Monthly Archives: July 2017

HRT and blood clots

This study further adds to the evidence that it is how you take oestrogen, that can result in a blood clot. (VTE). Taken as a pill, it increases the chance of a clot. If taken transdermally (Cream, troche, patch) it does not increase the risk of a blood clot.
Menopause:
doi: 10.1097/GME.0000000000000611
Original Articles

Risk of venous thromboembolism associated with local and systemic use of hormone therapy in peri- and postmenopausal women and in relation to type and route of administration

Bergendal, Annica MD, PhD; Kieler, Helle MD, PhD; Sundström, Anders PhD; Hirschberg, Angelica Lindén MD, PhD; Kocoska-Maras, Ljiljana MD, PhD

Abstract

Objective: The aim of the study was to assess the risk of venous thromboembolism (VTE) associated with systemic hormone therapy according to type and to route of administration and the risk of VTE associated with locally administered estrogen.

Methods: In this case-control study, conducted in Sweden between 2003 and 2009, we included 838 cases of VTE and 891 controls with a mean age of 55 years. Controls were matched by age to the cases and randomly selected from the population. We used logistic regression to calculate odds ratios (ORs) with 95% CIs and adjusted for smoking, body mass index, and immobilization.

Results: Current use of any hormone therapy was associated with an increased risk of VTE (OR 1.72, 95% CI 1.34-2.20). For estrogen in combination with progestogen the OR was 2.85 (95% CI 2.08-3.90), and for estrogen only the OR was 1.31 (95% CI 0.78-2.21). In orally administered estrogen combined with progestogen, the OR was slightly, but not significantly, higher among users of medroxyprogesterone acetate (OR 2.94, 95% CI 1.67-5.36) than among norethisterone acetate users (OR 2.55, 95% CI 1.50-3.40). Transdermal estrogen combined with progestogen was not associated with VTE risk (crude and imprecise ORs ranging from 0.87 to 1.16). For local effect of estrogen, there was no association with VTE risk (OR 0.69, 95% CI 0.43-1.10).

Conclusions: The risk of VTE risk is higher in users of systemic combined estrogen–progestogen treatment than in users of estrogen only. Furthermore, the risk of VTE was lower for women who used local estrogen than among those using oral estrogen only. Transdermal estrogen only treatment and estrogen for local effect seem not to be related to an increased risk of VTE.

Would you rather not know if you have an inherited, increased risk of cancer?

Would you rather not know if you have an inherited, increased risk of cancer?

I recently read an article of a personal account of a woman who was diagnosed with a BRCA gene mutation and the difficult decisions she now faces with having positive results.  A BRCA gene mutation can lead to increased risk of cancer, particularly breast or ovarian in women. Genetic testing for both BRCA or Lynch syndrome in Australia involves a simple collection of sputum.

This article that I read contained a number of lessons that could be of value to our readers.

1. If you will have a gene test you will get results. And with those results may come knowledge, but also more questions and uncertainty. It is a personal decision that should be made after you have talked to a medical professional experienced with BRCA or Lynch about what having the test means, potential benefits and consequences, and how you will cope with the results. Knowing the result may reduce any stress and anxiety that comes from not knowing in some patients; in other patients a test can cause anxiety.

dna 1811955 1920

2. Results will give you a choice of actions. Risk-reducing surgery is effective, but may cause physical and emotional problems for some. To prevent gynaecological cancer, screening and prevention is ineffective; surgery virtually eliminates that risk. To reduce the breast cancer risk, options of surgery versus screening are available. Colonoscopies are also effective to reduce colon cancer mortality. With a positive result you can also make additional lifestyle changes to lower your risk, such as physical activity and a healthy diet.

3. Unfortunately, ovarian cancer screening is fraught with problems. A lot of cancers are not detected by the blood test CA125 because certain cell types (e.g., clear cell) do not produce CA125 and shed it into the blood stream. Ultrasound is also not reliable because small lesions that should be detected are frequently missed. On the other hand, harmless and non-canorous (normal) medical conditions will display a high CA125 count or come up as suspicious on ultrasound.

4. Half of BRCA carriers do not show a family history of cancer. This means that only testing those who have a family history of cancer would miss half of the true BRCA and Lynch carriers.

5. The BRCA test is only $400 in Australia at present (was up to $4,000 until recently).

7. Hormonal replacement after risk-reducing surgery is safe. If the uterus is preserved, HRT would require oestrogen plus progesterone. If the uterus is removed as part of risk-reducing surgery, only oestrogen, which is the safer of the two, needs to be supplemented.

8. Life is not a trial run. It’s real. In the end, there is no right or wrong answer about what you should do and it is a decision only you can make. However, once a decision is made you should make sure that you are perfectly happy with it and stand by it, regardless of what the later outcome will be.

Lower Death Risk for Vascular Dementia than for Alzheimer’s Disease with Postmenopausal Hormone Therapy Users.

J Clin Endocrinol Metab. 2016 Dec 1:jc20163590. [Epub ahead of print]

Lower Death Risk for Vascular Dementia than for Alzheimer’s Disease with Postmenopausal Hormone Therapy Users.

Author information

  • 11 University of Helsinki and Helsinki University Hospital, Obstetrics and Gynecology, Haartmaninkatu 2, 00029 Helsinki, Finland.
  • 22 Folkhälsan Research Center, Biomedicum, Haartmaninkatu 8, 00029 Helsinki, Finland.
  • 33 EPID Research Oy, Metsänneidonkuja 12, 02130 Espoo, Finland.
  • 44 National Institute for Health and Welfare, Mannerheimintie 166, 00271 Helsinki, Finland and Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Stockholm, Sweden.

Abstract

CONTEXT:

There are conflicting data on postmenopausal hormone therapy (HT) and the risk of vascular dementia (VD) and Alzheimer’s disease (AD).

OBJECTIVE:

We analyzed the mortality risk attributable to VD or AD in women with a history of HT use. Design, Patients, Interventions and Main Outcome Measures: A total of 489,105 Finnish women using systemic HT in 1994-2009 were identified from the nationwide drug reimbursement register. Of these women, 581 died of VD and 1057 of AD in 1998-2009. The observed deaths in HT users with <5 or ≥5 years of exposure were compared with those having occurred in the age-standardized female population. Furthermore, we compared the VD or AD death risk of women who had started the use of HT at <60 versus ≥60 years of age.

RESULTS:

The risk of death caused by VD was reduced by 37-39% (<5 or ≥5 years of exposure) with the use of any systemic HT, and this reduction was not associated with the duration or type (estradiol-only or estradiol-progestin combination) of HT. The risk of death caused by AD was not reduced with systemic HT <5 years of use, but was slightly reduced (15%) if the HT exposure had exceeded 5 years. The age at systemic HT initiation of <60 versus ≥60 years did not affect the death risk reductions.

CONCLUSION:

Estradiol-based HT use is associated with a reduced risk of death both from VD and AD, but the risk reduction is larger and appears sooner in VD than AD

New study shows more time walking means less time in hospital

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New study shows more time walking means less time in hospital

February 20, 2017 6.10am AEDT

Disclosure statement

Ben Ewald has received funding from NH&MRC to conduct research promoting physical activity, and is a member of the group Doctors for the Environment Australia.

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University of Newcastle provides funding as a member of The Conversation AU.

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In my practice as a GP, I have been impressed by a few energetic and active 80 year olds who remain in good health while many their age have succumbed to various chronic diseases. So in 2005, when the University of Newcastle established a large community based health study of people aged 55 to 80, I made sure we recorded the participants’ physical activity in detail.

