Medical Acupuncture: A Western Scientific Approach
Edited by Jacqueline Filshie and Adrian White Edinburgh, Churchill Livingstone, 1998 448 pages. £52.50 - £55 (depending where bought)
(Reviewed by David Mayor, EJOM Vol. 2 No. 5)
'In acupuncture there are many roads to Rome' - Felix Mann
Like it or not, this is a hugely important book, and a challenge to anyone who believes that there is only one best way of practising acupuncture. It is very different from any other acupuncture book ever published, and a welcome addition to the Churchill Livingstone ranges of TCM blockbusters and comprehensive acupuncture/TENS textbooks for physiotherapists.
The book, which will surely become the British Medical Acupuncture Society (BMAS) textbook, is really a collection of mini-monographs. It consists of twenty-one chapters grouped in six sections, including (2) 'Practical aspects,' (3) 'Theory and basic science,' (4) 'Specialized forms of stimulation,' and (5) 'Clinical usage and evidence.' Some of the material is new, and a significant addition to the literature, whereas much has already appeared in one form or another in the BMAS journal Acupuncture in Medicine (AiM) and in other journals and publications. While the book as a whole should be required reading for any acupuncturist (I do not think I have ever taken so many notes on a book I have read before!), I do have some reservations.
One of these is the lack of definition of what constitutes medical acupuncture as opposed to any other form. While the editors begin their 'Introduction' by declaring that their intention has been 'to provide a scientifically based view of the place of acupuncture within modern medicine,' I think that the implications of the title, that 'scientific' and 'medical' are somehow exclusively wedded, is arguable. Chan Gunn, for example, in the chapter following the Introduction, writes about 'scientific acupuncture' and 'medical acupuncturists.' Maybe what the editors mean by medical acupuncture is, in fact, acupuncture practised by medical practitioners. But non-medical acupuncturists (ie, non-medically qualified acupuncturists) can be ruthlessly scientific, while, as Vincent and Furnham point out in their recent book on Complementary Medicine (Complementary Medicine. A research perspective. Wiley 1997), medicine is not always necessarily supported by science. And, as any practitioner knows, whether orthodox or complementary, medical or non-medical, science and the bounds of reason are often transcended in the actual therapeutic encounter. Healing is not the sole prerogative of any one group of acupuncturists.
Another major reservation I have is in response to how the editors end their Introduction: 'It is hoped that this textbook celebrates the emergence of acupuncture from its mystical, alternative roots and hastens its complete integration into conventional medicine over the next decade.' I certainly agree that it is important to balance an over-reliance solely on traditional models with something a little more hard-headed. I also agree that one important way forward for acupuncture is very much in partnership with orthodox medicine. But to totally debunk the mystical, and to look forward to complete integration into the 'conventional' (whether this refers to medicine or science) both strike me as dangerously limiting, if not reductionist. Following Manaka, I prefer to think of acupuncture as involving both science and art, neurophysiology and subtle energy. To stretch a metaphor, water - as also the fluids of the body - is a holder of subtle signals (as quantum theory can demonstrate). To impatiently throw out the bath water because we cannot (yet) see its value means that only the hefty baby of the 'scientific' is left, demanding our attention with its measurable action potentials and neurotransmitters. My belief is that there is more to life and acupuncture than that.
A third reservation I have is that, in this book as in some other acupuncture and many other medical textbooks, the patient does not seem to exist. By this I mean that the individual patient is barely considered here, lost in a welter of technique and theory and evaluation of group (normative?) responses to often standardised treatments. While Felix Mann and Anthony Campbell do at least discuss individual differences in acupuncture response, the only other major discussion of individuality in the whole book, so far as I can see, is in two highly technical case studies of segmental acupuncture. I am not so sure that leaving out the contribution of the patient to the therapeutic dyad except as some kind of object to be analysed in groups of similar objects is these days altogether scientific, however problematic it is to scientifically examine what does happen in the individual treatment situation.
