MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

There must be well over 10 000 clinical trials of acupuncture; Medline lists ~5 000, and many more are hidden in the non-Medline listed literature. That should be good news! Sadly, it isn’t.

It should mean that we now have a pretty good idea for what conditions acupuncture is effective and for which illnesses it does not work. But we don’t! Sceptics say it works for nothing, while acupuncturists claim it is a panacea. The main reason for this continued controversy is that the quality of the vast majority of these 10 000 studies is not just poor, it is lousy.

“Where is the evidence for this outraging statement???” – I hear the acupuncture-enthusiasts shout. Well, how about my own experience as editor-in-chief of FACT? No? Far too anecdotal?

How about looking at Cochrane reviews then; they are considered to be the most independent and reliable evidence in existence? There are many such reviews (most, if not all [co-]authored by acupuncturists) and they all agree that the scientific rigor of the primary studies is fairly awful. Here are the crucial bits of just the last three; feel free to look for more:

All of the studies had a high risk of bias

All included trials had a high risk of bias…

The studies were not judged to be free from bias…

Or how about providing an example? Good idea! Here is a new trial which could stand for numerous others:

This study was performed to compare the efficacy of acupuncture versus corticosteroid injection for the treatment of Quervain’s tendosynovitis (no, you do not need to look up what condition this is for understanding this post). Thirty patients were treated in two groups. The acupuncture group received 5 acupuncture sessions of 30 minutes duration. The injection group received one methylprednisolone acetate injection in the first dorsal compartment of the wrist. The degree of disability and pain was evaluated by using the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) scale and the Visual Analogue Scale (VAS) at baseline and at 2 weeks and 6 weeks after the start of treatment. The baseline means of the Q-DASH and the VAS scores were 62.8 and 6.9, respectively. At the last follow-up, the mean Q-DASH scores were 9.8 versus 6.2 in the acupuncture and injection groups, respectively, and the mean VAS scores were 2 versus 1.2. Thus there were short-term improvements of pain and function in both groups.

The authors drew the following conclusions: Although the success rate was somewhat higher with corticosteroid injection, acupuncture can be considered as an alternative option for treatment of De Quervain’s tenosynovitis.

The flaws of this study are exemplary and numerous:

  • This should have been a study that compares two treatments – the technical term is ‘equivalence trial – and such studies need to be much larger to produce a meaningful result. Small sample sizes in equivalent trials will always make the two treatments look similarly effective, even if one is a pure placebo.
  • There is no gold standard treatment for this condition. This means that a comparative trial makes no sense at all. In such a situation, one ought to conduct a placebo-controlled trial.
  • There was no blinding of patients; therefore their expectation might have distorted the results.
  • The acupuncture group received more treatments than the injection group; therefore the additional attention might have distorted the findings.
  • Even if the results were entirely correct, one cannot conclude from them that acupuncture was effective; the notion that it was similarly ineffective as the injections is just as warranted.

These are just some of the most fatal flaws of this study. The sad thing is that similar criticisms can be made for most of the 10 000 trials of acupuncture. But the point here is not to nit-pick nor to quack-bust. My point is a different and more serious one: fatally flawed research is not just a ‘poor show’, it is unethical because it is a waste of scarce resources and, even more importantly, an abuse of patients for meaningless pseudo-science. All it does is it misleads the public into believing that acupuncture might be good for this or that condition and consequently make wrong therapeutic decisions.

In acupuncture (and indeed in most alternative medicine) research, the problem is so extremely wide-spread that it is high time to do something about it. Journal editors, peer-reviewers, ethics committees, universities, funding agencies and all others concerned with such research have to work together so that such flagrant abuse is stopped once and for all.

3 Responses to Acupuncture research: I am afraid, much of it is unethical abuse

  • Dear Dr. Ernst,

    As a licensed and practicing acupuncturist in the United States, you may be surprised to see that I am in complete agreement with your critique on the research done in acupuncture thus far. It seems to me that rather than taking the time to coordinate robust and efficacious studies, hundreds/thousands of sub part studies are being pumped out to flood the arena. This is doing nothing but creating a dynamic of confusion and clutter about the realm of acupuncture, and it’s frustrating to watch it happen.

    I stand by my form of medicine completely, but also realize it’s not a panacea and it’s not for everybody. It is my hope that it will eventually find it’s niche in modern medicine without abandoning the principles it is founded on.

    Thank you for your candor.

    Cheers,
    Andrea

  • Sadly, in addition to patients being deceived by bad research, many people who choose to become acupuncturists are convinced by the bad research that it “works.” By “works” it means that the points in the book have the functions described in the text. Functions are often *very* specific and suggest actual disease modifying actions. Apologists now look at endorphin changes and other transitory changes on subjective symptoms (pain, nausea) and claim acupuncture “works.” This is a far cry from the claims in TCM texts. Even suggestive research around endorphins shows small, if any, difference from non-penetrating sham needles (when blinding is as optimal as can be). But once one is invested in the system, there are enough pro-acupuncture sites which cherry-pick and distort low quality research that many acupuncturists can just accept that as ‘state of the science’ and go on believing their treatments are “working.” When the natural course or regression to the mean happens to a patient, both acupuncturist and patient often attribute the improvement to acupuncture. This further reinforces belief in the modality. However, with a large enough, properly randomized sample with a credible placebo treatment is done, putting needles into specific locations is no better than pretending to put needles in non-specific locations. The communication style and claims of the practitioner are the most important factor. Does this justify being highly charismatic and making confident, exaggerated claims? Those behaviors will get a “better” result on subjective reports of improvement. So, too, will charging more for a treatment.

    But charging a lot for a treatment which doesn’t produce the actual claimed results in terms of modifying the course of an actual disease while pumping up the placebo effects with caring, confident communication is generally regarded as unethical. At this point, acupuncturists must be hoping their patients don’t read Wikipedia, Cochrane reviews, or many of the well-referenced skeptical blogs about acupuncture. Or perhaps they explain those sites away with Big Pharma Conspiracy theories, which many alternative medicine patients are already inclined to believe.

    If an acupuncturist learns of the best quality evidence showing acupuncture to be equivalent to fake acupuncture and continues doing it, they should feel pangs of conscience as they see low-income patients continue to spend money they can’t really afford on a wide range of ineffective treatments. Sure, one can add science-based recommendations for diet and exercise during a treatment session, but if the patient is coming for acupuncture and expects to have a disease cured, there is deception involved even if the expectations aren’t coming directly from the acupuncturist charging for the treatments.

    This was my line of realization when I stopped doing acupuncture. I’ve been happier and felt more ethically congruent since.

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