Page by Page outline for London Acupuncture Talk:Veterinary Acupuncture: A Western Invention from the 1970’s?

1. Introduction of Chinese medicine (human and veterinary) into the West: 16th – mid-20th Centuries.

A. Acupuncture reaches Europe with return of missionaries in the 16th century. At the end of the sixteenth century, Jesuit missionary Wilhelm Ten Rijn writes, in Latin, the treatise De Acupunctura.

B. Subsequently, acupuncture is rejected, forgotten, and then rediscovered in at least four major waves.i

C. 18th and 19th centuries: Acupuncture embraced by several French physicians, but equally prominent physicians accuse them of “resurrecting and absurd doctrine from well-deserved oblivion.”ii

D. Acupuncture introduced into England on February 18, 1821, when Edward Joukes, sourgeon-accouher (midwife) to the Westminster Medical Institution applies needles to a Mr. Scott who suffers from severe pain in the loins.iii

E. In a 1828 British Veterinary journal, an anonymous author wrote:iv On the whole, these [acupuncture] experiments have been very unsatisfactory. One case of chorea in the dog was cured by acupuncturation, and another relieved… Two cases of supposed rheumatism were cured, but not as short a time as that in which we generally succeed in removing a rheumatic affection by other means… In strain of the extensor muscles of the forearm [of a horse]…although, at last, the lameness was removed, the cure is to be traced to the state of rest in which the animal was suffered to remain so long, more than the influence of the needles. In paralysis of the hinder extremities, acupuncturation was totally useless… Two things are, however, sufficiently evident, that the sudden and magical relief which the human being has sometimes experienced has not been seen in the horse, and probably from the thickness of the integument, the animals suffered extreme torture during the insertion of the needles.”

Was this distemper chorea or epilepsy or some other seizure/neurologic disorder the author was dealing with in dogs?

i Skrabanek P. Acupuncture: Past, Present and Future, in Examining Holistic Medicine, (Stalker D and Glymour C, eds.) Prometheus Books, Buffalo NY, 1989; 182.

ii Lacassagne J. Le docteur Louis Berloiz – Introducteur de l’Acupunture en France, Presse Médicale 62, 1954:1359-60

iii Bowers, JZ, 1973. Proc. Amer. Philosoph. Soc. 117:143-157

iv Anon. 1828. On Acupuncturation and Veterinary Practice. The Veterinarian 1:203-5

F. 1816: French physician, Louis Berlioz, applies DC current to acupuncture needles.v

F. Electroacupuncture undertaken in humans by Chevalier Sarlandière before 1825 by means of Leyden jar.

G. In 1825 physician and chemist Franklin Bache, a great-grandson of Benjamin Franklin, translates (from French) Morand’s Memoir on Acupuncture and has an American edition published in Philadelphia.vi

H. In 1826, J. Hunter Ewing reports that he has used acupuncture “many times” and has “been present when others have performed it,” apparently with positive results.vii

I. In the same year, three Philadelphia physicians, Edward J. Coxe, D. T. Coxe, and Samuel Jackson, conduct experiments with acupuncture as a possible means of resuscitating drowned people.viii

J. European experimenters had claimed to have successfully revived drowned kittens by inserting needles into their hearts. (Strangely reminiscent claims regarding the resuscitation of kittens have very recently appeared in the Journal of the American Veterinary Medical Associationix and have likewise been contested.x,xi)

K. The American physicians were unable to duplicate these alleged European successes and therefore “gave up in disgust.”

L. Edward Coxe reported that “whatever others may think of the possibility of resuscitating drowned persons by acupuncturation, I can only say that I should think myself highly culpable, if, called to a case of asphyxia, I were to waste time, every moment of which is precious, in endeavoring to resuscitate by a means which I sincerely believe to be good for nothing.”xii

M. 1836: First mention of veterinary acupuncture appears in print in France. The case reported is of a paralyzed ox that was treated by implanted needles 3

v http://www.icmart.org/baltic/abstract/ab21.html

vi Morand. 1825. Memoir on Acupuncture. Trans. F. Bache. Philadelphia: Desilver.

vii Ewing J. Case of neuralgia cured by acupuncturation, N. Amer. Med. Surg. J., 1826, 2:77-88

viii Coxe E. Observations on asphyxia from drowning, N. Amer. Med. Surg. J., 1826, 292-293

ix Skarda J. JAVMA 1999 Jan 1;214(1):37-9

x Fausel S. J Am Vet Med Assoc 1999 Mar 1;214(5):618

xi Rattan J. J Am Vet Med Assoc 1999 Mar 1;214(5):616, 618

xii Coxe E. Op cit.,1826, 2:292-293

inches long in two rows bilateral to the lumbar spine. The needles are described as being driven in with a mallet and left in place for two days.

N. By 1860, popularity seems to have waned. There are only half a dozen references to acupuncture in the medical literature during the second half of the 19th century.

O. References to the use of acupuncture appeared in two standard human medical texts in the early 20th century.

P. In 1907, A. R. Edwards wrote regarding the treatment of myalgia, “Deep injection of water into the muscles of the back may relieve pain… but is often vigorously opposed by the patient.”xiii

Q. William Osler, in 1917, recommended treating lumbago by thrusting three to four inch long needles into the lumbar musculature. He assures the reader that “ordinary bonet needles, sterilized, will do.”xiv

R. Note that, in none of these pre- and early 20th Century examples of acutherapy in the West is there any referecnce to acupoints or channels. Needles are simply inserted near the point of the pain or the lesion in question. This is quite different from acupuncture as practiced by the early Chinese.

S. 1939: Georges Soulié de Morant, writes L’Acupuncture Chinoise, and invents “meridians” and equates “qi as energy.” (The latter was originally vapor rising from food and the former were either channels or channel vessels.) Soulié de Morant went to China at the turn of the century, where he served as French Consul for Shanghai and as a judge in the French Concession in Shanghai. He became convinced that acupuncture could cure cholera, among other things. Soulié de Morant returned to France in 1917, where he began actively promoting acupuncture among medical professionals.

T. During WWII a small group formed in Paris, working more or less in secret. The French Society for Acupuncture was founded in 1943, making it the oldest such society in the western world. Thus Paris became the center for western acupuncture for many years.

U. The Deutsche Gesellschaft fur Akupunktur (The German Society for Acupuncture) founded in 1952.xv

V. The Austrian Society for Acupuncture founded in 1954.W. 1950s – Frenchman P.M.F. Nogier invents ear acupuncture – a traditional

Chinese therapy based on his “sudden intuition” that the antihelix of the ear is equated with the human vertebral column “in the inverse direction.” (image)

X. 1950-1963: At least four doctoral theses dealing with veterinary acupuncture are published in France.xvi,xvii,xviii,xix

Y. In the 1970s, veterinary acupuncturists co-opt ear acupuncture. (image)

xiii Edwards A. R. 1907. Principles and Practice of Medicine. Philadelphia: Lea Bros.

xiv Osler W. 1917. Principles and Practice of Medicine, St. Louis, Mosby.

xv http://www.doctorgetwell.org/AcupunctureHistory.asp?more=europe

Z. Proponents of both human and veterinary acupuncture tend to overlook the fact that, subsequent to the introduction of scientific biomedicine in Asia, the practice largely fell out of favor there.

AA. In an effort to modernize medicine, the Chinese government attempts to ban acupuncture first in 1822, and several times later.xx In Japan, acupuncture is similarly prohibited in 1876.

BB. By 1911, acupuncture is no longer a subject for examination in the Chinese Imperial Medical Academy.xxi

CC. Prior to the Second World War, the Nationalist Chinese government tries to ban the use of traditional Chinese medicine altogether.

DD. 1949 – 1956: acupuncture revived for political reasons on Mao’s orders. There are not enough scientifically trained practitioners to go around (only about 10,000). Mao originally expresses the intention that Chinese medicine and its practitioners would be brought up to “scientific snuff.”

