Acupuncture

[WisconsinWildcard]

Re: Acupuncture

For those interested in more reading on the subject, I thought I would provide a list of books I found well written.

The first two are by Ben Goldacre. Both are written for a lay audience.
Bad Science is a great book on critical thinking and as the title states, poorly designed research.
http://www.amazon.com/Bad-Science-Quacks-Pharma-Flacks/dp/0865479186

His second book is Bad Pharm, which focuses on pharmaceutical research and the approval process.
http://www.amazon.com/Bad-Pharma-Co...TF8&qid=1416776790&sr=1-1&keywords=bad+pharma

For those interested in evidence based medicine and how it applies to alternative medicine, try this. Written by a statistician, it can be quite dry but really hammers home evidence based medical principles.
http://www.amazon.com/Snake-Oil-Sci...=1416776843&sr=1-1&keywords=snake+oil+science

For a good history and current state of alternative medicine, try this. It is written by Edzard Ernst. He is trained in multiple types of alternative medicine including homeopathy and acupuncture. He became the worlds first professor of CAM (Complementary and Alternative Medicine).
http://www.amazon.com/Trick-Treatme...1416776924&sr=1-1&keywords=trick+or+treatment

 

[leswp1]

Re: Acupuncture

This statement is in direct opposition to this.


All knowledge is provisional. Nothing is fully understood. Everything is subject to revision. Given the time, I could tell you exactly what would be needed to change my mind about every single thing I believe in.


Not sure what "Standard medicine" is. It is either supported by evidence or it is not (there is room for discussion, and shades of grey). Why not state it like that? Why make arbitrary divisions like this?

Also, if you mix cow pie with apple pie, it does not make the apple pie taste better.


Why can we study certain things that are nuanced but not others? This is where the power of a study is important. See women's health study.


Every mystery ever solved throughout history has turned out to be not magic.

We never will. All scientific knowledge, by design, is provisional.


I live in a world of grey and love it.

And before we knew how it worked we thought it either wouldn't work or it was magic. Some of what we thought worked actually didn't.

I find it fascinating that you can say knowledge is provisional yet not include this in provisional. There is no way you can have a control group that exactly matches the subject group. An acupuncturist does not treat the 'back pain'. They treat the back pain in the context of a bunch of other things. Do I think they are connected? Not really. But- if that is how they choose a treatment you would need to see if the control responded the same way. I don't think it is magic just because I don't understand it.

I want to make clear that I do not believe chiropractors or acupuncturists cure all things. If a patient pursues it, as long are not forgoing the treatment I know is approved, have done everything else I know and have failed I cannot see taking it away as an option. If they get relief I could give a fig if it is placebo or not. If it achieves the result and does no harm then good for them. Saying they shouldn't do it because it there is no proof it works when they are finding it works for them is silly. Telling them not to do it because it just perpetuates a belief in something you logically think should not work does not help the patient achieve relief.

You may be allergic to anectdotal results but I cannot ignore what I see. No one can offer any explanation to me (and all the staff including Docs on that floor) how the guy achieved a level of function he shouldn't. Either you believe in miracles or you associate it to the treatment used at the time.

I would prefer to think of it as not magic but as something that medicine has not figured the mechanism out for yet.

I am sure that makes your collective logical brains explode. Sorry. And I am off to bake for the holiday.....

 

[dxmnkd316]

Re: Acupuncture

No, that's what's wrong with medicine today. People are treating the symptoms and not curing the disease.

If it "works then who cares" is the exact wrong way to look at it. It's a waste of money and resources and worse yet, the patient isn't cured. If it's the placebo effect then it by definition is ineffective.

 

[dxmnkd316]

Re: Acupuncture

Or perhaps the worst thing that could happen is these people cause injury to the patient or the underlying condition gets worse when the person should be seeking medical help.

