Friday, January 18, 2008

Veterinary acupuncture

...a quixotic quest for evidence?

Brief notes of the state of acupuncture efficacy
To date, the attempts at scientifically confirming veterinary acupuncture as an effective modality and bring it fully into the fold of legitimacy have borne only dry and brittle fruit. The research landscape has produced precious little in the way of high quality studies and those that are out there raise more doubt than not as to whether veterinary- or human - acupuncture has any effect beyond placebo.
Over the years, this has become an increasingly important and hard nut to crack for acupuncture medicine supporters. This is because even with strong mainstream acceptance, the demand for evidenced based data supporting veterinary acupuncture has been steadily rising. There is increasing pressure to finally pin down the concept of acupuncture echoing from many in academia, general practice, and even some veterinary acupuncturists- all expecting and demanding that this modality earn its place at the therapeutic table.
We should probably be thankful there is any upwelling of this nature at all. The number of credulous or apathetic veterinarians, some in positions of influence and power, seem to be on the rise. Sadly, the siren call of Complementary and Alternative Veterinary Medicine (CAVM) has bewitched or blindsided the scientific world of veterinary medicine and become a household word without much more effort than a shady salesman sells the “latest thing a mabob” for a one time low $19.99.
The good news is that, on balance this is still a problem bubbling around the fringes of mainstream medicine. On the other hand, many are quick to note the dangers of tolerating CAVMs’ dubious presence in the realm of science based medicine as it only serves to muffle critical and reasoned thought.
Though the by laws of the American Veterinary Medical Association explicitly state that veterinary medicine is a science based endeavor, CAVM has enjoyed a certain level of benign neglect and tolerance over the last several decades. It will only get worse in time.
There are academicians and researchers from in and out of CAVM that are demanding more evidence based research for acupuncture and other modalities. This is an encouraging sign that the tide for unwittingly embracing unproven medical modalities can be stopped as critical thought reasserts itself in its rightful place as watchdog over effective medicine.
These signs of a more prudent academic stance regarding acupuncture are due in part to the gathering lack luster acupuncture efficacy in evidence based data bases. Several systematic studies illustrate the paucity of solid reliable data for acupuncture efficacy in human medicine. According to Bandolier “Large, high-quality randomized trials of acupuncture have been published…all were negative compared with sham acupuncture…Both large trials and this review of reviews come to the same general conclusion; that over a whole range of conditions and outcomes acupuncture cannot yet be shown to be effective.”

In an evaluation regarding acupuncture trial quality and proper interpretation of study results they state “Most high quality studies either showed no benefit or that acupuncture was worse than control. Forty to fifty percent of the trials or patients showed acupuncture to be better than control. Studies of low methodological quality showed significantly higher treatment effect than those of high quality.”

Table: Effect of quality of trial reporting on whether trials of acupuncture in chronic pain are better, the same, or worse than control

Number of trials
Number of patients
Quality score 3 or more
Acupuncture better than control
Acupuncture same as control
Acupuncture worse than control
Quality score 2 or less
Acupuncture better than control
Acupuncture same as control
Acupuncture worse than control

This figure reveals how the quality of information from several studies varies and how they might skew a practitioner’s interpretation of acupuncture effect depending on what information they rely on. The Bandolier authors add “Without laboring the point about poor quality studies over-estimating effects of treatment, or that evidence for acupuncture is thin on the ground, this study demonstrates both with some clarity…There are two bottom lines. First is to emphasize again the importance of using quality information for decision-making. Using poor quality information is likely to result in poor quality decision-making. The second bottom line is that the use of acupuncture for chronic pain is unsupported by any evidence of quality. Consumers and providers should beware.”

