Comments on: Acupuncture and back pain: some interesting background references

By: danleywolfe

danleywolfe — Mon, 26 Sep 2011 19:37:18 +0000

One of the wonderful things about blogs like this one is the range of responses and opinions that are given and that they are timeless or you might say cumulative over time … learning on learning. As a former acupuncture patient (treatment of ideopathic neuropathy) I can say that I found only incremental and temporal relief that is after treatment stops there was a return to the original condition. I am unable to judge and there is not enough evidence to make inferences as to whether the treatment caused an improvement or a placebo effect was at work. There is no question that electro – needling stimulates the nerve channels running from the neck to the pinkies. And little doubt that distal symmetric primarily axonal (rather than demyelinating ) sensory “dying back” neuropathy involves a disabling of nerve transmission. So the theory goes that acupuncture can juice up the nerves involved, at least temporarily. by the way the German paper now is available to the public free of charge at: archinte.ama-assn.org/cgi/content/full/167/17/1892

By: Pierre de Lasteyrie

Pierre de Lasteyrie — Wed, 26 Jan 2011 23:45:09 +0000

Hiyaa,

I’ll try to share my doubts about acupuncture using a different perspective:

If you want a therapy to be effective you need a balance between the diagnostic and treatment capabilities. In fact you should have more diagnostic tests that treatment techniques. Why is that ? Because for each “treatment technique” you need a diagnostic test to tell you that you need this technique applied to that area. Theoretically you even need more diagnostic techniques in order to delimit the capabilities of the therapy itself.

If you don’t have enough diagnostic tests but too many treatment possibilities, your therapy will be like playing darts with a blind fold!

For example in modern medecine you have blood test, BP, spirometer, ECG, EEG, MRI, Xray, orthopedic test, palpation…Each variation within the results will imply a different treatment and the range of treatment is pretty big too (pills, physio, casts, diet advice, dialysis, surgery…)

What about acupuncture ?
During a session you will “stab” about 10 needles and there is 350 points of acupuncture (2000 if we follow more recent trends). If we consider that each point could be stabbed (because this therapy is really holistic) it means that there is 350!/340! different possible treatments. If I am not wrong this is equals to 2.4 x 10^25 possible treatments or 24 000 000 000 000 000 000 000 000 (1,0 x 10^33 with the 2000 acupuncture points)!!! The number of different possible treatments is enormous.

Now Let’s have a look at the diagnostic capabilities of acupuncture:
4 pulses sites(?) with 3 different depths. 7 possible colours in the tongue, eyes and cheeks and 10 questions with 7 different answers possible.
If we settle on these, this is 7.8 x 10^12 different diagnostic possibilities.

You can add a few tests if you wish. But for the moment the ratio is 1 diagnostic test for 3 x 10^12 possible treatments: You will need a bit more than luck to get the right treatment…

By: JustMe

JustMe — Wed, 30 Jun 2010 23:23:34 +0000

It appears to me that people are not subjecting Ben Goldacre’s views to the same kind of critical appraisal he is advocating. I agree with much of what Dr Goldacre says in terms of EBM, but whilst it should form the foundation of research and medicine, it is not perfect. The views expressed by Dr Goldacre are all being supported with attempting to question whether there are in fact other reasons why this may actually be a positive result. This shouldn’t be viewed as a study which demonstrates that acupuncture is no more effective than sham acupuncture (which one person above comments “is NOT acupuncture”. This highlights the ignorance and lack of thought that is given when interpreting results, even in a community that believe themselves to be proficient in critical appraisal. This study actually shows pretty much NOTHING…..not one way or another. If it does show anything, it shows that the theory of meridians is probably flawed. However, it also shows that actually just putting several needles into the skin is beneficial. Placebo? Maybe yes, maybe no. It may well also be that the needling actually results in physiological changes (such as endorphin release) which benefit pain. It maybe that regularly doing this allows a physiological state of relaxation to be achieved…I wonder how many people have actually tried acupuncture? The lesson of Dr Goldacre’s views are certainly beneficial, we should all seek to be critical but it should not be “critical” in the sense that all positives should be dismissed as nonsense purely in a bid to sound like a “good scientist”. If we are to “appraise”, the correct way is to debate both sides of the argument and offer a fair interpretation. The comment at the top which says ” I was ranting about the sort of people who get chronic back pain being just the sort who might be susceptible to placebo this morning as soon as I heard the study” – sums this all up, a sweeping statement that implies that people who have chronic pain are just mad, depressed people who are suggestible enough to “fall” for the placebo effect (despite Dr Goldacres statement about the complexity of the placebo effect). Everyone of us is susceptible. Despite how much your ego may be telling you you are different, your mind stronger, you are not.

