Respectful Insolence

Several months ago, I wrote a post about the experimentation with acupuncture by an Air Force physician, Col. Robert Niemtzow. In the post, I started with an admittedly exaggerated vignette–a story, if you will–of a soldier whose leg was shredded by a mortar in battle. When the medic came to treat his wounds and get him ready for transport, this soldier was in for a surprise, because after applying a tourniquet to his leg, this medic offered him not morphine for his pain but acupuncture. At the time, the military acupuncture program spearheaded by Col. Niemtzow was not proposing anything like the incident I fictionalized. Indeed, I was intentionally exaggerating to make a point. It was nothing more than creative license. (I know, I know, calling anything “creative” on this blog is a bit of a stretch, but stay with me for the moment.)

Now I’m not so sure if what I was writing was creative license or uncanny prediction. In fact, I’m beginning to wonder if maybe I should take James’ Randi’s $1,000,000 challenge before he folds it, because my prediction is starting to sound almost prescient.

But first, here’s a little recap of the background of acupuncture in the military. It’s actually a relatively recent phenomenon. The first thing you need to know is that the infiltration of infiltration of acupuncture into the normally hard-nosed military is directly attributable almost entirely to one man, the aforementioned Col. Niemtzow. Indeed, less than three years ago, the use of acupuncture in the military was very uncommon, so much so that Col. Niemtzow lamented in an interview that he was the only acupuncturist around and had to cover Andrews Air Force Base, the Pentagon and Walter Reed Army Medical Center. (In retrospect, those look like the good old days to me.) In the article on Military.com from earlier this year, it’s clear that between 2006 and early 2008, the acupuncture program had expanded considerably. Clearly, acupuncture, thanks to Col. Niemtzow’s proselytizing, has now established a significant foothold in military medicine.

Another thing that I noted at the time is that there was no mention of science or well-designed clinical trials to test whether “battlefield acupuncture” does anything at all for chronic pain syndromes observed in military medical facilities. At the time, all I could find was a slew of articles in that repository of pseudoscience and woo, the Journal of Alternative and Complementary Medicine. There was one article in Military Medicine and one in JACM, the latter of which, as I noted at the time, was a photo essay. The article in Military Medicine was indeed a pilot study, but when I looked at it using even the usually comparatively weak standards applied to pilot studies, I remained unimpressed. The study was completely unblinded, and no sham acupuncture was used for the control group. Certainly there was no control using the preferred placebo control for rigorous studies of acupuncture, namely retractable needles that look like real acupuncture needles but do not penetrate the skin. Even less impressive to me, given the shortcomings of such a pilot study that are almost guaranteed to lead to bias, the results were still not particularly impressive in terms of raw numbers and results. Although the acupuncture group was reported to decrease by 23% initially and the conventional therapy group reported no pain relief at all, within 24 hours there was no difference between the two groups. Even using the usually lax standards to which “CAM” studies “aspire,” these results here were not striking.

I wondered at the time: This is all that Col. Niemtzow is basing his assessments of the “success” of acupuncture in phantom limb pain syndromes and various other chronic pain conditions resulting from combat injuries on? This is all that he’s using as the basis for testing his woo on our brave men and women in the military? This is the evidence on which he’s basing his advocacy of acupuncture in military hospitals and even in combat zones? It’s mighty thin gruel indeed. But apparently it’s enough for Col. Niemtzow. Now, let’s fast forward to last week, when a story appeared that makes my prediction start to look not quite so crazy anymore. It would appear that Col. Niemtzow is about to get his wish. The Air Force announced a program to train physicians in battlefield acupuncture before they are deployed to Iraq:

ANDREWS AIR FORCE BASE – Using ancient Chinese medical techniques, a small team of military doctors here has begun treating wounded troops suffering from severe or chronic pain with acupuncture.

The technique is proving so successful that the Air Force will begin teaching “battlefield acupuncture” early next year to physicians deploying to Iraq and Afghanistan, senior officials will announce tomorrow.

The initiative marks the first high-level endorsement of acupuncture by the traditionally conservative military medical community, officials said.

