Why have NICE included acupuncture in their guidelines for chronic pain?

Earlier this month the National Institute for Health and Care Excellence (NICE) released a draft of their new guideline on chronic pain and one of the treatment recommendations was acupuncture. Although acupuncture is commonly used to treat pain, recent research found that the evidence is conflicting and inconclusive. NICE usually takes a rigorous approach to developing guidelines, so how did they end up recommending a treatment that does not have good evidence of effectiveness? This is a complex issue that deserves further investigation.

Summary of conclusions:

1. The evidence in favour of acupuncture for chronic pain is weak and in many cases conflicting.

2. Traditional Chinese acupuncture is based on entirely false beliefs in qi, meridians and other pre-scientific concepts. It shouldn’t be included in any health guidelines.

3. NICE seem to have made a mistake in recommending acupuncture in their draft guidelines for chronic pain. Hopefully they will correct this mistake in the final guidelines.

What is acupuncture?

There are many different types of acupuncture, with all of them being based in some way on placing needles in various parts of the body. There are two main ideas that underpin acupuncture: (i) Traditional Chinese acupuncture based on qi (or chi) and meridians and (ii) Modern acupuncture based on a neurophysiological model (that acupuncture needles stimulate nerve endings and alter brain function). Qi and meridians are based on pre-scientific beliefs and should have no place in modern healthcare.

What do the NICE guidelines for chronic pain say about acupuncture?

The NICE guidelines state:

Consider a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:

  • is delivered in a community setting, and
  • is delivered by a band 7 (or lower) healthcare professional, and
  • is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries).

Besides the recommendation for acupuncture itself, it’s concerning that NICE refer to “a traditional Chinese or Western acupuncture system” (emphasis mine). As previously stated, traditional Chinese acupuncture is based on Qi and meridians. These are concepts that conflict with modern science and have never been shown to actually exist.

Looking in the more detailed Evidence review for acupuncture, things get even worse. In that section, NICE refer directly to the concept of Qi and talk about this as if it’s a real thing. Here is what they say:

“Therapists trained in traditional Chinese medicine operate under the assumption of optimising the flow of the vital energy “Qi” in the body.”

Now there is no such thing as “vital energy” but, for some reason that I’m struggling to understand, NICE appears not to know this. They also go on to say:

“protagonists of traditional Chinese medicine (TCM) choose distant points in their attempts to harmonise the perceived misbalance of body functions and emotions.”

This is complete nonsense, yet here is the organisation that is responsible for producing evidence-based health and social care guidance in the UK taking about it in their guideline for chronic pain.

I have written previously on this blog about other guidelines produced by NICE such as this post about acupuncture for low back pain. Their approach to developing guidelines is usually extremely rigorous. I have also personally worked with them on other topics and seen the same thorough approach there too. I am staggered, and I don’t use this word lightly, that an organisation that is usually so careful and thorough is referring to traditional Chinese acupuncture, Qi and related concepts in the evidence used to develop their guideline on chronic pain.

What does the actual evidence say?

Within NICE’s Evidence review for acupuncture they include a series of “Clinical evidence statements”. For acupuncture versus sham acupuncture they have a large number of these statements. In almost all cases the evidence is labelled as low or very low quality. Is evidence of such low quality sufficient to make a recommendation in favour of a treatment? I would argue that it is not. When you take into account that several of the papers used to prepare these evidence statements are based on traditional Chinese acupuncture, I would suggest that the argument in favour of acupuncture looks even more dubious.

I have looked more closely at some of the papers that NICE refer to in their Evidence review for acupuncture. I have focused on those papers that a) compare acupuncture to sham and b) have a reasonably large sample size. A detailed explanation of why I have done this is beyond the scope of this article but in short: a) comparison with sham is important to control for non-specific treatment effects such as placebo and b) studies with larger sample sizes are more likely to provide accurate results than those with smaller sample sizes. Overall the quality of papers is poor with numerous methodological flaws in most of them, ranging from problems with blinding to issues with the statistical analysis. Even where these poor quality papers found a benefit the improvement was actually pretty small and unlikely to be clinically significant. Importantly, several of the studies are also based on the use of traditional Chinese acupuncture. Here is an example quote from one of the papers:

“The most frequently diagnosed TCM syndromes were Liver Qi stagnation (44.4%), followed by Spleen and Kidney Yang deficiency (21%) and Yin deficiency (13.6%).”

