JAMA Internal Medicine just published an article titled: Acupuncture vs Sham Acupuncture for Chronic Sciatica From Herniated Disk, A Randomized Clinical Trial. In an accompanying editorial comment, Jerard Z. Kneifati-Hayek and Mitchell H. Katz write: “This was a methodologically rigorous study; there were multiple experienced acupuncturists, the comparison group used a well thought-out sham control, and patients were followed up for 1 year—with persistent improvements.”
So – is that it, then? Should SBM alter our general stance on the scientific status of acupuncture? Nope, not even close. We will see why shortly, but first lets review why proponents of science in medicine remain skeptical about the claims for acupuncture.
First, we must consider scientific plausibility. Acupuncture is the claim that sticking needles in specific locations in the body (acupuncture points) can have specific and even remote effects on physiology and symptoms. There are many scientific problems with this claim. After more than a century of promotion, acupuncturists have been unable to demonstrated that acupuncture points exist, that there is even any internal validity or consistency in where they are and what they do, or any meaningful potential mechanism by which they could function. Science, in other words, cannot see acupuncture points – anatomically, biochemically, or physiologically. They remain a figment in the mind of the acupuncturist.
The traditional explanation for how acupuncture works is chi – a life energy that flows through the body and is influenced by sticking needles in key locations of flow. Chi also remains a scientific figment, with no basis in reality. Some proponents have therefore tried to set chi aside and offer more scientific explanations for the existence of acupuncture points and the efficacy of acupuncture, but they have been unable to do so. They frequently point to non-specific effects (what you would expect from sticking a needle through the skin) but nothing consistent, replicable, or able to explain acupuncture’s putative effects.
Plausibility, in short, remains extremely low. But in medicine we can look for efficacy in the absence of a known mechanism. However, a key principle of SBM is that plausibility should always be taken into account. Efficacy evidence is complex and fraught with potential pitfalls, not the least of which is observer bias and many forms of placebo effects. Especially for subjective outcomes (like pain), therefore, we need the most rigorous studies to draw any useful conclusions. The baseline for efficacy research should be extremely high – and higher still when evaluating a treatment with no plausible mechanism.
History is clear that if we do not take this very rigorous approach, and make sincere efforts to prove efficacy claims wrong, then we can easily fall into a culture of self-deception. The history of medicine has many examples of treatments enjoying wide support, but that eventually collapsed under rigorous scientific evidence. There are also copious examples of treatments, and even entire professions, that are clearly pseudoscientific, but persist because of a culture that is soft on scientific rigor in medicine.
Acupuncture is perhaps the best example of this phenomenon – a treatment with lots of cultural inertia, but never able to cross the line of scientifically verifiable. Where is that line?
For any treatment, but especially one that is inherently implausible, we like to see a few things. There needs to be a statistically significant and clinically relevant effect with rigorous methodology, and this effect needs to reliably replicate. We do not have that with acupuncture – and we still don’t.
Let’s look at the current study that so impressed the editors at JAMA Internal Medicine. Your first clue that something is amiss is in the title – “A Randomized Clinical Trial”. Studies that are double-blind always bill themselves as a “double-blind” clinical trial. Perhaps this was a strange oversight, so I verified the status of the trial:
“Given the nature of acupuncture manipulation, acupuncturists in this trial were not blinded. The semistandardized treatment scheme was aligned with our recent expert consensus.”
The acupuncturists were not blinded. They tried to justify this by saying how the acupuncturists need to know what they are doing, in order to do proper acupuncture. But this has never been established. In fact, studies have shown that the experience of the acupuncturists does not matter to efficacy. It also does not matter if the treatment is standardized – this is because the treatment does not matter, only the interaction of the acupuncturist seems to matter.
Regardless of justification – a non-blinded study with a subjective outcome is not rigorous, it is scientifically worthless. In fact it is worse than worthless, it is actively harmful because it is useful for propaganda and deception. The editors of JAMA Internal Medicine have now played into this propaganda.
It also has to be noted that this is an entirely Chinese study. This is relevant for acupuncture studies because reviews have found that Chinese studies on acupuncture are essentially never negative. They have a near 100% positive bias. This is statistically impossible, and absolutely calls into question the results of acupuncture studies coming out of China. In the context of this clearly documented bias, any methodological wiggle room (such as not blinding the acupuncturists) is unacceptable.
Even if the study were reported as rigorous, given this extreme bias, I would remain skeptical of the outcome unless it were reliably replicated in countries without a massive cultural bias.
Keep in mind what we are being asked to accept. Look at the protocol and the difference between true and sham acupuncture – the difference in needle location is based entirely on “meridians”, which scientifically do not exist.
What this study is great evidence for is exactly what SBM promotes – the notion that we really do need highly rigorous studies in order to make confident conclusions in medicine. Further, we need to close the loop on mechanism of action. All of the science needs to work together toward a consistent understanding. We cannot gloss over mysteries, unknowns, or inconsistencies. Acupuncture represents a medical self-deception on a massive scale, one that has been exported from China to the West.
Doctors, other clinical professionals, and medical scientists need to maintain the highest levels of skepticism toward any claims or treatments in medicine. Otherwise we will slide into pseudoscience. History is very clear on this fact.
