I was just on Radio 4’s PM program talking about the acupuncture study that’s in the news today, you can listen to it here (37 minutes in to the programme):
Here are some references and background bits and bobs.
The paper itself was very interesting. It took 1200 people, with an average of 8 years back pain each: we can assume not been helped by biomedical treatments. They were split into three groups: one group had medical treatment; one group had proper, real, bells and whistles, needles in the “meridiens” acupuncture; and one group were treated with pretend acupuncture.
The results were fascinating: they set a threshold for “improved” (which was either a 33% improvement in 3 aspects of one score, or 12% improvement on another measuring scale). They found that people having acupuncture were almost twice as likely to reach this level of improvement in back pain as people on medical treatment (which had already let them down for 8 years of course). But even more interestingly, the pretend acupuncture group, where they just bunged needles in any old place with a bit of ceremony, did just as well as the people having proper, posh, theatrical, genuine acupuncture.
The press release is here, and the full academic paper is here:
archinte.ama-assn.org/cgi/content/full/167/17/1892
I’ll try tomorrow to encourage them to make it free as always.
[edit 26/9/07: the American Medical Association have basically said no I think.]
I’ve written about the placebo before, how it about much more than a pill, but is about the cultural meaning of a treatment, our expectations, and more. It’s worth seeing these fascinating acupuncture results in that context:
Here’s what I wrote just last week on the subject:
There’s nothing inherently wrong with the idea of giving out sugar pills. The placebo effect can be very powerful, because it’s not just about the pill, it’s about the cultural meaning of the treatment: so we know from research that four placebo sugar pills a day are more effective than two for eradicating gastric ulcers (and that’s not subjective, you measure ulcers by putting a camera into your stomach); we know that salt water injections are a more effective treatment for pain than sugar pills, not because salt water injections are medically active, but because injections are a more dramatic intervention; we know that green sugar pills are a more effective anxiety treatment than red ones, not because of any biomechanical effect of the dyes, but because of the cultural meanings of the colours green and red. We even know that packaging can be beneficial.
It’s also really worth checking out this fascinating paper, comparing two different placeboes: a placebo pill, up against an elaborate placebo ritual involving a medical device (it was modelled on acupuncture). They found that the more elaborate placebo ritual was more effective than the tablet.
www.bmj.com/cgi/content/full/332/7538/391
More even than that, I think back pain is incredibly interesting: in 90% no cause is found, and we know that things like psychosocial stressors, work problems, bed rest and depressive symptoms are significant risk factors for moving from a twinge to chronic enduring pain. There is no doubt that eg brief educational interventions (don’t avoid exercise, do avoid rest, do avoid specific exercises) are helpful.
Back pain is clearly a problem which requires more than simply pharmaceutical pills. The question is whether an elaborate, expensive, gimmicky and theatrical placebo ritual is an effective use of money, or whether other, cheaper, more pragmatic, honest psychosocial interventions might be more appropriate and cost effective.
Here is an excellent review of causes and treatments for back pain, setting out the clear evidence for keeping active, avoiding rest, and the role of psychosocial factors in the move from acute to chronic. I’ve pulled out some key quotes for people with lazy clicking fingers.
www.bmj.com/cgi/content/full/332/7555/1430
What are the most important prognostic indicators for chronicity?
Early identification of patients with low back pain at risk for long term disability and sick leave is theoretically and practically important because early and specific interventions may be developed and used in this subgroup of patients. This is of special importance because recovery for people who develop chronic low back pain and disability is increasingly less likely the longer the problems persist.
The transition from acute to chronic low back pain seems complicated, and many individual, psychosocial, and workplace associated factors may play a part. In this respect, increasing evidence indicates the importance of psychosocial factors.w7 A recently published systematic review of prospective cohort studies found that distress, depressive mood, and somatisation are associated with an increased risk of chronic low back pain.13
Table 1 shows a list of individual, psychosocial, and occupational factors, which have been identified as risk factors either for the occurrence of low back pain or for the development of chronicity. “Yellow flags” have been developed for the identification of patients at risk of chronic pain and disability. A screening instrument based on these yellow flags has been validated for use in clinical practice.14 The predictive value of the yellow flags and the screening instrument need to be further evaluated in clinical practice and research.
How effective are treatments in acute low back pain?
