Qi Spot

A problem with acupuncture is not so much the lack of research – there are kaboodles of it – but the way these researches are conducted.  A recent online conversation I had with a fellow Xavier high school alumnus made this obvious to me.  Here is a quote from an email I wrote which I think summarizes my thoughts on this.

Is there a "proper" way to do acupuncture research?

Anyway here is the text:

(A) major misunderstanding (is) that the idea that acupuncture is like a pill – that can be single blinded (meaning that recipient doesn’t know that they’re getting the real thing or not) or double blinded (pill giver doesn’t know either.)  Obviously, using fake needles or sham treatments would necessitate that the “treatment” giver NOt be blinded.

However, the first difficulty comes in designing an adequate “sham”

First objection: sometimes inserting needles anywhere seem to stimulate an effect as well.

Second objection: even just pretending to insert needles seems to have an effect.  this is the “placebo” being indicated here.

The conclusion skeptics derive from these observations is thus: since inserting a needle into specific “points” doesn’t seem to be much different than inserting anywhere or simulating points without insertion, acupuncture is thus “useless”.

A closer examination of how acupuncture works biophysically (and yes, I do explain this to patients who ask) reveals that it works by simulation of the immune and nervous system.  Chris Kresser’s blog elaborates on this quite well.  Now is this the only way to stimulate the nervous and immune system? No.  Acupuncture evolved from touch/massage.  The question thus begged is, why not just touch?  My answer is that inserting needles saves time and effort.  Imagine if I had to stimulate ten points on a patient with my fingers?  By inserting needles to achieve the same stimulation, I can then leave the patient and attend to another one.

I'll bet Doctor Octopus would make a great masseuse...

So what is my proposal for an appropriate acupuncture “sham” procedure: it must involve NOT triggering the a-delta fibers.  A-delta fibers are the key to the “qi-sensation” or heavy feeling accompanying acupuncture (as opposed to sharp).  Research has shown that acupuncture analgesia is obliterated by blocking the transmission of a-delta fibers.  The best way to do that that i know of is through naloxone.  Hypothetically, a control group would have no treatment, another with conventional treatment, and two experimental groups – both with real acupuncture given by the SAME practitioner (more on this later) but with one blocked by naloxone.  The latter is the “sham”.  ”fake” needles that touch the skin also won’t work because the mere touching of the skin sets off similar reactions in the patient’s central nervous system, albeit to a lesser intensity as with acupuncture.

Now for the importance of the practitioner.  I once gave a lecture in a geriatrics convention and a participant commented to me that he used to practice acupuncture but his practice died out.  He then asked me “what are the points to use for migraine?”  I then said to myself, “kaya pala. (so that’s why…)” What does this incident tell us? Let me illustrate – it also explains to me why it is difficult to formulate studies for acupuncture.

It's not the size that counts. It's how you use it!

Acupuncture is not just inserting a needle and plugging it into a machine.  Acupuncture involves selecting points (although Chris Kresser disagrees with me there) , choosing how thick the needles are, determining how deep the insertion will be, and trying to control the sensations the patient feels through manipulation of the handle.  About manipulations, there are many which I shan’t specify now.  Suffice it to say that I have personally discovered that errors in any of the above will lead to treatment failure.  It is like surgery, the procedure itself is standard, but a lot also depends on how well the surgeon handles things.  i would normally not be so heretical as to compare something like acupuncture skills to the taxing physical and mental requirements required of a surgeon, but I hope the reader grasps my point (pun intended.)

Another problem is something I have been trying to get to with my earlier comments on different culture and world view.  Chinese medicine diagnoses things in a method somewhat different from western medicine.  I’m not just talking about differences in terminology.  I did touch on this with the example of dyspepsia.  I will try to elaborate more using headache, which is the disease condition that got me into acupuncture in the first place.

Point selection and manipulation in acupuncture depend on too many variables.  Ten people can have headaches.  One will have it in the front, another at the temples, another at the nape.  One will have headache associated with chronic sinusitis, another will have it due to migraines, yet another because he is a computer encoder always looking at CRT screens, another will have it after a flaring temper, yet another associated with menses.  Acupuncture treatment then, will seldom be the same for any two of these patients.

Hence, what would be my suggestion for a proper study?  In addition to the conditions above, we can also add something to make the patients even more homogenous (can never be totally homogenous though) – same race, same diet, same emotional pattern, same job, same associated factors for the headache.  Difficult yes, but necessary because of the nature of proper acupuncture point selection.

