MD, PhD, FMedSci, FSB, FRCP, FRCPEd

TCM

In alternative medicine, good evidence is like gold dust and good evidence showing that alternative therapies are efficacious is even rarer. Therefore, I was delighted to come across a brand-new article from an institution that should stand for reliable information: the NIH, no less.

According to its authors, this new article “examines the clinical trial evidence for the efficacy and safety of several specific approaches—acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga—as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.”

The results of this huge undertaking are complex, of course, but in a nutshell they are at least partly positive for alternative medicine. Specifically, the authors state that “based on a preponderance of positive trials vs negative trials, current evidence suggests that the following complementary approaches may help some patients manage their painful health conditions: acupuncture and yoga for back pain; acupuncture and tai chi for OA of the knee; massage therapy for neck pain with adequate doses and for short-term benefit; and relaxation techniques for severe headaches and migraine. Weaker evidence suggests that massage therapy, SM, and osteopathic manipulation might also be of some benefit to those with back pain, and relaxation approaches and tai chi might help those with fibromyalgia.”

This is excellent news! Finally, we have data from an authoritative source showing that some alternative treatments can be recommended for common pain conditions.

Hold on, not so fast! Yes, the NIH is a most respectable organisation, but we must not blindly accept anything of importance just because it appears to come form a reputable source. Let’s look a bit closer at the actual evidence provided by the authors of this paper.

Reading the article carefully, it is impossible not to get troubled. Here are a few points that concern me most:

  • the safety of a therapy cannot be evaluated on the basis of data from RCTs (particularly as it has been shown repeatedly that trials of alternative therapies often fail to report adverse effects); much larger samples are needed for that; any statements about safety in the aims of the paper are therefore misplaced;
  • the authors talk about efficacy but seem to mean effectiveness;
  • the authors only included RCTs from the US which must result in a skewed and incomplete picture;
  • the article is from the National Center for Complementary and Integrative Health which is part of the NIH but which has been criticised repeatedly for being biased in favour of alternative medicine;
  • not all of the authors seem to be NIH staff, and I cannot find a declaration of conflicts of interest;
  • the discussion of the paper totally lacks any critical thinking;
  • there is no assessment of the quality of the trials included in this review.

My last point is by far the most important. A summary of this nature that fails to take into account the numerous limitations of the primary data is, I think, as good as worthless. As I know most of the RCTs included in the analyses, I predict that the overall picture generated by this review would have changed substantially, if the risks of bias in the primary studies had been accounted for.

Personally, I find it lamentable that such a potentially worthy exercise ended up employing such lousy methodology. Perhaps even more lamentable is the fact that the NIH (or one of its Centers) can descend that low; to mislead the public in this way borders on scientific misconduct and is, in my view, unethical and unacceptable.

A new Cochrane review evaluated the effectiveness and safety of Chinese herbal medicines (CHM) in the treatment of menopausal symptoms. Its authors conducted a thorough search for randomised controlled trials (RCTs) comparing the effectiveness of CHM with placebo, hormone therapy (HT), pharmaceutical drugs, acupuncture, or another CHM formula in women suffering from menopausal symptoms.

Two review authors independently assessed 864 studies for eligibility. Data extractions were performed by them with disagreements resolved through group discussion and clarification of data or direct contact with the study authors. Data analyses were performed in accordance with Cochrane Collaboration guidelines.

In total, 22 RCTs (2902 women) could be included. When CHM was compared with placebo (8 RCTs), there was little or no evidence of a difference between the groups for the following outcomes: hot flushes per day (MD 0.00, 95% CI -0.88 to 0.89; 2 trials, 199 women; moderate quality evidence); hot flushes per day assessed by an overall hot flush score in which a difference of one point equates to one mild hot flush per day (MD -0.81 points, 95% CI -2.08 to 0.45; 3 RCTs, 263 women; low quality evidence); and overall vasomotor symptoms per month measured by the Menopause-Specific Quality of Life questionnaire (MENQOL, scale 0 to 6) (MD -0.42 points; 95% CI -1.52 to 0.68; 3 RCTs, 256 women; low quality evidence). In addition, results from individual studies suggested there was no evidence of a difference between the groups for daily hot flushes assessed by severity (MD -0.70 points, 95% CI -1.00, -0.40; 1 RCT, 108 women; moderate quality evidence); or overall monthly hot flushes scores (MD -2.80 points, 95% CI -8.93 to 3.33; 1 RCT, 84 women; very low quality evidence); or overall daily night sweats scores (MD 0.07 points, 95% CI -0.19 to 0.33, 1 RCT, 64 women; low quality evidence); or overall monthly night sweats scores (MD 1.30 points, 95% CI -1.76 to 4.36, 1 RCT, 84 women; very low quality evidence). However, one study reported that overall monthly vasomotor symptom scores were lower in the CHM group (MD -4.79 points, 95% CI -5.52 to -4.06; 1 RCT, 69 women; low quality evidence).

When CHM was compared with HT (10 RCTs), only two RCTs reported monthly vasomotor symptoms using MENQOL. It was uncertain whether CHM reduces vasomotor symptoms (MD 0.47 points, 95% CI -0.50 to 1.44; 2 RCTs, 127 women; very low quality evidence).

