Acupuncture, some dodgy maths and a cracking review paper

I have a challenge for you. Imagine you’re in ancient China and you’ve had this idea that health and disease hang on the flow of energy through invisible energy pathways called meridians that can be manipulated by applying needles in certain specific points. How do you go about systematically validating this theory? How do you know where the points are and which combinations work?

grey Acupuncture, some dodgy maths and a cracking review paper

Some colleagues* and I were thinking about what it would have taken to develop acupuncture systematically by gathering basic case study level evidence. We are not mathematicians though and have made some cheekily broad assumptions and our maths could be wrong (since, to a man, we consider ourselves borderline innumerate). Here is what we came up with, but if anyone has a flair for this kind of thing then wade in and do better. It amused us greatly.

Here goes:

There are around 400 different acupuncture points in the early acupuncture texts.
If you stick in just 4 needles the possible permutations of different needle patterns are 25,217,757,600
If you stick in 10 needles the possible permutations are 9.4 to the power of 25
If you stick in 20 needles the possible permutations are 6.8 to the power of 51
If you stick in 200 needles the possible permutations are 2.1 to the power of 254

Let’s be generous and stick with just 4 needles.

The population of China when the first known Chinese acupuncture tome was published (200AD) = 60,000,000

25,217,757,600/ 60,000,000 = 420 is the number of treatments each member of the population must have to endure to collect n of 1 study data for all treatment possibilities.

The Chinese life span at that time (generously estimated without data at 50 years) would mean that the number of separate n of 1 studies that every member of the Chinese population at the time would need to have had each year in order to systematically test acupuncture is: 420/50 = 8.4. So every member of the population would had to have the same condition throughout their lives and then receive 8 separate treatments per year for every year of their life in order to get all these combos tested (for just one condition –  and acupuncture is recommended for a lot more than one condition).

But then we realised we have been too generous. To systematically develop the system from scratch you would not know a priori where the points are. Thus you would need to needle the whole body to find your hotspots. So here goes:

The average body surface area is 17,000cm2 (this is based in Europeans as we don’t have data from the Chinese population 200AD). Based on giving each acupuncture point a specificity of 1cm2,  if you stick in just 4 needles the possible permutations of different needle patterns are 35,000,000,000,000,000 (3.5 to the power of 15)

Following the same calculations as above the number of different n of 1 studies that every member of the Chinese population at the time would have to have had each day in order to systematically test acupuncture: 3,176 per day. That’s a treatment every 27 seconds of their waking and sleeping life just to achieve case study level evidence (which does not sit high on our evidence based hierarchy).

Our model is ridiculously lazy (but fun), in large part due to the fact that we scribbled it down on the back of a paper napkin in the coffee shop. It doesn’t factor in time for a start, and there has been a lot of that. But nonetheless I guess it is unlikely that the theory was developed systematically. What we must be left with then is a case of “special wisdom”; that is someone a long time ago was privy to an understanding of the body that others were not and that this authority underpins acupuncture.  As with most arguments from authority it would more than surprise me if it were true.  As Benjamin Franklin famously declared “It is the first responsibility of every citizen to question authority.”

Mathematical tomfoolery aside in the latest edition of “The Rheumatologist” Professor Donald Marcus has written a comprehensive assessment of the evidence relating to acupuncture for the treatment of pain. I would strongly recommend that you read this review as it is one of the best I have seen. The evidence that acupuncture is essentially a placebo treatment, the real meaning of the current plethora of  “acupuncture lights up the brain” studies ,the discussion regarding what this means for the provision of this therapy and how you might address the issues with patients strikes a great balance and is presented with genuine clarity. It is also open access with no pay-wall so get stuck in….

*A big hug for John Cossar, Physio lecturer extraordinaire who boldly got out his abacus for the good of science.

About Neil

grey Acupuncture, some dodgy maths and a cracking review paperNeil O’Connell is a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He divides his time between research and training new physiotherapists and previously worked extensively as a musculoskeletal physiotherapist. He also tweets! @NeilOConnell

Neil is currently fighting his way through a PhD investigating chronic low back pain and cortically directed treatment approaches. He is particularly interested in low back pain, pain generally and the rigorous testing of treatments. He also tends to get all geeky over controlled trials.

References

grey Acupuncture, some dodgy maths and a cracking review paper

Donald M. Marcus (2010). Is Acupuncture for Pain a Placebo Treatment? An examination of the evidence. The Rheumatologist

Comments

  1. Sara Brentnall says:

    Sounds like a shiraz conversation not a coffee one!
    A great read!

