May 29 2009

The NICE Fiasco

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Comments: 50

The National Institute for Health and Clinical Excellence (NICE) is an independent UK organization that provides advice on which treatments and medical practices are likely to promote health. In other words, they comment on what they think is or should be the standard of care. This is a very important function, and the NICE is generally taken seriously.

That is why it was very disturbing to find that in their latest guidelines for low back pain they include recommendations for both spinal manipulation (wihout explicity naming chiropractic) and acupuncture.

The spinal manipulation recommendation is at least semi-reasonable, in that there is some evidence for modest benefit for spinal manipulation for acute uncomplicated low back pain. However there are still problems that derive from the bait and switch tactic employed by many practitioners of spinal manipulation.

David Colquhoun discusses this issue well. Patients may be referred to a chiropractor for uncomplicated low back pain, and then be hit up for treatment of their asthma, or to bring their child in to treat the colic. In fact, to demonstrate this he called a couple of chiropractic offices posing as a patient and they were happy to offer treatment for asthma and colic, and to assess him for whatever else might be ailing him.

Acupuncture is even more of a clear-cut issue – the evidence clearly shows that acupuncture does not work for low back pain.  And the bait and switch also applies – once you are visiting with an acupuncturist you are likely to hear about non-existent life energy and meridians and how acupuncture can cure all sorts of medical problems.

Colquhoun reports that NICE normally does a good job of making science-based recommendations – so what went wrong. I agree with his assessment that three factors likely played a role: infiltration by proponents, political correctness, and the bait and switch. In short, NICE took their eye off the ball and got snookered.

Colquhoun documents the infiltration of NICE by proponents – people who have a financial stake in the recommendations, specifically chiropractors and acupuncturists.  I have seen this happen in universities as well, and it has occurred in the US at almost every level of political and academic regulation. These are the same people, by the way, who scream about the influence of Big Pharma in medicine (sometimes legitimately), but then see no problem with people who’s entire practice is based upon medical acupuncture being in a position to make official recommendations about the evidence for acupuncture.

It is an unfortunate reality that proponents, especially those with a financial stake, tend to have a much higher degree of motivation and persistence to promote their claims than those who do not have a personal stake but may be skeptical of the claims to be vigilant against them.

And so the nonacupuncturists advising the NICE may not be familiar enough with the evidence, they may not really care about or understand the secondary consequences of recommending quackery, and they are easily put off their game by rhetoric about being “open-minded” – rhetoric which CAM proponents have perfected over the years. The bait and switch works, and the most plausible and benign-sounding claims for acupuncture are used to recommend referral to acupuncturists – who will then inflict all manner of pseudoscience on their patients.

Even worse – once they gain the imprimatur of official recognition they will increasing work their way into the system. Eventually they will be their own gate-keepers and regulators. Critics will be dismissed as being closed-minded, as having an ideological axe to grind, as being politically “incorrect.” They will even be sued for libel, as the British Chiropractic Association is doing to silence Simon Singh for daring to say that the BCA makes recommendations that are not evidence-based.

It is still amazing to me how CAM propoenents have successfully created a bizarro world in which to operate – where the usual rules of science, transparency, and criticism are turned on their head. I have been personally told by academics (CAM shruggies who have fallen for the line of BS) that lack of transparency is necessary because proponents fear that otherwise they will be criticized. Think about that sentiment very carefully. In simply wishing to discuss the published evidence about a specific claim I have been accused of being closed-minded and having an agenda. Well, I do have an agenda – it’s called science-based medicine. But that’s not what they meant.

What amazed me most is that otherwise bright and savvy academics and regulators have fallen for the bait and switch. CAM proponents are steadily infiltrating the very organizations that would review and regulate their claims and practices. They are systematically insulating themselves from outside criticism. They are bamboozling the public, and more importantly those whose job it is to know better.

I also personally know many scientists and physicians who are as appalled by all of this as I am, but who simply cannot be bothered to speak out against it. They fear they will become the targets of recrimination. Now they rightly fear they will become the target of law suits. Most wish to simply ignore the issue, hoping it will go away. They express to me that they are glad that I and others are speaking out, because that means they don’t have to.

Well – they are wrong. The evidence is clear. The entire question of science-based medicine vs so-called alternative medicine (CAM) needs a very public and transparent airing. All scientists and professionals need to understand the issues and to speak out.

The NICE episode is just the latest example. It won’t be the last. And the public health will suffer.

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50 responses so far

50 Responses to “The NICE Fiasco”

  1. RSon 29 May 2009 at 10:23 am

    From reading these guidelines and hearing some of the comments from people on the committee the problem appears to be simply one of an uncritical attitude to alternative therapies.

