acupuncture studies where do we go from here; peter e rubin (vol 18 no 2)

7/30/2019 Acupuncture Studies Where Do We Go From Here; Peter e Rubin (Vol 18 No 2)

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Perspective

ACUPUNCTURE STUDIES:WHERE DO WE GO FROMHERE?Peter E. Rubin, M.D.

ABSTRACTThis paper discusses some significant limitations ro clinical trials as a means of assessing acupuncture'sscope of practice. Most of the research on acupuncture has incorporated the use of clinical trials rodetermine its effectiveness for the treatment of specific conditions. With great variability in themethods, training, experience, and ability of the acupuncturists, it is not surprising that these studieshave often produced conflicting results.These limitations of acupuncture clinical research remain even if the trials themselves are well designed.A biochemical explanation still prevails among physicians roday. Relatively scant attention has beengiven ro the many clinical observations and physiological studies published outside the mainstreammedical journals which have strongly suggested a circulating flow of energy throughout ou r bodies.Investigation of acupuncture's intimate relationship with energy would be a more potentially rewardingground for study, and several specific avenues of research are suggested.A greater awareness of pulse diagnosis and its implications is one sllch area fot fertile study, especiallyif there can be free and open communication among the different disciplines involved. Only throughgenuine interdisciplinary communication can the existing wide gaps between Eastern and Westernmedicine be narrowed.

KEYWORDS: Acupuncture, Traditional Acupuncture, Energy Medicine, Clinical Trials, PulseDiagnosis, Mind-Body

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A cupuncture has undergone major shifts.Ll..in public opinion since it first becamewidely known in the United States in 1972.Skepticism, hostility, and/or indifferencewere common reactions among physicians.Nobody, it seems, thought much of this'new' modality except for many of thepatients.Since then, medical acceptance of acupuncture has slowly changed, particularly in thelast 15 years. In 1993, a well publicizedarticle from Harvard reported that thepublic's usage of acupuncture and otherforms of complementary and alternativemedicine (CAM) had been greatly underestimated and was actually a multibilJiondollar out-of-pocket industry. I At about thesame time, the National Center forComplementary and Alternative Medicine(NCCAM) was formed and began to fundresearch in a variety of CAM modalities.Increasing numbers of CAM practitioners,including acupuncturists, were soonemployed, not only within medicalpractices, but also in university settings aswell. There has also been a correspondingrise nationally in the number of bothphysician and non-physician acupuncturetrall1l11g programs. Degree requirementshave ranged from 200 hours of lectures andvideo instruction to three years of academicwork and hands-on training. Licensingvaries considerably from state to state.Acupuncture is widely practiced around theworld and is an accepted modality for avariety of problems. In 2002, a WorldHealth Organization (WHO) report listed28 conditions for which acupuncture was

proven to be scien ti fically effective;"another 63 for which the "therapeutic effectsare promising but not proven". 2 Theconclusions are more modest in the UnitedStates. In 1998, a National Institute ofHealth (NIH) Consensus DevelopmentPanel on Acupuncture mentioned "efficacious results" in treating four conditions;another 11 for which acupuncture "may bea useful adjunct or acceptable alternative fortreatment".3The biggest controversies confrontingacupuncture today are: What does it treatand how do we evaluate it? Most physiciansdemand that it s scope of practice begoverned by the same rules of 'evidencebased medicine' (EBM) as any other experimental modality. If acupuncture is aneffective therapy for, say, arthritis of theknee, does it then necessarily follow that italso helps arthritis of the hip? Whilethousands of clinical trials have beenpublished internationally on acupuncture,relatively few have met the 'gold standard'criteria of EBM.4 Of those that have, theresults have often been ambiguous, evencontradictory. "Needs more study" is atypical conclusion reached by manyindependent medical panels reviewing thecurrent available studies of acupuncture. '5

Thus there is a call for more and betterrandomized clinical trials (RCT's).Physicians want to know whether or not apatient referral for acupuncture is justified bysolid scientific evidence. Some insurancecompanies, most notably Medicare, arewithholding reimbursement until acupuncture is shown to be more than an 'experi-



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mental procedure.' Most acupuncturists liketo participate in these studies hoping theresults will help to gain greater professionalacceptance and insurance reimbursement.

