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Urinary Tract Infections Cause Depression. Directors Cut.*

As some may know I am infectious disease doctor. Urinary tract infections (UTI) butter my bread. Figuratively speaking. There is an enormous amount known about the pathophysiology of UTI’s. It is both a common and complex problem. But for all our knowledge, chronic and recurrent UTI’s remain a vexing issue for the patient and the doctor.

One reason people develop recurrent UTI’s is not because of altered chi along meridians altered by needles stuck in the skin distant from the bladder. That would be ridiculous. I like reasoning from basic principles. Given what we know about anatomy, physiology and microbiology, how might acupuncture interfere with the development of a urinary tract infection? Would it prevent colonization with pathogenic E. coli? Prevent retrograde travel of bacteria up the urethra into the bladder? Stop E. coli from binding to uroepithelial cells? Have a bactericidal or bacteriostatic effect?

None of the above seem likely. To my mind, postulating any of the above as a potential mechanism for acupuncture as a preventative for UTI’s would be ludicrous. And spare me your Boosting the Immune System, a concept that exists as a marketing tool, not a useful therapeutic intervention. My boss used to say that many an academic career floundered on attempting to prevent and treat UTI’s using an immune system approach. With some exceptions, and there are always exceptions, recurrent UTI’s in normal humans are usually due to anatomic or microbiological anomalies.

Despite its popularity, it is clear that acupuncture is not based on reality and, like all pseudo-medicine, only has demonstrable efficacy in poorly-designed studies. Acupuncture displays the usual progression of all pseudo-medicines. Increasingly-well-done studies show decreasing effect until a study that removes all bias shows it to be no better than placebo. Which one would expect for an intervention based on fantasy. Prior plausibility (the toy boat of SBM, try saying it three times very fast) would predict that acupuncture is worthless. And that should be acupunctures, all 6 styles are an elaborate ritual with no more likelihood of efficacy than the superstitions in a Budweiser commercial.

Much to my embarrassment, Clinical Infectious Disease (CID), the flagship journal of my specialty, published “Recurrent urinary tract infections among women: comparative effectiveness of 5 prevention and management strategies using a markov chain monte carlo model.” One of the five interventions included in their analysis was acupuncture. Really. They thought a pseudo-medical intervention divorced from reality to be worthy of consideration for the prevention of UTI.

As to be expected, the study generated the usual ‘acupuncture works’ headlines, especially as the analysis suggested acupuncture was second only to antibiotics in preventing UTIs, and better than cranberry pills, estrogens, and symptomatic self-treatment.

Now we get into problems, given my non-statistical brain. What is a markov chain monte carlo model? Fortunately I have a statistician at work who was kind enough to translate statistics into Crislip, a.k.a. dumb it down.

It is a simulation. In this case they simulated 10,000 patients over a year and then summarized what happened on average for each intervention.

Each virtual patient in the model had an assigned probability per day of having a UTI, and there are probabilities for the various interventions being effective. They used an algorithm to determine whether or not a UTI occurs on a given day. That is why “Monte Carlo”: they pick outcomes at random with a certain probability. So if you sample enough virtual patients a UTI will occur roughly the correct percent of the time.

The “Markov Chain” part means that what happened in the past for the virtual patient is irrelevant, all that matters is what state they are in that ‘day’. So it’s a simplifying assumption, which makes evidently makes the simulation much easier.

It is a simulation and, like all simulations, the end results are dependent on how the initial conditions are set.

There is a table of Probability Values for Variables in Model. They have risk reduction probabilities for the interventions evaluated in the simulation:

  • Daily antibiotics/nitrofurantoin, 100 mg once daily, risk reduction 0.86
  • Acupuncture, risk reduction 0.68
  • Estrogen use, risk reduction 0.65
  • Cranberry risk reduction 0.50

I appears to me that the initial conditions are set up to show, as the accompanying editorial says, the ‘surprising’ result that acupuncture was second only to antibiotics in UTI prevention. The order of efficacy that came out of the simulation appears to parallel the order of the initial conditions. Go figure. Again, I am no statistician, correct me if I am wrong.

They derived their probability of risk reduction of 0.68 from two clinical trials. I asked my statistician how that number was derived and he said it was a mystery as he could not tell from the paper and that I should email the authors. As I publish this I have not heard back from the author, who said a week ago they would get back to me. When they do, I will post an addendum.

I would have expected the risk reduction probability of acupuncture to be zero, since there is zero prior plausibility acupuncture would work. It made me curious about the articles that demonstrated efficacy. Both were done by the same authors in Sweden. As we learned from Benveniste and homeopathy studies, the same group doing a study does not a reproduction make.

The most recent study, “Acupuncture Treatment in the Prevention of Uncomplicated Recurrent Lower Urinary Tract Infections in Adult Women”, did not have a sham acupuncture group, so the study is worthless. Equally important is the patients were only followed for 6 months, probably not long enough to decrease normal variability of recurrent UTI’s. What is the natural history of uncomplicated urinary tract infections in women (bold added)?

we observed 51 infection-prone women in a standardized fashion for a median of 9 years. During intervals when patients were not receiving antimicrobial prophylaxis, infections occurred at an average rate of 2.6 per patient-year, but the rate varied widely from patient to patient (range 0.3-7.6 episodes per year). Seventy-three percent of the observed episodes were symptomatic, with an 18:1 ratio of cystitis to pyelonephritis episodes. Infectious episodes were strikingly clustered, and rates of infection decreased in the winter months.

Their microbiologic definition of UTI is probably outdated and would fail to diagnose many UTI’s:

bacteriuria (10^5 or more colony-forming units per milliliter of uropathogen or any amount of Staphylococcus saprophyticus).

As a recent NEJM study, “Voided Midstream Urine Culture and Acute Cystitis in Premenopausal Women”, suggests 10^2 CFU of E. coli is predictive of UTI.

And with a p value of 0.08, it is far from the .005 that would be suggestive.

An earlier study, “Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women”, has the same fatal flaws they were to repeat later: inadequate duration of follow up, an inadequate microbiologic definition of UTI (although of course they could not have known), poor statistical validity and very small numbers in each arm of the study (acupuncture (27), sham acupuncture (26), and control (14)).

There was no microbiologic information in the latest study, but the early study reported 5 patients with enterococcus as the pathogen, with the NEJM article suggesting that enterococcus is not a pathogen in this population.

In the latest study no mention was made as to what mechanisms was used to get follow up, in the earlier study it was patient initiated. We have no way of knowing, given the self-limited nature of cystitis, if patients became symptomatic and did not bother to come in or sought care elsewhere.

And, importantly in the first study, no mention was made as to whether blinding to sham or real (as if there is a difference) acupuncture was successful, which the authors recognize was a flaw with plenty of opportunity for the clever Hans effect (unconscious cuing):

The study otherwise mainly applied a single-blind design, since patients were not informed about the type of treatment they were receiving. It is however difficult to ensure that there was no non-verbal communication about treatment type between the acupuncturist and the patient, and patients receiving real acupuncture may have felt an increased anticipation of an effect.

Two profoundly flawed studies from which no valid conclusions can be made about the efficacy of acupuncture, much less an estimated acupuncture risk reduction of 0.68. There was a recent review of UTI prevention in the Journal of Urology with the same conclusion:

Cranberries decreased urinary tract infection recurrence (2 trials, sample size 250, Jadad score 4, RR 0.53, 95% CI 0.33-0.83) as did acupuncture (2 open label trials, sample size 165, Jadad score 2, RR 0.48, 95% CI 0.29-0.79)

This is a classic example of the difference between evidence and science-based medicine. There is evidence for acupuncture that stinks on ice if anyone would take a moment to read the articles. A science-based consideration of reality, anatomy, physiology, microbiology would suggest that any real risk reduction by acupuncture should be zero. Prior plausibility would suggest any positive outcome in an acupuncture study would be a false positive due to methodologic errors in the study. As we have discussed at great length over the years, there is zero reason to suspect any true efficacy of acupuncture beyond study bias and poor methodologies, which were rife in these studies.

That being said, the authors say:

Somewhat surprisingly, we found that acupuncture was the next most effective prevention method. Acupuncture’s high efficacy may be a function of publication bias, as there were fewer studies on acupuncture compared to other management

No. Acupuncture’s high efficacy was a function of profoundly horrible studies and an estimation of risk reduction that is too large by 0.68. No one involved gives the appearance of having read the original papers to see if the estimated risk reduction is reasonable. The editors and reviewing peers evidently did not as well.

It is an oddity of medicine. I would wager that astronomy journals do not publish editorials touting astrology as a solution for difficult problems. Similarly, psychology journals do not look to psi and chemistry journals do not advocate the methods of alchemy. In medicine, the editors have no problem with suggesting nonsense on the basis of GIGO in their journal. The accompanying CID editorial says:

For example, in an individual case, a clinician and patient working together may opt to use acupuncture in combination with cranberry juice and self- directed therapy at the first sign of symptoms.

Did the editorial writer read the paper? The simulation evaluated cranberry pills, not juice. Goodness gracious great balls of fire, an editorial in CID recommending two simultaneous worthless therapies, acupuncture and cranberry juice. I would so love to have the editors and authors come up with a plausible explanation for how acupuncture may work for UTI prevention and why this simulation had any validity as to the efficacy of acupuncture after reading the original papers. I did not go back and read the papers touting cranberry pills, but my father taught me to judge a risk reduction by the company it keeps.

I used to have a slightly smug attitude about CID since it had been the only journal I regularly read that had not published an article erroneously promoting pseudo-medicine based on bad studies. No longer. And to add salt to the wounds, it comes out of the institution where I did my fellowship. When ID falls for pseudo-medicine (because we are the best and brightest in medicine) we are indeed doomed.

I am so bummed. I am going to have to look into treatment for reactive depression. I wonder if acupuncture would work…

——-

*A much expanded version of an essay from the Society for Science-Based Medicine blog.

Posted in: Acupuncture, Clinical Trials, Traditional Chinese Medicine

Leave a Comment (142) ↓

142 thoughts on “Urinary Tract Infections Cause Depression. Directors Cut.*

  1. Can you pressure them to withdraw the article? I would think most of their readers would object to this nonsense.

  2. windriven says:

    ” As we learned from Benveniste and homeopathy studies, the same group doing a study does not reproduction make.”

    Reproduction? Perhaps not. But nonetheless f**ked up.

    ***

    CID is published by Oxford Journals. Their quality statement reads in part:

    “An integral part of our scholarly mission is to publish journals of the highest quality with the greatest impact, presenting innovative research that furthers future advances. ”

    And looking at it from just the right angle one might indeed call this research innovative.

  3. CC says:

    Wait – they ran a simulation with pre-set probabilities and then were surprised that the result probabilities matched?

    Do they believe that computers do anything other than calculate exactly what you tell them to calculate?

    1. theLaplaceDemon says:

      I was confused by this as well. Surely the model had to be more complicated than that?

      Also, let me raise my hand as someone who has had awful recurrent UTIs for several years in the past. I tried some of the alt med BS (cranberry juice/pills, probiotics, d-mannose) because my primary care provider at the time was very hesitant to put me on prophylactic antibiotics. Guess what didn’t work at all? And guess what worked 100% of the time?

    2. MTDoc says:

      Sounds like “virtual” science to me. Actually, my computer doesn’t always do what I tell it to, but that is because it hates me.

    3. jokke says:

      Hear, hear!

      I sort of run simulations for a living. And, The results are of course never more reliable than the model (and its input). So wtf is this?

  4. Eugenie Mielczarek says:

    Reading the science journals for over 40 professional years has left me convinced there are no “Flagship” publishing houses. Publishers and their editorial boards are not perfect and often cannot recognize mythology. I served on an editorial board for a flagship house for several years–the pressure is to produce products as opposed to scientifically valid information. I made several tries to get the Journal of Orthopaedic research to retract the article which claimed that Therapeutic Touch practitioners ( in a L shaped room) could decrease the growth of cancerous bone cell cultures by waving their hands over the culture plates. Another classic was the medical journal which published the claim that the growth of different cancers could be halted by tuning to specific frequencies of rf radiation . The problem begins with the pressure on educators and especially on science professors to assign only grades above a C students. As a physics professor who taught the pre med physics this pressure came directly from my department chair. Deans and chairs are easily intimidated by students.

    1. goodnightirene says:

      What you report is frightening, but something I’ve suspected in a general sense about ALL education in the last 30 or so years. I saw this in my own college experience (I was a “mature” student having gone back to school at age 30). It was at about that time that “evaluations” of classes and professors were introduced. The result being that professors became fearful of failing anyone, or even being critical.

      During this time I was a TA and graded some essays for an introductory Anthropology course. They were awful! I went through two red pens. They were returned to the students without being seen by the Prof. What an uproar ensued! Most of the papers were regraded upward to my dismay. The Professor expressed sympathy but reminded me that all our jobs (including my paltry stipend) depended on student “satisfaction”.

      1. weing says:

        “The Professor expressed sympathy but reminded me that all our jobs (including my paltry stipend) depended on student “satisfaction”.”
        Guess what our paltry pay is going to be tied to under Obamacare? Patient satisfaction.

        1. irenegoodnight says:

          I’m not sure which aspect of Obamacare you are referring to or how such “satisfaction” is to be measured. Unless you can be more specific, I can only take your remarks to be a personal complaint about Obamacare in general.

          1. windriven says:

            “I can only take your remarks to be a personal complaint about Obamacare in general.”

            Irene, I know you are invested in ACA and I have real regard for you. So I will try to be as relaxed about this as I can.

            The realization that the traditional US health care model is a disaster was and remains very important. It is inconceivable to me that we spend 18% of GDP on health care while our OECD neighbors spend 10 or 11%. If you do the math that works out to roughly $1.25 trillion wasted. So good on President Obama and Nancy Pelosi and all the rest for recognizing this.

            That said, ACA was very poorly conceived, it was drafted without engaging the body politic in an examination of the flaws and problems with the current system, as finally drafted it amounted to little more than modest insurance reform, and it never even tried to understand the inefficiencies that have shaped the old model much less done anything much (I do expect electronic medical records to become useful at some time in the future) to improve them.

            And that’s the good stuff! Because the execution made the conception look good – if such a thing is possible. Incompetence on that scale would have led to (figurative) blood in the hallways in any serious private business. Top executives, conceivably the CEO, would have resigned in disgrace. This was a disservice to ACA and a much more dangerous disservice to government in general because it adds to the perception in some quarters that the government screws up most of what it touches.

            Mr. Obama assumed the presidency with control over the Executive branch and both Houses of Congress. ACA was passed without a single Republican vote – so there is no blaming this on the other side of the aisle. Why didn’t they opt for a single payer system? Or even a single payer running parallel with the existing system? It doesn’t take a genius or, for that matter, an act of Congress to look around the world for models that work better than ours. Denmark leaps immediately to mind.

