After nearly 100 hours on online instruction and independent study, my acupuncture training has concluded with a 5-day hands-on practicum and both a written and practical exam. All that remains to do to finish my certification in Veterinary Medical Acupuncture is a brief case report. This seems, then, like a good opportunity to wrap up SkeptVet’s Acupuncture Adventure and see what, if anything, has changed in my views and understanding of acupuncture as a result of this process.
Clinical Intensive Portion of the Acupuncture Course
I will begin by sharing my experience in the practical training portion of the course. Many folks who know my skeptical and science-based views have asked if I met a lot of strange people or dedicated adherents to pseudoscience in this course, but that really wasn’t the case. For one thing, this particular course is heavily marketed as science-based and an alternative to the TCVM approach to acupuncture, so it tends to attract a more mainstream set of students. And it is important to remember that despite the significant limitations and problems in the acupuncture literature, it is pretty widely accepted in the medical community as having at least a few legitimate benefits. While I’m still not completely convinced this is true when one looks into the literature deeply and critically, I recognize that many vets and MDs who are genuinely science-based in their views and practices view acupuncture as perfectly consistent with that approach when it doesn’t involve too much talk of Qi and other TCM metaphors.
I also think we have to be wary of the natural human tendency, as strong among skeptics as those who believe in alternative medicine, to stereotype and caricature people who disagree with us. While there are interesting trends and correlations to investigate between temperament and a variety of views and beliefs, the world is not neatly and rigidly divided into the skeptical and the credulous. I have always emphasized that even believers in the most egregious nonsense, such as homeopathy, often turn out to be as intelligent and reasonable on a day-to-day level as the most committed skeptic. Perhaps the greatest challenge to skepticism and rationalism is the fact that the road to irrational or pseudoscientific beliefs is paved with many normal, ubiquitous humans cognitive features we all share. It would be easier to mitigate the dangers of pseudoscience if only the stupid or the gullible believed in it, but that isn’t reality.
As a skeptic, I am routinely assumed to be negative, argumentative, cynical, closed-minded, and generally unpleasant by people who know nothing of me other than my views on alternative medicine. This is unfair and inaccurate, but it is no more unfair or inaccurate than assuming anyone who might be interested in learning acupuncture must be gullible or some kind of caricature of a New Age hippy.
Generalizations are sometimes useful and interesting, but they are also a hair’s breadth away from the kind of stereotyping that impedes accurate understanding. For those of you who haven’t seen it yet, here is Tim Minchin offer some thoughts that strike me as relevant to this issue.
For the most part, the students and instructors I talked to in this course seemed drawn to acupuncture for fairly typical reasons. Some simply felt frustrated by the lack of validated therapies for many important clinical problems and felt that exploring something new might be worthwhile. Given the poor quality research evidence for much of conventional veterinary practice, the lack of strong scientific evidence for acupuncture didn’t necessarily seem to be a deterrent for most.
And of course, I heard a lot of stories about personal experiences that had drawn participants to acupuncture. As always, in conventional medicine nearly as much as alternative medicine, anecdote is king. Some students had experienced improvement after receiving acupuncture treatment themselves for medical problems that had been persistent or otherwise recalcitrant to treatment. Others had seen patient who were very ill, had poorly understood conditions, or had been expected not to recover improve dramatically after acupuncture treatment. Almost everybody had some experience with acupuncture, laser, massage, or some other kindred practice that they felt was of benefit to them.
These experiences naturally create a very compelling sense that the improvement must be due to the therapy, despite all the reasons why this may not be true, and the long history of the failure of anecdote-based medicine. And there is an equally natural and unfortunate tendency for one such experience to lead people to be more accepting in general of anecdotes as evidence, even for the more implausible treatments. Many prominent advocates of alternative practices describe such “conversion” experiences as the start of their CAM careers. There is sometimes a sense that if one claim for an alternative therapy turns out to be true (or at least seems to), then they must all be taken seriously. Obviously, this is fallacious reasoning, and each claim and modality has to be evaluated independently regardless of whether it carries some vague and often misleading label as “integrative” or “Western” or something else.
Unfortunately, very few vets have the time, training, or inclination to critically appraise the scientific literature when investigating therapies that are new to them. And sadly, the limitations in the veterinary literature (and the scientific literature generally) make much of it less reliable a guide to what works and what doesn’t than we might wish. This only strengthens our reliance on personal experience and anecdote.
