This double-blind RCT aimed to test the efficacy of self-administered acupressure for pain and physical function in adults with knee osteoarthritis (KOA).
150 patients with symptomatic KOA participated and were randomized to
- verum acupressure,
- sham acupressure,
- or usual care.
Verum and sham, but not usual care, participants were taught to self-apply acupressure once daily, five days/week for eight weeks. Assessments were collected at baseline, 4 and 8 weeks. The numeric rating scale (NRS) for pain was administered during weekly phone calls. Outcomes included the WOMAC pain subscale (primary), the NRS and physical function measures (secondary). Linear mixed regression was conducted to test between group differences in mean changes from baseline for the outcomes at eight weeks.
Compared with usual care, both verum and sham participants experienced significant improvements in WOMAC pain, NRS pain and WOMAC function at 8 weeks. There were no significant differences between verum and sham acupressure groups in any of the outcomes.
The authors concluded that self-administered acupressure is superior to usual care in pain and physical function improvement for older people with KOA. The reason for the benefits is unclear and placebo effects may have played a role.
Another very odd conclusion!
The authors’ stated aim was to TEST THE EFFICACY OF ACUPRESSURE. To achieve this aim, they rightly compared it to a placebo (sham) intervention. This comparison did not show any differences between the two. Ergo, the only correct conclusion is that acupressure is a placebo.
I know, the authors (sort of) try to say this in their conclusions: placebo effects may have played a role. But surely, this is more than a little confusing. Placebo effects were quite evidently the sole cause of the observed outcomes. Is it ethical to confuse the public in this way, I wonder.
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This non-author concludes that people with osteoarthritis enjoy touching themselves 🙂
The reason for the benefits could not be more clear.
I don’t need to spell it out.
The authors apparently couldn’t spit it out without choking on the word.
The unspeakable “P” word!
Yet another study where placebo outperforms usual care. What’s going on with “usual care”?
I think the reason is simple: the experimental treatments that are being compared to conventional care are perceived as exotic and hopeful by patients. this raises expectations to which subjective outcomes easily respond, particularly in short-term.
Together with the nocebo effect of being randomised to what was hardly better than placebo itself when tested. What once got the placebo bump, now gets the nocebo hump.
Thanks. I never would have thought that some basic massage to a painful part of the body would be considered ‘exotic’. Who knew?
Next episode:
Sham treatment vs. Usual care + icecream buffet.
It’s clear that sham and verum have no differences in this trial. But a patient or even a alternative therapy proponent might pointed out that if verum/sham acupressure was better than the usual care, why not use them? or even, what would happen with we combine both?
Many evidence-based researchers argue that we should compare medications to be approved with the usual care, instead of a placebo. So, I think that question above deserves a proper response.
I did a look in the paper. The authors say “In this double-blind RCT, we found that participants performing Verum acupressure experienced significantly more improvement in pain and physical function than UC participants after 8 weeks of treatment”. Then they note there was no statistical difference. I wouldn’t write in that way. It looks like they want to tell a story that acupressure worked.
by combine both, I meant to combine acupressure (sham or verum) with usual care
We could add sham and useless practices to the usual care, but perhaps a better approach is to have better nursing (with science-based practices) in the first place, instead of dispersing resources in order to accommodate the preferred sham practitioners of the day and pay them full price.
I mean, if all they are doing is rubbing people’s knees, you can settle for an apprentice wizard rather than hiring Gandalf, right? 🙂
There are other reasons related to the quality and timeliness of care. “What’s the harm” is a good search term if you visit the Respectful Insolence blog to read about this subject.
As with anything, how can something last for a couple of thousands of years if it did not work. It would be long gone from history. But no Acupressure has stood the test of time and once again only to be copied by the west as in trigger point therapy.
blood-letting lasted even longer and in more cultures
Hey blood letting was a mainstream practice of early contemporary Western Medicine along with giving patients high amounts of mercury. I would have thought you would have already known that. Check your facts before you weild your pen Edzard
I merely said it was used for millennia
the claim about which ‘camp’ it belonged to is irrelevant
anyway there was only one medicine then
Check your facts before you weild your pen !!!
