Does Acupuncture Work? Let's Talk About Evidence Based Healthcare
/Fifty-five year old Andy came to came to see me with chronic back pain. He’d tried a few other treatments without success. Now, with the tough physical challenge of a sailing race looming, he desperately needed help.
Could acupuncture help him?
It’s one of the questions I’m most often asked …… “will acupuncture work for me and my problem?”.
And it’s understandable. No-one wants to waste their hard-earned cash on an ineffective treatment. In answer, I usually give an indication of the likelihood of acupuncture helping someone. But I also add that I can’t guarantee it - and nor can any other practitioner. Here’s why…..
I know I get good results in clinic, but I often think the question is really “ is there evidence for acupuncture and my problem?” . To answer, firstly we need to look at what evidence-based medicine IS. This blog dives into the principles of evidence-based medicine and the challenges of research. In my next blog we’ll talk about where acupuncture fits into this picture.
What is Evidence Based Medicine?
Western medicine can often seem to be all about “the science” or evidence-based medicine, a concept developed by Canadian epidemiologist David Sackett.
Back in 1981 he and his colleagues at McMaster University began publishing a series of articles in the Canadian Medical Journal advising physicians how to appraise medical literature. But an evidence-based medicine approach doesn’t rely solely on research. Sackett also advocated using the physician’s expertise, considering the individual needs of the patient, and the patient’s wishes.
Challenges in Evidence-Based Medicine
Once Sackett had given us a starting point for evidence-based medicine, you’d think it would be easy to understand what “works” But no, the research aspect of evidence-based medicine is a minefield.
Firstly, there needs to be a hypothesis – an assumption that can be tested to see if it’s true or not.
Secondly, you need to test that hypothesis. There are many different ways to research a treatment; case studies, cohort studies, randomised controlled trials (RCT’s), systematic reviews, and many more. These studies are not all equal - some are far more rigorous than others. A randomised controlled trial (RCT) is considered the “gold standard” of research.
Thirdly you need money. A condition affecting a big chunk of the population is likely to attract more research funding than a rare illness. Decent trials cost money, lots of it. And the better-quality trials like RCT’s cost more. Because these trials are so expensive it makes sense to make sure that someone will benefit from doing them (if the hypothesis is right!), whether in terms of prestige or financial gain. This could explain the dominance of pharmaceuticals in medicine nowadays.
AND THEN once you’ve for the money, you must find a big enough chunk of similar folk to test your hypothesis on. Only then can you say the result was due to the treatment, not chance.
The big question – will it work for you?
Let’s imagine that, like Andy, you’ve hurt your back. Your neighbour tells you that she saw someone who helped her. It’s always good to have a personal recommendation, so you make an appointment.
But will it work for you? The reality is you don’t know. One person’s experience carries little weight in scientific terms.
Let’s add more people, perhaps everyone in the town with back pain, and do a proper study. That will give us more information. It might be that 50% improve with treatment.
“Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice
”
But will it work for you? You still don’t know, you might in the portion of people the treatment is successful for, you might not. And something else might work better in any case.
Let’s make it a bit trickier. We’ll add in some comparisons, like a placebo or another treatment. That other treatment might be whatever is on offer now, often known as ‘standard care’. We might find that 60% of people in the new treatment group see an improvement- but so do 45% in the standard care group, and 30% of the folk in the placebo group. Again, you don’t know which camp you would fall into.
The downsides
We’ve started to see some of the issues with research. The huge amount of expense and time required for good quality research such as randomised controlled trials means that only a fraction of the options available to you could be “evidence based”. And even then, evidence-based treatments take time to filter into common usage – usually about 17 years, according to the British Medical Journal.
And, as American astronomer Carl Sagan put it, “Absence of Evidence is not Evidence of Absence” . A lack of research for a treatment doesn’t mean it’s not effective. It could be that the evidence isn’t there because researchers don’t see a benefit from doing the research. Remember though, that if something has been tested and found wanting, that could be a different matter.
“Absence of Evidence is not evidence of absence”
Also remember, researchers need to ask the right question (the hypothesis) and test it on the right group of people. It’s not unusual to find studies with conflicting results because researchers have chosen to test a different group of people, or asked the question in a slightly different way.
The existence of an evidence base can give you some confidence to make an informed decision, based on the likelihood of a positive impact against any potential side effects, but finding a definite answer is a tricky business.
The U.K position - N.I.C.E
In April 1999 The National Institute for Clinical Excellence was created to create consistent guidelines and end “postcode rationing “across the U.K. Now known as the National Institute for Health and Care Excellence (NICE) , they continue to provide standard guidance for treatment of a range of conditions. This guidance is given in relation to the evidence base and to cost. But it rarely takes into account the expertise of the physician or the individual patient, as David Sackett suggested.
“We use the best available evidence to develop guidance to improve health and social care”
Limitations of NICE Guidelines
Sadly, NICE hasn’t stopped the postcode lottery as each area manages its own funds. As an example, treatment offered to people struggling with fertility varies across the country. As I write this, NICE recommend 3 cycles of IVF for women struggling to conceive, but only one cycle is offered in Harrogate and the rest of North Yorkshire.
Where does that leave you?
Western science is a wondrous thing. The experimental approach means that new ideas are tested, and many a life has been saved by interventions developed following scientific studies. Studies also help organisations such as The National Centre For Care and Excellence (NICE) to decide what treatments to recommend when there are a myriad of options available and budgets are tight, but they can’t promise every treatment will work for everyone. Nor can they factor in the skill of the person treating you, or your individual wishes, the two strands of David Sackett’s model of ‘Evidence Based Medicine’ that are so often forgotten. Remember too, that not every treatment is tested for every condition.
Did acupuncture help Andy? Yes! His pain started to decrease after his first treatment. Six sessions later, he was pain free, and looking forward to his epic sailing challenge.
Does that mean I can promise to help you, as I have helped Andy and many others? No, I can never promise a result as everyone is unique. But I can promise that if I think a different treatment would be better for you, I’ll tell you. I can promise that I’ll give you an honest opinion of the likelihood of success based on my clinical experience, and I can promise that I’ll give you the best treatment possible for you, based on my experience and the experience of other acupuncturists over the last two thousand years.