More On The Crisis In The Acupuncture Profession

As a followup to my previous post – http://www.wellnessclarity.com/?p=183, I am reposting an essay below I wrote almost 10 years ago called – Toward a Post-Traditional Revision Of Acupuncture. Judging by emails received after the initial posting, acupuncturists in the US and a few other countries found it useful. The essay was also published on the National Guild of Oriental Medicines website in an edited form.

For the reasons summarized below the need for change in the acupuncture profession has become more apparent and more urgent in the intervening 10 years since writing the above article.

The two main concerns are; the failure to thrive financially for the majority of practitioners and continuing isolation of the profession in the contemporary scientific medical environment. Little has changed on these two linked fronts in the past ten years, in fact despite increased research and media attention given acupuncture therapy, the situation has worsened.

Also the high quality research carried out mostly in the West shows that elaborate traditional or neo-traditional acupuncture treatment models and types of acupuncture fail to show better outcomes compared to simple treatment models based on modern anatomy and physiology.

In other words – the sit up and take notice implication is – style or length and complexity of acupuncture training have little effect on clinical outcomes as long as practitioners are trained for contemporary medical competency. As an acupuncturist friend said recently, “I now know this could be taught in a year, not three or four years”.

See Medscape Medical News > Neurology  Acupuncture Superior to Placebo, Usual Care for Chronic Pain, by Pauline Anderson, September 10, 2012 in which Dr Andrew Vickers a seasoned researcher of acupuncture states –

The type of acupuncture didn’t seem to make a difference to the results, said Dr. Vickers. “Some acupuncturists will tell you not to go to such and such a person because that person doesn’t put the needles in the right way, or they don’t use the right theories, or they’re not as well trained, but the particular type of acupuncture you get doesn’t seem to make a large difference.”

Though feared by some practitioners, the wholism and naturalism associated with acupuncture and oriental medicine is not lost with a modern scientific iteration. Nor is this reconfiguring a capitulation to scientific materialism as a final statement on human life, it simply follows from the clear evidence that acupuncture is a neuromuscular mediated treatment that positively modifies physiological functioning.

I have no affinity with the arrogant debunking of acupuncture often featured in contemporary medical editorials. Simply put however acupuncture, by the very best evidence available, is a nervous system mediated treatment, not energy medicine. The continuing wholesale depiction of it as energy medicine does disservice to both acupuncture as a physiological treatment and to authentic practice of healing. This also ignores the central mind-body effect in all medicine, the placebo effect, a strong real world addition to the physiological proven acupuncture effect. An effect that has been poached from, so to speak, by the plethora of acupuncture styles used today, arrogating healing via the placebo effect into their own preferred mystical or quasi scientific theories.

To summarize the main points are –

The Qi/meridian theory is being increasingly abandoned by discerning acupuncturists given lack of evidence for it despite decades of research. (there is a strong movement in this direction even in China according to YunTao Ma)Also for lack of historical support due to poorly translated and misinterpreted traditional texts, and due to failure to cohere with contemporary medical science. And I might add, as many acupuncturists, after years of real-world experience, find themselves outgrowing the belief systems and closed, untestable theories inculcated at acupuncture school.

High quality research shows little or no difference between acupuncture styles/theories and treatment outcomes, suggesting a common physiological basis. Showing that simple contemporary medical acupuncture works at least as well as elaborate, arcane traditional and neo-traditional acupuncture. This also provides an opportunity for cost effective, streamlined training programs that don’t involve learning new, almost religious like, belief systems. As far as I know acupuncture schools have yet to respond whole heartedly to this in transforming their programs. Nor to link their programs and curriculums to the ability of graduates to pay down their loans in 10 years.

As outlined in my previous article http://www.wellnessclarity.com/?p=183, the acupuncture profession is only economically viable for a few. For the vast majority it is essentially a part time profession either requiring financial support from other means or featuring sustained low economic status. Job prospects are close to nil with well over 90% of graduates forced to setup private practices.

Along with this it is usual that acupuncture school graduates start their professional life with high debt burdens ($80,000 to $180,000) they may never repay through professional earnings. It is an open question whether acupuncture schools are abusing the federal student loan system with these facts becoming more established.

Below are some resources that clearly show how acupuncture can be learned, practiced, researched and explained entirely within a contemporary scientific view without downplaying its wholism and the non-quantifiable aspects of the art of practice. You will enjoy the clarity, simplicity and for the most part lack of dogmatism of this evolving approach!

