Aug 20 2010

More Evidence that Acupuncture is a Placebo

I have written numerous blogs both here and on SBM about the acupuncture literature, which clearly shows that acupuncture, for any indication, is nothing but an elaborate placebo. Rigorous studies of acupuncture that actually try to isolate variables have shown that it does not matter where you stick the needles or even if you stick the needles – those variable do not have any specific effect. Acupuncture points and meridians are an illusion – nothing but superstition.

But there does appear to be a significant placebo effect, in addition to non-specific effects from relaxation and therapeutic attention, to the ritual of acupuncture. Does this mean “fake acupuncture works?” No – it means acupuncture does not work, but there are known placebo effects from the process of getting treated.

Now we have yet another study that supports the conclusion that acupuncture is just a placebo – but with an added element that is very interesting. Researchers compared traditional Chinese acupuncture (TCA) with sham acupuncture (non acupuncture points, shallow needle insertion) and another control group with no treatment for knee osteoarthritis. The researchers also did one very interesting thing, and one very sloppy and annoying thing (in my opinion). The sloppy thing was to use “electroacupunture” – which isn’t pure acupuncture. It’s acupuncture plus transcutaneous electrical nerve stimulation, which is an already proven modality for pain. In the TCA group they gave full “electroacupuncture” and in the sham group they gave less stimulation – enough to serve as an active placebo but not enough to have any effect.

This is problematic because it adds a variable that was unnecessary. In addition, I am disturbed by how stealthy this was – you can read the abstract and have only the slightest clue that this is a study of “electroacupuncture”. The authors clearly are equating “electroacupuncture” with acupuncture, which is not reasonable. It conflates two treatments, and makes for bad research.

In this particular study the TCA and sham groups had the same effect, and both were greater than the no intervention group. From this we can conclude that either both treatment groups had no physiological effect on pain, and the entire effect was due to placebo effects. Or we can conclude that both groups had placebo effects plus a similar effect from the electrical stimulation, despite the difference in intensity. There is no way to tell, which is why the addition of the electrical stimulation modality was a mistake.

However, the researchers also did something very interesting which I think is independent of their mistake with the electrical stimulation – they also altered another variable, the interaction between the acupuncturist and the subject. They split the treatment groups into “high” or “neutral” expectations. Essentially, either the acupuncturist said they had great success with this treatment, or they said that the treatment may or may not work. This is what they found:

455 patients who received treatment (TCA or sham) and 72 controls were included. No statistically significant differences were observed between TCA or sham acupuncture, but both groups had significant reductions in J-MAP and WOMAC pain compared to the waiting group (-1.1, -1.0, and -0.1, p<0.001; -13.7, -14, -1.7, p<0.001). Statistically significant differences were observed in J-MAP pain reduction and satisfaction, favoring the ‘high’ expectations group. Fifty-two percent and 43% in the TCA and sham groups thought they had received TCA (kappa=0.05), suggesting successful blinding.

So acupuncture does not work, but a positive attitude on the part of the acupuncturist does. This supports the conclusion that a significant portion of the effect measured in this trial is due to placebo effects.

This is not a perfect study, but it adds to the growing literature that is consistently showing that acupuncture does not work and is nothing more than an elaborate placebo. As we saw in a recent NEJM review, however, this kind of research is being used to recommend TCA – complete with acupuncture points and all the superstition that has been repeatedly disproven by research. At this point we can comfortably dispose of any notion of acupuncture points – they do not exist. They never had any scientific plausibility, and it is not surprising that research cannot demonstrate their existence (let alone clinical utility), and in fact strongly shows that they do not exist.

Further, clinical research also shows that it does not matter if you stick needles through the skin – simulating acupuncture by poking the skin with toothpicks or dull needles is sufficient. What does matter is the interaction between the acupuncturist and the patient. This is something that has been known for decades – that a positive therapeutic interaction will have non-specific placebo effects in the patient’s perception of their symptoms and well-being. That is precisely why we do placebo-controlled trials.

But proponents of acupuncture and other “alternative” modalities want to live in a bizarro world where placebo effects are used to justify a specific treatment. New York Times writer Tara Parker-Pope covered this article, writing:

The results don’t mean acupuncture doesn’t work, but they do suggest that the benefits of both real and fake acupuncture may have something to do with the way the body transmits or processes pain signals. Other studies have suggested that the prick of a needle around the area of injury or pain could create a “super-placebo” effect that alters the way the brain perceives and responds to pain.

Actually, these results do mean that acupuncture does not work. When you compare a treatment to a placebo treatment and there is no difference, that means the treatment does not work – it is not adding anything to the placebo.  The math is simple: treatment = treatment effect + placebo. Sham treatment = placebo.  Then you simply subtract the latter from the former: treatment effect + placebo – placebo =  treatment effect, which in this case = zero, zip, nada – no treatment effect, which means that acupuncture does not work.

CAM proponents have pulled a Jedi mind trick on the media and large portions of the public, however, and convinced them that no treatment effect = an effective treatment. This nonsense is infiltrating academia and medicine because proponents were never very good at thinking scientifically (apparently, since they think magical superstition works) and most everyone else is a shruggie who is content to look the other way because they don’t see a threat. The public then thinks it’s all legitimate because they read about it in the NY Times referencing articles in the New England Journal of Medicine.

At least I can rant about it whenever it happens.

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