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More Acupuncture Misrepresentation

Poorly done acupuncture studies are published every week, so I can’t write about every one that comes out. I probably would have passed this one by, except for the New York Times article using it to tout the effectiveness of acupuncture.

The headline reads: “Acupuncture, Real or Not, Eases Side Effects of Cancer Drugs.

I know that authors, in this case Nicholas Bakalar, often do not write their own headlines, but in this case the article itself is just as bad. It begins:

Both acupuncture and sham acupuncture were effective in reducing menopausal symptoms in women being treated with aromatase inhibitors for breast cancer, a small randomized trial found.

This is, in fact, not true, but this fallacy has become the centerpiece deception of acupuncture promotion. See if you can spot the fallacy, but before I discuss it let me review the study itself.

The one thing Bakalar gets right is that it was a small study. The study had two arms, real acupuncture (RA – 23 subjects) and sham acupuncture (SA – 24 subjects). These were all women with breast cancer on an aromatase inhibitor (AI) who were getting musculoskeletal side effects from the medication. They were treated for 8 weeks with either RA or SA. Outcomes included several scales that essentially involve reporting subjective symptoms.

The study found that both groups reported improvement in symptoms with treatment, but there was no statistically significant difference between the two. In the real world we refer to this as a negative study.

Trying to rescue something interesting from the results, the authors also report:

Post-hoc analysis indicated that African American patients (n = 9) benefited more from RA than SA compared with non-African American patients (n = 38) in reducing hot flash severity (P < .001) and frequency (P < .001) scores.

Those P-values are completely worthless, because you cannot interpret P-values of a post-hoc analysis. What we don’t know is how many post-hoc analyses were done, and there does not seem to be any correction for multiple comparisons. There are many possible subgroups that could have been pulled out – by age, weight, and severity of symptoms, for example. There were also multiple possible comparisons as multiple subjective outcomes were measured at different time points. The fact that one subgroup had an outlier result is meaningless. Also, this study is far too small for such subgroup analysis – only 9 subjects in the African American group.

I think it was deceptive to even report these results with those P-values. The authors conclude from this:

Racial differences in response to acupuncture warrant further study.

Even that tepid conclusion (probably all they could get away with in peer-review) is not justified by this data, in my opinion. It seems like they wanted to show some positive trend to make it seem like acupuncture has promise.

The only justified conclusion one can make from this study is that it failed to show any effect from acupuncture for treating AI side effects – this is a negative study. The authors conclude, however:

Both RA and SA were associated with improvement in PROs among patients with breast cancer who were receiving AIs, and no significant difference was detected between arms.

While accurate, it is misleading, which gets back to the core fallacy of recent acupuncture promotion. When the treatment and control groups, in a blinded comparison, show no difference, the only conclusion to draw from that is that the treatment had no measurable effect in that study (in plain terms, the treatment did not work).

Stating that both the treatment and the control showed improvement is a non-sequitur in the context of a controlled clinical trial. The comparison of baseline symptoms to post treatment (real or sham) is unblinded, and therefore it is not possible to make any efficacy claims from that change alone, especially with subjective outcomes. Comparison to baseline or historical controls is only justified with objective outcomes (like death). Even then the data is suspect, unless there are blinded controls.

Interestingly, the authors provide a working definition of acupuncture in the introduction to the published study:

Acupuncture is a traditional Chinese medicine technique that involves inserting filiform stainless steel needles into specific points in the body to achieve therapeutic effect.

Acupuncture is sticking needles into specific points – those are the two variables that define acupuncture. If the specific points do not matter (sham acupuncture is sticking needles in the “wrong” points) then acupuncture, as defined, does not work.

The New York Times article reports:

The results may be attributable to a placebo effect, but the scientists suggest that the slight pricking of the skin could cause physiological changes. In any case, the lead author, Dr. Ting Bao, a medical oncologist at the University of Maryland, Baltimore, said there is no harm in trying acupuncture.

The results are attributable to placebo effects, by definition – there was no difference between the treatment and placebo groups. The authors (still trying to put a positive spin on their negative data) suggest that perhaps it is the sticking of needles that works, and not the specific points. However, their study did not control for the sticking of needles, so it is disingenuous to speculate about this variable.

We do have acupuncture studies, however, that control for the sticking of needles – so-called placebo acupuncture where the skin is poked with toothpicks or a dull needle and there is no penetration. Most famously is this study of acupuncture for back pain, which used the toothpick control.

What the evidence shows is that poking the skin randomly with tooth picks is as effective as traditional acupuncture performed by a trained acupuncturist. But “as effective” could mean not effective at all, because all we have are unblinded comparisons to no treatment for subjective outcomes.

Dr. Bao also makes the “what’s the harm” fallacy. The study was negative. Stating that patients should try the treatment anyway is not justified. It is also untrue that there is no possible harm. There is harm in wasting time and resources on a treatment that demonstrably does not work. Promoting implausible and ineffective treatments also instills health misinformation in the public. Further, acupuncture is not without risks. Even if the risks are small, they are not justified when the evidence indicates no benefit.

The NYT article ends with this further quote from Dr. Bao:

“Acupuncture as a medical procedure has been practiced for thousands of years,” she said. “It has a minimal risk and potentially significant benefits.”

This is propaganda, not science. Acupuncture, as it is practiced today, is a fairly recent invention of the early 20th century. What was practiced for thousands of years bears more of a resemblance to bloodletting than modern acupuncture. In any case, this is nothing but the argument from antiquity logical fallacy. Culture and mechanisms of deception can propagate ineffective treatments for thousands of years.

Saying that a treatment has “potentially significant benefits” is unjustified opinion, and is especially odd coming from a scientist who just published a completely negative study showing the treatment is ineffective.

In fact there have been several thousand acupuncture studies over decades. After all of this clinical research, acupuncture has not been clearly demonstrated to be effective for any indication. In short, acupuncture does not work. It is too late to talk about acupuncture’s “potential,” as if we just need to study it more. It has been studied. It doesn’t work.

Proponents, however, will continue to publish poorly conducted studies where biases and degrees of freedom can generate positive results, and more rigorous studies with negative results that they will promote nonetheless as if they were positive.

For acupuncture true believers, acupuncture research is a “heads I win, tails I win” situation.

Posted in: Acupuncture

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128 thoughts on “More Acupuncture Misrepresentation

  1. windriven says:

    And published in Cancer, the highest impact journal in the field of oncology. Nice.

  2. Chris says:

    Could you talk about what *does* work occasionally, on this blog. I enjoy the articles, but they aren’t very actionable!

    1. NoEsBueno says:

      Western medicine is more limited than the public tends to believe. I think part of this stems from the fact that medical dramas on TV portray doctors as being able to solve any medical problem or cure any disease regardless of the causality. I’ve worked in the medical field as a physician for 10 years now, and I’ve never met a Dr. House. . .and I’ve trained at a very prestigious institution or two. Prevention is actually the model that is being pushed by primary care providers today. The bio-psycho-social model of disease tends to address the “other” aspects of a patient’s health that effect their chief complaint (reason to seek medical care). Some things, such as trauma resuscitation and management of chronic disease, we do well in the US. Other aspects of medicine still challenge us. Not every study that emerges produces actionable change, that’s just how it is. . .at least for now.

      1. WilliamLawrenceUtridge says:

        NoEsBueno, could you let me know at which line of longitude that “Western medicine” ceases to work? I’ll plan my vacations around avoiding it. Also, does “Western medicine” still work if you go the other way around the globe?

        My point being, of course, that there is no such thing as “western” medicine. There is proven medicine. There are assertions about medicine, health and disease that are unproven. But there is nothing “western” about scientific testing of medicine to see if it actually does anything.

        But it would be great if patients stopped believing in magic bullet cures and doctors, and just quit smoking, ate their vegetables, got enough sleep, exercised regularly and got vaccinated.

        1. NoEsBueno says:

          Agreed. Very much Agreed!

    2. Chris says:

      Another Chris: “Could you talk about what *does* work occasionally, on this blog.”

      Actually, they do. You might want to check out several posts by Harriet Hall including her book reviews, and the one about the neti pots. Then there are several by David Gorski on the efficacy of chemotherapy.

      They are sprinkled in here and there, but it is quite difficult when there is so much dreck being touted. Perhaps they could add a category called “Stuff that actually works.”

    3. Sawyer says:

      While I find the negative stories sometimes put me in a foul mood, I think you have to consider the niche that’s being filled.

      There are hundreds of books, websites, and documentaries that extol the fantastic discoveries in modern medicine. There are numerous charities and advocacy organizations that tell success stories whenever possible. I get alumini newsletters with decent science covereage and the university PR department makes sure they are 100% positive. With the exception of Quackwatch, this is literally the only resource I know that consistently brings the hammer down on the pseudoscience in medicine. I’m not going to demand the ratio of positive:negative articles change until we start to see a shift in public sentiment.

      And I guarantee if there were more positive stories written the “Big Pharma Shill” accusations would increase ten-fold. It’s already hard enough have a conversation without them butting in.

      1. Gkh says:

        Well said

  3. Roman100 says:

    Could you talk about what *does* work occasionally, on this blog. I enjoy the articles, but they aren’t very actionable!

    And by “actionable” you mean … ?

  4. JW says:

    Merriam Webster definition:
    2. actionable – capable of being acted on

    1. irenegoodnight says:

      Yes, we know what the WORD means, but what did the user mean–that is what Roman100 is asking.

  5. Wonderer says:

    Would like to hear your thoughts on the recent review article in Anesthesiology on the mechanisms of electroacupuncture.
    When the leading journal in the field publishes such a review the message that goes out is this-Acupuncture’s effectiveness is a given.
    Not sure how things are in the US but in India that pretty much puts the lid on any debate……. “if The editors at Anesthesiology had any doubts about it would they review its mechanism?”
    I suspect that very soon we will not be permitted to practice pain medicine unless we are certified in acupuncture .The numbers of the faithful swell every year

    1. Electroacupuncture is not acupuncture. It’s transcutaneous electrical nerve stimulation (TENS) masquerading as acupuncture. It’s just another form of deception by playing loose with definitions.

      Why not practice “pharmacoacupunture” by injecting drugs through hollow acupuncture needles.

      1. David Weinberg says:

        OK Novella, you scooped me. I actually have a satire post I have been writing entitled “pharmacoacupuncture”

      2. MadisonMD says:

        I find pharmaco-venipuncture very effective for certain diseases.

