JAVMA Article on Electroacupuncture for IVDD

A couple of readers have asked me to comment on a study that appears in this month’s Journal of the American Veterinary Medical Association, Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing neurologic deficits.

The study was performed in Brazil at the School of Veterinary Medicine and Animal Science in Sao Paulo, where a similar study published last year and another in 2007 were also performed. The authors created 3 study groups, all of which consisted of dogs that had severe neurological disease of >48 hours duration attributed to intervertebral disk disease (IVDD). Group 1 (DSX) was a group of dogs (N=10) selected retrospectively from patients that had undergone surgery for IVDD at the authors’ hospital between 2003 and 2006. Group 2 (dogs treated with electroacupuncture-EAP, N=19) and Group 3 (dogs treated with both surgery and electroacupuncture-DSX+EAP, N=11) consisted of dogs seen at the hospital between 2006 and 2008, and patients were assigned to these groups based on their owners’ choice.

All dogs were treated with oral steroids. Dogs in Group 1 were treated surgically with a couple of different techniques and presumably with whatever unspecified medical treatment and post-surgical care the individual surgeon elected. Dogs in Group 2 were treated surgically (and again presumably with additional unspecified followup care) and were also treated with electroacupuncture. This treatment consisted of the insertion of metal electrodes into the body at points determined by “traditional Chinese theory.” Electrical current was passed through these electrodes for 20 minutes weekly for from 1-6 months. Scores were assigned to quantify the level of neurologic dysfunction initially and at 6 months after the beginning of treatment. Improvement was judged based on decrease in neurologic score and regaining the ability to walk unassisted.

The results can be summarized as follows:

  DSX EAP DSX+EAP
Score Unchanged 6/10 4/19 3/11
Score Improved 4/10 15/19 8/11

 The text indicates that the proportion of dogs in the DSX group that improved was statistically significantly lower than in the other two groups, and the proportion of DSX dogs that remained unchanged was significantly greater than in the other groups. From this, the authors concluded that “EAP was more effective than DSX for recovery of ambulation and improvement in neurologic deficits in dogs with long-standing severe deficits attributable to thoracolumbad IVDD.”

So is this conclusion justified? I believe not. To begin with, of course, we must decide what if anything this paper has to do with “acupuncture.” Electroacupuncture has been referred to as a bait-and-switch, because it is arguably not acupuncture at all. Obviously, the ancient Chinese lacked electricity, so the theories and guidelines developed for acupuncture in humans are not really relevant to the effects of electricity on the body (there were no specific guidelines for animals, and despite claims to the contrary it does not appear the Chinese routinely practiced acupuncture on animals before the mid 20th century). There is, however, a scientific medical therapy involving electrical stimulation to treat pain, transcutaneous electrical nerve stimulation (TENS). The only difference between TENS and electroacupuncture appears to be the selection of electrode location. TENS places electrodes in locations associated with known nerves, and in electroacupuncture the electrodes are placed at acupuncture points with no consistent relationship to any identifiable anatomic structures. However, by chance or perhaps some trial and error experience, some acupuncture points do happen to coincide with the locations of nerves, so it is possible that electroacupuncture might effectively be the same thing as TENS in some cases. So one might justifiably question whether any benefit seen in this study represents a validation of the theory and practice of acupuncture or an example of TENS with irrational selection of electrode locations.

However, there are other reasons to view the authors’ conclusions skeptically. A major methodological flaw of the paper is the process of selecting and assigning subjects. It is highly likely that there are biases inherent in allowing owners to choose what treatment group their pets should be in and in selecting one group retrospectively from one period of time and another prospectively during a different time period. This process does not allow the owners or researchers to be blinded in any way to the treatment, and it makes it likely that the patients and the treatment they receive in the various groups will differ with respect to many variables other than the one of interest in the study. The lack of blinding is of particular concern since the research center has consistently produced papers showing positive results for electroacupuncture and thus the researchers likely have a strong a priori bias in favor of the approach.

Very little information is presented to allow us to evaluate whether the patients differed in meaningful ways in terms of the medical therapy, surgical care, and post-surgical care they received. We do know that the EAP and DSX+EAP subjects received weekly treatments at the hospital for from 1-6 months after the onset of the study, and it is likely that they received much more intensive followup and post-surgical care (for the DSX+EAP group) as well as better owner compliance due to seeing the doctor so often after the study commenced. It is also quite possible that the differences in outcome were due to any number of differences in the populations of the various groups or the biases of the authors since these were not controlled for effectively.

