Acupuncture and the Evidence
I have spent several hours, now, listening to lectures discussing scientific evidence and acupuncture. I have also made an effort to find and read many of the specific papers discussed so that I can evaluate their strengths and weaknesses for myself. The instructors for this course have taken a varied and somewhat scattered approach to discussing the scientific evidence, but their presentations seem to fall into three broad categories: discussions of animal model studies investigating the physiologic effects of needling and electrical stimulation of tissues with needles; discussions of the nature of placebo effects; and discussion of the epistemology of science and evidence-based medicine.

The framework for the discussion, of course, begins with the assumption that acupuncture, in some form for at least some conditions, is an effective therapy. This appears to be based predominantly on personal clinical experience. Science is then seen as a means for validating this fact and understanding the mechanisms and application of acupuncture in more detail. The appropriate null hypothesis, that acupuncture has no clinically meaningful beneficial effects, seems to be off the table, which undermines somewhat the instructors’ claims to be approaching this therapy in a truly scientific and evidence-based way. Nevertheless, bias does not itself prove a belief is wrong, only that it may not be based entirely on a rational assessment of the evidence. So I have tried to evaluate the evidence and arguments presented on their own merits.

Pre-clinical Acupuncture Research
This has always been the strongest element in the arguments for acupuncture. There is abundant research evidence that there are physiologic responses to the stimuli generally employed by acupuncturists: dry needling and electrical stimulation via acupuncture needles. And there are plausible mechanisms by which some of these responses could result in clinically meaningful benefits for a number of symptoms. While it remains unclear that any particular needling locations have more or better effects than any other (1, 2), there are undeniably effects to  needling and so-called electroacupuncture.

The instructors cite a number of research studies to illustrate specific effects of acupuncture and to at least imply that these represent mechanisms for clinical benefits. Up to this point in the course, these studies are mostly rat models for pain or gastrointestinal motility, and they often focus on the activity or expression of particular neurotransmitters or other neuroactive compounds, ion channels, or other signaling mechanisms within the nervous system. I think the evidence is convincing insofar as needling and electrical stimulation have measurable physiological effects.

However, this is a long way from demonstrating these techniques are effective clinical therapies. Those the effects identified might be mechanisms for clinical benefits, this has to be demonstrated at all levels, from the animal model to the clinical trial, and this has generally not been done. And it is clear that many other stimuli have similar effects. Pinching the skin or needling without penetration or even hitting your thumb with a hammer have measurable effects that could conceivably modify pain, blood pressure, or other variables affected by the nervous system. An effective therapy is not simply any intervention that does something, but an intervention than consistently and reliable does something specific and desirable in a particular patient population. This cannot be proven in lab animal studies, for acupuncture or any other potential therapy.

The studies cited, like all research, have plenty of limitations that have to be acknowledged. Often, there is a lack of blinding or control stimulation, and again the vast majority seem to involve electro-acupuncture, which begs the question of whether needling in predetermined locations traditionally sued by acupuncturists is itself the source of the observed effects, or if electrical stimulation is the treatment actually being studied.

So far, these lectures have added some depth to my understanding of the specific, and quite varied, effects of needling and electrical stimulation, but this is low-level evidence that only supports the claim that acupuncture might be a useful clinical therapy, not the claim that it actually is. That has to be demonstrated by clinical trials.

Clinical Trial Evidence
So what does the clinical trial evidence say about acupuncture. Well, it is a bit tricky. It is difficult to do a well-controlled acupuncture study because it is difficult to effectively employ some of the best methods to control for bias and placebo effects; a placebo control and blinding of patients and therapists to whether placebo of real acupuncture is being used. Patients, especially those with previous experience of acupuncture, can often tell if they are in the treatment or control group, and acupuncturists always know. This makes the results of most trials somewhat unreliable.

There are many, many studies of acupuncture, most of pretty poor quality or high risk for bias. When these are aggregated and assessed for quality in systematic reviews, generally there is no consistent difference between real and sham acupuncture, though both do better in terms of subjective outcomes like pain than no treatment at all or less dramatic ineffective therapies. This evidence is most consistent with acupuncture being mostly a placebo therapy, with perhaps some small effects on pain and other symptoms via non-specific mechanisms.

To their credit, the instructors in this course acknowledge that from an evidence-based perspective, the clinical trial literature does not support much efficacy for acupuncture.

[Acupuncture] activates the brain in areas that are activated when patients take a placebo, thinking it may be a real treatment.

