In so-called alternative medicine (SCAM) we have an amazing number of ‘discoveries’ which – IF TRUE – should have changed the world. Here I list of 10 of my favorites:
- Diluting and shaking a substance makes it not weaker but stronger.
Homeopaths call this process ‘potentisation’. They use it to produce highly ‘potent’ remedies that contain not a single molecule of the original substance. The assumption is that potentisation transfers energy or information. Therefore, they claim, molecules are no longer required for achieving a clinical effect.
2. A substance that causes a certain symptom in a healthy person can be used to cure that symptom when it occurs in a patient.
The ‘like cures like’ principle of homeopathy is based on the notion that the similimum provokes an artificial disease which in turn defeats the condition the patient is suffering from.
3. Subluxations of the spine are the cause of most diseases that affect us humans.
DD Palmer, the inventor of chiropractic, insisted that almost all diseases are due to subluxations. These misplaced vertebrae, he claimed, are the root cause of any disease by inhibiting the flow of the ‘innate’ which in turn caused ill health.
4. Adjusting such subluxations is the best way to restore health.
Palmer, therefore, was sure that only adjustments of these subluxations were able to restore health. All other medical interventions were useless or even dangerous, in his view. Thus Palmer opposed medicines or vaccinations.
5. An imbalance of two life forces is the cause of all illnesses.
Practitioners of TCM believe that all illnesses originate from an energetic imbalance. Harmony between the two life forces ‘yin and yang’ means health.
6. Balance can be restored by puncturing the skin at specific points.
Acupuncturists are convinced that their needling is nothing less than attacking the root cause of his or her problem. Therefore, they are convinced that acupuncture is a cure-all.
7. Our organs are represented in specific areas on the sole of our feet.
Reflexologists have maps of the sole of a foot where specific organs of the body are located. They palpate the foot and when they feel a gritty area, they conclude that the corresponding organ is in trouble.
8. Massaging these areas will positively influence the function of specific organs.
Once the diseased or endangered organ is identified, the area in question needs to be massaged until the grittiness disappears. This intervention, in turn, will have a positive influence on the organ in question.
9. Healing energy can be sent into our body where it stimulates the self-healing process and restores health.
Various types of energy healers are convinced that they can transmit energy that comes from a divine or other source into a patient’s body. The energy enables the body to heal itself. Thus, energy healing is a panacea and does not even require a proper diagnosis to be effective.
10. Toxins accumulate in our bodies and must be eliminated through a wide range of SCAMs.
The toxins in question can originate from within the body and/or from the outside. They accumulate and make us sick. Therefore, we need to eliminate them, and the best way to achieve this is to use this or that SCAM
I could, of course, list many more such ‘discoveries’ – SCAM is full of them. They are all quite diverse but have one important thing in common: they are false (i.e. there is no good evidence for them and they fly in the face of science).
If they were true, they would have changed the world by revolutionizing science, physics, physiology, anatomy, pathology, therapeutics, etc.
ALL THESE UGLY FACTS DESTROYING SUCH BEAUTIFUL THEORIES!
WHAT A SHAME!!!
Well-conducted systematic reviews (SRs) should in principle provide the most reliable evidence on the effectiveness of acupuncture. However, limitations on the methodological rigour of SRs may impact the trustworthiness of their conclusions. This cross-sectional study was aimed at evaluating the methodological quality of recent SRs of acupuncture.
The Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE were searched for SRs focusing on manual acupuncture or electro-acupuncture published during January 2018 and March 2020. Eligible SRs needed to contain at least one meta-analysis and be published in the English language. Two independent reviewers extracted the bibliographical characteristics of the included SRs with a pre-designed questionnaire and appraised the methodological quality of the reviews with the validated AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2). The associations between bibliographical characteristics and methodological quality ratings were explored using Kruskal-Wallis rank tests and Spearman’s rank correlation coefficients.
A total of 106 SRs were appraised. The results were as follows:
- one (0.9%) SR was of high methodological quality,
- no review (0%) was of moderate quality,
- six (5.7%) were of low quality,
- 99 (93.4%) were of critically low quality.
Only ten (9.4%) provided an a priori protocol, only four (3.8%) conducted a comprehensive literature search, only five (4.7%) provided a list of excluded studies, and only six (5.7%) performed a meta-analysis appropriately. Cochrane SRs, updated SRs, and SRs that did not search non-English databases had relatively higher overall quality. The vast majority (87.7%) of the 106 reviews included in this analysis originated from Asia. Conflicts of interest of the review authors were declared in only 2 of the 106 reviews.
The authors concluded that the methodological quality of SRs on acupuncture is unsatisfactory. Future reviewers should improve critical methodological aspects of publishing protocols, performing comprehensive search, providing a list of excluded studies with justifications for exclusion, and conducting appropriate meta-analyses. These recommendations can be implemented via enhancing the technical competency of reviewers in SR methodology through established education approaches as well as quality gatekeeping by journal editors and reviewers. Finally, for evidence users, skills in SR critical appraisal remain to be essential as relevant evidence may not be available in pre-appraised formats.
On this blog, I have often complained about the lack of critical input and the poor quality of systematic reviews of so-called alternative medicine (SCAM), particularly of acupuncture, and especially of Chinese reviews, and even more especially Chinese reviews of (mostly) Chinese studies. This new paper is a valuable confirmation of this fast-growing deficit.
