I suppose that I embrace the statement “I believe in acupuncture,” but in reality it is one those catchphrases that most nettles me.
My conflict came to mind after reading a fascinating and heartening article in the New York Times by Christopher McDougall, “What Donkeys Know About Autism.” (http://www.nytimes.com/2016/12/08/well/move/what-donkeys-know-about-autism.html) The piece, from the 12/8/16 issue, reports on Hal Walter, a Coloradan skilled “in the art of burro racing, the old Rocky Mountain sport of running marathon distances alongside a trotting donkey.” (Burro, it turns out, is Spanish for donkey.) Of greater interest to me, however, lies in the therapeutic effect donkeys seem to have on “challenged kids,” which includes Hal Walters’ son, Harrison, who is autistic. The article also reports on another boy whose family has been involved with donkey riding and racing for four years; his formerly frequent epileptic seizures have disappeared for as long as six months at a time. The use of horses and donkeys falls under the umbrella rubric “equine therapy.” You can learn more about equine therapy at Wikipedia: https://en.wikipedia.org/wiki/Equine-assisted_therapy.
McDougall’s piece contained the following: “Like acupuncture and meditation, equine therapy lives in that anecdotal world where plenty of credible people are convinced it works but science can’t yet prove why.” By “credible people”, I assume that Mr. McDougall means people who are believable when they express an opinion, a status fondly to be hoped for.
Many people have told me that they “believe” in acupuncture. I understand and applaud their good intentions. But why do they need to say it? Do they say they believe in cardiology, dermatology, emergency medicine or anesthesia? Do they believe in double-entry bookkeeping? Do they believe in gravity?
I “believe” they say it because of the way that acupuncture frames itself. There’s simply too much that’s strange and unbelievable, even magical, about much of acupuncture theory.
What is Qi and what does it have to do with how acupuncture actually works? What, really, is a meridian, and where can anyone find one? Why do trajectories of meridians change from one culture to the next and why do the locations of the fixed acupuncture points change? Why is the notion of Five Elements important, and how does that frame the work of acupuncture in a way a non-acupuncturist can understand? Despite its deep beauty and its place as an essential aspect of Chinese philosophy, in what way does the concept of yin and yang have operational value; that is, how does it inform what I as an acupuncturist do in any clinical sense? Most importantly, in the age of evidence-based medicine, where’s the scientific evidence? These are all important questions, and ones which I intend to explore in this blog over time.
Today, let’s tackle a piece of the science question.
Can science validate acupuncture?
From the perspective of outcome studies – i.e., did an acupuncture intervention make any difference for this person or that? -- I don’t believe science will ever prove that acupuncture works. Across several millennia and in different cultures, acupuncture has been proven empirically but never scientifically, which, in an evidence-based world, poses a problem for my profession. In my experience, physicians are likely to roll their eyes and say “Whatever works for you,” when you mention acupuncture. Most memorably, a doctor told me, several years ago, during introductions at my first visit to his office, yes, you guessed it, “I believe in acupuncture,” no doubt in a heartfelt attempt to make me feel welcome. His physician father was an early visitor to China after it opened to the West in the seventies and found therapy with needles impressive and effective. I didn’t take the bait and we moved on to other, medical matters, including the fact that I wasn’t interested in the evidence-based medication that he insisted was needed for a problem that was no more than an inconvenience. (This was about five years ago, the problem is still inconvenient, I live with it, and I’m still not on medication.)
The gold-standard for scientific proof is the placebo-controlled, randomized, double-blinded trial. Placebo-controlled means that some subjects receive the real intervention and some a sham. By double-blinded is meant that neither the recipient nor the provider knows whether the intervention is the real or sham. Randomized means that participants in the study are assigned randomly to pools of subjects that receive either the real or sham interventions. This triple-process for insuring the validity and reliability of a scientific study didn’t exist for most of acupuncture’s history. Acupuncture survived because it was seen, through the experience of providers and recipients, to work.
Is it possible for acupuncture to meet these requirements of the gold standard? Randomization is simple: assuming you’ve selected a pool of subjects, it’s easy to assign them randomly to the study and control groups. But let’s take a look at placebo controls. When you’re testing a pill, the real-sham distinction is ironclad: it’s either the real medication at the right dose, the real-medication at a reduced dose, an alternative medication, or the famous sugar pill (i.e., an inert substance with no pharmacologic action, like lactose), to take several among a host of possibilities. It’s not so simple for acupuncture: you can’t substitute a sham needle for a real one. Correct? Wrong. In fact, there are two ways to manage this problem. First, you can treat one group of subjects in the study group using the specific treatment protocol you’re testing (Acupuncture Point 1 + Acupuncture Point 2 + Acupuncture Point 3) and use an alternative protocol for the placebo group (substitute Acupuncture Point XYZ for Point #3). You might call the latter a placebo point array. Then you look for different outcomes across the two groups. One problem with this approach is that there are so many perspectives in acupuncture that determining the proper array of needles becomes as much a reflection of ideology as a rigorous determination of what might actually work. There’s another problem with it, one that I will get to in a moment.
Alternatively, you could use a device which creates a momentary skin sensation. I don’t recall the name of this gizmo but I saw and experienced it in 2007 when I attended a seminar in acupuncture in the care of cancer patients at Memorial Sloan-Kettering Cancer Center. It caused a tiny sting that was real enough to cause a naïve recipient (i.e., someone who’s never had acupuncture) or perhaps even an experienced recipient to believe that a needle had been inserted. If you don’t look to see whether a needle has actually been placed, or can’t see where it’s placed (perhaps on your back, while you’re face down), you may think you’ve actually received a needle.
