Enough with answering back at mudslingers.  I get more than enough of that in the local media, with the Philippine elections just around the corner.  Let’s move on to being proactive instead of being defensive.

A common “debunking” technique of anti-acupuncture bigots is to come up with “evidence” that acupuncture is clinical similar to placebo and then “conclude” that acupuncture is therefore useless or irrelevant.  This plays the assumption that placebo = no effect, when in actuality placebo  = the doc does nothing but the patient feels an effect. (http://qi-spot.com/2010/04/28/the-smear-campaign-continues-acupuncture-does-not-relieve-childbirth-pain/)

Of course, even if both acupuncture and sham acupuncture have clinical effects that seem similar (and studies have shown that the real thing beats the fake stuff, even if not by much), the argument the skeptics pose is that if acupuncture is no different than placebo, then what’s the point of doing real acupuncture at all?

Well, a while back, I posted about a study I was looking forward to. (http://qi-spot.com/2010/04/04/a-study-to-look-forward-to-acupuncture-more-than-just-placebo/).  Thanks to Chris, I now have the whole article.   I would like to start by quoting thus:

As long as acupuncture and sham acupuncture treatments produce similar clinical improvements, the results of respective trials can only be taken as evidence against the efficacy of acupuncture. (I don’t think so… – Philip) Only when it can be shown that acupuncture and sham acupuncture effects are mediated differently, this can be taken as evidence that acupuncture effects are different from placebo effects, although both may still be equally effective.

I still can’t help but detect a bit of bias.  When something can be interpreted negatively, it “can only be taken as evidence against…” meaning there is no other way to interpret it, supposedly.

Similar clinical effect, different mechanism of action

Still the point is valid.  If we can show that the real deal triggers physiologic reactions distinct from sham, then that should construe evidence that acupuncture is not only valid, but should be encouraged.

According to the article “Acupuncture, Psyche and the Placebo Response” (the article mentioned above) they HAVE found such physiologic differences.  Why does this matter?  It matters because a) skeptics can’t say it’s like placebo anymore and b) we now have an increased knowledge of acupuncture mechanism of action, which is more than what we can say for such western drugs as lithium.

Take two of these and call me in the morning, even if we don't know how they work

So how does the real thing differ from the fake stuff?  Let’s count the ways as enumerated by Enck et al:

a) “Acupuncture but not sham acupuncture was found to induce both cerebellar as well as limbic cortex activation indicating both motor as well as affective component modulation of the pain matrix.  Acupuncture resp. electroacupuncture at non-acupuncture points and tactile stimulation alone served as controls in early fMRI studies (Wu et al., 2002; Yoo et al.m 2004)

b) Verum (true) acupuncture in contrast to non-penetrating placebo nedles activated cortical centers involved in affective pain modulation (Chae et al., 2009)

c) Greater activation of sensorimotor areas by sham procedure (superficial manipulation at acupuncture points) than by true acupuncture (Napadow et al 2009) – (note that stimulation of true acupuncture points by non-needling methods was considered sham by the authors, whereas in chinese medicine it is a valid method of stimulation)

d) Variances of time of central activation between verum and sham acupuncture, attributed to stronger peripheral actions of true acupuncture

e) PET scans on fibromyalgia patients show that needling at true points elicited significant activation of mu opoid receptor binding capacity in the cingulate, caudate, thalamus and amygdala both after one session and after four weeks, while with sham (insertion into non acupuncture points), small DEactivations were noted, an effect that is seen with placebo analgesia. (Zubieta et al., 2005)

There are more, but these should suffice to prove the point.

All in all I believe this evidence validates my personal belief that real acupuncture has longer lasting effects than sham acupuncture.  This is shown by the fact that real acupuncture has more central (meaning up in the brain, as opposed to just local pain mediation) effects.

Another thing worth noting is that different people have different definitions of sham.  For some, it’s using real points but not inserting.  For others, it’s inserting into non-acupoints.  Logic dictates that both have different effects.  Controls used in acupuncture studies should be standardized!

The crazy thing is that all this has been known by Stux, Berman and others since I was in grammar school in the early 80s!  Jeez!

_________________________

Enck, P., et al., Acupuncture, psyche and the placebo response.  Auton. Neurosci. (2010), http://www.ncbi.nlm.nih.gov/pubmed/20359961

Harris, Zubieta et al. ” Traditional Chinese Acupuncture and placebo (sham) acupuncture are differentiated by their effects on Mu-Opioid Receptors (MORS)” Neuroimage.  2009 Sep; 47(3):1077-85. Epub 2009 Jun 6. http://www.ncbi.nlm.nih.gov/pubmed/19501658

Firstly, I’d like to apologize for not posting for two weeks. I’ve been travelling a lot through Hong Kong and China. I will blog more on some observations I’ve made while in Hong Kong as soon as I get some of my photographs uploaded to my laptop.

