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Dr. Barrett谈中医(警惕针炙、气功、与中医) 寻正/译
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发表时间:2008-03-13
更新时间:2008-03-13
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美国医生谈中医(警惕针炙、气功、与中医)

  Stephen Barrett, M.D.,寻正/译

  【应原作者要求,凡转载此文,请保留这个链结:
http://www.quackwatch.org。此文英文原文链结为:
http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html】

  【译者导言:Barrett医生是一位退休的精神病医生,在美国是著名的作家、
编辑和消费者权利代言人,他是全美反卫生欺诈委员会的副会长、美国科学与健
康委员会科学顾问、超自然现象科学调查委员会(CSICOP)特别会员。他曾在
1984年因反对营养物品欺诈获得FDA局长公众服务特别贡献奖,2001年从美国健
康教育协会获得健康教育卓越服务奖,是美国食品协会的荣誉会员。此文为众多
的Barrett医生反医疗营养欺诈的作品之一,发表在他主持的QuackWatch网站上。
〖〗内容为译者根据原文意译所加。针炙是中医在美国流行的主要形式,所以本
文侧重讨论针炙。】

  中医,常称东方医学或者中国传统医学(TCM),包括大量的基于神秘的各
种民间医疗实践。它宣称身体内存在一种生命能量(气),循特定路线运动,叫
做经络,与身体脏器与功能相连。疾病是气平衡失调或者〖运行〗受阻引起的。
古传实践技术如针炙、气功以及各种草药的使用据称可以〖帮助〗恢复〖气〗平
衡。

  传统的针炙,正如现行实践那样,要用不锈钢针刺入身体各部位。低频电流
可能被施于炙针以产生更大的刺激。其它可以单用或者结合针炙的技术包括灸术
(对皮肤使用燃烧的药絮或者草药),通过插入的炙针注入无菌水、普鲁卡因、
吗啡因、维生素、或者极度稀释疗法的药品,使用激光(激光炙),对外耳部进
行针炙(耳炙术),按摩(使用按压〖穴位〗的方法)。所有治疗都针对所谓的
“穴位”,据称穴位在全身都有分布。最早的穴位有365个,跟一年365天相对应,
随后在过去的2000年里炙术支持者们相继扩展了穴位的个数,达到2000个左右
[1]。一部分实践者对疾病部位或者邻近部位进行针炙,其他人则根据症状选择
〖治疗〗穴位。在传统的针炙治疗中,通常多个穴位结合使用。

  气功也宣称能影响生命能量〖气〗的运动。内气功是为自己练功,涉及深呼
吸、集中意念及放松技巧。外气功则为“气功大师”所发,据称可以用他们手指
发出的能量治疗大范围内的疾病。但是对中国气功师们进行科学调查的研究者未
能发现任何证明超自然力量的存在的证据,〖相反〗有一些〖故意〗欺骗的证据。
比如他们发现,躺在距气功师有八英尺远的桌面上的病人随着气功师手掌运动而
有节奏地运动或者翻腾,但是当〖病人〗她不能看见气功师时,她的运动跟气功
师就没有联系[2]。数年前被中国取缔的法/轮/功就是一种气功,它宣称是“一
种强有力的治疗、释放压力与提高健康度的机制”。

  绝大多数针炙师坚持对健康与疾病的中国传统观念,认为针炙、草药以及相
关实践技术是对整个疾病领域的都有效的〖系列〗手段。其他的人则拒绝这种传
统看法,认为针炙只是止痛的一种简单有效的手段。中医先生所使用的诊断过程
包括问(医疗疾病史、生活方式),望(皮肤、舌头、肤色),闻(呼吸声),
与切脉。据说有六大经脉相对应于身体器官与功能,每只手都可以通过切脉诊察
哪股经脉缺气〖气虚〗。(现代医学只确认一种脉博,对应于心脏跳动,可以在
腕、颈、足及其它地方察探到。)一些针炙师认为在症状发生数周乃至数月前就
发生了身体能量失衡。他们宣称针炙可以用于治疗这类病人,这些病人没有明显
的疾病而只是感到不适。

  中医(以及其它亚洲国家的民间医学实践)对一些特定物种〖的生存〗构成
威胁。比如说,黑熊——因它们的胆囊而身价倍增——在亚洲几乎被猎杀绝迹,
偷猎黑熊在北美也是一个越来越严重的问题。

  含糊的主张

  据说针炙有效的病症包括慢性疼痛(颈、腰痛,偏头痛),急性损伤痛(扭
拉伤、肌肉与韧带撕裂伤),胃肠疾患(消化不良、溃疡、便秘、腹泻),心血
管疾患(高低血压),泌尿生殖疾患(月经不调、性冷淡、阳萎),肌肉神经疾
患(瘫痪、失聪),以及行为疾患(暴食症、药物依赖、吸烟)。但是,支持这
些主张的证据多为针炙师们的观察〖经验〗及有严重科学设计缺陷的研究。一个
设有对照的研究发现电炙耳朵对慢性疼痛的治疗作用不比安慰剂刺激(轻柔刺激)
更好[3]。在1990年,三位荷兰流行病学者分析了51项有对照的针炙治疗慢性疼
痛的研究,结论说“即使是较好的研究的质量也很差……针炙对慢性疼痛的治疗
的功效仍旧可疑。” [4]他们也研究了针炙治疗香烟、海洛因、与酒精的成瘾性
的报告,认为针炙作为对这些疾患的有效治疗手段不受合格的临床研究所支持
[5]。

  针炙麻醉在东方用于手术并未象其支持者所建议的那样普遍。在中国医生会
剃除那些看上去不适合的病人。针炙不被用于急诊手术,〖若被用于手术则〗要
常常伴随着局部麻醉或者结合镇静安眠药物[6]。

