MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Is acupuncture an effective treatment for pain? This is a question which has attracted decades of debate and controversy. Proponents usually argue that it is supported by good clinical evidence, millennia of tradition and a sound understanding of the mechanisms involved. Sceptics, however, tend to be unimpressed and point out that the clinical evidence of proponents often is cherry-picked, that a long history of usage is fairly meaningless, and that the alleged mechanisms are tentative at best.

This discrepancy of opinions is confusing, particularly for lay people who might be tempted to try acupuncture. But it might vanish in the light of a new, comprehensive and unique evaluation of the clinical evidence.

An international team of acupuncture trialists published a meta-analysed of individual patient data to determine the analgesic effect of acupuncture compared to sham or non-acupuncture control for the following 4 chronic pain conditions: back and neck pain, osteoarthritis, headache, and shoulder pain. Data from 29 RCTs, with an impressive total of 17 922 patients, were included.

The results of this new evaluation suggest that acupuncture is superior to both sham and no-acupuncture controls for each of these conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than those of sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs.

Based on these findings, the authors reached the conclusion that “acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture”.

Only hours after its publication, this new meta-analysis was celebrated by believers in acupuncture as the strongest evidence yet on the topic currently available. Much of the lay press followed in the same, disappointingly uncritical vein.The authors of the meta-analysis, most of whom are known enthusiasts of acupuncture, seem entirely sure that they have provided the most compelling proof to date for the effectiveness of acupuncture. But are they correct or are they perhaps the victims of their own devotion to this therapy?

Perhaps, a more sceptical view would be helpful – after all, even the enthusiastic authors of this article admit that, when compared to sham, the effect size of real acupuncture is too small to be clinically relevant. Therefore one might argue that this meta-analysis confirms what critics have suggested all along: acupuncture is not a useful treatment for clinical routine.

Unsurprisingly, the authors of the meta-analysis do their very best to play down this aspect. They reason that, for clinical routine, the comparison between acupuncture and non-acupuncture controls is more relevant than the one between acupuncture and sham. But this comparison, of course, includes placebo- and other non-specific effects masquerading as effects of acupuncture – and with this little trick ( which, by the way is very popular in alternative medicine), we can, of course, show that even sugar pills are effective.

I do not doubt that context effects are important in patient care; yet I do doubt that we need a placebo treatment for generating such benefit in our patients. If we administer treatments which are effective beyond placebo with kindness, time, compassion and empathy, our patients will benefit from both specific and non-specific effects. In other words, purely generating non-specific effects with acupuncture is far from optimal and certainly not in the interest of our patients. In my view, it cannot be regarded as not good medicine, and the authors’ conclusion referring to a “reasonable referral option” is more than a little surprising in my view.

Acupuncture-fans might argue that, at the very minimum, the new meta-analysis does demonstrate acupuncture to be statistically significantly better than a placebo. Yet I am not convinced that this notion holds water: the small residual effect-size in the comparison of acupuncture with sham might not be the result of a specific effect of acupuncture; it could be (and most likely is) due to residual bias in the analysed studies.

The meta-analysis is strongly driven by the large German trials which, for good reasons, were heavily and frequently criticised when first published. One of the most important potential drawbacks was that many participating patients were almost certainly de-blinded through the significant media coverage of the study while it was being conducted. Moreover, in none of these trials was the therapist blinded (the often-voiced notion that therapist-blinding is impossible is demonstrably false). Thus it is likely that patient-unblinding and the absence of therapist-blinding importantly influenced the clinical outcome of these trials thus generating false positive findings. As the German studies constitute by far the largest volume of patients in the meta-analysis, any of their flaws would strongly impact on the overall result of the meta-analysis.

So, has this new meta-analysis finally solved the decades-old question about the effectiveness of acupuncture? It might not have solved it, but we have certainly moved closer to a solution, particularly if we employ our faculties of critical thinking. In my view, this meta-analysis is the most compelling evidence yet to demonstrate the ineffectiveness of acupuncture for chronic pain.

24 Responses to Acupuncture for chronic pain? Almost certainly not!

  • Edzard, can you explain “the often-voiced notion that therapist-blinding is impossible is demonstrably false”?

    Many acupuncturists would consider that an important component of adequate peripheral nerve/muscle stimulation involves a needle insertion of some depth with strong rotation of muscle fibres around the needle (and not for mystical purposes related to “qi”). That requires a good amount of manual dexterity.

    How would you propose that somebody could administer this sufficiently and be blinded to the process?

  • Blinding the therapist: an acupuncturist diagnosis and marks the correct points in group A and non-acupuncture points in group B. the patient then sees a technichian who has been taught the technique of needling without knowing anything about acupuncture. A blinded evaluator assesses the clinical outcome.

  • Wouldn’t that just tell you whether a non acupuncturist gets different results from needling at acupuncture points or not? If there’s no such thing as an acupuncture point as they were traditionally conceived of, I’m not sure what needling at ‘non’ acupuncture sites would tell you?