It doesn’t say much for the editorial board of this journal that the authors were able to get away with such a disingenuous conclusion. This style of presentation is quite common in acupuncture papers, when the authors seem to almost claim the placebo arm as acupuncture anyway. Very strange, like a drug company marketing their latest product on the basis it was as effective as a sugar tablet.
I had a look at this paper, and I find it quite bizarre. For anyone with some knowledge of acupuncture/acupressure, the points used in the ‘real’ acupressure group were: Anmian, HE-7, SP-6, LIV-3, and Yintang. The explanation given for the first 4 is that they were previously shown to offer pain relief in breast cancer survivors, and that they ‘reduced fatigue and sleep disturbance, common comorbidities in patients with OA and pain’. No explanation given for Yintang. Indeed, these points seem much more obvious for insomnia (if you were forced into using a ‘protocol’ without individualisation).
The ‘sham’ points included 3 points apparently on the Stomach and Bladder sinew channels, which would be areas I’d certainly want to consider for treatment in knee pain. So not only is the ‘placebo’ arm of this trial clearly not inert, it’s arguably a more specific set of points than the ‘real’ ones! In a clinical setting, points are chosen (whether for acupuncture or acupressure) based on individual presentation, and would almost certainly include points around the site of pain itself. The results are what I would expect with such an approach, and an example of one of the common problems with acupuncture/acupressure studies – the people designing them don’t know what they’re doing!
Oh gawd! There’s now no true acupuncturist, as well!
Tom, you criticise the legitimacy of points selected and question whether sham was really sham, in this trial.
If you ever choose to show how it should be done and undertake your own trial employing what you consider to be true acu-puncture/pressure against legitimate sham, please don’t do as the authors of this trial did.
If you decide to test true A-P against the null hypothesis (against placebo) and duly obtain a null result, don’t equivocate.
Just state the simple truth: true A-P was found to be no more effective than placebo.
@ Frank & Leigh
Did you do a google search for acupressure for knee pain/OA knee pain? Even if you know nothing about Chinese medicine…a quick search will leave you wondering about point choices used for the study. You would come to the same conclusion that Tom did.
@jm
Thanks for the suggestion. I googled “acupressure for knee pain” and the results provided me so much hilarity I now need to google “acupressure for splitting side pain”. Particularly valuable finds were a set of YouTube videos that belong somewhere on Comedy Central, and the discovery that I don’t need to use acupressure to relieve knee pain: I can get the same results by kneading my hands and feet with the reflexology approach.
A serious question: do any of you supporters of various alternative medical ‘systems’ actually know and understand the first thing about the way the body really works?
Frank
Was it funnier than doing a knee pain study using points for pain relief in breast cancer survivors, sinew channel points as the sham, and having them both outperform usual care? I’ll see if I still have the link for “acupressure for splitting side pain” – had to look them up after Tom mentioned the points used for the study.
My reply to Tom’s reply to me will suffice.
Do you honestly think that they want there bogus tests to work. Do you think that if they find a natural, healthy, low cost, clean alternative to the toxic, high cost, highly profitable medicines that it will ever see the light of day?
I see!
your “natural, healthy, low cost, clean alternative” therapy does nothing for your paranoia
What can modern medicine offer than isn’t toxic and comes with pages and pages of side effects. Maybe you should read those little leaflets that come with those pills or read those waivers that you sign.
Where is the logic in “we will fix this problem but in so doing we may create a secondary problem” or in order to get better you may get sicker first. Apply common sense to this equation and what do you get.
maybe you should try to understand some of the basics before you utter more nonsense: the value of a therapy cannot be estimated either by its efficacy nor its safety but by the balance of the two, the risk/benefit balance.
TOO DIFFICULT FOR YOU?
If a therapy works for millions of people over thousands of years then who are you to insult there innate intelligence and say “oh no it doesn’t.” Oh that’s right empirical evidence, people’s accounts and personal testimonials don’t count for anything in the world of science.
