sham and MRIs

[Guest guest]

fMRI's show that some acupuncture points affect specific brain areas

and nearby sham points do not. This is reported by Kapchuk in the

annals of internal medicine in 2002. He also reports and cites that

the impossibility of blinding the acupuncturist plus other factors

results in acupuncture studies exhibiting a high placebo effect which

may make it impossible to distinguish between sham and actual

intervention. given that normal placebo rates are 30% and that sham

points may cause some generalized endorphin response on top of this and

that failure to blind the px results in another increment of placebo,

it is easy to see how even sham acupuncture would have pretty good

results. However it has been physiologically proven that acupuncture

has specific CNS effects, so there is something more than sham. Its

just hard to detect due to study control issues. However the fact

remains that good results can be had with minimal or even no training.

Whether we like it or not, it is up to us to to prove we can do better.

I think there are ways to design studies that address these issue

without resorting the cop-out that this method does not work for

acupuncture. that attitude will just result in losing everything.

After reading Kapchuk and looking at his citations, I think the german

researchers were not careful enough to address key issues. their

studies are flawed and it is right up Ted's ally to prove this. We

should be careful about who we dismiss as no longer relevant to the

field. Ted is relevant, not because anyone thinks much of the web

anymore, but because he understands research and evidence.

 

 

Chinese Herbs

 

 

FAX:

 

 

[Guest guest]

I am happy to see someone finally address some of the issues relevant

to studies involving " sham " acupuncture treatment as a

control/comparison group. In my 4th year of study I did a paper in our

acupuncture research methods subject on sham and placebo in acupuncture

research design.

 

Bottom line is that to my knowledge (review done 2001); no

scientifically valid control/comparison design had been discovered to

fairly compare " real " acupuncture treatment with a truly relevant or

non-physiologically active control. Needling " non-acupuncture " points,

" non-insertion " treatment and other " Sham's " all influence the nervous

system in some way and certainly can not be easily separated from some

of the Japanese styles of acupuncture. Particularly treatments where

non-needling or shallow needling protocols and the emphasis on finding

active points which often do not correspond exactly with textbook point

locations are practiced.

 

What was this German study using as REAL acupuncture anyway? Active

point location? Point location by cun? Point location by electrical

resistance? Were the REAL acupuncturists chinese, korean, vietnamese,

japanese style? Moderen medical acupuncture? Was de qi a pre-requisite

for REAL acupuncture treatment group?

 

Has anyone seen the study design and methods? If so, does it rate well

in terms of Cochrane?

 

It is certainly valid to suggest that it is up to us to PROVE efficacy

of acupuncture if we are to make it into mainstream healthcare.

However, I have yet to see a relevant control/comparison design that

can give a true indication of the relative benefits of " real "

acupuncture treatment.

 

I also feel it is equally up to us to point out when a study is poorly

designed and does not actually test acupuncture at all (very often the

case).

 

This whole debate/discussion on the German study seems rather premature

until far far far more is known about the study design and results.

 

I feel that outcome studies or comparison studies involving a different

treatment modality are all that are currently available to measure

treatment benefits of acupuncture for our patients.

 

Steve

 

On 24/03/2004, at 7:47 AM, wrote:

 

> fMRI's show that some acupuncture points affect specific brain areas

> and nearby sham points do not. This is reported by Kapchuk in the

> annals of internal medicine in 2002. He also reports and cites that

> the impossibility of blinding the acupuncturist plus other factors

> results in acupuncture studies exhibiting a high placebo effect which

> may make it impossible to distinguish between sham and actual

> intervention. given that normal placebo rates are 30% and that sham

> points may cause some generalized endorphin response on top of this and

> that failure to blind the px results in another increment of placebo,

> it is easy to see how even sham acupuncture would have pretty good

> results. However it has been physiologically proven that acupuncture

> has specific CNS effects, so there is something more than sham. Its

> just hard to detect due to study control issues. However the fact

> remains that good results can be had with minimal or even no training.

> Whether we like it or not, it is up to us to to prove we can do better.

