Why can’t more western doctors and skeptics adapt the attitude of the Mayo Clinic?

Earlier I had blogged about how a physician from the Mayo Clinic endorses acupuncture for low back pain.  Now I had chanced upon their website primer on acupuncture under the heading “Tests and Procedures”

http://www.mayoclinic.com/health/acupuncture/MY00946

Here are some notable exerpts:

Under “Definition”

Acupuncture involves the insertion of extremely thin needles in your skin at strategic points on your body. Acupuncture originated in China thousands of years ago, but over the past three decades its popularity has grown significantly within the United States.

Traditional Chinese theory explains acupuncture as a technique for balancing the flow of energy or life force — known as qi or chi (chee) — believed to flow through pathways (meridians) in your body. By inserting needles into specific points along these meridians, acupuncture practitioners believe that your energy flow will re-balance.

In contrast, many Western practitioners view the acupuncture points as places to stimulate nerves, muscles and connective tissue. This stimulation appears to boost the activity of your body’s natural painkillers and increase blood flow.

Nice to see that the website presents both theories with neither preference nor prejudice.

Now, under “Why It’s Done”, and this is a beaut.

Scientists don’t fully understand how or why acupuncture affects the amount of pain you feel. Several studies have found that acupuncture has little or no effect beyond that of the sham treatment used in some study participants — the control group — for comparison. The lack of firm results can be explained, in part, by the difficulty of devising a realistic but inactive stand-in for acupuncture. (emphasis mine)

A Good Stand-In is hard to find.

Difficulty in devising a realistic but inactive stand-in… isn’t that what I’ve been trying to point out for a long time?  How come THEY get it and some can’t? (or won’t?) (see http://qi-spot.com/2010/03/30/how-to-research-acupuncture/)

Now do we remember this line? (http://qi-spot.com/2010/03/20/new-bashing-technique-acupuncture-causes-disease/) Here’s what Mayo has to say:

The risks of acupuncture are low if you have a competent, certified acupuncture practitioner. Possible side effects and complications include:

• Soreness, bleeding or bruising at the needle sites
• Internal organ injury, particularly to the lungs, if the needles are pushed in too deeply
• Infectious disease, such as hepatitis, contracted from reused needles

Again, balanced and fair and most of all, TRUTHFUL.

The rest of the site talks about who is eligible and who is not, how to prepare, what to expect, etc.  And it ends with a balanced note:

The effects of acupuncture are sometimes difficult to measure, but many people swear by it as a means to control a variety of painful conditions.

Several studies, however, show that simulated acupuncture appears to work just as well as real acupuncture. There also is evidence that acupuncture works best in people who expect it to work.

Since acupuncture has few side effects, it may be worth a try if you’re having trouble controlling pain with more-conventional methods.

I post this knowing skeptics will come in and say “see? placebo!” Yet I still do so because I am interested in the truth.  And the truth is any treatment will work better in people who expect it to work.  But the fact that it works in patients who also don’t expect it to work says something.

And yes, darned well worth a try.

Ah Germany, land of good beer, great sausages, and acupuncture research.  Stux et al have contributed much to acupuncture, and now a new study awaits publication that I am eager to read.

From http://www.ncbi.nlm.nih.gov/pubmed/20359961?dopt=Abstract:

Acupuncture, Psyche and the Placebo Response

Enck P, Klosterhalfen S, Zipfel S.

Auton Neurosci. 2010 Mar 30. [Epub ahead of print

University Hospital Tübingen, Dept. of Psychosomatic Medicine, Tübingen, Germany.

With growing use of acupuncture treatment in various clinical conditions, the question has been posed whether the reported effects reflect specific mechanisms of acupuncture or whether they represent placebo responses, as they often are similar in effect size and resemble similarities to placebo analgesia and its mechanisms. We reviewed the available literature for different placebos (sham procedures) used to control the acupuncture effects, for moderators and potential biases in respective clinical trials, and for central and peripheral mechanisms involved that would allow differentiation of placebo effects from acupuncture and sham acupuncture effects. While the evidence is still limited, it seems that biological differences exist between a placebo response, e.g. in placebo analgesia, and analgesic response during acupunture that does not occur with sham acupuncture. It seems advisable that clinical trials should include potential biomarkers of acupuncture, e.g. measures of the autonomic nervous system function to verify that acupuncture and sham acupuncture are different despite similar clinical effects. (emphasis mine)

Copyright © 2010 Elsevier B.V. All rights reserved.

