Thursday, January 10, 2008

Failure to launch

Another disappointing veterinary acupuncture study

Blogging on Peer-Reviewed ResearchA recent study published in the September 2007 issue of the Journal of Veterinary Medicine discusses the potential positive effects of electroacupuncture for treating varying degrees of intervertebral disk disease (IVDD). The authors describe the putative effects of utilizing this modality as an adjunct along with oral medications, particularly steroids, as a possible alternative therapy before surgical intervention.

This prospective controlled study titled Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs” starts off routinely enough but quickly begins to unravel in the methods and materials section and finally leaks like a rusty bucket in the discussion.

The authors compared two groups of dogs suffering varying degrees of compressive spinal disease based on clinical, neurological, and radiographic signs. Both groups received some form of standard oral medical treatment during the study (some seem to have been started before the study) and one group also received electroacupuncture using an electroacupuncture a devise (model DS 100 CB) and acupuncture needles (0.25x 25mm).

The animals were evaluated with respect to the clinical degree of disease using a “functional numeric scale” or FNS and distributed into 5 subgroups (Table 1) in an attempt to standardize a base line to better determine any subsequent changes during the study. The goal was to minimize the necessarily subjective nature of the evaluators and owners. The authors also used statistical measures to account for discrepancies between groups.

Table 1

Grade 1-2

No neurological signs to some back pain and weakness- but walking

Grade 3-4

Can not walk, but can feel limbs- with or with out urinary incontinence

Grade 5

Paralyzed- with or with out urinary incontinence

According to the study, Selection and determination of the site of the acupuncture points were based on the authors’ clinical experience and the veterinary literature. Acupuncture points were previously selected by the theory of traditional Chinese medicine…” The electroacupuncture consisted of using three paired points or “sets” at several areas of the animals’ body and simultaneously passing alternating currents of frequencies of 3Hz and 100Hz for three seconds. Other acupuncture points were utilized as well at the same time with no electrical stimulation. The average totals treatments consisted of at least three applications with more severely affected animals receiving more (twice weekly for two weeks, then weekly for at least two weeks).

The studies results basically reveal that, on average, the groups undergoing electroacupuncture- especially in the three to four FNS group- improved in neurological deficits faster than the other group, although both groups eventually finished (after several weeks) with similar FNS scores.

The authors go on to conclude that electroacupuncture can serve as an important option before surgical intervention and then, unfortunately go on a meaningless ramble discussing questionable acupuncture theories and other related acupuncture use in IVDD.

Though, this just one small study among many it is meant to contribute some modicum of meaningful information. Unfortunately it doesn’t. In addition, a variety of concerns immediately come to mind as to this studies ultimate value. The overall trial design brings significant concerns that decrease its potential for adding meaningful data to add to further larger systematic reviews (garbage in/ garbage out sequence). This is especially true when evaluating any claimed effects of alternative modalities often rife with implausible theoretical concepts that have scant scientific support. The results of this study are blunted by several problems that may alter the observations and increase the likelihood of bias and equivocal conclusions.

For example, it is not blinded with regards to the patient owners and researchers. Additionally the same researchers who apply the acupuncture treatment also interpreted the results of this treatment. The authors do partly acknowledge this problem stating “A variety of neurological signs were observed in the study, which can result in difficulties for comparison among treatment groups” but consider the FNS and recovery of ambulation in those dogs that could not walk a mitigating factor. This is not enough to cover for the lack of blinding.

Blinding in and of itself can dramatically alter any meaningful results in a study- often giving completely different results than a non-blinded study. Granted, blinding is difficult to accomplish in acupuncture, but it is not impossible to minimize many of these issues to improve the “fidelity” of the data

The blinding issue also diminishes the effort made by the authors initially at randomizing as well as accounting for differences between the two compared groups of dogs. A lack of proper randomization can overestimate any putative treatment effect by as much as 41%.

Additionally, the small size of this study decreases its impact as larger studies are much better at reducing random effects related to possible treatment results. In fact, the significance of treatment can be over estimated in these cases by as much as 30%. For example larger and better quality acupuncture studies in humans are consistently negative as are systematic reviews that utilize high quality smaller studies as a back bone.

Though the authors made an attempt at ascertaining that the dogs in the study indeed suffered from IVDD and categorizing them according to severity, using clinical, radiographic, and neurological findings gets you only so far in differentiating this from a constellation of similar maladies from cancerous lesions to muscular traumas. Three dogs in the non electroacupuncture three- four groups ended up going to surgery before they recovered. Though not mentioned, a myelogram at the least was likely performed in order to localize the lesion or lesions in these cases. This brings to mind that further attempts at better defining the parameters of an often difficult to diagnose disease by using myelograms, MRI, and spinal fluid analysis on all the dogs (not mentioned as having been done) could have added more significance to the study.

Perhaps among the most critical errors within this study is the existence of an important confounding factor, also noted in many if not most other animal acupuncture studies. The authors combine the concept of acupuncture and electrical stimulation1- two different things and call it the same. It remains to be seen if the electrical component of these acupuncture studies has anything to do with any effects. But if they do, then many animal acupuncture studies have a big problem.

Another big problem is that the authors used traditional Chinese medicine and clinician experience to determine the acupuncture points used- neither of which is conducive to objective analysis. Traditional Chinese medicine is a historical quagmire of non science and no matter how proficient a clinician might be, their individual opinion falls into the notoriously self aggrandizing testimonial category.

This study reflects a large amount of the “same old” issues that has hampered so many other acupuncture studies. Another familiar “a failure to launch” attempt for acupuncture efficacy has been added to the books.


1) The use of electricity to treat a variety of maladies without the needles is another modality that has been around for some time. Known as Transcutaneous Electrical Nerve Stimulation (TENS) it is often utilized for pain management. With regards to efficacy, this modality has problems of its own.

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