MD, PhD, FMedSci, FSB, FRCP, FRCPEd

acupressure

A reader of this blog recently sent me the following message: “Looks like this group followed you recent post about how to perform a CAM RCT!” A link directed me to a new trial of ear-acupressure. Today is ‘national acupuncture and oriental medicine day’ in the US, a good occasion perhaps to have a critical look at it.

The aim of this study was to assess the effectiveness of ear acupressure and massage vs. control in the improvement of pain, anxiety and depression in persons diagnosed with dementia.

For this purpose, the researchers recruited a total of 120 elderly dementia patients institutionalized in residential homes. The participants were randomly allocated, to three groups:

  • Control group – they continued with their routine activities;
  • Ear acupressure intervention group – they received ear acupressure treatment (pressure was applied to acupressure points on the ear);
  • Massage therapy intervention group – they received relaxing massage therapy.

Pain, anxiety and depression were assessed with the Doloplus2, Cornell and Campbell scales. The study was carried out during 5 months; three months of experimental treatment and two months with no treatment. The assessments were done at baseline, each month during the treatment and at one and two months of follow-up.

A total of 111 participants completed the study. The ear acupressure intervention group showed better improvements than the two other groups in relation to pain and depression during the treatment period and at one month of follow-up. The best improvement in pain was achieved in the last (3rd) month of ear acupressure treatment. The best results regarding anxiety were also observed in the last month of treatment.

The authors concluded that ear acupressure and massage therapy showed better results than the control group in relation to pain, anxiety and depression. However, ear acupressure achieved more improvements.

The question is: IS THIS A RIGOROUS TRIAL?

My answer would be NO.

Now I better explain why, don’t I?

If we look at them critically, the results of this trial might merely prove that spending some time with a patient, being nice to her, administering a treatment that involves time and touch, etc. yields positive changes in subjective experiences of pain, anxiety and depression. Thus the results of this study might have nothing to do with the therapies per se.

And why would acupressure be more successful than massage therapy? Massage therapy is an ‘old hat’ for many patients; by contrast, acupressure is exotic and relates to mystical life forces etc. Features like that have the potential to maximise the placebo-response. Therefore it is conceivable that they have contributed to the superiority of acupressure over massage.

What I am saying is that the results of this trial can be interpreted in not just one but several ways. The main reason for that is the fact that the control group were not given an acceptable placebo, one that was indistinguishable from the real treatment. Patients were fully aware of what type of intervention they were getting. Therefore their expectations, possibly heightened by the therapists, determined the outcomes. Consequently there were factors at work which were totally beyond the control of the researchers and a clear causal link between the therapy and the outcome cannot be established.

An RCT that is aimed to test the effectiveness of a therapy but fails to establish such a causal link beyond reasonable doubt cannot be characterised as a rigorous study, I am afraid.

Sorry! Did I spoil your ‘national acupuncture and oriental medicine day’?

One of the most commonly ‘accepted’ indications for acupuncture is anxiety. Many trials have suggested that it is effective for that condition. But is this really true? To find out, we need someone to conduct a systematic review or meta-analysis.

Korean researchers have just published such a paper; they wanted to assess the preoperative anxiolytic efficacy of acupuncture therapy and therefore conducted a meta-analysis of all RCTs on the subject. Four electronic databases were searched up to February 2014. Data were included in the meta-analysis from RCTs in which groups receiving preoperative acupuncture treatment were compared with control groups receiving a placebo for anxiety.

Fourteen publications with a total of 1,034 patients were included. Six RCTs, using the State-Trait Anxiety Inventory-State (STAI-S), reported that acupuncture interventions led to greater reductions in preoperative anxiety relative to sham acupuncture. A further eight publications, employing visual analogue scales, also indicated significant differences in preoperative anxiety amelioration between acupuncture and sham acupuncture.

The authors concluded that aacupuncture therapy aiming at reducing preoperative anxiety has a statistically significant effect relative to placebo or nontreatment conditions. Well-designed and rigorous studies that employ large sample sizes are necessary to corroborate this finding.

