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A response to the CPA acupuncture article.

I always read the CPA magazine because it is important to stay abreast of what our professional organization is discussing, implementing and supporting. I was disappointed in the recent edition (Oct 2018, promoting the value of physiotherapy) when I read a feature article on acupuncture. As a profession we claim to be evidence based and to offer best practice to our communities, yet this article was wrought with opinion, poorly supported and overly simplistic. I understand the CPA magazine is not peered reviewed but I would have thought that an editor would have questioned the language used in this article. I want to review key aspects of the article but essentially it read like an advertisement for acupuncture. It was produced by the Acupuncture Association of Canada so bias is expected but it was not even close to being skeptical. Something we sorely need more of in our profession. If you have access to the magazine pull it out and read it so you can follow along…sadly I could not find an online version.

The first red flag was question 1. Despite lack of strong evidence that acupuncture and dry needling work, can you give an explanation to why YOU BELIEVE it works….do I really need to question this. Opinion is not the best evidence and does not lend more credibility to a modality.

Barb S and Elizabeth describe the therapeutic relationship as probably the most important tool in our toolbox – exactly. This is why acupuncture works – contextual factors, an interaction with someone who cares, listens, and offers help. Why bother with the needling part! They  go on to list molecules and neuronal pathways effected by acupuncture. Lets look at each of these more carefully.

  • Peptides are proteins. They are released by thoughts, movement, or touch – this is nothing special.
  • Descending endogenous opioids: also released by exercise, positive thoughts and beliefs, and comforting environments
    . This is also one of the mechanisms at play in manual therapy.
  • Changes in blood pressure, blood glucose and cortisol levels can be important but are changing all the time. There are many less invasive and empowering ways to alter these variables.

The physiological terms are used to give acupuncture credibility yet these systems, chemicals and molecules are transformed and changed through thousands of means (eating, sleeping, thinking, worrying, having fun, etc). Acupuncture is not necessary to make these changes. Of course acupuncture has effects but no better than sham or placebo (Madsen MV, Gotzsche PC, Hrobjartsson A.).

The next author, Doug F continues in support of acupuncture by describing his methods of assessment and treatment. Although treatment of the brachial and lumbo-sacral plexus sounds impressive and complicated most of the corresponding descriptions are vague and non-sensical.

  • Why would a needle poked into a nerve root make it function better? How does one define a correction in nerve root irritation? Is it a just a reported change in symptoms or do they regain lost strength? Changing a persons exper
    ience of neck pain does not have to be so complicated.
  • He uses other spurious terms including:
  • Lesions: The spinal cord and nervous system is bioplastic, it is under constant change.  A lesion leads us to believe that their is a physical break in the nervous and through some leap of logic would get fixed when a metal object hits it? A more appropriate term is probably sensitized (a change in chemical sensitivity to certain stimuli).
  • Where is the evidence to suggest chronic back pain is from neck pain? Please refer to the lancet articles to familiarize yourself with low back best practices. The fallacy of regional interdepence is a tempting explanation but sometimes work for reasons other than a described dysfunction (see a good list of references on this topic through EIMs blog).
  • What are mechanical dysfunctions? I thought as a profession we were moving towards the bio-psychosocial approach and away from a bio-medical model? Even if we could identify dysfunctions  our current understanding ofbio-mechanics and pain tells us recovery from pain occurs and bio-mechanics often stay the same. A lovely description by Anoop Balcahndren, “Why should mechanical stress caused by “faulty movement patterns” always “lead to microtrauma and injury”? Why can’t tissues just positively adapt and get stronger just like a normal biological tissue? If indeed faulty movement patterns were the cause of injury, all those cerebral palsy patients, stroke victims, people with neurological disorders and amputees should be in complete pain. There are double amputees who run faster than most of us and still feel no pain. The compensations and asymmetries are 100% in these amputees and they should be crying out loud in pain than running around. Maybe that movement pattern is “ideal” for them and the tissues have adapted to it.”
  • SI joint movement is barely noticeable and even if it were it probably does not matter.
  • Fascial mobility. Yes we have fascia and it is integral to movement but it is not a magical tissue. Tissue needs stress to adapt. We don’t expect muscle or brain tissue adaptation through laziness, why would thin metal needles spur growth and change in fascial mobility? How could they possibly make longer term adaptations?
  • Energy depletion, leaky gut, and long term high sugar intake. How in the world does acupuncture cure muscle dysfunction, nerve dysfunction, offer analgesic effects, change blood pressure, decrease stress, and cure energy depletion, bowel problems and a persons intake of sugar? Sound silly – it is but this is exactly what this article is claiming. I do not disagree, a diet high in sugars, smoking and alcohol is bad for you. The route to change these habits is not though more passive treatments and dubious medical claims. Doug F continues by boasting about his attempt to black mail the Ontario Ministry of health. I am sure Doug is a nice fellow but the province of Ontario should have a stronger mandate to protect science and challenge medical quackery. Taking a line from Neil O’Connel, “his discussion on acupuncture obfuscates rather than enlightens.”

