Acupuncture – the mysterious case of the missing razor

Acupuncture is all the rage in the treatment of pain. Recent clinical guidelines in the UK recommend it in the treatment of persistent back pain. This decision is somewhat controversial and has led to much discussion, because while the research in back pain suggests people feel somewhat better after acupuncture, it also demonstrates with clarity that they feel just as much improvement after receiving sham acupuncture. Nevertheless therapists seem to be queuing up for acupuncture training. There’s gold in them there needles.

So how about this acupuncture training? A paper just published in the Journal of Pain analysed the combined results from four big recent trials of acupuncture for chronic pain. They scrutinised this big data-set (almost 10,000 patients treated) to see what influence the characteristics of the treating clinician (primarily their level of training and clinical experience) had on the success or failure of treatment. Intriguingly no real influence of training or expertise was found. If you have just completed your training and started practising acupuncture for chronic pain then savour this moment. You may be at the peak of your (acupuncture specific) therapeutic powers.

These results add to a growing body of evidence that challenges the principles of acupuncture. A review across all conditions showed us that using the principles of Traditional Chinese Medicine (TCM – with all the trappings of Qi and meridians) to determine the location of the needles confers no added benefit to putting them in anywhere and across studies of pain real acupuncture does not perform convincingly better than sham acupuncture regardless of what type of sham you use. Even more interesting is that while clinical expertise and treatment characteristics make no difference to the clinical outcome, several studies show that the patients’ expectations of acupuncture (see here and here) and their beliefs about whether they are getting real or sham treatment do have an effect (see this great study by Barker Bausell –  the beliefs had more influence on success than the actual treatment received!).

So where does this leave us? Acupuncture is used because it has been around for a long time, is based on years of supposed wisdom and of course ”we know that it works”. But when we test the traditional principles underpinning acupuncture (the original reasons for doing it) they come up short. These days some clinicians follow the paradigm of Western Medical Acupuncture, ignoring the old TCM lore and based on the idea that this novel and specific sensory stimulus has specific physiological effects. But the evidence suggests that it doesn’t even matter even whether the patient can feel the stimulus, let alone where you put them and whether they penetrate the skin which implies that any effect might be rather non-specific .

Efforts continue to investigate the mechanisms of acupuncture. All of this reconceptualising and research effort is driven by one underlying construct that is accepted as truth: “We know that acupuncture works”. Of course this is a logical fallacy. You can’t know a treatment works until you’ve tested it in controlled trials and when we do that…..

What we can say with some confidence is that it does not seem to matter what you do with the needles, why you do it or how expert you are at it. If I were to be cheeky I might suggest that evidence-based acupuncture training could consist only of where you really mustn’t put the needles and the basics of antiseptic technique! We know that people feel a bit better after any convincing treatment (real or sham) and that adding a therapeutic ritual and empathetic clinician interaction enhances this effect (see here and here). Proving a negative is difficult but the weight of evidence strongly points in the direction that any clinical efficacy of acupuncture is due to the placebo effect.

Of course there may still be unknown reasons why this might not be so (e.g.“all of the sham treatments (even the non-penetrating ones and the ones that you can’t feel) have an active specific effect and are therefore also acupuncture” or “the trials are wrong” or “we just don’t know the mechanism yet”) but for me as the evidence base expands this becomes more of an exercise in creative thinking and starts to sound a little desperate. Worse, it pushes acupuncture into the realms of the unfalsifiable hypothesis. If we consider that old scientific principle of Occam’s Razor (what can be made with fewest assumptions is made in vain with more, or more simply, the simplest explanation that requires the fewest flights of fancy is the best one) then the placebo conclusion is the fairest.

The very human error common in the therapies is that when research does not confirm our opinion we are quick to find reasons for this failure that do not include “our theory was wrong”. Acupuncture research will no doubt continue to test all of these possible reasons but I would suggest that it’s now about time we had good look for that old lost razor (it probably fell down the awkward gap behind the sink).
Witt CM, Lüdtke R, Wegscheider K, & Willich SN (2010). Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture? The journal of pain:official journal of the American Pain Society, 11 (5), 431-5 PMID: 20439056

MOFFET, H. (2008). Traditional acupuncture theories yield null outcomes: a systematic review of clinical trials Journal of Clinical Epidemiology, 61 (8), 741-747 DOI: 10.1016/j.jclinepi.2008.02.013

Madsen, M., Gotzsche, P., & Hrobjartsson, A. (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

Kalauokalani D, Cherkin DC, Sherman KJ, Koepsell TD, & Deyo RA (2001). Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine, 26 (13), 1418-24 PMID: 11458142

Linde K, Witt CM, Streng A, Weidenhammer W, Wagenpfeil S, Brinkhaus B, Willich SN, & Melchart D (2007). The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain, 128 (3), 264-71 PMID: 17257756

Bausell RB, Lao L, Bergman S, Lee WL, & Berman BM (2005). Is acupuncture analgesia an expectancy effect? Preliminary evidence based on participants’ perceived assignments in two placebo-controlled trials. Evaluation & the health professions, 28 (1), 9-26 PMID: 15677384

Madsen MV, Gøtzsche PC, & Hróbjartsson A (2009). Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ (Clinical research ed.), 338 PMID: 19174438

Kaptchuk TJ, Stason WB, Davis RB, Legedza AR, Schnyer RN, Kerr CE, Stone DA, Nam BH, Kirsch I, & Goldman RH (2006). Sham device v inert pill: randomised controlled trial of two placebo treatments. BMJ (Clinical research ed.), 332 (7538), 391-7 PMID: 16452103

Kaptchuk TJ, Kelley JM, Conboy LA, Davis RB, Kerr CE, Jacobson EE, Kirsch I, Schyner RN, Nam BH, Nguyen LT, Park M, Rivers AL, McManus C, Kokkotou E, Drossman DA, Goldman P, & Lembo AJ (2008). Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ (Clinical research ed.), 336 (7651), 999-1003 PMID: 18390493

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