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Alternative Arthritis Treatments

A recent report commissioned by Arthritis Research UK reviewed 25 so-called “alternative” therapies for arthritis. They found, not surprisingly that there is little evidence to support most the studied treatments.

“There’s either no evidence that they’re effective or there’s some evidence that they are not effective.

Says lead author, Dr Gareth Jones.  It is important to note that we are not just talking about that these treatments are poorly studies, but also that to the extent they are studied the evidence is mixed or shows lack of efficacy.

I want to discuss, however, the exceptions – the treatment the report found were effective. They include acupuncture, tai chi, yoga, and massage.  Tai chi and yoga are basically forms of exercise and stretching, so it is not surprising that they are helpful in treating musculoskeletal disorders. It is deceptive, in my opinion, to even consider them “alternative” and lump them into the same artificial category as copper bracelets and magnet therapy. Exercise is not alternative – it is a very basic form of science-based activity for health, conditioning, and for musculoskeletal symptoms. The same is essentially true for massage, which is known to relax muscles (at least temporarily). Relaxation therapy should also not be considered “alternative” and existed long before this category was invented.

The only item on the list of treatment modalities that the report concluded showed some efficacy that is reasonably defined as “alternative” was acupuncture. This claim caught my attention because other reviews of the literature indicate that acupuncture is not effective for arthritis (or anything else). The report itself is not published in a peer-reviewed journal (at least not yet), but the lead author, Gareth Jones, has published prior systematic reviews.

For example, a 2012 review of acupuncture for low back pain found:

Three studies found a significant difference in pain scores when comparing acupuncture, or sham acupuncture, with conventional therapy or no care. Two studies demonstrated a significant difference between acupuncture treatment and no treatment or routine care at 8 weeks and 3 months. Three studies demonstrated no significant difference between acupuncture and minimal/sham acupuncture with no difference in pain relief or function over 6 to 12 months.

This is a consistent pattern for acupuncture research in general. When compared to no treatment or usual care (which is necessarily an unblinded comparison) there is a difference in outcome. This is sufficiently explained as placebo effects, which can be entirely bias and expectation. There is probably also some non-specific benefit from the kind attention of the practitioner. When acupuncture is compared to sham or placebo acupuncture, however, there is no difference. Since acupuncture is the insertion of needles into alleged acupuncture points, and the research shows it does not matter where or even if you insert needles, the only reasonable conclusion is that acupuncture does not work. There are placebo effects from the ritual surrounding acupuncture – but no effect from acupuncture itself.

What about acupuncture for rheumatoid arthritis? A recent review of systematic reviews concluded:

In conclusion, penetrating or non-penetrating sham-controlled RCTs failed to show specific effects of acupuncture for pain control in patients with RA.

Same outcome – no specific effects from acupuncture.

A 2010 systematic review of acupuncture for osteoarthritis showed:

Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding. Waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects.

Different wording, but same meaning – there is no compelling evidence that acupuncture has effects beyond placebo. I would add again that comparing acupuncture to “wait list control” (which means no treatment, and of course this means unblinded) is worthless and misleading.

The report also considered fibromyalgia – so here is a recent review of acupuncture for fibromyalgia:

A small analgesic effect of acupuncture was present, which, however, was not clearly distinguishable from bias. Thus, acupuncture cannot be recommended for the management of FMS.

To summarize, published reviews of acupuncture for back pain, rheumatoid arthritis, osteoarthritis, and fibromyalgia all show that acupuncture is no better than placebo. Reviewers vary slightly as to wording , but they all add up to the same thing. There are small effects when comparing acupuncture to essentially no treatment, but specific effects of acupuncture cannot be separated from placebo effects. In other words – acupuncture does not work.

It is surprising, then, that the UK report concluded that acupuncture is useful for arthritis. I can only presume that they consider superiority over no treatment as justification for acupuncture – which is usually the case. This is profoundly unscientific, however. This same standard would never be applied to conventional treatments, not shrouded in the distortion field of  ”alternative” medicine. When a treatment only seems to work when it is looked at in an unblinded fashion, and proper blinding causes any effect to evaporate – that treatment does not work.

Posted in: Acupuncture

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76 thoughts on “Alternative Arthritis Treatments

  1. The Dave says:

    I think the reason Tai Chi and Yoga get lumped with SCAM is because there is a strong “Eastern Mysticism” element to them. When my wife was pregnant, she borrowed a prenatal yoga DVD and I could hardly watch it for that reason.

    Speaking of alternative treatments, has any one seen this website:
    http://www.naturalstandard.com/

    I discovered it was on my school’s list of academic resources (along with lexicomp, clinical pharmacology, etc) and was dismayed to see the worst grade it gave homeopathy was a C. I guess that’s the difference between EBM and SBM

  2. Janet says:

    We get this message repeatedly (no complaint) and yet this week I received a sample issue of a new magazine that purports to be very cutting edge and promises to make you the best-informed person at the party. In the “Health” section I found the following:

    “Acupuncture can ease your pain. New research (no link) shows that the ancient Chinese healing technique–which involves sticking needles into specific points in the body to encourage the flow of “qi”, or energy, through unseen pathways–often works better than over-the-counter remedies. About 50 percent of people who have migraines, arthritis, and chronic back or joint pain reported feeling significantly better after undergoing acupuncture, compared with 30 percent of people who tried traditional remedies. Doctors still don’t understand how acupuncture works, says Andrew Vickers of Memorial Sloan-Kettering Cancer Center, but they how have “firm evidence” that it’s an effective treatment for chronic pain.”

    It looks as though they covered just about every logical fallacy/trap you all have covered. I trashed the rag in the recycle bin–had to dig it out to post this. It’s called, “The Week”, The Best of the US and International Media. Hah!

    I was going to write them, but it seems useless. I think I’ll go ahead anyway if I can find where to write–nothing in the sample issue.

    What really bugs me is how many people read that and say, “oh, wow, it really does work! Those ‘ancient Chinese’ were onto something that these modern docs just don’t want us to know about so they can get rich, along with BigPharma, off of our misery”. There wasn’t even a pretense of rebuttal, let alone the slightest effort to document such extraordinary claims.

  3. mousethatroared says:

    Regarding Tai Chi and Yoga as “Alternative Medicine” I suppose one can make the argument that both are “alternative” depending upon how you define alternative, standard, science based, conventional ect. But, honestly, I just don’t care that much. :) What I need to know, as a consumer, is what forms of care are most likely to help, least likely to hurt and are most cost effective. Categorizing treatments as alternative or not undermines a broad comparison.

    Recently I was diagnosed with Undifferentiated Connective Tissue Disease, which is one of those nebulous rheumatological* conditions that can cause joint, tendon, muscle pain. Finding aerobic and strength training exercises that don’t seem to aggravate some of my more touchy joints and tendons is more difficult than before.

    I’d love a chart or study that covers the most popular (accessible) exercises with pros and cons for folks with UCTD or other rheumatological conditions. I haven’t really found that much useful online.

  4. rork says:

    “When compared to no treatment or usual care (which is necessarily an unblinded comparison) there is no difference in outcome. ” Most readers will overcome what I take to be an error in that, but a fix might help some people (and these posts might live a long time). Thanks, as always.

  5. WilliamLawrenceUtridge says:

    Like so many things in life, some excellent perspective on yoga can be found on King of the Hill, specifically season 8, episode 20Hank’s Back.

  6. rork – thanks, corrected.

  7. nybgrus says:

    Speaking of alternative treatments, has any one seen this website:
    http://www.naturalstandard.com/
    I discovered it was on my school’s list of academic resources (along with lexicomp, clinical pharmacology, etc) and was dismayed to see the worst grade it gave homeopathy was a C. I guess that’s the difference between EBM and SBM

    Indeed. It was advocated as a reference during my first year of medical school.

    During my second year I attended the repeat first year lecture live blogged commentary on what was going on.

    The completely lack of rigor in decided what is and isn’t evidence based becomes immediately evident. She (the lecturer) had a section on glucosamine and one for feverfew. The Cochrane reviews for each are equally negative. Natural Standard gave both an “A” ranking for evidence supporting their use. The lecturer said that based on this she recommended glucosamine for patients but not feverfew. No explanation as to how or why to make the distinction. After the lecture I and some classmates chatted with her for over an hour. No resolution to this at all. The final conclusion she could come up with when faced with us being rather knowledgeable on the topic was that she was just the messenger and said whatever the government/school authorities said to. She said that she was enlightened and recommended we strive to get to be in a position to make the changes necessary to have our rigorous views made the standard.

    I’ll also add that the way my school of medicine picked NaturalStandard as “the” definitive source for CAM evidence base is because they did their own lit review of (IIRC) ~10-15 “popular and common” CAM therapies and then chose the website/database that most agreed with their analysis based only on those popular and common therapies. No others, and no mention of how well it agreed.

    Lastly, I’ll add that the managing editor for NS is a naturopath and that they hand select all reviews rather than sytematically reviewing. ‘Nuff said.

  8. Robb says:

    “Lastly, I’ll add that the managing editor for NS is a naturopath and that they hand select all reviews rather than sytematically reviewing. ‘Nuff said.”

    This isn’t true at all – their editorial board has far more MDs than NDs as well as a number of pharmacists and PhDs. There are several dozen on their Senior Editorial Board. Personally I prefer Natural Medicines Comprehensive Database anyway though. I don’t have a subscription to NS anymore but I remember not liking the way they broke down the literature review as much as NMCD.

    For comparison, NMCD lists Feverfew as “Possibly Effective” for migraines while “Possibly ineffective” for RA. Homeopathy gets an “Insufficient Reliable Evidence to Rate” which seems incredibly generous, but perhaps better than a “C” over at NS. The explanation under “Insufficient…” goes into more detail and covers it quite honestly I think: “analyses of studies published in peer-reviewed journals that are indexed in MEDLINE generally show homeopathy to be ineffective”.

  9. Thanks Dave. I am always intrigued how non-evidence for acupuncture gets spun into “evidence for” acupuncture.

    https://sites.google.com/site/skepticalmedicine/pseudoscience-in-health-care/acupuncture#TOC-Is-There-Evidence-for-Acupuncture-

  10. Malvinia says:

    The tone of the writer in this case is a real archetype — a classic. The presupposition of the entire monologue — is “The western world – which is widely presumed to be scientific – can be the arbiter of truth in regards to medicine.

    Not only is this false, it is ludicrous. All of western medicine, the medicine of the University system of intellectual prostitution, has developed only two fundamental interventions to treat every kind of illness: Highly invasive or drug based. If one ever has experience with this horrible system of human experimentation puffed up by phony studies and a bloviated self image, you know, quite well how easy it is to categorize its barbarisms into either of the two categories that I have proposed: Highly invasive or drug based.

    If the aural “small print” provided in the drug company poisons isn’t enough for you, try getting really sick with a chronic illness. You will eventually pray for death. And furthermore, most people (who indeed are deeply retarded), cannot recognize that doctors are in no way scientists. Now if you were to say, “pimps for the system” you would be approaching truth. And if you were to define the whole of university research in medicine as pseudo-intellectual pimpery… you would be correct again. The “independent studies” touted by the author of this article are never so. There is no science at all. All of “science” is paid for by someone, and all of those someone’s are not scientists, they are capitalists looking to make money. They care not if you are destroyed as a byproduct of a chemical intervention in your health, just so long as they will not be blamed for it — thus the “side effects” will always be hidden from you, and your gradual deterioration and death due to those side effects will always be blamed on weaknesses in your genetics or your bad luck.

