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Research in Oriental Medicine - the 2000 Society for Acupuncture Research Symposium

by Belinda Anderson, Ph.D. and Moshe Heller, L.Ac.

The Society for Acupuncture Research (SAR) held its seventh annual symposium in October 2000 at the University of Maryland, Baltimore, MD. The SAR was established seven years ago as a focal point for practitioners and researchers interested in conducting, improving and disseminating research on acupuncture and Oriental medicine (OM). This year’s meeting was co-sponsored by the Complementary Medicine Program at the University of Maryland School of Medicine. The sessions over the two days of the meeting were basically divided into a small number of longer overview presentations followed by many shorter research project reports. This article describes the key points of the overview presentations and lists the research projects that were discussed.

The first talk was given by Brian Berman, M.D. (Univ. of Maryland School of Medicine), who has been involved in conducting many clinical trials investigating the efficacy of acupuncture. He presented an overview of the systematic reviews and randomized trials in acupuncture that have been undertaken to date. He pointed out that while a number of reviews demonstrate the efficacy of acupuncture, many more report inconclusive findings. One of the primary reasons for inconclusive findings in OM research that is aimed at assessing efficacy is in the design of such studies. Dr. Berman suggested that the randomized control trial (RCT) is the best model for yielding conclusive data. The RCT is referred to as the gold seal of clinical research because it reduces sources of experimental error that other trial designs cannot eliminate. The hallmark characteristics of the RCT is randomization of study subjects to treatment and placebo groups such that ideally both the subjects and personnel conducting the study do not know which group the subjects belong to. This eliminates error from subjects being influenced by knowing what treatment group they are in, and from study personnel treating subjects differently based on knowing their group assignment, or interpreting the results in a biased manner due to knowledge of group assignment.

There is currently a great deal of debate within the OM research community as to the compatibility of the RCT and OM practice and philosophy. The RCT is a classic example of the Western scientific reductionist ideology where systems are taken apart to allow systematic investigation of individual parts isolated from the whole. In Western scientific research, the aim is to remove as many variables as possible such that the effect of selected variables can be specifically studied, and the outcome can be known with confidence to be associated with the variables under investigation. In the case of the RCT, if the treatment is shown by statistical analysis to be effective, then it is also known that this efficacy is not due to placebo or subject bias effects, it is due to the treatment itself. It is easy to see why the RCT is viewed as such a powerful model of investigation. However, when we try to apply such a research model to OM there are some fundamental ideological problems. Most obvious is that the philosophy of OM is holistic. The body is viewed more in terms of relationships and interactions rather than as isolated parts with functions that can be separated from the whole. From a pragmatic point of view, it has been argued that the practice of sham acupuncture (to eliminate placebo effects); standardized OM treatments for specific symptoms; removal of the patient-practitioner relationship; and the practice of certain OM modalities alone (and in some cases just using single acupuncture points or single herbs); does not resemble clinical practice and is therefore not a valid way of accurately assessing the efficacy of OM.

These issues were addressed by the second speaker, Hugh MacPherson, L.Ac., who discussed pragmatic research and the assessment of acupuncture in real world settings. In a pragmatic randomized control trial there is still randomization of subjects to treatment groups, but all subjects have a positive attitude about acupuncture and there is no placebo group. Both practitioner and subject know what group the subject belongs to, and those receiving acupuncture experience the development of a practitioner-patient relationship. In such trails there is no strict adherence to a prescribed treatment protocol, rather the practitioner goes through the regular procedure and treatment deemed appropriate to the diagnosis of the subject. It may also include any combination of possible modalities (moxa, cupping, dietary recommendations, etc.) in addition to acupuncture. Pragmatic trails are designed to assess OM as compared with other treatments, for example pharmaceuticals. Such studies indicate the effectiveness of OM when practiced in as near to usual clinical conditions as possible, and therefore provide data that is directly useful and informative to practitioners of OM and Western medicine.

The keynote speaker was Beverly Rubik, Ph.D., a physicist, who gave a presentation about the mechanism of acupuncture from a bioelectromagnetic perspective. This view of the mechanistic basis of acupuncture is not widely known about and/or accepted within the OM research community. The reductionist molecular explanation for acupuncture which suggests that acupuncture works via the nervous and endocrine systems has been quite extensively investigated and demonstrated to play a role in certain conditions, for example electrical needle stimulation and pain relief. However such an explanation is inadequate for certain types of acupuncture, for example Japanese styles with minimal mechanical stimulation, and does not provide any conceptual framework for understanding OM theories such as the five phases and the meridians. Attempting to understand biology from a modern physics perspective requires a move away from the conventional paradigms that have dominated biology, and provides a path to understanding the possible phenomena underlying practices such as acupuncture and homeopathy.

