MD, PhD, FMedSci, FSB, FRCP, FRCPEd

The ACUPUNCTURE NOW FOUNDATION (ANF) has featured on this blog before. Today I want to re-introduce them because I just came across one of their articles which I found remarkable. In it, they define what many of us have often wondered about: the most important myth about acupuncture.

Is it acupuncture’s current popularity, its long history, its mode of action, its efficacy, its safety?

No, here is the answer directly from the ANF:

The most important myth that needs to be put to rest is the idea promoted by a small group of vocal critics that acupuncture is nothing more than a placebo. Many cite the fact that studies showing acupuncture to be highly effective were of low quality and that several higher quality studies show that, while acupuncture was clinically effective, it usually does not outperform “sham” acupuncture. But those studies are dominated by the first quality issue cited above; studies with higher methodological rigor where the “real” acupuncture was so poorly done as to not be a legitimate comparison. Yet despite the tendency toward poor quality acupuncture in studies with higher methodological standards, a benchmark study was done that showed “real” acupuncture clearly outperforming “sham” acupuncture in four different chronic pain conditions.3 When you add this study together with the fact veterinary acupuncture is used successfully in many different animals, the idea of acupuncture only being placebo must now be considered finally disproven. This is further supported by studies which show that the underlying physiological pathways activated by acupuncture sometimes overlap, but can be clearly differentiated from, those activated by placebo responses.

Disappointed?

Yes, I was too.

The myth, according to the ANF, essentially is that sceptics do not understand the scientific evidence. And these blinkered sceptics even go as far as ignoring the findings from what the ANF consider to be a ‘benchmark study’! Ghosh, that’s nasty of them!!!

But, no – the benchmark study (actually, it was not a ‘study’ but a meta-analysis of studies) has been discussed fully on this blog (and in many other places too). Here is what I wrote in 2012 when it was first published:

An international team of acupuncture trialists published a meta-analysed of individual patient data to determine the analgesic effect of acupuncture compared to sham or non-acupuncture control for the following 4 chronic pain conditions: back and neck pain, osteoarthritis, headache, and shoulder pain. Data from 29 RCTs, with an impressive total of 17 922 patients, were included.

The results of this new evaluation suggest that acupuncture is superior to both sham and no-acupuncture controls for each of these conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than those of sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs.

Based on these findings, the authors reached the conclusion that “acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture”.

… even the enthusiastic authors of this article admit that, when compared to sham, the effect size of real acupuncture is too small to be clinically relevant. Therefore one might argue that this meta-analysis confirms what critics have suggested all along: acupuncture is not a useful treatment for clinical routine.

Unsurprisingly, the authors of the meta-analysis do their very best to play down this aspect. They reason that, for clinical routine, the comparison between acupuncture and non-acupuncture controls is more relevant than the one between acupuncture and sham. But this comparison, of course, includes placebo- and other non-specific effects masquerading as effects of acupuncture – and with this little trick (which, by the way is very popular in alternative medicine), we can, of course, show that even sugar pills are effective.

I do not doubt that context effects are important in patient care; yet I do doubt that we need a placebo treatment for generating such benefit in our patients. If we administer treatments which are effective beyond placebo with kindness, time, compassion and empathy, our patients will benefit from both specific and non-specific effects. In other words, purely generating non-specific effects with acupuncture is far from optimal and certainly not in the interest of our patients. In my view, it cannot be regarded as not good medicine, and the authors’ conclusion referring to a “reasonable referral option” is more than a little surprising in my view.

Acupuncture-fans might argue that, at the very minimum, the new meta-analysis does demonstrate acupuncture to be statistically significantly better than a placebo. Yet I am not convinced that this notion holds water: the small residual effect-size in the comparison of acupuncture with sham might not be the result of a specific effect of acupuncture; it could be (and most likely is) due to residual bias in the analysed studies.

The meta-analysis is strongly driven by the large German trials which, for good reasons, were heavily and frequently criticised when first published. One of the most important potential drawbacks was that many participating patients were almost certainly de-blinded through the significant media coverage of the study while it was being conducted. Moreover, in none of these trials was the therapist blinded (the often-voiced notion that therapist-blinding is impossible is demonstrably false). Thus it is likely that patient-unblinding and the absence of therapist-blinding importantly influenced the clinical outcome of these trials thus generating false positive findings. As the German studies constitute by far the largest volume of patients in the meta-analysis, any of their flaws would strongly impact on the overall result of the meta-analysis.

So, has this new meta-analysis finally solved the decades-old question about the effectiveness of acupuncture? It might not have solved it, but we have certainly moved closer to a solution, particularly if we employ our faculties of critical thinking. In my view, this meta-analysis is the most compelling evidence yet to demonstrate the ineffectiveness of acupuncture for chronic pain.

END OF QUOTE

The ANF-text then goes from bad to worse. First they cite the evidence from veterinary acupuncture as further proof of the efficacy of their therapy. Well, the only systematic review in this are is, I think, by my team; and it concluded that there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals. Some encouraging data do exist that warrant further investigation in independent rigorous trials.

