MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Has it ever occurred to you that much of the discussion about cause and effect in alternative medicine goes in circles without ever making progress? I have come to the conclusion that it does. Here I try to illustrate this point using the example of acupuncture, more precisely the endless discussion about how to best test acupuncture for efficacy. For those readers who like to misunderstand me I should explain that the sceptics’ view is in capital letters.

At the beginning there was the experience. Unaware of anatomy, physiology, pathology etc., people started sticking needles in other people’s skin, some 2000 years ago, and observed that they experienced relief of all sorts of symptoms.When an American journalist reported about this phenomenon in the 1970s, acupuncture became all the rage in the West. Acupuncture-fans then claimed that a 2000-year history is ample proof that acupuncture does work.

BUT ANECDOTES ARE NOTORIOUSLY UNRELIABLE!

Even the most enthusiastic advocates conceded that this is probably true. So they documented detailed case-series of lots of patients, calculated the average difference between the pre- and post-treatment severity of symptoms, submitted it to statistical tests, and published the notion that the effects of acupuncture are not just anecdotal; in fact, they are statistically significant, they said.

BUT THIS EFFECT COULD BE DUE TO THE NATURAL HISTORY OF THE CONDITION!

“True enough”, grumbled the acupuncture-fans and conducted the very first controlled clinical trials. Essentially they treated one group of patients with acupuncture while another group received conventional treatments as usual. When they analysed the results, they found that the acupuncture group had improved significantly more. “Now do you believe us?”, they asked triumphantly, “acupuncture is clearly effective”.

NO! THIS OUTCOME MIGHT BE DUE TO SELECTION BIAS. SUCH A STUDY-DESIGN CANNOT ESTABLISH CAUSE AND EFFECT.

The acupuncturists felt slightly embarrassed because they had not thought of that. They had allocated their patients to the treatment according to patients’ choice. Thus the expectation of the patients (or the clinician) to get relief from acupuncture might have been the reason for the difference in outcome. So they consulted an expert in trial-design and were advised to allocate not by choice but by chance. In other words, they repeated the previous study but randomised patients to the two groups. Amazingly, their RCT still found a significant difference favouring acupuncture over treatment as usual.

BUT THIS DIFFERENCE COULD BE CAUSED BY A PLACEBO-EFFECT!

Now the acupuncturists were in a bit of a pickle; as far as they could see, there was no good placebo for acupuncture! Eventually some methodologist-chap came up with the idea that, in order to mimic a placebo, they could simply stick needles into non-acupuncture points. When the acupuncturists tried that method, they found that there were improvements in both groups but the difference between real acupuncture and placebo was tiny and usually neither statistically significant nor clinically relevant.

NOW DO YOU CONCEDE THAT ACUPUNCTURE IS NOT AN EFFECTIVE TREATMENT?

Absolutely not! The results merely show that needling non-acupuncture points is not an adequate placebo. Obviously this intervention also sends a powerful signal to the brain which clearly makes it an effective intervention. What do you expect when you compare two effective treatments?

IF YOU REALLY THINK SO, YOU NEED TO PROVE IT AND DESIGN A PLACEBO THAT IS INERT.

At that stage, the acupuncturists came up with a placebo-needle that did not actually penetrate the skin; it worked like a mini stage dagger that telescopes into itself while giving the impression that it penetrated the skin just like the real thing. Surely this was an adequate placebo! The acupuncturists repeated their studies but, to their utter dismay, they found again that both groups improved and the difference in outcome between their new placebo and true acupuncture was minimal.

WE TOLD YOU THAT ACUPUNCTURE WAS NOT EFFECTIVE! DO YOU FINALLY AGREE?

Certainly not, they replied. We have thought long and hard about these intriguing findings and believe that they can be explained just like the last set of results: the non-penetrating needles touch the skin; this touch provides a stimulus powerful enough to have an effect on the brain; the non-penetrating placebo-needles are not inert and therefore the results merely depict a comparison of two effective treatments.

YOU MUST BE JOKING! HOW ARE YOU GOING TO PROVE THAT BIZARRE HYPOTHESIS?

