MD, PhD, FMedSci, FSB, FRCP, FRCPEd

There are numerous types and styles of acupuncture, and the discussion whether one is better than the other has been long, tedious and frustrating. Traditional acupuncturists, for instance, individualise their approach according to their findings of pulse and tongue diagnoses as well as other non-validated diagnostic criteria. Western acupuncturists, by contrast, tend to use formula or standardised treatments according to conventional diagnoses.

This study aimed to compare the effectiveness of standardized and individualized acupuncture treatment in patients with chronic low back pain. A single-center randomized controlled single-blind trial was performed in a general medical practice of a Chinese-born medical doctor trained in both western and Chinese medicine. One hundred and fifty outpatients with chronic low back pain were randomly allocated to two groups who received either standardized acupuncture or individualized acupuncture. 10 to 15 treatments based on individual symptoms were given with two treatments per week.

The main outcome measure was the area under the curve (AUC) summarizing eight weeks of daily rated pain severity measured with a visual analogue scale. No significant differences between groups were observed for the AUC (individualized acupuncture mean: 1768.7; standardized acupuncture 1482.9; group difference, 285.8).

The authors concluded that individualized acupuncture was not superior to standardized acupuncture for patients suffering from chronic pain.

But perhaps it matters whether the acupuncturist is thoroughly trained or has just picked up his/her skills during a weekend course? I am afraid not: this analysis of a total of 4,084 patients with chronic headache, lower back pain or arthritic pain treated by 1,838 acupuncturists suggested otherwise. There were no differences in success for patients treated by physicians passing through shorter (A diploma) or longer (B diploma) training courses in acupuncture.

But these are just one single trial and one post-hoc analysis of another study which, by definition, cannot be fully definitive. Fortunately, we have more evidence based on much larger numbers. This brand-new meta-analysis aimed to evaluate whether there are characteristics of acupuncture or acupuncturists that are associated with better or worse outcomes.

An existing dataset, developed by the Acupuncture Trialists’ Collaboration, included 29 trials of acupuncture for chronic pain with individual data involving 17,922 patients. The available data on characteristics of acupuncture included style of acupuncture, point prescription, location of needles, use of electrical stimulation and moxibustion, number, frequency and duration of sessions, number of needles used and acupuncturist experience. Random-effects meta-regression was used to test the effect of each characteristic on the main effect estimate of pain. Where sufficient patient-level data were available, patient-level analyses were conducted.

When comparing acupuncture to sham controls, there was little evidence that the effects of acupuncture on pain were modified by any of the acupuncture characteristics evaluated, including style of acupuncture, the number or placement of needles, the number, frequency or duration of sessions, patient-practitioner interactions and the experience of the acupuncturist. When comparing acupuncture to non-acupuncture controls, there was little evidence that these characteristics modified the effect of acupuncture, except better pain outcomes were observed when more needles were used and, from patient level analysis involving a sub-set of 5 trials, when a higher number of acupuncture treatment sessions were provided.

The authors of this meta-analysis concluded that there was little evidence that different characteristics of acupuncture or acupuncturists modified the effect of treatment on pain outcomes. Increased number of needles and more sessions appear to be associated with better outcomes when comparing acupuncture to non-acupuncture controls, suggesting that dose is important. Potential confounders include differences in control group and sample size between trials. Trials to evaluate potentially small differences in outcome associated with different acupuncture characteristics are likely to require large sample sizes.

My reading of these collective findings is that it does not matter which type of acupuncture you use nor who uses it; the clinical effects are similar regardless of the most obvious potential determinants. Hardly surprising! In fact, one would expect such results, if one considered that acupuncture is a placebo-treatment.

38 Responses to Acupuncture: it’s a placebo, isn’t it?

  • Geoffrey Cor says:

    feedback from the Clinic. One of the better researched CAM modalities for pain and found wantting. One of the ultimate unpackaged and standardised accupuncture methods that is currently doing the rounds in physiotherapy is “Dry Needling’ – it avoids any eastern medicine rhetoric and it is basically just sticking an accupuncture or more into a tender spot in a muscle. And yes it is probably a good placebo although it is plausible there is a nociception-modulating effect.

