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Stephen Barrett,
M.D.
"Chinese medicine,"
often called "Oriental medicine" or "traditional Chinese medicine (TCM),"
encompasses a vast array of folk medical practices based on mysticism. It
holds that the body's vital energy (chi or qi) circulates
through channels, called meridians, that have branches connected to
bodily organs and functions. Illness is attributed to imbalance or
interruption of chi.. Ancient practices such as acupuncture, Qigong,
and the use of various herbs are claimed to restore balance.
Traditional
acupuncture, as now practiced, involves the insertion of stainless steel
needles into various body areas. A low-frequency current may be applied to
the needles to produce greater stimulation. Other procedures used separately
or together with acupuncture include: moxibustion (burning of floss or herbs
applied to the skin); injection of sterile water, procaine, morphine,
vitamins, or homeopathic solutions through the inserted needles;
applications of laser beams (laserpuncture); placement of needles in the
external ear (auriculotherapy); and acupressure (use of manual pressure).
Treatment is applied to "acupuncture points," which are said to be located
throughout the body. Originally there were 365 such points, corresponding to
the days of the year, but the number identified by proponents during the
past 2,000 years has increased gradually to about 2,000 [1]. Some
practitioners place needles at or near the site of disease, whereas others
select points on the basis of symptoms. In traditional acupuncture, a
combination of points is usually used.
Qigong is also
claimed to influence the flow of "vital energy." Internal Qigong involves
deep breathing, concentration, and relaxation techniques used by individuals
for themselves. External Qigong is performed by "Qigong masters" who claim
to cure a wide variety of diseases with energy released from their
fingertips. However, scientific investigators of Qigong masters in China
have found no evidence of paranormal powers and some evidence of deception.
They found, for example, that a patient lying on a table about eight feet
from a Qigong master moved rhythmically or thrashed about as the master
moved his hands. But when she was placed so that she could no longer see
him, her movements were unrelated to his [2]. Falun gong, which China
recently banned, is a Qigong varient claimed to be "a powerful mechanism for
healing, stress relief and health improvements."
Most acupuncturists
espouse the traditional Chinese view of health and disease and consider
acupuncture, herbal medicine, and related practices to be valid approaches
to the full gamut of disease. Others reject the traditional approach and
merely claim that acupuncture offers a simple way to achieve pain relief.
The diagnostic process used by TCM practitioners may include questioning
(medical history, lifestyle), observations (skin, tongue, color), listening
(breathing sounds), and pulse-taking. Six pulse aspects said to correlate
with body organs or functions are checked on each wrist to determine which
meridians are "deficient" in chi. (Medical science recognizes only
one pulse, corresponding to the heartbeat, which can be felt in the wrist,
neck, feet, and various other places.) Some acupuncturists state that the
electrical properties of the body may become imbalanced weeks or even months
before symptoms occur. These practitioners claim that acupuncture can be
used to treat conditions when the patient just "doesn't feel right," even
though no disease is apparent.
TCM (as well as the
folk medical practices of various other Asian countries) is a threat to
certain animal species. For example, black bears -- valued for their gall
bladders -- have been hunted nearly to extinction in Asia, and poaching of
black bears is a growing problem in North America.
Dubious Claims
The conditions
claimed to respond to acupuncture include chronic pain (neck and back pain,
migraine headaches), acute injury-related pain (strains, muscle and ligament
tears), gastrointestinal problems (indigestion, ulcers, constipation,
diarrhea), cardiovascular conditions (high and low blood pressure),
genitourinary problems (menstrual irregularity, frigidity, impotence),
muscle and nerve conditions (paralysis, deafness), and behavioral problems
(overeating, drug dependence, smoking). However, the evidence supporting
these claims consists mostly of practitioners' observations and poorly
designed studies. A controlled study found that electroacupuncture of the
ear was no more effective than placebo stimulation (light touching) against
chronic pain [3]. In 1990, three Dutch epidemiologists analyzed 51
controlled studies of acupuncture for chronic pain and concluded that "the
quality of even the better studies proved to be mediocre. . . . The efficacy
of acupuncture in the treatment of chronic pain remains doubtful." [4] They
also examined reports of acupuncture used to treat addictions to cigarettes,
heroin, and alcohol, and concluded that claims that acupuncture is effective
as a therapy for these conditions are not supported by sound clinical
research [5].
