Acupuncture: Small risks versus no benefit

Since I’ve been on a bit of a roll with respect to acupuncture over the last week or so, I thought I’d just round out the trilogy with one more post. One myth that acupuncture apologists like to promote relentlessly is that acupuncture is completely harmless, that it almost never causes complications or problems. While it’s true that acupuncture is relatively safe, it still involves sticking needles into the skin, and, given that, it would be delusional to think that there couldn’t be injury caused by that. Rarely, however, have I seen a story like this from Canada reported in the National Post, Canadian Olympian’s ‘nightmare’ after acupuncture needle collapses her lung. It is the story of what happened to Kim Ribble-Orr, a world-class judoka who had competed in the Olympics in 2000 and harboring dreams of competing in the Olympics again, as a mixed martial artist. Those dreams were cast in doubt by a stray acupuncture needle:

When a massage therapist tried to treat the headaches she suffered after a 2006 car crash with acupuncture, however, he set off a cascade of health problems that would shatter Ms. Ribble-Orr’s sports-centred life — and raise questions about the popular needle therapy.

The therapist accidentally pierced Ms. Ribble-Orr’s left lung during acupuncture treatment that was later deemed unnecessary and ill-advised, causing the organ to collapse and leaving it permanently damaged. An Ontario court has just upheld the one-year disciplinary suspension imposed on therapist Scott Spurrell, rejecting his appeal in a case that highlights a rare but well-documented side effect of acupuncture.

Mr. Spurrell, who learned the ancient Chinese art on weekends at a local university, had no reason to stick the needle in his patient’s chest, and had wrongly advised Ms. Ribble-Orr that the chest pain and other symptoms she reported later were likely just from a muscle spasm, a discipline tribunal ruled.

Ribble-Orr had suffered many injuries due to her competition, including a dislocated elbow and shoulder, a broken hand, head injuries and repeated knee injuries. She had overcome them all to compete again, but appears unable to overcome this one. Basically, what happened is that in 2006, Ribble-Or was trying to get into mixed martial arts competition and was eying a job as a police officer. However, she was also recovering from injuries suffered in an auto collision and seeing Scott Spurrell, a massage therapist who had learned acupuncture during a weekend course at a local university. She was suffering from pounding headaches, and Spurrell convinced her that he could relieve those headaches by inserting a two inch needle, according to the disciplinary ruling, “into a muscle located between the clavicle bone and ribs.” From the description, it’s not clear to me exactly which muscle they meant, although it could conceivably have been the scalenes, the sternocleidomastoid, or perhaps even just the pectoralis major. Whatever muscle Spurrell was targeting, going between the clavicle and the ribs is basically where surgeons stick the needle when trying to place central venous catheter into the subclavian vein, and, yes, a pneumothorax is a known potential complication of placing such lines. What also puzzles me is how on earth Spurrell could have stuck the needle in deep enough to cause a pneumothorax? It would be one thing if Ribble-Orr were a fragile little old lady, but she wasn’t. She was an athlete, presumably with well-developed musculature. It would take a lot to get a needle through all of that muscle to get to the pleural cavity.

As can happen from a pneumothorax, even in a healthy person, Kibble-Orr developed pneumonia and required a thoracotomy. To be honest, it’s not clear from the account provided why she needed a thoracotomy, but it’s clear that the pneumothorax led to a cascade of complications, as described:

Shortly after leaving the clinic, Ms. Ribble-Orr began having difficulty breathing, chest pain and a “grinding” sensation. She returned to the therapist later, wondering if she had suffered a pneumothorax. He told her it was more likely a muscle spasm, but said she could go to the hospital if she felt it was more serious or if the symptoms worsened.

The next morning, she did feel worse and finally headed to the emergency department. Ms. Ribble-Orr’s lung had indeed collapsed and she spent the next two weeks in hospital, as a serious lung infection and then a blood infection followed. She was left with just 55% function in one lung.

One notes that if you do not have the knowledge to recognize symptoms and signs of potential complications resulting from your treatment, you have no business administering that treatment. It used to be that if you didn’t know how both to recognize and treat potential complications of your treatment, you shouldn’t be administering that treatment, but those days are gone. For instance, gastroenterologists do colonoscopies, even though they are not able to repair the inevitable (and thankfully uncommon) colon perforations that are a recognized risk of the procedure. But they can recognize the signs and symptoms. They know how to diagnose a potential perforation and when to call a surgeon to fix it. Spurrell was clearly utterly clueless, basically dodging responsibility by telling Kibble-Orr that she could go to the ER if she wanted to. Obviously, he didn’t think that she needed to. What should have happened, if Spurrell knew what he was doing, was a quick physical exam, which likely would have diagnosed a significant pneumothorax, through decreased breath sounds or and elevated diaphragm on the affected side, or both.

While the ruling against Spurrell is heartening, what is rather depressing is how Canadian authorities came around to it. Acupuncture is a licensed specialty. So authorities had to “prove” that Spurrell had no valid reason to insert a needle there (“valid” being defined within the system of traditional Chinese medicine undergirding acupuncture). In other words, they had to show that there was no reason under TCM to think that a needle stuck in that particular location would treat Kibble-Orr’s recurrent headaches. Moreover, it wasn’t the College of Acupuncturists who had jurisdiction, but rather the College of Massage Therapists, that had jurisdiction, and the College only requires a certain number of hours of extra training to be able to administer acupuncture, a requirement that Spurrell had met. Of course, we at SBM would argue that there’s no science-based reason at all to think that sticking a needle in a point between the clavicle and the ribs would have any effect whatsoever on recurrent chronic headaches, and that should be enough. That’s the problem with regulating quackery; to prove misconduct or malpractice, you have to do it within the system of magical thinking of the quackery that has been licensed. If, for instance, Spurrell had been able to show that there was a valid rationale under TCM for inserting the needle there, he still might have been nailed for incompetence because he stuck the needle in too deep, but quite possibly he might not have been.

Particularly depressing are the comments. For instance, one commenter named Dr. Joanny argues:

Only a bonafide doctor of Chinese medicine or acupuncture is qualified to practice Chinese medicine. The problem is not acupuncture but who is inserting the needles into your body. Only someone who has trained and studied for several years, who has passed board/state/provincial exams, is qualified to practice. All reports of puncturing lungs involve people who are people who took a little bit of training.

Yes, this acupuncturist is seriously arguing that “well-trained” TCM practitioners wouldn’t have had this complication and then goes on to cite a paper from a very acupuncture-friendly source that shows a surprising number of serious complications from acupuncture, including cardiac tamponnade, infection, various reports of needles breaking off and migrating elsewhere in the body (shades of the President of South Korea!), and even neurological injury. One remembers a recent review of the Chinese literature by Edzard Ernst describing complications of acupuncture, including pneumothorax (201 cases), spinal epidural hematoma (9 cases), subarachnoid hemorrhage (35 cases), right ventricular puncture (2 cases), intestinal perforation (5 cases), and a whole lot of other complications and infections. Indeed, Ernst found that pneumothorax was by far the most common significant complication of acupuncture, and, as we’ve discussed, acupuncture is not harmless. There are quite a few potential complications up to and including 90 deaths in the world literature.

All medicine is a risk-benefit analysis. All effective treatments have risks, and those risks have to be weighed against the potential benefits. When the benefits are significant (e.g., saving life), then greater risks are tolerable. When the potential benefits are minimal, then even minor risks might not be acceptable. When the potential benefits are none, no risk is acceptable. That is the case for acupuncture. It does not work, no matter how much acupuncturists try to prove it does.