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According to the National Institute of Health more than 10 million adults in the U.S. have used acupuncture at some time in the past or are using it currently.
There's never been an acupuncture study in China with a negative result. What are the odds? About the same as a fair coin flip coming up tails 99 times in a row or a fair investor always beating the market.
Acupuncture is a medical technique usually involving the shallow insertion of needles through the skin at particular points on the body (called acupoints). There are many different kinds of acupuncture, involving different kinds of needles, different insertion points, different techniques, and the use of various accompaniments such as electricity or moxibustion. Some acupuncturists use low energy laser beams; others use magnetic BBs on patches applied to acupoints. There are other variations as well, such as microacupuncture, which uses forty-eight non-traditional acupoints located on the hands and feet, and auriculotherapy or ear acupuncture, which postulates that the ear is a map of the bodily organs. Similar notions about a part of the body being an organ map are held by those who practice iridology (the iris is the map of the body) and reflexology (the foot is the map of the body) and traditional Chinese medicine (the tongue is the map of the body). Staplepuncture, a variation of auriculotherapy, puts staples at key points on the ear hoping to do such things as help people stop smoking. Acupressure applies pressure, rather than needles, to acupoints.
Acupuncture is thought to have originated in China, but its origins and early use are controversial (Basser 1999). Today, acupuncture, in one form or another, is practiced in dozens of countries by thousands of acupuncturists on millions of people and their animals.
People go to acupuncturists for treatment of AIDS, allergies, arthritis, asthma, Bell's palsy, bladder and kidney problems, breast enlargement, bronchitis, colds, constipation, cosmetics, depression, diarrhea, dizziness, drug addiction (cocaine, heroin), epilepsy, fatigue, fertility problems, fibromyalgia, flu, gynecologic disorders, headaches, high blood pressure, hot flushes, irritable bowel syndrome, migraines, nausea, nocturnal enuresis (bed wetting), pain, paralysis, post traumatic stress disorder, PMS, sciatica, sexual dysfunction, sinus problems, smoking, stress, stroke, tendonitis, vision problems, and just about anything else that might ail a human being.
While the origins and early development of acupuncture remain murky, it is clear that today many people around the world believe acupuncture is an effective medical treatment for a vast variety of disorders. This belief is not based simply on the fact that acupuncture is perhaps thousands of years old. Most people recognize that many medical treatments have been considered effective for many years before being discarded as our knowledge expanded. Most people also recognize that some medical therapies have been discarded not because they were found to be totally ineffective, but because other kinds of treatments were found to be more effective or to have fewer side-effects.
The belief in acupuncture's effectiveness is based on experience and scientific experiments. Millions of people have experienced the beneficial effects of acupuncture and thousands of scientific studies have concluded that acupuncture is effective for such things as the relief of pain, increasing fertility, treating rheumatoid arthritis, and relieving nausea after chemotherapy. Skeptics challenge these studies, but with so much evidence piled up in favor of the effectiveness of acupuncture, one wonders why there are still many people who are skeptical of the practice. If the evidence from millions of personal testimonies and from thousands of scientific studies doesn't convince the skeptics, what will?
It may seem obvious to acupuncturists and to millions of their patients that the skeptics are mad, daft, or just being obstinate. To them, it is obvious that acupuncture works and anyone who denies this must have some sort of mental defect. Is it possible that millions of people could be wrong? Well, yes, it is possible for millions of people to be wrong, but I must state up front that those skeptics who say that acupuncture doesn't work, or that it is not an effective medical treatment for some ailments, are wrong. The evidence from both personal testimony and from scientific studies clearly shows that acupuncture works and is an effective medical treatment for many ailments. The evidence from the scientific studies also shows clearly that sham acupuncture is just as effective as true acupuncture. What is not so clear to some people, but is easily ferreted out from the evidence, is that acupuncture most likely works by classical conditioning and other factors that are often lumped together and referred to as "the placebo effect." Furthermore, in some cases sham acupuncture works better than other placebos. This does not mean that acupuncture is "all in the head," however.
A common misunderstanding regarding placebos is that a placebo must be an inert substance that tricks the patient into thinking he's been given an active substance. This misunderstanding leads to the belief that the placebo effect is "all in the head." That is no more true than that people's physiological responses to what they think is alcohol or a drug are purely psychological. People can be conditioned to have physiological responses to placebos. Furthermore, Martina Amanzio et al. (2001) demonstrated that "at least part of the physiological basis for the placebo effect is opioid in nature" (Bausell 2007: 160). That is, we can be conditioned to release such chemical substances as endorphins, catecholamines, cortisol, and adrenaline. One reason, therefore, that people report pain relief from both acupuncture and sham acupuncture may be that both stimulate the opioid system. So can a lot of other things of course, like running a marathon, having an orgasm, eating habanero chiles, or getting a saline injection that you think is morphine.
Medical anecdotes regarding the effectiveness of a treatment fall into several categories. This is true whether we are talking about alternative medicine (such as acupuncture, homeopathy, or chiropractic) or whether we are talking about science-based conventional medicine. Some of the stories are unquestionably true and probably justify the conclusion that the treatment was effective. For example, the pain in your wrist is so severe that you can't grip the brake on your bicycle. You go to your acupuncturist, your chiropractor, your aromatherapist, or your physician for treatment. You leave the medical office feeling great and ride your bike home with no problem gripping and squeezing the brake lever. I hope it will become clear below why a thoughtful healer should wonder when such a patient leaves the office whether the success was due to the needles unblocking chi, the touching and massaging, the comforting and hopeful words, the injection, the spontaneous or natural resolution of the problem, or one of a host of other factors that might actually be the most significant causal agent in that particular healing process.
Some stories are unquestionably true, but they probably do not justify the conclusion that the treatment was effective. For example, we know that many people seek relief for their pain from a physician, chiropractor, or acupuncturist only when the pain becomes severe. We also know that many types of pain follow cycles: periods of relative freedom from pain are followed by periods of gradual increase in severity; and periods of severe pain are followed by gradual reduction in pain. The natural regression of pain and other disorders often leads both medical practitioners and patients to erroneously conclude that the treatment was effective when in fact the patient would have improved even if he or she hadn't sought any treatment. In short, most pains and illnesses go away on their own, but some of them go away shortly after seeking treatment and this leads us to think erroneously that there is a causal connection between the treatment and the relief. We know for a fact, for example, that many patients who are given antibiotics by their physicians erroneously attribute their recovery from a viral infection to the medicine. The patients really feel relief. They really show physiological changes. They really get better. Yet, we know that none of this has anything to do with the antibiotic because antibiotics don't act on viruses; they act only on bacteria.
Skepticism regarding the actual cause of recovery is clearly justified in some instances. But is skepticism regarding the cause of the recovery unwarranted in those cases where the patient has clearly benefited from the treatment? In other words, is it possible to be wrong about the cause of recovery in cases where we are clearly justified in attributing the recovery to acupuncture, homeopathy, chiropractic, or scientific medicine? Yes, it is, and we know this from various studies involving such things as conditioning. We'll get to the studies below, but a couple of anecdotes will illustrate this point.
In her book, Women Aren't Supposed to Fly: The Memoirs of a Female Flight Surgeon, Dr. Harriet Hall tells the story of a man who got a vasectomy without anesthesia because he was mistakenly injected with saline solution rather than lidocaine. She also tells the story of a woman whose severe headaches went away after being injected with saline. The latter swore that only Demerol worked for her, but she had been conditioned to feel relief when she got a shot. Likewise, the vasectomy victim didn't feel excruciating pain because he also was conditioned to get pain relief from certain injections.