> I think there are ways to design studies that address these issue

> without resorting the cop-out that this method does not work for

> acupuncture. that attitude will just result in losing everything.

> After reading Kapchuk and looking at his citations, I think the german

> researchers were not careful enough to address key issues. their

> studies are flawed and it is right up Ted's ally to prove this. We

> should be careful about who we dismiss as no longer relevant to the

> field. Ted is relevant, not because anyone thinks much of the web

> anymore, but because he understands research and evidence.

>

>

> Chinese Herbs

>

>

> FAX:

>

>

[Guest guest]

I think there are ways to design studies that address these issue

without resorting the cop-out that this method does not work for

acupuncture.

 

>>> I think now that we are finally being taken seriously, ie, we are no longer

under the radar, real science is going to determine our survival. Up to now we

got away with counter-culture attitudes and a small patient base mostly with

like-minded attitude. However, now that we are taken seriously the game WILL NOT

BE CHANGED just for us. We and most of alternative medicine have been

functioning on a kind of a free pass. There was no real data for or against us

in the west. But now we, as well as other alternative medicines, are being

looked at closely. If we do not show better results than Sham we are in big

trouble. And I am willing to bet even with our long time supporters, including

our patients. Even though Sham acupuncture in not a good placebo because it is

not an inert intervention, if we can not do significantly better than sham than

we will be labeled as doing nothing of real medical significance, and we will

not be able to dismiss this. The western world will not support acupuncture and

that means us as a profession. I do not know who is best able to pressure those

that have excess to large monies but we must do this fast.Look at what is

happening with chiropractors.They are very quickly loosing the ability to have

insurance coverage and that is only the beginning, and they are much more

powerful then we are at this point (although at this point we have more medical

support than they do).

By the way, this is also a place were those that state that knowing Chinese or

anything more traditional can be used. So far we only have Bob Flaws with a

negative study on neuropathy. While i agree with Bob that the knowledge of

general Chinese medicine is probably not as important in acupuncture as it is

when using herbs, this is the only place that such rhetorical positions will

have any meaning at all. Let see those that push for such standards do some

studies, step up to the plate, and not just sell more courses. If they want to

do anything of significance for our profession now its the time to do it or we

will not have a profession to have this debate with.

Alon

 

 

[Guest guest]

I feel that outcome studies or comparison studies involving a different

treatment modality are all that are currently available to measure

treatment benefits of acupuncture for our patients.

 

Steve

>>>This is not going to be acceptable for the general medical community.

Alon

 

 

[Guest guest]

On 24/03/2004, at 10:39 AM, Alon Marcus wrote:

 

> I feel that outcome studies or comparison studies involving a different

> treatment modality are all that are currently available to measure

> treatment benefits of acupuncture for our patients.

>

> Steve

>>>> This is not going to be acceptable for the general medical

>>>> community.

> Alon

>

 

Sorry Alon; but what is the " acceptable " alternative you intimate? A

control must be definition be " controlled " in that its effects MUST be

known and variables minimised and factored in to be useful.....that is

the point. " Sham " acupuncture controls are an oxymoron; they are

neither controlled nor the variables understood. This is the issue I am

trying state.

 

On 24/03/2004, at 10:32 AM, Alon Marcus wrote:

 

> I think there are ways to design studies that address these issue

> without resorting the cop-out that this method does not work for

> acupuncture.

>

>>>> I think now that we are finally being taken seriously, ie, we are

>>>> no longer under the radar, real science is going to determine our

>>>> survival. Up to now we got away with counter-culture attitudes and

>>>> a small patient base mostly with like-minded attitude. However, now

>>>> that we are taken seriously the game WILL NOT BE CHANGED just for

>>>> us.

 

Sorry again. But the game HAS been changed for us by many of the

studies that are used to judge us not using actual REAL treatment

protocols with skilled technicians or established control designs in

the acupuncture research.

 

At the very least, acupuncture is a physical skill that requires a

certain degree of proficiency. How do you blind the skilled

practitioner? How can you call a control/ " sham " group a real control

when it actually resembles certain styles of acupuncture treatments and

contains an unknown amount of variables? That is simply not scientific!

