Today the GUARDIAN published an article promoting acupuncture on the NHS. The article is offensively misleading, I think, and therefore deserves a comment. I write these comments with a heavy heart, I should add, because the GUARDIAN is by far my favourite UK daily. In the following, I will cite key passages from the article in question and add my comments in bold.
Every woman needing pain relief while giving birth at University College London hospital (UCLH) is offered acupuncture, with around half of the hospital’s midwives specially trained to give the treatment. UCLH is far from typical in this respect, though: acupuncture is not standard throughout the UK and many health practitioners claim patients are often denied access to it through the NHS because of entrenched scepticism from sections of the medical establishment.
Entrenched scepticism? I would say that it could be perhaps be related to the evidence. The conclusions of the current Cochrane review on acupuncture for labour pain are cautious and do not seem strong enough to issue a general recommendation for general use in childbirth: “acupuncture and acupressure may have a role with reducing pain, increasing satisfaction with pain management and reduced use of pharmacological management. However, there is a need for further research.”
“There are conditions for which acupuncture works and others where it doesn’t. It is not a cure-all, and should be open to scrutiny. But the focus of my work is for acupuncture to become a standard part of midwifery training, and at the same time change perceptions among clinicians about its appropriate use for a whole range of other conditions.”
Open to scrutiny indeed! And if we scrutinise the evidence critically – rather than engaging in uncritical and arguably irresponsible promotion – we find that the evidence is not nearly as convincing as acupuncture fans try to make us believe.
The UK lags behind many other European countries in its support for acupuncture. Just 2,500 medical professionals here are qualified to practice it, compared with 45,000 in Germany. The National Institute for Clinical Excellence (Nice) recommends WMA specifically for the treatment of only two conditions – lower back pain (which costs the NHS £1bn a year) and headaches.
Yes, the UK also lags behind Germany in the use of leeches and other quackery. The ‘ad populum’ fallacy is certainly popular in alternative medicine – but surely, it is still a fallacy!
A growing body of healthcare practitioners believe it should be offered routinely for a variety of conditions, including pain in labour, cancer, musculoskeletal conditions and even irritable bowel syndrome (IBS).
Here we go, belief as a substitute for evidence and fallacies as a replacement of logical arguments. I had thought the GUARDIAN was better than this!
At a time of NHS cuts the use of needles at 8p per unit look attractive. In St Albans, where a group of nurse-led clinics have been using acupuncture since 2008 for patients with knee osteoarthritis, economics have been put under scrutiny. WMA was offered to 114 patients rather than a knee replacement costing £5,000, and 79% accepted. Two years later a third of them had not required a knee transplant, representing an annual saving of £100,000, as estimated by researchers to the St Albans local commissioning group.
This looks a bit like a ‘back of an envelope’ analysis. I would like to see this published in a reputable journal and see it scrutinised by a competent health economist.
So why is acupuncture not being used more widely? The difficulty of proving its efficacy is clearly one of the biggest stumbling blocks. An analysis of 29 studies of almost 18,000 patients found acupuncture effective in treating chronic pain compared with sham acupuncture.
This passage refers to an analysis by Vickers et al. It was severely and repeatedly criticised for being too optimistic and, more importantly, it is not nearly as positive as implied here. Its conclusions are in fact quite cautious: “acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.”
But even treatment proponents question whether a randomised controlled trial – the gold standard of medical research – works, given that faking treatment is nearly impossible.
What do you mean ‘even treatment proponents’? It is only proponents who question these sham needles! The reason: they frequently do not generate the results acupuncture fans had hoped for.
The article is clearly not the GUARDIAN’s finest hour. It lacks even a tinge of critical assessment. This is regrettable, I think, particularly as the truth about acupuncture is not that difficult to transmit to the public:
- Much of the research is of woefully poor quality.
- Its effectiveness is not proven beyond doubt for a single condition.
- Serious adverse effects have been reported.
- Because it requires substantial amounts of therapist time, it also is not cheap.
It was pointed out to me on twitter that the article was “sponsored by Brother”.
It certainly won’t help their image much.