  针炙如何止痛是不清楚的,一种理论建议疼痛信号在传输到脊髓或者大脑前
在许多连接到局部的“门户”被阻止;另一种理论认为针炙刺激躯体产生镇痛类
的物质叫做内啡呔,可以止痛;其它理论涉及安慰剂效应、外部诱导(催眠效
应)、习得条件作用作为重要因素。Melzack与Wall注意到针炙产生的止痛作用
可以用许多其它类型的感觉过度刺激所产生,比如说电与热应用于针炙穴位上或
者身体的其它部位,他们结论说“这些类型的刺激的有效性证明针炙并非一种神
奇的治疗方式,而只是许多通过增强感觉输入而产生镇痛作用的方式之一。”在
1981年美国医生协会科学事务委员会表明〖针炙〗止痛作用在大多数人并非总是
存在或者可以重复观察到,在不少人中根本就观察不到[7]。

  1995年密苏里大学医学院精神病临床教授George A. Ulett(MD,Ph.D.)宣
布“去掉超自然的想法,针炙实际上是一种很简单的可以用于非药物性止痛的技
术。”他认为中国传统式的针炙〖因为缺乏适当刺激〗实际只是安慰剂作用,而
用电刺激大约80个针炙穴位被证实有止痛作用[8]。

  在中国的中医研究的质量奇差无比,最近一个对2938份发表在中国的医学杂
志上的临床研究报告进行的分析断定它们中的绝大多数毫无结论价值。研究者表
示:

  在大多数的研究中,疾病是通过传统〖中医〗医学的体系来定义与诊断的,
研究结果是通过主观或者客观或者二者皆有的传统医学方法认定的【作者可能是
指这些研究是通过“传统方法”认定附合现代医学标准的结果,比如用中医的方
法判定肝炎的治愈与否,译者注】,还往往加以传统中医的结果判定〖比如气虚
血瘀等〗。发表在非专科类的杂志上的超过90%的研究是评估大多为中国秘方
【秘方一词在西方学术界及公众眼里都具有强烈的贬义,译者注】的草药方剂……

  虽然近年来在方法学的质量上有所进步,仍旧存在大量的问题。随机化过程
多数描述欠当,只有15%的研究应用了盲法,少量的研究才有超过300的样本量,
许多研究中使用另一种缺乏随机对照研究证实疗效的中国传统方法来作为对照,
大多数研究只关注短期与中期而非长期效果,大多数研究不报告研究对象顺从治
疗状况与随访的完全度,疗效极少用量化来表示与汇报,从来没有提到过原设治
疗分析【Intention to treat analysis,指实验分组按最初设计治疗手段,而
非实现了的治疗手段分组,比如说有的病人不遵从研究人员分配的组而私自或者
征求得同意变换了组别,或者退出研究等,在原设治疗分析中还放在原设组内分
析,译者注】,超过半数的研究没有汇报〖研究对象〗基线特征或者副作用。许
多研究只是短篇报道。大多数研究都取得了对检验效果的阳性结果,表明发表偏
差的普遍存在,通过对49篇研究针炙对中风的疗效的研究的漏斗图分析【测定样
本大小与确切临床疗效大小的关系,漏斗图不对称及样本大小与疗效临床大小成
反比分别表明发表的选择性偏差及测试疗效的无效性,译者注】,证实在该领域
内的选择性发表阳性结果的偏差,提示针炙可能不比对照的效果更好[9]。

  在Heidelberg大学的两位科学家发明了“假针”,可以帮助针炙研究者设置
更好的对照研究。该装置是一个有钝头的针,可以在铜柄里自由移动,当钝头接
触到了皮肤,病人有针炙针插入的感觉,同时该针的暴露部分不断地缩入柄内,
造成针插入皮肤的印象。当此假针用于志愿者时,没有人怀疑此针实际未插入皮
肤内[10]。

  在2004年,Heidelberg大学的一个团队在对妇女在乳房及妇科手术术后恶心
与呕吐的针炙疗效研究中证实了其假针的价值。该研究中有220位妇女在前臂内
侧的“心包经6号穴”【可能指郄门穴,译者注】针炙穴位上接受了针炙或者假
针治疗,在术后恶心呕吐的后果或者抗吐药使用〖频度〗上两组没有区别,在麻
醉前接受治疗或者在麻醉后接受治疗的基础上两组也没有区别[11]。对上述研究
进行更细致的分组分析显示呕吐在针炙组病人中有“显著降低”,但是作者们正
确地表明此类发现可能是因为关注多个结果造成的。(当关注的结果愈多,在结
果中发现一个假的有统计显著性的结果的机率也随之增加。)这项研究之所以重
要,因为术后恶心呕吐减少是少有的有科学杂志中报道支持的针炙疗效之一,
〖那些〗其它〖针炙防治术后恶心呕吐〗研究有阳性结果的未能实现如此严格的
对照控制。

  Harriet Hall是一位对医疗欺诈感兴趣的退休了的家庭医生,他用很有趣的
方法总结了针炙研究的显著结果:

  各种针炙研究证实了你在哪里放置炙针都不重要,或者你当真使用炙针与只
是假装使用炙针(只要被实验对象相信你使用了炙针)都是一样的。许多针炙研
究者正在做我称为牙妖科学:测量枕头下钱还剩多少,丝毫不管牙妖是否真的存
在。【西方的传统,小孩换牙时脱牙睡觉前藏枕头下,熟睡后父母用硬币或钞票
换之,醒后告之牙妖用钱换走了小孩的牙。译者注】

  风险是存在的

  不适当的针炙操作可以导致昏迷、局部血肿(因为刺穿了血管)、气胸(刺
穿了肺)、惊厥、局部感染、乙肝(炙针传播)、细菌性心内膜炎、接触性皮炎、
以及神经损伤。针炙师使用的草药没有受到安全性、疗效、实效上的法律管制。
此外如果针炙师不采用科学知识体系进行诊断,还存在漏诊危险疾病〖而不能得
到及进治疗〗的风险。