Speaking of Hong Kong, I am beginning to wonder if there is some grand plot to discredit acupuncture in Hong Kong. First comes the “letter to the editor” concerning acupuncture spreading disease (http://qi-spot.com/2010/03/20/new-bashing-technique-acupuncture-causes-disease/) and now this.

“Acupuncture does not relieve childbirth pain” (http://www.guardian.co.uk/society/2010/apr/28/acupuncture-childbirth-pain-study)

I am the first person in the world to admit where acupuncture is one big FAIL (such as in colour blindness). But I would like to call the attention of the reader to the weasel wording evident in this smear campaign of a headline.

Look at the title. “Acupuncture does not relieve childbirth pain.” What does this imply to the reader? It implies that acupuncture has no effect at all on the pain felt by mummy.

Yet the sub-title below the headline betrays a hint of the truth:

“Research suggests results from complementary therapy during labour may be placebo effect”

Now, we have no idea, based on this sub-headline if this is a single study or a meta-analysis.  As we have said before, a meta-analysis is a fancy way of saying, “let’s put different studies together just to get the numbers up.  We can always find a way to put the studies together that the sum total numbers can be made to say whatever we want.”

Secondly, it “suggests” (whatever that means) that the results may be placebo effect.  Wait.  Results?  RESULTS?  I thought that acupuncture “does not relieve” childbirth pain?  So if it is useless, why are there “results”?  That means there WAS relief of pain.

So why come up with a headline saying otherwise?  Because the results “may” be placebo effect.

Actually, I wouldn't use those points in pregnancy... but what the heck. Then again, he just might be some really fat guy...

The finding, which has already prompted a vigorous debate about the value of acupuncture, came from British and Korean researchers who examined previous studies of its use in labour.

“The results show that there is little convincing evidence that women who had acupuncture experienced less labour pain than those who received no pain relief, a conventional analgesia, a placebo or sham acupuncture,” researchers told BJOG: An International Journal of Obstetrics and Gynaecology. The journal is owned by the Royal College of Obstetricians and Gynaecologists, which represents most of the UK’s doctors specialising in childbirth and maternity care.

The finding, which has already prompted a vigorous debate about the value of acupuncture, came from British and Korean researchers who examined previous studies of its use in labour.
“The results show that there is little convincing evidence that women who had acupuncture experienced less labour pain than those who received no pain relief, a conventional analgesia, a placebo or sham acupuncture,” researchers told BJOG: An International Journal of Obstetrics and Gynaecology. The journal is owned by the Royal College of Obstetricians and Gynaecologists, which represents most of the UK’s doctors specialising in childbirth and maternity care.

So it IS a meta-analysis.  Strike one.  I wonder what points were used? Hmmm…

Prof Edzard Ernst, of the Peninsula medical school at Exeter and Plymouth Universities and co-author of the report, said: “The effects of acupuncture perceived by women are largely due to placebo. Acupuncture has many qualities that maximise placebo effects: it involves touch and is invasive and, psychologically, is attached to the mysticism of the east.”

Ernst is a known skeptic of acupuncture and makes a living (i.e. buy his book!) by bashing it.  Then again, I make my living healing patients with it, so I guess we cancel each other out.  Still, he admits that acupuncture DOES have an effect, it’s just that he either cannot or will not recognize the evidence that acupuncture DONE PROPERLY is more than placebo. (http://qi-spot.com/2010/04/04/a-study-to-look-forward-to-acupuncture-more-than-just-placebo/)

I would like to point out that even in western medicine, there exist drugs for which the mechanism of action is unknown.  Lithium is used for bipolar disorder and it is not known how it works.  Yet it is given, despite toxicity, because it has been observed to work.  I leave it to the reader to witness where the double standard lies.

Also, I find it disturbing that people will look down (albeit unintentionally) on patients’ experience just to pooh-pooh acupuncture.

Prof Philip Steer, BJOG’s editor-in-chief, said labour pain can be so intense that a women would do anything to minimise it.

Please, by that logic we can get a shaman in pyjamas to conduct ritual chants and that would work.  Yet it doesn’t, and acupuncture does.

“Acupuncture is a drug-free approach and that may explain why some women prefer its use during labour. This review shows that in a very small number of cases acupuncture may be of help, usually for short periods of time after treatment, and this may be down to psychological rather than a physiological effect. Generally the consensus is that the evidence does not support its use.”

