuncture

    Main point: perhaps all the debate over “true” and “sham” acupuncture will turn out to be a debate over different variations of the same intervention. Just as the guy who operates without pedicle screws is doing true fusion, not sham fusion, the guy who uses toothpicks (AKA blunt needling) could turn out to be doing a variation of what the guy does who uses needles.

    Now for the big irony:

    For all three studies, I see a graph with three bars: the one on the left is true acupuncture, the one in the middle is sham acupuncture, and the one on the right is standard care. The two bars on the left are about the same height, and both are noticeably higher than the one on the right. If these were studies of a drug, I would conclude that the ones on the left worked better than the one on the right, and represented a similar class of drug. They are higher, and are about the same size; they appear to be similarly effective, and better than the third one with which they are being compared.

    Others look at the same three graphs, notice the bar on the right, and see that, even though it is shorter than its neighbors on the left, the latter two are about the same height; they say, “Aha! I told you the ones on the left did not really work. Look! They are about the same size! I know this is true because I understand the one on the right but not the ones on the left!”

    These studies are an examination of some long-held assumptions about acupuncture technique, and this examination is long overdue.

    These three studies, all of them well done, lead the authors to do what one would expect of scientific physicians: re-examine some of the assumptions of their practice, particularly in the emphasis traditionally placed on the exact location of the needles, and on the need for depth of penetration. More superficial penetration may be just as effective as the deeper penetration in the “true” acupuncture tradition. It is likely to be safer.

    Perhaps these studies will lead to changes in how acupuncture is practiced. It is just a matter of getting acupuncturists to abandon long-held practice patterns and entrenched habits. No problem.

    What is so hard about that? After all, when needle biopsy was shown to be just as effective as open biopsy for tissue diagnosis in suspicious mammograms, all the surgeons changed their traditional practices just like that, didn’t they!

    Uh-oh. Wait a minute…

  72. GLaDOS says:

    All the talk of “sham” acupuncture for RCTs in which the sham group had superficial or alternative needle placement, or toothpicks instead of needles, has rested on one critical, and from my observation, unexamined assumption.

    The person making the claim bears the burden of defining his terms. The people who believe acupuncture has some benefit defined “acupuncture” as a procedure involving needles penetrating the skin along “meridians.” You might call this an “assumption,” but the TCM guys would not accept that. They have many books with complex line drawings and instructions regarding needle placement. They charge people a lot of money to learn this material.

    Using points apart from the qi lines is a way to test the hypothesis about needle position in pain relief.

    Because the sham procedure worked about as well as the true procedure, we can say that needle position is not important. The TCM guys got this bit wrong.

    Next up: needling verses poking the skin. TCM guys got this wrong also.

    Given these failures, a reasonable person should conclude that the TCM guys don’t actually know what they’re talking about. If they say anything useful it will be sheer luck rather than understanding.

    You know what else sometimes works by sheer dumb luck? Dictionary fishing. That’s when you close your eyes, ask a question, then pop open a dictionary at random. You drop your finger on the page and open your eyes. The closest noun to your finger is your answer.

    You want to do a bunch of studies on some treatment that rests upon a method of investigation about as reliable as dictionary fishing?

  73. nybgrus says:

    All the talk of “sham” acupuncture for RCTs in which the sham group had superficial or alternative needle placement, or toothpicks instead of needles, has rested on one critical, and from my observation, unexamined assumption. That “acupuncture” refers to an exact set of procedures done in accordance with a manual of some kind, such that superficial needle placement, rather than being called a variant procedure, is called a “sham” procedure.

    That has been pretty well addressed by Ben Kavousi’s posts on the topic. I suggest you read those before you continue.

    Others look at the same three graphs, notice the bar on the right, and see that, even though it is shorter than its neighbors on the left, the latter two are about the same height; they say, “Aha! I told you the ones on the left did not really work. Look! They are about the same size! I know this is true because I understand the one on the right but not the ones on the left!”

    Once again, if you look at Ben’s posts that will help you understand why it is reasonable to do so. It is very important to define what you are looking to measure and what your measure is. If you have a large enough sample of data and try and work backwords to find “something” in the data, you always will. A more accurate anology would be if you have 3 bars of data, one with a Drug X in a gelatin capsule, one with just an empty gelatin capsule identical to that used to contain Drug X, and one with a placebo sugar pill. You look at the 1st two and see they are identical and the last bar is much smaller. Then you would say that indee, Drug X doesn’t actually work. You would be lead to think that it is the capsule. Ergo, acupuncture doesn’t work – it is the wrapper that it is in.

