For years I was convinced acupuncture was a valid medical procedure with clear benefits backed by reams of good evidence. Although I never did believe in the meridian qi energy theories associated with this treatment, I routinely encouraged clients and friends to add acupuncture to their health and wellness toolbox. After all, the Chinese people have been utilizing acupuncture for approximately 2500 to 4000 years and it has stood the test of time, right? – turns out this is not completely true. Many U.S. health insurance companies reimburse their customers for the service, believing it brings quantifiable benefits. However, skeptics suspect this simply makes prudent fiscal sense because acupuncture is a cheaper payout than traditional medical care. In an effort to appease customer demand, many prestigious hospitals have added acupuncture to their wellness and rehab programs despite pushback from the scientific community. The anecdotal evidence was and is overwhelming. I constantly hear intelligent thoughtful people talk about the efficacy and personal success in regards to the treatment. Almost unbelievably, the United States Military started using acupuncture to treat pain on the battlefield (they also practice cupping – our tax dollars hard at work). How can all these hospitals, insurers, government agencies and smart people be wrong? After doing a deep dive into the research and talking with a few doctors and scientists I am no longer convinced acupuncture treatment is better than a placebo. As it turns out, it makes no difference where you put the needle. In fact, it doesn’t matter whether you use a needle at all! In the best-controlled studies, only one thing mattered: whether the patients believed they were getting acupuncture. Even then, people responded no better than the placebo control.
Acupuncture has been around for millennia. The exact origins are murky and there is doubt if it even originated in China. The best evidence to date places acupuncture’s origin at 100 BCE. It was first described in the document ‘The Yellow Emperor’s Classic of Internal Medicine’. Back then acupuncture was more about blood letting than pain relief and the needles were typically unsterilized and huge. Interestingly, all traditional Chinese Medicine (TCM) including acupuncture was created without the benefit of dissection. The foundation of this medicine was based on observational evidence (and magical thinking) because dissection was prohibited and the study of anatomy did not exist in ancient China. It is a great example of pre-scientific medicine (aka folk remedy). The foundation of this alternative medicine was comprised of superstition and guesswork. Between 1300-1600 the practice was refined and developed into what we recognize as acupuncture today. In the 1700’s it declined in popularity, becoming eventually outlawed in China in 1929. Chairman Mao brought acupuncture back in the 50’s, specifically to treat the poor, although he did not use it himself. It was a convenient and inexpensive way to give patients the impression of better well-being and make up for the lack of real doctors in post-war China. Acupuncture became increasingly associated with lower-class and illiterate practitioners. Gentlemen scholars and the aristocratic class stayed away from it. By the 1970’s acupuncture moved across oceans and became popular in the United States. This was largely due to a false narrative widely disseminated by the NY Times. Read more about it here.
Before we begin to dissect the efficacy of acupuncture we need to agree on a general definition. Wikipedia defines acupuncture as:
“Acupuncture is a form of alternative medicine in which thin needles are inserted into the body. It is a key component of traditional Chinese medicine (TCM). There are a diverse range of acupuncture theories based on different philosophies, and techniques vary depending on the country. The method used in TCM is likely the most widespread in the US. It is most often used for pain relief, though it is also used for a wide range of other conditions.”
I deliberately looked for a definition without the mention of chi, meridians, chakras or energy flow. I hope we can all agree that there is absolutely no real scientific basis for any of these alternative medicine terms. There is no way to detect, disprove or manipulate these ‘energies’ so I’ve taken them off the table for the sake of this article.
Acupuncture has a wide array of treatment protocols. For the benefit of simplicity, this article will look at the traditional Chinese-based form most widely used in the United States. Currently, it is promoted and considered by some to be a panacea for a multitude of conditions including smoking cessation, weight loss, anxiety, sleep apnea, depression all the way to erectile dysfunction (red-herring anyone?). Carl Sagan was fond of stating, “Extraordinary claims require extraordinary evidence.” Any treatment which claims to alleviate all these issues inches closer to miracle cure territory. Snake oil, anyone? Aside from this growing list of indications, acupuncture’s primary function is the assuagement of chronic pain. When it come to scientific evidence, the vast majority of the research focuses on the efficacy of acupuncture in the area of pain relief.
