Don't do this: 150 medical practices that all fail, especially acupuncture

This is ineffective - and cruel.

Why do people keep doing things to their bodies that don't work, and that even hurt them? This seemingly self-destructive behavior is what allows bad medicine to thrive. One problem is that people are easily fooled by self-interested con artists selling snake oil: homeopathy and acupuncture fall into this category. Another problem is that even doctors can be fooled, especially when a practice seems to make sense.

One great example of this is stenting: the use of a small, flexible tube to re-open and hold open clogged arteries. This seems like such a reasonable idea–if a pipe is clogged, unclog it and put something in there to keep it clear. And it does work, sometimes, but the evidence shows that for people with minor blockage, it usually does more harm than good. A new article in The Atlantic, "When Evidence Says No, but Doctors Say Yes", explains that in a recent 5-year period in the U.S., "about half of all stent placements in stable patients were either definitely or possibly inappropriate," as shown in a new study. The authors also point out that stenting remains the go-to procedure for any patient with clogged arteries, even among physicians who have read the studies. The problem here is that stenting just seems so darned logical.

At least stents work some of the time. What about procedures and medications that don't work at all, and that sometimes cause harm? Five years ago, a team of scientists in Australia conducted a massive review of evidence for thousands of medical practices, and found 156 that either don't work or actually cause harm. Their list of ineffective and harmful procedures should be required reading for anyone who is considering a medical procedure.

I can't go through all 156 bad practices, but one group of procedures stands out as particularly ridiculous (by which I mean the original sense of the word, "deserving of ridicule"). These are the various uses of acupuncture, all of them ineffective, none of them with even the slightest plausibility, but all of them promoted by quacks acupuncturists. Here they are–and remember, each of these has been tested scientifically and shown to be either useless or, even worse, harmful:

1. Acupuncture for women in labor. From the study: "In the absence of sufficient evidence that proves either effectiveness or harm, acupuncture as a method of induction is not recommended."
2. Acupuncture for uterine fibroids. "There is no reliable proof of effectiveness of acupuncture for uterine fibroids." (Aside: if a woman has fibroids, multiple options are available, many quite effective. The claim that acupuncture might treat them is patently ridiculous.)
3. Acupuncture for irritable bowel syndrome. Studies have found "no significant effect of acupuncture on IBS global symptoms, pain, and quality of life compared with placebo." 
4. Acupuncture for otitis media with effusion (fluid in the middle ear). This condition is common in children, and acupuncturists are only too happy to plunge their needles into unsuspecting kids. The study found no evidence that this works, and concluded that "acupuncture should not be used for the management of patients with OME."
5. Acupuncture for lower urinary tract symptoms in men. This too doesn't work. I wonder where they stick the needles?
6. Acupuncture to treat hyperbilirubinaemia. This condition, commonly known as jaundice, is often seen in very young infants. The suggest that we treating babies with acupuncture is, frankly, primitive and terribly cruel. The study concluded starkly that "there is no evidence to support the use of acupuncture to treat hyperbilirubinaemia–NICE recommends that this treatment not be used in this population." (NICE is the Australian National Institute for Health and Clinical Excellence.)
7. Laser acupuncture for carpal tunnel syndrome. Multiple studies found that acupuncture doesn't work for this either. One study concluded that "more rigorous studies are needed." Why waste more time on this hopeless pursuit?
8. Acupuncture for depression. Lots of studies, most with a "high risk of bias," and all of them finding that acupuncture doesn't work for depression. This is depressing.
9. Acupuncture for osteoarthritis. Not surprising, acupuncture for arthritis is no better than placebo.
10. Acupuncture for Bell's palsy. Eight trials, none of them showing any reliable benefits. Subject patients to more of these trials would be cruel and unethical.

So there you have it: 10 out of the 156 bad medical practices involved acupuncture. If you want to see the rest of the list, check out the full study. As for acupuncture, this is by no means a complete list of the claims that acupuncturists make. Indeed, just last week a new study claimed that acupuncture helps treat migraines, prompting a rebuttal from UC San Francisco's Amy Gelfand, in the same journal, saying no, it doesn't. (Dr. Gelfand explained a lot more than that, but I'm summarizing.) The pro-acupuncture study was done in China, where virtually all acupuncture studies report positive results, and the lead author works at the Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine.

We should all thank Drs. Elshaug, Watt, Mundy, and Willis for their tireless effort in reviewing thousands of studies, so that the rest of us don't have to. Acupuncture studies will keep appearing, but there's no reason to believe anything new will emerge. It's time for people to stop fooling themselves about this particular brand of pre-scientific pseudoscience.

Washington Post's Science section descends into pseudoscience

The Washington Post has some bad news about migraines.

Every Tuesday, the Washington Post has a special section devoted to Health and Science. It’s usually my favorite section, with features such as “medical mysteries” and highlights of the latest news from the world of science.

