When a top journal like PNAS (Procedings of the Nationsl Academy of Science) publishes an article entitled “What’s the science behind acupuncture?“, I must take notice. Here is my take on the (sadly disappointing) effort:
My very short summary of the paper (I do encourange my readers to read it in full)
The article starts from the premise that acupuncture is proven to work, an assumption that – as we will see in a minute – is not based on sound evidence. It describes the evolution of acupuncture from a traditional practice rooted in ancient concepts like “qi” and “meridians” to a modern medical treatment increasingly validated by science. It argues that practitioners like Min Chen are today able to provide evidence-based explanations for their work. While early clinical trials were plagued by the “sham” acupuncture paradox, the text argues that more recent, rigorous studies and technological projects are bridging the gap between Eastern philosophy and evidence-based medicine, suggesting that acupuncture’s effects are physiological realities rather than mere placebo.
My concerns of the paper
The article attempts to bridge the gap between Traditional Chinese Medicine (TCM) and conventional medicine suggesting that several anatomical discoveries “correspond” to ancient meridians. This, however, is a post hoc ergo propter hoc fallacy. Finding a morphological structure (e.g. fascia) and claiming it represents the meridian system ignores that meridians were conceptualized as functional energetic conduits, not anatomical vessels. Citing an 80% overlap between acupoints and connective tissue planes lacks specificity. Given the ubiquity of connective tissue in the human frame, any randomized point on the body would likely “overlap” with a tissue plane, rendering the “meridian” map a possible exercise in pattern-seeking rather than anatomical discovery.
The paper acknowledges the “most puzzling” finding that sham acupuncture often produces results comparable to “true” acupuncture. This, it would seem to me, invalidates the foundational TCM theory of specific “acupoints” and “meridians” is invalidated. Yet, the article suggests that sham acupuncture is “not a true placebo” because it also triggers biological pathways. If needling anywhere produces an effect, acupuncture is merely a generalized, non-specific neuro-modulatory stimulus.
The article quotes Chen on “harmonizing organ functions” and “regulating qi” as well as researchers referring to “fibroblast activation” and “vagus nerve stimulation”. The author seems to consider both to be true; yet they seem mutually exclusive. Translating metaphysical concepts into physical phenomena does not “validate” the original theory but merely replaces it.
The article employs the opioid crisis to justify the rise of acupuncture. Yes, the need for non-pharmacological pain management is urgent, but clinical necessity does not equate to scientific validity. The text quotes the “lasting benefits” observed in some meta-analyses without discussing the often fatal flaws in these papers. Furthermore, it fails to cite the substantial body of evidence suggesting that acupuncture is not effective. Moreover, it hardly mentions the small effect sizes and hence limited clinical usefulness found in the positive studies.
The final section of the paper essentially rebrands acupuncture as “bioelectronic medicine”. If its mechanism of action is purely the electrical stimulation of the vagus nerve or the release of endogenous opioids, then the TCM concepts are all but superfluous. If a cheap and wearable TENS unit is more or less equivalent, the “meridian” and “qi” myths are obsolete.
In summary, the paper reads, I fear, only marginally better than a Chinese government promotional text – most disappointing for an article published in a journal of high standing. It attempts to preserve the cultural prestige of TCM while stripping it of its internal logic in order to make it compatible with science. For acupuncture to gain a true “scientific footing”, research must, in my view, move beyond finding “tantalizing” correlations. It should address fundamental problems, e.g.:
- As long as we have no convincing proof that acupuncture works beyond placebo, discussions about its mechanisms are futile.
- If qi, acupoints and meridians are illusions and irrelevant for the clinical outcome, then the science is not validating acupuncture but merely re-discovering a well-known non-specific form of peripheral nerve stimulation.
14 Responses to What’s the science behind acupuncture? – About the recent and most disappointing PANS paper
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Given the prestige of Proceedings of the National Academy of Sciences (PNAS), it is troubling to see such an uncritical framing presented under its banner. The article effectively takes for granted what remains very much in dispute – namely, that acupuncture has effects beyond placebo – and then proceeds as if the only question worth asking is one of mechanism. That is not a minor oversight; it is a fundamental distortion of the evidential and plausibility landscape.
