MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Acupuncture remains a highly controversial treatment: its mechanism of action is less than clear and the clinical results are equally unconvincing. Of course, one ought to differentiate between different conditions; the notion that acupuncture is a panacea is most certainly nonsense.

In many countries, acupuncture is being employed mostly in the management of pain, and it is in this area where the evidence is perhaps most encouraging. Yet, even here the evidence from the most rigorous clinical trials seems to suggest that much, if not all of the effects of acupuncture might be due to placebo.

Moreover, we ought to be careful with generalisations and ask what type of pain? One very specific pain is that caused by aromatase inhibitors (AI), a medication frequently prescribed to women suffering from breast cancer. Around 50 % of these patients complain of AI-associated musculoskeletal symptoms (AIMSS) and 15 % discontinue treatment because of these complaints. So, can acupuncture help these women?

A recent randomised, sham-controlled trial tested whether acupuncture improves AIMSS. Postmenopausal women with early stage breast cancer, experiencing AIMSS were randomized to eight weekly real or sham acupuncture sessions. The investigators evaluated changes in the Health Assessment Questionnaire Disability Index (HAQ-DI) and pain visual analog scale (VAS). Serum estradiol, β-endorphin, and proinflammatory cytokine concentrations were also measured pre and post-intervention. In total, 51 women were enrolled of whom 47 were evaluable (23 randomized to real and 24 to sham acupuncture).

Baseline characteristics turned out to be balanced between groups with the exception of a higher HAQ-DI score in the real acupuncture group. The results failed to show a statistically significant difference in reduction of HAQ-DI or VAS between the two groups. Following eight weekly treatments, a significant reduction of IL-17 was noted in both groups. No significant modulation was seen in estradiol, β-endorphin, or other proinflammatory cytokine concentrations in either group. No difference in AIMSS changes between real and sham acupuncture was seen.

Even though this study was not large, it was rigorously executed and well-reported. As many acupuncturists claim that their treatment alleviates pain and as many women suffering from AM-induced pain experience benefit, acupuncture advocates will nevertheless claim that the findings of this study are wrong, misleading or irrelevant. The often remarkable discrepancy between experience and evidence will again be the subject of intense discussions. How can a tiny trial overturn the experience of so many?

The answer is: VERY EASILY! In fact, the simplest explanation is that both are correct. The trial was well-done and its findings are thus likely to be true. The experience of patients is equally true – yet it relies not on the effects of acupuncture per se, but on the context in which it is given. In simple language, the effects patients experience after acupuncture are due to a placebo-response.

This is the only simple explanation which tallies with both the evidence and the experience. Once we think about it carefully, we realise that acupuncture is highly placebo-genic:

It is exotic.

It is invasive.

It is slightly painful.

It involves time with a therapist.

It involves touch.

If anyone had the task to develop a treatment that maximises placebo-effects, he could not come up with a better intervention!

Ahhh, will acupuncture-fans say, this means that acupuncture is a helpful therapy. I don’t care how it works, as long as it does help. Did we not just cover this issues in some detail? Indeed we did –  and I do not feel like re-visiting the three fallacies which underpin this sentence again.

16 Responses to Acupuncture = placebo?

  • Sigh, another 36 gauge nail in the coffin. In the early 90s when I started studying acupuncture, it seemed like such a hopeful field. Results were (supposedly) impressive, the history was detailed, and much of academic society was open minded to multiculturalism and “other ways of knowing.” I would have been better served to go into research to have answered questions about how and if acupuncture works, but instead I became an acupuncturist. The more I learn about research, placebos, and what the best studies have found, the less I want to be an acupuncturist.

    I used to think acupuncture could help with smoking cessation. Nope. Hot flashes. Nope. Simple pain? Is it better than placebo? Ignorance and ego are strong in the “profession.” As are incredibly implausible claims and fraudulent devices. I tend towards extremes. It’s easy to get mad and flip to the “other side” of science and skepticism. Should I spend the time and energy trying to educate and warn patients, students, and open-minded practitioners about the dangerous and implausible parts of the acupuncture world? Or should I just walk away and leave the other ducks to play in the poisoned pond they enjoy so much?

