There are a couple of fantastic boy bloggers here at ScienceBlogs who write about the marketing of unvalidated alternative therapies to patients (a practice they call "woo"). I agree with them that is completely unethical to market a therapy (or, non-therapy) using claims that have not been scientifically tested and peer reviewed. That said, is there any value to treatments we traditionally think of as "alternative?" Do they have a place in traditional medicine, provided they are subjected to the same rigorous scrutiny as traditional therapies?
In a paper published in this month's Journal of Applied Physiology Liang-Wu Fu and John C. Longhurst of the University of California, Irvine use techniques well-regarded in the field of neurophysiology to describe a potential role for electroacupuncture in the treatment of hypertension and cardiovascular disease. The authors studied a site in the brain known to control cardiovascular function, the midbrain periaqueductal gray (IPAG), and describe the biochemical changes in the region caused by electroacupuncture stimulation of Neiguan-Jianshi acupoints P 5-6.
Electroacupuncture is similar to traditional acupuncture in that the practitioner inserts a series of thin needles into the body based on the Chinese belief that there are "meridians" in the body along which one's "qi" or life force flows. These needles affect the flow of qi and improperly flowing qi is thought to be a source of disease. According to the NIH consensus statement on acupuncture, theories in Chinese medicine "are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture." In electroacupuncture, a low voltage is applied to the needles to generate an electrical current. The FDA has serious concerns about the safety of current electroacupuncture devices. They note that, "For each device [studied], at least two measured parameters were not within 25% of the manufacturer's claimed values." Given the NIH and FDA's statements, clinicians are well-justified in being skeptical about the safety and efficacy of electroacupuncture.
That said, the data from Dr. Longhurst's lab are worth stopping to take note of. In experiments published before the study I describe here, researchers in Dr. Longhurt's lab demonstrated that electroacupuncture stimulation lowered blood pressure in intact animal models of hypertension caused by gastric distension or splanchnic stimulation. In the study published this month, Fu and Longhurst extend their laboratory's findings by describing biochemical changes in a specific brain region caused by electroacupuncture in hypertensive animals.
Similar to their previous work, the investigators induced hypertension in anesthetized rats by placing a balloon in the stomach and briefly inflating it (ie, gastric distension). The investigators then placed very thin, permeable tubes called microdialysis probes into different brain regions. Through these microdialysis probes the investigator can obtain samples of the tissue's extracellular fluid and also deliver drugs.
Fu and Longhurst collected samples of cerebral spinal fluid and delivered drugs to block a receptor they thought might be mediating the response to the electroacupuncture while they stimulated the hypertensive rats at acupoints P 5-6. Electroacupuncture was effective in preventing 50% of the gastric distension-induced increase in blood pressure and caused a decline in the neurotransmitter GABA in the ventral IPAG (vIPAG), a brain region whose activation has been shown to lower blood pressure. Administration of AM251, a drug that blocks the cannabinoid type 1 receptor, to the vIPAG prevented the electroacupuncture-induced decline in GABA. AM251 did not, however, alter blood pressure and the investigators do not appear to have used it in combination with their gastric distension technique.
So, what's the point Isis? While the authors do not quite seal the deal, defining a specific causative link between the cannabinoid type 1 receptor, GABA, blood pressure, and electroacupuncture, they provide compelling evidence that electroacupuncture causes discrete biochemical changes in a region of the brain responsible for lowering blood pressure.
Are these data enough to ask clinicians to alter practice guidelines, stop prescribing blood pressure lowering medication, and start sending hypertensive patients to their local acupuncture practitioner? No, but no data from a single study will be. This study, done with the proper controls and published in a highly respected journal, does provide sufficiently compelling evidence to continue asking questions. It is exactly the type of methodical, introductory work that must be done to support the incorporation of "alternative" therapies into traditional medicine. Future studies may reveal that electroacupuncture is not efficacious in the treatment of hypertension in human patients, but we will at least be able to say this with sufficient evidence to say it definitively.
