editorial
. 2019 Jun 17;31(3):136–138. doi: 10.1089/acu.2019.29115.rfh
Richard F Hobbs , III
1,✉
PMCID: PMC7497961PMID: 32952791
Is acupuncture merely a trigger for placebo response (which parenthetically is not necessarily a bad thing), or does it deserve a rightful place in modern, scientific medicine? Currently, it depends upon whom you ask.1 Obviously, anatomy and physiology are a constant, regardless of paradigm. Likewise, there is overlap between what Western medicine treats and the purview of acupuncture. So, how do we answer the question? Historical perspective may provide some clues.
Early Western medicine was based on spiritual interpretations. If you angered the gods, you came down with seizures. However, around 400 BCE, the Hippocratic physicians turned the prevailing view from supernatural explanation for disease to a system based on natural causation. Specifically, diseases resulted from an imbalance of the humors—blood, black bile, yellow bile, and phlegm. The physician's role was to diagnose those dyscrasias and to advise the patient on how best to restore the natural state.2
Investigative science relating to Western medicine would not enter the picture for centuries to come. Dissection of cadavers by Vesalius in the 1500s led to a deeper understanding of gross anatomy; description of the circulation by Harvey in 1628 was a sentinel event in grasping human physiology; and use of the microscope by Hooke, first described in 1664, provided a tool for studying simple organisms, histology of tissues, and disease processes.2
With the emergence of science, new approaches for both diagnosis and treatment appeared. Ether anesthesia was first used in 1846, making it possible to conduct more technical procedures. Thanks to pioneers such as Semmelweis, Pasteur, and Lister, aseptic techniques and antisepsis made surgery and childbirth much safer. Roentgen discovered x-rays in 1895; insulin came along in 1921; Fleming happened onto penicillin in 1928. As a consequence of these developments and others, premature deaths became less common. In 1900, the average life-span (at birth) for males was 46 years and for females, 48 years. By 1950, the average life-span had increased to 66 years for males and 71 years for females. During that half-century, gains averaged about four years per decade. This was certainly an admirable accomplishment. In 1960, American males had an average life-span of 67 years, and for females, the average was 73 years. Since then, average life-spans for Americans have increased to 76 and 81 years for males and females, respectively.3,4 This constitutes an increase of just less than two years per decade—still moving in the right direction, but there has been a slight dip over the last two years. Perhaps we are coming upon the physiological limits of the human life-span, or maybe other factors are involved. Clearly, though, it is not all about length of life. Terms such as “wellness” and “quality of life” now figure prominently in setting health-care goals. Seventy is the new fifty, as the saying goes.
Have we always gotten it right? No. Consider hormone replacement therapy, the opioid crisis, aspirin for primary prevention. The reason we have these misadventures is that, sadly, medical science is not always good science. There are many reasons why this is so. Investigator bias related to funding sources; the Aristotelian trap that if something makes sense, it must be true; and the complexities of living organisms and incomplete understanding of disease processes are just a few examples. No wonder Western medicine seems to undergo a metamorphosis every five years or so. Interestingly, the vector is not always in what might be considered a positive direction. What was true five years ago may no longer be true. However, it might be true again in another five years. Consider the number of times that Digoxin has come into and out of vogue over the past 50 years. Still, on balance, Western medicine has made great progress, and we have science to thank. Progress has been directed not only toward lengthening life-span, but also on reducing suffering and improving quality of life.
So, what about acupuncture? Chinese medicine traces its origins to ancient shamanic practices, not very different from the spiritual roots of Western medicine. Eventually, Daoist concepts of Qi and Yin and Yang replaced shamanism. This resulted in an intellectual framework that was based on the principle that nature prefers a balance between Yin and Yang and that Qi has the capacity of maintaining that balance through a transformative process. Interestingly, this happened at around the same time as the Hippocratic movement in the West. The two systems shared the concept of balance being necessary for wellness. I do not believe that this was a coincidence. Nature does, after all, have its organizing principles, its symmetries. Scientists intuitively look for these patterns.
As in Western medicine, new theories in acupuncture have arisen from time to time. For the most part, those that have survived have done so on the basis of empirical evidence. You keep what works and discard what doesn't. Empiricism is a crucial element in the scientific method. So, in that sense, acupuncture is and always has been informed by science. However, an under-emphasized component has been that process of constant refinement necessary for confirmation and evolution of theories. In classical acupuncture, the Nei Jing is still the bible.