  2. Dr. Marcus writes in the linked article “Expectation of benefit plays an important role in the efficacy of placebo treatments. A number of acupuncture trials revealed a correlation between patients’ pretrial expectations of benefit and outcomes.” Well, duh. This can be said of many treatments, often including surgeries (for pain) given its subjective nature.
    Carol Levy
    author, A PAINED LIFE, a chronic pain journey
    Founder, womeninpainawareness.ning.com

  3. rory solomon says:

    Couldn’t you make a similar argument for the development of, say, penicillin? I mean, western scientists could’ve taken a purely combinatorial approach to finding cures for different ailments. Consider the periodic table, calculate the number of combinations — except, that number is actually infinite since elements can chain together to form new molecules. And when you consider other things like possible dosages, and the amount time required to administer treatment, it becomes a wonder we’ve discovered anything at all! Of course experimentation arose out of other methods, and even folk knowledge (apparently people had been using penicillin to treat certain conditions since the Middle Ages) as I’m sure was also the case in China regarding acupuncture.

    cheers -

  4. Julia Hush says:

    I really loved this article. The confronting thing is that, as an equally geeky sciencey character as Neil, I can’t help but wonder how placebo alone (I’m not dissing it here for a second!) has sustained one billion savvy Chinese people for over 2000 years (that’s 2 with a lot of zeros for you maths dudes). What does all that tell us???

    Neil O'Connell Reply:

    thanks Julia,

    I think it tells us that the non-specific effects of care, regression to the mean, wishful thinking, polite patients and natrural recovery make pretty much any therapy appear to be effective.

    Julia Reply:

    Hi Neil,

    Understood. But what about for chronic conditions (so natural recovery not going to be a player), that are not episodic (so statistical regression to the mean out too) for patients that don’t care about being polite? That would have to account for a reasonable chunk of the billion people over 2000 years – all non-specific effects or positive expectations? Entirely possible and interesting.

    Playing devil’s advocate and not being any sort of champion for acupuncture (I tried it once myself and hated it!) I’m wondering whether the effects just can’t be readily explained by our Western biomedical worldview. The rational response to that is: if it can’t be explained by biomedical science in any other way than placebo etc, then there are no specific effects of the therapy. That is most likely the case.

    But… (going completely out on a limb here and risking being considered a complete loon), is that a little like trying to develop a mathematical formula that explains how to catch the perfect wave, and if you can’t then you conclude it isn’t possible to catch the perfect wave? I guess I’m giving a nod to good old Karl Popper with his analysis of how scientists readily, but occasionally erroneously, dismiss anything that doesn’t fit into the current scientific worldview or paradigm.

    These are just coffee-fuelled early morning ramblings… feel free to completely ignore!

    Julia

    Sean Carmody Reply:

    Paradigms? Isn’t that Thomas Kuhn rather than Popper? I haven’t read very much Popper, so he may have talked about them too.

    Neil O'Connell Reply:

    Steady on the coffee Julia!

    First on chronic conditions – the course of chronic conditions while stable overall generally remains cyclical, and since you seek care, or enroll in a trial when symptoms become so bothersome as to demand action, regression to the mean and the natural course can still play a role.

    In terms of the historic endurance of acupuncture (can they all be wrong?) I would say surely they can. Folk medicine all over the world has an enduring appeal despite that fact that it doesn’t do well in trials – why? Because of all of those confounders we mentioned before. I would wager we could invent a fake therapy today (lets call it “lunar energy dynamics” from scratch, promote it and we would see “responders” in no time. It is very rare for any bogus therapy not to appear to work. It’s what Sir Peter Medawar called part of this the “conspiracy of goodwill” – the full quote is in the quotes section on this page: http://www.dcscience.net/?page_id=13

    Also the endurance and ancient history of acupuncture isn’t as simple a story as we might think – see here: http://www.sciencebasedmedicine.org/?p=252

    Finally in terms of paradigm shifts (Sean is right that was Kuhn) we might try to think of reasons why the data might not be correct but I think this is a false errand.

    We should consider Occam’s razor (what can be made with fewest assumptions is made in vain with more, or more simply, the simplest explanation that requires the fewest flights of fancy is the best one). We can test the logical predictions based on acupuncture theory, and where this is done rigorously it falls short. So rather than conclude that it might still work, which would require us to invent whole new theories about the body and contradict a huge body of knowledge, we can look at all the reasons we know of why it falsely might appear to work, consider its base implausbility, and look at the data that shows no difference over any kind of sham, and small effects compared to nothing in RCTs and conclude to the negative.

    Now I need that coffee…

  5. Jenny Moore says:

    Its an interesting bit of maths. I don’t think for a minute though that anyone in their right mind (and in saying this I am aware that this subject is plagued by people with wildly varying definitions of what ‘in their right mind’ actually means) has ever claimed that acupuncture treatments were developed systematically, but if they ever do, I will know what to say to them. I’d also add that since the ancient Chinese back in the mists of time probably didn’t have those lovely single use sterile disposable needles, almost certainly quite a lot of the test subjects would have died from septicaemia. This would further add to the number of tests to be done I reckon, and decimated the population.

    The whole placebo-or-not question is very interesting for me, and its great to see a decent paper address this. Unfortunately the majority of people I’ve stuck a load of needles in for therapeutic purposes seem depressingly uninterested in whether its actually makes them better or just tricks them into feeling a bit better. Most of em seem happy to allow themselves to trick themselves into feeling better from whatever ailment has responded poorly to all the non-placebo treatments they have tried in the past. Pesky bunch.

