Note: This is the fifth article in an ongoing series. If you haven’t read the first four, I recommend doing that before continuing:
- Chinese Medicine Demystified (Part I): A Case of Mistaken Identity
- Chinese Medicine Demystified (Part II): Origins of the Energy Meridian Myth
- Chinese Medicine Demystified (Part III): The “Energy Meridian” Model Debunked
- Chinese Medicine Demystified (Part IV): How Acupuncture Works
- Chinese Medicine Demystified (Part V): A Closer Look At How Acupuncture Relieves Pain
- Chinese Medicine Demystified (Part VI): 5 Ways Acupuncture Can Help You Where Drugs and Surgery Can’t
In this article we’re going to take a closer look at one of the latest theories on how acupuncture relieves pain. I’m going to break it down in plain language for my readers who don’t have a scientific background, but I’ll also provide references at the end of the article for those of you that want the nitty-gritty detail.
Keep in mind that pain research is a constantly evolving topic, and more is being learned each year about the mechanisms of pain relief via acupuncture. (Although as an interesting side note, according to Professor Bruce Pomeranz of the University of Toronto, we know more about acupuncture analgesia than many chemical drugs in routine use. For example, we know little about the mechanisms of most anesthetic gases but still use them regularly. 1)
What I’m going to share with you here represents the latest information from the American Academy of Pain Management and papers published in major peer-reviewed journals.
The physiology of pain
Before I explain the mechanism, I have to give you a little background on the physiology and neurology involved.
These nerves travel to the spine and pass their information on to neurons in the spinothalamic tract. This tract travels up the lateral dorsal horn of the spinal cord to the mid-brain.
The sensory nerves register pain. The position nerves tell the brain where that pain is coming from. So the sensory nerves say “ouch!” and the position nerves say “my knee!”.
There are two different types of sensory nerves involved in the acupuncture response. There are A-Delta fibers, which transmit sharp, burning pain messages. And there are C-fibers, which transmit dull, throbbing pain messages. A-Delta fibers are responsible for acute pain, and the signals they send are short-lived. They fire for a while and then the signals die off. C-fibers are responsible for chronic pain, and fire over an extended period of time.
A-Delta fibers are surrounded by a fatty, myelin sheath and the signals they send travel at 60 ft/second (that’s fast!). C-fibers are unmyelinated and their signals travel at 20 ft/second.
The A-Delta fibers mediate what is known as the “gamma loop”. The gamma loop is what gets activated when you stick your hand in a fire and your hand jumps back. These nerve fibers respond so quickly that your hand is immediately pulled back out of the fire. Chronic pain is a C-fiber problem, so C-fiber signals don’t travel quite this quickly.
Now, if the signal strength of the position nerves (the ones that register the location of pain) is what it’s supposed to be, the brain will release powerful natural pain relieving substances called enkephalins when it starts to receive those C-fiber messages. The enkephalins then plug up pain receptor sites in the brain, spine and capillary beds where the pain is located. This stops the pain in its tracks.
When things go wrong
Unfortunately, this is not what happens in people with chronic pain. Why? The current explanation is that the position nerve signal going up to the brain is too weak. The mid-brain can’t figure out where the pain is coming from, so the enkephalins don’t get released. This is why people in chronic pain often have trouble identifying exactly were the pain is. The neural threshold of the position nerve pathway is too low, so these people aren’t getting a clear signal where the pain is emanating from.
So that’s the first problem. The nerve signals are too weak and aren’t stimulating the brain to release the natural painkillers.
The second problem involves a survival mechanism that the brain evolved a very long time ago. Let’s take a knee injury as an example. When we bang our knee into something, the brain immediately takes measures to protect it. The brain doesn’t know what happened to the knee, but it assumes a worst-case scenario. Maybe you were bitten by a poisonous snake, or perhaps you seriously cut your knee and are losing a lot of blood.
What the brain does in this situation is restrict the blood supply going into the knee and the blood return coming out of the knee. This is actually a very intelligent choice. If you were bitten by a venomous snake, reducing blood flow around the knee will lessen the chance that the poison will spread. And if you were cut badly, reducing the blood flow will lessen your chances of bleeding to death.
