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

The new NICE draft guideline on acupuncture for chronic pain has been published several months ago, and we discussed it here. Now the final document entitled ‘Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain‘ has been published on 7/4/2021. Like the draft, it includes quite a bit about acupuncture. Let me just quote three essential sections:

Recommendations: Acupuncture for chronic primary pain

Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:

  • is delivered in a community setting and
  • is delivered by a band 7 (equivalent or lower) healthcare professional with appropriate training and
  • is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries) or
  • is delivered by another healthcare professional with appropriate training and/or in another setting for equivalent or lower cost.

_____________________________

Many studies (27 in total) showed that acupuncture reduced pain and improved quality of life in the short term (up to 3 months) compared with usual care or sham acupuncture. There was not enough evidence to determine longer-term benefits. The committee acknowledged the difficulty in blinding for sham procedures, but agreed that the benefit compared with a sham procedure indicated a specific treatment effect of acupuncture. There was a wide variation among the studies in the type and intensity of the intervention used, and the studies were from many different countries. The committee agreed that the type of acupuncture or dry needling should depend on the individual needs of the person with pain.

Two economic evaluations (1 in the UK) showed that acupuncture offered a good balance of benefits and costs for people with chronic neck pain. However, both studies had limitations; a notable limitation being that the costs of acupuncture seemed low. Threshold analysis based on these studies indicated the maximum number of hours of a band 6 and 7 healthcare professional’s time that would make the intervention cost effective.

An original economic model was developed for this guideline, which compared acupuncture with no acupuncture. The model used data from studies with usual care comparisons, not comparisons with sham acupuncture, because the committee agreed that a usual care comparison in an economic model better reflects the real world benefit of the intervention. The model showed that acupuncture was likely to be cost effective. The committee considered the results to be robust, and agreed that the studies used in the model were representative of the whole evidence review. Acupuncture remained cost effective when the assumed benefits and costs were varied (sensitivity analysis).

Overall, the committee agreed that there was a large evidence base showing acupuncture to be clinically effective in the short term (3 months); the original economic modelling also showed it is likely to be cost effective. However, they were uncertain whether the beneficial effects would be sustained long term and were aware of the high resource impact of implementation. Taking these factors into account, the committee made a recommendation to consider acupuncture or dry needling for chronic primary pain, caveated by the factors likely to make the intervention cost effective. These were: only if delivered in the community, and with a maximum of 5 treatment hours (based on the average resource use in the trials in the model and on the threshold analysis), and from a band 7 (equivalent cost or lower) healthcare professional (based on the threshold analysis). It was agreed there may be different ways of delivering the service that enable acupuncture to be delivered for the same costs, which would equally be appropriate. The committee agreed that discontinuing before this total amount of course time would be an option if the person finds that the first few sessions are not effective.

_______________________________

Acupuncture versus sham acupuncture
Pain reduction
Very low quality evidence from 13 studies with 1230 participants showed a clinically important benefit of acupuncture compared to sham acupuncture at ≤3 months. Low quality evidence from 2 studies with 159 participants showed a clinically important benefit of acupuncture compared to sham acupuncture at ≤3 months.

Low quality evidence from 4 studies with 376 participants showed no clinically important difference between acupuncture and sham acupuncture at >3 months. Moderate quality evidence from 2 studies with 159 participants showed a clinically important benefit of acupuncture compared to sham acupuncture at >3 months. Low quality evidence from 1 study with 61 participants showed no clinically important difference between acupuncture
and sham acupuncture at >3 months.

______________END OF QUOTES____________

I will leave this here without a comment for the moment and look forward to reading what you think about this.

26 Responses to Acupuncture for chronic pain: the new NICE guideline

  • As you probably know, I’ve written about this previously: https://complementaryandalternative.wordpress.com/2020/08/29/why-have-nice-included-acupuncture-in-their-guidelines-for-chronic-pain/ My views are very similar to those that you expressed previously. I’ve shared some views on the final published version this morning: https://twitter.com/compandalt/status/1380068792244523013?s=20 . I do understand that producing guidelines for chronic pain must have been challenging given the lack of good treatments. However, their recommendation for acupuncture doesn’t seem to align with the available science and evidence.

  • Let me see; sticking needles in to imaginary points on the body is meant to be some form of healthcare?
    Only the delusional.