    Neil O'Connell Reply:

    Cheers Jenny,

    Those pesky patients may have been placebo responders although the placebo effects appear small http://www.ncbi.nlm.nih.gov/pubmed/19174438

    But we shouldn’t forget that natural history and regression to the mean might also take some of the credit, as discussed recently here: http://bodyinmind.com.au/research-into-back-pain-treatments/

  6. Neil O'Connell says:

    Hi Rory,

    Penicillin was essentially stumbled upon by an error in the lab. The interesting results were subsequently developed within a scientific framework and led to penicillin as the medicine we know. Luckily the idea fit with an established germ theory of disease and the results were world changing.

    I wonder how one stumbles upon meridian theory? It is so odd and complex that it can’t have been “discovered” by accident. But equally fro our dodgy maths it seems that it can’t have been developed systematically. To add to that it is at odds with everything a scientific model knows about the body (and indeed the universe!).

    Maybe meridian theory is the elaborate story that developed around the observed phenomena that sticking needles in”works”. But of course we can’t tell that by observation – any therapy one cares to think about or invent is likely to appear to work. So perhaps it is the story built around the observed illusion of efficacy.

    This post is ultimately just playfully fascetious becasue we have tested meridian theory and it confers to additional therapeutic benefit to sticking the needles in any old spot. Indeed for pain it doesn’t even seem to be important to stick the needles in at all, as long as you convincingly pretend to. A good explanation of that? Placebo.

  7. I don;t know if there is, or can be, a ‘scientific’ basis or not. What we do have to keep in mind is that Western methods are often diametrically opposed to Eastern. It is interesting that docs here have found ‘trigger points’, how did they come up with that, and acupressure sites. These are now in the mianstream. As a hypnotherapist, hypnotherapy was dismissed for ages and is now a legitimate medical tool.
    Carol

    Neil O'Connell Reply:

    Hi Carol, the great thing about a scientific approach is that it doesn’t matter what culture or approach an idea has emerged from – one can make reasonable predictions basedon the model, rigorously test them and find out if they are correct. And to borrow from a response I have made previously on another comments thread:

    “TCM is a system of medicine built on rather prescientific foundations. The last couple of hundred years have seen stratospheric strides in our scientific understanding of health and disease. It seems unlikely that this body of knowledge can be true whilst simultaneously a completely separate and contradictory explanation is true.”

    Finally as for triggerpoints – they may be mainstream in clinical practice (and to my frustration acupuncture moves in that direction – if we define mainstream as popular), but there is no consensus as to what they really are, their physiology or clinicians ability to reliably identify them. As such they are an interesting idea/phenomena of uncertain clinical importance. Clinically mainstream but scientifically …. the vote is not in.

  8. Cristi Stoica says:

    Interesting and fun calculations. They inspired me to wonder what will happen if you make the following substitution:

    400 points of acupuncture -> the number of medicines in modern medicine
    the number of people on which acupuncture was applied during the history -> the number of people medicated in modern times

    It seems to me that, although there may be more people treated by modern means than those treated by acupuncture, the number of modern medicines is way much larger than the number of acupuncture points. So, how on earth could they be tested? You will answer (correctly perhaps) that modern medicine got its many medicines from a much lower number of fundamental principles, which were applied to many situations and therefore many medicines resulted. Well, the specialists in acupuncture claim the same about their practice (in particular, you cannot just assume that they randomly plugged needles at various depths in the skin and waited to see the results as in the black-box method). They consider that the points resulted from a few fundamental principles.

    So, even if you are right to dismiss acupuncture, this particular argument rejects in the same measure modern medicine.

    Neil O'Connell Reply:

    But from where did those few fundamental principles come, are they themselves backed up by evidence?

    My admittedly flippant argument is not that this is how acupuncture came about. Clearly it isn’t. So the question is from where did those ancient folks derive their knowledge – and can it be tested? Of course it has been tested and it doesn’t do very well.

    Cristi Stoica Reply:

    > So the question is from where did those ancient folks derive their knowledge – and can it be tested? Of course it has been tested and it doesn’t do very well.

    I do not discuss the validity acupuncture vs. modern medicine. My only point was that this particular counting argument you provided works to the same extent with modern medicine. If you can’t test 400 points in acupuncture in thousands of years, how can you test millions of medicines in few decades?

    I do not say this to reject modern medicine or to sustain acupuncture, I am only discussed your particular argument. I think that, no matter how right you are about your conclusion, you should only give the correct arguments. If the conclusion is correct, why compromising it by bringing in arguments which can be easily dismissed? Thou shall not fight pseudoscience with pseudoscientific arguments :-)

    Of course, I know that you told your counting argument as a joke, and I find it funny. I find a joke even funnier when it has unpredicted implications :-)

    Nice post.