Fu and Longhurst's data are intriguing. Intriguing enough to make me want to give them a call and ask him to try electroacupuncture in a cold pressor model of human hypertension.
Fu, L., & Longhurst, J. (2009). Electroacupuncture modulates vlPAG release of GABA through presynaptic cannabinoid CB1 receptors Journal of Applied Physiology, 106 (6), 1800-1809 DOI: 10.1152/japplphysiol.91648.2008
Medicine & Health
Brain & Behavior
Comments
As an older person whose blood pressure has become elevated enough to require I purchase a BP monitor and record my readings for a while... I am suspicious.
For one reason is that I know that anxiety and stress do increase my readings. I made the mistake of taking my blood pressure while waiting for a prescription for my son because of yet another condition he had been diagnosed with, right after talking to one of his special ed. teachers about the fantasies this young man was spinning to explain the lack of homework compliance. Needless to say my blood pressure was a bit high.
I believe my blood pressure would spike again if I were given small electric shocks.
Oh crap, I think it just went up thinking about this inanity!
Posted by: Chris | June 22, 2009 1:41 AM
As another older person whose blood pressure became elevated for a time, I too am suspicious of electro-acupuncture, but I am outraged by the way hypertension is usually treated medically. First, remember, the current medical thinking is about 85% or more of hypertension is ideopathic (meaning, we just dunno what causes it) But doctors are perfectly willing to prescribe medications for a condition they don't understand. (I got a round of beta-blockers that might be helpful for some people, but had terrible side effects for me that my former MD, a leading professor at a major medical school, refused to acknowledge, forcing me to change doctors) A combination of therapies, including another prescription drug, acupuncture and some herbal stuff prescribed by an ND, has gotten my hypertension under control (daily systolic reduced from about 150 to about 115 after 1 yr trying various treatments) The most important part of my treatment has been some very effective talk-based psychotherapy. I was encouraged to do this by reading "Healing Hypertension" by Dr. Samuel Mann, a brilliant physician at Cornell medical school -- Dr. Mann makes a compelling case that the leading cause of hypertension is suppressed emotions. He frankly admits, it isn't feasible to scientifically test his hypothesis -- think about doing a control group of people with suppressed emotions vs not. Plus, given the variation of effectiveness of therapists, talk therapy's also extremely difficult to test. So one can dismiss Dr. Mann's work (and other approaches to treating hypertension on a systematic basis) as woo because it isn't experimentally verifiable, and rely entirely on the variety of drug based therapies for a very serious common medical condition that medical science has been unable to explain the cause of. I think the woo stuff has gotten to be name calling by people who can't otherwise justify their position. Hopefully, you don't persuade anyone with dangerous hypertension that the best approach is popping pills.
Posted by: Albion Tourgee | June 22, 2009 5:38 AM
Who are you and what have you done with Dr. Isis? I don't usually comment, but I read your blog every day, and I will seriously cry if you've given in to those bastards who say you should have a "real science blog." Don't leave us, Goddess! Your muffins/chickens/whatever-you-want-to-call-us-today need you! You are a fabulous role model for aspiring mommy-scientists like myself, and we love your very personal stories and snarky comments about life in science. Please don't change anything about your blog!
Posted by: Aspiring Mommy-Scientist | June 22, 2009 7:02 AM
HA HA HA! When I woke up and read this, I seriously giggled aloud. I am not changing, you lovely little thing. I am a vascular physiologist and I thought this was an interesting article considring what my fellow bloggers here write about, so I figured I would write about blog post about it. I'll post either some lovely shoes or something hilarious later to assure you I haven't left you.
Posted by: Isis the Scientist | June 22, 2009 7:50 AM
I would like some independent trials of real and fake electroacupuncture on ordinary people and those suffering mild to moderate hypertension. I'd say with and without various combos of meds as well. I am a mid fifties woman with 150/80 for many years- couldn't get anyone to treat it- failed trying meditation and relaxation myself- no change except for 5 mins after I finished relaxing! Now the silly GP has me on beta-blockers only and my asthma is playing up. I'm sure there must be a better way!
