Pictured: Relevant. Oh yeah, it's going to get weird. Image courtesy of the Wellcome Trust Image Library via the Wikimedia Commons.

Pictured: Relevant. Oh yeah, it’s going to get weird.

I had a dickens of a time writing this entry. The last week has been spent in New York for NECSS. It is safe to say that New York has plenty of distractions for us Dug the Dog types. Reality may be a honey badger, but New York is a squirrel. I say that when I travel I usually do not come across food better than I can find in Portland. Nope. Not true of New York. It joins Paris and New Orleans in the holy trinity of good eats, although I will stick with Pacific Northwest beer. And the rule is that for every day you are gone, three days’ worth of work piles up. I really need to stop taking time off.

I spoke at NECSS on a favorite topic of mine, how acupuncture works. It doesn’t. But I discussed a few studies that I found interesting. Like all studies, no single paper is definitive. The third law of the medical literature states that for every study, there is an equal and opposite study. A bit of an exaggeration perhaps but I do find the direction that the following studies point interesting both as to acupuncture’s mechanism of inaction and how the mind functions, making them worth collecting in an essay.

In a weird way, the Secret is true. Expectations can influence the outcomes of an intervention such as acupuncture. If you have confidence in the procedure and believe you are going to have a salubrious effect, acupuncture will work. In “The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain” they took:

864 patients [who] received either 12 sessions of acupuncture or minimal (i.e. sham) acupuncture (superficial needling of non-acupuncture points) over an 8 week period. Patients were asked at baseline whether they considered acupuncture to be an effective therapy in general and what they personally expected from the treatment. After three acupuncture sessions patients were asked how confident they were that they would benefit from the treatment strategy they were receiving. Patients were classified as responders if the respective main outcome measure improved by at least fifty percent.

The patients had four kinds of pain: migraine, tension-type headache, chronic low back pain, and osteoarthritis of the knee, (one each; no one suffered from all four) and had 12 sessions of acupuncture or sham acupuncture, in this case superficial needling of non-acupuncture points. Since the only places on the body that do not have acupuncture points (depending on the acupuncture style) are the eyes, under the nails and the genitals, this must have been a very unhappy control group.

If the patient had the expectation that acupuncture was going to be effective in relieving pain, then they were better off than their long-suffering skeptical compatriots with a decrease in pain, and the response lasted for 6 months.

This is not the only study to show that the expectation that acupuncture will be effective is important in causing a beneficial effect. “Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture” found that fake acupuncture was equal to real acupuncture but it was the:

beliefs about treatment veracity [that] shape how patients self-report outcome.

It is not just the patients’ belief:

The individual practitioner and the patient’s belief had a significant effect on outcome

There have been other studies that show a similar correlation between expectation and acupuncture outcome, but in concordance with the third law:

Eight trials analyzed the association between pre-randomisation expectations for assigned treatment and outcomes, and six the effect of pre-randomisation expectations across all patients independent of treatment allocation. Some showed associations but others did not.

CONCLUSIONS:

There is some evidence that response expectancies interact with outcomes in acupuncture trials however the variety of question phrasing and analysis methods precludes drawing a firm conclusion about for whom and under which circumstance.

Adequate blinding of patient and practitioner and patient expectations need to be controlled for and reported in any future acupuncture trial in order for the study to be properly performed and interpreted. Although I would suggest that based on the data to date, no further acupuncture studies need be done nor are such studies ethically justified.

Also, if a patient is told that a needle is being used to cause pain instead of to relieve pain they will have a different response to the same jab. A needle perceived as beneficial activates different parts of the brain than a needle perceived as painful, but it is the same needle stuck in the same place:

Although the applied stimuli were physically identical in both groups, the verbal instructions differed: participants in the AS group were primed to consider the acupuncture as a painful stimulus, whereas the participants in the AT group were told that the acupuncture was part of therapeutic treatment. Acupuncture yielded greater brain activation in reward-related brain areas (ventral striatum) of the brain in the AT group when compared to the AS group. Brain activation in response to pain stimuli was significantly attenuated in the bilateral secondary somatosensory cortex and the right dorsolateral prefrontal cortex after prior acupuncture needle stimulation in the AT group but not in the AS group. Inserting needles into the body in the context of treatment activated reward circuitries in the brain and modulated pain responses in the pain matrix.

Except for a masochist I suppose. And people can be conditioned to have the ‘right’ response to being jabbed with a therapeutic needle. Pain relief from acupuncture is a learned response, probably not unlike ‘heat’ from hot sauce being added to food to ‘enhance’ it.

If I had no ethics I would train our phlebotomy techs to tell patients that when they were searching for a good vein from which to draw blood they were also looking for acupoints and that they were going to draw the blood using an acupuncture needle technique to decrease pain and discomfort. I bet it would work and it would make for an interesting study of placebo effects.

But it gets even weirder. All the above studies involve touching people, albeit with needles. There is a spooky literature of inducing the same effects as acupuncture but not even touching the person.

There is this curious effect called the rubber hand illusion. First you place a rubber hand in such a manner that it is positioned as if it is part of a person’s body, and hide their real hand. Then you simultaneously stroke the real and rubber hand with a brush. By doing this you trick the brain into thinking that the rubber hand is the real hand. If you touch the rubber hand with an ice cube, or even a fake ice cube, the brain will feel cold. Or hit the hand and the brain will feel pain. Weird.

If you do acupuncture on the rubber hand? Meridians and chi spontaneously form in the rubber hand and the patient will experience some of the effects of acupuncture. They will have some of the same physiologic effects of acupuncture to a real hand if sham or real acupuncture is done to the rubber hand. And acupuncture on a rubber hand will induce the same fMRI changes in the brain as real acupuncture on a real hand.

Weird yes, but it gets even weirder.

Someone (probably a former mime, doing acupuncture against the wind or some such) developed phantom acupuncture, where the therapist goes through the motions of acupuncture but does not actually touch the patient. Some people find the phantom credible, even having the Deqi sensation. The result is the same: some of the physiologic responses of real acupuncture occur with phantom acupuncture. And the physiologic response to the phantom intervention varied depending on whether the subject was convinced by the phantom acupuncture.

So real acupuncture has the same effects as sham acupuncture such as twirled toothpicks. It never matters where the needles are placed, or even if needles are used. Effects depend in large part on expectancy and beliefs that can conditioned in patients. And the effect of acupuncture can, in part, be induced in a rubber hand or even thin air.

Steve Novella refers to acupuncture as a theatrical placebo, or as one author stated,

a complex, ritualistic somatosensory intervention,

but these studies would suggest that all the effects of acupuncture are manufactured in the mind, with no cause or effect in external reality. We create our own acupuncture reality from the quantum…man…oh…hell. Chopra was right.

Just kidding. He is still full of shit.

Further reading

Acupuncture Doesn’t Work. The definitive review.


Image courtesy of the Wellcome Trust Image Library via the Wikimedia Commons.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.

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