Respectful Insolence

ResearchBlogging.orgAt the risk of once again irritating long time readers who’ve hear me say this before, I can’t resist pointing out that, of all the various forms of “alternative medicine” other than herbal medicines (many of which are drugs, just adulterated, impure drugs), acupuncture was the one treatment that, or so I thought, might actually have a real therapeutic effect. Don’t get me wrong; I never bought magical mystical mumbo-jumbo about “meridians” and “unblocking the flow of qi” (that magical mystical life energy that can’t be detected by scientists but that practitioners of woo claim to be able to manipulate for therapeutic intent). The point is (sorry, couldn’t resist) that acupuncture actually involves doing something physicial to the body, namely inserting thin needles into it. Shorn of its trappings of prescientific Eastern mysticism, acupuncture struck me as something that might have something to it.

Five years ago.

Since I started actually studying acupuncture and acupuncture studies, I’ve become acutely aware that my previous assessment was incorrect, and my pointing that out from time to time sometimes results in comments along the lines of, “We don’t need to hear this again.” Tough. For the benefit of new readers and readers who might not have read some of my previous posts on acupuncture before, I consider it important to reinforce that I have, in fact, undergone a bit of a change of heart. I have reviewed studies that showed that sham acupuncture works as well or even better than “true” acupuncture, with the needles placed right where those fancy acupuncture charts say they should be placed and that you don’t even need needles. Toothpicks with their points twirled against the skin will do. I’ve also come to realize that many of the explanations postulated by acupuncturists and doctors who believe in acupuncture are actually far less interesting than actual scientific results that they produce in their search for “proof” that “acupuncture works.” Sometimes, acupuncturists substitute active sorts of treatment for acupuncture and call it something else, like “electroacupuncture, which involves hooking up a weak electrical current to acupuncture needles. Electroacupuncture is in essence nothing more than transcutaneous electrical nerve stimulation (TENS), an accepted modality to treat pain.

Add to the evidence pile yet another study demonstrating that acupuncture is placebo medicine, reported in Arthritis Care & Research by a team of investigators based primarily at the M.D. Anderson Cancer Center that I heard about via the TIME Magazine Wellness Blog. The study, entitled A Randomized controlled trial of acupuncture for osteoarthritis of the knee: Effects of patient-provider communication, demonstrates about as unequivocally as one can imagine that one form of so-called “acupuncture” is, as far as can be detected, virtually all placebo. What is surprising about this study is not so much that it shows that acupuncture doesn’t work. In fact, it doesn’t actually show that, because what is being used is not acupuncture. What is being used is “electroacupuncture, which is in essence nothing more than TENS! More amazingly, no one whom I’ve yet seen seems to be mentioning this. In essence, the results of this study are entirely consistent with the hypothesis that it doesn’t matter whether you place TENS needles on acupuncture points or not. Will wonders never cease? Actually, that’s not quite the right interpretation, as we shall soon see.

Let’s, as they say, go to the tape. Rather, let’s go to the study.

The study was actually a rather straightforward nested randomized design. First, certified acupuncturists were trained to communicate in one of two styles, either “high expectation” or “neutral expectation. I’ll only mention in passing all the description about how all the acupuncturists were licensed in Texas (who cares, given that it’s licensing woo?) and that they all had at least two years of experience. 455 patients were randomized first to acupuncturists using one of these two styles of communication, after which they were randomized in a nested fashion to “sham” or “real” acupuncture, the latter of which was called “traditional Chinese acupuncture” or TCA. I don’t understand how TCA can be called TCA, given that there weren’t electrical sources to hook up to needles 2,000 years ago, but that’s what it’s called in he paper. Thus, the experimental groups were as follows:

  • High expectation/TCA
  • High expectation/sham
  • Low expectation/TCA
  • Low expectation/sham
  • Waiting list control

More importantly, acupuncturists were trained thusly:

Because the individual communication patterns of each acupuncturist could be different in the first half of the study, the acupuncturists were randomized, three to interact with a high expectations style and the other three in a more uncertain, neutral fashion. In the second half of the study, the high expectations acupuncturists were retrained to act neutrally and viceversa. One acupuncturist had to leave the study towards the end of the first half of the trial, so in order to maintain a balanced design, only 4 acupuncturists participated in the second half.

  1. High expectations. Acupuncturists conveyed high expectations of improvement, using positive utterances such as “I think this will work for you,” “I’ve had a lot of success with treating knee pain,” “Most of my patients get better.” A high expectations brochure was developed and given to patients. The research coordinator assisting with these patients was also trained to interact with a high expectations style.
  2. Neutral expectations. Acupuncturists conveyed uncertainty with utterances such as “It may or may not work for you,” “It really depends on the patient,” We’re uncertain, and that’s why we are doing the study.” and words like “uncertain”. A neutral expectations brochure was given to patients. The research coordinator for this group was trained to interact with a neutral style.

Training materials were developed for each style. Before the trial started, acupuncturists participated in two 2-day training sessions including didactic instruction, one-on-one coaching, and group role play to practice the assigned style, with video-recording to provide feedback. After completion of the first half of the trial acupuncturists were retrained.

As I said, this was a rather clever design, and, in general scientifically sound. But what were the exact natures of the “treatments” offered. TCA consisted of acupuncture needles placed in the “right place” along meridians, placed to the “proper” depth and then hooked up to the juice:

For TCA, TENS was set to emit a dense disperse (DD) wave impulse at 50Hz, dispersing at 15Hz, 20 cycles/minute. Voltage was increased slowly from 5V to 60V until maximal tolerance was achieved. Patients rested for 20′ with continuing TENS

That doesn’t sound like an ancient Chinese practice to me. Be that as it may, the “sham” points were chosen outside the “correct” locations along meridians. Thsese needles were not placed as deeply, and they got a different amount of juice:

For sham, instead of DD, a 40Hz adjustable (ADJ) wave was used. Voltage was increased until the patient could feel it and then immediately turned off. Patients rested for 20′ with the needles retained, but without TENS stimulation.

Well, there you go. Change the location, change the depth, change the juice, and you have a perfect ancient placebo. Actually, right here, I feel obligated to be very explicit with what the TCA and sham groups really were, because you won’t find it in any of the descriptions of this study I’ve seen thus far:

  • “True acupuncture” in meridians, electricity cranked up to 60 V for 20 minutes
  • Sham acupuncture, electricity with enough voltage just long enough for the patient to feel it, then stop. Leave needles in for 20 minutes.

So what were the results? Not surprisingly, both the TCA and “sham” groups reported significant improvements in their pain scores compared to the poor bastards on the waiting list control, and there were no detectable differences between the TCA and sham groups. Surprise, surprise. It wasn’t even a surprise that it didn’t matter whether the TENS electrodes (which, let’s face it, is all that these needles were) are placed along acupuncture meridians or not.

Now here’s where things get interesting. What we have here is a study that failed to have a proper control for what it was doing (TENS) because the investigators designed their control for what they thought they were doing (acupuncture), but they still managed to come up with an interesting result! The study was intentionally designed to be able to analyze the effect of using “high expectation” versus “neutral” language in describing acupuncture to patients. So that’s what the investigators did. What they found is that patients in the “high expectation” group had statistically significant (in some cases highly statistically significant) improvements in four different pain scores and that another pain score almost achieved statistical significance (p = 0.07). The effects were not huge (0.25), but they did appear to be real.

Sadly, instead of looking at the real finding of their research, the investigators spend much of the Discussion section trying to rationalize it away and ignore the true finding, namely yet another result showing that patient expectation and practitioner attitude influence the placebo effect, in this case using what is in essence TENS. Instead, we’re treated to passages like this:

Our study used a sham procedure with superficial needling in non-meridian points and minimal electric stimulation. While the procedure was minimally invasive, it was sufficient to allow successful blinding, as compared to some recent studies where blinding was unsuccessful. Our sham procedure may have had an analgesic effect from superficial needling such as release of endorphins, yet, this effect is also observed with oral pain placebo. Meridian point insertion following TCA practices did not have an additional effect. Furthermore, using continuous electrical stimulation in the TCA group (compared to a few seconds in the sham group) was also ineffective. Whereas the improvement observed in both TCA and sham groups is due to needling (deep or superficial) or to the placebo effects of participating in a study with frequent contact with research staff, cannot be easily established.

Nonesense. In this study, both the sham and TCA used active treatment, namely electricity. In reality, it could reasonably be argued that this study suggests that TENS works primarily through placebo effects, given that it didn’t matter whether current was applied for the whole 20 minutes or just for a brief period of time. Unfortunately, we can’t say that for sure because it could well be that meridians chosen represent crappy locations for TENS electrodes. We’d have to do the same experiment with and without electricity using the same electrode needle locations. We can, however, say that placebo effects did appear to play a significant role in both groups, even if based on this experiment we can’t say much else.

Right on cue, as epected, we’re seeing the usual apologia that inevitably appears whenever results of this sort are published about acupuncture, with bloggers getting it wrong in their rush to try to downplay just how little the results of this study support the efficacy of acupuncture. For example, although Laura Blue at TIME gets it right when she entitles her post Acupuncture: A 2,000-year tradition of placebo effect? (although, like almost everyone else, she failed to notice that this study was not really about acupuncture but TENS), Tara Parker-Pope unfortunately stumbles badly when she writes:

The results don’t mean acupuncture doesn’t work, but they do suggest that the benefits of both real and fake acupuncture may have something to do with the way the body transmits or processes pain signals. Other studies have suggested that the prick of a needle around the area of injury or pain could create a “super-placebo” effect that alters the way the brain perceives and responds to pain.

