Is acupuncture a pseudoscience? An interesting question! It was used as the title of a recent article. Knowing who authored it, the question unfortunately promised to be rhetorical. Dr Mike Cummings is (or was?) the ‘Medical Director at British Medical Acupuncture Society’ – hardly a source of critical or sceptical thinking about acupuncture, I’d say. The vast majority of his recent publications are in ‘ACUPUNCTURE IN MEDICINE’ and his blog post too is for that journal. Nevertheless, his thoughts might be worth considering, and therefore I present the essence of his post below [the footnotes refer to my comments following Cummings’ article]:
…Wikipedia has branded acupuncture as pseudoscience and its benefits as placebo [1]. ‘Acupuncture’ is clearly is not pseudoscience; however, the way in which it is used or portrayed by some may on occasion meet that definition. Acupuncture is a technique that predates the development of the scientific method [2] … so it is hardly fair to classify this ancient medical technique within that framework [3]. It would be better to use a less pejorative classification within the bracket of history when referring to acupuncture and other ancient East Asian medical techniques [4]. The contemporary use of acupuncture within modern healthcare is another matter entirely, and the fact that it can be associated with pre-scientific medicine does not make it a pseudoscience.
The Wikipedia acupuncture page is extensive and currently runs to 302 references. But how do we judge the quality or reliability of a text or its references? … I would generally look down on blogs, such as this, because they lack … hurdles prior to publication [5]. Open peer review was introduced relatively recently associated with immediate publication. But all this involves researchers and senior academics publishing and reviewing within their own fields of expertise. Wikipedia has a slightly different model built on five pillars. The second of those pillars reads:
Wikipedia is written from a neutral point of view: We strive for articles that document and explain major points of view, giving due weight with respect to their prominence in an impartial tone. We avoid advocacy and we characterize information and issues rather than debate them. In some areas there may be just one well-recognized point of view; in others, we describe multiple points of view, presenting each accurately and in context rather than as “the truth” or “the best view”. All articles must strive for verifiable accuracy, citing reliable, authoritative sources, especially when the topic is controversial or is on living persons. Editors’ personal experiences, interpretations, or opinions do not belong.
Experts within a field may be seen to have a certain POV (point of view), and are discouraged from editing pages directly because they cannot have the desired NPOV (neutral POV). This is a rather unique publication model in my experience, although the editing and comments are all visible and traceable, so there is no hiding… apart from the fact that editors are allowed to be entirely anonymous. Have a look at the talk page behind the main acupuncture page on Wikipedia. You may be shocked by the tone of much of the commentary. It certainly does not seem to comply with the fourth of the five pillars, which urges respect and civility, and in my opinion results primarily from the security of anonymity. I object to the latter, but there is always a balance to be found between freedom of expression (enhanced for some by the safety of anonymity) and cyber bullying (almost certainly fuelled in part by anonymity). That balance requires good moderation, and whilst there was some evidence of moderation on the talk page, it was inadequate to my mind… I might move to drop anonymity from Wikipedia if moderation is wanting.
Anyway my impression, for what it’s worth, is that the acupuncture page on Wikipedia is not written from an NPOV, but rather it appears to be controlled by semi professional anti-CAM pseudosceptics [6]. I have come across these characters [6] regularly since I was introduced to the value of needling in military general practice. I have a stereotypical mental image: plain or scary looking bespectacled geeks and science nuts [6], the worst are often particle physicists … Interacting with them is at first intense, but rapidly becomes tedious as they know little of the subject detail [6], fall back on the same rather simplistic arguments [6] and ultimately appear to be motivated by eristic discourse rather than the truth [6].
I am not surprised that they prefer to close the comments, because I imagine that some people might object rather strongly to many of the statements made in this text.
Here are my short comments:
[1] I should perhaps stress that I am not the author of nor a contributor to this Wiki (or any other) page. [2] Is this an attempt to employ the ‘appeal to tradition’ fallacy? [3] The Wiki page does by no means classify the ancient history of acupuncture as pseudoscience. [4] I have always felt that classification of science or medicine according to geography is nonsensical; they should not be classified as Western or Asian but as sound or not, effective or not, etc. [5] As we have often seen on this blog, the ‘hurdles’ (peer-review) are often laughable, particularly in the realm of alternative medicine. [6] This article is essentially trying to show that the Wiki page is biased. Yet it ends with a bonanza of insults which essentially reveal the profound bias of the author.IS ACUPUNCTURE PSEUDOSCIENCE? Cummings’ article promised to address this question. Sadly it did nothing of the sort. It turned out to be an incompetent rant about a Wiki page. If anything, Cummings contributed to the neutral reader of his text getting convinced that, indeed, acupuncture IS a pseudoscience! At least Wiki used facts, arguments, evidence etc. and it went a lot further in finding a rational answer to this intriguing question.
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A trick that’s used quite often now on the Internet- asking a rhetorical question such as this, in order to draw unsuspecting readers in to what they are led to think will be a rigorous analysis of the subject in question, but which, it quickly becomes obvious, is nothing of the sort. A way of getting your defensive blow in first, by acknowledging that there are many out there who are indeed critical or sceptical, and thus attempting to be disarmingly honest and objective.
For some reason, I had missed this previous opinion piece by Cummings, also in the bmj: BMJ blogs: Acupuncture in Medicine Blog » Blog Archive » Too NICE – there appears to be a glaring orthodox bias in NG59.
There is no COI statement (the article that Edzard discusses above did not initially have one, but was added later, after concerns were raised), but I’ve asked him about it on Twitter.
For what it’s worth I don’t think acupuncture is pseudoscience. I think it’s a quasi-religious practice, but that the study of acupuncture is largely pseudoscientific. However, what I think doesn’t matter: the sources identify acupuncture as pseudoscience, so Wikipedia follows them.
The problem the trypanophiles have right now is that the trajectory of evidence is against them, and they are fighting a rearguard action to preserve their lucrative practice. Inevitably the more the science refutes their claims, the more heavily they will rely on politics, anecdote, fallacious appeals and the like. NICE removing acupuncture for back pain is a body blow. The response will always be to try to use resources like Wikipedia to replace those which no longer promote their beliefs.
