MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Acupuncture has remained one of the most controversial topics in the area of alternative medicine. Is it plausible? Is it safe? Is it effective? The arguments have been raging for decades and are by no means settled yet. The June issue of Anesth. Analg. is partly dedicated to this debate; the editor has invited two teams of experts to put forward their contrasting views.

The team of experts arguing in support of acupuncture conclude as follows: “clinical trials support the efficacy of acupuncture in reducing post-operative nausea and vomiting and postoperative pain; however, evidence supporting acupuncture as a treatment for chronic pain conditions is mixed. It should be noted that acupuncture trials in chronic pain have concluded that acupuncture treatment is often superior to standard of care or wait list controls and that acupuncture has minimal side effects and is cost effective. Brain imaging studies have demonstrated that there are different neural correlates between verum and sham acupuncture stimulation. Additionally, all clinical trials and many research studies have assumed that the acupuncture effect is equal to the “needle” effect, failing to recognize that factors in addition to specific effects of needling are also important contributors to the therapeutic effect of acupuncture in the setting of chronic pain.

Last, acupuncture is an ancient medical intervention first developed in an era when there were no laboratory tests, technology, or science of anatomy. The reason that the practice of acupuncture has survived for thousands of years is because it has evolved over time, with changes ranging from the number of acupuncture points to the practice techniques. Instead of criticizing this ancient art with arguments culled from modern medicine and science, physicians and scientists should try to integrate current knowledge into this ancient, yet ever-evolving practice so it may be used to treat conditions for which pharmaceutical interventions are ineffective and/or potentially dangerous. Over the last decade, there has been a growing green movement and eco-sustainability trend as well as an increased awareness that the same medication may not be effective in treating every patient with the same biomedical diagnosis. This “new age-integrative medicine in Western culture promotes a patient-oriented medical practice that complements the ancient Chinese theory behind acupuncture practice. Overall, acupuncture practice should not be seen as a placebo intervention or merely a needle therapy, but a medical option that not only treats disorders but also fosters a greater awareness of how harmonic interactions between self, family, work, and environment play a role in promoting health and restoring order”.

The two experts arguing against the usefulness of acupuncture draw the following conclusions: “It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions.  After thousands of trials of acupuncture and hundreds of systematic reviews,arguments continue unabated. In 2011, Pain published an editorial that summed up the present situation well.

“Is there really any need for more studies? Ernst et al. point out that the positive studies conclude that acupuncture relieves pain in some conditions but not in other very similar conditions. What would you think if a new pain pill was shown to relieve musculoskeletal pain in the arms but not in the legs? The most parsimonious explanation is that the positive studies are false positives. In his seminal article on why most published research findings are false, Ioannidis points out that when a popular but ineffective treatment is studied, false positive results are common for multiple reason, including bias and low prior probability.”

Since it has proved impossible to find consistent evidence after more than 3000 trials, it is time to give up. It seems very unlikely that the money that it would cost to do another 3000 trials would be well-spent.

A small excess of positive results after thousands of trials is most consistent with an inactive intervention. The small excess is predicted by poor study design and publication bias. Furthermore, Simmons et al. demonstrated that exploitation of “undisclosed flexibility in data collection and analysis” can produce statistically positive results even from a completely nonexistent effect. They say this is “… not driven by a willingness to deceive but by the self-serving interpretation of ambiguity, which enables us to convince ourselves that whichever decisions produced the most publishable outcome must have also been the most appropriate.”

With acupuncture, in particular, there is documented profound bias among proponents. Existing studies are also contaminated by variables other than acupuncture, such as the frequent inclusion of “electroacupuncture” which is essentially transdermal electrical nerve stimulation masquerading as acupuncture.

The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research. The most parsimonious conclusion is that with acupuncture there is no signal, only noise.

The interests of medicine would be best-served if we emulated the Chinese Emperor Dao Guang and issued an edict stating that acupuncture and moxibustion should no longer be used in clinical practice.

No doubt acupuncture will continue to exist on the “High Streets” where they can be tolerated as a voluntary self-imposed tax on the gullible (as long as they do not make unjustified claims).”

The readers of this blog will no doubt make up their own mind as to which arguments are stronger, more logical, more convincing, and based on more reliable evidence. I recommend reading the full articles and studying the references.

Personally, I have no hesitation in agreeing with the second, more sceptical view, and I have to admit finding the pro-acupuncture arguments weak as well as full of clichés, fallacies and errors.

I look forward to a lively discussion.

32 Responses to Acupuncture: a ‘needle in the haystack’ or a ‘theatrical placebo’?

  • I used to be a sceptic of acupuncture until Goldman et al published their acupuncture study in 2010. Since the study was done on rats, its findings can’t simply be explained by the placebo effect right?

    http://www.nature.com/neuro/journal/v13/n7/abs/nn.2562.html

    • you are right: this is an interesting study and a potentially important finding. yet I recommend considering 3 points:
      1) this is just one study and it requires independent replications before its results can be accepted.
      2) the results might not be transferable to human pain patients.
      3) the findings might reveal a mechanism how acupuncture works; that does not necessarily mean that it works. we need good evidence for its clinical effectiveness; and that is missing at present. there could easily be a plausible mechanism without meaningful clinical benefit.