Posted by: Murf | June 22, 2009 8:44 AM
It seems to me that most of the theories of alternative treatments are superstitious hogwash. The theories were created in the pre-science era. That does not mean that the treatments may not have some physical basis. The treatments deserve rigorous investigation.
Note that because something *may* have a physical basis does not make it a Good Thing. I would not advise anyone to use alternative treatments instead of modern medicine.
Thanks for the wonderful blog!
Posted by: Sweetwater Tom | June 22, 2009 8:46 AM
Personally, Isis, I love your blog: be it on hot science or hot shoes. Keep it coming (and if you would offer advice on hot shoes that I could actually wear while performing my med tech/phlebotomist on my feet all day, my 22yo dd would be eternally grateful. She, rightfully, threatened to disown me if I ever wore my crocs in her presence.)
One thing that strikes me, a humble lay person, as a major difference between science and woo is the scope of the claim. This study appears to be looking at two very specific causes of hypertension and it is interesting. The trouble this hen (because I'm waaay too old to be a chick) might have with the reporting on a study like this is knowing when it might be applicable to me. You may think the universe revolves around you dear Isis, but really, it revolves around me......
Thank you for all your hard work in all the arenas of your life.
Posted by: brook | June 22, 2009 8:47 AM
How DARE you blog about science? What is this place coming to....
Posted by: SockMonkey | June 22, 2009 9:20 AM
For the record, I love your science posts just as much as I love your other posts because you're so good at explaining things that I just know I'm smarter when I'm done reading.
Okay, on to my comment. The body does some weird shit. And sometimes weird shit does even weirder shit to the body. Think about electro-shock therapy. It has turned out that it's actually pretty effective in patients suffering from severe depression. Why? Who the fuck knows?
But the people who started experimenting with electro-shock therapy did not start doing it because it was "alternative" medicine. It had nothing to do with life forces or any of that. Just the newly-discovered (at the time) electrical properties of the brain.
So here's my point: it's only "alternative" medicine if it requires the belief in something supernatural in order to believe it works. Anything else I would term "experimental medicine." If, and that's a big IF, they continue their research and discover that yes, this really is working, it will no longer be "alternative" medicine. It will be actual medicine, because it won't require the belief that the body has qi flowing through its various channels.
I do not use or advocate for alternative medicine, but I am all for any and all new medical discoveries that lead to treatments not involving chemicals in pill form.
Posted by: JLK | June 22, 2009 1:28 PM
...the investigators do not appear to have used it in combination with their gastric distension technique.
I'm not familiar with the journal so maybe this would make me a Bad Reviewer but I'd have asked for that experiment before approval.
Posted by: CC | June 22, 2009 1:32 PM
Dear Dr. Isis, as a humble but dedicated reader of(and first time poster to) this blog, I am thrilled that you posted this research. I am a licensed acupuncturist and have a background in research neuroscience, and I find the results from this study really fascinating. I've had the benefit of seeing abstracts and posters for some of the previous studies at the Society for Neuroscience meetings and had a chance to talk to both the authors and think they are on the right track and would love to see future progressions of this type of study.
I agree with you that this is exactly the type of research that needs to happen in this field, and am very grateful for both your posting and sharing of thoughts!
Posted by: L | June 22, 2009 1:38 PM
What are you skeptical about, commenters 1 & 2? Are you skeptical about the data or the application to humans?
Posted by: Funky Fresh | June 22, 2009 1:48 PM
Ha ha, I had the same initial reaction as Aspiring Mommy-Scientist. Thanks for setting us straight, Dr. Isis!
But as for the initial question -
My answer is an unequivocal yes, as long as they are subject to the proviso you state, Dr. Isis, of being rigorously tested.
I think there is definitely a few things that traditional medicine can learn and improve upon from "alternative medicine" in terms of treating the whole patient and not being so quick to write a prescription, however there is definitely a line one can cross into whackaloonery and I am not advocating for the wholesale abandonment of traditional medicine.