  • This is an appalling mistake from NICE.
    There is VERY weak to no evidence of the usefulness of acupuncture beyond that of a THEATRICAL PLACEBO and much the same effect can be achieved by sticking toothpicks in at random points on the body, or applying pressure.

    “Traditional Chinese” acupuncture which NICE misguidedly seeks to legitimize by mentioning Qi and so on is pure pseudoscience with no basis in logic, reason or reality. It talks about “liver stagnation” and other such complete BS and does not recognize conventional body systems or diagnoses.
    It is highly irresponsible and dangerous to legitimize this fantasy medical system to the public and encourage patients to go down this route not just for pain but other complaints.

    It also encourages anti-science thinking and pseudoscience in general.
    Chronic pain sufferers are prey to enough bogus remedies as it is without inflicting on them the acupuncture hucksters for no real benefit and just muddying the waters further. This is a massive own goal.

  • There will be many critical responses to NICE’s recommendation of acupuncture, and rightly so: the evidence it is based on is very weak.

    But equally, why are the recommendations of exercise and psychotherapy not being criticized?

    Like acupuncture, the evidence that NICE reviewed for these interventions mostly comprised low to very low quality studies, first and foremost non-blinded trials with subjective outcomes. Even then, most differences in outcomes between control and active groups were clinically insignificant (under the thresholds for a minimally important difference), e.g. varying by just a few points or decimals on questionnaires.

    A critical appraisal of the guideline needs to take all of the evidence into account — not only that which receives the most attention –.

    • “But equally, why are the recommendations of exercise and psychotherapy not being criticized?”
      In case you’ve missed it: this blog is on so-called alternative medicine (SCAM).

    • @ cassava7

      you have a point – BUT as Edzard says this forum is all about SCAM and in any event exercise is not deceitful and need not be expensive and a waste of money nor is it pseudoscientific nonsense.

      psychotherapy at least has the benefit of being empathetic and giving the patient an understanding framework, and there are not usually grand false promises being made, neither are there fantasy prone made-up nonsensical stories about miracle cures and implausible methods of delivery.

      Additionally neither of these undermines the public’s understanding of science or encourages them to seek out pseudoscientific nonsense for their other ailments. It is NICE’s endorsement of pseudoscientific crap that is so very damaging here – as they are undermining the whole of science and medicine by legitimizing TCM and the whole fantasy of Qi and meridians and the spleen as a digestive organ and all the rest of pre-scientific fantasy that is TCM.

      Going forward how can anybody ever again trust NICE to be science based when they have produced this crapola?

      • So why isn’t exercise and CBT SCAM? Just stop and think. Using these therapies if they do not work IS just as deceitful as acupuncture – exactly the same. They are not so cheap. Why are they not pseudoscientific nonsense if they do not work? Isn’t that the hallmark of pseudoscience – something that claims to be based on valid theory but is not?
        And I am absolutely sure that acupuncturists are empathetic. Psychologists are often very patronising and self-absorbed. What is the point of giving a patient an understanding of a bogus framework. There is no evidence that psychologists actually understand unexplained pain – after all it is by definition unexplained. If they think they know the explanation then it isn’t. There is deep doublethink here. And for sure there are grand false promises and made up nonsensical stories. Come on! That is what clinical psychology is all about.

        The irony of your proposals is quite remarkable.

        And of course they undermine the public understanding of science if they are phoney and based on invalid trials. They ARE pseudoscientific nonsense. I( have spent the last few years carefully going through trials of exercise and CBT for related conditions – they are worthless. And you can read my report in NICE documentation.

        It is certainly NICE’s endorsement of pseudoscientific crap that is the problem but exercise and CBT fall bang in the middle of that for chronic pain. Theories of predictive coding or central sensitisation are just as much woo as meridians I am afraid.

        • @ Jonathan Edwards

          you are missing the point. This blog is about SO-CALLED ALTERNATIVE MEDICINE. SCAM i.e things like acupuncture, homeopathy and the like. These people are hucksters and are dangerous delusional snake-oil sales people who put out an enormous amount of misinformation, cause delay in diagnosis, proffer useless therapies, useless diagnostic tests, delusional diagnoses for which they sell fake treatments, often persuade patients to come off real medicines sometimes even chemotherapy for cancer, are often anti-vaccine and create a general anti-science atmosphere which confuses the general public.