  • I totally agree with you on all three points.

    Now, H. Langevin has proposed a hypothesis that:

    1) When acupuncture needles are rotated, the loose connective tissue under the skin became mechanically attached to the needle. A small amount of rotation causes the connective tissue to wrap around the needle, like spaghetti winding around a fork. This winding caused the surrounding connective tissue to become stretched as it was pulled by the needle’s motion. Using ultrasound, Langevin and team reported that the same phenomenon occurs in live human tissue (http://www.ncbi.nlm.nih.gov/pubmed/15550321)

    2) In response to sustained stretching, such as due to physical assertion or the acupuncture needle or otherwise, fibroblasts change their shape and there is a significant release of ATP, which, according to Langevin, functions outside the cell as a signaling molecule and can, of course, be converted into adenosine. (http://www.the-scientist.com/?articles.view/articleNo/35301/title/The-Science-of-Stretch)

    Now, this is surely a novel hypothesis which needs to be rigously tested by independent researchers and backed up by rock-solid evidence before we can accept it. However, do you think this is even remotely possible? Do you see any serious flaws in Langevin’s hypothesis?

    Thanks for your time

    • 1)if you totally agree with me on those 3 points, how come the article in question has turned you from a sceptic into a believer?
      2) the spaghetti theory looks very far fetched to me, and I wonder what profound effects a firm handshake might have, if such minimal actions have such remarkable effects. all of this is speculation, and I don’t like to speculate on what might be true. I prefer to understand what is true based on existing knowledge.

      • 1) Because 2 years after Goldman et al published their study on rats, they did the same thing on humans with stringkingly similar results. (http://www.ncbi.nlm.nih.gov/pubmed/23182227), which might reveal a mechanism for acupuncture and warrants further investigantion by independent researchers

        2) Connective tissue needs to be stretched for 30 minutes before fibroblasts change their shape and release ATP. Perhaps a firm handshake lasting at least half an hour, or at least as long as an acupuncture session, may lead to such effects as well? I believe this warrants further investigation

  • I don’t have free access to the Goldman article and am not about to pay to read it. With that in mind, the abstract states, “We found that adenosine, a neuromodulator with anti-nociceptive properties, was released during acupuncture in mice and that its anti-nociceptive actions required adenosine A1 receptor expression. Direct injection of an adenosine A1 receptor agonist replicated the analgesic effect of acupuncture..”

    It sounds to me as if they are concluding that acupuncture released adenosine which resulted in an analgesic effect and that the injection of adenosine A1 receptor agonist produced the same effect. Was that conclusion based on what they expect them to do, the observation of the mice or both?

    If the conclusion was based on the observation of the mice, their observations are subjective and can very well be wrong and influenced by bias. If it was based on what they expected those chemicals to do, then, if they were correct, acupuncture would have consistently produced an analgesic effect in humans in the studies that have already been conducted on it.

  • I don’t have free access to the Goldman article and am not about to pay to read it. With that in mind, the abstract states, “We found that adenosine, a neuromodulator with anti-nociceptive properties, was released during acupuncture in mice and that its anti-nociceptive actions required adenosine A1 receptor expression. Direct injection of an adenosine A1 receptor agonist replicated the analgesic effect of acupuncture..”

    It sounds to me as if they are concluding that acupuncture released adenosine which resulted in an analgesic effect and that the injection of adenosine A1 receptor agonist produced the same effect. Was that conclusion based on what they expected the chemicals to do, the observation of the mice or both?

    If the conclusion was based on the observation of the mice, their observations are subjective and can very well be wrong and influenced by bias. If it was based on what they expected those chemicals to do, along with the assumption that they would do the same thing in humans, then, if they were correct, acupuncture would have consistently produced an analgesic effect in humans in the studies that have already been conducted on it.

    • Studies do not consistently show an analgesic effect on humans and that is due to the interference of caffeine, which is an antagonist of the adenosine receptor. This could explain why:

      1) Mice and animals, who obviously do not consume beverages containing caffeine, respond to acupuncture all the time

      2) People from East Asian countries, who generally do not consume coffee and seldom drink beverages containing caffeine, respond to acupuncture most of the time

      3) People from Western countries, many of whom consume coffee and a lot of beverages containing caffeine, do not respond to acupuncture because caffeine blocks the adenosine receptor and reduces its analgesic effect to almost zero (http://www.nature.com/neuro/journal/v13/n7/fig_tab/nn0710-783_F1.html)

      Highly speculative, but worth investigating.

  • Well, a very recent study showed that “Caffeine at Moderate Doses Can Inhibit Acupuncture-Induced Analgesia in a Mouse Model of Postoperative Pain”

    http://online.liebertpub.com/doi/abs/10.1089/jcr.2013.0014

    Its up to the sceptics to prove otherwise

    • Oh, and it also means that most of these studies done on acupuncture are probably worthless because they do not take into account the inhibitory effects of caffeine which are consumed much more often in Western countries than in Asia.

