Harriet Hall, a retired family practitioner who is interested in quackery, has summed up the significance of acupuncture research in an interesting way:. Acupuncture studies have shown that it makes no difference where you put the needles. Or whether you use needles or just pretend to use needles as long as the subject believes you used them.
Many acupuncture researchers are doing what I call Tooth Fairy science: measuring how much money is left under the pillow without bothering to ask if the Tooth Fairy is real. Improperly performed acupuncture can cause fainting, local hematoma due to bleeding from a punctured blood vessel , pneumothorax punctured lung , convulsions, local infections, hepatitis B from unsterile needles , bacterial endocarditis, contact dermatitis, and nerve damage.
The herbs used by acupuncture practitioners are not regulated for safety, potency, or effectiveness. There is also risk that an acupuncturist whose approach to diagnosis is not based on scientific concepts will fail to diagnose a dangerous condition. The adverse effects of acupuncture are probably related to the nature of the practitioner's training.
A survey of 1, Norwegian physicians revealed 66 cases of infection, 25 cases of punctured lung, 31 cases of increased pain, and 80 other cases with complications. A parallel survey of acupuncturists, who are more apt to see immediate complications, yielded cases of fainting, 26 cases of increased pain, 8 cases of pneumothorax, and 45 other adverse results .
However, a 5-year study involving 76 acupuncturists at a Japanese medical facility tabulated only 64 adverse event reports including 16 forgotten needles and 13 cases of transient low blood pressure associated with 55, acupuncture treatments. No serious complications were reported. The researchers concluded that serious adverse reactions are uncommon among acupuncturists who are medically trained . In , members of the British Acupuncture Council who participated in two prospective studies reported low complication rates and no serious complications among patients who underwent a total of more than 66, treatments [14,15].
An accompany editorial suggested that in competent hands, the likelihood of complcations is small . Since outcome data are not available, the studies cannot compare the balance of risks vs benefit. Nor do the studies take into account the likelihood of misdiagnosis and failure to seek appropriate medical care by practitioners who use traditional Chinese methods. There is also financial risk. Herbal products, which many practitioners commonly prescribe, could range anywhere from a few dollars to a few hundred dollars per month.
In , an acupuncture boom occurred in the United States because of stories about visits to China by various American dignitaries. Entrepreneurs, both medical and nonmedical, began using flamboyant advertising techniques to promote clinics, seminars, demonstrations, books, correspondence courses, and do-it-yourself kits.
Today some states restrict the practice of acupuncture to physicians or others operating under their direct supervision. In about 20 states, people who lack medical training can perform acupuncture without medical supervision. The FDA now classifies acupuncture needles as Class II medical devices and requires labeling for one-time use by practitioners who are legally authorized to use them .
Acupuncture is not covered under Medicare. The March issue of the Journal of the American Chiropractic Association carried a five-part cover story encouraging chiropractors to get acupuncture training, which, according to one contributor, would enable them to broaden the scope of their practice . In , it reported that its certification programs or exams were be recognized for licensure in 40 states and the District of Columbia and that more than 20, practitioners are licensed in the United States .
The Acupuncture. The credentials used by acupuncturists include C. Some of these have legal significance, but they do not signify that the holder is competent to make adequate diagnoses or render appropriate treatment. In , the U. However, such recognition is not based on the scientific validity of what is taught but upon other criteria . Ulett has noted:. Certification of acupuncturists is a sham. While a few of those so accredited are naive physicians, most are nonmedical persons who only play at being doctor and use this certification as an umbrella for a host of unproven New Age hokum treatments.
Unfortunately, a few HMOs, hospitals, and even medical schools are succumbing to the bait and exposing patients to such bogus treatments when they need real medical care. In , a Consensus Development Conference sponsored by the National Institutes of Health and several other agencies concluded that "there is sufficient evidence. Rather, they reflected the bias of the panelists who were selected by a planning committee dominated by acupuncture proponents . Although the report described some serious problems, it failed to place them into proper perspective. The panel acknowledged that "the vast majority of papers studying acupuncture consist of case reports, case series, or intervention studies with designs inadequate to assess efficacy" and that "relatively few" high-quality controlled trials have been published about acupuncture's effects.