    And it is this cabal – this grand institution of liars – that is supposed to render the voice of truth regarding a system like Chinese Medicine, which is undoubtedly a large reason for the massive number of Asians on planet earth. But this kind of obvious observation is ignored in favor of the elitist nonsense proffered above in the glib pseudo-scientific pablum used as a screed against acupuncture?

    Meanwhile, any serious thinker can recognize the superiority of the general systemic platform that Chinese medicine emanates from. It is conceptually superior because takes a whole and complete view of the human body as a system. The western surgeon says, “I have a gall bladder at 7″ – and what he means by the statement (besides the denigrating dig at the human he has mentally reduced to a pile of flesh), is “Yeah, I’m goin’ in after the fact — after the damage is done… to rip out this bad organ.” And that’s the western way — wait until it is a deep problem, then treat it – even if the patient is never going to survive, and often the patient dies as a result of the treatment.

    Anyway, it is certainly your business whether or not to trust the whore. Many people rely on prostitutes for their happiness.

  11. ricw says:

    Most Tai chi chuan training includes Qi exercises. Just as yoga can involve prana exercises and meditation. In that context including it with “alternative” methods is understandable.

    I’m curious what Tai chi practice the participants in these studies did. Tai chi can includes set movement patterns, stretching, breath control, partnered sensitivity training, relaxation training, visualisation, conditioning…

    Particularly relevant to Arthritis treatment, in my view, is the focus on relaxing as much of your musculature (especially that supporting joints) as possible during movement, while maintaining an upright and supported structure. This is a non-intuitive way to move, but should result in fluid movement with relaxed
    open joints.

    So with all of these available methods under the one banner, which of them were used in each trial… and was the control ever sham tai chi?

    As a tai chi practitioner myself I’m fascinated by what part of the practice may be beneficial to arthritis sufferers.

  12. gears says:

    Oh dear.

    I don’t even know where to start. It is true that doctors are not scientists. I think just about everything else is wrong, though. I am impressed that you managed to include all the tropes and logical fallacies I’ve seen discussed on this blog. I suppose we can tackle that tomorrow.

    It’s also not very nice to bandy about phrases like “deeply retarded” in such a derogatory fashion.

  13. BillyJoe says:

    gears,

    Well, we could kill him with science based medicine information overload or just let him die a natural death.
    I vote we let him die a natural death, especially as that is what he seems to be aiming for anyway.
    Besides it sounds like a hit and run type of post.

  14. Badly Shaved Monkey says:

    From the BBC story;

    Terry Cullen of the British Complementary Medicine Association said: “I am not disappointed or surprised that a number of therapies did not indicate any apparent benefit – there are no treatment panaceas in any form of medicine.”

    Well, Terry, panaceas would be lovely, but in the meantime some minimal efficacy would be nice, yet you seem to be neither disappointed nor surprised by SCAM’s lack of these while, I suspect, you continue to sell them.

    I think Mr Cullen displays the SCAMster approach to evidence in a nutshell.

  15. DugganSC says:

    @ricw:

    ^_^ I’m highly amused at the idea of trying to introduce “sham tai chi”. Perhaps we could bring over some folks from the Oom Yung Doe school? (This is a mildly playful jibe at a franchise martial arts group formerly known under a variety of names including Moo Duk Kwan whose quality varies sharply. I took a class during a “Free Tai Chi Day” here in Pittsburgh and what they taught resembled something someone might make up after watching an episode of Kung Fu and trying to emulate the movements) If our goal is to provide something that looks like Tai Chi, but isn’t done properly, I suspect that we’d find either less effect than normal exercise (some of the Tai Chi classes I’ve seen that do little more than breathing and overly slow movement with no impact) or a worsening of the joint issues (movements which put strain on the joints due to awkward positioning which “look exotic” but aren’t stable).

  16. Doctors are not scientists per se (they are practitioners), but some doctors are scientists (MD PhD’s, or academic MDs who do clinical research). Further it is the doctors who are scientists who generally set the standard of care, do the research, etc. So the point is really moot.

    It is also interesting to point out that I did not discuss any drugs nor tout any pharmaceutical research in my article. I discussed research into acupuncture, among other topics – research mostly funded by government grants, and performed by acupuncturists. Even still – the data is negative and shows that acupuncture does not work.

    The boiler-plate ranting criticism above is therefore not even relevant to this post.

  17. petarjons says:

    The completely lack of rigor in decided what is and isn’t evidence based becomes immediately evident. She (the lecturer) had a section on glucosamine and one for feverfew.I discussed research into acupuncture, among other topics – research mostly funded by government grants, and performed by acupuncturists. Even still – the data is negative and shows that acupuncture does not work.
    http://www.ocdermatology.com/orange-county-botox/

  18. Janet says:

    @Mouse

    I’d ask the doctor what exercise is best for your condition–which I think would have come up at the time of diagnosis?. I would guess there is some physical therapy available that the doc could prescribe. If stretching is the treatment, then I suppose yoga or tai chi would fit the bill, but as I tell all my yoga devotee friends, I can stretch without the mumbo jumbo and “aura” that goes with these practices–to say nothing of the way that hyped up claims have come to be associated with them.

  19. mousethatroared says:

    @Janet – Yeah, I was seeing the doctors alot this summer/fall. I’m kinda “sick” of it, so I’m possibly procrastinating going back. The tentative diagnoses was made on the basis of other symptoms (fatigue, shortness off breath…I won’t list everything) plus blood tests. Those symptoms have improved quite a bit with the medication prescribed.

    The joint/tendon stuff is a more recent development and honestly I just keep thinking it’s going to settle down any day now…but I do need to stay active in the mean time. When I do art fairs or workshops it’s very physically demanding, lugging equipment and boxes around. Inactivity in between is just asking for back problems and muscle spasms. I just hate to bug the Rhuematologist, because it’s all so minor compared to the folks with RA and Lupus, I think he’ll think I’m fussing over nothing.

    I’m rather fond of a few dvd or youtube yoga workouts, although I tend toward programs that leave out all the spiritual stuff. It’s nice to have a program to follow along with and they often have a good mix of upper body, lower body stretching/strengthing moves. It’s mentally challenging enough to not be excruciatingly boring, like many exercise programs. But some of the major moves seem to stress the shoulders/wrists, which is a problem for me right now.

    I just keep thinking there’s a fabulous workout program out there that is guaranteed to raise your heart rate, be easy on your joints, tendon, muscles and be mentally engaging enough to not dread doing…preferably narrated by David Tennant or Daniel Craig with a customized soundtrack to fit your mood. Is that too much to ask? :)

  20. pmoran says:

    The following study may have influenced Arthritis Research UK to include acupuncture. Loss of blinding remains the most likely explanation for the persistent small differences between sham and real acupuncture, I suppose. Any other suggestions?

    Look also at the solid effect sizes shown for sham over “usual care”.

    http://archinte.jamanetwork.com/article.aspx?articleid=1357513

    In Steven’s post Tai chi, Yoga, massage, and relaxation are accepted because of weakly plausible modes of action, but not acupuncture-based programs, which offer several: — regular spells of relaxation and meditation, likely counterritant and distractant effects in some, as well as a framework for extended psycho-medico-social interaction.

    A little thought reveals that the RCTs put forward as showing “acupuncture doesn’t work” test certain imputed mechanisms of action. They do not test the effectiveness of acupuncture as a constellation of potentially beneficial therapeutic influences. These may come largely (we cannot quite say totally) under the heading of “placebo and non-specific influences”, but probably not to a decisively greater degree than applies to Tai chi or Yoga, or even massage, when these are put forward as medicine. .

    Given the effect-sizes commonly shown for sham acupuncture, I would be surprised if it didn’t outperform these “approved” modalities , as well as being easier than most to apply as a medical treatment — the patients require no cultural priming and no special training.

    Other matters –

    A waiting list control is not “doing nothing” –it mostly means “regular medical care “. This is the whole point to even thinking about acupuncture — could it help patients further with these troublesome conditions?

    The statement “it doesn’t work” needs clarification. We are NOT in a secure enough scientific position to be able to say that patients derive no benefit from treatment programs based upon variants of acupuncture .

    I go along with not fully endorsing acupuncture for mainstream use while we lack solid evidence as to its cost/risk/effectiveness under the conditions that might apply within various likely mainstream settings. I merely don’t think we have a case which justifies wanting to poison this well for everyone, everywhere.

    Mark Crislip has gone a further step beyond what the available science permits, with this — .They do not mention that all of the above have no basis in reality and none have benefit for any objective findings and barely have any effect for the subjective endpoint of pain and that the entire subjective effect of acupuncture can be accounted entirely by bias on the part of the patient and the practitioner.

    It is true that it is difficult to distinguish subjective benefits from reporting bias, but there are very sound reasons for expecting at least some of the benefits reported to be “real”.

  21. nybgrus says:

    In Steven’s post Tai chi, Yoga, massage, and relaxation are accepted because of weakly plausible modes of action,

    No, they are accepted as forms of exercise and de-stressing (relaxation) which are quite science based. When you add in the mysticism of chakras and meridians, it becomes woo.

    but not acupuncture-based programs, which offer several: — regular spells of relaxation and meditation, likely counterritant and distractant effects in some, as well as a framework for extended psycho-medico-social interaction.

    Don’t be ridiculous. The counterirrtant effects have been shown to be absolutely implausible and if you continue to try and cling to that you show extreme bias yourself. Every single model of counterirritant has been tested and the best they could get is the tiniest molecular response when coupled with a piezo vibrator at 50Hz. To try and claim that a needle so thin it can barely be felt going through the skin can produce a counterirritant effect at all, let alone one that is remotely clinically significant is absurd and shows your bias.

    There are myriad other ways to get someone to relax and meditate without sticking them full of needles. If that is the best you can come up with, I can’t imagine what other ridiculous ideas you would have for getting patients to do things. Besides, the claim is not that making people afraid to move because they have a bunch of needles stuck in them helps them relax. If you want to make that claim, fine. Test it. If it works, see how many people are willing to sign up for your therapy. At best you are violating informed consent if that is your rationale.

    Distractant effects are also patently absurd. Once again, how does a needle which you can’t even feel distracting you from anything?

    And if you need to jab needles into your patients to get an “extended psycho-medical-social interaction” with your patients then you need to work on your communication skills, not your needle jabbing skills.

    They do not test the effectiveness of acupuncture as a constellation of potentially beneficial therapeutic influences.

    So after literally thousands of studies testing all the various supposed MOA’s of acupuncture showing nothing, we are left with a “constellation” of potentially beneficial influences? Some other magic ones we haven’t tested yet? I’m always amazed at how thin a straw you are willing to grasp at for acupuncture.

    These may come largely (we cannot quite say totally) under the heading of “placebo and non-specific influences”, but probably not to a decisively greater degree than applies to Tai chi or Yoga, or even massage, when these are put forward as medicine. .

