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Making
sense of the science—
Acupuncture for treating HIV neuropathy
Acupuncture
therapy for HIV-related neuropathic pain was recently evaluated
in a large, randomized placebo-controlled clinical trial.
This study, which failed to support this use for acupuncture,
has been criticized for the choice of acupuncture methods
that it evaluated. Although the conclusions that can be drawn
from this study may be limited to the specific acupuncture
intervention, some of the methodological considerations for
which this study has been criticized can be generalized to
any acupuncture study.
Given
the lack of an effective therapy for HIV-related neuropathic
pain, and the reluctance of many infected individuals to add
to an already heavy pill burden, many who suffer from this
condition have sought alternative therapeutic approaches such
as acupuncture.
Although
acupuncture is apparently effective in treating chronic pain
from many causes, and anecdotal information supports the use
of acupuncture for treating HIV-related neuropathic pain,
scientific evidence for this has been lacking. Since neuropathy
affects as many as a third of all HIV-infected individuals,
such data would be expected to substantially impact the quality
of life of a great number of people.
This
interest led to a randomized, controlled clinical trial to
test whether acupuncture could reduce HIV-related neuropathic
pain. In this study, a standard acupuncture regimen was compared
against a "sham" acupuncture, which consisted of inserting
needles at points not expected to produce any effects. (In
pain research, the placebo effect can be quite substantial,
making it necessary to devise a sham treatment against which
the real treatment is compared). No difference was seen in
the average reduction in reported pain between the acupuncture
and sham groups.
How
can these results be interpreted? Clearly, the standardized
acupuncture treatment that was assessed in the study performed
no better than placebo, but whether this can be generalized
to other acupuncture treatments has been questioned on several
grounds. Three of the main ones are:
• Choice of acupuncture treatment. A number of
schools of acupuncture exist, each of which have a different
philosophical approach to treatment. Thus, reaching a consensus
on what the best acupuncture regimen to study is problematic.
It is quite possible that acupuncture systems other than the
one examined in the present study would be of benefit to HIV-infected
people with neuropathic pain.
• Standardizing the acupuncture. Those patients
that were randomly assigned to receive real (as opposed to
sham acupuncture) were given the same treatment. On this basis,
it has been argued that the present study did not address
the effectiveness of acupuncture as it is routinely practiced,
because in practice acupuncture is tailored to each individual.
However, without incorporating standardized regimens into
a study design, the study itself may not be replicable (that
is, it may not be possible to either verify or study the results
in further detail), and if the treatment proved effective,
it would not be possible to know how to apply the results
to routine practice.
Many
clinical trials of acupuncture incorporate a standardized
regimen, and in some cases have shown benefits for the procedure.
A literature review of randomized clinical trials of acupuncture
for the treatment of back pain was recently published by researchers
from the University of Exeter in England. Several studies
were clearly able to document significant benefits for back
pain using a standardized regimen. On the other hand, studies
that utilized individualized acupuncture did tend to show
stronger beneficial effects.
•
Quality of the sham. Some studies of acupuncture have
shown that needle points chosen for the "sham" treatment can
produce physiological effects. Since these physiological changes
might produce the same benefits as the real acupuncture, this
would tend to make acupuncture appear less effective. In the
present study, the "sham" patients did no better than those
who received a placebo consisting of an inactive pill, which
reduces the likelihood that the benefits of the real acupuncture
were masked in this way.
Controlled
clinical trials are performed to assess the relative effectiveness
of a treatment on average in a select group of people. Such
trials are not designed to provide information about how a
given individual is likely to respond to the treatment. The
gap between trial results and the specific needs of each patient
in routine care must be bridged by the expertise of the healthcare
provider with the individual on a case-by-case basis.
Acupuncture
is an example of a treatment option that magnifies this gap,
since it is intended to be an individualized treatment. As
such, although it can be studied in a clinical trial setting,
the interpretations of trial results may be more problematic
than trials of Western-style therapies.
These
issues notwithstanding, one can surely conclude that the acupuncture
intervention that was evaluated in the present trial was ineffective.
Other acupuncture treatments might well deserve further study,
but to date all that can be said is that the clinical evidence
is lacking to support the use of acupuncture in treating HIV-related
neuropathic pain.
The
study discussed above was conducted at multiple sites of the
Terry Biern Community Programs for Clinical Research on AIDS.
Findings were published in the Journal of the American Medical
Association (JAMA, Nov. 11, 1998, Vol. 280, page 1590). For
a different perspective of the acupuncture study discussed
above, and for more information on neuropathy, see the article
"Numb and number" in the Jan. 1999 issue of Poz.
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