Respectful Insolence

ResearchBlogging.orgI have to hand it to acupuncture mavens. They are persistent. Despite numerous studies failing to find any evidence that acupuncture is anything more than an elaborate placebo whose effects, such as they are, derive from nonspecifice mechanisms having nothing to do with meridians, qi, or “unblocking” qi. Moreover, consistent with the contention that acupuncture is no more than an elaborate placebo, various forms of “sham” acupuncture (needles that appear to insert but don’t or acupuncture in the “wrong” locations, for example) produce results indistinguishable from “real” acupuncture.

That record won’t change with the latest acupuncture study for low back pain that was published on Monday and is making the rounds through the media. Let’s start with a news report on Medpage Today:

WHEELING, W.Va., May 11 — Acupuncture was more effective than conventional treatment for relieving lower back pain in a randomized trial, but performed no better than poking patients gently with toothpicks.

The editors of Medpage Today should really know better than to publish nonsense like this. They shouldn’t have allowed a story about this particular study to start out by saying that acupuncture was bound to be “more effective” than conventional treatment because this study showed nothing of the sort, for reasons that I’ll discuss later. Actually, I bet that astute regular readers here will be able to identify immediately exactly why such a conclusion is unjustified when I describe how the study was done. If not, I promise I’ll make it painfully clear to you by the end. I’ll also feel like I’m repeating myself because I’ve mentioned this very same defect in acupuncture studies. In any case, the study did show that “real” acupuncture was no better than sham acupuncture.

Back to the study. It appeared in Archives of Internal Medicine and was published by a team of investigators led by Dr. Daniel Cherkin of the Center for Health Studies in Seattle; investigators from Northern California Kaiser Permanente, Cancer Research and Biostatistics in Seattle; Department of Family Medicine, Oregon Health and Science University; and (of course) the National Center for Complementary and Alternative Medicine, National Institutes of Health. Yes. NCCAM had a hand in this study. Is anyone surprised? In any case, the study was entitled A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain (Arch Intern Med. 2009;169(9):858-866).

The study was a four-arm study that enrolled 638 adults with chronic mechanical low back pain. The group, which I quote from the study, were:

  1. Individualized acupuncture. This was the treatment prescribed by the diagnostician at the beginning of each visit. It could include any acupuncture points that could be needled with the participant lying prone. There were no constraints on number of needles, depth of insertion, or needle manipulation. Treatments averaged 10.8 needles (range, 5-20) retained for 18 minutes (range, 15-20 minutes). Seventy-four distinct points were used, half on the “Bladder meridian” that includes points on the back and legs.
  2. Standardized accupuncture. We used a standardized acupuncture prescription considered effective by experts for chronic low back pain.15 This included 8 acupuncture points commonly used for chronic low back pain (Du 3, Bladder 23-bilateral, low back ashi point, Bladder 40-bilateral, Kidney 3-bilateral) on the low back and lower leg.14 All acupuncture points were needled for 20 minutes, with stimulation by twirling the needles at 10 minutes and again just prior to needle removal. Therapists manipulated the needles to elicit “de qi,” which they perceive as a biomechanical response in tissue as it tightens around the inserted needle and constricts its movement.
  3. Simulated acupuncture. We developed a simulated acupuncture technique using a toothpick in a needle guide tube, which was found to be a credible acupuncture treatment by acupuncture-naïve patients with back pain.Simulating insertion involved holding the skin taut around each acupuncture point and placing a standard acupuncture needle guide tube containing a toothpick against the skin. The acupuncturist tapped the toothpick gently, twisting it slightly to simulate an acupuncture needle grabbing the skin, and then quickly withdrew the toothpick and guide tube while keeping his or her fingers against the skin for a few additional seconds to imitate the process of inserting the needle to the proper depth. All acupuncture points were stimulated with toothpicks at 10 minutes (ie, the acupuncturist touched each acupuncture point with the tip of a toothpick without the guide tube and rotated the toothpick clockwise and then counterclockwise less than 30°) and again at 20 minutes just before they were “removed.” To simulate withdrawal of the needle, the acupuncturist tightly stretched the skin around each acupuncture point, pressed a cotton ball firmly on the stretched skin, then momentarily touched the skin with a toothpick (without the guide tube) and quickly pulled the toothpick away using the same hand movements as in regular needle withdrawal. The acupuncturists simulated insertion and removal of needles at the 8 acupuncture points used in the standardized treatment.
  4. Usual care. Participants in the usual care group received no study-related care–just the care, if any, they and their physicians chose (mostly medications, primary care, and physical therapy visits). All participants received a self-care book with information on managing flare-ups, exercise, and lifestyle modifications.

I included a full description of each straight from the study because I think it’s important. In fact, with one glaring error, this is actually a very good experimental design for this sort of clinical trial. I’m not going to say what that glaring flaw is right now, as I want you to try to figure it out. Don’t worry, it will be revealed soon enough. But first I want to reveal the reported results of the study.

Back pain was assessed in each patient upon entry into the study using a standard, well-validated questionnaire for back pain, the modified Roland-Morris Disability Questionnaire (RMDQ), and then again at 8 weeks, 26 weeks, and 52 weeks. Strengths of the study included a reasonably number of subjects, a good placebo control group in terms of the simulated acupuncture, and a comparison of “individualized” versus “standardized” acupuncture. I mention this latter aspect of the trial because one complaint that woo-meisters often make is that clinical trials are too “artificial” and do not adequately reflect their “individualized” practice. This trial provided the opportunity to put that claim to the test.

So what was the result? Check out the graphs below, which show two measures of relief of back paint as assessed at the various time points:

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The bottom line is that there was no significant difference between any of the three acupuncture groups when compared to each other. Individualized acupuncture was no different from standardized acupuncture, and neither were any different than sham acupuncture. True, all of them were reported as better than “usual treatment,” but can you tell what the problem was? Sure, I knew you could. I’ve mentioned it before enough times when looking at other acupuncture studies. While it’s true that the three acupuncture groups were fairly well blinded, as far as studies like this go, there was no blinding at all between the “usual treatment” group and any of the acupuncture groups. The patients in the acupuncture groups all knew that they were assigned to an acupuncture group. They didn’t know which acupuncture group they were in (which is good experimental design), but they knew they were getting acupuncture. Similarly, the patients in the “usual care” group all knew they were assigned to a non-acupuncture group. They knew they weren’t getting acupuncture. That makes any comparison between the two virtually worthless, other than as an estimate of what the placebo effect was during the study.

In fact, the very fact that there was a difference between all the acupuncture groups and the “usual treatment” group is best described as being due to the placebo effect. The reason? There was no restriction on “usual care” among the acupuncture groups. Not just the “usual treatment” group used standard medical treatments. All four groups were allowed to continue using their standard conventional treatments for low back pain, and all four groups did. Consequently, the three acupuncture groups received their acupuncture in addition to whatever nonsteroidal anti-inflammatory drugs they were taking, the same care regimen that the “usual care” group was getting. Given such an experimental design, I would have been shocked if the acupuncture groups didn’t show superiority to the “usual treatment” arm. Such a result was exactly expected based on the expected placebo effect from being in one of the acupuncture arms of the study.

That doesn’t stop the authors from incorrectly concluding about their trial and other recent acupuncture trials:

Collectively, these recent trials provide strong and consistent evidence that real acupuncture needling using the Chinese meridian system is no more effective for chronic back pain than various purported forms of sham acupuncture. However, both real and sham acupuncture appear superior to usual care.

Particularly irritating are news reports like this, with reporters saying that acupuncture “works” and the question is how:

I do, however, express some amusement at the discomfiture of acupuncture boosters in trying to explain why there was no difference at all between any of the three acupuncture groups and being forced to admit that “patient beliefs” (code word among CAM boosters for nonspecific placebo effects) are the reason for their observed results showing more pain relief among the acupuncture groups than among the “usual care” group. True, the discomfiture caused by this study is not as amusing as that caused by a study from about a year ago, which forced acupuncturists to try to explain why the study’s sham acupuncture group had a stronger response than than the “true” acupuncture group. The logical contortions the authors made in order to try to justify that result as somehow being anything other than yet another large study showing acupuncture to be nothing more than a placebo were truly something to behold.