The study design may also have blurred the lines between real and fake acupuncture, muting the effects of the real thing. For instance, in traditional Chinese acupuncture, the needle insertion points are along specific areas called meridians, but the exact point of insertion is decided on a patient-by-patient basis, depending on the patient’s body and area of pain. In the study, however, a standard map was used so that the needle insertion point was the same for every patient. In addition, trained acupuncturists also were asked to administer the fake treatment and insert needles at specific points outside of traditional meridians. Although researchers sometimes stepped into treatment sessions to check on the location of the needles, it’s possible that some of the sham treatments were similar to real acupuncture.

Ms. Parker-Pope should be careful. She’ll hurt herself contorting herself to justify acupuncture using the time-dishonored trope that the treatments weren’t sufficiently “individualized” and that standardization somehow kept the magic from working. Even worse, she didn’t seem to notice that what was being studied was not acupuncture, but rather TENS, even though the authors refer to it as “acupuncture.” It’s a rather obvious rookie, although when I see journalists analyzing “alt-med” studies, rookie mistakes seem to continually plague even experienced reporters. Let’s finish with how the authors finished:

This is the first study examining TCA and sham acupuncture in knee OA that also included experimental manipulation of the acupuncturists’ communication style. In summary, TCA was not superior to sham acupuncture, and needling of meridian points was not more effective than use of sham points. Continuous electrical stimulus or increased needle penetration in the TCA group did not improve response. Acupuncturists’ communication style had a small but statistically significant effect in pain reduction and satisfaction suggesting that the perceived benefits of acupuncture may be partially mediated through placebo effects related to the acupuncturists’ behavior.

This study is a mess, as I pointed out before, but, for the sake of argument, let’s assume that the control was actually a valid control for what was being done and that this really was a study of TCA versus sham acupuncture, rather than a trial of 20 minutes of TENS on acupuncture meridians versus less than a minute of weaker TENS away from acupuncture meridians. In other words, let’s use the authors’ own assumptions behind their design of the study. What do you call a procedure in which it doesn’t matter if you place the needles in the “correct” spots or not and doesn’t matter whether there’s any juice turned on or not, but does matter how optimistic the practitioners’ communication style is?

A placebo. I call it a placebo.

REFERENCE

Suarez-Almazor, M., Looney, C., Liu, Y., Cox, V., Pietz, K., Marcus, D., & Street, R. (2010). A Randomized controlled trial of acupuncture for osteoarthritis of the knee: Effects of patient-provider communication Arthritis Care & Research DOI: 10.1002/acr.20225

Comments

  1. #1 Richard Wolford
    August 19, 2010

    Just an aside, but TENS doesn’t work either. I have a chronic pain disease and underwent TENS treatment during one of my visits to my physical therapist; it did absolutely nothing. A few weeks later I saw an article at Live Science that summarized a study showing TENS to be no more effective than placebo, so I immediately stopped the treatment and stuck with the stretching exercises (I have ankylosing spondilitis). Instead of wasting my time with nonsense like acupuncture or whatever the sham of the week is, I see my physical therapist, my general practitioner, my rheumatologist and my pain management doctor (pain medications, targeted steroid injections). Not a long time reader here but I’m really enjoying what I find.

  2. #2 Brad
    August 19, 2010

    Ms. Parker-Pope should be careful. She’ll hurt herself contorting herself to justify acupuncture

    A bit of chiropractic adjustment will fix that right up.
    Did the study state whether the acupuncture points were anywhere near the focus of the pain being treated? If I have lower back pain, I’d expect tens to be more effective if applied to my lower back than, say, my shoulder or cheek or whatever. I’d expect that even with a placebo.

  3. #3 Sivi
    August 19, 2010

    I know you harped on this a lot in the post, but I want to harp on it some more.

    How the hell did they get calling TENS ‘TCA’ past their reviewers? I know people like to be trendy, but someone really ought to explain how electrifying the needles using specific voltages and frequencies is ‘traditional Chinese medicine.’

    I wish our papers (my lab’s) got through reviews so easily.

    Actually, scratch that. Rigorous though honest review strengthens our science, and I’d rather that than publish a shoddy article.

  4. #4 homunq
    August 19, 2010

    What they should study is the placebo effectiveness of the words “traditional”, “chinese”, and “accupuncture”. That is, two groups, same needles (where doesn’t matter, but OK, you can split them up into “TCA” and “sham”). One group gets told “this is a placebo, it doesn’t actually do anything but it helps you think that you’ll feel better and that actually really helps”; the other group gets told “this is the ancient mystical practice of unblocking your qi using traditional chinese accupuncture, you seem to have a lot of wood in your constitution so I will choose the metal meridian, etc.”. I suspect that the second group will have measurably better results. In other words, accupuncture doesn’t work, but “accupuncture” does, and that’s actually worth something.

  5. #5 Paul
    August 19, 2010

    I’m intrigued that placebos seem to work better when they hurt a bit, make you feel sick, or are very expensive. Historically people have sung the praises of strychnine, arsenic, and mercuric chloride, in doses which we which we now know are toxic, and more recently sodium chlorite, aka MMS, which is a potent gastrointestinal irritant.

    BTW, the high priest of MMS, Jim Humble, has started a new pseudoscientific cult religious movement with himself as the Messiah bishop, and claims that he has cured more people of incurable diseases (isn’t that an oxymoron?) than anyone else. For only $1000 you can become a Minister of Health, and poison cure as many people as you like! I can’t imagine why it’s based in the Dominican Republic and not in the USA…

  6. #6 Sivi
    August 19, 2010

    @Paul

    Fuck that noise, I can become a preacher for free, and start faith-healing. Lower overhead, more legal, and better social acceptance.

    I could even add a bit of penance to help the holy medicine go down.

    …That ended up kinkier than I’d intended.

  7. #7 NYC RVT
    August 19, 2010

    Speaking of worthless acupuncture studies–what in this world is happening to the NE Journal of Medicine? This am I got the online table of contents which lists a study by NCCAM researchers which concludes with dubious evidence and logic about the ill-defined fibromyalgia disease that tai chi may be a beneficial palliative! Of course, more $ should go into this “research!”

  8. #8 James Sweet
    August 19, 2010

    I am increasingly of the mindset that we can capture this “high expectation” placebo effect via the use of doctor-prescribed “therapeutic spa”. The doctor writes you a prescription to get spa treatments that have “been shown to improve subjective patient outcomes”. There’s no lying, no concealing of information. Hell, you can’t even say that it’s “no better than sham treatments”, because what the hell would a “sham spa” be??

    Obviously research would have to be done, but I have feeling that “therapeutic spa” could be a way to basically prescribe a placebo, with all of the accompanying benefits, but without deceiving the patient.

  9. #9 Sivi
    August 19, 2010

    @James Sweet

    You know, I think that’s the first time I’ve heard someone propose what I’d consider a truly ethical placebo.

    There’s no pretence of medical intervention, the doctor primes the patient to expect to feel better, and the spa’s likely to be relaxing and fun without any potential side-effects.

  10. #10 Antiquated Tory
    August 19, 2010

    @James Sweet 10:34,
    James, they’ve been doing that here in the Czech Republic since the 19th century. At least until recently, you could still get a physician to send you to one of the “medical” spas at Carlsbad, Marianenbad, etc, and insurance would cover it.
    I don’t know if they still do that, as there’s quite a funding crisis in medical insurance now. Do any readers know if the Germans, Swiss, or Austrians do this?

  11. #11 Adam
    August 19, 2010

    Interesting stuff.

    I must admit that, although I’m generally pretty skeptical about most forms of woo, I’ve kept a fairly open mind on acupuncture hitherto. As you say, it does actually do something to the body, and I have seen one or two reasonably convincing sham-controlled studies.

    But it sounds like you think we now have adequate evidence that acupuncture is, in fact, just another placebo. Perhaps I should have another read of the evidence when I have the time.

  12. #12 Tom D
    August 19, 2010

    As a non-new reader who uses your information to re-present arguments to friends and family: Thank you for posting again on this topic.

  13. #13 DVMKurmes
    August 19, 2010

    There has been something of a rash of this type of paper in the veterinary literature recently as well. It seems to be a developing trend to use electroacupuncture with no mention of TENS, and no or inadequate controls, and then claim it is proof that acupuncture works. It seems a bit desperate to me, and maybe it indicates a weakening of acupuncture proponents position.

  14. #14 Vicki
    August 19, 2010

    NYC RVT:

    As far as I can tell, fibromyalgia is a syndrome, and to some extent a definition of exclusion: the symptoms are real, and the causes are unknown. There certainly may be multiple causes.

    Given that, I don’t see anything inherently problematic in looking at a group of patients with a currently-incurable syndrome, and testing a defined set of exercises as treatment.

  15. #15 Denice Walter
    August 19, 2010

    “Placebos seem to work better…… or are very expensive”: because you are then motivated to discover something – anything! – positive to justify your effort, suffering, or expense. I just saw something funny in Vogue (Sept.’10) -and it *wasn’t* the new khaki nail polish- : a writer (who shall remain nameless because I feel merciful today) discusses her health complaints ( bleeding gums, hip pain, high bp, “puffy eyes”) and dissatisfaction with her doctor’s solutions. She seeks a unifying theory of malaise and finds it in “inflammation”. She discusses inflammatory woo and other (possibly) more legitimate, less generalizable research. She consults ” mass-market inflammation books” and eliminates the “processed foods”, “refined flours and sugars”, “cut back on dairy” and selects ” whole grains, nuts, organic fruits and vegetables, fish, and grass-fed meat”. She feels great! Her conditions improve! However, she finds that this diet is too difficult to maintain. Often our woo-meisters present a “protocol”( or their personal regime) which is nearly impossible to fulfill or to continue for any protracted period of time. This allows any failure to be explained away by lack of adherence *and* gives the creator of the plan an opportunity to sell supplements to make up for the “backsliding” of those who fail. The few who are able to meet the stringent requirements ( through sheer will power or obsessive tendency) are rewarded with applause and comparison to the woo-meister’s shining example. And they feel great!

