Acupuncture point by point
Does acupuncture work? It's often heralded as proof that alternative medicine works and you can find it in many hospitals. But a lot of the observed benefit is the placebo effect. I deal with the issue in my latest article for the Montreal Gazette.
Alternative medicine is creeping into hospitals. Reflexology, homeopathy and reiki are being adopted by big medical centres across the continent. Demanded by patients and reimbursed by insurers, the popularity and acceptance of these therapies are on the rise. Acupuncture has been particularly popular recently and its interest was bolstered by a recent Cochrane review suggesting it might help with tension type headaches. However, this review had a number of statistical problems with it.
First, the data listed in the meta-analysis didn’t match the data presented in the published studies. Second, the review used a fixed-effects rather than a random-effects model. This is a subtle statistical point, but it means that a less rigorous statistical approach was used.
My big problem with the paper, though, was that the reported benefit was largely driven by one trial. This 2007 study examined traditional acupuncture against “sham” acupuncture where needles were inserted in random locations.
There was no significant difference between the two groups in terms of the trial’s primary endpoint. Roughly 33 per cent and 27 per cent of patients responded, respectively. However, the study’s authors then proceeded to redefine what constituted success, and the success rates jumped to 66 per cent and 55 per cent. I become worried when endpoints change and negative studies become positive.
How can the response rate be so spectacularly high? It’s worth noting a quote from another study by the same research group. In that study, on low-back pain, the authors stated: “Effectiveness of acupuncture, either verum (true) or sham, was almost twice that of conventional therapy.”
In other words, no matter what was done — whether traditional acupuncture or some guy randomly sticking needles into your back — people felt better. In that study, the response rate was 47.6 per cent for true acupuncture, 44.2 for the sham group, and 27.4 per cent for those who had nothing done to them.
The truth is, most of the benefits of acupuncture likely stem from the placebo effect. Proponents of traditional acupuncture say inserting needles along meridians redirects the Qi, a life force energy that flows from organs to the skin. Having looked inside many human bodies over my career, I can tell you that no such meridians exist.
The larger problem is that it is impossible to completely tease out the placebo effect when it comes to acupuncture. It is not like trials with medications, where the placebo group is given sugar pills.
A number of placebo techniques have been tried. For example, needles can be inserted into the patient randomly or only superficially. There are also special retractable needles that pop back into the shaft of the device after piercing the skin. However, patients who’ve undergone acupuncture know what the traditional procedure is supposed to feel like, and where the needles are supposed to go. At the same time, the practitioners obviously know whether they are using real needles or inserting them differently, and their behaviour often clues in the patients as well.
Not surprisingly, this has led to the finding that much of the effect of acupuncture is guided by the acupuncturist’s style and bedside manner more than anything else.
Some will use the “what’s the harm” argument and suggest that any benefit — even that of a placebo — is worth the effort. I disagree.
For one thing, acupuncture is not entirely risk-free. Complications like infections and punctured lungs have been reported, as Edzard Ernst details in his 2011 paper in Pain.
As well, the practice uses precious health care resources we can scant afford to waste in a time of repeated budget cuts.
Finally, the medical profession decided long ago that selling placebos to patients was unethical, no matter how convenient or profitable it might be.