Skeptvet’s Acupuncture Adventure- Part 7: Emerging Themes

I haven’t updated my acupuncture adventure in a while, largely because I’m past the part of the course making general claims and justifications of acupuncture and into the portion that consists mostly of memorizing individual points and associated anatomical and functional elements. The details don’t matter a great deal if the general principles and the evidence related to them don’t hold up, and I remain unconvinced on that count. I appreciate the absence of mystical explanations concerning energy fields and extensive empty metaphors about Heat, Wind, Yin/Yang, and so on. However, the themes that are emerging in place of these concepts still seem quite problematic. I thought I would summarize some of the major principles being expounded in this course, and my concerns about them.

  1. Evidence of anatomical connection is taken as evidence of functional connection.

The instructors seem to feel that if any sort of physical connection can be traced between an acupuncture point and some other part of the body, it is fair to assume that stimulation at that point should influence that part. For example, if a point on a limb has sympathetic innervation that can be traced back to sympathetic nervous system (SNS) centers in the brain, it is assumed stimulation of that point can influence SNS.

There are several problems with this assumption. To begin with, as I discussed earlier, one can stick a needle almost anywhere on the body and find a nerve, muscle, blood vessel, or some other organ that it is claimed responds to needle stimulation. There is little evidence to suggest the particular points identified in traditional acupuncture, and still used in supposedly scientific acupuncture, are anatomically or functionally special. The assumption that they are underlies all the use of these, but the case for that assumption is weak and contradicted by abundant research showing that needling location makes little if any difference in the response to needling.

The other problem with the idea that because one can trace a nerve or blood vessel at one location back to other parts of the nervous or circulatory system one can manipulate the distant structures by needling this point is similar. In the body, everything is connected to everything else. There is almost no part of the body that can’t be connected in some way to any other part. Without showing that particular points used to cause specific effects, such as modulation of the SNS, have unique or specific connections that should cause those effects which other points don’t have, you are just arbitrarily identifying some locations as more special or connected than others in a way that isn’t evidence-based.

2. Any stimulus provided is assumed to result in the desired effect.

There seems to be another unproven assumption that when one stimulates a point believed to have special influence over some body organ or system that the stimulation will result only in the desired effect. Again as an example, if you needle a point that influences the SNS, it is assumed the influence will be what you want for the patient, increasing or decreasing SNS activity as desired. The main evidence for this seems to be the historical use of particular points for particular purposes. But if you can stimulate the SNS by needling a given muscle point, why isn’t it just as likely to cause undesired change? If point X downregulates SNS and point Y upregulates the parasympathetic nervous system (PNS), why couldn’t it be the other way around?

While the instructors acknowledge that acupuncture can have negative effects, these are mostly described as errors in needling, such as puncturing blood vessels, internal organs, or other structures one does not intend to puncture. It is also acknowledged that the needling itself can be painful. But the idea that correctly stimulating a particular point could have effects other than those desired has not, so far, been mentioned. This implies only beneficial effects with no side effects, which violates McKenzie’s Law.

3. Myofascial trigger point theory.

Dr. Robinson is an osteopath as well as a veterinarian, and a common element of osteopathic training is myofascial trigger point theory. This is the theory that pain and dysfunction, both locally and at distant parts of the body, can be caused by “knots” or “taut bands” of tension in muscles, which one can relieve by manipulation of these trigger points with massage, laser therapy, and needling. Dr. Robinson seems to suggest in her course that perhaps the most important way to identify which acupuncture points to treat in a given patient is to look for these trigger points and focus on relieving them locally, as well as treating the patient’s problem through other effects of acupuncture at points elsewhere on the body.

The problem is that trigger point theory is itself not much better supported by scientific evidence than acupuncture. It is widely believed and utilized among osteopaths, massage therapists, chiropractors, physical therapists, and others in both conventional and alternative medicine who treat musculoskeletal problems, but there is plenty of controversy and not a robust body of evidence to show the theory is correct or the effects of manipulative treatments occur through trigger point release. So it isn’t helpful to explain the unproven benefits of acupuncture using a similarly unproven, though somewhat more widely accepted, theory.

