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

They say that minds are like parachutes – they function only when open. Having an open mind means being receptive to new and different ideas or the opinions of others.

I am regularly accused of lacking this quality. Most recently, an acupuncturist questioned whether acupuncture-sceptics, and I in particular, have an open mind. Subsequently, an interesting dialogue ensued:

___________________________________________________________

Tom Kennedy on Wednesday 01 August 2018 at 19:27

@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?

@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.

edzard on Thursday 02 August 2018 at 12:46

“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

Edzard on Thursday 02 August 2018 at 14:09

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

Tom Kennedy on Thursday 02 August 2018 at 14:43

‘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 brain falls out!

Tom Kennedy on Friday 03 August 2018 at 11:20

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’d say it comes across as ‘negative assessment’ rather than ‘critical assessment’.
have you noticed that criticism is often experienced as negative to the person(s) it is aimed at?

Tom Kennedy on Friday 03 August 2018 at 12:55

‘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

Edzard on Friday 03 August 2018 at 13:18

it seems to me that the ‘screwing things as you see fit’ is your game.

____________________________________________________________________

This exchange shows how easily I can be provoked to get stroppy and even impolite – I do apologise.

But it also made me wonder: how can anyone be sure to have an open mind?

And how can we decide that a person has a closed mind?

We probably all think we are open minded, but are we correct?

I am not at all sure that I know the answer. It obviously depends a lot on the subject. There are subjects where one hardly needs to keep an open mind and some where it might be advisable to have a closed mind:

  • the notion that the earth is flat,
  • flying carpets,
  • iridology,
  • reflexology,
  • chiropractic subluxation,
  • the vital force,
  • detox,
  • homeopathy.

No doubt, there will be people who even disagree with this short list.

Something that intrigues me – and I am here main ly talking about alternative medicine – is the fact that I often get praised by people who say, “I do appreciate your critical stance on therapy X, but on my treatment Y you are clearly biased and unfairly negative!” To me, it is an indication of a closed mind, if criticism is applauded as long as it does not tackle someone’s own belief system.

On the subject of homeopathy, Prof M Baum and I once published a paper entitled ‘Should we maintain an open mind about homeopathy?’ Its introduction explains the problem quite well, I think:

Once upon a time, doctors had little patience with the claims made for alternative medicines. In recent years the climate has changed dramatically. It is now politically correct to have an open mind about such matters; “the patient knows best” and “it worked for me” seem to be the new mantras. Although this may be a reasonable approach to some of the more plausible aspects of alternative medicine, such as herbal medicine or physical therapies that require manipulation, we believe it cannot apply across the board. Some of these alternatives are based on obsolete or metaphysical concepts of human biology and physiology that have to be described as absurd with proponents who will not subject their interventions to scientific scrutiny or if they do, and are found wanting, suggest that the mere fact of critical evaluation is sufficient to chase the healing process away. These individuals have a conflict of interest more powerful than the requirement for scientific integrity and yet defend themselves by claiming that those wanting to carry out the trials are in the pocket of the pharmaceutical industry and are part of a conspiracy to deny their patients tried and tested palliatives….

END OF QUOTE

And this leads me to try to define 10 criteria indicative for an open mind.

  1. to be free of conflicts of interest,
  2. integrity,
  3. honesty,
  4. to resist the temptation of applying double standards,
  5. to have a track record of having changed one’s views in line with the evidence,
  6. to not cling to overt absurdities,
  7. to reject conspiracy theories,
  8. to be able to engage in a meaningful dialogue with people who have different views,
  9. to avoid fallacious thinking,
  10. to be willing to learn more on the subject in question.

I would be truly interested to hear, if you have further criteria, or indeed any other thoughts on the subject.

21 Responses to Random thoughts on the issue of an ‘open mind’

  • Sticking needles in people is scientifically established to be a waste of time unless you are administering an injectable substance, an intravenous infusion, removing a splinter or taking blood for analysis. Moreover, we know exactly and can observe and measure how all these things are supposed to work and how they do work. On the other hand, acupuncture is based entirely on woo-woo made up nonsense about invisible “energy fields” (the favourite nonsense of many delusional quacks, including reiki and homeopath quacks ) and other total stupidity. I’ve never yet seen a world champion boxer or athlete draw down any of this so-called chi energy and beat their non-adept competitors with their otherwise unfair advantage.

