Acupuncture versus science, linguistic edition

Acupiuncture is a system of treatment rooted in the prescientific vitalism of traditional Chinese medicine (TCM). It doesn't work. For anything. As Steve Novella and David Colquhoun put it, acupuncture is basically a theatrical placebo, which is why rigorous studies consistently fail to find a treatment effect due to acupuncture that is detectably greater than placebo. Not that that's stopped acupuncturists and acupuncture advocates from trying desperately to show that acupuncture "works," even if it means hooking up acupuncture needles to electrodes and turning it into transcutaneous nerve stimulation (TENS). Never mind that two thousand years ago even the Chinese didn't understand electricity.

That's why I was rather amused to come across an article in the Journal of Integrative Medicine by Ted Priebe et al entitled Can a science-based definition of acupuncture improve clinical outcomes? It's tempting just to say no and leave it at that, but there's too much amusement to be had by examining parts of the article and the contortions of logic the authors undergo to try to justify the use of acupuncture. Indeed, in the introduction, it's almost as though Priebe et al admit that acupuncture is based on prescientific superstition, as they declare their purpose to "to unwind this entanglement and conduct acupuncture research according to biomedical principles." Good luck with that. They also suggest that "avoiding prescientific arguments is one approach towards explaining acupuncture mechanism of action, efficacy and effectiveness." Good luck with that, too.

First, Priebe et al liken acupuncture to the construction of knives, which is a perhaps a bit more apropos than they realize, given how acupuncture also "evolved" from primitive bloodletting of the kind favored by "traditional European medicine" (as I like to refer to it) in the Middle Ages:

Acupuncture, like knives, has evolved over millennia. They have ancient origins, modern utility, varied history, and even today, spiritual value. The manufacture of knives has evolved further than has the application of acupuncture. Acupuncture needs to migrate from a mind- body-spirit medicine described by Hui et al.[1] to a healing art based on science. Knife construction has moved past a “hand me down” craft to a precise, replicable, and standardized industry where quality is measured scientifically. Although knife making and acupuncture still value the traditional master-apprentice teaching practices, it is time for acupuncture, like knife manufacture, to advance towards scientific methodology for assessing practice outcomes and effectiveness.

One might also point out that knives, unlike acupuncture, can be shown unambiguously to be useful tools to accomplish specific tasks. Acupuncture, not so much. Of course, the big question I have is basically: How do you take a modality that posits the existence of anatomic structures that do not exist (meridians) and "energies" (qi) that have never been detected and make it scientific? Science requires parameters that are reliably detectable, measurable, and reproducible. Indeed, a Nobel Prize likely awaits the first acupuncturist or "integrative medicine" specialist who can definitively demonstrate the existence of qi and meridians and definitively demonstrate that inserting thin needles into these meridians somehow "unblocks" the flow of qi.

Of course, acupuncturists are starting to figure that out, but, instead of resulting in the rejection of acupuncture as the pseudoscience that it is, instead acupuncturists now tend to sweep all that inconvenient mystical mumbo-jumbo about qi and meridians under the rug:

Kendall [3] scientifically described the mechanisms of action of acupuncture as based upon early Chinese descriptions of “blood circulation, organization of the cardiovascular system, somatovisceral relationships (communication between the external body and the internal organs), immune system function and the organization of the musculoskeletal system.” The American College of Occupational and Environmental Medicine Guidelines recognized the effectiveness of needling without providing evidence of “meridians” or defining vital energy ow (qi).[4]

Let's talk a bit about these early Chinese descriptions, shall we? TCM involves various modalities like pulse and tongue diagnosis. In the former, it is claimed that detailed diagnoses can be made just by feeling the pulse. Of course, the pulse is valuable in science-based medicine, but mainly as an indicator of cardiovascular status. In TCM, there are at least 29 different pulse types ranging from floating to slippery to forceful. Try to figure out how to recognize the Ge Mai (Leathery, Drumskin, Tympanic, Hard) pulse, for instance:

Bowstring and large (wide) with an empty center; feels like the head of a drum. Felt with light pressure. Floating, large, and hard and resistant to pressure.

Supposedly Ge Mai is associated with "Hemorrhage, Spermatorrhea, Abortion, Excessive Menstrual Flow, Xu Cold" and means, "The Qi becomes detached and floats to the exterior, the healthy Qi is failing to store sperm and blood." There's lots more where that came from, with the vague, mystical diagnoses failing to correspond with any physiological condition. Physiologically, these pulse diagnoses are meaningless. It's diagnosis disconnected from reality.

Don't even get me started on tongue diagnosis. Skeptics rightfully make fun of reflexology, which posits a homunculus on the soles of the feet and the palms of the hands, where various areas of the soles and palms "map" to various organs or body parts. Well, where do you think reflexologists got the idea? Probably from TCM tongue diagnosis, which basically maps different areas of the tongue to different organs and claims that by looking at the tongue one can diagnose illness in various organs. While it's true that looking at the tongue is a useful part of physical diagnosis in science-based medicine, the way it's used in TCM is, like pulse diagnosis, meaningless.