The only benefits were 11% less pain in the first 30 minutes after receiving acupuncture and a need for less pharmacological pain relief, the authors say.

Wait wait wait.   The “only” benefits? So “they” begrudgingly admit that there are benefits!  Back to my first question: why the irresponsible headline, then?  The last part of the sentence betrays the answer:

“…a need for less pharmacological pain relief” – in english: LESS DRUGS.

Less drugs, less profit for big pharma.

I will skip to the last part:

Mike O’Farrell, chief executive of the British Acupuncture Council, said: “We’re surprised by these findings as previous trials, along with the evidence that our members see in their practices every day, suggest that acupuncture can be effective in providing pain relief in many different circumstances.”

Again, as I have said before, people not biased by big pharma can see where acupuncture works and it doesn’t.  I am happy to report, both first hand and through correspondence with other OB-Gynecologists even in the US, that acupuncture can work in reducing childbirth pain IF DONE PROPERLY.

My final thoughts: this article should have been entitled “Acupuncture apparently no better than placebo” instead of “Acupuncture doesn’t work”.  News bias, bah humbug.

Campbell, Denis.  ”Acupuncture does not relieve childbirth pain” The Guardian.  28 April 2010.  <http://www.guardian.co.uk/society/2010/apr/28/acupuncture-childbirth-pain-study> Accessed 28 April 2010

A Korean study has demonstrated how Acupuncture can help patients with spinal cord injuries recover function.

In this article indexed by pubmed, two acupuncture points are shown to control the inflammation associated with traumatic spinal cord injury.  Inflammation is a good thing, but too much inflammation just bogs everything down.  In fact, that’s how steroids became wonder drugs – they mediate excessive inflammation.  Swelling then goes down, encouraging function.

Here’s the abstract:

Acupuncture-mediated inhibition of inflammation facilitates significant functional recovery after spinal cord injury.

Choi DC, Lee JY, Moon YJ, Kim SW, Oh TH, Yune TY.

Age-Related and Brain Diseases Research Center, Biology, School of Medicine, Kyung Hee University, Seoul 130-701, Korea; Neurodegeneration Control Research Center, Biology, School of Medicine, Kyung Hee University, Seoul 130-701, Korea.

Here, we first demonstrated the neuroprotective effect of acupuncture after SCI. Acupuncture applied at two specific acupoints, Shuigou (GV26) and Yanglingquan (GB34) significantly alleviated apoptotic cell death of neurons and oligodendrocytes, thereby leading to improved functional recovery after SCI. Acupuncture also inhibited caspase-3 activation and reduced the size of lesion cavity and extent of loss of axons. We also found that the activation of both p38 mitogen-activated protein kinase and resident microglia after injury are significantly attenuated by acupuncture. In addition, acupuncture significantly reduced the expression or activation of pro-nerve growth factor, proinflammatory factors such as tumor necrosis factor-alpha, interleukin-1beta, interleukin-6, nitric oxide synthase, cycloxygenase-2, and matrix metalloprotease-9 after SCI. Thus, our results suggest that the neuroprotection by acupuncture may be partly mediated via inhibition of inflammation and microglial activation after SCI and acupuncture can be used as a potential therapeutic tool for treating acute spinal injury in human. Copyright © 2010. Published by Elsevier Inc.

In addition to the mediation of inflammation, it appears that acupuncture also promotes constructive mechanisms.  The study actually mentions two points, GV 26 Shuigou and GB 34 Yanglingquan.  Let’s examine those two.

Renzhong or Shuigou is a well known resuscitation point in chinese medicine.  Normally it is known as a point to press to revive consciousness.  In addition, a list of it’s functions includes “benefitting the spine” which is the obvious mechanism here.  However, GV 26 is located at the very end of the GV channel.  This would imply that it would be best for treating the spine as a whole in general but the lumbar spine in particular.  This is because one maxim in meridian-style acupuncture is that points on one end can affect the meridian’s other end. I wonder if there is a significant difference in using GV 26 for cervical/thoracic spine injury as opposed to lumbar spine injury?

Pressing of GV 26 Renzhong from the movie Red Cliff Part 1

Gallbladder 34 is known as the influential point of the sinews and is indicated for neuromuscular problems in general.  In addition to strengthening the sinews and tendons, it also clears Damp Heat.  I believe that the terms “Heat” and “Fire” in Chinese medicine refer to the same thing westerners refer to as “inflammation”.  To be inflamed, if you think about it, means to be on fire, yes?  Dampness in Chinese can indicate heaviness – a consequence of inflammation, perhaps?

All in all I wish to know more details about this study: what was the method for stimulating the points? Was it light stimulation on the needle or heavy?  What were the animal models used in this study? etc etc

Again, more studies to look forward to.

