Acupuncture – An Implausible Premise Lacking Evidence

How could something thousands of years old be wrong?

How could I ignore acupuncture’s popularity?

I received the same typical questions from friends and family when I told them that I oppose acupuncture. They also told me anecdotes of how acupuncture worked for them. My family and friends have a powerful ally on their side, Dr. Oz of Oprah fame, who makes many of the same arguments. It seems the deck is stacked against me on this.

I think what they’re getting at is this… where do I get the balls to say with confidence that acupuncture, an ancient medicine with hundreds of satisfied customers, is useless bunk? Let me state up front that, besides having a wife who studied acupuncture, I am not an authority on alternative medicine. I’m a skeptic, I respect science, and I’ve spent some time researching the subject, but I don’t hold a PhD in eastern or western medicine.

As for anecdotes, they are outside the realm of what I can assess. There can be any number of reasons that acupuncture may seem to be effective; I have no way of analyzing or comparing one person’s positive anecdote with any number of uninteresting negative anecdotes. The only way to test whether a claim works is to verify it using properly controlled peer reviewed studies, and under those conditions, the extraordinary claims made by acupuncturists have been found to be lacking.

But what I’m about to write may shock you, considering my introduction to the topic… acupuncture works for some conditions. People feel better after they’ve been treated with acupuncture, and I won’t deny that. Yes, needles piercing strategic points along specific invisible meridians have been shown to reduce pain, but… fake non-piercing needles placed at random points on the body also reduce pain. It’s been proven numerous times that acupuncture is only as effective as a sham placebo.

There may even possibly be an endorphin response of opioids that comes from being needled, further adding to the placebo effect detected in research trials.

So why am I hating on acupuncture if it has an actual effect? Because acupuncture doesn’t work as claimed, because people who seek an acupuncturist may need actual medicine, and treating with placebo is unethical because deception must occur for the response to be most effective.

As for the endorphins, those aren’t anything special. You can get the same response by pinching your skin, running a mile, or having sex.

The Concept of TCM
Before the origins of accepted traditional Chinese medicine, the Chinese believed that illnesses were caused by ancestors and demons. Those who say that there is a value in ancient ideas should remember that even the Chinese have justifiably abandoned ideas even more antiquated than acupuncture.

Acupuncture itself is rooted in the ancient Chinese philosophies that led to Taoism, associated with Lao-Zi of the 6th century but understood to be much older, which says that humans should strive to be in harmony with nature.

In TCM, the force that separates humans from nature is Qi (chi), an energy which Taoists believed to be flowing through our bodies, giving us life. There are two opposing forces, yin (dark and cold) and yang (light and hot), representing the duality of nature. The chi flows through twelve meridians (one for each month of the year), or channels, and each meridian is associated with a specific organ. Along the pathway of these meridians are supposed points where needles can be inserted to stimulate the chi. There were originally around 365 acupuncture points (one for each day of the year), but now there are nearly 2000, with no explanation of how these points were determined.

The meridians are based on the philosophical Taoist philosophy that there are six elements represented in the body, each associated with two major organs (one for yin and another for yang): water (kidney/bladder), wood (liver/gallbladder), earth (spleen/stomach), metal (lungs/large intestine), fire (heart/small intestine), and finally, inexplicably, an imaginary sixth element called Minister Fire, which is associated with the debatable meta-organs called the pericardium and san jiao or “Triple Warmer”.

A patient of Chinese medicine might be diagnosed with a combination of external pathogens: damp, cold, heat,wind (+ summer heat and dryness). The four main external pathogens are, in turn, an exchange of ideas from the ancient Greek idea of humourism: damp is “phlegm”, cold is “black bile”, heat is “yellow bile”, and wind is “blood”.

Further evidence of an association between external pathogens and the four humours include the fact that they are diagnosed for exactly the same diseases as the four external pathogens. You’ll also find recommendations in both cultures to adjust your diet depending on the pathogen or humour in which you are in excess. Down the line, pathogens and humours match up: the seasons, the colors, the foods, etc… The only major difference is that the Chinese have two extra, and I suspect that those two were added because the Chinese prefer the number six (which is why they have six seasons).

