Acupuncture and Constipation: Ignoring Feynman's Adage

Acupuncture and Constipation: Ignoring Feynman's Adage

The first principle is that you must not fool yourself and you are the easiest person to fool. Well, you, journal editors and medical journalists. 

Richard P. Feynman. Kind of.

What can I say about acupuncture that I (and others) haven't said before? Because I am going to say again. Remember, our logo is Sisyphus.

Acupuncture theory of qi and meridians is nonsense, a pre-scientific fantasy with no basis in anatomy, physiology or reality.

In practice, it is no better than a theatrical placebo.

Acupuncture is only effective for subjective endpoints that are not measurable by unbiased observers.

So what about  acupuncture for constipation? The most recent meta-analysis suggests the usual: a lot of mays and mights from bad methodologies.

After strict screening, 15 RCTs were included, containing 1256 participants. All of them were conducted in China and published in Chinese journals. Meta-analysis indicated that acupuncture for chronic functional constipation was probably as effective as conventional medical therapy in the change of bowel movements. For the colonic transit activity, acupuncture might be the same as conventional medical therapy and could be better than sham acupuncture. For the Cleveland Clinic Score, acupuncture was unlikely inferior to conventional medical therapy and the deep acupuncture was better than normal depth acupuncture in abdominal region. No obvious adverse event was associated with acupuncture for constipation. In conclusion, acupuncture for chronic functional constipation is safe and may improve weekly spontaneous bowel movements, quality of life, and relevant symptoms. However, the evidence was limited by the small sample size and the methodological quality.

Of course, if you are a Bayesian kind of person, given the prior plausibility of almost zero that acupuncture would be effective against any process, any positive result is likely to be a false positive due to bias and poor methodologies. And  bias and poor methodologies are the raison d'être of all CAM clinical trials.

And what, exactly, is acupuncture, since damn near anything can be said to be a form of acupuncture if the practitioners want to call it such.

Like electro-acupuncture. Is it really acupuncture? A form of TENS tarted up with Eastern Mysticism? Or just shocking people?  

Which brings us to the profoundly flawed Acupuncture for Chronic Severe Functional Constipation: A Randomized, Controlled Trial which allegedly demonstrates that 'acupuncture' relieves constipation. Well, 'electro' acupcunture.

Not.

The study is out of China. Unfortunately, studies out of China are virtually always positive for acupuncture. They may be a lot of cultural bias in the results of Chinese acupuncture studies as 99% are positive.

This is all important given that the acupuncturists were not blinded and so there was ample opportunity for the Clever Hans effect of involuntary and unconscious cuing.

Most importantly it was the study design:

Half received electricity plus acupuncture at traditional deep muscle acupuncture sites and the rest received acupuncture at non-traditional sites with shallow needles and without electricity.

Two variables changed, but since it never matters where needles are placed the only variable that mattered was the presence or absence of electricity.

They say it was the acupuncture that lead to the better outcome. Let us say for the sake of argument that the outcome, which is patient reported, is valid. As if.

Then it would not be the acupuncture but the damn electricity that was having the effect.  Is there any literature on the effects of electrical current on constipation?  Yes, although not stellar studies.

The data on TENS and electricity for constipation suggests variable results

The very low quality evidence gathered in this review does not suggest that TES provides a benefit for children with chronic constipation.

vrs

This systemic review found moderate support for the effectiveness of electrical stimulation therapy in slow transit constipation in children. However, better-designed studies, with larger and more diverse patient populations followed for longer time periods, will be needed in order to reliably determine the efficacy of electrical stimulation therapy in the treatment of this disorder.

and

Transcutaneous IFC increased colonic PS frequency in STC children with effects lasting 2–7 months. IFC may provide a treatment for children with treatment-resistant STC.

and

The findings of this pilot study suggest that FES applied to the abdominal muscles may be an effective treatment modality for severe chronic constipation in patients with MS.

So while I suspect this is the usual positive acupuncture study due to fatal methodologlic flaws and bias, if there is a real effect, it's not acupuncture, it's the electrons.

And as is so often the cause, the pseudo-scientific wrapper gets all the credit: the headlines on the web  refer to 'acupuncture' relieving constipation.

And of course they want to do further useless studies with flawed methodologies that are guaranteed to show positive results.

Future clinical trials may need a comparison to standard care or a waiting list.

How about adequate blinding and appropriate controls for once?  

Same as it ever was: using Why Most Published Research Findings Are False as guide rather than a warning.

Points of Interest 09/14/2016
Points of Interest 09/13/2017

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