Respectful Insolence

ResearchBlogging.orgOf all the “alternative” therapies out there, arguably the most studied is the modality known as acupuncture. Perhaps the reason is that, unlike homeopathy, which based on physics, chemistry, and biology alone is so implausible that, for it to “work,” huge swaths of well-established physics and chemistry would have to be shown to be not just wrong but extravagantly and outrageously wrong (making homeopathy far more akin to magic than science), or reiki, which, when you come right down to it, is nothing more than faith healing based on Eastern mysticism rather than Christianity, acupuncture actually involves doing something physical. Indeed, at the risk of annoying or boring long time readers, who have seen me write this many times before, even I used to think that there might be something to acupuncture. Certainly, I recognized that the concepts of meridians along which life energy (qi) flows and how sticking needles into just the right locations on these meridians somehow “unblocks” the flow of qi and thereby relieves pain and heals disease was prescientific nonsense on the order of thinking that evil spirits cause disease. Such ideas may have made sense hundreds of years ago, before scientists developed an understanding of how the body works, but now, in 2010, they are vestiges of a time when medicine really had close to no idea how the body works and when medicine was more often worse than the disease being treated.

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Yet the fascination with acupuncture remains, so much so that an inordinate amount of research dollars are spent on studying it. Of course, as Steve Novella has pointed out, in general in medicine (at least these days), the trajectory of research is from bench research to animal models to small scale, less rigorous, pilot studies in humans to large scale, rigorously designed studies using many subjects. True, this order doesn’t always hold. For instance, if physicians make a compelling observation “at the bedside” of response to therapy or how a disease progresses, frequently, after making closer observations to confirm the initial observation, researchers will jump back to animal models and bench top research to try to figure out what’s going on. For such a progression to be useful, though, scientists have to be sure that the phenomenon in human patients under study actually exists. Unfortunately, such is not the case for acupuncture. As larger, more well designed studies using real placebo or sham acupuncture techniques, have increasingly shown that acupuncture does not function any better than placebo in human beings (and sometimes even worse), acupuncturists and acupuncture believers have been reversing the usual order of things, doing smaller studies and “pragmatic” (i.e., uncontrolled) clinical trials, where the placebo effect is not controlled for. Never mind that it doesn’t matter where the needles are placed (thus blowing the whole “meridian” idea out of the water) or even if the needles puncture the skin. Toothpicks work just as well as needles. Also never mind that the mythology of acupuncture as having been routinely practiced for over two thousand years (or, sometimes, four thousand years, is largely a creation of Chairman Mao, who elevated what was a marginal practice at the time to a modality that the state supported and promoted (1,2,3,4). Unfortunately, even the National Center for Complementary and Alternative Medicine (NCCAM) falls for this mythology.

Sometimes, acupuncture studies even end up in high impact journals like Nature Neuroscience. Of course, what is being studied is not really “acupuncture” per se, but rather sticking needles into either people or animals. Since a bunch of you have deluged my mail box with this particular study, I felt obligated to have a look at it. Before I get to the study itself, though, let’s take a look at the press release:

The research focuses on adenosine, a natural compound known for its role in regulating sleep, for its effects on the heart, and for its anti-inflammatory properties. But adenosine also acts as a natural painkiller, becoming active in the skin after an injury to inhibit nerve signals and ease pain in a way similar to lidocaine.

In the current study, scientists found that the chemical is also very active in deeper tissues affected by acupuncture. The Rochester researchers looked at the effects of acupuncture on the peripheral nervous system – the nerves in our body that aren’t part of the brain and spinal cord. The research complements a rich, established body of work showing that in the central nervous system, acupuncture creates signals that cause the brain to churn out natural pain-killing endorphins.

The new findings add to the scientific heft underlying acupuncture, said neuroscientist Maiken Nedergaard, M.D., D.M.Sc., who led the research. Her team is presenting the work this week at a scientific meeting, Purines 2010, in Barcelona, Spain.

“Acupuncture has been a mainstay of medical treatment in certain parts of the world for 4,000 years, but because it has not been understood completely, many people have remained skeptical,” said Nedergaard, co-director of the University’s Center for Translational Neuromedicine, where the research was conducted.

Why does Nedergaard say “certain parts of the world,” instead of what she really means, namely China, from which the practice apparently spread? Who knows? As I will discuss in a moment, Nedergaard’s study is interesting, but it really doesn’t show that “acupuncture works” any more than it really shows compelling evidence for a specific mechanism behind acupuncture. Unfortunately, as is commonly the case, much of the press reporting this study earns an EPIC FAIL in falling for the spin being put on it. The Guardian, for instance, states:

The discovery challenges a widely held view among scientists that any benefit patients feel after having acupuncture is purely due to the placebo effect.

“The view that acupuncture does not have much benefit beyond the placebo effect has really hampered research into the technique,” said Maiken Nedergaard, a neuroscientist at the University of Rochester Medical Centre in New York, who led the study.

“Some people think any work in this area is junk research, but I think that’s wrong. I was really surprised at the arrogance of some of my colleagues. We can benefit from what has been learned over many thousands of years,” Nedergaard told the Guardian.

Ah, yes. The “arrogance” gambit, coupled with the “appeal to ancient wisdom” fallacy. Nice. If you want to irritate Orac, pull the “arrogance” gambit and then couple it with appeals to ancient wisdom. After all, the ancients were heavily into bleeding and purging, not to mention treating with toxic heavy metals. Does that mean such treatments were “wise” or efficacious. Meanwhile The Daily Mail entitled its report Let’s get straight to the point, acupuncture DOES ease pain, and The Telegraph entitled its report Acupuncture does work as it stimulates a natural pain killer, scientists find, while The Raw Story exulted, Researchers prove acupuncture’s effectiveness in pain therapy. Even Science Magazine was not immune. ScienceNow entitled its article on the study How Acupuncture Pierces Chronic Pain.

Perhaps the silliest and most credulous commentary on this study comes from Elizabeth Armstrong Moore on CNET, who even entitled her post Think Acupuncture’s a hoax? Think again (Scientific research shows natural healing compounds):

And yet another pin in the proverbial coffin for skeptics like myself: The researchers even found that in “adenosine receptor knock-out mice” not equipped with the adenosine receptor, acupuncture had no effect.

So what do revelations about a 4,000-year-old technique have to do with modern technology? The better we understand exactly how needles relieve pain, the more likely we are to invent modern acupuncture kits that are affordable, portable, and safe.

“Skeptic.” You keep using that word. I think it does not mean what you think it means, Ms. Armstrong, as you will soon see.

So, with all this hype going on, even during a holiday weekend in the U.S. and the U.K. (apparently Monday was some sort of Bank Holiday in the U.K.), what does the study actually show? Are the headlines of “acupuncture works” and “scientists discover how acupuncture works” justified? Well, not exactly. Despite all the spin, however, the study actually shows quite a bit of interesting biochemistry behind the pain response. Unfortunately, what it doesn’t show is that “acupuncture works,” despite all the whining about “arrogance” from the study’s lead investigator. All it shows are two things: (1) that a chemical called adenosine is released when needles are stuck into the skin of mice and twisted and (2) that adenosine decreases the pain response. These are actually very interesting findings. However, contrary to the way they are being spun, they in now way validate the belief system behind acupuncture or show that “acupuncture works.”

Let’s get to the science in more detail, although I hate to do it by pointing out the credulous and annoying opening paragraph of the paper that reviewers should have shot down in flames but didn’t:

Acupuncture is a procedure in which fine needles are inserted into an individual at discrete points and then manipulated, with the intent of relieving pain. Since its development in China around 2,000 B.C., acupuncture has become worldwide in its practice. Although Western medicine has treated acupuncture with considerable skepticism, a broader worldwide population has granted it acceptance. For instance, the World Health Organization endorses acupuncture for at least two dozen conditions and the US National Institutes of Health issued a consensus statement proposing acupuncture as a therapeutic intervention for complementary medicine. Perhaps most tellingly, the U.S. Internal Revenue Service approved acupuncture as a deductible medical expense in 1973.

Ugh. This is yet another example of an appeal to ancient wisdom, but this time it’s coupled with argumentum ad populum, better known as the appeal to popularity. I never thought I’d see the introduction to a scientific article appeal to, much less mention, the fact that the IRS allows a modality to be a deductible medical expense, but here it is. Where the hell were the reviewers? I could equally point out that the IRS allows medical deductions for the services of Christian Science prayer healers. Does that mean that Christian Science prayer is an effective treatment for anything? No, it does not. Add to that the whole false dichotomy between “Western” and “Eastern” medicine, a particularly odious and, yes, racist, construct in which the mythical “East” is represented as more “wholistic” and “spiritual” compared to the “reductionistic” and scientific brand of medicine, and it’s a perfect example of what Kimball Atwood would term the Weasel Words of Woo. Note how no evidence for the actual–oh, you know–efficacy of acupuncture is presented in the introduction. True, in the second paragraph, Nedergaard does mention the possibility of the release of opiod receptors, but there is zero discussion of the evidence for and against acupuncture, not even much of an acknowledgment other than that nasty “Western medicine” being so nastily “skeptical” of the practice, as though that were a bad thing.

