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

acupuncture

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Prof Ke’s Asante Academy (Ke claims that asante is French and means good health – wrong, of course, but that’s the least of his errors) offers many amazing things, and I do encourage you to have a look at his website. Prof Ke is clearly not plagued by false modesty; he informs us that “I am proud to say that we have gained a reputation as one of the leading Chinese Medicine clinics and teaching institutes in the UK and Europe. One CEO from a leading Acupuncture register commented that we were the best in the country. One doctor gave up his medical job in a European country to come study Chinese medicine at Middlesex University (our partner) – he said simply it was because of Asante. Our patients, from royalty and celebrities to hard working people all over the world, have praised us highly for successfully treating their wide-ranging conditions, including infertility, skin problems, pain and many others. We are also very pleased to have pioneered Acupuncture service in the NHS and for over a decade we have seen tens of thousands of NHS patients in hospitals.”

He provides treatments for any condition you can imagine, courses in various forms of TCM, a range of videos (they are particularly informative), as well as interesting explanations and treatment plans for dozens of conditions. From the latter, I have chosen just two diseases and quote some extracts to give you a vivid impression of the Ke’s genius:

CANCER

There are some ways in which Chinese medicine can help cancer cases where Western medicine cannot. Various herbal prescriptions have been shown to help in bolstering the immune system and some herbs can actually attack the abnormal cells and viruses which are responsible for certain types of cancer.

Chinese Medicine treatment aims first to increase the body’s own defence mechanisms, then to kill the cancer cells. Effective though radiotherapy and chemotherapy may be, they tend to have a drastic effect on the body generally and patients often feel very tired and weak, suffer from stress, anxiety, fear, insomnia and loss of appetite. Chinese Medicine practitioners regard strengthening the patient psychologically and physically to be of primary importance.

Chinese Medicine herbal remedies can help reduce or eliminate the side-effects from radiotherapy or chemotherapy. Astragalus will help raise the blood cell count, the sickness caused by chemotherapy can be relieved with fresh ginger and orange peel, and acupuncture can also help. To attack the cancer itself, depending on type and location, different herbs will be used.

A Chinese Medicine practitiioner will decide whether the illness is the result of qi energy deficiency, blood deficiency or yin or yang deficiencyGinseng,astragalusChinese angelicacooked rehmannia rootwolfberry rootChinese yam and many tonic herbs may be used. But it is vital to remember that no one tonic is good for everybody. All treatments are dependent upon the individual. Some anti-cancer herbs used are very strong and sometimes make people sick, but this is because one poison is being used against another. How they work, and how clinically effective they are, is still being researched. No claims can be made for them based on modern scientific evaluation.

Acupuncture and meditation are also very important parts of the Chinese Medicine traditional approach to the treatment of cancer. These alleviate pain and induce a sense of calmness, instill confidence and build up the spirit of the body, so that patients do not need to take so many painkillers. In China, they have many meditation programmes which are used to treat cancer.

MENINGITIS

Chinese Medicine herbal treatment for meningitis has been very successful in China. In the recent past there were many epidemics, particularly in the north, and the hospitals routinely used Chinese herbs as treatment, with a high degree of success. One famous remedy in Chinese Medicine is called White Tiger Decoction, the main ingredients of which are gypsum and rice. These are simple things but they reduce the high fever and clear the infection from the brain. Modern medicine and Chinese Medicine used together is the most effective treatment.

END OF QUOTES

Ghosh, I am so glad that finally someone explained these things to me, and so logically and simply too. I used to have doubts about the value of TCM for these conditions, but now I am convinced … so much so that I go on Medline to find the scientific work of Prof Ke. But what, what, what? That is not possible; such a famous professor and no publications?

I conclude that my search skills are inadequate and throw myself into studying the plethora of courses Ke offers for the benefit of mankind:

Since 2000, Asanté Academy has officially collaborated with Middlesex University in running and teaching the BSc and MSc in Traditional Chinese Medicine.

  • BSc Degrees in Acupuncture and Traditional Chinese Medicine
  • MSc Degree in Chinese Medicine
  • Professional Practice in Herbal Medicine, Chinese Herbal Medicine and Acupuncture

But perhaps this is a bit too arduous; maybe so-called diploma courses suit me better? Personally, I am tempted by the ‘24-day Certificate Course in TCM Acupuncture‘ – it’s a bargain, just £ 2,880!

PS

Prof Ke, if you read these lines, would you please tell us where and when you got your professorship? Your otherwise ostentatious website seems to fail to disclose this detail.

