Research design in acupuncture

[Luke Rickards]

As we all know, objective evidence for diagnostic reliability, outcomes, cost effectiveness, and (to a lesser degree) therapeutic mechanism, are becoming increasingly demanded from health professions, particularly from CAMs.

I was flipping around the web the other day, as I do, and noticed that one of the special research areas at UTS is clinical trial methodology, which means we have a few members who are actively examining these issues.

I am hoping here to elicit some discussion about the current thoughts on acceptable research design for the study areas above, particularly for outcomes. I'd also love to hear from those at the grindstone (practitioners) regarding thoughts from your clinical experiences about what kinds of research might best capture the benefits your patients report and why these should be valued over other approaches to the same health problems.

[peter meier]

Luke,

this is a huge topic. You could virtually start a thread for each component - though likely only those in need of cures for sleep disorders would read it.

There is no standard outcome measure for all instances - obviously. It all comes down to what you are trying to measure.

Take depression as a prime example - I currently have a masters student undertaking a trial in this area. We are using a range of outcome measures two of which happen to be BECK BDI II and Hamilton. Now depending on what literature you read the Hamilton is either the gold standard or irrelevant, old hat, crap. There are however always validated scales around and as long as you recognise the limitations of each one then you can try and come to some sensible conclusions from your results.

Now while the BECK my be useful in a trial situation, how many practitioners are actually going to apply it - not because they don't know about it but because they could not be bothered, don't have the time or believe that it will not produce results relevant to them or that will help them improve their success rates.

How often do you use the McGill pain scale on your patients or even a simple VAS. If you do then good on you, you are likely collecting some very valuable data but if not then why aren't you? (not a criticism - but think of the reality of the situation is a practitioner going to engage in an activity that does not bring direct and immediate benefit to them? How do you change this culture or even laziness in some cases)

Personally, i would encourage all practitioners to use objective (or at least as close as we can come to it) outcome measures and then look at these results to gain a better understanding of what you are actually doing in clinic because you will likely find that what you think you are doing does not match your data. Nothing like cold hard data to get you thinking.

Another pet hate of mine is the concept of "sham" acupuncture - what a load of cobblers - but that is a whole topic unto itself - what constitutes a suitable control for an acupuncture study.

As i said, the topics in these kinds of questions are huge but i think that is enough to start things off.

[Luke Rickards]

Hi Peter,

Thanks for getting us started. I know it's huge, so let's stick to outcomes for the time being.

Another pet hate of mine is the concept of "sham" acupuncture

I agree with you here. I can't see how it is possible to create a benign and still appropriate sham procedure. This leads to the question of what kinds of design would be appropriate. I wonder if you could share your thoughts on pragmatic research designs for acupuncture, where acupuncture is compared to other standard treatments. Or, since sham is not useful then comparing, say, individualised traditional, standardised 'traditional', and MTrP only needling or needle anywhere groups.

Regarding the use of outcome measures in everyday practice, I would recommend them as strongly as you do. I find though, that their use is often more for the patient's benefit than for mine. It is quite common for patients to be so overwhelmed by their problems that they can't see change even when it has clearly occurred. Reflecting change back to patients ("See, this is what you put down 3 weeks ago, and this is what you marked today!) can be a very useful validation tool. In terms of pain though, I wouldn't recommend the McGill. If you must measure pain intensity, then a VAS or QVAS will suffice, but it is better to focus on measures of specific and general function (I've got references if you want); eg Patient specific functional scale (PSFS), Neck disability Index (NDI), Revised Oswestry Low Back Q (ROWQ) etc.

Of course, questions on what to measure should also include what the patient feels is important. Which is why I want to hear from other clinicians as well. As I alluded to above, for chronic pain patients, there is some evidence that many care more about improved function than they do about decreased pain. I read another study a while back suggesting that patients are more satisfied with practitioners who take a very thorough history and examination and explain things but do not help the problem, than practitioners who may give some beneficial changes but don't take their time with the patient. As well as evidence of efficacy, perhaps these kinds of issues should also be documented by the acupuncture community.

