Complementary and alternative medicine Medicine Pseudoscience Quackery Skepticism/critical thinking

Acupuncture versus science, linguistic edition

In the Journal of Integrative Medicine, acupuncturists argue for modernizing acupuncture by uncoupling it from its traditional Chinese medicine background and avoiding the mystical language about qi and meridians. Hilarity ensues, because acupuncture can’t be separated from the prescientific mysticism from which it arose.

Acupiuncture is a system of treatment rooted in the prescientific vitalism of traditional Chinese medicine (TCM). It doesn’t work. For anything. As Steve Novella and David Colquhoun put it, acupuncture is basically a theatrical placebo, which is why rigorous studies consistently fail to find a treatment effect due to acupuncture that is detectably greater than placebo. Not that that’s stopped acupuncturists and acupuncture advocates from trying desperately to show that acupuncture “works,” even if it means hooking up acupuncture needles to electrodes and turning it into transcutaneous nerve stimulation (TENS). Never mind that two thousand years ago even the Chinese didn’t understand electricity.

That’s why I was rather amused to come across an article in the Journal of Integrative Medicine by Ted Priebe et al entitled Can a science-based definition of acupuncture improve clinical outcomes? It’s tempting just to say no and leave it at that, but there’s too much amusement to be had by examining parts of the article and the contortions of logic the authors undergo to try to justify the use of acupuncture. Indeed, in the introduction, it’s almost as though Priebe et al admit that acupuncture is based on prescientific superstition, as they declare their purpose to “to unwind this entanglement and conduct acupuncture research according to biomedical principles.” Good luck with that. They also suggest that “avoiding prescientific arguments is one approach towards explaining acupuncture mechanism of action, efficacy and effectiveness.” Good luck with that, too.

First, Priebe et al liken acupuncture to the construction of knives, which is a perhaps a bit more apropos than they realize, given how acupuncture also “evolved” from primitive bloodletting of the kind favored by “traditional European medicine” (as I like to refer to it) in the Middle Ages:

Acupuncture, like knives, has evolved over millennia. They have ancient origins, modern utility, varied history, and even today, spiritual value. The manufacture of knives has evolved further than has the application of acupuncture. Acupuncture needs to migrate from a mind- body-spirit medicine described by Hui et al.[1] to a healing art based on science. Knife construction has moved past a “hand me down” craft to a precise, replicable, and standardized industry where quality is measured scientifically. Although knife making and acupuncture still value the traditional master-apprentice teaching practices, it is time for acupuncture, like knife manufacture, to advance towards scientific methodology for assessing practice outcomes and effectiveness.

One might also point out that knives, unlike acupuncture, can be shown unambiguously to be useful tools to accomplish specific tasks. Acupuncture, not so much. Of course, the big question I have is basically: How do you take a modality that posits the existence of anatomic structures that do not exist (meridians) and “energies” (qi) that have never been detected and make it scientific? Science requires parameters that are reliably detectable, measurable, and reproducible. Indeed, a Nobel Prize likely awaits the first acupuncturist or “integrative medicine” specialist who can definitively demonstrate the existence of qi and meridians and definitively demonstrate that inserting thin needles into these meridians somehow “unblocks” the flow of qi.

Of course, acupuncturists are starting to figure that out, but, instead of resulting in the rejection of acupuncture as the pseudoscience that it is, instead acupuncturists now tend to sweep all that inconvenient mystical mumbo-jumbo about qi and meridians under the rug:

Kendall [3] scientifically described the mechanisms of action of acupuncture as based upon early Chinese descriptions of “blood circulation, organization of the cardiovascular system, somatovisceral relationships (communication between the external body and the internal organs), immune system function and the organization of the musculoskeletal system.” The American College of Occupational and Environmental Medicine Guidelines recognized the effectiveness of needling without providing evidence of “meridians” or defining vital energy ow (qi).[4]

Let’s talk a bit about these early Chinese descriptions, shall we? TCM involves various modalities like pulse and tongue diagnosis. In the former, it is claimed that detailed diagnoses can be made just by feeling the pulse. Of course, the pulse is valuable in science-based medicine, but mainly as an indicator of cardiovascular status. In TCM, there are at least 29 different pulse types ranging from floating to slippery to forceful. Try to figure out how to recognize the Ge Mai (Leathery, Drumskin, Tympanic, Hard) pulse, for instance:

Bowstring and large (wide) with an empty center; feels like the head of a drum. Felt with light pressure. Floating, large, and hard and resistant to pressure.

