Unwieldy title. I need to shorten the concept to some sort of acronym. I can’t come up with what that would be. Hm. I will think about it.
More acupuncture nonsense this week, this from the Annals of Internal Medicine. I will give the Annals this: they have been consistent in embracing the nonsense that is SCAM for decades. It was their reviews of the topic back in the 90s that got me interested in SCAM. And, by the way, Annals always has two n’s. If you are looking for a review on, say, the treatment of S. aureus bacteremia that was published in the Annals and you forget an n? Lets say the resultant search that pops up on the screen at the nursing station is NSFW.
I digress.
The topic today is Efficacy of Acupuncture for Chronic Spontaneous Urticaria. A negative study that is spun as a win. That’s so Annals.
Lets go through the study and see just how they they are attempting to make acupuncture great again.
The Intro
They discuss chronic spontaneous urticaria, a miserable itching disease, with therapies that are either less than efficacious or costly. So what do you do when you lack an effective and inexpensive treatment? Acupuncture. Which is expensive and ineffective, as we will see.
First, as always, is a nod to the ‘appeal to antiquity’ fallacy. Of course.
Acupuncture has been used to treat pruritus for more than a thousand years.
As has bleeding and cupping. Doesn’t mean the intervention actually works, mind you, and the myth of the antiquity of acupuncture has been discussed many a time here at SBM.
I suppose once upon a time acupuncture was great, back before science-based medicine and randomized clinical trials revealed the nothing-burger that is acupuncture. Time to make acupuncture great again.
…relevant studies have found that acupuncture can inhibit the peripheral and central transmission of pruritus by altering the signaling pathway and transcriptional activity.
It can? So acupuncture doesn’t work with meridians and chi. Great. That quote references a review of acupuncture and itch, Acupuncture for the Treatment of Itch: Peripheral and Central Mechanisms.
The review is interesting in that it is mostly about mouse models and mostly the results of electroacupuncture. Which isn’t acupuncture, at least in the classic sense of the antiquity of acupuncture. Unless you consider the 1950s ancient. Having been born in 1957, I do feel increasingly ancient.
I will admit, I do have a bias towards therapies that are very narrow in their application. The fewer the effects, the better. I would be hesitant to give an intervention for urticaria, like acupuncture, that had simultaneous effects on
neuropeptides and hormones, including β-endorphin, serotonin, oxytocin, adrenocorticotropic hormone, gonadotropin-releasing hormone, corticotrophin-releasing hormone, cholecystokinin, and acetylcholine, as well as insulin sensitivity, immunomodulation (anti-inflammation), and autonomic nerve activity.
They then note that the studies of acupuncture and urticaria stink on ice and quality studies need to be done to make acupuncture great again. At least for chronic urticaria.
They reference a meta-analysis that I found curious in that it was a hodgepodge of treatment durations, forms of acupuncture, and acupoints. the usual dumpster fire trying to pass as a single coherent medical intervention.
In total, all the treatments adopted in the included trials were based on traditional Chinese medicine theory. Electroacupuncture was applied in 2 RCTs, while manual acupuncture was used in the other 4 RCTs. Xuehai (SP 10), Zusanli (ST 36), and Quchi (LI 11) were applied the most frequently in the included studies (4/6, 66.7%). Other acupoints used were Sanyinjiao (SP 6), Hegu (LI 4), Pishu (BL 20), Ganshu (BL 18), and Shendao (GV 11).
They specifically excluded non-TCPM (traditional Chinese pseudo-medicine) acupunctures in the meta-analysis. Why? They don’t say. But curious.
That is one of the ongoing issues in trying to make acupuncture great again: acupuncture proponents always act like acupuncture is a monolithic thing, when there are dozens and dozens of acupuncture styles. Which is supreme? Trick question. They are all crap. Except Tong Ren. The only legitimate form of acupuncture. But no two acupuncture studies uses the same style, duration, or acupoints.
The Study
300 patients were randomized to either real or non-penetrating sham acupuncture. As if there is a difference. And there was a wait list. Patients were blinded, but the acupuncturists were not. The patients kept a diary of the symptoms and antihistamine use.
Why the traditional Chinese form of acupuncture and not Tong Ren and why the particular acupoints were used are not discussed.
Yet another recurrent mystery in an acupuncture study. A system of interventions based on nonexistent anatomy and physiology (chi and meridians) and a fanciful diagnostic modality (tongue and pulse examination) is somehow mapped onto a process that is mostly mediated by abnormal histamine release. How and why is not explained. And why those seven acupoints used? Not mentioned. I looked at a couple of acupoints for clarification.
How about the Quchi (aka Charo) point in the arm. It’s quite the acupoint.
