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Acupuncture Vignettes

I seem to be writing a lot about acupuncture of late. As perhaps the most popular pseudo-medicine, there seems to be more published on the topic. I have a lot of internet searches set up to automatically feed me new information on various SCAMs. Interestingly, all the chiropractic updates seem to be published on chiropractic economics sites, not from scientific sources. Go figure.

Here is a hodgepodge of articles, mostly from the scientific literature, I have read concerning acupuncture and TCM.

Tooth Fairy science and the constitution

Harriet Hall coined the term “Tooth Fairy science” which is:

to doing research on a phenomenon before establishing that the phenomenon exists…You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned, because you haven’t bothered to establish whether the Tooth Fairy really exists.

The concept encompasses most of pseudo-medicine. Much of traditional Chinese medicine is based on concepts divorced from anatomy and physiology and are perfect for Tooth Fairy science.

An example comes from the introduction of “The Association between Yang-Deficient Constitution and Clinical Outcome of Highly Active Antiretroviral Therapy on People Living with HIV.”

Before you read further, spit take warning. If you are drinking, swallow, so liquid does not squirt out your nose and onto the computer.

…more evidence is emerging that much of the wisdom of traditional medicine can in fact be explained at genomics level (Joshi et al. and the references therein). Recently, HLA class II polymorphisms were found associated with the physiologic characteristics defined by Traditional Chinese Medicine (TCM). In TCM, constitution is believed to be a distinct characteristic of an individual. Constitution has been used to guide disease prevention, health care, and medical practice. Yang-Deficient Constitution is one of the major constitutions, which is characterized by chills, cold limbs, and also spontaneous sweating; loose tools [sic] and/or profuse clear urine; and lassitude.

So they decided to:

…systematically investigate whether there is any association between Yang-Deficient Constitution and complications incurred from HIV infection and design evidence-based treatment, we conducted a prospective observational study for evaluating the association between Yang-Deficient Constitution and clinical outcomes.

On a scale of 1 to 5 they asked HIV patients the following questions to see if they were Yang-Deficient:

  1. Do you feel cold at your limbs?
  2. Are you sensitive to cold at stomach, back, waist, or laps? Are you usually sensitive to cold weather and dress more than others?
  3. Are you more sensitive to cold air (such as outside of winter, air-conditioning, or electric fan)?
  4. Do you have flu- or cold-like symptoms more frequently or easily than others?
  5. Do you feel uncomfortable or worried for cold water or foods?
  6. Do you have pulpy bowel after having cold water or foods?

I have taken care of AIDS patients since the beginning of the epidemic and I cannot imagine how those questions could be relevant in any way to HIV, its treatment and complications.

They then collected a tonne (English measurement, it is that large) of data and ran it through the old p-value machine and found some barely significant results. They concluded:

Yang-Deficient Constitution score has a potential to be developed as a predictor for early HIV-related mortality and side effects. The interrelation and underlying mechanisms should be further investigated for evidence-based design of a more appropriate treatment strategy.

They go so far as to suggest it is the mitochondria. Medication toxicity in HIV is often due to mitochondrial toxicity. Mitochondria are important for energy. Yang deficiency syndrome patients have weak or imbalanced energy. Therefore:

Yang-Deficient Constitution is susceptible to mitochondrial toxicity is worth further investigation.

At least quantum effects are not blamed.

I keep going back to Ioannidis and there are at least three reasons, besides thinking the idea that Yang-Deficient Constitution is valid, that the conclusions of the study are false:

  • Corollary 3: The greater the number and the lesser the selection of tested relationships in a scientific field, the less likely the research findings are to be true.
  • Corollary 4: The greater the flexibility in designs, definitions, outcomes, and analytical models in a scientific field, the less likely the research findings are to be true.
  • Corollary 5: The greater the financial and other interests and prejudices in a scientific field, the less likely the research findings are to be true.

