How Does One Test Acupuncture Against Placebo Anyway?

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Today’s 30-Second Summary

If you don’t have time to read the whole email today, here are some key takeaways:

• Acupuncture is very difficult to test in randomized clinical trials, because of the difficulty in administering sham acupuncture as control, in a manner that is a) believable and b) not going to have its own effect by the logic of Traditional Chinese Medicine

  • However, as best the scientific world has been able to test it, acupuncture reliably (albeit marginally) outperforms placebo for the treatment of pain and nausea. This is attributed to such things as stimulating the production of endorphins.

    • Outside of those uses, Western science has no explanation for why acupuncture should work, nor any reliable evidence that it does work.

• Would your health benefit from a relaxing vacation?

  • Today’s sponsor Dollar Flight Club is offering up to 90% off flights, so that could be a lot sooner than you think!

Read on to learn about these things and more…

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Rice, beans, and the "myth" of protein combining (11:42)

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Protein menu:

• 5:58 | Protein combining controversy

• 6:22 | Protein combining myth

• 8:05 | Position statement of the American Dietetic Association

Prefer text? Click here to read the lead-cited paper on this topic 🤓

📍 MAIN FEATURE

Pinpointing The Usefulness Of Acupuncture

We asked you for your opinions on acupuncture, and got the above-depicted, below-described, set of answers:

• A little under half of all respondents voted for “It's well-backed by modern science, per neurology, cardiology, immunology, etc”

• Slightly fewer respondents voted for “We don’t understand how it works, but it works!”

• A little under a fifth of respondents voted for “It may have some limited clinical applications beyond placebo”

• One (1) respondent voted for for “It’s placebo at best”

When we did a main feature about homeopathy, a couple of subscribers wrote to say that they were confused as to what homeopathy was, so this time, we’ll start with a quick definition first.

First, what is acupuncture? For the convenience of a quick definition so that we can move on to the science, let’s borrow from Wikipedia:

Now, that’s not a promising start, but we will not be deterred! We will instead examine the science itself, rather than relying on tertiary sources like Wikipedia.

It’s worth noting before we move on, however, that there is vigorous debate behind the scenes of that article. The gist of the argument is:

• On one side: “Acupuncture is not pseudoscience/quackery! This has long been disproved and there are peer-reviewed research papers on the subject.”

• On the other: “Yes, but only in disreputable quack journals created specifically for that purpose”

The latter counterclaim is a) potentially a “no true Scotsman” rhetorical ploy b) potentially true regardless

Some counterclaims exhibit specific sinophobia, per “if the source is Chinese, don’t believe it”. That’s not helpful either.

Well, the waters sure are muddy. Where to begin? Let’s start with a relatively easy one:

It may have some clinical applications beyond placebo: True or False?

True! Admittedly, “may” is doing some of the heavy lifting here, but we’ll take what we can get to get us going.

One of the least controversial uses of acupuncture is to alleviate chronic pain. Dr. Vickers et al, in a study published under the auspices of JAMA (a very respectable journal, and based in the US, not China), found:

Source: Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis

If you’re feeling sharp today, you may be wondering how the differences are described as “significant” and “relatively modest” in the same text. That’s because these words have different meanings in academic literature:

• Significant = p<0.05, where p is the probability of the achieved results occurring randomly

• Modest = the differences between the test group and the control group were small

In other words, “significant modest differences” means “the sample sizes were large, and the test group reliably got slightly better results than placebo”

We don’t understand how it works, but it works: True or False

Broadly False. When it works, we generally have an idea how.

Placebo is, of course, the main explanation. And even in examples such as the above, how is placebo acupuncture given?

By inserting acupuncture needles off-target rather than in accord with established meridians and points (the lines and dots that, per Traditional Chinese Medicine, indicate the flow of qi, our body’s vital energy, and welling-points of such).

So, if a patient feels that needles are being inserted randomly, they may no longer have the same confidence that they aren’t in the control group receiving placebo, which could explain the “modest” difference, without there being anything “to” acupuncture beyond placebo. After all, placebo works less well if you believe you are only receiving placebo!