Are acupuncture clinical trials, however welldesigned, the best use of our limitedresearch ti me and money? Must weexamine all the potentially treatable medicalconditions before arriving at a consensusregarding acupuncture's scope of practice?Why are the studies often ambiguous-andsuppose they continue to be so? Thequestions we ask wil1 ultimately help todetermine the quality of our answers. Thepurpose of this paper is to discuss some ofthe limitations of acupuncture clinical trialsand to suggest other avenues which mightlead to more productive ways of assessingits potential.By way of introduction, I would like toprovide a brief sketch of my own professional background. I graduated from theUniversity of Rochester Medical School in1967 and trained in internal medicine atJohns Hopkins Hospital and the Universityof Florida where I was chief resident inmedicine. Shortly after the Army draftedme into the Medical Corps in ] 972, Ipurchased a paperback book on acupuncture, improvised some needles, and beganto practice (literally). The patients werefrom and around the army base insoutheastern Alabama, and most had neverheard of acupuncture. The results of thesetreatments over the next few months weresomewhat unpredictable but encouraging.Shortly after I was transferred to my nextbase in New Jersey, I met my first teacher,

a Viet Nam captain in the Signal Corps.Coming from a long family line ofacupuncturists, he first introduced me tosome of the diagnostic and therapeuticcomplexities of this system.When I reentered civilian life I I I 1974, Icontinued to combine acupuncture with thepractice and teaching of internal medicineat a university-affiliated hospital. Wantingto learn more about acupuncture, I beganthe fol1owing year to travel periodical1y toEngland where I received further trainingfrom Dr. j.R. Worsley for the remainder ofthe decade. By 1980, I felt that I no longerwanted to devote a significant portion ofmy time to internal medicine and thereforeresigned my institutional appointments atLankenau Hospital and Jefferson College ofMedicine. I moved into a home-office inWayne, Pennsylvania, where I havepracticed acupuncture exclusively ever sincewith my wife, Joan Michel1and, who is alsoan acupuncturist. During this time, I havehad the opportunity of observing a numberof excellent practitioners representing awide spectrum of approaches. In myopinion, no one system has all the answers.While this exposure has been quite helpfulto me, the views expressed here have beenshaped primarily by my own experiences inthe clinical practice of acupuncture over thelast 35 years.Before discussing some of the current issuessurrounding the study of acupuncture, Iwould first like to give a reasonable definition. This is not an easy task. Onenormally thinks of acupuncture as theinsertion of needles into specific locations

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on the skin for the purpose of producing alocal or systemic therapeutic response.Since acupuncture is such an ancient systemand is practiced worldwide, it is notsurprising that major variations in techniquehave evolved over the years. In some formsof 'acupuncture,' needles are not used:Laser beams, u1rrasound, surface electrodes,and heated herbs (moxibustion) have aUbeen used to stimulate the acupuncturepoints, or acupoints. Some acupuncturiststreat patients by limiting the stimulation ofacupoints to specific areas of the body: Theear (auriculotherapy), scalp, hand, and footare the most common sites used. Forlocalized problems, some practitioners insertneedles around the affected area; others useacupoints distal to the problem-or on theopposite side. Preferences regardingacupoint location and needle technique varyas well. Needles are sometimes inserted,manipulated and then removed, or left inplace for extended periods of time, orstimulated continuously to produceanalgesia. There is also a form (Toya Hari)where the needles may not penetrate theskin at all.A further way to categorize acupuncture isto note the distinction between nontradi-tional acupuncture (NTA) and traditionalacupuncture (TA). With NTA, theselection of a treatment plan often (thoughnot exclusively) depends upon suchvariables as the patient's presentingproblems, the location of trigger points,andlor the existence of abnormal electricalskin resistance changes recorded at specificacupoints. There are, furthermore, manydifferent ways of measuring and interpreting

