Hello, I am Kim Kyung-ryeol, an acupuncturist. Today, I will talk about the effects of acupuncture. Acupuncture is one of the representative treatments in traditional medicine. It is applied to a wide variety of diseases but is primarily known to be effective for musculoskeletal disorders and chronic pain. It's quite common to hear stories of someone who went to the hospital for back pain but didn't improve until they received acupuncture treatment at a traditional medicine clinic. Therefore, today I will review research papers on the effects of acupuncture. However, it is impossible to discuss the effects of acupuncture using just one or two studies, given the variety of results in the related literature. Additionally, due to the invasive nature of acupuncture, it is somewhat challenging to establish a control group. For a double-blind experiment, both the patients and the practitioners must be unaware of whether they are receiving real or sham acupuncture. While this may be manageable for patients, it becomes complicated for the practitioners administering the sham acupuncture.

Are you unaware that it's difficult? So usually, in such papers, the control group uses needles that do not cause dizziness or they proceed by stabbing any location other than the blood site. Then, the real effects of acupuncture and placebo needles are compared. There are hundreds of papers on the effects of acupuncture, many of which are Chinese papers, and most of them have an impact factor of zero or are not significant, so those papers are all excluded. Moreover, even if it's a highly authoritative paper published in a journal, discussing it based on just one or two is not relevant to today's topic. Therefore, today we will look at two reviews that compile various studies on the effects of acupuncture. Both are, of course, chosen from the most prestigious journals. This approach is much more cost-effective and reliable than me sorting through dozens of papers alone. One was published in NEJM in 2010, and the other in Nature in 2014.

The content discusses two journals, noting that while it may seem meaningless to compare the impact factors of leading medical and scientific journals, it is worth mentioning that Nature has an impact factor of 41.5 and the New England Journal of Medicine (NEJM) has an impact factor of 79.258. These figures are quite remarkable. Nature covers the topic of pain management in cancer patients through acupuncture, while NEJM focuses on the effects of acupuncture on lower back pain. 

Let's first look at the content published in NEJM. The title is as follows: Acupuncture for Chronic Low Back Pain: A Randomized Trial. Since it is a review article, it comprehensively addresses the findings of various studies, and what we need to focus on is the clinical evidence. Here, three papers are introduced. The first paper, published in 2008 in the journal Spine, studies the effects of acupuncture treatment on lower back pain.

This is a meta-analysis of randomized controlled trials on acupuncture. A total of 6,359 patients were divided into groups that received real acupuncture, those that received sham acupuncture, and those that received no treatment at all. Both the real acupuncture and sham acupuncture groups experienced a reduction in pain compared to the no treatment group; however, there was no significant difference between the two acupuncture groups. This suggests that whether the needle was inserted at specific points or not, or even just pretending to insert the needle, had the same effect. 

The second paper was published in 2007 in the Archives of Internal Medicine. The study involved patients suffering from chronic lower back pain for an average of eight years. Initially, 162 patients were divided into three groups: one receiving real acupuncture, another receiving sham acupuncture, and the third receiving traditional medication and physical therapy.

The treatment was conducted for a total of 10 sessions, each lasting 30 minutes, twice a week. After the acupuncture treatment, there was a short session of manual therapy. This treatment lasted for about 5 weeks, and the effectiveness was assessed 6 months later. However, there was no significant difference between the acupuncture and the control group. Interestingly, acupuncture showed better results compared to conventional medications and physical therapy. 

The third study I want to mention is from 2006, published in the American Journal of Love FM. This study was also conducted in Germany and involved 313 patients who had been suffering from chronic back pain for an average of 7 years. It was not a double-blind study; instead, patients received standard treatment while also being divided into groups that received acupuncture and those that did not. Three months after the treatment ended, a survey was conducted to compare the two groups, and it was found that the group that received acupuncture showed greater treatment effectiveness.

The results of the three outstanding papers indicate that acupuncture is effective regardless of the location of the needle insertion. Particularly, in the second study, it is impressive that both real acupuncture and sham acupuncture showed better effectiveness than conventional drug treatments or physical therapy. Of course, there are many studies suggesting that neither real acupuncture nor sham acupuncture is effective. There are various opinions on this matter. However, the authors conclude that in cases where patients have persistent lower back pain despite having no abnormalities on X-rays or MRIs, acupuncture can be considered as one of several alternative therapies. This conclusion aligns with the guidelines jointly published by the American College of Physicians and the American Pain Society, which state that the evidence level for acupuncture is strong.

The results can change at any time and are classified as one of the non-drug treatments that can be used alongside physical therapy, thermal therapy, yoga, and massage. I will provide links below to the review papers by NA and the updated guidelines from the American College of Physicians last year. Next, let's look at a paper published in the journal Nature. The title is Integrative Approaches for Cancer Patients: Discussing the Effectiveness of Alternative Medicine. This paper addresses acupuncture as one of the alternative therapies to alleviate pain in cancer patients. It notes that previous reviews did not find significant differences in effectiveness between acupuncture and other treatments. It explains that the location of the acupuncture points and the frequency of treatment do not significantly matter, and that sometimes effects similar to actual acupuncture treatments can occur even without needles, or the results can be better.