I’m sympathetic to the financial plight of newspapers. That’s why I pay for a print copy of the paper despite reading it mostly on the web. I joined as a Guardian member too. I don’t want, in return, to get badly=researched cheapskate informercials -advertisements disguised as editorial content.
Acupuncture and essential oil “therapy” are two “complementary” methods increasingly used by midwives at the University Hospital in Reykjavik, Iceland. Their handbook for these “therapies” could just as well have been written by JK Rowling for use at Hogwart’s school of sorcery.
The two methods are used extensively at the department of obstetrics, both during pregnancy, in preparation for labour (e.g. acupuncture for promoting softening of the cervix !) and in labour, where the mother as often as not hasn’t been informed or asked for consent beforehand. Acupuncture is regularly thrust upon women under distress of labour, sometimes denying them other forms of pain management until acupuncture has been tried! This regularly delays effective pain measures until it is to late anyway. Of course many mothers have prior expectations of such exotic measures and duly believe the needling and aroma fantasy helped. But most do not want to be bothered and are glad to bring home a baby in one piece and prefer to forget the pungent aromas and nerdy needling the midwife thrust upon them during their labour.
Too me, the driving force behind this extra-scientific excursion of supposedly academic health care providers, seems to be a (subliminal?) wish to elevate their professional status and have something powerful to offer, preferably over and above what the drearily reductionistic doctors have to offer.
It is difficult to counteract or work against this trend as the nurses/midwives have long since gained independence as a profession and sort under a separate authority within the hospital. Be that as it may, but it does create the proverbial “silo effect”, which can be so deleterious to progress and efficacy in organisations.
Also, the physician leadership finds this particular conflict way too hot to handle and choose to shrug and hope the midwives do no serious harm with their (hopefully) innocent antics.
I worked in supply in a major teaching hospital in Melbourne, Australia, for a short time, and found nurses to be the biggest impediment to change in the place. I agree with your assessment; ” the driving force behind this extra-scientific excursion of supposedly academic health care providers, seems to be a (subliminal?) wish to elevate their professional status and have something powerful to offer, preferably over and above what the drearily reductionistic doctors have to offer.”
Nurses don’t have the same exceptional high criteria to enter university or the rigorous training while there, and it shows. A couple of years ago, a nurse friend had one unit to complete her masters, basic statistics. The task was finding a standard deviation of a fairly short, non-demanding list. While having a rudimentary understanding of statistics, I had not ever done such a calculation. Nonetheless, since I can read, I offered to help.
We went the exercise, with me doing a lot of prompting and we (mostly me) arrived at an answer. I had done a rough mental approximation and the answer looked good. I then said we will plug the list into M$ Excel and get the answer quickly to check. Unsurprisingly, the answer we (I) calculated was correct.
While I have a great deal of respect for the work nurses do and their commitment, I can’t say I have the same, generally, for their intellects. They learn largely by rote and seem to have a great resistance to change, despite the evidence.
A report in Australia a few years ago revealed that funding of healthcare was NOT the cause of poor delivery of services; instead, it found that poor management was the primary cause, largely lead by nurses. You may be surprised to learn that nothing has changed. (Sorry, couldn’t help the sarcasm.)
While at the hospital, I made several suggestions for faster, more accurate, and more frequent deliveries of ward medical consumables that were rejected by the NUMs (great title, as a seeming pejorative for Nurse Unit Managers) because it may compromise patient care. How a far better, cheaper, and more frequent service would do that is completely beyond me.
‘Of course many mothers have prior expectations of such exotic measures and duly believe the needling and aroma fantasy helped. But most do not want to be bothered…’
Those silly hysterical women – they can’t be trusted to know whether something relieved their pain or not. And which is it, that many believe it helps, or most don’t want to be bothered? Any stats (evidence) to back up your opinions?
Yes I have Tom. Massive evidence. It has all been discussed here on this blog. Just dial in the keyword and read on.
