When people think of Chinese medicine, they most commonly think of acupuncture. When they think of acupuncture, they instantly think of back pain. It is true that back pain is the first ailment for which Western countries accepted Eastern solutions. However, there is a vast array of different conditions for which all components of Eastern medicine can be used.

Eastern medicine is composed of various strands: acupuncture, herbal formulas, bodywork, tai chi, qigong, dietary therapy, exercise, and meditation. Any or all of these practices can be used to improve many chronic and some acute conditions. For certain life-threatening acute conditions, Western medicine would still be the modality of choice. If you had a shattered leg from a car accident, you'd want an orthopedic surgeon. If you had an overwhelming bacterial infection, you'd want intravenous antibiotics. If you were a woman in labor with a baby who was too big to be born naturally, you'd want a cesarean section. In our Western society, we all too often forget that the "natural" consequence of certain conditions is severe disability or death. It is in these situations that Western medicine shines, saving the lives of people who would normally die in another time or place where these techniques were not available.

But no system is perfect. What Western medicine lacks is the capacity to effectively treat many chronic illnesses. This is where Eastern medicine makes its greatest contribution. Many people are surprised to learn that Eastern medicine can be used for such diverse conditions as cardiac arrhythmias, digestive complaints, insomnia, gynecologic problems, infertility, and asthma.

Eastern and Western Research

If you were to go to your computer and use a common medical search engine such as PubMed to look for research articles on Eastern medicine, you would find thousands. By searching the subject "East Asian medicine," you would be presented with over 10,000 papers. If you looked specifically for articles about acupuncture, more than 17,000 would appear.

It is one thing to say that research has been done, but it is important to know a little about how the studies were designed and what questions they were set up to answer. These two questions are crucial, regardless of the modality being tested. It could be the latest drug for diabetes, the newest surgical technique, or a therapy as ancient as acupuncture. The question being posed and the study design are key to yielding meaningful results that can be applied to the individual patient.

Research itself is a relatively new concept. In Western medicine, up until around the Second World War, the effectiveness of a certain treatment was measured by the improvement of the patient. During that time, the validity of a therapy was based upon the accumulated outcomes of its use. Over time, with repeated successes, practitioners would incorporate an intervention into their usual practice. Those therapies that did not benefit the majority of patients were discarded. This is the manner in which East Asian medicine has developed over the millennia. It is a very practical way of looking at the utility of a treatment. The bottom line was this: did the patient improve or not?

Just before the Second World War, researchers studied the effects of certain agricultural fertilizers. These studies compared the growth of two groups of plants. One group was treated with the active substance and one group was not. The untreated group was designated the "control" group. So began the era of controlled trials.

Then the idea of randomly assigning participants (human or otherwise) to either the clinical or control group gave rise to the randomized controlled trial. This is commonly referred to as an RCT. Randomized controlled trials were further refined by "treating" the control group with a placebo. In essence, the control group was managed in exactly the same way as the study group, except the control group was not given the active substance that was being tested.

At the end of the trial, differences between the groups had to be sufficiently large to show that the active substance or treatment was having an effect. This is referred to as being statistically significant. It was no longer enough to say that a patient or group of patients improved after an intervention. It was now required that the improvement in the study group was greater than the improvement seen in the placebo control group. There are several problems with this methodology, particularly with respect to Eastern medicine and acupuncture.

Randomized controlled trials are designed to answer a specific question. That is, does the treatment/drug/intervention being tested cause the observed effect? This sort of study design is said to be "explanatory," and it looks at the efficacy of a treatment. It is best suited to the sort of biochemical experiments seen in drug trials. This represents a simple cause-and-effect relationship between the intervention and the outcome. The expectation is that as long as all other factors remain unchanged, the same cause will always result in the same effect. RCTs are designed to test interventions on a homogeneous population in order to decrease variability between the treatment and placebo group and also within the groups themselves. Statistically significant results yield a great degree of predictability, and those results translate easily into clinical practice guidelines.

Unfortunately, the real world is somewhat more complicated. It has frequently been found that, in spite of excellent results during research trials, certain drugs or interventions do not give the same degree of benefit when applied to the general population. Within the general population there is a wider range of differences among patients.

Additionally, the practitioner who is administering the intervention can also influence the outcome. Here again, the factors are numerous and include level of training, innate skill, and the relationship that the practitioner has with the patient.

