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Acupuncture is a theatrical placebo: the end of a myth

May 30th, 2013 · 52 Comments

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Anesthesia & Analgesia is the official journal of the International Anesthesia Research Society. In 2012 its editor, Steven Shafer, proposed a head-to-head contest between those who believe that acupuncture works and those who don’t. I was asked to write the latter. It has now appeared in June 2013 edition of the journal [download pdf]. The pro-acupuncture article written by Wang, Harris, Lin and Gan appeared in the same issue [download pdf].

Acupuncture is an interesting case, because it seems to have achieved greater credibility than other forms of alternative medicine, despite its basis being just as bizarre as all the others. As a consequence, a lot more research has been done on acupuncture than on any other form of alternative medicine, and some of it has been of quite high quality. The outcome of all this research is that acupuncture has no effects that are big enough to be of noticeable benefit to patients, and it is, in all probablity, just a theatrical placebo.

After more than 3000 trials, there is no need for yet more. Acupuncture is dead.

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Acupuncture is a theatrical placebo

David Colquhoun (UCL) and Steven Novella (Yale)

Anesthesia & Analgesia, June 2013 116:1360-1363.

Pain is a big problem. If you read about pain management centres you might think it had been solved. It hasn’t. And when no effective treatment exists for a medical problem, it leads to a tendency to clutch at straws.  Research has shown that acupuncture is little more than such a straw.

Although it is commonly claimed that acupuncture has been around for thousands of years, it hasn’t always been popular even in China.  For almost 1000 years it was in decline and in 1822 Emperor Dao Guang issued an imperial edict stating that acupuncture and moxibustion should be banned forever from the Imperial Medical Academy.

Acupuncture continued as a minor fringe activity in the 1950s.  After the Chinese Civil War, the Chinese Communist Party ridiculed traditional Chinese medicine, including acupuncture, as superstitious.  Chairman Mao Zedong later revived traditional Chinese Medicine as part of the Great Proletarian Cultural Revolution of 1966 (Atwood, 2009).  The revival was a convenient response to the dearth of medically-trained people in post-war China, and a useful way to increase Chinese nationalism.  It is said that Chairman Mao himself preferred Western medicine. His personal physician quotes him as saying “Even though I believe we should promote Chinese medicine, I personally do not believe in it. I don’t take Chinese medicine” Li {Zhisui Li. Private Life Of Chairman Mao: Random House, 1996}.

The political, or perhaps commercial, bias seems to still exist. It has been reported by Vickers et al. (1998) (authors who are sympathetic to alternative medicine) that

"all trials [of acupuncture] originating in China, Japan, Hong Kong, and Taiwan were positive"(4).

Acupuncture was essentially defunct in the West until President Nixon visited China in 1972.  Its revival in the West was largely a result of a single anecdote promulgated by journalist James Reston in the New York Times, after he’d had acupuncture in Beijing for post-operative pain in 1971. Despite his eminence as political journalist, Reston had no scientific background and evidently didn’t appreciate the post hoc ergo propter hoc fallacy, or the idea of regression to the mean.

After Reston’s article, acupuncture quickly became popular in the West. Stories circulated that patients in China had open heart surgery using only acupuncture (Atwood, 2009). The Medical Research Council (UK) sent a delegation, which included Alan Hodgkin, to China in 1972 to investigate these claims , about which they were skeptical.  In 2006 the claims were repeated in 2006 in a BBC TV program, but Simon Singh (author of Fermat’s Last Theorem) discovered that the patient had been given a combination of three very powerful sedatives (midazolam, droperidol, fentanyl) and large volumes of local anaesthetic injected into the chest.  The acupuncture needles were purely cosmetic.

Curiously, given that its alleged principles are as bizarre as those on any other sort of pre-scientific medicine, acupuncture seemed to gain somewhat more plausibility than other forms of alternative medicine.  The good thing about that is that more research has been done on acupuncture than on just about any other fringe practice.

The outcome of this research, we propose, is that the benefits of acupuncture, if any, are too small and too transient to be of any clinical significance.  It seems that acupuncture is little or no more than a theatrical placebo.  The evidence for this conclusion will now be discussed.

Three things that are not relevant to the argument

There is no point in discussing surrogate outcomes such as fMRI studies or endorphine release studies until such time as it has been shown that patients get a useful degree of relief. It is now clear that they don’t. 

There is also little point in invoking individual studies.  Inconsistency is a prominent characteristic of acupuncture research: the heterogeneity of results poses a problem for meta-analysis.  Consequently it is very easy to pick trials that show any outcome whatsoever.  Therefore we shall consider only meta-analyses.

The argument that acupuncture is somehow more holistic, or more patient-centred, than medicine seems us to be a red herring.  All good doctors are empathetic and patient-centred.  The idea that empathy is restricted to those who practice unscientific medicine seems both condescending to doctors, and it verges on an admission that empathy is all that alternative treatments have to offer.

There is now unanimity that the benefits, if any, of acupuncture for analgesia, are too small to be helpful to patients.

Large multicenter clinical trails conducted in Germany {Linde et al., 2005; Melchart et, 2005; Haake et al, 2007, Witt et al, 2005), and in the United States {Cherkin et al, 2009) consistently revealed that verum (or true) acupuncture and sham acupuncture treatments are no different in decreasing pain levels across multiple chronic pain disorders: migraine, tension headache, low back pain, and osteoarthritis of the knee.

If, indeed, sham acupuncture is no different from real acupuncture the apparent improvement that may be seen after acupuncture is merely a placebo effect.  Furthermore it shows meridians don’t exist, so the "theory" memorized by qualified acupuncturists is just myth. All that remains to be discussed is whether or not the placebo effect is big enough to be useful, and whether it is ethical to prescribe placebos.

Some recent meta-analyses have found that there may be a small difference between sham and real acupuncture.  Madsen Gøtzsche & Hróbjartsson {2009) looked at thirteen trials with 3025 patients, in which acupuncture was used to treat a variety of painful conditions.  There was a small difference between ‘real’ and sham acupuncture (it didn’t matter which sort of sham was used), and a somewhat bigger difference between the acupuncture group and the no-acupuncture group.  The crucial result was that even this bigger difference corresponded to only a 10 point improvement on a 100 point pain scale.  A consensus report (Dworkin, 2009) that a change of this sort should be described as a “minimal” change or “little change”.  It isn’t big enough for the patient to notice much effect.

The acupuncture and no-acupuncture groups were, of course, not blind to the patients and neither were they blind to the practitioner giving the treatment.  It isn’t possible to say whether the observed difference is a real physiological action or whether it’s a placebo effect of a rather dramatic intervention.  Interesting though it would be to know this, it matters not a jot, because the effect just isn’t big enough to produce any tangible benefit.

Publication bias is likely to be an even greater problem for alternative medicine than it is for real medicine, so it is particularly interesting that the result just described has been confirmed by authors who practise, or sympathise with, acupuncture.  Vickers et al. (2012) did a meta-analysis for 29 RCTs, with 17,922 patients.  The patients were being treated for a variety of chronic pain conditions. The results were very similar to those of Madsen et al.{2009).  Real acupuncture was better than sham, but by a tiny amount that lacked any clinical significance.  Again there was a somewhat larger difference in the non-blind comparison of acupuncture and no-acupuncture, but again it was so small that patients would barely notice it.

Comparison of these two meta-analyses shows how important it is to read the results, not just the summaries.  Although the outcomes were similar for both, the spin on the results in the abstracts (and consequently the tone of media reports) was very different. 