    What are your thoughts Professor?

    • RNB says:

      I’m a myotherapist and I use dry needling in conjunction with other methods to treat myofacial pain and dysfunction; I never use needling in isolation, I use it where I feel that it is strongly indicated as opposed to other techniques.

      Unfortunately the understanding of myofascial pain is not completely understood, and therefore nor is dry needling, or any other treatment method for myofascial pain. From my clinical experiences it’s effectiveness varies from individual to individual, and case by case. In general, I personally have a fairly subtle response to DN, whereas many clients have quite significant responses. It also has a lot to do with each practitioner’s technique. There is an art to ‘hitting’ the trigger point.

      Karen Lucas has done some clinical studies in DN as has Tekin et al, 2012 – http://www.ncbi.nlm.nih.gov/pubmed/23138883

        • RNB says:

          Alan Henness. If someone is in acute pain and digital pressure would aggravate their condition, dry needling can be useful to treat trigger points as it requires no physical pressure. Other times when digital pressure and manual techniques simply don’t seem to ease their symptoms, dry needling often will. Certain conditions such as lateral elbow tendinopathies are generally quite responsive to dry needling as opposed to manual therapy. Patients with fibromyalgia often report better results with less post treatment soreness with dry needling.

          Bjorn Geir. If your condition improved with the treatment you received then you certainly didn’t miss out by not having needling done. It’s just another tool to achieve the same result. Some people like it, some people don’t; sometimes it works, sometimes it doesn’t, that’s true of any form of therapy.

          • RNB says:

            There are dribs and drabs of clinical evidence around if you want to spend the time to search, but probably the most well known would be Karen Lucas’ thesis on the effect of myofascial trigger points on muscle activation patterns where she found an improvement after dry needling against a sham placebo. I’ve taken part in a reconstruction of this study in a class room setting and received similar results.
            From my personal experience I find that needling is more effective than digital pressure on treating trigger points when the aim is to increase muscle facilitation.

          • RNB says:

            Did you read the thesis or the Tekin study I posted?

            I agree the evidence is not abundant (albeit based on myofascial pain and trigger point theory which is relatively well understood and does have a far greater wealth of study surrounding it). This lack of evidence is for many reasons, MDN is a relatively recent modality; it is still not widely used and is still largely unheard of by the general public; those who practice it are generally TAFE qualified myos who may not have the means to conduct the calibre of research required to stand up as being meaningful.

            What I can say is that the myotherapy profession is evidence based and goal orientated, in that results are measured tangibly by noting pre and post treatment range of motion of musculoskeletal joints, motor function, as well as subjective levels of pain.

            I make clinical decisions based on recent sports medicine publications and what has worked for my clients in the past.

      • Björn Geir says:

        Well… Since I learned the importance of it a couple of decades ago, I have always been able to cure my myofascial pains with stretching, massage, physical activity and attention to ergonomics and stress. Tennis elbow, shoulder impingement, mouse-arm, supraspinatus myotendinitis and different neck and back muscle cramps and inflammations etc. etc… Been able to deal with it all.

        Did I miss out on not using wet or dry needling?

  • Bob Dobbs says:

    In a kind of defence of acupuncture, I don’t know many acupuncturists who can do anything at all with back pain. I can’t imagine you’d get good stats out of them. I mean when they claim in a leaflet that CM can treat back pain, a notion that’s neither backed up by studies or any personal clinical expectation, you’ve got to wonder……

    • Edzard says:

      are you sure? back pain is one of the rare indications that is NICE-approved; the evidence is not brilliant but it is not negative either. Here are the conclusions from the most recent SR [http://www.ncbi.nlm.nih.gov/pubmed/23269281]: “The current evidence is encouraging in that acupuncture may be more effective than medication for symptom improvement or relieve pain better than sham acupuncture in acute LBP.”

