acupuncture as a legitimate adjunctive therapy?

[montos]

Out of all the "alternative" treatments out there, Acupuncture is the one treatment modality I find I have a hard time dismissing out of hand. Reiki, homeopathy? No problem, obvious junk.

For acupuncture there seems to be a fair body of evidence that shows effectiveness for some conditions.

Now, what I think a lot of skeptics find distasteful about acupuncture is the amount of woo and mysticism that's wrapped up in it. I myself find the idea of Qi meridians pretty hard to swallow.

So the question is: Are there legitimate scientific principals behind acupunture and dry needleing that are yet to be elucidated? The fact that sham acupuncture seems to work as well as "real' acupunture would lend some credence to that theory. Ie/ acupuncture may have legitimate effectiveness but the whole meridian/Qi therory is pretty implausible and probably irrelevent.


So, when I have a patient who asks me if they should try acupuncture because their conventional therapy is insufficient do I tell them it's all woo because the "principles" behind it are scientifically unsound or do I tell them there is some evidence that it works but we just really don't understand why. (which by the way is completely acceptable, since there are a large number of prescription medications whose mechanism of action is unknown)

In other words; Is is possible that acupuncture is a potentially legitimate treatment championed by quacks who really don't understand what they're doing?

Sorry, I had some links to support my points but because i'm more of a lurker than a poster the site won't let me post them

 

[JoeyDonuts]

Here's an idea. Apply your logic to a recognized legitimate therapy practice and see if it makes any sense.

Personally, I find most accupuncture apologists and "therapists" get highly defensive and in some cases downright hostile when you approach the subject of scientific argument.

You'd think that if they were as confident as they seem to be, they would welcome double-blind scientific trials and critical overview of the practice.

This is sadly, not the case.

 

[Skeptic Ginger]

....
For acupuncture there seems to be a fair body of evidence that shows effectiveness for some conditions....

The serious problem here is much of the research is unreliable for reasons ranging from no easy means of providing a matched placebo, to the fact much of the research is tainted because of the Chinese culture that currently discourages failure to find positive results, as well as a cultural trend of finding positive results to save face re this traditional practice.

 

[montos]

Right, but double blind scientific studies abound on the subject and many show acupuncture to be more effective than no intervention but often sham acupuncture is just as effective as "real" acupuncture.
My point is, what does this show? Is this merely a placebo effect or does the practice work but not in the way that they believe?

The letter below states my point a little better than I can

a j p h .a p ha pu bli ca ti ns .o rg /c gi/ co n ten t/f ull/ 93/ 7/10 37

 

[Mr.Samsa]

Right, but double blind scientific studies abound on the subject and many show acupuncture to be more effective than no intervention but often sham acupuncture is just as effective as "real" acupuncture.
My point is, what does this show? Is this merely a placebo effect or does the practice work but not in the way that they believe?

The letter below states my point a little better than I can

a j p h .a p ha pu bli ca ti ns .o rg /c gi/ co n ten t/f ull/ 93/ 7/10 37

Here you go: http://ajph.aphapublications.org/cgi/content/full/93/7/1037

Your article there talks about electroacupuncture, which is irrelevant to acupuncture as electroacupuncture works through nerve stimulation, which we already knew was an effective treatment - Steven Novella discusses this more here: http://theness.com/neurologicablog/?p=2233

Basically, keep in mind that "sham acupuncture" includes not only stabbing people in random places (which rules out the mechanism of qi), but also non-insertion methods. That is, traditional acupuncture (along meridian lines) and modern acupuncture (placed according to some more "scientific" guideline) are no more effective than randomly poking people with toothpicks and not breaking the skin.

Acupuncture is undoubtedly a placebo.

 

[montos]

I fail to see the point of the Steven Novella article. It quotes a terrible study with significant design flaws to prove that acupuncture doesn't work. I can reference 100 terrible studies that show that it does.
If your point is that electroacupuncture is not the same as regular acupuncture then fair enough. Though that somewhat proves my assertion that acupunturists are doing something that may actually work without realizing how or why.

Tell me something else, when I read something like this

w w w2. c o c h ran e.o rg/r ev i ews/ e n /ab0 0135 1.htm l
(again I apologise for the spaces)

what am I to make of it? I mean I don't have the time or knowledge base to critique all these studies so I defer to references like cochrane who are fairly well respected for doing just that.

