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

Most people probably think of acupuncture as being used mainly as a therapy for pain control. But acupuncture is currently being promoted (and has traditionally been used) for all sorts of conditions. One of them is stroke. It is said to speed up recovery and even improve survival rates after such an event. There are plenty of studies on this subject, but their results are far from uniform. What is needed in this situation, is a rigorous summary of the evidence.

The authors of this Cochrane review wanted to assess whether acupuncture could reduce the proportion of people suffering death or dependency after acute ischaemic or haemorrhagic stroke. They included all randomized clinical trials (RCTs) of acupuncture started within 30 days after stroke onset. Acupuncture had to be compared with placebo or sham acupuncture or open control (no placebo) in people with acute ischaemic or haemorrhagic stroke, or both. Comparisons were made versus (1) all controls (open control or sham acupuncture), and (2) sham acupuncture controls.

The investigators included 33 RCTs with 3946 participants. Outcome data were available for up to 22 trials (2865 participants) that compared acupuncture with any control (open control or sham acupuncture) but for only 6 trials (668 participants) comparing acupuncture with sham acupuncture.

When compared with any control (11 trials with 1582 participants), findings of lower odds of death or dependency at the end of follow-up and over the long term (≥ three months) in the acupuncture group were uncertain and were not confirmed by trials comparing acupuncture with sham acupuncture. In trials comparing acupuncture with any control, findings that acupuncture was associated with increases in the global neurological deficit score and in the motor function score were uncertain. These findings were not confirmed in trials comparing acupuncture with sham acupuncture.Trials comparing acupuncture with any control showed little or no difference in death or institutional care or death at the end of follow-up.The incidence of adverse events (eg, pain, dizziness, faint) in the acupuncture arms of open and sham control trials was 6.2% (64/1037 participants), and 1.4% of these patients (14/1037 participants) discontinued acupuncture. When acupuncture was compared with sham acupuncture, findings for adverse events were uncertain.

The authors concluded that this updated review indicates that apparently improved outcomes with acupuncture in acute stroke are confounded by the risk of bias related to use of open controls. Adverse events related to acupuncture were reported to be minor and usually did not result in stopping treatment. Future studies are needed to confirm or refute any effects of acupuncture in acute stroke. Trials should clearly report the method of randomization, concealment of allocation, and whether blinding of participants, personnel, and outcome assessors was achieved, while paying close attention to the effects of acupuncture on long-term functional outcomes.

This Cochrane review seems to be thorough, but it is badly written (Cochrane reviewers: please don’t let this become the norm!). It contains some interesting facts. The majority of the studies came from China. This review confirmed the often very poor methodological quality of acupuncture trials which I have frequently mentioned before.

In particular, the RCTs originating from China were amongst those that most overtly lacked rigor, also a fact that has been discussed regularly on this blog.

For me, by far the most important finding of this review is that studies which at least partly control for placebo effects fail to show positive results. Depending on where you stand in the never-ending debate about acupuncture, this could lead to two dramatically different conclusions:

  1. If you are a believer in or earn your living from acupuncture, you might say that these results suggest that the trials were in some way insufficient and therefore they produced false-negative results.
  2. If you are a more reasonable observer, you might feel that these results show that acupuncture (for acute stroke) is a placebo therapy.

Regardless to which camp you belong, one thing seems to be certain: acupuncture for stroke (and other indications) is not supported by sound evidence. And that means, I think, that it is not responsible to use it in routine care.

26 Responses to Yet another confirmation: the effects of acupuncture are due to placebo

  • One of my main foci for following this blog was to gain an understanding of acupuncture’s credibility under the scrutiny of scientific endeavour.
    For a long time, I’d been doubting my doubt that these little pricks were ought but charlatanry.
    This is the first time I’ve read anything that tips me conclusively into the view that it’s truly a sibling of homeopathy, astrology, religion and psychics.
    Though I must continue reading.

    • Rich,
      Sorry to say, but if you thought acupuncture was anything other than nonsense makes you less than a critical thinker. The notion that there is any credibility associated with sticking a needle in some remote part of the body and it will affect an unrelated organ or organs is fantasy at best.

      Science works by quantifying evidence, not unsustainable opinions.

      • That’s why I love science focused conversation: straight talk and zero BS.
        You’re totally right, Frank. Intellectually I couldn’t see how it’d work but those occasional experiences where a punch in once place caused a twinge in another (coincidence seemed unlikely) were enough for me to seek an explanation for such events.
        Clearly, the between-the-ears mulch seeks to make sense of its input, but I couldn’t wholly reject the anecdote until I understood how marketing hijacks placebo for profit in the needle zone, too.
        Always, without exception, bring it to my attention when I’m wrong: how else can I correct errors?
        Top man, thanks for ernestness Frank.

      • “Sorry to say, but if you thought acupuncture was anything other than nonsense makes you less than a critical thinker.”