Bioelectromagnetics, an emerging area in science, deals with the interaction of electromagnetic (EM) fields and life and includes endogenous EM fields (generated within the organism), and the effects of externally applied non-thermal (low intensity) EM fields on organisms. Although there are many examples of specific molecular responses to these EM fields (for example, the geomagnetic field and the fluctuating level of melatonin secreted from the pineal gland), there exists the beginnings of a move away from the conventional particle (molecular) view of understanding biology. Instead, living systems are starting to be seen as nonlinear dynamic systems that collectively interact within a sea of EM fields.

An important leader in this emerging field is Fritz-Albert Popp, Ph.D., who along with Chang-Lin Zhang have developed a hypothesis of acupuncture called the “standing wave superposition hypothesis.” Briefly, the basis of their hypothesis is that movement of the many charged atoms and molecules in the body results in the emission of EM radiation. The combined action and interaction of such waves produces a relatively stable interference pattern (characteristic stable pattern of wave interactions that is continuously generated) which then form standing waves. Where two waves meet each other in phase they combine (constructive interference) to produce a larger wave. Such interactions are thought to generate the acupuncture points and meridians and result in the skin conductance being highest in these regions of the body. The interference pattern is stable but not static, and therefore changes in response to chemical and physiological changes in the body, external EM fields, and geocosmic factors. The contour of the standing wave might be expected to constantly wiggle over time, making a macromovement over the body that may explain qi.

The ideas about the mechanism of acupuncture that are emerging from modern physics can be seen as broadening our overall understanding rather than providing an alternative explanation to the neurohumoral theories. Quite possibly, acupuncture stimulation results firstly in the elicitation of changes to energetic component(s) of the body which are followed by corresponding changes in body biochemistry and physiology, which finally produces an observable clinical response. In biology we are so unfamiliar with thinking about biological function in terms of charges and energy fields that there has been very little exploration of the role of energetic processes in the regulation of biological processes. This is where the investigation of the phenomena associated with acupuncture has so much to offer the evolution of biological paradigms and thought.

A representative from the National Institutes of Health (NIH), Christine Goetz, Ph.D., gave an overview of funding priorities for alternative medicine. It is interesting to look briefly at the history of alternative medicine funding at the NIH in terms of better understanding the context of current priorities. Government funding for alternative medicine research started in 1992 with a congressional mandate to create the Office of Alternative Medicine (OAM) within the NIH. At that time the primary focus was to prove the efficacy of complementary and alternative medicine (CAM) modalities, so-called evidence-based testing. The RCT (described above) was viewed as the most appropriate method to do this. The OAM office was later decentralized and a series of academically based research centers were established. Each center was focused upon either an area of healthcare or a particular CAM modality. Four of the centers included research on the efficacy of acupuncture. The OAM became the National Center of Complementary and Alternative Medicine (NCCAM) in 1999. The annual budget was increased from $20 million to $50 million and an expanded authority to propose, review and fund new areas of research was established. Currently there are 13 NCCAM research centers in universities, research institutions and OM schools. The focus of the research has also changed to encompass other areas in addition to efficacy trials. These include devising appropriate methodology to investigate CAM modalities, training researchers, developing education programs about CAM for practitioners of conventional medicine, and investigating the mechanistic basis of CAM.

The rest of the Symposium included a presentation from an FDA representative, Yuan-yuan Chiu, on botanical drugs and regulatory considerations, and many brief descriptions of research in progress. These included the effectiveness of acupuncture and herbal medicine for substance abuse and HIV; the effectiveness of acupuncture for pediatric spastic cerebral palsy, temperomandibular disorder, chronic low back pain, fibromyalgia, carpal tunnel syndrome, dysphagia in stroke, wheelchair induced shoulder pain and depression in spinal cord injured patients, Alzheimer’s disease and vascular dementia; Chinese herbal medicine for breast cancer and Hepatitis C.

Several presentations looked at aspects of the mechanistic basis of acupuncture and included measurement of acupuncture needle grasp, functional MRI to identify brain regions that respond to acupuncture stimulation, physiologic effects of superficial acupuncture, and neuroimaging and acupuncture. Other brief research presentations included placebo acupuncture and alternatives, Bai Shou Wu and anti-tumor activity using tumor cells grown in culture, a survey to determine patient satisfaction with acupuncture, consistency of diagnostic assessment by TCM practitioners, acupressure beads for attention deficit hyperactivity disorder, immunomodulation using acupuncture, breech version by acumoxa, flexibility of treatment verses standardization in research trials, and how to get started in research.

The Symposium demonstrated that OM research is growing at a very rapid rate and that there is much interest in finding out more about both the effectiveness and the mechanistic basis. The vast majority of the research is being undertaken by researchers trained in conventional medical fields, and there is real need for people with proper OM training and experience to become involved. This would greatly enhance the quality of the research being undertaken by making it more relevant and appropriate to the real clinical practice of OM, and perhaps most importantly for our community would result in information that was useful to us in our clinical practice.

Dr Anderson is a research scientist at Memorial Sloan Kettering Cancer Center, and Head of the Biomedical Department at PCOM (NY). Moshe Heller is a graduate of PCOM (SD), is Academic Dean at PCOM (NY), and maintains a busy private practice in NY.