These general concerns aside, which still for me do not detract from the value of the book, I would now like to move on to commenting on its individual chapters. These comments follow more or less the same order as the numbered sections of the book.
Peter Baldry and Chan Gunn each contribute two chapters, the longer of these being scaled down (but not diminished) versions of their books on trigger point and intramuscular stimulation methods (both, incidentally, Churchill Livingstone productions). These chapters are useful introductions to their methods (Baldry's careful attention to detail is always rewarding to read and reread). Incidentally, although Gunn's work is included, I am surprised that no mention is given of another major Canadian system, the anatomical approach to acupuncture therapy developed by Joseph Wong. Is this perhaps because it is mainly taught to physiotherapists, or because this book is limited pretty much to a British view of acupuncture?
In addition to their main chapters, Gunn provides a somewhat pernickity and unsatisfactory introductory offering on 'Acupuncture in context,' and Baldry briefly covers 'Laser therapy' (as he has in AiM; his reference to the important woman Estonian researcher Karu as 'he' makes me wonder if he has read her original articles; it is also indicative of the male dominance in this field: of the twenty authors in this book, only four are women). More readable and balanced than Gunn's somewhat critical contribution is Anthony Campbell's practical one on 'Methods of acupuncture' (his Web pages on acupuncture are similarly readable), while Felix Mann's minimalist account of his own findings over the years is gently thought-provoking without being judgemental.
On the other hand, David Bowsher's chapter on 'Mechanisms of acupuncture' is not an easy read, and nor is the one on 'Segmental acupuncture' by two Dutch doctors, Robert Bekkering and Robert van Bussel. The latter is dense, and as with so many systems that start with simple ideas, their account ends up making things unduly complicated in order to assimilate differences and uncertainties ('different authors draw different maps of the dermatomes'), reminding me of some of the idiosyncratic systems created by manipulative therapists earlier this century. Bowsher's language is that of the older scientist, categorical and dogmatic, which immediately makes me suspect that something is creaking in the underpinning somewhere (I am afraid I see no 'reason to believe that mechanisms of acupuncture will eventually be explained by science,' as the editors optimistically state in their 'Introduction,' although I have no problems with belief as such). I am also curious why Bowsher gives only cursory mention of the work of JS Han in Beijing. Alex Macdonald's coverage of 'Acupuncture's non-segmental and segmental analgesic effects' that follows is more accessible to the non-scientifically minded acupuncturist (medical or not), and thankfully does justice to Han's immense contributions. His pragmatic approach to what he calls 'algotomes' I would also find more immediately useful than the complexification of the two Dutchmen.
Adrian White's 'Electroacupuncture and acupuncture analgesia' is again very readable, although maybe oversimplifying a complex subject. In this process he makes a number of statements (no doubt correct) that I would have liked to see more clearly referenced. He also includes some diagrams from work by Jean-Claude Willer and his group in France that are not well explained. While his coverage of electroacupuncture is succinct and useful, the real value for me of his chapter is his account of its use in analgesia for the control of surgical pain, information which is not otherwise readily available. John Thompson, in the next chapter on 'TENS,' repeats very much what he and others of his Newcastle colleagues have written elsewhere. Nonetheless, his is a useful review. I particularly like his statements that 'there is no correlation between the frequency and/or pattern of stimulation that relieves particular pains,' and 'an important axiom is that no pain should be considered untreatable by TENS unless proved otherwise.'
For me the meat of the book lies in section 5, 'Clinical usage and evidence.' Practical aspects are best taught practically, theory and basic science may change, and there are (or soon will be) whole books on the specialised forms of stimulation covered. But what all acupuncturists need is provided in the first two chapters of this section: 'The clinical evaluation of acupuncture' (by George Lewith and Charles Vincent), and 'The clinical use of, and evidence for, acupuncture in the medical systems' (by the book's editors).