these electrical patterns. In TA, on theother hand, different signs suggestive of asystemic imbalance are evaluated to reach adiagnosis. Abnormalities in a patient's facialcolor, voice, emotion, tongue, bodylanguage, verbal expressions, and thepresence of certain findings on the abdomenare some of the factors which may beevaluated. Palpation of the patient's pulsesis, however, a hallmark of TA and will bediscussed in greater detail later.TA encompasses a number of differentschools. Traditional Chinese Medicine(TCM) or Eight Principle is a more recentmodification of acupuncture's traditionalroots in China and often includes the useof herbs. Six Energetic Levels began in VietNam and was subsequently brought toFrance during the ] 930's where it wasfurther modified. Five ElementAcupuncture was initially practiced inChina and Japan, but was popularized inthe West by Dr. Worsley in England. ToyaHari was developed in Japan where some ofthe early practitioners were blind, atradition still carried on today. EightConstitutions is a fifth form of TA whoseorigins are in Korea. This list is notcomplete. Rather it is only a brief summarymeant to illustrate the diversity andcomplexity of the subject 'acupuncture.'More extended discussions of the differentschools and the introduction of TA into theWest are referenced.6,7 In practice, new andrevised approaches are constantly beingproposed, and many acupuncturists use theinsights and methods from a number ofsources while planning their treatments.



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Another longstanding application ofacupuncture has been in the field of veterinary medicine and has been widely used inthe United States on animals ranging fromrace horses and dogs to exotic birds. In1996, the American Veterinary MedicalAssociation's Guidelines for Complementaryand Alternative Medicine concluded that"veterinary acupuncture and acutherapyare considered an integral part of veterinarymedicine".8 Manv clinical trials andtextbooks have been published in this area.')Although veterinary acupuncture has beenextensively studied, a major focus of humanclinical trials has been to try to determinethe extent to which the results are 'real' ordue to patient suggestibility. To minimizethe placebo effect, most advocate that theRCT's should be at least single blinded sothe subject does not know whether true orsham acupuncture is being administered.There have even been attempts to developdouble blind approaches during which theacupuncturists do not know themselves thedifference between true and false needling.There is little doubt that patient expectations play a significant role with any formof therapy. The issue here is: Is the placeboeffect the most important variable ininterpreting the results of acupuncturetherapy?Beside the need for suitable controls,another hallmark of EBM is replicability:Can the results of one study be confirmedby another? To accomplish this goal, manystudies have required the acupuncturists tofollow a predefined protocol while treatingtheir subjects. Some of the difficulties with

this approach include the wide variabilityamong acupuncturists regarding such basicskills as point location, needle insertionand/or manipulation as well as the manydifferent ways of treating the same problem.Furthermore, these protocols are a greathandicap to the individual practitioner inhis or her ability to diagnose and treatappropriately the specific needs of thepatient as would be done in practice.Finally, it is the antithesis of TA for theprimary focus of a study to be on a'condition' rather than on the imbalances ofspecific patients. The many difficulties ofapplying the principles of well designedRCT's to the study of CAM disciplines ingeneral have been discussed thoroughly ina report from the National Academy ofScience Institute of Medicine (NASIOM).lO This scholarly 300 pagedocument describes the need for greaterflexibility in the design and interpretationof CAM studies, but concludes that theymust ultimately be held accountable to thesame standards of evidence as with conventional medicine.As this report emphasizes, there is a largedifference between the study of the efficacyof a modality (which compares the resultsof two technologies) and its effectiveness(which examines the outcomes under reallife conditions of actual medical practice).Although the training, experience, andability of the practitioner or 'healer' wasacknowledged in the NAS 10M report (andby a few others) to be a significant variablein evaluating acupuncture's effectiveness,their importance is still, in my opinion,under-emphasized. Of the practitioners

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whom I have seen, I believe that each one'sclinical skills and 'essence' were far morerelevant to the outcome of care than theparticular school or treatment modality thateach represented. The results of any clinicaltrial are really only a report of one groupof acupuncturists at one particular time.Like most practitioners, my own approachand skills have evolved over the years. Theprospect of acquiring new insights has beena major source of motivation for me inpractice. When failures occur, and theycertainly do, the question inevitably arises:To what extent do the failures represent thelimitations of acupuncture and to whatextent the limitations of the acupuncturist?This question is not an easy one to answerregardless of the quality of the study(s).While the focus of this article is onacupuncture, I believe these same considerations should apply when assessing thepotential of other Eastern modalities suchas yoga, tai chi, and qi gong. These are, inmy opinion, highly complex disciplineswhose significance is greatly dependentupon the individual practitioner. Manywestern 'alternative' therapies may also beincluded here. There will always be ademand for clinical trials to 'test' theirefficacies; what is important is that weappreciate their limitations. The practicalimplications of these studies is also unclear.Patient satisfaction (or lack thereof) andword of mouth, rather than publishedreports, have usually provided the mainimpetus for the utilization of acupunctureand the other disciplines. Even manyinsurance companies have made theirreimbursement decisions based primarily on

