Gut Check is a periodic look at health claims made by studies and by newsmakers. We ask: Should you believe this?
The Claim: Acupuncture and the Alexander Technique each reduce neck pain more than standard care alone.
The Backstory: You could insulate a small bungalow with the scientific papers on acupuncture and pain — about 60,000 since 1995, says Google Scholar. Rather than dipping into this pile, STAT turned to reviews of studies, and even reviews of reviews. For instance, one 2011 analysis of all 57 relevant reviews since 2000 found “little truly convincing evidence that acupuncture is effective in reducing pain.” (Acupuncture proponents disputed that.) But for neck pain, specfically, the systemic reviews were “unanimously positive.” That gave STAT hope for the latest such study, published last month in Annals of Internal Medicine.
First Take: For their experiment, researchers at England’s University of York randomly assigned 517 people with chronic neck pain (median duration: six months) to either 10 acupuncture sessions or 14 lessons in the Alexander Technique, which aims to fix poor posture, reduce muscle tension and stress, and improve coordination. In all cases, patients got acupuncture or Alexander on top of the usual care, which is basically pain meds and physical therapy. Based on patients’ answers to a standard questionnaire about neck pain and its effects (whether it causes trouble sleeping, sitting, driving, and the like), the researchers reported that both alternative therapies “led to significant reductions in neck pain and associated disability compared with usual care” after 12 months.
Second Take: STAT is sorry to say that this conclusion didn’t accurately describe the study. The researchers did not compare acupuncture or Alexander to usual care. They pitted those two alternative medicine practices plus standard care against standard care alone.
The way the paper states its conclusions is “factually wrong,” said Dr. Edzard Ernst of the University of Exeter, who did the 2011 analysis mentioned above. “They should read ‘acupuncture sessions plus usual care and Alexander Technique lessons plus usual care both led to significant reductions in neck pain’” compared with usual care alone. Acupuncture and Alexander were both add-ons.
This kind of study design fails to control for the extra attention, time, and empathy that the acupuncture and Alexander patients got compared to the poor souls assigned to standard care — which, remember, the acupuncture and Alexander groups got, too. As a result, Ernst argues, it “can make ineffective therapies appear to be effective.”
STAT’s astute readers likely notice something missing here: the study had no patients who received Alexander or acupuncture alone, rather than in addition to standard care. For a clean comparison, alternative treatments should be tested against placebo; that is, standard care + acupuncture vs. standard care + lots of non-acupuncture attention and sympathy from a caring provider. “When you add anything to usual treatment, you are almost guaranteed to get better results, especially when the addition is something impressive that involves a lot of one-on-one time” with a provider, Dr. Harriet Hall, a retired family physician-turned-crusader against quackery, told STAT.
The University of York’s Hugh MacPherson, who led the study, told STAT that “it would not be ethical to conduct a trial offering only acupuncture and no medication” for patients with severe, chronic neck pain.
Hall, who blogs for Science-Based Medicine as Skepdoc, suspects that the reported benefits of adding alternative therapies “were largely due to a combination of suggestion, exercise, relaxation” and other factors not specific to either acupuncture or Alexander. For instance, she said, “the extensive contact time may have triggered psychological factors like wanting to please the provider by reporting improvement.”
One more factor was in play: expectations. Patients’ hopes and beliefs, numerous studies have shown, are the basis for placebo effects. Buried deep in an appendix, the researchers reported on patients’ expectations. Of those getting usual care alone, 24 percent expected it to be fairly or very effective. Far more expected their therapy to work in the usual-care-plus-acupuncture group (45 percent) and in the usual-care-plus-Alexander group (39 percent). Those effects are more likely to explain the add-on benefits of alternative therapies than the supposed mechanisms of such therapies. MacPherson allowed that placebo effects could have occurred, though he thinks “better coping strategies” learned from acupuncture or Alexander probably played a bigger role.
The Takeaway: STAT cannot say it better than the Bard. Quoth Hamlet, “thinking will make it so.”