One of the reasons I chose the acupuncture course I am currently taking is that the instructors are very clear about rejecting the Traditional Chinese Medicine mythology of Qi, Yin and Yang, and all the rest that is often used to justify or explain the potential benefits of needling. The course purports to take a purely scientific approach to understanding and using acupuncture. As I have discussed previously, however, a fair bit of traditional acupuncture practice is accepted as effective based on anecdotal experience and then rationalized post hoc with sometimes questionable anatomic or neurophysiologic explanations. One of the most intensively used of these is the myofascial trigger point concept (MTrP).

Myofascial trigger points are supposed to be focal areas of tension or contraction in muscles which are irritable and contribute to chronic refractory pain. The argument is that these develop in response to local injury, to certain postural or activity patterns, or even to diseases in internal organs or the nervous system. Practitioners who treat such trigger points claim to be able to detect them as knots or taut bands within muscles.  Such trigger points are treated primarily by “releasing” them via some kind of stimulus, such as needling, electrical stimulation, massage, laser therapy, and so on.

The concept of the MTrP is more widely accepted in the conventional medical community than acupuncture more generally, though it is primarily utilized by osteopathic physicians, chiropractors, and others who focus on physical manipulative therapies, such as massage therapists, physical therapists, etc. However, the validity of the concept and the effect of needling and other rMTrp releasing therapies is often assumed as proven in this course and then used as a explanation for some of the proposed effects of acupuncture. This is not surprising since the course director, Dr. Robinson, is an osteopath as well as a veterinarian.

There certainly is some research evidence to support the concept of MRtP and the effect of needling as a treatment. But then there is also research evidence that appears to support acupuncture, and as we have seen when looking at it carefully and critically, it doesn’t necessarily mean what advocates claim it means. (1, 2) There is clearly controversy about the MTrP concept and the effects of therapies focused on myofascial release, and it is worth bearing this in mind rather than simply accepting the idea as true and using it to then justify some claims for acupuncture.

The most recent narrative review challenging this concept was published last year, and the authors make a quite definitive claim about it:

Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392-9.

We have critically examined the evidence for the existence of myofascial TrPs as putative pathological entities and for the vicious cycles that are said to maintain them. We find that both are inventions that have no scientific basis, whether from experimental approaches that interrogate the suspect tissue or empirical approaches that assess the outcome of treatments predicated on presumed pathology. Therefore, the theory of MPS caused by TrPs has been refuted.

Their claim rests on several grounds. The first is the problem with consistent identification of trigger points. Several studies involving experts who treat MTrP look at inter-observer reliability. These experts were asked to examine the same patients and give independent assessments of where trigger points were found. In these studies, the practitioners claimed to locate trigger points in different places and did not agree with each other to any significant extent unless they were first told what the underlying diagnosis was. This suggests that without knowing what is wrong with the patient in advance, even experts cannot reliably detect trigger points on physical exam and that they are inclined to base their subjective identification of such points primarily on what they expect to find when they already know the diagnosis, rather than on what they actually feel when doing a physical exam.

This is a pretty serious problem given that physical examination is supposed to be the main way trigger points are found. It is the same kind of problem that helped demonstrate that the Vertebral Subluxation touted by chiropractors as a major cause of illness was actually imaginary. If such inability to detect trigger points turns out to be a consistent finding, it would strongly suggest that such points don’t exist as objective entities which can be detected by physical examination, which would greatly undermine the idea that they exist at all or are a major source of clinical symptoms.

The authors also review other ways of identifying and characterizing trigger points, including biopsy findings, electromyography, and others, and they conclude that the evidence is mixed and unclear as to whether there is a single, common lesion that can be found on physical exam and associated with clinical disease.

This review also examines the evidence that needling to release trigger points is clinically effective. A number of systematic reviews and clinical trials have been done on this question, and the over conclusions are: the quality of the research evidence is mixed and often too low to be reliable; many other therapies are usually used along with trigger point needling, so it is difficult to determine which, if any, might be responsible for improvement; trigger points are identified in many very different patients with very different underlying diseases, so variation in how these patients do is high and complicates comparison of studies looking at needling for trigger point release.