Foremost, there is of lack of evidence. Just as there is massive lack of evidence for the existence of Santa Claus. Despite all the anecdotes and stories. The problem with midwives dabbling in this delusional nonsense is not that they cater to the imagined needs of the occasional new-age fancying mother. It is that they are disturbing others with unsolicited antics. And in particular, they are disturbing both the natural and normal process of pregnancy and birth and adding an element of unnecessary risk. Mothers have been complaining afterwards of irritating “aromatherapy” fumes and having needles thrust upon them without consent. The rsk of infection is real albeit low.
The responsibility of evidence is really yours and your few colleagues who still sell this service. If acupuncture was any good, why isn’t everybody using it? I see only the occasional pin-parlour, usually combined with other new-age nonsense or fondling therapy like craniosacral or crystal healiing.
Do you have any evidence that acupuncture works Tom? Other than the count of your customers of course. Can you provide evidence that the ancient bloodletting type with the nine classical brass knives and lances described by contemporary observers or the modern invention using thin needles, invented in the advent of the chineses cultural revolution, has any effects beyond the placebo? If so I can help you get in touch with the Nobel committee.
Would you mind pointing me specifically to the evidence you have on the University Hospital service you mention? Then I’ll try to reply to your other points, for what it’s worth.
Not sure Tom what you want from me. The burden of evidence lies on you and other users of acupuncture, not on us who have already brought forth evidence that the recently remade relic of acupuncture has no demonstrably useful function other than that of a theatrical stunt.
If you mean evidence corroborating my story, that would be in Icelandic, a language I doubt you will comprehend. If you question my honesty then please explain why.
“Those silly hysterical women – they can’t be trusted to know whether something relieved their pain or not.”
Which is why proper studies are double-blinded and the rest, to remove personal perceptions. By the way, what do the RCTs show about acupuncture? (Rhetorical question.)
” And which is it, that many believe it helps, or most don’t want to be bothered?”
Maybe both? While appreciating the argument from authority fallacy, Björn has been up to his elbows in other people’s guts. Instead in sticking pissy little needles in someone’s skin, he has cut through that skin, the muscle and exposed the deepest anatomy, then surgically manipulated internal organs. While this may surprise you, Tom, a few people (this is sarcasm) appreciate his efforts, because they are alive. Just out of curiosity, how many lives did you save last week?
“Any stats (evidence) to back up your opinions?”
This is my turn for a Tu Quoque, but how much evidence do you have for your fiddling around the edges with your needles?
According to you website (http://www.tomtheacupuncturist.com/acupuncture-tuina-chinese-massage-bristol/#about-acupuncture), inter alia, “WHAT TO EXPECT…….Adverse reactions are rare, although bruising can occasionally occur which usually clears within a few days. You may notice your bowel movements and other bodily functions alter as your system adjusts to treatment, and some people may experience what is sometimes called a ‘healing crisis’, where the condition temporarily worsens following treatment before getting better. You may feel tired after a treatment and should allow time to recover before driving etc.”, you lack understanding of such simple terms as, ‘regression to the mean”, “self limiting”, and “natural progression”.
You also say this, (http://www.tomtheacupuncturist.com/#tom-kennedy-tuina-acupuncture-bristol), “Although he doesn’t promote false hope, he believes strongly that everyone can at least improve their health and well being, and in many cases they can revolutionise it.”
Sorry Tom, you may be very earnest, but you are a fiddler around the edges dealing with the worried well. Even your “work” at the Penny Brohn Centre is after the real work is done by real doctors doing real medicine.
Your approach reminds why I shouldn’t waste my time trying to engage reasonable, grown-up debate on this forum. I’ll wearily respond to a few of your points, and leave you to own devices.
‘By the way, what do the RCTs show about acupuncture? (Rhetorical question.)’
Why is this rhetorical? Despite all the inherent problems with this imperfect way of evaluating the therapy, there are RCTs that show positive results for ‘true’ acupuncture (I use the word ‘true’ lightly, as what is studied is often far from the clinical norm, and I understand the reasons for this). Cochrane reviews are often seen as the best evidence available, and here are a couple of examples:
‘In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.’