    So NICE wouldn’t dream of proposing a drug therapy that wasn’t better than placebo pills, or of proposing a drug therapy that hadn’t been tested in placebo controlled trials.

    But when it comes to alternative (sorry, ‘complementary’) therapies the explicit rationale of these guidelines was to compare them to standard care, or, essentially, no treatment. The fact that these treatments were no better than their placebo arms (e.g. sham acupuncture) or other non-specific interventions (e.g. ‘spinal manipulation’ vs. exercise) was not considered.

    The problem is that these guidelines essentially embrace the placebo effect for alternative therapies and declare it not a problem. This is particularly worrying because, as even the guidelines point out, these alternative therapies only show very modest benefits over no treatment anyway. So while it is true that placebo arms are difficult to devise and interpret for these trials, the balance of evidence would suggest that the positive effects are probably largely placebo. I think at least part of the problem is that this was defined as a GP problem and headed by the RCGP – so they are taking a rather pragmatic approach (i.e. ‘never mind if it is placebo, as long as it gets them out my office’) – but if we adopt this approach for this problem, why not extend it to all treatments?

    Compare this with the coverage of the Kirsch et al study on antidepressants. There it was not good enough for antidepressants to show an effect better than the placebo arm (and a real placebo in this case, not just compared to doing bugger all for the patients), no, following on from NICE’s own guidelines in fact, the beneficial effect over and above the placebo response had to be greater than a certain (arbitrary) threshold to be considered ‘clinically’ significant.

    This double standard highlights the sort of special pleading that alternative medicine gets.

  2. Steve Pageon 29 May 2009 at 10:47 am

    I actually phoned NICE to complain about this decision two days ago, and I’m in the process of composing an official letter of complaint. If it is okay, Steve, I’d like to refer them to your blog posts on this topic (not just this one but there are at least two or three others that I’ve logged). The primary concern that I voiced when I phoned is that even if acupuncture is an effective placebo, they are lending legitimacy and credibility to a procedure that is utterly unscientific and, in doing so, may lead people to think that acupuncture can be used in place of real medicine.

  3. titmouseon 29 May 2009 at 10:48 am

    The American Psychiatric Association meeting in San Francisco this year has left me depressed. The vast majority of my colleagues are either believers or shruggies. Academics I respect and admire feel that fighting quackery is a bad idea.

    I related my problem with MDs promoting chelation and other unproven therapies for autistic children to Paul Applebaum. He agreed with my statement to parents, that experimental or unproven therapies must be done in the context of a registered clinical trial so we can learn more about their safety and effectiveness. But when I asked how we as a profession might fight quackery, he shook his head. “I don’t know about ‘fight’,” he said. He seemed to feel that it’s enough to limit one’s own practice to science-based therapies.

    I had a similar conversation with Howard Zonana, who said that there have always been promoters of fringe ideas in medicine. What counts as evidence can be a matter of opinion.

    Yes, I said. There are gray areas. But some ideas contradict established basic science. For example, homeopathy– which is so dilute no active ingredient is present– if it works, we need to re-write physics and chemistry. For that reason we can reject it.

    Zonana pointed out that homeopathy was pretty useful in its day when medicines were often quite toxic. He mentioned that the osteopaths, who once held some pretty odd beliefs, have become mainstream.

    I started to argue that the shift in osteopathic practice was no natural evolution but the result of the Flexner report.

    Zonana interrupted, saying the Flexner report was devastating to a lot of communities. “It closed all the black medical schools. The AMA was politically powerful and really, pretty awful toward blacks.”

    The implicit point in all this seemed to be: political battles against bad ideas can have unintended, negative consequences.

    Chill. Be a lover not a fighter, they seem to say.

    And yet Applebaum quite effectively fought against psychiatric involvement in coercive interview settings with military detainees. He said, “not ethical,” and snap! Case closed.

    Oh, if only. If only he’d take a look at autism quackery and say, “not ethical,” in the same way.

    Makes me weep. Srsly.

  4. Skepticoon 29 May 2009 at 10:50 am

    Eventually they will be their own gait-keepers and regulators.

    They want to regulate the way we walk?

  5. tmac57on 29 May 2009 at 11:00 am

    For years, I have relied on Consumer Reports OnHealth publication for unbiased,and reliable medical information geared to the layperson. But they too, have bought in to the acupuncture and chiropractic recommendations for back pain. While I still generally trust the information they put out, I am disappointed that they aren’t more circumspect about those two modalities.