EE. Eventually he seems more interested in dealing a blow to the “elitist,” “arrogant” and politically suspect Western medical community by forcing them to swallow the distasteful pill of embracing Chinese Medicine. According to his Western-trained personal physician, Mao stated that “even though I believe we should promote Chinese medicine, I personally do not believe in it. I don’t take Chinese medicine…”xxii

FF. 1954 the term Traditional Chinese Medicine first appears. Prior to that, in the Chinese literature it was just “Chinese Medicine.”xxiii (Moreover, what is currently known as TCM is by and large a post-1950 invention.)

xx Skrabanek P, Acupuncture: Past, Present and Future, in Examining Holistic Medicine, (Stalker D and Glymour C, eds.) Prometheus Books, Buffalo NY, 1989; 183

xxi Prioreschi, P. A History of Medicine. Volume 1. Horatius Press, Omaha, NE, 1995: 179

xxii Li Z. The Private Life of Chairman Mao: The Inside Story of the Man Who Made Modern China. London, Chatto & Windus; 1994:84

xvi Lepetit J. 1950. Essais d’Acupuncture Practique sur les Animaux. Doc. Thesis, National Vet. Sch., Alfort, France.

xvii Bernard J. 1954. Contribution a l’etude de l’acupuncture chez les carnivores. Doc. Thesis, National Vet. Sch., Alfort, France.

xviii Metivet, J. M. 1963. Contribution a l’ètude compare de la Resistance Electrique Cutanee. Application a la Therapeutique Cher urgicale Veterinaire. Doc Thesis, National Vet. Sch., Alfort, France.

xix Viet F. 1963. Contribution a l’etude de l’acupuncture en pathologie osteoauticulaire. Doc Thesis, National Vet. Sch., Alfort, France.

GG. 1971-2: Journalist James Reston’s and Richard Nixon’s physician’s experiences during a 1972 visit to China are often cited as the seminal events leading to the introduction of acupuncture in the West.xxiv,xxv

HH. It was widely reported (and many people still believe) that Reston had his appendix removed “under acupuncture anesthesia.”

II. In fact, chemical anesthesia was used. Acupuncture was administered the day after surgery, and Reston claimed that an hour after the needles were inserted, he experienced pain relief. It’s more likely that pain relief was the result of the return of normal bowel motility.xxvi

JJ. Ironically, over the last 35 years, as TCM has grown ever more popular in the West, it seems to have grown ever less popular in China.

KK. 1995. The Committee for Scientific Investigation of Claims of the Paranormal (CSICOP) was invited by the Chinsese Association for Science and Technology (CAST) to send physicians and scientists to investigate the current status of TCM in China. Oncologist, Wallace Sampson, and psychologist Barry Beyerstein made the following observations while describing their visit to the China Academy of Traditional Chinese Medicine in Beijing:xxvii

We were told that, these days, the proportion of Chinese patients choosing TCM, nationwide, is only about 15 to 20 percent, a figure that surprised us… The 15 to 20 percent estimate was later reiterated by other informants who practiced TCM in Shanghai… Diagnoses for the patients we saw had generally been made by biomedical physicians, and the patients had elected to receive TCM in addition to their Western treatments.

2. Veterinary Acupuncture, Mid-20th Century to Present

A. No evidence of verum acupuncture in animals – i.e. the manipulation of qi in channels by means of needling – anywhere in the world prior to the mid-20th century.

xxiv Unschuld P. Chinese Medicine, op. cit., 110.

xxv Ernst E. Complementary medicine: the facts, Phys. Ther. Rev., 1997, 50

xxvi Taub A, Acupuncture: Nonsense with Needles, from The Health Robbers: A Close Look at Quackery in America.

xxvii Bayerstein B, Sampson W. Traditional Medicine and Pseudoscience in China: A Report of the Second CSICOP Delegation (Part 1), Skeptical Inquirer, July/August 1996, http://www.csicop.org/si/9607/china.html

xxiii Taylor K. Chinese Medicine in Early Communist China, 1945-63; A Medicine of Revolution, RoutledgeCurzon, 2005.

B. “There is no information on small animal acupuncture from ancient China.” Klide and Kung, 1997

C. Small animal veterinary medicine (i.e., medical practice applied to dogs, cats and domestic fowl) did not exist in ancient China. Despeux has observedxxviii:“The art of healing horses was […] well-developed. Then comes the buffalo, the hog and the camel. Fowl (chicken and ducks) have never been the subject of developed treatments, and even less dogs and cats [the latter] having become pets only recently among a small minority of Chinese. Living in a half-wild state, the dog and the cat were only accepted as guardians and hunters of rodents. Just look at the strong reactions of many Chinese in France to the many pets there to understand the scorn the Chinese have for all animals in general, except for the most useful. The human and civilized world should never mix with the savage one, according to Confucian tradition […]”

D. 1950s – 1960s: “European pioneers of modern vet AP in the 1950's and 60's included Kothbauer (Austria), Milin (France) and the late Westermayer (Germany). American pioneers, coming to the field a little later than the Europeans, included Altman, Bressler, Cain, Jaggar, Klide and the late Grady Young.” Phillip A. M. Rogers.

E. Kothbauer’s idea of animal acupuncture is injecting drugs at alleged acupuncture points.

F. 1961; Kothbauer publishes “On pain point diagnosis and neural therapy in animals,” Wiener Tierarztl. Monattschr., 53, 282-.

G. 1977: Klide and Kung’s Veterinary Acupuncture published. Offers the first English translations of Chinese veterinary medical texts (essentially all post-1950 publications).

H. Curiously, nothwithstanding the title of their book, in most instances Klide and Kung don’t directly refer to the techniques described and illustrated in these Chinese texts as “acupuncture.” They often use the term “hemoacupuncture.” It’s never made clear why they tend to avoid the more straightforward terms “therapeutic phlebotomy” or simply “bleeding.” Perhaps it’s because they thought some readers might realize that therapeutic phlebotomy not only isn’t acupuncture, it’s not even an original Chinese intervention.

I. Provide images of “acupuncture needles” from Klide and Kung. Also provide images of required restraint for acupuncture, and the “acupuncture hammer” required to drive in some of these “needles.” The few filiform needles depicted are “fire needles” used for cautery.

xxviii Despeux C, Apercu historique de l'art vétérinaire en Chine. Revue d'acuponcture vétérinaire, 1981; 9:21-22

J. Small animal veterinary medicine (i.e., medical practice applied to dogs, cats and domestic fowl) did not exist in ancient China. Despeux has observedxxix:

The art of healing horses was […] well-developed. Then comes the buffalo, the hog and the camel. Fowl (chicken and ducks) have never

been the subject of developed treatments, and even less dogs and cats [the latter] having become pets only recently among a small minority of Chinese. Living in a half-wild state, the dog and the cat were only accepted as guardians and hunters of rodents. Just look at the strong reactions of many Chinese in France to the many pets there to understand the scorn the Chinese have for all animals in general, except for the most useful. The human and civilized world should never mix with the savage one, according to Confucian tradition […]

K. In fact, the Yuan Heng Liao Ma Chi (Treatise on Treating Horses), 1609, specifies that the lancets and blades employed in “needling” (bloodletting, cautery and lancing) should not be rotated for fear of causing uncontrollable hemorrhage.

L. Xu Da-chun. The fact that Chinese medicine has not “descended intact through the ages” was recognized centuries ago by the Chinese themselves. As early as 1757, Chinese physician and scholar Xu Da-chun pointed to the “loss of acupuncture tradition” and noted that the acupuncture points, channels, and practices in use at the time were very different from those described in the ancient texts.xxx

M. Over the last 30 years, the offering of acupuncture courses wherein Western health care professionals and others travel to China for training has developed into a small but profitable industry.