Other critics of MTrP theory have made similar criticisms, including some physical medicine practitioners who have shifted from automatic acceptance of the concept to skepticism. I haven’t invested the time in examining the evidence as closely as I have looked at that concerning acupuncture, so I don’t have a strong opinion, but I do have some skepticism about the concept.

In particular, I am concerned by the inherent subjectivity in detection of trigger points and assessment of patient response to therapy. In demonstrating the location and treatment of trigger points, Dr. Robinson rests a lot of weight on interpretation of patient behaviors that could reasonably be interpreted differently. As not only a vet who has practiced for many years but someone with training in animal behavior, I know how easy it is to project our own expectations onto the behavior of other animals. If I expect to find pain in a certain spot and initially don’t, it is easy to press just a little harder until I get the reaction I expect, often without even realizing I am doing so. The lack of an objective, verifiable way of detecting trigger points and their resolution with needling is, then, a significant problem for this concept in veterinary medicine.

Given the lack of clarity on MTrP theory, it is not very helpful to use this concept as an explanation or guide for acupuncture. It simply shifts the ground from one muddy and poorly demonstrated set of ideas to another. There is no doubt, of course, that people often feel better when given various kinds of manual treatments. I suspect the same is true of many companion animals who have, after all, been intensively selected for generations to accept or even desire human contact. However, we must be cautious in projecting our expectations, beliefs, and theories onto our animal patients without robust objective evidence, since we run the risk of being fooled by the caregiver placebo effect and other phenomena that can leave us believing we have helped them when in reality we have not.

References–

Here are a few of the studies discussed in the Quintner review:

Inter-observer reliability in MTrP detection:
Hsieh CY, Hong CZ, Adams AH et al. Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Arch Phys Med Rehabil 2000;81: 258_64.

Lew PC, Lewis J, Story I. Inter-therapist reliability in locating latent myofascial trigger points using palpation. Man Ther 1997;2:87_90.

Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Arch Phys Med Rehabil 2008;89:1169_76.

Wolfe F, Simons DG, Fricton J et al. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol 1992;19:944_51.

Clinical effect of needling trigger points:
Annaswamy TM, De Luigi AJ, O’Neill BJ et al. Emerging concepts in the treatment of myofascial pain: a review of medications, modalities, and needle-based interventions.PM R 2011;3:940_61.

Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001;82:986_92.

Ho KY, Tan KH. Botulinum toxin A for myofascial trigger point injection: a qualitative systematic review. Eur J Pain 2007;11:519_27.

Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: a systematic review of the literature. Int J Osteopathic Med 2006;9: 120_36.

Tough EA, White AR, Cummings TM et al. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and metaanalysis of randomised controlled trials. Eur J Pain 2009; 13:3_10.

A recent blog post promoted by the American Holistic Veterinary Medical Association (AHVMA) asks the question, “Is Evidence-based Medicine at a Dead End?” Since scientific evidence often fails to support the beliefs and claims of alternative vets, and the AHVMA has demonstrated many times that it accepts only evidence that supports the approaches it promotes, it is no surprise that the article contains a variety of tired misconceptions about EBVM and unproven assumptions about CAM that lead to the inevitable conclusion the author wanted to arrive at.

The first step is to suggest that EBM has somehow diverged from the presumably pure state in which it originated under the impetus of the “founding father” of EBM, Dr. David Sackett:

Evidence-Based Medicine (EBM) as practiced today (and not as originally conceived by Sackett), emphasizes fact-based medicine.

I suspect Dr. Sackett would be surprised to hear that emphasizing facts over beliefs and opinions is somehow a departure from his vision for EBM. The very fact that this can be used as a criticism of EBM highlights the disdain CAM practitioners and the AHVMA have for those pesky facts, and their preference for belief and pure faith-based medicine.

