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Acupuncture
Getting to the real point of it all

By Harriet Hall

A slightly abridged version, with added headings and glossary, of an article that originally appeared in the US Skeptic, 14(3), 8-9, 2008. It is a very readable alternative to the dozens of books and hundreds of articles that have been published on acupuncture, most of them written by converts impervious to criticism. Dr Hall is a retired family doctor in Washington state who writes about alternative medicine and pseudoscience. She recently published Women aren't supposed to fly: The memoirs of a female flight surgeon. Visit her at www.skeptdoc.com

Acupuncture cartoon by JeanPaul Buquet

People keep telling me that acupuncture has been proven to work. They say "It is supported by lots of good research, more and more doctors are using it, and even insurance companies pay for it." The reality is different. Almost everything you've heard about acupuncture is wrong.

Neither ancient nor Chinese
To start with, this ancient Chinese treatment is not ancient and may not even be Chinese. From studying the earliest documents, Chinese scholar Paul Unschuld suspects the idea may have originated with the Greek Hippocrates of Cos and later spread to China. It's definitely not 3000 years old. The earliest Chinese medical texts, from around 300 BC, do not mention it. The earliest reference to "needling" is from 90 BC, but it refers to bloodletting and lancing abscesses with large needles or lances. The means to make the thin needles used in acupuncture didn't exist until about 400 years ego.

History
The earliest accounts of Chinese medicine reached the West in the 13th century and they didn't mention acupuncture at all. The first Westerner to write about acupuncture, Wilhelm ten Rhijn, in 1680, didn't describe acupuncture as we know it today. He didn't mention specific acupuncture points or qi -- he spoke only of large gold needles that were implanted deep into the skull and left in place for 30 respirations.

Acupuncture was tried off and on in Europe after that. It was first tried in America in 1826 as a possible means of resuscitating drowning victims. They couldn't get it to work and "gave up in disgust." I imagine sticking needles in soggy dead bodies was pretty disgusting.

Key Chinese terms were invented by Frenchmen
In the 1900s no Western account of acupuncture referred to acupuncture points. Needles were simply inserted near the point of pain. Qi was originally vapor arising from food, and meridians were channels or vessels. In 1939 a Frenchman, Georges Soulie de Morant, was the first to use the term meridian and to equate qi with energy. Ear acupuncture was invented by another Frenchman in 1957.

[According to acupuncturists: Qi is the body's life force (which so far has escaped detection by science). Meridians are imaginary lines on the body's surface, beneath which qi runs like an underground river. Acupuncture points are positions on these meridians where the qi is reachable by a needle. Acupressure (shiatsu) uses finger pressure instead of needles at acupuncture points.]

The Chinese government tried to ban acupuncture several times, between 1822 and World War II during the time of the Chinese Nationalist government. Mao revived it in the "barefoot doctor" campaign in the 1960s as a cheap way of providing cure to the masses (he didn't use it himself because he didn't believe in it). It was Mao's government that coined the term "traditional Chinese medicine" or TCM.

Acupuncture in the West
In 1972 James Reston accompanied Nixon to China and returned to tell about his appendectomy. It was widely believed that his appendix was removed under acupuncture anesthesia. In reality, acupuncture was used only as an adjunct for pain relief the day after surgery, and the relief was probably coincident with the expected return of normal bowel motility. A widely circulated picture of a patient allegedly undergoing open heart surgery with acupuncture anesthesia was shown to be bogus. If acupuncture is used in surgery today, it is used along with conventional anesthesia and pre-operative medication, and it is selected only for patients who believe in it and are likely to have a placebo response.

As acupuncture increased in popularity in the West, it declined in the East. In 1995, visiting American physicians were told only 15-20% of Chinese chose TCM, and it was usually used along with Western treatments after diagnosis by a Western-trained physician. Apparently some patients choose TCM because it is all they can afford (China does not have universal health coverage despite being a Communist country).

Safety in numbers
There were originally 360 acupuncture points, loosely based on the number of days in a year rather than on anatomy. Currently more than 2000 acupuncture points have been "discovered", leaving almost no skin that is not an acupuncture point. And there are either 9, 10, or 11 meridians -- take your pick. Any number is as good as another, because no research has been able to document the existence of acupuncture points or meridians or qi.

