Dear editor,

As you may know, there is long time hot debate in the researcher area and online environment whether acupuncture is a placebo effect or not. Researchers in the western countries indeed have spent a lot of effort to get clear answer but positive and negative clinic data still show up to now. Due to this, some reviews and even journal editor come to a disappointed and weary emotion to support continuous study on acupuncture. This is very ridiculous to us, as an acupuncturist.

I therefore tried to find where might be the problem for acupuncture study reaching such an awful situation.

After compare the clinic data published from the western countries and China, we found that, it should not be difficult to tell if acupuncture is a placebo effect or not. A basic condition to allow a placebo effect to happen is that the patient should be in a clear consciousness condition. While there are a lot of data from China indicated that acupuncture can work well in a condition where a patient was out of consciousness or the consciousness is very weak, such as in coma, shock, persistent vegetative state, under anesthesia, delayed wake-up after general anesthesia or after surgical operation… However there are very little such studies from the western countries. So, simply try to repeat acupuncture in those special clinic condition would be helpful to solve this simple but very important issue.

For acupuncture used in the treatment of ordinary diseases, I found the potential errors or mistakes in the following aspects:

(1). In acupuncture treatment: the acupuncture conduced in the studies in the western countries was mostly once or twice a week for about 10 to 12 sessions. Whereas that in China, it was usually once a day for 5-6 days a week and for totally 15-30 sessions. Apparently, the acupuncture stimulation dose applied in the first research group is much less than that in China.

The insufficient stimulation makes the acupuncture not work properly, so that, no matter the acupuncture group is compared with a sham group, or compared acupuncture points with non-points, all failed to get a statistically significant different between the acupuncture group and the sham group.

This could be, among some other weakness, the major weakness in acupuncture technique aspect.

(2). It is a nature that the placebo effect is variable among people, as showing in the studies where a healing effect of a sham group can be as less as 5%, or up to 55%. Therefore, once the healing effect of the acupuncture group, in the western countries, coupled with a low healing effect of a sham group, it tends to be significantly different favor the acupuncture. When the acupuncture group coupled with a higher placebo effect of the sham group, it would be hard to get a statistically significant different between the acupuncture and sham group, so favoring the conclusion that acupuncture is a placebo effect. Indeed, our data show that about 75% of positive studies come with a low placebo effect of the sham group (less than 23% healing effect), and interestingly also about 75% of the negative studies come with a high placebo effect (more than 31% healing effect) of the sham group.

After pooling data from all studies where contain a sham group, we found that the average (placebo effect) of a sham group is pretty much same for acupuncture, massage, physiotherapy: about 23%. The data cited by researcher or reviewers to tell that acupuncture is a placebo effect are mostly those with high (placebo effect) sham group. They omit the data where the (placebo effect) of the sham group is low.

Since there is no data can tell that the sham group with high placebo effect would be more trustable or more acceptable than the sham group with low place effect, the question is one to the acupuncture researchers:  the data from which study, the one with high placebo effect or the one with low placebo effect, should be accepted?

The current situation in the acupuncture study is:

(a), comparing acupuncture with non-treatment group, acupuncture always works better than the non-treatment group. This is even not denied by those researchers who believe that acupuncture is a placebo effect.

(b), comparing acupuncture with a sham group, some data showed acupuncture significantly better than a sham, some not. The positive and negative results can be seen in the treatment of almost all clinic conditions. As we pointed out above, the results are largely affected by the level of placebo effect in a sham group.

(c ), comparing sham group with non-treatment group, sham group may be better than the non-treatment group in some clinic conditions, such as pain, but not in most other conditions such as stress, anxiety, craving syndrome; it showed no difference from a non-treatment in objective index of a disease (such as blood pressure, blood WCB counting), or a binary index of a disease, such as incidence of smoking. This means that the placebo effect is limited and variable in different clinic conditions.

So, when a not properly worked acupuncture met a variable sham treatment, the final result (the difference in the healing effect between the two groups) is largely variable.

In China, the acupuncture is performed with higher frequency, but the number of the study which contained a sham group is limited. However, after collect the available acupuncture data with a sham, as well as the studies in physiotherapy (with TENS or laser treatment) with sham group, we can see that, with higher treatment frequency as once a day for more than 15 sessions, the treatment groups are almost always significantly higher than the sham group, while the placebo effect in the related sham group tended to be less.

(3), the quality of the person who conducted acupuncture treatment in a study. Our data suggest that, nearly half of the acupuncture was performed by non-acupuncturist, but by physician, or physiotherapist. The quality of these persons is questionable, since we need to admit that acupuncture is a personal skill-related technique. Telling how many years of acupuncture experience is not enough to tell the level of the true level of the person’s skill. If one uses acupuncture only once a day or several times a week, though for several years, does not convince us that the person is qualified to represent acupuncture in a stud.  The low quality can be evidenced that they do not realize that acupuncture should be performed with higher frequency, if it is used alone (not combined with other therapies, such as in a real clinic situation).

(4), additional problem comes from the reviewers: they confuse acupuncture with acupressure, moxibution, cupping. If we want to comment that acupuncture is or is not a placebo effect, we should not mass these complementary therapies into the review. Acupuncture is introduced by acupuncturists from China for local anesthesia in last contrary, what they showed is acupuncture needle treatment, not with any other therapies. 

For all of these reasons, we feel that it is too early to tell that acupuncture is a placebo effect. More studies are needed in the aspects as we outlined above.

We suggest that, after clearing that acupuncture is not a placebo effect, we can consider to omit a sham group in the acupuncture study, since it is much difficult to involve a sham group in a clinic study. It is enough to compare acupuncture group with the currently mostly used therapies for a given disease, such as western medicine, or a surgical operation. If the acupuncture works equal to, or better than, those conventional therapies, it should be accepted, for its less-side effect and for long-term money-saving potential.

To support my idea above, I prepared an article. It can be reached online:

Chinese：http://www.acupuncture123.ca/Placebo%20Ch1.html

English：http://www.acupuncture123.ca/Placebo%20En1.html

I do not intend to publish it to your journal, for its too long and too much data. Also, I want to keep it online so as to be able to clear misunderstanding about acupuncture, not only for professionals, researchers, but also to the public. We have already had experience that some patients refused to try acupuncture, because they see Google and found that it is said that “Acupuncture is a theatrical placebo: the end of a myth”.

This letter is aimed for your editor members and reviewer only, to remind how an acupuncturist looking at the current data on acupuncture researches.

With best regards.

Dr. Martin Wang, MD, Ph. D.

Millwoods Acupuncture Center

Edmonton AB, T6L 6W6

Canada