This phenomenon is known as “guarding”. One of the results of reducing blood flow to the knee is that it becomes stiff and weak (sound familiar?). The brain wants it to feel weak because it is attempting to protect the knee. The brain doesn’t want whatever happened to the knee to threaten your chances for survival. So the brain sacrifices the health of the knee in order to keep you alive.
This was a great strategy before the advent of western emergency medicine. Almost everyone would prefer to lose function in their knee to death. But this isn’t a choice most of us have to make anymore, because when we cut our knee or get bitten by a snake we can go to the hospital and they can save our lives. And the problem is that cutting off blood flow to the knee – while it may have saved our lives in times past – dramatically limits the knee’s ability to heal.
Why? Because everything we need to heal is in the blood.
Stop and think about this for a minute. It’s such an obvious fact that it’s often overlooked in medicine. It’s not taught in such a direct way in medical school, but when I’ve explained it to a couple of doctors they both said something to the effect of, “Huh. I never thought of it that way, but it makes perfect sense.”
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How acupuncture helps
Okay, now we’re finally coming to the part where I explain how acupuncture fits into this picture. Inserting needles into the skin at peripheral sites “jumps” the neural threshold on the position nerve pathway, so that the signal can reach the brain. Once the signal reaches the brain, the whole series of events I described in the paragraphs above kicks in. The brain recognizes there is pain and where it’s coming from and releases enkephalins (painkillers).
This initial response is very fast. It should be perceived as almost instantaneous by the patient. But after the needling therapy the patient goes home and the pain comes back. The old bad habit of the nerve chronically firing below the threshold re-establishes itself. The body, just like the mind, has a hard time breaking bad habits.
But if the patient returns in a couple of days to get another treatment, the neural threshold will be jumped again. And if you keep jumping the neural threshold, eventually the central and peripheral nervous system figure out that it’s better to operate in the non-pain state than in the pain state. The technical term for this is re-establishment of neurological homeostasis.
Once this happens, the brain is no longer receiving pain signals from the knee. It no longer thinks the knee is injured or threatening the survival of the body. Now, instead of restricting blood flow to the knee, the brain does the opposite. It immediately vasodilates the capillaries and venules around the knee, which increases blood flow and begins the healing process.
What I’ve described above is how acupuncture relieves pain via the peripheral and central nervous system. There’s another pain relief mechanism that involves activating the immune system. Acupuncture needles are seen as foreign invaders to our body. Inserting a needle into the skin creates a micro-trauma that in turn stimulates the activity of immune cells that control inflammation.
There are millions of immune cells called mast cells in the dermis of the skin. These cells are like water balloons full of fatty molecules called leukotrienes and prostaglandins A & B. When a needle is inserted into the skin, it pops the mast cells and releases the leukotrienes and prostaglandins. Prostaglandins cause the cutaneous nerve in the area to fire (which activates the process described in the previous paragraphs). Leukotrienes are the strongest anti-inflammatory substance the body can produce.
Leukotrienes cause local capillaries to vasodilate and become permeable. White blood cells called macrophages leak out through the capillaries and immediately begin to heal the damage caused by the needle stick.
However, the healing caused by the needle insertion isn’t limited to the damage caused by the needle. If there is other damage in the area from previous traumas or injuries, that will also be addressed by the immune chemicals released by the needle insertion.
This means that the anti-inflammatory effect of acupuncture persists for 2-3 days (and sometimes as long as a week) after the needle is withdrawn.
Summary
Genetically the body is not designed to be in chronic pain. It will do everything it can to get us out of pain. Acupuncture “reminds” the body how it should be functioning, and helps its powerful inbuilt pain relieving mechanisms kick into gear. It’s a bit like jump starting a car. You’re not changing how the car works, or even adding anything to the engine. You’re just giving the battery a little jolt so the car can run how it’s supposed to.