Adverse effects were not fully reported in the included studies. Adverse events reported by women taking CHM included mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects were inconclusive because of imprecise estimates of effects: CHM versus placebo (RR 1.51; 95% CI 0.69 to 3.33; 7 trials, 705 women; I² = 40%); CHM versus HT (RR 0.96; 95% CI 0.66 to 1.39; 2 RCTs, 864 women; I² = 0%); and CHM versus specific conventional medications (such as Fluoxetine and Estazolam) (RR 0.20; 95% CI 0.03 to 1.17; 2 RCTs, 139 women; I² = 61%).

The authors concluded: We found insufficient evidence that Chinese herbal medicines were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Effects on safety were inconclusive. The quality of the evidence ranged from very low to moderate; there is a need for well-designed randomised controlled studies.

This review seems well done and reports clear findings. The fact that there was insufficient evidence for CHM is probably no surprise to most readers of this blog. However, I would like to draw your attention to a finding that could easily be missed: most of the primary studies failed to mention adverse effects; to be perfectly clear: they did not state “there were no adverse effects”, but they simply did not mention the subject of adverse effects at all.

In my view, this is a breach of research ethics. I have been banging on about this phenomenon for some time now, because I think it is important. Many if not most clinical trials in this area neglect reporting adverse effects. This means that we get an entirely misleading impression about the safety of the treatments in question. Reviewers of such studies are bound to conclude that they seem to be safe, while, in fact, researchers have only been withholding crucial information from us.

The solution to this fast-growing problem would be simple: trialists must be forced to fully report adverse effects. This is less complicated that it might seem: journal editors must insist that all authors fully report adverse effects of alternative treatments. Even if there were none at all – a very unlikely proposition if you think about it – they must disclose this fact.

“THERE IS A SUCKER BORN EVERY MINUTE” – this quote is commonly attributed to P.T.Barnum. If he really coined the sentence, he certainly did not think of the little cups sucking in the skin of patients undergoing cupping therapy. Yet, the recent media coverage of cupping made me think of this quote. The suckers here are not the therapeutic devices employed for cupping but the athletes, the journalists and the general public.

In my experience, athletes are often very worried about their body. This is perhaps understandable but, at the same time, it makes them the ideal victims of all types of charlatans. I am therefore not really surprised to see that some Olympic athletes fell for cupping. They want to use every means allowed by the doping rules to enhance their performance. Cupping therapists claim all sorts of strange and unwarranted things, and some athletes seem to be gullible enough to believe them. Belief can perhaps not move mountains, but it might give you the edge in an Olympic competition.

The ‘beauty’ of cupping when applied to an athlete’s body is that its traces are so publicly visible. During Olympic games, this means that the entire world knows within hours about the cupping-habit of an athlete. What could be more exciting for journalists than these odd cupping marks decorating the muscular bodies of some Olympic athletes? If they are not worth a good story, what is?

There is hardly a newspaper on the planet that did not jump on this band-waggon full of snake oil – there is a sucker born every minute! Nothing wrong with reporting what is happening at the Olympic games, of course. But what has sometimes been reported in the press about cupping beggars belief. Rarely have I read so much nonsense about an alternative therapy in such a short time.

Do you need an example? The DAILY MAIL is as good – or rather bad? – as most; this is what the DM published yesterday on the subject: Chinese media have been cheering cupping’s appearance at the Olympics as proof of the value of traditional culture, with both the official Xinhua news agency and Communist Party mouthpiece People’s Daily touting the soft-power benefits. “Chinese traditions and products proliferate Olympic village”, read one headline on the People’s Daily website. Ding Hui, manager of the Lily Spring Health & Spa in Beijing, said she has seen a 30 percent jump in clients asking for cupping treatment since the Olympics started. “Even though Chinese people have known about it for a long time, they see a great athlete does it and see it really works,” Ding said. “For athletes, they build up harmful lactic acid in the body and cupping can help relieve it.”

You might think that, when reporting about a weird therapy, journalists have little options but to interview weird ‘experts’ relating cupping to even weirder ‘energies’, ‘life forces’, ‘meridians’, yin and yang, TCM, etc. But you would be wrong. They do of course have other options; they would only have needed to log on Medline to find hundreds of references related to the subject. If they had done that, they would even have found an abstract of mine that might have answered many of their question and would have clarified many of the questions about the scientific evidence for or against cupping. Here it is:

The objective of this study was to assess the evidence for or against the effectiveness of cupping as a treatment option for pain. Fourteen databases were searched. Randomized clinical trials (RCTs) testing cupping in patients with pain of any origin were considered. Trials using cupping with or without drawing blood were included, while trials comparing cupping with other treatments of unproven efficacy were excluded. Trials with cupping as concomitant treatment together with other treatments of unproven efficacy were excluded. Trials were also excluded if pain was not a central symptom of the condition. The selection of studies, data extraction and validation were performed independently by three reviewers. Seven RCTs met all the inclusion criteria. Two RCTs suggested significant pain reduction for cupping in low back pain compared with usual care (P < .01) and analgesia (P < .001). Another two RCTs also showed positive effects of cupping in cancer pain (P < .05) and trigeminal neuralgia (P < .01) compared with anticancer drugs and analgesics, respectively. Two RCTs reported favorable effects of cupping on pain in brachialgia compared with usual care (P = .03) or heat pad (P < .001). The other RCT failed to show superior effects of cupping on pain in herpes zoster compared with anti-viral medication (P = .065). Currently there are few RCTs testing the effectiveness of cupping in the management of pain. Most of the existing trials are of poor quality. Therefore, more rigorous studies are required before the effectiveness of cupping for the treatment of pain can be determined.