I guess they did not read the paper. Few in the pseudo-medical world seem to. Data mining garbage does not lead to diamonds. Tooth Fairy science at its more pure. Supported by the Chinese Government and Stanley Ho Centre for Emerging Infectious Diseases. Good money thrown away.

Look on my works, ye Mighty, and despair!”
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare
The lone and level sands stretch far away.

Acupuncture beer goggles

I most studies, sham acupuncture is no better than real acupuncture for the relief of pain. The usual interpretation is that if an intervention is no different than a placebo, the intervention does not work. But there is always the issue that sham and real are better at relieving pain than doing nothing. So, goes the thinking, the efficacy of acupuncture comes from the power of placebo.

I have always referred to pseudo-medical therapies as beer goggles: they do not change reality, just the perception of reality. Changing perception of disease is an important result of an interaction with the patient. I attempt it all the time, although unlike pseudo-medical practitioners, I try do it truthfully.

Little did I realize there is a medical term for beer goggles: tactile discrimination training. It is when:

…stimulation of some form is applied to the painful area and the patient is asked to decide on the locality or type of stimulation, an approach that has been shown to be effective in the management of certain chronic pain problems.

In this study they decided to compare acupuncture to acupuncture used as tactile discrimination training in chronic low back pain. The protocol was:

After locating the points, the 14 needles were inserted. We used 15 mm needles fully inserted to ensure that the depth of needling was the same across conditions. In the experimental condition, participants participated in a sensory discrimination training task similar to that described by Moseley et al.19 A picture of a back with the position of each needle numbered (see figure 1) was positioned so that it could be comfortably viewed by the participant. The clinician then rotated a single needle in accordance with a random number sequence and the participant was required to nominate which needle was being stimulated, if the participant committed an error, they were told which point had in fact been stimulated. Each needle was stimulated for 3 s with a 10-s interval between each stimulus. This task was performed with visualization of the back via a mirror in the first 10 min and progressed to no visualisation in the last 10 min. In the control condition, participants were asked to lay comfortably and relaxed and to not attend to the needles. During the 20 min control condition the therapist manipulated needles at the same rate and using the same random sequence as they did in the experimental condition.

Of note, both were done by the same person, an acupuncturist. The only difference between the acupuncture and the tactile discrimination was:

participants responded to each needle manipulation by trying to localize the position of the needle that was being manipulated.

And the tactile discrimination acupuncture outperformed acupuncture for pain reduction.

This helps explain why sham and real acupuncture have the same effect, why acupuncture does not depend in where the needles are placed or even if needles are used. It is a form of tactile discrimination training, aka beer goggles. Perception is altered, not underlying pathology.

Blind men and the elephant in the room

There was a recent PLOS article, “Decreased Risk of Stroke in Patients with Traumatic Brain Injury Receiving Acupuncture Treatment: A Population-Based Retrospective Cohort Study.”

It was a:

a retrospective cohort study of 7409 TBI patients receiving acupuncture treatment and 29,636 propensity-score-matched TBI patients without acupuncture treatment in 2000–2008 as controls.

And it found that:

TBI patients with acupuncture treatment (4.9 per 1000 person-years) had a lower incidence of stroke compared with those without acupuncture treatment (7.5 per 1000 person-years), with a HR of 0.59 (95% CI = 0.50–0.69) after adjustment for sociodemographics, coexisting medical conditions and medications.

Interesting result. Why did they do the study? Well, in Taiwan acupuncture is a common treatment and no one had ever looked to see if it could prevent a stroke. It is a tough job, but someone had to do it.

Retrospective studies are always interesting, but not definitive, since there may be differences between the treatment and controls that would be potentially avoided in a prospective randomized trial. So were there differences in the two groups? Yep.

The acupuncture group was more likely to be on anti-coagulants, (p= 0.0003), antiplatelet drugs (p < 0.0001), and lipid lowering drugs (p < 0.0001). Seriously. The treatment group was more likely to be on stroke preventing medications yet it was the acupuncture that was responsible for fewer stokes? Because the statistics suggested it?

