Wednesday, July 27, 2011

Notes On 'Trick Or Treatment'- Chapter 2- Acupuncture by Ernst & Singh

Before we begin we should define our terminology, Ernst and Singh define Acupuncture as such:
"An ancient system related to the flow of a life force (Ch'i) through pathways (meridians) in the human body. Acupuncturists place fine needles into the skin at critical points along the meridians to remove the blockages and encourage a balanced flow of the life force. They claim to be able to treat a wide range of diseases and symptoms." (Ernst & Singh, pg-40, 2008)  
Before the Acupuncturist can attempt to place needles along the patients meridians (which generally go to about 1-10cms in depth) they need to begin with a diagnosis of the patient which is relies on 5 techniques known as inspection, auscultation, olfaction, palpation and inquiring (for more on what that means see pg 44).

The authors trace Acupuncture's supposed origins to the Mongolian war, 2,600 B.C where according to legend  a warrior was supposedly shot by an arrow which, instead of killing him, cured him of a longstanding illness (pg 42). Despite this tale and a long history of it's usage, is there any reason to believe that Acupuncture actually works though?

There have been many demonstrations of it's seeming authenticity, originating in China, like that in 1970 of a patient going through open heart surgery with only the power of Acupuncture to dull the pain. Colour photos were taken of the smiling patient with an open chest (a similar demonstration was shown as late as 2006 on the BBC TV series "Alternative Medicine"), however it now seems likely that the Chinese (the BBC TV) demonstrations were faked, and  involved supplementation by local anaesthetics, sedatives and other means of pain control (pg 48).

This "evidence" did create a mad rush for Acupuncture practitioners in the 70's, and in response, during that time, the World Health Organisation (WHO) summarized the evidence for Acupuncture concluding that there were 20 conditions that lent themselves to it's treatment, including tonsillitis, the common cold, bronchitis, asthma, duodenal ulcers, dysentery, constipation, diarrhoea, headache and migraine, frozen shoulder, tennis elbow, sciatica, low back pain and arthritis (pg 51).This added credibility (as WHO is a widely respected organisation) to Acupuncture as a practice, resulting in the slow acceptance of Acupuncture by western doctors, the only problem, was the mechanism that caused the needles in specific meridians to interrupt the flow of Ch'i, as these terms "have no meaning in terms of biology, chemistry or physics, but rather they are based on ancient tradition." (Ernst & Singh, pg-52, 2008)

Several theories were developed to attempt to demonstrate mechanisms, (1) being the " gate control theory", (2) being the existence of chemicals called "opioids", but unfortunately for Acupuncturists both of these theories fell to something a little more mundane, the placebo effect. The word 'placebo' is Latin for 'I will please' and it was "used by writers.. to describe insincere expressions that nevertheless can be consoling" (Ernst & Singh, pg-57, 2008). The reason for this? Ernst and Singh discuss 3 criteria that enhance the likelihood of bunk treatments causing the placebo effect; the doctors reputation (or administrators reputation), the cost of the treatment (the more it costs the more it must work), and the novelty of the product used (for an in-depth analysis of the placebo effect, on whether the benefits it produces are worth the risk, and whether it is a Pavlovian response or not please see pages 57-62).

Improvement of trial methodology
The problem of the placebo effect forced practitioners to re-define their clinical trial methodology, to keep the results hidden from the participants and the doctors performing the trials, an experiment methodology called "double blind" was developed, but what is it exactly? To answer that we must demonstrate what standard trials consist of, to quote Ernst and Singh:
"The simplest for of clinical trial involves a group of patients who receive a new treatment being compared against a group of similar patients who receive no treatment. Ideally there should be a large number of patients in each group and they should be randomly assigned. If the treated group then shows more signs of recovery on average than the untreated group, then the new treatment is having a real impact.. or is it?" (Ernst & Singh, pg-63, 2008)
This details a simple clinical trial, with only a test group and a control group, Ernst and Singh continue:
"We must now also consider the possibility that a treatment might have appeared to be effective in the trial but only because of the placebo effect. In other words, the group of patients being treated might have expected to recover simply because they are receiving some form of medical intervention, thus stimulating the beneficial placebo response." (Ernst & Singh, pg-63, 2008)
This led to the development of the blind trial (the patients are unaware if they are the control group or the test group) and the double blind trial (the doctors administering the test and the patients in the test do not know who is in the control group or the test group). The benefit of course being; the experimenters have the best chance to remove unconscious bias and the placebo effect.

This new methodology allowed clinicians to go back and look at the WHO meta- analysis and see which trials were high quality and which weren't, which drastically reduced the support for Acupuncture. In the 90's skeptics pushed for "a major reassessment of Acupuncture, this time with placebo-controlled clinical trials involving sham needling" (sham needling is a method to make it seem to the patient as if they are being needled when they aren't) (Ernst & Singh, pg-69, 2008) .

Acupuncture has since been tested and the summary of that literature has been reviewed by an organisation called "The Cochrane Collaboration", the reason they are superior to WHO is due to their acceptance of only the trials with the best methodology, as opposed to WHO, who published "nothing more than casual uncritical overviews." (Ernst & Singh, pg-76, 2008)

What are the Cochrane Collaboration's primary results? Ernst and Singh summarize: 
"1. Cochrane reviews deem that the evidence from clinical trials does not show acupuncture to be effective.
2. Cochran reviews conclude that the clinical trials have been so poorly conducted that nothing can be said about the effectiveness of acupuncture with any confidence.
3. The research is so poor and so minimal that the Cochrane Collaboration has not even bothered conducting a systematic review." (Ernst & Singh, pg-78, 2008)
Cochrane has recently given it's tempered support behind Acupuncture (it's important to note their support is half hearted, they do not find the evidence "fully convincing") to help with pelvic and back pain during pregnancy, post-operative nausea and sweating, low back pain, neck disorders, chemotherapy induced nausea and sweating and bedwetting (most beneficial procedures relate to pain). The amount and quality of evidence needs to be improved before any strict recommendations can and should be recommended (pg 78-9).


Ernst and Singh summarize by stating that "if acupuncture were to be considered in the same way that a new conventional painkilling drug might be tested, then it would have failed to prove itself and would not be allowed in the health market." (Ernst & Singh, pg-84, 2008) It seems that Acupuncture's seeming reluctance to disappear has less to do with it's efficacy and more to do with the multi-billion dollar industry surrounding, and promoting it (much like of the supplement industry). Whatever benefits there are to Acupuncture they are small, the cost of the procedure outweighs the possible benefit of the placebo effect and there are far better (and cheaper) treatments for pain relief with adequate evidential support.

Ernst E., Singh,. S. (2008). Trick Or Treatment. New York, New York. W.W Norton & Company. Pp- 40, 42, 58, 51, 52, 57, 63, 69, 76, 78, 79 .

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