With just one further click on their keyboard, they would have been able to read the full text of my article which cautioned in no uncertain terms: The number of trials and the total sample size are too small to distinguish between any nonspecific or specific effects, which preclude any firm conclusions. Moreover, the methodological quality was often poor.

Sadly, few journalists seemed to have bothered to do this tiny bit of research. Why? Surely, journalists are trained to investigate their subject before putting pen to paper! Yes, most of them are, but a headline like THE EVIDENCE FOR CUPPING IS FLIMSY does not sell newspapers. The public wants something much more interesting – there is a sucker born every minute!

And what should be wrong with that? People deserve a bit of an entertaining story about their Olympic idols! Perhaps, but there is a downside, of course. The media-hype of the last week will create a demand. The general public will now want the very therapy that helped athletes win gold medals (never mind that it didn’t). Thanks to the media, cupping is now destined to become the alternative therapy of the future.

And what is wrong with that? Quite a lot, I think!

For one, quacks will jump on this fast-moving band-waggon filled with snake oil and try to divert as much cash as they can from their victims’ into their own bank accounts. Perhaps that would not be the worst effect. The worst would be, if some people believe what some quacks will undoubtedly tell them, that cupping is effective (“they see a great athlete does it and see it really works”) for all sorts of conditions, including serious diseases (“Cupping has also been used by some as an alternative treatment for cancer.”) – THERE IS A SUCKER BORN EVERY MINUTE (and some might even die sucking)!

No, I don’t want to put you off your breakfast… but you probably have seen so many pictures of attractive athletes with cupping marks and read articles about the virtues of this ancient therapy, that I feel I have to put this into perspective:

Cupping burnsI am sure you agree that this is slightly less attractive. But, undeniably, these are also cupping marks. So, if you read somewhere that this treatment is entirely harmless, take it with a pinch of salt.

Cupping has existed for centuries in most cultures, and there are several variations of the theme. We differentiate between wet and dry cupping. The above picture is of wet cupping gone wrong. What the US Olympic athletes currently seem to be so fond of is dry cupping.

The principles of both forms are similar. In dry cupping, a vacuum cup is placed over the skin which provides enough suction to create a circular bruise. Eventually the vacuum diminishes, and the cup falls off; what is left is the mark. In wet cupping, the procedure is much the same, except that the skin is injured before the cup is placed. The suction then pulls out a small amount of blood. Obviously the superficial injury can get infected, and that is what we see on the above picture.

In the homeopathic hospital where I worked ~40 years ago, we did a lot of both types of cupping. We used it mostly for musculoskeletal pain. Our patients responded well.

But why? How does cupping work?

The answer is probably more complex than you expect. It clearly has a significant placebo effect. Athletes are obviously very focussed on their body, and they are therefore the ideal placebo-responders. Evidently, my patients 40 years ago also responded to all types of placebos, even to the homeopathic placebos which they received ‘en masse’.

But there might be other mechanisms as well. A TCM practitioner will probably tell you that cupping unblocks the energy flow in our body. This might sound very attractive to athletes or consumers, and therefore could even enhance the placebo response, but it is nevertheless nonsense.

The most plausible mode of action is ‘counter-irritation’: if you have a pain somewhere, a second pain elsewhere in your body can erase the original pain. You might have a headache, for instance, and if you accidentally hit your thumb with a hammer, the headache is gone, at least for a while. Cupping too would cause mild to moderate pain, and this is a distraction from the muscular pain the athletes aim to alleviate.

When I employed cupping 40 years ago, there was no scientific evidence testing its effects. Since a few years, however, clinical trials have started appearing. Many are from China, and I should mention that TCM studies from China almost never report a negative result. According to the Chinese, TCM (including cupping) works for everything. More recently,also some trials from other parts of the world have emerged. They have in common with the Chinese studies that they tend to report positive findings and that they are of very poor quality. (One such trial has been discussed previously on this blog.) In essence, this means that we should not rely on their conclusions.

A further problem with clinical trails of cupping is that it is difficult, if not impossible, to control for the significant placebo effects that this treatment undoubtedly generates. There is no placebo that could mimic all the features of real cupping in clinical trials; and there is no easy way to blind either the patient or the therapist.

So, we are left with an ancient treatment backed by a host of recent but flimsy studies and a growing craze for cupping fuelled by the Olympic games. What can one conclude in such a situation?