Non-specific effects of needling ANYWHERE activate similar brain regions, but many studies use “non-verum” points as the placebo.

Unsurprisingly, in the vast majority of RCTs studying acupuncture, the treatment is superior to non-treatment, but not superior to placebo.

The most appropriate conclusion to draw from this, using a science-based perspective, would be that acupuncture is likely merely a placebo and does not have predictable, meaningful clinical effects beyond placebo. However, you can imagine the cognitive dissonance accepting such a conclusion would induce in folks not only practicing but teaching acupuncture, and of course the instructors do not come to this conclusion. They appear genuinely committed on some level to the science-based view. However, they also clearly believe acupuncture is effective based on their personal clinical experiences. When the science supports this, they are happy to rely on it. But when the science does not support their experiences, they begin looking for ways to explain the results that do not require giving up their beliefs.  Most of the rest of the lectures on evidence for acupuncture consist of this sort of salvage operation, attempting to explain why an effective therapy consistently fails to be validated in clinical trials. This involves redefining placebo effects, challenging the methods of clinical trials, and a lot of goalpost moving.

Placebos
These lectures spend a lot of time discussing the nature of placebo effects, and they make a number of troubling claims about placebos that suggest a fundamental misunderstanding of the nature of controlled scientific research. This understanding is most often and articulately represented by the work of Ted Kaptchuk, a proponent of Chinese medicine and a researcher into the nature of placebo effects. Dr. Kaptchuk’s research is interesting, but the conclusions and claims he makes are quite controversial, though they are presented in this course as established science.

One idea that the instructors try to suggest is that placebo effects may not be simply the false perception of improvement in one’s symptoms but real healing.

The meanings and expectations created by the interaction of doctors and patients matter physically, not just subjectively.

This is an idea Ted Kaptchuk has suggested as well, and it is really a rationalization to preserve belief in a therapy that does not outperform placebos in clinical trials. The reason placebos are used, and part of the reason clinical trials have proven so much more effective than individual experience in evaluating medical therapies is that placebos represent a collection of errors that create the impression of improvement without a real, objective change in health.

One of the best explanations for what goes into the placebo effects seen in clinical trials comes from Science-based Medicine in a translation of a French article.  This graphic illustrates the relationship between research placebos and actual healing.

Many different kinds of error feed into the apparent improvement experienced by patients getting placebos in clinical trials, but these do not represent actual , objective healing caused by the placebo therapy. A number of studies have looked at the question of whether or not placebos have meaningful clinical benefits, as opposed to simply creating the perception of improvement in subjective symptoms while leaving objective measures of health unchanged, and the conclusions do not support the “powerful placebo” idea.

Asbjørn Hróbjartsson, M.D., and Peter C. Gøtzsche, M.D., Is the Placebo Powerless? — An Analysis of Clinical Trials Comparing Placebo with No Treatment. Engl J Med 2001; 344:1594-1602.

Conclusions

We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.

Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Database Syst Rev.2010 Jan 20;(1):CD003974. doi: 10.1002/14651858.CD003974.pub3.

Authors’ conclusions:

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.

The literature best supports the traditional idea that placebos fool patients (or, in the case of veterinary medicine, clients and vets) into thinking their condition is improved when it is not by objective measures. Some acupuncture studies illustrate this patter, including one I’ve written about before  involving sham acupuncture as a treatment for acute asthma attacks.

Wechsler, ME. Kelley, JM. Ph.D. Boyd, IOE. Dutile,S. Marigowda, G. Kirsch, I. Israel, E. Kaptchuk, TJ. Active albuterol or placebo, sham acupuncture, or no intervention in asthma. N Engl J Med 2011; 365:119-126

In addition to asking the patients how they felt after each treatment, the investigators also measured their lung function, using an instrument that records, among other data, how much air the patients could force out of their lungs in a given period of time. It turns out that this objective measure showed a 20% improvement with the bronchodilator inhaler, but a significantly lower 7% improvement with the inert therapies or no treatment at all. So while the patients couldn’t tell the difference between real and fake therapies, their lungs certainly could.

As David Gorski from Science-based Medicine put it,

[This finding] indicated how dangerous it could be to rely on placebo effects to treat asthma in that it could easily result in the death of your patients by lulling them into a false sense of security of not feeling short of breath when, from a physiologic standpoint, they are on the knife’s edge of respiratory failure.