An article in yesterday’ Times makes the surprising claim that ‘doctors turn to herbal cures when the drugs don’t work’. As the subject is undoubtedly relevant to this blog and as the Times is a highly respected newspaper, I think this might be important and will therefore comment (in normal print) on the full text of the article (in bold print):

GPs are increasingly dissatisfied with doling out pills that do not work for illnesses with social and emotional roots, and a surprising number of them end up turning to alternative medicine.

What a sentence! I would have thought that GPs have always been ‘dissatisfied’ with treatments that are ineffective. But who says they turn to alternative medicine in ‘surprising numbers’ (our own survey does not confirm the notion)? And what is a ‘surprising number’ anyway (zero would be surprising, in my view)?

Charlotte Mendes da Costa is unusual in being both an NHS GP and a registered homeopath. Her frustration with the conventional approach of matching a medicine to a symptom is growing as doctors increasingly see the limits, and the risks, of such a tactic.

Do we get the impression that THE TIMES does not know that homeopathy is not herbal medicine? Do they know that ‘matching a medicine to a symptom’ is what homeopaths believe they are doing? Real doctors try to find the cause of a symptom and, whenever possible, treat it.

She asks patients with sore throats questions that few other GPs pose: “What side is it? Is it easier to swallow solids or liquids? What time of day is it worst?” Dr Mendes da Costa is trying to find out which homeopathic remedy to prescribe. But when NHS guidance for sore throats aims mainly to convince patients that they will get better on their own, her questions are just as important as her prescription.

This section makes no sense. Sore throats do get better on their own, that’s a fact. And empathy is not a monopoly of homeopaths. But Dr Mendes Da Costa might be somewhat detached from reality; she once promoted the nonsensical notion that “up to the end of 2010, 156 randomised controlled trials (RCTs) in homeopathy had been carried out with 41% reporting positive effects, whereas only 7% have been negative. The remainder were non-conclusive.” (see more on this particular issue here)

“It’s very difficult to disentangle the effect of listening to someone properly, in a non-judgmental way, and taking a real rather than a superficial interest,” she says. “With a sore throat [I was trained] really only to be interested in, ‘Do they need antibiotics or not?’ ”

In this case, she should ask her money back; her medical school seems to have been rubbish in training her adequately.

This week a Lancet series on back pain said that millions of patients were getting treatments that did them no good. A government review is looking into how one in 11 people has come to be on potentially addictive drugs such as tranquillisers, opioid painkillers and antidepressants.

Yes, and how is that an argument for homeopathy? It isn’t! It seems to come from the textbook of fallacies.

And this week a BMJ Open study found that GPs with alternative training prescribed a fifth fewer antibiotics.

That study was akin to showing that butchers sell less vegetables than green-grocers. It provided no argument at all for implying that homeopathy is a valuable therapy.

Doctors seem receptive to alternative approaches: in a poll on its website 70 per cent agreed that doctors should recommend acupuncture to patients in pain. The Faculty of Homeopathy now counts 400 doctors among its 700 healthcare professional members.

Wow! Does the Times journalist know that the ‘Faculty of Homeopathy’ is primarily an organisation for doctor homeopaths? If so, why are these figures anything to write home about? And does the author appreciate that the pole was open not just to doctors but to to anyone (particularly those who were motivated, like acupuncturists)?

This horrifies many academics, who say that there is almost no evidence that complementary therapies work.

It horrifies nobody, I’d say. It puzzles some people, and not just academics. And their claim of a lack of sound evidence is evidence-based.

“It’s a false battle”, says Michael Dixon, a GP who chairs the College of Medicine, which is trying to broaden the focus on treatment to patients’ whole lives. “GPs are practical. If a patient gets better that’s all that matters.”

Here comes the inevitable Dr Dixon (the ‘pyromaniac in a field of straw-men’) with the oldest chestnut in town. But repeating a nonsense endlessly does not render it sensible.

Dr Dixon says there are enormous areas of illness ranging from chronic pain to irritable bowels where few conventional treatments have been shown to be particularly effective, so why not try alternatives with fewer side effects?

Unable to diagnose and treat adequately, let’s all do the next worst thing and apply some outright quackery?!? Logic does not seem to be Dixon’s strong point, does it?

He recommends herbal remedies such as pelargonium — “like a geranium, quite a pretty little flower” — acupressure, and techniques such as self-hypnosis. To those who say these are placebos he replies: so what?

