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[ THE SCIENCE OF S T E V E N NO V E L L A Steven Novella, MD, is assistant professor of at , the host of the Skeptics’ Guide to the Universe podcast, author of the NeuroLogica blog, executive editor of the Science-Based Medicine blog, and president of the New England Skeptical Society.

What Is ?

cientific jargon can be impenetra- of action. Some definitions mention Tra- the insertion of thin needles into acu- ble, but it’s often necessary—ideas ditional Chinese Medicine (TCM) and puncture points. Smust be precisely and unambigu- either directly state or imply that acu - Clinical studies into the effectiveness ously defined in order to be useful. It’s puncture works by influencing the flow of acupuncture have evolved over recent difficult to test a vague notion or subject and balance of chi, or life . Such years, and there have actually been quite an amorphous concept to examination. notions are little more than prescientific a few well-designed studies that ade- So we must first define what acupuncture superstition, so modern proponents are quately isolate these two variables actually is before we can ask whether often vague on mechanism or refer to (acupuncture points and needle inser- acupuncture works. This is not as easy as highly speculative and unproven physio- tion). For example, many studies com- it might seem. logical mechanisms. Regardless of any pare verum acupuncture (true acu - Acupuncture is often referred to as potential mechanism, there are two fea- puncture in which needles are inserted an ancient Chinese practice, but in ac- tures that seem to define acupuncture: into the alleged proper acupuncture tuality it’s neither very ancient nor ex- the existence of specific acupuncture points for the condition being treated) clusively Chinese. The modern practice points at various locations on the body to sham acupuncture (in which needles of acupuncture is only decades—not and the stimulation of these points by “a are inserted into the “wrong” locations). centuries or millennia, as is often variety of techniques,” most commonly These studies overwhelmingly show claimed—old (Ramey 2010). It has an- inserting thin needles through the skin. that needle location does not matter— tecedents in ancient times, but the prac- So-called electroacupuncture is very verum acupuncture is no more effective tice of needling in Asia was not much problematic in terms of scientific speci- than sham acupuncture (Moffet 2009; different from the practice of blood - ficity, because electrical stimulation Ernst 2009). letting in the West (Novella 2010). through the skin has known physiolog- Some trials also control for the vari- The National Center for Comple - ical effects independent of the existence able of needle insertion, using placebo mentary and of acupuncture points. Scientific exper- or simulated acupuncture in which iments are designed to control for as opaque sheaths are used and a dull nee- (NCCAM) has this to say about the many variables as possible; only by iso- dle is pressed against the skin when the definition of acupuncture: lating variables can we say which vari- plunger is depressed, but there is no The term “acupuncture” describes a able is having which effect. Electro - skin penetration. Alternatively, tooth- family of procedures involving the acupuncture mixes variables, making it picks have been used to simulate the stimulation of anatomical points on the body using a variety of techniques. impossible to separate out the ones spe- sensation of acupuncture without going The acupuncture technique that has cific to acupuncture from the effects of through the skin. Again, when this been most often studied scientifically electrical stimulation itself. variable is isolated, it turns out that involves penetrating the skin with Needle insertion also has nonspe- simulated acupuncture works as well as thin, solid, metallic needles that are cific physiological effects independent verum acupuncture. This is true of the manipulated by the hands or by elec- of any notion of acupuncture, but these largest and best trials of acupuncture for trical stimulation. (NCCAM 2011) are likely minimal, transient, and local. the most common uses, such as reduc- It appears the definition of acupunc- So for the purpose of experimentation, ing back pain (Haake et al. 2007) and ture is not tied to any alleged mechanism it is reasonable to define acu punc ture as treating nausea (Enblom et al. 2011).

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Therefore, if we define acupuncture We have known for decades that a and Symptom Management. 37(4) (April): as using needle insertion to stimulate good bedside manner, with some relax- 709–14. Haake, M., H.H. Müller, C. Schade-Brittinger, acupuncture points, and the best scien- ation and encouragement, makes peo- et al. 2007. German acupuncture trials tific evidence shows that acupuncture ple feel better. This may create the illu- (GERAC) for chronic low back pain: Ran - points do not exist (it doesn’t matter sion that whatever specific intervention domized, multicenter, blinded, parallel-group where you stick the needles) and needle accompanies these nonspecific effects is trial with 3 groups. Archives of Internal Medi- cine. 167(17): 1892–98. insertion has no effect (it doesn’t matter itself having some effect. That is the Moffet, H.H. 2009. Sham acupuncture may be as whether or not you stick the needles), very point of scientific experiments: to efficacious as true acupuncture: A systematic then does acupuncture work? I think isolate these variables. And when that review of clinical trials. Journal of Alternative the only reasonable answer is no; there is properly done, it becomes increas- Complementary Medicine. 15(3) (March): 213–16. is no reality to acupuncture or the con- ingly clear that acupuncture (the stick- National Center for Complementary and Al tern - cepts upon which it is based. ing of needles into alleged acupuncture ative Medicine (NCCAM). 2011. Acu - If anything can be said to have a points) does not work. n puncture: An Introduction. Available online measurable effect in acupuncture trials it at http://nccam.nih.gov/health/acupuncture/ References introduction.htm. is the therapeutic ritual that surrounds Novella, S. 2010. Modern bloodletting (blog post). acupuncture (but not the acupuncture it- Enblom A., M. Lekander, M. Hammar, et al. 2011. Getting the grip on nonspecific treat- Neurologica ( July 6). Available online at self). Even these effects are modest and ment effects: Emesis in patients randomized http://theness.com/neurologicablog/?p=2099. nonspecific—they re sult from a subjec- to acupuncture or sham compared to patients Ramey, D. 2010. Acupuncture and history: The tive sense of well-being gained from the receiving standard care. PLoS ONE 6(3): “ancient” therapy that’s been around for sev- e14766. doi:10.1371/journal.pone.0014766. eral decades (blog post). Science-Based Medi- kind attention and relaxation that attends Ernst, E. 2009. Acupuncture: What does the cine (October 18). Available online at the acu punc ture ritual. most reliable evidence tell us? Journal of Pain www.sciencebasedmedicine.org/?p=7660.

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