    After all, if they do not do them all exactly the same way, then what else are you to think? The guys who use pedicle screws are doing “true” fusion and the others are doing “sham” fusion, right? Wrong! These are variations of fusion, not qualitatively different procedures!

    Because a spinal fusion is not defined by putting in a pedicle screw. It is defined by the outcome in terms of measurable and observable differences in the vertebra and using a pedicle screw is one method of achieving that. Read the actual definitions of what acupuncture is, how it is actually taught, and how it is actually practiced. That is “true” acupuncture. “Sham” would therefore take away the integral part of “true” and thus offer a suitable comparison group. Thus, all you are left with is the placebo and non-specific effect of the ritual associated with it – nothing of “acupuncture” is left behind.

  74. drmarcelli says:

    Dear Harriet,

    as a founder of Science Based Medicine you should absolutely write to Gen. George W. Casey Jr. US Army’s Chief of Staff to stop this medieval bloodletting medical activity against US ill soldiers.

    At the moment US Army is the most powerful army in the world. Maybe because of a sense of inferiority from the Yellow Face is US Army seriously thinking to acupuncture as a pain-reliever method for its soldiers?

    http://www.army.mil/-news/2010/11/01/47448-acupuncture-gains-momentum-in-army-health-care/

    The father of (western) Battle Acupuncture is Richard C. Niemtzow, Colonel, MD, Consultant of Alternative and Complementary Medicine to the Air Force Surgeon General. His works are these:

    http://www.n5ev.com/battlefield_acupuncture.htm
    http://www.n5ev.com/PDF%20BATTLEFIELD%20UPDATE.pdf

    As a direct descendant from an ancient Roman General http://en.wikipedia.org/wiki/Claudius_Marcellus, whom should I believe and trust? A Science Based Medicine or an Intelligence Based Army, to which scientists of all times gave their best discoveries (from Archimedes’s Mirrors, to Leonardo’s cannons and Einstein’s bombs?)

    As I am here to learn to be a honest skeptic with no trespassing into the cospiracy theory that the introduction of acupuncture in the US Army is an idea of BigPharma, please answer me: could I call Colonel Niemtzow a medieval bloodletter?

    As so friendly as military :-),

    Stefano Marcelli MD
    and ex captain of (NATO) Italian Army

    My observations on Gross Anatomy and Acupuncture are here:
    http://www.geneticacupuncture.com

  75. Harriet Hall says:

    Acupuncturists believed acupuncture worked.
    They wanted to validate their beliefs with science.
    They devised the best studies they could think of.
    They devised a sham acupuncture procedure that they had every reason to think was a good placebo control. Indeed, patients couldn’t tell which they were getting.
    The studies showed no difference between their sham and true acupuncture.
    They were surprised and shocked.
    Since they believed that acupuncture worked, the only way they could salvage their belief was to postulate that sham acupuncture worked too.
    Then, after the fact, they came up with hypotheses about the depth of stimulation, etc.

    Reminds me of the patient who thought he was dead. Doctor asked him if dead men bleed; he said no. Doctor pointed out that patient was bleeding. Patient said “Wow, dead men DO bleed!”

    There’s a name for this logical fallacy.

  76. Ed Whitney says:

    “You might call this an “assumption,” but the TCM guys would not accept that. They have many books with complex line drawings and instructions regarding needle placement. They charge people a lot of money to learn this material.

    Using points apart from the qi lines is a way to test the hypothesis about needle position in pain relief.

    Because the sham procedure worked about as well as the true procedure, we can say that needle position is not important. The TCM guys got this bit wrong.

    Next up: needling verses poking the skin. TCM guys got this wrong also.

    Given these failures, a reasonable person should conclude that the TCM guys don’t actually know what they’re talking about. If they say anything useful it will be sheer luck rather than understanding.”

    “Read the actual definitions of what acupuncture is, how it is actually taught, and how it is actually practiced. That is “true” acupuncture. “Sham” would therefore take away the integral part of “true” and thus offer a suitable comparison group. Thus, all you are left with is the placebo and non-specific effect of the ritual associated with it – nothing of “acupuncture” is left behind.”

    Aha! I think I see part of the problem. Our perspectives may not be all that different after all. When I have been reading these well-done studies and concluding that they support the use of “acupuncture,” you have been thinking that I am concluding that they support the use of TCM. We may have been talking at cross purposes.

    I rated the Brinkhous, Haake, and Cherkin studies as good quality because they do what I ask of RCTs of other kinds of intervention in controlling the risks of bias that threaten internal validity. I rated Haake the highest quality, because he did something that is often lacking in RCTs of pharmacology. In Table 3, he checked the adequacy of blinding, and found that most patients did not correctly identify or did not know whether they had received true or sham acupuncture. (Yes, I know, CONSORT 2010 has deleted this from their guidelines for reporting RCTs, but Haake was working in 2007 and his Table 3 shows that he was making every effort to control bias).

