What’s the Point of Acupuncture?

Acupuncture is one of the most well-known alternative therapies. While only 5-10% of Americans have had acupuncture treatment, most people are familiar with the practice, and surveys show many people, including medical professionals, have a positive view of acupuncture and its benefits.1–4

Like many other therapies, acupuncture has been adapted for veterinary use from its origins in human medicine, and it appears to be growing in popularity among pet owners and veterinary professionals. It is recommended in the American Animal Hospital Association pain control guidelines5 and included in the curricula and practice of a number veterinary colleges. Training programs in veterinary acupuncture are common, and lectures on the subject are included in most mainstream veterinary continuing education conferences. 

You may be surprised, then, to learn that a sizeable number of scientists and clinicians in both human and veterinary medicine remain unconvinced of the benefits of acupuncture.6–8 This is not for want of research. There are thousands of published clinical trials investigating acupuncture in humans, and several dozen veterinary trials have been reported. However, not all research studies produce equally reliable and convincing results, and acupuncture is particularly challenging to study in a rigorous scientific manner. 

Though I am certified in veterinary medical acupuncture and use the method in practice, I remain skeptical about its value. Whatever benefits acupuncture may have can only be identified if the uncertainties about the practice and associated research are understood and if reliable, high-quality research evidence is generated. Therefore, I want to highlight here some problems with the theory and practice of acupuncture and the research evidence used to justify it in order to balance the misleading information put forward by some proponents and the positive, but often uninformed, view many have about the practice.

The Roots of Acupuncture

Acupuncturists often claim veterinary acupuncture is an ancient Chinese practice. This is somewhat misleading. Acupuncture certainly originated in China long ago. However, it was originally a bloodletting practice which evolved over time into the modern treatment using ultrafine needles.6,9,10 The current collection of ideas, methods, and therapies included under the label Traditional Chinese Medicine (TCM) is actually a mélange of competing folk medicine traditions collated and marketed by the Chinese government under Chairman Mao for largely political reasons.11,6

The theoretical roots of TCM are a mix of Daoist, Confucian, Buddhist, and other religious and philosophical systems. The core concepts informing diagnosis and treatment involve balancing spiritual forces (e.g. Ch’i, Yin and Yang) and adjusting the strength and function of elements in the body corresponding to the elements that make up the universe (e.g. Fire, which is associated with the heart, summer, bitter flavors, and the early afternoon, and Wood, which is associated with the liver, sour flavors, springtime, and the early morning hours).6,9,10,12

Similar beliefs have underlain many pre-scientific systems of folk medicine. The theories of TCM resemble the philosophy of European humoral medicine, with its own bloodletting and herbal practices. Historical communication between cultures and universal features of human cognition have led to great similarity between folk medicine traditions in different cultural and historical settings.9

However, such beliefs are unproven and unfalsifiable, and they are not compatible with science-based medicine.13 Folk medicine has never been very effective, and the dramatic improvements in our health and life-expectancy over the last two centuries have been achieved by abandoning such systems and replacing them with scientific evaluation of medical therapies. It is naïve and misguided to portray the mystical notions of TCM theory as a legitimate foundation for modern medical treatment. 

Of course, many acupuncturists claim that TCM is merely a set of metaphors used to describe practices that have actually been studied and validated in conventional scientific ways. However, such claims are disingenuous. If there are sound physiologic rationales for how acupuncture is employed, why is there any need to learn a complex and imaginary set of explanations for disease and treatment in order to practice acupuncture? 

Nearly all veterinary acupuncture organizations explicitly endorse the TCM approach. And regardless of the extensive scientific research done on acupuncture, most acupuncturists still think in terms of TCM concepts and still make diagnoses and plan their treatments according to this system. This is misleading to our clients and undermines rigorous scientific evaluation of acupuncture. 

What’s the Evidence?

