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Dr Stephen Birch has practiced acupuncture since graduating from acupuncture school in 1982. He studied acupuncture extensively in Japan with Yoshio Manaka and senior Toyohari instructors. He has a PhD from the Centre for Complementary Health Studies at Exeter University, Exeter UK, focusing on acupuncture research methods. He has coauthored six books on acupuncture (one with Manaka) has taught acupuncture in both undergraduate and postgraduate level training programs, and has become an internationally renowned instructor in acupuncture. He has also lectured at a number of medical schools and medical conferences in the US. In addition he has been involved in academic and research debates in the field.
He helped found the Society for Acupuncture Research, was project director of a clinical trial of acupuncture at Yale University for two years, was involved with acupuncture research at Harvard Medical school, and a consultant to other studies. He participated in both the US Food and Drug Administration's review and eventual approval of acupuncture, and the recent US National Institutes of Health consensus development conference on acupuncture which led to a greater recognition of the value of acupuncture. He currently practices in Holland with his wife where he also continues to pursue his diverse interests in the field of acupuncture.
In 1973, after studying massage, medicinal cooking and acupuncture, Bob Felt founded Redwing Book Company, the first US bookseller to concentrate on complementary medicine. In 1981, with his partner Martha Fielding, he founded Paradigm Publications, a publishing company specializing in advance texts and language resources for the study and practice of traditional East Asian medicines. He has edited several of the fields seminal texts, served as the first publically-elected director of the New England School of Acupuncture, is a member of the Mercy College and CAOMJ advisory boards and
a Governor of the National Academy of Acupuncture and Oriental Medicine.
The authors are participants in the Council of Oriental Medical Publishers and support their effort to inform readers of how works in Chinese medicine are prepared.
"A book whose time has come". The authors clearly have an impressive breadth and depth of perspective on the various forms of acupuncture practice and how these forms mesh with the medical and scientific worldviews. (The book) belongs on the bookshelf of everyone interested in acupuncture, whatever their reason for interest. The broad, deep, objective perspective will earn it the position of 'first reference' when questions arise.
-C David Lytle PhD, Food and Drug Administration, USA
"This book brings together the many disciplines necessary to achieve a deeper understanding of acupuncture. It tackles the complex history, nature and practice of acupuncture and attempts to bridge this ancient medicine with modern science. An important book for anyone interested in the field."
-Brian Berman MD, Complementary Medicine Program, University of Maryland School of Medicine, USA
"Once in a decade a book comes along that both defines and extends the boundaries of professional acupuncture practice. Understanding Acupuncture is such a book. Its simple title belies the breadth of content and scholarly approach taken by the authors in achieving such a task. Drawing from such diverse fields as history, philosophy and science, they weave together a discourse that examines the evolution of acupuncture, both in the West and the Orient, and set the stage for its development into the new millenium."
-Chris Zaslawski, Lecturer, College of TM, University of Technology, Sydney, Australia
"Understanding Acupuncture delivers the promise of its title. True scholars, the authors have given us individual chapters that stand on their own merits but are even better appreciated within the context of the entire book. Replete with the political turmoil of the history of this medicine and the practical information to make it relevant to a broad audience, this book will soon be a mainstay of the libraries of acupuncturists, students, consumers, medical historians and scientists."
-Patricia Culliton MA, Lac, USA
"The authors skilfully demystify acupuncture's fantastic biography, offering instead a profound and scholarly analysis of this complex medical system. It is an impeccably researched and engaging book. I will definitely direct my patients and colleagues to consider this book as an important source for their understanding of acupuncture."
-Christina Stemmler, MD, Immediate past President, American Academy of Medical Acupuncture, USA
Reviewed by Michael P. Milburn, PhD,DAc
Frontier Perspectives at Temple University's Center for Frontier Sciences.