Happened to Steve Jobs. His original thought was to go seek a homeopathic cure and it allowed his cancer to spread uninhibited. If he had sought out actual medical care as opposed to going to what effectively amounts to faith healing, he may have had a chance.

 

[WisconsinWildcard]

Re: Acupuncture

I find it fascinating that you can say knowledge is provisional yet not include this in provisional. There is no way you can have a control group that exactly matches the subject group.

This is a tremendous red herring. Of course you can not have a control group be an exact match. However, good science limits confounders and isolates variables.

An acupuncturist does not treat the 'back pain'. They treat the back pain in the context of a bunch of other things. Do I think they are connected? Not really. But- if that is how they choose a treatment you would need to see if the control responded the same way. I don't think it is magic just because I don't understand it.

This is how I can tell you have not taken the time to read what I have referenced. The study I posted a while back did exactly that. You pretend that this stuff has not been extensively researched when, in fact, it has. Hundreds of millions of dollars have been used to study acupuncture yet you present it as a mysterious process that is out of the reach of science.

If they get relief I could give a fig if it is placebo or not. If it achieves the result and does no harm then good for them.

That type of practice belongs in the 19th century. How can you tell if it is harmful unless you study it? I know you are familiar with the womens health study, as you have brought up hormonal replacement in the past. Estrogen replacement is something that provided relief. It had no observable harm. However, when a large scale study was performed with sufficient power, we were able to see that it slightly, but statistically significantly increased the risk cardiovascular events. Now, we use it judiciously as to maximize the benefits and minimize the risks, according to current knowledge. And we will alter our practice as further study warrants.

Telling them not to do it because it just perpetuates a belief in something you logically think should not work does not help the patient achieve relief.

It does not matter if I think it should not work or not. What I am discussing is if it does work. Granted, we had different definitions of work. You seem to prefer an anecdotal approach. I think anecdotes are helpful for hypothesis formulation, but they in no way test a hypothesis. Many of the things you state "work" have been studied and failed to find an effect. You prefer to take your anecdotes over evidence.

No one can offer any explanation to me (and all the staff including Docs on that floor) how the guy achieved a level of function he shouldn't. Either you believe in miracles or you associate it to the treatment used at the time.

Regression to the mean. Hawthorne effect. Misdiagnosis of the original condition. Spontaneous remission. Post hoc ergo propter hoc. I could go on. All of those are alternative explanations that you leave out.

I have worked in a spinal cord injury unit and have seen this happen. If I had more details about your story, I could probably come up with more specific alternative explanations. The story I told about the patient who passed away was real. You have offered no explanation how we can reconcile our anecdotes, so we could do several things:
1. Think that acupuncture can improve the spinal cord function of a quadriplegic as well as kill a quadriplegic.
2. Develop a hypothesis based on our anecdotes. Test it. Revise or reject it.

 

[Old Pio]

Re: Acupuncture

Or perhaps the worst thing that could happen is these people cause injury to the patient or the underlying condition gets worse when the person should be seeking medical help.

Happened to Steve Jobs. His original thought was to go seek a homeopathic cure and it allowed his cancer to spread uninhibited. If he had sought out actual medical care as opposed to going to what effectively amounts to faith healing, he may have had a chance.

I seem to recall Jim Henson refused proper treatment, opting instead for crystals. Worked about as well as you would expect.

 

[St. Clown]

Re: Acupuncture

Every mystery ever solved throughout history has turned out to be not magic.

So, clearly, the inverse must hold true in that all unsolved mysteries are magic.