Using tiny needles that barely penetrate the skin of a patient’s ear, Air Force doctors here say they can interrupt pain signals going to the brain.

Their experience over several years indicates the technique developed by Col. Richard Niemtzow, an Air Force physician, can relieve even unbearable pain for days at a time.

That enables badly wounded patients who arrive here by medevac aircraft to begin to emerge from the daze of pain-killer drugs administered by surgeons in the field.

“This is one of the fastest pain attenuators in existence – the pain can be gone in five minutes,” said Niemtzow, a physician, acupuncturist and senior adviser to the Air Force surgeon general.

Ugh. I’m getting a headache. Maybe I should get some acupuncture for it. Oh, wait. Acupuncture doesn’t work for headache.

How on earth would Col. Niemtzow even know that his test has been a success anyway? On what basis does he make such dramatic statements about acupuncture? Inquiring minds want to know, and mine is an inquiring mind! So over the weekend I redid my searches of PubMed to see if perhaps he had published something new since my last inquiring brain fart on the subject. He hasn’t. His most recent publication in a peer-reviewed journal remains the aforementioned pilot study in Military Medicine. Next, I did another PubMed search for “battlefield acupuncture” again. Nothing. Nada. Zip. A search for “acupuncture AND Air Force.” Ditto. No, there’s nothing new here that I can find that would be compelling enough to justify investing in training physicians and medics in acupuncture techniques before they are deployed to Iraq.

I think the key to understand where Co. Niemtzow and his disciples in the Air Force are coming from is the phrase “their experience over several years.” (Emphasis mine.) In other words, Col. Niemtzow is relying on anecdotal experience to come to the conclusion that his “auricular acupuncture” works–and little, if anything, else. At least, it certainly appears that way to me. I’m always open to being shown scientifically rigorous data about the efficacy of this program, but, quite honestly, I have yet to see anything. Indeed, I haven’t been able to find anything, and I have looked. All I could find besides his unimpressive studies on PubMed, the most recent of which is two years old is Col. Niemtzow’s CV, which lists two publications “in preparation” entitled Rapid Electroacupuncture Technique for the Treatment of Peripheral Neuropathies Induced by Cancer Chemotherapy and Xerostomia Secondary to Radiation and its Treatment Employing Acupuncture: Mechanisms of Actions, but that’s about it. There’s nothing more there about the use of battlefield acupuncture, at least in terms of peer-reviewed articles. Certainly there are no well-designed, randomized clinical trials listed that I could find.

Still looking for evidence, I checked out Col. Niemtzow’s website, and it became clear to me he is a true believer. For example, Col. Niemtzow asserts, without presenting any convincing scientific or clinical trial evidence, that acupuncture can be used to treat macular degeneration, xerostomia, and obesity. I don’t see listed even a single high quality study that supports any of these assertions. I wish I did, but I don’t. Perhaps someone can point me in the right direction. Worse, he spouts the same nonsense about “ancient knowledge” about acupuncture that Harriet Hall (a.k.a. The SkepDoc) demolished a few weeks ago:

“We use acupuncture as an adjunct” to traditional therapy, said Niemtzow. “The Chinese have used it for 5,000 years. It works, and it’s powerful.”

The procedure developed by Niemtzow is a variation of traditional Chinese acupuncture in which long, hair-thin needles are inserted into the body at any of hundreds of points to ease pain.

Niemtzow’s variation uses one or more needles inserted into any of five points on the ear. The needles, which penetrate about a millimeter (or 4/100ths of an inch) into the skin, fall out after several days. The procedure can be repeated.

The ear acts as a “monitor” of signals passing from body sensors to the brain, he said. Those signals can be intercepted and manipulated to stop pain or for other purposes.

Even 18th-century pirates were convinced of the value, piercing their lobes with earrings “to improve their night vision,” Niemtzow said with a grin.