In any case, a more correct way to have done this trial would have been to leave out the “usual care” group altogether because it couldn’t be blinded. Mixing blinded groups with unblinded groups always mucks up a study design, and the sham acupuncture group was a more than adequate control group for this study, if the question to be answered was whether individualized acupuncture or “standardized” acupuncture provided better pain relief than a placebo. Indeed, I can’t help but think that the investigators must have known when they included that group that there would be a placebo response and that in the event they didn’t find what they wanted to find it was likely that the acupuncture groups would appear to do better than the “usual treatment” group. If the reason for that group was to estimate the degree of placebo response, that would be justifiable, but the wildly inaccurate misinterpretation of the observed placebo effect as meaning that acupuncture “did better” than standard care shows the peril of including such a group in studies such as these. Not only did the investigators wildly misinterpret the meaning of the difference observed between the “usual care” group and the three acupuncture groups, but the woo brigade has latched onto this difference as though it really did indicate that acupuncture is “better” than conventional therapy for low back pain. Witness Mike Adams’ lackey over at NaturalNews.com, where S. L. Baker crows Acupuncture Beats Western Medicine for Treating Low Back Pain:

The results of the largest randomized back pain trial of its kind shows acupuncture clearly helps people with chronic low back pain more than standard medical care. But the results of the SPINE (Stimulating Points to Investigate Needling Efficacy) study, just published in the May 11, 2009 Archives of Internal Medicine, has some researchers scratching their heads over the remarkable findings. The reason the study’s results are so intriguing? Not just one but three different forms of acupuncture beat out western medicine in helping relieve low back pain.

Uh, no. What it shows is that there is no difference between “individualized” acupuncture, a standardized acupuncture regimen, or a placebo control sham acupuncture treatment. That’s all it shows. Contrary to the way this study is being spun, it is yet another in a long line of negative acupuncture studies, showing that acupuncture for back pain is no better than placebo. Indeed, it is about as resoundingly negative a study as I can imagine, showing clearly that acupuncture has no specific effects that can be attributed to anything that makes a procedure considered to be “acupuncture”: individualization of needling, needling location according to traditional Chinese medicine precepts, or even bothering to put the needles into the skin at all. None of it matters at all. Indeed, the result showing that all three acupuncture groups produced results indistinguishable from each other is very strong evidence that none of it matters and that it’s all placebo effect. Unfortunately, the NaturalNews.com article is not a Mike Adams flight of fancy; it more or less quotes authors of the study, who speculated that the reason for their results is that the sham acupuncture group was the equivalent of “acupressure” and therefore nothing more than another form of acupuncture. Never mind that, were that truly the case, the “usual care” group would have been the real control group, making their experimental design unblinded with respect to the control group and therefore utterly worthless.

NCCAM strikes again, and your taxpayer dollars are funding it all. Acupuncture is based on a prescientific philosophy of disease, but apparently that doesn’t stop credulous 21st century investigators from wasting taxpayer money producing yet another study showing that it does not work.

REFERENCE:

Daniel C. Cherkin, Karen J. Sherman, Andrew L. Avins, Janet H. Erro, Laura Ichikawa, William E. Barlow, Kristin Delaney, Rene Hawkes, Luisa Hamilton,, Alice Pressman, Partap S. Khalsa, & Richard A. Deyo (2009). A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain Arch Intern Med, 169 (9), 858-866

Comments

  1. #1 Emp
    May 13, 2009

    How do studies like this get funded in the first place when even a twenty-year-old student like me can recognize the huge, glaring design flaw? It was my impression that getting funding for research requires a lot of work, including rewriting your proposals if something seems amiss. It’s currently my superiors doing this, not me, so I could be misinformed.

    And of course, the sCAMers and credulous news media will take this study and run with it. :\

  2. #2 Jojo
    May 13, 2009

    I read an article on this yesterday and half way through I had to stop and check the article’s title that claimed acupuncture works. It was clear from the author’s wording that the study did not show that it worked. It was hard to wrap my head around the first half of the article and the second because the author clearly contradicted himself. Very odd.

  3. #3 Dave Ruddell
    May 13, 2009

    I may be a little slow here, but what’s the difference between the ‘A’ graph and the ‘B’ graph? They seem to be showing the same data (% with improvement after 8, 26, and 52 weeks).

  4. #4 drjaylee
    May 13, 2009

    They should have reported the mode not the “average” number of needles inserted. “10.8″ is absolute nonsense. How does one insert “10.8″ needles. When the stats start out bad usually the reason is rubbish. This was funded?

  5. #5 Enkidu
    May 13, 2009

    This same story was reported on our local news last night (in the Philadelphia area), also completely misinterpreted: they reported that the study showed that acupunture works, when really sticking people randomly with needles and calling it acupuncture is what works.

    It is amazing how poorly some news outlets interpret information… the transfer of information to the public is their job and they tend to fail miserably, especially when it comes to science and medicine.

  6. #6 Dave S.
    May 13, 2009

    Dave Ruddell:

    Probably some text missing that explains the difference. I’d guess they were divided into male/female.

  7. #7 Lab Rat
    May 13, 2009

    “Not just one but three different forms of acupuncture beat out western medicine in helping relieve low back pain.”

    That does seem to imply that randomly poking people with toothpicks counts as ‘accupuncture’

    I wouldn’t have been been able to attest that those results were ‘significant’ in a Part III undergraduate dissertation, how on earth they can get away with it is beyond me.

  8. #8 Scott
    May 13, 2009

    Pretty much a smoking gun for the complete intellectual dishonesty of the pro-acupuncture crowd. This is about as unequivocal a result that acupuncture has no effect beyond placebo as it’s possible to get, yet they STILL present it as the opposite!

    Clearly, there is no possible study, and no possible result, that would lead them to conclude that it doesn’t work.

  9. #9 Militant Agnostic
    May 13, 2009

    The one thing we learn from all these accupunture studies is that the average journalist is incapable of simple logical thought is totally lacking in critical thinking skills.

  10. #10 Sarah P
    May 13, 2009

    I just thought it was really funny they used toothpicks. My headline would have been “Toothpicks cure back pain!” At least people would laugh. Except the woo meisters, who seem to share a total lack of ability to find anything around their woo funny. Ah, where’s Monty Python when you need them?

  11. #11 Mu
    May 13, 2009

    What the study really proves is : It’s all in your head!
    Also, if you really look at the data, only about 1/3rd of the patients who got acupuncture actually saw improvements above of what the “standard treatment” control would let you expect.
    So I’m wondering if we can use the improved non-bloody acupuncture protocol, maybe by integrating some natural organic blessed special aroma sandalwood toothpicks, as a new income source. I mean, NIH has shown it works.

  12. #12 catgirl
    May 13, 2009

    If poking people in random places with toothpicks is just as effective, then why don’t all acupuncturists start doing that instead? It’s certainly more hygienic than re-using needles, and cheaper than using disposable needles. Also, a lot more people would be more comfortable knowing that it’s just toothpicks and not needles, which might enhance the placebo effect. It would also be cheaper for patients since the acupuncturists wouldn’t need any training. I should start a place like this with a sign that says, “As effective as acupuncture, but without the needles!” Too bad I would feel guilty about taking people’s money for a placebo.

