It’s Acupuncture Awareness Week! According to the British Acupuncture Council, this event ‘aims to help better inform people about the practice of traditional acupuncture’. Perhaps it is a good reason to have a closer look at this currently popular therapy.
I first learnt acupuncture as a medical student some 40 years ago. Later, I occasionally used it clinically and, since I became professor of complementary medicine at Exeter in 1993, I have researched it systematically. Even though many people think they know much about the subject, it turns out to be full of surprises.
The fact that acupuncture has been around for thousands of years indicates to its enthusiasts that it has ‘stood the test of time’; its long history proves its therapeutic value, they believe. Prince Charles likes to promote the idea of ancient ‘wisdom’ in modern healthcare: ‘By integrated medicine, I mean the kind of care that integrates the best of new technology and current knowledge with ancient wisdom.’ Whenever we hear this argument — and, in the realm of alternative medicine, we hear it often — it is worth reminding ourselves that it is but a fallacy. A long history of usage is no substitute for evidence. Just think of how long blood-letting was used in many cultures, even though it was not just useless but probably killed millions. One could even turn the argument on its head and point out that, thousands of years ago, people had no idea about anatomy, physiology, pathology etc. Viewed from this perspective, acupuncture’s long history might merely show how truly obsolete it is today.
We often think of acupuncture as being one single entity. Yet there are many different variations. According to believers, acupuncture points can be stimulated not just by inserting needles but also by heat, electrical currents, ultrasound, pressure, etc. Moreover, there is body acupuncture, ear acupuncture, hand acupuncture and even tongue acupuncture. The result is that we have not one acupuncture but a confusing array of different acupuncture types; general judgments are thus rendered more difficult.
Similarly, it would be erroneous to believe that all acupuncturists are more or less the same. Some practitioners, like those belonging to the British Acupuncture Council, employ the traditional Chinese approach based on the assumption that life forces need to be rebalanced by acupuncture to restore health. This explains why they see acupuncture as a panacea, or ‘cure all’. Traditional Chinese acupuncturists have not normally studied medicine and base their practice on the Taoist philosophy which has no basis in science. By contrast, so-called ‘Western’ acupuncturists (usually doctors or physiotherapists) tend to adhere to the concepts of conventional medicine and claim that acupuncture works via scientifically verifiable mechanisms. They tend to cite neurophysiological explanations as to how acupuncture might work. Even though these theories may appear plausible, they are currently just theories and constitute no proof for the validity of acupuncture as a useful medical intervention. Anyway, as long as we are not sure that acupuncture is effective, it is pretty useless to ponder about a mechanism of action.
The therapeutic claims made by acupuncturists are legion and often seriously bizarre. According to the traditional view, acupuncture is useful for virtually every condition affecting mankind. According to the more modern view, it is effective only for a range of mostly painful conditions. On closer examination, the majority of either of these sets of assumptions are based on rather flimsy evidence. Once we critically evaluate the data from reliable clinical trials, we find that acupuncture is associated with a powerful placebo effect and that, at best, it might work better than a placebo merely for very few conditions.
Even if we concede that, for a handful of conditions, acupuncture could be superior to a placebo, we must ask: is it more effective than the best conventional therapies available today? The short answer to this question is no. I am not aware of a single condition where acupuncture demonstrably out-performs what modern medicine currently offers.
The interpretation of the evidence from the 1,000 or so acupuncture studies available today is, however, far from straightforward. Most of these studies originate from China and other Asian countries, and several independent investigations (for instance, this one) have shown that perilously close to 100 per cent of these papers arrive at positive conclusions. This means that their results have to be taken with more than a small pinch of salt.
In order to control for patient expectations, clinical trials now often employ sham needles which do not penetrate the skin but collapse much like miniature stage daggers. At Exeter, we have invented and validated such a device, and I am convinced that it is a reasonable research tool for ‘blinding’ patients and determining whether a clinical outcome is due to the needling or to the context of the therapeutic encounter. This method can, however, not control for acupuncturists’ expectations; ‘blinding’ of the therapists remains difficult and therefore truly double-blind trials of acupuncture (ie, patient and therapist) hardly exist. In other words, even the most rigorous studies of acupuncture are usually burdened with a significant residual bias which tends to over-estimate acupuncture’s true efficacy.
Most people believe acupuncture has no potential to cause harm, and few acupuncturists seem to warn their patients of possible adverse effects. This may be because the side effects of acupuncture — occurring in about 10 per cent of patients — are mostly mild. However, serious complications of acupuncture are on record as well: acupuncture needles can injure vital organs like the lungs, the spinal cord, major blood vessels or the heart; and they can introduce all sorts of infections into the body. It is thus hardly surprising that about 100 fatalities after acupuncture have been reported in the medical literature — a figure which, due to the lack of an effective monitoring system, is likely to be just the tip of the iceberg.
In addition to such direct risks, there are various indirect risks to consider. Arguably, for instance, practitioners inflict harm to their patients if they persuade them to use acupuncture instead of a more effective treatment. Such advice might even, in extreme cases, cost a patient’s life. In less extreme instances, the harm would be confined to the patient’s bank account when paying for a treatment that did not help.
And what can we conclude from all this? For the vast majority of conditions, there is no strong evidence that acupuncture works beyond placebo. Furthermore, acupuncture is associated with finite risks. What follows is, I think, clear: in most situations, the risk/benefit balance for acupuncture fails to be convincingly positive.
Perhaps, then, the week should be renamed Acupuncture Bewareness Week?
Edzard Ernst, emeritus professor at the University of Exeter, is the author of A Scientist in Wonderland and the awardee of the John Maddox Prize 2015 for standing up for science. He blogs at edzardernst.com.