    In addition, he did something at the very beginning of the trial similar to what they did in SPORT when they were studying surgical and nonoperative treatment of herniated discs: he had a separate cohort study of acupuncture which prospective participants could choose to enter. This was done so that patients with positive expectations of acupuncture and negative expectations of conventional therapy could be excluded from the outset.

    Each of these authors, in their discussion sections, speaks of the need to re-examine traditional assumptions about needle placement. Earlier, I praised them for doing so, and for seeking less invasive methods to do acupuncture. This should have dispelled any impression that I was sticking up for TCM, but my communications are not always as clear to others as they are to me.

    I used to see patients who had gone to TCM practitioners for their health complaints, and the impressions they gave me were not favorable. They would be given bags of herbs with no explanation of what was in them, how they worked, or how to recognize if they were not working. When they returned to their TCM “doctors,” they would be given another bag of herbs, again with no explanation of what they were or what they did. TCM looked like a rigid, closed, authoritarian system of practice. And the replies of GLaDOS and nybgrus show that they and I are of one mind with respect to that system. Those TCM docs were pursuing the worst habits of the old paternalistic “Doctor knows best; don’t ask questions” of some practitioners of scientific medicine, with none of its virtues.

    Cherkin, Brinkhaus, and Haake, in their eagerness to open up a closed system, are major threats to the rigid system of TCM that uses ancient charts of meridians and qi to dictate practice, charging lots of money for teaching this system. I was about to add this to my last post, but it was already running a bit long. If these authors go ahead with the research they want to do, it is safe to say that their strongest opposition will come from the ranks of TCM. These guys are threatening their territory, and they will not like that one bit. Like any other authoritarian system, TCM says that there is only one right way to do things, and they are the custodians of that right way. GLaDOS, nybgrus, and I are on the same page with respect to that. I think.

    More than one right answer, of course, does not mean that “anything goes.” It does not mean that any random or arbitrary answer is as good as any other answer. Quadratic equations have two right answers and cubic equations have three right answers, but that does not mean that anything goes; it only means that the space in which they are represented in analytical geometry has more than one dimension.

    Saint Augustine gave an example of an eternal truth: seven plus three is ten, has always been ten, and will always be ten. In setting up the discussion of truth in this manner, he laid the ground for a rigid dogmatism which had an inflexible model for considering what it means to look for truth. Most of the time, we are not confronted with problems of the form “What is seven plus three?” We are confronted with problems of the form, “Which two numbers, added together, equal ten?” Here, if the answers are constrained to be positive integers, there are only a few right answers, but more than one. If constrained to be rational numbers, there are an infinite number of right answers, but not all answers are right.

    TCM authoritarians have a real problem with that. They will freak out if Haake and his colleagues proceed in the direction they are going. You can absolutely, positively bet your virginity on that, as my old first sergeant used to say.

  77. Ed Whitney says:

    “They devised a sham acupuncture procedure that they had every reason to think was a good placebo control. Indeed, patients couldn’t tell which they were getting.
    The studies showed no difference between their sham and true acupuncture.
    They were surprised and shocked.
    Since they believed that acupuncture worked, the only way they could salvage their belief was to postulate that sham acupuncture worked too.
    Then, after the fact, they came up with hypotheses about the depth of stimulation, etc.

    Reminds me of the patient who thought he was dead. Doctor asked him if dead men bleed; he said no. Doctor pointed out that patient was bleeding. Patient said “Wow, dead men DO bleed!”

    There’s a name for this logical fallacy.”

    I don’t know how shocked they were, and cannot guess what they wanted to salvage, not having ESP and lacking the ability to channel thought waves. I propose another possibility: their data showed that sham acupuncture was better than standard care, and they concluded that there is more than one right answer to the question about how needles should be used and placed. A shock to TCM, perhaps, but not to anyone else.

    What exactly did Cherkin, Brinkhaus, and Haake do wrong?

    That bar graph representing the response to conventional therapy (the short one), to the right of the two bars representing true and sham acupunture (the taller ones), remains to be examined and explained. For some reason I am reminded again of my army days, when the drill sergeant used to lead marching cadence with, “Look to your right and what do you seeeeeeeeee”

  78. Harriet Hall says:

    @ Ed Whitney, “their data showed that sham acupuncture was better than standard care, and they concluded that there is more than one right answer to the question about how needles should be used and placed.”