That last comment caused me more serious head pain, a.k.a. cephalalgia, a.k.a. headache. I hope Niemtzow was joking when he made the crack about the pirates, because the only reason I withheld one of my characteristic variations on my favorite blogging catchphrase (“the stupid, it burns,” abbreviated TSIB) is out of what may be a misguided desire to tone down my usual not-so-Respectful Insolence in this instance. (Actually, the real reason is that I’m running out of clever variations on this catchphrase and am giving it a rest for a while until new inspiration strikes.) Also note the extreme scientific implausibility. This “ear acupuncture” is based on a physiological principle that makes every bit as much sense as reflexology, and I mean that in the worst way possible. In any case, our seriously wounded veterans are what the Common Rule would refer to as a “vulnerable” population. They’ve suffered grievous injury and are in a system in which they are accustomed to following orders. If a military physician tells them to try acupuncture, they’re not likely to argue. If a military physician approaches them with a clear attitude that he or she believes acupuncture works, they’re not likely to express skepticism. Indeed, if a military physician approaches a soldier to recommend “alternative” therapies, I have to wonder if the hierarchical structure of the military and the soldier’s ingrained training and duty to follow orders might actually enhance the placebo effect.

In any case, there is clearly a movement to take battlefield acupuncture to the next level: the actual battlefield. Indeed, Army Rangers are considering using it:

Battlefield acupuncture caught the eye of U.S. Army Rangers, who often operate in remote locations. At their invitation, Niemtzow and his team trained some Rangers last summer.

Meanwhile, military acupuncturists pat themselves on the back for their enlightenment in the face of skepticism:

Nonetheless, advocates of the practice recognize that they must overcome skepticism within the ranks of military doctors.

“Oh, sure, some haven’t gotten the word,” said Burns, the clinic chief. “We are very much ahead of the curve.”

Hello, Galileo gambit! Goodbye, science and reason!

Our wounded soldiers, indeed all our soldiers, deserve only the finest in science- and evidence-based medicine that can be delivered to them, be it on the battlefield, the mobile hospital, or military hospitals overseas or in the U.S. Unfortunately, as I’ve documented for academia, there appears to be a major push by its advocates to introduce so-called “complementary and alternative medicine” (CAM) into military medicine. For example, earlier this year, initiatives were reported to use yoga, “Samurai meditation,” and even reiki and other “energy treatments” to treat PTSD. In October, it was reported that the military is testing out more and more “alternative” therapies:

WASHINGTON — The Pentagon is seeking new ways to treat troops suffering from combat stress or brain damage by researching such alternative methods as acupuncture, meditation, yoga and the use of animals as therapy, military officials said.

“This new theme is a big departure for our cautious culture,” Dr. S. Ward Casscells, the Pentagon’s assistant secretary for health affairs, told USA TODAY.

Casscells said he pushed hard for the new research, because “we are struggling with” post-traumatic stress disorder (PTSD) “as we are with suicide and we are increasingly willing to take a hard look at even soft therapies.”

So far this year, the Pentagon is spending $5 million to study the therapies. In the previous two years, the Pentagon had not spent any money on similar research, records show.

The image we have of the military is that it’s made up of a bunch of hard-nosed realists who don’t tolerate nonsense. They are, after all, in the business of defending this nation, using deadly force and highly destructive weapons to achieve this aim if necessary. One tends to picture them as not being prone to this sort of idiocy, but they can be.

Wartime has always been a time of intense experimentation and often dramatic innovation. For example, during the Napoleonic Wars, the concept of triaging casualties according to severity of injury instead of rank. During World War II, medics were integrated into individual units, and plasma, blood, and morphine became widely available in the battlefield, along with the rapid introduction of penicillin and other antibiotics. By the end of World War II, MASH units were introduced and became common during the Korean War. During the Vietnam conflict, there were also numerous innovations in the treatment of the wounded, most prominent of which was a Medevac system that could fly the wounded out of the war zone in under two hours. These advances have continued during the current conflict. Particularly impressive is a system by which casualties can be evacuated from the battlefield to nearby mobile hospital bases, stabilized (and operated on emergently if that is necessary to stabilize them), and then evacuated to regional hospitals in nearby countries or even all the way to Europe or elsewhere within 12-24 hours of being wounded. Facilitiating this evacuation are C5 cargo planes turned into flying hospitals, complete with intensive care unit capability. If there’s one thing that we’ve learned during the last six years of war, it’s that getting casualties to definitive treatment faster does indeed save lives that would otherwise be lost. By the end of 2004, the military medical system had achieved an unprecedented 90% survival rate for wounded soldiers. However, there is a dark side to the culture of experimentation that war or external threats spawn in the military. After all, the military has been known to dabble in other woo, such as the study of psychics, UFOs, dowsers, and other paranormal phenomena during hot wars or, famously, during the Cold War.

