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The issue of science and evidence based medicine has interested me since I first entered the profession of traditional acupuncture. I am fascinated by the far reaching capabilities of science, particularly how modern thought correlates with the traditional philosophical concepts of health that still form the main foundation of traditional Chinese Medicine. It is through this respect however that I have also learnt the limitations of what human beings can explain or understand.
The evidence base for acupuncture is a big subject in which many pitch battles are fought, usually between the relatively niche worlds of scientific skepticism and research savvy complementary therapists. Its dominated by big brains and personalities and an arena into which I feel intimidated to even dip my toe. However! The recent episode of BBC’s “Trust me, I’m a Doctor”, in which they tackled the question “does acupuncture work” in about 8 minutes has convinced me to offer some observations that may better equip people to make a more informed decision for themselves.
Acupuncture has been researched since the 19th Century and appeared in the first ever issue of the world acclaimed medical journal The Lancet. The scientific interest however gathered momentum in the 1950’s when Chairman Mao established a number of acupuncture research institutes as part of a “reinvention” of traditional medicine”. This and an increasing interest in acupuncture from the scientifically minded west led to a substantial amount of acupuncture research. It is now most likely the most widely researched complementary medicine in common use.
The Gold Standard of Evidence
When we hear about scientific evidence in medical terms it is really defined by the Randomised Control Trial (RCT) which is considered the Gold Standard of evidenced. In order to establish how well a particular treatment or intervention works it is studied alongside one or more “control groups”. Trial subjects are randomly allocated to one of the groups or “streams” in which they will receive either a treatment or a control treatment. In the best studies one of the control groups will be treated with a placebo i.e. designed so that the person giving and receiving it cannot differentiate from the active treatment. In a blind trial they will have no idea which treatment they are getting. In a double blind study the practitioner will also be blind as to which treatment they are giving. In its simplest terms a positive outcome would see the tested treatment or intervention outperforming the controls in a statistically significant way. Sounds simple? Its not. Its a complex time and resource intensive process. There are numerous quality indicators within the process and any deviation risks invalidating or at least undermining the entire study.
Difficulties of designing and RCT of Acupuncture
Firstly, there are a lot of poorly designed studies out there and I’m not decrying the ones that say acupuncture doesn’t work. Actually the opposite. Some of the early studies of acupuncture that consistently found it to be better than sliced bread aren’t worth the paper they are written on.
There are of course good ones too and it is in some of the larger and better quality studies of acupuncture that we hear one of the commonly cited criticisms that ‘whilst acupuncture outperforms “usual care” with statistical significance, it fails to compare so well to sham acupuncture’. This is interpreted by many as meaning it is no better than a placebo. I think we should consider more information before leaping to this conclusion.
Lets be clear, RCTs are designed for and lend themselves to researching drugs. In this type of research, creating a placebo is a simple matter of handing the subject a pill or liquid without any active ingredients, usually a sugar pill. The subject takes it as they would any other drug and in the main, this is a direct representation of how a patient would be treated with drugs.
For interventions using holistic therapies like acupuncture it is far more complex. Typical clinical practise for a traditional acupuncturist involves a great deal more than just needling. Palpation, case history, lifestyle advice, the list goes on. And then there’s the needling, tailored individually to the patient and their unique presentation. Many trials of acupuncture use pre-defined acupuncture points and seek to isolate it from the other parts of treatment like lifestyle advice etc. You end up with a highly sanitised treatment that bears little if any resemblance to a typical clinical encounter.
The issue of using a placebo control is also highly controversial. Creating a placebo for acupuncture means designing an “act” for real and false acupuncture that nobody can differentiate. The favoured methods are retractable needles that don’t penetrate the skin or normal needling on “non” acupuncture points. The latter at least involves needling which arguably activates a bodily response making it far from inert. The former is also far from infallible. During a practise sessions with various types of non-penatrative placebo needles I found that in fact they frequently break the skin and this corresponds with the experience of research acupuncturists too. If they penetrate the skin, can it be considered as a placebo or non-active intervention?
I’d suggest not so what you end up with is a placebo that may not be inert and an intervention that does not represent normal clinical practise. Yet in spite of this, both still outperform usual care. What does this say? My interpretation is that even bad acupuncture is better than usual care or no treatment. Imagine the potential for proper acupuncture!