The result is not merely weak scholarship but the amplification of a deeply entrenched misconception. One hears it constantly – even from students and, depressingly, from academics – that “homeopathy and reiki are nonsense, but acupuncture is different; that one actually works.” This is not a conclusion reached through careful appraisal of the evidence; it is a cultural artefact, sustained by repetition and rarely subjected to serious scrutiny.
Publications like this risk further entrenching that belief. When a journal of this calibre implicitly endorses the premise of efficacy, it lends unwarranted legitimacy to a claim that remains highly contentious. At that point, the issue is no longer just poor framing – it is the normalisation of a view that the evidence simply does not support.
Hear, hear!
Given that, after more than 40 years of research, the body of evidence has produced little more than noise, it is entirely inappropriate to treat the medical efficacy of acupuncture as a given in a scientific publication.
As Harriet Hall has already pointed out: if, after such a long period of research, there is no consolidation of evidence for an effect, it is reasonable to assume that no such effect exists. We are therefore left with the conclusion reached by Novella and Calquhoun: acupuncture is a theatrical placebo.
And to retroactively attribute justifications from recent research and other fields of knowledge to a ‘traditional’ method that has so far not been supported by evidence is not illegal, but highly problematic.
What never ceases to amaze me: the whole business of points and meridians. Their completely differing interpretations and applications in practice are surely the best evidence that the method (which, after all, defines itself through meridians) is inherently inconsistent. And yet one repeatedly finds defences of precisely this aspect – as is also the case in the work criticised here.
Researchers have already investigated whether there are patterns or just chaos here; there is even a systematic review on the subject:
https://www.sciencedirect.com/science/article/pii/S2005290118300530
With a result that is hardly encouraging for acupuncture.
The paper criticised here might – with a slight reworking – have found a place in a journal on sociocultural effects. But medically, it is worthless, as it is blind to reality.
I quite agree
Dear Udo
The question is whether or not there is a place in the healing arts for ‘theatrical placebo’ to treat people with ‘theatrical conditions’? If anecdotal evidence suggests that people respond to theatrical placebo, is it not a useful modality? If a treatment enables people to feel better despite their medical condition remaining unchanged, is this not a good thing?
The caveat must always be stated: this is theatrical placebo/magic medicine that science does not yet have convincing evidence of efficacy and mechanism within the framework of biological medicine. Do you wish to proceed?
good medicine is the one that maximises both: the specific and the non-specific effects of the therapy for the optimal benefit of patients. with acupuncture, this does not seem to be possible.
Do you believe that modern medicine can treat every medical condition with treatments that have proven specific effects?
https://www.sciencedirect.com/science/article/abs/pii/S0895435622001007
Tsutsumi Y, Tsujimoto Y, Tajika A, Omae K, Fujii T, Onishi A, Kataoka Y, Katsura M, Noma H, Sahker E, Ostinelli EG, Furukawa TA. Proportion attributable to contextual effects in general medicine: a meta-epidemiological study based on Cochrane reviews. BMJ Evid Based Med. 2023 Feb;28(1):40-47. doi: 10.1136/bmjebm-2021-111861. Epub 2022 Jul 19. PMID: 35853683; PMCID: PMC9887379.
no
but I believe that your distraction from the issue is rather cunning
Dear Edzard
I disagree that my comment is a ‘distraction from the issue (and) is rather cunning’.
In fact, I believe that it is the core of the issue of So Called Alternative Medicine. SCAM. It is a domain of debate and is definitely not a distraction.
Perhaps you need to contact NICE to get them to stop endorsing bogus treatments?
https://www.nhs.uk/tests-and-treatments/acupuncture/
My post was about acupuncture as a treatment of pain;
you resonded by stating “there is a place in the healing arts for ‘theatrical placebo’”;
I explained that “good medicine is the one that maximises both: the specific and the non-specific effects of the therapy for the optimal benefit of patients. with acupuncture”.