          The pseudoscientific nonsense pervades the whole culture and its tentacles get everywhere. By NICE embracing the ridiculous fantasy that is TCM they are legitimizing magical thinking and pre-scientific thinking based on models of the body that have no basis in reality. This is not only ridiculous it is damaging to the very fabric of society and is promoting anti-scientific thinking.

          I was not suggesting that treatments with no evidence should be recommended in their place but there is a world of difference between psychology and exercise and TCM. Can you not see that? Yes it would be incorrect to recommend exercise and CBT if there is no evidence for them – but neither is an outlandish suggestion IN AND OF ITSELF! It might be inappropriate in a particular situation – but it would be appropriate in some situations for another indication.
          THERE IS NO INDICATION WHATSOEVER IN ANY SITUATION WHERE TCM IS EVER APPROPRIATE. PERIOD.
          Now do you get the distinction?

          Yes psychology has problems with reproducibility and has a lot of house cleaning to do. But at least there is good reason to suppose that psychological interventions are at least plausible and there is good evidence for the effectiveness of CBT in certain situations. It is not based on “magical thinking” and neither is it based on pre-scientific systems of the body or on a false anatomical and physiological body system. It does not rely of imaginary meridians or an imaginary life force Qi. The fact that NICE may be endorsing unreliable or evidentially weak theories in the psychology of pain does not mean that the whole of Psychology is pseudoscience. If there are false theories pervading psychology then these ought to be rooted out – but that does not make all of psychology false. There is at least an attempt to make it science and evidence based given the limitations of a discipline where measurements are bound to be very subjective.

          NICE has to move away from accepting weak and equivocal evidence for interventions. Where there is no convincing evidence they ought to say so and leave it blank. Suggesting best guesses is potentially harmful and only encourages charlatans and outliers. But there is still a world of difference between mislabelling exercise or CBT as potentially useful (yes it SHOULDN’T HAPPEN) and promoting pre-scientific fantasy medicine like TCM (liver stagnation indeed!) as this merely undermines science altogether.

          The answer is to improve the science and do better – not to introduce pre-scientific thinking.

          And anyway this is a blog about (S)CAM

          • “These people are hucksters and are dangerous delusional snake-oil sales people”

            Ah, OK, I get it now. This website is dedicated to getting rid of a certain group of people who happen to be quacks. Quackery is OK when promoted by higher status groups like psychiatrists and psychologists.

            People like Wessely and pals keep insisting that thinking the wrong thoughts causes illness. They insist CBT and exercise treats everything. That seems like implausible magic to me, and so far they have zero reliable evidence for a theory with more holes than Swiss cheese.

            Personally I am opposed to quackery from any source, but to each their own…

          • “Ah, OK, I get it now.”
            I am afraid you just showed that you haven’t got it at all.

      • When NICE promotes acupuncture at least this is a relatively clear example of quackery so those keen to avoid quackery can google it and choose against it. If the evidence of efficacy for exercise and psychological care is no better than for acupuncture then patients seem even more likely to assume that they can just trust NICE. Isn’t that even worse?

        “in any event exercise is not deceitful and need not be expensive and a waste of money nor is it pseudoscientific nonsense.”

        Exercise can be sold to patients with misleading claims of efficacy as a treatment for particular conditions and that can be as deceitful as CAM. While it may not cost the NHS much money, for patients there can be a real cost of time, effort and the hardship of pushing themselves engage in more exercise than they would otherwise choose to do. Any misleading or exaggerated claim about the efficacy of treatments can cause harm in a wide range of way.

        I’ve not recently looked in detail at the evidence for chronic pain treatments but I worry that within medicine there is a culture of assuming that recommending things like exercise and psychological care is always likely to be of some use so therefore there can be less caution in medicalising those aspects of patients lives. This can combine with the incentives in academia which seem to encourage a degree of hype about the value of ones field.

        Holistic biopsychosocial care is not necessarily more evidence based or useful than the supposedly holistic care provided by CAM practitioners.

        • @ Chucky

          it is extremely naive to say that patients can google acupuncture and find out that it is quackery!
          what they will find is an avalanche of misinformation telling them the exact opposite! Have you ever looked online?
          Have you ever read anything posted by SCAM – it is a fetid sewer of the most rank nonsense.

