Sunday, 18 November 2018

Battlefield acupuncture to treat low back pain in the ED; witchcraft in action


Acupuncture has been around for thousands of years… so it must be good.

We all dread treating the patient with low back pain. We don’t have a magic bullet that will provide a fix. It’s frustrating for the patient and provider.

As such, maybe we should engage in witchcraft! Perhaps something that “has been around for thousands of years.”

This was a “feasibility study” enrolling 30 patients with low back pain in New York City. They were randomised to either standard care alone vs. standard care plus “battlefield acupuncture.” Evidently, this is ear acupuncture that has been used by the US military… so, it must be good.

Primary outcome was the 10 point numerical rating scale (NRS) and the “get-up-and-go” test (GUGT). The GUGT is how much time it takes a patient to get out of a chair, walk three meters, turn around and sit back down again.

Results?

Abracadabra! The post-intervention NRS in the acupuncture group was better at 5.2 vs. 6.9 (p=0.04). The GUGT showed no difference.

But wait a minute…

This study was listed at www.clinicaltrials.gov. This is where original study protocols are published. All too often researchers change the goal posts mid-study or suppress negative results. (My all-time favourite example was gabapentin for off-label use.)

A search of registration number NCT02399969 shows the GUGT as the sole primary outcome. The NRS was a secondary outcome. Research misconduct anyone? One would hope the peer review process would pick up on this… it’s not hard! At the very least, the manuscript should mention why they changed their primary outcome to give them favourable results.

But there’s even more than an allegation of research misconduct.
  • Acupuncture was not blinded. Not even a sham acupuncture arm. This introduces bias that favoured acupuncture.
  • Placebo works; in particular for pain and nausea. Acupuncture is theatrical placebo at it’s best. All the results in the NRS can easily be explained by placebo effect. The GUGT is a more objective measure and the trend favoured standard care alone.
  • A quarter of patients approached for enrolment declined to participate. Did they screen out the patients who were acupuncture non-believers?
  • There’s more… but for brevity, I’ll stop now…

What are we to conclude?

Please stop the nonsense.

Acupuncture has been around for a long time. Currently we have no consistent good quality evidence to demonstrate efficacy beyond placebo effect.

No more study is needed.  


Covering:

Fox LF, Murakami M, Danesh H, et al. Battlefield acupuncture to treat low back pain in the emergency department. Am J Emerg Med. 2018;36:1045-1048. [link]
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