            What should have been a slam dunk and a rocket that propelled the 44th president to the top tier of US presidents has instead made him look all the chump (don’t even get me started on foreign policy). The program was half-butted to start with, the execution was laughable, and the president didn’t do anything about it. There is a real chance that it will cost his Party control of the Senate in the next election thereby guaranteeing the lamest of lame duck endings to his presidency.

            And I’m saying all this as someone who absolutely knows that the historic health care system in the US is a disaster and was actively rooting for change! How do you take something that can’t be made worse and, at least in the near term, make it worse? It defies my imagination.

            1. Andrey Pavlov says:

              As for precisely how the ACA will affect physician pay, I am not sure, except that more people will be able to pay physicians.

              But the real point is exactly as windriven states – this was health insurance reform, not health care reform. Insurance reform is certainly necessary and in a vacuum is a good move (albeit neutered, as windriven pointed out). But the problem is we haven’t touched the root of why American healthcare is so expensive (and I won’t dive into my thoughts on that at this juncture). So what we have done is just given millions of more people access to a system that is highly inefficient and expensive. That cliff* we have been barreling towards? We just picked up the speed by a lot. It is impossible to predict exactly what will happen, but the system will collapse on itself**. There is simply no other possibility. When exactly, how that will manifest, what will actually get affected, I wouldn’t hazard a guess.

              *I actually see us like Wile E. Coyote in the roadrunner cartoons. He can run past the edge of a cliff until he finally looks down and falls. We have been past the edge of the cliff for some time now (not just with healthcare, in general) and this may be what finally forces us to look down. While I couldn’t hazard a guess as to what will actually happen, it certainly won’t be anything other than a precipitous drop of some kind.

              **I was in surgery with a urologist who came into the OR ranting about “ObamaCare.” Besides parroting off all of the typical – and false – tropes we’ve all come to to know and love from our friends at Faux News, he was convinced that Obama specifically and intentionally designed and implemented the ACA to make the entire system collapse so he could point to the failure and force the American public into a single payer system at political gunpoint. It is still sometimes startling to me to see my professional superiors speak like that and believe such ridiculous things. On a happier note, those who are in med school and residency seem to be more reasoned and reasonable. Of course, that is my own small and likely biased sample.

          2. weing says:

            “I’m not sure which aspect of Obamacare you are referring to or how such “satisfaction” is to be measured.”

            http://www.keybridgemed.com/revenue-cycle-minute/patient-satisfaction-and-the-affordable-care-act/

            http://thehealthcareblog.com/blog/2012/10/26/patient-satisfaction-the-new-rules-of-engagement/

            We’re still trying to figure this out. I feel like we are being nickel and dimed, actually more like pennied.

            1. windriven says:

              @weing

              Be glad we don’t live in the UK. They still have the halfpenny.

    2. Sawyer says:

      The problem begins with the pressure on educators and especially on science professors to assign only grades above a C students.

      I think the “standards have dropped” argument is probably valid, but I try to avoid phrasing it that way because it is so easily misconstrued. The conversation always seems to evolve into a rant about how terrible the youth of today are, or how academia is just a giant money pit. I don’t feel either of these routes conducive to coming up with practical solutions.

      The core issue is not lower standards, but a lack of emphasis on the methods, history, and philosophy of science in favor of individual factoids. I could rant forever on this, but one dastardly symptom I keep noticing is that a shift to online education often ends up cutting out laboratory courses for science and engineering curriculum. I imagine it’s really easy to buy into pseudoscience even with a tremendous work ethic and curiosity when you haven’t learned how messy real experiments are.

      1. Andrey Pavlov says:

        Well said Sawyer. How we actually know what we know is not only fascinating but crucial. Understanding how knowledge is built on and how we actually know what we do is integral to understanding why certain things simply can’t or won’t work. Or can’t be determined in a particular way (a la my argument with Andres and VitC). I did a lot of bench science back in the day and am glad I don’t have to do it anymore… because it is tedious, messy, and the smallest thing can make you have to start all over again. I’ve had to scrap weeks of work because I screwed up one little thing or forgot or didn’t realize something. I have the utmost respect for the guys on the bench – I simply don’t have the head and patience for it. My colleague had to cut the ovaries out of 1000 flies for a GC analysis. And that was for a very minor and single data point in our work. People seem to think that we just want to know an answer and magically we can get it. We worked very hard to be able to take a tube of blood and have a precise sodium value in a couple hours. It used to be, not long ago, that the physician himself (at the time it was much more likely to be a he) and spin down the serum, burn it in a flame with a loop, and use colorimetry to determine the sodium level. That was regularly done as recently as the 60′s and in some places into the 70′s. Ask any medical student if they know how chem panels were performed back just 40-50 years ago and they won’t have a clue.

        1. WilliamLawrenceUtridge says:

          How the fork do you remove fly ovaries? How do you remove a thousand of them?????

          Science is awesome.

          1. Moebius says:

            Very carefully.

  5. Andrey Pavlov says:

    I’m utterly blown away that this could be published literature. As CC Prof pointed out – they set the initial parameters! What would have been surprising is if somehow the cranberry became better then the antibiotics – or anything with a lower pre-simulation probability made it higher.

    I used to play poker professionally for a while after I finished undergrad. It was my sole source of income for about 8 months and my major source of income for about a year and half. I trained for this by playing poker with a bunch of PhDs in statistics and economics and we discussed the statistics involved in great detail and very rigorously. We also ran Monte Carlo simulations based on our real-world experiences playing cards. It is common that you have a strong but not very strong hand with multiple possibilities for being beat at the end. Knowing what the odds actually are is vital to make money in the long term. So we would run sims with various boards and various numbers of people in and out of the hands to see what the outcomes are likely to average out to in the long run to better understand our pot odds and how to hedge a bet. That is the use of a Monte Carlo – to integrate a lot of unknowns such that you have a list of probabilities of outcomes to make better decisions on where probabilities will converge. We knew what the odds of getting your 4-to-the-flush hand made was, what is interesting is how does the actual board distribution and how many unknown hands folded actually affect that. If we just set the prior probability of pulling a 5th spade and ran it, we would get the answer we already knew from the beginning. Why would we waste our time running a Monte Carlo?

    Part of me wants to just publish garbage to pad my CV but I would be embarrassed to have my name on a paper like this.

    1. CHotel says:

      Exactly, this. Monte Carlo isn’t even a good model for a study like this one, unless they had far more variable than Dr. Crislip discussed (don’t have access to the article at the moment so I haven’t yet read it).

      I had to (try to) teach myself the basics of Monte Carlo models because they’re used so often in pharmacokinetic studies, for example empiric antimicrobial dosing. Great model for something like that: you have known PK data that you pull from a small population (Vd, clearance, half life, etc), and then you can test for your PD targets (%T/MIC, AUC_24/MIC, etc) based on 1000s of patients worth of simulated variables (weights, renal functions, MIC of organism, etc) and see if your standard dosing will work well.

      1. CHotel says:

        http://jac.oxfordjournals.org/content/66/2/343.full.pdf+html

        This paper is an example of a Monte Carlo simulation being used properly, if anyone is interested. And I’m only slightly (read: incredibly) biased in choosing that one since it came from my Alma Mater and I was taught by all 3 authors.

      2. Andrey Pavlov says:

        @Chotel:

        I feel like this sort of knowledge should be basic level stuff for people with doctoral level degrees whose daily work actually depends on such knowledge (e.g. physicians) but sometimes I feel like my knowing of this stuff is unusual. I don’t get it. I actually covered this stuff in high school and then more in undergrad. I couldn’t actually run a Monte Carlo right this second or really get into the detailed nitty gritty of it, but I can definitely understand the application and if you gave me a day or so I could re-learn it enough to run a simple one.

  6. Mister Wu says:

    Evidence not speculation. http://www.acupuncturetoday.com/mpacms/at/article.php?id=28133 Or just wave you hands and cry, “Placebo!”

    1. DevoutCatalyst says:

      No, I would jerk my knee and think you dropped money and time on a worthless education.

    2. Mark Crislip says:

      Drives you nuts, doesnt it? Mister Wu refers to a press release rather than the original literature and evidently failed to read my entry as I go through the flaws in the very study he refers to. I bet he is was a reviewer for CID

    3. windriven says:

      “Or just wave you hands and cry, “Placebo!””

      Placebo!

      You’ll have to imagine my hands waving.

    4. That is an old article. Acupuncture is not what dogmatic scientist think it is.

      1. MadisonMD says:

        @SSR: Please, define ‘acupuncture’ in one sentence.

        1. @madisonMD sure who may I ask why?
          Which type? little “a” is different than big “A”
          And who are you?
          what do you practice?

          1. MadisonMD says:

            What is the difference between ‘Acupuncture’ and ‘acupuncture?’ Maybe you should define both– one sentence each.

            1. “A” you need 3 yrs of study.
              “a” all you need are the needles and some guts.

              1. MadisonMD says:

                Do you know what the definition of definition is, SSR?

              2. WilliamLawrenceUtridge says:

                You can’t define “acupuncture”, it varies according to country (and probably practitioner). There’s no unitary set of principles that applies everywhere. Our version of acupuncture, with fine steel needles, is very different from Chinese acupuncture, but very similar to Japanese acupuncture (but Japanese acupuncture uses only very superficial penetration). And we use steel needles, unlike Tibet where needles are gold. And we use acupuncture everywhere, unlike Korea where it is restricted to the hand.

                Stephen thinks he uses “real” acupuncture, because his acupuncture “works”. Of course, so do the Chinese acupuncturists, and Japanese, and Korean, and French (who needle the ear). When your standard is “patient satisfaction”, when your outcome measure is whether someone feels better rather than an objective outcome, it’s easy to see it “working”.

                A point we’ve made to Stephen repeatedly, which he never seems to grasp. More accurately, a point he never grapples with, because he is unwilling to think critically about his own experience. Certainly unwilling to engage with the large volume of literature that shows acupuncture, with specific points and practices, is an illusion and almost none of it matters.

              3. QWilliamLawrenceUtridge, good attempt at the basic concepts of Acupuncture. Do you practice acupuncture or have you had it done? It would take hours of study to understand the discipline, To physicians and definitely to non-physicians, it is difficult to grasp the discipline without altering your static mechanical scientific dogma. Reading a study will not give you any airtight conclusions. It just works! The future will answer all those questions.

                Acupuncture is a therapy which is as varied as the makes and models of cars. It’s a way to begin healing by igniting the healing cascade.

                What stops healing? Errors of repair called Trigger Points that are corrupted muscle fibers. These corrupted muscle fibers should heal automatically but if they don’t because of known and unknown causes, a sequence of detrimental events begins. This cycle will wax and wane possibly forever. It could spread to other parts of the body like a cancer making the host miserable with pain and dysregulations.

                To unlock and break this cycling you need heat and manipulation, be it hands-on or with a needle. If the muscle is very corrupted than only a needle can do the job. The needle has to be metallic (steel, copper, silver or gold) can able to conduct electricity.

                The scientific method is a vast array of study options which include trial and error, guesses and causes and effects. When a patient has failed all of the static modern medicine chemicals and surgeries, in the real world outside of the 2D paper, pen and statistics, you have to resort to non-traditional options. My best tool in this case are needles … the patient has pain and after treatment they feel better. You continue on a regular basis until a plateau is reached, then you reassess.

                If you have any inquisitive questions, ask. If you are still stuck in a narrow view of material mechanical science, I will simply label you stubbornly dogmatic and invite you to spend more time doing face to face interviews with a few failed medical cases and live in a medical library.

              4. MadisonMD says:

                Cripes, I just asked for a definition so I could understand what SSR was saying. No definition.

                SSR says:

                Acupuncture is a therapy which is as varied as the makes and models of cars. It’s a way to begin healing by igniting the healing cascade.

                I can’t tell if he’s talking about ‘Acupuncture’ or ‘acupuncture’ since the word is capitalized at the beginning of the sentence.

                SSR: It is not possible to understand what you are saying. If you want to convince anyone, you need to organize your thoughts, provide definitions, and be clear.

                Perhaps it is not worth trying.

              5. WilliamLawrenceUtridge says:

                Stephen, you may have noticed (actually, you didn’t), I was pointing out that there is no consistent definition of acupuncture. Every culture that encounters it, interprets it in a different way.

                As for it taking “hours” of study, it doesn’t really. Since it doesn’t matter where you put the needle (or even whether you penetrate the skin), your entire “discipline” comes down to “don’t jab the toothpicks in their eyes”. I would add to that, “make sure you pretend really, really hard that you know what you’re doing and you’re sure it’s going to work.” Congratulations, now everyone who reads this comment can practice acupuncture with greater safety, but equal efficacy, as you do.

                As for trigger points, all you really need is a hot bath and a firm rubber ball. That works great at resolving my trigger points, and it has the added advantage of being self-care. I can release them a whole lot better than you can, because I can control intensity and location a lot better than you can. And really when it comes down to it – all your “magical” treatments seem to be basically about fixing musculoskeletal pain. Yup, that sucks. But I’m not sure why you’re so devoted to acupuncture when massage is safer as it doesn’t penetrate the skin. Has some nice patient-doctor interaction too, without pretending it’s magic.

      2. WilliamLawrenceUtridge says:

        Acupuncture isn’t what you think it is either Stephen. Acupuncture varies according to what country you are in. Acupuncture is practiced very differently, and used for different indications, in China, Tibet, Japan, America, Germany, France, Korea, Thailand and basically everywhere else. There is no “one” acupuncture, which rather argues against it being a real intervention based on a single set of principles (i.e. like say, pharmacotherapy, or surgery, or physics, or chemistry). It’s closer to a religion, with dogma and no way of resolving disputes, than it is a science or medical practice.

        1. No it is closer to how a surgeon navigating through the belly of an 60 yr/o obese patient with prior abdominal surgeries and a normal sized 20 yr old with no priors. To get to the appendix.
          or
          A physical therapist from China, or Mexico or Germany working with a patient. They all know what to do but will address the problem slightly differently based on training and expertise. All with good outcomes.

          You have mechanics on your dogma. People are not machines or simple chemicals. Nix the mechanics and the dogma then you will being to see differently.

          1. WilliamLawrenceUtridge says:

            You’re not asking us to “nix the dogma”, you’re asking us to “abandon all evidence except my personal experience”. Who is more dogmatic, the person claiming their personal experience trumps scientific research, or someone who reflects on the interpretations of the scientific literature within the vast body of knowledge accumulated about the human body?

            And incidentally, there may be different ways of doing things via surgery and physiotherapy, but all rely on basic principles of anatomy, physiology and biochemistry.

  7. Mika says:

    Cranberry has been proven inefficient in preventing recurrent UTIs, but what about using it to manage UTI symptoms? In Finland I hear it’s often recommended by nurses and doctors alike for (female) patients who have an UTI going. Is it just that drinking something helps or that the contents (high on sugar and other stuff) of cranberry juice are somehow subjectively alleviating? Is there anything wrong with recommending a girl with a UTI to drink some cranberry juice if you don’t make any mention of it curing the disease or helping prevent recurrence?

