Monday, March 02, 2009

CAM Paper Part V: Acupuncture

Although the practice of acupuncture is commonly associated with traditional Chinese medicine, there is evidence that acupuncture actually dates back several thousand years in the histories of both Eastern and Western medicine. The Chinese conception of acupuncture revolves around the idea of qi, or vital energy. More specifically, traditional Chinese medicine holds that health is a state of balance between two opposing forms of qi called yin and yang. According to this theory, each person inherits a form of qi that circulates throughout 14 meridians (channels) in the body, thereby nourishing and defending it. Diseases are thought to be caused by a disturbance or blockage of qi, which leads to an imbalance of yin and yang. Thus, the purpose of acupuncture is to correct this energy disturbance and bring yin and yang back into balance.(11)

Several theories have been proposed to explain how acupuncture alleviates pain, and there is some evidence in the literature that supports these ideas. Examples include stimulation of A delta fibers in the skin, activation of enkephalin-producing interneurons, release of endorphins, activation of descending pain control pathways, and modulation of the pain control center in the brain. In addition, modern practitioners sometimes associate yin and yang with the sympathetic and parasympathetic divisions of the autonomic nervous system.(11)

Acupuncture involves inserting fine needles into any of 365 specific points on the meridians. (The number of points was chosen to correspond to the number of days in a year.) Needles may be used alone therapeutically, or they may be used along with electrical stimulation, ultrasound, or heat. Conditions that are commonly treated with acupuncture include back pain, myofascial pain, and arthritis. There is some evidence that acupuncture is useful for treating some forms of pain and certain other conditions, including fibromyalgia, nausea and chronic back pain.(11,12) However, other conditions do not appear to be effectively treated with acupuncture, such as headaches.(11)

Despite the existence of multiple studies showing improvement in several conditions after acupuncture treatment, there is a strong possibility that acupuncture is mainly effective due to the placebo effect. The original acupuncture studies showing efficacy were necessarily performed unblinded; that is, both the patient and the acupuncturist knew whether or not the patient had received acupuncture. However, when sham acupuncture is used as a control in acupuncture-na├»ve patients (a single-blinded design), most studies show no difference in improvement between the groups. Patients who choose to try acupuncture commonly cite the possibility that it will help, curiosity, and their belief that conventional medicine will not help. Thus, it appears that the patient’s beliefs about the effects of acupuncture have a strong effect on their subjective perception of pain.(11)

I was able to observe the importance of patient belief in the effectiveness of acupuncture. Those patients who had the most confidence in the treatment reported the greatest relief of their symptoms. The acupuncturist, a practitioner of traditional Chinese medicine, mainly treated patients suffering from chronic pain conditions such as osteoarthritis. He attributed his patients’ problems to “weakness” in certain organs, especially the liver, kidneys, and heart. Beyond that, the acupuncturist did not really explain the causes of the patient’s problem or how his therapies worked. He did not ever mention concepts such as qi, yin, and yang. In fact, when patients directly asked him how he knew a particular organ was weak, he would respond that his diagnosis was based on prior experience. Essentially, he was asking the patients to trust his judgment without any explanation at all. Unsurprisingly, the more skeptical patients did not benefit as much from their treatments.

Each acupuncture treatment began with an examination of the patient’s energy. If the acupuncturist felt that the patient’s energy was low, he would have the patient go into a special room set aside for raising energy. Here, the patient would be asked to hold a metal bar in each hand. The metal bar was connected to a machine that provided electrical stimulation. The patient would sit holding the bars for several minutes, and would then be moved to another room for the acupuncture treatment. After having the patient lie down, the acupuncturist would insert needles one by one, usually in the patient’s feet, legs, hands, and arms. Some patients also got needles in their ears, forehead, and neck. It was not made clear how the acupuncturist decided where the needles were needed. Finally, the needles were connected to a machine that provided electrical stimulation.

Along with needles, the acupuncturist used several other modalities. For example, he asked one patient whom he diagnosed with a weak heart to take a Chinese herbal remedy that he said would strengthen her heart. The bottle’s label was printed in Chinese, and there was no way for the patient or me to know what was in it. She asked him what it did, but all he would say was that it would help her weak heart. Another patient who was diagnosed with a weak liver was treated with a magnet placed over the right side of her abdomen. The acupuncturist also manipulated this patient’s energy level by passing his hands over her body without touching her. This patient had full faith in the efficacy of acupuncture, and she reported having significant pain relief.

I came away from this experience feeling very skeptical of acupuncture for at least two reasons. First, unlike the chiropractor, the acupuncturist made no pretense of being a physician or using science in his treatments. His diagnoses of weak organs do not have any correspondence with any diseases recognized in Western medicine. Even more discomforting, the acupuncturist made no effort to offer explanations or education. In fact, he discouraged patient questioning by simply saying that he knew what he was doing based on experience. It is possible that this implicit command to just trust him was at least in part a cultural disconnect, but his attitude would probably not be acceptable to many Western patients.

1 comment:

NYCTCM said...

See http://nccam.nih.gov/health/acupuncture/ for an introduction to acupuncture from National Institute for Health.

Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups.

However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain.

There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.