Chapter 6: The ability of an acupuncturist 

6.1. The length of license does not represent clinic skill of acupuncturist

Colquhoun D noticed that the positive articles about acupuncture come mostly from mainland of China, Taiwan, Hong Kong, and Japan, and so on. We also noticed that the negative articles mostly come from Western countries and from the hands of physician or physiotherapists. In such Western articles, the healing effect of acupuncture in acupuncture groups is about 30% to 40% higher than no-treatment groups, and about 10% to 15% higher than sham acupuncture groups. Such healing effect is much less than our own clinic efficiency, and also much less than the reports from China or other parts of Asian countries.

The ability of an acupuncturist is not determined by how long time the person hold acupuncture license, or where the person get acupuncture training. These should not be the absolute parameters to tell the clinic skill of an acupuncturist. We believe that, the acupuncturist in an acupuncture research should be the one of higher level of clinic skill. It would be better if the acupuncturist is recommended by Acupuncture associations.

Acupuncture is a profession of highly personal skill dependence. It does not mean that high academic level or longer education in acupuncture would ensure the higher clinic skill.  

In the Western countries, some physiotherapist, chiropractic, or physician, can also get the license for acupuncture after taking part in acupuncture training for some time. For example, a physician has an acupuncture certificate after 140 hours training would be allowed to participate acupuncture study.  Some times, even new graduated students can participate the research. ^,

In review the acupuncture studies in the Western countries, it seems that anyone may act as an "acupuncturist" in the study, if they get hundreds of hours of acupuncture training and get acupuncture license for some years. It seems that they feel that, to practice acupuncture, it is already enough if they choose the acupuncture points used by other researchers, and if they indeed induced the Deqi needle sensation. Under this condition, whether the results are positive or negative is the credit of the acupuncture, nothing related to their own level of skill in acupuncture.

The acupuncturists in China who participate the acupuncture study is ensured by their published articles. Their articles would not at all be accepted for publish, if their acupuncture study cannot improve the healing effect of current acupuncture technique, or if their work does not allow better understanding of acupuncture mechanism or other aspects of acupuncture. However, any articles about acupuncture can be published in the Western countries, if the article meets the need of some basic requirements for the publication, such as randomization, blindness, with a sham acupuncture group, or a waiting group, more than 20 to 30 patients in each group, and statistically analysis of the data. To the view of acupuncturists in China, they learned almost nothing from so many published articles from Western countries.

If we do not pay attention to the personal skill of acupuncturist, no any acupuncture studies of best design would reach truth. Such as to let a new person shoot a gun, the best gun does not ensure that the person would shoot to the target.

Unlike medical research in Western medicine, which mostly studies uniform of chemical tables, any study involving personal skill, such as acupuncture, massage, chiropractic, physiotherapy (if it is manual therapy), needs to choose the highest level of practitioners to take part in. We cannot just pick up a student infighter from US school to match the infighter of national level in Tailand. If the US infighter lost, can we say that US infighter level is lower than that of a Tailand infighter?

White P (2012) had a study of acupuncture for the treatment of osteoarthritic pain. The study involved three acupuncturists. The healing effects of the three practitioners are 37%, 17% and 62%. Though it was explained by the author that the highest healing effect by the third acupuncturist might be due to the impression of him by patients more professional and more like an expert, it cannot exclude that his personal skill in acupuncture might be really highest. No matter what could be the reason, the huge difference in the healing effects by the three acupuncturists will affect the data analysis for sure. It is possible that to compare the healing effect by the third acupuncturist with sham acupuncture, it would show statistically significant difference (63% vs 28.4%, or 63% vs 39.2%), rather than no difference as reported.

Hawk C (2002) reposted their chiropractic study on chronic pelvic pain. The study involved 3 clinic locations. After 6 weeks of chiropractic treatment, the pain level reduced by 59.1%，26.9%，84.6%, in the three locations, respectively, average of 56.6%, while the reduction rate in sham group is 68.5%. The healing effect of the treatment group is even less than the sham group! The practitioners in the 3 clinic locations were reported to have 20, 10 and 12 years of clinic experience. Having no alternative but the author have to admit that "The technical and personnel resources required to achieve adequate standardization of procedures at multiple sites may make a placebo-controlled trial unfeasible, given our current lack of knowledge about the active agent in manual chiropractic procedures. It might be more efficient to reverse the traditional order of experimentation used for pharmaceuticals, which begins with safety, proceeds to efficacy and finally to effectiveness. Because chiropractic—a CAM profession using manual methods for more than 100 years—can scarcely be considered in the same category as a newly developed medication, it might be reasonable to first investigate effectiveness. If chiropractic care that is provided by experienced chiropractors who are allowed to use their best clinical judgment of how to apply the procedures is documented in such studies to improve patient outcomes compared to standard medical care alone, more in-depth and controlled studies would then be warranted to identify specific aspects of that gestalt of care that are most responsible for the outcomes or if there are certain subpopulations of patients who benefit most from them."

Apparently, it is not reliable to tell the personal skill of chiropractic practitioners by license holding time, neither of acupuncturist.

Forbes A reported their acupuncture study. Acupuncturist A treated 12 patients with IBS, 50% patients had the symptom level reduced by 4. Acupuncturist B treated 15 such patients and 33.3% of patients had the symptom level reduced by 4. The author had no alternative by to combine the data together, so as to reduce the unlikelihood of the study conclusion.

So, for these of large scale clinic researches involving many clinic locations and many practitioners, how high level of the creditability for their study conclusion?

Another example is from report of Deng G (2007) for the treatment of hot flash by acupuncture. During the study, the acupuncturist was changed and the reduction curve of the hot flash even reversed up. They had acupuncture twice a week for 4 weeks. The hot flash reduced by about 30% to 35%, similar to that in sham group.

Fregni F (2010) pointed out, in an international placebo symposium working group, that "a great number of interventions used in PRM depend on the technician’s or clinician’s skills such as the application of acupuncture, injections, and nerve blocks. Therefore, controlling for these interventions becomes difficult with this important source of variability. This makes it even more difficult to design an appropriate placebo in these situations. To control for skills and levels of experience, it would be necessary to conduct multicentric studies with various levels of skills and experiences and perform multivariate analyses to adjust for these variables. In this scenario, a large number of patients would be necessary, increasing the difficulties to conduct such studies."

If the personal skills among several acupuncture operators are so different, how can we trust the stuy involving 67 physiotherapists, 122 physician, or 320-340 physician?

As pointed out by Forbes (2005) that the possibility that simplified acupuncture as delivered by Western-medicine-trained acupuncturists might have given a different result is intriguing and may warrant further study.

6.2. Additional issue for acupuncturists in acupuncture studies

Of course there is another possibility that the acupuncture in a study is requested by acupuncture researcher, not accepted by the acupuncturists themselves. The acupuncturists in an acupuncture study may suffer from emotional stress, that may affect their perform of acupuncture treatment.

McManus CA (2007) have dad a survey to the acupuncturists in thir acupuncture study. They send surveys to 12 acupuncturists and get 8 responded.

They reported that  “all respondents reported feeling challenged by their work as investigators as opposed to their “normal” roles as clinicians. Although all agreed that the protocol was reasonable at the outset, in particular, they still felt strong urges to apply the typical tools of their clinical practices such as active needling, heat, external herbal treatments, treatments for the “whole” person, and counseling. (To our best knowledge, none of them acted on these urges.) During monitoring interviews, many acupuncturists indicated how difficult it was not to be permitted to offer dietary, ergonomic, or physical advice to the participants. Several acupuncturists reported that they frequently hoped that participants would be randomized to the genuine acupuncture group after the placebo run-in had been completed. In one instance, an acupuncturist actually called the clinical coordinator and requested that a patient be re-randomized to the genuine treatment group. Unwilling to comply with the rigors of RCTs, this acupuncturist (whose responses are included here) was not assigned to treat more participants in the study.

Although 12 acupuncturists were originally trained for the RCT, 5 did not stay with the trial for its entire course. Study coordinators ceased assigning participants to 3 acupuncturists because they broke the protocol (e.g., for using nonprotocol points in the active phase, failing to keep accurate records, or for being unclear about the study’s procedures.) Two (2) other acupuncturists resigned from the trial: 1 because of the ethical concerns with administering the sham treatment and the other because of re-locating out of the state.”

Apparently, the mode of acupuncturists in an acupuncture study could be different from their routine clinic work. Could this unstable emotion condition of acupuncturists affect the acupuncture efficacy?

6.3. Selection of acupuncturist for acupuncture research

Certainly we should not carelessly image, as others, the level of personal skill of any acupuncturists. We propose a preliminary idea for the selection of  acupuncturist for acupuncture study:

Basic selection: the acupuncturist should have a comprehensive healing effect for most of diseases in his/her clinic as high as 75% (within one to two months). The comprehensive therapies mean the use of acupuncture, cupping, moxibustion, bleeding therapy or whatever commonly used therapies in an acupuncture clinic.

It should not be difficult to find such acupuncturists.

Specific selection: the acupuncturist should have at least 75% of an average healing effect (as published data, for example from China) for the disease/symptom to be studied, when only the acupuncture was used in a pilot study. The average healing effect by acupuncture is different for different disease/symptom. For example, if an average healing effect for non-specific low back pain, treated by acupuncture alone, reported from China, is 55%, the healing effect of the candidate acupuncturist for the same kind of low back pain should be more than 41%.

The reasons for the basic selection is: if the acupuncturist cannot reach such healing effect with their own natural matter, it would be impossible for them to create a positive result in a Western style of acupuncture study [16], in which only acupuncture, not moxi, not cupping, or any other kind of therapies, are allowed. What is the use to create so many negative data by untrustable ways of studies?

The reasons for the special seletion is that even if the acupuncturist passes the basic selection, it still does not mean that he or she is able to treat the disease to be studied. For example, if an acupuncturist never treated coma patients (due to stroke), it would be hard to believe that the acupuncturist can treat such patients in a study.

If there is no any people passes such selections, it would mean that the conditions for an acupuncture study are not met. The acupuncture study should not be started. Can any surgeon perform a craniotomy without anesthesia by an anaesthetist?

The ability of the acupuncturist can be tested in a pilot study or in a large scale study with a free-treatment group, in which the acupuncturist can treat the patient by whatever his natural way. If the healing effect in the free-manner could not exceed 45% ,[17] it is ready to tell that the study fails at least because the poor skill of the acupuncturist. Before the study, the researcher should ask the acupuncture if the acupuncture has confidence for the disease to be studied by acupuncture. If the acupuncture said yes, then the researcher would mean "show to me".

In the acupuncture study, we should not only pay attention to the diagnosis of the disease to be studied, the selection of patients, randomization, blindness, or cross-group, such organizing issue, but also the quality of an acupuncturist.

Brief summary:

The personal skill of an acupuncturist is one of the most important factors determining the success of an acupuncture study. It is needed to set up a role for the selection of an acupuncturist for an acupuncture study. 

Chapter 7. Similarity and difference between acupuncture studies in and out China

There are several differences between the acupuncture studies in and out of China, beside what we have discussed above .

7.1. Design of study

For acupuncture study in the Western countries, the so called high quality studies means: randomization, blindness (single or double), with sham group (plus waiting group). If there is a sham group, it is better to also have a cross design.

If there is no waiting group, it would be hard to exclude natural regress of the disease from the sham group. This might be true since the acupuncture studies in the Western need a long time to finish, up to 1 to 2 years. A disease might get better by itself. With a sham group, it would be not so ethical to "cheat" patient, so a cross design was used and the patient initially in the sham group can be later treated with real acupuncture.

Actually, no matter for acupuncture or for Western medicine or surgical studies in Western countries, only little studies met these standards. Most of acupuncture studies do have randomization, blindness, using Western medicine as control group but no sham group or no waiting group (no-treatment group). The presumption of such design is that the healing effect of the control group (Western medicine group) have been tested to be effective by "strict" randomization, blindness, compared with sham group. Therefore, if the healing effect of acupuncture group is equal to, or higher than, the control group, the healing effect of acupuncture group should be accepted. This is true especially for the treatment of some difficult diseases, for which the current Western medicine shows some effectiveness but also terrible side effects.

Unfortunately, this presumption might not be true. The medicine in the control group may not be tested by the "strict" studies at all. It is not a long time that FBA of US asked a new medicine to compare with a sham group. Many medicine are still in use for a long time though they have never been tested comparing with a sham.  It may cause an uncertainty to compare acupuncture with such non-tested medicine. Secondly, someone might ask if the placebo effect in the medicine group and in the acupuncture group are not the same level.

The acupuncture studies in China mostly have also a randomization, but compared with Western medicine, or compared with other type of acupuncture technique. Rarely there is blind design, or a sham group. This might be because the acupuncturists in China do not believe their own acupuncture could be a placebo effect. The data we could collect (Fig. 20a, 20b, 20c, 20d) appear to support their confidence.

Because the healing effect of acupuncture group is only 10% to 15% higher than the sham group, after analyzed by statistic, the dada are easy to loss significant. Acupuncturists in the Western did not realize that it is due to the low healing effect of the acupuncture group, but to an improper sham group. So, they have paid much attention to modify the sham group and study the mechanism of the placebo effects. While acupuncturists in China do not believe that acupuncture could be placebo effect, and they do not believe that to insert needle to a non-point could result in a higher healing effect than insert the needle into typical acupuncture points. So, they usually use inserted needle (into non-point) as sham group. In such sham, the sham needle is even inserted the same depth as real acupuncture group. (see Attached list 19a,19b, 19c）.

Acupuncture study in the Western uses sham treatment. This cause a ethical problem. It is therefore needed to tell the patient that he or she might be allocated into a sham group, or a new treatment group and so triggers patient expect for healing. Researchers have to try to bind the patient from which group he was allocated, to eliminate the communication between the acupuncturist and the patient, to design a cross design, all of which increase the complex of the study and also largely "modified" the real acupuncture treatment course. For this reason, we would say that the acupuncture study in the west is an "modified" acupuncture, not a real one.