N. Since acupuncture is based on ideology and philosophy rather than science or even empiricism, perhaps it should come as no surprise that some proponents of veterinary acupuncture speak of it in sectarian terms.

“On the surface, the future of vet AP seems assured. But is this so ? We must be very careful. Our baby is very fragile and there are wolves outside the nursery, ready to savage it to death.” Philip A.M. Rogers h ttp://users.med.auth.gr/~karanik/english/vet/histor1.htm

3. What is acupuncture?

A. There is no “one acupuncture.” In addition to Chinese acupuncture, there are Korean, Japanese, Thai, Taiwanese, Ayurdedic and various forms of “Western medical” acupuncture.

B. What about hand vs ear vs scalp vs tongue vs foot acupuncture?C. What about herbal acupuncture vs. constitutional acupuncture vs Saam

acupuncture?xxxi

D. What about deep vs. superficial needling vs. sham needling vs digital acupressure vs laserpuncture vs therapeutic hand-waving over acupuncture points?

E. What about running electrical current through needles with or without twirling vs through dermal pads without needles at all?

F. What about systems that depend on specific points and meridians vs those that don’t? Felix Mann, co-founder and former president of the British Medical Acupuncture Society has asserted that it makes little difference exactly where one places the needles.

G. Just about the only thing all these various interventions have in common is that practitioners and proponents of each are convinced that they’re highly effective for a wide variety of conditions.

H. How likely is it that all or even most of them are right? Isn’t it at least as likely that most or all of them have merely come to the same, erroneous conclusion for largely the same reasons?

4. Do acupuncture points really exist?

A. In humans, there were originally 360 acupuncture points. The basis for this number was cosmological (i.e. the number of days in the year) rather than empirical or observational.

B. Currently, more than 2000 acupuncture points have been “discovered” in humans. Mann has commented that “, if modern human acupuncture texts are to be believed, there is no skin left which is not an acupuncture point.”xxxii

C. In any case, according to the Huang di nei jing, the ancient Chinese were quite insistent that the needling points in animals are entirely different from those in people. (Cite)

D. As anatomical entities, acupuncture points may be located in the vicinity of peripheral nerves, ligaments or tendons.xxxiii However, there is no consistent association with any one specific gross anatomical structure.

E. Several investigators have reported various histological findings at acupuncture points, such as nerve terminals, neurovascular bundles or mast cell accumulations; however, none of the studies used statistical evaluation of quantitative histological data to confirm the significance of their findings.xxxiv

F. No method of determining acupuncture point locations has yet been shown to be precise, or repeatable.

G. Electrical skin resistance, which can be detected by various devices, has been shown to be an inaccurate and unreliable method of locating acupuncture points and is influenced by factors such as the shape and surface area of the electrode, dryness of the skin, local variations in skin thickness, surface secretions, pressure placed on the electrode, inclination of the electrode, electrode gel used, scanning speed of the device, and even room temperature and humidity.xxxv,xxxvi,xxxvii,xxxviii,xxxix,xl

H. Traditional methods of measuring to determine acupuncture point location in man rely on the cun unit, said to be equal to the width of the interphalangeal joint

of the human thumb. However, this method, subject to individual anatomical variation, has also been shown to be unreliable.xli

I. Acupuncture points have failed to demonstrate sensitivity to palpation relative to other points on the human body; therefore, relying on point sensitivity as the sole form of point location is likely to be of dubious utility.xlii

J. Finally, directional and proportional methods for measuring acupuncture point locations - the most widely used methods for locating acupuncture points in man - have also been shown to be grossly imprecise.xliii

K. There are literally dozens of ‘systems’ of human acupuncture, as well as myriad approaches to using needles within those systems. In some of these approaches, e.g. ‘western’ acupuncture, needle placement may be unrelated to the presence or absence of actual anatomical acupuncture point entities.xliv

L. The irrelevance of specific points for any effects of acupuncture is underscored by the fact that most studies that have compared ‘sham’ and ‘real’ acupuncture points have been unable to show a consistent difference in response to manipulation between sites.xlv I.e., overall, ‘sham’ acupuncture tends to work nearly as well as ‘real’ acupuncture in controlled clinical trials.

M. In that same vein, similar efficacy has been asserted between ‘traditional’ and ‘transpositional’ points in horses (i.e. points misidentified from ancient Chinese equine bleeding and cautery charts vs those transposed onto horses from human acupuncture charts).xlvi

N. Felix Mann: “…acupuncture points are no more real than the black spots that a drunkard sees in front of his eyes.”xlvii

5. Do acupuncture meridians really exist – in humans or in animals?

A. The term meridian was coined by Georges Souliét de Morant in 1939, the same man who first equated qi with energy.xlviii

B. Equine acupuncture meridians date only to the 1970s and were invented at the insistence of Western practitioners.xlix

C. Since then, various authors (mostly Western) have “discovered” meridians in cattle, pigs, dogs, cats, and various other species, mostly by “transposition” from one of many human charts,l,li,lii,liii and sometimes by misinterpreting the bleeding points on medieval Chinese animal illustrations as “acupuncture points.

D. Show incorrectly labeled and identified vet acupuncture illustrations from various proponent texts.

E. Some modern practitioners frankly question the very existence of acupuncture meridians in the horse.liv

F. In human acupuncture, meridians have changed dramatically in number, name, character and even position through history.

G. The Mawangdui texts describe eleven mai (vessels) which were described as containing both blood and qi.lv No distinction is made between vessels containing blood and those containing qi, however, the vessels did not appear to connect with each other.

H. “Blood vessels are the obvious original referent of mai. The earliest attestation of the word is fourth century B.C., in a Zuozhuan description of a horse: ‘chaotic vapor, untamed, erupts; dark blood springs forth, coursing; ridges of swollen vessels (mai) bulge.’ (Zouzhuan, Xi 15,14.3a)”lvi

I. By the late first century B.C. (in the Huangdi neijing suwen) the number of vessels had grown to twelve, and they comprised a connected and more complex system. Moreover, blood and qi sometimes seem to flow in separate vessels, while at others they seem to flow in a mix.lvii Vessels carrying qi are by this time referred to as “conduits” (ching) or “conduit vessels” (ching-mai.) In later texts, the qi vessels and blood vessels are separate.

J. “The transition from the old idea of blood vessels to physiological theory whose main purpose was to explain the movement of vapor in the body directed attention away from the blood vessels per se and towards an idealized system which meshed with correlative cosmology.”lviii

K. Perhaps most significantly, the twelve vessels described in the Huangdi nei jing follow substantially different courses than the eleven described in the earlier Mawangdui texts.

L. The “true” original location of human acupuncture meridians was further obscured when, in 1993, a lacquer conduit-figurine was recovered from a Western Han tomb depicting only nine mai, even though it ostensibly dates from after the Mawangdui treatises describing eleven mai. Moreover, two of the mai etched on the figurine are ones that the Mawangdui treatises fail to discuss.lix,lx

M. Later, Chinese medical philosophers overtly lamented the “loss” of the original conduits.lxi Wherever the meridians may be, they are clearly not where they started.

N. How many real anatomical structures have radically changed in number, direction and fundamental nature over a 2,000 year period?

O. What about the various studies that have alleged to demonstrate the existence of meridians?

P. Histological Evidence: In humans, meridians have been examined for their correspondence with nerves, blood and lymphatic vessels.lxii It is difficult to assess these reports, because they have often included minimal detail. It does appear that points are occasionally linked by the same nerve, or the same blood vessel or, although less likely, the same lymphatic channel. However, no channel studied has ever completely correlated with any of these three structures.lxiii

Q. Electrical Resistance: One investigation concluded that the electrical resistance along one meridian in the human arm was less than that which was found between non-acupuncture points,lxiv however, such investigations would be subject to the same problems that beset determination of acupuncture points by that methodology.