Acupuncture
anesthesia is not used for surgery in the Orient to the extent that its
proponents suggest. In China physicians screen out patients who appear to be
unsuitable. Acupuncture is not used for emergency surgery and often is
accompanied by local anesthesia or narcotic medication [6].
How acupuncture may
relieve pain is unclear. One theory suggests that pain impulses are blocked
from reaching the spinal cord or brain at various "gates" to these areas.
Another theory suggests that acupuncture stimulates the body to produce
narcotic-like substances called endorphins, which reduce pain. Other
theories suggest that the placebo effect, external suggestion (hypnosis),
and cultural conditioning are important factors. Melzack and Wall note that
pain relief produced by acupuncture can also be produced by many other types
of sensory hyperstimulation, such as electricity and heat at acupuncture
points and elsewhere in the body. They conclude that "the effectiveness of
all of these forms of stimulation indicates that acupuncture is not a
magical procedure but only one of many ways to produce analgesia [pain
relief] by an intense sensory input." In 1981, the American Medical
Association Council on Scientific Affairs noted that pain relief does not
occur consistently or reproducibly in most people and does not operate at
all in some people [7].
In 1995, George A.
Ulett, M.D., Ph.D., Clinical Professor of Psychiatry, University of Missouri
School of Medicine, stated that "devoid of metaphysical thinking,
acupuncture becomes a rather simple technique that can be useful as a
nondrug method of pain control." He believes that the traditional Chinese
variety is primarily a placebo treatment, but electrical stimulation of
about 80 acupuncture points has been proven useful for pain control [8].
The quality of TCM
research in China has been extremely poor. A recent analysis of 2,938
reports of clinical trials reported in Chinese medical journals concluded
that that no conclusions could be drawn from the vast majority of them. The
researchers stated:
In most of the
trials, disease was defined and diagnosed according to conventional
medicine; trial outcomes were assessed with objective or subjective (or
both) methods of conventional medicine, often complemented by traditional
Chinese methods. Over 90% of the trials in non-specialist journals
evaluated herbal treatments that were mostly proprietary Chinese
medicines. . . .
Although
methodological quality has been improving over the years, many problems
remain. The method of randomisation was often inappropriately described.
Blinding was used in only 15% of trials. Only a few studies had sample
sizes of 300 subjects or more. Many trials used as a control another
Chinese medicine treatment whose effectiveness had often not been
evaluated by randomised controlled trials. Most trials focused on short
term or intermediate rather than long term outcomes. Most trials did not
report data on compliance and completeness of follow up. Effectiveness was
rarely quantitatively expressed and reported. Intention to treat analysis
was never mentioned. Over half did not report data on baseline
characteristics or on side effects. Many trials were published as short
reports. Most trials claimed that the tested treatments were effective,
indicating that publication bias may be common; a funnel plot of the 49
trials of acupuncture in the treatment of stroke confirmed selective
publication of positive trials in the area, suggesting that acupuncture
may not be more effective than the control treatments. [9]
Two scientists at the
University of Heidelberg have developed a "fake needle" that may enable
acupuncture researchers to perform better-designed controlled studies. The
device is a needle with a blunt tip that moves freely within a copper
handle. When the tip touches the skin, the patient feels a sensation similar
to that of an acupuncture needle. At the same time, the visible part of the
needle moves inside the handle so it appears to shorten as though
penetrating the skin. When the device was tested on volunteers, none
suspected that it had not penetrated the skin [10].
In 2004, a University
of Heidelberg team proved the worth of their "sham acupuncture" technique in
a study of postoperative nausea and vomiting (PONV) in women who underwent
breast or gynecologic surgery. The study involved 220 women who received
either acupuncture or the sham procedure at the acupuncture point
"Pericardium 6" on the inside of the forearm. No significant difference in
PONV or antivomiting medication use was found between the two groups or
between the people who received treatment before anesthesia was induced and
those who received it while anesthetized [11]. A subgroup analysis found
that vomiting was "significantly reduced" among the acupuncture patients,
but the authors correctly noted that this finding might be due to studying
multiple outcomes. (As the number of different outcome measures increases,
so do the odds that a "statistically significant" finding will be spurious.)
