I have written numerous blogs both here and on SBM about the acupuncture literature, which clearly shows that acupuncture, for any indication, is nothing but an elaborate placebo. Rigorous studies of acupuncture that actually try to isolate variables have shown that it does not matter where you stick the needles or even if you stick the needles – those variable do not have any specific effect. Acupuncture points and meridians are an illusion – nothing but superstition.

But there does appear to be a significant placebo effect, in addition to non-specific effects from relaxation and therapeutic attention, to the ritual of acupuncture. Does this mean “fake acupuncture works?” No – it means acupuncture does not work, but there are known placebo effects from the process of getting treated.

Now we have yet another study that supports the conclusion that acupuncture is just a placebo – but with an added element that is very interesting. Researchers compared traditional Chinese acupuncture (TCA) with sham acupuncture (non acupuncture points, shallow needle insertion) and another control group with no treatment for knee osteoarthritis. The researchers also did one very interesting thing, and one very sloppy and annoying thing (in my opinion). The sloppy thing was to use “electroacupunture” – which isn’t pure acupuncture. It’s acupuncture plus transcutaneous electrical nerve stimulation, which is an already proven modality for pain. In the TCA group they gave full “electroacupuncture” and in the sham group they gave less stimulation – enough to serve as an active placebo but not enough to have any effect.

Continue Reading »

Check out this photo gallery of strange medical treatments (the title says “unorthodox cures” which is begging the question – do they cure anything). Seeing a photo of a treatment being given has more impact than just reading a description.

My favorite is the woman with smoking sticks jammed in her ears. This is a form of moxibustion, often mixed with acupuncture. I couldn’t find an explanation for the walnut in the eye.

I have covered bee venom therapy before.

Continue Reading »

One of the core “pearls” of this blog is that not all scientific studies are created equal. It is common for the media and the public to cite the fact that “a study shows” some claim or other, but such appeals to evidence are worthless unless we can assess the quality of the study. We now have a gaggle of science bloggers – real scientists blogging about research – to help explain all the various ways to look at the quality of a study, and hopefully this is resulting in a more savvy population of science enthusiasts (the kind of people who read science blogs).

Let’s take the following hypothetical study: The study included 24 subjects who were all treated openly with the intervention in question. There was no blinding or control group – so everyone in the study, subjects and experimenters, knew that every subject was getting the treatment. The treatment involves active physical intervention with the subject. The protocol also calls for multiple interventions if initial treatments are not effective – essentially the subjects receive repeat treatments as long as possible until they report a response.

The outcome was either a change in vision or hearing. Subjects reported impaired vision or hearing at the beginning of the study and were tested with standard vision or audiology tests before and after treatment. All subjects demonstrated improvement from the intervention.

Continue Reading »

John (a fictitious patient) is suffering from fatigue, poor sleep, difficulty concentrating, and has been noticing little bumps on his skin. His primary care doctor performed a basic workup, which was completely negative, and started asking John about his stress levels and sleep habits. But John was convinced that something was happening to him and so sought additional opinions.

He was referred to Dr. Charles Rank, an allergist, by a work colleague. Dr. Rank took a typical medical history but then also asked John extensively about his environmental exposures and his diet. Dr. Rank believed that John’s history was suggestive of an allergy, and so he brought out his newly acquired Vega II diagnostic testing machine.

The Vega II is a sophisticated-looking piece of electronic equipment, and Dr. Rank seemed confident in working its many knobs and buttons. He attached a few electrodes to John and then pressed a metal probe against his skin while John held in turn a series of glass tubes, each filled with a different substance. Each time the Vega II squealed and beeped, and John could see a gauge registering to varying degrees. It all looked quite complex and impressive.

Continue Reading »

Here is the conclusion quoted from a recent New England Journal of Medicine (NEJM) review article on acupuncture for back pain:

As noted above, the most recent wellpowered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture. The simplest explanation of such findings is that the specific therapeutic effects of acupuncture, if present, are small, whereas its clinically relevant benefits are mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.

Translation – acupuncture does not work. Why, then, are the same authors in the same paper recommending that acupuncture be used for chronic low back pain? This is the insanity of the bizarro world of CAM (complementary and alternative medicine).

Continue Reading »

I used to think that bloodletting was a Western cultural invention – part of Galenic medicine involving the balancing of the four humors, one of which being blood. Bloodletting faded away with the advent of science-based medicine in the 19th century. But it turns out that bloodletting was common throughout ancient cultures and not unique to the west.

In fact acupuncture was originally a form of bloodletting – the “needles” were really lances and the acupuncture points locations over veins to be opened. Chi, or the Chinese concept of the life force, was believed to be partly in the blood, and bloodletting could be used to free the flow of chi. This was closely related to the Galenic concept of using bloodletting to free the flow of static blood in the tissue.