    I just don’t get this. Why should they conclude that? Why not conclude that the reason both interventions were better than standard care was that both interventions evoked a stronger placebo response than standard care? That is the most parsimonious and logical explanation of all the observed data.

  79. GLaDOS says:

    When I have been reading these well-done studies and concluding that they support the use of “acupuncture,” you have been thinking that I am concluding that they support the use of TCM.

    Nope. Acupuncture is the procedure under discussion, not some other TCM procedure.

    BTW, if you weren’t sure whether I was talking about TCM or acupuncture, you might have asked and so saved yourself a teal deer (tl;dr aka “too long; didn’t read).

    Allowed potential conclusions must be stated PRIOR to any study to avoid the sharpshooter’s fallacy. Once you go looking for patterns in the data AFTER the study is over, you’re starting from scratch as if there had been no study.

    You can use patterns in study results to generate new hypotheses. But you can’t use those patterns to draw conclusions.

  80. Ed Whitney says:

    “Allowed potential conclusions must be stated PRIOR to any study to avoid the sharpshooter’s fallacy. Once you go looking for patterns in the data AFTER the study is over, you’re starting from scratch as if there had been no study.

    You can use patterns in study results to generate new hypotheses. But you can’t use those patterns to draw conclusions.”

    Fair enough; I will be as brief as possible. Haake and Brinkhaus were done in Germany and had no registration of their trials on clinicaltrials.gov. Cherkin was done in the US and the trial registration is at the end of the abstract. I make it a rule to look at the trial protocol to rule out the Texas sharpshooter fallacy, when those protocols are available. http://clinicaltrials.gov/archive/NCT00065585/2005_06_23 has ruled this out.

    From your having said, ” You might call this an “assumption,” but the TCM guys would not accept that. They have many books with complex line drawings and instructions regarding needle placement. They charge people a lot of money to learn this material,” I thought you were somehow talking about TCM. But I did not ask if this were the case.

    Busted again.

  81. nybgrus says:

    Exclusion criteria:
    * non-mechanical causes or potential causes of low back pain (i.e. sciatica, underlying systemic or visceral disease, pregnancy, spondylolisthesis, spinal stenosis, cancer or unexplained weight loss, recent vertebral fracture)

    >90% of mechanical back pain, even recurrent pain, will eventually go away. The chronicity of back pain in these circumstances and it is a well understood phenomenon that it has to do with expectation and incentive. Patients either expect that they will not get better, are afraid of their back pain and too much movement and thus perpetuate their sick role or they have incentive to continue with the sick role from worker’s comp, insurance payments, or even how their family treats them because of their back pain. I actually spent a week in med school learning about these things so that we can adequately handle these issues and avoid contributin to chronicity.

    So your study specifically includes only a population defined by a self limiting disease process, which has been shown would be ameliorated by expectation of getting better (i.e. acupuncture is new maybe it will work!) and incentive to get better (they’ve enrolled in the study, maybe they want to get better but have been afraid of their back pain). The point being, you are looking at a study on a process in a population that is expected to have a variable course but with a measured outcome we expect to get better regardless of the treatment modality.

    I have this awesome tea you can drink. It works for almost everyone and it will cure your cold/flu in 7-10 days. Maybe we should study it?

  82. Ed Whitney says:

    “So your study specifically includes only a population defined by a self limiting disease process, which has been shown would be ameliorated by expectation of getting better (i.e. acupuncture is new maybe it will work!) and incentive to get better (they’ve enrolled in the study, maybe they want to get better but have been afraid of their back pain).”

    This was precisely the point I tried to make earlier, that the principle of “extraordinary claims require extraordinary evidence” does not apply. A self-limiting condition resolves faster with slender needles than with NSAIDS and PT. This claim, mundane though it is, should be supported with mundane evidence, and that has been done. Rule out chance, confounding, and bias, and you are entitled to attribute the faster resolution to the study intervention.

    “I have this awesome tea you can drink. It works for almost everyone and it will cure your cold/flu in 7-10 days. Maybe we should study it?”

    Cold/flu remedies are judged effective if they can cure you in 4-6 days. If you can resolve a self-limiting condition more efficiently with one intervention than with a comparison intervention, you have done something useful. Won’t get you a Nobel or Lasker, but worth someone looking at.

  83. Ed Whitney says:

    ” Why not conclude that the reason both interventions were better than standard care was that both interventions evoked a stronger placebo response than standard care? That is the most parsimonious and logical explanation of all the observed data.”

    “Placebo” is an explanatory principle, belonging to the world of concepts. It lacks a concrete referent in the world of extra-verbal reality. To speak of “placebo” as if it had an extra-verbal referent is, it seems, to entertain the Fallacy of Misplaced Concreteness.

