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You. You. Who are you calling a You You?

The YOU Docs, for those of you (YOU?) who are unaware, are Doctors Mehmet Oz and Mike Roizen, authors of books about YOU and a weekly newspaper column called The YOU Docs. It’s all about YOU.

There are two areas of the knowledge where I have more than passing understanding: infectious diseases and sCAMs. It always concerns me when I read nonsense in the few areas where I have some expertise. I have to wonder about the validity of other information in the paper like war and the economy. You know, important stuff. It could probably be argued that since the YOU Docs are in the “How We Live” section, the same section that carries horoscopes, the movie and TV reviews, the weather report — the fiction section — it should not taken seriously. After all, it is usually adjacent to the People’s Pharmacist, and my father always told me that you can judge a person by the company they keep.

The YOU Docs had a column with the headline: “Research backs acupuncture for a range of ills“. More fiction? Research backs acupuncture? News to me, but they are, after all, YOU Docs, and therefore may have information not accessible to mere docs with a small ‘d’. I grant up front to the authors that it is hard to be rigorous, or even coherent, in a 452 word essay. I am over 3,200 words for this entry. There are also no references, so I have to assume I found the correct research mentioned by the hints in the text.

They start with the usual appeal to antiquity:

Acupuncture has been around a long, long time: Archeologists have unearthed 5,000-year-old stone needles in Inner Mongolia.

If it is old, it must be efficacious. People would not use ineffective treatments for centuries, would they? This, of course, assumes that the Chinese, and other ancient healing modalities, had at their disposal an organized, consistent way to keep track of data to judge the efficacy of a therapy. While the use of acupuncture may stretch into antiquity, clinical and epidemiologic studies from ancient times are non-existent. The ancients only had anecdotes to guide them, and if there is no other lesson to be learned from SBM, the three most dangerous words in medicine remain “in my experience.”

One indirect way to evaluate the benefits of acupuncture and Chinese medicine in general is life expectancy. In 1900 it was 30 years. Good job traditional Chinese medicine. Now life expectancy is 71. Why?

“This can be attributed to the advancement of science and technology, especially in medical science,” said Zhao Baohua, vice-director of China Association for Aged People.

Goodness gracious. Reductionist Western Medicine more than doubling life expectancy. If only they had relied on acupuncture, perhaps population control would not have become such an important issue in the Peoples Republic.

As an aside, I cannot find anything but secondary references about the 5,000-year-old stone needles used for acupuncture. How it is ascertained that these needles were not used for sewing and were in fact used for acupuncture I cannot discover. A 5000-year-old package insert? I find one argument that these 5,000-year-old needles were used as scalpels and not for acupuncture.

The YOU Docs proceed to

But we like this popular form of energy medicine because it’s backed by an impressive body of 21st-century research. Energy medicine? Yes, it seems to change the electric currents or nerve impulses in your body.

That is what is nice about alternative medicine, a lack of consistency in terminology. Usually the term ‘Energy Therapy’ refers to energies that no one has ever measured, not altering nerve conduction. The NCCAM definitions are as good as any:

Energy Medicine

Energy therapies involve the use of energy fields. They are of two types:

Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch.

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

Usually I do not think of nerve impulses as being part of energy therapy, but that just may be me.

So as I am given to understand the YOU Docs, the mechanism of action of acupuncture is to alter nerve impulses. It would also suggest, then, that the cause of the diseases treated by acupuncture is due to altered nerve impulses, or perhaps the acupuncturist is only treating symptoms and not the underlying disease. All those diseases treated by one intervention that alters nerve conduction. And I thought aspirin was the wonder drug that works wonders. The YOU Docs have a different understanding of physiology than I learned at school.

What is the data to support the effect of acupuncture on diseases and symptoms by altering nerve conduction? It would be simple enough. Pick a disease or symptom. Nerve impulse measured before treatment. Acupuncture. Resolution of disease or symptom. Nerve impulse altered.

There is one study, small (which I could not get before the post went up), that demonstrates this effect in diabetic neuropathy. There are studies that show alterations in nerve function in rats and MRI studies that show CNS changes with acupuncture. But the simple temporal relationship that would suggest a cause and effect does not exist for any other process treated by acupuncture.