    You can write this with a straight face?? Laying still with needles in your body that you can’t feel is not more likely to induce placebo or “non-specific influences” than Tai chi or Yoga? Have ever even experienced any of these things? Have you ever stretched before a run? There’s your Tai chi. Have you ever actually done yoga? It is actually quite strenuous exercise. You think they have no more actual specific MOA’s than laying still with needles you can’t feel in your body? That is absolutely ludicrous.

    Mark Crislip has gone a further step beyond what the available science permits, with this — .They do not mention that all of the above have no basis in reality and none have benefit for any objective findings and barely have any effect for the subjective endpoint of pain and that the entire subjective effect of acupuncture can be accounted entirely by bias on the part of the patient and the practitioner.

    Actually that is a pretty darned accurate statement. Unless you would like to show me a study which demonstrates rigorously an improvement in an objective endpoint. And I suppose you disagree with the meta-analyses and the conclusion of the journal Pain that the subjective benefit to pain is small if any at all.

    Of course it also seems that you can’t fathom a difference between acupuncture, yoga, and tai chi since they are all, after all, “non-Western alternative medicines” so they must all be the same, right? Jeez. Yoga is one of the most physically strenuous exercises I do, and I have run half-marathons and cycled 100 miles in a go. Tai chi is active stretching exercises which actually can and do produce neural feedbacks through spindle fiber efferents. Acupuncture needles don’t do diddly. Resting and relaxation is undoubtedly a good – and science based thing – but you shouldn’t resort to stabbing your patients to get them to do it.

    but there are very sound reasons for expecting at least some of the benefits reported to be “real”.

    Nobody here says they aren’t “real.” Placebo responses are “real.” They are just small, ephemeral, and unethical to use as intended monotherapy. And it seems that even the “real” placebo responses are pretty small when it comes to acupuncture.

    You always manage to surprise me with how desperately you want to cling to acupuncture for some reason.

  22. pmoran says:

    You always manage to surprise me with how desperately you want to cling to acupuncture for some reason.

    It’s a grey area that almost certainly does help some people with difficult conditions. That should be enough for anyone to think very carefully about what we say to the public about it, even if we choose not to use it ourselves.

    Nobody here says they aren’t “real.”

    Mark just did precisely that.

    I have counters to everything else that you say, Nybgrus, but life’s too short to go through point by point material that mostly and very carelessly quite unresponsive to what I am actually saying. Get rid of the bombast, focus on precisely the point I am making, sober up, or whatever, and get back to me.

    Placebo responses are “real.” They are just small, ephemeral, and unethical to use as intended monotherapy. And it seems that even the “real” placebo responses are pretty small when it comes to acupuncture.

  23. pmoran says:

    Placebo responses are “real.” They are just small, ephemeral, and unethical to use as intended monotherapy. And it seems that even the “real” placebo responses are pretty small when it comes to acupuncture.

    Sorry, this last sentence was Nybrus’s, echoing how he inteprets the SBM party line, and all of which is challengable with current scientific evidence.

    If he was familiar with recent placebo research he would say something different. Also, who is suggesting using placebos as “intended monotherapy”?. Those difficult-to-ignore effect sizes from acupuncture programs can be achieved when added on to standard medical care. As I have said, this is the whole point.

  24. nybgrus says:

    I’m sure you do pmoran. But none of them are based in reality or science. And they all necessarily cling to the tiniest gray area you can. Go on living in the gray area. If you think that is enough, then we will continue to fundamentally disagree. We are past the age of witch doctors and magical nostrums where the best we could do is gray area.

    And isn’t one of the age-old and best adages of medicine “Do to your patients what you would do to yourself, your grandma, or your brother”? So how can we now be content to say “You go ahead and do that, even though I wouldn’t because I know better.” Seems like giving our patients short shrift.

  25. Quill says:

    Monotherapy. There’s a word that seems to be losing its meaning. Properly, as I understand the term, it means treating a condition with a single drug. But in current use it seems to mean treating a condition with one form of medicine, regular or sCAM. But given the research on placebo effects, is there any such thing as a mono-therapy? Doesn’t simply visiting the practitioner’s office create measurable effects, along with whatever treatment is given?

  26. pmoran says:

    So how can we now be content to say “You go ahead and do that, even though I wouldn’t because I know better.” Seems like giving our patients short shrift.

    We can still speak the truth. To say baldly and authoritatively “it doesn’t work” is true about many treatments in a highly specific, technical sense that conveys meaning for mainstream medical science, but it is less meaningful in the messy, complicated, even counterintuitive world of practical subjective medicine, where the human psyche is an unpredictable wild card.

    Again, “unmet medical needs” comes into it. Once we in the mainstream have done the best we can it is the height of dog-in-the-mangerism to be trying too hard to deny even small benefits to our patients from other sources. Acupuncture merely stands out as providing the most substantial levels of reported benefits, as one might expect from such an elaborate combination of influences.

  27. nybgrus says:

    Quill:

    You are right that my usage is not technically precise. I mean it as providing a treatment that is nothing but placebo.

    pmoran:

    Care to point me to the latest in placebo research that would change my mind? I thought I was pretty up to date. If you are referring to the Benedetti research and others like it which demonstrate molecular level effects through conditioning, I don’t see how that applies. Their methodology does not translate to the placebo responses of CAM therapy and Benedetti explicitly says so. Once we have a way in which to actually do what Benedetti does in the lab in our patients, we can talk further about it.

    And there are no difficult to ignore effect sizes from acupuncture. That’s kind of what this post was about. And why every robust analysis shows the effect size is clinically insignificant, if it even exists.

    And there is no reason to believe why acupucnture as a placebo-on-top of standard therapy is any better than merely talking to your patients for a bit longer. And safer than sticking needles in them.

    And by your standards of when we can and cannot say “something doesn’t work” there is just about nothing we can say doesn’t work. Scrabbling for the tiniest of effect sizes may seem reasonable, except there is good reason to believe and evidence to back it up that this is actually an overal disservice to patients. Ernst has written about this a number of times.

  28. pmoran says:

    Care to point me to the latest in placebo research that would change my mind? I thought I was pretty up to date. If you are referring to the Benedetti research and others like it which demonstrate molecular level effects through conditioning, I don’t see how that applies. Their methodology does not translate to the placebo responses of CAM therapy and Benedetti explicitly says so. Once we have a way in which to actually do what Benedetti does in the lab in our patients, we can talk further about it.

    The most relevant Benedetti research has to be the finding that placebo influences can reduce morphine requirements in severe pain, just as the original observations of Beecher and others suggested. This is described in one of the links you yourself posted here.

    And there are no difficult to ignore effect sizes from acupuncture. That’s kind of what this post was about. And why every robust analysis shows the effect size is clinically insignificant, if it even exists.

    I have been careful to refer to “acupuncture-based programs”. It so happens that the studies you have in mind are really only testing out certain aspects of certain theories of acupuncture, not the overall effect that such a collective of influences can exert. This last is all that most potential users will care about and this is where effect sizes are regularly found that can accommodate a useful proportion of genuine symptom relief..

    And by your standards of when we can and cannot say “something doesn’t work” there is just about nothing we can say doesn’t work.

    Well, it is true that just about anything would elicit a placebo response if offered confidently as a medical treatment.

    It is useful for the public to know that, for example when assessing CAM testimonials!!! It is also by no means a foreign idea to them that people can think themselves into feeling better. Let’s build upon what they already know!

    One of the threads of thought feeding into my present reconsideration of skeptical dogma is that the public will probably trust us better if we respect and trust them better. We tend to judge them through the lens of our own confirmation biases — our interest in “healthfraud” matters confronts us constantly with the extremes of quackery, fraud and human ignorance. Yet most people are far more sensible, and most of those that use CAM do so with considerable discrimination.

    The extremes will still distress us, and perhaps unduly influence our reactions to CAM, but they are the most difficult to do anything about. It is with them that legislation may sometimes be helpful.

  29. nybgrus says:

    The most relevant Benedetti research has to be the finding that placebo influences can reduce morphine requirements in severe pain, just as the original observations of Beecher and others suggested. This is described in one of the links you yourself posted here.

    Yet we are in a position where we cannot ethically do what Benedetti does outside of a clinical trial.

    And I’ve already stated (and so has Dr. Hall on a complete post) that if we as clinicians recognize these effects, we can build them into administration of actual medicine. No need for magic hocus locus. I do this with my own patients. I make the ritual of the administration more transparent, talk up the effects (within the limits of science of course) to increase expectancy effects, and assure them there are other avenues should this one fail but we expect it to work in most people. That does a pretty darned good job. I don’t need to jab them with needles and chant incantations.

    I have been careful to refer to “acupuncture-based programs”

    But if you take away everything from the “program” that is acupuncture, you are left with doing exactly what I described above. There is no unique benefit to the “program” as you call it that cannot be conferred in the context of actual medicine.

    One of the threads of thought feeding into my present reconsideration of skeptical dogma is that the public will probably trust us better if we respect and trust them better.

    I fully agree here. And also find your silence on the threads where I posted about patient-physician partnerships and the CFS comment thread quite conspicuous.

    Yet most people are far more sensible, and most of those that use CAM do so with considerable discrimination.

    Also agreed. The problem we face is two-fold though. 1) The CAM promoters (Bravewell, etc) have taken the language and essentially tied our hands and made it very difficult to not come down firmly somewhere closer to my position than yours (note, I am careful not to say exactly my position – I want to avoid the implication of hubris here). and 2) the infiltration of quackademic medicine into the teaching of medical students. This undermines signficantly everything modern medicine has achieved and strives for. I know you don’t seem to think it that big a deal. It isn’t yet but it is getting there. Better to nip it in the bud, as it were.

  30. pmoran says:

    PJM “The most relevant Benedetti research has to be the finding that placebo influences can reduce morphine requirements in severe pain, just as the original observations of Beecher and others suggested. This is described in one of the links you yourself posted here.”

    Nybgrus: Yet we are in a position where we cannot ethically do what Benedetti does outside of a clinical trial.

    We are discussing what symptomatic benefits patients might derive in practice from complex, mainly placebo modalities such as the many variants of acupuncture. This is a legitimate free-standing question for medical science, but also of importance to how we choose to “inform” the public.

    Mark Crislip and Steve Novella claimed here, with your support, that any benefits must be trivial or non-existent. In that case there would be no need to even consider reproducing them within mainstream medicine, as you claim to be able to do.

    I ask, is it correct to be saying that?

    (Incidentally, assuring your patients of “other avenues should this one fail” will quickly become a lie, if you are referring to strictly evidence-based methods for chronic pain. This is another area where the very limitations of mainstream methods encourages the use of “irregular” methods. )

  31. weing says:

    “This is another area where the very limitations of mainstream methods encourages the use of “irregular” methods.”
    I don’t understand this. You are referring to chronic pain here. Are you saying that mumbo-jumbo helps in chronic pain?

  32. nybgrus says:

    Mark Crislip and Steve Novella claimed here, with your support, that any benefits must be trivial or non-existent. In that case there would be no need to even consider reproducing them within mainstream medicine, as you claim to be able to do.

    I ask, is it correct to be saying that?

    Yes, I believe it is. And Benedetti’s research does not apply in the context of this question. You are conflating the two concepts and research results.

    The real benefits in pain reduction from placebo are indeed trivial and ephemeral. The more robust placebo responses Benedetti demonstrates are fundamentally different than what we would expect to see from “acupuncture programs.” At a minimum, you have absolutely no scientific basis for saying any differently and plenty to be quite skeptical.