Hi guys
Nice little gathering here 😉
I am happy to respond to serious comments on published data or my interpretation of that data, but I’m not into blog banter.
Re NICE, this is ongoing, but I think the data is quite clear. I have spent a good many hours on the analysis, and the data errors. There are still basic errors of data entry in the full guideline meta-analyses on acupuncture – have a look at the sensitivity analyses on pain and see if you can spot them (it took me 30 seconds :D).
If you want to debate with me, you need to read my stuff carefully and read the refs. Don’t dismiss it because you think I am excessively biased – we are all biased and it is important to be aware of our individual bias and motives.
That last blog was not a review, and not tagged as such. It was an opinion piece. I did not intend to cause offence, I am holding up a mirror for you to consider your own biases. I understand the effort behind this work, and I applaud it.
I have followed the data on acupuncture for over 20 years and had the privilege of debating it with nearly all the most well-informed (English-speaking) academics – its been great fun…
Best
M
Most on this blog have only one bias or motive and that is factual truth(not money). Exposure of chicanery serves that purpose.
@Mike Cummings on Tuesday 03 January 2017 at 21:57
I beg to differ on multiple points Dr. Cummings. I do not have time to address them thoroughly but here are some hastily assembled words on the main issues.
Your declaration that you are “not into blog banter” and only “…happy to respond to serious comments on published data or [your] interpretation of that data” fails on the fact that you have come forth here with a comment and that you have denied comments on your own blog posts. You have posted your opinions in online blog articles/posts. You will therefore have to face the flak.
Now where do you expect us to carry the dialog about your blog writings – here in this thread in which you are have made yourself a participant or are you going to open for comments on your own blog?
Your comment is in effect an invitation to a dialog about your expressed opinions and their worth and value.
Your equating our bias-situations is in its own right biased and fallacious. Trying to barricade your own bias by pointing out that we have our own biases is to me paramount to trying to build ‘straw men’ and trying to set fire to them.
You have chosen to promote acupuncture as a career and as your income generating vocation if I am not mistaken? Such a conflict of interest is consequently the basis for severe bias, which is clearly very different from the position of, I dare say all of the critics of acupuncture who partake in the discussions on this blog at least. Acupuncture is in no way a competing modality to my income or professional standing. My (our) bias is towards finding the truth. My bias is also towards protecting the public from unnecessary cost, time expenditure, false hopes and the factual harm and risk of serious complications that is inherent in the promotion and practice of invasive, injurious alternative medicine like acupuncture.
I speak only for myself but I wager that any one of us acupuncture critics on this blog would happily consider changing our attitude and our minds were we presented with convincing evidence for intrinsic efficacy of acupuncture.
I am a general and bariatric surgeon myself with over 30 years professional, wide ranging experience. I was until a number of years ago rather intrigued and interested in acupuncture and quite convinced there should be a useful clinical effect to it, at least in pain management but also postoperative nausea and vomiting. In the past decades I have seen no benefit from any of the attempts at acupuncture, acupressure etcetera that I have witnessed. All[sic] except one of the physicians I know of who tried acupuncture in their practice have abandoned it, albeit reluctantly. They simply do not find it worthwhile. Trying to dismiss this as them not having the right skill-set or learnt the tricks of the trade properly is known as the No true Scotsman fallacy. I am referring to devoted physicians, most of them anesthesiologists.
I criticise acupuncture because I fail to find any convincing evidence and on the basis of readily available historical facts that show it to be in essence a twentieth century construct.
I have no interest in the failure of acupuncture. On the contrary, I have a very large interest in anything that may improve postoperative pain management, effective cancer-palliative therapy, postoperative nausea/vomiting prophylaxis… and so on.
So my bias in this respect has generally the opposite orientation to what you infer in your comment. One might even deduce that we have parallel interests in a way.
Your use of the term “pseudoskeptics” in your blog post that spawned this debate, about most if not all critics of acupuncture is not only fallacious but deeply disrespectful as it implies we are driven by faith and beliefs rather than rationality and scientific thinking.
In your referenced blog-post about the NICE guidelines (http://blogs.bmj.com/aim/2016/11/30/too-nice/) you go through logical convolutions to draw conclusions about acupuncture from trials using electric stimulation via transdermal electrodes (the PTNS) This is seriously fallacious as electrostimulation is NOT acupuncture in any sense. You simply cannot draw conclusions on the simple sticking of needlesinto the skin i.e. acupuncture (an moxaburning, GuaSHa, cupping or any other injurious antics) from a completely different methodology that. No more than you can compare surgery with massage.
BTW your first reference link is dead.Here the 2009 Guidelines can be found. They are elaborate on the matter of acupuncture so the revision to one of total dismissal is all the more radical and telling of the failure to find efficacy and benefit.
You seem to develop one of your main arguments out of the fact that three-armed comparison between verum, sham and conventional therapy has in trials shown inferiority of the conventional therapy arm vs. shma and verum AP and therefore infer that both sham and verum must be active. This is another fallacious deduction. It fails on the false assumption that the (theatrical) administration of sham/verum has no placebo effect, which must be missing from conventional arm. And on the fact that the studies were designed to compare verum vs. sham, not conventional therapy vs. sham/verum AP. The studies were neither intended nor designed for an unblinded and bias-prone comparison of this kind. They were primarily designed to compare verum vs. sham and verum vs. conventional. Inference from a-posteriori hypothesis testing of this kind can never be valid and unintended findings can only be used as hypothesis generation for another, different study.
The fact that studies comparing verum and sham have consistently showed no difference as was famously shown in the german (GERAC) acupuncture trials, only reinforces the notion of them both being pure, albeit theatrical, placebo activities. It also tells us that conventional therapy is wanting, at least the kind they chose to compare with, but that does not instantiate the efficacy of acupuncture.
This has to suffice for now.
