Acupuncture

Acupuncture

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CONTENTS

1. WHAT IS IT?

2. DOES IT WORK?

3. WHAT'S THE EVIDENCE?

4. SUMMARY OF A FEW PROPOSED USES FOR ACUPUNCTURE

5. IS IT SAFE?

6. TOO LONG; DIDN'T READ! (TLDR)

7. REFERENCES

WHAT IS IT?

Acupuncture is an alternative medical practice which falls under the umbrella of “Traditional Chinese Medicine”. Its origins are rooted in a belief system which suggests that human health and disease are controlled by a vital force/energy known as “Qi”. It is believed that this energy flows throughout the body via pathways called “meridians”, each of which correspond to a major organ or body function. When the flow of Qi through one or more of these meridians is unbalanced, weak, or otherwise disturbed, one’s health can be negatively impacted. Luckily, the flow of Qi can be altered via access points known as “acupuncture points”. These points are located along the body’s meridians and can be stimulated by the insertion of needles (i.e. “acupuncture needling”) or other means. By altering the flow of Qi with acupuncture needles, balance can be reinstated to the affected meridians, and good health is restored [1].

It should be noted: there is no evidence that Qi, meridians, or acupuncture points actually exist.

Flow of Qi
Acupuncture Restores Qi

Historically, acupuncture has existed for thousands of years, but it has not always been viewed as useful. Indeed, despite its Chinese origins over 2000 years ago, acupuncture and related practices were banned in Chinese medical practice in 1822 by Emperor Dao Guang and were later outlawed entirely in 1929 [2]. The reason for its decline in popularity? It came to be viewed in China as “superstitious and irrational” [2]. Acupuncture did not meaningfully resurface until 1966 when it was revived by Chairman Mao Zedong for nationalistic and pragmatic purposes during the Chinese Cultural Revolution [2-3]. However, Mao did not actually believe in acupuncture (or other forms of Traditional Chinese Medicine) and refused to personally use it [2-3].

Acupuncture is promoted for the treatment of many conditions, including:

  • Pain
  • Nausea and vomiting
  • Headache
  • Smoking cessation
  • Addiction
  • Depression
  • ADHD in children
  • Menopausal hot flashes
  • Asthma
  • Arthritis
  • Irritable bowel syndrome (IBS)
  • Autism
  • Many more

DOES IT WORK?

Probably not. Any effects are most likely non-specific. In other words, the effects of acupuncture are probably not related to being poked with a needle, and more to do with either:

a) the placebo effect or

b) a physiological response that can be elicited without needles.

In the case of (b), this would suggest that acupuncture needling is not necessary to achieve the desired effect and could be substituted for other less-invasive (and less expensive) techniques.

WHAT'S THE EVIDENCE?

For most of the uses for which acupuncture is recommended, there is little to no evidence to support its use.

For a few conditions, more evidence is available, but it is mostly low-quality and weak.

The best evidence for acupuncture relates to its use for the treatment of pain, but even then, many clinicians/scientists suggest that the science is not very compelling [3-6].


 

Quick Definition: "Systematic Review"

A systematic review (and/or “meta-analysis”) is a scientific study that examines the agreement between many clinical trials. Instead of looking at a single study, systematic reviews attempt to analyse the totality of evidence related to a topic. By doing so, the true answer to a given question can be more accurately estimated. For example, a single study might indicate that a particular treatment is effective, leading readers to believe that this treatment works. However, what if three other studies conclude that the same treatment does not work? A systematic review might analyse the data from all four of these trials and conclude (correctly) that the totality of the evidence indicates that the treatment does not work (3 say no, only 1 says yes). The relative importance of each study is determined by things like study size (number of participants – more is better), chance for bias, consistency of measurements, and many others.

Because of their strength, systematic reviews are generally considered one of the highest standards of evidence. However, they are also not perfect, and are subject to the quality of the contributing clinical studies. Hence, if only low-quality studies are used, low-quality results will emerge (a.k.a. “garbage in, garbage out”).

 

Acupuncture For Pain

Multiple systematic reviews demonstrate that acupuncture needling is clinically indistinguishable from “fake” acupuncture (known as “sham acupuncture” or “placebo acupuncture”) when it comes to treating pain [4-5, 7-8]. Even one of the most favorable reviews of acupuncture for pain demonstrated that the difference between acupuncture and sham acupuncture is not clinically relevant [9]. In other words, a patient cannot tell the difference between an acupuncture needle and “fake” needling (e.g. poking with a toothpick, or poking in random locations). The pain-relieving effect they experience is essentially the same, regardless of whether “real” or “fake” acupuncture is used.