    Two years ago, the national health service in the UK (via a midwife) booked my daughter, in London, in for an acupuncture session whilst in labour to help her with what they expected to be a painfully delivery of her second child. It never had any effect at all apart from multiply puncturing her skin and exposing her to a lot of exceptional childbirth pain before she switched to proven proper pain reduction treatment of “gas and air”. As with all acupuncture woo acupuncture was a total waste of time and money. Importantly, the patient suffered by not receiving proper treatment in the interim.

  • From Wikipedia:
    “The mind is a set of cognitive faculties including consciousness, perception, thinking, judgement, language and memory. It is usually defined as the faculty of an entity’s thoughts and consciousness. It holds the power of imagination, recognition, and appreciation, and is responsible for processing feelings and emotions, resulting in attitudes and actions. There is a lengthy tradition in philosophy, religion, psychology, and cognitive science about what constitutes a mind and what are its distinguishing properties.”

    The phrase ‘open mind’ implies all thoughts, judgement etc are up for grabs, and equivalent in some way – but Edzard’s Blog is concerned with rational thoughts and reality (as far as it can be experienced), based on evidence obtained and applied by methods developed down the centuries as ‘scientific’. That is the best we can do.

    Nothing wrong with having fantasies and using imagination, but those thought processes do need to be distinguished from ‘reality’.

    Many folks appreciate the attention of an empathic practitioner in a constructive therapeutic relationship (which I term ‘type I effects’) – but the issue for those of serious about genuine progress in healthcare is whether any modality has type II effects from the pummeling, pillules, potions, pricking or preternatural powers they offer.
    And to date, ‘puncture of the skin with a needle’ (Latin: a needle) has not been shown to have any significant effect – the best (most ‘open’) that can be said is that it is a ‘theatrical placebo’ (Colquhoun).

    IMHO ‘acupuncture’ would be better termed using the Ancient Greek rather than Latin – Greek for a needle is ‘belone’ – hence ‘belonetherapy’. Sums it up.

  • Interesting that in response to a post about open-mindedness, the first two comments clearly breach several points on the ’10 criteria indicative for an open mind’, and display exactly the kind of unhelpful stance that I was trying to highlight in my quoted comments above.

    @Mike – ‘Sticking needles in people is scientifically established to be a waste of time’ – that’s just not true. And your n=1 anecdote is the kind of thing roundly criticised on this blog whenever a CAM advocate does the same. Although currently not enough high quality evidence has been gathered to draw firm conclusions, it appears at the moment as though acupuncture/acupressure may not reduce caesarean rates, but may improve cervical readiness: https://www.cochrane.org/CD002962/PREG_acupuncture-or-acupressure-induction-labour

    @Richard – ‘to date, ‘puncture of the skin with a needle’ (Latin: a needle) has not been shown to have any significant effect’ – again, just not true, or at the very least, highly debatable. ‘IMHO ‘acupuncture’ would be better termed using the Ancient Greek rather than Latin – Greek for a needle is ‘belone’ – hence ‘belonetherapy’ – very clever and amusing, but this joke perhaps loses some of its impact each time you tell it (at least 3 times on this blog and once on the BMJ site).

    • @ Mr. Kennedy,
      No surprise, again one of your typical, reflective and self-critical comments.
      But you know: when you point one finger, there are three fingers pointing back to you.
      So let me ask: how would you, Mr. Babyneedler, evaluate yourself regarding the criteria from Prof. Ernst?
      • Are you free of conflict of interest?
      • Do you resist applying double standards for acupuncture vs. evidence based treatment options?
      • Do you resist clinging to absurd theories like the existence of meridians?
      • Do you avoid fallacious thinking?
      • Do you honestly try to understand the scientific method?

      • @Jashak I’m not sure why I should respond to ‘Mr. Babyneedler’, but in the spirit of number 8 on the list I’ll try to remain polite:

        • Are you free of conflict of interest?
        No, I’ve admitted as such.
        • Do you resist applying double standards for acupuncture vs. evidence based treatment options?
        Yes, I think so. And I would consider acupuncture an evidence-based treatment option for some conditions.
        • Do you resist clinging to absurd theories like the existence of meridians?
        I don’t believe in the ‘existence of meridians’ in the way I assume you mean, i.e. magical invisible tubes of ‘energy’, but that’s not the only way to understand them. At the least they are a useful way of navigating and partitioning the body when planning and carrying out a treatment, and I watch with interest for more research into their physiological nature, which may back up or refute my clinical experience.
        • Do you avoid fallacious thinking?
        I try to.
        • Do you honestly try to understand the scientific method?
        Yes, it’s one reason I occasionally read this blog.