I am sorry that I only address a few of the more general points and do not have time to produce a less wordy comment and a more detailed analysis of the logical convolutions you present as refutations to the Wikipedia article or the revision of the NICE guidelines.
Let me just conclude by applauding you for coming forth in person and by saying that your argumentation in the two blog posts or your comment above have totally failed to positively impress upon me or incite hope for the efficacy of acupuncture.
Hi Björn
Thanks for the detailed comments.
I am interested by your clinical experience with needling. I have taught acupuncture and dry needling techniques to doctors for some 20 years, since finding needling of muscle trigger points in young military men to be so apparently efficient. At the time I would only inject LA or LA steroid combinations. I went on to perform an SR on all needling techniques in myofascial trigger point pain, to find that nothing worked better than its own sham, but the overall changes were large, so either the needle or the context or both or the trials were all too small etc. My hands on experience was convincing – I could miss the point; the effects were often instantaneous and often associated with very localised muscle twitch (LTR).
I got sucked into the medical acupuncture field – my intention had been to develop a career in MSK medicine & sports medicine. I was exposed to a lot of what I thought was really weird. Slowly I was forced to become a little more open-minded, but not much…
I was really sceptical of immune-modulating effects, and years later we have pretty good clinical evidence of specific effects, and even more surprising effects in a mouse model of septic shock where one of the outcomes was mortality – 10 minutes of EA to tibialis anterior seemed to stop the mice dying… all refs here by the way: http://www.medical-acupuncture.co.uk/Default.aspx?tabid=130
Anyway, my original point is about why some clinicians take up needling and some don’t. I don’t think it is about skill. I have developed my needling skills to the point that there are few skeletal muscles that I cannot reach safely, but my results do not seem to be better than my most junior students. Sham acupuncture has up to a 50% RR in migraine prophylaxis, so it is hard to imagine why one might give up doing this, since a 50% RR is about as good as anything gets in chronic pain. A few RCTs do start to open a window into practitioner differences, and these can be large – up to a 3 fold difference in two trials). So I think whether or not the technique is taken up has more to do with the population and the peer support than with the skill of the practitioner.
On the other matter to which I wanted to respond – PTNS
This involves an acupuncture needle being inserted behind and above the medial malleolus in an attempt to electrically stimulate the posterior tibial nerve. Much of the time the nerve is not stimulated, but the deep somatic tissue is always stimulated. The technique originally derives from a US physician called Stoller, and he research acupuncture points (KI7 & SP6 I believe) before developing the technique he called SANS (Sensory Afferent Neuromodulation after Stoller). So this is a form of segmental electroacupuncture – something we have used in Europe since the mid 19th century. So it is not new, it is just that the device is now patented…
And one last comment on the subject of pseudoscience:
I think this is a good example of it: https://www.nice.org.uk/guidance/ipg552
The very title includes a completely impractical claim since you cannot stimulate the cervical branch of the vagus from the surface of the front of the neck. This has been ‘sold’ to many of my neurology and pain colleagues, to whom it seems plausible. It has tentative NICE approval for further evaluation… the expert advisor was from the industry – the details are all available from the link above. I could see no advice from an independent expert in electrical stimulation techniques – either transcutaneous or percutaneous.
Best
M
“I have taught acupuncture and dry needling techniques to doctors for some 20 years”
as I mentioned before, fallacies [appeal to tradition/authority] do not go down too well here.
Surely it’s important and often helpful to establish one’s credentials when contributing to a debate? Hasn’t Bjorn done the same here? I seem to recal occasions on this blog when you’ve reminded people of your own credentials, positioning yourself as someone qualified to criticise CAM researchers, no?
except, tradition is no acceptable credential
I have spent twenty years working as a unicorn wrangler and dragon herd. Any fool who says unicorns and dragons don’t exist, should bow down before the weight of my authority.
Hi Mike
thanks for joining this ‘nice little gathering’.
my post is not primarily about the NICE guidelines; we discussed these ad nauseam here: http://edzardernst.com/2016/03/nice-no-longer-recommends-acupuncture-chiropractic-or-osteopathy-for-low-back-pain/
my post is about the ‘blog banter’ you recently published. so, if you want to make a meaningful contribution here, please explain why and how the Wiki page that you criticised is factually wrong, why acupuncture is not a pseudoscience, and whether you feel that hauling a lot of insults at those who disagree with your views is the right way to show that acupuncture is science.
you state “if you want to debate with me, you need to read my stuff carefully…” I did read your ‘opinion piece’ carefully and I am willing to debate with you – but please abstain from employing fallacies like ‘tu quoque’ or appeal to authority [it does not go down very well with this ‘nice gathering’]. or perhaps you think that [your] ‘opinion pieces’ are excluded from criticism and debate?
Hi Edzard
It has been a while 🙂
Thanks for the link – it contains little discussion of forest plots or heterogeneity or GRADE scores… the crux of the recommendation decision. My blogs contain all that, and I have had no response to that analysis.
My blog is not about the content of the Wiki page, but about the publishing model and the background talk page – please have a look at that page. I do sympathise with the difficulty of managing such a huge resource with such an open publishing model, and the senior editors clearly need to band together and support each other. I am an entirely orthodox medic who has ended up in an unorthodox field, and I was a protagonist of eristic discourse in my youth, so I recognise it when I see it.
My latest blog has got more reaction than usual, and I guess it concerns perceived insults by those that may not have read it carefully enough. The anti-CAM pseudosceptic tag is supported by ‘banter’ on the talk:acupuncture page… you will be familiar with the style because it is all over this blog too, but the key difference is that you are not trying to edit an encyclopedia 😉
“…My blog is not about the content of the Wiki page…” you could have fooled me!
is it not about acupuncture/pseudoscience either?
@Mike Cummings
With full respect… I read your blog posts several times over and I still perceive both an implied and outspoken denigration towards critics of acupuncture as I tried to delineate for you in my comment above.
You, on the other hand have evidently not read my comment more than summarily or your comprehension must be adversely influenced in some way? Your response reveals a sad misinterpretation of what I wrote and it does not address my criticisms of your opinion and interpretation of data.