An even more extreme example of spin occurred in the CACTUS trial of acupuncture for " ‘frequent attenders’ with medically unexplained symptoms” (Paterson et al., 2011).  In this case, the results showed very little difference even between acupuncture and no-acupuncture groups, despite the lack of blinding and lack of proper controls.  But by ignoring the problems of multiple comparisons the authors were able to pick out a few results that were statistically significant, though trivial in size.  But despite this unusually negative outcome, the result was trumpeted as a success for acupuncture.  Not only the authors, but also their university’s PR department and even the Journal editor issued highly misleading statements.  This gave rise to a flood of letters to the British Journal of General Practice and much criticism on the internet.

From the intellectual point of view it would be interesting to know if the small difference between real and sham acupuncture found in some, but not all, recent studies is a genuine effect of acupuncture or whether it is a result of the fact that the practitioners are never blinded, or of publication bias.  But that knowledge is irrelevant for patients. All that matters for them is whether or not they get a useful degree of relief.

There is now unanimity between acupuncturists and non-acupuncturists that any benefits that may exist are too small to provide any noticeable benefit to patients.  That being the case it’s hard to see why acupuncture is still used.  Certainly such an accumulation of negative results would result in the withdrawal of any conventional treatment.

Specific conditions

Acupuncture should, ideally, be tested separately for effectiveness for each individual condition for which it has been proposed (like so many other forms of alternative medicine, that’s a very large number).  Good quality trials haven’t been done for all of them.  It’s unlikely that acupuncture works for rheumatoid arthritis, stopping smoking, irritable bowel syndrome or for losing weight.  And there is no good reason to think it works for addictions, asthma, chronic pain, depression, insomnia, neck pain, shoulder pain or frozen shoulder, osteoarthritis of the knee, sciatica, stroke or tinnitus and many other conditions (Ernst et al., 2011).

In 2009, the UK’s National Institute for Clinical Excellence (NICE) did recommend both acupuncture and chiropractic for back pain. This exercise in clutching at straws caused something of a furore.  In the light of NICE’s judgement the Oxford Centre for Evidence-based medicine updated its analysis of acupuncture for back pain.  Their verdict was

“Clinical bottom line. Acupuncture is no better than a toothpick for treating back pain.”

The paper by Artus et al. (2010) is of particular interest for the problem of back pain.  Their Fig 2 shows that there is a modest improvement in pain scores after treatment, but much the same effect, with the same time course is found regardless of what treatment is given, and even with no treatment at all.  They say

“we found evidence that these responses seem to follow a common trend of early rapid improvement in symptoms that slows down and reaches a plateau 6 months after the start of treatment, although the size of response varied widely. We found a similar pattern of improvement in symptoms following any treatment, regardless of whether it was index, active comparator, usual care or placebo treatment”.

It seems that most of what’s being seen is regression to the mean. And that is very likely to be the main reason why acupuncture sometimes appears to work when it doesn’t.

Although the article by Wang et al (2012) was written to defend the continued use of acupuncture, the only condition for which they claim that there is any reasonably strong evidence is for post-operative nausea and vomiting (PONV).  It would certainly be odd if a treatment that had been advocated for such a wide variety of conditions turned out to work only for PONV.  Nevertheless, let’s look at the evidence.

The main papers that are cited to support the efficacy of acupuncture in alleviation of PONV are all from the same author: Lee & Done (1999), and two Cochrane reviews, Lee & Done (2004), updated in Lee & Fan (2009).  We need only deal with this latest updated meta-analysis.

Although the authors conclude “P6 acupoint stimulation prevented PONV”, closer examination shows that this conclusion is very far from certain.  Even taken at face value, a relative risk of 0.7 can’t be described as “prevention”.  The trials that were included were not all tests of acupuncture but included several other more or less bizarre treatments (“acupuncture, electro-acupuncture, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, an acu-stimulation device, and acupressure”).  The number needed to treat varied from a disastrous 34 to a poor 5 for patients with control rates of PONV of 10% and 70% respectively.

The meta-analysis showed, on average, similar effectiveness for acupumcture and anti-emetic drugs.  The problem is that the effectiveness of drugs is in doubt because an update to the Cochrane review has been delayed (Carlisle, 2012) by the discovery of major fraud by a Japanese anesthetist, Yoshitaka Fujii (Sumikawa, 2012). It has been suggested that metclopramide barely works at all (Bandolier, 2012; Henzi, 1999).

Of the 40 trials (4858 participants) that were included; only four trials reported adequate allocation concealment. Ninety percent of trials were open to bias from this source. Twelve trials did not report all outcomes.  The opportunities for bias are obvious. The authors themselves describe all estimates as being of “Moderate quality” which is defined this:Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate”.  That being the case, perhaps the conclusion should have been “more research needed”.  In fact almost all trials of alternative medicines seem to end up with the conclusion that more research is needed.

Conclusions

It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions.  After thousands of trials of acupuncture, and hundreds of systematic reviews (Ernst et al., 2011), arguments continue unabated.  In 2011, Pain carried an editorial which summed up the present situation well.

“Is there really any need for more studies? Ernst et al. (2011) point out that the positive studies conclude that acupuncture relieves pain in some conditions but not in other very similar conditions. What would you think if a new pain pill was shown to relieve musculoskeletal pain in the arms but not in the legs? The most parsimonious explanation is that the positive studies are false positives. In his seminal article on why most published research findings are false, Ioannidis (2005) points out that when a popular but ineffective treatment is studied, false positive results are common for multiple reasons, including bias and low prior probability.”

Since it has proved impossible to find consistent evidence after more than 3000 trials, it is time to give up.  It seems very unlikely that the money that it would cost to do another 3000 trials would be well-spent. 

A small excess of positive results after thousands of trials is most consistent with an inactive intervention.  The small excess is predicted by poor study design and publication bias. Further, Simmons et al (2011) demonstrated that exploitation of "undisclosed flexibility in data collection and analysis" can produce statistically positive results even from a completely nonexistent effect.  With acupuncture in particular there is documented profound bias among proponents (Vickers et al., 1998).  Existing studies are also contaminated by variables other than acupuncture – such as the frequent inclusion of "electroacupuncture" which is essentially transdermal electrical nerve stimulation masquerading as acupuncture.

The best controlled studies show a clear pattern – with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are what define "acupuncture" the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research. The most parsimonious conclusion is that with acupuncture there is no signal, only noise.

The interests of medicine would be best-served if we emulated the Chinese Emperor Dao Guang and issued an edict stating that acupuncture and moxibustion should no longer be used in clinical practice. 

No doubt acupuncture will continue to exist on the High Streets where they can be tolerated as a voluntary self-imposed tax on the gullible (as long as they don’t make unjustified claims).