However, when acupuncture and fake acupuncture are compared to doing nothing, both of these options appear to reduce pain. This situation is what researchers refer to as a "placebo effect": both the "active" and "inactive" treatments have essentially the same effect. For example, if researchers wanted to test a new headache medication, they would compare it to a sugar pill (a placebo – an inactive treatment). If patients reported that both pills (medication and sugar pill) made them feel better when they tried them separately, but they could not tell any difference between the pills, the effect would be a "placebo effect". In other words, the effect of the medication (and sugar pill) is not specific to the pill – it is simply the act of taking any treatment that led to improvement. This appears to be the case for acupuncture.

Quick Research Highlights

Toothpick Acupuncture: When acupuncture needling is compared to poking patients with a toothpick, patients cannot tell the difference – the effects are the same [10].

 
Toothpick Acupuncture
 

Needling Location/Acupuncture Points: The best available studies demonstrate that it does not matter where acupuncture needles (or toothpicks) are stuck – the effects are the same [5]. This would suggest that “acupuncture points” are meaningless.

 
Needling Location
 

Acupuncture Expectations: Patients who have a more favorable view of acupuncture, or who have higher expectations for its effectiveness, generally report greater symptom relief from acupuncture [11-12]. In other words, patients who believe acupuncture will work are more likely to benefit from it. This is a characteristic of placebo effects.

 
Acupuncture Expectations
 

Blinding Bias: Researchers point out that because trials of acupuncture are rarely double-blinded (i.e. the person delivering the acupuncture usually knows if it is “real” or “fake” acupuncture), potentially significant bias can be introduced into such studies [3, 5-6]. For example, if an acupuncturist knows the treatment is “fake”, they may not emphasize psychological aspects of the interaction as strongly as they would with “real” acupuncture (e.g. encouragement, reassurance of efficacy, explanation of the power of Qi, etc.). This potential bias can probably account for some, if not all, of the small (but clinically irrelevant) differences occasionally observed between “real” and “fake” acupuncture [5].

SUMMARY OF A FEW PROPOSED USES FOR ACUPUNCTURE

 
*Toothpick = Sham Acupuncture

*Toothpick = Sham Acupuncture

 

IS IT SAFE?

Generally speaking, acupuncture appears to be relatively safe and serious adverse events (side effects) are rare [4, 33]. However, such events do occur.

Serious adverse effects of acupuncture include:

  • Pneumothorax (air in the chest cavity causing lung collapse)
  • Infection (bacterial and/or viral)
  • Internal bleeding
  • Death

It should also be noted that indirect harm can come from acupuncture if it serves to delay or replace necessary evidence-based treatments. This is true of all forms of natural health practices.

TOO LONG; DIDN'T READ!

When it comes to reducing pain, acupuncture is better than nothing, but probably no different than poking with a toothpick. In other words, acupuncture is most likely a placebo. For pretty much everything else, there is little to no evidence to support its use.

 
Acupuncture Placebo
 

REFERENCES

1)  Vickers A, Zollman C. ABC of complementary medicine: Acupuncture. BMJ. 1999;319(7215):973–976. doi:10.1136/bmj.319.7215.973.

2)  White A, Ernst E. A brief history of acupuncture. Rheumatology. 2004;43(5):662–663. doi:10.1093/rheumatology/keg005.

3)  Colquhoun D, Novella SP. Acupuncture is theatrical placebo. Anesthesia & Analgesia. 2013;116(6):1360–1363. doi:10.1213/ane.0b013e31828f2d5e.

4)  Ernst E, Lee MS, Choi T-Y. Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011;152(4):755–764. doi:10.1016/j.pain.2010.11.004.

5)  Madsen MV, Gotzsche PC, Hrobjartsson A. Acupuncture treatment for pain: Systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009;338(jan27 2):a3115–a3115. doi:10.1136/bmj.a3115.

6)  McGeeney BE. Acupuncture is all placebo and here is why. Headache: The Journal of Head and Face Pain. 2015;55(3):465–469. doi:10.1111/head.12524. http://dx.doi.org/10.1111/head.12524.

7)  Manheimer E, Linde K, Lao L, Bouter LM, Berman BM. Meta-analysis: Acupuncture for osteoarthritis of the knee. Annals of Internal Medicine. 2007;146(12):868. doi:10.7326/0003-4819-146-12-200706190-00008.