  6. Harriet Hall says:

    How would they report a study of a new pharmaceutical? “NewRx and a placebo both significantly reduced the pain of migraines. Placebo has fewer side effects, so it is worth trying.” I don’t think so! The double standard is so obvious, how can journal editors not realize that!

  7. Frederick says:

    Good readings, Although i don’t know if i could convince my friends who believe in Acupuncture that it is just a elaborate placebo, one of his friend is a Acupuncturist ( he told me that the guy is a really traditional one, that even modern Acupuncturist don’t follow his ways lol wow i don’t know what he meant by that, i prefer not to know :-) ).

    Having articles on what work or new REAL promising research could of course be good, but i think the goal of this blog is to debunk and inform people. There is so much lies in the health market that there is a lot more thing that do not work that one that actually does. and Skeptics like on this site have to work hard to defend what work against the lies and deception of those getting rich with those Scam. I guess that is why there a lot of “this do hot work” article.

    1. WilliamLawrenceUtridge says:

      Such blogs, dedicated to specific areas of research, do exist (see ERV over at scienceblogs for instance, I love reading her work because it delves into a specific area of virology that I know nothing about, but explains it at a level that I am able to understand). However, they are of necessity generally sub-sub-sub specialty areas, such that they are only comprehensible to a few, or would post relatively infrequently. CAM, on the other hand, requires much less expertise, allows much broader commentary, and there is always fodder. Frankly, if Dr. Gorski kept us updated on his day to day research at the day-to-day level, I’m guessing none of us would understand it.

      I would think it hard for a member of the general public to be strongly interested, in an ongoing basis, in a blog focused on a single stream of research. I like to consider myself relatively well-read, and the few I have tried to keep up on tended to go over my head.

  8. Roman100 says:

    … but i think the goal of this blog is to debunk and inform people. There is so much lies in the health market that there is a lot more thing that do not work that one that actually does. and Skeptics like on this site have to work hard to defend what work against the lies and deception of those getting rich with those Scam. I guess that is why there a lot of “this do hot work” article.

    Now that, to me as a layman interested in the topics under scrutiny on this blog, sounds like a good and functional definition of “actionable”. Lots of valuable info for the taking, to absorb and to act upon.

    1. Frederick says:

      That’s what i was going for. I’m a Science geek science i’m 8 years old, i know a lot about science, and know couples of peoples in science ( i have Met a physicist last week who work on dark matters detection! so cool!) by i know a lot, i meant for a layman. I ( unfortunately ) have no real science education except the basis chemistry and physics class. I learn a lot by myself. With science magazine ( like the french science et vie) physic science site, astronomy etc.
      I’m this site is perfect for people like me. I have a open minded, and i don’t like dogma, that is why i don’t like pseudo-science and CAM, because they are so closed and dogmatic. I want to be convince, but with real proven and rigorous proof. i’ve learn so much here. This was the perfect blog for me!

    2. Frederick says:

      Damn i hate when i press enter before I’m finished lol
      I think that informing people and helping them NOT being screw is a real action, and not to loose money and time. that’s really pro-active to me. Also helping people understand how to use you critical thinking and to recognize your own bias and cognitive limitation.

      1. dingo199 says:

        Forgive me if I find it hard to believe someone who discusses dogma, pseudoscience, critical thinking, bias, elaborate placebos and cognitive limitations is only 8 years old.

        1. Sloosh says:

          I think he meant “since I’m 8 years old” not “science I’m 8 years old”.

        2. b says:

          I believe he meant “since he was” as in from 8 years old and on.

  9. irenegoodnight says:

    Is anyone interested in a letter-writing campaign to the NY Times? I respond to these articles whenever I see them (by email), and I usually get a politely bland reply from an intern with questionable writing skills. Occasionally I get something from the author, usually a “present both sides” gambit.

    Perhaps if they received a hundred letters in response to something like this, they might start to think about the way they report these studies.

    It is virtually impossible to counter this level of misinformation once it takes hold as I have found out from the comment section of the NYT. People eat this up. The posts are filled with disdain for “western” medicine and all sorts of conspiracy theories. Studies such as this one are taken at face value by most readers and this could easily lead to harm.

    Copies of our letters should go the journal in question as well as whatever institution the study authors are affiliated with. This post would be attached, of course!

    1. angorarabbit says:

      Irene, this is completely worth doing. Some years ago, I wrote NYTimes to protest the claim that Kate Hepburn had Parkinson’s. She didn’t – it was familiar essential tremor. Very shortly thereafter I was called by Clairborne Ray at NYT; I directed her to the ET Foundation, and she turned the letter into her QA column about ET. It was brilliant.

      So I say, let’s go for it! “What is a placebo?” would be a great QA column.

    2. theLaplaceDemon says:

      YES I am interested.

    3. windriven says:

      Happily.

  10. JW says:

    Using context clues I would guess that the user doesn’t find much in these articles that they can act on.

    Hence the word actionable.

    Why did Roman100 add quotes around the word?

  11. JW says:

    Has there ever been a meta analysis of on the number of people who actually seek out acupuncture for pain vs standard treatment?

    1. Harriet Hall says:

      I don’t know about that, but this study found that 4% of American adults had ever tried acupuncture. 2002 CDC study http://www.cdc.gov/nchs/data/ad/ad343.pdf I read somewhere (can’t find the source at the moment) that a large percentage of people who try acupuncture go for one visit and never return, and a large percentage go 3 times or less.

      1. JW says:

        Thank you for the link. Did they elaborate on the reasons they went so infrequently? Not effective, too costly, something else?

        1. Andrey Pavlov says:

          I guess I am in that minority that went many times. I don’t recall how many times I had acupuncture but it was at least a dozen or so.

          I personally stopped going after the effect seemed to wear off. I have chronic pain in my joints (literally every joint in my body) and nothing seemed to help. Was recommended acupuncture which was done by none other than my PCP at the time. Tried it and felt amazingly better afterwards. Of course, I was primed in my belief as well. As a kid I did kung-fu and once I got glass in my foot. The Shifu used acupuncture to numb the pain as he pulled the glass out. He built it up of course, with a bunch of hokum about how it works, and after it was all over I seemed to recall experiencing not much pain… wait, maybe no pain at all! So after a number of acupuncture sessions, I found that the initial feeling of euphoria and pain relief was diminishing and lasting less and less time. I had to go more frequently. The hassle of actually going and paying for it started to annoy me. Suddenly the effect was minimal. Another promising treatment failed. So I stopped going.

          Funny enough, you know what does work? I lost a bunch of weight, became more fit, had better sleep, and learned to manage stress. Now, thanks to the holidays and some personal matters I am (by my new standards) horrendously out of shape and my joints ache again. Yet I’m not tempted to go to get acupuncture. I just need to go work out regularly again.

          Oh, and I did have another session of acupuncture after learning what I know about it. For S’s and G’s, baby. I’ll let you guess what the effect was.

          1. JW says:

            12 times in a year? Or more spread out?

          2. Frederick says:

            I like you point, Like you said, Actually what did work? Acupunture or the fact that you have taken care of yourself, and did exercise. Exercise is good ( of course since you have joint pain i suppose moderate low impact exercise) for pain in muscle/joints. But lots of people use lots of thing, do lots of thing that actually work. but will put all the merits in their favorite sham.

            About exercise that help with pain : I have a minor scoliosis, my spine is slingthing “not right”. it does not cause lots of trouble except for low back pain regularly. I had some advice for people i know with the same problem and her Dr said to do back exercise, like sit-ups ( i do them with my knee at 90 degrees on a small table, and i don’t go all the way up) ans couple of thing like that. And it does help, when i do them like 2-3 time a week, my back is fine, but when i stopped for couple of week ( like right now) the pain come back. Of course this could all be a placebo, but it work like everytime. And the is a possible mechanism for it, muscle! anyway

            1. Andrey Pavlov says:

              In retrospect it seemed rather clear that the acupuncture just masked my symptoms from me. Made me feel like i was doing something. When the burden of going and getting acupuncture outweighed the masking of the effects… it suddenly stopped “working” because it never was really “working” at all, just making me ignore my symptoms.

              As for my joint point, it is due to a minor collagen synthesis issue that leaves my joints hypermobile. Strengthening my muscles and decreasing my weight (I went from 105kg to 75kg) is what helps because that allows my muscles to actually hold my joints in place properly.

              The beauty of your situation is that exercise is good no matter what and there is a plausible mechanism for why it may help. It is absolutely win-win and so it can reasonably be recommended regardless of whether it is placebo or not since it definitely serves a second non-placebo purpose. The same cannot be said for acupuncture.

            2. WilliamLawrenceUtridge says:

              Frederick, you might be interested in Paul Ingraham’s take on scoliosis and back pain:

              http://saveyourself.ca/articles/structuralism.php

              Among other articles (use the search box).

              Of course, you might also be interested in his article on low back pain:

              http://saveyourself.ca/tutorials/low-back-pain.php

              My anecdote is I tried his bath trick and it worked amazingly well. My pain appeared to be caused solely by trigger points.

      2. JW says:

        Is this perhaps the study you were refering to?

        http://nccam.nih.gov/sites/nccam.nih.gov/files/nhsrn18.pdf

        If I am reading it correctly, it says that the average acupuncture user went around 3 times in 12 months and spent about $100 total.

        It’s too bad it was data collected in 2007, I’d love to know post 2008 spending on acupuncture.

  12. I’m beginning to worry about the journals as much as the quacks, My most recent posts give examples of poor reviewing and shocking hype from Science, NEJM and JAMA. It’s getting out of hand and people will suffer.
    http://www.dcscience.net/?p=156
    http://www.dcscience.net/?p=6369

    1. Angora Rabbit says:

      And we’re supposed to be surprised at that? When the system promotes exaggeration in order to publish? I’m shocked to find gambling in this establishment.

      Here’s the problems:
      Science Citation Index and the ranking of journal and paper citations. Given a choice between AJP and Science, which article would you cite first? The citation index is a binner (science speak for mouse poop). If you are in a field that is not “hot”, then your paper will not be in Science etc. But who cares? With PubMed, all articles in all journals can be found. This craving for a “name” journal is ridiculous. As is the craving of publishers to have a high index – that speaks to $$, not science. Should we be surprised this is happening in a context when there are fewer and fewer publishers, replaced with global behemoths?

