sham and MRI

[Guest guest]

In a message dated 3/24/04 1:55:23 AM, writes:

 

<< On the other hand, the mere

fact that the " sham " group does so well is still troubling. Whatever

it reveals about the flaws in the study design, it also demonstrates

that effective acupuncture can be performed with total disregard for

traditional theory, point location and selection. >>

 

It has already been stated on this list (by you, I think) that the

study in question is not over, will run until 2008 and has yet to be reported on

in a respectable medical journal. And you are ready to throw out thousands of

years of medical theory over this one study? To me your position is more than

needlessly alarmist, in short, it lacks wisdom. I can't imagine that you

would be able to raise money among your fellow acupuncturists for your proposed

'research arm' when you espouse such views.

 

I don't know what crystal ball you and Alon are looking into in CA, but

things look different here in NY. Our PCOM program here (yes, I'm a student,

but

I'm 52 yrs old, so please don't say I'm a victim of juvenile wish-fulfillment)

is headed by an MD and we have a number of MD's on our faculty. There's

nothing new-age about the school, far from it. Our faculty are developing a

number

of programs in hospitals here, and there is a very strong push toward

integrating CM and WM. Yes, there is a dire need for research and a dire need

to

raise money for research. That cannot be denied. But I can't imagine how that

can be done without holding a firm, positive vision of CM. I'm SURE it can't

be done from a position of running scared.

 

Yes, there are things in CM that probably don't work as advertised. And yes,

there are problems with the educational system (plenty!) and problems with

the push to join CM and WM. But I don't foresee a mass exodus from CM - no

matter what the German study 'proves'.

 

-RoseAnne S.

 

-RoseAnne S.

[Guest guest]

Steve,

 

You make some excellent points points about sham acupuncture and the

nature of a " control " . I think you are right that this so-called

control is not really a control at all. On the other hand, the mere

fact that the " sham " group does so well is still troubling. Whatever

it reveals about the flaws in the study design, it also demonstrates

that effective acupuncture can be performed with total disregard for

traditional theory, point location and selection. So it may not

technically be a sham, but the result is still troubling to me. I also

have to disagree that we should not get alarmed about this study. I

think we have stuck our heads in the sand for too long on far too many

occasions, just hoping things would work out. Better to be alarmed now

and turn out to be wrong than to sit idly by. I know that's not what

you are suggesting, but for many only a sense of alarm will stir one to

action. Better to be alarmed now years in advance of something than to

get riled up long after its too late.

 

However, I also believe Alon is correct. Outcomes studies are not

adequate to demonstrate the cost effectiveness of a therapy. while you

might be able to argue that an outcomes study shows that acupuncture in

a normal clinical setting is an effective procedure for a wide range of

complaints, that is not the sole variable in determining the viability

of a therapy. While some doctors are rejecting the current HMO system

and going back to cash based practices, it is pure fantasy to think

this trend will seep through medicine. 40,000,000 americans are

uninsured and can't afford insurance, much less out of pocket care.

Another group that size is on medicare or medicaid. Much of Europe

uses socialized medicine and that is actually why this study was

undertaken - to determine if the german government would continue

paying for acupuncture services. When it comes to a purely market

based medicine, all that matters is outcomes. And because of this,

some patients will continue to pay for acupuncture out of pocket

because they prefer it to the fully covered alternatives. However when

it comes to medicare, worker's comp, insurance, HMO's, etc., cost must

go hand in hand with effectiveness.

 

On this level, it would seem to me that if you can train people to do

" sham " acupuncture in just a two year associate degree instead of 2-4

years undergrad plus 4 years masters that the savings to the healthcare

system would be immense. With students making so minimal an investment

in their careers, they could not expect to make more than $20 per hour,

which would dramatically lower the cost of the service to patients and

so on. With these issues in mind,I do not believe the decisonmakers

will ever accept pure outcomes research. So I propose two other

options. One is to compare acupuncture to standard therapies. Such a

study could equalize some confounding variables regarding blinding by

making each group (WM and CM) equally " unblinded " . Rather than sorting

out dr./pt. interaction and belief and intention, just try to make sure

these are pretty much the same in each group. Now such a study won't

show what each therapy does all by it lonesome, but you should be able

to compare the differences in each group after adding a sole variable,

such as acumoxa vs. physical therapy. It then wouldn't matter if there

was a sham or not. If acumoxa did better than an already covered

service, logic would dictate it now be covered.

