NEJM and Acupuncture: Even the best can publish nonsense.

I realize that the New England Journal of Medicine (NEJM) review of acupuncture has already been covered by Drs. Gorski and Novella. But my ego knows no bounds; so I thought I would add my two cents, especially since this review, more than any paper I have read, generates a deep sense on betrayal.

There was a time when I believed my betters. Then the Annals of Internal Medicine had their absolutely ghastly series on SCAMS, the publication of which was partly responsible for interest in the topic. Since that series of articles, I have doubt whenever I read an Annals article. When a previously respected journal panders completely to woo, they lose all respectability. Sure, the editors that were responsible for that travesty are long gone, but the taint remains. I tell my kids that once a trust has been violated, it is difficult to get it back. The Annals has permanently lost my trust, I am afraid.

But we will always have Paris. I mean the NEJM. The NEJM is the premier medical journal. Just because an article is published in the NEJM doesn’t mean it’s right; the results of clinical trials are always being superseded by new information. But the article has supposedly been rigorously peer reviewed. Its like Harvard and… Oops, Bad example. Harvard, as we have seen, has feet of clay, and so, evidently, does the The New England Journal of Medicine.

Goodness, gracious, great balls of fire, the editors of the NEJM have fallen into the depths of nonsense with this one.

Let’s go through it, shall we.

First up, the authors:

Brian M. Berman, M.D., Helene H. Langevin, M.D., Claudia M. Witt, M.D., M.B.A., and Ronald Dubner, D.D.S., Ph.D.

From the Center for Integrative Medicine, University of Maryland School of Medicine (B.M.B.), and the University of Maryland Dental School (R.D.) — both in Baltimore; the Department of Neurology and the Program in Integrative Health, University of Vermont College of Medicine, Burlington (H.H.L.); and the Institute for Social Medicine, Epidemiology, and Health Economics, Charité University Medical Center, Berlin (C.M.W.).

You always want acknowledged experts in a field to write your review. If you want a review of Lyme disease, you ask a Lyme expert (The Connecticut Attorney General not withstanding), and if you want a review of heart attacks, you ask a cardiologist.

So in that spirit, if you want a review of prescientific magic, you want someone well-versed in the practice of prescientific magic. Fortunately, these authors seem well qualified. Dr. Berman founded the Center for Integrative Medicine at University of Maryland and has a long history of research into acupuncture. The center has on its staff a reflexologist/reiki master. Really. And the center offers:

Physician Consultations, Acupuncture, Nutrition, Massage, Homeopathy, Mindfulness-based Stress Reduction, Shiatsu, Reflexology, Yoga, Qi Gong, Tai Chi, Osteopathic Manipulation.

The University of Maryland proudly offer both acupuncture and reiki to their trauma patients.

Reiki is a Japanese technique of relaxation that works similarly to acupuncture, in that you are releasing and moving energy,” explains Donna Audia, R.N., a nurse on Shock Trauma’s pain management team and a certified Reiki master. “By using Reiki with trauma patients, we are not only helping them to relax, we’re also making them active participants in their own healing, and that can be very empowering.

Reaction from trauma patients has been positive, with most requesting follow-up treatments. In fact, many family members ask to be a part of the Reiki session. A group of volunteers trained in Reiki now visits Shock Trauma regularly. The University of Maryland Medical Center is the only facility in the country offering Reiki to trauma patients, although it has also been used to treat people with cancer and other illnesses.

Seriously. Your body has been shattered in a car accident and your health care providers think they can improve your condition by moving and releasing your energy by waving their hands over you.

If, god forbid, you have trauma in Maryland, get transferred. Fast.

Dr. Berman has published extensively on acupuncture and Dr. Witt has published multiple articles on homeopathy, including one using homeopathy for low back pain.

So two of the authors are well grounded in magical thinking: who better to write a NEJM review on acupuncture? They found a Dumbledore, a Gandalf, to write the article, which explains the content as the editors of the NEJM were evidently hit with the confundus charm. As I think about it, that is not the best metaphor, since in the fantasy world, magic is real, but in the real world, magic is fantasy, as well as a review article in the NEJM.

The authors start with a case of chronic low back pain with mild degenerative disease but no anatomical or physiologic reason for the pain. The vignette ends with:

The patient wonders whether acupuncture would be beneficial and asks for a referral to a licensed acupuncturist.

Nope. Simple enough. Acupuncture is nonsense. Oh wait. There’s more.