None of these things is recognised or accepted as a medical diagnosis and they are based on an outdated and incorrect approach to carrying out such a diagnosis. Taking all of this into account, it is hard to understand why NICE think acupuncture is a viable treatment for chronic pain.

Why did NICE include acupuncture as a recommendation for chronic pain?

The evidence for acupuncture as a treatment for chronic pain is pretty thin on the ground and in a recent review has been described as conflicting and inconclusive. The traditional Chinese medicine approach to acupuncture is based on things that do not exist and makes no logical sense. Why then did NICE include it as a recommendation in their guidelines for chronic pain? I had given this significant thought and not come up with a good answer. I did wonder if they were just short of interventions to include as a treatment for chronic pain and had concluded that acupuncture is the best of a bad bunch. However, I think that on balance there are two better explanations:

  • As described in the post from Steve Novella on Science Based Medicine, NICE have failed to consider Science Based Medicine altogether. This is a serious failing for an organisation that has such an important role in creating guidelines for health and social care.
  • One of the members of the NICE committee is Jens Foell, a GP who makes use of acupuncture in his practice and has even authored papers supporting acupuncture. In the Declaration of Interests register for the committee members he declares “I have been a member of the council of BMAS, the British Medical Acupuncture Society and member of the editorial board of “Acupuncture in Medicine” in the 12 months preceding joining the advisory I stood down from these posts in the last weeks”. This is someone who is clearly a strong supporter of acupuncture and provides a potential explanation for the inclusion of acupuncture within the guideline. The DoI was handled by having him “Declare and withdraw from drafting recommendations on acupuncture.” However, it also states that “The committee member will remain in the room for presentation of the evidence and may be asked to respond to specific questions from the committee regarding this topic.” Is having a fellow member of the committee who could speak confidently and strongly in favour of acupuncture likely to influence the committee’s decision? Absolutely! My thanks to David Colquhoun for highlighting this issue.

The other important point raised in the Science Based Medicine post is the risk of legitimising acupuncture and the potential for acupuncturists to use this NICE recommendation to market acupuncture for other conditions. Quoting from the SBM article “By recommending acupuncture for pain, based upon very weak evidence of a clinically tiny effect in the face of a lack of a plausible mechanism, you are throwing patients to the wolves.”

To conclude, it is a serious concern that NICE has failed to apply any sort of science-based approach when selecting treatments to include in their guideline. This has resulted in them recommending a treatment based on Qi, meridians and other nonsensical concepts. Even putting the lack of plausible scientific basis to one side, the evidence supporting acupuncture as a treatment for chronic pain is very weak. I am not the only one to have these concerns. Besides the article by Steve Novella on SBM, Edzard Ernst has also written about this and reaches similar conclusions. I think that NICE have made a serious mistake here and hope that they correct this error when they produce the final version of the guideline.

Last updated 06/09/20

Osteopathic practice makes misleading claims about acupuncture helping the immune and respiratory systems

During the current COVID-19 pandemic there is understandably a big focus on the immune and respiratory systems. Unfortunately, some practitioners are exploiting this pandemic for their own benefit by making unsubstantiated claims about their treatments helping these systems. One such example is Lymm Osteopathic Practice, which claimed that acupuncture can benefit the immune and respiratory systems and that this may be helpful during the COVID-19 pandemic. There is simply no evidence to support these claims. The acupuncturist (Daniel Windridge) went on to claim that he uses this in his practice to treat Asthma, COPD and Lung Sarcoidosis. Daniel even claimed that “results can be immediate”. These can be serious conditions and an acupuncturist is not qualified to treat them. They should instead be treated by a doctor.

Acupuncture beliefs and (lack of) evidence

Acupuncturists believe that there are specific “acupuncture points” that influence particular organs or parts of the body. This isn’t supported by science or evidence. In this particular case, the promoted idea is that there are twelve “immune acupressure points” and that by applying pressure to these points there will be improvement in the immune and respiratory systems. According to the article, five of the acupressure points are located on the arms and seven on the legs. I do wonder, what on earth makes someone believe that they can influence the immune system by pressing on different parts of the arms and legs? There is simply no plausible biological mechanism by which this could possibly happen and no evidence to support these claims. These (and any other) special “acupuncture” points simply don’t exist. The ideas behind them are based on pre-scientific beliefs and should have no place in modern healthcare.