One does not need to be a prophet to predict that this pollution of the literature with complete rubbish will have detrimental effects. Because poor reviews almost always draw an over-optimistic picture of the value of acupuncture, this phenomenon must seriously mislead the public. The end result will be that the public believes acupuncture to be effective.
I cannot help thinking that this is, in fact, the intended aim of the authors of such poor, false-positive reviews. Moreover, a glance at the subject areas of the reviews in the list below gives the impression that China is heavily promoting the idea that acupuncture is a panacea. Yet there is good evidence to show that acupuncture is little more than placebo therapy.
In my last post, I have reported that I am an author of many of the frequently-cited systematic acupuncture reviews. You might thus assume that I am a significant part of this pollution by rubbish reviews. This would, however, be an entirely wrong conclusion. The above analysis covers a period when my unit had already been closed, and I am thus not responsible for a single of the papers included in the above analysis.
List of included systematic reviews
|ID||Included systematic reviews|
|1||Acupuncture for primary insomnia: An updated systematic review of randomized controlled trials|
|2||Efficacy and safety of acupuncture for essential hypertension: A meta-analysis|
|3||Acupuncture for the treatment of sudden sensorineural hearing loss: A systematic review and meta-analysis: Acupuncture for SSNHL|
|4||Effectiveness of Acupuncturing at the Sphenopalatine Ganglion Acupoint Alone for Treatment of Allergic Rhinitis: A Systematic Review and Meta-Analysis|
|5||Acupuncture and clomiphene citrate for anovulatory infertility: a systematic review and meta-analysis|
|6||Acupuncture for primary trigeminal neuralgia: A systematic review and PRISMA-compliant meta-analysis|
|7||Acupuncture as an adjunctive treatment for angina due to coronary artery disease: A meta-analysis|
|8||Conventional treatments plus acupuncture for asthma in adults and adolescent: A systematic review and meta-analysis|
|9||Optimizing acupuncture treatment for dry eye syndrome: A systematic review|
|10||Acupuncture using pattern-identification for the treatment of insomnia disorder: a systematic review and meta-analysis of randomized controlled trials|
|11||Efficacy and Safety of Auricular Acupuncture for Cognitive Impairment and Dementia: A Systematic Review|
|12||Acupuncture for cognitive impairment in vascular dementia, alzheimer’s disease and mild cognitive impairment: A systematic review and meta-analysis|
|13||Effectiveness of pharmacopuncture for cervical spondylosis: A systematic review and meta-analysis|
|14||Acupuncture combined with swallowing training for poststroke dysphagia: a meta-analysis of randomised controlled trials|
|15||Scalp acupuncture treatment for children’s autism spectrum disorders: A systematic review and meta-analysis|
|16||Acupuncture for Post-stroke Shoulder-Hand Syndrome: A systematic review and meta-analysis|
|17||Systematic review of acupuncture for the treatment of alcohol withdrawal syndrome|
|18||Acupuncture for hip osteoarthritis|
|19||Clinical Benefits of Acupuncture for the Reduction of Hormone Therapy-Related Side Effects in Breast Cancer Patients: A Systematic Review|
|20||Combination therapy of scalp electro-acupuncture and medication for the treatment of Parkinson’s disease: A systematic review and meta-analysis|
|21||Acupuncture for migraine: A systematic review and meta-analysis|
|22||Acupuncture to Promote Recovery of Disorder of Consciousness after Traumatic Brain Injury: A Systematic Review and Meta-Analysis|
|23||Acupuncture Compared with Intramuscular Injection of Neostigmine for Postpartum Urinary Retention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials|
|24||Acupuncture for the relief of hot flashes in breast cancer patients: A systematic review and meta-analysis of randomized controlled trials and observational studies|
|25||Effectiveness and Safety of Acupuncture for Perimenopausal Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials|
|26||Acupuncture plus Chinese Herbal Medicine for Irritable Bowel Syndrome with Diarrhea: A Systematic Review and Meta-Analysis|
|27||Electroacupuncture as an adjunctive therapy for motor dysfunction in acute stroke survivors: A systematic review and meta-analyses|
|28||Acupuncture for Acute Pancreatitis: A Systematic Review and Meta-analysis|
|29||Acupuncture for chronic fatigue syndrome: a systematic review and meta-analysis|
|30||Compare the efficacy of acupuncture with drugs in the treatment of Bell’s palsy: A systematic review and meta-analysis of RCTs|
|31||The effectiveness and safety of acupuncture for the treatment of myasthenia gravis: a systematic review and meta-analysis of randomized controlled trials|
|32||Acupuncture therapy for fibromyalgia: A systematic review and meta-analysis of randomized controlled trials|
|33||The effectiveness of acupuncture therapy in patients with post-stroke depression: An updated meta-analysis of randomized controlled trials|
|34||Fire needling for herpes zoster: A systematic review and meta-analysis of randomized clinical trials|
|35||Comparison between the Effects of Acupuncture Relative to Other Controls on Irritable Bowel Syndrome: A Meta-Analysis|
|36||Manual Acupuncture for Optic Atrophy: A Systematic Review and Meta-Analysis|
|37||Effect of warm needling therapy and acupuncture in the treatment of peripheral facial paralysis: A systematic review and meta-analysis|
|38||The Effect of Acupuncture in Breast Cancer-Related Lymphoedema (BCRL): A Systematic Review and Meta-Analysis|