Instead you elaborate on what you practice and how your fancy for it developed. This however throws a light on how you have become enthralled in, as you call it, “unorthodox” use of needles (deep needling of internal structures) and electrostimulation. Your practice seems to consist mainly of dry needling, right?
Dry (and wet) needling have little resemblance and no physiological parallel with ‘acupuncture’ as it developed during the twentieth century i.e. as a reinvention of ancient blood-letting and rituals and philosophical surgery using shallow, thin needling.
Confusing electrostimulation and deep needling of muscle and other structures with the practice of ‘acupuncture’ is one of my main criticisms of your argumentation. It would be interesting to hear your views on why you consider studies of electrostiulation with needles and of deep needling injury-stimulation of muscles and tendons to be studies of acupuncture.
Hi Mike
Can you say whether it was you or the bmj who just this afternoon changed the category in which your two articles are published from ‘Wikibollocks’ to ‘Wikisceptics’, and can you say why that happened?
Acupuncture is only one of a number of Wikipedia articles on SCAM therapies. All of them have, to a greater or lesser degree, the same problem: the article covers the topic according to the best available science, True Believers don’t like that, and they besiege the article, with the result that every new repetition of the same many-times-rejected demands is met with progressively less patience.
The main problem for trypanophiles is that the current evidence shows it doesn’t matter where you put the needles or whether you actually insert them at all, and the strongest determinant of outcome is the elimination of bias. More bias gives a positive outcome, less bias gives a null outcome. Consistently. This is not helped by the existence of “journals” such as the Journal of Acupuncture and Meridian Studies which depend for their very existence on the validity of the thing they are supposed to test. How can you study meridians, when there’s no actual evidence that they exist? That just makes the acupuncture research community look like a bunch of magical-thinking fools. And how can an acupuncture journal be trusted to honestly assess the science which, if it refuted the core belief, would result in the journal having to shut its doors?
Most conditions have a net negative evidence base for acupuncture by now, and the handful for which the evidence is net positive, the effect size is small, the endpoints subjective and the study results are still consistent with the null hypothesis.
If this was a drug I think it’s safe to say it would be off the market by now.
If you want to influence the reality-based view of acupuncture, I have a suggestion for you. Work with the acupuncture community to stop offering treatments where the evidence base is negative. I have personally had acupuncture treatment for knee pain. It didn’t work for me, and if there had been informed consent I would have refused it. Yes, you read that right: a therapist stuck needles in me without asking first. There’s no good evidence acupuncture works for knee pain, and we know it has this in common with washout surgery and other theatrical placebo interventions. Knee pain waxes and wanes, and the joint is a piss-poor design, any honest practitioner would have to focus on ensuring stability, dealing with muscular asymmetry, and leave the theatrical placebos out of it.
I think acupuncture will get a lot more respect when it learns sterile technique and then restricts itself to those conditions where there is unambiguous evidence of effect, decent effect size, results that are not transient, a plausible mechanism for non-transient effect (which rules out every mechanism proposed thus far) and – crucially – does not begin practice until the evidence is there.
Just like chiropractors, every acupuncturist who “treats” conditions for which there is no good evidence ,or where the evidence shows it doesn’t work, is undermining the entire community of practice. And int his case it means the 99% of practitioners who exceed the bounds of the evidence, give the 1% a bad name.
“If you want to influence the reality-based view of acupuncture, I have a suggestion for you. Work with the acupuncture community to stop offering treatments where the evidence base is negative.”
EXCELLENT SUGGESTION!
So, straight away your tone leaves no doubt that you are blinded by bias. Calling acupuncture “SCAM”, calling acupuncturists “tyranophiles”, its all very perjoritive and derogatory in tone. Therefore, it cheapens your claim to rely on “the best science”, because “the best science” would speak for itself without you having to introduce a derogatory tone if it really did say what you say it says.
But second of all, and more importantly, you’re plain wrong: the current evidence doesn’t show at all what you’re claiming it to show. All that the current evidence shows is that its entirely inappropriate and foolish to try to measure the efficacy of acupuncture with the tool of the Randomised Clinical Trial. It just doesn’t work, it gives you no valuable results at all.
It is said that to the man with a hammer, every problem looks like a nail, and similarly to sceptics, every medical modality looks like it should be evaluated with the RCT. But that’s simply not true. Its like a medieval preacher getting down and the ground with a ruler and measuring the ground and saying “Ah ha! This proves it! The Earth IS flat just like I said!!” i.e. you’re simply using the wrong tool for the job.
“All that the current evidence shows is that its entirely inappropriate and foolish to try to measure the efficacy of acupuncture with the tool of the Randomised Clinical Trial.”
show it to us, please. perhaps not all but just some of what you consider compelling.
and more importantly: please tell us how, in your opinion, the efficacy of acupuncture should be measured.
So why have you disabled discussion on your BMJ “opinion piece”?
And why have you not declared an interest?
In the above comment, five minutes were not enough for me to correct all typo’s. I beg everyone’s pardon for those that escaped. I also failed to supply the link to the now defunct 2009 NICE guidelines, which contained an elaborate recommendation of acupuncture sessions for lower back pain. A recommendation now totally eliminated and overturned.
Here is a shortened (tested just now) link to an archived PDF version:
http://bit.ly/2hNCXoU
I just saw this comment about MC’s rant:
http://scienceblogs.com/insolence/2017/01/04/an-acupuncturist-attacks-pseudoskeptics-on-wikipedia-hilarity-ensues/
Edzard – the quote you use has nothing to do with tradition, only Mike’s professional experience.
Guy – that’s a pretty silly line of argument. You may equate acupuncture with magic and unicorns, but most sensible practitioners don’t. Mike – who has vastly more experience than you in this field – has made it clear that his perspective is very much non-mystical. Edzard recently called for more respect – your comment displays none.
fine – if you see it that way.
but experience is the name we tend to give to our mistakes!
@Tom Kennedy
As you may have seen above, one of my main criticisms of Dr. Cummings’ argumentation is that he equalises very different therapy modalities in the context of research and evidence.