  针炙的副作用很可能跟针炙师所受训练有关。对1135位挪威医生的调查揭示
了66例感染、25例肺穿透、31例疼痛加重、与80例其它并发症。对197位更倾向
于认识到即时并发症的针炙师平行调查显示132例昏迷、26例疼痛加重、8例气胸、
与45例其它意外[12]。但是一个在日本医疗设施内五年内对76位针炙师的研究在
55591次针炙治疗中只发现了64例有害事件(包括16例遗忘的炙针与13例暂时性
低血压),没有严重的并发症,研究者结论说接受过适当〖现代〗医学训练的针
炙师不容易出现严重的有害事件[13]。

  在2001年英国针炙委员会的成员参加了两个前瞻性研究后报告说在经历了超
过66000次针炙治疗的病人中〖观察到〗并发症机率低而且没有严重并发症[14,
15]。伴随的社论认为并发症在称职的针炙师手上很少发生[16]。因为缺乏后果
资料,上述研究不能对风险与效益进行对比评估,这些研究也没有涉及针炙师使
用传统中医方法进行不适当诊断(而未能及时得到有效治疗)的机率。

  靠不住的〖治疗〗标准

  在1971年,因为许多美国名人到中国带回来的〖神奇〗故事,针炙突然变得
热门起来。创业者,包括医学界的或者没有医学背景的,开始用夸张的广告手法
宣传〖有关的〗诊所、研讨讲习会、现场表演、书刊、远程学习课程、以及业余
自修成套装备。目前一些州限制只有医生才能进行针炙,或者针炙者必须在医生
的监督下才能执业,在大约20个州里人们可以不需要医生的监督就执业针炙。
FDA现在规定炙针为二类医疗用品,要求合法执业者在执业活动中标记其为一次
性用品[17]。针炙不在老年保险(Medicare)的保险范围内。1998年3月的美国
脊柱按摩协会杂志用了一个分五部分的封面报道鼓励脊柱按摩术师进行针炙训练,
其中之一的作者声称这样可以扩大他们的执业范围[18]。

  全国针炙与东方医学认证委员会(NCCAOM)出台了志愿认证的认证标准,对
东方医学、针炙、中医草药学、亚洲躯体治疗术进行分别认证。在2007年,据称
该认证项目或者测验在40个州及哥伦比亚特区得到执照认可,在全美有2万多有
执照执业者[19]。(Acupuncture.com网站提供各州执照执业信息。)针炙师的
〖专业〗证件通常包括C.A.(持证针炙师)、Lic. Ac.(执照针炙师)、M.A.
(针炙硕士)、Dip. Ac.(针炙毕业证)、Dipl.O.M.(东方医学毕业证)、以
及O.M.D.(东方医学博士)。其中一些有法律价值,但它们并不保证〖证书〗持
有人有能力进行必要的诊断或者进行合理的治疗。

  在1990年美国教育部承认现在被叫住针炙与东方医学认证委员会的认证资格,
但是此认同并非基于〖认证人员〗所学的科学基础,而是基于其它因素[20]。
Ulett表示:

  针炙的认证是一个假打欺骗。虽然得到认证的包括一些头脑简单的医生,大
多数是非医学专业人员,他们假装医生,使用认证作为一系列未经证实的新时代
医疗骗术的保护伞。遗憾的是,一些健康维持会(HMO)、医院、甚至医学院都
经不起引诱,从而将真正需要现代医疗的病患暴露给庸医骗术〖作为欺骗目标〗。

  全美反卫生欺诈委员会作出了如下结论:

  针炙是未经证实的治疗方法。
  其理论与实践是基于原始及幻想的疾病与健康概念上,这些概念跟现代科学
毫无关系。
  在过去20年的研究中证明针炙对任何疾病都没有明确的效果。
  经验中的针炙效果多半是基于期望、暗示、反刺激、条件化、以及其它心理
机制的综合效果。
  针炙的使用应当被限制在适当的研究机构与活动中。
  保险公司不应该被强制要求为针炙服务提供保险覆盖。
  允许非医学专业的针炙师执业〖的政策〗应当被逐步废除。
  希望尝试针炙的消费者应当同有相关专业知识、而又没有任何商业利益相关
的医生〖而非针炙师〗就其情况进行咨询[21]。

  发神经的国立卫生研究院(NIH)

  在1997年,国立卫生研究院及其它一些政府机构组织了求同发展会议,该会
议建议说“现已有足够的证据……支持针炙有价值进入正统医学以及鼓励更多的
对其生理机制与临床价值的研究。”[22]其评审团也建议联邦政府与保险公司扩
大保险覆盖范围让更多的人有机会得到针炙治疗。这些结论没有基于在全美反卫
生欺诈委员会立场公告发表后的相关研究,相反,它们反应了一个由针炙支持者
控制的计划委员会所选择的评审团成员的偏见[23]。全美反卫生欺诈委员会董事
长Wallance Sampson医生认为该求同会议是“〖针炙〗鼓吹者们的求同,而非基
于合理科学观点的求同”。

  虽然该会议的报告也描述了一些重要的问题,但它未能用适当的角度来阐述。
该评审团承认“研究针炙的绝大部分报告都是个案、个案系列、或者是缺乏合理
设计以验证疗效的研究”,以及只有“相对很少”的高质量的有对照的针炙疗效
的实验研究,但是它报告说“世界卫生组织列举了40多个适合于针炙治疗的疾病
状态。”这一句话的后面应该加一句,〖世界卫生组织的〗这个清单缺乏有效性。
【世界卫生组织也受政治影响,在很多领域并不具有权威性结论(或权威性结论
的能力),中国易于受骗的消费者似乎对国际组织的观点与看法,有时甚至是名
称看上去象国际组织的,都一定程度上缺乏免疫力。译者注】