    1. Andrey Pavlov says:

      There is no evidence or mechanism by which it can really help manage symptoms or do particularly anything for UTI. Dr. Crislip wrote about it here and here.

      There really isn’t much harm, except that cranberry juice – like most juices – tend to be high in sugar and calories. Adding in to a diet, particularly in someone already overweight or with diabetes, certainly wouldn’t be particularly helpful. And considering that most people will, thanks to PR not science, associate cranberry juice with doing something for the UTI I would argue that you can’t just recommend it for no stated reason in the context of UTI since it is easy to see that as a therapeutic recommendation. Otherwise you are just recommending a beverage to someone and may as well say orange or mango juice.

      1. Mika says:

        Andrey, the second “here” looks like a link but doesn’t go anywhere?

        The first linked post, like most others I’ve read, talks mainly about UTI prevention, and I don’t see Crislip really mentioning treatment anywhere else besides his ending words where he says “But I would predict that the use of cranberry juice will have little effect on either the treatment or prevention of cystitis. “.

        He also writes that “No one has been methodical in their evaluation of cranberry juice, so we are left with a hodgepodge of incomplete studies.”, which seems to imply we really can’t say for sure either way (for the lack of studies, but SBM principles would suggest to lean on the side of caution).

        There’s one commenter on that linked post who says that drinking cranberry juice helped alleviate the pain for him/her, is it purely plasebo or just drinking anything that might help? Remember, we’re talking about managing symptoms here, not treating the actual disease.

        1. Harriet Hall says:

          Having experienced cystitis myself, I can think of a possible confounder. Sometimes doctors give patients with recurring infections a prescription for antibiotics so they can treat future infections without having to make an appointment each time. Patients want to treat themselves at the earliest sign of an infection to prevent the more severe symptoms of a full-blown infection, and it is easy to misinterpret minor transient nonspecific symptoms as evidence of a new infection. When patients are required to come in for urine cultures each time before treatment, some of these episodes prove not to represent actual infections, and the symptoms would have resolved on their own with no treatment.

          An analogous situation is those TV ads that advise taking Zicam for a “pre-cold” (scratchy throat or runny nose) and when those symptoms don’t develop into a cold, instead of realizing that the symptoms did not indicate a cold, they give Zicam the credit for preventing a cold from developing.

        2. Andrey Pavlov says:

          MIka, here is the second link.

          To my knowledge there is no particularly good data about symptoms, but there is no reason to think that it would be particularly more effective than any other fluid intake for symptom management. So yes, while it is a hodge podge, we can take the gestalt of it all including the first principles and say with reasonable confidence that either there is very little likelihood that cranberry helps UTI or that the help is rather small and probably not clinically significant (meaning maybe it helps, but so little it doesn’t matter).

          The symptom relief is probably partly placebo and partly as Dr. Hall pointed out just increasing fluid intake and thus diluting urine. The cytokines released by the immune system in fighting the UTI actually mediate the pain response directly and thus decreasing their concentration would decrease the pain. Also, just flushing away excess bacteria, pus, immune cells, etc would also decrease pain because that melange is irritating to the tissues.

          The point is that there is no reason to believe cranberry has any unique benefits over any other fluid intake for treatment or symptoms.

      2. Calli Arcale says:

        From personal experience (DANGER, ANECDOTE!!!!), drinking lots and lots of cranberry juice helps somewhat with symptoms. But drinking lots and lots of *anything* helps — the sheer volume of liquid dilutes the urine, and it also gives you something to do when you’re in the bathroom attempting to find out if the sensation of urgency actually means anything this time. ;-)

        So it makes the UTI somewhat less frustrating, basically. But that’s about it, from my experience. Though I have to say, getting a taste for cranberry juice led me to try a cranberry mimosa (since I’m allergic to oranges), and it was awesome. ;-) If you want symptom relief, the ONLY thing I’ve found that works is phenazopyradine. (Which you can get OTC. Warning: wear old undies and pantyliners, and make sure to wipe thoroughly to avoid damage to clothing. They’re understating it when they say “may alter color of urine.” But damn, it really does work.) Warm compresses on the tummy help a little. Warm baths are very soothing. But phenazopyradine is the only thing that gives relief from that damnable urgency.

        I get recurrent UTIs. Always have. So this stuff is of interest to me. Indeed, the cause for me is not misaligned vertebrae or blocked chi; it’s a urinary diverticulum. It’s amazing the amount of woo I’ve encountered on the subject, though. It’s a common ailment that is easily confused with harmless, self-limiting conditions.

        1. theLaplaceDemon says:

          Oh my god. I cannot tell you how much I love phenazopyradine.

          When I used to get UTIs, they were BAD. Excruciating pain within a few hours of noticing any discomfort at all. Phenazopyradine made the time I had to wait to get antibiotics and have them kick in so much more bearable.

  8. Greg says:

    i think it’s been clearly established that acupuncture does not work, so why waste all those keystrokes? You’re flogging a dead horse.

    1. windriven says:

      “i think it’s been clearly established that acupuncture does not work…”

      Greg,
      Meet Mr. Wu above.
      Don’t you just love the homophone?

      1. Mark Crislip says:

        I did not notice the homophone until now
        Glad I was not drinking coffee.

      2. Frederick says:

        At least he does not sign Doctor, that will be totally confusing :-)

    2. Only in your mind acupuncture does not work. You should do some more study.

      1. WilliamLawrenceUtridge says:

        Oh Stephen, you clueless hypocrite. What about studies like these?

        http://www.ncbi.nlm.nih.gov/pubmed/23897589
        http://www.ncbi.nlm.nih.gov/pubmed/21463162
        http://www.ncbi.nlm.nih.gov/pubmed/21440191

        Of course, I know the answer. You don’t care about studies like these, because they contradict what you want to believe.

        1. Those studies are not done properly with the modern data we have related to what and how acupuncture works. You should not use the discipline like a machine … it is much more dynamic, customization and can not be studies like a pill or chemical.

          It is a therapy and all good therapies can be tailor made to a specific patient.

          1. WilliamLawrenceUtridge says:

            So where is this “modern data” that you claim to have? Because the acupuncture evidence base actually eroded considerably once we began to control for skin penetration, and found out it doesn’t matter as much as believing your skin is being penetrated. This happened quite recently, making more recent meta-analyses come out far more critical. It doesn’t matter where you put the needle. It doesn’t matter if you penetrate the skin. All that matters is that the patient thinks they are getting acupuncture, and the practitioner looks upbeat about it.

            And how does acupuncture “work”? No explanation for acupuncture has been proven definitively. There are lots of theories, but the only one that seems to account for the data is “placebo”.

      2. Harriet Hall says:

        Acupuncture does work. It just doesn’t work any better than placebos.

        1. Harriet you are being dogmatic!! I fear a little biased and ignorant of the truth of Acupuncture.

          1. WilliamLawrenceUtridge says:

            You keep saying “dogmatic” when really what we are doing is reflecting on the data. What you’re saying is that we’re “dogmatic” because we aren’t taking your word for it.

            What you’re saying is that your personal beliefs are more important than science. Which is why nobody here takes you seriously – because they recognize how easy it is for personal experience and beliefs to deceive.

          2. MadisonMD says:

            We need to help SSR. He has trouble seemingly with the definition of “definition.”

            Dogmatic definition (Merriam-Webster):
            Characterized by or given to the expression of opinions very strongly or positively as if they were facts.

            So it boils down to who can substantiate statements as fact rather than opinions, Stephen. Guess what, Harriet can substantiate. You cannot in any meaningful way substantiate your opinions as facts (although you appear to blissfully lack self-awareness on this point).

      3. Greg says:

        In my mind, i was hoping it did work – i’ve tried it a few times with 3 different practitioners and it didn’t do anything other than drain my wallet.

  9. Stella B says:

    As someone who long ago worked in the field of statistical modelling, I have to say that this is a paper that can best be described as “dopey”. As others have pointed out, building a model with the assumption that acupuncture works is a good way to “prove” that acupuncture works. Really, this paper should be withdrawn.

  10. amy says:

    N=67 does not a valid trial make, Mister Woo.

  11. This is a good example of the power of myofascial release with hands-on and with needles. Travell/Simons have a chapter on lower abdominal/pelvic/bladder/pelvic floor treatment protocols.

    The protocols are safe, work great, can be a diagnostic tool and can be curative.

    I know you won’t ask the proper questions or look in the approtirate places. LOL

    Lost in Space!

    1. PMoran says:

      Stephen, you may have noticed that I am on occasions dubious about views expressed on SBM. I have some thoughts for you, too.

      I accept that you probably do help some patients, possibly a lot of them.

      You are, however, almost certainly mistaken on some matters — e.g..

      1. — in your belief that your successes derive from finesse in the application of theories peculiar to the use of acupuncture. Good results can more plausibly be explained in other ways.

      2. You will have an exaggerated impression of your success rates, their completeness and durability. All practitioners do, when given the opportunity. This has been proved repeatedly. It arises from a spectrum of factors ranging from “answers of politeness” from your patients, to the fact that patients who are not helped don’t come back and remain less visible.

      3. Your methods will not have the general applicability that you think they do. You probably have some ability to select and be selected by those who are most likely to be receptive and responsive to your methods, even sometimes primed to respond to anything at all at that point in time.

      This is one of the reasons why I don’t think acupuncture can be advocated in the routine care by doctors of any condition. We cannot know that acupuncture will be appropriate in any particular patient population without directly testing that out. This applies also, but to a much lesser extent, to drug therapy or other interventions that have more predictable physiological activity.

      1. All good points. But flawed logic due to cherry picking.

        In the alternative wold of medicine patients gravitate to what actually works for them. They get to decide.

        In your view or world, YOU decide what is best for a person and YOU have no idea what the other options are available if YOUR therapy fails. Remember a diagnosis is a guess and the treatment is trial and error.

        Those points are the same in the real world where the standard of care for lower back pain to knee pain are flawed and failures are common. But the AMA allows these expensive surgeries to be performed without recourse or critical data analysis. This group of physicians have a vested interest in the business of medicine.

        1. WilliamLawrenceUtridge says:

          In the alternative wold of medicine patients gravitate to what actually works for them. They get to decide.

          True, but those decisions should be limited to, and guided by, the science. Otherwise patients will choose laetrile (and die of cyanide poisoning instead of cancer) on the basis of some quack assuring them that it’s a miracle. Or Burzynski’s piss extracts.

          Or your acupuncture.

          This group of physicians have a vested interest in the business of medicine.

          But you don’t have a vested interest in your own approach? You don’t charge for acupuncture treatments?

          Note that Choosing Wisely recommends against knee surgery for knee pain.

          http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-orthopaedic-surgeons/

          1. cyanide … don’t be an idiot, who will do that to make a living they will get sued and put in jail. We kinda know that if a treatment is allowed by the the AMA and the RUC has given it a code and payment amount, doctors will do it even if the outcomes are poor or the odds are low. Why? That is the way the system is set up so that they all get paid! Even if the patient does not need the surgery, failed the surgery, has to have additional surgeries, repeated surgeries. Win for the AMA vs Lose for society.

            My vested interest is in alternatives that work because the present mechanical push-button medicine is failing and costing lots of money, resources and a lot of lives. (yes I have a caring honorable heart)
            Did y’all know that despite what FOX new states about how we have the best healthcare in the world, they to are distorting the information and deceiving the public just as you guys. Hmmm I wonder if y’all work for the same funding entities?

        2. weing says:

          “In the alternative wold of medicine patients gravitate to what actually works for them. They get to decide.”
          You mean a patient is brought in with an acute abdomen and I diagnose acute appendicitis and refer for surgery, the patient decides that what work for him is to go to SRR for acupuncture?

          1. weing says:

            That should have been SSR

          2. Just because some of us use alternative dose not mean we are stupid and negligent. Of course you use the marvels of modern medicine but they are not 100%.

            Oh … did you know that less than 100% means that some people will be left without care and will suffer.

            Does that bother you? What do you do … just sacrifice them to science.

            1. windriven says:

              “Of course you use the marvels of modern medicine but they are not 100%.”

              No. But medicine gets better and better every day through the diligent application of science. Meanwhile acupuncture bathes in the netherworld of placebo while barking fools proclaim it fabulous.

              Your arguments are as empty as your treatments. But keep it up – every court needs a jester.

              I’ll ask you again – and you avoid this challenge like the plague:

              Name your top ten disease entities that acupuncture has brought to heel and I’ll name my ten for medicine. No cheating now, Steve. You’ve got to be able to prove what you claim.

              So … Are you all just empty words and batcrap delusions or do you have something useful? Put it up Steve. Awe us with the majesty of acupuncture.

        3. Vicki says:

          In the world of actual medicine, my doctors do give me choices. Things like “there are three possible treatments for this. A is on average most effective, but they all have different side effect profiles, so we need to figure out what you can tolerate” or “The possible treatments for this are physical therapy, a cortisone shot, and surgery. We advise everyone to try PT first.”

          Now, the surgeon can say that, but if I hadn’t gone to PT, or had gone to the appointments and not done the exercises, they would have gone on to the next thing, the same way they would have if PT hadn’t worked for me. And of course there was nothing to force me to do *any* of those three things, if I had somehow thought that they all seemed dubious or scary, so I’d just give myself three months off from the gym and take lots of Advil. I *chose* to walk into my GP’s office for the shoulder pain, and I *chose* to take her referral to an orthopedic surgeon. The HMO model may prevent a patient from seeing a surgeon when s/he’d like to; it’s not going to chase someone into the surgeon’s office if she is terrified of surgery. Do you believe that orthopedic surgeons–or dentists, or any other medical professionals–should be compelled to provide treatments that they consider ineffective or high-risk and unnecessarily expensive? (PT is more work than a cortisone shot, certainly; but that shot is less work for both patient and doctor than orthopedic surgery.)

  12. Mark Crislip, MD, want do you think?

    You post these articles sit back and watch the bickering.

    1. windriven says:

      No bickering Steve – just your mindless chatter cluttering up the joint. Why do you keep slinking around here? You add nothing to the conversation, you repeat the same tired memes, you ask the same old questions. What’s the draw?

    2. Mark Crislip says:

      Actually, I post these articles and go off to a very busy practice and work all day. I will catch up with the bickering tomorrow probably and then everything I might have said will probably have been said by others and articulated better

    3. WilliamLawrenceUtridge says:

      Stephen, what do you think? You show up in these comments, repeat how your own experience is better than anyone else’s, and never reply to others about how easy it is to fool yourself.

      1. Sorry I’m busy and just want to educate on the topic of alternatives that I know about. Modern medicine needs alternative that will complement the inherent deficiencies and biases.

