Respectful Insolence

Ten months ago, I thought I was joking. I really did.

Regular readers may (or may not) remember back in March, when, in one of my usual flights of fancy, I decided that I could write a short fictional interlude, a combat scene. True, I didn’t do it because I wanted actually to write a fictional story (although I have always wondered if I could write decent short stories or a novel if I put my mind to it). Rather, I did it to make a point, and argument, a reductio ad absurdum, if you will, of a program in the Air Force to bring “battlefield acupuncture” to the our fighting men and women in the military. You see, I was rather perturbed. The reason was simple: I happen to believe that the men and women who put their lives on the line for this nation deserve nothing but the best science- and evidence-based medicine. Unfortunately, that’s not what I perceived “battlefield acupunture” to be. So I made up a story of a wounded soldier in Iraq who, after having been seriously wounded, was most disturbed to see a medic bringing him, not the morphine he needed to control his pain, but Colonel Robert Niemtzow‘s special brand of woo, his “battlefield acupuncture, which is in reality acupuncture lite in that it only involves sticking really tiny needles into the earlobe. Heck, this wasn’t even “real” acupuncture! Worse, the studies upon which he based his acupuncture program included a pilot study that was completely unblinded and didn’t use any control at all and a photoessay. Even by the standards of acupuncture studies, these were thin gruel indeed.

Months went by and I didn’t hear anything about Col. Niemtzow or his special brand of woo again. Then in December, right before the holidays, Col. Niemtzow resurfaced. Boy, did he ever resurface with a vengeance! This time around, he was again pushing his “battlefield acupuncture,” but he had also published a new study that purported to show the great efficacy of his technique. Unfortunately, its design was no better than Col. Niemtzow’s previous study–and arguably even worse. Again, there was no real blinding, no real control group. As a clinical trial, it was about as lame as lame can be. Then, shortly thereafter, I found out that he was going to take his woo to a whole new level.

Now the nation is learning just how high Col. Niemtzow’s willing to take his “battlefield acupuncture.” I’m just not sure whether I mean “high” as in height or “high” as in…well, high. See what I mean:

WASHINGTON – Chief Warrant Officer James Brad Smith broke five ribs, punctured a lung and shattered bones in his hand and thigh after falling more than 20 feet from a Black Hawk helicopter in Baghdad last month.

While he was recovering at Walter Reed Army Medical Center in Washington, his doctor suggested he add acupuncture to his treatment to help with the pain.

On a recent morning, Col. Richard Niemtzow, an Air Force physician, carefully pushed a short needle into part of Smith’s outer ear. The soldier flinched, saying it felt like he “got clipped by something.” By the time three more of the tiny, gold alloy needles were arranged around the ear, though, the pain from his injuries began to ease.

“My ribs feel numb now and I feel it a little less in my hand,” Smith said, raising his injured arm. “The pain isn’t as sharp. It’s maybe 50 percent better.”

Acupuncture involves placing very thin needles at specific points on the body to try to control pain and reduce stress. There are only theories about how, why and even whether it might work.

Regardless, the ancient Chinese practice has been gradually catching on as a pain treatment for troops who come home wounded.

Now the Air Force, which runs the military’s only acupuncture clinic, is training doctors to take acupuncture to the war zones of Iraq and Afghanistan. A pilot program starting in March will prepare 44 Air Force, Navy and Army doctors to use acupuncture as part of emergency care in combat and in frontline hospitals, not just on bases back home.

They will learn “battlefield acupuncture,” a method Niemtzow developed in 2001 that’s derived from traditional ear acupuncture but uses the short needles to better fit under combat helmets so soldiers can continue their missions with the needles inserted to relieve pain. The needles are applied to five points on the outer ear. Niemtzow says most of his patients say their pain decreases within minutes.

Here we go again. Once again, the plural of “anecdote” is not “data,” and all that’s been presented in favor of “battlefield acupuncture” is in essence a collection of antidotes. Col. Niemtzow has yet to produce anything resembling a scientifically acceptable clinical trial with appropriate control groups and appropriate blinding of either the patients or the practitioners. All he’s ever produced to support “battlefield acupuncture” are two transparently bad studies that don’t support anything except for the wonders of the placebo effect. Morever, as I (and others) have pointed out before, the military is a very hierarchical system, which makes me wonder whether having a superior officer clearly believe that acupuncture will help enhances the placebo effect in enlisted men undergoing acupuncture. This is not an unreasonable speculation, given that the military trains its members to follow orders without question and that that trained deference to and faith in an authority figure might heighten the expectation of benefit.