        • Quote:” I’m not sure why I should respond to ‘Mr. Babyneedler (…)’”

          Well… you have a documented habit of sticking needles into babies, so the name seems pretty accurate.

          Would you be interested in my assessment on how well (according to your posts in this blog and your video material) you fit for being open-minded regarding the 10 criteria?!

          • @Jashak

            ‘Well… you have a documented habit of sticking needles into babies, so the name seems pretty accurate.’

            My point was that referring to me as ‘Mr. Babyneedler’ is childish and provocative – not in line with Edzard’s point 8.

            ‘Would you be interested in my assessment on how well (according to your posts in this blog and your video material) you fit for being open-minded regarding the 10 criteria?!’

            Honestly, no. I can make a good guess about your opinions of me, but please bear in mind you don’t know me at all.

          • @ Mr. Kennedy
            • Quote#1:” My point was that referring to me as ‘Mr. Babyneedler’ is childish and provocative – not in line with Edzard’s point 8.”

            So you think that it is a great idea to stick needles into infants without supportive evidence for efficacy of this invasive treatment. You are also fine with calling a baby a “willing volunteer” in your video.
            However, you strongly disagree being labelled as “Babyneedler”. Weird priorities, I must say.
            I can understand that you don´t like this provocative label. Good thing: You can easily avoid it. Simply stop sticking needles into babies!
            As a side-note, I don’t see why the term I used should not be in line with E.E. point #8. A meaningful dialogue does not exclude hearing things that you don´t like… sometimes the truth hurts. And face it: you ARE a Babyneedler, even a very convinced one, proudly promoting it in your video.

            • Quote#2:” (…) I can make a good guess about your opinions of me, but please bear in mind you don’t know me at all.”
            This is why I offered to make my assessments on your comments & videos. They provide ample examples that lead me to conclude that you think quite highly of yourself as being critical and open-minded guy. This self-delusion allows you to conduct your chosen profession with a good conscience, even if infants are the victims of your belief.
            However, your open-mindedness does not pass the test of several criteria that Prof. Ernst suggested. Of course you disagree (again: the truth can hurt), as this is part of your self-delusion.

        • I’m sorry, Tom but I disagree you avoid fallacious thinking.

          From your website and parts of your comments on this blog, I get the impression you are only a hairsbreadth away from becoming a practitioner of ‘therapeutic touch’ (your ‘deep qi’ and ‘tuina massage’, for example).

          From your dissembling response to Jashak about resisting clinging to absurd theories like the existence of meridians you demonstrate very clearly that your mind is not sufficiently open ever to reject any of the unscientific baggage that comes with your firm belief in acupuncture as a valid therapeutic modality.

          Let’s face it, Tom, your convictions about the value of acupuncture come mainly from your personal, hands-on experience, shored up by cherry-picking the tiny proportion of published clinical trials that appear to show minor benefits from acupuncture. This is not evidence for an open mind, nor of any appreciation of the scientific method. To quote Carl Sagan: “Science is a way not to fool ourselves”.

          When I suggested, a while ago, you should try applying for a proper research grant to investigate your acupuncture work scientifically you responded with a cop-out. Yet I suspect the experience of going through the grant application mill, which would expose you to some seriously brilliant open minds in the form of referees and grant committees, just might give you reason to reassess the essentially superstitious beliefs you cling to.

          • @Frank

            ‘you are only a hairsbreadth away from becoming a practitioner of ‘therapeutic touch’ (your ‘deep qi’ and ‘tuina massage’, for example)’

            My ‘deep qi’ treatments are gentle, relaxing bodywork sessions – please let me know if you think I claim otherwise anywhere. ‘Tuina massage’ is traditional Chinese bodywork, and again I make no ‘woo woo’ claims about it, as far as I know.

            ‘Let’s face it, Tom, your convictions about the value of acupuncture come mainly from your personal, hands-on experience…’

            Yes, I can’t (and don’t) deny that my personal experiences have strongly influenced my opinions.

            ‘…shored up by cherry-picking the tiny proportion of published clinical trials that appear to show minor benefits from acupuncture’

            I don’t agree with that. I try to look at the totality of the evidence – I just draw different conclusions than you do.