    In other words what I am saying is that the benefits of “acupuncture programs” are not worth reproducing in clinical medicine and that the results of Benedetti’s research does not apply to “acupuncture programs.” I do think there may be a time when we could take what Benedetti does and apply it ethically in a clinical setting, but “acupuncture programs” do not replicate what Benedetti does.

    And if an attending professor of neurology at Yale agrees with this, who am I to disagree? That’s not an argument of authority, it is merely saying that to the best of my knowledge this is the case and Dr. Novella seems to agree and he knows a whole heck of a lot more than I do, specifically in relevant medical sciences.

    (Incidentally, assuring your patients of “other avenues should this one fail” will quickly become a lie, if you are referring to strictly evidence-based methods for chronic pain. This is another area where the very limitations of mainstream methods encourages the use of “irregular” methods. )

    You seem to be focusing on a rather narrow subset of the patient population. There are numerous science based avenues to pursue before reaching that point. Including standard of care with a heightened and intensified patient-practitioner interaction and specific attention to heightening expectancy effects. All within the limits of science and ethics. But even when all of that fails, acupuncture is not only unethical to provide, but meta analyses of the subjective pain benefits still don’t support its use. Not just specific and narrow aspects of the MOA of acupuncture, but the whole of it in terms of relieving pain. Good evidence shows us it simply doesn’t. At best you can just keep the patient chasing a solution without resolution while wasting their time and money.

    And you keep trying to convince me there is “something” beyond pure placebo (or ritual or non-specific effects) that acupuncture offers. There is simply no evidence for this nor any rational basis for assuming it to be the case.

  33. pmoran says:

    “This is another area where the very limitations of mainstream methods encourages the use of “irregular” methods.”
    I don’t understand this. You are referring to chronic pain here. Are you saying that mumbo-jumbo helps in chronic pain?

    No, this was mainly a reference back to the recent discussion of “why patients use CAM”?

    Though I suppose patients who are accepting of the “mumbo-jumbo” are more likely to have a placebo response to methods based upon it.

    That is, if you believe in placebo responses, which I find it very difficult not to do, despite the fact that their absence would greatly simplify thinking about CAM and some other aspects of medicine.

  34. pmoran says:

    You seem to be focusing on a rather narrow subset of the patient population. There are numerous science based avenues to pursue before reaching that point. Including standard of care with a heightened and intensified patient-practitioner interaction and specific attention to heightening expectancy effects

    Oh, for Pete’s sake –! I cannot discuss placebo-related matters with someone who does not realise that “expectancy effects” are one variety of placebo response, and who, apart from in the above, also regards them as of trivial usefulness and unethical to boot.

    Get your thoughts in better order before you respond. Ideally, if you don’t have time to do some reading up on all the other material on placebo, that you seem at present to be unaware of. (much of it discussed here by Harriet, IIRC), leave the subject alone altogether for now.

  35. Quill says:

    Would it be fair to say that one of the principal difficulties in studying what are termed placebo responses is that it is difficult to control for variables? By that I mean it’s hard to measure only one or two things without running into correlation problems.

    For instance, what pmoran noted as expectancy effects. If one expects something to happen, then that can alter the result. But does that mean it’s a mental process or perhaps something else? For instance, as part of my arthritis treatment I might expect cortisone injections into my thumb joints to be extremely painful. Knowing this I decide to get as relaxed as possible before the procedure and have a body massage. When the procedure happens it is painful but not as bad as I expected. Did I mentally alter my response to the pain, or did the massage simply relax me so I wasn’t tensed up and more receptive to pain, or was it all that and something else? Or (hee!) did one of the needles hit a meridian and my qi was diverted around the pain?

  36. Sialis says:

    The following study may have influenced Arthritis Research UK to include acupuncture. Loss of blinding remains the most likely explanation for the persistent small differences between sham and real acupuncture, I suppose. Any other suggestions?

    I’m out of my league commenting here, but speaking as a patient, I agree with nybgrus. I believe I understand both of your points of view, pmoran and nybgrus. I’ve experienced what each of you have described. I regret doing exactly what nybgrus describes as “chasing a solution without resolution while wasting their time and money.”

    Perhaps for minor complaints of pain, the placebo effect as pmoran describes would indeed be effective, but I doubt this discussion is focused on minor, temporary complaints of pain. Chronic pain needs more than a placebo. Eventually the placebo effect will wear off, even if the provider does push the benefits with “expectancy effects”. When that happens, the patient is left wondering what changed, and what went wrong. In those instances, the patient knows that they had some initial benefit, but the benefit changed. In trying to regain that benefit, without the understanding that it was indeed merely a placebo effect, they are likely to keep trying the treatment just for the hope. This is especially true if the physician continues to push the expectancy effect of the placebo.

    In the long run, such treatment is a waste of the patient’s money and time, and in a way it is toying with their emotions. It’s also dangerous in some cases since undoubtedly these placebos require traveling to and from the treatment facility. Such travel may not be in the best interest of the patient, especially if they are also taking medications for the pain, which might impair them to some degree or if they have significant mobility issues. If they are employed, they may be taking time off from work, all for a placebo. That’s not right for a physician to encourage a patient to take off from work for a mere placebo.

    It is a tough decision, but as a patient I would prefer the straight answers. I don’t want any sugar pills, and I most certainly don’t want to be spending a few hundred dollars a month for a placebo. Money that I don’t have. Acupuncture is expensive. L.Ac’s generally require one or two appointments a week. Ethically speaking, how much money should a physician encourage a patient to spend on a placebo? Do you plan to take into consideration the household income and expenses of your patient when advising them on the best placebo? Is it ethical to advise a low-income patient, for example, that a $100 per week acupuncture treatment would help their pain when you know it is merely a placebo?

    Down the road, if the patient ever figures out that their physician had them wasting money on an expensive placebo when a much less expensive one would have sufficed, you may lose the trust of your patient. It’s like sending someone on a wild goose chase. Frankly, I feel jerked around from such treatment, not to mention exploited as a fool. A fool and their money are soon parted, as the saying goes. That’s the truth. I don’t like it when my physician chooses not to fully inform me about something, and instead lets me run around town foolishly seeking placebos. How is that any different as compared to selling your patients expensive salt water and telling them it will cure their illness or resolve their chronic pain? I suggest that it is not any different. Dr. Hall recently wrote an article here on ASEA, salt water, an expensive placebo at best.

    Patients need pain relief. They need something. Nothing, no treatment at all is not acceptable. What I would like to see is greater availability of more practical proven methods like the exercise programs mentioned above (for example Tai Chi, or yoga, or similar low impact exercises). Some patients need the on-going guidance available in a custom, guided instruction class in order to stick with such programs, especially if they are in pain and have special needs. They also need accommodations in their exercise routines. Most of these things are are not currently available or affordable on a continuing basis to many patients. Physical therapy is not tailored to address this type of continuing need for instruction and exercise routine modifications.

    Massage therapy has been discussed here as being a temporary solution to pain. I am strong proponent for massage therapy as long as it is done by highly skilled, trained providers. I find it a much safer and healthy alternative as compared to taking prescription pain medications long-term. The only drawback is that massage may not be advisable for all types of conditions. People with neuromuscular diseases, fibromyalgia or myofascial pain syndromes would likely benefit, in my opinion. The massage would hopefully provide them with enough temporary relief so as to allow them to participate in other life activities, thus improving their overall quality of life. Like with any chronic pain management plan, the massage therapy would have to continue indefinitely as part of their disease management program.

  37. Sialis says:

    The first paragraph in the above comment was meant to be a quote in italics.

  38. nybgrus says:

    Though I suppose patients who are accepting of the “mumbo-jumbo” are more likely to have a placebo response to methods based upon it.

    The evidence demonstrates to us that those patients are more likely to pretent the pain is decreased and is thus a facet of reporting bias, rather than a true decrease in levels of pain experienced. This is indeed hard to differentiate from actual pain relief since, as we know, pain is modulated by higher order neural processes. However enough studies have demonstrated that the higher order modulation is difficult to sustain and certainly does not completely relieve pain (which is likely why it is hard to sustain the reductions in the face of ongoing pain).

    You need to get your thoughts straight here pmoran. The placebo response includes exactly this scenario – reporting bias and error based. These are absolutely not what you want to be giving your patients. It is akin to telling your patient to just shut up and not talk about their pain. The true placebo effects as demonstrated by Benedetti are fundamentally different. And, as I said, there is no evidence “acupuncture programs” induce these real effects and plenty to be skeptical that they would.

    Oh, for Pete’s sake –! I cannot discuss placebo-related matters with someone who does not realise that “expectancy effects” are one variety of placebo response, and who, apart from in the above, also regards them as of trivial usefulness and unethical to boot.

    Hey, I can’t have a conversation with someone who conflates placebo responses with placebo effects in what is supposed to be a nuanced and scientifically erudite conversation either. But you don’t see me telling you to bugger off. Besides, if I’ve been wrong, it sure seems I am in good company here with the authorship. Unless you wish to call into question their scientific acumen and medical knowledge as well.

    But for the record, I absolutely do realize that expectancy effects are part of the placebo response. Which is why I continually and consistently say they are unethical to provide in isolation from actual medical therapy. But when used within reason in the context of actual medical treatment, they can – and should – be used to heighten the actual effect. As sialis pointed out, persistent pain makes it clear to a patient that whatever they have been doing isn’t “working” once the placebo responses and effects have worn off. If a patient expects complete pain relief and it doesn’t come, even after a while, then whatever it was wasn’t “working.” If they expect reductions, but not complete resolution, and we explain why and how we might be able to strive for better reductions and combine that with coping skills education for the remainder, then we have better outcomes and less incentive to go chasing every woo du jour trying to grab the unicorn’s tail of placebo.

    If you actually understood Benedetti’s research you would note that in every case of a demonstrated objective effect by placebo it is always the result of classical conditioning by actual medical interventions. He has not (and to my knowledge nobody has – but please, link me the article) demonstrated the same objective placebo effects using nothing but placebo from the get-go. All we get from those are placebo responses, which are absolutely trivial, ephemeral, and on top of that unethical. That is why I say that the research you wish gave you grounds for advocation of acupuncture “programs” doesn’t. And in fact, turfing your patient to an acupuncturist or other sCAM artist could only serve to further that mistrust you yourself talk about. I advocate for caring and responsible patient partnership which will go a lot further than trying to trick them with placebo responses.

    Get your thoughts in better order before you respond. Ideally, if you don’t have time to do some reading up on all the other material on placebo, that you seem at present to be unaware of. (much of it discussed here by Harriet, IIRC), leave the subject alone altogether for now.

    So no thanks, I have my thoughts pretty well in order and for all the bluster you have been giving me you can’t seem to produce one single article or study I haven’t already read to support your case. Just rants about how I need to get my thoughts in order, leave the conversation, and a pretty nasty rant of ad hom at me a while ago, as I recall (one which Dr. Hall called you out on). So perhaps you should get your thoughts straight on the differences between placebo effects and responses in order to have a more nuanced conversation. I won’t ask you to leave the conversation until you do though. And I’ll even refrain from the closing jab I had already written but erased.

  39. mousethatroared says:

    @Sialis – What a great set of observations and recommendations. Bravo!

