Evaluating the Clinical Effectiveness of Acupuncture

Putting acupuncture under a microscope can be like trying to capture a spirit out of the clouds.
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If someone starts talking to you about meridians, they're either brushing up on their geography or about to launch into a discussion about the medical efficacy of acupuncture. If it's the latter, and you're a traditional scientist, you might be in for a heated discussion.

Acupuncture 101

Most people know something about acupuncture; mainly, that very skinny needles are inserted into various areas of the body. In Traditional Chinese Medicine (TCM), treatment is applied to the meridian (channel) that governs the site of the pain, not necessarily the place where the pain is being experienced. Ch'i, the invisible nutritive energy that flows from the universe into the body at any one of 500 acupuncture points, is conducted through the 12 main meridians in (ideally) an unbroken circle. Meridians conduct either Yin energy (from the sun) or Yang energy (from the earth). All maladies are caused by disharmony or disturbances in the flow of energy. Acupuncture treatment is meant to realign or reharmonize these disturbances, and on a more elevated level, to enable the realigned cells to unite with the cosmic energy of the universe.

You don't have to have to have graduated medical school to see that this can be difficult to reconcile with modern science. And this is the heart of the problem. Acupuncture is a pre-scientific paradigm based on concepts with no counterpart in contemporary western medicine. Its treatments are founded on philosophical constructs, subjective impressions and responses to patterns of disharmony, whereas Western treatments are the result of controlled scientific research. Putting acupuncture under a microscope can be like trying to capture a spirit out of the clouds.

But before the commenters start typing wildly, let me say that there has been a fair amount of research that demonstrates acupuncture's efficacy. Nevertheless (a word you see a lot in acupuncture research summaries), the conclusion of most studies, or of organizations reviewing the results of clinical trials, is that there was insufficient evidence to recommend for or against acupuncture, or that the results were equivocal, or that further research would be required.

Testing the Tests

This is a result of the difficulty in creating an appropriate controlled, double-blind testing situation. Acupuncture is an invasive treatment, so it's hard to design an effective placebo control group for a study the way standard double blinding practices are used in trials for new drugs. Acupuncture is also a process, not a pill. A process has a lot of variables, including the influence of the acupuncturist, which is a major factor. Blinding both the acupuncturist and the patient as to the treatment being given is a challenge. To rectify this, the "sham" acupuncture placebo was developed, where needles are inserted, but not in the accepted acupuncture points, or not inserted at all (using retractable needles that just appear to be penetrating the skin).

Even with these efforts, as the Institute of Medicine has acknowledged, it's difficult to standardize a process and to separate the effectiveness of a treatment from that of the person providing it. True Traditional Chinese Medicine acupuncture is tailor-made for each patient based upon the condition and the examination, and there are multiple variables such as manual or electrical stimulation, number of acupuncture sites treated, frequency of the sessions, and length of treatment. Additionally, many of the trials suffered from low numbers of subjects and mixtures of conditions rather than examining a single homogenous condition. For example, headache trials often include patients with tension headaches, migraines, headaches due to cervical spine disease and other causes, each of which may have a different cause, and, thus, unlikely to respond to a "one size fits all" approach. On the upside, the quality of acupuncture research is improving. Still, the evidence for and against continues to grow, with many layers of nuance in-between.

Tests such as a positron emission tomography (PET) scan have shown that treatment with genuine needles, as opposed to the use of "sham" needles, does create objective changes in brain states. But, random placement of placebo needles also had that effect.

Where acupuncture seems to have gained the most clinical ground is in the area of pain reduction. Researchers in Germany conducting acupuncture trials for patients with chronic low back pain found that only 15 percent of subjects who received genuine acupuncture treatment needed extra pain medication, compared with 34 percent who were receiving "sham" treatments, and 59 percent receiving conventional therapy. Long-term pain reduction was also best for subjects who received either real or "sham" acupuncture versus those that received conventional therapy.

In another study, researchers used "sham" acupuncture controls entirely and compared it to the drug Effexor for relieving hot flashes in breast cancer patients. They found that acupuncture relieved hot flashes as effectively as the drug and with fewer side effects, namely the lack of energy and reduced sex drive.

So which is it? Does acupuncture work or not? Or does it work if you think it works? While some findings support acupuncture's efficacy, especially for post-operative or chemotherapy-induced nausea and vomiting and post-operative dental pain, others posit that its clinical effectiveness depends mainly on a placebo response.

Proponents of acupuncture say that it doesn't matter if a placebo effect is at work or not because the ultimate goal is to activate the body's power to heal itself. This, in fact, seems to be the point at which Western medicine and the relatively new approaches of Integrative Medicine (IM) or Complimentary Alternative Medicine (CAM) finally do converge. Over the past decade, integrative care has become an accepted element of treatment at many major medical institutions and part of traditional academic curriculums. It combines conventional Western medicine with holistic treatments like acupuncture, massage, biofeedback, yoga and stress reduction techniques to treat the whole person, not just a disease.

In this expanding holistic universe, acupuncture is a key player, even though scientists and scientific institutions continue to question the existing data and testing methodologies, which, of course, is the most scientific way to deal with the issue. The quintessential scientist, Einstein, noted that finding the right question is 95 percent of finding the solution. In the case of demonstrable clinical outcomes for acupuncture, perhaps the best question we have so far is, "Does it make you feel better?"

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