|39||The Efficacy of Acupuncture in Chemotherapy-Induced Peripheral Neuropathy: Systematic Review and Meta-Analysis|
|40||The maintenance effect of acupuncture on breast cancer-related menopause symptoms: a systematic review|
|41||The effectiveness of acupuncture in the management of persistent regional myofascial head and neck pain: A systematic review and meta-analysis|
|42||Acupuncture for the Treatment of Adults with Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis|
|43||The effectiveness of superficial versus deep dry needling or acupuncture for reducing pain and disability in individuals with spine-related painful conditions: a systematic review with meta-analysis|
|44||Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis|
|45||Is dry needling effective for low back pain?: A systematic review and PRISMA-compliant meta-analysis|
|46||The effectiveness and safety of acupuncture for patients with atopic eczema: a systematic review and meta-analysis|
|47||Comparing verum and sham acupuncture in fibromyalgia syndrome: a systematic review and meta-analysis|
|48||Acupuncture for symptomatic gastroparesis|
|49||The Efficacy and Safety of Acupuncture for the Treatment of Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis|
|50||Acupuncture Versus Sham-acupuncture: A Meta-analysis on Evidence for Non-immediate Effects of Acupuncture in Musculoskeletal Disorders|
|51||Acupuncture Treatment for Post-Stroke Dysphagia: An Update Meta-Analysis of Randomized Controlled Trials|
|52||Effectiveness of Acupuncture Used for the Management of Postpartum Depression: A Systematic Review and Meta-Analysis|
|53||Clinical effects and safety of electroacupuncture for the treatment of post-stroke depression: a systematic review and meta-analysis of randomised controlled trials|
|54||Placebo effect of acupuncture on insomnia: a systematic review and meta-analysis|
|55||Acupuncture for Chronic Pain-Related Insomnia: A Systematic Review and Meta-Analysis|
|56||Evidence for Dry Needling in the Management of Myofascial Trigger Points Associated With Low Back Pain: A Systematic Review and Meta-Analysis|
|57||Warm needle acupuncture in primary osteoporosis management: a systematic review and meta-analysis|
|58||Acupuncture for overactive bladder in adults: a systematic review and meta-analysis|
|59||Traditional acupuncture for menopausal hot flashes: A systematic review and meta-analysis of randomized controlled trials|
|60||The effectiveness of acupuncture for osteoporosis: A systematic review and meta-analysis|
|61||Long-term effects of acupuncture for chronic prostatitis/chronic pelvic pain syndrome: Systematic review and single-Arm meta-Analyses|
|62||Does acupuncture the day of embryo transfer affect the clinical pregnancy rate? Systematic review and meta-analysis|
|63||Acupuncture treatments for infantile colic: a systematic review and individual patient data meta-analysis of blinding test validated randomised controlled trials|
|64||Acupuncture performed around the time of embryo transfer: a systematic review and meta-analysis|
|65||Is Acupuncture Effective for Improving Insulin Resistance? A Systematic Review and Meta-analysis|
|66||Efficacy of acupuncture in the management of post-apoplectic aphasia: A systematic review and meta-analysis of randomized controlled trials|
|67||Acupuncture for lumbar disc herniation: a systematic review and meta-analysis|
|68||Traditional Chinese acupuncture and postpartum depression: A systematic review and meta-analysis|
|69||Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis|
|70||Acupuncture Therapy for Functional Effects and Quality of Life in COPD Patients: A Systematic Review and Meta-Analysis|
|71||Electroacupuncture for Reflex Sympathetic Dystrophy after Stroke: A Meta-Analysis|
|72||The Effect of Patient Characteristics on Acupuncture Treatment Outcomes|
|73||The efficacy and safety of acupuncture in women with primary dysmenorrhea: A systematic review and meta-analysis|
|74||Role of acupuncture in the treatment of insulin resistance: A systematic review and meta-analysis|
|75||Appropriateness of sham or placebo acupuncture for randomized controlled trials of acupuncture for nonspecific low back pain: A systematic review and meta-analysis|
|76||Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomised placebo- or sham-controlled trials|
|77||The effects of acupuncture on pregnancy outcomes of in vitro fertilization: A systematic review and meta-analysis|
|78||Acupuncture for migraine without aura: a systematic review and meta-analysis|
|79||Acupuncture for acute stroke|
|80||Acupuncture at Tiaokou (ST38) for Shoulder Adhesive Capsulitis: What Strengths Does It Have? A Systematic Review and Meta-Analysis of Randomized Controlled Trials|
|81||Acupuncture for hypertension|
|82||The effect of acupuncture on Bell’s palsy: An overall and cumulative meta-analysis of randomized controlled trials|
|83||Effects of acupuncture on cancer-related fatigue: a meta-analysis|
|84||Acupuncture for adults with overactive bladder|
|85||Electroacupuncture for Postoperative Urinary Retention: A Systematic Review and Meta-Analysis|
|86||Meta-Analysis of Electroacupuncture in Cardiac Anesthesia and Intensive Care|
|87||Acupuncture therapy improves health-related quality of life in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis|
|88||The effect of acupuncture on the quality of life in patients with migraine: A systematic review and meta-analysis|
|89||Cognitive improvement effects of electro-acupuncture for the treatment of MCI compared with Western medications: A systematic review and Meta-analysis 11 Medical and Health Sciences 1103 Clinical Sciences|