  13. #13 wp
    May 13, 2009

    this abstract may be of interest:

    Expectancy and treatment interactions: A dissociation between acupuncture analgesia and expectancy evoked placebo analgesia

    Author(s): Kong J (Kong, Jian)1,2, Kaptchuk TJ (Kaptchuk, Ted J.)3, Polich G (Polich, Ginger)1, Kirsch I (Kirsch, Irving)4, Vangel M (Vangel, Mark)2,5, Zyloney C (Zyloney, Carolyn)1, Rosen B (Rosen, Bruce)2, Gollub R (Gollub, Randy)1,2,3
    Source: NEUROIMAGE Volume: 45 Issue: 3 Pages: 940-949 Published: APR 15 2009

    Abstract: Recent advances in placebo research have demonstrated the mind’s power to alter physiology. In this study, we combined an expectancy manipulation model with both verum and sham acupuncture treatments to address: 1) how and to what extent treatment and expectancy effects – including both subjective pain intensity levels (pain sensory ratings) and objective physiological activations (fMRI) – interact; and 2) if the underlying mechanism of expectancy remains the same whether placebo treatment is given alone or in conjunction with active treatment. The results indicate that although verum acupuncture+high expectation and sham acupuncture+high expectation induced subjective reports of analgesia of equal magnitude, fMRI analysis showed that verum acupuncture produced greater fMRI signal decrease in pain related brain regions during application of calibrated heat pain stimuli on the right arm. We believe our study provides brain imaging evidence for the existence of different mechanisms underlying acupuncture analgesia and expectancy evoked placebo analgesia. Our results also suggest that the brain network involved in expectancy may vary under different treatment situations (verum and sham acupuncture treatment). (c) 2008 Elsevier Inc. All rights reserved.

    Reprint Address: Kong, J (reprint author), Massachusetts Gen Hosp, Dept Psychiat, Bldg 149,13th St,Suite 2661, Charlestown, MA 02129 USA
    Addresses:
    1. Massachusetts Gen Hosp, Dept Psychiat, Bldg 149,13th St,Suite 2661, Charlestown, MA 02129 USA
    2. MGH MIT HMS Athinoula A Martinos Ctr Biomed Imagi, Charlestown, MA USA
    3. Harvard Univ, Sch Med, Osher Res Ctr, Boston, MA USA
    4. Univ Hull, Kingston Upon Hull HU6 7RX, N Humberside England
    5. MGH CRC Biomed Imaging Core, Charlestown, MA USA
    E-mail Addresses: kongj@nmr.mgh.harvard.edu

  14. #14 Skeptico
    May 13, 2009

    Josephine P. Briggs, MD, director of NCCAM, noted that SPINE "..adds to the growing body of evidence that something meaningful is taking place during acupuncture treatments outside of actual needling. Future research is needed to delve deeper into what is evoking these responses."

    “More studies are needed” – CHECK. Because whenever the results of the woo trial is not positive for the woo, “more studies” are always needed. It’s never, “oh, it doesn’t work then”, it’s always “more studies are needed”. Ad infinitum.

  15. #15 Michael Simpson
    May 13, 2009

    I’m a little unclear as to what was the “usual” treatment. Was it, “take two ibuprofen and call me in the morning?”

    In other words, what would the results be (and it’s still going to be impossible to blind the study) comparing two groups with similar clinical presentations of chronic mechanical low back pain? One group would receive acupuncture, and and the other group would receive aggressive, standard, evidence based treatments.

    I stand by a basic policy in analyzing CAM treatments. Is there a logical and rational physiological basis for the potential success of the treatment. Short of Qi or something nonexistent like that, there are no explanations of why acupuncture might work. It’s a simple question that, if answered honestly, helps point me in the direction of whether CAM can work.

    Of course, don’t get us started on how NCCAM funds these studies without asking the basic scientific questions.

  16. #16 hazur
    May 13, 2009

    Caption for Figure 3. Participants with improvement. Percentage of participants improving by at least 3 points on the Roland-Morris Disability Questionnaire scale (A) and by at least 2 points on the symptom bothersomeness scale (B).
    This is the Author’s Conclusion:
    Conclusions: Although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appear to be unimportant in eliciting therapeutic benefits. These findings raise questions about acupuncture’s purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.

    Cheers,

  17. #17 Aaron Luchko
    May 13, 2009

    I don’t really mind the inclusion of the “usual” group, it helps measure the size of the placebo effect, the stupid bit was interpreting that as supporting acupuncture. The study author in the video wasn’t that bad (didn’t emphasize placebo effect enough) but the medpage reporter and article don’t seem to have a clue.

  18. #18 Rick
    May 13, 2009

    I think you are all missing one big point here. Yes the study was flawed and the data showed essentially placebo effect only. However, placebo effect is still an effect. The patients felt better!. While there are medical ethics issues with prescribing a placebo, you cannot deny that patients felt significantly better. So please try to remember that the ultimate priority is the patient, not the treatment. Whether it is acupuncture, sham-upuncture, morphine, physical therapy, osteopathic manual medicine, laminectomy, if it works for the patient that is what matters in the end. The fact that this is less invasive and less expensive than surgery, and provides the patient with some brief moments of peace and relaxation means that it should be considered by healthcare professionals. Frame it with appropriate disclosures of course, but make it an option for patients.

  19. #19 Pen
    May 13, 2009

    I really wish that as a society we could now turn our attention to finding the most effective, inexpensive, ethical and honest ways of using the placebo effect to good purpose.

    Does anyone know of anything being done on this, such as assessing the limitations imposed by patient non-belief?

  20. #20 Jane
    May 13, 2009

    Here’s a study I’d like to see. Divide participants into four groups.
    1. real acupuncture
    2. sham acupuncture
    3. NSAIDs
    4. sugar pill

    This way, groups 1 and 2 will know they’re getting acupuncture, but won’t know if it’s real or fake, and groups 3 and 4 will know they’re getting pills, but won’t know if they’re real or fake. It would be particularly interesting to compare groups 2 and 4.

  21. #21 techskeptic
    May 13, 2009

    Rick,

    You get placebo effects in all medicine. It doesnt matter if its woo or not. The benefit of actual evidence based medicine is that you get the plaebo effect plus the actual effect of the proven medicine.

    When you base your medicine purely on placebo effect of other people, you risk failing to treat serious conditions. Its a stupid choice.

    Orac (or anyone),

    In any case, the correct way to have done this trial would have been to leave out the “usual care” group altogether because it couldn’t be blinded.

    I think I disagree. When you do that, you fail to show that EBM is better and that gap will always be there. Instead why not enhance the placebo effect for the EBM in the same way that it is done for the woo?

    I would propose an alternative, but perhaps I am wrong about this.

    The patients in the study should just be told that they will be receiving treatment for their back pain, but not be told that this is an acupuncture study. Their interpretation of this would create the placebo effect for ibuprofen, which they would be told was something new. The patients should not be allowed to have contact with each other so that they wont know that other patients are receiving acupuncture.

    Unless I am totally wrong (which is possible), this would not only allow a comparison between woo and EBM to take place, it should show better results from the “usual care” because, you know…usual care have decades of positive evidence behind it.

  22. #22 emote_control
    May 13, 2009

    I had to go google for Archives of Internal Medicine, just to make sure that it was the peer-reviewed medical journal that I thought it was.

    And now I have a question: how in holy hell did this pass review with such a glaring methodological error? If I tried to publish something like this, I’d get spanked. I have to wonder if perhaps Arch Int Med’s review process isn’t entirely credible these days.

    I stopped believing headlines about medical experiments years ago, preferring to look up and read the papers myself if they interested me. Now I need to stop believing the authors themselves, in nominally peer-reviewed publications? Good grief! What is happening to science?

  23. #23 Zombie
    May 13, 2009

    From the description of the “usual care” group it sounds as if that group was completely uncontrolled and may not have been recieving the standard of care in the first place, making the comparison even more bogus.

  24. #24 emote_control
    May 13, 2009

    @techskeptic: I would suggest that the placebo group be made to go through the same regimen of visits, but be told that they were undergoing a new treatment with some made-up name. Then, simply touch their backs at random points with the needle guide, or place droplets of water at those points, or something similar. That way, they will not believe that they are receiving acupuncture, but will be undergoing “treatment” in a controlled environment, which may enhance the placebo effect.

