Qi Spot

I have recently begun calling the placebo effect the Saint Jude Thaddeus of Medical Terminology.  This is not because placebo effects are miraculous – although they might sometimes seem to be – but because the placebo effect (or things even remotely connected to it) has gotten a bad rap for something it didn’t do. So what’s the connection to Saint Jude?  Note this excerpt from a traditional prayer:

…faithful servant and friend of  Jesus, the name of the traitor who delivered your beloved Master into the hands of the enemies has caused you to be forgotten by many, but the Church honors and invokes you universally as the patron of hopeless cases and of things despaired of…

So basically, Judas Thaddeus got a bad rap because of Judas Iscariot, so much so that there are now two ways of translating the name into English, Judas and Jude. So what does this have to do with placebo?  First we define placebo and placebo effect:

In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which “showed that real acupuncture treatments were no more effective than sham acupuncture treatments.”

The authors then editorialized: “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.”

In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which “showed that real acupuncture treatments were no more effective than sham acupuncture treatments.” The authors then editorialized: “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.”

Dear writer (Mr. Ho), this controversy emerges from clinical trials comparing real and sham acupuncture. What you did not elaborate in your article is what is meant by ‘sham’ acupuncture? As acupuncture can be done not merely by piercing needles like in the photo, but also using laser, ultrasound, even with pressure or touch/ stroking the body surface. So, is the ‘sham’ acupuncture really sham? The modality of action is through neurophysicoendocrine pathway, by any modes of stimuli like stroking, piercing, etc. our body will react by showing the therapeutic effects like wellbeing, pain relieving, blood pressure downregulating (for hypertension, but not for normotensive)

First, they admit that pooled clinical trials of the best sort show that real acupuncture does no better than sham acupuncture. This should mean that acupuncture does not work – full stop. But then they say that both sham and real acupuncture work as well as the other and thus is useful. Translation: Please use acupuncture as a placebo on your patients; just don’t let them know it is a placebo.

The authors trotted out the same conclusion after they reviewed an important German trial which also showed acupuncture to be merely a placebo.

In any randomized and blinded clinical trial of any mode of treatment for any condition, the finding that the treatment is no better than a placebo always leads to one conclusion only: It is therapeutically useless. Acupuncture, it would seem, is exempted from this rule.

In Chinese cosmology, all life is animated by a numinous force called qi, the flow of which mirrors the sun’s apparent “movement” during the year through the ecliptic. (The ecliptic is the imaginary plane of the earth’s orbit around the sun).

Moreover, everything in the Chinese zodiac is mirrored on Earth and in Man. This was taught even in the earliest systematised TCM text, the Yellow Emperor’s Canon Of Medicine, thus: “Heaven is covered with constellations, Earth with waterways, and man with channels.”

This means that if there is qi flowing around in the imaginary closed loop of the zodiac, there is qi flowing correspondingly in the body’s closed loop of imaginary meridians as well.

These meridians run from head to toe to form a network interlinking 361 points on the skin. But why are there 361 points? Since the earth takes three minutes under 24 hours to rotate 360 degrees on its axis, the sun appears to revolve through 361 degrees on the ecliptic every 24 hours. Hence 361 points. This factoid alone is sufficient to nail down the acupuncture-astrology linkage.

Since qi flows around in a closed loop, needles can be inserted at one of these points far removed from your site of pain to rechannel qi. If done well, this supposedly can cure your spot of trouble.

Yes, that’s the title of an article published today in the Philippine Star.  (http://www.philstar.com/Article.aspx?articleId=630865&publicationSubCategoryId=63)

The way the headline is written, one would think that the warning issued was against Chinese Medicine as in Chinese Medicine the tradition, such as the medicine I practice.  It does not say “Warning Issued On Chinese Medicines” or “Warning Issued on Fake Chinese Medicine”.  No, it uses the general term “Warning Issued on Chinese Medicine”.

I will quote the article in full here:

MANILA, Philippines – People are urged to exercise caution when taking Chinese medicine.