A decade later, we can report the influence of physical activity on the need for hospital care as published in the Medical Journal of Australia today.

We used pedometers to record daily step counts, giving a much more precise measure of activity than the usual self-report questionnaires. Median daily step counts ranged from 8,600 in the youngest to 3,800 in those over 80 years, and weekend days had on average 620 fewer steps than weekdays.

The inactive people (taking 4,500 steps per day) averaged 0.97 days of hospital care per year. The more active people (taking 8,800 steps per day) needed only 0.68 days of care per year. In our analysis we adjusted for the effects of age, sex, the number of illnesses people had when they started, smoking, alcohol intake and education.

We wondered if the causation might be running the opposite direction. That is, that sick people walk less rather than activity preventing illness. To test this idea, we repeated the analysis ignoring all hospital admissions in the first two years of follow up to remove the immediate effects of serious illness. The difference is shown in the graph below.

https://datawrapper.dwcdn.net/IXblF/1/

The association extends right across the range of activity levels, showing any activity is good for health, and the more the better. The participants in our study wore the pedometers from morning until night, so a lot of what we recorded as steps was general activity around the house or the workplace, not necessarily continuous walking. Recent research shows any that activity is better than sitting down, so even light activity is protective of health. Pedometers don’t capture swimming or cycling accurately, but these things make up a small part of daily activity.

Looking at why these patients were in hospital, more active people had fewer admissions for cancer and diabetes, but surprisingly, there was no difference for heart disease. We suspect that might be due to a gap in the data for heart admissions to private hospitals for a few of the years.

What if everyone got walking?

The difference of 0.29 hospital days per year between the inactive and active people is about a 30% reduction. Does this mean if we could get everyone in the population taking 8,800 steps per day we could shut a third of all hospital beds, and send a third of all doctors and nurses off to practice their golf swing? Unfortunately not.

It turns out our study sample is a rather healthy lot, requiring less hospital care than the average for their age. Compared to our average value of less than one day per year of hospital care, figures from the Australian Institute of Health and Welfare for 2014-15 show Australians between 55 and 85 years required 14.2 million days of hospital care, or 2.65 bed days per person.

Getting in 40 minutes of walking a day would reap big rewards in overall health. from http://www.shutterstock.com

Whether increasing activity would be of more or less benefit across the whole of the Australian population is unclear. It may be that the general population would have even more to gain from physical activity than our study participants, or it may be that they have serious chronic diseases that make increased activity impossible.

Let’s imagine for a moment that something changes the walking habits of all Australians, so everyone is walking at least 8,800 steps per day – maybe a combination of a Fitbit craze and an oil shortage that sends petrol to A$10 a litre. What effect would this have on health services?

Considering only the people aged over 55, at a minimum it would reduce the need for hospitalisation by 975,000 bed days per year, for a saving of $1.7 billion dollars. Given there are health benefits at other ages, and the less healthy Australians not represented in our study could benefit more, the actual benefit is likely to be even greater.

An extra 4300 steps per day is not much. It’s just 40 minutes walking, which might include going to the shops, picking up kids, or taking the stairs at work. It doesn’t have to be “exercise”, although higher intensity activity for those who enjoy it has greater health benefits.

With governments searching for ways to reduce spending, and 16% of the federal budget being spent on health, tackling physical inactivity of individual patients, as well as ensuring our urban centres are walking- and cycling-friendly would make a major difference.

Can vitamins supplement a poor diet?

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Health Check: can vitamins supplement a poor diet?

September 12, 2016 3.29pm AEST
There are things that come from plants that aren’t in multivitamins. from http://www.shutterstock.com.au

To the rescue come vitamin and mineral supplements, but can they deliver on their promises and are they for everyone?

Who needs a supplement?

When writing about supplements, a glib approach is to state we can get everything we need from food, so we don’t need them. Eat your veggies. Don’t take supplements. End of story.

That isn’t the whole story, though. Already, our food supply is fortified with folic acid, iodine and thiamin to prevent serious public health issues related to conditions arising from deficiencies of these nutrients in some groups of people. So the rationale of needing to supplement for best health has some validity, but is underpinned by our generally poor eating habits to begin with.

There are groups of people for whom vitamin and mineral supplements would be recommended. Women planning pregnancy can benefit from a range of nutrients, such as folic acid and iodine, that reduce the risk of birth defects. People with limited exposure to sunlight would certainly be advised to consider a vitamin D supplement.

Frail and aged people are candidates as well due to food access problems, chewing and swallowing difficulties, absorption problems and medication. People with malabsorption problems, some vegetarians and people following chronic low-calorie diets all make the list as well. And, of course, people with a clinically diagnosed deficiency could all benefit from supplementation.

Why nutrients from food are better than from supplements

So should everyone take supplements “just in case”? Not so fast. Taking multivitamins as a nutritional insurance policy may be an issue for more than just your wallet. Seeing a supplement as a solution may contribute to neglecting healthy food choices, and this has bigger consequences for long-term health.

Food is a complex mix of vitamins, minerals and phytochemicals (plant chemicals). Phytochemicals are an important component of food and help to reduce the risk of conditions such as heart disease, type 2 diabetes and some cancers. Vitamin and mineral supplements do not provide the benefits of phytochemicals and other components found in food, such as fibre.

Whole foods usually contain vitamins and minerals in different forms – for example, vitamin E occurs in nature in eight different forms – but supplements contain just one of these forms.

We should get all of our vitamins, minerals and phytochemicals from vegetables, but that’s if we’re eating them. from http://www.shutterstock.com

If you look at habits linked to long-term health, it is eating plenty of plant-based foods that comes out on top, not so much taking supplements. This meta-analysis of 21 multivitamin-multimineral supplement clinical trials failed to find any benefit of improved life-expectancy or lower risks of heart disease or cancer from taking supplements.

The promise of possible benefits from supplements takes the focus from what really does promote better health and less chronic disease: eating a varied diet with plenty of minimally processed plant-based foods, regular activity, drinking within guideline recommendations and not smoking.

For a healthy adult, if supplements are used, these should normally be taken at levels close to the recommended dietary intake. High-dose supplements should not be taken unless recommended under medical advice.

Formulations of multivitamins vary between manufacturers, with further market segmentation due to products aimed at different genders and life stages. For example, a multivitamin targeting women of childbearing age will likely be higher in iron than one for adult men. The government’s recommended dietary intakes for each vitamin and mineral are set out by gender and age, and manufacturers generally mirror these recommendations in their formulations.

Although taking too much of certain vitamins or minerals can be harmful, the doses present in multivitamins are typically low. After all, you can only pack so much of each nutrient into a multivitamin pill, and often it is not even close to the recommended dietary intake.

Vitamin and mineral supplements can’t replace a healthy diet, but a general multivitamin may help if your diet is inadequate or where there is already a well-supported rationale for you to take one. If you feel you could be lacking in certain vitamins and minerals, it is better to look at changing your diet and lifestyle first, rather than reaching for supplements.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy.

I do not recommend hormone holidays, as I see no need for it, and it may lead to a return of symptoms, and may have deleterious effects. The study below is one of those negative effects.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy. – PubMed – NCBI

J Clin Endocrinol Metab. 2015 Dec;100(12):4588-94. doi: 10.1210/jc.2015-1864. Epub 2015 Sep 28.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy.

Author information

  • 1Department of Obstetrics and Gynecology (T.S.M., P.T., O.Y.), Helsinki University Hospital, 00029 Helsinki, Finland; Folkhälsan Research Center (T.S.M.), 00250 Helsinki, Finland; EPID Research Oy (H.L., P.K., F.H., P.V.), 02130 Espoo, Finland; National Institute for Health and Welfare (M.G.), 00271 Helsinki, Finland; and Nordic School of Public Health (M.G.), 40242 Gothenburg, Sweden.