  更为严重的是,尽管求同报告提及了中医针炙理论,它未能指出〖消费者〗
到缺乏合理诊断能力的针炙师处寻求诊治的风险与经济浪费。该报告提出:

  针炙的主要理论是基于在身体内存在对健康至关重要的能量流(称气)的各
种模型,这些能量流的阻断是导致疾病的根源,而针炙师可以通过可辩认的皮肤
穴位去纠正能量流失衡。
  针炙主要采用全面的、基于能量的方法而非基于疾病的诊断与治疗模式。
  尽管对穴位的解剖与生理进行了大量的研究,对这些穴位的准确定义与描述
仍然存在大量争议。一些关键的传统东方医学的概念比如气的循环、经络系统、
五行理论的科学基础更难以捉摸,难以与现代生物医学知识体系相弥合,但它们
在针炙治疗过程中评估病人与决定治疗方式上有着重要作用。

  简单地说,上述讨论的意思就是如果你找到传统中医执业者,你不可能得到
适当的诊断。很少有发表文章提到这个事实,让我觉得甚为惊讶。即使是《消费
者报告》杂志也建议寻求针炙治疗的读者向有ACCAOM认证的针炙师求治,我建议
人们避免这样的认证执业者,因为认证所需要的训练是基于毫无道理的中医理论,
得到针炙最安全的途径是大学医学院里做此方面研究的不相信此类理论的医生。

  诊断方面的研究

  在1998年,我在一个社区学院听一个报告以后,一位很有经验的中医执业者
察看了我的脉博与舌苔,他诊断说我的脉相显得有“疲劳紧张”,舌苔上看我有
“血瘀”。不一会儿他又告诉一位妇女她的脉相显示有心脏早搏(一种心脏节律
有异常的情况,有没有意义要看个人是否存在潜在的心脏疾患)。他对我们都建
议进行针炙与草药治疗——大约要花90美元治疗一次。我察看了那位妇女的脉博,
发现她的脉博完全正常。我认为非医学专业的针炙师们大多依据不适当的诊断
〖来进行治疗〗,国立卫生研究院求同会议评审人员应当强调这个问题的严重性。

  一个在2001年发表的研究显示了中医实践的荒唐。一位有慢性腰痛的40岁的
妇女在两周内看了7个针炙师,有6个诊断她“气滞”,5个“血瘀”,2个“肾气
虚”,1个“阴虚”,以及一个“肝气虚”。建议的治疗更是各有天地,在6个明
确写下治疗的意见中,针炙师计划用7-26个炙针在背部、腿、手、与足上的4-
16个特别的“穴位”治疗,在28个选定的穴位中只有4(14%)个穴位有两个以上
的针炙师选定〖其它穴位均取决于特定针炙师〗[24]。该研究试图通过设计使得
结果更一致。所有的针炙师都在同一个中医学校受过培训,另外6个〖针炙师〗
志原者因为他们使用“非常特别的治疗方法”被排除了,有3 个因为执业不满三
年而被排除了。基于科学的方法被详细研究〖与应用〗以确保其可靠性,这好象
是最早的一个已发表的关注中医诊断与治疗的稳定一致性的研究。我期望有更大
的研究证实中医诊断毫无意义,跟病人的健康状态毫无关系。该研究的作者宣称
那些诊断显示“高度一致”,因为几乎所有的针炙师都发现了气或血瘀,不过,
更合理的解释是几乎任何人都会得到这样的诊断。如果一个健康的人被多位针炙
师检查,其后的〖诊治〗过程肯定极为精彩。

  更多的信息请至:

  CSICOP关于中医与伪科学在中国的调查
(http://www.csicop.org/si/9609/china.html)
  全美反卫生欺诈委员会关于针炙的立场公告
(http://www.ncahf.org/pp/acu.html)
  质问Isadore Rosenfeld医生的针炙故事
(http://www.csicop.org/si/9907/news.html)

