If there's one thing that's become clear to me over the years about acupuncture, it's that it's nothing more than a theatrical placebo. Many are the times that I've asked: Can we finally just say that acupuncture is nothing more than an elaborate placebo? Most recently, I asked this question in 2012. What science-based medicine answers is yes. However, there's a large contingent of physicians under the sway of practitioners of traditional Chinese medicine (TCM) who have fallen under the spell of that theatrical placebo, leading to a whole subdiscipline of quackademic medicine in which tooth fairy science is used to try to convince people that acupuncture actually works, even if they involve misinterpreting adenosine signaling or rebranding regional anesthesia as a form of acupuncture they dubbed PAPupuncture.
While I grudgingly admire the imaginative creativity of some of the attempts to torture acupuncture into seeming scientific, I also take note of studies that go against the seeming flow of propaganda designed to convince you that acupuncture has real, specific effects. Remember, it wasn't so long ago that I considered acupuncture, of all alternative medical treatments, as the one that might actually have something to it. The reason, at the time at least, was that acupuncture actually involved sticking needles into people. Perhaps there was some sort of physiological effect. Then I actually started paying close attention to the acupuncture literature. There, I learned that it doesn't matter where you stick the needles, thus invalidating any concepts of acupuncture meridians. Nor does it even matter if you stick the needles in at all; twirling toothpicks against the skin produces a similar effect. Basically, when compared to usual care or wait list controls, patients treated with acupuncture report improvement in pain and other subjective measures. However, when a rigorous sham acupuncture control is included in such studies, the apparent differences between acupuncture and control disappear. Acupuncture effects are virtually all nonspecific placebo effects.
With that in way of background, I just saw another study that sheds light on acupuncture effects by way of story in Medical News Today story entitled Acupuncture back pain success determined by psychological factors. It's a story about study by George T. Lewith's group at the University of Southhampton. He's bit of a controversial figure, as no doubt David Colquhoun could tell you, given that he apparently still prescribes homeopathy even though he's published studies showing that it isn't effective. Be that as it may, this study is called Psychological Covariates of Longitudinal Changes in Back-related Disability in Patients Undergoing Acupuncture.
Basically, it's longitudinal study using a questionnaire mailed to patients undergoing acupuncture for chronic back pain. Data were collected at baseline (pretreatment), 2 weeks and then at three and six months on a total of 485 patients from 83 different acupuncturists. The questionnaires were designed to measure variables from four theories (fear-avoidance model, common-sense model, expectancy theory, social-cognitive theory). In addition, clinical and sociodemographic characteristics, and disability were surveyed. The primary outcome was back pain-related disability. This was assessed using the 24-item Roland Morris Disability Questionnaire (RMDQ), which asks patients to think about “today” and to indicate whether their back pain interferes with 24 activities. An example: "I stay at home most of the time because of my back." High scores indicate greater back-related disability. At the same time, a variety of psychosocial scales were also examined to try to hone in on what psychological factors most contribute to the patient-perceived efficacy of acupuncture.
You can tell that Lewith is a believer by the introduction to the study:,
Personally, economically, and socially, back pain is costly. Acupuncture is recommended by UK clinical guidelines for low back pain (LBP) and is commonly used for LBP. In randomized clinical trials acupuncture has shown large effects on chronic pain compared with usual care or waiting list controls but often only small effects compared with sham acupuncture. This suggests acupuncture has large nonspecific effects, that is, factors other than needling characteristics contribute to patients’ outcomes. Indeed, acupuncture can be conceptualized as a complex intervention in which changes in patients’ health are produced not only by needling but also by more psychosocial factors such as empathic therapeutic relationships and holistic consultations in which discussions of lifestyle and self-care can trigger changes in how patients think and feel about their symptoms and their ability to manage them. However, little is known about the psychosocial factors and processes that might be involved in acupuncture for LBP: established psychological models have not been applied to understand acupuncture’s effects. Although variables from such models may not be explicitly addressed by acupuncturists, this does not mean they are not involved in patients’ ongoing LBP in this treatment context. Therefore, a comprehensive and theoretically informed investigation of psychological covariates of acupuncture’s effects on LBP was designed, drawing on major theoretical frameworks that have predicted LBP outcomes in patients undergoing other interventions: the fear-avoidance model (FAM), common-sense model (CSM), expectancy theory, and social-cognitive theory (SCT).
It is rather interesting to me that UK clinical guidelines for LBP would include the use of a placebo. One wonders why, if acupuncture is viewed as an acceptable clinical option for LBP in the UK, UK medical authorities don't also allow doctors to prescribe placebo sugar pills. It's basically the same thing. Of course, homeopathy is still common in the UK, albeit not recommended, and that's a placebo, too. Be that as it may, it's interesting that Lewith admits to conceptualizing acupuncture as an interaction in which it's not "just" the needling that causes supposed therapeutic effects but also the empathetic therapeutic relationship and the "holistic" consultation. In fact, reading the introduction, I could tell that this would be almost certainly what Lewith's group found, particularly given that a more rigorously designed study from a few years ago found that an empathetic acupuncturist expressing high expectations for the treatment would do better; i.e., that patient expectation and practitioner attitude influence the placebo effect caused by the whole theatrical placebo that is acupuncture.
So what were the findings? Within individuals (individuals compared to themselves), reductions in back-related disability compared to the individual's mean were associated with reductions in fear-avoidance beliefs about physical activity, consequences, concerns, emotions, and pain identity. Similarly, within person reductions in disability were associated with increases in personal control, comprehension, and self-sufficiency for coping. It was also noted that people who were less disabled had more positive outcome expectancies. In other words, they expected to get better.
These results are, of course, completely consistent with acupuncture being a theatrical placebo. Unfortunately, instead of making the most obvious conclusion (that acupuncture is a placebo and that these various psychological constructs modulate placebo effects), the authors just can't let acupuncture go. As lead author of the study, Felicity Bishop, said in an interview:
People who started out with very low expectations of acupuncture - who thought it probably would not help them - were more likely to report less benefit as treatment went on.
Which is, of course, an unremarkable observation that is usually true for any treatment with a large placebo component. In the paper itself, Bishop et al write:
The findings also have implications for understanding acupuncture’s large nonspecific effects and, more generally, for understanding the processes whereby acupuncture may result in decreased disability. Given that similar variables predict disability in other settings, patients’ perceptions of pain and self-efficacy could be influencing disability outcomes in patients receiving both real and sham acupuncture in clinical trials. These psychological variables offer one means by which major components of acupuncture as a complex intervention, such as ritual, the therapeutic relationship, and lifestyle advice, could trigger positive clinical outcomes. In the context of a warm relationship and therapeutic ritual, providing positive self-help advice encouraging physical activity could help patients to develop more positive illness perceptions, confront their fear of activities and become more active, breaking the negative cycle proposed in the fear-avoidance model and triggering a more positive perception of back pain as controllable and enabling an increasing sense of self-efficacy for coping. According to social-cognitive theory, enhanced self-efficacy for coping could then trigger a positive feedback loop increasing actual coping ability and reducing disability.
And at the very end:
Acupuncture patients experience less back-related disability when they are less afraid and avoidant of physical activity and work, perceive fewer symptoms emotions and consequences of LBP, perceive their LBP as less threatening, and when they feel greater control over, understanding of, and ability to cope with their back pain. Future studies should test whether integrating acupuncture and psychological interventions targeting these constructs can enhance patient outcomes.
Of course, the science-based view would be to ask this: Why is acupuncture even needed at all in this model? All of these observations could be used to use placebo mechanisms to accentuate the perceived benefits of science- and evidence-based treatments. Given that rigorous studies of acupuncture for low back pain routinely fail to find a difference between the acupuncture group and a well-designed sham control while finding significant differences between both sham control and acupuncture groups versus usual treatment or wait list controls, the results of this study can best be viewed as what psychological factors modulate placebo effects, and, to be honest, not a very rigorous study given that there is no control group, waitlist or sham, and the data were all collected using various questionnaires designed to assess back-related disability and various model measures.
