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Its been a while since we discussed acupuncture. I thought this was jolly interesting so i thought i'd share
Quote:
Ben Goldacre
The Guardian
Saturday September 29 2007
One thing that always fascinates me, as I tug on my pipe in this armchair, is how reductionist, how mechanical, how sciencey and medical we like our stories about the body to be. This week a major new study was published on acupuncture. Many newspapers said it showed acupuncture performing better than medical treatment: in fact it was 8 million times more interesting than that.
They took 1162 patients who had suffered with back pain for an average of 8 years (so these were patients who had failed with medical treatment anyway) and divided them into 3 groups. The first group simply had some more medical treatment; the second group had full on acupuncture with all the trimmings, the needles all put carefully into the correct “meridiens” in accordance with ancient Chinese stuff, and so on; while the third group just had some bloke pretending to be an acupuncturist, sticking needles in their skin at random. The study set a threshold for “response to treatment”, which was an improvement of 33% on 3 items out of a bigger scale, or 12% on one symptom scale. So this was not “getting better”, or a “cure”.
I’m not carping, I’m just telling you what they measured. And what were the results? Firstly, 27% of the medical treatment group improved: this is an impressive testament to the well known healing power of simply “being in a trial”, since medical treatment hadn’t helped these patients for the preceding 8 years. Meanwhile 47% of the acupuncture group improved, but the sting is this: 44% of the fake acupuncture group improved too. There was no statistically signficant difference between proper, genuine ancient wisdom acupuncture, and fake, “bung a needle in, anywhere you fancy, with a bit of theatrical ceremony” acupuncture.
There are three possible explanations for this finding. One is that sticking needles in your body anywhere at random helps back pain due to some physiological mechanism. The second is that theatrical ceremony, reassurance, the thought of someone doing something useful, and a chat with someone nice helps back pain. (The third option is “a bit of both”).
Now as I have said so many times before, the placebo effect is not about a sugar pill, it’s about the cultural meaning of a treatment, and our expectations: we know from research that two sugar pills are more effective than one, that a salt water injection is better for pain than a sugar pill, that colour and packaging have a beneficial effect, and so on. Interestingly, there has even been a trial on patients with arm pain specifically comparing a placebo pill against a placebo ritual involving a sham medical device, modelled on acupuncture, which found that the elaborate ritual was more effective than the simple sugar pill. “Placebo” is not a unitary phenomenon, there is not “one type of placebo”.
But the most important background information missing from the news reports wasn’t about the details of the study: it was about back pain. Because back pain isnt like epilepsy or tuberculosis. Most of the big risk factors for a niggle turning into chronic longstanding back pain are personal, psychological, and social: things like depression, job dissatisfaction, unavailability of light duty on return to work, and so on.
And the evidence on treatments tells an even more interesting psychosocial story: sure, anti-inflammatory drugs are better than placebo. But more than that, bed rest is actively harmful, specific exercises can be too, and proper trial data shows that simply giving advice to “stay active” speeds recovery, reduces chronic disability, and reduces time off work.
We don’t like stories and solutions like that for our health problems. There are huge industries telling you that your tiredness is due to some “chromium deficiency” (buy the pill); your cloudy headed foggy feeling can be fixed with vitamin pills, pills, and more pills. It is a brave doctor who dares to bring up psychosocial issues for any complaint when a patient has been consistently told it is biomedical by every newspaper, every magazine, and every quack in town.
But in conditions like back pain or fatigue, information alone can make a difference to the suffering of millions. In Australia, a simple public information campaign (“Back Pain: don’t take it lying down”, arf) was shown to reduce back pain significantly in the whole population. Meanwhile journalists, patients, quacks, politicians and editors would all rather talk about magical, technical pills and rituals.
References:
Here is the paper which compares two different placeboes, a placebo pill in one arm, against an elaborate placebo ritual involving a sham medical device modelled on acupuncture:
Re: Notparticularlyrelevantnewsbot-Acupuncture and back pain
Hello Robert-
You do right bringing this to the attention of the Arena.
No time for an in depth comment at the moment, suffice to say that Ben Goldacre writes lucidly, clearly, and carries out an excellent service to the public in spreading proper understanding about science.