  40. Janet says:

    @Mouse

    I don’t think you should ever feel that your needs are not as important as people who are more seriously affected. Your questions could be answered by other medical staff in some cases or by a short chat or visit with the doc if he/she requests it. Still, it is certainly up to you and very considerate of you as well, so I hope you find something suitable on your own. I’m still looking for a massage therapist who doesn’t claim to be a “healer” and ask me for my “treatment goals”!

    I love your idea of the ideal exercise video! I settle for walking the wiener dog most days, though. :-) A serious lack of snow is ruining my winter x-country skiing (which is my usual winter exercise) although I only got a couple of days in before the melt started.

  41. mousethatroared says:

    @Janet – Thanks for the suggestion. I will keep them in mind.

    I had a good massage therapist – mostly she just asked my problem areas, then focused on those. She did recommend drinking lots of water to “flush out toxins” but I’m often not so great on my hydration, so I don’t mind the reminder. She worked out of the spa side of my salon. But I will say that service providers don’t generally open up with me and immediately start telling me their spiritual philosophies. Maybe it’s because I’m kinda quiet and don’t ask a lot of question or maybe I have a skeptical face.

    I’ve always thought the key to getting a good basic deep tissue massage was to avoid the “wellness” and “healing” type places that offer massage and go for the salon spas and health clubs. But I haven’t really tested that theory.

    The website “massagetherapy” with a www and .com beginning and end, allows you to search for massage therapists locally. They also list all the modalities the MT specializes in, so you could avoid the folks selling Reiki and Craniosacral therapy if you like. I’m never sure how true to life those web listings are, though. Maybe go the groupon route, so at least you’re not overpaying for an unwanted dose of mumbo jumbo.

    Walking the dog is something I do a lot…since we have a rampaging mini terrier of a dog whose joy at being taken outside is very infectious, as is his mournfulness at being pent up inside.

  42. pmoran says:

    Yes, Sialis, there are a number of reasons why the medical profession cannot endorse the use of placebo medicines or CAM.

    The strongest reason derives from the duty of our profession to advise third party payers what kinds of medicine are worth paying for. A line has to be drawn somewhere and working better than placebo is as good as any.

    That does not necessarily mean we are applying an abrupt cut-off point for all medical usefulness. Almost any modality may help some people under the right conditions nby eliciting placebo responses, or by helping with the other human needs that patients bring into medical interactions.

    It is extraordinarily difficult for many skeptical minds to acknowledge that, but it is almost certainly true. It is the only way to make complete sense out of all the information we have, ranging from cultural aspects of medicine, through anecdote, clinical studies, placebo research, psychological research, plausibility, evolutionary probabilities etc etc .

    Not only does the tendency to trivialise such influences conflict with too much science, it is an instant and powerful alienating influence, making communication with a public that is itself quite knowing in these matters more difficult than it needs to be.

  43. Sialis says:

    Yes, Sialis, there are a number of reasons why the medical profession cannot endorse the use of placebo medicines or CAM.

    The strongest reason derives from the duty of our profession to advise third party payers what kinds of medicine are worth paying for.

    @pmoran: I disagree with your reasoning as it is explained, but maybe I misunderstood. Also, it seems you are assuming that any given patient even has a third party payer, which clearly may not be the case.

    The strongest reason why my physicians should not endorse the use of placebos with me is that they will likely have to lie to me or distort and hide the truth in order to accomplish the endorsement, and they will be promoting something to me that they know has no real, long-term tangible benefits or efficacy. A sure way to get me angry, and lose my business, as well as my trust is to lie to me. It’s as simple as that.

    That does not necessarily mean we are applying an abrupt cut-off point for all medical usefulness. Almost any modality may help some people under the right conditions nby eliciting placebo responses

    Who gets to decide how much money a given patient should spend on a placebo, and which placebo will be used? The treating physician? So, the physician gets to decide which placebo to promote as well? Basically, a placebo is only as good as it is promoted, and as naive as the patient. To recap, a naive, needy patient and a good placebo promo, make for a great placebo treatment. You’re losing me here. Do you sell homeopathy as a placebo? What if you misdiagnosed your patient, yet they think they are receiving appropriate care because they don’t know that they are getting a placebo. What if their referring doctor misdiagnosed them, overlooking a serious condition, and now you are treating that with a placebo? Are you so sure of your skills that you will never make a mistake?

    Are you of the opinion that acupuncture is a placebo?

    It is extraordinarily difficult for many skeptical minds to acknowledge that, but it is almost certainly true.

    I don’t see where any of the “skeptical minds” here are not acknowledging that. On the contrary, they seem to understand it quite clearly, the issue is that they find it unethical and not in the continuing best interest of their patients. As do I.

  44. nybgrus says:

    Sorry to butt into your convo Janet and mouse:

    Maybe go the groupon route, so at least you’re not overpaying for an unwanted dose of mumbo jumbo.

    A friend of mine gave me a fabulous tip. Use the groupon or whatever to find the therapist and the deal, then call them and offer to pay the groupon rate as cash. You will (almost) always get a better shake.

    The way groupon (specifically) works is they only pay the person/entity after a certain number of groupons are redeemed, keeping the cash until then and forever if they don’t redeem enough. Thus, in some cases, if the groupon offerer has no hope of redeeming enough then any service provided will be free to them and group on takes the money and runs.

    In any event, each of them take a cut so the therapist is making less than the groupon rate. As such, they often limit the availabilities of appointments for groupons, so you will have an easier time scheduling it.

    So yeah, just call them up and offer the same rate as the groupon – they have every incentive to take it.

    That’s how I found the masseuse I will be sticking with after about 6 or 7. She is a former RN and only every so slightly woo-ey. And offers students a deal for 5×1 hour massages for $200 and she comes to your home if you can’t make it to the office.

  45. mousethatroared says:

    Good tip nybrgus!

  46. pmoran says:

    As I said, Sialis, — there are a number of reasons why the medical profession cannot endorse the use of placebo medicines or CAM.

    Yet you are reacting as though I am proposing just that.

    “It is extraordinarily difficult for many skeptical minds to acknowledge that, but it is almost certainly true. ”

    I don’t see where any of the “skeptical minds” here are not acknowledging that. On the contrary, they seem to understand it quite clearly, the issue is that they find it unethical and not in the continuing best interest of their patients. As do I.

    Not so (that beneficial influences from placebo are acknowledged). Nybgrus and Mark Crislip are claiming in as many words that placebo responses are entirely due to biased reporting. They are saying, in essence, that patients are lying about how they now feel in order to please the doctors. Steve Novella is not very far off the same position.

    If there IS no real benefit to patients from placebo medicines no further thought is needed. The ethicality of doctors using them hardly arises.

    So what is the truth? I acknowledge that reporting biases are a probable component of the reported benefits, I cannot ignore a lot of other relevant evidence, including compelling plausibility to “real” symptom relief from what we know about human suggestibility, among other matters.

    Also any ethical considerations would only apply within medical practice . They cannot apply to patients who might choose to try out these methods or those who believe that these treatments really work . At least one ethicist says that placebo use is ethical if the doctor believes that placebos work (and, presumably, only employs them when there are no superior evidence-based methods).

    But I am not pushing that either. I am drawing attention to the considerable preciousness required when deciding which of a number of semi-placebos deserves approval or not, and the disparity between those niceties and the disproportionate consequences for a “non-approved” modality. There are probably trivial differences in outcomes between acupuncture, Tai chi etc, massage, etc with many conditions, yet acupuncture will be singled out for extreme hostility, as will anyone who seems to be supporting it.

    If you are not sure how opportunities for ongoing psychosocial interaction and the 20 minute “time-outs” of acupuncture programs may help anyone with arthritis, try applying the same thoughts to tension headaches, one of the other “chronic pains” where acupuncture programs produce results that on the face of it rival any other approach. While you are at it consider the difficulties in deciding what constitutes “treatment” and what constitutes “placebo”.

    Mainly I am interested in the deepest and most unbiased understanding of our craft. That will best inform our approach to many matters.

  47. pmoran says:

    Some critical formatting fixed.

    As I said, Sialis, — there are a number of reasons why the medical profession cannot endorse the use of placebo medicines or CAM.

    Yet you are reacting as though I am proposing just that.

    “It is extraordinarily difficult for many skeptical minds to acknowledge that, but it is almost certainly true. ”

    I don’t see where any of the “skeptical minds” here are not acknowledging that. On the contrary, they seem to understand it quite clearly, the issue is that they find it unethical and not in the continuing best interest of their patients. As do I.

    Not so (that beneficial influences from placebo are acknowledged). Nybgrus and Mark Crislip are claiming in as many words that placebo responses are entirely due to biased reporting. They are saying, in essence, that patients are lying about how they now feel in order to please the doctors. Steve Novella is not very far off the same position.

    If there IS no real benefit to patients from placebo medicines no further thought is needed. The ethicality of doctors using them hardly arises.

    So what is the truth? I acknowledge that reporting biases are a probable component of the reported benefits, but I cannot ignore a lot of other relevant evidence, including compelling plausibility to “real” symptom relief from what we know about human suggestibility, among other matters.

    Also any ethical considerations would only apply within medical practice . They cannot apply to patients who might choose to try out these methods or those who believe that these treatments really work . At least one ethicist says that placebo use is ethical if the doctor believes that placebos work (and, presumably, only employs them when there are no superior evidence-based methods).

    But I am not pushing that either. I am drawing attention to the considerable preciousness required when deciding which of a number of semi-placebos deserves approval or not, and the disparity between those niceties and the disproportionate consequences for a “non-approved” modality. There are probably trivial differences in outcomes between acupuncture, Tai chi etc, massage, etc with many conditions, yet acupuncture will be singled out for extreme hostility, as will anyone who seems to be supporting it.

    If you are not sure how opportunities for ongoing psychosocial interaction and the 20 minute “time-outs” of acupuncture programs may help anyone with arthritis, try applying the same thoughts to tension headaches, one of the other “chronic pains” where acupuncture programs produce results that on the face of it rival any other approach. While you are at it consider the difficulties in deciding what constitutes “treatment” and what constitutes “placebo”.

    Mainly I am interested in the deepest and most unbiased understanding of our craft. That will best inform our approach to many matters.

  48. nybgrus says:

    You are either being disingenuous are showing a surprising lack of understanding.

    Nybgrus and Mark Crislip are claiming in as many words that placebo responses are entirely due to biased reporting. They are saying, in essence, that patients are lying about how they now feel in order to please the doctors. Steve Novella is not very far off the same position.

    Yes. That is exactly what placebo responses are. These are different do placebo effects. It is a nuance, but an important one, especially in a conversation purporting to be a high level nuanced discussion by scientifically literate people.

    including compelling plausibility to “real” symptom relief from what we know about human suggestibility, among other matters

    “compelling plausibility” hardly seems a reasonable basis on which to suggest therapies. Especially in the lack of other supporting evidence. And especially in the presence of evidence of how ephemeral the “real” effects are and the real downsides once the patient finds out and thinks (s)he has been duped (as sialis points out).

    They cannot apply to patients who might choose to try out these methods or those who believe that these treatments really work .

    Agreed. Which is why nobody is advocating berating a patient for using acupuncture. We merely take it one step further and say that we should also act as consumer protection advocates for the myriad reasons outlined below. Just as we wouldn’t advocate our patients to smoke, nor would we berate them for doing so, but can push for legislation to make it less available and less convenient to do.

