Qing Dynasty (1662-1722) painting, traditional Chinese medical view of the human viscera from the back.  Image L0039962 from the Wellcome Trust image library, via the Wikimedia Commons.

Qing Dynasty (1662-1722) painting, traditional Chinese medical view of the human viscera from the back. Image L0039962 from the Wellcome Trust image library, via the Wikimedia Commons.

As I have noted before, more is published on acupuncture and traditional Chinese pseudo-medicine than the other SCAM. Here are some of the articles that drew my attention.

Captain Hook and acupuncture

Here is one of the more curious articles on acupuncture I have yet to find, “Psychophysical and neurophysiological responses to acupuncture stimulation to incorporated rubber hand.”

I did not know this, but you can fool a person into thinking that a rubber hand is their own.

The synchronous tactile stimulation of the real hand of an individual and rubber hand leads to the feeling that the rubber hand is incorporated with the body of that individual. This is referred to as the rubber hand illusion (RHI), and it occurs because the brain is attempting to interpret the interaction of the visual, tactile, and proprioceptive systems of the body, which in turn, leads to a re-calibration of the touch and the felt position of the hand. The multimodal visuotactile stimulation inherent in the RHI induces the brain to temporarily incorporate external objects into its body image. In addition, when the experimenter threatens the rubber hand with a needle during this illusion, it generally elicits an enhanced sympathetic response and a measurable cortical anxiety response, which indicates that the bodily ownership of the rubber hand causes changes in the interoceptive system of the brain.

Cool. Check out this video to see how it is done. So what happens when you do acupuncture on a rubber hand that the brain thinks is its own?

The findings of the present study clearly demonstrate that acupuncture stimulation to a rubber hand resulted in the experience of the DeQi sensation when the rubber hand was fully incorporated into the body.

As judged by fMRI findings (always taken with a grain of salt substitute) and patient reports. DeQi is what dey feel when de needle is twirled in de skin.

So acupuncture of a rubber hand causes the same response as acupuncture in a real hand. What does that say about acupuncture? That meridians and qi are spontaneously generated in the rubber hand? Or that the response to acupuncture is all psychological with no effect on an underlying physiology, real or imagined?

And now that there are socks with built in acupuncture I wonder if the socks would have the same effect on an artificial leg.

Acupuncture: Beer goggles or over-priced wine?

Painting with a broad brush, I would say that acupuncture doesn’t work. By ‘work’ I would say that it causes no change in the underlying physiology or anatomy of the person receiving the acupuncture.

‘Works’ is different from having an effect, even a beneficial effect. Positive interactions between a patient and a health care provider, even when offering a pseudo-medicine, will make some patients feel better about their disease. I compare these pseudo-medicines, like acupuncture, to beer goggles. They change perception but not reality.

While changing the perception of disease for the better is of benefit, it is just not ethical to base treatment on a lie.

What happens with a process like acupuncture to alter patient perceptions? It doesn’t matter where the needles are placed or even if needles are used; twirled tooth picks are just as effective as acupuncture needles. What matters most for efficacy is if the patient thinks they are getting acupuncture and if they believe acupuncture is effective. Then acupuncture will have an effect. That’s it. So what is going on?

Another hint on the mechanism of acupuncture is in “When pain is not only pain: Inserting needles into the body evokes distinct reward-related brain responses in the context of a treatment.”

In this study 24 people received three identical stimuli: tactile, acupuncture, and pain stimuli. There were two groups to receive the three stimuli, an acupuncture treatment (AT) group and an acupuncture stimulation (AS) group. What differed is what they were told before the stimuli

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.

They had an fMRI (who doesn’t) and a questionnaire about their subjective experience.

Behavioral results generally revealed no differences between the AT and AS groups. The questionnaire results confirmed that there were no significant differences in expectancies, fear, or anticipation and subjective pain ratings related to needles being inserted into the body between patients in the AT and AS groups.

