NEEDLE OF SUSPICION

From Journal Watch:

Acupuncture may be better than conventional therapy for the treatment of chronic low back pain, but it seems to offer no benefit over sham acupuncture, according to a study in Archives of Internal Medicine.

Nearly 1200 adults with chronic back pain for at least 6 months were randomized to undergo acupuncture, sham acupuncture, or conventional therapy that included physiotherapy, exercise, and medication. All interventions involved ten 30-minute treatment sessions, with five additional sessions for patients who experienced pain reduction after the first ten.

At 6 months, the response rate was significantly higher with real acupuncture (48%) and sham acupuncture (44%) than with conventional therapy (27%). The difference between the two acupuncture groups was not significant.

The authors say the lack of difference between acupuncture groups “forces us to question the underlying action mechanism of acupuncture and to ask whether the emphasis placed on … traditional Chinese acupuncture points may be superfluous.

That is my point! In several instances, we have seen that any procedure has a temporary benefit arising from its placebo value. The fact that something has been seen to be done itself has a role in providing symptomatic relief.
Doctors who disregard this in their practice tend to believe in their awesome healing prowess, and are likely to be pretentious pricks!

21 responses to “NEEDLE OF SUSPICION

  1. I’m not convinced that Acupuncture can be dismissed summarily when WHO, NIH and AMA have studied it and recommend it for certain ailments. Unless you’re saying that they’re all wrong and their studies were faulty. 😉

    I have no issue with evidence-based medicine, and if the research indicates positive results. I am glad that here in the US, there’s willingness to explore it and study it, even if the theory can’t be explained from the perspective of western science. That to me indicates openness. Of course, more studies are warranted, but to dismiss it entirely is nothing short of hubris. Your mileage, of course, varies. 🙂

    Also, is the placebo effect enough to explain the huge difference of 48% and 27%, even taking into account the possibility (which I don’t know is true) that the ones receiving Acupuncture had positive opinion of Acupuncture, and the ones receiving western medicine treatment had negative opinion of western medicine?

    Amit,
    There are levels of evidence, with the most reliable being large, well-designed randomised prospective trials.
    The response rates between acupuncture and sham puncture are very similar, and the difference was not statistically significant.
    Of course, I have no axe to grind for or against acupuncture, but this is what recent evidence suggests!
    Welcome to my blog, BTW!
    🙂

  2. Great blog! Just found you through Vijay. Looking forward to exploring your archives! :o)

    Blogrolling you!

    Thanks, mate!

  3. I am out of my depth here, because I have no idea whether this traditional Chinese therapy is of value or not. But experts should gather more evidence and I am open to be convinced either way.

  4. Dont know much about acupuncture or other chinese therapy, but more research should be done on it before publicising the hell out of it… although as soon as you say ‘ancient’, half of the population already falls for it…

  5. This post came up on the main wordpress page under Science – way to go 🙂

    This (placebo effect) reminds me of the same way people (in rural areas) look at getting an injection/shot for illnesses. For them – if they are sick and they went to see a doctor, they want a shot – only then they think the doctor did something 🙂

  6. Thanks Doc. Is this my first comment on your blog? I know we have had conversations on other blogs. 🙂

  7. I agree with Nita, Oemar, and Arun. Omigod, what’s happening – me agreeing with so many people at once?! 😉

  8. “.. whether the emphasis placed on … traditional Chinese acupuncture points may be superfluous.”

    I think the best test is this.

    Next time, someone around us complain of back pain (thus becoming a pain in our backsides, as people with back pain often can become), we should randomly poke them with needles, till they say the pain is gone. 😉

    If they report the back pain “gone” mainly because the pain from random poking with needles is greater, well too bad. As effectiveness goes, this ISs better than the placebo effect, is it not?

  9. //In several instances, we have seen that any procedure has a temporary benefit arising from its placebo value.//What is your take on people being cured by Reiki or Acupressure.
    A senior surgeon made a funny comment when I asked him if a particular surgery was absolutely safe and effective. He said 100% guarantee can only be given by Bengali Babas or tantriks.