8.1. Acupuncture in a study in most time is a single form of acupuncture

Acupuncture performed in an acupuncture study is usually just the acupuncture per se. While the acupuncture in clinic is usually combined with other therapies, such as moxibustion, cupping, Guasha, Tuina, acupressure, auricular acupressure, traction, bleeding therapy, bleeding-cupping therapy, or electrical acupuncture, warm acupuncture, or TENS, and so on. 

8.2. Acupuncture in a study is a fixed manner

Acupuncture in a study is usually performed in a fixed manner: fixed treatment schedule, fixed acupuncture points selected, fixed numbers of needles, and fixed treatment length, etc. with the aim to standardize the treatment course, so as to reduce the variation of healing effect from patient to patient. While the acupuncture in clinic is in a flexible manner, it can be changed among patients, and during the treatment for a given patients, the acupuncture points, the number of the acupuncture points, the length of each session, combined or not combined with other therapies, etc. The aim of the flexibility is to make the acupuncture treatment match the conditions of the patients: the tolerability of patients to the needle stimulation, the change of the severity of the disease, the life schedule of the patients, the financial situation of the patients, etc.

Even for the acupuncture, we may use different acupuncture points rather than those introduced in acupuncture text book. For example, we may choose trigger points, start-end point of a muscle group, and so on.

Sometimes, we may even combine the acupuncture with Chinese herbal therapy, especially by those of acupuncturists who come from China but now work in the Western countries, when we feel that Chinese herbal therapy might work better than acupuncture. In this case, the acupuncture treatment could be a complimentary therapy to the herbal therapy.

 8.3. Acupuncture in a study is for a limited group of patients

Acupuncture study is performed usually to a given group of patients: patients with the same diagnosis (Western medicine disease category), and within a given severity of the diseases, a given age of range, a given sex and so on. However, the patients in clinic are largely variable. For example, the patients with knee pain in clinic might belong to different categories of arthritis, or sprain, or strain, with various level of severity, various length of the disease, and so on. Especially speaking, some diseases we see their research from a study may not be seen in a clinic often. For example in our clinic, most popular diseases we see are various pain syndrome, poor sleep, stress, anxiety, constipation, hot body or cold body (hands), menopause syndrome, disorders in menstruation, infertility, overweight, quit smoking, but very little of some other kinds of diseases, such as cancer, AIDS, post-stroke syndrome. We mentioned in the early of this article that our clinic effectiveness could be up to 85%. This does not mean that we can treat every kind of disease with such successful rate.

All of these mean that, if it does not work for the acupuncture in an acupuncture study, it does not mean that the acupuncture in clinic neither work; or if the acupuncturist in that study cannot improve the disease condition, it does not mean other acupuncturist can not either.

The acupuncturists in an acupuncture study should tell the researchers what the difference is between the experimental acupuncture and the actual acupuncture. It is not fare and injustice to test the "artificial' Western style of acupuncture and contribute its study results to clinic acupuncture or Chinese style of acupuncture. If the acupuncturist in the study tells that this is indeed their own way of acupuncture in clinic, we would have to suspect and question about the healing effect of acupuncture in their clinic.

 Brief Summary:

(1). The acupuncture used in an acupuncture study could be different from that in a clinic.

(2). Acupuncture in an acupuncture study is a single form of acupuncture, while that in a clinic is a combined therapies.

(3).  Acupuncture in an acupuncture study is a fixed manner, while that in clinic is flexible manner.

(4). The healing effect of acupuncture in an acupuncture study may not be necessarily represent that in a clinic.

Chapter 9. Direct evidence that acupuncture is not a placebo effect 

9.1. Treatment of coma with acupuncture

It should have no argument that a placebo effect only happens when a person is in a consciousness condition and with a clear mind to able to analyze stimulations from out side of the body. Now let us see how and if acupuncture can be used to treat some special clinic conditions in which the person is out of consciousness, such as coma, shock, persistent vegetative state, anesthesia, etc.  

For the treatment of coma patients with brain trauma and stroke, we collected about 40 articles.^, For such coma patients, acupuncture (Attached list 21a), together with conventional rehabilitation therapies, can speed up the wake-up rate from 51%±17% increased to 79%±12% (Fig.22a), or to increase the degree of consciousness (the GCS index increased from 3.02±1.2 to 4.73±1.3) (Attached list 21b ，Fig.22b). Or, it can be said that acupuncture treatment can shorten the time needed to wake-up from 35.74±16.7days down to 22.78±11.7 days (Attached list 21c，Fig. 22c).

Acupuncture alone can also reach such healing effect. The combination of  Western conventional treatment with acupuncture treatment can no doubt increase the cure rate and to reduce the sequela rate.

It should be pointed out that, when acupuncture is used for the treatment of such severe conditions, as coma, shock, persistent vegetative state (see later), it is the modified acupuncture that was used. The acupuncture treatment is at least once a day. It would not be possible to reach such healing effect if it is till performed once a week as current Western style acupuncture.

蔡化理 (1961) treated 27 patients with shock due to toxic dysentery. Within 10-30 min of acupuncture, the blood pressure started to increase. Only 2 cases needed blood pressure increasing medicine.  

9.2. Treatment of shock with acupuncture

Doctors in Second Affiliated Hospital of Hunan Medical College (1973) reported their way of treatment of shock for 160 cases. Based on ordinary conventional ways, all cases were given acupuncture treatment first. If the blood pressure did not increase within 30 min, then started the addition of pressor agent. By this way, blood pressure in 122 cases (76.3%) clearly increased. The apparent effective rate was 76.3% and total effective rate is 87.5%. This means that the blood pressure in only 23.7% of patients did not respond to the acupuncture treatment. This suggests that acupuncture treatment has a function to increase blood pressure in shock patients. These doctors found that for half of patients, their blood pressure can start to increase within 30 min, some after 60 min. There had been 9 patients, for whom the use of pressor agent did not work satisfactory, after addition of acupuncture, blood pressure increased in 8 cases (systolic pressure up to 90 mmHg). This suggests that for those cases whose blood pressure increase is not stable, acupuncture can work to help the pressor agent. For some patients, if the manipulation of the needles (by twisting) stop for a longer time, the blood pressure would tend to reduce. After stronger manipulation, the blood pressure would increase again, suggesting that manipulation of needle can influence the healing effect.

俞勤龙 (1997) reported that doctors in the department of gynaecology and obstetrics in the Jiangyin Hospital of traditional Chinese Medicine treated 52 cases of shock patients after induced abortion. The patients showed, during or after the operation, pale face, cold hands and feet, palpitation, press in chest, nausea or vomit, even reduction in blood pressure, come, etc. The body condition became worse very quickly and changed very fast. The blood pressure of the 52 cases all increased after stimulation of Sanyinjiao point for several seconds. The patients then turned conscious to recovery. No one case needed intravenous infusion or other conventional emergency treatment.

宋智静 (1996) treated 40 cases of shock patients due to allergic reaction to penicillin by using acupuncture and epinephrine. For all of the patients, after injection of epinephrine and acupuncture on Neiguan point for 5 min, the face turned pink, sweat stopped, consciousness turned back, blood pressure increased, and pulse increases. The healing effect showed as average 10 min (as fast as 5 min). Except for one case who needed additional intravenous infusion and steroid medicine, other 39 cases got recovered within 5 to 15 min. No any death case. It can be commented that in this clinic report, there is no control group to tell how much death rate might be without use of acupuncture in the emergency treatment. However, according to our own previous work experience in emergency department in China, it has been a very effective emergency treatment for those patients who is already in a coma status, for the fact that their live were saved within 5 to 15 min.  

刘应柯 (1999) and his colleagues  treated hemorrhagic shock 33 cases with acupuncture (no pressor agent). After half hour, systolic pressure increased from average 62.6 mmHg to average 98.3 mmHg. At the same condition, similar shock patients 31 cases were treated without acupuncture (with pressor agent). Their systolic pressure increased from average 67.7 mmHg to average only 77.9 mmHg.  

赵滨 (2008) and his colleagues treated various kinds of shock 40 cases. After acupuncture for 30 hour (no pressor agent), systolic pressure increased from average 70.9 mmHg to average 95.6 mmHg. At the same condition for another 40 cases using pressor agent (no acupuncture), systolic pressure increased from average 68.9 mmHg to only average 85.5 mmHg. For diastolic pressure in the acupuncture group, within half hour treatment, it increased form average 42.3 mmHg to average 58.7 mmHg. In the pressor agent group, it increased from average 43.2 mmHg to only 55.24 mmHg.

傅立新 (2008) treated various shock patients 138 cases. Within less than 30 min of acupuncture (no pressor agent), systolic pressure increased from average 83.1 mmHg to average 101.1 mmHg. Under the same condition with pressor agent use on another 138 shock patients, systolic pressure increased from 83.3 mmHg to 89.2 mmHg. In the acupuncture group and within less than 30 min of acupuncture (no pressor agent), the diastolic pressor increased from average 49.5 mmHg to average 59.3 mmHg. The diastolic pressure in the pressor agent group increased from average 48.8 mmHg to 50.4 mmHg.

冀慧霞 (1999) treated allergic shock 50 cases. With conventional emergency treatment, the total effectiveness rate is 76%, while it is 90%, when the conventional way is combined with acupuncture.

The successfulness of acupuncture treatment is of course also related to the intensity of the shock. The effectiveness to low to mild level of shock is higher than severe shock. It is also related to the type of shock.  Generally speaking, the effectiveness in allergic shock and infective shock is higher, but that in cardiac shock and hypovolemic shock, lower.

吴敬 (2000) reported their treatment of cardiac shock, hypovolemic shock, infectious shock and allergic shock with conventional medicine plus acupuncture. The total effectiveness for these different types of shock is 80%，82.6%，100% and 100%, respectively.  

张从道 (1989) reported that, treated with acupuncture alone (no pressor agent) for cardiac shock, the total effective rates for hypovolemic shock, infectious shock, allergic shock, nervous shock and traumatic shock are 90%, 95%, 93.3%, 95%, 93.3% and 96%, respectively. 

It should be noticed that acupuncture can not only work together with pressor agent to increase the emergency treatment of the shock, but also solve the emergency condition by itself alone.

Clinic studies suggested that ，in the treatment of shock with acupuncture, the blood pressure increase occurs mostly within 30 min, while with pressor agent, mostly after 3 hour. With acupuncture treatment, the blood pressure increased earlier and higher. Especially it happened in the earlier stage of shock. This is very important to improve functions of important organs, such as heart, brain and kidney, so as to prevent irreversible damage to these organs.  

To treat shock, every minute is very important to patient's life. No time to allow us to have a sham group or a non-treatment group. It should be accepted to compare acupuncture-alone group and the acupuncture plus pressor agent group, e.g. to compare conventional treatment with or without acupuncture. Studies here all tried half hour of acupuncture first. If the blood pressure does not increase, it is added right away with pressor agent. The results showed that combination with acupuncture worked much better than without acupuncture. Indeed sham acupuncture and no-treatment groups have been used in animal shock models. There are many such animal studies, but animal model study (instead of clinic study) is not used as data sources for our articles here.

Patient in low level shock appears anxiety, cloudy consciousness and slow reaction. Upon middle to severe shock, patients lose consciousness. That acupuncture can increase blood pressure when the patients is with very low level consciousness suggests that a placebo effect is not the only mechanism by which acupuncture works, and that acupuncture works not only for subjective disorders, such as pain, but also objective disorders, such as blood pressure.  

 9.3. Treatment of persistent vegetative state by acupuncture

Along with the development of medical diagnosis technique and emergency treatment, the death rate of emergency patients has been dramatically reduced. At the same time it also induces a new social and medical problem: there are more patients with persistent vegetative state. There are higher death rate and cripple rate in such group of patients. The persistent vegetative state is hard to treat, causes heavy burden to patient's family and society, even if after lots of efforts of medical services. It has become a very serious social concern in and out China.

Estraneo A （2010） observed 50 cases of persistent vegetative state. Under the treatment of conventional medicine, only 10% of patients regressed into shallow consciousness, another 14% returned consciousness, but all happened after one year of treatment. Before the publication of his paper, it was commonly believed that it is almost impossible to get recovery of consciousness for persistent vegetative state due to brain trauma for more than one year, or due to other reasons for more than half year. For a long time, due to no effective way of treatment, the attitude of medical society is negative and passive for persistent vegetative state. In US, the doctors can stop any treatment and nurse service to allow the patient to euthanasia, according to patient's willingness before sick and to the agreement of patient's family.

However, it is a quite different picture of the treatment of persistent vegetative state in China. A lot of studies and clinic reports suggest that acupuncture can work to speed up the wake-up of patients with the persistent vegetative state (Attached list 22).  

We can make a summary of these data into Fig. 23.  

Fig. 23. n = number of experiments. Acupuncture in the “Mixture with Acup” and “Mixture without Acup” groups are ordinary acupuncture. Con: conventional supportive therapies. HPO: high pressure oxygen. Mixture: high pressure oxygen, rehabilitation therapy (exercise), tuina, massage, physiotherapy, sound-light simulation therapy.

Data in Fig. 23 suggest: if treated with traditional conventional medicine, the wake-up rate for the persistent vegetative state is 25%. Conventional medicine plus high pressure oxygen, the wake-up rate can increase to 43%. When the conventional medicine combined with high pressure oxygen, rehabilitation, sound-light stimulation, it increases furthermore to 54%. With high pressure oxygen plus acupuncture, the wake-up rate is 67%. When high pressure oxygen plus ordinary acupuncture, is combined with rehabilitation, plus sound-light stimulation, the wake-up rate remained the same (64%). Conventional medicine plus special acupuncture, the wake-up rate reaches 70%, suggesting that the special acupuncture technique works much better than the ordinary acupuncture technique, and also better than combination of complex and expensive therapies. Even with ordinary acupuncture, its combination with high pressure oxygen works better than combination with other more rehabilitation remedies.