        Because I’m tired of seeing all the failures! Do to dogma and stupidity.

        Hey listen buck o … I’m one of a few blogging in the open easily reachable.

        You guys are safe and secluded (HIDING) and seem to be playing a game and people are getting hurt.

        It is exhausting trying to save someone from their own dogma. I have real patients I need to spend time with.

  13. PMoran says:

    Is this acupuncture week?

    Acupuncture is indeed an implausible treatment or preventative of UTIs and of most other diseases, and not only because of its association with archaic TCM concepts. It is also true that there has been a lot of bad science and self-service in the performance and interpretation of acupuncture studies. It also bothers me when top journals publish unsound work, whether to do with CAM or conventional methods.

    Nevertheless there is evidence and substantial plausibility to the view that any credible placebo can help some patients with some kinds of complaints. Treatment programs centred around “acupuncture” of various types stand out over other supposed placebos for several reasons –.

    1. They have an apparently considerably larger effect size than most placebos, when compared to non-”acupuncture”, mostly “usual care”, controls, in such studies as http://archinte.jamanetwork.com/article.aspx?articleid=1357513

    (I don’t agree with all of their conclusions, either.)

    The lack of blinding is a problem in those specific comparisons but only a terminal one if you are prepared to believe that all these patients are telling fibs about their status.

    I have issued a challenge to those who think I am making a fuss about nothing to show how this “reporting bias” component can be proved. Or, show why it is the most likely explanation, when we have other evidence for the placebo aspect and no plausibility problem with influences like relaxation, distraction, counter-irritation and ongoing psychosocial support as per No 2.

    2. Some facets of “acupuncture” (mentioned above) will have useful physiological influences that a sugar pill will not.

    3. Acupuncture seems able to help in difficult problems like chronic pain.

    So to be scientifically accurate “acupuncture does not work” should be either preceded by an explanation of the semantics that make that statement accurate, or it should accompanied by a rider such as ” — other than (possibly/probably — choose one) via a variety of non-specific medical influences in subjective and psychosomatic states”.

    This matters, not only from the point of view of what is the unvarnished medical truth, and how certain we can be of it, but also from the point of view of not creating unnecessary dissonance in those who we might hope to be leading to a better understanding of medical science. It helps reconcile otherwise immiscible viewpoints.

    1. windriven says:

      Dr. Moran says

      “Nevertheless there is evidence and substantial plausibility to the view that any credible placebo can help some patients with some kinds of complaints. ”

      Before the conversation about placebo effect magnitudes shouldn’t there first be a conversation about the ethics of using placebos at all? Not that it matters a whit but I am probably less troubled by at least some of the ethical issues than some of your colleagues in these pages. Still how can the relative merits of various placebos be discussed before the ethical propriety of any placebo use is discussed?

      1. Andrey Pavlov says:

        Actually I tend to agree with Peter here. We can investigate thinks for scientific and intellectual curiosity without necessarily establishing their utility yet. That said, that is not what he is doing. As he has demonstrated in the past few days he is talking about an acupuncture that doesn’t exist and that people aren’t studying and then claiming that is clearly what they mean and how wrong we are for attacking some ridiculous caricature of the “evolved” version of acupuncture that he has in his head. The worst part is that he is obviously doing so without actually reading what is written here let alone the actual paper in question (as I demonstrated) and instead just takes any opportunity to blather on he possibly can. It’s like he is conditioned that any time the word “acupuncture” is written here he just copy pastes his thoughts ad nauseum, regardless of the fact that they have no bearing on the actual topic or the reality of what he is commenting on.

        1. Harriet Hall says:

          He seems to believe there is a physiologic effect in addition to the theatrical placebo effects. That has not been established. Yes, there are studies that show endorphin release in the brain with acupuncture, but placebos have been shown to produce endorphins in the brain, and dogs produce brain endorphin when you throw a stick for them to fetch. I see no reason to think the nonspecific treatment effects might not be responsible for any physiologic findings. At most, this would justify using acupuncture as a “comfort measure” like back rubs and TLC.

          It is not enough to tell patients some people have been “helped” by acupuncture. I would say something like “Science has studied acupuncture and has found that it is nothing more than a theatrical placebo. A lot of people try acupuncture once and never go back because it doesn’t help them, but some people have a placebo response and think they feel better after acupuncture, so if you want to try it I have no objections.”

          1. MadisonMD says:

            He seems to believe there is a physiologic effect in addition to the theatrical placebo effects.

            I’m not so sure he believes there is. Peter seems to mostly agree acupuncture is a placebo, and as such it is good enough to use. When pushed on this point, he falls back on the idea that scientists and doctors *cannot rule out* a physiologic effect.

            This, of course, has the effect of shifting the burden of evidence. It requires physicians to prove the negative for each and every condition. Of course, proving acupuncture fails to have a specific physiologic effect for everything is an infinite and impossible task akin to the eternal punishment of Sisyphus.

          2. Kathy says:

            If it comes to placebo, a back rub would be my first choice, hopefully followed up by a cup of tea and the delivery of several “Get Well” cards. Maybe a bunch of flowers too. I’d much rather have any or all of these than get needles stuck all over me. What amazes me about all this is why anyone would prefer needles over the above.

    2. MadisonMD says:

      @Pmoran and Windriven:
      I do not have a problem with using placebos. I do have a problem with deceiving patients. So if to be used ethically, patients need to be apprised that mechanism and best evidence demonstrate acupuncture is a placebo.

      @Pmoran:
      If you can substantiate your claim that acupuncture is a better placebo than other nonspecific interventions, then we have something to talk about. If you cannot, it is incumbent on the ethical physician to recommend a placebo with a better safety profile and lower cost (in addition to indicating it is a placebo).

      ————-
      Now about “acupuncture doesn’t work,” which you apparently find offensive, Peter. If an RCT of paroxetine versus placebo pill demonstrated that both arms showed equal improvement in depressive symptoms, would you also object to the conclusion “paroxetine” doesn’t work? That would be my conclusion (and that of the FDA and other regulatory authorities).

      1. Mechanical medicine is deceiving everyone even me sometimes.

        You can not fool a patient into becoming well if their illness is deeply seeded into the flesh.

        I must admit the ability of some personnel to take a leap from a narrow paradigm to a more broader one is not easy and can be frighten. I took me a decade to clear out all the modern medicine and scientific fog.

        I realize this group is stuck on the simple word Acupuncture!!?? You must study the discipline in detail to begin to unlock and toss your biased paradigms.

        You will not find it is PubMed … it ain’t there!!!

        1. WilliamLawrenceUtridge says:

          Stephen, what’s your paradigm? It appears to be “real science doesn’t matter, whatever I think works is better”. May I point out that this is what bloodletters, priests of Thoth, and the peers of Ignez Semmelweis thought. If your paradigm works, surely systematic tracking of outcomes (i.e. research) would demonstrate this. Why not do some, prove us all wrong?

          Why are you so proud of your ability to treat diseases of unknown origins, that are self-limiting, and ultimately just clusters of symptoms?

          1. You made an assumption that I was all alternative …NO, I still practice regular medicine except I have found a special tool that helps in a lot of my new protocols. Most of the cases that used to be mostly failures are now assisted and helped with the needles.

            There is a lot that I now know to be considered malpractice and a travesty of justice. I’m so sure that soon we will see a renaissance of this alternative option.

            1. WilliamLawrenceUtridge says:

              So what you’re saying is, when you find a condition for which there is no scientifically-validated option, you deceive your patients and provide them with a placebo treatment. Got it.

            2. MadisonMD says:

              What he’s saying, WLU, is that he experiments on people. He claims to “have a legal right to experiment with people’s lives.”

              I have asked whether he informs his patients he is experimenting, in accordance with the most basic of ethical precepts, enshrined in the Nuremberg code.

              He has avoided answering this question.

    3. Andrey Pavlov says:

      I mean, really Peter! You could have just stopped after the first paragraph. Instead you are on this ridiculous mission to keep repeating the same stuff over and over again regardless of whether it is relevant to the discussion at all. Someone mentions acupuncture in a specific context and you aren’t satisfied just agreeing, you simply must take every conceivable opportunity to thrust your “acupuncture as a superior delivery of placebo and placebo is intrinsically physiologically useful in some conditions sometimes” piffle. We get it. And we agree with you. But it is irrelevant here. And it actually demonstrates quite nicely that what you are calling acupuncture is not what people actually think of, research, or practice when it comes to acupuncture. You are arguing against an entity that doesn’t exist in the real world.

      In the previous article you make specific claims about that specific article which I completely and utterly demolished and you just ignored it all and weaseled out whilst still asserting you are right. Now you are asserting you are right on a completely irrelevant topic! Seriously?

    4. irenegoodnight says:

      But…PMoran, pray tell, WHAT IS THE MECHANISM by which acupuncture has any “effect”? Magic?

  14. Denise says:

    Over at the Sjogren’s Syndrome forum that I visit, almost every week someone posts something like this one today:

    “Hi – My rheumy has suggested acupuncture, to see if it helps me at all with my fatigue.”

    As a patient, I find this very frightening. I’m especially frightened that my doctors could be more ignorant about some things than I am. I may not know much, but at least I know better than to think acupuncture is going to help me.

    My rheumatologist suggested I try a gluten-free diet. I wish I knew whether she’s basing this on science or not. Whom can you trust?

    1. MadisonMD says:

      *sigh* Your doctors want to help you and offer you something. I am sure they mean well. They are almost certainly “shruggies.” When confronted by colleagues they tell reason: “What’s the harm?”

      I would suggest you and the poster on the other forum politely ask your doctors:
      (a) Have they ruled out other specific causes of your symptoms?
      (b) What is the mechanism by which placing needles in meridians might reduce fatigue? …or, for you, how the diagnosis of celiac diseasewas made?
      (c) Is there a substantive reason to believe the recommended interventions are more effective than placebo?
      (d) What do the practice guidelines recommend for your condition?

      1. Denise says:

        I don’t have celiac. I’m pretty sure I know what my doctor would say about the gluten-free – that lots of people claim they feel better on it so it’s worth a try. I know they do: over at the Sjogren’s group half the people don’t eat gluten and believe it helps a lot. It comes up on a regular basis and one after the other they swear by it. I hear it so much that sometimes I do wonder if I should try it, except I haven’t been able to find any real evidence.

        This came up with my doctor when I asked her if there was anything to the idea that some foods are pro-inflammatory. She probably thought I wanted some dietary advice; actually, I was hoping she’d say no. I have no desire to become a food nut, not unless it’s really going to help a lot.

        As to the other posters at the Sjogren’s forum, it’s woo city over there. I have to button my lip or I wouldn’t be welcome.

        1. MadisonMD says:

          This “gluten intolerance” idea has gotten so popular with the woomeisters, that it has been spoofed on the BBC

          I suspect eliminating gluten “works” by helping people feel in control, and through placebo effect. There is no reason to think that wheat would be pro-inflammatory. In fact, it’s not hard to find the exact opposite claim: that eliminating gluten boosts the immune system. Boosting the immune system is the last thing you’d want to do if you have autoimmune disease like Sjogren’s

          I suspect eliminating gluten neither “boosts immunity” nor “reduces inflammation.” [In fact, these terms are so poorly defined that just about any data could be used support either of these contradictory concepts.]

          Your doc sounds like a shruggie–most are. Ask about how the intervention would work– placebo versus effect specific to the intervention. Show her the book saying gluten-free boosts the immune system and ask if that might be bad. At least you’ll get your doc thinking.

    2. irenegoodnight says:

      Eeekk! My granddaughter’s rheumy also suggested a gluten-free diet. This Grandma hit the ceiling and is shopping for a new doc for g-daughter.

      All our fears are coming to pass–young docs have now been trained (or lack proper training) to “believe” in nonsense.

  15. Lytrigian says:

    I am so bummed. I am going to have to look into treatment for reactive depression. I wonder if acupuncture would work…

    “Stop being depressed or I’ll stick more needles in!”

    There, see? It works.

  16. rork says:

    I’m fond of our author, but he might consider having a friendly statistician review more, so as to remove overly simplistic advice like p=.005 being suggestive.
    Let me run pairs of sample treated with A and B three time and measure the abundance of substance G, and obtain 1,3 1,6 and 1,9 for the three experiments. Paired T-test on log-transformed data (with abysmal power) gives p=.034. It’s true that our experiments or assay could use work, but I think it suggests B makes more G than A does. It seems less likely that A makes more than B. No?
    Hypothesis tests are not the only tool in the arsenal – they’re actually rather odd creatures. Imagine we were to gamble on the next experiment comparing A and B, and you are setting the odds on which will make more G, and I determine which way to bet.
    Nothing in this should be construed as support for quackery like acupuncture, just a math police visit.

  17. PMoran says:

    Thanks for engaging with one of my points, Harriet.

    You mention endorphin release, which any placebo may be able to produce to some extent , whereas acupuncture programs are of special interest because of the variety of plausible, mostly minor, therapeutic influences that are combined together in one package, and the fact that there is nothing quite comparable within evidence-based medical care.

    Then there are the effect sizes shown in the Vickers review (see above), and most other similar studies of “acupuncture” (whether sham or real). . In the relevant study design, where a simple placebo is compared to “usual care”, effect sizes are typically around 0.2, 0.3 at the most (look at Hrobjartsson’s meta-analysis) .

    With “acupuncture” programs the effect sizes are regularly 0.5 or more, and that with normally difficult to treat conditions. (This partially answers one of your points, MadinsonMD)

    Again, some of that is likely to be due to increases in reporting bias, but surely we should have some curiosity as to what it all means for the patients involved. Are we justified in ignoring this finding, or explaining it away with what is in truth little more than speculation?

    EBM/SBM’s focus has always been upon the meaning of the relatively trivial differences between sham and real in the usual clinical trial of acupuncture, which I agree can be reasonably attributed to non-specific influences including placebo leaking past controls with such difficult to blind intervention. That is definitely more plausible than that TCM theory is responsible.

  18. PMoran says:

    Argh! Sorry about all the italics, although the font is pleasing enough and the sense of it all probably remains.

    1. MadisonMD says:

      Says I:

      If you can substantiate your claim that acupuncture is a better placebo than other nonspecific interventions, then we have something to talk about.

      Says you:

      With “acupuncture” programs the effect sizes are regularly 0.5 or more, and that with normally difficult to treat conditions. (This partially answers one of your points, MadinsonMD)

      Well, it doesn’t really answer whether you would achieve the same magnitude of placebo effect by other interventions.

      The “effect sizes” compared with no treatment in the two references you cite are are difficult to interpret in meaningful terms, but fortunately, the authors helped us: The effect sizes range from 4-24mm on 100mm scale per Hróbjartsson review; and 13mm on 100 point scale in the Vickers et al.. These range from clinically insignificant to modest.