But it reported that "the World Health Organization has listed more than 40 [conditions] for which [acupuncture] may be indicated. Far more serious, although the consensus report touched on Chinese acupuncture theory, it failed to point out the danger and economic waste involved in going to practitioners who can't make appropriate diagnoses. The report noted:. Simply stated, this means that if you go to a practitioner who practices traditional Chinese medicine, you are unlikely to be properly diagnosed.
Very few publications have mentioned this, which strikes me as very strange. I advise people to avoid "certified" practitioners.
Because the training needed for certification is based on nonsensical TCM theories, the safest way to obtain acupuncture is from a medical doctor who does research at a university-based medical school and does not expouse such theories. In , following a lecture I attended at a local college, an experienced TCM practitioner diagnosed me by taking my pulse and looking at my tongue. He stated that my pulse showed signs of "stress" and that my tongue indicated I was suffering from "congestion of the blood.
I took the woman's pulse and found that it was completely normal. I believe that the majority of nonmedical acupuncturists rely on improper diagnostic procedures. The NIH consensus panel should have emphasized the seriousness of this problem. Subsequent research has confirmed that TCM diagnosis has very little to do with people's real health problems. At least six studies have found that when multiple practitioners see the same patient, their TCM diagnoses vary considerably.
In a study published in , a year-old woman with chronic back pain who visited seven acupuncturists during a 2-week period was diagnosed with "Qi stagnation" by 6 of them, "blood stagnation" by 5 , "kidney Qi deficiency" by 2, "yin deficiency" by 1, and "liver Qi deficiency" by 1. The proposed treatments varied even more. Among the six who recorded their recommendations, the practitioners planned to use between 7 and 26 needles inserted into 4 to 16 specific "acupuncture points" in the back, leg, hand, and foot.
The study appears to have been designed to make the results as consistent as possible. All of the acupuncturists had been trained at a school of traditional Chinese medicine TCM. Six other volunteers were excluded because they "used highly atypical practices," and three were excluded because they had been in practice for less than three years. The study's authors stated that the diagnostic findings showed "considerable consistency" because nearly all of the practitioners found Qi or blood stagnation.
However, the most likely explanation was that these are diagnosed in nearly everyone. In another study, six TCM acupuncturists evaluated the same six patients on the same day. Twenty diagnoses and 65 acupoints were used at least once. However, consistency across acupuncturists regarding diagnostic details and other acupoints was poor. No diagnoses, and only one acupoint, were used preferentially for a subgroup of patients.
Some diagnoses and treatment recommendations were dependent more on the practitioner than on the patient. Fine-grained diagnoses and most acupoints were unrelated to either patient or practitioner. The researchers concluded that TCM diagnoses and treatment recommendations for specific patients with chronic low back pain vary widely from one practitioner to another . Another study examined TCM diagnoses and treatments for patients with chronic low-back pain using two separate sets of treatment records.
Information from more than initial visits was available for analysis. An average of needles was used in each treatment. Although more than 85 different acupoints were used in each data set, only 5 or 6 acupoints were used in more than 20 of the treatments in each data set.
The Role of Acupuncture in Treating Chronic Pain
Only two of those acupoints UB23, UB40 were the same for both sources of data. There was substantial variability in treatments among providers . Each patient filled out a questionnaire and underwent a physical examination that included tongue and pulse diagnosis. Then each practitioner provided both a TCM diagnosis and a herbal prescription. The degree to which the herbal prescriptions agreed with textbook recommended practice of each TCM diagnosis ranged from The study's authors concluded:. When less stringent, but theoretically justifiable, criteria were employed, greater consensus was obtained.
The correspondence between the TCM diagnosis and the herbal formula prescribed for that diagnosis was high, although there was little agreement among the 3 practitioners with respect to the herbal formulas prescribed for individual patients . The University of Maryland researchers then repeated the above study using 40 RA patients and three practitioners who had had at least five years of experience. The results were nearly identical to the previous findings .
In another study, 37 participants with frequent headaches were independently evaluated by three licensed acupuncturists said to be highly trained in TCM. The acupuncturists identified the meridians and type of dysfunction they believed were contributing to the participants' symptoms. The acupuncturists also ascribed one or more TCM diagnoses to each participant and selected eight acupuncture points for needling.
Some variation in TCM pattern diagnosis and point selection was observed for all subjects. It would be fascinating to see what would happen if a healthy person who needed no medical treatment was examined by multiple acupuncturists. TCM theory and practice are not based upon the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community.