This study is important because PONV reduction is one of the few alleged
benefits of acupuncture supported by reports in scientific journals.
However, the other PONV studies claiming to show positive results have not
been as tightly controlled..
Risks Exist
Improperly performed
acupuncture can cause fainting, local hematoma (due to bleeding from a
punctured blood vessel), pneumothorax (punctured lung), convulsions, local
infections, hepatitis B (from unsterile needles), bacterial endocarditis,
contact dermatitis, and nerve damage. The herbs used by acupuncture
practitioners are not regulated for safety, potency, or effectiveness. There
is also risk that an acupuncturist whose approach to diagnosis is not based
on scientific concepts will fail to diagnose a dangerous condition.
The adverse effects
of acupuncture are probably related to the nature of the practitioner's
training. A survey of 1,135 Norwegian physicians revealed 66 cases of
infection, 25 cases of punctured lung, 31 cases of increased pain, and 80
other cases with complications. A parallel survey of 197 acupuncturists, who
are more apt to see immediate complications, yielded 132 cases of fainting,
26 cases of increased pain, 8 cases of pneumothorax, and 45 other adverse
results [12]. However, a 5-year study involving 76 acupuncturists at a
Japanese medical facility tabulated only 64 adverse event reports (including
16 forgotten needles and 13 cases of transient low blood pressure)
associated with 55,591 acupuncture treatments. No serious complications were
reported. The researchers concluded that serious adverse reactions are
uncommon among acupuncturists who are medically trained [13].
Moe recently, members
of the British Acupuncture Council who participated in two prospective
studies have reported low complication rates and no serious complications
among patients who underwent a total of more than 66,000 treatments 14,15].
An accompany editorial suggests that in competent hands, the likelihood of
complcations is small [16]. Since outcome data are not available, the
studies cannot compare the balance of risks vs benefit. Nor do the studies
take into account the likelihood of misdiagnosis (and failure to seek
appropriate medical care) by practitioners who use traditional Chinese
methods.
Questionable
Standards
In 1971, an
acupuncture boom occurred in the United States because of stories about
visits to China by various American dignitaries. Entrepreneurs, both medical
and nonmedical, began using flamboyant advertising techniques to promote
clinics, seminars, demonstrations, books, correspondence courses, and
do-it-yourself kits. Today some states restrict the practice of acupuncture
to physicians or others operating under their direct supervision. In about
20 states, people who lack medical training can perform acupuncture without
medical supervision. The FDA now classifies acupuncture needles as Class II
medical devices and requires labeling for one-time use by practitioners who
are legally authorized to use them [17]. Acupuncture is not covered under
Medicare. The March 1998 issue of the Journal of the American Chiropractic
Association carried a five-part cover story encouraging chiropractors to get
acupuncture training, which, according to one contributor, would enable them
to broaden the scope of their practice [18].
The National
Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) has
set voluntary certification standards and certified several thousand
practitioners. By November 1998, 32 states had licensing laws, with 29 of
them using NCCAOM examination as all or part of their educational, training,
or examination requirement, and three with addditional eligibility criteria.
The credentials used by acupuncturists include C.A. (certified
acupuncturist), Lic. Ac. (licensed acupuncturist), M.A. (master
acupuncturist), Dip. Ac. (diplomate of acupuncture), and O.M.D. (doctor of
Oriental medicine). Some of these have legal significance, but they do not
signify that the holder is competent to make adequate diagnoses or render
appropriate treatment.
In 1990, the U.S.
Secretary of Education recognized what is now called the Accreditation
Commission for Acupuncture and Oriental Medicine (ACAOM) as an accrediting
agency. However, such recognition is not based on the scientific validity of
what is taught but upon other criteria [19]. Ulett has noted:
Certification of
acupuncturists is a sham. While a few of those so accredited are naive
physicians, most are nonmedical persons who only play at being doctor and
use this certification as an umbrella for a host of unproven New Age hokum
treatments. Unfortunately, a few HMOs, hospitals, and even medical schools
are succumbing to the bait and exposing patients to such bogus treatments
when they need real medical care.