    But I also think that the omission of the fourth group altogether would have sufficed to demonstrate that actual application of acupuncture needles has no benefit over causing patients to believe that the needles had been applied. That clearly demonstrates that any effect attributable to acupuncture is only placebo and that the claims of acupuncturists are not supported by science.

  25. #25 ABradford
    May 13, 2009

    This sort of study makes me wonder if a better study might be done in animals. I hear about veterinary acupuncture fairly frequently, and I think the stories would be convincing to the general public compared to my skepticism. It’s conceivable that the results could be communicated via the owners at least similarly to the self-reporting of this study. I’m just not sure that ethically it could be blinded by telling owners their pet may or may not be receiving acupuncture treatment.

  26. #26 Ahistoricality
    May 13, 2009

    The problem with placebo effects is that it depends on ignorance: if you institutionalize it, you have to perpetuate the ignorance, and that’s clearly unethical (though easier than we’d like to think).

    I don’t understand why they didn’t standardize the “usual treatment” by the control and acupuncture groups. Yeah, it’s a lot of work, but it would yield much more robust (and potentially useful) results. Or at least use a large enough control group that was tracked carefully enough to compare “usual” modalities…..

    Oh, well.

  27. #27 A Guy
    May 13, 2009

    I disagree that mixing the blinded groups with the unblinded groups in the study is a problem for this study. The problem was the interpretation of the results, as you noted, but including the “no acupuncture, or even pretend acupuncture” group allows comparisons to be done to a group of relevance.

    Acupuncture (which is from “real” acupuncture to “completely pretend without needles at all”, by all indications of this and other studies) is properly compared to the no acupuncture group. What the study needs, in my opinion, is another treatment, known to be an effective placebo, to compare it to. A “new back pain drug” sugar pill, or simply the “lay there and relax for half an hour while we play soft music” group. Don’t underestimate the benefits of simply lying still and relaxing for something like back pain. I would think acupuncture might come off poorly against that though, since without the needling, it might be more relaxing and beneficial.

    Is acupuncture an exceptionally effective placebo (in which case I can see offering it and not explaining it to patients, for their benefit), or just a regular “patient feels better because someone tells them they will” placebo? To me, that’s the question I want to see answered at this point.

  28. #28 A Guy
    May 13, 2009

    Hey, that was odd, a bunch of us all made the same point in 15 minutes about putting in another placebo…

  29. #29 Joseph
    May 13, 2009

    I get that the ‘usual care’ group could not be blinded, but isn’t it pretty bad that ‘usual care’ performs worse than a placebo even under these circumstances?

  30. #30 Kate
    May 13, 2009

    What I really want to know, and what I think would show better than this whether or not acupuncture works at all, is why the hell were the acupuncture groups allowed to continue with thier “usual care” regimen? That’s ridiculous, either you do a little something extra for the usual care group to generate an equal placebo effect (give ‘em a freakin’ b-vitamin or something) or you take usual care away from the accupuncture groups. That way, everyone’s on an even footing.

    Or maybe I’m just a bitch and like seeing idiots writhe in pain.

    Yeah…I think that’s it.

  31. #31 Mu
    May 13, 2009

    You forget that this was not “placebo vs. usual care” aka acupuncture INSTEAD of usual care, but “usual care + placebo vs. usual care”. Patients were not relying on the acupuncture to completely take over, they were still on their regular regime. It’s not sugar pill vs. morphine, its morphine vs. morphine + super potency enhancing sugar pill.

  32. #32 trrll
    May 13, 2009

    I disagree that mixing the blinded groups with the unblinded groups in the study is a problem for this study. The problem was the interpretation of the results, as you noted, but including the “no acupuncture, or even pretend acupuncture” group allows comparisons to be done to a group of relevance.

    I agree. The magnitude of the placebo effect is a topic of legitimate medical interest, and can only be evaluated by comparing a placebo group against a no treatment group. The idea that a study is “flawed” by virtue of obtaining this information is nonsensical.

  33. #33 Dave S.
    May 13, 2009

    Question (no doubt a naive one): Does the placebo effect still hold if the patient knows he is taking a placebo?

    Coomon sense would say no, but my common sense has been wrong before.

  34. #34 octopod
    May 13, 2009

    Dave S.: for some people yes, for some people no. Very much a matter of individual psychology.

    Why don’t we treat people with the placebo effect, anyhow? I think it’s a giant piece of possible treatment strategy that we totally overlook.

  35. #35 Dave S.
    May 13, 2009

    Thanks octopod.

    Now that I think about, I seem to recall a story of a dentist POW in a Japanese camp during WWII who routinely injected his patients with nothing but water to relieve, pain, and it seemed to work pretty well.

  36. #36 Karl Withakay
    May 13, 2009

    techskeptic,

    The problem with your idea is that it fails to account for the different strengths of various placebo responses.
    To Quote Harriet Hall at SBM:

    “There’s another reason the sugar pill would be a poor control. There is a hierarchy of placebos: injections work better than pills, etc. Bausell elaborates in Snake Oil Science. Pills are at the bottom of the hierarchy – they elicit the least response.”
    ——————————————————–
    To the others who think inclusion of the unblinded standard treatment group was not a design flaw, I have to disagree. The whole point of a blinded study is to level the playing field and eliminate bias as much as possible so that only objective results remain.

    Including the unblinded standard care group introduces an obvious potential for bias and adds result data that is not relevant to the question at hand for any experiment: If a subject does not know whether they are in the experimental or control groups, is there a statistically significant difference in the outcomes.

    The abstract makes the following statement about the trial:

    “This trial addresses the importance of needle placement and skin penetration in eliciting acupuncture effects for patients with chronic low back pain”

    The abstract does not even claim to be a test of the efficacy of acupuncture, it seems to take that acupuncture’s efficacy as a given (without addressing the nature of this supposed efficacy) and address the question of whether needle placement of penetration is meaningful or not. A standard care group (even if it could be blinded) is not relevant to the purpose stated in the abstract.

    In regard to determining the relative magnitude of the placebo effect, although it is an interesting and worthwhile topic, it is not relevant to this study, and would need it’s own study. There is no need to “piggy back” another question onto this study with results data that distract both reviewers and investigators with unnecessary data.

  37. #37 Marcus Ranum
    May 13, 2009

    Clearly, there is no possible study, and no possible result, that would lead them to conclude that it doesn’t work.

    2,000+ years of use in China and no appreciable effect on life-span compared to the rest of the world?

    My favorite way of amusing myself with acupuncture woo woos is to ask them if they can adjust my qi to give me the same effect as, say, heroin or mdma. If their “theories” are correct, they ought to be able to get you wasted – or dead – right?

  38. #38 Marcus Ranum
    May 13, 2009

    BTW, acupuncture needles are really cheap on Ebay. They’re interesting to work with. I bought a box and found that you can “drill” them about 1/2″ into muscle without sensation, if you’re careful to avoid the nerves in the skin (it’s hard NOT to shift a bit to avoid them when you are searching for where to insert the needle). When you take the needles out, there’s little to no bleeding. It doesn’t show anything that’d convince a woo-woo but if an untrained computer geek like me can do “painless” and “bloodless” inacupuncture on his first try it doesn’t impress me much that these retards need to study for it.

  39. #39 Karl Withakay
    May 13, 2009

    “Including the unblinded standard care group introduces an obvious potential for bias and adds result data that is not relevant to the question at hand for any experiment”

    Last part should read “the experiment” not “any experiment”

    I consolidated two different sentences into one, and failed to clean it up as well as I intended.

  40. #40 Rogue Medic
    May 13, 2009

    This interpretation has been bothering me, too. I put my own spin on things in Eureka – Conventional Treatment Plus Placebo Beats Conventional Treatment Alone.