So what indeed! There are over 200 species of pelargonium; only 2 or 3 of them are used in herbal medicine. I don’t suppose Dr Dixon wants to poison us?

“Aromatherapy does work, but only if you believe in it, that’s the way you have to look at it, like a mother kissing knees better.” He continues: “We are healers. That’s what we do as doctors. You can call it theatrical or you can call it a relationship. A lot of patients come in with a metaphor — a headache is actually unhappiness — and the treatment is symbolic.”

It frightens me to know that there are doctors out there who think like this!

What if a patient is seriously ill?

A cancer is a metaphor for what exactly?

As doctors, we have the ethical duty to apply BOTH the science and the art of medicine, BOTH efficacious, evidence-based therapies AND compassion. Can I be so bold as to recommend our book about the ethics of alternative medicine to Dixon?

Such talk makes conventional doctors very nervous. Yet acupuncture illustrates their dilemma. It used to be recommended by the NHS for back pain because patients did improve. Now it is not, after further evidence suggested that patients given placebo “sham acupuncture” did just as well.

No, acupuncture used to be recommended by NICE because there was some evidence; when subsequently more rigorous trials emerged showing that it does NOT work, NICE stopped recommending it. Real medicine develops – it’s only alternative medicine and its proponents that seem to be stuck in the past and resist progress.

Martin Underwood, of the University of Warwick, asks: “So are you going to say, ‘Well, patients get better than they would do otherwise’? Or say it’s all theatrical placebo because it shows no benefit over sham treatment? That’s the question for society.”

Society has long answered it! The answer is called evidence-based medicine. We are not content using quackery for its placebo response; we know that effective treatments do that too, and we want to make progress and improve healthcare of tomorrow.

Although many doctors agree that they need to look at patients more broadly, they insist they do not need to turn to unproven treatments. The magic ingredient, they say, is not an alternative remedy, but time. Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “Practices which offer alternative therapies tend to spend longer with patients . . . allowing for more in-depth conversations.”


I am sorry, if this post turned into a bit of a lengthy rant. But it was needed, I think: if there ever was a poorly written, ill focussed, badly researched and badly argued article on alternative medicine, it must be this one.

Did I call the Times a highly respected paper?

I take it back.

The media have (rightly) paid much attention to the three Lancet-articles on low back pain (LBP) which were published this week. LBP is such a common condition that its prevalence alone renders it an important subject for us all. One of the three papers covers the treatment and prevention of LBP. Specifically, it lists various therapies according to their effectiveness for both acute and persistent LBP. The authors of the article base their judgements mainly on published guidelines from Denmark, UK and the US; as these guidelines differ, they attempt a synthesis of the three.

Several alternative therapist organisations and individuals have consequently jumped on the LBP  bandwagon and seem to feel encouraged by the attention given to the Lancet-papers to promote their treatments. Others have claimed that my often critical verdicts of alternative therapies for LBP are out of line with this evidence and asked ‘who should we believe the international team of experts writing in one of the best medical journals, or Edzard Ernst writing on his blog?’ They are trying to create a division where none exists,

The thing is that I am broadly in agreement with the evidence presented in Lancet-paper! But I also know that things are a bit more complex.

Below, I have copied the non-pharmacological, non-operative treatments listed in the Lancet-paper together with the authors’ verdicts regarding their effectiveness for both acute and persistent LBP. I find no glaring contradictions with what I regard as the best current evidence and with my posts on the subject. But I feel compelled to point out that the Lancet-paper merely lists the effectiveness of several therapeutic options, and that the value of a treatment is not only determined by its effectiveness. Crucial further elements are a therapy’s cost and its risks, the latter of which also determines the most important criterion: the risk/benefit balance. In my version of the Lancet table, I have therefore added these three variables for non-pharmacological and non-surgical options:

EFFECTIVENESS ACUTE LBP EFFECTIVENESS PERSISTENT LBP RISKS COSTS RISK/BENEFIT BALANCE
Advice to stay active +, routine +, routine None Low Positive
Education +, routine +, routine None Low Positive
Superficial heat +/- Ie Very minor Low to medium Positive (aLBP)
Exercise Limited +/-, routine Very minor Low Positive (pLBP)
CBT Limited +/-, routine None Low to medium Positive (pLBP)
Spinal manipulation +/- +/- vfbmae
sae
High Negative
Massage +/- +/- Very minor High Positive
Acupuncture +/- +/- sae High Questionable
Yoga Ie +/- Minor Medium Questionable
Mindfulness Ie +/- Minor Medium Questionable
Rehab Ie +/- Minor Medium to high Questionable