    At least one ethicist says that placebo use is ethical if the doctor believes that placebos work (and, presumably, only employs them when there are no superior evidence-based methods).

    And at least one biological scientist believes evolution is false and creationism is true. What’s your point?

    There are probably trivial differences in outcomes between acupuncture, Tai chi etc, massage, etc with many conditions, yet acupuncture will be singled out for extreme hostility, as will anyone who seems to be supporting it.

    The fact that you cannot see why acupuncture would be singled out is quite telling. The fact that you neglect the reams of writing here in which is is expounded quite clearly that Tai chi, massage, and yoga are actually science based exercise and stretching programs with direct effects and are perfectly reasonable when divorced from the magical mumbo jumbo they normally come packaged with is also quite telling.

    Take yoga. If you claim it has health benefit beyond that of exercise because it balances your chakras, then it becomes an unreasonable woo that should not be recommended to patients. But we can strip away the chakra nonsense and still do exactly the same thing and reap the benefits of yoga – as an exercise modality. Same with all the other modalities listed. Strip away the useless nonsensical parts which have no utility or scientific basis for action, and the practice remains nearly identical, and the benefits are there, but not overstated.

    Try the same with acupuncture. Take away all the nonsensical parts and you are left with a person laying down quietly. The practice – or “program” as you like to call it – becomes radically different. To the point where it resembles nothing like acupuncture. It becomes indistinguighable from Qi-gong or Reiki for that matter.

    So as I said before – if the benefit is 20 extra minutes of psychosocial interactions, relaxation, and introspection then why do I need to jab my patient with needles in order to trick him/her into spending an extra 20 minutes with me? The claim then becomes that the needles are doing “something” when all evidence demonstrates to us that if they are it is so trivial as to be meaningless.

    To give a real world example – the Memorial Sloan Kettering Cancer Center (MSKCC) has an “alternative” therapy department where they offer (amongst other things) Reiki for cancer patients. On pressing the director of the department, she admitted to me that energy and biofield therapy is rank quackery but that Reiki is not energy therapy it is “light touch massage and relaxation.” But the definition(s) of Reiki are pretty clear. So either they are committing fraud by selling something that is not Reiki to consumers wishing to buy Reiki, or by calling “light touch massage” something that it isn’t. The exact same applies to acupuncture.

    And that, pmoran, is why we would be so against acupuncture and not the other modalities. It is not divorceable from its overstated claims and magical mechanisms of action without literally making it into something entirely different. You should be educated enough to understand this distinction, however fine you think it may be.

    If you are not sure how opportunities for ongoing psychosocial interaction and the 20 minute “time-outs” of acupuncture programs may help anyone with arthritis, try applying the same thoughts to tension headaches, one of the other “chronic pains” where acupuncture programs produce results that on the face of it rival any other approach.

    From the NCCAM:

    “For example, a 2009 systematic review of research on the pain-relieving effects of acupuncture compared with placebo (simulated) or no acupuncture was inconclusive. The reviewers found a small difference between acupuncture and placebo and a moderate difference between placebo and no acupuncture; the effect of placebo acupuncture varied considerably, and the effect of acupuncture appeared unrelated to the specific kind of placebo procedure used.”

    There are then ten conditions listed in regards to pain alleviation by acupuncture. Every single one was essentially negative, with the best being osteoarthritis pain relief saying:

    “Acupuncture appears to be effective for osteoarthritis, particularly in the area of knee pain… However, authors of a 2007 systematic literature review suggested that although some large, high-quality trials have shown that acupuncture may be effective for osteoarthritis of the knee, differences in the design, size, and protocol of the studies make it hard to draw any definite conclusions from the body of research. These authors concluded that it is too soon to recommend acupuncture as a routine part of care for patients with osteoarthritis.”

    And even the best of the best indication for acupuncture – chronic low back pain – states:

    “but actual acupuncture was not more effective than simulated acupuncture or conventional treatment. However, a large, rigorously designed clinical trial reported in May 2009 found that actual acupuncture and simulated acupuncture were equally effective—and both were more effective than conventional treatment—for relieving chronic low-back pain. There is insufficient evidence to draw definite conclusions about the effectiveness of acupuncture for acute low-back pain.”

    Boy, with all those studies done and the NCCAM’s obvious bent towards, well, CAM, you’d think there would be enough evidence to draw conclusions. Everything was utterly mixed, equivocal, and it clearly states that the better the study design and larger it is, the smaller and smaller the effects are.

    All of this is consistent with no effect, as has been outlined here at SBM numerous times. So yeah, they “rival any other approach” if you non-critically accept the various biased studies, poorly done studies, small sample sized studies, and the heterogeneity of what “acupuncture” is (hint: electroacupuncture is not acupuncture, it is TENS, but is often included in many reviews and analyses).

  49. Sialis says:

    Nybgrus and Mark Crislip are claiming in as many words that placebo responses are entirely due to biased reporting. They are saying, in essence, that patients are lying about how they now feel in order to please the doctors. Steve Novella is not very far off the same position.

    Yes. That is exactly what placebo responses are. These are different do placebo effects. It is a nuance, but an important one, especially in a conversation purporting to be a high level nuanced discussion by scientifically literate people.

    nybgrus: Please clarify. Do you think patients are lying about how they feel solely in order to please their doctors? That they are intentionally making completely false statements and false reporting of treatment results? If not for my potentially misunderstanding that part of your comment, I would agree with you entirely. You express my points much better than myself, however I do not think that most patients intend to deceive their physicians, i.e. “lie”.

    Aside from that, most acupuncture sessions include a brief massage at the beginning and end of the session. Some include laying a hot towel over the patient’s back. Massage and heat might very well temporarily alleviate some symptoms of muscle spasms to a degree where the patient might confuse that improvement as if it had been provided by the acupuncture needling itself.

  50. nybgrus says:

    @sialis:

    It is well documented that patients often feel pressure to “please” the doctor or researcher. What this means is when I ask a patient “Are you feeling better” the patient isn’t lying to me when he says “yes, a little” but is trying to find any justification to say so. Lying implies that the patient wishes to deceive me intentionally for some purpose. In this case there is a small component that is like this (patients actually don’t want to “disappoint” their doctors) but mostly it falls under the idea of “fooling oneself” into thinking things are better. Sort of like how most people reflexively answer the question “How are you doing?” with “Great, thanks!” even if they really aren’t.

    In the case of subjective outcomes measures like pain, a patient may rate pain as a “6″ before intervention and then through a combination of wishful thinking, fooling oneself, and wanting to please the doctor say it is a “5″ after the intervention. This can, and does, skew results purely from a placebo response perspective. Tack on a very small placebo effect (in the case of acupuncture this would be a higher-order modulation effect [I can explain this further if you wish]) and you can demonstrate a larger effect than is real and take something clinically trivial and make it appear significant.

    This of course is very difficult to suss out, but after countless studies it seems to be that most of acupuncture’s effects really are non-existent and fall under the placebo response category, with some contribution of placebo effects; however none of the effects are analagous to those demonstrated by rigorous placebo researchers such as Benedetti.

    In any event, there are very few studies and very little evidence of any dramatic effect of acupuncture and those that do demonstrate this have been demonstrated to have severe methodological flaws.

    Hopefully that helps clear things up a bit. If you need more background on higher order modulation of pain experiences, I’d be happy to oblige.

  51. pmoran says:

    Nybgrus:“Nybgrus and Mark Crislip are claiming in as many words that placebo responses are entirely due to biased reporting. They are saying, in essence, that patients are lying about how they now feel in order to please the doctors. Steve Novella is not very far off the same position.”

    Yes. That is exactly what placebo responses are. These are different do placebo effects. It is a nuance, but an important one, especially in a conversation purporting to be a high level nuanced discussion by scientifically literate people.

    Nybgrus, — (holds tongue — also head —)!! Nybgrus, you don’t even go on to explain why such a distinction would matter or how it is relevant to the present question. Too “nuanced” for present parties, I suppose.

    Placebo “effects” are ALWAYS patient responses, because by definition a placebo should “do” nothing (although some talk about “pure” and “impure” placebos, the latter referring to complex procedures like acupuncture, wherein patients are subjected to additional potentially therapeutic influences that are not possible with a sugar pill ).

    While most people still refer to “placebo effects”, even in technical writings, I decided long ago that this was confusing and that I would try and use “placebo responses”. “Placebo effects” wrongly focused attention on the placebo itself, leading people to also assume that the “effect” was an invariant constant within medical interactions, as it often looked to be in clinical studies, but we now know that is incorrect.

    The placebo “effect” is in fact an individual patient response to everything else about the therapeutic interaction, but including whatever perceptions the patient has as to the worth of the supposed “treatment”. It is in its purest form it is a purely psychogenic response to a collection of different influences, but along with an admitted and indistinguishable element of reporting bias. With “impure placebos” there is the possibility of other more difficult to classify influences such as relaxation, and distractions from symptoms, and opportunities for extra psycho-medico-social interactions.

    Leaving that irrelevancy aside, Why on earth would you assume I am unfamiliar with all those studies you quoted?

    I earlier described how they are all based upon seeking differences between “real” acupuncture, and a “sham” version containing a trivial difference in technique. You don’t mention the most interesting finding in those studies which is the much bigger, more difficult-to-ignore differences found when both of these are compared to “usual care” or waiting list controls. This is the only bit of those studies relevant to the present question of how beneficial placebo responses can be, or, if you prefer, “what can placebo medicines ‘do’”.

    The small, but remarkably consistent differences between real and sham, together with the substantial (0.5 plus) effect sizes in comparisons with usual care or waiting list controls are exactly what you would expect if the outcomes from “acupuncture” (meaning all its variants including sham) are mainly from the placebo and other non-specific influences that these all possess in common. Moreover, theylook to be substantial. Take away some reporting bias and you still have room for worthwhile benefits iin some of these difficult conditions. If it were not for this I would not be here questioning certain opinions.

    Your task remains to show that those benefits are nil (“All of this is consistent with no effect“) — i.e. that those 0.5 plus effect sizes are entirely due to reporting biases. It has to be one or the other.

    I’ll keep my side of the argument simple, for now. I suggest that they are largely due to the power of suggestion or the expectancy component to placebo. You previously were desirous of exploiting expectancy effects within your own practice, but you have now backed yourself into the corner of having to show why they don’t exist.

    We both know you can’t. It merely suits certain of the inclinations of medical skepticism to assume that this is the case. We can be better than that.

    One reason that this subject is close to my heart is personal shame about my own one-time biases. I caught myself explaining to some elements of CAM why their testimonials could be explained by placebo effects, while elsewhere claiming that those didn’t really exist — mainly on the basis of the Hrobjartsson meta-analysis (that you will know all about, being a placebo expert) .

    When I looked at ALL the evidence, with less prior bias, it was the latter viewpoint that had to give most ground. Since then the evidence for that side has expanded. I should not be having to direct you, as a participant in “an high level nuanced discussion by scientifically literate people” and presumed expert on these matters, to all the studies on experimental pain, and those demonstrating various neurobiological responses to placebo use.

