Acupuncture: Is there any evidence?

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is acupuncture a sham?

Thank you for the feedback

My recent blog post: Did you know that some massage therapists use acupuncture, received feedback along the following lines:

• "is there any evidence?"
• "the science just isn't there"
• "acupuncture is a sham!"
• "acupuncture is no better than a placebo!"

I write to clarify my thoughts and feedback like this gives me the opportunity to see the topic from another point of view. I respect my peers, but I find most conversations about acupuncture start off with knee jerk skepticism based on a number of misconceptions. One of these misconceptions is that there is no room for acupuncture in healthcare, but that just isn't true, take this review published in Current Pain and Headache Reports. 

“While there are risks associated with acupuncture, general consensus suggests that the benefits of acupuncture outweigh the drawbacks. Informed consent and education about the procedures are important. If patients are interested in exploring acupuncture, it is the responsibility of the health-care provider to understand the potential of acupuncture treatment and how it may affect additional pain treatments or medications and quality of life.”

Like Patil and his colleagues, I agree that when used by a trained profession as part of an evidence based practice acupuncture has the ability to improve patient outcomes. In this post I will back up that assertion with scientific evidence in hopes of stimulating some serious conversation about acupuncture. 

 

The modernization of acupuncture

It is often assumed that acupuncture is synonymous with Traditional Chinese Medicine (TCM) and that anyone who uses acupuncture does so based on 'qi' or 'meridians'. This is a misconception, according to Zhou et al. 2015. 

“‘acupuncture’ is a translation of 针刺术 (zhen ci shu in Chinese pin yin) or in short 针 (zhen), and is literally equivalent to the term ‘needling’ or ‘needling technique’. Based on the traditional and official definition, the term acupuncture refers to the actual insertion of a needle (usually a solid needle) into the body.”

China is known for its long history of acupuncture, dating back over 2500 years, but this is not a continuous history though. The Chinese approach has taken a number of forms and has adapted over the years. To state that acupuncture is synonymous wit TCM is a misconception, various style and practices of acupuncture have developed all over the world, many with their own belief system. Scholars believe that acupuncture in the form that is used today is influenced by a Japanese approach reintroduced to China in the 1930, so began 'the modernization of acupuncture'.

 
“Acupuncture points and meridians, in the traditional sense, do not exist”
— Felix Mann

Medical acupuncture

Shortly after the reintroduction of acupuncture, the concept of medical acupuncture was pioneered by Felix Mann who began to view acupuncture as a form of peripheral nerve stimulation. 

Medical acupuncture is a precise peripheral nerve stimulation technique, in which acupuncture needles are inserted into anatomically defined sites, and stimulated manually or with electricity. Needle insertion is based on an understanding of anatomy and neurophysiology and acknowledges that the fact that, regardless of where the needle is inserted (skin, fascia, muscles, tendons, periosteum, joint capsules etc.), there will be a number of  physiological responses.

“Medical acupuncture is a precise peripheral nerve stimulation techniques, in which acupuncture needles are inserted into anatomically defined sites, and stimulated manually or with electricity. Needle insertion is based on a understanding of anatomy and neurophysiology and acknowledges that the fact that, regardless of where the needle is inserted there will be a number of physiological responses.”

Treatment targets are based on patient presentation, but preferential sites for acupuncture stimulation are associated with areas rich in specialized sensory receptors such as muscle spindles, Golgi tendon organs, ligament receptors, Paciniform and Ruffini’s receptors (joint capsules), deep pressure endings (within muscle belly), and free nerve endings (muscle and fascia). 

In terms of electrostimulation, a preferential target is the neuromuscular junction, this technique is colloquially referred to as motor point stimulation. A motor point is where single muscle contractions can occur with minimum intensity and short-duration electrical pulses. Anatomically, it is the area where motor end plates, namely the terminal area of motor nerve fibres, are dense.  

In addition to motor point stimulation, there are other electro-acupuncture approaches, that is rebranded in more formal settings as percutaneous electrical nerve stimulation.

 

From the physiological perspective, there are nerve endings all over the body, any time you insert a needle into the body there is going to be a peripheral and central effect.

 

It is often assumed that acupuncture is no better than a placebo, but is that true?

Headlines like this are based on a number of misconceptions and lead the casual reader to assume that sham acupuncture is inert, but how do you create a credible dummy needle?

Headlines like this are based on a number of misconceptions and lead the casual reader to assume that sham acupuncture is inert, but how do you create a credible dummy needle?

We are all familiar with the headlines that state 'Acupuncture is no better than a placebo', but there are a number of design flaws that should be taken into consideration:

Placebo acupuncture is a misnomer
Placebo acupuncture is a misnomer, in most research studies the difference between acupuncture and placebo acupuncture is merely location. Placebo approaches may use lasers, toothpicks, fake needles (that retract into the tube), but the most common approach is inserting an acupuncture needle into the 'wrong' point. It is well known that the insertions of acupuncture needles will have a physiological effect on the body, nonetheless ‘sham acupuncture’ is still used as a 'placebo'. 