The model used by Nedergaard is a model of inflammation that involves injecting complete Freund’s adjuvant (CFA) into the mice’s paws. As a result, the mice’s paws would become more sensitive to innocuous stimuli and the latency period for withdrawal to painful stimuli and heat would decrease; in other words, the mice’s paws would be more sensitive, and the mice would react more strongly and rapidly to the stimuli of heat or touching. This sensitivity peaked at day four or five and then decreased. As a preliminary experiment, the investigators noted that, after the insertion of acupuncture needles into the mouse limb at the “Zusanli point,” which is located near the knee a microdialysis probe inserted less than a millimeter away registered a spike in extracellular adenosine levels, as well as ATP (which is broken down to adenosine outside of the cells), ADP, and AMP, that peaked at around 30 minutes:

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(Click for full image)

Having established that adenosine was increased within 30 minutes of an acupuncture stimulus, Nedergaard then injected an chemical that binds to the cell receptor activated by adenosine, the A1 receptor agonist, 2-chloro-N(6)-cyclopentyladenosine (CCPA). Injecting CCPA into the Zusanli point greatly improved touch sensitivity and in essence reversed the increased sensitivity to heat. So far, so good. Apparently in the mouse adenosine has a lot to do with modulating pain response in peripheral nerves. Even better, this effect was not observed in mice genetically engineered not to make the adenosine A1 receptor, known as A1 receptor knockout mice. Investigators also tested CCPA in a model of neuropathic pain (pain due to nerve dysfunction) and found it worked as well as it did in their model of inflammatory pain.

So what’s the link to acupuncture? Well, one thing that this paper failed to mention is that the Zusanli point is not actually a leg acupuncture point, although it is located on the leg, just inferior and lateral to the knee, it is described as the leg portion of the stomach meridian. According to traditional Chinese medicine, this point is also known as Stomach-36 and its current indications are:

The current standard indications for zusanli, as reviewed in Advanced Textbook of Traditional Chinese Medicine and Pharmacology (21) are: stomach ache, abdominal distention, vomiting, diarrhea, dysentery, indigestion, appendicitis, flaccidity and numbness of the lower limbs, edema, mastitis, mania, epilepsy, cough, vertigo, palpitation, and emaciation due to consumptive disease. This latter indication corresponds to the concept that needling this point can tonify the sea of qi and thereby help to stop the wasting disease and restore ones body weight and vitality.

To illustrate the uniformity of indications amongst the Chinese authorities, the following were listed in Chinese Acupuncture and Moxibustion (22, 23), with slight differences on translation between the original Chinese and later Western publications: gastric pain, hiccup, abdominal distention, vomiting, diarrhea, dysentery, emaciation due to general deficiency, constipation, mastitis, intestinal abscess (acute appendicitis), numbness (motor impairment) and pain of the lower extremities, edema (beriberi), manic depressive psychosis.

Thus, according to acupuncturists, most associated with stomach and abdominal problems far more than lower extremity pain. Strange that the investigators didn’t mention that. Be that as it may, here’s what the investigators found:

  • In normal mice of adenosine, acupuncture reduced discomfort by two-thirds.
  • In A1 receptor knockout mice, acupuncture had no effect on the reactions of the mice to the stimuli of touch or heat.
  • During and after an acupuncture treatment, adenosine levels in the tissues near the needles was 24 times greater than before the treatment.
  • Deoxycoformycin, a drug that inhibits the removal of adenosine by the tissues, increased the length of time that the adenosine remained in the tissues (surprise! surprise! given its known mechanism of action) but also appeared to increase the length of time that acupuncture treatment was effective.
  • In mice who had acupuncture but in which the needle wasn’t rotated every five mintues, acupuncture had no effect.

So what does this all mean? First of all, this study is actually quite interesting for its implications for adenosine as a mediator of both inflammatory and neuropathic pain. It was cleverly done and is pretty clear in supporting the conclusion that mimicking the action of adenosine or somehow increasing its local concentration around a nerve might be a good strategy for relieving pain in humans. But does it actually support the efficacy of acupuncture, as Nedergaard claims.

Not so fast.

All this study shows isthat sticking needles in mice causes adenosine production and that that adenosine can blunt the pain response in nerves by binding to the A1 receptor. That’s all well and good, but it doesn’t validate acupuncture. The only thing in common with acupuncture is the needle sticking part, and the investigators might as well conclude that this study validates ear piercing for pain relief. (Egads! Battlefield acupuncture strikes back!) So, it’s quite possible that needles twisted in the area near a nerve might release a flood of adenosine that might bind to A1 receptors in nearby neurons and blunt the pain sensation. No “meridians” or qi needed to explain that. Moreover, this study notwithstanding, Nedergaard seems at a loss to explain how her results might be reconciled with numerous studies in humans that show clearly that (1) it does not matter where you stick the needles and (2) it doesn’t even matter if the needles are stuck through the skin. As I’ve pointed out before, just twisting the end of a toothpick against the skin produces the same effect as acupuncture. She does, however, give it the old college try to explain this, although she does so using the hated term “allopathic” to describe “Western” medicine:

One may speculate that other non-allopathic treatments of chronic pain, such as chiropractic manipulations and massage, modalities that involve the mechanical manipulation of joints and muscles, might also be associated with an efflux of cytosolic ATP that is sufficient to elevate extracellular adenosine. As in acupuncture, adenosine may accumulate during these treatments and dampen pain in part by the activation of A1 receptors on sensory afferents of ascending nerve tracks. Notably, needle penetration has been reported to not confer an analgesic advantage over nonpenetrating (placebo) needle application, as opposed to our observations (Supplementary Figs. 2 and 3) and those of others. However, it is possible that ATP release from keratinocytes in response to mechanical stimulation of the skin results in an accumulation of adenosine that transiently reduces pain, as A1 receptors are probably expressed by nociceptive axon terminal in epidermis. In fact, vibratory stimulation applied to the skin depressed the activity of nociceptive neurons in the lower lumbar segments of cats by release of adenosine. However, this effect differs from the anti-nociceptive effect of acupuncture, which does not depend on the afferent innervation of the skin. Acupuncture is typically applied to deep tissue, including muscle and connective tissue, and acupoints may better overlap with their proximity to ascending nerve tracks than to the density of cutaneous afferents.

This is pure speculation without any compelling evidence. It would also have been easy enough to test. Contrary to her implication, Supplemental Figures 2 and 3 do not refute the results showing that non-penetrating acupuncture works as well as penetrating acupuncture. In Figure S2, all that is shown is that using acupuncture at the Zusanli point on the other leg doesn’t affect the reaction of the leg being tested. All Figure S3 shows is that failing to rotate the needle results in loss of the analgesic effect. Neither refute findings in humans that non-penetrating acupuncture “works” just as well as penetrating acupuncture, where the needles are inserted to the “correct” points. Absent evidence from the current study showing that stimulating the skin results in the release of adenosine and subsequent blunting of the pain response in the extremities of these mice, Nedergaard would have been better off leaving this paragraph out of the paper. Finally, remember: This paper says absolutely nothing at all about all the other myriad claimed benefits of acupuncture in fertility treatments, headache, or hot flashes after menopause, to name a few.

Finally, there are two huge problems with this paper. Here’s the second biggest. Mice are much, much smaller than humans. This Zusanli point in a mouse is going to be within a couple of millimeters of the sciatic nerve. In the human, it’s going to be centimeters away. In the mouse, the size of the needle relative to the size of the leg and distance from the sciatic nerve, as well as the nerve’s branches, the tibial and peroneal nerves, is going to be very close. The tissue damage, virtually no matter where the needle is stuck, is going to be close to these nerves. In humans, this is unlikely to be the case, particularly since the nerves are much further beneath the skin than they are in mice. Thus, there is no good reason to think that these results will necessarily translate easily to humans. Moreover, contrary to the claim that “merdians” map to ascending nerve tracts is stretching it a bit, if you look at these maps. For instance, the kidney, stomach, and spleen acupuncture points line up somewhat with nerves at certain points in the body but are nowhere near ascending nerves in other parts. However, this works in mice, size differences alone will make it hard to replicate in humans.

What really bugs me about this article, though, is that it’s cool science. These guys have found something interesting that may even have a potential clinical application. For instance, local injection of A1 receptor agonists works the same as the “acupuncture.” Adding compounds that slow the removal of adenosine fromt the tissues improves the efficacy of the adenosine released into the tissues by minor trauma. Scientists can work with that. Scientists could take this observation and use it as a justification to work on better, more specific, and longer acting A1 agonists. Perhaps they could even develop oral drugs that are broken down into adenosine or A1 receptor agonists in the peripheral tissues. If this paper’s conclusions regarding the importance of adenosine in pain signaling are correct, these would represent stragies that could very well work and very well improve pain control. One could even envision implantable pellets that could be placed in wounds or near relevant nerves to release A1 receptor agonists right where they’re needed over a long period of time. Unfortunately, Nedergaard and her team are too enamored of the woo that is acupuncture to emphasize the true significance and potential usefulness of their findings.

Instead of working to turn these observations into usable therapies, no doubt Nedergaard and her collaborators will use this preliminary data to apply to NCCAM for a grant to study adenosine in acupuncture further, rather than pursuing this observation in a manner far more likely to lead to a clinical benefit in human beings. So much the pity. Woo poisons the real science it touches.

REFERENCE:

Goldman, N., Chen, M., Fujita, T., Xu, Q., Peng, W., Liu, W., Jensen, T., Pei, Y., Wang, F., Han, X., Chen, J., Schnermann, J., Takano, T., Bekar, L., Tieu, K., & Nedergaard, M. (2010). Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture Nature Neuroscience DOI: 10.1038/nn.2562

OTHER COMMENTARY:

  1. Acupuncture Works, Say Scientists
  2. A biological basis for acupuncture, or more evidence for a placebo effect?
  3. Why was a study on ‘acupuncture’ reported so badly?