The evidence that non-steroidal anti-inflammatory drugs relieve pain better than placebo is strong. Advice to stay active speeds up recovery and reduces chronic disability. Muscle relaxants relieve pain more than placebo, strong evidence also shows, but side effects such as drowsiness may occur. Conversely, strong evidence shows that bed rest and specific back exercises (strengthening, flexibility, stretching, flexion, and extension exercises) are not effective. These interventions mentioned were equally as effective as a variety of placebo, sham, or as no treatment at all. Moderate evidence shows that spinal manipulation, behavioural treatment, and multidisciplinary treatment (for subacute low back pain) are effective for pain relief. Finally, no evidence shows that other interventions (for example, lumbar supports, traction, massage, or acupuncture) are effective for acute low back pain.3
|
Treatment
Recommended—Cognitive behaviour therapy, supervised exercise therapy, brief educational interventions, and multidisciplinary (biopsychosocial) treatment, short term use of non-steroidal anti-inflammatory drugs and weak opioids.
kim said,
September 27, 2007 at 4:32 pm
buffalo66 – I think that’s a good summary of their arguments. And I think that the assumptions they make are made in the interests of fairness. If they were to say (and this, as I understand it, is Ben’s argument) “The placebo effects of acupuncture are stronger than the placebo effects of conventional treatment”, they would just be making another assumption, again without evidence.
Of course, they could have said, “Maybe the placebo effects of acupuncture are stronger than those of conventional treatment, and maybe they’re not” but what scientist is going to admit to that degree of doubt in a published paper?
buffalo66 said,
September 27, 2007 at 4:55 pm
kim – i don’t think it would have harmed them to say that they couldn’t determine whether the effects of acupuncture were pure placebo or not. They still had some very interesting findings – acupuncture is better than conventional therapy, but no better than having someone shove needles into you at random. Scientists always look silly when their conclusions go beyond what the data can support, e.g. the evolutionary claims in Hurlbert & Ling’s “girls prefer pink” paper:
www.badscience.net/?p=518
buffalo66 said,
September 27, 2007 at 5:00 pm
@ ayupmeduck (#55): “But to be fair to The Independent, David Tredinnick, etc. they would necessarily notice this error, if indeed it is one, and so their comments on this paper are not nearly as bizarre as some people here, including Ben, would claim.”
That’s a good point – anyone who claims that this study shows acupuncture to be more than just a placebo is only reporting what the authors of the paper said. But I thought that David Tredinnick should have been more willing to discuss the fact that “real” acupuncture was no better than sham acupuncture – he didn’t seem interested in this finding at all.
buffalo66 said,
September 27, 2007 at 5:24 pm
@ three tigers (#57) “I don’t think the acupuncture or sham acupuncture is a placebo effect at all. It has all the hallmarks of the very real ‘counter irritation’ effect.”
But wouldn’t the counter irritation effect you describe cease after the source of irritation had been removed, rather than persisting for six months?
emilypk said,
September 27, 2007 at 5:34 pm
I am not sure it shows accupuncture is better than conventional per se, but that it has additional benefit for the as yet uncured. If the group had been people who had tried only accupuncture for a period of time and still had symptoms, and they went to a real versus sham g.p. what would those results look like?
buffalo66 said,
September 27, 2007 at 6:22 pm
good point, emilypk – novelty of the treatment to the patients does seem to be a confounding factor, as Emilyb pointed out earlier (#18).
emilypk said,
September 27, 2007 at 6:49 pm
It is more than novelty per se. This is a non-random sample and so shouldn’t be over generalised. The study group excluded those for whom conventional treatment was successful; a group that might have responded less to accupuncture if they had received it instead of their effective mainstream care. And a group inclusive of those whose complaint has causes other then those effectively treated by mainstream medicine (potential including systemic and psychological factors).
So it is not certain accupuncture (sham or otherwise) would be as effective as a first or simultaneous treatment regardless of the degree of novelty?
Ben Goldacre said,
September 27, 2007 at 7:01 pm
lots of interesting points here.
empilypk is absolutely right to point out that these were medical treatment failures of 8 years standing, not people passing through a surgery for the first time with back pain wondering “which treatment is best for me?”
but most interesting is that odd interpretation by the authors, who seem perhaps to suggest that because the sham acupuncture group performed differently than the medical treatment group, the benefits of sham acupuncture (and real) cannot be solely due to the placebo effect.
this is erroneous since it assumes that “placebo” is a unitary phenomenon. however there have been specific studies comparing one placebo with another showing that it is highly variable, related as it is to expectations, ritual, and meaning. there is even a paper (referenced in the post) comparing a placebo pill with a sham ritual involving a placebo device, modelled on acupuncture. i’ll have a look at the paper more carefully and might bung a reference-laden letter off to the journal on that, i think it’s well interesting.
misterjohn said,
September 27, 2007 at 11:04 pm
This article sheds some more light on the situation, I think.
Is acupuncture effective for the treatment of chronic pain? A systematic review.
Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB.
Complementary Medicine Program at the University of Maryland School of Medicine, Kernan Hospital Mansion, 2200 Kernan Drive, Baltimore, MD 21207-6697, USA.
