The discussion whether acupuncture is more than a placebo is as long as it is heated. Crucially, it is also quite tedious, tiresome and unproductive, not least because no resolution seems to be in sight. Whenever researchers develop an apparently credible placebo and the results of clinical trials are not what acupuncturists had hoped for, the therapists claim that the placebo is, after all, not inert and the negative findings must be due to the fact that both placebo and real acupuncture are effective.
Laser acupuncture (acupoint stimulation not with needle-insertion but with laser light) offers a possible way out of this dilemma. It is relatively easy to make a placebo laser that looks convincing to all parties concerned but is a pure and inert placebo. Many trials have been conducted following this concept, and it is therefore highly relevant to ask what the totality of this evidence suggests.
A recent systematic review did just that; specifically, it aimed to evaluate the effects of laser acupuncture on pain and functional outcomes when it is used to treat musculoskeletal disorders.
Extensive literature searches were used to identify all RCTs employing laser acupuncture. A meta-analysis was performed by calculating the standardized mean differences and 95% confidence intervals, to evaluate the effect of laser acupuncture on pain and functional outcomes. Included studies were assessed in terms of their methodological quality and appropriateness of laser parameters.
Forty-nine RCTs met the inclusion criteria. Two-thirds (31/49) of these studies reported positive effects. All of them were rated as being of high methodological quality and all of them included sufficient details about the lasers used. Negative or inconclusive studies mostly failed to demonstrate these features. For all diagnostic subgroups, positive effects for both pain and functional outcomes were more consistently seen at long-term follow-up rather than immediately after treatment.
The authors concluded that moderate-quality evidence supports the effectiveness of laser acupuncture in managing musculoskeletal pain when applied in an appropriate treatment dosage; however, the positive effects are seen only at long-term follow-up and not immediately after the cessation of treatment.
Surprised? Well, I am!
This is a meta-analysis I always wanted to conduct and never came round to doing. Using the ‘trick’ of laser acupuncture, it is possible to fully blind patients, clinicians and data evaluators. This eliminates the most obvious sources of bias in such studies. Those who are convinced that acupuncture is a pure placebo would therefore expect a negative overall result.
But the result is quite clearly positive! How can this be? I can see three options:
- The meta-analysis could be biased and the result might therefore be false-positive. I looked hard but could not find any significant flaws.
- The primary studies might be wrong, fraudulent etc. I did not see any obvious signs for this to be so.
- Acupuncture might be more than a placebo after all. This notion might be unacceptable to sceptics.
I invite anyone who sufficiently understands clinical trial methodology to scrutinise the data closely and tell us which of the three possibilities is the correct one.
Getting good and experienced lecturers for courses is not easy. Having someone who has done more research than most working in the field and who is internationally known, might therefore be a thrill for students and an image-boosting experience of colleges. In the true Christmas spirit, I am today making the offer of being of assistance to the many struggling educational institutions of alternative medicine .
A few days ago, I tweeted about my willingness to give free lectures to homeopathic colleges (so far without response). Having thought about it a bit, I would now like to extend this offer. I would be happy to give a free lecture to the students of any educational institution of alternative medicine. I suggest to
- do a general lecture on the clinical evidence of the 4 major types of alternative medicine (acupuncture, chiropractic, herbal medicine, homeopathy) or
- give a more specific lecture with in-depth analyses of any given alternative therapy.
I imagine that most of the institutions in question might be a bit anxious about such an idea, but there is no need to worry: I guarantee that everything I say will be strictly and transparently evidence-based. I will disclose my sources and am willing to make my presentation available to students so that they can read up the finer details about the evidence later at home. In other words, I will do my very best to only transmit the truth about the subject at hand.
Nobody wants to hire a lecturer without having at least a rough outline of what he will be talking about – fair enough! Here I present a short summary of the lecture as I envisage it:
- I will start by providing a background about myself, my qualifications and my experience in researching and lecturing on the matter at hand.
- This will be followed by a background on the therapies in question, their history, current use etc.
- Next I would elaborate on the main assumptions of the therapies in question and on their biological plausibility.
- This will be followed by a review of the claims made for the therapies in question.
- The main section of my lecture would be to review the clinical evidence regarding the efficacy of therapies in question. In doing this, I will not cherry-pick my evidence but rely, whenever possible, on authoritative systematic reviews, preferably those from the Cochrane Collaboration.
- This, of course, needs to be supplemented by a review of safety issues.