Canadian politics is often described as a tale of "two solitudes," referring to the country's two founding European peoples ' the French and the English ' and the vast gap in understanding between them. Stephen
Birch and Bob Felt's Understanding Acupuncture is also a tale of "two solitudes," in this case the skeptical scientific establishment unconvinced that acupuncture is anything more than a sometimes efficacious
placebo and the "acupuncture advocates" engrossed in an ancient and mystical "qi paradigm."
Birch is a pioneering Western acupuncturist who recently completed a doctorate in complementary health studies at Exeter University. Felt is a pioneer in publishing Asian medicine topics in the English- language.
Understanding Acupuncture is their attempt to build the foundation of a bridge between the "two solitudes" of acupuncture.
Understanding Acupuncture is impressive in its scope. The book presents a broad history of acupuncture and its transmission to the West. The authors show that an understanding of acupuncture requires a sense of
the historical, social and cultural factors that shape its actual practice in a particular place and a particular time.
Particularly impressive was the non-sectarian presentation of the practice of acupuncture in the West. Acupuncture encompasses a very diverse set of theoretical and practical approaches. This diversity, the
extent of which is not often appreciated, arises from the richness of acupuncture's spatial and temporal development. While Birch's practice is informed by Japanese influences, together with Felt he has set out an
excellent presentation of the major styles of acupuncture now used in the West.
While acupuncture is common in the West and certainly ensconced in the Zeitgeist, it is still only used by a small minority of people. Birch and Felt express their hope that acupuncture will enter into the mainstream of
medical practice, and in doing so become available to the bulk of the population. They argue that the best acupuncturist is the most skilled and experienced, not one from any particular style. Further, progress in
the more widespread adoption of acupuncture requires the kind of cooperation often lacking in the professional acupuncture community.
Highest quality scientific research is needed for acupuncture to progress,they argue, and to this end acupuncturists must go beyond the limits of their training.
To generalize about styles for the sake of this review, Japanese acupuncture can be characterized as very traditional, emphasizing tactile skills and using gentle techniques of needling. Modern Chinese TCM acupuncture has been shaped by the dialectical materialism of communism and by scientific biomedicine. Needling techniques tend to be strong. There is also a style of "Traditional Acupuncture" developed in England, a"Medical Acupuncture" devoid of traditional theory, and several approaches to "electroacupunture," among others.
The reader is offered examples of how various styles are actually practiced, and shown how the various styles fit into several classification schemes. Some styles are entirely traditional, using exclusively the ancient ideas of qi, yin, yang and the five phases.
Others eschew tradition, favoring a modern biomedical framework for practice. Other styles feature various admixtures of the two extremes. There is also a spectrum of needling techniques from the gentle to the strong. In some techniques the needle is inserted only in the most superficial dermal layers or even not at all. Stimulation of the needle is minimal. In other techniques the needle is inserted deeply and stimulated strongly, sometimes with electrical devices. Birch and Felt argue that this distinction is crucial for acupuncture research since the
effects of different techniques may be mediated via different biological pathways.
As a biophysicist and practicing acupuncturist, I was particularly interested in their discussion of the scientific understanding of acupuncture. Birch and Felt make it clear that we are only in the very early stages of understanding ' in scientific terms' how acupuncture works or, indeed, if it works at all. They point to serious flaws in many prominent studies and note the dearth of funds for research in this area. They also argue that scientists do not often understand how acupuncture is practiced and acupuncturists are not often well educated in the requirements of research. This gap between the "two solitudes" -- the scientists and the practicing acupuncturists -- is an impediment to the scientific understanding of acupuncture.