Pain is the major complaint of the estimated one million U.S. consumers who use acupuncture each year. Although acupuncture is widely available in chronic pain clinics, the effectiveness of acupuncture for chronic pain remains in question. Our aim was to assess the effectiveness of acupuncture as a treatment for chronic pain within the context of the methodological quality of the studies. MEDLINE (1966-99), two complementary medicine databases, 69 conference proceedings, and the bibliographies of other articles and reviews were searched. Trials were included if they were randomized, had populations with pain longer than three months, used needles rather than surface electrodes, and were in English. Data were extracted by two independent reviewers using a validated instrument. Inter-rater disagreements were resolved by discussion. Fifty one studies met inclusion criteria. Clinical heterogeneity precluded statistical pooling. Results were positive in 21 studies, negative in 3 and neutral in 27. Three fourths of the studies received a low-quality score and low-quality trials were significantly associated with positive results (P=0.05). High-quality studies clustered in designs using sham acupuncture as the control group, where the risk of false negative (type II) errors is high due to large sample size requirements. Six or more acupuncture treatments were significantly associated with positive outcomes (P=0.03) even after adjusting for study quality. We conclude there is limited evidence that acupuncture is more effective than no treatment for chronic pain; and inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care. However, we have found an important relationship between the methodology of the studies and their results that should guide future research.
misterjohn said,
September 27, 2007 at 11:28 pm
A homeopath writes (to the bmj)in response to this article;-
Effect of homoeopathy on pain and other events after acute trauma: placebo controlled trial with bilateral oral surgery
Per Lokken, professor,a Per Atle Straumsheim, Dag Tveiten, homoeopath,b Per Skjelbred, chief surgeon,c Christian Fredrik Borchgrevink, professor d
a Section of Dental Pharmacology and Pharmacotherapeutics, University of Oslo, 0316 Oslo, Norway, b Norwegian Institute for Natural Medicine, 1340 Bekkestua, Norway, c Section of Maxillofacial Surgery, Oslo City Hospital, 0407 Oslo, Norway, d Department of General Practice, University of Oslo, 0264 Oslo, Norway
Saint Hanshaugen Medical Centre, 0168 Oslo, Norway Per Atle Straumshein, homoeopath. Correspondence to: Professor Borchgrevink, Fr. Stangs gt 11/13, 0264 Oslo, Norway.
Abstract
Objective: To examine whether homoeopathy has any effect on pain and other inflammatory events after surgery.
Design: Randomised double blind, placebo controlled crossover trial with “identical” oral surgical procedures performed on two separate occasions in 24 patients.
Interventions: Treatment started 3 hours after surgery with either homoeopathy or placebo.
Main outcome measures: Postoperative pain and preference for postoperative course assessed by patients on visual analogue scales. Measurements of postoperative swelling and reduction in ability to open mouth. Assessment of bleeding after surgery.
Results: Pain after surgery was essentially the same whether treated with homoeopathy or placebo. Postoperative swelling was not significantly affected by homoeopathy, but treatment tended to give less reduction in ability to open mouth. No noticeable difference was seen in postoperative bleeding, side effects, or complaints. Thirteen of the 24 patients preferred the postoperative course with placebo.
Conclusions: No positive evidence was found for efficacy of homoeopathic treatment on pain and other inflammatory events after an acute soft tissue and bone injury inflicted by a surgical intervention. Differences in the order of 30% to 40% would have been needed to show significant effects.
The homeopath responds;-
Simon Rabinovich,
Homeopathic physician, Homeopathic Consulting Co.
Toronto, Ontario, Canada
I would like to discuss two points of provided article. Firstly, I must draw your attention to the methodology of giving homeopathic drugs “3 hours AFTER the surgery”. Any experienced homeopath would tell us that according to homeopathic science any surgical intervention including extracting of teeth is a clear CONTRAINDICATION to homeopathic treatment, i.e. that treatment is doomed to be ineffective at all. The surgery stands in the row with such other contraindications to homeopathic treatment like excessive coffee drinking and consuming mint in any form including toothpaste using. Actually, if the researchers desired to see ANY effect of homeopathy they should have given homeopathic medications BEFORE the surgery. It is advisable also to repeat the treatment after the surgery although no sufficient evidence exists in all known clinical trials, however extensive clinical experience indicates clear benefits of such move.
Secondly, the choice of homeopathic remedies and their dosage (potency) were, in my view, somehow inappropriate. The only homeopathic remedy that I would agree with giving to the patients in such circumstances was Arnica. Any “individualized homeopathic assessment” after such painful procedure would obviously lead to the almost similar “drug picture” as it was shown in your article and, accordingly, to the same drug – Arnica. Practically speaking, the results would have been remarkably better and indicating the obvious effectivness of homeopathic treatment if such remedy like Aconitum Nappelus was added to the treatment. The latter medicine is usually been prescribed in the cases of “great anxiety, mental shock and, sometimes, panic”. It is also known to any experienced homeopath that Aconitum is one of “homeopathic pain- killers” (because the feeling of pain is the expression of CNS’ condition). It is also known that Aconite demonstrates its extremely well effectiveness and works in almost every case, thus it is called the “universal” remedy just like Arnica. I presume, this attitude would have been totally denied by classical homeopaths you invited for participating in your trial.
