A Word about Evidence


The Detective

Photo by paurian on Flickr and used here with Creative Commons license.

The issue of science and evidence based medicine has interested me since I first entered the profession of traditional acupuncture.  I am fascinated by the far reaching capabilities of science, particularly how modern thought correlates with the traditional philosophical concepts of health that still form the main foundation of traditional Chinese Medicine.  It is through this respect however that I have also learnt the limitations of what human beings can explain or understand.

The evidence base for acupuncture is a big subject in which many pitch battles are fought, usually between the relatively niche worlds of scientific skepticism and research savvy complementary therapists.  Its dominated by big brains and personalities and an arena into which I feel intimidated to even dip my toe.  However! The recent episode of BBC’s “Trust me, I’m a Doctor”, in which they tackled the question “does acupuncture work” in about 8 minutes has convinced me to offer some observations that may better equip people to make a more informed decision for themselves.

Historical context

Acupuncture has been researched since the 19th Century and appeared in the first ever issue of the world acclaimed medical journal The Lancet.  The scientific interest however gathered momentum in the 1950’s when Chairman Mao established a number of acupuncture research institutes as part of a “reinvention” of traditional medicine”.  This and an increasing interest in acupuncture from the scientifically minded west led to a substantial amount of acupuncture research.  It is now most likely the most widely researched complementary medicine in common use.

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Photo by Jeremy Shultz on Flickr and used here with Creative Commons license

The Gold Standard of Evidence

When we hear about scientific evidence in medical terms it is really defined by the Randomised Control Trial (RCT) which is considered the Gold Standard of evidenced. In order to establish how well a particular treatment or intervention works it is studied alongside one or more “control groups”. Trial subjects are randomly allocated to one of the groups or “streams” in which they will receive either a treatment or a control treatment.   In the best studies one of the control groups will be treated with a placebo i.e. designed so that the person giving and receiving it cannot differentiate from the active treatment.  In a blind trial they will have no idea which treatment they are getting.  In a double blind study the practitioner will also be blind as to which treatment they are giving.  In its simplest terms a positive outcome would see the tested treatment or intervention outperforming the controls in a statistically significant way.  Sounds simple?  Its not.  Its a complex time and resource intensive process. There are numerous quality indicators within the process and any deviation risks invalidating or at least undermining the entire study.

Difficulties of designing and RCT of Acupuncture

Firstly, there are a lot of poorly designed studies out there and I’m not decrying the ones that say acupuncture doesn’t work.  Actually the opposite.  Some of the early studies of acupuncture that consistently found it to be better than sliced bread aren’t worth the paper they are written on.

There are of course good ones too and it is in some of the larger and better quality studies of acupuncture that we hear one of the commonly cited criticisms that ‘whilst acupuncture outperforms “usual care” with statistical significance, it fails to compare so well to sham acupuncture’.  This is interpreted by many as meaning it is no better than a placebo.  I think we should consider more information before leaping to this conclusion.

Lets be clear, RCTs are designed for and lend themselves to researching drugs.  In this type of research, creating a placebo is a simple matter of handing the subject a pill or liquid without any active ingredients, usually a sugar pill.  The subject takes it as they would any other drug and in the main, this is a direct representation of how a patient would be treated with drugs.

_DSC0027For interventions using holistic therapies like acupuncture it is far more complex.  Typical clinical practise for a traditional acupuncturist involves a great deal more than just needling.  Palpation, case history, lifestyle advice, the list goes on.  And then there’s the needling, tailored individually to the patient and their unique presentation.  Many trials of acupuncture use pre-defined acupuncture points and seek to isolate it from the other parts of treatment like lifestyle advice etc.  You end up with a highly sanitised treatment that bears little if any resemblance to a typical clinical encounter.

The issue of using a placebo control is also highly controversial.  Creating a placebo for acupuncture means designing an “act” for real and false acupuncture that nobody can differentiate. The favoured methods are retractable needles that don’t penetrate the skin or normal needling on “non” acupuncture points.  The latter at least involves needling which arguably activates a bodily response making it far from inert.  The former is also far from infallible.  During a practise sessions with various types of non-penatrative placebo needles I found that in fact they frequently break the skin and this corresponds with the experience of research acupuncturists too.  If they penetrate the skin, can it be considered as a placebo or non-active intervention?

I’d suggest not so what you end up with is a placebo that may not be inert and an intervention that does not represent normal clinical practise.  Yet in spite of this, both still outperform usual care. What does this say?  My interpretation is that even bad acupuncture is better than usual care or no treatment.  Imagine the potential for proper acupuncture!

Other evidence

What really grates on me is not the never ending argument of the wether or not an RCT has proved one thing or another.  Its the hailing of an RCT as the be all and end all of evidence like nothing else in the world matters. I think this is demonstrative of a far larger cultural shift driven by advances in technology, not just our attitude to medical science.  For example, in my previous profession of law and order we used to solve crime long before CCTV and DNA evidence (I hear the cynics amongst you! Lets have that debate another time!)  Now it seems that witness testimony doesn’t really cut it.  We need concrete proof and undisputed computer audit trails.  Does this mean that without them the crime never took place, that the evidence of a witness was wrong?  No, its just that we now have a higher expectation.  The same is true of medical science.  The old evidence is still evidence and actually, if theres enough of it or the “new” evidence is poor evidence it is arguably still “best” evidence!  Thats not to knock progress, just to encourage some humility because our expectations now are so high we seem to forget that in the greater scheme of things we actually still know very little.  Anyone who has suffered a migraine will back me up here.  Drugs may work, they may not, they may work for a time then stop working.  Actually, this commonly occurring but painfully debilitating illness is very poorly understood in spite of countless studies and amazing scientific developments.

Traditional acupuncture does not rely solely on what can and can’t be proved scientifically.  It is built primarily on the collective knowledge of recorded clinical practise over 2,000 years. It is good evidence stood next to science which has only really developed in the last 60 years and still has a long way to go.  I wonder then why some people would be so quick to dismiss it.

Conclusion

Wooden justice gavel and block with brass

Photo by Tori Rector on Flickr and used here with Creative Commons license

I hope that I have been able to give a good overview of the strength and potential weaknesses of scientific evidence in the field of acupuncture.  In my opinion, whilst science has a huge part to play in our future, it still stands very much in support of the historical knowledge and philosophy that is the bed rock of traditional acupuncture.  That doesn’t mean Im not excited about what it can and will bring to my profession as we make more and more advancements .  I simply advocate tempering this with an awareness of our own limitations and the openness of possibilities beyond our own limited knowledge.

In the meantime I will continue to be guided by “all of the evidence” to treat individual health needs with traditional acupuncture for as long as it continues to help people.  I have a feeling I won’t be retiring anytime soon!

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