Two recent acupuncture studies have received some media attention, both purporting to show positive effects. Both studies are also not clinical efficacy trials, so cannot be used to support any claims for efficacy for acupuncture – although that is how they are often being presented in the media.
These and other studies show the dire need for more trained science journalists, or science blogging – they only make sense when put into a proper context. No media coverage I read bothered to do this.
The first study comes out of South Korea and involves using acupuncture in a rat model of spinal cord injury. The researchers used a standard method of inducing spinal cord injury in rats, and compared various acupuncture locations to no-acupuncture control. They followed a series of metabolic outcomes, as well as the extent of spinal cord injury and functional recovery. They conclude:
Thus, our results suggest that the neuroprotection by acupuncture may be partly mediated via inhibition of inflammation and microglial activation after SCI and acupuncture can be used as a potential therapeutic tool for treating acute spinal injury in human.
The notion that acupuncture will actually improve outcome after acute spinal cord injury is, of course, extraordinary. This goes far beyond a subjective decrease in pain or some other symptomatic benefit. Therefore similarly extraordinary evidence should be required to support such a claim – and this study does not provide that.
In the Wall Street Journal last week was a particularly bad article by Melinda Beck about acupuncture. While there was token skepticism (by Edzard Ernst, of course, who is the media’s go-to expert for CAM), the article credulously reported the marketing hype of acupuncture proponents.
Toward the end of the article Beck admits that “some critics” claim that acupuncture provides nothing more than a placebo effect, but this was followed by the usual canard:
“I don’t see any disconnect between how acupuncture works and how a placebo works,” says radiologist Vitaly Napadow at the Martinos center. “The body knows how to heal itself. That’s what a placebo does, too.”
That is a bold claim, and very common among CAM proponents, especially acupuncturists. As the data increasingly shows that acupuncture (and other implausible treatments) provides no benefit beyond placebo, we hear the special pleading that placebos work also.
But is that true? It turns out there is a literature on the placebo effect itself, and the evidence suggests that placebos generally do not work.
One of the basic principles of science-based medicine is that a single study rarely tells us much about any complex topic. Reliable conclusions are derived from an assessment of basic science (i.e prior probability or plausibility) and a pattern of effects across multiple clinical trials. However the mainstream media generally report each study as if it is a breakthrough or the definitive answer to the question at hand. If the many e-mails I receive asking me about such studies are representative, the general public takes a similar approach, perhaps due in part to the media coverage.
I generally do not plan to report on each study that comes out as that would be an endless and ultimately pointless exercise. But occasionally focusing on a specific study is educational, especially if that study is garnering a significant amount of media attention. And so I turn my attention this week to a recent study looking at acupuncture in major depression during pregnancy. The study concludes:
The short acupuncture protocol demonstrated symptom reduction and a response rate comparable to those observed in standard depression treatments of similar length and could be a viable treatment option for depression during pregnancy.
The YOU Docs, for those of you (YOU?) who are unaware, are Doctors Mehmet Oz and Mike Roizen, authors of books about YOU and a weekly newspaper column called The YOU Docs. It’s all about YOU.
There are two areas of the knowledge where I have more than passing understanding: infectious diseases and sCAMs. It always concerns me when I read nonsense in the few areas where I have some expertise. I have to wonder about the validity of other information in the paper like war and the economy. You know, important stuff. It could probably be argued that since the YOU Docs are in the “How We Live” section, the same section that carries horoscopes, the movie and TV reviews, the weather report — the fiction section — it should not taken seriously. After all, it is usually adjacent to the People’s Pharmacist, and my father always told me that you can judge a person by the company they keep.
The YOU Docs had a column with the headline: “Research backs acupuncture for a range of ills“. More fiction? Research backs acupuncture? News to me, but they are, after all, YOU Docs, and therefore may have information not accessible to mere docs with a small ‘d’. I grant up front to the authors that it is hard to be rigorous, or even coherent, in a 452 word essay. I am over 3,200 words for this entry. There are also no references, so I have to assume I found the correct research mentioned by the hints in the text.
Credibility alert: the following post contains assertions and speculations by yours truly that are subject to, er, different interpretations by those who actually know what the hell they’re talking about when it comes to statistics. With hat in hand, I thank reader BKsea for calling attention to some of them. I have changed some of the wording—competently, I hope—so as not to poison the minds of less wary readers, but my original faux pas are immortalized in BKsea’s comment.
Lies, Damned Lies, and…
A few days ago my colleague, Dr. Harriet Hall, posted an article about acupuncture treatment for chronic prostatitis/chronic pelvic pain syndrome. She discussed a study that had been performed in Malaysia and reported in the American Journal of Medicine. According to the investigators,
After 10 weeks of treatment, acupuncture proved almost twice as likely as sham treatment to improve CP/CPPS symptoms. Participants receiving acupuncture were 2.4-fold more likely to experience long-term benefit than were participants receiving sham acupuncture.