Whatever the cause, however, the virus is spreading. Acupuncture, yoga, and other “soft” CAM modalities are just the foot in the door. They allow woo to creeps in, as they have done in academic medicine. How long will it be before we see homeopathy being used in military and VA hospitals? How long will it be before my little story above is no longer a fanciful exaggeration? I don’t know, but I fear the worst. I truly hope I’m just being alarmist, because our soldiers deserve much better. They deserve science- and evidence-based medicine and surgery.

Comments

  1. #1 Christophe Thill
    December 15, 2008

    To treat phantom limb pain by acupuncture, don’t you need to insert needles into the phantom limb?

  2. #2 xyzzy
    December 15, 2008

    A couple of years ago I dislocated my ankle in a cycling accident. Although I was less than a mile from a major hospital, I was on an inaccessible canal tow-path and it took a couple of hours to recover me, and by the time I arrived the blood supply to my foot was compromised and I was, with hindsight, beginning to get hypothermic. I’d declined morphine during the recovery, because I wasn’t in too much pain and I wanted to be able to make sure I understood any choices that needed to be made.

    My local NHS hospital is now the main hospital for the UK armed forces, and some shifts are handled by the military as part of the deal. I ended up being treated by the head of trauma medicine for the Army, author of several books on the topic, who — in best military tradition — did his own diagnosis, anaesthesia, reduction and plastering. I was given 0.5mg/kg of ketamine after a lecture delivered to the student doctors in attendance about how the military does analgesia right and the NHS just doesn’t get it.

    NHS protocol would either have reduced my ankle with the help of morphine or entinox (painful, wouldn’t give such good results) or given me a GA (risky, protracted, risks damage because longer loss of blood supply). Woo tossers would have given me accupuncture and messed about. Instead, a top trauma man (http://news.bbc.co.uk/1/hi/uk/7055491.stm) did the right stuff, quickly, which had me walking without crutches within a few weeks.

    Military medicine in my experience is top people doing top work. By sheer co-incidence I bumped into his wife recently and tried to communicate my admiration for the work his people do.

  3. #3 jake
    December 15, 2008

    I would think that the battlefield would be the best place to test, and consequently prove (at the patients level) that acupuncture does not work. I mean, there must be a world of difference between sticking pins in your head to the soothing sounds of rainforest birds, the smell of incense, and a well lit room and sticking pins in your head when you are in a helicopter or field tent suffering from shell shock from moments ago with gunfire outside.

    Meditation and animals sound nice though, who doesn’t smile at the sight of a miniature pony on a leash?

  4. #4 K
    December 15, 2008

    Ugh, this article has been hitting the ladyblogs today:

    http://www.telegraph.co.uk/health/healthnews/3758983/Schoolgirl-12-paralysed-after-receiving-cervical-cancer-jab.html

    If you write a scathing takedown, I can send it out to all my hysterical twenty-something friends. I hate news fearmongering.

  5. #5 The Perky Skeptic
    December 15, 2008

    This post made me fall in love with this blog all over again! Also, it made my head hurt from the horrible woo. Funny how those two things go hand in hand! :D

  6. #6 Mu
    December 15, 2008

    This program can be used to greatly enhance the “team” feeling in the military! Soldiers always liked to get tattoos to show their “bond”, so now every member of the military gets a set of “acupuncture points” tattooed in the correct spots. This will allow every member to give immediate relieve to any injured comrade, and all with a pouch of sterile, non-perishable needles.
    The only thing that surprises me is that the Chinese, with 3000 years of documented warfare, never had that brilliant thought.

  7. #7 Mike
    December 15, 2008

    I think you hit the nail on the head as to why that doctor’s claiming accupuncture “works”, even anecdotaly, in the military setting.