Clinical experience has shown that “cookbook” acupuncture, which means taking a western symptom “headache”, or “dysmenorrhea” CAN be effective, but I wouldn’t be surprised if it wouldn’t be AS effective.

What do you guys think?

Acupuncture did wonders for my migraines.  I had it so bad before that i had status migranosus for a week.  Imagine a whole week of having most lights and sounds burn like soldering torches.  Imagine a whole week of misery and pain.  That was the worst, thankfully.  Typically my mood would be trashed, my eyes heavy, and my head pounding.

That was there for years, only mildly relieved by sumatriptan and once I even needed ergotamine given in hospital.  I thought I was doomed to a life of drugs.

Until acupuncture.

One treatment.

Since then, for five years, nothing.  They’ve only began to return mildly recently – time for a “booster treatment”.

Anyway, once can see why I am “biased” towards acupuncture – it worked for me.

It’s also quite nice to see it verified by western medicine:

Acupuncture Eases Migraine Headache Pain

Acupuncture May Be Cost-Effective Option for Treating Chronic Headache

(http://www.webmd.com/migraines-headaches/news/20040315/acupuncture-migraine-headache-pain)

Note the term “cost-effective option”.  This means basically that it’s an option that uses up less money in the long run.  Hence, the patient benefits from the same health effects but at less cost.

By Jennifer Warner

WebMD Health News

Reviewed by Brunilda Nazario, MD

March 15, 2004 — Acupuncture may provide lasting relief from the pain of chronic headaches, such as migraines, according to a new study.

Researchers found that compared with standard medical care, acupuncture offers substantial benefits in preventing headaches and improving the quality of life for people who suffer from frequent headaches, especially migraines.

Acupuncture is commonly used to treat other types of chronic pain, but researchers say this is the first large-scale study to examine the effectiveness of acupuncture under real-life conditions. They say the results indicate that health insurance coverage of acupuncture services should be expanded to include the treatment of chronic headaches and migraine.

Darned right it should.

Pins and Needles Ease Migraine Pain

In the study, published in the March 15 issue of the British Medical Journal, researchers randomly divided 401 adults aged 18-65 years old with chronic headache (at least two headaches a month) — into two treatment groups. Participants had a history of having mostly migraine headaches.

I just found it interesting that six years ago, the BMJ seemed to support articles on acupuncture.  Now it publishes an editorial (not even a news article!) totally biased against it (see previous post).

One group received up to 12 acupuncture sessions during a three-month period in addition to standard medical care, and the other group received standard care alone.

A year later, researchers found those who received acupuncture:

• Experienced 22 fewer days with headaches
• Used 15% less medication
• Made 25% fewer visits to their doctor

Took 15% fewer days off sick from work than the control group

In my case it was no headaches, 100% less medication, 100% fewer visits and no sick days from work since the acupuncture.

One session btw.

Researchers say one limitation of their study is that the control group did not receive a sham acupuncture intervention. Therefore, some of the benefits found among the acupuncture group may have not been caused by the actual treatment but because of the “placebo effect,” which is based on the patient’s expectations of benefit from treatment rather than the effectiveness of the treatment itself.

But researchers say previous placebo-controlled studies have already shown that acupuncture is superior to placebo in treating migraine.

In a related study published in the same journal, British researchers found that acupuncture improves the quality of life for people with chronic headaches at a small additional cost. They say the findings show that acupuncture is a relatively cost-effective headache therapy compared with other treatments covered by the National Health Service of the United Kingdom.

A recent study I found (not online but I have the PDF file) entitled “Efficacy of Acupuncture for the Prophylaxis of Migraine: A multicentre randomised controlled clinical trial” (Lancet Neurology 2006;5:310-16)

The results were:

Findings Of 1295 patients screened, 960 were randomly assigned to a treatment group. Immediately after randomisation, 125 patients (106 from the standard group) withdrew their consent to study participation. 794 patients were analysed in the intention-to-treat popoulation and 443 in the per-protocol population. The primary outcome showed a mean reduction of 2·3 days (95% CI 1·9–2·7) in the verum acupuncture group, 1·5 days (1·1–2·0) in the sham acupuncture group, and 2·1 days (1·5–2·7) in the standard therapy group. These differences were statistically significant compared with baseline (p<0·0001), but not across the treatment groups (p=0·09). The proportion of responders, defined as patients with a reduction of migraine days by at least 50%, 26 weeks after randomisation, was 47% in the verum group, 39% in the sham acupuncture group, and 40% in the standard group (p=0·133).

