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May 03, 2005

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This is interesting. So does anyone know why inserting needles--wherever they are--seems to relieve pain? Is it just the power of distraction, or is there a physiological reason that a number of sharp pains would make a headach go away?

Acupuncture appears to work most likely for the same reasons other alternative therapies seem to work, namely:

• Placebo
• Misdirection (the needle makes you forget the other pain)
• The cyclical nature of the illness (it goes away by itself)
• Incorrect diagnosis to start with
• Temporary mood improvements due to the personal nature of the treatment
• Psychological investment of the patient in the success of the therapy
• Other medicines the patient is taking.

In addition acupuncture may stimulate the release of endorfins.

I think it's more accurate to say that fake acupuncture works. That's what the study says.

It seems that it doesn't matter where you stick the needles, migraine pain is reduced. That's an interesting result.

But the study directly contradicts your assertion that acupuncture does not work.

Agreed it calls into question the traditional acupuncture theories of qi and energy flows and whatnot. (Strange that no-one has tried that before, come to think of it.) And it's a pity the study did not distinguish the benefits of needle-sticking from the placebo effect, but still, the important thing to remember about the placebo effect is that it's real, and it works.

Blue state:

But the study directly contradicts your assertion that acupuncture does not work.

Agreed it calls into question the traditional acupuncture theories of qi and energy flows and whatnot.

Well, that is what acupuncture is, so it does directly show that acupuncture does not work.

The placebo effect may be real, but it is not acupuncture. Releasing endorphins by random application of needles is not acupuncture. These things are not acupuncture, whether you decide to call them acupuncture or not. This is an important distinction since we now know all the detailed training acupuncturists go through to learn about all these special magic points on the body, is a waste of time. You could train a nurse to stick needles in a patient at a fraction of the cost for the same benefit.

I think there is some confusion here between the theory of acupuncture, which the experiment discredits, with the effects of acupuncture, which the experiment confirms.

In general usage, to say something doesn't work means the effects aren't there. I'm sure you'd agree that a radio still works even if my theory is it works because there is a little man inside who talks when I turn it on.

Blue state:

I think there is some confusion here between the theory of acupuncture, which the experiment discredits, with the effects of acupuncture, which the experiment confirms.

Actually it doesn’t. It just confirms some pain relief.

Here is a list of things acupuncture is supposed to cure.
This study didn’t mention any of those.

In general usage, to say something doesn't work means the effects aren't there. I'm sure you'd agree that a radio still works even if my theory is it works because there is a little man inside who talks when I turn it on.

No, it means it doesn’t work. Your analogy is back to front. You are arguing that a person believes in “little men in a box” theory. He says my “little men in a box” theory is true because when I turn the radio on I hear voices. He’s wrong - it's a radio. It matters because he wastes time working out how to make the little men talk, whereas we all know there are no little men in the box.

Acupuncture is not “the placebo effect”, whether or not that is what you have arbitrarily decided to call it.

Maybe we need a new word for this activity, like "dermapuncture". Then we can divorce it from the mumbo jumbo theory of energy meridians. It's fair to say that learning this theory is a waste of time, but it doesn't follow that the treatment itself is a waste of time. Despite a lot of talk about the "placebo effect" in this article, this particular study isn't well designed for discovering a placebo effect; after all the control group got stuck with needles too! The placebo effect is supposed to be entirely mental. This quote from the researchers themselves is a more accurate assessment:

This may be due to "non-specific physiological effects of needling, to a powerful placebo effect or a combination of both", said the researchers.

The earlier knee study seemed to indicate a statistically significant improvement of the dermapuncture treated group over the control group, which received non-penetrating "sham acupuncture". This would seem to throw a wrench in the placebo theory, as well as the other reasons that Skeptico listed, with the exception of endorfins (caveat: this was but one, relatively small study). Of course nothing says that a treatment for one kind of pain is necessarily good for other kinds.

Anyway, a good skeptic can't throw the baby out with the bathwater. It looks like there may be some physiological effect here we don't understand. Learning about it might help us create better treatments for chronic pain (which is not particularly well handled by today's medicine), or if not, at least we could dismiss it with real authority.