Large numbers of responses are analyzed, so this is valid for populations as a whole. In veterinary medicine this is called herd medicine, and decisions are made that will best protect the whole herd.

This is intended to build up to the claim CAM practitioners often make that because scientific research involves studying groups the results aren’t applicable to individuals, who are all unique. This is a common fallacy I’ve covered before, and which involves both the Vegas Delusion and the Snowflake Fallacy.

The Vegas Delusion is the idea that because statistics apply to groups and the outcome of any even for an individual is not perfectly predictable, we can ignore statistics in making decisions. The name for this fallacy comes from the fact that gamblers often use it to justify their hopes of winning despite the odds being overwhelming that they will lose. It is true that some individuals win at games of chance, and sometimes they win big. But casinos are lucrative businesses and gambling is a problem that ruins lives because the statistics do predict what will happen to most people most of the time.

Similarly, in medicine the prognosis or response to treatment can’t be perfectly predicted for any individual patient. But the averages that affects groups are often a useful and realistic guide to what will probably happen, and ignoring these to make up treatments haphazardly for each individual patient is a dangerous and unreliable way to practice medicine.

The Snowflake Fallacy refers to the belief that because every individual is unique, we cannot use information about a group of patients to guide the treatment of any particular patient. While it is true that we are all unique in many ways, we are also very much alike in many ways. And often the differences that we notice immediately, in appearance or behavior, aren’t relevant to how we respond to medical treatment. The significance of such differences has to be demonstrated with good research, not simply assumed or made up.

There is also a lie inherent in the claim that CAM individualizes treatment more than conventional medicine because it doesn’t rely on controlled scientific research. CAM practitioners do use information about groups of patients to guide their treatment of each individual, they simply use the haphazard and uncontrolled personal observations of their patients and of other CAM practitioners instead of scientific research. A homeopath who chooses an “individualized” remedy from a repertory is doing so based on patterns of symptoms and responses to treatment observed in other patients by other doctors. This is applying group results to individuals, it is just doing so without any effort to control for bias, placebo effects, and other important sources of error.

The author then goes on to point out that it is often difficult to control for placebo effects when testing non-pharmacologic therapies, such as acupuncture. Because of this, she believes EBM automatically finds fault with research in such therapies and so denies their obvious benefits unfairly.

While it is true that it is challenging to control for placebo effects in such approaches, it often can be done. In the case of acupuncture, needling at locations not considered to be “real” acupuncture points, or not needling at all but simply convincing the patient you have, often has just as much a clinical effect as verum acupuncture (1, 2). This most likely means that the “real” acupuncture is only an elaborate placebo, but acupuncturists are unwilling to accept this conclusion, choosing instead to claim that the method of testing doesn’t work. They have no alternative to propose, and simply expect such therapies to be accepted as effective on the basis of clinical experience alone. This is clearly a self-serving approach and not an example of a fatal flaw in evidence-based medicine.

This vet then goes on to argue that because scientific research studies try to minimize variables and simplify circumstances to make results easier to evaluate, that science ignores complexity and can only be useful in evaluating and treating very simple problems with single causes. Again, there is some truth to the notion that one will almost never find a real-world situation as clear and simple as even the most complex research study, so there are things such studies can’t tell us about phenomena in the real world. But the issue isn’t whether scientific evidence is perfect, it is whether it is more reliable than the alternatives.

The alternative proposed to scientific research is simply trial-and-error experience with individual patients. The CAM alternative to clinical research is simply to try and identify patterns in anecdotal experiences and our own clinical practice and rely on those. This is what human beings did for all of history until the scientific method was developed. In was a spectacular failure in comparison to what we have achieved using science.

Haphazard uncontrolled observation never doubled average life expectancy, dramatically reduced infant and maternal mortality, eliminated entire diseases, or accomplished anything like the amazing improvements in health and well-being in thousands of years that we have achieved in a mere couple of centuries. People like this author are not suggesting a new alternative or improvement in understanding disease diagnosis and treatment. They are proposing we return to the folk medicine methods that served us so poorly for so long.

