Neurologist Steve Novella gave an analysis today of the acupuncture debate and the study described above with regards to migraine. He makes many very good points and this guy is totally grounded in science-based medicine like no other. I still don’t know if acupuncture really does a damn thing but the few times I’ve tried it, I sometimes got benefit from it while other times it did nothing. And even then I couldn’t be certain if it was the needles doing anything at all or just the great relaxing massage and the doctor’s insistence that he could “heal” me. He was very persuasive too which probably loaded me up with placebo effect.
Full blog post here for those interested: theness.com/neurologicablog/?p=532
Novella writes the following:
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Let’s look at the 2009 Cochrane review of acupuncture for migraine headache. The lead reviewer is Karl Lunde whose affiliation is given as Centre for Complementary Medicine Research, Department of Internal Medicine II, Technische Universitaet Muenchen. The authors of the review broke the eligible trials into three types - acupuncture compared to no intervention, acupuncture compared to standard treatment, and “true” acupuncture compared to “sham” acupuncture.
The results are not difficult to guess. The first two groups showed a benefit from acupuncture. Of course they did - these were unblinded studies. It is already well-established that most symptomatic interventions, acupuncture included, will have a perceived placebo effect, most notably for pain symptoms.
The only comparison any science-based practitioner should care about are the blinded comparisons between true and sham acupuncture, for which the reviewers found: “Fourteen trials compared a ‘true’ acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any outcome in any of the time windows, but the results of single trials varied considerably.”
Right - no effect when looked at together, with lots of variability in individual trials. This is exactly the pattern we see for treatments that have no real physiological effect.
Now again - imagine a pharmaceutical company going to the FDA with this evidence for their new anti-migraine drug. The unblinded trials show a benefit over doing nothing or standard care. But the blinded placebo-controlled trials show no effect. The FDA would tell them to take a hike.
This, by the way, is an excellent example of the difference between evidence-based medicine and science-based medicine. SBM considers prior-plausibility, which is low for acupuncture, and also has a greater respect for the vagaries and limitations of clinical trials. EBM, at least as practiced by Cochrane, in my opinion and that of others, puts too much faith in clinical trials.
But even according to Cochrane’s own criteria, this conclusion is not justified. The principles of EBM state that better quality evidence trumps lower quality evidence. With regard to acupuncture and migraine, the best evidence is all negative, while weaker evidence is mixed if overall positive. The best evidence (blinded controlled trials) says that there is no effect from acupuncture for migraine. That should have therefore been the conclusion of reviewers.
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He also says this about complimentary and alternative medicine (CAM) which I think is right on the mark:
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First [the question] treats “alternative medicine” as if it were one entity. The questioner claims that “alternative medicine works,” but this is a meaningless statement. Which CAM modalities work for which indications? Each modality has to be considered in its own right. This is precisely why the category of CAM itself is counterproductive and unscientific. It exists only to promote modalities which are not supported by science and evidence, because if they were they would not be “alternative” medicine, they would be medicine.
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Novella remarks, however, that “There is therefore no reason to think that acupuncture has any specific role to play in migraine therapy”. I don’t agree with this statement. As long as a person realises it isn’t going to cure the condition and is not sold false hopes or ripped off, I can’t see what’s wrong with dropping 50 bucks every now and then if someone comes out of the session feeling more relaxed and maybe even migraine-free for a few days. Any therapy that promotes relaxation can’t hurt when it comes to migraine. Personally, I’ll be skipping the pins from now on and stay with the massage.
Scott