Jul 29 2010

Acupuncture Pseudoscience in the NEJM

Here is the conclusion quoted from a recent New England Journal of Medicine (NEJM) review article on acupuncture for back pain:

As noted above, the most recent wellpowered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture. The simplest explanation of such findings is that the specific therapeutic effects of acupuncture, if present, are small, whereas its clinically relevant benefits are mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.

Translation – acupuncture does not work. Why, then, are the same authors in the same paper recommending that acupuncture be used for chronic low back pain? This is the insanity of the bizarro world of CAM (complementary and alternative medicine).

Let’s break down their conclusions a bit. They have reviewed the clinical evidence, as I and others have done before, and found that when real acupuncture is compared to various forms of sham acupuncture (the acupuncture version of a placebo) there is no difference. As I have written many times before – it doesn’t matter where you stick the needles, or even if you stick the needles. Since acupuncture consists of sticking needles in acupuncture points, the only reasonable conclusion from this evidence is that there is no specific effect from acupuncture – acupuncture does not work.

The phrase, “contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.” is a fancy way of saying “placebo effects.” In other words, there are some non-specific subjective benefits to getting attention from a practitioner. There is this assumption, however, that these benefits are real and worthwhile. However, they are likely to be illusory – an artifact of observation and reporting, not a real improvement in the patient’s condition. In real science-based medicine, that is the underlying assumption – placebo effects are largely illusory – a variable to be controlled for.

But there has been recent controversy over the role of the placebo effect in ethical and evidence-based practice. This is, in my opinion, largely a back door attempt to justify CAM treatments that do not work. The claim is that placebo effects are real and useful. But a systematic review of the placebo effect in clinical trials concluded:

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

In other words – for any objective outcome, there is no important placebo effect. For outcomes that are subjectively reported by patients, there is a highly variable placebo effect. It is plausible that the expectation of benefit could result in the release of dopamine and endorphins and produce a physiological decrease in pain, for example, in a subset of people, and there is some evidence for this. But this is, at best, a transient symptomatic effect – not therapeutic.

Such effects are also non-specific – meaning they do not derive from the intervention itself, but from the therapeutic ritual surrounding the intervention. Even treatments that do not work may therefore provide these non-specific benefits. My opinion is that the non-specific benefits of the ritual of treatment should be combined with an actually effective treatment, not magic pretending to be medicine. There are many reasons for this. One is the ethics of patient autonomy and informed consent – giving a fake treatment to a patient violates the patient’s rights, in my opinion.

Further, there is potential downstream harm from convincing patients that fake magical treatments are effective, because of placebo effects. Then using obscure language to hide the fact that the treatment actually does not work. This distorts the public’s view of medicine, and of what works, and sets them up to be victims of fake treatments when their ailment is not subjective or self-limiting. In other words – refer them to an acupuncturists when they have back pain and they may rely upon acupuncture, or some other non-scientific intervention, when they have a more serious illness.

The authors of this article recommend:

He has specifically requested a referral for acupuncture, and we would suggest a course of 10 to 12 treatments over a period of 8 weeks from a licensed acupuncturist or a physician trained in medical acupuncture.

This contradicts their own conclusions. Why is training in acupuncture necessary? That training largely consists of identifying acupuncture points, knowing which points to use on an individual patient, and knowing the technique of needle insertion – but none of these things matter. The sham ritual is all that matters – you can literally fake it and get the same response. I bet a 10 minute video is all that is necessary. In fact I bet even that is not necessary – you could probably fake it well enough to get a maximum placebo effect without any prior demonstration.

What the authors of this article have done is something that is increasingly common in CAM (when it is trying to infiltrate academia and peer-reviewed journals like the NEJM) – reviewing the evidence, admitting that the CAM treatment does not work, then making an elaborate and misleading appeal to placebo effects, and ending with a recommendation to use the treatment that does not work. Specifically, they not only recommend using the treatment, but in its fullest magical form, complete with all the disproven claims (that is what “medical acupuncture” is). It’s a bait and switch con game, nothing more. Come for the placebo effect, then be treated with magical nonsense.

Share

136 responses so far

136 Responses to “Acupuncture Pseudoscience in the NEJM”

  1. SteveAon 29 Jul 2010 at 8:45 am

    “I bet a 10 minute video is all that is necessary.”

    I can see a TV game show in this… ‘How Quickly Can YOU Qualify’.

  2. baconholioon 29 Jul 2010 at 10:09 am

    Happy Birthday

  3. Eric Thomsonon 29 Jul 2010 at 10:12 am

    Given the evidence that it is hard to distinguish acupuncture from strong placebo in many cases, it is still surprising to me that acupuncture worked in mice in the recent Nature study. Obviously placebo effect won’t explain the results in mice. Perhaps it depends on the cause of the pain?

  4. HHCon 29 Jul 2010 at 10:13 am

    Perhaps the medical profession holds a fascination for needles because of their utility?

  5. DrEvilon 29 Jul 2010 at 10:26 am

    “Worked” in mice how?

  6. disgruntledphdon 29 Jul 2010 at 10:27 am

    You know, that review you linked to, while correct is not the whole story.

    See Meissner and Distal et al 2009, where they found that the placebo effect was present when they stratified the studies by outcome measures they found a large (d=.55) effect for placebo. They replicated this analysis with the H&G data also, so placebo is definitely not as powerless as that study makes out.

    Also, there is some evidence that different placebo types can induce different effects (Kaptchuk et al 2008 in the BMJ) and that would argue for an approach where CAM treatments could be used for some groups of patients.

    I agree that it would be better to have a biologically effacious treatment, but given that we don’t really have one (long term admin of opioids does not count) then any results from acupuncture are surely better than no treatment?

    By the way, placebo effects are not always transient – see Wolf 2002 on surgery for effects that lastest up to three years.

  7. Pinkyon 29 Jul 2010 at 10:33 am

    @Eric, it didn’t really ‘work’ on the mice in the study you are referring to. There was an effect causing relief in pain, but in a practical sense the effect is not lasting.

    Another issue with your statement is that you use the all encompassing term ‘acupuncture’ which is in fact an undefined procedure. First you need to ask, “What is acupuncture?” before you start doing tests. Alternative medicine providers can’t even seem to sort an answer to that basic question.

    However, you should just save time (and money) and simply question the plausabilty of the approach to begin with.

    It doesn’t work. It’s very clear that is the case.

  8. Hubbubon 29 Jul 2010 at 10:46 am

    Might this perceived trend in dubiously supported opinions in mainstream journals have anything to do with reviewer selection? Might CAM-oriented reviewers be sympathetic to poorly-supported author commentary?

    If NEJM review is anything like journals I’m familiar with, sub-specialists in the article’s field are selected to review it. My field does not go within a hundred yards of medicine, so do you think your “average” NEJM reviewer would let such dubious opinions slide through publication?

    Between this and the Nature Neuroscience article, it sounds like you could build a case for a review article of your own (or at least a pointed Letter to the Editor).

  9. DevoutCatalyston 29 Jul 2010 at 10:54 am

    10 minutes of rigorous study for acupuncture sounds about right, and then you can fill out a questionnaire on the back of a postcard and send it off to get a diploma mill certificate to hang on your wall. Right next to the others if you’re an eclectic practitioner. Collect them all!

  10. CrookedTimberon 29 Jul 2010 at 11:27 am

    Despite my becoming a real annoyance to my family members who subscribe to all manner of CAM/New Age garbage, I am going to once again bombard them with e-mails of this post. It is such a clear write up of the existing evidence and I can only hope that one day it somehow gets through to them.

    I can already predict a response though. Something along the lines of “well, if it makes me feel better who cares if it is placebo effect or not.”

  11. ccbowerson 29 Jul 2010 at 11:31 am

    Pinky –
    I had a discussion over several days with Eric on that study, and I’m not sure why, but I couldn’t convince him of the limitations of that study. Perhaps my explanations were lacking. Even if we were to grant that the mice study was about accupuncture (which i would dispute) that study showed a transient, localized effect in mice, which in no way is reflective of a generalized clinical effect in humans (especially since those studies have been done).

  12. Eric Thomsonon 29 Jul 2010 at 11:45 am

    DrEvil: They showed a localized transient analgesic effect of acupuncture in mice (using standard touch and heat tests after inducing injury in mice). See this page for details.

    Some people quibbled with whether it was really acupuncture, but there is a broad sense of “acupuncture” that it certainly satisfied, and obviously a lot more follow up is needed.

    Note I’m not saying the study justified the clinical use of acupuncture (it isn’t clear aspirin wouldn’t be better partly because it is cheaper). But it was a good study and showed one mechanism by which acupuncture could relieve pain temporarily. That’s all they claimed.

    People here got all fussy about definitions, and some cheeky stuff in the intro to that paper, but it was a very solid paper and I’m not going to rehash everything I did at the previous thread.

    I like the use of an animal model, as it elminates placebo effects and allows for study of underlying mechanisms, as in that paper.

    That’s where my original question comes from: sometimes it seems to work, sometimes it doesn’t. Likely it depends on the etiology of the pain.

  13. ccbowerson 29 Jul 2010 at 11:48 am

    I agree with this post, however I mildly object to the characterization of placebo only affecting subjective versus objective measures. Mark Crislip has brought this point up as well, and I objected to it then.

    The effects of placebo (or nocebo as a related phenomenon) seems to be (at least partially) related to the effects that one’s emotional state, thinking or expectations can have on a given measure. (I realize that this maybe somwhat of an oversimplification, but it is the part of the effect that is relevant.) I’m not sure how the distiction between subjective or objective matters other than subjective measures are more likely to be affected.

    I noticed that pain and nausea were mentioned as subjective measures, but vomiting can result from excessive nausea ,and this is an objective meausre. Are we saying that placebos (or nocebos) can cause/prevent nausea but not vomiting? Blood pressure and heart rate are also objective measures, are these also immune to the effects of placebo or nocebo? How about agitation? Pyschogenic effects? I am lumping placebo and nocebo to some degree, so perhaps that is where we arive at different conclusions.

  14. ccbowerson 29 Jul 2010 at 11:54 am

    Eric Thomson –

    I agree that the substance of that mice study was very interesting and contributes to our knowledge, but I disagree with the conclusions and the framing of the paper. That is all (but I think that means a lot), and I am not trying throw the baby out with the bathwater.

  15. Steven Novellaon 29 Jul 2010 at 12:01 pm

    Eric – it is not quibbling about the definition of acupuncture. In the study they did not control for elements of acupuncture – there were no controls for needle location or for other types of minor local trauma. This is not a quibble, but directly contradicts the framing of the paper.

    Local trauma causes pain and inflammation. It is so surprise that there are built in biochemical mechanisms to restore the system by dampening down pain and inflammation after 20 minutes or so. The only thing that is interesting about the paper is the mechanism – adenosine. That was good science. Everything else was spin.

    And it is also a fallacy that there is no placebo effect for animals.

  16. Karl Withakayon 29 Jul 2010 at 12:07 pm

    Without side tracking the discussion too much. the treatment in the mice study was really no more acupuncture than a homeopathic remedy that contains measurable quantities of active substances is really a homeopathic remedy.