Constructive criticism and improvement to scientific methods, including evidence-based medicine, is essential, and no one challenges concepts or practices in science more vigorously than scientists. But identifying, exaggerating, and fabricating weaknesses in EBM and then proposing we return to the even more limited and unreliable methods of history is not in the best interests of patients, human or veterinary.

I ran across this article recently with a board-certified specialist in veterinary emergency medicine recommending so-called Traditional Chinese Veterinary Medicine (TCVM) for critically ill patients.

As I’ve discussed in detail, there is some very limited evidence for a few potentially useful effects from passing electricity through acupuncture needles. However, the bulk of TCVM practice, and all of the theories behind it, is pure folk mythology and pseudoscience. It is always amazing and disappointing to see someone with an advanced scientific education treating such beliefs systems, and the therapies associated with them, as if they were in any way equivalent to science-based medicine or legitimate to experiment with on our sickest patients without good research evidence to support the claims made for them.

Such individuals would never tolerate the same near complete absence of evidence for a conventional drug or therapy. They are willing to give untested chemicals (herbs) and needle patients based solely on individual clinical experience and the belief that these practices have been used historically with success (which is often untrue).

Ultimately, it comes down to believing that a therapy is helpful based on individual clinical experience not only in the absence of high-quality evidence but in the absence of any controlled evidence or even a plausible theory. The history of medicine is one long lesson in why uncontrolled clinical observation is a very, very poor second to scientific research in evaluating the efficacy of our therapies. From bloodletting to internal mammary artery ligation, from Lourdes water to antibiotics for cats with interstitial cystitis, every ineffective therapy ever tried has appeared to work sometimes based on trial-and-error use. Either every possible treatment works for some patients, or clinical observation is an unreliable way to validate our treatments. Personally, I think the case is much stronger for the latter conclusion than the former.

I also think it is more than a question of whether or not we have clinical trial evidence. Of course we lack that for many of our treatments. But even therapies based on sound basic physiology and pre-clinical in vitro and animal model testing fail most of the time when subjected to clinical studies. Isn’t even less likely that a therapy based on Tonifying Yang or Releasing Wind is going to be truly effective? The rationale matters, especially in the absence of good controlled evidence.

Of course, in challenging these beliefs, I am immediately subjected to accusations that I am “closed-minded.” An open mind means not judging automatically and without regard to evidence, but it doesn’t mean not judging. We all have to make judgments about the safety and efficacy of the therapies we use. There is nothing inherently better or fairer about a positive judgment. If someone chooses to believe TCVM or bloodletting, or any other unscientific approach works based on the weak evidence on uncontrolled personal observation, they are not being more fair or open-minded than a critic who asks for better evidence than this before accepting such therapies. They are simply applying a different, looser standard of evidence.

I don’t claim with certainty that these therapies do not work, only that their theoretical foundations are unscientific, which makes the prior probability of their working very low, and that there is no good reason to believe they work in the absence of good-quality evidence to raise this probability. This is not being closed-minded, merely applying the principles of science and evidence-based medicine, which it seems to me have proven their worth quite dramatically compared with history, tradition, and anecdotes.

While this vet is usually careful to recommend these treatments with conventional care or instead of it only if the owner declines conventional treatment, I still can’t help feel it is unethical for a specialist to promote and legitimize such pseudoscience. We are essentially experimenting on sick patients without acknowledging this and claiming to have effective treatments when they are both implausible and not properly tested. We are giving a special pass to something to avoid the usual scientific testing we require of all our other therapies only because someone has slapped the label “alternative” on it.
Here are some examples of the comments in the article that I find disturbing:

If you have a patient that is bleeding post-operatively (post-op spay) or an unstable hemoabdomen that needs to go to the operating room, you can try dry needling Tian-Ping.

