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How to Research Acupuncture?

A problem with acupuncture is not so much the lack of research – there are kaboodles of it – but the way these researches are conducted.  A recent online conversation I had with a fellow Xavier high school alumnus made this obvious to me.  Here is a quote from an email I wrote which I think summarizes my thoughts on this.

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Is there a "proper" way to do acupuncture research?

Anyway here is the text:

(A) major misunderstanding (is) that the idea that acupuncture is like a pill – that can be single blinded (meaning that recipient doesn’t know that they’re getting the real thing or not) or double blinded (pill giver doesn’t know either.)  Obviously, using fake needles or sham treatments would necessitate that the “treatment” giver NOt be blinded.

However, the first difficulty comes in designing an adequate “sham”

First objection: sometimes inserting needles anywhere seem to stimulate an effect as well.

Second objection: even just pretending to insert needles seems to have an effect.  this is the “placebo” being indicated here.

The conclusion skeptics derive from these observations is thus: since inserting a needle into specific “points” doesn’t seem to be much different than inserting anywhere or simulating points without insertion, acupuncture is thus “useless”.

A closer examination of how acupuncture works biophysically (and yes, I do explain this to patients who ask) reveals that it works by simulation of the immune and nervous system.  Chris Kresser’s blog elaborates on this quite well.  Now is this the only way to stimulate the nervous and immune system? No.  Acupuncture evolved from touch/massage.  The question thus begged is, why not just touch?  My answer is that inserting needles saves time and effort.  Imagine if I had to stimulate ten points on a patient with my fingers?  By inserting needles to achieve the same stimulation, I can then leave the patient and attend to another one.

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I'll bet Doctor Octopus would make a great masseuse...

So what is my proposal for an appropriate acupuncture “sham” procedure: it must involve NOT triggering the a-delta fibers.  A-delta fibers are the key to the “qi-sensation” or heavy feeling accompanying acupuncture (as opposed to sharp).  Research has shown that acupuncture analgesia is obliterated by blocking the transmission of a-delta fibers.  The best way to do that that i know of is through naloxone.  Hypothetically, a control group would have no treatment, another with conventional treatment, and two experimental groups – both with real acupuncture given by the SAME practitioner (more on this later) but with one blocked by naloxone.  The latter is the “sham”.  ”fake” needles that touch the skin also won’t work because the mere touching of the skin sets off similar reactions in the patient’s central nervous system, albeit to a lesser intensity as with acupuncture.

Now for the importance of the practitioner.  I once gave a lecture in a geriatrics convention and a participant commented to me that he used to practice acupuncture but his practice died out.  He then asked me “what are the points to use for migraine?”  I then said to myself, “kaya pala. (so that’s why…)” What does this incident tell us? Let me illustrate – it also explains to me why it is difficult to formulate studies for acupuncture.

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It's not the size that counts. It's how you use it!

Acupuncture is not just inserting a needle and plugging it into a machine.  Acupuncture involves selecting points (although Chris Kresser disagrees with me there) , choosing how thick the needles are, determining how deep the insertion will be, and trying to control the sensations the patient feels through manipulation of the handle.  About manipulations, there are many which I shan’t specify now.  Suffice it to say that I have personally discovered that errors in any of the above will lead to treatment failure.  It is like surgery, the procedure itself is standard, but a lot also depends on how well the surgeon handles things.  i would normally not be so heretical as to compare something like acupuncture skills to the taxing physical and mental requirements required of a surgeon, but I hope the reader grasps my point (pun intended.)

Another problem is something I have been trying to get to with my earlier comments on different culture and world view.  Chinese medicine diagnoses things in a method somewhat different from western medicine.  I’m not just talking about differences in terminology.  I did touch on this with the example of dyspepsia.  I will try to elaborate more using headache, which is the disease condition that got me into acupuncture in the first place.

Point selection and manipulation in acupuncture depend on too many variables.  Ten people can have headaches.  One will have it in the front, another at the temples, another at the nape.  One will have headache associated with chronic sinusitis, another will have it due to migraines, yet another because he is a computer encoder always looking at CRT screens, another will have it after a flaring temper, yet another associated with menses.  Acupuncture treatment then, will seldom be the same for any two of these patients.

Hence, what would be my suggestion for a proper study?  In addition to the conditions above, we can also add something to make the patients even more homogenous (can never be totally homogenous though) – same race, same diet, same emotional pattern, same job, same associated factors for the headache.  Difficult yes, but necessary because of the nature of proper acupuncture point selection.

Clinical experience has shown that “cookbook” acupuncture, which means taking a western symptom “headache”, or “dysmenorrhea” CAN be effective, but I wouldn’t be surprised if it wouldn’t be AS effective.

What do you guys think?

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  1. March 30th, 2010 at 22:20 | #1

    Hi Philip,

    Great article, and thanks for the links. I should clarify something. Based on my experience and what I’ve heard and observed with other practitioners, I think point selection does matter. However, I find it difficult to support that position in the current scientific literature.

    Most studies which have compared various methods of point selection (individualized for the patient) indicate that there is no significant difference between them. Some of them were very well designed. They had a no treatment group, and then two treatment groups – each with a different methodology for choosing points.

    I use Dr. Tan’s Balance Method and Master Tung’s points almost exclusively. I’ve found that this approach is more effective for me, or at least it seems that way. I also believe that this is essentially how acupuncture was practiced up until the creation of TCM in the 1950s.