I often hear a lot of 'poo-pooing' of research and the clinical application of evidence in our community, but I suspect it comes more from a misunderstanding of what it is about than a definitive disbelief in its usefulness. Not surprisingly, there is a huge amount of academic discussion of the issues surrounding 'evidence-based practice', which unfortunately many interpret as 'evidence-only practice'. For those interested in reading more about this I can thoroughly recommend
Tonelli, 2007 - Integrating evidence into clinical practice: an alternative to evidence-based approaches (give me your email address by PM if you want a copy of the fulltext).

A common complaint is that you can't distill the essence of a clinical encounter out in a randomised trial. But you can actually measure the effects of a real life encounter, which is why I am interested in the current thoughts of acupuncture academics on using pragmatic trials (you can more about these, read here). Another option, which I know Carole is a fan of, is observational studies ie, cases. Although these are considered poor evidence, they can be strengthened by having a baseline period and treating 3 or 4 patients instead of one (also called a single system research design -SSRD). These are really easy for clinicians in private practice to do* and can be very informative for other practitioners. *(because it is prospective, rather than retrospective as for normal case studies, you'd have to hassle someone like Peter to push an ethics approval through first).

That's all that's in my brain at the moment, but I'm sure there'll be more soon. Anyone else out there? - or perhaps Peter's opening statement was astute.

[Carole Rogers]

Another option, which I know Carole is a fan of, is observational studies ie, cases. Although these are considered poor evidence, they can be strengthened by having a baseline period and treating 3 or 4 patients instead of one (also called a single system research design -SSRD). These are really easy for clinicians in private practice to do* and can be very informative for other practitioners. *(because it is prospective, rather than retrospective as for normal case studies, you'd have to hassle someone like Peter to push an ethics approval through first).

Yes, I am a fan, and I agree that prospective rather than retrospective is to be preferred. My reasons are that such studies, which can be carried out in private clinics, can form the basis for much larger trials that may be undertaken by research teams in universities or other centres that may be able to gain access to funding - always a problematic area.

What I am interested in as a side issue is the question of ethics approval. I think both Peter and I have felt frustrated by ethics committees on a number of occasions. Not because they have blocked research for ethical reasons but because of the time taken to answer objections that stem from a lack of understanding of acupuncture as a modality - a preference for sham acupuncture to be included in research designs, a demand for double blinding, and even a request that we show 'proof' that the treatment protocol being used in the research is effective to ensure that we did not waste the subjects' time!

A solution that I believe is valid is that a properly constituted “acupuncture research ethics committee� should be established by the profession. It would need to include the usual spread of expertise in general research and ethics but also qualified practitioners who have some understanding of the problems that are specific to research within our discipline. I understand the difficulties of such a move but it must come at some time if we are to develop as a responsible profession.

[Luke Rickards]

Carole,

I'm no expert, but some of the issues you mention as being of concern to the ethics committee seem to be more related to the requirements for publishing in prestigious journals rather than strictly ethical concerns. Is it possible that the UTS ethics committee has an agenda here?

Your proposal is a pertinent one. Is there a model for such an ethics committee anywhere else in the world?

[Carole Rogers]

You may well be right, Luke. It is the UTS committee with which I have had most experience and I always felt that their comments were because they didn't have the slightest idea of what we were doing. Also, the fact that we are part of the Faculty of Science meant that they expect lab work from that area - not clinical studies in any form. I certainly don't think however that they have an agenda - just lack of knowledge which I hope will change over time. If there is any agenda then it would be that UTS always want us to publish in prestigious journals - Nature being preferred!

I don't know of any professional ethics committees that have been established anywhere else, although I don't see this as a reason for backing off such an idea. It would be good if it could establish ethical/CM research critera that was internationally accepted - perhaps with the support of an organisation such as WHO - although that may be a bridge too far.

[Luke Rickards]

I agree that prospective rather than retrospective is to be preferred. My reasons are that such studies, which can be carried out in private clinics

Carole,

It has even been argued that a version of these type of studies, the n-of-1 RCT, may offer the highest level of evidence relevant to clinical practice.