Supposedly Ge Mai is associated with “Hemorrhage, Spermatorrhea, Abortion, Excessive Menstrual Flow, Xu Cold” and means, “The Qi becomes detached and floats to the exterior, the healthy Qi is failing to store sperm and blood.” There’s lots more where that came from, with the vague, mystical diagnoses failing to correspond with any physiological condition. Physiologically, these pulse diagnoses are meaningless. It’s diagnosis disconnected from reality.

Don’t even get me started on tongue diagnosis. Skeptics rightfully make fun of reflexology, which posits a homunculus on the soles of the feet and the palms of the hands, where various areas of the soles and palms “map” to various organs or body parts. Well, where do you think reflexologists got the idea? Probably from TCM tongue diagnosis, which basically maps different areas of the tongue to different organs and claims that by looking at the tongue one can diagnose illness in various organs. While it’s true that looking at the tongue is a useful part of physical diagnosis in science-based medicine, the way it’s used in TCM is, like pulse diagnosis, meaningless.

Now here’s the funny thing. Priebe et al appear to realize that the philosophical underpinnings of TCM are mystical prescientific superstition. That’s probably why they want so desperately to get away from them, noting with unintentional drollness that “fealty to traditional themes may add complexity, raising the bar and occluding the picture” and listing four areas (placebo, comparative effectiveness, Deqi and linguistics) where “fealty to traditional themes needlessly confounds acupuncture research.” Perhaps most telling is how Priebe et al invoke Ted Kaptchuk and his arguments:

He argued that placebo research must move beyond the view wherein placebo signifies a failure, instead investigating it as a straightforward clinical outcome; “We need more research involving clinical interventions designed to elicit placebo effects in participants without deception … we need to know precisely when, how and in what dose … these interventions can provide therapeutic benefit.”[14] Kaptchuk applied the “dose × frequency × duration” model to a meta-analysis of complementary and alternative medicine (CAM) therapies limited to supplements and herbs used for treating irritable bowel syndrome.[15] The study is of interest here because it pooled CAM interventions excluding acupuncture and discussion of traditional, non-scienti c considerations.

Kaptchuk’s arguments flow from the observation that, as alternative medicine therapies have been more intensively studied using more rigorous methodology, inevitably their effects are found to be indistinguishable from placebo effects. So Kaptchuk embraces placebo effects and has spent decades trying to demonstrate that they are useful and can be evoked without deception (they can’t). His arguments are similar to those of other alternative medicine advocates like Deepak Chopra that their woo works by “harnessing the power of placebo.” Unfortunately, thinking does not make it so.

So what do Priebe et al propose, given that rigorous randomized trials of acupuncture fail to show its efficacy beyond that of placebo? I think you know the answer to that one:

Despite Kaptchuk’s best arguments, placebo effectiveness is viewed as damaging to clinical outcomes research. By contrast, comparative effectiveness research occupies one of the highest rungs on the research ladder. In our view, the most renowned studies of comparative effectiveness in acupuncture research, i.e., the “German studies” did not measure up to Kaptchuk’s standard of when, how and what dose.[16] Comparative effectiveness research in clinical applications should demonstrate cost savings and improved outcomes when comparing techniques or procedures. The model must be specific, as acupuncturists and researchers will attest.[17] Standardization is necessary when comparing outcome measures, targeted points, diagnoses, and experimental/ control models.

Yes, this is basically the same justification used for preferring “pragmatic” studies on acupuncture, and it has the same flaw. Yes, comparative effectiveness research is important. Indeed, you can view comparative effectiveness research as a form of pragmatic studies. The problem once again is that the premise of such studies is that the treatments whose effectiveness are being compared actually have strong evidence of efficacy from randomized clinical trials. In other words, we already know that they “work.” Acupuncture fails that basic test. However, because comparative effectiveness studies generally don’t have placebo control arms, pragmatic studies and comparative effectiveness research will produce a false impression that acupuncture actually works, at least for subjective outcomes.