      So, based on these data, I agree that sham acupuncture could be used ethically for a modest placebo effect (of course under the conditions of honesty, no skin penetration, and acupuncturists who refrain unsupportable claims or bad treatment recommendations–if that is even possible.)

      It might be that acupuncture is the “cadillac of placebos” as you and Harriet are saying. I suspect not. Yet, even if it is the optimal placebo in some societies today, it is not universally so. Beliefs in ritual healing vary across societies and time.

      1. lol caddy of placebos! Stuck in a paradigm fortified by dogma.

        “Acupuncture-acupuncture” is so vast you can not figure it out … I’m still mystified after 15 yrs. I’ve stopped and just use the “tool” and the patients have the positive results.

        It will not be long when science will catch up with this tool. AS long as propaganda and agenda don’t get in the way.

        1. weing says:

          “It will not be long when science will catch up with this tool. AS long as propaganda and agenda don’t get in the way.”

          Spoken like a true believer.

  19. PMoran says:

    These issues may not matter for the arm-chair scientist, whose hat we sometimes wear. We can then cling to a favoured null hypothesis while awaiting confirmatory or negatory evidence for as long as it takes, justifying that with the belief that we are protecting the purity of science..

    As doctors (or anyone interested in practical aspects of medicine) we have an often already bolshy public to relate to, and to advise, one that can have a very conflicting view as to how their physicians should react to methods that even may be of help to them.

    In EBM/SBM we are unfailingly and utterly ruthless in our resistance to that kind of public pressure, but we do have to make sure that our reasoning is absolutely sound if we are to aggressively oppose methods that may actually be sitting on some kind of borderline.

    1. Harriet Hall says:

      Acupuncture is not sitting on any borderline; it sits across the border at the high end of the spectrum of placebo interventions.

      1. Ms Harriet i wish you would do more study on needles because you patients will benefit. In a few yrs you will be eating your words.

        Y’all are getting wrapped up in the word Acupuncture and will not budge out of the rut to ask the proper questions.

        IT is NOT about Acupuncture (so much as a therapy with needles)

    2. MadiisonMD says:

      Bad argument, Pmoran. You castigate the scientific practitioner for “clinging to the null hypothesis.” Another way to say it is we refuse to accept an intervention that is claimed without evidence. (You do this too, Peter– you argue against liver flushes?) We will not use it until it has strong evidence of working*. This is not about “protecting the purity of science.” Its about identifying and offering effective interventions and avoiding bogus treatments.

      * That evidence can span the spectrum from basic (mechanism) to clinical (RCT) and is strongest if multiple lines are convergent on the same conclusion.

      while awaiting confirmatory or negatory evidence for as long as it takes

      I’ve said it before. You cannot prove the negative. To attempt it is fruitless waste of resources. There are an infinite # of potential hypotheses. Most hypotheses you can imagine are false. Science is not about proving them false. It is about identifying the useful findings and proving them true. Studying bogus treatments to prove them false–to do so in detail for every situation– is a worthless exercise. It diverts resources from productive lines of inquiry. It eliminates opportunities for identifying productive interventions that actually do improve human health.

    3. MadisonMD says:

      We can then cling to a favoured null hypothesis while awaiting confirmatory or negatory evidence for as long as it takes, justifying that with the belief that we are protecting the purity of science..

      The science viewpoint:
      Science is a quest to find needles of truth in an infinite haystack of hypotheses. To continue the metaphor, you do not pick up a straw and fiddle with it endlessly until you are absolutely certain there is no tiny needle inside. It is most efficient to keep sorting though the stack until a needle turns up, and then examine it.

      Enough of metaphors. You cannot prove the negative. You cannot test or rule out acupuncture for every single possible indication. It would be a Sisyphean task, foolish to attempt. The $ invested in acupuncture research could be deployed more fruitfully with ideas that have a plausible likelihood of benefit.

      The medical viewpoint
      Medicine should not adopt therapies that have little plausibility or evidence. Even plausible interventions, when tested, are often found not useful. Thus we are justified in not adopting interventions until there is a good reason to believe them useful.

  20. PMoran says:

    ” –sits across the border — ” is better for me, too. It suits my favoured definition of placebo as an inert intervention — it should “do” nothing. Then relaxation, distraction, counter-irritation, and psychosocial interactions (that would not otherwise eventuate) are “across the border” — not obviously placebo.

    At the other end of the scale the definition of “inert” becomes moot, if placebo use can trigger the reflex release of endorphins, and thereby reset patient perceptions regarding their illness.

    In my view there is no entirely satisfactory definition of placebo but “intrinsically inactive intervention” probably works best.

    I don’t actually a clear-cut definition of placebo because I accept that patients can probably derive benefits from a variety of such influences.

    SBM does need one if it is to set in stone policies based upon whether an intervention is classed as placebo or not.

    Even so, I have agreed that SBM policies against the systematic use of placebo or “irregular medicines” are correct, at least for the present . There remain ethical questions as to how we react to their use by others, in what is currently a de facto pluralistic medical environment.

    Windriven, I have not forgotten your important question about the ethics of placebo use. The above will go some way to outlining my perspective.

  21. weing says:

    That’s called moving the goalposts.

  22. MadisonMD says:

    @Peter:
    Yes, I have been operating with your definition of placebo (lacking effect specific to the intervention). I am hoping you could help me understand your reasoning.
    In particular, I have a hard time reconciling your objection to liver flushes with your acceptance of other placebos. Both could result in endorphins and both could improve subjective measures of pain or wellness due to effects that are not specific to the intervention.

    Can you shed light on the apparent inconsistency?

    1. PMoran says:

      Glad to try and clarify what you see as an inconsistency.

      Everything has to do with the specific claim. So yes, I have tried to prove that liver flushes won’t clear the gallbladder of gallstones and that the “stones” produced in the flushes are an artefact of the method.

      Nevertheless, if a patient says that they feel a lot better after a successful flush, that has some credibility. It is a dramatic experience, something to be proud of. . It has associated psychosocial rewards, when you get to tell admiring CAM associates of your achievement.

      That is not to say that I regard this as a wholly desirable outcome, but I did not make things the way they are..

      1. Harriet Hall says:

        Not a “wholly” desirable outcome? In other words, it is partly desirable? I suppose you could say any delusion is partly desirable. The psychotic patient who kills her children because she thinks God told her to feels virtuous for her obedience and because she is sure it is her ticket to Heaven; is that a partly desirable outcome? A cancer patient gets a lot of attention and sympathy and doesn’t have to go to work. Is that a partly desirable outcome? Jenny McCarthy has surely reaped psychosocial rewards for her anti-vaccine activism. Is that a partly desirable outcome? If you try hard enough, you can find some good in everything bad. If your argument is anything more than “It’s an ill wind that blows nobody any good,” please explain.

        How do you distinguish between what a patient thinks is good for him and what is really in his best interests long-term (and in the interests of those who might be influenced by his testimonials)? Aren’t reality and truth important?

        I think this speaks to one of the essential problems we have understanding you. You seem to be condoning anything that a patient thinks makes him feel better, even when there is no objective effect on the disease process. I condone those things only when they are clearly used as “comfort measures,” and I deplore the dishonesty of implying to the patient that it will “help” him in some objective sense.

      2. MadisonMD says:

        That is not to say that I regard this as a wholly desirable outcome, but I did not make things the way they are..

        It is apparent that Harriet sees this as equivocating. I also see it thus.

        Our actions and efforts affect how things will be in the future. Of course actions now cannot affect the way things are now. Your quackwatch article was written in the past. It provided an honest assessment of a quack remedy. You did make things better– you had an impact on how things are– by making it publicly available, Peter. Thank you.

        You could now determine that the article is worthless and withdraw it. Why? Because some individuals derive non-specific placebo benefits and risks are minimal. You might not want to people with the idea that “liver flushes don’t work.” But if you did this, your withdrawn action would perpetuate and assist things being as they are.

  23. PMoran says:

    Madinson MD, “– 12 mm on a 100 mm scale –”

    ???

    From the Vickers acupuncture meta analysis –

    “To give an example of what these effect sizes mean in real terms, a baseline pain score on a 0 to 100 scale for a typical RCT might be 60. Given a standard deviation of 25, follow-up scores might be 43 in a no-acupuncture group, 35 in a sham acupuncture group, and 30 in patients receiving true acupuncture. If response were defined in terms of a pain reduction of 50% or more, response rates would be approximately 30%, 42.5%, and 50%, respectively.”

    1. MadisonMD says:

      @Pmoran: 12mm???? What are you reading? My quote was:

      …and 13mm on 100 point scale in … Vickers et al..

      Isn’t 13 the difference between 43 and 30? That’s the difference of effect between acupuncture and no treatment.

    2. Sawyer says:

      I have no clue what you are confused about.

      The difference Madison referred to was the absolute pain score difference (43-30). Considering the pain scale is entirely subjective to begin with, this difference easily falls into the range of clinically insignificant. When you switch to relative pain changes, you’re automatically exaggerating those minor differences in the raw scores. Note that the standard deviation doesn’t magically disappear when going from absolute to relative scores, despite Vicker’s conveniently dropping his confidence intervals. (I admit I don’t remember the math on how to do this calculation but I’m not a statistician)

      But why are we even relying on Vicker’s work in the first place? Isn’t this the same person that has written a credulous review of Oscillococinum for influenza?

  24. PMoran says:

    Actually I have just seen the flaw in those figures myself. The effect sizes previously quoted are by comparison to a “no acupuncture” group, any improvements in which would be mainly due to spontaneous improvement and not a “response” to anything. So those derived “response rates” are incorrect.

    I can’t see where in that study they are related to a pain scale. Can you direct me to your source for the figures you quote? Effect sizes of that degree, although still a somewhat arbitrary judgement, are regarded as clinically worthwhile. Hrobjartsson does so in his most recent placebo meta-analyses.

    1. MadisonMD says:

      Peter,
      You quoted the relevant section of the Vickers study. Here is the relevant portion from Hróbjartsson:

      Interpreting a standardised mean difference clinically may be challenging. On the basis of the mean standard deviation from the trials that had used visual analogue scales, the effect of acupuncture (standardised mean difference −0.17, −0.26 to −0.07) corresponds to a reduction of 4 (2 to 6) mm on a 100 mm scale. The effect of placebo acupuncture (standardised mean difference −0.42 (−0.60 to −0.23), corresponds to a reduction of 10 (6 to 15) mm.

      So the reduction of 10mm on 100mm scale corresponds well to the Vickers value of 13mm. We are talking of acupuncture placebo effect that is about 10-13 points on a 100 point pain scale. For the ‘cadillac of placebos’ this isn’t much. We could even quibble about whether it is clinically significant.

      Here’s what the Hróbjartsson review says about what is clinically significant:

      Attempts at defining a clinically minimal pain improvement have reached quite different conclusions and have often reported percentage improvement and not an absolute effect size as we have.26 27 However, a consensus report characterised a 10 mm reduction on a 100 mm visual analogue scale as representing a “minimal” change or “little change.”27 Thus, the apparent analgesic effect of acupuncture seems to be below a clinically relevant pain improvement.

      So, Peter, you’ve been arguing that acupuncture recruits “a greater variety of psychological and physical influences” compared with other placebos. But, really, this is the magnitude of the placebo effect we are talking about. 10-13 on a 100mm scale. It’s on the cusp of clinical significance.

      1. Andrey Pavlov says:

        This is another bone of contention I have with Peter as well. The data does not support his conclusion of any sort of significant effect size for acupuncture. There is indeed the occasional smattering of something like that, but the majority of the data out there shows no particular benefit for clinical outcomes. In essentially every single meta analysis, systematic review, review of reviews, the conclusion is either that there is possibly some mild clinical benefit in subjective outcomes, but more commonly that there is none. Now this is just in an absolute sense, not just the sense of “does acupuncture perform better as a placebo than other placebos” sense. Even the most biased studies (of which VIckers is one of them – he is in the department of “Research in Complimentary Medicine” and his reviews are a big hodge podge that are very generous in their conclusions – the results are pretty underwhelming. And if you look at them in aggregate, you find that they don’t make sense.

        There is no consistent effect of acupuncture in doing anything. In one study he claims is has antiemetic properties but only if the patient is awake and participating. Anesthestized patients had no effect from “P6 acupuncture point stimulation.” He tries to rationalize this since, to him, acupuncture should have specific effects and the “P6 point” is actually meaningful. So he tries to redefine what “does it work” means. Then, in a later review he finds that pooled trial data shows a decrease of “acute vomiting” in acupuncture groups, but not severity of nausea. In other words, people still felt crappy but because they were getting some treatment for it managed to not puke. Hardly surprising nor any indication of acupuncture doing anything. But on top of that, he lumped “electroacupuncture” in with the pool to find that electroacupuncture is what actually decreased acute vomiting while “manual acupuncture” did not. Then he finds that acupressure reduced nausea symptoms, but not acute vomiting. And of course, all groups were still getting their usual antiemetics anyways. His conclusion?

        Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies combining electroacupuncture with state-of-the-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance. Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control.

        Seems to me like what you would expect to see when you are comparing multiple things across multiple bad studies, conflating TENS with acupuncture, and looking a population with an expected high variability of nausea and vomiting who are already on antiemetics and who will learn to cope with nausea and vomiting over the course of the trials to varying degrees of success. In other words, it tells us nothing. Even the most generous interpretation is that it can produce extremely minimal clinical effects of symptoms but essentially only get people to concentrate harder to not actually vomit. And Vickers views this as promising evidence.

        He also looks at various headache trials. And once again the results are all over the place. He bases his analyses on studies so heterogeneous that he has to throw some out because they are completely uninterpretable. Here we have a look at idiopathic headache and find:

        The majority of trials had methodological and/or reporting shortcomings. In eight of the 16 trials comparing true and sham (placebo) acupuncture in migraine and tension-type headache patients, true acupuncture was reported to be significantly superior; in four trials there was a trend in favor of true acupuncture; and in two trials there was no difference between the two interventions. (Two trials were uninterpretable.) The 10 trials comparing acupuncture with other forms of treatment yielded contradictory results.

        The majority had design issues, 8 of them showed that “true” acupuncture is better than sham (which the majority of all other data show is not the case and that there is no reasonable mechanism by which this could be the case, which means the results must have been spurious to some degree and in some way), 4 we find a “trend” to favor “true” acupuncture, 2 no difference, 2 uninterpretable, and 10 showing contradictory results. Seems to me like a whole bunch of noise in the signal, with any possible real effect size small enough to conveniently hide in the noise. Vickers conclusion?

        Overall, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches.

        Really? You call that support?

        So he does another review later on. This time he adds more trials that have happened since then. What kind?

        Small but statistically significant benefits of acupuncture over sham were found for response as well as for several other outcomes. Three of the four trials comparing acupuncture with physiotherapy, massage or relaxation had important methodological or reporting shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes in the control groups.

