Morley Acupuncture Clinic
1 Queen Street, Morley, Leeds LS27 8EG, UK
Founder & Director
John Heptonstall MD(MA), DSc (MA), BSc. (Hons) Applied Science, M.I.Ac.S., M.B.Ac.C
Traditional Chinese Medicine - Acupuncture & Moxibustion Specialist
Becka McGuire - Acupuncture & Massage - "Morley Community Acupuncture"
Miguel Cardoso - Phyisotherapist - PhysioMed
TIGER BOOK Publishing
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Research and General Information on TCM
1. Infrared radiant tracer study
The picture below is of results of a research project carried out by HU Xianglong, WU Bao-hua and WANG Pei-qing of the Fujian Institute of Traditional Chinese Medicine, Fuzhou 350003, CHINA, which 'displayed meridian courses traveling over the human body surface under natural conditions'. They used infra-red radiant tracer, which was connected to accurate infra-red photographic equipment and a computerized graphics process. It was the first type of 'non-invasive' procedure which appears to have captured certain meridians. Other than the non-invasive electrical detection experiments which utilized the acupuncture point phenomenon of low impedance to detect acupoints, and then extrapolated the information to chart 'meridian pathways' by connecting those points other research projects designed to capture meridians have tended to involve invasive activities such as the introduction of radio-isotopes or other chemical means through which to try identify the elusive pathways.
One can clearly identify part of the Stomach Meridian on the face and neck, the Triple Energizer Meridian on the head behind the ear, acupoint Small Intestine18 (SI18) on the cheekbone and aspects of the Urinary Bladder Meridian on the back of the person on the right.
The photo on the left shows the Arm Large Intestine Meridian beautifully, and even details the Collateral adjoining the Lung and Large Intestine Meridians as predicted accurately by Traditional Chinese Medical theory. The right hand photo exhibits both the Lung and Heart Meridians.
It is this kind of innovative research that is 'bringing to life' ancient knowledge through the use of modern technology. Not only will the knowledge improve the response of modern medical scientists to the concepts of TCM, but it also paves the way for safer medical intervention as to ignore such a valuable and important aspect of physiology ensures the meridian pathways will be damaged through the use of drugs and surgery as their effects on meridian integrity go unnoticed other than by TCM practitioners. Once the surgeon realizes that cuts or scarring to meridians can be dangerous to health, as one expects cuts to blood vessels or nervous pathways can be, patients will be relieved of the potential dangers associated with such damage
The TCM system of Meridians, and the concept of Life Energy, QI, which flows through these channels to attend and activate every part and aspect of bodily function will require more medical thought through the application of modern physics in medicine. It will find its rightful place alongside chemistry which has dominated Western medical thought for generations. The intercellular communication, QI Flow, can then be analyzed and utilized to bring ever greater health benefits; the knowledge gained may eventually supercede current modalities as quantum mechanics and electronics develop 'medical interventionist techniques' to rebalance the body electric so that disease disappears. The relationship between our chemical and electromagnetic environment and ill health will be more easier to define, leading to innovative ways to combat diseases caused by these damaging environments.
At the moment TCM-based knowledge allows for a deep appreciation of the deleterious effects of lifestyle and environment on our health, information obtained and validated over the millennia by objective observation by generations of TCM practitioners who must practice careful and consistent epidemiology in order to strive for the cures which can only be gained after the identification and elimination of the 'cause' of a disorder. When this knowledge and experience is coupled with TCM intervention such as 'acupuncture & moxibustion' one has a very powerful tool available to fight and defeat disease and disease processes.
The matrix of Channels and Collaterals (Meridian system) which forms the basis of Traditional Chinese Medicine diagnosis and treatment with connections to all organ and sensory systems is analogous to the household electricity system. Through conduits and wiring circuitry electrical energy runs to empower all household equipment from heating and cooling devices (heater/air-conditioning) to nutritional (cooker/fridge) and intellectual and emotional stimulatory (TV/radio/hi fi) systems. Our bodies have systems with similar responsibilities - the endocrine, nervous and circulatory systems that monitor and adjust our emotional and physical responses and maintain our nutritional and immune state. According to TCM the meridian system provides a relatively simple means to access the complexities of the other three systems as although it is a unique and independent 'equilibrium' it interconnects and interacts with the other three equilibria in ways only understood through knowledge of the TCM model. Gradually this role is being uncovered in modern scientific terms as more and more research is performed to reveal its 'secrets'. The TCM practitioner, often called an 'acupuncturist' or a 'herbalist' dependent on the modality through which TCM is practiced, learns to adjust the meridian circuitry (as would an electrical engineer adjust the house wiring and equipment) to optimize each aspect of its being and to counter any extraneous effects that may interfere with the correct performance of the essential circuitry of life.
