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Acupuncture Revisited

Believers in acupuncture claim it is supported by plenty of published scientific evidence. Critics disagree. Thousands of acupuncture studies have been done over the last several decades, with conflicting results. Even systematic reviews have disagreed with each other. The time had come to re-visit the entire body of acupuncture research and try to make sense out of it all. The indefatigable CAM researcher Edzard Ernst stepped up to the plate. He and his colleagues in Korea and Exeter did an exhaustive study that was published in the April 2011 issue of the medical journal Pain:   “Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews.” It is accompanied by an editorial commentary written by yours truly: “Acupuncture’s claims punctured: Not proven effective for pain, not harmless.” (The editorial is reproduced in full below.)

Ernst et al. systematically reviewed all the systematic reviews of acupuncture published in the last 10 years: 57 systematic reviews met the criteria they set for inclusion in their analysis. They found a mix of negative, positive, and inconclusive results. There were only four conditions for which more than one systematic review reached the same conclusions, and only one of the four was positive (neck pain). They explain how inconsistencies, biases, conflicting conclusions, and recent high quality studies throw doubt on even the most positive reviews.

They also demolished the “acupuncture is harmless” myth by reporting 95 published cases of serious adverse effects including infection, pneumothorax, and 5 deaths. Some but not all of these might have been avoided by better training in anatomy and infection control. (more…)

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How popular is acupuncture?

Everybody’s Doing It

One argument that often comes up when skeptics and proponents of so-called complementary and alternative medicine (CAM) debate is the question of the popularity of various CAM practices. Advocates of CAM often claim these practices are widely used and growing rapidly in popularity. Obviously, CAM proponents have an interest in characterizing their practices as widely accepted and utilized. Even though the popularity of an idea is not a reliable indication of whether or not it is true, most people are inclined to accept that if a lot of people believe in something there must be at least some truth to it. The evidence against this idea is overwhelming, but it is a deeply intuitive, intransigent notion that can only rarely be dislodged.

It might therefore be useful to get some idea of whether or not the claims of great popularity for CAM treatments are true. If they are not, fruitless debates about the probative value of such popularity could potentially be avoided, and it might be possible to diminish the allure associated with the belief that “everybody’s doing it.” 
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An ICD Code for the Running Piglets!

… animals are divided into (a) those that belong to the emperor; (b) embalmed ones; (c) those that are trained; (d) suckling pigs; (e) mermaids; (f) fabulous ones; (g) stray dogs; (h) those that are included in this classification; (i) those that tremble as if they were mad; (j) innumerable ones; (k) those drawn with a very fine camel’s-hair brush; (l) etcetera; (m) those that have just broken the flower vase; (n) those that at a distance resemble flies.

– Jorge Luis Borges (1899–1986)1

Not too long ago, I came across a disease taxonomy proposed by a certain East-West Medical Research Institute (EWMRI), that includes the kind of fantastic afflictions — such as “running piglet” disorder — fit for the best Borgesian list.

This obscure institute, located at Kyung Hee University in Seoul, Korea, is one of the 800 WHO Collaborating Centres designated to carry out various activities in support of the Organization’s programs. With the collaboration of China, Japan, Vietnam, Australia, and the US, this center is working to incorporate medieval Asian disease nomenclature to the 11th version of the International Classification of Disease (ICD-11).
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Posted in: Acupuncture, Basic Science, Science and Medicine

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The Good Rewards of Bad Science

All the world sees us
In grand style wherever we are;
The big and the small
Are infatuated with us:
They run to our remedies
And regard us as gods
And to our prescriptions
Principles and regimens, they submit themselves.

Molière, The Imaginary Invalid (1673)1

The passage above is part of a burlesque doctoral conferment ceremony, where the French playwright Molière (1622-1673) mocks the unscrupulous physicians of his time. “All the excellency of their art consists in pompous gibberish, in a specious babbling, which gives you words instead of reasons, and promises instead of results,” he writes. In Moliere’s plays doctors never cure anyone; they are put on stage just to display their own vanity and ignorance.2 The Spanish painter Francisco de Goya (1746-1828) also took on the same issue by painting in 1799 a well attired jackass taking the pulse of a dying man, in a pose that accentuates the large gem on his hoof.


Image 1. De qué mal morirá (Of what illness will he die?) by Francisco de Goya is held at the Biblioteca Nacional, Madrid, and The Metropolitan Museum of Art, New York.