        What a ringing endorsement. Admittedly small but statistically significant. 3 of 4 trials with important shortcomings. Findings difficult to interpret but… his conclusion?

        In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.

        Wow! So now those new trials – with important methodological problems and are difficult to interpret – now make the previous insufficient evidence sufficient to recommend for treatment. What was that word again? Oh right, bias. Difficult to interpret but we still somehow managed to interpret them as “suggesting” slightly better results. Clearly.

        How about specific types of headache? Migraine perhaps?

        After 3 to 4 months patients receiving acupuncture had higher response rates and fewer headaches. The only study with long-term follow up saw no evidence that effects dissipated up to 9 months after cessation of treatment.

        Hey that sounds pretty good, right?

        Fourteen trials compared a ‘true’ acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any outcome in any of the time windows, but the results of single trials varied considerably. Four trials compared acupuncture to proven prophylactic drug treatment. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment. Two small low-quality trials comparing acupuncture with relaxation (alone or in combination with massage) could not be interpreted reliably.

        Awww. So once again really crappy studies, some entirely uninterpretable, and pooled analysis shows nothing. But hey, if we look at these four over here we find an effect! A big effect right? Oh, no, there is that “slight” effect again. So what is our conclusion? Obviously…

        In the previous version of this review, evidence in support of acupuncture for migraine prophylaxis was considered promising but insufficient. Now, with 12 additional trials, there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. There is no evidence for an effect of ‘true’ acupuncture over sham interventions, though this is difficult to interpret, as exact point location could be of limited importance. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.

        I must have been taught science wrong, because somehow that is just not the conclusions I would have come up with. I mean, when pooled analysis shows nothing and selected subgroup analysis shows a slight effect, that is evidence of a “consistent” effect that should be considered as a treatment option? What was that word again? Right, bias.

        Oh but how about one more for funsies?

        Here we have headaches again. What did we find?

        The majority of the 14 trials comparing true and sham acupuncture showed at least a trend in favor of true acupuncture. The pooled responder rate ratio was 1.53 (95% confidence interval 1.11 to 2.11). The eight trials comparing acupuncture and other treatment forms had contradictory results.

        Oh well, as long as there is at least a trend that totally means something right? Those darned 8 trials with contradictory results though may end up forcing us to conclude that acupuncture really doesn’t have any sort of consistent signal of benefit, let alone clinically relevant effect size, though. Let’s see what Vickers has to say…

        Overall, the existing evidence suggests that acupuncture has a role in the treatment of recurrent headaches. However, the quality and amount of evidence is not fully convincing. There is urgent need for well-planned, large-scale studies to assess effectiveness and efficiency of acupuncture under real life conditions.

        Phew! Man, for a second there I thought we would have to conclude that all we had was crap evidence that didn’t show anything. Thankfully Vickers knows how to do science, unlike poor l’il me, and can read between the lines of the studies to find a role for acupuncture in the treatment of recurrent headaches. And, of course, an urgent need for more and better studies to prove it!

        Ok dangit. I just can’t help myself. One more

        Again headaches.

        Headache score at 12 months, the primary end point, was lower in the acupuncture group (16.2, SD 13.7, n = 161, 34% reduction from baseline) than in controls (22.3, SD 17.0, n = 140, 16% reduction from baseline). The adjusted difference between means is 4.6 (95% confidence interval 2.2 to 7.0; P = 0.0002). This result is robust to sensitivity analysis incorporating imputation for missing data. Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year (8 to 38).

        Wow. Now that sounds reasonably impressive. And yet….

        Control patients did not receive a sham acupuncture intervention. One hypothesis might be that the effects seen in the acupuncture group resulted not from the physiological action of needle insertion but from the “placebo effect.” Such an argument is not relevant to an assessment of the clinical effectiveness of acupuncture because in everyday practice, patients benefit from placebo effects.

        Well, there was no control so it could be all placebo, but who cares because people benefit from placebo anyways. And then some more handwaving to try and explain that there is probably still something intrinsically useful to acupuncture beyond placebo, but “[t]hat said, we are unable to rule out such an explanation given our lack of placebo control.” And, of course, “[p]atients in the trial were not blinded and may therefore have given biased assessments of their headache scores.”

        So the most significant offering Vickers could put up has its own serious methodological problems and once again shows Vickers’ obvious bias that there must be something intrinsically useful in acupuncture beyond placebo.

        So, no, I won’t exactly accept Peter’s citation of Vickers as demonstrating any sort of large or even clinically significant effect size of acupuncture. It would contradict his own work and analyses where he himself is forced to use the word “slight” to describe the effect size, even though it is obvious he is being generous even in that.

        And taken into context where pretty much all meta analyses, systematic reviews, and reviews of reviews have conclusions which all basically come out to be along the lines of “the efficacy of acupuncture in the treatment of pain remains doubtful” I don’t think Peter even has a case that acupuncture as placebo is useful at all let alone particularly useful.

        How about a systematic review in the journal Pain?

        We conclude there is limited evidence that acupuncture is more effective than no treatment for chronic pain; and inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care.

        And another from Pain looking at generating an objective measure to characterize the quality of pain reporting in trials and used acupuncture as an example where better quality trials were weighted more heavily in the final analysis. Some highlights:

        Five trials concluded that acupuncture was effective, and eight concluded that it was not effective for relieving back or neck pain. There was no obvious difference between the findings of trials using traditional and non-traditional points… There was no significant relationship between OPVS score and trial finding (positive versus negative). Authors’ conclusions did not always agree with their data. We drew our own conclusions (positive/negative) based on the data presented in the reports. Re-analysis using our conclusions showed a significant relationship between OPVS score and trial finding, with higher validity scores associated with negative findings. OPVS is a useful tool for assessing the validity of trials in qualitative reviews. With acupuncture for chronic back and neck pain, we found that the most valid trials tended to be negative. There is no convincing evidence for the analgesic efficacy of acupuncture for back or neck pain.

        From the journal Spine

        For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and in short-term follow-up. There is also evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, the effects are only small

        So a fleeting effect consistent with placebo response and possible placebo effect, and even then once again, the effect size was small.

        Cochrane review of Cochrane reviews?

        Several Cochrane reviews of acupuncture for a wide range of pain conditions have recently been published. All of these reviews were of high quality. <Their results suggest that acupuncture is effective for some but not all types of pain.

        Wait, if the mechanism of action that Peter agrees with me on is placebo response, plus placebo effect, plus non-specific effects and distraction/relaxation/etc… why is it effective for some but not all kinds of pain? Pain is pain, right? Why should it work for headache but not shoulder and elbow pain? (Never mind the actual effect size). Once again a huge inconsistency that is itself consistent with a small or nonexistent effect, that is a trial artifact, not an actual effect. Certainly nothing that would support acupuncture being a particularly good delivery vehicle for placebo effects (as I differentiate them from placebo response).

        How about a much more recent review in Pain?

        Fifty-seven systematic reviews met the inclusion criteria. Four were of excellent methodological quality. Numerous contradictions and caveats emerged. Unanimously positive conclusions from more than one high-quality systematic review existed only for neck pain. Ninety-five cases of severe adverse effects including 5 fatalities were included. Pneumothorax and infections were the most frequently reported adverse effects. In conclusion, numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse effects continue to be reported.

        So out of all the literature only 57 studies even met inclusion and only 4 were of excellent quality and only 1 condition seemed unanimously helped – neck pain. Once again, contradictory data for all sort of subgroup analysis and 1 indication manages to come out as seemingly positive. Seem like the effects of looking at enough things will always net you some sort of positive. And even then, no big effect sizes and no convincing evidence that acupuncture is helpful for pain at all let alone particularly good at placebo delivery.

        And Madison, you have already talked about the Hróbjartsson data and how that also shows improvements that are, at best, barely clinically significant. And Hróbjartsson himself talks about how he finds no utility to placebo treatments at all. Of course, many of these studies hide behind numerical tricks – some change their analysis, some will decide to report data as relative rather than absolute changes to make things seems more dramatic, and pretty much all of them conflate all sorts of things as acupuncture and typically only find effects after subgroup analysis or with significant suspicion of bias.

        So no, I don’t buy this “large effect size” BS that Peter is peddling. He’s slung a few references my way that support his claim, no doubt. But those references themselves are usually at least slightly questionable and regardless fly in the face of the entirety of the data on the topic showing, at best, barely clinically significant effects.

        Yet, somehow, when we say “acupuncture doesn’t work” we are being blinded by some “SBM dogma” and not strictly following the evidence and the science, which Peter somehow manages to do better than all those meta-analyses and systematic reviews and review of reviews by being able to read into the studies or something. And embarrassingly cites Vickers as a source to bolster his claims of effect size, when the corpus of Vickers’ own work demonstrates nothing of the sort and his clear bias towards acupuncture and shoddy methodology in his original work.

        Sorry Peter, but acupuncture doesn’t work. And that is a fair statement in every imaginable sense of the word. I’m not even convinced that acupuncture has a decent induction of placebo effect based pain control and you’ve provided nothing to say otherwise.

  25. This maybe of some interest to a few of you who are not stuck in a fog.

    http://youtu.be/1TerTgDEgUE

  26. PMoran says:

    MadinsonMD, sorry that I misremembered your quote by 1 mm, which is in turn why I did not recognize that you were extrapolating from the very same material that I quoted.

    I had not seen that particular meta-analysis of Hronjartsson, which related specifically to acupuncture and placebo acupuncture, whereas his previous ones dealt with placebo of all types in all conditions.

    This comment was interesting: “We found a tendency for an increase in the use of analgesic drugs in the no acupuncture groups compared with the placebo and acupuncture groups, which would tend to underestimate the effect of placebo acupuncture.”

    Anyway, the original claim was the blunt “acupuncture doesn’t work” . It is now — “anyway, it has no “clinically significant” influence.” ,

    This is a different assertion, and it is a more troublesome one for me at first sight. It is one of the reasons that I support the stance of SBM that acupuncture programs cannot be endorsed for routine patient care on present data. Regardless of all else, they may well not be cost-effective -effective over the patient mix of the usual conventional medical practice..

    Nevertheless in terms of “how do we advise inquiring patients about acupuncture” there are limitations to this approach, too.

    Firstly there is the critical question of “who is to decide what is a significant benefit?”. These patients may have been in chronic pain for months and not improving despite best mainstream care.

    The available evidence is also still somewhat short of clinching that order of “effect” and certainly any uniformity of such an effect for acupuncture, and for the same reasons that the ALL of the Hrobjartsson meta-analyses cannot be regarded as the final word. .

    Mainly, these studies weren’t primarily designed to measure the potential strength of placebo and non-specific influences upon symptoms. We would be all over that normally. The studies of Kaptchuk and others have shown how critical the whole clinical environment is to the effects of non-specific influences including placebo.

    Yet the subjects in the kind of RCT being examined here typically don’t know whether they are supposed to get better or not. That has to have a dampening effect upon reported outcomes. And we now know that negative perceptions can reduce the effect of even active agents such as analgesics upon symptoms.

    I am sure I will be accused of “special pleading” in this other point, but it is sound reasoning to also suggest that with the varied collection of influences acupuncture programs may exert, and likely vastly different patient attitudes towards acupuncture in any given population, patients will vary greatly in their receptiveness and responsiveness to it, when compared to a drug having a consistent physiological action (and which itself will work better in some than others). So any kind of “averaging” of effects can obscure much better results in some.

    One matter to do with the H study you are quoting, if acupuncture is held to be a pure placebo why not use the VAS differences between acupuncture and no acupuncture rather than sham and no acupuncture? Then we have 4mm (CI 2-6) being added to 10mm (CI 6-15) which delivers possible benefits of up to 21 (or 8, I allow) on a 100 mm VAS scale.

    So what do we really know about what acupuncture might do for any individual, should we accept that there is some plausibility for beneficial outcomes, occasionally suggestive testimonials, and a patient is expressing interest? Perhaps not a lot, other than that it will have no effect on most disease processes. I

    I know no one wants to examine these questions, but that is a very good reason for stretching our minds and being sure that we do understand what our own science permits. CAM does pose questions that we have never had to seriously consider before.

    I also know I am unlikely to change minds, but I would like a little less derision for those who may not have thought things through to this degree but who nevertheless sense that there might be something to this somewhat bizarre medical activity.

    Andrey I have not yet had time to go through your very long post, but I suspect this will be relevant to some of it.

    1. Harriet Hall says:

      “what do we really know about what acupuncture might do for any individual”

      Of course we can never know what any treatment might do for any individual. That doesn’t stop us from practicing medicine based on the best scientific evidence. If that is your basis for arguing that acupuncture might work, you logically ought to accept that any other treatment “might” work for a single or a small number of individuals. On that basis you could feel free to try bloodletting or any kind of snake oil or anything else supported only by individual testimonials.

      1. MadisonMD says:

        what do we really know about what acupuncture might do for any individual

        We know it might do this.

    2. Andrey Pavlov says:

      Actually Peter, my post time traveled and is actually still relevant to the one you just made.

      Anyway, the original claim was the blunt “acupuncture doesn’t work” . It is now — “anyway, it has no “clinically significant” influence.” ,This is a different assertion…

      Actually, I still make both statements. And they are both correct and not at all mutually exclusive. The reason you seem to find this to be interesting is that you refuse to accept what acupuncture actually is and instead substitute what you think it should be. So, no, they are not different assertions at all.

      Acupuncture has a definition and that definition is what is being practiced on the public and studied in the literature. It involved the insertion of filiform needles into specific locations for specific effects. That does not work. Even if you broaden it slightly to “needles inserted anywhere” for non-specific effects, it still doesn’t work. You needn’t put the needles anywhere in particular and you needn’t even put needles in. So, acupuncture doesn’t work.

      Now, the ritual of going into a room and being told a particular intervention will help you feel better and getting caring attention from a provider in whom you believe, along with some ritual of an intervention that may or may not be actual acupuncture but can also just mimic the general idea of what acupuncture is, that has a small but clinically insignificant effect mediated by placebo effects and confounded by placebo responses.

      A well thought out and nuanced understanding of the science would take that into account. But you’ve made it clear that you somehow are blind to the fact that these researchers are investigating “acupuncture” as we here define it, rather than what you are continuing to unreasonably call acupuncture. So yes, acupuncture with needles can have the same effect as what you are describing since that is a much more broad and vague thing which acupuncture can be described under. But the converse is not true.

      The available evidence is also still somewhat short of clinching that order of “effect” and certainly any uniformity of such an effect for acupuncture, and for the same reasons that the ALL of the Hrobjartsson meta-analyses cannot be regarded as the final word.

      And yet you are rather insistent that there is sufficient evidence to be convinced of a significant effect size of acupuncture and even enough to declare that acupuncture is a uniquely powerful vehicle for delivery of placebo effects. Yet all you have is a reasonable prior plausibility that this may be the case (with which I would agree) but no actual data to support the claim. Only a just-so story built on some prior plausibility, a few cherry picked studies, and torturing some possible evidence out of very bad studies.