Although TCM is 'ages old', this does not preclude a practitioner from moving with the times. During the passed few decades the introduction of modern technology into the TCM framework of treatment and diagnosis has helped tremendously. No longer is it necessary for needles to be regularly hand-twirled to ensure continued stimulation of acupoints, one can attach electrodes to the needles and a battery-driven electro-acupuncture machine will deliver a small current to keep the points stimulated. Soft lasers are used to stimulate acupoints, these are usually Helium Neon (visible red wavelength), as are electrical pointer 'pens'. Despite all the modern gadgetry many acupuncture & moxibustion specialists will recognize that the original method of hand twirling needles with or without moxa, according to disorder requirements, ensures a well tried and tested mode of intervention.
2. Research developments in China from the 70s to the late 90s.
Acupuncture & Moxibustion, and the fundamental theories that underpin this and other Traditional Chinese Medicine (TCM) modalities, are often attacked by skeptics who claim that there is little or no evidence or scientific support for the theoretical bases of TCM or its practices. Objective skepticism is healthy but, having long debated in the medical media with some of the apparently "regular skeptics" I reached the opinion that a majority appears to have strong pharmaceutical interests which may cloud their judgement.
I have therefore provided for the objective skeptic a tiny example of some of the hundreds of thousands of research papers that originate from some of the many centres of academic and medical excellence in China that inform on the vast subject and help to counter some of the unfounded criticism that "professional skeptics" generate in a pharma-friendly media.
The following briefs are from the 1970s to illustrate the kind of science that has long been used to inform on the mechanisms, principles and values inherent in techniques of proven over several millennia. Acupuncture has always been said to be mediated through the meridian system and we see how powerful the evidence is for the presence of meridians, and therefore acupuncture points (acupoints), many of which are found along the meridians.
MENG Zhaowei (Anhui College of TCM) had already postulated the existence of 4 equilibria from ancient charts - the 1st being somatic nerves (100m/s conduction, quick postural equlibrium), 2nd autonomic nerves (1 m/s conduction, visceral equilibrium), 3rd meridians (0.1m/s propagated sensation – PSM, somatovisceral equilibrium) and 4th internal secretion glands (in minutes, dispersion, slow equilibrium of the body); supported by the triune concept of the brain and behaviour of McLean denoting 3 portions in the higher brain, the cerebral cortex, the limbic system, and the complex body in the pallidum from which a 3rd factor for the nervous system arises, a 3rd equilibrium.
MENG Zhaowei et al (in 1977 a group from 4 provinces) studied the ancient charts using PSM (propagated sensation along the meridians when acupoints are stimulated; proven through various technical means, and believed after many and varied trials to be a manifestation of movement of Qi having characteristics long described as those of Qi and exclusion of any other known measurable origin) of 100 individuals and modified/revised the ancient charts finding limb portions, except LIV meridian, same as old after repetitive mapping; thoraco-abdominal part having greater upwards branching; head part widespread branching; all lines showing natural curves not abrupt zigzagging; all Yin meridians track to head.
ZHONG Jin et al (Harbin) in 1979 measured PSM and QiRA QiRA (Qi Reaching Affected organs – an aspect of PSM reaching the target/affected organ) in 281 cases showing that PSM can be excited and blocked mechanically (type of needle stimulation and pressure etc.). In 49,032 meridian observations the course of PS showed distinct variations specially affected by pathotaxis (more later); 2197 cases of dominant PS (more later) or 82.2% with +ve rate of PSM 78-93% in 39,537 meridian observations. After extensive observations, the team concluded that PSM characteristics could be described, moving along meridians, as having universality, potentiality, pathotaxis (4086 cases after excitation of PSM reached 96.3% plus effective reactions at internal organs 50-90% of time, suggesting a physiological basis for further study), effectiveness, controllability, excitability and variability.