  参考文献

  1. Skrabanek P. Acupuncture: Past, present, and future. In
Stalker D, Glymour C, editors. Examining Holistic Medicine. Amherst, NY:
Prometheus Books, 1985.
  2. Kurtz P, Alcock J, and others. Testing psi claims in China:
Visit by a CSICOP delegation. Skeptical Inquirer 12:364-375, 1988.
  3. Melzack R, Katz J. Auriculotherapy fails to relieve chronic
pain: A controlled crossover study. JAMA 251:1041?1043, 1984
  4. Ter Reit G, Kleijnen J, Knipschild P. Acupuncture and chronic
pain: A criteria-based meta-analysis. Clinical Epidemiology
43:1191-1199, 1990.
  5. Ter Riet G, Kleijnen J, Knipschild P. A meta-analysis of
studies into the effect of acupuncture on addiction. British Journal
of General Practice 40:379-382, 1990.
  6. Beyerstein BL, Sampson W. Traditional Medicine and
Pseudoscience in China: A Report of the Second CSICOP Delegation (Part
1). Skeptical Inquirer 20(4):18-26, 1996.
  7. American Medical Association Council on Scientific Affairs.
Reports of the Council on Scientific Affairs of the American Medical
Association, 1981. Chicago, 1982, The Association.
  8. Ulett GA. Acupuncture update 1984. Southern Medical Journal
78:233?234, 1985.
  9. Tang J-L, Zhan S-Y, Ernst E. Review of randomised controlled
trials of traditional Chinese medicine. British Medical Journal
319:160-161, 1999.
  10. Streitberger K, Kleinhenz J. Introducing a placebo needle into
acupuncture research. Lancet 352:364-365, 1998.
  11. Streitberger K and others. Acupuncture compared to
placebo-acupuncture for postoperative nausea and vomiting prophylaxis:
A randomised placebo-controlled patient and observer blind trial.
Anesthesia 59:142-149, 2004.
  12. Norheim JA, Fennebe V. Adverse effects of acupuncture. Lancet
345:1576, 1995.
  13. Yama????a H and others. Adverse events related to acupuncture.
JAMA 280:1563-1564, 1998.
  14. White A and others. Adverse events following acupuncture:
Prospective surgery of 32,000 consultations with doctors and
physiotherapists. BMJ 323:485-486, 2001.
  15. MacPherson H and others. York acupuncture safety study:
Prospective survey of 24,000 treatments by traditional acupuncturists.
BMJ 323:486-487, 2001.
  16. Vincent C. The safety of acupuncture. BMJ 323:467-468, 2001.
  17. Acupuncture needle status changed. FDA Talk Paper T96-21,
April 1, 1996
  18. Wells D. Think acu-practic: Acupuncture benefits for
chiropractic. Journal of the American Chiropractic Association
35(3):10-13, 1998.
  19. NCCAOM 25th Anniversary Booklet. Burtonsville, MD: NCCAOM, 2007.
  20. Department of Education, Office of Postsecondary Education.
Nationally Recognized Accrediting Agencies and Associations. Criteria
and Procedures for Listing by the U.S. Secretary For Education and
Current List. Washington, D.C., 1995, U.S. Department of Education.
  21. Sampson W and others. Acupuncture: The position paper of the
National Council Against Health Fraud. Clinical Journal of Pain
7:162-166, 1991.
  22. Acupuncture. NIH Consensus Statement 15:(5), November 3-5, 1997.
  23. Sampson W. On the National Institute of Drug Abuse Consensus
Conference on Acupuncture. Scientific Review of Alternative Medicine
2(1):54-55, 1998.
  24. Kalauokalani D and others. Acupuncture for chronic low back
pain: Diagnosis and treatment patterns among acupuncturists ????uating
the same patient. Southern Medical Journal 94:486-492, 2001.


Original artical:

Be Wary of Acupuncture, Qigong,
and "Chinese Medicine"
Stephen Barrett, M.D.
"Chinese medicine," often called "Oriental medicine" or "traditional Chinese medicine (TCM)," encompasses a vast array of folk medical practices based on mysticism. It holds that the body's vital energy (chi or qi) circulates through channels, called meridians, that have branches connected to bodily organs and functions. Illness is attributed to imbalance or interruption of chi.. Ancient practices such as acupuncture, Qigong, and the use of various herbs are claimed to restore balance.

Traditional acupuncture, as now practiced, involves the insertion of stainless steel needles into various body areas. A low-frequency current may be applied to the needles to produce greater stimulation. Other procedures used separately or together with acupuncture include: moxibustion (burning of floss or herbs applied to the skin); injection of sterile water, procaine, morphine, vitamins, or homeopathic solutions through the inserted needles; applications of laser beams (laserpuncture); placement of needles in the external ear (auriculotherapy); and acupressure (use of manual pressure). Treatment is applied to "acupuncture points," which are said to be located throughout the body. Originally there were 365 such points, corresponding to the days of the year, but the number identified by proponents during the past 2,000 years has increased gradually to about 2,000 [1]. Some practitioners place needles at or near the site of disease, whereas others select points on the basis of symptoms. In traditional acupuncture, a combination of points is usually used.

Qigong is also claimed to influence the flow of "vital energy." Internal Qigong involves deep breathing, concentration, and relaxation techniques used by individuals for themselves. External Qigong is performed by "Qigong masters" who claim to cure a wide variety of diseases with energy released from their fingertips. However, scientific investigators of Qigong masters in China have found no evidence of paranormal powers and some evidence of deception. They found, for example, that a patient lying on a table about eight feet from a Qigong master moved rhythmically or thrashed about as the master moved his hands. But when she was placed so that she could no longer see him, her movements were unrelated to his [2]. Falun gong, which China banned several years ago, is a Qigong varient claimed to be "a powerful mechanism for healing, stress relief and health improvements."

Most acupuncturists espouse the traditional Chinese view of health and disease and consider acupuncture, herbal medicine, and related practices to be valid approaches to the full gamut of disease. Others reject the traditional approach and merely claim that acupuncture offers a simple way to achieve pain relief. The diagnostic process used by TCM practitioners may include questioning (medical history, lifestyle), observations (skin, tongue, color), listening (breathing sounds), and pulse-taking. Six pulse aspects said to correlate with body organs or functions are checked on each wrist to determine which meridians are "deficient" in chi. (Medical science recognizes only one pulse, corresponding to the heartbeat, which can be felt in the wrist, neck, feet, and various other places.) Some acupuncturists state that the electrical properties of the body may become imbalanced weeks or even months before symptoms occur. These practitioners claim that acupuncture can be used to treat conditions when the patient just "doesn't feel right," even though no disease is apparent.

TCM (as well as the folk medical practices of various other Asian countries) is a threat to certain animal species. For example, black bears—valued for their gall bladders—have been hunted nearly to extinction in Asia, and poaching of black bears is a serious problem in North America.

Dubious Claims
The conditions claimed to respond to acupuncture include chronic pain (neck and back pain, migraine headaches), acute injury-related pain (strains, muscle and ligament tears), gastrointestinal problems (indigestion, ulcers, constipation, diarrhea), cardiovascular conditions (high and low blood pressure), genitourinary problems (menstrual irregularity, frigidity, impotence), muscle and nerve conditions (paralysis, deafness), and behavioral problems (overeating, drug dependence, smoking). However, the evidence supporting these claims consists mostly of practitioners' observations and poorly designed studies. A controlled study found that electroacupuncture of the ear was no more effective than placebo stimulation (light touching) against chronic pain [3]. In 1990, three Dutch epidemiologists analyzed 51 controlled studies of acupuncture for chronic pain and concluded that "the quality of even the better studies proved to be mediocre. . . . The efficacy of acupuncture in the treatment of chronic pain remains doubtful." [4] They also examined reports of acupuncture used to treat addictions to cigarettes, heroin, and alcohol, and concluded that claims that acupuncture is effective as a therapy for these conditions are not supported by sound clinical research [5].