By: Snuggie

Snuggie — Fri, 05 Feb 2010 08:52:04 +0000

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By: diudiu

diudiu — Mon, 21 Dec 2009 05:43:14 +0000

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By: MJJMZ60

MJJMZ60 — Tue, 11 Aug 2009 13:32:35 +0000

Pain is a difficult item to measure. What about papers where measurable things were measures, such as WBC?

For example the following study (From Medline!)

Lu W, Matulonis UA, Doherty-Gilman A, Lee H, Dean-Clower E, Rosulek A, Gibson C, Goodman A, Davis RB, Buring JE, Wayne PM, Rosenthal DS, Penson RT.

Leonard P. Zakim Center for Integrative Therapies, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA. Weidong_lu@dfci.harvard.edu

OBJECTIVES: The objective of this study was to investigate the effect of acupuncture administered during myelosuppressive chemotherapy on white blood cell (WBC) count and absolute neutrophil count (ANC) in patients with ovarian cancer. DESIGN: This study is a pilot, randomized, sham-controlled clinical trial. Patients received active acupuncture versus sham acupuncture while undergoing chemotherapy. A standardized acupuncture protocol was employed with manual and electrostimulation. The frequency of treatment was 2-3 times per week for a total of 10 sessions, starting 1 week before the second cycle of chemotherapy. SETTING: The setting was two outpatient academic centers for patients with cancer. SUBJECTS: Twenty-one (21) newly diagnosed and recurrent ovarian cancer patients were the subjects. OUTCOME MEASURES: WBC count, ANC, and plasma granulocyte colony-stimulating factor (G-CSF ) were assessed weekly. RESULTS: The median leukocyte value in the acupuncture arm at the first day of the third cycle of chemotherapy was significantly higher than in the control arm after adjusting for baseline value (8600 cells/microL, range: 4800-12,000 versus 4400 cell/microL, range: 2300-10,000) (p = 0.046). The incidence of grade 2-4 leukopenia was less in the acupuncture arm than in the sham arm (30% versus 90%; p = 0.02). However, the median leukocyte nadir, neutrophil nadir, and recovering ANC were all higher but not statistically significantly different (p = 0.116-0.16), after adjusting for baseline differences. There were no statistically significant differences in plasma G-CSF between the two groups. CONCLUSIONS: We observed clinically relevant trends of higher WBC values during one cycle of chemotherapy in patients with ovarian cancer, which suggests a potential myeloprotective effect of acupuncture. A larger trial is warranted to more definitively determine the efficacy of acupuncture on clinically important outcomes of chemotherapy-induced neutropenia.

By: RichardCarter

RichardCarter — Tue, 26 May 2009 23:53:23 +0000

I seem to have maligned The Observer: it turns out this ludicrous thing is true and NICE have, according to the BBC website anyway (news.bbc.co.uk/1/hi/health/8068427.stm), confirmed that they are recommending acupuncture (among other useless ‘remedies’) for the ‘treatment’ of back pain.

The report says that NICE are saying that “anyone whose [back] pain persists for more than six weeks and up to a year should be given a choice of several treatments, because the evidence about which works best is uncertain.” I love he last bit!

By: RichardCarter

RichardCarter — Sun, 24 May 2009 22:45:10 +0000

…. and now we read, from The Observer’s Health Correspondent no less, that back sufferers to receive acupuncture on the NHS – and, worse, that NICE is apparently going to recommend this!