Acupuncture research is a complex field difficult to summarize both briefly and accurately. From the basic science to clinical trials, the evidence is inconsistent in quality and results. Even the foundational task of identifying and defining acupuncture points has proven difficult.14–17 Various acupuncture traditions locate points quite differently. Some needle only in limited areas, such as the hand of the ear, while others use points widely distributed all over the body. Apart from the eyeballs and the genitals, there is hardly a spot anywhere that has not been claimed as an acupuncture point. And the features often cited to show such points are anatomically or functionally distinct are also widespread and found in many places not considered to be acupuncture points. 

Despite extensive effort, a consistent set of anatomic or physiologic features that convincingly define the existence of acupuncture points has not been demonstrated. Furthermore, many studies find the effects of needling to be as strong in sham locations used as controls for “true” acupuncture points.18–20 It is difficult to characterize and evaluate acupuncture as a coherent system for stimulating specific locations with predictable results if we cannot even prove that these locations exist or that it matters where the needling is done.

Clinical Studies of Acupuncture
There are thousands of clinical trials studying acupuncture in humans. Many claim positive results. Many also have severe methodological weaknesses. It is very difficult to create a “placebo” acupuncture intervention that fools patients, and it is impossible to create one that fools the acupuncturist. For this and other reasons, proving that real acupuncture is more effective than sham or placebo acupuncture has been difficult. Most positive results tend to be for outcomes such as pain, nausea, and subjective symptoms that are most susceptible to placebo effects, which undermines confidence in these results.

Over sixty systematic reviews of acupuncture research have been published by the Cochrane Collaboration, and none have concluded that there is strong, consistent evidence for meaningful benefits.6,14,21,22 When study quality, risk of bias (both within studies and in the preferential publication of positive results), and other quality criteria are evaluated, much acupuncture research is not reliable. The highest-quality studies often find no difference between verum and sham acupuncture.

The veterinary clinical trial literature is smaller and even more methodologically unreliable. Reviews of the veterinary literature have failed to find convincing evidence of clinically significant benefits.23,24 In 2016, the American Board of Veterinary Specialties rejected the application of veterinary acupuncture organizations for medical specialty recognition because of the lack of a sufficient scientific basis for acupuncture. The ABVS also recently rejected a similar petition from the American College of Veterinary Botanical Medicine, and most ACVBM members and practices rely on the same unscientific TCM principles as acupuncture. 

Scientific Medical Acupuncture?

A minority of acupuncturists disavow the folk medicine roots of the practice and approach it in a more rigorously scientific fashion. The former author of this column, Dr. Narda Robinson, is a leader of this effort, and it is her training course I completed in order to take as thorough and fair a look at acupuncture as I could. I believe using the principles, methods, and terminology of conventional science is the most promising way to evaluate acupuncture. 

Unfortunately, there is still not consistent and reliable evidence to show the value of acupuncture in veterinary patients regardless of the underlying theory. Studies frequently lack blinding and effective placebo controls, they often measure multiple outcomes and then dredge the data for statistically significant differences of questionable clinical relevance, and investigators inevitably interpret results as supportive of acupuncture even when they clearly are not. 

A recent study25, for example, predicted acupuncture would increase gastric motility in dogs. A small difference in motility was seen between treatment and control interventions, though only at three of the twelve time points assessed. This difference was statistically significant, but it was actually in the opposite direction from that predicted, with motility being slower in the acupuncture group at these times. The most likely explanation for this finding is that the hypothesis was wrong and the difference identified was not meaningful. 

The authors, however, instead chose to interpret the findings “based on the underlying theories of acupuncture” and suggested that further study and clinical applications may be appropriate because needling might “balance” physiologic systems, altering them in whichever direction is appropriate for restoring homeostasis in a given patient. This is simply the Daoist notion of spiritual balance from TCM couched in scientific terminology. It is an implausible interpretation of the data and shows how the religious concepts of TCM pervade the thinking of even ostensibly science-based acupuncture practitioners and interfere with objective, useful generation and interpretation of scientific research evidence.