As we will see below, when we review the scientific studies that have shown how conditioning affects our response to medical treatment, conditioning can involve much more than obvious factors like getting an injection, taking a pill, or being touched where it hurts. Conditioning can involve the theater of the medical setting and medical rituals, including the medical uniforms worn, medical jargon spoken, and medical gadgetry used. These conditions affect the patient's expectation of relief by the treatment, as does the manner of the healer. Patient expectation, it turns out, plays a significant role in the effectiveness of many kinds of treatment. In short, classical conditioning is "hypothesized to be the primary triggering mechanism for the placebo effect ... which must be learned before it can manifest itself...." (Bausell 2007: 131).
Whether a given effective treatment is due to conditioning and the placebo effect cannot be determined by asking either the patient or the healer, unless they are aware of scientific studies that have demonstrated whether the effectiveness is due to conditioning or the placebo effect. A physician who prescribes antibiotics for a bacterial infection does so with knowledge that there are many scientific studies that demonstrate the effectiveness of antibiotics. The physician also has knowledge that bacterial infections cannot be treated effectively with placebos. Likewise, there are no placebo chemotherapies or birth control pills. As long as there is sufficient knowledge to justify the treatment as a necessary condition for healing, the healer is warranted in concluding that successful treatment is due in large part to the treatment and not to a placebo effect. It is becoming more and more evident, however, that most successful medical treatments involve "placebo factors," i.e., factors other than a drug, a surgery, or the like.
It may seem absurd to some people to even consider the possibility that millions of satisfied customers around the world could be responding to conditioning and placebo effects when they receive medical treatment, whether it be acupuncture or some science-based conventional therapy. As noted already, however, no individual anecdote, no matter how dramatic, can provide us with enough information to know how much of the success was due to conditioning and placebo effects, and how much was due to some other mechanism such as the unblocking of chi along pathways called meridians, or the balancing of yin and yang, which are often offered as explanations of how acupuncture works. The only way to determine whether acupuncture works by some other mechanism besides conditioning and placebo effects is to do randomized, double-blind, controlled studies. If that is not possible, then scientific studies must be devised that rule out, as far as possible, conditioning and placebo effects as the main factors in the effectiveness of acupuncture.
Scientific control studies in medicine that attempt to determine whether something is a significant causal factor in producing a specific effect often use placebos as a control. In most of these studies, the placebo is defined as an inert substance, and it is pitted against an active substance to see if there is any significant difference in outcome in different groups. (The group getting the active pill is called the experimental group and the group getting the placebo is called the control group.) The classic case would compare a drug in pill form, of known chemical composition, with a pill that looks and is administered like the drug but is actually made of starch or sugar. It is known that placebos can have physiological and psychological effects. So, it is legitimate to assume that if there is a significant difference in outcome between the placebo group and the experimental group that the difference is probably due to the experimental drug in a properly controlled study. However, it cannot be determined from that data alone just how effective the drug is. To know that, it is necessary to determine if there was a placebo effect and, if so, what it was. One method of isolating the placebo effect is to have a third group in the trial that receives neither the experimental drug nor the placebo pill. If the placebo group shows a significant difference in outcome from this third group, it may seem reasonable to assume that the difference is due to the placebo effect. Such trials, however, tell us nothing about the mechanisms of the placebo effect. If they are not carefully designed, we may mistakenly attribute causal effectiveness to both the chemical substance and the placebo. Some or all of the effect could be caused by "false impressions of placebo effects," such as regression to the mean (Kienle and Kiene 1997).
A number of studies have shown that there is a placebo effect and that different people respond differently to placebos. Furthermore, some people are more susceptible to the placebo effect than others and this may be genetic (Furmark 2008). Most important is that the placebo and nocebo effects themselves have become the focus of study. The mechanisms of these effects are not adequately understood, but it has become increasingly evident that there are many factors besides the "medicine" given (or surgery done) and the body's own ability to heal itself that affect healing. As noted above, classical conditioning; the hopes, desires, confidence, and expectations of the patient; the rituals of the treatment; the dress, gadgetry, and jargon that imply technical know-how in the healing theater; and the demeanor of the healer all contribute to the healing process. These effects occur for all types of healing, alternative as well as scientific medicine.
Other factors might confound a causal study, as well. In 1997, Kienle and Kiene published an evaluation of the 1955 seminal placebo study by H. K. Beecher, "The Powerful Placebo." The new research found "no evidence of any placebo effect in any of the studies cited by him." Beecher had attributed 35% of the effects in 15 clinical trials to be due to placebo. Kienle and Kiene found a number of other factors that could account for the data. They called these factors "false impressions of placebo effects." I'll refer to these factors as "false placebos." Here is a short list of such factors:
Spontaneous improvement, fluctuation of symptoms, regression to the mean, additional treatment, conditional switching of placebo treatment, scaling bias, irrelevant response variables, answers of politeness, experimental subordination, conditioned answers, neurotic or psychotic misjudgment, psychosomatic phenomena, misquotation, etc.
A thoughtful healer should wonder when a patient leaves the office after a follow-up visit whether the success was due to the acupuncture (or the pill), or whether conditioning, placebos, and false placebos played major roles. Likewise, scientific researchers trying to isolate the effectiveness of a medical treatment must design their studies to control for not only placebo effects, but also for false placebo effects.
What is also becoming clear is that scientific medicine can be effective in many cases without any or much help from placebo or false placebo factors, while so-called alternatives such as acupuncture, aromatherapy, chiropractic, hypnotherapy, and homeopathy work primarily or exclusively by conditioning and placebo effects. A diabetic dependent on insulin will benefit from the insulin shots regardless of her physician's demeanor or her beliefs or expectations. (She probably wouldn't be taking the shots if she didn't trust that there is scientific evidence that it will reduce her blood sugar. There is no evidence that I know of that shows a diabetic must believe in the power of insulin for it to work.) Furthermore, it isn't very likely that the insulin-dependent diabetic is going to wake up one day and find that her diabetes has disappeared. If you get a cold, however, it is very likely that you will get up one day soon and your cold will be gone. Acupuncture, aromatherapy, or a homeopathic remedy for a cold probably won't do anyone any harm. In most cases, the cold will go away on its own in a week or two, and the treatment might make the patient feel better in the meantime. It would be criminal, however, to use acupuncture, chiropractic, or homeopathy to treat diabetes, AIDS, diphtheria, cholera, or the like. Also, besides the risk of infection from the needling process, there are cases where an acupuncture needle has punctured the right ventricle and a lung, causing it to collapse.
The most common claim of success by acupuncture advocates is in the area of pain relief. As noted above, it is likely that acupuncture and sham acupuncture have an opioid effect. I have seen this effect first-hand. My wife was treated for facial pain with acupuncture (among several other therapies) at Kaiser Permanente in Sacramento. Each acupuncture treatment would leave her groggy and unsteady on her feet. She got temporary relief from her pain. After several hours, however, she was back to where she was before the treatments. The therapy worked but it was impractical. She got relief from her pain for a short time after the therapy, but she was basically incapacitated during that time. When she recovered from the treatment to the point where she could function, the pain had returned. It would be pointless to go through such therapy if the effects were not long-term. Eventually, she quit the treatments.
Before looking at the results of some of the acupuncture and pain studies, we should review some of the difficulties in doing such studies. One major obstacle to doing a high quality acupuncture study is in devising an adequate sham acupuncture to act as a control. These problems are discussed in the entry on sham acupuncture, which is a procedure that must be a part of any acupuncture study if it is to demonstrate that the effects it measures are not due to conditioning or placebo effects. Even though there have been thousands of acupuncture studies, apparently the majority of them don't use sham acupuncture or any other relevant control group (Bausell 2007).
