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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.” 

Surveys of CAM Use

It is difficult to find good quality objective data on the popularity of particular CAM interventions, and many of the surveys that have been done are potentially misleading. For example,. the 2007 CDC National Health Interview Survey (NHIS) is widely cited as showing that about 30% of Americans use CAM therapies. A careful look at the details of this survey, however, shows that many of the supposed CAM therapies are really relaxation or exercise practices, such as massage and yoga, not medical therapies. Chiropractic is the only medical therapy generally classified as alternative that was used by more than 10% of people in the survey. And that was primarily for idiopathic lower back pain, an indication for which it is generally accepted, even by skeptics such as myself, as having some demonstrated benefit, about equal to standard medical interventions. These usage numbers haven’t changed in decades, which belies the notion that CAM is growing in popularity.

Similarly, much was made by the media of a recent CDC survey that supposedly showed widespread use of CAM therapies in hospice care facilities. A close analysis of this survey, also shows that most of the therapies listed are not truly alternative medical interventions and that fewer than half the facilities surveyed offered true CAM therapies, and fewer than 10% of patients in those facilities actually employed the CAM practices offered.

Studies of Acupuncture Use

I thought it might be useful to look at some of the data concerning the popularity acupuncture, since it is probably the most widely used and accepted CAM therapy after chiropractic, and there have been a few interesting studies in this area. There are certainly no comprehensive, high-quality data concerning how many people use acupuncture, for what indications, and with what sort of beliefs in its underlying theory or effectiveness. My purpose is not to make a definitive statement about how popular acupuncture is but simply to take a small step beyond vague impressions and unsupported claims about the popularity of this intervention and look at what research there is and what insight, if any, these numbers might give us. 

The 2007 NHIS data indicated 6.5% of Americans had reported ever using acupuncture. Of these, 22% had seen an acupuncturist in the last 12 months. 25% of those who had tried acupuncture had done so once, and 70% had seen an acupuncturist fewer than 5 times. The vast majority of those who had seen an acupuncturist had done so for some kind of pain, primarily arthritis and other orthopedic pain, headaches, or fibromyalgia. About 40% of the people who reported using acupuncture for a specific condition specifically reported not using conventional therapies for that condition, while 20-40% reported using some kind of conventional medical therapy for the same condition. 

It is often argued that lack of interest in the utilizing acupuncture is driven more by cultural prejudice or belief systems than by concerns about the evidence for its efficacy. There is likely some truth to the fact that people from different cultures prefer familiar styles of medical treatment, though of course this says nothing about what is actually safe or effective. And part of the appeal of acupuncture in the West is likely its exotic, “foreign” associations.

Some surveys of acupuncture use have looked at whether different ethnic groups in the West have differences in their utilization of acupuncture. Interestingly, one study from Canada found that while White and Chinese Canadians differed in their use of some CAM modalities, their overall use of CAM was the same, and their use of acupuncture specifically was about the same: roughly 8%. (Therapies included in definition of CAM in Quan et al 2008: Herbal remedies, massage therapy, chiropractic, acupuncture, amino acids, naturopathy, homeopathy, reiki, ayurvedic medicine, biofeedback, hypnosis.)

In contrast, a survey of Chinese Americans in a mental health services program found about 25% used acupuncture, and that this use was more prevalent among “less acculturated” individuals. This, of course, is a group not at all representative of the general population, so the relevance of this to overall acupuncture use among Chinese Americans and Americans of other ethnicities is not clear. Other studies have shown significant but complex relationships between ethnicity, education, and other variables and the likelihood of acupuncture use.

It seems reasonable that cultural traditions play some role in the acceptance or rejection of acupuncture as a medical therapy, but the current data do not support that cultural affiliation alone is the most important variable, and the reasons people use acupuncture seem quite consistent regardless of ethnicity or nationality. In any case, studies of populations in North America do not show anything approaching a majority of the population regularly using acupuncture as a medical therapy. Numbers vary from less than 10% to as high as 50% in some populations, but most tend to be in the lower end of that range.