An Introduction To Western Medical Acupuncture – http://www.amazon.com/Introduction-Western-Medical-Acupuncture-1e/dp/0443071772/ref=sr_1_1?s=books&ie=UTF8&qid=1400612651&sr=1-1&keywords=western+medical+acupuncture

Biomedical Acupuncture For Pain – http://www.amazon.com/Biomedical-Acupuncture-Pain-Management-Integrative/dp/0443066590/ref=sr_1_2?s=books&ie=UTF8&qid=1400612808&sr=1-2&keywords=yun+tao+ma

http://www.amazon.com/Gunn-Approach-Treatment-Chronic-Pain/dp/0443054223/ref=sr_1_1?s=books&ie=UTF8&qid=1400612969&sr=1-1&keywords=C+chan+gunn

Acupuncture In Medicine – http://aim.bmj.com

Energy Meridian Misconceptions by D Kendall http://www.tedpriebe.com/documents/Kendall_SJIM_meridians. pdf

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Toward a Post-Traditional Revision Of Acupuncture

by Thomas Martin, MA, LAc.

In recent years numerous researchers, practitioners and commentators of contemporary traditional acupuncture have questioned the validity of central concepts in this practice and therefore the integrity and accuracy of its core theories. The theoretical basis of contemporary traditional acupuncture is thus shown to be not what it has been made to appear like – an extraordinary metaphysical system linking all parts of the body/mind in a subtle energetic system. It is now clear to those who are prepared to think and look beyond the self enclosing loops of traditional dogma, that after four decades of research there is no evidence meridians exist nor that Qi as energy that moves around exists. Even precise acupoints for the most part don’t exist. (See Pomeranz; Ernst & White Ed.; Campbell; Mann; Ma, Ma and Cho; Kendall).

And yet acupuncture is effective, and that it appears to involve a physical interrelatedness of parts of the body via the peripheral and central nervous systems and brain increasingly recognized through scientific study.

Common contemporary usage of terms Qi and Meridian, both central concepts of acupuncture and Chinese medicine are based upon mistranslations (Kendall). Qi is thought to be untranslatable by many Chinese medicine scholars (the Chinese pictogram shows steam over cooking grains). Chinese medicine scholar Paul Unshuld considers the word “vapor” or “subtle influences” as close translations. Others consider “vital strength” or “functional activity” to be approximate meanings. Translation of Qi as energy is widely considered erroneous by scholars of Chinese medicine.

Consider the visual appearance of acupuncture meridians as they are shown in contemporary textbooks. Despite ancient comparisons of meridians with streams, rivers and seas their actual appearance is one of artificial superimposition over the body. Compared with the branching, flowing nature of the nervous system and blood vessels, meridians are depicted with straight lines and zigzags. This glaring discrepancy rarely seems to be questioned by traditionally trained acupuncturists and acupuncture teachers. Instead the implicit assumption seems to be that materialist science could never be privy to such subtle manifestations and that one day their existence will be proven.

Despite the historical evidence that it was originally meant to represent pre-modern shorthand for the vascular system, the meridian system shows up repeatedly in contemporary books and articles as supposed evidence of subtle metaphysical energy in the body. (Long-xiang Huang in Ma, Ma and Cho. Also see p 170 to 171 in Huang Di Nei Jing Su Wen, Chinese medicine scholar Paul Unschuld’s survey of this important classical work where the mai or conduit vessels are described as definite anatomical, tubular structures that carry blood).

Contemporary acupuncture continues to be “explained” to patients and the general public as unblocking energy flowing in the meridians, despite the fact that energy as usable force does not move around in the body but is produced in cellular organelles called mitochondria. Nutrients, oxygen and hormonal substances move around in the blood and nerves conduct signals.

Even the local State Acupuncture Association brochure states, “pain and disease are caused by either an imbalance or a blockage of energy circulating in the body. Acupuncture restores the proper flow of energy, returning the body to good health”. Given that such a statement, which is endemic in the practice of acupuncture, has zero supporting evidence and seems to ignore accumulating proof of a peripheral nervous system-brain connection in acupuncture stimulation, it is small wonder that acupuncturists continue to struggle on the fringes of evidence-based contemporary medicine despite growing public interest.

