Hi Tim,
A good email, covering several issues that have been discussed regularly for the 11 years I’ve been studying acupuncture, and I’m sure many years before that too. I’m sure Sean and Carole will have comments too if they have the time. Speaking of time, this is kind of long, so you might want to make yourself a hot drink now before you start.
It’s probably easiest to go through these issues in the order you presented them, so let’s start with the double-blind randomised controlled trial. RCTs (albeit obviously not double-blind) have been conducted for surgical techniques, although I’m only aware of a couple, and only one in the last 10-20 years. There are good reasons for the paucity of surgical RCTs.
Placing an arbitrary division between “procedural� and “chemical� interventions might be overly simplistic. Chiropractic, physiotherapeutic, and massage interventions are all procedural, but do lend themselves to RCTs if properly designed. Surgery is in itself an established and well-understood procedure, as far as it is measured. On one level you might consider surgery a fairly simple intervention – provide access to damaged tissue and repair it mechanically. Progress in the field of surgery is linked more strongly to technological advancement in the tools used, rather than in discovering a new surgical procedure. As the tools improve, access can be made to deeper and smaller structures, to which the basic surgical techniques are then applied. So in this sense, surgery should not in itself need to be re-evaluated every time a tool is improved.
The second consideration with surgery is an ethical one. If a patient needs surgery, can it ethically be denied while a study is conducted? In other words, can a group of patients receive either a placebo or no treatment at all? If a patient does not need the surgery, how ethical is it to expose that patient to the inherent dangers and stresses of surgery? In the very small number of cases where a technique is minor enough so that a patient can undergo the procedure twice (once while receiving the placebo or null treatment, and then once properly after the study), there is still the ethical issue of the value of conducting that study. Very, very few surgical interventions are going to get to this point and continue on to trial. One that recently did involved a very simple surgical technique on the knee (one enabled by technological advancements which drastically reduced the invasiveness of the technique).
Acupuncture, on the other hand, is relatively non-invasive (note I said “relatively� – having a metal needle stuck into you is not non-invasive – just far less so than having surgery!). Also, acupuncture is not, in 21st century Western society, an emergency therapy. The conditions practitioners treat are relatively benign. So the ethical consideration of delaying treatment is drastically lessened. Further, an ethical consideration is introduced by NOT conducting a RCT. Is the patient receiving the most appropriate treatment available for the condition being treated? How can we tell? By conducting, publishing, and reading research. Patients today have no shortage of choices for treatment. Why do they choose to have a dozen metal spiked inserted into their bodies instead taking medicine prescribed by their GP, or instead of another alternative or complementary therapy? Because acupuncture therapists assert that acupuncture is the answer. How do acupuncture therapists know this is true? Well, it gets a bit confronting for some acupuncturists here, so those with blinkers and short fuses might like to change channels now.
We assert that acupuncture works for their therapy because (a) we have read good quality research that found significant effects, or (b) we have read garbage research that claimed positive effects, or (c) we read in a book or heard in class that it works for the condition, so it must be so, or (d) acupuncture advertising is crucial to success as an acupuncturist, so it follows that I must be positive about its effects.
More often than not acupuncturists will be motivated by a number of these drivers at once. The critical point is that patients have choices, and it is in their interests for them to receive a treatment that has been proven to work. How ethical is it for us to promote a treatment which is unproven when in reality the patient will likely then forgo other treatments? Further, if the research is available and a practitioner hasn’t bothered to read it because “research is boring�, how can that person consider himself or herself a holistic therapist? All they’re doing is putting their own business interests before the health interests of the patient. Derryn Hinch would have a field day. Shame, shame, shame.
Okay, I’m getting a bit excited. Back to the point. The point is that acupuncture is researched and reported. Therapists have an ethical and professional duty to embrace it. RCTs are appropriate for acupuncture because they are a superior model and they work for acupuncture. Just look at the literature. Unfortunately, those practitioners who don’t like studying research methods, don’t like reading research, and/or have a chip on their shoulders are those most likely to cry foul on the issue of RCTs for acupuncture. True, double-blind studies are hard to design for acupuncture. I do think they are achievable. The question is whether there is value in going that far, but that’s an argument for another day…
Okay, your second point was why is it that sham acupuncture so often resembles Japanese acupuncture? I think the core of this issue is a clash of cultures – traditional medicine versus orthodox contemporary medicine. Traditional medicine, in this case the minimal stimulation school of Japanese acupuncture, does not relate the strength of stimulation to the strength of effect. Orthodox contemporary medicine does make this relationship. Therefore, in one school, minimal stimulation is correct for maximising therapeutic effect, in the other, it is appropriate to minimise therapeutic effect. How can we tell which is correct? How does conducting a number of RCTs sound? Research is the answer.
Your third question related to conducting a battery of general health tests that could tell us whether the patient's health status is improving over the course of treatment. There are a couple of issues to consider here. Firstly, such a raft of tests is resource-intensive (time, personnel, money, equipment, etc.) Secondly, why would these tests work? Acupuncture is supposedly a subtle medicine. The classics tell us that disease should be found before signs are evident. The tests you propose are relatively gross when compared to taking the pulse, palpating the body and reading the tongue. And what would they tell us? Where in the classics are blood-work results discussed? I think when we try to combine two disparate theories of medicine, we tread where monsters be. It’s akin to prescribing acupoints according to an orthodox contemporary medicine diagnosis. Acupuncture wasn’t designed that way. HOWEVER, if it can be established that certain physiological effects are caused by research, then yes, appropriate measurements, perhaps including blood-works may be useful. How would we find this out? Guess. RCTs.
And your final point is one close to my heart, and I think I’ve touched on it a couple of times already. No, the profession of acupuncture is not doing enough to be, well, professional. Individuals are doing a great deal. Kath Berry and her colleagues deserve kudos for establishing this forum and maintaining it. Meaghan Coyle has spent years working in the Australian hospital environment demonstrating how acupuncture can be researched and applied as a complement to orthodox contemporary medicine. Sean Walsh and Emma King both researched fundamental issues regarding the practice of acupuncture. Deirdre Cobbin, Carole Rogers and Chris Zaslawski paved the way for these people, and have done a tremendous amount to increase the professionalism in Australia and internationally. Many other people have made similar contributions, but the sad fact is that the majority of practitioners are pointed in the opposite direction, and spend more time disparaging research methods and acupuncture research, and ultimately, consciously or not, often making false claims about the efficacy of acupuncture. It is unrealistic to expect acupuncture is appropriate for all or even most diseases. No form of medicine is ever going to achieve that title. Better to invest our efforts in discovering what acupuncture can do better than other therapies, and promote that. And the road to that end is paved with many research studies which must be properly design and run, written and published, read and understood. Evaluating them and determining “how useless this trial or that one was� is how we as a profession learn what works and what is better left alone.
If you read this far, you probably need a Panadol. Or perhaps LR3. Check Medline and see which works better…
Mark
), can you help to enlighten me?