    Sean Carmody Reply:

    Cristi Stoica I don’t think your substitution works. If I understand Neil’s argument correctly (and I have to confess to knowing something about mathematics but nothing about acupuncture), a key point is that the selection and sequence of acupuncture points is (supposedly) an important aspect of the treatment. So, to simplify, if there were only 10 possible acupuncture points and a treatment involved a sequence of 3 pricks (so 2, 9, 3 is different to 9, 3, 2), then there are 720 possible treatments to test. As Neil’s calculations show, when the 10 and the 3 are increased, the numbers increase rapidly. In the case of Western medicine, the situation is much simpler: it is (generally) a matter of testing different medicines independently. While adverse interactions may be a concern, aspirin is a cure for some ailments and so is penicillin, but we do not consider aspirin and then penicillin versus penicillin then aspirin as two alternative treatments to consider. Sticking with the simple case, if there were only 10 Western medicines, there are only 10 things to test, but in the acupuncture case, sequences are important, so there are 720.

    Cristi Stoica Reply:

    @Sean Carmody: so many permutations for acupuncture, while modern medication is so easy by comparison! I wonder why they don’t make MDs by mail or summer schools :-)

    Seriously now, if the modern medicines act independently, then why do they come with a set of instructions as large as a contract with a bank? See for example the contraindications, side effects, misused and interactions of a very used medicine named diazepam (http://en.wikipedia.org/wiki/Diazepam).

    By the way, despites being among the most used (and tested?) medicines in the last 40-50 years, it seems to be evidence that diazepam is not better than placebo (http://www.ncbi.nlm.nih.gov/pubmed/6763943)

  9. Jono Stephens says:

    From the article by Dr Marcus:
    “A National Health Statistics Report estimated that in 2007, there were 17,629 visits to acupuncturists at an out-of-pocket cost of more than $827 million.”

    Really?

    My abacus tells me that this works out to $46,911 per visit which seems a little bit on the high side to me.

    Neil O'Connell Reply:

    Great spot Jono – I reckon they’re using them fancy gold needles! I wonder whether the costs figure isn’t the totak spent on all CAM therapies rather than just needling – seems high though and I don’t have the report he references.

    In saying that if you were spending that kind of money the old cognitive dissonance would see to it that you definitely felt better after!

  10. neil goodenough says:

    just thinking aloud, but
    does the placebo effect require a certain level of higher cognitive functioning on the part of the patient?
    just because, acupuncture has been used successfully on children with cerebral palsy,
    but has anyone studied the effect of acupuncture on groups which have been differentiated by their degree of cognitive function? with any condition, really?
    Just before we do a sys review or meta analysis and see if we can analyse the effect of acupuncture on those individuals with CP who do Vs those who do not have a cognitive impairment.
    i’m assuming (out loud and without prejudice and possibly without engaging brain first) that the placebo will have no effect on those who are unfortunate to have a cognitive impairment.

  11. neil goodenough says:

    i think i’ve opened a can of worms in my head, meaning yet more late nights on google scholar initiated yet again by one of neiloconnel’s blogs,
    but interestingly,
    Liu et al (http://en.cnki.com.cn/Article_en/CJFDTOTAL-REST201003007.htm) have tested the effects of acupuncture on rats with asphyxia induced CP, including a sham group, that concluded that acupuncture can contribute to proliferation of neural stem cells.
    no placebo there then.
    i think John Cossar might need a bigger abacus to do the maths on this one.

    neil o'connell Reply:

    Hi Neil, now get some sleep!

    I will tell John to stand down with the abacus for a bit. There are a few issues with these animal studies in general. They are rarely blinded (in terms of the researcher) and it puts me in mind of the Bienveniste “memory of water” homeopathy debacle: http://en.wikipedia.org/wiki/Jacques_Benveniste

    On top of that there is an uncomfortable problem that acupuncture studies published in China have a much higher chance of being positive than they do in the West.

    And finally who knew that there was a meridian system in rats that mirrored the one in humans? Wow, thats a whole lot more permutations to check that they match up. It reminds me of this recent study that was quite high profile that we blogged on before: http://bodyinmind.com.au/acupuncture-adenosine-and-cycling-fish/

    Do you have a reference I can check that establishes the efficacy of acupuncture in cerebral palsy (to achieve what outcome?). My suspicion is that there won’t be reliable data on that.

    Anonymous Reply:

    “My suspicion is that there won’t be reliable data on that.”
    how can you know before reading? It seems that you already decided that they are wrong. They may be wrong, but you can’t tell until you checked what they’ve done.

    “acupuncture studies published in China have a much higher chance of being positive than they do in the West”
    This argument works both ways.

    you choose one article which finds one treatment in acupuncture as effective as placebo, and reject from start other articles presenting positive evidence.

    If we should reject acupuncture because of one report on a particular treatment, should we as well reject western medicine because of some reports showing particular medicines to have the same effects as placebo? It looks that you have higher exigences for acupuncture as compared to the exigences for modern medicine. It seems like a double standard.