 

[Old Pio]

Re: Acupuncture

If the chiro I see is doing ART, which has nothing to do subluxations, why do I care about it? ART is a type of PT developed for overuse injuries. I'm not seeing a chiro to take a mole off my back by manipulating my spine into "proper alignment". For low back pain I'm seeing a chiro now who practices Cox technique. http://www.coxtechnic.com/about-us/flexion-distraction-relieves-spine-pain . He attempts to open up the passage around the nerves at L5S1 and L5L4. Its helped. He told me right from the get go, he can't cure me. I've been to an orthopedic surgeon, have had xrays and MRI. Spinal stenois, arthritis, ankylosing spondylitis. Again my options are painkillers, using radiowaves to kill nerves for temporary relief or non invasive measures such as the Cox technique, stretching and mild exercises. I do all 3 hoping to help with the pain and so I can continue to run my business.
Oh Yeah, I've had steroids shot into my back also, did nothing

This "therapy" of which you are so in love, as I understand it, is the product of one guy's work and he's had it copyrighted so he can make a huge pile of money. Doesn't make it worthless, of course. But I'm not pregnant with celestial fire as to its likely efficacy (never mind safety) either. If your "Dr. Magic Fingers" is a chiropractor, he was educated, schooled and indoctrinated about subluxations. The fact that he and many other DCs have turned away from espousing this 19th century nonsense to other, more scientific sounding (but nevertheless nonscientific modalities) does not explain away the quackery that is the basis of chiropractic.

If Dr. Magic Fingers is relieving your pain, good. Chronic back pain is among the worst non life threatening conditions which afflict humans. If he wants to be your primary care physician, bad. Is he among the enormous number of DCs advocating against vaccinations? Or offering worthless "nutritional" advice? Or claiming to be able to cure learning disabilities by squeezing skulls? Caveat Emptor.

 

[bigmrg74]

Re: Acupuncture

In our community the super-specialists refer to both chiropractic and acupuncture therapy. There is no financial connection. Many of the patients find it helpful. In the end, when you are caring for a patient, the thing that gives them relief is important.

Going Tuesday. Should be sooner. Too bad you weren't closer.

Good Girl.

No, that's what's wrong with medicine today. People are treating the symptoms and not curing the disease.

No, what's wrong with medicine today is that we got politicians and bureaucrats all beytching and moaning about what they're going to do to fix the health care system or vowing that they're going to fight tooth and nail to get rid of the change that the other side wants to do. Nobody working together to actually fix all of its problems so that doctors, nurses, and other medical assistants can go around taking care of patients without worrying about the fact that they're going to get paid so that they can continue to make payments to that towering pile of student debt they have all encumbered themselves with with going to school and learning the stuff that they did.

Excessive body hair? I can't even grow a ****ing beard It is no coincidence that some of my patients have referred to me as Doogie Howser

No beard?? No wonder you're so cranky!

If the chiro I see is doing ART, which has nothing to do subluxations, why do I care about it? ART is a type of PT developed for overuse injuries. I'm not seeing a chiro to take a mole off my back by manipulating my spine into "proper alignment". For low back pain I'm seeing a chiro now who practices Cox technique. http://www.coxtechnic.com/about-us/flexion-distraction-relieves-spine-pain . He attempts to open up the passage around the nerves at L5S1 and L5L4. Its helped. He told me right from the get go, he can't cure me. I've been to an orthopedic surgeon, have had xrays and MRI. Spinal stenois, arthritis, ankylosing spondylitis. Again my options are painkillers, using radiowaves to kill nerves for temporary relief or non invasive measures such as the Cox technique, stretching and mild exercises. I do all 3 hoping to help with the pain and so I can continue to run my business.
Oh Yeah, I've had steroids shot into my back also, did nothing

ART - Active Release Technique, falls well within the scope of Massage Therapy. We had a guy who did that a lot with his work at the studio where I'm at. I do miss having him around.

 

[busterman62]

Re: Acupuncture

Here's the question:

Pt. A is a 45y/o female with breast CA receiving CMF. Pt tells her Dr. A that she wants to use acupuncture and relaxation Tx to control her nausea. Dr. A says that Rx with Zofran and Ativan have a proven track record this is the therapy that he will use. Pt A has no chemo-related nausea.