According to the etiology, allergic diseases are related to wind and heat; according to the pathogenesis, most of allergic diseases are qi-blood diseases; from the theory of zangfu, allergic diseases are closely related to the depressed heat of yangming and stomach-intestine, and the common elements of the pathogenesis of allergic diseases are wind, heat, qi, blood and yangming. With reviewing the ancient literature and modern research, the key therapeutic effect of Quchi (LI 11) and its special treatment effect on allergic diseases are summarized. It is suggested that the key therapeutic characteristics of Quchi (LI 11), including dispelling the wind, clearing the heat, cooling the blood and regulating stomach-intestine function, are in accordance with the common causes and pathogenesis of allergic diseases. Therefore, Quchi (LI 11) is considered an important acupoint for the treatment of allergic diseases. Emphasis added
I understand the individual words, but they sum to meaninglessness. And how dispelling the wind, clearing the heat, cooling the blood and regulating stomach-intestine function that relates to the altering the signaling pathways and transcriptional activity is not mentioned, although it is the alleged justification of acupuncture efficacy for urticaria.
The next point used in Xuehai, near the knee. According to Master Tungs Acupuncture it
invigorates and cools blood, dispels blood stasis and harmonizes menstruation.
and is used for irregular menstruation, dysmenorrhea and uterine bleeding as well as urticaria, eczema and erysipelas. Certainly, diseases that are very closely related. That is sarcasm, btw.
I wonder. Each acupoint usually has two or more very different functions. If you treat, say, urticaria at Xuehai in someone with normal menses, will you induce, say, dysmenorrhea?
The closest I can find is
Moreover, acupoints have a bidirectional regulation effect (the idea that an intervention pushes the patient toward a homeostatic state rather than having a unidirectional effect that may help or harm). For example, acupuncture not only lowers blood pressure, but also modulates low blood pressure in patients and animal models . Acupuncture can increase enterogastric peristalsis for constipation symptom while also has anti-diarrhea effect . In addition, acupuncture at the same point also has the bidirectional regulation effect. Acupuncture at Bahui (GV20) has been shown to be effective in treating both hypertension and hypotension. Siguan (a combination of LI4 and LR3 bilateral meridian points) is one of the most important acupoints to treat multiple gastrointestinal symptoms including constipation and diarrhea . Despite the fact that the opposite regulatory effect of acupoints has been used for treating specific symptoms and/or diseases, it is not fully understood how the effect at acupoints works.
That last sentence did make me smile. As the proverb says, you can’t make a silk purse from a sows ear. Or a USB drive out of a breath mint.
How acupuncturists focus the effects of acupuncture at each point to get the desired effects and avoid the other potential interactions is not mentioned and is one of the mysteries of acupuncture.
Here is how to find the Xuehai point per Master Tung:
When the knee is flexed, the point is 2 cun proximal to the superior medial border of the patella, on the bulge of the medial portion of quadriceps femoris muscle. Or with the patient’s knee is flexed, place the heel of your right palm on the patient’s left patella, with the thumb and fingers fully extended and the thumb at a 45° angle with the index finger. The point is where the tip of your thumb rests.
And given the variation in hand and leg size, it is not a surprise that this is a difficult acupoint to locate:
The position of Xuehai (SP10) is clear, but its locating method is vague, resulting in the disunity of clinical application and even possibly affecting the curative effect. Also, when learning the meridians and acupoints, the beginners are often confused by this issue
So you have to wonder if they were indeed needling the correct acupoint in the urticaria study.
And they used the Shenmen point, which not only is used for
amnesia, stupor, mania, insomnia, palpitations due to fright, irritability, and chest pain
This point is so powerful it can be used alone, without the need for other complementary acupoints. Why the authors did not make use of this unique feature and spare the patient multiple needles can only be speculated.
I could go on with the others, but it would be…..pointless.
See what I did there? Acupuncture. They use needles. Needles, unlike acupuncture, have a point. Thast was a never before used play on words for the ages; classic comedy. It is why you read my blog entries. But I digress. Again.
So we know the acupoints used, but not why they were chosen or how their other effects were avoided.
The sham acupuncture was non-penetrating at non-acupoints. Although given the inexactness of acupoints and the multiple acupuncture styles it could be argued that every point on the body is a potential acupoint. Except, as I have noted, the eyes, the nail beds, and the genitals are oddly lacking in acupoints.
Patients kept a diary of symptoms and medication use. Perhaps not the most reliable method for reliable data. The primary outcome was the Weekly Urticaria Activity Score at 4 weeks. Secondary outcomes were a variety of other symptom scores. All subjective endpoints and so subject to bias.
The original protocol said serum IgE levels were to be measured at the beginning and end of the trial. It was not reported in the final paper and the lack of IgE testing was not addressed.
Drum Roll, Please
The results?
Acupuncture had greater improvement in the various scores than sham or wait list but the effect was not clinically important.