I have an idea. Placebo effects are definitely a worthy area of study, even though in the world of "complementary and alternative medicine" (CAM), or, as it's becoming more commonly called, "integrative medicine" (really the integration of pseudoscience with science-based medicine) they are often endowed with downright magical, mystical, and even religious properties that far outstrip the magnitude and utility that placebo effects are, in fact, likely to have. The problem with CAM practitioners is that, rather than seeking ways by which placebo effects might enhance the patient-perceived effectiveness of actual medical interventions that have been shown to work, they just can't give up their ineffective modalities like acupuncture despite all the evidence showing they don't work.
Quackademic medicine marches on.
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acupuncture being a theatrical placebo
I find myself imagining "PLACEBO: the musical".
Next up: Study of sham acupuncture modality using nothing more than light fingertip pressure on the lower back region. Results: Confirmation of therapeutic effect of laying-on hands!
Serious question: Has anyone investigated the effects of placebo alcohol? I'm thinking of the frequent horror stories of college kids ending up in the ER with alcohol overdoses due to binge drinking.
If college kids were first exposed to placebo alcohol beverages (water, flavorings, and some kind of hot pepper to simulate the "hot" or "burning" sensation of drinking distilled beverages), and then "had a good time," perhaps they could be persuaded that drinking actual alcohol isn't necessary to "have a good time"?
Followed by "PLACEBO II: This Time It's Personal!"
@ Gray Squirrel
One episode of the Big Bang Theory played with the idea (the one with Summer Glau as herself).
Gray Squirrel @2: We used to have something like that in the US. When my mother was a college student, you had to be at least 21 to buy most alcoholic beverages, but if you were 18-20 you could buy something called 3.2 beer. It wasn't exactly a placebo (the "3.2" refers to the percent alcohol by volume), but you would have had to drink quite a lot of it to get drunk. 3.2 beer mostly disappeared when the US drinking age was lowered to 18, and didn't come back when the drinking age was returned to 21.
My European colleagues are universally of the opinion that prohibiting all alcohol sales to people under 21, as is the law in the US, is a bad idea. It gives alcohol the lure of the forbidden, and it drives consumption underground, where people get hurt in such binge drinking episodes. Most European countries will sell alcohol to people under 21 (it may be beer/wine at a certain age and distilled liquor at a later age), and many of them don't have problems with binge drinking. (The UK does, but that is related to their rather strict rules about closing time.)
What are the chances we could convince people that they have a critical acupuncture meridian in one of their deltoids that needs to be needled exactly once every October?
Also, I would like to see a very honest and well executed study called “how to get the most placebo bang for your buck.” Pit the titans against one another: Reiki, acupuncture, sugar pills, really exotic sounding herbs, magnets, bigger magnets, and homeopathic noises. May the best sham win.
I meant homeopathic *nosodes*
But what the heck, make some homeopathic noises, too.
"Why is acupuncture even needed at all in this model?"
Indeed. Why is it needed at all, ever?
Peering thru the mists of time, I recall my physio prof and fellow students speculating about this with ideas that ranged from the purely physiological to the entirely psychological-
the needling interfered with the pain signal, the action liberated endogenous opiates, the expectation of relief led to physiological response that quelled the pain, interaction with a perceived reliever of pain ( person) led to physio response, acupuncture distracts a person from pain, etc.
Right now, I wonder about how locus of control affects perception: if the subject habitually assigns causation to external sources will he or she be more likely to experience an effect?
Interestingly, the authors mention social cognition in respect to self-efficacy ( as well as the idea of controllability itself) which leads me to ask: if they are truly concerned with actions originating in themselves, why would they not go straight to the toothpicks or home acupuncture kit in the first place?
I can imagine a self-initiated system of pain relief that totally excludes the acupuncturist. ( -btw- don't people buy TENS units and similar devices for at-home usage?)
Woo and external locus of control go together like supplements and salemen.
@CTGeneGuy: There is a famous example of homeopathic noise due to John Cage, who was something of a bad boy in the classical music world.
Ah yes, John Cage. I suppose the "control group" could sit quietly at a piano for 4'33"
The control group couldn't sit quietly at a piano for 4'33" because that's exactly what the E group ( Cage) was doing.
While I certainly agree with all the comments about the placebo effect. I also wonder if any of you have tried acupuncture?
Personally, it worked very well for me for anxiety. After a treatment I would literally "float" out of the office. I only did it for several weeks until I was back on my feet again an able to exercise, but it certainly helped. And, I certainly would not recommend it for most of the "wo" stuff they try and sell it for. And, while I didn't try it, I am fairly sure that twirling toothpics on my back would not of had the same effect.
The opening gambit is a bit strong.
"Acupuncture is recommended by UK clinical guidelines for low back pain (LBP) and is commonly used for LBP. "
NICE actually States:
"The National Institute for Health and Care Excellence (NICE) only recommends considering acupuncture as a treatment option for chronic lower back pain, chronic tension-type headaches and migraine."
My layman's understanding is that NICE is the body that decides whether a treatment is cost effective (simplification). So my take on the NICE position is "Jury is out but, the NHS won't pay but go take a look yourself if it floats your boat."
I know there are other UK folk better qualified than me to clarify or correct this.
Perhaps you can elaborate on your reasoning.
It appears that there is a substantial number of people who are helped by acupuncture, clearly because they have a prior belief that it works.
The secondary psychological factors, as you say, are common to all placebo modalities (and logically, to 'non-placebo' interventions in some individuals.)
As I understand LBP, most of it resolves by itself, and much of the disability is in fact psychologically based.
But what exactly is the plan by which one might 'eliminate' acupuncture? Replace it with a different theatrical placebo? If you have a patient who believes it works, what would you do-- first put them through some kind of deprogramming, and then convince them that "nothing" works just as well if only they will 'believe'?
You do realize that these things persist *because* they are effective at getting people to believe in them?-- they are well designed 'woo' if you like. And you do realize that different folks like different strokes and all that-- or is there only one form of psychological intervention for mental ills that has your approval as well?
The point being, if you have medical supervision so the needles are clean, why deny people an effective placebo effect? Why deny them access to the psychological support of well-trained practitioners?
I really wish we could study the mechanism of placebo with the idea of using it therapeutically. The problem with it is the ethics.
I used to work in a prison; the jail doctor regularly ordered "Cebocet" for inmates with histories of drug seeking. They all swore it worked far better than Vicodin, Percocet or Darvocet. They would ask for it specifically when booked back to jail on a later charge.
It was a sugar pill.
I was inexperienced at the time and didn't see the ethical issue. I do see it now. And that's the problem I have with CAM "medicine" since it all seems to be placebo how can we ethically appy this to patients and tell them it works when we know it doesn't?
I think that's an excellent idea. If I ever need to ask my GP for treatment for LBP and he gives me a choice which includes acupuncture and chiropractic (yes, chiropractic -- I checked the NICE guidelines), I'm going to reject those options and insist on something with a far, far greater placebo effect: Satanic ritual.
Surely Satanic ritual will be better for me than acupuncture. After all, how could I not be influenced by the sight of a coven of hooded Satanists, circling the altar stone, chanting to Lucifer and sacrificing two black cockerels in a plea for the Fallen Angel to relieve my back pain? I'd say that it would be particularly effective in the case of this Christopher Lee horror film fan. Plus there'd be fried chicken afterwards.
I hope I can get Satanic rituals on the NHS. I don't think I could afford to go private.
why deny people an effective placebo effect
The reason it''s called a placebo effect is because the treatment isn't really doing anything, other than to trick your mind into thinking that you are being treated. It's generally not ethical to do that in cases where an effective and safe treatment is known to exist. Placebos are legitimately used as controls in trials where the question is whether a prospective treatment method is effective: it has to do better than the placebo, or it gets discarded as a treatment method.
There is a gray area in cases where no safe and effective treatment is known to exist. There, it's palliative care. For instance, I know somebody who tried acupuncture, successfully, in order to avoid a risky (at the time) surgery (and it was also not clear at the time, as Orac notes in the OP, that acupuncture was not an effective treatment). But an honest and ethical doctor would not resort to such methods when a better alternative exists. I doubt that choosing acupuncture, a defensible choice for that person's situation at the time, would be a reasonable choice today (though I don't know if the alternative surgery is less risky today than it was at the time).
Rich -- I'd settle for lying in a hammock with Russell Crowe giving me a foot massage.
(and Viggo Mortensen making me margaritas). Now that's a healthcare initiative I could support.
This is an odd case in which it's by weight rather than volume; that 4% ABV, or about the strength of ordinary bitter.