Routine = consider for routine use

+/- = second line or adjunctive treatment

Ie = insufficient evidence

Limited = limited use in selected patients

vfbmae = very frequent, minor adverse effects

sae = serious adverse effects, including deaths, are on record

aLBP = acute low back pain

The reason why my stance, as expressed on this blog and elsewhere, is often critical about certain alternative therapies is thus obvious and transparent. For none of them (except for massage) is the risk/benefit balance positive. And for spinal manipulation, it even turns out to be negative. It goes almost without saying that responsible advice must be to avoid treatments for which the benefits do not demonstrably outweigh the risks.

I imagine that chiropractors, osteopaths and acupuncturists will strongly disagree with my interpretation of the evidence (they might even feel that their cash-flow is endangered) – and I am looking forward to the discussions around their objections.

The plethora of dodgy meta-analyses in alternative medicine has been the subject of a recent post – so this one is a mere update of a regular lament.

This new meta-analysis was to evaluate evidence for the effectiveness of acupuncture in the treatment of lumbar disc herniation (LDH). (Call me pedantic, but I prefer meta-analyses that evaluate the evidence FOR AND AGAINST a therapy.) Electronic databases were searched to identify RCTs of acupuncture for LDH, and 30 RCTs involving 3503 participants were included; 29 were published in Chinese and one in English, and all trialists were Chinese.

The results showed that acupuncture had a higher total effective rate than lumbar traction, ibuprofen, diclofenac sodium and meloxicam. Acupuncture was also superior to lumbar traction and diclofenac sodium in terms of pain measured with visual analogue scales (VAS). The total effective rate in 5 trials was greater for acupuncture than for mannitol plus dexamethasone and mecobalamin, ibuprofen plus fugui gutong capsule, loxoprofen, mannitol plus dexamethasone and huoxue zhitong decoction, respectively. Two trials showed a superior effect of acupuncture in VAS scores compared with ibuprofen or mannitol plus dexamethasone, respectively.

The authors from the College of Traditional Chinese Medicine, Jinan University, Guangzhou, Guangdong, China, concluded that acupuncture showed a more favourable effect in the treatment of LDH than lumbar traction, ibuprofen, diclofenac sodium, meloxicam, mannitol plus dexamethasone and mecobalamin, fugui gutong capsule plus ibuprofen, mannitol plus dexamethasone, loxoprofen and huoxue zhitong decoction. However, further rigorously designed, large-scale RCTs are needed to confirm these findings.

Why do I call this meta-analysis ‘dodgy’? I have several reasons, 10 to be exact:

  1. There is no plausible mechanism by which acupuncture might cure LDH.
  2. The types of acupuncture used in these trials was far from uniform and  included manual acupuncture (MA) in 13 studies, electro-acupuncture (EA) in 10 studies, and warm needle acupuncture (WNA) in 7 studies. Arguably, these are different interventions that cannot be lumped together.
  3. The trials were mostly of very poor quality, as depicted in the table above. For instance, 18 studies failed to mention the methods used for randomisation. I have previously shown that some Chinese studies use the terms ‘randomisation’ and ‘RCT’ even in the absence of a control group.
  4. None of the trials made any attempt to control for placebo effects.
  5. None of the trials were conducted against sham acupuncture.
  6. Only 10 studies 10 trials reported dropouts or withdrawals.
  7. Only two trials reported adverse reactions.
  8. None of these shortcomings were critically discussed in the paper.
  9. Despite their affiliation, the authors state that they have no conflicts of interest.
  10. All trials were conducted in China, and, on this blog, we have discussed repeatedly that acupuncture trials from China never report negative results.

And why do I find the journal ‘dodgy’?

Because any journal that publishes such a paper is likely to be sub-standard. In the case of ‘Acupuncture in Medicine’, the official journal of the British Medical Acupuncture Society, I see such appalling articles published far too frequently to believe that the present paper is just a regrettable, one-off mistake. What makes this issue particularly embarrassing is, of course, the fact that the journal belongs to the BMJ group.

… but we never really thought that science publishing was about anything other than money, did we?

What an odd title, you might think.

Systematic reviews are the most reliable evidence we presently have!