In addition, the TCM technique of “cupping”, lighting a vacuum under a glass bowl and placing it onto the skin, was also used to treat an imbalance of the humours.

Could it also be that acupuncture may have been a form of bloodletting, the idea of puncturing the body to release excess humours? Many of the earliest references to acupuncture talk about needling the blood vessels and draining blood. At the least, acupuncture and humourism share the same origins, and yet, society dismissed humourism as implausible many years ago.

The History of TCM
The oldest evidence of acupuncture is not 4000 years old, as is sometimes claimed. There have been arguments by some that the Iceman Otzi found in the mountains of Italy might have acupuncture marks tattooed on his back that correspond with his medical condition, but this idea is speculation (and extraordinary speculation since he would predate the earliest known acupuncture texts by thousands of years – and he was a full continent away from China).

The earliest confirmed documents on TCM are the Yellow Emperors Classics of Internal Medicine, or the Huang Ti Nei Ching, which probably originated in the first century CE. Although the manuscript is attributed to the Yellow Emperor, it’s authorship is dubious. In fact, the historicity of the Yellow Emperor is debatable; he has been described as a virgin-born legend who ascended to heaven after living a life of miracles. Sound familiar? Scholars are certain that the Huang Ti Nei Ching was written and revised over the years, much like the Bible. It does not give specific instructions on how acupuncture works, but instead gives zodiacal recommendations for the best times to perform needling in the form of Socratic dialogue.

The earliest reference to Chinese needles references lancing abscesses and bloodletting of blood vessels, and what is now known as acupuncture points were probably spots that were suggested for bloodletting. Archaeological and historical evidence of the time indicates nine large bulky needles were used, and they would more likely draw blood than stimulate energy.

A rudimentary form of acupuncture was first tried in America in 1820, when needles were used, to no avail, in an attempt to revive drowned kittens. Acupuncture was popular in Europe at this time, but lost favor during the opium wars of the mid 1800s.

The Chinese government attempted to ban the use of acupuncture several times, until it was revived by Chairman Mao in the “barefoot doctor” campaign. Mao did not believe in acupuncture, nor did he treat himself with it, but he used it as a way to bring his people the inexpensive health care he had promised . “Even though I believe we should promote Chinese medicine. I personally do not believe in it. I do not take Chinese medicine.”

New York Times journalist James Reston wrote a front page article about how he was treated for an appendectomy while he was in China. It’s common for acupuncturists to say that instead of using anesthesia, he was treated for pain with needling. In fact, this is not true. He was treated with chemical anesthesia and an epidural during the surgery, and he reported getting a shot for the pain in post op. It wasn’t until a few days after the surgery that he was treated with acupuncture. Reston described it as painful, and his only words of kindness was that the pain from the needles distracted him from the mild discomfort in his stomach. His stomach discomfort went away, as it naturally would, the following day.

Where did TCM theories come from?
We don’t know who discovered chi, the meridians, the acupuncture points, or any of the other complex diagnostic techniques of TCM. We don’t know how these things were found, since they can’t be detected, measured, or verified. How can we believe in a system based on invisible energy that flows through invisible channels and is regulated by needles stuck in invisible points? Furthermore, this is a claim that doesn’t meet testable predictions, such as other invisible universal properties like gravity and magnetism.

Truth be told, medieval Chinese did not have a practical understanding of anatomy, nor did they have any concept of the measurable forces of nature. Indeed, their explanations of internal organs are quite lacking. Chinese anatomy is even embarrassingly described in the introduction to the Huang Ti Nei Ching by the English missionary, Dr. Lockhart as if “…some person had seen some imperfect dissection of the interior of the body, and then sketched from memory a representation of the organs, filling up parts that were obscure out of his own imaginings, and portraying what, according to his own opinion ought to be, rather than what they in reality are.”

