Tag Archives: does acupuncture work

A Word about Evidence

The Detective

Photo by paurian on Flickr and used here with Creative Commons license.

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.

Historical context

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.

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Photo by Jeremy Shultz on Flickr and used here with Creative Commons license

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.

_DSC0027For 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!

Other evidence

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.

Conclusion

Wooden justice gavel and block with brass

Photo by Tori Rector on Flickr and used here with Creative Commons license

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!

Does Acupuncture Hurt?

Today I want to deal with the elephant in the room.  The needles!  My work involves a lot of different skills, needling being just one of them, but theres no point in avoiding the obvious fact that if you book in for acupuncture, at some point (pun intended), we are going to face the needles.

The first thing to say about this is that almost everyone I see has some trepidation about needling.  Its common and its natural.  Lets put things into context.  Until now, your only experience of a needle is likely to be a pin prick, unpleasant, or worse a syringe, painful.

I believe that much of aversion to needles is built into our psychology from birth.  Its one of the first things a baby experiences these days when its brought into the world and in my opinion, its also a fairly classic betrayal of trust.  Consider the scenario from a babies eyes.  You are with your parent(s), the person(s) solely charged with your safety and development in the early years and someone with whom you have formed a loving and highly reliant bond.  You gaze lovingly into the eyes of this person who may be talking reassuringly to you as part of a distraction technique.  All of a sudden, WHAM!.  Into the backside with a big old needle.  Then you are pumped with a mild dose of something horrible that may make you ill for a few days.   I’d like to be clear, this isn’t an anti-vaccination stand point, but just think about the psychology for a moment. Is it any wonder most of us develop a thing with needles?

As the syringe is likely to have formed the fear of needles I find it useful to compare this to my own practise because acupuncture is about as far removed from a syringe as its possible to get (in needling terms anyway).  There are a few clear differences that make it so.

  1. The size of the needles.  Syringes are intended to either put something in or take something out of the body.  For this purpose they need a hole.  By comparison, acupuncture needles are not hollow  and this means they can be much smaller.  How much smaller? Acupuncture needles are roughly the size of a human hair.  In fact, Acupuncture needles are so fine that most people don’t feel them being inserted.
  2. The purpose of the needling.  Syringes are basically used for two purposes, putting something into your body or taking something out.  If its putting something in that will generally be a drug or vaccine, foreign substances which your body may object to.  If its to take something out thats usually blood and will involve going into a vein.  Veins in the normal scheme of things aren’t meant to be messed around with and as a consequence the body has an alarm system built around them to let us know something bad is happening.  In other words, it will hurt because its meant to.  Your body is warning you of danger.  Acupuncture needles by contrast do neither of these things so the natural pain response isn’t pre-built into what we are doing. In rare cases there may occasionally be some discomfort but this is relative to what we are trying to achieve and always very carefully managed and controlled.
  3. The reason and consent for the needling:  It is an easily overlooked fact but generally speaking, although you consent to being needled in a regular medical environment, your choices and control over wether or not you give this consent will be limited by whatever is going on with you medically.  There could be some pretty high stakes involved and if a doctor breaks out the needles theres likely to be a lot less “choice” in the real sense of the word.  By contrast, the acupuncture treatment room its much different.  Although our patients are often feeling very desperate it is normally conscious choice that has brought you there in the first place.  In all but a handful of cases coming for treatment will be a decision you have made yourself following some research.  I live for the day when acupuncture becomes the first line treatment for problems like back pain but until it does I rely on people coming because they know how well it can work, not because its the only thing the world can offer them.  Psychologically this very small shift in conscious thought makes a huge difference in how you personally approach treatment.

This is all well and good but accepting that acupuncture needles are not the same as syringes, what do they feel like?  It can’t be pleasant surely?  Actually it can be.  Many patients report feelings of deep relaxation or warmth.  This video featuring my colleague and good friend Deb Conner explains in a little more detail.

 

I’ll leave you with a final thought.  Nearly all acupuncturists in the UK are self employed or in private practise.  Our patients chose, not only to come to see us, but also to keep coming back.  The results are part of this but I can assure you, if we were hurting people left right and centre I’m sure we’d be out of business very quickly.

Still not convinced?  Give me a call without pressure or obligation.

 

How does acupuncture work?

There is a wealth of theory, opinion and evidence that has built up over hundreds of years seeks to answer this question so summarising it in a few words is difficult.
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