Yes, this is my often-voiced and honestly-held opinion but, like any other type of research, systematic reviews can be badly abused; and when this happens, they can seriously mislead us.

new paper by someone who knows more about these issues than most of us, John Ioannidis from Stanford university, should make us think. It aimed at exploring the growth of published systematic reviews and meta‐analyses and at estimating how often they are redundant, misleading, or serving conflicted interests. Ioannidis demonstrated that publication of systematic reviews and meta‐analyses has increased rapidly. In the period January 1, 1986, to December 4, 2015, PubMed tags 266,782 items as “systematic reviews” and 58,611 as “meta‐analyses.” Annual publications between 1991 and 2014 increased 2,728% for systematic reviews and 2,635% for meta‐analyses versus only 153% for all PubMed‐indexed items. Ioannidis believes that probably more systematic reviews of trials than new randomized trials are published annually. Most topics addressed by meta‐analyses of randomized trials have overlapping, redundant meta‐analyses; same‐topic meta‐analyses may exceed 20 sometimes.

Some fields produce massive numbers of meta‐analyses; for example, 185 meta‐analyses of antidepressants for depression were published between 2007 and 2014. These meta‐analyses are often produced either by industry employees or by authors with industry ties and results are aligned with sponsor interests. China has rapidly become the most prolific producer of English‐language, PubMed‐indexed meta‐analyses. The most massive presence of Chinese meta‐analyses is on genetic associations (63% of global production in 2014), where almost all results are misleading since they combine fragmented information from mostly abandoned era of candidate genes. Furthermore, many contracting companies working on evidence synthesis receive industry contracts to produce meta‐analyses, many of which probably remain unpublished. Many other meta‐analyses have serious flaws. Of the remaining, most have weak or insufficient evidence to inform decision making. Few systematic reviews and meta‐analyses are both non‐misleading and useful.

The author concluded that the production of systematic reviews and meta‐analyses has reached epidemic proportions. Possibly, the large majority of produced systematic reviews and meta‐analyses are unnecessary, misleading, and/or conflicted.

Ioannidis makes the following ‘Policy Points’:

  • Currently, there is massive production of unnecessary, misleading, and conflicted systematic reviews and meta‐analyses. Instead of promoting evidence‐based medicine and health care, these instruments often serve mostly as easily produced publishable units or marketing tools.
  • Suboptimal systematic reviews and meta‐analyses can be harmful given the major prestige and influence these types of studies have acquired.
  • The publication of systematic reviews and meta‐analyses should be realigned to remove biases and vested interests and to integrate them better with the primary production of evidence.

Obviously, Ioannidis did not have alternative medicine in mind when he researched and published this article. But he easily could have! Virtually everything he stated in his paper does apply to it. In some areas of alternative medicine, things are even worse than Ioannidis describes.

Take TCM, for instance. I have previously looked at some of the many systematic reviews of TCM that currently flood Medline, based on Chinese studies. This is what I concluded at the time:

Why does that sort of thing frustrate me so much? Because it is utterly meaningless and potentially harmful:

  • I don’t know what treatments the authors are talking about.
  • Even if I managed to dig deeper, I cannot get the information because practically all the primary studies are published in obscure journals in Chinese language.
  • Even if I  did read Chinese, I do not feel motivated to assess the primary studies because we know they are all of very poor quality – too flimsy to bother.
  • Even if they were formally of good quality, I would have my doubts about their reliability; remember: 100% of these trials report positive findings!
  • Most crucially, I am frustrated because conclusions of this nature are deeply misleading and potentially harmful. They give the impression that there might be ‘something in it’, and that it (whatever ‘it’ might be) could be well worth trying. This may give false hope to patients and can send the rest of us on a wild goose chase.

So, to ease the task of future authors of such papers, I decided give them a text for a proper EVIDENCE-BASED conclusion which they can adapt to fit every review. This will save them time and, more importantly perhaps, it will save everyone who might be tempted to read such futile articles the effort to study them in detail. Here is my suggestion for a conclusion soundly based on the evidence, not matter what TCM subject the review is about:

OUR SYSTEMATIC REVIEW HAS SHOWN THAT THERAPY ‘X’ AS A TREATMENT OF CONDITION ‘Y’ IS CURRENTLY NOT SUPPORTED BY SOUND EVIDENCE.

On another occasion, I stated that I am getting very tired of conclusions stating ‘…XY MAY BE EFFECTIVE/HELPFUL/USEFUL/WORTH A TRY…’ It is obvious that the therapy in question MAY be effective, otherwise one would surely not conduct a systematic review. If a review fails to produce good evidence, it is the authors’ ethical, moral and scientific obligation to state this clearly. If they don’t, they simply misuse science for promotion and mislead the public. Strictly speaking, this amounts to scientific misconduct.