  16. #16 Jojo
    August 19, 2010

    The results from this study seem to indicate that it would make sense for doctors treating patients with pain to sound very positive about the patient’s treatments to maximize the benefit of the placebo effect. I can’t see any ethical issues resulting from communicating in a positive manner with a patient as long as no false claims are made.

    Paul @5. I had an emergency room doctor tell me that patients respond to treatments better if they hurt a little. I’m torn between being glad he told me an interesting fact, or mad that he ruined it for me. Either way, I was there to get a piece of plastic out of my eye, which he failed to remove, so it was a moot point for that visit.

  17. #17 DrWonderful
    August 19, 2010

    Any baseball fans hanging around here? I love baseball and feel like reading a baseball book while we head into the best part of the season. I know I antagonize you folks a bit but in the end I think y’all are pretty bright and probably would know a good book. Any suggestions?

  18. #18 Ian
    August 19, 2010

    @NYC RVT

    I saw some media coverage of the study. It’s not a tiny sample size (n = 66) and it has a control group. It’s not beyond the realm of possibility to imagine that controlled movement exercises could alleviate pain. I’m not so quick to dismiss it, although my skeptic hat remains firmly screwed on.

  19. #19 DrWonderful
    August 19, 2010

    @NYC RVT- If the study was titled something a little more snarky like “Enhanced mechanoreceptor stimulation moderates nociceptor output” would you be so skeptical?

    Or is your pre-determined bias and cynicism against something called “Tai Chi” what got your knickers all bunched up? I understand this study upsets the agenda but this is yet another addition to the growing pile of evidence that shows movement decreases pain. You do shake your finger after you jam it, right?

  20. #20 Pareidolius
    August 19, 2010

    DW, I think that pretty much everyone here will agree that for many people suffering from certain types of pain (mostly muscular and non-rheumatoid joint pain), movement has a beneficial, palliative effect. By movement I mean stretching and limbering up in general. That includes Massage, Yoga, Pilates, Stretching, Physical Therapy, Tai Chi, etc. You don’t have to accept the woo behind the “ancient mystical” modalities on the list for them to be effective.

  21. #21 Rogue Medic
    August 19, 2010

    Acupuncture vs. not acupuncture?

    It seems that the study design included the use of acupuncture (acupuncture needles placed at acupuncture locations to acupuncture depth for at least 20 minutes) vs. sham acupuncture (acupuncture needles, but placed away from acupuncture locations and not to acupuncture depth for at least 20 minutes). Then there is the difference between the electroacupuncture electricity and the least amount of electricity noticed by patients as an electricity sham. And you have the expectations grouping.

    While not just an acupuncture vs. sham acupuncture study, this does seem to add to the growing pile of research by acupuncturists producing the same result.

    Acupuncture – it doesn’t matter what you do with the needles, or if you even use needles.

    Acupuncture just doesn’t work.
    .

  22. #22 James Sweet
    August 19, 2010

    Jojo: When I first read the following paragraph from you, I was going to disagree with it. But I had missed two very important words in it, which I have bolded:

    The results from this study seem to indicate that it would make sense for doctors treating patients with pain to sound very positive about the patient’s treatments to maximize the benefit of the placebo effect. I can’t see any ethical issues resulting from communicating in a positive manner with a patient as long as no false claims are made.

    You may have a point there. I think it would be ethically problematic to be overly positive about objective outcomes, but in regards to subjective outcomes, you might be right.

  23. #23 Ian
    August 19, 2010

    Of course, any time I hold the same position as Dr. Wonderful, I am immediately uneasy. However, having critically reviewed the tai-chi/fibromyalgia paper, it appears sound.

    – 30 randomized patients received tai chi instruction and were asked to practice every day for 20 minutes
    – 29 randomized patients received counseling and stretching instruction, asked to perform exercises 20 minutes every day
    – Adherence measured through self-report journals
    – Participants were told that it was a comparison of two different approaches, not that tai chi was being tested
    – Participants were asked to fill out a standardized HRQoL survey
    – Scores on the survey were significantly (p < 0.03) improved at 24 weeks when compared to the control group

    They authors note that the lack of a sham tai-chi means that it's not a perfect control group, but since exercise and counseling are the current standard, it at least suggests that it's better than current therapy. They propose a mechanism for reducing anxiety and increasing confidence, both of which are associated with pain reduction in other situations.

    As skeptical as I am of anything that involves "qi”, this study doesn’t trip any of the woo alarm bells for me. I’d appreciate a second look to see if I missed anything.

  24. #24 CatherineMD
    August 19, 2010

    It seems that “Therapeutic spa” would do wonders for almost anyone in pain or stressed out. Oh how it goes around and comes around! The old docs were doing this way back when there was nothing else to do; now its been proven to work by meeting our high expectations of it working. A bit of intuition proven. Now off to the spa! Truly, “spa” would likely be less expensive and provide more relief that all the other crap out there. I think that is a wonderful prescription of placebo.

  25. #25 Ian
    August 19, 2010

    I don’t know what happened to the rest of that sentence but it should have read:

    – Scores on the survey were significantly (p lessthan 0.02)lower at 24 weeks for the tai-chi group compared to the control group.

  26. #26 Scientizzle
    August 19, 2010

    @DrWonderful (& totally OT)

    I enjoyed The Echoing Green: The Untold Story of Bobby Thomson, Ralph Branca and the Shot Heard Round the World (amazon link in my name)…you might check that one out.

  27. #27 Shasta
    August 19, 2010

    My mother decided to treat the chronic pain in her back with acupuncture instead of taking the advice of her doctor, which was to dry out for six months and get on a liver transplant list due to cirhossis. She was in denial and wasn’t truthful to family members about the fact that she was in liver failure and may not have believed it herself.

    so instead of drying out and getting a new liver she got the acupuncture, kept drinking, and died of liver failure.

    additionally, family members are now even more suspicious of “doctors” because of their perception that the doctors “did nothing” for my mother.

    :-\ I freakin hate acupuncture and its cult followers.

  28. #28 Shasta
    August 19, 2010

    Er, I don’t mean I hated my mom. I hate the altmed practitioner who convinced her to try acupuncture, though. :-\

  29. #29 Jojo
    August 19, 2010

    James Sweet @21. I actually had trouble even typing it out because I typically think that the use of placebo is unethical. It just seems wrong. But the more I think about it, if being honest in a positive manner has positive benefits it seems like a win/win situation. I agree with you that it needs to be limited to subjective outcomes and not at the expense of other treatments.

  30. #30 Anonymous
    August 19, 2010

    I learned a lot about Tara Parker-Pope when she did (and promoted) an event with Deepak Chopra earlier this year.

    And I quote:

    “On Saturday [April 2010], Dr. Chopra will be joining me in The TimesCenter in New York City to talk about the role of the mind, body and relationships on health. Tickets are still available for the talk, which will also explore Dr. Chopra’s journey into alternative medicine, and how issues like the economy and the environment can influence personal health. At the end of our talk, Dr. Chopra will answer audience questions and sign copies of his recent book, “Reinventing the Body, Resurrecting the Soul.”

    Integrity as a health writer? Gone.

  31. #31 Shay
    August 19, 2010

    It’s bad enough that people are willing to try this crap on themselves; but I’ve actually run into idiots who swear by it for pets.

    I hope they all get bitten by an angry, hurting German Shepherd.

  32. #32 Elaine Schattner, M.D.
    August 19, 2010

    Orac,
    I share most of your view on the messiness of this particular study. Nonetheless, I’ve known a lot of people, some of who seem quite rational, who’ve benefited from acupuncture.

    So maybe acupuncture works, some of the time, but it’s one of those things that we just can’t explain (at least not yet).

  33. #33 Scott
    August 19, 2010

    I think that pretty much everyone here will agree that for many people suffering from certain types of pain (mostly muscular and non-rheumatoid joint pain), movement has a beneficial, palliative effect. … You don’t have to accept the woo behind the “ancient mystical” modalities on the list for them to be effective.

    However, it’s reasonable to be concerned about whether focusing on the woo, rather than the exercise, impedes it from being maximally effective. After all, an exercise designed to loosen up the movement of the shoulder (for example) is likely to do better at that than an exercise designed to ease the flow of qi down the meridians.

  34. #34 Scott
    August 19, 2010

    I share most of your view on the messiness of this particular study. Nonetheless, I’ve known a lot of people, some of who seem quite rational, who’ve benefited from acupuncture.

    So maybe acupuncture works, some of the time, but it’s one of those things that we just can’t explain (at least not yet).

    Note that exactly the same could be said of bleeding and purging. The fact that some people seem to benefit is not meaningful evidence that there’s anything happening beyond placebo. And the meaningful evidence that we have is firmly against the proposition that acupuncture is anything other than an elaborate placebo carrying an unnecessary risk of infection.

  35. #35 Travis
    August 19, 2010

    Elaine Schattner, I would recommend you search the archives for articles about this topic. If this was the only study that had problems it might not be much of an issue but it is not. Also multiple studies have now shown that acupuncture does not work any better than sham acupuncture. Acupuncture is just a placebo.

  36. #36 jacques hughes
    August 19, 2010

    After having a discussion upon the relative merits of osteopathy vs chiropractic, and sending her the link to Tim Minchin’s outstanding ‘Storm’ (http://tinyurl.com/yavm3y6) a Kiwi colleague of mine sent me a link to this site: http://tinyurl.com/yavm3y6

    She ran down the list with me, to see if I had opinions about some of the items in the list. The only one I’d never heard of was ‘IRS Denialism’. However, thanks to Orac, PZ and Richard Dawkins.net, I did have an opinion about the others.

    Seriously, do we really have to teach critical thinking as a subject now? Are people so gullible that they can’t read a newspaper or blog and have their own opinion after reading an article?