To properly evaluate whether acupuncture treatment is associated with reduced stroke risk in TBI patients, we used propensity score to match the difference of age, sex, low income, and density of TCM physicians, mental disorders, hypertension, diabetes, ischemia heart disease, hyperlipidemia, migraine and epilepsy between TBI patients with and without acupuncture treatment. To accurately estimate risk of stroke after TBI for patients with and without acupuncture treatment, residual confounding effects were adjusted in the multivariable Cox proportional hazard models.
Seems so.

They had 2 possible explanations for the effects of acupuncture. The first was that acupuncture had biologic effects. I would bet against it. There is no plausible reason acupuncture could prevent stoke. The other was that patients in the acupuncture group had better care.

…patients with TBI who choose acupuncture treatment may have better knowledge, attitudes and practices regarding physical rehabilitation and disease prevention, which we believe could also contribute to reduce new-onset stroke event after TBI.

Given that the acupuncture patients were more likely to be on a medical therapy that prevents strokes, that is a more likely answer.

It wasn’t the acupuncture, it was the medications.

When I first read this article and looked at the table that demonstrated the marked difference in medications in the two groups, I could not believe it. I read it over and over, thinking “no, that couldn’t be.” I could not understand how anyone could be blind to what would appear to be a simple explanation of the difference between the two groups. The most impressive example of confirmation bias I have ever seen.

Electroacupuncture is not acupuncture

“When I use a word,’ Humpty Dumpty said in rather a scornful tone, ’it means just what I choose it to mean — neither more nor less.”
“The question is,” said Alice, “whether you can make words mean so many different things.”
“The question is,” said Humpty Dumpty, “which is to be master— that’s all.”

In my feeds I kept seeing variations of the theme: acupuncture treats sepsis. As an infectious disease doc it tweaked my interest since sepsis (a particularly severe manifestation of infection) is a disease that I routinely treat and routinely kills.

So what was this amazing study? “Dopamine mediates vagal modulation of the immune system by electroacupuncture.”

First, it was in mice.

Second, the reasoning was as follows. Many of the symptoms of sepsis are due to inflammation medicated by cytokines. Stimulating the vagus nerve decreases the inflammatory response in a variety of other diseases. It is hard to stimulate the vagus nerve directly since it is deep in the neck and check. So

We hypothesized that electroacupuncture can be an alternative strategy for vagal stimulation.

The key word is electroacupuncture.

Recently they excavated a 2000 year old tomb in China, and what they found was, in a word, incredible. First was a set of acupuncture needles. But more amazing was a set of dead AA batteries in a mechanical dragon that evidently rolled across the floor while playing cymbals. It strongly suggests that the ancient Chinese used electroacupuncture.

So they stuck a needle in the ST36 Zusanli point of mice. Which is in the leg, below the knee. Who knew that mice and humans had the same meridians and acupoints? Then they cranked in some voltage and measured various cytokines and other inflammatory mediators under various conditions to see what happens. The results were interesting. The electroacupuncture-treated mice had decreased mortality by an:

…anti-inflammatory mechanism mediated by the sciatic and vagus nerves that modulates the production of catecholamines in the adrenal glands.

But here are some key discoveries from the paper:

The anti-inflammatory effects of electroacupuncture are voltage dependent.

And:

Direct electrical stimulation of the vagus nerve mimicked the production of dopamine and norepinephrine induced by electroacupuncture.

And:

…direct electrical stimulation of the sciatic nerve mimicked the anti-inflammatory effects of electroacupuncture (Fig. 1f) in a voltage-dependent manner.

They did not use a random peripheral site to apply the voltage or another acupuncture point as a control. As best I can tell, the study actually had nothing to do with acupuncture. What they demonstrated was electrical stimulation of peripheral nerves or the vagus nerve had anti-inflammatory effects. The use of the specific acupuncture point was, well, pointless.

This is the kind of study that drives me nuts. You could remove all the references to acupuncture and the results would be just as applicable. I suppose it would then lack the sexiness that acupuncture adds. Without acupuncture as a hook, I wonder if it would have been published in Nature Medicine or get the notice it did.