LU Chongyau (Anhui College of TCM) made comparative studies between dominant and recessive PSM – for some meridians 2 incomplete coincident lines of PSM may be drawn by different experimental methods, dominant and recessive lines of PSM (ZHONG Jin and LI Yangguang first advanced concept of recessive PSM in 1976) by electrical resistance, tetra electrode technique in 100 persons showing significantly that dominant and recessive methods play an important part in PSM. He used H and L meridians, finding significant differences in characteristics comparing meridian and non-meridian tissue, and between meridian lines eg. mean values for L, 16.1 ohms, 16.9, 19.6 but for H, 17.4 ohms, 17.8 and 19.9.
ZHONG Ruxin (Beijing Hospital of TCM) working in Guinea found African nationals exhibited dominant and recessive PSM also with the former at higher levels than Chinese nationals similar to LI Bonings’ findings in Mozambique, suggestive of higher temperature in tropics, or racial differences, or natural environment, or living habits etc. He also found that curative actions were better in ‘dominant PSM’ patients than recessive evidencing active significance in the action of treatment.
ZHONG, LI and Qu showed from the 1950s that PSM can be controlled by blocking and reversing flow; they identified different blocking techniques for numbness, soreness, distension, needle techniques, depth, manipulation, pressures between 100gm/cm2 to 600gm/cm2. Also that recessive PSM can be transformed into dominant PSM, needling manipulation is a very important external factor in promoting such transformation, the universality of dominant PSM verified, reliability of transformation verified by blocking technique and that ‘Qi reaching affected area/QiRA’ is justified by results observed.
LI Yangguang et al showed that PSM is related to diseases by observing 854 cases and 1000 cases in 1975; 2107 cases summarised concluded that relationship bears universality in patients, affected areas and affected meridians such that they named the phenomenon pathotaxis; they also analysed PS in another 2861 patients over 5 year showing PS +ves 63.2% of time in 39,537 meridian observations; and found PSM in more than 150 kinds of diseases – common diseases of viscera, heart 67.2% of, Liver 67.6% of, Sp/S 71.8% of, Lung 73.6% of, Kidney 59.8% of. He observed 227 cases for occurrence rate of PS in single meridian and found great uniformity with the kind of disease 71.8% of time for meridian belonging to the viscera. Observing 515 meridian times in 45 cases for 14 meridians for QiRA rate such that he could conclude that the relationship between PSM and a disease provides a basis for diagnosis and treatment of disease – reinforcing the ancient concept of Qi reaching the effected area, or arrival of QI at the affected area.
Developing the theme studies were carried out observing PSM in various guises, treatments and diseases. For example
GAO et al (Shanghai College of TCM and Beijing Academy of TCM) by means of impedance cardiography measured alterations in child cardiac pump function one-week pre, and post, operations as PSM reached the affected area. PSM induced favourable changes for recovery (Chi squared=3.4018, p=0.05). ZHAO et al (Shaanxi College of TCM) showed PSM desirability using acupoint P6 in 12 cases of cardiovascular disease including immediacy of effect when QiRA;
CHENG Lianhu et al (Baoding District Hospital of TCM) found influence of QiRA on the functional state of the cardiovascular system – cardiac constriction index raised after acupuncture (14.57+/-1.89 to 17.6 +/- 3.1), pre-ejection period shortened (90 +/- 9.4 secs to 82.5 +/- 11.7 secs), peripheral resistance reduced (2253 +/- 803 dyne. Sec. Cm –5 to 1796 +/- 644 dyne.sec.cm –5), vasoanterograde raised (1.31 +/- 0.25 ml/mm Hg to 1.54 +/- 0.37 ml/mm Hg), and cardiac output increased (3.62 +/- 0.41 lit/min to 4.28 +/- 0.67 lit/min) showing that cardio muscular constriction strengthened etc. after QiRA.
Although Qi had not yet been defined other than as ‘vital energy’, its long recognised characteristics were being demonstrated through the PSM/QiRA phenomenon that was validated by the 1980s in hundreds of trials; PSM had become one outward measurable manifestation of Qi. The presence of meridians and acupoints had similarly been demonstrated by various experimental means. PSM lines/meridian lines and acupoints were shown to have low impedance character.