From these conclusions most casual readers might get the impression that acupuncture is indeed effective. One has to dig a bit deeper to realise that is perhaps not so.

Why? Because the quality of the primary studies was often dismally poor. Most did not even mention adverse effects which, in my view, is a clear breach of publication ethics. What is more, all the studies were wide open to bias. The authors of the meta-analysis include in their results section the following short paragraph:

The 14 included studies exhibited various degrees of bias susceptibility (Figure 2 and Figure 3). The agreement rate, as measured using Cohen’s kappa, was 0.8 [32]. Only six studies reported concealed allocation; the other six described a method of adequate randomization, although the word “randomization” appeared in all of the articles. Thirteen studies prevented blinding of the participants. Participants in these studies had no previous experience of acupuncture. According to STRICTA, two studies enquired after patients’ beliefs as a group: there were no significant differences [20, 24].

There is a saying amongst experts about such meta-analyses: RUBBISH IN, RUBBISH OUT. It describes the fact that several poor studies, pooled meta-analytically, can never give a reliable result.

This does, however, not mean that such meta-analyses are necessarily useless. If the authors prominently (in the abstract) stress that the quality of the primary studies was wanting and that therefore the overall result is unreliable, they might inspire future researchers to conduct more rigorous trials and thus generate progress. Most importantly, by insisting on pointing out these limitations and by not drawing positive conclusions from flawed data, they would avoid misleading those health care professionals – and let’s face it, they are the majority – who merely read the abstract or even just the conclusions of such articles.

The authors of this review have failed to do any of this; they and the journal EBCAM have thus done a disservice to us all by contributing to the constant drip of misleading and false-positive information about the value of acupuncture.

Blinding patients in clinical trials is a key methodological procedure for minimizing bias and thus making sure that the results are reliable. In alternative medicine, blinding is not always straight forward, and many studies are therefore not patient-blinded. We all know that this can introduce bias into a trial, but how large is its effect on study outcomes?

This was the research question addressed by a recent systematic review of randomized clinical trials with one sub-study (i.e. experimental vs control) involving blinded patients and another, otherwise identical, sub-study involving non-blinded patients. Within each trial, the researchers compared the difference in effect sizes (i.e. standardized mean differences) between the two sub-studies. A difference <0 indicates that non-blinded patients generated a more optimistic effect estimate. The researchers then pooled the differences with random-effects inverse variance meta-analysis, and explored reasons for heterogeneity.

The main analysis included 12 trials with a total of 3869 patients. Ten of these RCTs were studies of acupuncture. The average difference in effect size for patient-reported outcomes was -0.56 (95% confidence interval -0.71 to -0.41), (I(2 )= 60%, P = 0.004), indicating that non-blinded patients exaggerated the effect size by an average of 0.56 standard deviation, but with considerable variation. Two of the 12 trials also used observer-reported outcomes, showing no indication of exaggerated effects due lack of patient blinding.

There was an even larger effect size difference in the 10 acupuncture trials [-0.63 (-0.77 to -0.49)], than in the two non-acupuncture trials [-0.17 (-0.41 to 0.07)]. Lack of patient blinding was also associated with increased attrition rates and the use of co-interventions: ratio of control group attrition risk 1.79 (1.18 to 2.70), and ratio of control group co-intervention risk 1.55 (0.99 to 2.43).

The authors conclude that this study provides empirical evidence of pronounced bias due to lack of patient blinding in complementary/alternative randomized clinical trials with patient-reported outcomes.

This is a timely, rigorous and important analysis. In alternative medicine, we currently see a proliferation of trials that are not patient-blinded. We always suspected that they are at a high risk of generating false-positive results – now we know that this is, in fact, the case.

What should we do with this insight? In my view, the following steps would be wise:

  1. Take the findings from the existing trials that are devoid of patient-blinding with more than just a pinch of salt.
  2. Discourage the funding of future studies that fail to include patient-blinding.
  3. If patient-blinding is truly and demonstrably impossible – which is not often the case – make sure that the trialists at least include blinding of the assessors of the primary outcome measures.