In conclusion, the use of correct homeopathic treatment in the case you presented would have been proved extremely effective, as it happened not once in the clinical experience of our clinic and number of dental surgeon’s clinics in Toronto.
Squander Two said,
September 28, 2007 at 10:32 am
I find it interesting that almost no-one here is even discussing the possibility that this not be placebo. It’s hardly far-fetched to suggest that sticking needles into flesh can have an effect on that flesh, yet the entire discussion here seems to revolve around the certainty that the only way these patients could have got positive results is placebo.
Sure, traditional acupuncturists talk a lot of bollocks about energy lines and such, and I’d heard long before this study that the evidence shows that the needles work just as well no matter where you stick them. A friend of mine is a chiropractor, and she uses needles to relax muscles, but she refuses to call it “acupuncture” on the grounds that acupuncture is quackery whereas what she’s doing is based on evidence. Another friend needed therapy after a rather nasty car crash, and his GP referred him to a specialist who used needles but, again, didn’t call it acupuncture, telling his patients frankly that all the stuff about acupressure points is bollocks. What he said was that the problem with most treatments for muscle problems is that they are confined to the surface; using needles allows you to apply heat to the muscle much deeper down — he used needles with heating elements. That theory is at least sensible enough to warrant proper consideration of the physical mechanisms, rather than to write it off out of hand as psychological.
Meanwhile, my GP’s “treatment” of disabling back pain was to prescribe me ibuprofen, giving me the wonderful opportunity to buy for £6.50 some pills that would usually cost me 60p. If you talk to patients who have left the conventional system to have their back pain treated, you don’t find a large number of the anti-MMR, anti-chemicals, anti-pills brigade, but rather lots of people who believe in the benefits of evidence-based medicine and were extremely disappointed by their doctors’ ineffectuality in this area. When it comes to joints and muscles, many GPs won’t even touch the affected area, instead merely writing down the patient’s description of the pain, and their treatments tend to revolve around painkilling rather than isolating the cause.
Conventional medicine is brilliant at surgery, the workings of internal organs, and biochemical effects, but has a bit of a blind spot when it comes to the physical mechanics of the skeleton and muscles. No idea why.
On the subject of experiment design, I amaware that there have been proper scientific studies into the effects of enemas. I’ve often wondered about the placebo control group: how do you persuade someone that they’re receiving an enema when they’re not?
wilsontown said,
September 28, 2007 at 10:52 am
To add to that, if the placebo effect varies for different placeboes, how can you perform placebo-controlled trials? They would only be controlled for one particular placebo. For example, if, as I would assume, homeopathy is basically an elaborate placebo, it might be a more effective placebo than a blank pill given without all of that homeopathic individualised treatment. Then, a ‘placebo-controlled’ trial would be bound to show an effect for homeopathy.
It is confusing…(or maybe I’m just confused)…
kim said,
September 28, 2007 at 11:25 am
Are people doing research on how placebos work? Presumably it’s not a question of thinking, “I’ve been given a pill and now I feel better.” I assume there’s some process going on where the brain is sending out chemical signals that somehow speed up the body’s own healing process. Likewise, when you’re depressed, as is often the case with chronic back pain sufferers, perhaps your brain is sending out chemical messages that block that process.
Is it possible to test in any way what actually happens when someone receives a placebo?
kim said,
September 28, 2007 at 11:30 am
I think Suw and SquanderTwo make very good points – to assume that the acupuncture is just acting as a “placebo” is to explain away an incovenient result in the way that alternative medical practitioners are often accused of doing.
The other interesting thing about this study is that it couldn’t have been double-blind – the people applying the “fake” acupuncture must have known it was fake, yet the patients still got better. Interesting.
buffalo66 said,
September 28, 2007 at 12:19 pm
@ Suw (#70). You’re right that it’s difficult to define what is meant by a placebo effect. If it’s defined as a purely “psychological” effect, then that means any psychological treatment, like cognitive behavioural therapy, is a placebo by definition. I think a placebo is a treatment that lacks something that is claimed to be an essential element (physical or psychological) of the treatment being assessed. If the essential element is claimed to be putting the needles in the right place, then the sham acupuncture in this study is a placebo. But if it’s claimed that it’s the physical effect of putting needles into someone that causes the improvement, and the exact location doesn’t matter, then the placebo treatment can’t involve inserting needles.
ayupmeduck said,
September 28, 2007 at 2:09 pm
@Squander Two: I see what you are saying. Maybe I’m being too pedantic, but it seems to me that both in the discussion here and in the paper, the terms are not well defined.
Look at it this way: The authors of the study have defined Acupuncture and have also defined “sham acupuncture”. To my mind the “sham acupuncture” is *NOT* acupuncture. It doesn’t use the rules that the normal acupuncture professionals practice. It’s just “random needle insertion” – I think this is a clearer term than “sham acupuncture”.