    The practice of acupuncture is defined by the use of chi points (regardless of what you define them to be) in needling for non local effects. If poking with needles in localized, non-specific points produces some kind of clinical effect in pain relief, that might be some kind of validation of needling, but not of acupuncture.

    Adding 250mg of aspirin to a 100C homeopathic preparation of cyanide and getting clinical relief does not validate homeopathy, it validates aspirin.

  17. cwfongon 29 Jul 2010 at 12:19 pm

    Steven, could you comment as well on Electroacupuncture, as described at http://acupuncturetoday.com/abc/electroacupuncture.php

    This has been used in China and seems to be catching on in the USA.
    How can this not add some serious prospects of danger to the equation?

  18. SARAon 29 Jul 2010 at 12:21 pm

    My gut reaction to this entire issues is that we need to make sure there is disclosure with all treatments on their actual effectiveness. Ideally this would prevent mis-use of placebo as effective treatment, the subsequent validation of nonsense as real medicine, and the loss of real research money which gets wasted re-testing things that have already been disproved.

    But sadly that won’t be the answer. Already we are overwhelmed with too much information. We are surrounded with proof that providing humans with disclosure and lots of information does not insure rational decision making. See Financial Investments as an example.

    I don’t know what the answer is and its a frustrating problem.

  19. Eric Thomsonon 29 Jul 2010 at 2:23 pm

    Steven rightly points out that we can get placebo effects in animals. For instance, train an animal on sugar water with morphine and then give only sugar water.

    However, in the mouse study there is no reason to think there were placebo effects that would account for the pain reduction. The expectation required for placebo effects in nonhumans must be built up via some kind of conditioning which wasn’t done in this paper.

    My original question stands: they observed an analgesic effect in mice, but it doesn’t seem to work for back pain in humans. What are the relevant differences that could help us make predictions about when sticking in a needle will, or will not, help? What types of pain will acupuncture work for, which will it not work for, and is it better than an “easy” solution like aspirin?

    Obviously I don’t care as much about the “framing” of the paper as many here, I’m more interested in the science which is solid. If they had untethered the methods and results from acupuncture would be disingenuous as that was obviously the entire motivation for the study! The discuss that this may be a species of a more general phenomenon you could recreate with things like massage, so I’m not sure why people keep pointing that out as a serious criticism of the paper. Species of a genus.

    In terms of implications for the more specific and esoteric theoretic framework of acupuncture, clearly they didn’t support that. This is obvious. However, they did support a more general claim result about what happens with needle insertion, correlated it with pain reduction, and if any normal person went and had this procedure done they would call it acupuncture.

    Those that don’t like using that word because of the associations with kooky quackery are free to call the research acupuncture “inspired” or something. Frankly I don’t care much about the words, the data and results are more interesting. This could be something that puts acupuncture in a new more evidence-based direction. That is, I see the needle as half in.

    It’s exciting research with interesting implications, even for acupuncture construed more narrowly.

    At any rate, getting to the original question relevant for the post, what types of pain would we expect acupuncture to actually work on based on the mouse study? What is the density and distribution of A1 receptors, for instance? The effect seems quite short-term, so for chronic back pain we would not expect it to be helpful. Perhaps it will end up being useful as an analgesic (short term) where there is a high density of A1-receptors. That’s the prediction of the mouse paper, anyway.

  20. Eric Thomsonon 29 Jul 2010 at 2:29 pm

    Steven has said multiple times of the mouse study that “there were no controls for needle location.” This is not quite true. They did the acupuncture on the opposite leg, and there were no analgesic effects. So we are not observing a generalize analgesic response or anything, but localized effects of needle insertion.

    Note I know Steven means “location” in the mystical framework of acupuncturists with meridians and such, but as I’ve repeatedly emphasized, the paper didn’t test that, but a more casual use of the term to refer to the effects of needle insertion more generally. In that more liberal sense, they did do controls for needle location, and the results were positive.

    At any rate, the results are solid, what others point out as fatal shortcomings I see as details that need to be filled in with future studies. I say this because the results were solid, the evidence strong, their claims were not overblown or kooky.

  21. Eric Thomsonon 29 Jul 2010 at 3:56 pm

    I just read over the paper, and the flat claim that acupuncture doesn’t work, that it is no better than placebo, does not reflect the content of the paper. In all cases cited, both ‘sham’ acupuncture and acupuncture provided more relief than no acupuncture needles.

    Rather than throw out the baby (the needles) with the bathwater, the authors conclude that “These studies also seem to indicate that needles do not need to stimulate the traditionally identified acupuncture points or actually penetrate the skin to produce the anticipated effect.”

    They also point out, of sham acupuncture, “it is difficult to design a sham procedure that is both believable to patients and physiologically inactive.”

    The glass looks half full to me. This all suggests that we can strip acupuncture (the needle insertion method) from the weird Eastern theories that traditionally have undergirded the method (meridians and chi or whatever). We can study it scientifically, and more research is needed. The paper is quite clear that animal models consistently show effects, which to me suggests it isn’t placebo (the Nature paper only confirmed that).

    This research is obviously hard to do with good controls, because it is so hard to design a sham that mimics the actual thing without triggering adenosine release and such. If it turns out that is one of the physiological causes of pain relief with acupuncture needles, then the “sham” acupuncture is not a proper control. It’s like using tylenol as the control with aspirin and saying there is no effect of tylenol because it is no better than aspirin.

    I recommend folks read the paper, as Steven’s review is fairly biased. His “translation” of his first blockquote that ‘acupuncture does not work’ is just not accurate: this is even more clear from reading the paper rather than the selection. Perhaps more accurate is that using acupuncture has small effects, and it is hard to study it well and more research is needed. That is the conclusion, and it seems well-supported by the evidence in the paper.

    Again, this is with all my previous caveats about people quibbling about how to define acupuncture. If you must, go ahead and call the use of acupuncture needles to relieve pain ‘acupuncture inspired’ treatment rather than ‘acupuncture.’

  22. Karl Withakayon 29 Jul 2010 at 4:01 pm

    “if any normal person went and had this procedure done they would call it acupuncture.”

    …and they would be mistaken.

    When you play soccer on ice with a stick and puck, you don’t call it soccer, you call it hockey.

    When you play soccer by bouncing the ball on a hard floor, and you replace the goal with a post mounted basket, you don’t call it soccer, you call it basketball.

    Just because it’s a sport about moving something across a playing area in order to get it into a goal, that doesn’t make it soccer, even if you use a round ball.

    The term acupuncture has a very clear and well understood meaning relating the the use of needles at specific points on the body (typically called chi points or meridians) for affecting other, generally distant areas for therapeutic effect. When you use pressure instead of needles, it’s not still called acupuncture, it’s called acupressure. When you don’t use chi points or meridians, it’s not acupuncture, it’s needling.

  23. Eric Thomsonon 29 Jul 2010 at 4:24 pm

    Free to call the insertion of acupuncture needles for pain relief ‘acupuncture inspired’ pain relief.

    It’s not as if the definition has to stay fixed. If science shows them that the meridians and such are bologny, and the discipline evolves to absorb and be transformed by modern science, it will still be a branch of acupuncture. Pre- and post-copernican astronomy were both astronomy. There could well be “traditional” acupuncture, and “modern” acupuncture.

    Word meanings are flexible and evolve. To insist that acupuncture can only be one thing, that you have somehow fixed on the correct meaning of the term and that it cannot change, seems a mistake. I’m sure there are acupuncture practitioners that welcome advancements of the science. There are already multiple branches of acupuncture and there will likely be even more once some of them absorb the science.

    I see this as promising, an opening up of a somewhat suspicious and new-agey field to the tools of modern science. And people here are all fixated on what we call it. It comes off as shallow and superficial frankly.

  24. Karl Withakayon 29 Jul 2010 at 4:30 pm

    “In all cases cited, both ’sham’ acupuncture and acupuncture provided more relief than no acupuncture needles.”

    And virtually every pain or anti nausea drug study ever done would show the sugar pill provides more relief than no pill if they had a no pill arm added, so what? More relief from the sham acupuncture than no treatment at all is not evidence that the sham is effective.

    “These studies also seem to indicate that needles do not need to stimulate the traditionally identified acupuncture points or actually penetrate the skin to produce the anticipated effect.”

    That statement by itself is a pretty safe statement to make, but does it really tell us anything?

    Compare that with this statement regarding an anti nausea drug:

    “These studies also seem to indicate the actual active drug does not need to be taken to produce the anticipated effect.”

    You may speculate that your control has an effect counter to your intentions, but you may not conclude that without evidence.

    Throw out the unneeded risk of needles, which the studies show aren’t needed. Also throw out the complicated map of meridians, which the studies show don’t matter. You’re left with a somewhat implausible possibility of clinical benefit from being poked in random locations with a tooth pick. Are we really talking about the science of acupuncture anymore?

    Doesn’t Occam’s razor require us to at least assign higher probability to the idea that the effect is a placebo response?

    Is any one out there who studies acupuncture trying to design an experiment to determine in random poking (or poking and twisting) with tooth picks has an statistically significant effect? If we’ve determined the needles aren’t needed, and the location of application doesn’t matter, why are we STILL studying traditional acupuncture at all?

    The mouse study hasn’t yet really been fully embraced by bulk of those advocating acupuncture either. To embrace the mouse study would be to also throw out the chi points along with many of the claimed benefits of acupuncture. The more you define a potential mechanism fro effect, the more claimed effects you necessarily rule implausible.

  25. Karl Withakayon 29 Jul 2010 at 4:42 pm

    “Pre- and post-copernican astronomy were both astronomy. ”

    Before modern astronomy came around, there was astrology; astronomy was mostly inseparable from astrology.

    Before modern chemistry came around, we had alchemy; chemistry was mostly inseparable from alchemy.

    Words have meaning, and they do matter. Sometimes the meanings of words change, and sometimes words get replaced. Word meanings tend to change gradually over time in slow and subtle way, like the process of evolution. They tend to not change in meaning dramatically quickly like a crocoduck, though the internet has perhaps changed that a bit these days.

    We already have enough information to tell us the traditional understanding of acupuncture is dramatically wrong on many (nearly all) levels such that it’s simpler to just dismiss it as a valid modality. If some alternative modality that incorporated some related aspect, such as random poking or localized needling, were to be soon validated, it would be clearer and less confusing to use a different word than it would be to continue to use the same word with all its current baggage.

    Scientific Astrology? Nope. Scientific Alchemy? Nope.
    Scientific Acupuncture? Nope.

  26. Eric Thomsonon 29 Jul 2010 at 5:13 pm

    Karl: Clear positive results in nonhuman animals that were not sullied by placebo effects suggest that the placebo interpretation is incorrect.

    Obviously it is hard to conduct a well-designed study. If sham/non-sham acupuncture is like aspirin/tylenol, then the control is not good. That doesn’t mean acupuncture doesn’t work, it just means better research is needed. The data so far don’t support the conclusion that it is bull, especially given the animal studies.

    OTOH, clinically speaking it isn’t clear it should be prescribed or that the costs outweigh the benefits. I’m just talking about the basic science question.

    How the conventions about word meanings will evolve is anybody’s guess, and the science is a much more interesting question so I’ll focus on that from now on.