On the status of veterinary acupuncture

Acupuncture studies in veterinary medicine are more scant, many of questionable quality, and often confounded by other factors such as the use of electrical impulses. A 2006 veterinary acupuncture systematic review co-authored by Dr Ernst, a CAM researcher utilizing evidence base techniques, came up with a group of mostly low quality trials- granted the best they could find- and concluded “there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals.” adding the typical caveat “Some encouraging data do exist that warrant further investigation in independent rigorous trials.” Though these trials should be done and may prove interesting, based on the human research results, it does not look promising.
As further independent studies are done it is important to acknowledge that there are some CAM (Dr Ernst) and possibly some CAVM practitioners that support taking part in high quality well designed studies in an honest effort to get to the truth- where ever it may lead.
In the veterinary scene, there is an interesting article written by Dr Narda Robinson, the Shipley Complementary and Alternative Medicine professor at the Colorado State University. Dr Robinson seems interested in pursuing the science- if any- behind acupuncture and alternative medicine.
Though I have significant concerns regarding the promulgation and teaching of CAVM as an accepted medical practice at this university or any, her 2007 paper titled “Evidence-Based Veterinary Medical Acupuncture” offers a hint that there may be a willingness in some practitioners to dispassionately examine CAVM from a critical point of view as all modalities should be.
She States “Evidence-based medicine plays an important role in helping clinicians ensure that the procedures they employ in their practice are safe and effective, and helps veterinarians meet their ethical obligations to their patients by recommending treatment plans that are clinically sound and appropriate. Applying the standards of evidence-based medicine (EBM) is a challenge and opportunity to improve the quality of practice and training programs in acupuncture.” I would agree with most of this quote, although I question the very legitimacy of having acupuncture or any unsubstantiated modality in a teaching hospital until it is/ or not incorporated into the realm of “one medicine”- that which has been adequately tested.
Dr. Robinson adds “When evidence indicates either serious risk or inefficacy, the health care provider should avoid and actively discourage pursuit of such treatments” This is an important statement by a CAVM practitioner and provides some hope that some in CAVM might have the scientific courage to walk away from a pet theory if it is proven wrong. Time will tell.
Unfortunately, as mentioned, there is already an effort to incorporate veterinary acupuncture into mainstream veterinary practice through continuing education seminars and university sanctioned courses not just at the Colorado State University, but other veterinary teaching hospitals as well. This is putting the cart before the horse in a big way.
As the data base is objectively interpreted via independent evidence based perspectives, a general consensus will better inform the discussion. However -so far- acupuncture appears to be a complex morass of confusing practices with blurry effects and continues to be an unsubstantiated medical modality. The mounting evidence is not going acupunctures way.


Danio said...

Someone just slipped me the business card of a vet who is a 'certified veterinary acupuncturist'. I am quite unapologetically skeptical when it comes to modalities outside the realm of evidence based medicine, but my science brain longs to know the methods of the animal studies in question. I assume that most animals would not lie quietly while needles were placed subcutaneously--must they then be sedated? And if so, have the controls been done to show whether the pharmacologically induced relaxation of sedation alone is comparable to whatever benefits sedation + acupuncture are believed to impart for, say, arthritis in large breed dogs?

Needless to say, I won' be terribly surprised to discover that no such studies have been conducted. However, the rise in popularity of veterinary acupuncture in my admittedly very woo-friendly community (along with 'whole food' diets, herbal supplements, and homeopathy for pets) is as intriguing as it is alarming.

Al B said...

