I want more placebo effect, please

[Sanity Claws]

In this forum, non-western medicine is often labeled as a placebo. I cited an acupuncture study that showed people doing better after acupuncture than those who continued with standard western medicine. http://www.ncbi.nlm.nih.gov/pubmed/20070551?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=3
It was met with the traditional response that the study was somehow tainted and that the study doesn't mean what it says. Acupuncture was again labeled as a placebo.

In my mind, labeling something as a placebo just raises new issues, not ends discussion.

Why did the western treatment not result in the same placebo affect? If you are claiming that the ones who got better under acupuncture are just more susceptible to the placebo effect than those who got standard western treatment, this just begs the question why?

You can place whatever label on things in an effort to disregard them, but the point is that real healing is taking place. I want to know how to tap into the so-called placebo effect to heal myself and others. I want studies on how to maximize the placebo effect.

What is your take on this?

:hide:

[Celebration]

1. my take is exactly the same

I think maybe once I even started a poll here, or thought about it.....

Which treatment would you choose for Condition?

a. Treatment a., which has a trial showing efficacy in 40% of people with condition a, while a placebo of treatment a shows only 20% efficacy. Treatment a. has no known side effects.

b. Treatment b., which has a trial showing a 70% efficacy for the condition, with a placebo of that treatment working 68% of the time. There are no known side effects.

Each of the above has the same cost. Treatment a. was shown to be significantly better than its placebo, but treatment b. wasn't.

I would like to know why any sane person would choose treatment a over treatment b under those circumstances?

[Name removed]

2. Deleted sub-thread

Sub-thread removed by moderator. Click here to review the message board rules.

[beam me up scottie]

3. Huckle is right, you posted two different studies.

This is the first one you posted: http://www.ncbi.nlm.nih.gov/pubmed/19433697?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


HB provided a link to Orac's response to this particular study but since most people don't follow links, I'll make it easy and post the gist of it:

Another acupuncture study misinterpreted

I have to hand it to acupuncture mavens. They are persistent. Despite numerous studies failing to find any evidence that acupuncture is anything more than an elaborate placebo whose effects, such as they are, derive from nonspecific mechanisms having nothing to do with meridians, qi, or "unblocking" qi. Moreover, consistent with the contention that acupuncture is no more than an elaborate placebo, various forms of "sham" acupuncture (needles that appear to insert but don't or acupuncture in the "wrong" locations, for example) produce results indistinguishable from "real" acupuncture.

***

I included a full description of each straight from the study because I think it's important. In fact, with one glaring error, this is actually a very good experimental design for this sort of clinical trial. I'm not going to say what that glaring flaw is right now, as I want you to try to figure it out. Don't worry, it will be revealed soon enough. But first I want to reveal the reported results of the study.

Back pain was assessed in each patient upon entry into the study using a standard, well-validated questionnaire for back pain, the modified Roland-Morris Disability Questionnaire (RMDQ), and then again at 8 weeks, 26 weeks, and 52 weeks. Strengths of the study included a reasonably number of subjects, a good placebo control group in terms of the simulated acupuncture, and a comparison of "individualized" versus "standardized" acupuncture. I mention this latter aspect of the trial because one complaint that woo-meisters often make is that clinical trials are too "artificial" and do not adequately reflect their "individualized" practice. This trial provided the opportunity to put that claim to the test.

So what was the result? Check out the graphs below, which show two measures of relief of back paint as assessed at the various time points:






The bottom line is that there was no significant difference between any of the three acupuncture groups when compared to each other. Individualized acupuncture was no different from standardized acupuncture, and neither were any different than sham acupuncture. True, all of them were reported as better than "usual treatment," but can you tell what the problem was? Sure, I knew you could. I've mentioned it before enough times when looking at other acupuncture studies. While it's true that the three acupuncture groups were fairly well blinded, as far as studies like this go, there was no blinding at all between the "usual treatment" group and any of the acupuncture groups. The patients in the acupuncture groups all knew that they were assigned to an acupuncture group. They didn't know which acupuncture group they were in (which is good experimental design), but they knew they were getting acupuncture. Similarly, the patients in the "usual care" group all knew they were assigned to a non-acupuncture group. They knew they weren't getting acupuncture. That makes any comparison between the two virtually worthless, other than as an estimate of what the placebo effect was during the study.

***

I do, however, express some amusement at the discomfiture of acupuncture boosters in trying to explain why there was no difference at all between any of the three acupuncture groups and being forced to admit that "patient beliefs" (code word among CAM boosters for nonspecific placebo effects) are the reason for their observed results showing more pain relief among the acupuncture groups than among the "usual care" group. True, the discomfiture caused by this study is not as amusing as that caused by a study from about a year ago, which forced acupuncturists to try to explain why the study's sham acupuncture group had a stronger response than than the "true" acupuncture group. The logical contortions the authors made in order to try to justify that result as somehow being anything other than yet another large study showing acupuncture to be nothing more than a placebo were truly something to behold.v

http://scienceblogs.com/insolence/2009/05/another_acupuncture_study_misinterpreted.php

You claim you want "to know how to tap into the so-called placebo effect to heal myself and others." and that you " want studies on how to maximize the placebo effect."

