Stick It In Your Ear! How Not To Do Science Ear acupuncture claims to relieve sore throats. A new study seeming to support that idea is so poorly done that it provides a textbook example of how to distinguish between good and bad science.

HARRIET HALL

ave a sore throat? No worries! No need for lozenges, doesn’t matter whether you use needles at all. In one study, simply touching the medicines, or home remedies. All you need to do is skin surface with a toothpick worked Hlet someone stick needles in your ear! According to just as well as penetrating the skin with a needle (Cherkin et al. 2009). There a recent study, ear acupuncture relieves sore throats. Do was even a study where subjects were you believe that? I don’t. That’s one of those extraordi- given a “phantom limb” illusion that a nary claims that would require extraordinary evidence, but rubber hand was their own hand, and they got similar results from acupunc- the researchers didn’t even provide ordinary evidence. The turing the rubber hand! (Chae et al. study is a great example of how not to do science. 2015). The main thing that seems to matter is whether the patients believe Acupuncture theory is based on a acupuncture will work. If they get a prescientific vitalistic concept: an un- sham procedure but think they got the measurable, undetectable energy called real thing, they will think it worked. If “qi” supposedly flows through meridi- they get the real thing but think they ans and can be accessed at acupoints, got a sham procedure, they will think where needle stimulation is supposed to it didn’t work. It has been pretty well somehow unblock the flow of qi, which established that acupuncture is nothing is somehow supposed to relieve pain more than a theatrical placebo (Col- and improve health. Qi, meridians, quhoun and Novella 2013). and acupoints are imaginary, but that The Center for Inquiry issued a po- doesn’t necessarily mean acupuncture sition paper on acupuncture that con- can’t possibly work. It’s not implausi- cludes: ble that sticking needles into the skin It is becoming increasingly clear might have some physiologic effects, that the placebo effect accounts for so it is reasonable to do scientific stud- much of the optimistic research on ies—and thousands of studies have acupuncture published between the been done, some better than others. 1970s and 1990s. With the devel- The results have been disappointing. opment of sham needles during the past decade—needles which retract It is not reasonable to conclude from like stage knives—researchers have the existing published studies that acu- tion and the surrounding rituals, and since been able to more accurately puncture works. the effects are too small in magnitude assess the therapeutic effects of Some people believe acupuncture to have any clinical importance. The acupuncture. The result has been is an effective way to relieve pain, but most rigorous studies have shown that a complete unraveling of nearly all acupuncture claims. . . . The bulk the evidence from scientific studies and sham acupuncture works just as well as of recent research strongly tends systematic reviews is mixed. Any posi- “real” acupuncture. It doesn’t matter towards the hypothesis that acu- tive effects can be attributed to sugges- where you put the needles, and in fact it puncture’s positive effects are mainly