    Thank goodness there are sites like this that just show up the charlatans for what they are.

    Next one Orac; accupressure ;)

  37. @DrWonderful

    Seeing as Detroit is Orac’s hometown, maybe a book by Ernie Harwell, the long-time radio announcer for the Tigers?

    Can’t say as I’ve ever read any books on baseball, other than as research for a 4th grade term paper (assemble a baseball dream team, modern or classic, and justify your choices – there was a non-baseball option, obviously aimed at girls)

  38. #38 NYC RVT
    August 19, 2010

    @Dr.Wonderful
    Actually my cynicism and bias was such that I read the whole study and an accompanying editorial. It is this kind of statement from the study authors that makes me wonder about the NEJM lately:
    “Tai chi is a mind–body practice that originated in China as a martial art. It combines meditation with slow, gentle, graceful movements, as well as deep breathing and relaxation, to move vital energy (or qi) throughout the body. It is considered a complex, multicomponent intervention that integrates physical, psychosocial, emotional, spiritual, and behavioral elements.10 Because of its mind–body attributes, tai chi could be especially well suited to the treatment of fibromyalgia.”
    http://www.nejm.org/doi/full/10.1056/NEJMoa0912611#articleTop

  39. #39 Bronnie Thompson
    August 19, 2010

    I’m not a fan of acupuncture because the evidence is too weak (and I loath woo), but I did wonder what your response is to the following Cochrane review?
    Furlan AD, van Tulder MW, Tsukayama H, Lao L, Yazdi F, Tsertsvadze A, Sherman K, Ammendolia C, Wang E, Shin BC. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2.
    The reason I ask is because a student of mine asked me whether this would change my position on not recommending acupuncture (I won’t) – and it does pose some questions for me. Thoughts?

  40. #40 Bronnie Thompson
    August 19, 2010

    Regarding tai chi for fibromyalgia: is it the chi or simply moving gracefully and thoughtfully with effective breathing technique that does the trick? I can get a similar effect from bellydance, walking the dog and SCUBA for my fibromyalgia. When one type of exercise is consistently found to be superior than another, I may chance my exercise practices, but right now? I’ll do what I enjoy and reap the benefits.

  41. #41 DrWonderful
    August 19, 2010

    @NYC RVT- I understand your apprehension then. Even as a chiropractor I would assign any potential benefit to purely mechanical means with a touch of relaxation (which chronic pain patients have trouble with) and not much else.

    @Ian- I too am uneasy although slightly flattered.

    @Scientizzle- I think the Bobby Thompson book is a great idea all things considered. What a special moment that was in baseball and American history and since he died just yesterday I may want to live in that moment a little myself.

  42. #42 Scott
    August 19, 2010

    @39:

    Based on the abstract, the conclusion of the review seems to be “acupuncture has an effect beyond no treatment or [some unspecified] sham treatment”. Which is of course not a terribly relevant question; the relevant question is whether it has an effect beyond an appropriate placebo. And the abstract, at least, doesn’t even suggest that it does.

  43. #43 Agashem
    August 19, 2010

    I have been a physiotherapist for 25 years (eeek!) and I am one of the few (very few) physical therapist (physiotherapist=British, physical therapist=American, hence as a Canadian, we use both) who has worked in private practice that has resisted learning acupuncture. Oh sure, it brings in more patients and you could make more money, but I never saw the need. I have used TENS knowing full well that there is limited support in the literature at least I am not puncturing the skin. I am pretty sure that in the late 1990s Melzack out of McGill published a study comparing TENS with acupuncture and found they furnished similar results so I have happily stuck to TENS. You can’t imagine how many physiotherapists get very hot under the collar if you question the need for using acupuncture. I am always glad to read more about this to keep my arguing skills sharp.
    Thanks.

  44. #44 rob
    August 19, 2010

    i am going to start up a homepathic voodoo accupuncture treatment.

    just send me $100 and i won’t insert any needles into a tiny doll that doesn’t resemble you.

    (if that business doesn’t take off i can always start sticking the needles in the doll and make people pay me $100 to take them out.)

  45. #45 Mu
    August 19, 2010

    Rob, you will be surprised, but poking a small pillow with toothpicks is just as effective. Making it look like the person and using sharp needles is just mambo-jumbo.

  46. #46 Rogue Medic
    August 19, 2010

    @ 32 Elaine Schattner, M.D.,

    I share most of your view on the messiness of this particular study. Nonetheless, I’ve known a lot of people, some of who seem quite rational, who’ve benefited from acupuncture.

    If you don’t know the difference between anecdote and research, then you probably do not understand research enough to intelligently comment on research.

    So maybe acupuncture works, some of the time, but it’s one of those things that we just can’t explain (at least not yet).

    You just explained acupuncture.

    You described the placebo effect.

    Acupuncture is almost as good as a placebo, but acupuncture has significantly greater risks.
    .

  47. #47 Passerby
    August 19, 2010

    The jury ain’t out yet on acupuncture. You can squeal all you want about placebo effects, but the fact is the acupuncture activity maps through nerve bundles, musculo-skeletal groups and brain centers. CNS receptors appear to be activated by needles – with or without applied charge.

    It’s a testable process and it’s being studied through application rigorous science. Meanwhile, a helluva lot of physicians appear to be willing to try it as pain and inflammation management technique. Tai chi is also being tested by physicians to potentially manage complex diseases like fibromyalgia. Not a cure, but does provide definitive improvement in symptoms in many patients. It appears to have similar effector mechanisms at the cellular level, through nerve stimulation of major muscle groups that also effects endocrine and paracrine signaling systems.

    online.wsj.com/article/NA_WSJ_PUB:SB10001424052748704841304575137872667749264.html

    I wouldn’t be quite so quick to lump acupuncture in with the more obvious types of medical woo.

  48. #48 Chris
    August 19, 2010

    So when did the Wall Street Journal become a medical journal?

  49. #49 Bob
    August 20, 2010

    This is a great breakdown of a chaotic study (which as you pointed out is a study of electroacupuncture)It’s a good example of how the people conducting acupuncture research are usually not competent to do so. However what’s often shown is that needling DOES produces physiological effects through sound biological models. In that respect how is needling a placebo? It’s an active treatment creative measurable physiological change.

    That positive expectation bolster effectiveness is proven across all forms of medicine so that’s no surprise. Fabrizio Benedetti in his book ‘Placebo effects’ notes that only 25% of the effect of an anti depressant is due to its active ingredient as revealed by meta analysis.

    Acupuncture effects can exist independent of its theoretical explanations, so traditional concepts don’t invalidate acupuncture. All that we know so far is that for simple mechanical problems like knee pain, lower back pain, needle location is not important but does produce segmental analgesia and therefore pain relief. Shallow needling is the exclusive style of some acupuncture styles, and all styles use needling ‘off point’ needling all the time. Of course meridians and qi don’t exist, it was the attempt of a pre-scientific culture to explain the effects of it’s medicine. I would hope that anybody interested in a scientific balanced analysis of acupuncture would examine both sides, and consider the very valid case the acupuncture trials are often poorly conducted with little understanding of the complex variables in assessing the treatment.
    Great analysis though, very indepth where other blogs skirt the surface

  50. #50 Scott
    August 20, 2010

    However what’s often shown is that needling DOES produces physiological effects through sound biological models. In that respect how is needling a placebo?

    Because the physiological effects it produces are not such to relive pain, and it’s been demonstrated that the pain relief is just as effective if no actual needling takes place.

    A similar argument would be “I put capsaicin on my skin, and then my cold got better. The capsaicin has a physiological effect, therefore it must be responsible for my cold getting better!”

  51. #51 Bob
    August 20, 2010

    Interesting. What studies are there that show that no needling produces the same pain relief as needling?

  52. #52 Mu
    August 20, 2010

    It’s a testable process and it’s being studied through application rigorous science.
    Complete agreement here – unfortunately for acupuncture, every time someone does it rigorously, it’s shown to be placebo effect based.
    There is a misunderstanding about placebos so, even if it’s all in your head, it still can have a measurable biological effect. For a simple “head case”, you walk into the street without looking, and the bus comes to a halt 1 ft from you, with squealing brakes. By the time you make it back onto the sidewalk, you’re heart rate is 180, you’re sweating profusely and your legs are wobbly. And it was all in your head, nothing touched you at all.

  53. #53 CherryBomb
    August 20, 2010

    @ DrWonderful

    If you come to a blog like this looking for recommendations for a baseball book, we will *have* to send you to “The Physics of Baseball” by Robert K. Adair. A classic.

    And to Orac about 2,000 year old TEM, some people speculate that the “Baghdad Battery” was used for acupuncture. Not certain the thing was even a battery at all, but it is remotely possible.

  54. #54 Scott
    August 20, 2010

    Interesting. What studies are there that show that no needling produces the same pain relief as needling?

    The toothpick study Orac linked in the main post is the most interesting IMO:

    http://scienceblogs.com/insolence/2009/05/another_acupuncture_study_misinterpreted.php

  55. #55 Scott
    August 20, 2010

    Apologies, hit Post when I meant to hit Preview so the prior post was incomplete.

    There’s also a large and growing body of studies which use special collapsible needles that don’t penetrate the skin (an excellent way to double-blind the study, which is crucially important when dealing with a placebo effect). They consistently find equivalent results to real needles.

  56. #56 Michael Cote
    August 20, 2010

    Doing sham acupuncture to prove or disprove the effects of acupuncture is like rolling a sham wheel down a hill to prove or disprove gravitational theory. It doesn’t make any sense. We really ought to have an understanding of epistemology.