- If wanted, I could also say a few words about the importance of the placebo effect.
- I also suggest to discuss some of the most pertinent ethical issues.
- Finally, I would hope to arrive at a few clear conclusions.
You see, all is entirely up to scratch!
Perhaps you have some doubts about my abilities to lecture? I can assure you, I have done this sort of thing all my life, I have been a professor at three different universities, and I will probably manage a lecture to your students.
A final issue might be the costs involved. As I said, I would charge neither for the preparation (this can take several days depending on the exact topic), nor for the lecture itself. All I would hope for is that you refund my travel (and, if necessary over-night) expenses. And please note: this is time-limited: approaches will be accepted until 1 January 2015 for lectures any time during 2015.
I can assure you, this is a generous offer that you ought to consider seriously – unless, of course, you do not want your students to learn the truth!
(In which case, one would need to wonder why not)
THIS POST IS DEDICATED TO HRH, THE PRINCE OF WALES WHO CELEBRATES HIS 66TH BIRTHDAY TODAY AND HAS SUPPORTED HOMEOPATHY ALL HIS LIFE
Like Charles, many people are fond of homeopathy; it is particularly popular in India, Germany, France and parts of South America. With all types of health care, it is important to make therapeutic decisions in the knowledge of the crucial facts. In order to aid evidence-based decision-making, I will summarise a few things you might want to consider before you try homeopathy – either by buying homeopathic remedies over the counter, or by consulting a homeopath.
- Homeopathy was invented by Samuel Hahnemann, a charismatic German doctor, about 200 years ago. At the time, our understanding of the laws of nature was woefully incomplete, and therefore Hahnemann’s ideas seemed far less implausible than they actually are. Moreover, the conventional treatments of this period were often more dangerous than the disease they were supposed to cure; consequently homeopathy was repeatedly shown to be better than ‘allopathy’ (a term coined by Hahnemann to insult conventional medicine). Thus Hahnemann’s treatments were an almost instant worldwide success. When, about 100 years later, more and more effective conventional therapies were discovered, homeopathy all but disappeared, only to be re-discovered in developed countries as the baby-boomers started their recent love-affair with alternative medicine.
- Many consumers confuse homeopathy with herbal medicine; yet the two are fundamentally different. Herbal medicines are plant extracts with potentially active ingredients. Homeopathic remedies may be based on plants (or any other material as well) but are typically so dilute that they contain absolutely nothing. The most frequently used dilution (homeopaths call them ‘potencies’) is a ‘C30’; a C30-potency has been diluted 30 times at a ratio of 1:100. This means that one drop of the staring material is dissolved in 1 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 drops of diluent – and that equates to one molecule of the original substance per all the molecules of many thousand universes.
- Homeopaths know all of this, of course, and they thus claim that their remedies do not work via pharmacological effects but via some ‘energy’ or ‘vital force’. They are convinced that the process of preparing the homeopathic dilutions (they shake the mixtures at each dilution step) transfers some ‘vital energy’ from one to the next dilution. They cite all sorts of fancy theories to explain how this ‘energy transfer’ might come about, however, none of them has ever been accepted by mainstream scientists.
- Homeopathic remedies are usually prescribed according to the ‘like cures like’ principle. For instance, if you suffer from runny eyes, a homeopath might prescribe a remedy made of onion, because onion make our eyes water. This and all other basic assumptions of homeopathy contradict the known laws of nature. In other words, we do not just fail to understand how homeopathy works, but we understand that it cannot work unless the known laws of nature are wrong.
- The clinical trials of homeopathy are broadly in agreement with these insights from basic science. Today, more than 200 such studies have been published; if we look at the totality of this evidence, we have to conclude that it fails to show that homeopathic remedies are anything other than placebos.
- This is, of course, in stark contrast to what many enthusiasts of homeopathy insist upon; they swear by homeopathy and claim that it has helped them (or their pet, aunt, child etc.) repeatedly. Nobody doubts their accounts; in fact, it is indisputable that many patients do get better after taking homeopathic remedies. The best evidence available today clearly shows, however, that this improvement is unrelated to the homeopathic remedy per se. It is the result of an empathetic, compassionate encounter with a homeopath, a placebo-response or other factors which experts often call ‘context effects’.