Comments

  1. #1 Dave
    June 1, 2010

    I’m so glad you wrote this orac. I read all the media reports of this paper and was convinced they were all missing something. Now I’ve read this I don’t need to read the paper – WIN

  2. #2 Rene Najera
    June 1, 2010

    Bias, bias, bias… I don’t think it’s so much the woo that poisons the science. I think it’s human nature and propensity to bias that poisons the science. If everyone that believed in woo could see their own recall or any other bias, they wouldn’t believe the woo.
    People on fad diets lose weight because they’re cutting calories, not because they’re on a certain diet. People feel much better after a massage because they took a nice nap during it than because of the massage. (Happy endings excluded.) It’s all a matter of perspective… a certain point of view.

  3. #3 Amadan
    June 1, 2010

    Acupuncture?

    I don’t see the point.

  4. #4 MikeMa
    June 1, 2010

    Rene @2,
    I notice an absence of disclaimer. Good news? I will miss them but I think maybe that you wont.

    My ex wanted to do this. It was one of the few woo things I think I talked her out of.

  5. #5 David
    June 1, 2010

    nice post. you’re one of the few sane people to react skeptically to this puffery publication.

    There’s a long literature on use of adenosine for pain treatment (a quick medline search found over a hundred articles on human application of either adenosine or related compounds or agonists/modulators). I know of at least 3 pharmaceutical companies that have, or recently had, adenosine agonists in clinical development. I’ve worked on a few myself. There’s nothing at all new about the idea that increasing adenosine agonists might alleviate pain.

    There’s also nothing new about the idea that damaging tissues leads to adenosine release. purine receptors of all types are well-studied parts of the inflammatory & pain signalling pathways.

    So what actually is new about this study? Only this: they used needles, and added the marketing twist of associating the findings with accupuncture. Guaranteed media attention. But nothing actually new.

    Now, it might have been interesting if they had repeated the study with the needles inserted at random points. That may have led to a new and maybe interesting observation: that adenosine responses either are or are not linked to accupuncture points.

    Disclaimer: I work for a pharma company on pain treatments. I currently have no conflict-of-interest regarding adenosine mechanisms. My opinions are solely my own and are not those of my employers or anybody else foolish enough to maintain association with me.

  6. I think I’ll open a School for Homeopathic Acupuncture Medicine (SHAM).

    We’ll combine the best principals of homeopathy and acupuncture:

    We’ll use imaginary needles.

    Jim Purdy

  7. #7 Clayton
    June 1, 2010

    @jim
    I think you mean you’ll create a salve that is made from diluted and succussed needles and or damaged tissue from said needles. I’m sure the lead investigator of this research has a few she could lend you to make a lifetime supply.

  8. #8 Knotfreak
    June 1, 2010

    I’m going to have to print this and carry it around with me to hand to al the woo-friendly types I run into on a regular basis.

  9. #9 James Pannozzi
    June 1, 2010

    Orac!!! At it again, eh? Ah, the futility of denialism. Still, you’re a good bloke, and the predictability of your foolish consistency is so wonderful, even if “foolish consistency is the hobgoblin of ….” etc. etc..

    Since my field is oriental medicine, including of course, Acupuncture, I find all this theorizing quite amusing. It rather reminds one of some scene from the Medieval era of history, where a group of very learned scholars are defending Aristotle’s theoretical statement of the number of teeth that should be in a horse’s mouth. Of course, eventually, some dimwit had to spoil the discussion by actually counting the teeth and discovering that Aristotle was wrong.

    Now there are all sorts of theories attempting to explain Acupuncture. As is the case with Homeopathy, the evidence of curative success is so overwhelming that the pathetic placebo argument will be summarily ignored. Those that wish to acknowledge the obvious curative effects of both systems of alternative medicine but then attempting to do a quick denialism and ascribe it to “placebo”, which is a genuine phenomenon but of unknown mechanism itself, are welcome to engage in their self effacing rationalizations all they like, just don’t waste my time with it.

    The Chinese? Well, they’ve had a bit of a problem coming up with the one true theory themselves. There’s the “5 element” theory, the theory of “qi”, the supposedly wrong interpretation of “qi” as energy by the French Sinologist George Soulie de Moran who was not a Doctor. Then there’s Van Nghi, who had an ancient un-bowdlerized copy of the Ling Shu written in Ancient style Vietnamese which nobody has ever seen from which he developed his idea of the one true Acupuncture and has left the world a pristine translation. I’ve heard it’s quite good but have not looked at it (yet). Are his theories correct? It is controversial but van Nghi was one hell of a good Acupuncturist and Doctor. One of the greats. Available transcripts of his seminars brilliant. By the way Moran’s book, “Chinese Acupuncture”, written in the 1950′s before any modernistic and scientizing “reinterpretations” had gotten fully underway is highly recommended and gives some idea of the scope and depth of the historical Chinese conceptions. Other good books are out there by the Sinologist Porkert (please DON’T read his book on Acupuncture, it’s a linguistic nightmare, though the stuff of genius, but his other books are good). For the mechanics of Acupuncture as well as a smattering of theory, the standard textbook, by Deadman is quite good, despite the rather poor anatomical diagrams. And, for superb Anatomical diagrams, see books by Quirico and also by Fochs.

    In the 1920′s an official Chinese government attempt to ban the traditional Chinese medicine systems was attempted and failed completely. And in the 1950′s, Chairman Mao, recognizing major inadequacies in China’s medical care systems overall, demanded that the numerous families, sects and groups still holding herbal and Acupuncture “secrets” publish them, give them up and the modern Chinese system of combining Western and Eastern medicine, often in a single complex began It remains today, a model of the successful integration of a countrywide medical system – no theories needed.

    The Japanese? Ah, but they have their theories which (pardon the pun to insiders) “diverged” from the Chinese quite some time ago.
    Their results are often spectacular. Barely touching needles to certain selected meridians, the legendary Japanese acupuncturist Manaka obtained significant success in neck whiplash injuries (in the era before car seat head rests became standard). See his book,
    “Chasing the Dragon’s Tail” for details.

    The Koreans? Yet more theories. And developed systems of hand acupuncture and other techniques.

    But…. that’s theory. What about practice. Well, if Orac is a good little scientifically minded Doctor (and I know he is!!)
    maybe he will go get a copy of “Acupuncture Case Histories” from China, edited by Dr Jinai MD and N. Wang, and read of actual case histories for which modern western medicine had no answer, was inadequate, or produced insufficient results (Chinese herb treatments pooped out too, pun intended) and in which the final resolution including long term cure was effected by (surprise!!) Acupuncture.

    Maybe with that background, drawing some overall conclusions about Acupuncture might prove more useful than drawing sweeping conclusions from a study involving mice paws (poor little mice, why don’t they leave them alone).

    Is all this WOO? Hey, there are some inexperienced Doctors over in Britain calling Homeopathy “witchcraft”. If you want the dark ages, they’re REAL EASY to get to.

  10. #10 Salk
    June 1, 2010

    Orac,

    How do you feel about acupuncture to treat sports injuries (namely, muscle tears)? I have heard many anecdotal claims that it’s extremely effective, although I haven’t actually looked at the literature.

  11. Huh. If toothpicks have the same effect as needles, maybe it’s not the “puncture” that matters, but applying pressure to various points on the body?

    I know that applying pressure to a certain point on the sole of my foot causes my whole leg to relax, so there might be something to it. But, I am not an expert, and that is only my experience — YMMV.

  12. #12 Rich Scopie
    June 1, 2010

    “Research has shown that the wider the needle, the better the acupuncture results. This would explain Jesus’ “miraculous” resurrection – the Romans hammered roofing nails through his chi points.”

    (Source: “A Little Book Of Lies” – Lockwood / Potz-Rayner)
    :-)

  13. #13 MikeMa
    June 1, 2010

    @James Pannozzi
    I stopped reading your drivel at the claim for homeopathy’s overwhelming success. Yikes, are you full of it. I’ll bet you’d make a great used-car salesman or fundamentalist preacher. If this oriental crap gig goes south on you, I’d look into one of those fields.

  14. #14 Rogue Medic
    June 1, 2010

    From the paper, which is available for free at the web site under Advance online publication.

    For instance, the World Health Organization endorses acupuncture for at least two dozen conditions3

    One problem here is that I do not have access to the full text of the paper listed at footnote 3, but the abstract does not appear to have anything to do with whether the WHO is capable of identifying valid science. Maybe the WHO does approve acupuncture, but the abstract seems to be about insurance coverage.

    The abstract of footnote 3 concludes –

    CONCLUSIONS: Acupuncture is an economic substitute for some medical services and pharmaceuticals, a finding of some importance to insurers, healthcare practitioners, and policy makers. The fact that acupuncture has an effect on other medical services needs to be explored more fully with an emphasis on how this substitution impacts patient health.

    Imagine being interested in the way acupuncture affects a patient’s health, rather than how it affects a patient’s health insurance.

    and the US National Institutes of Health issued a consensus statement proposing acupuncture as a therapeutic intervention for complementary medicine. Perhaps most tellingly, the U.S. Internal Revenue Service approved acupuncture as a deductible medical expense in 1973.

    I always want to know more about whether a treatment is tax deductible, than whether the treatment is safe, or efficacious. Of course, the IRS did get Capone, when nobody else seemed to be able to. Maybe the IRS should hire some scientists to review the evidence for acupuncture.

    Although the analgesic effect of acupuncture is well documented

    Well documented?