REFERENCES
 

1. Acupuncture Centre. . About Acupuncture. Available at: http://www.acupuncturecentre.org/aboutacupuncture.html. Accessed March 30, 2013

 

2. Atwood K. “Acupuncture Anesthesia”: a Proclamation from Chairman Mao (Part IV). Available at: http://www.sciencebasedmedicine.org/index.php/acupuncture-anesthesia-a-proclamation-from-chairman-mao-part-iv/. Accessed September 2, 2012

 

3. Li Z Private Life of Chairman Mao: The Memoirs of Mao’s Personal Physician. 1996 New York: Random House

 

4. Vickers A, Goyal N, Harland R, Rees R. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials. 1998;19:159–66 Available at: http://bit.ly/WqVGWN. Accessed September 2, 2012

 

5. Reston J. Now, About My Operation in Peking; Now, Let Me Tell You About My Appendectomy in Peking … The New York Times. 1971 Available at: http://select.nytimes.com/gst/abstract.html?res=FB0D11FA395C1A7493C4AB178CD85F458785F9. Accessed March 30, 2013

 

6. Atwood K. “Acupuncture anesthesia”: a proclamation from chairman Mao (part I). Available at: http://www.sciencebasedmedicine.org/index.php/acupuncture-anesthesia-a-proclamation-of-chairman-mao-part-i/. Accessed September 2, 2012

 

7. Linde K, Streng A, Jürgens S, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes MG, Weidenhammer W, Willich SN, Melchart D. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005;293:2118–25

 

8. Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes M, Hummelsberger J, Irnich D, Weidenhammer W, Willich SN, Linde K. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ. 2005;331:376–82

 

9. Haake M, Müller HH, Schade-Brittinger C, Basler HD, Schäfer H, Maier C, Endres HG, Trampisch HJ, Molsberger A. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007;167:1892–8

 

10. Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S, Hummelsberger J, Walther HU, Melchart D, Willich SN. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet. 2005;366:136–43

 

11. Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009;169:858–66

 

12. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009;338:a3115

 

13. Dworkin RH, Turk DC, McDermott MP, Peirce-Sandner S, Burke LB, Cowan P, Farrar JT, Hertz S, Raja SN, Rappaport BA, Rauschkolb C, Sampaio C. Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations. Pain. 2009;146:238–44

 

14. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, Sherman KJ, Witt CM, Linde K. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172:1444–53

 

15. Paterson C, Taylor RS, Griffiths P, Britten N, Rugg S, Bridges J, McCallum B, Kite G. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms: a randomised controlled trial (CACTUS study). Br J Gen Pract. 2011;61:e295–e305

 

16. . Letters in response to Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract. 2011;61 Available at: http://www.ingentaconnect.com/content/rcgp/bjgp/2011/00000061/00000589. Accessed March 30, 2013

 

17. Colquhoun D. Acupuncturists show that acupuncture doesn’t work, but conclude the opposite: journal fails. 2011 Available at: http://www.dcscience.net/?p=4439. Accessed September 2, 2012

 

18. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011;152:755–64

 

19. Colquhoun D. NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself. 2009 Available at: http://www.dcscience.net/?p=1516. Accessed September 2, 2012

 

20. Colquhoun D. The NICE fiasco, part 3. Too many vested interests, not enough honesty. 2009 Available at: http://www.dcscience.net/?p=1593. Accessed September 2, 2012

 

21. Bandolier. . Acupuncture for back pain—2009 update. Available at: http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Chronrev/Other/acuback.html. Accessed March 30, 2013

 

22. Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology (Oxford). 2010;49:2346–56

 

23. Wang S-M, Harris RE., Lin Y-C, Gan TJ. Acupuncture in 21st century anesthesia: is there a needle in the haystack? Anesth Analg. 2013;116:1356–9

 

24. Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg. 1999;88:1362–9

 

25. Lee A, Done ML. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2004:CD003281

 

26. Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2009:CD003281

 

27. Carlisle JB. A meta-analysis of prevention of postoperative nausea and vomiting: randomised controlled trials by Fujii etal. compared with other authors. Anaesthesia. 2012;67:1076–90

 

28. Sumikawa K. The results of investigation into Dr.Yoshitaka Fujii’s papers. Report of the Japanese Society of Anesthesiologists Special Investigation Committee. http://www.anesth.or.jp/english/pdf/news20120629.pdf

 

29. Bandolier. . Metoclopramide is ineffective in preventing postoperative nausea and vomiting. Available at: http://www.medicine.ox.ac.uk/bandolier/band71/b71-8.html. Accessed March 30, 2013

 

30. Henzi I, Walder B, Tramèr MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies. Br J Anaesth. 1999;83:761–71

 

31. Hall H. Acupuncture’s claims punctured: not proven effective for pain, not harmless. Pain. 2011;152:711–2

 

32. Ioannidis JP. Why most published research findings are false. PLoS Med. 2005;2:e124

 

33. Simmons JP, Leif DN, Simonsohn U. False-positive psychology: undisclosed flexibility in data collection and analysis allows presenting anything as significant. Psychol Sci. 2011;22:1359–66

Follow-up

30 May 2013 Anesthesia & Analgesia has put the whole paper on line. No paywall now!

9 June 2013. Since this page was posted on May 30, it has had over 20,000 page views. Not bad.

26 July 2013. The Observer had a large double-page spread about acupuncture. It was written by David Derbyshire, largely on the basis of this article.

26 December 2013

Over christmas the flow of stuff that misrepresents the "thousands of years" of Chinese medicine has continued unabated. Of course one expects people who are selling Chinese herbs and acupuncture to lie. All businesses do. One does not expect such misrepresentation from British Columbia, Cardiff University School of medicine, or from Yale University. I left a comment on the Yale piece. Whether it passes moderation remains to be seen. Just in case, here it is.

One statement is undoubtedly baseless ““If it’s still in use after a thousand years there must be something right,” It’s pretty obvious to the most casual observer that many beliefs that have been round for a thousand years have proved to be utterly wrong.

In any case, it’s simply not true that most “Traditional” Chinese medicine has been around for thousands of years. Acupuncture was actually banned by the Emperor Dao Guang in 1822. The sort of Chinese medicine that is sold (very profitably) to the west was essentially dead in China until it was revived by Mao as part of the great proletarian cultural revolution (largely to stir up Chinese nationalism at that time). Of course he didn’t use it himself.

This history has been documented in detail now, and it surprises me to see it misrepresented, yet again, from a Yale academic.

Of course there might turn out to be therapeutically useful chemicals in Chinese herbs (it has happened with artemesinin). But it is totally irresponsible to pretend that great things are coming in the absence of good RCTs in human patients.

Yale should be ashamed of PR like this. And so should Cardiff University. It not only makes the universities look silly. It corrupts the whole of the rest of these institutions. Who knows how much more of their PR is mere puffery.

18 January 2014. I checked the Yale posting and found that the comment, above, had indeed been deleted. There is little point in having comments if you are going to delete anything that’s mildly critical. It is simply dishonest.

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Tags: Academia · acupuncture · badscience · Bait and switch · quackademia

52 responses so far ↓

  • 1 Acupuncture is a theatrical placebo: the end of a myth | SecularNews.Org // May 30, 2013 at 11:13

    […] By David Colquhoun […]

  • 2 Akupunktur ist tot | der zweite knall // May 31, 2013 at 05:24

    […] David Colquhoun schreibt in Acupuncture is a theatrical placebo: the end of a myth: […]

  • 3 FrankO // May 31, 2013 at 08:36

    *Hard kicking against the pricks who think magic cures disease.  Great stuff, David!

  • 4 JEdgarHoover // May 31, 2013 at 10:54

    *

    UCL anatomy prof and pain expert Pat Wall visited China — at their invitation, and with 2 others — prior to the 1972 trip to see acupuncture anaesthesia in action.
    He told me about the best and and the worst operations he saw.

    The best was an thyroid op on a woman who came in to the op room, bowed politely, sat in a sort-of dentists chair, had her op, thanked everyone, and was escorted back to bed.

    The worst was a man who had open-chest surgery  — I cannot now recall what for. He groaned in agony throughout, despite many doses of top-up anaesthetic.