 

In addition, all future research should address the fMRI issue. You

can't say the sham is the same as the real point when they have

different effects on brain function. But we still may be left with the

nagging fact that shamupuncture works. And this will no doubt bolster

the cases of those who want acupuncture to be practiced by nurses and

PT's. Maybe even candy stripers and janitors now. Just kidding. I

hope. :-) However it is not too soon to consider whether we should be

devoting our resources to battles we cannot win. I have never felt it

was worth fighting over the issue of who can insert needles into the

body. I think now more than ever it is a losing cause to try and block

MDs and lower tiers of the profession from doing medical acupuncture.

We really need to somehow prove what we do works better and is more

cost effective than alternatives. Because I see no reason for

authorities to listen to us when we demand control of our turf, yet

have no evidence to prove why we should be in charge. And other

evidence does exist to challenge our very premise, that one must be

expertly versed in chinese medicine in order to practice acupuncture.

 

 

 

Chinese Herbs

 

 

FAX:

 

 

[Guest guest]

On 24/03/2004, at 5:54 PM, wrote:

 

> Steve,

>

> You make some excellent points points about sham acupuncture and the

> nature of a " control " . I think you are right that this so-called

> control is not really a control at all. On the other hand, the mere

> fact that the " sham " group does so well is still troubling. Whatever

> it reveals about the flaws in the study design, it also demonstrates

> that effective acupuncture can be performed with total disregard for

> traditional theory, point location and selection.

 

Yes, I agree......but we must let the cards fall where they may. Truth

is truth, no use holding onto ancient beliefs if they are found to be

mistaken.

>

 

> will ever accept pure outcomes research. So I propose two other

> options. One is to compare acupuncture to standard therapies. Such a

> study could equalize some confounding variables regarding blinding by

> making each group (WM and CM) equally " unblinded " . Rather than sorting

> out dr./pt. interaction and belief and intention, just try to make sure

> these are pretty much the same in each group. Now such a study won't

> show what each therapy does all by it lonesome, but you should be able

> to compare the differences in each group after adding a sole variable,

> such as acumoxa vs. physical therapy. It then wouldn't matter if there

> was a sham or not. If acumoxa did better than an already covered

> service, logic would dictate it now be covered.

>

 

These ideas are also how I feel research must proceed. Perhaps I wasn't

clear in my previous post about my use of the term " outcome " . I was

referring to outcome studies comparing therapies, particularly the

current standard. What is the correct term for these again?

Comparative? Anyway, we are certainly in the same chapter if not the

same page on this issue.

 

This is certainly how university research is heading in Australia for

complementary therapies. Funding is gradually appearing from our

government as they begin to see the possibilities of making health care

cheaper. NSAIDS versus glucosamine for OA sent some serious shock-waves

through the medical establishment here recently when it was

demonstrated the HUGE savings that could be made (plus saving

lives.....a second consideration for most beaurocrats unfortunately).

 

To me, well qualified and competent practitioners from the relevant

fields should be the ones used in treatments is these studies, at least

initially. Not MD's doing the acupuncture etc. The therapy should

include the relevant traditional diagnosis and treatment protocols (ie.

syndromes inside a disease state) etc. Certainly, such research will

most likely have to be based upon a group said to be suffering a

certain western defined disease but after that, the treatment should be

flexible to be true to the therapy tested.

 

 

> In addition, all future research should address the fMRI issue. You

> can't say the sham is the same as the real point when they have

> different effects on brain function.

 

Certainly; as many different measures should be included as possible.

Although expensive, any lab measurement could potentially kill many

birds with one stone in such a study. That is evaluation of efficacy,

possible mechanisms, directions of future research and potential for

advancement of current therapies or discoveries of new.