|90||Oriental herbal medicine and moxibustion for polycystic ovary syndrome: A meta-analysis|
|91||The Effect of Acupuncture and Moxibustion on Heart Function in Heart Failure Patients: A Systematic Review and Meta-Analysis|
|92||Acupuncture therapy for the treatment of stable angina pectoris: An updated meta-analysis of randomized controlled trials|
|93||Traditional manual acupuncture combined with rehabilitation therapy for shoulder hand syndrome after stroke within the Chinese healthcare system: a systematic review and meta-analysis|
|94||Effects of moxibustion on pain behaviors in patients with rheumatoid arthritis: A meta-analysis|
|95||Acupuncture Treatment for Chronic Pelvic Pain in Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials|
|96||The effectiveness of dry needling for patients with orofacial pain associated with temporomandibular dysfunction: a systematic review and meta-analysis|
|97||Acupuncture for postherpetic neuralgia systematic review and meta-analysis|
|98||Acupoint selection for the treatment of dry eye: A systematic review and meta-analysis of randomized controlled trials|
|99||Warm-needle moxibustion for spasticity after stroke: A systematic review of randomized controlled trials|
|100||Acupuncture for menstrual migraine: a systematic review|
|101||The efficacy of acupuncture for stable angina pectoris: A systematic review and meta-analysis|
|102||Acupuncture and weight loss in Asians: A PRISMA-compliant systematic review and meta-analysis|
|103||Effects of Acupuncture on Breast Cancer-Related lymphoedema: A Systematic Review and Meta-Analysis|
|104||Acupuncture for infertile women without undergoing assisted reproductive techniques (ART): A systematic review and meta-analysis|
|105||Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer|
|106||Acupuncture for stable angina pectoris: A systematic review and meta-analysis|
It was only when I came across this recent paper that I realized that, apparently, I am THE WORLD CHAMPION in acupuncture reviews. The aim of this paper was to analyze the 100 most-cited systematic reviews or meta-analyses in the field of acupuncture research.
The Web of Science Core Collection was used to retrieve lists of 100 most-cited systematic reviews or meta-analyses in the field of acupuncture research. Two authors screened literature, extracted data, and analyzed the results.
The citation number of the 100 most-cited systematic reviews or meta-analyses varied from 65 to 577; they were published between 1989 and 2018. Fourteen authors published more than 1 study as the corresponding author and 10 authors published more than 1 study as the first author.
In terms of the corresponding authors, Edzard Ernst and Linde Klaus published the most systematic reviews/meta-analyses (n = 7). The USA published most of the systematic reviews or meta-analyses (n = 24), followed by England (n = 23) and China (n = 14). Most institutions with more than 1 study were from England (4/13). The institutions with the largest numbers of most-cited systematic reviews or meta-analyses were the Technical University of Munich in Germany, the University of Maryland School of Medicine in the USA (n = 8), the Universities of Exeter and Plymouth in England (n = 6), and the University of Exeter in England (n = 6). The journal with the largest number of most-cited systematic reviews or meta-analyses was the Cochrane Database of Systematic Reviews (n = 20), followed by Pain (n = 6). The majority of the 100 most-cited reviews are on pain or pain-related conditions. Only 4 of them focus on safety issues, and all of these are by my team.
The authors concluded that the 100 most-cited systematic reviews or meta-analyses in the acupuncture research field are mostly from high impact factor journals and developed countries. It will help researchers follow research hot spots, broaden their research scope, expand their academic horizons, and explore new research ideas, thereby improving the quality of acupuncture research.
The authors show that, both in the list of corresponding as well as first authors, I am in place number one! Not only that, they furthermore reveal that my department is also in place number 1 (as Universities of Exeter and Plymouth in England (n = 6), and the University of Exeter in England (n = 6) both refer to my unit [in the 19 years it existed the Exeter medical school changed affiliation twice]). This is remarkable, particularly because acupuncture was only one of several research foci of my team (the other 3 being herbal medicine, homeopathy, and spinal manipulation), and my department was closed almost 10 years ago.
When I write about acupuncture these days (mostly on this blog), I often get the impression that the true believers in this therapy don’t especially like what I have to say. I, therefore, fear that the concept of me being the WORLD CHAMPION of acupuncture reviews might cause some degree of displeasure to them.
What can I say?
The non-specific effects constitute part of the overall effect of acupuncture. It is unclear whether responders and non-responders of acupuncture experience non-specific effects differently. This analysis aimed to compare their experiences in a nested qualitative study embedded in an acupuncture trial on functional dyspepsia.
Purposive sampling was used to capture the experience of responders (n=15) and non-responders (n=15) to acupuncture via individual in-depth interviews. Design and analysis followed a framework analysis approach, with reference to an existing model on acupuncture non-specific effects. Themes emerging outside of this model were purposefully explored.