Bottom Line

Most acupuncture treatment is still based on unscientific religious and philosophical principles. Despite extensive research over many decades, plausible scientific explanations for how traditional acupuncture might work have not been clearly validated. Clinical studies in humans have failed to find clear evidence of meaningful benefits for most conditions compared with sham interventions. 

There is little high-quality clinical research on veterinary acupuncture, and the widespread belief that it is an effective therapy is based mostly on anecdote and low-quality evidence. Better research evidence has been challenging to generate due both to the difficulty in creating an effective placebo comparator for acupuncture and to the impact of entrenched bias and unscientific beliefs among acupuncturists evaluating the practice.

References

1.        Mann B, Burch E, Shakeshaft C. Attitudes Toward Acupuncture Among Pain Fellowship Directors. Pain Med. 2015;17(3):pnv001. doi:10.1093/pm/pnv001

2.        Chen L, Houghton M, Seefeld L, Malarick C, Mao J. A Survey of Selected Physician Views on Acupuncture in Pain Management. Pain Med. 2010;11(4):530-534. doi:10.1111/j.1526-4637.2010.00815.x

3.        Halpin SN, Perkins MM, Huang W. Determining attitudes toward acupuncture: a focus on older U.S. veterans. J Altern Complement Med. 2014;20(2):118-122. doi:10.1089/acm.2013.0229

4.        Burke A, Upchurch DM, Dye C, Chyu L. Acupuncture Use in the United States: Findings from the National Health Interview Survey. J Altern Complement Med. 2006;12(7):639-648. doi:10.1089/acm.2006.12.639

5.        Epstein ME, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats. J Feline Med Surg. 2015;17(3):251-272. doi:10.1177/1098612X15572062

6.        Magalhães-Sant’Ana M, Magalhães-Sant’Ana, Manuel. The Emperor’s New Clothes—An Epistemological Critique of Traditional Chinese Veterinary Acupuncture. Animals. 2019;9(4):168. doi:10.3390/ani9040168

7.        Colquhoun D, Novella SP. Acupuncture is theatrical placebo. Anesth Analg. 2013;116(6):1360-1363. doi:10.1213/ANE.0b013e31828f2d5e

8.        McGeeney BE. Acupuncture Is All Placebo and Here Is Why. Headache J Head Face Pain. 2015;55(3):465-469. doi:10.1111/head.12524

9.        Buell PD, May T, Ramey D. Greek and Chinese horse medicine: déjà vu all over again. Sudhoffs Arch. 2010;94(1):31-56. http://www.ncbi.nlm.nih.gov/pubmed/21294441. Accessed November 13, 2018.

10.      Ramey DW, Rollin BE, eds. Complementary and Alternative Veterinary Medicine Considered. Ames, Iowa, USA: Iowa State Press; 2003. doi:10.1002/9780470344897

11.      Levinovitz A. Chairman Mao Invented Traditional Chinese Medicine. Slate. October . https://slate.com/technology/2013/10/traditional-chinese-medicine-origins-mao-invented-it-but-didnt-believe-in-it.html.

12.      Schoen AM, Wynn SG. Complementary and Alternative Veterinary Medicine?: Principles and Practice. 1 ed. St.Louis (Misuri): Mosby; 1998. https://www.worldcat.org/title/complementary-and-alternative-veterinary-medicine-principles-and-practice/oclc/991736718&referer=brief_results. Accessed November 14, 2018.

13.      McKenzie BA. Is complementary and alternative medicine compatible with evidence-based medicine? J Am Vet Med Assoc. 2012;241(4). doi:10.2460/javma.241.4.421

14.      ERNST E. Acupuncture – a critical analysis. J Intern Med. 2006;259(2):125-137. doi:10.1111/j.1365-2796.2005.01584.x

15.      Zhang H, Bian Z, Lin Z. Are acupoints specific for diseases? A systematic review of the randomized controlled trials with sham acupuncture controls. Chin Med. 2010;5(1):1. doi:10.1186/1749-8546-5-1

16.      Ramey DW. A Review of the Evidence for the Existence of Acupuncture Points and Meridians. In: Proceedings of the Annual Convention of the American Association of Equine Practitioners. ; 2000:220-224. http://www.ivis.org/proceedings/aaep/2000/220.pdf.