Speaking to reporters, Leonila Ocampo, Philippine Pharmaceutical Association (PPA) president, said many Chinese medicinal and herbal products are not registered with the Food and Drug Administration (FDA).

Therefore they are considered counterfeit, although legitimate in the country where they were manufactured, she added.

Under Republic Act 8203, or the Special Law on Counterfeit Drugs, fake medicine pertains to unregistered imported drug products, Ocampo said.

Dr. Minerva Calimag, Philippine Medical Association (PMA) food, drugs and cosmetics committee chairman, said security in the country’s coasts is weak, enabling smugglers to bring in counterfeit medicine.

“If fake drugs are coming from outside (the country), our problem is how to secure the borders because there are many channels through which it could come into the market,” she said.

The government must be able to prevent the entry of counterfeit drugs into the country, Calimag said.

The PPA and PMA are members of Samahan Laban sa Pekeng Gamot.

It has been estimated that one of every 10 drugs in the country is fake, based on the cases reported to the FDA.

The country’s pharmaceutical market is steadily growing, making it a target of counterfeiters.

In its website, Samahan has identified Binondo, Manila as among the hotspots for counterfeit medicine.

The funny part is, I actually AGREE with most of what is said in the article.

Yes, there are tons of smuggled Chinese medicine products of questionable integrity.  I am the FIRST to admit that probably half of all over the counter drugs sold in Chinese drugstores are of poor quality or fake.

But in NO WAY should that merit a headline that passes judgment on the Chinese medical tradition as a whole!

Now for the one part of the article I don’t agree with: the idea that if a Chinese materia medica does not pass through the FDA, it should not be used at all.

Hence, let’s ban drinking tea for health purposes.

Let’s ban the use of ginger tea or salabat to relieve sore throat.

Let’s ban the use of eating watermelon to keep cool.

Why? Because those are all examples of using materials in the Chinese tradition, as per my previous post.

Shall I go on?  Let’s not use tawas or alum to relieve body odor.  That’s a materia medica used in Chinese medicine, to relieve Heat which manifests as body odor.

Let’s not massage using ginger oils for body aches, let’s ban medicinal massage, let’s ban…

You get the idea.

Firstly, I’d like to apologize for not posting for two weeks. I’ve been travelling a lot through Hong Kong and China. I will blog more on some observations I’ve made while in Hong Kong as soon as I get some of my photographs uploaded to my laptop.

Speaking of Hong Kong, I am beginning to wonder if there is some grand plot to discredit acupuncture in Hong Kong. First comes the “letter to the editor” concerning acupuncture spreading disease (http://qi-spot.com/2010/03/20/new-bashing-technique-acupuncture-causes-disease/) and now this.

“Acupuncture does not relieve childbirth pain” (http://www.guardian.co.uk/society/2010/apr/28/acupuncture-childbirth-pain-study)

I am the first person in the world to admit where acupuncture is one big FAIL (such as in colour blindness). But I would like to call the attention of the reader to the weasel wording evident in this smear campaign of a headline.

Look at the title. “Acupuncture does not relieve childbirth pain.” What does this imply to the reader? It implies that acupuncture has no effect at all on the pain felt by mummy.

Yet the sub-title below the headline betrays a hint of the truth:

“Research suggests results from complementary therapy during labour may be placebo effect”

Now, we have no idea, based on this sub-headline if this is a single study or a meta-analysis.  As we have said before, a meta-analysis is a fancy way of saying, “let’s put different studies together just to get the numbers up.  We can always find a way to put the studies together that the sum total numbers can be made to say whatever we want.”

Secondly, it “suggests” (whatever that means) that the results may be placebo effect.  Wait.  Results?  RESULTS?  I thought that acupuncture “does not relieve” childbirth pain?  So if it is useless, why are there “results”?  That means there WAS relief of pain.

So why come up with a headline saying otherwise?  Because the results “may” be placebo effect.

Actually, I wouldn't use those points in pregnancy... but what the heck. Then again, he just might be some really fat guy...

