Having begun the online portion of my acupuncture course, I am beginning to get into the work of identifying, remembering, and locating the main acupuncture channels and points that are used for clinical treatment in several varieties of acupuncture. This section of the course touches on a key point I have discussed previously about acupuncture, namely do the points and channels acupuncturists use for needling exist in any verifiable sense?
Do Acupuncture Cannels and Points Exist?
TCM and other folkloric acupuncture styles utilize particular locations for needling based on maps or descriptions from historical sources, sometimes ancient but often more recent that you might think. Veterinary acupuncturists, in particular, utilize systems that are quite modern inventions since traditionally Chinese medicine did not involve fine needling as a therapy for animals. The rationales given for the locations of these points and channels are unscientific and unverifiable talk of energy forces, and historical research suggests they were dictated as much by astrological, philosophical, and religious principles as any observation of clinical effects in patients. As I have already pointed out, I don’t see any value in taking such unscientific approaches seriously.
Medical acupuncturists in more conventional, science-based practice, however, tend to try to rationalize the use of acupuncture maps adapted from traditional or folkloric sources by identifying measurable anatomic or functional features to the points chosen. They frequently claim that such points and channels can be consistently associated with nerves, locations where nerves divide or emerge from channels in bones (foramina), blood vessels and their associated innervation, tendons and ligaments, and the connective tissue planes that separate muscles and other structures (fascia). They may also claim that there are special features of the tissue in the region of acupuncture points identifiable with biopsy, with equipment testing electrical conductivity, or by other means. Some also claim that acupuncture points often correspond to “trigger points,” areas of pain or sensitivity which are themselves somewhat uncertain in definition. Stimulation of these sorts of structures could plausibly have physiological and even clinically beneficial effects since there are functionally important means of communication between different parts of the nervous system, and between nerves and other anatomic structures and organs.
The question then becomes what is the evidence for such claims? Are acupuncture channels and points just metaphoric ways of describing nerves and other anatomic structures that we understand in ways folk acupuncturists in history could not have? This is not an easy question to answer. A nice review of this subject by Dr. David Ramey points out that:
Research on the nature of acupuncture points and meridians is often difficult to evaluate because of the diverse nature of the claims made, incomplete data provided in published studies and the variety of parameters involved in the assessment of these claims. Many of the studies purporting to have identified acupuncture points or meridians come from China; the role of publication bias in Chinese literature needs to be considered in light of the fact that no trial published in China from 1966 through 1995 found a test treatment to be ineffective.
There is no question that if you take a particular channel or set of points from any acupuncture map and look at the anatomy underlying it, you can find all sorts of structures that could possibly respond to needling in potentially beneficial ways. But there are a number of problems with this strategy.
Acupuncture channels and points are quite vague and inconsistent between schools of acupuncture and individual acupuncturists. Some even in the acupuncture community have denied that the location of needling matters at all. And even among well-trained and experienced traditional acupuncturists, the identification of particular points can vary considerably. One study found the following:
This study took the approach of testing whether properly trained and experienced acupuncturists could consistently identify commonly used acupuncture points on a single patient. Twenty-three common points were selected and identified by the 71 test subjects. The area within which specific points were identified by 95% of the acupuncturists ranged from 2.7cm in diameter to 41.4cm in diameter. Because of the variability with which experienced acupuncturists identified common acupuncture points, the authors concluded that to stimulate fake points as a placebo control for a clinical trial, it would be best to stimulate the skin at least 6cm away from the spot identified as the real point on the face or hands and at least 12cm away from a proposed real spot anywhere else on the body.
Given the vague nature of points and channels, and the fact that structures which might respond to needling are densely packed in nearly every part of the body, it is inevitable that any map at all is likely to overlie some structure that could be claimed to be the intended target of stimulation. It would be like dropping a large net on a sidewalk in Manhattan and then claiming that the location chosen was exactly the right one because some people were caught in the net. The same outcome would have happened wherever you dropped the net. Similarly, much clinical research shows that the apparent effects of acupuncture seem to be the same regardless of the location chosen for needling. Indeed, even some prominent acupuncturists have claimed that the location for needling is irrelevant.
The question of how folkloric practitioners could have come up with maps of anatomic structures that had not yet been discovered is also a bit problematic. Since it is clear that traditional systems for locating acupuncture points relied heavily of spiritual beliefs, astrology, and the like, it seems unlikely that they would be in any sense anatomically accurate. Some argue that by trial and error, acupuncturists might have found effective needling locations and then rationalized these with pre-scientific theories. This too seems unlikely, however, given how ineffective trial and error is in finding effective medical treatments, and also given the fact that early acupuncture was often a system for bloodletting, and the anatomic structures of interest would most likely have been blood vessels.
Nomenclature
The section of the course I am currently working on requires learning the names and locations of acupuncture channels and points. While the rationale given for the use of these points is based on the physiologic and anatomic arguments I have outlined, the nomenclature used is still that of traditional folkloric acupuncture. The WHO accepts an alphanumeric nomenclature and Chinese names for acupuncture points based on the traditional system, and these are used in this course. This system requires classification of channels as Yin or Yang based on designation of associated organs in order to help keep track of the point numbering system, even though the concepts of Yin and Yang are specifically rejected in the curriculum.
The reasoning here is that the use of this nomenclature is widespread and entrenched and facilitates communication between practitioners of different schools, so it must be tolerated. However, the use of these terms does not imply that the underlying metaphysics has anything to do with the function of the channels and points, which are intended to be defined and understood in terms of anatomic structures and physiological functions.
This may be innocuous, like referring to sunrise and sunset even though we now know that is an erroneous characterization of celestial mechanics, or referring to the days of the week and months of the year by the names of gods. Still, it seems unfortunate since it lends some sense of legitimacy to those who still actively use the system as if the metaphors were actual descriptions of reality. I would think that a serious commitment to a scientific approach to acupuncture might ultimately require renaming any maps of locations for needling used in terms of the actual anatomic structures or physiological functions they are supposedly associated with.
Bottom Line
While it makes sense that needles nerves, tendons, and other such structures could have beneficial effects, the evidence that traditional acupuncture maps have a meaningful or predictable relationship to these structures is weak. The associations claimed between acupuncture channels and points and identifiable anatomic structures seem more likely to be rationalizations after the fact for locations originally chosen without any actual understanding of or relationship to functional anatomy and retained as historical holdovers.
If the proposed effects of acupuncture really do relate to stimulation of nerves, myofascial planes, etc., it would make more sense to argue that the locations chosen for needling should be selected on the basis of the location of such structures and research showing functional responses to needle stimulation of them. There would then be no need for terms like Bladder 2 and Governor Vessel 12. We could simply say we are needling the radial nerve or the trigeminal nerve, and we would be more accurate and less associated with folkloric acupuncture practices.
This system requires classification of channels as Yin or Yang based on designation of associated organs >>>>>
Sunrise and sunset wording is used when not scientifically correct. What does the “evidence based” veterinarian acupuncturist do with the gallbladder channel in an animal like a horse that’s missing a gallbladder? Let me guess. Study’s have shown that the spot on a horse where the gallbladder would be is effective but some veterinary acupuncturist dispute this.
I’m a regular reader of your blog, a sincere believer in the EBVM cause, and I’m a bit dismayed at this undertaking. “Hypocritical?” Not necessarily, but at least inconsistent with what I perceived as a clear stance that the burden of proof is on the one making a claim. I don’t think you (or I) have any obligation to understand or accommodate acupuncture therapy unless / until there is a great deal more compelling evidence of its efficacy, if not its specific mode of action. Researching the field, even taking the course to “know the enemy” or satisfy yourself that there’s not something of substance you may have overlooked would be one thing (or two things, I suppose). But offering the service in your office, even with disclosures, crosses a line I wouldn’t have predicted. Just my $.02.
Having said that, I’m a big fan of your work. Keep fighting the good fight.
I certainly agree that the burden of proof is on the one making a claim. In the case of acupuncture, there is abundant “proof” in the form of literally thousands of research studies. The trick is figuring out whether or not it amounts to anything. I have read probably a few dozen of these over the years, and generally I conclude that the controls for placebo effects, bias, and other sources of error are not usually strong enough to support a predictable and clinically meaningful effect. However, there are a lot of trials suggesting physiologic effects which might be useful, even though the location of needling doesn’t seem to matter. And there are even a couple of trials with decent methodology that suggest sufficient effects for pain and nausea in humans to be worthwhile, though again I think it highly likely these are due to a combination of expectancy, counter-irritation, and other non-specific effects.