Unfortunately there are far too many veterinarians, physicians and researchers who dismiss acupuncture as a hoax or as in this case lacking adequate scientific and clinical proof to warrant its use. Clearly the problem has been that clinical and scientific studies of acupuncture have lacked adequate controls. Without proper controls study results are nothing more than hearsay. However more recent scientifically controlled studies would argue that perhaps acupuncture therapy has merit. In this regard recent studies using microarray technology to examine acupuncture effects on gene expression in peripheral blood are no less than fascinating. For example Shiue et al (2008) have shown that acupuncture therapy significantly reduced allergic rhinitis symptoms, including nasal symptoms, non-hay fever symptoms, and sleep in human patients and this was accompanied by and alteration in the balance between T-helper 1 and T-helper 2 cell-derived proinflammatory versus anti-inflammatory cytokines in the blood. Such studies are paving the way for a more scientific explanation of acupuncture's effects. One only has to examine the recent fMRI studies of acupuncture effects on brain activity in humans and animals to conclude that acupuncture point stimulation has remarkable effects on brain activity compared to non-acupoint stimulation (see for example Napadow et al., Hum Brain Mapp, 2005). These are real effects and whether they underlie the ability of acupuncture to alter pain sensation in humans and animals remains to be proven with certainty, but nonetheless acupuncture has the capability to change brain activity. In our own studies we have found that acupuncture can prevent tumor growth if given at the very early stages of tumor cell proliferation. Conversely if acupuncture is applied later on after a tumor begins to grow, it significantly enhances tumor growth, which is why acupuncture is typically not recommended as a treatment for cancer. On the other hand acupuncture provides clear relief of pain in animal models of neuropathic pain and inflammatory pain. These effects are real folks and I have seen them first hand, so I refuse to believe that acupuncture is of no value in the medical community, be it veterinary or human medicine. There is evidence that acupuncture does not work in certain individuals and works well in others, so there is clearly individual variation in the ability of acupuncture therapy to work effectively. Taking all of this into account, I would argue that you shouldn't dismiss acupuncture until you have tried it!

Dr G said...

The real unfortunate issue is not that acupuncture is dismissed as a hoax, but that – even with a preponderance of disappointing evidence- this modality continues to expect unearned acceptance.

Though plagued with poorly designed studies that are often replete with equivocal results or laced with regional geographic biases, better designed acupuncture studies are out there. However, the news is not good for any real acupuncture effect. The infamous placebo –among other problems (i.e.; expectation, suggestion, counter-irritation, operant conditioning, and other psychological mechanisms) - continue to confound even “modern” acupuncture technique (that is to say; those acupuncture practices that use needling and claim no association with the ‘elam vital’, points, or meridians).

The studies you mention do not address a critical issue with respect to acupuncture- whether or not its putative effects exist. The attempt to correlate a claimed acupuncture effect to epigenetic influence puts the cart before the horse (and is reminiscent of what ‘nutritional supplement support’ advocates claim for a favorite herb, vitamin, or tonic du jour) and purported brain responses apparently observed by fMRI are interesting but it seems apparent that any mechanical puncturing of the dermis –on points or no points, shallow or deep- will effect changes.

There is little or no evidence that acupuncture is effective for any real medical disease (i.e.; neoplasm) nor, for that matter, for less well defined symptoms (including chronic pain, depression, allergies, asthma, arthritis, bladder and kidney problems, constipation, diarrhea, colds, flu, bronchitis, dizziness, smoking, fatigue, gynecologic disorders, headaches, migraines, paralysis, high blood pressure, PMS, sciatica, sexual dysfunction, stress, stroke, tendonitis and vision problems). Interestingly, promising and plausible mechanisms –if any- seem associated with completely different modalities that are confused with acupuncture (i.e.; TENS, psychosomatic, placebo).

Seeing acupuncture effects “first hand”, no matter how impressive, is simply anecdotal testimony and adds nothing to a scant evidence and science based foundation supporting acupuncture. In short, the accumulating evidence suggests most of the perceived beneficial effects of acupuncture are probably due to the power of suggestion and forms of the ‘placebo effect’.

Whether or not acupuncture is of any value to the medical community might be better discussed in a philosophy of science course. For example, acupunctures place might be better off in the realm of personal belief or preference (i.e.; priest or shaman) and well of outside medicine (If you believe in it will make you think you feel better – that’s your business).

As for having tried acupuncture…been there done that. I’ve also extensively observed its use in animals by certified veterinary acupuncturists.

Not impressed.

trucker said...

