The interpretation itself varies with your perception of what “placebo” means, what “placebo effects” are in acupuncture research, and what you consider ethical (or unethical) in “using placebo effects”.

 

 

The statement follows a Weak recommendation that specifically notes the efficacy may be no greater than sham acupuncture:

 

Guidance: Consider acupuncture for chronic low back pain in adults, but consider counseling patients that sham acupuncture may be as effective (Weak recommendation).

 

And the phrasing before that statement may put the statemen in some perspectrive:

 

Clinical perspective: Guidelines are inconsistent with one recommending acupuncture, one recommending against acupuncture, and one not making a recommendation for or against acupuncture. Across many potential interventions for chronic low back pain, doing something is more effective than doing nothing, and doing something appears as effective as doing something else. Acupuncture can seem effective whether real or sham. Some clinicians may consider any efficacy a placebo effect, and find suggesting acupuncture unwarranted. Despite not having proof that a specific (or any) technique is involved in patients feeling better with using acupuncture, it still could be a reasonable option based on relative safety compared to other active interventions for patients with chronic low back pain who are looking for a different therapeutic option.

 

 

 

The statement right before this statement is “Some clinicians may consider any efficacy a placebo effect, and find suggesting acupuncture unwarranted.”

 

So for those that equate “sham” with “placebo”, and equate “placebo” with “dishonesty/unethical” the full context is acupuncture is unwarranted and those suggesting it anyway should consider “counseling patients that sham acupuncture may be as effective” so there is no dishonesty.

 

But for those who equate “sham acupuncture” with “doing something” (for example consider this as an experience of getting attention in a form where a person with healing intent provides a stimulus for the patient to think quietly about overcoming their pain in some way that they mentally connect with that stimulus) and not a “placebo” (for example taking an inert pill but not putting any time or attention into thinking about healing), a look at the evidence will find High-quality evidence that “doing something” or “acupuncture (sham or real)” improves pain and function in adults with chronic low back pain.   If so, it could be unethical to tell someone they should avoid this (because the exact pattern of what it is has not been determined) and instead do something else that is more toxic.

 

So in this situation different people can honestly and appropriately argue either of these interpretations as the “right” approach.   The differences are not in the critical appraisal of the evidence.  Either of the interpretations discussed below is a type of bias in interpretation, even among people with a shared view of what the evidence provides. Any thoughts on a more concise way to present the whole view without introducing bias? 

 

The full concise summary is:

 

Synthesized guidance

Use of acupuncture for chronic low back pain
Guidance: Consider acupuncture for chronic low back pain in adults, but consider counseling patients that sham acupuncture may be as effective (Weak recommendation).
Evidence sources: Multiple systematic reviews but only 4 sham-controlled randomized trials with ≥ 40 patients per treatment arm that reported responder rates.
Evidence synthesis All 4 trials found a clinically significant improvement in pain and function was more likely with acupuncture than with usual care. In comparing acupuncture to sham acupuncture, 2 high quality larger trials found no difference in likelihood of clinically significant improvement, while the other 2 smaller trials reported that clinically significant improvement was more likely with acupuncture than with sham. Systematic reviews reported comparable findings (consistent benefit compared to usual care, inconsistent results suggesting no difference compared to sham) but were limited by use of mean scores rather than responder rates.
Clinical perspective: Guidelines are inconsistent with one recommending acupuncture, one recommending against acupuncture, and one not making a recommendation for or against acupuncture. Across many potential interventions for chronic low back pain, doing something is more effective than doing nothing, and doing something appears as effective as doing something else. Acupuncture can seem effective whether real or sham. Some clinicians may consider any efficacy a placebo effect, and find suggesting acupuncture unwarranted. Despite not having proof that a specific (or any) technique is involved in patients feeling better with using acupuncture, it still could be a reasonable option based on relative safety compared to other active interventions for patients with chronic low back pain who are looking for a different therapeutic option.
Contributors: Alan Ehrlich, Brian Alper, Ashvin Shah, James LaRue, Eric Manheimer

 

 

Brian S. Alper, MD, MSPH, FAAFP

Founder of DynaMed
Vice President of Innovations and EBM Development, EBSCO Health

www.dynamed.com, health.ebsco.com

Twitter: @BrianAlperMD

 

What is QUALITY in health care? ... https://lnkd.in/eCAQibZ

 

From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Rakesh Biswas
Sent: Sunday, September 04, 2016 4:41 AM
To: [log in to unmask]
Subject: Re: A +B versus B design, acupunture and more

 

Brian i found this statement from the Dynamed link that you shared interesting, "Despite not having proof that a specific (or any) technique is involved in patients feeling better with using acupuncture, it still could be a reasonable option based on relative safety compared to other active interventions for patients with chronic low back pain who are looking for a different therapeutic option." http://www.dynamed.com/topics/dmp~AN~T906249/Acupuncture-for-chronic-low-back-pain

 

Not sure if i am interpreting it right but does/can it mean that given any chronic disease a safer intervention (not having any proof that it is better than placebo) is a reasonable option for people who are looking for a different therapeutic experience?

