White Coat Underground

Acucebo

Posted by PalMD on January 28, 2009
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ResearchBlogging.orgIt’s hard to hide severe back pain. When I stand up, I look like a question mark. The visibility of the problem, combined with the general goodness of my fellow human beings, leads to lots of unsolicited advice. Folks have given me great advice (take some NSAIDs, stretch, and don’t lay in bed) and some questionable advice (go to the chiropractor, get some acupuncture). My colleagues and I have written a lot about acupuncture. It’s sort of a “gateway CAM”, in that it has a patina of plausibility. But the evidence of its efficacy has pointed toward it being an elaborate placebo.

To help settle the question, the British Medical Journal (BMJ) has published a systematic review (which is different from a meta-analysis) of studies of acupuncture that were as well-controlled as possible. Much of the acupuncture literature suffers from lack of proper controls, as it’s difficult to blind either the subject or practitioner to pointy needles in flesh. But it can be done, to a certain extent, with “sham” acupuncture, and the current review aimed, “to analyse all trials of acupuncture for pain that had two control groups consisting of placebo acupuncture and no acupuncture.” This type of systematic is especially important for implausible medical claims. If you do enough studies, you can always find “positive” results—a key question is do the positive results reflect reality. A well-done systematic review can help determine what the preponderance of the data mean.

So, what did they find?

It turns out that so-called placebo acupuncture has some analgesic effect compared to no acupuncture at all, but that both “real” and “placebo” acupuncture provide no significant benefit that can be separated out from the effect of undergoing an intervention.

In other words, if someone is in pain, and you do something to them, they will often report feeling better. Acupuncture shows no consistent effect above and beyond this.

This should settle the issue. It seems like there’s a new acupuncture trial every couple of months, and none has been particularly ground-breaking. This systematic analysis should be the end of it. No matter how many times you try it, it’s still, in aggregate, no better than placebo. This study, combined with the greater part of the available evidence, should lead us to abandon support for acupuncture.

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M. V. Madsen, P. C Gotzsche, A. Hrobjartsson (2009). Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups BMJ, 338 (jan27 2) DOI: 10.1136/bmj.a3115

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Comments

  1. #1 ColinB
    January 28, 2009

    Question – presumeably if you are aware that acupuncture has no more effect that placebo acupuncture then you would not experience a placebo effect?

    Second Question – has anyone figured out what CAUSES the placebo effect? Because if it can be understood, harnessed, and turned to the light side of the force…

    (not holding my breathe… :-)

  2. #2 Jen
    January 29, 2009

    If the goal is symptom improvement – which in the case of something like back pain is really what you’re looking for – the benefit to the patient is the same if the improvement is due to a placebo effect brought on by acupuncture, or through pain medication, for instance, assuming the alternative treatment does no harm. Especially when the pain medication would likely have side effects that the acupuncture doesn’t.

    Saying the treatment is no better than placebo really doesn’t tell us much – placebo can be very effective medicine. What percentage of patients experienced an improvement in symptoms following treatment? And how does that compare to other therapies, such as pain medications or surgery?

    Obviously you don’t want to use CAMs such as acupuncture for treatment of a serious illness that requires actual medical treatment. But for something like back pain that there is little medicine can do (short of surgery or ongoing medication, both of which have mixed results), why limit the patients options, if the patient feels they benefit from it?

    I think complementary/alternative therapies have a place, and I’m not sure why it is such an issue where the benefit comes from, as long as the patient feels better.

    As for your back pain – I swear by yoga. I don’t know if there is science to support it,but it has proved extremely effective for me in reducing my pain (as long as I am consistent – like any treatment).

  3. #3 PalMD
    January 29, 2009

    In a previous post, i pointed out the danger of this approach.

    Placebo “effect” is an artifact of the patient’s interaction with the health care system. There is no such thing as placebo “treatment”, in that it isn’t in any way predictable. If you prescribe an inert treatment (like acupuncture or homeopathy), certain patients in certain situations may improve, which will have nothing to do with the intervention, on the fact of the intervention. It is an important distinction.

  4. #4 Patient
    January 29, 2009

    In this case, the placebo effect might be from endorphins released from the needles puncturing the skin. As I understand this study was a meta analysis and “placebo” acupuncture can be defined as acupuncture with needles that puncture in the “wrong” place, or acupuncture with “sham” needles that merely press the skin without puncture. In either case, the meta analysis may not have made the distinction between the two, or it is possible that even the “sham” needles create endorphin release. Endorphins would explain why the effect is short lived, and why there is a difference between acupuncture/placebo acupuncture vs. no acupuncture.
    Sorry about your back PAL. Not that you need any more advice, but I have found Earth shoes to be a great relief, as wearing them shifts the weight of the back and creates just enough of a difference in your posture to fool the nerve endings.

  5. #5 ColinB
    January 31, 2009

    I remember that article, and agree. But what I was really pondering was what was causing this effect. Is it simply a lowering of stress/anxiety that makes the patient “feel” better?

  6. #6 Jaban
    February 1, 2009

    “placebo can be very effective medicine”

    What I’m about to say in response only addresses one aspect of the placebo effect: when you aren’t sick but you think you are.

    Not everyone has an actual physical malady causing their symptoms. They have some emotional stress and need the hour of care and empathy provided by their ‘practitioner’ to feel better. And so what if he told them he manipulated some magical energy fields and sold them some cherry seed extract?

    The danger is twofold (or twentyfold; I’m simplifying):

    1) There is no inherent distinction between a person who feels sick and a person who is sick. If you go to a practitioner for treatment when you feel sick, and he does make you feel better, you will tend to think what he does actually works the way he says. But it won’t work when you go to him with salmonellosis.

    A practitioner is not qualified to diagnose whether your problem can be treated by lending a hearing ear, and probably doesn’t realize that’s what he’s doing when it works.

    2) The way us laymen understand our health problems is overly simplified. You and I may both have “high blood pressure”, but in actuality you have stress-related essential hypertension and I have secondary hypertension caused by my congenital aortic coarctation. You may think cherry seed extract lowers your blood pressure, but it doesn’t. Talking to the practitioner about your problems lowered your stress level. That won’t work for me.

    We may both understand our problems to be the same thing, and think the same sham treatment will work for both of us, but they aren’t and it won’t. And our practitioner is unlikely to understand the subject any better than we do, and is unqualified to diagnose us or prescribe treatment.

    If we set up a system that allows and encourages placebos as treatments, people with legitimate health problems will unwittingly use them too, and it will not work for them.

  7. #7 Jaban
    February 1, 2009

    Sorry to add more so soon. In case it wasn’t clear…

    By saying practitioners are unqualified, I mean to say that without the training to be able to diagnose the problem properly, they are not qualified to choose who would benefit from their services and who should go to a real doctor.

    A kinesiologist won’t know you have cancer, and will therefore not realize he should send you to a doctor. Of course, even if he were qualified he’d have to recognize his treatment as a placebo before he would.

    I hope that answers your question, Colin :)