    It is well documented that acupuncture is almost as good as placebo. How is this a positive for acupuncture?

    However, a centrally acting agent cannot explain why acupuncture is conventionally applied in close proximity to the locus of pain and why the analgesic effects of acupuncture are restricted to the ipsilateral side7,8.

    No, but magic can easily explain this contradiction.

    As Orac did point out that inserting the needles in close proximity is not using the acupuncture points.

    Our findings indicate that adenosine is central to the mechanistic actions of acupuncture.

    Our findings indicate that adenosine is central to the mechanistic actions of placing needles far away from the relevant acupuncture points.

    If only there were some way that could benefit acupuncture patients.

    We found that the A1 receptor agonist CCPA sharply reduced inflammatory and neurogenic pain and that suppression of pain mediated by acupuncture required adenosine A1 receptor expression

    Maybe they have made a discovery that will be useful in the understanding of the mechanism of action of placebo.

    After recording the responses to foot shock during baseline conditions for 20 min, we injected CCPA (0.1 mM, 20 μl) into the Zusanli point of the left leg, that is, contralateral to the foot receiving the painful stimuli. CCPA administered contralateral to the painful stimulation had no effect on fEPSPs, excluding the possibility that CCPA acted centrally

    Maybe it is just me, but injecting CCPA by local contralateral injection and seeing no effect would only suggest that CCPA doesn’t work contralaterally, not centrally.

    If they wanted to find out if CCPA worked centrally, they should administer it in a way that distributes it centrally.

    Similar to CCPA injection, acupuncture in the left Zusanli point (contralateral to the stimulation) had no effect on the fEPSP in response to painful stimulation (data not shown).

    Everybody’s favorite – data not shown. They can spend large amounts of money on this study, but then act as if they are worried about wasting paper. As if most of the readers are not going to be reading an electronic version of this study. How many kilobytes are they saving?

    Combined, these observations provide direct evidence for a role of adenosine in acupuncture-mediated anti-nociceptive effects in models of inflammatory and neuropathic pain.

    Too bad there isn’t any direct evidence of any acupuncture effect greater than that provided by placebo.

    The fact that deoxycoformycin potentiated and prolonged adenosine increases induced by acupuncture raises the question of whether deoxycoformycin can be used as an adjuvant to acupuncture, which potentiate the anti-nociception.

    It might be interesting to see what effect deoxycoformycin (Pentostatin) has on other placebos.

    Notably, needle penetration has been reported to not confer an analgesic advantage over nonpenetrating (placebo) needle application39, as opposed to our observations (Supplementary Figs. 2 and 3) and those of others40,41. However, it is possible that ATP release from keratinocytes in response to mechanical stimulation of the skin results in an accumulation of adenosine that transiently reduces pain, as A1 receptors are probably expressed by nociceptive axon terminal in epidermis37.

    In other words, we are still trying to come up with some sort of explanation for why anyone should use acupuncture, since acupuncture is not as good as placebo.

    If we are putting needles in people to indirectly stimulate the local release of adenosine, to create an effect that is almost as good as placebo, what would happen with local injections of similar amounts of adenosine? What about transdermal adenosine?

    How is this misplacement of acupuncture needles close to the area of pain any different from the effect of slapping, or pinching, an itch to change the sensation?

  15. #15 T. Bruce McNeely
    June 1, 2010

    @James Panozzi:

    Wow! Nice rant!

    However, your story about theorists arguing about horses’ teeth completely undermines everything else you have to say. I love when that happens.

  16. #16 Rene Najera
    June 1, 2010

    @MikeMa
    No news. Is that good news? I think I have given “them” a reasonable amount of time to get back to me on their inquisition. I can either walk on eggshells or be happy. I choose not to walk on eggshells.
    Although, it makes me wonder… If people believe in homeopathy, then it is reasonable to conclude that some will construe my opinions to also be those of my employers (all of them), which is sad.

  17. #17 Scott
    June 1, 2010

    But…. that’s theory. What about practice. Well, if Orac is a good little scientifically minded Doctor (and I know he is!!)
    maybe he will go get a copy of “Acupuncture Case Histories” from China, edited by Dr Jinai MD and N. Wang, and read of actual case histories for which modern western medicine had no answer, was inadequate, or produced insufficient results (Chinese herb treatments pooped out too, pun intended) and in which the final resolution including long term cure was effected by (surprise!!) Acupuncture.

    Because, of course, case histories trump large, carefully designed, placebo-controlled blinded randomized trials. Everybody knows that, right?

    Excuse me while I finish laughing.

    If you actually care about science and facts (which, if you care about patients, you most definitely should) you’re going to have to either explain why the most rigorous trials show an effect compatible with placebo, OR produce equally rigorous trials demonstrating a specific effect. Until you do, you have no leg to stand on.

  18. #18 Tsu Dho Nimh
    June 1, 2010

    it is possible that ATP release from keratinocytes in response to mechanical stimulation of the skin results in an accumulation of adenosine that transiently reduces pain

    Are they really saying, in complex terminology, what every 3 year old child has figured out: Rub the boo-boo and it will hurt less.

  19. #19 Rogue Medic
    June 1, 2010

    @ 18 Tsu Dho Nimh,

    it is possible that ATP release from keratinocytes in response to mechanical stimulation of the skin results in an accumulation of adenosine that transiently reduces pain

    Are they really saying, in complex terminology, what every 3 year old child has figured out: Rub the boo-boo and it will hurt less.

    Not intentionally, but Yes.

    Especially, since they seem to have avoided explaining why they are not using the correct qi points for the acupuncture.

    Posted by:

  20. #20 Jen
    June 1, 2010

    I don’t believe in acupuncture and reiki (although I have tried both. I am a migraneur and pain relief is key for me and friends who suffer from even worse chronic pain.

    I have absolutely no problem with placebos, since the human mind is one of the best pain relievers available. While they may not work for me they do work for my friend, and I will say nothing to disabuse her of that notion since she is under a real doctor’s care.

    Question: what is wrong with a placebo for chronic pain as long as one is getting real treatment for the underlying problems? Especially if it reduces use of serious pain meds.

  21. #21 Scott
    June 1, 2010

    @ Jen:

    One point is ethical – it’s not really ethical to give a placebo to a patient without being explicit that it IS a placebo, which may interfere in its effect.

    A second point has to do with safety. Can you really justify breaking the skin (with some resultant risk of infection) when there are other placebos available which do not carry that risk?

    Thirdly, if one is going to use placebos with the full understanding that they are placebos, then the natural question to ask is how the placebo effect may be most effectively elicited. Denying that the treatment is placebo interferes with that.

    Others may have other objections; those are the three that come to me quickly.

  22. #22 Denice Walter
    June 1, 2010

    I’ve used the tooth-pick study to successfully talk my SO and his BF out of costly, ineffective treatments (physio class over 20 years ago led me to conceptualize accupuncture as being mostly “rub-the-boo”.)So you might ask:”What’s the harm?” Well,for people like those I know,they’d lose a little money, and if the problem were more serious-*they’d go to doctors*.Not everyone thinks like this:previously I’ve recounted the tale of a local accupuncturist(The Record;5/1/10; by K.Markos)who treated his 2 year old’s misdiagnosed(by him) appendicitis and *not* take her to the hospital *despite* her continued illness, pain, and warning from another accupuncturist he had consulted.She died in 7 days;he got 5 years in jail; his wife got off without time in jail:an example of the “arrogance of ignorance” compounded by the “parents-know-best” idea with which we’re all so familiar.

  23. #23 Jojo
    June 1, 2010

    It bothers me every time I see a picture of acupuncture being performed and they show the practitioner without gloves on. The pictured used for this post is even weirder. Only one glove? Who’s doing the acupuncture here, Michael Jackson?

    Are there any studies on the rates of infection in acupuncture patients?

  24. #24 Jeff Read
    June 1, 2010

    …actual case histories for which modern western medicine had no answer, was inadequate, or produced insufficient results (Chinese herb treatments pooped out too, pun intended)

    Dara O’Briain again: “Just because science doesn’t know everything doesn’t mean you can fill in the gaps with whatever fairytale most appeals to you!”

  25. #25 Rogue Medic
    June 1, 2010

    @ 20 jen,

    Question: what is wrong with a placebo for chronic pain as long as one is getting real treatment for the underlying problems? Especially if it reduces use of serious pain meds.

    Depends on what is causing the head ache.

    what is a placebo provider going to do for a legitimate illness, except give more placebo?

    No knowledge of medicine, just pushing placebo.

  26. #26 DesertHedgehog
    June 1, 2010

    So, wait… After half a lifetime of being thrilled by the scene in “Emmanuelle 2″ where Sylvia Kristel reaches multiple orgasm via acupuncture, you’re telling me that…I was lied to?

  27. #27 Rogue Medic
    June 1, 2010

    @ 26 DesertHedgehog,

    So, wait… After half a lifetime of being thrilled by the scene in “Emmanuelle 2″ where Sylvia Kristel reaches multiple orgasm via acupuncture, you’re telling me that…I was lied to?

    I hate to be the one to tell you, but this may not even be the first recorded case of a faked orgasm. However, the Easter Bunny is real.

  28. #28 Kathy
    June 1, 2010

    People with diabetes like me have been performing acupuncture on ourselves for years with insulin needles. I’m no more immune to pain after 27 years and 40,000 shots–must have missed all those qi points.

  29. #29 MikeMa
    June 1, 2010

    @Kathy,
    I’m with you. I have cut down on my shots though – I love my pump!