  6. titmouseon 29 May 2009 at 11:09 am

    …they are taking a rather pragmatic approach (i.e. ‘never mind if it is placebo, as long as it gets them out my office’)

    Sure, alternative/complementary/integrative medicine can seem like nice backrubs and a few sugar pills. But then in come the chelators and the chemical castrators.

    Even a seemingly benign intervention like a gluten-free/casein-free diet can be pretty unpleasant for many patients. Imagine being ten years old and unable to eat pizza with your friends at the lunchtable.

  7. Silverbeeon 29 May 2009 at 11:42 am

    I’m a UK pharmacist and this latest report from NICE just depresses me. The worst thing is that the NICE Guideline documents in detail the studies that they base their work on, and in true bad science form, they completely draw the wrong conclusion from this evidence. It just makes me more sceptical of the other NICE Guidelines, not due to any hidden CAM content, but rather due to the advice they have provided that may be based in incorrect trial conclusions.

    How do we (science based medicine supporters) defend our position and provide ligitimate evidence against CAM, when one of the major institutions within the UK Healthcare Network is as deceived as any other quack nutritionist or healer. Its just so saddening.

  8. superdaveon 29 May 2009 at 12:29 pm

    I think this bizzaro world phenomenon is worthy of its own post. I read the piece in SBM about how Dr. Eisenstien created his own IRB, many CAM modalities now operate their own journals dedicated to that modality, each CAM modality has at least one genuine MD as a supporter. It is at the point where they have developed their own ecosystem to support their claims. Superficially it all looks kosher, especially to the layperson and the effort to debunk a claim rises exponentially with each new layer. It’s a tremendous problem.

  9. RSon 29 May 2009 at 1:04 pm

    Silverbee,

    at least partly it is explained by the concept of ‘stakeholders’ – the idea that certain groups or individuals ought to get a say just because they have a financial interest rather than an expertise.

    looking at the NICE guideline committee:

    Martin Underwood, GP and researcher – but carried out the main study relied on for the spinal manipulation conclusions and thus having a conflict of interests.

    Peter Dixon, Chiropractor

    Steven Vogel, Osteopath

    Michael Cummings, Acupuncturist

    Dries Hettinga, Patient representative and head of research at the charity BackCare, who has also researched TENS and spoken favourably of CAM treatments

    Now there are many others on the committee, including pain specialist and rheumatologists (I haven’t bothered looking in any detail at their previously published views) – but these individuals made up 5/19 people present at the first meeting I looked at (the minutes are published online).

  10. pecon 29 May 2009 at 1:21 pm

    http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102276047.html

    http://www.ncbi.nlm.nih.gov/pubmed/16980316?dopt=AbstractPlus

    http://www.ncbi.nlm.nih.gov/pubmed/16798792?dopt=AbstractPlus

    Of course you will say it’s all delusional placebo effects. Even if patients are still improved months after the treatment.

  11. Steven Novellaon 29 May 2009 at 5:22 pm

    Uncontrolled or unblinded trials show an effect.

    Blinded trials show no effect

    Apply that to any claim, regardless of plausibility or presumed mechanism, and the conclusion is the same – this is consistent with no real effect, just placebo.

  12. pecon 29 May 2009 at 7:33 pm

    “Uncontrolled or unblinded trials show an effect.
    Blinded trials show no effect”

    Always, without exception? Or according to one “skeptical” meta-analysis?

    And why would a placebo effect last for months?

  13. artfulDon 29 May 2009 at 8:02 pm

    It’s no less ephemeral than its memory.

  14. Neur0manceron 29 May 2009 at 10:14 pm

    >> “Uncontrolled or unblinded trials show an effect.
    >> Blinded trials show no effect”
    >
    >Always, without exception? Or according to one “skeptical” >meta-analysis?

    >And why would a placebo effect last for months?

    Extraordinary claims require extraordinary evidence.

    A claim that a method of treatment which does not have any intelligible mechanism of action should get scarce medical dollars is an extraordinary claim.

    Your objections put the burden of proof in the wrong place.

  15. Michael Kingsford Grayon 29 May 2009 at 10:26 pm

    …as the British Chiropractic Association is doing to silence Simon Singh for daring to say that the BCA makes recommendations that are not evidence-based.

    Did you actually mean to write “evidence-based” rather than “science-based”?
    If so, why?

  16. Doctor Evidenceon 29 May 2009 at 11:10 pm

    the compromise of integrity. its spreading…
    success to those fighting the good fight.
    appreciation, at least.