BTW: electroacupuncture doesn’t count as acupuncture for the purpose of this discussion. That is not acupuncture as defined in the article. To the best of my understanding the ancient Chinese lacked electricity.

This therapy involves inserting hair-thin needles into specific points on the body to treat countless problems, ranging from easing chronic pain and insomnia to reducing the side effects of cancer treatments and helping smokers quit.

Note “specific points.” A consistent result of recent acupuncture studies is that the effects of acupuncture do not depend on where the needles are placed or even if the needles break the skin. I realize that it is a short article, but we are only a few paragraphs in and it appears the YOU Docs lack a good command of the literature concerning acupuncture. I may be picky, but precision of understanding is important in medicine. You wouldn’t want your, oh, I don’t know, heart surgeon to say, “We are going to bypass one of your arteries, somewhere there in your chest.”

As to smoking cessation? Not so much.

The significant short-term effect was lost with the random-effects model for pooling, or by removing the outlying study that led to heterogeneity. The long-term result shows no effect of acupuncture compared with sham acupuncture. There was no consistent evidence that acupuncture is superior to no treatment, and no evidence that the effect of acupuncture was different from that of other anti-smoking interventions, or that any particular acupuncture technique is superior to other techniques.

The YOU Docs go on to give specific examples of acupuncture efficacy, managing, with awesome consistency, to get it wrong every time. I come to this with a slightly unforgiving attitude. I am a specialist. What defines a specialist is, in part, is mastery, or an attempt at mastery, of the relevant medical literature. I also work in a teaching hospital. I expect my residents and medical students, when reading a paper, to get the basic concepts of the paper correct and understand some the nuance of the papers they read. It is expected that the teaching attendings, when quoting the literature, will get it right, understand the nuance of the medical literature, and not cherry pick.

Just months ago, a Hong Kong University study of 60 insomniacs found those who got acupuncture fell asleep faster and were more likely to stay that way than those who got a fake version of the treatment.

I guess they are referring to “Electroacupuncture for primary insomnia: a randomized controlled trial” which, while not being acupuncture, does meet the criteria as mentioned for being the correct reference.

The authors conclusion of the study?

MEASUREMENTS AND RESULTS: Self-reported questionnaires, 1-week sleep diaries, and 3-day actigraphy were collected at baseline and 1 week after treatment. The Insomnia Severity Index was used as the primary outcome measure. Both groups showed significant improvement compared with the pretreatment baseline. One-way analysis of covariance adjusted for baseline scores showed that there were significantly greater improvements in sleep efficiency by sleep diary and actigraphy in the electroacupuncture group. However, no significant between-group differences were observed in the Insomnia Severity Index and other outcome measures. The proportions of subjects having less than 30 minutes of wake after sleep onset and a sleep efficiency of at least 85% at the posttreatment visit were significantly higher in the electroacupuncture group. All adverse events were mild in severity.

CONCLUSION: We found a slight advantage of electroacupuncture over placebo acupuncture in the short-term treatment of primary insomnia. Because of some limitations of the current study, further studies are necessary to verify the effectiveness of acupuncture for insomnia.

Not exactly a ringing endorsement of acupuncture for insomnia.

Of interest there is another acupuncture study for insomnia that used sham acupuncture and it was equally unimpressive.

RESULTS: No statistically significant differences were observed between the groups relating to parameters associated with the definition of insomnia. The treatment group experienced that it was easier to wake up in the morning compared with the control group (repeated-measures analysis of variance, p = 0.04). Both groups showed a statistically significant recovery in subjective sleep parameters during the study period (weeks 1-6) compared with baseline values (week 0).

CONCLUSIONS: Only modest evidence was found supporting the hypothesis that AAT may have an effect on insomnia. Least improvements were found in total sleep time and number of awakenings, 2 parameters directly associated with the definition of insomnia. AAT may have a role in the treatment of insomnia, especially in combination with other treatments such as cognitive behavioral therapy. This study provides an example of how to perform studies using alternative therapies for sleep disorders.

Funny. The treatment group woke up easier and that was a benefit for those suffering from insomnia how?

One difference between the two insomnia studies was that the second study used auricular acupuncture. They stuck the needles in the ear. So what nerve or nerves associated with sleep would warrant sticking needles in the ear in one study and sticking them in another site in a different study. According to the YOU Docs the needles were supposed to be placed in ‘specific sites’. What anatomy and physiology could the two studies have in common? Maybe in this context specific refers to anywhere on the patient. Or I am I trying to find a logical consistency with tooth fairy science?

