Acupuncture and Cupping – Part 2: Alternative Therapies and the Placebo Effect

Note: this article is the second of a two-part series on alternative therapies like acupuncture and cupping. You can read Part 1 here: Acupuncture and Cupping – Part 1: Ancient Medicine or Pseudoscience?

In Part 1 of this series, I considered the claim that acupuncture and cupping are extreme and unproven alternative therapies for relieving pain, preventing injury and improving athletic performance. While fact-checking this claim revealed some questionable source material, the scientific research on acupuncture and cupping raises additional questions.

Some studies indicate that patients with certain ailments can benefit from these alternative therapies. But some of these benefits may be due to a placebo effect. In the case of acupuncture, there is often little difference in the outcomes of subjects who receive true acupuncture and those who receive sham acupuncture. Critics also point out the possibility of bias, since those who perform research on acupuncture and cupping are often themselves practitioners of these alternative therapies. And different studies on acupuncture and cupping often show conflicting results.

In Part 2 of this series, I will take a closer look at these critiques of acupuncture and cupping research. I will also compare research in these fields to scientific studies on exercise and present a science-based explanation for acupuncture. And finally, I will suggest what role, if any, acupuncture and cupping should have in healthcare and maximizing athletic performance.

A Parallel Example

Sham Controls

Interestingly, exercise faces similar challenges to those raised against these alternative therapies. Like acupuncture and cupping, it is difficult to create a sham exercise control. In randomized controlled trials of drugs, a placebo can look, feel and taste exactly like the drug being tested but contain inactive ingredients instead of the drug. But when the therapy involves inserting needles or moving one’s body, placebo design faces unique challenges.

For example, a 2001 randomized controlled trial on elderly adults with depression compared exercising versus attending a series of lectures. Not surprisingly, the group that exercised saw significantly greater improvements in their condition compared to the control group. Other studies compare exercise to no treatment or to the standard treatment for the condition under study. But I am not aware of any research that incorporates a sham exercise control, nor is it clear what exactly sham exercise would look like.

Phoebe and Rachel running on Friends
True running versus sham running?


Additionally, many scientists who choose to do research on exercise are also themselves exercisers. It makes sense that those who embrace a physically active lifestyle would want to see their interests represented in their professional work. But here, exercise runs into the same problem of bias as acupuncture and cupping.

People with a specific health complaint likely benefit psychologically from seeing a practitioner who offers concrete suggestions to help them feel better. If a researcher provides a subject with an exercise program, the researcher’s positive attitude toward exercise might make the subject feel that her complaint is being addressed with due consideration. In contrast, a subject in a no-intervention control would not have an equally positive encounter. Such bias on the researcher’s part, coupled with the design of the experiment, could contribute to a placebo effect.

Furthermore, biased researchers might shade their interpretation of the data to reflect their preconceived opinions. This outcome of bias is not exclusive to research on alternative therapies. If there is a chance that biased acupuncture and cupping researchers overstate their findings, that same chance exists with biased exercise researchers.

The Explanatory Mechanism

So if exercise research faces some of the same challenges as research on acupuncture and cupping, why is exercise widely accepted as a treatment for everything from cardiovascular disease to depression while any apparent benefits of these alternative therapies are derided as a placebo effect?

Part of this discrepancy stems from the mounting volume of research demonstrating exercise’s many benefits. Unlike acupuncture and cupping research, there is very little conflicting data about the benefits of exercise. But I suspect that another part of this discrepancy stems from the explanations of these alternative therapies. For example, according to the Mayo Clinic:

”Traditional Chinese medicine explains acupuncture as a technique for balancing the flow of energy or life force—known as chi or qi (chee)—believed to flow through pathways (meridians) in your body. By inserting needles into specific points along these meridians, acupuncture practitioners believe that your energy flow will re-balance.”

Body meridians used in acupuncture and other alternative therapies

Words like “energy flow,” “life force,” and “meridians” do not suggest a scientific procedure. By contrast, we have a pretty good understanding of how exercise produces beneficial changes in the body. There are plausible anatomical explanations for how regular physical movement improves heart function, muscle strength and oxygen uptake and reduces stress hormones. And we know that exercise promotes the release of endorphins, which can lead to improvements in mental health. In other words, even though it’s hard to create a sham exercise control group, the experimental benefits of exercise are consistent with a scientific understanding of how the human body works. That’s not the case with the common understanding of acupuncture.

Explaining Alternative Therapies

But what if there was a way to explain acupuncture that was consistent with modern science? In a six-part series on acupuncture, functional medicine practitioner Chris Kresser offers such an explanation. According to Kresser:

“The ‘energy meridian’ model that has become the default explanation of Chinese medicine [in the] US is not only out of sync with our modern, scientific understanding of the body—it’s also completely inconsistent with classical Chinese medical theory. In other words, we’ve made up our own western version of Chinese medicine that has little to do with how it was understood and practiced since it began more than 3,000 years ago in China.”

Instead, Kresser argues, there is research identifying the mechanisms by which acupuncture relieves pain, reduces inflammation and restores homeostasis. In short, acupuncture promotes blood flow, which leads to better delivery of oxygen, nutrients and immune cells to affected areas and better removal of cellular waste. Furthermore, acupuncture creates micro-traumas near the site of injury. As the body heals these micro-traumas, it also heals the surrounding damaged tissue. Additionally, acupuncture promotes the release of endorphins (just like exercise), which act as natural painkillers. It also stimulates the release of the hormone oxytocin, which regulates the parasympathetic (“rest-and-digest” or “calm-and-connect”) nervous system, leading to a reduction in stress.

True and Sham Acupuncture

Now it’s possible that Kresser is wrong about how acupuncture works. But at the very least, his explanation of the biological changes caused by acupuncture seems plausible. What’s also interesting is that Kresser’s explanation doesn’t appear to rely on acupuncture needles being inserted into precise points on the body.

For example, if a patient is suffering from lower back pain, inserting a needle at a point near the acupuncture-prescribed point should produce many of the same physiological effects as a needle inserted at the precise acupuncture point. We should still expect increased blood flow, micro-traumas leading to healing of the surrounding tissue, and the release of hormones to reduce pain and stress.

In other words, Kresser’s explanation accounts for the observed benefits of true acupuncture and sham acupuncture. Of course, acupuncturists can’t be too imprecise. Piercing a patient’s kidney would likely be counterproductive. But this latter concern is not a strike against acupuncture. It merely highlights the importance of seeking out reputable practitioners.

There is a plausible explanation for any observed physiological benefits of acupuncture. And if we can’t distinguish between “true” and “sham” exercise, that shouldn’t be a criterion for good acupuncture research.

Acupuncture and Exercise

In the same way, the physiological explanation of exercise accounts for the benefits of any kind of physical movement. Running improves cardiovascular fitness, whether you follow a strict training program and practice perfect technique or whether you run as fast and as far as you want without paying attention to your form. The former might produce greater performance benefits and reduce the risk of injury, but both “true” and “sham” running result in similar physical benefits.

Does this example show that acupuncture works just as well as exercise? Certainly not. But it does reveal some unfair standards applied to acupuncture research but not exercise research. As with exercise, there exists a plausible explanation for any observed physiological benefits of acupuncture. And if we can’t distinguish between “true” and “sham” exercise, that shouldn’t be a criterion for good acupuncture research.

Low-Hanging Fruit

However, Nick Tiller makes an important point in his original article:

“One solution that has been proposed is for athletes and coaches to invest their resources in performance aids that are underpinned by both empiricism and powerful expectation/belief effects—for example, supplements such as caffeine that have both physiological and psychosomatic outcomes.”

In other words, anyone trying to improve their health or reach new levels of athletic performance should start with the proverbial low-hanging fruit. Interventions like exercise, nutrition and sleep have well-studied benefits and will account for the vast majority of physical health and fitness improvements. Once those practices are dialed-in, athletes looking for an additional boost should turn to supplements and therapies whose effectiveness is backed by multiple randomized controlled trials, such as caffeine and creatine.

Basketball player sleeping

Appropriate alternative therapies should be something of a last resort. In selecting these therapies, athletes and coaches should opt for those that have some evidence of addressing the athletes’ goals and have a low risk of side effects. And as with any performance aid, finding a reliable practitioner is essential.

An Answer to the Question

I suspect that this stepwise approach is exactly how most high-level athletes operate. Robin van Persie didn’t become one of the top soccer players in the world by lounging on the couch and eating pints of ice cream. And when he got injured, he likely turned to horse placenta after other more proven therapies failed to get him the results he wanted.

So the answer to the original article’s headline, “Why do so many athletes turn to extreme and unproven remedies?,” is a simple one. They do it because they have exhausted mainstream, research-backed remedies. At the upper echelons of a sport, the difference between winning and losing, between lucrative contracts, prize money and sponsorships and getting cut or passed over is infinitesimal. Even if a therapy carries a risk that would be unacceptable to the rest of us, it may be worth it for an elite athlete seeking a career-defining victory or life-changing payday.

A Place for Alternative Therapies

That said, I remain unconvinced that acupuncture and cupping should fall under the same category as treatments like horse placenta. We have seen evidence of their effectiveness in certain circumstances. And while difficulties remain in teasing out sham versus true effects, critics do not apply that criterion to related interventions. With a plausible biological explanation in place, acupuncture and cupping look less and less like pseudoscience. By finding a reliable practitioner and taking simple steps to mitigate some risk factors, these procedures become even safer.

No, acupuncture and cupping do not have the same scientific backing as nutrition, exercise and certain exogenous supplements. But that does not make them worthless. While they may not be appropriate as an athlete’s first choice of performance enhancement, they can still serve a role in improving physical performance. As in many scientific fields, more research is necessary. But the existing acupuncture and cupping research should not be cast aside so easily.