      Editors are told by publishers to turn away papers. Their job is no longer to accept papers and mentor authors; their job is to reject. It’s like the idiotic school rankings – the more applicants you reject, the better you must be. Not true. The best papers emerge when editors and reviewers work together to nurture and encourage authors, especially young scientists. But since most editors are no longer broadly read, that’s another problem – the editors don’t understand what they are reading, and thus don’t pick the right reviewers.

      Third – sex sells. If I want my paper to be looked at by the Nature Med editor, I have to “sex it up.” It wouldn’t be looked at without strong claims for significance. But what is significance? We can all point to many papers that were not “significant” when published, but turned out to be hugely important later, when we understood better what was going on.

      Blame the reviewers? Do you have time to review? I sure don’t, nor am I paid for my time. As an Associate Editor, I can be desperate for any warm body to offer a review on a submitted paper. The last paper I handled took 6 requests to get 2 reviewers. And I don’t blame them. We are all overworked and asked to do more with less and less resources. I’m happy if I have a full morning to dedicate to reviewing a manuscript.

      Honestly, I can’t blame the authors. They are just responding to the editors and publishers. It is easy to point fingers, but hard to address solutions.

      1. Andrey Pavlov says:

        I am in the same boat Angora. I am writing a paper as first author and we are looking to submit to the Journal of Respiratory and Critical Care Medicine. The highest impact factor journal in my field of interest. Why? Because it would really be huge for me to put a first authorship in “The Blue Journal” on my CV. And yes, I have to sexy it up a bit. Thankfully a 5% absolute reduction in mortality is pretty sexy, but I still need to sell the design and implementation as something novel.

        As for reviewing… yep. I get tapped from some senior reviewers to help them review articles. I bust my ass to do it – usually takes me around 6-8 hours to do a full review. Obviously as I get better at it and learn the field more and more that will become less and less, but I actually spend time to vet certain details I find relevant and look for contradicting data, confirming literature, read some of the sources cited, do my own lit review. It is time consuming and requires effort. I currently have that time but I probably won’t in the not-to-distant future.

        In the meantime, we can all just submit to the best journal of the all The Journal of Universal Rejection. Clearly, they have the highest standards in peer reviewed literature since nothing is good enough to get in ;-)

      2. windriven says:

        @Angora

        But what are the solutions?

        Perhaps getting out from under Elsevier, Lippincott, et al would be a start. Elsevier alone publishes 2800 journals in various fields. Subscription costs are enormous, reprint access ridiculous ($35 for a 10 year old article? Really?) and quality of peer review often … relaxed.

        These are quite profitable companies. Elsevier reported operating profits (2012) of 2.1 Billion Euro on sales of 7.5 billion Euro. That’s one hell of an operating margin. And they can’t support quality editing?

  13. pavoldi says:

    A co-worker of mine takes her dog for acupuncture treatments. I feel sorry for the poor thing (the dog, that is), as the placebo effect is nonexistent. Poor dog wonders why people are poking her; knows nothing about ancient Chinese wisdom.

    1. WilliamLawrenceUtridge says:

      Placebo effects aren’t absent for dogs. They pick up on their owners’ body language, and if that body language says “I am relaxed because you will feel better after this”, the dog will relax too. I have no doubt your co-worker thinks it works because their dog reacts positively to the treatments – in the sense of showing signs of comfort, whining less, showing less agitation, etc.

      1. DBonez5150 says:

        WLU: “Placebo effects aren’t absent for dogs. ”

        No kidding! My dog ate something nasty and was sick and lethargic. After a day he hadn’t gotten better, so I took him to the vet. The second I said the words “bye bye,” he sprang to life excited to leave – as he always did. The vet said his vitals were good, the worst was over, and he would be fine. Sure enough, after his “fun” time at the vet, he ate, rested, and quickly recovered.

        Had I taken him anywhere, including for acupuncture or even a homeopathy treatment, he still would have gotten better, and sCAM followers would attribute it all to their useless methods.

      2. MadisonMD says:

        WLU:
        Another–perhaps simpler– explanation is placebo by proxy. Since animals cannot report their symptoms, all outcome reports are obtained through a human observer. The human observer would look for– and likely perceive– a more upbeat behavior in an animal after placebo treatment, whether or not there was a meaningful change in behavior (the behavior which indirectly reflects the actual but inscrutable feelings of the animal).

        [Of course such bias could be eliminated by blinding the human observer as to whether or not the intervention occurred.]

  14. Sugarbubbie says:

    Does any of these studies ever delve into the psych makeup of these patients? As a breast cancer patient I’ve been approached more than once to participate in “trials” like this and I’ve always said no. Because I am not a believer in quack medicine. So how many more of patients like me aren’t included in these studies, in other words……are you getting participants who would be more likely to believe this hype? You know, kinda like when you have hypochondriacs going to the dr all the time.

    1. Andrey Pavlov says:

      An excellent comment. And one that has been addressed here from time to time as well. When you are touting a CAM methodology or looking to see if open-label placebo works, the people who agree to participate are much more likely to be those already inclined to believe in such things. All studies have a selection bias, some greater than others. I don’t know that it has been quantified but I think it is reasonable to think that those who would be CAM type studies are at least a somewhat self selected group.

  15. Greg says:

    It is laughable for the authors to write that RA and SA were both effective. I don’t know how many people would fall for that but it seems they must consider the general public to be very dull witted.

    Anyhow I just want to say thanks for another illuminating post. I have to admit that I have been taken in by some sCAM artists but this blog has opened my eyes to the disenginuity of sCAM proponents

  16. Frederick says:

    effective.. in what proportion Placebo is around 30%, if a drug was only efficient on 30% of people, even if it was a real effect not placebo effect, it would not be called effective. But of course sCAM always use double standard.

  17. PMoran says:

    Steve can claim the study shows “acupuncture doesn’t work” by imparting a specific meaning to the word “acupuncture”, one which inextricably links the practice to ancient Chinese medical theories. Then the trivial difference between “sham” and “real”, in a medical interaction that actually has the potential to recruit a variety of other everyday therapeutic influences, comes to have overriding significance in its interpretation .

    If you ask a different question e.g. “is this kind of intervention nevertheless of benefit to some recipients” as the authors and many others interested in acupuncture are clearly doing, it is apparent that this study alone offers no conclusive information one way or the other. To answer that question you would need to have included a randomised “no treatment” group (perhaps “waiting list”) in order to “control for”a likely subsidence in symptoms such as these with continued use of the drugs.

    We can predict the results of such a study. They almost always show both varieties of acupuncture producing better reported outcomes, sometimes substantially, than patients receiving normal medical care.

    There are potential confounding influences both ways in those studies, that I will not go into. All I want to say is that Is that for this reason we do not have a clear answer to this second question.

    From certain points of view Steve’s answer may be an adequate approximation of “the Truth”. From others, including having the fullest understanding of medical interactions, and not standing in the way of optimal care for any who may be receptive of and responsive to acupuncture, I am not so sure.

    ( I have made it clear that there remain reasons why the mainstream might choose not to include it in the routine care of any condition.)

    1. Pmoran – I disagree. I am not “imparting” a specific definition to acupuncture. This is the accepted definition, the one used by the authors in that very paper. It is up to researchers to give a specific definition of what they are studying. By their own definition, acupuncture did not work.

      Also – this is not tied to any mechanism – it;’s just an operational definition about procedure.

      I further explained that in other studies when the pricking of the skin is controlled for, that variable does not matter either.

      I also disagree that studies using a no-treatment group will give us any convincing answers. Such comparisons are necessarily unblinded. Unblinded comparisons of subjective outcomes are essentially worthless, and will never settle the debate.

      In any case – randomly poking the skin with toothpicks is so far removed from acupuncture, that it is misleading to call it acupuncture. If you want to study counterirritation through superficial skin stimulation, then study that. Don’t call it acupuncture.

      1. PMoran says:

        Steve Novella: “I further explained that in other studies when the pricking of the skin is controlled for, that variable does not matter either. ”

        When adequately controlled for, the patient still believes that the skin is being penetrated and there will be some confirmatory sensation.

        The sham thus still provides a plausible basis for distraction from symptoms, and other psychogenic responses, possibly including the release of endorphins or other neurophysiological effects. (Andrey’s story should cause pause for thought.)

        ” I also disagree that studies using a no-treatment group will give us any convincing answers. Such comparisons are necessarily unblinded. Unblinded comparisons of subjective outcomes are essentially worthless, and will never settle the debate.”

        All I claimed was that ” — we do not have a clear answer to this second question”, — which the above suggests you accept to a degree (the second question was “is this kind of intervention nevertheless of benefit to some recipients”)

        You have not yet expressed an opinion on that question. Why is that? Do you not wish to muddy the waters — you want to keep things as simple as you can?

        I can understand that urge, while being less accepting now than I once was that “near enough is good enough” is a desirable strategy for either scientific or practical medical objectives, especially when there is a question of patient benefits for whatever reason.

        I think that respecting the public, by taking them into our confidence, and admitting uncertainty where it exists, might do wonders for a sometimes strained relationship; whereas dogmatism for reasons that are hard for the public to follow, and which is not shared by some fellow scientists and professional bodies, who we then have to also savage, may have the opposite effect. It can look as though a scientific elite begrudges even the possibility of medical benefits that we have not provided or given prior approval to.

        “If you want to study counterirritation through superficial skin stimulation, then study that. Don’t call it acupuncture.”

        The scientist in me agrees with that. Yet a program of “acupuncture” can evoke many other influences: relaxation, “time out”, distraction, ongoing practitioner interaction, even possibly acting in some as a late resort “illness-mode-breaker”, that would be difficult to mimic with any proven mainstream method.

        As a package of care it may thus be an unusual mixture of frank placebo and credible and perhaps (usually modest) therapeutic influences. There is nothing comparable within the mainstream although massage might go some of the way.

        So the practical physician in me is still searching for what to say to someone with a condition that I have not been able to quickly resolve, such as chronic pain, or low back pain asks “would acupuncture help me?” I would feel justified in saying “some think it helps — would you like to try it?” but not the excessively semantics-dependent “‘It’ doesn’t work”.

        When I raise these matters I get swamped with “we don’t mean that” or “but you don’t understand such and such” and various mischaracterisations.

        The simple fact that I am working from is that even with chronic conditions for which the mainstream has no very good answer, “acupuncture” (in the broad sense that includes sham) is shown in numerous studies to significantly improve reported outcomes (not patient satisfaction, Harriet, but symptom levels on “validated instruments” and sometimes pill counts, migraine diaries and such like) .