Since acupuncture as it is currently understood and practiced in Europe and North America originated in China and has been employed there and in other Asian countries for a lot longer than it has been used in the West (though not nearly as long as is usually claimed), it makes sense that it would be far more widely used in that part of the world if it is truly as popular a therapy as its proponents claim.

One 2007 study in Taiwan found about 11% of beneficiaries of national health insurance had used acupuncture in a given year. Interestingly, while the survey found that overall use of Traditional Chinese Medicine (TCM) therapies was much higher than this (primarily due to use of herbal remedies), the use of TCM was still far behind the use of so-called “Western” medicine. TCM clinic visits accounted for only 9% of outpatient visits reimbursed under the national health insurance. This is similar to another study which found Chinese medicine (of all covered types) accounted for only 5% of the reimbursed care under the national health insurance system. The same study indicated that “Western” medicine was utilized more than Chinese medicine, especially among children, the elderly, and those with severe disease (consistent with the pattern of CAM use in the U.S., which is generally for self-limiting or chronic disease).

Yet another study in Taiwan specifically investigated acupuncture use and found about 6.2% of people covered by national health insurance utilized acupuncture in a given year, and over the seven years surveyed about 25% of covered individuals had received acupuncture treatment. As in the U.S., the vast majority of the acupuncture treatment sought was for musculoskeletal conditions or injuries (88%).

And a recently published series of surveys conducted in Japan found that about 5-7% of respondents used acupuncture in a given year, and that over a lifetime between 20-27% of respondents had at some time tried acupuncture. More than 80% of the use of acupuncture was for musculoskeletal complaints. About half of those who had used acupuncture indicated they would use it again, and about 37% indicated they would not.

The Bottom Line

So what does all of this mean? Well, probably not very much. Of course, differences in healthcare systems, insurance systems, study methods, and many other factors that are difficult to identify and asses, make direct comparisons between the use of specific CAM interventions in different countries very unreliable. I don’t believe the quality of the data generally allow very confident statements about the popularity of acupuncture or other specific CAM methods. However, proponents of acupuncture, and CAM generally often make such statements, trying to convey the impression that their approaches are growing rapidly in popularity and only perverse, closed-minded curmudgeons still resist them. The little evidence we have certainly does not support such claims. 

In the case of acupuncture, for example, the data show relatively low levels of utilization even in those countries generally regarded as having long historical traditions of using acupuncture. Informal investigations (e.g. 1, 2) have suggested that acupuncture and other CAM practices associated with China may not be as popular even in their native land as proponents in North America claim, and the formal studies I have discussed here seem to support that impression.

A large majority of people who seek acupuncture therapy, regardless of ethnicity or nationality, do so for treatment of musculoskeletal conditions and pain. There is good evidence that the therapeutic ritual of acupuncture has some symptomatic benefit for such indications. This is almost certainly a non-specific treatment effect (aka “placebo”). It does not seem to matter where needles are inserted or if they are inserted at all, and acupuncture therapy does not appear to measurably affect the course of any actual disease. (The Skeptic’s Dictionary has a clear and concise review).

The research data on acupuncture utilization suggests that from about 5-25% of people, regardless of nationality or ethnicity, will at some time try acupuncture for, mostly for some kind of musculoskeletal pain. Conventional therapies are often used along with acupuncture, and they are far more popular overall, especially for serious or acute conditions. So the little research there is suggests that acupuncture occupies a niche common to many CAM therapies. It is used at a low level by a small to moderate proportion of the population for conditions that are either mild, self-limiting, or without a definitive conventional treatment, and it is rarely used in lieu of conventional medical care. This is hardly a mounting wave of enthusiasm for acupuncture itself, much less the mystical theories and postmodern cognitive relativism often associated with it. 

