Ah Germany, land of good beer, great sausages, and acupuncture research.  Stux et al have contributed much to acupuncture, and now a new study awaits publication that I am eager to read.

From http://www.ncbi.nlm.nih.gov/pubmed/20359961?dopt=Abstract:

Acupuncture, Psyche and the Placebo Response

Enck P, Klosterhalfen S, Zipfel S.

Auton Neurosci. 2010 Mar 30. [Epub ahead of print

University Hospital Tübingen, Dept. of Psychosomatic Medicine, Tübingen, Germany.

With growing use of acupuncture treatment in various clinical conditions, the question has been posed whether the reported effects reflect specific mechanisms of acupuncture or whether they represent placebo responses, as they often are similar in effect size and resemble similarities to placebo analgesia and its mechanisms. We reviewed the available literature for different placebos (sham procedures) used to control the acupuncture effects, for moderators and potential biases in respective clinical trials, and for central and peripheral mechanisms involved that would allow differentiation of placebo effects from acupuncture and sham acupuncture effects. While the evidence is still limited, it seems that biological differences exist between a placebo response, e.g. in placebo analgesia, and analgesic response during acupunture that does not occur with sham acupuncture. It seems advisable that clinical trials should include potential biomarkers of acupuncture, e.g. measures of the autonomic nervous system function to verify that acupuncture and sham acupuncture are different despite similar clinical effects. (emphasis mine)

Copyright © 2010 Elsevier B.V. All rights reserved.

Now like I've been blogging, I'm not out to prove acupuncture works or not.  I believe it does for many but not all conditions.  However, data such as this would only verify what I've been saying.  Yes, there ARE changes differentiating between sham and "real" acupuncture.  I am sure this refers to stimulation of a-delta fibers, stimulation of the periaqueductal gray and the VPL nuclei of the hypothalamus.  Nonetheless, I shall be on the lookout for the actual article.

Interestingly, I see another, seemingly contradictory article, while browsing the first one.  This time, from Sweden.  Now we see they've got more than just massage and meatballs: (http://www.ncbi.nlm.nih.gov/pubmed/19525330)

Is Placebo Acupuncture What it Is Intended to Be?
Evid Based Complement Alternat Med. 2009 Jun 12. [Epub ahead of print]
Lundeberg T, Lund I, Sing A, Näslund J.
RPT, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden. jan.e.naslund@ki.se.
Randomized, placebo-controlled clinical trials are recommended for evaluation of a treatment’s efficacy with the goal of separating the specific effects (verum) from the non-specific ones (placebo). In order to be able to carry out placebo-controlled acupuncture trials, minimal/sham acupuncture procedures and a sham acupuncture needle has been used with the intention of being inert. However, clinical and experimental results suggest that sham/minimal acupuncture is not inert since it is reported that both verum acupuncture and sham/minimal acupuncture induce a significant alleviation of pain. This alleviation is as pronounced as the alleviation obtained with standard treatment and more obvious than the one obtained with placebo medication or by the use of waiting list controls. These results also suggest that sham acupuncture needles evoke a physiological response. In healthy individuals sham acupuncture results in activation of limbic structures, whereas a deactivation is seen in patients with pain, i.e. results from healthy individuals do not reflect what is seen in clinical conditions. Also, depending on the etiology of pain (or any under clinical condition under investigation), the response to sham acupuncture is varying. The acupuncture ritual may also be seen as an emotional focused therapy allowing for psychological re-orientation. Sham needling in such context may be as powerful as verum acupuncture. We recommend that the evaluated effects of acupuncture could be compared with those of standard treatment, also taking the individual response into consideration, before its use or non-use is established. (emphasis and italics mine)

What do these two studies together mean?

1) Current methods of sham and real acupuncture seem to evoke similar physiological responses. Studies have shown that at times, sham and real acupuncture seem to be effective.  Skeptics are quick to jump and say there, that means acupuncture is no better than placebo!  The proper term is that acupuncture SEEMS to be just the same as sham.  The problem with the skeptic logic is that they forget that both sham and real acupuncture are better than nothing, or TRUE placebo.  I can see it now:

Skeptic: Fake needling just the same as real needling! Hence, acupuncture isn’t real!

Acupuncturist: But both fake and real needling is better than nothing, what say ye?

Skeptic: So why not just massage? Why use needles?

Acupuncturist: I only have two hands right? (refer to Doctor Octopus as per my previous post http://qi-spot.com/2010/03/30/how-to-research-acupuncture/) And clinical experience says it works faster.

Skeptic: “Clinical experience” bah humbug!

On to point two:

2) So the second research says there’s a difference between nothing and acupuncture, whether sham or not.  The first research says there’s a difference, physiologically, between sham and real acupuncture.  I can foresee the dialogue now:

Skeptic: okay you say that clinically there’s a difference between sham and real acupuncture.  I want empirical evidence that there is a difference.  Otherwise I can just ignore your clinical experience like I ignore all other evidence that acupuncture can work and work well.  I’ll take the words of statisticians and published journals funded by Big Pharma over clinicians anyday.

Acupuncturist: Well what if there is proof that there is a physiologic difference between real and sham?

Skeptic: Is there?

Acupuncturist: That’s what the first study quoted above says.

