It’s not just acupuncture; it’s laser acupuncture!

ResearchBlogging.orgWhy, oh, why do I keep perusing NaturalNews.com?

Why do I subject myself to wave after wave of neuron-apoptosing stupidity of a magnitude that even activation of NF-kappaB, Akt, and neuronal cell survival signaling pathways can barely keep the killing stupidity at bay? I guess it’s because it provides such good blog fodder for a skeptical blog dedicated to science- and evidence-based medicine. On the other hand, it often gives me a headache to read its contents. Really, it does. I mean, looking at how Mike Adams, the Woo-meister Supreme and Chief Tin Foil Hat responsible for the lunacy there, regularly serves up fare that alternates between the simply over-the-top hilarious (unintentionally, of course) and the truly vile (although leaning more towards the vile) that the alternating current of fun woo and dumb woo seriously stresses the electrical impulses flowing through my brain.

Perhaps I could use some acupuncture for that headache.

But not just any acupuncture. Oh, no. That would be too mundane, too boring, too…pedestrian. Needles? Stuck into the skin? Physically? How primitive! There might even be a tiny drop of blood! We can’t have that! No, I’m a 21st century kind of guy, and I need a 21st century form of woo. It needs to be high tech woo of the finest caliber. Just like Dr. Evil, I want my frikkin’ sharks to have frikkin’ laser beams.

That’s right: Laser acupuncture! Fellow woo-traveler of Mike Adams Dave Gabriele shows me the way right there on NaturalNews.com:

The July 2008 issue of Pain, a prestigious peer-reviewed medical journal published by the International Association for the Study of Pain (IASP), featured a German study conducted by eight pediatric doctors and clinicians. The researchers attempted to determine whether or not laser acupuncture would prove effective in relieving the symptoms of chronic headaches in 43 children.

Oh my! Science! (I can’t help but think of Magnus Pyke in Thomas Dolby’s video for the song She Blinded Me With Science popping up periodically to shout “Science!” Or maybe, “Good heavens, Miss Sakamoto! You’re beautiful!”) Let’s see what Gabriele has to say about it:

The treatment for each child was individualized and completely based on the traditional Chinese medical theory. The theory contends that bioelectricity, or the electrical current that is produced by living organisms, has a tendency to follow paths of higher conductivity within the human body. These paths, called meridians, have been shown to be composed of points that have a higher electrical conductivity (lower electrical impedance) than other parts of the body. The ancient Chinese somehow discovered that stimulating these points, or “acupoints,” produced changes in the body’s flow of current, and by doing so, influenced the health of an individual. Stimulation of these points include many different methods, the most well-known being acupuncture. Acupuncture is when very thin, electrical-conducting needles are inserted into these “acupoints” with the intention of manipulating the current.

Laser acupuncture, a relatively new method of stimulation, uses low-energy lasers to influence the flow of current at the acupoints. The German study, which is titled “Laser acupuncture in children with headache: A double-blind, randomized, bicenter, placebo-controlled trial,” specifically focuses on the effect of laser stimulation compared to placebo-stimulation.

Lasers.

Why did it have to be lasers?

Oh, sorry. Let me continue. I find the above explanation to be utterly hysterical. Here we have a prescientific concept of how disease works, namely the idea of a mystical life force flowing through the body through “meridians” in such a way that blockages cause problems and that these “blockages” can be unblocked somehow by sticking needles into the skin into very special points along lines through which this life force (qi) flows. It doesn’t matter that these so-called meridians do not correspond to any anatomical structures yet uncovered by scientists, and that there is no physiological basis yet known that corroborates or corresponds to the explantion in traditional Chinese medicine offers to explain how acupuncture “works.” Besides, don’t be a hater, all questioning-like. It’s ancient. It’s Chinese. That means, by the principle of antiquity, that it must be good. You know that.

Of course, I was intriqued. After having been (sort of) a believer that, among non-herbal modalities in “alternative medicine,” there might be something to acupuncture, over the last year or two I’ve progressively found myself disabused of that notion. This realization that acupuncture is almost certainly nothing more than an elaborate placebo came about as I delved into the actual scientific literature studying acupuncture and found that (1) no specific effects can be attributed to acupuncture above and beyond placebo; (2) placebo acupuncture, be it of the sham variety that uses the “wrong” acupuncture points or of the variety that uses various sham needles that don’t actually penetrate the skin, generally produces the same results as “real” acupuncture; and (3) no plausible physiological mechanism that would explain all the effects attributed by believers to acupuncture has yet been postulated.