I read that just before going to bed and apparently my brain worked on this all night...
(apologies in advance, bad doggerel is my superpower)
(to the tune of Oklahoma!)
It's Placebo, where the cure is all inside your brain!
Sugar pills are sweet, but they don't treat
Bad infections, cancer or migraine!
It's Placebo, all the needles poking at your skin.
Though the studies tell it works just as well
If they never put those needles in!
Yes, we know we all work with a sham,
But the sham that we work with is grand!
So when we say
We're only saying you're doing fine with Placebo!
Placebo, that's P L A C E B O, it's Placeeeebo!
What are the chances we could convince people that they have a critical acupuncture meridian in one of their deltoids that needs to be needled exactly once every October?
Good thought. I'm fairly sure the anti-vaccination brigade slightly to my north are just fine and dandy with acupuncture...
@ Rich Woods:
You might do better if you called it
_Traditional Druidic Medicinal and Psychotherapeutic Folkways_
I can see it now.
White robes, incantations in Brythonic, blue body paint, mead and cheese afterwards.
Lots of other better distractions is right.
How about piercing instead of acupuncture? Endorphins for real.
Skyclad or nothing.
Wait a minute there, skyclad IS nothing.
Hi, Orac. Placebos are very powerful, hence why they are still in use, I suppose. There is some interesting journalism in this (BBC Horizon) if you've got an hour spare (yeah, I know that isn't likely!): http://www.dailymotion.com/video/x1moo91_horizon-2013-2014-8-the-power-…
There's been a fair bit of research on alcohol placebo. (a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1403295">Here's a bit of it.) In terms of your strategy for curbing binge drinking - showing college kids that they don't have to drink alcohol to have a good time - The Atlantic had an article a couple years ago with a similar hypothesis. I can see how it might work to an extent.
I'm ambivalent when it comes to ideas like lowering the drinking age. I really sort of feel like it ought to be 18, mainly because it doesn't make a whole lot of sense that in the USA, you can vote, join the military, etc, between your 18th and 21st birthdays, but you can't buy a beer. (I suppose one could argue, actually, that we ought to raise the age of military eligibility back to 21.)
OTOH, I understand that a drinking age of 21 has made the roads somewhat safer, preventing about 900 fatalities per year.
Regarding the argument that a drinking age of 21 ends up causing more binge drinking: I'm not even sure that's the case. It would be safer if college kids were going out to bars to drink - as long as they didn't drive - since servers are legally obligated to stop serving them past obvious intoxication. The thing is, though, I think a lot of kids would just keep having house parties anyway, even if the drinking age were lowered - they're cheaper and more fun than going out, and the range of possibilities is much greater in a house than in your typical bar.
Meh, piercing isn't really painful enough to really get the endorphins flowing, at least in my experience. I suppose one's milage might vary based upon, uh, the location of the piercing.
Emma, if you add a second verse, it should include a reference to 3.2% beer, which Oklahoma still has.
Rich, if you ever visit Oklahoma, they are soon to have a statue of Satan on the capitol lawn, due to a Ten Commandments statue and an equal representation lawsuit. Hope that helps with your pain.
Meh, piercing isn’t really painful enough to really get the endorphins flowing, at least in my experience. I suppose one’s milage might vary based upon, uh, the location of the piercing.
I got a Christine a short while ago (do not image search at work), and it was the only piercing I've gotten that caused me to, well, vocalize. I left the procedure room in the back of the parlor and saw a number of young (collegeish) girls looking at me a little wide-eyed, and I said to my husband, loudly, "Wow, that ear piercing hurt more than I expected!"
Seriously, though, that's the only one that's hurt. And I'm in roaring good health, so hey, good enough evidence for the alt-med crowd.
Wait a minute there, skyclad IS nothing.
No, no, it's homeopathic.
I think the problem is using "effective" in different ways.
"For instance, I know somebody who tried acupuncture, successfully, in order to avoid a risky (at the time) surgery (and it was also not clear at the time, as Orac notes in the OP, that acupuncture was not an effective treatment)"
It apparently was effective, for your friend, right? How is "successful" different from "effective"?
And it is doubtful that the surgery has now become so risk-free that it is less risky than medically supervised acupuncture.
This just seems like treating a condition which is psychosomatic using a psychological method-- there's no need to show any physiological effect other than the perceived cessation of pain.
Yes, I have tried acupuncture and I also experienced something I have referred to as “floating” or “high” which the Chinese MD-turned-acupuncutiest-because-he-found-out-how-lucrative-it-can-be-in-Portland-Oregon (apologies to Dr. Crislip) told me was a “side effect”. He put the needles in my earlobe for this and I’ve always thought it might have had some pysiological effect, but I remain skeptical. There are other explanations. I did this 30 years ago and never did it again. It did nothing for my tennis elbow, which is what I went for.
Not at actually curing diseases, though, or alleviating symptoms that can be objectively measured. Ben Goldacre can point to amazing research showing that a stimulant given as a sleep medicine will make people sleepy (and vice versa). I have no doubt that this is true. I also have no doubt that giving something to someone to "ease pain" will improve their life, particularly if they've become sedentary in order to avoid pain. So the power of suggestion can help people feel better or worse. But powerful?
I think it's called "actually treating the underlying condition."
Because surgery is offered for "psychosomatic" conditions? Check.
Hey, maybe that would work for asthma.
An acquaintance of mine is a physical therapist, and he is trained in "dry needling". Researching dry needling leads me to suspect that the mechanism is roughly the same. The practice has been controversial in chiro and PT circles, apparently.
Anyone have any insight on this?
"Because surgery is offered for “psychosomatic” conditions?"
1) Yes, surgery is offered for LBP, which can also be treated successfully, as described, by psychological intervention.
2) Also, we know that not all surgery for LBP relieves symptoms, even though by your definition (there is physiological change) it is 'effective'-- therefore it is not 'successful'.
3) Logically, some 'effective' surgery must be 'successful' due to placebo effect-- the physical outcome is the same as in (2) but the psychological outcome is the same as in (1).
Narad, I think you should stick to doing elementary numerical calculations and stay away from the logic department.
The point is that for LBP (not asthma or any other strawman) there is evidence that both things alleviate symptoms.
Surgery can be one of the most powerful placeboes there are, actually.
Much more theatrical than acupuncture!
But the question remains-- what's the plan to replace the placebo effect of acupuncture for those patients who might benefit because they have a prior inclination to think it's effective?
3.2 beer is actually still made in the US; in my state it has a considerable market thanks to our blue laws. Our age restriction is purely black-and-white -- before 21, you can't buy alcohol, after that you can -- but *where it is sold* varies. Off-sale alcohol sales are tightly controlled here. Until fairly recently, you could only get an off-sale license if you were a liquor store. No convenience stores, no gas stations, no grocery stores, no drugstores. If a grocery store wanted to sell wine, they had to set up a completely separate shop (possibly attached, though you cannot access it from inside the grocery store -- the closest you can get it is to have them share a vestibule) and if there is a school within a certain radius, it can't even share a common wall with a grocery store. And no off-sale alcohol on Sundays. (Restaurants and bars are open on Sunday, though, and free to sell drinks to be consumed on site.)
Then they finally opened it up just a teensy bit: "near beer" can now be sold in grocery stores. Still only grocery stores; you can't get it in convenience stores or gas stations or Target or Walmart. And now they even let them sell that on Sunday. This of course has opened up a pretty big market for near beer, wine coolers, and so forth. If you want some beer but don't want to make a second stop, you can get the weak stuff at the grocery store. The strong stuff is over at the liquor store, and only available Monday through Saturday.
Also, we can't buy cars on Sunday. Minnesota blue laws. ;-)
The liquor stores in MN close at ungodly early hours, too, as I remember from a trip to visit a friend there 4 or 5 years ago.
Ha...acupuncture doesn't work..that's funny..you are one dumb fool...I personally have used acupuncture to help with everything from chronic back pain to torn shoulder ligaments...when I went first,I thought it was bullshit too but my wife convinced me to go..I was expecting nothing from it,so the placebo effect was not valid here...my pain shrank in half by the next day and I had been in constant pain for months...the issue is acupuncturists are not all created equal...some are better than others but to say it doesn't work just makes you sound ignorant..its the longest running sham in medical history....thousands of years because it doesn't work...ha...
Each to their own!
