Author's reply III: Can we finally see the light?
The discussion and debate goes on, and little has changed over the years,[1,2] but in reading these responses I have come to realise that neither side has fully understood the position of the other. I hope that we can move things forward after reading these responses.
I came across acupuncture rather by accident in the British military as a medical officer. At the time I was informally pursuing training in musculoskeletal medicine, and naturally I used injection techniques that I had been taught in my orthodox training. The acupuncture needle was much quicker and easier to use than injection needles, and the fine filiform shape was virtually atraumatic. It was like a tiny finger that could be used to probe soft tissues and apply pressure to different layers of soma. By contrast I never used injection needles to probe tissues, but only to deliver what was in the syringe to a target. I never reflected with the patient on the referred pain they experienced with an injection as I started to do when using a filiform acupuncture needle. The use of these needles started to help me refine my diagnosis of peripheral pain sources by acting rather like an extension of my examining fingertip.
It was somewhat of a surprise to me to find that the injections I had been performing had no evidence of efficacy to support them, ie there was no benefit in injecting any particular substance over water or 0.9% saline. Yet these injections were a normal part of my orthodox education and acupuncture was not. Indeed, despite a lack of evidence these injection techniques persist in conventional medicine, whereas acupuncture has never found its way to full acceptance. The reasons for this are likely to be multifactorial, but certainly include cultural attitudes, political expediency and conflicts of interest, as well as the more recent hurdle for entry: the minimum important clinical difference (MICD) over sham. The latter has been the main focus of this debate.
There is no doubt that acupuncture has not met this latest hurdle, but it is also frustrating that this hurdle is often not applied equally to conventional medicine.
Why does acupuncture not meet this requirement of MICD over sham? It would not be new to propose that this is because in the most rigorous efficacy studies there is little physiological difference between the interventions. Neither are inert, but are they both theatrical procedures working through context or are the needles actually doing something themselves aside from the drama of inserting them?
My father drilled into me the importance of working out problems from first principles. He was a chemist by training and designed rocket motors, so getting the basic principles wrong could be an explosive mistake. I took this principle into medicine, and later into my interest in acupuncture. It surprises me to constantly hear the assertion that mechanisms are opaque, but reading these responses has finally made the pin drop for me…
In the laboratory, electroacupuncture consistently alters nociceptive thresholds in a variety of pain models, and we understand these mechanisms intimately.[6–8] They require functional nerve endings in deep somatic tissue for the characteristic effects to be observed. But what do I mean here by electroacupuncture? I focus on the stimulus strength of the current passed through acupuncture needles into muscle tissue rather than the precise position of the needle in muscle, but in this debate my opponents have started to focus more on “specific acupuncture points”.
It has dawned on me again, after all this time, that I still have not managed to make the ironic statement about “missing the point” in the control group entirely clear. From the physiological perspective acupuncture points are defined by the needle insertion rather than the other way around. Wherever the needle goes into the same muscle compartment it is likely to have the same effect on peripheral nerves. Classically described acupuncture sites are a useful nomenclature for teaching and clinical practice, but have no unique physiological or anatomical substrate, so you can miss them without degrading the effect of treatment, hence little difference between real and sham in efficacy trials. The small difference we see is likely to be related to the difference in stimulus strength, so we see much larger effects for electroacupuncture over non-penetrating sham,[9,10] than we do for manual needling versus gentle superficial needling.
Sackett et al said the following (selected quotes):
"The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."
"By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine…"
"Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough."
"Without clinical expertise, practice risks becoming tyrannised by evidence…"
"Evidence based medicine is not restricted to randomised trials and meta-analyses."
Basic science tells us that the mechanisms of acupuncture derive principally from stimulation of deep somatic nerves, not from stimulation of specific sites; therefore we must plan and interpret clinical trials of acupuncture for pain from the perspective of the physiological stimulus, not the precise location of that stimulus.