    I have not seen any studies comparing the Balance Method to zang fu acupuncture. That might be an interesting comparison, because the methods are fundamentally different. All of the studies I’ve seen simply compare different methods of selecting points that are still based on zang fu theory, i.e. SP3 for SP Qi xu, or LR3 for LR Qi stag., etc.

    I don’t think we need standardized populations (i.e. homogenous w/ same race, diet, job, etc.) to perform a good study. If you set up the study so that the practitioner is able to select the appropriate points for each patient, which is not hard to do, then it shouldn’t be necessary for all of the patients to be similar. What is being evaluated is how well individualized point prescription works, not how well acupuncture works for a given population.

    So the design would be:

    Group A: no treatment control

    Group B: sham group using Streitenberger placebo needling at random non acupoints

    Group C: treatment group using zang-fu methods of point selection, individually tailored to each patient’s presentation

    Group D: treatment group using Balance Method methods of point selection, individually tailored to each patient’s presentation

    Ideally Groups C & D would each have 8-10 expert practitioners of each method selecting the points and treating the patients. That way we are not just comparing the skill level of one practitioner to another, we’re comparing how the methods of points selection work amongst a group of skilled practitioners of each method.

  2. Philip
    March 30th, 2010 at 22:31 | #2

    Thanks for the comments, Chris. It’s always a pleasure to compare and contrast with you.

    I speak about standardized populations not for our benefit but for the benefit of western researchers. They’re the ones who are obsessed with ruling out every possible variable – or at least attempting to.

    For us, what is important is individualized point prescription. For “them” it is how well acupuncture in general works for a given condition, not recognizing that what is one condition for them may be a myriad of conditions for us and vice versa.

    Personally I think I’ve come to develop my own personal style, using an eclectic mix of Balance Method, Five Transporting Points and Meridian style. Zang Fu differentiation for me seems more relevant in herbal medicine.

    That’s the beauty of Chinese medicine – individual practitioners can tailor fit styles to their liking so long as the fundamentals are still there.

  3. Nalan
    April 4th, 2010 at 00:15 | #3

    I do like the Doc Oc cameo there. Very cute. :D

    I can see that it would be difficult indeed to conduct studies regarding acupuncture, but I think that in addition to the suggestion Chris made up there of using two methods to choose points to treat, adding a third group with randomly selected points and measuring those responses would also be beneficial. We know that the needles and contact do indeed trigger a response; the question is how beneficial is the effect created by acupuncture, and it seems to me that contrasting carefully selected points with completely random ones, alongside the control group with no treatment whatsoever, would be the rational way to go about testing the idea.

    Contrasting acupuncture with Western medicine would be the second stage of study, I would think — once the appropriate method has been determined.

  4. March 27th, 2012 at 07:27 | #4

    Wow, there are so many good topics for research in Chinese medicine! Some of them can be broken down to specific claims, especially the diagnostics. Similar to studies done on iridology which showed it to be random and useless in diagnosising kidney failure and severe gallbladder disease, photographs of tongues of patients with kidney failure, heart disease, gallbladder disease, liver disease, etc., should be shown to TCM diagnosticians to see if they can be divided into consistent categories. Perhaps there is a way to choose or describe the target groups to reduce the ‘wiggle room’ which would have TCM people saying “liver failure isn’t the same as Chinese liver problems.” For example, most often, people with severe hypertension are said to have “liver yang rising.” Often secondary symptoms such as red eyes or irritability confirm that TCM diagnosis. Obesity with fatigue is a much different pattern–usually Spleen Qi deficiency. If liver heat signs are absent (i.e. no red eyes, high blood pressure, irritability), we could hope that a TCM diagnostician could tell the difference between pictures of tongues or feeling the pulse without seeing the rest of the patient (though obesity may be seen in the tongue as well). I think you know what I’m getting at. It seems to me that people with insomnia are more likely to have a red tongue tip, but I don’t know how well that holds up if you look at 1000 people with no insomnia who don’t go to an acupuncturist.

    When I first started studying acupuncture and saw in a text that a point could induce sweating and also saw the claim that twirling a needle one way had one effect and the other way had the opposite effect, I thought “I wonder if anyone’s studied that and shown it to be accurate.” I still wonder that, but now am more skeptical of some of these types of point function claims. I’ll be writing more about that on my own blog as time allows. Suffice it to say that when an acupuncture text says one point is good for “beriberi” and another is good for “schizophrenia” and another for “paralysis” it’s fair to be skeptical and ask for evidence. Most good research on acupuncture is still trying to determine if it is reliable for treating pain, yet most acupuncture students are taught that with proper point selection they can treat/cure schizophrenia, paralysis, and even beriberi. This is a problem. My first acupuncture teacher (a Chinese man) slyly told us in secret that you could run a practice with 10 acupuncture points. Then we had to memorize hundreds of them for testing purposes. For the acupuncturist who values research and wants to know how much more effective than placebo their style is, there are more unanswered questions than answered ones.

    Oh, I meant to say when I started this comment that it’s been found that Naloxone blocks much of the placebo effect as well, which complicates things further.

    Thanks again for your blog!

    Kevin O’Neil, L.Ac.

  1. April 3rd, 2010 at 12:24 | #1

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