One of the overarching themes of this blog, if not the overarching theme, is to expose and combat the infiltration of quackery into medicine. What I’m referring to, of course, is the phenomenon that’s risen over the last 25 years or so in which various pseudoscientific alternative medicine therapies (but I repeat myself) have found increasing acceptance, thanks largely to a major lack of critical thinking skills among both patients and, worse, the physicians who have embraced modalities such as acupuncture, naturopathy, chiropractic, and the like. In fairness, it’s not just a lack of critical thinking skills, but rather a defect in the very concept of evidence-based medicine, which fetishizes clinical trial evidence über alles and ignores incredibly compelling evidence from the basic sciences that various prescientific modalities, such as much of traditional Chinese medicine, or quackery based in vitalism, such as homeopathy, cannot possibly work. In the case of homeopathy, for instance, many of the remedies are diluted far beyond the point where there is likely to be even a single molecule left.
Such treatments first wormed their way into medicine under the guise of “complementary and alternative medicine” (CAM), which was later renamed “integrative medicine,” mainly because its advocates didn’t like the subsidiary position relative to real medicine implied by the term “complementary.” Unfortunately, a whole cottage industry within medical academia has developed to study such incredibly implausible treatments, all with the idea of validating them, a phenomenon I like to refer to as quackademic medicine.
Given this background, you knew I’d be very unhappy to see this news story last night on NBC Nightly News, Overcoming Back Pain: New Doctor Recommendations:
Basically, the American College of Physicians has issued new guidelines for the treatment of low back pain, as announced yesterday in this press release:
The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published today in Annals of Internal Medicine that physicians and patients should treat acute or subacute low back pain with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation. If drug therapy is desired, physicians and patients should select nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.
For patients with chronic low back pain, ACP recommends that physicians and patients initially select non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.
Acupuncture? And the ACP started out so well. Yes, it is advisable to start out treating acute and subacute low back pain with nonpharmacological therapies. That’s nothing new. What is new—and unwelcome—is the ACP’s inclusion of acupuncture as one of its suggested first line “non-drug” therapies.
Now go back and watch the news report above, if you haven’t already. It’s only a minute and a half; so go ahead. Notice how it starts out with a yoga class, where, the correspondent Kristen Dhalgren intones, most of the people in the class are there to overcome “often crippling” back pain, and the caption says, “Back pain relief without drugs or surgery.” We meet a woman who used to get cortisone injections but is now doing well with yoga, after which the recommendations. Now, as I’ve said before, there’s nothing special about yoga or Tai Chi when it comes to back pain or anything else. Stripped of its underpinnings in Eastern mysticism, yoga is nothing more than a system of exercise that emphasizes mobility, and the same is true of Tai Chi.
The segment on acupuncture is even worse, though. It’s so credulous, so downright atrocious, that it might as well have been a commercial for the acupuncturist, Dr. Houman Danesh, a physical medicine and rehabilitation physician, as well as a pain specialist, at Mt. Sinai Medical Center, who is shown administering acupuncture to a patient and then later saying that there is a “lot of benefit to it” and that acupuncture is “based in science.” (No, it’s not. The evidence is overwhelming that acupuncture is nothing more than a theatrical placebo. It doesn’t work.) Not surprisingly, this patient is very happy and satisfied with acupuncture. He’s asked where he would be if not for alternative medicine and responds that he probably would have been considering surgery. His assessment? “Amazing!”
That’s what’s so infuriating about the ACP recommendations. Several of them are perfectly reasonable. Then there’s the quackery, and it’s all “integrated,” just as “integrative medicine” preaches.
I always like to go straight to the source when discussing guidelines like this. So I had to go immediately to the source, the actual guidlines themselves, published in the Annals of Internal Medicine. Interestingly, the way the recommendations are discussed in the actual guidelines is belied by the news reports. Take a look at the first two recommendations:
Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)
The main two recommendations are hard to argue with. For example, most patients with acute and subacute back pain do get better, regardless of treatment (or lack thereof). Almost anything that is done will appear to result in improvement. Of course, that’s the very same reason why pretty much any quackery used to treat acute back pain seems to “work.” The patient gets better because it is the natural history of the condition to get better, not because it is necessarily effective. That’s also the reason why it is difficult to do randomized clinical trials for acute low back pain, because the placebo group will get better. The question is whether whatever intervention is being used results in faster improvement, at least in most patients. Similarly, given the often intractable, long term nature of chronic back pain, it is certainly preferably to avoid drugs at first if possible.