Orac disagrees:

NCCAM strikes again, and your taxpayer dollars are funding it all. Acupuncture is based on a prescientific philosophy of disease, but apparently that doesn't stop credulous 21st century investigators from wasting taxpayer money producing yet another study showing that it does not work.

And when you make statements like this:

"This just shows that we don't understand how or why Acupuncture works but it sure is more effective than western medicine."

it proves you've already tapped "into the so-called placebo effect to heal (your)self and others": magical thinking






edit: oops, forgot to post link to Orac's blog and fixed html

[Celebration]

4. Although I think this was meant to be a discussion of the placebo effect

And yet not another blog thread about acupuncture, nevertheless, since the thread has indeed taken on the energy of the anti acupuncture blogs, the newer study in the OP above has an entirely different take on the question of the placebo effect in acupuncture--

The accumulating evidence from recent reviews suggests that acupuncture is more than a placebo for commonly occurring chronic pain conditions. If this conclusion is correct, then we ask the question: is it now time to shift research priorities away from asking placebo-related questions and shift toward asking more practical questions about whether the overall benefit is clinically meaningful and cost-effective?

Now, let's let another thread discuss the placebo effect, because there is a lot of noise in here, and also the LATEST info seems to be that the accumulating evidence is that acupuncture is MORE than the placebo effect.

And, a discussion on the placebo effect really has nothing to do with reiterating a bunch of anti acupuncture blog posts.

Notwithstanding that, acupuncture does have the advantage of generally having a large placebo effect, which I personally welcome.

[beam me up scottie]

5. Respectful insolence is written by a surgeon and research scientist.

Unlike the woo-peddlers on DU, he is qualified to interpret the data from research studies.

[Celebration]

6. it is his

non peer reviewed OPINION. That of course, is valid to post here, but it should not be taken as the gospel truth. Do I think he has an agenda? The answer is yes.

Nevertheless, I do agree with at least most of what he said that you quoted, when he talks about that one study. But it appears that in researching all the latest evidence, acupuncture is shown to have an effect outside the placebo effect. Do I expect him to agree with the peer reviewed research? No, not at all. In fact, I can predict that he won't, and it won't have anything to do with the "science", just his particular filter. Most people with blogs HAVE filters. That is the purpose of setting up the blog in the first place.

[beam me up scottie]

8. It is the opinion of a respected surgeon and scientist.

And he didn't always dismiss acupuncture:

Sham acupuncture is better than "true" acupuncture!

Category: Alternative medicine • Medicine • Quackery
Posted on: April 3, 2008 8:48 AM, by Orac


Believe it or not, there was a time when I didn't consider acupuncture to be a form of woo.

I know, I know, it's hard to believe, given the sorts of posts I've done recently on acupuncture, but it's true. Certainly, I didn't believe the whole rigamarole about needles somehow "restoring the flow of qi" or anything like that, but I did wonder if maybe there was some physiologic mechanism at work behind acupuncture that produced real benefits in terms of pain relief above that of placebo. Sure, I may have dismissed homeopathy as the pure magical thinking that it was, but acupuncture I wasn't so sure about.

Obviously, that's changed.

The reason my opinion has changed and now I place acupuncture firmly in the "woo" category is that I've actually been reading the scientific literature on acupuncture over the last year or so. From such a reading of the literature, it has become very obvious to me that (1) the vast majority of research into acupuncture is shoddy in the extreme, with methodological problems that greatly increase the probability of false positive trials; (2) many investigators conflate electroacupuncture which is in reality nothing more than the "conventional" modality of transcutaneous electric nerve stimulation rebranded, with acupuncture itself (unless the ancient Chinese knew how to make electrical nerve stimulation devices, which I highly doubt); and (3) when trials are done with true sham acupuncture there is almost invariably no difference detected between the true acupuncture and the control group.

This time around, I've come across yet another acupuncture study that serves to demonstrate that acupuncture is nothing more than an elaborate placebo. The paper, published in the most recent issue of the Clinical Journal of Pain joins a long line of papers that show that, when the study is well-designed and includes true sham acupuncture, the results virtually invariably show acupuncture to be useless as a therapy. This http://www.ncbi.nlm.nih.gov/pubmed/18287826?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum">particular study came out of a collaboration between Harvard Medical School, the University of Michigan School of Public health, and the Harvard School of Public Health and examined the effect of acupuncture on persistent arm pain due to repetitive stress injuries (RSIs).

***

So what were the results?