It is interesting that you demand solid scientific evidence for this alternative treatment modality while ignoring the fact that the same expectations of acceptance occur in western medicine. So called "modern" medicine has committed this error time and time again, and these accepted treatments are often far less benign than acupuncture. Some things I can think of off the top of my head include circumcision, tonsillectomy, removal of wisdom teeth, and induction of labor in women. These procedures, while perhaps having their place under some circumstances, have not been shown to be effective in disease prevention by any scientific study. Yet they have been performed on a routine basis in hospitals throughout the US, without any "real evidence" (as you put it) that they are helpful. Further, many treatments employed by Western medicine have been shown to be harmful despite scientific evidence showing that they were safe (Thalidomide and Celebrex come to mind).

It is important to recognize that all studies have their flaws, and by dismissing something based on too few studies, we may discard important information. Scientific study in this area is confounded by the fact that treatment may depend on operator skill and individual variation. While it is true that we cannot say for certain that acupuncture works, it is a non-invasive alternative that we can offer to patients that have no other options. And in some cases, it does improve quality of life.

While I agree that we need a certain amount of evidence before accepting a treatment, I think it is a big mistake to ignore the very promising preliminary results supporting acupuncture. You dismiss them very easily, however, I highly doubt that you have read most of the literature. I am not as familiar with other fields of study, but in my own field (reproduction) current scientific evidence is convincing enough to routinely offer acupuncture as an adjunct therapy. It is used in male infertility treatments as well as for IVF and embryo transfer in women, and has had good results so far. I can send you the articles if you wish.

It is time for North American physicians and veterinarians to quit being so arrogant and accept that there may be better ways of treating reproductive problems and chronic diseases. Our current methods are out of date and in some cases, downright harmful.

Dr G said...

Your input and time reading this humble blog is appreciated and though I pretty much disagree with most of your claims...thanks!

You do bring up interesting points that have been addressed and discussed in other posts here and even better elucidated in excellent blogs such as "science based medicine", "Orac", "nuerologica" and "quackometer" among many others.

Please remember arrogance, assumptions, appeals to openness, appeals to other ways of knowing...etc is not the MO for science based activities...on the contrary, it is the very acknowledgement of fallibility that defines part of the scientific endeavor.

Your impression of this post indeed seems to reveal a misunderstanding of science- it is critical and skeptical about everything.

The term "conventional" medicine is a misnomer...a fallacy...there is just medicine- and our honest struggle to figure out what works.

Here damocles sword should hang over all we do as doctors as we strive towards as unbiased progress as humanly possible.

Unfortunately postmodern versions of medicine haven't cut it- no matter how the cookies been me some of the promising studies (after over one billion dollars spent by NCCAM not much to be impressed over) I'm happy to go over it (see "failure to launch" post)and check out promising venues, but there does come a time to call a spade a spade. DR Ernst, Offit and Colquine (Google them) offer interesting perspectives about this if you like reading and research as you seem to claim...and tiredly assume I haven't.

BTW, here is some more interesting reading...from the science based medicine blog...

Between hysteria and quackery: some reflections on the Dutch epidemic of ‘pelvic instability’. J Psychosom Obstet Gynecol 2000;21:235-239.

Alternative treatments in reproductive medicine: much ado about nothing. Human Reproduction 2002;17, 528-533.

A Comparison between Alternative Pseudodiagnoses and regularly Accepted Fashionable Diseases: An analysis Prompted by the Dutch Epidemic of Obstetric “Pelvic Instability.” The Scientific Review of Alternative Medicine. 2002, vol 6 (2): 91-96.

The sharp end of medical practice: the use of acupuncture in obstetrics and gynaecology. (Letter to the Editor). Br J Obstet Gynaecol 2002, 109: 1418-9.

Proving the unlikely: trials in alternative medicine. Focus on Alternative and Complementary Therapies. 2003,8(3):307-308.