They review the epidemiology, physiology and anatomy of chronic low back pain and note that the understanding of the disease is a long way from satisfactory and conclude with:

In addition, psychological and behavioral factors, including fear of movement, appear to play an important role in patients with chronic low back pain. Such patients have been shown to have altered brain-activation patterns at subcortical and cortical sites associated with emotion and postural control. Studies comparing psychosocial variables with anatomical findings have shown the former to have greater predictive value than the latter.

In other words, with low back pain there is a big psychological overlay. It is the psychological overlay of pain that makes it difficult to determine the effectiveness of a therapy meant to decrease the pain. When treating a condition in medicine, most interventions attempt to alter the underlying pathophysiology: block a receptor with a drug, alter anatomy with a procedure as examples. If the intervention has no effect on the underlying pathophysiology, then there is little reason to expect benefit beyond a placebo effect, which is almost no effect.

Then they jump into acupuncture.

Acupuncture is a therapeutic intervention…

It is an intervention, yes, but therapeutic? Therapeutic means relating to healing of disease. So they are front loading the language, saying at the beginning that acupuncture is effective rather than proving the case. I would have used ‘useless magical’ instead of ‘therapeutic,’ but that’s me.

Although a number of different techniques or schools of acupuncture practice have arisen, the approach used in traditional Chinese medicine appears to be the most widely practiced in the United States.

Why? Is Chinese acupuncture better? Or is popularity the criteria we use for determining appropriate medical care? There is Chinese and Japanese and tongue and foot and ear and the German head acupuncture. Is there any justification offered for using one over the other? Which is the correct style? As I have said before, it is a trick question, like asking which is the real astrology: European, Indian or Mayan. It makes no difference.

Then they delve into real nonsense.

Traditional Chinese medicine espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature. Internal disharmony is believed to cause blockage of the body’s vital energy, known as qi, which flows along 12 primary and 8 secondary meridians. Blockage of qi is thought to be manifested as tenderness on palpation. The insertion of acupuncture needles at specific points along the meridians is supposed to restore the proper flow of qi.

I hate to point out that the physiologic system I use, based on so-called “Western scientific empiricism,” is also based on anatomy, chemistry, biochemistry, histology etc. All based on physical structures that can be isolated and examined.

Meridians and qi blockage is based on what? Nothing. Meridians and qi do not exist. Here is the NEJM offering up, complete with a picture, the idea of meridians and qi as if they are a meaningful construct. Next up in the NEJM will be:

Traditional European medicine espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature. Internal disharmony is believed to cause blockage of the body’s vital energy, known as humors: black bile, yellow bile, phlegm, and blood which flows in the body. Blockage of humors is thought to be manifested as illness. Bleeding and purging is supposed to restore the proper flow of balance of humors.

If anyone sees a conceptual difference between the two paragraphs, let the editors of the NEJM know after they accept my review on therapeutic bleeding. Being published in the NEJM is the medical equivalent of being on the cover of the Rolling Stone, and I think I have my opportunity.

Efforts have been made to characterize the effects of acupuncture in terms of the established principles of medical physiology on which Western medicine is based.

Why? Isn’t an ancient physiological system enough upon which to base a therapeutic intervention?

These efforts remain inconclusive, for several reasons. First, the majority of studies have been conducted in animals, and it is difficult to relate findings from such studies to effects in humans. Second, acupuncture has been shown to activate peripheral-nerve fibers of all sizes, rendering a systematic study of responses complex. Third, the acupuncture experience is dominated by a strong psychosocial context, including expectations, beliefs, and the therapeutic milieu.

And fourth, having no basis in reality, acupuncture can’t work any more than homeopathy or reiki. It is tooth fairy science, published in the NEJM.

Then they delve into the physiology of acupuncture and the basic science studies. Fine. You stick people with needles, you will get a variety of physiologic responses, both locally and in the brain. The question is whether these effects are specific to acupuncture or nonspecific results of poking people with a sharp object. Like all acupuncture apologists, they lack a certain precision in what they consider acupuncture, and offer electroacupuncture as evidence.

In the rat, electroacupuncture has been shown to induce pituitary secretion of adrenocorticotropic hormone and cortisol, leading to systemic antiinflammatory effects.

Ah yes, electroacupuncture. I remember when they discovered those ancient Chinese Duracell’s and alligator clips that allowed the Chinese to shock their patients.

I quote from the electroacupuncture article, referenced above:

While the EA frequency was held constant, intensity was adjusted slowly over the period of approximately 2 min to the designated level of 3 mA, which is the maximum EA current intensity that a conscious animal can tolerate. Mild muscle twitching was observed… For sham treatment control, acupuncture needles were inserted bilaterally into GB30 without electrical stimulation or manual needle manipulation.