  17. Steven Novellaon 30 May 2009 at 7:00 am

    MKG – EBM is a lower standard than SBM, and the recommendations to not even meet that.

    pec – of course not without exception. Science is messy, especially clinical science. But also not just as seen by one skeptical metaanalysis. Rather, this is the pattern in the vast majority of acupuncture studies – blinded comparisons are negative. And virtually all systematic reviews conclude that there is insufficient evidence to reject the null hypothesis, although how that is spun depends on the reviewers. Proponents generally say – “more research is needed.” That is now code for – “the evidence is negative but I don’t want it to be.”

    And again – this is not even considering plausibility. If we add that factor in, we have a highly implausible treatment with essentially negative or ambiguous evidence.

  18. pecon 30 May 2009 at 2:49 pm

    “And again – this is not even considering plausibility. If we add that factor in, we have a highly implausible treatment with essentially negative or ambiguous evidence.”

    Plausibility according to materialist/atheists can be very different from plausibility according to alternative scientists. A meta-analysis of 13 acupuncture studies showed that real acupuncture was significantly more effective than sham acupuncture, although sham acupuncture was also effective. The fact that sham acupuncture has been shown to be effective led “skeptics” to conclude the benefits of acupuncture are mostly placebo.

    However, there are other possible explanations. For example, there is evidence for energy healing techniques such as reiki and therapeutic touch (of course you will deny it, but there is). It is possible that an acupuncturist may inadvertently help patients through some kind of energy healing, even though he/she is not using real needles or is not placing the needles correctly.

    So the sham acupuncture procedure effects might not be merely placebo.

    That is only a possible explanation, but one that cannot be easily ruled out.

  19. Doctor Evidenceon 30 May 2009 at 9:12 pm

    “energy healing”?

    Pec, I think you’ve taken a swig too many from Russell’s teapot.
    either that, or you’re just saying weird stuff to get reactions.

  20. tmac57on 31 May 2009 at 12:08 am

    pec, has anybody on this blog ever said anything to make you question your own positions on any CAM modality? You certainly don’t seem to be swaying others with YOUR arguments. So I just have to ask, why are you here? You keep making the same assertions time after time, and you get the same criticisms time after time. Are you learning anything?

  21. sonicon 31 May 2009 at 4:55 am

    Perhaps the NICE people got this one right-

    Another study (this one from Germany with 1100 patients)-

    http://archinte.ama-assn.org/cgi/content/abstract/167/17/1892

    “Results At 6 months, response rate was 47.6% in the verum acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group…

    Conclusions Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy. “

    Given this conclusion I would suggest that

    a) acupuncture is an effective treatment or
    b) conventional therapy is actively harmful or
    c) both a) and b)
    Note: with this study we can see that the ‘real’ acupuncture was more successful than the sham.

    It would seem to me that a person showing up at with ‘low back pain’ would be directed to the acupuncturist based on the experimental scientific evidence. One may have a problem with the experimental evidence (personal incredulity, for example). But we must base our judgements on experimental evidence or we have no science.

  22. daedalus2uon 31 May 2009 at 6:51 am

    sonic, you missed the most likely explanation, that the placebo effect is real and has real and long lasting positive health promoting effects. I have talked at length about the physiology behind the placebo effect, how we would actually expect there to be something like it. It represents the normal neurogenic control of physiology and allocation of metabolic resources between the various physiological tasks that an organism is trying to accomplish.

    http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html

    Energy physiology has to be controlled in a feed-forward manner. That is, ATP needs to be generated before it can be used. ATP isn’t stored, the instantaneous ATP production matches the ATP consumption virtually exactly, even as that ATP consumption goes up and down by large amounts (an order of magnitude in some tissues such as the heart).

    Since ATP is used to do just about everything, if the body diverts ATP away from healing so it can better run from a bear, then healing will be adversely affected. This is not pathology per se, it is normal and correct metabolic control simply operating in a parameter space that causes a bad outcome.

    Everything that physiology does has to be under physiological control, that includes healing. When that control system diverts ATP away from healing and holds it in reserve in case it needs to run from a bear, then healing will happen slower and less effectively. That is what we would expect to see under conditions of stress and that is what is observed under conditions of stress.

    We don’t need to postulate any magical or non-physical or non-material “life-energy” to explain any of this, normal physiological effects mediated through normal physiological pathways explains it quite well.

    In your acupuncture example, “real” acupuncture simply is a better placebo than is sham acupuncture. Not a surprise because the people delivering the acupuncture believe it works and so will do a better job of convincing the patients when they think they are doing something therapeutic.

  23. Steven Novellaon 31 May 2009 at 7:25 am

    Sonic – the study you reference showed no statistically significant difference between verum and sham acupuncture. That was the only blinded comparison. That means that acupuncture does not work.