 

I ask.....how can the efficacy of a therapy be proven either way unless

firstly the therapy is the actual therapy as it is PRACTICED and

secondly, that the control is known to be a true placebo?

 

These studies if done on biomedical treatments would be laughed at in

terms of study design and relevance of results. The results of such

studies are totally meaningless to me also. Where is the real science

you are talking about?

 

Evidence Based Medicine is the way to go.........and besides this;

treatment outcome is all that matters. The biomedical community is

using them as REAL evidence and as the future of research in clinical

protocols........why can't we?

 

>>>> We and most of alternative medicine have been functioning on a kind

>>>> of a free pass. There was no real data for or against us in the

>>>> west. But now we, as well as other alternative medicines, are being

>>>> looked at closely. If we do not show better results than Sham we

>>>> are in big trouble. And I am willing to bet even with our long time

>>>> supporters, including our patients. Even though Sham acupuncture

>>>> in not a good placebo because it is not an inert intervention, if

>>>> we can not do significantly better than sham than we will be

>>>> labeled as doing nothing of real medical significance, and we will

>>>> not be able to dismiss this. The western world will not support

> acupuncture and that means us as a profession.

 

You are exactly correct! Sham is not inert, but worse than

that..........it's effects have not be sufficiently studied in and of

themsleves. The SHAM is almost what some practitioners would call a

style of acupuncture!! Better than sham matters not when the sham could

still be considered acupuncture. Hell, the sham protocol could even be

a NEW discovery for those research designers due to the apparent

medical benefits of its application (slight tongue in cheek but not

totally). Especially when the sham is more effective than the

biomedical interventions!! (which unless I read it wrong as I glanced

at it, is the case parts of the German study).

 

Such study designs could be said to compare acupuncture styles; but not

acupuncture efficacy in and of itself.

 

Just my opinion for what it is worth.

 

Best to all,

 

Steve

 

 

 

 

 

 

Dr. Steven J Slater

Practitioner and Acupuncturist

Mobile: 0418 343 545

chinese_medicine

[Guest guest]

Another way to minimize the sham / placebo effect is to use acupuncture

for things that aren't just related to patient response. For example,

you can do studies on turning breech babies, paralysis, etc. We don't

always have to do pain studies.

Geoff

 

 

> ____________

> __________

>

> Message: 3

> Tue, 23 Mar 2004 12:47:54 -0800

> <

> sham and MRIs

>

> fMRI's show that some acupuncture points affect specific brain areas

> and nearby sham points do not. This is reported by Kapchuk in the

> annals of internal medicine in 2002.

[Guest guest]

Sham " acupuncture controls are an oxymoron; they are

neither controlled nor the variables understood. This is the issue I am

trying state.

>>>>Sham acup is the only way to see if for example there is any point is

studying acup. If a trained acup's can not do better than anyone sticking

needles anywhere than this is not a professional medical intervention. Why than

should we charge people to go to school. May be a weekend course is sufficient.

We MUST show that we can do better than sham. We must also show that we can get

changes that are documentable, beyond pain scores. I do not know about you, but

i have spent 25 years or so studying CM and many forms of acupuncture. If for

all my effort one can do as well just throwing darts at the patient, not only it

would very depressing to me, but also would make it immoral for me to charge the

patients as much as I do. What are we saying here? well we get such small

effects over sham outcome that when studied in real large numbers the

significance disappears. But well lets change the rules of assessment of

medical significance so we can continue to practice?

If we want to talk about the purity of the science when using sham, then you are

correct. Sham needles are not a placebo period. So perhaps we shoud not say this

study is acup vs placebo, but professional acup vs non-educated needle

insertion.

Now as for me, at this point i use much of what one could call neuroanatomical

acup integrated mostly Tong-style acup. Much of the sham points probably can be

explained on a neuroanatomical bases ideas and than justified as active

treatments. But even so, if i can not do better than a non-trained needle

sticker than why should the system pay me to do what i do. If we do not take a

very active role in showing that we can do much better we will be a little

footnote in western medical history and example of why the scientific methods

must be adhered to before any treatment is allowed.

Alon