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reader comments: acupuncture

15 Mar 2008
I agree with about everything you say in your dictionary, except what you say about acupuncture. I was a design Engineer for quite a while, now I am almost through my masters in the health field, and just finished a grad level class called critical appraisal of the literature, so I have some education on how to read medical periodicals and journals and have been steeped in scientific method in my 37 years.

Why did you put the studies you put on there? Why didn't you put on this [from NIH] and I quote: "On joining the study, patients' pain and knee function were assessed using standard arthritis research survey instruments and measurement tools, such as the Western Ontario McMasters Osteoarthritis Index (WOMAC). Patients' progress was assessed at 4, 8, 14, and 26 weeks. By week 8, participants receiving acupuncture were showing a significant increase in function and by week 14 a significant decrease in pain, compared with the sham and control groups. These results, shown by declining scores on the WOMAC index, held through week 26. Overall, those who received acupuncture had a 40 percent decrease in pain and a nearly 40 percent improvement in function compared to baseline assessments."

reply: You know you should consider all the evidence, not just what favors your position. You don't mention another study published in the same journal (Annals of Internal Medicine) two years later ["Acupuncture and Knee Osteoarthritis: A Three-Armed Randomized Trial," Scharf et al.] that found no statistically significant difference between the acupuncture and sham acupuncture group, a fact that indicates acupuncture is a placebo.

The article you cite states: "By week 8, participants receiving acupuncture were showing a significant increase in function and by week 14 a significant decrease in pain, compared with the sham and control groups." But the article doesn't give the numbers for the sham or control groups, so we can't tell from this article what this "significant" difference amounts to.

You just put the (and I am paraphrasing) "It seems to help pain" part in there from an abstract which is deceptive, that wasn't all they said. And you know as well as I do if you included the part I just quoted above it would weaken your argument. There is a difference between being skeptical and using critical thinking, critical thinking would include the data that the NIH published, and IMHO only someone with an agenda would leave it out and completely discredit it. Any explanations?

reply: You may not like it but in fact the authors did not draw as strong a conclusion from the data as you did. They do say: "Acupuncture seems to provide improvement in function and pain relief as an adjunctive therapy for osteoarthritis of the knee when compared with credible sham acupuncture and education control groups." (Italics added.) They seem to have understood that a single study with data not as robust as one might like should not be taken to prove anything grandiose.

Another thing to consider is that it has not been easy to design studies where participants don't know whether they are getting "real" or "faux" acupuncture. The better designed studies keep coming up with similar results for the true and sham acupuncture in a positive direction, evidence of a placebo effect at work.

For those who like statistics, the data are:

At 26 weeks, the true acupuncture group experienced significantly greater improvement than the sham group in the WOMAC function score (mean difference, –2.5 [CI, –4.7 to –0.4]; P = 0.01), WOMAC pain score (mean difference, –0.87 [CI, –1.58 to –0.16];P = 0.003), and patient global assessment (mean difference, 0.26 [CI, 0.07 to 0.45]; P = 0.02).

Another statistic of interest is that 43% of the control group dropped out and 25% dropped out in each of the acupuncture and sham acupuncture groups.

This was further meta-analyzed with 7 other studies in Acupuncture in Medicine 2006;24(suppl):S40-48 and I quote: "for reduction in pain and improvement of function acupuncture was significantly superior to sham acupuncture" and of course "usual care" (which is no intervention). Of course it did it without side effects.

reply: I would be very careful of making grand claims from this kind of meta-analysis. Everything depends on all the studies being of high quality, which is not the case.

The NCAHF is not a good source, it is a brainchild of Stephen Barrett and his cohorts to make money lobbying and try and sue any healthcare practitioner who does not fit their narrow definition of Western Medicine. They obviously are trying to deceive people by creating a name that sounds like a government council. Go to quackpotwatch.org to find out more about Mr. Barrett and his nefarious and other illegal activities including racketeering. quackpotwatch.org could be sued for defamation if what they are saying is not true about your "star witness"...in fact Stephen Barrett tried to sue and shamefully lost. Canadian and California courts have discredited him as a deceptive man with an agenda who has no credibility. As far as articles on acupuncture why do you quote a discredited source like the NCAHF many times before you mention any credible sources?

reply: I have been reading Stephen Barrett's material on quacks for over a decade and have found him to be one of the most reliable sources on the Internet. Tim Bolen, who runs the site you mention is, in my opinion, not a trustworthy source regarding Dr. Barrett. I don't need to defend Barrett against Bolen. I suggest you read Barrett's response to Tim Bolen. Why anyone would trust Bolen is beyond me. Sources don't become incredible when an unreliable source says they are.

If you are interested in Barrett's attempt to sue people who libel him, check out my comments here.

Credible sources: Acupuncture is not just taught at the UCLA and Stanford Medical Schools but is endorsed by the National Institutes of Health for many diseases, and by the World Health Organization for treating at least 81 diseases. It is accepted by more and more insurance companies, needles are approved by the FDA, and State Medical Boards recognize Licensed Acupuncturists as legitimate health care practitioners. If Acupuncture was able to be shown as unscientific in a court of law, the high priced lawyers and lobbyists from the Insurance companies, Pharmaceutical companies, HMOs, the AMA, Allopathic medical device manufacturers would be ALL over it and would have them put out of business faster than you can say Stephen Barrett is a quackpot. The FDA shuts quacks down faster than that. Why is that our government, UCLA, Stanford, the WHO, the FDA, the NIH, insurance companies, state medical boards etc accept it as legit but skepdic doesn't?

reply: First, the FDA and other government agencies do not regularly shut down quacks. Read my piece on why woo always wins. Second, there are a number of medical schools who are offering quack remedies as a matter of course these days because it is the "in" thing to do and customers demand it. The fact that UCLA or Stanford teaches acupuncture is not a sign of the validity of a technique developed before any studies on human anatomy were done, which claims "energy" is unbalanced along invisible pathways ("meridians") and is restored to balance by pin pricks. It is a sign that major universities have caved in to the pressure to be integrative and complementary in its approach to medicine.

If the WHO claims that acupuncture can cure 81 diseases, then the WHO is making an incredible claim that I would like to see the evidence for. If it is just saying that acupuncture is being used to treat 81 or 801 diseases, then I say: "so what?"

The NIH went over to the dark side in 1991 when it set up its alternative medicine division, thanks to Sen. Tom Harkin's superstitious belief about bee pollen curing allergies.

I've come to expect better things from your website than including this.

(Name withheld to avoid embarrassing anyone)

reply: Perhaps I wasn't as critical as I should have been of NCAHF material and perhaps I haven't given attention to the details I should have in the NIH study you cite, but it is disheartening that a student who just finished a course in critical appraisal of scientific studies would not consider all the evidence for acupuncture before concluding what you have. It is also disheartening that such a student can't tell a credible source from an incredible one.

There is no way you could have evaluated the best studies done on acupuncture and not have concluded that acupuncture is primarily a placebo. This does not mean that it doesn't have physiological effects. We know it does. I highly recommend Bausell's Snake Oil Science, which reviews the best scientific studies on acupuncture and is written by someone who has been involved in designing and evaluating acupuncture studies.

Acupuncture is the current darling of the media and of many alternative and conventional healers. Articles appear on a daily basis claiming that this or that study has shown that acupuncture works wonders on just about anything of interest in the medical world, whether it relates to humans or any other animal. Careful examination of these studies and the claims made on behalf of acupuncture has demonstrated to me that these beliefs are based on little more than wishful and selective thinking, a lot of ignorance about how placebos work, and indifference as to how the studies were designed or carried out.

Please note that I do not claim that acupuncture is not followed by pain relief. It often is. What I claim is that the evidence is not at all strong that there is anything more than a placebo effect in this pain relief. Here are some references to some recent literature on acupuncture and pain:

1. Pain. 2001 Aug;93(2):198-200. Is acupuncture effective for the treatment of chronic pain? A systematic review. Pain is the major complaint of the estimated one million U.S. consumers who use acupuncture each year. Although acupuncture is widely available in chronic pain clinics, the effectiveness of acupuncture for chronic pain remains in question. Our aim was to assess the effectiveness of acupuncture as a treatment for chronic pain within the context of the methodological quality of the studies. MEDLINE (1966-99), two complementary medicine databases, 69 conference proceedings, and the bibliographies of other articles and reviews were searched. Trials were included if they were randomized, had populations with pain longer than three months, used needles rather than surface electrodes, and were in English. Data were extracted by two independent reviewers using a validated instrument. Inter-rater disagreements were resolved by discussion. Fifty one studies met inclusion criteria. Clinical heterogeneity precluded statistical pooling. Results were positive in 21 studies, negative in 3 and neutral in 27. Three fourths of the studies received a low-quality score and low-quality trials were significantly associated with positive results (P=0.05). High-quality studies clustered in designs using sham acupuncture as the control group, where the risk of false negative (type II) errors is high due to large sample size requirements. Six or more acupuncture treatments were significantly associated with positive outcomes (P=0.03) even after adjusting for study quality. We conclude there is limited evidence that acupuncture is more effective than no treatment for chronic pain; and inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care. However, we have found an important relationship between the methodology of the studies and their results that should guide future research.

2. Cephalalgia. 1999 Nov;19(9):779-86; discussion 765. Acupuncture for recurrent headaches: a systematic review of randomized controlled trials. OBJECTIVE: To assess whether there is evidence that acupuncture is effective in the treatment of recurrent headaches. DESIGN: Systematic review. STUDY SELECTION: Randomized or quasi-randomized clinical trials comparing acupuncture with any type of control intervention for the treatment of recurrent headaches. DATA SOURCES: Electronic databases (Medline, Embase, Cochrane Field for Complementary Medicine, Cochrane Controlled Trials Register), personal communications and bibliographies. DATA COLLECTION AND ANALYSIS: Information on patients, interventions, methods, and results were extracted by at least two independent reviewers using a pretested form. A pooled estimate of the responder rate ratio (responder rate in treatment group/responder rate in control group) was calculated as a crude indicator of trial results as meta-analysis of more specific outcome data was impossible due to heterogeneity and insufficient reporting. RESULTS: Twenty-two trials, including a total of 1042 patients (median 36, range 10-150), met the inclusion criteria. Fifteen trials were in migraine patients, six in tension-headache patients, and in one trial patients with various headaches were included. The majority of the 14 trials comparing true and sham acupuncture showed at least a trend in favor of true acupuncture. The pooled responder rate ratio was 1.53 (95% confidence interval 1.11 to 2.11). The eight trials comparing acupuncture and other treatment forms had contradictory results. CONCLUSIONS: Overall, the existing evidence suggests that acupuncture has a role in the treatment of recurrent headaches. However, the quality and amount of evidence is not fully convincing. There is urgent need for well-planned, large-scale studies to assess effectiveness and efficiency of acupuncture under real life conditions.

3. Pain. 2000 May;86(1-2):119-32. Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. The objectives of the study were (1) to carry out a systematic review to assess the analgesic efficacy and the adverse effects of acupuncture compared with placebo for back and neck pain and (2) to develop a new tool, the Oxford Pain Validity Scale (OPVS), to measure validity of findings from randomized controlled trials (RCTs), and to enable ranking of trial findings according to validity within qualitative reviews. Published RCTs (of acupuncture at both traditional and non-traditional points) were identified from systematic searching of bibliographic databases (e.g. MEDLINE) and reference lists of retrieved reports. Pain outcome data were extracted with preference given to standardized outcomes such as pain intensity. Information on adverse effects was also extracted. All included trials were scored using a five-item 0-16 point validity scale (OPVS). The individual RCTs were ranked according to their OPVS score to enable more weight to be placed on the trials of greater validity when drawing an overall conclusion about the efficacy of acupuncture for relieving neck and back pain. Statistical analyses were carried out on the OPVS scores to assess the relationship between trial finding (positive or negative) and validity. Thirteen RCTs met the inclusion criteria. Five trials concluded that acupuncture was effective, and eight concluded that it was not effective for relieving back or neck pain. There was no obvious difference between the findings of trials using traditional and non-traditional points. Using the new OPVS scale, the validity scores of the included trials ranged from 4 to 14. There was no significant relationship between OPVS score and trial finding (positive versus negative). Authors' conclusions did not always agree with their data. We drew our own conclusions (positive/negative) based on the data presented in the reports. Re-analysis using our conclusions showed a significant relationship between OPVS score and trial finding, with higher validity scores associated with negative findings. OPVS is a useful tool for assessing the validity of trials in qualitative reviews. With acupuncture for chronic back and neck pain, we found that the most valid trials tended to be negative. There is no convincing evidence for the analgesic efficacy of acupuncture for back or neck pain.

4. Arch Intern Med. 1998;158:2235-2241. Acupuncture for Back Pain: A Meta-Analysis of Randomized Controlled Trials.

Background Acupuncture is commonly used to treat back pain, but there is no published meta-analysis of trials of its effectiveness for this condition.

Objective To perform a meta-analysis of trials of acupuncture for the treatment of back pain.

Methods A systematic literature search was conducted to retrieve all randomized controlled trials of any form of acupuncture for any type of back pain in humans. The adequacy of the acupuncture treatment was assessed by consulting 6 experienced acupuncturists. The main outcome measure for the meta-analysis was numbers of patients whose symptoms were improved at the end of treatment.

Results Twelve studies were included, of which 9 presented data suitable for meta-analysis. The odds ratio of improvement with acupuncture compared with control intervention was 2.30 (95% confidence interval, 1.28-4.13). For sham-controlled, evaluator-blinded studies, the odds ratio was 1.37 (95% confidence interval, 0.84-2.25).

Conclusion Acupuncture was shown to be superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo.

5. Annals of Internal Medicine. 19 April 2005. Volume 142 Issue 8. Pages 651-663. Meta-Analysis: Acupuncture for Low Back Pain.

Background: Low back pain limits activity and is the second most frequent reason for physician visits. Previous research shows widespread use of acupuncture for low back pain.

Purpose: To assess acupuncture's effectiveness for treating low back pain.

Data Sources: Randomized, controlled trials were identified through searches of MEDLINE, Cochrane Central, EMBASE, AMED, CINAHL, CISCOM, and GERA databases through August 2004. Additional data sources included previous reviews and personal contacts with colleagues.

Study Selection: Randomized, controlled trials comparing needle acupuncture with sham acupuncture, other sham treatments, no additional treatment, or another active treatment for patients with low back pain.

Data Extraction: Data were dually extracted for the outcomes of pain, functional status, overall improvement, return to work, and analgesic consumption. In addition, study quality was assessed.

Data Synthesis: The 33 randomized, controlled trials that met inclusion criteria were subgrouped according to acute or chronic pain, style of acupuncture, and type of control group used. The principal measure of effect size was the standardized mean difference, since the trials assessed the same outcome but measured it in various ways. For the primary outcome of short-term relief of chronic pain, the meta-analyses showed that acupuncture is significantly more effective than sham treatment (standardized mean difference, 0.54 [95% CI, 0.35 to 0.73]; 7 trials) and no additional treatment (standardized mean difference, 0.69 [CI, 0.40 to 0.98]; 8 trials). For patients with acute low back pain, data are sparse and inconclusive. Data are also insufficient for drawing conclusions about acupuncture's short-term effectiveness compared with most other therapies.

Limitations: The quantity and quality of the included trials varied.

Conclusions: Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.

What are the limitations of this review?

Conclusions about the effectiveness of acupuncture compared with other treatments or for patients with acute low back pain may change as new studies are done and new drugs or new acupuncture techniques are developed.

What are the implications of the review?

For chronic low back pain, acupuncture seems to work better than no treatment. Additional studies are needed to determine whether acupuncture works better than traditional treatments or whether it helps patients with acute low back pain.

6. Archives of Internal Medicine. Vol. 167 No. 17, September 24, 2007. German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups.

Background: To our knowledge, verum acupuncture has never been directly compared with sham acupuncture and guideline-based conventional therapy in patients with chronic low back pain.

Methods: A patient- and observer-blinded randomized controlled trial conducted in Germany involving 340 outpatient practices, including 1162 patients aged 18 to 86 years (mean ± SD age, 50 ± 15 years) with a history of chronic low back pain for a mean of 8 years. Patients underwent ten 30-minute sessions, generally 2 sessions per week, of verum acupuncture (n = 387) according to principles of traditional Chinese medicine; sham acupuncture (n = 387) consisting of superficial needling at nonacupuncture points; or conventional therapy, a combination of drugs, physical therapy, and exercise (n = 388). Five additional sessions were offered to patients who had a partial response to treatment (10%-50% reduction in pain intensity). Primary outcome was response after 6 months, defined as 33% improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale questionnaire or 12% improvement or better on the back-specific Hanover Functional Ability Questionnaire. Patients who were unblinded or had recourse to other than permitted concomitant therapies during follow-up were classified as nonresponders regardless of symptom improvement.

Results: At 6 months, response rate was 47.6% in the verum acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group. Differences among groups were as follows: verum vs sham, 3.4% (95% confidence interval, –3.7% to 10.3%; P = .39); verum vs conventional therapy, 20.2% (95% confidence interval, 13.4% to 26.7%; P < .001); and sham vs conventional therapy, 16.8% (95% confidence interval, 10.1% to 23.4%; P < .001.

Conclusions: Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.

Note well: If acupuncture were not a placebo, sham acupuncture would not be equally effective. Please read this article from MSNBC: Acupuncture - real or fake - best for back pain Study: Needling, even if not done right, eases ache more than usual care. "Positive expectations the patients held about acupuncture — or negative expectations about conventional medicine — could have led to a placebo effect and explain the findings."

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