It’s often the case that immediately after an acupuncture treatment a patient will experience a kind of dreamy, euphoric state. When I was in school students and teachers would refer to the after-effects of acupuncture as “aculand.” It’s not something any acupuncturist is attempting to achieve, it just seems to be one of the side effects of treatment.

My guess is it’s responsible for the items I often find left behind in my office or treatment room – checkbooks, sunglasses, watches. And it’s certainly on my mind when I schedule subsequent appointments. I always write them down on an appointment card and make sure they end up in a purse or pocket.

A research study of short term reactions to acupuncture

So imagine my surprise when I came across a research report on this very subject (“Short term reactions to acupuncture – a cross-sectional survey of patient reports” in Acupuncture in Medicine (2005, 23(3): 112-120 [abstract]). The authors don’t use the term “aculand.” Maybe it’s a term that’s not going to make it into the research vocabulary.

It’s a UK study with a sample size of 9408 patients! They were asked about their reactions during or immediately after treatment by practitioners of their choice (a total of 638 different acupuncturists).

The results

Well, I have to say, I was surprised at the frequency of responses. An amazing 95% of the patients reported experiencing at least one short-term reaction. The most common reaction? 79% reported feeling “relaxed.” Next, 33% felt “energized.” (This is more than 100% already because patients could report more than one response. The average number of responses was 1.8.) Next, 24% reported feeling “tired or drowsy.”

There were some responses on the “negative” side of the ledger, too. Which doesn’t surprise me. Temporary discomfort can be a part of healing. Some people get worse before they get better. It is totally normal for symptoms occasionally to flare up before they resolve. It’s my experience that if symptoms do get worse, they usually will last 24-48 hours and then improve.

And sometimes a small amount of pain is not really a negative thing. It can be the sensation of de qi, an integral component of acupuncture that is receiving its own research attention.

There was a very low response level for persistent “aggravation of symptoms” (1.8%). Interestingly, only 13 patients (an incredibly low 0.14%) responded that they were unwilling to have acupuncture again because of these “negative” reactions.

My new perspective

First of all, thanks to Hugh MacPherson and Kate Thomas for having conducted and published this study. It’s important to bring objective information to the table when talking about patient reactions to acupuncture. I was aware of the existence of short-term reactions, and my patients sometimes refer to them in their testimonials, but this study alerts me to its nearly universal – and variable — nature.

I’ll be watching my patients a little more closely. And maybe reducing the content of my lost and found drawer.

We’re all N = 1

There is a ton of interesting acupuncture research being conducted these days, and there is no doubt that we all will benefit from this work, practitioners and patients alike. Our aims are the same – bringing about healing. As I’ve been thinking about the actual research itself, though, I’ve become aware of a kind of disconnect between medical researchers and the patients they recruit for their work. These researchers are most interested in “Does treatment/drug X have a measurable effect on symptom Y?” And as a matter of good research protocol, they have to remain as neutral as possible about the outcome. That is to say, they can’t bias their work by hoping for one result or another.

Double blind research protocol

More importantly, some sort of randomized trial has to be set up and a placebo chosen. In the case of acupuncture studies, some type of “sham acupuncture” is employed (either inserting needles at random points disregarding established meridians, or only pretending to insert needles). Controls such as these are needed to ascertain whether the main treatment variable is the one responsible for any positive effects that might ensue. And then, in an attempt to remove bias from the gathering of data, a double-blind situation is set up whereby neither the doctor nor the patient is aware of which group he/she is in. (A real hurdle, for obvious reasons – the acupuncturist knows what group the patient is in, but at least the recording of results can be performed by someone who is unaware of treatment group assignments.)

A conundrum – two different views of sample size

The medical researcher is interested in the statistical results of the test. Does the treatment group differ significantly from the placebo group(s)? Statistics are based on samples of patients, and the larger the sample, the better. Sample sizes are referred top as “N,” so a sample size of 100 patients would be N = 100. The patients, on the other hand, are interested in their own personal health. Each is a sample of one. Hence the N = 1 in the title of this blog. How does the perspective of N = 1 relate to the perspective of the N = 100? Here’s where it gets interesting.