YU Shuhuang et al showed that latent PSM lines and low resistance lines corresponded with classical meridian lines. ZHU Zongxiang et al showed that the latent PSM phenomenon is universal on all peoples. A biophysics approach demonstrated PSM lines had low impedance, high potential, high luminescence and high percussion sound, compared to adjacent areas. Excised limbs after amputation (Beijing Institute of Biophysics, Institute of Aeronautics, Hospital of TCM, Jisutan Hospital) before amputation found 279 of 293 LIPs (low impedance points) coincided with LPSM 95.2%. After amputation excised limbs had 498 of 507 LIPs remaining at original LPSM 98% and the low impedance remained in skin, high percussion sound remained +ve as long as deep fossa was intact, indicating that low impedance and high percussion are independent of the functioning of known nervous and circulatory systems and the specific material basis must exist on body surface along line of LPSM and meridian. ZHU Zongxiang et al showed the LIPs exist in animals and humans (rat and rabbit), ZHONG Longshan showed them in sheep.
YANG Zhiquang measured Cold Luminescence of meridian of human body surface precisely on 144 subjects and 144 meridian lines, intensity of luminescence of 10,512 points of skin both at and outside 12 meridians, intensity of luminescence of points at meridians were 1.5 times higher than those 0.5cm apart from meridians (t-test at alpha=0.01 diff sig), and lines of luminescence were coincident with classical meridians. 5256 acupoints skin resistance 40-60% lower than control points 0.5 cm apart from meridians. 5256 acupoints percussion of LPSM closely coincident with meridians – providing more evidence of the meridian system.
GUO Wuying et al measured EMG signals during acupuncture induced muscle contraction finding there may be electrical signals produced at the needle electrode with frequency spectrum of EMG signals lying within 0-1000 Hz, mainly under 500Hz; during needle sensation frequency spectrum of signals, concentrated in low frequency section to greater extent around 55Hz and 165 Hz, without needle reaction saw no irregularity in EMG. Measuring along same meridian during needle reaction the 165Hz was picked up, illustrating relative specificity; at control meridians only scattered frequencies were identified – suggesting a physiological basis for existence of meridians and needle reaction.
SONG et al (General Hospital of PLA, Beijing) 1979-82 studied effect of 110 acupoints stimulations on 21 patients using I/R thermographic system. 5/21 had hot sensation along meridian showing as bright zone on thermograph, 2/21 had cold sensation along meridian shown as dark zone or double dark bands. Provided more evidence about meridians lines under temperature rises and eliminated suggestion that ‘superficial veins may be meridians’ as they manifested differently on thermograph.
ZHU Zongxiang et al, WANG Pinshan et al, HU Rongdu et al, SUN Pingshen et al studied the phenomenon of sound information along meridians (PSIM) by LPSM and acoustic techniques in health subjects, paraplegics, animals, proving a material basis for generation of sound information during PSM; after animal deaths the rate of occurrence of sound information drops markedly from 56.3% to 18.8% showing the sound not to be a purely physical signal but a biological signal closely related to activities of meridians. XU Guansun et al analysing acoustic emission signals (AES) found they had 3 main properties, propagation along meridians, bipolarity and capacity of repeat. CHEN Moxun et al studying AES showed dominant and recessive types of PSM when meridian system active, that frequencies and amplitudes of wave patterns of human AES along meridians are different with corresponding parameters EMG, EDG, EEG and ECG and display each specificities. PSM speed was measured as 6.5 – 9.9 cm/sec, faster as leaves acupoint/location of propagation and slower further away. A magnetic material of 3000Gs held above point Wenliu blocked PSM.
LI Baojiao in 14 subjects and HU Xianglong et al in 250 cases showed that strong suggestion could not induce PSM so PSM must be a physiological ability. ZHUANG Ding et al showed intravertebral anaesthesia had no effect on PSM, neither speed not nature.
Numerous studies were performed using electron microscopy observation on the effects of acupuncture in ultrastructures by YANG Youmi et al (Beijing) , FU Zhiliang et al (Hebei) , ZHANG Shuqin et al (Guizhou), YUAN Dexin et al (Hebei), identifying activity of Substance P closely related to acupuncture analgesia, recovery of oxygen deficiency in mitochondria could be restored through acupuncture and synthesisation of ATP, positive changes to adrenocortical cells, using acupoint S36 positive changes in NE, ACP, ATPhatase, MAO and 5HT, mast cell changes, T lymphocyte, e Rosette, etc. requirement for intact hypothalamus, for P6 action, and stellate ganglion in cats.
