Wednesday, October 12, 2016

Not quite placebo

This 2008 article, A Randomized, Controlled Pilot Study of Acupuncture Treatment for Menopausal Hot Flashes, evaluates the effect of acupuncture on menopausal hot flashes. I'm only interested in the methods used in this study. 56 women aged 44 to 55 are divided into three groups, receiving (A) "usual care" (i.e. no acupuncture or needle treatment), (B) sham acupuncture (needle points not on documented meridians), and (C) TCM (Traditional Chinese Medicine) acupuncture. The result shows that groups B and C have significantly less hot flashes than group A. In spite of a small sample size, this study can be said to show a positive effect of acupuncture. But more interesting is that both groups B and C show about the same effect, with C slightly more improvement during the early stage of the treatment. While A and B are both used as control groups, B is used as a placebo group. Therefore this study can also be said to prove that acupuncture is no better than placebo.

Alternative medicine supporters would quickly point out the difference in efficacy between groups A and C, and opponents make use of the lack of difference between B and C. But neither covers the full picture. Not all control groups are created equal, and a placebo may be designed incorrectly. This may be particularly relevant in the acupuncture study, where by convention a sham acupuncture is the same as true acupuncture except for the needle points. Unfortunately, more and more tests seem to show that such sham acupuncture is not sham enough, so to speak, although it probably also points out that the acupuncture point locations are not as important as traditionally believed.[note1]

(See also my March 27 posting of Acupuncture is removed from back pain treatment guideline in UK)

(See also A radical new hypothesis in medicine: give patients drugs they know don’t work. "His own randomized controlled trials found that giving patients open-label placebos — sugar pills that the doctors admit are sugar pills — improved symptoms of certain chronic conditions that are among the hardest for doctors to treat, including irritable bowel syndrome and lower back pain.... You don’t have to give a drug that’s more than placebo; the placebo effect itself is something".)

[note1] The acupuncture points used in group C of this study are as follows: CV-4 关元, KI-3 太溪, SP-6 三阴交, BL-23 肾俞, HT-6 阴郄, KI-7 复溜. I'll leave this list to TCM experts to judge the quality of this selection in treatment of hot flashes.

Sunday, May 22, 2016

Not all cars block UV light on the side efficiently

According to a paper published on May 12, 2016 in the Journal of the American Medical Association Ophthalmology, Americans have more cataract on the left eye and skin cancer on the left face than the right eye and right face, respectively, because drivers sit on the left side, and because UV-A, the major UV component responsible for skin wrinkles among other effects, is not blocked efficiently on the side window. (The windshield blocks UV-A almost completely.)

The paper also tabulates the efficiency in UV blocking by the side windows of various automobile models. 2013 BMW is the worst, blocking only 55%, while 2011 Lexus blocks 96%, which is the best. If you drive a car with poor UV blocking efficiency on the side, drive less, use sunscreen, or install a UV blocking film on the left window.

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.