We had many discussions and consensus meeting amongst the most brilliant brains in acupuncture about this issue and have arrived at the conclusion that your obsession with placebo, cause and effect etc. is ridiculous and entirely misplaced. In real life, we don’t use placebos. So, let’s instead address the ‘real life’ question: is acupuncture better than usual treatment? We have conducted pragmatic studies where one group of patients gets treatment as usual and the other group receives acupuncture in addition. These studies show that acupuncture is effective. This is all the evidence we need. Why can you not believe us?

NOW WE HAVE ARRIVED EXACTLY AT THE POINT WHERE WE HAVE BEEN A LONG TIME AGO. SUCH A STUDY-DESIGN CANNOT ESTABLISH CAUSE AND EFFECT. YOU OBVIOUSLY CANNOT DEMONSTRATE THAT ACUPUNCTURE CAUSES CLINICAL IMPROVEMENT. THEREFORE YOU OPT TO PRETEND THAT CAUSE AND EFFECT ARE IRRELEVANT. YOU USE SOME IMITATION OF SCIENCE TO ‘PROVE’ THAT YOUR PRECONCEIVED IDEAS ARE CORRECT. YOU DO NOT SEEM TO BE INTERESTED IN THE TRUTH ABOUT ACUPUNCTURE AT ALL.

14 Responses to Never let the truth get in the way of a lucrative story

  • The incredibly long, and difficult to remember, list of cognitive biases includes many explanations for the prevalence of alternative medicine in the 21st Century. “Cognitive biases are tendencies to think in certain ways. Cognitive biases can lead to systematic deviations from a standard of rationality or good judgment…”
    http://en.wikipedia.org/wiki/List_of_cognitive_biases

    Obviously, CAM practitioners have a vested interest in defending their businesses as does the tobacco industry, for example, but this does not explain why CAM customers defend CAM for more vehemently, aggressively, and illogically than smokers defend their habit.

    What I propose as a possible explanation is the widespread reliance on opinion, which is a quick and easy shortcut to the hard graft of learning critical thinking skills then acquiring knowledge via application of these skills.

    Opinions are personal possessions therefore, as with our physical possession, we are very likely to become hostile if someone threatens to destroy them or to take them away from us.

    When we acquire knowledge to replace our personal opinions the situation changes completely. Knowledge is not a personal possession therefore it cannot be taken away from us. I have learnt the value of pi, that the Moon is not made of cheese, that the Earth is not flat, and that acupuncture and homeopathy perform no better than their sham equivalents, therefore I have no need to feel threatened by deniers of these facts. Deniers cannot make the facts disappear however aggressively they try.

    Justifiable anger is a generally useful animal trait, but unjustified anger is not useful. One cause of unjustified anger (even rage) is being in a situation in which one starts doubting one’s opinions/beliefs yet decides to hold onto them no matter what — even to the point of becoming a total jackass in the eyes of all observers. This self-destructive behaviour is practiced by some of the commentators on this blog. The phrase “practice makes perfect” so often comes true, but I try to avoid becoming a perfect jackass (being one isn’t “cool”).

  • This is a very fine explanation of the scientific method in action. It’s the path trodden long since by homeopathy (where a convincing placebo is much easier to achieve) and more recently by (e.g.) the TACT chelation trial.

    The response of any SCAM practitioner to disconfirming evidence, is always rationalisation and denial.

    Obvious comparisons with medical advances such as Marshall & Warren shows that medicine, faced with new evidence, changes its practice in a way SCAM does not.

    My background is in control engineering. I think I know why this happens.

    Science has the equivalent of a negative feedback loop: it constantly compares new data with the existing understanding and seeks to close the gap. This is inherently stable, it will always self-correct.

    SCAM has the equivalent of a positive feedback loop: it compares new data with what it believes and gives more weight to confirming than disconfirming evidence. This is inherently unstable: it cannot self correct, it will always drive to the limit (the path of pathological science to pseudoscience to outright nonsense).

    This also explains the long-standing dispute between science and SCAM. The difference is inherent and cannot be changed. SCAM is SCAM *because* it uses positive feedback. Science is science *because* it uses negative feedback.

    There is no way of breaking the vicious circle short of determined regulatory action. Quacks need to start going to jail.

  • Everyone who does not embrace science as you see it should go to jail?