Pt. B is a 45y/o female with breast CA receiving CMF. Pt tells her Dr. B that she wants to use acupuncture and relaxation Tx to control her nausea. Dr. B says that Rx with Zofran and Ativan have a proven track record whereas acupuncture has no provable benefits. Pt. B opts for acupuncture and Dr. B allows it. Pt B has no chemo-related nausea.

Is Dr. B a quack? Which one is caring for the "whole Pt"?

 

[WisconsinWildcard]

Re: Acupuncture

Here's the question:

Pt. A is a 45y/o female with breast CA receiving CMF. Pt tells her Dr. A that she wants to use acupuncture and relaxation Tx to control her nausea. Dr. A says that Rx with Zofran and Ativan have a proven track record this is the therapy that he will use. Pt A has no chemo-related nausea.

Pt. B is a 45y/o female with breast CA receiving CMF. Pt tells her Dr. B that she wants to use acupuncture and relaxation Tx to control her nausea. Dr. B says that Rx with Zofran and Ativan have a proven track record whereas acupuncture has no provable benefits. Pt. B opts for acupuncture and Dr. B allows it. Pt B has no chemo-related nausea.

Is Dr. B a quack? Which one is caring for the "whole Pt"?

No. Dr. A is practicing paternalistic medicine. Therapy should be a choice between the patient and doc, not just the doc. Dr. B said his bit (how ever accurate that may be) and the patient still chose acupuncture. I am not sure what you mean by "Dr. B allows it" as I am not sure how one would stop a patient from seeking other care, at least in this scenario. It also would be a good idea for Dr. B to give the patient the prescription for the medication anyway, if she were to suffer from nausea. That way, she could fill it quickly if she was suffering or leave it unfilled if she was asymptomatic.

A large minority of my patients seek alternative treatments. That is their choice. The most important thing, for me, is that they feel comfortable talking about it so I can be sure there are no outstanding contraindications. However, I do not give false hope and tell them they work when they are lacking evidence.

I would also add that stress is a universal risk factor. Relaxation will help, no matter what. However, I would rather my patient find relaxation in non-invasive ways, ones with less risk for an adverse event, and ones with practitioners who respect their scope of practice.

It is also important to note the difference between "allowing it" and a direct referral. A physician takes a level of responsibility for his referrals, whereas patient choice outside of the office is a different matter.

 

[busterman62]

Re: Acupuncture

No. Dr. A is practicing paternalistic medicine. Therapy should be a choice between the patient and doc, not just the doc. Dr. B said his bit (how ever accurate that may be) and the patient still chose acupuncture. I am not sure what you mean by "Dr. B allows it" as I am not sure how one would stop a patient from seeking other care, at least in this scenario. It also would be a good idea for Dr. B to give the patient the prescription for the medication anyway, if she were to suffer from nausea. That way, she could fill it quickly if she was suffering or leave it unfilled if she was asymptomatic.

A large minority of my patients seek alternative treatments. That is their choice. The most important thing, for me, is that they feel comfortable talking about it so I can be sure there are no outstanding contraindications. However, I do not give false hope and tell them they work when they are lacking evidence.

I would also add that stress is a universal risk factor. Relaxation will help, no matter what. However, I would rather my patient find relaxation in non-invasive ways, ones with less risk for an adverse event, and ones with practitioners who respect their scope of practice.

It is also important to note the difference between "allowing it" and a direct referral. A physician takes a level of responsibility for his referrals, whereas patient choice outside of the office is a different matter.

Agree 100%

I used the word "allow" to indicate neither approving of or condemning the therapy. Condoning might have been a better choice of words.

The main thing I think that Les and DrD have been saying is that if said therapy is not harmful AND the Pt finds it beneficial for whatever reason, they're OK with that. So am I, and so are many physicians. If the outcome is positive, I'm not going to lose sleep if the MOA is placebo effect or realignment of the chi. This kind of attitude may make me a poor scientist but it makes me a good clinician. The other day I had a little old lady tell me that her arthritis was better because she's taking white raisins soaked in Gin. When I was young and idealistic, I would have told her about the placebo effect and talk to her about NSAIDs. Now, I just asked what brand of gin she used.