4. Vague terms with little specific evidence for their meaning

There is a lot of use of scientific and general terminology in ways that are not always defined very specifically and which seems to cover up the lack of evidence for implied clinical effects. For example, many purported effects of acupuncture are explained in terms of “neuromodulation.” I discussed this briefly earlier in the course, and the explanation or evidence presented for this concept hasn’t gotten a lot more detailed. Again, the assumption seems to be that if a point is connected to part of the nervous system then stimulation of that point will have desirable effects on that part of the nervous system. Calling this “neuromodulation” doesn’t explain or prove it to be true.

Similar problems pertain to other terms like “stimulating,” “releasing,” and so on. These may be descriptions of real actions and effects, but often they seem not to have very specific meaning or much evidence behind them.

Ultimately, I think Dr. Robinson and the other instructors are sincere in their belief that acupuncture can and should be scientific in its principles and validation. However, I also think they tend, as we all do, to interpret the limited and ambiguous evidence in ways that support beliefs they hold primarily based on clinical experience and habit. The tendency to gloss over evidence that contradicts our experiences and beliefs and to put the best possible face on evidence that supports them, even when it is weak, is universal. Unfortunately, even with the best intentions, that phenomenon can leave us with a firm commitment to our beliefs without a sound, scientific basis for them.

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17 Responses to Skeptvet’s Acupuncture Adventure- Part 7: Emerging Themes

  1. v.t. says:

    I’m sure Robinson, other teachers, and the vets who practice acupuncture are sincere in their beliefs…..including no qualms taking your hard earned money and that of their clients – which is essentially, practicing health care fraud.

    Do ANY of these courses include an ethics category?

  2. skeptvet says:

    Always amazing to see how easily conventional specialists accept stuff like this with a near complete absence of evidence they would never tolerate for a conventional therapy.

  3. v.t. says:

    Oh my god, hemorrhaging patients, congestive heart failure, the worst of the worst in critical situations, let’s use acupuncture! (and be sure to state it’s terrific as an “adjunct” to real emergency medical treatment). Where has all common sense gone (not to mention ethics)?!

  4. Ed says:

    The question still remains, as you work through the online modules and then experience the practical training, will you actually “try it and see for yourself”? Will you treat patients with acupuncture? Then, if some patients clearly improve, will you become a convert to this therapy? Fascinating!

  5. skeptvet says:

    Yes, that is a worry/hope for some readers, depending on their perspective. 🙂 No decision yet.

  6. Cloudskimmer says:

    I can’t see how it can be a question at this point. You’ve thoroughly shown that there is no medical basis for doing acupuncture. While perceptions vary, most animals will experience pain when you stick them with needles. If there is no reason to think acupuncture will be beneficial, even a small chance of doing harm is violating your professional ethics. My cat — now dead — sometimes developed large, open wounds when bites became infected; one on his neck remained open for weeks. It’s one reason why I now think cats should be kept indoors. In this discussion, sticking needles into a cat could introduce infections that could have long-lasting effects. No benefit, rare harms; is that a good reason for causing an animal pain because the owner wants acupuncture?

    I have a lot of respect for you and enjoy your blog. I hope you won’t join the dark side.

  7. skeptvet says:

    Well, I think it’s a bit less simple than that. I agree that in principle we shouldn’t take any risk of harm unless there is a clear benefit that justifies doing so. However, we give subcutaneous fluids, injections of many different kinds of pharmaceuticals, and do other things that are much riskier than acupuncture all the time in veterinary medicine without clear evidence that they benefit the patient. We often extrapolate from whatever evidence we have, including human studies and lab animal or in vitro studies or even basic pathophysiology, when we lack the specific evidence we would like to have. So that alone doesn’t make acupuncture unusual.

    The key is balancing the uncertainty about outcome against the urgency of action. If we don’t have high-level evidence but the patient has an urgent need and there is nothing proven to help, we can ethically reach for therapies with only low-level evidence as long as the client clearly understands the uncertainty involved.