The instructors refer to this study, but they draw a very different lesson from it than I do. To them, it illustrates the second idea concerning placebos which they suggest might justify acupuncture even if it has no more than a placebo effect, which is that the outcomes of interest ultimately should be the patient experience, not necessarily objective measures of health and disease. As one put it,

A patient centered approach requires that patient-preferred outcomes trump the judgment of the physician.

This strikes me as a dangerous approach to medicine. It is true, of course, that the ultimate goal of medical treatment is the total well-being of the patient. And for humans, at least, the values and goals of the patient are a major determinant of what constitutes well-being. However, there is a reason patients seek the advice and guidance of doctors. Our training and experience gives us a perspective that is different from the patient’s and useful to them. And part of this perspective is an understanding that subjective symptoms are influenced by many factors besides the true trajectory of a disease or overall health. Something can make you feel better without making you truly physically better, and if doctors have methods of assessing this that patients do not have, it is our duty to put this knowledge to the service of the patient’s overall well-being, even if it may sometimes conflict with their short-term perceptions of their symptoms.

In the case of entirely subjective symptoms, of course, the experience of relief is relief, and it cannot reasonably be declared “unreal” without wading into the philosophical morass of qualia, which I try to avoid. However, the experience of symptomatic relief, valuable as it may be in itself, should not be confused with true amelioration of disease or restoration of health. If asthmatics feel temporarily better with placebo therapy, that doesn’t mean we have restored their well-being. Placebo effects, remember, tend to be mild, short-term, and not associated with significant, sustained improvement in health condition.

What the instructors also fail to acknowledge is that placebo effects which lead to subjective experience of relief occur with truly, objectively effective therapies as well as with placebos. We can have both effective treatment and symptomatic relief, and there is no need to settle for only perceived improvement. In fact, I would argue that it is unethical to rely on a placebo therapy to make patients feel better when there are objectively effective therapies available. And when there are not, we are obliged to inform patients of this even if it diminishes our ability to use placebos to relieve their symptoms by fooling them into thinking we have improved their physical health.

Finally, the issue of placebo effects is complicated in veterinary medicine by the fact that some of the effects in the diagram above, those based on belief and expectation, don’t apply to veterinary patients. We can’t fool our pets into feeling better with placebos. However, we can fool their owners and ourselves into believing we have made them feel better when we haven’t. This makes the use of placebos doubly dangerous and unethical in veterinary medicine.

Imperfect Science
The instructors spend some time discussing flaws and sources of bias and error in clinical trials of acupuncture and in the methodology of systematic reviews and meta-analyses used to summarize clinical trial research. The majority of these criticisms are quite valid. There is no question that medical science is, like all human endeavors, deeply flawed and subject to bias and error. I have written about the problematic nature of much research evidence myself, and I actually just completed a master’s thesis specifically looking at some quality measures of veterinary clinical trials, which are far, far from ideal in many ways (hopefully something from this will be published reasonably soon). So questioning the reliability of the scientific literature is fair game, and it is not inconceivable that the benefits of acupuncture could be greater than they appear due to methodological problems with how it is studied.

That said, this begs the question of how else we evaluate therapies like acupuncture. Science is imperfect, but it is far, far superior to any other method we have ever used. The dramatic and unprecedented improvements in human health and longevity that have been brought about by the application of controlled scientific research to health, nutrition, and other related areas, are undeniable. If we must make judgments, and we must make them on the basis of the evidence we have rather than the ideal evidence we would like to have, then what can we rely on that is better than clinical research? While they might not admit it, I suspect deep down the instructors of this course believe their personal experiences are compelling proof that acupuncture is effective, and they find the inability of clinical science to confirm this to be more likely a failing of the research than of acupuncture. The potential bias in this view is obvious. My own view is that we are more likely to come to the right answer more often if we rely on scientific research, flawed as it is, than if we trust out personal experiences.

Bottom Line
The instructors present reasonably good evidence that acupuncture (dry needling and electrical stimulation) have wide-ranging physiologic effects that could plausibly have local and distant clinical benefits. They acknowledge, however, that clinical trials have not tended to support a meaningful, consistent benefit above placebo for acupuncture. Unfortunately, despite their ostensible commitment to evidence-based medicine, they appear to have a strong belief in the efficacy of acupuncture based on their personal experiences, and this has led the to respond to the absence of good clinical trial evidence for the practice by questioning the appropriateness of the methods and outcomes used to obtain this evidence rather than their belief in acupuncture.