The effectiveness of acupuncture treatment of the persistent vegetative state is related to the length, the severity and the cause of the disorder, the length of treatment course of acupuncture, the age of the patient, etc.  The longer the disorder before acupuncture treatment, the harder the treatment. The persistent vegetative state due to brain trauma is easier to treat than that due to cerebrovascular accident. The persistent vegetative state due to cerebral infarction is the most difficult to treat. Acupuncture does not work if the length of treatment is not long enough.

There are data suggest that 37% to 43% of patients with persistent vegetative state may still have slight or shallow consciousness and be able to respond to the doctor's order. However, such shallow consciousness is not complete consciousness. It is similar to the consciousness in early stage of shock, in which it can be doubted for the ability of patient to remember things or to analyze outside stimulation, not to speak of a hint to them. We can image our own consciousness and ability to respond to a hint when we did not have sleep for two nights. Yes, we have consciousness, but our response to outside stimulation would be very slow and our mind is cloudy to a hint. Therefore, it would be very difficult to link the increased wake-up rate of those patients after treatment with acupuncture to a hint or to a placebo effect.

Here we paid attention to the wake-up rate, not to the recovery of body function or life ability after wake up. We emphasize that acupuncture can work when a patient is no, or almost no, consciousness [20]. Some paper reported not the wake-up rate, but a PVS scale. Some reported a grade mark, such as the rate of basically cured, dramatically cured, improved, or no change, or such as improved, effective, no effective. For former grade report, we choose their  "basically cure + dramatically improved" as indication of wake-up. In the later grade paper, we only choose their "improved" as wake-up rate.

Therefore, in the calculation of wake-up rate, we have tried to exclude those patients who only come into a shallow consciousness state after treatment.  

9.4. Acupuncture used before or during anesthesia

梁洁 (2007) reported the use of transcutanious electrical stimulation (HANS machine, 30 min before anesthesia until the end of operation, stimulating acupuncture points) for 30 cases of breast cancer undergoing radical masectomy (HANS group). The patients were given intravenous induction plus general anesthesia. Another 30 similar cases were only give intravenous induction plus general anesthesia but no acupuncture (control group). It was found that, 12 hours after operation, the pain level (VAS scale) in the HANS group is dramatically less than control group (2.14±0.85 vs 3.38±0.91) . The HANS group showed much less rate of nausea/vomit than the control group (19% vs 34%).

谢健 (2009) treated 30 cases of patients for radical resection of colon cancer. The patients were given general anesthesia plus scalp acupuncture (Acupuncture group). Another 30 similar patients were given general anesthesia only (no acupuncture, control group). Acupuncture started 20 min before anesthesia and lasted until the end of the operation. They found that the involvement of scalp acupuncture reduced the pain during skin incision (isoflurane MAC is 0.75 and 0.88, respectively), showed some level of pain inhibit and anesthesia (the isoflurane MAC during operation is 0.95 and 1.29, respectively). It means that the use of acupuncture reduced the use of anesthesia drug by 26%.

欧阳铭文 (2009)  allocated 100 patients who were for Laparoscopic gastrointestinal surgery, randomly and blindly into two anesthesia groups: general anesthesia plus acupuncture (acupuncture group, 50 cases) and general anesthesia only (control group, 50 cases). The acupuncture (on Neiguan point both sides) was started before induction and lasted until the end of operation. After operation, the needle was removed. The acupuncture points were covered with an opaque tape. It was found that the incidence of nausea for 6 hours after the operation was 12% and 28% in the acupuncture group and the control group, respectively. The postoperative pain level was no difference between the two groups .

池浩 (2014)  randomly allocated 160 patients who were to have heart valve replacement operation, into general anesthesia plus electrical acupuncture (acupuncture group, 80 cases) and general anesthesia only (control group, 80 cases). Electrical acupuncture (on Zhongfu, Chize and Ximen points) were started 20 to 30 min before induction, lasted until the end of the operation. The anesthesia in acupuncture group did not use trachea cannula, only use little amount of anesthesia. The result is: the acupuncture group and the control group had similar level of anesthesia, but the acupuncture group showed less amount of anesthesia drug, less case who needed blood infusion, earlier time to get up the bed, short time to stay in observation room, less days in hospital, less expense for medical cost, less case with lung infection, earlier time to start to eat, less days to use antibiotics, all of which were significant different.

吴群 (2013) randomly allocated 40 cases of craniotomy into two groups: 20 cases were given general anesthesia (control group) and 20 cases of general anesthesia plus electrical acupuncture (Acupuncture group). The acupuncture started 20 min before anesthesia until the end of the operation. For the control group, electrical patch was adhered to the acupuncture points, but no electrical was connected. They found that, compared with the control group, the acupuncture group showed shorter time to wake up (15 min vs 20 min) after operation, and needed less amount of anesthesia drugs (average 2000 mg vs 2500 mg). Note that the control group is a sham group.

幸志强 (2012) and his colleague randomly allocated 60 patients undergoing subtotal thyroidectomy surgery into two groups of anesthesia: general anesthesia group (control group, 30 cases) and general anesthesia plus transcutaneous acupoint electrical stimulation ( TAES)(Acupuncture group, 30 cases). TAES started 20 min before induction of anesthesia and lasted until the end of the operation. They found that the use of TEAS could significantly stabolize the blood circulation (heart rate, blood pressure), reduce the time of the extubation (6.43±1.08 vs 10.83±2.64 min), and shorten the time to stay in observation room (12.31±1.79 vs 17.83±2.87 min), reduced the usage of anesthesia drugs (46.7±6.3 mg vs 67.5±5.6 mg) , and reduced the cost of medicine (211.78±34.5 vs 291.53±22.81 yuan).

张兆伟 (2014) randomly and blindly allocated 60 patients undergoing Gynecologic laparoscopic surgery into two groups: electrical acupuncture plus general anesthesia (acupuncture group, 30 cases) and general anesthesia alone group (control group, 30 cases). Electrical acupuncture started 30 min before induction and lasted until the end of the operation. They observed the effect of electrical acupuncture on the gastric function of these patients, by observing the changes of gastric mucosal partial pressure of C0₂ (PgC0₂), arterial partial pressure of C0₂ (PaC0₂), and the partial pressure difference [P(g-a)C0₂] during surgery. They found that after intervention, there were significant differences in comparing PgC0₂ and [P(g-a)C0₂] (P<0.01, P<0.05). The intra-group differences in comparing all indexes were statistically significant between both groups (p<0.01). They commented that electrical acupuncture adopted in laparascopic surgery with general anesthesia can guarantee the supply of blood oxygen to gastric mucosa, thus protecting the gastric function. Please note that the control group is also a sham group.

安立新 (2011)  and his colleagues randomly and double blindly allocated 80 patients undergoing supratentorial tumor resection into two anesthesia groups: general anesthesia group (control group, 40 cases) and general anesthesia plus electrical acupuncture (acupuncture group, 40 cases). The electrical acupuncture were started from the beginning of the induction until the end of the operation. In the control group, only attached electric line to the acupuncture points (on skin) but no connection to electric. Compared with the control group, the acupuncture group showed less consumption of anesthesia drugs, less time needed to restore automatic breath, time to extubation, to open eyes, to restore automatic movement, automatic direction, and shorter time to stay in operation room. After operation, the incidence of irritation, nausea and vomit, all were less in the acupuncture group. For example, the time needed to open eyes in acupuncture group and in the sham group was 18.5±8.5 min and 28.5±13.4, respectively.

安立新 (2013)  randomly allocated 120 patients undergoing supratentorial tumor resection into three anesthesia groups: electrical acupuncture plus general anesthesia (acupuncture group, 40 cases); TENS plus general anesthesia (TENS group, 40 cases) and general anesthesia only group (control group, 40 cases). Acupuncture and TENS started before induction and lasted until the end of the operation. In the control group, there were electrical wire attached to the acupuncture points, but no electric connected. They found that, during the recovery period, the time needed for automatic breath, extubation time, time to open eyes, time to have automatic movement, time to have direction ability, time to leave operation room, all were shorter in the acupuncture group and the TENS group, than that in the control group. The postoperative pain level (VAS scale) in the acupuncture group (3.33±1.09) and the TENS (3.40±1.30) group was lower than that in the control group (6.43±1.52) .

虞慧畅 (2009)  randomly allocated 60 patients undergoing modified radical mastectomy into two groups of anesthesia: TENS plus general anesthesia (TENS group, 30 cases), and general anesthesia (control group, 30 cases). TENS started before induction and lasted until the end of operation. They found that the heart rate, the blood pressure, blood concentration of catecholamin, and cortisol after extubation are all increased compared that at the end of operation in each group. The increment in the TENS group is significantly less than that in the control group. The Airway adverse reaction is also much less in the TENS group than that in the control group.

宫丽荣 (2013) randomly allocated 80 patients undergoing elder abdominal operation into two groups: general anesthesia plus acupuncture (acupuncture group, 40 cases) and general anesthesia only (control group, 40 cases). The electrical acupuncture started 20 min before induction and lasted until the end of the operation. They found that the usage of anesthesia drugs, the time to open eyes, the time to finish order, and the time to restore normal direction, the restless rate, are all lower in the acupuncture group than those in control group. For example, the time to wake up in the acupuncture group is 7.18±2.73 but that in the control group is 12.81±4.42 min. They concluded that combined acupuncture assisted general anesthesia could stabilize the hemodynamics, reduce the stress to the surgery in elderly patients undergoing abdominal surgery, thus being suitable and favorable for these patients.

林舜艳 (2013) randomly allocated 75 elderly patients undergoing colorectal cancer resection surgery into two groups: general anesthesia plus acupuncture (acupuncture group, 38 cases) and general anesthesia only (control group, 37 cases). The electrical acupuncture started 20 min before induction and lasted until the end of the operation. They found the time needed to wake-up was shorter in the acupuncture group than that in the control group (20.35±6.05 min vs 28.24±7.68 min). The rate of disorder of recognition is also low in the acupuncture group than that in the control group (23.7% vs 35.1%).

杨琼卉 (2012) randomly allocated 90 patients undergoing gynecologic laparoscopic surgery into three groups: general anesthesia plus HANS (acupuncture group I, on Zusanli and Sanyinjiao points, 30 cases) and general anesthesia plus HANS (acupuncture group II, on Hegu and Taizhong points, 30 cases) and general anesthesia only (control group, 30 cases). The TENS acupuncture started 30 min before induction and lasted until the end of the operation. They found that the Sevoflurane concentration during operation is much less in the two acupuncture group (acupuncture group I is much less than that in acupuncture group II). The blood pressure and heart rate were more stable in the acupuncture group. The time before opening eyes and removing the tube were shorter; the anxiety scale, pain level, nausea scale, and incidence to hold lower jaw, are all lower, in the two acupuncture groups than those in the control group. The time before passing gas was also less in the two acupuncture groups than that in the control.

周红 (2002) randomly allocated 66 cases undergoing video assistant thoracoscopy into two groups: acupuncture plus pain-killer anesthesia group (acupuncture-drug group, 33 cases) and general anesthesia group (control group). The acupuncture started 30 min before induction and lasted until the end of the operation. they found that the consumption of the pain killer is much less in the acupuncture-drug group than that in the control group (0.039±7.419 ml/kg vs 0.068±0.023 ml/kg).  The blood pressure and heart rate were similar in both group. The good anesthesia rate of the acupuncture-drug group is 78.8%. 

顾陈怿 (2004) randomly allocated 22 patients undergoing tumorectomy into two groups: general anesthesia plus acupuncture (acupuncture group, 11 cases) and general anesthesia only (control group, 11 cases). The acupuncture started 20 min before induction and lasted until the end of the operation. They found that the inhibition effect of the surgical operation was less in the acupuncture group than that in the control group. The blood circulation is more stable during the operation in the acupuncture group than that in the control group.

顾陈怿 (2010) randomly allocated 90 patients undergoing cholecystectomy into three groups: general anesthesia plus traditional electrical acupuncture (acupuncture group, 30 cases), general anesthesia plus sham acupuncture (sham group, non-acupuncture points, also with electric stimulation, 30 cases),  and general anesthesia only (control group, 30 cases). The acupuncture started 15-30 min before induction and lasted until the end of the operation. The acupuncture needles in the sham group were inserted into non-acupuncture points and also connected with electrical stimulation. They found that the consumption of anesthesia drug in the acupuncture group is much less than that in the sham group and the control group. For example, the consumption of Propofolum in the acupuncture group, the sham and the control groups are 451.33±136.30 mg, 524.57±180.66 mg, and 600.47±153.84 mg, respectively. The time before opening eyes, before extubation, and before recovery of direction ability, all were shorter in the acupuncture group, than those in the sham group and in the control group. The use of pain killer after the operation is also much less in the former than that in the later two groups. The postoperative pain level was less in the former than that in the later two groups. Acupuncture at acupoints can enhance the anesthetic effect of compound general anesthesia and prolong the analgesia period. Acupuncture at non-points has certain effect , but their effectiveness is less than that of acupoints. Thus, the acupoint has the specificity and accurate acupoint selection is the key factor affecting analgesia effect.

丁依红 (2013)  randomly allocated 90 patients undergoing cholecystectomy into three groups: general anesthesia plus traditional electrical acupuncture (acupuncture group, 30 cases), general anesthesia plus sham acupuncture (sham group,  non-acupuncture points, also with electric stimulation, 30 cases),  and general anesthesia only (control group, 30 cases). The acupuncture started 15-30 min before induction and lasted until the end of the operation. They found that the acupuncture group can stabilize blood circulation, reduce CO2 pneumoperitoneum, reduce postoperative stress reaction, enhance postoperative pain-reducing effect, compared with the sham and control groups. The time before  opening the eyes, time before extubation, and time before recovery of direction ability, all are significantly shorter than sham group and the control group. The acupuncture groups worked better than the sham group. 