And, as a final note, a Cochrane review of acupuncture and insomnia says

The small number of randomized controlled trials, together with the poor methodological quality and significant clinical heterogeneity, means that the current evidence is not sufficiently extensive or rigorous to support the use of any form of acupuncture for the treatment of insomnia.

The YOU Docs say “We like this popular form of energy medicine because it’s backed by an impressive body of 21st-century research.”

I guess it doesn’t take much to impress the YOU Docs. Actually, the totality of acupuncture studies are impressive in the same way a large pig farm can be impressive.

The YOU Docs continue.

Arthritis relief: British researchers who analyzed five well-designed studies of 1,334 people with bum knees have confirmed that acupuncture relieves debilitating joint pain related to arthritis.

What made these studies ‘well designed’? If the authors considered the acupuncture to be adequate it was well designed:

we defined acupuncture as ‘adequate’ if it consisted of at least six treatments, at least one per week, with at least four points needled for each painful knee for at least 20 min, and either needle sensation (de qi) achieved in manual acupuncture, or electrical stimulation of sufficient intensity to produce more than minimal sensation.

The definition was, it seems, mostly based on the authors’ opinion. The references do not suggest the definition is derived from rigorous testing. There is, by the way, no interest in whether the same specific points are used, just that a sufficiency of needles were used. There is more to a well-defined study than the authors opinion as to what constitutes adequacy of a clinical trial. How about sample size, blinding, etc.? Multiple needles would lead to one adequate outcome.

How good was the pain control? As the authors state in the discussion,

The size of the effect on pain was not dramatic: recalculating the data as standardized mean difference, the effect size compared to sham acupuncture is 0.4 which is considered ‘moderate’

Another ringing endorsement for the efficacy of acupuncture.

The Annals of Internal Medicine meta-analysis of acupuncture for knee pain comes to an alternative conclusion.

Sham-controlled trials show clinically irrelevant short-term benefits of acupuncture for treating knee osteoarthritis. Waiting list-controlled trials suggest clinically relevant benefits, some of which may be due to placebo or expectation.

Given the great heterogeneity in the studies of acupuncture and arthritis one can probably come to any conclusion you desire if you pick the right subsets of studies. Another group of British scientists (they call themselves Oxford Scientists) did a systematic review of systematic reviews of acupuncture and concluded:

Qualified support for acupuncture was originally reported in 12 out of 35 systematic reviews, and strong support was found in another six. Applying stricter inclusion criteria, however, showed that none of the 35 reviews supported acupuncture, predominantly because there were too few patients in the randomized, double blind studies. Six reviews with more than 200 patients in randomized, double blind studies had good evidence of no benefit. Systematic reviews of acupuncture have overstated effectiveness by including studies likely to be biased. They provide no robust evidence that acupuncture works for any indication.

I guess the Oxford Scientists don’t know an adequate trial when they see one.

The YOU Docs continue:

Squelching pain: In a landmark German study of 1,162 back-pain sufferers, twice as many got relief from acupuncture as from conventional fixes such as drugs or physical therapy. Acupuncture also has been proved at least as effective as pain drugs not only for treating migraines, but for preventing them, too.

This refers to the Archives of Internal Medicine where back pain patients had ‘real’ acupuncture, fake acupuncture or standard care. The sham acupuncture was twirling a toothpick on the skin. Really.

The ‘real’ acupuncture (both individualized and standardized placement of needles, that pesky need for ‘specific’ acupuncture points keeps disappearing) and the toothpick had the same improvement in pain.

Would you conclude that this is a landmark study showing the efficacy of acupuncture or conclude that whatever led to the pain improvement, it was not specific to acupuncture? Or do twirled toothpicks alter nerve conduction? If treatment and placebo have the same effect, one usually concludes that the treatment doth not work. Unless you never bothered to read past the press release.

Also, in the landmark study

Rates of adverse experiences differed by treatment group: 6 of 157 participants for individualized acupuncture, 6 of 158 for standardized acupuncture, and 0 of 162 for simulated acupuncture.

