Acupuncture for lower back pain?

In My Humble Opinion
101

If you read my position as that then we have a major failure to communicate. I do however think that applying the similar standards of evidence and likely benefits vs harms and costs should be applied whether a particular approach is one we are biased to believe or disbelieve.

I think you have very different standards of evidence based on biases. Do you use the word “woo” for all the cold medicines that are fairly well proven to not do shit? For potentially harmful surgical interventions that have little high quality evidence of efficacy?

My approach to patients’ use of what is “on the woo side” is NOT to condemn or mock it. I am honest with patient families about my read of the evidence, whether it is solidly against or at best of weak strength, clear about my skepticism of the proposed mechanism, and very strong against if it delays doing something else that needs to be done. I express no objection to acupuncture as part of a plan that also includes exercises and PT for persistent low back pain. I do not recommend it but I won’t try to dissuade either. I try to keep away from chiropractors because the potential for them to cause harm is in my mind greater (in many ways, direct and indirect) and the costs are larger as they keep people coming back … forever.

Maybe part of the efficacy of acupuncture is what many of us … whatever word you like here … have been not doing. The actual time and compassion that many of them express that many of us just don’t have the time for in our busy jammed practices? I dunno.

Honestly if you want to continue the conversation re “Western tradition” medicine as a phrase, vs “mainstream” vs “science based” or “allopathic” we should probably open up another thread. I don’t have strong opinions really. I do not generally read “science based” anywhere and I see it as more self serving than anything else. If it is what you do it is science based … whether or not there is any actual science or evidence involved.

You use the phrase you like though.

102

Not specific to back pain, more about inflammation responses, and not in humans, but an interesting article out of Harvard, which I hope won’t be dismissed due to their use of the phrase “Western Medicine” … :slightly_smiling_face:

To needle a bit on the point: not yet having a plausible mechanism does not mean that there is no plausible mechanism.

103

Here are a few articles written by Dr. Steven Novella, host of The Skeptics Guide to the Universe and a clinical neurologist and associate professor at Yale University School of Medicine.

104

Harvard, or at least a portion of it affiliated health departments, seems to be all in on acupuncture woo.

It’s not a rare phenomenon. Other (once) respected medical establishments have gone down the rabbit hole as well. Acupuncture is offered by Cleveland Clinic’s “Center for Integrative and Lifestyle Medicine”, not to be confused with CC’s Center for Functional Medicine, founded by Mark (I’m-going-to-live-to-150-and-you-should-too) Hyman. Because you can’t be functional without lots of OTC supplements, The Cernter for Functional Medicine sells them in its Healthy Living Shop (there’s a disclaimer that the Shop offers supplements sold by Hyman’s company with a cut of sales potentially going to both Cleveland Clinic and Hyman’s outfit).

And there lies an important reason why otherwise prominent health entities and hospitals offer blatant woo. Beyond the desire to appear “holistic” and attract patients turned off by ostensibly cold, hard science-based care, this stuff is profitable, and it’d be foolish to allow the snake oil crowd to reap all the benefits.

Steve Novella also writes for Science-Based Medicine, and among numerous other medical topics discusses acupuncture, including (recent article) a study that doesn’t support what its supporters claim.

105

It appears your argument is, “This was published by Harvard, so it must be legit!” If so, the argument is a logical fallacy.

Do you also believe crystal healing might be legit? After all, there is a chance we haven’t yet found a plausible mechanism.

106

The name “Harvard” carries a certain cachet - at least, devotees of reiki hope so.

Remember that reiki, crystals, acupuncture etc. all fall under the heading of “energy healing”. Ours is not to question plausibility, but to go with the flow, so to speak. :smiley:

107

And here is a fairly recent meta analysis covering acupuncture for chronic pain.

Acupuncture was superior to both sham and no acupuncture control for each pain condition (all p<0.001)

Were the effects dramatic? Nah. But the discussion makes a good point:

It is also illustrative to compare our results to those of other interventions routinely used in clinical practice. For instance, in one meta-analysis of non-steroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis of the knee, the effect size for NSAIDs vs placebo for trials that did not preselect NSAID responders was 0.23;10 for chronic low back pain, the effect size for NSAIDs is < 0.2029

IOW the evidence for clinically relevant effects is better for chronic pain for acupuncture than it is for NSAIDs. One gets called woo here though.