    Neil O'Connell Reply:

    Hi anonymous,

    I think I should be clearer – my comments are often rattled off in haste between real work!

    I stand by my assertion that I doubt there will be reliable data on that as I have become quite familiar with the literature and it is the common story. It is well evidenced in the following systematic review of systematic reviews of acupuncture for any indication, as well as in pain: http://www.ncbi.nlm.nih.gov/pubmed/16956145

    From this one might conclude that we might not “reject (ing) acupuncture because of one report on a particular treatment” but based on a mountain of evidence.

    It is perfectly acceptable to have a hunch about what data will show, particularly in the light of the bulk of evidence and in this case in the absence of genuine prior plausbility. You will notice I did not say “NO WAY”, merely “can you point me to the evidence”. For that I make no apology. I have not rejected the article since no article has been presented for me to appraise.

    As for the thing about positive trials coming from China – that comes from this review: http://www.ncbi.nlm.nih.gov/pubmed/9551280

    Now I can understand cultural differences affecting placebo response rates, but if the TCM model of meridians etc were true why would it vary from place to place?

    I am all for seeing the evidence. But I do need to see it. Until then I feel entirely justified in making reasonable predictions based on a large body of evidence.

  12. As you know, some of these trigger points are used also for pressure or application of heat. Natural usage of finger pressure is a well proven method to find small tiny relevant spots on our bodies. Touch and pressure, warmth and cold are tools even most of y’all used to do the one thing thought mathematically impossible by the typical parents – against all odds at the earliest moment conceivable, you found the sweet spot and started to masturbate. If you ever – as myself- had repeated upper respiratory tract infections with underlying asthma and spent time actually fingering all over your body to find interesting spots to make the cough irritation better, to make any of these feelings better, you would find that after a few days and nights there actually are such spots. Then I got myself a book and to this day, some massaging does offer the “placebo” relief I know works, is free, and no side effects. But if your analysis is correct – pure permutation and try outs are implausible – then the Chinese must have used other means to come up with their model based acupuncture treatments. They may have worked towards establishing a theory and then derive solutions and test these, rather than permutating. Similarly, many of our modern day inventions are not the result of sheer permutation but came about much differently.

  13. NIH actually gives some credence to acupuncture http://consensus.nih.gov/1997/1997Acupuncture107html.htm
    re the rats, anecdote – my mother used homeopathic meds for dog who shook so uncontrollably from thunder and lightning that she needed tranquilizers.
    Vet gave the dog a homeopathic med and she was equally tranquilized.
    How in the heck did this dog’s brain know to behave as with a placebo? Odd.

  14. “but we do not consider aspirin and then penicillin versus penicillin then aspirin as two alternative treatments to consider”
    Actually that is often the case, “take 2 aspirin and call me in the morning.” – and, if no better, you may well get a script for penicillin. The penicillin doesn’t work – obviously not an infection (or one penicillin will help) so take some aspirin and you may feel better.

    Sean Carmody Reply:

    That is still rather different from the scenario Neil considers. In the example you give, it is a case of penicillin failing to work and so on to the next option. You still are working through on a yes/no basis for each possible treatment. It will not be a case of saying, “we tried penicillin then aspirin and that didn’t work, so now let’s try aspirin then penicillin”.

    carol Reply:

    I was responding to your quote but yes it is somewhat apples and oranges in terms of penicillin will cure syphilis for instance but aspirin won’t. (But then of course the doc would know the ailment for which he was giving treatment.)

    Sean Carmody Reply:

    The point of the quote was whether or not “A then B” and “B then A” should be considered two completely different possible treatments rather than considering A and B independently (each of which may or may not work).

  15. (Neil, you might find this interesting. I have an experimental sensory cortical implant for my face and eye pain.)

    neil o'connell Reply:

    Hi Carol, that is fascinating (I recently published a Cochrane review on non-invaiseve brain stimulation techniques for pain). Would love to know where the electrodes were targeted and how helpful you are finding it.

    As far as the “it works in animals argument thereforwe not a placebo” argument goes I don’t really buy it. The data on this is generally poor quality and not adequately blinded, and of course the observewrs are prone to their own biases. The skeptic blogger Xtaldave covers it noicely here: http://xtaldave.wordpress.com/2010/05/19/quick-follow-up-to-homeopathy-is-witchcraft/

    carol Reply:

    I can only tell you sensory cortical right, directly attached to the dura. (for left sided pain).
    Talk about permutations and combinations. I believe it helps somewhat. I would never have it removed believing that there is some benefit. I cannot truly say it is a lot but it is more my eye pain at this point not facial so that may be part of the issue of benefit. I have 4 polarities, that can be changed, pos, neg, or off. I also have the ability to change the amplitude, range, and cyclical, from 0 off to as I now have for instance, 15 minutes on 3 hours off, to 1 minute on 23 hours off, vice versa and so on. (Most patients don;t get the computer to do this but I was entrusted with one when I first was given a dorsal column stimulator implant.) I do notice some change, though it is not quantifiable when I plateau with a certain formula.
    The battery is dying and needs to be changed soon. That being the case I can only say the combination now in play is done. Replacing the battery gives me the chance to try those, I imagine, thousands of other combinations. (I know the term but not the math (: )
    As for our dog, I don’t know I would extrapolate to this worked so therefore……
    (that being said the difference between an animal shaking so hard with fear even the vet feared damage to her to ‘who cares it’s thundering and lightning’ so I don;t need to hide and shake was astounding to me. Why the heck did that work? (I still, honestly, do not believe in homeopathics despite first eye experience.)