8)  Rubinstein SM, van Middelkoop M, Kuijpers T, et al. A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain. European Spine Journal. 2010;19(8):1213–1228. doi:10.1007/s00586-010-1356-3.

9)  Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain. Archives of Internal Medicine. 2012;172(19):1444. doi:10.1001/archinternmed.2012.3654.

10)  Cherkin DC, Sherman KJ, Avins AL, et al. A Randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine. 2009;169(9):858. doi:10.1001/archinternmed.2009.65.

11)  White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G. Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain. 2012;153(2):455–462. doi:10.1016/j.pain.2011.11.007.

12)  Linde K, Witt CM, Streng A, et al. The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain. 2007;128(3):264–271. doi:10.1016/j.pain.2006.12.006.

13)  Lee MS, Ernst E. Acupuncture for surgical conditions: An overview of systematic reviews. International Journal of Clinical Practice. 2014;68(6):783–789. doi:10.1111/ijcp.12372.

14)  Lee A, Chan SK, Fan LT. Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews. November 2015. doi:10.1002/14651858.cd003281.pub4.

15)  Linde K, Streng A, Jürgens S, et al. Acupuncture for patients with migraine: A randomized controlled trial. JAMA. 2005;293(17):2118. doi:10.1001/jama.293.17.2118.

16)  Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews. June 2016. doi:10.1002/14651858.cd001218.pub3.

17)  Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews. April 2016. doi:10.1002/14651858.cd007587.pub2.

18)  White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews. January 2014. doi:10.1002/14651858.cd000009.pub4.

19)  Gates S, Smith LA, Foxcroft D. Auricular acupuncture for cocaine dependence. Cochrane Database of Systematic Reviews. January 2006. doi:10.1002/14651858.cd005192.pub2.

20)  Li S, Yu B, Zhou D, et al. Acupuncture for Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents. Cochrane Database of Systematic Reviews. April 2011. doi:10.1002/14651858.cd007839.pub2.

21)  Smith CA, Hay PP, MacPherson H. Acupuncture for depression. Cochrane Database of Systematic Reviews. January 2010. doi:10.1002/14651858.cd004046.pub3.

22)  Shen X, Xia J, Adams CE. Acupuncture for schizophrenia. Cochrane Database of Systematic Reviews. October 2014. doi:10.1002/14651858.cd005475.pub2.

23)  Cheuk DK, Wong V. Acupuncture for epilepsy. Cochrane Database of Systematic Reviews. May 2014. doi:10.1002/14651858.cd005062.pub4.

24)  Dodin S, Blanchet C, Marc I, et al. Acupuncture for menopausal hot flushes. Cochrane Database of Systematic Reviews. July 2013. doi:10.1002/14651858.cd007410.pub2.

25)  McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupuncture for chronic asthma. Cochrane Database of Systematic Reviews. July 2003. doi:10.1002/14651858.cd000008.pub2.

26)  Wechsler ME, Kelley JM, Boyd IOE, et al. Active Albuterol or placebo, sham acupuncture, or no intervention in asthma. New England Journal of Medicine. 2011;365(2):119–126. doi:10.1056/nejmoa1103319.

27)  Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews. January 2010. doi:10.1002/14651858.cd001977.pub2.

28)  Casimiro L, Barnsley L, Brosseau L, et al. Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews. October 2005. doi:10.1002/14651858.cd003788.pub2.

29)  Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews. May 2012. doi:10.1002/14651858.cd005111.pub3.

30)  Cheuk DK, Wong V, Chen WX. Acupuncture for autism spectrum disorders (ASD). Cochrane Database of Systematic Reviews. September 2011. doi:10.1002/14651858.cd007849.pub2.

31)  Cheuk DK, Yeung W-F, Chung K, Wong V. Acupuncture for insomnia. Cochrane Database of Systematic Reviews. September 2012. doi:10.1002/14651858.cd005472.pub3.

32)  Deare JC, Zheng Z, Xue CC, et al. Acupuncture for treating fibromyalgia. Cochrane Database of Systematic Reviews. May 2013. doi:10.1002/14651858.cd007070.pub2.

33)  Zhang J, Shang H, Gao X, Ernst E. Acupuncture-related adverse events: A systematic review of the Chinese literature. Bulletin of the World Health Organization. 2010;88(12):915–921. doi:10.2471/blt.10.076737.