Now here's the funny thing. Priebe et al appear to realize that the philosophical underpinnings of TCM are mystical prescientific superstition. That's probably why they want so desperately to get away from them, noting with unintentional drollness that "fealty to traditional themes may add complexity, raising the bar and occluding the picture" and listing four areas (placebo, comparative effectiveness, Deqi and linguistics) where "fealty to traditional themes needlessly confounds acupuncture research." Perhaps most telling is how Priebe et al invoke Ted Kaptchuk and his arguments:

He argued that placebo research must move beyond the view wherein placebo signifies a failure, instead investigating it as a straightforward clinical outcome; “We need more research involving clinical interventions designed to elicit placebo effects in participants without deception ... we need to know precisely when, how and in what dose ... these interventions can provide therapeutic benefit.”[14] Kaptchuk applied the “dose × frequency × duration” model to a meta-analysis of complementary and alternative medicine (CAM) therapies limited to supplements and herbs used for treating irritable bowel syndrome.[15] The study is of interest here because it pooled CAM interventions excluding acupuncture and discussion of traditional, non-scienti c considerations.

Kaptchuk's arguments flow from the observation that, as alternative medicine therapies have been more intensively studied using more rigorous methodology, inevitably their effects are found to be indistinguishable from placebo effects. So Kaptchuk embraces placebo effects and has spent decades trying to demonstrate that they are useful and can be evoked without deception (they can't). His arguments are similar to those of other alternative medicine advocates like Deepak Chopra that their woo works by "harnessing the power of placebo." Unfortunately, thinking does not make it so.

So what do Priebe et al propose, given that rigorous randomized trials of acupuncture fail to show its efficacy beyond that of placebo? I think you know the answer to that one:

Despite Kaptchuk’s best arguments, placebo effectiveness is viewed as damaging to clinical outcomes research. By contrast, comparative effectiveness research occupies one of the highest rungs on the research ladder. In our view, the most renowned studies of comparative effectiveness in acupuncture research, i.e., the “German studies” did not measure up to Kaptchuk’s standard of when, how and what dose.[16] Comparative effectiveness research in clinical applications should demonstrate cost savings and improved outcomes when comparing techniques or procedures. The model must be specific, as acupuncturists and researchers will attest.[17] Standardization is necessary when comparing outcome measures, targeted points, diagnoses, and experimental/ control models.

Yes, this is basically the same justification used for preferring "pragmatic" studies on acupuncture, and it has the same flaw. Yes, comparative effectiveness research is important. Indeed, you can view comparative effectiveness research as a form of pragmatic studies. The problem once again is that the premise of such studies is that the treatments whose effectiveness are being compared actually have strong evidence of efficacy from randomized clinical trials. In other words, we already know that they "work." Acupuncture fails that basic test. However, because comparative effectiveness studies generally don't have placebo control arms, pragmatic studies and comparative effectiveness research will produce a false impression that acupuncture actually works, at least for subjective outcomes.

Finally, here's the part that made me laugh the loudest, in which Priebe et al argue for changing linguistics:

Chinese “words” frequently have more than one meaning.[21] The symbol for “qi” can mean air or gas as well as “energy or life force”. For acupuncture traditionalists the word “qi” implies a dynamic functional view of all body systems.[30,31] The word “energy” is central to the cultural description of acupuncture and cannot be separated from Chinese medicine.[32,33] According to this view acupuncture works by releasing blocked energy circulating through invisible meridians. Use of these and similar terms when describing needling therapy is central to the claims, beliefs and practices among a cohort of TCM and acupuncture practitioners unconcerned these ideas have not been demonstrated scientifically. Schnorrenberger[30] has argued acupuncture finally needs an anatomical nomenclature for daily practice and scientific research. Yang et al.[34] has attempted to resolve the mysterious balance of yin and yang with the biophysical, i.e., positive and negative charge or matter and anti-matter.

These are not prejudices if one takes it as sun and moon, positive and negative charge, or matter and antimatter. However, we must focus on the science alone as there were quite a bit of superstitions, mystics, voodoo, and philosophical musing in the ancient world that should have no place in our scientific thoughts.[34]

Well, I can certainly agree with that last paragraph, but that's the problem. Acupuncture cannot be separated from its origins in prescientific vitalisms. That "quite a bit of superstitions, mystics, voodoo, and philosophical musing in the ancient world that should have no place in our scientific thoughts" is the very basis of acupuncture. There is no anatomy that corresponds to meridians, nor is there physiology that generates or depends upon qi. That's why there will always be this:

Pritzker describes a “tension” between “biomedical” and “anti-biomedical” camps that has proved “contentious” for more than a decade. In our view, this tension extends into the research domain.

Those acupuncturists who have a "biomedical" view are perhaps even more deluded than the "anti-biomedical" camp. After all, they seem to think that there is a biomedical basis to acupuncture and will contort all sorts of research findings to justify their belief in acupuncture. Priebe et al seem to fall into this category, as they conclude:

Despite decades of scientific arguments that support a biomedical model, steadfast insistence on the use of traditional terms remains a standard in the conduct of acupuncture research. The use of prescientific language in place of medical language commonly used in mainstream healthcare is harmful to the profession, practitioners and the public. It is our view that this insistence frequently dissolves into a defensive posture that places the patient at risk. This same view compromises and hamstrings practical outcomes in acupuncture research.

"Practical outcomes." You keep using that term. I do not think it means what you think it means. Notice how Priebe tortures language (and himself) in order to continue to use acupuncture even though he has just admitted that it's rife with mysticism, superstition, and "voodooo" that has no place in modern medicine. How can a system that is based in such nonsense ever be scientific? It can't. Therein lies the conundrum. Priebe et al view themselves as science-based and, because they believe in acupuncture, assume that there must be a way to justify it scientifically as well. There isn't, but that doesn't mean that acupuncturists like Priebe et al won't keep torturing science and language to keep trying.