[Carole Rogers]

That's interesting. Do you have a reference? It would be helpful if we could proide chapter and verse for this opinion as we may be able to encourage more activity among clinicians.

[Luke Rickards]

Carole,

I've emailed two paper to you.

[peter meier]

A common complaint is that you can't distill the essence of a clinical encounter out in a randomised trial. But you can actually measure the effects of a real life encounter, which is why I am interested in the current thoughts of acupuncture academics on using pragmatic trials

Ah yes - the pragmatic trial - a shelter for rapscallions.

I'm sure there is some proverb along the lines of ethics being the shelter or refuge of some sort of dishonorable character but i can't think of it for the moment - but lets leave ethics for another time - I actually don't mind what the committees do- its just the ridiculous constraints they put on you - cover every conceivable ethical dilemma that may occur, put it in an acupuncture context (which you have to explain to us because we don't understand it) and do it all in 300 words????

Anyway back to the topic at hand - pragmatic trials. No doubt this was thought up by someone after the fact in an attempt to explain why they did not use a placebo and why they stuffed up their randomisation - and a bloody good strategy from one perspective. Pragmatic trials have their place but to cut through all the crap - your chances of having a large scale pragmatic trial (which by their very nature require huge subject numbers to maintain experimental power) is substantially less than if you propose a standard RCT (explanatory) study (at least here in Australia). Why - because the powers that control the $$$ understand RCTs and they don't understand or don't like or don't see the value in pragmatic trials.

The most important question you need to ask yourself is why are you undertaking this research?

Are you trying to prove the effectiveness of acupuncture or the importance of research to an existing segment of the profession that already operate without a research base (just fine thank you very much - the yin/yang/5 qi/8 evils/9blah blahs of it all) and likely don't want proof of what they already "know" - preaching to the choir?

No - let me guess - your a crusader - the joan of ark of acupuncture needing to fight those evil western doctors who never understand the yin/yang,9 blah blah of it all - lets open their eyes, integrate it into hospitals and get a medicare rebate for ALL - acupuncture jihad!!

OR are you undertaking research in an attempt to CHANGE CLINICAL PRACTICES? This is one of the fundamental questions asked by funding agencies - how will your research change fundamental clinical practices. If you like, place it back into the context of the beautiful baby point we were discussing in another thread. There are those that say the beautiful baby point is a load of cobblers, those that say it will change the genetic coding to produce superbaby and those (like me) who say - I don't know, but lets design a trial that will test the concept so that if it is true we can all use KI9 to produce superbabies that will save our planet or we can stop wasting our time and ripping off patients on something that has no validity. (ie a trail whose results will change clinical practices - hopefully for the better)

So this is a very long winded way of saying you design your study according to the outcomes you are trying to achieve.

If my goal in an exploratory study (mechanism) - placebos are irrelevant, subjects can act as their own controls.

If my goal is an explanatory study (efficacy) - i must build in suitable placebos, blinding etc

If my goal is a pragmatic study (effectiveness) - i should build in placebos and blinding if i can, but if i cant who cares because the ultimate question is not WHY does it work or HOW does it work, but is there an EFFECT?

If my goal is to explore the types of research questions that may be relevant to clinical practice and hence guide the design of RCT then i will engage in clinical auditing (which i do at UTS) or an SSRD.

Each method is valid in its own context and in most cases of acupuncture research today we actually bastardise the lot in an attempt to find a hybrid that cover most (but not all) sins.

Coming back again to pragmatic trials, as this was the central question, there are certain issues that arise.

1) because you have no placebo, your effect size (outcome of treatment) has to be very large otherwise your experimental power is reduced. The only way to boost the experimental power back up is to increase the subject numbers which increases costs.