The National Council
Against Health Fraud has concluded:
-
Acupuncture is an
unproven modality of treatment.
-
Its theory and
practice are based on primitive and fanciful concepts of health and
disease that bear no relationship to present scientific knowledge
-
Research during the
past 20 years has not demonstrated that acupuncture is effective against
any disease.
-
Perceived effects
of acupuncture are probably due to a combination of expectation,
suggestion, counter-irritation, conditioning, and other psychologic
mechanisms.
-
The use of
acupuncture should be restricted to appropriate research settings,
-
Insurance companies
should not be required by law to cover acupuncture treatment,
-
Licensure of lay
acupuncturists should be phased out.
-
Consumers who wish
to try acupuncture should discuss their situation with a knowledgeable
physician who has no commercial interest [20].
The NIH Debacle
In 1997, a Consensus
Development Conference sponsored by the National Institutes of Health and
several other agencies concluded that "there is sufficient evidence . . . of
acupuncture's value to expand its use into conventional medicine and to
encourage further studies of its physiology and clinical value." [21] The
panelists also suggested that the federal government and insurance companies
expand coverage of acupuncture so more people can have access to it. These
conclusions were not based on research done after NCAHF's position paper was
published. Rather, they reflected the bias of the panelists who were
selected by a planning committee dominated by acupuncture proponents [22].
NCAHF board chairman Wallace Sampson, M.D., has described the conference "a
consensus of proponents, not a consensus of valid scientific opinion."
Although the report
described some serious problems, it failed to place them into proper
perspective. The panel acknowledged that "the vast majority of papers
studying acupuncture consist of case reports, case series, or intervention
studies with designs inadequate to assess efficacy" and that "relatively
few" high-quality controlled trials have been published about acupuncture's
effects. But it reported that "the World Health Organization has listed more
than 40 [conditions] for which [acupuncture] may be indicated." This
sentence should have been followed by a statement that the list was not
valid.
Far more serious,
although the consensus report touched on Chinese acupuncture theory, it
failed to point out the danger and economic waste involved in going to
practitioners who can't make appropriate diagnoses. The report noted:
-
The general theory
of acupuncture is based on the premise that there are patterns of energy
flow (Qi) through the body that are essential for health. Disruptions of
this flow are believed to be responsible for disease. The acupuncturist
can correct imbalances of flow at identifiable points close to the skin.
-
Acupuncture focuses
on a holistic, energy-based approach to the patient rather than a
disease-oriented diagnostic and treatment model.
-
Despite
considerable efforts to understand the anatomy and physiology of the
"acupuncture points," the definition and characterization of these points
remains controversial. Even more elusive is the scientific basis of some
of the key traditional Eastern medical concepts such as the circulation of
Qi, the meridian system, and the five phases theory, which are difficult
to reconcile with contemporary biomedical information but continue to play
an important role in the evaluation of patients and the formulation of
treatment in acupuncture.
Simply stated, this
means that if you go to a practitioner who practices traditional Chinese
medicine, you are unlikely to be properly diagnosed.
Diagnostic Studies
In 1998, following
his lecture at a local college, an experienced TCM practitioner diagnosed me
by taking my pulse and looking at my tongue. He stated that my pulse showed
signs of "stress" and that my tongue indicated I was suffering from
"congestion of the blood." A few minutes later, he examined a woman and told
her that her pulse showed premature ventricular contractions (a disturbance
of the heart's rhythm that could be harmless or significant, depending on
whether the individual has underlying heart disease). He suggested that both
of us undergo treatment with acupuncture and herbs -- which would have cost
about $90 per visit. I took the woman's pulse and found that it was
completely normal. I believe that the majority of nonmedical acupuncturists
rely on improper diagnostic procedures. The NIH consensus panel should have
emphasized the seriousness of this problem.