Not that any of this stops Col. Niemtzow and his acolytes. Indeed, it’s very depressing to see hard-nosed military men fall for the woo-iest of woo:

Niemtzow and his colleague Col. Stephen Burns administer about a dozen forms of acupuncture _ including one type that uses lasers _ to soldiers and their families every week.

Col. Arnyce Pock, medical director for the Air Force Medical Corps, said acupuncture comes without the side effects that are common after taking traditional painkillers. Acupuncture also quickly treats pain.

“It allows troops to reduce the number of narcotics they take for pain, and have a better assessment of any underlying brain injury they may have,” Pock said. “When they’re on narcotics, you can’t do that because they’re feeling the effects of the drugs.”

Niemtzow cautions that while acupuncture can be effective, it’s not a cure-all.

“In some instances it doesn’t work,” he said. “But it can be another tool in one’s toolbox to be used in addition to painkillers to reduce the level of pain even further.”

Smith says the throbbing pain in his leg didn’t change with acupuncture treatment but that the pain levels in his arm and ribs were the lowest they’ve been since he was injured. He also said that he didn’t feel groggy afterward, a side-effect he usually experiences from the low-level morphine he takes.

In other words, acupuncture “works,” except when it doesn’t.

I can’t emphasize enough just how thin the evidence upon which “battlefield acupuncture” rests is. We have Drs. Niemtzow and Burns’ anecdotes, of course. We also have two uncontrolled, unblinded studies that seem almost custom designed to produce a seemingly “positive” result. No, check that. There’s no “almost” about it. Col. Niemtzow could have done a scientifically rigorous study to test whether his “earlobe acupuncture” that he now plans to take to our combat troops in Iraq and Afghanistan. In fact, his ambition to bring woo into combat knows no bounds:

Ultimately, Niemtzow would like troops to learn acupuncture so they can treat each other while out on missions. For now, the Air Force program is limited to training physicians.

He says it’s “remarkable” for the military, a “conservative institution,” to incorporate acupuncture.

“The history of military medicine is rich in development,” he said, “and a lot of people say that if the military is using it, then it must be good for the civilian world.”

That’s exactly what I’m afraid of and exactly what Col. Niemtzow is counting on. The military is viewed by the vast majority of Americans as a hard-nosed, no-nonsense sort of institution. That’s why it’s probably true that, if the military is using it, civilians will likely believe it’s effective. Indeed, I’m sure that that’s exactly what advocates of acupuncture are counting on.

Unfortunately, the military is not as hard-nosed as is generally believed. I wish it were, but it’s not. If you don’t believe me, check out The Men Who Stare At Goats by Jon Ronson. If anything, Ronson’s book shows that there’s no woo like military woo, as he demonstrates as he describes a secret wing of the U.S. military called First Earth Battalion, which was created in 1979 with the purpose of creating “Warrior Monks,” soldiers capable of walking through walls, becoming invisible, reading minds and even killing a goat simply by staring at it. Some of the characters involved seem well-meaning enough, such as the hapless General Stubblebine, who is “confounded by his continual failure to walk through his wall.” General Stubblebine, as readers of this blog might recall, later remade himself into a warrior for “health freedom,” better known as the freedom of quacks to do whatever they want without any government interference.

I’ll say it before, and I’ll say it again–as many times as I have to. Our men and women serving out country in the military bear enormous burdens and suffer incredible hardships in the defense of this country. They willingly place themselves in harm’s way in the service of you and me through our government. When they are wounded, they do not deserve quackery. They do not deserve woo. They deserve only the very best science- and evidence-based medicine to treat their injuries. Unfortunately, ideologues like Col. Niemtzow have hijacked the military’s desire to do whatever it can to help wounded soldiers and used it to infiltrate the military with their ideology and pseudoscience. That they have succeeded based on essentially no scientifically valid studies is a disgrace. Our wounded soldiers deserve better. Every man and woman serving their country deserve better. They deserve science- and evidence-based medicine, not quackery.