marketing and cost-benefit analyses ratherthan 'definitive' RCT's.Another difficulty with the interpretation ofacupuncture research has been its emphasison pain, a notoriously subjective symptomto assess. Headaches, osteoarthritis of theknee, and low back pain have been particularly popu la r subjects. The areas ofinquiry have begun to expand in the UnitedStates as the scope of investigation haswidened, and the proportion of federallyfunded basic science studies relative toclinical ones has increased. For instance, arecent summary by the NIH of current orprojected studies on acupuncture includes21 of 50 clinical trials focused on disordersunrelated to pain.]l Such problems asgastroparesis, ileus, and post-operativewound healing are included here and readilylend themselves to objective analysis of theresults. Functional neuroimaging is nowbeing used at institutions like Harvard andthe University of California at Irvine toassess the effects of needling on neurocircuitry and autonomic nervous systemregulation. 12 ,13,14 There is a recent reviewof the effects of acupuncture on brainactivation as measured by functionalmagnetic imaging and positron emissiontomography. 1SAs (if) the relevance of acupuncture to otherphysiological systems is documented, thequestion of its mechanism{s) of action mustinevitably be revisited. Since most of theresearch has centered on its applicability forpain control, there has been a generalconsensus that acupuncture stimulated therelease of a variety of neurotransmitters



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which in turn suppressed the perception ofpain.16 The explanations, in other words,have been mostly biochemical ones.However, even if acupuncture's solefunction were to stimulate neurotransmitters, there is still a big physiological gapbetween the insertion of a needle and thesubsequent release of these peptides.The whole matter of causation brings to theforefront an issue that divides most (thoughnot all) of the medical and acupuncturecommunities. The presence of a circulatingflow of energy (also known as ch'i)throughout the whole body has been a basictenet of acupuncture and many otherdisciplines for centuries. This belief hasbeen based not only on theoretical concepts,but also on the day-to-day observations ofthe practitioners. Yet the reluctance of mostphysicians to explore the possibility that ch'iexists has been puzzling to me. Theinterchangeability of matter and energy hasbeen an essential aspect of modern physicsfor more than 100 years. Surely the lawsof physics apply to medicine as well. Weknow, for instance, that all human organsproduce energy fields, the heart being thestrongest. Energy medicine is also used ina wide variety of diagnostic and therapeuticsettings. There is, however, no expansIVeview of energy as an integral and coherentpart of the life process itself.A major objection to this concept is asfollows: If energy is such an importantcomponent of health, then why has it notbeen discovered yet? Part of the answer is:It probably has. Literally hundreds ofarticles and books on energy and living

systems have been published, often in thebasic scientific journals rather than in themainstream medical press. As science hasbecome increasingly specialized, meaningfulcommunication among the broaderdisciplines and even within specialitieshas become more fragmented.Another reason for the widespread skepticism has been the lack of context in whichto interpret all this seemingly disparate data.No forest has emerged to give meaning toall the trees. In my opinion, the best bridgebetween biophysics, medicine, andacupuncture (and some other forms ofCAM) is a book by James Oschman,Energy Medicine in Therapeutics andHuman Behavior.l? Dr. Oschman, abiophysicist, reviews the extensive evidencethat there is a dynamic matrix within livingbeings which provides a continuousenergetic and informational network amongall the cells of the body and their chemicalreactions. This vibrating system producesbiomagnetic and bioelectrical fields whichprovide the vital sensory and feedback loopsnecessary for the optimal functioning of theorganIsm. He emphasizes the roles ofconnective tissue and water assemiconductor media for the flow of thisenergy and notes that fascia is alsopiezoelectric, whereby mechanical stimulation of connective tissue will producecorresponding changes in the surroundingelectrical fields. These concepts arebeginning to receive increasing attention,and a First International Congress on FasciaResearch was recently sponsored by HarvardMedical School. 18