    The Hanover Functional Ability Questionnaire (the functional outcome of Haake) uses language, but uses it to refer to things in the extra-verbal world. After receiving the needle-based intervention, more patients were able to reach for books on high shelves, carry a 10 kg suitcase at least 10 meters, wash their hair over a washbasin, pick a crumpled piece of paper up off the floor, stand for 30 minutes without interruption, lie in bed on their backs, and run 100 meters to catch a departing bus, than were able to do the same things with conventional therapy. To measure and compare these things is to engage in Appropriately Placed Concreteness.

  84. nybgrus says:

    Rule out chance, confounding, and bias, and you are entitled to attribute the faster resolution to the study intervention.

    But the study intervention is not acupuncture. That is the point that Dr. Hall and I have been trying to get across. The intervention is the interaction with the practitioner and the expectation of benefit. You are correct that that is not an extraordinary claim and needs only mundane evidence to support it. Which is why we have accepted that as the evidence. What the evidence does not show is that the intervention producing these results is acupuncture. If you can change everything about acupuncture except that patient interaction and the expectancy effects, then you are left with nothing resembling acupuncture! You don’t need the qi points. You don’t need the meridians. You don’t need the needles. What is left of acupuncture??? You even say:

    A self-limiting condition resolves faster with slender needles than with NSAIDS and PT.

    But we have shown that you don’t need the slender needles. And it doesn’t matter if you stick them in a particular spot or not. The only commonality between sham, fake, true, what-have-you acupuncture is the ritual associated with it and the expectancy of the patient. We lump those into a term called a “placebo” since they are non-specific and difficult to quantify and implement. So yes, the mundane evidence shows us a mundane effect – which has nothing to do with acupuncture. So why must you keep trying to advocate for the use of needles or nociceptive points or counter irritation to justify a practice that has been shown to be irrelevant to the actual effect??

  85. Harriet Hall says:

    @Ed Whitney,

    Placebo “lacks a concrete referent in the world of extra-verbal reality”?!

    If you want to play word games, I’ll reword my question to “Why not conclude that the reason both interventions were better than standard care was that the nonspecific treatment factors in both resulted in patients reporting less pain than when they received standard care? That is the most parsimonious and logical explanation of all the observed data.”

    I agree that objective endpoints are more meaningful than subjective reports of pain intensity. I have criticized studies that reported pain relief but didn’t result in patients using fewer rescue pain pills. But does that mean we can disregard all the studies that have used patient reports as endpoints? I don’t think so.

  86. nybgrus says:

    ack! sorry for the mistake in formatting:

    Rule out chance, confounding, and bias, and you are entitled to attribute the faster resolution to the study intervention.blockquote

    But the study intervention is not acupuncture. That is the point that Dr. Hall and I have been trying to get across. The intervention is the interaction with the practitioner and the expectation of benefit. You are correct that that is not an extraordinary claim and needs only mundane evidence to support it. Which is why we have accepted that as the evidence. What the evidence does not show is that the intervention producing these results is acupuncture. If you can change everything about acupuncture except that patient interaction and the expectancy effects, then you are left with nothing resembling acupuncture! You don’t need the qi points. You don’t need the meridians. You don’t need the needles. What is left of acupuncture??? You even say:

    A self-limiting condition resolves faster with slender needles than with NSAIDS and PT.

    But we have shown that you don’t need the slender needles. And it doesn’t matter if you stick them in a particular spot or not. The only commonality between sham, fake, true, what-have-you acupuncture is the ritual associated with it and the expectancy of the patient. We lump those into a term called a “placebo” since they are non-specific and difficult to quantify and implement. So yes, the mundane evidence shows us a mundane effect – which has nothing to do with acupuncture. So why must you keep trying to advocate for the use of needles or nociceptive points or counter irritation to justify a practice that has been shown to be irrelevant to the actual effect??

  87. nybgrus says:

    argh. OK. I give up. sorry for the formatting. Hopefully it is still readable.

  88. Ed Whitney says:

    Damn! I think we may be getting close!

    I have been saying that Brinkhaus, Cherkin, and Haake (henceforth to be known as BCH) have shown something interesting: by poking someone, they can hasten a person’s ability to lift a jug of water from the floor to a table with ease. Further, they have shown that there is more than one way to poke a cat. I insist that it has not been shown that any old kind of poking will do; that was what I meant by all that stuff about higher order equations having more than one solution, but not just any solution.

    You have been trying to get me to see that the effective intervention is not acupuncture. I think I am pretty close to agreeing with that, at least insofar as it is an integral part of a system of thought we have been calling TCM. You call it woo, I call it folderol, but we are not all that far apart on this issue.