    All the sticks didn’t do a thing for my pain level when I crashed my road bike last winter. Hurt like hell.

  30. #30 lucy
    June 1, 2010

    @Kathy and @MikeMa – Fellow diabetics in the crowd! I will atest to the fact that needle pricks in my fingers have dulled their sense of pain – but I have to adjust my pricker for deeper pricks to get blood, so I guess its no-win.
    Also there is PLENTY of woo being sold to diabetics in the form of nutritional supplements and magic powders.
    I hope everyone won’t mind me diverting the conversation, but are you guys type I or type II? (I am type I).

  31. #31 Agashem
    June 1, 2010

    Thank you for this Orac. My colleague keeps trying to convince me of the efficacy of acupuncture. As a physical therapist in private practice, almost all other physios practice acupuncture. 25 years I have resisted and insist that there is no reason to puncture the skin. My colleague actually sent me to this article and I said essentially the same that mice are not humans. I am so glad I am not the only one who resists the siren call of acupuncture…..

  32. #32 MikeMa
    June 1, 2010

    @lucy
    I am T1. I had to switch to a meter that I could test using blood from my forearm because the finger sticks, while a bit more accurate, were inhibiting my playing guitar chords. At 8-10 sticks a day, I kick acupuncture butt.

  33. #33 Mojo
    June 1, 2010

    Finally, there are two huge problems with this paper. Here’s the second biggest. Mice are much, much smaller than humans. This Zusanli point in a mouse is going to be within a couple of millimeters of the sciatic nerve. In the human, it’s going to be centimeters away.

    The next step should therefore be to apply to NCCAM for a grant to breed much bigger mice.

  34. #34 Ron
    June 1, 2010

    @31 Agashem: I wish there were more of you! I don’t have back problems often but managed to do something back in December that caused me a lot of grief. I went to physio to straighten it out and ended up with what I thought was someone who was a straight physio therapist (sans woo). HOwever, it didn’t take long for him to bring out the acupuncture needles. Eventually the problem was solved and I know he would say that the acupuncture was a major reason for that (correlation is not causation I would say). My position is that the rest of the treatment (real physio) seemed to irradicate the problem and all that the acupuncture did was distract me from the rest of the treatment because I am super afraid of needles!

  35. #35 Ron
    June 1, 2010

    @31 Agashem: I wish there were more of you! I don’t have back problems often but managed to do something back in December that caused me a lot of grief. I went to physio to straighten it out and ended up with what I thought was someone who was a straight physio therapist (sans woo). HOwever, it didn’t take long for him to bring out the acupuncture needles. Eventually the problem was solved and I know he would say that the acupuncture was a major reason for that (correlation is not causation I would say). My position is that the rest of the treatment (real physio) seemed to irradicate the problem and all that the acupuncture did was distract me from the other things he was doing because I am super afraid of needles!

  36. #36 Mike
    June 1, 2010

    I’m a community acupuncturist in woo-loving California. I read everything I can about acupuncture and Chinese Medicine, including all the material out there against the validity of acupuncture as a treament modality for anything. I deliberately expose myself to the arguments against the practice that ultimately I have experienced as beneficial to myself and to the people who receive these treatments. I have to tell you that whenever the media picks up on a study/piece of news about acupuncture I look into it with a mix of interest and dread: interest just because it’s about what I practice, dread because of how incomplete news coverage of the study/news is (which all acupuncture detractors consistently point out). There is no context for the study as many blogs have pointed out (and this piece of news has brought out many bloggers).
    In placing the validity of my experiences in the line of fire I can say that it has been rough going often living in doubt of one of a handful of major lifetime decisions. But my experiences in helping people out as the “last resort” that so many patients mention have all been worth the doubt. I have no illusions about my or any practitioner’s anecdotes convincing anyone about the usefulness of acupuncture. I hope no one has illusions of convincing me that my experiences are wrong. All I have left to say is that I will continue to expose myself to points of view outside of the one I’m comfortable with/accepting of because it is to my and my patients’ benefit that I work on gaining a balanced view. So thanks for the good blog entry. Take care all.

  37. #37 Rogue Medic
    June 1, 2010

    @Kathy and @MikeMa and @ lucy and other diabetics,

    If you are attempting to get some blood out, it might help to create more favorable conditions. In general, blood vessels dilate when they are warm and constrict when they are cold. You can run warm water, not hot water, over your finger for a minute or two to warm the area up. That should increase the blood supply to the area. More blood available means less digging to obtain that drop, and all you really need is a drop, or two.

    Relaxation also helps to increase blood supply to the skin. Stress does the opposite. Try to use breathing exercises, or other methods of relaxation to make it easier to get the blood sample that you need. Whatever helps you to relax.

    You may also want to keep track of the way you feel, but write this down before you check your blood sugar. You may find that you have certain warning signs when your blood sugar is dropping to a level that requires treatment with sugar. The more you are able to understand the way your body behaves/feels when your blood sugar is low, the less likely that this will cause problems for you.

    When your blood sugar is low, the instinct is to consume the purest sugar in large quantities in order to raise the blood sugar as quickly and as much as possible. This is effective, but is often followed by a rebound drop in the blood sugar. This is to be avoided. You want to consume at least some more complex foods, so that your body has continuous fuel to digest.

    Always follow your medication (insulin, glyburide, et cetera) with some food that will keep your blood sugar from dropping too much. The whole purpose of the medication is to lower the blood sugar by helping to move the sugar into the cells, where it can be useful. You just want to avoid lowering the blood sugar too much.

  38. #38 tioedong
    June 1, 2010

    years ago, while at a CME course on medical hypnosis at Columbia U Med school, our teacher pointed out two facts:
    One: That people having open heart surgery during acupunctures seemed calm, suggesting they were in a trance.

    Two: That hypnosis didn’t work in the patients where acupuncture didn’t work.

    There is a neurophysiological test for the ability to undergo hypnosis: The eye roll (look up, close your eyes while looking up, and measure the amount of white that shows).

    We need more tests that incorporate the neurophysiology of placebo/hynosis with all these sham “cures”, whether it be faith healing, Reiko, or acupuncture.

  39. #39 harbo
    June 1, 2010

    How big is acupuncture department, in the pain unit, in Beijing?

  40. #40 Nick
    June 1, 2010

    “I hope no one has illusions of convincing me that my experiences are wrong”

    How very scientific of you, Mike. Includes 1) belief in the efficacy of acupuncture without evidence 2) a unstated assumption that personal revelations/experiences are valid methods of gauging medical efficacy. 3) a stated unwillingness to change present mindset no matter the evidence presented (aka don’t try to convince me).

    It must be truly wonderful to be free of the human condition- a condition that comes with bias, post hoc ergo propter hoc and confirmation bias. Us mortals must still toil in the world of double-blind, clinical studies and look at actual data. Clearly, you are beyond this process with your super-human woo abilities.

    Mike’s aforementioned comment is really a pleasant and idyllic way of expressing a sentiment of faith.

  41. #41 Travis
    June 1, 2010

    Mike’s statement

    “I hope no one has illusions of convincing me that my experiences are wrong”

    is a common one among many people who simply want something to be true. A physicist friend of mine (some physicists have some funny ideas, I know. But I am not dumping on physicists here at all, I have a physics degree, and still love the topic) is a tarot master and on a poster advertising his services I once saw that exact same sentiment. He actually said it did not matter what the evidence was, it was true and worked.

  42. #42 gaiainc
    June 1, 2010

    Scarring can also happen, which makes capillary blood draws more challenging. It is one reason to rotate injection and finger-prick sites.

    I had gestational DM, was asked to test four times a day, and ended up on a whiff of a dose of a sulfonylurea that one day dropped my sugar to 40. I hope never to experience that drop again and I was trying very hard to coordinate my medication with my eating to avoid the drop. I’m also a family physician and knew very well the importance of tight sugar control. Yet there were multiple times when I had the lancet out, was going to prick my finger, and had to talk myself into actually pressing the button. I’m really glad I don’t have to do that again.

    Mike, read up on confirmation bias and recall bias. They are real and placebos can have interesting effects.

    More on topic, I must tell you that I’m shocked, absolutely shocked that when you cause a noxious stimuli a body releases substances to minimize the noxious stimuli. /sarcasm/ That said, there’s nothing here that supports accupuncture unless you want to devolve accupuncture into something that just gives a noxious stimuli. Somehow I don’t think that’s what most accupuncturists think that is what they are doing.

  43. #43 Phoenix Woman
    June 1, 2010

    Shorter Mike @ 36: I don’t care what you all say about the placebo effect — I know what I do works and I’m not ashamed to do it!

  44. #44 Graphictruth
    June 2, 2010

    I think it’s safe to say that some large proportion of cures attributed to acupuncture could be attributed to placebo effect.

    But then, some large proportion of ALL medicine may well be attributed to placebo.

    http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect?currentPage=all

    The observation in comments above that those who could successfully be treated with acupuncture were also the same people that could be hypnotised successfully is interesting, and worth consideration.

    But in the meantime, on the ground and in the trenches, as a practical-minded healer, I’d first ensure that the treatments I had were as effective as could be achieved – and then add such “woo” as I felt would tend to increase my patient’s faith that the medicine would work.

    I remember reading a factoid, years ago, that some estimates suggested that placebo effect accounted for 60% of all medical success. Most likely it was the Reader’s Digest, so let’s just say 15%.

    Well, what other harmless and broadly effective treatment do you have that improves a patient’s healing by that amount?

    I’d suggest that wearing feathers and dancing would be a small price to pay – but in fact a white coat and a stethoscope have the same impact on a patient. It’s suggestion, it’s trickery, it’s a species of woo… and it works.

