Journal of chinese Medicine. Number 90. June 2009 Chinese Medicine in the West 2009 whatever system of acupuncture they practise, they you ask, "is a 36 gauge needle better than a 20 gauge all say"well it works!".What I'm interested in is, is needle", but I could say that in this patient I'm using there a difference? Are some techniques of needling a 36 gauge and in that patient I'm using a 20, and here more effective than others? Im focusing on five phases and here I'm focusing on that, and then I'm putting them together. So to HM: It's actually very difficult to get funding to do that me,one of the shortcomings of any kind of research kind of research for two reasons: one is that its hard is that you need numbers of patients and numbers enough to get funding just for a single acupuncture of practitioners. And as long as you need numbers trial. To get a head to head with two acupuncture of patients and numbers of practitioners you need arms of different styles is even more difficult. So, one groups, groups who are defined through something, reason is no-ones going to want to fund you. The through an illness, say, or through a style of practice. second reason isif you put any two types acupuncture So if you configure your questions in that way, you into the trial, the difference between the effects is are creating certain social realities, people who suffer not likely to be very big. The size of the trial has to from asthma, vis a vis, people who are individuals be absolutely huge if you want to find a difference, who have all kinds of different symptoms Or people and even if you did find a difference it would only who always use 36 gauge needles, vis a vis, Japanese probably be very small, in which case you'd say well acupuncturists who never insert the needle that's not clinically meaningful. So I would think it would actually be a big waste of resources if you PD: I've often thought of acupuncture as old fashioned tried to do that. But the problem remains-we don't medicine, and I don't think old fashioned medicine have a clue if thick needles or thin needles are better was ever particularly nice- you know, whatever you had to have done to you was probably pretty PD: Well that's just a hypothesis that the difference will unpleasant, including acupuncture. And they yweren't be tiny. That would imply that the specific effects making these fantastically fine needles, thats modern of needling are only a very small part of the overall technology. Acupuncture was probably nasty, brutish effects? and painful, in the same way scarring moxibustion was. At some stage acupuncture be HM: No. The specific effects for five element acupuncture became soft and gentle and you didn't really feel are different from the specific effects of another very much. And that to me is a crucial issue that I'm intervention, say TCM acupuncture. What you really interested in. We can philosophise as much looking at is the difference between two lots of we like, but in the end, I'm really interested in what specific plus non-specific effects. What it doesn't sticking a needle in the body should feel like? tell you is the relative proportion of specific and non-specific effects. The non-specific effects may FM: Well there are lots of different ideas and theoretical may not be relatively large, but that's not the issu models, like the neurological idea that comes from when you're comparing head to head with two medical acupuncture and the muscle chain idea, yles of acupuncture. Because they've got different and then theres the more ethereal side of what is theoretical models, theyre harnessing different qi, especially if you're putting qigong into the mix. specific effects, so they could both be strong So it's quite complex. The theoretical models of how acupuncture might work are out there. PD: Although the five element interview is substantially different from the non-five element interview, which HM: Peter I think your question is better answered in a you would call a non-specific effect. more experimental context, where we don't try to do these field trials or "in the wild" type work with HM: I think that goes back to my point earlier, that ar large populations with very mixed conditions which interview is generically non-specific, but you have to weve been talking about quite a bit this afternoon. define"specific"as those aspects within the content What we need to do is much more tightly controlled that are specific to acupuncture theory. Theres a lot experiments, where we actually try to check what of things that happen in an interview with a five happens physiologically when you put a needle in. element practitioner that are specific You can see very clear differences between using a real needle and a sham needle in physiological PD:Though enthusiasm is the actual needling isn'tit? studies, big differences with regard to needle location and needle depth; we' ve got lots of information about VS: My fantasy about the ideal practitioner is that he that. The trouble is, although we can get correlations actually transcends all these issues of styles. Because with physiological changes in the here and now, itsJournal of Chinese Medicine • Number 90 • June 2009 Chinese Medicine in the West 2009 15 whatever system of acupuncture they practise, they all say “well it works!”