21 St Edmunds Avenue, Porthill, Newcastle under Lyme, Staffordshire ST5 0AB, UK
SIR, While the article by David et al. [1] reflects concerns among many scientific acupuncturists, its research methodology is flawed and contrary to traditional Chinese acupuncture. The paper seems more concerned with statistical rigour than with an adequate understanding of acupuncture in the treatment of rheumatoid arthritis (RA). This letter deals with specific aspects of acupuncture methodology and includes some general comments.
The authors claim that the acupuncture point Li3 alone is enough to treat RA, noting that it is considered capable of inducing a significant endogenous, endorphin and encephalin response. But, in explaining their failure to obtain a therapeutic effect, they conclude Li3 may be an incorrect or inadequate point on its own.
First, there is no published evidence that needling a single acupuncture point is sufficient to treat RA. As an acupuncturist with 14 yr experience, I have had success in treating osteoarthritis [2, 3] and RA by using at least four acupuncture points. In systemic inflammatory diseases such as RA, a combination of acupuncture points [4] and sometimes ear acupuncture points [5] must be used, including local points for the affected joint, distal points for the underlying cause and back points for other factors.
Secondly, the authors' citation of Mann [6], supporting their selection of Li3, is unsound. Mann [6] discounts his own earlier publications on acupuncture saying they were largely based on ancient tradition and added, This book is the reverse. It concentrates on what I have discovered myself [6a]. In particular, he wrote, Liver 3 is one of my favourite (non-existing) acupuncture points [6b]. Thus, it seems that the authors' selection of Li3 was based on anecdote rather than on scientific evidence.
The design of the clinical trail is arbitrarily restrictive and poses three questions: (1) Why are the needles left in for no more than 4 min? (2) Why is the number of treatments limited to five? (3) Why is manual stimulation used alone, excluding electrical stimulation and the combination of acupuncture with moxibustion?
These questions suggest the following comments. (1) According to both traditional Chinese and Western acupuncture theory, good results can be achieved in various painful disorders when needles are left inserted for 1530 min [2, 3, 7a]. Thoman [8] reported that Thirty minutes has been shown to be an effective treatment period for chronic nociceptive pain. In chronic conditions, like RA, treatment may be extended to 4560 min per session with possibly more than the normal number of needles [7b]. (2) In standard practice, acupuncture treatments twice weekly for at least 5 weeks may be sufficient to produce good analgesia in chronic painful conditions such as RA [7c]. (3) In painful conditions, electroacupuncture [9] provides more analgesia at 2 Hz for the release of enkephalin and at 100 Hz for the release of dynorphin. Acupuncture and moxibustion have been combined in the treatment of RA [10].
Factors which might have affected the results were ignored. (1) The progress of RA at different rates with relapses and remissions among randomly allocated patients could produce differences between groups. (2) Medications used by the patients may potentiate or inhibit acupuncture treatment. (3) Li3 can overcorrect certain physiological conditions. It is prudent, therefore, to ascertain whether a patient is on any medication before commencing acupuncture.
In sum, the paper describes an inadequate method for acupuncture administration. It does not improve our understanding of RA and acupuncture, and can lead only to mistrust of acupuncture, both publicly and in the medical profession.
Accepted 17 March 2000
References
Department of Rheumatology, Royal Berkshire and Battle Hospitals NHS Trust, Battle Hospital, Oxford Road, Reading RG30 1AG, UK
The points made by Dr Tukmachi outline many of the factors that we recognize regarding acupuncture therapy and rheumatoid arthritis (RA). Our study set out to evaluate a trial methodology for acupuncture in RA, and was not aimed to make a broad statement on the value of acupuncture. We felt that Liver 3 was a good point to choose if one were to isolate a single point for the trial. It is traditionally used for bone and joint problems and also for reduction of stress. We accept that traditional acupuncture would generally use more than one point in the holistic therapy of rheumatoid. Liver 3 allows one to deal with the practical problems of blinding. The short duration of treatment, i.e. 4 min, also allows the placebo needle to be held in place for a practical length of time. The standard British Medical Acupuncture Society treatment time is shorter than the traditional Chinese approach. Electroacupuncture would complicate matters and is not indicated in treating inflammatory hot rheumatoid disease.
Our conclusions therefore were not concerned with the claim that acupuncture has no role in the management of RA; rather, we concluded that the type of acupuncture used in the study was not useful for RA, and we wished to further highlight the difficulties of the randomized placebo controlled study of acupuncture.
Accepted 17 March 2000