There are other problems as well. First, there is the problem of getting unbiased volunteers to participate in such studies. Those who would volunteer for an acupuncture study are most likely to be people who already use acupuncture or desire to because they believe there is likely to be something to it. I don't think this is a major obstacle, especially if those getting the sham acupuncture can't tell whether they are getting real acupuncture. But if the needles are stimulating an opioid response above and beyond what a placebo treatment might provoke, a researcher might find that the dropout rate in the sham group is very high. Subjects do drop out of studies, and this could be a major problem if they are in pain and are getting no relief. In addition, subjects who do not feel like they are getting any pain relief might conclude that they are getting the placebo treatment and drop out. They may have joined the study more to alleviate their pain than to aid science. This could result in a drop-out effect that artificially elevates the perceived or actual relief in both the experimental and the placebo groups. Thus, any high quality acupuncture study on pain must indicate the drop-out rate and that rate must be low. Also, it should go without saying, that a proper study should have a large enough sample to reduce the chance of statistical bias.
What qualities should we look for in a high-caliber scientific study? According to R. Barker Bausell, the most credible type of evidence available to us comes from "large [at least 25 in each group], double-blinded randomized, placebo-controlled clinical trials with low experimental attrition published in high-quality scientific journals that have been independently validated by other investigators" (Bausell 2007: 104). Unfortunately, that eliminates most acupuncture studies from consideration. Bausell is an expert in biostatistics and served for five years as the director of research at the National Institutes of Health Complementary Medicine Program (now called the Center for Integrative Medicine and located at the University of Maryland). He knows how to tell a well designed and implemented medical study from a faulty or incompetent one, and he knows how to evaluate the statistical data that is the backbone of such studies.
One high quality acupuncture and pain study involved over 1,100 subjects with chronic back pain. Pain researchers often use the Von Korff Chronic Pain Grade Scale questionnaire and the back-specific Hanover Functional Ability Questionnaire (for back pain studies) to measure changes in back pain after various kinds of treatment. In this study the subjects were given different treatments and evaluated after six months using both the Von Korff and the Hanover instruments. The study compared treatment by (1) acupuncture using traditional acupuncture points and methods, (2) sham acupuncture that used non-traditional points and methods (the needles weren't inserted as deeply or twirled as in traditional acupuncture, and (3) treatment involving drugs, exercise, and physical therapy. About twice as many in the groups stuck with needles responded to the treatment as in the non-needle group. It did not matter whether the subjects were stuck in traditional points using traditional methods or in non-traditional points using non-traditional methods. About 45% responded in these groups compared to about 25% in the group treated with drugs, exercise, and physical therapy. According to the BBC:
The researchers, from the Ruhr University Bochum, say their findings suggest that the body may react positively to any thin needle prick - or that acupuncture may simply trigger a placebo effect.*
The results of this and another study done at Linköping University in Sweden, which found no significant difference in response from those getting true acupuncture and those getting sham acupuncture, provide evidence against the accuracy of the traditional Chinese meridian map. It doesn't seem to matter where you stick the needles, whether you stick them in deeply or twirl them, or, as we shall see, whether you stick them in at all. The fact that it has been shown that the same effect can be induced from true acupuncture and fake acupuncture that doesn't stick needles into the subject casts doubt on the need to claim that some sort of mysterious energy, called chi, is needed to explain acupuncture's effects.
The Linköping study involved 215 patients with various types of cancer being treated with radiotherapy, which often leads to severe nausea and vomiting. It has been hypothesized that acupuncture can be a significant causal factor in the relief of such nausea. One group was treated with traditional acupuncture. The other group got a sham treatment that involved an identical looking and feeling needle that retracted into a handle on contact with the skin. This method prevents the patients from knowing whether they've actually been stuck with a needle. Both the true and the sham groups believed the treatment had been invasive and effective in reducing nausea:
....68 percent of patients who got the acupuncture experienced nausea for an average of 19 days during radiotherapy and 61 percent of the patients who got the sham treatment suffered nausea for an average of 17 days....Vomiting was experienced by 24 percent of the patients getting acupuncture and 28 percent of patients receiving the sham treatment....Fifty-eight of the patients received chemotherapy in combination with radiotherapy. Among them, 82 percent of those in the acupuncture group developed nausea, compared with 80 percent of those treated with the sham needles....66 percent of patients who got acupuncture and 71 percent who got the sham treatment said they would be highly interested in having acupuncture again if it turned out they needed another course of radiotherapy.
The differences between the two groups are not statistically significant. These results strongly suggest that the effects of acupuncture are placebo effects. Apparently, as long as the patients believe they are getting acupuncture, they get some relief from the treatment, but it doesn't really matter whether they are stuck with needles. Of course, there is no way to disprove the claim that just coming near the acupoints triggers the unblocking of chi along one of the major meridians, thereby leading to a restoration toward balance of yin and yang. This, of course, would mean that acupuncture's use of needles is superfluous. It might also turn out that touching the patient is unnecessary. It is possible that an energy treatment such as reiki or therapeutic touch, or voodoo acupuncture like Tong Ren, could produce similar results to sham acupuncture or acupressure. If so, then physical contact would be proven to be unnecessary. Furthermore, if one compared distant healing, say over the phone or through prayer, to reiki or therapeutic touch, one might get similar results and thereby eliminate the necessity of even being near the patient to achieve an effect. But such explanations seem superfluous when there is a simpler explanation that can plausibly account for the same data. In fact, developments in modern physics and biology since the 19th century have rendered unnecessary all forms of vitalism and explanations of biological processes in terms of energies that can't be measured by any scientific instrument but can be felt by something much less sensitive, the human hand.
Even though sham acupuncture that involves pressure, but not needle insertion at acupoints, has been shown to be as effective as true acupuncture, one study claims to have shown that true acupuncture is much more effective than acupressure or sham acupressure. Since this study may have the appearance of a well-designed study in the eyes of many acupuncture advocates, even though it is fatally flawed, it is worth examining in detail.
The study in question, "The management of cancer-related fatigue after chemotherapy with acupuncture and acupressure: A randomised controlled trial," was published in the journal Complementary Therapies in Medicine (Volume 15, Issue 4, Pages 228-237). It was done in England at Manchester’s Christie Hospital by Alexander Molassiotis et al. The study had 47 participants divided into three groups, and is described by the researchers as "a randomised placebo-controlled trial."
The patients were randomly assigned to one of three groups to receive either acupuncture or acupressure – placing physical pressure on acupuncture points with hands or objects – or sham acupressure.
The acupuncture subjects received six 20-minute sessions over a period of three weeks. The acupoints "were selected for their supposed propensity to boost energy levels and reduce fatigue." The acupressure subjects administered their own therapy. They were taught to massage the same acupoints for one minute a day for two weeks. The sham acupressure subjects also administered their own therapy, but they were given different points to massage.
One key ingredient of a placebo-controlled study seems missing: the administration of the therapy by the healer in the clinical setting for the two acupressure groups. Also, the way this study was conducted meant that compliance with the acupuncture group was known and likely to be high, whereas compliance with the acupressure groups would have to rely on self-reporting. In fact, even though this is a rather small study, one would predict—based on what we know about placebo effects—that the difference in method of delivery of the treatment would lead to the acupuncture group reporting the best results.
Another defect in the study is that the acupressure groups applied their therapy a minute a day for two weeks (28 minutes of self-treatment), while the acupuncture group received its therapy for three weeks (two 20-minute sessions per week, for a total of 120 minutes of therapy in a clinical setting). The results were that "patients in the acupuncture group reported a 36% improvement in fatigue levels, whilst those in the acupressure group improved by 19%. Those in the sham acupressure group reported a 0.6% improvement." "People felt better and had more energy after the acupuncture," Molassiotis told New Scientist. "Patients had the energy to walk to the shops and to socialize, so their quality of life improved significantly." These claims may be true, but because of the way the study was designed Molassiotis can't be sure what part of the effect, if any, was due to the acupuncture. The study was very small, so all it would take would be one or two outliers to skew the data for any of the groups. We aren't told how many participants dropped out of the study. If only two dropped out, there might be 15 in each group. These samples are too small to justify drawing any grand conclusions about acupuncture improving the quality of life. The small sample sizes might account for all of the difference in outcome between the two acupressure groups, but it probably does not account for all the difference between the acupuncture group and the two acupressure groups.