          AT least proponents of gentle exercise and the suggestions made by psychotherapists are for more general healthy changes and they make no miracle promises nor do they espouse pseudoscientific BS and expound anti-vaccine and other harmful ideology.

          I am not extolling the virtues of evidence free methods – just that there is a world of difference between the two!

          • @John Travis:

            Maybe I sounded too sanguine, and there is certainly a lot of misinformation being promoted about acupuncture, but for a member of the general public just looking it up on wikipedia the article (currently) starts: “Acupuncture[b] is a form of alternative medicine[2] and a key component of traditional Chinese medicine (TCM) in which thin needles are inserted into the body.[3] Acupuncture is a pseudoscience,[4][5] the theories and practices of TCM are not based on scientific knowledge, and it has been characterized as quackery.[6]”

            That’s a reasonable indication that the recommendations from NICE should be viewed with caution.

            It’s certainly not that I’m unconcerned by NICE’s decision to promote acupuncture but I do worry that some people can underestimate the problems associated with less obvious forms of quackery, even though it is when things are less clearly absurd that they are more likely to have greater influence.

            As for ‘harmful ideology’, the exaggerated claims made about the value of biopsychosocial rehabilitation have played a considerable role in shaping UK disability policies over the last two decades: https://journals.sagepub.com/doi/abs/10.1177/0261018316649120 A 2016 UN inquiry found that these policies amounted to a gross and systematic violation of the rights of disabled people: http://www.ohchr.org/Documents/HRBodies/CRPD/CRPD.C.15.R.2.Rev.1-ENG.doc In the UK, acupuncturists don’t seem to have the influence needed to do so much harm.

          • @ Chucky

            it depends where they land up. Wiki is fairly anti-pseudoscience but the bulk of hits will be for CAM practitioners or websites promoting CAM or blogs or adverts for some kind of CAM or articles promoting CAM of one sort or another. Most folks are not very good at checking what the source is that they are reading – they just take it as verbatim.
            Natural News will be taken as reliable as Forbes or Reuters.

            Currently Trump has got his new website out which has completely re-written the whole of his presidency – no mention of the storming of the Capitol or the 550,000 deaths from Covid – apparently his management of the “China Virus”was a great success. SO it all depends upon where you land and whether you are able to discern the reliability of the site you land on.

            I take your point about the biopsychosocial stuff – but I don’t think weird claims have ever put people off – look at the following for QAnon in the US – the whole premise is just too fanciful to be true – yet a very large percentage of the population do. Before a large chunk of them defected to QAnon there was a fair following on You-Tube for Flat EArthers – I mean really?

            But re the Biopsychosocial thing – I really think that the problem there was not so much the model as the political interpretation of it – It was Ian Duncan Smith who pushed that lot through and it was driven by ideology. In the same way as the Devil can quote scripture, politicians can twist any piece of science or social thinking to fit their agenda. He got a knighthood out of it. He just wanted to get as many people off benefits as conceivably possible regardless of need.

            It’s much the same way that the Russians and Chinese appropriated Marx’s ideas for communism and twisted it to their own different ends in different ways. (Not that it would have worked the way Marx imagined either.) But by misappropriating someone else’s idea and claiming either their lofty ideals or using their conclusions as an excuse for your actions you can usurp their work but implement it to your own ends while laying the blame at another’s door.

          • @john travis

            “it depends where they land up” – that’s true, and I think that you’re probably right that I gave the impression of being overly relaxed about this, though I think that really reflects my view that other problems are even worse than a lack of real concern.

            I’d disagree with “I don’t think weird claims have ever put people off”. People will always have blind spots and make foolish mistakes, but I think that acupuncture and things like its claims about circulating chi will still raise instinctive scepticism amongst much of the UK population. That provides a degree of protection from some of the most serious abuses of power that quackery can lead to. Nonetheless, the idea of patients suffering from serious problems with chronic pain being encouraged to see an acupuncturist is certainly still disturbing.

            “I really think that the problem there was not so much the model as the political interpretation of it – It was Ian Duncan Smith who pushed that lot through and it was driven by ideology. In the same way as the Devil can quote scripture, politicians can twist any piece of science or social thinking to fit their agenda. He got a knighthood out of it. He just wanted to get as many people off benefits as conceivably possible regardless of need.”