Comments

  1. #1 D. C. Sessions
    February 3, 2009

    s/collection of antidotes/collection of anecdotes/

  2. #2 Christophe Thill
    February 3, 2009

    “There are only theories about how, why and even whether it might work.”

    Might be useful to remind people that, no, fancy ideas built on thin air and ancient philosophies are not “theories”. Not in any scientific sense, at least.

  3. #3 Michael
    February 3, 2009

    I manage a small affordable community style acupuncture clinic here in Manhattan and since we treat at a low price (around $20) we a few veterans with varying degrees of muscle spasm (mainly from heavy lifting) and decreased joint motion due to surgery and honestly I think we have a high success rate. We don’t guarantee anything it is nice to see people walking away with an increased range of motion in their shoulder then they had with surgery and PT alone. Its not like no one has been studying this. Do you also refute the WHO’s study as well… you can find it at http://www.who.int/medicinedocs/en/d/Js4926e/#Js4926e.

    Also as someone with severe psoriasis I can tell you that your very best science- and evidence- based medicine “works,” except when it doesn’t which in my case was every time with several doctors. This is why I turned to acupuncture in the first place.

  4. #4 Mu
    February 3, 2009

    I was going to make another joke about this, but I’m afraid the good colonel will actually add the Siberian tiger gall bladder to his treatment protocol.

  5. #5 NJ
    February 3, 2009

    {Ahnuld voice}

    I’ve got your ‘battlefield acupuncture’ right here!
    (SFX: Automatic weapon)

    {/Ahnuld voice}

  6. #6 Becca Stareyes
    February 3, 2009

    Michael, you may want to click on Orac’s ‘Alternative Medicine’ tag at the top. About five articles down, there is this post, which pretty much shows that Orac is quite familiar with acupuncture studies and has noticed that when controlled studies which compare acupuncture with fake acupuncture as well as nothing are preformed, there’s no difference if the acupuncture is performed incorrectly or even if anything penetrates the skin.

    At least the standards for science-based/evidence-based medicine is that ‘is probably doing something beyond the placebo effect’, as opposed to ‘better than nothing, even if it’s just a placebo from getting an expert’s attention’. No one can guarantee 100% effectiveness, though a few things are pretty close.

  7. #7 Alan Henness (zeno)
    February 3, 2009

    Michael

    I’ll see your WHO report and I’ll raise you a Cochrane systematic review: http://www.bmj.com/cgi/content/full/338/jan27_2/a3115:

    Conclusions
    A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.

  8. #8 Alan Henness (zeno)
    February 3, 2009

    The BMJ URL above has a superfluous semicolon at the end. The URL should be:

    http://www.bmj.com/cgi/content/full/338/jan27_2/a3115

  9. #9 Marcus Ranum
    February 3, 2009

    “gold alloy”??? Wooo hooooo!!

    I was curious about inacupuncture so I bought a box of needles on Ebay ($6 for 100!) and stuck a few into the muscles of my upper arm. It’s interesting – by spinning them you can “drill” quite deep with virtually no pain; I assume it’s because we tend to avoid drilling right into a nerve. The needles are very very very thin and don’t leave any mark beyond a tiny little red dot that fades in about an hour. My girlfriend was horrified by watching me drill a needle 1/2″ deep in my arm, and immediately tried it herself, with similar results. We were both surprised by the lack of sensation but, after we thought about it a bit, it made sense. And my penis grew an extra 4″, which I thought was nice.

    OK, the part about my penis wasn’t true. But the rest was.

  10. #10 John H (Militaris Inasnum)
    February 3, 2009

    Followed the link to Stubblebines website.

    A veritable vipers nest of woo – with jabbophobia scoring highly. (You can download a jabbophobe charter for $39.95 – forty dollars for a .pdf FFS).

    I thought the “Men Who Stared at Goats” was a joke, a fiction of Ronson’s imagination and that Stubblebine was a made up character. It would appear almost impossible to underestimate quackery and woo and the morons who peddle it.

  11. #11 Marcus Ranum
    February 3, 2009

    As I’ve pointed out before, here, acupuncture has had thousands of years to prove its effectiveness, according to the claims of its proponents.