The “verum” group was defined as receiving true acupuncture, the sham were placed in random points and standard as… standard western medical care.  Note that the condition for success was “reduction of migraine days”.  Personally I find that some patients can respond by having the same amount of headaches but less intensity and duration – they hurt much less and last shorter.

Anyway the results still show that real acupuncture works better than either sham or standard treatment.  Not statistically significant, but significant to patients.

And doctors like me.

This is a new low.  Hitting below the belt.  No, taking a jackhammer and hitting below the belt.

“Acupuncture Spreads Disease” (http://www.theage.com.au/lifestyle/wellbeing/acupuncture-spreads-disease-20100319-qjgo.html)

My first reaction is: of course it does.  Just like ANY OTHER MEDICAL PROCEDURE, acupuncture CAN spread disease, if done improperly.  But you don’t hear the media say that oh no…

First they say there’s no scientific basis.  Then research destroys that argument.

Then they say there’s no evidence.  Then research shows otherwise.

Now they have to scrape the bottom of the barrel just to discourage people from a safe (if done properly) procedure with less side effects (if any) than conventional therapies just so Big Pharma can continue hooking us on drugs.

Many people don’t read past the headline.  This headline implies that STANDARD acupuncture spreads disease.  The first paragraph, while finally implying that it is not acupuncture itself but substandard sterilization procedures cause disease, makes you forget that fact by pairing it with HIV and Hepatitis… causing panic in the reader.

Bacterial infections, hepatitis B and C, and possibly even HIV are being transmitted via acupuncture through the use of contaminated needles, cotton swabs and hot packs, experts have warned.

Note that he says “contaminated”.  However, by that time you’ve already read “hepatitis” and “HIV” despite the fact that to get HIV through acupuncture, you hypothetically have to dip the needle in an infected patient’s blood, and while it’s still fresh (HIV dies in dried blood) poke it in ANOTHER patient.

Even the article (begrudgingly, and at the END) says as much.

“Although no clear evidence exists to support a link between acupuncture and HIV infection, there are reports of patients with HIV who had no risk factors other than acupuncture,” it said.

Yes, I had heard about this in a lecture where CDC numbers are mentioned.  The number of these reports? uh ONE? (http://www.hivatwork.org/tools/factshts.htm) and that was only because they couldn’t think of any other reason.  Similar to those babies in eastern europe that tested positive for HIV despite having HIV negative mothers – so they couldn’t think of any other reason except contaminated needles.

In an editorial published in the British Medical Journal, microbiologists at the University of Hong Kong said the number of reported acupuncture-related infections worldwide was the tip of an iceberg and they called for tighter infection control measures.

“To prevent infections transmitted by acupuncture, infection control measures should be implemented, such as use of disposable needles, skin disinfection procedures and aseptic techniques,” wrote the researchers, led by Patrick Woo, microbiology professor at the University of Hong Kong.

Woo and his colleagues said acupuncture may be risky as needles are inserted up to several centimetres beneath the skin and they warned of a new syndrome – acupuncture mycobacteriosis – in the 21st century.

“This is an infection caused by mycobacteria that rapidly grow around the acupuncture insertion point as a result of contaminated cotton wool swabs, towels and hot-pack covers. There is a long incubation period but the infection usually leads to large abscesses and ulcers,” they wrote.

oh so THESE don't cause disease if improperly used?

“So far, more than 50 cases have been described globally. In most cases … bacteria were transmitted from the patient’s skin flora or the environment because of inadequate skin disinfection before acupuncture,” they wrote.

So this can happen in ANY penetrative procedure with inadequate skin disinfection.  Why not say “inadequate skin disinfection causes disease” oh! that won’t get people to read the article! That also won’t be bashing acupuncture per se!

There have been at least five outbreaks of hepatitis B virus infection that are linked to acupuncture.

In most of these cases, the sources were infected patients and the virus was transmitted through dirty needles, although in one case, it was the acupuncturist who was the source, they said.

Let’s see in China a good number of patients are already Hep B positive.  How do we know that they didn’t already have it in the first place?  This is also why needles are never to be re-used.  If the physician doesn’t practice good practice guidelines, then blame the idiot not the acupuncture procedure!

Funny about the acupuncturist being the source.  What did he do? Take a needle, jab himself, then jab the patient?

Using these hands with anything can spread disease. Why single out acupuncture?

And finally:

The paper also laid out the possibility of transmission of hepatitis C and HIV via acupuncture.

