Sunday, March 27, 2016

Acupuncture is removed from back pain treatment guideline in UK

The National Institute for Healthcare and Clinical Excellence in the U.K. recently removed acupuncture from the guideline for back pain treatment and recommended exercise as the best option. The 819-page guideline states that

Do not offer acupuncture for managing non-specific low back pain with or without sciatica

The GDG [Guideline Development Group] noted that although comparison of acupuncture with usual care demonstrated improvements in pain, function and quality of life in the short term, comparison with sham acupuncture showed no consistent clinically important effect, leading to the conclusion that the effects of acupuncture were probably the result of non-specific contextual effects...such as the attention given by the therapist or the expectation of success of an active treatment that might explain, at least in part, the observed effects to the likelihood of over-estimating the effect

The GDG considered that there was a substantial body of evidence relating to acupuncture in this review and that further research was unlikely to alter conclusions.

Interestingly, when the British news media Daily Mail reports NHS's decision, readers' comments are almost exclusively in favor of acupuncture as a treatment option for back pain. The first page of the news report web page displays the most liked comments, such as

"What works for one person, doesn't necessarily work for another, I swear by acupuncture, and have never had success with physiotherapy, it seems a bit short sighted to just remove it as an option.

"Experts should try it for themselves. Acupuncture was the only effective treatment that I had for chronic back and neck pain following a car accident in which I was a passenger."

"I have spent a fortune on all the conventional methods of pain relief for my back and nothing was permanent but acupuncture seems to have worked. Don't take it away."

This is interesting because NHS's decision apparently contradicts a large number of ordinary people's personal experience. NHS definitely has followed the scientific methodology with strict adherence to the universally accepted medical research standard. But it's not wise to dismiss all users' anecdotal evidence as false, sham, or even "contextual". Unless there is bias in users' comments (e.g., only those with positive results care to post), there appears to be a statistical disconnect between the research and personal evidence-based public opinion. Multiple explanations may be offered. I suspect that the definition of sham acupuncture, commonly used in double- or single-blind trials may need to be reviewed. Unlike other types of placebo such as in medication, "sham" acupuncture may actually not be completely sham; due to complex interconnections between the meridians and hundreds of acupuncture points, acupuncture at a random or sham needle point may partially contribute to the treatment effect as a real treatment does albeit at a lesser degree. Sham acupuncture may need to be "improved" to be more or completely sham without compromising the blindness in medical trials. If no better alternative is found, putting the people participating in the trial in sleep may be an option.

Even more interestingly, when a Chinese microblogger posted a brief message to Weibo, the Chinese equivalent of Twitter, with no link to any news report or the NHS Web site, it generated mostly sneering comments on acupuncture. Since the posting page requires login to be read and is in Chinese, here is my literal English translation of the beginning part of the message, which is relevant to the topic.

#Acupuncture has no effect# Big (news)! NHS news: Acupuncture has already been removed from the list of treatments in the back pain treatment guideline newly published in the U.K., because research concludes that there is no evidence to prove its effectiveness.

Note the hash-marked title, sensational and without mention of its applicability (for back pain only), and readers' comments (not shown here) ignore the "back pain only" part and reject acupuncture categorically. It is ironic that acupuncture is held in contempt by Chinese netizens but regarded favorably by non-Chinese, at least according to their anecdotes, considering the fact that the technique originated in ancient China (except for ear acupuncture, which originated in France in the 1950s). It is so true that "Acupuncture grew and diminished in popularity in China repeatedly, depending on the country's political leadership and the favor of rationalism or Western medicine", according to Wikipedia, citing A. White and E. Ernst's 2004 book A Brief History of Acupuncture. Chinese Internet users are generally young and cynical. Acupuncture or the whole traditional Chinese medicine system often becomes the victim of indiscriminate satire, just as it happened in the early 1900's when China woke up to face the powerful and fearful western world.

On the U.S. side, both a 2013 and a 2015 systematic review on the NIH web site find relatively low quality of research but nevertheless benefit of acupuncture on low back pain. It's unlikely that NIH will take a drastic measure as NHS did.