“Naturally,” I wouldn’t trust anything that NaturalNews.com says about any study. I learned long ago that it’s not exactly what you would call your “reliable” source of information. So I went straight to the source, so to speak, and looked up the actual paper, Laser acupuncture in children with headache: A double-blind, randomized, bicenter, placebo-controlled trial. The study came out of Germany, with most of its investigators based at Saarland University, and the corresponding author is Sven Gottschling.

Before I looked at this paper, I just had to know: What the heck is laser acupuncture? I had no idea, and, unfortunately, the paper was maddenly vague on just what it meant, although the actual laser was described as follows:

The patients were treated with a class 3B laser. The laser used was a schwa-medico , continuous wave, power density 3.8 W/cm2, 1 mm laser beam diameter, REF 205237, schwa-medico, Ehringshausen, Germany. Before the laser was switched on, the patient, the acupuncturist and any other person in the room (e.g. parents) put on protective glasses specific for 830 nm wavelength. The glasses were used for eye protection, as required for Class 3B lasers. For both, the acupuncturist and the patient, it was impossible to differentiate between active and placebo laser because of the invisible infrared laser beam, being subthermal. Therefore no perceptible physiological changes occurred.

What the hell? What’s this “subthermal” nonsense? How did they test that it was impossible to differentiate between the two. At a wavelength of 830 nm, this is an infrared laser, and infrared light generates heat. It may not be perceptible if the laser is not held in the same spot for long, but it isn’t clear how long the laser was held at each acupuncture point chosen. It is true that 3.8 W/cm2 is pretty darned low power (the laser power ranges used to treat, for example, condylomata, is in the range of 300-1000 W/cm2. However, those are energy ranges meant to fry the warts. Still, what, exactly, was the placebo? It must have been no laser light at all, but it is not clear that this was the case. Moreover, as far as I could tell, it wasn’t verified formally that the subjects couldn’t tell whether they were in the placebo group or the group receiving real laser treatments is a significant flaw in a study of this type. Indeed, look at how a medical laser acupuncture page describes near infrared lasers:

Gallium-Aluminum-Arsenide Laser (780-890 nm)
Deeper penetration. Near infrared, invisible light. Many applications, inexpensive, very useful for the treatment of pain, but also effective in healing. Most popular therapeutic laser. Valuable to reach very deep acupuncture points or deep Ah Shi points (Figure 4).

Gallium-Arsenide Laser (904 nm)
Greatest depth of penetration, deeper than gallium-aluminum-arsenide. This is due to a much longer wavelength and because they are pulsed, forcing the laser light deep into the tissues. Useful for reaching deep acupuncture points and for the treatment of pain. Continuous wave lasers are now also available (Figure 4).

Of course, just from the descriptions above, you can tell that shooting a laser beam at the skin is very different than sticking a needle in the same point. A needle is simply a physical object, but laser is light and it transmits energy as long as it is turned on. This is a slight of hand that acupuncture enthusiasts like to use, particularly when they hook up electricity to acupuncture needles and call it “electroacupuncture.” All “electroacupuncture” really is is transcutaneous nerve stimulation, a valid, evidence-based method of treating pain whose efficacy has nothing to do with qi or meridians. It’s quite possible that, if this study shows a real result, something like that is going on. In other words, if laser light aimed at the skin affects pain pathways, it is almost certainly not a validation of acupuncture as a concept. Moreover, most reports of laser usage (for example, for laser-evoked potentials, report the total energy delivered to each spot. For example, this study reported the laser stimuli used as 17.0 ± 3.4 mJ/mm2, an energy level that subjects reported as “moderately” painful. Actually, even though comparisons between visible light laser (as in the LEP study just mentioned) and infrared laser, which penetrates deeper, I strongly suspect that the subject could probably perceive whether they were receiving real laser energy, as it was reported that each point received 0.9 J.