I cannot insult your intelligence because you seem to have none: experience is not evidence http://edzardernst.com/2012/11/what-is-and-what-isnt-clinical-evidence-and-why-is-the-distinction-important/
“What can modern medicine offer than isn’t toxic and comes with pages and pages of side effects.” Those pages and pages come from ‘post marketing surveillance’ The major side effects of any drug emerge during the first clinical trials. If they’re very serious, then the drug will be used only in cases where the benefits greatly outweigh the side effects. For the rest, candidly, the ‘rare’ side effects, which take up pages on package inserts, are comparable to homeopathic ‘provings’: highly subjective sensations that are more probably attributable to psychology than to the drug.
You should look up any placebo-controlled clinical trial of any drug and see the remarkable list of side effects recorded in the placebo arm!
“Those pages and pages come from ‘post marketing surveillance’…” I would add that such PMS does not exist for alt med, if it did, the list of side-effects might be just as long!!!
What world do you live in where synthetic drugs made by the petrochemical industry produce side effects because the body clearly rejects them is considered normal. A world where nearly everyone is on them because no doctor or scientist has a clue about real medicine anymore and it’s easier to write a script than actually attend to the real issues of the patient. With most ailments stemming from diet or lifestyle how can these problems be fixed by a pill. Oh that’s right they can’t but take the pill anyway and let’s see what happens. Mass delusion that’s what that is. To justify it as the norm makes crazy crazier. But when your income is connected to such beliefs it’s understandable why people think that way.
” But when your income is connected to such beliefs it’s understandable why people think that way.”
whose income?
you make all sorts of vague claims and platitudes.
try to be a little less meaningless, please.
“If they’re very serious, then the drug will be used only in cases where the benefits greatly outweigh the side effects.”
Good one, Frank. If only…
It is deeply regrettable and shameful that you and other commenters like you reserve that sort of cynicism and precaution for the “big pharma” while giving a free pass to “big supplement”, which is the true money-making, hypochondria-exploiting, paranoia & fake-news-peddling branch of alt.med.
@the vodka diet guru
You can have your pharma synthetic petrochemical tar based pills and formulas. I’ll stick to my whole food based phytochemical, vitamin, mineral, enzyme enriched formulas no problems at all.
The whole basis of your argument is built on the premise that man made is better than nature made…
If you think that Artificial is better than the real deal… You are a fool
“man made is better than nature made… ”
nobody here said this!!!
you are fantasising again – what most of us here think is: GOOD EVIDENCE IS A PRECONDITION FOR ROUTINE HEALTHCARE.
@swellen just be careful with choosing your suppliers… “natural product” suppliers are not regulated like pharma is, so they add random things to their products and then claim that the industry can self-regulate just fine…
https://www.nature.com/articles/srep17475
“So not only is the ‘placebo’ arm of this trial clearly not inert”
That’s one big claim right there.
@The Vodka Diet Guru: Are you suggesting manipulation of the skin and underlying tissue has no physiological effect? It takes very little effort to research that for yourself.
@Leigh Jackson: If I did as you suggest, I fear the results would be dismissed as ‘at risk of bias’ because I’m an acupuncturist.
@Frank sorry, no idea what you mean.
Help me out then. The research may be abundant, but as the original post illustrates.. can be poor. Please point me in the right direction to the good quality research that supports your claim that those specific points in the body are clearly not inert.
Thanks.
@vodka I’m talking about the generalised effects of massage, not those of specific points. You could start here for example: https://scholar.google.co.uk/scholar?q=physiological+effects+of+massage&hl=en&as_sdt=0&as_vis=1&oi=scholart&sa=X&ved=0ahUKEwjJ982j4t3TAhVK5xoKHVInAewQgQMIGjAA
The point being, massage is not an inert placebo, and will therefore skew the results in studies like this.
Well if the goalposts keep moving, no evidence will ever suffice, and no research will ever be worth doing.
See why Dr Ernst’s (and other experts) critique of that published studies is important? Without this kind of effort people can carry on saying “Research supports X”, disregarding the quality of the methods, the validity and the relevance of results.
@Tom
“sorry, no idea what you mean.”
OK, I keep saying this, so — for the benefit of those who, like Tom, don’t understand what I’m referring to… “The no true scotsman fallacy is a way of reinterpreting evidence in order to prevent the refutation of one’s position. Proposed counter-examples to a theory are dismissed as irrelevant solely because they are counter-examples, but purportedly because they are not what the theory is about.”
