Can we finally just say that acupuncture is nothing more than an elaborate placebo? Can we?

ResearchBlogging.orgI think my title says it all: Can we finally just say that acupuncture is nothing more than an elaborate placebo? Can we?

The reason I ask this question is because yet another large meta-analysis has been released that is entirely consistent with the hypothesis that acupuncture is a placebo. Because I've written about so many of these sorts of studies over the last year or two that I really had a hard time mustering up the will to write about one more. But I got in pretty late last night and therefore knew I could handle this in a reasonably expeditious fashion. Besides, it is a fairly interesting study as far as methodology. Also, I've been on a roll writing about antivaccine nonsense, but it's taken a toll. My foray into the discussion forums resulted in a real assault on my neurons, so much so that, while I had considered taking on the not-so-dynamic duo, two crappy tastes that taste crappy together, otherwise known as David Kirby and Robert F. Kennedy, Jr. in the pages of The Huffington Post. Truly, just when I think HuffPo can't go any lower, damn if it doesn't prove me wrong. In any case, I thought it ill advisable to subject myself to more of Kirby and RFK, Jr. so soon on the heels of waves of burning mommy stupid. Better to take on this study, because it's yet another piece of evidence that backs up what I've come to accept after having actually read that acupuncture literature: That acupuncture is nothing more than a placebo.

So let's take a bit more of a look at the study. Entitled Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups appeared in the BMJ two days ago and was performed by Madsen et al at the Nordic Cochrane Center, meaning it's a Cochrane review.

A meta-analysis, as I hope you recall, is a systematic methodology for reviewing the peer-reviewed medical literature in which studies are examined and pooled together to try to produce a consensus. Of course, this is the sort of thing that's fraught with methodological problems. It's easy to wonder what pooling data means when the data come from multiple studies that may have variable inclusion criteria, different endpoints, different design. However, it can be done, although one should look at the results with a skeptical eye. After all, garbage in = garbage out, which means that study selection is almost always the most important aspect of any meta-analysis. Consequently, that's the part I always look at first.

This particular meta-analysis examined studies of acupuncture for pain. What's good about the search strategy used is that it not only discarded various types of acupuncture that aren't really acupuncture, such as electroacupuncture, but it also only included only trials that used some sort of placebo acupuncture, be it sticking needles into non-meridian points or using the special "placebo needles" that retract and give the illusion of penetrating the skin but do not actually do so. In other words, it used only trials that included an acupuncture group, a placebo acupuncture group, and a no acupuncture group. Another strength of the analysis is that it also included only studies in which both the acupuncture groups and the no-acupuncture groups were given the same medical interventions. If the no treatment group received a treatment substantially different from the acupuncture groups, the study was not included. Finally, trials in which the patients self-reported pain on a visual analog scale or similar pain scale were included.

The results were thirteen trials, with a total of 3,025 patients between them. Unfortunately, this leads me to mention one weakness of this analysis, namely that the studies included covered a rather wide range of conditions, including knee osteoarthritis,w7-w9 tension type headache, migraine, low back pain, fibromyalgia, abdominal scar pain, postoperative pain, and procedural pain during colonoscopy. Moreover, the duration of treatment varied from one day to 12 weeks. I could also complain about the way the term qi and meridians are described in the manuscript as though they had any validity other than as prescientific magical thinking, but what would be the point? Be that as it may, what were the findings?

In essence, zilch, nada, zip.

Well, not quite, but the results were meager. Let's take a look at these relative risks. Here is the plot of acupuncture versus placebo acupuncture:


The diamond represents the pooled results of all the studies. Although it is statistically significantly different than zero, it is barely so. Indeed, it's so small that that it falls below the minimally accepted threshold for a clinically noticeable reduction in pain. The authors even speculated that it was so low that it could not be distinguished from bias that might result from the difficulty in truly double-blinding acupuncture studies (generally, it's very difficult to blind the practitioners doing the acupuncture to who is getting placebo and "real" acupuncture). Incomplete blinding could account for this small difference.

The authors also looked at placebo acupuncture versus no acupuncture. There, as expected given the lack of blinding of patient or practitioner, there was a more significant apparent reduction in pain due to the placebo effect, but even then it only just barely approached the threshold accepted as being a clinically noticeable and relevant analgesic effect. Interestingly, the magnitude of this effect did not depend upon the type of placebo used (retractable needles versus needles stuck in the "wrong" places). Also, the effect was quite variable, with some trials showing large effects that would clearly be clinically relevant and others showing much smaller, clinically irrelevant effects.