2) if you are testing a standard acupuncture protocol (a set of points) against standard practice (pointed individually selected according to patient) what are you actually testing? Does it really matter? How is your outcome going to actually change clinical practice and be of benefit to the profession and community? Testing a free set of points compared to a standard set really does not tell you much if acupuncture has a system wide, physiologically balancing effect. Its not like testing one form of manipulation for back pain compared to a completely different manipulation because the different manipulations would be designed to activate different muscles/nerves etc. QI however is QI and in many respects the channel system is closed so sticking one acupuncture point somewhere in the system will ultimately affect the qi elsewhere - this is the basis of 5 element treatments - balance the liver to affect the spleen.

3)pragmatic trials by their nature can be seen to be loose with their randomisation because they already work from a biased population. In that respect do we choose the sickest patients or only those that are mildly sick. What intervention will we use if it is not standardised and how does the knowledge that you are dealing with the sickest of the sick affect the experimenters interaction with the subject?

there are many other issues to deal with as well but this is already getting too long. At the end of your pragmatic trial, what are you actually left with? What have you measured? Certainly not the acupuncture effect. What you have measured is a change in that patients outcomes based on a range of variables (acupuncture, experimenter bias, placebo, time etc) most of which can't be effectively separated out.

consequently, return to your base question - how do my results change clinical practice - if they don't why did you bother? If they did or at least show the potential that they will, then your pragmatic trial design was clearly appropriate to your end goals.

there is no one fits all - all models have inherent problems - it is the case of finding the best fit for the outcome you want to achieve

[Luke Rickards]

So, Peter, relating back to the first post, it seems then that any 'trend' in acupuncture research may be more related politics and funding than professional goals.

[Luke Rickards]

Here is a good example of some of the issues you raised above, Peter.

[peter meier]

Yes it a very good example of some of the issues surrounding pragmatic trials. Of course it does not make their results any less valid - it just means you have to interpret them in light of the method. You will also note that the abstract states that further "explanatory" studies are required - ie if who ever ran that trial wants to convince the establishment, at some point in time the gold standard RCT will need to be applied.

The really interesting thing here though is that you only really need one large scale RCT to prove your point. Rarely in medicine does anyone actually replicate a trial even though your trial is meant to be designed and reported in a way that can be replicated.

What actually happens in medicine is that there are usually are large number of small trials. When these are subjected to a meta-analysis, if the outcome is such that a body of evidence exists to show efficacy -practice is normally changed. Otherwise we go back to relying on the large single trial (and by large i mean thousands of subjects across international borders).

There is an interesting trend emerging now for the prospective meta-analysis. Rather than looking back to studies that have been done, many with flawed methods, researchers are now designing studies that are meant to occur in multiple sites using a common method and organisational structure, but funded and run at the local level with the intention of subjecting the results to a meta analysis in the future. It is a very clever way to go about obtaining relevant evidence but without the need to seek mega mega bucks from a single funding agency.

[peter meier]

So, Peter, relating back to the first post, it seems then that any 'trend' in acupuncture research may be more related politics and funding than professional goals.

Yes and no.

On the local level, students come to me with research ideas that they then move forward in to trials and PhD's etc because they truly believe in what they are doing and that their idea may change practice and increase knowledge in the field. Their research is done on the smell of an oily rag and hence will always have limitations brought about by the lack of funds necessary to properly run phase 2 and phase 3 trials.

Where the politics comes in is that you have to understand the game and rules of the funding agency you are dealing with if you wan to get the big bucks you need for your phase 2 trial. If its the NHMRC in Australia, then there are very clear expectations you have to meet if you want their money.

The recent NICM funding (national institute for complementary medicine) funded by the federal and state governments is a highly, highly politicised process. I doubt if any truly relevant grass roots research outcomes will come from this for acupuncture (and probably herbs). If the players in that game spent half the time (and leverage money) they bring to the table on pursuing research outcomes relevant to the profession instead of trying to show who has got the biggest balls and who is going to be top dog, something might be achieved. The process however is still only starting so there may be hope for a turn around.

All processes in human endeavor have an element of politics - in terms of research, politics in itself does not exclude the possibility of achieving relevant research outcomes that are professionally driven - the only problem is when the politics of ego start to drive research outcomes.