        The onus is on us to show that these patients aren’t really feeling better, if that is the position we want to back ourselves into with the bald “acupuncture (now not defined precisely) doesn’t work”. (Note that the design of the studies I refer to makes another option, spontaneous changes in symptoms, unlikely — that is controlled for, to at least some extent, by “usual care” or “waiting list” groups.)

        This is obviously not going away, and not because of the “bad science” that I agree is often displayed by acupuncture researchers, but because there is a body of evidence from a variety of sources suggesting that there is “something there”.

        1. MadisonMD says:

          … whereas dogmatism for reasons that are hard for the public to follow …. may have the opposite effect.

          This, in my mind, is paternalistic. You are underestimating the public and your patients. it is necessary for a physician to be absolutely honest and to explain recommendations in a manner that is understandable.

          The simple fact that I am working from is that even with chronic conditions …, “acupuncture” … is shown in numerous studies to significantly improve reported outcomes…

          Why do you fail to admit the effect is non-specific? You have previously asserted that acupuncture recruits stronger placebo effects than other modalities– without any evidence for this assertion. If you could substantiate your assertion, then there is something to discuss.

          So the practical physician in me is still searching for what to say to someone … [who] asks “would acupuncture help me?” I would feel justified in saying “some think it helps — would you like to try it?” but not the excessively semantics-dependent “‘It’ doesn’t work”.

          So, to be consistent, I suppose you would say the same ofPerkins tractors?
          I think the honest–and ethical– answer would be: “Acupuncture makes some people feel better and has some risks. However, research has shown it works as a placebo. You might be able to get similar effects with lower cost and fewer risks through relaxation, massage, or a nice glass of wine.” If pressed, I would state that acupuncture doesn’t work and recommend against it. To be entirely consistent, I would say the same if asked about Perkins tractors.

          1. Andrey Pavlov says:

            Madison, it is beyond clear now that Peter is not at all being consistent – not across the board and not with reality.

            What we can say, and should say, about acupuncture is “Some people do report they feel better with acupuncture, just like some people report they feel better from voodoo spells, homeopathy, and massage. I would recommend massage over acupuncture since there is much less risk associated with it.”

            “Wait doc, are you trying to tell me acupuncture is a placebo?”

            “Well, pretty much yes. It is a way to relax and release stress and tension that some people like, just like some people like deep tissue massage or Swedish massage or a jacuzzi. The problem I have with acupuncture is that they stick needles in you which does carry some risk with it, whereas getting a massage or sitting in a jacuzzi with a beer has much less risk. The key is to find a way that works for you to relax and feel better without taking unnecessary risks. The one thing we do know is that the needle part of acupuncture is not a necessary part of the effect people feel from it.”

            1. MadisonMD says:

              @Andrey:

              Your counseling is 100% honest and consistent with the best scientific evidence available to date. On this basis, it should pass muster with Peter and with any ethical standard of medical practice.

              I think it paternalistic, unfair, and dishonest to hide the lack of efficacy, as Peter is proposing to do with his hypothetical patient.

              1. Andrey Pavlov says:

                @Madison:

                Thanks. This sort of approach – tailored to the patient, for example I would not recommend jacuzzi and a beer to an elderly person or someone with orthostatic hypotension – seems imminently reasonable to me. Peter’s approach of just saying “Some people seem to be helped by it” is indeed technically true but I also think lies by omission of what we do know and what we can reasonably expect our patients to want to know. Patients do not want to be lied to and they want something that works, but not in the highly pedantic ivory tower sense that Peter is splitting hairs over. They want something that actively, directly, and unambiguously works. Now, obviously we can find exceptions to everything and I have had patients that flat out say to me “Doc, you’re the doc. I don’t need no explanation, you just do anything you think you need to do and tell me what I have to do.” They are consciously and willingly abdicating their autonomy to me. Which, quite frankly, I don’t prefer because now I have a lot more responsibility on my shoulders. I do it, because it is a reasonably uncommon occurrence and because I believe that physicians have a higher level of onus to bend over backwards for their patients (e.g. I have “prayed” with patients in dire circumstances because they initiate it and ask and I know it will be more harmful for me to say I am an atheist and think all that is horse hockey).

                The point is, Peter’s tack first makes an unwarranted academic and scientific assumption and second makes an unreasonable and unethical assumption on the part of his patient. He quibbles incessantly about what “work” means and ignores the fact that this is not at all what the average patient will care about or have in mind when (s)he asks what “works.”

    2. windriven says:

      ” To answer that question you would need to have included a randomised “no treatment” group (perhaps “waiting list”) in order to “control for”a likely subsidence in symptoms such as these with continued use of the drugs. ”

      Or perhaps a control group where an NP or PA has a nice cup of tea with the patient while discussing the pain, then gives a thorough massage. I’m not kidding.

      1. PMoran says:

        Andrey: “You go off on me (and us) about being utmostly scientifically rigorous to the point of being ridiculously pedantic about defining what “works” means and then you take this paper – in which the authors themselves define what acupuncture is!!!! – and then disagree with our assessment that it doesn’t work by inserting a different definition of acupuncture than the authors themselves used. On what planet is that being scientifically rigorous? ”

        Did I defend that? If so, inadvertently, but Steve’s approach has always been to define acupuncture a certain way and then interpret the studies in that light when heading towards his bald “‘it’ doesn’t work” conclusion.

        That is what I was responding to, while drawing attention to the fact that there is another concept of “acupuncture” (as the term is commonly applied), as a “complex intervention”, that many here seem unaware of, and to which such studies are virtually irrelevant. They are meaningful only if you want to take ancient Chinese medical theories seriously, although it is perhaps impossible to completely avoid the influence of that mystique.

        It is clear that many acupuncturists (Kaptchuk is an example) are having to revise their opinion on acupuncture, as the result of negative studies like this, while still not being quite able give up the impression that it does work — somehow.

        The authors are reflecting similar tensions, created by the failure of their own study to show what they hoped for. Thanks for the further information about the study’s flaws, which don’t affect the point I am making about the general body of evidence on acupuncture.

        If anyone wishes to challenge my basic point, they need to show that the reported benefits from “acupuncture programs” of various types in many OTHER studies, many reported upon here, are entirely, or very substantially, due to patient reporting biases. I would be very interested to learn how to do that.

        The reductions to absurdity are fun but not really apt. To be comparable there need to be studies showing that indistinguishable “sham” puppies (or sham cups of tea with sham nurses) produce considerably better reported outcomes than no puppies or added attentions at all. That is what the “acupuncture science” is suggesting.

        1. MadisonMD says:

          If anyone wishes to challenge my basic point, they need to show that the reported benefits from “acupuncture programs” of various types in many OTHER studies, many reported upon here, are entirely, or very substantially, due to patient reporting biases. I would be very interested to learn how to do that.

          Whoa– out of the way! Did you hear something?

          1. Andrey Pavlov says:

            Notice how he not only moved the goalposts but completely sidestepped the fact that his comment was specifically about this paper and this post? The moment I demonstrated that he was 100% off the mark in his comment, (by, I might add, reading the entirety of that horrible study for which I feel dumber for having read it) he simply sidesteps it – without being person enough (I know the term is “man enough” but I think that is unnecessarily sexist) to admit his profound error – and moves them goalposts not just further but to an entirely different sport.

        2. windriven says:

          Peter,
          I’d like again to suggest an acupuncture study where the control population gets meaningful interaction with a trained massage professional who has received additional training to provide empathetic verbal responses and a spiel about a (placebo) transdermal lubricant all delivered in a non-threatening setting.

          This avoids all the crap with toothpicks and meridians and whatnot. The basic concept is to match a non-intervention with what we believe to be a bogus intervention. The null hypothesis is simply that acupuncture offers no benefit over empathetic discourse and massage. The length of “treatment” should be matched, e.g. 30 minutes of talk therapy and massage versus 30 minutes of acupuncture. The massage would be performed with a placebo ‘medicinal’ dermal lubricant.

          We have the pitch (discussion of acupuncture versus discussion of the (placebo) transdermal ointment) , we have the empathy, we have the physical contact, and we have the intervention (medicinal lubricant v needles). Who needs placebo sticks? If acupuncture can’t beat a cuppa and a massage then why would anyone continue to talk about it?

          It is not striclty blinded, true. But the therapies are both (given the null hypothesis) placebos. The acupuncturists believe in acupuncture. The massage therapists can be told that the ‘medicinal’ lubricant is the best thing since oxycontin. So in that sense it is blinded in that neither group can be expected to recognize whether or not theirs is the control group.

          1. PMoran says:

            interesting study, and thanks for thinking things through to this, but I am not sure what conclusions you could draw if there were equivalence.

            As with acupuncture, massage is not obviously a simple placebo in the sense of something which lacks any intrinsic physiological activity. I am sure this is why some conventional circles are interested in acupuncture, reasoning that it shouldn’t attract the same opprobrium that frank placebo use can.

            Thus, massage can induce profound relaxation and a sense of well-being . It can also distract from symptoms. Whether any neurophysiological responses would be the same as with the thought of “needling” is a question.

            Both programs would almost certainly improve coping with the condition being treated. You may have merely created another option that we are not quite sure what to do with.

            Certainly, should a massage program (alone, without the magic cream)) perform as well as acupuncture in a target population, then I would go for it rather than acupuncture, simply on the grounds that many will feel more comfortable with it. I have no special brief for acupuncture. It merely does pose some special questions through what it seems able to achieve in clinical studies in some populations..

            1. Andrey Pavlov says:

              I have no special brief for acupuncture.

              Bullshit. And that is painfully obvious to everyone but you.

              It is maddening how incredibly unscientific you are in your thoughts on this topic. No, the reason we would go with massage over acupuncture even if acupuncture proves better than massage is because we are not inventing magical bullshit as the mechanism for massage and we are not exposing our patients to the increased risk of penetrating the skin with needles, instilling magical thinking, and all the other baggage that comes along with acupuncture. We here operate in the real world, not your imagined world of “acupuncture as defined by Peter Moran.” There are many more considerations to acupuncture use that you completely ignore.

              So maybe you are “not quite sure what to do” with massage if demonstrated equivalent to acupuncture, but us here in the real world who use objective and rigorous scientific thinking do. And it is plainly obvious. You ditch the magical bullshit with risk of penetrating needles for the much less risky and just as effective program.