      • Tom Kennedy says:

        I’m confused Edzard – I thought acupuncture was a placebo treatment, as you categorically state at the end of your piece above? Even though the evidence is ‘not brilliant’, it strongly suggests something beyond placebo, even when all the well-known problems related to acupuncture trials are considered, doesn’t it?

        And Bob, as an acupuncturist, I’m delighted when back pain patients turn up as I (like many others) usually get very good results with them.

  • Geoffrey Cor says:

    I managed to find a systematic review that was published in the The Journal of Orthopaedic and Sports Physical Therapy this year. The review selected 12 RCTs for dry needling. While the review found a positive treatment effect in neck/arm myosfascial pain when compared to either sham or control treatments the authors admit the lack of precision in their result with wide confidence intervals. I am not sure I am keen to rush out and do a course in dry needling based on this review but it is interesting that a prolonged treatment effect was noted (4 weeks post treatment).

  • Michael Burns says:

    I have seen an appendectomy done using just acupuncture during the surgery and for post opp pain (Chinese Patient who had great faith) – Whyalla Hospital, South Australia – circa 1989. Theatre full of observers ! Note I am in no way promoting acupuncture, a very good placebo maybe.

      • TomTheAcupuncturist says:

        Alan – you seem like an intelligent person from your posts. Can’t you see that, even when performed by untrained practitioners under unrealistic conditions, ‘real’ acupuncture has been shown many times to be more than a placebo? Yes, maybe generally not a great deal more under these conditions, but when I look at the points chosen and the people used to conduct many of these trials it’s no wonder the results aren’t better. Edzard and others are convinced practitioner blinding constitutes a fair trial – to me that is preposterous. There is a great deal of skill and nuance involved in a good acupuncture treatment, and if this isn’t taken into account in a trial then in my opinion it is of little value.

        • Alan Henness says:

          TomTheAcupuncturist said:

          even when performed by untrained practitioners under unrealistic conditions, ‘real’ acupuncture has been shown many times to be more than a placebo

          Has it? What is ‘real’ acupuncture’?

          when I look at the points chosen and the people used to conduct many of these trials it’s no wonder the results aren’t better.

          I’m sure many of the trials – particularly those conducted in China and Korea for example – will have been carried out by trained acupuncturists. But if you believe they have been negligent in some way, perhaps you could give details and say what you think needs to be done better?

          There is a great deal of skill and nuance involved in a good acupuncture treatment

          But you have just said that acupuncture performed by an untrained practitioner is more than a placebo. No doubt there are varying ‘skill’ levels (although I don’t know how this could be measured), so what level of skill should practitioners be required to have before taking part in a trial?

          • Tom Kennedy says:

            Exactly, what is ‘real’ acupuncture? My point was that many trials that refer to ‘real’ and ‘placebo’ arms are using either untrained practitioners, or a highly restricted version of what most practitioners would consider a proper treatment. And the ‘placebo’ is often not inert.

            I suggest that the often disappointing difference between the ‘real’ and ‘placebo’ arms is explained by these problems. Commonly there are better results for these pseudo-’real’ legs. But you cannot divorce the skill from the treatment and expect really significant differences between the groups. When the ‘real’ arm isn’t really real, and the placebo isn’t really a placebo, I think these are pretty encouraging results.

          • Alan Henness says:

            Tom

            You’ve said that many trials use untrained acupuncturists, but have not yet supplied any evidence to substantiate your assertion. It would be a more fruitful discussion if you did.

            You also said that the placebo is often not inert. It is certainly true that it remains difficult to separate out the specific from the non-specific effects for such an invasive treatment, but it’s not impossible to tease out the effects of various elements. Many trials give a good indication of the effect of the actual needle insertion is not significant. Perhaps you could say what you believe the effect size is for each of these separate elements is and how they contribute overall?

        • Edzard says:

          we once did an interesting study [http://www.ncbi.nlm.nih.gov/pubmed/9810069] where we asked 6 well-known experts of acupuncture to score how well acupuncture had been performed in a series of clinical trials. and guess what? they failed to agree what good acupuncture technique was. this seems to invalidate your argument completely, don’t you agree?

