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Hui, K. K. S., Napadow, V., Liu, J., Li, M., Marina, O., Nixon, E. E., et al. Monitoring Acupuncture Effects on Human Brain by fMRI. J. Vis. Exp. (38), e1190, doi:10.3791/1190 (2010).
Hui, K.K.S., Liu, J., Marina, O., Napadow, V., Haselgrove, C., Kwong K.K., Kennedy, D.N., Makris, N. The integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 as evidenced by fMRI. Neuroimage 27 (3), 479-496 (2005).
Hui, K.K.S., Marina, O., Claunch, J.D., Nixon E.E., Fang, J., Liu, J., Li, M., Napadow, V., Vangel, M., Makris, N., Chan, S.T., Kwong, K.K., Rosen, B.R. Acupuncture mobilizes the brain's default mode and its anti-correlated network in healthy subjects. Brain Res 1287:84-103 (2009).
Napadow, V., Dhond, R.P., Purdon, P., Kettner, N., Makris, N., Kwong, K.K., Hui, K.K. Correlating acupuncture fMRI in the human brainstem with heart rate variability. Conf Proc IEEE Eng Med Biol Soc 5:4496-4499 (2005).
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This study is missing a control: they should have also monitored the effects of needling points of the body that are not associated with traditional acupoints. It is interesting to note that, "during acupuncture stimulation at LI4, ST36 and LV3 show virtually identical patterns with the DMN." Would needling in non-acupoints produce the same effects?
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The existence of needling points not associated with traditional acupoints, so called control points that have zero acupuncture effect is, I believe, a mythical , misplaced and unfortunately a firmly ingrained belief. The meridian system is a schematic which suggests which needling points have the strongest acupuncture effect. It is a leap to conclude that needling points outside the traditional acupoints would then have no acupuncture effect. Any analogy is in order. If an artery is cut, it will bleed profusely. It would be a logical leap to conclude that if tissue outside the artery is cut, it must not bleed. The important idea that came out of of Hui's study is that acupuncture manipulation engages an enormous brain network, not just localized brain responses. Needling "control" points should naturally also engage large areas of the brain network. Since there is only so much real estate in the brain matter, it won't be surprising that there will be overlaps in the two brain networks. There should be differences which have however yet to be published. However, it would be rash to label whatever differences that will show up as brain regions that have zero acupuncture effect. It should likely be labeled as regions of different acupuncture effect, just like the differences observed with the stimulation of LI4, ST36 and LV3 despite a huge overlap of responses at part of the DMN. It is not surprising for the large overlap in brain responses to manipulation at different acupoints. Often one single acupoint, say LI4, is supposed to be multi-tasked, able to relieve pain, stress and anxiety, sharing basically many of the acupuncture functions of other acupoints. Differences in brain responses to manipulation of different acupoints do exist in smaller portions of the brain network which are being investigated for the specificity of each acupoint. Would any "control" point be able to show some general and vague acupuncture effect even though it may not be able to deliver as strong an acupuncture effect if specific clinical outcome is desired, for example an improvement of heart function? While I do not believe that one can find a "control" point with no acupuncture function, I do agree that imaging the brain responses of "control" point will clarify the relationship with traditional acupoints and non-traditional points.
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"The existence of needling points not associated with traditional acupoints, so called control points that have zero acupuncture effect is, I believe, a mythical , misplaced and unfortunately a firmly ingrained belief."
IE Just poke anywhere! You can't miss!
"Needling "control" points should naturally also engage large areas of the brain network. Since there is only so much real estate in the brain matter, it won't be surprising that there will be overlaps in the two brain networks"
&
"It is not surprising for the large overlap in brain responses to manipulation at different acupoints"
So why bother to do the study then? If you knew that poking anywhere will light up similar or the same areas of the brain, why show that? What credence does it lend the idea that poking one area will light up one region of the brain in a healing way, but poke another area and it will light up the same area, but not in a healing way? How can you draw a conclusion that they’re different if they’re indistinguishable by your own admission?
Why not have controls that act in a very similar but non-acupuncture fashion? Stimulate with a fine plastic bristle or something that produces a similar physical sensation. If acupuncture is effective shouldn't it show a vast difference in brain activity, as touching with a plastic tine is vastly different to inserting a fine metal needle in acupuncture terms? One should be active, the other inactive.
Totally omitting to carry out negative controls proves nothing further than confirming that your treatment is as effective as a placebo. Nothing more. It cannot show any greater effect as there is nothing to compare it to.
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"poking anywhere will light up similar or the same areas of the brain, why show that?" "if they’re indistinguishable by your own admission?" There is a big difference between lighting up "similar" areas and lightening up the "same" areas. There was no admission of lighting up only the same areas.
"Why not have controls that act in a very similar but non-acupuncture fashion? Stimulate with a fine plastic bristle?" The sensory control of touching with a fine plastic bristle was done and reported half a dozen times in the literature by MGH alone in the last 10 years. There was vast difference in brain activity.