Now like I've been blogging, I'm not out to prove acupuncture works or not.  I believe it does for many but not all conditions.  However, data such as this would only verify what I've been saying.  Yes, there ARE changes differentiating between sham and "real" acupuncture.  I am sure this refers to stimulation of a-delta fibers, stimulation of the periaqueductal gray and the VPL nuclei of the hypothalamus.  Nonetheless, I shall be on the lookout for the actual article.

Interestingly, I see another, seemingly contradictory article, while browsing the first one.  This time, from Sweden.  Now we see they've got more than just massage and meatballs: (http://www.ncbi.nlm.nih.gov/pubmed/19525330)

Is Placebo Acupuncture What it Is Intended to Be?
Evid Based Complement Alternat Med. 2009 Jun 12. [Epub ahead of print]
Lundeberg T, Lund I, Sing A, Näslund J.
RPT, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden. jan.e.naslund@ki.se.
Randomized, placebo-controlled clinical trials are recommended for evaluation of a treatment’s efficacy with the goal of separating the specific effects (verum) from the non-specific ones (placebo). In order to be able to carry out placebo-controlled acupuncture trials, minimal/sham acupuncture procedures and a sham acupuncture needle has been used with the intention of being inert. However, clinical and experimental results suggest that sham/minimal acupuncture is not inert since it is reported that both verum acupuncture and sham/minimal acupuncture induce a significant alleviation of pain. This alleviation is as pronounced as the alleviation obtained with standard treatment and more obvious than the one obtained with placebo medication or by the use of waiting list controls. These results also suggest that sham acupuncture needles evoke a physiological response. In healthy individuals sham acupuncture results in activation of limbic structures, whereas a deactivation is seen in patients with pain, i.e. results from healthy individuals do not reflect what is seen in clinical conditions. Also, depending on the etiology of pain (or any under clinical condition under investigation), the response to sham acupuncture is varying. The acupuncture ritual may also be seen as an emotional focused therapy allowing for psychological re-orientation. Sham needling in such context may be as powerful as verum acupuncture. We recommend that the evaluated effects of acupuncture could be compared with those of standard treatment, also taking the individual response into consideration, before its use or non-use is established. (emphasis and italics mine)

What do these two studies together mean?

1) Current methods of sham and real acupuncture seem to evoke similar physiological responses. Studies have shown that at times, sham and real acupuncture seem to be effective.  Skeptics are quick to jump and say there, that means acupuncture is no better than placebo!  The proper term is that acupuncture SEEMS to be just the same as sham.  The problem with the skeptic logic is that they forget that both sham and real acupuncture are better than nothing, or TRUE placebo.  I can see it now:

Skeptic: Fake needling just the same as real needling! Hence, acupuncture isn’t real!

Acupuncturist: But both fake and real needling is better than nothing, what say ye?

Skeptic: So why not just massage? Why use needles?

Acupuncturist: I only have two hands right? (refer to Doctor Octopus as per my previous post http://qi-spot.com/2010/03/30/how-to-research-acupuncture/) And clinical experience says it works faster.

Skeptic: “Clinical experience” bah humbug!

On to point two:

2) So the second research says there’s a difference between nothing and acupuncture, whether sham or not.  The first research says there’s a difference, physiologically, between sham and real acupuncture.  I can foresee the dialogue now:

Skeptic: okay you say that clinically there’s a difference between sham and real acupuncture.  I want empirical evidence that there is a difference.  Otherwise I can just ignore your clinical experience like I ignore all other evidence that acupuncture can work and work well.  I’ll take the words of statisticians and published journals funded by Big Pharma over clinicians anyday.