The difference in delivery of treatment by the healer in a clinical setting versus self-administration, plus the difference in duration of the treatments, probably accounts for a good part, if not all, of the difference in the effects between the acupuncture and acupressure groups. The acupuncture patients had more reason to believe in the effectiveness of the therapy and more reason to expect good results than the acupressure groups who were sent off to administer to themselves.
The large difference between the two acupressure groups is interesting, however. It could be an artifact of the small size of the samples or of the way improvement was measured; or it could indicate that traditional trigger points of acupressure might be more effective than non-trigger points. Whatever this study indicates, there is little justification for claiming that it indicates that acupuncture relieves cancer chemotherapy fatigue or that it improves the quality of life of chemotherapy patients.
Despite the obvious flaws in Molassiotis's research methodology, he has managed to get funding to do another study on acupuncture. It is a classic example of how not to design an acupuncture study. Molassiotis, a professor of cancer and supportive care at the University of Manchester, will recruit 320 women who have had chemotherapy in the past five years and have high levels of fatigue.
One type of proper study would randomly assign the women to one of two groups. Members of one group would receive needle pricks along traditional meridians at acupoints. Members of the other group would think they are receiving needle pricks but they would not be receiving any needle pricks. Both groups would feel as if they were getting true acupuncture, but only one group would be getting pricked with needles.
That's not what Molassiotis will be doing. Patients will be randomly selected to receive either weekly sessions of acupuncture or standard care for six weeks. Furthermore, the study "will also be the first to examine the benefits of self-acupuncture for women with breast cancer." The good doctor will have no way of knowing how much the expectation of relief from acupuncture affects patient response. We already know from many studies that people who expect relief from acupuncture generally get relief. We also know that the belief in the effectiveness of a therapy affects the efficacy of the therapy. A well designed study must control for both placebo and false placebo effects. This study will do neither.
more acupuncture studies
Bill Reddy, a practicing acupuncturist who believes that "acupuncture is a thoroughly proven system of healthcare," notes that PubMed alone lists some 13,000 published studies on acupuncture. Obviously, I am not going to run through these studies one by one. Reddy claims that "countless studies have proven acupuncture’s effectiveness in improving the viability and diameter of ova." He selects one such study for discussion. I assume he selected it because it is typical or he thinks it is one of the better studies. It was published in 1993 in the Journal of Chinese Medicine by Mo et al. Reddy notes that the "total effective rate was 82.35%," whatever that might mean. He quotes from the article, but he seems to gloss over the fact that the researchers are very cautious in their claims, using the word 'may' to qualify their conclusions:
...the results also showed that acupuncture may adjust FSH, LH, and E2 in two directions and raise the progesterone level, bringing them to normal. The animal experiments confirmed this result. Results showed that acupuncture may adjust endocrine function of the generative and physiologic axis of women, thus stimulating ovulation. (emphasis added)
Furthermore, the study cited had no control groups and was very small (34 patients). The authors also make some unsubstantiated claims that Reddy doesn't mention, e.g., that acupuncture at the Chong and Ren channels "nourishes uterus to adjust the patient's axis function and recover ovulation." Also, we should note that researchers at the University of Oklahoma studied more than 97 patients who were getting in-vitro fertilization, some of whom were also getting acupuncture 25 minutes before and after the embryo was transferred from the test tube to the womb. The pregnancy rate of the group that did not receive acupuncture was 69.9 percent, while the rate for those who got acupuncture was 56.2 percent.
Another highly touted study was done by the National Institutes of Health (NIH), which claimed in a press release headline that Acupuncture Relieves Pain and Improves Function in Knee Osteoarthritis. According to the NIH:
On joining the study, patients' pain and knee function were assessed using standard arthritis research survey instruments and measurement tools, such as the Western Ontario McMasters Osteoarthritis Index (WOMAC). Patients' progress was assessed at 4, 8, 14, and 26 weeks. By week 8, participants receiving acupuncture were showing a significant increase in function and by week 14 a significant decrease in pain, compared with the sham and control groups. These results, shown by declining scores on the WOMAC index, held through week 26. Overall, those who received acupuncture had a 40 percent decrease in pain and a nearly 40 percent improvement in function compared to baseline assessments.
Unfortunately, the article doesn't give the numbers for the sham or control groups, so we can't tell from the press release what this "significant" decrease in pain amounts to. The article was published in the Annals of Internal Medicine (December 21, 2004). There were 570 patients in the study. Participants were randomly assigned to receive one of three treatments: acupuncture, sham acupuncture, or participation in a control group that followed the Arthritis Foundation's self-help course for managing their condition. The NIH press release fails to mention that 43% of the control group dropped out, while 25% dropped out in each of the acupuncture and sham acupuncture groups. The high dropout rate in all the groups suggests that a significant number of subjects were not getting any relief from either true or sham acupuncture, or from conventional treatment. If they were getting pain relief, do you think they would have dropped out? Furthermore, two years after this study was published, the same journal published "Acupuncture and Knee Osteoarthritis: A Three-Armed Randomized Trial" by Scharf et al. That study found no statistically significant difference between the acupuncture and sham acupuncture group, indicating once more that acupuncture is a placebo treatment.
Obviously, this review of acupuncture studies could go on forever. I challenge the defenders of acupuncture to find a high-caliber study published in a first-tier journal to support their case that the effects of acupuncture can't be explained by conditioning, placebo factor, or false placebo factor. Please, no more studies that don't use proper controls or randomization, or are based on small samples. Yes, there are thousands of studies on acupuncture, but finding high-caliber studies published in first-tier journals is like finding a needle in a haystack.
Further confounding the difficulty in evaluating acupuncture studies is the fondness for meta-analysis of many researchers.
Keeping this entry up-to-date has become impossible due to the sheer number of new studies being done on acupuncture. My rule of thumb is to ignore small studies or meta-analyses of small or large studies. For example, I'll see a headline like this from News-Medical.net:
Acupuncture before and during surgery reduces the need for powerful painkillers*
Once I find that the conclusion is based on a meta-analysis of "15 small randomized acupuncture clinical trials," I move on. Meta-analysis of several small studies, most of which aren't large enough to produce anything of statistical significance--much less of social importance--is no substitute for conducting large clinical trials, yet the practice remains popular. There is something obviously wrong about using meta-analysis to lump together a number of studies that individually don't really tell us much about anything and then declare that by lumping them together they magically provide statistical significance on the order of odds against chance of a zillion to one. Dean Radin, for example, has wrapped himself and parapsychology in the mantle of meta-analysis to the point of absurdity. He did a mega-meta-analysis of over 1,000 studies on dream psi, ganzfeld psi, staring, distant intention, dice PK, and RNG PK that concluded that the odds against chance of getting these results are 10104 [that's 10 with 104 zeroes after it] against 1 (Entangled Minds: p. 276). Radin seems to think he can build the Taj Mahal out of scraps from the junk yard when he's actually built a hologram out of swamp gas in a moonbeam.
People who do meta-analyses of small studies in hopes of turning lead into gold attract the journalist more interested in a good story than the truth. Well, I guess we can just say that such studies attract journalists, since in the area of medical reporting the concern for the truth doesn't seem to be as important as hyping a story. For example, in the article following the headline posted above about acupuncture, surgery, and painkillers, the author concludes: "The National Institutes of Health says that acupuncture has also been shown to reduce nausea after chemotherapy and surgery." The article made no mention of a news report published a few weeks earlier on the Linköping study that found acupuncture did no better than sham acupuncture to reduce nausea after chemotherapy. When both true and sham acupuncture groups respond positively in studies at about the same level, the data support the placebo hypothesis. Such data are consistent with the hypothesis that traditional acupoints are irrelevant and so is the actual insertion of needles. This fact seems lost on many journalists and defenders of acupuncture.
