Back • Home • Up • Next

Acupuncture?
 
Confusion on acupuncture benefit

A major review of the effectiveness of acupuncture has concluded that it is hard to find a difference between "true" and "sham" versions.

BBC Online
28 Jan 2009

The research comes just a week after a similar review suggested that both could prevent headache.

It looked at trials involving 3,000 patients with arthritis, migraine, low back pain and post-operative pain.

The results questioned the "traditional foundation" of acupuncture, the British Medical Journal study concluded.

 
“ Sham acupuncture often consists of superficial, off point needling, but this may still have a physiological effect ”
Dr Adrian White
Peninsula Medical School
 
The value of acupuncture remains highly controversial, with conflicting results from many studies.

Much of the argument surrounds the status of "sham" acupuncture, which is frequently used in trials against traditional acupuncture.

While traditional acupuncturists insert needles in acupuncture points located along what they describe as "energy meridians" - a concept for which many scientists say there is no evidence - sham acupuncture places needles away from these points.

However, the needles are still inserted beneath the skin in both varieties, and proponents of non-traditional acupuncture suggest that both varieties may be having a physiological effect - just not in the manner suggested by traditionalists.

The latest review, compiled by the Nordic Cochrane Centre in Copenhagen, found no "clinical relevance" to the differences between traditional and "sham" acupuncture, but found that patients given "sham" acupuncture did experience a small amount pain relief compared to those who had received no treatment.

Genuine effect

The authors said that future trials should be trying to work out how much of this effect was due to "placebo" - the effect of undergoing the acupuncture ritual - and how much was a genuine physiological effect.

They said that the findings cast doubt on both traditional acupuncture, and the theory that acupuncture had an important effect on pain.

However, a similar trial carried out by the Cochrane Collaboration last week into the effects of acupuncture in preventing headache and migraine concluded that both sham and traditional acupuncture offered more benefits than conventional painkillers.

Dr Adrian White, a researcher into acupuncture at the Peninsula Medical School in south west England, and a member of the Medical Acupuncture Association, said that "sham" acupuncture might well be having an effect rather than acting as a simple placebo version of the treatment.

"Sham acupuncture often consists of superficial, off point needling, but this may still have a physiological effect.

"Sham controlled studies are of little value in estimating benefits to patients."
 
Puncturing the Acupuncture Myth

By definition, “alternative” medicine consists of treatments that have not been scientifically proven and that have not been accepted into mainstream medicine. The question I keep hearing is, “But what about acupuncture? It’s been proven to work, it’s supported by lots of good research, more and more doctors are using it, and insurance companies even pay for it.” It’s time the acupuncture myth was punctured — preferably with an acupuncture needle. Almost everything you’ve heard about acupuncture is wrong.

by Harriet Hall, M.D.
eSkeptic, Oct 8th 2008

To start with, this ancient Chinese treatment is not so ancient and may not even be Chinese! From studying the earliest documents, Chinese scholar Paul Unschuld suspects the idea may have originated with the Greek Hippocrates of Cos and later spread to China. It’s definitely not 3000 years old. The earliest Chinese medical texts, from the 3rd century BCE, do not mention it. The earliest reference to “needling” is from 90 BCE, but it refers to bloodletting and lancing abscesses with large needles or lancets. There is nothing in those documents to suggest anything like today’s acupuncture. We have the archaeological evidence of needles from that era — they are large; the technology for manufacturing thin steel needles appropriate for acupuncture didn’t exist until about 400 years ago.

The earliest accounts of Chinese medicine reached the West in the 13th century: they didn’t mention acupuncture at all. The first Westerner to write about acupuncture, Wilhelm ten Rhijn, in 1680, didn’t describe acupuncture as we know it today: he didn’t mention specific points or “qi;” he spoke of large gold needles that were implanted deep into the skull or “womb” and left in place for 30 respirations.

Acupuncture was tried off and on in Europe after that. It was first tried in America in 1826 as a possible means of resuscitating drowning victims. They couldn’t get it to work and “gave up in disgust.” I imagine sticking needles in soggy dead bodies was pretty disgusting.

