I am occasionally interviewed by journalists writing articles about alternative medicine for pets. Many of these articles deal focus on acupuncture, and they tend to follow a pretty consistent pattern:
1. Story about a dog or cat with some pain or disability, often that has not responded to conventional treatment.
2. Owner takes pet to veterinarian who recommends acupuncture (or other alternative treatment).
3. Brief summary of claims for benefits for acupuncture ad reference to long history of use in people and pets. Sometimes there is a reference at this point to research studies supporting the use of acupuncture (almost never to studies that do not support it).
4. Brief quote from grumpy, killjoy token skeptic (that would be me) to create the impression of “balanced” reporting.
5. Return to story of pet from beginning of article, now all better and frolicking happily.
It is well known that the media caters to our inherent preference for stories over statistics, and that when journalists cover scientific subjects, especially those that are controversial, nuance and thoughtful analysis of evidence are often sacrificed for a compelling narrative. And the well-meaning notion that a journalist should present voices from “all sides” of a controversy all too often results in stories that suggest a legitimate debate about scientific facts when, in reality, there is strong evidence and consensus on one “side” and the unshakeable faith of a small minority on the other.
I was pleased, therefore, to see a recent piece about veterinary acupuncture in Slate which took the scientific evidence, and the perspective of skeptics, more seriously than the feel-good anecdotes of believers.
If Your Veterinarian Offers Acupuncture, Find a Different Vet
Sticking needles in your dog won’t make it feel better.
By Brian Palmer
The title may be a bit extreme, since unfortunately a lot of otherwise excellent veterinarians have been fooled by the claims and shaky evidence for acupuncture, but the overall message of the article is right on target. Mr. Palmer appreciates that while the scientific evidence is mixed, an appropriate evaluation requires considering the quality and limitations of studies and the preponderance of the evidence.
If you’re an acupuncture enthusiast, you’re probably getting ready to point me toward studies proving the efficacy of veterinary acupuncture. Before you do that, let’s make a deal: I will concede that there are studies supporting veterinary acupuncture if you concede that there are studies opposing it. The issue is assessing the quality of the studies and determining where the weight of the evidence lies.
His conclusion, with which I agree entirely, is that the most reasonable interpretation of the balance of the evidence is that acupuncture is a placebo for humans and likely has little to no predictable beneficial effects in animals. Most veterinary acupuncture studies are deeply flawed, and better research could be justified, but the best evidence in humans does not suggest this is a promising area for veterinary medicine.
Mr. Palmer’s piece also points out that the potential financial conflicts of interest which alternative medicine proponents so blithely use to dismiss research on pharmaceuticals or other conventional therapies are just as much of an issue in research on alternative veterinary therapies, including acupuncture. One of the most prominent researchers in veterinary acupuncture and so-called Traditional Chinese Veterinary Medicine (TCVM) also makes his living teaching TCVM and selling herbs and related products. While this does not automatically invalidate the research Dr. Xie is involved in, it points to a clear a priori bias which necessitates rigorous scientific controls, including replication by others, in order to generate reliable evidence. These controls are seldom present in veterinary acupuncture research.
It is encouraging to see the mainstream media identify the unimpressive scientific reality behind the widespread positive, and anecdote-driven claims for veterinary acupuncture. Here are some links to previous posts on veterinary acupuncture and TCVM which offer more details about these claims and the science, or lack of science, associated with them.
“Electroacupuncture” as a Treatment for Nausea & Vomiting Caused by Morphine in Dogs
Acupuncture vs Opioids for Surgical Pain in Dogs: Which is Better?
JAVMA Article on Electroacupuncture for IVDD
Traditional Chinese Veterinary Medicine
The History of Veterinary Acupuncture: It’s Not What You Think
“Extreme “?????
Replace “veterinarian” with pediatrician
Replace “dog” with child or Alzheimer’s patient
I think those doctors who stick needles in patients who cannot be offered informed consent should not get a free pass. That includes the administrators of the vet schools who allow acupuncture double speak to be taught to young vet students.