In this sense they seem to have shown that Acupuncture actually has *NO* effect whatsoever.
They have shown that “random needle insertion” does have an effect. The “random needle insertion” effect may be a placebo effect or it may not.
Or is my own logic tying me in knots?
emilypk said,
September 28, 2007 at 2:50 pm
Indeed. I would think that what makes it a placebo effect it that the sham inaccupuncturists stuck the needles in some harmless but random place. If where you stick them doesn’t matter at all then accupuncture is at the very least rather less complicated than one has been lead to believe.
doris said,
September 28, 2007 at 3:46 pm
A fascinating discussion,although I don’t know whether I ‘ve fully followed all the logical arguments.
However,more personal stuff to add.
My other sister,who only has one functioning kidney,has been having regular weekly acupuncture treatments for the past couple of years.
She swears by their eficacy:the lumbar pain and accompanying urinary difficulties which used to trouble her regularly,are now much improved:(howver,before objections are raised,she hasn’t had kidney function tests done for some time).
She had a renogram a few years ago,and was offered a cystoscopy a while later.
She has found the conventional investigations so distasteful and distressing that she has decided to rely on acupuncture.
her argument is that,since she has relied on only one kidney for the past 36 years,she knows instinctively when things are going wrong for her.
I really don’t know whether this can be attributed solely to a placebo effect,and as I said earlier,no clinical data is available to substantiate her assertions.
However,I find her case fascinating,not least because she is my sister.
Finally,to return to the far off days of my undergraduate study;the anaesthetist who provided the acupuncture for pain relief used the chinese system but did not adhere to the belief system.
He said that if it seemed to work when all else had failed,that was fine by him.
Again,any placebo effect was not separated out during my study.
Joe Dunckley said,
September 28, 2007 at 6:17 pm
Apologies if anything like this has already been discussed, I haven’t had time for anything more than a glance over the thread so far.
So, anyway, I just happened to catch the letters on PM. This bloke objects to having his back pain described as “imaginary”, does he? I didn’t hear Ben’s piece, so I don’t know whether he used the word “imaginary”, but if Ben didn’t, it’s interesting that the letter writer chose to use that word, for several reasons, starting with the ambiguity of the word.
Does “imaginary” (and thus psychosomatic) mean to the letter writer “making it up”? If so, I think he’d be quite right to be furious (leaving aside the obvious).
Or perhaps the letter writer really does understand psychosomatic and is scared of it: an activity of the brain that is unconcious and beyond his control. It starts sounding awfully like a mental illness. Feeling pain that isn’t really there is not a very big step from hearing voices that aren’t really there. Is it another case of the mental illness taboo? Mental illness is still seen more as an accusation than a diagnosis. Much better to be diagnosed with an injury than accused of having an imagination.
Pepper said,
September 28, 2007 at 8:33 pm
Silly paper
These results can appeared only due to NON-COMPETENCE OF AUTHORS IN ACUPUNCTURE! Or unsufficient competence.
That is why – the paper presents almost the same data (%) both in real acupuncture and in sham acupuncture!
Read the paper attentively.
You are discussing here THE INCORRECT DATA!!
And no more.
joal said,
September 29, 2007 at 6:04 pm
Thanks for an excellent site.
This is very interesting indeed as it confirms the history of mankind and our ancestors widespread use of voodoo like ceremonies. It works! The more elaborate the ceremony the more effective it will be. Mind over matter!
Pepper said,
September 29, 2007 at 9:56 pm
It seems this paper about acupuncture is wrong.
These results can appeared only due to NON-COMPETENCE OF AUTHORS IN ACUPUNCTURE! Or unsufficient competence.
That is why – the paper presents almost the same data (%) both in real acupuncture and in sham acupuncture!
Read the paper attentively, please.
We are discussing here THE INCORRECT DATA.
And no more.
Are you wrong?
Ben Goldacre said,
September 30, 2007 at 10:41 pm
psychosocial has absolutely nothing whatsoever to do with psychosomatic or psychogenic. psychosocial risk factors are very significant in back pain, that means psychological and social factors are very important in back pain. there was no ambiguity, even for people who can’t understand english, i gave clear examples, things like, whether you rest it, whether there is a low-strain job for you to go back to as an intermediate post, depression, brief educational interventions, public information programs, all the stuff i specifically mentioned. psychosocial risk factors and interventions, like i said.
i didnt say back pain was psychosomatic. i didnt say back pain was psychotic. i didnt say back bain was psychopathic or sycophantic or cyclical. i said that psychosocial risk factors were significant in the development and treatment of back pain, and they are. very.
in fact, amazingly, even the person whose letter they read out didnt say psychosomatic. its post 11 here:
www.bbc.co.uk/blogs/pm/2007/09/accupuncture.shtml
the letter said “I would take issue with your speaker, Ben Goldacre,) who, if I recall correctly, said that 90% of back problems are physcosymatic disorders.”
