One of the things that disturbs me the most about where medicine is going is the infiltration of quackery into academic medicine. So prevalent is this unfortunate phenomenon that Doctor RW even coined a truly apt term for it: Quackademic medicine. In essence, pseudoscientific and even prescientific ideas are rapidly being “integrated” with science-based medicine, or, as I tend to view it, quackery is being “integrated” with scientific medicine, to the gradual erosion of scientific standards in medicine. No quackery is too quacky, it seems. Even homeopathy and naturopathy can seemingly find their way into academic medical centers.
Probably the most common form of pseudoscience to wend its way into what should be bastions of scientific medicine is acupuncture. Harvard, Stanford, Yale, M. D. Anderson, and many others, they’ve all fallen under the sway of the idea that somehow sticking thin little needles into points that bear no relationship to any known anatomic structure and that supposedly “unblock” the flow of some sort of “life energy” that can’t be detected by any means that science has. Most recently, as I described, studies that seek to “prove that acupuncture works” have found their way into high quality, high impact journals whose editors should know better but apparently can’t recognize that the evidence in the study doesn’t actually show what the authors claim it shows. Even so, there are some journals that I didn’t expect to see this sort of infiltration of quackademic medicine. Granted, I never expected it to show itself in one of the Nature journals, as it did in the study I just mentioned. I also never expected it to show up in that flagship of clinical journals, a journal that is one of the highest impact and most read medical journals that exists. I’m talking the New England Journal of Medicine, and, unfortunately, I’m also talking an unfortunately credulous article from Dr. Brian M. Berman, who is the founder of the Center for Integrative Medicine, University of Maryland School of Medicine and the holder of multiple NCCAM center grants, and other institutions, entitled Acupuncture for Chronic Low Back Pain.
The article appeared under the section of the NEJM known as Clinical Therapeutics. Articles published in this section begin:
…with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines, if they exist, are presented. The article ends with the authors’ clinical recommendations.
And this is the clinical vignette:
A 45-year-old construction worker with a 7-year history of intermittent low back pain is seen by his family physician. The pain has gradually increased over the past 4 months, despite pain medications, physical therapy, and two epidural corticosteroid injections. The pain is described as a dull ache in the lumbosacral area with episodic aching in the posterior aspect of both thighs; it worsens with prolonged standing and sitting. He is concerned about losing his job, while at the same time worried that continuing to work could cause further pain. The results of a neurologic examination and a straight-leg–raising test are normal. Magnetic resonance imaging (MRI) shows evidence of moderate degenerative disk disease at the L4–L5 and L5–S1 levels and a small midline disk herniation at L5–S1 without frank nerve impingement. The patient wonders whether acupuncture would be beneficial and asks for a referral to a licensed acupuncturist.
Berman et al begins with a simple discussion of low back pain, which, as he correctly notes, is an incredibly common clinical problem. He also points out that most of the really bad causes of low back pain (tumors, infection, or inflammatory disorders) are seen relatively infrequently in common practice. The most common cause of low back pain is the dreaded “I” or “N” word: idiopathic or nonspecific, both of which basically mean that we don’t know what causes it. So far, fair enough. Berman et al even produce a fairly good discussion of the pathophysiology of low back pain, including the role of the central nervous system, behavioral elements, and musculoskeletal contributions, among others. Then, unfortunately, the authors go off the deep end:
Traditional Chinese medicine espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature. Internal disharmony is believed to cause blockage of the body’s vital energy, known as qi, which flows along 12 primary and 8 secondary meridians (Figure 1). Blockage of qi is thought to be manifested as tenderness on palpation. The insertion of acupuncture needles at specific points along the meridians is supposed to restore the proper flow of qi.
They even include a figure of acupuncture points
It was at this point that I wondered whether I was reading the NEJM or a quackademic medical journal such as the Journal of Alternative and Complementary Medicine. Here was an actual discussion of qi as though it might actually exist and as though meridians and qi were anything other than the result of prescientific concepts about how the body works and disease develops. One wonders if, for its next trick, the NEJM will publish Clinical Therapeutics articles touting the wonders of the humoral theory of disease and how the four humors must be balanced. Or maybe the miasma theory. That was a good one, and quite in accord with the modern day obsession with contamination and “detoxification.”
My expectation to see greater woo appearing in the NEJM notwithstanding, as most CAM advocates do, Berman et al next try to justify acupuncture, starting with the belief that it works and then working backwards to cherry pick studies that they believe to support the hypothesis that acupuncture works for low back pain as anything other than a placebo effect. They begin with several inconclusive and conflicting animal studies, concluding by mentioning the study that I blogged so extensively about two months ago without noting that it didn’t show what the authors thought it showed, nor did it demonstrate that adenosine mediates the effects of acupuncture. As I pointed out, what really irritated me about the adenosine study was that it was relatively interesting science but it was yoked into the service of trying to justify acupuncture with an animal model that had very little to do with acupuncture.
Next, Berman et al decide to delve into the clinical evidence for acupuncture:
A number of clinical trials have evaluated the efficacy of acupuncture for chronic low back pain. A meta-analysis in 2008, which involved a total of 6359 patients,44 showed that real acupuncture treatments were no more effective than sham acupuncture treatments. There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.