    I’m surprised that we haven’t observed life-spans in China to be significantly higher than in the rest of the world during those thousands of years. That would be consistent with acupuncture not actually doing anything. In fact, if you look at lifespans worldwide, we’ve only seen them go above 35 years since Pasteur, specifically, and science-based medicine in general. The numbers speak for themselves.

    Acupuncture: 2,000 years of fail.

  12. #12 PalMD
    February 3, 2009

    “In some instances it doesn’t work,”

    Morphine always works, is cheap, portable, and if a little doesn’t do it, a little more will.

  13. #14 Mac
    February 3, 2009

    Orac, Thank you for raising greater attention to this travesty of medicine.

  14. #15 Dangerous Bacon
    February 3, 2009

    Re acupuncture for pain relief: there’s an article in the new issue of the Journal of the American Medical Association. It summarizes the recommendations of the American Academy of Orthopedic Surgeons on nonsurgical interventions for osteoarthritis of the knee. On the approved list are such things as weight loss and aerobic exercise. Not recommended: acupuncture, due to lack of sufficient evidence of efficacy.

    Maybe people with dicey knees will want to volunteer for battlefield duty, to get in on the really effective acupuncture that Doc Niemtzow is using.

    I’m not so sure that military endorsement of acupuncture will be viewed as a victory by the woo-ists. They’ll suspect Big Brother is infiltrating their ranks (remember, Gen. Stubblebine and his goofy “health freedom” movement are bitterly opposed by other “health freedom” nutters on the grounds that he must be some kind of secret agitator for Big Gummint.

  15. #16 Bob O'H
    February 3, 2009

    Worse, the studies upon which he based his acupuncture program included a pilot study that was completely unblinded…

    Well, you wouldn’t want a blind pilot in the army, would you?

  16. #17 AnthonyK
    February 3, 2009

    Surely acupuncture, if it’s effective, should entirely remove pain? I mean a 50% reduction is within what might be expected by distraction/imaging or some such technique to modify the sensation.
    On a different topic (but still involving needles and pain) is it true as I’ve heard that heroin, or diamorphine, is not available clinically in the US to treat pain, despite being the best painkiller on the planet? If so, it seems daft that this supremely useful drug is only available illegally and for self-medication by losers.

  17. #18 Karl Withakay
    February 3, 2009

    Michael , did you actually read the WHO report?

    It is not a scientific work, it is a report (NOT a meta-analysis) of selected existing study reports. Given that it goes into absolutely no details regarding the quality or details of the methodology of any of the trials it reports on, it can considered of slightly more value than an anthology of anecdotes.

    It is written from the perspective of credulity, presupposition, and a complete and utter lack of objectivity.

  18. #19 DLC
    February 3, 2009

    Why is it needle woo guys always go for the ears ?
    Seriously. . . we had a dentist slapping staples into patients ears back in the 80s, claiming it worked to remove pain. Then we had people with magnets to clamp to your earlobe to stop smoking/lose weight/throw your money out the window, and now we have this guy with his little gold-alloy needles ?

  19. #20 Ahistoricality
    February 3, 2009

    I’ve always thought that the slight analgesic effect of acupuncture could be pretty easily explained by the body’s normal pain response. My body reacts quite predictably when someone pokes me painfully with a needle: a slight rush of adrenaline, decreased sensitivity to pain generally, and a focus of attention on the new locus of pain rather than the old ones.

    You could get even better results with bigger needles, and great results if you actually amputate….

  20. #21 Sastra
    February 3, 2009

    DLC wrote:

    Why is it needle woo guys always go for the ears ?

    Why, it’s because of the huge amount of data supporting the well-known fact that women who wear earrings don’t suffer as much pain as those who don’t. How could anyone miss the results of this longterm social experiment?

    It’s true. Studies done in hospitals show that the women patients who are wearing earrings feel a lot better – and have more energy — than those patients who feel lousy. Walk through the halls, peek in the rooms, and check it out for yourself.
    ;)

  21. #22 khan
    February 3, 2009

    I have a vague memory of the military studying various ‘psychic powers’ in the ’70s.

    So what’s next? Haruspicy?