And when shocked, the rabbits released ACTH and cortisol, as any animal would if electrocuted. Release of ACTH and cortisol is part of the response to stress. I can just see the poor rat, “placed under an inverted clear plastic chamber” for observation saying,” don’t tase me bro, don’t tase me bro.” Wait. It’s not a taser. It’s a projectile electroacupuncture remote deliver system, and if I use it on you, you are going to release some cortisol and ACTH as well, bro.

Did the NEJM editors look at the references? They seriously need some new reviewers.

But I will grant them that sticking needles in people has physiologic effects and shocking a rat makes it squirt cortisol.

However, acupuncture is about putting needles in specific sites. In the animal models and human studies they attempt to needle specific sites that correlate with treating a disease. Most acupuncture studies use the traditional sites associated with whatever illness they are not really treating; acupuncture is about putting the needle just so.

The basic science concerns, as I read it, the effects of needling people. If you are going to recommend acupuncture, and they will, then you need to justify the use of needles in specific sites by people trained in acupuncture, and the literature doesn’t support that. It doesn’t matter where you put the needles, or even if you use needles at all, as we have mentioned, since twirling a toothpick has better effects on knee pain than needling. And I will ask again: whose style of acupuncture are you going to use? Ear, tongue, foot, Japanese or German or Chinese?

Then they move on to the clinical trials and my gaster is flabbered.

… real acupuncture treatments were no more effective than sham acupuncture treatments. There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.

Lets take a trip back in time.

There was procedure for the treatment of angina where they ligated the internal mammary artery. The theory was that by tying off the artery the back-pressure forced blood down the coronary arteries and relieved cardiac pain.

Angina improved and there are about 40 plus papers in the 50s and 60s on the benefit of the procedure as well as the underlying physiology of the procedure. Mammary artery ligation ‘worked’ and was popular in the early 60s. Until the procedure was compared to a sham operation. That’s right. They opened people up and did nothing.

The result?

The combined results of two RCTs comparing an earlier surgical procedure for angina — bilateral internal mammary artery ligation (BIMAL) — to a sham surgery clearly show that patients “experienced significant subjective improvement,” with both BIMAL (67% substantial improvement) and the sham procedure (82% substantial improvement). [see Moerman, Meaning, Medicine and the “Placebo Effect”, 2002]

So how would you interpret the study? If a procedure is equal sham, then I would say the procedure does not work. In the case of sham surgery, no underlying change occurred in the blood supply to the ischemic heart. This study is perhaps the classic clinical trial that demonstrates the difficulty in assessing the results of an intervention for pain. Patients had significant improvement in their angina. Much better than doing nothing (although these studies did not have a ‘usual care’ wing), 2/3 of angina patients do not get significant improvement on their own.

And guess what? Open heart surgery “has been shown to induce pituitary secretion of adrenocorticotropic hormone and cortisol, leading to systemic antiinflammatory effects.” Surgery releases endogenous opioids and I bet it actives both peripheral and central pain fibers.

Hmmmm. Looks like we have a justification for going back to treating angina with internal mammary artery ligation.

The authors of the review justify the recommendation on the two studies that demonstrate the equivalence of sham acupuncture and real acupuncture in treating low back pain, the same number of studies for mammary artery ligation.

Now being an article on back pain, they did not include the article that showed knee pain treated with sham acupuncture (in this case twirling tooth picks on the skin) is superior to real acupuncture. It matters not where the needles are placed or even if needles are used.

So far the authors provide no historical scientific plausibility, non-specific modern pathophysiology, a bit of gratuitous rabbit torture, and two clinical trials that demonstrate no efficacy of acupuncture over placebo. Their level of justification reaches that of mammary artery ligation. I start to wonder if the NEJM editors actually read the review before publishing it. The authors then move on to clinical use.

(Acupuncture) not been established to be superior to sham acupuncture for the relief of symptoms of low back pain [translation: it doesn’t work]. As a result, it is not often regarded as the first choice of therapy [translation: clinicians do not like to use ineffective therapy].

However, since extensive clinical trials [er, since when did two become extensive? Are the authors even reading the manuscript?] have suggested that acupuncture may be more effective than usual care, it is not unreasonable to consider acupuncture before [you mean as first line therapy? when it doesn’t work?] or together with conventional treatments, such as physical therapy, pain medication, and exercise [adding nothing to something does not increase the net effect].

That is some interesting sentence structure, worthy of Animal Farm: even though acupuncture doesn’t work, and isn’t first line therapy for pain, it should be used for first line therapy. Although the qualifiers ‘not been established,’ ‘suggested’, ‘may be,’ and ‘not unreasonable’ muddy the water with their density.