R. Radiotracer Studies: There have been at least three attempts to validate the concept of meridians using radiotracer injections. Early investigators concluded that an injected radiotracer was cleared by non-lymphatic and non-venous pathways and suggested that this demonstrated the existence of

acupuncture meridians. However, a subsequent attempt to replicate this finding was unsuccessful and the authors concluded that the radiotracer was removed along normal venous pathways.lxv A third investigation concluded that technetium uptake was faster from certain acupuncture points than from non-points, but that thereafter it was removed by the venous system.lxvi

S. Radiation of sensation: Insertion of acupuncture needles may cause radiation of needle sensation in humans away from the point of insertion. However, this radiation of sensation does not generally correspond to the discrete paths of the postulated meridians. Furthermore, such sensations appear to be quite variable, occurring more typically in certain regions of the body and in response to certain needle techniques. Injection of local anesthetics into deep structures, but not subcutaneously under acupuncture points, blocks this sensationlxvii and direct nerve recording experiments in man show that the sensation of radiation results from direct activation of primary afferent nerve fibers.lxviii While these and other studies fairly conclusively demonstrate that it is the nervous system, and not changes in “qi” flow through “meridians,” that result in the acupuncture sensations reported in humans, still, it is interesting to speculate whether such sensations contributed to the development of the idea of meridians. Obviously, radiation of sensations can neither be confirmed nor denied in animals.

T. Thermography, ultrasonography, magnetism, light and heat: Some investigators have claimed that temperature changes on the surface of the body are a reflection of meridians.lxix Others have claimed that a variety of modalities, including ultrasound, magnetism and light have demonstrated variations between meridians and other areas.lxx Such experiments are difficult to assess because the details provided are generally sketchy and the investigations are rarely conducted under rigorous, well controlled conditions.lxxi At the very least, reports that meridians can be reliably located by some physical means require replication.

U. From a pragmatic standpoint, one might surmise that, if structures such as acupuncture points and meridians did exist and could reliably be demonstrated, they would be recognized in the study of anatomy and physiology; however, no such recognition has been forthcoming to date. Whatever the clinical efficacy of needling, there is as yet no compelling

lxvii Chian, CY, Zhang, QC, Zhu, XL, et al. Peripheral afferent pathway for acupuncture analgesia. Sci Sin

1973; 16: 210 - 217.

lxviii Wang, KM, Yao, SM, Xian, YL, et al. A study on the receptive field of acupoints and the relationship

between characteristic of needling sesation and groups of afferent fibers. Sci Sin [B] 1985; 28: 963-971.

evidence to show that acupuncture points or meridians exist as discrete entities (Ernst 1997; Ramey and Buell 2000).

6. What about Efficacy? Preliminary Issues

A. In the first place, it’s important to understand that the objective scientific evidence for acupuncture efficacy in animals is virtually non-existent.

B. The only attempt at a systematic review of acupuncture completed in animals to date was conducted in horses.lxxii The authors found that western equine acupuncture literature on whether acupuncture is considered for diagnostic or therapeutic purposes does not focus on quantitative analyses and rarely fits any of the relevant criteria considered necessary for a good scientific investigation. Protocols such as randomization, blinding and control groups, typical of quality studies, are lacking in virtually every published paper in the field (with a few exceptions). In general, equine acupuncture studies are quite small and vary in their endpoints, making a pooling of results impossible.

C. It consists almost entirely of case reports, anecdotes. The handful of RCTs that do exist are of such low quality that they are of little value. The evidence for efficacy of human acupuncture is also of generally low quality, but it offers the “best case for demonstrating acupuncture efficacy in at least one species.” So that is, primarily, the evidence I’ll be examining. As you all know only too well, it is never safe to assume that an intervention that’s effective and safe in one species will be effective and safe in any other species. Consider paracetamol and cats.

D. It’s interesting to note that while, at least in the West, the most common indication for acupuncture in man has been pain, in ancient and medieval China, “needling” was never employed specifically as a treatment for pain, per se. Acupuncture analgesia is an invention of the late 1950s.lxxiii

E. According to the ancient and medieval Chinese, acupuncture was not to be used in the treatment of “manifest disease” – only incipient disease.

7. The Evidence for Efficacy: How Convincing is it?

A Over 30 years of active acupuncture research through the last part of the 20th century have failed to unequivocally demonstrate its clinical efficacy in human medicine lxxiv

B. Sham acupuncture appears almost as active as “real” acupuncture.lxxv

C. Most acupuncture trials and reviews in man are handicapped by their poor methodological and design quality.

D. These flaws frequently include failure of blinding, failure of randomization and/or errors in allocation, variable or post hoc selection of endpoints, inadequate numbers of subjects, variable/inappropriate choice of control

lxxiv Moroz A Am J Acupunct 1999;27(1-2):95-103 Issues in acupuncture research: the failure of quantitative methodologies and the possibilities for viable, alternative solutions.

treatment/placebo, inappropriate lumping of various unrelated “acu-therapies” together.

E. Publication bias and other sources of error probably account for the slight edge active acupuncture seems to enjoy in some trials and systematic reviews.

F. It has been shown that the higher the quality of acupuncture/TCM RCTs, the more likely they are to yield “negative” results, and vice versa.lxxvi

G. Do certain countries produce only positive RCTs? Unfortunately, yes.lxxvii If you know that a given country produces only positive trial results, how much weight can one reasonably give a positive trial conducted/published in said country?

H. Undetected fraud. The Cochrane Collaboration and other entities putatively dedicated to “evidence based medicine” [EBM] fail to take into account either “prior probability of efficacy” or the possibility of fraud.lxxviii

8. The “Best Case” Evidence for Acupuncture Efficacy.

A. Post-operative nausea and vomiting (PONV), nausea due to chemotherapy, Post-operative dental pain, tennis elbow (lateral epicondylitis), and migraine have in recent years generally been considered the indications for which the best/strongest objective scientific evidence for acupuncture efficacy currently exists.

B. For most of the remaining conditions for which it is used, such as for human back painlxxix,lxxx, it is either impossible to draw conclusions about efficacy due to conflicting or poor quality data, or the conclusions are negativelxxxi,lxxxii,lxxxiii,lxxxiv,lxxxv.

C. In other areas for which acupuncture was previously advocated, such as for surgical anaesthesia, the use of acupuncture has been largely abandoned even in Chinalxxxvi

D. In addition to the western language literature, there is a body of ‘eastern’ literature pertaining to acupuncture in horses (from China and other east Asian countries).

E. The results of such studies are almost uniformly positive. However, it should be recognized that essentially none of this literature meets the criteria established for scientific quality; rather, it is most commonly uncontrolled case reports.

F. The poor quality of the eastern language veterinary literature parallels conclusions regarding published information on Chinese studies in human medicine. For example, in a review of randomized controlled trials of traditional Chinese medicine,lxxxvii the method of randomization was often described inappropriately. Blinding was used in only 15% of trials, trials were inhibited by small sample sizes and lack of controls and the long-term outcomes were not reported. Data pertaining to effectiveness was rarely expressed and reported quantitatively. Most trials claimed that the tested treatments were effective, which is in accordance with a previous report indicating that 99% of clinical reports from China (and 100% of reports on acupuncture) over a 30-year period were positive.lx Rather than indicating the effectiveness of

treatments, the high success rates in Chinese medical, and presumably veterinary, literature indicates that publication bias may be common.

G. Curiously, almost none of the studies performed in horses have evaluated filiform needle acupuncture; rather, they have looked at electrical stimulation of putative acupuncture points (‘electroacupuncture’).lxxxviii This is consistent with the majority of acupuncture research performed in the veterinary field.lxxxix

H. One problem with such studies is that control nonacupuncture points are almost never used; therefore, it is essentially impossible to separate effects that may be due to interventions at putative acupuncture points from simple nonspecific responses to an electrical stimulus. Therefore, it is entirely reasonable to consider that such clinical or chemical effects may not relate to precise placement of needles at all, questions of efficacy notwithstanding.