They found no analgesic effect in the acupuncture group. But there was a difference in the fMRI (for what that is worth):

We found that reward-related regions (specifically, the ventral striatum) of the brain were activated by acupuncture stimulation and that in response to painful simulation, activity in pain-processing regions(the SII and DLPFC) was decreased only when participants were told that acupuncture needles were a therapeutic tool.

And

As greater activation of the ventral striatum is generally correlated with more expectations of pleasure and rewards, our results could be interpreted to suggest that acupuncture stimulation was associated with the expectation of a reward – possibly an analgesic effect – for patients experiencing acupuncture in the context of a treatment (AT group).

So depending on the context, people process the same stimulus differently. A needle for therapeutic acupuncture is different than the exact same needle used for stimulation.

Maybe. It is a small study and fMRI’s have issues as we know from dead salmon. But taken in the context of the literature pointing to the predominantly-positive subjective effects of pseudo-medicines it is curious finding. Maybe not beer goggles; probably more like making wine taste better by giving it a higher price.

Acupuncture works. If you believe it will.

I like antibiotics. They kill of the bacteria infecting my patients. It doesn’t matter what the patient thinks about the effectiveness of the antibiotics. They just work. Having a practice based almost entirely in acute care medicine, most of the interventions have effect (or not) independent of patient belief concerning the interventions.

Not so with acupunctures. As I have said many times, acupuncture doesn’t work i.e. alter any underlying physiologic process. But that doesn’t mean that the innumerable forms of acupuncture don’t have an effect. They do.

I have mentioned in other entries the importance of expectation in acupunctures effect. Believing does make it so is an example. The more patients thought acupunctures would have an effect, the greater the response. If the patients were unenthusiastic about acupunctures efficacy, nothing happened.

There is a paper in the Clinical Journal of Pain, “Psychological Covariates of Longitudinal Changes in Back-related Disability in Patients Undergoing Acupuncture“, that carries on that theme.

They note:

Indeed, acupuncture can be conceptualized as a complex intervention in which changes in patients’ health are produced not only by needling but also by more psychosocial factors such as empathic therapeutic relationships and holistic consultations in which discussions of lifestyle and self-care can trigger changes in how patients think and feel about their symptoms and their ability to manage them.

But they also ask what are the psycho-social factors that lead to success or failure of acupuncture for low back pain?

They had 485 patients from 83 acupuncturists before starting acupuncture for back pain who took several questionnaires over the 6 months of their acupuncture.

Interstingly, among other findings,

People who started out with very low expectations of acupuncture – who thought it probably would not help them – were more likely to report less benefit as treatment went on.

As is often the case with the response to pseudo-medicines, rather than concluding that since the effects of acupuncture are an elaborate ritual with no intrinsic value beyond placebo, and perhaps it should be abandoned as useless at best and unethical at worst, they suggest teaching acupuncturists to be better at their elaborate ritual. You know, be a better liar and manipulator:

Dr Bishop added that to improve the effectiveness of treatment, acupuncturists should consider helping patients to think more positively about their back pain as part of their consultations…his understanding could lead in the future to better targeting of acupuncture and related therapies in order to maximise patient benefit.

Why not keep the power of positive thinking but attach it to reality-based interventions instead of selling patients the TCM equivalent of supplements?

But researchers in pseudo-medicines are never looking to apply negative results to patient care.

Massive head scourge and acupuncture

I am old school. A germ theory kind of guy. Mumps, as an example, is due to the mumps virus, a Paramyxovirus that likes to infect the parotid glands and occasionally other organs. There is no treatment but tincture of time.

There are other, more curious, supposed etiologies for mumps:

Mumps is caused by invasion of the body by exopathogenic wind-heat toxin from the mouth and nose. This pathogen mixing with phlegm turns into fire to obstruct the Shaoyang and Yangming Channels, leading to lump due to accumulation of heat in the parotid region. Therefore, the principle of treatment should be to eliminate stagnated heat from the Shaoyang and Yangming Channels.