Personally, I would, whenever possible, recommend treatments that work beyond a placebo effect, because the placebo response tends to be unreliable and is usually of short duration – and I am not at all sure that cupping belongs into this category. I would also avoid wet cupping, because it can cause substantial harm. Finally, I would try to keep healthcare costs down; cupping itself is cheap but the therapist’s time might be expensive.

In a nutshell: would I recommend cupping? No, not any more than using a hammer for counter irritation! Will the Olympic athletes care a hoot about my recommendations? No, probably not!

 

The aim of a new meta-analysis was to estimate the clinical effectiveness and safety of acupuncture for amnestic mild cognitive impairment (AMCI), the transitional stage between the normal memory loss of aging and dementia. Randomised controlled trials (RCTs) of acupuncture versus medical treatment for AMCI were identified using six electronic databases.

Five RCTs involving a total of 568 subjects were included. The methodological quality of the RCTs was generally poor. Participants receiving acupuncture had better outcomes than those receiving nimodipine with greater clinical efficacy rates (odds ratio (OR) 1.78, 95% CI 1.19 to 2.65; p<0.01), mini-mental state examination (MMSE) scores (mean difference (MD) 0.99, 95% CI 0.71 to 1.28; p<0.01), and picture recognition score (MD 2.12, 95% CI 1.48 to 2.75; p<0.01). Acupuncture used in conjunction with nimodipine significantly improved MMSE scores (MD 1.09, 95% CI 0.29 to 1.89; p<0.01) compared to nimodipine alone. Three trials reported adverse events.

The authors concluded that acupuncture appears effective for AMCI when used as an alternative or adjunctive treatment; however, caution must be exercised given the low methodological quality of included trials. Further, more rigorously designed studies are needed.

Meta-analyses like this one are, in my view, perfect examples for the ‘rubbish in, rubbish out’ principle of systematic reviews. This may seem like an unfair statement, so let me justify it by explaining the shortfalls of this specific paper.

The authors try to tell us that their aim was “to estimate the clinical effectiveness and safety of acupuncture…” While it might be possible to estimate the effectiveness of a therapy by pooling the data of a few RCTs, it is never possible to estimate its safety on such a basis. To conduct an assessment of therapeutic safety, one would need sample sizes that go two or three dimensions beyond those of RCTs. Thus safety assessments are best done by evaluating the evidence from all the available evidence, including case-reports, epidemiological investigations and observational studies.

The authors tell us that “two studies did not report whether any adverse events or side effects had occurred in the experimental or control groups.” This is a common and serious flaw of many acupuncture trials, and another important reason why RCTs cannot be used for evaluating the risks of acupuncture. Too many such studies simply don’t mention adverse effects at all. If they are then submitted to systematic reviews, they must generate a false positive picture about the safety of acupuncture. The absence of adverse effects reporting is a serious breach of research ethics. In the realm of acupuncture, it is so common, that many reviewers do not even bother to discuss this violation of medical ethics as a major issue.

The authors conclude that acupuncture is more effective than nimodipine. This sounds impressive – unless you happen to know that nimodipine is not supported by good evidence either. A Cochrane review provided no convincing evidence that nimodipine is a useful treatment for the symptoms of dementia, either unclassified or according to the major subtypes – Alzheimer’s disease, vascular, or mixed Alzheimer’s and vascular dementia.

The authors also conclude that acupuncture used in conjunction with nimodipine is better than nimodipine alone. This too might sound impressive – unless you realise that all the RCTs in question failed to control for the effects of placebo and the added attention given to the patients. This means that the findings reported here are consistent with acupuncture itself being totally devoid of therapeutic effects.

The authors are quite open about the paucity of RCTs and their mostly dismal methodological quality. Yet they arrive at fairly definitive conclusions regarding the therapeutic value of acupuncture. This is, in my view, a serious mistake: on the basis of a few poorly designed and poorly reported RCTs, one should never arrive at even tentatively positive conclusion. Any decent journal would not have published such misleading phraseology, and it is noteworthy that the paper in question appeared in a journal that has a long history of being hopelessly biased in favour of acupuncture.

Any of the above-mentioned flaws could already be fatal, but I have kept the most serious one for last. All the 5 RCTs that were included in the analyses were conducted in China by Chinese researchers and published in Chinese journals. It has been shown repeatedly that such studies hardly ever report anything other than positive results; no matter what conditions is being investigated, acupuncture turns out to be effective in the hands of Chinese trialists. This means that the result of such a study is clear even before the first patient has been recruited. Little wonder then that virtually all reviews of such trials – and there are dozens of then – arrive at conclusions similar to those formulated in the paper before us.

As I already said: rubbish in, rubbish out!

Acupuncture Today is a much-read online publication for people interested in acupuncture. It informs us that Chinese medicine is quite complex and can be difficult for some people to comprehend. This is because TCM is based, at least in part, on the Daoist belief that we live in a universe in which everything is interconnected. What happens to one part of the body affects every other part of the body. The mind and body are not viewed separately, but as part of an energetic system. Similarly, organs and organ systems are viewed as interconnected structures that work together to keep the body functioning.