Not surprisingly, various press reports, perhaps the most egregious of which, have represented this study as being less negative in terms of whether acupuncture is more than a placebo than it is. For example, the BBC reported Confusion on acupuncture benefit when there really isn't much confusion when one looks at the science dispassionately. It even quotes acupuncture "experts" thusly:

Dr Adrian White, a researcher into acupuncture at the Peninsula Medical School in south west England, said that "sham" acupuncture might well be having an effect rather than acting as a simple placebo version of the treatment.

"Sham acupuncture often consists of superficial, off point needling, but this may still have a physiological effect.

"Sham controlled studies are of little value in estimating benefits to patients."
The British Acupuncture Council described the treatment as "a beneficial and effective therapy for a variety of conditions".

Mike O'Farrell, the chief executive, said the latest study contradicted the majority of previous research in the area.

He said: "Acupuncture does work and research results consistently demonstrate the positive outcomes of treatment on patients."

Ah, yes. Argument by assertion, no research results actually cited. Also, note the dismissal of sham-controlled studies. There's a reason why acupuncturists don't like sham-controlled studies. If you review them, you'll see that the preponderance of evidence from such studies shows that (1) it doesn't matter where acupuncturists stick the needles, and the effect is the same no matter where they are stuck; and (2) acupuncture produces no effects greater than placebo.

That's because it is a placebo. It's an elaborate placebo, and the relaxation and attention given patients is the only real "healing" going on. That, and the break that looking at this paper allowed me to take from subjecting myself to the burning stupidity I've been dealing with lately.


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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going on the BBC's interpretaion, it should make the training of acupuncturists al ot quicker and cheaper. No longer will they have to be taught all that tedious stuff about qi and meridians; just stick the needles in at random, guys.

I'm intrigued by the concept of true placebos versus sham placebos. What sort of test would be required to identify whether a placebo was a true placebo or a sham placebo?

On acupuncture, this excellent Cectic strip nailed it!

I like the way you think, Mojo, but it needs to be taken further...

Perhaps there should be a new discipline in medicine: randomised placebo treatment (someone would need to come up with a catchy title). All you have to do is wear a white coat, talk to a patient for 45 minutes a time in a comfy room with loads of plants, poke and prod them a bit (no X-rays required), stick in a needle or two and send them off with a sugar pill (green, red or blue as required). Oh! And wear a stethoscope around your neck. Since you could be trained to do this effectively in a couple of days, the cost saving to the NHS would be amazing!

This allows for a new technique then - automated acupuncture. If it's the needles only, independent of placement or "treatment", we can apply the needles by an automated needle gun, and have them removed by magnet. No question of blinding, no question of the effect of the "healer", it's either working or not.
How many needles can you get into a 12 gauge shotgun shell?

This bit about sham acupuncture justifies one thing that has bedeviled parents for decades:

The family is on a long trip, and one sibling is continually poking another, despite increased whining from the set upon and warnings from the parents. The studies referenced here support the claim by the guilty child: "I'm just poking him( or her) - it isn't really doing anything."

Just thinking about alternative medicine makes me cross. Is this placebo anger?
But seriously, since the placebo effect is real and demonstrable it makes me wonder how conventional, real, medicine uses it to help patients. My impression is that doctors will use pills and potions especially painkillers to help patients, even if the clinical benetits are minimal. No doubt many patients have been given antibiotics to treat viral infections for the same reson, though here there are clear contraindications. Incidentally one suggestion I heard recently, possibly here, is that physicians can do a lot simply by explaining clearly to patients the expected course and duration of "minor" diseases - ie, you'll probably feel ill for a few days, followed by a slow recovery - so that they understand how most things will clear up of their own accord whatever you do.
Also, as regards CAM my impression is that many doctors will suggest, eg homeopathy, as something they might try as some patients feel it is benificial - placebo by the back door, as it were. Doctors can't really prescribe a placebo per se, as that would be unethical, but the continued existence of alternative therapies within the medical community may well often be linked to such considerations.
So, is medicine taking full advantage of the placebo effect, and is there any way of doing so without directly giving money to quacks? Any thoughts?
P.S apparently "ear" acupuncture was not invented 1000s of years ago but only in 1957, by a Frenchman. See Rose Shapiro's book Suckers - How Alternative Medecine Makes Fools of Us All for this and other entertaining details.

Can we finally just say that acupuncture is nothing more than an elaborate placebo? Can we?

Wrong question.

Of course we can say it, but the real test is whether anyone listens.

By D. C. Sessions (not verified) on 29 Jan 2009 #permalink

Just like the fact that you don't see artificial legs and glass eyes left behind by those 'cured' by miracles at Lourdes, I don't see that acupuncture appears to be marketed for truly acutely painful procedures.