Some of this may be cultural - I'm no expert in this area but it strikes me that many "alternative" therapies and treatments come from elsewhere than the West (hence their description as alternative). So might the knee-jerk reaction and rejection of these in Western medicine be as much due to cultural differences? In other words, our view of what is "traditional" medicine is shaped and colored by what we are accustomed to. That and the fact that medicine is a pretty conservative field (I don't mean conservative in the political sense).
Posted by: Callinectes | June 22, 2009 2:28 PM
Of course there is, in so much as they can be validated. As Tim Minchin put it, "By definition, 'alternative medicine' has either not been shown to work or been shown not to work. Do you know what they call 'alternative medicine' that's been shown to work? Medicine!" As an example, salicylate-rich plants have been used in folk-remedies for thousands of years, but it has only been a touch over a century since they were scientifically tested, and now Aspirin is a commonly-accepted pain reliever.
And therein lies the problem. Until they are tested, they have no legitimate place in formal medicine outside of research proposals. Even then, that research needs to cleanly discard those numerous "treatments" that are ineffective or dangerous, which the NCCAM refuses to do.
Posted by: Mystyk | June 22, 2009 2:28 PM
My own personal example:
I have suffered from menstrual migraines since, well, my first period. These are severe enough to be completely debilitating and last for up to one-two days, regularly and once a month. Long story short, not wanting to take the prescriptions offered a little too quickly by my doctors and because they only seemed interested in treating the symptoms (they could and did not answer my questions about underlying/root cause of migraines) I did some reading of my own. I uncovered some research into the role of magnesium and since adding a magnesium and riboflavin supplement and being conscious of my dietary intake of the two, I have been migraine-free for over a year now. (research by Alexander Mauskop of SUNY and others)
Alternative treatments may not always work, but that does not necessarily mean they never do.
Posted by: Callinectes | June 22, 2009 3:11 PM
@ JLK - wonder if you'd care to comment further on why you distinguish "alternative" from "experimental" and why alternative you restrict to a belief in the supernatural.
I do like the use of experimental, but I would like to know more about the connection you make between alternative and supernatural.
Posted by: Callinectes | June 22, 2009 3:20 PM
First, I would like to see this study replicated at a lab not affiliated with a "School of Integrative Medicine".
Second, it appears that the response rate was less than 50%, if I am reading the abstract correctly, and the response was also reversed 35 minutes after the procedure so the benefits were not lasting. What did they define as "sham electroacupuncture"? If there were no electricity going through the "sham" probes, then it might be a very different response than if the "sham" probes were electrified and were placed in other areas of the brain NOT thought to be involved with the physiological response.
Posted by: Autodidactyl | June 22, 2009 3:37 PM
Did they include a sham electroacupuncture condition, where they stimulated different points or another body part? If yes, did the sham fail to decrease hypertension? That to me would be the key evidence for acupuncture points, otherwise, they found an interesting new use for electric stimulation.
Posted by: Perceval | June 22, 2009 3:42 PM
No, I think they provide evidence that Transcutaneous electrical nerve stimulation (TENS) can cause these biochemical changes. There's nothing in the design of this study that supports the inclusion of 'qi' or meridians, or whatever, in any mechanistic explanation of the results. I think this is a crucial distinction to make, and to address when putting the work in perspective and designing any future studies based on these findings. If this is a new application of TENS, which has been used extensively for pain management for many years, then great! I hope it pans out. For now, though, it seems like the alt med element of this is getting a free ride, and this is ultimately very bad for science and medicine, IMO.
Posted by: Jennifer B. Phillips (aka Danio) | June 22, 2009 5:52 PM
I personally prefer the thought of swallowing a rigorously tested pill daily to periodically being hooked up to electrified needles. The study is interesting, but would I really prefer this "alternative" therapy?
Many cases of mild hypertension could be effectively treated by diet (low sodium, generous potassium and calcium intake) with exercise and weight loss, if necessary. Most people won't work that hard, while they can take a pill once a day.
Now I gotta go do an ass-shaking jam to clear my head...