To me, this sounds suspiciously woolly. Do they think that conventional healthcare professionals view the various body-parts as separate entities? Do they feel that conventional practitioners see the mind entirely separate from the body? Do they believe others fail to realize that what affects the brain does not affect the rest of the body? These common preconceptions have always puzzled me. Intrigued, I read on.

Elsewhere we learn that Acupuncture Today and acupuncturetoday.com are the only complete news sources in the profession and we don’t take this honor lightly. The acupuncture and Oriental medicine profession is a blend of ancient traditions, healing styles and modern therapies. We provide content that is comprehensive enough to appeal to each of the profession’s diverse groups. In addition, we provide a complete suite of additional products including newsletters, calendars and classifieds that provide our advertisers with the contextual platform they need to communicate with our readers, their customers.

Acupuncture Today seems to reflect a lot of what many acupuncturists want to hear – and thus it might provide us with an important insight into the mind-set of acupuncturists. On their website, I found an article which fascinated me:

START OF QUOTE

A more efficient method for diagnosis and treatment by remote medical dowsing has been found and used in acupuncture with great success. The procedure involves a pendulum, a picture of the patient, an anatomy book, a steel pointer, and a very thin bamboo pointer.

Being a dentist, orthodontist, acupuncturist and dowser, I like to take the liberty of treating a person affected with lockjaw or temporal-mandibular joint ailments via remote dowsing…

…When the mandible cannot open due to a spasm, the chief symptom is pain. Until energy is restored, the muscle cannot lengthen and pain cannot be eliminated. Acupuncture is a good way to correct this condition without the use of a dental appliance. Dentists specializing in treating TMJ use a computerized equipment scan (electrosonography), surface electromyography and the myomonitor to relax the muscles.

Another procedure to treat TMJ is using dowsing. At this point, I will talk about dowsing procedures and information needed to successfully carry out the procedures. Remote dowsing requires the use of the pendulum, a slender bamboo pointer, an anatomy book, a picture of the patient and a steel pointer.

To treat a TMJ patient, the picture of the patient is dowsed holding a pendulum in the right hand while the left hand uses a bamboo pointer to touch the closing and opening muscles individually in the anatomy book. The closing muscles will have good energy (as evidenced by the circular movement of the pendulum) while the lower head of the lateral pterygoid will have no energy (as evidenced by little or no movement of the pendulum). Having advance information on TMJ acupuncture points helps, but these points will have to be tested if needling will supply energy. Master Tong has suggested a point between Liver 2 and Liver 3. I find Spleen 2, a distal point related to the lower head of the lateral pterygoid, to be more effective. This can be checked by having the patient hold the point of the steel pointer so it touches Spleen 2 on the large toe.

To treat a TMJ patient, the picture of the patient is dowsed holding a pendulum in the right hand while the left hand uses a bamboo pointer to touch the closing and opening muscles individually in the anatomy book. The closing muscles will have good energy (as evidenced by the circular movement of the pendulum) while the lower head of the lateral pterygoid will have no energy (as evidenced by little or no movement of the pendulum). Having advance information on TMJ acupuncture points helps, but these points will have to be tested if needling will supply energy. Master Tong has suggested a point between Liver 2 and Liver 3. I find Spleen 2, a distal point related to the lower head of the lateral pterygoid, to be more effective. This can be checked by having the patient hold the point of the steel pointer so it touches Spleen 2 on the large toe.

By dowsing the picture of the patient with the right hand and using a bamboo pointer to touch the lower head of the pterygoid muscle in the anatomy book with the left hand, it will be evident by the circular movement of the pendulum that these muscles now have good energy. This is done before the needle is inserted. In this manner all points can be checked for ailments such as TMJ, stroke, backaches, and neck and shoulder problems before needling. When the needles are placed and after the needling procedure, energy can be checked using the pendulum. By being very accurate on the location of acupuncture points, less treatments will be needed to obtain results. Another point is Small Intestine 19, a local point which is also very effective. Good results are obtained by careful and accurate needling. Therefore, the number of visits are few…

Dowsing is a diagnostic aid that has been used for other situations and can be very helpful to acupuncturists. In conclusion, I feel that remote dowsing is a great approach to diagnosis and treatment.

END OF QUOTE

If I had not seen alternative practitioners doing this procedure with my own eyes, I might have thought the article is a hoax. Sadly, this is the ‘real world’ of alternative medicine.

I tried to find some acupuncturists who had objected to this intense nonsense, but I was not successful in this endeavour. The article was published 6 years ago (no, not on 1 April!), yet so far, nobody has objected.

I have also tried to see whether articles promoting quackery of this nature are rare exceptions in the realm of acupuncture, or whether they are regular occurrences. My impression is that the latter is the case.

What can be concluded from all this?

In a previous post about quackery in chiropractic, I have argued that the tolerance of quackery must be one of the most important hallmarks of a quack profession. As I still believe this to be true, I have to ask to which extend THE TOLERANCE OF SUCH EXTREME QUACKERY MAKES ACUPUNCTURISTS QUACKS?