        3. MadisonMD says:

          The reductions to absurdity are fun but not really apt. To be comparable there need to be studies showing that indistinguishable “sham” puppies (or sham cups of tea with sham nurses) produce considerably better reported outcomes than no puppies or added attentions at all. That is what the “acupuncture science” is suggesting.

          You miss the point entirely. You are sharper than that. Windriven and others were not being absurd. The point is that the effects of acupuncture are completely nonspecific. Windriven and others merely proposed to reveal this by including a control intervention that most subjects would find comforting.

          1. Andrey Pavlov says:

            He is sharper, which is why he has been able to weasel his way around this topic for a long time. This time he gave up the ghost though and it is clear he has a soft spot in his head for acupuncture which he justifies by defining it in a way discordant with reality.

        4. weing says:

          “If anyone wishes to challenge my basic point, they need to show that the reported benefits from “acupuncture programs” of various types in many OTHER studies, many reported upon here, are entirely, or very substantially, due to patient reporting biases. I would be very interested to learn how to do that.”
          Extraordinary claims require extraordinary evidence. The onus is on the acupuncture studies and you to prove that the benefits are not due to patient reporting biases. I will patiently continue to wait until you learn to do that.

        5. Andrey Pavlov says:

          No Peter, you do not get to weasel out of this one.

          You clearly made clear statements using the word “clearly” about this study and this post. You don’t get to pull a fast one and say “oops, but my point still stands.”

          No it does not.

          I didn’t realize just how apt I was when I described you as the utterly ridiculous and intellectually dishonest “Sophisticated Theologians” who are arguing for the existence of a god that nearly nobody else actually believes in or argues about. You do not get to substitute your hifalutin idea of what “acupuncture” really means when it is blatantly obvious that the overwhelming and vast majority of actual acupuncture studies are precisely what we here – Dr. Novella included – describe it as. You do not get to have your holier-than-though “I am so much more nuanced and rigorous than you” attitude and say we are arguing against a straw man when in reality is is you arguing against a straw man. Get your head out of your ass and actually read the papers rather than assuming that they clearly must mean something about acupuncture that they clearly do not. You are arguing for an “acupuncture” that is not being studied, that is not being used in the real world, that is not what people actually think of when they think of acupuncture.

          Even readers like Mouse, who are not at all medical scientists but can clearly demonstrate critical thinking and incisive wit, managed to get your goat because of how incredibly lazy and obviously biased you were in this comment. And legitimate researchers of medical science – you know, a guy who has an MD and a PhD and does active clinical trials – can see right through your muddied and unscientific thinking. You are smart enough to be very slippery but this time you really let your deep bias and favoritism for acupuncture show through. Unless you’d like to argue that the authors studying the effect of acupuncture on UTI were clearly looking at non-specific effects of how feeling better about your UTI can actually treat the UTI?

          So no, your basic point is challenged by the fact that it doesn’t exist in the real world. You are arguing in an empty room with your eyes closed believing you have an audience.

          And with these latest comments you have lost the last shred of respect for you I had, whether that means anything to you or not. And with this level of lazy commenting and random jabs just to spout off your nonsense, you would have to have some serious gall to accuse us of a lack of scientific rigor. Scientists study the real world not the made up bullshit you think we are talking about. Go armchair philosophize about invented ideas that have no bearing on the actual word somewhere else. This is Science Based Medicine.

      2. WilliamLawrenceUtridge says:

        Counsellors who specialize in health-related coping would be a superb control group for most CAM trials. An absolute necessity for any test of homeopathy (not that any money should be wasted on such nonsense). You could even skip the massage, just a sit-down and chance to discuss their pain and symptoms with someone who knows enough to understand what’s going on with the disease.

    3. Andrey Pavlov says:

      Well, Dr. Novella already beat me to the punch, but seriously Peter? Seriously?

      You go off on me (and us) about being utmostly scientifically rigorous to the point of being ridiculously pedantic about defining what “works” means and then you take this paper – in which the authors themselves define what acupuncture is!!!! – and then disagree with our assessment that it doesn’t work by inserting a different definition of acupuncture than the authors themselves used. On what planet is that being scientifically rigorous?

      Your bias is becoming more and more clear with each post. Every time acupuncture is mentioned here you jump all over it, completely ignoring everything written here and in the article itself to try and insert some sort of meaning that you want in order to save the paper from our “horrible dogmatism.” It is like Jerry Coyne and the “Sophisticated Theologians” who argue that “god” is a “ground of being” rather than a guy with a beard in the sky. They argue that nobody really thinks he is the guy with a beard in the sky because that is just silly, but instead is some esoterically hifalutin idea of grounded beings and such, when in reality that does not comport with what religious people actually believe.

      You do the same thing here. You are trying to argue that we are using the wrong definitions of “acupuncture” and “work” and inserting these hifalutin twisted philosophical outlooks and saying patently ridiculous things like:

      If you ask a different question e.g. “is this kind of intervention nevertheless of benefit to some recipients” as the authors and many others interested in acupuncture are clearly doing,

      Really Peter? They are clearly doing that? And it is we who are foisting the definition of “acupuncture” as that which is inextricably tied to ancient Chinese practice?

      From the article itself (as Dr. Novella pointed out already):

      Acupuncture is a traditional Chinese medicine technique that involves inserting filiform stainless steel needles into specific points in the body to achieve therapeutic effect.

      Let’s see… traditional Chinese medicine… specific points in the body… for therapeutic effect. So is it we that are linking “acupuncture” inextricably to ancient Chinese medicine?

      From their discussion they say:

      The acupuncture points used in this study were designed to treat AIMSS; however approximately 60% of the acupuncture points overlap with those used in treating hot flashes, which may explain the significant improvement in hot flashes in the RA arm

      They are assuming that the specific points actually matter and, when their primary endpoint of AIMSS outcome was not statistically significant from baseline they did “multiple post-hoc subgroup analyses” and after dredging the data for a while pulled out hot flashes as having significant improvement. They then posit that this may be explained because the specific points for the therapeutic effect of acupuncture in hot flashes overlapped by 60% with those for AIMSS improvement that this was the mechanism by which the effect was achieved.

      So, how is it that we are making the definition of “work” and “acupuncture” something other than what the authors actually intended?

      In fact it is you that is inserting some definition other than what is both popularly accepted and what the authors actually clearly mean – that acupuncture is a traditional Chinese medical intervention which uses specific points to achieve an actual therapeutic effect. I really don’t understand your bias in trying to rescue all these execrable studies as if they are really trying to say what you wish them to say instead of what they are actually saying, as the authors themselves say!

      But since I’ve now read the full paper, perhaps a few fun tidbits about how incredibly bad this paper is?

      First off, they had “missing data” at each and every single assessment point of the protocol. Here take a look.

      There was no difference between baseline and 8 week assessment. Let me repeat that – no difference in either arm. Until they broke up the arms separately and looked at individual components of the questionnaires that they used. Here, take a look.

      They did twenty four subgroup analyses, none of which were the primary endpoint and found 8 statistically significant results. Of those, 3 were in the sham arm and 5 in the “real” arm. Already looks like a pretty random distribution. Of the two where the “real” arm was significant but the sham arm not, both demonstrated a significantly different baseline in the “real” arm with the “real” arm being much worse at baseline than the sham arm. In one of those cases the sham arm actually had a better end score and in the other they both ended up at the same end score (gee, seems like some regression to the mean there, don’t it?). In pretty much all subgroups looked at the end score was ultimately the same with the exception of HFRDI where the sham arm had a better end score than the “real” arm.

      So, how does this demonstrate any benefit to the patient, by any means, even the ridiculous one that you are putting forward as what the authors mean even though they don’t really mean it as clearly stated in their own paper?

      And of course, if you look at all their metrics, including the “multiple post-hoc subgroup analyses” that they did, they all have a huge variation around the mean. In fact, in literally every single one the variation was much larger than the actual reduction in symptoms with all cases having some worsening of reported symptoms.

      And of course, age and ethnicity were completely data dredged to try and find some benefit since basically nothing in their primary or secondary endpoints actually demonstrated benefit! Not between arms and not from baseline!.

      But of course, taking all of this they conclude:

      In our study, we used both nonpenetrating needles and nonacupuncture points as SA, which still significantly improved some patients PROs, suggesting that our sham control may not be inert…

      (emphasis mine)

      They throw in one line and quickly ignore it:

      The lack of between group difference may also be explained by the small sample size of the current study.

      That’s it. Everything else is about how the shams in acupuncture are hard, and there must be some sort of physiologic activity (not placebo activity!, but actual physiologic activity) of sham that mimics “real” acupuncture.

      They go on to say:

      The primary endpoint of this study was the improvement of AIMSS [which was not seen!], and it was not powered to detect… differences between RA and SA in improving PROs like hot flashes

      Yet… their entire positive result is based on what exactly? Oh yes, the differences between RA and SA in improving PROs and their biggest post-hoc subgroup finding? A difference in hot flashes. In specifically AA women. Which they state quite clearly they cannot detect. They even go on to discuss how all drugs used for hot flashes (except clonidine) have a larger effect size than what they have observed, even assuming that they observed anything at all! Oh and wait, it gets even better!.

      It is noteworthy that the median reduction in hot flash severity score for the SA arm was 54%, although the mean percentage… score increased by 79% because of 3 outlier patients who had significantly worsened… scores

      (emphasis mine)

      So they actually had a worsening of the hot flash severity but chose to negate the effect of what they called “outliers” by using a median score instead of a mean score. Dr. Novella might call that “researcher degrees of freedom” and I might agree. At least we can try and figure out what dead salmon are thinking about.

      So after every analysis of primary endpoint fails, secondary endpoints are basically worthless and, as they admit themselves, underpowered to detect a difference anyways, and post-hoc subgroup analysis that is literally data dredging all of which shows literally zero benefit to the patient by any conceivable mechanism (what the authors actually mean or what you decided you think they mean without even reading the paper), they are so convinced that “acupuncture works” (which means beyond placebo, as is absolutely clear from the paper itself) that they posit that the sham acupuncture must also be physiologically active somehow.

      I could go on even more because of how incredibly, horribly, terrible this study is. But I’ve wasted enough of my time on it.

      And you accuse us of being unscientific in our assertions and claims regarding acupuncture and its study? And that our “dogma” has inserted meaning into this specific paper such that it is we who are arguing against a straw man?