In summary, I agree with my opponents that needling in specific acupuncture points does not have a convincing benefit over needling away from these points, but I disagree that this means that acupuncture training is superfluous. Highly trained individuals, who are likely to be competent and safe by virtue of their extensive training, perform the sham acupuncture used in clinical trials. You cannot assume that the effect in these groups would be equivalent to random needling by a novice. This brings me back to classical acupuncture points. The main value of teaching points from my perspective is to allow practitioners to become familiar with the anatomy of an area for the purposes of safe treatment. It is easier to acquire this knowledge for a discreet number of points than to learn the entirety of somatic anatomy to allow needling anywhere in a safe manner.
Finally, as a teacher of Western medical acupuncture I use the classical points only as a teaching tool, but most Traditional Chinese Medicine trained colleagues will put greater emphasis on points and meridians within their practice. The lack of scientific support for these concepts is now starting to be acknowledged within this community. This difference clearly has implications for design and interpretation of research, so it is important to define what we mean by acupuncture at the outset of any debate over evidence. We did not do this here, and it has lead to misunderstanding of our relative positions.
1. Cummings M. Commentary: Controls for acupuncture - can we finally see the light? BMJ 2001;322:1578.pm:11431299
2. White A, Cummings M. Does acupuncture relieve pain? BMJ 2009;338:a2760. doi:10.1136/bmj.a2760
3. Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001;82:986–92. doi:10.1053/apmr.2001.24023
4. Cummings M. NG59 used different levels of evidence for conventional interventions compared with those for acupuncture and may not have adequately addressed personal financial COIs of the GDG chair. BMJ. 2017;356.http://www.bmj.com/content/356/bmj.i6748/rr-6
5. White A. Neurophysiology of acupuncture analgesia. In: Ernst E, White A, eds. Acupuncture - A Scientific Appraisal. Oxford: Butterworth Heinemann 1999. 60–92.
6. Bowsher D. Mechanisms of acupuncture. In: Filshie J, White A, eds. Medical Acupuncture - A Western Scientific Approach. Edinburgh: Churchill Livingstone 1998. 69–82.
7. Lundeberg T, Lund I. Peripheral components of acupuncture stimulation – their contribution to the specific clinical effects of acupuncture. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture – A Western Scientific Approach. London: Elsevier 2016. 22–58.
8. Zhao Z-Q. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008;85:355–75. doi:10.1016/j.pneurobio.2008.05.004
9. Mavrommatis CI, Argyra E, Vadalouka A, et al. Acupuncture as an adjunctive therapy to pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: a 3-armed, randomized, placebo-controlled trial. Pain 2012;153:1720–6. doi:10.1016/j.pain.2012.05.005
10. Vas J, Mendez C, Perea-Milla E, et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ 2004;329:1216.pm:15494348
11. Scharf H-P, Mansmann U, Streitberger K, et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med 2006;145:12–20.
12. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71–2.
13. Langevin HM, Wayne PM. What Is the Point? The Problem with Acupuncture Research That No One Wants to Talk About. J Altern Complement Med 2018;24:200–7. doi:10.1089/acm.2017.0366
Competing interests: I am the salaried medical director of the British Medical Acupuncture Society (BMAS), a membership organisation and charity established to stimulate and promote the use and scientific understanding of acupuncture as part of the practice of medicine for the public benefit. I am an associate editor for Acupuncture in Medicine. I have a very modest private income from lecturing outside the UK, royalties from textbooks and a partnership teaching veterinary surgeons in Western veterinary acupuncture. I have no private income from clinical practice in acupuncture. My income is not directly affected by whether or not I recommend the intervention to patients or colleagues, or by whether or not it is recommended in national guidelines. I have not chaired any NICE guideline development group with undeclared private income directly associated with the interventions under discussion. I have participated in a NICE GDG as an expert advisor discussing acupuncture. I have used Western medical acupuncture in clinical practice following a chance observation as a medical officer in the Royal Air Force in 1989. My opinions are formed by data that spans the range of quality and reliability, much of which is in the public domain. I have a logical mistrust of the motives of anyone who advertises an interest or hobby in being a ‘Skeptic’, as opposed to using appropriate scepticism within their primary profession, or indeed organisations that claim to promote generic ‘science’ as opposed to actually engaging in it.