The tone of the journal Nature is quite negative, to the extent that it uses the term pseudoscience, which is more critical than NEJM. The examples given are mostly ineffective. For people in our country, there is a significant misunderstanding. The Journal of Alternative and Complementary Medicine focuses on medicine, while Nature is a pure science journal. Koreans might think that doctors dislike alternative treatments, but from a foreign doctor's perspective, acupuncture is one of the alternative therapies that can be used alongside methods like massage or tai chi. Therefore, there is no reason to have a negative stance on it. Clinical doctors prioritize the immediate improvement of their patients, regardless of whether there is scientific evidence or not. As long as a patient feels better, that is what matters. This is why clinical doctors often refer to the Journal of Alternative and Complementary Medicine; although the scientific evidence may be lacking, there can still be clinical effectiveness, making it one of the alternative therapies.

Consider it to be a matter of degree. On the other hand, in a pure science journal like Nature, it is impossible to acknowledge acupuncture treatment as effective when tested under double-blind conditions. Since there is no effect under double-blind testing, it is not incorrect to say that most studies show a bias in favor of positive results. This is why a very negative tone emerges in the discourse. 

When I reviewed various studies, I found that acupuncture generally shows no effect when tested under double-blind conditions. However, it does show effectiveness when no other treatments are administered, or when it is combined with standard treatments. The effectiveness of acupuncture does not depend on the specific points where the needles are inserted; rather, it is significantly influenced by the relationship between the patient and the practitioner, as well as the atmosphere in the treatment space. 

There could be various explanations for the observed effects of acupuncture. For example, in animal experiments, when acupuncture was applied to mice, there was an increase in adenosine secretion.

There is research that suggests adenosine secretion activates adenosine A1 receptors, which in turn exhibits a regulatory effect on pain. However, the size difference between mice and humans is significant, and the distance in neural pathways is also quite large, making it difficult to apply this theory directly to humans. 

The second concept is the gate control theory. To explain it simply, when a painful stimulus is received, there is a neural pathway that allows that stimulus to travel to the brain. However, there is a limit to the signals that can pass through this pathway. Instead of all signals passing through, only certain signals are transmitted to the brain. In other words, when the sensory nerve or pain nerve is stimulated by acupuncture, the pain signals coming from the lower back cannot pass through this gate, resulting in reduced back pain.

It is a hypothesis that gently stroking the painful area with one's hand can reduce pain, which can be explained by a similar principle. This idea is somewhat accepted in clinical practice as well. The third factor is the psychological effect, specifically the placebo effect. It means that when a reputable practitioner spends a significant amount of time with the patient, it influences the patient's psychology, leading to a reduction in pain. 

Here, I would like to mention a very interesting study published in 2011 in the journal Annie Gam, which examined the treatment of asthma patients through acupuncture. In this study, 46 asthma patients were divided into groups: one group received real bronchodilators, another group received fake bronchodilators, a third group received fake acupuncture treatment, and the last group received no treatment at all. These groups were assessed for their ability to evaluate their symptoms, and the patients themselves were asked to check how much their asthma symptoms had improved.

As a result, the F2 V1, which indicates respiratory capacity, increased by 20% only in the group that received real bronchodilator treatment, while the other three groups showed no difference. However, the degree of improvement in asthma symptoms reported by the patients themselves showed that the real bronchodilator group experienced a 50% improvement, the fake bronchodilator group had a 45% improvement, and the fake acupuncture group reported a 46% improvement. All these groups felt a noticeable improvement compared to the group that received no treatment. This means that, regardless of actual lung function, the patients felt their symptoms had improved. So, does this mean that fake treatments are bad? Fortunately, that is not the case. It is a good thing when patients feel better, regardless of lung function, especially in the case of pain. Pain is a very subjective sensation; what may feel insignificant to one person can be painful for another. There is even a phenomenon called phantom pain, where individuals who have lost limbs can still feel pain in their missing arms or legs.

You can feel it, so pain is the most subjective among all diseases, and the psychological aspect is very important. Earlier, I mentioned three hypotheses regarding the effects of acupuncture. The first is the secretion of adenosine, the second is the gate control theory, and the last is the psychological effect, namely the placebo effect. In double-blind studies, acupuncture often shows no difference from sham acupuncture treatment, so we can think that the placebo effect is the main reason. However, does that mean we shouldn't receive acupuncture treatment? That's not the case. Clinical practitioners, including myself, routinely prescribe acupuncture, and particularly in the case of dementia, unlike in other countries, our country recognizes traditional medicine practitioners as healthcare providers. Acupuncture has been practiced for a long time, and it has been widely exposed in broadcasts, so the potential for greater effectiveness is very high. In our hospital, we also have a traditional medicine practitioner, and I actually refer patients for acupuncture treatment.

I often make comments. Bring my patient right away. As soon as I can, I will share something good. Now, let me summarize my conclusion. As a palliative care physician, my opinion on acupuncture is closer to the authors' views from the NEJM article rather than those from Nature. I believe it is reasonable to refer to the guidelines from the American College of Physicians. In other words, acupuncture can be considered as an alternative therapy when it poses no harm to the patient. I have talked a lot today, so I will wrap it up here. I will include links to all the papers and guidelines mentioned in today's video in the description below, so those who need them can check them out. If you found today's content helpful, please like and subscribe. I will come back next time with more helpful information. Thank you.

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