I. For scientific results to be validated, replication of results is important. Unfortunately, such good quality papers as exist in equine acupuncture fail to provide consistent results when studies have been conducted attempting to replicate previously obtained data. For example, whereas one study of 9 horses in which electroacupuncture stimulation of placebo (distant from the acupuncture site), control (one vertebral space in front of or behind the point) or ‘real’ acupuncture points showed a decrease in plasma cortisol levels for 1 to 2 h post treatment compared with sham treatment points,xc another study of 15 horses showed an increase in plasma cortisol levels when comparing ‘real’ to sham (nonacupuncture point) treatment.xci Similarly, another well-conducted investigation did not show any effect of low-dose prostaglandin derivatives administered at lumbar acupuncture pointsxcii and therefore failed to replicate a previously reported study.xciii

J. The poor design of veterinary acupuncture studies is consistent with evaluations of other ‘alternative’ modalities in human medicine (Linde et al. 2001).xciv There are exceptions, but as in human medicine, the best studies are least likely to show positive results. Therefore, given the general poor quality of equine acupuncture studies, there is at least the possibility that erroneous conclusions can be drawn about the value of equine acupuncture from taking poor quality studies or anecdotal reports of the ‘success’ of acupuncture at face value.

K. Due to time constraints, I’ll discuss just acupuncture for PONV. Upon careful scrutiny, the evidence even for this “best case” turns out to be extremely weak as well.

L. Unfortunately, in positive reports which exist on use of acupuncture for prevention of nausea and vomiting, researchers have sometimes failed to report important clinical details, or found effects only in selected subgroups, rendering readers of such reports largely unable to critically appraise them from a clinical standpoint.

xciv Linde, K., Jonas, W.B., Melchart, D. and Willich, S. (2001) The methodological quality of randomized controlled trials of homeopathy, herbal medicines and acupuncture. Int. J. Epidemiol. 30, 526-531.

B. Furthermore, the design of those reports is such that they preclude potential reviewers from establishing valid conclusions about the usefulness of acupuncture for such conditions.xcv

E. In 1999, Anesthesia and Analgesia published a meta-analysis by Lee and Done titled “The use of nonpharmacologic techniques to prevent post operative nausea and vomiting.”xcvi These techniques included “acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation [TENS], acupoint stimulation and acupressure.” Nineteen randomized trials (out of a total of 24 identified) were deemed eligible for the meta-analysis, and all of them involved stimulation of the P6 acupuncture point (on the wrist.)

D. Eleven trials were reported as positive and eight as negative. All four trials in children were negative.

E. Lee and Done concluded that these techniques are effective in adults, but not in children. Their conclusion is unlikely to be valid for the following reasons:

F. As I mentioned earlier, some countries produce only positive clinical trials. Prior to the publication of the meta-analysis an article had appeared demonstrating that during the period 1965-1995 (the entire period investigated) certain countries produced only positive RCTs of acupuncture -- or any other intervention, for that matter.xcvii The authors of that paper concluded that this was evidence of publication bias. It is also evidence of other types of bias. One of the countries that produced only positive studies was Taiwan.

F. In the Lee and Done meta-analysis four of the positive trials, but none of the negative, had been performed in Taiwan. Among these was the only trial that Lee and Done awarded the highest methodology rating, but that trial reported an improbable result: in the intervention group only 1/30 post-op caesarian patients had nausea and 0/30 had vomiting.xcviii

G. The incidence of nausea and vomiting after cesarean section in humans is typically at least 20-30%. Thus it is reasonable to dismiss all four reports from Taiwan as unreliable.

H. Of the seven remaining positive trials, Lee and Done gave a methodology rating of 1 point (out of a possible 5) to four. None of the negative trials received that low a rating. According to Lee and Done, a rating of “1” meant either that the study described itself as randomized—but with no explanation of the method of randomization—or that that the study gave the number and reason for withdrawals. Thus a study needn’t have been blinded, appropriately randomized, or randomized at all to be included in the meta-analysis. It is reasonable to dismiss all trials rated “1” as unreliable.

I. Of the three remaining positive trials, one reported an anomalous result: the incidence of vomiting in the intervention group was four times higher than the incidence of nausea in the same group.xcix The authors reported no methodological or statistical explanation for this (such as having intentionally counted nausea and vomiting as vomiting only). Vomiting without nausea in the postoperative setting is implausible and was not reported by any of the other trials. Thus it is reasonable to dismiss this report as unreliable.

J. This leaves two positive trials and eight negative trials. Even if we segregate the pediatric from the adult trials—a questionable decision in itself—there remain four negative trials in adults and only two positive trials.

K. Nausea is measured subjectively. Its prevention is psychogenic in some circumstances.c It is difficult, if not impossible, to perform strictly double-blinded, placebo-controlled acupuncture trials. These facts increase the chances for interpretive errors.

O. Trials subsequent to Lee and Done’s meta-analysis have been mixed, with the positives continuing to outnumber the negatives. Many of these are also vulnerable to fatal criticisms,ci including funding by the manufacturer of the device that was being tested.cii

P. All of the foregoing criticisms were pointed out by Kimball Atwood, MD, in a letter to the editors of Anesthesia and Analgesia, but they declined to publish same.

Q. Trials subsequent to Lee and Done's meta-analysis have been mixed. They continue to be vulnerable to serious criticisms, including financial support by the manufacturer of a device that was being tested.ciii

R. The letter was finally published last year in the Scientific Review of Alternative Medicine.civ

S. A recent randomized, double-blind, placebo-controlled trial found no difference in PONV between 109 women receiving P6 acupuncture and 111 women receiving placebo acupuncture.cv This is the most methodologically sound trial to date and, as such, holds more weight than a meta-analysis of lesser studies.cvi

T. Adding to the confusion, in 2004, the Cochrane Database for Systemic Reviews published yet another systematic review by Lee and Done dealing with “Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting.cvii Lee and Done did not consider this review of higher-quality trials in their Cochrane Review update of April 2004 because their search was limited to trials published before February 2003.

U. This larger, 2004 trial by Lee and Done alleged to show that P6 acu-stimulation reduced the risk of post-operative nausea but NOT vomiting.

V. The Cochrane Collaboration is ostensibly dedicated to the promotion of, and maintenance of standards in, evidence based medicine [EBM]. Have they dropped the ball with regard to acupuncture efficacy?

W. A number of reviews have cited Lee and Done’s 1999 review. These must be questioned regarding their conclusions about P6 stimulation and PONV.cviii,cix,cx

cviii Gan TJ, Meyer T, Apfel C et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003;97:62-71cix

? Linde K, Vickers A, Hondras M et al. Systematic reviews of complementary therapies - an annotated bibliography. Part 1: Acupuncture. BMC Complement and Altern Med 2001;1:3 Available at: http://www.biomedcentral.com/1472-6882/1/3 cx

X. The big picture: P6 acupuncture is alleged to be effective in preventing some kinds of nausea, but not others. It’s supposedly effective in adults but not children. (Could this be because blinding is usually compromised in these trials, and adults tend to realize that verum acupuncture is supposed to prevent PONV, but children are naïve in this regard? In other words, adults may know, or figure out, that acupuncture is supposed to help with PONV, but this is less likely to be so with children.)

