Medical Methodology in Review

Reply to “Review by Professor T-C Aw” (June/July 07 Issue)

The article concerning complementary medicine therapies as possible options for services within Occupational Health departments is encouraging in as much as the fact that this would not have been published thirty to forty years ago, which is when, with President Nixon’s visit to China in 1972, the more recent interest in Chinese medicine began.

The number of doctors and lay therapists practicing acupuncture has steadily increased since that date and more recently the government has set in motion a process which will eventually lead to a standard for the qualifications, continuing education etc. required for safe practice. However the number of professionals interested in research into acupuncture and the setting up of clinical trials has been small.

There has been a somewhat xenophobic tendency in the west to regard trials performed in China as inferior, as they are not double blind, randomized controlled trials.

The gold standard of RCT in such trials in western medicine is paramount for most western medical authorities, and the expectations in that any therapy needs to prove itself against this standard if it wishes to be accepted.

The article in Occupational Health discusses the “critical review” of “systematic reviews” of acupuncture. Unlike the trials on a new pharmaceutical product where a double blind randomised control work well, with acupuncture there are several variables unique to this therapy, e.g.

  • 1. The use of sham acupuncture as a control.

Several forms of technique including non-penetrating needles, use of so called non-acupuncture point etc.

  • 2. Point selection

May be based on traditional Chinese medicine theories, trigger point theories, segmental acupuncture theories.

  • 3. Dosage

i.e. Strong stimulation / weak stimulation / electro stimulation. Deep acupuncture / superficial acupuncture.

Thus when reviewing papers, unless one takes into account the above, you are likely to be mixing up good and bad trials within the inevitable result that reviews of reviews will tend to show less overall positive findings.

The CMIR (Chinese Medical Institute and Register) was the first institution to bring English speaking Chinese doctors from Beijing to teach a diploma course in the UK. The way we teach and practice is to combine the traditional theories with modern research.

The Chinese have the longest history of any modern nation and the wealth of medical knowledge should surely be the basic for new research into the effects of acupuncture.

A good example of the present state of affairs is highlighted by a study undertaken by Jorge Vas, a Spanish physician from Seville whose particular interest is acupuncture for osteoarthritic knee pain. He has recently published a paper entitled Evidence from RCT’s on optimal acupuncture treatment for knee osteoarthritis (Acupuncture in Medical June 2007). Jorge Vas, Adrian White

This is an article well worth reading, but I will just quote a paragraph from the “Discussion”: “The generalized use of clinical trials, introduction of qualitative synthesis, especially systematic reviews of the literature and meta-analysis, contribute to highlighting the current variability in clinical practice. This is particularly apparent in the case of studies assessing the efficacy or effectiveness of acupuncture.”

This paper and our previous comments highlighted the complexity of any attempt to do a true systematic review.

Further explanation of the basic tenets of methodology need to be explored and where possible an innovative approach is needed for future medical evaluation.
This discussion on methodology is ongoing and the authors welcome any contribution towards future development.

Prof Man Fong Mei
Dr Phillip Vernon
Steering Committee, CMIR