    • Science is not a belief system to be “embraced” or rejected. It is a method of investigation into the natural world. It relies on evidence which contributes to a body of knowledge that will expand as new evidence becomes available. Some people who are unschooled in the validity of the scientific method prefer the certainty of slavish belief in the Tooth Fairy and her many relatives.

      Quacks who take people’s money under false pretenses should, indeed, go to jail, especially if they cause harm–including harm by preventing or delaying the person from seeking medical treatment. Modalities that do not pass scientific muster should be outlawed, at least for children, and no one should be able to charge money for dispensing folklore and myths.

      • with this attitude, we would still be blood-letting and purging pretending that these ‘time tested’ treatments are cure alls! you have summarised in a few words a fool-proof method to avoid progress. did you not know that progress in medicine started when and because this attitude finally became obsolete?

      • I agree that people who stand in the way of medical intervention should be dealt with appropriately. What I don’t agree with is that if I want to go and see a quack for a massage and some back manipulation because I enjoy it and, rightly or wrongly, feel like it helps that I can’t because the scientific community has gone and got it outlawed.

        • Who is outlawing anything?

        • @CAM off it
          Are you saying you wish to enjoy CAM for its recreational value! That’s a good one.

          You happen to take as example two forms of therapeutic interventions, which often are effective when properly applied on accepted indications for adult sufferers. Your choices do not exemplify the CAM-fraud Irene and most of us consider criminal fraud. Your reasoning is flawed.
          Why do you not take examples like Gua Sha, Homeopathy and Chiropractic manipulation for subluxation to cure Asthma? All these are methods and means, which have no realistic mechanism of working and have not been shown to work (apart from the accompanying placebo effect of course). Services and sales which encompass these fraudulent methods should be dealt with in the same way as selling fake bomb detectors. If you do not agree with that, then please explain.

          • Thanks for your assertive response Björn, if I want to enjoy CAM for its ‘recreational value’ then not sure why you’d want to ridicule that?

            My examples where not meant to try and exemplify CAM, although you seem to have decided otherwise, but instead provide examples of quack treatments that have been suggested as law breaking treatment modalities because they fall under the CAM umbrella and anyone who carries them out should go to jail!

            I haven’t used the other treatments and had to look up Gua Sha as I’ve never heard of it! I think CAM practitioners should be held to account if they make far fetched claims about implausible mechanisms and likewise, as I said before, get in the way of medical intervention. Perhaps my visit for a CAM treatment is escapism or something else I don’t know.

            Science tells us not to drink, not to smoke, not to eat certain foods it tells us lots of things not to do, but that doesn’t stop people from doing it – should these things be outlawed because science says so?

            There is more to life then just science and living your life by the simplistic absolutist view it creates.

  • I’m rereading Trick or Treatment and had forgotten that Dr. Ernst was part of developing one of the retracting acupuncture needles, the Park needle. The other one is the Streitberger needle. I have a Pubmed window open with the search for Streitberger and Acupuncture. Upon refresh yesterday, 2 brand new studies came up:

    1. J Clin Rheumatol. 2013 Sep… http://www.ncbi.nlm.nih.gov/pubmed/23965480
    Integrating acupuncture with exercise-based physical therapy for knee osteoarthritis: a randomized controlled trial.
    Chen LX, Mao JJ, Fernandes S, Galantino ML, Guo W, Lariccia P, Teal VL, Bowman MA, Schumacher HR, Farrar JT.
    Source
    Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA.
    Abstract
    BACKGROUND:
    Knee osteoarthritis is a chronic disease associated with significant morbidity and economic cost. The efficacy of acupuncture in addition to traditional physical therapy has received little study.
    OBJECTIVE:
    The objective of this study was to compare the efficacy and safety of integrating a standardized true acupuncture protocol versus nonpenetrating acupuncture into exercise-based physical therapy (EPT).
    METHODS:
    This was a randomized, double-blind, controlled trial at 3 physical therapy centers in Philadelphia, PA. We studied 214 patients (66% African Americans) with at least 6 months of chronic knee pain and x-ray-confirmed Kellgren scores of 2 or 3. Patients received 12 sessions of acupuncture directly following EPT over 6 to 12 weeks. Acupuncture was performed at the same 9 points dictated by the traditional Chinese “Bi” syndrome approach to knee pain, using either standard needles or Streitberger non-skin-puncturing needles. The primary outcome was the proportion of patients with at least a 36% improvement in Western Ontario and McMaster Universities Osteoarthritis Index score at 12 weeks.
    RESULTS:
    Both treatment groups showed improvement from combined therapy with no difference between true (31.6%) and nonpenetrating acupuncture (30.3%) in Western Ontario and McMaster Universities Osteoarthritis Index response rate (P = 0.5) or report of minor adverse events. A multivariable logistic regression prediction model identified an association between a positive expectation of relief from acupuncture and reported improvement. No differences were noted by race, sex, or age.
    CONCLUSIONS:
    Puncturing acupuncture needles did not perform any better than nonpuncturing needles integrated with EPT. Whether EPT, acupuncture, or other factors accounted for any improvement noted in both groups could not be determined in this study. Expectation for relief was a predictor of reported benefit.
    PMID: 23965480 [PubMed – in process] PMCID: PMC3782092 [Available on 2014/9/1]

