Shares

Bloodletting, of course, was a major aim of early vessel therapy and is frequently described in the Su wen.1

Paul U Unschuld

“Cargo cult” is a metaphor that describes the act of imitating an activity or a practice without any insight into the underlying principles. In the literal sense, it refers to a magico-religious practice observed in tribal societies, where the members ritually imitate the activities of a technologically-advanced society they had contact with, so that they can magically draw their material wealth. For instance, after WWII, indigenous tribes in New Guinea who had come in close contact with cargo planes, started to build landing strips and populated them with plane-like effigies that were made of straw, bamboo, and coconuts, so that they can magically lure the passing planes.2 The term “cargo cult science” was introduced by Richard Feynman in a speech at Caltech in 1974 to describe pseudoscientific studies in which all the superficial aspects of a scientific inquiry are adhered to, but the underlying principles are not scientific. He classified many educational and psychological studies as such, for having the appearance of academic research but lacking the principles of a scientific inquiry.3

Another example of cargo cult science is the plethora of two-arm acupuncture studies that compare a needling regimen using the traditional concepts, and compare it with a non-interventional placebo. These studies might have the appearance of clinical research, but they are inherently flawed and inconclusive, because they do not rule out the possibility that the observed results are mainly due to the painful stimulus and injury caused by a needle, which can occur regardless of the insertion point. Indeed, an acute noxious stimulus from a prickle, heat, or any other painful stimulus – almost anywhere on the skin – can attenuate the perception of pain in another area of the body through a reflex called “counter-irritation,” also called the “pain-inhibiting-pain effect” or “diffuse noxious inhibitory control” (DNIC).4 DNIC was extensively studied by Fauve et al. in the 1980s, who showed in mice that it has an effect equivalent or superior to that of glucocorticoids.5,6



Counter-irritation has been known since antiquity, and is at the base of many noxious folk remedies, such as the application of cautery, blistering and moxibustion (the burning of dried Artemisia annua on the skin) to name but a few, whereby “one pain masks another.”7 These modalities were once widely used, generally in an attempt to reduce inflammation.9 It is therefore plausible that the nonspecific effects observed in some types of acupuncture are also linked to DNIC, since some authors have reported that acupuncture is only effective in producing analgesia when the stimulation itself is of a sufficient intensity to cause an unpleasant sensation. The DNIC induced by needles is believed to be mediated by the release of endogenous opioid neuropeptides and/or monoaminergic neurotransmitters, mainly because naloxone, a central and peripheral opioid receptor antagonist, is reported to reverse its effects.10,11 A true interpretation of this finding invalidates the traditional lore of the meridian-and-points system, and indicates that any needling regimen can lead to outcomes associated with DNIC. This finding echoes the position of Felix Mann, MD, the founder of the British Medical Acupuncture Society, who after decades of practice reached the conclusion that putting needles in “wrong” places was as effective as a “correct” treatment. He therefore wrote that “traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes.”12

There is also credible evidence that the stimulation of a myofascial trigger point (TrP), meaning a localized, hyperirritable nodule nested within a palpable taut band of skeletal muscle or fascia,13 can evoke short-term anti-nociceptive effects on the same segmental dermatome.14 This local hypoalgesic effect is reported to be greater than stimulation at remote dermatomes.15 It is based on this finding, that Janet Travell, MD, (1901-1997) began needling hyperirritable points with syringes in in the 1940s, injecting them first with procaine.16 Procaine was later replaced by saline solution,17 which was later replaced by “dry needling” (TrP-DN ) — without any fluid in the syringe.18,19 Although the dermatomal distributiosn of anti-nociceptive effects do not correspond to the distribution of the Chinese meridians, they do affect the outcome of two-arm studies because any needling regimen in the same dermatome should lead to similar results. Therefore, two-arm studies cannot rule out the possibility that the observed results are due to anti-nociceptive effects on the same segmental dermatome, which can occur regardless of the classical theories for point selection and means of stimulation.20