  57. #57 Bob
    August 20, 2010

    Thanks for the link. As far as I can see, a penetrating needle would still exert some physiological effect so theoretically couldn’t be considered placebo, so I wonder why the non penetrating needle isn’t always used as a control? There still seems to be demonstrable effect of acupuncture over the sham though:

    http://www.britannica.com/bps/additionalcontent/18/24282974/Acupuncture-vs-Streitberger-needle-in-knee-osteoarthritis–an-RCT

  58. What I don’t get is that if TENS+acupuncture is actually thought to be doing something then isn’t it “practicing medicine” and shouldn’t it be regulated by the FDA?

  59. With regards to James Sweet’s suggestion —
    I used to have a masseuse who changed her cards from “therapeutic massage” to “relaxing massage” when she concluded that “it feels great but doesn’t do anything more than make you feel great for a little while.” She was awesome.

    I went to a spa, once, at a shi-shi hotel and they did all kinds of neat massage stuff and hot bath and fussing and whatnot and it was fantastically enjoyable and, when I left, I felt great after 2 hours of pure sensual pleasure. It made my whole day. There’s nothing wrong with it, either.

    A spa where you went, didn’t think about work, didn’t drink loads of coffee, practiced tai-chi or tango dancing on a beach, drank yummy fresh-squeezed fruit juice, and had a massage, a hot soak, and a delicious dinner of something tasty, well-prepared, and apparently healthy – would make anyone feel good (at least until halfway through their commute to work the next day) “Pleasure Therapy”!

  60. #60 Jenn
    August 20, 2010

    Question: Am I correct in understanding placebo vs nothing has been shown to provide measurable response/relief for some patients with pain?

    If so what research is being done on placebo response itself?

  61. #61 Scott
    August 20, 2010

    There still seems to be demonstrable effect of acupuncture over the sham though

    A relatively weak study, as it was only single-blind. And in any case, what one wants to do is consider the entire body of evidence (which is why I pointed out my single favorite but then moved on to the broader picture), and most of the best-designed trials tend to no effect beyond placebo.

  62. #62 Chris
    August 20, 2010

    Jenn, go to http://www.pubmed.gov and plug in the words “mechanisms placebo effect”, you will several relevant hits (unfortunately “placebo” is used often in regular studies, so just using that word brings up tens of thousands hits that are not relevant).

    There is actually lots of research in placebo effects. One researcher, Dan Ariely, is quite proud he got an Ignoble Award in 2008 for his research showing that expensive placebos work better than cheaper placebos. He explains it in his book Predictably Irrational (and how he came to research things he does, which was while recovering from burns over 70% of his body! yes, he knows pain).

  63. #63 Rogue Medic
    August 20, 2010

    For all of those who do not seem to understand what the placebo effect is.

    The placebo effect is a real response by the body.

    The more elaborate, expensive, intrusive, uncomfortable, horrible tasting, . . . the more effective the placebo seems to be.

    Since acupuncture is many of these things, it is an excellent placebo.

    Acupuncture does produce an effect, but it is only a placebo effect, not any better than any comparable placebos.

    Why is that so hard to understand?

    There is no magic, no qi, no special acupuncture effect.

    Acupuncture is just a placebo.

    It does not matter how much training the acupuncturist has.

    Acupuncture is just a placebo.

    It does not matter if the needles are placed by a monkey or placed by an expert.

    Acupuncture is just a placebo.

    I can write it over and over (really just cut and paste), but I am only repeating what the best research shows.

    Acupuncture is just a placebo.
    .

  64. #64 Bob
    August 20, 2010

    lol, I think I’ve got your position that acupuncture is a placebo, but even Edzard Ernst, a man in full time employment to disprove CAM concludes that ‘the emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions’:

    http://www.ncbi.nlm.nih.gov/pubmed/17265547

  65. #65 Rogue Medic
    August 20, 2010

    The more recent studies have not been positive for acupuncture.

    A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.
    Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA.
    Arch Intern Med. 2009 May 11;169(9):858-66.
    PMID: 19433697 [PubMed – indexed for MEDLINE]
    Free PMC Article Free text
    http://www.ncbi.nlm.nih.gov/pubmed/19433697

    Reviewed here:

    http://scienceblogs.com/insolence/2009/05/another_acupuncture_study_misinterpreted.php

    Acupuncture for treatment of persistent arm pain due to repetitive use: a randomized controlled clinical trial.
    Goldman RH, Stason WB, Park SK, Kim R, Schnyer RN, Davis RB, Legedza AT, Kaptchuk TJ.
    Clin J Pain. 2008 Mar-Apr;24(3):211-8.
    PMID: 18287826 [PubMed – indexed for MEDLINE]
    http://www.ncbi.nlm.nih.gov/pubmed/18287826

    Reviewed here:

    http://scienceblogs.com/insolence/2008/04/sham_acupuncture_is_better_than_true_acu.php

    When even expert acupuncture is still no better than placebo, is acupuncture anything other than just a placebo?
    .

  66. #66 Harbo
    August 20, 2010

    Passerby @ 47
    Its a good thing we don’t rely on juries for scientific decisions.

  67. #67 Bob
    August 21, 2010

    I’m not sure that the statement that acupuncture is only a placebo can have the level of certainty implied here at all. Ernst in an overview of systematic reviews notes acupuncture’s effectiveness for OA, low back pain, and lateral elbow pain (although not for Fibromyalgia or arthritis). It is worth noting that he is the UK’s biggest anti CAM campaigner and yet still finds evidence of effectiveness:
    http://www.ncbi.nlm.nih.gov/pubmed/20591833

    He’s also concluded acupuncture effective for dental pain in a systematic review:

    http://www.ncbi.nlm.nih.gov/pubmed/9617000

    As regards the trials, they are by no means all negative, here are a couple:

    German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) – A pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment.
    Molsberger AF, Schneider T, Gotthardt H, Drabik A.

    Link: http://www.ncbi.nlm.nih.gov/pubmed/20655660

    Acupuncture for tension-type headache
    Klaus Linde1, Gianni Allais2, Benno Brinkhaus3, Eric Manheimer4, Andrew Vickers5, Adrian R White6

    link: http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007587/frame.html

    There is more than enough evidence to suggest that something other than placebo is going on, particularly since sham needling is shown to be an active treatment and not ‘sham’. Since some styles of acupuncture consist solely of superficial needling, this is evidence for effect.

  68. #68 stripey_cat
    August 22, 2010

    Maybe we should encourage philanthropists and governments to support free-access thermae again – get a shower, sit and gossip in a hot-tub, have a massage, and go for a swim should help with a lot of chronic health conditions (even if only because you’ll feel better) and reduce general stress levels which should help with the heart disease situation.

  69. #69 Molly Cooke
    August 23, 2010

    I believe most acupuncturists are appreciative of constructive analysis that results in greater understanding of our practice. When one provides a profound and measurable result through a modality that ‘scientifically makes no sense’, it does cause some uneasiness. But the fact is the patient gets healed…and so many acupuncturists end their day in awe and humility. Acupuncture, as well as physical therapy, massage and martial arts are often the most conservative approach to treating conditions. Egotistical WMDs are famous for prescribing pills and surgeries that do not work. Unfortunately those two forms of therapy are also economically formidable and often inhumane.

  70. #70 Ender
    August 23, 2010

    “But the fact is the patient gets healed…and so many acupuncturists end their day in awe and humility.”

    No, the fact is that the acupuncturist sees what they believe is an effect that they can attribute to acupuncture, and go home satisfied, because they either don’t understand, or don’t care about the scientific method, confirmation bias, regression to the mean, and the current state of research into its effectiveness.

    “I believe most acupuncturists are appreciative of constructive analysis that results in greater understanding of our practice”

    No, generally most acupuncturists are only appreciative of construcive analysis that concludes acupuncture has a positive effect beyond placebo, when the result is negative they generally waffle defensively about how they’ve ‘seen an effect’ with their own eyes.

    “When one provides a profound and measurable result through a modality that ‘scientifically makes no sense’, it does cause some uneasiness”

    How would you know? Acupuncture has not provided a measurable result that’s distinguishable from placebo.
    Generally when one provides a measurable result through a modaliy that ‘scientifically makes no sense’ it’s really really exciting, because we have clear evidence of something new, something provable and something where an ambitious research scientist can make stunning breakthroughs and make their name.
    That doesn’t apply in this case as there is no reliable evidence that acupuncture has any effect.

  71. #71 Calli Arcale
    August 23, 2010

    Bob @ 57:

    Thanks for the link. As far as I can see, a penetrating needle would still exert some physiological effect so theoretically couldn’t be considered placebo, so I wonder why the non penetrating needle isn’t always used as a control?

    It depends on what is actually being studied. Generally, scientific research needs a very specific question, or the results will not be meaningful. So the question may be “does sticking needles into a person make a difference?” In this case, you might compare needles which penetrate to some non-penetrating placebo. (In addition to toothpicks, another control method has been sneaky retracting needles, but the toothpicks are obviously much more cost effective. Obviously, the patient needs to be *literally* blinded so they don’t notice that there aren’t needles sticking out of their skin.) But if the question is “does acupuncture along the meridians make a difference?” then you would compare needles at the prescribed, traditional points against pretty much random needling as your control. Interestingly, studies which have done so tend to find no difference — that doesn’t invalidate acupuncture, but it does cast considerable doubt on the meridians.

    It also fails to *prove* acupuncture, though. These studies which compare acupuncture against sham acupuncture and which show a comparable response from the control arm do not prove that acupuncture is effective. Mostly, they show that it’s tough to come up with a true control. That could mean one of several things: maybe neither the study nor control groups were really benefiting significantly, maybe they are but it’s all a placebo effect, or maybe they are and it’s something to do with really tiny pokes (whether the skin is punctured or not). To study whether acupuncture is effective, you need to compare it to a standard treatment for whatever it is that the acupuncture is attempting to treat. This is not simple; there will be a lot of confounders, and so you’ll need a really large group of experimental subjects in order to even things out. Some studies compare a group receiving acupuncture to a group receiving pain medicine. I haven’t read one that was very large, so it’s difficult to know whether the effect observed (if any) is real.