    “Soldier we are going to treat you with accupuncture.”
    “Yessir”
    “You aren’t feeling any pain are you now, soldier?”
    “Nosir.”

    The placebo effect is powerful, and I can’t imagine it wouldn’t be a lot more powerful when someone you’re trained to take orders from tells you it will work.

  8. #8 Mojo
    December 15, 2008

    Makes a change from wire brush and Dettol, I suppose.

  9. #9 Josh in California
    December 15, 2008

    Alternative “medicine” is a hell of a lot cheaper than real treatment. The pentagon and politicians have demostrated many times in recent years that they don’t give a rat’s ass about the rank and file. If they can get away with treating real problems with cheap fake medicine, I’m sure they’ll do it.

  10. #10 D. C. Sessions
    December 15, 2008

    If it’s good enough for the rank and file on the front lines, it’s got to be better yet for the Joint Chiefs when they have their surgeries for the middle-aged, right?

  11. #11 Dangerous Bacon
    December 15, 2008

    “We use acupuncture as an adjunct” to traditional therapy, said Niemtzow. “The Chinese have used it for 5,000 years.”

    The Chinese have also bits of their dead relatives for thousands of years for therapeutic purposes (there’ve been recent reports that this “tradition” has not entirely died out). Maybe this time-honored remedy can be part of the next U.S. military health initiative.

  12. #12 Dangerous Bacon
    December 15, 2008

    That should be “The Chinese have also _eaten_ bits of their dead relatives” for thousands of years for therapeutic purposes.”

  13. #13 Cath the Canberra Cook
    December 15, 2008

    While I agree with you about the acupuncture, there’s nothing wrong with yoga and meditation for stress-related disorders. Gentle physical exercise, while deliberately slowing down and focussing on one’s breathing? Or the same thing without the exercise?

    This is a part of the standard clinical psychologist’s repertoire. It’s very useful for people who have panic attacks, anxiety disorders and/or depression. If your brain is going haywire with panic, then training it to slow down and be calm is pretty sensible. Generally the clinical psych people recommend meditation in conjunction with cognitive therapy, exercise, and medication, a multi-pronged approach. I’d be happy for the soldiers to be receiving today’s best practice in psych.

    Meditation affects brain function. You can see it on an EEG. It’s rapidly leaving the altie zone for incorporation into real medicine, because it works. The term you’d need for a literature search is “mindfulness”. http://scholar.google.com.au/scholar?q=mindfulness
    Or if you prefer pubmed, try “mindfulness meditation” for better search results.

  14. #14 D. C. Sessions
    December 15, 2008

    While I agree with you about the acupuncture, there’s nothing wrong with yoga and meditation for stress-related disorders. Gentle physical exercise, while deliberately slowing down and focussing on one’s breathing? Or the same thing without the exercise?

    What Cath wrote.

    Especially useful while trying to get a patient to calm down enough to get a worthwhile HX out of hir or enough to do a worthwhile field assessment prior to pack and ship.

    – says /me, watching the snow fall with mixed emotions. I’m not cleared to ski for another two months minimum, but the start of the season is always good.

  15. #15 DLC
    December 15, 2008

    This guy Niemtzow, he’s a doctor ?
    I mean, he’s actually been trained in medicine ?
    or is he just some kook who somehow managed to get to
    the rank of Lt. Colonel ?
    “The Chinese have used it for 5000 years.”
    Well, gee. Doctors in “The West” practiced using bleeding to balance the humors for quite a while, and yet that practice has somehow diminished in recent times.

  16. #16 Tsu Dho Nimh
    December 15, 2008

    That whirring sound you hear is my father, a Navy medic with the Marines during WWII, spinning in his grave.

  17. #17 inkadu
    December 16, 2008

    It’s stuff like this that really points to an amazingly annoying historical perspective. For as long as man has been man, he has experienced pain. Yet somehow only the Chinese figured out the solution. And unlike useful inventions like gunpowder and the printing press, accupuncture has not been put to popular use around the world. It kind of strains credibility. You’d have to think people really don’t like sharing useful information.

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