Project Syndicate Health - Like many other traditional Chinese medicines, acupuncture has for many centuries been viewed suspiciously in the West. It seems to work, but how? Is a scientific answer possible? Most Chinese doctors and patients have, for example, long regarded acupuncture as an effective treatment for stroke, using it to improve motor, speech, and other functions that have been destroyed. One survey showed that 66% of Chinese doctors use acupuncture routinely to treat the effects of stroke, with 63% of the doctors surveyed believing it to be effective. Some 36% of Chinese doctors think the effectiveness of acupuncture remains uncertain, perhaps because the scientific basis for it remains so new.
Recently, however, systematic scientific studies of acupuncture’s effects in such treatment has begun. Almost all trials on acupuncture as a treatment for stroke conducted within China have been positive. But another recent study done in the UK showed that research conducted in several countries was uniformly favorable to acupuncture as a treatment for the damage caused by stroke. Indeed, all the trials performed before June 1995 in China, Japan, Hong Kong, and Taiwan were deemed positive by the British researchers.
The Cochrane Collaboration, an international non-profit organization providing healthcare information, conducted a systematic review of the benefits of acupuncture, including 14 trials, of which 10 were conducted in China, involving 1,208 patients. Acupuncture started within 30 days of stroke onset, with control groups receiving a placebo – sham acupuncture – or no treatment. Compared to patients who received sham acupuncture or no treatment, far fewer of those who received acupuncture died or became invalid within three months. After three months or more of treatment, the numbers rose even more significantly in favor of those treated by acupuncture.
Oddly, when comparing acupuncture with sham acupuncture, the statistical difference concerning death or the need for institutional care was small. Indeed, another analysis, including 14 randomized trials with 1,213 patients six months after a stroke, compared the effects of conventional stroke rehabilitation with and without acupuncture as a supplement. Acupuncture was found to have no additional effect on motor recovery, but a small positive effect on disability, which may be due to a true placebo effect, or to the varied quality of the trials.
Indeed, the efficacy of acupuncture without stroke rehabilitation remains uncertain, mainly because of the poor quality of such studies—a problem that has affected most of trials undertaken so far. For example, many trials did not describe their method of measuring statistical relevance, and only called themselves “randomized controlled trials.” Only four trials, with 373 patients, could provide data on death or dependency (becoming dependent on others for activities of daily living). And only three trials—all conducted in Europe—used sham acupuncture as a control, whereas no acupuncture trials controlled with placebos or sham acupuncture have been reported in China, owing to high cultural barriers.
Part of the problem in China is choosing the patients to be studied. After all, patients come to hospitals that practice traditional Chinese medicine because they already believe in acupuncture and are likely to be using it to treat another illness. Getting such patients to accept being put into a control group where no acupuncture is applied is almost impossible. This difficulty makes random studies of the effects of acupuncture treatment on stroke patients particularly difficult in a traditional Chinese medicine hospital.
More fundamentally, however, Chinese doctors who use traditional medicine argue that outcome measures of acupuncture as a treatment for stroke should be different from conventional measures used in Western trials, because the theory of acupuncture is different. But no one has yet specified what the appropriate outcome measures for acupuncture should be.
A recent study conducted in China, including 862 patients who were between the second and tenth day after onset of acute stroke, is the largest truly randomized trial using death or dependency as the primary outcome. The patients were randomly allocated to an acupuncture group receiving acupuncture treatment plus routine treatment or a control group receiving routine treatment alone. The results will be reported after analysis of the trial data and could prove useful for therapy of stroke patients.
At present, however, there is insufficient evidence for routine use of acupuncture in stroke. More high-quality trials are needed. We do know that acupuncture is a safe, inexpensive, widely accepted, and potentially effective therapy. Particularly at a time when standard rehabilitation is not available for most Chinese stroke patients, few will wait to try acupuncture until its role is confirmed or refuted by reliable evidence.

Ming Liu is a Professor of Neurology, West China Hospital of Sichuan University, Chengdu, China.

Copyright: Project Syndicate, 2006.
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