Abstract

CONTEXT:

Current guidelines recommend annual discontinuation of postmenopausal hormone therapy (HT) to evaluate whether a woman could manage without the treatment. The impact of HT on cardiovascular health has been widely studied, but it is not known how the withdrawal of HT affects cardiovascular risk.

OBJECTIVE:

We evaluated the risk of cardiac or stroke death after the discontinuation of HT. Design, Patients, Interventions, and Main Outcome Measures: Altogether 332 202 Finnish women discontinuing HT between 1994 and 2009 (data from National Reimbursement register) were followed up from the discontinuation date to death due to cardiac cause (n = 3177) or stroke (n = 1952), or to the end of 2009. The deaths, retrieved from the national Cause of Death Register, were compared with the expected number of deaths in the age-standardized background population. In a subanalysis we also compared HT stoppers with HT users.

RESULTS:

Within the first posttreatment year, the risk of cardiac death was significantly elevated (standardized mortality ratio; 95% confidence interval 1.26; 1.16-1.37), whereas follow-up for longer than 1 year was accompanied with a reduction (0.75; 0.72-0.78). The risk of stroke death in the first posttreatment year was increased (1.63; 1.47-1.79), but follow-up for longer than 1 year was accompanied with a reduced risk (0.89; 0.85-0.94). The cardiac (2.30; 2.12-2.50) and stroke (2.52; 2.28-2.77) death risk elevations were even higher when compared with HT users. In women who discontinued HT at age younger than 60 years, but not in women aged 60 years or older, the cardiac mortality risk was elevated (1.94; 1.51-2.48).

CONCLUSIONS:

Increased cardiovascular death risks question the safety of annual HT discontinuation practice to evaluate whether a woman could manage without HT.

Does Acupuncture Work for Pain?

Does Acupuncture Work for Pain?

A review of modern acupuncture evidence and myths, particularly with regards to treating low back pain and other common pain problems

updated March 22 2016 (first published 2009)
by Paul Ingraham, Vancouver, Canadabio

I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

In early 2009, the British Medical Journal published a new analysis of acupuncture for pain … with discouraging results.1 Again! Not the first time, not the last. More recently and dramatically, the journal Pain did it again — one of the top ten journals for pain and injury science. In early 2011, Pain published a thorough and rather harsh scientific smack down of acupuncture, concluding that there is “little truly convincing evidence that acupuncture is effective in reducing pain,”2 or anything else.3

Even the friends of acupuncture have admitted that it doesn’t work, but they cleverly spin it as good news.45 For instance, the infamous case of the 2010 New England Journal of Medicine paper: pro-acupuncture authors clearly acknowledged that “sham acupuncture was as effective as real acupuncture” — results that would be called failure in any drug trial — and yet they endorsed it anyway.6 In 2009, back pain experts Cherkin and Deyo did much the same, reporting results that were quite disappointing … but they bent over backwards to make it sound like good news anyway.7

Plenty of others have declared acupuncture ineffective without any attempt to spin it. A major report on treatments for knee osteoarthritis — one of the most common pain problems, and as likely a target for acupuncture as any — declared it to be useless.8 All of this evidence is in stark contrast to what most people believe about acupuncture. People actually think science supports acupuncture. But there’s one source that is the most damning of all, the taxpayer boondoggle NCCAM, a huge organization funded by American taxpayers to research alternative medicine, continues to research acupuncture “even though many of its studies have found that acupuncture … works no better than a sham treatment at easing symptoms like pain and fatigue.”9 If NCCAM won’t say that acupuncture works … who will?

All of this evidence is in stark contrast to what most people believe about acupuncture. People actually think science supports acupuncture. That simply isn’t the case. Which isn’t really surprising, because we’re talking about a healing system that rests on a belief in auras: an alleged “energy” in and around the body that no one can actually detect.10

Acupuncture for pain has enjoyed a strong reputation

Somehow, acupuncture has managed to become the poster child of alternative medicine. Almost everyone seems to believe that there “must be something to it.” The term “medical acupuncture” is now ubiqitous, oxymoronic but successful propaganda that makes acupuncture seem more medically legitimate simply by labelling. Until the last few years, even many hardened skeptics and critics gave it a bit of a pass.11 But beliefs about acupuncture are much more specific than that: health care consumers and professionals particularly tend to believe that acupuncture is “good for pain.”

When North Americans think of using acupuncture for pain relief, they often visualize an almost magical anaesthetic effect. This mental image comes to us direct from the year 1972, when journalist James Reston wrote about his appendectomy during American President Nixon’s trip to China — he was apparently “anaesthetized” with acupuncture needles. Now that’s a dramatic effect!

Consequently, most Westerners still believe that acupuncture is good for pain, if not downright amazing for pain. And, throughout the 1970s, 80s, and 90s scientific research — of questionable quality — seemed to back that up. Certain countries have produced almost literally nothing but positive acupuncture trial results. Funny that.Even today, plenty of junky acupuncture studies are still constantly published, in all the worst journals of course, but even in good ones.12 Certain countries have produced almost literally nothing but positive acupuncture trial results!13 Funny that.

Garbage in, garbage out: the legacy of all that sloppy, biased research is that we still get research reviews with supposedly happy endings.14 To zoom in on just one, in 2005, the Annals of Internal Medicine looked at all the mostly poor quality evidence that had been produced up to that time and concluded, “Acupuncture effectively relieves chronic low back pain.”15 (And yet, importantly, they also had to admit that, “No evidence suggests that acupuncture is more effective than other active therapies.” Which don’t work very well. Because low back pain is notoriously difficult to treat. More on this below.) There were certainly good reasons for skepticism by then, but it was still all too easy to look at the available research and feel good about acupuncture — especially if you stuck to the Chinese research!

One of the first really meticulous, rigorous modern acupuncture studies finally arrived in 2007, with evidence that acupuncture could outperform some conventional therapies. Sounds good for acupuncture, doesn’t it? Unfortunately, there was a catch …

comic strip by <a href=”http: “=”” cectic.com=””>cectic.com

Real acupuncture versus fake acupuncture: the only contest that matters

The general problem with most acupuncture research, especially the older stuff, is that it had never been well “controlled.” That’s not a minor problem — “controlling” research by comparing a therapy or medicine to a persuasive fake is extremely important. The methodical Germans made note of this, writing that acupuncture has “never been directly compared” with a placebo or with conventional therapy. So they did it.

The results were published in 2007 in Archives of Internal Medicine. It was literally the first ever well-controlled study of acupuncture for back pain. Exciting! This was a big study (good sample size), and well designed. Looks to me like they really put all past research to shame: a “randomized, multicenter, blinded, parallel-group trial.” Phew. That’s all good. There were two clear, contradictory findings:

  1. Both acupuncture and sham acupuncture were better than conventional physical drugs, physical therapy, and exercise.
  2. And … wait for it … acupuncture was no better than sham acupuncture.

Yes, you read that correctly: acupuncture was no better than a sham … but both acupuncture and the sham were better than conventional therapy. Ouch! That was not a good day to be a physical therapist! Or an acupuncturist! Sort of!

It was a big, weird deal. It was both a significant and strange package of good and bad news for everyone concerned.

The expectation of positive outcome — simple optimism — is a major factor in healing from back pain, probably the greatest. People who believe that they are going to get better, get better.16 And people who receive acupuncture — the real thing or a clever imitation — simply feel better cared for … while conventional therapies simply fail to reassure.