  27. Steven Novellaon 29 Jul 2010 at 5:31 pm

    Eric – I don’t accept either of your premises – that the animal data is clear and positive. The studies with which I am familiar are mostly poorly controlled for experimenter bias.

    Also – you assume there is no placebo effect for animals, but there is, in the sense of a measured effect from an inactive treatments. Placebo effects as measured include experimenter bias and artifacts of observation.

  28. Karl Withakayon 29 Jul 2010 at 5:43 pm

    “Clear positive results in nonhuman animals that were not sullied by placebo effects suggest that the placebo interpretation is incorrect.”

    Which study or studies are you speaking of, and what specifically are you talking about the effects of? Needling in traditional chi points, needling in non specific locations, needling in localized areas, poking without penetration, or something else?

    How could anyone do a study on animals involving traditional acupuncture points which, presumably would not directly correlate to the map of human acupuncture points? Oh wait, the points don’t matter, and neither does the needling.

  29. BillyJoe7on 29 Jul 2010 at 5:48 pm

    Eric,

    The only part we are objecting to is the use of the word acupuncture in this context. It is not acupuncture. Period. For all the reasons that Steven Novella (and, before him, Harriet Hall) and Karl Withakay have detailed.
    And it is not a minor quibble about definitions.

    Here, from Steven’s article, is the reason to specifically not call it acupuncture:

    “there is potential downstream harm from convincing patients that fake magical treatments are effective, because of placebo effects. Then using obscure language to hide the fact that the treatment actually does not work. This distorts the public’s view of medicine, and of what works, and sets them up to be victims of fake treatments when their ailment is not subjective or self-limiting.”

  30. Karl Withakayon 29 Jul 2010 at 5:51 pm

    “The studies with which I am familiar are mostly poorly controlled for experimenter bias.”

    Aren’t animal studies fairly difficult to do well for subjective phenomenon? Doesn’t experimenter bias come into play when analyzing subjective criteria in subjects that can’t clearly communicate their experiences or their relative, qualitative or quantitative analysis of their perception of the phenomenon?

  31. Eric Thomsonon 29 Jul 2010 at 9:15 pm

    Experimenter bias is different from placebo effect in the subject. To get a placebo effect in an animal requires conditioning it in a special way as I mentioned above. That said, clearly experimenter bias is something to be considered. Obviously the results of that Nature paper need to be reproduced, extended, and elaborated by independent labs. There are a bunch of obvious experiments to do, based on the physiology in that paper.

    Karl I’m talking about the recent Nature study that we discussed here. The analgesic effect was significant but brief (which is why I keep comparing it to aspirin). There are decent operational criteria to use to assess pain levels (touch and thermal tests) that they used.

  32. Donna B.on 29 Jul 2010 at 9:40 pm

    The most numerous users of the placebo effect are the Drs. Mom. Perhaps the practice of kissing boo-boos or rewarding minor complaints with a band-aid have trained us to be react positively to placebos?

    The other “universal cure” according to these practitioners is a nap, though further research is needed to ascertain whether the effect is greater on the parent or the child.

    My father finally decided that acupuncture wasn’t worth it because the pain relief was so brief. Translation: his pocketbook began to hurt as badly as his back. My stepmom swears the homeopathic anxiety remedy her “witch doctor” (her term, not mine) prescribes for her works wonders. That she takes it at the same time she takes an Ativan is irrelevant… she says.

    Someone above wrote that long-term opioid use shouldn’t count as being effective. I disagree. Easing pain enough to get a reasonable amount of sleep goes a long way toward being an effective treatment.

  33. elmer mccurdyon 30 Jul 2010 at 3:13 am

    Note to self: follow up on Disgruntled Phd’s cites (I’ve already got it bookmarked).

    Really, I don’t understand what “illusory” is supposed to mean regarding pain. Would the effect be more “real” if it included something objectively measurable, like, say, liver damage?

  34. elmer mccurdyon 30 Jul 2010 at 4:05 am

    disgruntledphd:

    Can you give titles for those cites? Is “Distal” someone’s name?

  35. sonicon 30 Jul 2010 at 4:48 am

    Eric-
    Two things that might be of interest.
    1- I’ve had acupuncture treatment – but what I got does not fit the definition of acupuncture being used here.
    2- I’ve had some success with tendonitis problems. It seems many of the golfers I deal with have similar stories about acupuncture and tendonitis-
    Therefore I hypothesize that one would find a release of an analgesic (as has been found) and in some cases an anti-inflammatory response could be discovered. (There aren’t very good drugs for dealing with tendonitis now, perhaps this could lead to the discovery of one.)

    And yes- I would think that there are places in the body that would be more appropriate to put the needles than other places (# of A1 receptors…)

  36. SteveAon 30 Jul 2010 at 7:13 am

    “it is still surprising to me that acupuncture worked in mice in the recent Nature study.”

    What criteria did they use to tell if it was working or not?

  37. Karl Withakayon 30 Jul 2010 at 10:46 am

    As has already been discussed, the procedure in the Nature mouse study can not be accurately described as acupuncture. To continue to describe it as such is, whether intentional or not, unnecessarily clouding the discussion.

    Let’s say that hypothetically, the Mouse study eventually leads to a validation of clinical benefit (beyond placebo) from localized needling. Let’s also say that we discover that sham acupuncture (poking & twisting toothpicks in non specific locations) also is reasonably proven to have clinical benefit. Clearly these two practices are distinct from each other, and neither fits under the definition of traditional acupuncture. Wouldn’t you have to use different terminology to refer to these two new practices? If you used the term acupuncture for either or both practices, wouldn’t that lead to confusion as to what service a practitioner was offering for your therapy (traditional acupuncture, modern localized needling, or non specific acupoking)?

  38. elmer mccurdyon 30 Jul 2010 at 11:15 am

    sonic:

    After many years of being told my pains were the result of “tendonitus,” and being given treatments that were either ineffective (anti-inflammatories) or counterproductive (physical therapy ostensibly for the range-of-motion limitations my pain was causing) I began learning about trigger points and myofascial pain syndromes, and I believe very strongly that trigger points are in fact the cause of what I’d been struggling with. Problems are 1) neither diagnosis is based on an objective test; the distinction is a judgment call 2) although doctors are generally vaguely aware aware that trigger points are a real phenomenon, there are very few who make the effort to learn much about them, and therefore are overly dependent on the traditional diagnosis of tendonitus 3) although there are a lot of people around who claim to treat trigger points, very, very few of them have extensive training (this problem seems to extend to the few MDs who show an interest in the subject, who unfortunately seem prone to prescribe things like prolotherapy).

    Anyway, bringing all this back to acupuncture, I will note that some trigger point therapists do use a treatment called “superficial dry needling,” using acupuncture needles as an alternative to excruciatingly painful intramuscular injections. There’s also been speculation that one particular type of traditional acupuncture point called an “Ah-Shi” (“Oh, yes”) point may be based on trigger points. Honestly I think all these injection techniques are probably placebos, but I wouldn’t mind more experimental studies.

    In any case, again, I suspect that placebo effects can be stronger than this post implies, and that not all placebo effects are equal (and again, I hope disgruntledphd comes back with clearer info about the studies he cited).

  39. Eric Thomsonon 30 Jul 2010 at 12:19 pm

    SteveA: touch test and thermal test (change in threshold of withdrawal responses to touch or heat induced by injection of an inflamatory agent, or nerve damage). This is fairly standard in the rodent models of pain. It’s described briefly in the section of the paper ‘Effect of local application of A1 receptor agonist.’ When you are injured, it doesn’t take much pressure to evoke a pain response. Rodents seem to be built the same way. They call this ‘allodynia’ in the paper.

    For those skeptical of the use of animal models, it is a simple empirical question whether the same ATP release happens in humans when the needles are inserted, and whether such release has an analgesic effect. It would be very surprising if it weren’t the same in humans.

    Sonic: the problem with this research is it is so driven by anecdotes such as yours. It helped you, but could it have gotten better on its own in the same amount of time, or with aspirin, or physical therapy? Without properly controlled experiments with statistical power, it is very hard to interpret anecdotes.

    For instance, personally I have been seeing a PT for achilles tendonopathy, and the exercises clearly were making it worse, and when I stopped doing them it just improved on its own: what if I had gone to acupuncture during that time of rest? I would be saying that acupuncture was better than PT for achilles tendonopathy! (incidentally PT is almost as full of voodoo treatments as acupuncturists but insurance has no problem with PT).

    Unfortunatley, doing properly controlled studies is very difficult. The science is inconclusive, and for some reason rather than take that at face value people often want to say that somehow implies that we know it is bullspit, or that the science supports acupuncture. This seems to clearly be an instance where the scientific view implies agnosticism (at least about the broader acupuncture inspired treatments if not acupuncture proper (to satisfy the word police philosopher-types in our midst)). We need to beware of arguments from ignorance.

    However, given the obvious effects in some animal studies, I am getting pushed toward thinking there is some small and temporary effect of needle-sticking or acupuncture-inspired treatment (this Nature paper one being a great example because of the accompanying work at the molecular level which helped support the story at the behavioral level).

  40. sonicon 30 Jul 2010 at 4:27 pm

    Eric-
    I would agree with your last post completely.
    (BTW, I think it is good if we stick to strict definitions of words, but if acupuncturists are doing something other than what our definition of the word says they are doing, the problem is with the definition we are using, not the practitioners.)

    elmer-
    here’s an article you might like.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1796768/
    (I can’t find links for disgruntled’s stuff- bummer)

  41. elmer mccurdyon 30 Jul 2010 at 5:29 pm

    sonic:

    Thanks. I’ll look at that in a moment. Just in case you’re interested in the acupuncture/dry needling connection (and why, in conjunction with what I’ve learned here, I tend to think the latter is probably a placebo), here is an interesting historical overview:
    http://www.kinetacore.com/physical-therapy/assets/files/level1-pre/Baldry.pdf

    and here is a good literature review on trigger points from a few years back, including a number of studies on dry needling and/or acupuncture:
    http://www.bethesdaphysiocare.com/professionals/pdf/jmmt_mtrpmps-reviewrecentlit_06.pdf

  42. elmer mccurdyon 30 Jul 2010 at 6:02 pm

    sonic:

    Yes, I liked that article, except the concluding sentence, which made no sense whatsoever.

  43. BillyJoe7on 31 Jul 2010 at 1:31 am

    “Yes, I liked that article, except the concluding sentence, which made no sense whatsoever.”

    The idea is that, if you’re going to exploit the placebo effect, do it with something that has a therapeutic effect as well.

  44. cwfongon 31 Jul 2010 at 2:13 pm

    In China, we have confidence in our medical practitioners because we sense strongly that they have confidence in themselves. Which naturally has a catch, since they can be completely wrong and be uninterested in knowing how or why.
    And they can go to some lengths to build the walls that protect what they feel to be science, as the following has done, to find some basis for their confidence in the effectiveness of acupuncture.

    http://www.ratical.org/co-globalize/MaeWanHo/acupunc.html

  45. BillyJoe7on 31 Jul 2010 at 3:59 pm

    cwfong,

    Thanks for that link.

    You might remember that Mae Wan Ho is one of bindle’s heroes.
    Yesterday, in the thread titled “Moloney declares victory”, I linked to one of her articles where she buys into homeopathy and water memory.