I'm enjoying the science post. It's a nice interlude between asshattery, social causes, and Cyborgs...
Posted by: Pascale | June 22, 2009 9:07 PM
i don't see where their AM251 experiment demonstrated anything...
AM251 results in major dumpage of GABA into the synapse. woo! what do you think happens when one removes tonic inhibition of GABA release?! [catchup for those who might have missed my point: CB1 agonists like the endocannabinoids tonically inhibit GABA release from presynaptic terminals. blockade of such allows abovementioned major dumpage to occur in the presence of GABAergic neuronal stimulation.] look at how high those post-AM251 numbers go... that's beyond "rescue" to pre-EA levels- that's way the hell up there. how physiologically significant can that be in regards to normal levels, and how does that prove a causative anything?
if they had paralleled this experiment in shams, i would have been far more interested.
Posted by: cannabinoid geek | June 22, 2009 10:38 PM
"I personally prefer the thought of swallowing a rigorously tested pill daily to periodically being hooked up to electrified needles."
QFT
Posted by: sandy | June 23, 2009 12:14 AM
"Until they are tested, they have no legitimate place in formal medicine outside of research proposals."
That's a little too strong to the point of not being pragmatic. The statement apppears to miss the important idea that although "scientific research" is a vital part of "medicine" these two things actually have different objective priorities that are not always compatible (a fact highlighted by the ever present ethical quandary regarding who gets the "placebo").
Posted by: DSKS | June 23, 2009 11:14 AM
@Callinectes (#16, sp.?) - In general, when I hear or read discussions about alternative medicine, there are 2 camps - the people who regard it with disdain because of lack of evidence, and the people who firmly "believe" in it.
Let's just take regular old acupuncture as an example. Originating in the east, the practice began based on supernatural beliefs - the belief that qi or whatever is flowing through our chakras and what-not and acupuncture was a way to unblock channels and therefore improve your health. It's a a pretty old practice, but largely untested. In the west, we classify it as "alternative" medicine, even knowing that the practice would have died out if it wasn't doing SOMEthing for people.
Now let's say we test the hell out of it, and find out not only that it works, but the mechanisms behind the effectiveness. Acupuncture would then fall into traditional medicine and would no longer be associated with those supernatural elements.
Reiki is definitely alternative medicine, because it requires a belief in supernatural forces. But an herbal supplement for, say, heartburn is something I would consider "experimental" medicine - all we have is anecdotal evidence thus far, it needs testing. But all of science and medicine starts out this way. What distinguishes Reiki from an herbal supplement for heartburn is that you don't have to believe the herb has magical properties that are what makes it effective.
Am I making sense? It always seems so much clearer in my head...
Posted by: JLK | June 23, 2009 12:25 PM
"What distinguishes Reiki from an herbal supplement for heartburn is that you don't have to believe the herb has magical properties that are what makes it effective."
but you forget the incredible effect of placebo, JLK! ;)
Posted by: leigh | June 23, 2009 2:33 PM
Good point, Leigh.
BUT....the placebo effect requires a belief (conscious or subconscious) that something is working. (The Mind-Body Dilemma, if you will.) If an herbal supplement is actually helping, it will work just as well in a non-believer, whereas Reiki will not. (If you are a skeptic who WANTS to believe, you are also subject to the placebo effect.)
Posted by: JLK | June 23, 2009 3:56 PM
Dammit, I hit submit before I was finished.
If the placebo effect did not require a measure of belief, then double-blind trials would be useless, because every participant would exhibit the placebo effect.
