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There was a discussion this week by Dr. Ernst concerning “The most important myth about acupuncture.” It was in response to a blog entry at the Acupuncture Now Foundation who suggested

The most important myth that needs to be put to rest is the idea promoted by a small group of vocal critics that acupuncture is nothing more than a placebo.

Well, no, that is not a myth. Acupuncture is a placebo.

Dr. Ernst does not think that the placebo effect is the biggest myth of acupuncture:

So, what IS the most important myth about acupuncture? I am not sure and – unlike the ANF – I do not feel that I can speak for the rest of the world, but one of the biggest myths FOR ME is how acupuncture fans constantly manage to mislead the public.

I like his reply but with all due respect to Dr. Ernst, I disagree. Having a Beeblebroxian ego, I know and I can, and will, speak for the rest of the world.

I meta lotta analyses I didn’t like

I read a lot of meta-analyses, both for work and for my hobby here at SBM . It is always nice to think about what goes into the meta-analysis. They are unlike sausages and laws as you really do need to know goes into their production.

For example, consider the effects of statins. Statins are pretty much interchangeable from a mechanistic point of view and are comparable.

Beta blockers? Not quite so much. Beta blockers are a bit more variable in their effects, so you would be cautious of a meta-analysis that compared ß1, ß2 and those with beta agonist properties and it would depend on the pathophysiology treated, hypertension or heart attack or migraine.

Infections? The use of nafcillin, ciprofloxicin or metronidazole are vastly different. I can think of no process where it would make any sense in comparing these three antibiotics in a meta-analysis for any process: “A meta-analysis & systematic review of antibiotics for meningitis” would be ridiculous.

Proponents of acupuncture like to use favorable meta-analyses as evidence of efficacy. For example take “Acupuncture as an intervention to reduce alcohol dependency: a systematic review and meta-analysis.” Please.

They:

aimed to ascertain the effectiveness of acupuncture for reducing alcohol dependence as assessed by changes in either craving or withdrawal symptoms.

And after reviewing 15 RCT’s, came to the conclusion that:

acupuncture was potentially effective in reducing alcohol craving and withdrawal symptoms and could be considered as an additional treatment choice and/or referral option within national healthcare systems.

Of course, the studies were of poor methodological quality. That is almost always the case with pseudo-medical studies.

But here is an observation.

On the many varieties of acupunctures

Throughout most of the paper they discuss acupuncture as if were a single intervention, similar to how penicillin VK is a single intervention for strep throat.

But there is no one acupuncture I have counted dozens upon dozens of different styles of acupuncture. I suspect that there are actually as many styles of acupuncture as there are acupuncturists and that if an intervention was not imposed upon them by a study protocol that no two acupuncturists would ever puncture the same way.

And why would they? After all, the diagnostic modalities of Traditional Chinese Pseudo Medicine (TCPM) (pulse and tongue evaluation) are not based on reality but upon the delusions of the practitioner.

And it holds true in this meta-analysis as well.

They compare 4 different kinds of acupuncture (acupuncture, auricular acupuncture, auricular electro-acupuncture, and electro-acupuncture) as if they were all the same.

And no two studies used the same acupoints.

To digress.

And just how big is an acupoint? The size of a needle point? If so, those acupuncturists have good aim. Or a dime? A quarter?

The structure and size range of an acupoint are determined not only by the outlook of depression and blood vessel areas, but also its relationship with other acupoints in its vicinity. The different manipulations of puncturing recorded in the Yellow Emperor’s Canon of Medicine also show the ambiguous nature of the structure and size range of an acupoint. In theory, an acupoint has been characterized as various forms, which should not be limited to a mere round dot shape. Without such understanding, an acupuncture practitioner will be limited to a large extent in clinical application and the studies on acupoints will also go into a wrong direction.

It seems that acupoints are whatever the acupuncturists needs them to be, although I wonder what the deqi effect on Staysha Randall was.

Do we really know that when a study says the needle is was in a given acupoint that it actually was? It would be nice, like in x-ray studies, to have photographic documentation of needle placement evaluated by blind readers to conform the needles were indeed in the ‘correct’ space.

I remember my young days as an intern, placing a subclavian catheter by landmarks. Half a centimeter makes a big difference in whether you are hitting lung, artery or vein. Why not a similar requirement for acupuncture needles?

I digress further, but I also wonder: are acupoints reversed in situs inversus? If acupoints are actual structures and not a mythical metaphor, are their structures controlled by genes? And on what chromosome? Are there polymorphisms that lead to more or less active acupoints? Can you make a mouse knockout with no acupoints? Questions with answers if acupuncture is not a pseudo-science. Which it is.

And no two studies use the same frequency or duration of acupuncture.

None of the included studies are even remotely equivalent and cannot really be compared or pooled. It is like concluding pills are useful for treating hypertension, with the caveat that, being based on reality, some pills, like antihypertensives, do have actual effects.

They do note this weakness:

The clinical heterogeneity associated with the different acupuncture techniques limits our ability to identify which technique was more effective for treatment of alcohol disorders. Acupuncture treatments also varied in duration, frequency, and the acupuncture points used, making it difficult to assess the key characteristics that might be associated with the effectiveness of the intervention.

But are unworried by it.

Garbage in, sausage out

A quick look at acupuncture meta-analysis you see the same pattern. No two compared interventions are the same.

“Acupuncture for Spinal Cord Injury and Its Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials“? A hodgepodge of acupuncture techniques were evaluated but compared as if they were all equivalent. But the conclusion suggests that

The results of our systematic review and meta-analysis suggest that the evidence for the effectiveness of acupuncture as a symptomatic treatment for SCI and its complications is encouraging but limited.

And if acupuncture works by way of neurologic pathways, why would it be effective in spinal injury?

For gout? 28 studies, each acupuncture different in points and/or style. They didn’t care that:

The acupoint selection was inconsistent among included studies; nevertheless, Sp6, St36, and Ashi point were the most commonly used acupoint. In our present study, data was combined without differentiating acupoint selection and acupuncture techniques.

And suggested benefit from ‘acupuncture’, whatever ‘acupuncture’ could be. Ashi points, by the way, are essentially trigger points that vary from patient to patient. So the third most used acupoint was a random point.

Hot flashes? 12 different interventions. Yet they conclude ‘acupuncture’ is effective in decreasing hot flashes, as if ‘acupuncture’ were one intervention.

Sleep apnea? 5 different interventions, yet ‘acupuncture’ has efficacy?

And on and on and on.

There is no squaring this circle

In no meta-analysis are there ever two interventions that were even remotely the same.

I would suggest the great variability in the interventions with similar results is further evidence that the effects of acupuncture are that of a nonspecific, theatrical placebo. And journals really need to start using the plural form with these kinds of worthless meta-analysis. It is acupunctures.

And the myth? The greatest myth of acupuncture, perpetuated by the language used by proponents and skeptics, is that there is one intervention that can be called acupuncture. There is no acupuncture but a multitude; as many acupunctures as there are practitioners.

And they all do nothing.