The Eternal Question: Does Acupuncture Work?

The Eternal Question: Does Acupuncture Work?

Nope.

Time asked the question, Does Acupuncture Work? It is a bad question, since work for what? And which of the to numerous to count forms of acupuncture are they referring.

I just discovered a new, and in my opinion, the only true form of acupuncture, pestle needle acupuncture, a

method characterised by a unique set of points, specialised tools and their specific methods of manipulation. Until modern times it has remained a secret method, passed down through a lineage to its modern inheritor, Li Zhong Yu

Pestle needle doesn't even have needles but 'works' for low back pain.

Time, it should be noted, got the answer wrong, as is often the case. Acupuncture does not work for any process, nor should it.

But it is always an interesting question. Does an intervention work, does it provide a better result than placebo?

Knowing that an intervention has effects is often difficult. My favorite examples in the world of reality-based medicine are mammary artery ligation for angina, arthroscopic debridement for meniscal tear and vertebroplasty.

All were interventions that, unlike acupunctures (except, of course, pestle needle acupuncture) had some prior plausibility they would have beneficial effects. All failed when compared to a sham intervention. But in all three instances the patients reported improvement, often marked improvement. By the standards of acupuncturists we should still be using internal mammary artery ligation, arthroscopic debridement and vertebroplasty.

Pain is the trickiest of endpoints, prone to any number of ways of bias the result, and all the above interventions evaluated effect on pain.

It is more impressive when an intervention alters an objective endpoint, like atrial fibrillation. Afib, the diminutive address we use, is an abnormal heart rhythm that plagues patients with heart disease. One of the therapies is ablation, where they go in a snip the wires that cause the arrhythmia.

It seems like one of those strait-forward mechanical interventions that make sense.

Only?

There is a fascinating discussion over at Medscape entitled "Could Ablation for AF Be an Elaborate Placebo?".

One review suggests

There was insufficient evidence to draw conclusions regarding the efficacy, effectiveness, and safety of catheter ablation in the Medicare population. In the general population, there was moderate evidence that RFA is superior to medical therapy for enhancing patient freedom from recurrence of atrial arrhythmias in both the short and long term regardless of AF type, but reablation was common. RFA does not appear to impact all-cause mortality in the short or long term in those with paroxysmal AF (low strength of evidence); however, there was insufficient evidence to draw conclusions regarding other primary clinical outcomes in the short or long term.

And it is fascinating that

Canadian researchers found that the ratio of asymptomatic to symptomatic AF episodes increased more than threefold after ablation.

And what about those nice before and after EKG's that show the afib is gone?  And EKG would appear to be a hard endpoint.

In AF, one of these issues is disease fluctuation. Clinicians know this effect well: a patient with AF due to a flare of stress, infection, or injury often has remission of the episodes if given time and support. If an ablation is done during (or soon after) this flare, the improvement attributed to ablation may simply be regression to the mean.

It makes one wonder. The greater the theatrics, the bigger the placebo effect and ablation is quite the theatrical procedure.

The rest of the article considers the pros and cons of a sham trial for afib ablation. I hope that such a study will be done and if AF ablation is found wanting compared to sham, it will end up in the used needle bin of history. 

The methodologic issues in studying the efficacy reality-based interventions are many logs greater for pseudo-medicines with zero prior plausibility. And pseudo-medicines never change and are never abandoned because of negative efficacy or patient safety.

Except, of course, for the one true acupuncture, pestle needle, which now that its secret has been revealed to the world, needs no testing and should supplant all other forms of acupunctures.

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