Advances in the science of acupuncture


Acupuncture has been used in China for thousands of years – it’s one of the first ‘alternative’ treatments requested by patients experiencing persistent pain, and one that has been receiving increasing attention from the scientific community as neurobiological research progresses.

This paper by Wang, Kain & White provides an overview of the state of play for acupuncture and analgesia. As a result of this I’m taking another look at acupuncture as a potential modality for people with chronic pain – with a few proviso’s!!

What’s the evidence?
Traditional Chinese acupuncture is a philosophy that focuses more on prevention than treatment of illnesses. The ancient Chinese believed that Qi flows through a network of channels called meridians, which bring Qi from the internal organs to the skin surface. Along these meridians there are acupuncture points that can be stimulated to correct the imbalance and restore the body to normal health.

Western theories are primarily based on the presumption that acupuncture induces signals in afferent nerves that modulate spinal signal transmission and pain perception in the brain.

Over the last decade, advanced imaging technologies have been introduced, including positron emission tomography (PET), single-proton emission computer tomography (SPECT), and functional magnetic resonance imaging (fMRI). These imaging technologies have made it possible to noninvasively visualize the anatomic and functional effects of acupuncture stimulation in the human brain.

PET scanning found that only acupuncture stimulation at LI4 with De Qi sensation activated the hypothalamus – sham or needling in ‘incorrect’ positions didn’t.
In another study, during a PET scanning sequence Biella et al. found that acupuncture, but not sham treatment, activated the left anterior cingulum, superior frontal gyrus, bilateral cerebellum, and insula, as well as the right medial and inferior frontal gyri. These are the same areas activated by acute and chronic pain.

However, just in case you thought it was ‘simple’ – the anticipation and belief of a patient might also affect the level of therapeutic outcome. This has been specifically examined, and findings from Pariente et al. identified that both true and sham acupuncture activated the right dorsolateral prefrontal cortex, anterior cingulated cortex, and midbrain, however only true acupuncture caused a greater activation in insula ipsilateral to the site of stimulation.

SPECT and fMRI studies have also been conducted, with similar findings – only true acupuncture produced activation of specific areas of the cortex that are apparently involved in pain perception.

Physiological and imaging studies are providing insight into the neurophysiological mechanism of acupuncture analgesia. Recent data suggest that acupuncture triggers a sequence of events involving the release of endogenous opioid-like substances, including enkephalin, [beta]-endorphin, and endomorphin, that modulate pain signals processed along the pathway. Imaging studies demonstrate that the limbic system plays an important role in acupuncture-induced analgesia.

Now just because I can, I invite you to consider the place of placebo, or as Dan Moerman calls it ‘meaning response’.
Unless really good randomisation and double blinding (the patient and the assessor are ALL unaware of whether the procedure is ‘real’ or ‘placebo’) we will run into the effect of having treatment (of any kind) can have on an individual. And especially in the case of acupuncture where the practitioner can never be blinded to whether the procedure is ‘real’ or ‘sham’, inadvertent changes of nonverbal (and at times verbal) behaviour can and will be conveyed.

So…. a very fruitful area of study, methinks.

Oh and another concern I have with acupuncture, as I do for any procedure that involves another person rather than self management for a chronic health condition – acupuncture is usually done by someone to someone. The very process of attending a practitioner is a form of pain or illness behaviour. This action by definition means the person has:

  1. identified that they want help
  2. need to ask someone else to help them
  3. can’t manage by themselves

This means the person will inevitably relinquish a degree of self efficacy (confidence that they can manage their problem by themselves and out of their own efforts) to the actions of another person.

As someone who likes my independence, I’m not sure that I want that.

If you’re curious to learn more, trying searching under the term ‘acupuncture’ and ‘chronic pain’, and seeing what comes up. I visited Cochrane Collaboration and found a couple of older reviews of acupuncture, none of them particularly able to identify strong support for its use.
I also visited the Bandolier Oxford Pain Site, and searched under ‘acupuncture’ – again I couldn’t find much support, and most articles were out-dated.

My question is: if fMRI and other studies are demonstrating significant changes in blood flow etc, are they truly controlling for ‘meaning response’, ‘treatment effects’, inadvertent communication of expectations by the practitioner etc, or is this confounding these results?  And if it is a ‘meaning response’ – how can we integrate this into our practice?

Dan’s book, by the way, Meaning, Medicine and the Placebo Effect is a really GREAT read – with some good info on pain as well as health care and the sociology of ill health. Good stuff!

If you’ve enjoyed this post, want to know more, want to keep reading – don’t forget you can subscribe using the RSS feed – and do drop me a line! I love mail, and am very happy to reply (even if we don’t agree!!).