Chi has the same symbol as the character for “steam from cooked meat”. It was a way to describe the vapor that comes out of our mouth on cold days. Somebody who doesn’t have an understanding of water vapor and gas can be excused for describing it as a life force, but we understand anatomy and physics well enough now that such early descriptions should be ignored. Western culture had a name for this imagined element also: the quintessence.

Meridians, as I’ve suggested, were an explanation for blood vessels and the pulse. The ancient Chinese did not dissect cadavers, so they had no way of knowing that blood pumps through those channels that are mapped all over the body. But, they could feel the pulse, and it must have seemed supernatural. Indeed, the pulse is one of the first diagnostic tools that modern acupuncturists use when treating a patient.

Who knows how they came up with acupuncture points, but based on my experiences, the points correspond with recognizable pressure points that my wife loves to jab violently with her thumb when she wants to prove to me that the acupuncture points are real.

Modern veterinary acupuncture uses points that were transposed from a human chart onto an animal chart, which is why you’ll find a “gall bladder” meridian on an animal that has no gall bladder. Oops.

The Acupuncture Process
The initial TCM diagnosis has five components:

• Inspection – She examines your tongue and looks for any discoloration, bumps, or layers of film. The tongue like other body parts is thought to be a symbolic map of the body.
• Auscultation – She listens to your breathing and your heart beat.
• Olfaction – She smells you.
• Palpation – She checks your pulse. Acupuncturists claim to detect many problems from irregularities of the pulse.
• Inquiring – The acupuncturist asks a series of health questions, including questions about your poop.

Based on this input, the acupuncturist chooses which points to needle, or if required, she will do another form of TCM. The patients almost always lie prone and are told to relax during the session.

The points are found by using a unit of measure called sun (pron. soon), but the points are invisible. Many of the points are based around nerve clusters, so the patient can easily confirm whether the acupuncturist is at the right point. Needling a specific meridian does not necessarily correspond to the body part that needs healing. For instance, if I came in for a stomach ulcer, the acupuncturist might needle my lung meridian. The names of the meridians are arbitrary and do not signify their purpose.

Moxxibustion is when the dried mugwort herb is burned and waved over an area that is “cold”. It smells like marijuana, and the plant in its raw form can be hallucinogenic. Mugwort or Moxxa has been used by many cultures for many purposes.

Gua Sha is a technique that is used for congested individuals (with stagnant chi). Oil is rubbed on the patients back and then a spoon is used to scrape the back until it’s nice and red. The idea is that the aggravation draws toxins to the surface and away from the infection.

Cupping is a technique that involves lighting a vacuum into the bowl of a cup and placing the suction onto the patient’s skin.

Testing TCM
There are a few problems testing acupuncture, the most classic of which is finding a way to perform sham acupuncture. In order to have a well designed study, at least on group should be treated with fake needles. It’s been difficult to design a needle that stays upright but does not pierce the skin. A retractable needle has been developed that serves the purposes.

Placebos
The term placebo means “I please”, and it’s a complicated physiological response that we don’t fully understand. It’s been proven that placebos work better when the treatment is more psychologically convincing. We do know that the best way to test a medical claim is to compare two groups: one who receives the proper recommended treatment and one who unknowingly receives a fake treatment. Each group must be blind to whether they are receiving the real treatment of the fake treatment; in addition, an ideal situation would require each doctor to be unaware of which treatment they are providing.

Acupuncture is the perfect habitat for placebos, which thrive in situations of perceived power and perceived authority. When you arrive at an acupuncture clinic a doctor in a white coat spends time diagnosing you, asking you health and wellness questions, checking your pulse, and examining your tongue. The environment for TCM is usually very relaxing and calm and, of course, it’s also very hands-on. The strategic placement of needles gives an impression of precision, and knowing that the treatment is ancient provides enough perceived mysticism to boost the placebo even more. It’s been proven that the ritual of sham acupuncture outperforms the effects of a sugar pill, so there is something special about the acupuncture clinic’s placebo effect that must be noted. These are not excuses to explain away the anecdotes of TCM patients, but they are simply reasons to control for placebo.