            ‘When I suggested, a while ago, you should try applying for a proper research grant to investigate your acupuncture work scientifically you responded with a cop-out’

            I’m actually seriously considering it – I’ve been looking into grant possibilities etc. I can’t see this happening very soon, but I genuinely would be interested in this. I have certain opinions now, based on personal experience and my understanding of the scientific evidence, but I’d love the opportunity to prove myself wrong if indeed my thinking is fallacious.

    • Therapeutically stamping on someone’s hand would probably reduce the pain they associated with labour, as would self-flagellation or sticking needles in them or stinging them with bees. Acupuncture needle pricking is woo-woo hidden (can’t measure it because it’s simply made by simpletons woo-woo twaddle) energy field claptrap. Kick these money grubbing charlatans out of the NHS

    • Tom:
      And once in my book Real Secrets of Alternative Medicine which you would find helpful.
      A gag, yes – but it really is very hard to take the alternatives to scientific modern medicine too seriously.
      I guess you can see that perfectly well.
      Be well, press on.

  • I am sorry, I cannot accept the integrity of this review about acupuncture for the induction of labour.

    The authors are Mike Armour, Caroline Smith and Hannah Dahlen. Not quite the people you think would be unbiased with respect to acupuncture. It is especially of note that the first two work at the National Institute of Complementary Medicine in Australia.

    Of course, I don’t trust this review any more than I would trust a Cochrane review about homeopathy by Peter Fisher.

    Consistently hunting for a very few conditions that acupuncture appears to have some small effect on, based on a very small number of trials that appear to be relatively low on the risk-scale for bias, is the number one indication that acupuncture has no specific effects. The hunt begins with the most fallacious premise out there. That there is something that acupuncture must be effective for. I would expect prayers to have a similar track record of efficacy if a similar (cf. huge) number of trials had been carried out comparing them to placebo.

    You don’t begin your research by assuming that something has an effect and try to prove it doesn’t. It’s the other way around. You begin research by assuming it doesn’t work, and try to prove it does.

    Now, since we are going on about an open mind, I have come by this publication by this so called National Institude for Complementary Medicine:
    Effect of Acupuncture vs Sham Acupuncture on Live Births Among Women Undergoing In Vitro Fertilization
    A Randomized Clinical Trial

    This is by Caroline Smith, one of our people above.

    I understand that having an open mind is key for progress in science, but I do not feel comfortable accepting that such a randomized trial is not a waste of time and resources. I wish to ask Dr. Ernst, as a specialist in complementary and alternative medicine, do we not have enough evidence already in the year 2018 to accurately predict in advance that acupuncture cannot increase live births in women undergoing In-Vitro Fertilization? Do we need yet another randomized trial in the year 2018 to resolve this question?

    I mean, no mechanism, no plausibility, no explanation anyway, why is it necessary to perform a randomized trial? This trial could easily have been a false positive and it would have been yet another piece to be perpetuated by acupuncturists all over the world that shows “the positive effects of acupuncture”. Those completely unjustified research efforts are not a service to science by people with open minds. In my opinion, these are a disservice to science, they sacrifice science in the shrine of statistics, time and again. However, I would be very fond of getting the opinion of Dr. Ernst regarding the level of open-mindedness in this case.

    I am afraid statistics does not forgive obsession, especially in clinical research.

    • @James ‘I am sorry, I cannot accept the integrity of this review about acupuncture for the induction of labour.’

      Do you not trust the conclusion that acupuncture/acupressure doesn’t seem to reduce caesarean rates, or just the part about improving cervical readiness? Likewise, the other RCT you site draws negative conclusions. What have you got against Caroline Smith and the NICM, when they seem to be presenting honest conclusions?

      • In case it wasn’t clear, my problem with the randomized trial on IVF is that it was a trial on an extremely highly unlikely result. When someone undertakes such trials, it looks more like research on paranormal activity, rather than evidence-based complementary/alternative medicine.

        As for the review, the problem is in the conclusions. Of course I wasn’t expecting acupuncture/acupressure to reduce caesarean rates. What I want to show is how you would tout this review if acupuncture/acupressure DID have, at least low to moderate quality evidence, that it does reduce caesarean rates. Would you embrace the result immediately?