[I would be most interested to have my readers’ views on this question]

On this blog, I have discussed the lamentable quality of TCM products before (e. g. here, here and here). In a nutshell, far too high percentages of them are contaminated with toxic substances or adulterated with prescription drugs. It is no question: these deficits put many consumers at risk. Equally, there is no question that the problem has been known for decades.

For the Chinese exporters, such issues are a great embarrassment, not least because TCM-products are amongst the most profitable of all the Chinese exports. In the past, Chinese officials have tried to ignore or suppress the subject as much as possible. I presume they fear that their profits might be endangered by being open about the dubious quality of their TCM-exports.

Recently, however, I came across a website where unusually frank and honest statements of Chinese officials appeared about TCM-products. Here is the quote:

China is to unroll the fourth national survey of traditional Chinese medicine (TCM) resources to ensure a better development of the industry, said a senior health official…

With the public need for TCM therapies growing, the number of medicine resources has decreased and people have turned to the cultivated ones. However, due to a lack of standards, the cultivated TCM resources are sometimes less effective or even unsafe for human use, said Wang Guoqiang, director of the State Administration of TCM, at a TCM seminar held in Kunming, Yunnan Province in southwest China.

There is a pressing need to protect TCM resources, Wang said. “I’ve heard people saying that medicine quality will spell doom for the TCM industry, which I must admit, is no exaggeration,” he said.

The survey has been piloted in 922 counties in 31 provinces in China since 2011. According to its official website, it will draw a clear picture of the variety, distribution, storage and growth trends of TCM resources, including herbs, animals, minerals and synthetic materials.

TCM includes a range of traditional medical practices originating in China. It includes such treatments as herbal medicine, acupuncture, massage (tuina), exercise (qigong) and dietary therapy.

Although well accepted in the mainstream of medical care throughout East Asia, TCM is considered an alternative medical system in much of the western world and has been a source of controversy. A milestone in the recognition of TCM came when Chinese pharmaceutical chemist Tu Youyou won a Nobel Prize in 2015 for her discovery of Artemisinin, a medicinal herb, to help treat malaria.

END OF QUOTE

Surely, these are remarkable, perhaps even unprecedented statements by Chinese officials:

…cultivated TCM resources are sometimes less effective or even unsafe for human use…

…medicine quality will spell doom for the TCM industry…

Let’s hope that, after such words, there will be appropriate actions… finally.

We were recently informed that Americans spend more than US$ 30 billion per year on alternative medicine. This is a tidy sum by anyone’s standards, and we may well ask:

Why do so many people opt for alternative medicine?

The enthusiasts claim, of course, that this is because alternative medicine is effective and safe. As there is precious little data to support this claim, it is probably not the true answer. There must be other reasons, and I could name several. For instance, it could be due to consumers being conned by charlatans.

During the 25 years or so that I have been researching alternative medicine, I got the impression that there are certain ‘tricks of the trade’ which alternative practitioners use in order to convince the often all too gullible public. In this series of posts, I will present some of them.

Here are the first three:

TREAT A NON-EXISTING CONDITION

There is nothing better for committing a health fraud than to treat a condition that the patient in question does not have. Many alternative practitioners have made a true cult of this handy option. Go to a chiropractor and you will in all likelihood receive a diagnosis of ‘subluxation’. See a TCM practitioner and you might be diagnosed suffering from ‘chi deficiency’ or ‘chi blockage’ etc.

Each branch of alternative practitioners seem to have created their very own diagnoses, and they have one thing in common: they are figments of their imaginations. To arrive at such diagnoses, the practitioner would often use diagnostic techniques which have either been found to lack validity, or which have never been validated at all. Many practitioners appreciate all of this, of course, but it would be foolish of them to admit it – after all, these diagnoses earn them the bulk of their living!

The beauty of a non-existing diagnosis is that the practitioner can treat it, and treat it and treat it…until the client has run out of money or patience. Then, one day, the practitioner can proudly announce to his patient “you are completely healthy now”. This happens to be true, of course, because the patient has been healthy all along.

My advice for preventing to get fleeced in this way: make sure that the diagnosis given by an alternative practitioner firstly exists at all in the realm of real medicine and secondly is correct; if necessary ask a real healthcare professional.

MAINTENANCE TREATMENT

As I just stated, practitioners like to treat and treat and treat conditions which simply do not exist. When – for whatever reason – this strategy fails, the next ‘trick of the trade’ is often to convince the patient of the necessity of ‘maintenance’ treatment. This term describes the regular treatment of an individual who is entirely healthy but who, according to the practitioner, needs regular treatments in order not to fall ill in future. The best example here is chiropractic.

Many chiropractors proclaim that maintenance treatment is necessary for keeping a person’s spine aligned – and only a well-serviced spine will keep all of our body’s systems working perfectly. It is like with a car: if you don’t service it regularly, it will sooner or later break down. You don’t want this to happen to your body, do you? To many ‘worried well’, this sounds so convincing that they actually fall for this scam. It goes without saying that the value of maintenance treatment is unproven.

My advice is to start running as soon as a practitioner mentions maintenance treatments.