[Luke Rickards]

You will also note that the abstract states that further "explanatory" studies are required

Yes, which is one of the reasons I posted it as an example of what you are saying.

Another thing I've noticed with regards to meta-analysis are proposals for the development of standardized definitional taxonomy, diagnostic protocols and outcomes measurement to more easily allow pooling of results from all relevant studies.

[Michael Broer]

Hi everyone,
I find this type of discussion very important and interesting and, while I have very little in which to contribute in the way of ideas for methodological design and so forth, I would still like to ask what you guys think of studies that examine point function from bio-medical viewpoint. For example, a study to determine the effects of needling LV2 on intra-ocular pressure in patients with glaucoma,.... that sort of thing. I know there have been studies done on PC6 specifically for morning sickness and I wondered what relevance you guys think this type of research has in terms of clinical practice. Should we be doing more or less of this? etc..

[Carole Rogers]

Hi Moxamike,

In my view we need more of everything and it is all useful in increasing our understanding of our profession - if not now then later when more pieces of the jigsaw puzzle are in place. The one stipulation is that the quality of research needs to be high, and increasing quality and reliability tends to cost money. What is irksome is when financial support is provided for research that is poorly designed. For a long time there was an insistence that we should carry out double-blind studies, possible in herbal medicine but unrealistic in any physical therapy - including surgery!
Now there are some funding agencies that want placebo acupuncture as a control in clinical trials - again this is considered unrealistic by qualified practitioners.

But to answer your question perhaps a little more clearly. The type of research undertaken depends very much on what you are trying to find out and what use is to be made of the outcomes. For example, claims that acupuncture is only a form of suggestion and that there is no impact on the system are refuted if it can be shown that needles in specific points on the body cause specific and differing neurophysiologic changes. To test this type of reaction however, one has to hook the subject up to a battery of sensors with the result that it in no way mimics a normal clinical situation. Yes, you may discover that a point apparently stimulates the sympathetic nervous system but this is hardly immediately useful to the clinician, but if all the major points on the body could be mapped in a similar way it may be possible to demonstrate that single points or groups of points have a specific impact on certain organs and neurological systems of the body and that we are not dealing in some ancient folklore that is without basis. Acupuncture is not magic, it impacts on a physical system and this impact can be measured. How, it impacts is important in our understanding of our profession and ultimately in our ability to predict results of treatment.

On the other hand, the type of work that Peter has been doing at the UTS clinic indicates the average number of treatments given for a specific problem and the percentage results of such treatment over time. He has devised a system that could, if taken up by other clinics, provide solid data base of demographics and morbidity in acupuncture that would be of interest to Health Funds worldwide. He is currently seeking funding to extend this work to cover Chinese herbal medicine as well as acupuncture.

Sorry Peter, you could have explained your research much better than I.

In this thread we have been discussing pragmatic research which mimics the clinical situation and uses the patient as their own control. It is usually a single case study, or limited to a very small sample, and it's value is compromised by a number of factors, such as control of external variables, personal interaction between researcher and subject, and reliable measures of outcome to name but a few. If sufficient of these are carried out and properly reported however, then over time a picture builds up that may form the basis of a larger, and often very expensive RCT to asses the applicability of the approach used to other clinical situations. Such research is of immediate value to the clinician.

So you can see it is something of a 'horses for courses' situation. It is a long road but it has gradually changed things over the last 40 years so that we are no longer labelled as charlatans and money grubbing quacks - one medical practitioner at an international conference tried to give a paper on "quackapuncture" - but are now trained in government funded programs, are being integrated into the recognised health care system, and no longer fear being banned from practising. At least this is the case in Australia and good research, anywhere in the world, has helped us to gain this level of recognition.

[peter meier]

Hi everyone,
I would still like to ask what you guys think of studies that examine point function from bio-medical viewpoint.

I think these studies can be very useful when carried out using a well structured method. A human body is a human body and the physiological process are the same whether you describe them using TCM or western terms (disregarding wise cellular groups for one moment)

Consequently, understanding the biomedical effects of an acupuncture point can be used to explain TCM functions. This knowledge also helps expand the known or understood uses of particular points whether treating from a TCM perspective or symptomatic (western) perspective.