 

[JJM]

The best source for quackery on the Net is www.quackwatch.org You can find discussion of some recent articles here http://www.sciencebasedmedicine.org/ (there is an acupuncture button on the right-hand side). Also see www.skepdic.com and www.ebm-first.com

It is not right to ask if acupuncture works, one must give the condition as well. Most high-quality research shows that it is no better than placebo for several conditions. If one gets that result when testing a potential drug, the conclusion is that it doesn't work.

There are a few studies showing benefit, over sham acupuncture, for osteoarthritis; but blinding of the studies was dodgy.

Getting Cochrane reports is not simple for me. However, some of those I have seen recently make me doubt their continued quality. I believe they let quacks review quackery in some cases.

Finally, acupuncture is not without its hazards- even deaths have occurred. You have to weigh that small risk against an uncertain benefit.

ETA: I see the Cochrane summary is available to me http://www2.cochrane.org/reviews/en/ab001351.html It says, as always, more research is needed.

 

[Mojo]

That is, traditional acupuncture (along meridian lines) and modern acupuncture (placed according to some more "scientific" guideline)...

I wasn't aware that there were any "more scientific guidelines". Once you abandon the meridians etc. all you're left with is just sticking the needles in at random (which has, of course, been found to be just as effective when used as a placebo control for traditional acupuncture).

 

[Mojo]

Getting Cochrane reports is not simple for me. However, some of those I have seen recently make me doubt their continued quality. I believe they let quacks review quackery in some cases.

The review of homoeopathy for side-effects of cancer treatments was pretty bad.

ETA: see:

http://www.quackometer.net/blog/2009/04/homeopathy-does-not-cause-side-effects.html
http://neuroskeptic.blogspot.com/2009/04/bbc-homeopathy-works-oh-wait.html
http://neuroskeptic.blogspot.com/2009/04/more-on-that-homeopathy-analysis.html

 

[Delphinium]

My understanding of Acupuncture is that it's a pre-scientific, the Qi meridians are more than pretty hard to swallow, they've got nothing to do with any known anatomy and physiology. I've also yet to see any studies which show that acupuncture is administered in anything more than an ad hoc fashion by it's practitioners.

Studies that may show some effectiveness for acupuncture are limited to nausea and vomiting, along with pain control. The physical effects of inserting needles can provide an explanation for this. There is either a lack of evidence or negative evidence for use in any other condition.

Even for pain and other conditions the effect seems to be slight and researchers can't readily distinguish between placebo effects and bias and any real effect from the treatment. There are a number of explanations for when people show apparent effects from a treatment even if it is inert, such as regression to the mean, natural history of the disease and the Hawthorne effect.

"Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups" BMJ 2009; 338:a3115 is one recent systematic review that demonstrates just how unclear the evidence for effectiveness is. If there is no clear evidence of real benefit for any condition, it's important to consider whether the risks are worth it. They aren't if acupuncture is basically an elaborate placebo, but the risk of infection, nerve injury, pneumothorax and the like are very real.

I'd also suggest reading "Snake Oil Science" from R. Barker Bausell, this would help explain the issues with things like Acupuncture.

 

[Mr.Samsa]

I fail to see the point of the Steven Novella article. It quotes a terrible study with significant design flaws to prove that acupuncture doesn't work. I can reference 100 terrible studies that show that it does.
If your point is that electroacupuncture is not the same as regular acupuncture then fair enough. Though that somewhat proves my assertion that acupunturists are doing something that may actually work without realizing how or why.

My point was just that Novella discusses why it's disingenuous to discuss the efficacy of electroacupuncture and use it as support for acupuncture (since the "acupuncture" part is irrelevant). He just had a couple of paragraphs on the issue and I thought you might find it interesting.

Tell me something else, when I read something like this

w w w2. c o c h ran e.o rg/r ev i ews/ e n /ab0 0135 1.htm l
(again I apologise for the spaces)

what am I to make of it? I mean I don't have the time or knowledge base to critique all these studies so I defer to references like cochrane who are fairly well respected for doing just that.

The important part is probably this: "Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area."

Low methodological quality, combined with a tiny effect size, leads us to conclude that the results are probably a statistical quirk rather than a real effect - supported by further studies that have been conducted since that Cochrane review came out. Others have posted links to better studies (particularly the ones on the Science-Based Medicine page), and basically the better the methodology, the more the "effect" disappears.