The scientific question of whether acupuncture actually works, and if so, for what medical conditions, is a difficult one. One approach is to do outcome-based studies that compare acupuncture to other standard
treatments for particular medical conditions. A number of such studies are now underway and these are of great interest to health administrators and those directing the business of health delivery. Birch and Felt argue
that these studies are valuable but will not go far enough in convincing the skeptics and facilitating the more widespread adoption of acupuncture. What is needed, they claim, are well designed blinded, controlled trials the gold standard for proving therapeutic efficacy. Blinded, controlled trials work well for pharmacological agents. It is relatively easy to compare a drug to a sugar pill without either thephysician or patient knowing which is which. Not so with acupuncture. It is not at all clear what constitutes a sham acupuncture treatment, the
equivalent of the sugar pill, nor how an acupuncturist is to be blinded to the fact she is not giving a real treatment. In many styles of acupuncture the treatment is highly individualized and point selection is varied over time. Birch and Felt do an excellent job of discussing these and other research problems, but do not offer any clear solutions despite their insistence that blinded, controlled trials are crucial.
I feel that given the many obstacles in the design of blinded, controlled trials of acupuncture, outcome studies are a better approach. We need to know if acupuncture can be more effective, and even if its efficacy is comparable, whether it is safer and/or less costly than standard treatments. Surely questions of placebo are a luxury from a practical and global perspective on healthcare. We should find out first whether acupuncture is effective, safe, and affordable. Then we can move on to study whether any demonstrated effectiveness arises simply from a superior placebo power of acupuncture. (As the skeptics claim, acupuncturists may be better at engendering the placebo effect through a superior bedside manner, flattering possibility, or patients may be enamored with the ancient origins of acupuncture and mystical concepts like qi.)
In emphasizing the need for blinded, controlled trials to convince the skeptics and thereby open the way for the mainstream adoption of acupuncture, Birch and Felt overlook a more fundamental problem.
Acupuncture does not have an apparent modus operandi. That is to say,even if acupuncture appears to work we will still not know how it works. If we look at other debates, like the efficacy of homeopathy or the biological effects of subthermal intensities of non-ionizing electromagnetic waves, we can see that without a modus operandi the skeptics will remain just that - skeptics. Despite extensive evidence demonstrating that magnetic and electric fields have biological effects, for example, skeptics -- all pointing to theoretical implausibility, are plentiful. (1)
The question of how acupuncture works is an immensely challenging one. The wide range of physiological effects produced by needling are reviewed by Birch and Felt. Hormonal and endocrine changes from needling, like the release of endorphins, are well known. The classically described xue, or acupuncture points, show strong electrodermal correlates measured as a change in conductivity/resistance.
Birch and Felt discuss the important hypothesis mentioned above that strong needling may work via conventionally understood physiological and anatomical pathways. This kind of needling is particularly important in the analgesic use of acupuncture. In contrast, they argue that lighter needle techniques "activate mechanisms that are best described by emerging descriptions of the body's information processing systems." This means that we must look to frontier areas of science- like systems approaches, information theory, and bioelectromagnetics - for a scientific understanding of acupuncture, a contention with which I heartily agree.(2, 3)
Unfortunately, despite the urgent need to address directly the problem of biological organization, such frontier areas of biological and biophysical inquiry are gravely underfunded. Thus, progress in the scientific understanding of acupuncture will be slow in coming. Still, acupuncture itself represents a paradigm challenge that demonstrates the need for these new approaches to biology.
Birch and Felt suggest the classical theories of acupuncture be seen as the software that describes the operational features of an underlying "X-signal system," a term coined by Yoshio Manaka to describe as yet
unknown organizational and regulatory hardware. If this is true, frontier biosciences will have the opportunity to learn from, and not just about, the ancient and still mysterious practice of acupuncture. Traditional acupuncture recognizes, for example, that specific symptoms can occur from a background of different "patterns of disharmony," in effect setting the illness within the context of the system's organizational state. This is
a well developed systems approach to diagnosis and therapy that deserves study. The five phases can be viewed as a prototype systems approach, complete with positive and negative feedback and an emphasis on process,
rather than as primitive cosmological speculation (i.e. the five"elements"). (4)
Even the late, great statesman Pierre Elliot Trudeau was not able to bridge the gap between Canada's two solitudes. With the publication of Birch and Felt's Understanding Acupuncture there is hope that the gap
between the two solitudes of acupuncture will not be so unyielding. This is a fine text that will engage both acupuncturist and scientist alike, a text that describes acupuncture in its own terms while at the same time
reflecting the fascinating challenge of its scientific exploration.