It’s important to understand that this neurochemical mechanism not only provides pain relief, but also promotes homeostasis and tissue healing and regulates the immune, endocrine, cardiovascular and digestive systems. This explains why getting acupuncture treatment for your knee pain also addresses other problems you might have, such as asthma, irritable bowel, high blood pressure, anxiety and insomnia.
In the next and final article of this series, I’ll explain the advantages of Chinese medicine over western medicine for the prevention and treatment of most common health conditions.
Recommended resources for more information
- Biomedical Acupuncture for Pain Management, by Yun-Tao Ma, Mila Ma & Zang Hee Cho
- The Dao of Chinese Medicine, by Donald Kendall
- The Biology of Acupuncture, by George Ulett & Songping Han
- The Neuroimmune Basis of Anti-inflammatory Acupuncture, by Ben Kavoussi & Evan Ross
- Acupuncture in Medicine Journal (part of British Medical Journal)
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- Pomeranz B. Acupuncture analgesia – basic research. In Stux G, Hammerschlag R, editors: Clinical acupuncture scientific basis. Berlin 2001. Springer. ↩
Jesse,
Only one of the mechanisms I described (local tissue inflammatory response) absolutely requires puncture of the skin.
There are studies showing non-penetrative stimulation of points is as effective as penetrative acupuncture, and some that don’t. The jury is still out.
Chris and Philip,
At this point, I’m not suggesting that acupuncture, whether with needles or toothpicks, has no effect.
However, I thought the point of this article was to suggest a possible mechanism for the effects of acupuncture: that needles damage the skin, inducing release of painkillers, and that they stimulate the immune system, which helps healing and stuff.
It seems like these effects are dependent on the puncture of the needle, which toothpicks would not provide. So if toothpicks still work as well as needles, doesn’t this suggest that your mechanism is wrong?
That’s my concern at the moment. I think it would be good to discuss placebo at some point too, but I understand you’re planning some future posts on the subject, so I guess I’ll wait until then.
Jesse,
The following is an excerpt of a response I wrote to someone who claimed that acupuncture was “worthless” because it doesn’t outperform sham acupuncture (so-called placebo) in many clinical trials. I’m not saying you’re suggesting that, but my response to him applies here as well.
Here’s the short version: what we refer to as “placebo effect” should more accurately be called “self-healing”. Placebo effect involves known physiological effects, including the release of endorphins in the brain. To the body, placebo is just as real as any other “active treatment” that releases endorphins. The end result is the same, except that in the case of placebo, there are far fewer side effects and risks.
I think healthcare practitioners of every type should be doing everything they can possibly do to invoke the self-healing (i.e. placebo) response. Why wouldn’t we? Studies show it accounts for approximately 30-50% of most treatments, and sometimes as much as 100%. And that makes sense if you understand the holistic nature of the body and how it heals.
Read more below.
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I agree that the literature doesn’t support the idea that point selection matters, or that needling technique makes a difference, or that even breaking the skin makes a difference. However, I’ll also say that just because the literature doesn’t yet support a difference that doesn’t mean there isn’t one. As I pointed out earlier most studies on acupuncture are underpowered because sample sizes are based on the assumption of a 30% placebo effect, which is unsound.
You say that stimulating the skin without breaking it is not acupuncture. Perhaps not as it’s defined on the west. But here we have another mistranslation. Jesuit monks living in China translated the character “zhenzi” as “acupuncture”. Acus (needle) punctura (puncture). A more correct translation of the term is needle therapy. Sometimes the Chinese punctured the skin and left the needles there. Sometimes they used them for bloodletting. (Before you dismiss bloodletting as hopelessly archaic, keep in mind that it’s still used in modern medicine today. In fact, a fairly recent study showed that leech therapy [bloodletting] was more effective than surgery for osteoarthritis of the knee.) In Japan, some styles don’t puncture the skin at all.
My disagreement with you is on the nature, meaning and clinical significance of placebo.