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Many acupoints have been found to havelower electrical skin resistance than theirsurrounding areas. When these points arestimulated, significant electrical changesmay occur along the same meridian, buthave less or no effect on other areas.Electrical changes in selected acupoints mayalso reflect systemic medical problems, anda number of electrodiagnostic approacheshave been based on this phenomenon, mostnotably in Japan, Europe, and in Russia.Summaries of some of these methods arenoted. )9,20,21,22

For the duration of this paper, I would liketo offer some perspectives on certainsupposed conflicts between TA and westernmedicine, particularly as they relate toenergy. In my opinion, these seeminglyprofound differences may reflect, at least tosome degree, cultural and semantic differences as well as more substantive ones.Specialized vocabulary is often as significantan impediment to the exchange of information as are the ideas they represent.Take, for example, the terms 'yin and yang',the object of so much skepticism in theWest. There are, however, many ways andlevels of viewing this concept. A theoremof classical physics states that any action willproduce an equal and opposite reaction. Innuclear physics, light may be described interms of either a particle or a wave.Yin/yang is a broader concept philosophically than these two exam pIes, but theparallels are clearly there. Neils Bohr, whoreceived the Nobel Prize for his seminalwork in the principle of complementary,had the yin/yang symbol engraved in his

coat of arms when he was knighted by hisnative Denmark. There appears to be agrowing consensus among many theoreticalphysicists that there are profound similarities between several eastern disciplines andmodern physics. Just a few of the manyauthors who have explored this subject arelisted.23 .24,25Another controversial tenet of TA has beenthe existence of the five elements, the basicconstituents or building blocks of ch'i. Thenames of these elements (wood, fire, earth,metal, and water) seem quaint, even archaic,but they may be quite descriptive of apatient's demeanor and character. Changesin facial color, voice, and emotions mayreflect imbalances in one or more of theseelements and are often easily identifiableclinically.As one way to describe the elements interms of physics, we could suppose that ch'iwere a beam of light which could berefracted by a prism into five basiccomponents. A stronger prism could refractthe light further into 12 components, ormeridians, which are not only energypathways but have functional purposes aswell. Furthermore, each meridian iscomposed of the five elements within it,and the interplay of these 'elements-with inelements' has a significant effect upon thestate of our health. While a theoreticallymore powerful prism could expand thedivisions beyond 60 (five elements withineach of the 12 meridians) and reveal'elements-within-elements-within-elements'etc., this categorization is not clinicallypractical. However, what emerges from this



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brief picture of ch'i is a pattern of energynot too dissimilar from that of the electro-magnetic spectrum.A striking feature of TA is that there is noseparate pathway for the central nervoussystem (CNS). Instead, this frameworksuggests the existence of an additionalsystem in which essential information isconveyed at greater speeds throughout thebody than can be achieved by the CNSalone. This network may be an older oneon the evolutionary scale just as primitiveorganisms react to environmental stimuliwithout the benefit of a brain. Memoriesand emotions are, to some degree, thoughtto be stored in the cells throughout thebody as they are in the brain. The capacityfor joy and love are, for instance, as muchan integral part of the heart's 'energy' as isits capacity as a pump. Clinically, deep-seated feelings are commonly evoked byacupuncturists and many other hands-ontherapists in the course of their treatmentsessions. The distinction between mind andbody is a tenuous one indeed.Another aspect of TA is that no oneproblem, or imbalance, should be treated inisolation. A needle in one acupoint willaffect all of the pathways. The functions ofeach meridian are fully integrated withthose of the others by multiple intercon-nected loops. Loss of positive feedbackamong pathways, or the emergence ofnegative energy in one pathway, will havedeleterious consequences for the wholesystem. Thus the TA practitioner shouldaddress the major underlying imbalances ina patient before beginning treatment. The