And how would one eliminate stagnated heat from the Shaoyang and Yangming Channels? According to Dr. Long Wenjun, needles in the ear points of Antitragic Apex and Pancreas-Gallbladder are the first choice in treatment.

Although Song treated 1,000 cases with a single needle at the Pingjian point (MA-T2). As with all self-limited diseases, the effect is satisfactory. And don’t forget:

The needle should be sterilized carefully to prevent infection.

If the Pingjian point is the same as either the Antitragic Apex or Pancreas-Gallbladder, I can’t say for sure. The interwebs are not clear.

Both are incorrect, as the Fire-needle with sulfur is obviously better, although I can’t discover exactly what it is. It does sound better. Fire-needle. With sulfur. Kids will love that.

That is what I could find on Pubmed concerning mumps and acupuncture. Others on the web suggest different places on the skin to needle and perhaps a different etiology. I do like the terms ‘massive head scourge’ and ‘frog scourge’ for mumps and that website offers yet another acupuncture intervention point.

Give the known viral pathophysiology of mumps, there is zero reason to suspect that the fanciful and inconsistent interventions mentioned above would have any effect on the mumps. It doesn’t stop the Cochrane reviews from looking for something to meta-analyze. Like the prior review from 2012, they:

aimed to determine the effectiveness and safety of using acupuncture to treat mumps in children.

But:

identified no trials for inclusion in this updated review.

Oddly, the background does not mention that mumps is a virus but rather:

…caused by ‘wind warmth evil’ (epidemic heat) and ‘pyretic toxicity’ accumulated in the Shaoyang and Yangming meridians, thus the flow of Qi, sputum and ‘heat evil’ stagnate in and around the ears and the cheeks. Acupuncture can help expel ‘wind warmth evil’, clear pathogenic heat, remove toxic substances, act as an anti-inflammatory, alleviate pain and re-establish the normal flow of Qi, thus restoring internal balance.

That is a reasonable background? Makes their motto (“Trusted evidence. Informed decisions. Better health.”) suspect. Then they suggested that:

More high-quality research is needed.

More suggests there has been some quality research. There hasn’t. And is any research needed? I think not. I would hope that IRB’s would recognize useless pseudo-medicine when they see it and protect children from needless needles. Yeah. Right. Like that will happen.

Otzi the Iceman and Acupuncture, redux.

I try to be circumspect. I really do. Respectful of the person, if not the idea. Hate the sin, not the sinner. But some things are Just. So. Stupid.

Last year the stupidest comment by a reputable source I found was in the Cochrane review of vitamin C for the cold:

it may be worthwhile for common cold patients to test on an individual basis whether therapeutic vitamin C is beneficial for them.

Seriously. As I said at the time:

The uselessness of personal experience in determining efficacy of medical interventions is why we do clinical trials. For crying out loud, I though it the raison d’être of the whole Cochrane Collaborative: relying on evidence instead of anecdotes. Wrong.

Here it is, less than two months into the new year and I doubt you will find a more stupid interpretation of information for the rest of 2015 than “New tattoos found on Otzi the Iceman support prehistoric acupuncture theory.”

Ötzi, the 5,300-year-old corpse found in the Italian Alps, has 61 tattoos in 19 groups across his body. More were recently found using special photographic techniques:

Lars Krutak, an anthropologist who has published a book about the medicinal applications of tattoos, has said they may be on or near other acupuncture points.

Commenting on the findings, Krutak said: “I was intrigued by the possibility that the new set of tattoos were located on or near classical acupuncture points or meridians. If they were, perhaps these could be traced to Otzi’s known pathological conditions, such as gallbladder stones, whipworms in his colon and atherosclerosis.”

He consulted Gillian Powers, an acupuncturist, who said the location of the new tattoos corresponds with treatments associated with whipworms and gallstones.