Finally, here’s the part that made me laugh the loudest, in which Priebe et al argue for changing linguistics:

Chinese “words” frequently have more than one meaning.[21] The symbol for “qi” can mean air or gas as well as “energy or life force”. For acupuncture traditionalists the word “qi” implies a dynamic functional view of all body systems.[30,31] The word “energy” is central to the cultural description of acupuncture and cannot be separated from Chinese medicine.[32,33] According to this view acupuncture works by releasing blocked energy circulating through invisible meridians. Use of these and similar terms when describing needling therapy is central to the claims, beliefs and practices among a cohort of TCM and acupuncture practitioners unconcerned these ideas have not been demonstrated scientifically. Schnorrenberger[30] has argued acupuncture finally needs an anatomical nomenclature for daily practice and scientific research. Yang et al.[34] has attempted to resolve the mysterious balance of yin and yang with the biophysical, i.e., positive and negative charge or matter and anti-matter.

These are not prejudices if one takes it as sun and moon, positive and negative charge, or matter and antimatter. However, we must focus on the science alone as there were quite a bit of superstitions, mystics, voodoo, and philosophical musing in the ancient world that should have no place in our scientific thoughts.[34]

Well, I can certainly agree with that last paragraph, but that’s the problem. Acupuncture cannot be separated from its origins in prescientific vitalisms. That “quite a bit of superstitions, mystics, voodoo, and philosophical musing in the ancient world that should have no place in our scientific thoughts” is the very basis of acupuncture. There is no anatomy that corresponds to meridians, nor is there physiology that generates or depends upon qi. That’s why there will always be this:

Pritzker describes a “tension” between “biomedical” and “anti-biomedical” camps that has proved “contentious” for more than a decade. In our view, this tension extends into the research domain.

Those acupuncturists who have a “biomedical” view are perhaps even more deluded than the “anti-biomedical” camp. After all, they seem to think that there is a biomedical basis to acupuncture and will contort all sorts of research findings to justify their belief in acupuncture. Priebe et al seem to fall into this category, as they conclude:

Despite decades of scientific arguments that support a biomedical model, steadfast insistence on the use of traditional terms remains a standard in the conduct of acupuncture research. The use of prescientific language in place of medical language commonly used in mainstream healthcare is harmful to the profession, practitioners and the public. It is our view that this insistence frequently dissolves into a defensive posture that places the patient at risk. This same view compromises and hamstrings practical outcomes in acupuncture research.

“Practical outcomes.” You keep using that term. I do not think it means what you think it means. Notice how Priebe tortures language (and himself) in order to continue to use acupuncture even though he has just admitted that it’s rife with mysticism, superstition, and “voodooo” that has no place in modern medicine. How can a system that is based in such nonsense ever be scientific? It can’t. Therein lies the conundrum. Priebe et al view themselves as science-based and, because they believe in acupuncture, assume that there must be a way to justify it scientifically as well. There isn’t, but that doesn’t mean that acupuncturists like Priebe et al won’t keep torturing science and language to keep trying.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

32 replies on “Acupuncture versus science, linguistic edition”

So overall the idea is to remove all theoretical and historical rationale (nutty as they may be) thus repudiating anything that legitimzes acupuncture but to keep on needling?

Sounds like a great idea to me. Next we can expect the homeopaths to embrace Avogadro’s Number, admit there is nothing but distilled water in the medicines but say it works better than tap water?

I for one wholly endorse an imbalance between matter and antimatter.

They packed a lot of fail into that article.

For instance, if they could translate the descriptions of the various pulse types into something I might see on an EKG, I’d be willing to listen. But the description of Ge Mai is so full of mixed metaphor that I don’t know how you could predict what that looks like on an EKG. Bowstring and drum at the same time? Hard and light at the same time?