The primary endpoint was to be “a 6-point decrease in NIH-CSPI total score from baseline to week 10.” At week 10, 32 of 44 subjects (73%) in the acupuncture group had experienced such a decrease, compared to 21 of 45 subjects (47%) in the sham acupuncture group. Although the authors didn’t report these statistics per se, a simple “two-proportion Z-test” (Minitab) yields the following:
Sample X N Sample p
1 32 44 0.727273
Difference = p (1) – p (2)
Estimate for difference: 0.260606
95% CI for difference: (0.0642303, 0.456982)
Test for difference = 0 (vs not = 0): Z = 2.60 P-Value = 0.009
Fisher’s exact test: P-Value = 0.017
Wow! A P-value of 0.009! That’s some serious statistical significance. Even Fisher’s more conservative “exact test” is substantially less than the 0.05 that we’ve come to associate with “rejecting the null hypothesis,” which in this case is that there was no difference in the proportion of subjects who had experienced a 6-point decrease in NIH-CSPI scores at 10 weeks. Surely there is a big difference between getting “real” acupuncture and getting sham acupuncture if you’ve got chronic prostatitis/chronic pelvic pain syndrome, and this study proves it!
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a somewhat nebulous diagnosis with unknown etiology and no effective treatment. To make the diagnosis, bacterial infection must be excluded and the symptoms must last at least 3 months. Symptoms include pain in various locations (between rectum and testicle, in the testicles, at the tip of the penis, in the lower back, in the abdomen over the pubic or bladder area), pain or burning with urination, frequent urination, pain or discomfort during or after sexual climax. There are also systemic features like decreased libido, myalgias, and fatigue, and there is a higher incidence of chronic fatigue syndrome in these patients. The connection to the prostate is uncertain; in one study, women with chronic pelvic pain reported more of these symptoms than men did. Diagnosis is based on self-reported symptoms; there are no objective diagnostic markers. Somewhere between 2 and 10% of the male population are reported to suffer from this syndrome.
Since there is no effective mainstream treatment for this disorder, why not try acupuncture? Two randomized, placebo-controlled studies have reported positive results from acupuncture treatment. Is this enough evidence for us to recommend it to patients? (more…)
Editor’s Note: Please be aware that Ben is deployed in Iraq right now. What that means is that his Internet access is somewhat sporadic. He will show up from time to time to answer comments, however.
ERRARE HUMANUM EST, SED PERSEVERARE DIABOLICUM
- To err is human, but to persist diabolical -
Lucius Annaeus Seneca (c. 4 BC – 65 AD)
The California (CA) Department of Consumer Affairs (DCA) has an informational booklet on Acupuncture and Asian Medicine that besides depicting many New Age fantasies about prescientific medicine, also makes the unfounded claim that based on a 1997 consensus panel, the NIH formally “endorses” the use of acupuncture for a set of specific conditions, and that there is “clear evidence” that it is effective for some of them. This booklet is available at:
Wondering about this “clear evidence,” I wrote a letter a few months ago to the National Center for Complementary and Alternative Medicine (NCCAM) and asked for a clarification.
Their candid response explicitly stated that the CA booklet “misstates the purpose of the 1997 consensus panel on acupuncture.” The NCCAM also added that as a “Federal research agency, the NIH does not endorse any product, service or treatment, nor are NIH consensus documents statements of policy.”
My youngest and I often do the “Find 6 Different Things” in the Sunday comics. He is good at finding anomalies. All day at work I showed the picture in the link that follows and asked: What is wrong with this picture?
Almost everyone found at least one thing wrong (I find two) in less than 10 seconds, my 12 year old included.
Click on the link, look at the first photograph and you tell me.
What’s wrong with this picture?
I will post my answer tomorrow in the comments.
I subscribe to American Family Physician, the peer-reviewed journal of the American Academy of Family Physicians. It emphasizes evidence-based medicine and most articles include a table showing strength of evidence ratings for key recommendations for practice. Lately, its scientific rigor has been slipping. I have complained to the editor about several articles whose recommendations were not based on the best science, and I have been consistently ignored.
Acupuncture for Chronic Low Back Pain
A recent article on chronic low back pain recommended acupuncture and gave it an “A” rating corresponding to “consistent, good-quality patient-oriented evidence.” I wrote the following letter to the editor and to the author of the article: (more…)
The state of California (CA) which is home to the most advanced education and research in biomedical sciences, computational biology, genomics and proteomics, etc, is also home to 19 institutions that have state-approved training programs in Traditional Chinese Medicine (TCM), a pseudo-medicine that is based on ideas and practices sourced by ancient cosmology, mythology, astrology, and a range of other pre-scientific beliefs that have been partially “sanitized” during the Maoist era.
Emerging out of the recent hype about complementary and alternative medicine (CAM), the educational curricula of these institutions include the study of acupuncture’s point-and-meridian system, the health and safety beliefs of ancient and medieval China, humoral pathology, herbalism, Asian massage, and a limited amount of modern biomedical sciences at a level below what is required from vocational nurses. These curricula are supposed to provide the necessary knowledge and skills for the graduates to pass a comprehensive state licensing exam and provide “primary” healthcare in CA. However, pursuant to CA Code of Regulations, Title 16, Section 1399.451(b) it is improper for these “primary” healthcare providers, “to disseminate any advertising which represents in any manner that they can cure any type of disease, condition or symptom!” Nonetheless, both the internet and the local press abound with ads by CA licensed practitioners who claim that acupuncture can cure or mitigate many diseases, ranging from allergies and infertility to stroke and paralysis.
Under the banner of CAM, a handful of these practitioners also advertise that they can communicate with spirits and heal with crystals, colors or sounds; they practice healing touch (reiki) and distance healing (via PayPal!); provide spiritual counseling and ministerial services, and make implausible medical claims such as healing a chronic condition with just one needle!
All 19 programs are approved by the CA Department Affairs’ (DCA) Board of Acupuncture, since CA law requires that the content of an acupuncture training program be assessed and approved by the State.