Wang You-jing (2012)  randomly allocated 80 patients undergoing pneumonectomy into four groups: sham group (sham acupuncture plus general anesthesia, 20 cases), acupuncture (2 Hz) plus anesthesia (2 Hz Acupuncture group, 20 cases), acupuncture (100 Hz) plus anesthesia (100 Hz acupuncture group, 20 cases), and 2/100 Hz acupuncture plus anesthesia (2/100 Hz acupuncture group, 20 cases). The acupuncture started 30 min before induction and lasted until the end of the operation. In the sham group, electrical patch was attached to the acupuncture point spots, but no electric connected. They found that the consumption of fentanyl during surgery is less in 2 Hz acupuncture group and 100 Hz acupuncture group than in the sham and the 2/100 Hz acupuncture group. In all groups, the average arterial pressure increased after intubation, compared to that before induction, but the increase range in all acupuncture groups were less than that in the sham group. For similar comparison, the heart rate increased significantly in the sham group, but not so in all the acupuncture groups. After the surgery, the index for auto-immune function reduced, but not so in all the acupuncture groups. They concluded that, with the use of acupuncture during surgery, with less amount use of anesthesia drugs, the body circulation and immune function can be more stable, so as to reduce body stress reaction and to protect body important organ function. The electrical frequency of 2 Hz and 2/100 Hz were better than the 100 Hz.

唐育民 (2001) randomly allocated 45 patients undergoing radical operation of carcinoma of esophagus into three groups:  electrical acupuncture group plus general anesthesia (acupuncture group, 15 cases), electrical patch plus anesthesia (patch on acupuncture points, connected with electrical stimulation) (patch group, 15 cases), and general anesthesia only (control group, 15 cases).The acupuncture and the patch stimulation started 10-30 min before induction and lasted until the end of the operation. They observed anesthesia effect in the tree groups. The results were: the number of patient reached anesthesia level I in acupuncture group, patch group and control group were 11 (73.3%), 10 (66.7%), and 4 (26.7%), respectively. The efficiency of the electrical acupuncture plus general anesthesia, electrical patch stimulation plus general anesthesia worked better than general anesthesia alone. The authors commented that acupuncture point stimulation can adjust body function status, to increase pain threshold. Using acupuncture alone, there is possibility that the suppression of pain is not complete, muscle is not completely relax, and the contract reaction is strong, so that its application in the surgical area is limited somehow. On the other side, anesthesia drug tends to inhibit functions of cardiovascular system and respiratory system. Its inhibition effect is related to the dose used. Inhibition is risk to patients with cardiovascular diseases, if it is over used. When the acupuncture point stimulation technique (needle or electrical patch stimulation) is used together with general anesthesia, the patients' heart rate and blood pressure are stable. The patients loss consciousness without painful face and do not realize the surgical course. The usage of the anesthesia drug is reduced. The safety of the combined anesthesia is increased; the anesthesia effect is remained or improved; the cost of the anesthesia is also reduced.

付建峰 (2002) randomly allocated 40 patients, after general anesthesia, into two groups: TENS group (20 cases) and control group (no TENS stimulation, 20 cases). The electrical stimulation on acupuncture points started 10 min before skin incision, and lasted for 30 min. They found that, the heart rate and average arterial pressure were increased in both groups 10 min after skin incision, but the increment range in the TENS group in much less than that in the control group. For example, for average arterial pressure 10 min after skin incision, it was increased by 25% and 35% in the TENS group and in control group, respectively. Mean while, the heart rate increased by 15.9% and 27.6%, in the two groups, respectively. This result suggested that stimulation of acupuncture points by electrical stimulation could stabilize and buffer the body stress reaction due to skin incision. Because the fact that the electrical stimulation started after anesthesia when the patients lost consciousness, the stabilization effect of acupuncture point stimulation cannot be understand as any placebo effect.

郭继龙 (2002) reported electrical stimulation of acupuncture points one hour after general anesthesia on five patients undergoing excision of intracranial tumor. The electrical acupuncture could increase systolic blood pressure by 22.40±3.19 mmHg, diastolic blood pressure by 12.00±1.41 mmHg, mean arterial pressure by 15.99±1.65 mmHg, and heart rate by 24.00±6.66 bpm. They commented that after anesthesia, stimulation of acupuncture can still improve cardiovascular function.

尹利华 (2005)   randomly allocated 69 patients undergoing rectal cancer surgery into three groups: acupuncture before anesthesia (pre-acupuncture group, 23 cases), acupuncture after anesthesia (post-acupuncture group, 23 cases) and anesthesia alone (control group). They found that the efficiency of anesthesia is better in pre-acupuncture group than that in post-acupuncture group, and much better than that in control group. Although it cannot be excluded that this is due to the longer stimulation of acupuncture points in the pre-acupuncture group than in the post-acupuncture group, it indicated that stimulation of acupuncture points after induction of anesthesia could also enhance anesthesia level, and to reduce the consumption of anesthesia drugs. 

王庚显 (1959) have reported long time ago the acupuncture treatment of surgical accidents, such as stop of breath (2 cases), diaphragmatic spasm (11 cases), tachyrhythmia (2 cases), hypotension (2 cases) and shock (3 cases). Though the earlier reports did not design control group, sham group, blind group, they suggested that, under the anesthesia condition, acupuncture can still exercise healing effects. Such implication has been well documented in later researchers.

Based on the reports above, it can be said that the combination of general anesthesia with acupuncture (ordinary acupuncture, electrical acupuncture or TENS), could stabilize blood circulation, immune system, reduce the consumption of anesthesia drugs, while enhance anesthesia effect. It might be due to the reduction of the consumption of  anesthesia drugs, which makes possible shorter the time before opening eyes, time stay in the observation rooms, the time before extubation, the time to recover direction ability, the lower level of postoperative pain, and the lower incidence of postoperative nausea and vomit.

欧阳铭文 (2009) 301 study showed that the reduction of postoperative nausea/vomit rate is much more in the acupuncture group than that in the sham group, suggesting that acupuncture has its own specific healing effect.

Data from吴群 (2013), 安立新(2011), 安立新(2013), 顾陈怿(2004), 顾陈怿 (2010), 丁依红(2013), Wang You-jing (2012) all showed that the benefit of acupuncture group is much higher in the acupuncture group than in the sham group (no matter the sham is inserted or non-inserted needles), also suggesting that acupuncture indeed has unique healing effect in such non-conscious patients.

Then, the question is, is the reduction in the consumption of anesthesia drugs (and other benefit of acupuncture) due to the acupuncture stimulation in the period before anesthesia, or to that during anesthesia, or both? Data from付建峰 (2002) , 郭继龙(2002) 和尹利华（2005） indicated that even if the patients were under anesthesia condition (without consciousness), acupuncture can still work to stabilize blood circulation and to buffer stress reaction of the body to surgical operation. The acupuncture in the period before anesthesia surely would also work for this effect, ^[918-924] and the only thing we do not know is how long such effect could prolong into the period during anesthesia (during operation) and after operation. A review article also supports the positive function of acupuncture during the anesthesia.

9.5. Acupuncture started after general anesthesia

Alizadeh R (2014) randomly allocated 227 patients undergoin g general anesthesia into two groups: acupuncture on Neiguan points (112 patients) and acupuncture on Neiguan and Hegu points (115 patients). The acupuncture started after the induction of general anesthesia and lasted until the end of the operation. They found that both groups can reduce the incidences of postoperative nausea/vomit.

Arnberger M (2007) randomly allocated 220 patients undergoing general anesthesia into two groups: electrical acupuncture group (110 cases) and sham group (electrical stimulation on non-point spots, 10 cases). Both stimulation started after general anesthesia and continued until the end of the operation. They found that the incidence of postoperative nausea in the acupuncture group and the sham group were 33% and 51%, respectively, and that of vomit is 16% and 25%, respectively.

Certainly, there was a report by Liodden I (2015) that acupuncture started after the induction of anesthesia showed no more effect than a sham group. However, as pointed out by Alraek T (2015) that the acupuncture stimulation dose in this study was not at all sufficient to create a healing effect in the acupuncture group. When applied after anesthesia, the acupuncture stimulation should be kept during the whole course of the operation.

All of these data clearly suggested that, when the acupuncture started after general anesthesia, in which the patient has no consciousness, the acupuncture still works to reduce the post-operative incidence of nausea/vomit, suggesting that acupuncture has its own specific healing effect, not a placebo effect. The reduced incidence of nausea/vomit is not due to the aware of patient before anesthesia for which group they were allocated in.

Streitberger K (2004)  used acupuncture before and after general anesthesia to patients undergoing abdomen and breast surgical operation. They stimulate Neiguan point for 20 min before or after induction of general anesthesia. They found that the post-operative incidence of nausea/vomit in acupuncture group are 38.9%，48.1%, while those in placebo group are 47.3% and 54.9%, suggesting that acupuncture did not induced significant healing effect. However, most of the acupuncture studies on this topic using acupuncture either started before general anesthesia or after induction of general anesthesia, and lasted until the end of the surgical operation and the incidence of post-operative nausea/vomit reported is between 17.7% to 21% (see the current article). Therefore, the Streitberger (2004) experiment does not mean that acupuncture does not work, but that the 20-min acupuncture is not sufficient to bring out a healing or preventive effect for post-operative nausea/vomit.

9.6. Delayed wake-up after general anesthesia

After stop giving the general anesthesia medicine for 90 min, that the patient still does not wake-up can be regarded as delayed wake-up. This is a common complication after general anesthesia and one of the reasons that risk patient's life.

翟文生 (2011)   randomly allocated 30 patients in the delayed wake-up status into two groups: conventional medicine plus acupuncture treatment (acupuncture group, 15 cases) and conventional medicine only (control group, 15 cases). The acupuncture is a kind of modified acupuncture technique. The needles were kept for 30 min, with manipulated by hands once every 10 min. The acupuncture was repeated once every 2 hours until the consciousness returned. In the acupuncture group, the mean wake-up time is 150 min (30-380 min), while that in the control group is average 300 min (90-1080 min). The difference is significant. 

张全霞 (2014)   randomly allocated 50 patients in the delayed wake-up status into two groups: conventional medicine plus acupuncture treatment (acupuncture group, 30 cases) and conventional medicine only (control group, 20 cases). The acupuncture is similar as above: the needles were kept for 30 min, with manipulated by hands once every 10 min. The acupuncture was repeated once every 2 hours until the consciousness returned. The average wake-up time in the acupuncture group is 90 min (30 min to 380 min) and in the control group, 300 min (90 min to 1080 min).

Delayed wake-up is commonly seen in elderly patients. The reasons are varied. The old patients are with declined body function, slower metabolic rate, and are sensitive to anesthesia, so that it is easy to have remaining of anesthesia drugs in the body to cause the delayed wake-up.

王春爱 (2014) randomly allocated 80 elderly patients (after general anesthesia and surgical operation) into two groups: conventional medicine plus acupuncture (acupuncture group, 40 cases, acupuncture started after operation) and conventional medicine only (control group, 40 cases). They found that the average time before wake-up was 15.3±1.9 min in acupuncture group, while it was 18.7±2.4 min in the control group. The difference was significant.

 9.7. Anesthesia in shock patients

Acupuncture used in anesthesia can not only have pain-reducing effect, but also clear anti-shock effect. When the blood pressure of the patients are very low or no blood pressure, it would be very dangerous to give anesthesia drugs, since the anesthesia medicine tend to inhibit never system, and the medicine has side effects too, both of which could make the shock condition worse, bring risk to the surgical operation and cause complication after the surgery.

吴蓉蓉 (1980)   treated 99 shock patients who need surgical operation. The systolic pressure was all below 90 mmHg. The reasons for the shock included hypovolemic shock, toxic shock, traumatic shock, and so on. They treated the patients with conventional medical ways, such as infusion, oxygen, infusion of blood, antibiotics, correction of electrolyte disturbances, and so on. Meantime, they used body acupuncture, ear acupuncture, nose acupuncture, or mouth lip acupuncture to the patients. After induction with acupuncture for 15-25 min, it was observed increase in the blood pressure. During the induction period, blood pressure increased between 10-20 mmHg, 21-30 mmHg, 31-40 mmHg and more than 41 mmHg were 41, 22, 7, and 14 cases. In 3 cases, the blood pressure went down, and in 12 cases, no change. Among the 99 cases, only 11 cases changed to epidural anesthesia due to incomplete anesthesia with acupuncture. 15 cases needed addition of 0.5% procaine (local anesthesia medicine). The authors pointed out that acupuncture can not only have pain inhibition effect, but also relatively apparent anti-shock effect. After acupuncture, 84.85% of patients have had blood pressure increased, while at the same time, similar patients with continuous epidural anesthesia, no any case had blood pressure increased and 81% of patients with blood pressure decreased, and 72% of the patients with blood pressure down to zero. During acupuncture, blood pressure, pulse and breath were relatively stable (less variable). The recovery after surgery was faster. No side effects happened. The inhibition to respiratory system and cardiovascular system by the anesthesia medicine was prevented.