        I want to highlight to you how your deep involvement in acupuncture does not allow you to be skeptic of acupuncture itself. And by saying that, I mean that I would be skeptic of any result in any other treatment modality. Only robustly evidenced and consistent results would justify implementing a treatment for anything. Until then, it is wishful thinking that makes people see a “positivity” in some spurious results here and there.

        To be clear, let’s put it in a different way. If you know what “induction of labour” is about, we already know that stress “induces labour” in one way or another (not always as a desired effect, of course). I wouldn’t expect that stressing the body (by puncturing with needles, of course) would not have at least some moderate effect in inducing labour. I suggest that acupuncture is not a special way, it just induces stress on the body, thus increasing the probability of induced labour.

        Now, to set things straight, I am compelled to quote directly from the review:

        Data on cervical maturation were available from three trials, with data reported in the meta-analysis for one trial (Analysis 1.3). Overall, there was evidence of a benefit from acupuncture in increasing cervical maturity within 24 hours (MD 0.40, 95% CI 0.11 to 0.69, 1 trial, 125 women). The Bishop’s score was the most common measure of cervical change used in the included trials and provided a single score that encompassed five components including; cervical dilation, cervical effacement, cervical consistency, cervical position, and fetal station. A Bishop’s score of nine or greater suggested that labour would most likely commence without any
        need for induction methods (Tenore 2003). Data from the Smith 2008 trial were not included in the metaanalysis; it reported an increase in the Bishop’s score that did not differ between groups (RR 1.08, 95% CI 0.92 to 1.26, 1 trial, 364 women), data not shown. The Romer 2000 trial did not report on when the cervical change was assessed; however, the authors reported there was a significant change in the Bishop’s score (acupuncture 5.9 (1.3) (mean and standard deviation (SD)), nonspecific acupuncture 4.0, (0.9), and no acupuncture 3.6 (1.0))

        I have put the emphasis, of course. I certainly need some good explanation why data were not included in the metaanalysis, is it because the Bishop’s score did not increase adequately to provide a positive result for acupuncture? Or was the data not available? I guess it was readily available, Smith 2008 stands for Caroline Smith, 2008, this is one of the authors, I cannot believe that the authors did not have access to their own data.

        The only data that was “included in the meta-analysis” for this secondary outcome of cervical maturity after 24 hours was the study of Modlock, 2010. I am sorry, but this study does not seem to conclude what the endpoint that the Cochrane reviewers chose indicates. Quoting directly from the study:

        The results of this randomised controlled study revealed no effect of acupuncture on induction of labour in post-term women. Neither the primary endpoint (labour or delivery after 24 hours) nor the secondary endpoints differed between the groups. The risk of a clinically significant type 2 error is low because the primary endpoint was achieved in 12% of the acupuncture group compared with 14% in the control group, with a 95% CI of 0.33–2.2 for the relative risk.

        The Cochrane reviewers state, above, that (I repeat myself):

        The Bishop’s score was the most common measure of cervical change used in the included trials and
        provided a single score that encompassed five components including; cervical dilation, cervical effacement, cervical consistency, cervical position, and fetal station.

        In the entirety of the Modlock et al., 2010 trial, I cannot find even one mention of the word Bishop. Let me check once again, in case I have gotten the wrong trial:

        Modlock J, Nielsen BB, Uldbjerg N. Acupuncture for the induction of labour: a double-blind randomised controlled study. British Journal of Obstetrics & Gynaecology 2010;117 (10):1255–61.

        Nope, I’m afraid that’s it.

        Yes, that’s it. A derived calculation, not even existing in the original study, happened to be in favor of the acupuncture group (although I doubt even that, but I don’t have time to analyze it at the moment). This is your evidence, Tom. You are assuming that acupuncture successfully improves cervical readiness based on a trial that didn’t even show that (except maybe as a secondary outcome that has had to be cooked into something else to show some difference), and based on another trial that was not included in the meta-analysis because it didn’t show any difference, and another trial, in which no blinding is reported, but the authors conclude that this is a low risk (“No blinding reported, however unlikely to affected outcomes”), and which has a high risk of selective reporting (according to the authors), and a high risk of incomplete outcome data, AND no reporting of baseline characteristics.