Patients are cynical about conventional therapies, and with good reason. Believe me! I know — I saw it for many years in my work as a massage therapist. That cynism is why alternative health care professionals have busy practices. And it’s justified. Conventional therapies for low back pain are incredibly underwhelming. In fact, they’re so underwhelming that beating them by a little bit is nothing for acupuncture to brag about. All it really means is that acupuncture makes patients feel more cared for and hopeful than conventional therapies do.

This evidence should make patients cynical about acupuncture, too! The authors of the study wrote that the lack of difference between acupuncture groups “forces us to question the underlying action mechanism of acupuncture and to ask whether the emphasis placed on … traditional Chinese acupuncture points may be superfluous.” Yes, rather!

It has only gotten worse for acupuncture since

Haake et al’s 2007 study was one of many better experiments that have been done in recent history. Good modern scientific studies of acupuncture now effectively compare real acupuncture to fake or sham acupuncture, using various tactics,1718 and their results have now been replicated in high impact journals.19

What all this newer research shows, time and again, is that both real acupuncture and fake acupuncture perform equally well. (In fact, sometimes fake acupuncture works better!) That is, they both “work”20 as well as a placebo, neither of them routinely work any miracles, and they have the same effect regardless of whether or not the needles are being used according to the principles of traditional Chinese medicine.

In general, the higher the quality of the evidence, the more discouraging the results have been for acupuncture. This is a classic pattern to look for when you’re trying to evaluate research. Where is most of the good news coming from? What do the larger, better, newer studies show? Compare and contrast!

comic strip by  cectic.com

Not so ancient after all: acupuncture’s myths

Clinical evidence isn’t the only angle on this topic. Research and scholarship about acupuncture has also produced constant parade of smart debunkery and historical facts and cultural context that is really quite embarrassing to the Legend of Acupuncture, showing that it has all the characteristics of modern faddism … not ancient Chinese wisdom.

Indeed, even in China, acupuncture’s key concepts have a dubious history and provenance. For instance, Ben Kavoussi, a doctor and acupuncturist himself by training (and therefore an unusually credible critic) has explained how the supposedly “ancient” and mystical meridians of acupuncture are actually based on quite modern and arbitrary interpretations.21

Before that, for most of history, “acupuncture” existed primarily as a form of bloodletting — much like the prescientific medieval European practice — or much worse.222324 So, not so ancient after all.

“The smell could almost be heard.” That image refers to a child’s rotting leg — rotting because of the incompetence of traditional Chinese medicine, as described in The Reality of Ancient Wisdom. This article is essential, morbidly fascinating reading. I didn’t think I could get any more cynical about ancient folk medicine. I was wrong! Dr. Hall packages up a few excerpts from an old book by a physician working in China in the late 19th Century. His matter-of-fact reports of the actual medical habits of the Chinese at that time are chilling, and a harsh reminder that traditional Chinese medicine was not wise and profound, but rather cringe-inducingly horrible, just as brutal and bizarre as any pre-scientific European “medicine.” In particular, the stories concerning acupuncture expose a mess of superstitious and vicious excess. Bloodletting was the tip of the iceberg. Little wisdom is possible in a state of profound ignorance. 25 TCM is not wise: it’s a patchwork of superstition, habit, and guesswork.26

Then there’s the myth of acupuncture’s popularity. Even its alleged popularity and widespread use in China is quite trumped up — it is, for instance, not really used for anaesthesia. The anaesthia and popularity myths will be described more below.

Such historical perspectives are extremely useful in understanding how naively over-rated acupuncture has become in the world today.

“I put the needles in me instead of in you.”

But is acupuncture actually even popular?

Probably not nearly as popular as acupuncturists want us to think it is. Brennen McKenzie for ScienceBasedMedicine.org:27

I don’t believe the quality of the data generally allow very confident statements about the popularity of acupuncture. However, proponents of acupuncture often make such statements, trying to convey the impression that their approaches are growing rapidly in popularity and only perverse, closed-minded curmudgeons still resist them. The little evidence we have certainly does not support such claims.

There’s no question that acupuncture is somewhat popular: it’s certainly on the public’s radar as an option, something that might be “worth a shot.” However, it is still an option that mostly only desperate pain patients try, and no way is it even nipping at the heels of mainstream medicine in terms of “market share”; it remains a trivial, marginalized player in health care.28 It is not even remotely winning over every patient. Only quite rarely do I hear from a reader or a patient who “swears by” acupuncture, and of course the most emphatic testimonials invariably suffer from obvious flaws, such as recovery that could well have been powered by placebo, a concurrent treatment, or coincidence with natural healing.

Far more commonly, the reports are tepid and uncertain — “I think it might have made a difference” — or frankly negative — “Didn’t do a thing. Waste of money.” Hardly the stuff of serious popularity there.

If acupuncture is popular, it certainly isn’t saving the world from pain. All kinds of chronic pain problems continued to plague North Americans — quite possibly in record numbers, especially low back pain.29 After working for more than decade with chronic pain patients of all kinds, I have yet to see anyone “cured” by acupuncture, even though large numbers of my clients and readers have certainly tried it.30

What about the anesthesia thing? Another myth …

James Reston and the “acupuncture anaesthesia” myth

So … what really happened to James Reston? Did he actually have surgery without anaesthetic? He did not! Telling his story above was a setup.

By his own account, Reston was chemically anaesthetized in a thoroughly medical manner, an epidural — “a normal injection of Xylocain and Benzocain, which anesthetized the middle of my body…and then pumped the area anesthetic by needle into my back.” And, by his own account, Reston received no acupuncture of any kind until 24 hours later, and even that was for “considerable discomfort” — not the severe pain assumed by virtually all re-tellings of the story. By his own accoun, Reston was chemically anaesthetized in a thoroughly medical manner — an epidural — & received no acupuncture of any kind until 24 hours later.

These details are described in a thorough series for ScienceBasedMedicine.org.31 Dr. Kimball Atwood presents a strong case that the “acupuncture anesthesia” promoted from about 1958 through the mid-1970s by the People’s Republic of China — and becoming a powerful myth in North America and Europe — was essentially faked. Like Reston, most patients who underwent acupuncture for surgery were given also sedatives, narcotics, and local anesthetics. Statistics about the use and effectiveness of “acupuncture anesthesia” were grossly exaggerated. During the Cultural Revolution, patients were under extreme pressure to please their physicians and any authority figures — such as a Party representative proudly, conspicuously presiding over the procedure! — which meant they were rather unlikely to complain, even if it meant enduring a lot of pain.

Although it’s true that people can withstand painful procedures without anesthesia to a greater extent than is generally acknowledged in this era of safe anesthesia, the history of acupuncture “anesthesia” in the Peoples’ Republic of China is mainly one of state-sponsored torture.

— Dr. Kimball Atwood

In the late 1970s, when criticism became safe, knowledgeable doctors began speaking out publicly about the fakery, and use of and respect for Traditional Chinese Medicine has been declining in China since that time. Significantly, there is no longer any acupuncture anesthesia or analgesia — at least not to an extent that is either humane or clinically useful for surgery.

Acupuncture treatments, as sold in most places, are used to try to treat specific health conditions and chronic pain. Even if that worked, a true I-can’t-feel-anything anaesthetic effect would be a totally different animal (and a much bigger one). Using acupuncture for true anaesthesia actually is almost as impossible and absurd as it sounds. You don’t want to try it, any more than you want to try getting a tooth pulled after a good belt of whisky. Using acupuncture for anaesthesia actually is almost as impossible and absurd as it sounds. You don’t want to try it, any more than you want to try getting a tooth pulled after a good belt of whisky.