One of the major problems with meta-studies is that researchers must be selective in choosing which studies to include in their analysis. Some studies will have to be rejected because they are fatally flawed: they're too small, use no controls, didn't randomize the assignment of subjects, or the like. Different researchers will include and exclude different studies. Even if they agree on the criteria used to determine which studies to include, they will often disagree on the application of the criteria. In the end, one will often find two meta-studies that contradict each other and each side will claim the other excluded studies that should have been included or they included studies that should not have been included. A common accusation is that if the researcher got a positive result it was because he excluded too many studies that got negative results. Or, if the researcher got a negative result, it was because he included too many negative studies or didn't include enough positive studies. Furthermore, the media often have no clue as to how to properly evaluate a meta-analysis.
For example, a meta-study by Eric Manheimer et al. appeared in the British Medical Journal called "Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation [IVF]: systematic review and meta-analysis. " The news media hailed the study as finding evidence that acupuncture improves the chances of successful fertilization. The authors of the study, however, note that the connection between acupuncture and fertilization "is far from proven." They call their evidence "preliminary" and state that it "suggests that acupuncture given with embryo transfer improves rates of pregnancy and live birth among women undergoing in vitro fertilisation." The media erroneously reported that the data showed a 65% increase in fertility in those treated with acupuncture, when the actual figure was closer to 10%. Furthermore, acupuncture researcher Peter Braude claimed that "the BMJ paper didn't include all the studies, and if you include the negative ones there is no effect." I don't have a horse in this race, so I am not going to track down all the studies and come up with my own list of which ones should be included or excluded. I should note, however, that Braude supervised a team of researchers that recently finished a meta-study on acupuncture and IVF treatment that found no effect. The results of their work was presented to the European Society of Human Reproduction and Embryology conference in Barcelona, Spain. The researchers identified 83 trials in the medical literature, of which 13 were found to be of suitable quality to be included in the meta-analysis.* The way to avoid these kinds of conflicting reports is to avoid meta-analysis and do single studies that use large samples.
Acupuncture is the current darling of the media and of many alternative and conventional healers. Articles appear on a daily basis claiming that this or that study has shown that acupuncture works wonders on just about anything of interest in the medical world, whether it relates to humans or our dogs, cats, and horses. Careful examination of these studies and of the claims made on behalf of acupuncture have demonstrated that these beliefs are based on wishful and selective thinking, ignorance about how placebos work and how false placebos can confound our interpretation of data, and indifference to how the studies were designed or carried out.
Even the BBCNews online, which I consult regularly on a variety of topics and find generally reliable and trustworthy, used the headline Needles 'are best for back pain'* in a story about a study that found patients reported similar relief from pain from both true and sham acupuncture. The study also found that the subjects got significantly more relief from acupuncture, true or sham, than from a conventional treatment involving drugs, exercise, and physical therapy. The BBC and almost every other mainstream news source I consulted played up the difference between the two acupuncture groups and the conventional therapy group. (MSNBC was an exception, as it noted: "Positive expectations the patients held about acupuncture — or negative expectations about conventional medicine — also could have led to a placebo effect and explain the findings.") Bloggers, however, were quick to note that this study supports the idea that acupuncture is a placebo treatment (because there was no statistically significant difference between those reporting relief in the true acupuncture and the sham acupuncture groups). Steven Novella's NeuroLogica Blog, for example, has an excellent analysis of this study. So does Orac.
So, please, no more meta-analyses of acupuncture studies.
In much of the world, acupuncture is considered to be an ancient medical practice that originated in China thousands of years ago as part of what is called Traditional Chinese Medicine (TCM). TCM includes acupuncture, herbal remedies, special diets, massage, and exercises all aimed at affecting the flow of chi through bodily pathways (meridians) and the balance of yin and yang. Herbal remedies are found in every ancient culture, so it is likely that such remedies have been used in China for thousands of years. The term "traditional Chinese medicine," however, originated in 1954 by Chinese communist officials for political reasons (Taylor 1995).
Similar practices to TCM exist in India where chi is called prana and the medicine is called Ayurvedic. In fact, some Indian acupuncturists believe that acupuncture began in India and spread to China with Buddhism.
It is rather curious that the earliest manuscripts of Chinese medicine, which date from the second century BCE, make no mention of acupuncture (Basser 1999). A tomb of a Chinese prince dating from the second century BCE contained a set of four gold and five silver needles (Lewith 1995), but it is speculation that the needles were designed for acupuncture. The tips are rather large and the metals rather soft.
The earliest Chinese text that mentions acupuncture, the Huang-ti Nei-ching or the Yellow Emperor's Classic of Internal Medicine, may not have been written earlier than 200 BCE. The earliest extant texts date from the 5th to the 8th centuries CE.
Stone needles thought to be 5,000 years old have been found in a tomb in Mongolia, but how the needles were used is speculative. Ancient cultures around the world have used needles on humans for such things as tattooing, scarifying, burning, cauterizing, lancing, piercing, and bloodletting. Did the Chinese teach the rest of the world these things? Did they learn them from others? Did they develop independently in Europe, Egypt, Arabia, etc.? When and where acupuncture began is unknown if we restrict ourselves to acupuncture as a method of sticking needles through the skin to unblock energy and harmonize forces. [revised] But it is doubtful that sticking needles in many parts of the body, as is common today by acupuncturists, would have been looked upon with favor until the needles were very thin and unlikely to cause pain and infection without sterilization. According to Hanjo Lehmann:
And no matter which needles were used – once puncturing the skin, there were always two dangers. First, due to the lack of anatomical knowledge, the danger that any deep puncturing might damage internal structures or inner organs. Second, the danger that these needles, usually without disinfection of neither needle nor skin, caused inflammations, purulency or infections.
And although people in ancient time knew nothing about microbes, they knew very well that needling could do harm to the body....there are good reasons why there was always an inborn aversion of man against anything artificial inserted in the body.
Therefore, common sense lets us expect that acupuncture even in ancient China rarely was a standard therapy, but usually a therapy for special cases.
Willem ten Rhijne (1647-1700), a Dutch physician, was the first European to write a detailed account of Chinese and Japanese medicine. He also coined the term acupuncture--acus means needle in Latin and pungere means to prick--and was responsible for bringing the practice to Europe. (There is an image posted here of a sexless European's acupoints from ten Rhijne's treatise Dissertatio de arthritide: Mantissa schematica: De acupunctura: et orationes tres, I. De chymiae ac botaniae antiquitate & dignitate: II. De physiognomia: III. De monstris. [London: R. Chiswell, 1683].) According to Eleanor Cracknell, assistant archivist of the College of St. George, ten Rhijne made "little attempt to understand the theoretical basis behind Chinese thought."
In Dissertatio de Arthritide; Mantissa Schematica; De Acupunctura; et Orationes Tres, ten Rhyne states that the principles of Japanese and Chinese medicine are too difficult to explain, so rather than focusing on the theory, he concentrates on the practice itself, paying particular attention to pain relief, treatment of gout and arthritis. Ten Rhyne believed that the build-up of wind or energy in the body caused the pain, and by puncturing the skin, the wind would be released, curing the patient.*
The first use of the term 'acupuncture' that also connected needling with chi, meridians, yin and yang, was by the 20th century Frenchman George Soulié de Morant (1878-1955). Morant spent nearly twenty years in China at the beginning of the twentieth century. He spent the next 40 years actively promoting acupuncture among medical professionals in Europe. Just before his death in 1955, he completed L’Acuponcture chinoise, which introduced the notions of qi (chi) as energy (or life force) and meridians as the pathways of qi. In 1943, the first society of acupuncturists in the West was founded in Paris (Imrie). Auricular acupuncture was invented by French Physician Dr. Paul Nogier, who saw in the ear an inverted fetus.