17.      Molsberger AF, Manickavasagan J, Abholz HH, Maixner WB, Endres HG. Acupuncture points are large fields: The fuzziness of acupuncture point localization by doctors in practice. Eur J Pain. 2012;16(9):1264-1270. doi:10.1002/j.1532-2149.2012.00145.x

18.      Moffet HH. Sham Acupuncture May Be as Efficacious as True Acupuncture: A Systematic Review of Clinical Trials. J Altern Complement Med. 2009;15(3):213-216. doi:10.1089/acm.2008.0356

19.      MacPherson H, Maschino AC, Lewith G, et al. Characteristics of Acupuncture Treatment Associated with Outcome: An Individual Patient Meta-Analysis of 17,922 Patients with Chronic Pain in Randomised Controlled Trials. Eldabe S, ed. PLoS One. 2013;8(10):e77438. doi:10.1371/journal.pone.0077438

20.      Gorski DH. Integrative oncology: really the best of both worlds? Nat Rev Cancer. 2014;14(10):692-700. doi:10.1038/nrc3822

21.      Jiao S, Tsutani K, Haga N. Review of Cochrane reviews on acupuncture: how Chinese resources contribute to Cochrane reviews. J Altern Complement Med. 2013;19(7):613-621. doi:10.1089/acm.2012.0113

22.      Derry CJ, Derry S, McQuay HJ, Moore RA. Systematic review of systematic reviews of acupuncture published 1996-2005. Clin Med. 6(4):381-386. http://www.ncbi.nlm.nih.gov/pubmed/16956145. Accessed November 14, 2018.

23.      Habacher G, Pittler MH, Ernst E. Effectiveness of acupuncture in veterinary medicine: systematic review. J Vet Intern Med. 20(3):480-488. doi:10.1892/0891-6640(2006)20[480:eoaivm]2.0.co;2

24.      Rose WJ, Sargeant JM, Hanna WJB, Kelton D, Wolfe DM, Wisener L V. A scoping review of the evidence for efficacy of acupuncture in companion animals. Anim Heal Res Rev. 2017;18(2):177-185. doi:10.1017/S1466252317000068

25.      Radkey DI, Writt VE, Snyder LBC, Jones BG, Johnson RA. Gastrointestinal effects following acupuncture at Pericardium-6 and Stomach-36 in healthy dogs: a pilot study. J Small Anim Pract. 2019;60(1):38-43. doi:10.1111/jsap.12935

This entry was posted in Acupuncture. Bookmark the permalink.

18 Responses to What’s the Point of Acupuncture?

  1. v.t. says:

    This begs the question…why do you practice it, then?

  2. Jazzlet says:

    Indeed, just what I want to know.

  3. L says:

    I tried acupuncture a few decades ago for a minor ailment. It didn’t do a thing for me.
    Terribly time consuming and boring.
    But, going to a specialist did help my condition.

    I wouldn’t subject one of my pets to this.

    PS: SkepVet probably includes acupuncture in his practice because pet owners want the option of trying something “natural”. Otherwise they will go elsewhere where they do offer it.

  4. L says:

    Sorry if this is off topic, but the other thing being offered at some veterinary clinics is “Hemp CBD” for arthritis/pain management.
    No Thanks!

  5. skeptvet says:

    I have used it in several patients. As always the issue is balancing risks and benefits. I am not convinced there is much evidence of real benefit, but the evidence also suggests direct risks are low. The main risk is substituting acupuncture for truly effective therapy, and that is exactly what happens when people take their pets to a TCM vet. Acupuncture is very popular in my area, and if I tell a client it is likely useless, they end up at a TCM vet who stops their pain meds and gives them all kinds of untested herbs, raw diets, etc. I can’t just wash my hands and abandon these patients, so I sometimes will offer acupuncture if clients are willing to continue appropriate science-based care and if they sign a consent form indicating they understand it is probably a placebo. Not an ideal solution, but sometimes it is better for my patients than the alternative.