Y. Not only are clinical trials of acupuncture rarely randomized or adequately blinded, the published results of those that are rarely if ever specify exactly

? Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Ann Intern Med 2002;136(5):374-83

xxix Despeux C, Apercu historique de l'art vétérinaire en Chine. Revue d'acuponcture vétérinaire, 1981; 9:21-22

xxx Unschuld, P. Forgotten Traditions, op. cit., 244.

xxxi http://www.koma.or.kr/eng/theory/index.htm

xxxii Mann, F. (1998) A new system of acupuncture. In: Medical Acupuncture: A Western Scientific Approach, Eds: J. Filshie and A. White, Churchill Livingstone, London. p 62.

xxxiii Dung, H.C. (1984) Anatomical features which contribute to the formation of acupuncture points. Am. J. Acupunct. 12, 139-144.

xxxiv Langevin, H. and Vaillancourt, P. (1999) Acupuncture: does it work and, if so, how? Sem. Clin. Neuropsych. 4, 167-175.

xxxv Noordergraaf, S. and Silage, D. (1973) Electroacupuncture. EEEE Trans.Biomed. Eng. 20, 364-366.

xxxvi Yamamoto, T. and Yamamoto, Y. (1977) Analysis for the change of skin impedance. Med. Biol. Eng. Comput. 15, 219-227.

xxxvii Yamamoto, T., Yamamoto, Y., Yasuhara, K., Yamaguchi, Y., Yasumo, W. and Yoshida, A. (1988) Measurement of low-resistance points on the skin by dry roller electrodes. IEEE Trans. Biomed. Eng. 35, 203-209.

xxxviii Cho, S.-H. and Chun, S.I. (1994) The basal electrical skin resistance of acupuncture points in normal subjects. Yonsei Med. J. 35, 464-473.

xxxix Kwok, G., Cohen, M. and Cosic, I. (1998) Mapping acupuncture points using multi channel device. Aust. phys. Eng. sci. Med. 21, 68-72.xl Hot P, Naveteur, J., Leconte, P. and Sequeira, H. (1999) Diurnal variations of tonic electrodermal activity. Int. J. Psychophysiol. 33, 223-230.

how they were randomized or blinded. These are crucial deficiencies. Without knowing these things, it’s probably unwarranted to give any weight to positive trial results at all.

Z. For instance, if we don’t know how or whether a trial was randomized, how do we know that “acupuncture enthusiasts” weren’t allocated preferentially to the treatment rather than the control group, thereby skewing the results? If we don’t know whether or not the acupuncturists were allowed to chat with the subjects prior to or after treatment, how do we know that subjects weren’t

xli Coyle, M., Aird, M., Cobbin, D. and Zaslawski, C. (2000) The cun measurement system: an investigation into its suitability in current practice. Acupunct. Med. 18, 10-14.

xlii Aird, M., Coyle, M., Cobbin, D. and Zaslawski, C. (2000) A study of the comparative accuracy of two methods of locating acupuncture points. Acupunct. Med. 18, 15-21.

xliii Aird, M., Cobbin, D.M. and Rogers, C. (2002) A study of the relative precision of acupoint location methods. J. Altern. Complement. Med. 8, 635-642.

xliv Campbelle, A. (1998) Methods of acupuncture. In: Medical Acupuncture: A Western Scientific Approach, Eds: J. Filshie and A. White, Churchill Livingstone, London. pp 19-32.

xlv Sanchez-Aranjo, M. (1998) Does the choice of placebo determine the results of clinical studies on acupuncture? Forsch Komplementarmed., Suppl. 5, 8-11.

xlvi Panzer, R. (1993) A comparison of the traditional Chinese vs. transpositional Zangfu Organ Association acupoint locations in the horse. Am. J. Chinese Med. 21, 119-131.

xlvii Mann F. Reinventing Acupuncture: A New Concept of Ancient Medicine. Butterworth Heinemann, London, 1996, 14.

xlviii Soulié de Morant, G. Chinese Acupuncture, English Edition edited by Paul Zmiewski, Pradigm Publications, Bookline, MA, 1994

xlix White S in Schoen A (ed.), Veterinary Acupuncture, op. cit., 584

l Schwartz C, Four Paws Five Directions: A Guide to Chinese Medicine for cats and Dogs. Berkeley: Celestial Arts Publishing, 1996

li Rogers P. The study of acupuncture: points and channels in animals, <http://users.med.auth.gr/~karanik/english/vet/ptsmer1.htm>

exposed to clues regarding their “treatment vs. control” status, effectively unblinding the trial?

AA. It’s hard to imagine afflictions more different than nausea/vomiting, post-operative dental pain, migraine and osteoarthritis of the elbow. What is the common thread connecting them? How likely is it that a single intervention would be effective in treating these widely disparate conditions, yet be ineffective in treating more closely related ones? What mechanism of action is most likely to account for these facts? It makes much more sense that the positive results are the result of the limitations of the tools being employed to

lii Rogers P. Acupuncture in cattle and pigs,<http://users.med.auth.gr/~karanik/english/vet/oxpig1.htm>

liii Panzer R. A comparison of the traditional Chinese versus transpositional zangfu organ association acupoint locations in the horse. Am J Chin Med 993;21(2):119-31liv Schoen A (ed.) Veterinary Acupuncture, op. cit. 345

lv Harper D, Early Chinese Medical Literature: The Mawangdui Medical Manuscripts, Kegan Paul International, London, 1997, 5

lvi Harper D, ibid, 82

lvii Paul Unschuld. Personal correspondence.

lviii Harper D, op. cit., 83-84

lix Kuriyama, S. The Expressiveness of the Body and the Divergence ofChinese Medicine. New York, Zone Books, 1999, 43

lx Unschuld P. Chinese Medicine, op. cit., 35

lxi Unschuld P. Forgotten Traditions of Ancient Chinese Medicine. Paradigm Publications, Brookline, MA, 1998, 244

lxii Huang, DK. Relationship between the points and channels and peripheral nerves. Acup Electrother Res 1983; 8(3/4): 328.

lxiii Bensoussan, A. Part 1: Acupuncture Meridians- Myth or Reality. Comp Ther Med, 1994 (2): 21-26.

lxiv Cohenm N, Voumard, P, Birch, S, et al. Low resistance pathways along acupuncture meridians have

dynamic behavior. Biomed Eng - Applic Basis Commun 1995; 7: 137-142.

lxv Lazorthes, Y, Esquerre, JP, Simon, J, et al. Acupuncture meridians and

investigate these conditions (RCTs, poorly designed/uncontrolled trials, and systematic reviews), rather than any inherent acupuncture efficacy.

9. Mechanisms of action -- or Acupuncture: The Ultimate Placebo

A. It should come as no surprise to anyone with an education in basic physiology that inserting needles into a body will invoke some sort of a physiological response. Although most animal studies have demonstrated some physiological response to needle insertion, the clinical relevance of such effects remains questionable.

radiotracers. Pain 1990

Jan;40(1):109-12.

lxvi Wu, C-C, Chen, M-F and Lin, C-C. Absorption of subcutaneous injection of Tc-99m pertechnate via

acupuncture points and non-acupuncture points. Am J Chin Med 1994; 22: 111-118.

lxix Hu X, Wu B, Wang P. [Displaying of meridian courses travelling over human body surface under

natural conditions]. Chen Tzu Yen Chiu. 1993;18(2):83-9. Chinese.

lxx Yum C., Zhang, G., Lu, J, et al. Characteristics of acupuncture meridians and acupoints in animals.

Rev Sci Tech Off Int Epiz 1994; 13(3): 927-933.

lxxi Tang, J-L, Zhan, S-Y, Ernst, E. Review of randomised controlled trials of traditional Chinese medicine.