Here's where things get amusing. Both treatment groups, "true" and sham acupuncture, experienced decreases in the intensity of arm pain, arm symptoms, and noted improvement in arm function. However, patients in the sham acupuncture group improved more than patients in the "true" acupuncture group in the intensity of arm pain and just as much in measures of arm function and grip strength. The difference between the two groups was not sustained at a followup visit one month after the treatment ended, although the improvement in both groups remained detectable compared to baseline. Indeed, arm pain and arm symptoms scores declined faster in the sham compared with the "true" acupuncture group.

In this study, which was the largest, best-designed trial thus far for acupuncture for arm pain due to RSI, sham acupuncture was better than "real" acupuncture!

***

The bottom line is that this study is yet another in an increasingly long line of studies that demonstrate that acupuncture is nothing more than an elaborate and fancy placebo. Personally, if we're going to start using placebos to treat arm pain, I'd hope that we could find one that doesn't necessarily involve sticking needles into one's body to achieve its effects. Better yet would be to find and use therapies that actually produced a result greater than that of a placebo. Unfortunately, acupuncture isn't one of those therapies.

Also unfortunately this study is yet another in a long line of negative studies funded by the National Center for Complementary and Alternative Medicine. Yes, indeed, it's your tax dollars at work again.

http://scienceblogs.com/insolence/2008/04/sham_acupuncture_is_better_than_true_acu.php

Like Orac, I was on the fence about acupuncture but I have come down firmly on the side of science.

When people in this country are dying from easily treatable diseases I see no valid reason, after decades of magic maybe's,
to fund more studies that only get spun by the snake oil salesmen.

[Celebration]

9. completely ignoring

the PEER REVIEWED study in the OP, not to mention Harvard University teaching it, all in favor of a blog.

Yeah, that's real scientific.

:sarcasm:

[beam me up scottie]

10. The study cited by the op has nothing to do with Harvard or science-based medicine.

You didn't even look at it or read my posts, did you?

Colour me surprised.

[Celebration]

11. I looked at them, yes

They were completely unresponsive to my posts, however.

I do think that in this particular thread, people are going in too many directions, and it is hard to figure out which post is responding to which concern, so there is cause for confusion.

I don't know if we are talking about the placebo effect, or acupuncture. I am going to stick to threads that are more crisply defined.

This is not the fault of the OP, but in the replies. She meant this thread to be about the placebo effect, but because she used an acupuncture example, and a separate one in another thread, people began all the anti acupuncture blog posts. However, I started another thread about the placebo effect if you want to continue the discussion there. Sorry, but I don't have the time to debunk blog posts, particularly when I post peer reviewed studies and get no response.

[beam me up scottie]

7. I don't know if it's deliberate misrepresentation or genuine ignorance, but your conclusion is wrong

I cited an acupuncture study that showed people doing better after acupuncture than those who continued with standard western medicine.

This has nothing to do with "western" (iow: science-based) medicine, the study compared *real* acupuncture to sham acupuncture:

Acupuncture for Chronic Pain: Is Acupuncture More than an Effective Placebo? A Systematic Review of Pooled Data from Meta-analyses.

Hopton A, Macpherson H.
Department of Health Sciences, University of York, York, U.K.


Abstract Objectives: There is controversy as to whether or not acupuncture is more effective than placebo. To help clarify this debate, we synthesized the evidence gathered from systematic reviews on the pooled data of high-quality randomized controlled trials comparing acupuncture to sham acupuncture for chronic pain. Method: Systematic reviews of acupuncture for the most commonly occurring forms of chronic pain (back, knee, and head) published between 2003 and 2008 were sourced from Ovid databases: Medline, Allied and Complementary Medicine database, Cochrane Library and Web of Science during December 2008. Eight systematic reviews with meta-analyses of pooled data were eligible for inclusion. Data were extracted for short- and longer-term outcomes for the most commonly occurring forms of pain. Two independent reviewers assessed methodological quality. Results: For short-term outcomes, acupuncture showed significant superiority over sham for back pain, knee pain, and headache. For longer-term outcomes (6 to12 months), acupuncture was significantly more effective for knee pain and tension-type headache but inconsistent for back pain (one positive and one inconclusive). In general, effect sizes (standardized mean differences) were found to be relatively small. Discussion: The accumulating evidence from recent reviews suggests that acupuncture is more than a placebo for commonly occurring chronic pain conditions. If this conclusion is correct, then we ask the question: is it now time to shift research priorities away from asking placebo-related questions and shift toward asking more practical questions about whether the overall benefit is clinically meaningful and cost-effective?

Let's go over that again:

Abstract Objectives: There is controversy as to whether or not acupuncture is more effective than placebo. To help clarify this debate, we synthesized the evidence gathered from systematic reviews on the pooled data of high-quality randomized controlled trials comparing acupuncture to sham acupuncture for chronic pain.

Results: For short-term outcomes, acupuncture showed significant superiority over sham for back pain, knee pain, and headache. For longer-term outcomes (6 to12 months), acupuncture was significantly more effective for knee pain and tension-type headache but inconsistent for back pain (one positive and one inconclusive). In general, effect sizes (standardized mean differences) were found to be relatively small.