    The comparison to standard therapy was not blinded. We already know that unblinded comparisons result in measured placebo effects. Your conclusion is not rational or scientific – in clinical medicine you cannot draw reliable conclusions from unblinded comparisons.

    Daedalus – you are operating under the fallacy that there is “a” placebo effect. In reality there are multiple placebo effects, and you cannot separate them in this study. While there may be a non-specific physiological response to the ritual of acupuncture, that is not even necessary to explain these results. Confirmation bias, expense justification, and other psychological factors are sufficient. But having said that there probable is nonspecific effects of the therapeutic ritual of acupuncture. The acupuncture itself, however, is not a necessary component of that ritual – as the evidence now clearly shows, including this German study cited by Sonic.

  24. RSon 31 May 2009 at 9:19 am

    What is interesting, but a little bizarre, is that most of these trials include a sham acupuncture arm – indicating that the authors are aware of the need to control for a placebo effect – but when the ‘real’ acupuncture is no better than the sham acupuncture they decide that they’d rather compare it to the unblinded ‘treatment as usual’ (basically ‘no treatment’) arm instead.

    I wonder what the advocates of alternative medicine here would think is all drug trials were run with an active drug arm, a placebo pill arm, and an unblinded treatment as usual arm? Would they accept that a drug that did better than ‘no treatment’ should therefore be prescribed to people, even if it did no better than placebo?

  25. pecon 31 May 2009 at 9:43 am

    The 13 study meta-analysis showed a significant difference between real and sham acupuncture, although sham was also effective. It seems unlikely that acupuncture effects are merely placebo, when you consider the benefits can last for months. By that time, the patient might not even remember they had acupuncture. You also can’t explain why real was better than sham in that meta-analysis. As I said, some kind of unintentional energy healing could be occurring.

    And yes, there is evidence for energy healing but it is not usually published in mainstream journals, since life energy cannot possibly exist. Oh and there was one skeptic’s experiment showing that 20 energy healers, on average, could not detect energy fields. The proves conclusively and beyond possible doubt that all the millions of energy healers are fakes or crazy, and all the successful experiments resulted from fraud or error.

  26. daedalus2uon 31 May 2009 at 10:33 am

    Dr Novella, I don’t at all discount that there are multiple non-physiological effects that mimic the physiological placebo effect. Physiology is extremely complicated. There are many more degrees of freedom than can possibly be addressed with simple trials treating organisms as a “black box”, and only looking at inputs and outputs.

    I think we are arguing past each other. When I use the term “placebo effect”, what I really mean the “physiological placebo effect”, and reserve perceived healing observations not mediated through physiology to their proximate causes, (for example confirmation bias and mistakes). I appreciate that many clinicians do include diagnostic error in what they term the “placebo effect” because it does show up as an improved outcome not due to pharmacology or surgery. My preference is that diagnostic error be kept as a separate entity (even if we don’t know how big it is) so that it can be dealt with separately (at least conceptually), which it can be (to some extent) by having the diagnosis and follow up evaluation done by clinicians blinded to the treatment protocol. When there is good blinding of the diagnosis and endpoint evaluation, the differences between real and sham acupuncture go down but remain distinct from no treatment.

    You are quite correct that in many cases it is not possible to disambiguate which aspects of the trajectory of an individual’s healing path are due to what I call the physiological placebo effect and what is due to confirmation bias. Confirmation bias can be enhanced by the psychological factors, but the physiological placebo effect can also be enhanced by psychological factors.

    I am sure that you would agree that for any psychological effects to influence healing there must be physiology that couples those psychological effects to healing pathways. It is well known that increased psychological stress degrade healing and that psychological stress reduction improves healing. I see the physiological placebo effect as related to the physiology of how stress reduction improves healing. Most of those details are unknown and will remain unknown (for the foreseeable future) because the systems involved are too complicated.

    There are some placebo mediated effects which cannot be explained by confirmation bias. Nausea is made worse by a placebo said to make it better, and made better by the same inert compound said to make it worse. These results were not just subjective; there was simultaneous instrumental measurement of increased gastric motility.

    We know that there are hundreds of thousands or more physiological pathways that utilize ATP. The number of ways those pathways can be combined and regulated in concert is astronomical. We know that all of them are regulated exquisitely well. Which combinations we call the “physiological placebo effect” is to some extent arbitrary and will be idiosyncratically dependent on the idiosyncratic physiologic details of the individual organism under consideration as well as the state of that individual’s physiological control systems (which state is under constant and dynamic change).