I.e. he confuses acupuncture with both electrostimulation using embedded needles and with “dry” needling of deep “trigger” points in deep musculoskeletal structures. The former has quite plausible physiological effects by the local and distal effects of an electric current and is hardly distinguishable from using trans-cutaneously conducting electrodes for electro-stimulation. The latter is still rather controversial but has plausible modes of local physiological action by producing minor (hopefully) fresh injuries in affected tissues and thereby causing a local reaction that might stimulate to repair of long standing inflammation. This effect is however only local. Both these modalities are very different from acupuncture i.e. the purported effects and efficacy of shallowly placed thin needles,
As a ‘classical’ (is that the right term?) acupuncturist Tom, what is your opinion?
this is from the website of the BRITISH MEDICAL ACUPUNCTURE SOCIETY for which Mike Cummings serves as ‘medical director’:
What is acupuncture?
Acupuncture treatment involves fine needles being inserted through the skin and briefly left in position. Sometimes manual or low voltage electrical stimulation is applied to assist the process. The number of needles varies but may be only two or three. The practitioner will assess each patient’s case and treatment will be tailored to the individual; so it is impossible to give more than this general idea of what your particular treatment might involve.
@Björn
‘Both these modalities are very different from acupuncture i.e. the purported effects and efficacy of shallowly placed thin needles’.
I’m confused about this definition. Where do you get it from? The Neijing (generally agreed to be the original catalyst for all subsequent styles of acupuncture) discussed needling into various types of tissue at various depths. ‘Dry needling’/trigger point therapy is very similar to ‘ashi’ needling, again a technique that has been used for thousands of years. I’ve attended courses in trigger point acupuncture run by a physiotherapist, and ashi needling run by a classically trained acupuncturist, and there is a striking overlap.
Personally, I’m not too concerned about strictly defining the style of acupuncture I use. I think most modern practitioners use aspects of technique and theory from various traditions, in an attempt to discover what works best for them and their patient population. I use aspects of TCM, classical acupuncture, and trigger point therapy, depending on the situation.
I agree that this kind of pluralism adds to the difficulty of scientific assessment, but that’s the reality of the situation and something researchers (and practitioners/patients/skeptics) have to grapple with.
@Tom
Sorry about a belated response.
Why do you refer to an ancient scripture? Modern acupuncture is what we are discussing here, the versions originating in the last century using filiform needles placed relatively shallow in mystically determined points, usually anatomically unrelated to the pathology being addressed. The Neijing is from a prescientific era when acu-puncture consisted of lancing with rarher crude instruments for imaginary imbalance of humours with no background knowledge of anatomy and physiology. Points were chosen from astrological and philosophical ideas rather than experienc or biological knowledge. I have previously referenced nineteenth century accounts of these barbaric methods in Dugald Christie’s book “Thirty years in Moukden”. (I am writing this on the iPad so you will have to excuse the lack of direct reference this time.)
What is described in the Neijing has no discernible relevance to the subject and from what I have been led to believe, modern translations of this and similar texts may be misleading due to redaction in favour of modern practices.
Tom, your logical fallacy is: begging the question. Sensible practitioners don’t use acupuncture. It’s irrational and the evidence shows it definitely does not work for most things, and is unlikely to work for anything at all. Because, you know, there’s no such thing as qi.
@Guy, whether or not Qi exists as a detectable substance has nothing to do with the question ‘does acupuncture work?’. Mechanism of action and efficacy are separate things.
Hmm… Tom
My first thought is to say you are absolutely right, you certainly are confused – as are your brothers in arms including Dr. Cummings. I mean this respectfully as I hope you understand, but I have to say that what you call pluralism is to me nothing but confusion or even chaos. To propose that this confusion is a valid excuse for shabby scientific evaluation is just sad and deplorable lack of understanding of the scientific approach.
I am not at all the first to observe that the concept of “acupuncture” is generally a diverse jumble of different “styles” and modalities. And yet every practitioner by default maintains that his particular style or school of needling is effective. Someone pointed out that if assembled, the different styles left no point on the body unpunctured except for the male genitalia 😀
If research is to find any sense out of this potpourri of implausible puncturing styles, it has to begin by defining what constitutes the subject of each study. If you do not know yourself what or where the boundaries of “acupuncture” are how are we to design a study to find whether the effect of penetrating a point (that no one can tell why or how was chosen in the first place), can be confirmed? If you on top of that confusion, start widening the definitions of the study subject to include completely different methods like stimulation by electrical current or pushing the needles into musculoskeletal structures for local effect rather than the (purported) distant effects of classical(?) acupuncture… and then propose that the outcome of studies on these modality variants can be interpreted to instantiate acupuncture and even confirm the mystical manuals found in ancient scriptures, the confusion climaxes into total chaos.
As a surgeon with decades of schooling, training and experience, not the least in trauma, I am supposed and required to know what happens when a needle is stuck into flesh. I know about the effects of various mechanisms of injury, the different substances released at injury, their effects and the reparation and healing processes set in motion after injury. This knowledge is well established, uncontroversially based on repeatable scientific observation and measurements. What that knowledge tells me about the plausibility and likelihood for example that needling and/or herb-burning at the pinky-toes can help correct a fetal breech presentation is that it is based on pure fantasy and dangerous nonsense. Yet such nonsense is prevalent practice even by first-world University educated midwives that are supposed to have received an academic education (my own local observations). This kind of reliance on the equivalence of witchcraft is truly frightening.
As an avid enthusiast in the studies of false and fabricated health care methods and means I also know very well why and how the human mind can mistake a natural course (of disease, childbirth etc.) or simple luck for efficacy and mistake fabulation for fact. This is essential if you are to understand why for example Tom Kennedy (yes you 🙂 ) earnestly believes that needle-sticks or even finger pressure on mystically selected points on the extremities can prepare or induce labour, an absolutely improbable and unproven notion, which Tom (yes you) even admits himself in his online marketing. Why on earth you sell such drivel Tom, is beyond my comprehension. Or is it just because there is a demand for it that you cannot for economic reasons refute?