According to Jan Willem Nienhuys (personal correspondence), the introduction of fine steel needles in Japan and China was a 20th century development. The needles in De Acupunctura of Willem ten Rhijne "were quite thin, not of steel, and they were inserted through a tube to prevent buckling. A small hammer was used (presumably to exert forces exactly in the direction of the needle). Soulié imitated a Japanese acupuncture innovator (ca. 1920) who worked with thin steel needles but Soulié himself had rather thick needles made by a Parisian jeweler. In 1929 the Chinese physicians in the Republic of China voted more or less unanimously for a prohibition of all acupuncture. At that time the acupuncturists used political influence to cancel this prohibition, but soon thereafter they changed to thin steel needles." [/revised]
So, while acupuncture was being promoted in the West as an ancient healing art that could cure just about anything, it was being banned in China and Japan. After the introduction of scientific medicine in those countries, efforts were made to stifle ancient medical superstitions and myths. In 1822, the Chinese emperor Daoguang forbade the use of acupuncture and moxibustion by the physicians of the imperial court (Lehman 2013). Mao Zedong promoted Chinese medicine for political and practical reasons, but he did not use it or believe in it himself. Acupuncture came to the attention of the Western world in dramatic fashion when it was widely reported in 1971 that James Reston, the New York Times journalist, had undergone an appendectomy in Beijing with the only anesthesia being provided by acupuncture. In fact, he had chemical anesthesia for the operation, but acupuncture was administered afterward to relieve pain. Reston allegedly reported that about an hour after the acupuncture he felt pain relief. Was the relief due to the acupuncture? Perhaps. It may also have been due to his having a bowel movement. Did the acupuncture cause his bowel movement? I don't know, but I do know that after this story was reported in the Western press, acupuncture began its current run as the darling of alternative medicine in the West. Simultaneously, acupuncture has grown less popular in China (Beyerstein and Sampson 1996). It might be of interest to some readers that The National Council Against Health Fraud (NCAHF) found that of the 46 medical journals published by the Chinese Medical Association, not one is devoted to acupuncture or other so-called "traditional" Chinese medical practices.
Finally, for those who think that acupuncture on animals is an ancient practice, I suggest you read the account of acupuncture by Robert Imrie et al. The long and the short of it is that true acupuncture on animals didn't exist until the 20th century and the first texts on the subject in English and Chinese were published in the 1970s.
It's clear from the testimonial and scientific evidence that acupuncture benefits some people some of the time for some conditions, particularly for the relief of pain. It's also clear that acupuncture doesn't benefit anyone for some conditions, even though there are published studies that conclude otherwise. The evidence tells me that it is criminal to treat infertility with acupuncture, for example.
It's clear from the scientific studies that some medical interventions, whether by acupuncture or scientific medicine, appear effective but aren't. Apparent effectiveness is due to false placebo effects such as regression to the mean or a disease running its natural course. It is also clear from scientific studies and careful observation that some medical interventions are necessary for recovery. The evidence does not support the claim that acupuncture is a necessary treatment for a single ailment, however. If acupuncture is beneficial on its own or as a complement to scientific treatment for any condition, it is so because of conditioning and placebo factors such as patient expectation and confidence in the treatment. It's also clear that sticking needles in people is irrelevant for acupuncture to work, but appearing to do so is apparently necessary for it to work.
Knowing these things and given my experience with scientific medicine, I can see no reason to consult an acupuncturist for any ailment I might have. I understand, however, why practitioners and patients alike are convinced that the benefits of acupuncture are due to sticking needles into people. I'm not expecting these folks to change their minds about acupuncture on the basis of the evidence, which they will probably interpret differently. After all, there are plenty of opportunities for confirmation bias on both sides of this issue. Skeptics will continue to note any case where acupuncture doesn't help someone or causes harm, and we will continue to identify high caliber studies that support the hypothesis that acupuncture works by conditioning and placebo effects. Believers will continue to point to their successes and to the scientific studies that seem to support their viewpoint, while ignoring or misinterpreting the occasional high-caliber study that is published. Believers have the additional advantage of having on their side popular celebrities like "Deepak" Oprah and her celebrity doctor friend Mehmet Oz. A single celebrity endorsement carries more weight with many people than a thousand high-caliber scientific studies, especially with people who have a low opinion of scientific medicine. People who have had bad experiences with conventional medicine, or who are believers in the Big Pharma/AMA conspiracy to keep us sick so they can make money, can easily find examples of experiences that support favoring acupuncture or other forms of alternative treatment over scientific medicine. To them I say: I hope all your ailments are minor ones, but if you have a heart attack or a stroke I hope others will make sure you get the best treatment that scientific medicine has to offer.
I encourage more research on acupuncture and therapies like homeopathy and chiropractic, as long as they have controls that tease out placebo and false placebo elements. I encourage more research on hypnotherapy, but not to tease out placebo elements. I agree with Bausell that hypnosis and the placebo effect are "so heavily reliant upon the effects of suggestion and belief that it would be hard to imagine how a credible placebo control could ever be devised for a hypnotism study."
I encourage more research in scientific medicine that tries to tease out placebo and false placebo elements of a treatment. It's possible that many of the medications that physicians prescribe will be found to be no more effective than placebos. That wouldn't mean that the medications aren't effective, of course. But it would mean that the chemicals in the pills aren't the causal agents they are thought to be. (Some scientists think this is true of Prozac and some other anti-depressants, for example.)
To those acupuncturists who come to realize that their medicine works, but is a placebo treatment, you have a decision to make. You can act as one shaman did when he realized his medicine worked no matter what he did, and continue with the rituals and arcane ceremonies associated with your art. It would be easy to rationalize since you are helping people. You may even be helping people who otherwise wouldn't get any treatment from anyone. You'll have many satisfied customers and may make a decent living as well. You'll get a lot of communal reinforcement from other practitioners, the popular media, journalists, and celebrities. Unfortunately, unlike the hypnotherapist, you could not practice your art without deception. The hypnotherapist can openly admit that she is using the power of suggestion, conditioning, massaging patient beliefs, and the like. I know some consider any kind of deception unethical. I don't. I think that sometimes deception of ourselves and others can be justified if it is likely to bring about more good than harm. I'm what is labeled in some circles as a rule utilitarian and situation ethicist. I don't think that knowingly treating patients with placebos is always unethical, but this is not the place for a detailed defense of that position.
The danger from acupuncture is that it is being promoted as superior to scientific medicine, when in fact it is clearly inferior. Acupuncture is touted as appropriate for almost any disorder or disease in man or beast, when the evidence clearly shows that such a belief is a dangerous delusion. Scientific medicine isn't perfect, but it doesn't claim to have a treatment for everything. Furthermore, scientific medicine has numerous examples of treatments that have been shown not to be effective solely due to conditioning, placebo, or false placebo factors. Acupuncture has no such examples.
Finally, acupuncture is not without risks. There have been some reports of lung and bladder punctures, some broken needles, needles left in after treatment, and some allergic reactions to needles containing substances other than surgical steel. Acupuncture may be harmful to the fetus in early pregnancy since it may stimulate the production of adrenocorticotropic hormone (ACTH) and oxytocin, which affect labor. There is always the possibility of infection from unsterilized needles.* Some patients will suffer simply because they avoid a known effective treatment of science-based medicine in favor of an untested or inadequately tested treatment favored by some acupuncturist.* The most any skeptic can hope for is that such patients make an informed choice in a setting where acupuncture is used as a complement, not an alternative, to scientific medicine. At least then the patient might get the best medicine science has to offer if it is needed.