Acupuncture anesthesia is not used for surgery in the Orient to the extent that its proponents suggest. In China physicians screen out patients who appear to be unsuitable. Acupuncture is not used for emergency surgery and often is accompanied by local anesthesia or narcotic medication [6].

How acupuncture may relieve pain is unclear. One theory suggests that pain impulses are blocked from reaching the spinal cord or brain at various "gates" to these areas. Another theory suggests that acupuncture stimulates the body to produce narcotic-like substances called endorphins, which reduce pain. Other theories suggest that the placebo effect, external suggestion (hypnosis), and cultural conditioning are important factors. Melzack and Wall note that pain relief produced by acupuncture can also be produced by many other types of sensory hyperstimulation, such as electricity and heat at acupuncture points and elsewhere in the body. They conclude that "the effectiveness of all of these forms of stimulation indicates that acupuncture is not a magical procedure but only one of many ways to produce analgesia [pain relief] by an intense sensory input." In 1981, the American Medical Association Council on Scientific Affairs noted that pain relief does not occur consistently or reproducibly in most people and does not operate at all in some people [7].

In 1995, George A. Ulett, M.D., Ph.D., Clinical Professor of Psychiatry, University of Missouri School of Medicine, stated that "devoid of metaphysical thinking, acupuncture becomes a rather simple technique that can be useful as a nondrug method of pain control." He believes that the traditional Chinese variety is primarily a placebo treatment, but electrical stimulation of about 80 acupuncture points has been proven useful for pain control [8].

The quality of TCM research in China has been extremely poor. A recent analysis of 2,938 reports of clinical trials reported in Chinese medical journals concluded that that no conclusions could be drawn from the vast majority of them. The researchers stated:

In most of the trials, disease was defined and diagnosed according to conventional medicine; trial outcomes were assessed with objective or subjective (or both) methods of conventional medicine, often complemented by traditional Chinese methods. Over 90% of the trials in non-specialist journals evaluated herbal treatments that were mostly proprietary Chinese medicines. . . .

Although methodological quality has been improving over the years, many problems remain. The method of randomisation was often inappropriately described. Blinding was used in only 15% of trials. Only a few studies had sample sizes of 300 subjects or more. Many trials used as a control another Chinese medicine treatment whose effectiveness had often not been evaluated by randomised controlled trials. Most trials focused on short term or intermediate rather than long term outcomes. Most trials did not report data on compliance and completeness of follow up. Effectiveness was rarely quantitatively expressed and reported. Intention to treat analysis was never mentioned. Over half did not report data on baseline characteristics or on side effects. Many trials were published as short reports. Most trials claimed that the tested treatments were effective, indicating that publication bias may be common; a funnel plot of the 49 trials of acupuncture in the treatment of stroke confirmed selective publication of positive trials in the area, suggesting that acupuncture may not be more effective than the control treatments. [9]

Two scientists at the University of Heidelberg have developed a "fake needle" that may enable acupuncture researchers to perform better-designed controlled studies. The device is a needle with a blunt tip that moves freely within a copper handle. When the tip touches the skin, the patient feels a sensation similar to that of an acupuncture needle. At the same time, the visible part of the needle moves inside the handle so it appears to shorten as though penetrating the skin. When the device was tested on volunteers, none suspected that it had not penetrated the skin [10].

In 2004, a University of Heidelberg team proved the worth of their "sham acupuncture" technique in a study of postoperative nausea and vomiting (PONV) in women who underwent breast or gynecologic surgery. The study involved 220 women who received either acupuncture or the sham procedure at the acupuncture point "Pericardium 6" on the inside of the forearm. No significant difference in PONV or antivomiting medication use was found between the two groups or between the people who received treatment before anesthesia was induced and those who received it while anesthetized [11]. A subgroup analysis found that vomiting was "significantly reduced" among the acupuncture patients, but the authors correctly noted that this finding might be due to studying multiple outcomes. (As the number of different outcome measures increases, so do the odds that a "statistically significant" finding will be spurious.) This study is important because PONV reduction is one of the few alleged benefits of acupuncture supported by reports in scientific journals. However, the other positive studies were not as tightly controlled.

Harriet Hall, a retired family practitioner who is interested in quackery, has summed up the significance of acupuncture research in an interesting way:

Acupuncture studies have shown that it makes no difference where you put the needles. Or whether you use needles or just pretend to use needles (as long as the subject believes you used them). Many acupuncture researchers are doing what I call Tooth Fairy science: measuring how much money is left under the pillow without bothering to ask if the Tooth Fairy is real.

Risks Exist
Improperly performed acupuncture can cause fainting, local hematoma (due to bleeding from a punctured blood vessel), pneumothorax (punctured lung), convulsions, local infections, hepatitis B (from unsterile needles), bacterial endocarditis, contact dermatitis, and nerve damage. The herbs used by acupuncture practitioners are not regulated for safety, potency, or effectiveness. There is also risk that an acupuncturist whose approach to diagnosis is not based on scientific concepts will fail to diagnose a dangerous condition.

The adverse effects of acupuncture are probably related to the nature of the practitioner's training. A survey of 1,135 Norwegian physicians revealed 66 cases of infection, 25 cases of punctured lung, 31 cases of increased pain, and 80 other cases with complications. A parallel survey of 197 acupuncturists, who are more apt to see immediate complications, yielded 132 cases of fainting, 26 cases of increased pain, 8 cases of pneumothorax, and 45 other adverse results [12]. However, a 5-year study involving 76 acupuncturists at a Japanese medical facility tabulated only 64 adverse event reports (including 16 forgotten needles and 13 cases of transient low blood pressure) associated with 55,591 acupuncture treatments. No serious complications were reported. The researchers concluded that serious adverse reactions are uncommon among acupuncturists who are medically trained [13].