Ah Germany, land of good beer, great sausages, and acupuncture research.  Stux et al have contributed much to acupuncture, and now a new study awaits publication that I am eager to read.

From http://www.ncbi.nlm.nih.gov/pubmed/20359961?dopt=Abstract:

Acupuncture, Psyche and the Placebo Response

Enck P, Klosterhalfen S, Zipfel S.

Auton Neurosci. 2010 Mar 30. [Epub ahead of print

University Hospital Tübingen, Dept. of Psychosomatic Medicine, Tübingen, Germany.

With growing use of acupuncture treatment in various clinical conditions, the question has been posed whether the reported effects reflect specific mechanisms of acupuncture or whether they represent placebo responses, as they often are similar in effect size and resemble similarities to placebo analgesia and its mechanisms. We reviewed the available literature for different placebos (sham procedures) used to control the acupuncture effects, for moderators and potential biases in respective clinical trials, and for central and peripheral mechanisms involved that would allow differentiation of placebo effects from acupuncture and sham acupuncture effects. While the evidence is still limited, it seems that biological differences exist between a placebo response, e.g. in placebo analgesia, and analgesic response during acupunture that does not occur with sham acupuncture. It seems advisable that clinical trials should include potential biomarkers of acupuncture, e.g. measures of the autonomic nervous system function to verify that acupuncture and sham acupuncture are different despite similar clinical effects. (emphasis mine)

Copyright © 2010 Elsevier B.V. All rights reserved.

Now like I've been blogging, I'm not out to prove acupuncture works or not.  I believe it does for many but not all conditions.  However, data such as this would only verify what I've been saying.  Yes, there ARE changes differentiating between sham and "real" acupuncture.  I am sure this refers to stimulation of a-delta fibers, stimulation of the periaqueductal gray and the VPL nuclei of the hypothalamus.  Nonetheless, I shall be on the lookout for the actual article.

Interestingly, I see another, seemingly contradictory article, while browsing the first one.  This time, from Sweden.  Now we see they've got more than just massage and meatballs: (http://www.ncbi.nlm.nih.gov/pubmed/19525330)

Is Placebo Acupuncture What it Is Intended to Be?
Evid Based Complement Alternat Med. 2009 Jun 12. [Epub ahead of print]
Lundeberg T, Lund I, Sing A, Näslund J.
RPT, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden. jan.e.naslund@ki.se.
Randomized, placebo-controlled clinical trials are recommended for evaluation of a treatment’s efficacy with the goal of separating the specific effects (verum) from the non-specific ones (placebo). In order to be able to carry out placebo-controlled acupuncture trials, minimal/sham acupuncture procedures and a sham acupuncture needle has been used with the intention of being inert. However, clinical and experimental results suggest that sham/minimal acupuncture is not inert since it is reported that both verum acupuncture and sham/minimal acupuncture induce a significant alleviation of pain. This alleviation is as pronounced as the alleviation obtained with standard treatment and more obvious than the one obtained with placebo medication or by the use of waiting list controls. These results also suggest that sham acupuncture needles evoke a physiological response. In healthy individuals sham acupuncture results in activation of limbic structures, whereas a deactivation is seen in patients with pain, i.e. results from healthy individuals do not reflect what is seen in clinical conditions. Also, depending on the etiology of pain (or any under clinical condition under investigation), the response to sham acupuncture is varying. The acupuncture ritual may also be seen as an emotional focused therapy allowing for psychological re-orientation. Sham needling in such context may be as powerful as verum acupuncture. We recommend that the evaluated effects of acupuncture could be compared with those of standard treatment, also taking the individual response into consideration, before its use or non-use is established. (emphasis and italics mine)

What do these two studies together mean?

1) Current methods of sham and real acupuncture seem to evoke similar physiological responses. Studies have shown that at times, sham and real acupuncture seem to be effective.  Skeptics are quick to jump and say there, that means acupuncture is no better than placebo!  The proper term is that acupuncture SEEMS to be just the same as sham.  The problem with the skeptic logic is that they forget that both sham and real acupuncture are better than nothing, or TRUE placebo.  I can see it now:

Skeptic: Fake needling just the same as real needling! Hence, acupuncture isn’t real!

Acupuncturist: But both fake and real needling is better than nothing, what say ye?

Skeptic: So why not just massage? Why use needles?

Acupuncturist: I only have two hands right? (refer to Doctor Octopus as per my previous post http://qi-spot.com/2010/03/30/how-to-research-acupuncture/) And clinical experience says it works faster.

Skeptic: “Clinical experience” bah humbug!