IT MUST GET WORSE BEFORE IT GETS BETTER

Many patients fail to experience an improvement of their condition or even feel worse after receiving alternative treatments. Practitioners of alternative medicine love to tell these patients that this is normal because things have to get worse before they get better. They tend to call this a ‘healing crisis’. Like so many notions of alternative practitioners, the healing crisis is a phenomenon for which no or very little compelling evidence was ever produced.

Imagine a patient with moderately severe symptoms consulting a practitioner and receiving treatment. There are only three things that can happen to her:

  • she can get better,
  • she might experience no change at all,
  • or she might get worse.

In the first scenario, the practitioner would obviously claim that his therapy is responsible for the improvement. In the second scenario, he might say that, without his therapy, things would have deteriorated. In the third scenario, he would tell his patient that the healing crisis is the reason for her experience. In other words,  the myth of the healing crisis is little more than a ‘trick of the trade’ to make even these patients continue supporting the practitioner’s livelihood.

My advice: when you hear the term ‘healing crisis’, go and find a real doctor to help you with your condition.

 

 

 

 

The ‘ALT MED HALL OF FAME’ is filling up very nicely. Remember: so far, I have honoured the following individuals for (almost) never publishing anything else but positive results (in brackets are the main alternative therapies of each researcher and the countries where they are currently based):

Peter Fisher (homeopathy, UK)

Simon Mills (herbal medicine, UK)

Gustav Dobos (various, Germany)

Claudia Witt (homeopathy, Germany and Switzerland)

George Lewith (acupuncture, UK)

John Licciardone (osteopathy, US)

Today, I am about to admit another female to our club of alt med elite (the group was in danger of getting a bit too male-dominated) : Prof Nicola Robinson from the School of Health and Social Care, London South Bank University, UK. She may not be known to many of my readers; therefore I better provide some extra information. Her own institution wrote her up as follows:

Professor Nicola Robinson joined London South Bank University in March 2011 as Professor of Traditional Chinese Medicine and Integrated Health. Previously she was Professor of Complementary Medicine, University of West London. Professor Robinson’s former posts include; Consultant Epidemiologist Brent and Harrow Health Authority, Senior lecturer in Primary Healthcare University College London, Lecturer at Charing Cross and Westminster Hospital Medical School and Research Fellow at the London School of Hygiene and Tropical Medicine.

She graduated from Leicester University with a BSc (Hons) in Biological Sciences, and her PhD from Manchester University was in Immunology. She has been a registered acupuncturist since 1982. In 1985 Nicola was awarded an RD Lawrence Fellowship by Diabetes UK and in 1993 she was given an Honorary Membership of the Faculty of Public Health Medicine for her contribution to epidemiology and health services research. 

In 2004, Nicola was awarded a Winston Churchill Traveling Fellowship to visit China, to explore educational and research initiatives in Traditional Chinese Medicine at various universities and hospitals. Nicola has a keen interest in complementary medicine and its assimilation and integration into mainstream health care and has been involved in various research initiatives with professional groups. 

Nicola has written over 200 scientific articles in peer reviewed journals, prepared scientific reports and presented research at local, national and international conferences. She is the Editor in Chief of the European Journal of Integrative Medicine (Elsevier) as well as being on the editorial boards of other scientific journals. She has had considerable research experience in various aspects of public health that has covered a wide range of subject arenas including: complementary medicine, cancer, patient public engagement, mental health, diabetes, coronary heart disease, HIV, cystic fibrosis and psychosocial aspects of disease. She has various research links in China and has had successfully supervised both Chinese and UK PhD students.

As always, I conducted a Medline search for ‘Robinson N, alternative medicine’, which generated 50 articles. I excluded those articles that were not on alternative medicine (probably from someone by the same name) and those that had no abstract with conclusions about the value of alternative medicine. Of the rest, I included the most recent 10 papers. Below I show these articles with the appropriate links and the conclusion (in bold).

Integrative treatment for low back pain: An exploratory systematic review and meta-analysis of randomized controlled trials.

Hu XY, Chen NN, Chai QY, Yang GY, Trevelyan E, Lorenc A, Liu JP, Robinson N.

Chin J Integr Med. 2015 Oct 26. [Epub ahead of print]

Integrative treatment that combines CAM with conventional therapies appeared to have beneficial effects on pain and function. However, evidence is limited due to heterogeneity, the relatively small numbers available for subgroup analyses and the low methodological quality of the included trials. Identification of studies of true IM was not possible due to lack of reporting of the intervention details.

Complementary therapy provision in a London community clinic for people living with HIV/AIDS: a case study.

Lorenc A, Banarsee R, Robinson N.

Complement Ther Clin Pract. 2014 Feb;20(1):65-9. doi: 10.1016/j.ctcp.2013.10.003. Epub 2013 Oct 15

Complementary Ttherapies may provide important support and treatment options for HIV disease, but cost effectiveness requires further evaluation.

A review of the use of complementary and alternative medicine and HIV: issues for patient care.

Lorenc A, Robinson N.

AIDS Patient Care STDS. 2013 Sep;27(9):503-10. doi: 10.1089/apc.2013.0175. Review

Clinicians, particularly nurses, should consider discussing CAM with patients as part of patient-centered care, to encourage valuable self-management and ensure patient safety.