The problem with this sham sensation, however, is that in a sensitive-enough individual, it’s hypothetically possible to effect a change via such an intervention. The surface of the body is mapped into dermatomes. Each dermatome is innervated by a different pair of sensory nerves branching bilaterally from beneath cervical, thoracic and lumbar spines. (Here’s a link to a dermatome map: https://en.wikipedia.org/wiki/Dermatome_(anatomy) . As noted in the Wikipedia article, the nerves running to each dermatome relay “sensation (including pain) from a particular region of skin to the brain.” For instance, a wide swath of the sole of the foot has a direct neural connection to the large, peripheral nerve that runs from the L5 vertebra in the lumbar spine. A strong sensation experienced in the sole of the foot, even from a sham prick of a sham needle, may feed directly back to the central nervous system and initiate a nervous-system chain of events that can alter the experience of pain. Pain exists, after all, in the nervous system.
With regard to double blinds: It’s easy enough to package a real medication and a sham medication identically, so that the person administering the medication doesn’t know which one s/he is giving the subject. It’s impossible for an acupuncturist not to know the difference between a real and a sham needle. Double-blinding is close to impossible in acupuncture trials. An exception may be the administering of a treatment protocol without knowledge of the purpose of the protocol. In other words, (and here, for the purposes of argument, I’m adhering to a standard nomenclature for locating acupuncture points, one which I don’t believe has any validity) the acupuncturist administering treatment to the study group can use the “proper” grouping of points called Large Intestine 4, Liver 3 and Lung 7, while the acupuncturist for the control group uses the “proper” grouping of Large Intestine 4, Liver 3 and Lung 3. In other words, both acupuncturists or sets of acupuncturist believe they’re delivering the right set of needles. But since so much of acupuncture depends on touch and attitude, not to mention the rapport between the giver and the receiver, I believe this is fatally flawed as well.
(This begs an additional question: What is the proper protocol for addressing a given health problem? This is a huge question, one that must be answered, because if a given study, scientifically sound or otherwise, is promoting a protocol that is essentially off-base, why should it have validity? I’ll address this in another article.)
There are other kinds of outcome studies; longitudinal, retrospective, etc.. To the best of my knowledge, although they provide useful information, none of them can offer the validation of the “gold standard.” However, it’s also possible to scientifically study processes initiated by acupuncture, changes in tissue, for instance, that occur through treatment. That, again, is for a different article.
Acupuncture as an empirical practice
Acupuncture does not rest on scientific evidence as much as empirical evidence, a distinction I first encountered in 2008 in a seminar with Dr. Yun-tao Ma. In Biomedical Acupuncture for Pain Management, by Yun-tao Ma, Mila Mao and Zang Hee Cho, the authors make the point “that acupuncture does not treat any particular pathological symptom but normalizes physiological homeostasis and promotes self-healing.” Elsewhere, Dr. Ma states that “acupuncture is a non-specific healing modality.”
Dr. Ma’s essential point about empirical evidence is that acupuncture has survived for thousands of years because people have found it useful to alleviate pain and speed healing. If it were not beneficial, it would have disappeared. The essential quality of acupuncture that forms the basis of its empirical success is that it is a “non-specific healing modality.” As Dr. Ma explained in his first books and in that 2008 seminar, acupuncture activates the body’s survival mechanisms – the immune, cardiovascular, endocrine, and nervous systems – to induce homeostasis. This activation promotes the body’s own capacity for healing. Again, as Dr. Ma pointed out in a private conversation, different ages and cultures create different problems for health. In ancient China, the greatest problems were malnutrition and traumatic injury. In the world of 2016, the problems of traumatic injury and malnutrition notwithstanding, many health problems reflect over-nutrition and longevity, and yet acupuncture is seen to play a beneficial role in addressing the health concerns associated with these problems.
As we pursue a deeper understanding of the physiology of acupuncture, we can devise better strategies for employing it. And as this understanding begins to dovetail with the scientific view that prevails in the science-oriented age we live in, acupuncture will gain a greater acceptance. Our empirical experience will be illuminated by using the science-based analytical tools that shed light on the physiological processes underlying the action of the beautiful needles we employ.
The action of acupuncture does not depend on national, ideological or quasi-religious perspectives, but rather because the body responds in predictable ways to the insertion of needles. All acupuncture works. The etiology of disease in ancient China may have skewed differently from disease and illness in the world of today, but, for certain, the physiology of those ancient Chinese bodies was identical. Acupuncture itself will continue to survive no matter how it describes itself. It will thrive when it’s reframed to match our ever-deepening understanding of the natural world that we are part of.
I don’t believe in acupuncture. I know that acupuncture works. The question is how it works. We learn more about this every day. I'll address this in future articles.
With regard to the therapeutic qualities of equines: The New York Times article I mentioned at the top caught my eye because I have friends here in Ulster County, New York whose son works with a group called Horses for a Change. If you’d like to learn more, here’s their website: http://www.horsesforachange.org . Horses for a Change has a PATH-certified instructor who works with people of all different abilities using horses. (PATH stands for Professional Association of Therapeutic Horsemanship.) My friend tells me, too, that they have a zonkey named Zeke. . . .
© William Weinstein 2016