LI Yongguang and ZHANG Wenjuan, Harbin, identified a magnetic phenomenon on meridians and acupoints through treating 4939 cases by magnetic therapy with effective rate 86.92%. They measured the greatest range of magnetic information at area 5cm from GV20 was 1.67 gauss; the largest change rate of information was 6.7 gauss/s.
MENG Jingbi et al, Beijing, used radionuclide scintigraphy measurements of meridians system in humans. Injecting radio tracer observed by digital gamma camera showed movement along meridians from 20 to 110 cm from injection site, speed 3.5 to 76 cm/min, speed correlating with whether yin or yang meridian, and differences observed according to different channels in terms of latency, pattern or location.
YANG Zhiqiang et al (multiple disciplinary including medical, biophysics, aeronautics, astrophysics) extended their previous few years measuring ultra cold luminescence along meridians, with upgraded apparatus were now able to detect more accurately and specifically the phenomenon of superficial bioluminescence of acupoints along the classical channels. In 158 subjects 158 times for regular channels and 11582 times for acupoints they found that for the 14 main channels the phenomenon of intense cold bioluminescence is universal and 1.5 times more intense than points selected 0.5 cm lateral to the channel points, correlating and verifying the 14 channels existence and strong luminescence.
Extracts recorded by me 30 years ago………According to Russian biophysicists the human cell is an emitter of electromagnetic radiation. Intracellular structures emit identified frequencies 1900A (A = angstrom) 2800A, 3300A, 6200A-6800A, radio waves, hydrodynamic plasma waves from excitron and electron-hole plasma, and visible and invisible light frequencies (as described). Nucleus emits invisible UV light between 1900-3300A, mitochondria (with their high ion densities) emit visible red light 6200-6800A so weak that special detection methods are required…………
…….A Russian theory of Bioplasma:- Plasma is the fourth state of matter, with higher energy than the others (solid, liquid, gas); when individual atoms are ionised – as electrons for example, are forced away from their nuclei at high temperatures – an ion gas or high temperature plasma is formed containing nuclei, electrons and neutral particles in addition to positive and negative groups of ions. Enormous temperatures are reached (millions of degrees) making it impossible for any conventional container to be used – so how could such a plasma exist in the human body with its temperature of a mere 37 degree C? The Soviet answer being:-
In solid state electronics physicists speak of ‘electron gas’ within semiconductor elements at room temperatures; also about gases made up of electrons and holes (absence of electron) and of excitons (excited electrons) – such a hole + an electron. The density of electron-hole plasma in a semi conductor changes according to its temperature and the number of electrons per cm2 can be increased by up to one billion times. The Soviets belief is that forced vibrations in such a plasma can approach those of visible or UV light, giving rise to plasma radiations. In a solid each electron belongs to only one atom at a time but in plasma each electron or hole has broken free of the crystal lattice of the solid body to manifest itself as the totality of its structure. There are such ‘delocated’ electrons found in biological processes, and the evidence is strong for the existence of semiconductor properties in a variety of human components. Professor Sedlak of the Catholic University, Lublin, Poland was one of the first to produce a comprehensive model of the bioplasma body that he saw as the ultimate substratum of both chemical and electronic processes, and also as the carrier of all information within the system. He said that like is an electromagnetic wave generated in a medium of protein semiconductors; the biochemical processes familiar to traditional biochemistry take place within such a bioelectric medium. “One should think of metabolism in terms of transformation of energy rather than of matter, the problem of the nature of life can ultimately be reduced to the concepts of plasma and electromagnetic fields” he said. Dr V M Inyushin, biophysicist at Kazakh State University in Alma Ata said that bioplasma is an organised system, and with engineer V S Grishenko first postulated the existence of bioplasma in 1967. It is he says no less than the matrix of the biological field or biofield, which he described as a ‘frozen-in-hologram’, every fragment of which possess the characteristic of the essential properties of the whole organism. Of particular interest is that bioplasma is a changeable structure in which several kinds of waves – electromagnetic, acoustic and perhaps gravitational – are distributed, its energy state depending on the breathing of the cosmos. Solid ice when heated becomes liquid water and eventually gaseous steam; when cooled returns to ice via water. So with plasma, it is formed by processes of ionisation and formation of locally charged particles, then reverses by mutual interaction of particles and their return to lower energy states by binding themselves to a lattice of atomic nuclei. Both these processes are accompanied by the emission or adsorption of radiation quanta.