In yet another post on the subject of systematic reviews, I wrote that if you have rubbish trials, you can produce a rubbish review and publish it in a rubbish journal (perhaps I should have added ‘rubbish researchers).

And finally this post about a systematic review of acupuncture: it is almost needless to mention that the findings (presented in a host of hardly understandable tables) suggest that acupuncture is of proven or possible effectiveness/efficacy for a very wide array of conditions. It also goes without saying that there is no critical discussion, for instance, of the fact that most of the included evidence originated from China, and that it has been shown over and over again that Chinese acupuncture research never seems to produce negative results.

The main point surely is that the problem of shoddy systematic reviews applies to a depressingly large degree to all areas of alternative medicine, and this is misleading us all.

So, what can be done about it?

My preferred (but sadly unrealistic) solution would be this:

STOP ENTHUSIASTIC AMATEURS FROM PRETENDING TO BE RESEARCHERS!

Research is not fundamentally different from other professional activities; to do it well, one needs adequate training; and doing it badly can cause untold damage.

The UK ACUPPUNCTURE RESEARCH RESOURCE CENTRE (ARRC) is a specialist resource for acupuncture research information; the only such resource in the land. It is funded by the British Acupuncture Council (BAcC) and was established in 1994 by the BAcC in partnership with the Foundation for Research in Traditional Chinese Medicine.

The ARRC organise an annual meeting. This year’s meeting is special because it is their 20th! It is scheduled to take place in London on 17th March. In case you are already busy that day, or you want to save the £120 registration fee, I have copied for you the programme below and am even able to inform you about the content of each lecture.

  1. Hugh MacPherson – Celebrating twenty years of acupuncture research
  2. Lee Hullender Rubin  – The Impact of Whole Systems Traditional Chinese Medicine on In Vitro Fertilization Outcomes – A Retrospective Cohort Study
  3. Robert Davis – Beyond Efficacy: Conducting and translating research for policy-makers considering acupuncture reimbursement in a small, rural US state
  4. Lee Hullender Rubin – Acupuncture Augmentation of Lidocaine Treatment of Provoked, localized Vulvodynia – a Feasability and Acceptability Pilot Study
  5. Florian Beissner – A TCM-based psychotherapy with acupuncture for endometriosis
  6. Beverley De Valois – Using moxa on St 36 to reduce chemotherapy-induced pancytopenia: a feasibility study
  7. Ian Appleyard – Warm needle acupuncture for osteoarthritis of the knee: a pilot study
  8. Ed Fraser – Stand Easy: An Evaluation of the acceptability and effectiveness of acupuncture as a treatment for post-traumatic stress disorder for veterans in Norfolk

Having attended plenty of such meetings in my time, I can give you a fairly good idea about the contents of the 8 lectures. Below, I provide succinct (and slightly satirical) summaries of what the presenters will tell their audience on the 17th:

  1. Despite difficult circumstances, we (the ARRC) have done very well indeed. We managed to publish lots of papers, and we made sure that not a single one reported a negative result. That would be bad for business. We are optimistic about the future provided we get some funding, of course.
  2. Whole Systems Traditional Chinese Medicine has a profoundly positive effect on the outcomes of In Vitro fertilization. We are totally balled over! Only the most pedantic sceptics would have reservations and might argue that the study had no controls and was retrospective. But who cares, we believe in positive results, and therefore, we never listen to criticism.
  3. Because efficacy is a sticky issue in the realm of acupuncture, it is much wiser to tackle policy makers by persuading them that they can save money (lots of it), if they implement the abundant use of acupuncture. The evidence for this notion is flimsy to say the least, but policy makers do not understand the science (and neither do we).
  4. Our study showed that Acupuncture Augmentation of Lidocaine Treatment is extremely good for vulvodynia. We are very impressed, over the moon even. Of course, this was a feasibility study and we should really only conclude that a full study may be feasible, but let’s not be nit-picking.
  5. Based on my very extensive experience, I am able to confirm that TCM-based psychotherapy with acupuncture is an excellent therapy for endometriosis. Rigorous, controlled clinical trials do not exist, but my findings are so clear that, quite honestly, we do not need them.
  6. Using moxa on St 36 to reduce chemotherapy-induced pancytopenia is feasible. Isn’t that lovely?
  7. My trial of warm needle acupuncture for osteoarthritis of the knee showed most encouraging results. Of course, this was only a pilot study, and from it we should really only conclude that a proper study may be feasible, but let’s not be holier than thou!
  8. Our results demonstrate that acupuncture as a treatment for post-traumatic stress disorder is amazingly effective. A breakthrough! What is more, veterans found it most acceptable. The study is not rigorous, but I don’t mind. I advocate this treatment to be rolled out nationally as a matter of urgency.

