Note: This is slightly revised from an article I originally wrote as a “SkepDoc” column for Skeptic magazine. It was pre-released online in eSkeptic and it has already generated a lot of comments, including “a truly amazing piece of peurile pseudo-intellectualism,” “an ad hominem attack on one form of alternative medicine so beset by poor thinking that one must come to the conclusion this woman might just be paid to write such propaganda,” and “twaddle wrapped in swaddling rhetoric.” (I treasure comments like those as evidence that my critics are so bankrupt of real arguments that they have to dip into the insult pouch for ammunition.) I thought it would be interesting to post it here on the blog and see how much controversy it would stir up among my co-bloggers and readers. Please keep in mind that it was written for a popular audience and excuse the lack of scholarly citations. You may recognize some of the studies I refer to from previous blog entries.
“Alternative” medicine is by definition medicine that has not been scientifically proven and has not been accepted into mainstream scientific 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.
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. There’s certainly no evidence that it’s 3000 years old. The earliest Chinese medical texts, from the 3rd century BC, don’t mention it. The earliest reference to “needling” is from 90 BC, 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 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 WWII, when the Chinese Nationalist government tried to suppress it. 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 and he did not believe it worked. It was Mao’s government that coined the term “traditional Chinese medicine” or TCM, to include acupuncture, herbal medicine, moxibustion, and other traditional practices.
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 meds, 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 (based on the number of days of the 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 acupuncture, and what do you mean by work? There are various different Chinese systems, 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 lasers. With dermal pad electrodes and no skin penetration.
Acupuncture works, but placebos work too. Acupuncture 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. It’s mostly used for pain today, but early Chinese practitioners maintained that it was not for the treatment of manifest disease, was so subtle that it should only be employed at the very beginning of a disease process, and 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 almost everything coming out of China is positive. It’s not culturally acceptable to publish negative results – researchers would lose face and their jobs. In , “No trial published in China or Russia/USSR found a test treatment to be ineffective.” We can’t reach a valid conclusion based on positive published studies if we don’t know about negative studies that never saw the light of day.
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 was less likely to work. If they didn’t get it but believed they did, it was more likely to work.
Acupuncturists can rationalize with great ingenuity. In a recent study using sham acupuncture as a control, both the sham placebo acupuncture and the true acupuncture worked equally well and were better than no treatment. The obvious conclusion was that acupuncture was no better than placebo. Their conclusion was that acupuncture worked and the placebo acupuncture worked too!
One researcher decided it’s not meaningful to use placebo controls in acupuncture 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’s true, why not just caress or massage our patients instead of lying about imaginary qi and meridians?
Considering the inconsistent research results, the implausibility of qi and meridians, and the many questions that remain, all the current evidence is compatible with this hypothesis: acupuncture is nothing more than a recipe for an elaborate placebo seasoned with a soupcon of counter-irritant. That is what R. Barker Bausell concluded in his book Snake Oil Science. The world’s first professor of complementary medicine, Dr. Edzard Ernst, is more accepting of low-prior-plausibility evidence than some of us; but even he used the words “tentative” and “might” when he recently wrote, “While there is tentative evidence that acupuncture might be effective for some forms of pain relief and nausea, it fails to deliver any medical benefit in any other situations and its underlying concepts are meaningless.”
Acknowledgement: 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.
ADDED AFTER ORIGINAL POSTING:
At the request of several readers, I am adding these references. They are by no means comprehensive. Many of these references contain long lists of primary sources.
History of Acupuncture:
Unschuld P. Medicine in China: A History of Ideas (Comparative Studies of Health Systems and Medical Care). University of California Press, 1988.
Imrie RH, Ramey DW, Buell PD, Ernst E, Basser SP. “Veterinary Acupuncture and Historical Scholarship: Claims for the Antiquity of Acupuncture” The Scientific Review of Alternative Medicine. 2001, 5: 133-9.
Imrie, RH, Ramey DW, Buell PD. “Veterinary Acupuncture and Historical Scholarship: The ‘Traditions’ of Acupuncture and TCM.” The Scientific Review of Alternative Medicine. 2003-4. 7:61-8.
Basser S. “Acupuncture: A History” The Scientific Review of Alternative Medicine. 1999. 3: 34-41.
Imrie R, Ramey D, Buell P. “Veterinary Acupuncture and Historical Scholarship, Part III: Politics , Popularity, and the Promotion of TCM” The Scientific Review of Alternative Medicine. 2005. 9: 69-74.
Acupuncture for Heart Surgery:
Posner G and Sampson W. “Chinese Acupuncture for Heart Surgery Anesthesia” The Scientific Review of Alternative Medicine. 3:2, p. 15-19. 1999.
Posner G. Questioning Dr. Isadore Rosenfeld’s China Acupuncture Story, Skeptical Inquirer. 1999: Vol. 23 No. 4.
Mao not believing in acupuncture:
Zhi-Sui, Li. The Private Life of Chairman Mao. Random House, 1996.
Origin of ear acupuncture:
“Organ Representation on Extremities” on the American Acupuncture website. http://www.americanacupuncture.com/ear_ac.htm. Accessed Oct 21 2008.
James Reston’s Appendectomy:
James Reston. “Now, About My Operation in Peking” New York Times, July 26, 1971.
Current status of acupuncture in China.
Beyerstein B and Sampson W.“Traditional Medicine and Pseudoscience in China: A Report of the Second CSICP Delegation” (Part 1). Skeptical Inquirer. 1997.
Beyerstein B and Sampson W. “Traditional Medicine and Pseudoscience in China: A Report of the Second CSICOP Delegation (Part 2)” Skeptical Inquirer, 1996.
Sham acupuncture studies, research methods, meta-analyses:
Bausell, RB. Snake Oil Science: The Truth about Complementary and Alternative Medicine. Oxford University Press, 2007.
Ulett, GA and Han, S. The Biology of Acupuncture. Warren H. Green, 2001.
Preponderance of positive studies from China:
Vickers A, Goyal N, Harland R, Rees R. “Do certain countries produce only positive results? A systematic review of controlled trials.” Control Clin Trials, 1998: 19(2):159-66.
Excuse for not using placebo controls: http://private-investigator-detective.info/?p=44
Why ineffective treatments seem to work:
Beyerstein B. “Psychology and ‘Alternative Medicine’: Social and Judgmental Biases That Make Inert Treatments Seem to Work.” The Scientific Review of Alternative Medicine. 1999. Vol 3.
Beyerstein B. “Why Bogus Therapies Often Seem to Work”
Singh,S and Ernst, E. Trick or Treatment: The Undeniable Facts about Alternative Medicine. W.W. Norton, 2008.
Bausell, RB. Snake Oil Science: The Truth about Complementary and Alternative Medicine. Oxford University Press, 2007.
Carroll, R. “Acupuncture” The Skeptic’s Dictionary. http://skepdic.com/acupunc.html
Acupuncture Watch website. http://www.acuwatch.org/
Barrett, S. “Be Wary of Acupuncture, Qigong, and ‘Chinese Medicine’” http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html
Imrie, Robert. “Acupuncture: The Facts.” 2005. PowerPoint presentation available online at http://drspinello.com/altmed/acuvet/acuvet_files/frame.htm