    Curiouser and curiouser….

  46. cwfongon 31 Jul 2010 at 4:58 pm

    Yes, those free will conceptions seem to have come from hers as well:
    http://www.i-sis.org.uk/freewill.php

    Which seems odd since we Chinese tend to be predominantly fatalistic.

  47. elmer mccurdyon 31 Jul 2010 at 7:58 pm

    “The idea is that, if you’re going to exploit the placebo effect, do it with something that has a therapeutic effect as well.”

    Look, I’m not a doctor or a medical ethicist; I’m a patient who perhaps has missed out on some of the benefits of placebo due to my skepticism (though I have benefited from treating my doctors’ opinions with skepticism).

    But here are a couple quotes I came across the other day in a TOS forum:

    “I’ve been getting acupuncture since the very end of January on average 2 times a week and I have noticed:

    1. a serious decrease in inflammation in my arms. I have had weeks without having to employ pain relief (massage or medicine) for my forearms, wrists, shoulder blades of hands.
    2. I can also now raise my arms overhead completely extended.
    3. I’ve even been able to do small amounts of resistance exercises.

    For me, these are new developments. Haven’t been able to say any of these statements, much less ALL of them in 3 years. I am be nature a skeptic and I am by no means a New Age – Organic type of person.
    That’s why it surprises me to tell you I am fairly certain acupuncture is working for me and furthermore, I encourage you to try it.”

    “I discovered acupuncture during my first pregnancy 4 years ago. I pinched a nerve in my neck. After 2 months of constant pain, trying different medications, the pain mgmt doctor suggested acupuncture as he said I was risking permanent nerve damage. By this time, I had a partially numb thumb along with pain and muscle spasms. One treatment is all it took to settle down the nerves/muscles and relieve symptoms. Ever since then, when I get the hint of symptoms returning, I’m back in the acupuncturist’s office.

    It hasn’t worked on everything. I injured my shoulder/brachial plexus really bad two years ago. The acupuncturist said when the symptoms don’t relieve after a couple of sessions that there’s a bigger underlying problem and he talked extensively with the physical therapist and doctor. The shoulder is unstable so acupuncture will only temporarily relieve symptoms as the area is under constant aggravation.”

    All I know is that I had no inclination to jump in and say, “well, you know, in the last few years there’s been research that shows that what you experienced is almost certainly due to a placebo effect” (not that that would have changed any minds, fortunately).

    My point is that those are real benefits. And what struck me as wrong about that concluding statement was that often there are no treatments with no non-placebo “therapeutic benefits” (or at least none that the doctor is aware of, or feels confident in), or the treatments that exist have nasty side effects that things like acupuncture notably lack. Anyway, the idea that somehow the the best placebo would come from patients’ general faith in their doctors’ judgment struck me as a bit of pablum meant to end the article on a happy note.

  48. weingon 31 Jul 2010 at 8:37 pm

    I will always be skeptical of articles where an author is a board member of a company that stands to benefit from following its recommendations. It doesn’t matter whether they treat me to a dinner to present the article to me or I read it myself in a journal I paid for with my own hard earned money.

  49. weingon 31 Jul 2010 at 8:49 pm

    “Anyway, the idea that somehow the the best placebo would come from patients’ general faith in their doctors’ judgment struck me as a bit of pablum meant to end the article on a happy note.”

    And the reasons supporting the correctness of your impression are…? Please, please us with them.

  50. elmer mccurdyon 31 Jul 2010 at 8:58 pm

    Because one does not get the sorts of benefits described in those quotes simply from believing in one’s doctors, particularly if his judgment leads him to tell his patients there’s nothing to be done.

  51. elmer mccurdyon 31 Jul 2010 at 8:59 pm

    grammatical errors are typos…

  52. elmer mccurdyon 31 Jul 2010 at 9:00 pm

    “I will always be skeptical of articles where an author is a board member of a company that stands to benefit from following its recommendations.”

    Is this in reference to something in particular?

  53. weingon 31 Jul 2010 at 9:10 pm

    Please, read the NEJM article and disclosures especially Dr. Langevin’s. I hate paying for commercials.

    “Because one does not get the sorts of benefits described in those quotes simply from believing in one’s doctors, particularly if his judgment leads him to tell his patients there’s nothing to be done.”

    Your evidence for this is….?

  54. elmer mccurdyon 31 Jul 2010 at 9:38 pm

    You want me to cite a study for every statement I make? I’d never make it out my front door based on that principle. It’s a suggestion I’ve never heard made outside of that quote. I’ve never even heard any anecdotal evidence to support it.

    I could cite a few reviews of research on placebos that lack any suggestion of such a thing. I could cite countless occasions on this blog in which the Dr. Novella claims that a placebo control is meaningless because of some tiny discrepancy, followed by the inevitable joke-on-the-square in comments about how having the patient’s mother holds one’s hand would have the same effect (with nothing to back up this claim).

    Or perhaps it would have been better style for me to simply take the Platonic approach, and ask for evidence to support a concluding sentence that struck me be as going against common sense.

  55. weingon 31 Jul 2010 at 9:54 pm

    OK. So you are just assuming you are correct.

  56. elmer mccurdyon 31 Jul 2010 at 9:56 pm

    Alright, here’s a better answer.

    I could collect studies that show that real treatment gets superior results to placebo, which in turn gets better results to no treatment. But presumably you’ve already seen many of studies with such results, no?

  57. elmer mccurdyon 31 Jul 2010 at 10:13 pm

    Or, I could cite the very first post I saw here, which argued (very convincingly), that a particular study showed that acupuncture was a placebo, and provided no explanation (if memory serves) of why the very same study showed the placebo effects of acupuncture to be dramatically stronger than the “real” benefits of physical therapy.

    And it is because of this sort of phenomenon that belief in physical therapy persisted for so long among medical practitioners. Until recently, the argument has been that acupuncture showed more benefits for pain than no treatment, and there was unfortunately no known placebo to test it.

    The implication of that statement (which I can’t believe I’m wasting so much time on), is that no treatment would have as much effect on pain as a placebo such as acupuncture, so long as one had adequate faith in one’s doctor. It’s an implication that’s refuted by any well-designed study that has ever shown a placebo effect.

  58. elmer mccurdyon 31 Jul 2010 at 10:14 pm

    “belief in physical therapy” meant “belief in acupuncture”

  59. elmer mccurdyon 31 Jul 2010 at 10:17 pm

    “that statement (which I can’t believe I’m wasting so much time on)” refers again to the concluding sentence of that article. Vey’s mir…

  60. weingon 31 Jul 2010 at 10:29 pm

    “The implication of that statement (which I can’t believe I’m wasting so much time on), is that no treatment would have as much effect on pain as a placebo such as acupuncture, so long as one had adequate faith in one’s doctor. It’s an implication that’s refuted by any well-designed study that has ever shown a placebo effect.”

    Please, look up the meaning of placebo. I don’t think it even requires faith in one’s doctor. That placebos can influence the brain is supported by studies such as the following:
    http://www.physorg.com/news119531708.html

  61. sonicon 01 Aug 2010 at 12:43 am

    elmer-
    thanks- those did make interesting reading–
    The use of trigger points in determining where the needle goes fits with what my ‘acupuncturist’ did when I got good results.
    Interesting…

  62. BillyJoe7on 01 Aug 2010 at 3:36 am

    elmer,

    Is this what you are saying:

    The effect of acupuncture is placebo. The effect of other treatments is placebo + therapeutic. The placebo effect of acupuncture is greater than the placebo + therapeutic effect of other treatments.

    Or are you saying that acupuncture does indeed have therapeutic effects?
    (If you are, the objective evidence is against you.)

  63. BillyJoe7on 01 Aug 2010 at 3:41 am

    cwfong,

    “Yes, those free will conceptions seem to have come from hers as well:
    http://www.i-sis.org.uk/freewill.php

    My joke about free will:
    There is no basis for it!
    (Sorry, it’s not that sort of joke!)

    And that’s about all that needs to be said.
    …except for an explanation!

    Free will cannot be based on anything, otherwise it would not be “free”.
    Therefore, it cannot be based on deterministic cause and effect relations within the brain. In fact, that is the whole point isn’t it? That it is not deterministic.
    Similarly, it cannot be based on random quantum events (somehow randomly vetoing/not vetoing, the brain’s deterministic output) otherwise it is not “free”; and it cannot in any case be based on random events otherwise where does “will” come in?

    Free will is therefore an illogical concept.

    …unless you are as dualist.
    Then there’s no hope for you. ;)

    [This is a copy and paste from one of my posts in another blog:
    http://www.sciencebasedmedicine.org/?p=6348&cpage=1#comment-55178

  64. cwfongon 01 Aug 2010 at 4:15 am

    Compatibilism offers a solution to the free will problem. In fact, the Chinese have have followed a similar philosophy for centuries. For us it’s known as the Tao, the absolute principle underlying the universe, combining within itself the principles of yin and yang and signifying the way, or code of behavior, that is in harmony with the natural order. In other words an orderly and ordered universe, yet an order that we ourselves must want to follow. Our cooperation is desired rather than required.

  65. BillyJoe7on 01 Aug 2010 at 5:45 am

    Okay, a footnote:

    In Australia we have an adjective that can be added to any noun that is redefined to exclude a normally characteristic feature of that noun.
    The adjective is “claytons”.
    Hence a “claytons beer” is a beer that contains no alcohol.
    And a “claytons free will” is….

  66. weingon 01 Aug 2010 at 8:19 am

    My joke about free will:

    Do you believe in free will?

    I have no choice.

  67. BillyJoe7on 01 Aug 2010 at 8:45 am

    weing,

    :)

    The other thing about free will is this:

    The brain evolved over a period of 600 million years to take in information from the environment and produce an output appropriate to the organism’s continued survival.

    What possible advantage could free will have in this scenario?

    In fact, how could free will be anything but detrimental to the organism? Vetoing brain outputs that have been tuned to environmental inputs by 600 million years of evolution.

  68. tmac57on 01 Aug 2010 at 12:42 pm

    “In fact, how could free will be anything but detrimental to the organism? ” Who said it wasn’t detrimental? Modern humans are only about 200,000 years into it, and things are starting to look a little rocky regarding our interaction with nature. Not that that proves anything either way, but there is no reason to assume if there is such a thing as free will, that it is necessarily a positive thing.

  69. cwfongon 01 Aug 2010 at 12:58 pm

    In the Chinese philosophy, things behaved in particular ways not necessarily because of prior actions orimpulsions of other things, but because their position in the ever-moving cyclicaluniverse was such that they were endowed with intrinsic natures which made thatbehaviour inevitable for them.
    If they did not behave in those particular ways they would lose their relational positions in the whole (which made them what they were), and turn into something other than themselves. They were thus parts in existential dependence upon the whole world-organism. And they reacted upon one another not so much by mechanical impulsion or causation as by a kind of mysterious resonance.
    So in the East there was inevitability (just as in Western determinist philosophy) yet an uncertainty as to its path.
    In the West, the path is certain, but the future, in the view of western science, is not. While we say Western science that nothing can be known to a certainty, we say in our Western philosophy that we are certain that our destiny if fixed.
    So how do we resolve this paradox of incompatibility, that nothing except our destinies can be certain?