  52. Sialis says:

    I’ll keep my side of the argument simple, for now. I suggest that they are largely due to the power of suggestion or the expectancy component to placebo

    @pmoran, it seems you readily acknowledge that the benefits of acupuncture are largely due to the power of suggestion. This simply reinforces to me that patients are indeed being misled about how and why acupuncture works. This is a deceptive and misleading representation of a presumably medical service that is being sold. How is this not false advertising? The more you explain your “craft”, the more clear the intent of this deception becomes.

  53. nybgrus says:

    Nybgrus, you don’t even go on to explain why such a distinction would matter or how it is relevant to the present question. Too “nuanced” for present parties, I suppose.

    Apologies that my extensive discussions on the topic in previous threads to which you were party do not readily come to your mind.

    The distinction, with as much brevity as possible, is as follows:

    Benedetti’s research demonstrates objective molecular level changes in response to placebo administration after treatment with actual pharmaceuticals with known physiological activity. He himself calls these placebo effects, plural, and distinguishes them from what has typically been considered the placebo effect which is comprised of reporting bias, error, regression to the mean, natural variation, etc.

    He goes one further even and demonstrates that once conditioning has been established certain of the placebo effects can be elicited without deception of the patient. These tend to involve autonomic/unconcious processes rather than conscious/higher order processes (the latter stil requiring deception to maintain efficacy). This speaks to the underlying neurobiology of objective placebo effects.

    For the sake of preventing conflation and ambiguity, it was during these discussions here that I stated a reasonable nomenclature of placebo “response” to be comprised of the “traditional” notions of the placebo effect, whereas placebo “effect” to be the objective effects elicited by Benedetti during his research.

    How does this apply to the conversation? (bear in mind my distinction in nomenclature as outlined above)

    The data to date seems to demonstrate that placebo effects can only be elicited via the classical conditioning model, requiring actual medical therapies which work beyond placebo (as in the standard parlance of the RCT) to then be substituted with placebo.

    Acupuncture itself – the needling process which defines the practice – does not work beyond placebo. Ergo, it stands to reason that it cannot elicit the objective molecular responses of Benedetti’s placebo effects.

    But there is evidence of improvement in subjective pain reporting (although it is extremely mixed and studies of so poor quality that no strong conclusions can be drawn, but we’ll get to that a bit later) via acupuncture. If it has nothing to do with the needles, it stands to reason that this is from the ritual interaction and the expectancy aspects of it, which you yourself agree with.

    Now we must differentiate even further: between placebo responses and the higher order modulation of pain perception.

    The former you accept exists and accounts for at least some of the effect size one sees from acupuncture trials. It should also be noted that as studies become more rigorous the effect size decreases.

    The latter is a “real” reduction in pain. This is because the definition of pain in not confined to nociceptor firing and release of substance P, but the entire experience of pain – that higher order neuromodulation of pain efferents and the subjective experience of the pain. This accounts for the rest of the effect size seen.

    The former, we both can agree, is useless in terms of medical therapy.

    The latter is actually useful for symptomatic control, particularly in chronic pain. However, it is of varying effect size, poorly controlled, and indeed ephemeral. Since it hinges on higher order modulation of the pain experience, all it takes is for the patient to change his or her thoughts on the therapy in question in order for the modulation to change and the effect to vanish. After all, I hope you will concede that it does not affect the underlying etiology of the process causing the pain, merely the perception and interpretation of the pain experience.

    So where does that leave us with acupuncture?

    Little room, if any, for the objective placebo effects of Benedetti.

    Part of the effect explained by placebo responses.

    The remainder explained by higher order neuromodulation (a la Melzack).

    No objective effect on the underlying etiology of the cause of the pain.

    You don’t mention the most interesting finding in those studies which is the much bigger, more difficult-to-ignore differences found when both of these are compared to “usual care” or waiting list controls.

    So what about the studies which show effect sizes on the order of 0.5 in comparison with usual care or wait listing? (which is your justification both for the tacit approval of acupuncture and calling it an “impure placebo”)

    When taken in aggregate we find that this effect size is actually quite hard to verify. Very good studies and well done meta-analyses all admit an inability to conclusively determine any effect size over standard of care. The one consistent exception is the give away: chronic lower back pain.

    Good data demonstrate acupuncture is helpful beyond standard of care with a fairly large effect size in chronic LBP. However, that effect is completely absent in acute LBP. It is also absent in any good studies for any acute pain, but more present in studies of chronic pain syndromes though none demonstrate data nearly as robust as chronic LBP and all are fairly equivocal. The further evidence is that in severe chronic back pain, or back pain with a known anatomical cause, the effect size goes back down to nothing more than noise, if that.

    Also in previous threads I have explicated what I consider to be the most likely explanation of this, based on the known determinants of chronicity in LBP. For the sake of brevity in what is already a long post, I won’t expound since you should know these determinants yourself and IIRC were party to the discussions I refer to.

    The mild effect sizes that remain left over after all these considerations fall within statistical noise generated by large amounts of poorly done studies and are hardly significant given an appropriate Bayesian outlook based on the studies of specific MOA of needling itself and the acceptance of the transient and ephemeral “real” placebo effect of higher order neural modulation I outlined above. This, IMHO, all but completely rules out the possibility that acupuncture is an “impure placebo.” (And yes, I do know what you mean by that and I do accept that it is a valid term)

    So now we are left with a “program” of acupuncture devoid of any reasonable use of needling, built entirely on placebo responses and the one “real” effect I outlined above. It is my contention that these “real” effects of higher order neuromodulation can and are just as effectively induced in conjunction with actual medical therapy (which would include exercise programs like yoga and tai chi, and talk therapy including restful relaxation and meditation). It would still remain unethical to invoke even that one “real” effect by a modality with absolutely no actual intrinsic benefit (which, I reckon, is why you try and assert that it is an impure placebo, despite what I find to be a preponderance of evidence that it is not; though if you included electroacupuncture or chemical laced needles used in acupuncture then they are impure placebo, but then we aren’t talking about acupuncture anymore).

    Now in cases of chronic LBP, if we can get our patients to move and do what we know fixes LBP, then we will have been greatly beneficial to our patients. Acupuncture does this – but only by telling them that the needles are actually helping them. And that is deception to trick our patients into doing what we have been telling them to do anyways, which becomes unethical.

    I do not take quite as hard a stance as Dr. Crislip does that there is absolutely zero “real” benefit in pain with placebos for the reasons I outlined above. I still see no evidence that they are anything but small in effect size and certainly ephemeral. However in objective outcomes and most other subjective outcomes besides pain, I’m hard pressed to say there is any “real” effect to placebo medicine.

    Does that help make my ideas and stance on the topic more clear, and why I believe that acupuncture is an unethical crock, not worth the time and fundamentally different to yoga and tai chi?

  54. pmoran says:

    The data to date seems to demonstrate that placebo effects can only be elicited via the classical conditioning model, requiring actual medical therapies which work beyond placebo (as in the standard parlance of the RCT) to then be substituted with placebo.

    This response was more obfuscatory and diversionary waffle coupled with unnecessarily technical jargon to impress. It has little relevance to why placebo effects or the reported benefits from acupuncture are “entirely due to biased reporting” (your words).

    Also “higher order neuromodulation (a la Melzack)” is just a flash name for some of that which goes on in a placebo response.

    Nevertheless I am pleased to see you now backing away from what you previously claimed.

  55. pmoran says:

    “l keep my side of the argument simple, for now. I suggest that they are largely due to the power of suggestion or the expectancy component to placebo”

    @pmoran, it seems you readily acknowledge that the benefits of acupuncture are largely due to the power of suggestion. This simply reinforces to me that patients are indeed being misled about how and why acupuncture works. This is a deceptive and misleading representation of a presumably medical service that is being sold. How is this not false advertising? The more you explain your “craft”, the more clear the intent of this deception becomes.

    That over-simplification was to try and focus Nybgrus onto the key issues, such as by explaining exactly how he determines the percentage of reporting bias in the reported outcomes I was describing and that he now admits need to be understood. It didn’t work.

    Actually it is the variety of non-specific influences exerted by acupuncture, alongside probable more conventional placebo influences AND the rather solid evidence for patient benefit (for whatever reason) that should make us think about these matters. Certainly those considering using acupuncture deserve something better than a bald “it doesn’t work” .

    My “craft” is surgery.

  56. nybgrus says:

    My stance hasn’t changed. If you really want to try and nail me on a few less-than-absolutely-precise phrases I’ve dropped on occasion and call that a victory, then by all means revel in it.

    My stance hasn’t changed overall and the calculus on the question of whether acupuncture works or not stays the same – it doesn’t.

    You seem to have a significant difficulty understanding definitions of terms – like acupuncture – and why they are important. For a scientist, you should know better. Defining your terms clearly is important and smearing together all the random acts and garbage studies under a single term of “acupuncture” and hanging your hat on that is extremely weak – and by no means a justifiable basis for advocating it as “working” for our patients. The same goes for your smearing together of everything placebo so you can just say “it does stuff” without drilling down to what “it” is to justify your position.

    Whilst I am willing to explicate more clearly and show exactly why your accusation that we would embrace yoga and tai chi but not acupuncture as if we have some sort of ideological bent against the latter but not the former is patently absurd, you elect to simply not even address the point.

    You’d rather come in and harp on some incredibly narrow aspect of what goes on around here based on your own definitions, and conveniently ignore anything that discredits the points you try and make. It’s like trying to discuss a thesis with you and you want to focus on the use of periods on commas on page 24.

    But hey, if I am off the mark in my statements or assessments, I welcome any other criticisms of it. It is obvious that Drs. Gorski, Novella, Hall, and Crislip do read the comments even this far down and after the post since they comment from time to time. But you are the only one saying my analysis is lacking. Of course, I suppose if they do chime in and agree with me, it would just be more evidence of that “skeptical dogma” you prattle on about. It must be nice to never be able to be wrong and always ignore that which you can’t address.

    Sorry pmoran, but acupuncture doesn’t work.

    The ritual around it does work, to a very limited and ephemeral extent, and is nothing unique to acupuncture and can be applied to any actual treatment modality with intrinsic benefit.

    This is absolutely no different than anything I have been saying all along. If it is, I genuinely don’t realize it and welcome anyone else who is following and has been following long enough to say so. No need to dig back to quote me. If a number of folks here claim it, I am willing to take that as evidence that I at least have communicated badly and possibly did change my position to some degree without realizing it.

  57. Harriet Hall says:

    “Drs. Gorski, Novella, Hall, and Crislip do read the comments even this far down”

    I’ve been reading, and it all reinforces my previous decision not to comment on pmoran’s posts any more. I decided that trying to engage with him was a futile effort.

  58. weing says:

    “I’ve been reading, and it all reinforces my previous decision not to comment on pmoran’s posts any more. I decided that trying to engage with him was a futile effort.”

    Me too. I feel like the dog that heard the bell too many times without the meat. So I’ve stopped salivating to the placebo.

  59. nybgrus says:

    I’ve been reading, and it all reinforces my previous decision not to comment on pmoran’s posts any more. I decided that trying to engage with him was a futile effort.

    Fair enough and thank you. It still helps me to elucidate my own thoughts and ideas on the evidence. In all fairness, pmoran does make me work for it in distinct contrast to the CAM cranks that sometimes show up around these parts.

  60. pmoran says:

    I remind everyone that I was responding to a specific scientific claim, that is so highly arguable that I know that most doctors and medical scientists will not agree with it in the form stated and that even most lay people will find it puzzling.