 

Sincerely,

 

Steve

 

Dr. Steven J Slater

Practitioner and Acupuncturist

Mobile: 0418 343 545

chinese_medicine

[Guest guest]

On this level, it would seem to me that if you can train people to do

" sham " acupuncture in just a two year associate degree instead of 2-4

>>>Todd you can do it in a weekend

alon

 

 

[Guest guest]

Roseanne,

 

, ra6151@a... wrote:

And you are ready to throw out thousands of

> years of medical theory over this one study? To me your position is more

than

> needlessly alarmist, in short, it lacks wisdom. I can't imagine that you

> would be able to raise money among your fellow acupuncturists for your

proposed

> 'research arm' when you espouse such views.

 

You have an interesting way of characterizing my position. It is clear from

my post that you do not like my tone because you have failed to actually hear

my words. However I will try and address the substance of your post. I wrote

that I think there are serious problems with this study and it is incumbent

upon us to show the flaws in design and prove that a proper study will yield

different results. I am troubled notonly by this sham result, but dozens of

other smaller studies thatshow the same thing. this is not one study negating

thousandsof years of theory. It is a recurring trend in acupuncture research

that cannot be denied. I have offered ideas about more valid research and also

the use of MRI's to prove the so-called sham is not the same as so-called real

acupuncture.

 

You may call this running scared. I call it a battle cry to engage the enemy.

Ted Kapchuk is who I paraphrased in my last post. He is the one who said the

things about high acupuncture placebo rates and difficulty of separating sham

from real. And as for thousands of years of theory, I have made my position

clear. Just because someone said it don't make it true. Paul Unschuld has

clearly demonstrated that many chinese medical ideas served culturalneeds

and did not survive due to medical efficacy. In other words, belief and bias

was a big deal throughout allof CM history. It is naive to assume that all

chinese ideas are efficacious or will translate effectively to a radically

different culture. Your position is one that I categorically reject. That we

must have some faith in our tradition. We must have evidence pure and

simple. I am disappointed that your obvious personal dislike for my

skepticism would cause you to dismiss my attempts to raise money for

research. If someone like me doesn't work to undo the damage ALL these

studies have done, you will have to live with the fallout.

 

When we said this is the beginning of the end, we meant if nothing is done. I

suppose members will have to decide whether Alon and I, with our combined

35 years in the field are more likely to be right about this than you. But Dave

Molony of AAOM, in the field for over 2 decades, was always disappointed that

I was not more alarmist about the FDA and I now wish I had heeded his advice.

Longtime members will realize that my tone is much less conciliatory

towards the government than it used to be. I often advised people to settle

down on these issues. but anyone who thinks a study of 500,000 people to be

released in a few years is not a matter for alarm does view time the way I do.

A study of that size will overwhelm most other studies which have all largely

been dismissed due to poor design and small sample rates. the only thing the

NIH says has been proven about acupuncture is its use in nausea. There are

literally a handful of so-so studies and the rest were rejected. Everything

else they said needs more research.

 

So there really is no true counterweight to this german study. so this one

study will dramatically impact lawmakers and insurers. The lead german

researcher suggests the preliminary results point to eliminating acupunctue

from the national healthcare service. This has certainly alarmed german

patients. 4 years is right around the corner if we want to head off these guys

at the pass, rather than try and play damge control after the fact. It will

take

us four years to get our own study underway and producing enough prelimary

results of our own to counter the german report when it comes out. What you

call an alarmist lack of wisdom, I call strategic planning. but that just shows

you how far off the page I am from people like you. I doubt I'll ever convince

you of anything, so I post this to make sure a post like yours does not

sabotage what many of think is the only viable stategy we have.

 

And while you are certainly right that the true believers will not support a

guy who begins with skepticism rather than faith, I am pretty sure

mainstream decisionmakers are more interested in a skeptic doing research

than a true believer. I also think that while you might not support me, many

others in the field have already offered support or money. I have been in the

field for 14 years starting with my education. I know CM works and I want to

prove it. But faith has no place in my scheme of things. But to be clear, any

research foundation will be driven by a board of directors, not my personal

agenda. So any undue alarm and lack of wisdom I might display when trying to

rally the troops will tempered by other interests.

 

 

Chinese Herbs

 

 

FAX:

[Guest guest]

, ra6151@a... wrote:

 

> << On the other hand, the mere

> fact that the " sham " group does so well is still troubling. Whatever

> it reveals about the flaws in the study design, it also demonstrates

> that effective acupuncture can be performed with total disregard for

> traditional theory, point location and selection. >>

>

 

I can't imagine that you

> would be able to raise money among your fellow acupuncturists for your

proposed

> 'research arm' when you espouse such views.