There are other methodological problems, particularly the small number of subjects, but overall the two factors already discussed are enough to make me question the strong conclusions the authors draw from their results. It is certainly possible that electrical stimulation of some parts of the body could have a beneficial effect on outcome for dogs with neurological deficits attributable to IVDD. Better studies involving random prospective allocation of subjects, more consistency in the treatment of the subjects, blinding of the researchers and owners, and perhaps more precise assessment criteria would be valuable. I would be particularly interested, if there turns out to be some value to so-called electroacupuncture for this condition, in seeing a comparison of this procedure with electrode locations selected according to anatomic structures such as nerves compared with locations selected according to traditional Chinese medicine principles (insofar as such principles can be called “traditional” with respect to treating animals with electricity). It would take a robust and repeatable superiority of treatment at traditional acupuncture points compared with locations selected according to the principles of TENS to convince me that this procedure has anything to do with acupuncture.

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15 Responses to JAVMA Article on Electroacupuncture for IVDD

  1. Bartimaeus says:

    I just got my copy in the mail today, and I agree with your concerns. It is also not completely clear to me that the surgery patients were not more severely affected to begin with. The 10 surgery (DSX) cases were retrospectively selected from cases between 2003 and 2006, while the other two groups were treated between 2006 and 2008, opening another opportunity for bias. At the very least, they were not assigning patients randomly. This is at least the second paper in the last year that used electroacupuncture like this. Why has it not occurred to any of them to compare electroacupuncture to TENS?

  2. Swedish Vet says:

    At least one more flaw: There was no control group that received no treatment. What if (as it seems to be the case) expectancy is better than DSX?

  3. Swedish Vet says:

    At least one more flaw: There was no control group that received no treatment. What if (as seems to be the case) expectancy is better than DSX?

  4. skeptvet says:

    The absence of a no treatment group is a weakness of the study, though to be fair it is arguably unethical to have such a group when both medical and surgical therapies have been shown to have some efficacy for IVDD.

  5. Art says:

    They non-radomly assigned 30 dogs with disc extrusion to get either surgery or surgery plus electro-acupuncture and then assessed outcome in a non-blinded fashion. There was no statistically significant difference in outcome.

    This could be because there is no real difference. But using similar patients, power analysis shows you need about 87 patient per treatment group to detect a 20% change in function with a power of 95%. (Olby et al. J Neurotrauma. 2004 Jan;21(1):49-59.) So it’s likely the study was substantially underpowered.

    They then retrospectively selected 10 dogs that had surgery for disc extrusion for comparison, although the criteria for selecting these particular 10 patients was not clarified. Because this is not a contemporaneous and there is a lot of potential bias in the selection of this group, I think it’s really hard to make any valid comparisons. In fact, the 40% recovery rate for the dogs in the surgery group is less than published in most other studies and less than I would have expected based on my clinical experience. A review of the scientific literature I think would lead one to conclude that treatment of ivdd with surgery or acupuncture does not work.
    They non-radomly assigned 30 dogs with disc extrusion to get either surgery or surgery plus electro-acupuncture and then assessed outcome in a non-blinded fashion. There was no statistically significant difference in outcome.

    – Evidences suggest that discectomy is effective at short-term, but at long-term it is not more effective than conservative care. Valat, JP et al. Best Pract Res Clin Rheumatol. 2010. Apr;24(2):241-52.”
    Art Malernee dvm

  6. Art says:

    Should have said surgery or acupuncture does not work beyond placebo effect of acupuncture or surgery. Surgery is a very powerful placebo. So you get some short term benefit from disc surgery. We just do not know how to fix degenerative joints. That’s why we make artificial ones.
    Art Malernee dvm

  7. Heather says:

    Electroacupuncture is INDEED acupuncture. Historically, acupuncture needles were continuously twisted during treatment at different frequencies by assistants to the Acupuncturists. Electroacupuncture is proven to have effects on serotonin release and opioids at different frequencies.
    While it is good to question all studies, electroacupuncture is a proven modality. I have treated cases with no deep pain with EA with wonderful success. I think we should follow suit with AVMA recommendation of integration of complementary and western medicine. It is for the comfort and health of the animals we care for that we should pursue treatments.
    Heather Sacks Allen DVM CVA

  8. skeptvet says:

    Well, the key to evaluating therapies is to have clear definitions for what the therapy is and clear, objective measures of outcome. Acupuncture has many different definitions, and when comparing studies it is important to be sure we are comparing apples to apples. If sticking electrodes into areas with superficial structures such as nerves, muscles, etc that we wish to stimulate electrically seems to have a benefit, that’s fine. But that is indistinguishable from Trancutaneous Electrical Nerve Stimulation (TENS), and has no connection to the concept of Ch’i, the TCM system of diagnosis by pulse and tongue, the Five Elements, or the various maps of acupuncture points and merdians. So it seems pretty disingenuous to call that practice acupuncture and then claim that all those other things are valid too just because TENS has some measurable benefits.

    As for “I have treated cases….with wonderful success,” that is not a reliable measure of the efficacy of any therapy. Such clinical experience may be useful in the absence of more reliable evidence, but the unprecedented impact of scientific methods on health and well-being illustrate why millenia of relying on such experience got us nowhere in terms of improving healthcare.

