Changing the rules

Is acupuncture effective? In general, acupuncture vs. control rarely shows dramatic benefit when the control is "sham" acupuncture, where needles are placed at points not indicated by the underlying acupuncture theory. More dramatic results may be seen when the control used is sitting at home. This suggests that the therapeutic benefit of acupuncture is more in the time spent with the practioner and/or a placebo effect, rather than any actual benefit of the needles themselves. It is possible that just jabbing needles into someone has an effect as well.

When you think about the underlying idea of acupuncture, that there are energy lines running through the body that can be manipulated by needles, the lack of efficacy is not so surprising, as this is pretty far from what I’d consider mainstream biology.

But a commentary in BMJ rejects the whole idea of studying acupuncture using randomized trials:

In order to use a placebo or sham controlled design, an intervention has to be divided into characteristic (specific) and incidental (placebo, non-specific) elements. However, recent research suggests that it is not meaningful to split complex interventions into characteristic and incidental elements.

The idea is that the process of acupuncture (seeing the therapist, etc.) is not distinguishable from the act of placing the needles.

Of course, seeing a doctor, apart from any intervention, is helpful. If you have a rash and think it means you have cancer and go to your doctor and she tells you it's from a virus, you feel better, even though she didn't do anything to help the rash. Why is acupuncture different? Here is what they argue:

In a trial of acupuncture, however, the biomedical diagnosis that precedes the trial is not the theoretical understanding that guides treatment. The acupuncturist, through questioning and examination, will make a Chinese diagnosis during the first treatment session and will review and amend that diagnosis at each subsequent session. . . .

During subsequent treatment sessions needle insertion and healthcare advice are often varied to take into account any new concerns, whether physical, emotional, or social. This type of talking and listening may result in an increasingly participative interaction in which the whole burden of illness can be shared and partially relieved.

See, it it the Chinese diagnosis!

Seriously, there are two problems with this formulation.

First, what is claimed to be special about acupuncture is the needles, not the talking and handholding. Second, western medicine is also an iterative undertaking with successive rounds of testing, treatment, and revision of the diagnosis.

The overall message of the paper is that it’s unfair to expect alternative approaches to compete with the big boys like medicines which have real biological effects and plausible underlying biological rationales. Any attempt to actually study alternative medicine is unfair! Those who study alternative medicine have to throw off the shackles of actual testing and design trials where acupuncture can’t fail:

A sham controlled trial is only appropriate for comparing two acupuncture interventions—for example, to compare the effects of different needling techniques. In such a trial it is the effect of needling that is being compared rather than the total characteristic effect of the acupuncture.

But how can one study the effect of different techniques of acupuncture without knowing if it is effective to start! It's like saying you should only study two doses of a new drug because it is too hard for the drug to be compared to placebo or an effective alternative.

It’s because the system is biased! One tip-off to ridiculous articles is they inevitably descend into jargon (unfortunately, so do some reasonable articles).

This reticence in challenging the status quo may be because the assumptions that underlie dominant or commonly held theories such as biomedicine are invisible until they are illuminated by a body of primary research.

What exactly is the meaning of this sentence? I only have two doctoral degress, but my guess would be "the system is stacked against the wacky therapies we believe in; therefore we have to fight against the system."

My general belief is that much of so-called “alternative” medicine is effective, to the extent it is, because of the “hand-holding” effect. From a biological perspective the disease isn’t treated, but the patient feels much better from a psychological standpoint, since someone has spent time with them, talked about their feelings, and probably laid hands on them. And for many chronic conditions, one should never underestimate the power of positive thinking (which among other things may improve compliance with more mainstream therapies and encourage healthier lifestyles).

I don’t find it surprising that s mainstream medicine has become increasingly technical and doctors have less and less time to spend with patients, things like acupuncture and chiropractic are increasingly popular. The challenge going forward will be to identify what it is truly efficacious in these alternative therapies, avoid adverse outcomes, and help integrate more socially based therapies into mainstream practice.

UPDATE: I am not intrinsically opposed to acupuncture. If good quality trials show it works, I'm all for it. But those trials need to be rigorous.