    Neil O'Connell Reply:

    Thanks Carol,

    You’re so right – so many permutations again! It is the first I have heard of that approach, really fascinating and I hope it gives you relief.

  16. @Cristi ahh, now interactions I can accept. But that would take you into the realm of combinations not permutions: A, B is distinct from B, C, but A, B is not distinct from B, A.

    Cristi Stoica Reply:

    @Sean
    It is pretty obvious for someone who knows elementary math that there are more k-permutations of n than k-combinations of n. But you apply this in a misleading manner. In order to say this for particular numbers, you gotta have the same n for points and for medicines. Well, while points are somewhere under 400, the number of medicines is way much larger.

    Your second assumption is that you should consider k-permutations for needles, while you consider only k-combinations for medicines. I agree that the latter is close to reality, but not the former. Probably your assumption is founded on Neill’s post. But I don’t think he has any evidence that we should count all possible orderings of the needles. I rather assume that he didn’t think that there is a difference between k-permutations and k-combinations. To support my view, I would say that he doesn’t even know how to write numbers. His statements

    “If you stick in 10 needles the possible permutations are 9.4 to the power of 25
    If you stick in 20 needles the possible permutations are 6.8 to the power of 51
    If you stick in 200 needles the possible permutations are 2.1 to the power of 254″

    should be translated as

    “If you stick in 10 needles the possible permutations are 9.4 times 10 to the power of 25
    If you stick in 20 needles the possible permutations are 6.8 times 10 to the power of 51
    If you stick in 200 needles the possible permutations are 8.1 times 10 to the power of 493″

    which are not the same, although are all large numbers.

    These numbers and those observed by Jono Stephens in Dr Marcus’s article make me have serious concerns about how the much more difficult apparatus of statistics is used by some researchers. This in addition to using fallacious arguments when I am sure there are much better ones.

    Sean Carmody Reply:

    @Cristi: You are certainly correct that I am basing my comments on the post–I know nothing about acupuncture. As I see it, Western medicine is primarily about individual effects: does aspirin work for this condition, yes or no, does penicillin work for this condition, yes or no, etc. A secondary consideration is interaction effects and this is largely about negative implications or side-effects rather than whether treatment A+B can generate can provide a treatment that neither does by themselves. If this analysis were to apply equally to acupuncture (and I don’t know enough to judge), then individual pressure locations would have to either have or not have effect. The gist of this post, as I read it, is that both combinations and in fact permutations are relevant. Even if the order is not in fact important, if it is essential nun acupuncture that multiple needles are applied and that the yes/no analysis does not apply to individual pressure point, then the key point of the post remains, namely that there are far more possibilities to test that it may first appear and a direct substitution to Western analogies is not valid. I am happy, of course, to be told that individual points in acupuncture can be tested in isolation.

    Neil O'Connell Reply:

    Hi Cristi,

    Apologies for any numerical nomenclature naivety I have shown (I am clearly not a mathemetician). As Sean says the point is whichever way it is sliced there are just too many combinations. The difference between this and modern medicine is that on the whole I can trace the background and development of most modern treatments, I can check the underlying obervations/rationale that led to its development.

    I can’t do this from meridian theory as in scientific terms it makes no sense. If it is not underpinned by a logical rationale and it wasn’t developed by the iterative process imagined in the post then it is an argument from authority.

  17. Thanks Neil, I have been thinking about some issues I am having, extra facial swelling, higher light sensitivity, etcl. I am starting to think I do need the battery changed soon, that it was helping.
    You probably havent heard of it because supposedly I was only 12th in world to have it and majority have it for thalamic issues. My understanding is no one is now trying it (but as you probably know they are doing a lot with motor cortical implants for pain.)
    I do not think he has written about it but the surgeon was Giancarlo Barolat, in Colorado, Barolat Institute.

  18. Bronnie Thompson says:

    Re: Carol’s observation regarding homeopathy for dog in thunder…
    The reason dogs in particular might respond to ‘homeopathic’ preparations is their highly tuned recognition of human behaviour, and the history of associating being given something ‘good’ from said human – classical conditioning. A dog shaking with a thunderstorm, when given a homeopathic preparation in conjunction with a soothing human, especially the human who has been giving the dog food, warmth, shelter, treats, is likely to respond with a wonderful classical as well as operant conditioning response. Now if the preparation was administered to the dog by a machine, the behavioural observations recorded by video, and the human recording the responses was a cat lover and didn’t know the dog at all – and then there was a statistically and clinically significant response, I might be more inclined to believe there was something in it. Replace homeopathic preparation with acupuncture in said situation, voila.