This is, again, a natural and universal aspect of human reasoning. But while anecdotes provide both a wonderful source of testable hypotheses and at least a somewhat rational basis for specific practices pending the development of better evidence, they are, of course, a deeply unreliable basis for medical practice.
Much of veterinary medicine, again conventional as well as alternative, is largely anecdote based, and we have to live with this in the absence of better quality evidence. But this requires a solid understanding of why we should have only very weak confidence in practices that have not been scientifically validated, regardless of our own apparently miraculous personal and clinical experiences. Unfortunately, we do a very poor job of providing veterinarians with this understanding during their training. The students and instructors in this course were, in general, no less critical in their thinking and no more susceptible to the allure of anecdote and personal experience than those I meet in purely conventional practice.
The practical training itself struck me as a mixed bag. There was a strong emphasis on familiarity with anatomy, which is always a worthwhile way of approaching the physical exam. I found this a useful refresher, given I am 15 years out of school and haven’t formally studied anatomy in a long while. And I felt like the folks doing physical therapy and rehabilitation had a lot of useful insights into evaluating patients with musculoskeletal problems. While there is little data on physical therapy interventions in veterinary medicine, this is a well-established and useful dimension of human medicine, and it is highly likely it will be a useful addition to companion animal medicine, though as always the research identifying which practices are useful for which conditions and all the other important details will lag well behind clinical implementation of these practices.
There was a heavy emphasis on myofascial trigger points as a focus of diagnosis and treatment. I have discussed this topic before. The subjective nature of this phenomenon was very apparent, as different students and instructors often disagreed about the location and significance of MTrPs they felt they detected. In some patients, areas of muscle tension with repeatable behavioral responses to palpation did seem pretty obvious. But in other cases, confident claims about MTrP detection were made based on pretty weak behavioral responses and with great inconsistency in the opinions of different individuals examining the same patient.
As an example, one instructor was adamant about a MTrP being present at a specific spot on one dog. I could not appreciate this myself on palpation. As I was palpating, she noted the dog flick its ear and declared that as proof I had found the point. However, she couldn’t see from her position that the ear twitch occurred when I had accidently brushed that ear with my other arm, and I suspect the twitch was just a reaction to that mild direct irritation of the ear. This doesn’t mean there wasn’t a MTrP that the instructor could feel and I couldn’t, of course. But it does illustrate the problem of subjectivity and confirmation bias in MTrP theory.
While I am still agnostic about the MTrP as a clinical entity, I am concerned that with the strong element of subjectivity in its detection it seems a less than totally reliable concept upon which to base physical medicine interventions. That said, once again such subjectivity is ubiquitous in veterinary medicine, and the detection of pain, nausea, anxiety and many other clinically important variables are no less subjective than the detection of MTrP, so that alone isn’t sufficient reason to reject the concept.
The portions of the training specifically devoted to needling were interesting and also a mixed bag. The research evidence used to justify needling was mostly covered in the online portions of the course, so there wasn’t much discussion of that in the practical training. Some instructors were careful to make only relatively measured and limited claims for acupuncture, acknowledging that the evidence is complex, limited in significant ways, and generally not definitive. On the other hand, almost everyone had a quite obvious personal conviction that acupuncture was highly effective based on their clinical experiences. As I’ve already discussed, this is a ubiquitous and natural, but also deeply problematic, element of both alternative and conventional veterinary medicine.
I do think this type of course, ostensibly treating acupuncture the same as any other therapy in terms of striving for a plausible physiologic rationale and recognizing the need for pre-clinical and clinical research validation, is less faith-based than the sort of course provided by the Chi Institute and other TCVM organizations. There is at least some recognition that much of the practices being taught are not supported by high-level or high-quality evidence and that this is less than ideal. However, anecdote and personal experience remain sufficient in the minds of most of the practitioners, and what evidence there is tends to be interpreted in the most positive possible way. Negative studies are consistently dismissed due to methodological limitations, while positive studies are much more readily accepted as valid, and the general paucity of good evidence in veterinary medicine is seen as tacitly justifying the use of acupuncture despite the weakness of the science behind it.
On a practical level, I did find the application of needling to the many animals used in the practical training somewhat reassuring. Virtually none of the animals manifested any obvious anxiety or discomfort about their treatment. A variety of distractions were used, mostly food related, however many of the animals (mostly owned by the instructors or their clients) were quite comfortable and relaxed during treatment, even by inexperienced students, with no need for distraction at all.
In general, the needles used are extremely small (0.1-0.25mm diameter), and certainly far smaller than those I use routinely for blood and urine sampling, aspiration of masses and internal organs, and many other routine conventional procedures. I had a number of opportunities to needle myself or be needled by others, and while I didn’t experience any of the physical or emotional sensations often described as evidence of the powerful effects of acupuncture, I also didn’t find it particularly uncomfortable. Even the electrical nerve and muscle stimulation I experienced was pretty benign at the usually recommended levels of intensity.
Given that the evidence for benefits from acupuncture is poor, I think it is important that we not expose patients to significant discomfort or risk if we are going to try it for conditions that have no validated treatment. The instructors were all very cautious about causing any discomfort and very clear about the need to avoid reported complications, such as puncturing body cavities or vital structures. Such complications are reported for acupuncture, and some of the instructors had personal experience with them. However, even reviews of the literature by skeptics show that such complications are rare and usually associated with failure to follow standard safety recommendations or the result of needling done by improperly trained practitioners. So while the training didn’t add much in terms of evidence for the efficacy of acupuncture, it was reassuring in terms of reaffirming that the risk and discomfort associated with the practice are minimal.
View on Acupuncture from Start to Finish
At the beginning of this course, I summarized my starting views of acupuncture. In brief, my conclusions were these:
My current view is that while needling undoubtedly has physiological effects, it has not been convincingly demonstrated that these are predictable, repeatable, and controllable to achieve beneficial clinical outcomes. I also am not convinced that acupuncture points or channels exist as a consistent network of identifiable anatomical structures that can be predictably identified and manipulated to achieve a desired clinical goal.
Ultimately, much of the acupuncture literature cannot be viewed as very reliable due…[various] sources of bias. The best controlled studies seem to suggest that acupuncture affects subjective symptoms and perceptions more than objectively measurable indicators of disease. This is most consistent with a placebo effect, and perhaps some very non-specific physiologic effects. However, there is some room for rational uncertainty about the extent to which acupuncture might have small benefits in terms of pain, nausea, and a couple of other clinical symptoms.
There are definitely risks associated with acupuncture…Infections and injuries from needles, sometimes serious, have been reported. Overall, serious adverse effects seem to be quite rare when experienced, formally trained acupuncturists are doing the needling.
Not much in these conclusions has changed as a result of taking this course. I have had an opportunity to review the experimental literature at length. There are a few studies, almost all involving electrical stimulation of peripheral nerves, that are pretty convincing in terms of showing objective physiologic effects of needling that might have clinical relevance. However, as yet there are few veterinary studies that control for bias well enough to allow any firm conclusion about whether these potential benefits can actually be consistently realized in clinical patients.
David Gorski has described electroacupuncture as a “bait-and-switch” with electrical nerve stimulation as an example of the “bait,” a potentially real intervention labeled in such a way as to appear to validate a much larger, and less plausible collection of concepts and claims. I think there is some legitimacy to this argument. If some traditional acupuncture points fall close to peripheral nerves or other anatomic structures we might reasonably want to use as targets for medical treatment, this doesn’t show that the overall pattern of channels and points used, even if acupuncturists could agree on only one, is a rational or scientific schema. And even if electrical stimulation of specific nerves using needles, or potentially needling in some locations without electrical stimulation, turns out to have consistent and objective clinical effects, this doesn’t make any and all claims made for acupuncture plausible or sound any more than the efficacy of one antibiotic for one type of infection validates the use of all antibiotics or even all drugs. Specific interventions need to be evaluated individually.
That said, I also think that if there is some “bait” in acupuncture, some objectively measurable effects of needling with or without electrical stimulation, it is worthwhile taking this seriously even if it is “tainted” to some degree by association with TCM or other pseudoscientific acupuncture practices. If one throws out the mystical energy medicine nonsense, pulse and tongue diagnosis, and all the religious and philosophical trappings of TCM, there remains a degree of plausibility to the idea that some needling and electrical stimulation interventions, labelled as “acupuncture” or by some other name, may be useful. The evidence for this in veterinary medicine, at all levels from pre-clinical to clinical trial, is poor but no worse than for a surprising number of conventional interventions.