‘Compared with sham treatment P6 acupoint stimulation significantly reduced: nausea (RR 0.71, 95% CI 0.61 to 0.83); vomiting (RR 0.70, 95% CI 0.59 to 0.83), and the need for rescue antiemetics (RR 0.69, 95% CI 0.57 to 0.83).’
Many of the other reviews conclude that there are some positive indications, but more high quality research is needed. This is very different from saying it doesn’t work.
Acupuncture is an extremely complex intervention with multiple variables at play, and I applaud the efforts of those who try to study it scientifically and with an open mind. However, I also feel this approach will never reveal the best that acupuncture has to offer, due to the necessary restrictions of the double blind trial. This will never satisfy those with a obstinately black-and-white, reductionist view of reality.
‘a few people (this is sarcasm) appreciate [Björn’s] efforts, because they are alive. Just out of curiosity, how many lives did you save last week?’
I’m full of admiration for Björn’s skills and for his profession, and I never said otherwise. That doesn’t mean he’s right about everything, or that I should agree with what he says here. I don’t claim to save people’s lives, but that doesn’t diminish what I do – plenty of people will testify that acupuncture from me and others has completely changed the quality of their lives, including many at Penny Brohn, who far from being the ‘worried well’, are suffering not only from the trauma of cancer, but from the sometimes devastating side-effects of their treatment. I feel grateful that the skills I have learned can often help relieve this suffering, and the data being gathered by the team at Penny Brohn backs this up (although not in a way that will satisfy you – but frankly I’m more concerned about satisfying the patients).
‘you lack understanding of such simple terms as, ‘regression to the mean”, “self limiting”, and “natural progression”.’
I understand those terms perfectly well. These are phenomena that are true for any intervention and should indeed be taken into account. For what it’s worth (little, in your eyes, no doubt), I’ve had many patients arrive with problems that have been consistent in nature for months or years, that have responded obviously and quickly to acupuncture.
‘Even your “work” at the Penny Brohn Centre is after the real work is done by real doctors doing real medicine.’
Sadly, as I mentioned above, this ‘real’ work, even though often vital, tends to leave people with serious side-effects. I sincerely hope steadily more people in that situation are given the opportunity to try acupuncture, as I’ve seen it enhance quality of life enormously.
“Your approach reminds why I shouldn’t waste my time trying to engage reasonable, grown-up debate on this forum. I’ll wearily respond to a few of your points, and leave you to own devices.”
I didn’t think it would be long for an Ad Hominem. I shouldn’t be surprised because “grown-ups” try to argue about the evidence, or lack of it.
“Many of the other reviews conclude that there are some positive indications, but more high quality research is needed. This is very different from saying it doesn’t work.”
Some positive indications? This is not evidence for a treatment to be used before its efficacy is shown. All you show is wishful thinking, and a lack of understanding of basic anatomy and science. When you find some “qi”, please let us know? If you do, you might also be successful at finding the equally mythical chiropractic subluxation.
“even treatment proponents question whether a randomised controlled trial – the gold standard of medical research – works, given that faking treatment is nearly impossible.”
There are studies of acupuncture vs. other treatments such as medications. That seems a reasonable way of getting around this problem.
Edzard Ernst: ‘Severely, and repeatedly criticised’. I would like to ask by who, when, and how?
‘This passage refers to an analysis by Vickers et al. It was severely and repeatedly criticised for being too optimistic and, more importantly, it is not nearly as positive as implied here. Its conclusions are in fact quite cautious: “acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture’.
I think if you look up the paper on pubmed, you find some of the criticism.
Edzard Ernst: ‘Its effectiveness is not proven beyond doubt for a single condition’. Could you rephrase this please?
bravo! you managed to spell my name correctly once in 3 comments.
Bravo, you can count up to three and spell your own name!
However, you seem to lack the ability to take a different perspective on matters (as your response demonstrates).
Primitive responses are not useful. (Edzard you used the term ‘bravo’ to express disapproval because I spelt your name incorrectly. You enjoy, and prefer being sarcastic.)
While I think about the correct spelling of your name, you could start to advance your skills in research.