And, while interesting, given all the monitors on a patient in the ICU with sepsis, I can’t see any clinical utility until some clever researcher figures out a way to give the electricity without messing up the EKG etc.

Acupuncture and erectile dysfunction

Harvard Medical School has Harvard Health Publications. Their Editor-in-Chief, Dr. Anthony Koraroff has a column called Ask Doctor. K. In the recent issues they ask him, “Is acupuncture an effective treatment for erectile dysfunction?” Dr. K’s response suggests that being from Harvard is not a preventative for getting almost everything about acupuncture wrong.

One non-drug treatment used for ED is acupuncture, the ancient Chinese practice in which a practitioner inserts hair-thin needles into specific sites along the body’s “meridians.” According to traditional beliefs, the body’s Qi (pronounced “chee”), or vital force, flows along these meridians. By stimulating specific acupoints, the practitioner aims to restore the proper flow of energy in the body.

He fails to mention that this is a pre-scientific concept with zero basis in reality. There are no meridians or acupoints or any sort of life energy. It is nonsense. And which acupuncture does he advise as the ‘real acupuncture’: Chinese, Japanese, Hand, Foot, Tongue, Ear or the German MAPS?

In treating ED, the acupuncture needles are placed in the wall of the abdomen.

Of course they are. I would be more curious why no acupuncture map ever shows meridians and acupoints in the genitals. You would think the life force would be in the life-generating organs. I know why. If you are a male making stuff up, the last thing you would do is stick needles in the genitals. Makes one think it would be useless for erectile dysfunction.

Western scientists have a different explanation.

I have always found the phase “western scientist” at best patronizing and at worst racist, but that is me. There is one science, used by humans all over the world, and to judge from output the last decade those “eastern scientists” are kicking our research butts.

They speculate that the needles stimulate the release of endorphins, the body’s natural painkillers. Other theories claim the needles release neurotransmitters, chemicals that carry messages between nerve endings.

Let’s see. You stick needles in someone and twist them and you get a pain response? And in response to a noxious stimulus neurotransmitters are made? Who’da thunk it? And water is wet. And how would that have any effect on the panoply of diseases that acupuncture is supposed to help, from ED to fertility to herniated discs? Hint. It doesn’t.

Unfortunately, there just hasn’t been enough good research to determine if acupuncture is useful for ED.

Why unfortunately? Given prior plausibility, why waste time and money on a useless therapy. But he is right. From a recent meta-analysis of acupuncture and ED:

Most investigations had methodological flaws, e.g. inadequate study design, poor reporting of results, small sample size, and publication without appropriate peer review process.

He continues:

There are more studies of acupuncture as a treatment for chronic pain. Some scientists point to studies that compare acupuncture to “sham acupuncture,” in which the needles are deliberately not placed properly. Such studies sometimes find that both real and sham acupuncture relieve pain. This suggests to them that acupuncture may work by causing a placebo effect.

No, this suggests that acupuncture does nothing. If real acupuncture has the same effects as twirling toothpicks, safe to say it is ineffective. Or would he use the same justification for using internal mammary artery ligation for angina? And if he is suggesting placebo medicine, well, that is usually considered unethical.

Whether this is true or not, what matters to patients is that their condition has been improved. Some of my patients have had good relief of their pain.

It doesn’t matter that the costly treatment you are suggesting is not based in reality and has no efficacy? A classic example of why I say the three most dangerous words in medicine are “in my experience.”

As for acupuncture to treat erectile dysfunction, if you’d like to give it a try, go ahead. Be sure to seek out an experienced acupuncturist. And remember that it can be time-consuming and expensive. But in experienced hands, it is safe.