So if you were an ethical doctor who reads the literature carefully, if offered two treatments of equal efficacy but one treatment had no side effects, would you not choose the treatment with the least side effects? If you are going to offer advice based on a landmark study, and want to maximize efficacy and minimize side effects, how could you not recommend twirled toothpicks as the acupuncture modality of choice?

Migraines? The Cochrane review, if you want to believe them, demonstrated

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.

When compared to sham acupuncture, ‘real’ acupuncture is no better for migraines. Do you get the impression that acupuncture is no more than an elaborate, nonspecific placebo effect and only has results with subjective endpoints and only clinically irrelevant short-term benefits?

The YOU Docs go on (with an increasing lack of confidence in the authors. If I can find so much in error in a few short paragraphs, why bother to read on? I do it for you. But not YOU. My caps lock is not stuck).

Reducing treatment side effects: Dozens of studies show acupuncture helps quell pain, nausea, fatigue, hot flashes and dry mouth in cancer patients undergoing chemotherapy, radiation or both.

And dozens do not.

Three RCTs compared the effects of manual acupuncture with sham acupuncture. One RCT showed favorable effects of acupuncture in reducing hot flash frequency, while other two RCTs failed to do so.

or

There was no difference between combined acupuncture and acupressure treatment at P6 and at the sham point for the nausea score.

Just where is this “impressive body of 21st-century research” supporting acupuncture? Acupuncture research is mostly a collection of poorly done studies that demonstrate marginal effect and a few definitive studies that show no efficacy. The body of 21st century research does not support acupuncture, at least if you bother to acquaint yourself with the details of the studies. As a rule of thumb, when there are multiple studies hovering around efficacious, some showing benefit and others not, it is unlikely that any clinically relevant effect is occurring.

“How can one therapy do so much?”

Well, because it doesn’t.

Eastern and Western medical philosophies merge when a licensed acupuncturist inserts those sterile, disposable needles into your skin.

The needles may be sterile, but the photographs all too often show the bare fingers right at the insertion site. Search Google images of acupuncture. If you like sterile technique, the photos will give you the heebe jebees. Looking at Google images it is not surprising that there was at least one reported outbreak of MRSA due to poor technique. Acupuncture technique evidently doesn’t bother itself with the impressive body of 21st-century research on germ theory and infection control.

The YOU Docs conclude

You don’t have to believe in it for acupuncture to work. Case in point: Veterinarians know that acupuncture often helps ailing horses, goats, cats and dogs (including Titan, the world’s biggest Great Dane) in measurable ways, such as being able to walk and run again. With animals, there’s no placebo effect. It either works or it doesn’t. Same for people. Many skeptical people who’ve tried acupuncture as a last resort become believers when they see results.

I am not as well versed in veterinary literature, although I cannot imagine that acupuncture should be any less effective in animals than it is in humans. As one review suggests “on the basis of the findings of this systematic review, there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals.” Why the lack of a firm conclusion? “The methodologic quality of these trials was variable but, on average, was low.”

I guess only the YOU Docs find the veterinary research part of an “impressive body of 21st-century research.” The authors of the review did not. I will refer you Dr. Ramey for reviews on animal acupuncture and animal placebo for a more expert evaluation.

“It either works or it doesn’t. Same for people.” For acupuncture, it’s the latter. That statement, from the YOU Docs, is as simple a dismissal of evidence and scientific based medicine I have ever read. Anecdote rules!

In the end I am left wondering.

Did the YOU Docs read the references and not understand them?

Did the YOU Docs read the references and choose to interpret them in an original way to ensure that the conclusion ‘acupuncture works’?

“You keep using that phrase. I do not think it means what you think it means.” – Inigo Montoya.

Did the YOU Docs not read the references and relied on second hand reports?

It is a good thing the YOU Docs are not rotating on my service this month. Such scholarship would be difficult to award a passing grade, even for a 452 word essay, since it was wrong about almost every specific. However, I am one of the grumpy, old school docs who expect MDs to get it right, even if limited to 452 words.

Addendum

I am ever so proud that I made no L. Frank Baum references for this entry. But allow me to recommend Wicked, the Life and Times of the Wicked Witch of the West. I read it right after I having read the Wizard of Oz to my eldest. The sequels are awful and the musical is worse, but Wicked is a wonderful book.

Posted in: Acupuncture, Science and the Media

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