I'd certainly want to call it something like that if I were offering the treatment. I reckon the take-up around here would be embarassingly high. Just as well I have both a full-time job and a conscience.
I'm not convinced that even a placebo of that strength would be enough to overcome the pain of being faced with politicians so mind-numbingly hypocritical. I bet they're the type who loudly proclaim themselves patriots, while happily wasting public money on a show of undermining the Constitution.
It is not offered as a placebo, and lower back pain isn't a "psychosomatic condition." Moreover, conservative treatment isn't purely CBT. And where, precisely, did you get the "as described" from? LBP isn't in Eric Lund's comment.
"My definition"? No, that's your difficulty with reading comprehension shining through again.
Says the chairman of the irony department.
Asthma isn't a "strawman". Then again, I didn't mention it for your benefit.
If they ares still charging the traditional price for these things, you could afford it, but you may not want to pay it.
I think the question I raised is an interesting one, and I would be happy to engage in a sober discussion of the topic. You don't appear to meet the requirement for such a conversation right now.
Perhaps, if you would take some time and write a coherent paragraph or two articulating your viewpoint, my opinion might change.
Begin by reading the OP and Orac's comment at #39.
JP: The state requires they open no earlier than 8AM and close no later than 10PM on every day except Sundays, Thanksgiving Day, and Christmas Day (when they must be closed), and except on Christmas Eve, when they can be open until 8PM. Some cities are more restrictive.
Mind you, if you live in the Twin Cities, Hudson, WI isn't very far away, and then you can buy it under Wisconsin rules. They're quite a bit less restrictive. ;-)
Yeah, we were in a small town - my buddy's hometown - and I remember making a beer run one evening before 8 pm. It may well have been a Sunday.
As a matter of fact, he moved down to Wisconsin while I was making that particular visit - we drove down in a van he'd bought from his boss for a hundred bucks, and in which we crashed in various locales in Madison for a while; sadly, we never did park it down by any rivers. (Said friend is now a co-owner of a certain independent video store in Madison; he and his coworkers talked the former owner down to a very reasonable price for the place, and they're aware that the venture has, uh, a limited shelf life.)
But yeah, I remember stopping at a gas station past the state line and remarking upon the fact that most of what they seemed to be selling was beer.
Funnily enough, most of my best friends from college have ended up in the northern Midwest. Well, most of them were from the Midwest to begin with, and felt something almost like a moral obligation to move back - as one friend put it, "The Midwest needs its weirdos."
Zebra, I'm the only one who's much bothered paying any attention to you at all. Trying to tell me to "begin by reading the OP and Orac’s comment at #39," as though I somehow had missed those despite replying to another comment well before you yet again decided to "get people thinking about the issue in a ‘scientific’ way" by ultimately deploying your laser-like "epistemological" focus to state that "I think the problem is using 'effective' in different ways" and then being able to cobble together nothing better than that is merely – ¿cómo se dice? – running the fυck away.
Oh, dear, am I "filibustering"?
Looking at these two comments, we might consider the following:
Would garypetrol, for whom acupuncture has been successful in reducing perceived pain, be engaging in "needle-seeking" if he requested a prescription for acupuncture?
What if Orac succeeds in reversing the mainstreaming of acupuncture, so that it can't be covered by insurance? Would garypetrol turn to crime to support his habit?
The point, again, is that it isn't a trivial matter to replace this intervention that clearly has utility with something equally benign.
You seem to be conflating two very different forms of "needle-seeking" behavior.
Are there pills for irony deficit?
And maybe for "knee-jerk without even a little critical reasoning" disease?
Zebra, I was laughing at you. Your general humorlessness and unfounded condescension have become extremely tiresome.
How do we know that the reduction in garypetrol's pain would not have happened even if he didn't have acupuncture? Torn shoulder ligaments do heal, eventually.
Anecdotally, I was diagnosed with a frozen shoulder some years ago, and my GP said that it would take six months to heal unless I had a steroid injection in the joint. The doctor who was good at giving these injections was on vacation for two weeks, and I elected to wait until he returned. As it happened the pain resolved completely before the doctor got back. If I had had acupuncture during that time I might well have thought that it had led to this miraculous recovery, which was more likely a simple misdiagnosis.
There's this pervasive idea that placebos actually do something, when much of their perceived effects are due to regression to the mean, confirmation bias, or are not even perceived effects at all, but merely the patient wanting to please a therapist they like.
Why can't it be replaced by massage, relaxation, visualization, gentle exercise, hypnosis or another placebo? I suspect an inclination to believe in acupuncture is likely to be accompanied by an inclination to believe in other placebo therapies. Is all the nonsense about meridians, chi and ancient wisdom really necessary for a placebo to be helpful in the way acupuncture sometimes appears to be?
I was right!
zebra, original comment:
"But what exactly is the plan by which one might ‘eliminate’ acupuncture? Replace it with a different theatrical placebo? If you have a patient who believes it works, what would you do– first put them through some kind of deprogramming, and then convince them that “nothing” works just as well if only they will ‘believe’?"
I can see it now-- garypetrol goes to Dr. Krebiozen and requests acupuncture, and Dr. K says:
"feeerst, looook eentooo my eyeeees"...
and *hypnotizes away* any of that "ancient wisdom" foolishness.
Hypnotism, yeah, that's the ticket, hypnotism....
JP, what you think of as 'unfounded condescension' to me is eye-rolling amazement, about people who claim to be scientifically grounded.
How about trying a serious discussion of a serious question-- or is it too hard to let go of your simplistic ideology and be objective?
Krebiozen gives an excellent example in his anecdote, even if he doesn't realize it. Why is it better to give a (potentially harmful) steroid injection for a condition that will resolve anyway than to try acupuncture first? It even has some of the trappings of magical thinking itself, with "the doctor who was good at giving those injections"-- seriously? There was a clinical study involving this particular doctor that showed better outcomes? How is that different from what garypetrol said about the abilities of acupuncturists?
why do you think acupuncture wouldn't/couldn't be potentially harmful? (http://www.who.int/bulletin/volumes/88/12/10-076737/en/)
Or that choosing acupuncture wouldn't delay some effective treatment, thereby further aggravating the situation even if acupuncture didn't cause any adverse effects?
Why replace it with anything?
I'd suggest getting the word out that it does nothing, can be dangerous, and those that say otherwise are silly people. If we start early, say, grade school, and teach the kids, and keep reminding them every year, we could wipe out acupuncture in their lifetimes.
The same goes for homeopathy, which is just as silly.
You claimed that "it isn’t a trivial matter to replace this intervention that clearly has utility with something equally benign". I suggested a number of other placebos that are equally benign, and asked why these would not adequately substitute for acupuncture. Why does hypnosis, which has some evidence to support its efficacy in chronic pain generate your eye-rolling scorn when acupuncture apparently does not?
What have I written that is not scientifically grounded, exactly? Describing hypnosis as a placebo?
Frozen shoulder does not generally resolve spontaneously. The fact that my shoulder pain did resolve spontaneously strongly suggests misdiagnosis.
One GP in the practice had recently been on a training course on giving corticosteroid injections into joints. How is this magical thinking?
"The doctor who was good at giving these injections" sure sounds like gary's 'not all acupuncturists are as good as mine'. Only now do we hear about "recently been on a training course". By the way:
" If I had had acupuncture during that time I might well have thought that it had led to this miraculous recovery, which was more likely a simple misdiagnosis."
Likewise if you had had the injection-- exactly my point; the injection is a riskier placebo, compared with medically supervised acupuncture. In the future, you would be more inclined to request that treatment-- "steroid seeking".
Now, how does your listing of other alternatives answer my question? (Try to read slowly and carefully:)
"“But what exactly is the plan by which one might ‘eliminate’ acupuncture? Replace it with a different theatrical placebo? If you have a patient who believes it works, what would you do– first put them through some kind of deprogramming, and then convince them that “nothing” works just as well if only they will ‘believe’?”"
Also, I refer you again to the wise Donna Changstein.
As you're using the word placebo in a novel fashion, care to explain your definition of it for the rest of the class?
"As you’re using the word placebo in a novel fashion,"
How is 'the way I am using it' "novel"? I've used it multiple times in normal English sentences.
In your world, do placebo usually have such documented anti-inflammatory properties like corticortisoids has, or do you think effective drugs suddenly become placebos if the original diagnosis they were prescribed for was (possibly) incorrect?