Wikipedia gives a simple example with a fictional conversation, as follows.
Person A: “No Scotsman puts sugar on his porridge.”
Person B: “But my uncle Angus likes sugar with his porridge.”
Person A: “Ah yes, but no true Scotsman puts sugar on his porridge.”
The comments on this blog crawl with equivalent examples. Using [name your substance or dilution] to treat problem X is not true homeopathy. No true chiropractor believes in subluxations (or the contrary). Now you’ve added no true acupuncturist would call the acupuncture points used in this study as valid for verum and sham. “The results are what I would expect with such an approach, and an example of one of the common problems with acupuncture/acupressure studies – the people designing them don’t know what they’re doing!”
The common problems with all branches of Big Snakeoil is that, if you’ve no solid, empirical evidence to underpin what you practise, you’ll resort to constant reiteration of ‘no true Scotsman’-itis in order to explain away experimental results you don’t like. Leigh Jackson is saying this in different words: “…show how it should be done and undertake your own trial employing what you consider to be true acu-puncture/pressure against legitimate sham…” [my itallics] But I shan’t hold my breath waiting for this event: even were it to happen and you got negative or equivocal results, some other acupuncturist would come along saying you should have used other points.
Religions have been doing ‘no true Scotsman’ for milennia; it’s reflected in the proliferation of different sects and in words like ‘unchristian’ and ‘unislamic’, which can be pulled out of a hat to explain all sorts of things the speaker objects to. e.g. “No true Christian would support gay marriage.”
@Frank you make an interesting point, and of course this fallacy exists and plays itself out in many situations. It’s quite possible I’ve been guilty of it at times in the past myself. But that doesn’t mean that whenever an acupuncturist criticises a study like this, it’s by default a ‘no true Scotsman’ scenario. Can you see that the authors have picked these points on a very flimsy basis, and not in connection with knee pain/arthritis at all? Yes, there are many styles of acupuncture and they don’t always agree on the best approach, and I can see why that raises questions, but no style I know of would use these points for knee pain, certainly not for every patient, so why should the results be taken seriously? Maybe the results would be the same with a group of points chosen by consensus by a group of experienced acupuncturists, but this particular study seems almost meaningless, especially when the active nature of the ‘sham’ is considered. I’m just advocating for better study design, as Edzard is, but I’m coming from a different angle.
I’d also say that when poorly conceived studies like this are used to bash acupuncture/acupressure, it’s really just another type of fallacy on the part of skeptics, who are surely prone to such things too – ‘if a study shows similar results between real/sham arms, it must mean the therapy is placebo – no need to look into the rationale behind it’.
Tom,
Yes. And unlike you, I can see that all acupuncture/acupressure points are picked on a very flimsy basis!
@Tom
Which points should the authors have picked and why?
How do acupuncturists decide what points will work and how were these points found and tested?
Can you describe how you do when someone comes to you with a bad kne? How do you diagnose and how do you decide your therapeutic approach?
@Tom
I acknowledge that, since none of the authors of this study claims to be a specialist in acupuncture, you, who do make that claim, have every right to criticize their choice of acupuncture points.
I am, however, astonished that neither the Arthritis Foundation, who funded the study, nor the ethical committee who approved the study, nor any of the authors who ran the study queried the choice of acupuncture points or sought help or advice from a knowledgeable acupuncturist before 150 people were volunteered to subject themselves to the protocols involved: but, on the face of it, that seems to be the case. I have similar incredulity about the peer reviewers of the paper who, if they had no knowledge of acupuncture points on which to judge their validity, also sought no specialist help in the matter.
However, the authors do state clearly the rationale behind the study: “Acupressure is a Traditional Chinese Medicine based on a philosophy similar to acupuncture. In contrast to acupuncture that uses fine needles, acupressure involves using fingers or other devices to apply pressure on different acupuncture points (acupoints) to stimulate meridians and increase the flow of ‘qi’ (life energy). An advantage of acupressure over acupuncture is that once a person learns to administer acupressure, he/she requires little or no assistance to complete his/her treatment. Thus, acupressure has the potential to be a low-cost and safe alternative to manage pain.” So three of the five authors, trained health professionals working in a major university hospital, blandly accept the notion of meridians (for which there’s zero evidence) and ‘qi’ (ditto).