    This misunderstanding of placebo is a big problem for most people. At least acupuncturists tend not to try to prevent people from getting conventional treatment, as did the homeopath father with the child who died from homeopathic treatment of eczema that progressed to sepsis, then death.

  41. #41 Scott
    May 13, 2009

    The abstract does not even claim to be a test of the efficacy of acupuncture, it seems to take that acupuncture’s efficacy as a given (without addressing the nature of this supposed efficacy) and address the question of whether needle placement of penetration is meaningful or not. A standard care group (even if it could be blinded) is not relevant to the purpose stated in the abstract.

    I have a sneaking suspicion that this is because the purpose of the study changed between the time it was designed and the time the abstract was written. If they’d expected to find that the toothpick group had similar results to the standard care group, then they could have argued that it showed there isn’t a placebo effect of note and tried to call into question whether all the prior results really were consistent with placebo.

    But then when the toothpicks gave just as good of results as the “real” acupuncture, they had to change what it is they were trying to measure in order to avoid drawing the conclusion they didn’t want.

    That may not be the precise reasoning, but it would explain a lot if the standard-care group WAS relevant to the originally intended question. The further scientific dishonesty changing the question would imply is, unfortunately, not inconsistent with woo-promoters’ usual approach.

  42. #42 Karl Withakay
    May 13, 2009

    Scott, you’re probably right. That’s why I am an advocate for pre-registering trials so that investigators would be required to explain why they deviated from their original study plan: changed/altered hypothesis, methodology, statistical analysis methods, etc, and justify non-publication track records. (If you register and complete a large number of trials as an investigator, but only publish 10% of them, and most or all of those are “positive” trials, are you intentionally not publishing studies that don’t support your theories?)

  43. #43 Prometheus
    May 13, 2009

    So, “individualized” acupuncture, “standard” acupuncture and getting poked randomly with a toothpick (Flat or round? It might make a difference.) are all equally “effective” and are better than doing nothing.

    Hmm. This doesn’t seem to be a glowing endorsement of acupuncture.

    The next step would be to compare “individualized” acupuncture done by a “trained” practitioner (preferrably an elderly chinese practitioner) to getting poked at random places with a toothpick by the FedEx delivery guy in a white lab coat. And if this shows no difference, would it still mean that acupuncture is “effective”?

    Obviously, the journalist reporting this “landmark” study suffers from late-stage gullibility, but surely the editors and reviewers must have realized that the conclusion was bunk.

    In a way, this is a “landmark” study, since it clearly shows that “effective” acupuncture requires no specialized training or equipment. Anybody can poke you at random places with a toothpick. Heck, my kid brother did it to me lots of times! Does that make him an acupuncturist?

    Seriously, if the acupuncture apologists can’t see this as proof positive that acupuncture is placebo, then they are blind.

    Oh, and for the people agitating for medical use of placebos – do you really want your doctor to lie to you? Besides, as this study has shown, you don’t need a doctor (MD, DO or DAc) to administer a placebo – you can have your friends or family members do it!

    Just be sure they use a clean toothpick, not one they’ve just taken out of their mouth.

    Prometheus

  44. #44 trrll
    May 13, 2009

    Question (no doubt a naive one): Does the placebo effect still hold if the patient knows he is taking a placebo?

    Common sense would say no, but my common sense has been wrong before.

    I don’t think it is at all a naive question. I haven’t seen a controlled study on this. Does anybody know of one? I agree with your suspicion of common sense. It is certainly not necessarily the case that conscious knowledge can prevent an emotional reaction or physiological response–ask anybody with a phobia or OCD. It is quite possible that some component of the placebo response is due to low-level conditioning (you go to the doctor, you feel better) that operate below the level of conscious awareness.

    On the other hand, modern studies in which the placebo effect is compared to no treatment tend to find smaller placebo responses than one might expect based upon the older medical literature on placebos. Of course, in the old days, researchers outright lied to subjects, while today they are ethically constrained to disclose to subjects the possibility that they will receive placebo treatments.

  45. #45 trrll
    May 13, 2009

    To the others who think inclusion of the unblinded standard treatment group was not a design flaw, I have to disagree. The whole point of a blinded study is to level the playing field and eliminate bias as much as possible so that only objective results remain.

    The point of a blinded control is to randomize out all influences except the study variable. But if you are looking at the magnitude of the placebo response itself, the patient’s awareness that he is receiving a treatment is the study variable.

  46. #46 Rod
    May 13, 2009

    Why doesn’t anybody ever include the “M&M group” in these studies. Patients should be told that a new pain reliever that tastes just like M&Ms (or maybe Goobers) is being studied. Then, try to explain why M&Ms works as well as something like accupuncture.

  47. #47 Karl Withakay
    May 13, 2009

    “The point of a blinded control is to randomize out all influences except the study variable. But if you are looking at the magnitude of the placebo response itself, the patient’s awareness that he is receiving a treatment is the study variable. ”

    Yes, but studying the magnitude of the placebo response itself wasn’t the purpose of this study, which is why I said the unblinded standard treatment group wasn’t relevant to this study, and a separate study (a study designed expressly for that purpose) should be done if you want to look into that.

    I’m not saying an experiment designed exactly as this one for the purpose of a different question would be a bad design, but let’s remember the purpose of this study.

    If you accept the stated purpose in the abstract, the purpose was to determine if location and penetration mattered. The standard treatment group has absolutely no relevance to this question, blinded or not.

    If you doubt the honesty of the abstract, you may believe the original purpose was to determine if acupuncture was effective or not (and that perhaps the inclusion of the standard treatment group was a hedge of their bets against the possibility their results contradicted their hypothesis), but the inclusion of an unblinded group in this study still doesn’t help answer that question because they have information the other subjects don’t: they know they are not receiving real acupuncture.

  48. #48 Li
    May 13, 2009

    What exactly is the placebo effect? How is it defined for the purposes of studies like these?

  49. #49 Rorschach
    May 13, 2009

    Joseph,

    Usual care did not perform worse than placebo. All the accupuncture groups were ALSO receiving usual care. So they go the same genuine benefit as the control group, plus a placebo benefit from the accupuncture. Which just proves that, duh, there’s a placebo effect.

  50. #50 Sastra
    May 13, 2009

    octopod #34 wrote:

    Why don’t we treat people with the placebo effect, anyhow? I think it’s a giant piece of possible treatment strategy that we totally overlook.

    For one thing, I think it goes against the health care relationship most people would choose:

    “Informed-Consent Model:” Doctor and patient work together, with the doctor carefully explaining risks and benefits of various treatments, and assisting patient with choosing among options.

    “Parent-Child Model:” Doctor acts in the role of parent to the child-patient, telling pleasing and plausible fibs which might work better than letting them know the truth, in order to help make the patient feel better than they otherwise might.

    As a general strategy, that second one bothers me.

  51. #51 flim flam
    May 13, 2009

    Also the power of placebo is purely subjective, that is, it’s an effect on how the recipient FEELS rather than a measurable physiological effect.
    That is, a patient receiving a CAM treatment eg acupuncture may say they feel better, but there is no objective measurable change in their condition.
    Feeling better is not the same as being cured. for example, a placebo anti coagulant is not going to work wheres a placebo analgesic might, as pain is a far more subjective measure than an INR level.
    Placebo chemotherapy will not shrink tumours or halt the spread of cancerous cells but a cancer patient might report “feeling” better after a session of reiki ,as lying in a softly lighted room listening to relaxing music while someone waves their hands over you and pays you lots of attention while not administering medication that makes you nauseous is quite a relief after the rigours of (evidence based effective) chemo protocols.
    Does this make reiki an effective cancer treatment? of course not.
    This is fundamentally the basis of all cam “modalities” ( hate that word!!!). Doing stuff that makes people “feel” better then claiming some kind of ability to cure all manner of illness. I wouldn’t have so much of a problem with CAM if it’s proponents were honest about what they do, eg ” i’m going to give you some sugar pills, they have no actual effects but i’ll spend at least an hour talking to you and that might make you feel better.” ” I’m going to randomly stick needles in your back while you lie on a couch, some people find their pain is less noticeable afterwards”
    Not much money in that though…..

