One of the most comprehensive studies of acupuncture for chronic pain ever undertaken was published recently (Vickers et al, 2012), and the results were very positive. However, what was possibly more interesting than the results themselves was the difference in way they were interpreted and reported by different news sources.
Take a look at the following headlines (all reporting the same piece of research, each linking to the relevant news article):
Acupuncture Provides True Pain Relief in Study – New York Times
Acupuncture Superior to Placebo, Usual Care for Chronic Pain – Medscape News
You may wonder, why the discrepancy in how this research was reported?
The research results
The research found, over 29 studies and 17,922 patients, acupuncture was more effective in treating chronic pain than either sham acupuncture or no acupuncture (usual care only). The difference between acupuncture and usual care was greater than the difference between acupuncture and sham acupuncture.
It is worth noting that these 29 studies were deemed to be the best quality (with adequate controls and no reporting bias) of all the studies considered (a total of 909).
The reason for the discrepancy in reporting was due to the small difference between acupuncture and sham acupuncture. Some interpret this small difference as follows:
Sham acupuncture (either needling superficially away from agreed acupuncture points, using fake needles which retract into the handle without piercing the skin, or various non-needle alternatives involving lasers or electrical stimulators which are not active) produces effects better than usual care without acupuncture.
This must be a placebo as there is no ‘real’ acupuncture going on.
The difference between real and sham acupuncture is small, so most of the effect of real acupuncture is due to placebo.
Whatever small difference there is between sham and real acupuncture is probably due to the fact that the therapist knows whether they are giving real or sham acupuncture and probably communicate that to the patient subconsciously, so the placebo effect will be slightly stronger for those patients.
Because the benefits of acupuncture are mostly, or perhaps completely a placebo, acupuncture should not be offered to patients.
Medscape News commented on the placebo effect in this trial as follows, quoting lead study author, Dr Andrew Vickers:
In contrast to other interventions where the placebo is around one third of the effect of treatment, “in acupuncture, it looks like it’s two thirds.”
It is entirely possible that acupuncture has a stronger placebo effect than other interventions, but it remains that real acupuncture provides benefit beyond sham acupuncture that is statistically significant.
Professor Edzard Ernst has been quoted as saying:
“The differences between the results obtained with real and sham acupuncture are small and not clinically relevant.”
and Professor David Colquhoun said of this study:
“It hardly matters whether it is correct that acupuncture is better than sham… What really matters is that Vickers et al showed that the difference is far too small to be of the slightest clinical interest.”
What is not clear is the basis on which these two professors are determining what is clinically significant, because, clinically speaking, the difference that is relevant is that between acupuncture and no acupuncture, not between acupuncture and sham acupuncture. The question for clinicians is whether or not to recommend acupuncture for chronic pain, and the results of this study clearly show that acupuncture offers greater benefits than no acupuncture / usual care (usually anti-inflammatory medication).