- The wide-spread notion that homeopathy is completely free of risks is not correct. The remedy itself might be harmless (except, of course, for the damage it creates to your finances, and the fact that irrational nonsense about ‘vital energy’ etc. undermines rationality in general) but this does not necessarily apply to the homeopath. Whenever homeopaths advise their patients, as they often do, to forgo effective conventional treatments for a serious condition, they endanger lives. This phenomenon is documented, for instance, in relation to the advice of many homeopaths against immunisations. Any treatment that has no proven benefit, while carrying a finite risk, cannot generate more good than harm.
‘Healing, hype or harm? A critical analysis of complementary or alternative medicine’ is the title of a book that I edited and that was published in 2008. Its publication date coincided with that of ‘Trick or Treatment?’ and therefore the former was almost completely over-shadowed by the latter. Consequently few people know about it. This is a shame, I think, and this post is dedicated to encouraging my readers to have a look at ‘Healing, hype or harm?’
One reviewer commented on Amazon about this book as follows: Vital and informative text that should be read by everyone alongside Ben Goldacre’s ‘Bad Science’ and Singh and Ernt’s ‘Trick or Treatment’. Everyone should be able to made informed choices about the treatments that are peddled to the desperate and gullible. As Tim Minchin famously said ‘What do you call Alternative Medicine that has been proved to work? . . . Medicine!’
This is high praise indeed! But I should not omit the fact that others have commented that they were appalled by our book and found it “disappointing and unsettling”. This does not surprise me in the least; after all, alternative medicine has always been a divisive subject.
The book was written by a total of 17 authors and covers many important aspects of alternative medicine. Some of its most famous contributors are Michael Baum, Gustav Born, David Colquhoun, James Randi and Nick Ross. Some of the most important subjects include:
As already mentioned, our book is already 6 years old; however, this does not mean that it is now out-dated. The subject areas were chosen such that it will be timely for a long time to come. Nor does this book reflect one single point of view; as it was written by over a dozen different experts with vastly different backgrounds, it offers an entire spectrum of views and attitudes. It is, in a word, a book that stimulates critical thinking and thoughtful analysis.
I sincerely think you should have a look at it… and, in case you think I am hoping to maximise my income by telling you all this: all the revenues from this book go to charity.
Recently, I was invited to give a lecture about homeopathy for a large gathering of general practitioners (GPs). In the coffee break after my talk, I found myself chatting to a very friendly GP who explained: “I entirely agree with you that homeopathic remedies are pure placebos, but I nevertheless prescribe them regularly.” “Why would anyone do that?” I asked him. His answer was as frank as it was revealing.
Some of his patients, he explained, have symptoms for which he has tried every treatment possible without success. They typically have already seen every specialist in the book but none could help either. Alternatively they are patients who have nothing wrong with them but regularly consult him for trivial or self-limiting problems.
In either case, the patients come with the expectation of getting a prescription for some sort of medicine. The GP knows that it would be a hassle and most likely a waste of time to try and dissuade them. His waiting room is full, and he is facing the following choice:
- to spend valuable 15 minutes or so explaining why he should not prescribe any medication at all, or
- to write a prescription for a homeopathic placebo and get the consultation over with in two minutes.
Option number 1 would render the patient unhappy or even angry, and chances are that she would promptly see some irresponsible charlatan who puts her ‘through the mill’ at great expense and considerable risk. Option number 2 would free the GP quickly to help those patients who can be helped, make the patient happy, preserve a good therapeutic relationship between GP and the patient, save the GP’s nerves, let the patient benefit from a potentially powerful placebo-effect, and be furthermore safe as well as cheap.
I was not going to be beaten that easily though. “Basically” I told him “you are using homeopathy to quickly get rid of ‘heart sink’ patients!”
“And you find this alright?”
“No, but do you know a better solution?”
I explained that, by behaving in this way, the GP degrades himself to the level of a charlatan. “No”, he said “I am saving my patients from the many really dangerous charlatans that are out there.”
I explained that some of these patients might suffer from a serious condition which he had been able to diagnose. He countered that this has so far never happened because he is a well-trained and thorough physician.
I explained that his actions are ethically questionable. He laughed and said that, in his view, it was much more ethical to use his time and skills to the best advantage of those who truly need them. In his view, the more important ethical issue over-rides the relatively minor one.
I explained that, by implying that homeopathy is an effective treatment, he is perpetuating a myth which stands in the way of progress. He laughed again and answered that his foremost duty as a GP is not to generate progress on a theoretical level but to provide practical help for the maximum number of patients.
I explained that there cannot be many patients for whom no treatment existed that would be more helpful than a placebo, even if it only worked symptomatically. He looked at me with a pitiful smile and said my remark merely shows how long I am out of clinical medicine.