  27. daedalus2uon 31 May 2009 at 10:56 am

    pec, no, you have no basis for saying the effects of acupuncture are unlikely to be simply placebo. If placement of needles is not important and needles themselves are not important, what is the physiology behind acupuncture if not the physiological placebo effect? It can’t be chi flowing in meridians because the placement of needles doesn’t matter, and the “needles” don’t need to break the skin, they can be wooden toothpicks.

    If real acupuncture and sham acupuncture produce indistinguishable results, the most parsimonious explanation is that they both work via the same mechanism. If the trials are sufficiently well done that diagnostic error is unlikely, the most parsimonious explanation is they both work by the physiological placebo effect.

    And no, you can’t throw out centuries of scientific progress in chemistry, physics and physiology to postulate some unknown and otherwise undetectable “energy” that would violate much that is well known. Before you can consider an explanation with no evidence that violates well known science, you have to consider and prove inadequate explanations that are consistent with what is well known. The physiological placebo effect does explain all the observations with no need to contradict anything that is well known and well supported.

  28. pecon 31 May 2009 at 8:13 pm

    [you can’t throw out centuries of scientific progress in chemistry, physics and physiology to postulate some unknown and otherwise undetectable “energy” that would violate much that is well known.]

    It doesn’t violate anything that is known. Why do you think the idea of life energy violates science??? Why can’t there be any level of organization higher than the chemical?

    It doesn’t violate science, it violates materialism!

    “you have no basis for saying the effects of acupuncture are unlikely to be simply placebo.”

    The meta-analysis showed that real acupuncture was significantly better than sham acupuncture. And sham acupuncture was significantly better than sugar pills.

    So the most successful treatment was real acupuncture, which suggests that acupuncture is probably not all placebo effect. And my point was that sham acupuncture might not be a good control.

    Why do you think acupuncture would be so powerful as a placebo, with effects that last months?

    You “skeptics” just wanted some excuse to get rid of acupuncture once and for all, since you’re afraid it might violate your science.

  29. HHCon 31 May 2009 at 9:29 pm

    titmouse, When you talk about fighting quakery, the best way given your profession is fighting the real disease or the mental disturbance contributing to the disease. A doctor is not a lawyer. Those of us who have learned the laws and work with it have satisfaction in the way we pursue problems.

  30. daedalus2uon 31 May 2009 at 9:59 pm

    pec, what you call “life energy” would violate the principle of conservation of mass/energy if it had the properties that you say it has.

    There is no unknown “energy” that acupuncture could be affecting without violating the principle of conservation of energy.

    Real acupuncture worked the best, which just shows that real acupuncture is a better placebo than the other sham acupuncture techniques. Of course the best placebo is going to work the best. Why wouldn’t it?

    The best placebo is the one that both the patient and the provider think is a real authentic treatment.

  31. eiskrystalon 01 Jun 2009 at 4:15 am

    -It doesn’t violate science, it violates materialism! -

    Really, i have no words to describe that sentence. Your earlier mixing of atheism and science is also painful on the synapses.

    Energy is energy. It either exists or it does not, it either reacts with the material world or is undetectable. If it is undetectable then it may as well not exist since it has no use. Your magic eneergy would have to have other effects on other materials if it was real and not all in your pretty little head.

    Life energy is chemical in nature. Thats why we need to eat.

    Science will simply evolve and swallow any new ideas that can be proved. Science changes, it just doesn’t change on the whims of a few people who want the world to be full of faeries and magic.

  32. Steven Novellaon 01 Jun 2009 at 7:50 am

    pec – you are misrepesenting the acupuncture literature. For most indications the systematic reviews show no effect of verum acupuncture over sham or placebo acupuncture. For a few indications, like nausea, there is a very weak positive signal – but no high quality studies that show a clear effect.

    That is exactly what we would expect from a placebo treatment. If you look at enough indications, chance alone will produce the occasional positive result. Throw in even a little publication bias and a couple of biased researchers with their thumb on the scale, and that gives you a positive bias in the literature.

    There is a threshold that clinical evidence needs to rise above before we can say that the signal is greater than all the uncertainties in the research. Acupuncture is nowhere near that threshold. If there were a real effect the evidence should be much stronger and more consistent.

    Therapies with better evidence than acupuncture were eventually discarded as useless once truly definitive research was conducted. If acupuncture did not have unscientific supporters it would have been discarded long ago.

    We do not reject acupuncture because of a materialist bias (no matter how many times you repeat that fiction) – we reject it because the evidence is negative. You also miss the point that if the evidence were clearly positive (at least for acupuncture) we could (and people have) imagine a materialist explanation. So your ad hominem fantasies fail at every level.

