Thursday, March 31, 2011

Acupuncture no better than placebo???

You must be wary of studies that make such bold conclusions. This article will discuss problems with research into acupuncture.

There is a fundamental incompatibility with using Western methods to evaluate Eastern techniques. In the West, the gold-standard of research is the Randomized, Controlled,double-blind Trial (RCT). In this design, subjects are randomly assigned to either a treatment group or a control group that receives either no treatment or a placebo. There are concerns that if patients know that they are receiving the real treatment, that this expectation could alter their response (they think they should be getting better and therefore do get better, independent of the treatment they receive). This is why the patients are blinded- that is they don't know whether or not they are receiving the real treatment. And the subjects in the control group do not know that they are not receiving a real treatment. There is also concern about the influence that the treatment provider can have if he or she knows who is receiving the real treatment vs. placebo. If I know you are getting the real treatment, I may treat you differently somehow and that could alter your response. For this reason, the one providing the treatment is also blinded. This is what they mean by a double-blind study. Both the person receiving the treatment and the one administering the treatment do not know who is getting the real thing and who is getting placebo. This design works best for pills.  It is arguably impossible to use this model for acupuncture research.
But the RCT not the only way to determine something's effectiveness. I have read skeptic columns who assert that the lack of RCT evidence is PROOF that acupuncture does not work by anything more than placebo. My response to this is, "Can someone show me the RCT that show's that hip replacements work? If not, then any benefit that the patients experience must be due to expectations." Think about it; it is impossible for a surgeon to do the procedure and not know whether or not she performed the real replacement. Hip replacements have helped a lot of people and we don't need an RCT to prove it.

I find the placebo argument amusing. Although the number of skeptics has dropped significantly over the past 15 years (with the Mayo Clinic, John Hopkins, the World Health Organization, the National Institute of Health, and the American Medical Association all concluding that acupuncture DOES work), there are still a few die-hard skeptics that insist that acupuncture only works as a placebo. Most patients do not come to acupuncture as a first-line approach to a problem. For low back pain, a lot of my patients will start with over-the-counter medication, then see a physician, then physical therapy, then a chiropractor, and then finally come to see us. And then 90% of our back pain patients experience relief. For the placebo hypothesis to hold up, that patient must have had no faith that medication, Western orthopedics, physical therapy NOR chiropractic could possibly help them. But for some reason, they were sure that the acupuncture (their fifth choice) would be effective. I'm confident you see the flaws in that logic.  Why do acupuncturists give the best placebo?  If it is truly that we take more time with our patients and that alone truly improves patient outcomes, then don't all physicians then have the obligation to provide this "placebo" care? 

Another argument against the placebo hypothesis regards animal acupuncture. There are points that, when stimulated, produce measurable changes in animal physiology. For example, there are points that will increase the t-cell counts of rats. Even skeptical rats experience this improvement. The camel at the Brookfield Zoo in Chicago had an arthritic hip a few years ago and could not run. She was treated with acupuncture and was soon running again. This story was covered in the Chicago Tribune and the WGN news. Again, this was a skeptical camel.

But there are studies out there with headlines that read, "Acupuncture no better than placebo". First let's talk about what is placebo acupuncture. In fact, it does not exist. One method that researchers (usually MD's and not acupuncturists) use is called "Sham Acupuncture" where they pretend to put a needle into an acupoint but do not insert it all the way. Traditional Chinese Medicine acupuncture typically inserts needles, but not all forms of acupuncture do. Japanese style frequently uses this superficial technique and get great results.

The other method of "placebo" acupuncture is to do traditional needling at points other than the main acupuncture points, which I will call "wrong point" acupuncture. There is no spot on the body that is energetically inert. Every point will fall within an acupuncture meridian's path and inserting a needle there will affect the physiology.  There was one study I read that found that "real acupuncture" was 50% effective in treating back pain, "wrong point" acupuncture was 40% effective, and standard Western care was 13% effective. The conclusion: Acupuncture does not work, because real acupuncture was not significantly more effective than "placebo".  My take on this data is: one set of points helps 40% of people, another set of points helps 50%, and both are more effective than Western care. This is like saying Vicodin doesn't work because it was not significantly more effective than Ibuprofen.   What they call "placebo" is not a true placebo.
And lastly, a big problem is that the RCT treats everyone the same. Chinese medicine treats everyone individually. If I have to treat everyone the same in a study, I am not practicing Chinese medicine and the results say nothing about Chinese Medicine's effectiveness. If the study does not show benefit, then the conclusion is: "This set of points does not work for everyone".   And every acupuncturist already knows that using the same points for everyone will not be effective. 
So don't worry about the studies that try to discredit acupuncture. For some reason, most of the literature that is arging against acupuncture is coming from the UK lately. There seems to be a real campaign to deter people from using natural (translated - affordable) remedies. Believe in the Billions of people who know first-hand that it does work. Of course it does not work for everyone, nothing does. But it's safe, effective, and should be our first line of defense.   If it doesn't help, then you can proceed to the newer, less-studied, and riskier pharmaceutical and surgical interventions. 


Jason Bussell MSOM, L.Ac

President Emeritus - IL Assn of Acupuncture and Oriental Medicine

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