A change of attitude would be a good start, as well as responding to the questions I ask…
“However, you seem to lack the ability to take a different perspective on matters (as your response demonstrates).”
If that means he is not susceptible to the nonsense in your posts, I don’t see this as a criticism. Rather, it demonstrates a mindset based on the first principles of science.
“Primitive responses are not useful. (Edzard you used the term ‘bravo’ to express disapproval because I spelt your name incorrectly. You enjoy, and prefer being sarcastic.)
Another pathetic attempt at one-up-man-ship, which has failed, again.
“While I think about the correct spelling of your name, you could start to advance your skills in research.”
Please let us know where all your published papers are, George?
“A change of attitude would be a good start, as well as responding to the questions I ask…”
I can’t speak for the prof, however, I don’t know why he bothers with a troll like you; someone who contributes little to nothing yet is highly critical of others.
Edzard Ernest: ‘Much of the research is of woefully poor quality’. I’d agree there. Which is part of the problem you have. Actually, it is not unusual for health care research to be of poor quality.
no question here – but I can tell you that it is very unusual that, for one popular treatment, most of the 2 000 or so trials are rubbish.
Edzard Ernest: ‘Because it requires substantial amounts of therapist time, it also is not cheap’. Substantial amounts of therapist time?
There is evidence that contradicts this point of view. For example:
‘All CUAs showed that acupuncture with or without usual care was cost-effective compared with waiting list control or usual care alone…All CUAs were well-designed with a low risk of bias’.
There are cautions and qualifications to these conclusions, but to state simply that ‘it is not cheap’ doesn’t seem an accurate or thorough summary. What is more, a novel benefit of acupuncture is that it can be delivered in a ‘multi-bed’ style, offering further potential savings (essentially this means moving on to treat another patient once needles are in place, in a ‘conveyor belt’ fashion). The NHS fund an example of this in the Gateway Clinic which has a large waiting list of referrals from local GPs, and has attracted very positive feedback from doctors and patients alike. I believe there is a place for this style of clinic on a wider scale, and the indications are that the NHS could make substantial savings by doing this.
‘Not sure Tom what you want from me. The burden of evidence lies on you and other users of acupuncture, not on us who have already brought forth evidence that the recently remade relic of acupuncture has no demonstrably useful function other than that of a theatrical stunt.
If you mean evidence corroborating my story, that would be in Icelandic, a language I doubt you will comprehend. If you question my honesty then please explain why.’
I’m merely trying to hold you to the same standards this forum expects – personal opinions and anecdotes are routinely mocked (although I think they have value). What you said surprises me based on my own experience with obstetric acupuncture, and the integrity and professionalism of midwives, You give the impression that only a few delusional women perceived any benefit from acupuncture/acupressure, and I wondered what evidence you were basing that on. Is it your impression in passing? Is it based on systematic feedback questionnaires? I’m genuinely interested, and I have close Icelandic friends who would be happy to interpret for me.
I don’t question your honesty, I just happen to have a markedly different opinion to yours.
Well, do you really believe in the ‘theory’ of acupuncture ? (Meridian, chi etc…)
Do you realize that there is no physical/biological evidence for those ? (I would add no prior plausiblity either)
Do you really believe that the effect of such a simple and macroscopic action (stiking needle) would stay hidden ? (beside the fact that we can count atom, intricate photon, and even more, and i’m not even talking about biology).
Or maybe you know that all this is rubbish and that you are giving a placebo but acting as there is something. I really can’t say. So ?
@Quark I’m not really sure what you’re getting at but no, needless to say I don’t think it’s all placebo, and as stated above there are reviews that back this up. As for the theory, that’s a whole different debate. I see the channels of acupuncture as functional entities rather than ‘lines of energy’ or anything similar, and I don’t think modern TCM is perfect by any means. Acupuncture is diverse, sometimes confusing and fractured, and I can understand why some people find it hard to fathom. But on the flip side it is fascinating, rich, and hugely rewarding, both clinically and intellectually.
Well this is not an answer at all. It is not a whole different debate, it’s what we are talking about right now. Because it’s like saying ‘God do miracle’ and say ‘Well the existence of god is whole different debate’, it is not. It’s just carefuly putting the problem under the carpet and look away.