Indeed, a (Korean, for the record) group of researchers wrote about this—and how this confounding factor cuts both ways:

Source: Sham Acupuncture Is Not Just a Placebo

It's well-backed by modern science, per neurology, cardiology, immunology, etc: True or False?

False, for the most part.

While yes, the meridians and points of acupuncture charts broadly correspond to nerves and vasculature, there is no evidence that inserting needles into those points does anything for one’s qi, itself a concept that has not made it into Western science—as a unified concept, anyway…

On the other hand, the efficacy of the use of acupuncture for various kinds of pain is well-enough evidenced. Indeed, even the UK’s famously thrifty NHS (that certainly would not spend money on something it did not find to work) offers it as a complementary therapy for some kinds of pain:

Source: NHS | Acupuncture

Meanwhile, the NIH’s National Cancer Institute recommends it… But not as a cancer treatment.

Rather, they recommend it as a complementary therapy for pain management, and also against nausea, for which there is also evidence that it can help.

Frustratingly, while they mention that there is lots of evidence for this, they don’t actually link the studies they’re citing, or give enough information to find them. Instead, they say things like “seven randomized clinical trials found that…” and provide links that look reassuring until one finds, upon clicking on them, that it’s just a link to the definition of “randomized clinical trial”:

Source: NIH | Nactional Cancer Institute | Acupuncture (PDQ®)–Patient Version

However, doing our own searches finds many studies (mostly in specialized, potentially biased, journals such as the Journal of Acupuncture and Meridian Studies) finding significant modest outperformance of [what passes for] placebo.

Sometimes, the existence of papers with promising titles, and statements of how acupuncture might work for things other than relief of pain and nausea, hides the fact that the papers themselves do not, in fact, contain any evidence to support the hypothesis. Here’s an example:

Source: Acupuncture for Osteoporosis: a Review of Its Clinical and Preclinical Studies

So, here they offered a very sciencey hypothesis, and to support that hypothesis, “strong evidence may still come”.

“We must keep faith” is not usually considered evidence worthy of inclusion in a paper!

PS: the above link is just to the abstract, because the “Full Text” link offered in that abstract leads to a completely unrelated article about HIV/AIDS-related cryptococcosis, in a completely different journal, nothing to do with acupuncture or osteoporosis).

Again, this is not the kind of professionalism we expect from peer-reviewed academic journals.

Bottom line:

Acupuncture reliably performs slightly better than sham acupuncture for the management of pain, and may also help against nausea.

Beyond placebo and the stimulation of endorphin release, there is no consistently reliable evidence that is has any other discernible medical effect by any mechanism known to Western science—though there are plenty of hypotheses.

That said, absence of evidence is not evidence of absence, and the logistical difficulty of testing acupuncture against placebo makes for slow research. Maybe one day we’ll know more.

For now:

• If you find it helps you: great! Enjoy 🙂 

• If you think it might help you: try it! By a licensed professional with a good reputation, please.

• If you are not inclined to having needles put in you unnecessarily: skip it! Extant science suggests that at worst, you’ll be missing out on slight relief of pain/nausea.

Take care!

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📖 ONE-MINUTE BOOK REVIEW

The Twenty-Four Hour Mind: The Role of Sleep and Dreaming in Our Emotional Lives – by Dr. Rosalind Cartwright

We've reviewed books about sleep before, and even about dreaming, so what does this one have to offer that's new?

Quite a lot, actually! Before Dr. Cartwright, there were mainly two models of sleep and dreaming:

• The "top-down" model of psychoanalysts: our minds shape our dreams which in turn reveal things about us as people

• The "bottom-up" model of neuroscientists: our brains need to go through regular maintaince cycles, of which vivid hallucinations are a quirky side-effect.

And now, as Dr. Cartwright puts it:

This she does in the exploratory style of a 224-page lecture, which sounds like it might be tedious, but is actually attention-grabbing and engaging throughout. This book is more of a page-turner than soporific bedtime reading!

Bottom line: if you'd like to know more about the effect your waking and sleeping brain have on each other (to include getting in between those and making adjutments as appropriate), this is very much an elucidating read!

Click here to check out The Twenty-Four Hour Mind, and learn more about yours!

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May today see you well-prepared for the coming weekend,

The 10almonds Team