I wasn't aware that there were any "more scientific guidelines". Once you abandon the meridians etc. all you're left with is just sticking the needles in at random (which has, of course, been found to be just as effective when used as a placebo control for traditional acupuncture).

I'm not aware of any real scientific guidelines either, but sometimes they try to justify their placement when they design their studies saying that they've tested it along a particular nerve, or around the affected area, etc. Hence, the scare quotes around the word "scientific".

 

[Emet]

<snip> Though that somewhat proves my assertion that acupunturists are doing something that may actually work without realizing how or why.

I wasn't aware that there were any "more scientific guidelines". Once you abandon the meridians etc. all you're left with is just sticking the needles in at random (which has, of course, been found to be just as effective when used as a placebo control for traditional acupuncture).

Those that know more about acupuncture than I do can correct me if I'm wrong. I am a vet, and remember a vet anesthesiologist playing with acupuncture in the 80's. IIRC, the possible scientific explanations for efficacy relied on the theory of neurotransmitter release (endorphins, etc.).

 

[sadhatter]

My understanding of Acupuncture is that it's a pre-scientific, the Qi meridians are more than pretty hard to swallow, they've got nothing to do with any known anatomy and physiology. I've also yet to see any studies which show that acupuncture is administered in anything more than an ad hoc fashion by it's practitioners.

Studies that may show some effectiveness for acupuncture are limited to nausea and vomiting, along with pain control. The physical effects of inserting needles can provide an explanation for this. There is either a lack of evidence or negative evidence for use in any other condition.

Even for pain and other conditions the effect seems to be slight and researchers can't readily distinguish between placebo effects and bias and any real effect from the treatment. There are a number of explanations for when people show apparent effects from a treatment even if it is inert, such as regression to the mean, natural history of the disease and the Hawthorne effect.

"Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups" BMJ 2009; 338:a3115 is one recent systematic review that demonstrates just how unclear the evidence for effectiveness is. If there is no clear evidence of real benefit for any condition, it's important to consider whether the risks are worth it. They aren't if acupuncture is basically an elaborate placebo, but the risk of infection, nerve injury, pneumothorax and the like are very real.

I'd also suggest reading "Snake Oil Science" from R. Barker Bausell, this would help explain the issues with things like Acupuncture.

Currently in school to become a pharmacist, and here is the information that is given to us.

It has been shown to have no difference where the needles are stuck, and the benefit extends to nothing more than blocking a pain channel and distraction. ( this is a bit simplified of course.)

Or to break it down a bit further, the discomfort and invasiveness of the proceedure is making you think of it versus your pain.

You would have just as much luck having a loved one kick you in the kneecap, or jab you with ( sterile, small diameter, and in areas that will not be damaged.) a needle, as you would going to an accupuncturist.

Is this really all that ground breaking? Doctors have been using similar methods of distraction ( pinching the opposite arm, etc.) to calm children down for shots , since the dawn of injected drugs.

 

[jli]

I'd also suggest reading "Snake Oil Science" from R. Barker Bausell, this would help explain the issues with things like Acupuncture.

That would be my suggestion too. It is clearly explained that acupuncture looks and works like a placebo. And as Bausell puts it: If it looks and works like a placebo it probably is a placebo.

 

[fls]

It should be noted that it is fairly easy to create the appearance of an effect. When studies are rated as high vs. low quality, what is being addressed is the extent to which all the loopholes have been closed when it comes to creating the appearance of an effect. It isn't just that low-quality studies are more likely to give you false results, but also that they are more likely to give you a false positive result than a false negative.

Linda

 

[Skeptic Ginger]

Right, but double blind scientific studies abound on the subject and many show acupuncture to be more effective than no intervention but often sham acupuncture is just as effective as "real" acupuncture.
My point is, what does this show? Is this merely a placebo effect or does the practice work but not in the way that they believe?

Not only does sham acupuncture work, it doesn't matter where you put the needles either.

So one doesn't need needles and doesn't need meridian points. What's left that is still acupuncture?

The results we get when valid science is done to test acupuncture should give you a clue, it is not a valid therapy. Why continue using it? What benefit is there?

 

[casebro]

Placebery, the practice of using placebos? Done by a placebist?

To cover acupuncture, homeopathy, healing touch etc. More specific than the broader "Woo".

Looks like I invented those words/usage. And I'll donate them to JREF. Whaddya think?