The reinterpretation of placebo effects suggested in the course materials, as either true measures of real healing or as sufficient endpoints for therapy in themselves, seem misguided. While symptomatic relief is an important goal for patients, it is not sufficient in itself if it leaves the underlying disease unimproved. And such placebo effects can be obtained as easily by therapies with measurable objective benefits as by placebos. Offering placebos alone is ethically questionable, particularly if patients are misled into believing they are truly effective treatments, and it can harm patients if it creates a false impression of improvement.

The critiques offered of clinical trials and higher level scientific evidence are often valid. But they beg the question of what should be used instead to evaluate therapies such as acupuncture. The implication, that personal experience of success is sufficient reason to utilize a therapy despite an inability to validate its effects through clinical research, seems to suggest that such experiences are as or more reliable than controlled research. The history of science and medicine, and the state of human health, argue strongly against this view.

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.

I have written extensively about acupuncture since it is one of the most widely used and accepted of the alternative therapies. It is also complex, with many different definitions, associated theories, and a huge body of relevant research evidence. Sorting through all of this to make a rational, evidence-based assessment of whether any of the various practices called acupuncture have legitimate, demonstrable medical value is challenging. Over the years, my assessment has evolved, so I want to start by summarizing how I currently view this practice.

What is Acupuncture?
A general definition of acupuncture that captures most of the claims and practices of modern practitioners would probably be something like, “the insertion of fine needles into specific locations on the body with the intent of producing beneficial health effects.” This is necessarily vague because there are so many different and mutually inconsistent rationales and theories for how acupuncture is supposed to work and so many different clinical practices. Some say acupuncture manipulates mystical spiritual “energy” while others claim it works by stimulating nerves or inducing release of a variety of neurotransmitters or other endogenous compounds. Some acupuncturists place needles at points all over the body, and others limit their needling to the hand, or the ear, or other specific parts of the body. There is nothing like a consistent, agreed-upon definition or map of acupuncture points and channels. Even the use of needles is not universal, and sometimes needling is accompanied by electrical stimulation, the burning of herbs on needles, and many other practices.

Some of the theoretical constructs used to explain or justify acupuncture are clearly more religious than scientific, and there is no point in talking about Qi or spiritual energies if one is trying to seriously evaluate the use of acupuncture as a medical therapy. However, there are more plausible potential explanations involving the physiological effects of needling in locations associated with nerves and other anatomic structures. 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. It is not impossible that this is true, but the literature is not compelling.

Does Acupuncture Work?
There is an enormous amount of basic and clinical research on acupuncture, and a lot of it appears to show meaningful clinical effects. However, acupuncture is challenging to study because it can be hard to define “real” and “fake” acupuncture, it can be difficult to effectively blind patients to whether they are receiving real treatment or the sham, and it is impossible to blind acupuncturists. The demeanor and style of communication of acupuncturists has been shown to affect the perception of patients as to whether or not they benefit from treatment, so this inability to blind therapists is a real problem.

Ultimately, much of the acupuncture literature cannot be viewed as very reliable due to these and other 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.

Is It Safe?
There are definitely risks associated with acupuncture. Human patients have experienced dizziness and other unpleasant subjective symptoms, though again whether this is directly due to acupuncture or a nocebo effect is difficulty to determine. 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.

Bottom Line
Most of the theories behind how acupuncture might work are either complete nonsense or at best not fully validated by convincing evidence. There is clinical research that shows some benefits from acupuncture treatment, but this is mostly in terms of subjective symptoms and seems likely to be predominantly a placebo effect. Acupuncture is pretty safe, though there are some risks, especially when proper technique is not used.

My Acupuncture Adventure
Given this assessment, it will likely come as a surprise that I have signed up to take a training course in acupuncture. There are several reasons for this, and since I intend to share my experiences through this blog, I thought I would start by describing my goals and intentions at the beginning.

While I am perhaps 75-80% convinced acupuncture operates primarily as a placebo, as I said there are some plausible potential mechanisms by which it could have true clinical benefits, and there is some reasonable quality clinical literature to support these. In the interest of a truly skeptical evaluation of acupuncture, and following the principles of proportioning judgment to the evidence, I am interested in exploring some of the claims, theories, and evidence for acupuncture in more detail. The best way to do this is not only to seek information from sources that agree with my existing views of the practice but to engage with supporters and advocates who have different views. Challenging one’s own beliefs is a core value of skepticism, and I am hoping to put that into action.