Tackling these misleading claims

I reported this to the Advertising Standards Authority (ASA) on 29th May via their COVID-19 specific complaint form. Unfortunately, this didn’t result in a change and the misleading claims remained on the Lymm Osteopathic Practice website. The acupuncturist also continued to promote this misleading information via his twitter account with regular tweets about the “immune acupressure points”. Given the seriousness of these claims I decided to make a further complaint to the ASA on 18th July using their normal complaint form. This time around the ASA took action and contacted Lymm Osteopathic Practice to inform them that they had broken advertising rules and to provide guidance on the changes needed. The page has now been removed from the Lymm Osteopathic Practice website, which is good news.

If you would like to know more about the original claims, here is a screenshot of the first part of the article. (I also have further screenshots of the rest of it):Lymm Osteopathic Practice - Acupuncture - Keeping our immune & respiratory system in good working order - part 1 - www.lymmosteopathicpractice.co.uk

Although these particular misleading claims have been removed from the Lymm Osteopathic Practice website, many more misleading claims remain. For instance, look at this post about the treatment of a baby: https://www.lymmosteopathicpractice.co.uk/case-study-the-baby-with-sinus-problems/ It is worrying that any parent would think that they should take a baby with the following symptoms to an osteopath: “skin a strange shade of pink, with a bluey purple tinge, he also was subdued, lethargic and very floppy”. Osteopaths in the UK are complementary and alternative therapists, not doctors. According to the article, “There are several techniques that Osteopaths can employ to unblock sinuses”. This is nonsense. There are no osteopathic techniques that have been shown to be effective for unblocking sinuses. In this particular case, things turned out okay. However, it’s likely that this was just down to good luck rather than the actions of the osteopath. The outcome could have been very much worse and the baby should have been treated by a doctor straight away. The osteopath is now using this story to try and persuade other parents to take their babies in for treatment. This is potentially dangerous as maybe the outcome won’t be so good next time around. There are no infant health conditions for which osteopathy has been shown to be effective and no good reason to take any baby to an osteopath.

Conclusions

Osteopaths are regulated healthcare professionals and should not be misleading members of the public with unsubstantiated treatment claims. This includes claims made about their own treatments as well as by other therapists who work at their practices. Unfortunately, that is exactly what has happened here. Misleading claims like this are by no means an isolated incident within the osteopathic profession. I have previously reported on osteopaths and chiropractors making misleading claims about their treatments “boosting the immune system”. I have also written about many other misleading claims from the osteopathic profession such as giving the impression that they are doctors (they aren’t) and the leading UK osteopathic education institution training osteopaths to treat respiratory conditions in children. Not all UK osteopaths make these sorts of misleading claims but it is a problem that is far more widespread than should be expected from a regulated healthcare profession.

Acupuncture treatments won’t help the immune and respiratory systems. Not only is there no evidence to support these claims but there is no plausible biological mechanism by which this could possibly happen. In fact, there is little evidence to support the use of acupuncture for any health condition. Even in pain, the evidence on acupuncture is conflicting and inconclusive. It’s also important to be aware that acupuncturists are not doctors and any serious health conditions ought to be treated by a doctor.

During the COVID-19 pandemic, it is natural for people to look for ways to protect themselves by undertaking treatments that they hope will prevent and / or treat COVID-19. Unfortunately, this has led to the promotion of a wide range of “treatments” that do not actually help at all. If you find an acupuncturist, osteopath or chiropractor who claims that they can help you prevent or treat COVID-19 or that their treatments can benefit the immune system then please steer well clear.