Trials of poor methodological rigor
Similar to massage, one limitation with research into efficacy is that acupuncture is not amenable to strict trial designs developed for testing drugs, this has lead to trials of poor methodological rigor. Consequently, systematic reviews include trails of weak external validity leaving reviewers with a lack of evidence upon which to base judgement. 

“In most studies, the difference between acupuncture and ‘placebo acupuncture’ is merely location. A placebo control only works if it’s biologically inert and not providing any of the same physiological effects as the treatment itself. Nonetheless, the most common ‘placebo’ approach is inserting an acupuncture needle into the ‘wrong’ point.”

Heterogeneous research studies
There are a number of different schools of thoughts and styles, when it comes to the practice of acupuncture, in research it is all known as acupuncture. The terminology used to describe both needling and control procedures needs to be developed and standardized.

The complex etiology of pain
Pain is a complex biopsychosocial experience, passive treatment have a low success rate as far as the treatment of chronic pain, a better measurement of the efficacy of acupuncture is does it lead to improved function and reduce the need for Opioids or NSAIDS.

"It is obvious that clinical acupuncture research is more complex than, for instance, the investigation of drug treatments. To meet this complexity adequate funds would be a ‘conditio sine qua non’. Unfortunately, many of the normal sources for medical research have, in the past, been less than generous for acupuncture research. If we want to establish the true value of acupuncture the unfortunate funding situation would need to change dramatically”
- Edzard Ernst. Acupuncture: A Scientific Appraisal

 

Does acupuncture work?

Acupuncture is by no means a panacea, but according to The Cochrane Collaborative, there is compelling evidence that when acupuncture is used as part of an evidence based treatment it can be effective for a number of conditions including: low back pain, tension type headaches, neck pain and migraines. 

In addition to these reviews, a 2012 Meta-analysis published in The Archives of Internal Medicine examined the role of acupuncture for patients with chronic pain. In this paper researchers looked at all accumulated randomized controlled trials, examining how acupuncture fared in treating people with chronic pain, what it found was acupuncture often worked better than no acupuncture control groups. The meta-analysis also concluded that there were "significant differences between acupuncture and sham acupuncture".

 

Concluding thoughts

“Patients have a complex physiological response to acupuncture that INCLUDES but is not LIMITED to placebo.”

There are a couple of misconceptions to be aware of when reviewing acupuncture research. We are all familiar with the headline 'Acupuncture is no better than a placebo' but there are research design flaws that should be taken into consideration. In most studies, the difference between acupuncture and 'placebo acupuncture' is merely location. A placebo control only works if it’s biologically inert and not providing any of the same physiological effects as the treatment itself. Nonetheless, the most common 'placebo' approach is inserting an acupuncture needle into the 'wrong' point. 

Another misconceptions is that it is often assumed that acupuncture is synonymous with Traditional Chinese Medicine (TCM) and that anyone who uses acupuncture does so based on 'qi' or 'meridians', this is a misconception. Modern clinicians view acupuncture as a peripheral nerve stimulation technique, in which acupuncture needles are inserted into anatomically defined sites, and stimulated manually or with electricity. Needle insertion is based on an understanding of anatomy and neurophysiology. This approach is called Medical Acupuncture approach acknowledges that the fact that, regardless of where the needle is inserted there will be a number of physiological responses.

So, does acupuncture work?

Research indicates that patients have a complex physiological response to acupuncture that INCLUDES but is not LIMITED to placebo. Based on this conclusion, the use of acupuncture is not unfounded. In addition to this knowledge there is also compelling evidence from The Cochrane Collaborative (see below), when acupuncture is used as part of an evidence based treatment it can be effective for a number of conditions including: low back pain, tension type headaches, neck pain and migraines. Therefore it can be reasoned that when acupuncture is used as part of an evidence based practice it has the ability to improve patient outcomes for a number of musculoskeletal conditions.

Evidence for Acupuncture from The Cochrane Collaborative

• Furlan, A. D., Tulder, M. W., Cherkin, D., Tsukayama, H., Lao, L., Koes, B. W., & Berman, B. M. (2005). Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews.

• Linde, K., Allais, G., Brinkhaus, B., Fei, Y., Mehring, M., Shin, B., . . . White, A. R. (2016). Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews.

• Trinh, K., Graham, N., Irnich, D., Cameron, I. D., & Forget, M. (2016). Acupuncture for neck disorders. Cochrane Database of Systematic Reviews.

• Linde, K., Allais, G., Brinkhaus, B., Manheimer, E., Vickers, A., & White, A. R. (2009). Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews.

 

The RMT Education Project - 'Simplifying The Complex'

 
 

Disclaimer: This post is on the use of acupuncture to develop, maintain, rehabilitate or augment physical function, or relieve pain. I do not speak for other acupuncturists or physicians, where acupuncture may be used for other conditions.