Clinical evaluation is essential if acupuncture practice is to be evidence-based, as it must be in this day and age. Lewith and Vincent, who between them have a wealth of experience and knowledge of acupuncture research, cover the many difficult issues involved carefully, pointing out how few (twelve!) good true placebo controlled trials of acupuncture there are, and offering a useful review of existing reviews and meta-analyses. Interestingly, they could find no formal studies comparing traditional and formula methods, a situation which urgently needs to be rectified (to my knowledge, the only informal comparison was published by Leon Hammer in the American Journal of Acupuncture some years ago). This chapter (together with the book by Vincent and Furnham mentioned above) should be read and thoroughly digested by anyone considering an involvement in acupuncture research. It ends by outlining a testable hypothesis with important implications for the design of clinical trials: (1) in the treatment of some conditions (eg, nicotine addiction) acupuncture may be exclusively endorphin mediated, so that non-specific needling may be as effective clinically as using specific points, and a sham acupuncture control would be misleading; (2) in some non-endorphin mediated conditions (eg, nausea), the autonomic nervous system may be involved, point location become important, and sham acupuncture usable as a control; (3) some conditions (eg, chronic pain) may be mediated by both natural opioid and autonomic systems, and so studies should be designed accordingly. The authors suggest that Western acupuncture (is this medical acupuncture, scientific acupuncture, or something else?!) might be purely an endorphin-based treatment, and the more traditional approaches more autonomically based. Perhaps this hypothesis could help to clarify what I have mooted above on the differences between subtle and neurophysiological acupuncture.
The next chapter, by the book's editors, is a real tour de force, for which I admire them immensely. It is titled 'The clinical use of, and evidence for, acupuncture in the medical systems.' In it they review the effects of acupuncture on different conditions from the existing literature, giving priority (but not exclusivity) to controlled trials. A colossal undertaking, this is an essential resource for anyone wishing to know about the documented benefits of acupuncture. It is regrettable that the conclusion to the section on central nervous system conditions was inadvertently omitted, and there are the usual criticisms of Chinese studies as being of poor quality. However, as the authors say, 'it is definitely far easier to criticize a study than to complete a good one!' There are useful charts summarising trial results, and thought-provoking commentary throughout the chapter. Somehow I feel slightly uncomfortable that a coverage of the world's acupuncture research is included in a book subtitled 'a Western scientific approach.' While the authors' approach is obviously Western and scientific, much of the research which they review is not Western. It also provides information that is important for all acupuncturists, medical or not.
Christine McMillan writes next on 'Acupuncture for nausea and vomiting.' This is a fascinating and thorough account of her work with the late John Dundee on various methods of stimulating the acupoint neiguan, as well as a review of research by others. This is followed by a chapter on 'Acupuncture in the pain clinic' by Joan Hester. Unfortunately, although it starts well, the information here is covered at a bit of a gallop, and I ended up being unsure if this is a chapter on acupuncture in the pain clinic or a hurried review of the vast area of acupuncture as a treatment for pain. Even the references seem not to have had time to settle down into some sort of coherent order (this is the case in the next chapter too).
Virginia Camp's contribution on 'Acupuncture for rheumatological problems' again emphasises the need for better research. Her position is very clear too on the role of acupuncture. As she says, 'Acupuncture is essentially a treatment of symptoms, not diseases,' and she cautions against 'the single-minded use of acupuncture' as opposed to its use 'in the context of best medical practice' ('no one treatment will suffice' for spinal pain, for instance). However, traditional acupuncturists may take heart: aspects of orthodox medicine (such as inappropriate use of X-rays) also come in for their fair share of her criticism, and she is open-minded enough to state that 'it is always worth while trying a further approach using either the classical Chinese diagnostic techniques, electrical stimulation or the ear.' Although in some respects I find her approach a little (!) cavalier, this is a useful chapter to read in conjunction with other books on the subject.