The devil, of course, is always in the details. Look at the levels of evidence for each of the individual interventions. When examining levels of evidence, it is, of course, always a good idea to see exactly what sort of scale is being used to assess the evidence. In this case, here is the standard:
Diving into the details, I immediately noticed one thing. Although the strength of the overall recommendation for Recommendations 1 and 2 is “strong,” when you dive into the weeds you quickly will see that, in general, the quality of evidence for for individual interventions is disappointingly low. That doesn’t just include the acupuncture, but a lot of the other interventions for back pain as well. However, for acupuncture, you’d never get the feeling that the evidence for acupuncture and yoga is so poor. For example, notice how the only intervention for acute back pain with even moderate quality evidence is heat. Massage, acupuncture, and spinal manipulation all have low quality evidence for benefit. On the other hand, notice the almost ringing endorsement for nonsteroidal antiinflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs), comparatively speaking, where the recommendation states that the evidence is of moderate quality if pharmacological intervention is desired.
Looking at this, I had to wonder. For acute back pain, given that it will get better over time anyway, what’s wrong with using a short course of NSAIDs and/or SMRs to manage the acute pain while waiting for recovery? I understand why one would want to avoid opioids, if at all possible. I understand why, for chronic pain, one might wish to avoid drugs for as long as possible. After all, long term use of NSAIDs is not without potentially serious complications, but short term use is generally pretty safe.
I also couldn’t help but note the actual studies used to justify the recommendations. For example, this study showed that there was no difference between “true” acupuncture and sham acupuncture (which is what pretty much all well-designed acupuncture studies show). In other words, it showed that acupuncture is a placebo intervention. This study tested a sort of “scalp acupuncture” that I’ve never heard of before. Another study was from China, and, as has been discussed before, pretty much all acupuncture studies out of China are positive.
What about chronic low back pain? Take a look:
Low-quality evidence showed that acupuncture was associated with moderate improvement in pain relief immediately after treatment and up to 12 weeks later compared with sham acupuncture, but there was no improvement in function (125–130). Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment (125). Low-quality evidence showed a small improvement in pain relief and function compared with medications (NSAIDs, muscle relaxants, or analgesics) (125).
I laughed. At least, I laughed when I looked over the list of references. The authors actually included the GERAC study in its list, which basically showed that acupuncture does not work, given that sham acupuncture was indistinguishable from acupuncture. Another study was a “bait and switch” in that it studied “electroacupuncture,” which is in reality TENS. We’re talking thin gruel indeed.
Of course, I have no problem with massage or exercise for low back pain, be it acute or chronic. So I really don’t have a problem with recommending massage, Tai Chi, or yoga for back pain. I really don’t. What I do have a problem with is representing such interventions as somehow being “alternative” or “integrative.” Tai Chi and yoga are, at their hearts, little different than motor control exercise (MCS), which is a form of exercise that aims to restore coordinated and efficient use of the muscles that control and support the spine. Patients are initially guided by a therapist to practice normal use of the muscles during simple tasks. Then, as the patient’s skill increases the exercises are progressed to more complex and functional tasks involving the muscles of the trunk and limbs. There is low to moderate quality evidence, according to the Cochrane Collaborative, that MCS has a clinically important effect compared with a minimal intervention for chronic low back pain. There is, of course, no evidence that MCS is superior to other forms of exercise—pretty much a lot like Tai Chi and yoga.
Seeing Dr. Danesh in that NBC News report piqued my curiosity. I couldn’t help but look at Mt. Sinai’s integrative medicine offerings. Of course, there’s acupuncture. (Isn’t there always?) There’s yoga. And, of course, there’s “energy medicine,” which is the ultimate form of quackery. There’s even something that Mt. Sinai calls the Holistic Preparation for Surgery Program:
This program helps patients prepare for surgery using the following techniques:
- Centering and Grounding
- Guided Imagery
- Energy Healing (Therapeutic Touch, Reiki)
The program has been so successful in helping patients feel more comfortable and reduce medication use following surgery that Ms. Ortiz educated and trained nurses throughout surgical units at the hospital to teach patients breath control techniques and clinical imagery for pain management.
Argh! More “energy healing”!
That little detour aside, the ACP recommendations for back pain management are the epitome of what is “integrative medicine.” They integrate quackery with real medicine. Depressingly, when that happens, people don’t notice the part about how weak the evidence is for therapies like acupuncture. They only hear how great it is. The ACP really should have (and could have) done better. It’s just a measure of how far quackery has insinuated itself into medicine that the ACP chose not to do so.