Enoch F and Kien T

These two admit that acupuncture does not have strong evidence but they observe clinical outcomes. This is an anecdotal statement. Are we not taught in our masters degree to be cautious of anecdote? They admit that other modalities do not have strong evidence. I wont disagree but this is exactly why up to date therapists are abandoning electrotherapy’s, ultrasound, and laser for treatments with evidence. Namely: exercise, graded exposure, motivation interviewing, CBT, and therapeutic alliance. They attempt to further prop acupunctures benefits by touting the limited adverse effects – this should not be an extra point for a treatment. They are many safer treatments that require no needle insertion.

The two then try to answer three questions.

  1. Is there basic science to explain the treatment mechanism? No there is not – only in cherry picked, biased articles does it perform better than placebo or sham.
  2. Is there enough clinical evidence based on RCTs or review articles to support acupuncture. NO. Please refer to RCTs and systematic reviews at the bottom of this page.
  3. Are there any local studies to show that acupuncture could be implements in a Canadian health care system. Well yes – it is not hard to offer acupuncture in hospitals…but so is cupping, leaches, and blood letting.

Although they answer yes to all three questions they do no offer any evidence to support their claims. Even dodgy ones:) The final section does offer a few pro-acupuncture papers but I divulge to the cartoon below….(credit to www.painscience.com for this one)

I understand acupuncture has a division within the CPA. In my opinion there place in our professionally body should be questioned. It is ok for me to have an opinion and to disagree. We need debate and do not have to agree on everything. We should take a page from the Big Rs in England and get comfortable with grey, debating, and moving our profession forward in a positive manner.

Thanks as always

Dave Carter

For papers and blogs that do a much more thorough analysis of acupuncture please refer to the following articles or another blog I wrote on the topic earlier this year.

There are numerous papers on painscience.com, sciencebasedmedicine.org, and bodyinmind.org that provided wonderful insight. A few include:

  1. Trigger points strike out
  2. Dry needling for myofascial pain
  3. An appraisal of an acupuncture meta-analysis
  4. False claims of Acupuncture
  5. Is dry needling acupuncture?
  6. Madsen MV, Gotzsche PC, Hrobjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009;338:a3115. The reviews concludes that “a small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.” In the context of treating pain, a “small analgesic effect” is nearly worthless, and it hopelessly damns with faint praise, and that’s assuming it’s even a genuine effect of acupuncture. In fact, it’s vastly more likely to be an effect of being handled and taken care of (“the treatment ritual”).
  7. Ernst E, Lee MS, Choi TY. Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011 Apr;152(4):755–64. PubMed #21440191.
  8. Exercise and endogenous opioids
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By | 2018-10-16T17:50:53+00:00 October 16th, 2018|My thoughts|0 Comments

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