so not only did this person seem to ahve a completely garbled understanding of what i said, that was, in fact, completely obvious from what they wrote, from the fact that the PM team had to go out of their way to make sense of their garbled comment in order to say i’d said something which i didnt say. if they’d read out someone angry that i’d said back pain was a “physcosymatic disorder” then i wouldn’t be so bothered.
to be honest i’m amazed and appalled. this is why doctors and academics talk at length amongst themselves about what a bad idea it is to have anything to do with the media.
i have never, and would never, say that back pain is psychosomatic. there are psychological and social risk factors for acute back pain becoming chronic, of which i gave many good, clear, evidence based examples in the program, and there are examples of psychosocial interventions which are probably better than acupuncture, as a psychosocial intervention, such as brief educational interventions, public education programs (eg the australian “back pain, dont take it lying down” project i describe in the other post), and so on.
back pain is not physcosymatic. nor is it psychosomatic.
i have never suggested back pain is psychosomatic.
i would never suggest that back pain is psychosomatic.
back pain is not psychosomatic.
RS said,
October 1, 2007 at 10:31 am
Some back pain is psychosomatic surely Ben?
buffalo66 said,
October 1, 2007 at 10:34 am
Ben – I don’t think you can really blame people for being confused about the difference between psychosocial and psychosomatic. The Concise Oxford Dictionary (8th edition) has these definitions:
psychosocial: of or involving the influence of social factors or human interactive behaviour.
psychosomatic: 1 (of an illness, etc.) caused by or aggravated by mental conflict, stress, etc. 2 of the mind and body together.
Now, Table 1 in the BMJ paper you cited lists the following risk factors as “psychosocial”:
Stress; anxiety; negative mood or emotions; poor cognitive functioning; pain behaviour.
Number 1 in this list of “psychosocial” risk factors is “stress”, which is specifically mentioned in the Oxford dictionary’s definition of “psychosomatic”: according to this definition, an illness that is caused by or aggravated by stress is “psychosomatic”. I realise that there may be subtle differences between a “risk factor” and a “cause” or “aggravating factor”, but I don’t think you could blame anyone for thinking that the terms “psychosocial” and “psychosomatic” are virtually synonymous.
Perhaps medical professionals like yourself use a different definition of “psychosomatic” from that used in everyday language typified by the Oxford Dictionary definition (like the way “significant” has a precise meaning to statisticians which can be at odds with the definition used in ordinary language)?
It would be really helpful if you could explain how your definition of “psychosomatic” differs from “psychosocial”.
buffalo66 said,
October 1, 2007 at 11:57 am
i posted this earlier but, bizarrely, it can’t be seen unless you log in as me. Here’s another try:
Ben – I don’t think you can really blame people for being confused about the difference between psychosocial and psychosomatic. The Concise Oxford Dictionary (8th edition) has these definitions:
psychosocial: of or involving the influence of social factors or human interactive behaviour.
psychosomatic: 1 (of an illness, etc.) caused by or aggravated by mental conflict, stress, etc. 2 of the mind and body together.
Now, Table 1 in the BMJ paper you cited lists the following risk factors as “psychosocial”:
Stress; anxiety; negative mood or emotions; poor cognitive functioning; pain behaviour.
Number 1 in this list of “psychosocial” risk factors is “stress”, which is specifically mentioned in the Oxford dictionary’s definition of “psychosomatic”: according to this definition, an illness that is caused by or aggravated by stress is “psychosomatic”. I realise that there may be subtle differences between a “risk factor” and a “cause” or “aggravating factor”, but I don’t think you could blame anyone for thinking that the terms “psychosocial” and “psychosomatic” are virtually synonymous.
Perhaps medical professionals like yourself use a different definition of “psychosomatic” from that used in everyday language typified by the Oxford Dictionary definition (like the way “significant” has a precise meaning to statisticians which can be at odds with the definition used in ordinary language)?
It would be really helpful if you could explain how your definition of “psychosomatic” differs from “psychosocial”.
emilypk said,
October 2, 2007 at 9:04 pm
but can a placebo work while you are unconscious?
www.todaysthv.com/news/news.aspx?storyid=53832
RS said,
October 3, 2007 at 9:05 am
Since in animals the placebo effect is on the owners – anaesthetising the animal won’t make any difference.
emilypk said,
October 3, 2007 at 2:22 pm
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.
RS said,
October 3, 2007 at 6:26 pm
emilypk – the whole point is who determines whether the animal has gained any benefit? You can’t ask it!
emilypk said,
October 3, 2007 at 7:30 pm
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.
RS said,
October 3, 2007 at 8:31 pm
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.
emilypk said,
October 3, 2007 at 9:15 pm
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.
emilypk said,
November 13, 2007 at 4:51 pm
On the issue of vetwoo, thought this might interest-slash-amuse: vetpath.co.uk/voodoo/
emilypk said,
November 16, 2007 at 6:29 pm
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?
malucachu said,
December 13, 2008 at 12:10 pm
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.