      Yet the subjects in the kind of RCT being examined here typically don’t know whether they are supposed to get better or not

      An interesting point. Which further demonstrates that there is nothing particularly special about acupuncture but is, at least by and large, mediated by expectancy and placebo effects, which is, confounded by placebo responses. But further supports the fact that acupuncture doesn’t work. It is everything else around the acupuncture doing any “work” and even that is highly questionable and heavily confounded.

      I am sure I will be accused of “special pleading” in this other point, but it is sound reasoning to also suggest that with the varied collection of influences acupuncture programs may exert, and likely vastly different patient attitudes towards acupuncture in any given population, patients will vary greatly in their receptiveness and responsiveness to it, when compared to a drug having a consistent physiological action (and which itself will work better in some than others). So any kind of “averaging” of effects can obscure much better results in some.

      As Dr. Hall pointed out, this isn’t special pleading – it is moving the goalposts. You’ve taken your prior plausibility and hopelessly muddied and confounded data and assumed that it must work for some people… if only we can find those people. And identify them a priori. Yet that is all dependent on a cognitive state dictated largely by the culture in which people are in, rather than a SNP variant that alters the way a pharmaceutical will work with a person’s actual physiology. In other words, not only is it moving the goalposts to assert that we just haven’t found the population yet, that population can change on a cultural whim. We could build an entire literature to identify those most likely to have perceived or actual placebo effect based benefit from acupuncture and then 30 years later some popular journalist talks about how the medical established used acupuncture to hoodwink the population and that there was nothing about the actual sticking of needles in actual specific locations and poof! the population disappears. Seems like a lot of effort to find a small subset of people for an intervention with a small (or even modest) effect size that can vanish if the right article is published at the right time.

      if acupuncture is held to be a pure placebo why not use the VAS differences between acupuncture and no acupuncture rather than sham and no acupuncture? Then we have 4mm (CI 2-6) being added to 10mm (CI 6-15) which delivers possible benefits of up to 21 (or 8, I allow) on a 100 mm VAS scale.

      A perfect example right there. Even in a best case scenario you can only argue it may become a modest effect size, but that requires adding the two best case scenarios of two different analyses based on extremely heterogenous and poorly designed studies. When in reality the vast majority of that confidence interval ranges from nothing to barely broaching the cusp of clinically significant. Yet you continue to wish to hang your hat on the unlikelier side of the AUC on this one.

      Now, if you go back and read what I wrote before when you have the chance, you will note why your objections about the possible confounding of the effect size between acupuncture and no intervention via analgesic use doesn’t really matter; most studies and analyses show that the absolute effect size of acupuncture is “slight” at best. This is precisely the argument I have been making the whole time. We acknowledge that there are many components that could be contributing to the perceived total effect size of “placebo.” Yet even if we grant non-specific effects and genuine placebo effects 100% of that pie, the effect is still – in the words of Vickers himself, many times – “slight.” Start taking away even a few small pieces of that effect size, which you must concede we must do, no matter how small, and you just aren’t left with much.

      I know no one wants to examine these questions, but that is a very good reason for stretching our minds and being sure that we do understand what our own science permits. CAM does pose questions that we have never had to seriously consider before.

      Bollocks. We do examine them. Regularly. And discuss them in a nuanced way. And found it quite lacking.

    3. MadisonMD says:

      @Peter (and Andrey),
      I was just trying to inject some data in what is a repetitive discussion featuring repeated statement of the same opinions.

      Anyway, the original claim was the blunt “acupuncture doesn’t work” . It is now — “anyway, it has no “clinically significant” influence.” ,

      Peter, my opinion was and still is that “acupuncture doesn’t work.” I find this consistent with the following:
      (a) Drug X doesn’t work for depression if its effect matches that of a placebo pill;
      (b) No treatment doesn’t work even though it reduced pain scores by 17 in the Vickers et al. study.
      I understand your opinion differs. You have expressed your point of view. Repeatedly. I understand your point of view. We disagree. ’nuff said.

      ——
      What I was trying to do is to quantify the magnitude of the non-specific “placebo” effect of acupuncture using data. You have claimed that this effect is large and significant. The data I found said 10-13mm on a 100mm pain scale (and placebo response occurs in 12.5 – 20% of patients who receive it; re-read your Vickers et al. quotation above).

      One matter … if acupuncture is held to be a pure placebo why not use the VAS differences between acupuncture and no acupuncture rather than sham and no acupuncture? Then we have 4mm (CI 2-6) being added to 10mm (CI 6-15) which delivers possible benefits of up to 21 (or 8, I allow) on a 100 mm VAS scale.

      OK. Add 10mm+4 mm if you like. So its 13-14mm on a 100mm scale+/- errors instead of 10-13mm. Or perhaps average acupuncture (14) and no-acupunture (10) arms and get 12-13mm. BFD! We can agree with your interpretation that maximal placebo effect elicited by acupuncture does not exceed 21mm.

      So any kind of “averaging” of effects can obscure much better results in some.

      Averaging effects can also obscure that placebo makes pain worse in some individuals. So yes, this is a form of special pleading– thanks for pointing that out.

      Peter, get a grip. The data are the data– we have acupuncture placebo effects on the cusp of clinical significance plus a specific non-placebo effect that is not clinically significant (we can argue statistical significance). If you have more data to offer, I’m interested. If it is just your opinions (and Andrey’s), the walls of text and mutual recriminations are (IMHO) more obfuscating than enlightening. I have nothing to add to that discussion.

      1. Andrey Pavlov says:

        @MadisonMD:

        Apologies for my walls of text. Peter and I have done this dance many times before. I’m not quite sure why I still have the patience for it, but periodically I figure if I am still going to do it I may as well do more reading of the literature. Who knows, I could find out I am wrong. Or, more likely, understand better where I am right and get some additional insight along the way.

        In any case, you have said it well and focused in on probably the most salient point – one which I have argued with Peter many times. That there is no reasonable evidence that acupuncture has a large or even modest effect size for any indication and that there is no evidence to support it being a superior method of “placebo delivery”, whatever that may mean in Peter’s mind (and I do understand what it means in his mind, I just don’t feel like rehashing it).

        The corpus of data and the best of the data out there simply do not support the possibility of even a moderate effect size of acupuncture by any mechanism. At best there is a small, or in the words of Vickers, slight effect size.

        Peter’s argument seems to boil down to “What do you tell the patient who is experiencing profound effects from acupuncture?” (BTW, I myself used to feel euphoria when I first started having acupuncture treatments for my pain. That faded after just a few sessions). Well, that’s the rub for all these sorts of so-called CAM treatments, but it has nothing to do specifically with acupuncture. But for some reason he has a real soft spot for acupuncture which I just cannot fathom.

        1. windriven says:

          Andrey,

          “But for some reason he has a real soft spot for acupuncture”

          I’m pretty sure the soft spot is the spot where you keep needling him ;-)

          1. PMoran says:

            The fat lady has yet to sing, Windriven.

            I can’t quite “agree to disagree” because I am challenging some very dogmatic, or equally shuttered semantics, not with equal dogmatism, but the viewpoint that if looked at dispassionately the evidence is consistent with a range of possibilities relevant to patient interests (which should be the same as ours).

            Hrobjartsson himself allows “In some situations placebo acupuncture is associated with large analgesic effects, but in other situations similar procedures cause no, or only small, effects. Thus, to regard placebo acupuncture as a universally effective “super placebo” would be inappropriate.”

            I agree with the last sentence and never claimed either universality or that it can be classed as a pure placebo.

            All I am suggesting is that the evidence (including some anecdotal evidence that has been around for a long time, and suggestive laboratory-type studies) is consistent with there being significant responses to non-specific influences under the right conditions and in receptive individuals.

            So we would expect the considerable differences between different studies that H describes. Study outcomes are going to depend upon the population selected, how they are informed, how enthusiastically the sham (or real) “acupuncture” is performed and myriads of other factors such as how long the patients were permitted to relax, the confidence of the therapist, how much the needles hurt and even if the patient experienced “de qui” sensations, as our seriously misled friend Rodrigues suggests.

            So variable results would be inevitable on modern understandings in this field. We once thought that placebo influences were a more or less constant undercurrent in therapeutic interactions, but no longer..

            We have come full circle, back to reporting bias. You have to show that in those studies where strong outcomes are reported that patients are not really feeling better but are telling fibs, if you are to avoid my advice to keep some of your mind open on this matter. This is also where some of the “harder” findings, such as use of fewer analgesics under placebo influence come into significance because they suggest an actual alteration in symptom perception.

            Harriet: “Of course we can never know what any treatment might do for any individual. That doesn’t stop us from practicing medicine based on the best scientific evidence.”

            Which I have not disputed and insist that I am doing herein.

            1. Harriet Hall says:

              “That doesn’t stop us from practicing medicine based on the best scientific evidence.”
              Which I have not disputed and insist that I am doing herein.”

              Oh really? When meta-analyses show that a drug is not effective, do you give it to patients you think might possibly respond to it? When mammary artery ligation was proven ineffective in that sham surgery trial, did you continue to recommend it to patients?

            2. windriven says:

              Peter, I hope you didn’t take offense at my remark. I couldn’t resist the double entendre of the needle. I also considered ‘the needle and the damage done’, an allusion to a Neil Young song that I thought might be too obscure and certainly too inflammatory.

              I have followed the acupuncture debate in these pages for some years now. You are the only consistent and rational defender (too strong a word?) of acupuncture and I think that is what engages Drs. Gorski and Pavlov. The cranks like Rodrigues are easy to dismiss.

              That said, one of the lines that divides SBM from EBM is prior plausibility, some credible mechanism of action. The lack of one doesn’t make acupuncture impossible but it demands of acupuncture proof more stout than heretofore on offer.

              I suspect that any infinitesimal advantage over placebo is related to triggering endorphin release. That is one reason that I would love to see a head to head comparison of acupuncture and a wholly woo-free ‘soft’ therapy of empathetic conversation and massage in a non-clinical environment.

              Medicine does a terrific job of mechanical repair but all too often with the grace of a transmission mechanic in a setting not immensely more inviting than a garage. This I believe (without evidence) contributes to the perceived success, such as it is, of many alternate therapies.

              I’m not particularly fond of the idea of medical use of placebos if for no other reason than it encourages sloppy habits of mind. But then I don’t have to look patients in the eye and tell them to suck it up. So my personal – and entirely inconsequential – view is that tepid acceptance of acupuncture for those who want it is acceptable until medicine gets its act together and offers something less odious*.

              *As an aside I’ve thought about what this might look like; a day spa comes close. But I’ve also thought about the people who might be attracted to work in such a place and how easily it could slip into the land of make believe. The step between a pleasant scent and aromatherapy is tiny, the step between empathy and enabling behavior is similarly small.

              Also, the cost of delivering this care is not inconsequential. Cost-benefit would need to be closely examined.

              Setting and commitment matter. There’s a guy named Bill Strickland who has worked tirelessly to bring light to a couple of inner city neighborhoods. He has set up training schools and has insisted on these being beautiful buildings decorated with quality art and furnishings. Every element speaks to an expectation of excellence and largely the students there deliver it.

              I suspect if we worked just a tiny fraction as hard at the soft side of care as we do on the technical side most quackery would quickly atrophy and disappear.

              1. Andrey Pavlov says:

                @windriven:

                You are the only consistent and rational defender (too strong a word?) of acupuncture and I think that is what engages Drs. Gorski and Pavlov. The cranks like Rodrigues are easy to dismiss.

                Precisely. And still weird to be called “Dr. Pavlov” though technically correct. ;-)

                But then I don’t have to look patients in the eye and tell them to suck it up. So my personal – and entirely inconsequential – view is that tepid acceptance of acupuncture for those who want it is acceptable until medicine gets its act together and offers something less odious*

                Indeed tricky. Yet, in my limited experience, manageable. Those that are “true believers” and really believe it helps them, I will not “take that away” from them. But I will instead focus on the potential dangers and complications and ask them to keep me updated. Those that are more tepid about it and ask my opinion will get it. And it will not be Peter’s half-answer of “It seems to work for some people.” Because despite being technically accurate, does not live up to the full ethical and professional onus of informed consent and patient education. We are expected to disclose information that the patient would “reasonably” want to know. I think most patients would reasonably want to know that acupuncture is a theatrical placebo.

                I also then break down the aspects of said theatrical placebo that people find helpful and why and suggest other options to take advantage of this. I have zero problem suggesting meditation, progressive muscle relaxation, exercise, stretching, strength building, massage, spa days, relaxation as well as cognitive techniques for symptom management coupled with rational pharmacological use to augment as necessary. I have discussed my patients’ typical day and what causes them the most stress, where they feel the most pain, and prompt them to be introspective as to what they feel is the trigger for heightened negative symptom perception or a diminished capacity to deal with the symptoms. We then outline plans for how to recognize those situations ahead of time, options for coping at those times, etc etc.

                I suppose that may be the “soft side” of care, but I view it as complete care of my patient. And a much better option that passing the buck to a theatrical placebo to trick them in feeling better and relying on that to get by instead of giving them the tools by which to manage their every day experience of chronic pain. Because believe me, chronic pain sucks. I know this because for as long as I can remember I have had pain, every second of every day. I am in pain right now as I write this. I am in pain as I round on patients and I am in pain when I go to bed. I cannot sleep through the night because any position becomes painful after sufficient time.

                But when the acupuncture becomes too expensive for the patient, too time consuming to get there, or the acupuncturist stops practicing, or starts hawking dangerous stuff, we have a problem. And even before then all we have done is substitute on “quick fix” for another. Instead of popping a vicodin they now feel that they must get acupuncture to cope. Hell, I get regular massages and have one today in just a couple of hours but it can be difficult for me to find the time. So if I am in more than usual pain – which I have been for the last 3 days – I need something else to cope with it. And that has not been analgesics, but meditative exercises, stretching, and scheduling my massage.

                With all the data out there and having been through it all myself, having daily coping mechanisms in place is simply vastly superior than acupuncture could ever be.

              2. windriven says:

                @Andrey

                “I suppose that may be the “soft side” of care, but I view it as complete care of my patient.”

                No doubt. Unfortunately not every doctor has your perspective or your skill set in this regard.