A significant number of UK chiropractors and osteopaths make misleading claims about their treatments “boosting the immune system”

In the current COVID-19 (coronavirus) global pandemic, it is natural for members of the public to look for treatments that may reduce their risk of catching it or help them recover. Unfortunately, there are a significant number of UK chiropractors and osteopaths who believe that they can “boost the immune system” through their treatments. This is not supported by science or evidence and there is no plausible mechanism through which these treatments could have any effect on the immune system. That hasn’t stopped far too many chiropractors and osteopaths from advertising their treatments to do just that. Whilst specific claims relating to COVID-19 are relatively few in number (although they do exist), the more general “boost the immune system” claims are much more common and present some very serious risks to the public.

Example Claims

Here is a selection of examples of misleading immune system related claims from chiropractors. None of these have any evidence to support them:

Here is a selection of examples of misleading immune system related claims from osteopaths. None of these have any evidence to support them:

  • Health in Motion Osteopaths – Claims that osteopathy can help with the immune system and that this will help with COVID-19.
  • Eltham Osteopathy Clinic – Also claims that osteopathy will help the immune system and that this could help with COVID-19.
  • Core Clapton – Claims that “osteopathic treatment helps promote blood and lymph supply to enhance your innate healing capacity”.
  • Essential Osteopathy – Offers “Osteopathic treatment of the common cold” and claims that osteopathy can help strengthen the immune system.
  • Fiona Passey Osteopaths – Claims that osteopathy can help to treat the common cold and strengthen the immune system.
  • Teddington Osteopaths – Claims that osteopathy can be good for the immune system and help fight infections.
  • The Osteoperformance Clinic – Claims that cranial osteopathy may help with “Poor immune system or vitality”

I would like to make it clear that not all UK chiropractors and osteopaths make these misleading claims. However, this is also not just a small number of rogue osteopaths and chiropractors. I have provided here a few examples but this is really just the tip of the iceberg and there are a significant number of other such claims.

What does the research tell us about the effect of these treatments on the immune system?

The World Federation of Chiropractic (WFC) conducted a rapid literature review of the benefits of spinal adjustment / manipulation (the primary treatment used by chiropractors and osteopaths) on immunity and the immune system. They concluded: No credible, scientific evidence that spinal adjustment / manipulation has any clinically relevant effect on the immune system was found.” They went on to say “At the time of writing, there exists no credible, scientific evidence that would permit claims of effectiveness for conferring or enhancing immunity through spinal adjustment / manipulation to be made in communications by chiropractors”. This is very clear and it is good to see the WFC conducting research to provide such clarity on the position. All of the adverts from chiropractors and osteopaths above (as well as many others) are in direct conflict with this.

The National Council for Osteopathic Research (NCOR) has also provided what they call a “Quick review” about whether osteopaths can contribute to the care and management of COVID-19. Their headline summary is accurate and states “There is no current research evidence to indicate that osteopathic manual therapy care can specifically help in the direct treatment of COVID-19 or other types of corona virus illness.” Note that there are significant issues with other aspects of this review both in terms of the methodology and claims relating to treatment of pneumonia but I’ll address these in a future blog post.

It’s very clear from all of the available research evidence that treatments from a chiropractor or osteopath do not provide any benefits for COVID-19 or the immune system in general.

How can this issue be tackled?

The regulators have already taken some action with regards to specific claims relating to COVID-19 (coronavirus). The General Osteopathic Council (GOsC) wrote to osteopaths about advertising claims in relation to COVID-19. The General Chiropractic Council (GCC) has also issued a statement to chiropractors about not making claims relating to COVID-19. It’s good to see regulators taking these steps in order to protect the public. However, given the number of misleading claims that remain, there is clearly a lot more to be done. In particular, the regulators need to tackle general claims about “boosting the immune system” not just those relating specifically to COVID-19. Given the serious risks presented to the public, it would be good to see regulators taking disciplinary action against chiropractors and osteopaths who continue to make these claims.

Conclusion

There is no plausible mechanism by which the treatments offered by chiropractors or osteopaths could have any effect on the immune system. There is also no evidence that these treatments provide any benefits. In spite of this, many UK chiropractors and osteopaths continue to advertise these treatments. The regulators (GCC and GOsC) have provided guidance to chiropractors and osteopaths about this in connection with COVID-19 but this now needs to be widened to cover ALL claims relating to the immune system. This also needs to be enforced more rigorously in order to protect the public from being misled and placed at risk of harm.

What conditions do chiropractors treat and what treatment approaches do they use?