  22. #23 Patrick
    February 3, 2009

    It couldn’t be because those Women who can Afford to wear earrings aren’t as worried about getting the Bill paid Sastra?

  23. #24 Dangerous Bacon
    February 3, 2009

    “My body reacts quite predictably when someone pokes me painfully with a needle: a slight rush of adrenaline, decreased sensitivity to pain generally, and a focus of attention on the new locus of pain rather than the old ones.”

    Generally, if someone pokes another person painfully with a needle, any subsequent diminution of pain is dwarfed by the pain inflicted on the individual with the needle.

    Assuming of course that this sequence of events occurs on a bus or at the mall, as opposed to a physician’s office.

  24. #25 daedalus2u
    February 3, 2009

    In the military hierarchy, do a Doctor’s medical ethics allow him/her to refuse an order to perform an unethical procedure?

    The ethical principles that came out of Nuremburg made it quite clear that to use individuals for experimental treatments was a war crime.

    It is also a war crime to observe a war crime and not report it up the chain of command.

    It is also a war crime to retaliate against those reporting war crimes and trying to cover up war crimes.

    If it is a war crime to treat a POW a certain way, it should be no less a war crime to treat a non-POW that way (actually isn’t that what the common article 3 specifies, how one must treat all “non-combatants”, presumably including soldiers of your own side).

  25. #26 peaveydream
    February 3, 2009

    I think this is wonderful. This doesn’t mean we’re leaving away from conventional medicine, this sounds more like a supplement to what we’re used to, taking drugs for ailments. As based on Col. Richard Niemtzow’s treatment on the soldier’s injury, it’s fascinating he used this method and to see results. If I was all f’d up in war and in pain and they wanted to do a 5 minute acupuncture treatment to relieve my pain, I’d do it in a heartbeat. If that didn’t work, pop me a pill. If I was the patient and that stuff works, awesome, and if it didn’t let’s all move along. As for understanding how it works, doesn’t matter to me. This is an awesome example of opening up our options and we all just need to see it nothing more than that.

  26. #27 Tracy W
    February 4, 2009

    Patrick – as a woman who wears earrings, I can buy them for $1 to $2 a pair if I just want cheap ones. Getting the piercings cost me $10 when I was 12 years old including the studs. If someone is wearing earrings with large real diamonds in them they probably don’t need to worry about the medical bills, but we can’t deduce that about all earring wearers.

  27. #28 Nixxy
    February 4, 2009

    “Studies done in hospitals show that the women patients who are wearing earrings feel a lot better – and have more energy — than those patients who feel lousy. Walk through the halls, peek in the rooms, and check it out for yourself.”

    If you’re bed ridden and sick, why would you bother wearing earrings? The people who feel lousy would probably not be wearing earrings for that reason. Correlation is not causation, you know.

  28. #29 Prescott
    February 4, 2009

    We hope to really find a cure and that is long, say the same thing and so far many people still suffer and can not find any solution, something that is fast and effective because the pain of this disease is unbearable, I read about this page findrxonline.com and interesting information I think we can give adequate information for people who need it.

  29. #30 Stu
    February 4, 2009

    Thank you Prescott, you spamming sack of crap.

  30. #31 Jane
    February 4, 2009

    We’re talking about a treatment for pain, not a claimed cure for cancer. If it helps some people, even as a placebo, isn’t that a good thing? After all, opiates aren’t exactly benign.

  31. #32 Stu
    February 4, 2009

    If it helps some people, even as a placebo, isn’t that a good thing?

    Only if it never, ever, ever, ever, ever prevents people from seeking actual medical attention.

    How likely do you think that is?

  32. #33 Rebel Macaque
    February 4, 2009

    Prescott, dude, step away from the computer. Man, that is the weirdest grammar I’ve ever tried to read. It seems like it should make sense but it doesn’t. I to read it out loud in my best Mrs. Kuznetzov voice (our neighbor from Kiev) and it sure sounds like the kinds of things she says when she rambles on about her bursitis. You might try using those little keys that don’t have the letters on them. You know, the ones with the dots, squiggles and dashes on them. They’re kinda like traffic signals for readers. Your post had not stop signs.