(1) Milburn, M.P. and M. Oelbermann. (1994). Electromagnetic Fields and Your Health. New Star Books: Vancouver, BC.
(2) Milburn, M.P. (1994). Emerging Relationships Between the Paradigm of Oriental Medicine and the Frontiers of Western Biological Science.Am.J.Acu., Vol. 22, No. 2, pp. 145-157.
(3) Milburn, M.P. (1995). Bioelectromagnetics: Implications for OrientalMedicine and Acupuncture. Am.J.Acu., Vol. 23, No. 1, pp. 53- 62.
(4) Milburn, M.P. The Tao of Health and Healing: Chinese Medicine and the New Biology. The Crossing Press, Santa Cruz. In Press.
by Stephen Birch & Robert Felt
Reviewed by Ken Shifrin M.Ac., F.B.Ac.C.
Dean, College of Traditional Acupuncture
Journal of Alternative and Complementary Medicine
Midway through this excellent book, the authors state that, "the primary problem is inadequate knowledge of what constitutes acupuncture among medical researchers and inadequate knowledge of what constitutes research among acupuncturists." This statement neatly encapsulates one of the major problems in the development of acupuncture practice today. A thorough study of this book should do much to inform both of these parties, to the mutual benefit of all.
Acupuncture has been likened to a great and venerable tree, with deep roots, strong solid trunk, and diverse ranches. The fact that such a "tree" has managed to survive for over two thousand years ought itself to indicate evidence of efficacy, yet the authors insist that high quality scientific research must urgently be carried out if the potential of this system of medicine is to be fully realized. This is a view shared by many, both within and outside the acupuncture profession. Although described as an acupuncture textbook, this volume will be of greatest interest to those involved in, or planning to begin, research into acupuncture. It is extremely well referenced, including copious explanatory notes, and readers are provided with a rich resource for further study and exploration. For this alone, the authors deserve commendation.
The book is divided into two sections, each consisting of four chapters. The first section, "What acupuncture is," covers the history and cultural contexts in which East Asian medicine has developed over the past three millennia, and goes on to discuss the basic theoretical concepts of acupuncture as well as providing an account of how acupuncture may work. In the last of these chapters, the authors provide an extremely lucid account of the challenges facing researchers of all backgrounds and persuasions, one which may well have merited the subtitle, "On the slaughtering of sacred cows." Here they set out one of the central pillars of their argument, which is that proper research into acupuncture requires a deep appreciation of, and respect for, the traditions, diversity, and methodology of acupuncture theory and practice, combined with an equally broad understanding of western scientific research methods.
The authors make the crucial point that acupuncture is unlikely to win scientific acceptance simply by demonstrating its effectiveness, unless it can also provide a demonstrable physiological explanation of how it works. Recent cases of research into homoeopathy, where clear evidence of efficacy beyond placebo has been rejected on the basis that explanations of how homoeopathy works are considered "too fantastic to believe,"
provide an important lesson for those who argue that simply proving that acupuncture "works" should be sufficient in itself. However, they also make the point that outcomes research, in which the "mode of action" is less important than effectiveness in comparison to conventional treatment, is growing increasingly popular as the demand for safe and inexpensive treatments such as acupuncture increases. The increasingly important role played by political and socio-economic factors must therefore be factored in when considering how best to develop acupuncture practice.
The second section, "How acupuncture is practiced," considers what conditions acupuncture treats, the diagnostic and assessment methods used by acupuncturists, and the treatment techniques employed. A set of 17 case histories is provided, which help to enhance the descriptions of how practitioners actually go about diagnosing and treating patients, as well as aiding the reader to distinguish between the various acupuncture practice systems. Finally, the authors set out their conclusions and suggested strategies for the future. It comes as no surprise that they argue, forcefully, for the integration of acupuncture practice into mainstream medicine, and the adoption of research approaches likely to promote this direction.