      • You do know that tea contains caffeine, too, do you?

        • Amount of caffeine in tea is a fraction of that in coffee

          • Former sceptic said:

            Amount of caffeine in tea is a fraction of that in coffee

            No. The amount varies widely, but instant coffee is around 27 mg to 170 mg per 240 ml cup, espresso 40 mg to 75 mg, filtered 95 mg to 200 mg and black tea 14 mg to 61 mg. So it can be more and it can be less, depending on the form of coffee, but certainly is significant.

            Also, a coke is around 30 mg to 35 mg per can, so also significant. Then there are other foods and medications that contain caffeine, so any washout period would need to include all of those.

    • Former sceptic said:

      Its up to the sceptics to prove otherwise

      No. It is up to acupuncture researchers to demonstrate it is transferable from a mouse model to humans.

      • If caffeine inhibits the effects of acupuncture, like the very recent study a few posts above shows, then its further proof that adenosine is involved because we all know that the analegic effects of adenosine are inhibited by caffeine: http://www.ncbi.nlm.nih.gov/pubmed/7746802

        It has already been shown that acupuncture triggers a local increase in adenosine:

        1) Not just in mice: http://www.ncbi.nlm.nih.gov/pubmed/20512135 (Jul 2010)
        2) But also in human subjects: http://www.ncbi.nlm.nih.gov/pubmed/23182227 (Dec 2012)

        To date, I have yet to encounter a study that shows that this isn’t the case whether in humans, mice, or otherwise.

        • there are several possible mechanisms for acupuncture; they are however all nil and void, if it cannot be shown in rigorous trials to be clinically effective.

          • Like I’ve said in my previous post, these trials have a very limited value because they do not take into account the role of caffeine, which completely negates the effects of acupuncture-induced analgesia even at moderate doses.

            All future clinical trials have to ensure that subjects do not consume any caffeinated beverages at least a week before the trial starts.

          • if you say so.
            but this does not absolve anyone of the proof of efficacy!

  • Acupuncture has been proven to be efficient by numerous Asian trials. As we all know, a study by Vickers et al found that when it comes to acupuncture, “No trial published in China or Russia/USSR found a test treatment to be ineffective.” (http://www.ncbi.nlm.nih.gov/pubmed/9551280)

    Until there’s evidence to show that these Chinese and Russian researchers are falsifying their studies, I would concur that positive results of acupucture in Asia are attributed to minimal caffeine (not just coffee!) consumption levels among the general population, rather than publication bias. In fact, I personally think these trials are more valuable than those conducted in Western countries, where there’s consumption of, not just coffee, but all sorts of caffeinated soft drinks and beverages.

    Even Asians do not drink tea daily, which has only a fraction of the amount of caffeine.

    • a much simpler explanation is that Asian trials are on average of poorer methodological quality, thus generating false positive findings.

      • An even more fitting explanation is that caffeine causes contradictory findings in Western trials.

        • this is not an explanation, in my view, it is a hypothesis. show us the direct evidence and we can consider it seriously.
          [the fact that Asian studies are poor quality, by contrast, is well documented; and so is the fact that biased studies tend to generate false positive results]

          • If I may quote directly: “”’We found that acute preadministration of caffeine (10 mg/kg, i.p.) completely reversed AA in both types of acupuncture.” (http://online.liebertpub.com/doi/abs/10.1089/jcr.2013.0014)

            And this coming from a Swedish researcher: “Of the known biochemical actions of caffeine, only inhibition of adenosine receptors occurs at concentrations achieved during normal human consumption of the drug.” (http://www.ncbi.nlm.nih.gov/pubmed/7746802)

            Could you cite a rigorous Western clinical trial that actually took into account these findings in their methodology? Also, Im not sure if its really a “fact” that Western trials are of better quality than Asian trials. Could you show me a specific study regarding the alleged “poor quality” of Asian trials?

          • Before looking for trials that take this into account I want to be convinced that this is actually something that needs to be taken into account.
            Is an acute dose of 10 mg/kg bw really a “moderate dose”? For the average 70 kg person that’s 700 mg as a single dose (~4 cups of coffee at once, not over the course of a morning).
            The “Western” dose of caffeine (which I take to mean the dose the average “westerner” consumes – might be explained in the article, but I’m not inclined to pay $51 to find out) seems ridiculously high, too: 70 mg/kg bw/day. So the average “westerner” (70 kg) consumes 4900 mg caffeine a day?

  • As I understand it, randomly placing needles is just as effective as using Accupunture locations. It is laughable that a scientist can argue that because it has existed for thousands of years it must be effective or true. Therefore Santa Clause and the Tooth Fairy are real. Children across the globe can testify as to their veracity. Also all the various world religions, even if they contradict one another, must be true. The whole concept of these energy meridians in Accupunture are contradictory
    to our modern scientific knowledge and can’t be accepted because of something akin to religious dogma.

  • Mitchell Davis said: It is laughable that a scientist can argue that because it has existed for thousands of years it must be effective or true.

    Could you tell me the name(s) of the scientist(s) who made that argument and where did they publish their findings?

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