            It was also under Labour that the BPS model was being openly used to justify cuts to disability spending while presenting these cuts as a paternalistic and empowering intervention eg the replacement of Incapacity Benefit with Employment and Support Allowance and the introduction of Atos’s ‘biopsychosocial assessments’ – designed with assistance from Mansel Aylward. Much of IDS’s policies were following plans drawn up by the civil service under Labour.

            Looking at DWP records we can be how prominent academic proponents of the BPS model actively influence government policies. Another commenter mentioned Simon Wessely, and this document includes minutes of a 1992 meeting he had with the DSS about CFS in which he was recorded as claiming “Benefits can often make patients worse” (p10). : https://valerieeliotsmith.files.wordpress.com/2015/0/natarchbn141dss.pdf On page 18 Wessely writes to complain about a plan to class CFS as a neurological condition for the sake of benefit claims, stating that “As we, and now many other groups, have shown that the only [‘only’ emphasised in original] determinant of outcome in this condition is strength of belief in a solely physical cause, then it will also itself contribute to disability and poor outcome. I cannot believe that is the intention of the Department, if only on grounds of cost!”

            I’m not aware of anyone having found evidence that would justify those claims, but they are the sorts of views that would make an expert popular with those politicians and civil servants trying to find narratives to justify benefit cuts. And helpful Sir Simon went on to receive his own knighthood, in addition to sitting on the panel that helps decide who should receive such ‘honours’.

            To me it seems that the biopsychosocial model is so ‘holistic’ that it can easily be melded to suit the desires and interests of those with power, particularly when it is often so difficult to get reliable and objective evidence for the ‘psychosocial’ aspects of peoples lives and health. This can combine with the fact that ‘psychosocial’ elements are an important part of peoples lives and health to mean that while this flexible model may have some benefits it can so easily drift into pseudoscience while still still sounding plausible and respectable that it is likely to go on harming patients until genuinely enforced standards within academia are dramatically raised. At the moment it doesn’t feel like we’re going in the right direction.

          • @ Chucky

            in terms of CFS specifically the UK medical “establishment” has certainly painted itself into something of a corner versus the rest of the world with its determination to insist that the condition is primarily psychological rather than biological and to promote rather dodgy advice on that basis. But I think while this is certainly obviously wrong it is important to see it for what it is – the wrong experts getting involved – psychiatrists – who will therefore be looking for a psychiatric cause. If your only tool is a hammer you go around looking for nails! Starting with a pre-conceived theory and setting about proving it. Doing studies that are more or less aimed at proving your theory and then moving the goal-posts in the middle of the game. Then at the end of the game fudging the score. This is all terribly bad science and is not how scientists are meant to behave – but it is what people do when they have pet theories and want the evidence to conform to what they believe.

            The outcomes of such behaviour are bad for scientific endeavour and for science in general. They are pretty awful for the patients they are meant to benefit and they set things back years or decades. But it is incorrect to call any of this PSEUDOSCIENCE. It is science done wrong. It is scientists behaving badly. It is scientists being human and allowing their pre-conceived notions to interfere with their research. Allowing research grants, political or moral notions to get in the way of the facts, being too stubborn or pig-headed to change their minds or admit they were wrong.
            BUT IT IS NOT PSEUDOSCIENCE.

            So I think it is very important that people on here stop calling it that. What they are doing is not based on magic or fantasy. It is not based on some imaginary “life force” or mystical belief in thousand year old ancestor folk remedies. It was not made up on the basis of some delusional belief that god was speaking to them through some archangel or something.
            It is based on actual science just done appallingly badly, tainted by personal convictions, mangled by the researchers’ beliefs that they were right, and by reporting their results selectively. Granted this is the sort of conduct we see much more often in pseudoscientific research – but misconduct and fraud are becoming more common in real science as competition and rewards increase and researchers allow their convictions that they are “right” to permit them to “tweak” the results accordingly.

            But while my point doesn’t make their conduct any less reprehensible or their results any more correct I believe that the distinction is important. Had they conducted their research correctly and had they reported their findings in the correct manner then the results might well have been a useful negative finding. It would have been science. They were not delving into magical “biofield” theory that no-one can actually measure, or the implausible “memory of water” that no-one has proven to be the case, or relying on “meridians” that have proven to be physiologically and anatomically invisible.
            They had a hypothesis and were seeking to disprove it. They just did science appallingly badly and their behaviour was egregious.