What we need is a better experimental model. A procedure that is acutely painful across all populations, and produces an outcome that can be measured mechanically, not as a subjective patient evaluation.

Perhaps something like a spinal tap pain, measured as patient movement in centimeters, or moans per minute. Perhaps resetting a dislocated shoulder, measured in decibels. I'm sure you HCP's could come up with better proposals.

What you need is an acute pain that results in a measurable reflex.

Question - has anyone studied whether sticking multiple needles into a human being raises the levels of endorphins? If so, perhaps a suitable placebo would be a standardized swift kick in the shins, so to speak. Say, a four-hopper kick would produce an elevation of blood endorphins equivalent to 30 microscopic needles plunged into the flesh, and then twisted.

I think there is money available for research at the Marquis DeSade Institute.

By Gingerbaker (not verified) on 29 Jan 2009 #permalink

We were taught that a possible mechanism for acupuncture was subjecting the patient to diffuse low-level pain signals across nociceptors, which resulted in descending pain inhibition. If this is true, it doesn't particularly matter where the needles are stuck as long as it's in a wide area.

If these studies prove that acupuncture only has a placebo effect (that is what you're saying, isn't it?), this rubbishes the diffuse pain theory.

By Medical Student (not verified) on 29 Jan 2009 #permalink

I totally agree with you, but the placebo effect works in 1 out of 3 people. And in those people, it does have an actual physical effect, not just delusion. So if someone does have issues with pain that are not solved by other methods acupuncture may still be worth a try.

Why doesn't the blue diamond come with a confidence interval?

I just sent a link to this post to Andrea Kremer from NBC Sports. I heard earlier this week that her contribution to the interminable schlockfest of pre-Superbowl coverage is a 'well researched' piece on acupuncture--apparently a preferred modality for many of the Pittsburgh Steelers. So, if she's any kind of journalist, she has to present the skeptical side of the story now, too, right? Right? Why are you all laughing at me?

@medical student,

Stick with this blog. Is your school among those that foist quackery on students, as if it were legit?…

The best evidence is that acupuncture is an impressive, elaborate placebo. Fake needles that do not impale the skin (therefore, painless) produce the same effects. I think you have been fed a hand-waving explanation for a non-effect.

Self-acupuncture, another form of self-abuse to while away the hours. Or couples acupuncture - a relaxing weekend making each other into porcupines. Fun for the whole family! Time to start marketing the needles as part of home health care....

Ahh, Orac rightly needles the acupuncture crowd again!
could I just applaud with "Stick it to em! " ?
Thanks folks, I'm here all week.

I have a work colleague who hurt his hand boxing a while back. He went to see an acupuncturist who put a needle in his hand and one near his stomach (or some such), and bibbety bobbety boo! His hand hurt less and he was able to move it more he claims.

Itâs hard to tell someone âYou probably imagined it, the mind can trick itself in many powerful waysâ without sounding completely condescending. They would instantly be on the back foot and I would probably sound like Charlie Brownâs teacher every word after that (muffled âwhaa whaa whaâ for those too young to remember).
So I said, âOh, okay. I guess I am just dubious in general because just about every study that I know of has had results no better than a placebo. Also, practically all of them adhere to the meridian crap, and when they start talking about that, my mind just starts trailing off because itâs just ridiculousâ.
Of the Meridians, he said âyeh, I donât believe in any of that stuff, but it worked!â. I was back to square one.

How do we fight that sort of thinking/talk? What the hell do you say?

Serious question. I was stumped.

You can see the consequences of this from a fellow medical student at my school:

I'm stickin' around here, Joe. Sounds like hand-waving was what it was. It's always odd to me to find that something under the list of treatments in lectures hasn't even been evaluated for efficacy sometimes (hypnosis?). I think they like to call things under debate a theory, then leave it up to us to make our minds. They seem to not particularly care about placebo or not, as long as it works for whatever individual patient.

By Medical Student (not verified) on 29 Jan 2009 #permalink

Darya comments:

"I totally agree with you, but the placebo effect works in 1 out of 3 people. And in those people, it does have an actual physical effect, not just delusion."

When people say that the "placebo effect" is due to psychological effects, it is not the same as saying it is a "delusion".

More importantly, the "placebo effect" is relatively short-lived and of low potency. Using it for treatment of pain that is refractory to other treatments has been shown to be only useful for short periods and pain of moderate intensity or less.

You'll notice that most (all?) acupuncture trials are against low to medium intensity pain and only look at improvement immediately after treatment. It is placebo (plus a possible endorphin release due to needle puncture - another short-term "fix" for pain).