I wonder if archeologists are ingesting some of the hallucinogenic indigenous plants to come up with ideas like that.

It seems that every time someone comes across a tattoo on a mummy, goodness gracious, it is near an acupuncture point. Find tats on the neck of a Peruvian mummy?

A possible therapeutic origin may lie in the fact that the circles on the neck lie close to acupuncture points, having a relaxing and pain-relieving effect in the neck and head region.

There are perhaps 350 common acupoints, with some estimates putting the number at over 2,000. The average male is about 2900 square inches, so there is an acupuncture point every .68 square inches. Except, curiously, and understandably, the eyes, under the nails, and the genitals.

With that many points, it is not hard to find associations because every point on the skin is on or near an acupuncture point. He doesn’t seem to consider the notion that acupoints and meridians are nonsense that have no therapeutic effect on any process. One gets the feeling this is the worst example (or best example?) of confirmation bias ever.

It cannot be ruled out that the Iceman’s tattoos were indeed applied as a therapeutic treatment. In future studies, the location of the new tattoos and its relation to acupuncture points and/or meridians should be further explored and discussed.

I think the tats were put there to ward off Big Foot and Nessie. Cannot rule that out either and it should be further explored and discussed.

Body art is currently popular. 5,000 years from now they will pull the body of an Oregonian out of an ice crevice on Mt. Hood or from a bog along the coast. Looking at the barbed wire on the arm, the Chinese character on the calf or the abstract tramp stamp in the small of the back, they will find the tats near acupoints and conclude they were medical tats.

So stupid. But the year is young. I still am betting the Cochrane Collaboration will surpass this bit of idiocy. They have yet to fail me.

It’s a bad flu season. Use acupuncture!?!

It was a bad flu season. We have had one death in my hospital system from influenza this year. So what is to be done for the prevention and treatment of influenza? University Hospitals in Cleveland suggests a worthless pseudo-medicine: “Acupuncture for Cold and Flu Season.”

As an infectious disease doctor when I think of treating or preventing a potentially fatal illnesses, somehow magic doesn’t jump to the top of the list.

They suggest that acupuncture:

could also help you avoid colds and flu this winter – or at least send them packing sooner.

Weasel word, “could”. A search of PubMed for ‘influenza’ and ‘acupuncture’ yields nothing of note; even less after searching for ‘cold’ and ‘acupuncture.’ As far as the Pubmeds goes, there are no clinical trials to suggest that acupuncture helps influenza or cold prevention or treatment.

Well not clinical trials but philosophy is the basis of treatment. Yes. Philosophy.

Eastern medical philosophy, acupuncture works by balancing and harmonizing qi (pronounced “chee”), or vital, life-force energy.

At one time Western philosophy thought illness was due to an imbalance of humors. That was superseded by treating illness not based on philosophy but rather on the reality of the sciences. Eastern medical philosophy evidently prefers the philosophical fantasy of unblocking and revitalizing a mythical qi. Why a University is treating diseases based on philosophy instead of reality eludes me. I mean, besides the whole “getting money for nothing” thing.

Western medicine views acupuncture as a form of therapy that releases hormones into the bloodstream, sending signals to the nervous system.

No. Western medicine (and I hate the terms Western and Eastern, that seem slightly racist and suggests there are two versions of reality when there is one) sees acupuncture as an elaborate placebo that has never been shown to have efficacy in well-controlled clinical trials for any objective endpoint. They continue:

Q: How can acupuncture help during the cold and flu system?

A: Studies have shown that patients receiving acupuncture have elevated immune-enhancing hormones and blood counts for up to three days after treatment. If you begin to feel the symptoms of the cold or flu coming on, it is important to visit your acupuncturist right away to get the most benefit from your treatment. Acupuncture can:

  • Prevent colds and flu by boosting the immune system
  • Help you get over the cold or flu faster if you already have it
  • Reduce chills, fever and body aches
  • Relieve sore throat and congestion

Absolute nonsense unsupported by known biology or clinical trials. As I have said before, you cannot boost the immune system, much less with fantastical acupuncture, against influenza. Having your immune system boosted may be part of the reason for worse outcomes in the obese and pregnant.

