More Denial

More Denial

One of the lessons I have learned in my time in the pseudo-medical world is how difficult it can be to know if a therapeutic intervention works and how hard it is to do a good clinical trial. There are so many ways that you can fool yourself and to be fooled into thinking there is an effect when, in fact, there is no there there.

Even more remarkable can be how the answer can be right in front of you and it will be denied. I have seen this clinically many times over the years. First time was as a medical student in the ER where I saw a patient with severe anemia. Initial histroy resulted in no reason for the anemia, but on exam I found a bleeding tumor on his back the size of a large button mushroom. He completely denied there was anything on his back. I have seen similar cases over the years and am amazed at the ability for people to completely ignore information they do not want to process.

A couple of weeks back I mentioned a paper where patients who had a stroke had fewer repeat strokes if they received acupuncture. The acupuncture group was also more likely to be on medications that prevent stroke, a more likely reason for the improved outcome, but the authors were unable to see it.

The inability to recognize probable medical causality continues in Acupuncture for Essential Hypertension: A Meta-Analysis of Randomized Sham-Controlled Clinical Trials.

When you treat a patient for hypertension besides medications you also suggest diet changes and exercise as adjuncts for the treatment and expect the interventions to have gradual effects over time on the blood pressure. You also will titrate medications to control the blood pressure, often following the rule of start low and go slow. Over time you will, one hopes, get a lower blood pressure due to the cumulative effects of the different interventions.

So what would you conclude from this studies finding:

Our results are consistent with acupuncture significantly lowers blood pressure in patients taking antihypertensive medications. We did not find that acupuncture without antihypertensive medications significantly improves blood pressure in those hypertensive patients.

I would conclude that acupuncture was added nothing to the treatment of hypertension and all the effects were due to the medications and other interventions for hypertension.

The also say

Results from many studies in China suggested that acupuncture is a safe and effective treatment for essential hypertension, lowering SBP (about 10–20 mmHg) and DBP (about 6–10 mmHg) with few adverse events [20]. Studies conducted in Western countries showed much smaller changes in SBP (−4.36–14.8 mmHg) and DBP (−2.4–6.8 mmHg). Therefore, our meta-analysis including Western and Korean studies may underestimate the effect of acupuncture for hypertension.

Given that studies from acupuncture friendly countries show better outcomes for acupuncture than 'western' countries, I would suggest that the results are probably over, not under, estimated the effects of acupuncture on hypertension.

And just to clarify, there was no difference between the effects of 'real' and 'sham' acupuncture, as if there is a difference between real and sham:

No significant differences were found with the random-effects model between acupuncture and sham groups with respect to SBP change (n = 386; mean difference = −3.80 mmHg, 95% CI = −10.03–2.44 mmHg; I2 = 99%) or DBP (n = 386; mean difference = −2.82 mmHg, 95% CI = −5.22–(−0.43) mmHg; I2 = 97%)

The conclusion I would draw is that acupuncture has no utility in the treatment of hypertension, not as the authors suggest

Results from this meta-analysis of randomized sham-controlled trials provide evidence that acupuncture helped (lowered) BP in patients taking antihypertensive medications. Our results did not provide support that acupuncture alone significantly lowers BP in patients with hypertension. Larger RCTs with longer follow-up periods would help clarify the potential efficacy and safety of acupuncture for treating hypertension.

I have no doubt the authors think hypertension may be treated with acupuncture despite what their data shows. The ability of humans to deny reality is amazing. Denial.  It's more than a river in Syria.

Points of Interest: 4/18/2014
Points of Interest: 4/17/2014