Skeptical Inquirer | May/June 2016 51 due to a built-in expectation. . . . anatomy. They transposed human dia- five short needles that are left in place (Slack 2010) grams onto animals without any testing to eventually fall out on their own; the When The Medical Letter reviewed for validity; the acupuncture diagram method is taught to non-acupuncturists acupuncture in 2006, it concluded for horses, for example, shows gallblad- in a four-hour workshop. The authors “Acupuncture alone has not been shown der meridians. Horses don’t have gall- claim that there is research supporting bladders. ear acupuncture, but they admit that in rigorous, duplicated studies to bene- There are many different systems of there is only “limited data” regarding fit any defined medical condition.” Our acupuncture, some involving needles the modified technique. You’d think own CSI fellow, Steven Novella, coau- and some involving various kinds of that before they forged ahead to use it thored the paper that concluded acu- stimulation of acupoints through in- on wounded soldiers on the battlefield, puncture was nothing more than a the- tact skin (with electricity, light, heat, they’d want convincing evidence that it atrical placebo (Colquhoun and Novella and other modalities). The number of worked. There isn’t any. 2013). Medical ethicists unanimously meridians and acupoints varies among Ear acupuncture isn’t as silly as tong agree that doctors should not prescribe the different systems. In traditional ren, but it’s still pretty silly. It was in- placebos. So why are some doctors still acupuncture, there were originally 365 vented by a Frenchman, Dr. Paul No- recommending acupuncture? acupoints to symbolically correspond to gier, in 1957. He invented it all by him- the days of the year; now there are over self—not through science but through 2,000. In Korean acupuncture, there are intuition and epiphany. He looked at 300 acupoints, all on the hand. In other the external ear, the pinna, and imag- systems, they are found only on the ear, ined that it looked sort of like a fetus scalp, tongue, or foot. With all those curled up in its mother’s womb. I can different acupoints in all those different tell you he had a much better imagina- systems, is there any spot on the body tion than I do; I can’t see the resem- The Air Force doctors that isn’t an acupoint in some system? blance. He arbitrarily assigned a spot on clearly have drunk the Yes, there is: no system uses points the ear to correspond to the part of the on the male genitalia. Draw your own imagined fetus, tried inserting needles Kool-Aid, because they conclusions! A variant called “tong ren” in ears, and confirmation bias kicked allege that points on the doesn’t use acupoints at all; the patient in to convince him that it worked on rhythmically taps an acupuncture doll the corresponding part of the body. He ear correspond to areas with a metal hammer. The online video originally used thirty points; now ear on the body and stimu- of tong ren (https://www.youtube. acupuncturists claim to have identified com/watch?v=_I4r3FrzFBc) has to be 120. The ear is pretty small to accom- lating them “balances seen to be believed: Is there no limit to modate 120 acupoints, and anyway human gullibility? As far as I know, no there are no connections between the the flow of the body’s one has ever thought to try testing one ear and those other parts of the body. energy or qi.” system of acupuncture against another The study, “Ear Acupuncture for to find out which one is superior. For Acute Sore Throat: A Randomized that matter, no one has ever thought Controlled Trial,” (Moss and Craw- to test homeopathy, chiropractic, acu- ford 2015) was published in the Journal puncture, and Reiki against each other. of the American Board of Family Medi- Alternative medicine simply doesn’t cine. The fact that the editors did not think that way. Anything goes. reject the study is both surprising and The sore throat study didn’t use tra- disappointing. ditional acupuncture. It used ear acu- Moss and Crawford studied fif- puncture—and not even standard ear ty-four patients who presented to an Air Unfortunately, there are many doc- acupuncture but a simplified version. Force family medicine clinic with pain tors who lack critical thinking skills and Why? Because the researchers were from sore throat. They were random- don’t really understand science or the Air Force doctors, and the Air Force ized into two groups: one got standard psychology of cognitive errors. They has been teaching ear acupuncture as treatment (ibuprofen, plus antibiotics don’t all read SKEPTICAL INQUIRER or “battlefield acupuncture” to its doctors when indicated); the other got standard the Science-Based Medicine blog. They under the guidance of Col. Richard treatment plus ear acupuncture. There should. Niemtzow. They clearly have drunk was no blinding and no sham acupunc- The history of acupuncture research the Kool-Aid, because they allege that ture control group. They didn’t even is revealing. There were never any con- points on the ear correspond to areas standardize the treatment: they placed trolled studies to verify the alleged loca- on the body and stimulating them “bal- “up to 10” needles. Unblinded research tion of meridians and acupoints or their ances the flow of the body’s energy or associates assessed the results by phone alleged connections to other parts of the qi.” Their modified procedure involves interview. Patients in the acupuncture