  70. BillyJoe7on 01 Aug 2010 at 5:32 pm

    tmac,

    “there is no reason to assume if there is such a thing as free will, that it is necessarily a positive thing.”

    Say the brain is 99.9% efficient at keeping you alive. If free will is not based on anything, if it is random vetoing of the brain’s output, the efficiency would drop to 50% every time free will is invoked. How could such a feature gain traction in an environment full of predators that need to be avoided and of prey that needs to get caught?

  71. BillyJoe7on 01 Aug 2010 at 5:37 pm

    cwfong,

    I still can’t see free will in the Chinese philosophy as you have described it.

  72. cwfongon 01 Aug 2010 at 7:13 pm

    BillyJoe7,

    Essentially, it is in the role of intrinsic versus extrinsic causes for behavior. The Chinese conception is that change is coming from within the thing, whereas in Western thought, change always came from without. Speaking mechanically, every event has an antecedent, but in today’s science (both East and West) we are seeing mechanical action as the playing out of the laws of physics, rather than the result of some particular cause.

    In a Western philosophy which views all change as being extrinsic, one is led inevitably to a primal god-like cause. But the Chinese philosophy is at home with the concept of the universe defining itself, and containing within it both laws by which actions are restricted, and actions by which change is made. Ironically we might find the East more hospitable to the present atheist viewpoint than the West from whence most atheistic philosophies arose.

    As atheists in the East, we are self-deterministic, where in the West we remain predeterministic in philosophy, yet now self-deterministic in our science. The yin and yang in this respect have somehow switched from East to West

  73. tmac57on 01 Aug 2010 at 8:16 pm

    Billyjoe7- I’ll be the 1st to admit that my understanding of this philosophical debate is fairly shallow, but it seems that it would be hard to fix a value on the brain as 99.9% efficient at keeping you alive. Based on what? If you mean the brain’s ability to process information and make an evidence based choice of behavior to stay alive, I still see “choice” as elective, because some people don’t make good choices despite the evidence. If we were truly deterministic, wouldn’t we all eventually make the same choices?

  74. Eric Thomsonon 02 Aug 2010 at 12:43 am

    tmac57 asked:
    If we were truly deterministic, wouldn’t we all eventually make the same choices?

    No, because:
    1) We don’t have the same brains (partly for genetic reasons, and partly because our environment shapes the development of our nervous system), so the same input will lead to different outputs in different brains.
    2) Even our own brain is probably never in the exact same state twice (synaptic strengths are constantly changing, for instance), so we’d expect some variability in behavior. Our weighting of the merits of different outcomes will change over time (e.g., having one beer was a big deal when I was 15), and this will influence behavioral selection.
    3) If our brains follow chaotic dynamics, tiny differences in initial conditions would lead to radically different behavioral outputs even if it is deterministic (indeed, most chaotic systems are deterministic).

    Note I’m not endorsing determinism about brains. There are so many layers to work through to make such a claim, we can’t (empirically) say that brains are deterministic systems. Indeed, it is likely they are not, that there are some ‘geiger-counter’ like events in individual photoreceptors and ion channels.

    That said, I think the idea of ‘free will’ is too useful to leave to the dualists. We can naturalize it. But this is a thread on acupuncture, so I’ve already painted the herring red enough.

  75. cwfongon 02 Aug 2010 at 2:50 am

    Not to bicker, but “Classical Chinese thought—which began with the teaching of the philosopher Confucius (flourished early 5th century bce) and ended with the close of the Warring States period in 221 bce—upheld the notion of a dynamic universe and thus generally eschewed the radical dualism that emerged in India, Iran, and Europe. The notion of yinyang, the opposed polarities of cosmic flux, may at first seem dualistic: yin is associated with passivity and femininity, yang with activity and masculinity. Yet yin and yang are not radically separate; they complement and permeate each other.”
    http://www.britannica.com/EBchecked/topic/172631/dualism/38191/China

  76. BillyJoe7on 02 Aug 2010 at 7:14 am

    tmac,

    I hope your brain is at least 99.9% efficient at keeping you alive.
    Also, if there is no freewill, then there are no choices. In other words, if freewill is an illusion, then choice is also an illusion.

  77. Eric Thomsonon 02 Aug 2010 at 9:15 am

    BillyJoe you are conceding too much linguistically if you want to say that choice is an illusion. I go to the vending machine and choose between Snickers and gum every day. This doesn’t imply anything metaphysically weird or dualistic, which is the only reason I can see for rejecting such language. In other words, you made a serious wrong turn somewhere I think.

    The neuroscience of decision making (synonym for ‘choice’) is thriving.

  78. tmac57on 02 Aug 2010 at 11:17 am

    The sheer diversity of human behavior within and among individuals seems to imply the ability to make choices. If that is an illusion, it is such a strong and complex illusion as to be indistinguishable from reality as far as I can tell.

  79. cwfongon 02 Aug 2010 at 12:01 pm

    The chosen path to destiny is a long and winding road. Lao Tzu.

  80. BillyJoe7on 02 Aug 2010 at 5:27 pm

    Eric,

    “BillyJoe you are conceding too much linguistically if you want to say that choice is an illusion. I go to the vending machine and choose between Snickers and gum every day.”

    And that is not the result of your brain’s dispositional states, but just a random choice? Do you really believe that there is no reason you choose snickers rather than gum? That it is just a random choice?

    “This doesn’t imply anything metaphysically weird or dualistic, which is the only reason I can see for rejecting such language. In other words, you made a serious wrong turn somewhere I think.”

    I am happy to use the language. Dualistic language is much easier to use and it is the common form of intercourse. But it is strictly incorrect.

  81. BillyJoe7on 02 Aug 2010 at 5:43 pm

    tmac,

    “The sheer diversity of human behavior within and among individuals seems to imply the ability to make choices.”

    Eric explained why you were wrong the last time you said this. I think you need to respond to his criticism rather than just repeat your opinion.

    “If that is an illusion, it is such a strong and complex illusion as to be indistinguishable from reality as far as I can tell.”

    No argument.
    In fact, that is the reason why most believe in freewill – it just seems to be true. But it matters that there is actually no freewill. Freewill is actually an illogical concept as I have explained previously.

  82. cwfongon 02 Aug 2010 at 6:02 pm

    BillyJoe7, with regard to responding to criticism, I had no response to the following, which was not meant as criticism per se, but did seem to me to raise a critical question:
    “In the West, the path is certain, but the future, in the view of western science, is not. While we say Western science that nothing can be known to a certainty, we say in our Western philosophy that we are certain that our destiny if fixed.
    So how do we resolve this paradox of incompatibility, that nothing except our destinies can be certain?”

    How as a student of science, do you reconcile the uncertainty that science recognizes with the certainty of your convictions regarding the hard version of determinism? Are you not somehow, as I am, a compatibilist after all?

  83. Eric Thomsonon 02 Aug 2010 at 9:42 pm

    BillyJoe asked:
    And that is not the result of your brain’s dispositional states, but just a random choice? Do you really believe that there is no reason you choose snickers rather than gum? That it is just a random choice?

    I never said that choice implies randomness (though it is an empirical question the degree of noise that exists in the decision-making apparatus of the brain). You are letting silly people set the terms of the debate, and ending up at an unecessarily austere and frankly unbelievable conclusion.

    I chose where to go to college, what type of candy to get out of the vending machine, etc.. Whatever you mean by choice, it ain’t what I mean, because I make choices all the time, and neuroeconomics is booming (the study of the neuronal basis of decision making). It doesn’t imply dualism, but a selection from among different alternatives. As I said, it is naturalizable and doesn’t have any weird connotations.

  84. cwfongon 02 Aug 2010 at 10:12 pm

    I think (but silly as I am I could be wrong) that BillyJoe is concerned with whether we knew why we chose a particular candy, knew why we chose the particular machine, and why we chose the college that may have influenced our eventual taste in candy bars. Otherwise choice without a reason fits the description of randomness by default.

  85. cwfongon 02 Aug 2010 at 10:54 pm

    And I was naturalized by choice. Ergo sum, naturalizable.

  86. BillyJoe7on 03 Aug 2010 at 6:56 am

    Eric,

    I’m simply saying that your “choices” are based on dispositional states* within the brain, not freewill. Do you disagree?

    *these brain dispositional states (except possibly for the odd random quantum event) are produced deterministically.

  87. BillyJoe7on 03 Aug 2010 at 6:58 am

    cwfong,

    “Otherwise choice without a reason fits the description of randomness by default.”

    Yes, except not by default but by definition.

  88. BillyJoe7on 03 Aug 2010 at 7:00 am

    cwfong,

    “How as a student of science, do you reconcile the uncertainty that science recognizes with the certainty of your convictions regarding the hard version of determinism?”

    Because it is a logical argument, not a scientific one.

  89. elmer mccurdyon 03 Aug 2010 at 9:24 am

    “elmer,

    Is this what you are saying…”

    I’m saying that the not all placebos are equal, for reasons that we don’t understand as well as some of us may pretend. For whatever reason, the “placebo” effects of acupuncture appear to be unusually strong.

    I just think that the following, from the Mayo Clinic, seems like level-headed advice for patients:

    “The effects of acupuncture are sometimes difficult to measure, but many people swear by it as a means to control a variety of painful conditions.

    Several studies, however, show that simulated acupuncture appears to work just as well as real acupuncture. There also is evidence that acupuncture works best in people who expect it to work.

    Since acupuncture has few side effects, it may be worth a try if you’re having trouble controlling pain with more-conventional methods. ”

    Incidentally, I do also think there is still a possibility of a non-placebo effect for some kinds of acupuncture for some conditions involving trigger points, which haven’t yet been studied in depth for various reasons; but I’m leaning against it, and it’s not something I’ve been willing to pay to explore as a treatment for my own pain (trigger points themselves are, of course, a medical condition causing pain and other symptoms, not a kind of medicine. I occasionally see apparent confusion about this).

  90. Eric Thomsonon 03 Aug 2010 at 9:53 am

    BillyJoe again I think you are being misled by overly restrictive philosophical views about what certain words imply, and ending up in an untenable corner.

    I recommend reading some science to get a bit more perspective, especially Glimcher’s book ‘Decisions, Uncertainty, and the Brain’. What I’m talking about is independent of these debates about determinism versus randomness, which are philosophical garden paths. If you want to understand how brains make decisions/choices, read the science, and I don’t mean Libet. Glimcher’s book is probably the best place to start to jostle your thinking on these issues and get up to speed on where things are, and where they are headed. I think he has a Scholarpedia article on neuroeconomics.

  91. ccbowerson 03 Aug 2010 at 11:30 am

    “I’m saying that the not all placebos are equal, for reasons that we don’t understand as well as some of us may pretend. For whatever reason, the “placebo” effects of acupuncture appear to be unusually strong.”

    There are many factors influence the magnitude of the placebo effect and acupunture has two characteristics that increase the effect: it has a physical component (direct touching and the needle itself) and it is a fairly involved intervention.

  92. cwfongon 03 Aug 2010 at 2:12 pm

    Neuroeconomics? Philosophical garden path if ever there was.
    BillyJoe7, if you feel that science, with it’s ultimate faith in uncertainty, is to that extent illogical, read about why the brain makes decisions, not simply how: The Feeling of What Happens, Antonio Damasio.
    To see where the views of the East and West come together with respect to the determinative aspects of destiny, look into the writings of John Searle.
    http://philosophy.uwaterloo.ca/MindDict/searle.html

  93. tmac57on 03 Aug 2010 at 2:27 pm

    BillyJoe-”Eric explained why you were wrong the last time you said this. I think you need to respond to his criticism rather than just repeat your opinion. ”
    I didn’t respond because I actually agreed with what Eric said. I don’t really equate my 1st question of ” If we were truly deterministic, wouldn’t we all eventually make the same choices?” with my second statement :“The sheer diversity of human behavior within and among individuals seems to imply the ability to make choices.”
    I suspect that we may differ in what we think of as ‘choice’, so this may be more of a semantic disagreement.

  94. Eric Thomsonon 03 Aug 2010 at 2:49 pm

    To cite Damasio and dismiss neuroeconomics in one breath is a bit strange. Damasio’s work on how emotions/feelings influence decisions is an important part of neuroeconomics (which is simply the neuroscience of decision making and choice, after all, not sure what cwfong thinks it is).

    These questions are already being attacked empirically, and are much too interesting to leave in the hands of philosophers waving their hands about from their armchairs.

    How the hell did the topic of free will come up in this thread? Bindle hasn’t been here, thankfully, so who derailed it?

  95. [...] Steve Novella points out, what Berman is doing in this article in the NEJM is the same thing that CAM advocates in general [...]

  96. elmer mccurdyon 03 Aug 2010 at 4:01 pm

    “There are many factors influence the magnitude of the placebo effect and acupunture has two characteristics that increase the effect: it has a physical component (direct touching and the needle itself) and it is a fairly involved intervention.”

    That’s fine, the point being that, from the pov of the patient, the effects on pain are real (albeit temporary, just like an an analgesic pill, albeit without the side effects).

    That said, at the moment I can’t find the study that showed it to have more effects on pain than physical therapy (which also has the characteristics you describe). I would be interested in seeing an explanation for that. Or for the reason that (correct me if I’m wrong), believers in God live longer, independent of lifestyle.

    As Henry Chinasky said, “More crap you believe in, the more better off you are.”

  97. cwfongon 03 Aug 2010 at 4:20 pm

    What I think neuroeconomics is about is largely what it isn’t.

    Damasio’s work provides the ‘why’ component, and he was inspired with regard to that essential element by the Western philosophy of Spinoza – yet one who, like Lao Tzu, was a Monist.
    From: http://www.harcourtbooks.com/authorinterviews/bookinterview_damasio.asp

    Q: Why bring Spinoza in to this?
    A: Because Spinoza prefigured in a remarkable way some of the ideas on emotion, feelings, and ethics that are now taking shape as a result of modern neuroscience (Spinoza’s views on the mind body problem are especially modern). Also because Spinoza’s uncanny foreshadowing of modern views on biology and mind have not been recognized by contemporary science and deserve to be so. Finally, as I studied Spinoza with the purpose of giving him his due, I became intrigued by the person and the times, and both found their way into the book.

    Free will seems to have been the subject of some of BillyJoe’s objections to the writings of Mae Won Ho, who in his opinion (and I don’t necessarily disagree) has gone somewhere beyond the pale in that regard.

    And it was I who first referred to her in reference to the origins of acupuncture. Wherein she commented, rather bizarrely, as follows:
    “Thus, the liquid crystalline continuum possesses all the qualities of a ‘body consciousness’ that may indeed be sensitive to all forms of subtle energy medicines including acupuncture.”

    BillyJoe then took the ball and ran, and Eric drew up his dualistic defense, and the rest was naturalizable.

  98. cwfongon 03 Aug 2010 at 4:29 pm

    I meant to say BillyJoe took up the monist ball and ran.

  99. cwfongon 03 Aug 2010 at 5:01 pm

    What is a dualistic defense? According to Sun Tzu, one that sees only half the battle.

  100. ccbowerson 03 Aug 2010 at 6:07 pm

    “That’s fine, the point being that, from the pov of the patient, the effects on pain are real (albeit temporary, just like an an analgesic pill, albeit without the side effects).”

    Substitute “tiny” for the word “real,” and you are getting close. It is not accurate to equate the temporary effects of acupuncture with the temporary effects of medications. Used appropriately (which isnt always done) medications can have marked effects on many pain conditions. People with chronic pain conditions cannot throw out their effective treatments for acupuncture.

    “That said, at the moment I can’t find the study that showed it to have more effects on pain than physical therapy (which also has the characteristics you describe). I would be interested in seeing an explanation for that.”

    Its likely that many people don’t have the same expectations regarding PT as they do for acupuncture. Not to mention the impact of seeing/feeling the needle must have. Depending on the condition, PT is done not for pain relief, but to help with physical rehabilitation (which may or may not help pain in certain conditions). So if there is such a study, it may not be surprising at all.

  101. cwfongon 04 Aug 2010 at 12:04 am

    BillyJoe7, to get back to acupuncture, which DOES have a philosophical component, and to move away from the derailment that ended up with a recommendation to study what purported to be science, yet relied upon the somewhat discredited soft science known as game theory, you might want to read more about the history of acupuncture here:
    The Biology of Acupuncture and the Science of China
    http://www1.umn.edu/ships/culture/acu.htm

  102. BillyJoe7on 04 Aug 2010 at 7:40 am

    Eric,

    I have found you a credible source of information and opinion so, on the strength of that, I will have a look at the scholarpedia article on Neuroeconomics and maybe even read the book.
    I believe there is also a Daniel Dennett book on the subject called “Varieties of free will worth wanting”.

    cwfong,

    That article you referenced is unfortunately a fount of misinformation. And I’m afraid I’ve read all I care to read about acupuncture. Clinical trials say it works no better than sticking needles in where ever you like, which works no better than not actually sticking them in. Additionally, meridians and chi or qi have never been demonstrated so the plausibility factor is close to zero. And it may interest you to know that acupuncture started as off as bloodletting!
    I’m afraid I have put it alongside homeopathy and chiropractic.

  103. Eric Thomsonon 04 Aug 2010 at 11:47 am

    I’ve read that Dennett book (Elbow Room). I guess if you are interested in the philosophy, Dennett might be a good place to start (his books almost always have entertaining thought experiments). I favor a more empirical, evidence-driven approach (just as I do with consciousness).

  104. cwfongon 04 Aug 2010 at 12:10 pm

    BillyJoe7, you may not realize it, but Eric was arguing with Dr. Novella that acupuncture had more going for it than simply a placebo. And oddly enough he was not wrong, because the philosophy behind it led to expectations that it would alleviate pain, and expectations can be the most powerful motivating forces around. That’s what the article was supposed to demonstrate, but evidently didn’t. (And personally, as a student of Western science, I don’t have any such expectations, so it doesn’t work for me.)
    And Dennett’s book is, as I recall, about compatibilism, which I had earlier suggested you look into. (And Eric has not!)
    And you may not realize that you have actually been arguing, as in the Chinese version of compatibilism, that on the path of probability one will always find the certainty one was seeking at the inevitable end.
    That’s Dennett’s argument as well.
    (Not Eric’s, as his recommended book has nothing to do with free will versus determinism, or with acupuncture, or with anything except possibly wanting it know that he’s read it.)
    So good luck on your journey to see if in fact your logical argument, after all is said and done, is that while science sees uncertainty, the universe sees the inevitable.

  105. Eric Thomsonon 04 Aug 2010 at 12:40 pm

    cwfong: ‘Free will versus determinism’ is a false dichotomy, as we’ve known since the 1920s. I would never recommend someone explore a distinction based on such a confusion.

    I was addressing BillyJoe’s claim that naturalists should abandon the word ‘choice’. The work on the neurobiology of decision making suggests we should not (aphorisms from Sun Tzu notwithstanding).

    For instance, some good recent papers include Perceptual decision making in less than 30 milliseconds and The Neural Basis of Decision Making and Modulation of Drosophila male behavioral choice .

  106. cwfongon 04 Aug 2010 at 1:13 pm

    Eric Thomson,
    Explain to BillyJoe7, if you can, why free will versus determinism is a false dichotomy. Dennett doesn’t seem to think so, or are you trying to make some etymological point irrelevant to this discussion?
    And we all know that living organisms are essentially choice making mechanisms. That their strategies can be determined on the basis of economic game theory is a scientific naivety at best.

  107. cwfongon 04 Aug 2010 at 2:46 pm

    Eric Thomson,
    Tell the authors of the following to find a different title than Free Will vs Determinism:
    http://blogs.salon.com/0001561/stories/2002/11/17/freeWillVsDeterminism.html
    http://atheism.about.com/library/glossary/general/bldef_freewill.htm
    http://www.spaceandmotion.com/Philosophy-Free-Will-Determinism.htm
    http://www.rationality.net/freewill.htm
    (and many more)

  108. Eric Thomsonon 04 Aug 2010 at 2:55 pm

    cwfong: quantum indeterminacy doesn’t imply electrons are free, that’s why ‘determinism versus free will’ is a false dichotomy. Individual neuronal function is usefully described using probabilistic models, but that doesn’t imply individual neurons have free will. The whole ‘free will versus determinism’ distinction is a philosophical relic that does little to illuminate the details about how brains make choices. Citing Dennett, a philosopher, doesn’t obviate that fact. Finally, even within philosophy the existence of compatibilists is simply a restatement of my ‘false dichotomy’ claim.

    Obviously it is everyone’s prerogitave to sit in the armchair and consider their thoughts on the matter and see how much progress they make. For the past 50 years, that approach hasn’t been useful. For much of anything.

    Also cwfong you keep focusing on game theory, but game theory is just one mathematical tool among many that people have explored. Whether and how well it applies in a given experimental situation is an empirical question.

    The three papers I cited above do not use game theory, and they are very much in the mainstream. GT is just one room in the mansion that is the neuroscience of decision making. The most important rooms are those where data are being collected, as data are hands down the most powerful fuel for conceptual innovation in science. That’s what philosophers don’t understand, and are missing out on. That’s why they are not helpful in science and don’t come up with the greatest conceptual advances.

  109. cwfongon 04 Aug 2010 at 3:04 pm

    “The most important rooms are those where data are being collected, as data are hands down the most powerful fuel for conceptual innovation in science. That’s what philosophers don’t understand, and are missing out on. That’s why they are not helpful in science and don’t come up with the greatest conceptual advances.”
    Here’s what Massimo Pigliucci, Philosopher and Evolutionary Biologist, had to say about that today:
    “The two points I made here amount to claiming that many scientists do not understand the nature of science as well as philosophers do, and are hence prone to make exaggerated claims about how science works and what it can do. This should not surprise anybody, since the business of scientists is to do science, not to spend time thinking about its history and methods. That is why philosophy (and history) of science are scholarly activities that are legitimately distinct from science itself.”

  110. Eric Thomsonon 04 Aug 2010 at 3:23 pm

    cwfong I agree with him to a some degree. I got my MA in philosophy before switching to neuroscience. I studied philosophy of science and philosophy of mind extensively. I knew the annoyance of talking to scientists who thought that Popper was be-all and end-all of philosophy of science.

    I switched fields because I wanted to understand how brains work, and (among other things) philosophy is as helpful for that as science is for philosophy (maybe less so). Philosophical approaches do not gain the crucial conceptual traction provided by data and experiments. Philosophy is simply the wrong discipline for those that want to understand how brains work.

    I’m not sure why you quoted him. His quote doesn’t directly address anything I said, and I stand by everything I said above about the usefulness (or lack thereof) of philosophy for understanding brain function.

    And if it’s a pissing contest you want, then let me know what substantive results has philosophy shown in the past 50 years? What are the major contributions that philosophy has made to science in the past 50 years? The fact is, the arrow of influence is strongly asymmetric: new results come in from science, and the philosophers scurry to make sense of it. New results come in from philosophy, and… oh wait nevermind philosophy doesn’t produce results. :)

  111. cwfongon 04 Aug 2010 at 3:48 pm

    All scientific hypotheses are philosophical constructs. Einstein’s theory of relativity was such a construct – perhaps the most successful scientific thought experiment ever. Darwin’s works involved the philosophical examination of data.
    The list of productive philosophers of science goes on and on:
    http://everything2.com/title/Philosophers+of+science

  112. Eric Thomsonon 04 Aug 2010 at 3:53 pm

    My question was this: what substantive results has philosophy shown in the past 50 years?

    Einstein and Darwin?

    ‘nuf said.

  113. cwfongon 04 Aug 2010 at 4:07 pm

    Nice try, since Einstein died n 1955. Is it then your argument that philosophy’s contribution to science died with him? Check out that list again, why don’t you?

    A.J. Ayer
(1910-1989) British Logical Positivist, and originator of the verifiability principle.
    Niels Bohr
(1885-1962) Danish physicist and philosopher, particularly noted for his principle of complementarity.
    Rudolf Carnap
(1891-1970) Member of the Vienna Circle and a Logical Positivist, Carnap did a lot of work on what constitutes a scientific theory, and also what can be considered a ‘fact’. He was one of the main supporters of the verification principle.
    Paul Feyerabend
(1924-94) Advocate of epistemological anarchy, an attempt to criticise the cosy, institutionalised world of modern science.
    Michel Foucault
(1926-1984) Although perhaps more of a philosopher of the social sciences, Foucault’s work sheds light on the relationship between power and truth, which is obviously significant within the field of science.
    Bas van Fraassen 
(1941-….) American logician and philosopher of science, working at Princeton University, who’s work attempts to find a middle ground between Carnap and Putnam
    Martin Heidegger
(1889-1976) German phenomenologist. Although not primarily a philosopher of science, he is included here for his work connecting modern science to enlightenment modes of thinking, particularly in the paper ‘What is a thing?’
    Werner Heisenberg
(1901-1976) German physicist, responsible for the Uncertainty Principle.
    Douglas Hofstadter
(1945-….) American mathematician and philosopher, included here largely for his mathematical approach to the philosophy of mind, and his contributions to the excellent anthology The Mind’s I.
    Philip Kitcher
(1947-….) Contemporary British philosopher of science currently lecturing at Columbia University. His interests include the apparent conflict between science and religion.
    Thomas Kuhn
(1922-1996) One of the most important modern philosophers of science, he came up with a model to explain how scientific beliefs changed over time, and coined the phrase ‘paradigm shift’.
    Imre Lakatos
(1922-1974) Hungarian mathematician and logician, who attempted to refine and improve Popper’s work.
    Bruno Latour
(1947-….) Contemporary French writer, described in cabin fever’s excellent write-up as a ‘sociologist of science’.
    Karl Popper
(1902-1994) One of the most influential philosophers of science, his work (especially his belief that, in order to qualify as scientific, a theory must be fasifiable) is closely related to logical positivism.
    Willard Van Orman Quine
(1908-2000) American philosopher of science (and almost everything else). His philosophy of science was holistic, and as such refuted the work of Popper. The idea of ontological relativity also poses some interesting questions concerning the truth.
    Bertrand Russell
(1872-1970) British philosopher, most famous for his vocal political opinions, but he also did some very important work in the philosophy of mathematics earlier in his career.

  114. Eric Thomsonon 04 Aug 2010 at 4:18 pm

    OK, cwfong, you have your list so it should be easy for you to tell us what you think of as the important results produced by philosophers in the past 50 years. What results specifically? I saw your list describing what people studied. That’s different from you telling us what specific results from the past 50 years you are most impressed by.

  115. Eric Thomsonon 04 Aug 2010 at 4:46 pm

    If someone asked me that question, I’d be tempted to mention Popper. His stuff is hotly contested though (see Massimo’s page on Popperian falsificationism). And that’s what philosophy typically gives us. A neverending cycle of hotly contested claims, where people battle with little to no data, no experiments, going back and forth in a neverending cycle.

    The worst is the ‘realism vs antirealism’ debate in philosophy of science. Can we say that electrons really exist, or are they just useful fictions? How many different ways can we argue about that before you vomit.

    Perhaps Kuhn is a better example, but his claims about incommensurability and even the claims about ‘paradigm shifts’ are hotly contested. It seems the same cycle holds.

    That’s fine: for those that prefer the library to the laboratory, who like to argue about what words mean, and don’t mind not ending up with real results or consensus, then philosophy will be fun.

    While there typically aren’t any results in philosophy, there is progress. Fallacies are noticed and filtered out of discourse. Thought experiments helpl stretch people’s conceptual imagination. It’s not useless, as producing results isn’t the only useful thing for a discipline to do. One useful thing to do is to act as a question incubator, and philosophers are great at that. Answers? No, not usually. But questions? Yeah, they are great at that.

    OK thanks for the discussion, it was fun.

  116. elmer mccurdyon 04 Aug 2010 at 4:56 pm

    I found one of the studies disgruntledphd cited:
    http://www.biomedcentral.com/1741-7015/5/3

    If someone with good statistics chops could comment on this, that would be super.

    He’s got a blog (hope he doesn’t mind me mentioning this, since he doesn’t seem to be in the habit of linking to it).

  117. cwfongon 04 Aug 2010 at 5:07 pm

    Wikipedia: “Werner Heisenberg (5 December 1901 – 1 February 1976) was a German theoretical physicist who made foundational contributions to quantum mechanics and is best known for asserting the uncertainty principle of quantum theory. In addition, he made important contributions to nuclear physics, quantum field theory, and particle physics.
    Heisenberg, along with Max Born and Pascual Jordan, set forth the matrix formulation of quantum mechanics in 1925. Heisenberg was awarded the 1932 Nobel Prize in Physics for the creation of quantum mechanics, and its application especially to the discovery of the allotropic forms of hydrogen.[1]
    Following World War II, he was appointed director of the Kaiser Wilhelm Institute for Physics, which was soon thereafter renamed the Max Planck Institute for Physics. He was director of the institute until it was moved to Munich in 1958, when it was expanded and renamed the Max Planck Institute for Physics and Astrophysics.
    Heisenberg was also president of the German Research Council, chairman of the Commission for Atomic Physics, chairman of the Nuclear Physics Working Group, and president of the Alexander von Humboldt Foundation.”
    Most impressive, I’m not sure, but pretty sure this qualifies as both impressive and resultive.
    Also useful.

  118. elmer mccurdyon 04 Aug 2010 at 8:26 pm

    btw, getting back to my obsession with trigger points, the only reason I brought up injections is because they’re relevant to a comment that was made. If you go back to Travell and Simons, even though they give very detailed directions for injections, they don’t claim that they are the most effective treatment for trigger points, based either on clinical experience or on studies cited, and neither do any of the other reviews I’ve looked at…

    Meanwhile, I’m really chomping at the bit regarding the earlier post that touched on this subject. Oh, well…

  119. numberninedoctoron 06 Aug 2010 at 12:31 am

    Hold on a minute. Acupuncture is NOT alternative medicine!
    It is, in fact, standard practice for a considerable percentage of the world’s population, who have been experiencing it’s benefits for millennia. How many people need to rely on a treatment over how many years before you deign to consider it mainstream?

    The article you reference is much like the one in Science News in 1979 that concluded that acupuncture and other eastern medicine procedures worked, but only because the patients were culturally conditioned to believe in their efficacy.
    You may not be aware of this, but acupuncture has also been found to be very effective and is common practice in the treatment of various maladies in thoroughbred horses, who tend to lack “cultural conditioning.”
    Stupid horses always fall for the placebo, huh?

    Give a listen to the litany of disclaimers hurriedly run through at the end of any prescription drug commercial (Ask you doctor if poison is right for you.), then talk to me about “fake, magical treatment.”

  120. Steven Novellaon 06 Aug 2010 at 2:34 pm

    numbernine – there are a number of fallacies in your statement. The first is that acupuncture has been used for millennia – it hasn’t. Up until the 20th century acupuncture had more in common with bloodletting and astrology than what passes today for acupuncture.

    Speaking of which, blood letting was used for thousands of years (still is) – and yet we generally recognize that it is worthless – showing that your second premise, the argument from antiquity, is also a fallacy.

    Next you assume that the only source of placebo is cultural conditioning (a straw man) then you knock down that straw man. But there are many placebo effects, conditioning only being one. And there is a placebo effect for animals which can derive from observation bias but also just getting attention from a person.

    You end up with a tu quoque logical fallacy – the safety and effectiveness of drugs have nothing to do with the lack of efficacy of acupuncture.

    Read the actual article – a review of the evidence shows acupuncture does not work. The only response I get from proponents is a string of logical fallacies. At least they’re consistent.

  121. Steven Novellaon 06 Aug 2010 at 2:53 pm

    And BTW – acupuncture has an equally long list of possible side effects – acupuncturists just don’t disclose them.

    - Local pain, redness, swelling, bleeding/hematoma, and nerve injury (http://www.ncbi.nlm.nih.gov/pubmed/20609604). Infection is also a serious concern, including infections like HIV and hepatitis (http://www.bmj.com/cgi/content/full/340/mar18_1/c1268). In rare cases collapsed lung (http://www.ncbi.nlm.nih.gov/pubmed/19420954) may require hospitalization.

    Say that in 30 seconds.

  122. BillyJoe7on 07 Aug 2010 at 4:36 am

    Steven Novella,

    “And there is a placebo effect for animals which can derive from observation bias but also just getting attention from a person. ”

    Apparently “getting attention from a person” doesn’t work as a placebo in animals. It’s all “observation bias”. At least that what I was told by a vet on another forum. I was unable to find any study that contradicted her.

    Of course, if you have a study that does, I will go right back and dump it on her. ;)

  123. Eric Thomsonon 07 Aug 2010 at 3:44 pm

    Placebo effects imply an expectation of improvement from a particular treatment. Experimenter bias is different from placebo effect. Someone fudging data or experimenters treating one group differently from another group would not be placebo effect. That would be fraud or bias, not placebo.

    Most experimental animals strongly dislike getting handled by people, but some can learn to tolerate or perhaps welcome it (my rats associate fruit loops with being handled by people). Perhaps dogs are an exception, and primates in some circumstances.