Perhaps the best description for a placebo response in acupuncture comes from Ch’i Po in the manuscript Haung Ti Nei Ching. He said, “This is the way of acupuncture: if man’s vitality and energy do not propel his own will his disease cannot be cured.”

An article from NPR dances around using the term “Placebo”. In the interview, Cherkin refused to use the word “placebo” because he claimed that people usually dismissed it as “something that doesn’t work”. But just because a term has a negative connotation, doesn’t mean that using the definition of the term (and not the name) will help your argument.

Researchers are also unclear how the ancient practice actually stimulates a healing effect. An interesting twist to Cherkin’s findings is that people who were given simulated acupuncture — the needles push on the skin, but don’t penetrate — reported just as much benefit as those who had standard acupuncture.

It’s possible, says Cherkin, that stimulating these standardized points on the body, even without piercing the skin with needles, does cause a specific physiological process that reduces pain.

But there’s another possible explanation, too: Perhaps the whole ritual of performing an acupuncture treatment has a generalized effect. “The patient is feeling that they are getting a helpful treatment,” explains Cherkin, “and as result the brain reacts in a way that leads to improvement.”

False Placebos
In addition to placebo relief there are false placebo indicators, such as natural regression, additional treatment, and answers of politeness. Natural regression means that the symptoms disappeared naturally and that causation does not imply causation. A patient could also be on other medications and treatment and simply attribute their relief to needling. Answers of politeness are a significant problem depending on the culture. There are countries and regions where they are compelled by a social code to submit their will to authority. None of these examples are excuses, they are just more reasons why we must have adequate controls.

Logical Fallacies

• Appeal to Antiquity – Just because a treatment has been used for “thousands of years” does not mean that it has value. Acupuncture was developed in a time when we knew very little about human anatomy, when very few understood biological processes. I don’t think any of us would accept bleeding with leeches or treating the humours, and yet both of those ideas were developed thousands of years ago too.
• Three Men Make a Tiger (Argument Ad Populum) – I use the Chinese saying here to illustrate my point. It means that if one man says that there’s a tiger in the marketplace nobody would believe him, but people might start believing the story if three men were to say that there’s a tiger in the marketplace. Just because more people are receiving acupuncture doesn’t mean that it’s true. The merits of a medicine are not defined by it’s popularity, but by it’s objective value.
• Special Pleading – Acupuncture should not get a special pass that excludes it from the laws of science. It’s not the job of science to invent new ways to detect something that is undetectable. Chi is a cultural concept that has no anatomical meaning, so anyone who insists that chi is real should examine whether they are asking for special treatment that would defy observation.
• Confirmation Bias – We have a tendency to note (even exaggerate) the occasions when our beliefs are verified, and ignore the times when our beliefs are contradicted.
• Appeal to Personal Anecdote – Humans have an enormous capacity to fool themselves into a belief based on what seems to be a very real personal experience. Personal Anecdotes are not an acceptable way to explain a claim. We all know of products and services which were once verified by anecdotes (even dating back to bleeding with leeches), but no matter what somebody says subjectively, it doesn’t change the objective facts best explained through the scientific method.

Claims
Unlike western doctors, acupuncturists can make any claim without being legally challenged by a regulatory system. I examined the claims of a Cincinnati acupuncturists to see whether they are supported by the evidence compiled by the Cochrane Review. The following claims by Carol Paine, a Cincinnati acupuncturist, are contradicted by the evidence against them: stroke, asthma, Bell’s Palsy, depression, drug addiction, smoking addiction, insomnia, and period pains.

Evidence against TCM
There are several factors that go into judging the quality of a study. As stated before, we must control for placebo by providing a control group who receives sham acupuncture. We must also make sure that a low number of the study’s participants had a prior positive belief of the treatment’s value. The study should have at least 25 individuals in each group, and it should have a low attrition rate. Finally, the study should be published in a reputable peer reviewed journal, and it’s even better if the study has been independently vetted via replication and critical analysis.