The finding, which has already prompted a vigorous debate about the value of acupuncture, came from British and Korean researchers who examined previous studies of its use in labour.

“The results show that there is little convincing evidence that women who had acupuncture experienced less labour pain than those who received no pain relief, a conventional analgesia, a placebo or sham acupuncture,” researchers told BJOG: An International Journal of Obstetrics and Gynaecology. The journal is owned by the Royal College of Obstetricians and Gynaecologists, which represents most of the UK’s doctors specialising in childbirth and maternity care.

The finding, which has already prompted a vigorous debate about the value of acupuncture, came from British and Korean researchers who examined previous studies of its use in labour.
“The results show that there is little convincing evidence that women who had acupuncture experienced less labour pain than those who received no pain relief, a conventional analgesia, a placebo or sham acupuncture,” researchers told BJOG: An International Journal of Obstetrics and Gynaecology. The journal is owned by the Royal College of Obstetricians and Gynaecologists, which represents most of the UK’s doctors specialising in childbirth and maternity care.

So it IS a meta-analysis.  Strike one.  I wonder what points were used? Hmmm…

Prof Edzard Ernst, of the Peninsula medical school at Exeter and Plymouth Universities and co-author of the report, said: “The effects of acupuncture perceived by women are largely due to placebo. Acupuncture has many qualities that maximise placebo effects: it involves touch and is invasive and, psychologically, is attached to the mysticism of the east.”

Ernst is a known skeptic of acupuncture and makes a living (i.e. buy his book!) by bashing it.  Then again, I make my living healing patients with it, so I guess we cancel each other out.  Still, he admits that acupuncture DOES have an effect, it’s just that he either cannot or will not recognize the evidence that acupuncture DONE PROPERLY is more than placebo. (http://qi-spot.com/2010/04/04/a-study-to-look-forward-to-acupuncture-more-than-just-placebo/)

I would like to point out that even in western medicine, there exist drugs for which the mechanism of action is unknown.  Lithium is used for bipolar disorder and it is not known how it works.  Yet it is given, despite toxicity, because it has been observed to work.  I leave it to the reader to witness where the double standard lies.

Also, I find it disturbing that people will look down (albeit unintentionally) on patients’ experience just to pooh-pooh acupuncture.

Prof Philip Steer, BJOG’s editor-in-chief, said labour pain can be so intense that a women would do anything to minimise it.

Please, by that logic we can get a shaman in pyjamas to conduct ritual chants and that would work.  Yet it doesn’t, and acupuncture does.

“Acupuncture is a drug-free approach and that may explain why some women prefer its use during labour. This review shows that in a very small number of cases acupuncture may be of help, usually for short periods of time after treatment, and this may be down to psychological rather than a physiological effect. Generally the consensus is that the evidence does not support its use.”

The only benefits were 11% less pain in the first 30 minutes after receiving acupuncture and a need for less pharmacological pain relief, the authors say.

Wait wait wait.   The “only” benefits? So “they” begrudgingly admit that there are benefits!  Back to my first question: why the irresponsible headline, then?  The last part of the sentence betrays the answer:

“…a need for less pharmacological pain relief” – in english: LESS DRUGS.

Less drugs, less profit for big pharma.

I will skip to the last part:

Mike O’Farrell, chief executive of the British Acupuncture Council, said: “We’re surprised by these findings as previous trials, along with the evidence that our members see in their practices every day, suggest that acupuncture can be effective in providing pain relief in many different circumstances.”

Again, as I have said before, people not biased by big pharma can see where acupuncture works and it doesn’t.  I am happy to report, both first hand and through correspondence with other OB-Gynecologists even in the US, that acupuncture can work in reducing childbirth pain IF DONE PROPERLY.

My final thoughts: this article should have been entitled “Acupuncture apparently no better than placebo” instead of “Acupuncture doesn’t work”.  News bias, bah humbug.

