One of my continuing goals in China is to find traditional Chinese medicines and practices that I can integrate into my Western, allopathic-style family practice. As I’ve reported a few times, I’ve been struggling to find Chinese herbal medicines that I am comfortable prescribing, usually due to lack of evidence for a clear benefit.
As for acupuncture, there are actually a lot more well-designed studies done on this field when compared to Chinese herbs, mostly because Europe and the West have become very interested over the last couple decades and are funding better clinical trials. The evidence trail is building, which is great for everyone. So, what works, and what doesn’t?
The New York Times has a very readable article last week which covers this issue. The gist of the article discusses the most recent, well-designed studies on back pains and other disorders; the studies usually show no difference between acupuncture and placebo (usually a “sham” needle that doesn’t penetrate the skin). In other words, the best studies lately are usually showing that most of the perceived effect from acupuncture is simply a placebo effect.
These recent findings are by no means surprising, as most of the best studies have been reporting similar conclusions for many years. The best collection of acupuncture research is from the Cochrane Review Group, which performs the world’s most rigorous reviews of all treatments, including alternative medicines. They have an outstanding collection of the best literature on acupuncture which details the best evidence regarding a number of acupuncture treatments. Unfortunately, as many other researchers have noted, the only treatments for which acupuncture is even mildly effective are for musculoskeletal problems and nausea. There is some evidence of effectiveness for treatments for IVF, as well as insomnia. But many well-designed studies have specifically shown no benefit over placebo for a host of other treatments. The Cochrane group also commonly finds that the quality of studies is very poor and cannot recommend either for or against.
Readers should be aware that this is not simply a Western bias against alternative medicines; in April a group from Beijing Hospital published in a Chinese journal a similar literature review of acupuncture for insomnia, and couldn’t even make a conclusion because the studies were so poor:
Regarding the assessment of the therapeutic effect, measuring scales are often adopted in overseas studies, while in domestic researches, self-drawn standards are frequently used. In conclusion, there have had no high-quality clinical trails about acupuncture treatment of primary insomnia in China at the present, and the related evaluating methods could not definitely confirm the efficacy of acupuncture in relieving insomnia. Therefore, a strict and scientific clinical trail scheme being in line with evidence-based medicine is urgently needed in the coming studies on acupuncture treatment of primary insomnia.
The Cochrane’s reports cover a lot of therapies that I’m sure many readers have tried. Here’s an example of Cochrane’s findings on the most common acupuncture treatment — low back pain:
Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and “alternative” treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.
“…Thirty trials, and 2812 participants were included in the review and meta-analysis, however there was insufficient evidence that acupuncture can assist with the management of depression.”
In the four trials in which acupuncture was compared to a proven prophylactic drug treatment, patients receiving acupuncture tended to report more improvement and fewer side effects. Collectively, the studies suggest that migraine patients benefit from acupuncture, although the correct placement of needles seems to be less relevant than is usually thought by acupuncturists.
Seven studies were eligible for inclusion in the review, involving 590 participants. The studies were of low methodological quality and were diverse in the types of participant, acupuncture treatments and sleep outcome measures used, which limited the ability to pool the findings and draw conclusions. Currently there is a lack of high quality clinical evidence supporting the treatment of people with insomnia using acupuncture. More rigorous studies are needed to assess the efficacy and safety of various forms of acupuncture for treating people with insomnia.
Other reputable sources of evidence include the National Center for Complementary and Alternative Medicine. Also, the excellent evidence-based blog The C.A.M. Report has a section on acupuncture studies. Another blog, Science-Based Medicine, has a section on acupuncture. And I’ve started to read a couple of recently published books which also take a rigorous, evidence-based review of alternative medicines, and I recommend them to my readers. One is called Trick or Treatment: The Undeniable Facts About Alternative Medicine; the other is called Snake Oil Science: The Truth About Complementary and Alternative Medicine. Both can be downloaded via Amazon.com as an e-book. The New England Journal of Medicine has a book review of Trick or Treatment.
Does It Even Matter What The Science Shows?
Many readers may remark that complementary medicine, even if it is just a placebo effect, is still better than nothing. And I think that’s partly true; the placebo effect is simply a person believing and hoping they will get better. It’s an amazing and profoundly humbling revelation that simply believing in healing can set off a biochemical cascade which can boost your immune system and help your body to heal itself. The placebo effect is proven time and again in every study ever done. It’s called faith, and it’s crucial in any illness and is crucial just for living. Here’s a nice quote from the New York Times article:
…acupuncture believers say it doesn’t really matter whether Western scientific studies find that the treatment has a strong placebo effect. After all, the goal of what they call integrative medicine, which combines conventional and alternative treatments like acupuncture, is to harness the body’s power to heal itself. It doesn’t matter whether that power is stimulated by a placebo effect or by skillful placement of needles.
“In general in integrative medicine, when patients are involved in their healing process, they have a tendency to do better,” said Angela Johnson, a practitioner of Chinese medicine at Rush Children’s Hospital in Chicago who is conducting a pilot study of acupuncture to relieve pain in children. “I believe that’s part of the reason why they get better.”…
But one of the problems of relying on alternative medicines (which probably are a placebo effect) would be that you are losing valuable time in getting proper, effective treatment for something which may be serious. Also, you will potentially be spending a lot of your personal money for treatments no better than a placebo.
My Bottom Line
I personally feel that if a patient wants to try acupuncture for musculoskeletal problems like back pains, then they are welcome to try. It’s usually very safe, and sometimes can help; it’s also an interesting experience to do at least once. For almost all other treatments, I would try to pull up Cochrane Database evidence for such treatment and show my patients, and let them make their own decisions.
Hopefully by now, my long-term readers are convinced that evidence-based medicine is the most proper method of testing therapies, and that all treatments of any culture’s medical systems should be tested and proven with rigorous clinical trials. So, I hope we are all open-minded enough to believe that when the best trials show no benefit for a specific treatment — whether mainstream or alternative — then doctors shouldn’t recommend that, and consumers should think twice before wasting their money on it. On the flip side, doctors such as myself should be open-minded and recommend alternative treatments that are proven to work. There just aren’t that many…yet?
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