    Of course, Pat said, it was impossible to what drugs they had received beforehand. All the patients he saw were carefully selected beforehand, and elaborately schooled.

    He came away unconvinced.  I forgot to mention this in his obituary, which was in the Independent and is now behind a paywall.

    Best,  Caroline

  • 5 Needless | Neonatal Research // May 31, 2013 at 15:46

    […] article about acupuncture that he wrote for “Anesthesia and Analgesia” entitled “Acupuncture is a theatrical placebo: the end of a myth” his co-author is one of the founders of “Science Based Medicine” which publishes […]

  • 6 BadlyShavedMonkey // May 31, 2013 at 21:29

    I have watched with interest the slow death-by-meta-analysis of acupuncture, but still find myself unable to answer questions relating to what I believe are called dry-needling/trigger-point acupuncture. 
    As far as I can tell, the trials of acupuncture deal largely with techniques based on the fictitious notion of meridians. I presume this is because the work is done by people based in variants of the Chinese tradition. Trigger-point acupuncture seems to be different. One of my wife’s colleagues practises it and she applied it to Mrs Monkey for a painful hip. The pain was localised (or referred to) a particular muscle and insertion of the needle caused immediate pain then relief of the intense pain for a period afterwards. 
    I am left with the following issues;
    1. I don’t think I’m surprised that sticking a needle into a painful muscle hurts. 2. I don’t think I’m surprised that some principle of counter-irritation or release of muscle-spasm might give immediate relief of symptoms. 3. I doubt that relief had any impact on the chronic history of the condition. 4. I wonder whether the acute effect specified in 2 leads patients to believe there is a chronic effect as per 3 even when none exists. 5. I don’t think “placebo effect” quite captures the peracute process specified in 2.6. I suspect the peracute effect of sticking a needle in a patient predisposes them to infer a chronic effect. 7. I strongly suspect that any reported chronic benefit from this mode of needling is likely to be illusory, i.e. placebo effects, but what is the evidence on this particular type of needling?

  • 7 » Acupuncture is a theatrical placeboAlternatives to Medicine // Jun 2, 2013 at 22:51

    […] An interesting read: Acupuncture is a theatrical placebo: the end of a myth […]

  • 8 The acupuncture debate – is it over? | Science or not? // Jun 3, 2013 at 01:41

    […] Hat tip to DC’s Improbable Science. […]

  • 9 Skeptical reporter @ 2013-05-31 - Sceptici în România // Jun 6, 2013 at 13:48

    […] http://www.dcscience.net/?p=6060 […]

  • 10 …en tot zover acupunctuur — Michel Vuijlsteke's Weblog // Jun 6, 2013 at 20:14

    […] is theatrale placebo. Einde verhaal. […]

  • 11 The Power Of Placebo | Belief | Health | Freedom | Prosperity | Comedy -Narcotic Lollipop // Jun 10, 2013 at 13:41

    […] Research boffins, David Colquhoun (UCL) and Steven Novella (Yale), have reviewed thousands of scientific papers and concluded that ‘acupuncture is a theatrical placebo.’ […]

  • 12 Connect Physical Health sells quackery to NHS // Jun 10, 2013 at 18:05

    […] such treatment is acupuncture. Having very recently reviewed the evidence, we concluded that "Acupuncture is a theatrical placebo: the end of a myth". Any effects it may have are too small to be useful to patients. That’s the background […]

  • 13 Connect Physical Health sells quackery to NHS | SecularNews.Org // Jun 10, 2013 at 22:57

    […] such treatment is acupuncture. Having very recently reviewed the evidence, we concluded that “Acupuncture is a theatrical placebo: the end of a myth“. Any effects it may have are too small to be useful to patients. That’s the background […]

  • 14 Majikthyse // Jun 12, 2013 at 15:35

    ….and here’s my much more modest offering on the subject:

    http://onlinelibrary.wiley.com/doi/10.1111/fct.12014/full

  • 15 Muscleman // Jun 14, 2013 at 16:14

    @BadlyShavedMonkey – It seems to me that what happened in your wife’s case might be somewhat analogous to Ramachandran’s mirror box to enable his patient to relax his phantom arm that the patient felt was painfully in contraction such that the fingernails were digging into the hand, all phantoms. 

    Most people do not have individual volitional control of many of their muscles, partly because they cannot visualise them. Thus your wife could not relax her hip muscle. The needle insertion thus acted as a sort of focal point or simply activated the specific reflex arc for the muscle allowing it to relax. 

  • 16 toots // Jun 17, 2013 at 16:16

    “40 disorders have been recognized by the World Health Organization as conditions that can benefit from acupuncture treatment”.

    It takes no time at all for Wang et al to refer to the lamentable report by Xiaorui Zhang of 2003.

    This notorious document was slated by Mike Cummings, director of British Medical Acupuncture, as hopelessly biased and therefore unfit to provide evidence of the value of acupuncture. I would go further and describe it as a farcical document since its remit was to look for solid evidence to support the use of acupuncture and yet it saw fit to systematically exclude all placebo controlled trials.

    The document is often quoted to support the claim that the WHO recommends the use of acupuncture. Wang et al. do not perpetrate that scurrilous lie but the fact that they mention the paper at all, grossly undermines their credibility.

    Every time someone tries to attach the cache of the WHO to acupuncture they should be shot down in flames.

    Xiaorui Zhang

    “40 disorders have been recognized by the World Health Organization as conditions that can benefit from acupuncture treatment”

     This document was slated by Mike Cummings, director of British Medical Acupuncture, as hopelessly biased and in no way providing evidence to support the use of acupuncture. I would go further and describe it as a farcical document since its remit was to look for solid evidence to support acupuncture and yet the person responsible for producing it chose to systematically exclude all placebo controlled studies. 

    The document also states: “Only national health authorities can determine the diseases, symptoms and conditions for which acupuncture can ne recommended”. Very often this document is quoted in defence of the claim that the  WHO recommends acupuncture. Wang et al. stop short of propagating this scurrilous falsehood but to quote it at all

     

     

     

  • 17 toots // Jun 17, 2013 at 17:38

    Ah, so that’s where my first attempt disappeared – I thought it had gone forever somehow, somewhere. And “cache”! I really must spend less time on the internet…

  • 18 Acupuncture Doesn’t Work « Science-Based Medicine // Jun 19, 2013 at 11:42

    […] researchers agreed to write the pro-acupuncture article, Wang, Harris, Lin and Gan . They asked David Colquhoun to write the con position, and David asked me to write it with him (which, of course, I […]

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    […] a good example of a situation where no more research needs to be done – on the theatrical placebo that is acupuncture. By David […]

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  • 22 Dudeistan // Jul 2, 2013 at 21:58

    @BadlyShavedMonkey – see this link about trigger point therapy:http://www.fmperplex.com/2013/02/14/travell-simons-and-cargo-cult-science/

  • 23 ma ba // Mar 27, 2014 at 01:40

    *Acupuncture works. My Husband had severe chronic pain in his hip and required a hip replacement. He did not believe that Acupuncture works, neither did I. He had an Acupuncture treatment where I watched the Practitoner insert a needle into my Husband’s leg. His entire leg stiffened and his foot and toes curled down ( and it was extremely painful, my Husband told me later ), then the needle was heated. Within minutes of the treatment his pain was gone. Permanently. I GUESS THE NEEDLE CUT AND THEN CAUTERISED THE NERVE THAT HAD BEEN SENDING THE PAIN SIGNAL. 