 

[WisconsinWildcard]

Re: Acupuncture

This kind of attitude may make me a poor scientist but it makes me a good clinician.

Quite right. It is important to note most physicians are not scientists and that you do not have to be a scientist to be an excellent clinician. I strive to wear both hats, but one has to recognize when to wear what hat. Pragmatic clinical practice is not an issue I was trying to address earlier, just the underlying evidence and basic principles in evidence based medicine.

The other day I had a little old lady tell me that her arthritis was better because she's taking white raisins soaked in Gin. When I was young and idealistic, I would have told her about the placebo effect and talk to her about NSAIDs. Now, I just asked what brand of gin she used.

My grandmother used Gordons gin and it had to be 9 raisins daily. She is 94, has a 70 pack year smoking history (quit at 85, not sure why haha), and in generally good health. She attributes it to the raisins. Every bell curve needs it outliers

 

[DrDemento]

Re: Acupuncture

Agree 100%

I used the word "allow" to indicate neither approving of or condemning the therapy. Condoning might have been a better choice of words.

The main thing I think that Les and DrD have been saying is that if said therapy is not harmful AND the Pt finds it beneficial for whatever reason, they're OK with that. So am I, and so are many physicians. If the outcome is positive, I'm not going to lose sleep if the MOA is placebo effect or realignment of the chi. This kind of attitude may make me a poor scientist but it makes me a good clinician. The other day I had a little old lady tell me that her arthritis was better because she's taking white raisins soaked in Gin. When I was young and idealistic, I would have told her about the placebo effect and talk to her about NSAIDs. Now, I just asked what brand of gin she used.

Buster: Please ask if Vodka works as well. I am not a gin drinker but I do like my vodka. You summarized my attitude fairly well. After 45 years of practicing medicine you usually can get a good feel for when a patient is feeling better. And that should always be the major concern. Certain maxims still apply for me. First, do no harm. Second , if you are not going to make something better, at least do not make it worse. I am most concerned with making my patient feel better(either physically or emotionally). My next concern is of course, trying to get the right diagnosis and then prescribe the most effect and safe treatment. As long as a patient is not delaying getting a proper evaluation for a diagnosis and what might be the most effective medical treatment by spending time with the unproven, the ineffective and the outlandish. I mentioned earlier in this thread-I have always told my patients that I know about 75% of what I do is science. About 20% of what I do is the art of medicine(which is slowly disappearing I might add). And 5% of what I do is luck. I have always found that I sleep better and feel far more rewarded by being totally honest with the people who trust me enough to put their lives in my hands. I do admit though, that in the past, I always lied to every girlfriend.

 

[leswp1]

Re: Acupuncture

Proving once again I am not an eloquent poster. Both of you said it much better than I.

Dr. D I agree with the Art part disappearing. Part of that Art is dealing with the medical condition in the context of the attitude/spiritual component of the person. As medicine has become more 'evidence based' it has lost some of the rituals/things a patient may have found comforting even if the treatment didn't work. SO fascinating to read old medical herbals.There are all sorts of non-herb parts to the preparation, use, etc that met that need for both the practitioner and the pt even if the rest didn't work. And no, I am not advocating the return to only preparing things in the first day of the full moon, only saying that part did meet a a need.