              3. Andrey Pavlov says:

                @windriven:

                There is always a Bell curve in everything. Some people are much better, much worse, and many around average for their field in everything. We just need to continually strive to improve the mean since, slightly paraphrased, Jesus was right:

                The bottom tail of a distribution you shall always have with you…

            3. Andrey Pavlov says:

              I agree with the last sentence and never claimed either universality or that it can be classed as a pure placebo

              I agree with with H on this one as well. Where I disagree with you is that acupuncture is a pure placebo. Now, where the water can get muddied ever so slightly is if the patient actually feels the needling. In that case, I absolutely agree that there is likely to be some intrinsic physiological response that would likely result in some endogenous opioid release. But, that is not acupuncture. Acupuncture, as it is known, practiced, and studied is intended to be using incredibly slim needles that you cannot feel entering the skin. It is considered inappropriate if the patient actually feels the needle beyond a mere pressure and even that is not the goal, but an acceptable side effect. I have had acupuncture and only once do I recall feeling the needle – it hit a nerve and hurt a lot. It was certainly not therapeutic and was actually rather jarring. But moreso, that needling effect is completely independent of location and depth of penetration – which is counter to acupuncture – as per Vickers and nearly all other researchers – that it must be specific points.

              So in other words, there is nothing unique about “acupuncture” that equates it to needling and everything about acupuncture is actually supposed to minimize the feeling and effect of needling.

              So it is perfectly rational and scientifically rigorous to say that acupuncture is 100% pure placebo and that in certain cases an unintended actual effect can be elicited, which is itself both small and not acupuncture.

              including some anecdotal evidence that has been around for a long time, and suggestive laboratory-type studies

              Anecdotal evidence, no matter how long it has been around or how profound it may seem, has next to zero relevance to the conversation here. You should know that by now. It is nothing more than a hypothesis generator and we have a lot more than guesses at what to study to guide this discussion.

              consistent with there being significant responses to non-specific influences under the right conditions and in receptive individuals.

              Agreed. But that can be said for literally anything. You do realize you’ve said absolutely nothing of value, right? Let’s try a quick experiment:

              Homeopathy has some anecdotal evidence that has been around for a long time is consistent with there being significant responses to non-specific influences under the right conditions and in receptive individuals.

              Reiki has some anecdotal evidence that has been around for a long time is consistent with there being significant responses to non-specific influences under the right conditions and in receptive individuals.

              Qi gong has some anecdotal evidence that has been around for a long time is consistent with there being significant responses to non-specific influences under the right conditions and in receptive individuals.

              Faith healing has some anecdotal evidence that has been around for a long time is consistent with there being significant responses to non-specific influences under the right conditions and in receptive individuals.

              Snake handling has some anecdotal evidence that has been around for a long time is consistent with there being significant responses to non-specific influences under the right conditions and in receptive individuals.

              Trepany has some anecdotal evidence that has been around for a long time is consistent with there being significant responses to non-specific influences under the right conditions and in receptive individuals.

              You see where I am going with this? Of course we agree with that statement. But it is a pointlessly vague statement that has nothing in particular to do with acupuncture and everything to do with “the right conditions and in receptive individuals.” The fact that in order to keep justifying your particular bent for acupuncture you must come to such an incredibly general statement that can be applied to literally anything should tell you something about whether acupuncture “works” and whether it is itself a particularly useful placebo delivery vehicle or whatever else it is that you are trying to claim for it.

              For us here, we acknowledge these things, but realize that acupuncture is relegated to roughly the same level as homeopathy, reiki, therapeutic touch, etc. and you have yet to present evidence otherwise. Your best volley was the Vickers article which MadisonMD showed you did not demonstrate anything particularly profound and I showed how biased Vickers is in all his other analyses and studies. Researcher degrees of freedom run rampant in such analyses, and we have every reason to believe Vickers would use them (unconsciously, probably) to skew the results. And even then the results are not exactly impressive.

              So we would expect the considerable differences between different studies that H describes.

              Yes, but we would also expect such heterogeneity if we are studying nothing – tooth fairy science is expected to give the same exact results. No matter how you slice it they simply do not support your stance (as best as I can figure it out, since it is always fluid and muddy). You can’t argue that the heterogeneity of studies is indicative of anything uniquely beneficial to acupuncture when it just as easily argues that acupuncture is wholly a sham.

              You have to show that in those studies where strong outcomes are reported that patients are not really feeling better but are telling fibs, if you are to avoid my advice to keep some of your mind open on this matter

              No, we don’t actually. And I have demonstrated why. Firstly, your choice of words is telling – I have never intimated that the patient is lying. But reporting something different to what you are actually feeling is common and often reflexive, particular when you are in a study and/or feel is if you should have been feeling somewhat better. Have you ever had someone greet you and say “How are you today?” and despite being miserable your gut reflexive response is to say “Oh, I’m OK.” You are in a study, with all sorts of things going on, just had needles (maybe) stuck in your body and you have to now sit and think “did I feel better?” “Well, yeah, I suppose I did. A little better. Yeah.”

              But the key point is that you must admit that at least some amount of reporting bias and “fibbing” as you call it exists. And the effect size of acupuncture taking into account all possible causes for the effect size is small at best. So unless you can prove that all those other confounders are equal to zero then you must be taking a small effect and making it even smaller.

              So what are you left with Peter? An effect size so small and ephemeral that the best case scenario where all confounders are zero is still barely useful. In an intervention that has been known to cause deaths. Plus all the other baggage associated with it.

              This is also where some of the “harder” findings, such as use of fewer analgesics under placebo influence come into significance because they suggest an actual alteration in symptom perception.

              No, not necessarily. They could also reflect a pressure to simply “buck up” and take the pain. You cannot differentiate that from these studies and we know it is a phenomenon that happens. It could be better symptom management rather than perception which itself would have nothing unique to do with acupuncture.

              All you are doing is unreasonably shifting the burden to us to try and prove something the study can’t show us and assuming on your end that your particular interpretation of what it possibly could be showing is correct. All in the context of a best case scenario of overall effect size to be of absolutely marginal clinical benefit.

  27. P Moran says:

    Everything about that last post of yours is wide of the mark, Andrey, except that some of the pooled “positive” outcomes will be due to reporting biases, as I stated about ten posts ago..

    Yet you cannot show how much is that, or that it applies to all “responders”, and I have pointed out major flaws in the argument that pooled outcomes will always be trivial to start with. Even the person whose evidence is most often quoted admits that this is not so, and there is other evidence (yes, including anecdotal evidence and uncontrolled observations as well as laboratory studies) that supports the probability/possibility of stronger effects in some.

    You talk to me as though I have personally pulled this hypothesis out of thin air. It has been accepted since ancient times that the mind can have a powerful effect upon some kinds of illness, also by a large section of the medical profession and of its researchers today.

    This is, I am sure, the main reason why we are constantly have to complain about the “softness” of — well — just about everyone else — to CAM. They may be equally reluctant to appear to be supporting pseudoscience, yet not quite sure where the patient’s best interests lie or of where their own entitlement to intrude upon patient’s lives begins and ends.
    .
    If anything it is SBM that is the minority view, when insisting that such influences will be so trivial under all circumstances that we can safely and ethically ignore any that might occur outside of our own practices. And this very same SBM wears its bias on its sleeve; the desire not to leave the least footing for CAM is explicit.

    Your laboured attempts at reduction to absurdity were pointless. The hypothesis under discussion indeed predicts that anything>/I> offered as a medical treatment could provoke placebo and incidental, unintended medical influences under the right conditions..

    A lot of what you say about acupuncture is irrelevant, or of little import for my position. I am not “supporting acupuncture” except in the colloquial sense that patients will have of it, and from a very limited perspective. From this viewpoint it doesn’t matter much whether it is “sham” or real so long as it has the qualities that trigger certain responses and soothe certain nerves.

    I am essentially speaking to the ethics of too aggressively turning patients against methods on grounds that may be largely irrelevant to their personal welfare.

    But there are other matters. There is some questionable scientific rigor, not looking as critically at our own evidence and what it really means as that of others. We all do that, but professedly science-based enterprises should do less of it than I have seen over some years now. It was catching myself out in it that set me on a slightly different sceptical tangent.

    There is fairness and respectfulness towards those who hold not unreasonable views on the available evidence. There is the tendency of groups of like-minded people like this to gravitate towards, or become overly tolerant of extreme positions without realising it. That needs to be guarded against.

    There is inconsistency — you personally can hold acupuncture is of no real benefit to anybody despite your own rather profound experiences with it. It is the profound sense of well-being that’s some describe after using some forms of CAM that suggests that it can have useful, even enduring, influence on some kinds of illness, just as certain testimonials suggest.

    This is getting repetitive so you can have the last word.
    .

    1. Andrey Pavlov says:

      Everything about that last post of yours is wide of the mark, Andrey

      Then we agree to disagree. Yet I seem to be in good company.

      Yet you cannot show how much is that, or that it applies to all “responders”, and I have pointed out major flaws in the argument that pooled outcomes will always be trivial to start with

      You are arguing that our methods are missing certain individuals for whom the response is enduring and/or very significant. I do not deny this is the case. This is the case for literally everything we study that seems to have any effect whatsoever, regardless of mechanism. It in no way demonstrates the validity of acupuncture, nor the utility of it.

      You talk to me as though I have personally pulled this hypothesis out of thin air

      No, I am speaking to you as someone who is conflating acupuncture with what you think acupuncture is, and reaching beyond the evidence as in above – “well certainly there must be some people for whom it is highly useful.” Sure, but that is speculation and we know must be a reasonably small portion of the population and we have no way to identify who they will be, or which specific set of acupuncture rituals will actually be that trigger. In other words, absolutely nothing unique about acupuncture and all about the actual art of medicine – working with incomplete information and bedside manner.

      It has been accepted since ancient times that the mind can have a powerful effect upon some kinds of illness

      Argument from antiquity? Really?

      also by a large section of the medical profession and of its researchers today.

      I happen to be part of that section of the medical profession. But that is not acupuncture that is a wholly different line of scientific inquiry and acupuncture happens to exploit it, in some people, to varying degrees, but not hugely better than just about any other non-specific effects in a complex ritual of healing with a credulous audience.

      Really Peter, you could be making a much more persuasive argument about faith healing! Have you seen the videos of it? How incredibly profound that experience is? How they feel electricity surging through their bodies? How it cures them of everything, which we both recognize is bollocks but it certainly gets rid of all those subjective complaints, just like acupuncture would.

      So I am not arguing that acupuncture is nothing and placebo is nothing. Far from it. I am arguing that acupuncture is nothing special and that there is nothing unique to it, including its effect size. It is an elaborate placebo and nothing more.

      If anything it is SBM that is the minority view, when insisting that such influences will be so trivial under all circumstances that we can safely and ethically ignore any that might occur outside of our own practices.

      Scientific veracity is not a popularity contest. There are many reasons to consider the fact that a known placebo, no matter the effect size, will always be ignored safely and ethically. It is a non-starter, and whether it happens to have a large effect for some random person that otherwise would be condemned to a life of chronic pain and misery is an interesting academic discussion but a moot point when it comes to actual medical practice. And there is enough demonstrated harm from the “irregular medical” providers ancillary to it that it is eminently reasonable to admonish people that it is nothing more than a placebo and to avoid it.

      <blockquote.The hypothesis under discussion indeed predicts that anything offered as a medical treatment could provoke placebo and incidental, unintended medical influences under the right conditions..

      We do not disagree on this.

      A lot of what you say about acupuncture is irrelevant, or of little import for my position.

      That’s the problem. A couple years down the road and nobody here can understand your position! I’ve tried desperately, so has Dr. Gorski, Dr. Hall (she and I discussed it over dinner and in all sincere honesty and simply could not figure it out), other commenters here like windriven, Madison, WLU, and even Mouse also cannot understand what your position actually is.

      Perhaps taking the time to clearly elucidate it in a post is very much a good idea. Honestly, you’d probably be (pleasantly) surprised at the comments that follow it.

      .I am essentially speaking to the ethics of too aggressively turning patients against methods on grounds that may be largely irrelevant to their personal welfare.

      We disagree here. There are many reasons to believe that, on the whole, this is a net negative for their personal welfare. The fact that isolated and unpredictable individuals may derive significant benefit does not negate this.

      There is the tendency of groups of like-minded people like this to gravitate towards, or become overly tolerant of extreme positions without realising it. That needs to be guarded against.

      Agreed. Which is why I have relentlessly re-assessed my viewpoints, revisted the literature, and genuinely tried hard to see where you are coming from. I have discussed it in private with other commenters and the editors here as well. I have discussed the general concept with colleagues both with and without the context of SBM. Each time I have done so ready to prove myself wrong, and failed.

      There is inconsistency — you personally can hold acupuncture is of no real benefit to anybody despite your own rather profound experiences with it. It is the profound sense of well-being that’s some describe after using some forms of CAM that suggests that it can have useful, even enduring, influence on some kinds of illness, just as certain testimonials suggest.

      Testimonials are worth very, very, very little. My own included. My own demonstrates quite clearly how well even intelligent people can be fooled. It is not an inconsistency – it is an admonishment to be wary of how easily we can fool ourselves. You pejoratively call this “lying” when a patient reports improved symptoms even though they really aren’t. But you are vastly underestimating the ability of humans to convince themselves of patently and absurdly false things, even internal things, even in the face of mountains of evidence to the contrary. I have also seen people in obvious agony absolutely deny, vehemently, that they are in pain. Until they are given a narcotic and then suddenly realize after the pain has finally left that they actually were in pain. This level of self deception is not uncommon and works in every way imagineable. Including reporting bias in studies on acupuncture.

  28. Andrew Clark says:

    Hello Mark,
    I must say great article. I am still in dilemma that is that really happen? Yes It can be because we are still not know what is the exact reason behind depression.
    Thanks
    Andrew Clark
    tmsofasheville.com/

    1. WilliamLawrenceUtridge says:

      Yeah, you’re a spamming douchebag and you didn’t actually read the article.

  29. ladentduchat says:

    Hey! I just realized. The 2 studies mentioned above (by our almighty Dr. Crislip) are Norwegian, not Swedish! Huge difference, especially now during the Winter Olympics. And now I don’t have to be embarrassed.
    Time to go kill a polar bear for dinner.

    1. Chris says:

      Remember to not eat the liver!

  30. June Toner says:

    This article doesn’t mention the possibility of urethral diverticulum in women with recurring uti and with which I’ve just been diagnosed after several years of non-specific symptoms and going on 3 years of constant utis, 20+ courses of antibiotics – some lasting 30 days and the most horrendous of experiences, trying to maintain a job throughout….
    Having been told by several GPs and at least 2 Consultant Urologists that ‘this is just something that happens to women at a certain age’ and ‘we tend to treat with prophylactic antibiotics’, my response was “there is something causing this, you just haven’t found out what, yet!” I had to insist on the CT-KUB that ultimately exposed a ‘vaginal cystic lesion’, which 4 months later was finally diagnosed as a urethral diverticulum.
    6 wks after that diagnosis, I am still waiting to speak to the Urogynaecologist who will perform the necessary surgery… I am completely demented!

    Please tell your colleagues in the medical profession… women have to be tested for this condition when presenting with recurrent uti… had I known of its existence, I’d have self-diagnosed 3 years ago!

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