  6. Kiran Shelar says:

    Thank you for this blog.
    I wonder why Acupuncture has been included in AAHA guidelines of Pain management if it has questionable scientific base. Do you think it is because of relentless promotion by TCM practitioners invading and influencing most of the core science driven organisations? I will not be surprised in future if Laser therapy , Hyperbaric Oxygen Therapy or Ozone therapy making rounds in scientific CEs and influencing standards of care before getting rigourously evaluated by unbiased studies for their claims.

  7. v.t. says:

    Thanks for answering, skeptvet, I suspected as much but wanted to hear it from you. I know this isn’t the only alternative ‘method’ that science-based vets have to struggle with regarding their clients – it has to be difficult wondering what the client would do at Dr-Woo down the street – poor pets, I understand your position, if it meant the pet was still receiving otherwise adequate treatment and care.

    Next question, how did you come up with a cost for acupuncture treatment? I’ve always wondered how doctors and vets come up with an appropriate charge for acupuncture (and other alternatives), given there is virtually no evidence of efficacy.

  8. skeptvet says:

    There is at least one TCM-certified acupuncturist on the guideline committee for those guidelines, so acupuncture was likely included simply because that author believes in it and accepts the weak evidence available as sufficient. There is also a widespread belief that acupuncture is effective, at last for pain and nausea, among vets and the general public spit the poor evidence for this. It is a claim that has been repeated so many times over dads that it has come to be accepted out of familiarity more than an accurate understanding of the evidence.

  9. skeptvet says:

    I don’t have much say over prices at my practice since I’m not part of the management. Acupuncture visits are charge just like any office visit based on the length of the visit, with the first costing more and subsequent followup visits less. The treatment itself is charged at a similar level to other outpatient procedures that take similar time.

    I do require a no-charge initial consult to evaluate the patient and explain the limitations in the evidence and the possible risks, and if there is a clearly appropriate conventional therapy not being used or the patient seems unsuited for treatment (e.g. they dislike restraint or handling), then I won’t perform acupuncture for that patient. With these restrictions, I’ve treated about 6 patients over the last three years, mostly dogs with chronic degenerative neuromuscular disease progressing despite appropriate conventional treatment. I can’t say as I’ve seen any obvious sign of benefit, though predictably my clients often feel their pets are benefiting, at least at first. But as I’ve said before, my subjective impressions aren’t any more reliable than anyone else’s, so in the absence of better quality controlled research evidence, they shouldn’t be thee basis for any definitive judgment.

  10. v.t. says:

    Thank you, I’m glad to hear you require a prior consult, I’m guessing a number of vets don’t (think laser therapy, just hand the client the colorful brochure, leave the room for a moment, then re-enter the room with the laser therapy machine and some cute puppy goggles).

  11. art malernee says:

    most vets believe acupuncture is effective for certain conditions
    63.55% polled this month on Vin.com. Vets are not any better detecting placebos than their clients. Laser makes a better rain dance in my option.

  12. Christopher says:

    Brennen how do you respond when someone uses the lack of knowledge of the mechanism of action of say Isoflurane as a supportive argument of the use of acupuncture…? I know this is a straw man but , there should be a better response than this.

  13. CG says:

    In response to art’s quote on the vin poll, I conducted my own informal poll of boarded experts in many of the disciplines of veterinary medicine. Anesthesia, cardiology, oncology, ophthomology, etc… All of the people polled were diplomats….I can tell you that the results of this informal poll were much different than the poll of the general population of vin vets. In fact I would say that less than 1% of experts utilized acupuncture or any cam modality in their specialty practices.

  14. skeptvet says:

    I’m not sure I understand your question.