Now, please tell me whether a theatrical placebo as a treatment for pain is what you prefer to a conventional treatment.
Dear Edzard
Your article is fine and your point of view is valid. Your aversion to debating points of view by labeling them ‘distractions’ when they are not distractions could be something for you to reflect on.
I don’t use acupuncture and rarely use conventional medicine but I will use it if it is the best treatment for a condition.
However, the topic is the science behind the use of acupuncture to treat pain and it looks like there is credible backing for its use in medicine.
If conventional medicine could treat all (acute and chronic) pain effectively then there would be little point in looking for ‘alternatives’.
To be clear: theatrical treatments may be of use when conventional medicine does not have a fully satisfactory treatment. The majority of these issues are related to chronic conditions. Conventional medicine is highly advanced in treatment of acute conditions. Here, theatrical treatments would be unsuitable.
While conventional medicine is highly effective for most acute pain, it frequently struggles with chronic pain, which often persists despite medical intervention.
In the medical community, this is known as the “pain management gap.”
Acute Pain: High Success, Clear Cause
Conventional medicine is generally very successful here because the cause (injury, surgery, infection) is usually clear and temporary.
Success Rate: Most patients achieve significant relief using standard treatments like NSAIDs (ibuprofen), nerve blocks, or short-term opioids.
The Goal: Heal the underlying tissue damage. Once the injury heals, the pain almost always disappears.
Main Challenge: Inadequate initial management can sometimes cause acute pain to “centralise” and become chronic.
Chronic Pain: Lower Success, Complex Reality
Chronic pain is often treated as a separate disease rather than just a symptom. Conventional treatments often fail to provide complete relief for the following reasons:
Partial Relief: For many chronic conditions, a 30% reduction in pain is considered a “success” in clinical trials, which often leaves patients still suffering significantly.
Treatment Failure: At least 40% of patients in routine practice fail to achieve adequate relief from their primary pain through conventional means alone.
Medication Tolerance: Over time, the body becomes used to painkillers like opioids, requiring higher doses that carry greater risks of addiction, overdose, and side effects without necessarily improving the pain.
The “Invisible” Cause: In conditions like fibromyalgia or complex regional pain syndrome (CRPS), the nervous system itself is misfiring, meaning there is no “injury” to fix surgically.
Why Conventional Medicine Struggles
Biomedical vs. Biopsychosocial: Conventional medicine often focuses purely on physical tissue damage. Chronic pain, however, is heavily influenced by psychological stress, sleep, and social factors, which pills and surgery don’t address.
Side Effect Barriers: Roughly 88% of doctors report that the risk of side effects (kidney damage, stomach ulcers, sedation) prevents them from adequately treating moderate-to-severe pain.
High-Impact Chronic Pain: Approximately 7% of U.S. adults suffer from “high-impact” chronic pain, which significantly restricts their daily life and often resists all standard medical treatments.
Conclusion
There is ample room for theatrical treatments for the treatment of chronic conditions that involve pain!
Apart from NICE and NHS, here is another reputable institution that has an open-minded perspective of acupuncture:
https://hms.harvard.edu/news/exploring-science-acupuncture
thank you for the compliment; sorry to hear that you do not get my point.
Another smartarse with a meaningless word salad.
Why do you bother blathering about, essentially, nothing?
As a former editor of the PNAS and no friend of quackery, I was pissed off by the Peebles article. After some correspondence I received 500 words for a rebuttal, for which I recruited two additional authors, current editors of PNAS.
Our initial letter was rejected. It contained unacceptable words, like quackery and pseudo-science. Our toned-down version was also found unacceptable. It contained the expression ” pricking needles into patients”, which could be read as sarcastic. The final version is now published in the 12 May issue of the PNAS:
“Acupuncture does not work and has no place in science-based medicine”
Piet Borst, Anton Berns and Roel Nusse
Not a very powerful statement, but at least it shows that not all NAS members are happy with the promotion of quackery in the PNAS.