        That’s somewhat harsh, Frank. Rich has startted with the not unreasonable idea that acupuncture might, by virtue of needling, have some useful effect and is happy to concede that, in the face of proper evidence, he might have been wrong and is prepared to change his point of view.

        This suggests to me a truly enquiring and flexible mindset and I would have thought deserved a considerable amount of praise – it’s how science is supposed to work. I can’t see why calling him ‘less than a critical thinker’ is i any way helpful. I am happy to confess I too once held the same views as Rich but after assessing the evidence now feel otherwise.

        Welcome aboard, Rich!

        Niall

        • Thanks Niall.
          I didn’t and don’t take Frank’s words negatively: quite the opposite.
          In many ways, I took his forthright terms as respectful of my capacity and desire to change views as information and understanding grows.
          It’s little different to how I address some woo merchants here and elsewhere. If someone is promoting a claim, the responsibility is theirs to ensure accuracy. My recently ditched susceptibility to buy some aspect of acupuncture was rightly highlighted for error.
          Thanks again, Frank and Niall: it’s why I enter this arena – to learn.

          • @Rich It sounds to me as if you are at least partly open-minded, and take a more genuinely scientific approach than most here – i.e. rather than dismissing something with a lot of intriguing evidence behind it (even if much of this evidence is still hotly debated) mainly on the grounds that it ‘sounds a bit silly’, you understand that it’s possible to look at something like acupuncture objectively without being put off by the strange terminology associated with it. I strongly urge you to consult various other outlets as well as this one before coming to any final judgement. http://www.evidencebasedacupuncture.org/ for example is run by intelligent people genuinely trying to present the facts as they see them. Yes, they have an ‘agenda’ in that they are acupuncturists, but I can assure you, having had detailed discussions with some of them, that they are motivated by the urge to see acupuncture help more people rather than anything sinister, and they are trying to present an honest appraisal of the evidence. No doubt virtually everyone here will dismiss everything there with (or without) a cursory glance, but perhaps you won’t fall into that category. I hope you find something of interest there, and come to a balanced opinion.

          • the EVIDENCEBASEDACUPUNCTURE site you recommend quotes the Vickers meta-analysis thus:
            “A meta-analysis of 17,922 patients from randomized trials concluded, “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.”
            Pity that they forgot a bit. The full conclusion reads:
            “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.”
            AND YOU TRY TO LECTURE US ABOUT AN OPEN MIND?

  • Of course the effects of ‘acupuncture’ (if any) are due to placebo responses (and perhaps nocebo responses in some cases).
    What else?

    The big issue for me is the failure of (most, if not all) acupuncturists to obtain properly informed consent from patients for their practices – by telling them the effects of acupuncture are due to placebo.
    That is unethical and to be deprecated.
    Acupuncturists should hang their necks in shame.

  • Just made me laugh ot loud! This review is by itself a hoax as long as it leads readers into thinking acupuncture as a whole is placebo. Research helps set one thing apart from the other, and this is something specific: for stroke.

    On the ohter hand, we all forget the reflex arch theory that states a long infliccted pain may lead to endorphin release. And this is where acupuncture stands. By stimulating a given area (“acupoint”) with a needle, one is able to stimulate the neuro-endocrine axis and thus a given response can be measured. Not all acupuncturists are born the same. Not all treatments deliver the same result in the same patient. It largely depends on the acupuncturist´s expertise and training (above all). Try http://www.healthcmi.com/Acupuncture-Continuing-Education-News/786-mriub60tb5 AND https://www.researchgate.net/publication/230677300_A_PET-CT_study_on_the_specificity_of_acupoints_through_acupuncture_treatment_in_migraine_patients and join experts.

  • @Edzard I’m not sure I understand your point. ‘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.’ Perhaps the full conclusion should always be quoted, but I don’t think that addendum changes the context significantly. Acupuncture has been shown to be more than a placebo in a large meta-analysis (when compared to arguably active sham controls). The authors put it well I think, in the ‘Interpretation’ section:

    ‘Our finding that acupuncture has effects over and above sham acupuncture is therefore of major importance for clinical practice. Even though on average these effects are small, the clinical decision made by doctors and patients is not between true and sham acupuncture, but between a referral to an acupuncturist or avoiding such a referral. The total effects of acupuncture, as experienced by the patient in routine practice, include both the specific effects associated with correct needle insertion according to acupuncture theory, non-specific physiologic effects of needling, and non-specific psychological (placebo) effects related to the patient’s belief that treatment will be effective.’

    Compare this to Richard’s comment here, for example: ‘Of course the effects of ‘acupuncture’ (if any) are due to placebo responses (and perhaps nocebo responses in some cases). What else?’. And your post tile includes the line ‘the effects of acupuncture are due to placebo’. These are the kinds of comment that to me seem closed-minded in the face of some significant evidence.

