Another Popular Back Procedure found to be ineffective

The Mayo clinic has found that using medical cement to fix cracks in the brittle vertebrae of elderly people is no better than placebo. The reason that this article is of interest to me is that it fits in the category of things that make sense from a Western Medicine point of view, and so are enthusiastically performed even though there is no evidence for efficacy. Or as my blog post of 4.2.09 was titled, "Believing in Treatments that Don't Work." Given the rigorous standards for acupuncture research, the use of sham needles, sham placement or even (ridiculously) trying to control for the practitioner interaction, it is nice to see the Mayo clinic applying the same rigor to a "logical," popular, western medical procedure.
They go on to say at the end of article that the "miraculous" recoveries seen could be due to the anesthesia, placebo, or the fractures healed on their own. The anesthesia in this case was local anesthesia, so it is possible that the needling helped.
I am the first to admit that there are mysteries in the healing process and that placebo can play a large roll in any therapy, including acupuncture. But Western Medical procedures should be treated with the same level of skepticism as acupuncture is, if not more, since they are often more dangerous and almost always much more expensive. A quick search to determine how much the back cement treatment costs shows that it it runs $526-558 for the first level and then $236 for each level after that. That doesn't include the anesthesia or recovery room fees etc... In addition, particularly with the drama of surgical procedures the placebo effect has the potential to be quite powerful indeed.

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/08/06/MNN9194H2O.DTL

Cement for backs ineffective from San Francisco Chronicle,
Stephanie Nano, Associated Press
Thursday, August 6, 2009
A common treatment that uses medical cement to fix cracks in the spinal bones of elderly people worked no better than a sham treatment, the first rigorous studies of the popular procedure reveal.
Pain and disability were virtually the same up to six months later, whether patients had a real treatment or a fake one.
Tens of thousands of Americans each year are treated with bone cement, especially older women with osteoporosis, some of them stooped and unable to stand up straight. The treatment is so widely believed to work that the researchers had a hard time getting patients to take part when it was explained that half of them would not get the real thing...
"All of us who do the procedure have seen apparently miraculous cures," said Dr. David F. Kallmes, a radiologist at the Mayo Clinic who led one of the studies. But he said there were also "miraculous cures" among those who got the fake treatments.
Bone cement has long been approved for many medical uses, but this particular use had not been tested.
The findings, published in today's New England Journal of Medicine, mean patients and doctors need to review the options together, wrote Dr. James N. Weinstein of Dartmouth Medical School in an accompanying editorial. "When best evidence suggests a tossup between treatment options and no benefit, informed patient choice is essential," he said.
The researchers do not know why people felt better, but suggest it could be due to the anesthesia, the placebo effect or that the fractures healed on their own over time.

Britain's National Health Service Prioritizes Acupuncture for Back Pain

(I'm not sure how I missed this study which came out in May. This is great news for the practice of acupuncture and great news for patients in Britain. )

"NHS pins its hopes for treating back pain on acupuncture"

"Unprecedented approval for alternative therapies from health service watchdog"

"Tens of millions of pounds are being wasted by the NHS(National Health Service) on useless treatments for back pain, money that should be diverted to alternative therapies such as acupuncture and spinal manipulation, a health service watchdog says today.

From among 200 treatments and devices claimed to help a bad back, the National Institute for Clinical Excellence (Nice) has passed judgement on what works and what doesn't. X-rays, ultrasound and steroid injections are out and osteopathy, chiropractic and "needling" (i.e. acupuncture) are in, it says.

The new guidelines mark a watershed in the treatment of the condition and for Nice itself. It is the first time that the institute has issued a positive recommendation that the NHS provide, and pay for, alternative therapies.
But Nice says a careful review of the evidence shows that acupuncture and spinal manipulation work."

