Is Acupuncture just placebo?
When people discover that I’m an acupuncturist a common question I get asked is “isn’t acupuncture just placebo?” The short answer is yes and no. I have written this article in response to this question and to examine the placebo effect. I have tried to be as objective as possible but obviously my view is going to be biased as I am an acupuncturist so I obviously think it is more than placebo.
To start with the definition of the placebo effect is needed “A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well.” Broadly speaking placebo is an effective treatment that is present in all therapies. The similarities in all therapeutic relationships are that a person goes to a medical authority, they air they complaint, receive reassurance in most circumstances and receive treatment of some description. This process alone is a placebo effect. Trust and the relationship between practitioner and the patient is a huge element. The bedside manner is hugely important as rapport in itself will have a positive impact on the patient. Then there is the expectation of the treatment, the higher the expectation the greater effect.
One other important factor in increasing the placebo effect is ritual. The greater the ritual the greater the placebo effect is. Acupuncture does have a large ritual in terms of the initial consultation, examination and treatment so therefore is considered to have a large placebo effect.
Many people do not realise that placebo effect is present in all medicine.One such story below gives a fascinating account of how placebo can be performed in surgery.
“Forty years ago, a young Seattle cardiologist named Leonard Cobb conducted a unique trial of a procedure then commonly used for angina, in which doctors made small incisions in the chest and tied knots in two arteries to try to increase blood flow to the heart. It was a popular technique—90 percent of patients reported that it helped—but when Cobb compared it with placebo surgery in which he made incisions but did not tie off the arteries, the sham operations proved just as successful. The procedure, known as internal mammary ligation, was soon abandoned("The Placebo Prescription" by Margaret Talbot, New York Times Magazine, January 9, 2000).”
You can’t obviously prescribe placebo surgery for obvious ethical reasons but this demonstrates both placebo and the power of ritual quite nicely.There are other factors involved in placebo effect that are not directly concerned with acupuncture but interesting none the less. For example red pills are more effective than blue ones. Four pills are more effective then two. There is great deal more to the placebo effect and I suggest you read Ben Goldacres book “Bad Science” if this interests you.
Acupuncture is also used on animals for muscular skeletal problems and arthritis mainly. Again the positive results seen in animals have been contributed to the placebo effect. The theory goes that even animals benefit from acupuncture because their guardians or owners have been influenced by the placebo effect.
Current understanding of Acupuncture
To start with a definition of acupuncture is needed.
“According to traditional Chinese philosophy, our health is dependent on the body's motivating energy - known as qi - moving in a smooth and balanced way through a series of meridians (channels) beneath the skin. The flow of qi can be disturbed by many factors, physical, mental and emotional: anxiety, stress, anger, fear or grief, poor nutrition, weather conditions, hereditary factors, infections, poisons and trauma. By inserting fine needles into the channels of energy, an acupuncturist can stimulate the body's own healing response and help to restore its natural balance.”
British Acupuncture Council
Acupuncture is often accredited with purely just being placebo effect because modern science as yet doesn’t understand the process involved upon which the theory is based. In acupunctures case this is the understanding of energy which flows through meridians/channels throughout the body. This is where the two worlds collide as Bausell states (page275). “No CAM therapy has a scientifically plausible biochemical mechanism of action over and above those proposed for the placebo effect.”
Modern science has further problems with acupuncture as Bausell (page106) goes onto state “But if the primary biochemical explanation for how these little needles reduce pain involves an unmeasurable energy force surging through some unobservable meridians with no documented connection to pain or anything else, then most members of the scientific community will have a difficult time believing these positive results.”
Presently there are two forms of acupuncture in use in the uk, traditional acupuncture based on the theory of qi or energy as used in China, Japan and Korea and medical acupuncture often referred to as dry needling as practised by doctors, physiotherapists and other primary care physical therapists. Acupuncture has been reinterpreted by the west as Campbell clarifies.
“In practice, sticking needles into people often does relieve symptoms, especially (but not exclusively) pain. Largely for this reason, acupuncture has been taken up by a number of health professionals in the West, many of whom have reinterpreted it in terms of modern anatomy, physiology, and pathology. This form of acupuncture has been called Western medical acupuncture or dry needling. People who practise in this way accept that the ancient Chinese made many correct observations but do not see the need to follow them in the theory that they erected on these observations. Modernists therefore ignore, partially or completely, the traditional apparatus of "meridians", "acupuncture points", yin and yang and so forth and use different criteria in deciding where and how to insert the needles."
Problems with clinical trials
Currently there is a great deal of interest into acupuncture which has resulted in numerous clinical trials researching the effects acupuncture. Doctors and other medical professionals will base their opinion on acupunctures effectiveness based on these results. These results will also be used by newspapers so they have a huge impact on public opinion.