But if the asinine doctors of Molière and de Goya’s time never cured anyone, it is because they held prescientific views, and believed that disease was caused by imbalances in “humors,” and by malefic influences of the Heavens. Even the most educated among them treated illnesses in good faith by purging, bloodletting and enema at astrologically auspicious times. In contrast, current physicians who for the sake of funding embrace and endorse unscientific views and practices under the guise of CAM or integrative medicine, do so knowing that they often contradict the established principles of physics, chemistry, and biology. Therefore, in addition to promoting “snake oil science”3 (as R. Barker Bausell calls it), these physicians are also guilty of bad faith. Most of this takes place at large academic centers, where funding seems to outweigh the concern for science. As Val Jones, MD, writes in 2009′s Top 5 Threats To Science In Medicine:

Often referred to by David Gorski as “Quackademic” Medical Centers – there is a growing trend among these centers to accept endowments for “integrative” approaches to medical care. Because of the economic realities of decreasing healthcare reimbursements – these once proud defenders of science are now accepting money to “study” implausible and often disproven medical treatments because they’re trendy. Scientists at these centers are forced to look the other way while patients (who trust the center’s reputation that took tens of decades to build) are exposed to placebo medicine under the guise of “holistic” healthcare.

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Of SBM and EBM Redux. Part III: Parapsychology is the Role Model for “CAM” Research

This is the third post in this series*; please see Part II for a review. Part II offered several arguments against the assertion that it is a good idea to perform efficacy trials of medical claims that have been refuted by basic science or by other, pre-trial evidence. This post will add to those arguments, continuing to identify the inadequacies of the tools of Evidence-Based Medicine (EBM) as applied to such claims.

Prof. Simon Replies

Prior to the posting of Part II, statistician Steve Simon, whose views had been the impetus for this series, posted another article on his blog, responding to Part I of this series. He agreed with some of what both Dr. Gorski and I had written:

The blog post by Dr. Atwood points out a critical distinction between “biologically implausible” and “no known mechanism of action” and I must concede this point. There are certain therapies in CAM that take the claim of biological plausibility to an extreme. It’s not as if those therapies are just implausible. It is that those therapies must posit a mechanism that “would necessarily violate scientific principles that rest on far more solid ground than any number of equivocal, bias-and-error-prone clinical trials could hope to overturn.” Examples of such therapies are homeopathy, energy medicine, chiropractic subluxations, craniosacral rhythms, and coffee enemas.

The Science Based Medicine site would argue that randomized trials for these therapies are never justified. And it bothers Dr. Atwood when a systematic review from the Cochrane Collaboration states that no conclusions can be drawn about homeopathy as a treatment for asthma because of a lack of evidence from well conducted clinical trials. There’s plenty of evidence from basic physics and chemistry that can allow you to draw strong conclusions about whether homeopathy is an effective treatment for asthma. So the Cochrane Collaboration is ignoring this evidence, and worse still, is implicitly (and sometimes explicitly) calling for more research in this area.

On the other hand:

There are a host of issues worth discussing here, but let me limit myself for now to one very basic issue. Is any research justified for a therapy like homeopathy when basic physics and chemistry will provide more than enough evidence by itself to suggest that such research is futile(?) Worse still, the randomized trial is subject to numerous biases that can lead to erroneous conclusions.

I disagree for a variety of reasons.

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Posted in: Acupuncture, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Herbs & Supplements, Homeopathy, Medical Academia, Medical Ethics, Science and Medicine

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Compare and Contrast

I have been in Infectious Diseases for almost 25 years. I have two major jobs: I see inpatient consults and I chair the Infection Control program. I have been involved in quality improvement, especially as it relates to hospital acquired infections, for my entire career. It has been an interesting quarter century. Year after year we have driven down infection rates and other kinds of mortality and morbidity in hospitalized patients. Everyone recognizes that medicine is difficult and dangerous and its biggest problem is medicine is practiced by humans, who, I would venture to observe, are prone to mistakes and any number of cognitive errors.

It has not been a easy journey. People hate change and there has not always been certainty as to the best options to choose to solve a problem, a problem that continues today. For example, how best to treat a patient with potential methicillin resistant Staphylococcus aureus colonization (MRSA). Should we screen everyone? Screen high risk patients? Surgical patients? Do we decolonize, with the long term consequence of accelerating antibiotic resistance? Do we place everyone with MRSA in isolation, with the known decrease in care that patients in isolation may have? Everything we do has potential downsides and unintended consequences. No good deed ever goes unpunished.

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Posted in: Acupuncture, Chiropractic, Science and Medicine

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The Acupuncture and Fasciae Fallacy

Let us be certain of a fact before being concerned with its cause. It is true that this method is too lengthy for most people who naturally run to the cause and overlook the certitude about facts; but at last we will avoid the ridicule of finding the cause of what does not exist.1

Bernard le Bovier de Fontenelle (1657-1757)

Amidst the plethora of flawed, implausible, and wasteful research on acupuncture and Chinese medicine, a 2002 study on the “Relationship of Acupuncture Points and Meridians to Connective Tissue Planes” stands out as the height of factual neglect. In it, Helene Langevin and Jason Yandow of the University of Vermont’s College of Medicine claim to have matched real anatomical structures with the elusive acupuncture “meridians.” It should be noted that the widely accepted term “meridian” is a metaphor coined by George Soulié de Morant (1878 – 1955), a French delegate to China, and has no semantic relationship with the original Chinese word.2 The original designation is the composite word jing luo (經絡), which literally means “channel-network.” The term has been translated to English as chinglo channels, channels, vessels or more commonly, meridians. Debunking this study is of particular relevance because it is often used by acupuncturists and a wide range of other CAM providers to legitimize the meridian lore. The principle author, Helene Langevin, is a CAM celebrity and a member of the “Scientific Committee” of the International Fascia Research Congress, an organization dedicated to the “emerging field of Fascia Studies.” She is an Associate Professor of Neurology and the Director of the Program in Integrative Health at the University of Vermont; and has conducted multiple NCCAM-funded studies on the role of connective tissue in chronic pain, acupuncture and manual therapies.
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California Forbids Chinese Bloodletting

In November 2010, the California Department of Consumer Affairs (DCA) finally decided to act responsibly and forbid the prevalent practice of Chinese bloodletting by licensed acupuncturists.

The practice became a concern for the DCA when allegations of unsanitary bloodletting at a California (CA) acupuncture school surfaced.

The incident allegedly occurred during a “doctoral” course for licensed practitioners. The instructor was reportedly demonstrating advanced needling and bloodletting techniques. During the process, he took an arrow-like lancing instrument that is called a “three-edged needle” (三棱针), sharpened it with sandpaper, cleaned it with alcohol, and then asked a student-volunteer to roll a towel around his neck (similar to what is depicted in Image 1). The instructor then cleaned the student’s temporal region with alcohol, and punctured a superficial blood vessel with the arrow-like instrument. The student then held his head over the garbage can, gushing blood for a while.

Images 1 & 2. Chinese bloodletting. Image 1 shows a technique used to bleed the head or the face, where a towel is rolled around the neck to control the arterial pressure. Image 2 shows the practice of “wet cupping.”

The ancient practice of bloodletting, with or without cupping, is still widely used in Chinese medicine to remove “stagnant blood, expel heat, treat high fever, loss of consciousness, convulsion, and pain.”1 The amount of blood let depends on the condition, and the location of the incision. A contemporary book recommends letting a tiny amount from a point adjacent to the thumbnail for a condition described as “wind-heat invasion” of the lung. The symptoms associated with this unscientific nomenclature include chills and fever, sore throat, stuffy or runny nose, and a yellow discharge,2 which could correspond to many respiratory conditions, including the common cold, influenza, pneumonia, etc.
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Acupuncture and the Hazard of Nonsense

A recent study published in the Archives of Opthalmology compare patching of one eye vs acupuncture in the treatment of amblyopia in older children, and finds positive results from acupuncture. The study, and its press, are a good example of the hazards of studying highly implausible modalities.

First let’s dissect the study itself – from the abstract:

In a single-center randomized controlled trial, 88 eligible children with an amblyopic eye who had a best spectacle-corrected visual acuity (BSCVA) of 0.3 to 0.8 logMAR at baseline were randomly assigned to receive 2 hours of patching of the sound eye daily or 5 sessions of acupuncture weekly. All participants in our study received constant optical correction, plus 1 hour of near-vision activities daily, and were followed up at weeks 5, 10, 15, and 25. The main outcome measure was BSCVA in the amblyopic eye at 15 weeks.

For background, amblyopia occurs when the brain tends to ignore visual information from one eye. This results from a variety of causes, but commonly from the two eyes having different refractive errors (anisometropic) – one eye may be more near-sighted or far-sighted than the other. The brain cannot combine information from both eyes, so it ignores one. This can be corrected in younger children, up to age 7, by correcting the vision for the refractive problems. If visual correction alone is not enough, then patching one eye (the strong eye) to force the brain to use the weak eye can be effective. This is usually done for only 2 hours a day, otherwise amblyopia of the patched eye can occur.

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Sky Maul

The worst part of flying is the take off and landing. Not that I am nervous about those parts of the trip, it is that I am all electronic. Once I have to turn off my electronic devices, all I am left with is my own thoughts or what is in the seat pocket in front of me. Since there is nothing to be gained from quiet introspection, I am stuck with either the in-flight magazine or SkyMall. I usually choose the latter. SkyMall, for those of you who do not fly, is a collection of catalogs bound in one volume. I have occasionally purchased products found in SkyMall and thumb through it with mild interest.

This time one product caught my eye, the Aculife home acupuncture/acupressure device. I had never noticed the ‘health’-related products in SkyMall before, usually looking for electronic gadgets that I really do not need. I was curious. How many other products besides Aculife are in the catalogue? According to the interwebs, about 100,000,000 Americans fly every year and well over half a billion people world wide. A lot of people can potentially look at SkyMall, including the occasional skeptic.

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