Without refinement, any discipline becomes stagnant. Without refinement, we would still be thinking of Earth lying at the center of the universe and of Newtonian mechanics being the final say. Thankfully, Copernicus and Einstein came along at just the right times to take a fresh look. So, from the center of everything, we have come to know that our lives are relegated to a rocky planet, orbiting an ordinary star, in a galaxy containing a few hundred billion solar masses, in a universe containing hundreds of billions of galaxies. Our concept of physical interactions has moved from falling apples to quantum entanglement. We have had to wrap our minds around things not being the way they seem. As a result, our scientific curiosity has blossomed in ways our ancestors would never have imagined. And, through the basic sciences, we have reaped the fruits of innovation. Think about what has happened in Western medicine, just since 1960. We've seen the development of computed tomography, magnetic resonance imaging (MRI), diagnostic ultrasound, genomics, and genetic testing, not to mention advanced drug treatments, transplant surgeries, coronary artery bypass, luminal stents, joint replacements, robotics, and a plethora of other modalities for diagnosis and treatment. None of these would have been possible without an underpinning of basic science research.
As acupuncturists, practitioners of Chinese medicine, are we stuck, forever depending on ancient texts, unsubstantiated theories, and anecdotes in shaping our practices, or are we willing to take things to the next level? Are we willing to take a chance and shed the light of science on what we do?
In my opinion, we are headed in the right direction. A regression analysis of acupuncture-related publications between 1995 and 2014 revealed an exponential growth. Of these, randomized controlled trials increased from 7.4% of publications in 1995 to 20.3% of publications in 2014. This compares to a 4.5% increase for Western medicine.5 Beginning with a sentinel study in 2012, systematic reviews and meta-analyses looking at clinical effectiveness have become commonplace, especially for painful conditions.6 Using effect size to compare acupuncture with other interventions has also come into vogue. Based on evidence, although not a panacea, acupuncture clearly helps many people and for a variety of conditions.
Although acupuncture research is catching up, much work remains to be done. For example, we have no evidence supporting one style of acupuncture over another, an obvious indication for comparative effectiveness studies. We also need to be looking at the effectiveness of acupuncture in treating symptoms other than pain. Basic science research is gaining some ground, especially in China. However, we still have a long way to go in delineating underlying mechanisms.
From activation likelihood analysis of functional MRI data, we know that acupuncture affects many parts of the brain, including the default mode network, the limbic system, and centers for autonomic regulation. Furthermore, we know that patterns of activation and deactivation are point specific. Not surprisingly, LI4, LR3, and ST36 are the three most influential points on metabolic activity in the brain.7 Research aimed at determining signaling mechanisms and integrative functions may help us to determine why points have unique projections on the brain. This, in turn, will add to our understanding not only of acupuncture effects, but also of the brain and how it is connected to and regulates the rest of the body.
In time, we may be choosing points based on a new paradigm, one based on selective access to neural pathways. In the meantime, we honor the methods we have been taught, those that we know work, those that tell us where to put the needles. But, looking to the future, just as with Western medicine, our hope, our intention, must be improved outcomes.
So, back to the original question. Clearly, acupuncture does deserve recognition as an empirically derived system that truly helps to relieve suffering and promote wellness. Evidence exists that it is not just a trigger for placebo effect. However, it is in the early stages of scientific exposition. I'm thinking we are about where Western medicine was in 1960. Potentially, we have tremendous tools at our disposal—tools such as diffusion tensor imaging, a means for visualization of neural pathways. Funding and allocation of resources in the research community will be a critical issue. Acupuncture does not share the same financial incentives enjoyed by the pharmaceutical industry. We have to make our case to the National Institutes of Health and to academic centers that the cost and the effort is in the public interest and that acupuncture is a safe, cost-effective alternative to drugs and other, more expensive, physical interventions.
In my opinion, our goal as physician acupuncturists should be to promote the application of the full breadth of science to examine this ancient healing practice, both mechanistically and clinically, until we understand it fully. Fortunately, clinical acceptance is growing, largely as a result of anecdotal evidence plus, of course, those randomized controlled trials and systematic reviews. However, if medical acupuncture is to be fully welcomed under the umbrella of Western medicine, we have to be serious about understanding the underlying mechanisms. Rather than falling into that Aristotelian trap, we must rigorously adhere to where the evidence takes us. There is no reason to be fearful that the treasures of ancient wisdom will be lost or that one theory might take precedence over others. As Sir Isaac Newton alluded, we stand upon the shoulders of giants, and from that perspective, we will see our way into the future.
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