Saturday, August 9, 2008

Acupuncture: still no point to the point...

This has been a summer full of distractions and challenges needing a lot of attention. Add to that a touch of blog writer “blues” and you get a dry spell regarding postings. Consequently, this blog –not to mention the new blog baby - has been neglected and hungry for forward movement and novel discussion.

Hopefully, this little post will get things going again. All in all, this is a fun and gratifying way of expressing ideas and thoughts and helps to keep the mind sharp and attentive.

The following is a comment on my “Veterinary acupuncture” post that, although friendly and thoughtful, latches on to a few canards and fallacies in order to defend the concept of acupuncture as a viable medical therapy. Obviously, I disagree and felt compelled to write a quick response which follows the commentators blurb.

"Unfortunately there are far too many veterinarians, physicians and researchers who dismiss acupuncture as a hoax or as in this case lacking adequate scientific and clinical proof to warrant its use. Clearly the problem has been that clinical and scientific studies of acupuncture have lacked adequate controls. Without proper controls study results are nothing more than hearsay. However more recent scientifically controlled studies would argue that perhaps acupuncture therapy has merit. In this regard recent studies using microarray technology to examine acupuncture effects on gene expression in peripheral blood are no less than fascinating. For example Shiue et al (2008) have shown that acupuncture therapy significantly reduced allergic rhinitis symptoms, including nasal symptoms, non-hay fever symptoms, and sleep in human patients and this was accompanied by and alteration in the balance between T-helper 1 and T-helper 2 cell-derived proinflammatory versus anti-inflammatory cytokines in the blood. Such studies are paving the way for a more scientific explanation of acupuncture's effects. One only has to examine the recent fMRI studies of acupuncture effects on brain activity in humans and animals to conclude that acupuncture point stimulation has remarkable effects on brain activity compared to non-acupoint stimulation (see for example Napadow et al., Hum Brain Mapp, 2005). These are real effects and whether they underlie the ability of acupuncture to alter pain sensation in humans and animals remains to be proven with certainty, but nonetheless acupuncture has the capability to change brain activity. In our own studies we have found that acupuncture can prevent tumor growth if given at the very early stages of tumor cell proliferation. Conversely if acupuncture is applied later on after a tumor begins to grow, it significantly enhances tumor growth, which is why acupuncture is typically not recommended as a treatment for cancer. On the other hand acupuncture provides clear relief of pain in animal models of neuropathic pain and inflammatory pain. These effects are real folks and I have seen them first hand, so I refuse to believe that acupuncture is of no value in the medical community, be it veterinary or human medicine. There is evidence that acupuncture does not work in certain individuals and works well in others, so there is clearly individual variation in the ability of acupuncture therapy to work effectively. Taking all of this into account, I would argue that you shouldn't dismiss acupuncture until you have tried it!”

The real unfortunate issue is not that acupuncture is dismissed as a hoax, but that – even with a preponderance of disappointing evidence- this modality continues to expect unearned acceptance.

Though plagued with poorly designed studies that are often replete with equivocal results or laced with regional geographic bias, better designed acupuncture studies are out there. However, the news is not good for any real acupuncture effect. The infamous placebo –among other problems (i.e.; expectation, suggestion, counter-irritation, operant conditioning, and other psychological mechanisms) - continue to confound even “modern” acupuncture technique (that is to say; those acupuncture practices that use needling and claim no association with the ‘elam vital’, points, or meridians).

The studies you mention do not address a critical issue with respect to acupuncture- whether or not its putative effects exist. The attempt to correlate a claimed acupuncture effect to epigenetic influence puts the cart before the horse (and is reminiscent of what ‘nutritional supplement support’ advocates claim for a favorite herb, vitamin, or tonic du jour) and purported brain responses apparently observed by fMRI are interesting but it seems apparent that any mechanical puncturing of the dermis –on points or no points, shallow or deep- will effect changes.

There is little or no evidence that acupuncture is effective for any real medical disease (i.e.; neoplasm) nor, for that matter, for less well defined symptoms (including chronic pain, depression, allergies, asthma, arthritis, bladder and kidney problems, constipation, diarrhea, colds, flu, bronchitis, dizziness, smoking, fatigue, gynecologic disorders, headaches, migraines, paralysis, high blood pressure, PMS, sciatica, sexual dysfunction, stress, stroke, tendonitis and vision problems). Interestingly, promising and plausible mechanisms –if any- seem associated with completely different modalities that are confused with acupuncture (i.e.; TENS, psychosomatic, placebo).

Seeing acupuncture effects “first hand”, no matter how impressive, is simply anecdotal testimony and adds nothing to a scant evidence and science based foundation supporting acupuncture. In short, the accumulating evidence suggests most of the perceived beneficial effects of acupuncture are probably due to the power of suggestion and forms of the ‘placebo effect’.

Whether or not acupuncture is of any value to the medical community might be better discussed in a philosophy of science course. For example, acupunctures place might be better off in the realm of personal belief or preference (i.e.; priest or shaman) and well outside of medicine (If you believe in it, it will make you think you feel better – that’s your business).

As for having tried acupuncture…been there done that. I’ve also extensively observed its use in animals by certified veterinary acupuncturists.

Not impressed.


Anonymous said...

I have observed animals treated with acupuncture and treated them myself. A common example would be a dog who is treated for arthritis walking into a treatment limping and leaving the treatment walking normally. After extensively observing acupuncture on animals done by certified veterinary acupuncturists I would assume you have observed a similar situation. How would you explain the effect of acupuncture on animals in terms of the placebo effect?

Dr G said...

This was an impression I also had until I began to sit down and critically evaluate my assumed perceptions. Looking across the whole spectrum of client/animal/doctor interactions I realized I could say the same thing regarding a plethora of examination room interactions beyond needling.

It seems just walking into the client/animal sphere or a ‘laying on of hands’ can seem to do wonders for the pet! Careful observation exposes this cognitive perception and allows for a glimpse into a very complex and nuanced series of interactions between all parties- including, to a degree, pets.

In essence, you allude to a host of inter-related phenomena that involve human to human and human to pet responses that include conditioned behavior, confirmation bias, the Hawthorne effect (perceived improvement after a treatment where there is none), expectancy, practitioner profiles (touching, listening, communicating can alter perception), regression to the mean, confounding treatments and the list goes on. These effects are often described under the ‘umbrella’ term of placebo or placebo ‘effects’.

Your comment of a dog limping into the exam room, then walking out lame free after acupuncture – a common CAM claim- paints with far too broad a stroke and overlooks a host of more plausible (i.e.; weight of current quality acupuncture research pretty disappointing), simple, intriguing and often fascinating phenomena.