Pain is a subjective and nebulous sensation that is different for everyone. It is a complex experience generated by the brain, incorporating social and physiological influences. The perception of pain is usually in a state of flux, a moving target. The metric for quantifying pain is usually “Do you feel better?” or a simple 1-10 pain scale. The imprecise nature and amplitude of pain makes it an easy target for alternative therapy. Pain sensations and the fear of pain are rooted in a variety of realms and can be effectively manipulated.
“Fifty years ago what passes today as CAM (complementary and alternative medicine) was snake oil, fraud, folk medicine, and quackery. The promoters of dubious health claims were charlatans, quacks, and con artists. Somehow they managed to pull off the greatest con of all — a culture change in which fraud became a legitimate alternative to scientific medicine, the line between science and pseudoscience was deliberate blurred, regulations designed to protect the public from quackery were weakened or eliminated, and it became politically incorrect to defend scientific standards in medicine.” – Dr. S. Novella
There have been reams of evidence over the last 40 years supporting the effectiveness of acupuncture. Proponents can easily point to a few studies that show positive results. On the face, it is hard to disprove. The fact is, in over 2000 trials published to date, there are no consistent results in acupuncture’s favor. When one digs deeper some alarming facts come to light:
- The Cochrane Reviews, widely considered to be the most authoritative unbiased clearinghouse of evidence-based medicine, found in seven large systemic reviews that: “no clear evidence exists of an analgesic effect of acupuncture”.
- Most of the evidence does not pass the sniff test. Experiments are generally flawed by methodological problems.
- There’s a lack of randomization and/or an accurate placebo control. Incidentally, the only proper control group for an acupuncture study is something called ‘sham acupuncture’ . This is fake acupuncture using retractable needles, toothpicks or placing needles in non-meridian points.
- Research subjects who are not aware (blinded) to the knowledge that they are getting acupuncture treatment typically show no benefit, whereas patients who know they are getting acupuncture treatment show a much higher benefit. Beliefs and expectations are a huge component in placebo effects.
- The meta-analysis that does show a benefit, above a placebo response, are always cherry picked and usually a hodge podge of variable non-specific intervention styles. You can’t compare apples to oranges.
- Inconsistency is a prominent characteristic of acupuncture research: the heterogeneity of results poses a problem for doing a proper meta-analysis.
- Publication bias is a huge problem for alternative medicine. There is a tendency to publish only those studies that show positive effects specifically in publications outside of the U.S. To be fair, this is a systemic concern in all of science.
- The Oxford Center for Evidence-Based Medicine states that “Acupuncture is no better than a toothpick for treating back pain.”
- Patients who don’t believe in acupuncture are not likely to volunteer for an acupuncture study. This is why we need controlled randomization for trials.
- China and Russia have thousands of studies published in peer review journals regarding acupuncture yet the vast majority (over 99%) of them show positive results! That is just plain crazy.
- True double blind trials, in which both patient and doctor are unaware of which type of treatment they are using hardly exist in sham acupuncture. This imbues the procedure with a significant bias.
- There is also no difference in the nocebo effect (negative response to a sham/inert treatment) of real acupuncture compared to sham acupuncture.
The theatrical placebo that acupuncture seems to trigger, does offer temporary benefit, for some, provided they are aware that they’re getting acupuncture. In randomized control studies (RCT), which use a form of sham acupuncture, the advantage is statistically insignificant. Yes, I’m sure one can point to several studies that proclaim acupuncture ‘works’. But in order to be truly evidence based we need to see these positive effects reproducible in an RCT. This has never been the case. Most studies examining the effectiveness of acupuncture are not rigorous. The trend shows the more rigorous a trial, the greater likelihood it will demonstrate the ineffectiveness of acupuncture, with results no better than a placebo. Clinical studies have clearly shown ‘benefits’ (placebos) with acupuncture in cases where the practitioner sticks the needles in willy-nilly (not in the acupuncture meridian points); uses toothpicks instead of needles, or uses retractable needles that don’t actually penetrate the skin. These three sham interventions do as well as actual acupuncture. It is reasoned the placebo effect may be amplified by the very performance of this ritual. Having a reassuring and caring practitioner who listens and lays out expectations of success may significantly increase the placebo effect. There is also some evidence that having a doctor examine and touch you may offer therapeutic relief.