No reason whatsoever in the discussion to suggest it would have any efficacy at all, but use it any way despite the cost. And those experienced hands? Yet another photo without gloves; bare fingers poking around the needle site. Acupuncture is not safe in any hands experienced or otherwise:

468 patient safety incidents were identified; 325 met our inclusion criteria for analysis. Adverse events reported include retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), Bruising or soreness at needle site (2%), Pneumothorax (1%) and other adverse reactions (12%). The majority (95%) of the incidents were categorized as low or no harm.

And this did not include the numerous reports of infection from the sloppy infection-prevention technique that defines acupuncture.

Let’s see. No reason it should be effective for ED, no clinical trials to suggest efficacy, has complications and cost, and in my experience it occasionally works for pain so try it for ED. I am not impressed with the advice. Ask Dr. K? Maybe not so much if it concerns acupuncture.

Combinations

Pseudo-medicines combine and recombine in a continual fantastical dance. Pick any two alternative medicines and someone, somewhere, has combined them into a unique treatment modality. My favorite is Tong Ren, a voodoo form of acupuncture.

I had thought, perhaps incorrectly, that no one could come up with a more ludicrous combination. Perhaps it would be dark energy homeopathy or dark matter acupuncture. I suppose it is just a matter of time before someone combines some pseudo-medical modality with the time cube and their nonsense will reign supreme.

Until then it is more mundane combinations.

There is the idea that as long as you are sticking needles in people you might as well add other substances to the needle and drag them into the dermis. It is called mesotherapy. Like much of pseudo-medicine, the concept doesn’t entail the concept of germ theory, which is just a theory after all.

There have been 35 reports of odd infections associated with mesotherapy, often atypical mycobacteria.

Evidently there is also bee venom acupuncture:

Bee venom acupuncture is growing in popularity, especially in Korea, and is used primarily for pain relief in many kinds of diseases as an alternative medical treatment.

And, in a new report, bee venom acupuncture is also associated with odd infections:

We report 3 cases of Mycobacterium chelonae infections after bee venom acupuncture. All were treated with antibiotics and surgery.

A common organism in the environment and water, Mycobacterium chelonae is not an uncommon cause of soft tissue infections where simple infection control interventions are ignored.

The authors finish with inadvertent whimsy:

Considering the increasing use of bee venom therapy and considerable morbidity of NTM infection, prevention efforts of infections are needed through strict adherence to infection control principles, including sterilization of venom extraction, purification process, injection equipment, and environment.

Strict adherence? LOL. I would be happy with gloves.

Acupuncture as gamma-hydroxybutyrate

Interesting headline: 80-Year-Old Man Paralyzes Women with Acupuncture, Molests Them.

Seo is also accused of taking off A’s panties and molesting her after paralyzing her with acupuncture needles in the foot, he got access to A after promising to treat her uterus. Another victim, a 22-year-old employee, was also molested after receiving paralyzing acupuncture from Seo.

As one commentator said:

I thought paralysis acupuncture was only possible in movies.

You are correct, Sir. There is no way acupuncture could cause paralysis. It cannot and does not do anything. But what might have happened? I lack information in this particular case, but I have seen two patients with hysterical paralysis and hysterical blindness (aka conversion disorder). Neither had a physiologic cause of their problem but neither could walk or see. I have seen patient with melanomas the size of a large button mushroom and another with an erosive tumor on his abdomen the size of a dinner plate. Both completely denied anything wrong. It was hard to believe the patients were unaware of the problem. I have been amazed over the years of what people can do given the right situations.

I wonder what kind of social expectations allowed the acupuncturists to convince his victims that they were paralyzed. Some odd combination of male dominance, conversion disorder and Stockholm syndrome? I don’t know. If indeed the event occurred as written. Given the inability of most news outlets to be even remotely accurate about pseudo-medicines, I am a touch skeptical that the events occurred as reported. It is more interesting, if true, about a milieu that allows a predator to use a worthless pseudo-medicine as a weapon for abuse.
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A gentle reminder. Check out the Society for Science-Based Medicine.

Our announcement was a month ago and it is going along nicely, if taking up a huge amount of my time.

Posted in: Acupuncture, Clinical Trials

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