MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

An international team of researchers wanted to determine the efficacy of laser and needle acupuncture for chronic knee pain. They conducted a Zelen-design clinical trial (randomization occurred before informed consent), in Victoria, Australia (February 2010-December 2012). Community volunteers (282 patients aged ≥50 years with chronic knee pain) were treated by family physician acupuncturists.

The treatments consisted of A) no acupuncture (control group, n = 71), B) needle (n = 70), C) laser (n = 71), and D) sham laser (n = 70) acupuncture. Treatments were delivered for 12 weeks. Participants and acupuncturists were blinded to laser and sham laser acupuncture. Control participants were unaware of the trial.

Primary outcomes were average knee pain (numeric rating scale, 0 [no pain] to 10 [worst pain possible]; minimal clinically important difference [MCID], 1.8 units) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0 [no difficulty] to 68 [extreme difficulty]; MCID, 6 units) at 12 weeks. Secondary outcomes included other pain and function measures, quality of life, global change, and 1-year follow-up. Analyses were by intention-to-treat using multiple imputation for missing outcome data.

At 12 weeks and 1 year, 26 (9%) and 50 (18%) participants were lost to follow-up, respectively. Analyses showed neither needle nor laser acupuncture significantly improved pain (mean difference; -0.4 units; 95% CI, -1.2 to 0.4, and -0.1; 95% CI, -0.9 to 0.7, respectively) or function (-1.7; 95% CI, -6.1 to 2.6, and 0.5; 95% CI, -3.4 to 4.4, respectively) compared with sham at 12 weeks. Compared with control, needle and laser acupuncture resulted in modest improvements in pain (-1.1; 95% CI, -1.8 to -0.4, and -0.8; 95% CI, -1.5 to -0.1, respectively) at 12 weeks, but not at 1 year. Needle acupuncture resulted in modest improvement in function compared with control at 12 weeks (-3.9; 95% CI, -7.7 to -0.2) but was not significantly different from sham (-1.7; 95% CI, -6.1 to 2.6) and was not maintained at 1 year. There were no differences for most secondary outcomes and no serious adverse events.

The authors drew the following conclusions: In patients older than 50 years with moderate or severe chronic knee pain, neither laser nor needle acupuncture conferred benefit over sham for pain or function. Our findings do not support acupuncture for these patients.

This is one of the methodologically best acupuncture studies that I have seen so far.

  • its protocol has been published when the trial started thus allowing maximum transparency
  • it is adequately powered
  • it has a very clever study-design
  • it minimizes bias in all sorts of ways
  • it tests acupuncture for a condition that it is widely used for
  • it even manages to blind acupuncturists by using one treatment arm with laser acupuncture

The results show quite clearly that acupuncture does have mild effects on pain and function that entirely rely on a placebo response.

Will acupuncturists learn from this study and henceforward stop treating knee-patients? Somehow I doubt it! The much more likely scenario is that they will claim the trial was, for this or that reason, not valid. Acupuncture, like most of alternative medicine, seems unable to revise its dogma.

19 Responses to More evidence to show that acupuncture is a ‘theatrical placebo’

  • “Acupuncture, like most of alternative medicine, seems unable to revise its dogma.”

    This is the hallmark of CAM and religion–at least religion doesn’t charge a fee up front (although the hand is always out for the “donation”).

  • Today is my 1 year anniversary of shuttering my acupuncture clinic. While I miss some of the social interaction, the positive feedback, and the income, I could no longer ethically do acupuncture after learning of what the best research repeatedly finds–doing ‘real’ acupuncture to ‘real’ points selected according to ‘real’ tradition gets the same results as doing fake acupuncture on random points, if the clinical communication is the same.

    It’s sad in that I never intended to be a quack, but approached alternative medicine through an interest in nutrition and then herbs (particularly looking for herbs to treat my own conditions which I was reluctant to seek mainstream treatment for). While I try not to regret the choices I’ve made, it would be foolish for me to pretend I don’t regret the time and money I spent learning acupuncture and TCM. Had I spent the same time (and less money) following a more productive interest (such as an actual science, real medicine, computer programming, or graphic arts), I would be leading a different life, probably with a greater sense of meaning and a better income. But there is a chance then that I’d always be thinking I was missing some mystical spiritual insight I could gain through some woo-master. At least I have taken care of that delusion.

    I would very much like to see some country, state, insurance plan, or financial aid system stand up to TCM and refuse to grant it ‘real’ status due to its equivalence to ‘sham’ system. It may seem like a worthy cultural compromise to accept and endorse TCM, but it really doesn’t do anyone good except the schools and companies making money from it.

    Oh, patients will say it made them better (but they don’t know if they would have gotten better anyway or if perhaps they still have a real problem they now are ignoring), practitioners will swear they have ‘seen’ the results (though they most likely have never employed a convincing placebo treatment in the same manner), and proponents will cherry pick and twist poorly done studies to suggest that there is merit in the treatments.

    But more and more, people considering TCM look to the internet for peer-reviewed and authoritative studies and find convincing and poorly-rebutted articles by skeptics and scientists clearly showing that acupuncture is no better than a convincing placebo treatment, and that neither makes a real difference in a real disease (just a temporary subjective shift in perception of symptoms such as pain and nausea, while regression to the mean and natural course of disease goes on in the background).

    Anyhow, I am much happier with my ‘new life’ this past year, and while it hasn’t been easy to transition (I still need an income), I haven’t seriously reconsidered my stopping of acupuncture. I continue to work on a book about my path and experiences, but am quite busy with non-TCM pursuits which I find meaningful and fulfilling.