  10. Oemar, but more research should be done on it before publicising the hell out of it

    Care to elaborate on this “publicizing”? How many ads on TV do you see that publicize acupuncture? Though if you’re in the US, you’ll see lots of ads with happy, shiny people dancing in slow-mo in sunflower meadows or green pastures as the result of taking a pill (and a loooong list of side-effects – which can be taken care of with, you got it, more pills). 😉

    Also, the article seemed pretty balanced to me and reported the results in an unbiased manner. Are you saying that they shouldn’t report such results because people already have a bias against acupuncture? 🙂

    And why do you think that the “ancient” has nothing to offer? Mayan civilization was quite advanced in maths, astronomy etc. and this was independent of the western civilization. The Incas are known to have performed skull surgery. Do a search for trephination/trepanation and Inca.

    Here’s another example of modern science getting some help from an “ancient” culture (from http://thephoenix.com/article_ektid43578.aspx
    ):

    Ancient healers such as the Mayans and at least one aboriginal tribe in Australia knew this; they noticed long ago that severe wounds infected with maggots healed faster and with less scarring than wounds that didn’t. So it was that they began the practice of deliberately leaving certain flesh injuries uncovered — or even wrapping them in a dressing made of congealed beef blood, thus attracting flies and their larvae.

    The unfortunate part is that any honest desire to explore with an open and skeptical mind the “ancient” in India gets lumped with the saffron brigade.

    Amit,
    Thanks for the links! Oemar, any comments?

  11. Compelling study, and although I’ve not ever had acupuncture, there is a _very_ long tradition of this. .. so hard for me to discount. The mind-body connection is still one of the great unsolved mysteries of the human body.

  12. I used to recommend this book to Westerners but now I think this also needs to be read widely in India and the Middle East. (As you can see I reviewed it 3 years ago…)

    http://www.amazon.co.uk/Lost-Discoveries-Ancient-Science-Babylonians/dp/074324379X/ref=sr_1_4/026-2975742-4293214?ie=UTF8&s=books&qid=1190962439&sr=8-4

  13. @Amit
    Yes I was talking about ads in US…. as you already said, I do see happy and smiling people who swear by the miracle that is acupuncture on TV, in newspapers and pamphlets distributed on streets…. thats is exactly what I meant by “publicising the hell out of it”.
    I never said the article is unbalanced or that results should never be reported… but there is way of reporting result… one is simple and the other is flashy… the latter one, is a hidden advertisement using words like ‘ancient’, ‘secret’ etc…. like the Hoodia diet pill ads here – ‘from the depths of South African desert the secret of XYZ tribe is brought to you……’ … I was referring to things like these….
    /And why do you think that the “ancient” has nothing to offer?/ Where DID you get this from my comment?????? I am a big fan of ancient stuff, but I dont think that every other thing should be leveraged using this word…. that was my point…..
    By ‘ancient in India’ if you mean Ayurveda, then let me assure you that it doesnt “get” lumped with the saffron brigade… on the contrary, the saffron brigade uses these ancient medicine art to publicize their objectives… so whose fault is it if ayurveda is lumped with saffron brigade.. same is the case with Yoga… I know this is wrong, but see who is to blame for this…
    http://www.bjp.org/today/jan_0206/jan02_p_34.htm
    http://www.butterfliesandwheels.com/articleprint.php?num=190

  14. Oemar, my mistake regarding “ancient.” I misinterpreted your words to mean that you yourself were critical of it. 🙂

    Thanks for the clarification regarding “advertising the hell out of it.” From your comment, it wasn’t clear whether you were referring to the study that Doc mentioned or something else. To the best of my knowledge, one has to go to a school for a few years and be licensed before one can practice acupuncture in the US, and there are strict rules in place (I know people who are acupuncturists). Yes, there are quacks who take advantage of gullible and sick people so it is very important to be careful. As I mentioned in my previous post, NIH, WHO and AMA (all reputable organizations) do approve of acupuncture for certain ailments. Which doesn’t mean that they can never be wrong, but the probability is very low.

    Yes, I am aware of the lumping that goes on in India. As for the fault, it can go both ways – people who constantly look down upon and dismiss everything “ancient” in the name of rationality will probably give rise to entities like BJP who look for all solutions in the Vedas. Action-reaction.

    I agree with many of the points raised by Meera Nanda in her essay. I’m all for separating the wheat from the chaff backed by research, and for not throwing the baby out with the bathwater, and also for not drinking the bathwater as a cure for illnesses. 🙂

    Doc, thanks for the discussion space.

    You’re always welcome, Amit!

  15. Doc, a bit OT but seems somewhat relevant to the discussion. I came across this news item in yesterday’s Boston Globe.