    One problem is blinding the participants. You could give all of them what appears to be a painkiller and acupuncture, but with one of them being a placebo version. (Acupuncture plus a sugar pill, or sham acupuncture plus a real painkiller.) We do still get into the “what is a good sham acupuncture?” problem, though. I think I remember one study that alternated painkiller and acupuncture, so each group spent some time in each therapy and could compare them. That has problems too, of course.

    The hardest part in science can be figuring out what question to ask — and then making sure that you actually are asking that question through your study design, rather than something else.

    Molly Cooke @ 69:

    Acupuncture, as well as physical therapy, massage and martial arts are often the most conservative approach to treating conditions.

    I would not consider martial arts a conservative approach. If you approach it properly, it is an entire lifestyle, and with the exception of Tai Chi (which basically takes the “martial” part out of martial arts and leaves the rest), tends to regard pain and injury as the price you must pay in order to attain higher degrees. It is considered normal to go home with bleeding knuckles and multiple bruises, especially in the early stages when you are still learning to overcome your body’s self-protective reflexes and actually strike through solid bricks, and broken bones (especially hand bones) are not unusual. I’ve got family who are serious about martial arts; I suspect calling it “conservative” (in the medical sense) would insult them by showing a disregard for just what it asks of you. It’s good exercise; my brother-in-law (who teaches Tae Kwon Do) is exceptionally fit. But injuries go with the territory, so it’s not conservative as far as risk goes.

    For comparison, I’d say taking ballroom dance is a good conservative approach to getting more flexibility and movement. But taking ballet would not be conservative at all, even though you’d wind up with an extremely toned, muscular body.

  72. #72 Scott
    August 23, 2010

    I’m not sure that the statement that acupuncture is only a placebo can have the level of certainty implied here at all.

    I think this is an oversimplification of the position generally accepted here. Important points it neglects:

    1. The conclusion is that the current evidence is consistent with the null hypothesis (no effect beyond placebo), and inconsistent with any large specific effect.

    2. The proposition that sticking needles into meridians to improve the flow of qi and thereby improve health has a vanishingly small prior probability.

    3. Even if needling has some specific effect (must be small per point #1), the overwhelming likelihood is that it would have nothing to do with qi or meridians (see #2) and therefore “acupuncture” per se is not only unhelpful, but actively counterproductive. Achieving maximum efficacy and safety with a technique is greatly facilitated by a firm understanding of how said technique works – but acupuncture advocates a grossly implausible understanding which accordingly will be quite useless.

    There is more than enough evidence to suggest that something other than placebo is going on, particularly since sham needling is shown to be an active treatment and not ‘sham’.

    This betrays a lack of understanding of how to evaluate scientific literature. When studying an ineffective treatment, it is expected that a certain percentage of trials will find a statistically significant result. These will be due either to flaws in the study methodology (e.g. inadequate blinding) or statistical fluctuations. Accordingly, the expected state of the literature for an ineffective treatment is for a significant fraction of lower-quality studies to find an effect, while higher-quality studies are less likely to find an effect (approaching 5% for perfectly-executed studies, assuming that we’re using a 95% confidence threshold). This precisely describes the state of the acupuncture literature, and therefore pointing to individual studies which DID find an effect is entirely unavailing.

    It is also crucially important to note that “produces measurable physiological effects” is not the same as “is an active treatment” unless said physiological effects are such as to effectively treat the condition under study. It is therefore incorrect to conclude that “sham needling is shown to be an active treatement.”

  73. #73 Rogue Medic
    August 23, 2010

    @ 67 Bob,

    It is worth noting that he is the UK’s biggest anti CAM campaigner and yet still finds evidence of effectiveness:

    You claim that Dr. Ernst is biased, but you provide no evidence that he is biased. You actually provide evidence that Dr. Ernst is not biased.

    You are only exhibiting your own bias.

    Dr. Ernst looks for evidence that treatments work.

    Few CAM practitioners look for evidence that what they do works. They are practicing religion, not medicine.

    You blame Dr. Ernst for the lack of evidence that CAM works.

    The problem is not the person pointing out the lack of evidence. Not just a lack of evidence, but a huge amount of evidence that CAM is just a placebo.

    When Enron collapsed, they blamed the short sellers (the ones pointing out the problems), but the problem was the fraud.

    The problem is not Dr. Ernst.

    The problem is that CAM does not work.
    .

  74. #74 Skeptical Grad Student
    August 23, 2010

    The New York Times seems to be continuing its woo-ery, and Tara Parker-Pope continuing to display her complete ignorance of what a placebo is. Assuming good faith, though it gets harder and harder, a re-education campaign in the comments section of that article seems to be in order.

    http://well.blogs.nytimes.com/2010/08/23/studying-acupuncture-one-needle-prick-at-a-time/?ref=health

  75. #75 Bob
    August 23, 2010

    As a general note it’s worth bearing in mind that there are no agreed upon standards in place for the delivery of ‘true’ acupuncture as distinct from ‘sham’ purely in terms of level of strength of stimulation, this is a variable which often doesn’t get considered but is critically important.

    @ 71 Yes I take your points Calli on the specificity of the question and the point that it’s no simple matter with your ‘what is good sham acupuncture’ being the most pertinent point. While those studies don’t prove the efficacy of acupuncture in an absolute sense, they do appear to point at some level of effectiveness (even though the minutiae of that might be difficult to tease out, ultimately maybe impossible to tease out). It does seem important to consider that the placebo being used is not inert which is generally what I was pointing to, and this doesn’t seem to be being given much consideration. We therefore can’t say with certainty that acupuncture is exerting no effect over placebo which is what I was taking issue with. With no agreed definition of ‘dosage’ of acupuncture as delivered in trials, lack of clarity over a suitably inert placebo, it’s very murky to be making absolute statements. I think it’s safe to say that meridians and points don’t exist in the way they were initially conceived so perhaps research on proving that is wasted, but there are plausible biological mechanisms as posited by western medical acupuncturists for a mechanism, so it seems it shouldn’t be dismissed as total bunk. It does seem important to consider what the levels of effectiveness from the potential view of the patient. I know there are trials where acupuncture proved at least as effective as Effexor for hot flashes with less side effects which brings up important questions for acupuncture’s use in a pragmatic sense. How and to what extent is it important to know the exact specific effect against the non specific effects in something of a complex intervention like acupuncture which make that seemingly very difficult to deduce?

    @ 72 Scott yes I take your point about physiological effect not being the equivalent of active treatment, but I think the said physiological effects are relevant in these cases as pain is being assessed. Physiologist Thomas Lundeberg has drawn attention to this:
    ‘Is placebo acupuncture what it is intended to be?’(http://www.ncbi.nlm.nih.gov/pubmed/19525330

    @ 73 Rogue medic you have pretty much entirely misunderstood my post. I’m not for one moment saying Ernst is biased. I’m saying even the man who sets out to critically dispel use of CAM finds use for acupuncture in some conditions so perhaps it should be given more consideration than dismissed outright as quackery. CAM is not one thing, it is different modalities which have to be considered individually. Acupuncture is not osteopathy, herbal medicine is not chiropractic etc etc (Ernst found St John’s wort effective for depression and I know has publicly campaigned for other herbal medicines to be used as they do demonstrate efficacy). ‘ CAM doesn’t work’ is a sweeping generalisation. Homeopathy is patently implausible, acupuncture warrants more consideration given the complex nature of it’s assessment.

  76. #76 Rogue Medic
    August 23, 2010

    @ 75 Bob,

    @ 73 Rogue medic you have pretty much entirely misunderstood my post. I’m not for one moment saying Ernst is biased.

    In that case, I apologize for even hinting that you would claim that Dr. Ernst sets out to critically dispel use of CAM.

    I’m saying even the man who sets out to critically dispel use of CAM . . . .

    Maybe I did not misrepresent the bias that you seem to continue to attribute to Dr. Ernst, even while denying that you are accusing Dr. Ernst of setting out to critically dispel use of CAM.
    .

  77. #77 Chance Gearheart, NREMT-P/EMD
    August 23, 2010

    @Bob, 75

    (No, it’s not the Medics ganging up on you.)

    The problem I have with this, is while accupuncutre elicits a pathophysiological response in regards to inflammation, pain sensation, and damage to the surrounding tissue (And I could go on and on in detail about cytokines, prostiglandins, serotonins, dopamine, norepi/epi, and the like being released), the question is, basically, does this release of chemicals create a form of medical treatment for the underlying condition, or does it do nothing more than create a psychological effect comparable to the placebo effect and just illicit the standard injury response cascade in local tissues and sympathetic response in regards to the sensation and associated psychological state.

    The overwhelming evidence seems to point to the later, with much of the former not being the case in studies to date.

    It seems to me that many people who champion accupuncture want to do so based on somehow adding a new function to tissues by penetrating it with a needle, or harnassing some form of energy which doesn’t exist and isn’t measurable. I hate to say this, but, even with a basic knowledge of Patho, the mechanism most people propose for accupuncture working really doesn’t make sense on a biological level, or require some pseudospirtial belief which would require an utter stretch of mind to believe.

  78. #78 Bob
    August 24, 2010

    @ 77 Hi Chance, yes I understand the question over to what extent does the physiological response constitute the total effect, and whether that is meaningful beyond placebo, and I do realize where the current evidence base is at, but trials are often very poorly conducted and up until last month no guidelines at all in place for how the acupuncture is delivered. If there are no guidelines on that, there is no quality control over what’s getting tested which doesn’t scientifically evaluate acupuncture. It is also important to realize the difficulties of assessing acupuncture with solely the double blind RCT. You cannot double blind an acupuncture trial for example and test acupuncture in any meaningful way.
    In terms of biological models, Thomas Lundeberg, a physiologist and researcher in pain management has lectured on this extensively and it’s worth looking at for someone that is not bent on dismissing it all outright. His considerations are sound physiology with no reference to mysticism. The pro acupuncture croud dish more than their fair share of logical fallacies, no argument there, but ‘acupuncture can’t work because the theory is pre-scientific’ is also fallacious, the theory is separate from the actuality of the practice and clinical trials are fraught with problems on delivery of acupuncture. No pseudo scientific belief is required to understand how acupuncture can work.