In 1981 "The World Health Organisation Provisional List of Diseases that Lend themselves to Acupuncture Treatment" described more than 40 disorders for which acupuncture could be of benefit, the sections covering the 40 odd disorders are separated into disorders of the Upper respiratory tract, Respiratory system, Eye, Mouth, Gastrointestinal, Neurological and Musculoskeletal (see Treatment page for complete list).
The Chinese journal Acupuncture Research published a paper in the mid 1990s “Progress in China over the past 4 years in acupuncture clinical study”. It described successes and developments, treating with TCM modalities………..
1. Contagious & Infectious diseases (incl viral diseases and bacterial diseases, acute and chronic hepatitis, bacterial dysentery, epidemic haemorrhagic fever, mumps, influenza and anaemia due to septicaemia) 2. Respiratory and Circulatory system diseases (incl pulmonary oedema, chronic bronchitis, bronchial asthma 80% effective, coronary heart disease, rheumatic heart disease, hypertension) 3. Metabolic & Endocrine disorders (incl diabetes, obesity acupuncture 70% success) thyroidism 4. Urogenital system disorders (incl male sterility, chronic nephritis, prostatitis, enuresis, retention of urine) 5. Digestive system disorders (incl Gastroptosis, ulcerative colitis, intestinal ascariasis, infantile diarrhoea) 6. Articular disease (incl rheumatic arthritis, sciatica average acupuncture success rate 95%, spondylitis, 650 cases rheumatoid arthritis 96.7% success) 7. Neurophysiological disorders (incl headache, schizophrenia, neurasthenia, depression, epilepsy, sequellae of CVA) 8. Diseases of surgery, dermatosis & orthopaedics (incl scalp ringworm, psoriasis, herpes zoster) 9. Gynaecological, obstetric and paediatric disorders (incl dysmenorrhoea, pelvic inflammation, habitual miscarriage, infantile fever, infantile diarrhoea) 10. Eye, ear and nose disorders (incl. toothache, optic atrophy, myopia, hyperopia, deafness) 11. Emergency cases (incl. syncope high fever and acute abdomen problems) and other diseases illustrating TCM interventions successfully applied over a very wide range of disease.
More very recent scientific studies from various centres of excellence worldwide, that provide more insight into the effects and effectiveness of acupuncture & moxibustion for various conditions are :-
Wien Klin Wochenschr. 2011 Feb 17.
Auricular electroacupuncture reduces frequency and severity of Raynaud attacks.
Schlager O, E Gschwandtner M, Mlekusch I, Herberg K, Frohner T, Schillinger M, Koppensteiner R, Mlekusch W. Division of Angiology, Department of Internal Medicine II, Vienna Medical University, Vienna General Hospital, Vienna, Aust
J Gastrointest Surg. 2011 Feb 15.
Electroacupuncture in Reduction of Discomfort Associated with Barostat-Induced Rectal Distension-A Randomized Controlled Study. Leung WW, Jones AY, Ng SS, Wong CY, Lee JF. Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China.
Guang Pu Xue Yu Guang Pu Fen Xi. 2010 Dec;30(12):3338-42.
[Comparative study of reflectance spectroscopy of women's acupoints around menstruation].
[Article in Chinese] Jiang XH, Liu HP, Guo ZY, Meng YY, Zeng CC, Liu SH. College of Biophotonics, South China Normal University, Laboratory of Photonics Chinese Medicine of State Administration of Traditional Chinese Medicine, Guangzhou 510631, China.
Clin J Pain. 2011 Feb 11.
Patient Characteristics and Variation in Treatment Outcomes: Which Patients Benefit Most From Acupuncture for Chronic Pain? Witt CM, Schützler L, Lüdtke R, Wegscheider K, Willich SN.
*Institute for Social Medicine, Epidemiology, and Health Economics, Charité Medical Center, Berlin †Carstens-Foundation, Essen ‡Institute for Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany.
J Altern Complement Med. 2011 Feb;17(2):133-7.
Acupuncture treatment as breastfeeding support: preliminary data. Neri I, Allais G, Vaccaro V, Minniti S, Airola G, Schiapparelli P, Benedetto C, Facchinetti F. 1 Mother-Infant Department, University of Modena and Reggio Emilia , Modena, Italy .
