Shining a light on Evidence Based Acupuncture- an organisation promoting acupuncture research and disseminating good quality evidence based information on acupuncture.
The Evidence for Acupuncture
When we see discussions of acupuncture in the press and over other media, the tone is overwhelmingly from the point of view of the sceptic. Those few vocal acupuncture haters get a platform again and again to repeat their views and point out, supposedly from the ‘scientific’ viewpoint, that there is little evidence that acupuncture has beneficial specific effects over those of placebo etc. I have written about these areas elsewhere on this website but have been inspired to put some of these arguments together again in this blog format to promote the work of Evidence Based Acupuncture.
This group founded by Mel Hopper Koppelman has the aim of collecting, examining and disseminating evidence on acupuncture in order to equip the professional acupuncturist with tools and knowledge to have evidence based discussions with such skeptics. They have also been vocal in pointing out a balance of the evidence and challenging the status quo so often put forward in the press. It is important that someone do so on an academic and serious level, I appreciate the voice in the corner of professional acupuncture.
After I had completed my masters and was expecting my first child I got a couple of articles out into the Journal of Chinese Medicine and the Lantern, but made the decision that I would hold back on the academic style of writing as it is so terse and restrictive, and takes such a long time! I realised that if everything I wrote was rigorous and referenced I would not get very much out there, this decision developed into the decision to write the blog in an informal voice, plain speaking and easy to understand, though ultimately open to criticism. So I am very pleased that someone is out there engaging with the research and speaking out from an evidence based position and getting involved in debates on that level as they did recently on a discussion in the British Medical Journal.
It is my contention that most often the journalists that write these pieces are most often humanities graduates who do not actually understand the methodological issues of the research or even how to interpret the results, but rather take the word and interpretation of a few vocal acupuncture hatersuncritically, safe in the belief that science, and therefore right, is behind them.
A few issues summarised
Here follows a few of the issues that come up time and again in discussions of acupuncture and evidence base, informally, in my own words, and without a list of academic references. Please trust that I have read quite a bit of research in my time, and you can fill in some gaps with the British Acupuncture Council here, and with Evidence Based Acupuncture here.
Sham acupuncture control is not an inert placebo
The placebo controlled randomised controlled trial (RCT) is a method that has been considered the gold standard for clinical research, but it has grown out of a pharmaceutical model. It makes sense with drugs, you can give someone a sugar pill or inject saline without the subject’s knowledge, this becomes more difficult in a body centred, individualised treatment approach like acupuncture.
There are studies which show that the effect size of sham acupuncture modalities, several of them are between two and three times the size of what is expected of placebo effects. Other research shows that stimulating the nerve endings of the tissue has a physiological effect, and is thus an inappropriate control for acupuncture trials. It is like comparing two different styles of acupuncture, channel acupuncture with tendinomuscular acupuncture, or in some cases, accurate well applied acupuncture vs. sloppy ill applied acupuncture
Acupuncture performs well when compared to other clinical interventions
These days when a new pharmaceutical product comes to market it is considered unethical to give a patient an inert treatment so instead a new product is trialed against the accepted treatment currently available. When acupuncture is compared to other treatment interventions, standard care in the form of NSAID’s for example, or physiotherapy, it performs very well.
Some of the biggest acupuncture trials performed in Germany in the 2000’s showed very clearly that acupuncture performed better than standard care and physiotherapy for osteoarthritis of the knee, headaches and back pain, but because they were cohort studies rather than RCTs they are ignored by the anti-acupuncture scientific establishment. There is a more detailed account of evidence in this area in Mel Hopper Koppelman’s response article here. When comparing across trials it can be seen that even the sham acupuncture out performs standard care, and even has lower associated risks.
Acupuncture does outperform controls in many trials despite the control being more effective than some standard treatments
It is only by fixating on the placebo/ sham acupuncture issue that the critical voices are able to assert there is ‘no evidence’. In fact there is a lot of evidence, and it is indeed the case that around half the published randomised control trials do not show a significant difference between real and sham acupuncture- the other half do show a significant difference. If there were no effect of ‘real’ acupuncture over and above ‘sham’ acupuncture it would be unlikely that around half the trials would show a significant effect. Indeed the National Institute for Clinical Excellence (NICE) now recommends acupuncture for headache and migraine on the basis of a Cochrane review finding a beneficial effect.
Different research design answers different questions
In short, the randomised control trial design that feeds the idea that acupuncture doesn’t have evidence for effectiveness because it often does not show a significant difference to sham, answers only a very specific question about efficacy. Looking at acupuncture in a laboratory setting, comparing it to a treatment designed to be as close to acupuncture as possible, a standardised set of points, sometimes delivered by a technician with no experience in order to ‘double blind’ the patient and practitioner as to which is the real treatment is, will only yield results about that very artificial set up.
A pragmatic control trial design or a cohort study monitors outcomes in a real world context comparing groups with the same conditions treated with different modalities. And guess what, in trials of this design, acupuncture tends to perform rather well. So a question to you is, what is more important? Answering whether acupuncture (or any other treatment) benefits actual patients in the real world in a meaningful and rigorous way? Or whether it is significantly different from a bastardised version of itself in a laboratory?
Acupuncture is safe
In the right hands, properly trained hands, acupuncture is incredibly safe and well received. There is a small risk of a tiny bruise forming, and there are a few points over bodily structures that you wouldn’t want a needle going into, but if the practitioner has the proper training and anatomical knowledge, they will needle the points safely. So when you compare acupuncture in a large scale, including the thousands of treatments given each year, to other mainstream treatments, it comes out as a lot safer. And the number of treatments is growing, especially as more and more physiotherapists, osteopaths etc use the technique more and more. I also know of neurologists and EENT consultants who use acupuncture in their hospital work. Would that be the case if there weren’t observable clinical effects?
Which brings me to one of the main points made in the Evidence Based Acupuncture response article (link), standard pharmaceutical treatments for pain carry significant risks of morbidity and increased mortality in large numbers of patients. That piece goes through each major group of drugs systematically and with references, I suggest you read it.