For example, in the ancient medical text of Suwen, we find:

When heaven is warm and when the sun is bright,
then the blood in man is rich in liquid
and the protective qi is at the surface
Hence the blood can be drained easily, and the qi can be made to move on easily…

Continue Reading »

The development of drugs and other treatments for specific symptoms or conditions relies heavily on either serendipity (the chance finding of a beneficial effect) or on an understanding of underlying mechanisms. In pain, for example, there are limited ways in which we can block pain signals – such as activating opiate receptors, or inhibiting prostaglandins. There are only so many ways in which you can interact with these systems. The discovery of a novel mechanism of modulating pain is therefore most welcome, and has the potential of leading to entirely new treatments that may have a better side effect profile than existing treatments and also have an additive clinical effect.

A recent study by Nana Goldman et. al., published in Nature Neuroscience, adds to our understanding of pain relief by identifying the role of adenosine in reducing pain activity in the peripheral nervous system. The researchers, in a nice series of experiments, demonstrated that producing a local painful stimulus in mice causes the local release of ATP (adenosine triphosphate) that peaks at about 30 minutes. This correlates with a decreased pain response in the mice. Further, if drugs are given that prolong the effect of adenosine, the analgesic effect itself is prolonged.

Also, if drugs are given that activate the adenosine A1 receptor, the observed analgesic effect is replicated. When these experiments are replicated in knockout mice that do not have the gene for the adenosine A1 receptor, there is no observed analgesic effect.

Together these experiments are fairly solid evidence that local pain results in the local release of adenosine that in turn binds to the adenosine A1 receptor inhibiting the pain response. This is potentially very exiting – it should lead to further investigation of the adenosine A1 receptor and the effects of activating and inhibiting it. This may lead to the development of drugs or other interventions that activate these receptors and may ultimately be a very useful addition to our ability to treat acute and chronic pain.

Continue Reading »

Language is a powerful but tricky thing – it not only is a tool for expressing our thoughts, to a large degree it shapes and frames our thoughts. This is true in every area of intellectual enterprise – where expanding one’s vocabulary literally expands the palette of ideas and concepts available, and technical or specialized language typically develops to precisely capture the necessary concepts.

This is true in my own field of medicine. I often caution students, for example, to use the proper terminology – not out of convention, but because sloppy language leads to (equals, in fact) sloppy thinking. The legs are not “below” the arms, they are “caudal” to the arms – further along the neuraxis away from the brain. Not only is it important to use terms that are precise, it is important (and a more subtle problem) to use words that are not prematurely precise. Disease taxonomy is often hierarchical, and if you commit yourself too early to a narrow branch, you will prematurely narrow your thinking as well. The patient did not present with “seizures”, they presented with “episodes” – and it is for us to determine if these episodes are seizures or something else.

Politicians and marketers use language differently from scientists and philosophers. The latter is concerned with precision and accuracy, while the former with emotion, deliberate vagueness, and false implication.

The specific example I am getting to today is a particular peeve of mine – the gross overuse of the term “therapy.” It seems you can throw the term “therapy” at the end of any activity and thereby imply that it has a specific medical application, or some benefit beyond the obvious pleasure or benefits of engaging in that activity. So now we have aromatherapy, massage therapy, music therapy, and dance therapy. “Therapy” has become a marketing term, like “natural” – rendered devoid of precise meaning and used to create vague implications.

Continue Reading »

Some of the pseudoscientific “alternative medicine” modalities we deal with are easy to summarize: homeopathy is 100% nonsense – nothing but water; acupuncture (if you define it as placing needles in specific acupuncture points) has no measurable effect beyond placebo, and therapeutic touch and other forms of energy healing are nothing but magical thinking. But when people ask me, “What do you think about chiropractic?” there is no one-liner. This is partly because “chiropractic” is not a monolithic profession; it is a many-headed beast. It is a mixture of legitimate interventions and pure pseudoscience in widely varying proportions. But also, chiropractors tend not to be self-reflective as a profession, and are shy about outside scrutiny.

But the internet contains a wealth of information and is increasingly useful as a tool to survey practices and claims. Edzard Ernst has recently published a survey of English-speaking chiropractic websites and found some very informative results. Ernst is a professor of complementary and alternative medicine and has become the Energizer Bunny of holding CAM up to the light of rigorous science.

The question is this – since many chiropractors mix evidence-based and non evidence-based practices, what can we say about the percentage of chiropractors who are basically evidence-based vs pseudoscientific?  Are most chiropractors mostly scientific, or are most chiropractors peddling pseudoscience with just a patina of legitimacy?

Continue Reading »

Acupuncture is a so-called complementary and alternative medicine (CAM) modality I frequently tackle because it often provides excellent  teaching points on the relationship between science and the practice of medicine. My reading of the literature is that acupuncture is highly implausible and the evidence does not support its efficacy for any indication.

And yet it is one of the more popular CAM modalities (although still a small phenomenon – only 6% of Americans have ever used it), especially in its penetration of hospitals and academia. There is a great deal of misinformation out there about acupuncture, and this seems to garner the most attention from naive physicians.

In vitro fertilization (IVF) is one of the applications of acupuncture that has been most touted by proponents. The evidence for any positive effect from acupuncture for IVF, however, has been consistent with no effect. By this I mean that there are poor quality studies with mixed results, but trending positive (as poor quality studies tend to do), especially in China and other nations culturally predisposed to acupuncture, but the better designed studies tend to be negative.

Continue Reading »