“The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work”
When deciding to give acupuncture a try, the process usually entails: talking to people who had positive responses to the treatment (gathering lots of anecdotal evidence); starting to believe it will work (expectations); visiting the doctor’s office where a caring medical professional listens to your issues; immediately ‘feeling’ the treatment (needles going in the body); being touched by the practitioner (which has healing properties in itself); listening to the treatment specialist or doctor state with certainty this treatment will undoubtedly work (reinforcing one’s beliefs). It is not uncommon for relief to precede treatment! The expectations, beliefs, and professional care can have a huge effect on one’s own psychobiological composure.
Anecdotally, a client of mine and her sister were taken to an acupuncturist when they were young children for a stubborn sinus infection. She still remembers the horror they both felt at seeing needles sticking out of their skin. Regardless to say, despite their parents’ priming, they did not respond to the treatment. I suspect this is not an uncommon event. Some people go one step further and actually bring their unsuspecting pets into the acupuncturist’s office. I can only imagine what is going on in their heads.
The scientific method is a specific process that we utilize to move us closer to the truth over time. It isn’t perfect, far from it, but it is the best tool we have to explain why and how things work. After thousands and thousands of studies published in peer-reviewed journals, it is still impossible to point to any legitimate evidence that acupuncture works well for pain relief. The default position for science is to assume something is not true (null hypothesis). Skepticism is required in science and the burden of proof falls squarely on the treatment. At what point do we say, it is clear the benefits of acupuncture are inconsistent at best and likely due to the placebo effect? The most favorable evidence available for acupuncture efficacy is also the oldest, weakest and the most biased. Even when taking those old conclusions into account, they are barely clinically significant. A simple Tylenol or NSAID will do more for your pain than acupuncture. This and many other treatments are referred to as ‘alternative medicine‘. Alternative to what? If it is alternative to evidence-based efficacious medicine then that’s a real problem. Typically a medicine is no longer considered ‘alternative’ when it can be shown to reproduce consistent effective results. This is not the case with acupuncture.
So in the end, acupuncture seems to offer a powerful placebo effect. What is so bad about that? For starters, it costs money and time and promotes bad medicine science. Secondly, I am not aware of any condition where acupuncture outperforms modern-medicine. So treatment may result in delayed relief which modern medicine can provide. Saddest of all, desperate patients might be convinced to forgo all evidence-based treatments (a la Steve Jobs) and travel down the slippery slope of alternative medicine. We need to remember that all treatments have placebo effects. What we are looking for are effects above the placebo. And not every patient will experience a placebo effect. A placebo may help reduce pain, but it’s unlikely to do anything about the cause of the pain. The effects are often short-lived and the original symptoms are likely to pop up again in one form or another. Lastly, acupuncture does come with risks (42% have adverse events), mainly infections, soreness, bruising and sometimes but rarely death. Why risk doing something when there is no clear and consistent justification for treatment?
Bottom Line: Acupuncture may provide some individuals temporary pain relief via the placebo effect, although not for any of the reasons acupuncturists claim. Furthermore, there are real risks associated with the treatment.
It was a challenge for me to change my mind about acupuncture. For most of my life, I’ve blindly believed it worked. When presented with new contradictory data I chalked it up to the simple anomalous pattern within the research. I wanted it to work – it was an easy non-pharmaceutical way to mediate pain. However, after awhile I could not dismiss the overwhelming evidence that it was no more than an elaborate placebo. The Cochrane Reviews group analysis really solidified my thinking. As a personal trainer in NYC, I am constantly bombarded with queries about health and fitness. My field of work is rife with pseudoscience. It is my responsibility to provide the best evidence-based information I can find. In the case about acupuncture, the evidence does not hold up to rigorous scientific scrutiny.