Acupuncture is considered to be a holistic medicine which treats the whole person. As a result it takes into account many signs, factors and observations that are considered irrelevant in western medicine. Any treatment with acupuncture is therefore based on individual symptoms so there is no treatment protocol for one particular disease. For example when performing a trial on the effectiveness of acupuncture for back pain the trial is riddled with problems from the start whether it is investigating the effectiveness of acupuncture, osteopathy or any other intervention. Chaitow a prominent osteopath comments on the problems encountered when performing clinical trials on back pain.
“Acute back pain’ may have a wide variety of causes, ranging from biomechanical to pathological, psychological and functional, possibly involving intervertebral disc problems, facet joint dysfunction, hypermobility, muscular and/or ligamentous imbalances, sacro-iliac restrictions, trigger points and disturbed emotion/ somatisation (among others), making it a virtual certainty that ‘acute back pain’ will not respond to a single intervention, whether HVLA manipulation or anything else.”
This is a huge obstacle in the promotion of acupuncture as clinical trials are used to determine effectiveness of such treatments. There are many more trials being conducted on the use of acupuncture all of which have had various outcomes some positive and some negative. There are many more problems with conducting clinical trials for acupuncture and is a huge topic. The Holy Grail for acupuncturists at the moment is finding a way of putting acupuncture through clinical trials that satisfy both acupuncturists and the medical community.
East meets West a clash of cultures
One must understand how acupuncture was born in order to understand. Acupuncture is a system that was created before the advent of clinical trials and imaging techniques. The concept of an energy system is not unique to acupuncture or to china and can be found where intuition and observation were the only tools available. In India for example qi is called prana and they have a very similar healing system.
The origins of acupuncture are somewhat unclear but I will offer some views that may enlighten the reader. Chinese culture has a long tradition of martial arts and mediation practice stemming from religious traditions such as Buddhism and Daoism. Through these techniques a quietening of the mind occurs and practitioners become aware of subtle feelings in the body. Through these observations the energy system of the body were mapped. In fact it’s not particularly difficult to feel this energy just sign up to your local tai chi class for 6 months. This is further illustrated in Chinas early history. China for a long time did not perform autopsies because they saw no point in studying something that had no life in it. How the use of fine needles originated is still somewhat unclear but pressing and rubbing on various points to relieve symptom was in use for some time and acupuncture is an extension of this practice.
As westerners we have extremely analytical minds and we are educated to reason and analyse through the use of logic. Intuition and feeling are not valued highly and few roles utilise these skills. It is very hard to convince someone in the west that acupuncture exists without data to back it up and as previously stated clinical trials involving acupuncture are fraught with problems. For the acupuncturist the reverse is true placing a great deal on training of the senses so are frustrated with such a great emphasis based on clinical trials which are limited in there scope of understanding and recording the benefits of acupuncture. The benefits of acupuncture will often extend into all levels of ones life both physical and emotional.
You could conclude then that yes acupuncture does have a placebo effect and because western medicine can not attribute the data to the effect of qi that acupuncturists claim then the positive effect can only be placebo.Another conclusion could be again that acupuncture does have a placebo effect and that the additional positive effects are due to an unknown effect. You could also conclude that some of the observations made are correct i.e. that sticking need les into parts of the body does reduce pain but subscribe to a western model of understanding.
The goal of medicine is always to preserve health, prevent disease and treat illness. Although both approaches to medicine would agree on these fundamental points they reach them from entirely different perspectives.
Personally I know that qi exists from having done qi gong for a number of years and have felt the sensation of qi moving through the channels in my body. Other students can perceive this energy too. When I have acupuncture I also feel this same sensation. My old qi gong teacher practised a form of qi gong known as hard qi gong which is used to condition the body. When the body is conditioned you can perform unimaginable feats such as bending spears on your throat and having bricks broken on your head, you may of seen such displays performed by the Shoalin monks. They are all using their qi. There are also stories of great masters of acupuncture diagnosing patients simply by looking at them and telling them in great detail about their personnel life and there present condition. I have also seen the great benefit acupuncture has had from my time doing clinical observations with practitioners which has ranged form hyperactive 2 year old through to arthritic 80 year olds with disc degeneration.
Qi or energy may not ever yield to scientific instrumentation but it easily recognizable only by living beings. There are many mysteries in the world that science has yet to solve and acupuncture may be one of them.
Bausell Snake Oil Science - The Truth about Complementary and Alternative Medicine
British Acupuncture Council available from http://www.acupuncture.org.uk/
Campbell “Is acupuncture CAM” Available from http://www.acampbell.org.uk/
Chaitow, L Osteopath available from http://www.leonchaitow.com/index.htm