      You should be ashamed Peter. You are doing the very thing you consistently accuse us of doing and without even reading the paper in question. You try to show we are wrong and dogmatic by changing the definition of things as you see fit without doing a reality check of what the authors actually mean. You assume that some benefit was shown to patients by acupuncture (assuming it is by non-specific effects) when the paper shows absolutely nothing of the sort, and can show nothing of the sort. You say that we show it doesn’t work by saying we pick a definition by which it cannot work, and that the authors clearly mean something different when it is beyond abundantly clear that they do not and even more clear that you didn’t even bother to read what Dr. Novella wrote, let alone the actual paper. You’ve assumed that “acupuncture works” by your definition and using non-specific effects and that others who research it use that paradigm by which to investigate it, which is absurdly false.

      You should not be lecturing us on being scientifically rigorous and should instead actually put in the work to be so yourself rather than speaking from nothing but your own bias and substituting what you think into what is actually being done. You should not let yourself be in a position to be schooled so hard by a newly graduated physician, it is just embarrassing.

      I’ll let the last paragraph of the actual paper which you didn’t read speak for itself:

      Our study was limited by its small sample size, which was not powered to detect differences between RA and SA, and by a lack of usual care group to determine whether SA is an active intervention beyond regression to the mean. Our trial demonstrated that, in patients with early stage breast cancer who were receiving AI’s, some PROs, especially hot flashes, improved significantly after 8-weekly RA or SA, although there was no significant difference between responses to the 2 interventions. Failure to observe between group differences may have been because of the small sample size of the trial and because SA may not be inert. It is noteworthy that no significant side effects were associated with either intervention. Further studies of a larger sample size are required to definitively evaluate the benefit of acupuncture

      Literally not a single thing in that paragraph is supported by the actual data of the paper.

      1. Harriet Hall says:

        I think I may be beginning to glimpse part of what Peter is advocating: patient satisfaction. If a patient feels that “something is being done,” that has some value to the patient’s psychological well-being, at least temporarily. But how could we measure that transient value compared to the harm it can do? Acupuncture is admittedly very good at eliciting placebo responses and patient satisfaction, but it involves false hope, the unethical use of placebos, time and money spent, etc.

        Peter has been repeatedly asked to explain himself in a guest post. This continual sniping is tiresome and unproductive.

        1. Andrey Pavlov says:

          I am beginning to think it is even deeper than that. My last couple of “big” tangles with him have revealed that he simply cannot believe and cannot accept that people with drastically different worldviews that cannot comport with scientific reality can still “do” science, either by publication or reference of scientific studies.

          Note that he clearly and without reservation assumes what the authors of this particular paper must have been thinking and even goes so far as to say that it is clear that this is what they were thinking, despite the fact that the actual paper unequivocally demonstrates that to be false. He is inserting what he is thinking about acupuncture studies into what the actual researchers are. Now he sort-of attempts to justify this by implying that this substitution of working paradigm doesn’t matter and/or that said researchers “clearly” are working under that same paradigm.

          The problem is that the latter is demonstrably false if you just read the paper and the former is simply untrue. The framework by which you approach the development and analysis of a research project heavily influences the outcomes, particularly the significance and implications drawn from it (once again as this paper demonstrates quite abundantly).

          And of course, all of this was done with actually reading the paper! Worse than that, also done by completely ignoring what was in this post in regards to what the authors themselves defined as “acupuncture.” Peter is doing much more than arguing that patient satisfaction is beneficial to patient well being (another can of worms I won’t digress into) – he is also arguing that just because it appears in a peer reviewed journal and cites other peer reviewed literature the authors themselves must have the same scientific framework he has in mind because he simply cannot imagine it any other way.

          In many cases he can slip away with that, but not in this case. Here it has blown up in his face because there is simply not possible way anyone without a radically different paradigm than his can interpret this data as demonstrating any beneficial effect regardless of what you think the mechanism may be. A 24 sub group analysis on an sample size of 47, none of which were primary endpoints, none of which were even powered to answer the question, and additional post-hoc subgroup analysis? All of which showed basically nothing, except for one which was post-hoc and required a minimization (without justification) of “outliers” in order to exist?

          There is simply no possible way that any of what Peter wrote could possibly be correct in regards to this paper or this post here at SBM and his bias in merely reflexively spouting off pro-acupuncture piffle has blown up in his face this time. He wants to talk dogma of SBM while writing completely uninformed opinion like this which is painfully obviously just something he made up out of thin air without even remotely reading anything relevant to the discussion. And we are the ones who reflexively dismiss “non specific” and “placebo” effects because of our dogma.

          I’m sorry Dr. Hall, but I am (obviously) indignant right now. In every conceivable sense Peter should know better and has finally revealed just how little interaction he has with reality in his ongoing bias towards acupuncture and against us, particularly myself and Dr. Gorski. I will pull no punches because he deserves no leeway here.

          I’ll be much less inclined to engage him in the future since he is obviously being lazy about these sorts of discussions and doesn’t deserve the amount of thought and effort I put into my own side of the discussion. He’s no better than the creationist who comes in and snipes some random BS that has nothing to do with the actual topic of discussion and made up off the top of his head. And yes, I hope that stings Peter. Sack up and actually read what is written and the papers instead of just asserting you are correct because you and you alone have the more sophisticated and nuanced understanding of what people really mean.

        2. WilliamLawrenceUtridge says:

          I always thought Pete was barking up the “patient satisfaction” tree. My interpretation of his comments was usually along the lines of “if they say they feel better, that is the most important thing”. Coming from someone with such outrage over cancer quackery, I simply can’t understand it. Want someone with cancer to feel better? Stop giving them chemotherapy, they’ll feel great. Too bad they’ll die of cancer that much quicker, but at least they’ll feel better!

          That’s why I stopped reading his comments, just the replies to them. Saves time.

    4. MadisonMD says:

      “Acupuncture doesn’t work”

      So, previously, PMoran claimed this false based on the “special meaning” applied to ‘work.’
      Now PMoran claims the verity depends on the “specific meaning” of acupuncture.

      What’s next? Obviously, he argues the definition of “doesn’t.”
      ‘Sophistry’ keeps leaping to mind.

      From certain points of view Steve’s answer may be an adequate approximation of “the Truth”. From others, including having the fullest understanding of medical interactions, and not standing in the way of optimal care for any who may be receptive of and responsive to acupuncture, I am not so sure.

      Yes, indeed, I feel it strongly now. ‘Sophistry’ leaps to mind.

  18. mousethatroared says:

    “The results may be attributable to a placebo effect, but the scientists suggest that the slight pricking of the skin could cause physiological changes. In any case, the lead author, Dr. Ting Bao, a medical oncologist at the University of Maryland, Baltimore, said there is no harm in trying acupuncture.”

    OMG – then grab some pointy tooth picks and have your friend or spouse poke you a several times and be done with it. If the slight pricking of the skin is the thing, then it should work.

    Also, if they’re going to publish this kinda of hype, can’t the intervention at least be more fun. “Holding Puppies and Kittens Equally Effective for Lower Back Pain.

    1. Andrey Pavlov says:

      “Holding Puppies and Kittens Equally Effective for Lower Back Pain.

      Sign me up for that study! Though I am a little afraid of what the control group might be…

      1. Andrey Pavlov says:

        Ah dangit! Of course it clicks right after I had post. I was reading it as holding both puppies and kitten at the same time equally effective to acupuncture and picturing a hilarious sham puppy and kitten holding regimen.

        1. CHotel says:

          It could still be that. I think our options here are to study either:
          1) Kitten vs Puppy vs Placebo/No Intervention
          or
          2) Kitten and Placebo Puppy (stuffed animal?) vs Puppy and Placebo Kitten vs Double Placebo

          In any case, we should get a vacuum for the study area. Is there Journal of Adorable Medical Interventions that we could submit to?

        2. Frederick says:

          We have 5 cats in my home, and they like to massage us, they all have their claws, i just got acupunctured in the face by the our news female kitten. lol

          1. Sawyer says:

            Remember that if it’s winter and the air is dry there’s the risk of a small static shock when touching the kittens. How do we know the benefits you got are from real kitten acupuncture or electro-kitten acupuncture?

            And note that just because the foundations of catupucture are bogus, that doesn’t mean that more modern versions can’t work. Maine Coon cats have carefully refined the techniques started by their Siamese brethren.

            1. mousethatroared says:

              Catupucture! Damn, you beat me to it.

              I get regular treatments of catupucture from my elderly tabby who has claws, poor balance and still like to leap into laps.

              I have to admit his treatments are more likely to acerbate my symptoms than improve them. Maybe he needs CME.

            2. Frederick says:

              That is BRILLANT. I always wonder what i could do with all that static. I though of building some kind of accumulator, or some kind of cats free energy devices. electro-catupunture! All natural!

        3. brewandferment says:

          if you try to hold both puppy and kitten at the same time, unless both creatures have been properly acclimated to each other, what you most likely will get is puppypuncture, followed by a kittenclaw vampire facial to the holder of said small animals, and nearly immediate anointing of puppypee to your genitals or whatever portion of your body is in immediate range of punctured puppy.

      2. mousethatroared says:

        The backstory – In ancient roman times people believed holding a puppy was a cure for many ills. Recently people have noticed improvement in their lower back pain after holding a puppy. An esteemed scientist noted a unique smell around his puppies ears and postulated that puppy pheromones trigger pain relief. The hypothesis, puppy pheromones interact with anabolic hormones to support healing*. The noted scientist decided to do a study. But, what is similar to a puppy, without including the specific puppy pheromone that the scientist wishes to prove effective in healing lower back pain? Kittens, of course.

        The study is a success! It turns out that BOTH puppies and kitten improve lower back pain, in comparison with no intervention. The scientist postulate that perhaps the fluffy texture of the creatures initiates a release of endorphins in patients. More study is needed.

        *I have no idea what this means.

        1. MadisonMD says:

          This is very good, MTR. It certainly establishes prior plausibility. You can send this to NCCAM and get funded. Here are some helpful hints on designing your study to get a good score and to get results you can publish:

          (1) Propose an RCT: puppy vs. puppy placebo (stuffed animal) vs. adult dog vs. no intervention [Always use no intervention arm when proposing to NCCAM; then you and PMoran can point out that for practical purposes, *everything* works!]

          (2) Add some secondary endpoints: include subgroup analysis by puppy age and breed, and by whether the subject actually prefers cats. Keep track of subject race/gender/age so you can do as many post-hoc analyses you will need to get p<0.05.