  52. #52 sff
    May 14, 2009

    “On the other hand, modern studies in which the placebo effect is compared to no treatment tend to find smaller placebo responses than one might expect based upon the older medical literature on placebos.”

    This might be due to less trust in doctors these days — a combination of general distrust for authority, the anti-Big Pharma woo seeping into the public consciousness, and the Internet and other modern communications leading people to believe themselves experts.

  53. #53 Bix
    May 14, 2009

    flim flam-

    There are plenty of things TCM and other forms of Oriental Medicine can be used for that can be quantified, like increasing hormone levels or shrinking cysts and fibroids.

  54. #54 trrll
    May 14, 2009

    Yes, but studying the magnitude of the placebo response itself wasn’t the purpose of this study, which is why I said the unblinded standard treatment group wasn’t relevant to this study, and a separate study (a study designed expressly for that purpose) should be done if you want to look into that.

    A well constructed study can answer more than one question. In writing a paper, on the other hand, one generally focuses on the most newsworthy of the results, because space is limited, and a paper that tries to make too many points can come across as diffuse, and be difficult to follow. This is sometimes imposed by reviewers. On one occasion, I had a reviewer complain that the rationale for a particular experiment was not adequate. What was I suppose to do about that? Delete the results, which were informative? Lie about why I did it? My initial draft of the response, which was never actually mailed, read “It is fortunate that we did not have the benefit of the reviewer’s insight while planning these studies, or we would never have done these experiments.” Ultimately, I ended up deleting the offending statement; the final draft of my response thanked the reviewer for his “insightful comments”

    Nobody is going to be surprised that there is a placebo effect, so it doubtless was not the primary goal of the study. But there is considerable interest and some controversy as to the magnitude of the placebo effect, so inclusion of this study group is a valuable contribution the literature.

  55. #55 Ben
    May 14, 2009

    I think the placebo effect is fascinating, especially when you consider that it also has degrees (needles > big pills > red pills > small white pills). We also know that mood and mental activity (e.g. visualization) can affect the immune system. It seems (as others have noted) there’s a lot we could leverage here for *real* gains.

    To me the combining technique could be hypnosis, which I imagine would work well with the same people that resond to placebo, and have the advantage of not involving lying/misleading the patients. Do you know of any work in this direction?

    As to the actual study, well, sadly quite shameful.

  56. #56 Eliza
    May 14, 2009

    And why does my insurance cover acupuncture?

    Even better question – why is the acupuncture co-pay less than the mental health co-pay?

  57. #57 a lurker
    May 14, 2009

    I might had generous in saying that whatever sticking the pin did, the toothpicks did also. It is the individualized vs. standard that impresses me. After all, is it not the individualized acupuncture what its practitioners are getting paid for? Is that not where they use their “best” techniques postulated by their “theory”?

    /I never understood how anyone could accept qi. That is clearly a pre-scientific concept contrary to medicine.

  58. #58 Rogue Medic
    May 14, 2009

    Eliza,

    And why does my insurance cover acupuncture?

    Even better question – why is the acupuncture co-pay less than the mental health co-pay?

    Because they are crazy about acupuncture?

  59. #59 trrll
    May 15, 2009

    lso the power of placebo is purely subjective, that is, it’s an effect on how the recipient FEELS rather than a measurable physiological effect.
    That is, a patient receiving a CAM treatment eg acupuncture may say they feel better, but there is no objective measurable change in their condition.
    Feeling better is not the same as being cured.

    If a cure is the criterion for a valid medical therapy, then a lot of medicine does not qualify. Analgesics don’t cure much of anything, but when it comes to pain, what the patient “FEELS” is the point. That’s why, when you go to the doctor, they don’t hook you up to a pain meter to see how bad you are hurting–they show you a little scale with smiley faces and frowny faces and ASK you where on the scale you fall.

  60. #60 migg
    May 15, 2009

    anybody would care to send me an original paper? ( to migg.migg (at) gazeta.pl)
    thanks in advance1

  61. #61 RevRon
    May 15, 2009

    “I never understood how anyone could accept qi. That is clearly a pre-scientific concept contrary to medicine.”

    Spiritual/philosophical beliefs are based upon criteria that do not exist within the same framework as does scientific research. Dismissing as patently invalid any information that is “anecdotal” – ie, is not measured within the framework of a controlled study – might be satisfying, but is in reality making an assumption for which one lacks conclusive evidence. IMO, this is little different than the woo practice of accepting the efficacy of a treatment regimen for which there is virtually no supporting evidence beyond thinly stretched and illogical anecdotal examples.

    It would be valid to state that based upon empirical evidence available, there is no such thing as qi – or God, for that matter – yet there are a significant number of highly-educated and respected scientists who hold to a belief in some power which they are unable to quantify. Even though they may recognize that such beliefs are not supported by evidence in the classical sense, the beliefs remain strong, even among individuals whom it would be ludicrous to classify as being ignorant or unscrupulous.

    My whole point is that while science is compelled to accept only that which can be proven via controlled studies, it would seem prudent to acknowledge that some things might exist which do not fall within the scope of those studies. The progress of human knowledge throughout history has relied upon those individuals who were willing to logically follow evidence that led them beyond their current frames of reference. Not that which was blatantly contrary to logic and common sense, mind you, or that which would obviously endanger patients. As with any research, there is a thesis, countered by an antithesis; the final hypothesis – the “truth,” if you will – being a melding of the two. It would seem only reasonable to approach the apparent discord between the scientific and the spiritual in a similar manner.

    I’ve engaged in this discussion elsewhere – on forums both woo and skeptical – and have been thoroughly flamed by both camps. I have hope that the responses here will fall within the scope of “respectful insolence.”

  62. #62 Impatient Patient
    May 15, 2009

    I was relieved to read this. I have unfortunately married someone who LOVES alternative therapies (but honest, he’s a good guy). Recently I was diagnosed with IC, and he is moving heaven and earth to find the “cure,” and wants to start me on acupuncture next week (I was more than skeptical).

    I am more comfortable now telling him to save his money. If only I could get back some of what he’s already wasted!

  63. #63 trrll
    May 15, 2009

    I never understood how anyone could accept qi. That is clearly a pre-scientific concept contrary to medicine.

    It is, but the question of the efficacy of acupuncture is quite separate from the question of the reality of qi. The flaming chariot in the sky is a pre-scientific concept, but the sun still warms. The nervous system is complicated enough that it is plausible that accupuncture could work through conventional neuronal mechanisms. This is different from, say, homeopathy, which is plainly physically ridiculous.

  64. #64 Felix
    May 16, 2009

    I hope they follow this up with a study in which they offer the same 3 ‘acupuncture’ based treatments and the standard treatment group, but the 3 ‘acupuncture’ groups are told at random that their practitioner is either ‘an expert in chinese acupuncture’, ‘a medical doctor shown how to do it’ or ‘an actor hired for the purposes of the study’.

    This would provide probably provide a pleasing amount of ammunition against acupuncture supporters whilst providing little scientific information.

    However the series of studies may be able to turn into a useful investigation of the placebo effect, which as Ben Goldacre says at #55, is a fascinating area worthy of serious study.

    (At least I believe that is Ben Goldacre and I thought so after reading his first sentence, before I had seen that the post was indeed attributed to ‘Ben’ :-)

  65. #65 RevRon
    May 16, 2009

    I’d really like to read some in-depth studies of the placebo effect, as well. It would be interesting to more fully understand the physical mechanisms by which the placebo effect works, beyond the purely subjective “feeling better.”

  66. #66 Chris
    May 16, 2009

    RevRon, there have been a couple of books written recently about the placebo effect and how it is studied. One of them them is Snake Oil Science (it goes into how to evaluate studies), and Predictably Irrational (the author of that one won the IgNobel prize in medicine for his study showing more expensive placebos work better than cheaper placebos).