It’s actually not all that unusual for human beings to endure awful things without any kind of anaesthetic. My father, a Vietnam veteran who has both witnessed and experienced extreme traumas, demonstrates this himself occasionally by submitting to dental drilling without freezing — “I hate the freezing so much, I’d rather just deal with the pain and get it over with.” There are numerous social and personal factors that can lead to high pain tolerance … and it can be completely situational. Ask any nurse or doctor: people are full of surprises, and often hurt much less (or much more) than you might expect.

In her book, Women Aren’t Supposed to Fly: The memoirs of a female flight surgeon, Dr. Harriet Hall tells the story of a man who got a vasectomy without anesthesia because he was mistakenly injected with saline solution rather than lidocaine. She also tells the story of a woman whose severe headaches went away after being injected with saline. The latter swore that only Demerol worked for her, but she had been conditioned to feel relief when she got a shot. Likewise, the vasectomy victim didn’t feel excruciating pain because he also was conditioned to get pain relief from certain injections.

The Skeptic’s Dictionary, “Acupuncture

So, while it might seem spooky that anyone has used acupuncture as an “anaesthetic,” it’s actually just not nearly as interesting a phenomenon as it might seem to be at first. Madsen et al interpret this kind of pseudo-anaesthesia effects as a dramatic example of a placebo effect and they definitely found no evidence that such effects can be reliably reproduced. “To regard placebo acupuncture as a universally effective ‘super placebo’ would be inappropriate.” To get a ‘super placebo’ from acupuncture, you need rather a lot of emotional drama surrounding the treatment — which probably depends strongly on a perfect storm of psychological factors that just do not and cannot exist at a low-rent acupuncture office in a mini mall.32

There is a world of psychological difference between experiencing acupuncture in its native cultural context, and experiencing it as a commercialized fad in North America. I was in an acupuncturist’s office this morning, by chance. It had the usual cheesy alternative medicine decor — obligatory fountain, Chinese characters, Vitruvian Man on the business card, cheap diploma — and the acupuncturist was a shy young woman who couldn’t make eye contact, doubtless anxious to sell her services in a struggling economy. It was pretty uninspiring, honestly. In that bland environment, there was no chance of me getting swept up in a powerful placebo effect there … even if I wasn’t a skeptic.

Acupuncture’s glory days are over

It’s all but over for acupuncture as a pain treatment. The recent science doesn’t just cast doubt on acupuncture — it puts more nails in the coffin, nails that are no longer necessary. In 2009, Madsen et al wrote:

Our finding of limited, at best, analgesic effects of acupuncture corresponds with the seven Cochrane reviews33 on acupuncture for various types of pain, which all concluded that no clear evidence existed of an analgesic effect of acupuncture.

Madsen et al was just confirming what was already painfully clear: the evidence was already overwhelming that there is simply nothing of great interest going on in acupuncture except some interesting placebo.

There’s always more to study, more to learn — but all of this evidence is certainly the death of any realistic hope that acupuncture is anything more than an ancient Chinese superstition. Even the most optimistic assessment of the existing scientific research can grant acupuncture no more than the slight possibility of subtle efficacy.

Whoopty-do. Who wants “subtle” when you’re in agony? Treating serious pain is serious business. There’s not much room for “subtle” benefits when you’re trying to help people who are in great pain.34

So it’s time to move on.

Acupuncture has seemingly been studied to death…and yet it will not die. It has a zombie like ability to live again as credulous reporters and health professionals write about the benefits after reading a poorly controlled study. Acupuncture produces a strong placebo effect and that’s it, and when studied with proper controls this has been verified again and again. Why won’t it just die already?

Melany Hamill, for Skeptic North

More studies are not the answer. No matter how many studies showed negative results, they would not persuade true believers to give up their beliefs. There will always be “one more study” to try, but there should be a common-sense point at which researchers can agree to stop and divert research time and funds to areas more likely to produce useful results.

Harriet Hall, Acupuncture Revisited

Fiddling while Rome burns

Acupuncture wouldn’t bother me so much if there were nothing better to think about, no better research to be discussing. But people are suffering from real, horrible chronic pain — they write to me every day, and statistics about chronic pain are thoroughly alarming — and there is urgent work to be done finding solutions for them, and educating both patients and professionals about realistic, rational options.

At best, acupuncture is a waste of valuable time — and now so is the debate about it. I haven’t heard an original or valid argument in defense of acupuncture in years,35 and I haven’t seen any compelling evidence ever I haven’t heard an original or valid argument in defense of acupuncture in years, and I haven’t seen any compelling evidence ever., because it doesn’t exist. As every critic of acupuncture has explained ad infinitum, the most favourable evidence available is also the oldest, weakest and the most biased, and even that evidence is underwhelming, benefits that barely register as clinically significant — much ado about not much, even if it’s actually real, which no better study has ever confirmed.

Carl Sagan famously asked the Dalai Lama what would happen to Tibetan Buddhism if proof that there is no reincarnation could be found. The Dalai Lama sensibly replied:

Then Tibetan Buddhism would have to change.36

And it should be no different for acupuncture. If new evidence emerges that shows that it isn’t what we all hoped it would be, then it must change. That evidence has emerged. Practically everything I once optimistically believed/hoped about acupuncture has been crumbling for years. Science blogger Orac explains a similar evolution in his thinking:

Believe it or not, there was one area of so-called “alternative” medicine that I used to be a lot less skeptical about than I am now. Homeopathy, I always realized to be a load of pseudoscientific magical thinking. Ditto reiki, therapeutic touch, and other forms of “energy healing.” It didn’t take an extensive review of the literature to figure that out, although I did ultimately end up doing fairly extensive literature reviews anyway. Then, the more I looked into the hodgepodge of “healing” modalities whose basis is not science but rather prescientific and often mystical thought, the less impressed I was.

Even so, there was always one modality that I gave a bit of a pass to. There was one modality that, or so I thought, might actually have something to it. There was one modality that seemed to have a bit of suggestive evidence that it might do something more than a placebo. I’m referring to acupuncture. No, I never bought all the mystical mumbo-jumbo about how sticking needles into “meridians” somehow alters or “unblocks” the flow of a mysterious “life force” known as qi that is undetectable by science. I did wonder if perhaps it worked as a counterirritant or by releasing endorphins.

Then I actually started paying attention to the scientific literature regarding acupuncture, including literature like this and this. The more I read, the more I realized something. I realized that there was far less to acupuncture than I had previously thought, and, even with my previous openness to it, I hadn’t thought all that much about it anyway. What I had thought about it was that it might have a very mild beneficial effect. What I know now is that acupuncture is almost certainly no more than an elaborate placebo. What I know now is that virtually every study of acupuncture claiming to show a positive effect has serious methodological flaws and that the better-designed the study the less likely there is to be an effect.

Safety concerns

To conclude, I want to emphasize that acupuncture is not actually even safe.

As with any treatment that breaks the skin, disastrous infection is possible, and outbreaks of mycobacteria infection caused by acupunture have been reported in the last decade.37 Furthermore, placebo effects tend to backfire: the patient is betrayed in the end, and the failure to achieve a lasting cure paradoxially cements the patient’s idea their pain is untreatable, “even by acupuncture.”38

Ernst et al did a good job of backing this up, and explained that “serious adverse effects continue to be reported,” such as infections and collapsed lungs. Nothing like a little sepsis and collapsed lung to add to the fun of chronic pain!