Art Malernee Dvm
Fla Lic 1820
Well, Art, we’ve always disagreed on this one. I’m not as willing to write people off just because of disagreements about a specific therapy. In the case of acupuncture, there is a pretty large number of vets (and MDs, for that matter) who have the wrong idea about it, and I think it is simplistic to say we should just avoid or write off anyone who believes that. Productive debate and any influence we might have on the opinions or practices in our profession requires engagement, discussion, and a bit more nuance than that.
I think it is simplistic to say we should just avoid or write off anyone who believes that. >>
Do you refer to vets and practices that promote acupuncture? I did years ago, thinking it was better to have a vet stick needles in animals than someone without a license. I no longer think that’s true. There are plenty of neurologist, speciality practices and vet schools that do not do acupuncture so why refer to vets who do? Where do you draw the line? Would you refer a client who had a horse to a practice that pin fired horse ankles with hot irons?
Art
You’re taking a sensationalist article and systematically revising its components to make it more palatable. As the president of the EBVMA I would think you would distance yourself from such articles in order to preserve your integrity as well as the integrity of the association. However, mainstream journalism is always far from biased and appeal to emotion rather than facts. Still, that doesn’t necessarily make scientific reporting an oxymoron.
It’s worth noting that the 2006 JVIM concludes “there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals. Some encouraging data do exist that warrant further investigation in independent rigorous trials.”
So, for me, the scientific literature seems black-and-white. It’s a shame Mr. Palmer could not meet that expectation.
I’m not exactly clear on what revision you think I am performing here. I also think the scientific evidence is clear. It indicates that acupuncture is primarily a placebo and there is no legitimate basis on which to perform it on veterinary patients, and that is the message of the article.
The main difference of opinion I have with the author is the suggestion in the title that pet owners should avoid veterinarians who practice acupuncture. While I think such practice is misguided, it is not by itself evidence of incompetence or inadequate care.
The JVIM article reviewed the veterinary literature and found it too weak to draw any firm conclusions. However, if one looks at the balance of the evidence, which includes many hundreds of trials in humans, it becomes clear that the most methodologically rigorous trials reveal acupuncture not to have benefits beyond placebo effects. What do you believe the “black-and-white” message of the literature is?
. What do you believe the “black-and-white” message of the literature is?>>>
I think as practiced in the literature acupuncture would be defined as ” promotion of unproven medical care in the market place. You could set up a trial study so it would not be promoted that way so I would be ok with a referral to a properly controlled trial.
I thought that the overarching problem with acupuncture studies (re pain) was the fact that “sham” acupuncture works too, although by a different means. That “real” acupuncture changed the brain’s opioid receptors, while “sham” acupuncture releases endorphins, and fills up pain receptors (there was a Science Daily article a number of years ago that made this point; I’m trying to find it now) So when they do a study with both “real” and “sham” treatments, and the “real” does no better, people often say that shows that the “real” doesn’t work, but actually both worked a bit. I don’t know how they would get around that problem in setting up a study.
Since I’ve already interjected the layperson’s view here, here’s my happy anecdote. A number of years ago we adopted an ancient corgi/beagle (perhaps) mix. He was about three feet long and about a foot tall. After a year we asked the housecall acupuncture vet to treat him along with our other ancient dog who was already being treated; we didn’t know if he was in pain but it seemed likely due to his age and bizarre build. After the second treatment, my husband ran into my room, shrieking, “Arby has collapsed!!” Actually, Arby had SAT DOWN for the first time since we had gotten him a year before. (When a dog who is that long/low sits down, it looks like their hind end has collapsed.) He felt okay enough to sit down, for a change, and that continued.
Well, I know that’s no “proof” of anything, but we sure kept up the acupuncture on him.
Not exactly. Any change in the perception of one’s symptoms (pain, nausea, etc.) has to involve some change in brain chemistry since all our sensations are the result of brain chemistry. So when you feel “better” by virtue of a placebo effect, there is something happening in your brain. Why, then, isn’t this a “real” therapeutic result? Several reasons:
1. Placebo effects only impact a limited set of subjective and autonomic outcomes. The latest example of this is a study which found that fake inhalers, and acupuncture, made asthmatics feel like they could breath more easily. However, neither affected actually measures of lung function, whereas an inhaler with real medicine in it did. So placebos run the risk of making you think your disease is improved when the only change is your perception of your symptoms. In the case of acupuncture, this creates a false belief that one is effectively treating the disease. If the acupuncture really did change the disease in an objective way, there would be a difference between the results of the “real” and “sham” acupuncture. If the sham works just as well, then only one’s perception is being affected.