In 2001, members of the British Acupuncture Council who participated in two prospective studies have reported low complication rates and no serious complications among patients who underwent a total of more than 66,000 treatments [14,15]. An accompany editorial suggested that in competent hands, the likelihood of complcations is small [16]. Since outcome data are not available, the studies cannot compare the balance of risks vs benefit. Nor do the studies take into account the likelihood of misdiagnosis (and failure to seek appropriate medical care) by practitioners who use traditional Chinese methods.

Questionable Standards
In 1971, an acupuncture boom occurred in the United States because of stories about visits to China by various American dignitaries. Entrepreneurs, both medical and nonmedical, began using flamboyant advertising techniques to promote clinics, seminars, demonstrations, books, correspondence courses, and do-it-yourself kits. Today some states restrict the practice of acupuncture to physicians or others operating under their direct supervision. In about 20 states, people who lack medical training can perform acupuncture without medical supervision. The FDA now classifies acupuncture needles as Class II medical devices and requires labeling for one-time use by practitioners who are legally authorized to use them [17]. Acupuncture is not covered under Medicare. The March 1998 issue of the Journal of the American Chiropractic Association carried a five-part cover story encouraging chiropractors to get acupuncture training, which, according to one contributor, would enable them to broaden the scope of their practice [18].

The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) has set voluntary certification standards and offers separate certifications on Oriental medicine, acupuncture, Chinese herbology, and Asian bodywork therapy. In 2007, it reported that its certification programs or exams were be recognized for licensure in 40 states and the District of Columbia and that more than 20,000 practitioners are licensed in the United States [19]. (The Acupuncture.com Web site provides information on the licensing status of each state.) The credentials used by acupuncturists include C.A. (certified acupuncturist), Lic. Ac. (licensed acupuncturist), M.A. (master acupuncturist), Dip. Ac. (diplomate of acupuncture), Dipl.O.M. (diplomate of Oriental medicine), and O.M.D. (doctor of Oriental medicine). Some of these have legal significance, but they do not signify that the holder is competent to make adequate diagnoses or render appropriate treatment.

In 1990, the U.S. Secretary of Education recognized what is now called the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) as an accrediting agency. However, such recognition is not based on the scientific validity of what is taught but upon other criteria [20]. Ulett has noted:

Certification of acupuncturists is a sham. While a few of those so accredited are naive physicians, most are nonmedical persons who only play at being doctor and use this certification as an umbrella for a host of unproven New Age hokum treatments. Unfortunately, a few HMOs, hospitals, and even medical schools are succumbing to the bait and exposing patients to such bogus treatments when they need real medical care.

The National Council Against Health Fraud has concluded:

Acupuncture is an unproven modality of treatment.
Its theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge
Research during the past 20 years has not demonstrated that acupuncture is effective against any disease.
Perceived effects of acupuncture are probably due to a combination of expectation, suggestion, counter-irritation, conditioning, and other psychologic mechanisms.
The use of acupuncture should be restricted to appropriate research settings,
Insurance companies should not be required by law to cover acupuncture treatment,
Licensure of lay acupuncturists should be phased out.
Consumers who wish to try acupuncture should discuss their situation with a knowledgeable physician who has no commercial interest [21].
The NIH Debacle
In 1997, a Consensus Development Conference sponsored by the National Institutes of Health and several other agencies concluded that "there is sufficient evidence . . . of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value." [22] The panelists also suggested that the federal government and insurance companies expand coverage of acupuncture so more people can have access to it. These conclusions were not based on research done after NCAHF's position paper was published. Rather, they reflected the bias of the panelists who were selected by a planning committee dominated by acupuncture proponents [23]. NCAHF board chairman Wallace Sampson, M.D., has described the conference "a consensus of proponents, not a consensus of valid scientific opinion."

Although the report described some serious problems, it failed to place them into proper perspective. The panel acknowledged that "the vast majority of papers studying acupuncture consist of case reports, case series, or intervention studies with designs inadequate to assess efficacy" and that "relatively few" high-quality controlled trials have been published about acupuncture's effects. But it reported that "the World Health Organization has listed more than 40 [conditions] for which [acupuncture] may be indicated." This sentence should have been followed by a statement that the list was not valid.

Far more serious, although the consensus report touched on Chinese acupuncture theory, it failed to point out the danger and economic waste involved in going to practitioners who can't make appropriate diagnoses. The report noted:

The general theory of acupuncture is based on the premise that there are patterns of energy flow (Qi) through the body that are essential for health. Disruptions of this flow are believed to be responsible for disease. The acupuncturist can correct imbalances of flow at identifiable points close to the skin.
Acupuncture focuses on a holistic, energy-based approach to the patient rather than a disease-oriented diagnostic and treatment model.
Despite considerable efforts to understand the anatomy and physiology of the "acupuncture points," the definition and characterization of these points remains controversial. Even more elusive is the scientific basis of some of the key traditional Eastern medical concepts such as the circulation of Qi, the meridian system, and the five phases theory, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture.
Simply stated, this means that if you go to a practitioner who practices traditional Chinese medicine, you are unlikely to be properly diagnosed. Very few publications have mentioned this, which strikes me as very strange. Even Consumer Reports magazine has advised readers who want acupuncture treatment to consult a practitioner who is NCCAOM-certified. I advise people to avoid "certified" practitioners. Because the training needed for certification is based on nonsensical TCM theories, the safest way to obtain acupuncture is from a medical doctor who does research at a university-based medical school and does not expouse such theories.