4 comments

  1. A topic close to my heart, and one that fills me with many dilemnas. My first question is how can we expect any intervention by a clinician to be without a meaning response? We know that different peole will respond in different ways to different stimuli (and at different times). Why aspire to fit non-medical interventions into ‘their’ medical model? We spend all our time trying to convince our patients of the psychosocial aspect to their experience, yet continue to conduct research, and atttempt to derive evidence, using their model.

    As a physiotherapist I know that to attain ‘high quality’ evidence of any intervention I conduct is almost impossible as I am unable to double-blind, and often even blind the patient. So the retort is always that their is no strong evidence to support these interventions.

    With regard to acupuncture, the Jan ’08 edition of Spine gives a whole battery of systematic reviews
    on interventions with chronic LBP and concludes that whilst acupuncture compared to exercise or back education is no more effective, if conducted ALONGSIDE these interventions then the outcomes in regard to both function and pain levels are improved at both end of treatment and medium term.

    I agree wholeheartedly with the notion of maintaining the individual ‘sick role’ by coming to a passive intervention, but having heard a recent 3x week programme participant conclude that one of the positives of attending was that ‘it proved’ to their friends that there was ‘something wrong’, then surely ANY contact with a ‘specialist’ service would decrease the patients independence and control.

    I agree – more chat required. Am happy to contribute my thoughts, if they are of any use!

  2. Hi Mary
    We can’t eliminate the ‘meaning response’ from our interactions with people seeking care – so we must support research that begins to investigate the components of meaning and culture and so on – and then integrate those that support (well for me anyway) independence, individual autonomy, development of self efficacy and reduce treatment seeking. These values I freely admit are mine – and I’m open about them. The last thing I want is for a person seeking treatment to continue needing to see me in the long term, and if that’s an outcome they want then I would prefer to refer them to someone else.

    Re: nonmedical models and medical models – in the search of ‘truth’ if you like, or what science is striving for, I don’t think there can be differing models of ‘truth’ – there is truth or there isn’t. So I personally don’t hold to a belief that just because acupuncture (or colour therapy, vibrational healing, macro-ionising rays or anything else!) uses a ‘different’ model, we should judge it by that model alone. In the end, the closest thing we have to ‘truth’ is the scientific method. This means I’d prefer to use the scientific method to judge all treatments.

    It’s not a case of ‘medical’ or ‘nonmedical’, it’s a case of ‘science’ or nonscience. As Prof Denis Dutton said in a lecture I heard: there may be physics and ‘alternative physics’ and you may believe fervently in ‘alternative physics’ – but I’m not going up in an aeroplane that has been built using ‘alternative physics’!

    And as new information is brought to light over time, I think it’s important for us as therapists to revisit things like whether acupuncture could become part of a range of strategies for managing chronic pain. By comparison with anaesthetic procedures, at least acupuncture has few side effects, and doesn’t require the person to come into a hospital for treatment (therefore becoming a patient). But on the other hand, like many things, it continues to be a strategy that increases or at least maintains health care seeking behaviour, which I would prefer not to encourage.

    With respect to the person stating that by attending a programme their pain problem was ‘really something wrong’ – well, validating that the experience of pain is real is an important component of acceptance. If someone’s needing to defend the authenticity and truth of their pain experience to significant others, they will hardly have time (or will) to want to become well. So, perhaps one first step towards developing a sense of self as able to make changes in life is acknowledgement from others that pain is valid – then they can start to step towards reconceptualising themselves as people first, who just happen to have pain.

    I don’t agree that by seeing a specialist service we are reinforcing dependence and loss of control – we only do if we continue to investigate to ‘find’ the ‘source’ of the pain, or persist with ineffective or pain reduction strategies that provide short-term relief only, or fail to let the person know that the next step towards becoming ‘well’ again is to accept that their condition is chronic.

    It would be GREAT if you’d like to contribute an article to my blog – go to the “Introductions” pages and email me something! It would be great!

    cheers
    Bronnie

  3. Not sure about the article, think I may be a little out of my depth on that one!

    Think your response is great though. And I don’t particularly disagree with your perspective although the science / non-science concept doesn’t sit so well with me. I feel that there are more shades of grey than that and it’s more a reflection on the outcome measures / criteria being used.

    Some aspects of physio (and other allied health professions) are firmly entrenched in science whilst others are not. My thoughts are really are we using scientific tools to measure something, and then write it off as ineffective, when it may really have a role.

    All sounds a bit waffly now, will try and come up with a more concise way of putting it. Something about round pegs and square holes……

  4. Hi Mary
    I’ll be posting some more on ‘science’ and ‘truth’ in the next few months, so keep watching. To me it’s about making sure that we can, hand on heart, reassure patients and funders that we are offering strategies that help our patients achieve functional goals, while minimising dependence on ‘us’. That may be a bit of me imposing my beliefs on to others, but I think that’s what both evidence-based health care and cognitive behavioural pain management are all about. I think. (!)

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