            In the same way recommending exercise or CBT in cases where they are not going to help is wrong – but it is NOT pseudoscience or SCAM! It is just incorrect or bad medicine in the same way as prescribing antibiotics for a virus or giving the wrong medicine for a certain condition or doing an operation the has been shown not to be effective. These are bad practice of medicine or unscientific but they are NOT pseudoscience.
            The practice of medicine and science are meant to be self-correcting and to be constantly changing – learning and evolving. Often that can be painfully slow with poor practices taking far too long to die out and some people displaying the human qualities of reluctance to change or refusal to give up their beliefs. We need stronger incentives or enforcements to make sure that these things happen.

            But what you see here is rampant in SCAM where the most bizarre and outrageous misconduct in research is commonplace and the most paltry and pathetic case series is hailed as a major success story for some ridiculous SCAM. It will get a press release as recently happened in India with an alleged “cure” for Covid-19 for some nonsense AYUSH remedy that achieved a mass of publicity all of which was pure rubbish.

            I’m afraid that I don’t share your faith in the general public’s ability to tell fact from fiction or to be deterred by the extremity of the lie. Recent polls have shown that in the US 40% of the population still think that the election was rigged and that 80% of republican do. The vast numbers who flock to QAnon sites belies that thinking too. There are large numbers who do not believe the Holocaust ever happened. David Icke who believes that we are governed by alien lizard people has a large internet following.
            Alex Jones hosts a conspiracy laden far right radio show of totally off the wall nut-job ideas that gets 2 million listeners who buy into his idiotic theories. They are so unbelievable they would be rejected as sci-fi plots but his listeners seem to think not.

            Do you get my point?

          • John,

            You have reminded me of the time I went to an international symposium on urological cancers hosted by the European Association of Urology. As somebody more used to Oncology conferences, where the presentations generally involved presentation of trial data, often large international trials where the results led to changes in practice worldwide, I was rather surprised to see presentations along the following lines:

            “Last year we heard my eminent colleague Herr Professor Schmidt discuss his new operation and present his series of 8 cases where it had been so successful. I would like to present my own case series of 11 patients undergoing the same surgery. Unfortunately my results have not been as successful as Professor Schmidt’s. But as we all know he is an extremely skilled surgeon. My conclusion is that we should all be adopting this treatment as the new gold standard.”

          • and some say that urologists have no humor!

          • @John Travis:

            We may just have a fairly minor semantic disagreement here that makes it sound as if we are further apart than we are.

            re ‘pseudoscience’ vs “science done wrong” and how important this difference is:

            If we had two identically designed and run trials lead to identical results, with a high risk of bias and researchers looking to show that the treatments they use are effective, but one was for a form of biopsychosocial rehabilitation and the other for something based on tarot reading, past lives and a healer claiming to have “developed a powerful and magical program” and to be able “to step into other people’s bodies”. How important a difference is that?

            What if the healer then realises that he can change his narratives and get support from academics looking for positive result so the same person starts talking about biopsychosocial rehabilitation and “switching on health promoting neurological pathways”, now with promotion from a major university, has he now moved from pseudoscience to anything more respectable? How important a difference is that?

            We are seeing things like this happen. There is a difference, but my view is that actually the more obvious forms of CAM are often less of a threat to patients.

            Different people and groups tend to use language differently and possibly even a mini-culture like the regular commentators on this blog end up with a consensus view. Personally, my instinct is to avoid a term like ‘pseudoscience’, particularly if I’m talking to someone who has faith in the claims I believe are unfounded, as it tends to be taken as an ad hominem and make further discussion more difficult.

            re My “faith in the general public’s ability to tell fact from fiction or to be deterred by the extremity of the lie”.

            I’m not known for my confident faith in the judgements of the British public, but I still think that on matters relating to circulating chi, past lives, etc, they have some instinctive scepticism. That is better than nothing!

            Thanks for talking things through – always good to exchange ideas and viewpoints.