 

 

to be clear, I did not espouse the above view. I just reported the evidence.

What other way can you interpret the effectiveness ofsham acupuncture?

rather than attacking me for not espousing politically correctviews about " a

firm, positive vision of CM. " , why don't you try something constructive and

offer another rational interpretation of this evidence. I already wrote that I

thought it was flaws in study designs that led to this result. But this is the

result reported by the lead german researcher, not me. If the study is

accepted as properly designed, than this is the only possible interpretation I

can see. That is why we must do research to counter what will be otherwise

be regarded as overwhelming evidence. I said we have stuck our heads in the

sand for too long. In case people missed the metaphor, that is the cowardly

position that lacks wisdom.

 

 

[Guest guest]

, ra6151@a... wrote:

Yes, there is a dire need for research and a dire need to

> raise money for research. That cannot be denied. But I can't imagine how

that

> can be done without holding a firm, positive vision of CM.

 

I totally disagree with this statement. Openminded skepticism is the basis

for sound research. an a priori belief in the positive effects of CM is

something I am quite SURE invalidates reseach in the minds of many. I think

you have really got this thing upside down and backwards. Politics is about

firm visions. research is about skepticism. I also don't see how your family

background changes any of this, either. claiming a heritage of intellect is

meaningless to me.

 

[Guest guest]

And you are ready to throw out thousands of

years of medical theory over this one study?

>>>Nobody is but if we do not start taking action we may find ourselves in the

hole. Also when the principal investigator gives such an interview I think we

need to pay attention

Alon

 

 

 

[Guest guest]

We must have evidence pure and

simple.

>>>>Amen

Alon

 

 

[Guest guest]

What you

call an alarmist lack of wisdom, I call strategic planning.

>>>And having the minimum amount of prudence

Alon

 

 

[Guest guest]

Steven if we cannot show better result than shem but better than let say NSAIDs

this will not support paying 50-100$ per visit to an acup's. And by the way the

i do not know how many patient with OA you treated with glucosamine, but i am

willing to bet that the first large study will take it down about 10 notches. I

have seen, between my practice and the MDs i work with hundreds of cases of both

injectable and oral use of GS. Many of the therapies have been studied in very

small groups were bias can effect outcome greatly. Now that real money is being

spent on research and we are going to see much larger studies i think many

treatments such as GS will show to be not as promising as we will like to sell

of being. Even the radiology in the study that showed slowed degeneration has

already been seriously challenged. I think we better brace ourselves for much

more shock waves when these larger studies are going to be published.

Regardless, I do not know what the atmosphere in Australia is, but in the US,

the general medical attitude is one of wait and see. It can change on a dime and

it is up to us to make sure that the final judgment is fair. This will only

occur when we do well designed studies. To try to trash these other studies will

just sound as crying babies.

Alon

 

 

[Guest guest]

Roseanne,

 

, ra6151@a... wrote:

And you are ready to throw out thousands of

> years of medical theory over this one study?

 

Dear all, Roseanne and

I would like to make a few comments;

 

1) about the respect for Chinese observations. Although I have great respect

for their observations, I have several times been utterly astonished over their

" observations " . Most when I read the " Horse Classic " from the 16th century.

There it is written that " if you want to buy a good horse, see to that it has

more than 12 ribs. The more ribs the better horse " . Everybody here in the west

know that all horses do have 18 ribs.

Also it is said that if the horse have certain so and so whirls in the hair,

it will live to be 80 years. Everybody knows that the horse never will be that

old. So, I agree with we must think ourselves!!

 

2) Within veterinary medicine several investigations have shown that when you

blind, double-blind or make such investigations that eliminate " Intention " the

results seem to vanish.

 

Are

 

 

 

Are Simeon Thoresen

arethore

http://home.online.no/~arethore/

 

 

[Guest guest]

Are,

I appreciate the horse stories. And I, too, agree with Todd that we can and

should think for ourselves. What I was addressing didn't have to do with

that issue. Since I feel I articulated my concerns fairly well already, I won't

repeat them here.

-RoseAnne

[Guest guest]

Things on the list have been very quite. What is going on?

Alon