Doctors in the department of anesthesia in the Furth Hospital of Harbin City (1973)  reported their treatment of 30 shock patients who needed anesthesia. The reasons for the shock were toxic shock and hypovolemic shock. Acupuncture was mostly body acupuncture. 12 cases were also with auricular acupuncture. Upon skin incision, 21 cases was given little amount of local anesthesia medicine. During surgical operation, there was no accident as respiratory inhibition as easily seen in medicine anesthesia. For anesthesia efficiency level, 2 cases reached excellent level, 10 cases reached good level, 13 reached acceptable level, and 5 cases failed and changed to medical anesthesia. The blood pressure-increasing effect by acupuncture is gradual with less variation. After increase, it was easy to keep consistent, unlike the blood pressure increased by pressor agents in which the blood pressure could largely fluctuate. Except for 1 case whose blood pressure did not increase, in all other 29 cases, the blood pressure increased and kept in some level as well. The acupuncture could work in coordination with pressor agents. Under acupuncture, the use of pressor agents was much less than when pressor agent alone was used; the pulse was stronger; the difference between systolic and diastolic pressure was larger, and breath was stronger. All of these are helpful to solve shock condition. In hypovolemic shock, the use of acupuncture reduced the volume of blood infusion needed. It reduced the blood infusion average about 400 ml. Shock patients have failure of functions of liver and kidney. Under such condition, the use of medical anesthesia tends to make the condition worse, especially after the operation to cause severe consequence. Upon the acupuncture use, no any case was with worse liver-kidney function due to anesthesia, since the internal environment was disturbed less with acupuncture anesthesia.

Doctors in the department of anesthesia in An-yi Affiliated Hospital (1973) reported the treatment of 50 cases of shock or severe patients undergoing surgery. The shock included hypovolemic shock, toxic shock, and traumatic shock. To the 50 cases, used were auricular acupuncture (27 cases), auricular acupuncture plus body acupuncture (7 cases), nose acupuncture (6 cases), nose acupuncture plus auricular acupuncture (4 cases), auricular acupuncture plus ear-root point injection (1 case), auricular acupuncture plus body acupuncture plus ear-root point injection (1 case), and nose acupuncture plus intradermal acupuncture (4 case). After acupuncture for about 10 to 15 min, the blood pressure could start to increase. Together with intravenous infusion of liquid and blood, correction of acid toxic, and pressor agent, the blood pressure returned to normal gradually. In all the 50 cases, blood pressure increased 10-20 mmHg, 21-30 mmHg, 31-40 mmHg, and more than 41 mmHg were 21, 16, 7, and 5 cases, respectively. Only one case was with no change in blood pressure. The whole course of the operation was stable. For the acupuncture anesthesia level, 43 cases are satisfied and 7 cases were with incomplete anesthesia and had changed the way of anesthesia. Among the 43 success cases, 8 cases used local anesthesia in the skin incision spot with 0.5% procaine.  

It was commented that the adrenal gland point on ear has stronger blood pressure-increasing effect. Nose acupuncture works better for surgical operation in lower abdomen for loss muscle. Nose acupuncture plus intradermal acupuncture works satisfied for reducing pain during skin incision. Using acupuncture in hypovolemic shock, the volume of blood to infusion can be reduced but the blood pressure goes up gradually. It was commonly found that, with medical anesthesia, the increased blood pressure can reduce again, so that the use of pressor agents is very common. But it would be dangerous to use large amount of pressor agents. With acupuncture for anesthesia, it is rare that the blood pressure would go down again. The author^[1] reported that they treated 50 cases of shock or severe patients, except for only one case, other patients had blood pressure increased after acupuncture induction. Only 12 out of the 50 cases used little amount of pressor agents, which was much less than with ordinary medical anesthesia. Therefore, acupuncture used in shock patients also prevented the side effect of pressure agents (especially as noradrenalin), such as skin necrosis and reduced volume of urine. With intratracheal anesthesia, the chance of complications increased, but with acupuncture anesthesia, it was never seen such complication as respiratory inhibition as seen with former.  

Doctors in the department of anesthesia in Affiliated Hospital of Shandong Medical College (1973) reported their treatment of 45 shock patients undergoing anesthesia. Among the 45 cases, light shock, middle shock and severe shock were 8, 26, and 12 cases, respectively. Most of patients did not get any medicine before acupuncture. Several patients got pain killer Sauteralgyl, or sedative Phenergan, or atropine or Dong Lang scopolamine. Among the 45 cases, 33 cases combined with local anesthesia (73.3%); 27 cases with Sauteralgyl (60%). 12 cases did not use any of these medicine (26.7%). The anesthesia efficiency: very good is 71.1%, not good is 28.9%. Blood pressure increased in 82.2% of patients; not changed in 6.7%; reduced in 11.1% of patients, at the end of the surgical operation. 

Doctors in the anesthesia group of the Fifth People's Hospital of Guangzhou City (1975) reported their treatment of 55 shock patients who needed surgical operation. The operation included cesarean, subtotal gastrectomy, ectopic pregnancy, ovariocystectomy, cholecystectomy, intestinal resection and anastomosis, splenectomy, debridement and suture fixation. Before operation, used was only sedative luminal. Before and during the operation, used only the acupuncture for anesthesia (did not use anesthesia). The anesthesia efficiency: very good level is 67.3% of patients; more than 100 mg of Sauteralgyl was needed in another 25.4% of patients. Acupuncture anesthesia failed in 7.3% of patients. Postoperative blood pressure increased more than 100 mmHg in 87.2% of patients; increased 80-90 mmHg in 10.9% of patients and failed to increase in 1.8% of patients. Only in 2 cases needed pressor agents.

杨生泰 (1987) reported their treatment of 60 shock patients undergoing anesthesia and surgical operation. Among the 60 cases, 28 were hypovolemic shock and 32 infectious shock.14 cases used 50 mg Sauteralgyl, 0.5 mg atropine. 16 cased used 50 mg Sauteralgyl only. 7 cased used 0.5 mg atropine only. They did not use any other pain killer or sedative. 56 cases used auricular acupuncture, and 4 cases used body acupuncture. The anesthesia efficiency: reached level I, II, III, and IV were 21, 22, 12, and 5 cases, respectively. The authors stated that for abdomen surgery, auricular acupuncture worked better.

Doctors in the acupuncture anesthesia group in the Shanggao County People's Hospital of Jiangxi Province (1977) reported their treatment of 37 shock patients who needed surgical operation. They used acupuncture to 37 patients (acupuncture group), and medical anesthesia (medical anesthesia group) to 15 cases (including general anesthesia, lumbar anesthesia, Epidural anesthesia, and local anesthesia). In the acupuncture group, most of the patients did not use sedative, little patients used pain killer 25-50 mg Sauteralgyl and used local anesthesia during operation. The shock was mostly hypovolemic shock and toxic shock. In the 37 patients, blood pressure increased after acupuncture was 70.3%; no change was 24.3%; reduced was 2.7%; and fluctuated was 2.7%. In the medical group, the blood pressure increased in 13.3%; not changed in 26.7%; reduced in 40% and fluctuated in 20% of patients. Anesthesia efficiency reached level I, II, and III in the acupuncture group was 29.7%, 56.8%, and 13.5%, respectively.

The Acupuncture-anesthesia cooperation group in Yuling, Guangxi Province (1977) reported acupuncture anesthesia to 88 shock patients who needed surgical operation. The shock was hypovolemic and toxic shock. The surgery was stomach, intestine, gall bladder, and uterine surgery. During acupuncture and operation, blood pressure increased less than 10 mmHg was 39 cases; increased 11 - 20 mmHg was 10 cases; increased 21-30 mmHg was 7 cases and no change was 32 cases. 

胡宗泽 (1978) reported acupuncture anesthesia to 60 shock patients who needed surgical operation. Among the patients, 26 were hypovolemic shock; 28 were toxic shock; and 6 were traumatic shock. 30 min before the operation, patients were given 0.5 mg atropine, 0.1 g luminal sodium intramuscular injection. The acupuncture anesthesia was: nose acupuncture plus auricular acupuncture 49 cases; nose acupuncture plus auricular acupuncture plus body acupuncture 8 cases. Before operation, Sauteralgyl was injected intramuscularly. It was not used if the condition was not severe. The anesthesia efficiency reached level I, II, III, and IV, was 10, 19, 29, and 2 cases, respectively. After acupuncture started, intravenous infusion of liquid and blood, and oxygen inhalation, and others were started too. After 15-20 min of acupuncture, blood pressure started to increase. At the end of operation, 91.6% of patients had blood pressure increased gradually with larger difference between the systolic and diastolic pressure. The heart beat sound stronger gradually and the microcirculation started to be improved gradually too. In the 32 patients with hypovolemic and traumatic shock, the systolic pressure increased average 24 mmHg, in which 12 patients increased 30 mmHg. In the 26 hypovolemic shock, the hemochrome was average 7.6 g, average loss of blood 1500-1800 ml, while the blood infusion needed was only 230 ml, which was less than 1/6 of the lost blood volume.

Doctors in the People's Hospital of Guangxi Province (1975)  reported acupuncture use to 61 shock patients who needed surgical operation. The reasons of the shock were hypovolemic (14 cases), toxic (19 cases), traumatic (2 cases), and severe diseases (26 cases). The acupuncture included: body acupuncture 27 cases; body acupuncture plus auricular acupuncture 15 cases; body acupuncture plus mouth lip acupuncture 4 cases, body acupuncture plus nose acupuncture 5 cases, auricular acupuncture 2 cases, mouth lip acupuncture 5 cases, and no record 3 cases. The anesthesia efficiency was excellent 55.7%, accepted 37.7%, and failed 6.5%.

For the use of acupuncture to shock patients, as summarized by doctors in the department of anesthesia in the Affiliated Hospital of Shandong Medical College (1973): (1), acupuncture could clearly increase blood pressure. The most safe anesthesia in shock patients is local anesthesia but it was found that when the operation area is too large, the local anesthesia is hard to produce complete anesthesia and satisfied relax of muscle. During the operation, blood pressure could reduce due to the operation stimulation, the pain reaction, and the pulse could become faster, so as to make the shock worse, even cause accident death. In the intravertebral anesthesia, it is inhibited the use of intraspinal anesthesia in the shock patients. The epidural anesthesia is neither good choice for shock patients. Because the shock patients had poor tolerance to the medicine used in epidural anesthesia, personal variation is very large, it is very easy to cause relative over-dose of anesthesia due to improper anesthesia, so as to cause blood pressure reduced to accident die. Ether inhalation is hard to keep stable and even shallow anesthesia and the breath tract is hard to keep smoothly open. It is also not good choice for a shock patient and it should be prevented to use in shock patient. The most ideal anesthesia might be the combination of ether and muscle relaxer. It can not only induce satisfied muscle relax and keep opening breath tract, but also reduce the use of ether and keep longer time and evenly shallow anesthesia; block the operation stimulation to the brain, to provide satisfied muscle relax and keep open the breach tract. However, this way of anesthesia need expert skill of the anesthesia operator and the equipment is complex. The advantage of acupuncture used in the shock patients is (1), it does not use medicine, so no possibility to inhibit respiratory or blood circulation system, so not interfere the body function. (2), acupuncture per se has no side effect, but has benefit to the body function (as to stabilize body internal environment). (3), for acute patients, especially for acute traumatic upper digestive tract bleeding, acute intestine obstruction, there is no way to inhibit food intake to empty stomach. Because during the acupuncture, the patients are awake, so prevented the chance of vomit or mis-inhalation accident. (4), acupuncture to shock patients, the anesthesia efficiency is satisfied, and it is simple to operate. The most realization with the acupuncture anesthesia is safe and ensured no worry about possible overdose of medicine or block of breath tract, etc. Therefore, it is easy to be handled by ordinary anesthesia operators, and it is a better choice for shock patient undergoing surgical operation.

From above reports, it can be seen that, acupuncture alone can be used in shock patients, to reduce the amount of usage of pain killer and sedative medicine, the volume of blood infusion, to reach satisfied anesthesia level and to improve shock condition the same time.

Because the shock patients are in severe diseased condition, their consciousness are cloudy, or even lost, they are hard to react to outside language or action hint to cause a placebo effect.

Someone may have questioned that for the acupuncture anesthesia, there is still the use of pain killer and sedative medicine. The above data showed that for most patients and in most reports, the pain killer and sedative are not used. Even they are used, the amount are in a level, in which it cannot normally produce satisfied anesthesia effect by them.

 9.8. Dementia treatment by acupuncture

Dementia can be separated at least into senile dementia and vascular dementia. Vascular dementia is one of the common kinds of dementia in China, which is caused by disorder in brain blood circulation. The word dementia describes a set of symptoms that can include memory loss and difficulties with thinking, problem-solving or language. In vascular dementia, these symptoms occur when the brain is damaged because of problems with the supply of blood to the brain. It has become a serious problem to human mental health, and has caused a severe burden to the family life and society too. It is a hard task for medical society to solve. It was reported that among patients over 65 years of age, about one third (25% - 41%) would develop into vascular dementia within three months after acute cerebral accident. Epidemiologic study in US showed that among survivors over 60 years of age from acute cerebral accident, about 26.3% developed vascular dementia. 951

Currently, there is no effective therapy for the treatment of any kind of dementia. Because dementia patients have slow mental reaction, analysis, and poor memory, it would be hard to believe that those patients can react to a hint, as normal people, to develop a placebo effect during treatment. So, let us have a look at how acupuncture can work for dementia.

Data in Attached list 23a, 23b, 23c are collected from China. As usual, the effective rate from China was either reported as grade improvement (cure, much improved, improved, or no effect), or as MMSE scale (or HDS scale) change. For the grade reports, we combined the "cure rate" and "much improved rate" together and got Fig. 24a. For the later, we got Fig. 24b. 

Fig. 24a. n = experiment groups.

Fig. 24b. n = experiment groups.

Data showed as MMSE change (Fig. 24b) also showed similar results [22]. The effective rate of acupuncture group (20.6%±11%) is higher than conventional medicine alone (14.3%±8%). With the combination of conventional medicine with acupuncture, the MMSE scale increased by 23.8%±8%. With the combination of acupuncture with Chinese herbal therapy, MMSE can be increased by 27.1%±10%.

When the healing effect is expressed with the HDS scale, the results were similar (Fig. 24c).

Fig. 24c. n = experiment groups.

Apparently, acupuncture has its one specific healing effect. Combination of acupuncture with either conventional medicine or Chinese herbal therapy can further increase the healing effect.  