  79. #79 ANB
    August 24, 2010

    Dr. Wonderful:

    I like Moneyball by Michael Lewis.

  80. #80 Vicki
    August 24, 2010

    Bob,

    If I read you right, you’re saying that the problem with doing double-blind studies of acupuncture is that there’s no agreed-on definition of acupuncture. If that’s true, one also cannot meaningfully say “acupuncture works,” because it’s like saying “medicine can cure disease,” without specifying the medicine or dosage. So it might be the equivalent of “ibuprofen will cure your lung cancer” rather than “ibuprofen will reduce your menstrual pain.”

  81. #81 Calli Arcale
    August 24, 2010

    Bob @ 75:

    We therefore can’t say with certainty that acupuncture is exerting no effect over placebo which is what I was taking issue with.

    True. We can, however, say it is exerting no effect over controls. I think the mass media has done an exceptionally good job of removing all the nuance from studies like these, so that point (usually made by the researchers, though not always; studies are of variable quality) is frequently lost.

    I think a more important is that while the studies to date cannot show that acupuncture is worthless they also cannot show that it is worthwhile. If it is no better than control, then one of two things are happening: either the control is as effective as acupuncture, or acupuncture is as useless as the control. You are right to point out the former possibility, but be wary of neglecting the latter.

    I know there are trials where acupuncture proved at least as effective as Effexor for hot flashes with less side effects which brings up important questions for acupuncture’s use in a pragmatic sense.

    To me, a woman who will likely have to deal with hot flashes in another ten years or so, this concerns me in that as acupuncture has no proven track record of its own (an asserted track record, certainly, but the studies are ambiguous, as discussed above), it suggests Effexor may not be as effective as we think for this purpose — which maybe isn’t surprising considering that it’s an antidepressant. I’m actually rather skeptical Effexor would help with hot flashes in the first place. (It is worth noting that, at least as far as I can tell, Effexor is not approved for treatment of hot flashes. This is an offlabel use.)

    How and to what extent is it important to know the exact specific effect against the non specific effects in something of a complex intervention like acupuncture which make that seemingly very difficult to deduce?

    In my opinion, it’s always better to know the specific biological reason why something does what it does, because then you have knowledge you can build upon. Otherwise you run the risk of doing “cargo cult” science, where you attempt to apply it in other areas without knowing whether or not it’s really applicable. (I’m a software engineer. In my field, this would be like knowing that a particular block of code does something but not knowing why. Developers will reuse that snippet of code blindly, because they don’t dare cut portions out without understanding them, and then it gets repeated throughout the codebase, with oftentimes unexpected results.)

    You can certainly test whether or not something has a particular effect, but if you don’t know how it causes the effect, then your evidence of an effect needs to be stronger to account for that. If the evidence of an effect is ambiguous at best, then you’ll need to take a bit more of a forensic approach to actually demonstrate that there was an effect. Consider a murder investigation. If two men are locked together in a room for an hour, and when you open the door up again, one of them has been stabbed to death, it’s pretty clear who’s responsible for it. You won’t even need fingerprints off the knife handle. But if two men have lunch together and then two hours later one of them is found stabbed to death in a nearby park, you’ll need forensic evidence to actually link the surviving man to the murder.

  82. #82 Rogue Medic
    August 24, 2010

    @ 78 Bob,

    I do realize where the current evidence base is at, but trials are often very poorly conducted and up until last month no guidelines at all in place for how the acupuncture is delivered. If there are no guidelines on that, there is no quality control over what’s getting tested which doesn’t scientifically evaluate acupuncture.

    Do you have anything to support this claim?

    If the real patients cannot differentiate between the sham acupuncture and the real acupuncture, why do you claim otherwise?

    Simulated acupuncture: We developed a simulated acupuncture technique using a toothpick in a needle guidetube, which was found a credible acupuncture treatment by acupuncture-naïve patients with back pain.14,17

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2832641/

    Is this claim based on the same apparent bias that produced the accusation that Dr. Ernst sets out to critically dispel use of CAM?

    Do you also claim that Sen. Tom Harkin sets out to critically dispel use of CAM, since the result of NCCAM has been repeated demonstration that CAM does not work?

    Are you able, in any way, to differentiate between intent and result?
    .

  83. #83 Bob
    August 24, 2010

    @ 80 Vicki, Yes I’m in agreement. The haziest thing from the beginning is there is no one thing called Acupuncture to assess, so as you rightly say that makes claims for success or failure equally as inaccurate. If we term acupuncture as the stimulation of the peripheral nervous system with needles, there’s an enormous variation in strength of stimulus elicited, thickness of needles used, number of needles used location etc among different styles of acupuncture. It seems a reasonable proposition that the effect or lack of, will be dependent on the way in which the strength of the stimulus is delivered which makes the whole situation complex. Japanese acupuncture for example consists solely of superficial needling. ‘Sham’ needling is in effect poorly delivered Japanese acupuncture used and claimed as an inert placebo. Again the reference for Lundeberg’s problems with this is (http://www.ncbi.nlm.nih.gov/pubmed/19525330). I think there are a number of problems with acupuncture in a double blind RCT the first one being it can’t be double blind, which creates somewhat of an impasse.

    @81 Calli, Yes a pattern seems to be that acupuncture and ‘sham’ come out similar which as you say could mean a number of things. It’s worth noting that the Cochrane collaboration has concluded acupuncture should be a consideration for tension type headache based on acupuncture outperforming sham (http://www.ncbi.nlm.nih.gov/pubmed/19160338) On the physiological question of understanding mechanism this is one of the primary aims of western medical acupuncture, and Lundeberg has done most in this area, but naturally it takes time and can’t be produced immediately. I don’t know much about Effexor, but what do you do with acupuncture if it were to consistently outperform current treatments with less side effects and the mechanism of acupuncture is becoming better elucidated? Again the Cochrane collaboration are recommending the consideration of acupuncture as treatment for migraine in light of this: http://www.ncbi.nlm.nih.gov/pubmed/19160193 From a patient perspective or a doctor in the care of a migraine patient, this seems an important consideration.I think the need for the “forensic approach” as you to say acupuncture research is needed and there is a strong movement toward that. Hugh Macpherson’s book ‘Acupuncture Research’ being a good example.

    @82 Rogue Medic I can feel your quiet seething climbing out my laptop, so let me correct my poorly phrased sentence (as you rightly pointed out)from ‘critically dispel’ to critically assess. I should say I’m a supporter of Ernst’s work not the other way around. Nevertheless I think you missed the meaning of my post which was not to criticise Ernst but rather to make the point, which I’ll put again in a respectful way that you say “ CAM does not work” (again generalising several modalities as one) and yet Ernst concludes that acupuncture does work in some conditions:

    ‘the emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions’:
    http://www.ncbi.nlm.nih.gov/pubmed/17265547

    He has also found efficacy for herbal medicine and campaigned for others to be used where there was evidence for it.

    Are both his conclusions and yours correct?

    I’ll use one trial as evidence that acupuncture trials are hazy and poorly conducted which is the very trial this post is based on. A trial that seems to bear no resemblance to what it claims to assess.

  84. #84 Leigh Jackson
    August 24, 2010

    @75 Bob

    Murkiness, not clarity, serves the interest of true-believers but it is not true that clarity is not possible. Sufficiently good sham-needling techniques now exist.

    In his editorial in the Journal of Clinical Oncology, Mark Levine listed serious problems with the study claiming to show that acupuncture is as effective as venlafaxine, (Effexor), for hot flashes, including the probability of being underpowered and possibility of being biased.

    He pointed to the fact that the acupuncture study had 50 subjects (two arms), compared with 191 patients (four arms) in the original trial which tested venlafaxine against a placebo. The acupuncture trial had no placebo controls for drug or needles. Effexor has been tested more stringently than has acupuncture. To equate their efficacy is premature without more carefully designed trials.
    http://jco.ascopubs.org/cgi/content/full/28/12/1979

    See, also, Steven Novello and comments on the same study:
    http://www.sciencebasedmedicine.org/?p=3314

  85. #85 Chris Turner
    August 25, 2010

    First saw acupuncture at a talk at university in 1978.
    Was shown a film where sticking needles into someones foot, made different parts of the ear change temperature (heat sensitive paint on ear). Anyone seen anything like that?
    Looked impressive at the time, appeared repeatable, testable and all that. Problem was when ever anyone asked him a question, the answer was allways in terms of qi and balance and utterly unintelligible.

    My question was, if sticking a needle in a certain point on your foot can cure you of something, then if you simulate the wrong point (through say a nail in your shoe or on purpose) could it make you ill?

    His answer, no natural healing functions of body stop that.

    At the end of the “doctor” measured my pulses and apparently found that my lower bowel was unbalanced (which no-one wants do they). Quick pinch on a couple of points put that straight – apparently – phew.

  86. #86 Rogue Medic
    August 25, 2010

    @ 83 Bob,

    @82 Rogue Medic I can feel your quiet seething climbing out my laptop,

    I was borrowing somebody else’s computer. I did not realize it had an active quiet seething font. That is so cool!

    Now, I’m jealous. I just must have one of those quiet seething computers.

    If you are trying to convince me that you are writing something worth reading, pretending you can read my mind is not a credible approach.

    If you can read my mind, why do I even need to respond?

    You don’t even need any of us to respond, if your psychic powers really work.