    Both books were educational, and fun to read.

  67. #67 RevRon
    May 16, 2009

    Thanks, Chris. Both are interesting and well-thought out treatises, however their focus is behavioral, rather than physiological. In Snake Oil Science, the author does acknowledge the brain’s release of opioids as the reason for patients’ decreased perception of pain post administration of placebos, but does not really go into the physiological mechanism that initiates the release of the opioids. That – to me at least – is the significant missing link I’m looking for.

    I know how powerful the placebo effect can be. Many years ago, while working as a psych tech at a Naval hospital, we had one actively psychotic patient whom, despite having been administered a toxic level of Thorazine over the previous 18 hours, was becoming increasingly violent. As senior tech on the ward, I determined that the patient needed to be restrained and isolated to prevent him from harming himself, as well as other patients. Once we had him down, I ordered one of the student techs to get the Placebin from the med cabinet (our term for a syringe filled with sterile water for injection, which we pronounced plass’ e ben so as to fool the patients). The student hesitated, and I hollered for him to MOVE!

    When he returned, I administered the injection, and after a few moments, ordered the other techs to release the patient, commenting what we had given him would “put an elephant out.” I’d assume that the mild discomfort as the “medicine” was injected helped convince the patient that he was being given a powerful drug, and he “succumbed” to its effects very quickly. Once released, we placed the patient in loose restraints and wheeled him to the “quiet room,” where he slept for hours.

    I can understand that the power of suggestion was the precipitating factor in the patient’s change in behavior, but especially since we have come to understand that schizophrenia is biochemically caused (and treated), I’ve always wondered at the physiological mechanism behind such an acute remedy.

  68. #68 SquirrelElite
    May 17, 2009

    This has been a hot topic on several blogs and Skeptics Guide to the Universe this week. One thing that occurred to me while looking at your graphs and I haven’t seen or heard anyone mention is that all the response to all three of the “acupuncture” therapies (plus usual care) doesn’t change significantly over time after the first 6 weeks for either Measure A or Measure B. The usual care alone group however, while the total response is less, shows an improvement in that response over time.

    In other words, it appears that the usual care alone treatment is having a real and improving therapeutic benefit. This would suggest that the placebo effect of the “acupuncture” treatments is declining over time.

    Measure A showed a decline in this benefit from 20% to 15% to 13% after 52 weeks, a small but noticeable difference.

    Measure B showed a decline from 18% to 6% to 3%! I.E. the placebo benefit for all three forms of “acupuncture” is gone after 52 weeks.

    It is interesting to speculate about what the results might have been after another 26 or 52 weeks following these trends. Would the usual care group for Measure B have passed the three “acupuncture” groups? Would that mean that acupuncture, however you want to do it, has a negative effect on treatment results?

  69. #69 Chris
    May 18, 2009

    RevRon:

    Thanks, Chris. Both are interesting and well-thought out treatises, however their focus is behavioral, rather than physiological.

    But isn’t behavior and psychology the entire basis behind the efficacy of placebo? By the definition of placebo, there can not be any kind of physiological effect from the fake meds! Though if there is a physiological effect from the psychological, then you get into the whole “mind/body” interaction, which is where I declare I have a headache and remove myself from the conversation. ;-)

    Anyway, if you have already read both books, then you know how to use PubMed and the directions to the closest medical school library, so you are well equipped to study the particulars that tickle your fancy!

  70. #70 Chris
    May 18, 2009

    AAAgh… I forgot to add, this study made it on “Wait Wait, Don’t Tell Me!” Just listen to the Listener Limerick Challenge to see how well well placed pricks played out on NPR!

  71. #71 RevRon
    May 18, 2009

    “Though if there is a physiological effect from the psychological, then you get into the whole “mind/body” interaction, which is where I declare I have a headache and remove myself from the conversation. ;-)”

    That’s pretty much the wall I’ve run into… if an individual’s symptoms have no physiological source, and are purely psychosomatic, their elimination (or “cure”) would be a simple matter of training the mind to elicit a different response. However, if the symptoms are caused by some observable mechanism, be it disease or trauma, there should be a measurable mechanism whereby a placebo eliminates them. While I make no claim to have done a comprehensive study, all I’ve found relative to that mechanism amounts to little more than speculation.

  72. #72 sirhcton
    May 18, 2009

    Ms. Aubrey, the NPR science or health reporter also got it wrong this morning.

    http://www.npr.org/templates/story/story.php?storyId=104200910

  73. #73 James Sweet
    May 19, 2009

    My wife goes to an acupuncturist from time to time when she is experiencing various pains or discomfort. It is mostly covered by insurance (never understood that, but whatever)

    I have observed that placebos seem to have quite a powerful effect on her, so I don’t really have a problem spending the relatively small amount of money for the copay — but it kinda bothers me that these woomeisters are making a career out of it. I just don’t know how I feel about that. I was in the office one time and saw their permits showing they are license acupuncturists in the state of New York, and it really didn’t sit well.

    So… I know my wife feels better after she spends half an hour in a darkened room with relaxing music and someone hovering over her paying very close attention to her and saying reassuring things, and I don’t mind shelling out thirty clams for that (hell, it’s cheaper than a massage…). But should I feel bad about the acupuncturist getting paid by my insurance company? I just don’t know… :/

  74. #74 JingLi
    May 22, 2009

    Interesting how you pull out information you like and overlook others.
    A lot of you mentions ‘randomly poking people using a toothpick’.
    This is not the case in this study. The toothpick was actually used at the exact same points as the needles in group 2.

    And remember, there are other therapies using these points without deep needling too. Japanese acupuncture just barely penetrate the skin, acupressure with fingers or sticks does not penetrate, and a form of light therapy does not even touch the skin.

    So what actually is measured in this study is the effectiveness of using individualized acupuncture points with deep needling compared to standardized acupuncture points with deep needling compared to standardized acupuncture points with non penetrating stimuli.

    There should have been a group with toothpick on non-acupuncture points, but even that is difficult as different systems define points different too, and the standard TCM points are not all points described.

  75. #75 LarryG
    May 23, 2009

    Hey all. If any of you are in or near Tucson, Az, come to my clinic, Tucson Community Acupuncture. You mention this blog and I’ll do it for free. Since your lack of belief in the woo will shield you from the placebo effect(?), it would be a nice personal experiment (though perilously subjective) to see how you respond to the needles. I guarantee the opioids will flow.

    Caution: I bring the deqi…big time.

  76. #76 Sourmash
    August 9, 2009

    < <<"I stand by a basic policy in analyzing CAM treatments. Is there a logical and rational physiological basis for the potential success of the treatment. Short of Qi or something nonexistent like that, there are no explanations of why acupuncture might work. It's a simple question that, if answered honestly, helps point me in the direction of whether CAM can work.>>>

    Wow, you claim to be scientific yet you can’t think of a single mechanism by which acupuncture could be effective? The nervous system is extremely complex, interacting with every system of the body, particularly endocrine system which regulates many of the most powerful chemicals our bodies possess. A series of acupuncture points lies directly over the sympathetic and parasympathetic ganglia. Have you heard of trigger points; have you read any of the research in the area of myofascial pain syndrome and its relationship to the presence of trigger points? Do you know what viscero-somatic and somato-visceral reflexes are? All of these phenomena have a material basis and could very easily account for the efficacy of acupuncture. Not to mention the role of the fascial system, which is proving to be an extremely complex system of tissue demanding inquiry. Not being able to think of a mechanism by which acupuncture could possibly work is demonstrative of one thing only: your utter ignorance of the complexity and profundity of life and the human body.