RichardCarter said,
May 24, 2009 at 10:45 pm
…. 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).
RichardCarter said,
May 26, 2009 at 11:53 pm
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!
MJJMZ60 said,
August 11, 2009 at 2:32 pm
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.
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JustMe said,
July 1, 2010 at 12:23 am
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.
Pierre de Lasteyrie said,
January 26, 2011 at 11:45 pm
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…
danleywolfe said,
September 26, 2011 at 8:37 pm
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
Points of Life said,
October 6, 2013 at 5:51 am
Hello all, sorry I found this blog after so many years, but what’s a century or a two. I just want to add what Acupuncture is and what it is not. And believe it or not all of it is documentable if you read the associated textbooks.
americannewsreport.com/nationalpainreport/acupuncture-the-most-powerful-therapy-in-medicine-8820052.html
Vic said,
November 17, 2013 at 11:41 pm
Perhaps a lot of attacks on alternative medicine (I prefer the name complementary medicine) are from the conventional medical establishment who have not considered the following: if the complementary practitioner can cause the powerful “placebo” to help the patient, why poo-poo it?
The “elaborate” one hour procedure results in the relief of symptom the patient experiences, so he/she continues the treatment – its their choice and their money, surely! The people who come to see me have exhausted what help the conventional medical can give them and about 80% of who I treat get the relief they are looking for. They would not come back if they did not value the results they get.
Acupuncture is very difficult to trial with double-blind tests because putting a needle in a non-point cannot be guaranteed to have no effect! And choosing the point is not one done by mechanical computation but a complex, individual assessment that changes as the patient changes and gets better.
So please – don’t knock procedures that help people, especially as the NHS is crippled by lack of resources and many hospitals are under investigation for incompetence and negligence.
pogopatterson said,
October 9, 2014 at 2:00 pm
I undertook acupuncture for 5 years for stress following brain surgery, and although it didn’t yield all the benefits I hoped it would, I know that it should be considered to be a serious medical therapy for the neurological/emotional instability caused by damage to parts of the hypothalamus (possibly hypocretin neurons) following brain surgery. Not that surgery itself is classically seen as damaging in its own right by modern medicine- only the problem it was being used to overcome is ever mentioned. That in itself is a form of semantic quackery- but I digress.
The study on back pain has been unscientifically used as a tool to bludgeon all acupuncture. I know people who have had no success for their back pain from acupuncture. Without the benefit of the study above, I didn’t conclude that I was merely undergoing a placebo affect, and these back pain cynics somehow saw through the ruse.
Not unlike my own very specific stress related reaction to neurological damage, not all stress has the same cause, and therefore one presumes does not all have the same blanket cure. Equally all back pain cannot be assumed to have the same causes- and therapies which claim to alleviate that pain presumably have to tackle different roots of that problem in different ways.
I’d suggest the only common denominator in the back pain study is the anatomical location of the problem, though even the back itself covers a fair amount of physical real estate. The causes of that pain could be manifold and the extent of damage also would need to be assessed independently of the patient’s own assessment. I suspect though that there are no means of accurately evaluating the extent of nerve and deep tissue damage, as well as bio-chemical messaging issues. Without an accurate objective baseline, the sham acupuncture study cannot be assumed to measure anything in a scientific way.
It is quite possible even that the direct physiological source of all causes of back pain, have yet to be identified by modern medicine. The hypocretin peptide that I suspect has been compromised in my neurological damage was only discovered in 1998.
Since most mainstream medical treatments for back pain simply block out the perception of pain, most observers are equating two very different approaches. The comparison is with a western medical approach which isn’t actually successful in any way other than masking the pain, with another technique which could actually be curing or at least reducing the underlying problem albeit in a minority of patients.
It seems that the power of the scientific method is such that one vaguely focused study on the ambiguous subject of back pain can over turn the practical experience accumulated in the last 3,000 years of (billions of) satisfied customers across cultures for a variety of ailments from acupuncture.
Except that counter factual scientific evidence such as the Georgetown University study doesn’t get reported in the same press to the same degree which shows measurable evidence of the therapeutic effect of acupuncture on Rats
explore.georgetown.edu/news/?ID=61392&PageTemplateID=295
As a scientific endeavour I’d be more inclined to believe the Georgetown study with its measurable levels of changes in neuro-peptide Y, rather than the approach of the “Sham acupuncture” study, which relied on purely on human testimony. That acupuncture can increase the levels of a neuropeptide associated with relieving some forms of stress, does not mean acupuncture necessarily can cures all forms of back pain. But for all we know (though I wouldn’t argue the case necessarily) there were measurable improvements in the level of tissue/nerve/pain signal damage to the back pain patients backs- but this hadn’t reached the level of human consciousness or wasn’t yet enough to appreciably limit the experience of pain. Perhaps even the experience of pain was illusory and the attention received as a result of claiming to be in pain, is enough for the patient to willingly continue the subjective experience at some level. That’s all speculative but it gives me grounds to doubt the Sham acupuncture study and does encourage me to keep an open mind about where the true fraud lies.