sicker the patient, the more important it isto get an accurate diagnosis. An old maximstates that the most effective acupoim onthe body is-whichever point the patientneeds the most at that particular time.The previous discussion of TA was notmeant to be a comprehensive or universallyaccepted review. Rather, these opinions arebased on my training and interpretations ofthe theory and reflect my own experienceswith their clinical applications. They arealso expressed in ways which I believe arecompatible with western scientific theoryand can be subjected to the same rigorousmethods of evaluation.For the remainder of the paper, I would liketo discuss an aspect of TA which rarelyreceives more than a passing reference in thestandard medical literature: pulse diagnosis.This method has, I believe, the potential tobe a valuable adjunctive means ofunderstanding the development andprogression of disease in patients andtherefore deserves greater scrutiny. Pulsediagnosis is no t unique to TA: Ayurvedicand Tibetan medicine both use somewhatdifferent versions of this method. In TA,the pulses are felt at three specific locationson the left and right radial arteries. Each ofthese six locations has both a superficial anddeep component. Thus there are 12 pulsesin all which, when carefully palpated,provide important information about thestate of health in each of the 12 meridians.The pulses may be examined at otherlocations on the body, but it is importantthat the placement of the fingers beaccurate. In my own practice, I generally

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take a patient's pulses at least five times inthe course of a typical visit to help indicatethe sources of his or her imbalances, tomonitor the response to treatment, and tosuggest what further needling, if any, isindicated.When an acupoint is stimulated or sedated,

the resultant changes can be felt instanta-neously on all ] 2 pulses. I recall seeing anelderly blind Toya Hari masterdemonstrating acupoint location to hisstudents. While a subject lay supine on anexamining table, another student slowlydrew a needle lightly along the surface ofthe subject's foot. Using his exquisitelysensitive touch, the teacher monitored thesubject's pulses and then told the studentwhen the precise location of the point wasreached.A variety of information can be gained fromthe pulses and, inevitably, there are signifi-cant differences among acupuncturistsregarding the interpretations and implica-tions of the readings. As with westernmedicine, the rate and regularity of the pulseis a starting point. Increases or decreases inthe volume of each of the] 2 pulses beforeand after needling are also noted. I believethat many of these quantitative variationscan be readily appreciated by most reason-ably sensitive non acupuncturists after arelatively brief period of instruction.The most important diagnostic andprognostic information provided by thepulses is obtained through the reading oftheir qualities. These qualities may bedifficult to identifY, and their mastery may

take many years of practice. In TCM, thereare classically 28 different pulse qualitieswith such names as hesitant, floating, andhollow, each having its own particular signif-icance.26 For many centuries in China, thedoctor was forbidden to examine his femalepatients with the exception of the pulses.Even today, there are practitioners who arereputed to be able to obtain a significantportion of a medical history on the basis ofthe pulses alone.No explanation exists in western medicinefor the phenomenon of the different pulsesor for the changes which occur in themimmediately after needling. However, theremay be an interesting way of approachingthis subject from an experimental perspec-tive. The pulse qualities are, in essence, adescription of the whorls and eddies of theflow within specific locations of the arterialtree. In some sections, the flow may berelatively smooth and orderly; in others,turbulent or chaotic. In still others, onemay sense an obstruction to flow, thuscreating a dissipation of energy and ageneralized weakness within the system.Seasonal and diurnal variations may bereflected in the pulse patterns which alsotend to change when a patient is followedover many years.In one sense, the descriptions of the pulsequalities are remarkably similar to those offluid mechanics and chaos theory.27 Thedynamics of fluid systems, including theonset and progression of turbulence, can beextremely complex. Pulse diagnosis couldbe considered one way of describing theoscil1ations of flow within specific locations

http:///reader/full/icance.26http:///reader/full/icance.26http:///reader/full/theory.27http:///reader/full/icance.26http:///reader/full/theory.27


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and using that data as another diagnosticand monitoring tool. Quantitative recordings of differential pulse volumes might verywell be feasible, though their significance isprobably more limited than the informationthat might be obtained from the pulsequalities. Can these qualities be objectivelyevaluated, or even approximated? I don'tknow, but only a combined effort of investigators from the fields of fluid mechanics,medicine, and TA could possibly answerthat question.Before leaving the subject of pulse diagnosis,I would like to be less theoretical and offera specific example of its clinical use. The sixpulses palpable on the left wrist (heart, smallintestine, liver, gall bladder, kidney, andbladder) are known as the 'husband' side;those on the right (lung, large intestine,stomach, spleen, triple heater, andpericardium), the 'wife' side. In a relativelyhealthy person, the strength and vitality ofthe pulses on each side should be roughlyequal to and harmonious with the other. Ifthe left sided pulses become sufficien tly weakand are 'dominated' by those on the right,then a husband-wife imbalance, or H-W, issaid to exist.In the earlier stages, the signs and symptomsof H-W may be vague and nonspecific. Apatient may have increased difficulty inadapting to changes in daily living patternsor feel generally 'in a rut' physically and/oremotionally. If H -W progresses, thenpreviously intermittent symptoms maybecome more pronounced and continual.There may develop a sense of 'loss ofcontrol' or greater passivity in dealing with