TCM practitioners disagree among themselves about how to diagnose patients and which treatments should go with which diagnoses. Even if they could agree, the TCM theories are so nebulous that no amount of scientific study will enable TCM to offer rational care.
Dubious Claims The conditions claimed to respond to acupuncture include chronic pain neck and back pain, migraine headaches , acute injury-related pain strains, muscle and ligament tears , gastrointestinal problems indigestion, ulcers, constipation, diarrhea , cardiovascular conditions high and low blood pressure , genitourinary problems menstrual irregularity, frigidity, impotence , muscle and nerve conditions paralysis, deafness , and behavioral problems overeating, drug dependence, smoking. The researchers stated: In most of the trials, disease was defined and diagnosed according to conventional medicine; trial outcomes were assessed with objective or subjective or both methods of conventional medicine, often complemented by traditional Chinese methods.
Harriet Hall, a retired family practitioner who is interested in quackery, has summed up the significance of acupuncture research in an interesting way: Acupuncture studies have shown that it makes no difference where you put the needles. Risks Exist Improperly performed acupuncture can cause fainting, local hematoma due to bleeding from a punctured blood vessel , pneumothorax punctured lung , convulsions, local infections, hepatitis B from unsterile needles , bacterial endocarditis, contact dermatitis, and nerve damage.
Questionable Standards In , an acupuncture boom occurred in the United States because of stories about visits to China by various American dignitaries.
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Ulett has noted: Certification of acupuncturists is a sham. Its theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge Research during the past 20 years has not demonstrated that acupuncture is effective against any disease. Perceived effects of acupuncture are probably due to a combination of expectation, suggestion, counter-irritation, conditioning, and other psychologic mechanisms. The use of acupuncture should be restricted to appropriate research settings, Insurance companies should not be required by law to cover acupuncture treatment, Licensure of lay acupuncturists should be phased out.
Consumers who wish to try acupuncture should discuss their situation with a knowledgeable physician who has no commercial interest . The report noted: The general theory of acupuncture is based on the premise that there are patterns of energy flow Qi through the body that are essential for health.
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Disruptions of this flow are believed to be responsible for disease. The acupuncturist can correct imbalances of flow at identifiable points close to the skin. Acupuncture focuses on a holistic, energy-based approach to the patient rather than a disease-oriented diagnostic and treatment model.
Despite considerable efforts to understand the anatomy and physiology of the "acupuncture points," the definition and characterization of these points remains controversial. Even more elusive is the scientific basis of some of the key traditional Eastern medical concepts such as the circulation of Qi, the meridian system, and the five phases theory, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture.
Diagnostic Variability In , following a lecture I attended at a local college, an experienced TCM practitioner diagnosed me by taking my pulse and looking at my tongue. The Bottom Line TCM theory and practice are not based upon the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community. Acupuncture: Past, present, and future. In Stalker D, Glymour C, editors.
Understanding the Difficult Patient - AcuMedic Shop
Examining Holistic Medicine. Amherst, NY: Prometheus Books, Kurtz P, Alcock J, and others. Skeptical Inquirer , Melzack R, Katz J. Auriculotherapy fails to relieve chronic pain: A controlled crossover stud y. Acupuncture and chronic pain: A criteria-based meta-analysis. Clinical Epidemiology , A meta-analysis of studies into the effect of acupuncture on addiction. British Journal of General Practice , Beyerstein BL, Sampson W. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.
Commitment to professional competence. Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal. Commitment to honesty with patients. Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred.
This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that in health care, medical errors that injure patients do sometimes occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.
Commitment to patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an increasing availability of genetic information.
Physicians recognize, however, that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest for example, when patients endanger others. Commitment to maintaining appropriate relations with patients.
Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose. Commitment to improving quality of care.
Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patient safety, minimize overuse of health care resources, and optimize the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions, and systems responsible for health care delivery.
Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care. Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care.
Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession. Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.
They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost effective care. Commitment to scientific knowledge. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience.
Commitment to maintaining trust by managing conflicts of interest. Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms.
Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals. Commitment to professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self regulation, including remediation and discipline of members who have failed to meet professional standards.
The profession should also define and organize the educational and standard-setting process for current and future members.