A reiteration of the very simple idea (to be verified) presented in the previous response: Traditional acupoints are chosen presumably due to their strong acupuncture effect while non-traditional points yield weaker effect (there is no need to postulate a null effect). If I were a clinician, it makes sense to always go for the stronger effect and not just to poke anywhere.
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The design of controlled experiments for acupuncture studies is fraught with difficulties, and few attempts have satisfied Western scientific standards [Richardson and Vincent, 1986; Vincent and Richardson, 1986]. One reason is the difficulty of finding a true ‘‘sham point’’ to use in comparison with the acupuncture point. According to traditional Chinese acupuncture, focal stimulation of a needle at relatively specific points with the evocation of the deqi sensation is important in generating therapeutic acupuncture effect. The specific location of acupuncture points along each meridian is derived from thousands of years of clinical experience. It is known that needling at points other than those indicated on acupuncture charts also can have therapeutic effects. For instance, Ah Shi and trigger points are focal tender points that are used in therapeutic acupuncture to treat chronic pain. An ideal ‘‘sham point’’ would be an area of skin located some distance from any known acupuncture point or trigger point. However, some of the physiological effects of acupuncture have been observed when such supposed ‘‘sham points’’ were stimulated [Margolin et al., 1993b]. This may be due to fact that the acupuncture ‘‘point’’ is actually an ‘‘area’’ overlying densely innervated muscle [Melzack, 1989]. We chose to use a number of controls including imaging during ‘‘needle at rest’’ and matched scans during tactile stimulation of the overlying area. Our data showed that neither ‘‘needle at rest’’ nor tactile stimulation produced the marked signal decrease in deep structures associated with needle manipulation. As can be seen from the time courses shown in Figures 2 and 4, insertion of the acupuncture needle caused at most transient signal changes (increases or decreases), never the sustained signal decreases observed during needle manipulation. The tactile stimulation paradigm used for the quantitative comparison was exactly matched to the acupuncture paradigm (2 epochs of 2 min stimulation separated by 4 min of rest and stimulus delivery 120 times per min) because the magnitude of the fMRI signal change is affected by these parameters. We tried another experimental design, needle manipulation within the subcutaneous tissue just beneath the corium (n 5 2) (data not shown). This method did not yield significant signal decreases in the deep structures described for acupuncture at LI 4. Our results indicate that insertion of the needle into the muscle and its manipulation are necessary to produce the deqi sensation and the prominent fMRI signal changes in the deep structures of the human brain. Additional evidence in support of this is provided by the results of an earlier preliminary study conducted in our center. They reported similar signal decreases in several of the limbic structures described above during acupuncture needle manipulation at acupuncture point Stomach 36 (ST 36, Zusanli) on the leg, but not during the control paradigm, pricking the skin over the ST 36 acupuncture point [Wu et al., 1997]. We did additional control scans (data not shown) in which several of the subjects were imaged for up to 8 min during needle insertion without manipulation. There were no accompanying signal decreases even during this prolonged needle insertion.
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The design of an optimal control for acupuncture stimulation remains unresolved (Ernst and White, 1997). It is known that acupuncture performed to sites that are not located on meridians can have varying degrees of physiological and clinical effects. Therefore, we chose to deliver superficial tactile stimulation to the skin surface as a non-invasive control at the acupoint rather than invasive needling at a non-acupoint. Lying supine in the magnet bore, the subjects could not see the devices being used to conduct the tests on their extremity. They were not aware which test was being performed, the sensory control or the real acupuncture. When control stimulation is given in an environment where the subject’s view of the site of stimulation ubiquitous, the use of a nearby non-point (not on any meridian) for control cannot be viewed as inert or inactive (Dincer and Linde 2003, Complement Ther Med; Lund and Lundeberg, 2006; Kong et al., 2009). There is no consensus as to the proper selection of a non-point, for example, how far from the classical acupoint in use, the minimal distance from another meridian point in the neighborhood, and how different in histological components and segmental innervations. In our exploration for a non-point control in our early acupuncture fMRI studies, the response of the point chosen was very variable, ranging from minimal to pronounced response. Although successful use of non-points as control is purported by many authors, reports are emerging that fail to find significant differences between non-points and real acupoints (Fang et al., 2008). The common practice of placebo needles for sham acupuncture is also problematic (Tsukayama et al., 2006, White et al., 2003, 2008). We, therefore, have opted to deliver superficial tactile stimulation to the acupoint, not as an inert control but as a means to help understand how acupuncture compares with a conventional form of sensory stimulation (Hui et al., 2000, 2005; Napadow et al. 2005, 2007). A recent study suggests tactile stimulation to be a “better control paradigm to extract the acupuncture specific brain responses”, which is in support of our findings (Ho et al., 2008).
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ReplyPosted by: Jacqueline G.April 9, 2010, 11:14 AM