One indication for acupuncture could be in a post-op soft palate resection in a brachycephalic dog. By injecting B-12 at An-Shen to help calm a patient instead of writing an order for Acepromazine PRN

there are six typical Traditional Chinese Veterinary Medicine (TCVM) patterns for heart failure….If an owner is unwilling to do MV and the pet has collapse of Yang Qi, points for shock can be used as well.

If you have a feline patient with megacolon, and the owner is unwilling ? or it is too risky ? to place a pet under anesthesia for a de-obstipation, then enemas, lactulose, intravenous fluids and acupuncture can be used. There are 2 typical patterns for the Eastern diagnosis of megacolon, it is either Qi deficiency, or Yin and Blood deficiency. The acupuncture points would be selected based on what pattern they were exhibiting.

We treat many primary IMHAs and when they respond quickly it is great, but often we have patients that do not respond to the typical immunosuppressives. The traditional Chinese medicine pattern would need to be identified since there are different patterns. Typically for an extravascular hemolysis case, the main issues tend to be spleen Qi deficiency/blood deficiency. So selecting acupuncture points that would tonify the Qi/Blood, support the spleen, and immunomodulating points such as (LI-4, LI-10, LI-14, ST-36, GV-14) would be best. If the patient has evidence of intravascular hemolysis, clearing the heat and damp would be important and thus direct your acupuncture approach. The use of herbal therapy is becoming more popular and for a non-responding, primary ITP case Gui Pi Tang may be helpful.

the cat that is having an acute asthma attack that is not responding to typical interventions such as oxygen, steroids, and bronchodilators. Knowing LI-20, Bi-tong and Lung-hui acupuncture points can come in very handy. There are really countless uses for dry needling, aqua and electrical acupuncture in the CCU and it will likely become a more routine treatment in the critical care veterinary setting.

I have written several times about the efforts of alternative vets to circumvent the systems intended to ensure quality and scientific legitimacy in continuing education for veterinarians. In brief, most states require vets to regularly take a certain number of hours of continuing education. The idea is that scientific and medical knowledge grows and changes over time. Since states give vets an exclusive monopoly on practicing veterinary medicine, they want to ensure the public is protected against veterinarians who have outdated or inaccurate knowledge and skills.

Such requirements are meaningless if there is no control over the kinds of education vets can use for this license requirement. If I can take a class in origami or a Renaissance poetry, that’s great fun but it doesn’t help ensure I am an up-to-date and competent vet. So most states require continuing education (or CE) courses be accredited to be used for licensure. Vets can still take any courses they want in any subject, they just can’t get credit for them for licensing purposes unless they are accredited.

The American Association of Veterinary State Boards (AAVSB) is the main organization recognized as accrediting CE courses, through its RACE group. Appropriately, RACE requires the content of CE courses have some minimal scientific evidence or compatibility with science.

[Courses must] build upon or refresh the participant in the standards for practice and the foundational, evidence-based material presented in accredited colleges or schools of veterinary medicine or accredited veterinary technician programs…CE programs that advocate unscientific modalities of diagnosis or therapy are not eligible for RACE approval…All scientific information referred to, reported or used in RACE Program Applications in support or justification of an animal-care recommendation must conform to the medically accepted and scientifically supported standards of experimental design, data collection and analysis.

This category includes all conventional medical and surgical sub-categories that are evidence based… Based on scientific principles, there must be an established “probability” of success that conforms to the medically accepted and scientifically supported standards of experimental design, data collection and analysis.

1. Content of a Category One: Scientific Program must be supported by:
2. Availability of beneficial evidence (peer reviewed journal) OR
3. Three peer reviewed studies OR

iii. Study review – Case control studies leading to the benefit of the patient OR

1. Evidence based studies OR
2. Proven usefulness /effectiveness OR
3. Evidence of rigorous scientific research OR

vii. FDA (animal approved) objective information/about the product (safety) plus one of the categories above.