We have a constant struggle, particularly in the printed press, with poorly reported medical research time after time, which does nothing but confuse the public. Newspapers do have a tendancy to portray orthodox medicine as cold and uncaring (Nasty scientists!!), and at the same time show 'alternative' practitioners in an altogether 'friendlier' light.
Writing like this goes a long way toward countering the effects of this, but unfortunately, the coverage of national newspapers will eclipse the coverage of writing like Goldacre's, and the public may easily be mis-informed.
Thanks for sharing Robert - Spread the word!!
__________________
Kind regards
Gavin Wylie
Podiatrist (Paediatrics),
Perth Royal Infirmary,
Perth, UK
Re: Notparticularlyrelevantnewsbot-Acupuncture and back pain
I cannot speak to the placebo effect on treatment of chronic pain. I can, however, speak to the chronic pain that was alleviated after acupuncture treatment for recurrent Morton's neuromae in both feet. I have had four surgical procedures to remove neuromae in the past five years, two on the same spot of the same foot! Each time the surgery was successful and removed a sizable mass. The pain never left and continues to be problematic. It has caused problems in my personal life and professional career. As a last resort I went to an acupuncturist —anything to stop the pain and to help me walk. I felt relief after the first session and have walked without a limp or major discomfort for nearly four months. I have been converted into a walking advertisement for acupuncture.
I do not discount anything that my podiatrist did. He followed protocol each time and was as frustrated as was I with the recurrence of neuroma in my feet. Orthotics help and surgery was needed. But acupuncture has given me a quality of life that I had started to tell myself was no longer possible. It was no placebo, I watched the doctor insert the needles each time.
How it works is a mystery. I am grateful to the Ancients for their study and their persistence that still works today.
Re: Notparticularlyrelevantnewsbot-Acupuncture and back pain
Whilst being delighted that you are now relieved of the pain from which you were suffering, unfortunately, your experience proves nothing in the overall picture.
If the secondary mass which you describe was identified by a histo-pathologist as consistent with a neuroma then it suggests stump neuroma rather than re-growth which is not possible in these tissues. On the other hand it may have been a bursa or some other neoplasm. If the neuromata were fully removed then the pain may have been due to some other factor. Were these other factors fully investigated?
You say that there was definitley no placebo effect becuse you 'watched the doctor insert the needles each time'. Might that not be a placebo effect per se?
I am open minded about the effects of acupuncture, but I think from just these few remarks that you will appreciate that there are an enormous number of variables which have to be assessed. In the wider world of medicine it is simply not possible to state 'it worked for me, ergo, it is a fully recognised treatment with an accepted rationale'. We have to show how and why it works and the best method yet arrived at is a Random Controlled Trial. Sadly, many treatments which have been shown to be efficacious on individuals, rapidly fail at this hurdle, frequently because of the placebo effect.
To put it crudely, if patient belief were the only criteria then like the Saxons we would still be hanging dog faeces around the necks of our patients to drive out infection. It proved to be effective because by and large people recovered and therefore created a belief system.
Having said that, I am delighted that you have recovered, but instead of appealing to your sense of superstition (the mystery of the ancients to which you refer) wouldn't you really like to know how and why the treatment worked?
Re: Notparticularlyrelevantnewsbot-Acupuncture and back pain
Quote:
like the Saxons we would still be hanging dog faeces around the necks of our patients to drive out infection.
You mean that DOES'NT work?!?! Dammit. Well thats my bit of holistic medicine bu**ered then. I've been doing that for years! Its good for VP's as well apparently.:p
Re: Notparticularlyrelevantnewsbot-Acupuncture and back pain
Quote:
Originally Posted by jpb63
I cannot speak to the placebo effect on treatment of chronic pain. I can, however, speak to the chronic pain that was alleviated after acupuncture treatment for recurrent Morton's neuromae in both feet. I have had four surgical procedures to remove neuromae in the past five years, two on the same spot of the same foot! Each time the surgery was successful and removed a sizable mass. The pain never left and continues to be problematic. It has caused problems in my personal life and professional career. As a last resort I went to an acupuncturist —anything to stop the pain and to help me walk. I felt relief after the first session and have walked without a limp or major discomfort for nearly four months. I have been converted into a walking advertisement for acupuncture.