  • 24 David Colquhoun // May 4, 2014 at 09:01

    @ma ba

    I have had three hip replacement operations now.  The recovery is usually quite quick, so there is no reason to think that acupuncture helps.  If a nerve was really cauterised, that would be very dangerous indeed.  He’s lucky if he survived such a treatment/ 

  • 25 Yashen Mungaroo-u14104289 // May 4, 2014 at 09:36

    Many people swear by the healing powers of acupuncture
    and others are skeptics of alternative treatment. However the treatment is believed to work by most, be it mind over matter or medical innovation this is an undeniable fact. Recent studies showed that acupuncture may have actual benefits in pain relief and therefore by definition it cannot be a placebo.
    Although this procedure may have benefits it can also be very dangerous with one misplaced needle.

  • 26 David Colquhoun // May 4, 2014 at 11:49

    @Yashen Mungaroo

    If you had read this article more carefully you would realise that your assertions that “recent studies showed that acupuncture may have actual benefits in pain relief” is simply not true.  Quite on the contrary, it  is now quite clear that acupuncture has, at best, a small placebo effect and that usually that placebo effect is too small to be useful to the patient.

    I do agree, though, that acupuncture, like most forms of alternative medicine, can sometimes be dangerous,

  • 27 AndrewMan // Sep 8, 2014 at 09:20

    Who wrote this article?

    Are you guys trying to convince me of ANYTHING using an article with NO AUTHOR’S NAME. (Please help me, I may be blind: everything I see is the Name of the Article, a Very Low Quality Article, References (maybe to make the article’s assumptions look less ridiculous), and a bag of teenage turtles comments.)

    Article’s Author Name, Anyone?

  • 28 AndrewMan // Sep 8, 2014 at 09:30

    found the name, not at the start of the article…Acupuncture is a theatrical placebo: the end of a mythMay 30th, 2013 · 26 Comments

    BUT INSTEAD IN THE MIDDLE OF THE ARTICLE: (FINALLY)

    Acupuncture is a theatrical placebo

    David Colquhoun (UCL) and Steven Novella (Yale)

    Anesthesia & Analgesia, June 2013 116:1360-1363.

    Cool, not bad guys at least you put your names down, why are you trying to hide it?

     

    Now the question is: Who are you?

  • 29 AndrewMan // Sep 8, 2014 at 09:37

    David Colquhoun (Farmacologist)

    Steven Novella (MD) Assistant Professor of Neurology

    Nice to meet you guys. Now that I know you, we can talk.

    FIRST QUESTION: Why do you dissagree with NICE guidelines with regards to acupuncture?

    (Please give me an intelligent answer, I’m expecting something good from science professionals)

  • 30 David Colquhoun // Sep 10, 2014 at 18:51

    @AndrewMan

    (1) Sorry I didn’t reply at once.  I’m having a bit of holiday while on my way to Plymouth, to talk about the practice and principles of the analysis of single ion channel recordings -more on that here, if it interests you.

    (2) The front page of this blog says clearly that it is written by me (apart from three guest posts about Steiner schools).

    (3) You ask who I am.   You could use Google, or try the links to biographical stuff near the bottom of the front page.  I never write anonymously (unlike you, it seems).  

    (4) Most NICE assessments are good, but the quality does depend on the guidance group that’s  chosen.  In the case of low back pain, the group was biassed towards alternative stuff (it even had a chiropractor on it).  I’m afraid that they were guilty of clutching at straws. I wrote three posts about the NICE low back pain guidance (they are linked from the third post on the topic), so you can find a more detailed answer to your question there.  I think the NICE realise that there were some problems, and a new guidance group has been established.  I suspect strongly that the revised guidance will not include acupuncture because, as the article says, there is no substantial evidence that acupuncture (or, indeed, anything else) works.

  • 31 AndrewMan // Sep 10, 2014 at 23:44

    Great start, answers 1-3 didn’t impress me at all, however answer number 4 was very intriguing.

    I’d like to contribute to your website and inform you that NICE recommended the use of acupuncture for lower back pain in 2009, and now in 2014 – NICE recommendations for acupuncture includes lower back pain, chronic tension-type headaches and migraine (according to then – this is based on scientific evidence). Reference: 

    “Currently, the National Institute for Health and Care Excellence (NICE) only recommends considering acupuncture as a treatment option for chronic lower back pain, chronic tension-type headaches and migraines. NICE makes these recommendations on the basis of scientific evidence.” (NHS – Choices – Acupuncture – 2014)

    1st question: why not upgrade this article using up-to-date information? (Just a note at the end would be great)

    2nd question: why do you think NICE extended the recommendations for acupuncture from only lower back pain (2009) to include lower back pain, chronic tension-type headaches and migraine in 2014?

    3rd Taking into consideration that the NHS uses a very strict scientific “evidence-based” system. Why do you think that acupuncture has been expanding in the NHS for the last 5 years? 

    4th Newspapers (The Guardian, 26th July 2013) reported that more than half of Britain Doctors referred patients to acupuncture treatment? In your opinion are all these Doctors wrong?

  • 32 David Colquhoun // Sep 11, 2014 at 14:50

    @AndrewMan

    I have already explained in 2009 why I think that NICE made a mistake in the low back pain guidance.  I linked to the three posts on this topic in my last response, but it seems that you haven’t yet bothered to read them.  The faact that NICE is rewriting the guidelines so soon suggests to me that they realise they made a mistake

    I have great difficulty in believing that 50% of doctors have recommended acupuncture. One possibility is that privatisation  has resulted in more referrals to private “musculo-skeletal services” some of which push acupuncture onto unwilling patients -there is a good example under Connect Physical Health sells quackery to NHS.  Such companies as this are quite incapable of assessing evidence, especially if it reduces their profits.

    I’m intrigued by the fact that, although you accused me (incorrectly) of being anonymous, you yourself seem happy to post condescending comments without revealing your identity, your credentials in assessment of evidence, or your conflicts of interest.

  • 33 AndrewMan // Sep 12, 2014 at 23:48

    I’m intrigued to know, why would a non-medical professional write an article about acupuncture.

    I’m also intrigued to know, why a science teacher would write a “sensational” misleading article that goes against the “National Guidelines” – (NICE -NHS) using ridiculous and non-sense explanations. 

    Let me enrich your Article with “factual” information.

    “NATIONAL GUIDELINES”:

    - You said that NICE done a mistake and is re-writing their guidelines on Lower Back Pain (published in 2009) as in your opinion they must have had realised their mistake. (This doesn’t sound factual at all)

    Acupuncture and Lower Back Pain: NICE recommended Acupuncture treatment for lower back pain in 2009 (this policy has been reviewed in June 2012 – nothing changed with regards to acupuncture) this new policy is under review and the new recommendations are schedule to be published in November 2016. 

    http://www.nice.org.uk/guidance/indevelopment/GID-CGWave0681 

    NICE do carry emergency reviews, however it just looks like (in this case) it’s gonna be a normal update, as a new guideline is not schedule to be published for the next 2 years. QUESTION: Don’t you think that NICE is not really concerned with the meta-analysis published in 2013, that you are promoting? Maybe this new meta-analysis has little or no clinical value at all. 

    Example: if someone publish a meta-analysis in something as broad as Acupuncture, for example “surgery” looking into all the researches from the start of this technique till now, combining good quality researches with poor quality ones, mixing highly skilled and talented surgeons results, with portly trained and not-as-talented surgeons from all over the planet: and publish a conclusion that “surgery” is no better than placebo. Do you think that NICE is gonna stop recommending Surgeries in the NHS? You are not a Doctor are you?