See also alternative health practice, anecdotal evidence, complementary medicine, magical thinking,traditional Chinese medicine, post hoc fallacy, pragmatic fallacy, the regressive fallacy, and Mistakes Were Made & I Made Them: Acupuncture & CAM.
reader comments (note: some comments may refer to earlier versions of this page)
I have written several articles and short pieces about acupuncture and related topics. The following is a list of those I think are most relevant to the acupuncture article above.
Review of R. Barker Bausell's Snake Oil Science: The Truth about Complementary and Alternative Medicine
Burnstock, Geoffrey. 2011. Puncturing the Myth Purinergic signaling, not mystical energy, may explain how acupuncture works. The Scientist. August 31. Burnstock offers an alternative to the placebo explanation. He proposes several experiments, but his theory will still have to account for the fact that pain reduction doesn't differ between those who get real and those who get sham acupuncture.
Furmark, Tomas et al. (2008). A Link between Serotonin-Related Gene Polymorphisms, Amygdala Activity, and Placebo-Induced Relief from Social Anxiety. Journal of Neuroscience. December 3, 28(49):13066-13074.
Hall, Harriet. (2008). "What About Acupuncture?" Skeptic. Volume 14, Number 5. The link here is to a version of this article that is posted on the Science-Based Medicine blog.
Huston, Peter. "China, Chi, and Chicanery - Examining Traditional Chinese Medicine and Chi Theory," Skeptical Inquirer, Sept/Oct 1995. Huston provides an unbiased evaluation of acupuncture anesthesia. Here is an excerpt:
There has been considerable interest in the West in the effects and applications of acupuncture anesthesia. A typical, yet highly dramatic exhibition of this technique was shown on the [Bill] Moyers series [TCM was a subject of Moyers’s television series, “Healing and the Mind ,” 1993]. The patient had a brain tumor and needed surgery to remove it. The procedure was performed in what appeared to be an operating room by a Chinese surgical staff The surgical techniques appeared to be quite up to date, the only addition being the inclusion of acupuncture as a supplement to a greatly decreased dosage of conventional sedatives and anesthetics. The patient remained fully conscious throughout the operation, and Moyers and his travel companion, David Eisenberg, M.D., an American expert on TCM, were allowed to observe the proceedings. Moyers and this home viewer were noticeably impressed.
Yet before wholeheartedly accepting this as a miracle, we have to stop and look back at the procedure to see what it says about the capabilities of the body and the possible role that Chi played in the process. Can science explain this anesthetic effect?
As in so many such cases, we must first define the effect for which we wish to find an explanation. The claims of acupuncture anesthesia cannot be accepted without careful analysis. Acupuncture anesthesia came to the attention of the Western world dramatically when James Reston, the New York Times journalist, developed an inflamed appendix while in China in the summer of 1971. Acupuncture anesthesia was used, and this organ was removed in Beijing's Anti-imperialist Hospital (Porkert 1982). The name is significant and typical of the time, for it was during China's notorious period of chaos known as the Cultural Revolution. At this time, ultra- Communist ideology gripped the country. Those who were suspected of "counter-revolutionary tendencies" often found their homes ransacked, their careers ruined, and themselves shipped off to the countryside to "learn from the peasants through labor." The only way to keep oneself alive and remain afloat was to keep one's mouth shut, and when asked a question, to repeat the official party line.(3)
This is relevant to acupuncture anesthesia and the belief that it showed great untapped potential, because it was part of the official party line. To question its effectiveness, even in a scholarly manner, was to risk seeming disloyal and suffering personal injury or disruption of one's career. Whether they liked it or not, many medical practitioners were virtually forced to use and parrot the effectiveness of acupuncture anesthesia regardless of their opinions about its usefulness (Keng and Tao 1980). Needless to say, this is counterproductive to good scholarship. Since it was during this period that interest in TCM began to develop in the West, it is not surprising that many books from this period were translated into English. Some are still in print, and few question the efficacy of the techniques described in the texts.
Although it was impressive that, during the operation on the Bill Moyers program, the patient was fully conscious and alert, this is relatively standard practice in many types of brain surgery in both the West and China. By keeping the patient conscious, the surgeons are able to carefully monitor the effects of their work and the stimulation of various portions of the brain.
Price, D. D. et al. (1999). An analysis of factors that contribute to the magnitude of placebo analgesia in an experimental paradigm. Pain, Volume 83, Number 2.
Price, Donald D. et al. (2005). Conditioning, expectation, and desire for relief in placebo analgesia. Seminars in Pain Medicine. Volume 3, Issue 1. Abstract.
Acupuncture Doesn’t Work by Steven Novella. Acupuncture Is Theatrical Placebo.
More Acupuncture Misrepresentation by Steven Novella "Stating that both the treatment and the control showed improvement is a non-sequitur in the context of a controlled clinical trial. The comparison of baseline symptoms to post treatment (real or sham) is unblinded, and therefore it is not possible to make any efficacy claims from that change alone, especially with subjective outcomes. Comparison to baseline or historical controls is only justified with objective outcomes (like death). Even then the data is suspect, unless there are blinded controls."
"I’ve said it before, and I’ll say it again (at the risk of boring my readers): I actually used to think that maybe there was something to acupuncture, for the simple reason that it involves an actual physical act on the human body, namely sticking needles into it. On a strictly conceptual level, one can speculate that maybe sticking needles into the skin does something. However, the more I read about acupuncture, the more I delved into the actual scientific literature purporting to support acupuncture, the more I realized that there’s no “there” there, even from studies done by advocates, in which negative or equivocal results are almost uniformly spun to be supportive of acupuncture, and mechanisms that probably have little to do with any purported effects of acupuncture. The “adenosine” mechanism I wrote about three years ago comes to mind. The bottom line when it comes to acupuncture is that it’s almost certainly all placebo. It doesn’t matter where you stick the needles. In other words, acupuncture “meridians” are nonsense, which is not surprising, given that attempts to associate any real anatomical structures to meridians have uniformly failed. It doesn’t even matter if the needles are stuck in; twirling toothpicks against the skin does just as well, dubious systematic reviews of acupuncture not withstanding."
A new meta-study on acupuncture studies and pain is out. As usual, the defenders of acupuncture and the media have overhyped and misstated the worth of the study. I'm tired of going over the same old ground, but fortunately two stalwart skeptics with superior knowledge about science-based medicine have blogged about the study and there's nothing I have to add that I have said above in this entry.
An Acupuncture Meta-Analysis by Steven Novella, M.D. "The Vickers acupuncture meta-analysis, despite the authors’ claims, does not reveal anything new about the acupuncture literature, and does not provide support for use of acupuncture as a legitimate medical intervention. The data show that there is a large difference in outcome when an unblinded comparison is made between treatment and no treatment – an unsurprising result that is of no clinical relevance and says nothing about acupuncture itself."
Can we finally just say that acupuncture is nothing more than an elaborate placebo? by David Gorski, M.D. "I’m pretty much unimpressed at the whole study, although no doubt it will be touted by acupuncturists for years to come as “proof” that acupuncture really and truly works and isn’t just placebo medicine. It doesn’t, and it is. In fact, the study strongly suggests that any effect of acupuncture observed is almost certainly due to nonspecific and placebo effects and that the “positive” result is, as Ernst describes, likely due to small residual biases."
More “bait and switch” acupuncture studies by David Gorski "No wonder, of all the CAM modalities other than supplements, people tend to think that acupuncture “works” more than any others. It is, after all, sticking needles into the skin. That’s one reason why acupuncture also makes a most excellent Trojan horse. After all, doctors stick needles into people, don’t they? So it’s easy enough for a scientist curious about acupuncture and perhaps not so well-versed in placebo effects to allow his curiosity to lead him to stick some needles into some mice, measure some adenosine levels, and then rebrand a science-based mechanism of analgesia that could be turned into a new technique of anesthesia as somehow being based on acupuncture, and the message is that acupuncture works. As that message, as unjustified as it is, spreads, by extension the idea spreads that there might just be something to all this CAM stuff. That is how and why quackademic medicine is on the rise."