life's challenges. Apathy, helplessness, andhopelessness are frequently found in thelater stages. One reason I have chosen thisexample is because it is a relatively commonphenomenon in patients who develops i g n i fi can t c h ron i c me d i c a I and / 0 remotional illnesses Furthermore, the relativedisparity of strength on both wrists can,with a little instruction, be readily appreciated if the patient's H-W is advanced andhis or her pulses are easily palpable.The treatment of H-W consists of sedatingthe right sided pathways and stimulatingthose on the left. This session is usually aquite vigorous one as the chronic disparitybetween the two sides may be difficult tocorrect. While a single treatment iscertainly not curative, the patient often feelssignificant positive changes if the equilibrium is restored, and subsequent treatmentscan progress much more smoothly. In myexperience, if the H-W still persists aftertwo or three visits, then the prognosis withfurther acupuncture treatments is limited.

WHERE DO WE GO FROMHERE?A cupuncture, like any system, has its

.t\..Iimitations. I have a great deal ofrespect for western medicine and ampersonally grateful for the many benefitsthat it has provided in my own life. Yetthe prevalence of so many chronic medicalproblems would suggest that our currentmodels of health and disease could beexpanded.

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During the last 35 years, a major focus ofacupuncture research has been the use ofclinical trials to assess its effectiveness (orlack thereof) in treating specific conditions,especially pain. These trials perform auseful function in providing us with somegeneral guideposts regarding its scope ofpractice and efficacy. However, as discussedearlier, the validity of extrapolating theresults of these clinical trials, no matter howwell designed, to 'acupuncture's effectiveness' as a whole is based upon severalquestionable assumptions. Moreover, thebroader issues of acupuncture'smechanism(s) of action and its ultimatepotential are often deferred.A circulating flow of energy throughout ourbodies has always been the commondenominator joining acupuncture with anumber of other 'alternative' therapies.Several potentially answerable questions canbe raised in this regard: Does the quantity,quality, and distribution of this energy havea significant effect upon the state of ourphysical and emotional health? Do themeridians within the fascia act as semiconductor pathways to rapidly convey information to all parts of our body-minds? Doelectrical changes in specific areas of theskin correlate with pathophysiologicalchanges in the organs, and vice versa? Dowave patterns within certain locations of thearterial tree provide important clues to thedevelopment of disease?It may be possible that these questions,when framed as hypotheses, can besubjected to the same rigorous analysis asany other form of inquiry. To begin to

answer them, however, a perspectiveextending beyond our current areas ofspecialization is needed. Dr. Oschman'sreview of energy medicine reflected not onlyhis expertise in cellular biology, but also anobvious substantive understanding of manyalternative therapies. I suspect that theexpansive nature and scope of the previouslycited research projects at universities likeHarvard and California at Irvine werepartially the result of meaningful communications between their basic science andacupuncture communities. These genuineinterdisciplinary dialogues appear to beexpanding nationally and will hopefullycontinue to do so.The emphasis of this paper has been tosuggest ways in which some of theseemingly large differences between TA andwestern medicine can be narrowed. Theremay, however, be limits to this goal. InTA, as in so many other disciplines, thepractitioner's compassion, intent, and touchare often an integral aspect of the healingprocess. Although much has been said andwritten about the spirit, its nature and scoperemain elusive. To what extent can theessence of the spirit be explored andevaluated by conventional medicalapproaches? Should we even consider thatthere may be limits to the scientific methoditself? Attempting to answer these questionsmay prove to be a major--andexciting-challenge in itself.

CORRESPONDENCE: Peter E. Rubin, [email protected]

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acupuncture studies where do we go from here; peter e rubin (vol 18 no 2)

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