    In the case of acupuncture, I think the evidence is generally poor, but I wouldn’t agree there is “no medical basis for doing acupuncture.” The evidence is not very convincing, but if you ignore all the “Qi” and Chinese Medicine nonsense, the evidence is not any worse for some kinds of acupuncture than for a lot of other things we do. If there is an urgent need and nothing available with better evidence to support it, I don’t think it is entirely unreasonable to consider some kinds of needling.

    I almost wonder if the problem isn’t partly the word “acupuncture.” As David Gorski at Science-based Medicine often points out, “acupuncture” is a bit of a bait-and-switch. As an example, there is reasonable evidence for some kinds of conventional electrical nerve stimulation, often called Transcutaneous Electrical Nerve Stimulation (TENS) or Percutaneous Electrical Nerve Stimulation (PENS). These are accepted conventional therapies for some problems. So sometimes acupuncturists will insert needles at places near nerves that happen to be traditional acupuncture points (because there is hardly any place you can insert a needle that isn’t next to something, as I’ve pointed out before), apply electrical stimulation and call this “electroacupuncture.” Even if it works, it clearly doesn’t validate the entire system of acupuncture, much less all the Chinese Medicine nonsense. But by the same logic, we can’t deny that it works just because someone calls it acupuncture instead of PENS. The key is to follow the evidence, rather than blindly adhere to ideology.

    In any case, while I appreciate your support, I think “join the dark side” is a bit excessive. Just as I am not the closed-minded, pharma shill monster CAM vets sometimes paint me to be when I judge the evidence to show that their methods aren’t useful, neither am I an apostate or sellout if I occasionally find something that is useful amidst the plethora of CAVM practices. The odds are pretty good that even with only low-quality trial-and-error evidence, they will occasionally stumble on something that actually works (even a broken clock is right twice a day). We need to be careful not to become as dogmatic or clannish as the proponents of pseudoscience often are. My current suspicion is that there are few tiny little grains of wheat amidst the pile of chaff that is traditional, non-TCM acupuncture. If this is true, I might put a few of them to use even if it shocks or offends some folks.

  8. art malernee dvm says:

    http://scienceblogs.com/insolence/2016/03/04/cat-upuncture-what-did-those-poor-cats-ever-do-to-deserve-this/
    Check out all the needles stuck in a cats head.
    I’m still looking for the fancy chicken picture that was taken down from the Colorado veterinary website with all the needles stuck in the chickens neck. The Florida and Colorado vet school teach the kids in school acupuncture.

  9. Crash Hammerdog says:

    I am a little unsettled that Skepvet would even consider acupuncture. Problem is, when you throw out the chaff you find there was no wheat to begin with. There was no baby in the bathwater.
    I understand that clients are often low information, but that doesn’t mean you need to taint your practice with hooey medicine. I am a minority, but if I saw my vet offered acupuncture I would leave. I already left the vet pushing cold lasers from information I received here. I wish there was a database for science based vets.

  10. skeptvet says:

    The problem is, of course, that few of these things are that simple. If you read my articles on cold laser, for example, you should know that while I don’t think there is any strong clinical trial evidence for its use in dogs and cats, there is plenty of pre-clinical evidence to support plausibility. It’s unproven, but it’s hardly quackery, so it shouldn’t be a reason to give up on your vet. Like stem cell therapy and many other practices in vet med, it is being marketed well ahead of the scientific research that should be done to determine its real risks and benefits, but it’s a long way from outright nonsense like “energy medicine,” homeopathy, and so on. There is a huge middle ground between quackery and interventions with low-level or low-quality evidence, which makes up most of veterinary practice, so be careful about lumping people into rigid, binary categories based on the therapies they offer.

    As you can also see from reading my posts on the acupuncture course, I’m not exactly a convert even to supposedly science-based acupuncture practice, much less TCM nonsense. But given the pretty good evidence for conventional therapies like TENS, sacral nerve stimulation , percutaneous tibial nerve stimulation, and a few other bits of bait from the acupuncture bait and switch, it is not automatically a sign of a quack to wonder if some needling practices might have value.