So when proponents of acupuncture say it must work because it has been widely used for thousands of years in Asia and is growing rapidly in popularity in the West, rebutting the argumentum ad populum and argumentum ad antiquitatem fallacies may not be the skeptic’s only option. It may be worthwhile, and simpler, just to point out that acupuncture is neither as old nor as popular as is commonly supposed.

References

Chang LC. Huang N. Chou YJ. Lee CH. Kao FY. Huang YT. Utilization patterns of Chinese medicine and Western medicine under the National Health Insurance Program in Taiwan, a population-based study from 1997 to 2003. BMC Health Serv Res. 2008 Aug 9;8:170.

Chen FP. Chen TJ. Kung YY. Chen YC. Chou LF. Chen FJ. Hwang SJ. Use frequency of traditional Chinese medicine in Taiwan. BMC Health Serv Res. 2007 Feb 23;7:26.

Chen FP, Kung YY, Chen TJ, Hwang SJ. Demographics and patterns of acupuncture use in the Chinese population: the Taiwan experience. J Altern Complement Med. 2006 May;12(4):379-87.

Eisenberg DM. Kessler RC. Foster C. Norlock FE. Calkins DR. Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993 Jan 28;328(4):246-52.

Ishizaki N. Yano T. Kawakita K. Public status and prevalence of acupuncture in Japan. eCAM 2010;7(4):493-500.

Quan H. Lai D. Johnson D. Verhoef M. Musto R. Complementary and alternative medicine use among Chinese and White Canadians. Can Fam Physician. 2008 Nov;54(11):1563-9.

Upchurch DM. Burke A. Dye C. Chyu L. Kusunoki Y. Greendale GA.A Sociobehavioral Model of Acupuncture Use, Patterns, and Satisfaction Among Women in the US, 2002Womens Health Issues. 2008; 18(1): 62–71. 

Posted in: Acupuncture

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35 thoughts on “How popular is acupuncture?

  1. Apropos of this is the latest review of reviews, by Edzard Ernst, finding that acupuncture is no better than sham acupuncture for pain, and that it is more dangerous than people think:

    10.1016/j.pain.2010.11.004

    There is an accompanying editorial by our own Harriet Hall:

    10.1016/j.pain.2011.01.039

  2. windriven says:

    It is difficult for me to believe that CAM and TCM are not growing rapidly. Consider for a moment the appearance of CAM departments in prominent medical schools, hospitals and medical centers. Graze through the comments here at SBM and take note of the number of readers who have had idiotic therapies proposed by their physician.

    “The 2007 NHIS data indicated 6.5% of Americans had reported ever using acupuncture.”

    I suspect that in 1957 that fraction would have been immeasurable. The notion of growth depends in part on the time scale chosen.

  3. @windriven:

    It is true that acupuncture use is growing, but it is still far more modest than might be imagined based on anecdotes. Here are the annual figures for adults reported by the most credible recent US surveys:

    1996: 0.6%

    2002: 1.1%

    2007: 1.4%

    I believe that this modest increase is mostly due to inappropriate hyping by Those Who Should Know Better, rather than what is usually claimed: that the pontifications of TWSKB are mere responses to the rapidly growing demand.

  4. I agree that CAM is growing in popularity. But as Dr. Atwood points out, on an absolute basis it is still quite marginal compared to conventional medicine, even in places like Taiwan which are billed by CAM advocates as more “open-minded” than we here in the West to “Eastern Wisdom.” CAM advocates oversell the popularity of their preferred methods and, ironically, I think we skeptics probably do as well.

    Personally, since CAM is an issue I have an interest in, I find I see it everywhere. When I complain to my friends about the proliferation of alternative medicine outlets in my area, most of them have no idea what I’m talking about and haven’t noticed the burgeoning of local CAM providers. Could it be I’m a victim of confirmation bias?! :-)

  5. windriven says:

    Gentlemen, I don’t fundamentally disagree. The context of today’s blog was rate of growth and the point was well made. My concern is that this will be used by some as an argument that CAM opponents are overstating the problem.

    The growth rate may not be exponential but it is steady. Tides rise slowly too, but their rise is inexorable.