Of course these risks are not common complications. And when medicine works, costs and risks are acceptable, even a “no brainer.” But if there are no clear, consistent, measurable benefits to a treatment? Then there is no justification for any risk.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

Appendix
A personal perspective: How it felt to change to my mind about acupuncture over a period of several years

I used to “believe” in acupuncture. I think almost everyone did. Probably not this guy. And probably not this one either. But just about everyone else, even skeptics, cut acupuncture some slack.

Over the years, I have been persuaded by more and more good quality evidence — and the steady stream of patients with nothing better to say about it than “maybe it helped for a while” — that there is really nothing at all to acupuncture. It’s just another folk medicine tradition, about as therapeutically meaningful as a manicure.

So how did it feel to change my mind? Oh, a little awkward. It was like diving into water you just know is cold enough to make you gasp. I felt some emotional resistance to the evidence. I also remember feeling comforted whenever I read anything that seemed to bolster my besieged beliefs I felt some emotional resistance to the evidence. I also remember feeling comforted whenever I read anything that seemed to bolster my besieged beliefs., and there was plenty of that. It took me quite a while to notice the disturbing pattern that the evidence supporting acupuncture was of consistently lower quality, while the evidence undermining it was of consistently higher quality.

Things started to get more comfortable when I noticed that I rather liked the doctors, scientists and skeptics who were challenging acupuncture. They seemed ridiculously bright — and I like bright people. I actively seek out people who are smarter than I am, because I figure it’s the most obvious way to get smarter: you are who you hang out with. I certainly didn’t like them because they agreed with me on much of anything, because we didn’t agree at that time. But they won me over.

Having my beliefs challenged by such intelligent people was uncomfortable at first, but it was overshadowed by the desire to understand. Despite my initial reluctance, in the end I’m proud to say that I was much more interested in just knowing how the world works than anything else.

Related Reading

Notes

  1. Madsen MV, Gotzsche PC, Hrobjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009;338:a3115. The reviews concludes that “a small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.” In the context of treating pain, a “small analgesic effect” is nearly worthless, and it hopelessly damns with faint praise, and that’s assuming it’s even a genuine effect of acupuncture. In fact, it’s vastly more likely to be an effect of being handled and taken care of (“the treatment ritual”). BACK TO TEXT
  2. Ernst E, Lee MS, Choi TY. Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011 Apr;152(4):755–64. PubMed #21440191. A dozen of the best scientific studies of acupuncture treatments for pain were carefully analyzed in this review. The acupuncture treatments were for conditions like osteoarthritis, headache and migraine, low back pain, fibromyalgia, and more. The authors found a statistically significant but “small difference between acupuncture and placebo acupuncture.” They concluded that “the apparent analgesic effect of acupuncture seems to be below a clinically relevant pain improvement.” They also note that “serious adverse effects continue to be reported.”Pain invited a well-known voice of reason in medicine, Dr. Harriet Hall, to write an editorial about this paper. Dr. Hall’s editorial is an easy-reading summary for both patients and professionals. It is reproduced in full on ScienceBasedMedicine.org: see Acupuncture Revisited.BACK TO TEXT
  3. Ee C, Xue C, Chondros P, et al. Acupuncture for Menopausal Hot Flashes: A Randomized Trial. Ann Intern Med. 2016 Jan. PubMed #26784863. Real acupuncture once again fails to beat sham acupuncture, this time for menopausal hot flashes. Large trial, good methodology, fine journal, low risk of researcher bias… and completely consistent with the trend in acupuncture research: the better the test, the harder it fails.Treatment of hot flashes is a classic claim made for acupuncture. BACK TO TEXT
  4. This is an annoying general trend in alternative medicine: exaggerating “the power of placebo” as a way to justify therapy that can’t beat it. Therapies that perform no better than placebo are now often spun as being “as good as placebo,” as though placebo is the new gold standard to meet. Acupuncture is the most glaring example of this, but the same trick has been pulled with homeopathy, chiropractic, scammy supplement products, and more. The phenomenon is described in full in Placebo Power Hype: The placebo effect is fascinating, but its “power” isn’t all it’s cracked up to be. BACK TO TEXT
  5. An acupuncturist once confessed to me that he was considering retiring because the evidence so strongly shows that acupuncture is useless. After much hand-wringing conversation by email, in which he appeared to be on the brink of being super ethical and changing his career, he decided instead to keep his day job selling the power of placebo. BACK TO TEXT
  6. Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942.A bizarre and already infamous paper: bizarre because the authors clearly acknowledge that acupuncture is no better than a placebo, and bizarre because they conclude that it should be recommended, and most bizarre of all because it is published in The New England Journal of Medicine. Truly, one of the lowest moments in the history of that famous journal!The best criticisms of the NEJM’s editorial choices here can both be found on Science-Based Medicine, by Drs. Crislip (NEJM and Acupuncture: Even the best can publish nonsense) and Novella (Acupuncture Pseudoscience in the New England Journal of Medicine). Dr. Crislip’s post is really quite funny. BACK TO TEXT
  7. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009 May;169(9):858–66. PubMed #19433697. PainSci #54907.More than 600 participants were either given standard acupuncture treatments or simulated acupuncture. Although this study has been widely reported as if it was a controlled comparison of acupuncture to “standard medical treatment” for back pain, in fact it is not controlled (or blinded), and does not have the power to prove that acupuncture works for back pain.The apparent difference between real and fake acupuncture they observed was minor. Nevertheless, the authors are excessively friendly to acupuncture and declare it to be “effective” in their conclusion in spite the obvious poverty of the data. In particular, they gloss over the damning implications of their most important finding: what little effect they think they found had nothing at all to do with needle placement. Acupuncture means nothing if needle placement doesn’t matter. The interpretation of Dr. Steven Novella is much more sensible: “The only reasonable scientific conclusion to draw from this is that acupuncture does not work.” For Dr. Novella’s meticulous and expert analysis, see Acupuncture Does Not Work for Back Pain (Part I).BACK TO TEXT
  8. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee – 2nd Edition. AAOS.org. 2013. PainSci #54555. Along with glucosamine, chondroitin, “lube jobs” (injection of joint lubricant), and surgical lavage and debridement. What does work? Exercise, weight loss, and painkillers are praised. BACK TO TEXT
  9. Chicago Tribune [Internet]. Tsouderos T. CAM: Taxpayer money spent on studies with questionable scientific value; 2011 Dec 16 [cited 12 Feb 19].NCCAM has also gotten around no-better-than-placebo findings essentially by fluffing up the importance of the placebo effect and claiming that it is inherently interesting. Tsouderos explains: “To most scientists, that would mean the treatments are failures — drug companies cannot sell medicines that work no better than salt water or a sugar pill. But in the case of acupuncture and other mind and body medicine, the center and its supporters say it’s unclear whether the benefits represent a placebo response or something more complicated” — something more complicated meaning, basically, a really good placebo effect.Officially, and with regards to other kinds of treatments like saw palmetto, “NCCAM considers studies finding that a supplement does no better than a placebo to be evidence that it does not work.” But NCCAM has failed to apply the same standard to acupuncture, and continues to spend vast sums of money to prove over and over again that acupuncture cannot do better than placebos.“And yet, instead of declaring these studies convincingly negative, NCCAM is pouring more research money into acupuncture. ‘The intellectual dishonesty is just astounding,’ said Dr. Steven Novella, a neurologist at Yale School of Medicine and a critic of NCCAM. ‘They are just quietly changing the question and the rules.’

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  10. Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic touch. JAMA. 1998 Apr 1;279(13):1005–10. PubMed #9533499. PainSci #56856.This paper is an entertaining chapter in the history of the science of alternative medicine: a child’s science fair project published in the Journal of the American Medical Association, showing that “twenty-one experienced therapeutic touch practitioners were unable to detect the investigator’s ‘energy field.’ Their failure to substantiate TT’s most fundamental claim is unrefuted evidence that the claims of TT are groundless and that further professional use is unjustified.”Therapeutic touch practitioners could not demonstrate any ability to detect a person by feeling their aura, let alone manipulating it therapeutically. The test made them look ridiculous.BACK TO TEXT
  11. Historically, skeptics often acknowledged that traditional Chinese medicine is so extremely different from medicine as we know it in Europe and North America that there was probably something of medical interest going on, somewhere, somehow, in the world of acupuncture. It’s easy to state the case so broadly that it’s nearly impossible to disagree with: yes, there’s probably “something” of medical interest, “somewhere” in traditional Chinese medicine! As evidence accumulated, however, skeptics have turned against acupuncture en masse. BACK TO TEXT
  12. Li Y, Zheng H, Witt CM, et al. Acupuncture for migraine prophylaxis: a randomized controlled trial. Canadian Medical Association Journal. 2012 Mar;184(4):401–10. PubMed #22231691. PainSci #54425.This is a disturbing and typical example of sloppy modern acupuncture research, methologically flawed in several ways with clearly negative results, despite the fact that it was clearly built to give acupuncture an unfair advantage, by researchers who wanted to prove that acupuncture works. They concluded that acupuncture has only “a clinically minor effect on migraine,” damning with (very) faint praise, but even that is a biased exaggeration — cherry-picking the best results, and ignoring the more important negative ones. As summarized by Dr. Steven Novella for ScienceBasedMedicine.org: “Despite all of these shortcomings, all of which would bias the study in the direction of being positive, the study was negative. For the primary outcome measure there was no statistically significant difference between any of the acupuncture groups and the sham acupuncture group.”BACK TO TEXT
  13. Vickers A, Goyal N, Harland R, Rees R. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials. 1998 Apr;19(2):159–66. PubMed #9551280. Apparently “research conducted in certain countries was uniformly favorable to acupuncture.” Russia and China in particular effectively do not publish any negative results about acupuncture. I love this ripe, juicy understatement: “Publication bias is a possible explanation.” YA THINK?!BACK TO TEXT
  14. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Coch. 2005;(2):CD005319. PubMed #15846753. PainSci #54322. This 2005 review of acupuncture for shoulder pain is one of the most popular of all Cochrane reviews, but it’s a disappointing review of only a handful of mostly crappy little studies (9) that clearly states that “there is little evidence to support or refute the use of acupuncture for shoulder pain,” but the authors bend over backwards anyway to acknowledge that “there may be short-term benefit with respect to pain and function.” This is based on scraps of incredibly unimpressive and unreliable data: “The improvements with acupuncture for pain and function were about the same as the effects of receiving a fake therapy for 2 to 4 weeks.” Emphasis mine. BACK TO TEXT
  15. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005;142(8):651–663. PubMed #15838072. BACK TO TEXT
  16. Schultz IZ, Crook J, Meloche GR, Berkowitz J. Psychosocial factors predictive of occupational low back disability: towards development of a return-to-work model. Pain. 2004 Jan:77–85. PubMed #14715392. This study identified factors affecting return-to-work time after an episode of low-back pain. From the abstract: “The key psychosocial predictors identified were expectations of recovery and perception of health change.”BACK TO TEXT
  17. Fake acupuncture involves the insertion of needles into non-acupuncture points, or the use of non-penetrating needles (kind of like a stage dagger, where the blade collapses into the handle). It may be difficult or impossible for the patient to tell whether or not they are receiving “real” acupuncture. “For example,” Madsen et al write, “when patients are asked whether they feel Qi, a high proportion of patients will say yes, even when they have been treated with a non-penetrating placebo acupuncture needle.” Bizarre and a bit funny, patients will even “feel the chi” when the needles are — I’m not make this up — being stuck in a rubber hand. It’s a fascinating experiment that deserves more than a brief mention, but the relevant thing here is that you can definitely fool people into feeling, and the sensations are associated with what the brain thinks is going on — not what’s happening in tissue. BACK TO TEXT
  18. Many proponents of acupuncture have griped about this, arguing that the fake is not an effective control. They are missing the forest for the trees. It’s true, it’s certainly not a perfect control — but it’s good enough (and a heck of a lot better than no control at all). If acupuncture worked, it should be dramatically superior to any fake. Trying to argue your way out of that takes mental gymnastics. BACK TO TEXT
  19. Vas J, Aranda JM, Modesto M, et al. Acupuncture in patients with acute low back pain: A multicentre randomised controlled clinical trial. Pain. 2012 Sep;153(9):1883–9. PubMed #22770838. BACK TO TEXT
  20. Madsen et al’s analysis shows that real acupuncture works slightly better than placebo — but by so little that it’s not even remotely exciting. The difference could easily just be due to the fact that real acupuncture is somehow a little bit more convincing, on average, than sham acupuncture — and thus there’s a slightly strong placebo effect. BACK TO TEXT
  21. ScienceBasedMedicine.org [Internet]. Kavoussi B. The Acupuncture and Fasciae Fallacy; 2011 Jan 13 [cited 14 Sep 24].In this article, Ben Kavoussi explains that acupuncture its current form is a modern invention of the pediatrician Cheng Dan’an (承淡安, 1899-1957) in the early 1930s.BACK TO TEXT
  22. Ramey D, Buell PD. A true history of acupuncture. Focus on Alternative and Complementary Therapies. 2004;9(4):269––273. PainSci #53782. BACK TO TEXT
  23. ScienceBasedMedicine.org [Internet]. Ramey D. Acupuncture and history: The “ancient” therapy that’s been around for several decades; 2010 Oct 18 [cited 14 Nov 27].

    It seems that just about every article about acupuncture makes some reference to it having been used in China for thousands of years. The obvious reason for such a statement is to make the implication that since it’s been around for so long, it must therefore also be effective. Of course, longevity doesn’t argue for efficacy, otherwise everyone would likely agree that astrology is the way to chart one’s life; astrology has been practiced for many more years than acupuncture. What’s maddening about the acupuncture longevity myth is that it isn’t true, and demonstrably so.

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  24. Some readers have complained that there were indeed needles and meridians and points in ancient Chinese medicine, and therefore it is ancient. There were recognizeable antecedents to the modern forms of “points” and “meridians” and “needling.” However, they were so different that there is no meaningful continuity between them. David Ramey elaborated on this for me via email:

    There is nothing from the time that describes what was actually done. When we have descriptions and pictures, it shows something wildly different from modern acupuncture. And, yes, the ancient Chinese used “needles.” The first written description of the needles was that of ten Rhijne, which showed that the needles were large awls that were pounded in with a hammer. I have a Japanese picture from the early 1600s that showed that the “needles” were lancets and hooks (not needles). And, yes, there were channels (“mai”). The points didn’t necessarily rest on the channels, and there were all sorts of different channel maps. But all this eventually turned into today’s mostly French interpretation (Soulie de Morant).

    Ergo, modern acupuncture is its own thing, and ancient acupuncture-ish practices were clearly something else.

