Edzard Ernst, Adrian White (eds.)


A scientific appraisal

Book review by Anthony Campbell. Copyright © Anthony Campbell (1999).

Acupuncture is one of the most widely practised forms of alternative or complementary medicine and is also the form considered most acceptable by doctors. However, there are still many questions about its scientific validity. This book sets out to assess the present status of acupuncture from a scientific standpoint.

The first question addressed is: what is acupuncture anyway? Most people think at once of the traditional Chinese system based on yin and yang, 'points', and 'meridians'. Not everyone is aware that in the last fifteen or twenty years there has developed what might be called a modern or non-traditional ('Western') version of acupuncture, which largely ignores or at least reinteprets the ancient ideas. This book covers both forms of acupuncture (which are not totally distinct in any case). There are chapters describing both approaches. Stephen Birch and Ted Kaptchuk make the important point that the traditional version is not monolithic: acupuncture has been practised in other East Asian countries besides China, and all these have introduced their own biases and ideas, while even within China itself there have been changes over the centuries. We should be wary of indulging in romantic views of the all-knowing East. Western medical acupuncture, likewise, is performed in various ways, and Jacqueline Filshie and Michael Cummings remark that there are probably as many ways of practising acupuncture as there are acupuncturists.

The two chapters alluded to above serve to set the scene and give a balanced and fairly comprehensive overview of acupuncture. We then come to an important chapter by Adrian White, summarizing what is known about the neurophysiology of acupuncture analgesia. This title might suggest that White is talking about analgesia for surgery, but in fact he is concerned with the wider question of acupuncture as a treatment for pain. People with only a superficial familiarity with acupuncture might suppose that the whole topic could be summed up in terms of the endogenous opioids, but anyone who thinks this will be quickly disabused by White's discussion. The real situation is considerably more complex and almost every statement has immediately to be qualified. One important group of researchers (Chapman and colleagues) are cited as saying that their work and that of others 'provided little convincing evidence that endorphins play a significant role in acupunctural analgesia'. Some writers seem to assume that acupuncture is definitely mediated by the A-delta (small diameter myelinated) nerve fibres, but this has not been proved beyond doubt. In summary, there are plenty of pointers to the mechanisms of acupuncture analgesia but few firm conclusions can be drawn from the available research.

As a practising medical acupuncturist myself, I found White's contribution to be the most useful in the book. It gives a clear and comprehensible account of the pathways thought to be involved in acupuncture analgesia, but it avoids dogmatism and over-confident pronouncements. White reiterates the important point that there are several kinds of acupuncture and they probably don't all work in the same way. Thus, manual and electrical acupuncture are different, and repeated acupuncture (as used in clinical practice) probably has different effects from the one-off treatments usually used in laboratory studies. There is also the difficulty of explaining the prolonged analgesic effects of acupuncture found in clinical practice, and the perennial question of whether any of the classic acupuncture points described in the traditional Chinese literature have the properties ascribed to them. There is some evidence that at least a few of them do (for example, Pericardium 6 for nausea), but many modern acupuncturists have abandoned the traditional system more or less completely without any apparent loss of effectiveness.

Other chapters look at the effects of acupuncture on the circulatory and immune systems (Thomas Lundeberg), the clinical effectiveness of acupuncture (Edzard Ernst), and adverse effects of acupuncture (Hagen Rampes and Elmar Peuker). As regards efficacy, Ernst thinks that there is some evidence from published trials that acupuncture can alleviate dental pain and low back pain; whether it helps neck pain is uncertain. There is no good evidence that it works for weight loss or stopping smoking. There is also little to support the use of acupuncture to treat osteoarthritis. Ernst may well be right about this so far as research is concerned, but that goes to show how large is the gulf that separates scientific research in acupuncture from everyday clinical experience.

A concluding chapter by the two editors summarizes the message of the book, which is, predictably, that we need more and better research. This may lead to various possible outcomes. Acupuncture may be shown to do more harm than good, in which case it should be abandoned (but they think this is unlikely). It may be shown to be simply a powerful placebo, in which case doctors should be aware of this and should try to maximize the placebo effect. Traditional Chinese acupuncture may be shown to be more effective than modern Western acupuncture or the reverse may prove to be the case; each outcome would have different implications.

This is an important book which should be read by any acupuncture practitioner, whatever their theoretical stance may be. Inevitably it raises far more questions than it answers, but that can't be helped at present. Out-and-out skeptics, such as members of Committee for the Scientific Investigation of Claims of the Paranormal (CSICOP) should read it, though they probably won't, for it contains sufficient material to show that there is at least a prima facie case to be made out for acupuncture as an effective form of treatment.

%T Acupuncture
%S A scientific appraisal
%A Ernst, Ezard %A White, Adrian (eds.)
%I Butterworth-Heinemann
%C Oxford
%D 1999
%G ISBN 0-6-4163-0
%P 156 pp
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