  • Acupuncture is quite an old treatment yet, somehow, no one has yet provided enough research to show how it works. As it is, it sounds as though the benefit is the attention of the acupuncturist rather than the acupuncture itself. NICE should not be suggesting this as a treatment if, and until, there is good evidence that it works and we know how it works.

    That might take a while, though….

    • Acupuncture is quite an old treatment …

      Yes, about 70 years old now – at least acupuncture as we know it.

      Some 120 years ago, it was, erm, ‘somewhat different’ … see https://archive.org/details/thirtyyearsinmo00chrigoog book page 33:
      “The only mode of treatment in vogue which might be called surgical is acu-puncture, practised for all kinds of ailments. The needles are of nine forms, and are frequently used red-hot, and occasionally left in the body for days. Having no practical knowledge of anatomy, the practitioners often pass needles into large blood vessels and important organs, and immediate death has sometimes resulted. A little child was carried to the dispensary presenting a pitiable spectacle. The doctor had told the parents that there was an excess of fire in its body, to let out which he must use cold needles, so he had pierced the abdomen deeply in several places. The poor little sufferer died shortly afterwards. For cholera the needling is in the arms. For some children’s diseases, especially convulsions, the needles are inserted under the nails. For eye diseases they are often driven into the back between the shoulders to a depth of several inches. Patients have come to us with large surfaces on their backs sloughing by reason of excessive treatment of this kind with instruments none too clean.”

      Next time someone enthusiastically tells you that age-old acupuncture cured their ailment, ask them if they got the real traditional type of acupuncture (and let them read the above), or the wishy-washy superficial treatment that was introduced relatively recently.

  • As a patient suffering from pain in my lower back since 35 years, I have a suggestion for the health care: Be better at diagnostics . Thats the only way to treat pain. In Sweden doctors in general are really bad at the clinical examination, they need better MRI equipment and better skills to evaluate the xraypictures. I have tried acupuncture several times- even under that time I believed in it, it didn’t work at all. Not even a placeboeffect. Now I´ve had an upright MRI and for the first time I know what’s wrong. A lot of the pain related to back pain and neck pain is due to compressed nerves. Thats very common. And of course there are other causes too. Acupuncture is a vast of time and money. Instead the patient could have had an adequate examination and diagnosis and get treated in time.

    • @ Ulla Nilsson

      there is a vast amount of evidence that X-rays and MRI of the lower spine is a complete waste of time and money as it almost never yields any useful information in the absence of certain “red flag” indications.
      Having better skills at reading the pictures is not going to help this because the vast majority of lower back pain is not going to have a cause that is readily amenable to easy”fixing.”

      It is not mostly caused by compressed nerves as you seem to think and as many chiropractors would have you believe. It is a highly complex multi-faceted (no pun intended) disorder and is largely the result of humans evolving from being quadrupeds into bipeds. Our spines were not “intended” to work this way. It places stress and strains on areas not built to take them. Our necks are not “built” to look forward in the way we do all the time.

      I’m afraid that you are suggesting an incredibly simplistic solution to an incredibly complex problem – and you could do 100 times as many MRI scans with the most expert radiologists and not improve the situation one single jot.

  • Patient well-being seems to be low priority. We don’t care about labels such as “complementary” or “psychological” or “bio-medical”. We want our lives back. We want treatments that work and do not cause harm. And we want to see evidence, not baseless assertions like, “There is nothing that isn’t made better through exercise, OK, nothing” from Dame Clare on BBC. [1]

    From the outside looking in, most medical research (especially the endless reviews and reviews of reviews) appears to be turf-building and marketing. Why should we pay any attention whatsoever to any evidence rated less than high quality? Would a physician buy a car rated very low quality?

    The new guideline is not fit for the purpose of helping patients. The inclusion of acupuncture is the least of its problems: it is the exercise and psychotherapy recommendations that will be inflicted on the patients.

    [1] https://www.meaction.net/2021/02/09/appgs-should-collaborate-on-me-and-long-covid/

  • I have to say that I am rather disappointed that NICE are making any recommendations for acupuncture at all based on the quality of the evidence they are referencing. However, their primary remit is cost-effectiveness, and “only if delivered by a band 7 or lower healthcare professional” is very telling, as this specifically refers to salary scales. Possibly the committee are taking the view that someone undergoing acupuncture is saving the NHS the expense of another intervention provided that the costs of the acupunture can be kept down.

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