    Brennan McKenzie said: “When I complain to my friends about the proliferation of alternative medicine outlets in my area, most of them have no idea what I’m talking about and haven’t noticed the burgeoning of local CAM providers. ”

    It would be interesting – if not entirely scientific – to examine the Yellow Page listings for acupuncturists, herbalists, homeopaths, and so forth in several cities comparing the number of listings in, say, the 1970 books versus current books. My guess is that the numbers have increased significantly.

    Entirely anecdotally, a friend of mine is an ND in southern California and earns a solid six figure income from her practice. My point is that someone seems to be paying these providers and the number of providers is growing. Adam Smith’s “invisible hand” seems to be showing itself.

  6. BKsea says:

    Given its great popularity and the large populations of Asian countries, I suggest we rename “Western medicine” to “Eastern medicine.”

    I work with a number of acadmeic medical centers throughout China and can report that the dedication to science-based medicine and research is very strong and rapidly growing

  7. cervantes says:

    I wonder whether you really want to buy into the term “CAM.” If it works, it’s medicine. If it doesn’t work, it’s neither complementary nor alternative, it’s just nonsense. Why don’t we get in the habit of saying something like “useless methods,” or, if you aren’t willing to consider them as definitively known to be useless, “baseless methods,” or something like that.

    By using the term CAM you are essentially endorsing the world view of their proponents.

  8. The semantic debate about what we call medical interventions that have dedicated adherents but lack fundamental plausibility and/or compelling supportive scientific evidence is a perennial one, and while I accept that the words we choose have implications and influence on people’s views, I also think some kind of shorthand is necessary from the point of view of convenience and verbal efficiency. I use a variety of terms of varying degrees of specificity depending on the context. While CAM is often used by proponents of such therapies, in the context of this critique and this venue, I think there is little chance I will be misunderstood as endorsing the notion that these therapies are legitimate alternatives to science-based medicine or that they complement it in any real way. I do take your point, but I am comfortable that the chance of undermining my own message by my use of the term here is negligible, so I am willing to employ it as a convenient shorthand.

  9. cervantes says:

    Okay, you’re willing to do it, but nobody is forcing you. Why give aid and comfort to the enemy? It’s easy enough to use a different term.

    It’s like any other public debate — language and framing matter. If you’re willing to call acupuncture and homeopathy “complementary” and “alternative,” then you are simply reinforcing in readers’ minds that those are legitimate labels. I don’t think people will misunderstand you as endorsing them but that’s beside the point.

    What if an advocate of abortion rights continually spoke about the “pro-life” position and defined himself as “not pro-life”? Would you view that as merely a convenient shorthand, or can you not see that it is counterproductive?

  10. noophy says:

    Would it be possible to do an entry on IMS ( Intramuscular stimulation) ? It seems to be big in Canada among physiotherapists, and I’ve been told it’s most definitely not acupuncture.

  11. ConspicuousCarl says:

    Determining the true popularity of something is never easy, but at least the users themselves know if they are using acupuncture.

    A problem with homeopathy, aside from the fact that it is insane, is that people who don’t specifically know that homeopathy is nonsense might be duped into buying it at stores which shamelessly stick it on a shelf as if it were real medicine. A perfectly reasonable person has no reason to know that “200c” refers to an exponential denominator, or that the long Latin string on the back of the box means duck parts. It just looks like another drug in a box, and most people probably don’t suspect that nationwide retailers like Walgreens or CVS are selling witchcraft.

  12. BKsea says:

    To ConspicuousCarl’s point, most people also think that homeopathic nonsense is subject to the same FDA regulations as real medicine, which it is not. When I have confronted homeopathy users, the response I have gotten is “well, if it did not work, they would not be able to sell it would they?”

  13. Scott says:

    @ cervantes:

    For better or worse, CAM is the term that will be understood. If another term were used, few people would get the meaning.

  14. cervantes says:

    How about quackery? That’s what Orac calls it.