Yeah, the “possibility”.  Why, because it doesn’t happen that way.  Geez. Scare tactics.

There’s this phenomenon called Post Traumatic Stress Disorder.  A pilot study funded by the National Institutes of Health suggest Acupuncture may be of use for it.  Again, this is something that Chinese medicine practitioners have known for quite a while now.

According to the National Institute of Mental Health’s Website (http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/index.shtml), PSTD can be defined as “…an anxiety disorder that some people get after seeing or living through a dangerous event.”  Kinda like watching the 3-D version of Avatar without 3-D glasses.  Not like I’ve tried.

The website has a great way of explaining the situation to laymen:

When in danger, it’s natural to feel afraid. This fear triggers many split-second changes in the body to prepare to defend against the danger or to avoid it. This “fight-or-flight” response is a healthy reaction meant to protect a person from harm. But in PTSD, this reaction is changed or damaged. People who have PTSD may feel stressed or frightened even when they’re no longer in danger.

So people reading the newspapers everyday have PTSD?  I mean they feel stressed and frightened despite not being in immediate danger…  Seriously though, I’ve heard stories of people having recurring nightmares because of this.

Soldiers may go home with their bodies healed, but their psyches scarred.

So what exactly does Post Traumatic Stress Disorder mean clinically?

PTSD can cause many symptoms. These symptoms can be grouped into three categories:

1. Re-experiencing symptoms:

• Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
• Bad dreams
• Frightening thoughts.

Re-experiencing symptoms may cause problems in a person’s everyday routine. They can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing.

2. Avoidance symptoms:

• Staying away from places, events, or objects that are reminders of the experience
• Feeling emotionally numb
• Feeling strong guilt, depression, or worry
• Losing interest in activities that were enjoyable in the past
• Having trouble remembering the dangerous event.

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

3. Hyperarousal symptoms:

• Being easily startled
• Feeling tense or “on edge”
• Having difficulty sleeping, and/or having angry outbursts.

Hyperarousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

It’s natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months.

In traditional Chinese medicine, there is such a notion as a vicious cycle caused by severe, sudden emotions.  These affect certain organs, which in turn increase our susceptibility to the aforementioned emotions.  For example, frustration upsets the Liver, causing Qi stagnation, which leads to a greater tendency to feel anger or frustration – a vicious cycle.  Sometimes, the person is able to correct this on their own – as evidenced by healing after a time.  Sometimes, it gets stuck.  Chinese medicine works by breaking that cycle.

Let’s look at the study: (from http://nccam.nih.gov/research/results/spotlight/092107.htm)

Acupuncture May Help Symptoms of Post Traumatic Stress Disorder

A pilot study shows that acupuncture may help people with posttraumatic stress disorder. Posttraumatic stress disorder (PTSD) is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat.

Can it treat my stress secondary to watching Knicks games?  That’s very terrifying these days, and will be more so if we don’t get any free agents this summer…

Anyway here’s the gist:

Michael Hollifield, M.D., and colleagues conducted a clinical trial examining the effect of acupuncture on the symptoms of PTSD. The researchers analyzed depression, anxiety, and impairment in 73 people with a diagnosis of PTSD. The participants were assigned to receive either acupuncture or group cognitive-behavioral therapy over 12 weeks, or were assigned to a wait-list as part of the control group. The people in the control group were offered treatment or referral for treatment at the end of their participation.

And the results?

The researchers found that acupuncture provided treatment effects similar to group cognitive-behavioral therapy; both interventions were superior to the control group. Additionally, treatment effects of both the acupuncture and the group therapy were maintained for 3 months after the end of treatment.

The limitations of the study are consistent with preliminary research. For example, this study had a small group of participants that lacked diversity, and the results do not account for outside factors that may have affected the treatments’ results.

The abstract may be found here: (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17568299)

The purpose of the study was to evaluate the potential efficacy and acceptability of accupuncture for posttraumatic stress disorder (PTSD). People diagnosed with PTSD were randomized to either an empirically developed accupuncture treatment (ACU), a group cognitive-behavioral therapy (CBT), or a wait-list control (WLC). The primary outcome measure was self-reported PTSD symptoms at baseline, end treatment, and 3-month follow-up. Repeated measures MANOVA was used to detect predicted Group X Time effects in both intent-to-treat (ITT) and treatment completion models. Compared with the WLC condition in the ITT model, accupuncture provided large treatment effects for PTSD (F [1, 46] = 12.60; p < 0.01; Cohen’s d = 1.29), similar in magnitude to group CBT (F [1, 47] = 12.45; p < 0.01; d = 1.42) (ACU vs. CBT, d = 0.29). Symptom reductions at end treatment were maintained at 3-month follow-up for both interventions. Accupuncture may be an efficacious and acceptable nonexposure treatment option for PTSD. Larger trials with additional controls and methods are warranted to replicate and extend these findings.