  45. #45 Mojo
    June 2, 2010

    @Graphictruth:

    But then, some large proportion of ALL medicine may well be attributed to placebo.

    This is acknowleged, and that is why treatments are tested against placebo controls. You are arguing against a strawman.

    The difference between medicine and most forms of CAM is that medicine includes the placebo effect as well as effective treatments, while CAM includes the placebo effect instead of effective treatments.

  46. #46 Muscleguy
    June 2, 2010

    @33 Mojo

    We already have larger mice, they are called rats. When the rats are too small we use rabbits and move from there. Sheep are roughly the same body weight as adult humans for eg.

    You choose your experimental animal appropriately. However this experiment was done in mice I suspect purely because mice have this wonderful resource of knockouts you can just order up from the Jackson Labs. So if you want to include A1 receptor knockouts in your experiment you are limited to doing the work in mice. Such are the compromises you must make in doing science.

    What gets me about the media coverage of this is the assumption that the placebo effect is either nothing or works by magic. That it might work through adenosine or endorphin release never occurs to them. Even placebo effects need mechanisms.

  47. #47 DNAl ady
    June 2, 2010

    @37

    21+ years of prickin’ your fingers causes a lot of scar tissue so that it doesn’t matter how warm your hands are. Also, diabetics seem to have very thick skin on the hands and feet. A podiatrist told me that. You have to prick deeper and harder on fingers, or move to the arm testing system.

  48. #48 DNA lady
    June 2, 2010

    Oops, my previous post was off subject. My apologies.

  49. #49 Observer
    June 2, 2010

    Hmmmmm Peer reviewed journal article, versus some blogger? Of course, go for the blogger who validates one’s biases anytime in the same way certain folks go for Rush Limbaugh and Sarah Palin versus Paul Krugman when thinking (in its loosest sense) about economic policy.

    I have had acupuncture treatments for my back, in particular sciatica, and found them incredibly helpful. So, one can take muscle relaxants (flexoril), do physical therapy, etc. for years as I did with no benefit. Or, one could try acupuncture; three acupuncture treatments for me and my back is sorted out for months to a year. Of course Mr. Pharma would assure us it was merely a coincidence that each time I had a flare-up the acupuncture immediately helped.

    Who are you folks? Drug (pharma) reps? This Orac character seems to have the intellectual wattage of the average Creation Scientist, who is woefully less clever than the none-too-clever Behe. Striving for the back-up junior writer slot on “Myth Busters”?

    Good luck, and keep those Pharma profits coming.

  50. #50 Todd W.
    June 2, 2010

    @Observer

    I doubt anyone would argue that you did not experience what you claim (i.e., reduction in pain after receiving acupuncture).

    That said, do you have specific arguments against what Orac wrote? Can you show where he is incorrect in his review of this study? And, most importantly, can you make your arguments without resorting to the Pharma Shill gambit and insults?

  51. #51 JohnV
    June 2, 2010

    Ok who is really posting as observer? No one could repeatedly throw out the pharma shill gambit and then use their anecdotal experience as proof of anything then compare other people to stupid creationists.

  52. #52 Alan
    June 2, 2010

    Wow. It’s amazing that people can still claim that experiments and trials FAIL because of some case studies done. Please, for goodness sakes, case-histories are the single least generalisable form of scientific medical enquiry.

    Evidence=wise a case-history vs. a trial is like an under 8 footballer vs. a particularly cranky Mike Tyson. For those CAM fans who like to think of themselves as sceptics, wouldn’t you expect the amazing things that happen in case-histories to come through in trials? Because that’s like a whole big whack of case histories all looked at together (simplistically speaking). Or do these things only work when they’re in a closed room with the CAM therapist? Very odd.

  53. #53 Colin Day
    June 2, 2010

    What would happen if you inserted a needle in such a way that it blocked a synaptic gap? Or is that not how acupuncturists believe that acupuncture works?

  54. #54 Muscleguy
    June 3, 2010

    @53 Colin Day

    The tip of an acupuncture needle is an order of magnitude too big to fit in a synaptic cleft. We have incredibly fine drawn glass recording pipettes that can’t do that. We stick them into the sending nerve terminal or the postsynaptic cell instead. Also a needle into a ganglion, which is the only place you would find nerve synapses in a limb, would hurt like hell.

    Also there are no ganglia in that part of a mouse limb, just nerve fibres all bunched together as Orac explains. They really are very close to the surface there in the mouse, when skinning a mouse limb you have to take special care not to rip them off with the skin. The muscles are organised differently in humans due to us being bipedal so the same nerves are relatively much deeper down.

  55. #55 WLU
    June 3, 2010

    Does anyone know anything about dry needling? It basically looks like acupuncture without the magic. It also looks like it’s being co-opted by acupuncturists to validate their claims rather than co-opting acupuncture to have a science-based alternative for an actually medically meaningful practice of jamming needles into people.

  56. #56 Mike
    June 3, 2010

    @gaiainc: thanks for the reading direction on the different biases. I’ll be looking into it. I personally found it interesting that respondents focused on my comment about not subjecting me to arguments re: the scientific evidence against acupuncture as a way to convince me of my how wrong I am/could be. I’ll disillusion myself, thank you. The gist of the actual post–in my mind at least–was that I’m looking for answers. I work in doubt when I read the research available about this modality that as I’ve stated before has benefited me, my family, my patients. But that doubt disappears when I see the results that many–not all–of my patients achieve. And then I look more specifically into my failures to see what I missed, to see how I can improve. But maybe this particular search for answers does not fit with the purpose of this forum. I’ll leave you with something else that will irritate many of you: when I speak of my experiences as real to me I also include my witnessing the results of practitioners far superior to me. And some of these results have been extradordinary. So now not only am I basing my belief in the efficacy of acupuncture (my faith, as Nick pointed out) on personal experiences but I’m also basing it on the experiences of others. Like I said, I’ll disillusion myself, thank you. Take care all.

  57. #57 greenasil
    June 4, 2010

    I read a book recently that I feel is an excellent work. Well worth the read for non-technical, but science-curious audiences.
    Trick or Treatment: Alternative Medicine on Trial by Edzard Ernst and Simon Singh

  58. #58 Mojo
    June 5, 2010

    @Muscleguy:

    We already have larger mice, they are called rats.

    We already have rats, so there probably wouldn’t be much point in applying for grants to develop them. But bigger mice, now…

  59. #59 Mojo
    June 5, 2010

    @Colin Day

    Or is that not how acupuncturists believe that acupuncture works?

    No, it isn’t. They claim that it works by enabling qi (or “vital energy”) to flow freely along meridians.

  60. #60 tanya.
    June 6, 2010

    The plural of Denial is not science!
    And the reference to Ernst and Singh are ludicrous. They are people in the UK who spearhead the denialist camp against CAM. However, besides being shills for Big Pharma, they have little but noise to make. And if the media wasn’t so biased, then their voices would be drowned out in an avalanche of laboratory science and clinical evidence that contradicts everything they ignorantly and/or arrogantly blab on about.

    The so-called god of science that this writer seems to lord over the world of health, is not so scientific. The number of drugs that have been scientifically tested are very few in number, particularly for many of the conditions they are used to treat. The public becomes the clinical guinea pigs without their consent.

    Look at the number of drug recalls after major health disasters from their toxicity. A recent one is the diabetes drug Avandia which is known to cause heart disease. And what brilliant science sold the world on Vioxx that killed between 40-60,000 deaths from heart disease–the very thing that it was presumably preventing.

    Ralph Moss writes extensively about the so-called science of the cancer industry. He worked for the Sloane-Kettering Cancer Institute for many years. He is a medical journalist and was quite embedded in that industry. He calmly and rationally notes many of the bogus research studies done and the even more bogus manipulation of the data in order to sell what the medical industry is pushing. What else is new.

    Vaccines have NEVER been proven either effective or safe. That is right–Never proven! But lots of money selling the poisons and denying their short and long-term toxic effects.
    However, the ‘science’ is out there that shows the harmful effects of these drugs. And what kind of science is it that puts known neurotoxins and carcinogens into drugs that are pumped into newborns for diseases that they will never have. Yes, why are newborns given Hep B for a disease that is rare in this country, but is a mandatory drug given within hours of birth? A simple blood test for the mother would indicate if she has Hep B and might contaminate the newborn. How about the science of the CDC that clearly shows that public health improvements of sanitation, better food and housing, cleaner water are the reasons for many diseases fading out of a population. The list of bogus and manipulated ‘science’ around vaccines fills several encyclopedias but mass marketing and the buying of congress is what sells these dangerous poisons. And if anyone dare to even raise a question, they are pilloried and guillotined in kangaroo courts.

    As for acupuncture and homeopathy and other forms of naturopathic healing, I can only attest to the fact that they do work. The science for them is strong. Healing occurs and it is not placebo. It is not placebo when animals, babies, or plants heal. They are not trying to please the owner and they don’t know they are being treated.
    Very recently there were lab tests in the USA showing the ability of homeopathy to kill cancer cells–4 remedies had this effect in petri dishes. There was no placebo effect here. The cells were not trying to please the researcher.
    All remedies tried did not work. That is simply because there are distinct differences between the remedies and they each have their unique sphere of action.