  15. DonSelgin says:

    Interesting blog post. Certainly nothing a CAM-leaning blog would post – no bullet-proof conclusions, no definitive answers – characteristically science-based.

    I must say I almost thought there was profanity going on, though – you might review the following:

    “Well, probably not very much. Of course, differences in healthcare systems, insurance systems, study methods, and many other factors that are difficult to identify and asses, “

  16. daijiyobu says:

    Dr. Atwood said: “it is true that acupuncture use is growing.”

    I wonder what the growth of acupuncture grads is.

    Supply seems to be outstripping the demand.

    The AANP’s President, an LAc too, stated (see http://physicianswholisten.blogspot.com/2010/10/cream-rises-to-top.html ) in 2010-10-18:

    “licensed acupuncturists graduate and get licensed, but then struggle for years to pay off student loans [...] many fail.”

    He quotes Lisa Rohleder, LAc of the Community Acupuncture Network :

    “acupuncture education, and the conventional acupuncture business model, ought to come with a warning label, the way cigarettes do: NOT SUSTAINABLE. May take years of your life and leave you with nothing, except huge student loans.”

    -r.c.

  17. Ben Kavoussi says:

    @ daijiyobu

    licensed acupuncturists graduate and get licensed, but then struggle for years to pay off student loans [...] many fail.”

    Lisa Rohleder is right: acupuncture education leaves you with nothing, except huge student loans.

    As I have mentioned in the past, acupuncture schools are a shady group of “professional” schools that give a bogus vocational Master’s degree in TCM or “Oriental medicine.”

    In most states, licensed graduates can practice acupuncture, herbalism (the nonscientific and non-pharmacological prescription of herbs), and Oriental massage.

    But in reality there are almost no jobs available to LAcs, because they have very little training in medicine.

    The existing acupuncture jobs in community clinics or with mainstream clinical practices are mainly open to physicians.

    The student loans benefit the TCM schools only. Graduates are left without the possibility of repaying them by using what they have learned in schools. This has forced many to work in fields other than acupuncture to repay their loans. I know one that drives a taxi to make the payments!

    There are many indebted acupuncturists in this situation, but most are choosing to remain quiet about their debt because they are embarrassed, or ashamed, of their educational and professional situation.

    In order to gain employment, graduates have to undertake more debt to attend programs in nursing, physician assistant, or other healthcare professions, so they can provide a sustainable income to support their families.

    This is a real fraud in the name of “alternative medicine.” Former and current students should take action and request the reimbursement (or the forgiveness) of their tuition and its interest.

    Stiff regulation should be implemented, requiring full disclosure of employment data and opportunities before or at the time of enrollment, so students are not saddled with unmanageable debt.

    This is a real fraud.

  18. windriven says:

    @cervantes and Scott

    “If it works, it’s medicine. If it doesn’t work, it’s neither complementary nor alternative, it’s just nonsense.”

    Well said. I for one will stop using the term, opting instead for quackery. Call a spade a spade.

  19. daijiyobu says:

    @ BK:

    Similarly, I’ll keep SBM out of trouble by not mentioning any specific entities…and I agree.

    I follow naturopathy mainly. What I see are NDs / NMDs coupling an LAc onto that degree thinking that that M.S. is a sure money-maker. Also, the naturos in unlicensed states use an ‘acupuncture license’ as legal cover.

    Last night, coincidentally, I took pictures of an interstate highway billboard around where I live that labels an ND degree and a TCM/acupuncture degree “health science”.

    Fascinating self-regulating nonsense that isn’t — when boiled-down — what is being advertised.

    -r.c.

  20. Ben Kavoussi says:

    @ cervantes

    With your permission, I am going to use your phrase in one of my future posts: “If it works, it’s medicine. If it doesn’t work, it’s neither complementary nor alternative, it’s just nonsense.”

    How do you want me to state your name? Dr. Cervantes?

    Thanks.