    Acupuncture and Chronic Type Head Ache: This guideline has been published in September 2012 recommending acupuncture for the treatment of chronic type head ache. This guideline is NOT under review.  

    Acupuncture and Migraine: This guideline has been published in September 2012 recommending acupuncture for the treatment of migraine. This guideline is also NOT under review. 

    http://www.nice.org.uk/guidance/cg150/chapter/1-Guidance#management-2

    QUESTION 1: Don’t you think that it could be anti-ethical to promote an article that clearly states that “acupuncture is a theatrical placebo” while the “National Guidelines” (NICE – NHS) recommends acupuncture for the treatment of lower back pain, chronic type head ache and migraine: based on scientific evidence? Did you realise that you are not a Doctor and so, should not talk about medical treatments what so ever?

    DOCTOR’S PRESCRIPTIONS FOR ACUPUNCTURE TREATMENT:

    Over Half Britain Doctors have prescribed Acupuncture to their patients: You proposed that “privatisation” could be a factor that would incentive this phenomena. I find it hard to believe as this is not a new tendency. 

    15 years ago: 25th June 2000 British Medical Association reported that about half of all UK’s GPs have arranged acupuncture for their patients. In this report Doctors expressed their desire for acupuncture to be considered under NICE guidelines.

    http://web.bma.org.uk/pressrel.nsf/a4a6effeb2d171b8802568590051feb8/0083a901e4c072498025692100346d5e?OpenDocument

    And nowadays everything continues to favour acupuncture as a medical option as reported by “Daily Mail – 14th September 2013″ and “The Guardian – 26th of July 2013″ both written similar reports: they estimates that the government spent £25million on Acupuncture – and half of British Doctors are prescribing it. 

    http://www.theguardian.com/science/2013/jul/26/acupuncture-sceptics-proof-effective-nhs

    http://www.dailymail.co.uk/health/article-2420717/Whats-POINT-acupuncture-It-costs-NHS-25million-promises-cure-morning-sickness-ache–just-placebo.html

    QUESTION 2: Taking into consideration that you are NOT a Doctor. And privatisation doesn’t seem to be a reasonable factor. Why (in your opinion) Half of British Doctors are prescribing acupuncture for the last 15 years?  

  • 34 David Colquhoun // Sep 13, 2014 at 15:31

    @AndrewMan

    You are quite right. I’m not a medical doctor and that’s plain public knowledge. In contrast, you still haven’t said what your interest is in the matter. Are you a medical doctor? Or perhaps an acupuncturist?  My interests lie in assessment of evidence.  You might find it interesting to read my text book on statistics (it is now free). In that area, I am rather better qualified than the original guidance group was.

    Thanks for the reference to “50% of doctors”.  I notice that it is 14 years old.  In the last decade, the enthusiasm for alternative medicine has decreased considerably, thanks, in part, to writers like Ben Goldacre, who have explained clearly the lack of evidence for its effectiveness.  For example the prescribing of homeopathy on the NHS has fallen by 95% in that time.

    I’m amused by the fact that you should cite the 2013 Guardian article by David Darbyshire, because that article was pretty anti-acupuncture and it cites me quite extensively.

    I’m a bit baffled by the syntax of your question 2.  I think that there are several reasons why some doctors continue to prescribe ineffective treatments.  (1) They were misled by the NICE guidance into thinking that it works (the guidance itself rates the evidence as poor, but most people read only the headline conclusions).  (2) They are sometimes misled by their own journals.  The best recent example is a paper in the British Journal of General Practice.  That isn’t a quack journal, yet recently it published an article which claimed that acupuncture works, while failing to notice that the last author runs an expensive acupuncture clinic (an interest that he failed to declare).  You only have to glance at the paper itself to see that the conclusions it drew were totally unjustified by the data. In fact the paper showed that there wasn’t even any noticeable placebo effect.  (3) Perhaps even more important, is simple desperation.  Low back pain is very common and there are no effective treatments.  MRI doesn’t help. NSAIDs are not very effective and have side effects if taken for long.  Manipulative therapies may work occasionally, but haven’t solved the problem.  And of course acupuncture doesn’t work well either.  So what’s the poor doctor to do when faced with a patient with low back pain?  The temptation to push the responsibility on to someone else must be considerable.

    Looked at another way, if acupuncture is widely prescribed, and works, why is low back pain such a common problem?  If there was anything that worked, it should be uncommon. The fact that it remains an enormous problem implies that we should say “Sorry but there is no good treatment”, not to clutch at ineffective straws.

  • 35 AndrewMan // Sep 15, 2014 at 09:46

    I like your enthusiasm, however I don’t buy your misleading arguments. Why are you ignoring the NICE/NHS recommendations for acupuncture to be used for “Tension Type Headaches and Migraines” (published in 2012)? Your article was written in 2013, did you intentionally refused to include these recommendations trying to pretend that NICE recommendation for acupuncture was weak, and exclusively for lower back pain? Did you also “intentionally” forget to explain that NICE/NHS recommendations for lower back pain treatment – was also reviewed in 2012 and the recommendations continued to include acupuncture treatment? Are you refusing to admit that you were wrong?

    Let me enrich your website with more realistic views about “Lower Back Pain Treatment”: As you can see on my previous posts, Doctors love acupuncture. Bare in mind that Doctors have other options for lower back pain treatment: prescription of medicines (several types/makes/concentrations of pain killers, including injections), physiotherapy (by the way it is extremely rare to find an anti-acupuncture physiotherapist), gym exercise-referral sessions specialised in lower back pain, postural exercise sessions (Pilates, tai-chi and Yoga), etc. PS. Just for the record – Majority of Doctors in UK are NOT anti-ethical, if half of them are prescribing acupuncture – this reflects their personal experience, as they witness it’s effectiveness for their patients. I cant imagine Doctors prescribing ANYTHING (for many years) while not getting sufficient results. Medical data in Acupuncture is great, these meta-analysis (carried out by “anti-acupuncture” groups – only damages the image of an effective treatment (don’t take my word for it – take half of British Doctors opinion about it).

    Did you just say that Doctors have been mislead by NICE? No, they actually wanted NICE to include acupuncture as a treatment, you saw that reflected on the BMA – “British Medical Association” Article  published in 2000.  

    At the end of your article, I noticed that you claimed not having financial conflict of interest in this “anti-acupuncture” article. Are you serious? You run an “anti-acupuncture” website/blog, you also only get media exposure for been an “anti-complementary medicine” activist. How can you be so misleading to the public and get away with that? 

  • 36 David Colquhoun // Sep 15, 2014 at 10:12

    @AndrewMan

    I do not run an “anti-acupuncture web site”. I run an web site that attempts to explain evidence and to distinguish between truth and myth.  

    I pay the costs of the web site myself and accept no advertising, so it costs me money. So much for financial interests.

    You say “I cant imagine Doctors prescribing ANYTHING (for many years) while not getting sufficient results”.  That’s simply not true.  For many years, doctors prescribed “cough medicines” and “tonics” which we now know don’t work.  And for many years tonsillectomies were common, despite the fact that we now know they are useless.