Campbell, Denis.  ”Acupuncture does not relieve childbirth pain” The Guardian.  28 April 2010.  <http://www.guardian.co.uk/society/2010/apr/28/acupuncture-childbirth-pain-study> Accessed 28 April 2010

One of the greatest frauds being intentionally perpetuated by some unscrupulous agents on both eastern and western medical “sides” is the idea that the two are mutually exclusive and never shall the two meet.  If one’s motivation is merely to profit from the medicine then it stands to benefit the practitioner to see the other side as “competition” and try to discredit it.  On the other hand, if one has in mind the benefit of the patient, then I believe one must at least be open to what the other side shall contribute.

Now THIS kind of West vs East I heartily encourage!

On the “alternative” medicine side in general, there is a conscious effort to paint “Big Pharma” as some evil, money-grubbing organization deliberately poisoning the population.

On the “conventional” or western side, there is an effort by a powerful few to brand alternatives as unscientific, or at the very least, incompatible with conventional medicine.

Both are lurid extremes hurting both sides and ultimately the patient.

I acknowledge that it is difficult to reconcile apparently conflicting ideas.  Some acupuncture instructors, when training western MDs, sometimes begin their didactics by saying that the MD must first “forget” western medicine to appreciate eastern medicine.  Boulderdash.

On the other hand, I remember some of my western medicine professors in university commenting on how “primitive” Chinese medicine seems because of Chinese medicine’s use of “nature” terms in it’s vocabulary such as “wind”, “cold” and “dampness”.  It is conveniently forgotten that the root word for the western medical term “inflammation” is in fact, “flame”.

In a spirited email exchange, I was warned that I, being biased towards acupuncture (and freely admitting it, although I am not biased because of financial reasons – I could make a heckuvalot more money as a pure western MD with all the drug company money and laboratory test kickbacks…) might suffer from “cognitive dissonance” when faced with “evidence” that acupuncture apparently doesn’t work.

So what is “cognitive dissonance”?

Changingminds.org defines it thus:

This is the feeling of uncomfortable tension which comes from holding two conflicting thoughts in the mind at the same time.

Dissonance increases with:

• The importance of the subject to us.
• How strongly the dissonant thoughts conflict.
• Our inability to rationalize and explain away the conflict.

Dissonance is often strong when we believe something about ourselves and then do something against that belief. If I believe I am good but do something bad, then the discomfort I feel as a result is cognitive dissonance.

Cognitive dissonance is a very powerful motivator which will often lead us to change one or other of the conflicting belief or action. The discomfort often feels like a tension between the two opposing thoughts. To release the tension we can take one of three actions:

• Change our behavior.
• Justify our behavior by changing the conflicting cognition.
• Justify our behavior by adding new cognitions.

Unfortunately for skeptics I do not feel any cognitive dissonance in my practice of medicine and with the research.  It is because I realize that I am not God. I do not know everything.  No one knows everything.  What we know are bits and pieces of things, and even how they fit together is subject to personal, collective societal and cultural bias. I adapt the attitude of St. Thomas Aquinas thus, as quoted by William G. Most:

Father William G. Most

Let us imagine that this theologian is standing on the circumference of a circle. From each of two or more points on the circumference, he tries to draw a line that will reach the center of the circle, that is, the true solution. If he has done his work well, all lines will come to a focus in the center.What will a good theologian do if not all the lines seem to focus? First, he will recheck his work for possible errors. But what should he do if he finds no error? If he is following theological rather than philosophical method, he will not try to make one line focus with another line. Rather he will say: “Now we are in theology, in lofty divine matters. It is not strange if mysteries appear. Therefore, even though I cannot see how to reconcile two lines, yet I must hold both truths.” And so, he will confess simply that he cannot go further.

(Most, William G. Grace, Predestination and the Salvific Will of God, accessed online  April 3, 2010 http://www.catholicculture.org/culture/library/most/getchap.cfm?WorkNum=214&ChapNum=4)

We are not theologians yes, and we are not dealing with “lofty divine matters”.  However the attitude should be the same. What happens if the lines don’t seem to focus? First we check for errors.