————————————————————————————————————————————

So, there you are; that’s all you need to know about the 20th annual meeting of the ARRC.

You don’t need to go.

I have thus saved you £120!

No, I don’t expect thanks – I prefer, if you would send half of this amount (£60) to my account.

 

Today, the BMJ published our ‘head to head‘ article on the above question. Dr Mike Cummings argues the pro-part, while Prof Asbjorn Horbjardsson and I argue against the notion.

The pro arguments essentially are the well-rehearsed points acupuncture-fans like to advance:

  • Some guidelines do recommend acupuncture.
  • Sham acupuncture is not a valid comparator.
  • The largest meta-analysis shows a small effect.
  • Acupuncture is not implausible.
  • It improves quality of life.

Cummings concludes as follows: In summary, the pragmatic view sees acupuncture as a relatively safe and moderately effective intervention for a wide range of common chronic pain conditions. It has a plausible set of neurophysiological mechanisms supported by basic science.12 For those patients who choose it and who respond well, it considerably improves health related quality of life, and it has much lower long term risk for them than non-steroidal anti-inflammatory drugs. It may be especially useful for chronic musculoskeletal pain and osteoarthritis in elderly patients, who are at particularly high risk from adverse drug reactions.

Our arguments are also not new; essentially, we stress that:

  • The effects of acupuncture are too small to be clinically relevant.
  • They are probably not even caused by acupuncture, but the result of residual bias.
  • Pragmatic trials are of little value in defining efficacy.
  • Acupuncture is not free of risks.
  • Regular acupuncture treatments are expensive.
  • There is no generally accepted, plausible mechanism.

We concluded that after decades of research and hundreds of acupuncture pain trials, including thousands of patients, we still have no clear mechanism of action, insufficient evidence for clinically worthwhile benefit, and possible harms. Therefore, doctors should not recommend acupuncture for pain.

Neither Asbjorn nor I have any conflicts of interests to declare.

Dr Cummings, by contrast, states that he is the salaried medical director of the British Medical Acupuncture Society, which is a membership organisation and charity established to stimulate and promote the use and scientific understanding of acupuncture as part of the practice of medicine for the public benefit. He is an associate editor for Acupuncture in Medicine, published by BMJ. He has a modest private income from lecturing outside the UK, royalties from textbooks, and a partnership teaching veterinary surgeons in Western veterinary acupuncture. He has participated in a NICE guideline development group as an expert adviser discussing acupuncture. He has used Western medical acupuncture in clinical practice following a chance observation as a medical officer in the Royal Air Force in 1989.

My question to you is this: WHICH OF THE TWO POSITION IS THE MORE REASONABLE ONE?

Please, do let us know by posting a comment here, or directly at the BMJ article (better), or both (best).

I was reliably informed that the ‘Australian Acupuncture and Chinese Medicine Association’ (AACMA) are currently – that is AFTER having retracted the falsehoods they previously issued about me – distributing a document which contains the following passage:

It is noted that Mr Ernst derives income from editing a journal called Focus on Alternative and Complementary Medicine which is published by the British Pharmaceutical Society and listed in pharamcologyjournals.com. Ernst has not declared his own pecuniary conflicts of interest and links with the pharmaceutical industry. I note that the FSM webpage declares that:

‘None of the members of the executive has any vested interests in pharmaceutical companies such that our views or opinions might be influenced’.

This statement is disingenuous and deceptive if instead you base your critique on the blog of a person with such pharmaceutical interests without declaring it.

This is a repetition of the lies which the AACMA have already retracted (see comments section of my previous post on this matter). In my view, this is highly dishonest and actionable. For this reason, I today sent them this ‘open letter’ which I also publish here:

Dear Madam/Sir,

As explained more fully in this blog-post, you have recently accused me of undeclared links to and payments from the pharmaceutical industry. This is a serious, potentially liable allegation.

My objections were followed by your retraction of these allegations (see the comments section of my above-mentioned blog-post). However, your retraction displays an embarrassing level of ignorance and contains several grave errors (see the comments section of my above-mentioned blog-post). Crucially, it implies that I formerly had an undeclared conflict of interest. This is untrue. More importantly, you currently distribute a document that continues to allege that I currently have ‘pharmaceutical interests’. This too is untrue.