Except acupuncture is a placebo, intra-articular steroid injections are not placebos, and there is good evidence that placement of intra-articular steroid injections has a significant effect on outcomes. Is there any evidence that a skilled acupuncturist elicits a stronger placebo response than a rookie? Maybe there is, I don't know.
Sorry, I didn't realize I had too explain in exquisite detail why my GP believed her colleague would be the best person to administer this treatment. I'll try harder in future.
How precisely does that conflict with what I wrote?
I don't see your point at all. The injection is not a placebo for correctly diagnosed frozen shoulder: there is good evidence that it is both safe and effective. Waiting a couple of weeks and/or trying physiotherapy before the injection would seem better options than acupuncture to me. Personally, since I'm aware of cognitive biases, I try to look at the evidence, and not rely on what seems to have worked for me in the past.
I love it when you get didactic, it's adorable, though I don't think you have quite mastered the Socratic approach.
I wasn't attempting to answer that question. It's a straw man since I don't think anyone is suggesting we eliminate acupuncture; I'm certainly not. I don't care what therapies people want to use, as long as they are properly informed about the risks and benefits and they don't put their children at risk. I just object when people claim that acupuncture is any better than an elaborate placebo, when they teach doctors how to perform it in medical schools, or use my taxes to pay for it.
I was responding to your suggestion that "it isn’t a trivial matter to replace this intervention that clearly has utility with something equally benign". I don't see why it isn't a trivial matter when we have a plethora of treatments that are essentially placebos, and that don't necessarily come with supernatural trappings like chi and meridans or the patina of 'ancient wisdom'. "Massage works just as well as acupuncture, doesn't involve any needles and feel much nicer", seems pretty persuasive to me
I just watched that episode of Seinfeld, out of idle curiosity. A woman adopts a Chinese-sounding name, people assume she is Chinese until they meet her and she adopts some stereotypical Chinese characteristics with hilarious consequences. Maybe it's me, but the only relevance to placebos in general or acupuncture I see is that the woman takes acupuncture classes. How is she wise? Because she quotes Confucius?
OK, got it.
I don't know the exact details of K's case, so it may not be perfectly applicable, but for LBP, where most cases resolve themselves in a few days, I mean it in the original sense:
Doing it to please the patient.
Now, Krebiozen seemed to indicate originally that he would have taken the jab had that other doctor been around, but now he is saying that he would have waited or done the other options like physiotherapy. Again, I don't know enough about his case. In other instances I know about the doctor has been reluctant to recommend that kind of injection before waiting and using NSAIDS, at least.
I also refer you to Orac at #39:
"Surgery can be one of the most powerful placeboes there are, actually."
Which fits with my other comments-- just because something has *some* physical/physiological effect (e.g. fusing vertebrae) doesn't mean that the pain relief isn't the result of placebo effect or just time.
If you read my earlier comments, I mentioned that Orac's goal would be to have acupuncture not payed for by insurance (or NHS or whatever), and you seem to agree.
So there is no strawman at all. For garypetrol, you would be taking away something that works for him, and replacing it with your preferred placebo. Seeking that goal is your prerogative as a religious/ideological/political matter, but it isn't science.
For gary, like the characters in Seinfeld, the 'ancient wise Chinese' association may make acupuncture more believable than hypnosis, and therefore it will be more effective as a placebo. Belief by both the practitioner and the patient, as far as I know, affects outcomes.
(By the way, I really don't understand why you put massage in the category of placebo, at least for LBP and frozen shoulder and stuff like that.)
As I recall, I had already waited for a few weeks and done some exercises suggested by my GP. Had the GP trained in giving the injection been available I probably would have gone for it, as the condition was very painful and inconvenient - I couldn't drive, for example. Had I done so I might well have attributed my recovery to the injection just as I might have attributed it to acupuncture, had I had that. That was the point of my anecdote. That's why we have clinical trials; we can't come to conclusions from individual experiences like this because they are misleading. Why you felt it necessary to make such a meal of it is beyond me.
BTW, I don't know if you can describe an active treatment for a misdiagnosed condition that would have resolved anyway as a placebo. It comes down to semantics, I guess.
I had already done that.
That's why we have clinical trials. I don't think anyone is suggesting that placebo effects are not part of conventional treatments. You get a free placebo effect with every intervention. The point is that there are conditions that are not amenable to placebos, like frozen shoulder, for example.
Not having acupuncture paid for by insurance or the NHS is hardly "eliminating" it.
I'm not taking anything away from him. If he can afford insurance, presumably he can afford acupuncture, and there are plenty of acupuncturists available for him to choose from. I wouldn't want other placebos paid for by insurance either, as I don't believe they should be a part of SBM.
I don't know how many insurance companies reimburse for acupuncture or how much it costs the average person as a result. I do know the NHS spends about £25 million every year on acupuncture, money that could have been better spent on hip replacements, cancer drugs or transplants.
It's politics based on science. In my opinion insurance companies and the NHS should only pay for treatments that have a compelling scientific evidence base. Acupuncture and other placebos do not. A weekend break in the countryside may also make someone feel better, but I don't think other people should pay for it whether through insurance or taxes.
It doesn't affect hard outcomes, as placebos do not affect objective endpoints. That's the point.
Massage, as far as I know, does not address the underlying cause of those conditions. It doesn't reduce joint inflammation or correct a prolapsed vertebra. That's why.
That's some impressive OR availability.
Now that you mention it, you seem to be desperately reliant upon "the short memory," to upend a certain IWW intro.
Yes, folks, you're just not up to this epistemological level.
"It doesn’t affect hard outcomes, as placebos do not affect objective endpoints. That’s the point. "
" It comes down to semantics, I guess."
The substance of your position is actually accessible in what you've written, but it is difficult to discuss if there is no agreement about terminology.
First, let's agree that what I call insurance is your NHS-- the baseline of access to treatment for citizens of limited means. (As I'm sure you know, our USA patchwork system defies any simple description.)
So, you say you don't want to pay for a poor person, who like gary finds relief from pain through medically prescribed acupuncture, but you are comfortable paying for highly addictive opioid drugs, and any subsequent intervention should he indeed become dependent.
(There are other interesting points to discuss but let's be clear about this first.)
Do you assume acupuncture would be equally effective to opioid drugs, for pain relief? Or would have been as effective as corticosteroid injections for frozen shoulder?
And you explained your word choice with:
[talking about placebos] I mean it in the original sense:
Doing it to please the patient.
But that's not the definition of placebo, and I think it's telling that two posts after your explanation you complain how "it is difficult to discuss if there is no agreement about terminology".
Mangled the second blockquote, but the point should still be obvious.
<blockquote≥Why can’t it be replaced by massage, relaxation, visualization, gentle exercise, hypnosis or another placebo? I suspect an inclination to believe in acupuncture is likely to be accompanied by an inclination to believe in other placebo therapies. Is all the nonsense about meridians, chi and ancient wisdom really necessary for a placebo to be helpful in the way acupuncture sometimes appears to be?
Placebo treatments are psychology, not physical medicine. They don't affect any dysfunction of the trunk or limbs. They affect the way the patient perceives and experiences them — which CAN improve their function. Like any psychological treatment one size does not fit all, and how well the theater will work depends on the mental state in which the individual enters.
To cross to to other threads: 'Integrative Medicine' centers serving Ojibwe First Nations people in Canada use traditional rituals with apparent success in treating mental health and substance abuse issues, also in providing support for long term chronic physical illness being treated as best it can by available sbm. These rituals would be unlikely to help us if he had similar problems, as we wouldn't believe in them.
I suspect the opposite of your suspicion. I suspect the variety of placebo 'modalities' proliferates exactly because people inclined to believe in one are not inclined to believe in others. Yes, any placebo can be replaced by any other the patient believes in equally. This is not a matter of expectation going in, though that's pre-requisite, but the way the individual interacts with the ritual.
For one person, some belief in qi may be necessary for acupuncture to 'work' on their psychology. Another patient may benefit less if qi i discussed. I suspect the pseudo-science of meridians and of 'insertion points' are completely disposable for almost anyone. Again one patient might benefit more from a rubric of 'traditional wisdom' another from one of 'new discovery'. It's all a head game.