    In saying that BCH were going to get serious pushback from the TCM community, I was in essence saying what I think you are saying when telling me that the BCH intervention is not acupuncture. I am not sure that BCH actually realize the significance of what they have done. They may be on to something entirely new, thinking that they are defending something old.

    The dividing point between us may be how we respond to the phenomenon we are looking at. In calling “placebo” an explanatory principle, I meant that an explanation of a phenomenon is a way of setting the mind at rest. A guy can hardly put on his socks without great difficulty, Haake tweaks him with a needle, and soon he can put them on with ease, sooner than he could have if he had just kept taking Aleve and doing his pelvic tilt exercises. “Placebo” is an explanation that places this into the category of “what we already know.” Further inquiry is truncated. This is not a word game, but has real consequences for what comes next.

    But I want to say, “These guys are on to something! I wonder what it is?” Further inquiry then begins. Maybe anyone can poke the guy with the same favorable result, but I will insist on good evidence for that. Someone may make that claim, but until that is proven, to me they will sound like the yahoo at the art museum who says his kid can paint a Jackson Pollock. BCH are all trained acupuncturists, and what they are doing has my full respect.

    If low back pain were a rare condition that had no effects on work absenteeism, chewed up a trivial amount of physician time, and had no impact on health care system costs, I would be less inclined to propose that the BCH phenomenon is worthy of further research. This, judging from most of the comments on this thread, is not the case; further research is wasted effort because the effectiveness of acupuncture is a question that has been settled. You may as well waste your research resources on the design of a perpetual motion machine. That is what I have been getting from the SBM community so far.

    If I were unfortunate enough to be a health care system administrator, and there was a possibility that a new intervention could have an effect on my total system costs, I would be motivated to give BCH a grant to develop an intervention that may save the system money and get me a giant bonus.

    Are we any closer to common ground?

  89. Harriet Hall says:

    “by poking someone, they can hasten a person’s ability to lift a jug of water from the floor to a table with ease.”

    Maybe they are only hastening the person’s willingness to try harder to lift a jug.

  90. Ed Whitney says:

    Could be. Or to change their answer to “Können Sie einen schweren Gegenstand vom Boden auf den Tisch stellen?”

    Question is: are you curious to know more?

  91. Harriet Hall says:

    Sure I’m curious to understand more about the placebo response, but I don’t think studying variations of acupuncture and claiming there is some kind of specific effect is a fruitful approach. It is the placebo response itself that should be studied, as Benedetti’s group is doing.

  92. nybgrus says:

    A guy can hardly put on his socks without great difficulty, Haake tweaks him with a needle, and soon he can put them on with ease, sooner than he could have if he had just kept taking Aleve and doing his pelvic tilt exercises. “Placebo” is an explanation that places this into the category of “what we already know.” Further inquiry is truncated. This is not a word game, but has real consequences for what comes next.

    A litte closer perhaps. The problem is that you are stipulating there is something to the “tweaking with a needle” that is helping this person. That is clear. As Dr. Hall has said, it may be that the person is just willing to try harder to lift the jug. That is hardly a trivial point. However, when you are looking at the utility and implementation of an intervention, as we have said, you cannot take a large amount of data and try and connect some dots. You must develop a hypothesis and test it and determine its sigficance. So what do we have?

    Needles aren’t necessary, toothpicks work as well.

    Specific points as dictated by TCM aren’t necessary, any poking will do.

    It doesn’t seem to work on non-self limiting processes – a person with paraplegia won’t walk again and it won’t cure diabetes.

    So what are we left with? What hypothesis would you put forth to test and develop a treatment that isn’t TCM acupuncture (since you draw that delineation) but is BCH acupuncture? What is it that separates them?

    The SBM crowd is dismissing these because we advocate a Bayesian, a priori, basic sciences metric to be added to our analyses and experiments. Since the needles aren’t necessary, the points are not defined, and there is no plausible mechanism for the acupuncture that you and I are both (apparently) agreeing to dismiss, then what kind of experiment could you design that would shed new light on this? Countertraction/irritation? Been done. Distraction? Been done. Placebo? Understood to be able to motivate and have measurable effect. So what is left? Focus on that question and try and frame a hypothesis from the beginning and come up with an experiment. Don’t start with your conclusion and work backwards.