So you say ‘A funtionnal entity’ ? What is it ? How no one is able to see it ? Why all this is so vague ? Why it would diverse or fracturing ? You put needle in any personn, then the system should be the same. Or you can tell that one personn got ‘funtionnal entity’ and not the other ? Then how ?
You can then found some study (of poor quality) that show some effect beyond placebo, maybe, but tons of other telling the opposite (of better quality). So then, what is the most plausible : statistical error due to low quality, or wonder method with no physical/biological backing ?
You enthusiastically endorse your own brand of woo and claim it to be efficacious.
I have a question for you; which of the alt-meds do you not regard as not being efficacious? Are they all as good as yours, or are there some you believe cannot and/or do not work?
@Frank, a strange question I think, but as you asked, I don’t know enough about other therapies to endorse or dismiss them. I certainly don’t go solely by the scientific evidence base though – I feel there’s value in my own judgement and the experience of others too.
We can readily agree on that!
I am still not sure what part of my account you are questioning. I have written about concerns that many people at this hospital are having about the use or rather misuse of two unproven, unlikely and potentially deleterious interventions used by midwives in a hospital that declares high academic standards. There is still no study or report to hand over as evidence, if that is what you wish me to do. The evidence is, as I have said previously, that Aromatherapy and acupuncture have not proven to be clinically useful therapy modalities. Your opinion is different as we have confirmed but I am afraid that it does not constitute evidence. Your perception of success can be easily explained by other mechanisms than a therapeutic action of the AP and your adherence to this fallacy is based on a mixture of faith, finance and pride.
Now, please, prove that I am wrong and convince us all that AP is indeed useful and efficacious.
As to the time and cost effectiveness discussed in a recent entry below, it so happens that I had a chat today with an anesthesiologist who specialises in chronic pain management. He used to practice AP. I asked him why he did not continue to build upon this methodology, which he had studied in depth and at length. His reply was interestingly that of profound disappointment. He obviously wanted so much for this to work, and still had hopes but it was just too time consuming and cumbersome for very limited and uncertain effect. He simply found other methods better, more reliable and more efficient. He reluctantly admitted that yes, it was probably only placebo effects that he had produced but even if these sometimes could be useful and satisfactory, it was just too much time and trouble for an effect that could be produced with good manners, empathy and compassion.
Now tell us Tom, is AP on its way back to its roots in archaic blood letting? Can it be that practitioners are getting dissatisfied with simple needling and moxa-burning and going into more dramatic displays?
I am seeing quite a lot of references to “wet cupping” and articles about frank bleeding techniques, seemingly written by “modern” AP-ists.
What do you for example make of this or this ??
In fact, Cochrane Reviews – the gold standard of evidence based medicine, has confirmed that acupuncture has positive efficacy for many conditions including nausea & vomiting, breech presentation, pelvic pain, low back pain, tension headache, labor, dysphagia after stroke, migraine.
Is this you? http://ihome.ust.hk/~cechii/
“In fact, Cochrane Reviews – the gold standard of evidence based medicine, has confirmed that acupuncture has positive efficacy for many conditions including nausea & vomiting, breech presentation, pelvic pain, low back pain, tension headache, labor, dysphagia after stroke, migraine.”
I find that interesting, inasmuch as the good prof has been doing this type of research for about 25 years (please correct me, prof) and he has been unable to unearth these treasures. What are you doing that he doesn’t? Perhaps you are not reading the RCTs fully, and you wouldn’t be the first, it seems. Is there any cherry-picking involved?
Anyway Prof, this is the paper has has written; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2644274/
Do you have any comment on it?
Anyone who is ignorant about acupuncture research should look up the Cochrane Reviews – the gold standard of evidence based medicine:
The evidence is clear and growing over the years that acupuncture has positive efficacy for many conditions including nausea & vomiting, breech presentation, pelvic pain, low back pain, tension headache, labor, dysphagia after stroke, migraine. Do not believe in hearsay from biased ‘expert’.