    This study appears to have had good methodology. It clearly shows that the “expectation for relief” is more important in acupuncture than whether or not a needle actually pierces the skin. 1000 years ago, this expectation would have been even stronger. It is a problem that the expectation is based on deception and delusion (i.e. that traditional acupuncture “works” to “cure” diseases if the “right points” are pierced with needles in the “right way”, not just to change perception of pain).

    2. Evid Based Complement Alternat Med. 2013… http://www.ncbi.nlm.nih.gov/pubmed/23983775
    Validity of the “streitberger” needle in a chinese population with acupuncture: a randomized, single-blinded, and crossover pilot study.
    Xie CC, Wen XY, Jiang L, Xie MJ, Fu WB.
    Source
    Department of Acupuncture and Moxibustion, Guangdong Provincial Hospital of TCM, Guangzhou 510120, China.
    Abstract
    We studied the validity of a “Streitberger” needle as a valid approach in a Chinese population with experience of acupuncture. Volunteers were recruited from students of the School of Acupuncture and Moxibustion, Guangzhou University of Chinese Medicine. Sixty students receiving education in acupuncture theory and experience in practical acupuncture were tested in study determining whether needling with the placebo needle felt any different from conventional acupuncture. Outcomes included measures of penetration sensation, VAS ratings, and Deqi sensation questionnaire. As a result, needle penetration, VAS ratings for either needle and Deqi sensation were not significantly different between two kinds of needles. Our findings show that the use of “Streitberger” needle is credible in a Chinese population with acupuncture experience.

    To be not guilty of ‘comment bias,’ I also found this abstract, co-authored by Dr. Ernst, which concludes that ‘real’ acupuncture (including electroacupuncture) is better than sham acupuncture for osteoarthritis pain, particularly of the knee: http://www.ncbi.nlm.nih.gov/pubmed/16936326. Full text is free here: http://rheumatology.oxfordjournals.org/content/45/11/1331.long
    That was from 2006 (can that really be 7 years ago?). Skeptics convincingly argue that electroacupuncture should not be considered traditional acupuncture, and perhaps that is the limitation of this study. Please, Dr. Ernst, share any thoughts regarding this article.

  • The truth is most conventional and non conventional medicine rely strongly on placebo.Whether it is sham knee surgery providing the same relief from pain as actual surgery or the idea of a needle piercing the skin providing relief.
    My theory is the development comes from “mummy kiss it better” creating long term potentiation.Indeed children who have suferred neglect/abuse are more prone to inflammatory illnesses in later life i.e heart disease,diabetes and even cancer.
    As an osteopath I know we need to prove evidence in our field but we must remember that if someone feels they are benefitting they probably are.In the same way being at the doctors can ease your problems before the consultation has started.
    Remember the brain creates the pain and our understanding of this extraordinary instrument is only really in its infancy.
    So chill out and let people make their choices.Just to point out as Rod Liddle likes to remind us the medical profession manages to kill about 20-30000 people a year through medical negligence( my son being one of them).Pharmas are at best disingenuous about their medicines efficacies(Ben Goldacre).I feel you are really going after the wrong people.Plus you seem to have a pop for not producing evidence and when we do you question the results.
    I guess thats statistics for you.

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