Then there’s that bit about Chinese “words” (their scare quotes) having multiple meanings. Which is true; e.g., the character zhong can mean either “China” or “center”, depending on context. But that happens with English words, too. “Row” can be something you do with oars in a boat, or it can be a fight of some kind.

So Priebe et al. have set themselves an impossible task, but are too incompetent to recognize that the task is impossible.

Is it true that frequent acupuncture therapy, in a clinical setting, may reduce the incidence of dust in your living space?

If this is true, the theatrical placebo may become a useful dust buster. 🙂

. . . Comparative effectiveness [of acupuncture] research in clinical applications should demonstrate cost savings and improved outcomes when comparing techniques or procedures. . . .

So the basic plan is:

1. Rigorous clinical studies
Comparative effectiveness studies
2. ?
3. Profit

Apologies to underpants gnomes everywhere.

I think there is a typo in Clay Jones blog post over at SBM:

Bethesda, MD- Researchers at the National Center for Complementary and Integrative Health (NCCIH) have announced the discovery of a revolutionary form of “needleless” acupuncture that may soon replace the use of surgical-grade, .25 millimeter thick stainless steel needles that have been in use for millennia.

Shouldn’t the NCCIH have not added le to the word needleless. Needless acupuncture reads so much better,

Rich, do you mean the Clay Jones’ highly satirical blog post at SBM? At the end of the article: ” Tagged in: acupuncture, Humor, Satire”

Rich, do you mean Clay Jones satirical blog post at SBM? At the bottom are these words: “Tagged in: acupuncture, Humor, Satire”

Ooops…. got caught in moderation. Well, remember to look at the words at the bottom of Dr. Jones’ blog post. It is not a typo.

“surgical-grade, .25 millimeter thick stainless steel needles that have been in use for millennia.”

Stainless steel has been in existence for millennia? And surgical-grade, no less? Not to mention .25mm thick. I learn so many things on RI…


My next comments will be coming from either Chiang Mai or Puhket, over the next several weeks.

Rich@6: Both forms of acupuncture are equally needless, so I don’t see what’s so revolutionary about the former. I’d also ask how exactly the new technique differs from “electro-acupuncture”, but I’m not sure I want to know.

Not to mention that the kind of acupuncture that uses 0.25mm surgical grade needles goes all the way back to the ancient times of the mid 20th century. Meaning it’s even newer than reiki, which at least goes back to the early 20th century.

My guess is that some idiot PR flack (pardon the redundancy) wrote that press release.

Eric @9: Hate to burst Rich’s bubble but It’s Clay having a good laugh (and playing upon the Emperor’s New Clothes).

Although I can totally see someone advertising acupuncture needles that disintegrate upon being looked at. “Skip that pesky sterilization step and use new inviso-needles!”

The scientification (scientific sanctification??) of acupuncture by means of pragmatic studies?

Delusion redux.

The local paper recently devoted the front page of the Lifestyle section to what can only be described as a love letter to some nutbag who advertises heavily. Acupuncture is her game, and she desperately wants to be integrated into the “holistic” practices on call at our regional hospital.

The stupidest of the stupid was her claim that “the NIH recommends acupuncture for a wide variety of ailments,” by which she means the propaganda arm going by the name of NCCIH.

But these people do know their audience.

… positive and negative charge or matter and anti-matter.

Sure. Adopt those terms. That will impress people – except the people who happen to know those terms already have actual accepted meanings will likely be impressed on the negative/anti side. Hooey is hooey, even if you prefer to call it alternative facts.

Speaking of inane, have you heard the one about a TCM remedy for bleeding in childbirth? It’s a fish bladder that sells for more than cocaine, and it’s threatening the world’s most endangered species of porpoise, along with the existence of the fish from which the bladders are taken from.

@Robert L Bell

The 1997 NIH Consensus Statement on acupuncture was one of the more unfortunate episodes in the annals of the NIH.

Checking the references in Priebe et al. makes for a gruesome experience. Lousy quality studies of scant relevance to the case being made.

For example reference 10 is supposed to show scientific confirmation of traditional acupuncture points.