What really grates on me is not the never ending argument of the wether or not an RCT has proved one thing or another. Its the hailing of an RCT as the be all and end all of evidence like nothing else in the world matters. I think this is demonstrative of a far larger cultural shift driven by advances in technology, not just our attitude to medical science. For example, in my previous profession of law and order we used to solve crime long before CCTV and DNA evidence (I hear the cynics amongst you! Lets have that debate another time!) Now it seems that witness testimony doesn’t really cut it. We need concrete proof and undisputed computer audit trails. Does this mean that without them the crime never took place, that the evidence of a witness was wrong? No, its just that we now have a higher expectation. The same is true of medical science. The old evidence is still evidence and actually, if theres enough of it or the “new” evidence is poor evidence it is arguably still “best” evidence! Thats not to knock progress, just to encourage some humility because our expectations now are so high we seem to forget that in the greater scheme of things we actually still know very little. Anyone who has suffered a migraine will back me up here. Drugs may work, they may not, they may work for a time then stop working. Actually, this commonly occurring but painfully debilitating illness is very poorly understood in spite of countless studies and amazing scientific developments.
Traditional acupuncture does not rely solely on what can and can’t be proved scientifically. It is built primarily on the collective knowledge of recorded clinical practise over 2,000 years. It is good evidence stood next to science which has only really developed in the last 60 years and still has a long way to go. I wonder then why some people would be so quick to dismiss it.
I hope that I have been able to give a good overview of the strength and potential weaknesses of scientific evidence in the field of acupuncture. In my opinion, whilst science has a huge part to play in our future, it still stands very much in support of the historical knowledge and philosophy that is the bed rock of traditional acupuncture. That doesn’t mean Im not excited about what it can and will bring to my profession as we make more and more advancements . I simply advocate tempering this with an awareness of our own limitations and the openness of possibilities beyond our own limited knowledge.
In the meantime I will continue to be guided by “all of the evidence” to treat individual health needs with traditional acupuncture for as long as it continues to help people. I have a feeling I won’t be retiring anytime soon!
A video from 2 years ago of Toyah Willcox talking to the British Acupuncture Council about insomnia and how acupuncture helped her.
If you are after easing the sands of time a little, options have traditionally involved either surgery, fillers or botox. Increasingly people are turning to acupuncture as a way of enhancing and rejuvenating their looks. In this blog post I am looking at the two treatments and how they stack up.
What is it – Botox is a drug made from neurotoxin called botulinum toxin. The toxin comes from the bacteria that causes Botulism , a rare but life threatening disease that attacks the nervous system.
Scientist have estimated that 1 gram of Botulinum toxin could kill around one million people. Never the less it is generally well tolerated when injected into human beings in the correctly diluted levels.
It is important to distinguish between Butolinum Toxin and Botox. Botox is one of many commercially adapted Butolinum Toxin products. Whilst it is most famously known for cosmetic treatments, it has a range of clinical applications including involuntary muscular spasm, eye blinking, underarm sweating, and on some circumstances overactive bladder. More recently it has been reported as benefiting migraine though the evidence of this is disputed.
The first licensed use of Botox for cosmetic reasons was in 2002 and since then it has enjoyed increasing popularity, probably due to its use by the rich and famous, many of whom have spoken openly about their own treatments. It is now the most popular cosmetic procedure with in excess of 6 million treatments worldwide.
Treatments involve injecting botox into the face causing temporary muscular paralysis which helps to reduce the appearance of lines and wrinkles. The results are reported to last between 4 to 6 months. Side effects to treatment are rare but wide ranging and can be life threatening including: Problems swallowing, speaking, or breathing.
Prices seem to vary greatly from place to place and may not be openly advertised. People on the Money Saving Expert forum I looked at seemed to be paying around £150 per facial area in 2009, most needing 3 areas injecting. The NHS website and many other resources recommend that you find a suitably qualified therapist to carry out your procedure however, providers of cosmetic treatments that do not involve surgery don’t have to be registered with the Care Quality Commission (CQC), which is the independent regulator for health services in England. Many providers of services in non regulated industries will belong to a professional body of some sort and qualify their standards by declaring “Member of such and such professional body”. The reality is that these professional bodies too are often unregulated so these words alone mean nothing. You would need to do a bit of homework to satisfy yourself of the level of training and expertise your therapist has.
Acupuncture is a system of health that traces its routes through a rich and varied history back to ancient China. It involves the insertion of tiny needles into the body at specific points to illicit a specific clinical effect.
Whilst existing in european countries for hundreds of years, it started to gather in popularity in the 1970’s.
Research into acupuncture dates back to the beginning of the 1800’s but really gathered momentum in the 1950’s when Chairman Mao invested heavily in Chinese research facilities. It is now probably the most researched complementary medicine in the world.