OK, my examples above are some of the more extremely silly claims of “acupuncture” effects. (albeit never as silly as my favourite “acusillypoint”, the ‘Conception vessel one point’ just in front of the anal orifice, useful for among other for such diverse predicaments as constipation, untoward penile tumescence or the resuscitation of the drowning, as described in seemingly serious manuals of acupuncture :D)
The only physiologically plausible use of acupuncture ever was that for pain relief. This hope has been practically eliminated by proper scientific trials. For all practical purposes, multiple, adequately designed studies of such effects, e.g. the German GERAC studies of acupuncture for lower back pain, have shown beyond reasonable doubt that there is no detectable difference between make-believe acupuncture (sham) and real acupuncture. Jumping through hoops and tying knots on the data to make other inferences from such studies is simply not valid as I have tried to explain before. Such misinterpretation is usually based on the same appeal to confusion that you (Tom) call pluralism.
Well, I could go on rambling at length here but it is past bedtime and I’ll have to let go now.
But first I wish to yet again remind the audience… I am actually biased in favour of acupuncture, believe it or not. I have a vested interest in anything that can improve and aid the well being of our patients,not the least pain and nausea control. Anyone accusing me of bias against acupuncture or any other possible utilities to that end are severely mistaken. Anyone calling me a pseudosceptic is simply out fishing for a searing satirical retort to such an insolent accusation.
Have a good night.
@Bjorn
‘As a surgeon with decades of schooling, training and experience, not the least in trauma…’ – careful, ‘appeals to authority do not go down too well here’! Although your articulate posts and CV are most impressive, I find it very hard to understand the certainty with which you seem to observe the world. As I’ve probably said here before, I simply don’t think any of us can be certain our opinions are correct, or that our experiences can be trusted. To paraphrase a quote from Marcus Aurelius – the universe is in a constant state of transformation: life is nothing more than opinion. The scientific method is an admirable attempt to make sense of the world, but the frequency with which scientific ‘fact’ is overturned and re-written demonstrates that it is far from infallible. Even the orthodox and reputable world of surgery may not be as solid as it seems. Isn’t the value of specific surgical techniques limited by the relative lack of placebo controls? Haven’t several surgical techniques previously assumed to be effective been shown in recent years to be no more effective than placebo? (https://www.painscience.com/biblio/fascinating-landmark-study-of-placebo-surgery-for-knee-osteoarthritis.html). I would have thought these findings would encourage a little more humility.
As for the plurality of acupuncture, I do not imply that ‘this confusion is a valid excuse for shabby scientific evaluation’. I simply mean to highlight that the field of acupuncture research is mind-bogglingly complex and problematic, and any suggestion that acupuncture (in all its various guises) is sufficiently understood, or proven to be ineffective, is in my view preposterous – we’re just scratching the surface. Just to pluck one fascinating area of investigation out of the pot, some fMRI studies suggest acupoint-specific CNS modulation at distal locations.
On the implication that I do what I do ‘for economic reasons’, whilst of course I try to make a living and help provide for my family, I made a conscious choice to leave a much more lucrative career in favour of acupuncture. 10 years since making that choice, I still earn much less than I did before, but the satisfaction of regularly seeing the well-being of my patients improve makes up for the financial shortfall. And I always strive to present what I do with the utmost honesty.
And whilst I understand why it might drive those of a certain mindset mad, I have also learned to enjoy the challenges and learning opportunities presented by the pluralism/’chaos’ of the field.
Tom,
Of course CNS modulation can, and does, occur at distal locations: “acupoint-specific” is a red herring; as would be “reflexology-specific”. If you think that this is not a red herring then you need to provide robust evidence that acupuncture is more efficacious than reflexology, homeopathy, chiropractic, etc. for the same set of illnesses.
nihilism [philosophy]: the belief that nothing in the world has a real existence.
This is what fuels quantum flapdoodle, such as: Each observer creates their own reality due to them having collapsed the wave function of infinite possibilities.
I’m very sure that it is, and it will remain, “mind-bogglingly complex and problematic” to everyone who abjectly refuses to accept the very simple hypothesis that acupuncture, reflexology, homeopathy… might just be nothing other than theatrical placebos.
I can’t imagine how mind-bogglingly complex, shameful, and problematic it must be for those who’ve discovered that they’ve dedicated themselves to a life of folly; then rather than admit their folly, they decide to cling tightly to their sinking ship and to lash out at not just each and every potential rescuer, but also lash out at science and its methods. E.g.
The frequency with which the alt-med empire overturns its ‘facts’ is very close to, if not, zero. Why? Not because its ‘facts’ are correct, but because it has no mechanism to change its multi-branded, business-model-driven, dogma.
Alt-med is, at best, pseudoscience; most of it is outright anti-science — as you have so clearly demonstrated.
@Pete if you read my post and felt I was ‘lashing out’ at anything, well, you’ve led a sheltered life!
‘I’m very sure that it is, and it will remain, “mind-bogglingly complex and problematic” to everyone who abjectly refuses to accept the very simple hypothesis that acupuncture, reflexology, homeopathy… might just be nothing other than theatrical placebos.’
This statement is telling. Firstly, why should I or anyone else be expected to accept a hypothesis, as you correctly describe it? A hypothesis isn’t a fact, it’s a ‘proposed explanation made on the basis of limited evidence as a starting point for further investigation’. Secondly, why do you feel the need to lump all ‘alt med’ together as if it were a single, malevolent entity? This is simplistic at best, and certainly not scientific.
Because alt-med is, by definition, that which has failed to refute its null hypothesis: the default hypothesis for all evidence- and/or science-based claims.
Alt-med that has successfully refuted its null hypothesis is called medicine.
Please stop cherry-picking my detailed comment.
Minchin’s Law: by definition, alternative medicine either has not been proved to work, or has been proved not to work. The name for alternative medicine test gas been proved to work is: medicine.