This book is very important and timely. As acupuncture continues to increase in popularity, both as a treatment and as a career, the debate about how best to research it grows ever more important and ever more heated. It is argued in certain quarters that any acceptance of biomedical research methods amounts to a surrender of traditional acupuncture's basic tenets, beliefs, and values, and will simply hasten the demise of the essence of this practice. Parallels may be drawn with the biomedical response to herbal medicine, where "whole plant" remedies are discarded in favor of "active ingredients" provided in controlled doses, much to the chagrin of medical herbalists. This would, it is argued, play into the hands of those who advocate the adoption of what is referred to as "modern
scientific acupuncture," although much of the research upon which this approach is based is itself limited and/or flawed. Counter to this is the view that traditional acupuncture must demonstrate its validity and efficacy in terms understandable to mainstream medicine, or else the very thing most feared by its proponents is likely to come true, namely the adoption by biomedicine of those parts which can be (apparently) explained by science, and the discarding of the rest.
In the midst of these "paradigm wars" the authors have, in my view, made a valiant and quite effective attempt to square the circle. Their overview of acupuncture's history and practice is very well done, as is their discussion of the many problems and pitfalls of modern research methods. Their insistence that proper investigation into acupuncture must start with a deep appreciation of acupuncture's rich tradition is an essential step towards reconciling the divergent views described above. Understanding Acupuncture represents an important, powerful voice in this debate, and I recommend it to all who wish to inform themselves of the issues involved.
Extended Description 2
C. David Lytle PhD
Research Biophysicist, Division of Life Sciences,
Food and Drug Administration, Rockville MD, USA
Understanding Acupuncture is a book whose time has come. In fact, the information, perspective and objective analyses were sorely needed a few years ago when the US Food and Drug Administration and the National Institutes of Health's Office of Alternative Medicine were wrestling with 'what to do about acupuncture'. It is especially important now that acupuncture is starting to break out of the alternative medicine mold and become a serious candidate for complementary medicine.
For the first time in English, we have an up-to-date scholarly treatise on the various forms of acupuncture practiced around the world. The evolution of each different form is traced against the social, economic, medical and scientific settings of that time and place. Understanding Acupuncture commences with treatments described in classic Chinese texts and arrives at the current situation in the West, relating the 'theoretical' basis of acupuncture to the tenets of modern medicine and science.
The practice of acupuncture can sound rather mystical. Understanding Acupuncture removes the mysticism while retaining the esthetic and practical value of the Qi paradigm. The book is readable, with the many aspects of acupuncture necessary for a thorough and balanced understanding illustrated clearly by carefully chosen examples. It is not a how-to book. Its purpose is to promote understanding by stressing careful scholarship and objective analysis. A particularly educational feature is the side-by-side presentation of the different systems of diagnosis and treatment to illuminate the diverse approaches to acupuncture practice. Boxes, that explain important issues without breaking the flow of the main text, are interspersed throughout. Several models developed to explain acupuncture are presented, from the neurophysiological model to Yoshio Manaka's X-signal model. The reasons for the high level of acceptance by the Western biomedical world of the neurophysiological model for analgesia are elucidated, along with reservations that show just how limited such a model is.
Perhaps one of the most important issues addressed is how biases and assumptions in research can lead to misinterpretations and misrepresentations, misleading all but the most discerning and knowledgeable. An unfortunate result has been the delayed acceptance of acupuncture by the medical and scientific communities in the West. Understanding Acupuncture provides an objective examination of some key studies to illuminate many of the pitfalls waiting to dupe the naive and uninformed. An unbiased comprehension of these issues will continue to be important in the foreseeable future.