I explained that doctors as well as patients have to stop that awfully counter-productive culture of relying on prescriptions or ‘magic bullets’ for every ill. We must all learn that, in many cases, it is better to do nothing or rely on life-style changes; and we must get that message across to the public. He agreed, at least partly, but claimed this would require more that the 10 minutes he is allowed for each patient.
I explained….. well, actually, at this point, I had run out of arguments and was quite pleased when someone else started talking to me and this conversation had thus been terminated.
Since that day, I am wondering what other arguments exist. I would be delighted, if my readers could help me out.
Do you suffer from any of the following conditions/problems?
• Feeling of being forsaken and SEPARATION; huge despair.
• Oppression (political, family, abuse-sexual, religious, being bullied) and perceiving yourself as victim.
• States of possession.
• Children of ambitious parents who are pushed.
• Caring professions which give rise to burn out and/or brain deadness.
• Indescribable evil/darkness.
• Not showing anything: MASKS, unsmiling.
• Suspicious, uneasy, shifty eyes; cannot look you in the eye.
• Hangdog of head, beaten.
• Frequent weeping, tears just flow; sense of numbness or despair over them.
• Deep grief which cannot be accessed, unspoken, but it hangs in the air.
• Depression, sense of blackness, total isolation, aloneness, despair.
• Panic, need to escape but can’t. TERROR.
• Feel brainwashed, lack the courage to break free, unable to break from the past.
• Everything will fail; despair of recovery.
• Aggression against yourself.
• Impulsivity – anything can happen.
• Aggression to others or animals (fascinated by it). Child who hangs a cat with a rope around the neck to see what happens.
• Guilt, not resolvable.
• ASTHMA, crushing on chest, suffocation.
• Headache, deep crushing, congestion, bursting with depression and photophobia; gives the feeling of being cut off and isolated.
• After strokes, for parts not connected yet again.
• Temporary blindness and deafness in emotional situations.
• Stiffness of joints-swelling: ” a claw coming into it”.
• Emptiness, a hole in the gut (ulcers).
• Narcolepsia (20 hrs a day).
If so, you are, according to some homeopaths, in need of a very special homeopathic remedy: BERLIN WALL.
No, I am not joking! There are even case reports of successful treatments with this extraordinary remedy: A case of asthma, fear and depression, solved with the remedy ‘Berlin Wall’.
Homeopathy is based on the ‘like cures like’ principle. This means that anything which causes symptoms in a healthy person, can be used to treat these symptoms when they occur in a patient. ANYTHING! Even fragments from the BERLIN WALL.
Of course, the bits of the wall are not administered in their original form; this might be unhealthy and, eventually, it could even exhaust the supply of the raw material. It is ‘potentized‘ which means it is diluted and diluted and diluted and diluted and…
So, the homeopathic BERLIN WALL is as safe as a placebo – in fact, it is a placebo!
Many readers of this blog will be agree that the founder of homeopathy invented placebo-therapy. However, few might know that he did this not once but twice (albeit in entirely different circumstances).
Samuel Hahnemann (1755-1843) was the first physician who administrated placebos to his patient on a systematic and regular basis – at least, this is the thesis that a medical historian with a special interest in homeopathy, R Juette, recently published. His study is based upon unpublished documents (e.g. patients’ letters) kept in the Archives of the Institute for the History of Medicine of the Robert Bosch Foundation in Stuttgart. It also profited from the critical examination of Hahnemann’s case journals and the editorial comments which have also been published in this series.
Hahnemann differentiated clearly between homeopathic drugs and pharmaceutical substances which he considered as sham medicine and called ‘allopathic medicine’. Juette’s analysis of Hahnemann’s case journals revealed that the percentage of Hahnemann’s placebo prescriptions was very high – between 54 and 85 percent. In most instances, Hahnemann marked placebos with the paragraph symbol (§). The rationale behind this practice was that Hahnemann encountered many patients who were used to taking medicine on a daily basis as it was typical for the age of ‘heroic medicine’. His main reason for giving placebos intentionally was therefore to please the impatient patient who was used to the regimen of frequent medications of ‘allopathic’ medicine.
Being a proponent of homeopathy, Juette does not mention Hahnemann’s second invention of placebo therapy: in the shape of his very own, highly diluted homeopathic remedies. Hahnemann was, of course, convinced that they differed from placebo. Two hundred years ago, this attitude was perhaps forgivable. Today, we know that a typical homeopathic medicine contains no substance that could have any meaningful health effects, and that the best evidence fails to show that homeopathic remedies produce effects that differ from placebos. In a word, they are placebos.