BMJ 1999;319:160-161

lxxii Ramey, D.W., Lee, M.L. and Messer, N.T. (2001a) A review of the Western language equine acupuncture literature. J. equine vet. Sci. 21, 55-58.

lxxiii Hsue E. Innovations in acumoxa: acupuncture analgesia, scalp and ear cupuncture in the People’s Republic of China. Soc. Sci. Med. 1996, 42, 421-430.

lxxv Sanchez Aranjo M Does the choice of placebo determine the results of clinical studies on acupuncture? Forsch Komplementarmed 1998; 5 Suppl S1:8-11lxxvi Tang J, Zhan S, Ernst E, Review of randomised controlled trials of traditional Chinese medicine BMJ 1999;319:160-161 ( 17 July )

B. In man, functional MRI studies, which measure increased oxygen uptake in areas of the brain, have suggested that the brain is aware when a needle has been placed in the body. However, such studies have generally failed to demonstrate that this response is specific, i.e. that the points stimulated with acupuncture needles correlate to those areas of the brain said to be influenced by those points.cxi

C. The erythema and inflammation that result from needle insertion are not unique to acupuncture points, and human patients report identical sensations whether ‘real’ or ‘sham’ acupuncture points are used.cxii The distribution of the effects

lxxvii Vickers A, Goyal N, et al. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials 1998 Apr;19(2):159-166

lxxviii Sampson W, Atwood K, Propagation of the absurd: demarcation of the absurd revisited. MJA 2005; 183 (11/12): 580-581. http://www.mja.com.au/public/issues/183_11_051205/sam10986_fm.html

lxxix Cherkin, D.C., Sherman, K.J., Deyo, R.A. and Shekelle, P.G. (2003) Areview of the evidence for the effectiveness, safety, and cost ofacupuncture, massage therapy, and spinal manipulation for backpain. Ann. intern. Med. 138, 898-906.

lxxx Furlan, A., Tulder, M., Cherkin, D., Tsukayama, H., Lao, L., Koes, B. and Berman, B. (2005) Acupuncture and dry-needling for low back pain. Cochrane Database Syst. Rev. 1, CD001351.

lxxxi Mayer, D.J. (2000) Acupuncture: an evidence-based review of theclinical literature. Ann. Rev. Med. 51, 49-63.

lxxxii Anon (2001) Acupuncture: searching for benefits. Prescrire Int. 10, 84-88.

lxxxiii Ramey, D.W. and Sampson, W. (2001) Review of the evidence for the clinical efficacy of human acupuncture. Sci. Rev. Alt. Med. 5, 195-201.

lxxxiv Rabinstein, A.A. and Schulman, L.M. (2003) Acupuncture in clinicalneurology. Neurolog. 9, 137-148.

lxxxv Birch, S., Hesselink, J.K., Jonkman, F.A., Hekker, T.A. and Bos, A. (2004) Clinical research on acupuncture: part 1. What have reviews of the efficacy and safety of acupuncture told us so far? J.

lxxxvi Nishimura, N. (2002) Anesthesiology in People’s Republic of China in the year 2001. Masui. 51, 314-317.

lxxxvii Tang, J.-L., Zhan, S.-Y. and Ernst, E. (1999) Review of randomised controlled trials of traditional Chinese medicine. Br. med. J. 319, 160-161.

of acupuncture on pressure pain threshold does not support either neural segmental or traditional Chinese medicine channel theories, and needling nonacupoints leads to statistically significant increases in pain pressure threshold at 6 sites when needles are manipulated (Zaslawski et al. 2003).cxiii Finally, identical, transient, quick reflex responses of the sympathetic nervous system have been observed whether ‘real’ or ‘sham’ points are needled.cxiv

D. Purported scientific mechanisms of action for acupuncture generally involve suggestions that the procedure elevates circulating levels of various neurochemicals, especially endorphins (‘endogenous opiates’). While

lxxxviii Xie, H., Ott, E.A. and Colahan, P. (2001) Influence of acupuncture on experimental lameness in horses. Proc. Am. Ass. equine Practnrs. 47, 347-357.

lxxxix Carlsson, C. (2002) Acupuncture mechanisms for clinically relevant long-term effects - reconsideration and a hypothesis. Acupunct.Med. 20, 82-99.

xc Glardon, O.J. (1988) Variation of plasma cortisol values in horses afteracupuncture. Prat. vet. Equine 20, 32-34.

xci Cheng, R.S.S., McKibben, L.S., Roy, B. and Pomeranz, B. (1980) Electroacupuncture elevates blood cortisol levels in naive horses; sham treatment has no effect. Intl. J. Neurosci. 10, 95-97.

xcii Nie, G.J., Goodin, A.N., Braden, T.D. and Wenzel, J.G. (2001) Luteal and clinical response following administration of dinoprost tromethamine or cloprostenol at standard intramuscular sites or at the lumbosacral acupuncture point in mares. Am. J. vet. Res. 62, 1285-1289.

xciii Alvarenga, M.A., Ferreira, J.P.C., Luna, S.P.L. and Burns, P.J. (1998) Induction of luteolysis in mares utilizing a micro-dose of prostaglandin F2in the sacral lumbar space. J. equine vet. Sci. 18, 167-168.

xcv Elorriaga, C.A., Hanna, S.E. and Fargas-Babjak, A. (2003) Reporting of clinical details in randomized controlled trials of acupuncture for the treatment of migraine/headaches and nausea/vomiting. J.Altern. Complement. Med. 9, 151-159.

xcvi Lee A, Done M, The use of nonpharmacologic techniques to prevent post operative nausea and vomiting, Anesth. Analg. 1999, June;88(6):1362-9

xcvii Vickers A, Goyal N, Harland R, Rees R. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials 1998;19:159-166xcviii

? Ho CM, Hseu SS, Tsai SK, Lee TY. Effect of P6 acupressure on prevention of

elevations in endorphins are certainly associated with some acupuncture investigations, such an explanation is not convincing. Endorphins have a very short half-life and should not be responsible for the prolonged effects claimed by acupuncture proponents; endorphin levels in human serum have a half-life of around 22 mins,cxv while those in the human CNS persist for approximately 317 mins and are of limited use in managing chronic human cancer pain under any circumstances.cxvi Furthermore, fine needle acupuncture is not associated with rises in CNS endorphins in horses and neither fine needle acupuncture

nausea and vomiting after epidural morphine for post-cesarean pain relief. Acta Anaesthesiol Scand 1996;40:372-375

xcix Al-Sadi M, Newman B, Julious SA. Acupuncture in the prevention of postoperative nausea and vomiting. Anaesthesia 1997;52:658-661c

? Enqvist B, Bjorklund C, Engman M, Jakobsson J. Preoperative hypnosis reduces postoperative vomiting after surgery of the breasts. A prospective, randomized and blinded study. Acta Anaesthesiol Scand. 1997 Sep;41(8):1028-32. ci

? Elorriaga Claraco A, Hanna SE, Fargas-Babjak A. Reporting of clinical details in randomized controlled trials of acupuncture for the treatment of migraine/headaches and nausea/vomiting. J Altern Complement Med 2003;9:151-159cii

? Zárate E, Mingus M, White PF, et al. The use of transcutaneous acupoint electrical stimulation for preventing nausea and vomiting after laparoscopic surgery. Anesth Analg 2001;92:629-635ciii Zárate E, Mingus M, White PF, et al. The use of transcutaneous acupoint electrical stimulation for preventing nausea and vomiting after laparoscopic surgery. Anesth Analg.2001;92:629-635 civ Atwood K. Analysis: The P6 acupuncture point and post-operative nausea and vomiting. Sci. Rev. Alt. Med. Fall/Winter 2004-5, v.8, n.2. http://www.sram.org/0802/acupuncture.html

cv Streitberger K, Diefenbacher M, Bauer A, et al. Acupuncture compared to placebo-acupuncture for postoperative nausea and vomiting prophylaxis: a randomised placebocontrolled patient and observer blind trial. Anaesthesia. 2004;59(2):142-149.

cvi Bailar JC III. The promise and problems of metaanalysis. N Engl J Med. 1997;337:559-561.

cvii Lee A, Done M, Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2004;(3):cd003281. In: The Cochrane Library, Issue 4. Chichester, England: John Wiley & Sons; 2004. Available at:

nor electroacupuncture elevations in opiates in either the CNS or plasma correlate with cutaneous analgesia.cxvii,cxviii

E. Further confusing the picture is the fact that endorphins may rise due to any number of stimuli. Stress, running and shipping may elevate plasma endorphins in horses.cxix Endorphins are also credited for placebo analgesia responses.cxx Other measured hormonal changes attributed to acupuncture do not appear to have any obvious clinical relevance.