If you want to talk pragmatics - who cares about (epidemiological) efficacy if there is evidence that the point has an effect.

all well designed research has its place in building understanding - and as Carole clearly stated - its a jig saw puzzle and each piece is necessary to complete the picture.

[Michael Broer]

Peter and Carole,
I agree with all of that. I suppose, like all types of research, it has its uses if it is well designed. My only concern with point function studies is that they promote a symptomatic approach to acupuncture which, while it has its uses particularly in acute and sub-acute conditions, diverts our attention away from the need to individualise treatments.

But on the upside, any research which debunks a "quackupuncture" POV is going to be good for everyone.

Thank you both for your responses.

[peter meier]

My only concern with point function studies is that they promote a symptomatic approach to acupuncture

Yes and no. If your only intention is to look at it from the point of symptomatics then I suppose that is what you will get. Nothing stops your however from looking at the mechanisms behind the research.

eg all the studies on electro on PC6 for chemotoxicity/nausea from cancer drugs. So we look at this and say well this means PC 6 is only good for nausea? No - just because the other functions have not been tested does not invalidate them. Well designed clinical trial only have 1 primary end point and so if no one has designed a study where shen calming is the end point - it does not mean that PC6 does not calm the shen.

If we do know that PC6 does in fact affect nausea (because the RCT tell us) (little Britain - the computer says yeeesss!) then we can start to speculate that the connections to the middle heater may be valid. We can start to look at channel connections and build evidence that shows their validity. We can slowly build up a picture that may explain the mechanism behind PC 6 or at least point us in the direction of better designed studies that explore this because we have a better understanding of how the point functions since we can define its physiological effects. .......but sure if you only want to look at is as PC6 treats nausea because the RCT told me so then fine - who am I to argue.

diverts our attention away from the need to individualise treatments.

Now there is an interesting concept!!! Who said we have to individualise our treatments. That is not how they do it China. All the Profs in the hospitals i worked at used to write prescriptions that one of their minions would then administer for the next week to 10 days before they changed the point prescription. Not very individualised. Perhaps individual treatments are so common in the west because of the dominance of the ego and "I" culture?

We need a pragmatic RCT to test a set of prescriptions against individualised treatments. There have been studies like these done but if i remember correctly (and i may not) I don't think the results for an individualised approach was that great - but then there are huge design problems when tailoring interventions.

[Carole Rogers]

Peter, do you really want to challenge the sacred cow of individualised treatments? You will be hung, drawn and quartered - a most unpleasant and non-individualised way of dying - really more dividualised!

Okay, so when I treat, I take the pulse, ask the salient questions, I think a bit, and start to work out what this patient needs - then I pop in the needles, and take the pulse again to find out if the treatment is working as I expect, perhaps I then needle an additional point or even remove a needle, and take the pulse again. Is that individualised? I think not.

I have my favourite set of points for bringing up the yin kidney qi, I have a favourite point or two for a specific symptom (syptomatics but I know they work), I have my favourite times for checking out the ah shi points, I have the set of conditions for which I use moxa - and the set of conditions for which I might suggest herbs or supplements (not Chinese, and I don't sell them to patients - I send them to the health food store because I want them know that they are taking them for their health, not the health of my pocket). I also have points that I don't like to needle because of location or my own prejudice.

What is done is perhaps an individualised practitioner approach, rather than an approach individualised for the patient, because another practitioner would have their individualised approach. Were it not so every well trained practitioner would provide identical (individualised) treatments to the same patient and we know this is not so.

In all cases, individualised treatments are an educated guess as to what will work best for the patient, and really it all depends on how good the practitioners "guesswork" is in each individual treatment. Then we have all the rest of what is going on in the treatment - clinical environment, patient practitioner interaction etc, etc. And we haven't even touched on the diagnosis - which can be as eccentric as the treatment.