At least Berman’s honest about this one in admitting that the meta-analysis showed that real acupuncture is no more effective than sham acupuncture, something that regular readers of this blog know. Then Berman tries to do what acupuncture apologists do every time they encounter studies that show that “true” acupuncture performs no better than the acupuncture control. Rather than simply admitting that acupuncture doesn’t work and that acupuncture effects are placebo effects, they try to spin the results by pointing out that both sham and “real” acupuncture “work” and therefore are useful! In other words, they argue for placebo medicine without calling it placebo medicine. They then do it again for a German trial. Unfortunately for them, it’s a study in which, as is the case with many acupuncture studies, the results didn’t mean what the authors claimed they mean. Once again, Berman tries to represent the finding that sham acupuncture was just as effective as “real” acupuncture. In any randomized clinical trial of a conventional therapy, such a result would lead to the conclusion that the therapy doesn’t work, but not in acupuncture. If both the placebo control and the treatment are indistinguishable from each other, then that means acupuncture must work.
The third study that Berman chooses is a so-called “pragmatic” trial. Basically, it’s a mixed randomized trial with a non-randomized cohort. Let me quote one small passage from the trial that demonstrates why it is an utterly useless study:
In this study, neither providers nor patients were blinded to treatment. Therefore, a bias due to unblinding cannot be ruled out.
That’s putting it mildly. Basically, the study is utterly worthless because it can’t account for the rather large placebo effect that is common in intervention studies for back pain. In fact, it’s fairly amazing that the peer reviewers at the NEJM let that pass. Be that as it may, Berman et al next write an amazing series of statements, beginning with:
Acupuncture is considered to be a form of alternative or complementary medicine, and as noted above, it has not been established to be superior to sham acupuncture for the relief of symptoms of low back pain.
In other words, acupuncture does not work. Even so:
However, since extensive clinical trials have suggested that acupuncture may be more effective than usual care, it is not unreasonable to consider acupuncture before or together with conventional treatments, such as physical therapy, pain medication, and exercise. Many pain specialists incorporate acupuncture into a multidisciplinary approach to the management of chronic low back pain.
In other words, even though acupuncture does not work, we should use it anyway because there are enough practitioners who believe it works and use it even though extensive clinical trials have shown that acupuncture is no better than sham acupuncture, and neither are better than placebo effects.
Even though:
As noted above, the most recent well-powered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture. The simplest explanation of such findings is that the specific therapeutic effects of acupuncture, if present, are small, whereas its clinically relevant benefits are mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.34,65 These studies also seem to indicate that needles do not need to stimulate the traditionally identified acupuncture points or actually penetrate the skin to produce the anticipated effect.
In other words, acupuncture does not work.
Let’s put it this way. Berman concedes that “true acupuncture” doesn’t work any better than sham acupuncture for low back pain. He concedes that it doesn’t matter where you stick the needles. It makes no difference; the effect is the same. He concedes that any perceived benefit from acupuncture in low back pain is due to nonspecific factors, in particular psychosocial factors, patient’s expectations, and the attention paid to the patient by the acupuncturist. What, I ask, do we call such a treatment, a treatment that is no better than placebo control and whose efficacy depends on beliefs and expectations, attention from the provider, and contextual factors.
We call it a placebo. A placebo.
That’s just what Berman is recommending to this patient in the clinical vignette that started out this post, a placebo intervention. We can argue about whether it’s ever ethical to use a placebo intervention, particularly for conditions that don’t respond well to conventional therapy and for which eschewing conventional therapy probably won’t cause harm, but we should be honest about the nature of the intervention. That’s the problem with CAM interventions like acupuncture. Its practitioners and advocates don’t acknowledge that they are placebos, and, whether they realize it or not, by failing to do so they are deceiving patients. In fact, Berman’s recommendation that the patient go to a licensed acupuncturist with “adequate training” doesn’t even jibe with his findings in his review article. After all, if it doesn’t mater where you place the needles, then it doesn’t matter if the acupuncturist is trained.
As Steve Novella points out, what Berman is doing in this article in the NEJM is the same thing that CAM advocates in general and acupuncture apologists in particular have a maddening tendency to do. They either cherry pick studies that appear to indicate that their favored woo works. When, as Berman et al were, they are forced to admit that well-designed studies with lots of patients show that their woo is no better than a valid placebo control, they then shift to embracing the placebo, to owning it, so to speak, all without actually calling it placebo.
What I find so disturbing about this NEJM article is not so much that Berman et al pulled these usual CAM tricks. I expect that. I see it all the time in CAM journals and sometimes in unsuspecting legitimate medical or scientific journals. What I find so disturbing about this NEJM article is that the peer reviewers did not spot the obvious CAM abuses of language designed to obscure the fact that acupuncture is no better than placebo. The editors of the NEJM should be ashamed of themselves. The peer reviewers who reviewed this article should be ashamed of themselves. Those of us who rely on the NEJM for evidence-based findings and assessments of various treatments should be afraid.
After all, if quackademic medicine can infiltrate the NEJM, there’s nowhere it can’t go.