    • “Perhaps the full conclusion should always be quoted…”
      YES, IF NOT, IT’S CALLED ‘BEING ECONOMICAL WITH THE TRUTH’
      “…I don’t think that addendum changes the context significantly.”
      IT’S NOT AN ADDENDUM, BUT PART OF THE CONCLUSION; AND YOU ARE WRONG, FOR ME, IT CHANGES A LOT.
      “…your post tile includes the line ‘the effects of acupuncture are due to placebo’.”
      BECAUSE THIS IS WHAT THE PAPER DISCUSSED IN THAT PARTICULAR POST IMPLIED.

      • I think you need a new keyboard – the caps key seems to be stuck.

        ‘IT’S CALLED ‘BEING ECONOMICAL WITH THE TRUTH’’

        The title of this post is: ‘Yet another confirmation: the effects of acupuncture are due to placebo’. That’s also being economical with the truth I think. You argue ‘BECAUSE THIS IS WHAT THE PAPER DISCUSSED IN THAT PARTICULAR POST IMPLIED’, but is it? The authors state ‘Future studies are needed to confirm or refute any effects of acupuncture in acute stroke’, and that would have been a much more balanced headline. You clearly imply here that it has been CONFIRMED that the effects of acupuncture are due to placebo, and that this trial is further confirmation. This is misleading at best. Yes, you add in brackets ‘(for acute stroke)’ at the end of the post, but why not in the title, unless you want to give the impression this is true for acupuncture in general?

        • my post is about critical evaluation of the published literature.
          and this is what follows from a critical evaluation of this particular article.
          I am not surprised that you cannot follow this line of reasoning.
          could it be that the lack of an open mind is not my but your problem?

          • ‘could it be that the lack of an open mind is not my but your problem?’

            Who knows, maybe the problem is both of ours? I’m open to all possibilities!

          • VERY GOOD!
            ok, let’s have a look.
            you 1st: learnt acupuncture [a therapy that relies on a 2000 year old dogma], never published anything negative about it, never used any other therapeutic modality, even treated my own daughter with acupuncture when she suffered from infant colic, earn my livelihood by doing acupuncture.
            [I MIGHT BE WRONG HERE, AS I DON’T KNOW ALL THAT MUCH ABOUT YOU, SO PLEASE CORRECT ME]
            me next: studied acupuncture during my time in med school, used it occasionally, learnt to use dozens of other therapeutic modalities, published lots about acupuncture based on the current evidence [this means that some conclusions – even of my Cochrane reviews – were positive but have since changed], worked with acupuncturists from across the globe, published one book about acupuncture together with several acupuncture fans, now dedicate my time to the critical analysis of the literature and bogus claims, have no conflicts of interest.
            [IN CASE YOU KNOW MORE RELEVANT THINGS ABOUT ME, PLEASE ADD]

  • @Edzard Your summaries seem to be more or less accurate. However, a) I wouldn’t agree with your use of the term ‘dogma’; b) I haven’t published any scientific papers, but I’ve acknowledged various problems in the acupuncture field through informal pieces; c) I’ve used other CAM modalities, and I’ve directly or indirectly experienced many conventional modalities; d) I only earn part of my livelihood by doing acupuncture. Yes, my background makes it more likely that I’ll be biased in favour of acupuncture. But your credentials in no way guarantee open-mindedness on the subject, and personally I don’t see that displayed often on this blog. It still makes for interesting and stimulating reading though.

    • what problems in the acupuncture field have you acknowledged through informal pieces?
      can you provide links?
      I want to get a feel for the openness of your mind.
      “…your credentials in no way guarantee open-mindedness on the subject, and personally I don’t see that displayed often on this blog.”
      1) you seem to forget that blog-posts are not scientific papers, not even close.
      2) you also forget that my blog is dedicated to the CRITICAL assessment of alt med.
      finally, what would make you think that someone has an open mind towards acupuncture, if not the fact that someone has a track record of publishing positive conclusions about it when the evidence allows?
      remember: an open mind should not be so open that your barin falls out!

  • Here’s one example: https://www.tomtheacupuncturist.com/blog/2017/2/24/does-acupuncture-really-work

    ‘what would make you think that someone has an open mind towards acupuncture, if not the fact that someone has a track record of publishing positive conclusions about it when the evidence allows?’

    I think there’s plenty of evidence that allows for positive conclusions about acupuncture, but you don’t report these. I understand the slant of this blog, but I’d say it comes across as ‘negative assessment’ rather than ‘critical assessment’. Perhaps you’ll argue that your critical assessment has led you to a negative assessment? I’ll just have to disagree that that’s a fair and open-minded summary of the evidence.

    Out of interest, can I ask what your acupuncture training involved (hours, theory, clinic time etc.)?

  • ‘I am sorry to say that I see no critical evaluation in the post you linked to’

    I’ll just have to live with that. I feel as though it acknowledges some of the problems in the acupuncture world, in an attempt at balance. I don’t feel your posts aim for balance, but as you said, a blog isn’t a scientific paper so it’s your prerogative to skew things as you see fit.

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