    You seem to rely heavily on NICE recommendations. In the cases you mention, I have looked at the same evidence that they did, and have come to a different conclusion.  My credentials for assessing evidence are at least as good as those of the guidance groups in these particular cases. In fact a lot better.  The Pain Society said at the time 

    “The full GDG members panel of 13 individuals included two proponents of spinal manipulation/mobilisation (P Dixon and S Vogel). In addition, the chair of the panel (M Underwood) is the lead author of the UKBEAM trial on which the positive recommendation for manipulation/mobilisation seems to predominately rest”. 

    I don’t think there is much point in continuing this discussion until (1) you start discussing data rather that flinging abuse at me, (2) you declare your own interests and credentials. 


  • 37 AndrewMan // Sep 17, 2014 at 14:17

    Please dont get upset, always “remember” that you are giving a hard time to NICE/NHS and to all professionals that work with CAM. If you love criticising others, why cant you get criticism back?

    FIRSTLY: I have the “duty of care” of correcting an article that does not display NICE/NHS guidelines correctly (you have the right to disagree with the guideline, however please display the correct recommendations) 

    SECONDLY: I’m enriching your article with “inside” knowledge, as I have been working for the NHS for many years. My intentions are purely in inform the public with accurate and up-to-date information. (I’m not here to promote myself in anyway)

    THIRDLY: The medical acceptance, prescription and use of acupuncture in the NHS is larger than what you would imagine, and the large majority of acupuncture practitioners are Doctors and other medically qualified practitioners. For instance, there are over 4,000 physiotherapists that currently practice acupuncture in the NHS. (CSP – 2014)

    http://www.csp.org.uk/frontline/article/research-vindicates-acupuncture-say-physio-specialists

    You have a good science background is pharmacology, however medical/clinical recommendations are not set by an individual’s opinion, instead NICE/NHS uses (impartial) groups of professionals that will not only consider systemic reviews and consultations, but also “internal” clinical evidence from the NHS trusts that offer this service.

    PS. I think your website has some good points (and others “not-so-good” points), and I’m not completelly against your criticism. Remember, we can aways “agree to disagree”.

  • 38 David Colquhoun // Sep 18, 2014 at 07:32

    FIRST. I have written a lot about the guidelines. In my opinion, they got it wrong.

    SECOND.  I prefer evidence to anecdotes, and you assertions do not “enrich” my blog.

    THIRD.  There are something like 48,000 physiotherapists in the UK. The fact that less than 10 percent of them have been taken in by myths is less than impressive.

    As I have already pointed out, in the case of the low back pain guidance, the group was anything but impartial.  Neither did it have much expertise in the assessment of evidence.

    All you have done so far is to repeat assertions.  If you disagree with our interpretations of data in our paper, please say why.  It really does not help to keep asserting that I’m wrong.  You have to look at the evidence.

  • 39 AndrewMan // Sep 18, 2014 at 15:45

    I will agree to disagree that NICE got it wrong in 2009 and 2012 with regards to Lower Back Pain acupuncture recommendations; I will also agree to disagree that NICE got it wrong with the Migraine and Tension Type Head Ache acupuncture recommendations. Most of the Acupuncture treatments provided in the NHS are done by Medical Professionals using Western Medical Acupuncture.

    Professional Discussions can always help, for example: – You are correct in the number of Physiotherapists in UK its about 48,000. You are incorrect in stating that only 10% practice acupuncture. 4,000 practice in the NHS alone, bare in mind that band 3-4 assistant physiotherapist and band 5 physiotherapists (normally on rotation) are not allowed to practice acupuncture. Only Senior Physiotherapists are allowed to treat patients with acupuncture, if you think that band 7 and above are senior physiotherapists (managers) and will treating less patients  while busy with meetings.

    In 2011 CSP reported that more than 6,000 Physiotherapists are registered acupuncturists (bare in mind that physiotherapists need to be qualified with CSP course to be registered as an Physiotherapist Acupuncturist.) If you add all physiotherapists that decided to undertake a TCM acupuncture post graduation; and also add all physiotherapists that decided to undertake a “Western Medical Acupuncture Course”. This number will be much greater.

    Never found even one physiotherapist that is against acupuncture, inside or outside the NHS.

  • 40 David Colquhoun // Sep 18, 2014 at 20:33

    You “Never found even one physiotherapist that is against acupuncture”?  In that case you haven’t looked very hard.  I’ll ask some to contribute,

    It seems to me tragic that what should be an honourable job has been invaded by silly myths.  If you want physiotherapists to earn the respect of the rest of the world, what you should be doing is trying to find out which bits of physiotherapy work (the evidence base for real physiotherapy is pretty weak).  What you should not be doing is embracing quackery.  That will make physiotherapy the laughing stock of the medical world.

  • 41 AndrewMan // Sep 18, 2014 at 23:49

    I will have to agree to dissagree on that, bare in mind that Doctors, Nurses and other medicaly qualified professionals also use acupuncture, and their findings are different than what you wrote here.

    Look at this conclusion from an acupuncture survey published in the “British Medical Journey” – 11th January 2012.

    Conclusions
    From this survey, we estimate that almost 4 million acupuncture treatments were provided in the UK in 2009 by the practitioners of the major acupuncture associations. Approximately one-third of these treatments were provided within the NHS. The consultation rates were highest for musculoskeletal conditions, commonly back, shoulder, neck and knee pain, and neurological conditions, primarily headache and migraine. These findings are consistent with the current evidence base on clinical efficacy and cost-effectiveness of acupuncture.

    http://bmjopen.bmj.com/content/2/1/e000456.full 

  • 42 AndrewMan // Sep 19, 2014 at 00:40

    *BMJ “British Medical Journal”

  • 43 AndrewMan // Sep 19, 2014 at 00:41

    *BMJ British Medical Journal

  • 44 Megan // Sep 19, 2014 at 00:50

    Hi. I am a physiotherapist. I did a residential course in traditional acupuncture in Nanjing in 1988 and used this modality in practice for some years. I did a PhD and moved into academia teaching evidence-based practice and supervising higher degree research students. I now also teach basic critical thinking about health-related claims to first year health science students. Basic, as in recognising the myriad biases and fallacies that flesh (and research) is heir to.

    I have to agree with David that the accumulated evidence leads to a conclusion that any benefits of acupuncture are most likely due to non-specific treatment effects. It is probably a ‘theatrical placebo’.

  • 45 neoconnell // Sep 19, 2014 at 07:53

    Andrew,

    I am a physiotherapist. In truth I always expected that acupuncture could really be no more than a placebo and over the years a wealth of studies have emerged that confirm that position for me. On that basis I am a physiotherapist who is “against” acupuncture.  I have written as much a number of times (http://www.bodyinmind.org/?s=acupuncture )

    I suspect you are right that the number of physios performing acupuncture is higher than DC has estimated, though it will depend on the area in which they are working –  it will clearly be highest in musculoskeletal physio where, to my disappointment it has really taken off over recent years, being actively promoted by enthusiastic and organised advocates. Ultimately the number of physios who use or like acupuncture is irrelevant. It is an argument from popularity, but popularity is a poor marker of veracity.

    Physiotherapy is prone to these fads in treatment. Acupuncture has been a particularly large scale fad. I wonder if we are over the peak of this fad and starting the downwards curve. I hope so, though perhaps that just means a shift to other ill-conceived placebos such as brightly coloured stretchy tape. Or maybe there is room for more than one theatrical placebo on the block? Again, popularity is not the same as veracity.

    I personally know or have engaged with a whole host of physios who for the same reasons are “against” acupuncture. I am sure there is a selection bias but they do exist and in numbers. I hope they continue to make their evidence-based case actively.