  33. #34 Jane
    February 4, 2009

    Stu,

    In this case, pretty darn likely! We’re talking about pain from fairly severe injuries.

    If you think alternative/placebo treatments for a subjective phenomenon like pain are dangerous because they might cause some people to not see a doctor, shouldn’t you also be opposed to OTC aspirin and Tylenol?

  34. #35 Shawn S.
    February 4, 2009

    These anecdotes are not even an indicator how strong the placebo effect is! Even if we wanted a treatment that has a strong placebo effect we don’t know that it does based solely on these anecdotes or even the poorly designed studies that were cited. If the placebo effect was fairly high in a tightly controlled study then you might be able to say, “Well it helps with the pain even though it has no direct pharmochemical effect” (Is pharmochemical a word? It seemed to work… at least as well as placebo) then maybe it is useful in that application, as someone suggested. I tend to disagree if only because it is deceptive. I will also make an argument from final consequences and say that it might lend a false credibility to all the claims of whatever pseudoscientific woo the placebo is attached to. So for that reason alone we should avoid it. After all, in order to sell acupuncture we have to convince the patient that it works. That is unethical because it is disseminating false claims (energy healing) through the authority of real medical science (Placebo effect). If you told someone that their medication was placebo and worked because the patient believed it worked than that kind of defeats the placebo effect!

  35. #36 Shawn S.
    February 4, 2009

    These anecdotes are not even an indicator how strong the placebo effect is! Even if we wanted a treatment that has a strong placebo effect we don’t know that it does based solely on these anecdotes or even the poorly designed studies that were cited. If the placebo effect was fairly high in a tightly controlled study then you might be able to say, “Well it helps with the pain even though it has no direct pharmochemical effect” (Is pharmochemical a word? It seemed to work… at least as well as placebo) then maybe it is useful in that application, as someone suggested. I tend to disagree if only because it is deceptive. I will also make an argument from final consequences and say that it might lend a false credibility to all the claims of whatever pseudoscientific woo the placebo is attached to. So for that reason alone we should avoid it. After all, in order to sell acupuncture we have to convince the patient that it works. That is unethical because it is disseminating false claims (energy healing) through the authority of real medical science (Placebo effect). If you told someone that their medication was placebo and worked because the patient believed it worked than that kind of defeats the placebo effect!

  36. #37 DrBadger
    February 5, 2009

    Knowing the way the US government works, now there’s going to be 10 billion dollars going to “military acupuncture” research, while real medical researchers get to enjoy another cut in funding.

  37. #38 DrBadger
    February 5, 2009

    @Jane

    If you think alternative/placebo treatments for a subjective phenomenon like pain are dangerous because they might cause some people to not see a doctor, shouldn’t you also be opposed to OTC aspirin and Tylenol?

    The difference is that when someone goes to an alternative medicine practitioner, they may be going with the (incorrect) assumption that they are being seen by a professional.

  38. #39 peaveydream
    February 5, 2009

    Stu, you sound like a belligerent sped.

    “How likely do you think that is?”

    This article doesn’t mention anywhere about replacing medical attention.

  39. #40 Jane
    February 5, 2009

    @DrBagder,

    The difference is that when someone goes to an alternative medicine practitioner, they may be going with the (incorrect) assumption that they are being seen by a professional.

    Agreed, but again, that would not be the case in this situation. Serious injuries would be treated as they were before. As for honesty and legitimizing future use, why not say something like, “Acupuncture sometimes helps with pain and stress; however, it cannot treat serious illnesses”?

  40. #41 Prometheus
    February 5, 2009

    OK, maybe the good colonel didn’t know about the studies showing that acupuncture isn’t good for severe (or even persistent moderate) pain, but don’t you think someone on his staff would have made the following connections:

    [1] A good deal of battlefield trauma involves being punctured by various objects (from shrapnel and bullets to large framents of buildings).

    [2] Do you really think that sticking an itty bitty needle in someone’s earlobe is going to have a significant effect when they have a bullet hole in their belly?

    Granted, this would not be the first time the US armed forces have wasted money on obvious nonsense (the remote viewing “research” comes to mind) and I’m sure it won’t be the last. However, they should’ve had enough experience in nonsense to see it coming and sack this bird before he got a chance to embarass them…..again.

    Prometheus

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