RACE does approve some CE offerings involving alternative therapies, but many do not qualify for accreditation due to lack of compliance with RACE requirements for scientific validity. Organizations of alternative medicine providers have often responded to the denial of RACE approval not by producing better scientific support for the disputed content but by circumventing the approval process. The American Holistic Veterinary Medical Association (AHV MA) and other groups have advocated bypassing RACE and getting CE approval directly through the states. Smaller numbers of individuals are better able to influence the political process at the state level, so this has often been a successful strategy.

Also, since the AHVMA has now qualified for a seat in the AVMA House of Delegates, some states automatically accept their content as legitimate CE regardless of scientific validity or RACE approval. House of Delegate membership essentially only requires only a certain number of members who also belong to the AVMA, so it is not a mark of any kind of legitimacy to the mission of the organization. However, it is a useful component to an overall campaign to market alternative medicine, and in this case it facilitates bypassing the usual standards veterinary CE courses must meet.

The Academy of Veterinary Homeopathy (AVH) actually sued AAVSB over denial of RACE approval, unsuccessfully. (1,2)

But the CAVM community has gone even further, creating an alternative CE accreditation board specifically to approve alternative medicine content, RAIVE. As they state on their web site:

The CAVM community now relies on RAIVE to validate their educational meetings. We urge all state boards to do the same for CAVM courses. The opinion of the RACE committee is no longer valid.

Failing to approve every element of their CE offerings, regardless of scientific validity, apparently invalidates the entire CE approval process. The AHVM, RAIVE and other CAVM organizations are now attempting to get state veterinary medical boards to accept RAIVE accreditation as comparable to RACE approval. Washington state, for example, is currently accepting input on a proposal to do just this (The proposal)

The RAIVE web site argues there is no need to demonstrate scientific validity for CE offerings, only that CAVM should be taught by “experts” in that field. As I have pointed out before, that by definition requires that any judgment of CAVM be made by individuals who already believe in its safety and efficacy and have committed themselves to practicing and teaching specific modalities. This effectively eliminates any possibility for falsifying or even significantly challenging these methods, and makes the standard of validity not scientific evidence but expert opinion. It is the perfect closed shop.

The site further specifically states that scientific evidence is a secondary consideration and need only be developed if the methods they advocate are already accepted and taught:

RAIVE recognizes that evidence based medicine does not define the practice of veterinary medicine, but is a process of clinical decision-making, and veterinarians can also benefit from education in emerging subjects with little scientific support. In these cases, RAIVE approved CE must incorporate experts with advanced training or deep clinical experience in these subjects.

RAIVE recognizes that not all CAVM modalities meet the currently accepted standards of evidence. However, RAIVE also recognizes that in order for the evidence to be produced, CE in these modalities must be encouraged in order to develop and strengthen skills in practitioners of these modalities.

So we should teach people to use these methods first, and then maybe test them scientifically later? This effort to avoid the usual standards of evidence that conventional veterinary CE offerings are expected to meet, and to specifically reject scientific testing as the primary standard in favor of individual expertise, reflects the common view often manifest in the CAVM community that science is useful only for proving what one already “knows” from personal experience or for convincing others of the validity of such knowledge. The issue is not whether CAVM methods are or can be scientifically validated. Some practices might meet this standards, and others clearly do not. As I’ve said repeatedly, many aspects of CAVM can and should be investigated scientifically. But others, like Chinese Medicine and Reiki, cannot be because they are belief systems not scientific hypotheses. Others, like homeopathy, have already been evaluated and proven not to work. And CAVM proponents themselves often claim scientific evaluation is unnecessary or inappropriate for their methods. Is it really appropriate for a vet to maintain their license, their legal monopoly to practice veterinary medicine, by study things that are inherently unfalsifiable or incompatible with science or that have already been proven false?

The core issue is that the ethos of the CAVM community views scientific evidence as, at most, a nice extra to add on after one has already figured things out by trial and error and, at worst, completely irrelevant to the evaluation of the treatments we use on our patients. This is not just a disagreement about the evidence for specific practices, but an attempt to fundamentally alter the epistemological foundations of veterinary medicine.