Fig. 24a showed that, treated with conventional medicine, the Cure-much-improved rate is 33.4%±19%. With the treatment with acupuncture, it was 44.7%±20%. With Chinese herbal therapy, it was 40.0%±24%. With combination of conventional medicine and acupuncture, it was increased to 61.8%±19%. With combination of acupuncture and Chinese herbal therapy, it is similarly increased to 57.2%±20%.

9.9. Anesthesia by acupuncture alone or combined with local anesthesia

Acupuncture can not only work during general anesthesia to reduce the consumption of anesthesia drugs, enhance anesthesia effect, and reduce the post-operative side effect of surgical operation, but also work alone or together with nerve blocking anesthesia or local anesthesia to enhance the anesthesia effect and reduce side effect of the anesthesia drugs

It has been reported in earlier years that, when acupuncture alone was used in 138 patients undergoing nose surgical operation, the anesthesia efficiency reached level I was 39 cases (28.2%), level II 72 cases (52.1%). Most of the operation is correction of nasal septum (58 cases) and nasal polypectomy (42 cases). The patients were given 0.06 g of phenobarbital (sedative drugs) before going to bed the day before the operation, and again the same dose one hour before the surgical operation. Only in 28 cases (20.2%), it was used pain killer Sauteralgyl.

Another clinic report stated that to use acupuncture alone for local anesthesia to 254 patients undergoing nose surgical operation (did not use electrical stimulation), the anesthesia level reached level I, II were 203 cases (79.9%) and 30 cases (11.8%), respectively.  They did not report whether the patients were given any sedative drugs.  

周继福 (1989)  summarized their use of electrical acupuncture anesthesia to patients undergoing ear-nose-through surgical operation. Among their 2046 patients, the anesthesia efficiency level reached level I and II are 90.2%. They did not mention if their patients were given sedative or not before acupuncture. The author stated that the anesthesia efficiency and the acupuncture stimulating dose had close relationship. The anesthesia efficiency (especially muscle relax) and pain reduction effect under longer time acupuncture induction (30-60 min) is better than short time induction (less than 30 min). Acupuncture anesthesia not only stimulates clear pain reduction and muscle relaxation effect, but also works to modulate or adjust functions of various organs and has some other biophysiological effects. To perform endoscopic examination under mucosal surface anesthesia, the patients usually feel palpitation, short of breath, difficulty feeling in chest, etc. This phenomenon was never observed during acupuncture anesthesia.

孙鎏熙 (2001)  randomly allocated 96 patients undergoing nasal polypectomy into two anesthesia groups: electrical acupuncture anesthesia (acupuncture group, 50 cases) and local anesthesia alone (control group, 46 cases). The anesthesia efficiency: 100%. In the acupuncture group, the surgical operation was finished without use of any complementary medicine in 46 cases. Only 4 cases were given 10 mg diazepam  or 50 mg pethidine. The anesthesia efficiency reached level excellent, good, and no effect, was 92%, 8%, and 0%, while those number in the control group was 60%, 40%, and 0%.

张道武 (2002) randomly allocated 60 patients undergoing nasal polypectomy into two anesthesia groups: acupuncture anesthesia (acupuncture group, 30 cases) and local anesthesia (control group, 30 cases). In the acupuncture group, 36.7% of the operation reached local anesthesia level I with acupuncture alone. In 63.3% of cases, it was added with local anesthesia drugs, but the amount of the drugs were less than used with typical local anesthesia group. The incidence of postoperative pain was less in the acupuncture group than in the control group.

童秋瑜 (2012) randomly allocated 60 patients undergoing nasal endoscopy into two anesthesia groups: acupuncture plus amethocaine anesthesia (combined group, 30 cases) and amethocaine anesthesia (control group, 30 cases). In the combined group, the usage of amethocaine is 71.33±8.90 mg, while that in the control group, 118.33±26.21 mg. Pain level was lower than in the combined group than in the control group, and the satisfied rate was higher in the former than in the latter group.

It has been reported that 80% patients had stress; some had depression or fear, before surgical operation. Some patients undergoing local anesthesia showed anxiety or shock, or changes in heart rate and blood pressure, etc., due to too heavy emotional stress. There are rich nerves in the nose-throat area and it is very tender to pain in this area. The way of local anesthesia in this area is mostly surface anesthesia or local infiltration anesthesia.354

Some researchers had a survey to 100 patients undergoing nasal surgery under local anesthesia and found that 32 patients showed heavy sweat, anxiety, nausea, palpitation, short of breath, fast pulse, change in heart rate and blood pressure, etc., affecting the continuing of the operation. Apparently local anesthesia cannot reach satisfied anesthesia effect. The use of general anesthesia is used in the nasal endoscopic surgery can avoid the incomplete anesthesia (as by local anesthesia), so to ensure the continuing and finish of the surgery operation. However, it needs trachea cannula to help keep smooth breath. Because the trachea cannula is close to the operation area, it can cause difficulty for the manipulation of operation. Also due to trauma and stimulation to the throat, it is easy to cause bleeding and swelling. There is rich nerves and blood in the face, mouth, and jaw, it is easy to cause bleeding, so to cause block of breath tract after general anesthesia. After nasal endoscopic surgery, it is needed to fill the nose cavity; the patient has to breathe by mouth. If the throat has swelling or other trauma, the postoperative reaction would be very strong. Therefore, the general anesthesia is neither a perfect way of anesthesia in nasal surgery, though it can create complete no pain status. The data above suggests that, acupuncture anesthesia can dramatically reduce the dosage of anesthesia medicine during the surgical operation. The combination of acupuncture with local anesthesia medicine used less amount of the local anesthesia medicine, so reduced the chance of swelling of local tissue, while the pain reduction level is still satisfied. Apparently, the combination of acupuncture and local anesthesia medicine could reduce the side effect and weakness of the local anesthesia and improve the quality of surgical operation.  

雷健 (2000)   and his colleagues randomly allocated 532 patients undergoing thyroid operation into two anesthesia groups: acupuncture anesthesia group (acupuncture group, 324 cases, with sedative before acupuncture) and Superficial cervical plexus block anesthesia (control group, 208 cases). It is reported that the usage of meperidine in the control group is more than that in the acupuncture group. There was no difference for the average arterial pressure and heart rate in each stage of the operation between the two groups. There were no complications in the acupuncture group, while there were 12 cases of recurrent laryngeal nerve paralyses and 6 cases of diaphragmatic paralysis in the control group.

马越英 (2005)   randomly allocated 100 patients undergoing thyroid operation into three anesthesia groups: electrical acupuncture anesthesia (acupuncture group, 20 cases), cervical plexus block anesthesia (plexus group, 40 cases) and the combined acupuncture and cervical plexus block anesthesia (combined group, 40 cases). They found that the heart rate and blood pressure in the acupuncture group and the combined group was more stable than that in the plexus group. There are no recurrent laryngeal nerve paralyses or diaphragmatic paralysis in the acupuncture group. There are 3 patients with recurrent laryngeal nerve paralyses and 1 diaphragmatic paralysis in the plexus group. There is 1 patient with recurrent laryngeal nerve paralyses and no diaphragmatic paralysis in the combined group. 

There are also large amount of other studies ^,reported that with acupuncture anesthesia in the thyroid surgical operation, the vital sign is stable and there is no side effect as those caused by medical anesthesia drugs. The complication is little, so favoring the recovery of patients after the operation. However, upon handling the upper part of the thyroid or separating the tissues around the trachea, most of patients showed more or less tractive reaction, suggesting that the acupuncture anesthesia is not a complete anesthesia yet. cervical plexum anesthesia does not affect the breath of patients; the anesthesia efficiency is ensured; and is simple to manipulate. So it is wildly used in the surgical operation of neck area. However, after cervical plexum block, the heart rate and blood pressure increase, so that the heart consumption of oxygen also increases, which is not good for patients with hyperthyroidism, hypertension and coronary heart disease. The combination of acupuncture with cervical plexum block anesthesia, the pain reduction was enhanced and the usage of the drugs was reduced about 40%-50% , so also prevented increase in the heart rate and blood pressure caused by cervical plexum block anesthesia alone.

高成杰 (2004) randomly allocated 60 patients undergoing appendectomy into two anesthesia groups: acupuncture plus epidural anesthesia (combined group, 20 cases), and sauteralgyl alone (sauteralgyl group, 20 cases) and epidural anesthesia alone (epidural group, 20 cases). Their results were that the pain reduction effect of the combined group was much better than the other two groups. The pain reduction excellent rate was 100%, 85%, and 70% in the combined group, the sauteralgyl group, and the epidural group, respectively. In the combined group, the heart rate, blood pressure, mean arterial pressure, all were stable, but those parameters in the other two groups, increased. .

吴焕淦 (2007) summarized the experience of doctors in their hospital (1960-1987) about the use of acupuncture anesthesia in lobectomia pulmonalis. The skin incision was 24-27 cm long. The process of the surgical operation included skin incision, muscle incision, strip of bone membrane, cutting of rib, open of chest, separation of adherence, clearing of sick tissues, clearing of blood vessels, separation of space of lobs, prevention of mediastinal flutter, prevention of cough, close of chest, sew of muscle, sew of skin, insert of drainage-tube and so on for 15 steps. Acupuncture was used mostly to reduce pain when the operation touched the skin, muscle, and bone, and to control the fluttering of mediastinal. In this early stage, they used mostly manual acupuncture for anesthesia. The patients were completely clear in mind. No tubulation used, no medicine used and very rarely used local anesthesia drugs. They finished totally 1385 cases. The excellent anesthesia rate was 65.12%. In later stage, they studied the use of acupuncture plus general anesthesia in 1089 patients for lobectomia pulmonalis. They found that by this combination, the dosage of anesthesia drug was reduced by 42%-45%, compared with the medical anesthesia alone. With intramuscular injection of weak opioid analgesic drugs Tramadol 100 mg and acupuncture-effective enhancing cerucal 20 mg, the dose of the medical anesthesia can be further reduced by 45%, while the pain reduction effect was further improved. The combined anesthesia can not only reduce cardiovascular reaction during trachea cannula and tracheal extubation during induction of general anesthesia, but also reduce the total amount of the use of the anesthesia drugs, so as to make the blood circulation more stable and the wake-up earlier after the operation. From year 2001 till now, they turned to study the influence of acupuncture on the immune system in lung cancer patients undergoing surgical operation. They have finished the combined acupuncture and general anesthesia 898 cases. The dosage of the general anesthesia in the combined group is the same as that used in the general anesthesia group alone. They found that acupuncture can not only work to reduce pain, but also has immune adjusting effect, so as to improve the healing to the lung cancer, to be benefit to the recovery of such patients after surgical operation. They found that the acupuncture anesthesia can increase the number of the subgroup of T8 lymph cells at the 8th day after operation, increase the number of the subgroup of T3 lymph cells on the forth chemotherapy, increase the activity of NK cells, and increase the serum γ-interferon, so to increase the immune function of the cancer patients.

吴玉芳 (2002) randomly allocated 40 patients undergoing colonoscopy into two anesthesia groups: acupuncture anesthesia (acupuncture group, 20 cases), and general anesthesia (control group, 20 cases). They found that acupuncture induced better pain deduction.

When acupuncture was used alone or combined with various local anesthesia methods, the patients are clear in mind. So, those of people who insist that acupuncture is only a placebo effect would again say that the effect of acupuncture in the local anesthesia is also a placebo effect. We do not deny that there could be some placebo effect that could contribute to the good anesthesia effect in the acupuncture group, but it appears hard to set up a sham acupuncture group to test this hypothesis. Can we hint the patient that he will have acupuncture which could reduce his pain to zero during the operation, and we do a sham acupuncture (pseudo-acupuncture, such as just put a patch on the skin but no any electrical stimulation connected to the patch), pretend that we are perform an acupuncture to him, and then to cut a 24-27 cm open on the skin of the patient? Who had ever and who dare to study sham acupuncture as such? Remember that even in a sham surgical operation, the researchers used local anesthesia before they cut the skin and then sewed the cut, to pretend that a surgical operation was done! That is a sham surgical operation, in which the operation per se was not performed. But here, it means a sham anesthesia, the anesthesia was not given, but the patient would get the skin cut.

Surely in some studies, there was a use of sedative before the acupuncture. Colquhoun D mentioned this, and hinted that acupuncture per se does not work but the sedative. This is a misleading to the public. Sedative can work to calm down anxiety but not to reduce the pain level. Also, the sedative can also produce some placebo effect. Can anyone only use sedative (even little amount of pain killer, such as Sauteralgyl 50-100 mg) to start a surgical operation? Why you dare not to use the placebo effect from the sedative and pain killer as such, but dare to use the placebo of acupuncture to finish the surgical operation?

Because it is hard to design a sham group in the acupuncture-induced local anesthesia study, we indicated that the data here is indirect evidence that acupuncture is not a placebo effect. We can only prove our opinion by the effect of acupuncture used before, during, or after a surgical operation (above), in which the patients were without consciousness but acupuncture still worked. If we accept the conclusion from these previous studies with general anesthesia, we should now comment that, even if there could be some level of placebo effect in the acupuncture-induced local anesthesia, acupuncture still exercises its unique anesthesia effect.  

Brief summary:

(1). Placebo effect needs that the person is in a clear mind condition. Data here showed that acupuncture works in a condition when a person is without or with very week level of consciousness, such as coma, shock, persistent vegetative state, general anesthesia (before, during, of after operation). This is direct evidence that acupuncture has its own specific healing effect.

(2). Data in the acupuncture treatment of dementia and in local anesthesia are listed as indirect evidence, since in the dementia, low level of patient could still have clear mind though they could have less ability to remember; in the local anesthesia, there is no sham data allowing a direct comparison between the acupuncture group and the sham group.   