Does acupuncture work?
First, which type of acupuncture? And what is meant by "work"? There are different Chinese systems, plus Japanese, Thai, Korean and Indian systems, most of which have been invented over the last few decades. Application can be to the whole body or limited to the scalp, hand, ear, foot, or cheek and chin. It can be deep or superficial. Needles can be electrified or even not used, as with skin electrodes and no skin penetration.

Acupuncture works in the same manner that placebos work. [A placebo, pronounced pla-see-bo, from the Latin "I shall please", the opening word of the Roman Catholic service Placebo Domino, is anything not directly related to the treatment, like a sugar pill, but which is nevertheless effective. No understanding is needed of how the sugar pill might work, just the belief that it will work.] Like any placebo, acupuncture has been shown to relieve pain, nausea, and similar symptoms, but it has never been shown to alter the natural history or course of any disease. Today it's used mostly for pain relief, but early Chinese acupuncturists said it was not for treating disease. They also said it was too subtle to be used except at the start of an illness, and was likely to work only if the patient believed it would work. Think about that. Ancient wisdom as its best!

Endorphins and placebos
Studies have shown that acupuncture releases endorphins (natural pain relievers) in the brain. Animal vets have pointed out that leading a horse into a trailer or throwing a stick for a dog also releases endorphins. Probably hitting yourself on the thumb with a hammer would release endorphins too, and would take your mind off your headache.

Psychologists have discovered many things that could explain the placebo response to acupuncture, that is, the things that fool us into believing acupuncture will work. The list is a long one but essentially it boils down to human nature and being uninformed. In technical terms it includes expectation, suggestion, diverting attention from symptoms, mutual consensus and compliance demand, causality error, classic conditioning, reciprocal conditioning, operant conditioning, operator conditioning, reinforcement, group consensus, economic and emotional investment, social and political disaffection, social rewards for believing, variable course of disease, and regression to the mean. Finally, not all placebos are equal -- an elaborate system that requires relaxing and spending time with a caring authority will produce a greater placebo effect than simply taking a sugar pill.

Research into acupuncture
There are plenty of studies showing that acupuncture seems to work for things like pain and nausea. But we must be cautious, simply because the results are inconsistent -- some studies find an effect but others (especially the higher quality studies) do not. Most of the studies are done by believers, and in any case subjects are unlikely to volunteer for an acupuncture trial unless they believe it might work. The studies coming from China and other oriental countries are all positive. But then nearly everything coming out of China is positive -- in China it is hard to publish negative results because researchers would lose face and their jobs.

The biggest problem with acupuncture studies is finding an adequate control (in this case something that looks like acupuncture but isn't, so the real source of any effect can be identified). People notice if you're sticking needles in them! Maybe you could fool them into thinking a needle was used when it wasn't, but you cannot fool the person doing the needling. Nevertheless two kinds of control have been used -- inserting needles in non-acupuncture points, and using a fake needle in a sheath that seems to have penetrated the skin when it hasn't.

In George Ulett's research, he found that applying an electrical current to the wrist worked just as well as inserting needles anywhere in the body. Furthermore, it doesn't matter where you put the needle. Nor does it matter if you don't use needles at all. In the best studies, only one thing mattered -- whether patients believed they were getting the real thing. If they did, they got better pain relief regardless of whether they actually got acupuncture or not. Conversely, if they got acupuncture but believed they didn't, it didn't work.

Conclusion
Given the inconsistent research results, the implausibility of qi and meridians, and the many questions that remain, it seems reasonable to conclude that acupuncture is no better than a placebo. You can play human pincushion if you want, and you might get a good placebo response if you did, but there's no evidence you'll get anything more.

More information. Part of this article was adapted from a PowerPoint presentation prepared by the late Dr Robert Imne. His entire presentation is on-line at http.//drspinello.com/altmed/acuvet_files/frame.htm. It includes great pictures of camel-puncture, goat-puncture, and chicken-puncture, and is well worth a visit..

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