    It is also evident in Harriet’s own posts that she herself does not hold that placebo influences cannot provide benefits to patients. Her stated approach has also been, not that placebo medicines cannot work, but that it is unethical for doctors to use them and anyway we think we can do much the same in our own practice.

    The oft-quoted Benedetti does not believe it, either. Here is something he said in June last year :

    “This recent research has revealed that these placebo-induced biochemical and cellular changes in a patient’s brain are very similar to those induced by drugs. This new way of thinking may have profound implications in clinical trials and medical practice both for pharmacological interventions and for nonpharmacological treatments such as acupuncture.” (My emphasis.)

    http://www.ncbi.nlm.nih.gov/pubmed/22682270

    I accept that some of my other remarks will be indigestible to most medical skeptics, but they deserve at least some little consideration once the basic contention regarding the influence of “placebo and non-specific effects” is allowed. We have for now a de facto pluralist medical system and it influences how we respond to that.

    The point at issue is simple enough. How does one distinguish reporting biases from true patient benefits when both real and sham treatments produce substantial response rates as compared to a waiting list or usual care control? These have to be the dominant influences. The position being stated here that beneficial placebo responses are simply reporting bias is not only impossible to determine with present technology, this conclusion contradicts strong expectations arising from other areas of research.

    I find it pathetic that legitimate scientific argument should be be brushed off in this manner on a purported science-oriented forum. That Nybgrus’s garbled, pretentious and inconsistent responses should pass as an acceptable, sole standard for argument on this site is also beyond belief.

    All that was needed was for someone to either show how the disputed conclusion was reached, or it is allowed that it was overstating the present state of scientific knowledge (which Nybgrus, bless him, is finally now prepared to do, a little). In either case you will not have to listen to me on this particular point any more.

  61. David Gorski says:

    I’ve been reading, and it all reinforces my previous decision not to comment on pmoran’s posts any more. I decided that trying to engage with him was a futile effort.

    I usually drift away from looking at the comments of specific posts after maybe three days because there are so many others, both here and at my other blog.

    However, I agree with Harriet. Of late, trying to discuss these things with Peter is like pounding my head against the wall. It feels so good when it stops. So I rarely do anymore. I also stand in awe of Nybgrus. Either that, or Nybgrus just hasn’t dealt with Peter for as many years now as Harriet and I have and developed the headache I have from it.

    Once Peter started becoming increasingly disparaging and condescending a couple of years back, I think the die was cast, although foolishly every so often I sometimes gave in to the temptation to try to engage him (and, for all I know, might do so again, but, I suspect, not any time soon). After all, if I want to deal with condescension, confusing (and confused) arguments, and an ability to avoid being nailed down that rivals Jello, all leavened with insults interspersed with cries for “civility,” I get plenty of those at my not-so-super-secret other blog, minus the cries for civility. I don’t need to come here for that.

  62. David Gorski says:

    Fair enough and thank you. It still helps me to elucidate my own thoughts and ideas on the evidence. In all fairness, pmoran does make me work for it in distinct contrast to the CAM cranks that sometimes show up around these parts.

    After you’ve gone round and round and round the exact same argument going nowhere a few more times, I rather suspect you won’t find it so stimulating anymore.

  63. weing says:

    “After all, if I want to deal with condescension, confusing (and confused) arguments, and an ability to avoid being nailed down that rivals Jello, all leavened with insults interspersed with cries for “civility,” I get plenty of those at my not-so-super-secret other blog, minus the cries for civility. I don’t need to come here for that.”

    I was thinking of a farrago of nuances. BTW. I get all that at home. Spouses have a wonderful way of keeping one’s ego in check.

  64. DugganSC says:

    *grumble* All of this talk about acupuncture and placebo and we lose track of the real subject, the sheer hilarity of trying to find “sham” versions of exercise!

    I am disappoint.

  65. nybgrus says:

    I also stand in awe of Nybgrus. Either that, or Nybgrus just hasn’t dealt with Peter for as many years now as Harriet and I have and developed the headache I have from it.

    Well, thanks, I think, for the compliment ;-)

    It’s been about 3 years now, and yes, I am realizing the diminishing returns on investment. However, I do find it useful to try and put my ideas to the test as it were. Every once in a while I pause and think about whether my decision to accept philosophical naturalism is a valid one, for example. I try not to take anything for granted and realize that it is quite possible and rather easy to become entrenched in your way of thought and actually close one’s mind. I am well aware that a mind too open leads to brains falling out, but we all realize here that too closed is also a bad thing.

    On the occasions pmoran decides to fire up a chat about such things, it helps keep that fresh in my mind. I often tell my lowerclasspeople (ahem, just realized this could be taken the wrong way – I was referring to those in the years below me with a gender neutral term) whom I tutor that actually going through the thought process of the medicine you are studying is not only helpful but necessary. We all take mental shortcuts and when we study a topic we can be tempted to quickly realize we understand something superficially and then let our brain just “complete the thought” and move on, without having actually completed the thought. Then when the chips are down and the attending is pimping us, that part we “yadda yadda’d” over can’t come to our minds because it was never really there in the first place. By taking the time to actually write out my thoughts in detail I learn it better and can elucidate even for myself nuance that I “yadda yadda’d” over. Hence pmoran’s accusation that I have changed my position on the topic. I haven’t – I merely actually stated in detail what had been in my head the whole time. (I also think this is not the first time I have done so, but a refresher for myself isn’t such a bad thing).

    Of course there must be a time to move on at some point, lest I spend my time spinning wheels and not learning anything new. Thankfully I have the time at the moment and I plan to take advantage of it. My intern year (which will begin July 2014) will not yield me such luxury of time – as every physician here knows all too well. So I take advantage while I can.

    Well, time for me to jet off to my first clinic of the year! Thank you all – including pmoran – for the comments.

  66. mousethatroared says:

    DugganSC – It may be funny to envision, but maybe the humor comes from the difficulty and importance of the task.

    Imagine going to a physical therapist for tennis elbow and having them tell you “just exercise…it’s all good.” The challenge is (I speculate, I’m no expert) testing certain mechanisms that may be helpful (or harmful) like increasing blood flow to the muscles, strengthening opposing muscle, stretching muscle against something that doesn’t engage that mechanism.

  67. DugganSC says:

    @mousethatroared:

    I’m agreed that it is a serious subject. And frankly, the number of gimmick exercise routines/equipment out there is just as bad as the SCAM situation in my opinion. This blog reviewed a good book scientifically exploring exercise, Which Comes First: Cardio or Weights? and there’s another entertaining commentary on it when Penn & Teller’s BS covered exercise and fitness programs (they do take a lengthy shot at supplement-pushers at gym including a hilarious segment where the front desk person at the gym tried to convince the guy with a hidden camera that glucosamine is “good for building muscles”). I think that the primary issue is how you can provide a flawed program that is indistinguishable from the real thing without doing active harm. :) Although I suppose that if you simply eliminated any mention of “chi” from Tai Chi (which frankly, most people teaching it do), then you have your “sham” version of it, which works just as well.

  68. mousethatroared says:

    “Although I suppose that if you simply eliminated any mention of “chi” from Tai Chi (which frankly, most people teaching it do), then you have your “sham” version of it, which works just as well.”

    That would depend upon what you are testing, right? If you are testing whether being aware of “Chi” works, then that would be an adequate comparison. What if your are testing the idea that a variety of movements that take joints through a range of motion slowly without abrupt changes in direction and mildly increase heart rate decrease the incident of joint pain (or use of pain medication or need for joint replacement, etc) in people with arthritis?

  69. DugganSC says:

    {nods} Yeah. The question is, how do you test it? Compare it to a higher-impact exercise? Use a purposefully borked version where the joints are put under unnecessary strain due to awkward positioning? Have them move around slowly, waving their arms in non-purposeful ways? :) As I said above, the upper two get taught by some unscrupulous schools…

  70. mousethatroared says:

    “As I said above, the upper two get taught by some unscrupulous schools…”

    And that’s the kicker, even you you have research indicating a particular exercise is helpful…you still have the problem of the variation in therapist or instructor in teaching that form of exercise. You get the same thing with other interventions…speech therapy may work for some speech delays, but some speech therapist who claim to practice those forms of speech therapy, don’t know what they are doing, are inept or even (rarely, I’m sure) dishonestly stating their credentials, same for physical therapists and cognitive behavioral therapists.

    I’d be curious to know how to ID a good Tai Chi dojo. I tried Tai Chi years ago, but gave up because 1. The class was taught so slowly, I found it excruciatingly dull. 2. Certain stances made my knees hurt.

    I think I was doing something wrong to cause the knee pain, but the instructor didn’t seem to recognize it or be able to communicate the issue. I was surprised because I did Choi Swang Do for years without knee pain, but the impact was hard on my SI joint, shoulders, wrists. I was just looking for a low impact, esthetic martial art.

  71. Sialis says:

    Mouse, have you tried light exercise in a heated therapy pool? It’s very easy on the joints, low impact.

  72. mousethatroared says:

    Sialis – No – I’m just sorta trying to figure out what works at this point. I had several tendon/inflammation issues before I was diagnosed with hashimoto’s years ago, so I learned some tips from a physical therapists at that time (who was really good). Once I started taking synthyroid, those problem went away… was great for years, could pretty much do anything I wanted except one shoulder impingement issue. Just recently things are acting up again.

    Exercise in a heated pool sounds dreamy…not sure how to gain access to one though.

  73. Sialis says:

    Exercise in a heated pool sounds dreamy…not sure how to gain access to one though.

    Health insurance companies should provide coverage for things like heated-pool exercise therapy and massage, instead of relatively worthless services like acupuncture, applied kinesiology (muscle testing, NAET), and chiropractor visits.

  74. mousethatroared says:

    Yeah, That would be great. Even a percentage payment or an annual allowance for folks with conditions where evidence supports a benefit from those things would be excellent.

  75. nybgrus says:

    Health insurance companies should provide coverage for things like heated-pool exercise therapy and massage, instead of relatively worthless services like acupuncture, applied kinesiology (muscle testing, NAET), and chiropractor visits.

    My knowledge may be outdated on this but the French national health system at least used to cover this stuff. They also used to cover CAM, particularly homeopathy since the French just love homeopathy for some reason, but to my knowledge they have dumped most of the CAM aspect because it wasn’t cost effective. However, physicians there still prescribe the equivalanet of spa days and the government health insurance picks up the tab.

    Also, America is the only developed country in the world that does not have a national minimum employee vacation time. The typical standard for most countries is 4 weeks. Often 6 is quite common. In France, maternity leave is granted (IIRC) about 6 months for the first baby, with ~2-3 months paternity leave. Second baby is 1 year + 6 months paternity, 3rd baby is 1 year + the option for 1 more year at half pay, plus the 6 months of paternity.

    I’ve heard an economist on NPR argue that increasing vacation (to a point, of course) actually improves the economy. Since there is more vacation, you need to hire more people to ensure work is done year round, so unemployment goes down. More vacation typically means a more recharged and refreshed (and happy) employee, so each employee is more productive when (s)he actually is working. And more vacation means more opportunity to spend the (paid) vacation money thus further driving the economy.

    Seems to work reasonably well for most other developed nations.

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