Sunday, 8 May 2016

The Human Pin Cushion

Dat gotta hurt

Would you consider acupuncture an alternative medical therapy or would you lump it with mainstream medicine? I ask because 50% of British General Medical Practitioners are of the professional opinion that acupuncture is an effective treatment for a host of conditions and consequently are willing to refer patients to registered acupuncture practitioners, ultimately at the tax payer's expense. In fact, it is estimated that the British government spends £25 million a year on acupuncture treatments alone

Of all the alternative therapies acupuncture is endowed with the most credibility amongst health professionals and lay folk alike. Doctors who are happy to send patients to an acupuncturist would baulk doing the same if a crystal healer was involved. And yet when we examine the respective empirical evidence both 'therapies' are found wanting (see later discussion). So why does acupuncture deserve its status as the king of alternative medicine? There are several reasons for this spurious exalted status : Acupuncture has an ancient pedigree. Acupuncture has been practised by the Chinese for at least two millennia. Age imparts respectability on almost anything especially if you don't think too hard and allow intellectual laziness to feed complacency. There is a physical intervention: Sticking needles into flesh may have a mechanistic effect that meditating/medicating on crystals can never have. This is even true if the underlying so-called 'theory' underpinning acupuncture is complete bollocks. Just because the ancients were unaware of scientific principles and made up stuff based on primitive animistic principles doesn't necessarily make the practice invalid. Mayhap the medical elders discovered an effective therapy based solely on a long evolved trial and error process. Initially, Western medicine came about this way; science came limping after, but with distingused aplomb.

Acupuncture: Theatrical placebo with sharp objects

So here is the news: There have been more than 3,000 scientific studies conducted into acupuncture since the 1970s. Most were performed according to the 'double blind trial' methodology. This represents the gold-standard to determine the efficacy of a treatment or drug. In essence, the study group is divided into two. One group receives the treatment while the second group receives a sham treatment or placebo. Neither the patients or researchers conducting the trial are aware who is receiving the treatment or placebo. And herein lies the power of the technique. In this way subjective, often unconscious, bias is removed as a factor. Some of the better studies have involved 'meta-analysis'. The data from good and separate studies are combined thus allowing conclusions to made based on a large number of participants. In 2009, a meta-analysis combining 13 trials and involving over 3,000 patients was published in the British Medical Journal. The authors concluded: "A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear." At best acupuncture is about as useful as taking half an Aspirin, at worst it has no therapeutic benefit whatsoever. As for other claims made for acupuncture, that is a valid treatment for depression, rheumatoid arthritis, asthma, epilepsy, insomnia, carpal tunnel syndrome, smoking cessation, stroke rehabilitation, Bell's palsy and any other medical condition which ails mankind, there is absolutely no evidence for its efficacy.

I suspect acupuncture will remain popular with the public. There will always be folk who attest to its effectiveness. The power of suggestion and the placebo effect can work wonders if you let it. And let us not forget the phenomenon of 'regression to the mean' (post hoc ergo propter hoc), or in prosaic terms: illnesses have a way of getting better regardless of medical intervention. Our psychological makeup is such that we are happy to ascribe a cure to a preceding treatment, even though it may have played no part in the healing process.

You may ask what is the problem? If patients are happy to receive the treatment, especially if it is endorsed by their doctor, then at worst no harm will occur. However, it could be argued that the £25 million squandered every year would be better spent on proven and effective treatments. A cash-strapped NHS should take heed. Some see it as the thin end of the wedge and a gateway to the introduction of equally useless, 'alternative therapies'. Ultimately it is down to education. Information concerning the ineffectiveness of acupuncture and other alternative therapies should not only be disseminated to health professions it also needs to be impressed upon the general public. Tis all about data-driven evidence-based medicine. Conventional medicine is subject to immense scientific scrutiny and rightly so. Alternative therapies have a knack for circumventing rigorous process. Research into alternative therapies wastes valuable research time and money. After 3,000 studies, we shouldn't be saying: "Further research is required." We should be saying, "Enough is enough" and consequently moving diminishing research resources into more fruitful areas of medical endeavour.

Is it medically ethical to prescribe placebo?

My own doctor is an avid fan of acupuncture and suggested that my wife seek the services of an acupuncturist for her long-standing rheumatoid arthritis. I was present during the consultation and challenged the medical validity of the ‘therapy’. The doc had unwittingly strayed into an area in which I have some expertise. I expressed some concern that the so-called treatment could not be backed up with evidence-based data and that the numerous trials and investigations had not conclusively shown acupuncture's efficacy for treating anything. I think she was taken aback and was happy to fall on anecdotal evidence from her patient’s experience. I pointed out that this did not constitute objective evidence and did not take into account the subjective influence of the placebo effect and that is why it is crucial we engage in well-designed double blind trials to get to grips with the phenomenon if any. I learnt that day that doctors are not happy when their professional judgement is taken to task. Indeed, she became uncharacteristically flustered and could not articulate a valid response. My relationship with my doctor changed that day. Still, I see her seldom and she is still a good all-round competent generalist and a first class referrer to specialist care when required. And that is all you should ask from your GP.

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