On to point two:

2) So the second research says there’s a difference between nothing and acupuncture, whether sham or not.  The first research says there’s a difference, physiologically, between sham and real acupuncture.  I can foresee the dialogue now:

Skeptic: okay you say that clinically there’s a difference between sham and real acupuncture.  I want empirical evidence that there is a difference.  Otherwise I can just ignore your clinical experience like I ignore all other evidence that acupuncture can work and work well.  I’ll take the words of statisticians and published journals funded by Big Pharma over clinicians anyday.

Acupuncturist: Well what if there is proof that there is a physiologic difference between real and sham?

Skeptic: Is there?

Acupuncturist: That’s what the first study quoted above says.

Skeptic: Hmmm it says that it’s clinically similar, just physiologically different!

Acupuncturist: Jeez, I don’t know how to talk to you guys sometimes.  You say the real thing is no different than sham, so who cares if it works or not.  Then we say but both sham and real thing are better than nothing, you say that guys like Ernst et al say the studies suck, utterly ignoring that western medicine is also guilty of the same sins at times (perhaps more on that on a later blog post.. oh wait, lots of those already!)

Skeptic: Not all acupuncture studies suck, just the ones that prove acupuncture doesn’t work.

Acupuncturist: Then you insist in your holy grail of treating acupuncture like a pill, even though I’ve explained kabodles of times that Acupuncture is a procedure, not a pill (ka ching, five cents).

Patient (sneaking in): Uh guys, I don’t give a crap about that stuff, I just want to feel better so I can get on with my life.

Skeptic: You’re an idiot.  You don’t know squat.  We’re the only ones with brains and we know what’s best for you and what medicines you should buy.  Any perceived benefits from acupuncture and Chinese medicines are all in your head.  You’re too dumb to know the difference.

Philip: Okay I should stop now.  I’m going overboard with this blog post ha ha.

Shi Xue Min is a legend in acupuncturist circles.  He is the head of the single largest acupuncture department in the world in Tianjin, China.  In his hospital, a new 22 storey acupuncture building is being constructed just to deal with patient load.  I bring him up now because I want to show through his example why acupuncture is a procedure and not a pill, and why not all acupuncturists are created equally.

From Blue Poppy I quote:

At any rate, Shi Xue-Min is the chief editor of many important acupuncture texts in China, including the “gold standard” yellow hardbound Acupuncture Treatment (Zhen Jiu Zhi Liao) textbook that is found in any good Chinese TCM library. One thing that stands out when reading Chinese acupuncture textbooks (in comparison with English ones) is the emphasis on needling sensation and stimulation methods. Many English textbooks say “needle point x” while Chinese texts say “needle point x with even supplementing and draining technique for 30 seconds of continuous stimulation, until the qi sensation propagates to the lower abdomen.” Similarly, Shi Xue-Min’s lecture placed a tremendous emphasis on HOW the points should be needled, which techniques were appropriate, how long the stimulation should be, etc. (emphasis mine)

In virtually every western style study I have seen, I have seen the use of electroacupuncture.  There is practically no mention of needling technique.  Is it any wonder, then, that results may be inconsistent?

It's how you use it that counts!

Let’s go back to what I’ve been saying.  Acupuncture is being studied in the west as a PILL and not as a PROCEDURE.  Jesus Christ if I had a nickel for every time I’ve tried to hammer that into skeptics’ brains I’d be rich.  Let’s explain further. You can prick and get a moderate effect, or you can needle properly, get the achieved qi sensation and increase your success rate.  Can this qi sensation be obtained with massage alone? Yes.  But it’s much harder.

It was once said (I forgot where I read it – I think it was from a Maciocia book) that “the meridians are like strings, the body the instrument, and the acupuncturist the player”.  If the musician is lousy, does that mean that the musical instrument is inherently bad?   Just because your next door neighbor can’t play the piano to save his life does that mean we should discount pianos altogether?

I'm tempted to do the same to lousy pseudo-acupuncturists who give the real thing a bad name.

The Yellow Emperor’s Medical Classic, or Huangdi Neijing, is clear on this.  When needles are inserted proper needling sensation must be obtained.  The problem these days is that “acupuncturists” just follow the book (bypassing proper diagnosis) on point selection, then stick needles without performing proper technique (how would you know what technique to use if you didn’t diagnose right?) and then ignore proper technique and just hook the patient up to some machine that tries to do your work for you?

Show me an acupuncturist who knows how to modulate the qi sensation using proper manipulation and I’ll show you someone with a long line of satisfied patients.

And for the Nth time – study acupuncture as a PROCEDURE, not a PILL.

Now where’s my nickel?