Skeptic: Hmmm it says that it’s clinically similar, just physiologically different!

Acupuncturist: Jeez, I don’t know how to talk to you guys sometimes.  You say the real thing is no different than sham, so who cares if it works or not.  Then we say but both sham and real thing are better than nothing, you say that guys like Ernst et al say the studies suck, utterly ignoring that western medicine is also guilty of the same sins at times (perhaps more on that on a later blog post.. oh wait, lots of those already!)

Skeptic: Not all acupuncture studies suck, just the ones that prove acupuncture doesn’t work.

Acupuncturist: Then you insist in your holy grail of treating acupuncture like a pill, even though I’ve explained kabodles of times that Acupuncture is a procedure, not a pill (ka ching, five cents).

Patient (sneaking in): Uh guys, I don’t give a crap about that stuff, I just want to feel better so I can get on with my life.

Skeptic: You’re an idiot.  You don’t know squat.  We’re the only ones with brains and we know what’s best for you and what medicines you should buy.  Any perceived benefits from acupuncture and Chinese medicines are all in your head.  You’re too dumb to know the difference.

Philip: Okay I should stop now.  I’m going overboard with this blog post ha ha.

Remember how I wrote about biased headlines? (http://qi-spot.com/2010/02/09/another-biased-headline/)  In that previous article, I had mentioned that one can subtly affect comprehension by careful(?) selection of words to use in a headline.  The headline in question then read “Researcher Warns on Herbal Medicines”.  Only when you read the article itself will you see that it actually warns against misuse of herbal medicines or potential side effects from mixing with western meds.  The typical reaction, however, is to just glance over the headline – giving one the impression that herbal medicines PER SE are something generally unsafe and thus there is a need to warn the public about it.

Compare that with this headline: “Mixing medicine with herbal remedies can be risky.” (http://news.medill.northwestern.edu/chicago/news.aspx?id=158237)  This is much better and not misleading at all.

A few quotes from the article proves the spirit of the writer’s intent.  Allow me to refresh you:

Dr. Arshad Jahangir, a cardiologist at the Mayo Clinic in Phoenix/Scottsdale Arizona, who wrote the review, said the main reason patients look to herbal remedies is because they want to preserve their health.

“They think it’s natural and probably safe to use,” he said. “We’re not saying anywhere in the review that people should not take these products. But they should, at the very least, consult with their doctors who can look at their other medications and identify the potential for harm.”Herbal medications readily found over-the-counter can adversely affect the way prescription drugs are absorbed by the body by either enhancing or reducing their effectiveness.” (emphasis mine)

Yes! The article fits the headline!  And for the record, I perfectly agree. Next we see that integration between “eastern” and “western” medicine is promoted.  (albeit in a method I don’t agree with 100%, but I’ll take what is given.)

Christina Ferrari-Noonan, an acupuncturist and herbalist at Ancient Healing Chicago downtown, said patients who want to take herbal remedies should consult their doctors first.

“Patients should definitely go by the physician’s recommendation and see what they’re comfortable with,” she said. “There are definitely a lot of over-the-counter herbs that can be considered dangerous.”

Ferrari-Noonan, who has a background in Eastern and Western medicine, said herbalists should work in conjunction with doctors “We’re diagnosticians in traditional medicine not in western medicine,” she said. “Patients need to go their doctor first to get diagnosed. That diagnosis needs to be in place, and then as herbalists, we can go from there. Blood tests are especially valuable as a starting point.”

What I don’t agree with is the last sentence.  At times, people present with discomforts that cannot be classified in western medicine (how do you translate “Spleen Qi deficiency leading to weakness of the four limbs” into western medicine?  It isn’t CFS, it isn’t a movement disorder, etc etc) or do not appear in blood tests.

Jahangir agreed that herbalists and physicians should work together. “We’re not at war with herbalists and they are not against what we do,” he said. “Our goals are common, which is to serve our patients and to give them medicine or products that will do the job it’s supposed to do without causing harm.”

Tell that to the skeptics who insist that only commercial pharmaceuticals are worthwhile.

Mary Helen Lee, an herbalist at Chicago’s White Moon Healing Center, said herbal supplements could be beneficial as a compliment to chemical-based drugs, if taken correctly. “It’s definitely possible to take herbs to reverse the toxic side effects and lessen the harm the chemicals medications can have on your body,” she said. (I do this a lot with cancer patients on chemotherapy – Phil)

Lee said incorrect dosage amounts could also cause problems. “Either people are taking too much or too little, which can have a major effect,” she said. “Obviously, there are some dangerous herbs out there and people should be cautious. Patients should see a professional and get the correct herb and the correct dose for their problem.”

Experts agree that the biggest mistake people make is to self-diagnose on the Internet and treat themselves with over-the-counter herbal remedies without consulting doctors first. (emphasis mine)

“The Internet can be very helpful in educating yourself about herbs and possible effects, but it can also be very dangerous,” Ferrari-Noonan said.

So there you have it – a more balanced view that can be summarized thus:

a) herbs can work if used properly

b) always tell any healthcare professional about everything you’re doing for your health.  If they become biased against you because of that, then it’s time to find another provider.

c) never self medicate – there ARE herbal scammers out there who are only out to sell you stuff.

d) physicians of all traditions CAN and SHOULD work together.