The defence of acupuncture by Mike O'Farrell who is Chair of the British Acupuncture Council doesn't bode well. He has recently (according to CNHC minutes) been co-opted to the board of the Complementary and Natural Healthcare Council (aka Ofquack)- a body that concerns itself with the processes of various CAM interventions but not the issue of whether or not they have any evidence-base or can support claims of effectiveness.

Madsen et al. wrote in their conclusion

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

This may be conservative language typical of a scientific paper, but I can see how the BBC could interpret this as confusion on the subject. I agree that it is probably due to bias by the acupuncturist. Unless I am mistaken, Table 1 of the study shows that only patients were blinded, not the practitioner (3 studies of 13 are listed as "unclear" in terms of blinding).

Are there perhaps studies on the placebo effect that show how the practitioner can influence the placebo effect?

I just read (on AOL news, so take with grain of salt) that Air Force medics and docs are being trained in acupuncture, specifically for soldiers in Iraq and Afghanistan. You'd think that the last thing they'd need is more punctures.

it's worth mentioning here that outcomes for pharmacological pain treatments are often only slightly better than placebo and they come with some pretty irritating side effects, like weight gain, loss of libido, and diminished cognitive ability. western pain treatment would be lost without the help of the placebo effect!

By what's so terr… (not verified) on 30 Jan 2009 #permalink

Of course accupuncture doesn't work. As its proponents like to point out, it's been being used by the Chinese for thousands of years. If it had any effectiveness, we'd expect Chinese life-spans to have been higher than the rest of the world's for thousands of years. They haven't been. Case closed.

What we need is a better experimental model. A procedure that is acutely painful across all populations, and produces an outcome that can be measured mechanically, not as a subjective patient evaluation.

A meta-analytic examination of the impact of acupuncture on brain activity might be useful.

By Tony Jeremiah (not verified) on 30 Jan 2009 #permalink

What we need is a better experimental model. A procedure that is acutely painful across all populations, and produces an outcome that can be measured mechanically, not as a subjective patient evaluation.

A meta-analytic examination of the impact of acupuncture on brain activity might be useful.

By Tony Jeremiah (not verified) on 30 Jan 2009 #permalink

I checked a past paper and they did actually test us on the mechanism of acupuncture: " diffuse noxious stimulus" being the "right" answer. I suppose I shouldn't be surprised, considering that the exam I had today asked me whether the site of binding of glutamate on a picture was on a triangle or an oval on a picture of the NMDA receptor (Basically, they were checking if we had eidetic memories for pictures they used in our lectures. How this contributes to our medical education? I have no idea.)

By Medical Student (not verified) on 30 Jan 2009 #permalink

it's worth mentioning here that outcomes for pharmacological pain treatments are often only slightly better than placebo and they come with some pretty irritating side effects

It's also worth mentioning that patients who receive placebos can develop "side effects" and "withdrawal symptoms."

I've read that some people claim that there's no placebo effect in veterinary medicine (mentioned - but not supported by the authors - in Trick or Treatment), and I've read that some people claim that "acupuncture" worked on an aging tapir for aches (see ).

My guess so far is that for animals who have regular veterinary care, there may still be some placebo effect after all (especially if they are larger than the veterinarians instead of cat size and get house calls instead of trips in pet carriers in cars). For example, of course George the tapir in question can't read the hype about acupuncture. However, no doubt over the years there have been times when George wasn't feeling well, then was seen by one of the zookeepers (the veterinarian, but George doesn't know about medical qualifications) who did something other than the everyday usual (maybe with another unfamiliar human there), then felt better. So, I bet George's recovery in this case was less about the "acupuncture" than the vitamin B12 in these injections and/or the placebo effect that comes with a Keeper Feelgood visit.

"It's also worth mentioning that patients who receive placebos can develop 'side effects' and 'withdrawal symptoms.'"

That's the nocebo effect, right?

Acupuncture is commonly used on race horses. Horses don't respond to placebo. Yet owners and trainers see objective perform improvements when their horses get acupuncture. The acupuncture is doing something (unless you believe the placebo is acting on the stop watch).

So to answer your initial question, no. We need more and better data. It seems you're seeking to confirm your biases. Be more skeptical sir.

By true skeptic (not verified) on 02 Feb 2009 #permalink

true skeptic said "Yet owners and trainers see objective perform improvements when their horses get acupuncture"

I think you mixed up the definitions for "objective" and "subjective". It is a common mistake.

How about some real OBJECTIVE documentation for your claims. You know, that real sciency stuff that is so bothersome, just to show us that it really IS doing something... or that you know what you are talking about.

