Volume 5, Number 3 | Fall 2010

EditorialHouse of Cards
1. Placebo
It was around 1970 that acupuncture and moxibustion treatment began to be recognized as a scientific researchsubject in Western societies. Since then 40 years has been spent to mainly pursue a single proposition. The special
position is “acupuncture and moxibustion treatment is just placebo.”The placebo effect is defined in a medical
dictionary as the phenomenon in which “actions such as pain relief occur after a placebo, pharmacologically inert orineffective, on the patient with the intended disease was administered aiming for its psychological effect.” Although theexistence of the placebo effect is hypothesized from the operational perspective and its mechanism and actual entity are
unknown notions, the effect is widely recognized in the area of medicine. When acupuncture was going to cross theboarder and was to be incorporated into the medical domain, one of the challenges the acupuncture world was asked toaddress from a skeptical standing was to substantiate “acupuncture treatment is not placebo.” Since a mythical literatureexplaining “The powerful placebo” by Beecher in 1955 contributed the placebo effect, which existence is believed basedon a priori assumption, it has become the methodological foundation for scientific assessments in the medical domain
together with various anecdotes. One of the authoritative medical journals, New England Journal of Medicine (NEJM)
carried a journal with aggressive title “Is the placebo powerless?” by Hróbjartsson and Gøtzsche in 2001.
This literature describes the first attempt to objectively identify the quantity of placebo effect by consolidating dataof randomized trials conducted earlier. The results of this study were incredible, showing that compared tonon-treatment, there were none or very few evidences, if any, of the placebo effect that had been believed to be tens ofpercent in all treatments – this is still fresh in my mind.
The editor in chief commented about the results that “as everyone believed that the witches in the Wizard of Oz
had supernatural power, they had power…similarly we had not seen things beyond the curtain, so we thought placebo
was powerful.” Mr. Bailar, the editor in chief of NEJM linked the people related to the medical field including himself tothe inhabitants of the Oz. On the other hand, the keyword of in fact have not sufficiently substantiated is used as an
obvious word, which functions as a high wall set up relentlessly before the persons who are trying to enter the medical
territory.
Placebos have not been well accepted in the medical field, where they have been labeled and categorized as
subjective and empirical things of no value. A factor contributed to the situation is that from a historical standpoint,
physicians and surgeons have been dependent for a long period of time on what patients claimed. Other factor is thatphysicians and surgeons who were exposed to competition with practitioners of other fields have counteracted
discourses of patients on the basis of objective and scientific theories to overwhelm and control patients and persons
involved in other medicines. The emergency of Western medicine may have implications for the paranoid notion forplacebos.
2.

Is the “Sham Acupuncture” assumed placebo equivalent or not?
An intervention with sham acupuncture needles, which are made undistinguishable from real ones, is required
for measuring the placebo effect and a wide variety of procedures have been attempted. The procedures can largely
be grouped into invasive standard stimulation sham acupuncture, which applies needling into points consideredinappropriate; invasive minimal sham acupuncture, which applies shallow needling into a fewer points to give as
least stimulation as possible compared to real acupuncture; and noninvasive sham acupuncture, which seems likeneedles are inserted but they do not penetrate the skin. Although these are regarded as having validity because “thosewho have not experienced acupuncture cannot distinguish the differences between real acupuncture and shamacupuncture,” evidence-based studies on the other important factor “ineffective” about placebos has not been made andthe placebo effect is dependent on the unverified hypotheses - (a) “ineffective” when needles are inserted into
non-acupuncture points, and (b) as well as the effect, the amount of stimulation increases or decreases according to thenumber of needles inserted and the needling depths. Proving the placebo effect is now required in general but the situation
seems notions are running up before proving.
The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

1

Volume 5, Number 3 | Fall 2010

A result of this was yielded from a large scale project called German Studies carried out in Germany in the first decadeof this century. This project is Phase III clinical trials in which 100 people were engaged for each trial to study whether tocover the effects of acupuncture treatment in the adjuvant setting for chronic pains including low back pain, knee pain, andheadache by the public health insurance. Participants recruitment called for mobilizing clinical practitioners for 100 ordersper trial with these hyper multi centre trials. The result of these trials showed that the real acupuncture group and the control
group of sham acupuncture had equivalent potency. This matter requires analysis on whether the treatment effect in the realacupuncture group was inadequate, or whether the effects in both groups were equivalent. However, monitoring informationin multi-centers and other quality control information are insufficiently available to plan a process analysis, and althoughtherapeutic protocols are described, the information of the procedures actually performed cannot be collected from thesetrials. About skill of practitioners, factors related to the effect of treatment are not found. Whatever the case, such recognitionis necessary that the beliefs of (a) “needling at non-acupuncture points has no effect”, (b) the amount of stimulation increases
or decreases depending on the number of inserted needles and the insertion depths” are hypotheses.
3. To miss trigger points on purpose
Nonetheless, if you are asked if the parties in the East Asia region concerned with acupuncture and moxibustion areinvolved in the runaway of researchers in the United States and European countries, you will not say “they are notresponsible for it.” This is because it is the parties in the East Asia region that have emphasized the differences between theacupuncture points and non-acupuncture points at every opportunity in order to advocate the meridian/acupuncture point
system.
Japanese traditional acupuncturists define concept of acupoint (acupuncture point) as the point where the needle isinserted and manipulated in acupuncture therapy. Acupoint include following points,
・ Meridian point: a point on the fourteen meridians and location had been predefined in classical text books.
・ Extra point: a point that is not located on the fourteen meridians but the position and the property such as
statement of virtues were predefined in the text books.
・ Ashi point: an acupuncture point with no specific name nor definite location, the site of which is determined bytenderness or other pathological responses in palpation. It is hard to differentiate the ashi point on muscle
meridian from the trigger point.
In other words, the locations of all acupoints used in treatment are not determined before starting the session. Somepoints are determined based on the condition of the patient of the day. In treating the musculoskletal system, the existence ofashi point often cannot be ignored. “Non-trigger points” in sham acupuncture or “acupuncture points not used for the relatedcomplaints” should be defined carefully.

Hiroshi Tsukayama, Ph.D., L.Ac., Professor
Department of Acupuncture and Moxibustion
Tsukuba University of Technology, Ibaraki, Japan2The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)