Diagnostic Studies
In 1998, following a lecture I attended at a local college, an experienced TCM practitioner diagnosed me by taking my pulse and looking at my tongue. He stated that my pulse showed signs of "stress" and that my tongue indicated I was suffering from "congestion of the blood." A few minutes later, he told a woman that her pulse showed premature ventricular contractions (a disturbance of the heart's rhythm that could be harmless or significant, depending on whether the individual has underlying heart disease). He suggested that both of us undergo treatment with acupuncture and herbs—which would have cost about $90 per visit. I took the woman's pulse and found that it was completely normal. I believe that the majority of nonmedical acupuncturists rely on improper diagnostic procedures. The NIH consensus panel should have emphasized the seriousness of this problem.

A study published in 2001 illustrates the absurdity of TCM practices. A 40-year-old woman with chronic back pain who visited seven acupuncturists during a two-week period was diagnosed with "Qi stagnation" by 6 of them, "blood stagnation" by 5 , "kidney Qi deficiency" by 2, "yin deficiency" by 1, and "liver Qi deficiency" by 1. The proposed treatments varied even more. Among the six who recorded their recommendations, the practitioners planned to use between 7 and 26 needles inserted into 4 to 16 specific "acupuncture points" in the back, leg, hand, and foot. Of 28 acupuncture points selected, only 4 (14%) were prescribed by two or more acupuncturists. [24] The study appears to have been designed to make the results as consistent as possible. All of the acupuncturists had been trained at a school of traditional Chinese medicine (TCM). Six other volunteers were excluded because they "used highly atypical practices," and three were excluded because they had been in practice for less than three years. Whereas science-based methods are thoroughly studied to ensure that they are reliable, this appears to be the first published study that examines the consistency of TCM diagnosis or treatment. I would expect larger studies to show that TCM diagnoses are meaningless and have little or nothing to do with the patient's health status. The study's authors state that the diagnostic findings showed "considerable consistency" because nearly all of the practitioners found Qi or blood stagnation. However, the most likely explanation is that these are diagnosed in nearly everyone. It would be fascinating to see what would happen if a healthy person was examined by multiple acupuncturists.

For Additional Information
CSICOP Investigation of TCM and Pseudoscience in China
NCAHF Position Paper on Acupuncture
Questioning Dr. Isadore Rosenfeld's Acupuncture Story
References
Skrabanek P. Acupuncture: Past, present, and future. In Stalker D, Glymour C, editors. Examining Holistic Medicine. Amherst, NY: Prometheus Books, 1985.
Kurtz P, Alcock J, and others. Testing psi claims in China: Visit by a CSICOP delegation. Skeptical Inquirer 12:364-375, 1988.
Melzack R, Katz J. Auriculotherapy fails to relieve chronic pain: A controlled crossover study. JAMA 251:1041­1043, 1984
Ter Reit G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: A criteria-based meta-analysis. Clinical Epidemiology 43:1191-1199, 1990.
Ter Riet G, Kleijnen J, Knipschild P. A meta-analysis of studies into the effect of acupuncture on addiction. British Journal of General Practice 40:379-382, 1990.
Beyerstein BL, Sampson W. Traditional Medicine and Pseudoscience in China: A Report of the Second CSICOP Delegation (Part 1). Skeptical Inquirer 20(4):18-26, 1996.
American Medical Association Council on Scientific Affairs. Reports of the Council on Scientific Affairs of the American Medical Association, 1981. Chicago, 1982, The Association.
Ulett GA. Acupuncture update 1984. Southern Medical Journal 78:233­234, 1985.
Tang J-L, Zhan S-Y, Ernst E. Review of randomised controlled trials of traditional Chinese medicine. British Medical Journal 319:160-161, 1999.
Streitberger K, Kleinhenz J. Introducing a placebo needle into acupuncture research. Lancet 352:364-365, 1998.
Streitberger K and others. Acupuncture compared to placebo-acupuncture for postoperative nausea and vomiting prophylaxis: A randomised placebo-controlled patient and observer blind trial. Anesthesia 59:142-149, 2004.
Norheim JA, Fennebe V. Adverse effects of acupuncture. Lancet 345:1576, 1995.
Yamashita H and others. Adverse events related to acupuncture. JAMA 280:1563-1564, 1998.
White A and others. Adverse events following acupuncture: Prospective surgery of 32,000 consultations with doctors and physiotherapists. BMJ 323:485-486, 2001.
MacPherson H and others. York acupuncture safety study: Prospective survey of 24,000 treatments by traditional acupuncturists. BMJ 323:486-487, 2001.
Vincent C. The safety of acupuncture. BMJ 323:467-468, 2001.
Acupuncture needle status changed. FDA Talk Paper T96-21, April 1, 1996
Wells D. Think acu-practic: Acupuncture benefits for chiropractic. Journal of the American Chiropractic Association 35(3):10-13, 1998.
NCCAOM 25th Anniversary Booklet. Burtonsville, MD: NCCAOM, 2007.
Department of Education, Office of Postsecondary Education. Nationally Recognized Accrediting Agencies and Associations. Criteria and Procedures for Listing by the U.S. Secretary For Education and Current List. Washington, D.C., 1995, U.S. Department of Education.
Sampson W and others. Acupuncture: The position paper of the National Council Against Health Fraud. Clinical Journal of Pain 7:162-166, 1991.
Acupuncture. NIH Consensus Statement 15:(5), November 3-5, 1997.
Sampson W. On the National Institute of Drug Abuse Consensus Conference on Acupuncture. Scientific Review of Alternative Medicine 2(1):54-55, 1998.
Kalauokalani D and others. Acupuncture for chronic low back pain: Diagnosis and treatment patterns among acupuncturists evaluating the same patient. Southern Medical Journal 94:486-492, 2001.

This article was revised on December 30, 2007.

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