I suggest that you (and any like-minded supporters) should write letters of protest to the Arthritis Foundation and to the University of Michigan complaining that poorly conceived studies like this one should not be undertaken under their patronage. That in future only professionally trained acupuncturists (who clearly never disagree about the location, function and effect of acupuncture points) should be entitled to conduct such research. In this way you will boost the prestige of acupuncture and avoid serving grist to the mill of skeptics like myself and other regular posters on this blog who argue that, if it sounds like nonsense, smells like nonsense, and is unsupported by credible evidence, it probably is nonsense.
Bjorn
While waiting for Tom’s response, you could check out this:
http://acupressurepointsguide.com/acupressure-points-for-knee-pain/
Looks like it’s geared toward ‘home use’, and they talk briefly about what the points are generally used for. One thing they have in common: “knee pain”. I’m not an acupuncturist, but I’d be curious to know why the authors of the study chose to focus on ‘fatigue and sleep disturbance, common comorbidities in patients with OA and pain’…rather than ‘knee pain’.
But I guess the sham group got to use points that would help with that :).
Why?
To add to my growing collection of absurd make-believe-medicine perhaps?
Bjorn, you do seem fond of the absurd and the make believe. You even make up your own. But I posted the link for you because those are pretty common points used for treatment of knee pain.
Or do you really think it’s logical that they picked points because they were previously shown to offer pain relief in breast cancer survivors, and that they ‘reduced fatigue and sleep disturbance, common comorbidities in patients with OA and pain’?
Although who knows – their choice outperformed standard care, so maybe they’re on to something.
@tom
Not by me. By other acupuncturists, very likely.
“@Leigh Jackson: If I did as you suggest, I fear the results would be dismissed as ‘at risk of bias’ because I’m an acupuncturist. ”
Actually, if the methods are sound and explained well enough, your profession will lend credibility to the study. Nobody is 100% unbiased, but as long as the study makes sense, there’s always something to learn, even if it’s “No conclusion could be reached using this method”.
@Pete I’m not sure referencing a page that is heavily policed by skeptics really proves anything, do you?
http://www.abetterwaytohealth.com/wikipedia-we-have-a-problem/
“policed by skeptics”
what’s that supposed to mean?
@Edzard – the link I pasted explains what I mean (which is why I pasted it).
Hi again,
Wikipedia and encyclopaedias in general are a good start for researching a subject. Encouraging people to go beyond the first article is not a new thing, nor specific to Wikipedia. I read the article linked above and then dug a big deeper into the Cochrane meta-study used to support the idea that in general acupuncture is worthwhile. Here’s a highlight:
“Headache frequency halved in 52 of 100 participants receiving true acupuncture compared with 43 of 100 participants receiving ‘fake’ acupuncture.”
Considering that humans don’t have a “pain-o-meter” dial to show an accurate measure of pain, doesn’t it worry even a tiny bit that sham treatment and not-sham score so close? Is our NHS paying for this?!
Another highlight is from the article that lists acupuncture in the 7 recommendations for lower back pain. At first it shows:
Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Optimistically we could disregard the “weak recommendation” and dig into the article behind the recommendation:
Thirty-five randomized clinical trials were included: 20 were published in English, 7 in Japanese, 5 in Chinese, and 1 each in Norwegian, Polish, and German. There were only 3 trials of acupuncture for acute low back pain. These studies did not justify firm conclusions because of their small sample sizes and low methodologic quality.[…]
CONCLUSIONS: The data do not allow firm conclusions regarding the effectiveness of acupuncture for acute low back pain.
The other link (115) is better support for the acupuncture case, concluding:
CONCLUSIONS: Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.
(still not great, IMHO)
I get the impression that the author of “Wikipedia we have a problem” is keen to show a LOT of sources but didn’t analyse them with enough careful scepticism. Maybe those other sources that are in books rather than links to pubmed show something different – I don’t know.
@The Vodka Diet Guru:
I just finished reading through this piece (and some other articles on the site) and was underwhelmed, to put it mildly. The author is certainly keen to pick the sweetest looking cherries and forget others in a frantic attempt to build arguments. The reference list is an incompetently assembled shambles. I guess the author is not keen on such dull details as providing proper references?
@Tom
Just imagine what Wikipedia would be like if it was really free for all to edit. Any idiot could ruin many peoples’ ardent and honest efforts by hammering away on its keyboard. Of course it needs rigour and adherence to rational, scientific standards. That is why acupuncturists, homeopaths, Reflexologists, etc… don’t like Wikipedia, it is policed by people who like verifiable facts and defend its articles against fantasies and fiction. If you want to call it skepticism, I guess that term is as good as any, but I like to call it honesty and integrity.
This article (against WP’s handling of “acupuncture”) is so full of fallacies I could spend days dissecting it but I am going to let it pass.
Look forward to see your explanation Tom, of how acu-points were systematically(?) found, defined and tested and how you acupuncturists know which points to poke in each case. I am especially curious about pulse diagnostics. Why has no one made an automated apparatus to measure and output these seemingly (to the practitioners) simple analyses. It should be light work for engineers with machine learning and AI skills to analyse and automate this mystical methodology based on easily objectivised characteristics of the wrist pulse. This has been done ages ago with electrocardiograms, the machines are almost better than humans in diagnosing disturbances in them.
Bjorn, that’s a fantastic write-up of pulse diagnosis. I see you’re growing your collection :).
@Frank it seems we’re at least partly in agreement for once. However:
‘only professionally trained acupuncturists (who clearly never disagree about the location, function and effect of acupuncture points) should be entitled to conduct such research’
None of us would claim to always agree on these matters. I have some theories on this which I’ll try to find time to share at some point.
@Bjorn – your questions are reasonable and deserve a proper response. I’ll do my best to provide one as soon as I have time.
@Bjorn Sorry for the delay in responding to your questions. You asked ‘which points should the authors have picked and why?’, but I’ll briefly address your other questions about my own clinical reasoning first. As you know, traditional acupuncturists attempt to individualise their treatments, so a full answer would depend on the patient in question. And yes, there are many styles of traditional acupuncture, and mine is somewhat of a hybrid, so to fully describe my rationale is well beyond the scope of this post. Suffice it to say that I try to keep the core principles of Chinese Medicine (found mainly in the Neijing) in mind while I ask questions and examine a patient. I then try to synthesise all I know from my education and clinical experience, and come up with a treatment plan aimed at stimulating the patient’s body back towards homeostasis (or yin-yang balance). This usually involves using a combination of recognised points that are commonly used for a specific situation, along with tight/tender points in related areas.
Of course, this will in no way satisfy you, but I’d need to describe multiple case studies and expand greatly upon the fundamentals of Chinese Medicine to even begin to address this properly. I acknowledge that there isn’t currently any overall consensus on treatment approaches within the field, so practitioners develop their own styles based on the sources and authorities they come to trust. This is what I’ve tried to do – listen to what any given teacher or writer has to say, weigh it up against my understanding of the fundamentals of the medicine, and if it seems to be grounded in a solid understanding I will try it out clinically and evaluate its relative usefulness over time.
I also acknowledge that in this field, systematic testing of theories in line with the scientific method on a large scale is uncommon. This must partly be due to the immense complexity involved in doing this with an individualised approach, and without major funding. That’s not to say it shouldn’t be an ambition of the community, it’s just hard to see how this could happen in a meaningful way.
All of the above have certainly been sources of frustration for me over the years, but the life-changing results I have witnessed on a regular basis have always been enough to keep these frustrations largely at bay. These are just anecdotal examples of the placebo effect to most readers of this blog, but they are far more than this to the real people who experience them. One quick example. I saw a lady last November who had been suffering from severe urticaria for several months. She had tried various medications prescribed by her GP, which had not helped, and had caused various side-effects (her GP said he had ‘run out of ideas’). I only treated her once in my community clinic, and didn’t hear back from her. I have to admit I didn’t follow up on her (something I’m working on doing more systematically now), but I received an email from her last week saying her problem cleared up entirely following that single treatment and hadn’t recurred since. Being able to offer a treatment for as little as £15 to people on a low income, which can sometimes yield results like this, is something I feel very comfortable doing despite all the inherent frustrations and inconsistencies.