Thousands of years of experience shows that inserting a needle in acupoint Hegu relieves pain in general, and the effects are supposedly different depending on the manipulation and the patient condition.  I am but one physician, but I have duplicated this in the clinic.  I know many others who have.  Acupuncture is now accepted in many conventional hospitals in the United States to assist in childbirth (email correspondence with Dr. Eleonor Lazo, MD) Yet the skeptics who would destroy any possible synergy between the two medical traditions would try to use statistics to bash us. They say research shows that it doesn’t work.  When we show them research that shows acupuncture works, they’ll always find something to put it down, such as sample size, or it’s just a preliminary study etc etc, utterly forgetting their own sins (http://qi-spot.com/2010/02/21/another-big-pharma-cover-up/, http://qi-spot.com/2010/02/22/more-magic-numbers-this-time-its-celebrex/) And now apparently Lipitor causes increase in blood sugar too!  So much for peer review.

Is it too much for me, therefore, to suggest that when statistics apparently contradict clinical experience, we examine the statistics first?   It seems to me that when acupuncture is shown to work, the studies are supposedly “faulty” yet perfectly alright when the opposite is apparently shown.  My last post (http://qi-spot.com/2010/03/30/how-to-research-acupuncture/) shows why I believe current research paradigms for acupuncture are imperfect, thus leading to apparent conflicts.

The second problem is how we perceive if something “works”.  Most studies try to compare a treatment to the placebo effect.  I think the placebo effect is like St. Jude Thaddeus – getting a bad rap because of nomenclature.  Selling something known to be placebo is bad – you’re cheating customers.  Encouraging the placebo effect with good bedside manner – is that bad?  Now the argument is that acupuncture is “just a placebo”.  How can acupuncture be just a placebo when there are many studies (I refer the reader to http://www.acupuncture.com.au/articles/archive.html because I am too lazy to cut and paste them now) that show the specific physiological mechanisms of how it works?  A placebo by definition doesn’t do anything.  Acupuncture does something.  The question is is that something it does good?  As I have blogged before, improved sleep is good.  Easier walking is good.  Regular bowel movement is good. More energy is good. Decreased pain is good.  It had previously been pointed out that western medicine by definition should have a greater “placebo effect” due to cultural bias.  Yet acupuncture can work where western medicine doesn’t.  So much for “placebo”.

I also examine motivation.  What is my end point? To prove acupuncture works? No.  I believe it does.  To prove it doesn’t work?  Well, I’m not OUT to prove it doesn’t work, but I AM on the lookout to see where it works best, and where it sucks.  How? By personal study, reading both eastern and western medical journals (although I ignore 60s and 70s Chinese studies as those are ridiculously biased – hello cultural revolution!) By learning from the experiences of clinicians (I think it’s obvious I am biased towards the clinical experiences of great practitioners – lots of clinical pearls there) and from personal experience (I’ve developed some acupuncture manipulation tricks of my own ha ha).   I put a LOT of value on genuine clinical experience by great thinkers.  Edward Jenner was initially ridiculed for proposing his cowpox innoculation theory to protect against smallpox, because it went against the theory of the time.  Yet he was adamant because he was backed by clinical experience.

Edward Jenner was ridiculed for his ideas, as seen in this contemporary cartoon. (Click to enlarge)

If one is out on a witch hunt, to prove Chinese medicine doesn’t work, then everything you see will be filtered through that lens.  The same accusation can be made against me, that I see everything differently because I believe Chinese medicine works.  In that sense, we’re all bothered by cognitive dissonance!  Skeptics try to rationalize their position by citing statistics (which we know can be manipulated).  We rationalize our position by citing different statistics (which again, we acknowledge are manipulable).

I guess where I’m going with this is: unless we be like what William G. Most describes: true lovers of knowledge acknowledging our intellect is limited, we’ll be going nowhere.  In the meantime, what I do often (of course not always) works for my patients, the advice I give them based on Chinese medicine principles often (of course not always -THAT would be true placebo) works.  So if it ain’t broke, don’t fix it.

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.