    Furthermore, the phenomenon you describe is actually described, noticed, taught, and becoming more and more understood. The chronicity, social factors, personal factors, placebo effect, motivation, etc etc vis-a-vis back pain are understood to be a complex milieu. Thus when all the facets of acupuncture can be changed with no change in effect, we are left looking for the parsimonious conclusion. Dr. Hall said it quite well: “Maybe they are only hastening the person’s willingness to try harder to lift a jug.” It has been shown that even when painful, pushing through the pain to regain mobility is the best way to alleviate mechanical back pain. I have personally experienced this myself. But people are usually scared to do so – back pain hurts a lot. Give them a placebo to motivate them and voila! You have your explanation and it further shows that there is nothing to acupuncture.

    Nothing unique anyways. There are many ways to poke a cat, you say. There are many ways to placebo a cat as well. In medicine, when there is no difference like that, you must always choose the method with the least amount of side effects. And when you know your treatment is reduced to nothing but placebo, you cannot ethically use it on your patients. That, Ed, is why the SBM crowd is dismissing acupuncture.

  93. daedalus2u says:

    For non-specific effects to do “something”, there must be physiology that couples the non-specific effects to what ever “something” is happening. We may not know what that physiology is, but I don’t think that anyone at SBM would deny that there must be physiology to produce the “something” that is observed.

    nybgrus is correct. The only way that adherents of SBM can use placebos is if they occur only as a result of actual physiological relevant treatment. A good bedside manner is a placebo, it is an ethical placebo, it is actually unethical to not use a good bedside manner.

    If there was a pharmacological treatment that did trigger the placebo effect over and above the placebo effect of a good bedside manner, then it would be ethical to use that pharmacological treatment provided the risk was low enough.

    What should be looked at in acupuncture research is the comparison of acupuncture with an equivalent time of “good bedside manner” instead of “standard care”.

    I think that spending equivalent time with a real doctor going over the patient’s symptoms, taking history, blood pressure, discussing diet, exercise, stress reduction, that the “effects” would be equivalent to the acupuncture and the sham acupuncture groups, or maybe even superior because the good bedside manner also includes advice on other things which could help in addition to its placebo effects.

  94. GLaDOS says:

    Are we any closer to common ground?

    No. You keep saying “acupuncture.” But there is no acupuncture, just nonspecific stuff.

    Moreover, you miss the big picture. The whole point of “research” in the alt med world is to keep the wolves of real science away from the front door. The alties have already built their schools, award their degrees, vertically integrated their manufacturing and distribution streams across international borders, and formed their professional societies and accreditation committees. The “studies” are just part of their marketing budget.

    The alt med schools, degrees, and products must be scrapped. Too many young people are seduced into throwing their lives away on worthless degrees. They then see no escape, apart from perpetuating the lies that were told to them.

  95. Ed Whitney says:

    @ nybgrus

    “A little closer perhaps. The problem is that you are stipulating there is something to the “tweaking with a needle” that is helping this person. That is clear. As Dr. Hall has said, it may be that the person is just willing to try harder to lift the jug.”

    I am not at all certain that the tweaking of the needle was helping the person, only that the BCH intervention was causal. Basically, I made that causal inference based on having ruled out chance, confounding, and bias, and having satisfied myself that the observed difference in response rate between BCH and standard care did not arise from post-hoc cherry picking of data (the Texas sharpshooter problem). The causal inference applies to the entire BCH and I am not ready to defend attribution to a single component.

    “…any poking will do.”

    Not at all proven; the sham poking in BCH has all been planned in advance and done according to protocols.

    “So what are we left with? What hypothesis would you put forth to test and develop a treatment that isn’t TCM acupuncture (since you draw that delineation) but is BCH acupuncture? What is it that separates them? ”

    I have been wondering the same thing and have nothing approaching an answer. Serves me right for knowing next to nothing about classical TCM acupuncture, never having been much attracted to it. All I know is that in their sham interventions, they inform me that they are departing from their customary procedures in various ways. They place the needles away from acu-points, but I do not know what that means. Are they placing them in the same dermatome? So I would postpone making hypotheses until I was preparing to design an original study of BCH.

    “Dr. Hall said it quite well: “Maybe they are only hastening the person’s willingness to try harder to lift a jug.” It has been shown that even when painful, pushing through the pain to regain mobility is the best way to alleviate mechanical back pain.”

    This is likely to be an important effect of BCH; fear-avoidance is a major part of what moves back pain from a self-limiting to a chronic condition. Getting up and about and doing things is the cure of nonspecific back pain, and all other interventions are justified insofar as they contribute to that end. Passive modalities, whether ultrasound, massage, or BCH, are only adjuncts to active therapy. Cognitive-behavioral therapy and exercises was just as good as fusion with pedicle screws (Brox, Ann Rheum Dis 2010;69:1643–1648) for chronic low back pain in one well-done study.