Does Chinese acupuncture affect the brain's ability to regulate pain? by Christina Stephens A recently published study by Richard E. Harris et al. suggests that true acupuncture appears to make the body more responsive than sham acupuncture to opioid painkillers. Stephens writes: "it seems fairly obvious to me that measuring neurobiological responses in a PET scan while some subjects have needles inserted during the scan and others do not is measuring a neurobiological response to needles being in the skin versus not in the skin. Sticking needles in subjects would likely provoke a different neurochemical response in subjects when compared to placebo acupuncture, which involved no needle insertion. So, if you do two different physical things to people, this provokes different neurochemical responses. Didn't we already know this?" See also "Needles in the skin cause changes in the brain, but acupuncture still doesn’t work [any better than placebo treatment]" by David Gorski. Gorski writes: all Harris has "shown is that opioid receptors light up more if there are needles in the skin than they do if there are not–hardly a finding that shows that acupuncture “works” and certainly not any sort of finding to validate the entire system of acupuncture, which relies upon the idea of qi flowing through meridians, flows that can be altered to therapeutic effect by sticking needles into those meridians."
Acupuncture Benefit Seen in Pregnancy "The study, published Monday in the journal Obstetrics & Gynecology, is the largest to date examining the effectiveness of acupuncture to treat depression in pregnant women....As many as 14% of women are thought to develop a significant depression at some point during their pregnancy, according to the study authors, comparable to numbers who suffer from postpartum depression....In the study, 150 clinically depressed pregnant women who weren't previously taking antidepressants were randomly assigned to get either acupuncture for depression, acupuncture not specifically designed for depression, or massage for eight weeks. Those who got acupuncture targeting depression had a significantly greater decrease in depressive symptoms, compared with the other women. Some 63% of women in the acupuncture-for-depression group responded to treatment, compared with 44% in the other groups. There wasn't a difference between the groups in full recovery from the depression."
To determine whether acupuncture is more effective than a placebo, only the true acupuncture and faux acupuncture groups need be compared. There were 52 women who received acupuncture "specific for depression" according to some standardized treatment manual, while 49 women received acupuncture in real acupuncture points that are not specific for depression according to this manual. My reading of the methodology of the study is that the way the acupuncture was administered one would expect similar results from the two groups. How they compare with the massage group is irrelevant to the issue of the placebo effect of acupuncture.
The primary outcome was the Hamilton Rating Scale for Depression, administered by masked raters at baseline and after 4 and 8 weeks of treatment. According to the researchers, those who got the needles in the "standardized" points had a 63% response rate, while those who got jabbed in non-standardized points showed a 37.5% response rate.
Women who received acupuncture specific for depression experienced a greater rate of decrease in symptom severity (P<.05) compared with the ... control acupuncture alone (P<.05; Cohen's d=0.46, 95% CI 0.01–0.92). They also had significantly greater response rate (63.0%) than the ... control acupuncture alone (37.5%; P<.05: number needed to treat, 3.9; 95% CI 2.2–19.8).
Unless the antidepressants usually prescribed to depressed pregnant women are placebos, this study indicates that acupuncture needling at specified points is not a placebo. The effect rate for the acupuncture is about the same as for treatment by antidepressants, according to the authors. Furthermore, the data indicate that acupuncture at "wrong" sites is not as effective as acupuncture at "standardized" points.
One should not draw any grand conclusions from a single study, but this one seems to justify the usual conclusion that further studies need to be done. If I were designing a further study, I would dump the massage group and introduce a sham acupuncture group (where the needles aren't actually inserted) and an antidepressant group.
York study maps the effects of acupuncture on the brain The study found that acupuncture deactivates areas of the brain associated with the processing of the sensation of pain. Dr Aziz Asghar, of the York Neuroimaging Centre and the Hull York Medical School, said: "The results are fascinating. Whether such brain deactivations constitute a mechanism which underlies or contributes to the therapeutic effect of acupuncture is an intriguing possibility which requires further research." I have no idea how many subjects were studied or what protocols were used.
More nails in the coffin for acupuncture: and some bad journalism ("A new review appeared in the BMJ today....The results confirm, yet again, that there is essentially no difference between 'real' acupuncture and sham acupuncture." So writes David Colquhoun on DC's Improbable Science. The bad journalism refers to two recent articles on the BBC news website. Colquhoun complains that the title of one article—“Acupuncture works for headaches”—is precisely the opposite of what was shown in the article, which was that acupuncture is no better than sham acupuncture for headaches. His other complaint was that the BBC greatly exaggerates the confusion about acupuncture in its story on the new BMJ study. A short, clear, and fair account of the new study appears in Modern Medicine.) See also Respectful Insolence. An accurate headline from Med News Today read: Acupuncture Only Minimally Effective in Treating Pain. Another from the Daily Telegraph read Acupuncture 'has almost no effect in relieving pain'.
100,000 unaware they have hepatitis C, poll suggests ("...around four in 10 people don't know that they can catch hepatitis C by using unsterile equipment when getting a tattoo, piercing or acupuncture....")
Acupuncture to be used on bases, battlefield More on battlefield acupuncture. This article reveals that treatment includes applying electronic pulses to the affected area along with the acupuncture. Reports from the field show effectiveness, but there's no way to tell whether the effect is a placebo effect. Of course, when the acupuncture is given along with another treatment, there's no way to know how effective, if at all, the acupuncture alone is.
Medical Acupuncture Gaining Acceptance by The US Air Force / Sandy at Junkfood Science has the complete story on Richard C. Niemtzow, M.D., the man who single-handedly has sold the Air Force a bill of goods called "battlefield acupuncture" that is to be implemented in Afghanistan next year. Sandy writes: "Most Americans feel the men and women serving our country deserve the highest quality, science-based medical care, which made this news story especially disturbing." Niemtzow has an impressive resume that omits mention of his work with MUFON and his alien encounters. (update: MSNBC reports (from the AP): Air Force trains combat docs in acupuncture. "The U.S. military encountered acupuncture during the Vietnam War, when an Army surgeon wrote in a 1967 edition of Military Medicine magazine about local physicians who were allowed to practice at a U.S. Army surgical hospital and administered acupuncture to Vietnamese patients.")
Acupuncture Proven to have an Effect beyond Placebo, Harvard Study Concludes (The researchers did indeed claim that they had proved that true acupuncture has an effect beyond sham acupuncture [based on different fMRIs in the two groups], but the study only had twelve subjects and needs to be replicated with a larger sample. It is possible, of course, that sticking needles into the flesh affects the brain differently than pretending to do so and that this difference is a valid measure of different opiod response. It is possible needle pricking does provide some sort of pain relief that sham acupuncture doesn't, but I don't think comparing the results of six people with six other people warrants such a grand conclusion. Since reading fMRIs is partly subjective, it is important that those reading the fMRIs are blinded to whether a given patient got true or sham acupuncture. The method of evaluation of the fMRIs was not discussed in this article or in the sources it cites.)
Fake acupuncture 'aids migraines' (This study supports the acupuncture as placebo therapy hypothesis.)
Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee A Randomized, Controlled Trial (This was a large study but had a huge attrition rate, so the best the researchers could conclude was "Acupuncture seems to provide improvement in function and pain relief as an adjunctive therapy for osteoarthritis of the knee when compared with credible sham acupuncture and education control groups.")
Acupuncture does combat pain, EUR study finds, by Steve Connor, The Independent, January 21, 2006 (Note: despite the headline, what this article says is that MRI brain scanners showed that certain forms of acupuncture have a measurable effect on some people's brain. How many brains were studied isn't mentioned. The link between the MRI scans and relief from pain by acupuncture is speculation.)
Acupuncture a kind of chiropractic? (my question, not the title of the article)