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Integr Med Res. 2022 Jun;11(2):100834

On defining acupuncture and its techniques: A commentary on the problem of sham

Stephen Birch 1, Myeong Soo Lee 2, Tae-Hun Kim 3, Terje Alraek 1 4

1 School of Health Sciences, Kristiania University College, Oslo, Norway.
2 Division of Clinical Medicine, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea.
3 Korean Medicine Clinical Trial Center, Korean Medicine Hospital, Kyung Hee University, Seoul, Republic of Korea.
4 Department of Community Medicine, Faculty of Medicine, National Research Center in Complementary and Alternative Medicine, UiT The Arctic University of Norway, Tromso, Norway.

(no abstract)

Free full text:
https://www.sciencedirect.com/science/article/pii/S2213422022000038

Excerpts:

"While the notion of acupuncture as a method of inserting needles into the body to help treat symptoms is a commonly held opinion, is this understanding and definition correct?

"The term translated as ‘acupuncture’ in Chinese is ‘zhen’...a noun that means needle or pin...But the earliest etymological dictionary in China describes zhen in relation to sewing [Box 2], which implies insertion of some kind; while the tool used for sewing cloth may need to be sharp and thin like a needle, the tool for sewing thick leather is usually thicker and can be non-sharp, even blunt as it is pushed through pre-made holes. The term can thus refer to a variety of metal tools some of which are inserted....When zhen were first described as treatment devices in the Huangdi Neijing (Yellow Emperor's Classic of Internal Medicine), circa 100 BCE, nine types of zhen were described.4 Among the nine zhen, the round-pointed needle and spoon needle were not intended for penetration of the skin but to be used by pressing or massaging acupuncture points or meridians,5, 6, 7 and detailed illustrations of the non-penetrating needles is shown in the paper by Kim and colleagues.7 With one of the nine zhen, the thinnest needle the ‘haozhen’, ‘hair’ or filiform needle, becoming dominant and most commonly inserted into the body, the other eight are less commonly used, but remain in use in Asia and the West.1, 6, 7, 8, 9, 10 We thus immediately see a problem with the choice of the term ‘acupuncture’ as translation for the term ‘zhen’ since some ‘zhen’ tools are not inserted when used in treatment...While the term ‘acupuncture’ has de facto become the word that refers to a family of medical procedures that involve needles and commonly involve recourse to traditional Chinese or East Asian concepts like ‘qi’, ‘yin-yang’, ‘meridians’ and so on, 5,6 the misunderstanding implicit in this word can be problematic for researchers. Here, we continue to use the term ‘acupuncture’ since it has fallen into common use, but our intended use is as a term that refers to a broader family of therapies that employ zhen tools. We propose that there should at least be an academic discussion of whether the continued use of the term ‘acupuncture’ is appropriate or whether a better term should be developed that is not so misleading or at variance with historical and modern practice methods.

"1. Examples of the varieties of contemporary ‘acupuncture’ methods
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"Round ended, blunt tools or sharp pointed needles with touch or light pressure applications"
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"Round ended, blunt tools or sharp pointed needles with pressure, potentially with discomfort or pricking sensations (e.g. Shonishin, contact needling, Toyohari) .7,9, 10, 11, 12
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"Thin needles (0.12–0.18 mm gauge) shallowly inserted (1–3 mm) e.g. the Japanese ‘chishin method,’8,15,18 or short thin needles (0.20 mm gauge) inserted shallowly and taped to remain in place."
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"Thin needles inserted a little deeper (2–5 mm) and sometimes further (5–20 mm), usually intramuscularly without deliberate sensory stimulation"
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"Somewhat thicker needles (=0.20 mm gauge) inserted often deeper and with manual manipulation so as to deliberately elicit sensory stimulation – called ‘deqi’ – often inducing a twitch in the muscle (TCM style needling methods).24,25 This has become the more common method taught in China and in most Western acupuncture schools.
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"Slightly thicker needles (=0.20 mm gauge) inserted often deeper (2–50 mm) with manual manipulation so as to deliberately elicit sensory stimulation, and then with electrical stimulation added to the needles (electroacupuncture)."

"Research implications

"It has been routine for clinical and laboratory researchers to assume that when they are investigating ‘acupuncture’ that they are studying the physiological effects and/or the clinical effects of needle insertion."

"Another common assumption of laboratory and clinical researchers investigating acupuncture is that the needling should elicit the sensory stimulation of deqi."

"It is also commonly assumed that there should be a general mechanism or set of mechanisms by which acupuncture should work, but with such a range of different types of technique used we must expect large differences according to the types of structures and tissues stimulated and whether the technique causes e.g. nociceptive input."

"In the formulation of scientific acupuncture studies, it is fundamental that the researchers demonstrate an accurate and comprehensive understanding of the topic they are investigating. Furthermore, a number of key problems might arise from deficits in this understanding.

"a. It is problematic to assume that the effects of acupuncture arise only after insertion of the needles

"b. It is problematic to assume that the effects of acupuncture arise only after eliciting the sensory stimulation associated by e.g. TCM practitioners inducing deqi

"c. These problematic assumptions led to the selection of techniques that sought to avoid the sensory stimulation associated with deqi and/or that avoid insertion of the skin as sham techniques in controlled clinical trials.33,34 These are inappropriate as ‘sham’ control treatments since they employ a number of physiological pathways that are known to be involved in the practice of acupuncture,32,35 making them potentially incapable of controlling for placebo effects"

"d. It is not clear what has been controlled for in sham comparison trials.40 It is often assumed that the sham treatment is a placebo treatment.41,42 When the trial does not find a statistically significant difference between treatment groups researchers and many reading those trials draw the questionable conclusion that acupuncture effects are primarily due to the placebo effect.

"e. Hence analysis of results from sham-controlled studies have influenced the accurate estimation of treatment effect size, potentially leading to faulty conclusions.

"f. Acupuncture studies usually test one of many acupuncture techniques and then draw conclusions about ‘acupuncture’ in general."

"g. More fundamental problems arise for scientific studies of acupuncture. If knowledge of what constitutes the practice of zhen therapies is constrained due to faulty assumptions from an understanding of what the term ‘acupuncture’ means, deeper problems arise in how scientific questions, hypotheses and null-hypotheses are developed...If we now examine clinical studies in acupuncture, we immediately encounter significant challenges: There is a paucity of basic research including academic studies about the nature of acupuncture, so that clinical and laboratory research are often insufficiently informed and researchers operate with inaccurate assumptions...Although there is an acknowledged difficulty associated with defining the precise mechanisms of acupuncture due to the complexity of potential mechanisms that can be involved,32,40 there remain unrecognised problems regarding what constitutes the nature and practice of ‘acupuncture.’ The research community has not devoted enough effort to exploring what it is that they are investigating."

"3. Conclusions

"While research on acupuncture has increased, especially in the last 20 years, core issues about what is acupuncture, as described in this paper, have been omitted or poorly addressed. They were neither present in the early days of acupuncture research nor have they fully been understood in contemporary acupuncture research. This has created significant problems for research on acupuncture, in particular clinical research efforts that attempt to control for placebo effects using sham acupuncture."