Skepticism requires a careful, critical, nuanced evaluation of claims, relying on scientific evidence where possible and proportioning confidence in our conclusions to the strength of the evidence. At the beginning of this course, I had a pretty low level of confidence that acupuncture has meaningful clinical benefits, and that is still true. But I began with the belief that “there is some room for rational uncertainty about the extent to which acupuncture might have small benefits in terms of pain, nausea, and a couple of other clinical symptoms,” and that remains true as well. A detailed review of the evidence presented in the course leads me to believe that acupuncture is generally safe, probably objectively neutral with some placebo and other mild non-specific effects in most cases, and potentially truly beneficial in a few applications, especially those involving subcutaneous electrical stimulation of peripheral nerves.
So what does this lead to in terms of my clinical practice? I have mentioned before that I am considering offering some kinds of needling or electrical stimulation practices under the rubric of “acupuncture.” My reasons for this include: 1) the small, but not non-existent, potential for clinical benefits; 2) the lack of better-validated treatments for many important clinical problems where pre-clinical research suggests needling might be useful; 3) the low risk; and 4) the desire to avoid seeing clients fall into the hands of TCVM vets or other practitioners they are currently being referred to for acupuncture and who consistently undermine their use of science-based therapies.
Some readers have expressed concern about my potentially offering acupuncture treatments to patients. This concern appears to be founded in a number of particular objections.
Some have a strong confidence that no version of what is often called “acupuncture” can possibly have any clinical benefits, so any use of it would be unjustified. I have already addressed this in my detailed analysis of the evidence concerning specific acupuncture practices. While my confidence in the potential benefits of most specific needling practices is low, it is not zero for all of them, as it appears to be for these readers.
It is, of course, a philosophical issue whether or not it is ethical to offer treatments with only weak supporting evidence, and under what circumstances such might be legitimate to try. My own feeling is that when a practice has at least some evidence of plausibility (it could work), and perhaps even some weak evidence of clinical effects (it might work), even if it doesn’t have strong supporting clinical trial evidence to show it does work, it can be acceptable to offer such a therapy. One condition for doing so, in my opinion, is that any claims made must be proportional to the evidence, so clients need to be told that the hoped-for benefits are speculative. And if the benefits are uncertain, the risk and discomfort associated with the practice must be minimal, and it must not be used as a substitute for any better-supported treatment. I do think there are a few circumstances in which acupuncture can be justified under these conditions.
Other readers have suggested that needling animals is “torture” due to the discomfort it causes in patients who can’t give their own consent for the experience. Again, while I believe we must tolerate very little in the way of risk and discomfort when our confidence in the benefits of our therapies is low, my belief is that acupuncture is very unlikely to cause injury or pain, certainly less so than any other conventional practices I use routinely and which also have limited and weak evidence of benefit.
My own biggest concern about potentially offering acupuncture is the problem with distinguishing the many and incompatible associations of the term. Given it is pretty safe, needling of muscles and electrical stimulation of peripheral nerves strike me as reasonable interventions when used for specific indications that have some supporting evidence (e.g. pain, vomiting, GI motility disorders, etc.), when there are no better validated interventions available, and when owners are clearly and honestly informed about the lack of strong evidence. However, just as suggesting this may strike some skeptics as evidence that I have “drunk the Kool-Aid” that is TCVM acupuncture, so it may strike some pet owners as an endorsement for all the varied claims and practices labeled “acupuncture,” including those which I think are utter nonsense.
Distinctions between acupuncture as a form of “percutaneous electrical nerve stimulation” versus a means of “tonifying Yang” and “moving Wind” are meaningful but likely to be lost on many lay people. I share the concerns others have raised that even if I stick with the few plausible needling practices and am very careful about limiting my claims and explaining my rationale, I could still be misinterpreted as supporting a range of claims and myths associated with acupuncture which I actually see as pseudoscience.
A popular metaphor for “integrative medicine”, which I have quoted many times, comes from Mark Crislip. He has said, “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.” In the course of digging through the claims and evidence concerning acupuncture, I have come up with a related simile that fits my feelings about this topic a bit better.
I believe that the few potentially beneficial practices in the acupuncture collection are like ponies buried under a large pile of horse manure. The trick is to dig the ponies out and put them to work without getting thoroughly covered in manure. I’m not sure exactly how to go about this, but I also feel obliged to not ignore even the limited potential for benefit to patients in those cases where there is some reason to think needling and electrical stimulation might be helpful and better-validated options have failed or don’t exist.
Since I think these are interesting and important issues, for veterinarians and pet owners, I will continue to share my thoughts and experiences about them here. I welcome questions and comments from both “sides” of the issue, though as always I prefer substantive and civil input. Thanks for coming along on SkeptVet’s Acupuncture Adventure!