I’ve also read other respondents talking about placebo affects on animals as being a possible reason for acupunctures effectiveness on larger mammals. But if you want to suggest the same thing is happening with acupuncture and rats in the Georgetown University study then you must conclude that rats are open to the placebo affect from all the multifarious drugs they have been given for many years through various clinical trials. That would be a crushing blow for biological science everywhere, best not go there….
For a site that claims to be debunking poor scientific method, the gaps in the poorly conceived back pain acupuncture study are obvious, but yet it seems to be naively trusted in the face of wider field experience. I’d suggest what is really at play here is a kind of western cultural imperialism which assumes that anything that doesn’t come in a shiny plastic container that beeps, must be an inferior technology. That can be the only reason why one study with a limited number of patients can be deemed to be greater than 3,000 years and a billion(?) patients.
Moreover if the average western medical surgery was able to offer satisfactory treatments or explanations for the problems many of us patients have, then we wouldn’t have to be imaginative and go outside the NHS corral. We are aware of course that this does leave us open to alternative medicine charlatans. But is this really that different from our every day experience of western medical quackery? How many patients leave appointments with their GP having undergone no further investigation and been told they are imagining it? Or that whatever ails them is caused by your age, how you are managing stress and interpersonal relationships, that you’re not eating right or not exercising enough. Equally the solution posited is that it is mind over matter, or that immediately post surgery that the operation was a complete success. That’s just bland misdirection in a lot of cases- with no attempt to establish whether there is an underlying cause or sequelae. Since studies of what goes on in a private GP surgery are rarer than hen’s teeth, whether I am wantonly exaggerating the extent of the problem or have highlighted a major issue, is debatable.
Nor are there any guidelines for the patient to gauge how well their doctor is performing. There are no measures of GP success, either in diagnosis or treatments successfully delivered. You are expected to trust their mastery of the subject based on paper exams, perhaps completed 20 years ago, and that in the meantime they have kept abreast of modern developments in medicine since graduation. The fact that the internet contains reputedly over 200 million medical facts, and GP’s can retain an impressive 2 million, has not seemingly opened the GP surgery to Information Technology as a diagnostic tool. This is despite the fact that the rest of society moved into the 21st century 14 years ago.
More often than not, the doctor tells the patient that nothing can be done, and that is supposed to be taken as the definitive judgement on the subject. You are instructed to get a second opinion, if you are dissatisfied, as only a last resort of redress. But should for example it be proven that a therapy was available no censure is ever brought on the original doctor for failure to disclose an appropriate therapy. That is unless of course the absence of the appropriate therapy kills. No GP in the UK gets censured for a patient rash caused by prescription medicine, though if it had been caused by a Branded detergent, the manufacturers would be financially penalized. Failure to spot Alzheimer’s 18 months on average after their German counterparts also goes unchallenged let alone unpunished.
Assuming that most problems a doctor has to confront are not immediately life threatening, and the drugs offered to counter problems equally non life threatening, outcomes other than mortality do not get measured, and a vast swathe of medical practice goes unchallenged in its effectiveness. That’s about as unscientific an approach to any human endeavour that I can imagine. Don’t attempt to scrutinize this human activity, because it can’t be measured. I can’t imagine that would be the credo of an Isaac Newtown or an Einstein.
Worst of all, the “Surgery Appointment” the medium in which most initial diagnoses are made, is staged to give total control to the GP. I’ve been in consultations where the doctor sat in total silence because I believe he didn’t want to spend money on me, the patient. So, do I have to take the GP to court every time financial considerations hold sway? For example we do not have a system of patient advocates who could sit in on appointments and could intercede, where we suspect foul play has taken place, but where we don’t either want our medical problems made public and we suspect some additional pressure would open the GP’s wallet.
In conclusion, and back to the acupuncture – a much better use of scientific enquiry would be to find out how acupuncture does work, in those situations where it has been scientifically proven to be effective. Again I would want more studies than the Georgetown experience, because one study (particularly the sham acupuncture study) like one swallow- does not make a summer. Reliance on one study to dismiss 3,000 years of experience is woefully unscientific- in fact shamefully arrogant. Such a general enquiry into acupuncture could open up a new understanding of the body, if Traditional Chinese medicine is to be believed on the subject of meridians. Opening up new fields of enquiry seems a much more stimulating course of action, than dismissing wholesale a relatively successful indigenous medical paradigm. It would bring I am sure ultimately benefits for all in Big Pharma and the medical establishment, with their history of subsuming other disciplines discoveries under their own paradigm.