Last week a patient came in to the clinic with a history of severe acid reflux / GERD. He had an h. pylori infection with ulcer about twelve years ago, and since then he’s had intractable reflux. He’s been treated with all of the PPIs and H2 blockers, has seen numerous doctors and has tried several different special diets. Nothing helped. As a last resort he came to try acupuncture. This was a difficult decision for him because he works as a research scientist. He came in saying “I don’t believe in this stuff, but I don’t want to have surgery so I’m willing to try it.” Fair enough, I said. Let’s give it a shot.
After four acupuncture treatments his symptoms have improved by 80%. For the first time in twelve years he is able to eat without having heartburn afterwards. And he’s been able to completely get off his medication.
You may argue that this is “placebo”. You may be right. But I say, “so what”?
What my patient is concerned with is getting rid of his problem. The western drugs, which arguably have a stronger placebo effect than acupuncture because of the widespread cultural belief in their effectiveness, weren’t able to help. Acupuncture has almost completely cured his problem in just two weeks. Do you think he cares whether it’s “placebo” or “active treatment”?
Experiences like this are common in the clinic. That’s why more and more people are getting acupuncture, in spite of what the clinical research shows or doesn’t show. People want to feel better and address their health problems, and acupuncture helps them do that.
I’m sorry this is so long but I still have a few points to make. My argument, as I already stated above, is that the concept of placebo has probably outlived its usefulness. Why? Because defining it in a consistent way that distinguishes it from specific treatment effects seems impossible. We should instead be focusing on the choice of outcome measure and the magnitude of the effect, rather than on interventions that are difficult to define.
As an example, when compared with usual obstetric care, the presence of a support person during labor has dramatic effects on the use of analgesics, anesthesia, episiotomy, and cesarian section and the incidence of severe postpartum depression. (http://www.ncbi.nlm.nih.gov/pubmed/10796179)
What do we call the additional effect of a support person, which are clearly measurable and are clearly producing real physiological changes? Do we call it placebo? Why? How is that distinguishable from the effects of the other methods of obstetric care?
The answer is that it’s only distinguishable by the name and meaning we’ve applied to those effects. We’ve decided that they are secondary (and by implication less important) than the effects of the treatment being primarily studies. But I assure you that from the patient’s perspective (and one would hope the doctor treating her) those so-called “placebo” effects are no less significant in the outcome.
Let me pose a hypothetical question for you. Say you could choose between two treatments for a particular condition. Both of these treatments have roughly the same outcome in clinical studies. However, one treatment carries significant side effects and risks, including irreversible physiological damage that in fact perpetuates and worsens the problem you sought help for. The other treatment is relatively free of side effects and risks, is well tolerated, and does nothing but improve your problem.
Which would you choose?
The scenario above is not hypothetical. It describes the choice a patient with depression has when deciding between an SSRI or a sugar pill. Sapirstein and Kirsch conducted a meta-analysis of 3,000 patients who received either antidepressants, psychotherapy, placebo or no treatment at all. They found that 27% of therapeutic responses were attributable to drug activities, 50% to psychological factors, and 23% to “non-specific” factors. In other words, 73% of the response to the drug was unrelated to its pharmacological activities – and antidepressants may be no better or more specific than placebos. (Read this article for more info: http://chriskresser.com/antidepressants-not-as-effective-as-research-suggests)
If you’re going to be consistent with your terminology, you’ll have to refer to antidepressants (and some other commonly used drugs) as placebos. They are no less of a placebo than acupuncture is according to the research.
Some doctors are in fact aware of this, and yet they go on prescribing them. They argue that the benefit of recovering from depression outweighs the ethical considerations of prescribing a placebo without the patient’s knowledge. Doctors are willing to do this in spite of the fact that these “placebos” (active drugs, in this case) have serious side effects and risks.
If it were me, I’d take the placebo, thanks. I’ll get the same improvement without any of the risks.
This is why I asked you what your definition of placebo is. The terminology is important here, because what you refer to as placebo is in fact a measurable treatment effect with a significant clinical outcome.
Moreman and Jonas suggest what I believe is a more useful term, which is “meaning response”. They define the meaning response as “the physiologic or psychological effects of meaning in the origins or treatment of illness.” (http://www.annals.org/content/136/6/471.full) They provide many examples where the meaning ascribed to a treatment produces different outcomes.