And
All the adverse events were in the acupuncture group. 15 patients had 21 adverse reactions. 13.6%, although mild and transient.
And.
While not significant, more guessed they were in the sham acupuncture group.
So a negative study. No surprise here.
What little difference between acupuncture and sham acupuncture could be accounted for by blinding failure and the study being done in a society that usually has positive effects for acupuncture. In fact, I was surprised at the lack of effect in a study whose effects are based on the subjective reports of the studied.
And if you are a Baysean kind of person, given the prior probability that acupuncture would do anything is zero, you would rightly conclude that any positive effect is a false positive, especially given the flaws in the study.
If this were a pharmaceutical, say an antibiotic, that had no clinically relevant effects, had more adverse reactions, and was very time and money intensive (10 sessions in the first two weeks, 6 in the second can’t be cheap), you would declare the pharmaceutical a bust and move on. But if you are the Annals? How about an editorial by an acupuncturist promoting acupuncture? Time to
Make Acupuncture Great Again
Yep. They released the Kraken.
The editorial briefly documents the authors use of acupuncture, never clarifying which type or which points are used and conflating electo and standard acupuncture. A lack of precision and clarity that is always the hallmark of acupuncture discussions. He also does not mention Tong Ren, which, as I have mentioned, is the only legitimate form of acupuncture. If anything will make acupuncture great again, it would be Tong Ren.
The author of the editorial appears to think that the effects of acupuncture are due to altering inflammation.
I had come to terms with the fact that some of the more surprising claims from traditional Chinese medicine might have a basis in science. (nerp) A good example is the influence of acupuncture on the immune system. The vagal anti-inflammatory reflex suggested a mechanism by which neural activity could modulate systemic inflammation
When you read paragraphs like this, you realize how little alt med providers really know about illness and inflammation. And it was ELECTROacupuncture that had the effect. I suppose those who die in the electric chair, the contacts at acupoints on the head and feet, were impressively anti-inflamed.
Oddly, the greater the inflammation, the greater the effects of the at best trivial interaction that is acupuncture. The effects of acupuncture in sepsis being greater as there is so much more inflammation in sepsis. I have discussed sepsis and acupuncture. I was not impressed.
When I saw the results of Zheng and colleagues’ article on acupuncture for chronic spontaneous urticaria (CSU) (7), I was not surprised to see a demonstration of efficacy over sham and waitlist control. But the results do not seem to be as dramatic as we have seen in sepsis, which may reflect the fact that the degree of inflammation is much more modest.
A homeopathic-like mindset, I guess. The greater the inflammation, the more acupuncture effect. So the greater the disease burden, the more effective the therapy. By that rationale, 500 mg of cephalexin would be more effective for prosthetic valve endocarditis than for a boil. The Annals thought this was a reasonable assertion?
The author credits acupuncture for risk reduction for coronary artery disease in patients with rheumatoid arthritis. That is an interesting article. The acupuncture analyzed was based on procedure codes for acupuncture and electoacupuncture.
We analyzed the acupuncture type that patients received by the treatment codes, which included manual acupuncture of TCM type (B41, B42, B45, B46, B80-B84, B90-B94, P27041, P31103, P32103, and P33031) and electroacupuncture (B43, B44, B86–89, and P33032)
I cannot for the life of me find the details of what these codes represent. So just having acupuncture, irrespective of type or acupoints used, will decrease CAD in RA patients. Amazingly powerful intervention. I think I may be a bit skeptical here. But the article does have the most amusing artwork (see figure two) to demonstrate the two types of acupuncture. Of course, no gloves used with acupuncture.
The author concludes, in the attempt to make acupuncture great again, evaluates a loss and calls it a win:
this is the first description of the efficacy of acupuncture in yet another nonpain condition, albeit lacking in clinical importance in terms of the magnitude of the mean difference from baseline. We should stay open to the potential for adjunctive use of acupuncture to influence outcomes, even in serious medical conditions, and remember that it is easily overlooked because it lacks the commercial backing of many of our modern interventions.
Nope. It was a negative study. Acupuncture is a theatrical placebo with no real physiologic effects outside of local trauma.
But consistent with those who want to make acupuncture great again, hint at malign conspiracies as to why your intervention is a failure.
It must be awful to be a SCAM provider. Time, money, and ego invested into a farce. The sunk cost must be in the Mariana Trench. It must be depressing to be a SCAM provider and live with the knowledge, however slight, that what you are doing is nonsense but you are stuck.
I can’t find data on how many acupuncturists lose faith. But it is common enough in pastors, so I would suspect there are more than a few SCAM providers who do not buy into their particular delusion but cannot change. A sad way to spend the one life you have.
So another failure from the make acupuncture great again crew.
Hmmm.
Maybe the Annals has one too many n’s after all.