    There are only 2 reasons why someone has difficulty accepting new ideas. The first is simple: they are being paid by a special interest to promote the idea. Doctors receive $1000′s/year to act as speakers for drug companies at many prestigious events. They allow their names to be put on industry written papers for publication in medical journals. This scandal has been exposed numerous times involving prestigious, international medical journals such as the Lancet and JAMA. The problem is always lack of transparency–otherwise the ruse wouldn’t carry much weight. Medical schools teach to the drug companies interests as they take money from that industry for their teaching facilities. Pure sleaze! Finally, medical students today are beginning to push back against the heavy presence of the drug companies in their schools and classes.

    The second reason is more difficult in a way. It involves a Social Psychology concept called Cognitive Dissonance. That means that people have a difficult time taking in information that doesn’t jive with deeply held belief systems, or facts and ideas that don’t fit their experience. The trick is that when confronted with facts that don’t fit one’s beliefs or paradigms in life, people will make all kinds of excuses to save their strongly held perceptions. And they will try to use what they call science to justify their close-mindedness. Belief systems are not just in the arena of religion. We have belief systems about our politics and our economic system and our education system. We have belief systems about class, race and sex ideas. And these belief systems come with value judgements.

    In the case of acupuncture or homeopathy or other naturopathic healing protocols, cognitive dissonance prevents people from taking in new concepts of healing. When people do not want to have their reality tested, they will fight tooth and nail to defend their cherrished beliefs. This article is a case in point. Clinical evidence shows the efficacy of acupuncture. If sticking needles anyplace on a person were to produce ATP, or any other numbing response, then we would all be able to do this for ourselves in the comfort of our homes. The truth is that acupuncture treatments are not just about pain relief. It has been used to rebuild tissues and heal some pretty deep seated conditions. And sometimes it doesn’t work, or it needs repeated treatments to effect cure. As one acupuncturist said to me a long time ago, it is the people who will let her work deeply on emotional issues that receive the deepest cure. She was recognizing that emotional energy gets locked into the body and without releasing it, we do not get to the cause of our susceptibility for whatever ails us. That includes some of our deepest diseases such as cancer.

    This author seems to be part of the organized denialists in the USA in concert with those in the UK who are trying to destroy our freedom of health access. While trying to sound erudite, throwing around scientific terminology, they are just showing their own medical bigotry and ignorance. Most healing systems in the world were based on energy and it has been known by man for millenium that we all relate to energy. It is the pathway that enabled humans to live, develop and thrive over the 1000′s of years without toxic drugs and multi-million dollar advertising campaigns and the need to buy medical schools and congressman to ensure their control over our bodies. The god of science has been used to sell billions of dollars of useless drugs to people which make them sicker. This science has been used to sell all kind so bigotry. Witness the attempts every few years to try and use science to promote racial inequality and bigotry. And it is always the same bogus information that get used like retreads on an old tire.

    It seems always good to remember that new ideas are first fought against, then ridiculed, tolerated and finally accepted. Those suffering from cognitive dissonance would do well to remember this. Those who are being paid for their dishonesty–well they know who they are and we will find out in due course!

  61. #61 Chris
    June 7, 2010

    My, my, my, my… lots of verbiage, but no evidence. Those this bit is a little silly from someone who defends homeopathy: “It seems always good to remember that new ideas are first fought against, then ridiculed, tolerated and finally accepted.”

    So are you saying that homeopathy is a new idea compared to antibiotics and vaccines?

    Continuing with: “Those who are being paid for their dishonesty–well they know who they are and we will find out in due course!”

    Unfortunately it took ten years to figure out that Wakefield was a lying fraud.

  62. #62 Martin Voelker
    June 7, 2010

    You concluding sigh that these researchers will likely waste their energy barking up the wrong tree reminds me of another example from the history of science. As told by science historian Elizabeth Thornton, Sigmund Freud snuffed loads of cocaine and prescribed it to his “hysterical” patients but failed to recognize its true medical glory: as a local anesthetic for eye surgery. It was right in front of him but eventually, someone else earned the fame.

  63. #63 Stevescrutton
    June 7, 2010

    I wish all those people who get better from serious diseases using homeopathy and acupuncture would just stop lying about it.

    Ah! But of course it only works because of placebo!

    Anything, any argument, to prevent lazy scientists looking into why they work, and explaining what has been observed for millenia – that people consistently get better.

    Pity. I thought the task of science was to explain what is observed. Obviously not!

  64. #64 Travis
    June 7, 2010

    Stories of people getting better using homeopathy are anecdotal, who knows what else they have done, or taken, or whether the condition would have just gotten better on its own. That is the problem with these stories. No one accuses them of lying.

    Scientists have looked into whether homeopathy works and has found it does not. There is little point in trying to find out why they work when there is no evidence of this. So they have explained what was observed, it is just that what was observed is not what you want.

    Feel free to show some published, peer-reviewed evidence that they work, and if they survive scrutiny then perhaps there is something to it, but there is a mountain of evidence against that has to be scaled. So they had better be good.

  65. #65 Orac
    June 7, 2010

    Tanya looks like a hit-and-run troll. My guess is that she won’t be back.

  66. #66 woowoodoc
    June 19, 2010

    I’d like to see orac’s placebo-controlled, double blind studies on the surgeries he performs, as well as long-term studies on their effects (20-40 years) on physiology and incidence of pain. and then a comparison with the risks of nocosomial infections and other iatrogenic diseases and deaths caused by surgeons every year. let’s let the cat out of the bag and see how safe “standard” medical care really is, orac.
    and then let’s compare it to acupuncture’s risk/benefit ratio, and you tell me what seems like the more rational choice for pain reduction. something that’ll possibly kill you and still not work, or might work now but make you more debilitated later on (hello laminectomy!)…or something that might simply not work?

    waiting…

  67. #67 Antaeus Feldspar
    July 2, 2010

    “woowoodoc” @ 66 is demonstrating the tu quoque fallacy. “Sure, I can’t prove that acupuncture is any good at all, but don’t pay attention to that, pay attention to my vague allegations that conventional medicine is bad!”

  68. #68 anon45
    January 21, 2011

    Are you discounting all of ‘homeopathy’? The idea of controlling allergy (at least to a small degree) by giving a small dose of the allergen to the patient on a regular basis does not seem so crazy to me from a biological point of view. Perhaps there is ensuing T-cell tolerance that holds off a full immunological response? Anyhow, I’d love to know your references that show that this does not happen, because my mother is currently undergoing this treatment.

  69. #69 Vicki
    January 21, 2011

    Anon45:

    There are numerous studies showing that homeopathy doesn’t work; more to the point, there are no good studies showing that it does. This means that, at best, it’s in the same epistemological place as, oh, the claim “If you wear a Derek Jeter jersey, you won’t get the flu” (a random but untested claim. Except that people haven’t spent decades trying, and failing, to prove that Derek Jeter’s name is protective against disease.

    Giving a small dose of allergens to desensitize someone is not homeopathy. The treatment you describe involves small but measurable amounts of the allergen. A homeopathic preparation of an allergen would contain no molecules of the allergen. If a homeopathic preparation is done “properly,” that is according to the rules of homeopathy, it will be pure water. Or, perhaps, pure water carried in a mixture of alcohol or sugar.

  70. #70 Leanne Jarak
    February 20, 2011

    I have seen many people seriously damaged, injured and even killed by western medicine. People have had lives ruined by this form of “medicine” which uses heavy handed tactics (immuno supressants, anyone) for conditions which should FIRST be approached with acupuncture, or even diet and physio changes.
    Western mds are incredibly arrogant; they use doulbe blind studies as some type of strange religion. Yet there is no such thing as a true double blind study as every subject is different.
    Yet most docs blather on how alt meds are woo. In my eyes, after seeing people unable to walk, and having spinal paralysis after back surgery, I will try gentle, effective medicine which works. Dear Doctor, you don’t know everything, and your patriarchial arrogance turns many people off. Medicine is about healing, not studies.
    In any case, you are wrong. And in the end your old fashioned approach to medicine will die-is dying, just look at how alt medicine is integrated for best outcomes for the patient. In the end, that is what you should care about instead of your huge ego.
    What is best for the patient?

  71. #71 Antaeus Feldspar
    February 20, 2011

    What is best for the patient?

    What is best for the patient is what actually works. Not what the doctor, or the patient, has deluded themselves into thinking it works. If your alternative medicine doesn’t work when subjected to double-blind testing, that means that it doesn’t work, period – except in the eyes of a deluded observer.

    You probably don’t comprehend this, as you make the nonsensical claim that “… there is no such thing as a true double blind study as every subject is different.” It raises the question of what you think a double blind study is. If neither the investigators nor the patients have knowledge of who received the experimental intervention and who received placebo, that’s double-blinding. An experiment could be conducted where an acupuncturist/homeopath/other woomeister determined what the “correct” woo for each patient would be, but randomization would be utilized to select which patients received the woo treatment and which received placebo. So much for “… there is no such thing as a true double blind study”.

  72. #72 novalox
    February 20, 2011

    I pity these troll necromancers, they talk all this crap but don’t have a damn clue of what the hell they are talking about.

  73. #73 Martin Varesio
    March 1, 2011

    This means that, at best, it’s in the same epistemological place as, oh, the claim “If you wear a Derek Jeter jersey, you won’t get the flu” (a random but untested claim.!!!

  74. I think the main difference between homeopathy and acupuncture is the big drugs companies can make loads of cash out of homeopathy but not acupuncture.

    If the big companies could make a killing out of acupuncture, you can be sure there’s be more docs and specialists claiming it’s the univeral panacea.