    I had a happy patient this morning. He had rib pains of unknown origin and went to a neurologist. The neurologist told him to go to an acupuncturist, and if that didn’t work, he’d do some more invasive diagnostics. Last week was his first treatment for this pain, this week he reported it was much improved and he hasn’t taken any Advil, etc. all week. Could be placebo, could be regression to the mean, could be from putting tiny sterile needles around the dermatome origin for those ribs? Is that stretching?

    I still want to know when acupuncture is better than non-penetrating sham acupuncture. I see the abstract in this article says “As sham acupuncture used in this study may not be equivalent to placebo, further studies with a non-acupuncture arm may be required to establish whether acupuncture is beneficial for the treatment of AIMSS.” When I looked at the full text article, the sham acupuncture was a non-penetrating needle put half way between ‘real’ acupuncture points. I detect bias and spin in the abstract. If you use a retracting, telescoping needle which has been shown to be a credible placebo, and get the same results as putting needles through the skin, it’s hard to justify the pain and risk of putting needles through the skin… Another sigh…

  • I have long been skeptical of the worth of acupuncture as a mode of treatment. At the same time I am not at all skeptical that acupuncture is a dandy way to cause infections in trusting clients, especially when administered by poorly trained “practitioners”.

  • Interesting. So it seems we have defined another condition in which acupuncture might have worked, but actually didn’t.

    Is it time to write acupuncture off completely? To be honest, I’m not sure, and am keeping an open mind for now. It is clear that acupuncture certainly doesn’t live up to the vast majority of the claims made for it, but could there still be a narrowly defined range of conditions (perhaps of a musculoskeletal nature?) for which it genuinely is of benefit?

    I don’t know. It’s up to supporters of acupuncture to have a good hard think about what those conditions might be, and do some good trials to prove that they’re right. Each year that passes without those trials appearing will make me more skeptical that acupuncture has any benefits at all.

  • Yet another poor result for acupuncture and non-evidence based practice in general. Keep it up. What’s their woo theory behind pain relief, does anybody know?

  • I was enquiring more as to the explanatory framework used by Chinese medicine for pain relief. Is it mentioned in the study and do you know what terminology might be used?

  • Indeed they probably would, that is what they do. Do you know what the chinese medicine interpretation or interpretations of the western medical condition were, or how the acupuncturists involved went about addressing it?

  • Hi everyone.
    Let’s keep always into consideration that having a rational mind, adopting the scientific method, or simply thinking before acting is a step. Scientific thought comes out from magic thought, like adult from child, bird from egg. If he’s saying the truth :-), Skeptical Acupuncturist has been an acupuncturist, like Felix Mann before his conversion to scientific medicine, and even apparently merciless :-) Prof Ernst, as Wikipedia reports, has been an homeopath when he was a young MD. Because they were young, as mankind was, made with more elementary minds, more suggestible Beings. We should consider all humans, ourselves included, as on a step, on the top of a tiny or ample platform of launch to the following step, condition, state of evolution. How many astronauts there are on the Earth at the moment? Two dozens? One hundred? How many car drivers there were in 1900? Also big companies, banks, most governments are in a childish if not yet an egoistic royal child step, avid and militarized beyond real necessities. They will change, they will become skeptic adults, that’s they finally will succeed to consider the truth as something always relative and above all beyond our material or psychological conflict of interest. How many car drivers and astronauts, there will be in 3013?

  • The most basic TCM teaching about pain is kind of a Chinese pun, and involves the tones of the language to get it right. It’s:
    Tong Ze Bu Tong
    Tong Ze Bu Tong

    The first is “open is no pain”
    The second is “pain is no open”

    Essentially, this defines blockage/stagnation of energy (Qi) or blood (Xue) in the channels/meridians as the cause of pain, and opening those up (through acupuncture, massage, etc.) as the method to relieve the pain. This is somewhat of a self-referential belief, and I’m not presenting it as a belief I hold, but to answer the above questions about TCM framework of pain.

  • This is the only simple explanation which tallies with both the evidence and the experience. Once we think about it carefully, we realise that acupuncture is highly placebo-genic:

    It is exotic.

    It is invasive.

    It is slightly painful.

    It involves time with a therapist.

    It involves touch.

    If anyone had the task to develop a treatment that maximises placebo-effects, he could not come up with a better intervention!

    And even better we now know that a placebo has a biological and physical effect that can be measured. As the Harvard Prof, said “placebo is real”

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