Doyen of European Medical Acupuncture Felix Mann abandoned the meridian/Qi theory several decades ago after writing some of the first English language textbooks on traditional Chinese medicine and studying in China. Even as a rough imaging guide he points out that acupuncture meridians are clearly as artificial as the meridians around the globe, and that the radiation sensation evoked by acupuncture simply doesn’t conform to meridian pathways. He also abandons precise acupoint location, showing that acupuncture effects can often be obtained by needling fairly large areas and in some cases anywhere on the body. This is frequently borne out in studies that show the efficacy of so called placebo needling at a distance from classical acupoints.

The sheer anatomical precision of contemporary acupuncture meridian charts replete with detailed connections to organs and musculature are clearly a modern construction. The irony here is that these centrally important charts really owe a great deal to modern medical anatomy in that Chinese medicine never had detailed anatomical charts and so certainly could not have had such precisely detailed diagrams of the meridians connected to anatomical organs.

Chinese medicine scholar Paul Unschuld has stated that 95% of books written in the west on Chinese medicine “reflect Western expectations rather than Chinese historical reality.” (Acupuncture Today, July 2004) In other words western literature on this subject (including probably most texts used in acupuncture schools) say more about what westerners would like to have in modern biomedicine than about accurate renditions of Chinese medicine.

The seemingly unified, metaphysically sophisticated traditional system taught to most acupuncture students turns out in fact to be a pastiche of various traditions and theories of both Chinese and Western origin. In many ways the traditional Chinese medicine that has become so popular in contemporary alternative medicine is a fairly confused theoretical construction highly influenced by western New Age vitalist hopes and expectations. Author and longstanding Chinese medicine practitioner D. E. Kendall makes it clear in the introduction to his book The Dao Of Chinese Medicine that for centuries Chinese medical thought has been deeply affected by Western ideas and mistranslations via redaction. The mistranslations of “mai” as meridians and not blood vessels, and of Qi as energy and not as oxygenated blood, are what Kendall considers to be the main confusions driving Chinese medicine into the realm of the metaphysical, and largely alienating it from mainstream medicine.

Even in the history of Chinese medicine, theories have often been retained due to excessive conservatism, and made to coexist with theories more empirically verifiable, thus adding to the current confusion. Professor Long-xiang Huang of the Acupuncture Research Institute of the Academy of Traditional Chinese Medicine in Beijing has, over many years, extensively researched traditional manuscripts. He has concluded that classical medical books such as the Huang Di Nei Jing comprise various channel (meridian) theories from different authors, different historical periods and different areas of medical experience. The tendency was to create an often forcedly integrated theory of acupuncture and Chinese medicine. Long-xiang Huang points out that when clinical facts did not fit the theory they where suppressed in favor of continuance of the theory. The Chinese term for this is “cutting the foot to fit the shoe”. (See the introduction to Biomedical Acupuncture for Pain Management, Ma, Ma and Cho)

A glaring example of disconnection between theoretical description and actual clinical use of meridians is the absence of empirical uses for the Large Intestine and Small Intestine points to treat the anatomical intestines. Apart from the generalized anodyne and anti-infective effects of Li4 and Li11, these meridians don’t treat diseases of the small and large bowels. For any truly empirical theory such glaring discrepancies would mean the questioning of that theory. Why then doesn’t this happen in Chinese medicine? Why does so much of Chinese medical dogma continue to be taught in Western acupuncture colleges without being questioned and abandoned when found wanting? In a recent article in The New York Times (October 22nd 2005) Dr. Xu Tian a Chinese scientist from Zhejiang Province who has made an international breakthrough in cellular genetics stated that his country needs a “new revolution” in order to break free from a “system that teaches people to follow the rules, not to be an innovator”. He adds that thousands of years of tradition would have to be overcome. A tradition “that has always avoided exploring different ways of thinking and exploring, and has emphasized staying within the system.” Why do Westerners tolerate so much dogma, obscurity and unquestioning acceptance at acupuncture school?