The findings suggest that responders had a more trusting relationship with the acupuncturist in response to their expression of empathy. In turn, they were more actively engaged in lifestyle modifications and dietary advice offered by acupuncturists. Non-responders were not satisfied with the level of reassurance regarding acupuncture safety. They were also expecting more peer support from fellow participants, regarded that as an empowerment process for initiating and sustaining lifestyle changes.
The authors concluded that our results highlighted key differences in acupuncture non-specific effect components experienced by responders and non-responders. Positive non-specific effects contributing to overall benefits could be enhanced by emphasizing on empathy expression from acupuncturists, trust-building, offering appropriate explanations on safety, and organizing patient support groups. Further research on the relative importance of each component is warranted.
I doubt that this tiny study lends itself to drawing any firm conclusions. However, what they seem to imply and what the authors (proponents of acupuncture) ignore totally is the following: acupuncture responders are those people who respond to the context of the treatment situation. Thus their positive result is not due to the specific effects of acupuncture itself but to non-specific effects. In other words, acupuncture operates predominantly or entirely via non-specific effects. Or, to put it bluntly: this analysis confirms what we have discussed many times before (see for instance here, here, and here), namely that
acupuncture is a placebo therapy.
The authors of this review start their paper with the following statement:
Acupuncture has demonstrated effectiveness for symptom management among breast cancer survivors.
This, I think, begs the following question: if they already know that, why do they conduct a systematic review of the subject?
The answer becomes clear as we read thier article: they want to add another paper to the literature that shows they are correct in their assumption.
So, they do the searches and found 26 trials (2055 patients), of which 20 (1709 patients) could be included in the meta-analysis. Unsurprisingly, their results show that acupuncture was more effective than control groups in improving pain intensity [standardized mean difference (SMD) = -0.60, 95% confidence intervals (CI) -1.06 to -0.15], fatigue [SMD = -0.62, 95% CI -1.03 to -0.20], and hot flash severity [SMD = -0.52, 95% CI -0.82 to -0.22]. Compared with waitlist control and usual care groups, the acupuncture groups showed significant reductions in pain intensity, fatigue, depression, hot flash severity, and neuropathy. No serious adverse events were reported related to acupuncture intervention. Mild adverse events (i.e., bruising, pain, swelling, skin infection, hematoma, headache, menstrual bleeding) were reported in 11 studies.
The authors concluded that this systematic review and meta-analysis suggest that acupuncture significantly reduces multiple treatment-related symptoms compared with the usual care or waitlist control group among breast cancer survivors. The safety of acupuncture was inadequately reported in the included studies. Based on the available data, acupuncture seems to be generally a safe treatment with some mild adverse events. These findings provide evidence-based recommendations for incorporating acupuncture into clinical breast cancer symptom management. Due to the high risk of bias and blinding issues in some RCTs, more rigorous trials are needed to confirm the efficacy of acupuncture in reducing multiple treatment-related symptoms among breast cancer survivors.
Yes, I agree: this is an uncritical white-wash of the evidence. So, why do I bother to discuss this paper? After all, the acupuncture literature is littered with such nonsense.
Well, to my surprise, the results did contain a little gem after all.
A subgroup analysis of the data indicated that acupuncture showed no significant effects on any of the treatment-related symptoms compared with the sham acupuncture groups.
Acupuncture seems to be a placebo therapy!
Acupuncture is usually promoted as a safe therapy. This may be good marketing but, sadly, it is not the truth. About 10% of all patients experience mild to moderate adverse effects such as pain or bleeding. In addition, there are well-documented complications, for instance:
However, there have been few reports of deaths due to pneumothorax after acupuncture treatment, especially focused on electroacupuncture.
Japanese authors recently reported an autopsy case of a man in his 60s who went into cardiopulmonary arrest and died immediately after receiving electroacupuncture. Postmortem computed tomography (PMCT) showed bilateral pneumothoraces, as well as the presence of numerous gold threads embedded subcutaneously. An autopsy revealed two ecchymoses in the right thoracic cavity and a pinhole injury on the lower lobe of the right lung, suggesting that the needles had penetrated the lung. There were marked emphysematous changes in the lung, suggesting that rupture of bullae might also have contributed to bilateral pneumothoraces and fatal outcomes. The acupuncture needles may have been drawn deeper into the body than at the time of insertion due to electrical pulses and muscle contraction, indicating the need for careful determination of treatment indications and technical safety measures, such as fail-safe mechanisms.
This is the first case report of fatal bilateral pneumothoraces after electroacupuncture reported in the English literature. This case sheds light on the safety of electroacupuncture and the need for special care when administering it to patients with pulmonary disease who may be at a higher risk of pneumothorax. This is also the first report of three-dimensional reconstructed PMCT images showing the whole-body distribution of embedded gold acupuncture threads, which is unusual.
One-sided pneumothoraxes are common events after acupuncture. Several hundred cases have been published and the vast majority of such incidents remain unpublished or even unnoticed. These events are not normally life-threatening. If ‘only’ one lung is punctured, the patient may experience breathing difficulties, but in many cases these are temporary and the patient soon recovers.