From the same article:

In terms of implications for clinical practice, we have confirmed that acupuncture has a clinically relevant, persistent effect on chronic pain that is not completely explained by placebo effects. Referral for a course of acupuncture treatment is therefore a reasonable option for a patient with chronic pain.

Evidence based guidelines declared it as a reasonable adjunct in the care of chronic low back pain.

By standards used for most of our mainstream Western tradition science based medicine decision making, acupuncture should come before chronic NSAIDs use. Fair quality evidence, better than for many of the things we do, with low risk and cost. Evidence based guidelines across the world include it. It doesn’t though. Because of our biases. Which some of us seem proud to display, what a good skeptic am I!

These biases play out in other ways as well. Another example - The evidence for lavender oil to treat anxiety is actually pretty good. Low risk. How many of us advise it? Why not? Because we are biased to think of it as woo. I’m guilty of it.

It should all just be medicine. But it isn’t because we are humans, social creatures even professionally. Some try to exempt their “natural” or “ancient” approaches from any burden of evidence, and ignore reasoned risk benefits analysis. We need to combat that. But giving mainstream approaches preferential bias and holding approaches unfamiliar to us to different bars is not the optimal answer. It is apparent to our patients, it undermines their trust in us, it makes them less likely to believe us, and it makes them less likely to share what they are doing knowing that judgement awaits.

I don’t dismiss it because it is Harvard. Which seems to be the tact being taken? The study is interesting. At least I thought so.

108

This note was interesting (found at the end of the list of authors):

… on behalf of the Acupuncture Trialists’ Collaboration

Color me shocked that a meta-analysis conducted by a pro-acupuncture group concludes that acupuncture gives superior pain relief.

A bit surprising though that they think their analysis shows “real” acupuncture superior to “sham” acupuncture (where needles don’t pierce the skin, or do so in the “wrong” areas), as a number of other reviewers have come to a radically different conclusion.

A major problem with meta-analyses touted as showing acupuncture is useful for chronic pain, even if not prone to author bias, is that the individual trials of acupuncture that make up these analyses are generally of poor quality. A relatively large number of crummy/inadequately blinded trials can swamp out a smaller number of larger, more rigorous trials which are negative for efficacy.

Speaking of undermining trust:

Another clinician’s take.

I think you walked into that one by describing it as “an interesting article out of Harvard”, as though its status was enhanced by having a Harvard imprimatur. Better just to call it “an interesting article”. :wink:

There could be a swell chance for me to give acupuncture another go, right here in my small town. I was driving past a strip mall today when I saw a store adjacent to a discount liquor outlet and laundromat with the sign “Acupuncture By ___”. Looking in the window I saw a haphazard pile of boxes and no indications of activity, so they’re either getting ready to open or have closed and are moving out. If the former, I’ll let you know what develops.**

*More on the Paley and Johnson “review of reviews” here.
**the acupuncturist advertises a bunch of modalities, including cupping. Sounds like the real deal. :thinking:

109

I had honestly missed that, and indeed there is a risk there of bias at what to include or not. Of course I also see your beloved skeptics site also at that risk of conclusion looking for support. Be that as it may, other reviewers come to similar positive conclusions reviewing the sham acupuncture control data (SA).

Based on currently available evidence, our meta-analysis found that, overall, acupuncture was superior to SA in terms of pain relief and disability reduction for patients with musculoskeletal disorders.

No question about that, and that is true for many conditions.

Which is why the evidence based guidelines, which judge on strength of evidence balanced with associated risks of harm, rate pretty much all of the recommendations as being based on low quality evidence, including the ones you and I would recommend strongly. The recent WHO one gave NSAIDs moderate strength at least, albeit not recommended for the elderly.

Unfortunately we have to make decisions based on the evidence we have, which is very commonly not of the strength we would want it to be. The guidelines are a reasonable start at synthesizing the available evidence and considering both possible benefits and harms. In this case those “science based medicine” experts are usually including acupuncture as a reasonable option supported as helpful by the evidence to a similar degree as other options they list and with low risks of harms.

I strongly advise guided specific exercise as the first choice, AND if asked about acupuncture I would state that there is similar level evidence of its effectiveness - it does help some, even if at least some of how it works is as a very effective placebo (and I state that, my patients know my skepticism), and it is unlikely to cause harm - but the the exercise programs offer much more. They also will provide a base for prevention of future recurrence. I strongly discourage chiropractic involvement as more at risk of causing a variety of harms and think that the best way to find a good acupuncturist is by way of a recommendation from a physiatrist. And I have several good names of those to offer up. Yes those experts sometimes recommend acupuncture.