 

Apologies if i may have interpreted it wrongly (and currently i shall just think of my interpretation as a hypothesis till i hear more). 

 

best, 

 

rb

 

On Wed, Aug 24, 2016 at 2:10 AM, healingjia Price <[log in to unmask]> wrote:

Thank you, this work on Acupuncture is excellent. It shares transparently what is available, how the results were gathered and it is fairly written without emotionally laden drama or judgement. I have downloaded the article to share with the many people who ask me what does EBHC/EBP/EBM say about acupuncture so far, the work also makes it clear that the question is far from answered and that there is work to do.

Best,

Amy

On 8/21/16, 1:43 PM, "Brian Alper MD" <[log in to unmask]> wrote:

    How to interpret a sham control for acupuncture, and what that means for recommendations regarding acupuncture.  This is fascinating and complex, but how do you make it simple without biasing to one particular perspective?

    We synthesized it recently in DynaMed Plus for the topic Acupuncture for chronic low back pain at http://www.dynamed.com/topics/dmp~AN~T906249/Acupuncture-for-chronic-low-back-pain

    And summarized this for a quick read in European Journal of Integrative Medicine at http://www.sciencedirect.com/science/article/pii/S1876382016301536

    I posted on this through last week, commenting on different stages of the effort each day:

    8-15-16: ACUPUNCTURE - How do we know what we know and how well we know it? . https://lnkd.in/e_CDcNe
    8-16-16: EVIDENCE AWARENESS needed for good decision-making . https://lnkd.in/eD7d5PQ
    8-17-16: EVIDENCE UNDERSTANDING - much more complex than evidence reporting . https://lnkd.in/erMSZGH
    8-18-16: CLINICAL PERSPECTIVES - much more complex than guideline reporting . https://lnkd.in/e7rkM-d
    8-19-16: SYNTHESIZED GUIDANCE -- when it all comes together ... lnkd.in/e_Yvyae

    Brian S. Alper, MD, MSPH, FAAFP
    Founder of DynaMed
    Vice President of Innovations and EBM Development, EBSCO Health
    www.dynamed.com, health.ebsco.com
    Twitter: @BrianAlperMD

    SYNTHESIZED GUIDANCE -- when it all comes together... lnkd.in/e_Yvyae

    -----Original Message-----
    From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of healingjia Price
    Sent: Friday, August 05, 2016 8:37 AM
    To: [log in to unmask]
    Subject: Re: A +B versus B design, acupunture and more

    What would work would be useful as there are pitfalls mentioned in this design as well as waitlist and most certainly for deciding a sham for Acupuncture. It is not just this form of treatment, a lot of what is used for OT and PT  are in this category.

    Best,

    Amy

    -----Original Message-----
    From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of jenny whitehall
    Sent: Friday, August 05, 2016 8:05 AM
    To: [log in to unmask]
    Subject: Re: A +B versus B design, acupunture and more

    ________________________________________
    From: Evidence based health (EBH) [[log in to unmask]] on behalf of Juan Gérvas [[log in to unmask]]
    Sent: 03 August 2016 09:28
    To: [log in to unmask]
    Subject: A +B versus B design, acupunture and more

    Acupuntura (y otros tratamientos). Diseño de ensayo clínico que lleva a resultados positivos.
    Acupunture (and others treatment). A trial design that generates only ''positive'' results.
    In recent years, we have seen a plethora of RCTs adopting a design  where patients are randomized to receive either usual care (the control  group) or usual care plus the experimental treatment. Schematically this  design could be depicted as 'A + B versus B'. At first glance, such  comparisons may seem reasonable. However, on closer inspection, doubts  emerge regarding whether such RCTs are fair scientific tests of the  experimental intervention. These doubts originate from the theoretical  view that 'A plus B' will invariably amount to more than 'B' alone. Even  in cases where treatment A is a pure placebo, its placebo and other  nonspecific effects could lead to a better outcome in the experimental  group than in the control group. This would be particularly likely if i)  the experimental treatment is associated with sizable nonspecific  effects, ii) a subjective outcome measure is used, and iii) the  experimental intervention 'A' causes a deterioration of the condition  being treated.
    http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2008;volume=54;issue=3;spage=214;epage=216;aulast=Ernst

    Effectiveness of acupuncture for the prevention of episodic migraine. Cochrane. NNTB of 4.
    http://www.ncbi.nlm.nih.gov/pubmed/27351677?dopt=Abstract
    -un saludo juan gérvas @JuanGrvas