Acupuncture is a regulated discipline, and patients should be referred only to practitioners who are licensed by the state in which they practice.

Why? It’s like Duck’s Breath Mystery Theatre’s Dr. Science. A license to practice ineffective nonsense still results in ineffective nonsense.

In the traditional practice of acupuncture, needle insertion itself may be accompanied by a variety of ancillary procedures, including palpation of the radial artery and other areas of the body, examination of the tongue, and recommendation of herbal medications. All of these steps are based on the application of principles of traditional Chinese medicine, as opposed to Western physiological and medical concepts. To what extent such procedures may contribute to the psychological milieu of acupuncture is unknown, and only a few studies have examined the context in which acupuncture treatment is delivered.

Note, it is not that radial artery palpation and tongue examination increase the diagnostic accuracy, it is to contribute to the psychological milieu. Like a psychic talking to your dead parent, it is important to make the environment conducive to fooling the patient into believing that an actual effect is occurring.

Take the pulse. In TCM they are not looking for tachycardia, but imaginary diseases based on imaginary diagnosis. An example:

Each pulse position can reflect different phenomena in different situations. For example, in a state of health, the left middle pulse (Liver) will be relatively soft and smooth, neither superficial nor deep. Therefore, we can say the liver and gall bladder energies are balanced or that the Yin and Yang within the Liver/Gall Bladder sphere are balanced. If a patient is experiencing migraine headaches and her pulse feels wiry (harder or tighter than normal) and more superficial and pounding, then we may diagnose this as Excessive Liver Fire (Yang) Rising (up the Gall Bladder channel to the head). The pulse reflects the rising energy.”

Or tongue examination, which is another example of prescientific nonsense where the body is represented on the tongue.

The editors of the NEJM seem to think this is reasonable, worthy of unqualified discussion. Of course, there is no reference to demonstrate that these additions increase diagnostic or therapeutic accuracy.

The practitioner may further stimulate the needle with electrical current (electroacupuncture), moxibustion (burning the herb artemisia vulgaris at the end of the acupuncture needle), or heat.

Why? No data given that this nonsense increases efficacy. I keep telling myself this is the NEJM, adding their imprimatur to the respectability of burning a plant on top a needle stuck in the skin to ease chronic pain. Then they note that patients need multiple treatments, a minimum of 12, with boosters, and they need to come in to prophylactically keep their spine aligned — no wait, the last is what chiropractors do. It seems, at 65 to 125 dollars a pop, that acupuncturists have recognized the financial wisdom of D.D. Palmer’s descendants. The NEJM is suggesting that people pay around 1200 bucks for what is, at best, a placebo.

The authors go on to the adverse effects. “8.6% reported at least one adverse event, and 2.2% reported one that required treatment.” Pretty impressive complication rate for an expensive, ineffective therapy! They do not mention that in the acupuncture/toothpick for knee pain study, toothpicks had the same effect as acupuncture and zero side effects, nor do they mention the well-reported cases of infection from sloppy aseptic technique.

I will ask you. If you have two procedures of equal efficacy and one has zero side effects, are you not ethically bound to suggest the procedure with no complications? If you are going to suggest acupuncture, ethically you have to offer sham acupuncture with twirled toothpicks, especially when what you offer is no better than a placebo effect.

Then, in the areas of uncertainty section of the review, they note that the effects of acupuncture are mostly explained by elaborate placebo effects. Benefit from acupuncture is

mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient. These studies also seem to indicate that needles do not need to stimulate the traditionally identified acupuncture points or actually penetrate the skin to produce the anticipated effect.

It does nothing, and you do not need to do acupuncture to get the effect. Acupuncture has complications and ethically can one recommend and charge for an elaborate placebo? I do not think so. Not the authors.

The patient in the vignette has chronic back pain that has not responded to a number of medical treatments.

So instead, we will go with the unethical, expensive, useless placebo.

He has specifically requested a referral for acupuncture, and we would suggest a course of 10 to 12 treatments over a period of 8 weeks from a licensed acupuncturist or a physician trained in medical acupuncture.

Can you believe this? From the NEJM! Such total tripe. I rely on the NEJM to provide reviews of relevant medical topics as, outside of ID and quackery, I do not have the time to read the primary literature. If this is the best NEJM can do on a topic upon which I have some background, then I suppose I cannot trust them in the future. As I tell my kids, you can judge a person by the company they keep.

The NEJM has lost some of its credibility. I doubt they will ever get it back.

Posted in: Acupuncture

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