Acupuncturist: Well what if there is proof that there is a physiologic difference between real and sham?

Skeptic: Is there?

Acupuncturist: That’s what the first study quoted above says.

Skeptic: Hmmm it says that it’s clinically similar, just physiologically different!

Acupuncturist: Jeez, I don’t know how to talk to you guys sometimes.  You say the real thing is no different than sham, so who cares if it works or not.  Then we say but both sham and real thing are better than nothing, you say that guys like Ernst et al say the studies suck, utterly ignoring that western medicine is also guilty of the same sins at times (perhaps more on that on a later blog post.. oh wait, lots of those already!)

Skeptic: Not all acupuncture studies suck, just the ones that prove acupuncture doesn’t work.

Acupuncturist: Then you insist in your holy grail of treating acupuncture like a pill, even though I’ve explained kabodles of times that Acupuncture is a procedure, not a pill (ka ching, five cents).

Patient (sneaking in): Uh guys, I don’t give a crap about that stuff, I just want to feel better so I can get on with my life.

Skeptic: You’re an idiot.  You don’t know squat.  We’re the only ones with brains and we know what’s best for you and what medicines you should buy.  Any perceived benefits from acupuncture and Chinese medicines are all in your head.  You’re too dumb to know the difference.

Philip: Okay I should stop now.  I’m going overboard with this blog post ha ha.

In several previous posts, I have often lambasted the self-induced blindness of skeptics who love to “point out” that real acupuncture seems to be no better than sham acupuncture (http://qi-spot.com/2009/11/15/news-bias-a-pain-in-the-neck/, http://qi-spot.com/2009/11/11/associated-press-needs-new-glasses/, http://qi-spot.com/2009/10/17/lend-me-your-ears-ear-acupuncture-for-back-pain-in-pregnant-women/).  Well now comes another article (http://www.reuters.com/article/idUSTRE5BL3J320091222) this time talking about Acupuncture in relieving itch.

Acupuncture may ease the itch of eczema
Amy Norton
Tue Dec 22, 2009 1:22pm EST

NEW YORK (Reuters Health) – An acupuncture session may bring some itch relief to people with the allergic skin condition known as atopic eczema, a preliminary study suggests.

Eczema is a general term for conditions marked by inflammation and dry, red, itchy patches on the skin. The most common form, atopic eczema, is seen in people with a predisposition to allergies, like hay fever or asthma.

In other words, skin wheals in people with Lungs that are deficient in Defensive Qi.

In the new study, German researchers looked at the short-term effects of acupuncture on skin inflammation and itching in 30 people with atopic eczema.

They found that the therapy, when done minutes after patients’ skin was exposed to an allergen (either pollen or dust mites), appeared to soothe subjective feelings of itchiness.

In addition, when patients were exposed to the allergen for a second time shortly after the acupuncture session, they tended to have a less-severe skin reaction, the researchers report in the journal Allergy.

Allergy.  Not just some two bit journal that can be bashed.  Also, note the effect on subsequent attacks.  Of course, it would be better if it works weeks after treatment.  Wait, it does.

The findings show that in this “experimental setting,” acupuncture seems to ease the itch of atopic eczema, lead researcher Dr. Florian Pfab, of the Technical University of Munich, told Reuters Health in an email.

The study does not, however, answer the question of whether acupuncture as practiced in the real world would have similar benefits.

For the study, Pfab and his colleagues looked at all 30 patients under three different test conditions.

In one, patients had their skin exposed to either pollen or dust-mite allergens, then received true, or “point-specific,” acupuncture — in which needles were placed in traditional acupuncture points that, according to Chinese medicine, are related to itchy skin.

In another condition, the allergen exposure was followed by “placebo-point” acupuncture, where the needles were inserted into skin areas not used in traditional Chinese medicine. In the third condition, patients received no treatment.

Again, needles were inserted in true points, non points and in a third group, nothing.  According to the skeptics, inserting a needle anywhere activates the placebo effect – the patient THINKS they’ll feel better – and so they do.