There are so many variables, and so much woo in the way, that any placebo treatment is difficult to research. At a minimum, you'd need consistency among patient interaction skills and 'theatrical talent' of practitioners across experimental groups.
Why, we may wonder, are many acupuncturists (not most, but a significant number) NOT afraid of an 'Integretive' system that would deny them the opportunity to claim effect in treating physical illness — no it won't fix the problem IN your shoulder joint, but you might have more use of your shoulder because it will relieve the mental pile-on heading back to your shoulder through the CNS — thus restricting their practice to palliative care?
Because they believe they have a more broadly effective palliative care theater than the competiton. They think they can go head to head with massage, relaxation, visualization, gentle exercise, hypnosis — and come out ahead in patient self-reports and other tests of pragmatic quotidian function in the same way CBT has proven to be more generally effective that other talking therapies. They believe when all is said and done, and behind the curtain they nudge and wink with all the MDs that its just theater, they'll still have secure well-paying jobs.
The thing is. They might be right. About being better theater for a wider range of people...
Trying to have a fruitful discussion with you is extremely frustrating, as you appear to be either unable to state your position clearly and provide evidence to support it, or you are unwilling to do so for some reason.
You took my second quote out of context to make it look as if I meant something else. This isn't the first time you have played silly games like this. There is agreement about terminology: a placebo is an inert treatment, i.e. one that has no objective therapeutic effect.
I was musing on whether a non-inert treatment that does have an objective effect on one condition (i.e. steroid injection for frozen shoulder) could be considered a placebo for another condition (i.e. idiopathic shoulder pain). If I had experienced improvement after having an injection, even though the condition would have resolved within a couple of weeks anyway, is that really a placebo effect? I would argue not, as the injection would probably have had the objective effect of reducing the pain and inflammation. I might have been spared a week or so of pain and immobility.
I'm not very familiar with the US system, especially since recent changes were introduced. You seem to be conflating medical insurance, Medicaid and Medicare.
The NHS provides for all residents, not just citizens, by the way - my wife is American and gets free treatment. The NHS has limited resources, and I think those resources should be used in a cost-effective manner. I don't believe acupuncture is cost-effective. Paying £25 million every year for acupuncture means there is £25 million less to be spent on doctors, nurses, expensive cancer treatments or whatever. This isn't an abstract argument, several hospital trusts have run out of money and been unable to pay for cancer treatments (Google "cancer drugs postcode lottery" for examples).
As I understand it Medicaid provides for those of limited means, and only a small minority of Medicaid programs (15.2%) pay for acupuncture. Medicare, for the elderly and disabled, does not cover acupuncture at all. It looks like gary may be out of luck anyway.
As for the NHS, when the best evidence tells us that gary is mistaken and the treatment has no objective effect on his condition, no, I don't think the NHS should pay for it. The analgesic effects of acupuncture are small and barely clinically significant; I don't think depriving poor people of this will be terribly onerous for them. Physiotherapy and effective medication like NSAIDs are available free of charge on the NHS for those of limited means.
I'm not a great fan of slippery slope arguments, but I do have to wonder where we draw the line if acupuncture becomes a part of mainstream medicine. Does exorcism qualify? I'm sure it might have great psychological benefits for some - it's even more theatrical than surgery. If a person's experience of pain is affected by a glass of wine and a good movie, should we provide those on insurance or on the NHS?
Where did I say that? I don't think opiates are indicated for the sort of problems gary described; NSAIDs are more useful as they also have an anti-inflammatory effect. I doubt very much that acupuncture would be very helpful in cases where opiates are required (see cited review above). Anyway, I suspect that gary's conditions would have resolved without acupuncture, so no long term medication would have been required. He reported, "my pain shrank in half by the next day". None of the studies I have seen on acupuncture report that kind of effect, not reliably anyway.
There is an argument to be had over whether placebos should be prescribed by doctors. I don't think there is a logical or scientific way of determining this; it depends on your philosophical and ethical approach to medicine. I would prefer us to use only science-based treatments, and to use what we know about placebo effects to maximize patients' subjective as well as objective improvements. We have other specialists who deal with people's emotional and 'spiritual' (whatever that means) well-being, and I see no reason for doctors to get involved unless these become pathological. YMMV.
Sadmar, I thought I had this all covered way back at #15 with my folksy yet erudite "different strokes", but sure, jump in with your fancy talk like "pragmatic quotidian function" to make me feel like a rube. ;-)
Agreed, Krebiozen, my brief experience with the NHS medical model is very different from what we have here in the States. When I fell down Glastonbury Tor on vacation and broke my ankle, NHS gave me treatment without question and without charging me a cent. Here it would have been hundreds of dollars for an ER visit (often even the case with insurance), even before considering costs of x-rays, etc. All they asked of me was to please return the crutches before leaving the country as the hospital only owned three sets. There was also a notice in the hallway asking for donations towards the purchase of a new x-ray machine. Maybe without paying for acupuncture they'd have been able to afford modern equipment?
Meanwhile, until the ACA went into effect, we were unable to buy individual health insurance for our family, because my son is autistic, even though none of the plans available covered anything related to autism in the first place.
The whistling of the goalposts is like an Aeolian harp in reverse.
Let's try again:
"So, you say you don’t want to pay for a poor person, who like gary finds relief from pain through medically prescribed acupuncture, but you are comfortable paying for highly addictive opioid drugs, and any subsequent intervention should he indeed become dependent."
I didn't ask for your gratuitously offered diagnosis or medical opinion about gary. As you say, there is a philosophical (or political or ideological) issue here. I'm just trying to establish some concrete parameters about your position.
"Someone... who like gary finds relief from pain through MPA" doesn't mean "gary" in USA English at least; it means someone who according to the study in the OP is most likely to respond to MPA-- a 'believer', whether through experience or conviction.
So, again, is it correct that you think NHS should pay for opiates to relieve pain, but it shouldn't pay for MPA *even for people like gary,* who are likely to report relief given their history, and might in fact request the treatment?
I didn't offer any sort of diagnosis; it was you suggested that he would require opiates and become a helpless junkie if cruelly deprived of free acupuncture (that mostly isn't available free for those of limited means in the US anyway). Acupuncture and opiates are the only possible treatment choices for "chronic back pain" and "shoulder ligaments", obviously (that's sarcasm, should it not be clear).
I suspect you are heading back down the road of, "medicine isn't perfect so why are you worried about altmed", again. How can I complain about acupuncture when doctors are prescribing antibiotics for viral infections and people are getting hooked on opiates? Well I don't think that should happen either, two wrongs don't make a right, and I'm not at all convinced that acupuncture is an effective way of reducing opiate or antibiotic prescriptions.
I think that doctors should be using the most cost-effective treatments available, treatments that have compelling evidence for objective hard endpoints. I don't really think placebos should be prescribed, and I certainly don't think they should be paid for by insurance or the NHS. Clear enough?
Correct. I don't think the NHS should pay for a million other things that might result in gary experiencing less pain yet have no objective effect on his injuries at all either.
You seem to assume that gary's reported improvements after acupuncture were due to the acupuncture and/or his beliefs about it. I think it is more likely that those improvements would have happened anyway, and he erroneously attributed them to the acupuncture - part post hoc fallacy and part confirmation bias.
You further assume that the next time gary is injured and has acupuncture, his beliefs about it will have some profound effect on his pain perception. I very much doubt it. The review I cited above found that acupuncture resulted in an average 4% reduction in pain, which is clinically insignificant. What I suspect would happen is that his injury would heal, just as it would have without acupuncture, and his confirmation bias would lead him attribute the improvement to the acupuncture. If the improvement isn't as rapid as he expects, he will blame the acupuncturists, because, "acupuncturists are not all created equal".
The whole idea that placebos have miraculous effects in people who believe in them is suspect, in my opinion. I plowed my way through the paper referred to in the OP to see what magnitude of effect psychological correlates might have on the efficacy of acupuncture for LBP, but I couldn't find it. Statistical significance does not mean clinical significance, and I strongly suspect that these effects are small and temporary.
I'm willing to be persuaded otherwise - show me the evidence. Some years ago I was very hopeful about the effects of placebos, until I started looking more closely at the evidence for their efficacy and slowly but surely became more and more skeptical.
Who needs acupuncture when we've got yoga?
"“There is no downside to teaching cancer patients yoga,” said Cindy Finch, a clinical psychologist with the Mayo Clinic and with Reimagine, an online resource for cancer survivors."