          (3) Add some cool correlative studies. I’d suggest deep sequencing of Regulatory T cells. Very hot. These little babies might modulate back inflammation, and could well be affected by puppies. Metabolomics or proteomics of scented puppy excretions might also be good. I’m not joking. For inspiration, see this NIH-funded study which is an RCT of acupuncture for xerostomia (dry mouth), with correlative study to see how proteins in saliva change with versus without acupuncture. [What a deal-- only costs US taxpayers $647,171 this fiscal year-- year 3 of 5; you can crunch # to get the total cost-- what a steal!]

          (4) In case your primary endpoint (back pain) doesn’t score p<0.05, you'll still want to publish. So include a host of subjective secondary endpoints (Quality of life, happiness scale, back function scale, and MRI imaging of spine evaluated subjectively by blinded radiologists).

          (5) Be sure to include 'surgery' and pain med use as endpoints. It is virtually certain that interventions will reduce these, even if merely because you are keeping subjects too busy with their puppies. It will help that the subjects that sign up will expect puppies to work. In any case, your findings will reinforce your conclusion that all interventions work and–even if placebo– reduce the rate of dangerous medical interventions. You will get traction with this endpoint even among those with a serious scientific bent.

          There you go. NIH funding awaits.

          1. mousethatroared says:

            Cor blimey! So there’s really money in that? I guess I’m missing out.

            Having spent the week building a praying mantis, leaves and branches from paper clay, paper and book pages I really shouldn’t complain about how other’s spend their time, but…

            1. mousethatroared says:

              Perhaps you have noticed, others shouldn’t have an apostrophe. …just trying to correct a apostrophe surplus I have.

          2. Angora Rabbit says:

            But…but…everyone knows it is really adorable little cuddly bunnies that have the greatest potency! Just visit Cuteoverload.com. But beware because the LD50 can be pretty narrow.

  19. Hey Skeptics!!!
    My post to the original article:
    I’m a general medical doctor of 30 yrs and 15 yrs ago I incorporated Acupuncture into my everyday practice. I must say that there are many misconceptions related to this valuable discipline. Until these misunderstandings of terms are clarified any study or research will have some flaws and thus possibly be invalidated due to a these issues;

    1. Acupuncture actually needs to be defined in modern scientific terms and the standard old traditional terms, which are ambitious. Acupuncture is not the same and can vary depending on the regions of the world or training; French Energetic is different than Traditional Chinese.
    2. We must settle the fact that Acupuncture can not be “shammed” due to the inherent nature of the tool used. You can not sham the incredible sensation of a needle and DeQi.
    3. Realize that Acupuncture is much more that a pill and will not fit the parameters use to test chemicals in the human body. It may need to be compared with a surgery or another physical therapy.
    4. Establish new study parameters that will fit all the nuances of the Acupuncture tool’s ability.
    Modern medicine academics must come to grips with the fact that Acupuncture will be a part of our future health care system because it just makes sense. Patients will benefit from the safe and effective therapy along with experiencing better clinical outcomes. Modern medicine has great benefits and when combined with Acupuncture will be of great value to all.

    OK …. will anyone ask the appropriate questions?? If I know anything I know Acupuncture and all of it’s variations.

    1. windriven says:

      Hey Steve – nobody cares.

    2. weing says:

      “You can not sham the incredible sensation of a needle and DeQi.”
      You have evidence for this?

      ” Realize that Acupuncture is much more that a pill and will not fit the parameters use to test chemicals in the human body.”
      You mean realize without testing or evidence?

      “Modern medicine academics must come to grips with the fact that Acupuncture will be a part of our future health care system because it just makes sense.”
      It just makes sense? Again, without any studies or evidence. Wouldn’t marketing, such as yours, and gullibility, of patients and politicos who don’t know any better, be a better explanation for such an eventuality?

    3. WilliamLawrenceUtridge says:

      Stephen, we know who you are, and we know you believe in acupuncture. No need to introduce yourself. Or post at all.

      As for the rest of your points – by saying “acupuncture can’t be shammed”, you’re essentially saying “acupuncture can’t be tested”, which leads to “I personally can always justify never giving up acupuncture”. Which is the real goal of your reasoning.

      While there may not be an absolute 100% sham for acupuncture, we can still test each specific factor. And doing so, we find out that needling location doesn’t matter. You put the needle in the ankle, foot, hand or skull, the effects are the same. We can test for skin penetration in a variety of ways – toothpicks instead of needles, or retracting needles. And doing so, we find out that skin penetration doesn’t matter. We can test for practitioner enthusiasm, and doing so we find that it matters significantly. So what do we ultimately have? It doesn’t matter what kind of acupuncture you use, it doesn’t matter if you break the skin, it doesn’t matter where you put the needle – all that matters is a ritual and a practitioner who thinks they can help. The nuances you calim we need to study? They’ve been studied, and these are the results. Those differences you think are important? They aren’t.

      I don’t really have much problem with acupuncture as long as it’s practiced with shallow, filiform needles, well away from organs, joints, blood vessels and nerves, and not wrapped in science-corroding nonsense.

      Also, in terms of safety – adverse events do exist, including deaths. If you like your evidence a little more anecdotal, you could always google Kim Ribble-Orr.

      Overall, it really sounds like the appropriate questions have been asked – you’re just unaware of the answers. You should read more.

      1. Frederick says:

        So in short you are saying to change the entire process of scientific testing to be sure it become vague engouh so you can prove acupunture work ? so that way you don’t have to face reality and apply critical and rational to you belief and not change them. to stay in you dogma, to never have to evolve, to never have to face you own cognitive biases and logical fallacy.
        Well stay in the dark as much as you want, but don’t tell us ajusting everything so you can make it look like it work, is legitimate or even honest, that just lying.

        1. WilliamLawrenceUtridge says:

          I think you need to work on your threading there boss…

          1. Frederick says:

            I guess you are right.

  20. Sawyer says:

    We must settle the fact that Acupuncture can not be “shammed” due to the inherent nature of the tool used. You can not sham the incredible sensation of a needle and DeQ

    So the collective wisdom of the acupuncture community is that sham acupuncture works and demonstrates the benefits of real acupuncture, and that sham acupuncture doesn’t work?

    Hooray for quantum sham acupuncture!

  21. This is a game to you all … stuck in your science dogma fog. I hope none of you have an authority to make clinical decisions or you will be ripe for conflict of interest or malpractice cases. Do any of you all have valid medical licenses and in what states? I’m sure you medical broads will want to know your positions and biases.

    Acupuncture of many types can work, sham or true … all you have to do is clear the fog and grasp the simple concepts. All these issues can be clarify with a well conceived study.

    weing … 5000 yrs is not enough proof?
    windy … many people in medicine who are about alternatives care. The zealots of science care less about the health and well-being of patients in need.

    1. Sawyer says:

      Yes, clearly everyone here has a terrible conflict of interest by getting paid $0 to leave comments and for adhering to modern scientific standards of evidence. Malpractice suits incoming!

      “I hear the jury’s still out on science” – Gob, Arrested Development

      1. Frederick says:

        Says the man in the 3000 dollars suit. COME ONE!

    2. weing says:

      “weing … 5000 yrs is not enough proof?”

      Proof of what? Are you saying it couldn’t be bullshit? It could be old bullshit.

    3. WilliamLawrenceUtridge says:

      I’ll note, Stephen, that you are sticking to your own dogma, and never seem to engage with the evidence base – only your self-conforming experience. Prescientific doctors (and current acupuncturists) were convinced, by their self-confirming experience, that bloodletting was the optimal treatment for essentailly all diseases. Personal experience may be convincing (to you) but it is extremely deceptive.

      I don’t have authority to make clinical decisions for anyone but myself, but that doesn’t invalidate my understanding of the scientific literature, or my criticisms of your reasoning.

      Prayers to the Egyptian God of Medicine, Thoth, date back 5,000 years as well. Are you going to try that? Also, where is the link between acupuncture as (allegedly) practiced 5,000 years ago, and the current practice of using thin, steel needles? The technology to manufacture thin, stiff, sharp needles like those used currently did not exist until a few short centuries ago. “Acupuncture needles” from 5,000 years ago are more like sharp, spindle-shaped stones. Not needles.

      And have you read Kim Taylor’s delightful book about acupuncture, post-resurrection by Mao in the 50s? Yeah, the “ancient” wisdom you preach about? Its current form dates back to a mere 1% of the timespan you believe it occupied.

    4. Frederick says:

      Conflict of interest? i thought you were the one doing acupuncture, i guess you don,t do it for free, if one doing you see the light and decide to let go you religious dogma about it, And stop doing it and tell you patient ( or client since i doubt you do it for free) “do use Acupuncture anymore it does not work, people are screwing you for your money with it” I guess lot of you patients who are still believer will go see another doctor. So you have all the interest in the world to keep yourself blinded and close minded in you never changing belief ( or DOGMA yes i say it again, you not even capable of using it in the right context so ).

      And yes i”m judgmental, I guess people like you deserve it.

      People like you always want others not to be judgmental of others, and “open minded” but that’s a double standard because you are a bad case of “judgmentalism”. and it is always like that with people like, never listen to others, never accepting anything but what thy thinking is true, despite all evidence ( Confirmation Bias).
      The funny thing, is that everything you “dislike” about us and science ( althought you judgment of it is pretty far from reality), is exactly what do and apply to you comment and argumentation.
      It will be really funny if i did know that you brainwash peoples with those belief

      At least, you have one positive side, You are the perfect example of what is NOT critical/rational thinking, and how not to argue. So Thank for that!

      1. Frederick says:

        sorry everybody Lots of typo here, sorry, french speaking person here, trying hard to type in another language :-)
        “If one DAY [...] couple you that should be your. yeah.. this one is pretty bad

        DON’T use not DO use acupuncture

        “it will be very funny if i DID NOT know that you brainwash”

        I wish for a “edit” post options.

  22. @weing @sawyer yall don’t exist in the real word, yall are just digital avatars.

    1. WilliamLawrenceUtridge says:

      Stephen, you show considerable evidence of being a Turing engine yourself.

      Of course, that’s because you never really engage in the criticisms of your posts, you just flounce off to return and repeat your “it works for me” mantra on a different page. We know it “works” for you, we’ve told you repeatedly why that’s not a particularly convincing claim.