Alternative mecicine is indeed a heterogeneous group of refuted or unproven practices, but the category us valid because they all share one critical defining feature: they have failed to pass the bar of science. Nobody disputes that giving meaningful doses of pharmacologically active substances can have objective effects on the body. It is legitimate therefore to judge pharmaceuticals on clinical evidence. Acupuncture is based on a philosophy which is completely unsupported by objective evidence. There is no evidence qi exists, no evidence for the existence of meridians or acupoints, no consistent definition of where these lie or what they do, and no soup porting anatomy.
In an attempt to reverse engineer support for their beliefs, some have suborder electrostimulation and other reality-based concepts, but matching these to the dogmas of acupuncture is classic pseudoscience, working back from a conclusion. If dry needling a nerve ganglion has some effect, no acupuncturist has shown why this might offer generalisable support for the many purported acupoints that to not lie on ganglia. It’s like the medical equivalent of astrology: all hits, however ambiguous, validate the entire belief system, all misses are waved away.
@Tom:
Lumping alt-med together is as legitimate as lumping all science together. Which is to say: perfectly legitimate when discussing an approach to knowledge, less so when discussing the body of knowledge yielded by that approach.
Alt med, by definition, is not evidence based. The defining characteristic of alt med is that the base premise is never up for negotiation. Virtually all alt-med studies start by stating the beliefs of practitioners *as fact*, often based on fallacious reasoning. Acupuncture is not the worst offender (that would probably be homeopathy) but a very high proportion of acupuncture studies start with statements like:
Even statements such as “We conducted this systematic review and meta-analysis to evaluate the effectiveness of acupuncture for improving learning and memory in animal experiments” (https://www.ncbi.nlm.nih.gov/pubmed/27543143) are effectively begging the question. Not: Is this true? but, How true is this?
SCAM is based on the pseudoscientific method. It has to be, because it is based on quasi-religious convictions which must be protected against refutation. The best example of this is the hilarious “Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials” (https://www.ncbi.nlm.nih.gov/pubmed/19250001).
Hint: if your intervention is indistinguishable from a properly designed placebo, then your intervention does not work. The trypanophile community spun this as validating acupuncture. Look! Even fake acupuncture works! It’s amazingly powerful! No reality-based treatment would get that kind of special pleading in the literature (at least I hope not, though in psychology it’s arguable that it might).
And isn’t is strange that the CNS is supposedly linked to different distal locations in Chinese versus Japanese versus Korean members of, as far as I can tell, exactly the same species.
Of course if acupuncture was a *science*, this would not be the case. All traditions would have converged on a common set of acupoints based on repeatable experiment. There are no cardiologists of any nation who think the heart is in the abdomen.
“To summarize acupuncture, a topic discussed at length in this blog, its basic principles, those of meridians and chi, are fictional. I tried to find a meridian map of turtles and failed. I found a pig, a cat, a dog, a cow and a horse diagram, but no turtle. Not that it matters, since the meridians are fantasy. The horse, which has no gallbladder, does have a gallbladder meridian, although it conveniently has nothing to do with the gallbladder:
Although the horse does not have a gall bladder organ as such, the meridian is the same as in the human, and it has a lot to do with the integrity of ligaments especially in the hips and pelvis.
” — Mark Crislip, People Encouraging Turtle Agony*: Animal Acupuncture
https://sciencebasedmedicine.org/people-encouraging-turtle-agony/
I would be encouraged if I saw a slew of “responsible” acupuncturists queuing up to condemn the blatant acufruit-loopery that infests the Crislip blogpost cited by @pete. From what I have seen so far, I am not encouraged. At all.
@Tom
I am not sure if ‘appeal to authority’ needs to be seen as a logical fallacy when you are appealing to your own authority for a good reason i.e. trying to explain why you do and should know something better than most people outside my field of learning.
I am only trying to establish the ground for my part in this discussion and clarify why I have changed my mind so completely about acupuncture.
I am also trying to get people to talk about the same thing here, not compare apples with oranges when evaluating and analysing research.
Your appeal to some kind of plurality of the reality we live in is like appealing to fairy tale. There is only one palpable and demonstrable reality and we know that reality rather well. This knowledge has brought mankind forward to unprecedented lengths of technology and medicine… Trying to point at particle physicists and say that quantum- something or other shows the existence of such plurality or instability of existence, has been thoroughly debunked by said experts.
Anyone who comes with tales of alternative reality (-ies?) and tries to sell health-care products or services marketed with appeals to such an alternative reality will have to face the same level of criticism and questioning as anyone trying to market clippings from ‘The Terrible Snowman’s’ beard with promises of genuine origin. Before we can say it works, it has to be either corroborated by undoubted existence of The Terrible Snowman that no doubt needs to be about its validity or proper scientific methodology prove that its existence is unlikely and the alternative hypothesis, that it does not exist should be accepted.
I made an example of how you are marketing services for pregnant women, unproven and very[sic] unlikely to have any useful effects. I seriously question their efficacy and even effectiveness and so do you in a half-hearted manner on your webpage, yet you do not take the consequences and stop offering them. Why not?
Arguing that medicine (the real one) has its shortcomings is a dead argument. It can in no way instantiate claims of efficacy in alternative medicine. You should know by now that this is a dud and your example only demonstrates how progress is made in medicine and surgery, albeit slower than we would like.
The same kind of progress has not happened since acupuncture was invented during the cultural revolution. No form, style, modality or variation of acupuncture has ever been actively abandoned by the acupuncturist community as being useless. Instead, new variations on the theme are constantly being invented by people who immediately start marketing them as efficacious. Endless, more or less foolish attempts at proving its effectiveness are made and over interpreted by the aficionados themselves as we have discussed at length.
We have already shown and discussed how fMRI is easily misused and why these studies are invalid.
I did not imply dishonesty or that you are doing something solely for economic gain. I asked why you continue to sell a product that you yourself openly declare unproven and was really hoping the answer was not because it is lucrative business. There must be other reasons why you do not take the combination of low plausibility and lack of evidence and stop offering the product even if popular media marketing has misled the customer base and created a demand for such theatricals?