It can be difficult to get a clear understanding of what conditions chiropractors treat and the treatment approaches they use. For instance, some chiropractors claim to use a “package of care” consisting of exercise, manual therapy (hands on treatments) and self-management approaches but is this the way that they actually treat in practice? This review provides a useful insight to actual chiropractic practice. Here are the key points that I picked up:

  • Yet again it was found that babies and children are being treated by chiropractors for a whole range of unsuitable reasons including infection, asthma, ENT, gastrointestinal and neurologic conditions: https://chiromt.biomedcentral.com/articles/10.1186/s12998-017-0165-8/tables/2. This is a serious concern as these are all conditions that should be treated by a doctor rather than a chiropractor. I have the same concerns about osteopaths treating babies and children as the picture seems similar there.
  • The results for adults were less concerning with most people going to chiropractors for back pain, neck pain or other similar issues. However, some patients did attend for wellness / maintenance (7.5%), headache (5.5%) and non-musculoskeletal problems (3.1%): https://chiromt.biomedcentral.com/articles/10.1186/s12998-017-0165-8/tables/3 None of these things should be treated by chiropractors.
  • Nearly four out of every five people who sought chiropractic care received spinal manipulation. This is a concern as spinal manipulation is not a particularly effective treatment and, being passive, does not encourage self-management. In the case of low back pain, for instance, in their 2016 guidelines NICE changed spinal manipulation to a secondary rather than primary treatment due to lack of evidence for spinal manipulation when used alone.
  • Nutritional supplements (30.9%) were prescribed by chiropractors more often than exercise (26%)! In the absence of a deficiency or specific NHS recommendation, there is no value in nutritional supplements. This very low use of exercise by chiropractors puts a rather large pin in their claims about providing a “package of care”. It’s quite clear, regardless of what they may claim, that most chiropractors continue to focus on hands-on manual therapy treatments in spite of a lack of evidence to support this approach.

Conclusions

The chiropractic profession claims to have moved forward and embraced evidence-based approaches such as providing a package of care including exercise and self-management. Whilst there may be a small number of individual chiropractors who do this, it’s clear that the profession as a whole remains very focused on hands-on spinal manipulation treatments in spite of their limited effectiveness.

The treatment of babies and children by chiropractors remains a very significant concern with chiropractors attempting to treat a range of serious medical conditions that should instead be handled by a doctor. The same situation applies to osteopaths who are, for instance, offered a 2-day training course in treating asthma and other respiratory conditions. It is high time that regulatory bodies stepped in to put a stop to this before serious harm is caused.

AECC University College newborn feeding clinic continues to make misleading claims about treatment of babies by chiropractors

Rulings - ASA - CAP - www.asa.org.uk AECC take 2I have previously written about how inappropriate it is to have chiropractors working in a newborn feeding clinic. In order to address this, I complained to the Advertising Standards Authority (ASA) about the misleading advertising claims made by the AECC University College Newborn Feeding Clinic. In response to my complaint, the ASA got the AECC University College to make changes to their claims. However, it was quite clear that the changes made were merely superficial and did nothing to address the underlying issues with chiropractors “treating” infant feeding problems. I therefore complained to the ASA a second time and again AECC University College was found in breach of advertising guidelines.

The AECC University College made some further changes to their advertising in response to this second complaint. However, in reality, it is virtually impossible for the AECC University College to amend the information about its clinic to align with the available evidence because the entire clinic is based on chiropractors treating babies. There is no evidence base that supports chiropractors treating babies for feeding problems or any other health condition. The only way that the AECC Newborn Feeding Clinic could become evidence based is by removing chiropractors entirely. The AECC aren’t going to do that because they are a chiropractic college. Therefore, the AECC will keep tweaking the wording of their advertising until the ASA no longer finds issues with it. Will the AECC still be misleading the public when this point is reached? Absolutely! The entire basis of the clinic relies on deceiving the public into taking their babies to see a chiropractor for help with feeding problems.

Advertising guidelines do not prevent chiropractors from treating babies but it is clear that clinics like this are misleading the public. It is time that the chiropractic regulator, the General Chiropractic Council (GCC), stepped in to protect the public from these unsuitable treatments by applying a minimum age limit for chiropractic treatment.