It follows that Hahnemann invented the routine use of placebo twice over: 1) intentionally to satisfy the demand for medication of patients who, according to his judgement, needed none, and 2) unintentionally in the form of homeopathic remedies which he thought were effective but are, as we know today, pure placebos.
The mechanisms thorough which spinal manipulative therapy (SMT) exerts its alleged clinical effects are not well established. A new study investigated the effects of subject expectation on clinical outcomes.
Sixty healthy subjects underwent quantitative sensory testing to their legs and low backs. They were randomly assigned to receive a positive, negative, or neutral expectation instructional set regarding the effects of a spe cific SMT technique on pain perception. Following the instructional set, all subjects received SMT and underwent repeat sensory tests.
No inter-group differences in pain response were present in the lower extremity following SMT. However, a main effect for hypoalgesia was present. A significant interaction was present between change in pain perception and group assignment in the low back with participants receiving a negative expectation instructional set demonstrating significant hyperalgesia.
The authors concluded that this study provides preliminary evidence for the influence of a non- specific effect (expectation) on the hypoalgesia associated with a single session of SMT in normal subjects. We replicated our previous findings of hypoalgesia in the lower extremity associated with SMT to the low back. Additionally, the resultant hypoalgesia in the lower extremity was independent of an expectation instructional set directed at the low back. Conversely, participants receiving a negative expectation instructional set demonstrated hyperalgesia in the low back following SMT which was not observed in those receiving a positive or neutral instructional set.
More than 10 years ago, we addressed a similar issue by conducting a systematic review of all sham-controlled trials of SMT. Specifically, we wanted to summarize the evidence from sham-controlled clinical trials of SMT. Eight studies fulfilled our inclusion/exclusion criteria. Three trials (two on back pain and one on enuresis) were judged to be burdened with serious methodological flaws. The results of the three most rigorous studies (two on asthma and one on primary dysmenorrhea) did not suggest that SMT leads to therapeutic responses which differ from an inactive sham-treatment. We concluded that sham-controlled trials of SMT are sparse but feasible. The most rigorous of these studies suggest that SMT is not associated with clinically relevant specific therapeutic effects.
Taken together, these two articles provide intriguing evidence to suggest that SMT is little more than a theatrical placebo. Given the facts that SMT is neither cheap nor devoid of risks, the onus is now on those who promote SMT, e.g. chiropractors, osteopaths and physiotherapists, to show that this is not true.
As promised in the last post, I will try to briefly address the issues which make me uncomfortable about the quotes by Anthony Campbell. Readers will recall that Campbell, an ex-director of what was arguably the most influential homeopathic hospital in the world and a long-time editor of the journal HOMEOPATHY, freely admitted that homeopathy was unproven and its effects were most likely not due to any specific properties of the homeopathic remedies [which are, in fact, pure placebos] but largely rely on non-specific effects.
I agree with much that Campbell wrote but I disagree with one particular implication of his conclusions: “Homeopathy has not been proved to work but neither has it been conclusively disproven….” and “…it is impossible to say categorically that all the remedies are without objective effect…”
This is an argument, we hear from proponents of alternative medicine with unfailing regularity: “MY TREATMENT MAY NOT BE SUPPORTED BY GOOD SCIENCE [BECAUSE GOOD SCIENCE IS EXPENSIVE, AND WE CANNOT AFFORD IT] BUT IT HAS NOT BEEN DISPROVEN EITHER – AND, AS LONG AS IT IS NOT DISPROVEN, NOBODY SHOULD STOP US USING IT”
Campbell does not explicitly draw this latter conclusion but he certainly implies it. In his book, he explains that, even though homeopathic remedies probably are placebos, homeopathy does a lot of good through the placebo effect and through its spiritual aspects. And that is, in his view, sufficient reason to employ it for healing the sick. The very last sentence of his book reads: “Love it or loathe it, homeopathy is here to stay”
So the implication is there: alternative therapies can be as bizarre, nonsensical, implausible, unscientific or idiotic as they like, if we scientists cannot disprove them, they must be legitimate for general use. But there are, of course, two obvious errors in this line of reasoning:
- Why on earth should scientists waste their time and resources on testing notions which are clearly bonkers? It is hard to imagine research that is less fruitful than such an endeavour.