Overall, Pfab’s team found, patients’ itchiness ratings were lower after they received true acupuncture, compared with both no treatment and placebo acupuncture.

Then, when the researchers exposed patients’ skin to the allergens a second time, skin flare-ups tended to be less-severe following the point-specific acupuncture. As for itchiness, however, both the true and placebo therapies had similar benefits compared with no treatment.

Again, effects that are explained by meridian theory: putting needles anywhere activates the meridian system, but it is most efficient when used in actual acupuncture points.  Why is this so hard for some to understand?  Oh I know, because they refuse to.  Kind of like what Saint Augustine once answered when asked if God is good why are not all men saved?  Augustine answered, “because they do not wish to be saved.”  (my paraphrasing).

People sometimes do not see the evidence because they refuse to see it.
Acupuncture has been used for more than 2,000 years in Chinese medicine to treat a wide variety of ailments. According to traditional medicine, specific acupuncture points on the skin are connected to internal pathways that conduct energy, or qi (“chee”), and stimulating these points with a fine needle promotes the healthy flow of qi.

Modern research has suggested that acupuncture may help ease pain by altering signals among nerve cells or affecting the release of various chemicals of the central nervous system.

Pfab explained that pain and itchiness have similarities in their underlying mechanisms, so acupuncture’s effects on pain mechanisms may also account for the benefits seen in this study.

The researcher pointed out, however, that more research is needed to see whether and why acupuncture might be helpful for people with eczema.

SOURCE: Allergy, online December 11, 2009.

Oh, and Merry Christmas to all! Happy Chanukah!

Once again, another study showing that “real” acupuncture is significantly better than “sham” acupuncture.  A single blind, randomized, sham-controlled trial was compared to use of standardized neck exercises aimed at chronic neck pain relief.  Shame on the Associated Press, really.

Certain Media Outlets' Ignorance of the Evidence is a Pain in the Neck

It seems that the Associated Press has gotten down to publishing, not one, but a series of articles proudly proclaiming that “experts” say that the benefits of alternative medicine are due to placebo.  A previous blog entry, “Associated Press Needs New Glasses” 11, Nov 2009, notes that these Associated Press-Big Pharma press releases proclaim that experts say that any beneficial effects of alternative medicine are due to placebo and that most studies that “prove” acupuncture effectivity aren’t worth reading because of lack of comparison of “real” acupuncture to “sham” acupuncture.

Before we cite another article that demolishes the “sham” sham, let’s examine some points (no pun intended) yet again.

Firstly, since it is obvious that alternative treatments do provide relief to patients, the powers-that-be can no longer use the “they don’t work” card.  They grudgingly acknowledge that they do make patients feel better but attribute it to being no better than placebo – or that the patient feels better because they THINK they’ll feel better.  The sheer irony here is that by that logic, we can also claim that western medicine works through placebo also.  Yet, for some reason, people are turning to alternative medicine precisely because western medicine doesn’t seem to work for them and their particular condition.  As my friend Noah Mckenna once told me, “just tell the naysayers that (our) placebo works better than (their) placebo”.

Secondly, since studies are indeed popping up proving that Chinese medicine (my thing) does have biomedical reasons for working, and has been shown to work, the next argument that “they” bring up is to critique the studies.  Among the most common whines are “the studies aren’t blinded”, or my favorite “acupuncture wasn’t compared to sham”.  My replies can be summarized in various previous blog entries.  (This Time, Chinese Herbal Medicine May Have Cure for Diabetes, October 15, 2009).  Sure, everyone has seen that back pain study that said sham acupuncture is the same as real acupuncture, but they have forgotten to note that sticking needles anywhere hypothetically can work because according to meridian theory, every square inch of the body is traversed by meridians and collaterals.  The point of using acupoints is that they are more specific in effect than common locus dolendi points.