Posted by: JLK | June 23, 2009 3:59 PM
Posted by: Jennifer B. Phillips (aka Danio) | June 23, 2009 6:01 PM
i agree with the basis of what you're saying, JLK. just let me clarify a couple of things for discussion's sake.
everyone, consciously or not, experiences a placebo effect. this in and of itself is not necessarily the same as belief in the supernatural (ie, that reiki aligns your energies or some such). the expectation that taking herbal pills will make you feel better may result in you feeling good about taking care of yourself by taking them. this may or may not have anything to do with the efficacy of the content of the pill.
the point of double-blind trials is to demonstrate that the active treatment in question (pill, procedure, manipulation of whatever sort) is significantly more effective at ameliorating the condition/problem than the placebo (inactive tablet, sham procedure, etc.) this is to ensure that the active compound (or surgery, or whatever) is actually responsible for the measured effect, and not the act of undergoing a clinical study and the hope that it can help treat the condition in question.
Posted by: leigh | June 23, 2009 6:19 PM
Thanks, JLK and others. Yes, you made sense. I was interested in the linguistic decision for alternative=supernatural, keeping in mind the placebo effect that Leigh and others have pointed out. Maybe the better question is how we define supernatural? My own interpretation of the word includes belief in something greater/beyond the natural world and which is not necessarily divine (though usually is).
(Btw, "callinectes" comes from the species name for the blue crab, which translates to "delectable beautiful swimmer" and is my favorite species name of all time).
Posted by: Callinectes | June 24, 2009 1:12 PM
"even knowing that the practice would have died out if it wasn't doing SOMEthing for people"
There a lot of therapies that have been shown to produce no measurable, beneficial effects with rigorous scientific testing. Their use persists because someone, patient or practitioner, believes in them. Lots of arthritis patients believe that magnets improve their symptoms. As long as it doesn't bankrupt them or keep them from pursuing proven therapies, I'm OK with this "placebo." On the other hand, multiple studies have shown no benefit to "renal dose dopamine," yet physicians persist in using it in ICU situations. If nothing else it is a costly drug, and some have suggested it could have harmful effects. I'm not certain what it will take to break the belief some physicians have in this treatment.
Posted by: Pascale | June 24, 2009 2:14 PM
fwiw, i posted a further critique over at orac's comment thread- since the discussion there was more on the topic of controls and criticism of the paper.
Posted by: cannabinoid geek | June 25, 2009 2:57 AM
What Jennifer B Phillips said at #19. This isn't an effect of acupuncture, it's an effect of electrically stimulating the nerves (heck an earlier Longhurst paper from 2005 shows that this is a nerve stimulation effect). But I suppose that "electrical stimulation of the median nerve lowers gastric filling induced hypertension" just doesn't have the media pulling power. For more discussion, with references and links to papers, see this comment and this comment over at respectful insolence.
Why Longhurst et al. don't cite the earlier papers showing transcutaenous nerve stimulation without regard to acupuncture points (or actually puncturing the skin) lowers blood pressure I don't know.
Posted by: Ian Musgrave | June 25, 2009 8:22 AM
Cannabinoid geek's very cogent comments can be found here and here. They are very much worth your time.
I hope that Isis will follow up this post with any additional commentary from the physiology community regarding their reactions to the findings in this paper.
Posted by: Jennifer B. Phillips (aka Danio) | June 25, 2009 1:24 PM
I go to a little chinese lady.. and she is very cool and is always taking your pulse and saying things like "OH much anxiety!.." OH kidney not good!" or "Oh stomach appetite much less" and stuff...
and then she says either go on your back or stomach and starts to poke around. She starts with the ears, works the chest and stomach, then does the knees and feet. Ouch! the feet ones hurt more than the others. they all hurt a bit at first and then are ok.
She only does the electric pulses for the knees or legs. She then puts on some heat lamps and the funky chinese music and I lay there for almost an hour.
I swear you start floating and dreaming and your whole body feels wierd. Afterwards I feel great!
I think that it actually works to balance out your body's functions.
Posted by: Kevin (NYC) | June 25, 2009 1:51 PM
Kevin, I find your comment here just astounding, considering what you just put up on the Catholics & HPV thread:
Do you notice any...conflict...between your disparagement of Catholicism and the wholesale embrace of acupuncture posted above?? If not, you may want to study up on the whole 'qi' thing just a bit more.
Posted by: Jennifer B. Phillips (aka Danio) | June 25, 2009 3:50 PM