Not this week. Instead, the front page of the section featured a lengthy article that was a long anecdote by a woman who firmly believes that acupuncture cured her migraines. The title gave me a feeling of dread: “Acupuncture needles stung, but they cured my migraines” (the online version linked here has a different title). As I feared, there wasn't a whit of science in it.

Let’s get one thing out of the way first: acupuncture is rank pseudoscience. It’s based on a primitive, pre-scientific notion of a “vital force” (for which no evidence exists), usually called qi, that runs through the body along meridians (no evidence for these either). Plunging needles into the meridians is supposed to manipulate this vital force and cure all sorts of things, ranging from pain to infections to cancer. All of this is nonsense. If you want to know more, I recommend Acupuncture Watch; or see Ben Kavoussi’s article explaining how postmodernism, with its notion that all truth is relative, has allowed acupuncture and other mystical, archaic beliefs to gain traction in medical practice; or check out Jann Bellamy’s discussion of acupuncture as “legalized quackery”.

I’ve written about the nonsense that is called acupuncture before (in 2013, and in 2012, and in 2010), so I won’t rehash that here. But it’s really disheartening to see a great (or once-great?) newspaper devote a large chunk of its weekly science section to pseudoscience.

Back to this week’s nonsense article. In this lengthy piece, author Margarita Gokun Silver describes how she began to experience debilitating migraines after the age of 40, which grew worse over time. She tried pain relievers, which worked at first but then stopped working. One expensive pill worked for the migrations but gave her severe nausea. Eventually, she writes, “exhausted by these side effects, I turned again to the Internet.”

Great. Now, there’s nothing wrong with looking for solutions in the Internet–we all do it. But this is an article in the Washington Post Science section! Nowhere does the author describe anything resembling actual science. Instead, she describes how she discovered a “breakthrough” in her yoga class, when another yoga student suggested acupuncture. She decided to give it a try.

(You might be wondering, who is Margarita Gokun Silver? She describes herself as a writer, novelist, and painter–not a scientist or a doctor.)

After several acupuncture sessions, the author tells us, her migraines seemed less frequent, and eventually she decided she was cured. She still gets migraines, but when they get bad she uses acupuncture again. This, she tells us, is her cure.

The entire story is a classic example of how we can fool ourselves into thinking that whatever we tried last is what worked. Migraines come and go, and this woman’s story is not unusual. She had a long series of bad migraines that eventually subsided, and she still gets them. When they were at their worst, she tried everything she could find, and when the episodes became less frequent, she gave full credit to acupuncture. She might just as well have tried chocolate milk, and then written an article claiming “chocolate milk cured my migraines!”

I don’t blame the author (well, not much) for wrongly believing that correlation equals causation. But we have scientific methods that are really, really good at figuring out if a treatment works. Scientists have already looked at this particularly claim, and the bottom line is that acupuncture doesn’t cure migraines. If you don’t believe me, then read the article about treating migraines by Dr. Steven Novella, a Yale neurologist who specializes in headaches, and look at his summary of how not to treat migraines, which points out that

“acupuncture proponents have been able to change the rules of clinical research so that essentially negative or worthless studies of acupuncture are presented as positive.”

Last week's Washington Post Science section was a major fail. I can't imagine why they gave a lengthy forum to a non-scientist to write about pseudoscience. If they wanted to feature a story about migraines, there's plenty of good science out there, even if there's no magical cure. What's next, Washington Post? Will you invite Jenny McCarthy to write about vaccines and autism, or Gwyneth Paltrow to discuss detox treatments? I sure hope not.

What Works for Knee Pain? Good Medicine, Bad Medicine, and Wasted Money

Knee pain is a very common problem, affecting young and old alike.  Among athletes, knees take a beating, particularly in sports that involve running and twisting.  Among older people, the cartilage that provides a cushion in our knees often just wears out, producing chronic stiffness and pain.

I've had knee problems myself, so I was interested to see an article posted on CNN, with content from Harvard Medical School called "Alternative Treatments for Knee Pain."  Would it describe "alternative" medicine, as in "complementary and alternative medicine," or would it present real medicine for knee pain?

A little of both, as it turns out.  But it does more: it inadvertently illustrates one of the major flaws with the U.S. health system.  We don't discriminate between effective and ineffective treatments, and some doctors seem content to let patients try anything, regardless of efficacy or cost.

The article describes several treatments for knee pain, and for each one it turns to Eric Berkson, M.D., for an opinion on how well the treatment works.  Berkson is an orthopaedic surgeon at Massachusetts General Hospital and an Instructor in Orthopaedic Surgery at Harvard Medical School.

Despite these excellent credentials, Dr. Berkson doesn't seem to have a firm command of science-based medicine. The article starts out strong, recommending the most effective therapies, but then wanders into unproven therapies, and concludes with Berkson making an unscientific recommendation for the most wildly ineffective treatment of all: acupuncture.  Let's look quickly at each "alternative."

The most effective treatments, according to Dr. Berkson, are physical therapy and weight loss.  Berkson is on solid scientific ground here: physical therapy strengthens the muscles around the knee, relieving some stress on the joint, and weight loss does the same thing by reducing the load directly.  If you stopped reading at this point, you'd be in great shape.

Next is a discussion of chondroitin and glucosamine, two very popular supplements that are often used to treat joint pain.  After many years of competing claims about these supplements, NIH conducted a large, $12.5 million study called GAIT to test whether these supplements worked for knee pain. The researchers looked at glucosamine and chondroitin separately and together, and compared them to a standard pain reliever (celecoxib, brand name Celebrex®, an NSAID) and to a placebo.

The conclusion: celecoxib worked, but the supplements did not.  In a small subset of patients with moderate to severe pain, there was a hint of a benefit for glucosamine-condroitin, but it wasn't significant.  For patients with mild pain, though, only celecoxib was better than a placebo.

Despite this large and compelling study, Berkson says

"there's a lot of evidence that they [glucosamine and chondroitin] work, but only in a certain percentage of patients." 

Perhaps he's referring to patients with moderate to severe pain from the GAIT study, but the article doesn't explain if that's what he means.  And then Berkson recommends them anyway, saying "there's little downside to trying the supplements."  Especially if it makes the patient think the doctor is helping.

The article then describes three different treatments that involve injections of various substances into the knee.  To keep this brief, I'll just consider the first: viscosupplementation, a fancy name which means that hyaluronic acid is injected into the knee. It's supposed to help lubricate the joint, which sounds plausible: after all, we lubricate machines to keep them running smoothly.  Shouldn't some "grease" help our knees?

For hyalonuric acid, the answer is simply no.  A large review just last year, involving over 12,000 patients (Rutjes et al. 2012) shows that hyaluronic acid has little or no benefit, and possibly causes harm.  Their conclusion:

"In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."

Berkson's own colleagues, the American Academy of Orthopaedic Surgeons, just issued a 1200-page report on treatments for knee osteoarthritis, and they found strong evidence against the use of hyalonuric acid.  To be specific, the AAOS says "We cannot recommend using hyaluronic acid for patients with osteoarthritis of the knee."  They label this a "strong" recommendation.

Despite the the advice of his own professional organization, Dr. Berkson says

"I have some patients who think [hyalonuric acid is] a miracle drug that keeps their symptoms at bay.  Given that the risks of injection are very low, it makes sense to try it if insurance will pay."

Oh my.  Here we have a medical expert recommending an expensive treatment - he estimates the cost is about $1500 - despite the evidence, apparently because he has patients who think it works.  Paying for expensive, ineffective procedures is a poor way to treat patients and a great way to run up costs.

(Aside: I might seem to be picking on Dr. Berkson here, but I think his responses are probably typical of many practicing doctors.  Not to excuse him, but it's easy to follow your instincts and to rely on anecdotes from patients.)

After briefly discussing two other injection therapies, the CNN/Harvard article addresses one last alternative: acupuncture.  It quotes Berkson again, this time saying:

"Acupuncture works in some patients, although I don't think science knows exactly why it works. It's worth trying if other things aren't working for you."

Despite Dr. Berkson's comment, the science doesn't support him.  Acupuncture for knee pain, and for other pain, simply doesn't work.  (See this article for a lengthy discussion, with citations.)  Just to pretend for a second: in order for acupuncture to work, there would have to be lines of force (called "meridians") through which a mystical, apparently unmeasurable life force ("qi") flows, and furthermore you'd have to be able to manipulate this life force by plunging needles into the skin.  There is no support whatsoever for these ideas in human biology and physiology.

The American Academy of Orthopaedic Surgeon's report addresses acupuncture too, stating that "We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of the knee."

Dr. Berkson's recommendation is akin to a shrug: while admitting that he doesn't know why it might work, he just says to give it a try.  His own professional organization, after an extensive review of the scientific evidence, disagrees.

The CNN Health article, with "content provided by the faculty of the Harvard Medical School," demonstrates in a microcosm how health care dollars are wasted in the U.S.  First it recommends the most effective and least expensive treatments: weight loss and exercise.  Both of these involve lifestyle changes that are difficult for many people.  The article then suggests alternative treatments for knee pain that include:

1. Glucosamine and chondroitin supplements - ineffective but cheap. 
2. Knee injections of hyalonuric acid - ineffective and very expensive.
3. Acupuncture - ineffective, wildly implausible, and sort of cheap.

Despite the evidence against them, the doctor quoted throughout the article recommends trying all three, especially if (as is common) the patient doesn't have to pay the bills.

Science only supports three treatments for knee pain, as physician Harriet Hall summarized in her recent blog post: exercise, weight loss, and NSAIDs.  The "alternatives" described by CNN, no matter how appealing they sound, are a waste of time and money.