An article in the ‘Huffpost Healthy Living’ recently discussed “the top three things that surprise people about acupuncture”. On closer inspection, they turn out to be the top three untruths about acupuncture. Here is (in italics and slightly abbreviated) what the article said.

Acupuncture is not just for pain

…It’s true that acupuncture can work wonders on pain conditions…However, acupuncture can alleviate a wide variety of ailments that have nothing to do with physical pain. Whether you have digestive issues, gynecological conditions, emotional concerns such as anxiety and depression, asthma, seasonal allergies, you name it, acupuncture can help address your symptoms.

Acupuncturists go to school for a long time

People tend to be unaware of the extent to which acupuncturists train to become licensed in their profession. Many assume becoming an acupuncturist is similar to becoming a massage therapist or Reiki practitioner or yoga instructor… At minimum, a licensed acupuncturist in the United States has been to three years of graduate school. Four years is more common. They hold master’s degrees. Some acupuncturists with doctorates have studied at the graduate level for five-plus years. Upon graduating from an accredited school, all acupuncturists must pass multiple board exams to become licensed in their state. In addition to the academic and state requirements for practicing acupuncture, many acupuncturists seek hands-on training and mentorship in the form of apprenticeships and continuing education seminars.

Acupuncture is relaxing

Acupuncture needles are surprisingly thin. They do not bear any resemblance to needles that are used for injections or to draw blood… In most cases, the insertion of acupuncture needles does not hurt…Once the needles are in, they start working their magic, which is where the relaxation part comes in. Acupuncture helps shift your body out of sympathetic mode (fight or flight) and into parasympathetic mode (rest and digest). It mellows out the nervous system, decreases muscular tension, and helps quiet internal chatter…

AND NOW THE FACTS:

1) There is not a single condition for which the evidence is truly compelling demonstrating that acupuncture is more than a placebo. Certainly there is no good evidence that acupuncture works for digestive issues, gynecological conditions, emotional concerns such as anxiety and depression, asthma or seasonal allergies.

2) In most countries, anyone can call themselves an acupuncturist, regardless of background or training.

3) The relaxing element of an acupuncture session is foremost the fact that patients lie down and have to keep still for 20 minutes or so. The insertion of needles does cause mild pain in many patients, and the claim about parasympathetic mode is mostly phantasy.

I despair about the nonsense that is published about alternative medicine on a daily basis – not because I have an axe to grind, but because it misleads patients into making wrong therapeutic decisions.

Whenever a new trial of an alternative intervention emerges which fails to confirm the wishful thinking of the proponents of that therapy, the world of alternative medicine is in turmoil. What can be done about yet another piece of unfavourable evidence? The easiest solution would be to ignore it, of course – and this is precisely what is often tried. But this tactic usually proves to be unsatisfactory; it does not neutralise the new evidence, and each time someone brings it up, one has to stick one’s head back into the sand. Rather than denying its existence, it would be preferable to have a tool which invalidates the study in question once and for all.

The ‘fatal flaw’ solution is simpler than anticipated! Alternative treatments are ‘very special’, and this notion must be emphasised, blown up beyond all proportions and used cleverly to discredit studies with unfavourable outcomes: the trick is simply to claim that studies with unfavourable results have a ‘fatal flaw’ in the way the alternative treatment was applied. As only the experts in the ‘very special’ treatment in question are able to judge the adequacy of their therapy, nobody is allowed to doubt their verdict.

Take acupuncture, for instance; it is an ancient ‘art’ which only the very best will ever master – at least that is what we are being told. So, all the proponents need to do in order to invalidate a trial, is read the methods section of the paper in full detail and state ‘ex cathedra’ that the way acupuncture was done in this particular study is completely ridiculous. The wrong points were stimulated, or the right points were stimulated but not long enough [or too long], or the needling was too deep [or too shallow], or the type of stimulus employed was not as recommended by TCM experts, or the contra-indications were not observed etc. etc.

