As an acupuncturist I dread talking about it socially, at least with the uninitiated. I get asked
- Does it hurt and,
- does it work.
The answers to both are more complex than they might appear but my pat answer is that most people find it surprisingly comfortable to receive an acupuncture treatment and that it certainly works for some, but not everyone or for everything. I’m then invariably asked, “Do you have to believe in it for it too work?” In a sense, this question is asking, does acupuncture have a specific verifiable effect? Does acupuncture placebo account for it’s perceived benefits? According to Wikipedia, a placebo is a:
“simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient. Sometimes patients given a placebo treatment will have a perceived or actual improvement in a medical condition, a phenomenon commonly called the placebo effect.”
Now, I find this a rather more interesting question. Over many years of practice I now recognize two polar opposite patients. I will get one of the following extremes every once in a while. I’ll have a quite, unassuming, usually female patient who says she loves acupuncture, loves alternative medicine, and is sure its going to work for her. Generally this will play out over 3 sessions along the lines that whilst there is some small improvement she is worried it is causing side effects such as a bad nights sleep, feeling tired and so on. We’ll agree to call it a day. The opposite patient is yang to the first’s yin. This patient is usually male (sorry, this does happen like this), usually in business. He’ll loudly declare he doesn’t believe in acupuncture and explain he’s only here because his partner made the appointment. He’ll come back the next week 90% better and I’ll give him a treatment to consolidate the improvement and won’t see him again (at least for a few years). I’ll get a host of referrals from him though because he’s excited to recommend acupuncture to his friends who are impressed because they know he thought it was a load of old tosh.
Placebo acupuncture research.
So, do we need to believe in acupuncture for it to work? Recent research shines a light on this question. This was a randomized controlled trial (RCT) designed to investigate the placebo effect of acupuncture (reported in (1) below). 262 patients with irritable bowel syndrome (IBS) were divided into three groups and compared over a six week period. Group 1 patients received no treatment but had to complete a long list of research questions at the start, middle and end of the 6 week period. 28% of these reported adequate relief on a validated IBS measure. This could be put down to natural fluctuation or improvement in symptoms or a response to the sympathetic attention of the researchers.
Group 2 received sham (fake) acupuncture, the same questions (at beginning, middle and end) and a limited patient-healer interaction with the acupuncturist. They were told the RCT was testing acupuncture so they weren’t allowed to engage in conversation (with the acupuncturist). Patients in this group had a 44% adequate relief.
Group 3 patients received the same questionnaire and sham acupuncture but this time the acupuncturists took the time, as they usually would, to engage with the patients and ask about their illness, medical history, family background, etc whilst demonstrating compassion, support and attentive listening. They showed 20 seconds of thoughtful silence and expressed confidence. Group 3 reported 62% adequate relief. The effect of this ‘augmented placebo’ was as large and significant as any drug ever test for IBS. “An analysis of biomarkers in the serum of all patients revealed that changes in immunological biomarkers were associated with symptom improvement and provides a possible molecular signature of response to placebo” (1). Remember, none of these patients had received real acupuncture!
27 patients within this trial were interviewed (at beginning, middle and end) by a medical anthropologist. This qualitative nested study found these patients had already seen numerous specialists, were desperate and whilst not having positive expectations, “consistently expressed hope and an openness to see what could happen”. This chimes well with my ‘yang’ patients, who whilst having no expectation of acupuncture working, nevertheless were open to change; successful business people have to be flexible, confident and open. Furthermore, an overall psychological analysis of all patients found that patients in group 3 who were extroverted and open to new experiences were especially likely to responsd to the augmented ministration.
According to T J Kaptchuk, “A subsequent RCT of 450 patients with knee osteoarthritis also examined placebo acupuncture in the context of an augmented versus a neutral patient-practitioner relationship. Again it was found a more persuasive clinical interaction positively affected clinical outcomes” (1).
Going back to the IBS study, it was also found that patient response ‘varied significantly’ among the four acupuncturists performing in this trial, even though each followed a scripted procedure which was recorded for ‘fidelity to treatment protocols’.
So, do you have to believe in acupuncture for it to work? Do you have to expect it to work? Well, according to my clinical experience, and the acupuncture placebo research discussed in this post, no, you don’t. But it does help, as a patient, if you are hopeful and open to change.
Before I finish I just want to make two short points:
Placebo medicine research.
Positive applications in the application of modern medicine, such as taking a drug, can also be mediated by placebo. According to Kaptchuk again, “While some of the amelioration observed in placebo groups in RCT’s is related to the natural course of an illness…., recent sophisticated laboratory studies of placebo treatment point to a genuine placebo effect beyond natural processes” (1).
How to choose an acupuncturist.
Secondly, for prospective patients, choose your acupuncturist carefully. On the one hand, make sure they are qualified from a bona fide college and belong to the top level of professional body. On the other, have a chat with a short-list of practitioners. The different responses to each of the four acupuncturists in the IBS study could be related to the charisma of the acupuncturist. Is the acupuncturist believable, positive, engaging, concentrated and compassionate? You’ll know after chatting to them which the best practitioner is for you.
Philos Trans R Soc Lond B Biol Sci. 2011 June 27; 366(1572): 1849–1858.