By the way you wrote "Horses don't respond to placebo."... but their humans do. Which is why the self-reported subjective data is not good enough.

it's worth mentioning here that outcomes for pharmacological pain treatments are often only slightly better than placebo and they come with some pretty irritating side effects, like weight gain, loss of libido, and diminished cognitive ability.

I'd be interested in seeing the study or studies showing that "pharmacological" pain treatments in current use are only slightly better than placebo.

While I am aware - from my previous work in pain research - that there have been some treatments (pharmacological and other) that have been shown to be not significantly better than placebo, I don't know of any that are still in use.

That's what makes "Western" (i.e. modern) medicine different from "alternative", "Eastern" or "complementary" medicine - it drops practices that are shown to be ineffective (granted - not everybody all at once, but eventually) and even adopts "alternative" practices that have been shown to be effective.

There's nothing wrong with the placebo effect - the problem is deliberately deceiving patients. If we know that acupuncture is simply a placebo (and we do know that), then using acupuncture on a patient - without telling them that it is simply a placebo - is lying to them.


Too much arrogance I detect in this post. Scientists need to be open minded and never, ever label non-scientists as stupid. You may think science was invented in the last 100 years and billion of people who lived before were idiots. Years ago I tried acupressure for pain and guess what it did work and it still does work. Placebo effect? You wish!

sargo said "You may think science was invented in the last 100 years "

If you did, you would be wrong.

Also, remember the plural of anecdote is not data.

Another Cochrane Review for your consideration:…

To investigate whether acupuncture is a) more effective than no prophylactic treatment/routine care only; b) more effective than 'sham' (placebo) acupuncture; and c) as effective as other interventions in reducing headache frequency in patients with episodic or chronic tension-type headache.

Authors' conclusions
In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.

...Agree or disagree, it's worth noting such research from the same distinguished source.

Hmm, no you can't say that, not when your own study used as evidence suggests some benefit, even if small. A true skeptic is precise and doesn't leap for emotive headlines just to be sensational.

You should look at other meta-studies (some of which ARE favorable against sham acupuncture and I have not seen you address except in vague, passing, argument-by-assertion statements), and perhaps try to improve it instead of relying on just this one study and thinking that there's no room for improvement.

You have quite confusing double standards. Cherry picking studies to suit your argument isn't helpful.

Given that a 2005 Cochrane Review study has found acupuncture for lower back pain to a beneficial adjunct therapy, it is rather apalling that you never brought it up. Either you really have done a very poor job reviewing the scientific literature, focusing almost exclusively on the studies which are obviously bunk (i.e. shooting fish in a barrel because real fishing isn't exciting enough) and ignoring meta-analysis on sham acupuncture that is favorable.

I'm sure though, you'd try to discredit Cochrane Review and be much more critical of consistency in sham acupuncture application in meta-studies if you found the others favorable to acupuncture first.

In fact, given what you said about argument from assertion, you sure seem very reluctant to actually cite the meta-analyses using sham acupuncture, with your actual citations of them far outweighing how many times you bring them up in a blog post.

If you can't even bothered to look at the citations on Wikipedia, what does that say? The section on evidence based medicine lists a variety of citations, some from the Cochrane Review, which are favorable to pain relief (and even IVF although that needs more study).

It is really, REALLY bad when someone with minimal Wikipedia skills could find studies that you either didn't read, or deliberately excluded from all of your posting simply because they aren't favorable. A true skeptic focuses attacks on the STRONGEST evidence for something, not the weakest.

You know what's funny? I've read past posts suggesting you were once open to acupuncture, but that seems like either a lie or gross exaggeration, since almost all of your rants are targeted at the most obvious, least supported studies, especially those which don't use consistent needling locations/technique, are done by practitioners of obviously supernatural hypotheses, and/or are for conditions (e.g. cancer) where there is clearly no conceivable benefit.

Now, if you were open to some possibility of it being helpful, you wouldn't waste time shooting fish in a barrel and would instead focus on the one thing that the medical community does have a fair amount of support for: pain treatment. And you keep implying, over and over, that there are very few or no studies with sham acupuncture supporting it, when in fact, there are large meta-studies supporting it.

You could have presented these studies and stated why you thought they were flawed, but you didn't, you just stuck with those dead fish in a barrel. The former would have at least been a respectable stance, even if people disagreed. So WHY do you have this obsessive need to shoot fish in a barrel?

P.S. Why would you expect a BBC article to have a citation in it? It's for lay people, they never have citations and the scientists don't choose what gets quoted in the article.

By Nathan J. Yoder (not verified) on 16 Mar 2009 #permalink