But what about the study design? I will give the investigators credit for trying to double blind the study, but, as I said, unfortunately they didn’t verify the quality of the blinding by asking both the practitioners and the subjects which group they thought they were in. The treatment protocol was rather unusual, too, in that it essentially allowed the acupuncturist to use the methods of traditional Chinese medicine to pick whatever he or she thought to be the best points to laser:

A combination of traditional Chinese body acupuncture and auriculotherapy was applied. Treatment was based on TCM criteria (history, pulse diagnosis, tongue diagnosis) in some patients combined with a computer-based measurement of skin resistance differences (Acussana Proacus, Acussana GmbH & Co. KG, Dautphetal, Germany) at defined points to narrow down the range of applicable points. Basic points for patients with frontal headache were large intestine 4 (He Gu) and stomach 36 (Zu San Li), for patients with lateral headache Sanjiao 5 (Zhi Gou) and gallbladder 34 (Yang Ling Quan), for patients with occipital pain small intestine 3 (Hou Xi) and bladder 60 (Kun Lun), and for patients with holocephalic pain Du Mai 20 (Bai Hui). Additional body acupuncture points (e.g. locus dolendi points) and ear acupuncture points could be chosen individually. There was no limitation of points in this study. The acupuncturist was allowed to decide whether to laser uni- or bilaterally. The settings and technique of laser radiation used on each patient were: continuous wave mode, using vertical contact with the skin and a duration of 30 s resulting in an intensity of 0.9 J/point.

Yes, I think htere’s a good chance that the subjects might have been aware if they were receiving the laser and not the placebo laser, which makes verifying successful blinding imperative. On the one hand, I like the fact that the investigators let the acupuncturists do whatever they want based on whatever woo they wanted. It takes away the usual excuse that randomized trials are “restricting” them and preventing them from treating the patient “wholistically.” On the other hand, it adds so much variability that it’s hard to interpret.

So what was the result? Primary outcomes were “headache days,” or days during which subjects had a headache, which were compared before and after treatment in both the placebo and treatment groups. Another method was to examine the headache intensity by a visual analogue scale (usually either a number from 1-10 for pain intensity or in younger children a scale of sad to happy faces). Finally, headache duration was measured to estimate “total headache time.” All reporting was by logs kept by subjects and/or parents. It was first noticed that the number of headache days decreased by 7.0 for the treatment group and 1.2 for the placebo group. It was observed that headache days decreased in the placebo group but then increased back to baseline, whereas the treatment group decreased and stayed down. Total headache duration was also reported decreased compared to placebo, although the duration of individual headaches did not. Similarly a less impressive decrease in headache intensity was also reported.

Does this study tell us anything? One thing it doesn’t tell us anything about is whether acupuncture works. I can’t emphasize that strongly enough. What is being tested is not acupuncture, and to call it acupuncture is a distraction. The only reason that I can think of to call it that is to ride the “complementary and alternative medicine” wave of popularity, perhaps for marketing or grant fudning. No, what we’re really looking at is whether laser stimulation of a bunch of points might do something that potentially relieves perceived intensity of headache. Another thing it doesn’t really tell us for sure is whether laser skin stimulation relieves headache pain any better than placebo. It may well be that it does, but there is sufficient doubt about whether the blinding in this study was successful, and the investigators didn’t test it. After all, if the laser is energetic enough to do these things:

There are data about laser-tissue interactions inducing an inhibition of Na+-K+-ATPase, exerting influence on the resting potential of cells. Moreover laser can induce a reversible blockade of mitochondrial transport, resulting in a neurotransmission failure in A-delta and C fibres leading to pain relief.

Why wouldn’t the laser be energetic enough to be felt? Even so, we can’t say that treating the skin with laser didn’t reduce headache pain in children compared to placebo. We just can’t say with a lot of confidence based on this study that it did, and we certainly can’t say that acupuncture works.

In fact, this study is an excellent example of the obfuscations of language inherent in CAM, not to mention a high degree of skill in coopting whatever’s hot and sexy in terms of therapies. It could well be that acupuncturists realized that, to the public, everything’s better with a laser, whether use of the laser is appropriate or not. Or, equally plausible, it could have been physicians who use lasers for other purposes, such as burning condylomata, who realized that acupuncture is hip and hot and thus decided that they want in on some of that action. Whatever the case, it doesn’t matter. What has happened, apparently, is that acupuncture and laser therapy have met, and they are now making beautiful woo together.

REFERENCE

S GOTTSCHLING, S MEYER, I GRIBOVA, L DISTLER, J BERRANG, L GORTNER, N GRAF, M SHAMDEEN (2008). Laser acupuncture in children with headache: A double-blind, randomized, bicenter, placebo-controlled trial Pain, 137 (2), 405-412 DOI: 10.1016/j.pain.2007.10.004