I do not discount anything that my podiatrist did. He followed protocol each time and was as frustrated as was I with the recurrence of neuroma in my feet. Orthotics help and surgery was needed. But acupuncture has given me a quality of life that I had started to tell myself was no longer possible. It was no placebo, I watched the doctor insert the needles each time.
How it works is a mystery. I am grateful to the Ancients for their study and their persistence that still works today.
One anecdote deserves another-my father tried acupuncture for chronic back pain, and it didn't work.
__________________
Kind regards
Gavin Wylie
Podiatrist (Paediatrics),
Perth Royal Infirmary,
Perth, UK
Re: Notparticularlyrelevantnewsbot-Acupuncture and back pain
Thanks Robert,
Every so often Robert starts up a thread on acupuncture and having used this modality for 16 years I usually rise to the bait and make a few comments
(obviously I've not altered Robert's opinion yet).
Well Robert you wrote:
Quote:
the second group had full on acupuncture with all the trimmings, the needles all put carefully into the correct “meridiens” in accordance with ancient Chinese stuff, and so on; while the third group just had some bloke pretending to be an acupuncturist, sticking needles in their skin at random.
Some time ago during the "Cultural Revolution" Chairman Mao had umpteen thousand "bare foot doctors" trained up in acupuncture. Acupuncture changed from an art for which practitioners trained under masters for many years learning to palpate for tender points in the body and "energy balancing" points on fairly vague meridians (alternative spelling) which were only based on generalized gross anatomy into a rote learnt system of very specific points and meridians aligned with the modern anatomical skeletal system. The "real" ancient Chinese stuff (not as correct as you'd imagine) has survived in many places and emerging in the west. The very dogmatic TCM (Traditional Chinese Medicine) guys (who have been caught up in the point specificity system developed for mass education) will, I think, not prevail under scientific scrutiny.
There is no doubt that the body is aware consciously and unconsciously of real needles being inserted into it. "Sham" acupuncture is becoming less favoured as a research method as western medical acupuncturists practice without meridians and some such as Felix Mann go about breaking all the rules. It is not surprising that "sham" acupuncture works about the same as TCM.
What is today called "dry needling" and used for the deactivation of myofascial trigger points is still a acupuncture of trigger points as was done in the past. I just think that modern anatomy and myotomal charts have made it a lot easier to practice.
So, I'm still very happy getting better than an enhanced placebo effect in my chronic pain patients, using this modality in combination with some manual therapy and orthotic therapy. Quite a complementary mix.
Re: Notparticularlyrelevantnewsbot-Acupuncture and back pain
Quote:
Every so often Robert starts up a thread on acupuncture and having used this modality for 16 years I usually rise to the bait and make a few comments
(obviously I've not altered Robert's opinion yet).
You love it.
I'm going to see martin harvey at a biomechanics get together in jan and we're going to have a play with prolotherapy (among other things) . I beleive he does dry needling, who knows perhaps he'll convince me.
Re: Notparticularlyrelevantnewsbot-Acupuncture and back pain
Hi Rob,
Quote:
You love it.
I can't resist.
Quote:
'm going to see martin harvey at a biomechanics get together in jan and we're going to have a play with prolotherapy (among other things) . I beleive he does dry needling, who knows perhaps he'll convince me.
I've not done any prolotherapy. From what I have seen, I'd say I could do the same with dry needling/acupuncture with far less trauma to the recipient for quite a bit of that, but they also do stuff that I don't do and so am interested in getting a closer look sometime.
Also on the dry needling of trigger points: the results are so obvious and so quick that you'd be an easy convert.
I've just run a workshop or 3 and with a larger group you will always have some good demonstrable results. I'll also say that "sham" dry needling will not go close to the expert location of a needle into a palpable trigger.
If Martin has a copy have a look at Travell and Simons.
Have fun - wait until folk pay you to just stick needles into them all day!
Notparticularlyrelevantnewsbot-Acupuncture and back pain
. Well thats my bit of holistic medicine bu**ered then. I've been doing that for years! Its good for VP's as well apparently.:p
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