Included in these studies are examples of when acupuncture seemed to help significantly, but failed to show greater results than the placebo group. Acupuncture makes specific claims that acupuncture only works at specific points on specific meridians, and those claims should be considered false if well designed studies show those points and meridians to be no better than placebo.

• Archives of Internal Medicine – May 2009 – Individualized, Standardized, and Simulated Acupuncture all do equally better than standard care.

• BMJ – January 2009 – A systematic review of acupuncture trials that indicate the analgesic effects are small and inadequate due to problems of bias from improper blinding.
• Journal “Human Reproduction” – February 2009 – Sham acupuncture did better than ‘real’ acupuncture for “in vitro” fertilization.
• Clinical Journal of Pain – April 2008 – Sham acupuncture did better than true acupuncture for arm pain.
• Archives of Internal Medicine – September 2007 – Both sham and real acupuncture did twice as well as conventional therapy for lower back pain.
• European Cancer Conference – September 2007 – There was no statistical difference between sham and proper acupuncture in the relief for radio-therapy induced nausea.
• University of Oklahoma – October 2007 – Acupuncture actually reduced the chances of a successful IVF treatment
• JAMA – May 2005 – Real and sham acupuncture helped with migraine pain.
• Cochrane Review – April 2005 – There is insufficient evidence for the use of moxxibustion to correct a breech presentation.

Evidence that seems to be in favor of TCM but the studies lack quality

• Journal “Birth” – March 2009 – Acupuncure is a good supplement to existing pain relief methods. STUDY WAS NOT BLINDED!
• Behavioral Brain Research – December 2009 – Acupuncture does better than sham in pain relief study. STUDY HAD EXTREMELY LOW SAMPLE SIZE
• Anasthesia & Analgesia – December 2008 – Meta Analysis indicates that acupuncture is better than sham for headaches. The lowest rated studies that were included in the meta analysis were all positive for acupuncture – ruining the curve.
• ASTRO Meeting – September 2008 -Acupuncture did better than Effexor on hot flashes – STUDY WAS NOT BLINDED! STUDY DID NOT CONTROL FOR PLACEBO!
• Cephalalgia – August 2008 – Acupuncture patients reported greater headache relief than standard care. STUDY WAS NOT BLINDED! STUDY DID NOT CONTROL FOR PLACEBO!
• Complimentary Therapies in Medicine – December 2005 – Real acupuncture did better than acupressure and sham acupressure in the management of cancer fatigue. STUDY WAS POORLY CONTROLLED!

• National Institute of Health – December 2004 – Acupuncture relieves knee pain and helps mobility STUDY HAD HIGH RATE OF ATTRITION

Evidence in favor of TCM

• A Chinese herb may prevent eczema
• A Chinese herb may prevent tooth decay
• A Chinese herb may help autoimmune diseases such as rheumatoid arthritis.
• A combination of Chinese herbs may prevent peanut allergy.

What’s the Harm

• This treatment typically costs $100 a session and most insurance companies don’t pay for it.
• An acupuncturist will treat you even if you are healthy and claim that it is preventative.
• Nine million dollars and more are spent every year studying acupuncture by our govt’s NCCAM program.

• There is a pervasive belief in TCM that symbolic medicines can heal certain ailments, but this belief has led to the endangerment and extinction of several animals, such as the tiger, the rhino, and the sea horse.
• It teaches a false idea of anatomy and physiology.
• Putting off scientifically proven western medication in favor of unproven eastern medicine may delay medically necessary or appropriate treatments.
• Using herbs that have not been tested may end up doing more harm than good. One study showed that Chinese herbs that were supposed to stop cancer made the cancer cells grow faster.
• The placebo effect is only good for certain things like reducing pain and discomfort
• TCM practitioners are not sufficiently regulated, and they are not subjected to the same protocols as western doctors. Their claims do not have to be proven.