No book on acupuncture would be complete these days without some mention of 'Acupuncture for the withdrawal of habituating substances,' here provided by Paul Marcus. While he writes ably on the clinical application of acupuncture for withdrawal and the research already done in this area, his explanations on the mechanisms involved left me feeling not altogether convinced. Much of what he states could be better referenced, and I would also like to see some justification for why he suggests 100-125 Hz as the electroacupuncture frequency to use. It very much concerns me that he recommends bilateral rather than unilateral auricular electrostimulation, and that he recommends probing ear points for tenderness before examining for sites of low electrical resistance. This, I would have thought, would inevitably entail false positive findings.
An important short chapter on 'Adverse reactions to acupuncture' is provided by Hagen Rampes, my only criticism being that his information on the position of blood donors treated by non-medical acupuncturists is nine years out of date! I would strongly suggest that the BAcC should support his proposal for a national database for acupuncture adverse reactions.
The final two chapters in the book are by François Beyens, Belgian general secretary of ICMART (the International Council of Medical Acupuncture and Related Techniques), and Simon Hayhoe, the consulting editor for the book, who has had a long term and central involvement with the BMAS.
Beyens offers a thoughtful 'Reinterpretation of traditional concepts in acupuncture.' While he makes some useful points (such as 'the ancientness of acupuncture does not justify a systematic acceptance of the Chinese vision of this particular technique'), his historical coverage is patchy (at times confusing the Nei Jing and the Nan Jing, for example!), and there have been many other reinterpretations over the years that are as useful as his, and possibly more profound. In particular, his emphasis on 'common sense' in acupuncture is very much in line with the book's editors' on the 'conventional' (discussed above), although his view that science and common sense somehow go together is hardly in line with the extraordinary paradigm revolutions that have overthrown successive scientific conventions in this century. However, his distinction between a basic pragmatic nucleus to acupuncture and the exaggerated extension of a few logical relations into a closed system of unjustified extrapolations is important, whatever we may feel about it as traditionalists. Personally I can only agree with his conclusion that 'the theory is there to be used only in so far as it helps in the selection of an effective point prescription,' whatever the theory is (Western scientific, TCM, or other).
Hayhoe, writing on 'The future,' emphasises the need for medical linguists to render Eastern European and Oriental acupuncture research more accessible to the West (and vice versa). He makes many useful points on how acupuncture research, journals and education might be improved, a number of which could usefully be considered by the BAcC. Peculiarly, he accuses non-medical acupuncturists of introducing the sham acupuncture control into clinical trials, and urges that advice on clinical trials be given by medical acupuncturists. It seems that he considers medical and traditional acupuncture as mutually exclusive, and only the medical acupuncturist as capable of scientific thought, something against which I have argued above, as has at least one of those contributing to this same book elsewhere (Vincent and Furnham, cited above).
One of the first Churchill Livingstone titles to appear since their takeover by Harcourt Brace, this book is beautifully produced (although I have some minor quibbles with proof reading of the References and the Appendix of 'Meridian/channel charts': some journal titles have been extrapolated wrongly from their Medline abbreviations without consulting the original articles, and some of the points are poorly illustrated in diagrams which are insufficiently detailed to warrant inclusion in a book of this calibre).
All in all, though, this book is of a consistently high standard, and will provide a benchmark against which to measure subsequent publications in the same line. As many of the contributors conclude, there is now a real need for further carefully conducted research into many aspects of acupuncture. Without this, future publications risk just reanalysing the same existing and often unfortunately poor quality studies in different ways. However, research resources are limited, in many ways more so for non-medical than for medical acupuncturists. Yet these limitations are different for the two groups, as are their strengths, and this in effect provides us all with a golden opportunity. There is great potential for collaboration between traditional acupuncture organisations like the BAcC, physiotherapy groups like the AACP (Acupuncture Association of Chartered Physiotherapists), and medical acupuncture bodies like the BMAS, collaboration that can only lead to a strengthening of the evidentiary basis for acupuncture. My hope is that this will become more than just potential, and sooner rather than later.
David Mayor David Mayor originally trained in traditional acupuncture at the Leamington college. However, his earlier academic scientific training and interests have always meant he has strong leanings towards the science as well as the art of acupuncture.