I urge you to either produce the evidence for your allegations, or to fully and publicly retract them. This strategy would not merely be the only decent and professional way of dealing with the problem, it also might prevent damage to your reputation, and  avoid libel action against you.

Sincerely

Edzard Ernst

Few people would argue that Cochrane reviews tend to be the most rigorous, independent and objective assessments of therapeutic interventions we currently have. Therefore, it is relevant to see what they tell us about the value of acupuncture.

Here is a fascinating overview of all Cochrane reviews of acupuncture. It was compiled by the formidable guys at ‘FRIENDS OF SCIENCE-BEASED MEDICINE‘ in Australia. They gave me the permission to publish it here (thanks Loretta!).

 

Considering this collective evidence, it would be hard to dispute the conclusion that there is no convincing evidence that acupuncture is an effective therapy, I believe.

What do you think?

A comprehensive review of the evidence relating to acupuncture entitled “The Acupuncture Evidence Project: A Comparative Literature Review” has just been published. The document aims to provide “an updated review of the literature with greater rigour than was possible in the past.” That sounds great! Let’s see just how rigorous the assessment is.

The review was conducted by John McDonald who no stranger to this blog; we have mentioned him here, for instance. To call him an unbiased, experienced, or expert researcher would, in my view, be more than a little optimistic.

The review was financed by the ‘Australian Acupuncture and Chinese Medicine Association Ltd.’ – call me a pessimist, but I do wonder whether this bodes well for the objectivity of the findings.

The research seems to have been assisted by a range of experts: Professor Caroline Smith, National Institute of Complementary Medicine, Western Sydney University, provided advice regarding evidence levels for assisted reproduction trials; Associate Professor Zhen Zheng, RMIT University identified the evidence levels for postoperative nausea and vomiting and post-operative pain; Dr Suzanne Cochrane, Western Sydney University; Associate Professor Chris Zaslawski, University of Technology Sydney; and Associate Professor Zhen Zheng, RMIT University provided prepublication commentary and advice. I fail to see anyone in this list who is an expert in EBM or who is even mildly critical of acupuncture and the many claims that are being made for it.

The review has not been published in a journal. This means, it has not been peer-reviewed. As we will see shortly, there is reason to doubt that it could pass the peer-review process of any serious journal.

There is an intriguing declaration of conflicts of interest: “Dr John McDonald was a co-author of three of the research papers referenced in this review. Professor Caroline Smith was a co-author of six of the research papers referenced in this review, and Associate Professor Zhen Zheng was co-author of one of the research papers in this review. There were no other conflicts of interest.” Did they all forget to mention that they earn their livelihoods through acupuncture? Or is that not a conflict?

I do love the disclaimer: “The authors and the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA) give no warranty that the information contained in this publication and within any online updates available on the AACMA website are correct or complete.” I think they have a point here.

But let’s not be petty, let’s look at the actual review and how well it was done!

Systematic reviews must first formulate a precise research question, then disclose the exact methodology, reveal the results and finally discuss them critically. I am afraid, I miss almost all of these essential elements in the document in question.

The methods section includes statements which puzzle me (my comments are in bold):

  • A total of 136 systematic reviews, including 27 Cochrane systematic reviews were included in this review, along with three network meta-analyses, nine reviews of reviews and 20 other reviews. Does that indicate that non-systematic reviews were included too? Yes, it does – but only, if they reported a positive result, I presume.
  • Some of the included systematic reviews included studies which were not randomised controlled trials. In this case, they should have not been included at all, in my view.
  • … evidence from individual randomised controlled trials has been included occasionally where new high quality randomised trials may have changed the conclusions from the most recent systematic review. ‘Occasionally’ is the antithesis of systematic. This discloses the present review as being non-systematic and therefore worthless.
  • Some systematic reviews have not reported an assessment of quality of evidence of included trials, and due to time constraints, this review has not attempted to make such an assessment. Say no more!

It is almost needless to mention that the findings (presented in a host of hardly understandable tables) suggest that acupuncture is of proven or possible effectiveness/efficacy for a very wide array of conditions. It also goes without saying that there is no critical discussion, for instance, of the fact that most of the included evidence originated from China, and that it has been shown over and over again that Chinese acupuncture research never seems to produce negative results.

So, what might we conclude from all this?

I don’t know about you, but for me this new review is nothing but an orgy in deceit and wishful thinking!

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