The bottom line is that while it is up to the claimants to produce the evidence, it is up to me to evaluate for myself before setting the confidence limits around my judgment, and engaging directly with a proponent who is at least ostensibly committed to a science-based approach gives me the opportunity to do this. As you can see from this post, the results may well turn out to confirm my initial impressions that the therapy is purely placebo, but at least at that point I will have done the due diligence of evaluating the evidence thoroughly and critically.
As for offering the practice myself, I agree it’s a grey area. I am really frustrated by the harm done to my patients when well-meaning owners take them to a TCVM practitioner for acupuncture and get a load of untested herbs and heavy pressure to abandon science-based therapies altogether. I feel like my efforts to educate clients in order to discourage this aren’t working very well, and it’s time to try something else. As I’ve said before, we’ll just have to see if this turns out to better encourage science-based care or not.
Anyway, I do appreciate your thoughts and support!
I saw an acupuncturist years ago for headaches (when insurance covered it), it was time consuming. I think it helped a little bit and I especially enjoyed the interaction with the acupuncturist. I found it very therapeutic going over diet choices and such.
However, I eventually saw a neurologist and got better results.
Anything serious for my pets or myself I prefer to seek out the services of a specialist (traditional, not homeopathic).
Jeff, I think most of us are initially “shocked” by skeptvet’s decision to pursue this adventure – none of us want our EBM vets to lend credibility to pseudoscience – but I think we should applaud skeptvet’s willing attempts to evaluate from a skeptical and critical point of view (I can imagine the difficulty in keeping bias and doubt in check). Not only will he will gain “inside knowledge”, he will also be able to present factual information to clients such that has probably never been truthfully given them before. Ultimately, they would have true disclosure to make informed decisions (rather than the silly testimonials by alt practitioners and the ultimate fleecing scams).
I also see this as a method to “reclaim” EBVM in practice. We’ve been moaning and complaining for too long that something needs to be done in the trial and research areas to validate or invalidate the bogus claims – I see this as skeptvet’s doing something about it.
I can also wholeheartedly agree with his frustration when clients are willing to pursue TCM because conventional medicine “failed” them somehow. It’s hard to change the mindset of clients who are desperate and misinformed – I think there are few vets willing to spend time and energy in client education where pseudoscience is concerned. Practicing do-no-harm with full disclosure is better than potential harm and false hope.
I’m confident skeptvet isn’t going over to the dark side of woo. We should be so grateful he did not choose the “Fun With Homeopathy” course, then we would have good cause to tar and feather him!
Thanks for the vote of confidence, v.t.! I hope you won’t change your mind about the tarring and feathering when you read this: 🙂
A Visit to Hogwarts
Oh sheesh, how could I forget that!
Since that intro course was free, you’re forgiven. 🙂
v.t., I’m on board with the entire “adventure,” except for offering the service itself. I don’t get it. But to be clear, the SkeptVet and his site are a huge asset to me in my daily practice of veterinary medicine, and I’m still a huge fan.
I don’t get it>>>
Anyone old enough to remember when Carl Osborne started putting religious stuff in his columns? A client brought me some holy water in a mason jar and got me to promise I would sprinkle it over their hospitalized dog. There I was all alone at 3am in the morning putting holy water on the dog wondering how I could have gotten out of this treatment. The dog, I thought was going to die, of course lived and 5 years. later when it was hospitalized again the owner did not even need to ask. Only this time the holy water was in a plastic statue of Mary. I told the owner that holy water was just tap water with the hell burnt out of it but the owner still thinks it saved the dogs life. I don’t get it either. At least the priest and I did not charge for the holy water or its administration. Maybe if the acupuncture is free as part of a good study I would be a supporter.
Dr. Perret, I think only skeptvet can answer that for us. I believe once he has completed his studies, and if he chooses to apply acupuncture in his practice, I assume he might provide us a bit more insight at that point in time. That said, I do hope that he does not practice acupuncture solely as a method of generating revenue for the clinic. (although he may be powerless to argue against the clinic admin/owner?)