Chapter 10. Different healing effect with different acupuncture technique

If acupuncture is only a placebo effect, then under the same experiment conditions, acupuncture on different acupuncture points, or manipulate the needle by different ways, or use different frequency of electrical stimulation... should yield a statistically similar or the same results. Indeed, there are some studies by acupuncturists in the Western countries on this topic, which showing so. However, when we review these studies, we again found that they performed acupuncture in a quite low treatment frequency, while similar studies by acupuncturists in China were performed in higher treatment frequency, and found quite different results, suggesting that acupuncture points have relative specificity, and that acupuncture is not a placebo effect.

10.1. Different acupuncture points

于慧娟 (2014) randomly and single-blindly allocated 50 patients with cardiac premature beat into two acupuncture groups: electrical acupuncture on Neiguan points (Neiguan group, 30 cases) and on Xuanzhong points (Xuanzhong group, 20 cases). They found that the total effective rate in the Neiguan group is 50%, while that in the Xuanzhong group, 5%. They did the acupuncture once a day for 10 days.

许凯声 (2014)  randomly allocated 82 coma patients due to severe traumatic craniocerebral injury into two groups: acupuncture on Suliao-focused point (Suliao group, 42 cases) and on Shuigou-focued point (Shuigou group, 40 cases). Under the same way of acupuncture, the cure-improve rate in the Suliao group is 45.2%, while that in the Shigou point is 22.5%. The acupuncture was performed once a day, five-day a week, two-week as a course.

Yiu  E (2004) randomly allocated 24 dysphonias patients into two electrical acupuncture treatment groups: acupuncture on Renyin, Lieque and Zhaohai points (12 cases) and on Kunlong and Houxi points (control, 12 cases). The acupuncture was 10 sessions within 20 days. After treatment, the voice frequency range in the former increased by 28.8%, while almost no change in the control group.

Yu YP (2010)   randomly allocated 66 cases of primary dysmenorrhea women into two acupuncture treatment groups: acupuncture on Sanyinjiao (33 cases) and on Xuanzhong points (33 cases). The acupuncture was performed during the menstruation for 5 min. They found that, the deduction in the pain level and the increase in the arterial blood flow in the Sanyinjiao group was much dramatic than that in the Xuanzhong group.

10.2. Between acupuncture points and non-points

It was reported that acupuncture on different acupuncture points, or using different acupuncture technique, the healing effects are similar. Some other studies showed that acupuncture on traditional acupuncture points or on non-points, the healing effects were similar.

Berman BM (2004) allocated 336 patients suffering from osteoporosis of knee joint into two acupuncture groups: acupuncture on points that are normally used for the treatment of osteoporosis of knee joint (acupuncture group, 173 cases), and that on non-points (non-point group, 163 cases). The acupuncture was twice a week for 8 weeks, then once a week for two weeks, again once every two weeks for 4 weeks (total 23 sessions). WOMAC functional score was improved in the acupuncture group much more than that in the non-point group, but not WOMAC pain scale.

Melchart D (2005)  randomly allocated 195 tension headache patients into two acupuncture treatment groups: traditional acupuncture group (132 cases), and non-acupuncture point group (63 cases). The acupuncture was twice a week for 4 weeks, then once a week for 4 weeks. After 8 weeks, the headache score reduced in the acupuncture group by 47.2%, while that in the non-acupuncture points was also 44.3%. No significant difference between the two groups.

Assefi NP (2005) randomly allocated 99 patients with fibromyalgia into four acupuncture treatment groups: traditional acupuncture group (25 cases), on non-point acupuncture group (24 cases), acupuncture needle not inserted group (25 cases) and non-specific acupuncture group (e.g. the acupuncture points normally not used for the treatment of fibromyalgia, 25 cases). The acupuncture was twice a week for 12 weeks. They found that the pain deduction rate in the acupuncture group, the non-specific group, non-points group and non-inserted group, were 21.4%,20.3%,41.1% and 33.8%, respectively. No significant difference between each groups [23].

Witt C (2005) randomly allocated 224 patients who suffered from osteoarthritis of the knee into two acupuncture treatment groups: acupuncture group (150 cases) and non-acupuncture point group (74 cases). The acupuncture was twice a week for 4 weeks, then once a week for 4 weeks. After the treatment, the pain reduced by 62.4% and 51.5% in the acupuncture group and in the non-point group, respectively, without significant difference.

Macklin EA (2006) treated primary hypertension by acupuncture and said that the healing effect is similar in the acupuncture group and the non-point group. We noticed that the acupuncture was performed in this study was twice a week. While for the treatment of hypertension in China, it is mostly once a day, even twice a day for 28 days.

Cabrini L (2006) randomly allocated 32 patients undergoing branchofiberoscope into two acupuncture groups, both were performed 20 min before the surface anesthesia: acupuncture on traditional points (acupuncture group, 16 cases), and that on non-points (non-point group, 16 cases). In both groups, the needles were kept until the end of the exam. The results showed that, after acupuncture for 20 min, the anxiety level was reduced by 42.7% in the acupuncture group, but did not change in the non-point group.

The studies above are mostly done with acupuncture once a week or twice a week, rarely three times a week. The difference between the acupuncture group and the non-point group are in most time insignificant. When the acupuncture was performed with higher frequency of treatment, the difference between the two groups tended to be significant. Such data are mostly from China. 

万明雨 (2014) randomly allocated 28 patients with primary migraine (hyperactivity of liver-Yang type in TCM) into two acupuncture treatment groups: acupuncture group (14 cases), and other-points group (points that are normally not used for the treatment of migraine, 14 cases). The acupuncture was once a day for 10 days. The number of points in both groups was the same (4 points). After the treatment, the pain level was reduced in the acupuncture group and in the other-point group was 50.0% and 26.2%, respectively.

章海凤 (2013) randomly allocated 59 migraine patients into two acupuncture treatment groups with the same numbers of acupuncture points: acupuncture group (30 cases) and non-acupuncture point group (29 cases). The acupuncture was once a day for 5 days. Have a two-day break between healing courses. It was totally 4 courses. They found that the pain was reduced by 42% and 10.4%, in the acupuncture group and in the non-point group, respectively.

张智龙 (2007) [1080] randomly allocated 255 constipation patients into two electrical acupuncture treatment groups: acupuncture group (126 cases) and non-point group (129 cases). The acupuncture was once a day for 28 days. The result showed that the electrical acupuncture treatment can dramatically improve the symptom, speed up the content passing speed inside intestine, reduce the usage of Constipation Relief Suppositories Glycerol and evacuant. The total effectiveness rate in the acupuncture group was 94.4% and that in the non-point group, 61.3% .

樊莉 (2005) randomly allocated 53 depression patients into two acupuncture plus auricular acupressure treatment groups: acupuncture group (28 cases) and non-point group (25 cases). Acupuncture was twice per week for 3 months. After treatment, the cure rate and the much-improve rate in the acupuncture group was 28.6% and 28.6%, respectively, while those in the non-point groups, 8.0% and 20.0%, respectively.

Chou CY (2005) randomly allocated 40 patients with later stage of uraemia with itch into two acupuncture treatment groups: acupuncture group (20 cases) and non-point groups (20 cases). Acupuncture was three times a week for one month. They reported that the itch level was reduced by 54.7% and 2.6%, in the acupuncture group and in the non-point group, respectively.

The results of some studies that also compare the healing effect of acupuncture group and the non-point group was cited as not support the relative specificity between acupuncture points. But actually they are not a proper study to function as such. For example in the study by Vickers AJ (2005), they used non-inserted needle, not the inserted needles into the skin.

Also in the study by Scharf HP (2006),  the used acupuncture points or non-points is together with physiotherapy. It is hard to evaluate the actual amount of healing effect in a mixed treatment program. Again, both acupuncture and manual therapy of the physiotherapy are much depending on personal skill. The overall healing effect could be even more largely variable. Again, in the Western style of physiotherapy, the practitioners usually ask client to do physical exercise, while in Chinese acupuncture, we ask patients stop physical activity whenever the pain is very severe. Too much physical activity would make the pain worse, rather than better. The way of the treatment and the requirement to patients are quite different among these two therapies.

10.3. Between different acupuncture techniques

There are many studies in China compared the healing effect of acupuncture by its ordinary technique or by its various modified techniques.

梅麟凤 (2008) randomly allocated 56 patients who suffered from coma due to severe cerebral trauma into two acupuncture treatment groups: one is with comprehensive combined treatment (including scalp acupuncture, auricular acupuncture and body acupuncture, 36 cases) and another with body acupuncture alone (20 cases). The acupuncture was once a day. 10-day was one course, with 3-day break between courses. They found that the effective rate in the two groups was 69.4% and 40%, respectively.

崔新华 (2005) randomly allocated 100 persistent vegetable states patients into two acupuncture treatment groups: one was with ordinary acupuncture (50 cases), and another was with special acupuncture technique (50 cases). The acupuncture was twice a day for 24 sessions. They found that the wake-up rate in the two groups were 62% and 86%, of significantly different.

睢明河 (2012) randomly and blindly allocated 293 patients of high blood pressure into different treatment groups. This is one time acupuncture. They found that, though the control group (in this group the patients do not feel Deqi sensation) showed some deduction of blood pressure, the blood pressure deduction was much more in the Deqi acupuncture treatment groups.

In the above studies in the comparison between a special acupuncture technique and a conventional acupuncture technique, the common characteristic of them is that they are real and inserted treatment. This means that, the group that was used as a control (the ordinary acupuncture group), can also be regarded as a sham group (though it is not a perfect sham, because it has its own healing effect too). The similarity between the two groups is that both are performed with the same treatment frequency and same level of emotional influence to the patients. However, readers might still question that the number of acupuncture points used, the amount of stimulation to the points, all are different between the two groups, so that the placebo effect might be more in the group, in which more number of acupuncture points were used, and stronger simulation was given.

For this question, we can also show some other studies, in which the kind of acupuncture points, the number of the points, and treatment frequency between the groups, were exactly the same. The differences between the groups are the direction of needles after they are inserted into the point. It sill showed that the acupuncture of special technique worked better than a conventional acupuncture.

 孙懿君 (2015) randomly allocated 200 patients with cervicalspondylotic radiculopathy into two acupuncture treatment groups: one was with conventional treatment (100 cases) and another with a special acupuncture technique (100 cases). The acupuncture was once a day. 10-session was one course for total 2 courses. They found that the pain level reduced by 79% and 45.4%, respectively in the special group and in the conventional group.

尚艳杰 (2011) randomly allocated 64 patients with shoulder periarthritis into two acupuncture treatment groups: one was with a special acupuncture technique (32 cases), and another with conventional technique (32 cases). The acupuncture points used were the same, and the acupuncture was done once a day for 6 days, with one day break before next course, for total 2 courses. They found that the cure rates were 53.1% and 31.2%, in the special acupuncture group and the conventional group, respectively.

时晓燕 (2014) randomly allocated 150 stomach pain patients into three acupuncture groups: special acupuncture technique I  (special group I, 50 cases), special acupuncture technique II (special group II, 50 cases), and conventional acupuncture (conventional group, 50 cases). They used the same acupuncture points, but the different ways of manipulating the needles. The acupuncture was once a day for one week. They reported that the effective rate was 96%, 94%, and 60%, in the special I, special II, and the conventional group, respectively. 

李伟 (2015) randomly allocated 160 patients who suffered from prolapse of lumbar intervertebral disc into two acupuncture treatment groups: special acupuncture technique (Wen-tong technique, 80 cases) and conventional acupuncture (80 cases). The acupuncture points used were the same. The acupuncture was once a day, 15-day as a course. They reported the excellent healing rate was 97.8% and 78.8% in the special acupuncture group and the conventional group, respectively.

陈美仁 (2007) randomly allocated 165 sciatica patients into two acupuncture treatment groups: one was with a special acupuncture technique (special group, 82 cases), and another with conventional electrical acupuncture technique (83 cases). Both groups used the same acupuncture points. The acupuncture was performed once every other day. Ten-session was one healing course. They reported that the cure-much-improved rates in the special group and the conventional group were 88.7% and 57.5%, respectively.  

10.4. Different influence of acupuncture and pseudo-acupuncture

A lot of studies have indicated that there happened many neurohumor changes in the body after acupuncture, but no such changes with a sham acupuncture (or a pseudo-acupuncture). For example, acupuncture can induce secretion of some nerve-chemical substances, such as Beta-Internal polyphenol, enkephalins, and serotonin.

Animal studies showed that acupuncture can change the transportation of nerve transmitter, such as opioid and monoamines in the brainstem, cerebral ganglia, hypothalamus and hypophysis.

Therefore it is deduced that acupuncture can work through changing the autonomic nervous system. For example, electrical acupuncture can reduce the sympathetic nervous activity. Because those effects and changes could not be observed in sham group, the effects of acupuncture treatment were induced to be due to the stimulation of acupuncture points or meridians.

If acupuncture is merely a placebo effect, how could be the difference between different acupuncture point(s), between acupuncture point and non-point, between different acupuncture techniques, and between different manipulating technique on the needle in the same acupuncture point？Also how can acupuncture stimulate various hormone secretion but the sham acupuncture not? In fact, the above comparison studies are reproducible. It should be pointed out again that these results were obtained with frequent acupuncture treatment schedules, e.g. the acupuncture was performed mostly once a day, or at least once every other day. If it is performed as once or twice a week, they may be hard to be reproduced.

Brief summary:

Another way to test if an acupuncture treatment is a placebo effect is to compare the healing effect between different acupuncture points, between acupuncture points and non-points, between different acupuncture techniques, under the same experimental conditions. Again, such comparison must be compared with higher treatment frequency. In low treatment frequency, such comparison might or might be significantly different. In higher treatment frequency, it tended to be statistically significant. This is additional evidence that acupuncture is not a placebo effect.

Chapter 11. More examples that acupuncture is not a placebo effect

We have already discussed why  Colquhoun D could make a summary that acupuncture is only a placebo effect, because the acupuncture in the studies that he cited are not the kind of acupuncture in clinic in China. What he means the acupuncture is not what we mean the acupuncture.