Through the early 20th century, no Western account of acupuncture referred to acupuncture points: needles were simply inserted near the point of pain. Qi was originally vapor arising from food, and meridians were channels or vessels. A Frenchman, Georges Soulie de Morant, was the first to use the term “meridian” and to equate qi with energy — in 1939. Auricular (ear) acupuncture was invented by a Frenchman in 1957.

The Chinese government tried to ban acupuncture several times, between 1822 and World War II during the time of the Chinese Nationalist government. Mao revived it in the “barefoot doctor” campaign in the 1960s as a cheap way of providing care to the masses; he did not use it himself because he did not believe it worked. It was Mao’s government that coined the term “traditional Chinese medicine” or TCM.

In 1972 James Reston accompanied Nixon to China and returned to tell about his appendectomy. It was widely believed that his appendix was removed under acupuncture anesthesia. In reality, acupuncture was used only as an adjunct for pain relief the day after surgery, and the relief was probably coincident with the expected return of normal bowel motility. A widely circulated picture of a patient allegedly undergoing open heart surgery with acupuncture anesthesia was shown to be bogus. If acupuncture is used in surgery today, it is used along with conventional anesthesia and/or pre-operative medication, and it is selected only for patients who believe in it and are likely to have a placebo response.

As acupuncture increased in popularity in the West, it declined in the East. In 1995, visiting American physicians were told only 15–20% of Chinese chose TCM, and it was usually used along with Western treatments after diagnosis by a Western-trained physician. Apparently some patients choose TCM because it is all they can afford: despite being a Communist country, China does not have universal health coverage.

There were originally 360 acupuncture points (loosely based on the number of days in a year rather than on anatomy). Currently more than 2000 acupuncture points have been “discovered”, leading one wag to comment that there was no skin left that was not an acupuncture point. There were either 9, 10, or 11 meridians — take your pick. Any number is as good as another, because no research has ever been able to document the existence of acupuncture points or meridians or qi.

Does acupuncture work? Which type of acupuncture? And what do you mean by “work”? There are various different Chinese systems, plus Japanese, Thai, Korean and Indian modalities, most of which have been invented over the last few decades: whole body or limited to the scalp, hand, ear, foot, or cheek and chin; deep or superficial; with electrified needles; with dermal pad electrodes and no skin penetration.

Acupuncture works in the same manner that placebos work. It has been shown to “work” to relieve pain, nausea, and other subjective symptoms, but it has never been shown to alter the natural history or course of any disease. Today it’s mostly used for pain, but early Chinese acupuncturists maintained that it was not for the treatment of manifest disease, that it was so subtle that it should only be employed at the very beginning of a disease process, and that it was only likely to work if the patient believed it would work. Now there’s a bit of ancient wisdom!

Studies have shown that acupuncture releases natural opioid pain relievers in the brain: endorphins. Veterinarians have pointed out that loading a horse into a trailer or throwing a stick for a dog also releases endorphins. Probably hitting yourself on the thumb with a hammer would release endorphins too, and it would take your mind off your headache.

Psychologists can list plenty of other things that could explain the apparent response to acupuncture. Diverting attention from original symptoms to the sensation of needling, expectation, suggestion, mutual consensus and compliance demand, causality error, classic conditioning, reciprocal conditioning, operant conditioning, operator conditioning, reinforcement, group consensus, economic and emotional investment, social and political disaffection, social rewards for believing, variable course of disease, regression to the mean — there are many ways human psychology can fool us into thinking ineffective treatments are effective. Then there’s the fact that all placebos are not equal — an elaborate system involving lying down, relaxing, and spending time with a caring authority can be expected to produce a much greater placebo effect than simply taking a sugar pill.

There are plenty of studies showing that acupuncture works for subjective symptoms like pain and nausea. But there are several things that throw serious doubt on their findings. The results are inconsistent, with some studies finding an effect and others not. The higher quality studies are less likely to find an effect. Most of the studies are done by believers in acupuncture. Many subjects would not volunteer for an acupuncture trial unless they had a bias towards believing it might work. The acupuncture studies coming from China and other oriental countries are all positive — but then nearly everything coming out of China is positive. It’s not culturally acceptable to publish negative results because researchers would lose face and their jobs.