 

[Percent]

There are some excellent links provided in the above posts. Mojo provided several and Delphinium’s suggested reading was great. I’m going to add a link to a position paper on acupuncture from the Center for Inquiry, which was linked on this thread in October by UncaYimmy. It speaks volumes and I was cheering as I read it b/c it covers so many aspects of the potential downside to acupuncture, including the loss of possible opportunity to have trained those practitioners in actual medicine.

Even for pain and other conditions the effect seems to be slight and researchers can't readily distinguish between placebo effects and bias and any real effect from the treatment. There are a number of explanations for when people show apparent effects from a treatment even if it is inert, such as regression to the mean, natural history of the disease and the Hawthorne effect.

"Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups" BMJ 2009; 338:a3115 is one recent systematic review that demonstrates just how unclear the evidence for effectiveness is. If there is no clear evidence of real benefit for any condition, it's important to consider whether the risks are worth it. They aren't if acupuncture is basically an elaborate placebo, but the risk of infection, nerve injury, pneumothorax and the like are very real.

I don’t think I’ve seen The Hawthorne Effect mentioned in a thread before, but then I'm new here. That was a very good point to mention, beyond the basic placebo concept. The Hawthorne Effect is named after a classic study of workers at an electric plant, Hawthorne Works. The intent was to measure the impact of changing lighting on work productivity but what occurred was that the workers’ productivity improved merely b/c they were participating in a study.

I don't think that patient compliance and power of positive thinking, while a steady hand is guiding you, is necessarily a bad thing but it isn’t what acupuncture is claiming. Acupunture claims things it hasn’t been proven to deliver.

Emet brought up endorphins. I, too, understand that much of the placebo effect for pain relief is mediated by a release of endorphins, due to conditioning, expectations, etc. There seems to be a similar release of serotonin, dopamine, and other neurotransmitters released for a variety of situations. What all goes into the placebo effect is an entire, fascinating, area of study. ( For a skeptics take on placebo, look here.)

To say, however, that placebo is this terrific thing, acupuncture taps into placebo and, therefore, acupuncture is a viable treatment isn’t sound reasoning. Acupuncture appears to be nothing more than window dressing and placebo isn’t necessarily such a terrific thing. It is, in actuality, a much smaller (and probably short lived) effect than commonly thought.

I can see that you care about your patients and it seems that you are curious to learn not only what people here might say about acupuncture but are curious about what we might say about advising patients on acupuncture? I’m wondering what your specialization is and under what circumstances patients would be asking for a referral to an acupuncturist. I ask this b/c I live in a predominantly Chinese city, abundant with acupuncturists, and I recently had an ob/gyn recommend I see an acupuncturist. She also recommended I drink alkaline water! I didn’t say anything to my M.D. but I was very upset with her. I gently insisted on labwork and an ultrasound. A few days later, lab results returned and her office called to request that I return for follow-up tests b/c there was great cause for concern. Gee, my pain was real. I won’t be returning to her office for treatment, and I’m currently looking for a more scientifically informed physician before I go forward. I’m fortunate that I have a solid scientific background myself, but that isn’t usually the case for patients. I had a wonderful conversation with my primary care physician after the “woo hoo” with my ob/gyn and the internist told me, quite honestly, that while there are many patients that want to go see acupuncturists my negative reaction was common, including my downgrading of my doctor based on the recommendation.

Please check out the position paper linked above. It is powerful and will answer many questions.

Anne

 

[pgwenthold]

Is this really all that ground breaking? Doctors have been using similar methods of distraction ( pinching the opposite arm, etc.) to calm children down for shots , since the dawn of injected drugs.

We used to bite on a spoon.

 

[Dinwar]

what am I to make of it? I mean I don't have the time or knowledge base to critique all these studies so I defer to references like cochrane who are fairly well respected for doing just that.

This type of statement always catches my attention. The simplest solution? Say "I don't know". You're not an expert--neither am I--and therefore are not expected to know. If it becomes necessary to determine whether to recieve accupuncture or not for some reason, there are experts you can consult, such as your general practitioner. It's the GP's job to know, or to direct you to someone who does.

If you want to form an opinion, gain the knowledge base and find the time.

That said, as others have pointed out, there's ample reason to disbelieve this, even from a lay perspective. First and foremost, there's this group with a million bucks to give out if someone can prove it works. What is that group again....? I swear I just saw the name a second ago.....Ah well, I'm sure it'll come to me.