Still, this advice is offered by a University Integrative Medicine program that offers multiple therapies divorced from known reality: Acupuncture, Ayurveda, reflexology and reiki. It would probably be unreasonable to expect them to offer actual useful therapies.

That a university hospital’s website suggests nonsense for a serious illness confirms the choice of Sisyphus for the logo of the Society for Science-Based Medicine.

Seriously. It’s a bruise.

Sometimes I see an article and I have to double check that it is not from The Onion. The Falun Gong-sponsored Epoch Times is not a satire publication (although their ad for seeing how acidic your body is gives me pause) but they did publish “Ancient Technique Scrapes Away Pain.”

The article concerns Gua sha, yet another ancient Chinese healing pseudo-medicine where the skin is scrapped with a tool such as:

something with a rounded edge that can be comfortably stroked across the body. Tools range from stones and bones shaped specifically for the job to large coins.

Gua sha is used to release congestion and stagnation of some sort or other to help the body heal itself from the usual hodgepodge of illnesses. There are few studies on the Pubmed on the technique and none of any quality.

Look at the pictures with article, or look at the picture of this fellow’s back after Gua sha:

Apparently his Chi wasn't up to par.  From Bradwesley69 on the Wikimedia Commons.

Apparently his Chi wasn’t up to par. From Bradwesley69 on the Wikimedia Commons.

It is a bruise from trauma.

Read the caption:

Gua sha raises dark marks that can be mistaken for tissue damage.

What? Are you nuts? It’s a BRUISE. It IS tissue damage. Are you blind?

The Gua sha instructor says

It looks like we are creating a bruise, or like we are breaking capillaries and causing some damage. What we’re actually doing is extravasating blood from the capillary bed,

“extravasating blood from the capillary bed?!?!” That’s what a BRUISE is.

Look at the results of an internet search for Gua sha. It’s bruising from trauma.

At least the medical literature recognizes a “contusion injury to underlying soft tissue” and an “intentionally create(d) therapeutic petechiae and ecchymosis representing extravasation of blood in the subcutis.”

Or:

Gua Sha is a traditional Chinese folk therapy that employs skin scraping to cause subcutaneous microvascular blood extravasation and bruises

It’s a bruise.

The most impressive denial of reality I have ever seen in years.

And finally

I received a tweet that said if acupuncture needs belief to work, why does it work on animals? Well, it doesn’t. The SkepVet is a nice source for more erudite discussions of the topic. With veterinary pseudo-medicine you are relying on the reports of the owner, or perhaps the zookeeper.

Acupuncture provides relief for Palm Beach Zoo Komodo dragon’s pain” is a perfect example of reporting bias and silly reporting. Bob and Ray would be proud.

Hannah, a Komodo dragon, has neck pain. So they corner the poor beast, hold her against her will and stick the poor animal with needles using horrible infection control technique. I see septicemia in her future. When she finally escapes, jacked up on fear and adrenaline, she goes to a place of prior safety and comfort to escape what to her must be a close call with death. However, the zoo says:

After receiving the acupuncture treatment, Hannah seemed to experience almost immediate relief, zoo officials said.

She seemed to get very active and very interested in heading back to her sunny spot after the acupuncture

Of course she did. Stress and fear can make even severe injuries temporarily seem insignificant as many a war story will confirm, a serious wound ignored until the firefight is over. An injured animal will get more animated when stressed to avoid being, I don’t know, killed and eaten? Lizards try and get warm when stressed by infection. It is part of their survival technique since they cannot mount a fever on their own.

That is animal acupuncture: a terrified animal trying to escape its tormenters, transiently appearing better after an intervention stops.

Sad.

 

 

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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