Agreed that compassion is something our patients look for and need. And that there are crap providers taking advantage of desperate people doing acupuncture in strip malls, and crap providers in fancy offices staffed by well credentialed surgeons. Honestly I think the latter do more harms overall. Hopefully spending some time, compassionately, establishes enough trust that we help patients avoid the worst of both.

Compassion is often an effective treatment. Unfortunately there are few studies with good sham controls … :grinning:

110

“An interesting article out of a school in Boston…well, not Boston, exactly, but nearby…no, not Tufts…”

111

Speaking of Tufts, students there have access not only to acupuncture, but also to cupping and gua sha; the latter involves scraping the skin with a smooth-edged implement (in one direction only) to unblock the flow of chi (or qi). According to WebMD, this technique was shown in one study (no doubt, rigorous as hell) to decrease liver inflammation seen in hepatitis B.

Reading stuff like this tends to make me face-palm, which is also good for getting the stuck chi flowing again.

112

I think we’ve both expressed our perspectives by now, so let me change the subject just a bit.

You did try acupuncture. I have great confidence that you were already very aware that the offered explanation of its mechanism of action was a crock of shit, and were aware that the evidence for its efficacy was not of high level. So why did you try it?

What is your take on the advice offered early in this thread to get imaging early and/or to push to get seen by ortho or neurosurgery on the front end? Imaging will find things often and surgical fixes of those things have good plausibility arguments. Are those approaches part of science based medicine in your view?

113

There seems to be general agreement that imaging is overutilized and potentially harmful for most patients presenting with low back pain, with exceptions based on clinical history and other factors.

https://www.jospt.org/doi/10.2519/jospt.2011.3618

My one foray into acupuncture occurred decades ago, long before arriving at my current state of wisdom. :stuck_out_tongue_winking_eye: Though the experience does come in handy when met with the objection “how can you criticize acupuncture when you haven’t tried it?”*

*there are limits. It’s not necessary or desirable to undergo cupping, ear candling, borax eating, urine drinking or bathing in MMS (industrial bleach) in order to have an experience base with which to counter objections from wooists. Besides, they’d probably just say “you did it wrong”.

114

There was such a time? You weren’t born a skeptic? A teenager maybe? :grinning: I’d have thought even then …

I don’t believe one needs to have tried something to have a take on it. FWIW. I have also never taken many medications I prescribe and ones I would not prescribe.

115

Opinions evolve based on knowledge and experience.

For instance, the percentage of pediatricians dismissing patients from their practice due to parental vaccine refusal nearly doubled between 2012 and 2020, due in large part to their wanting to protect their other patients from serious vaccine-preventable diseases.

Not all pediatricians feel that way, but their numbers seem to be dwindling, and they’ll face stark choices in coming years, especially if an RFK Jr.-led HHS sabotages childhood immunizations.

116

Just a reminder to people here, Ignaz Semmelweis’ use of antiseptics was once considered woo. I consider some “alternatives” like cupping or homeopathic complete nonsense and will never have a scientific basis and will never solve ailments. I have had, and know others that have, had acupuncture by certified traditional medicine doctors and the results seem to be 90% works to 10% doesn’t work. If in 50 years it comes out that there is a scientific reason it works like nerve stimulation I would not be surprised.

117

It was probably inevitable that we’d get the Semmelweis gambit.

118

You know you’re baiting me here … :grinning:

Pretty sure we’ve had that discussion before. I’ve not … yet … changed my position.

119

But isn’t that the point of science? It eventually gets tested? Just because someone was wrong it doesn’t mean "science"is wrong.

120

The way I would put it is that medicine is not really one of the simplest (ie, with the fewest meaningful variables) sciences.

“Simple” science is: you have two beakers full of a set quantity of distilled water. You add a measured amount of red food coloring to one of the beakers. The water in that beaker changes color.

Because of the inherent complexity in medicine, I personally tend to think that medicine calls for a bit more humility than many of its practitioners and most vocal adherents sometimes offer.

The beaker/food coloring study is infinitely reproducible, usually doesn’t require multicenter studies, large sample sizes, randomization, or (double) blinding.

Neither does it benefit substantially from a study of studies (ie, meta-studies) as a rigorous way to try to get control over and rationalize those profoundly numerous confounding variables I referenced :wink: