published 10/05/09

Acupuncture for Neck Pain

Even the most trusted sources of medical information must be questioned

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

How scientific is your science? Acupuncture research can have a surprisingly low science content. For instance, a flawed 2006 review of acupuncture science was published by the most esteemed of scientific publishers, the Cochrane Collaboration, an organization founded on a bedrock of evidence-based medicine principles. Nothing is perfect, and some Cochrane reviews leave much to be desired. Any source of information can be hopelessly compromised by the beliefs of the authors. You can just never leave your brain at the door!

I was introduced to the fallibility of Cochrane reviews at the Science-Based Medicine Conference in July. And today I spotted my first seriously flawed Cochrane review in the wild, a review of acupuncture for neck pain which makes acupuncture sound kinda good (or least distinctly un-bad). Unfortunately, it is compromised by a blatant author bias in favour of acupuncture.

Case in point: another bad Cochrane review

Bizarrely, the Cochrane Collaboration recently published a review of homeopathy science by … wait for it … a homeopath. Shockingly, this author came to optimistic conclusions about homeopathy. Of the studies he analyzed, only one was positive … and that one wasn’t a study of homeopathy, but rather of an undiluted (non-homeopathic) herbal remedy. This sort of dazzling intellectual inconsistency undermines Cochrane’s reputation in a big way. Homeopaths simply shouldn’t be reviewing homeopathy research! See Dr. Steve Novella’s predictably brilliant dissection of this homeopathy review.

So, speaking of bias, this is a bit delicate. I am on the record as an acupuncture doubter. Actually, I think that acupuncture has dramatically failed to prove efficacy in the last decade. So it doesn’t really look good if I dismiss a Cochrane review that says acupuncture works. Aren’t I just ignoring evidence that contradicts my views? How can I explain this?

Simple. It’s just a bad review. They happen.

Also, it’s okay to be biased and admit it. I’m a pundit. I wear my bias on my sleeve, and you decide whether or not to read on. And my bias says that this is a bad review. I object to it not because it contradicts my position, but because it does so poorly. It fails to persuade. There’s nothing “compelling” about the evidence. I am not compelled. If anything, I am repelled. Here’s what’s wrong with the analysis:

It considered only ten studies of poor quality (average quality of 2.3 out of 5 on the Jadad Scale, “the overall quality of these studies was not considered high”). So, in short, they analyzed a bunch of mostly terrible data from which you shouldn’t really be able to draw any conclusions.
They drew conclusions anyway. Rather than saying that there is insufficient evidence to draw conclusions — as many other Cochrane reviews do — they are phrased instead as statements in support of acupuncture. According to the authors, there is “limited” and “moderate” evidence of benefits. Limited evidence sounds better than it is: it’s really limited (“findings in a single low-quality” experiment, whoop-de-do). Moderate evidence isn’t much better: “consistent findings in multiple low-quality trials.” And the limited/moderate evidence is cherry-picked from the smallest and weakest of the studies analyzed, of course.
Like so many other acupuncture studies recently, the authors spin a placebo effect as being a benefit of acupuncture. For instance, they conclude that there is “moderate evidence that acupuncture relieves [chronic neck] pain better than some sham treatments.” You have got to admire the sneaky phrasing there: “better than some sham treatments,” meaning that acupuncture wasn’t better than some other sham treatments. This is not a high bar to get over. A therapy than can only “beat” some fake substitutes cannot possibly be very good! Would you take a drug if it was better than one kind of fake remedy, but no better than another?

Almost inevitably, the lead author has a blatant conflict of interest. Of course, this in itself does not make a paper bad. But it does tweak the cynical bone, doesn’t it? What a shock that the author, Kien Trinh, is chair of the McMaster University Health Sciences Medical Acupuncture Program, has largely built his career around acupunture, and has authored “two of the few positive systematic reviews on musculoskeletal conditions with acupuncture” (this acknowledgement is found in his bio). In short, he actually admits to being the only scientific reviewer who has published “positive” conclusions about acupuncture.

But let’s suspend judgement on acupuncture for neck pain for a minute. What about back pain? Surely, if acupuncture works as advertised, it should work for both, right? If acupuncture is really working its magic with the body’s energy channels — the meridians — then there’s simply no good reason it won’t work in both places. A rising tide lifts all boats, right? A boat floats as well on one side of the bay as the other! Or it should.

A therapy than can only “beat” some fake substitutes cannot possibly be very good!

But acupuncture’s boat sinks like a stone on the low back pain side of the bay. This subject has been studied much more thoroughly, with much higher quality studies than have ever been done for neck pain. Guess what they show? (You can read all about that in my article, Does Acupuncture Work for Pain? Or please see Dr. Harriet Hall’s excellent recent critical summary of acupuncture research.)

So we have a bunch of good quality and recent evidence that acupuncture simply does not work for low back pain … while for neck pain we have only a small amount of poor quality evidence that it does work for neck pain.

The SaveYourself.ca salamander proposes a little wager. He’s a betting amphibian. When researchers finally get around to doing some truly good quality studies of acupuncture for neck pain, how much do you want to bet that they will come out all nice and positive? Not “kinda” positive, not maybe positive, not the kind of positive that would be debatable, but truly, actually, this-stuff-really-works positive?

Yeah, me neither. I’d rather bet that Glenn Beck will endorse Obama’s health care reform.