In addition, both laboratory and clinical evidence have recently shown the existence of two-way interactions between the nervous system and the innate immunity. There is experimental evidence showing that percutaneous and transcutaneous neurostimulation can inhibit macrophage activation and the production of pro-inflammatory cytokines.21 Kevin J Tracey, MD and his collogues at Feinstein Institute for Medical Research have shown that an increase in the production of Acetylcholine (ACh) can inhibit the synthesis of TNF and other pro-inflammatory cytokines in organs rich in cells of the monocyte-macrophage system.22 Tracey argues that Ach interacts with members of the nicotinic ACh receptor (nAchr) family, in particular with the alpha-7 subunit (α7nAchr), which is expressed not only by neurons, but also macrophages and other cells involved in the inflammatory response.23 It is therefore conceivable that the anti-inflammatory actions that have been associated with needling – and have been used to justify the traditional concepts of acupuncture – are directly or indirectly mediated by neurostimulation and inflammatory macrophage deactivation, and can occur with transcutaneous or percutaneous neuromodulation anywhere proximal to nerves.24 This is consistent with the hypothesis of George A. Ulett and Songping Han, who argued that certain effects of needling, especially in the ear, might be explained by a “broad parasympathetic effects” due to the stimulation of vagus nerve, which also innervates the ear.25 Again, two-arm studies cannot rule out the possibility that the observed results are due to the broad neurostimulatory effects of needling, and regardless of the needling regimen.

In sum, for the reasons stated above, two-arm acupuncture studies that compare a traditional regimen with a non-interventional placebo are inherently inconclusive. I would further argue that the regimen used in these studies is not even reflective of the traditional methods, because the loci of cautery, blistering, cupping, moxibustion and acupuncture might have been selected simply because they were particularly sensitive and painful, and the alleged analgesic and anti-inflammatory effects of traditional regimens are not achievable by the “soft needling” technique used in clinical studies today. These studies unequivocally use quasi-unperceivable, painless, filiform, silicon-coated needles for ethical reasons and to prevent dropouts. This type of “acupuncture without tears” amounts to what Arthur Taub has suitably called “nonsense with needles.”26

Finally, the most compelling argument to qualify acupuncture of a cargo cult, is the fact that its apostles remain obstinately faithful that someday, someone will prove that “astrology with needles” is a panacea that can naturally restore health and longevity. This is despite the fact that well-conducted three-arm clinical trials that used sham controls with needle insertion at “wrong” points (points not indicated for the condition) or non-points (locations that are not known acupuncture points) along with a non-interventional control group, have failed to demonstrate that there is a reliable difference between sham and “true” needling. Three well-designed three-armed randomized controlled clinical trials with 302, 270, and 1007 patients, respectively, have demonstrated that acupuncture and sham acupuncture treatments were more effective than no treatment at all, but there was no statistically significant difference between true and sham acupuncture,27,28,29 suggesting that it does not have unique effects on the central nervous system, or on pain and pain modulation.30 These studies indicate that the “meridional theory” is of low importance, and does not lead to specific therapeutic effects.31,32 The most recent challenge came from a review article in the New England Journal of Medicine which concluded that acupuncture’s specific therapeutic effects – if any – are small, and its benefits are mostly attributable to “contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.”33

I see the pointless studies that aim to validate notions that date of Galen’s era, and hear the irrational narrative of the apostles of this cargo cult at the twilight of a dying hope, and I think of Baudelaire’s morose elegy to “The Swan:”

A swan which from its cage had made escape

Patting the torrid blocks with webby feet,

Trailing great plumes of snow, while beak agape

Tumbled for water in the parching street; Wildly it plunged its wings in dust again,

Mourning its native lake, and seemed to shrill:

“Lightning, when comest thou? and when, the rain?”