"Finch, who is also a cancer survivor, said she believed that health care need not treat patients exclusively with medications, surgery and other therapies that address only the physical side of illness. Treating the whole person, including the mind and spirit, helps the whole person recover, she said."
See, Orac's facility isn't really treating the whole person, just disembodied organs.
I see nothing wrong with yoga, as a form of gentle* stretching exercise: it seems to be moderately effective for LBP. I wouldn't want the NHS to pay for it though
I have read that hatha yoga was developed as a way of allowing meditators to live long enough to achieve enlightenment in a single lifetime, but you don't need to believe any of the metaphysical trappings to get the benefits. Incidentally, my mother was told by her local Church of England vicar that by practicing yoga she was "meddling with the occult", which amused both her and me no end.
I was thinking about this recently, and it occurred to me that this 'holistic' approach is, ironically, dualistic. You have to have a concept of the mind and body as separate to treat them 'holistically'. Treating the mind, by encouraging more healthy habits of thought, as I believe CBT does, makes sense, but treating the spirit? How does that work? And how does yoga do either any more than any other physical workout?
* Some yoga teachers like to push students until it hurts, but most that I have encountered say if it hurts you're doing it wrong.
On the question of whether acupuncture reduces analgesic medication use, one study in this review found:
Sounds promising, but:
It looks as if the NHS or insurers might end up paying for both acupuncture and painkillers.
I always heard that certain hatha yoga postures (not hatha yoga as we know it today) were developed as exercises to help enable longer periods of sitting meditation. Anybody who's ever done a long Zen (or Vipassana, I suppose) retreat will understand that anything which helps take the strain off of one's back and knees would be welcome.
Yoga as we know it know is hardly some ancient practice, although I did find a pretty vigorous vinyasa class in town that I like. (The instructor doesn't play crappy music - well, any music - or give anatomically impossible instructions like "open your clavicle." Okay, he doesn't really talk much at all, which is great.)
Krebiozen, first, you deny making diagnoses but you do it all the time:
"I think it is more likely that those improvements would have happened anyway,"
I don't want to discuss it further but it is annoying and time-wasting; nobody cares what you think is wrong with gary, and his individual case is irrelevant anyway. We should stick to LBP-- my only interest in gary was as an example of someone with a strong positive view of acupuncture.
Now, here's my first real problem with what you have been saying. You claim that you don't want to pay for things that don't treat the underlying condition, and you don't want to pay for things that make people feel good (slippery slope from previous comments.)
But guess what: Opioids make people feel good, and as far as I know, opioids have never healed a herniated disk. So instead of rambling on about gary and Medicare and Medicaid, maybe you could stop and think about exactly what your philosophical or ideological or political position is, and articulate it briefly and coherently. I don't care if we call something placebo or zazebo; I just want, as I said before, to establish some (concrete) parameters.
For example? I don't think speculating about the possible causes of someone's symptoms is making a diagnosis.
So why did you bring it up? And why did you imply his condition would require opiates if he couldn't get acupuncture?
It might annoy you, but I don't think it's a waste of time to clarify what is going on when people use a placebo like acupuncture. I don't think it is what you (and sadmar) seem to think.
You jumped from gary having a positive view of acupuncture to this positive view being the cause of his perceived pain relief. If you look carefully at the evidence this isn't what it suggests, it is more likely that regression to the mean combined with confirmation bias are responsible, as I have tried to explain.
I don't want the NHS or insurance to pay for things that just make people feel good, let's be clear.
Opiates don't justmake people feel good, they result in a clinically significant reduction in pain and mobility, unlike acupuncture:
If we're sticking to LBP, "NSAIDs are the most common analgesic medication used to treat low back pain" and according to the NIH, "Some specialists are concerned that chronic use of opioids is detrimental to people with back pain because they can aggravate depression, leading to a worsening of the pain". Comparing acupuncture with opiates for LBP (or anything else, really) is not a valid comparison, and presenting them as a stark choice is downright misleading.
You brought up gary and insurance, not me.
What was unclear about what I wrote above? I think that doctors should be using the most cost-effective treatments available, treatments that have compelling evidence for objective hard endpoints. Perhaps I should add "clinically significant" to that. Opiate drugs, "work at the spinal level by binding to opiate receptors at the interneuron level in the dorsal horn" (op. cit.), and have a clinically significant effect on pain and mobility in LBP (e.g. PMID: 10743823).
So Krebiozen, are you now dropping your oft-repeated requirement that the treatment must affect the underlying condition?
z: "(By the way, I really don’t understand why you put massage in the category of placebo, at least for LBP and frozen shoulder and stuff like that.)"
k: "Massage, as far as I know, does not address the underlying cause of those conditions. It doesn’t reduce joint inflammation or correct a prolapsed vertebra. That’s why."
Or would that wound your pride, so you will have to respond with yet another filibuster?
If it will make you feel better, we can in fact call pain medication like opioids "zazebos".
The point about "treating the underlying condition" arose during a discussion of surgery versus acupuncture. Surgery addresses, or is intended to address, the underlying condition. It's curative. Pain relief is intended to reduce pain. It's palliative. The best quality evidence we have tells us that acupuncture and massage are not curative though massage may be palliative, with an average 20 point improvement on a 100 mm pain VAS as compared to 4 mm for acupuncture.
You still don't know what 'filibuster' means, apparently, and my pride, such as it is, is quite intact, thanks. How's yours doing?
I'm just fine and dandy, thanks. Why would making up a silly word for palliative relief make me feel any better?
z: “(By the way, I really don’t understand why you put massage in the category of placebo, at least for LBP and frozen shoulder and stuff like that.)”
k: “Massage, as far as I know, does not address the underlying cause of those conditions. It doesn’t reduce joint inflammation or correct a prolapsed vertebra. That’s why.”
So is massage a placebo or a zazebo? "That's why." sounds pretty definitive to me; I can almost hear an exclamation point at the end there.
Somehow, I doubt acupuncture would help alleviate the effect of Zebra's painfully limited repertoire.
You're nothing if not zinzistent, I grant you that.
Massage is merely massage. It can provide temporary relaxation. It can provide temporary relief for muscular pain and muscle tension. It may make you feel more cared for, and may arouse you sexually.
"Thai soapy massage": Has it been compared with acupuncture?
I could, however, be convinced to pay a dollar for Zebra to misuse "interlocutor" again.
Two bucks if it quotes a dictionary.
It's touching to see how the Minion Squad rallies around Old Sarge Krebiozen when he can't quite keep his own arguments straight.
However, I think Mr "Why Don't You Define Placebo" Gaist should be a little embarrassed about the inconsistency of his demands.
It seems even Orac, in #39,
"Surgery can be one of the most powerful placeboes there are, actually."
demonstrates that maybe K needs to spend some time thinking through whatever he thinks he thinks.
We can't all be trained professionals like sadmar, but we should aspire to achieve some clarity and organization in our presentations. (Rather than just blathering on with personal opinions and cherry-picked quotations; K is getting very close to Creationist/Denialist territory.)
I have my arguments straight, thanks. The 'minions' only support me because what I have written makes sense. If I wrote something nonsensical I can promise you I would be called out on it immediately.
No doubt you will accuse me of 'filibustering' again, but you keep attempting to force me to give a yes/no answer to questions that require a more complex response.
Who cares? There's no such thing as a zazebo, you just made the word up for no apparent reason.
There are gray areas in the definition of placebo treatments, and some insist that the word 'placebo' should only be used to describe an inert treatment that has no physiological effects at all, like a sugar pill (though even that has led to problems where the sugar may have affected results). That's why many people prefer to talk about placebo effects, rather than arguing about whether a particular intervention is or is not a placebo.
Whether or not the effects of acupuncture on LBP are real physiological effects is a more useful question than getting bogged down in semantics. Even then we run into problems, as sticking a needle in someone clearly has some physiological effects, such as causing endorphin release and counter-irritation. Do these objective physiological effects mean that the effects of acupuncture are not placebo effects? Perhaps, though I would argue that these effects can be elicited equally well by stomping on someone's foot.