Meditative movement for respiratory function: a systematic review.

Lorenc AB, Wang Y, Madge SL, Hu X, Mian AM, Robinson N.

Respir Care. 2014 Mar;59(3):427-40. doi: 10.4187/respcare.02570. Epub 2013 Jul 23. Review

The available evidence does not support meditative movement for patients with CF, and there is very limited evidence for respiratory function in healthy populations. The available studies had heterogeneous populations and provided inadequate sampling information, so clinically relevant conclusions cannot be drawn. Well powered, randomized studies of meditative movement are needed.

Is the diurnal profile of salivary cortisol concentration a useful marker for measuring reported stress in acupuncture research? A randomized controlled pilot study.

Huang W, Taylor A, Howie J, Robinson N.

J Altern Complement Med. 2012 Mar;18(3):242-50. doi: 10.1089/acm.2010.0325. Epub 2012 Mar 2.

This pilot study suggests that TCA could reduce stress and increase the morning rise of the cortisol profile; however, this was not distinguishable from the effect of attention only.

The evidence for Shiatsu: a systematic review of Shiatsu and acupressure.

Robinson N, Lorenc A, Liao X.

BMC Complement Altern Med. 2011 Oct 7;11:88. doi: 10.1186/1472-6882-11-88. Review.

Evidence is improving in quantity, quality and reporting, but more research is needed, particularly for Shiatsu, where evidence is poor. Acupressure may be beneficial for pain, nausea and vomiting and sleep.

Autogenic Training as a behavioural approach to insomnia: a prospective cohort study.

Bowden A, Lorenc A, Robinson N.

Prim Health Care Res Dev. 2012 Apr;13(2):175-85. doi: 10.1017/S1463423611000181. Epub 2011 Jul 26

This study suggests that AT may improve sleep patterns for patients with various health conditions and reduce anxiety and depression, both of which may result from and cause insomnia. Improvements in sleep patterns occurred despite, or possibly due to, not focusing on sleep during training. AT may provide an approach to insomnia that could be incorporated into primary care.

Traditional and complementary approaches to child health.

Robinson N, Lorenc A.

Nurs Stand. 2011 May 25-31;25(38):39-47.

Health visitors had greater knowledge and understanding of TCA than practice nurses or nurse practitioners, often informed by patients and personal experience. Health visitors reported that they discussed TCA with families using a culturally competent and family-centred approach to explain the advantages and disadvantages of TCA. This is probably made possible by their ongoing, close relationship with parents in the home environment and their focus on child health. Other primary care nurses were reluctant to engage with patients on TCA because of concerns about liability, lack of information and practice and policy constraints. Practice nurses and nurse practitioners may be able to improve their holistic and patient-centred practice by learning from health visitors’ experience, particularly cultural differences and safety issues. Nurses and their professional bodies may need to explore how this can be achieved given the time-limited and focused nature of practice-based consultations.

A case study exploration of the value of acupuncture as an adjunct treatment for patients diagnosed with schizophrenia: results and future study design.

Ronan P, Robinson N, Harbinson D, Macinnes D.

Zhong Xi Yi Jie He Xue Bao. 2011 May;9(5):503-14

The study indicates that patients diagnosed with schizophrenia would benefit from acupuncture treatment alongside conventional treatment.

An investigation into the effectiveness of traditional Chinese acupuncture (TCA) for chronic stress in adults: a randomised controlled pilot study.

Huang W, Howie J, Taylor A, Robinson N.

Complement Ther Clin Pract. 2011 Feb;17(1):16-21. doi: 10.1016/j.ctcp.2010.05.013. Epub 2010 Jun 19

This pilot study suggests that TCA may be successful in treating the symptoms of stress, through a combination of specific and non-specific effects; but may not relate directly to how a person perceives their stress.

I think we have here a very clear case: Prof Robinson has investigated a range of very different alternative therapies for vastly different conditions. She drew 9 positive and one negative conclusions. This renders her ‘Trustworthiness Index’ truly remarkable. I am therefore confident that we all can agree to admit her to the ALT MED HALL OF FAME.

As if to celebrate the end of ‘Acupuncture Awareness Week’, I am off today to give a few lectures in Oslo. One title is most fitting: ACUPUNCTURE: FACTS AND FALLACIES. Here are some of the fallacies I intend to discuss:

  • Appeal to popularity
  • Appeal to tradition
  • Science can explain how it works
  • Acupuncture is a ‘cure-all’
  • It worked for me, my aunt, etc.
  • Acupuncture even works for animals
  • Even if it’s just a placebo, it helps patients.
  • It defies scientific testing.
  • Acupuncture research is productive
  • Acupuncture is by definition rubbish
  • Acupuncture is risk-free
  • Its benefits outweigh its risks

None of these themes need much by way of explanation for the readers of this blog, I think.

So, why do I mention them at all?

The answer is simple: I was hoping to get a few inspirations and tips from you for further subjects that I might include.

WHAT DO YOU THINK ARE THE MAIN FALLACIES IN THE REALM OF ACUPUNCTURE?

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