  21. Ben Kavoussi, I’ve heard this attributed to Tim Minchin in the form, “What do you call alternative medicine that works? Medicine!” I don’t know if he originated it or just popularized it.

  22. windriven says:

    @Ben Kavoussi and Alison Cummins

    cervantes’ locution is superior in that it states the central idea that medicine embraces all therapies with demonstrated merit while more clearly stating that so-called complementary and alternative practices offer no demonstrable medical benefit.

  23. Ben Kavoussi says:

    @ Alison Cummins

    Thank you very much for your help. I tend to agree with windriven.

  24. Ben Kavoussi,

    Sure, I was just thinking that if something is an old joke, or a variation on a stock popular phrase, you would want to think about how you credit it. Perhaps the person you heard it from first said it best. That’s fair and they should get credit for saying it best. But if you write an essay in which you attribute it *wholly* to the person you heard it from first, and I recognize the sentiment as being much older, I would question the rest of your attributions as well. That’s all.

  25. CLK says:

    I’m having trouble understanding how accupuncture- which involves piercing the skin several millimeters or centimeters with tiny pin sized needles could cause pneumothorax or paralyisis. Infection I get, that’s obvious. But some of these other claims? I just don’t see it. Can someone explain the method by which this practice could cause these complications?

  26. @CLK:

    Distance from skin surface to lung at intercostal (between ribs) spaces or in the supraclavicular fossa (neck just above the clavicle) can be as little as 0.5-2 cm in a child or thin adult, hence the risk of pneumothorax; distance from skin surface to major nerve or nerve plexus, for example the brachial plexus in the neck or the femoral nerve in the groin, as little as <1-2 cm in a child or thin adult; the spinal cord is only a bit deeper in some locations; hence risks of paralysis, which can be worsened by concomitant bleeding (also caused by needling).

  27. Jan Willem Nienhuys says:

    When one makes remarks about acupuncture and infection, the adherents claim that nowadays acupuncturists always sterile disposable needles. I don’t know whether that is true. But what risk of infection does a patient run if disposable needles are used and the practitioners use latex gloves?

    I imagine that injections and drawing blood must have similar risks, but maybe I am wrong, because those needles are used in a different way. I can imagine that puncturing the skin can push skin bacteria into places where they can proliferate.

    In a recent article by Ernst he mentions 38 cases of serious infections due to acupuncture, from all over the world and all published after 2000.

  28. GLaDOS says:

    If you say “quackery” instead of “CAM” all throughout an article, a casual reader will imagine that you are an over emotional loonie with an axe to grind, probably drooling.

    Better to provoke feelings in the reader that he can call his own rather than beat him over the head with your own passions.

  29. Ed Whitney says:

    @ Kimball Atwood:

    I read the Ernst article with some interest, but had trouble with something in the text that did not match the tables. Specifically, the text states that the authors evaluated the systematic reviews “using predefined criteria (Table 1).” However, Table 1 list no criteria, but only the results of the reported effects in the systematic reviews. I assume they used something based upon PRISMA or QUOROM, but I did not know how they distinguished between poor, moderate, good, and excellent systematic reviews. I think that the journal will have to publish a correction, or put the intended Table 1 online, but it is an important piece of information which was lacking from the

    @ the discussion thread as a whole:
    Acupuncture presents an interesting case because of the large placebo effect with sham acupuncture. Not all placebos are as effective as sham acupuncture; for example, see Zhang et al (The placebo effect and its determinants in osteoarthritis: meta-analysis of randomised controlled trials) Ann Rheum Dis 2008 Dec;67(12):1716-23.

    Placebo acupuncture was more effective than either placebo steroid injections or placebo herbs. Sham acupuncture appeared to be the most effective placebo of the 22 which were compared. Placebo acupuncture works pretty well, but placebo laser, placebo vitamins, and placebo magnets don’t do squat.

    I have put this into my pipe, but have not yet smoked it. Any suggestions?

    1. Harriet Hall says:

      Ed Whitney,

      The criteria are referred to in section 2.1 which includes a footnote (107) to a paper entitled “Validation of an index of the quality of review articles.”