Additionally, acupuncture is quite popular in veterinary medicine, at least where I practice. I have a moderately large number of clients who seek it out, as well as a number of colleagues who practice conventional, science-based medicine exclusively yet recommend or refer for acupuncture treatment. Currently, I share with clients who ask about acupuncture the views I have outlined above and emphasize that the existing evidence in veterinary medicine is limited, weak, and gives little reason to expect much harm or much benefit from the practice.

Despite this uncertainty, pet owners will often choose to try acupuncture anyway, even without much evidence it will benefit their pets. Currently in my area, the only way for them to receive this therapy is through a few local holistic veterinarians who not only practice acupuncture but who are fully committed to TCVM and other pseudoscientific practices and who actively counsel their clients to avoid science-based care. Despite some misgivings, I have come to feel that these patients would be better served receiving this therapy from someone who will be honest with clients about the lack of good evidence for real benefits and who will continue to provide them appropriate, evidence-based care as well. If acupuncture is, at worst, a relatively low-risk placebo therapy, then these patients will be better served by this approach than by being handed over to practitioners with a broader alternative, anti-science agenda.

I have long been interested in investigating acupuncture more directly, but I simply could not stomach the thought of slogging through textbooks and lectures than talked about Qi, Ying and Yang, the Five Elements, pulse diagnosis, and all the other TCVM folklore as if it were a legitimate way to approach health and disease in the modern world. Fortunately, I have the opportunity to take an acupuncture training course that largely eschews this sort of mysticism, Medical Acupuncture for Veterinarians (MAV), taught by Dr. Narda Robinson.

Dr. Robinson is a professor at the Colorado State University School of Veterinary Medicine, where she teaches and practices comparative and integrative pain management. She is one of the rare proponents of alternative medical practices who I believe has a genuine commitment to evaluating these through rigorous science, and she is a well-known opponent of pseudoscience in veterinary medicine. Dr. Robinson and I have spoken together at the AVMA annual conference, and we have interacted through our efforts on behalf of the AVMA resolution condemning homeopathy and through this blog. We often disagree about the conclusions that should be drawn from the evidence concerning acupuncture, glucosamine, and other specific topics. But it is not necessary to always agree in order to respect someone else’s efforts and goals.

Dr. Robinson describes medical acupuncture this way:

Scientific medical acupuncture utilizes modern medical knowledge of anatomy and physiology to design treatment protocols based on rational mechanisms of action and objectively identifiable endpoints without resorting to folkloric diagnostic approaches or metaphorical ideations. Veterinary medicine should be scientific and evidence-based.

I think that is a perfectly sound and reasonable way to approach the practice, and while Dr. Robinson has not yet convinced me that the evidence actually supports medical acupuncture as more than a placebo therapy, I accept that we share a commitment to a scientific approach to the question, so I am willing to evaluate her claims and the evidence she uses to support them carefully and seriously.

MAV consists of a series on online modules, followed by an onsite practical training course. Over the next eight months, I will be working through the online modules and preparing for the practical training. I plan to evaluate the content of the modules as thoroughly as I can, drawing on critical appraisal of published evidence, and then share my thoughts through a series of posts. If I ultimately begin providing acupuncture services to clients, I hope to write about those experiences as well.

This adventure, of course, raises the question of whether I am succumbing to the exhortations often made by advocates for alternative therapies to “try it and see for yourself.” If I start treating patients with acupuncture, even while clearly disclosing that it is most likely an elaborate placebo, and these patients appear to improve, will I become a convert to this therapy and start sliding down the rabbit hole into a Wonderland where every therapy works so long as someone has tried it and thinks it does? That seems unlikely.

I am well aware of the many cognitive biases and other sources of error that make uncontrolled personal experience a poor guide to cause and effect relationships. I make use of many treatments for which there is little real scientific evidence, as everyone who practices veterinary medicine unfortunately must given the paucity of high-quality research in our field. And some of these therapies sure look like they work! But I am always aware that this perception is based on shaky ground, and I have so far had no difficulty accepting new practices and abandoning familiar ones when good quality research evidence emerged that contradicted my intuition and experiences.

My goal in learning about and potentially employing acupuncture is not to validate or invalidate the practice through my own clinical experience, since this is not how science-based medicine works, but to engage with the theories, claims, and evidence in more depth and to hopefully minimize the exposure of my patients and clients to the egregious pseudoscience and anti-science ideologies of most of the veterinary acupuncturists they currently have access to.