But coming back to the main topic, what points should the authors of the study have chosen? Ideally they should have used real-world individualised treatments given by experienced practitioners, but if a ‘protocol’ approach was essential to the study design they should at least consult a number of acupuncturists for their opinions, otherwise how can the results be valid in any way? Even looking in the point indication index of the widely used ‘A Manual of Acupuncture’ for example, would have shown them that only one of the points in the ‘real’ group features (LIV-3). But there are points listed here which are very close to the ‘sham’ points chosen. So I don’t think cries of ‘No true Scotsman!’ are justified in this case.
@Edzard draws the headline conclusion that acupressure doesn’t work based on the results of this trial. He has overlooked the vital question of whether the ‘real’ and ‘sham’ groups are in any way meaningful, so I believe his conclusion is entirely spurious. Of course he and many others here are convinced that the choice of points makes no difference at all, but that opinion shouldn’t get in the way of full and proper evaluation of a trial, including whether it even tests what it claims to test.
Wow! And I thought real science could sometimes be complicated!
Forgive me for intruding on what you say is meant for Bjorn, but your reply is so far removed from whatever it was that Bjorn said, with all the indentations and intrusions of the sea of comments on this blog that your post is hanging in isolation.
Tom, you’re trying to unravel something so fundamentally nebulous, abstracted and ill-defined it’s just meaningless. You think you’re working rationally, but you include so many variables you’re never going to reach a conclusion. Science advances one small step at a time, not by trying to encompass the vast scale of all the possibilities that can or might be be addressed. You need to focus on a single question that’s capable of being answered, not on all the vagaries of Chinese Medicine, styles of traditional acupuncture, yin-yang balance and ‘usefulness over time’ that seem to be rattling round in your head like dried peas in a very large bucket.
Try to come up with a straightforward scenario. Does sticking my needles in a particular point — however it’s defined — objectively influence the outcome for a patient with a definable condition? And to achieve that objectivity, both you and the patient need to be blinded to what you’re doing: you need to involve other people in the experiment for that to be possible. Only this approach will begin to produce meaningful, relevant results. You simply can’t do it from your personal experience and observation, however reasonable you think you’re being.
@Frank
Nebulous (good word), abstracted and ill-defined maybe, but not at all meaningless to the people who benefit from it.
I agree, I don’t think I ever will reach a firm conclusion about all the mysteries of acupuncture. To you, that makes it meaningless – to me, that makes it rich and fascinating (as well as frustrating at times).
And here’s one of the major issues that I can’t see there ever being agreement on between the camps. To me, the idea of being blinded to what I’m doing makes no sense at all. I’ve heard acupuncture described as a type of micro-surgery, which I think is accurate. For example, when I needle the point GB-21 (in the trapezius) in someone with tension headaches, I use a very specific grip of the muscle with my left hand, insert the needle, and very carefully probe with the needle, focusing on the tip of the needle as it contacts the various tissues, and feeling for a twitch response. How can this kind of interaction be blinded? The type of experiment you describe may be interesting and worthwhile, but it wouldn’t be evaluating authentic acupuncture.
@Tom
Sorry, this lates post post eliminates any feelings of respect I might once have held for continuing discussion with you. You’re in over your head with the woo stuff and now you’re inventing language to rationalize your position.
“[Tom Kennedy] … I use a very specific grip of the muscle with my left hand, insert the needle, and very carefully probe with the needle, focusing on the tip of the needle as it contacts the various tissues, and feeling for a twitch response.”
The twitch response to what exactly: a response to nerve stimulation; a response to nerve damage; a response to tissue damage; or a twitch due to something else?
I shall refrain from asking why you seem to be deeply interested in probing people with needles despite your admitted lack of evidence for doing it:
Is it just me, or do other readers find Tom Kennedy’s comments uncomfortably sinister?
I wouldn’t call any of this sinister. Only… faith-based.
Maybe the needle twitches, or maybe it’s the practitioner who is shaking and reads too much into it… In the end, the patient goes into the room with faith that they are doing something useful, the practitioner has faith that they are doing something useful… and on that basis there’s an exchange of money and services. Perhaps it’s an improvement if afterwards the patient is ready to take their mind off of what was bothering them.