One of my favorites is a study in which 835 women who regularly used analgesics for headache were randomly assigned to one of four groups. One group received aspirin labeled with a widely advertised brand name. The other groups received the same aspirin in a plain package, placebo marked with the same widely advertised brand name, or unmarked placebo.
In this study branded aspirin worked better than unbranded aspirin, which worked better than branded placebo, which worked better than unbranded placebo. Aspirin relieved headaches, but so does the knowledge that the pills you are taking are “good” ones. (http://bit.ly/9JxGe0)
It is also known that placebo and acupuncture analgesia elicit the production of endogenous opiates. In both cases the analgesic effect can be blocked with injection of nalexone.
So, to say that a treatment such as acupuncture “isn’t better than placebo” does not mean that it does nothing. Nor does it mean that acupuncture doesn’t improve clinical outcomes. Nor does it mean that acupuncture is not a better choice than another treatment with similar outcomes, when all factors are considered (side effects, risks, complications, etc.)
In any event, while the research community goes on insisting that acupuncture is “just placebo” (an inane statement that reflects a lack of understanding of the nature and value of placebo), I will go on giving my so-called “placebo” treatment to patients and improving their health and quality of life.
I leave you with a quote:
“Most of us have been taught that western medicine is based on science, and science represents the unbiased, objective way to search for truth. However, subjective judgments lie behind all the facets of “scientific” research. (Not to mention that nowadays, most clinical research are funded by pharmaceutical companies)
All data are theory-, method-, and measurement-dependent. That is, “facts” are determined by the theories and methods that generate their collection; indeed, theories and methods create the facts.
This means that how the problem will be defined, which model(s) of inquiry will be considered to be relevant to the problem as defined, which model(s) of inquiry will be considered to be relevant to the problem as defined, where one shall look (and, by implication where on shall not look) for evidence–and even what one shall consider to be constitutive of evidence–are all determined by the paradigmatic “map” or world view to which the scientist is committed.”
–John Ratcliffe, Notions of validity in qualitative research methodology
@Jesse
According to classical meridian theory the meridians are like major vessels and the collaterals link them together. The whole body system is covered by them. It is similar to how you have major arteries and veins, then smaller ones, down to capillaries, yet every nook and cranny of the body is reached by it.
Hence, according to Sun Simiao (if memory serves me right), if there is pain, there is an acupuncture point. These are called locus dolendi or “ah shi” points. What can be deduced from this is that sticking a needle anywhere can have an effect. The points are just places where effects are more profound imho.
Now, there are many ways to influence these points and meridians. Acupuncture is one. Others include moxibustion and tui na massage. Think about it, in tui na you use touch to stimulate these points, and they also work. Moxibustion may not even have actual physical contact with the patient, but there is a physiologic reaction to the heat and volatile oils released. My point is traditional chinese medicine recognizes that acupuncture is not the only way to stimulate points and elicit reactions. Even simple touch can do. Given this, then even “fake” acupuncture can be as effective (at times) or only slightly less effective (sometimes even more) because it’s not how the stimulation occurs, it’s the fact that stimulation does occur.
So why use needles? If I want to hit eight points at once with only two hands, you can see how using needles makes treatment more efficient and less tiring than my hands and fingers! It also enables me to treat more than one patient at a time. From experience, using needles is sometimes less painful for the patient from using finger pressure to reach points, LI 4 and LIV 3 come to mind…
What I meant was, fake acupuncture using toothpicks is just as effective as any kind of needling, or any kind of needling is no more effective than fake acupuncture.
What do you think of this study? It seems like a good one: large size, decently done, published in a respectable journal. But it shows that fake acupuncture using toothpicks is no more effective than any kind of needling.
I don’t know much about reflexology as a system, and am not planning any articles on it.
Thanks for your feedback, Tim!
Now that you so brilliantly demystified acupuncture, what do you think of reflexology? Can you demystify that as well? Is that a part of chinese medicine as well or is that a western invention?
