Chinese Medicine in the West 2009 Journal of Chinese Medicine. Number 90. June 2009 sort of consultation The difference is that the content to Hugh, but surely people of your calibre have an of the wow moment in an acupuncture consultation opinion, even if it's subjective. I think that there is is rooted in Chinese medicine theory. I think that in a tendency for practitioners who are longer in the any sort of research we do we have to capture that tooth, some that I've spoken to, to think well maybe the process, because if we lose that-and I think that it's just placebo after al this is the problem with a lot of research where they are mechanistic in the sense of"you should use these VS: No it's not; not from my own experience. I have points"or"these are the parameters of treatment"-they a very special,'old style of practising, which re not allowing practitioners to create that moment or sequential needling, so I will do a point and then I create that experience for the patient. We risk losing will feel the pulse and then I will do another point so much, and I think thats one of the reasons the And I have learned to make predictions on the basis acupuncture trials in Germany or the United States of how the pulse changes. I have found a way of here they constrain the practitioners, were actually knowing: when this happens it's most likely that the chopping off something that is very special person' s going to get better. OK you could say I'm then communicating that to the patient in some kind DM: I think it is interesting, and illustrative that we of placebo way, yes, but my experience constantly are talking a lot about what happens outside the shows me that I do certain things and it works and I acupuncture itself, theories of Chinese medicine such don't do certain things and it doesnt. And for herbs as differentiation and so on, whilst to the patient who s the same thing is uneducated in terms of these theories the big part HM acebo? "But I think we need to move beyond that of acupuncture is what actually happens when you HM: It's not black and white. Its not"isit placebooris itnot put the needle in and you get movement of qi. To certain extent that eludes explanation or research or proof. When a patient feels certain sensations such as effects", there are in every consultation. a stuck feeling in the stomach or the hypochondrium, and then the needle goes in and they feel qi rising VS: I am talking about specific effects up the leg and something clearing: how much of that is to do with placebo and things like the way we HM: Well for specific effects the evidence now is coming flourish our fingers when we take the needle out, and through more clearly for some conditions. We're how much is the training and skill of the practitioner seeing significantly different results for acupuncture in the manipulation of qi. versus sham acupuncture in the most recent trial evidence, for some conditions, for example PD: I think it's a very big question-perhaps the biggest osteoarthritis of the knee, headache, low back pain, question for acupuncturists now. I'd like to see lots neck pain and rates of pregnancy among women of really good and appropriate acupuncture research undergoing in vitro fertilisation. So we know there has into this, because the thing I'm most interested in to be something specific there, and any practitioner in is does it make any difference whether you stick a clinic or anyone who has experienced acupuncture a needle in an acupuncture point or not, and does knows at an individual level that changes happen it make any difference if you get deqi or not; does The difficulty is to capture-at the population level it make any difference if you use a 36 or 38 gauge those changes and it's especially difficult to do that needle that the patient barely feels, or even whether when you standardise the treatment in any way or you hold the needle above the skin, or whack a great you dont allow the flexibility that we were talking big 30 gauge needle in two inches so that the patient about earlier. So that's why I echo your call for more is transfixed to the couch? You know, these seem to relevant research and that relevance means capturing me pretty essential questions to answer. And thethe flexibility that is characteristic of Chines problem is we can't just rely on practitioners to judge this because one universal rule is that whatever they do, they will invariably report that it works fine, but PD: What nobody has done-I may be wrong- is any theworking might be to do with the generic effects studies which compare different kinds of needling, of the treatment rather than the needling itself. for example mild, Japanese style needling with strong Chinese style needling Actually most acupuncturists, FM: And that's where we come to Hugh? To say how are for good or for ill, are not that bothered about seeing we going to do this? research that says that acupuncture works, most acupuncturists feel confident acupuncture works DM: Well hold on. hold on. Yes that is where we come In a way that's the problem; whatever they do,14 Chinese Medicine in the West 2009 Journal of Chinese Medicine • Number 90 • June 2009 sort of consultation. The difference is that the content of the wow moment in an acupuncture consultation is rooted in Chinese medicine theory. I think that in any sort of research we do we have to capture that in the process, because if we lose that – and I think that this is the problem with a lot of research where they are mechanistic in the sense of “you should use these points” or “these are the parameters of treatment”‑ they are not allowing practitioners to create that moment or create that experience for the patient. We risk losing so much, and I think that’s one of the reasons the acupuncture trials in Germany or the United States where they constrain the practitioners, were actually chopping off something that is very special. DM: I think it is interesting, and illustrative that we are talking a lot about what happens outside the acupuncture itself, theories of Chinese medicine such as differentiation and so on, whilst to the patient who is uneducated in terms of these theories the big part of acupuncture is what actually happens when you put the needle in and you get movement of qi. To a certain extent that eludes explanation or research or proof. When a patient feels certain sensations such as a stuck feeling in the stomach or the hypochondrium, and then the needle goes in and they feel qi rising up the leg and something clearing; how much of that is to do with placebo and things like the way we flourish our fingers when we take the needle out, and how much is the training and skill of the practitioner in the manipulation of qi. PD: I think it’s a very big question ‑ perhaps the biggest question for acupuncturists now. I’d like to see lots of really good and appropriate acupuncture research into this, because the thing I’m most interested in is does it make any difference whether you stick a needle in an acupuncture point or not, and does it make any difference if you get deqi or not; does it make any difference if you use a 36 or 38 gauge needle that the patient barely feels, or even whether you hold the needle above the skin, or whack a great big 30 gauge needle in two inches so that the patient is transfixed to the couch? You know, these seem to me pretty essential questions to answer. And the problem is we can’t just rely on practitioners to judge this because one universal rule is that whatever they do, they will invariably report that it works fine, but the ‘working’ might be to do with the generic effects of the treatment rather than the needling itself. FM: And that’s where we come to Hugh? To say how are we going to do this? DM: Well hold on, hold on. Yes that is where we come to Hugh, but surely people of your calibre have an opinion, even if it’s subjective. I think that there is a tendency for practitioners who are longer in the tooth, some that I’ve spoken to, to think well maybe it’s just placebo after all. VS: No it’s not; not from my own experience. I have a very special, ‘old’ style of practising, which is sequential needling, so I will do a point and then I will feel the pulse and then I will do another point. And I have learned to make predictions on the basis of how the pulse changes. I have found a way of knowing: when this happens it’s most likely that the person’s going to get better. OK you could say I’m then communicating that to the patient in some kind of placebo way, yes, but my experience constantly shows me that I do certain things and it works and I don’t do certain things and it doesn’t. And for herbs it’s the same thing. HM: It’s not black and white. Its not “is it placebo or is it not placebo?” But I think we need to move beyond that today, clearly there is placebo, so‑called “non‑specific effects”, there are in every consultation. VS: I am talking about specific effects. HM: Well for specific effects the evidence now is coming through more clearly for some conditions. We’re seeing significantly different results for acupuncture versus sham acupuncture in the most recent trial evidence, for some conditions, for example osteoarthritis of the knee, headache, low back pain, neck pain and rates of pregnancy among women undergoing in vitro fertilisation. So we know there has to be something specific there, and any practitioner in a clinic or anyone who has experienced acupuncture knows at an individual level that changes happen. The difficulty is to capture ‑ at the population level ‑ those changes and it’s especially difficult to do that when you standardise the treatment in any way or you don’t allow the flexibility that we were talking about earlier. So that’s why I echo your call for more relevant research and that relevance means capturing the flexibility that is characteristic of Chinese medicine. PD: What nobody has done ‑ I may be wrong ‑ is any studies which compare different kinds of needling, for example mild, Japanese style needling with strong Chinese style needling. Actually most acupuncturists, for good or for ill, are not that bothered about seeing research that says that acupuncture works, most acupuncturists feel confident acupuncture works. In a way that’s the problem; whatever they do