          • Tom Kennedy says:

            I don’t have access to the full article text so can’t comment on that trial I’m afraid. But I fail to see how one study completely validates or invalidates anything, do you? Especially when you consider acupuncture is pluralistic in nature – there’s more than one way to skin a cat, as they say.

  • Tom Kennedy says:

    Alan, I will try to find time to give you some examples of trials that use poorly trained practitioners, or restrictive protocols, but they are rife and it’s not hard to do if you get the opportunity first.

    In an effort to answer your other question, I’ll give you my own perspective (based on clinical experience and the experiences of trusted teachers). Whilst initial point of location isn’t insignificant, the most important aspect is what is done after insertion. If treating a muscular pain, for example, the correct muscle fibres should be stimulated, and often a ‘twitch response’ is desirable. In another situation, a deep, warm sensation may be optimum, or a electrical shooting sensation etc. In other words, simply ‘obtaining deqi’ is not enough, and even that isn’t always done in trials. The optimum type of deqi all depends on the situation, and deciding on this and achieving it reliably requires a great deal of skill and practice. To blindly stab a needle in a point and expect it to have specific effects more than once in a while is not realistic in my opinion.

    • Pete 628 says:

      Tom, I really don’t know where to start in order to explain your false analogies because they totally defy any semblance of critical thinking.

      It never ceases to amaze me that only the incompetent practitioners of sCAM engage in clinical trials while the competent practitioners endlessly lament about the disservice this is doing to their profession.

      Let’s get down to real-world basics: there are many different ways of performing surgery X if, and only if, the core principles of X are sound. Analogy: there is a plethora of mobile phones on the market because the core technology irrefutably works — if a device or a service provider does not work then the consumer is legally eligible for a refund. There are many independent reliable tests that can be performed to determine whether the phone is faulty or the service provider is faulty.

      When sCAM provides such independently verifiable tests for efficacy, and subjects itself to reasonable consumer money-back guarantees for its products and services, it could become a viable alternative to science-based medicine. Not all efficacious medicine is science based: as in many fields of engineering, independently verifiable evidence-based solutions are perfectly acceptable despite the fact they thus far lack robust science to support them.

      What you seem to be claiming is the equivalent of: The only reason that concrete structures collapse during an earthquake is because a really good homeopath was not used to reinforce the concrete and steel during construction. Perhaps a really good acupuncturist could’ve also added vital energy to the structures or to the designers involved.

      Because acupuncture relies on principles that are totally at odds with, say, homeopath and reiki, perhaps you would be kind enough to enlighten us as to which therapy we should seek for each of our health conditions. By “enlighten” I mean to provide us greater knowledge and understanding about a subject or situation; by “knowledge” I mean the epistemological, scientific, and critical thinking definition: justified true belief.

    • jm says:

      @ Tom – do you know of any western style studies that have actually looked at acupuncture? The only ones I’ve ever seen are things like “acupuncture to treat IBS” or something equally weird. Is there a study that, instead of “IBS” actually looks at “Large Intestine Damp Heat” as opposed to “Spleen Yang Deficiency” or whatever?

      And, where treatments were individualized? (You know…like they would be in the ‘real world’.)

      It seems bizarre to me that researchers would set up trials using point recipes alone…since from what I’ve heard, even students in clinic can’t just put needles in points a, b, and c and call it a treatment. They are expected to actually practice medicine.

      If you know of any *actual* studies that have been done with acupuncture – that are not sloppy pseudo-science – I’d love to know. I’ve heard of a study involving cupping and the common cold. But that type of study would be much more straightforward, since the cupping equivalent of deqi would be visible.

  • fedup says:

    “Hardly surprising! In fact, one would expect such results, if one considered that acupuncture is a placebo-treatment.”

    If placebo has been shown to produce a biological and physical change that is quantifiable and measurable, has this changed your opinion? Maybe if you had tried to discover WHY somethings worked rather than try to put them into the quackery and con artist box.

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