Understanding Acupuncture should be required reading for several groups. Most importantly, it should serve as a primary source for regulators and policy makers, including those who must discriminate among who should be regulated and in what manner. This book addresses several issues critical to the regulatory process. One of the most frustrating issues recently has involved discerning which scientific or clinical studies should be given attention, since most published studies have not met the standards of rigor normally demanded by the scientific and clinical communities. The authors have chosen key illustrative examples to educate the reader, drawing reasonable interpretations that policy makers should find helpful.
Inquiring acupuncture students, their instructors and other, practicing acupuncturists should know how the particular acupuncture scheme they are employing fits into the overall picture. Understanding Acupuncture will help them be better able to interact with their peers from other acupuncture traditions and, more importantly, with future patients who in turn arrive having had different levels and sources of acupuncture experience. This book will provide physicians, dentists and other members of the allopathic medical community with information to help them understand the utility of acupuncture and interact with patients who use acupuncture as a complementary or alternative health care modality. Indeed, this book would serve well as the acupuncture textbook for a medical school course on alternative/complementary medicine.
Clinical and laboratory investigators need to understand the current models of acupuncture mechanisms, but not be misled into unduly limiting paradigms. Understanding Acupuncture gives guidance on how to ask the right research questions and how to or how not to design and interpret experiments on acupuncture efficacy or mechanisms. Researchers also will benefit from detailed explanations on what constitutes adequate treatment (e.g., number and stimulation of needles, number and timing of treatments, individuality of treatment, etc) and what constitutes appropriate treatment controls.
The authors clearly have an impressive breadth and depth of perspective on the various forms of acupuncture practice and how those forms mesh with the medical and scientific worldviews. Few indeed are those with such depth and breadth of knowledge and experience, and fewer still are those who can enlighten others. Both authors know the acupuncture literature and have authored or edited English texts and participated in the evolution of acupuncture's acceptance in the United States. These latter activities have included dealing with bureaucrats with little, or no, initial understanding of acupuncture. The senior author is an experienced acupuncturist who was a major contributor of material submitted to the FDA, including the manner of presentation and analysis. Perhaps that experience motivated the substantial scholarly effort represented by Understanding Acupuncture.
There is a refreshing candor throughout the text. The importance of accurate translations and critical scholarship is stressed. The explanations and descriptions are presented with clarity and thoughtful organization, pointing out the strengths and weaknesses of one issue after another. Many assumptions about acupuncture are challenged, many answers are documented. This will hopefully raise and broaden the comprehension of proponents and opponents alike to the truths and limitations of the various issues in acupuncture and their supporting data.
Understanding Acupuncture belongs on the bookshelf of everyone interested in acupuncture, whatever their reason for interest. The broad, deep, objective perspective will earn it the position of 'first reference' when questions arise. Even my first quick skim through the chapters convinced me of its value. You will agree, and then place it in your place of 'first reference' on acupuncture.
Rockville, MD USA 1999 C. David Lytle
The first two chapters describe acupuncture's ancient and modern history, and emphasize its continual adaptation to the needs of East Asian populations and the refinement of Asian methods of problem-solving. The third chapter discusses the basic theories of traditional medicine, not as clinical instructions, but as expressions of Asia's refinement of naked-sense observation and the relationships of systematic correspondence. Chapters Four and Five consider the basic science and clinical efficacy of acupuncture. These chapters contain the first conveniently-accessible analyses of scientific work on acupuncture and openly discuss the biases that have affected scientific judgements. Chapter Six describes patient assessment, again, not as the clinical protocols of a particular school of practice but as a set of broadly shared intellectual and observational skills. This is also true of the following chapter where the authors present the central therapies of acupuncture in a framework embracing the tremendous variety of the field.
The authors conclude with a challenging assessment of the current economic status of acupuncture's pioneer institutions relative to the field's need to sustain its integrity in massive Western medical markets and delivery and education systems. The back matter contains information for patients and referring physicians, including a list of non-commerical resources, a list of seminal historic texts in Asian languages, and an extensive bibliography.