Facial Enhancement Acupuncture, also referred to as Cosmetic Acupuncture, is a relatively new application though it is starting to get quite a name for itself in the beauty industry. It is believed that the small trauma caused by an acupuncture needle causes the body to regenerate its naturally occurring elastin and collagen which gently eases the signs of ageing with repeated application.
Treatment involves the insertion of many tiny needles into the skin along lines, furrows or damaged areas (such as from acne). Some practitioners include other techniques like massage, to supplement treatment. A properly trained traditional acupuncturist is also likely to take a full case history and address underlying health and well being issues. Optimal results are said to be achieved after a course of regular treatment, between 6 and 10, after which periodic sessions to keep things topped up are recommended.
Side effects to acupuncture are also rare. As with an injection, you may experience bruising at a needle site. This is rare and a well trained practitioner will be able to minimise the effects with good after care however on the occasions when treatment does leave its mark you can expect the bruise to clear within a few days. For these reasons most credible acupuncturists will recommend that you don’t have treatment within 2 weeks of a big occasion. More information on side effects and their prevalence can be found at the British Acupuncture Council Website, www.acupuncture.org.uk
As with non surgical cosmetic procedures, acupuncture in the UK is unregulated and some individuals have sought to exploit this by offering their services with minimal training. A good measure of quality is the educational level of your therapist. Traditional acupuncturists have studied a 3 year degree course or equivalent. This level is a minimum requirement to become a member of the British Acupuncture Council (BAcC) so if your therapist belongs to this organisation you can be absolutely assured of the highest standards. Other providers of cosmetic acupuncture are likely to be doing acupuncture as a supplement to their main discipline training. The amount of training varies greatly from 1 day to more formalised week long courses.
Cost again varies and tends to be region specific. In central London you could be paying anywhere up to £250 per session. Elsewhere anything up to £80 is reasonable though this is not to say that those charging more are ripping you off. They may be offering a very deluxe product. Most acupuncturists are very transparent with their pricing so it should be easy to compare costs within your area.
If you are interested in trying out facial enhancement acupuncture the feel free to give me a call or book in for a session at one of my clinics in Girton and Ely.
The exact origin of Acupunctures is difficult to date as references of varying evidential value can be cited.
For example, there was much excitement amongst the world of acupuncture following the 1991 discovery of “Otzi the iceman” in the Italian Alps. This near perfectly preserved and mummified neolithic man had tattoo’s on his body that correspond to known acupuncture channels. Carbon dating showed that he had lived 5,000 years ago.
Even before this however some believe that stone needles or “Bian Shi”, recovered during archaeological digs in inner Mongolia, could place the practise at a much earlier point in history.
What is clearer is the written record which started approximately 2,000 years ago in the 3 Sovereigns period with the Huang Di Nei Jing, or Yellow Emperors Internal Cannon, a book on which the traditional practise of Chinese Medicine is founded and which remains a significant source of knowledge and inspiration to this day. Indeed a copy can be found in the personal library of many practitioners, including my own.
Since this book many other texts and schools of thought have been committed to paper to establish an unbroken literary record. Whilst remaining unbroken, it has however suffered over the years. The “Fen Shu Keng Ru” a dark period in Chinese History during the Qin dynasty when the emperor ordered the burning of books and scholars, did not succeed in wiping the history but it never the less delivered a serious blow. The extent of damage and amount of information lost during this time can only be imagined but could be assumed to be significant.
Acupuncture first started its journey out of China via the silk roads and is believed to have been brought back to Europe by French Jesuit missionaries. Whilst practised for many years, popularity in the west saw substantial growth in 1971 following the appendectomy of New York Times reporter James Reston who became ill whilst covering President Nixon’s impending visit to China. The surgery took place in a Chinese hospital where he received acupuncture during post operative recuperation, an integrated approach still practised in Chinese hospitals and much envied by western practitioners. He was so impressed with the treatment he wrote an article on it for the newspaper awakening the western audience to this little known form of healing.
Acupuncture has continued to grow in popularity and is now practised in a variety of styles and setting across the world. In a modern world of stress and resistance to drugs, many are seeing the benefits of holistic, natural healing as practised for nearly 2,000 years.
I hope you enjoyed reading my post. In the coming weeks I will be blogging about some of the historical influences that contributed to the development Traditional Chinese Medicine and its many philosophies.
Ok so recently one of my friends asked, what can acupuncture do during pregnancy? Lets start at the beginning. Lots of people want to known if Acupuncture can help you to get pregnant? Well, Celion Dion and Mariah Carey certainly think so. Both were reported to use it to help them conceive, article here