    Nevertheless I think you missed the meaning of my post

    I did not see any reason to address the rest of the comment until after addressing the apparent bias.

    This is one of the essential parts of the way that science works. Bias needs to be eliminated as much as possible before research is even worth looking at.

    I do not have access to the full text of the meta-analysis, so I have not had a chance to read it. Feel free to email me with it, so that we can discuss what is in the full paper.

    roguemedicblog@gmail.com
    .

  87. #87 Leigh Jackson
    August 25, 2010

    @83 Bob

    The authors of the Cochrane review for tension type headache did not conclude that acupuncture should be considered as a treatment on the basis of it outperforming sham.

    Had they recommended it on that basis the same authors could hardly have recommended the use of acupuncture as a prophylactic treatment for migraine. They found no benefit for acupuncture compared to sham in their corresponding Cochrane migraine review.

    In fact, the authors are loathe to draw firm conclusions, when comparing the results of the two reviews, and state that the benefits of acupuncture over conventional treatments may be entirely due to a powerful placebo effect or it may be that where the needles are placed is irrelevant.

    It is surprising that they recommend acupuncture, if they believe that it may be no more effective than a placebo, without discussing the ethical implications. The question of informed consent would seem to loom large.

    You say that the mechanism of acupuncture is becoming better elucidated. We may know more about the biochemical effects of having needles inserted into the body, but the Cochrane reviews already mentioned show that we don’t yet know that there is a mechanism of action.

  88. #88 Bob
    August 25, 2010

    @ 87 yes my mistake, not recommended on the basis of outperforming sham. I wasn’t proposing the mechanism is fully understood, but better understood than previously and without recourse to ‘Qi’ and meridians. Presumably the ethical implications are not of the usual variety because it has been suggested that the placebo is not in fact a placebo. I linked earlier to the physiologist suggesting this but another article detailing the issue is:

    http://www.faab.to/dokument/lund_06_are_minimal_superfiscial_or_sham_acupuncture_procedures_acceptable.pdf

  89. #89 Leigh Jackson
    August 25, 2010

    @88 Bob

    Understanding of the mechanism can only come when it is established that there is one. The authors of the two Cochrane reviews in question stated that their results could be due to a super-placebo effect.

    If that is the case then there is no mechanism and the question of informed consent must be addressed.

  90. #90 Calli Arcale
    August 25, 2010

    Bob, one other point that is easily overlooked. While there is research showing a physiological response to needling, I am not aware of any research connecting this effect to the desired (or, indeed, the *claimed*) outcomes for acupuncture. That is, we know the body reacts to the needles, but I haven’t yet seen anything that links that to an actual reduction in pain or nausea or whatever other proposed effect one wishes to test. So the thing to remember: just because there is an effect doesn’t mean it’s the one you’re looking for. In my stabbing murder analogy earlier, the police might stop looking as soon as they find someone with a knife. But they haven’t determined whether that knife actually killed the murder victim.

    It’s safe to say that most interventions (science-based and otherwise) have some sort of physiological effect (excluding things like homeopathy and distance healing). This doesn’t mean the effects are useful, or producing the claimed effect. Consider bloodletting to balance the humors, as was practiced a few centuries ago. This produces a rather large physiological effect (and in a few cases involving overenthusiastic physicians, actually caused death) but it didn’t do anything to help the patients. It certainly didn’t cause the effect the physicians were intending it to cause.

    Again, this doesn’t mean that needling is ineffective; just that merely finding an effect doesn’t mean we’re on the right track yet. I’m unconvinced at this point that the localized effects thus observed are actually producing a meaningful result. But I remain willing to be convinced.

  91. #91 Leigh Jackson
    August 26, 2010

    @Bob

    To paraphrase Lund and Lundberge on your last link:
    Before the therapeutic effects of acupuncture needling modalities are attributed to be other than placebo effects, a comprehensive and incontrovertible demonstration of the mechanism of action is required; and/or, the clear therapeutic superiority of one or more needling modalities compared with an unequivocally appropriate placebo must be demonstrated.

    Without one of these conditions being met, the null hypothesis stands. No mechanism of action needs to be explained, since none is presently recognised to exist.

  92. #92 Leigh Jackson
    August 26, 2010

    Sorry, that should be Lundeberg.

  93. #93 Jerry
    September 1, 2010

    The whole problem I have with the so-called studies about “acupuncture”, either to prove it works or to disprove it is that most of these studies are purely designed, and the researchers didn’t really what to measure or how to measure anything but “subjectively” — this probably can be said about some Western medicine research studies also.

    It’s like “scientists” in the 18th century using the techniques available now then to test whether people can actually communicate remotely via “radio waves” — a concept that didn’t exist at the time.

    Just today’s science can’t tell anything us the effect of acupuncture doesn’t mean that it’s all placebo, or woo, just like “scientists” in the 18th century couldn’t measure the effect of radio waves doesn’t mean people can’t communicate wirelessly.

    If you guys are truly scientists, well, you need to admit that the honest answer about acupuncture is that we still don’t know, but it works for some people at least for some diseases (well, this can be said about a lot of Western medicine pills), whether through “placebo” or not. Or as someone above claims, acupuncture simply leads to “stronger” placebo effect!

    It’s funny that in medicine research, often some unknown effect is attributed to the “placebo” effect. But does one need to ask why the “placebo” effect exists in the first place? Doesn’t it mean that somehow the human brain sometimes functions as a “healing” machine on its own? So there must be a mind-body connection that the scientists today still largely do not understand. Well, the human body and mind are very, very complex machines — it probably defies the “conventional” (and prevailing) Western scientific methods, namely, analytical methods by breaking big things into small parts and then focusing only on a tiny part (e.g., a chemical compound, or a single gene).

    The emergence of new science — “complexity theory”, the study of complex adaptive systems — still has a long, long way to go!!!

    In summary, instead of being open-minded, most of you guys here (that includes in particular the author of the article, Orac) sound like a bunch of dogmatic theologists. Just because my theory can’t prove it exists, it can’t exists! Such altitude is most dangerous to the progress of science! The scientific knowledge we have today, in particular, when it concerns about human body and mind, is still very limited. Most medicine research studies are mostly case studies based on statistics, we really don’t truly know why many drugs work, or work only for some people to a good effect, but not other. So please, do make the “science-based” medicine a dogma, just because the evidence is not there yet.

  94. #94 Jerry
    September 1, 2010

    Sorry, in the last sentence, I meant to say “So please, don’t make the “science-based” medicine a dogma, just because the evidence is not there yet.”

  95. #95 Jerry
    September 1, 2010

    “Its a good thing we don’t rely on juries for scientific decisions.”

    But unfortunately, more often than not we do, the jury process is called “peer-reviewed”. That’s how most scientific studies get published, and why so flawed studies get published.

    The problem I see with most medicine research is that they are basically case studies (or “experiments”), often with limited samples, where conclusions are drawn based only statistical inference. Many such studies are not exactly “reproducible” in its true sense (e.g., as used in physics), as another study can repeat the studies on the same samples. Even when done on the same people, they grow and change. Each human being a individually complex system that adapts and changes. The modern (Western) medicine is good at certain things, but notoriously poor at other things (e.g., curing certain chronic ailments). There is still a long way to go for modern medicine to fully understand how human body and mind work. Genetics helps, but again so far at best we may be able to explain (or rather guess) what a few genes do. But human body is a complex system of many interacting genes!

  96. #96 Jerry
    September 1, 2010

    Corrected version:

    “Its a good thing we don’t rely on juries for scientific decisions.”

    But unfortunately, more often than not we do, the jury process is called “peer-reviewed”. That’s how most scientific studies get published, and why some flawed studies get published.

    The problem I see with most medicine research is that they are basically case studies (or “experiments”), often with limited samples, where conclusions are drawn based on statistical inference. Many such studies are not exactly “reproducible” in its true sense (e.g., as used in physics), as another study cannot truly repeat the studies on the same samples. Even when done on the same people, they grow and change. Each human being a individually complex system that adapts and changes. The modern (Western) medicine is good at certain things (e., surgery), but notoriously poor at other things (e.g., curing certain chronic ailments). There is still a long way to go for modern medicine to fully understand how human body and mind work. Genetics helps, but again so far at best we may be able to explain (or rather guess) what a few genes do. But human body is a complex system of many interacting genes!

  97. #97 Vicki
    September 1, 2010

    Jerry–

    The problem with your radio wave analogy is that you’re confusing levels. No, Benjamin Franklin had no idea of what radio waves were or that they existed. Nonetheless, if someone had come to him and said “I have a device that will let you communicate instantly between Washington and London,” they could have shown him that it worked.

    Yes, the placebo effect is a real thing: the body, and therefore the mind, is a complex thing and can do all sorts of odd things. That doesn’t mean it’s a good idea to stick needles in people when you can get just as good healing results without risking infection.

    Nor does it mean that the placebo effect can cure everything.

  98. #98 Jerry
    September 1, 2010

    Vicki,

    But how could the “scientists” at Ben Franklin’s time _prove_ that it actually worked, if they would insist on using the “scientific” methods and tools available at the time? All they saw is a bunch of magic devices that allow people to magically talk to each other remotely, just like some acupucturists use “needles” to magically cure some ailments. Since they could prove it actually worked using the knowledge and tools they had at their disposal at the time, they could simply dismiss it as “magic”, or “woo” or “placebo” effect.

    In any case, all I am trying to say is that at the moment we still don’t really understand how the mind-body network works. I don’t know whether the needles indeed magically affect this network or not. Just simply because we can’t provide evidences (we don’t really know what to measure and what evidences to collect yet) doesn’t necessarily mean that acupuncture doesn’t work. (On the other hand, I understand that there are a lot of “woo” or “hype” around many “alternative medicines.” For one thing, I don’t buy into the Eastern mysticism regarding many things.)

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