    “It has been shown that even when painful, pushing through the pain to regain mobility is the best way to alleviate mechanical back pain. I have personally experienced this myself. But people are usually scared to do so – back pain hurts a lot”

    Ditto. See above.

    “Give them a placebo to motivate them and voila! You have your explanation and it further shows that there is nothing to acupuncture…the SBM crowd is dismissing acupuncture.”

    Insofar as “explanation” truncates inquiry, it should not be indulged in until we know why BCH was a better placebo than the evidence-based guideline care with which it was compared. Dismissal suffocates curiosity. There is no justification at this juncture for saying “voila!” Enough for saying, “Mon dieu! Qu’est-ce que c’est?”

    @ daedalus2u
    “I think that spending equivalent time with a real doctor going over the patient’s symptoms…”

    Even before managed care came along and strangled the doctor-patient relationship with its demands for “productivity,” the time for talking and listening was all too limited. Better stop here before beginning to rant and rave about this real tragedy of our time. My doctor has advised me against it.

    @ GLaDOS

    “No. You keep saying acupuncture.’ But there is no acupuncture…”

    Hence the switch to “BCH intervention.” Anyone who says “acupuncture” in the future will be sacked. And those responsible for sacking them will be sacked.

    “…just nonspecific stuff.”

    I have been tossing this term about and am in no position to cast stones, but “nonspecific” is a word without a scientific meaning. Like “idiopathic,” it is a confession of ignorance, and not an explanatory principle any more than “dormitive power” of opium in Le Malade Imaginere.” At least Moliere knew he was jesting.

    “Too many young people are seduced into throwing their lives away on worthless degrees”

    This does bring up an important reason for any placebo effect. We all know that expectations are an important part of the placebo response. Friendly and cordial cultural attitudes toward an intervention (e.g., everyone likes CAM) create the context in which positive expectations are formed. This increases the response rate in the placebo group, which makes it more difficult to detect specific effects, especially when the outcome is measured on a closed scale (like pain scores).

    If a celebrity or two died after a visit to the acupuncturist, these cultural attitudes might have to be re-calibrated. In the USA, they all use aseptic technique and do not operate like knuckleheads, so this is not likely to happen.

  96. Ed Whitney says:

    @ the whole gang

    Related questions for anyone who knows: in many states, physical therapists are doing dry needling of trigger points, which is within the scope of their practice after they complete an accredited training course. Obviously no lidocaine or Kenalog or anything can be injected. There was no evidence that the injectate added anything to the dry needling last I knew.

    Are you seeing this done in your area?
    Do you have any concerns about its becoming widely practiced?
    Is this to be considered CAM or is it conventional practice?

  97. @Ed Whitney

    “Sham acupuncture better than usual care, and about as good as true acupuncture–strong evidence, as Cherkin sees it, that this pattern points to a real phenomenon.”

    This is absolutely not strong evidence of anything. The problem in such three arm studies is that the usual care groups aren’t blinded like the true and sham acupuncture groups are. It’s highly problematic at best to compare one unblinded group with two blinded groups and draw any particularly useful or definitive conclusions on anything other than the relative strength of the placebo responses.

    To say otherwise seems to require ignoring or undervaluing the value of blinding.

    Also remember, since standard care is not particularly effective for the pain typically being studied here, you’re closer to comparing acupuncture to no treatment rather than seeing how it measures up to an established, effective treatment.

  98. More precisely, the acupuncture and sham acupuncture groups are blinded to each other, but there is no blinding between these two groups and the usual care group.

    You can say conclude that both acupuncture-like treatments produced greater effect than the usual care group, but since the usual care is not particularly effective for the type of pain studied (and very close to no treatment), you can’t say the results aren’t due to placebo response.

    The subjects are likely well aware that usual care is generally ineffective (which is probably why they are in the study), and have little or no expectation of relief from usual care. They are, if anything, primed for a “reverse placebo effect”, and thus the lack of blinding between usual care and the acupuncture-like meta group is particularly problematic.

    As a side note, instead of randopoking, I should refer to the potential clinical application of sham acupuncture as pseudopuncture.

  99. GLaDOS says:

    I have been tossing this term about and am in no position to cast stones, but “nonspecific” is a word without a scientific meaning. Like “idiopathic,” it is a confession of ignorance.

    What do you mean, “not a scientific meaning”? It’s very useful in science to say, “this part of the variance is down to God-knows-what.”

    Confessions of ignorance are all the rage in science. The mistake happens when you use “we don’t know” to justify some positive claim. Example: “You can’t say acupuncture has absolutely no effect. Therefore doctors should offer acupuncture as an option to their patients.”

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