“Because we practice in an environment dominated by evidence-based medicine.” True, and again, context is everything.
Chris, we may not agree on all points and that’s fine with me. I am glad to hear that your article is bringing more people to try acupuncture. That’s a really good thing. This discussion has prompted me to start reading the Dao of Chinese Medicine. When I can overlook Kendall’s occasional opiniated and dogmatic tone, I can see that there is a lot to learn from his interpretation. I think it is possible to discuss chinese medicine in terms of physiology without being dogmatic about it. It is also interesting to read Manaka’s Chasing the Dragon’s Tail, (which I highly recommend even if you don’t practice his method,) for a different viewpoint. I think it would be interesting to have this conversation again in 20, 30 years’ time to see what new breakthrough in the western medicine can shed more light on the subject. The fascinating thing about chinese medicine is that many new principles and findings in biophysics/physics/biochemistry was actually already mentioned in the ancient texts!
I appreciate your effort in writing this articles and the discussions. See you in school!
Touch also stimulates oxytocin release. Oxytocin plays a major role in regulating the parasympathetic nervous system. Although it’s commonly known for its effects in childbirth and lactation, it’s range of action is much larger.
All mammals, with the exception of humans now, have extensive grooming rituals. There’s a lot of physical contact during grooming, and that has a calming effect on the nervous system. This is one reason why any therapeutic modality involving touch – including acupuncture – can be so powerful. The desire for touch is in our genes.
addendum: hypothetically they can have an effect, but the points are areas which clinical experience has proven to have stronger more specific effects. Just my two cents.
My theory about why touch already has an effect is this: acupuncture can be considered a form of really really really deep tissue massage (think about it) and in some patients, just a light touch can already stimulate the same receptors that acupuncture needles stimulate.
TCM wise, the theory of meridians and collaterals infers that Qi and Blood ultimately cover the whole body – so hypothetically inserting a needle or applying pressure anywhere can have an effect.
As Philip has mentioned, it’s refreshing to have an intelligent conversation about this stuff.
Donna, it is becoming increasingly accepted in the research community that so-called “sham” acupuncture (that doesn’t penetrate the skin) has a biological effect. I have a book on the biophysics of energy medicine, so I’m familiar with the potential mechanisms for contact needling that you describe. However, it’s also possible that simply stimulating the surface of the skin with a needle is enough to activate the nerve impulse, which in turn would be enough to begin the cascade of neuroimmune responses I’ve described in previous posts.
Even acupressure and massage can be explained physiologically. It’s not really a mystery at all.
I’m not making the claim that biomedicine can explain everything that happens under the frame of Chinese medicine. But I am arguing that the general mechanisms are fairly well understood, and that they don’t depend on the mistaken idea that energy is circulating through the body. Energy doesn’t circulate. The potential for energy does.
I think we need to be aware of the research and find ways to validate acupuncture’s effectiveness within the existing framework. Why? Because we practice in an environment dominated by evidence-based medicine. Obama recently announced that he’s interested in incorporating acupuncture into the healthcare system. But he specifically added a caveat – that we need more research first.
Sure, we’ll always be able to help the people who are interested in acupuncture. But if we want to move beyond that 1.5% of the population (a pitifully small number), we have to find some common ground.
I’m interested in helping as many people as I can with this remarkable medicine. That’s why it’s so important to me to find ways to talk about it with people that get them interested and excited. That’s what these posts have been about.
I’m glad they’ve had some effect. I’ve received 10-12 requests for referrals to acupuncturists in various parts of the country from readers.
There are many issues to discuss here, not just one. I probably can’t get into discussing some of it without opening some other cans of worms. 🙂
Chris, I am not saying outcome or symptom reduction don’t matter, or that current research methods have absolutely no value in evaluating acupuncture. Current research methods have some value if you can see it for what it is–the context of it, the paradigm in which it is based on, notice what it omits, and the underlying limitations, instead of believing that is the objective whole truth.