Yet a bilateral pneumothorax is an entirely different affair. If both lungs malfunction, the patient’s chances of survival are slim unless he/she is close to an intensive care unit.
You might think that it needs an especially ungifted acupuncturist to manage to puncture both lungs simultaneously. I might agree, but we need to consider that acupuncture needles are often inserted in a symmetrical fashion into the patient’s body. This means that, if the therapist puts a needle at one point of the thorax that is close to a lung, he is not unlikely to do the same on the other side.
And how does one prevent such disasters?
- train acupuncturists properly,
- avoid needles on the upper thorax,
- or refuse acupuncture altogether.
This multicenter, randomized, sham-controlled trial was aimed at assessing the long-term efficacy of acupuncture for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Men with moderate to severe CP/CPPS were recruited, regardless of prior exposure to acupuncture. They received sessions of acupuncture or sham acupuncture over 8 weeks, with a 24-week follow-up after treatment. Real acupuncture treatment was used to create the typical de qi sensation, whereas the sham acupuncture treatment (the authors state they used the Streitberger needle, but the drawing looks more as though they used our device) does not generate this feeling.
The primary outcome was the proportion of responders, defined as participants who achieved a clinically important reduction of at least 6 points from baseline on the National Institutes of Health Chronic Prostatitis Symptom Index at weeks 8 and 32. Ascertainment of sustained efficacy required the between-group difference to be statistically significant at both time points.
A total of 440 men (220 in each group) were recruited. At week 8, the proportions of responders were:
- 60.6% (95% CI, 53.7% to 67.1%) in the acupuncture group
- 36.8% (CI, 30.4% to 43.7%) in the sham acupuncture group (adjusted difference, 21.6 percentage points [CI, 12.8 to 30.4 percentage points]; adjusted odds ratio, 2.6 [CI, 1.8 to 4.0]; P < 0.001).
At week 32, the proportions were:
- 61.5% (CI, 54.5% to 68.1%) in the acupuncture group
- 38.3% (CI, 31.7% to 45.4%) in the sham acupuncture group (adjusted difference, 21.1 percentage points [CI, 12.2 to 30.1 percentage points]; adjusted odds ratio, 2.6 [CI, 1.7 to 3.9]; P < 0.001).
Twenty (9.1%) and 14 (6.4%) adverse events were reported in the acupuncture and sham acupuncture groups, respectively. No serious adverse events were reported. No significant difference was found in changes in the International Index of Erectile Function 5 score at all assessment time points or in peak and average urinary flow rates at week 8.
The authors concluded that, compared with sham therapy, 20 sessions of acupuncture over 8 weeks resulted in greater improvement in symptoms of moderate to severe CP/CPPS, with durable effects 24 weeks after treatment.
The study was sponsored by the China Academy of Chinese Medical Sciences and the National Administration of Traditional Chinese Medicine. The trialists originate from the following institutions:
- 1Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China (Y.S., B.L., Z.Q., J.Z., J.W., X.L., W.W., R.P., H.C., X.W., Z.L.).
- 2Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China (Y.L.).
- 3ThedaCare Regional Medical Center – Appleton, Appleton, Wisconsin (K.Z.).
- 4Hengyang Hospital Affiliated to Hunan University of Chinese Medicine, Hengyang, China (Z.Y.).
- 5The First Hospital of Hunan University of Chinese Medicine, Changsha, China (W.Z.).
- 6Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China (W.F.).
- 7The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China (J.Y.).
- 8West China Hospital of Sichuan University, Chengdu, China (N.L.).
- 9China Academy of Chinese Medical Sciences, Beijing, China (L.H.).
- 10Yantai Hospital of Traditional Chinese Medicine, Yantai, China (Z.Z.).
- 11Shaanxi Provincial Hospital of Traditional Chinese Medicine, Xi’an, China (T.S.).
- 12The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China (J.F.).
- 13Beijing Fengtai Hospital of Integrated Traditional and Western Medicine, Beijing, China (Y.D.).
- 14Xi’an TCM Brain Disease Hospital, Xi’an, China (H.S.).
- 15Dongfang Hospital Beijing University of Chinese Medicine, Beijing, China (H.H.).
- 16Luohu District Hospital of Traditional Chinese Medicine, Shenzhen, China (H.Z.).
- 17Guizhou University of Traditional Chinese Medicine, Guiyang, China (Q.M.).
These facts, together with the previously discussed notion that clinical trials from China are notoriously unreliable, do not inspire confidence. Moreover, one might well wonder about the authors’ claim that patients were blinded. As pointed out above, the real and sham acupuncture were fundamentally different: the former did generate de qi, while the latter did not! A slightly pedantic point is my suspicion that the trial did not test the efficacy but the effectiveness of acupuncture, if I am not mistaken. Finally, one might wonder what the rationale of acupuncture as a treatment of CP/CPPS might be. As far as I can see, there is no plausible mechanism (other than placebo) to explain the effects.
So, is the evidence that emerged from the new study convincing?
No, in my view, it is not!
In fact, I am surprised that a journal as reputable as the Annals of Internal Medicine published it.
Acupuncture is a veritable panacea; it cures everything! At least this is what many of its advocates want us to believe. Does it also have a role in supportive cancer care?
Let’s find out.
