I subscribe to American Family Physician, the peer-reviewed journal of the American Academy of Family Physicians. It emphasizes evidence-based medicine and most articles include a table showing strength of evidence ratings for key recommendations for practice. Lately, its scientific rigor has been slipping. I have complained to the editor about several articles whose recommendations were not based on the best science, and I have been consistently ignored.
Acupuncture for Chronic Low Back Pain
A recent article on chronic low back pain recommended acupuncture and gave it an “A” rating corresponding to “consistent, good-quality patient-oriented evidence.” I wrote the following letter to the editor and to the author of the article:
In the recent article on chronic low back pain http://www.aafp.org/afp/20090615/1067.html I was very disturbed to see acupuncture listed as beneficial with an evidence rating of “A.” That rating was supported by 4 references:
Reference 2 (Chou et al.), consisted of practice guidelines recommendations that lumped acupuncture with other nonpharmacologic interventions (intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation).” And labeled all of these as a “weak recommendation, moderate-quality evidence.”
Reference 22 (Sherman et al.) addressed current practices but did not comment on the efficacy of acupuncture.
Reference 23 (Furlan et al.) was a Cochrane review showing no evidence that acupuncture is effective for acute low back pain and commenting that the studies indicating its effectiveness in chronic low back pain were of “lower methodologic quality.”
Reference 24 (Witt et al.) only showed that adding acupuncture to routine care improved outcome and was cost-effective: it did not assess the effectiveness of acupuncture as a stand-alone treatment.
In contrast, this recent systematic analysis http://www.ncbi.nlm.nih.gov/pubmed/19250001?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum showed that true acupuncture is no more effective than sham acupuncture. Numerous studies with a retractable sham acupuncture needle (like a stage dagger) have shown that the sham procedure is equally effective (and at least in one study the sham procedure was more effective). Even toothpicks seem to work! http://www.time.com/time/health/article/0,8599,1897636,00.html
This study http://www.ncbi.nlm.nih.gov/pubmed/19433697?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum showed that it doesn’t matter where you put the needle or whether you penetrate the skin and commented “These findings raise questions about acupuncture’s purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.”
Acupuncture studies are all less than ideal in that double-blinding is impossible: the acupuncturist always knows whether he is administering a sham treatment.
Some studies have suggested that acupuncture releases endorphins in the brain, but studies also show that placebos elicit endorphin release.
All this evidence is compatible with the hypothesis that acupuncture is nothing more than an elaborate placebo.
If we had similar evidence that an analgesic drug was no better than a sham drug (a sugar pill), you would not be recommending it. How can you justify recommending acupuncture? How can you justify an “A” evidence rating?
I received no response from either the editor or the author.
Acupuncture for Pain
The current issue features an article “Acupuncture for Pain” by Robert B. Kelly, a family physician who is associate director of a family medicine residency program and associate professor at Case Western Reserve University School of Medicine. He is also a member of the American Academy of Medical Acupuncture and a diplomate of the American Board of Medical Acupuncture. In the “author disclosures” this was not listed as a conflict of interest, but it should have been.
The article claims
Based on published evidence, acupuncture is most likely to benefit patients with low back pain, neck pain, chronic idiopathic or tension headache, migraine, and knee osteoarthritis. Promising but less definitive data exist for shoulder pain, fibromyalgia, temporomandibular joint pain and postoperative pain.
It assigns “A” strength of evidence ratings (consistent good-quality patient-oriented evidence) to acupuncture for low back pain, neck pain, headache (chronic idiopathic), and headache (migraine). It assigns “B” ratings (inconsistent or limited quality patient-oriented evidence) to acupuncture for shoulder pain, knee osteoarthritis, fibromyalgia, temporomandibular joint pain, and postoperative pain. Note the inconsistency: knee osteoarthritis is listed among the conditions “most likely to benefit” but then is given only a “B” rating.
It presents a biased picture of the published research. For chronic low back pain, it cites these studies:
- A systematic review of RCTs that found “There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief.” In other words, acupuncture is no better than placebo, and using a placebo is better than doing nothing.
- A randomized controlled trial showing that acupuncture was better than no treatment, but that the control (superficial needling at non-acupuncture points) was equally effective. In other words, acupuncture was no better than their placebo control.
- A randomized controlled trial that concluded “Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.” There was no significant difference between “verum” acupuncture and the sham (placebo).
- A pragmatic randomized trial that compared usual care to acupuncture. There was no attempt to control for possible placebo effects with a sham acupuncture control.
- A pragmatic randomized trial that compared routine care with or without acupuncture. There was no attempt to control for possible placebo effects.
- A Cochrane review that concluded “The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain. For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and “alternative” treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain. Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area.”
- A meta-analysis that concluded “Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.”
It does not cite these studies:
- A systematic review of RCTs that concluded “There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief.” No significant difference between acupuncture and sham acupuncture means acupuncture is not better than placebo.
- A Cochrane review that concluded “The evidence summarised in this systematic review does not indicate that acupuncture is effective for the treatment of back pain.”
- A systematic review of RCTs that concluded: “Because this systematic review did not clearly indicate that acupuncture is effective in the management of back pain, the authors would not recommend acupuncture as a regular treatment for patients with low back pain.”
It does not cite the other studies I cited in my letter showing that acupuncture is no better than placebo and that it makes no difference where you put the needle or even whether you use a needle (toothpicks and retractable needles are equally effective).
Other Kinds of Pain
Kelly says “A systematic review on temporomandibular joint (TMJ) pain concluded that acupuncture significantly improved symptoms.”
That’s not exactly what the review said. Its conclusion was:
Overall, their results suggest that acupuncture might be an effective therapy for temporomandibular joint dysfunction. However, none of the studies was designed to control for a placebo effect. CONCLUSION: Even though all studies are in accordance with the notion that acupuncture is effective for temporomandibular joint dysfunction, this hypothesis requires confirmation through more rigorous investigations. [emphasis added]
He also discusses the use of acupuncture for other painful conditions including neck and shoulder pain, headache, and arthritis. The evidence he cites is similarly unconvincing for those conditions.
Kelly offers excuses and special pleading in an attempt to validate his recommendations. He suggests that “Western scientific methods” like RCTs do not lend themselves to the study of individualized treatment based on such things as pulse diagnosis, tongue diagnosis, herbal therapies, dietary modifications, ear, hand, or scalp acupuncture in addition to or instead of body acupuncture. He admits that there is no statistical difference between sham and actual acupuncture, but he doesn’t acknowledge the implications of that fact.
Acupuncturists believe in what they are doing. Personal experience, patient gratitude, the natural course of illness, the placebo response and other factors conspire to impair judgment. This makes it difficult for them to be as objective as an outside observer.
This is a clear case of denial. To see why, substitute “drug” for acupuncture and “sugar pill” for sham acupuncture. When a controlled study shows that your treatment works no better than your placebo control, the only logical conclusion is that the treatment is no better than placebo. Imagine a drug company saying “Our drug works and the placebo works too.” Neither the drug nor the placebo would get past the FDA.
There is only one science. The same standards apply to acupuncture as to drug therapies. A placebo by any other name is still a placebo.
It is sad to see a journal I respected depart from rigorous science-based medicine and succumb to the CAM temptation, especially when it tries to justify its defection by misrepresenting the state of the evidence. It has been said that there is no such thing as alternative medicine: there is only medicine that works and medicine that doesn’t. When a treatment is shown to work, it is adopted by mainstream medicine and is no longer “alternative.” Acupuncture remains “alternative,” and even AFP recognizes that fact by listing this article as one in a series on “Alternative and Complementary Medicine.”