At least with syptomatics one can expect a much more standardised approach and one that can be measured more easily. The only trouble is - its dead boring for the practitioner!

[peter meier]

Peter, do you really want to challenge the sacred cow of individualised treatments?

Why not - I'm a beef eater!!

Lets first define what we mean by individualised - as you pointed out, a practitioner may have a stardardised approach eg, a favourite point for lifting kid yin that they alway use in kidney yin xu. In this respect the treatment is not necessarily individualised to the patient but reflects the individual approach of the practitioner (different to other practitioners) but for arguments sake always the same when treating kidney yin xu (ie I use my favourite point X) Is this a truly individual approach - certainly not in the context of patient-centric practice.

As to practitioners having their own favourite approaches - well write yours down and in 1500 years we can refer to it as a classic and hey presto!!

So lets focus on the patient centric model. The principle as I understand it is that each patient is different, each manifestation of disease is unique to that person (which is not really true otherwise we would not have populations of people suffering with particular diseases, we would all have our very own, but i am going of on an irrelevant tangent) and (going back to the original idea in this paragraph) thus each treatment is individualised to that person.

If we use an example, ten people suffer with gastric ulcer, they essentially have ten different causes (common roots but individual or personal differences) and hence will receive ten different treatments from the practitioner (because someone somewhere said this was the best way to treat)

Well were is the evidence?????? How do we know that a patient centric individual treatment is any better than a standard treatment???? Why would not the standard approach of points X, Y and Z for gastric ulcer give us an equivalent or even better result that an individual approach - particularly if there have been well designed RCTs that show point X lowers gastric secretions, point Y has an effect on mucosal tissue and point Z has some sort of effect on the stomach that can't be explained but the evidence shows an effect.

Obviously this is a hypothetical argument as the research on point X Y and Z has not been undertaken and so a standard treatment for gastric ulcer has not been defined or tested but the possibility to do so exists. Going back to Moxamike questions, this is why we study individual effects of points because it helps us better understand how to more effectively combine them (from both western and TCM points of view)

You may well argue there is insufficient research to justify a standard treatment for particular diseases and so we must not use standard approaches, but equally there is no research to show that a patient centric individual approach is any better.

I will often scold a student for adopting a symptomatic approach to acupuncture but i do so not because there is anything necessarily wrong with symptomatics but because the question is often borne from a lack of initiative to engage the brain to think about the problem at hand and a much too eager attempt to find a quick and easy solution.

As to sacred cows - bring out the Barbe!!!!! We can always burn the evidence we don't like - makes the meat taste better!! (sorry to all those vegans out there)

[Carole Rogers]

Perhaps the question of individualised treatment vs evidence based symptomatics should be raised in a more general part of the forum. I have a sneaking feeling that only a small precentage of our members and lurkers read this boring research stuff!

[Lorne Brown]

This is actually an important issue.

Brandon horn presented an informative discussion on this issue. It is currently available for free to members of CMT (free to register)

Link here
http://www.chinesemedicinetools.com/for ... e-research

[NuDaFu]

I am a supporter of population centric models though, if nothing else, for its practicality and realistic fit in existing analytical research models (right up to the point we have a paradigm shift from biology to quantum in medicine, but I digress). More and specific knowledge for any given subject matter of course has its place in improving the way we think, however, I wonder how much this actually translates to use in the clinical setting. What I worry about is the other extreme of symptom-based therapy: a 'one-size' fits all approach. For, medical history illustrates how we tend to over-use rather than under-use therapies that are effective for the larger majority of the population e.g. ST36, Panadol, Aspirin, Xiao Yao San.

lack of initiative to engage the brain to think about the problem at hand and a much too eager attempt to find a quick and easy solution

An issue with medical education methinks, rather than the individual. Critical thinking is a formal study (aka Philosophy, Formal Logistics, Classical Education). I would love to see subjects in critical thinking included into basic Biomedical Science courses.

We can always burn the evidence we don't like - makes the meat taste better!!

Reducing the 'holy cow' to the file drawer effect! What sacrilege!