Lots of studies have failed to establish a statistically significant difference between treatment and control groups. So the researchers must conclude that the treatment is not effective. But there may be many individual patients who experienced significant individual benefits! It’s just that the significant individual benefits in the treatment group did not exceed the benefits of the control group.

The researcher, in a sense, has to dismiss the treatment’s effectiveness as being no better than the placebo’s. But each patient that responded positively has to be delighted, right? Nobody ever claims that their symptoms were less severe or that their recovery was less real. From their perspective the treatment (even if it was the placebo, and I’ll have more to say about placebos in a later blog) was successful.

What this means to me as a practitioner

As I treat patients, I have to be aware of what research has revealed about the kind of medicine I practice, and it certainly informs my treatment options, but every patient I see is a sample size of one. And what that means is that I look for unique, individual avenues to explore, and these avenues are not constrained by statistical evidence. I find this liberating in a way because it allows me to be creative in my practice; but also because it reminds me that my goals and my patients’ are the same – healing. And it really doesn’t matter if the exact same treatment given to another patient would not have the same result.

Significant individual benefits are not dependent on statistical significance in a clinical setting. I’ll have to talk to my family doctor the next chance I get and see if she has come to this same conclusion.

Unexpected outcomes

Want to know one of my favorite things about being an acupuncturist? Watching people experience healing in unexpected ways. Someone comes in for shoulder pain, right? I treat her for a few weeks with LI 4, LI 11, TB 14, SI 10, TB 10, SI 11, and a few ashi points and her shoulder gets better. She’s happy about this, obviously, but then as we’re chatting about preventive care and other things, she says “Look at the nail on my index finger! It’s finally better.” This nail had been a nuisance to her for a long time because of a really gnarly crack right down the middle. Now it was growing normally. What a treat to share in her excitement. What a treat to watch people walk away with more healing than they had thought possible

And, of course, fellow professional acupuncturists will just nod their heads, because although the details of unexpected outcomes such as this can’t be predicted beforehand, the occurrence is by no means a surprise. I never explicitly said this to her, but I wasn’t directly treating her main symptom, shoulder pain. I was treating qi and blood stagnation in the TB, SI and LI channels for her shoulder but also liver qi stagnation, which is a common diagnosis and if treated properly will create a lot of change for the patient. Sometimes this is referred to as the root and the branch. The root cause is a fundamental imbalance that needs addressing, the branch is the specific symptom. If I am successful in resolving the root cause, the “main complaint,” or branch, will respond. But removing the root cause unleashes the possibility of an effect on any number of symptoms for which the patient wasn’t seeking treatment.

The phenomenon of fingernail healing

The patient’s surprise became my surprise when I was reading an article by Daniel Schulman in The Journal of Alternative and Complementary Medicine (abstract; sorry, you’ll have to go to the library to see the entire article). His article is titled The Unexpected Outcomes of Acupuncture: Case Reports in Support of Refocusing Research Designs. His main focus is on research (and I’ll get back to that myself in a minute), and he describes two clinical cases of unexpected results. Guess what one of them is. You’re right, a fingernail healed. This time, a thumbnail. A woman who had come in for treatment of acid reflux and headaches, among other things, never mentioned her thumbnail until one day she happily reported that this longstanding problem was gone.

Unexpected outcomes as a challenge in research methods

The existence of unexpected results such as these points to one of the difficulties that the scientific community is having in designing relevant tests – particularly when comparing the results of acupuncture to conventional biomedical treatments – for the effects of acupuncture. If either my patient or Daniel Schulman’s had been in a clinical trial for effectiveness of acupuncture in the treatment of their “main complaint,” would unexpected outcomes such as these even be documented? I haven’t read a case in which they have. Even more of a puzzle presents itself if a clinical trial reveals no statistical difference between treatment and no-treatment for a symptom. What if my patient still experienced shoulder pain, but slept better, was happier in general, and experienced any number of other unexpected outcomes?

I’m not a scientist, but I’m aware that the so-called “gold standard” of clinical research, randomized, controlled trials (RCT’s) have their inherent limitations and there are many challenges facing those in the research community who are interested in comparing different treatment modalities. I’ve just begun reading some of what Ted Kaptchuk has been writing about all of this (here’s his amazing bibliography) and look forward to learning more.

Until then, what to make of this fingernail phenomenon? How common is it?