Story here: www.guardian.co.uk/society/2009/may/24/back-pain-sufferers-acupuncture-nhs

Interestingly, The Guardian/Observer’s website had a story, on 12 May only, to the effect that simulated acupuncture using toothpicks pressed against skin was just as effective as “real” acupuncture:
www.guardian.co.uk/lifeandstyle/besttreatments/2009/may/12/acupuncture-needles-can-improve-back-pain-and-so-can-toothpicks

This appears to be based on a different BMJ paper than the 2006 one that Ben discusses above, but evidently with the same results. I wonder what NICE will have to say about this (if, indeed, The Observer report is accurate, not something I’d bet the farm on, given that paper’s previous form).

By: malucachu

malucachu — Sat, 13 Dec 2008 11:10:00 +0000

Physiotherapy is a profession, not a treatment!

Now that we have got that out of the way, let me explain my place in this circus. I am a physiotherapist with a particular interest in Low Back Pain (co-author of ‘The Management of Low Back Pain in Primary Care’ ISBN 0 7506 4787 6 – now out of print, but available in many medical libraries).

IMHO, physiotherapy is simply about motivating patients to follow the best available guidelines and advice on self care. It’s that simple.

However many physiotherapists have spent a great deal of time and money learning quasi-medical treatments and thus have a vested interest in making treatment care complicated and full of gobbledygook.

The good news is that this way of thinking is thankfully changing, albeit slowly.

By: emilypk

emilypk — Fri, 16 Nov 2007 18:29:52 +0000

I had an interesting thought today. What if these unsuccessfuly treated sufferers tended to have a history of using drugs that work via opiod receptors. Given that it is suggested that acupuncture operates via the same pathways they might be ‘immune’ to the potential benefits beyond placebo?

By: emilypk

emilypk — Tue, 13 Nov 2007 16:51:49 +0000

On the issue of vetwoo, thought this might interest-slash-amuse: vetpath.co.uk/voodoo/

By: RS

RS — Wed, 03 Oct 2007 20:38:13 +0000

But as soon as a human is involved you are susceptible to the placebo effect – which was my point.

By: emilypk

emilypk — Wed, 03 Oct 2007 20:15:14 +0000

It was an answer to the ‘you can’t ask’ statement which implies that pain can’t be diagnosed in the non-verbal subject. Cortisol typically increases in response to pain and has been used to assess lameness adn post-op pain in famr and zoo animals.

I don’t know if they are doing a formal analysis of the effectiveness, but they certainly could.

By: RS

RS — Wed, 03 Oct 2007 19:31:34 +0000

kim, the same could be said for any medical procedure, veterinary or otherwise, but we know that without blinding doctors assessing the patients will ‘detect’ lower levels of pain (which is the whole problem with non-objective measurements).

And I note that there is no evidence being presented here that acupuncture has helped these arthritic monkeys – so I don’t know what the talk of cortisol has to do with anything.

By: kim

kim — Wed, 03 Oct 2007 19:02:04 +0000

RS – well, presumably the same way you’d determine whether any veterinary procedure has worked.

By: emilypk

emilypk — Wed, 03 Oct 2007 18:30:25 +0000

You can however observe whether there is a return to normal movement, activites and socialisation as well as measure cortisol or other stress hormones in the faeces. On the whole speech is one of the less reliable pain indicators.

By: RS

RS — Wed, 03 Oct 2007 17:26:26 +0000

emilypk – the whole point is who determines whether the animal has gained any benefit? You can’t ask it!

By: emilypk

emilypk — Wed, 03 Oct 2007 13:22:00 +0000

Since the animal is an exotic one on exhibit with minimal human contact I suspect it would. The only significant human contact would be during the procedure itself.

By: RS

RS — Wed, 03 Oct 2007 08:05:58 +0000

Since in animals the placebo effect is on the owners – anaesthetising the animal won’t make any difference.

By: emilypk

emilypk — Tue, 02 Oct 2007 20:04:17 +0000

but can a placebo work while you are unconscious?