What we find is an RCT in which 41 healthy females were randomised to one of two acupressure groups (one group used points on the lower arm, the other group points on the leg) and a control group who received no acupressure. Subsequent physiological measurements on the trapezius muscles were similar for the arm acupressure and control groups but were significantly different for measurements of effects of leg-points acupressure. Reference is made to an earlier study by the authors which turns out to be a small study claiming to show acupuncture works for neck pain, but which could be perfectly well explained by placebo effects.

All of which amounts to nothing more than a waste of time.

It is always like this. Crap piled on crap all the way down.

Speaking of inane, have you heard the one about a TCM remedy for bleeding in childbirth?

Why can’t TCM remedies involve species like squirrels, or grackles, or coyotes?

@Shay Simmons #21: I know; it’s all a bit fishy. I mean, why couldn’t they use ergot?

@Leigh Jackson

Thank you! Properly forewarned, I will be properly forearmed in my next skirmish with the alt med people – who, sad to say, are a huge complex of businesses in my neck of the woods.

@Lighthorse: I was curious if one could go out on a limb to “justify” fish bladder (okay, only if pre-industrial or marooned somewhere) on the basis of a slight similarity to balloon tamponade for PPH. But, noooo. They had to go and eat a perfectly good, in a pinch balloon.

Plus, I second Shay’s suggestion. I think I’d choose mosquitoes, though. Likely there’d be enough Anopheles aegypti and Aedes aegypti extant to supply TCM demand and balance the ethical quandaries surrounding deliberate extinction, and still enough other spp. left over for the birds and bats, if we were to guess wrong.

But the main criterion for choosing ingredients in TCM — just as in other pre-modern, non-functioning traditions — is scarcity. Expense and unobtainability. Like bezoars in Traditional European Medicine. I can see several reasons for this:

1. If a curative ingredient were readily available, cures would also be readily available, in contradiction to the abysmal life expectancy in Traditional China. QED.

2. The clients for TCM were wealthy powerful people, who do not want a treatment that is also accessible for commoners.

3. “Oh, the patient died anyway? I guess that ground-up stone cut from the head of a toad from Tartary must have been a fake. It is so hard to tell the real stones cut from the heads of toads from Tartary.”

“Why can’t TCM remedies involve species like squirrels, or grackles, or coyotes?”

Or gullible H. sapiens (a few TCM cures do involve preserved human parts).

But the main criterion for choosing ingredients in TCM — just as in other pre-modern, non-functioning traditions — is scarcity. Expense and unobtainability.

There is a fine line to be walked here. The practitioner cannot prescribe unobtainium, because he has to be able to provide it when his powerful patient–especially if said patient is the emperor–demands it. Sure it can be expensive, but it must be available, at least to somebody who wants it badly enough.

Speaking of emperors, I have heard that one of the reasons that Qin Shihuangde’s tomb has not yet been excavated is that in his day mercury was thought to provide immortality, so one of the things they have to be prepared to deal with is serious mercury contamination. Yet another case where the “wisdom” of the ancients turns out not to be so wise. Of course the emperor was hedging his bets–this was the guy who ordered the creation of the terra cotta army to defend his body in the afterworld.

ang et al.[34] has attempted to resolve the mysterious balance of yin and yang with the biophysical, i.e., positive and negative charge or matter and anti-matter.


Did those guys think about that before they wrote it?

@Eric Lund #28: Mercury and then some. Writings from the time have it that the Emperor’s remains are entombed in the middle of a lake of mercury. Like the later practice of alchemists in Europe, from the fumes of their experiments, the quest for immortality through the manipulation of mercury by Chinese alchemists must have brought a number to madness, death, or both. Yet, to this day, practitioners of ayurvedic medicine in India insist that mercury can be rendered beneficial by means of “purification”, whereas they recognize unpurified mercury to be harmful. In years gone by, I found mercury, gold, lead, and other “purified” metals listed on boxes of ayurvedic herbal–mineral formulations sold domestically and abroad. An educational campaign among Indian pharmacists to root out such practices is ongoing in India., but formulations with “purifiied” (often abbreviated on labels as “purif.”) metals continue to show up in the marketplace.

Very interesting read. It’s always a good thing to be open to all angles on an issue.

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