As Felix Mann has pointed out in Reinventing Acupuncture, ancient Chinese scholars, like scholars anywhere, were prone to grandiose theoretical elaborations that speak more to the cosmological predilections of the day than to practical efficacy. Those doing the practical work in the messy realities of daily life are more inclined to use what works, with minimal theoretical basis. This is how acupuncture was likely discovered and how it has been practiced over the centuries, not necessarily by the practitioners who wrote books but by those we may never hear about. As Francois Beyens (See White and Ernst, p391 – p407) has put it, throughout the tradition of acupuncture there has always “run a strongly pragmatic approach to treatment” whereby theory has only been used as far as it helps. He adds that initially “the theory of acupuncture was firmly observation based, but the Chinese cultural love for symmetry and order caused the nucleus of practically based observation to be filled out and rounded off, so that it is now difficult to determine in the laws and theories that have been handed down to us by tradition where the scientific logic ends and the fantasy begins.” It appears that even in contemporary practice elaborate theoretical schemes are in a sense still parasitic on this basic efficacy.

My argument for contemporary acupuncture is that it can and does work well with a finely honed empirical skill and virtually no traditional theoretical basis. Acupuncture has complex effects yet is in the end a disarmingly simple technique. I think it is this fact that makes the practice of acupuncture so forgiving in its generosity to enable a plethora of systems and approaches. The theoretical system and its accompanying explanatory mesh can be entirely fanciful, however the fact is that piercing the skin in certain broad areas has complex physiological effects. The simple act of stimulating the peripheral nervous system with a needle defines acupuncture. It is important to note that when nerves supplying acupoint areas are cut or blocked there is no acupuncture effect.

There are some indications that even precise location of needle stimulus is not always essential in producing a healing effect with acupuncture. This is evident with so called placebo needling in modern studies where clinical results can be the same as or close to those using traditional acupiont locations. This fact is graphically demonstrated in fMRI brain studies of acupuncture stimulation where traditional and placebo points produce almost identical brain images of pain amelioration. (P39 Biomedical Acupuncture For Pain Management; Ma, Ma and Cho).

It may also be that acupionts can be virtually created through a kind of neuroplasticity. This effect is suggested in an experiment carried out where volunteers with normal neurological function were given tactile stimulation to the right lower lip and at the same time their right median nerve was painfully stimulated electrically. When the lip was again tactilely stimulated without the electrical pulse to the median nerve the volunteers nevertheless again felt the sensation in the medial nerve. This suggests the creation of a brain map resulting in a conditioned connection between two areas of the body hitherto considered unconnected by a direct neural pathway. (Campbell).

Similarly needling anywhere in the body may re-set the nervous system through connecting the treatment site with a distant area of pain previously not directly connected in the brain. According to Campbell in Acupuncture in Practice patient expectation may prime parts of the limbic system in the brain, which in turn may ready the nervous system for the acupuncture healing effect. Neural conditioning is then deactivated as acupuncture stimulates homeostasis resulting in a return to a healthier nervous system. This effect occurs despite there being no traditionally theoretical connection between the acupoint and the position of the pain.

It may be as suggested by the authors of Biomedical Acupuncture For Pain Management that acupuncture, for the most part is non-specific, the generalized homeostatic stimulation effect is what is important and not the traditional Organ, Meridian, 5 phases or other supposed nature of the acupoint. With further studies such as the fMRI study above this may well be shown. From research it’s clear that the so-called placebo effect in acupuncture is considerable. It’s also apparent from research examples that sham acupuncture points near standard acupoints are frequently as effective.

These facts don’t prove that acupuncture has no independent effect but that the effect of treatment (as with any medical treatment) is often bound up with and dependent upon psychological and other factors. This ‘enmeshing’ makes the practice of acupuncture fluid and somewhat plastic, sustaining a plethora of theories and practices often contradicting each other. As Ma, Ma and Cho point out there are 80 different styles of acupuncture in China alone. Belief/expectation effects will prime certain brain centers in the patient, perhaps at least some of the time, enhancing treatment outcomes. However this effect may well be rooted in the flavor of the day or of the current historical period (anti-materialism for example) so will be at least in part culturally conditioned. The effect may not be as robust when conditions change and are surpassed by new cultural expectations.

In any case the placebo effect tends to wear off over time in the course of a series of treatments, whereas the acupuncture effect increases through the intitial treatment series and frequently remains stable for many months. Additionally acupuncture is an effective treatment in animals.