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  25. ScienceBasedMedicine.org [Internet]. Hall H. The Reality of Ancient Wisdom: Acupuncture and TCM Weren’t So Great; 2014 Sep 25 [cited 15 Mar 29]. BACK TO TEXT
  26. Quah SR. Traditional healing systems and the ethos of science. Social Science & Medicine (1982). 2003 Nov;57(10):1997–2012. PubMed #14499521. Stella Quah on how traditional Chinese medicine is failing to adapt to modern times:

    …the pressure to comply with official health regulations and the inability to succeed under the ethos of science lead traditional Chinese medicine practitioners to respond with an ethos of pragmatic healing that eschews conceptual analysis, ignores the paradigmatic divide with biomedicine, and focuses on ‘using what works’.

    So it’s a nasty mess.

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  27. ScienceBasedMedicine.org [Internet]. McKenzie B. How popular is acupuncture?; 2011 Mar 28 [cited 12 Feb 19]. BACK TO TEXT
  28. Kanodia AK, Legedza AT, Davis RB, Eisenberg DM, Phillips RS. Perceived benefit of Complementary and Alternative Medicine (CAM) for back pain: a national survey. J Am Board Fam Med. 2010 May-Jun;23(3):354–62. PubMed #20453181. PainSci #54984.Alternative medicine for back pain is not as popular as most people assume. I was surprised myself when a 2010 American survey found that only about 6% of the US population uses any kind of alternative therapy for their back pain: about 75% chiropractic, 20% massage therapy, a few percent acupuncture, and a few percent divided up between everything else. Still, 6% of the American population is almost 2 million people annual looking for a crack, rub, or needle poke!BACK TO TEXT
  29. Although unsubstantiated and extremely difficult to prove, there seems to be evidence that several kinds of chronic pain, especially low back pain, have become much more common than they used to be. See Save Yourself from Low Back Pain! for some more information about that. BACK TO TEXT
  30. More about what I hear from patients and readers: I understand and appreciate that “cured” patients would probably not have come to see me later on for the same problem. However, I’m really plugged into the lives of a lot of pain patients, and there is simply no theme of acupuncture-cure stories. No one comes in for wrist pain and comments that “I used to have neck pain, too, but it was cured by an acupuncturist.” The stories just aren’t there, in my experience. The stories that are there are the failure stories. Seemingly every other patient who’s been through the “therapy grinder” (tried everything) has received acupuncture that did little or nothing to help them. BACK TO TEXT
  31. ScienceBasedMedicine.org [Internet]. Atwood KC. Acupuncture Anesthesia: A proclamation from Chairman Mao; 2009 May 15 [cited 12 Feb 19]. BACK TO TEXT
  32. The wishful thinker will be inclined to say, “But maybe there is an effect and it’s just erratic, hard for science to pin down!” Perhaps. But any effect that is so hard for science to pin-down that we can’t even prove it exists is also next to useless in practice. If a standardized treatment protocol can’t deliver the goods in a somewhat reliably fashion, it’s not really medicine — or at least it’s not medicine I want to spend my money on until its “erratic” nature is better understood. See also The “Impress Me” Test. BACK TO TEXT
  33. Cochrane reviews are generally considered to be the most authoritative summaries of the science on a topic so far. BACK TO TEXT
  34. Paula Kamen writes brilliantly (and hilariously) about the inadequacy of “subtle” treatments in All in My Head: An epic quest to cure an unrelenting, totally unreasonable, and only slightly enlightening headache. BACK TO TEXT
  35. When I published my own reaction to Ernst et al, many critics voiced their opinion at me on Facebook, with great contempt. They were angry, but they couldn’t actually defend their position. They could not and did not actually produce any evidence, and they (angrily) repeated myths that have long since been debunked, like the myth that acupuncture is used for anesthesia in China. I cannot emphasize strongly enough that this is what it’s always like: the apologists come out the woodwork to shout and pound the table, but they never have persuasive data, sound logic or consistent reasoning, or even basic historical accuracy on their side. BACK TO TEXT
  36. Of course, he also made it clear that he didn’t think it was bloody likely that anyone could ever prove that negative, and of course he’s right about that. It’s also rather hard to prove that there’s no teapot orbiting the sun between the Earth and Mars. But his initial answer certainly had the right spirit — evidence matters. If it can be had. BACK TO TEXT
  37. Woo PC, Lin AW, Lau SK, Yuen KY. Acupuncture transmitted infections. BMJ. 2010 Mar 18;340:c1268Oh, I. PubMed #20299695. PainSci #55627.What’s the harm in acupunture? A small but real risk of infection — as with anything that breaks the skin. Acupuncture has not only failed to prove that it works, but this British Medical Journal editorial presents new evidence that it also involves a risk of mycobacteria infection, and even that “… outbreaks of acupuncture transmitted infections may be the tip of the iceberg. The first reports of meticillin resistant S aureus (MRSA) transmitted by acupuncture appeared in 2009. The emergence of community associated MRSA infections may aggravate the problem.”A common objection to Woo’s article has been that it is “mongers fear” and that he cites old evidence, from the 1970s and 1980s, before sterized needles were widely used. But critics conveniently overlook that Woo also cite modern evidence of infection — about as blatant a case of biased interpretation as you could ask for. And is Woo a fear mongerer? He does not claim that the risk is great: he just reports what is known and titles his piece neutrally. It is always worthwhile to examine treatment risks, and especially when treatment benefits are also hotly disputed. It hardly constitutes “fear-mongering” to report risk data in a medical journal! If not there, then where?BACK TO TEXT
  38. Working as a Registered Massage Therapist, I routinely saw placebo backfire in this way. Pain patients in general, and low back pain patients in particular, are already strongly predisposed to anxious assumptions that their problem is “really bad.” When the placebo effect of acupuncture wears off, as it must, this anxiety is reinforced and the pain is elevated to the status of a fiercer enemy. A nice trap. I describe this in a little more detail in Save Yourself from Low Back Pain! BACK TO TEXT

Menopause, estrogens and frailty.

 

Gynecol Endocrinol. 2013 May;29(5):418-23. doi: 10.3109/09513590.2012.754879. Epub 2013 Feb 6.

Oestrogen is a hormone that just keeps giving to peri- and menopausal women. Frailty (also known as Sarcopenia – loss of muscle tissue) is common in older women. Oestrogen can help to avoid, or reduce, the effect of this muscle wasting. I have published previously all the other benefits of oestrogen at this time, and the safety of it in menopausal women.

Menopause, estrogens and frailty.

Author information

1
Nordic Bioscience – Biomarkers and Research (Part of CCBR Group), Herlev, Copenhagen, Denmark. afn@nordicbioscience.com

Abstract

The controversy surrounding the results from the Women’s Health Initiative (WHI) trials published a decade ago caused a significant decline in the use of menopausal hormone replacement therapy. However, these results have been vehemently contested and several lines of evidence suggest that in perimenopausal and non-obese women, estrogen therapy may indeed be of benefit. There is ample proof that menopause causes a loss of musculoskeletal tissue mass and quality, thereby causing a loss of health and quality of life. There is also solid evidence that hormone replacement therapy in itself prevents most of these effects in connective tissue in itself. Besides the independent, direct effects on the musculoskeletal tissues, estrogen deficiency also reduces the ability to adequately respond and adapt to external mechanical and metabolic stressors, e.g. exercise, which are otherwise the main stimuli that should maintain musculoskeletal integrity and metabolic function. Thus, normophysiological estrogen levels appear to exert a permissive effect on musculoskeletal adaptations to loading, thereby likely improving the outcome of rehabilitation following critical illness, musculoskeletal trauma or orthopedic surgical therapy. These effects add to the evidence supporting the use of estrogen therapy, particularly accelerated gain of functional capacity and independence