Right now, most studies in medicine are quantitative research. Because of the holistic nature of Chinese medicine, I would like to see more qualitative research being done. I don’t have an idea how it should be done, as designing studies has not been my area of focus. I would leave it to people who are more inclined to do so.
On the problem of current acupuncture studies: some “sham” acupuncture in researches use non-penetrating needle to stimulate a acupuncture point. However, many Japanese blind acupuncturists use non-penetrating “contact needles” in acu treatments. Dr. Bear, whom I studied with, uses such method, and I have witnessed its effectiveness. Sometimes, when I am deciding on which points to select, I would test them by placing my finger lightly on one point at a time. Patients can usually tell me which point has better effect on their pain, breathing etc.
So yes, even just placing my finger on an acu point can elicit a immediate response from the body. How can that be explained?
There are many ways to understanding the body that goes beyond the biochemistry model of western medicine, and actually more based on the 20-21st century modern physics findings, some look into the bioelectricity and electromagnetic field generated by the body (e.g. <i>Root of Chinese Qigong</i> by Dr. Yang Jwing Ming), some focuses on the signal system functions derived the way our body is organized and developed since it’s embryonic stage, (<i>Chasing the Dragon’s Tail </i> by Yoshio Manaka, MD, which I just started reading, fascinating work so far) some look at how universe is entirely holographic in nature, including our body (<i>Holographic Universe</i> by Michael Talbot), etc. etc.
Philip, I agree on the value of being open-minded and exchanging idea. There is a fable of the 3 blind people who never encountered an elephant before. One day, there is an elephant in town, they all touched a very different part of the elephant and drew a different conclusion of what an elephant is like, and started arguing with one another and insisting the others are wrong, and their own idea of the elephant is the only truth.
They would have learned from each other if they can just be open-minded and discuss more openly.
Jesse, I hope this is not too overwhelming. It has taken me many years of thinking/ learning about the subject of healing, what I found is a web that everything is connected with everything else, and that’s why it is hard to just talk about one thing without mentioning all other things.
“Defining what a healthy human being is seems like a good idea. How does one go about doing that?” This is entirely subjective. We can go on and go about what makes us healthy or not, but in the end, it is your direct experience that counts most.
Chris, thanks for mentioning the importance of meaning response, and that one of the important advantage of acupuncture is that it is low-risk with little side effects. I completely agree with that.
This is the benefit of open discussion and open minds: we exchange ideas, clarify misconceptions, etc etc. =)
Yes I am aware of those studies involving sham and active acu. I’ve blogged about some myself. I could always use more references though, and maybe you have some I’ve missed. I’d appreciate an email heh heh.
And lastly, yes that’s the important thing for us. If only it were the important thing for all.
To reiterate, I’m not saying I don’t think point selection matters. It certainly seems to in my experience.
What I am saying is that current research doesn’t support the idea that it matters.
There is a series of German studies that were very well designed that compared a no treatment group with a sham (minimal acupuncture) and active (traditional acupuncture) group. In four out of five of the studies, both sham and active acupuncture produced greater pain relief than no treatment, but active acupuncture didn’t outperform sham. (If you’d like the references for these, let me know).
In the end the important thing is that patients are getting better with almost no risk and side effects.
“I don’t entirely agree that it’s not possible to do good research on the effectiveness of acupuncture” I never meant to say that. I just said that I don’t think that double blind studies are the best way to do it.
“What probably has a greater effect on outcomes than the practitioner’s skill or point selection is the meaning that the patient attributes to the treatment. ”
-respectfully slightly disagree. I’ve had long time patients where, I admit, sometimes my diagnosis was wrong, my point selection didn’t work. But when I realized my error and corrected my manipulation and/or points used and that achieved the desired effect. These are patients that I have seen several times over the years and return for new problems. Hence, they already have confidence in me and in the medicine. Yet if you do the wrong thing it doesn’t work… Hardly ascribable to placebo effect.
I am aware that the WHO has separate guidelines for acupuncture research – I cannot bring up the info off the top of my head but I now have fodder for future blog posts.