    2. Sawyer says:

      I’m a digital avatar? Oh my. It all makes sense now. I was wondering why so many people told me I should audition for that new Joaquin Phoenix movie.

      In all seriousness, you are more than welcome to ignore every single anonymous commenter on this site. I am not an M.D. and never claim to be an expert on any topic that is addressed here so I don’t feel the need to advertise my personal information. But my attitude towards acupuncture mirrors those here that do have a much more extensive background in medicine. Why aren’t you taking their criticisms seriously? We’re all noticing the exact same flaws and weaknesses in acupuncture research.

    3. weing says:

      “@weing @sawyer yall don’t exist in the real word, yall are just digital avatars.”

      I don’t know what the real word is. OM? It must be magnetic ink. I guess, a thank you for noticing my nimble fingers would not be out of line. So, thank you.

  23. Frederick says:

    In the RUSH song “show don’t tell” there a really nice line i like very much
    – You can twist perceptions, reality won’t budge.

    I think that line reflect perfectly what it is all about here.

  24. DBonez5150 says:

    I’ve seen the acupuncture topic bounce around here many times and it seems the main issue is proper blinding and bias. I have a suggestion for a study, not that I think it would ever happen. Keep in mind this is coming from a layman’s perspective, so forgive the vagueness.

    Design an acupuncture study for low-back pain (for which it has purportedly some benefits) where the patients’ skin is numb. Prior to their session, patients would have a topical analgesic applied to their skin (obviously can’t be with needle sticks) so they cannot detect if they are actually receiving treatment. They could also not be allowed to see which treatment they are receiving, so the use of a massage-type table would be applicable so they lay face down looking down. There would be three arms to the study: real acupuncture (RA), sham acupuncture (SA), and non-acupuncture (NA) groups. Naturally it would have to be designed so each treatment arm was effectively identical (session time, formality, instruments (noises), etc.).

    With the patient truly not knowing which treatment they received, if any, their reporting would be either based on some real effect, their perceived results, or a guess. If done right, it seems the physiological and purely psychological influences could be easily separated. That entire study could be further broken into two sub-groups with one having minimal practitioner interaction and one with nurturing, positive reinforcement interaction. I’m sure the results would be obvious. The faithful will always believe acupuncture works, but imagine if a large, true placebo controlled study showed the results of RA, SA, and NA were basically equal. If the RA results equaled NA, and the high levels of practitioner interaction yielded much greater results, then it would be obvious recommending acupuncture is truly useless. It would also show massage, physical therapy, or even counseling would be far superior. Just a thought. This might make a nice open-challenge for the FoSBM website – which I LOVE by the way!

    1. DBonez5150 says:

      D’Oh! SfSBM, not FoSBM.

    2. WilliamLawrenceUtridge says:

      There’s a multitude of factors that need to be controlled for (and rarely are, and are almost impossible to control for in a single study). Needling location, needling depth, needle material (in Tibet they use gold needles, in years past the “needles” were stone, and quite large), needle size, needle manipulation, practitioner knowledge, practitioner enthusiasm, diagnostic process, type of acupuncture (because it schisms every time it moves to a new country, language and culture), practitioner intention, etc. Your control would add one more factor to be examined, a relevant one, that really controls for patient expectancy – and in my opinion, probably the most important factor. A patient who believes they are getting “real” acupuncture is more likely to report feeling better (much like a patient who believes they are getting the placebo arm of any experiment will report feeling worse).

      Research is hard.

      So while no experimental study can control for all of these factors at once, the interlacing of all the studies consistently point to acupuncture being ineffective for anything but the treatment of pain and nausea, the two symptoms most susceptible to the placebo effect and higher cognitive centers of all known. Which is unsurprising, because our ancestors had no special access or wellspring of knowledge to draw upon, so why would we expect them to get it right? They weren’t stupid, they just preferred retaining their cognitive models as they were rather than testing them against reality.

      Stephen.

  25. cpovey says:

    “Dr. Bao also makes the “what’s the harm” fallacy.” Complete fallacy.

    First harm is in the money removed from the patient for a procedure that his own study shows does not work. These patients may or may not have paid, but real one would pay, and generally a lot.

    Second harm is that a patient might try acupuncture instead of a procedure that does work.

    My question to the good Dr. Bao is why not try a third group, one with a real control, i.e. no treatment or a known conventional treatment? I suggest he is afraid the results would be worse than this negative one, if that’s possible.

  26. coz coleman says:

    I suffer from asthma, using medicine from my doctor it can take a few days to a week for the wheezing then the coughing to stop. I have been seeing a acupuncturist for over twelve years on a regular basis. After one session I stop wheezing and it has never taken more then two days for my coughing to stop. I have had many painful problems with my limbs that have been reduced instantly by acupuncture, my general health is much better after regular treatments, my chronic health issues barely affect me now where I used to spend so much time sick and in pain. I personally don’t care what proof against acupuncture I may read, I feel it works for me. happy day.

    1. Harriet Hall says:

      I certainly understand why you feel it works for you and I would never try to talk you out of continuing it, but did you ever wonder why something that was so effective for you keeps failing in controlled studies? Maybe you are the one person in a million that it works for?

    2. weing says:

      “After one session I stop wheezing and it has never taken more then two days for my coughing to stop.”
      Curious. Do you check your peak flow readings before and after the acupuncture treatments? You’ve been seeing an acupuncturist regularly for 12 years, are you exclusively treating your asthma with acupuncture and no meds for this time period?

    3. WilliamLawrenceUtridge says:

      Coz, have you changed anything else about your life in the past 12 years? Has the acupuncturist recommended things like better furnace filters, improved diet, exercise and sleep, weight loss or anyting similar? 12 years is a long time, and many things can be different in that time.

      Also, “I get a treatment and two days later I feel better” isn’t exactly a clinical slam-dunk.

  27. Jnik says:

    I never really believed in acupuncture

    After a terrible accident 2 years ago, leaving me with a spinal cord injury and paralysis from the waist down, my surgeon recommended adding acupuncture sessions to go along with my physiotherapy.

    I do physical rehab 3 hours a day 5 days a week. Slowly I am regaining more movement below the waist and increased strength.

    I resisted the acupuncture suggestion for 18 months after my accident.
    I revisited my surgeon for a checkup and pain review.
    Again he suggested acupuncture for my back, hip and leg pain.
    Finally, I thought I would give it a go. What could I lose right?

    I might add here that I live in Malaysia and we have many traditional Chinese practitioners in acupuncture.

    After the first 2 sessions I noticed that the areas my Dr worked on the previous day had increased ability to move (a little) over the next week. If the Dr worked on my hip connections, then the following week I found a tingling sensation appear and an ability to contract that muscle a little more.
    I visit the acupuncture Dr for one hour every Wednesday.

    Now, one could say that the increased sensation and sense of movement was solely a result of the intense physical rehab I was undertaking. That’s a fair comment, and what I would tell myself initially as I was still skeptical.

    However, increasingly , I would visit and tell her (the dr) about what I had been working on in rehab the previous week, and what areas where having the major difficulty. For example my right hamstring just doesn’t work at all. I cannot bend my knee.

    She has been working on it consistently, and the following day after a session, my physical therapist sees a contraction in that muscle.

    It cannot be a placebo, as being paralysed , I have no control over what I can move and cannot.

    I have many examples of seeing the doctor for a problem and then in the next week or so, the problem seeing some change.

    I now have no pain in back, hips and legs and am not on medication.

    I don’t know how or why, but for me, I am happy to continue my sessions once a week.

    1. weing says:

      “I have many examples of seeing the doctor for a problem and then in the next week or so, the problem seeing some change.”
      It’s called confirmation bias. I am glad to hear you are recovering.

  28. Fergus Kane says:

    “When the treatment and control groups, in a blinded comparison, show no difference, the only conclusion to draw from that is that the treatment had no measurable effect in that study (in plain terms, the treatment did not work).”

    This is not true. The only conclusion one can draw is that the treatment was no different from the active control. You’d never make the same conclusion if you compared two drugs, with no ‘no treatment’ arm. You’d simply say that they were indistinguishable.

    Steven, although we get the gist, if you wish to pick on other’s dodgy wording and conclusions, you need to be more careful about your own wording.

    1. Fergus – I disagree. The two situations are not analogous, unless one of the drugs was appropriate to use as a placebo because it would not plausibly cause an effect. In that case, I would conclude the study drug was ineffective.

      Sham acupuncture is not supposed to work. That is why it is used as a control. I also was very clear that these types of acupuncture studies show that needle placement has no effect. Other studies show that needle insertion has no effect. Since acupuncture is needle insertion in specific sites, the fact that these two variables do not work, that means acupuncture does not work.

    2. Andrey Pavlov says:

      As Dr. Novella said, this is a patently false assertion.

      If you have something that is supposed to inactive and it appears to have the same activity as what is supposed to be active, it doesn’t suddenly make both things active.

      But this is why it is important to define what you are studying beforehand. Having a pill that contains lactose only and comparing it to a pill that contains glucose only will be expected to have the same effect. So if you are arguing that lactose has some sort of benefit and the same benefit is experienced by glucose, then both do not do anything.

      Same with acupuncture. When you define it to be “insertion of needles in specific points” which is what pretty much all studies on it say, then when you “do not insert needles” or “insert needles at random points” or some combination thereof and it performs the same as what is defined as acupuncture, then acupuncture does not work. You don’t get to then go backwards and assume that acupuncture must be working, therefore your sham/control acupuncture is also active.

      You shift the paradigm and realize that “acupuncture” does not work, but that non-specific effects and placebo does have a non-zero effect. So by all rights, in every reasonable way, it is perfectly correct to say “acupuncture doesn’t work.”

  29. Nik Bryan says:

    I don’t know much about this sort of thing.
    I’m a gardener.
    But what I do know is what to call Complimentary Medicine that actually works…
    it’s called ‘Medicine’

  30. mamma seattle says:

    So sick of the condescending tone of so many “western medicine scientists” here. Skepticism is one thing. Rampant judgment and condescension is another.

    1. windriven says:

      So sick of quacks and their enablers doing drive-bys and scuttling off leaving nothing in their wake but a fetid stench. If you have something useful to add to the conversation, say it.

      Judgment mamma, is fundamental to the functional mind. You might reflect on that. Embracing stupidity because it sounds inviting or is uttered by what seems a well-meaning individual is childish on the one hand and evil on the other.

      Call a quack a quack. Calling him a misunderstood genius is a disservice to both parties.

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