The article goes on to say that Back pain is among the most common reasons for visits to family doctors (after colds and flu.) The NHS spends 1.5 billion pounds (about 2 billion dollars) treating 2.5 million patients. The study found that most of the money was wasted. The new guidelines pertain to patients whose back pain has persisted more than 6 weeks. The new guidelines say that these patients should be offered three options: an exercise programme, a course of manual therapy including manipulation or a course of acupuncture. If one treatment option does not work, patients may be offered a second.

The panel that drew up the guidelines expects acupuncture to be the most popular option, with an estimated annual cost of over £24m in England and Wales.

"To pay for the new treatments, the panel estimates that ending the use of steroid and other injections into the back will save more than £33m, stopping MRI scans will save £12m, and a further £1m can be diverted from funds for X-rays. Evidence shows that ordering X-rays can make patients worse, by confirming their invalid status. The overall net cost to the NHS of implementing the guidelines is estimated at just £77,000."

"Professor Peter Littlejohns, the clinical and public health director at Nice, said: "Most people will be affected by low back pain at some stage in their lives. The NHS now has evidence-based guidance on how to treat the condition effectively."...""In this case, the evidence was robust enough to make a positive recommendation," he said."

Acupuncture and Stress, in Rats?

This is a study looking at biochemical markers of stress in rats using a very common acupuncture point Pericardium 6. (Pericardium 6 is the point often used for motion sickness or nausea in pregnancy.)
They gave the animals mild stressors for 8 weeks and compared acupuncture at Pericardium 6 to Triple Heater 5 (another common point on the other side of the arm.)
Their conclusion was
"The present results demonstrated that acupuncture was effective in restoring CMS-related biochemical and behavioral impairments such as anxiety and anhedonia and that acupuncture point was more effective than non-acupuncture point. These results suggest that acupuncture has a therapeutic effect on chronic stress-related diseases such as depression and anxiety.
The effects of acupuncture stimulation at PC6 (Neiguan) on chronic mild stress-induced biochemical and behavioral responses."
Neurosci Lett. 2009 May 7.
Division of Brain Disease, Center for Biomedical Science, National Institute of Health, Seoul, 122-701 Republic of Korea.

Kim H, Park HJ, Han SM, Hahm DH, Lee HJ, Kim KS, Shim I.

Doctor Groups Urge End to Corporate Ties to Research

An article in the JAMA (Journal of the American Medical Association) published yesterday, April 1, was widely reported on the radio and today in the NYTimes and other publications http://www.nytimes.com/2009/04/02/health/policy/02journal.html?_r=1&ref=health.
A group of physicians and physicians groups are advocating for the elimination of funding by pharmaceutical companies for medical research because of the flagrant conflicts of interest. The concern is that these restrictions "were essential if physician associations are to maintain their scientific integrity and the trust of their patients."

This trust is clearly eroding. I see more evidence of this every day in my practice.

More discussion at a previous blogpost http://ksparrowmd.blogspot.com/2009/04/corruption-between-drug-companies-and.html

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Believing in Treatments That Don't Work

That is the title of author David H. Newman MD's piece today in the NYTimes. http://well.blogs.nytimes.com/2009/04/02/the-ideology-of-health-care/ On a medical acupuncturist's blog readers might conclude that the title refers to ineffective alternative medical treatments or supplements. But no. Dr. Newman is referring to many of the sacred tenets of medical practice that have been debunked but are still followed blindly.

He does a good job in pointing some of the biggest ideological practices in medicine, though there are many more than this. Beta-blockers for heart attacks, cough remedies for adults or children, antibiotics for ear infections, bronchitis, sinusitis or sore throats (cost $2billion/year), back surgeries (cost $20 billion): none have not been shown to be useful in carefully conducted medical studies.

He asks these questions of the medical community, "Can we abide by the evidence when it tells us that antibiotics don’t clear ear infections or help strep throats? Can we stop asking for, and writing, these prescriptions? Can we stop performing, and asking for, knee and back surgeries? Can we handle what the evidence reveals? Are we ready for the truth?"

At least there are those in the medical community asking the question.
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