MD, PhD, FMedSci, FSB, FRCP, FRCPEd

I have repeatedly cautioned about the often poor quality of research into alternative medicine. This seems particularly necessary with studies of acupuncture, and especially true for such research carried out in China. I have also frequently noted that certain ‘CAM journals’ are notoriously prone to publishing rubbish. So, what can we expect from a paper that:

  • is on alternative medicine,
  • focusses on acupuncture,
  • is authored by Chinese researchers,
  • was published in the Journal of Alternative and Complementary Medicine (JACM)?

The answer is PROBABLY NOT A LOT!

As if for confirming my prediction, The JACM just published this systematic review. It reports pairwise and network meta-analyses to determine the effectiveness of acupuncture and acupuncture-related techniques for the treatment of psoriasis. A total of 13 RCTs were included. The methodological quality of these studies was ‘not rigorous’ according to the authors – in fact, it was lousy. Acupoint stimulation seemed to be more effective than non-acupoint stimulation. The short-term treatment effect was superior to the long-term effect (as one would expect with placebo). Network meta-analysis suggested that acupressure or acupoint catgut embedding generate superior effects compared to medications. It was noted that acupressure was the most effective treatment of all the acupuncture-like therapies.

The authors concluded that acupuncture-related techniques could be considered as an alternative or adjuvant therapy for psoriasis in short term, especially of acupressure and acupoint catgut embedding. This study recommends further well-designed, methodologically rigorous, and more head-to-head randomized trials to explore the effects of acupuncture-related techniques for treating psoriasis.

And what is wrong with that?

EVERYTHING!

  • The review is of very poor quality.
  • The primary studies are even worse.
  • The English language is defective to the point of being not understandable.
  • The conclusions are misleading.

Correct conclusions should read something like this: Due to the paucity and the poor quality of the clinical trials, this review could not determine whether acupuncture and similar therapies are effective for psoriasis.

And then there is, of course, the question about plausibility. How plausible is the assumption that acupuncture might affect a genetic autoimmune disease like psoriasis. The answer, I think, is that the assumption is highly unlikely.

In the above review, most of the 13 primary RCTs were from China. One of the few studies not conducted in China is this one:

56 patients suffering from long-standing plaque psoriasis were randomized to receive either active treatment (electrostimulation by needles placed intramuscularly, plus ear-acupuncture) or placebo (sham, ‘minimal acupuncture‘) twice weekly for 10 weeks. The severity of the skin lesions was scored (PASI) before, during, and 3 months after therapy. After 10 weeks of treatment the PASI mean value had decreased from 9.6 to 8.3 in the ‘active’ group and from 9.2 to 6.9 in the placebo group (p < 0.05 for both groups). These effects are less than the usual placebo effect of about 30%. There were no statistically significant differences between the outcomes in the two groups during or 3 months after therapy. The patient’s own opinion about the results showed no preference for ‘active’ therapy. It was also clear from the answers that the blinded nature of the study had not been discovered by the patients. In conclusion, classical acupuncture is not superior to sham (placebo) ‘minimal acupuncture‘ in the treatment of psoriasis.

Somehow, I trust these conclusions more than the ones from the review!

And somehow, I get very tired of journal editors failing to do their job of rejecting papers that evidently are embarrassing, unethical rubbish.

2 Responses to A new meta-analysis of acupuncture in JACM – no prizes for guessing the conclusion

  • Acupuncturists, like “nutrionists” use exactly the same method as the tobacco industry: manufactured doubt. A non-stop stream of bad papers, accompanied by press releases, serve to maintain the fiction that there is still a controversy and that “more research is needed”. There is no longer any controversy and no more research is needed,

  • JAMA June 27 vol 317, contains two Chinese electro-acupuncture RCTs and an accompanying editorial by Josephine Briggs and David Shurtleff of the NCCIH (formerly NCCAM).

    NCCIH – the United States National Institute of Fairytale Medicine. Too good to be true and a happy ending guaranteed.

    However, it appears something went awry in one of the Chinese RCTs: Electro-acupuncture was found to be ineffective for Polycystic Ovary Syndrome compared with sham; both were ineffective compared with Clomiphene!

    The explanation seems to be that the RCT was of very high quality. What a cock-up!

    However, the exact same and identical treatment was found to reduce Stress Urinary Incontinence in women, six weeks after treatment, compared with sham electro-acupuncture.

    Electro-acupuncture in both RCTs consisted of deep needling with manual and electrical stimulation to produce deqi sensation in treatment groups. Control groups received the illusion of being needled without any of the sensations.

    Blind-busting sensations. Perhaps the needling sensations over a period of weeks provided stronger assurance of the power of the treatment compared with the sensationless sham treatment. Provided a growing placebo response, by comparison, in other words.

    Of course, if you carry on throwing enough RCTs at any treatment you are statistically guaranteed some kind of success every now and again. Carry on carrying on RCTs is the name of the game!

    http://jamanetwork.com/journals/jama/issue/317/24

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