We can cite more evidence that acupuncture is not a placebo effect, such as acupuncture used in children and in animal.

11.1. Acupuncture in children

Acupuncture can not only be used to treat diseases in adult, but also those in nursling and children. It can be used for the treatment of various diseases including various pain, migraine, infant catatonia, bedwetting, constipation, allergic rhinitis, saliva incontinence, spastic paralysis, laryngismus, postoperative vomit,  nausea/vomit after chemotherapy and so on.

Ecevit A (2011) reported that, by only acupuncture on Yintang point, it can reduce the pain level in premature with the pain in heels due to blood sample taking for analysis. The crying time can reduce from average 138.1 seconds down to 72.8 seconds. At the same time, the heart rate reduced from 152.2 times per min down to 138.3 times per min. The pain index reduced from 6.1 down to 4.2, suggesting that the tolerance of the premature to pain increased.

Liodden I (2011) did acupuncture to 77 children undergoing tonsillectomy and adenoidectomy. The acupuncture started after induction of general anesthesia on Neiguan points. The needles were taken out before wake-up of the children and a plastic needle was put on the same points for 24 hours (covered) . There was another group as a sham group. It was found that the incidence of postoperative nausea/vomit in the acupuncture group was 46.8% but that in the sham group, 66.2%. It is interesting that the incidence in the children aging 1-3 years of old (26.7%) is less (59.6%) than that in older children (4-11 years of old). Generally speaking, we should expect that the older children of 4-11 years of old should be more affected by the placebo effect of treatment, but the results here showed opposite. The possible explanation is that the acupuncture stimulation in the younger children group is relatively more than that in the older children. 

A survey in North America for 43 children hospitals showed that, about one third of the hospitals supply acupuncture treatment . Most of other studies said that the number of children who are suggested to use acupuncture treatment is also large. Generally speaking, the parents of the children also accepted this therapy and satisfied the healing effect. This is quite different from most of people thought, since generally speaking, children may fear the needles, and the parents may not want to increase pain and fear to the children

The age of the children who accepted acupuncture treatment can be as little as one month.  For so youth children, how can we expect that the baby can accept a placebo effect?   

Weimer K (2013) had a review, from which we know several other reviews about placebo effect in children and adolescence. We learned that the placebo responder rate is generally higher than that in adult, that the mechanisms behind the placebo effect in children might be different from that in adult, and that the clinic study design in children might need to be different from that in adult too. However, it seems that it is very rare that the studies included paid attention to compare children younger than one year old with those age more than , for example, 6 years or 12 years of old. We suspect that, the placebo responder rate and placebo effect in these groups might be different.

Someone may believe that the placebo effect can also happen in children younger than 2 years of old. However, this is not accepted by others, the later suggested that the placebo effect in such younger children might be due to the parent placebo effect, as proxy-placebo effect, which cause the bias report in the younger children.

11.2. Acupuncture on animal

If we are still not convinced by data of acupuncture on children, and still suspect that the acupuncture effect is a placebo effect, let us see the animal studies on acupuncture. Acupuncture not only works in human being, but also on animals. A lot of clinic studies supported this. 

Gakiya HH (2011) randomly allocated 30 dogs undergoing mastectomy into three groups. One is electrical acupuncture group, one is sham group, and another is no-acupuncture control groups. Each group is 10 dogs. After the treatment, the number of dogs that need pain killer in the electrical acupuncture group, the sham group, and the non-treatment group was 2, 6, and 6, respectively. They summarized that acupuncture could reduce the postoperative consumption of morphine and promote satisfactory analgesia in dogs undergoing mastectomy.

Cho SJ and Kim O (2008) did acupuncture for a dog suffered from cervical sympathetic paralysis syndrome, once a day for two days. After two days, all the symptoms disappeared. (This data suggested that acupuncture everyday worked better).

Ceccherelli F (1996) randomly allocated rats into three groups: acupuncture group (14 cases), morphine group (10 cases), and non-treatment control (20 cases). They found that acupuncture can significantly reduce the experimental swelling in the feet of the rats. Data from Zhang RX (2005) reported similar findings.

Carneiro ER (2010) randomly allocated rats into acupuncture group, non-point acupuncture group, activity-limited group, and no-treatment group. All rats were sensitized with heat-solidified hen egg white implant. Using clinical acupuncture points, EA treatment began 2 days after antigen priming and was repeated on alternate days for 2 weeks. They found that electrical acupuncture efficiently diminishes the bronchial immune-mediated inflammation induced in rats and that this effect is dependent on the choice of specific acupoints.

Luna SP (2015) had a study on dogs undergoing ovariohysterectomy. They found that acupuncture or pharmacopuncture were equally effective as morphine or carprofen to control postoperative pain in bitches undergoing ovariohysterectomy.

Cassu RN (2008)  compared the analgesic effect of uni- and bi-lateral electroacupuncture  in response to thermal and mechanical nociceptive stimuli and investigated the cardiorespiratory, endocrine, and behavioral changes in dogs submitted to electroacupuncture. They found that bilateral electroacupuncture produced a shorter latency period, a greater intensity, and longer duration of analgesia than unilateral stimulation, without stimulating a stress response. The effect of electrical acupuncture for pain reduction was confirmed by their later studies again. Although Gakiya HH did not find difference between the acupuncture group and the non-point group for the pain level reduction, but they did find that the pain killer used in the acupuncture was less than non-acupuncture group.  

Groppetti D (2011)   found that plasma β-endorphin levels in dogs receiving electroacupuncture increased significantly against baseline values after 1 and 3 h after surgery. Moreover, the end-tidal isoflurane concentration needed for second ovary traction was significantly lower in acupuncture-treated dogs than control animals. All animals having electroacupuncture experienced prolonged analgesia, over 24 h at least, while four out of six dogs treated with butorphanol needed post-surgical ketorolac and tramadol supplementation to their pain relief.  

Koh RB (2014) studied the effects of maropitant, acepromazine, and electroacupuncture on vomiting associated with administration of morphine in dogs. They found that maropitant treatment was associated with a lower incidence of vomiting and retching, compared with control treatments, and acepromazine and electroacupuncture appeared to prevent an increase in severity of nausea following morphine administration in dogs.

Jaeger GT (2006) reported their study: seventy-eight dogs with pain due to hip dysplasia were studied in a controlled, double-blind clinical trial to evaluate gold bead implantation as a pain-relieving treatment. The dogs were randomly assigned to two groups, 36 in the gold implantation group and 42 in the placebo group. Both groups were treated equally regarding anesthesia, hair clipping, and penetration of the skin with the same type of needle. The gold implantation group had small pieces of 24 carat gold inserted through needles at five different acupuncture points and the placebo group had the skin penetrated at five non-acupuncture points so as to avoid any possible effect of stimulating the acupuncture points. A certified veterinary acupuncturist marked the points, and two surgeons performed the implantations according to a randomization code made in advance. After 14 days, three months and six months, the owners assessed the overall effect of the treatments by answering a questionnaire, and the same veterinarian examined each dog and evaluated its degree of lameness by examining videotaped footage of it walking and trotting. The treatment was blinded for both the owners and the veterinarian. There were significantly greater improvements in mobility and greater reductions in the signs of pain in the dogs treated with gold implantation than in the placebo group. The veterinarian’s and the owners’ assessments corresponded well.

Laim A (2009)   studied the effects of adjunct electroacupuncture on severity of postoperative pain in dogs undergoing hemilaminectomy because of acute thoracolumbar intervertebral disk disease. Dogs were alternately assigned to treatment (conventional analgesics and adjunct EAP) and control (conventional analgesics alone) groups. Analgesic treatment was adjusted as necessary by the attending clinician, who was not aware of group assignment.  They found that total dose of fentanyl administered during the first 12 hours after surgery was significantly lower in the treatment group than in the control group, though dosages of analgesics administered from 12 through 72 hours after surgery did not differ between groups. Pain score was significantly lower in the treatment group than in the control group 36 hours after surgery, though did not differ significantly between groups at any other time.

Some people explained the healing effect of acupuncture in animal as conditioning. Due to a repeated conditioning, animals could also have psychological and physiological responses, so as to have improvement in their symptoms. For example, to bring a dog to a veterinary station, the dog may shack in body. This might be because the dog had been brought to the station before and suffered from pain stimulation, such as injection. If bring the dog to quiet and peace environment, the dog could show less level of the symptoms. This might be easy to understand.

For this, Ramey D explained that conditioning theory proposes that bodily changes result following exposure to a stimulus that previously produced that change. This is perhaps the most intuitively acceptable explanation for any placebo effects in animals. Indeed, animal studies support such a model for placebo effects, starting with the first descriptions on salivating dogs by Pavlov. Both human and animal studies support the idea that conditioning forms some basis for placebo responses. Since conditioning requires learning, it would be expected that repeated visits to a practitioner (of any particular persuasion) might increase the strength of the association between a learned stimuli and response in animals, good or bad. There are numerous examples of dogs shaking in fear when being taken into a veterinary clinic; on the other hand, a dog that enjoyed being handled in a soothing environment might appear to receive some relief from a chronic condition; as it learned to associate its visits with the comforting handling, conditioning effects could occur. This could certainly serve as reasonable explanations for purported placebo effects in animals. Nevertheless, the hypothesis that a healing or therapeutic effect can be dependably provoked as a result of conditioning cannot be supported at this time by any evidence.

Expectancy theory proposes that bodily changes may occur to the extent that the person receiving the therapy expects them to. There is considerable overlap between expectancy and conditioning, because learning is one of the major ways that expectancies are formed. To the extent that therapies are expected to provide relief from disease, or at least provide the client and/or veterinarian with a feeling of control over the disease process, they may alleviate adverse mental states (in the humans). Certainly, in humans, therapies that help restore patient control may evoke therapeutic effects, at least short term, but studies that investigate the expectancy model in animals have so far not been performed. Still, if animals were able to form an association between treatment-related signals (the attention and handling received, the way that the owner behaves towards the animal when it is receiving treatment) and the relief of its distress, expectancies of treatment effects might develop (on the part of both animal and owner).

There is a good body of research that demonstrates that human contact has measurable effects on animals. For example, petting by humans reduces heart rates in dogs and horses and causes major vascular changes in dogs. Gentle handling increases productivity in dairy heifers and increases reproductive efficiency in sows. Thus, it is plausible that human-animal contact might play an important role in the observed responses to therapeutic interventions. To take an “alternative” example, it has been shown that a single acupuncture treatment is as effective as petting a horse, when it comes to relief of signs of chronic airway disease; that is, there’s no demonstrable effect of acupuncture beyond simple handling. (9) On the other hand, handling may also be stressful to animals, so responses to handling may not necessarily be beneficial. Still, there’s no question that human contact can invoke responses from animals and animals may behave quite differently when they are not being observed; those shouldn’t be confused with placebo-effects, however.

It was reported that, after taking sedative, a dog was left in a room but its owner left the room, then let a stranger comes in the room, the dog showed quiet, rather than anxiety or stressful as if it was not given a sedative before. On the third time, the dog was given a vitamin, not a sedative; again the coming in of a stranger in the room does not create the same level of anxiety and stress reaction of the dog. This experiment suggested that, once a therapy worked, the following similar therapy or a sham therapy could produce the same healing effect. Here, it should be noticed that, precondition for such "replacing phenomenon" to happen is that the previous therapy worked. While in the experiments above, animal had acupuncture only once before surgery. No previous healing effect for the dog to remember in its brain.

It is the same in human being.

Goebel M (2008) has a study. Patients with allergic rhinitis underwent a conditioning protocol, receiving desloratadine, an H₁ receptor antagonist, paired with a novel drink, for five consecutive days. After the washout period, patients who were reexposed to the novel drink plus placebo showed improved symptom scores, decreased wheal size on the skin prick test, and diminished basophil activation. Numerous other pharmacological conditioning trials have shown that these placebo responses mimic active drug effects and that prior exposure to an effective treatment is an important part of the conditioned placebo response. 08D0C9EA79F9BACE118C8200AA004BA90B02000000080000000E0000005F005200650066003400360037003100350034003600320031000000

However, no matter for the expectancy, conditioning, or such replace effect, the animal needs a pre-experience to the stimulation. For acupuncture treatment, the question is, the acupuncture is only one time treatment, before the surgery, and it worked to reduce the incidence of postoperative nausea/vomit. The animal did not receive repeated acupuncture. The expectancy, the conditioning, or the replacement effect should not be established.

Another explanation is that the animal might get more care after sick, they would become quiet and calm, and so the symptom would be reduced. They explain this possibility as broad concept of a placebo effect. However, this theory has no any experiment to support, neither be able to answer how much extent a care could calm down a symptom. In addition, such care to calm down a symptom should not be confused with what is discussed here the placebo effect.

Based on the current data, it is most possibly that, the disease-treatment reaction in an animal is similar to that in an infant or children. They are not easily affected by a placebo effect (hint effect). They may be more affected by a calm effect. That means that the reduction of a symptom in an animal or in a child might become less after they get care and conciliation from the owner or parents. They may have reduced heart rate and reduced blood pressure. However, the pain level may not really be reduced by such conciliation. Such calm of animal or child might be regarded as an evidence of a reduction of pain. But we, as adult, know that, under conciliation, the emotion may become calm, but the pain level may not really reduce.

Therefore, the results of acupuncture studies on animal or on children support less as a placebo effect but some kind of conciliation effect. If, under the conciliation, the animal still is not willing to move, or a child is still crying, it should be regarded as the pain level (symptoms) is not improved yet. If, after acupuncture, the animal starts more motion, or a child stop to cry, it should be regarded that the symptom has been improved. Animal or children belong to not-cheating group. We do not really need to insist that the improvement of symptom after acupuncture is an exaggeration of the improvement by owner or parents.

Brief summary: