Back pain is a big problem, and Ben Goldacre has already written about the new study
The German Acupuncture Trials (GERAC) for chronic low back pain
Randomized. Multicenter, Blinded, Parallel-Group Trial wth 3 groups.
Sadly, the Journal of the American Medical Association have told me to remove the link to the original paper, so if you want to know more about it, email me. There is something rather irresponsible in the way journals promote papers to the media, but then deny the public the right to see the original work.
There has been a real orgy of bad science reporting about this interesting paper The main conclusion is that both sham acupuncture and ‘real’ acupuncture have essentially the same effectiveness in reducing back pain. Both the real and the sham treatment came out better than the group given ‘conventional therapy’ (a combination of drugs, physical therapy, and exercise).
Perhaps it isn’t surprising that many of the headlines in the press were misleading. So was the press release for the journal, which had the title “Acupuncture Treatment May Be More Effective Than Conventional Therapy In Treating Lower Back Pain, German Study Finds “. The bad journalism can be blamed in part by the self-promotion of journals, as so often.
My first take on what this means is
- a theatrical treatment can have a strong placebo effect, or any old prick produces a long lasting physiological effect
- acupuncture is a sham.
For an excellent account of the placebo effect, go to Goldacre.
This is the latest in a series of trials that shows essentially no difference between real and sham acupuncture. Here are examples.
This may not matter very much for patients, but it is enormously important in principle. It is enormously important for education, qualifications and for regulation. If, as seems to be the case, real acupuncture and sham are much the same, that means that all the ancient Chinese wisdom on which the acupuncture is allegedly based is just so much bunk. A typical statement of these was reproduced in the Dilemmas of Alternative Medicine.
. . . its advocates try to ‘explain’ the effects, along these lines.
- “There are 14 major avenues of energy flowing through the body. These are known as meridians”.
- The energy that moves through the meridians is called Qi.
- Think of Qi as “The Force”. It is the energy that makes a clear distinction between life and death.
- Acupuncture needles are gently placed through the skin along various key points along the meridians. This helps rebalance the Qi so the body systems work harmoniously.
I suppose, to the uneducated, the language sounds a bit like that of physics. But it is not. The words have no discernable meaning whatsoever. They are pure gobbledygook. Can any serious university be expected to teach such nonsense as though the words meant something?
|I’ll declare an interest. I get intermittent back pain too.
The picture is an X-ray of my spinal cord, You can see two lumbar vertebrae bolted together from the front and back with huge titanium woodscrews. The vertebrae had become disconnected in what the surgeon called the worst spondylolisthesis he’d seen.
One thing that I do know is that my back pain is enormously variable from day to day, for no obvious reason, That alone makes it almost impossible to tell whether any treatment helps.
|“The evidence that non-steroidal anti-inflammatory drugs relieve pain better than placebo is strong. Advice to stay active speeds up recovery and reduces chronic disability. Muscle relaxants relieve pain more than placebo, strong evidence also shows, but side effects such as drowsiness may occur. Conversely, strong evidence shows that bed rest and specific back exercises (strengthening, flexibility, stretching, flexion, and extension exercises) are not effective. These interventions mentioned were equally as effective as a variety of placebo, sham, or as no treatment at all. Moderate evidence shows that spinal manipulation, behavioural treatment, and multidisciplinary treatment (for subacute low back pain) are effective for pain relief. Finally, no evidence shows that other interventions (for example, lumbar supports, traction, massage, or acupuncture) are effective for acute low back pain”|
The main advice seems to be “avoid rest”. This is me avoiding
rest by walking across the Alps a few years ago.
The Times. The best so far seems to be from Nigel Hawkes in the Times “Sticking needles in a bad back “eases pain better than drugs”
“Acupuncture works better than conventional treatments in reducing lower back pain, according to researchers in Germany. But so does fake acupuncture, where the needles are inserted shallowly and in the wrong places.”
The BBC. The BBC report (anonymous) posted on 26th September misssed the point altogether, but a day later it is much better (could that have anything to do with the complaint that I made about it?).
The title changed overnight from “Acupuncture ‘best for back pain’.” to “Needles ‘are best for back pain’ Acupuncture – real or sham – is more effective at treating back pain than conventional
therapies, research suggests.”
“their findings suggest that the body may react positively to any thin needle prick – or that acupuncture may simply trigger a placebo effect.”
The Independent. On the other hand, The Independent makes a hash of it. “Acupuncture is best way to treat back pain, study finds” By Jeremy Laurance, Health Editor.
It starts “The ancient Chinese practice of acupuncture works better than anything modern medicine has devised for the treatment of back pain, scientists have concluded.”. That is precisely what they didn’t show. On the contrary they showed than any old pricking does as well as the ancient Chinese practice.
The Telegraph. Nic Fleming in the Telegraph missed the point too ” Acupuncture ‘best therapy for back pain’ By Nic Fleming, Science Correspondent. “Acupuncture can provide significantly more relief from lower back pain than conventional therapies, scientists say.”.
There is an excellent comparison of the newspaper reports at “Journalists are shit, study finds“
Quite remarkably, the Daily Mail does not do the worst here. Despite its bad headline, it says:
“But the study suggests that there are in fact no physical effects at all, and that the healing of pain stems from the patients psychological conviction that they are getting better. ”
I’ve seen mention of the gate control theory of pain in connection with purported effects of acupuncture. I was wondering what your thoughts are on this, David?
Acupuncture a sham? The author’s comment is a sham.
While both acupuncture on traditional points and in so-called “sham” points both may produce endorphins, or address benefits of placebo effect, it is premature to leap to the conclusion that acupuncture is a fraud, and that ideas of traditional chinese medicine theory are “meaningless”… based on ONE article.
READ more articles before running off at the mouth.
Acupuncture of certain points traditionally used to ‘brighten the vision’ have been shown to stimulate activity in the occiputal region of the brain where vision is processed, this was verified using PET scans, not just a patients’ subjective feedback, influenced by placebo effect, knowing that they got needled. needles placed beside the nose ellicit local cellular release of cytokines and chemotactically guide white blood cells to the nose of a patient with an upper respiratory infection, effectively guiding the immune system to where it’s needed. Chemotactic response to histamines are not gobbelygook but considered as known facts of science… (at least on THIS planet)
So the nomenclature may sound confusing to someone in the lay population, but the medicine remains as valid and applicable today as 3000 years ago, and has been useful for treating even emerging conditions as SARS, let’s see how pharmaceutical biomedicine stands after the test of time.
Coracle. I’m no expert in the “gate theory” of pain so I’ve asked someone who is. My understanding is, though, that what is known of the physiology could not explain the effects that persist (according to acupuncturists) for hours or days after the needles are removed.
Ryan Vos. Nobody denies for a moment that sticking a needle in someone elicits a physiological reponse and produces signals in the brain. But there are now several papers that suggest rather strongly that it doesn’t matter where the needles are stuck. It isn’t transmitter release that is sham, it is all the nonsense about meridians and ‘energy flow’.
It is also not demonstrated at all to what extent the release of endorphins or the signal measured in scans is of benefit to patients, That is just speculation.
Acupuncture enthusiasts are like homeopaths insofar as they like to use the language of science when it suits them, but are equally happy to use the language of magic in the absence of good science.
Gate control is on the way out for a more psychological view of chronic pain sensation. To be honest, im unconvinced as it seems like whishy-washy psychology. For me i think its a bit of both. Check out Melzack for these sorts of things.
I looked through that paper and couldnt find what drugs they used as part of the conventional therapy? Does anyone know?
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