As nobody can tell a correct acupuncture from an incorrect one, this ‘fatal flaw’ method is fairly fool-proof. It is also ever so simple: acupuncture-fans do not necessarily study hard to find the ‘fatal flaw’, they only have to look at the result of a study – if it was favourable, the treatment was obviously done perfectly by highly experienced experts; if it was unfavourable, the therapists clearly must have been morons who picked up their acupuncture skills in a single weekend course. The reasons for this judgement can always be found or, if all else fails, invented.

And the end-result of the ‘fatal flaw’ method is most satisfactory; what is more, it can be applied to all alternative therapies – homeopathy, herbal medicine, reflexology, Reiki healing, colonic irrigation…the method works for all of them! What is even more, the ‘fatal flaw’ method is adaptable to other aspects of scientific investigations such that it fits every conceivable circumstance.

An article documenting the ‘fatal flaw’ has to be published, of course – but this is no problem! There are dozens of dodgy alternative medicine journals which are only too keen to print even the most far-fetched nonsense as long as it promotes alternative medicine in some way. Once this paper is published, the proponents of the therapy in question have a comfortable default position to rely on each time someone cites the unfavourable study: “WHAT NOT THAT STUDY AGAIN! THE TREATMENT HAS BEEN SHOWN TO BE ALL WRONG. NOBODY CAN EXPECT GOOD RESULTS FROM A THERAPY THAT WAS NOT CORRECTLY ADMINISTERED. IF YOU DON’T HAVE BETTER STUDIES TO SUPPORT YOUR ARGUMENTS, YOU BETTER SHUT UP.”

There might, in fact, be better studies – but chances are that the ‘other side’ has already documented a ‘fatal flaw’ in them too.

What is ear acupressure?

Proponents claim that ear-acupressure is commonly used by Chinese medicine practitioners… It is like acupuncture but does not use needles. Instead, small round pellets are taped to points on one ear. Ear-acupressure is a non-invasive, painless, low cost therapy and no significant side effects have been reported.

Ok, but does it work?

There is a lot of money being made with the claim that ear acupressure (EAP) is effective, especially for smoking cessation; entrepreneurs sell gadgets for applying the pressure on the ear, and practitioners earn their living through telling their patients that this therapy is helpful. There are hundreds of websites with claims like this one: Auricular therapy (Acupressure therapy of the ear region) has been used successfully for Smoking cessation. Auriculotherapy is thought to be 7 times more powerful than other methods used for smoking cessation; a single auriculotherapy treatment has been shown to reduce smoking from 20 or more cigarettes a day down to 3 to 5 a day.

But what does the evidence show?

This new study investigated the efficacy of EAP as a stand-alone intervention for smoking cessation. Adult smokers were randomised to receive EAP specific for smoking cessation (SSEAP) or a non-specific EAP (NSEAP) intervention, EAP at points not typically used for smoking cessation. Participants received 8 weekly treatments and were requested to press the five pellets taped to one ear at least three times per day. Participants were followed up for three months. The primary outcome measures were a 7-day point-prevalence cessation rate confirmed by exhaled carbon monoxide and relief of nicotine withdrawal symptoms (NWS).

Forty-three adult smokers were randomly assigned to SSEAP (n = 20) or NSEAP (n = 23) groups. The dropout rate was high with 19 participants completing the treatments and 12 remaining at followup. One participant from the SSEAP group had confirmed cessation at week 8 and end of followup (5%), but there was no difference between groups for confirmed cessation or NWS. Adverse events were few and minor.

And is there a systematic review of the totality of the evidence?

Sure, the current Cochrane review arrives at the following conclusion: There is no consistent, bias-free evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation…

So?

Yes, we may well ask! If most TCM practitioners use EAP or acupuncture for smoking cessation telling their customers that it works (and earning good money when doing so), while the evidence fails to show that this is true, what should we say about such behaviour? I don’t know about you, but I find it thoroughly dishonest.

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