        That’s your evidence Tom… It’s, as I like to say, the scientific equivalent of quicksand (maybe this loses its impact each time I say it again). Your take-home points should be two. First, be careful of what you cite here as evidence. Second, don’t be excited with whatever positive results you happen to come across in the realm of acupuncture (and alternative medicine in general). This is VERY low quality evidence, if any, in the Cochrane review with respect to cervical maturity (not to mention some slight evidence of manipulation and methodological shortcomings in the reporting and analysis) and I can only attribute the “delicate positivity” in the authors’ conclusions with respect to this tertiary secondary outcome measure to their background and a small(!) bias in favor of acupuncture. If there is a different, more relevant and rational, explanation for the above observations, I would be more than willing to read it!

        And keep one thing in mind before you talk about partiality. I, personally, would be just as picky a reviewer with whichever peddled therapy around, whether from conventional or alternative medicine. Most people in here probably share this critical view without multiple standards in favor of medicine, but, you see, this is a blog about complementary and alternative medicine, so you are not going to find much analysis or criticism about conventional therapies here. It certainly exists, but this is not the blog for that.

        • I recently became aware of the Smith in vitro publication. After lookig through it my reaction was precisely the same as yours. How such a thing could get published is beyond me. There’s a big business connection between China and Australia and that includes TCM. Just saying.

      • I am sorry Tom, I forgot to reply directly, I got carried away in my analysis, because I was somewhat shocked with the twists that can actually intrude a Cochrane review. Yes, I trust the result that acupuncture doesn’t (strike “seem to”) reduce caesarean rates. After dozens of years of analysis, there is no reasonable way or mechanism, through which such an effect would be mediated, other than random chance. And after following the review closely, the trials really leave little room for playing with conclusions on that matter.

        • @James

          ‘This is your evidence, Tom. You are assuming that acupuncture successfully improves cervical readiness…’

          No, I don’t ‘assume’ that. My wording was ‘Although currently not enough high quality evidence has been gathered to draw firm conclusions, it appears at the moment as though acupuncture/acupressure may not reduce caesarean rates, but may improve cervical readiness’. This was a quick response to a specific point made by Mike. There are other trials that draw similar conclusions, but I didn’t have time to add more than a quick link. My point was that there is at least some evidence that warrants further research into acupuncture/acupressure and cervical readiness (and perhaps other aspects of labour).

          You make some very interesting points about the Cochrane review, and thank you for your analysis. I’ll look into it further when I have a chance.

          • To quote a study without having first made a critical assessment of it is doing things the wrong way round. If there’s better evidence than that of Caroline Smith et al. I would like to see it – assuming you are confident that the evidence is fit for purpose. Otherwise we will be left hanging whilst you also look further into that. Of course, really looking into a study may mean checking into the sources quoted, and then the sources quoted there etc. But without having first done so there’s no point at all in throwing out references.

            The Smith paper is waste paper.

  • The only recommendation for acupuncture from NICE is as second-line, preventive treatment for migraine or chronic tension-type headache.

    Vickers was a meta-analysis of RCTs of acupuncture for several pain conditions including chronic headache. The other conditions were neck pain, shoulder pain and osteoarthritis.

    Meta-analyses have their place in the process of evidence assessment. They are not the be all and end all, as demonstrated by the judgment of NICE. All forms of evidence assessment have their strengths and weaknesses. GIGO certainly applies in the case of meta-analyses.

    Vickers is a case in point. It was a mulch of several different pain conditions. RCTS without placebo controls were included. Those which did had the problem of lack of double blinding. The ultimate clinical effect was bordering on zero.

    NICE is not impressed.

    Or is their problem that they do not have an open mind?

    NICE have looked at as much relevant evidence as they can find and found acupuncture not to be a cure-all. They have found it to be a cure-nothing. It may perhaps help prevent headaches. How it might do so is an open question – if it indeed can do so, which is an open question. To my mind, at any rate.

    Or perhaps NICE is hopelessly biased or generally incompetent. In which case they can’t be trusted on any of their judgments. In which case anyone’s judgment is as relevant as anyone else’s.

    Maybe Tom thinks that is what being open-minded means.

    Francis Bacon got there first with his Idols of the Tribe. He identified some of the pitfalls which the human mind so easily falls into. Tom worships one of Bacon’s “Idols of the Cave”.

    Science is our best attempt to avoid all the Idols. That to my mind is the best kind of “open mind”.

    http://www.sirbacon.org/friedberg.htm

  • “The purpose of an open mind is to close it, on particular subjects. If you never do — you’ve simply abdicated the responsibility to think.” — William F. Buckley, Jr.

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