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Acupuncture Does Not Work for Back Pain

Posted in Science Based Medicine by Skepdude on May 13, 2009

Here goes Steven Novella’s take on the latest acupuncture study.

A new study which randomized 638 adults to either standard acupuncture, individualized acupuncture, placebo acupuncture using tooth picks that did not penetrate the skin, and standard therapy found exactly what previous evidence has also suggested – it does not seem to matter where you stick the needles or even if you stick the needles through the skin. The only reasonable scientific conclusion to draw from this is that acupuncture does not work.

But let me back up a minute. Imagine if we were evaluating the efficacy of a new pain drug. This drug, when tested in open trials (no blinding or control) has an effect on reducing pain – it is superior to no treatment. When compared to a placebo, however, the drug is no more effective than the placebo, although both are more effective than no treatment.

Now imagine that the pharmaceutical company who manufactures this drug sends out a press release declaring that their drug is effective for pain, but that their research shows that a placebo of their drug is also effective (FDA applications are pending). Therefore more research is needed to determine how their drug works.  Would you buy it?

That is the exact situation we are facing with acupuncture research.

Acupuncture is the traditional Chinese medicine practice of placing thin needles to a specific depth through the skin in specific acupuncture points in order to treat illness and relieve symptoms. Claims for acupuncture, including the number and location of acupuncture points, have changed greatly over the centuries, but there is no scientific evidence base for any of these claims. Acupuncture is philosophy-based medicine, not science-based medicine. The presumed mechanism for acupuncture, according to TCM, is that the needles unblock the flow of chi (life energy) through the body. Acupuncture points are supposed to corresponds to the pathways through which chi flow, correlating to specific organs or functions in the body.

Modern proponents of acupuncture come in two basic flavors – those who promote so-called medical acupuncture, and those who restrict their claims to symptomatic relief of pain, nausea, and other symptoms. Medical acupuncture is the claim that acupuncture can actually treat real medical diseases, like cancer. It is dependent entirely on the TCM philosophy of acupuncture, including the flow of chi. Medical acupuncture is pure pseudoscience without any basis in science or evidence and does not require further consideration.

Some proponents of symptomatic acupuncture have divorced their claims from the original philosophy of acupuncture, claiming that the needling works through more prosaic mechanisms, such as the release of pain-relieving endorphins or through nerve stimulation. While these explanations are plausible, they are post-hoc speculations and have not been demonstrated to occur to a clinically relevant degree.

But before we speculate about possible mechanism, we need to establish that acupuncture has an effect – that it works for some specific indication. This has not been established, despite rather robust clinical research efforts. If there were not a cultural inertia to the notion of acupuncture the existing research would have been sufficient to abandon this modality as a dead end.


3 Responses

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  1. red rabbit said, on May 15, 2009 at 10:04 AM

    Looking at acupuncture through a skeptical lens is important, but there is another aspect to this.

    Back pain has enormous psychological components. Patients hate to admit that depression (possibly due to the original injury) or other psychological factors may be contributing to their pain. Many patients will refuse the tricyclic antidepressants that have been shown to work so well in chronic pain syndromes (and in neuropathic pain) because they think that an “antidepressant” prescription means that the physician thinks “it’s all in my head.”

    Nobody knows how the TCAs help. It may not have anything to do with the mood effects. They hit so many receptors, they may have just happened to hit the right pain receptors. Or it might be the mood effects, who cares.

    My point, and I do have one, is that placebo effects are very important in back pain, and the illusion of relief may be more important than any physiologic effects. Acupuncture in back pain, whereas it is almost certainly placebo, has the potential to help many otherwise disabled folks.

    Being a physician who has been depressed, I can say unequivocally that treating depression helps pain, and depression hurts, physically, more than most would imagine.

    • Skepdude said, on May 15, 2009 at 11:08 AM

      I guess I see your point and this goes back to the story about physicians presciribing placebos to their patients. That is an ethical issue that can be argued for from both sides. But saying that acupuncture works as a placebo and saying that acupuncture works are two different things. That is what we as skeptics are concenred with, claims that acupuncture works. We come in and say “No it does not” for that cannot be questioned.

      I think the most interesting question is should doctors be prescribing placebos knowing full well they do nothing?

  2. red rabbit said, on May 18, 2009 at 1:01 PM

    It’s a hard question, for sure.

    Here’s my approach, in the office:

    Patient comes to me with complaint of (something hard to treat but benign like back pain, fibromyalgia, belly-aches, etc…). Has been doctor-shopping (I am doc #11 in six months). Has been fully investigated for said problem and it is a “functional” issue.

    Functional, in doctor-speak, means no organic issue. Potential psychological issues. Potential addiction issues. Likely personality issues. Probable lifestyle issues.

    Abuse, depression, sexual assault survivor, PTSD. Difficult and real problems.

    Patient says: I heard acupuncture (Feng Shui, aromatherapy, cupping, chiropractic…) could help for this. What do you think?

    I say, (if I don’t think it’s harmful in this case) I don’t know much about that. You should bear in mind the cost. It may or may not help, but it shouldn’t stop us from carrying on with our own treatment plan…

    I know it seems like tricking the patient, but the fact is, people just want to be doing something. Vitamin E cream? Doesn’t work for scars but people swear by it because it gives a sense of having done what you can.

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