  33. pecon 01 Jun 2009 at 10:29 am

    “Real acupuncture worked the best, which just shows that real acupuncture is a better placebo than the other sham acupuncture techniques.”

    The patients didn’t know they got real acupuncture, but they felt better months later than the placebo group. According to your logic, no successful treatment could ever be shown to be anything other than placebo.

    “We do not reject acupuncture because of a materialist bias”

    Yes you do — when you call something “implausible” you mean it contracts materialism. And one of the commenters here is worried that what he already knows could be violated. In other words, his materialist bias could be threatened.

  34. Eric Thomsonon 01 Jun 2009 at 12:18 pm

    Thanks for the useful summary, and Titmouse also provides interesting commentary.

    It is very disappointing because the question is simple: are there double-blind clinical trials that show a significant effect? If the answer is no, it isn’t clear what there is to argue about.

  35. HHCon 01 Jun 2009 at 11:10 pm

    titmouse, By the way the ethics which Applebaum proposes are currently under debate by the American Psychological Association. Psychologists are the only profession which continues involvement in the coercive interview settings with military detainees.@:-)

  36. sonicon 02 Jun 2009 at 5:50 am

    I’m sorry I just seem to be missing something.

    I have a problem- low back pain.
    There are three therapies offered-
    a) gets good result about 24% of the time
    b) gets good result about 43% of the time
    c) gets good result about 47% of the time.

    Given the choice of treatment options, I would opt for c). This is due to the fact I don’t like back pain, and would prefer to use the therapy that gets good results the most often.

    Can someone please explain why shoud choose a)?

  37. RSon 02 Jun 2009 at 8:39 am

    “Can someone please explain why shoud choose a)?”

    Because we don’t know how (b) and (c) will translate to clinical practice, which is the point of clinical trials. The placebo response in a trial doesn’t just mean that people ‘feel better’, it can also be due to people naturally getting better, or feeling that they should say they feel better to please the experimenter.

    Otherwise, by your logic, the NHS should be prescribing a whole raft of treatments (c) that were better than doing nothing (a), even though they were statistically no better than placebo (b). For instance, should the NHS pay for antibiotics to treat the common cold – I’m sure that those who receive them (c) report feeling better than those given no treatment (a), even if they’re not statistically different from givign them sugar pills (b) (which could still be better than no treatment at all).

    Basically, you’re rejecting the entire basis of evidence based medicine – you can do that if you want but the cost to the NHS will be enormous and the actual real benefit patients receive from all these treatments is likely to be small if any.

  38. daedalus2uon 02 Jun 2009 at 9:45 am

    They should do a trial where they give people a combination of alcohol, morphine and cocaine. I would bet that they would report feeling better after a few weeks too. Probably not so much after a few years.

    If you don’t know the mechanism for the effects, you don’t know what side effects that mechanism might cause.

  39. Steven Novellaon 02 Jun 2009 at 10:21 am

    Sonic – you are missing the two points I keep making over and over.

    1 – Unblinded comparisons are not reliable. You cannot conclude that group B or C does better than A – we don’t know from unblinded comparisons. They may just report that they do better.

    2 – Even if they actually do better, we cannot say why. The unstated premise of your question is that group C is having one thing done to them, so why not do that one thing. But they are having a dozen things done to them – attention from a health care provider, relaxation, palpation, insertion of needles, etc. We cannot say which of these interventions resulted in the reported improvement.

    But we can say, from this and other evidence – that it is NOT due to inserting needles, and it is NOT due to any attention paid to acupuncture points. Those variables can comfortably be discarded.

  40. tmac57on 02 Jun 2009 at 12:40 pm

    I wish it were ethically possible to administer the various procedures while the patient was unconscious (anesthesia) . This might remove all patient bias. They would have no idea if they even received any treatment. Then if the ‘real’ acupuncture group showed a significant improvement over the others, that might get my attention.
    Maybe you could get people to agree to this just after they had a colonoscopy, and were already out. I realize that this is probably unworkable for various reasons, but the current methods just don’t seem to be convincing enough (to some) to end the debate.

  41. sonicon 02 Jun 2009 at 6:27 pm

    Agreed- unblinded studies are less reliable than blinded studies.
    Agreed- unblinded studies make it difficult to impossible to be certain of the reason for the result.

    With those two statements in place, we have to agree that some therapies do not lend themselves to double-blind experimental protocols. (tmac57 makes the point well)

    This does not automatically mean that those therapies are not useful.

    The question is how to test the usefullness of the therapy that can’t be checked in a double-blind manner.

    At some point, the patients statements as to well being and lack of pain are the only measures we can go by and -perhaps- the only measures that matter. Another measure that is of interest is mobility or flexability (they can be measured objectively) and more studies including those measures would be helpful.