Right, I’ll re-read the layman version.

Here’s the reference:

Michael Hollifield, Nityamo Sinclair-Lian, Teddy D. Warner, and Richard Hammerschlag, “Acupuncture for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial.” The Journal of Nervous and Mental Disease, June 2007.

Worth mentioning: Acupuncture recommended by John Bartleson, MD, of the Mayo Clinic for low back pain as evidenced on their website:

(http://www.mayoclinic.com/health/acupuncture-for-back-pain/AN02055)

From wikipedia, the Mayo Clinic  ”is a non-profit organization and an internationally renowned group of medical practice headquartered in Rochester, Minnesota. Its headquarters consist of the Mayo Medical School, the Mayo Graduate School, the Mayo School of Graduate Medical Education, and several other health science Mayo Clinic partners with a number of smaller clinics and hospitals in Minnesota, Iowa, and Wisconsin, an organization known as the “Mayo Health System.” Mayo also provides medical treatment and performs research in its facilities in Arizona and Florida.”

So what does it have to say?

“When performed properly by trained practitioners, acupuncture has proved to be an effective therapy for back pain. Several studies have found that acupuncture can help reduce chronic back pain and improve daily function.”

Very very important: when performed PROPERLY by TRAINED practitioners.  Why do I emphasize this? Time and time again I say that acupuncture is not a pill but a procedure.  It’s not just sticking a needle in, but practitioner skill is vital in the selection of acupoints and proper manipulation depending on the patient’s particular condition.  In fact, I am giving a lecture later on low back pain and will be emphasizing on several “kinds” of lumbago such as Blood Stasis (trauma), Damp-Cold, Kidney Yin Deficiency, etc etc…

The point is that not all back pains are created equal, and each must be met at their own terms.

Oh but what about the studies showing sham acupuncture also works? Doesn’t that debunk acupuncture?  And how the heck does it work anyway?

Scientists don’t fully understand how or why acupuncture affects the amount of pain you feel. Several studies have found that acupuncture causes the same effects as sham (minimal or simulated) acupuncture used in some studies for comparison. Sham acupuncture involves tapping the skin with a toothpick at the same strategic points used in acupuncture to simulate the insertion of a needle. Sham acupuncture may not be an accurate way of studying the benefits of acupuncture, however, because it’s possible that acupuncture points can be stimulated by even surface pressure. Both acupuncture and sham acupuncture showed improvement over usual medical treatments. (emphasis mine)

If only I had a penny for every time I’ve said this.

And now to complete the cycle:

Acupuncture is generally recognized as safe if done by a competent, certified acupuncture practitioner. Possible side effects and complications can occur, which include soreness, bleeding, infection or bruising at the needle sites.

Acupuncture isn’t a cure and not everyone responds to acupuncture for back pain. If your back pain doesn’t begin to improve within a few weeks, acupuncture may not be the right treatment for you. If you’re considering acupuncture for back pain, talk with your doctor, who can refer you to an acupuncturist.

Acupuncture is generally recognized as safe if done by a competent, certified acupuncture practitioner. Possible side effects and complications can occur, which include soreness, bleeding, infection or bruising at the needle sites.
Acupuncture isn’t a cure and not everyone responds to acupuncture for back pain. If your back pain doesn’t begin to improve within a few weeks, acupuncture may not be the right treatment for you. If you’re considering acupuncture for back pain, talk with your doctor, who can refer you to an acupuncturist.

There you have it folks:

a) acupuncture is a procedure, not a pill

b) sham acupuncture seems to work because it is still stimulating the acupoints, albeit less directly and less strongly

c) we may now know exactly how it works, but would that stop you from trying it if it does work?

and d) like ANY other treatment, it may not work for everyone.

This last point requires me to point out a certain bias.  If a western medicine treatment doesn’t work for a particular patient, we’ll say that it just didn’t work for a particular patient.  No one questions western medicine in general if a pill didn’t lower someone’s blood pressure.  Yet we in the so-called “alternative” field have to overcome a tendency by people to dismiss acupuncture and herbal medicine if it didn’t work for a particular person.  Know what I mean?

Well, off to University to enlighten some minds.