I am still trying to figure out why people like you, who seem intelligent and honest, fall for fantasy-based fallacies and refuse to leave them when confronted with evidence of their futility. You seem to be struggling with keeping your finger hold on the narrow sill of hope that future development will prove your beliefs to be based on reality.
I have a feeling you would feel much better if you got up the courage to take a time-out and consider getting out of the rat-wheel of cognitive dissonance between demonstrable reality and the mumbo-jumbo world of Qi and other imaginary explanations of why the unlikely theatricals called acupuncture often seem to work.
@Tom
Acupuncture research only seems “mind-bogglingly complex and problematic” because no two acupuncturists use exactly the same methodology. Because of your confirmation bias you see this as complexity: the rest of us see it as one of the reasons why the prior probability of acupuncture is so low. Where, precisely, are the hundreds of acupuncture points located? How, precisely, do you measure chakras, yin and yang?
I bet if I visited three acupuncturists with the same complaint I’d come away with three different diagnoses in terms of exactly where the needles need to be placed and the fine detail of my yin and yang. Yep, that’s mind boggling, all right: mind-boggling that reasonable folk can pay any heed at all to such nonsense.
I guess Tom will argue ‘no true acupuncturist’ as a parallel to the ‘no true Scotsman’ fallacy.
Dr Cummings admission that for all his experience, he produces outcomes no better than his students is to be applauded.
(Cummings M, this blog, 04.01.17 at 11:01)
“I don’t think it is about skill. I have developed my needling skills to the point that there are few skeletal muscles that I cannot reach safely, but my results do not seem to be better than my most junior students.”
Apologies if my comment can be taken as ‘ad hominem’, but what are to make of this discourse if all we have is a ‘homo’ and his beliefs. i.e. – if the man and his mind set is the problem?
I know of no plausible evidence that meridians or puncture points exist (any more than unicorns) – whether bizarrely labelled as K17, SP6 or any other combination of letters and numbers.
This modality of treatment is styled ‘acupuncture’ from using the Latin word for needle: ‘acus’.
Might have been better if the Greek word had been used – ‘belone’.
@pete @guy you paint a black and white picture where all ‘alt med’ is worthless and has no evidence in its favour, and where ‘real medicine’ is all proven to be effective. In reality things are nowhere near as simple, as you surely must know. Many conventional medical treatments are ‘unproven’ if you apply the same standards you require of CAM (yes, yes, ‘extraordinary claims’ etc.). In turn, many studies conclude that acupuncture outperforms conventional medicine for various conditions (low back pain and migraine for example). Of course you’ll disagree that the data supports these claims, but many members of the scientific community see it this way, and not all are ‘acupuncture fans’. These results, coupled with the interesting work going on in fMRI/the study of fascia etc. should make acupuncture an area of great interest to anyone with a genuine interest in the wellbeing of patients, as opposed to those who have closed their minds to it because they find it implausible.
Curiously, I can’t find this assertion anywhere. Assuming it was not merely a disingenuous pretence made for rhetorical purposes, please could you point me to it, as I would like to take issue with it. Thanks in advance.
If there are indeed “many”, you should have no trouble with citing one (yes, just one) replicated robust-quality double-blinded trial that substantiates your claim. Until then, Hitchens’s Razor applies.
I would also be interested to know if you can cite one (again, yes, just one) replicated robust-quality double-blinded trial that demonstrates that acupuncture is distinguishable from sham-acupuncture.
I do hope Tom Kennedy is not going to engage in the classic SCAM tactic of saying that because some studies support X, therefore X is valid even though systematic review shows that it is not.
That is the exact opposite of what I said.
Again: Minchin’s Law: alternative medicine, by definition, either hasn’t been proven to work or has been proven not to work. So alternative medicine includes a mix of therapies ranging form the implausible and disproven (e.g. homeopathy), to the plausible but unproven (e.g. some fad diets).
Proof is an unambiguous body of evidence. Lack of proof doesn’t mean lack of any evidence, it just means the evidence is insufficient to prove the claims.
And yes, it really is simple: if you make therapeutic claims based on tradition or belief, in the absence of plausible mechanistic explanations, even if those are backed by some clinical evidence, then it’s alternative. It’s only not alternative if there is robust objective evidence with large effect sizes and no significant contradictory findings.
Of course there are problems with reality-based medicine as well. There is a crucial difference: when a reality-based intervention is shown not to work, it is unceremoniously discarded. Drotrecogin alfa for example.
It’s important to understand the difference between individual drug treatments and whole medical systems. It is hard to think of an example of a drug which is the only one to use a particular mechanism of action, in the case of something like acupuncture, which is normally promoted for pain management, the equivalent would be a class of drugs, say NSAIDs. NSAIDs have a known mechanism of action but are increasingly deprecated for many of the usual suspects (e.g. long-term nonspecific low back pain) because in the end there is no good evidence that they do much beyond placebo. Nothing does, frankly. The human back is an engineering disaster.
The most important difference between reality-based medicine and alternative medicine is that the reality-based medical community has no emotional investment in any specific treatment, so is not threatened by an open investigation of its efficacy. The alt-med community, by contrast, has an extremely high bar to acceptance of disconfirming evidence, and rarely, if ever, drops any practice that is making them money. Sometimes there will be schism within a community, as between “straight” and “mixer” chiropractors, but even within the divided community there is still no commitment to evidence based practice, because that would mean being genuinely open to the possibility that your entire belief system, training and commercial practice is based on error. That’s just human nature.
How many acupuncturists have stopped treating chronic low back pain following the NICE review? Any at all? I can point you to dozens of clinics offering acupuncture for conditions such as asthma, stroke rehabilitation, insomina and the like, where the best evidence shows it simply does not work.
So: my personal definition of alternative medicine is any system of treatment that has no objective mechanism of self-correction.
in fact, it is hard to find a website of an acupuncture clinic that does NOT make bogus claims.
Minchin and Hitchens good; Feynman best.
How easy it is to fail Feynman’s rule.
How difficult it is, having failed, to admit it to oneself, and even more to the world.