The biggest problem with acupuncture studies is finding an adequate placebo control. You’re sticking needles in people. People notice that. Double blinding is impossible: you might be able to fool patients into thinking you’ve used a needle when you haven’t, but there’s no way to blind the person doing the needling. Two kinds of controls have been used: comparing acupuncture points to non-points, and using an ingenious needle in a sheath that appears to have penetrated the skin when it hasn’t.

In George Ulett’s research, he found that applying an electrical current to the skin of the wrist — a kind of TENS (transcutaneous electrical nerve stimulation) treatment — worked just as well as inserting needles, and one point on the wrist worked for symptoms anywhere in the body.

Guess what? It doesn’t matter where you put the needle. It doesn’t matter whether you use a needle at all. In the best controlled studies, only one thing mattered: whether the patients believed they were getting acupuncture. If they believed they got the real thing, they got better pain relief — whether they actually got acupuncture or not! If they got acupuncture but believed they didn’t, it didn’t work. If they didn’t get it but believed they did, it did work.

Acupuncturists have used ingenious rationalizations to try to salvage failed studies. In a recent study using sham acupuncture as a control, both the sham placebo acupuncture and the true acupuncture worked equally well; both were better than no treatment. The obvious conclusion was that acupuncture was no better than a placebo. Instead, the researchers insisted that real acupuncture worked and that placebo acupuncture worked too! Another acupuncture researcher recently decided not to use a placebo control in his research because any stimulation of the skin might be effective — which seems to me to pretty much destroy the whole rationale for acupuncture, but he didn’t seem to notice that. If that were true, we could just caress or massage our patients instead of inserting needles and postulating imaginary qi and meridians.

Considering the inconsistent research results, the implausibility of qi and meridians, and the many questions that remain, it’s reasonable to conclude that acupuncture is nothing more than a recipe for an elaborate placebo seasoned with a soupçon of counter-irritant. You can play human pincushion if you want, and you might get a good placebo response, but there’s no evidence you’ll get anything more.

Note: Part of this article was adapted from a PowerPoint presentation prepared by the late Dr. Robert Imrie. It’s well worth a visit; it includes great pictures of camelpuncture, goatpuncture, and chickenpuncture.
 
Acupuncture 'like migraine pill'

Acupuncture - real or sham - is as good as medication for preventing migraine, a study has suggested.

BBC Online
March 2006

German researchers treated almost 900 patients with either standard drugs, traditional Chinese acupuncture or "fake" acupuncture.

Virtually the same proportion of people in each group found the number of days affected by migraine was halved.

The UK's Migraine Association said the Lancet Neurology study showed there was no "one-size-fits-all" treatment.

'Effectiveness key'

Migraine affects up to 15% of the UK population - around two thirds of sufferers are women.

An attack can last up to 72 hours, and sufferers experience an average of 13 attacks a year.

The results come from acupuncture trials in Germany, where the treatment is commonly used to treat migraine.

The people in the study were given two sessions of either traditional Chinese acupuncture or a "sham" version - where needles were put into areas of the skin not used in traditional practice.

A third group was given standard prophylactic treatment of either beta blockers, calcium channel blockers or antiepileptic drugs.

They were treated over six weeks.

'Very interesting'

The researchers then returned to the patients between 23 and 26 weeks later and checked on whether they had been "migraine free" for 50% of days.

It was found 47% of those receiving traditional acupuncture, 39% of those given sham acupuncture and 40% of those in the drug treatment group had been migraine-free for at least 50% of the time.

Writing in Lancet Neurology, the researchers led by Dr Hans Christoph Diener of the University of Duisberg-Essen, said the results were surprising and the mechanisms unknown.

They were therefore difficult to explain, he added.

He said: "Ultimately, one could argue that the efficacy of a treatment, especially a treatment with almost no adverse events of contra-indications, is more important than the knowledge of the mechanism of action of this particular therapy.

"The decision whether acupuncture should be used in migraine prevention remains with the treating physician."

Ann Turner, director of the UK Migraine Action Association, said: "This is very interesting research.

"Migraine is such an individual and complex condition that not one treatment will work for everyone."
 
Traditional Chinese acupuncture may have no point, research finds

Acupuncture can halve the incidence of headaches among people who are susceptible to them, scientists report today.