. What I’m interested in is, is there a difference? Are some techniques of needling more effective than others? HM: It’s actually very difficult to get funding to do that kind of research for two reasons: one is that its hard enough to get funding just for a single acupuncture trial. To get a head to head with two acupuncture arms of different styles is even more difficult. So, one reason is no‑one’s going to want to fund you. The second reason is if you put any two types acupuncture into the trial, the difference between the effects is not likely to be very big. The size of the trial has to be absolutely huge if you want to find a difference, and even if you did find a difference it would only probably be very small, in which case you’d say well that’s not clinically meaningful. So I would think it would actually be a big waste of resources if you tried to do that. But the problem remains ‑ we don’t have a clue if thick needles or thin needles are better. PD: Well that’s just a hypothesis that the difference will be tiny. That would imply that the specific effects of needling are only a very small part of the overall effects? HM: No. The specific effects for five element acupuncture are different from the specific effects of another intervention, say TCM acupuncture. What you’re looking at is the difference between two lots of specific plus non‑specific effects. What it doesn’t tell you is the relative proportion of specific and non‑specific effects. The non‑specific effects may or may not be relatively large, but that’s not the issue when you’re comparing head to head with two styles of acupuncture. Because they’ve got different theoretical models, they’re harnessing different specific effects, so they could both be strong. PD: Although the five element interview is substantially different from the non‑five element interview, which you would call a non‑specific effect. HM: I think that goes back to my point earlier, that an interview is generically non‑specific, but you have to define “specific” as those aspects within the content that are specific to acupuncture theory. There’s a lot of things that happen in an interview with a five element practitioner that are specific. PD: Though our enthusiasm is the actual needling isn’t it? VS: My fantasy about the ideal practitioner is that he actually transcends all these issues of styles. Because you ask, “is a 36 gauge needle better than a 20 gauge needle”, but I could say that in this patient I’m using a 36 gauge and in that patient I’m using a 20, and here I’m focusing on five phases and here I’m focusing on that, and then I’m putting them together … So to me, one of the shortcomings of any kind of research is that you need numbers of patients and numbers of practitioners. And as long as you need numbers of patients and numbers of practitioners you need groups, groups who are defined through something, through an illness, say, or through a style of practice. So if you configure your questions in that way, you are creating certain social realities, people who suffer from asthma, vis a vis, people who are individuals who have all kinds of different symptoms. Or people who always use 36 gauge needles, vis a vis, Japanese acupuncturists who never insert the needle. PD: I’ve often thought of acupuncture as old fashioned medicine, and I don’t think old fashioned medicine was ever particularly nice – you know, whatever you had to have done to you was probably pretty unpleasant, including acupuncture. And they weren’t making these fantastically fine needles, that’s modern technology. Acupuncture was probably nasty, brutish and painful, in the same way scarring moxibustion was. At some stage acupuncture became nice, became soft and gentle and you didn’t really feel very much. And that to me is a crucial issue that I’m really interested in. We can philosophise as much as we like, but in the end, I’m really interested in what sticking a needle in the body should feel like? FM: Well there are lots of different ideas and theoretical models, like the neurological idea that comes from medical acupuncture and the muscle chain idea, and then there’s the more ethereal side of what is qi, especially if you’re putting qigong into the mix. So it’s quite complex. The theoretical models of how acupuncture might work are out there. HM: Peter I think your question is better answered in a more experimental context, where we don’t try to do these field trials or “in the wild” type work with large populations with very mixed conditions which we’ve been talking about quite a bit this afternoon. What we need to do is much more tightly controlled experiments, where we actually try to check what happens physiologically when you put a needle in. You can see very clear differences between using a real needle and a sham needle in physiological studies, big differences with regard to needle location and needle depth; we’ve got lots of information about that. The trouble is, although we can get correlations with physiological changes in the here and now, its