A contemporary transparent approach to empirical acupuncture will place all theories on hold or at least be cautious and tentative with their use. Anyhow, a simple pragmatic use of empirical acupuncture brings along its own skill and confidence which more than adequately fulfills the non-specific psychological treatment enhancing side of the technique. In addition to this aura of skill and effectiveness the biomedical post-traditional practice of acupuncture (based on current and developing neuro-hormonal understanding) can be more readily explained and communicated to patients and other health professionals in the language of contemporary medicine and science. It is noteworthy that in studies of acupuncture there is little difference in outcomes between acupuncturists practicing different styles – including a modern biomedical approach. All styles achieve about a 75% effectiveness rate. (Campbell) This also suggests that whether acupuncture training is short or the usual 3 to 4 years, results are the same in the hands of an experienced clinician.

All medicine is headed to some degree in the direction of science. Even therapies that are not currently understood scientifically and may even suggest aspects of mind/body functioning that stand outside conventional paradigms need to be tested for effectiveness and appropriate application. A definition of science I find particularly cogent here is that attributed to the late physicist Richard Feynman; “science is a way of trying not to fool ourselves”. This is an important definition for the contemporary practice of Chinese medicine in the West where critical thinking is sorely lacking. As shown above, we are not even practicing traditional Chinese medicine in anywhere near its historical form, and this may in fact be impossible.

For decades Traditional Chinese Medicine practice has been based on central mistranslations and misconceptions pertaining to Qi, Blood and “mai” or channels. The argument that if it’s ancient it must be true does not look as convincing in this light. In the words of Long-xiang Huang it is the task of forward looking practitioners to pick out the “pearls” from the confusion of traditional theory and connect them with a new biomedical “string.” To this end there needs to be more open discussion about clinical efficacy without tying everything back to traditional dogma. Additionally the fostering of careful studies is needed to develop new approaches and to gain evidence for simple theories to replace old theories and approaches. (See Anthony Campbell’s Where To Place the Needles and for How Long for a discussion on modern theoretical approaches to acupuncture practice, as well as his outline of a contemporary atheoretical approach.) There is currently, decades of clinical experience in what could be termed a post-traditional approach to acupuncture especially in England and Europe. The approaches of the following highly accomplished practitioners of this medical art, to name a few, suggest a new beginning: Felix Mann; Anthony Campbell; C. Chan Gunn; Yun-Tao Ma, Mila Ma and Zang Hee Cho; H. C. Dung; P.E.Baldry; Adrian White. Their integrative theories and methodologies can and should be taught, in the very least, as an alternative track in contemporary acupuncture colleges.

In summary, to answer the charge that a modern approach to acupuncture lacks spirituality, it would be fair to say we practice acupuncture primarily to participate in the great medical adventure of relieving suffering and optimizing health and wellness, not simply to satisfy our own need for spiritual/philosophical meaning through grand theories. Is it not spiritual enough to have the capacity to relieve suffering for human beings of all walks of life and animals as well? Also as far as holism goes, acupuncture is inherently holistic without traditional theory, as it stimulates homeostasis and self-healing through the very act of piercing the skin. This probably occurs based upon ancient biological survival responses to wounds, acupuncture being a micro wound. (Ma, Ma, and Cho).

We need to be highly practical and effective yet simple and accessible and to fit the modality of acupuncture and Chinese medicine into the understanding and medical milieu of our times. Acupuncture is essentially a simple and effective technique, which can be taught in a simplified and contemporary manner, refined through experience, and integrated widely into modern biomedicine. It is a method of relieving suffering, inherently holistic in its effect, with minimal side effects. Hence the need of a post–traditional integrative revision.

© Thomas Martin,

Bibliography

Medical Acupuncture – A Western Scientific Approach, Jacpueline Filshie, Adrian White

Acupuncture In Practice – Beyond Points and Meridians, Anthony Campbell

Reinventing Acupuncture – A New Concept Of Ancient Chinese Medicine, Felix Mann

The Gunn Approach to the Treatment of Chronic Pain – Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, C Chan Gunn

Biomedical Acupuncture for Pain Management – An Integrative Approach, Yun-Tao Ma, Mila Ma, Zang Hee Cho

Huang Di Nei Jing Su Wen – Nature, Knowledge, Imagery in an Ancient Chinese Medical Text; Paul Unschuld

Problems with the Energy – Meridian Theory (PDF), D. E. Kendall.

Bruce Pomeranz interview by Bonnie Horrigen in Alternative Therapies in Health and Medicine; Nov. 1996, Vol.2, No.6, p.85 – 91

Where to Place the Needles and for How Long? Anthony Campbell

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