Eric:

The earlier knee study seemed to indicate a statistically significant improvement of the dermapuncture treated group over the control group, which received non-penetrating "sham acupuncture". This would seem to throw a wrench in the placebo theory, as well as the other reasons that Skeptico listed,

What study are you talking about? The earlier study I wrote about showed no different result, because they were not testing for a result, they were just measuring which portion of the brain was lit up:

During the trick needle treatment, an area of the brain associated with the production of natural opiates - substances that act in a non-specific way to relieve pain - were activated.

This same area was activated with the real acupuncture but, in addition, another region of the brain, the insular, was excited by the treatment.

No "statistically significant improvement" of anything.

Anyway, a good skeptic can't throw the baby out with the bathwater. It looks like there may be some physiological effect here we don't understand. Learning about it might help us create better treatments for chronic pain (which is not particularly well handled by today's medicine), or if not, at least we could dismiss it with real authority.

Unless you’re referring to a different study, I see no benefit other than placebo and the other things I listed.

I just got into a debate about the effectiveness of acupuncture on another site... which led me over to PubMed. There are an awful lot of abstracts there for research which has found at least some benefits to acupuncture, especially in pain relief. Lots that find the reverse, too... though most seem to opt for an 'inconclusive' verdict. Irritatingly unhelpful.

Skeptico:

Sorry, I got lazy and didn't include the link. I meant http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15611487>this study by Berman, et al. If I recall, this one was somewhat controversial because it was NIH funded, so it made the news. I also see that it wasn't as small as I had remembered (N=570).

OK, thanks. The abstract states:

Controls received 6 two-hour sessions over 12 weeks or 23 sham acupuncture sessions over 26 weeks.

But what do they mean by “sham acupuncture? This report states that it:

involved 2 needle insertions at "irrelevant" abdominal sites and a sham procedure at points utilized in (the acupuncture group)

So it’s partly sticking the needles in the wrong place, and partly sham needles, that don’t pierce the skin. This seems pretty dumb to me. The way the study was designed, if this report is correct, you can’t tell if the “real” acupuncture is better that (a)sticking needles in the wrong place or (b)pretending to stick needles in. If it’s (b), then the reasons for the success could be:

• Misdirection (the needle makes you forget the other pain), and/or
• Endorphins

It is a little odd that they would choose both fake needles and misplacement simultaneously, it seems like it would have been better to separate these two. I suspect that if they had tried an alternate "sham" treatment that involved treating the knee with needles in non-acupuncture points, they would have found much the same result as the real acupuncture treatment.

But, given the result that they saw an improvement over the control group, I think you can at least say that needles near the injury are better than not.

I don't think your suggested reasons are particularly plausible, for a number of reasons:

  • Subjects saw improvement over the whole treatment period, not just during treatment; it's not obvious to me that misdirection would be a lasting effect. Also I haven't heard of any long term healing effects of endorphins versus short-term pain relief (though I claim no expertise about this stuff).
  • Subjects saw improvement in their functional scores before improvement in their pain scores.
  • Acupuncture isn't known as a particularly painful treatment, so it seems unlikely that it would "overpower" other pain somehow.

It seems more likely to me that there's something going on that we don't quite understand yet. It may be something simple, like maybe the needles cause vasodilation and the increased blood flow helps an injury heal. Anyway, not to belabor the point, it may be worth some amount of investigation.

Richard,

This post is basically stating a bit differently what I was trying to say with my reply to your last post on this subject (http://skeptico.blogs.com/skeptico/2005/05/still_no_eviden.html) - that when a person THINKS they are being stuck by needles, even if in fact they are not, that has some measurable effect to alleviate pain, even if we do not yet understand that effect; and that this effect has nothing to do with "qi".

My point last time about the needles producing opiates "in excess of what the body might produce specifically for that needle's injury" is what I had in mind to explain effects such as we see in this study, where "both genuine and sham acupuncture reduced the intensity of headache compared to no treatment at all".

Mike

Before we jump to any conclusions here, let's remember that there have been TONS of studies comparing "sham" acupuncture to "real" acupuncture. Some conclude that real is better than sham, and some conclude that there's no difference.

Now if we look at mainstream biomedicine, we can find numerous examples of this kind - in addition to the many studies that prove this or that drug or procedure more effective than a placebo, there are undeniably a ton of studies that show that a placebo works just as well as (or in some cases better than) the "real" treatment. This has happened even for widely used and accepted remedies.