The Independent
29 July 2005

But it remains an open question whether traditional acupuncture arried out according to the principles of the ancient Chinese practice is necessary. Researchers found that sticking pins in randomly over the body so they just penetrated the skin was equally effective.

Scientists in Germany who carried out one of the largest studies into the alternative therapy found patients who received acupuncture had seven fewer days with headaches over the four weeks following treatment.

Acupuncturists say there are 365 pressure points that must be stimulated for the therapy to heal. These are said to tap into a dozen body energy channels, or meridians. But patients who had the minimal acupuncture, with randomly placed needles, had 6.6 fewer days with headaches following treatment, an improvement almost equal to that for the traditional acupuncture group.

Both groups received 12 sessions of the therapy over eight weeks. A third group, who received no treatment, had 1.5 fewer days with headaches in the four weeks following the trial.

There were 270 patients in the study in total who had reported suffering tension headaches at least eight days a month.

Writing in the British Medical Journal, the researchers from the Centre for Complementary Medicine Research at the University of Munich say the effectiveness of the "minimal" acupuncture is "intriguing". Even though fewer needles were used and they were inserted less deeply than in traditional acupuncture, their physiological effect cannot be considered "completely inert". Alternatively, the therapy may have produced a placebo effect more
potent than that associated with drugs, they suggest.

The study is the latest to suggest that "minimal" or "sham" acupuncture is as good as the real thing. A study last year of 302 mostly female migraine patients found both methods were equally effective in reducing attacks.

An earlier study, published in the BMJ last year, also found evidence for the effectiveness of acupuncture as a treatment for headaches and migraines. A trial organised by the Royal London Homeopathic hospital involving 400 patients with frequent head-aches found their headaches sharply reduced after 12 sessions of acupuncture.

The patients were mainly women who had been taking three or four paracetamol a day, on average, before the study. A year later, having had 12 acupuncture sessions, they had fewer headaches, made fewer visits to the GP, used less medication and took less time off sick.

But sceptics remain. At least 26 randomised controlled trials had previously been published showing no convincing effect of acupuncture on headaches.

Acupuncture can halve the incidence of headaches among people who are susceptible to them, scientists report today.

But it remains an open question whether traditional acupuncture carried out according to the principles of the ancient Chinese practice is necessary. Researchers found that sticking pins in randomly over the body so they just penetrated the skin was equally effective.

Scientists in Germany who carried out one of the largest studies into the alternative therapy found patients who received acupuncture had seven fewer days with headaches over the four weeks following treatment.

Acupuncturists say there are 365 pressure points that must be stimulated for the therapy to heal. These are said to tap into a dozen body energy channels, or meridians. But patients who had the minimal acupuncture, with randomly placed needles, had 6.6 fewer days with headaches following treatment, an improvement almost equal to that for the traditional acupuncture group.

Both groups received 12 sessions of the therapy over eight weeks. A third group, who received no treatment, had 1.5 fewer days with headaches in the four weeks following the trial.

There were 270 patients in the study in total who had reported suffering tension headaches at least eight days a month.

Writing in the British Medical Journal, the researchers from the Centre for Complementary Medicine Research at the University of Munich say the effectiveness of the "minimal" acupuncture is "intriguing". Even though fewer needles were used and they were inserted less deeply than in traditional acupuncture, their physiological effect cannot be considered "completely inert". Alternatively, the therapy may have produced a placebo effect more
potent than that associated with drugs, they suggest.

The study is the latest to suggest that "minimal" or "sham" acupuncture is as good as the real thing. A study last year of 302 mostly female migraine patients found both methods were equally effective in reducing attacks.

An earlier study, published in the BMJ last year, also found evidence for the effectiveness of acupuncture as a treatment for headaches and migraines. A trial organised by the Royal London Homeopathic hospital involving 400 patients with frequent head-aches found their headaches sharply reduced after 12 sessions of acupuncture.

The patients were mainly women who had been taking three or four paracetamol a day, on average, before the study. A year later, having had 12 acupuncture sessions, they had fewer headaches, made fewer visits to the GP, used less medication and took less time off sick.

But sceptics remain. At least 26 randomised controlled trials had previously been published showing no convincing effect of acupuncture on headaches.
 
Fake acupuncture 'aids migraines'
Fake acupuncture works just as well as the real thing in relieving migraines, scientists have found.