2. The kind of change in endorphins and brain activity one sees with acupuncture also occurs when you poke someone with a toothpick or stub your toe on a coffee table. Again, all sensation is brain chemistry. And stubbing your toe undoubtedly reduces your perception of pain elsewhere in your body, say from a cut on your finger, at least temporarily. So is stubbing your toe a medical therapy? Of course not. We need to be able to generate a predictable, consistent, ideally objective response greater than placebo to call something a medical therapy. Simply doing something to the body that can be detected isn’t enough.
3. Even a controlled trial of acupuncture inevitably comes with one weakness, which is you can’t ever fool the acupuncturist, so they are not blinded to the treatment. It has been shown that how the therapist presents the therapy influences whether the patient thinks it worked, so if there isn’t really any such thing as a “sham” acupuncture therapy because the therapist always knows if they are doing acupuncture or just pretending to do it, it is hard to eliminate the influence of the therapist on the outcome. Again, this might mean that the reason the sham treatment is as good as the real is that they are both placebos generated, at least in part, by the attitude of the therapist.
4. Finally, placebos only work if you lie to the patient (or in vet med, to the owner). If the only way acupuncture works is by placebo effects, then it is useless unless we choose not to tell people this, which places doctors in the position of lying to patients/clients for the sake of small benefits in the perception of subjective symptoms. That doesn’t seem a good deal to me.
It’s understandable that the anecdote encourages you to keep going with the therapy. It’s only a problem when there is better evidence the therapy doesn’t work. We know conclusively, for example, that homeopathy is nonsense. Yet people have plenty of similar experiences with that and keep using it. The same was true of bloodletting for thousands of years, of crazy diets, and all kinds of other therapies. It’s a big problem for scientists and for medicine because our brains are wired to believe our experiences rather than objective data even though we often know the data is more reliable.
Not a huge problem with acupuncture if you don’t use it in place of other, validated treatments, because acupuncture by itself is pretty harmless. But I’ve seen clients convinced acupuncture was helping their pets when the pets looked obviously in pain to me, and nothing I could say would convince them to try anything else. That sort of anecdote doesn’t prove anything either, but it’s part of why I’m so uncomfortable with placebo therapies since they can lead us to decisions that actually do cause harm.
If Arby had given signs of being in pain, we would have put him on Rimadyl or the like. None of his vets (he saw a neurologist, an ophthalmologist, a dental surgeon, an internal medicine vet, and a dermatologist in the 3 1/2 years we had him) suggested that he might be in pain. We saw the acupuncture as a (rather costly) “extra” that might get rid of pain that he might be in. His kidneys (initially full of stones which then dissolved when we prevented him from his apparent lifelong habit of licking up his own pee!!!) were in such poor shape that we wouldn’t have put him on Rimadyl on speculation, whereas acupuncture on spec was okay.
I absolutely agree that it would be horrible for a pet to be in pain while the person who tends it falsely thinks that the pain was being treated by acupuncture. That is an appalling thought.
“The kind of change in endorphins and brain activity one sees with acupuncture also occurs when you poke someone with a toothpick or stub your toe on a coffee table.”
Yes, exactly. And actually for some things that works very well!!!! I have an acupuncture pen that I use on myself for various discomforts, and it works brilliantly by that mechanism. Of course, when the patient can’t talk and say whether something is helping, I agree that that is a completely different situation.
“The latest example of this is a study which found that fake inhalers, and acupuncture, made asthmatics feel like they could breath more easily. However, neither affected actually measures of lung function, whereas an inhaler with real medicine in it did.”
Wow. I can see how that could be a real hazard of using acupuncture that treats symptoms (or perceptions of symptoms) without also treating the underlying problem.
http://archinte.jamanetwork.com/article.aspx?articleid=1357513
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