52 Volume 40 Issue 3 | Skeptical Inquirer group reported significantly less pain at and produce analgesia too, so sham boost their spirits? We can predict that fifteen minutes and twenty-four hours acupuncture wouldn’t be a placebo, it those would have “worked” too, maybe after the procedure, although at for- would actually be a treatment! If that equally well or better. That’s why prag- ty-eight hours there was no difference were true, it would mean that acu- matic studies such as this are useless. from the control group. Acupuncture puncture’s whole treatment rigmarole It’s an ill wind that blows nobody patients reported taking fewer ibupro- is unnecessary. There would be no rea- any good. This study is astonishingly fen pills. There was no difference be- son to specify acupoints: you might as poor science. It should not have been tween the groups in time missed from well just stick needles anywhere, and no done, and it should not have been work. training would be needed to administer published; it didn’t give us any useful What’s wrong with this study? Prac- the treatment. The authors didn’t even information about acupuncture. But it tically everything. It is a typical exam- think of comparing a usual treatment can serve as a bad example to help us ple of the “pragmatic trial” favored by learn to distinguish between good and ■ alternative medicine. Instead of asking bad science. whether acupuncture works better than References placebo to relieve pain, they gave ev- eryone standard treatment and added Chae, Y., I.S. Lee, W.M. Jung, et al. 2015. Psychophysical and neurophysiological acupuncture to one group. When you responses to acupuncture stimulation to incor- add anything to the usual treatment, porated rubber hand. Neuroscience Letters 691 you are practically guaranteed to get (March 30): 48–52. When you add anything Cherkin, Daniel C., Karen J. Sherman, Andrew positive results. Patients respond to L. Avins, et al. 2009. A randomized trial the extra attention and to suggestion. to the usual treatment, comparing acupuncture, simulated acupunc- They expect to feel better, so they do. ture, and usual care for chronic low back you are practically pain. JAMA Internal Medicine 169(9): 858– In this case, the needles were left in the 66. Available online at http://archinte.jama- ear as a continuing reminder that they guaranteed to get network.com/article.aspx?articleid=414934. had received special treatment. Pain is Colquhoun, David, and Steven P. Novella. 2013. subjective, and suggestion is powerful; Acupuncture is theatrical placebo. Anesthesia positive results. & Analgesia 116(6): 1360–63. Available that’s why we kiss our children’s minor online at http://journals.lww.com/anesthesia- injuries. Of course the acupuncture sub- analgesia/pages/articleviewer.aspx?year=2013 jects reported less pain; that’s exactly &issue=06000&article=00025&type=Full- text. what we could have predicted. Moss, David A., and Paul Crawford. 2015. Pragmatic studies test the real-world Ear acupuncture for acute sore throat: A practical performance of treatments. randomized controlled trial. Journal of the American Board of Family Medicine 28: 697– They have their place. A treatment that 705. Available online at http://www.jabfm. has been proven to work in a research org/content/28/6/697.full. setting with a select group of subjects Slack, Robert. 2010. Acupuncture: A science- group to an acupuncture group; both based assessment. Center for Inquiry, Inc. and carefully controlled methods might groups got the usual treatment. And (June). Available online at http://www. not work as well in a real-world setting why on Earth didn’t they blind the re- centerforinquiry.net/uploads/attachments/ Acupuncture_Final_Paper.pdf. with patients who might have other ill- search assistants who did the telephone nesses or be on other medications, or interviews? That would have been so where the providers might not be as simple to do, and it would have elim- Harriet Hall, MD, is rigorous in following treatment guide- inated any suspicion that they might a retired Air Force lines. Pragmatic studies can’t establish have subtly influenced the results in physician and flight whether a treatment works better than some way. surgeon who writes placebo, and they were never intended They got positive results, but they and educates about to be done on treatments that had not questionable med- already been proven to work. would have gotten positive results if ical claims. She is That’s why studies must have a they had added any other intervention an editor of the blog convincing control group. These re- to the usual treatment for sore throat. Science-Based Medicine, author of Women searchers could have used a sham acu- What if they’d offered massages, or Aren’t Supposed to Fly: Memoirs of a Fe- puncture control where they used re- training in meditation or relaxation male Flight Surgeon, and coauthor of the tractable needles or put the needles in exercises, or a warm scarf to wrap 2012 textbook Consumer Health: Guide the “wrong” spots, in the ear or in other around the neck, or therapeutic touch to Intelligent Decisions. She is an SI con- parts of the body. But they rejected to “balance their human energy fields,” tributing editor and a fellow and member the whole idea of a sham acupuncture or funny movies to take their mind off of the Executive Council of the Committee control. Their amazing rationale: sham the pain? Or even a gift certificate for for Skeptical Inquiry. acupuncture can stimulate “C” fibers a shopping spree at the local mall to

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