    Simplistic and automatic rejection of ideas is the, usually, unfair caricature given of skepticism. But we know that the reality of skepticism is withholding judgment until you have considered the evidence and then proportioning your confidence in your conclusions to the strength of the evidence. I have used this course as an opportunity to consider the evidence and challenge my own preconceptions. I have generally not found much reason for great confidence in most claims made for acupuncture based on that evidence. But I acknowledge that some non-TCM claims are plausible and have some pre-clinical evidentiary support, that most needling practices are low risk, and that trying therapies in which one has a low level of confidence with honest informed consent when all better-validated practices have been exhausted and there is little else to offer is not inherently irrational, especially if the alternative is handing one’s patients and clients over to someone who will sell them a load of clear rubbish along with such practices or simply euthanizing them. If that thought makes me an apostate to skepticism in the eyes of some, that’s disappointing, but after seven years of public skeptical activism, I’ve pretty much given up on the idea of being popular anyway! 😉

  11. art malernee dvm says:

    . I am a minority, but if I saw my vet offered acupuncture I would leave. >>>>>
    I stopped referring to the vet school in Florida because they teach the kids acupuncture there. I am a minority also.
    art malernee dvm
    fla lic 1820

  12. skeptvet says:

    Art, that really makes little sense. I agree, of course, that the influence of the Chi Institute at the vet school there is shameful. But the vast majority of the specialists working there have nothing to do with acupuncture. Would you really not give clients the option of seeking treatment at the only vet school near them just because a few of the individuals there teach TCVM nonsense?

  13. art malernee dvm says:

    If I was a specialist I would not work at the acupuncture promoting vet school in florida. I’m not a fan of mixing apple pie with cow pie. The referral practice close to me down the street has specialist but also promotes homeopathy on their website. I refer to specialist further away. I referred to Auburn before the state opened the vet school in Florida and plan to do that again.

  14. v.t. says:

    Art, unfortunately, institutions and practices are being infiltrated with woo more and more – it’s easy revenue (whether it works or not, and obviously as we’ve seen, to hell with science and ethics). I have to agree with skeptvet on this one, clients and their pets deserve referrals to a specialist who is nearby and has additional resources. Sending them miles away only increases the likelihood of little to no follow-up (and additional cost).

  15. art malernee dvm says:

    V.T, If you were a md would your refer to the cow pie Cleveland clinic because it was close?
    see
    http://scienceblogs.com/insolence/2013/02/27/the-cleveland-clinic-foundation-mixing-cow-pie-with-apple-pie-in-pediatrics/

    Maybe the problem is we now use words like cow pie and woo. In the” good old days ” the vet who wrote my recommendation to vet school would have told me the the vet school in florida teaches the kids acupuncture because the school is run by a bunch of quacks. That’s no longer politically correct but that may change as more pictures of animals with needles sticking out of their heads and necks appear on the internet.

  16. v.t. says:

    Art, no one hates that more than I, believe me – it’s a darn shame woo is taking over teaching hospitals, universities, and practice clinics.

    That said, and I don’t mean to imply a “if you can’t beat them, join them” sort of thinking, but we somehow have to learn to live with it (much as we are in the state of disrepair in politics) while still maintaining professionalism in advancing EBM- it’s not easy, it’s mind-blowing, it’s sickening, and it’s maddening and we all want to do something about it – unfortunately, IMO, current politics are the barrier.

    Clients who are referred to specialists obviously need a guiding hand, and convenience in an otherwise stressful and costly position of caring for a pet with a complicated case or those who require advanced care. By referring miles away or sometimes out-of-state, you’re not effectively giving them the best option that may be right for them. What if all of the teaching hospitals and universities on the east coast were infiltrated with woo in the next decade, what are you going to do for your clients then?

    I’m sure the professionals working in those institutions are as unhappy as we, should they also uproot and move elsewhere to another who will eventually employ the woo as well? There’s no easy answer, but denying a referral where a few practice woo isn’t one of them. (remember, you’re still the front-line primary care vet, you still have the means to educate and help your clients and their pets)

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