But the point of this particular blog article was my finding of yet another article comparing acupuncture treatment (albeit with electrostimulation) vs sham.  Here’s the abstract:

Source: Chan, et al.  “Electrical Stimulation of the Wrist for Chronic Neck Pain: A Randomized, Sham-controlled Trial Using a Wrist-Ankle Acustimulation Device” The Clinical Journal of Pain: May 2009 – Volume 25 – Issue 4 – pp 320-326.  Accessed 15 Nov 2009 <http://journals.lww.com/clinicalpain/Abstract/2009/05000/Electrical_Acustimulation_of_the_Wrist_for_Chronic.10.aspx>

Discussion: Electrical acustimulation of the wrist administered as two, 30 minutes sessions /wk added value to standardized neck exercise for chronic neck pain. A 4-week course of treatment produced effects lasting 1-month posttreatment.

Ear Acupuncture Chart (image courtesy http://www.acupunctureproducts.com

Afraid of having needles stuck in you?

The American Journal of Obstetrics and Gynecology noted that  “ear acupuncture” works better than sham acupuncture at “fake” points and control in relieving low back and pelvic pain.

Excerpts from the text (“Ear Acupuncture Curbs Back Pain in Pregnant Women” courtesy of Reuters Health), which again is “news” to some people who don’t know that this technique has been around for hundreds of years.

In a study, women who had pressure needles held in place with tape at three acupuncture points in their ears for one week, were more likely to experience significant reductions in lower back and pelvic pain than those who had the needles placed at three “sham” points or women in a control group who didn’t get real or fake acupuncture.

Some “skeptics” justify their position about acupuncture by citing studies claiming that fake acupuncture  – real needles inserted in non acupuncture points – work seemingly just as well as those inserted into real points.  They often claim this means points are useless.  They also forget that inserting needles is better than not inserting.

Actually this proves the meridian theory is real, since Qi flows through the meridians, thus putting needles along the meridians WILL have some effect, albeit not the ideal one.  So what did the researchers do here?

They randomly assigned 159 women in the 25th to 38th week of pregnancy to receive real acupuncture, acupuncture delivered to points that would theoretically not affect pain in the pelvic or lower back area, and a control group.

For ear acupuncture, the points are more specific and there are no “lines” connecting the dots.  Therefore, you have to use the points properly or have no effect at all, even if you put stimulation in other parts of the ear.

The results:

A 30 percent or greater reduction in pain was reported by 81 percent of women in the acupuncture group, 59 percent of women in the sham acupuncture group and 47 percent of women in the control group. The difference between the sham and control groups wasn’t statistically significant.

Thirty-seven percent of women in the acupuncture group were pain-free after a week of acupuncture, compared to 22 percent in the sham group and 9 percent of the control group. Improvements in function were significantly greater among women who had real acupuncture compared to those who got the fake version or received no treatment.

So, real acupuncture works better than fake or ordinary painkillers, etc…  Okay… maybe NOW the skeptics will believe us. (I wish.)

But the pain relief didn’t persist for some; a week after the end of acupuncture treatment, 68 percent of those who received the real thing still had a 30 percent or greater reduction in pain compared to the beginning of treatment, while 32 percent in the sham acupuncture group and 18 percent of the control group sustained this level of pain reduction. There was no significant difference among the groups in the percentage remaining free of pain two weeks into the study.

So one week of real acupuncture produced more lasting relief than fake acupuncture.  Imagine if we actually continued the treatment.

The original study: <http://www.ajog.org/article/S0002-9378(09)00424-4/fulltext>

Sources:

Reuters Health.  “Ear Acupuncture Curbs Back Pain in Pregnant Women” abcnews.go.com 16 October 2009.  17 October 2009 <http://abcnews.go.com/Health/WireStory?id=8847011&page=1>
Shu-Ming Wang, Peggy DeZinno, Eric C. Lin, Haiqun Lin, James J. Yue, Michael R. Berman, Ferne Braveman, Zeev N. Kain.  “Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study” American Journal of Obstetrics & Gynecology September 2009 (Vol. 201, Issue 3, Pages 271.e1-271.e9) Online June 29, 2009.  17 October 2009 <http://www.ajog.org/article/S0002-9378(09)00424-4/fulltext>