  30. Costner says:

    Say what you will about acupuncture, but Steven Seagal believes in it, and in his film Hard To Kill he successfully used acupuncture to bring himself from being in a coma with atrophied muscles back to kicking tail and taking names all in the matter of a few days.

    Are you going to seriously try to suggest that acupuncture doesn’t work when a man with a name of Mason Storm showed its magic on the silver screen? That is heresy!

    /sarcasm

    In reality I suspect acupuncture is a lot like hypnosis or a placebo. If you think it will work to help you lose weight or stop smoking etc then to some degree it might actually work simply due to the power of the human mind. However as the public becomes more educated about the science involved (or lack thereof), and as more people try it and experience no benefits whatsoever, fewer and fewer people will trust it and the popularity will fade.

    Keep in mind there was a point in history where Taebo and the Thighmaster were probably the two most popular forms of exercise in the nation… it doesn’t mean they were effective, just popular.

  31. Jann Bellamy says:

    I can understand how the credulous might be attracted to acupuncture, but M.D.s reccomending and performing acupuncture? There are two possible explanations I can think of: (1) some M.D.s actually believe in meridians/qi etc., in which case I can’t understand how they ever completed medical school and passed the boards; or (2) they think it works even if we don’t know exactly how, in which case I can’t understand how they ever completed medical school and passed the boards.

  32. pmoran says:

    Jann, I advise caution. I understand the communal urge to react to acupuncture purely as a manifestation of obsolete medical theory and superstition. but it is possible to view it differently.

    As I have just said elsewhere, “—–, acupuncture is mainly a placebo, but a very good one. It may also have some physiological effects through release of endorphins, distractant and counter-irritant properties and through the enforced relaxation of acupuncture sessions. It “works” better than doing nothing and can probably add something to “usual medical care” in most medical contexts.”

    We may, for other reasonably legitimate reasons, choose not to endorse or use acupuncture, but the actual science should place limits upon what we are entitled to say about it and those who choose to use it.

    We are also probably not yet in a position to state whether the decision to use or not to use acupuncture in slected settings has neutral significance for pateint outcomes.

  33. Ed Whitney says:

    Part of the answer to Jann’s question is in Madsen et al “Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo
    acupuncture, and no acupuncture groups” (BMJ 2009; 338:a3115). Doctors do not compare acupuncture with placebo in their patients; they compare acupuncture with continuing usual care (i.e., keeping on with what they have been doing unsuccessfully). The standardized mean difference (SMD) between acupuncture and sham acupuncture is 0.17, which is nearly negligible. The SMD between sham acupuncture and no acupuncture is 0.42, which is an appreciable, if not huge effect. It is larger than what would usually be considered a “minimal clinically important difference.”

    It is demanding on time and energy to calculate an SMD for differences between different interventions, but it is not all that conceptually difficult (RevMan software does the job nicely). Interpreting the calculation, on the other hand, is conceptually demanding, and calls for depth and subtlety. Some are tempted to say that the evidence says to the practitioner, “Don’t send anyone for acupuncture; it is just a waste of time.” This is the interpretation that thinks that acupuncture is no different from no acupuncture; the evidence does not support that interpretation.

    Hence, my earlier call for some suggestions about how to interpret evidence that suggests that some placebos (acupuncture) are more equal than other placebos (steroid injections) for osteoarthritis.

    EBM has the potential to save our health care system, but it is not just a matter of going with what the evidence says, any more than sound religious teaching is just a matter of going with what scripture says. The interpretation of EBM is likely to be thorny. I think that pmoran has got some of the spirit of the thing. A very similar debate is raging about the effectiveness of vertebroplasty for painful osteoporotic spine fractures; the sham and real procedures were shown to be similar in a couple of RCTs. The data appear to say one thing, but practitioners who see that vertebroplasty patients are some of the most grateful patients they ever treat have their lying eyes to contend with when they finish with morning rounds.

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