Does this mean that mainstream medicine as a whole is just a sham? Of course not.

I'm no PhD but I know enough to know that acupuncture is an extremely complex system, and to use one single study to discredit the entire system seems more than a little unreasonable.

Dan:

It is more than this one study. Well run studies show no difference between sham acupuncture and real acupuncture. Furthermore, all the studies I have seen show it doesn’t matter where you put the needles (which debunks the qi/meridians explanation).

I referenced many other studies in my article, specifically Still no evidence acupuncture works and Placebo - pregnancy pain cure. I also wrote Acupuncture does not cut blood pressure, and I linked it doesn’t matter where you stick the needles, and a detailed review of 50 Acupuncture trials and quality.

Not a single study – many. I think it’s got to the point now where there can really be very little doubt – acupuncture is little more than an extremely complex way of administering a placebo.

Acupuncture is not inextricably tied to the qi/meridian theory. There are many systems of acupuncture in Asia, and elsewhere, some of which do not even have any mention of this system. I agree that the qi/meridan idea is very suspect, but as it is understood in America it is largely the result of a misinterpretation of Chinese texts. There are also modern interpretations of acupuncture, such as Travells trigger point therapy, Chan Gunn's dry needling therapy and so on. The neurotransmitter response to needling has been closely examined. It is not the same as placebo. It comes down to if you can accept the fact that a needle in the right place with the correct technique can instigate a therapeutic outcome. I don't expect anybody to accept any metaphysical theories about this, and by the way most Chinese don't either. Full disclosure, I do this for a living and I don't have any patience for people who project some kind of Orientalist fantasy of their own onto this technique. Acupuncture IS the insertion of needles to elicit therapeutic benefit, and there are many rationales about how to decide where to put those needles, not just meridian theory.

Frank:

Re: It comes down to if you can accept the fact that a needle in the right place with the correct technique can instigate a therapeutic outcome.

But it seems it doesn’t matter where you put the needles:

the pessimist (or scientist) would insist that these results prove that acupuncture is merely a placebo therapy with no "real" effects of its own. It doesn't matter where we stick the acupuncture needle, the patient improves in any case, and this can only be due to a placebo response.

OK...and fake sugar pills (given as a placebo) will also cure migraine pain as well in some people. Does this mean real drugs don't work? C'mon - you can do better than this. Yeesh.

OK...and fake sugar pills (given as a placebo) often appear to have an effect against migraine pain in some people. Does this mean acupuncture is no better than sugar pills? C'mon Stephanie - you can do better than this. Yeesh.

stephanie, see my comment in the "Absurd homeopathy study" entry. You don't understand what the placebo effect is.

I think you should try acupuncture yourself, so you can have your own personal opinion. Then, decide if it works for you or not, and go from there.

I don't trust my non-deific senses enough to be completely accurate and impartial. That's why I insist on proper tests designed to reduce bias, such as double-blinding.

I have a very serious warning against acupuncture. Last year my legs started swelling and I had a shortness of breath. I went to a Chinese doctor who took a lot of money off me for a course of acupuncture and some completely ineffectual foul-tasting herbal teas. After a month I was getting worse and I was told the problem was my kidneys. At this point it was evident that something was very wrong so I went to hospital, was hospitalised immediately and was diagnosed with cardiomyopathy. The acupuncturist was happy to watch my health deteriorate as long as I was giving him money and his vanity was being gratified. I wanted to believe, but now I know from personal experience that this "alternative" approach is dangerous nonsense.

Just goes to show that even seemingly harmless quackery treatments can be dangerous: If Colin didn't go to an evidence-based doctor, he'd probably be in deep trouble.

I don't know anything about cardiomyopathy, but any condition with "cardio" in it can't be good.

Cardiomyopathy is a weaknening of the heart muscle. My symptoms were obvious signs of heart failure that the "doctor" failed to notice. My breathlessness was caused by my lungs filling up with fluid because the heart was not pumping as it should. Left untreated, this leads to suffocation. The heartless charlatan told me not to go to a proper doctor and each day my condition was getting worse. Now, after proper medical treatment I am much better. My condition was caused by sustained high blood pressure which is now under control. If I had continued going to the acupuncturist, I would certainly be dead by now.

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