This systematic review evaluated the effects of acupuncture in women with breast cancer (BC), focusing on patient-reported outcomes (PROs).
A comprehensive literature search was carried out for randomized controlled trials (RCTs) reporting PROs in BC patients with treatment-related symptoms after undergoing acupuncture for at least four weeks. Literature screening, data extraction, and risk bias assessment were independently carried out by two researchers. The authors stated that they followed the ‘Preferred Reporting Items for Systematic Review and Meta-Analyses’ (PRISMA) guidelines.
Out of the 2, 524 identified studies, 29 studies representing 33 articles were included in this meta-analysis. The RCTs employed various acupuncture techniques with a needle, such as hand-acupuncture and electroacupuncture. Sham/placebo acupuncture, pharmacotherapy, no intervention, or usual care were the control interventions. About half of the studies lacked adequate blinding.
At the end of treatment (EOT), the acupuncture patients’ quality of life (QoL) was measured by the QLQ-C30 QoL subscale, the Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES), the Functional Assessment of Cancer Therapy–General/Breast (FACT-G/B), and the Menopause-Specific Quality of Life Questionnaire (MENQOL), which depicted a significant improvement. The use of acupuncture in BC patients lead to a considerable reduction in the scores of all subscales of the Brief Pain Inventory-Short Form (BPI-SF) and Visual Analog Scale (VAS) measuring pain. Moreover, patients treated with acupuncture were more likely to experience improvements in hot flashes scores, fatigue, sleep disturbance, and anxiety compared to those in the control group, while the improvements in depression were comparable across both groups. Long-term follow-up results were similar to the EOT results. Eleven RCTs did not report any information on adverse effects.
The authors concluded that current evidence suggests that acupuncture might improve BC treatment-related symptoms measured with PROs including QoL, pain, fatigue, hot flashes, sleep disturbance and anxiety. However, a number of included studies report limited amounts of certain subgroup settings, thus more rigorous, well-designed and larger RCTs are needed to confirm our results.
This review looks rigorous on the surface but has many weaknesses if one digs only a little deeper. To start with, it has no precise research question: is any type of acupuncture better than any type of control? This is not a research question that anyone can answer with just a few studies of mostly poor quality. The authors claim to follow the PRISMA guidelines, yet (as a co-author of these guidelines) I can assure you that this is not true. Many of the included studies are small and lacked blinding. The results are confusing, contradictory and not clearly reported. Many trials fail to mention adverse effects and thus violate research ethics, etc., etc.
The conclusion that acupuncture might improve BC treatment-related symptoms could be true. But does this paper convince me that acupuncture DOES improve these symptoms?
We have discussed Marma massage, we have repeatedly discussed acupuncture, of course, but we have so far never considered marmapuncture. The ‘British Institute of Marmapuncture‘ explains what it is:
Marmapuncture is traditionally known as Bhedan karma (meaning the action of piercing through) is a time tested therapeutic intervention, which treats the energetic body through an elaborate network of channels known as srotas.
Despite the widely held belief that Marmapuncture is a derivative of Chinese Acupuncture, that was popularised in 200-400 BC in text of the Yellow Emperor) modern archaeological evidence points to the fact that Suchi Bhaden, Shira Bhedan and Bhadhan Karma where practised in Sri Lanka well before this time. Finds discovered in caves in the Balangoda region of Sri Lanka, suggest there has been continuous habitation for over 37,000 years. Micro lithic tools were crafted from flint, fish bones and a type of rock known as Chert. These where used to penetrate the skin, which affected a therapeutic response in the body.
Another website informs us what marmapuncture can achieve:
Marmapuncture can relieve a wide range of symptoms associated with musculoskeletal pain or injury, chronic fatigue, bowel complaints (IBS) and indigestion, stress, depression, anxiety, panic attacks, skin complaints, asthma and breathing disorders, low/excessive appetite and infertility (male and female).
And why do I mention all this? Last weekend, I read the Guardian (3/7/2021) and there it was: a half-page article entitled MARMAPUNCTURE. THIS INNOVATIVE FACIAL TREATMENT IS MORE THAN SKIN DEEP. WE FIND OUT HOW IT IS USED IN AYURVEDIC MEDICINE AND PUT IT TO THE TEST. In the article, Mattie Lacey-Davidson had the treatment and found that marmapuncture (dubbed ‘natural Botox’) is not truly comparable to botox. Then Mattie mentioned a 2013 study that allegedly reported ‘promising results as a therapy for facial elasticity with evidence of skin tightening across the face’. I think I found the study; here it is:
Background. The use of acupuncture for cosmetic purposes has gained popularity worldwide. Facial cosmetic acupuncture (FCA) is applied to the head, face, and neck. However, little evidence supports the efficacy and safety of FCA. We hypothesized that FCA affects facial elasticity by restoring resting mimetic muscle tone through the insertion of needles into the muscles of the head, face, and neck. Methods. This open-label, single-arm pilot study was implemented at Kyung Hee University Hospital at Gangdong from August through September 2011. Participants were women aged 40 to 59 years with a Glogau photoaging scale III. Participants received five treatment sessions over three weeks. Participants were measured before and after FCA. The primary outcome was the Moire topography criteria. The secondary outcome was a patient-oriented self-assessment scale of facial elasticity. Results. Among 50 women screened, 28 were eligible and 27 completed the five FCA treatment sessions. A significant improvement after FCA treatment was evident according to mean change in Moire topography criteria (from 1.70 ± 0.724 to 2.26 ± 1.059, P < 0.0001). The most common adverse event was mild bruising at the needle site. Conclusions. In this pilot study, FCA showed promising results as a therapy for facial elasticity. However, further large-scale trials with a controlled design and objective measurements are needed.