  124. ccbowerson 07 Aug 2010 at 10:19 pm

    Steve uses a very broad definition of the term placebo effect, and when he uses the term it includes multiple effects including other types of biases. How Eric describes the term is much more narrow, and is what most people think of when they hear the term.

    “Apparently “getting attention from a person” doesn’t work as a placebo in animals. It’s all “observation bias”. At least that what I was told by a vet on another forum. I was unable to find any study that contradicted her.”

    Well, there are other effects besides observer bias even in animal studies. Related to what Eric says animal handling can have a great effect on animals, and depending on the study being done this effect can be significant. An example that I remember from when I was working in an animal lab as an undergrad is that repeated temporary maternal separation of rat pups can have a significant effect on their stress response as an adult rat (mostly what we would consider positive effects in humans). The problem is that in order to create maternal separation in many studies the pups were physically handled by the researchers. This becomes a confounding variable if you are trying to determine the effect of the maternal separation only. Changes in behavior, HPA axis function, and hippocampus development can be observed, and I would not call this “observer bias.”

  125. BillyJoe7on 08 Aug 2010 at 7:03 am

    Eric,

    “Someone fudging data or experimenters treating one group differently from another group would not be placebo effect. That would be fraud or bias, not placebo.”

    I didn’t mean to imply any different.
    What I meant to say is that “the placebo effect” does not work in animals, and that, what appears to be placebo, is actually “observer bias”.
    Sorry for the confusion.

    ccbowers,

    “there are other effects besides observer bias even in animal studies…animal handling can have a great effect on animals”

    Fair enough.
    I was just making the point that “the placebo effect” is not seen in animals.

  126. ccbowerson 08 Aug 2010 at 10:42 am

    “Fair enough.
    I was just making the point that “the placebo effect” is not seen in animals.”

    I think that this is related to Steve’s use of the term, which is technically incorrect. He lumps multiple effects together and calls it the placebo effect. I think he does this because, in practice, these effects are not separated out.

  127. Eric Thomsonon 08 Aug 2010 at 12:18 pm

    My point wasn’t that animals don’t exhibit placebo effects. Steven is right to point out that they do. For instance, train an animal on sugar water with morphine and then give only sugar water, and it will likely kill some pain more than sugar water in an unconditioned animal.

    The point is that in animals the placebo effect (i.e., expectation of effects) must be built up via some kind of conditioning.

    I originally claimed that acupuncture studies in animals eliminates the possibility of placebo effects, but that was incorrect as pointed out by Steven. However, I should have said it is much easier to block that explanation of data, as to generate such effects takes a bit of work on the experimenter’s part. For instance, associate morphine and needle insertion in one group of animals, then test that group on needle insertion alone versus a naive group. My bet is the morphine group would show greater effects of acupunture needle insertion, and this would be a placebo effect.

    Because of the positive effort needed to create an expectation in the animal, it is basically effortless to block placebo effects in animal studies.

    That’s why the results in mice in the Nature study impressed me: no placebo in that study, but demonstration of localized transient analgesic effects of using acupuncture needles.

  128. BillyJoe7on 08 Aug 2010 at 5:51 pm

    Eric,

    “The point is that in animals the placebo effect (i.e., expectation of effects) must be built up via some kind of conditioning.”

    Most also exclude conditioning in the definition of the placebo effect.

    David Ramey in the science based medicine blog:
    http://www.sciencebasedmedicine.org/?p=263

    …there’s no evidence whatsoever that animals can benefit from, or even experience, placebo effects.

    …there are many explanations for how a placebo-like effect might be explained in animals. Take conditioning…

  129. Eric Thomsonon 08 Aug 2010 at 8:03 pm

    BillyJoe: I’d replace “most” with “some” in your post, and then agree :)

    It seems reasonable to say that associations can produces placebo-like effects in nonhuman animals. However, if someone wants to be more strict and insist that the animal must “recognize the intentional effort to treat” for a placebo effect to exist that would also be reasonable. And the latter is very uncommon, if not nonexistent, in nonhuman animals.

    Interesting topic!

  130. Steven Novellaon 11 Aug 2010 at 1:14 pm

    The problem with narrowing the definition of “placebo effect” is that it no longer correlates to what is measured in clinical trials. In clinical trials the measured “placebo effect” is everything other than a physiological response to the active treatment – the isolated variable.

    By the operational definition of placebo in trials, animals do have placebo effects.

    If you are going to use a more narrow definition (not include observer bias, for example) then you have to also control for the things you are excluding – and trials rarely do that. When they do, btw, the placebo effect shrinks to nothing, or just subjective reporting.

    It is important to understand the disconnect – using the size of the placebo effect measured in trials, which includes a variety of effects including bias, regression to the mean, and observational artifacts – to conclude that a subset of the placebo effect (by an arbitrarily narrow definition) is real.

  131. Eric Thomsonon 11 Aug 2010 at 2:21 pm

    In that case, to say “animals do display placebo effect” to someone using it in the typical sense (effects based on expectations of effects in the subject) would be equivocation. The operational use of the term in the studies you mention is clearly at odds with conventional usage.

    And I frankly question what you are saying. If I don’t control for temperature, but temp covaries with my treatement so I wrongly think my treatement has an effect when it is really temperature, that isn’t placebo effect. It would simply be a confounding variable.
    Animals that cannot build expectations cannot exhibit placebo effects. If confounding variables were sufficient to show placebo effects, then plants and single cells could display placebo effects, as could iron bars for that matter.

    I do a lot of reading of clinical literature and I have never seen it used so broadly. But whatever, I am not one to get too bogged down in semantics. As long as terms are clear and used consistently (i.e., no equivocation) then it isn’t that big a deal how you define the words.

  132. daedalus2uon 11 Aug 2010 at 2:25 pm

    It is preposterously unlikely that animals do not exhibit a placebo-like effect. Suggesting that animals do not implies some sort of human exceptionalism; that what ever physiology mediates the placebo effect sprang up de novo with humans.

    What ever the placebo effect is, it affects a great many different aspects of physiology. It must be very complex and integrated into the rest of physiology. Something that complex can’t suddenly appear without evolutionary precursors.

    I disagree that placebo effects necessitates the expectation of improvement. If that were true, then organisms that had no expectations could not exhibit placebo-like effects. The evolutionary precursors of placebo effects didn’t spring up de novo with the first appearance of a nervous system complex enough to have expectations of improvement.

    The definition of placebo effect that I am using is positive therapeutic effects not mediated through drugs or surgery. To me, the component of improvement that is produced by a good bedside manner is mediated through the placebo effect (because it is not due to drugs or surgery). A neutral bedside manner is not as good, and a harsh bedside manner is actively bad for patients. If you treat a sick animal harshly, it will do poorer than an animal that is treated gently. That is especially true for social animals like horses, dogs, and mice. That differential therapeutic result is not mediated through drugs or surgery, it is a placebo.

    If we did a clinical trial with one group treated harshly and one group treated with a good bedside manner, the good bedside manner group would do better. EBM would say, aha! A good bedside manner is an effective treatment. SBM would say, no, you didn’t use the right control group, you need to provide the equivalent of a “placebo good bedside manner”. You apply a “placebo good bedside manner”, and the effect goes away demonstrating that a good bedside manner is a placebo.

    I understand that many people don’t want to call a good bedside manner a placebo. They need to get over that bias about semantics.

  133. Eric Thomsonon 11 Aug 2010 at 3:04 pm

    Giving a plant sunlight and water isn’t placebo, but does cause improvement without surgery or medication. We need to be careful of admitting that everything living, or even iron bars, can exhibit placebo effect.

    Bedside manner is a tricky bordeline case, I would admit. I could go either way on that.

    Good bedside manner could produce confidence that their doctor is going to help them, which would fall under the more typical ‘expectation effects’ definition I’ve advocated. On the other hand, it may just relax them and calm them down, which has independent benefits. Whether we call all such auxilliary psychological responses to treatement ‘placebo’ is a fuzzy case: I could go either way. But that doesn’t mean it is a clear cut or canonical instance of placebo effect, which after all is the doctor giving you a sugar pill and saying it is morphine. :)

    The crux of placebo is belief in the animal that something will produce a certain desired result. All other uses, by my lights, are secondary.

    I hate arguments via dictionary citation (e.g., the Pais-indle strategy), but for what it’s worth, OED defines placebo as:
    ‘A drug, medicine, therapy, etc., prescribed more for the psychological benefit to the patient of being given treatment than for any direct physiological effect; esp. one with no specific therapeutic effect on a patient’s condition, but believed by the patient to be therapeutic (and sometimes therefore effective). Also: a substance with no therapeutic effect used as a control in testing new drugs, etc.; a blank sample in a test. ‘

    Bold added by me. This is what I have been saying is crucial.

  134. sonicon 11 Aug 2010 at 3:36 pm

    It appears Eric maybe correct about the expectations aspect–

    http://www.physorg.com/news199986147.html

    This would also indicate that different groups would have different responses to different placebos. (I believe there is experimental evidence to back that statement)

  135. daedalus2uon 11 Aug 2010 at 4:13 pm

    If you want to include plants, then sunlight and water are the equivalent of drugs. In air breathing organisms air is “drug-like” too. Water can be drug-like in humans also. Water is the drug of choice to treat dehydration. Sunlight can be drug-like too, to treat vitamin D deficiency.

    The problem with your definition is that when you test specific treatment modalities against “placebo” versions of the treatment modality (as in real acupuncture with needles vs sham acupuncture with toothpicks), you can end up concluding “toothpicks work too!”, rather than “acupuncture is a placebo”.

    If the doctor goes to give you a sugar pill, but palms it so you don’t really get it, you only think you get it, and you have a therapeutic effect. Was that a placebo effect because you didn’t really get a placebo, the doctor tricked you into thinking you got it. I think using such a narrow-hyper technical specification of the placebo effect is not useful if we are going to understand the physiology behind it.

    A placebo effect can come from non-health care providers too. If you shared a hospital room with someone who was loud, abusive and bullying, you would very likely do worse than if you shared a room with a kind gentle and nurturing person. You may not have the expectation that you will do worse with the abusive bully, but you will.

    If you did a clinical trial with abusive bullies and kind and nurturing room mates, you would see greater improvement with the kind and nurturing person. I suspect enough improvement that if you could bottle it, it would be worth tens of dollars per day due to reduced hospital stay length. If it reduces stay length by 1%, and hospital beds cost $1000 per day, that is a $10 per day savings.

  136. PharmD28on 02 May 2012 at 2:47 pm

    by the way, on the issue of accupuncture…in case no one did not notice this, but within that NEJM review of it for back pain

    http://www.nejm.org/doi/suppl/10.1056/NEJMct0806114/suppl_file/nejmct0806114_appendix.pdf

    there is this supplementary listing of the major studies that we ofen cite…notice closely that within the results column, they show multiple differences “favoring acupuncture” over sham is how they write it, but it is not statistically significant….just writing it that way shows how flawed they see this….no it could not just be a trend caused by some noise…it must favor accupuncture? Not sure if I am reading into this, but I would make sure to qualify it as “not statistically significant” or better yet, “no difference detecte”

Trackback URI | Comments RSS

Leave a Reply

You must be logged in to post a comment.