 

[geezer]

Re: Acupuncture

great thread. I love hearing the opinions of people more learned than I on this subject. I understand and believe the general points made about verifiable results etc. as they apply to quacks. However, not all DCs are quacks. They just need to know what they're doing and not overstep their usefullness; they need to be immediately be willing to refer to an MD when it's called for.
I'll show you a giant stack of the hated "anecdotes" regarding "Advanced Muscle Integration Technique", one of these vilified "pseudo therapies." And add one of my own: when I started running last spring, I was a little too enthusiastic and overdid it. My left foot stopped responding properly and rather than rolling through a step, was slapping down painfully on every stride. I couldn't run comfortably because I couldn't control the up/down motion of my foot. Now I could have gone to a surgeon and got sliced and diced and casted up for a few weeks. I went to a DC that does "AMIT" (which I had never heard of before), he told me exactly what was wrong, fixed it in ten minutes with some kind of magic witchcraft, and I was up and running pain free and in control immediately. It simply worked.
I know most of you will dismiss this horrifyingly anecdotal case because this kind of therapy isn't studied in medical school trials and so there's no data on it. But I'm really glad I went this route. The problem hasn't come back, and I never needed surgery. I'd do it again.

 

[FreshFish]

Re: Acupuncture

great thread. I love hearing the opinions of people more learned than I on this subject. I understand and believe the general points made about verifiable results etc. as they apply to quacks. However, not all DCs are quacks. They just need to know what they're doing and not overstep their usefullness; they need to be immediately be willing to refer to an MD when it's called for.
I'll show you a giant stack of the hated "anecdotes" regarding "Advanced Muscle Integration Technique", one of these vilified "pseudo therapies." And add one of my own: when I started running last spring, I was a little too enthusiastic and overdid it. My left foot stopped responding properly and rather than rolling through a step, was slapping down painfully on every stride. I couldn't run comfortably because I couldn't control the up/down motion of my foot. Now I could have gone to a surgeon and got sliced and diced and casted up for a few weeks. I went to a DC that does "AMIT" (which I had never heard of before), he told me exactly what was wrong, fixed it in ten minutes with some kind of magic witchcraft, and I was up and running pain free and in control immediately. It simply worked.
I know most of you will dismiss this horrifyingly anecdotal case because this kind of therapy isn't studied in medical school trials and so there's no data on it. But I'm really glad I went this route. The problem hasn't come back, and I never needed surgery. I'd do it again.

That has been my experience as well: when it comes to specific, localized problems with muscles, tendons, ligaments, and joints, my chiropractor has been very effective. He never once has used the word "subfluxation" and he never once has asserted that a manipulation of the spine will somehow treat anything other than back pain.

It is almost as if WW and OP are talking about one group of practitioners, while you, Walrus and I have dealt with a completely separate group.

I can't remember who said it, but it is as if some chiropractors are equivalent to a PhD in physical therapy, with advanced knowledge of human musculoskeletal anatomy, while other chiropractors are doing something else entirely that I've never once encountered ever.

 

[leswp1]

Re: Acupuncture

That has been my experience as well: when it comes to specific, localized problems with muscles, tendons, ligaments, and joints, my chiropractor has been very effective. He never once has used the word "subfluxation" and he never once has asserted that a manipulation of the spine will somehow treat anything other than back pain.

It is almost as if WW and OP are talking about one group of practitioners, while you, Walrus, les and I have dealt with a completely separate group.

I can't remember who said it, but it is as if some chiropractors are equivalent to a PhD in physical therapy, with advanced knowledge of human musculoskeletal anatomy, while other chiropractors are doing something else entirely that I've never once encountered ever.

FYP. I don't remember if I posted my anecdotal 'cure' but not only have I experienced one with the lower back, my non-surgical spine ortho Dr referred me back to the chiropractor and massage therapist as the best, most efficacious treatment he could recommend for my chronic neck issues.

I still see the massage therapist every 2 weeks. Without it my neck is so screwed up I get HA so bad I am nauseous and incapacitated. It is all ergonomics. If I didn't have the GD EMR with the required laptop to deal with I would be fine. When I am on vacation I am asx.

 

[geezer]

Re: Acupuncture

I'm also biased about this stuff because I married a massage therapist, and have never regretted it for a second.

 

[St. Clown]

Re: Acupuncture

When I am on vacation I am asx.

Are you answers when in the office?