Lastly, the ANF mentions acupuncture’s mode of action which they seem to understand clearly and fully. Congratulations ANF! In this case, you are much better than the many experts in basic science or neurology who almost unanimously view these ‘explanations’ of how acupuncture might work as highly adventurous hypotheses or speculations.

So, what IS the most important myth about acupuncture? I am not sure and – unlike the ANF – I do not feel that I can speak for the rest of the world, but one of the biggest myths FOR ME is how acupuncture fans constantly manage to mislead the public.

5 Responses to The most important myth about acupuncture

  • You’ve made a basic mistake, acupuncture can’t be therapist-blinding,
    As it’s not a drug. Can you do therapist-blinding for surgery or Physiotherapy? You are misleading people!
    Another mistake you’ve made is you think you are clever by saying “meta-analysis” is not study. Yes you are right, but if the studies are poor how can you get a good meta-analysis? Is it the best evidence? Of course no, how dare you say that! You have nothing but other people’s meta-analysis, you know nothing but meta-analysis, but sorry, you should feel hopeless because it’s like traveling, you’ve read all the comments, looked all the pictures, watched all the videos about your dream beach, but you just have never been there. You know nothing about real acupuncture. Real word is more interesting than your dream, please wake up!

    • stop foaming from the mouth, read my post again, and then quote exactly the passages where I have made mistakes [because I don’t think I did].

    • Ye Tian: You’ve made a basic mistake, acupuncture can’t be therapist-blinding

      .
      I’m afraid the mistake is yours, Ye Tian. For a double-blind surgical study, you only need to blind the patient and the evaluator, leaving the practitioner out of the loop. Quickly, you can read about one of the more famous examples of this sort of double-blinding in: An Evaluation of Internal-Mammary-Artery Ligation by a Double-Blind Technic. You might also check the WIKI article: Sham Surgery.

      As for studying TCM — acupuncture and the TCM herbal pharmacopeia, that is — I leave the blinding design to you. The major headache I see in this regard isn’t the double-blinding. That’s the easiest part. Rather, it’s translating between TCM diagnoses such as PHLEGM Misting the Orifices of the HEART as mental illness and LIVER QI Stagnation, DAMP Accumulation, and BLOOD Stagnation and a western diagnosis of glaucoma, for example. In bioscientific medicine, PHLEGM isn’t the phlegm we cough-up and HEART isn’t the heart that pumps blood. Moreover, BLOOD isn’t the blood that circulates in the circulatory system. Subjective “quantifications” of QI and JING are TCM medical concepts that are only useful within the mythological and unmeasurable physiology of TCM. So, the effectiveness of any given constellation of needles inserted to affect a given diagnosis or an herbal concoction brewed for a particular patient complaint can’t be evaluated even with triple blinding until the basic elements (QI, BLOOD, JING, SHEN, YIN, YANG, DAMP, ETC) can be measured and their unique and interesting interactions and “physiology” be reproduced.

      Take the treatment for LIVER YANG Rising. What’s a LIVER in TCM? Where’s it located and what does it do? Why are there two LIVER Channels that run inside and outside of the body and why does the TCM LIVER exit in the eye? What’s YANG and how do you know there’s too much of it, too little of it, or whether it’s “rising” or “descending?” What’s a SPLEEN in TCM and is it really an organ of Digestion as a TCM practitioner understands it and learned? Does a diagnosis of Reversal of SPLEEN QI neatly translate to a patient complaint of nausea? Really?

      Like I said, blinding is easy once you are able to define and measure what you’re studying. Without doing this in TCM, you’d just be talking to yourself with each and every experiment.

      Ye Tian: You have nothing but other people’s meta-analysis, you know nothing but meta-analysis, but sorry, you should feel hopeless because it’s like traveling, you’ve read all the comments, looked all the pictures, watched all the videos about your dream beach, but you just have never been there. You know nothing about real acupuncture.

      I agree that learning any given Alt-Med like “chiropractic,” TCM, and homeopathy (the Father, Son, and Holy Ghost of Alt-Med) is a lot like visiting another country. They all have their own language, customs, and beliefs. I’ve often used this analogy myself, but never to rationalize a medical fiction or protect my Alt-Medical nuts. Rather, I’ve invoked this “visitor to a strange planet” analogy in an attempt to penetrate more vertically what makes a quack, “quack” and to give insight into how the Alt-Medical trick is done.

      But since you’ve used this “You can’t know TCM without visiting TCMland,” it sounds like you may not have visited Science Country yet. I recommend you get yourself a passport as soon as possible so that you can begin to see through your own empty arguments. Science really can help. And, it’s portable from “country” to “country,” too 🙂

      ~TEO.

  • ‘Yet despite the tendency toward poor quality acupuncture in studies with higher methodological standards’

    Sad that good scientists routinely can’t recruit proper sCAM practitioners. Same with homeopaths, they always get the incompetent ones. Why!!!

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