F. Numerous plausible, and simpler, explanations for the ‘effects’ of acupuncture exist, including owner expectation,cxxi stress-induced analgesia,

http://www.cochrane.org/cochrane/revabstr/AB003281.html.

cxi Hui, K.K., Liu, J., Makris, N., Gollub, R.L., Chen, A.J., Moore, C.I., Kennedy, D.N., Rosen, B.R. and Kwong, K.K. (2000) Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum. Brain Mapp. 9, 13-25.

cxii Vincent, C.A., Richardson, P.H., Black, J.J. and Pither, C.E. (1989) The significance of needle placement site in acupuncture. J.Psychosom. Res. 33, 489-496.

cxiii Zaslawski, C.J., Cobbin, D., Lidums, E. and Petocz, P. (2003) The impact of site specificity and needle manipulation on changes to pain pressure threshold following manual acupuncture: a controlled study. Complement. Ther. Med. 11, 11-21.

cxiv Suter, B. and Kistler, A. (1999) Demonstration of the effect of acupuncture on the autonomic nervous system by examination of the microcirculation. Forsch Komplementarmed., Suppl. 6, 32-34. cxv Iranmanesh, A., Lizarralde, G. and Veldhuis, J.D. (1993) Coordinate activation of the corticotropic axis by insulin-induced hypoglycemia: simultaneous estimates of beta-endorphin, adrenocorticotropin and cortisol secretion and disappearance in normal men. Acta Endocrinol. 128, 521-528.

cxvi Max, M.B., Inturrisi, C.E., Kaiko, R.F., Grabinski, P.Y., Li, C.H. and Foley, K.M. (1985) Epidural and intrathecal opiates: cerebrospinal fluid and plasma profiles in patients with chronic cancer pain. Clin.Pharmacol. Ther. 38, 631-641.

cxvii Bossut, D.R.F., Leshin, L., Stomberg, M.W. and Malven, P.V. (1983) Plasma cortisol and beta-endorphin in horses subjected to electroacupuncture for cutaneous analgesia. Peptides 4, 501-507.

cxviii Skarda, R.T., Tejwani, G.A. and Muir, W.W. (2002) Cutaneous analgesia, hemodynamic and respiratory effects, and betaendorphin concentration in spinal fluid and plasma of horses after acupuncture and electroacupuncture. Am. J. vet.

counterirritationcxxii and operant conditioning, as well as the diffuse noxious inhibitory stimulus; for example, while one study found that acupuncture suppressed the pain response to a cutaneous prick or electrical stimulation of a rat’s tail, a simple pinch of the tail caused the most effective suppression..cxxiii

G. Other potential mechanisms of action of acupuncturerelated therapies are perhaps not so surprising. For example, electroacupuncture has been shown to provide mild rectal analgesia in an experimental model in horses (although less than that provided by butorphanol).cxxiv However, there is absolutely no reason to believe that the effects seen have anything to do with ‘acupuncture,’ given that precise needle placement was not shown to be important (i.e. the study lacked a sham control) and that electrical stimulation was involved. Indeed, such therapies as transcutaneous electrical nerve stimulation employ electricity for pain managementcxxv (albeit with conflicting results).

H. Furthermore, there is reason to doubt that even needle skin penetration is important when using electrical stimuli in efforts to control pain; variants of electroacupuncture exist using skin patch electrodes, and identical clinical effectiveness is claimed.cxxvi Likewise, acupuncture with non-penetrating sham needles, low-power laserpuncture, acupressure, and therapeutic (non) touch over acupuncture points.

I. Theories explaining yet-to-be-demonstrated above-placebo efficacy in human and veterinary acupuncture by means of endorphin secretion or neural “gating out” are superfluous. They are “explanations in search of something that needs explaining.” More mundane and well-understood mechanisms adequately explain perceived acupuncture efficacy.

J. Acupuncture is invasive, mildy noxious, involves direct and prolonged physical interaction between patient and practitioner and appeals to the mystical/philosophical inclinations of some clients/patients. Also, it’s difficult (but not impossible) to blind RCTs of acupuncture.

K. These include the placebo effect, counter-irritation, distraction, stress-induced hypalgesia,cxxvii the activation of diffuse noxious inhibitory controlscxxviii ) (whereby a noxious stimulus at one site interferes with the perception of pain at another site),and especially regression to the mean in concert with the variable natural history of many disease processes.

Res. 63, 1435-1442.

cxix Li, W.I. and Chen, C.L. (1987) Running and shipping elevate plasma levels of beta-endorphin-like substance in Thoroughbred horses. Life Sci. 40, 1411-1421.

cxx ter Riet, G., de Craen, A.J., de Boer, A. and Kessels, A.G. (1998) Is placebo analgesia mediated by endogenous opioids? A systematic review. Pain 76, 273-275.

cxxi Kalauokalani, D., Cherkin, D.C., Sherman, K.J., Koepsell, T.D. and Deyo, R.A. (2001a) Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine 26, 1418-1424.

L. Regarding the latter, many conditions result in clinical signs that vary over time. Patients/clients will usually seek treatment when the signs/symptoms are getting worse. When improvement is noted after said intervention, it’s often assumed the treatment was responsible even when/if it isn’t. That’s undoubtedly the main reason that therapeutic phlebotomy was embraced my medical systems world-wide until the late 19th century when it was finally made clear that the intervention almost always does more harm than good.

M. Endorphin theories have not stood up to scrutiny. Loading a horse into a trailer or throwing a stick for a dog will cause endorphin release, but that doesn’t mean these are effective medical interventions.

N. Cite contradictory endorphin studies, short half-lives, contradictory opiate antagonist studies.

O. PET scans and other studies that show brain activity during and after acupuncture merely indicate the obvious: When you stick a steel needle into to body, the brain notices it.

P. How could the placebo effect possibly come into play in animal patients? The therapist administers and inherently inert or ineffective therapy to the patient, and the owner subsequently perceives an improvement in the animals condition Many animals (and humans) respond positively to any intimate, physical interaction with humans.

cxxii Levine, J.D., Gormley, J. and Fields, H.L. (1976) Observations on the analgesic effects of needle puncture (acupuncture). Pain 2, 149-159.

cxxiii Murase, K. and Kawakita, K. (2000) Diffuse noxious inhibitory controls in anti-nociception produced by acupuncture and moxibustion on trigeminal caudalis neurons in rats. Jap. J. Physiol. 50, 133-140.

cxxiv Skarda, R.T., Tejwani, G.A. and Muir, W.W. (2002) Cutaneous analgesia, hemodynamic and respiratory effects, and betaendorphin concentration in spinal fluid and plasma of horses after acupuncture and electroacupuncture. Am. J. vet. Res. 63, 1435-1442.

cxxv Rushton, D.N. (2002) Electrical stimulation in the treatment of pain.Disabil. Rehabil. 24, 407-415.

cxxvi Ulett, G.A., Han, S. and Han, J.S. (1998) Electroacupuncture: mechanisms and clinical application. Biol. Psychiatry 44, 129-138.

cxxvii Flor, H. and Grusser, S.M. (1999) Conditioned stress-induced analgesiain humans. Eur. J. Pain 3, 317-324.

cxxviii Bing, Z., Villanueva, L. and Le Bars, D. (1990) Acupuncture and diffuse noxious inhibitory controls: naloxone-reversible depression of activities of trigeminal convergent neurons. Neurosci. 37, 809-818.

Q. Xu Da-chun: “The physicians of today have been cut off from the [ancient] tradition of [human] medicine; how much more does this apply to veterinary medicine!” Chinese physician and scholar Xu Da-chun, 1757cxxix

cxxix Unschuld, P, ibid, 352