Strange symbol! wretched bird, I see it still.34

Charles Baudelaire (1821 – 1867), Flowers of Evil

JAMA

JAMA

Shares

1. Unschuld PU. Huang Di Nei Jing Su Wen: Nature, Knowledge, Imagery in an Ancient Chinese Medical Text. University of California Press. 20032. Lawrence P. Road belong cargo: a study of the Cargo Movement in the Southern Madang District, New Guinea. Manchester University Press, 1964.3. Feynman RP. Surely You’re Joking, Mr. Feynman! (Adventures of a Curious Character). W. W. Norton & Company. 1997.4. Follett K. Neurosurgical Pain Management. Elsevier Health Sciences. 20045. Fauve RM, Fontan E, Hevin MB, Saklani H, Parker F. Remote effects of inflammation on non-specific immunity. Immunol Lett. 1987;16(3-4):199-203.6. Fauve RM. Endogenous counterinflammation and immunostimulation [in French]. Pathol Biol (Paris). 1987;35(2):190-194.7. Wand-Tetley JI. Historical methods of counter-irritation. Ann Phys Med 1956;3:90–88. Le Bars D, Dickenson AH, Besson J-M, Villaueva L. Aspects of sensory processing through convergent neurons. In: Yaksh TL, ed. Spinal afferent processing. New York: Plenum, 1986: 467–504.9. Holden AV, Winlow W. The Neurobiology of Pain: Symposium of the Northern Neurobiology Group, Held at Leeds on 18 April 1983. Manchester University Press. 1984.10. Pomeranz B, Chiu D. Naloxone blockade of acupuncture analgesia: endorphin implicated. Life Sci. 1976;19:1757-1762.11. Zhou ZF, Du MY, Wu WY, Jiang Y, Han JS. Effect of intracerebral microinjection of naloxone on acupuncture- and morphineanalgesia in the rabbit. Sci Sin. 1981;24:1166-1178.12. Mann F. Reinventing Acupuncture: A New Concept of Ancient Medicine. Butterworth-Heinemann; 2 edition. 2000.13. Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol 2004; 14: 95–107.14. Srbely JZ, Dickey JP, Lee D, Lowerison M. Dry needle stimulation of myofascial trigger points evokes segmental anti-nociceptive effects. J Rehabil Med. 2010 May;42(5):463-8.15. White PF, Craig WF, Vakharia AS, Ghoname E, Ahmed HE, Hamza MA. Percutaneous neuromodulation therapy: does the location of electrical stimulation effect the acute analgesic response? Anesth Analg. 2000 Oct;91(4):949-54.16. Travell J, Rinzler S, Herman M. Pain and disability of the shoulder and arm: treatment by intramuscular infiltration with procaine hydrochloride.. 1942;120:417-422.17. Sola AE, Kuitert JH. Myofascial trigger point pain in the neck and shoulder girdle. Northwest Med. 1955;54:980-984.18. Kraus H. Clinical Treatment of Back and Neck Pain. New York, NY:McGraw-Hill; 1970.19. Dommerholt J, Huijbregts P. Myofascial Trigger Points: Pathophysiology and Evidence-Informed Diagnosis and Management. Jones & Barlett Learning. 2009.20. Baldry PE. Acupuncture, Trigger Points and Musculoskeletal Pain. Edinburgh, UK: Churchill Livingstone, 2005.21. Wang H, Yu M, Ochani M, et al.Nicotinic acetylcholine receptor alpha7 subunit is an essential regulator of inflammation. Nature. 2003;421:384-8.22. Tracey KJ. The inflammatory reflex. Nature. 2002;420:853-859.23. van Maanen MA, Vervoordeldonk MJ, Tak PP. The cholinergic anti-inflammatory pathway: towards innovative treatment of rheumatoid arthritis. Nat Rev Rheumatol. 2009 Apr;5(4):229-32.24. Tracey KJ. Physiology and immunology of the cholinergic antiinflammatory pathway. J Clin Invest. 2007;117(2):289-296.25. Ulett GA, Han S. The Biology of Acupuncture. St Louis, MO:Warren H. Green; 2002.26. Taub A. Nonsense with Needles. In Barrett S and Jarvis W. The Health Robbers: A Close Look at Quackery in America. Prometheus Books, Amherst, NY. 1993. Article available online at http://www.acuwatch.org/general/taub.shtml27. Linde K, Streng A, Jurgens S, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes MG, Weidenhammer W, Willich SN, Melchart D. Acupuncture for patients with migraine: A randomized controlled trial.2005;293:2118-2125.28. Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes M, Hummelsberger J, Irnich D, Weidenhammer W, Willich SN, Linde K. Acupuncture in patients with tension-type headache: Randomised controlled trial. BMJ 2005;331(7513):376-382.29. Scharf HP, Mansmann U, Streitberger K, Witte S, Kramer J, Maier C, Trampisch HJ, Victor N. Acupuncture and knee osteoarthritis: A three-armed randomized trial. Ann Intern Med 2006;145:12-20.30. Campbell A. Point specificity of acupuncture in the light of recent clinical and imaging studies. Acupunct Med 2006;24(3):118-122.31. Moffet HH. Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials. J Altern Complement Med. 2009 Mar;15(3):213-6.32. Moffet HH. Acupuncture trial lacks a priori rationale to refute null. hypothesis. Arch Intern Med. 2008 Mar 10;168(5):550-1.33. Berman BM, Langevin HH, Witt CM, et al. Acupuncture for chronic low back pain. N Engl J Med 2010 Jul 29; 363(5):454-61.34. Shanks LP. Flowers of Evil. Ives Washburn. New York, 1931.