That leads us to clinical efficacy as a more useful measure of an intervention. Even if some effects of acupuncture are not placebo effects, the best evidence I have seen suggests that they are small and clinically insignificant. I think that the statistically significant but clinically insignificant effects of acupuncture have been used as a sort of Trojan horse to make people think that the sort of effects gary described, "my pain shrank in half by the next day", are real effects of the acupuncture, not merely regression to the mean combined with the post hoc fallacy. We see this with other altmed treatments, with people waving around clinical trials that show small effects of homeopathy as proof that homeopathy has the miraculous effects they claim.
Anyway, is it cost effective for the NHS or insurance to pay for a treatment that reduces pain by an average 4%? I doubt that a drug that did that would make it to market, and I wouldn't pay for a pill that promised that, I would prefer a NSAID that has a clinically significant effect (defined as greater than 15 mm on a 100 mm VAS) if memory serves), that is available over the counter for a few cents that anyone can afford and that has few side effects if used as directed for a short period.
I originally described massage as "essentially" a placebo, because it does have some physiological effects, as does acupuncture. It can reduce tension and lead to symptomatic relief, but it isn't going to cure a frozen shoulder or a prolapsed vertebra, whereas a steroid injection or surgery can.
I think I can pretty definitively describe massage as a placebo treatment for objective physiological conditions as compared to surgery or a steroid injection. Describing it as a placebo for muscular tension or as a palliative treatment for pain is more problematic.
Is insulin for type 1 diabetes and thyroid replacement therapy for hypothyroidism placebos, because they don't treat the underlying cause? Clearly not, because they have a clear and measurable and clinically significant physiological effect. Similarly pain medication that has a clear physiological and clinically significant effect is not a placebo by any definition of the word.
Oh the irony.
What inconsistency? Spell it out rather than insinuate. You're the one who called a tried-and-true treatment (steroid injections for frozen shoulder) as placebo. I pointed it out to you, and when you replied to that "OK, got it.", I assumed you had - in fact - actually got it and had just typed placebo erroneously in haste and were just too insecure to actually acknowledge the error. But obviously not. And for some reason it took you this long to whine and insinuate about it.
So, be specific. In your own words, define what a placebo is. Something "done to please the patient" like you explained it in #66 is not placebo like the rest of us understand it. If I get a serious bacterial infection I'm expecting the doctor to prescribe me antibiotics unless (s)he has a better idea. Me wanting it doesn't make it placebo. Me asking to get malaria medicine for a 2-month hike in India wasn't me asking for a placebo either, so your "definition", such as it is, is faulty.
Because it is your definition that differs from everybody elses. And yes, surgery can have a poweful placebo effect (and indeed, there have been clinical trials about mock surgery that demonstrated improvement), it doesn't mean surgery is only placebo. Trying to use the quote in your defense is both sad and weak.
And while you're at it, define zazebo in your own words too. How does it differ from whatever it is you call placebo?
only the is should have been in bold.
My favorite example of surgery as a placebo, which I have mentioned here more than once before, is this study which is often cited as evidence that sham knee surgery (making an incision and then simply sewing it back up) is as effective as lavage (washing out the joint) and debridement (basically scraping out the joint), thus demonstrating the awesome power of the placebo.
In other words, none of these interventions had any objective effect on knee function, only on subjective assessment of pain, and we don't even know if patients given no treatment at all might have reported a similar reduction in pain over time, since the study lacked a no treatment group. The placebo wasn't awesome at all, it was as useless as the surgical interventions. I suspect that other studies that show a placebo rivals a conventional treatment merely show that the conventional treatment isn't much good.
"No doubt you will accuse me of ‘filibustering’ again,"
Finally got something right.
"but you keep attempting to force me to give a yes/no answer to questions that require a more complex response."
My observation is that for you, everything does.
The question was whether *you* were no longer using the criterion "does not treat underlying condition" to characterize something as a placebo, which you have been doing. No long rambling discourse is necessary to answer that; you just have to tell us what you've decided.
Here I think we see why Krebiozen filibusters so much-- when he doesn't, his faulty reasoning is glaringly evident. Let me quote from the study referenced:
"These data suggest that the benefits of arthroscopy for the treatment of osteoarthritis of the knee is to provide subjective pain relief, and that the means by which arthroscopy provides this benefit is via a placebo effect."
And the Cleveland Clinic discussion:
"The authors conclude that “if the efficacy of
arthroscopic lavage or debridement in
patients with osteoarthritis of the knee is no
greater than that of placebo surgery, the billions of dollars spent on such procedures
annually might be put to better use.”
Well, maybe. When doctors treat arthritis, they are attempting, foremost, to offer subjective improvement. After all, the reason
patients come to them is because of a subjective complaint: pain. If arthroscopy offers subjective improvement, regardless of mechanism, it can be deemed successful.
Accordingly, one should state that funds
may be put to better use only if there is a
cheaper means to achieve that benefit, but
the authors did not show this. After all, a
placebo benefit is still a benefit. The obvious
question is whether this benefit could be
attained at lower cost and with lower risk."
end CC quote.
Begin End filibuster.
Fixed that for you.
You talk of my "oft-repeated requirement that the treatment must affect the underlying condition"; do remind me, where have I made this claim even once? There are many non-placebo interventions that do not treat the underlying condition. It depends on the context, as I explained.
What faulty reasoning? Please spell out precisely where my reasoning is faulty so I can correct it.
There was no improvement in knee function. Pain improved by about 15 mm on a 100 mm VAS (Figure 1), which is barely clinically significant*, and there was no 'no treatment' group so we don't know if that reduction in pain might have happened without any surgery at all. This is hardly a triumph for the mighty placebo effect, is it?
Are you seriously suggesting that we should use sham knee surgery as a treatment for osteoarthritis? Wouldn't a topical NSAID costing a few cents, which gives an additional 15 mm improvement over and above placebo effects for knee osteoarthritis, be more cost effective than a general anesthetic and all the other expenses knee surgery entails?
* An improvement of 10-20 mm on a VAS as compared to a placebo is usually considered clinically significant.
I'm amused by zebra insisting on a simple answer to the definition of a placebo, and when, if ever, placebos should be prescribed. The amount of discussion and argument that has been published in the medical literature on the subject is enough to make my 'filibustering' (I cringe every time I see him misuse the word) look like a mere drop in the ocean.
I'm also amused that my objection to the use of placebos is apparently the result of "faulty reasoning". The use of placebos without patient knowledge and consent is prohibited by the AMA:
I guess the AMA suffers from faulty reasoning too. At least I'm in good company.
I am thoroughly enjoying the spectacle of zebra, yet again, trying to teach people about a subject he clearly has no knowledge of whatsoever.
I think zebra is about as entertaining as watching a kid having temper tantrum in slow motion. The facial contortions are sort of silly, but you can't shake that nagging feeling that it's only going nowhere, and it's not even getting there any time soon.
It's positively darling that – in addition to being too lazy to even try to format its copypasta – Z. completely skips over the part where there was at least a functional rationale for the procedure (see also here).
How any of this actually bears on the faux timelessness that is a hallmark of acupuncture is anyone's guess. Arthroscopy for OA is no better than placebo? OK, it's no longer recommended.
I don't know why it took so long for this to occur to me, but Z. has a certain... dental student feel to it.
I was going to post this to something more recent, but felt that it should be kept on-topic:
Over the weekend I had dinner with my mom, and she told me she had tried actupuncture for the first time last week during physical therapy. She has a suspected small muscle tear in her shoulder, as far as I know they haven't done any imaging to confirm the injury (she is still in the requisite "try some PT and hope it goes away" stage of treament). Anyway, her physical therapist recommended acupuncture and she obviously went for it. Mom claims it relaxed her muscles where PT hadn't been able to for weeks and gave her 50% more range of motion than she had before.
As a regular reader of this blog, I was disappointed to hear that she went down that road. I tried to gently point out to her that there's no evidence that acupuncture is anything more than theatrical placebo, but her response was (unsurprisingly) that it worked for her and "even if it's a placebo, if it fixes my arm then sign me up!". I also tried pointing out that she had already had her normal physical therapy prior to her acupuncture session, which was almost certainly skewing her perception, but she shrugged it off.
Apparently, my mom was told that the "micro-trauma" of the needles stimulates blood flow to the poked muscle tissues, which relaxes them and encourages healing in these sorts of injuries. IANAD, so could someone more knowledgeable let me know if there's *any* merit to the idea? I suspect someone is feeding my mother BS, and I really don't appreciate it.