    Patients should probably be able to access both, as long as they pay themselves and it’s regulated so these snake oil salesmen are forced to say how useless these texhniques really are :-)

  75. #75 Jacob
    June 5, 2011

    Maybe go to the ‘proud parents of unvaccinated children’ page on facebook and see how many of them have tried acupuncture?

    Maybe it is just the needle they object to.

    Or maybe they are ‘reversing autism’ with acupuncture or a similar placebo?

    (lol. I am pro-vaccine, i know there is no ‘cure’ for autism)

  76. I hope it is worth your time to write all this. 4,000 years of results speak volumes

  77. #77 Beamup
    June 10, 2011

    They certainly do, especially when those results are all negative.

  78. #78 Chris
    June 10, 2011

    “Not quite a real” Dr. “Necromancer” Brown, that was a pointless appeal to antiquity.

  79. #79 Micah
    September 28, 2011

    @70 I do agree with you because traditional medicines or medication is more effective compared to what we called western type approach and has little or no side effects. I wonder if this acupuncture works on autism or any sense integration problem?

  80. Acupuncture is a good Chinese medicinal alternative. It is really effective though some claims it is not or it is harmful. But so far for me, there are no side effects.

  81. #81 James Chong
    December 13, 2011

    E² Acupuncture Science
    Any skeletal muscle pain can be easily cured by Tradition Chinese Medicine (TCM) Acupuncture.

    For 4,610 years (2600BC), Yellow Explorer’s time. Until now acupuncturist continues this ancient TCM practice to eliminating all diseases (trying). All the main hospitals of China use this to treat most patients as busy as KFC fast food.

    Acupuncture treatment will has needling sensation effect for first few days. This called “DE Qi/Chi” (Arrival of Oxy’Blood—needling sensation). it must be achieved so that Yin & Yang(Negative and Positive energy) can be balanced and body’s immune system has strengthens, else diseases can’t be eliminated. The fundamental manipulating techniques are Lifting and thrusting & Twirling or rotating. TCM Acupuncture therapeutic works and easily cures muscular pain if apply correctly.

    Beside sciatica(more trials needed), all others skeletal muscle pains are not recorded in TCM text therefore no “Acupoints(???)” can be provided to any acupuncturist as that they need to advancing the practice and pick the right AcuPoints.

    Be respectful, Acupuncture is not a device or voodoo magic, it does not release any things (certainly not endorphins, inflammation, etc, ..) or anti-inflammatory agents. Please do not mislead. It is a marvelous 4,610+ years old, micro surgical tool, etc, .

    An acupuncture is bad science”. not much can be expected in 4,610 years ago, good science & resources only available from 1850AD such great scientists: Heinrich Hertz (1887) & Albert Einstein (1905).
    Since 2005 E² Acupuncture has added a new chapter of modem acupuncture science. which has scientific proven, formulated, verified and even dispelling the amount of excessive Yins/-Toxin can be calculated. Treatment uses single new save disposal and painless micro-needle insertion to proper “Acupoints(??)” and has no side effects, least risk mainly due to accident same as any treatments. No Lifting and thrusting & Twirling or rotating manipulating needed so that patient cans comfortably having a cup of tea/coffee.

    Acupuncturist must fully understood the Five Elements(五行), Five Changes(五变) and Five Shu/Transports(五输/通) Yin & Yang balance principles. if any one treated by 5 X 30 minutes in 2 weeks and has no relief by 4 weeks, please discontinues and shop around.

    I have my Plantar fasciitis cured twice by my own EE Acupuncture, last cured was on march/2011 since then pain remains free and no sign of coming back. (EE: Eliminates Excessive Yins/-Toxin/Electrons)

    check/click on my site below
    google.com/site/jameschongpainfree

    or more help below sites
    talk.plantar-fasciitis.org
    groups.google.com/group

    Sciatica update (loc: buttock & 5 inches down, 2 spots).
    treated on 30th/10/2011.
    12 days after and feedback:

    “Been feeling the slight tenderness in the area where the needle were inserted. Felt my legs is tired but not the numbness.” (50% pain relief, 100% no numbness)

    5 weeks Later (email on 4th/11/2011):
    “Seems to be fine, slight tenderness but definitely better than before” (now 90% cure)

    why pain relief if it can be so easily cured.
    and the cost of curing it is so much less then a pair of PF shoes and not to mention others, .

    cheers
    James

  82. #82 Black Smith
    December 14, 2011

    Acupuncture operations for me is not safe if only done at home. We should need some medical assistance before doing it.

  83. #83 James Chong
    December 17, 2011

    To all the natural medicine, acupuncture supporters and the following sites
    google,
    plantar-fasciitis.org,
    pubarticle
    and many others

    especially this site scienceblogs
    Have allowed me to provides you the Great truth scientific facts of this hidden 4,610 years old TCM Acupuncture practice.
    Now you got the scientific facts from
    https://sites.google.com/site/jameschongpainfree/
    I hit to turn myself to be a science tutor , if you’re remain unconvinced, check on The Mad Man at http://www.topix.com/forum/life/veterans/TFDRMKGFDQM4H0C9J
    Of cause you’re entitle your opinions.

    For many perhaps thousand years of criticism such bad, dead, voodoo magic and snake oil sales man acupuncture science. Especially from those top most profession.

    Don’t you think TCM Acupuncture deserve an apology into this scienceblogs


    James.

  84. #84 lilady
    December 17, 2011

    @ James: Hmmm, no I don’t think any of us owe you an apology. Quite to the contrary…your spamming link reminds me of the posters I’ve seen that sell illegal firecrackers, and is perhaps the dumbest ad I’ve seen in a very long time.

  85. #85 Agashem
    December 17, 2011

    Also, Mr. Chong’s anecdote of someone’s sciatica resolving after many weeks of acupuncture is laughable. Very few people have sciatica that lingers that long and essentially, many cases of sciatica are self-limiting (same with back pain which, in 80% of people will spontaneously resolve given they don’t stop living their lives).

  86. #86 Mephistopheles O'Brien
    December 17, 2011

    Mr. Chong – I reviewed your web page for scientific evidence that acupuncture was in some way effective, and saw nothing. Could you please be more specific?

  87. In 2001, published Hendrik Sch..’s scientific scandal can only fool you a year or 2. But not to the scientific facts and so as acupuncture. It can’t fool you for 4610+ years long. simply because of languages barriers have mislead, . .

    Below another evidence since E² acupuncture science online.
    S/He shop around and now Pain free, ..

    from http://www.examiner.com/holistic-science-spirit-in-national/new-scientific-breakthrough-proves-why-acupuncture-works?fb_comment=16922196

    Anonymous 1 week ago

    I never thought acupunture worked, being a skeptic and never seeing any evidence, I had it once before and it didnt work for the condition I had. I recently reluctantly tried it on the urging of a friend at a free birthing clinic in a developing country. I found the acupuncturists to be very knowlegable about my condition which is Hashimotos. And they stuck the needles in deep this time, unlike the last time I had it. That was two months ago. I had been severedly fatigued everyday at the same time for a year without missing a day, and 24-48 hours after the treatment, I was not experiencing any fatigue. Its been 2 months without any fatigue, I would say it was either a miracle or it really does work. The quality may vary with practitioners I have guessed, make sure the needles go deep, you should feel a pressure feeling and a paralysis feeling. You will be unable to move for the duration of the treatment. Even while getting the treatment I was thinking this will not work!! And they moxibusted on the needles to, which gave off a lot of smoke, and I was even more skeptical, hating the idea of smoke for health. But by geez it worked, I still cant beleive it. There is so much we dont know, so much knowlege has been lost, just think of all the wars that are going on now, multiply that times 5,000 years and think of of all the things that were destroyed in the chaos. Hell, maybe god even exists….

    For latest scientific facts update, please check/click on my site
    https://sites.google.com/site/jameschongpainfree/

    James Chong

  88. #88 Visitante
    March 3, 2012

    The pseudoscientific attitude is pseudoskeptik blog: Reject all evidence, use fallacy arguments and use know technique of internte, in example: Pseudorefutation (i.e. this blog), and use opinions who arguments.

  89. #89 Chris
    March 3, 2012

    Visitante, I am sorry but this is a blog based in the United States of America. Try again in actual English if you wish to be understood.

  90. #90 mrs.marry
    May 21, 2012

    Mrs.marry TESTIFIER

    My Name is Mrs. Marry, I was married to my husband for 14 years and we were both bless with three children, living together as one love, until 2011 when things was no longer the way the was [when he lost his job]. but when he later got a new job 6 months after, he stated sleeping outside our matrimonial home. only for me to find out that he was having an affair with the lady that gave him the job. since that day, each time called him, he no longer pick up my calls and he don’t want to see me around him and he also deleted me from his facebook account.
    I reported him to harry SPRINGER ON NATIONAL TV [MESSY AFFAIRS], i did many things all just to see if i can just get my husband back. but nothing since to come out good. yet my husband just still keep on seeing the lady.
    Until I met a very good friend of my who was also having a similar problem, who introduced me to a very good love spell caster. but i told her that if it has to do with money that i am not interested, but she said that it has nothing to do with pay first. but the only thing she was ask to do was just to go and TESTIFIER, and that was what she did. And she gave me the spell caster e-mail address and phone number.
    When i contacted him, i was so surprise when he said that if i have the faith that i will get my husband back in the nest three [3] day, and off which it was really so. but i was so surck that i did not pay any thing but my husband was on his knells begging me and the children for forgiveness. this testimony is just the price i have to pay. This Mr.Dr.rivers is good and he is the author of my happiness.this is his e-mail Dr.rivershebalisthome @gmail.com

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