    If we were going to reliably assess acupuncture, how could we do that with acupuncture delivered by people that don’t know anything about it? (I’m aware of the desire and the purpose of blinding in trials)

  • @James: If needling “acupuncture points” and “non acupuncture points” yields the same results on a large number of patients, that clearly means that there is no such thing as “acupuncture points”. Which in turn at least puts into question the underlying concept of “qyi” or “energy flows” and “energy points” etc. If you can needle any one at or in any point of his or her body and get the same results no matter what that means that there’s nothing specific to acupuncture.
    Hypothetically there could still be something to needling in general other than placebo (and certainly having nothing to do with the concepty underlying acupuncture) but I am sure that there is a number of scientific trials to follow up on that question.
    For some “critics”, i.e. fans of acupuncture, that will not be enough evidence. They will probably point out the same thing you do: after all, the needling has not been done by an acupuncturist but “just” by a technician – who is as good at needling as any of them. But to me that’s just admitting that acupuncture is not about needling or qyi at all (as the technician hit all the “correct point” in the same manner they did) but actually about the attention and empathy a patient is given. Which would make it a classic placebo.

  • @ Christoph

    Yes, that’s the point I’m making. If there are no such things as acupuncture points, ‘off point’ needling is not a valid placebo control, off point needling is a control for traditional acupuncture point theory, which indeed shows points do not exist in the way once thought. In short, it’s all peripheral nerve stimulation, and the quality and way in which it’s administered may well be significant.

    We need to separate theoretical models from the physicality of the practice, of course “Qi” is an old culture’s erroneous explanation of what’s taking place.

    Saying there is no such thing as an acupuncture point is not the equivalent to saying the needling area is irrelevant, because it’s likely that needling produces local effects through minor muscle lesions/trauma/nerve stimulation + segmental analgesic effects via action potentials up nerve pathways to associated segments of the spine + more central regulatory effects via hypothalamic stimulation/neuropeptide release. The central regulatory effects would be less related to specific needling sites. The combination of these factors plus an undoubtedly strong non specific effect likely contributes to the total acupuncture response a patient experiences. The specifics of how all of that is delivered optimally to individual patients is complex, and once again not for mystical reasons but pragmatic ones.

    While as you say fans of acupuncture may take issue with aspects of trial design and use it to confirm their own bias, critics also need to not treat very valid questions about trial methodology as ‘just another excuse’. Bias exists on both sides.

    My point in my first post is just that trials of acupuncture do need to be advised upon and conducted by people with experience with acupuncture, which is quite reasonable.

    • yes that is reasonable but, in my trial design, there would of course be acupuncture-wizzards overseeing the trial

      • And of course the needling technicians could also be randomised between real and sham needling, which would remove the possibility of acupuncturists claiming that the entire body responds to needling in some special and unique way.

        The fact is, though, that the better we zero in on the fact that it’s a placebo response, the more determinedly they will try to design trials that prove acupuncture. And that’s the critical weakness with all CAM: every single trial I have ever encountered which is conducted by CAM proponents sets out to prove an effect, not test whether the effect is there. That’s why rational discussion of every single such trial immediately dissolves into a slanging match about people always picking holes in the trial methodology – the possibility of fixing crap methodologies is never really considered for fear of producing the “wrong” result.

  • The most interesting aspect of these comments is the fact that no acupuncture fan has yet denied that the new evidence shows the ineffectiveness of acupuncture. Is it possible that they all agree with me?

  • I don’t have time to fully comment, as I am too busy scamming my patients for lots of money with a treatment that only appears to make them feel better – they don’t realise they do not actually feel better. How stupid are they, and how crafty am I?

  • Prickly: well done! now you have understood sarcasm, you only need to understand which factors can contribute to a perceived therapeutic response!

  • What do you think of Swedish professor Robert Hahn ?? He he he

  • I Will start à new therapy. Called placebo ing. Good results. And no side effekts. Can it be better ???

  • @ Edzard

    I would think it unlikely acupuncturists would agree with your claim for its ineffectiveness because as you note the study does demonstrate acupuncture above placebo and of its benefits to patients (even if you do suspect that effect is due to residual bias).

    There is a difference between these questions at the level of academia and at the level of patient outcomes. Patients in pain are unlikely to lose sleep at night over questions of whether the benefits they received from acupuncture were possibly connected to residual bias. They likely want to know what will improve their quality of life. The choice they have with regard to acupuncture is to have it or not, and the effects of those two options are the ones that are meaningful to them, more so when the pharmaceutical alternatives can produce intolerable side effects or addiction. If acupuncture facilitated less pain killer use and gave chronic pain patients some relief I don’t see why it’s not considered a reasonable referral option.

  • I would be interested to read your analysis of studies showing that many antidepressants work only slightly better than placebo. Could this be another type of treatment that is used because doctors and drug companies and patients want to believe it helps, not because it actually does help?

  • DG: you might be right there; I cannot comment with authority because it is not my area of expertise.

  • I find myself in a scientific dilemma over acupuncture. I do not “believe” there is anything mystic or magical about acupuncture, nor do I think it can “cure” diseases, etc, BUT I do have a condition which causes very severe chronic pain for which I am prescribed morphine. There have been times when my condition has worsened to a point where I was almost suicidal. On one occasion, reluctant to consume even more morphine [side effects of which are unpleasant] as it wasn’t working, I was [even more reluctantly] persuaded to try acupuncture.

    The therapist [State Registered Physiotherapist] could confirm that I was the most awkward, difficult and skeptical patient she had ever met and only “submitted” to rule the treatment out. However, over a few sessions, I did get some relief. Nothing “magical” or dramatic but it did help to reduce my pain level to a point where I could cope better without resorting to more drugs.

    This is a life long problem; I have occasionally experienced similar reduction in pain after treatment with acupuncture. I would have put this effect down to placebo IF I had approached it with any positive expectation in the first place, but I did not – quite the opposite.

    Mike

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