  19. It is interesting that some people do not “believe” in meridians that are used by acupuncture etc. – The precise neurological mechanism may not be apparent, but it is a fact that nerves that carry consciously perceived stimulus or pain information do not just do that – and so irritatingly there is this thing called “referred pain”. While some have the comfort of being able to ignore that, others are not. I am reminded daily of this irritating reality of subthalamic and subcortical networking and branching of our human anatomy of nerves. As right below elbow amputee, the very moment of opening my bladder sphincter and starting to let the urine flow will cause an immense amount of buzz on my phantom sensation. It is like someone plugs my phantom hand into a 500 volt source and the hand sensation starts brimming enormously. It is occurring always, predictably, and cannot be avoided. I do not take any drugs – and it is happening each and every time. Given that reality, such reminders of there being cross links are not tangible to most and that makes it therefore hard to understand for others. In the amputee community there are others with some phantom / internal organ link they cannot block mentally either – but I don’t know who else gets such reminders on a daily if not hourly basis. What kicks my butt is that I never believe/d any of that myself. Given that however, we are dealing with neuroanatomy and not just fluff when it comes to meridians, no question. Given that, it must be that others researched any connection between referred pain and meridians. If we go back in time it was always that through defects or injuries, localized damage, that we learned about neuroanatomy – localized brain injuries found and documented by surgeons first lead to the discovery of specialized brain regions and the same principle could be applied to other neuroanatomy questions. From that and without effort, one finds this for example – http://www.jpain.org/article/S1526-5900(09)00010-8/abstract – Recently published data suggest substantial anatomic, clinical, and physiologic (referred pain to meridian) overlap of myofascial trigger points and acupuncture points, particularly in the treatment of pain disorders. This qualitative study examines whether myofascial referred-pain data from the Trigger Point Manual can provide independent physiologic evidence of acupuncture meridians. Trigger point regions were subdivided from prior, validated trigger point region–classical acupuncture point correspondence results into subsets according to the 12 acupuncture Organs of their anatomically corresponding acupuncture points (Bladder, Gallbladder, Heart, Kidney, Large Intestine, Liver, Lung, Pericardium, Small Intestine, Spleen, Stomach, and Triple Energizer). The referred-pain patterns for each subset of trigger point regions were graphically applied to a virtual human model along with the subset’s corresponding acupuncture Principal meridian. All 12 meridian distributions were compared qualitatively with the summed referred-pain distributions of their anatomically corresponding trigger point regions. For all 12 subsets of trigger point regions, their summed referred-pain patterns accurately predicted the distributions of their corresponding acupuncture meridians, particularly in the extremities. The myofascial referred-pain data from the Trigger Point Manual provides independent physiologic evidence of acupuncture meridians. Understanding these meridians may enhance treatment of both pain and non-pain conditions.

    Neil O'Connell Reply:

    Hi Wolf,

    Thanks for your comments and apologies for the delay in responding.

    The complexities of referred pain do clearly point to complex relationships in sensory processing between intero and exteroception. But this does not necessarily infer that meridians have validity.

    Also I would be less inclined to place much importance with regards overlap with trigger points. They are rather ill defined (and always where you look for them) and their locations have not been rigously established. From a scientific perspective trigger points (or as I prefer to call them “sore bits”) are a poorly understood phenomena that are not themselves a strongly validated concept and it is problematic to attempt to validate one phemonena via comparisons with another unvalidated phenomena.

    Similar things are being touted with regards fascia but it appears to me (and only in my opinion) to be an exercise in confirmation bias and speculative fishing. The problems with this approach are well discussed here: http://www.sciencebasedmedicine.org/?p=6995

    Finally and most importantly consider that all of the most rigorous trials point to a lack of added clinical benefit from applying acupuncture to merdian points. It doesn’t matter what you do with those needles. This lack of measurable specific clinical benefit to following meridian ideas seems to render all comparisons of meridians to any other phenomena pretty worthless.

    Wolf Reply:

    I agree, the presence of ill-understood yet at least somewhat repeatable and perceivable phenomena must be highly disturbing and, reading your reply, it probably is. Phantom pain is certainly disturbing to many and treatment is quite elusive, definitely to the Western medicine. Reading through your post it occurs to me when there were times when such perceptions as phantom sensations were attributed solely to an assumed mental derangement of the amputee! Clearly because the treating doctor could not “see” the problem and no “validated” “studies”. Luckily, these dark ages are over – but I will not hold it against anyone if they disagree. Using assumptions of deafferentiation, subcortical connections and remodeling, one can approximate a number of maneuvers that will improve phantom pain, and how cool is that. Expecting nature to work rectangularly will cause disappointment though and thus, attempts are not 100% reproducible and not 100% effective. Yet, there are clear indications generally and also, personally to me, that my phantom issues are a real neurological problem. And acupuncture as well as other activities one can undertake will produce quite similar and often repeatable results. You have the benefit of being able to dismiss such, and rightly so. What you cannot see does not exist. I perceive differently and I am not less critical – but I know and repeatedly cannot avoid experiencing that subcortical and thalamic cross over messups are real, daily, hard and often unpleasant reality that I cannot just wish away – as much as you may call that “fake”, which certainly does not diminish or alter the issue. At least it is clear *to me* that any anatomical substrate to explain the mechanism of acupuncture is not super easy to recognize – otherwise we’d read it here. I am confident that your critique remains a valid instrument to push researchers to do better studies. Such as this: http://precedings.nature.com/documents/4128/version/ “Using MicroPET Imaging in Quantitative Verification of Acupuncture Effect in Ischemia Stroke Treatment
    Xiaoyan Shen1, Hongtu Tang2, Jia Li2, Ting Xiang2, Huafeng Liu1 & Weichuan Yu3″ While acupuncture has survived several thousand years’ evolution of medical practice, its function still remains as a myth from the view point of modern medicine. Our goal in this paper is to quantitatively understand the function of acupuncture in ischemia stroke treatment. We carried out a comparative study using the Sprague Dawley rat animal model. We induced the focal cerebral ischemia in the rats using the middle cerebral artery occlusion (MCAO) procedure. For each rat from the real acupuncture group (n = 40), sham acupoint treatment group (n = 54), and blank control group (n = 16), we acquired 3-D FDG-microPET images at baseline, after MCAO, and after treatment (i.e., real acupuncture, sham acupoint treatment, or resting according to the group assignment), respectively. After verifying that the injured area is in the right hemisphere of the cerebral cortex in the brain by using magnetic resonance imaging(MRI) and triphenyl tetrazolium cchloride (TTC)-staining, we directly compared the glucose metabolism in the right hemisphere of each rat. We carried out t-test and permutation test on the image data. Both tests demonstrated that acupuncture had a more positive effect than non-acupoint stimulus and blank control (P 0.15). The immediate positive effect of acupuncture over sham acupoint treatment and blank control is verified using our experiments. The long-term benefit of acupuncture needs to be further studied.

    Wolf Reply:

    Unclear how that copy/pasted abstract became distorted here, taking away the conclusion.

    Anyway, another try:

    http://precedings.nature.com/documents/4128/version/1

    While acupuncture has survived several thousand years’ evolution of medical practice, its function still remains as a myth from the view point of modern medicine. Our goal in this paper is to quantitatively understand the function of acupuncture in ischemia stroke treatment. We carried out a comparative study using the Sprague Dawley rat animal model. We induced the focal cerebral ischemia in the rats using the middle cerebral artery occlusion (MCAO) procedure. For each rat from the real acupuncture group (n = 40), sham acupoint treatment group (n = 54), and blank control group (n = 16), we acquired 3-D FDG-microPET images at baseline, after MCAO, and after treatment (i.e., real acupuncture, sham acupoint treatment, or resting according to the group assignment), respectively. After verifying that the injured area is in the right hemisphere of the cerebral cortex in the brain by using magnetic resonance imaging(MRI) and triphenyl tetrazolium cchloride (TTC)-staining, we directly compared the glucose metabolism in the right hemisphere of each rat. We carried out t-test and permutation test on the image data. Both tests demonstrated that acupuncture had a more positive effect than non-acupoint stimulus and blank control (P 0.15). The immediate positive effect of acupuncture over sham acupoint treatment and blank control is verified using our experiments. The long-term benefit of acupuncture needs to be further studied.

  20. Wolf, I thought maybe your citation was fluff but it is not.
    Also as someone with anaesthesia dolorosa or ‘phantom pain’ in my face because of the attempted killing of my trigeminal nerve to stop trigeminal neuralgia, I do not have the consistent ‘if I do this then that’ sensations but do have the referred pain in other parts of my face as a result of the ad.

  21. Weird!

    This is how that should look like:

    We carried out t-test and permutation test on the image data. Both tests demonstrated that acupuncture had a more positive effect than non-acupoint stimulus and blank control (P 0.15). The immediate positive effect of acupuncture over sham acupoint treatment and blank control is verified using our experiments. The long-term benefit of acupuncture needs to be further studied.

  22. Entirely strange. Why is the last part of the abstract distorted here?

    Again I try:

    We _carried _out _t-test and _permutation test on the image _data. Both tests demonstrated _that acupuncture _had a more positive _effect than _non-acupoint stimulus and_blank control (_P 0.15). The _immediate positive effect of acupuncture_ over sham acupoint _treatment and blank control is _verified _using our experiments. The long-term benefit of acupuncture needs to be further studied.

  23. I apologize but it is impossible to paste the correct abstract here. This is NOT normal. Is an automatic search replace function in place that cripples posting that abstract? This is FUNDAMENTALLY wrong.

    Read the abstract here. The p-value is less than .025 for acupuncture results.

    http://precedings.nature.com/documents/4128/version/1