It’s not a terrible thing if the condition is mild enough that not much can go wrong, but we can only hope that if there’s real danger, the practitioner has the decency and knowledge to call the thing off and direct the patient to a proper healthcare facility.
As long as there’s proper consumer information, as in “This is not a medical/healthcare practice.”
“There are no doctors or nurses here.”
“There’s no known reason why this could work.”
“This product cannot be sold in pharmacies”
“This has no known value as therapy”
“Having untreated health conditions can be hazardous for your health” 😀
…and the NHS stays really far away from this, let them have faith.
@Tom & Vodka
Pete was probably making a faith based ‘uncomfortably sinister’ joke.
“…I use a very specific grip of the muscle with my left hand, insert the needle…”.
@Frank quite happy to leave it there, but I have to say I find it puzzling that someone ostensibly interested in the ‘truth’ is put off to the point of ending a discussion by a simple description of what happens during a typical clinical encounter. I’m not sure which ‘made up’ language offended you in particular, but I’m sorry it was too much for you. Ho hum.
@Tom
“When I needle the point GB-21…” You have may accepted the definition of this point without question, but — sorry — I don’t accept the mystic nonsense of acupuncture points. Sure, in a ‘speciality’ you have to use specialized terminology, but that’s normally based on evidence for the existence of something demonstrable for which to give a name. Acupuncture points (a) seem to vary between ‘schools’ of acupuncture ‘thought’ and between practitioners and (b) have absolutely no basis in anything demonstrable (all this cock and bull about meridians, qi and energy flows is utterly incompatible with what we know about biology). So I’m out at first base of this discussion.
Pete Attkins has already nailed the imprecision of your ‘twitch response’. Can you now understand why I wrote “You’re in over your head with the woo stuff and now you’re inventing language to rationalize your position.”
“And here’s one of the major issues that I can’t see there ever being agreement on between the camps. To me, the idea of being blinded to what I’m doing makes no sense at all. ” It’s not you who necessarily needs to be blinded. It’s whoever judges the outcome of a treatment. If I want to test whether people who go into room 25 for 10 minutes recover from the common cold faster than those who spend 10 minutes in room 32, obviously the person who shows a patient to room 25 (the equivalent of you as a practitioner) is not blind to which room has been used, but whoever assesses the outcome must be blind to which room the patient entered.
Pete asked “Is it just me, or do other readers find Tom Kennedy’s comments uncomfortably sinister?” From my perspective I don’t find them sinister, merely indicative of a basic failure to grasp any aspect of critical thought.
@Frank What you said was ‘both you and the patient need to be blinded to what you’re doing’ – you can see why I took this to mean being blinded to the treatment itself. I’m quite happy with the idea of someone else judging the outcome of treatments. I don’t know of an obvious way to do this as a part of my clinical practice, or even in a study setting when it comes to pain, as it will usually come down to what the patient subjectively reports, won’t it? Although here’s an interesting study that seems to show objective improvements for real v sham acupuncture for carpal tunnel syndrome:
https://www.ncbi.nlm.nih.gov/pubmed/28334999
@Edzard, I’d be interested in your thoughts on this.
@Pete ‘uncomfortably sinister’! That’s a new one to add to the things I’ve been called on this blog!
@Pete and @Frank ‘The twitch response to what exactly?’
The twitch response is a recognised phenomenon in various manual therapies, and common parlance. Here’s a definition from a recent study in the Manual Therapy Journal:
‘LTRs [local twitch responses] are involuntary contractions of muscle fibers, which may lead to muscle relaxation by reducing spontaneous electrical activity. This may cause a reduction of pain and stiffness.’
In this study the conclusion was that ‘dry needling of the upper trapezius leads to a decrease in sEMG activity, compared to rest when local twitch responses are elicited’. (‘Several studies have demonstrated a higher surface electromyography (sEMG) activity of the upper trapezius in patients with trapezius myalgia, compared to healthy controls’).
http://www.manualtherapyjournal.com.marlin-prod.literatumonline.com/article/S1356-689X(16)30259-4/abstract
I don’t mean to imply that LTRs are fully understood or free from controversy.