03/05/2005

In a study of more than 300 patients, both genuine and sham acupuncture reduced the intensity of headache compared with no treatment at all.

But real acupuncture was no better than needles placed at non-acupuncture points on the body, the Journal of the American Medical Association reports.

It goes against recent research showing acupuncture works in its own right.

Placebo effect
It has long been debated whether acupuncture works in a unique way or whether any benefits gained are merely down to a person's expectation that the treatment will work.

The latter is called the placebo effect.

To investigate this, Dr Klaus Linde and colleagues randomly assigned 302 people with migraines to one of three groups.

One group received 12 sessions of genuine acupuncture over eight weeks.

Another group received 12 similar sessions of acupuncture, except the needles administered were not placed in parts of the body thought to relieve migraine pain, hence any benefit would likely be placebo rather than real, according to the researchers.

The third group received no treatment but were placed on a waiting list to see a migraine doctor.

Less pain
All of the patients kept diaries about their migraine symptoms.

While the patients on the waiting list continued to have headaches just as often, the ones who received acupuncture - sham or real - had fewer headaches.

The average number of days blighted by a headache went down from about five to two.

This may be due to "non-specific physiological effects of needling, to a powerful placebo effect or a combination of both", said the researchers.

But Dr George Lewith, who recently published work suggesting acupuncture has an effect above and beyond placebo, said although the present study was well conducted, it did not truly test the placebo effect.

"We do not know whether this sham acupuncture is active or not. To test for placebo effect you have to use an intervention that only raises a patient's expectations.

"The authors note themselves that something else could have been going on as well."

The British Acupuncture Council said that using pre-prescribed acupuncture points for all patients might have skewed the results.

"Acupuncture treatment is different for each person. The formulaic treatment part of the study would be inappropriate for some patients. This would reduce the apparent effectiveness in the acupuncture group."

The council said there was good evidence to suggest acupuncture was helpful for treating migraine.

Ann Turner of the Migraine Action Association said: "Acupuncture may be a good treatment option for migraine sufferers to explore."

More than one-in-10 people in the UK experience migraines, two-thirds of whom are women.

Acupuncture 'more than a placebo'
Scientists say they have proof that acupuncture works in its own right.

BBC News 30 April 2005

Sceptics have said that any benefits gained from acupuncture are merely down to a person's expectation that the treatment will work.

But researchers at University College London and Southampton University say they have separated out this placebo effect.

Their findings, based on a series of experiments and brain scan results, are published in the journal NeuroImage.

Dummy treatment
The researchers used positron emission tomography (PET) scans to see what was happening in the brains of people having acupuncture treatment for arthritis pain.

Each of the 14 volunteers underwent each of three interventions in a random order.

In one intervention, patients were touched with blunt needles but were aware that the needle would not pierce the skin and that it did not have any therapeutic value.

Another intervention involved treatment with specially developed "trick" needles that give the impression that the skin was being penetrated even though the needles never actually pierced the skin.

The needles worked like stage daggers, with the tip disappearing into the body of the needle when pressure is applied. This was designed to make the patients believed that the treatment was real.

The third intervention was real acupuncture.

Brain activity
When the researchers analysed the patients' PET scan results they found marked differences between the three interventions.

Only the brain areas associated with the sensation of touch were activated when the volunteers were touched with the blunt needles.

During the trick needle treatment, an area of the brain associated with the production of natural opiates - substances that act in a non-specific way to relieve pain - were activated.

This same area was activated with the real acupuncture but, in addition, another region of the brain, the insular, was excited by the treatment.

This was a pathway known to be associated with acupuncture treatment and thought to be involved in pain modulation.

Sarah Williams of the British Acupuncture Council said: "This is very positive news for acupuncture and this latest research is an exciting illustration of what acupuncturists have known for a long time - that acupuncture works and its effectiveness goes beyond the placebo effect."

Professor Henry McQuay, professor of pain relief at the University of Oxford and member of the Bandolier group that looks at the evidence behind different medical treatments, said: "The great bulk of the randomised controlled trials to date do not provide convincing evidence of pain relief over placebo.

"Some people do report that acupuncture makes them feel better.

"But it is extremely difficult, technically, to study acupuncture and tease out the placebo effect."