  15. CG says:

    Lets see, Isoflurane remains an outlier in ebm . The mechanism of action for iso inhalant anesthetic remains mostly unknown. This seems not to be a common trait among ebm therapies. Acupuncturists often use this as a point against ebm in general as the moa of acupuncture for the most part is also unknown. What would be a good strategy when confronting this talking point in a debate about the efficacy of acupuncture. IMO from a debate perspective it would be a straw man to cite general anesthetic iso when talking about acupuncture but I wanted to know if you have any other strategy to use when faced with this false equivalency. thanks.

  16. skeptvet says:

    Ah, I see what you mean. Yes, the general argument seems to be that there are conventional treatments without strong evidence to support them, or that some things are accepted widely despite a lack of complete scientific understanding or validation, and therefore alternative therapies should be accepted without robust evidence as well. Several ways to answer this:

    1. Deficiencies and poor practice exist in science-based medicine, but these don’t make such practices appropriate or reliable. That would be the “tu quote” fallacy, that because one “side” in a disagreement has done something inappropriate, that side cannot criticize inappropriate behavior from thee other side. The worst one can legitimately say is that if an advocate of EBM does not acknowledge or attempt to correct deficiencies in EBM, then they inconsistent in their behavior or even, if one wants to be polemical, a hypocrite. This does not, however,r have anything to do with whether the principles of EBM are sound or the lack of evidence for alternative therapies is acceptable.

    Personally, I try to be consistent, and I acknowledge that tramadol, metronidazole, gabapentin, and all kinds of conventional treatments are used despite a lack of reliable evidence or even in the face of evidence against using the, and I believe this is as much of a problem for vet med as the use of acupuncture without reliable evidence. Both practices need to be challenged regardless of provenance.

    2. Overall, the evidence for science-based medicine is far better than for alternative therapies. Certainly, the evidence for the safety and efficacy of isoflurane is far stronger than that for acupuncture, despite any limitations in our understanding of its effects on a molecular level.

    What is more, proponents of evidence-based medicine generally acknowledge the need for scientific evidence, and practices are adopted and abandoned as the evidence changes, albeit often too fast or too slowly for purely psychological and cultural reasons. Alternative medicine, however, actively promotes its reliance on anecdote and history, its resistance to change, and its disdain for contrary scientific evidence as virtues. This makes it more consistently unreliable than science-based medicine even if th latter sometimes makes the same mistakes.

    3. Veterinary medicine will always be burdened by a lack of strong evidence due to the lack of resources needed to produce it. The answer to this is either to give up on the need for strong evidence and rely on anecdote nor to stand idle and not treat patients unless we have perfect evidence for our treatments. The answer EBM offers is to understand and identify the level of confidence we can have in each treatment, rely on the treatment with the best evidence first, and be explicit and honest with animal owners about the uncertainty involved in what we offer.

    I sometimes do acupuncture, but I explicitly discuss the lack of evidence, the risks, and the fact that it seems more likely to be a placebo for owners and vets than a truly effective therapy, and I only agree to do it when all better options have been tried. This is quite a different thing from a TCVM vet who lauds acupuncture as a proven method based on thousands of years of anecdote and mystical TCM theories. There is an ethical and a practical difference between misleading owners with such claims and offering unproven therapies as a last resort with full disclosure.

    Hope this helps!

  17. art malernee says:

    I sometimes do acupuncture, but I explicitly discuss the lack of evidence, the risks, and the fact that it seems more likely to be a placebo for owners and vets than a truly effective therapy, >>>>

    I take a its better if I do it attitude with some treatments after telling clients better let me do it then another vet. Not sure that’s the right thing to do. Clients seem as conflicted about the situation as I am.

  18. skeptvet says:

    Yes, it’s a tough call and not an ideal solution, but sometimes it may be the best compromise we can strike at the time.

Leave a Reply

Your email address will not be published. Required fields are marked *

This blog is kept spam free by WP-SpamFree.