  • Edward, after reading this post I’ve seen this one from the Harvard Health blog:http://www.health.harvard.edu/blog/acupuncture-knee-arthritis-fails-one-test-may-still-worth-try-201410017470

    I trust their advices, but now I’m confused. What do you say about this?

    • @porcupine
      my guess would be because the study found twice the NCID for needle acupuncture vs control at 12 weeks, hence what Wayne says:

      “When you compare acupuncture to no treatment, there seems to be clinically meaningful differences for many pain conditions, including back pain and knee pain. Based on this pragmatic comparison, if I were deciding whether to send a family member or friend for a pain-related acupuncture treatment, I would say ‘yes’.”

  • Hear hear, Ex-Acupuncturist! You got balls writing this stuff. You got balls get rid of your (acupuncture) income! But… income doesn’t mean too much. Except you have too pay your mortgages, if there is any.

    Here is an osteopath speaking. Just as many osteopaths have been physiotherapists in former life, they choose with full consciousness to become an medicaster, an alternative therapist, in my case: an osteopath. Same here fore me, when I had put all my money in a serious MSc education I would have been doctor right now of could have been doing great work in health or movement sciences, but but…

    In osteopathy land, there are may people writing about things as in: “I have treated this patient a couple of times and all the headaches are gone” YUP. Could be right, but most of the times it is NOT. Time is healing, the patient is dealing. With a psychological relief. The basics of osteopathy are in manner of philosophy quite right. General medicine could learn from this. Make your analysis, have time to question the good questions. Theres is of course ‘an arterial rule’, like Still said. Where no blood is, there is no life. Where the blood flow is being troubled, for example because of strained fascia, there is a great possibility that tissue isn’t functioning that good any more. Complaints come later.

    But what I wanted to say is that many osteopaths can’t get rid of the old outmoted habits. Craniosacral therapy, feeling the cranial rhythmic impulse, naming widespread cause and effect, ‘complaint here because of underdeveloped embryological rotations’, all of these are the unfundamental, not scientifically proved. Colleagues are working at their patients saying ridiculous things (“Oehh, stiff cecum here, there should be paid attention to it”). In this way I could fill my practice with income as well but… I come up against a wall of resistance. I know, reading a lot of RCT’s op PubMed aso, that the pretendings are not that much fundamental. There are many more lies being told than facts. Facts that are important to get a serious business, to get recognized by the government or health insurances. With facts you could help people, not with quackery sayings. So long the osteopathic profession is that divided and nobody is looking into the good direction, it will be hard for me to stay an osteopath.

    Osteopath. It is like a smear behind my name. Not being recognized, being entitled as an quacker. Though I do very good things in my daily practice and therefore I can’t and don’t like to say goodbye to my working life as osteopath. I regard myself as an osteopath who came back as a very competent physio therapeutical osteopath. I will do so on in spite of I am regretting not to start a new job….

    (I’m sorry for my English as I am speaking German in daily life)

  • My corrector substituted Edzard with Edward. I’m sorry.

  • The October issue of JAMA also has an article titled “JAMA patient page. Treating pain with acupuncture.” by Wang and Wu. There is no abstract in PubMed for this article (http://www.ncbi.nlm.nih.gov/pubmed/25268455) and the full article is obviously behind a paywall. Can you tell us what this article is about, professor Ernst? Is it about a new study, is it a systematic review or simply an opinion?

    • Laurens

      The article is free on the JAMA website: Treating Pain With Acupuncture, but it doesn’t say anything of interest!

      The links it gives for further information are NCCAM and what looks like an acupuncture trade body!

      For More Information
      National Institutes for Health: National Center for Complementary and Alternative Medicine
      http://nccam.nih.gov/health/whatiscam/chinesemed.htm

      National Certification Commission for Acupuncture and Oriental Medicine
      http://www.nccaom.org/regulatory-affairs/state-licensure-map

      • Thank you, Alan. That was indeed a bit boring. At least now I know what a “patient page” is.

      • So you prefer the Medical News Today article over the Harvard article that Porcupine linked to?

        “Weak results

        As in previous studies, people who had needle or laser acupuncture reported less pain and better physical function compared with the group that had no treatment at all. Keep in mind that the differences were quite small—like a 1-point reduction in pain on a scale of 0 to 10. That’s unlikely to impress someone with significant arthritis pain.

        As for the sham acupuncture, the benefit disappeared when researchers compared the real and simulated treatment groups. Does it mean the effect of acupuncture was all placebo in this study—essentially, all in the participants’ heads?

        Not necessarily. The study had only 70 people in each of the four groups. That would make it difficult to pick up differences in the effect of real and fake acupuncture. Wayne, a board member of the Society for Acupuncture Research, believes the totality of the evidence suggests acupuncture does actually relieve pain for many conditions—although exactly how remains a mystery.

        “This is a small study that replicates what we already know,” Wayne says. “When you compare acupuncture to no treatment, there seems to be clinically meaningful differences for many pain conditions, including back pain and knee pain. Based on this pragmatic comparison, if I were deciding whether to send a family member or friend for a pain-related acupuncture treatment, I would say ‘yes’.””

  • I wouldn’t expect acupuncture to help with chronic pain.
    The best non-placebo explanation I know of for the effects of acupuncture, is that micro-injury from the needle causes a release of adenosine, which is anti-inflammatory and anti-pain.
    But the adenosine would be cleared pretty fast, and the release would be localized. So acupuncture might work as a local anesthetic to some extent, but no reason to expect the effects to last much after the acupuncture session.
    Perhaps acupuncture could decrease some chronic pain via anti-inflammatory effects.

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