    One problem with the study of back pain, for example, is that we can take MRI’s of the patients and show them to the specialists, but the specialists won’t be able to tell us who is suffering with back pain. That is to say, the reason for the pain is currently not well understood. It is not outrageous to imagine that the reason for relief would be equally not well understood.

    Nobody understands the ‘quantum tunnel effect’ well, but we can still use it to good result. Nobody really understands the ‘collapse of the wave function’ (or even if it happens), but the science that acknowledges that ignorance (physics) is still useful.

    If I have pain I would want my doctor to recommend the treatment that the experiments show gets the best result. I really don’t care if it involves a magic wand. I would think most of the patients would agree with me on that.

    I don’t think that the purpose of science is to give reasons why we must suffer pain without reason. I realize that nobody is advocating that, but sometimes it does seem that way.

  42. pecon 02 Jun 2009 at 8:00 pm

    I agree Sonic. Acupuncture is hard to study this way. It might be more useful to forget about sham controls and instead use some kind of objective measurement, such as days missed from work, or levels of inflammation. Patient reports can be misleading anyway — the placebo group might report less pain because they thought they got the real treatment and didn’t want to disappoint the researchers.

    And other types of energy healing can be, and have been, studied using cell cultures, where of course no placebo is needed.

  43. wertyson 02 Jun 2009 at 11:15 pm

    Sonic

    As someone who makes a living from treating people with back pain, I can tell you that I regard my profession a little more seriously than just uncritically accepting the results of every single article I see, and changing my practice based on the next new study. If you had back pain you could not generalize from the artificial situation of a clinical trial into real life, and you would NOT want me to give you a made up treatment, because that would prevent you from using the single most effective treatment modality for CLBP, which is cognitive-behaviour therapy.

    The caveat for CBT being successful is that the back pain sufferer has to decide that the pain will be amenable to his/her own control, and that they can make changes to their beliefs and attitudes about their pain which will help them to do better in their lives. Simple, but definitely not easy. If you see (as I do so often every week ) people who with the best will in the world continue to seek a magical cure for a problem which will not be curable, you end up seeing them deprive themselves of opportunities to reduce their disability and get on with their lives. Decades of research in LBP have not gotten us as far as we would like, but there is a new tidal wave of sophisticated research on the way which may revolutionize the field the way that H2 anatgonists and the discovery of H Pylori revolutionized the understanding and treatment of stomach ulcers when I was a medical student.

    These gains will not be make by magical thinking, and they will not be made by taking a wishful and whimsical approach to tackling the problem. I can personally guarantee you pec, that these advances will not be brought about by energy fields or have anything to do with quantum mechanics.

  44. sonicon 03 Jun 2009 at 4:09 am

    wertys

    I can assure you that I am not interested in ‘made up’ treatments. I agree that you should not change your practice based on every study you see.
    I am interested in what you are talking about and admit an ignorance of the use of CBT for this purpose-
    Links for more info? please.

    (Just a note- Quantum mechanics is actually physics- advances in science usually have something to do with physics.)

  45. daedalus2uon 03 Jun 2009 at 5:52 am

    sonic, yes, quantum mechanics is physics. Advances in science usually do have something to do with physics. The supposed connection between CLBP and quantum mechanics is made by people who understand neither.

  46. Steven Novellaon 03 Jun 2009 at 2:00 pm

    Sonic – but we can test acupuncture in a blinded way – with sham and placebo acupuncture. And these results show that acupuncture does not work.

    You are recommending what the acupuncture proponents have started doing – backing off to lower grade unblinded trials because that is where they can get positive results. -

  47. pecon 03 Jun 2009 at 8:21 pm

    “I can personally guarantee you pec, that these advances will not be brought about by energy fields or have anything to do with quantum mechanics.”

    Were you given that information direct from God?

  48. artfulDon 03 Jun 2009 at 8:41 pm

    I received the same information by spontaneous conception.

  49. sonicon 05 Jun 2009 at 2:57 am

    If I told you my example was from headache tests
    a) no treatment,
    b) sugar pill, and
    c) aspirin
    would that change your thinking?

    It is possible to test acupunture with some blinding, but it can not be tested double-blind (as far as I know).

    To say a therapy works is not to validate any concept of mechanism the practioner might want to promote.

  50. Steven Novellaon 05 Jun 2009 at 7:52 am

    You can do a double-blind test of acupuncture – there are fake acupuncture needles with opaque sheaths and plungers, so that the acupuncturist does not know if the needle is going in or not.

    So far – these studies have been negative.

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