    This article ignores one crucial point: there is no way to design a good sham for acupuncture because we don’t know how to ensure that we aren’t invoking the mechanisms by which it might work. Using the double-blind RCT model for drugs is easy, we understand the biochemical basis for the efficacy of drugs and so the placebo model makes sense — not so for acupuncture. Comparative effectiveness research is proving to be one of the best research models we have for testing how acupuncture measures up to other types of therapy. That the acupuncture groups did better than the usual treatment group in this study means something. It indicates a possible benefit from acupuncture.

    I would also like to point out that when sham surgeries were performed, before IRBs, results for sham surgeries were very similar. I.e. both sham groups and groups receiving actual surgery showed similar improvement. Why is no one questioning the efficacy of surgery? Because we know it’s effective from clinical experience. Clinical empiricism is an important element of medical practice, not to mention the experience of patients seeking treatment.

  77. #77 Orac
    August 9, 2009

    Wow, you claim to be scientific yet you can’t think of a single mechanism by which acupuncture could be effective? The nervous system is extremely complex, interacting with every system of the body, particularly endocrine system which regulates many of the most powerful chemicals our bodies possess. A series of acupuncture points lies directly over the sympathetic and parasympathetic ganglia. Have you heard of trigger points; have you read any of the research in the area of myofascial pain syndrome and its relationship to the presence of trigger points? Do you know what viscero-somatic and somato-visceral reflexes are? All of these phenomena have a material basis and could very easily account for the efficacy of acupuncture. Not to mention the role of the fascial system, which is proving to be an extremely complex system of tissue demanding inquiry. Not being able to think of a mechanism by which acupuncture could possibly work is demonstrative of one thing only: your utter ignorance of the complexity and profundity of life and the human body.

    Pretty amusing strawman. Your reading comprehension clearly leaves a lot to be desired, as I said nothing of the sort. What I said is that, if acupuncture “works,” it doesn’t do so by that ridiculous “meridians” mechanism.

    This article ignores one crucial point: there is no way to design a good sham for acupuncture because we don’t know how to ensure that we aren’t invoking the mechanisms by which it might work. Using the double-blind RCT model for drugs is easy, we understand the biochemical basis for the efficacy of drugs and so the placebo model makes sense — not so for acupuncture. Comparative effectiveness research is proving to be one of the best research models we have for testing how acupuncture measures up to other types of therapy. That the acupuncture groups did better than the usual treatment group in this study means something. It indicates a possible benefit from acupuncture.

    Only if you misinterpret the results of an acupuncture study.

    Once again, you’re wrong. You’re using a classic appeal to other ways of knowing, and the very thing that bothers you is that the sham acupuncture in this study was in actuality a very excellent control. There was no difference.

    I would also like to point out that when sham surgeries were performed, before IRBs, results for sham surgeries were very similar. I.e. both sham groups and groups receiving actual surgery showed similar improvement. Why is no one questioning the efficacy of surgery?

    Note the clever but ultimately meaningless nonsense here. Yes, certain specific surgical procedures were shown to be no better than placebo. That does not mean that surgery itself is a placebo nor is it a reason why one should question the efficacy of surgery in general. Try again.

  78. #78 Sourmash
    August 10, 2009

    This quote from a comment to your post was supposed to be at the beginning of that post, don’t know how it got erased:

    “I stand by a basic policy in analyzing CAM treatments. Is there a logical and rational physiological basis for the potential success of the treatment[?] Short of Qi or something nonexistent like that, there are no explanations of why acupuncture might work. It’s a simple question that, if answered honestly, helps point me in the direction of whether CAM can work.”

    In other words, it wasn’t a straw man argument, just a mispost. And my response to that comment was apt.

    “Once again, you’re wrong. You’re using a classic appeal to other ways of knowing, and the very thing that bothers you is that the sham acupuncture in this study was in actuality a very excellent control. There was no difference.”

    Actually you’re wrong. You can’t say it was a good control because you don’t know what mechanisms it’s supposed to be controlling against. One of acupuncture’s possible mechanisms is the stimulation of the peripheral nervous system which can be stimulated at the surface of the skin. Some systems of acupuncture use cutaneous stimulation just like would be achieved with a toothpick. I.e. the toothpick sham actually mimicks a form of acupuncture in regular use. That’s why the sham procedure in this study is a poor control, it could have employed the very mechanism by which acupuncture operates. You sure are quick to discount something you obviously know nothing about, you’re clearly more interested in trashing acupuncture than investigating its potential as a therapy. And you’re not respectful at all, ironically.

    “Note the clever but ultimately meaningless nonsense here. Yes, certain specific surgical procedures were shown to be no better than placebo. That does not mean that surgery itself is a placebo nor is it a reason why one should question the efficacy of surgery in general. Try again.”

    Actually, both surgery and sham surgery were shown to be effective as is usually the case with acupuncture studies where the two groups are not significantly different. When compared to an average placebo effect for drug trials (a model that is know to work well) we find that both acupuncture and acupuncture sham have a much higher rate of efficacy than drug placebos, the same is true for surgery. Of course different placebos have different effects, etc., but that’s why more research is needed. Back the the subject of the sham surgeries, if sham surgery is equal to actual surgery in effect, you cannot conclude that the mechanism for surgery’s efficacy is the surgery itself. It could be the placebo effect just the same as with acupuncture. That’s the whole point of RCTs and it’s the standard you’re using to discount acupuncture as a placebo. You’re holding acupuncture to a double standard.

    Check out this recent article about a recent RCT for compression fracture pain surgery.

  79. #79 Joseph C.
    August 10, 2009

    You sure are quick to discount something you obviously know nothing about

    There’s really not much to know. Chairman Mao discovers that it’s cheaper to stick people with needles than to give them real drugs. Then a bunch of New Agey types in “the West” latch onto this because it makes them feel special. sCAM treatment then fails scientific scrutiny. Predictibly, the boosters of said sCAM treatment make a bunch of incredibly pathetic excuses for said failure and demand more investigation.

  80. #80 Sournash
    August 10, 2009

    Guess my arguments are pretty good if you don’t have any response to them. Thanks for proving my point about your ignorance.

  81. #81 Robb Shecter
    March 10, 2010

    I think your criticism may not have taken it far enough: The four arms ALL included “Usual Care”. This fact is left out in the study’s summaries, but is clearly stated in several places. For example:

    “COINTERVENTIONS

    Use of nonstudy treatments for back pain reported at the 8-week interview was similar across the real and simulated acupuncture groups . . .”

    So in reality the was NOT 3 acu arms vs. usual arm, but rather: 3 acu+usual vs. 1 usual arm.

  82. #82 Is this a joke?
    September 7, 2010

    There seem to be multiple science websites crediting the acupuncture placebo study, and from actually sitting down and reading the research, they had significant results. If a person placing toothpicks randomly to acupuncture-naive patients has a greater affect, or even if it had the same effect, it should show you that acupuncture is nothing more than placebo, but you people continue to argue.

    You can call it insolence or whatever you like, but acupuncture pushes itself across as an effective form of medicine, meaning a placebo should not have greater, or even similar results. That’s what science does, and you can whine and complain and call it insolence all you like, but if a prescription drug had the kinds of results acupuncture has, it would be pulled off the market.

    Please don’t post opinionated dribble like this in hopes of turning heads, especially when you’re lacking in evidence.

  83. #83 jenbphillips
    September 7, 2010

    @ is this a joke?

    Is this a joke? If not, you should probably slow down and read Orac’s post again.

  84. #84 Travis
    September 7, 2010

    Is this a joke? #82

    Maybe I am missing something but who are you responding to? First, Orac has posted about sham acupuncture many times and is no fan of acupuncture, to put it mildly. Second, if you are addressing some individual poster here you might want to indicate who they are and the post number, not that it matters in this case as the article is from May 2009 and they probably are no longer following this.

  85. #85 Pablo
    September 7, 2010

    This is a wild thread. Started in May 09. Resurrected with a flurry in Aug 09. Drive by post in March 10. And now a drive by post in Sept 10.

    It needs to be closed.