As we see, it is neither a study of marmapuncture or a controlled trial. Its results are utterly meaningless. But is there any evidence at all to support the many claims made for marmapuncture?
Last question: who is Mattie Lacey-Davidson?
Say no more!
Neuropathic pain is difficult to treat. Luckily, we have acupuncture! Acupuncturists leave us in no doubt that their needles are the solution. But are they correct or perhaps victims of wishful thinking?
This review was aimed at determining the proportion of patients with neuropathic pain who achieve a clinically meaningful improvement in their pain with the use of different pharmacologic and nonpharmacologic treatments.
Randomized controlled trials were included that reported a responder analysis of adults with neuropathic pain-specifically diabetic neuropathy, postherpetic neuralgia, or trigeminal neuralgia-treated with any of the following 8 treatments: exercise, acupuncture, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), topical rubefacients, opioids, anticonvulsant medications, and topical lidocaine.
A total of 67 randomized controlled trials were included. There was moderate certainty of evidence that anticonvulsant medications (risk ratio of 1.54; 95% CI 1.45 to 1.63; number needed to treat [NNT] of 7) and SNRIs (risk ratio of 1.45; 95% CI 1.33 to 1.59; NNT = 7) might provide a clinically meaningful benefit to patients with neuropathic pain. There was low certainty of evidence for a clinically meaningful benefit for rubefacients (ie, capsaicin; NNT = 7) and opioids (NNT = 8), and very low certainty of evidence for TCAs. Very low-quality evidence demonstrated that acupuncture was ineffective. All drug classes, except TCAs, had a greater likelihood of deriving a clinically meaningful benefit than having withdrawals due to adverse events (number needed to harm between 12 and 15). No trials met the inclusion criteria for exercise or lidocaine, nor were any trials identified for trigeminal neuralgia.
The authors concluded that there is moderate certainty of evidence that anticonvulsant medications and SNRIs provide a clinically meaningful reduction in pain in those with neuropathic pain, with lower certainty of evidence for rubefacients and opioids, and very low certainty of evidence for TCAs. Owing to low-quality evidence for many interventions, future high-quality trials that report responder analyses will be important to strengthen understanding of the relative benefits and harms of treatments in patients with neuropathic pain.
This review was published in a respected mainstream journal and conducted by a multidisciplinary team with the following titles and affiliations:
- Associate Professor in the College of Pharmacy at the University of Manitoba in Winnipeg.
- Pharmacist in Edmonton, Alta, and Clinical Evidence Expert for the College of Family Physicians of Canada.
- Family physician and Assistant Professor at the University of Alberta.
- Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta.
- Pharmacist, Clinical Evidence Expert Lead for the College of Family Physicians of Canada, and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta.
- Pharmacist in Edmonton and Clinical Evidence Expert for the College of Family Physicians of Canada.
- Pharmacist and Clinical Evidence Expert at the College of Family Physicians of Canada.
- Family physician, Director of Programs and Practice Support at the College of Family Physicians of Canada, and Adjunct Professor in the Department of Family Medicine at the University of Alberta.
- Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia in Vancouver.
- Pharmacist at the CIUSSS du Nord-de-l’lle-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montreal in Quebec.
- Care of the elderly physician and Assistant Professor in the Department of Family Medicine at the University of Alberta.
- Family physician and Professor in the Department of Family Medicine at the University of Alberta.
- Assistant Professor in the Department of Family Medicine at Queen’s University in Kingston, Ont.
- Research assistant at the University of Alberta.
- Medical student at the University of Alberta.
- Nurse in Edmonton and Clinical Evidence Expert for the College of Family Physicians of Canada.
As far as I can see, the review is of sound methodology, it minimizes bias, and its conclusions are therefore trustworthy. They suggest that acupuncture is not effective for neuropathic pain.
But how can this be? Do the authors not know about all the positive evidence on acupuncture? A quick search found positive recent reviews of acupuncture for all of the three indications in question:
- Diabetic neuropathy: Acupuncture alone and vitamin B combined with acupuncture are more effective in treating DPN compared to vitamin B.
- Herpes zoster: Acupuncture may be effective for patients with HZ.
- Trigeminal neuralgia: Acupuncture appears more effective than pharmacotherapy or surgery.
How can we explain this obvious contradiction?
Which result should we trust?
Do we believe pro-acupuncture researchers who published their papers in pro-acupuncture journals, or do we believe the findings of researchers who could not care less whether their work proves or disproves the effectiveness of acupuncture?
I think that these papers offer an exemplary opportunity for us to study how powerful the biases of researchers can be. They also remind us that, in the realm of so-called alternative medicine (SCAM), we should always be very cautious and not accept every conclusion that has been published in supposedly peer-reviewed medical journals.