Suffice it to say that I have previously written on one misconception about acupuncture that makes it difficult to formulate studies on it . In summary it can be stated that “Acupuncture is a procedure, not a pill.” It is practitioner dependent. There is no one set of “points” for every named western condition. A practitioner has to determine the root cause behind the given symptoms.
For example both “heat” and “cold” can cause similar respiratory symptoms. It takes skill both in history taking and physical exam to distinguish between them. This, plus taking into account the patient’s constitution, occupation, living conditions and diet, may lead a practitioner to prescribe seemingly totally different treatments for what appears to be the same condition. On the other hand, the same “root” may manifest differently in different people. Sudden fits of anger may manifest as vertigo in one patient, liver attacking the spleen/stomach and leading to indigestion in another. In that way, different conditions may appear to be getting similar treatments.
I hope this gives an idea on how difficult it is to do double blind studies.
Philip,
I don’t entirely agree that it’s not possible to do good research on the effectiveness of acupuncture. The variation of practitioner skill and point selection can be addressed, at least to some extent, in a well-designed study.
I know of several studies that have compared various methods of point selection. For example, such a study may have three groups: an untreated control, a “sham” group (with non-penetrating needles like the Streitenberg needle) and a “traditional acupuncture” (TCA) group. The sham group gets skin stimulation at non-acupoints. The TCA group gets regular acupuncture at points selected based on the patient’s disease condition and constitution, and any other appropriate diagnostic methods (i.e. tongue and pulse).
I’m not sure how much you follow the literature, but there are a surprising number of studies that compare traditional point selection methods including a full diagnosis with “cookbook” acupuncture (i.e. using the same points for each patient). Unfortunately for acupuncturists, these studies don’t demonstrate that point selection makes a difference in patient outcomes.
Note that I’m not saying point selection doesn’t make a difference. I’m saying the studies done so far don’t demonstrate that it makes a difference in outcomes.
I’ve seen studies that have used three different acupuncturists, all with more than ten years of training, to administer traditional treatments. Many researchers working in this field are aware that Chinese medicine diagnosis and treatment is individualized, so the more recent studies usually incorporate it.
What probably has a greater effect on outcomes than the practitioner’s skill or point selection is the meaning that the patient attributes to the treatment. This can be influenced by the practitioner’s manner, the patient’s attitude about the treatment and hope that it will work, and numerous other factors. The importance of the meaning response (which is usually referred to as placebo effect) can’t be underestimated, and as practitioners we ignore it at our own peril.
Donna,
I agree that the lens we look through and the way we define health and disease will affect both the design and outcomes of clinical research.
However, I don’t agree that current research methods aren’t useful for evaluating the effectiveness of Chinese medicine for particular outcomes.
We consider the role of the whole body when we examine and treat a patient, but if we fail to address their chief complaint, we’re not doing our job. That’s why a study that examines the effect of acupuncture on elbow pain is still useful in determining whether acupuncture can relieve elbow pain, provided the study is designed correctly (which all too often it isn’t).
Acupuncturists would point out that there are a multitude of factors influencing whether a person’s elbow pain improves above and beyond the acupuncture treatment. But that’s just as true in a study examining whether a drug works for elbow pain, and assuming the sample is properly randomized and the study is properly powered, the effect of this kind of variation should be minimized.
What is the research methodology you propose for evaluating Chinese medicine? How would it differ from current methodology?
I would like to thank everyone for your willingness to discuss things with me. I have encountered many ideas in this series for the first time, and am sorta working out what I think of everything as I go. So thanks for your patience.
Philip,
I’m glad to hear that Chinese medicine is based on science too. In that case it should eventually be accepted into the mainstream, I believe.
It’s true there is some corruption in science, but I think most of it is eventually worked out through peer review and replication. After all, scientists aren’t paid to question the work of their colleagues, but they do it anyway 🙂
I agree that reconciling terminology should help. Defining concepts precisely in ways everyone understands leads to clearer discussions.
Donna,
Defining what a healthy human being is seems like a good idea. How does one go about doing that?
You also say chinese medicine should be scrutinized a different way. What sort of research methodology might work for the purpose?