    And the fact that sticking needles into patients has measurable physiologic effects is not equivalent to saying acupuncture is an effective therapy. Dropping a hammer on your toe causes opiod and endorphin release and measurable changes in brian activity, but that doesn’t make it an effective clinical intervention. We can debate, of course, the details of clinical studies of acupuncture, but if your position is you believe it effective based primarily on your own clinical experiences and on physiologic studies of the effects of needling, that level of evidence is not sufficient to establish efficacy. FOr the comfort and health of our patients, we have a responsibility to make sure we test our therapies in rigorous and reliable ways.

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  10. Deidre says:

    My husband talked me into taking our dog for electro-acupuncture when the ortho specialists suggested shoulder surgery due to an unstable shoulder. The vet that performed the electro acupuncture thought that she could help and said that after three sessions if we did not see improvement we would need to reconsider. The first two sessions we thought we saw improvement but wondered if it was in our head. On the third session my dog walked through the door with the “horse gait” limp (as we called it) and came out never to limp again (that was 4 years ago). While I agree with the skepticism of the above study due to the lack of controls, in my case the condition resolved itself in front of my eyes. It is a shame that many traditional vets do not even consider these options and instead offer euthanasia to those that can not afford costly surgeries or where surgeries are incredibly risky.

  11. skeptvet says:

    The problem with such stories, of course, is that there is no way to know if the improvement was due to the acupuncture, or to the body’s natural healing ability. We can only find that out through studies comparing one treatment with another or with a placebo. That has been done with acupuncture and most of the time the cases not treated get better just as often as those that were treated. So while it’s great your pet got better, and while the acupuncture was less expensive than the surgery, it was probably more expensive that simply giving your dog time to heal naturally, which he or she might very well have done.

  12. Deidre says:

    I would agree if not for the fact that my dog walked in the vet door with the gait that she had for the past 3 months and walked out without a trace of limp. Did it resolve itself the moment that she got off the table through natural healing itself or was it due to the acupuncture she just received before getting off the table? The answer was apparent to me.

  13. skeptvet says:

    And the effect of prayer was just as apparent to this woman:

    In March, a woman was given six months to live. She was diagnosed with galloping Multiple Sclerosis about 29-30 years ago. She would have a burning skin sensation that she described like running an iron over a bad sunburn (pain level 10) constantly; no painkillers would work. She had limited movement and mobility with her arms, and her left hand was clenched up in a fist (for the past year). She has been mostly in a wheelchair for ten years as she had lost her sense of balance, and would often fall. From this she also has had 5 years of back pain (level 10). She had braces on her lower legs, and could barely lift her feet. Her husband said that earlier in the week she was feeling very hopeless, and she felt unworthy to ask God for help and healing. She was near the brink of taking her own life until she finally decided to yield herself and come to the Healing Rooms. On that morning, she didn’t take any pain medicine.

    On October 31st Thomas Blackmon prayed for her in the Encounter Room and suddenly her hands opened up and she was able to move both of them freely. For the first time she could open her hand wide and touch every finger to her thumb! She came into the Healing Rooms feeling a warmth over her back. Hamish Melville, Christina Delk and I took her to a spot where we began to pray for her and she said she could tell she was being healed. Suddenly she raised both her arms above her head and moved them about freely! We began to cheer, and others entered in rejoicing.

    Another prayer servant came over and asked if she would be willing to pray for a woman who couldn’t raise her arms until they prayed, and now she had partial mobility. They brought that woman over and the two touched hands and the woman with M.S. raised her arms up and the other woman followed her and she was instantly healed and could freely move and reach her arms up without pain. We all erupted with cheers and praised God for His goodness!

    She told us ALL the burning pain had left her body, and she had taken no pain medications that day!

    If every story like this means the therapy worked, then every therapy ever tried works. Is it more likely that no kind of healing is ineffective, or that we mistake causality sometimes?

  14. Alvin says:

    My dog lost total function of both her hind legs 4 weeks ago and the neurosurgeon we took her to diagnosed her as having IVDD and would require immediate surgery. She’s in her 4th week of post surgery and 3 weeks of physical therapy and she’s still not able to walk not have control of her urination and defacation. She has 2 more sessions of PT left and are now considering acupuncture. After reading all your comments, thank you by the way, I am not too sure about how effective acupuncture will be for my dog. However, I cannot let nature take its course and allow it to heal my dog. What if that does not happen? I would have wasted precious days where acupuncture is still beneficial.

  15. skeptvet says:

    As I point out here and elsewhere, the evidence for real benefits from acupuncture is weak, but there are few serious risks, so when you have done everything else appropriate to do, it certainly is not unreasonable to try acupuncture.

    Good luck!

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