Statistics from Altmetric.com
In our modern arena of modernised acupuncture, this issue brings spectators an unusual event: a hop and a step—but, instead of a jump, a stand-still.
Williams and colleagues hopped up when they heard a lecture by Benedetti demonstrating that patients with dementia do not show a placebo response: they lose their ability for expectation. The three authors had all used acupuncture successfully for patients with dementia. The patients clearly responded with genuine improvements in quality of life, as witnessed by carers—relief of pain, easier use of walking frame, and ability to climb stairs. These are non-trivial benefits, and acupuncture could be particularly appropriate for a patient group that has difficulty collaborating with treatments, and who are likely to also have significant comorbidities.
In presenting these cases, Williams and colleagues observe that it might be possible to take advantage of this situation by conducting clinical trials in such patients: in the absence of placebo response, all benefits would be ‘specific’ to the acupuncture needles. In a linked editorial, Benedetti comments that loss of placebo response is specific to loss of prefrontal lobe function, which may not have been the case with these particular patients. He also stresses that measuring clinical outcomes is particularly difficult in this population. Ethical issues need to be addressed: certainly, ‘exploitation’ of such patients must be avoided, but if acupuncture was offered as treatment when little else was available, the potential benefits to patients are obvious.
There seems to be surprisingly great potential arising from evidence that is, by normal standards, ‘soft’.
Over the past 40 years we have got used to explaining acupuncture in terms of transmitters and receptors: now we must step up—and talk about brain function. MRI techniques for exploring the brain have developed fast, and show the importance of the brain at rest: the ‘default mode network’. The key observation is ‘functional connectivity’. In a potentially seminal paper by Li and colleagues, patients with low back pain showed reduced connectivity compared with volunteers without pain; and after a course of acupuncture, not only was the pain score reduced from 6 to 1, but at the same time the connectivity is restored towards normal, as shown in figure 1.
But, in one aspect of acupuncture practice, we find we are standing still. Xie and colleagues report a study similar to one that we published 12 years ago. Acupuncture needles appear to the naked eye to be reassuringly smooth and shiny. But microscopy reveals some of them (mainly those from China, sadly in view of its claim to be the home of acupuncture) to be scratched, hooked, irregular and covered in scuff. The author of the original article, Hayhoe, puts these findings into perspective in an editorial: the defects are unlikely to present big problems in clinical practice. But we have to insist on higher quality from the needle manufacturers.
Other events in the arena include the importance of treatment ‘dose’: Glazov and colleagues used a particular dose of laser thought adequate when designing their RCT, but subsequently shown to be inadequate. Their negative results reinforce an important lesson: we urgently need to know what is an adequate dose of needle acupuncture. The dose of scalp (Yamomoto) acupuncture compared with non-penetrating sham control was clearly adequate to produce an effect: presumably it was a general response to needling any tender points, unless one is convinced by scalp acupuncture ‘maps’.
And Korean researchers bring a major and welcome contribution to the arena of acupuncture: body of 143 RCTs in peer reviewed journals. And yet another one in this very issue.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.