    While this is probably not a common practice among drug companies (but also not an isolated incident) and you would know more since you are a doc and have your ear to the ground, it does raise ethical questions about how western medicine is marketed (at least in the US). This also makes me wary of less government control, because if a company goes to such dishonest lengths when there are laws, there’s no knowing what they’ll do if there’s lesser government control. Which is not to say that I believe more government is the solution. I’m reminded of what Asimov said: “I don’t subscribe to the thesis ‘Let the buyer beware.’ I prefer the disregarded one that goes ‘Let the seller be honest.'”
    Would love to read your thoughts on this.

  16. Amit,
    In a free market, the companies which try to fleece customers will likely be wiped out fast. Look at the cell-phone provider market.
    Do you see many cases of companies trying to fraudulently bill you or cheat you? It might happen in the odd case, but a consistently reliable provider is what will stand competition.
    The market makes the seller honest. But it should be a free market. The pharma business is certainly not one.

  17. In a free market, the companies which try to fleece customers will likely be wiped out fast.

    Doc, but how? I’m equating free market with even less laws and controls. Is that correct? So, even if with current laws, a company is dishonest (and it continues to function even after being found out), how will free market make it more honest?
    My other point is that all the information about how a company operates (honestly or dishonestly) is
    a. not willingly made available to the public, and
    b. the companies go to great lengths to obfuscate, hide and even outright lie.
    This is not a function or the result of government control, but rather the drive to make a profit and satisfy the bottom-line.
    When a person goes to buy a product, he’s not thinking whether the product was created and brought to him in an honest manner, but rather whether it is cheap or not (and effective). Plus he’s probably influenced by all the ads he has seen. Very few people research a product before buying it.
    And you may be right that in the long run, a dishonest company won’t survive, but it can still inflict a lot of damage while it is functional and till its dishonesty is found out and reaches a tipping point to put it out of business (e.g. Enron), thus giving it an unfair advantage and profits over other honest and reliable companies, which may have already been put out of business.

    I think an underlying assumption is that under a free market, everyone will be honest and ethical, and may the best person profit. Sadly, human history does not lend credence to that. But it’s still a noble idea/goal to strive for.

    Do you see many cases of companies trying to fraudulently bill you or cheat you?
    Not outright, but if those frauds have been institutionalized and/or the costs externalized, then yes.

  18. “In a free market, the companies which try to fleece customers will likely be wiped out fast.”

    Look at USA healthcare – comination of free market and government programs. Insurance companies often cheat and cut back room (lobbying) deals with our representatives. Drug companies innovate, but many new drugs are me-too drugs or extended release formulations.
    That costs too.

    Government run programs cover many, but fraud is high in some states. Also, they don’t reimburse physicians well.

    We need a hybrid system of sorts. Some private, some public and oversight. Greed….changes people. Independent oversight is needed for many industries.

  19. Pingback: TWO MEDICAL STORIES FOR YOU « A Twist of Word and Mind

  20. Most research in acupuncture is bad science. These are not valid research articles. I understand that the general public may not have a background to understand such research but scientist do and we should expect better. First, you must be able to quantify and qualify the parameters. In general, acupuncture research does not do this because they do not understand them in the first place; therefore, most of these studies are studying dry needling and not acupuncture.

    I think it is important for people to realize that these studies are NOT really testing acupuncture at all. They may be testing dry needling and someone’s idea of acupuncture but they really are not applying acupuncture in any of these studies.

    First, how do you know the “real” acupuncture is actually real acupuncture? Most acupuncturist don’t actually needle acupuncture points 😉

    Traditional Chinese Medicine (modern communist acupuncture and herbology with western medicine thrown in) believes acupuncture points are very large and that you can just stimulate an area to get the desired effects. George Soulie de Morant learned acupuncture from master acupuncturist in the early 1900s in China and brought back what he called True Acupuncture. The difference between these styles is night and day. Once we understand that an acupuncture point is only 1-2 mm in diameter then we have to look at these studies and the current practice of acupuncture with a raised eyebrow. 😉

    The only thing these studies prove is, sticking a needle into the skin can cause some type of effects. Duh! Maybe that’s why some people turn white and pass out. If we do “dry needling” (using an acupuncture needle but not needling an acupuncture point) and stimulate an area till the muscles contract thus stimulating the nervous system we will most likely get some type of reaction neurologically in another area of the body. This is similar to trigger point therapy. It can have great benefit if used correctly but it is NOT acupuncture and these studies are not testing “real” acupuncture.

    Just more bad science!

  21. Johnny,
    Thanks for the comment, and welcome!

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