    Best Wishes

    Neil O’Connell

  • 46 AndrewMan // Sep 20, 2014 at 23:05

    Thanks Megan and Neil. I’ve always wanted to meet – at least one physio that is against Acupuncture. I didn’t want to meet someone that is agaisnt TCM acupuncture, but against Acupuncture in a general term including: TCM Acupuncture, CSP approved evidence based – Physio Specific Acupuncture, and evidence based Western Medical Acupuncture. (I hope you both are agaisnt all types of acupuncture mentioned, and so my dream finally came true).

    Going back to a Survey described above, BMJ supported NICE/NHS reporting a survey that concluded that Acupuncture is been effective, consistent with the evidence based and also cost effective, since introduced in the NHS in 2009. 

    http://bmjopen.bmj.com/content/2/1/e000456.full&nbsp

    Whats your opinion on that? Is the “British Medical Journal” mistaken? OR, Is Acupuncture a “Legit” treatment option as described by NICE/NHS? OR Is “Acupuncture Theatrical Placebo” more effective than other conventional treatments, and so cost-effective?

  • 47 AndrewMan // Sep 20, 2014 at 23:33

    Full report: http://bmjopen.bmj.com/content/2/1/e000456.full

  • 48 Megan // Sep 23, 2014 at 07:10

    Hi Andrew, firstly I’m not against Acupuncture, I’m for the evidence. Always happy to re-evaluate my stance on the basis of evidence. I hope David will indulge this lengthy comment.

    The BMJ article (a survey of who is using acupuncture and
    for what) cites 4 reviews. I don’t want to write a treatise here, so to illustrate the process I would go through in looking at the evidence (and because I’m rather pressed to time at the moment), I’ll use one of the Cochrane reviews (Linde et al 2009 Acupuncture for tension-type headache) as an example. The authors concluded that acupuncture “could be a valuable…tool in patients with …chronic tension-type headaches”.   This bottom line is not exactly an enthusiastic endorsement, but let’s look at some of the reported meta-analyses.

    I don’t bother looking at comparisons with no treatment because I always assume there will be a difference due to there being no control for non-specific treatment effects.

    A look at the meta-analyses for acupuncture vs sham shows:

    For short term outcome ‘response’ (count of people with at least 50% in the number of headache days in 4 weeks) (4 studies) the RR was 1.24 (95%CI 1.02, 1.50). Although this doesn’t cross the line of no effect (1), a risk ratio of 1.24 is pretty small, and it might really be as tiny as 1.02 and no bigger than 1.50 (still a small benefit).  Without going to the trouble of calculating NNT I’d say that this is a case of statistical significance, but doubtful clinical worth.  The results for later time-points were similar (except for long term, which was not significant).

    Looking at the outcome number of headache days (3 studies), the mean difference for the short-term outcome was -1.56 (95%CI -3.02, -0.10).  So on average a benefit of 1.56 days in the acupuncture group, which might be as large as 3 days or as small as .1 of a day.  Later time-points had similar results.  Whether this is a clinically worthwhile benefit is a matter for argument about the benefit vs risks. But let’s keep looking at the other results. There are many other outcomes analysed: headache scores (no difference at short or medium term, significant but small difference at longer term). Analgesic use (sign but small difference at short- medium term, none in longer term). Headache intensity (no signif diff except at longer term, very small effect).

    So overall there are statistically significant differences for outcomes at some time-points, with not a consistent story (some show benefit in short-term but not longer, others are vice-versa).  The size of any significant differences are uniformly quite small and of debatable clinical importance.

    In summary, when looking at a meta-analysis (assuming low risk of bias in the studies) I look for the overall pattern – is there a consistent story in the evidence for most outcomes, and how big are the effects.  Even if there are small statistically significant differences I always consider whether these are big enough to make the treatment worthwhile. If there is risk of bias then I discount at least some of any observed difference between the groups as being due to bias in the method.  In this review they noted that the quality of the 11 included studies “varied significantly” with there being only 1 really god quality trial, but it was a small pilot study (n=10).

    So it’s not as simple as being ‘for’ or ‘against’ acupuncture, but rather evaluating the evidence and making a decision about practice. 

  • 49 David Colquhoun // Sep 23, 2014 at 07:42

    @Megan

    Of course I will indulge your lengthy comment.  You are doing what’s sensible, discussing the quality of the evidence.  I wish AndrewMan would do the same.

  • 50 David Colquhoun // Sep 24, 2014 at 21:44

    @AndrewMan

    Thanks for drawing my attention to the BMJ Open article.  That enabled me to leave a comment.  It was written by people who are as enthusiastic as you about the enormous benefits of being pierced with needles, so it’s hard to believe they are serious about science.

  • 51 AndrewMan // Sep 25, 2014 at 08:19

    TO MEGAN: Thanks for your comment, as you may well know the Cochrane reviews are great and they influence the decisions of NICE to approve or reject treatments for the NHS.

     Just clarifying a few things – BMJ article mentioned is actually a survey confirming the efficacy of the first years of the acupuncture treatment in the NHS from 2009 till 2011 (published in January 2012) At that time lower back pain was the only condition that NICE/NHS endorsed. My question: How a Cochrane review about “tension type head ache” answer my question, this condition was only included in the NICE guidelines in 2012 – after the survey was concluded? 

    (Bare in mind that the Cochrane review mentioned concluded that there is “some” evidence that Acupuncture can be used as an effective treatment for “tension type head ache” – and as you described – acupuncture reached the “efficacy value” necessary to conclude that) 

    To David (DC): did you just say that the “British Medical Journal” publishes articles written by people that are not serious about science? How did you conclude that? 

    A) The Cochrane reviews: found “some evidences” that acupuncture works for some conditions. 

    B) NICE Guidelines: concluded that Acupuncture is an effective treatment option for Lower Back Pain(2009 and 2012), Tension Type Head Aches(2012) and Migraines(2012). 

    C) The NHS has been using acupuncture since 2009 and published surveys that confirms the efficacy of Acupuncture (Its also been shown to be a “cost effective” method of treatment)

    D) The BMJ publishes surveys that confirms the Cochraine reviews, NICE and  NHS expectations on the efficacy and “cost effectiveness” of acupuncture treatment.

    I dont see any problem with Acupuncture been used with these guidelines.

  • 52 Megan // Sep 26, 2014 at 02:32

    *Hi Andrew.  I am in Australia and I’m not familiar with the NICE guidelines.  Recommendations in guidelines are consensus decisions made by the people in the guideline group, usually on some explicit criteria applied to the available evidence.  In science, there can be robust disagreement about how to interpret evidence.  In my last comment I demonstrated to you how I would go about evaluating evidence from a meta-analysis (the example I used was a Cochrane review on acupuncture for headache).  The survey published in BMJ is only about who is using acupuncture and for what.  A survey cannot tell us anything about treatment efficacy.  In evaluating the evidence for efficacy for any modality, there are a range of factors to consider, including the quality of the evidence, the completeness of the evidence, the precision of the estimates of the meta-analysis, and the clinical importance of any statistically significant results.  The treatment estimates/effects are also quite specific in terms of comparison, outcome and timeframe.

    I understand that if you are not a researcher yourself it can be quite confusing that people like David and myself (among others) can disagree with recommendations made by organisations such as NICE.  But that is the great thing about science, and how we move healthcare forward over time.  

    I am about to go on extended leave so I won’t be able to continue this interesting discussion any further. If you want to develop your own skills in evaluating evidence, I can recommend the education resources at the Centre for Evidence Based Medicine.

     

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