- Disproving homeopathy [or similarly ridiculous treatments] is a near impossibility. Proving a negative is rarely feasible in science.
In the best interest of patients, responsible health care has to follow an entirely different logic: we must consider any treatment to be unproven, while it is not supported with reasonably sound evidence for effectiveness; and in clinical routine, we employ mostly such treatments which are backed by sound evidence, and we avoid those that are unproven. In other words, whether homeopathy or any other medicine is unproven or disproven is of little practical consequence: we try not to use either category.
While I applaud Campbell’s candid judgement regarding the lack of effectiveness of homeopathic remedies, I feel the need to finish his conclusion for him giving it a dramatically different meaning: Homeopathy has not been proved to work but neither has it been conclusively disproven; this means that, until new evidence unambiguously demonstrates otherwise, we should classify homeopathy as ineffective – and this, of course, applies not just to homeopathy but to ALL unproven interventions.
There are numerous types and styles of acupuncture, and the discussion whether one is better than the other has been long, tedious and frustrating. Traditional acupuncturists, for instance, individualise their approach according to their findings of pulse and tongue diagnoses as well as other non-validated diagnostic criteria. Western acupuncturists, by contrast, tend to use formula or standardised treatments according to conventional diagnoses.
This study aimed to compare the effectiveness of standardized and individualized acupuncture treatment in patients with chronic low back pain. A single-center randomized controlled single-blind trial was performed in a general medical practice of a Chinese-born medical doctor trained in both western and Chinese medicine. One hundred and fifty outpatients with chronic low back pain were randomly allocated to two groups who received either standardized acupuncture or individualized acupuncture. 10 to 15 treatments based on individual symptoms were given with two treatments per week.
The main outcome measure was the area under the curve (AUC) summarizing eight weeks of daily rated pain severity measured with a visual analogue scale. No significant differences between groups were observed for the AUC (individualized acupuncture mean: 1768.7; standardized acupuncture 1482.9; group difference, 285.8).
The authors concluded that individualized acupuncture was not superior to standardized acupuncture for patients suffering from chronic pain.
But perhaps it matters whether the acupuncturist is thoroughly trained or has just picked up his/her skills during a weekend course? I am afraid not: this analysis of a total of 4,084 patients with chronic headache, lower back pain or arthritic pain treated by 1,838 acupuncturists suggested otherwise. There were no differences in success for patients treated by physicians passing through shorter (A diploma) or longer (B diploma) training courses in acupuncture.
But these are just one single trial and one post-hoc analysis of another study which, by definition, cannot be fully definitive. Fortunately, we have more evidence based on much larger numbers. This brand-new meta-analysis aimed to evaluate whether there are characteristics of acupuncture or acupuncturists that are associated with better or worse outcomes.
An existing dataset, developed by the Acupuncture Trialists’ Collaboration, included 29 trials of acupuncture for chronic pain with individual data involving 17,922 patients. The available data on characteristics of acupuncture included style of acupuncture, point prescription, location of needles, use of electrical stimulation and moxibustion, number, frequency and duration of sessions, number of needles used and acupuncturist experience. Random-effects meta-regression was used to test the effect of each characteristic on the main effect estimate of pain. Where sufficient patient-level data were available, patient-level analyses were conducted.
When comparing acupuncture to sham controls, there was little evidence that the effects of acupuncture on pain were modified by any of the acupuncture characteristics evaluated, including style of acupuncture, the number or placement of needles, the number, frequency or duration of sessions, patient-practitioner interactions and the experience of the acupuncturist. When comparing acupuncture to non-acupuncture controls, there was little evidence that these characteristics modified the effect of acupuncture, except better pain outcomes were observed when more needles were used and, from patient level analysis involving a sub-set of 5 trials, when a higher number of acupuncture treatment sessions were provided.
The authors of this meta-analysis concluded that there was little evidence that different characteristics of acupuncture or acupuncturists modified the effect of treatment on pain outcomes. Increased number of needles and more sessions appear to be associated with better outcomes when comparing acupuncture to non-acupuncture controls, suggesting that dose is important. Potential confounders include differences in control group and sample size between trials. Trials to evaluate potentially small differences in outcome associated with different acupuncture characteristics are likely to require large sample sizes.
My reading of these collective findings is that it does not matter which type of acupuncture you use nor who uses it; the clinical effects are similar regardless of the most obvious potential determinants. Hardly surprising! In fact, one would expect such results, if one considered that acupuncture is a placebo-treatment.