There has recently been a keen interest in the biomedical community to adjust study designs, taking these complexities into account. In these instances, the study is not designed to determine whether a certain treatment causes a certain effect. In this sort of study, the treatment and control groups are still randomized. The initial structuring of the study is not that much different. It is the question that has changed. The new question posed is this: Does this intervention do what it is intended to do under real world conditions, without regard for the exact mechanism of action? These sorts of studies are called "pragmatic" and are concerned only with effectiveness, not causality. In other words, did the patient get better or not?

This is not to say that one type of study is better than the other. It is only meant to point out that you really need to know what question you are asking before you design a study. For a while now, biomedical researchers and medical anthropologists have been determining ways to investigate more complex biological systems that fall out of the realm of straight-ahead cause-and-effect reactions.

Eastern medicine certainly falls into the category of a complex system. There are many components and variables that determine whether or not a treatment is successful, and this presents the greatest obstacle to researching the efficacy of Eastern medicine. On the other hand, the effectiveness of Eastern medicine has been demonstrated, both through clinical research and in everyday use.

What Does the Research Show?

In 2012, the World Health Organization updated its list of those conditions for which acupuncture was deemed useful. In this report, the evidence for acupuncture's utility was taken only from clinical trials that were formally published in peer-reviewed journals. These studies were required to have an adequate number of patients to observe an effect. They were either randomized controlled trials or nonrandomized controlled trials. This means that in the randomized trials, patients were assigned at random to either the acupuncture group or the control group. In the control group, the patients received either conventional Western therapy or sham acupuncture. In the nonrandomized trials, those patients who received acupuncture were compared with similar groups of patients who did not, but none of the patients was randomly assigned into their groups.

The following is a list of ailments for which acupuncture was deemed useful to varying degrees in different clinical situations. The WHO divides the results into four groups:

• conditions for which acupuncture is definitely effective
• conditions for which there is a therapeutic benefit but more research is suggested
• conditions for which there is only some benefit but conventional therapies are problematic
• conditions in which acupuncture may be tried provided the practitioner has modern medical knowledge and means of monitoring the patient.

Over 80 percent of the listed conditions fall into the categories that show effectiveness and definite therapeutic benefit.

The diseases or disorders for which acupuncture therapy has been tested in controlled clinical trials reported in the recent literature can be classified into four categories, as shown below:

1. Diseases, symptoms, or conditions for which acupuncture has been proved through controlled trials to be an effective treatment:
   
   Some are: postoperative pain, renal colic, rheumatoid arthritis, sciatica, sprain, stroke, tennis elbow
2. Diseases, symptoms, or conditions for which the therapeutic effect of acupuncture has been shown but for which further proof is needed:
   
   Some are: abdominal pain, acne vulgaris, Bell's palsy, bronchial asthma, cancer pain, cardiac neurosis, female infertility, fibromyalgia and fasciitis, spine pain
3. Diseases, symptoms, or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which acupuncture is worth trying because treatment by conventional and other therapies is difficult:
   
   Some are: chloasma, choroidopathy, color blindness, deafness, irritable colon syndrome, neuropathic bladder in spinal cord injury, pulmonary heart disease, chronic small airway obstruction
4. Diseases, symptoms, or conditions for which acupuncture may be tried provided the practitioner has special modern medical knowledge and adequate monitoring equipment:
   
   Some are:  breathlessness in chronic obstructive pulmonary disease, coma, convulsions in infants, coronary heart disease, diarrhea in infants and young children. encephalitis, viral, paralysis

This list potentially underestimates the number of conditions for which acupuncture, and by extension, Eastern medicine can be effective. This is due to flaws in study design. For example, in the case of morning sickness in pregnancy, some studies show that acupuncture was as good as or better than standard medical treatment and certainly better than no treatment. Other studies were set up to compare women who received acupuncture against women who received sham acupuncture. Sham acupuncture has been variously described as needling prescribed points superficially, needling non-acupuncture points, needling points that have not traditionally been used for the condition being treated, or using retractable needles to simulate the experience of true acupuncture without the actual insertion.

Integration of Eastern and Western Medicine

Western medicine, for all its amazing technologies, has proven to be both expensive and, risky. It does save lives in acute, emergent situations, but does little to improve the quality of life in chronic illness. Most of the ailments in our society are persistent in nature and caused by poor lifestyle choices. The strength of Eastern medicine lies in its ability to enhance the day-to-day functioning of the chronically ill through a combination of acupuncture, tui na, herbs, exercise, and diet. The integration of these two systems could improve medical care in the United States by decreasing complications and costs while increasing the overall health of the population.

The above is an excerpt from True Wellness: How to Combine the Best of Western and Eastern Medicine for Optimal Health by Catherine Kurosu, MD, LAc and Aihan Kuhn, CMD, OBT.