A study published in
2001 illustrates the absurdity of TCM practices. A 40-year-old woman with
chronic back pain who visited seven acupuncturists during a two-week period
was diagnosed with "Qi stagnation" by 6 of them, "blood stagnation" by 5 ,
"kidney Qi deficiency" by 2, "yin deficiency" by 1, and "liver Qi
deficiency" by 1. The proposed treatments varied even more. Among the six
who recorded their recommendations, the practitioners planned to use between
7 and 26 needles inserted into 4 to 16 specific "acupuncture points" in the
back, leg, hand, and foot. Of 28 acupuncture points selected, only 4 (14%)
were prescribed by two or more acupuncturists. [23] The study appears to
have been designed to make the results as consistent as possible. All of the
acupuncturists had been trained at a school of traditional Chinese medicine
(TCM). Six other volunteers were excluded because they "used highly atypical
practices," and three were excluded because they had been in practice for
less than three years. Whereas science-based methods are thoroughly studied
to ensure that they are reliable, this appears to be the first published
study that examines the consistency of TCM diagnosis or treatment. I would
expect larger studies to show that TCM diagnoses are meaningless and have
little or nothing to do with the patient's health status. The study's
authors state that the diagnostic findings showed "considerable consistency"
because nearly all of the practitioners found Qi or blood stagnation.
However, the most likely explanation is that these are diagnosed in nearly
everyone. It would be fascinating to see what would happen if a healthy
person was examined by multiple acupuncturists.
For Additional
Information
References
-
Skrabanek P.
Acupuncture: Past, present, and future. In Stalker D, Glymour C, editors.
Examining Holistic Medicine. Amherst, NY: Prometheus Books, 1985.
-
Kurtz P, Alcock J,
and others. Testing psi claims in China: Visit by a CSICOP delegation.
Skeptical Inquirer 12:364-375, 1988.
-
Melzack R, Katz J.
Auriculotherapy fails to relieve chronic pain: A controlled crossover
study. JAMA 251:10411043, 1984
-
Ter Reit G,
Kleijnen J, Knipschild P. Acupuncture and chronic pain: A criteria-based
meta-analysis. Clinical Epidemiology 43:1191-1199, 1990.
-
Ter Riet G,
Kleijnen J, Knipschild P. A meta-analysis of studies into the effect of
acupuncture on addiction. British Journal of General Practice 40:379-382,
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Beyerstein BL,
Sampson W. Traditional Medicine and Pseudoscience in China: A Report of
the Second CSICOP Delegation (Part 1). Skeptical Inquirer 20(4):18-26,
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American Medical
Association Council on Scientific Affairs. Reports of the Council on
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Ulett GA.
Acupuncture update 1984. Southern Medical Journal 78:233234, 1985.
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Tang J-L, Zhan S-Y,
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Streitberger K,
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Streitberger K and
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Norheim JA, Fennebe
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Yamashita H and
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White A and others.
Adverse events following acupuncture: Prospective surgery of 32,000
consultations with doctors and physiotherapists. BMJ 323:485-486, 2001.
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MacPherson H and
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treatments by traditional acupuncturists. BMJ 323:486-487, 2001.
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Vincent C. The
safety of acupuncture. BMJ 323:467-468, 2001.
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Acupuncture needle
status changed. FDA Talk Paper T96-21, April 1, 1996
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Wells D. Think
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American Chiropractic Association 35(3):10-13, 1998.
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Department of
Education, Office of Postsecondary Education. Nationally Recognized
Accrediting Agencies and Associations. Criteria and Procedures for Listing
by the U.S. Secretary For Education and Current List. Washington, D.C.,
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Sampson W and
others. Acupuncture: The position paper of the National Council Against
Health Fraud. Clinical Journal of Pain 7:162-166, 1991.
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Acupuncture. NIH
Consensus Statement 15:(5), November 3-5, 1997.
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Sampson W. On the
National Institute of Drug Abuse Consensus Conference on Acupuncture.
Scientific Review of Alternative Medicine 2(1):54-55, 1998.
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Kalauokalani D and
others. Acupuncture for chronic low back pain: Diagnosis and treatment
patterns among acupuncturists evaluating the same patient. Southern
Medical Journal 94:486-492, 2001.
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