Zhongguo Zhen Jiu. 2010 Dec;30(12):989-92.
[Comparison of therapeutic effects of peripheral facial paralysis in acute stage by different interventions]. [Article in Chinese] Liu LA, Zhu ZB, Qi QH, Ni SS, Cui CH, Xing D.
Zhongguo Zhen Jiu. 2010 Dec;30(12):985-8.
[Clinical observation on pricking blood along meridians combined with electroacupuncture for treatment of prolapse of lumbar intervertebral disc].
Zhongguo Zhen Jiu. 2010 Dec;30(12):974-6.
[Brain arousal dysfunction in severe craniocerebral injury treated with acupuncture].
[Article in Chinese] Tu XH, He ZY, Fu X, Chen YH, Chen YL, Kang SJ. Department of Rehabilitation, The Third People's Hospital of Chongqing, Chongqing 400014, China.
Zhongguo Zhen Jiu. 2010 Dec;30(12):969-73.
[Dysphagia after stroke treated with acupuncture or electric stimulation: a randomized controlled trial].
[Article in Chinese] Huang Z, Huang F, Yan HX, Min Y, Gao Y, Tan BD, Qu F.
Rehabilitation Medicine Department, Guangzhou Panyu Central Hospital, Guangzhou 511400, Guangdong Province, China.
Tradit Chin Med. 2010 Dec;30(4):243-8.
Correlation of the cerebral microvascular blood flow with brain temperature and electro-acupuncture stimulation. Zhang D, Li L, Ma HM, Ye CF, Wang SY, Chen DS. Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing 100700, China.
Altern Ther Health Med. 2010 Nov-Dec;16(6):10-8.
Acupoint electrical stimulation reduces acute postoperative pain in surgical patients with patient-controlled analgesia: a randomized controlled study. Yeh ML, Chung YC, Chen KM, Tsou MY, Chen HH.
Systematic Reviews, Use and Abuse
Systematic Reviews may provide a valuable analysis of available papers, but they can also obfuscate since criteria adopted, material searched and the aims and objectives of the researchers impact heavily on an outcome. It is essential that reviews are carried out by persons with expertise in reviewing, have statistical expertise, have no vested or competing interests in any particular outcome and, perhaps most of all, have expertise and experience in the subject and intervention under review. TCM has emerged out of a paradigm that is dissimilar to WM, although there are interlinking associations and principles; the human body presents the same physiological and biological challenge to any paradigm with respect to a disorder, but the appreciation and perspective one applies from differing paradigms may vary enormously. For example, WM prefers the snapshot context to then treat what is seen in that snapshot, often without updating the snap for weeks or months. TCM infers that a disorder is subject to, and has become part of, the natural constant flux such that an initial prescription is likely to require constant modification as the patient’s condition evolves, if successfully treated, towards cure. Research design should always attempt to incorporate practices and principles inherent in WM or TCM when investigating their modalities, and subjects treated yet so many systematic reviews and meta analyses fail TCM in this regard, especially when carried out by researchers from the WM paradigm who try to fit WM investigative concepts and context to TCM trial data and limit their analysis to RCT studies to assess TCM modalities such as acupuncture & moxibustion rather than use more appropriate types of trial such as case series or cohort design. The following studies are attempts to describe issues:-
Stat Med. 2011 Feb 23. doi: 10.1002/sim.4003.
Evaluating traditional Chinese medicine using modern clinical trial design and statistical methodology: Application to a randomized controlled acupuncture trial. Lao L, Huang Y, Feng C, Berman BM, Tan MT. Center for Integrative Medicine, University of Maryland, School of Medicine, East Hall, 520 W. Lombard Street, Baltimore, MD 21201, U.S.A..
Traditional Chinese Medicine (TCM), used in China and other Asian counties for thousands of years, is increasingly utilized in Western countries but inherent differences in how Western Medicine (WM) and this ancient modality are practiced, employing the so-called WM-based gold standard research methods to evaluate TCM, is challenging. The paper discusses obstacles inherent in the design and statistical analysis of clinical trials of TCM based on the authors’ experience in designing and conducting an RCT of acupuncture for post-operative dental pain control in which acupuncture was statistically and significantly better than placebo in lengthening the median survival time to rescue drug. However, the PH assumptions in the common Cox model did not hold in that trial so TCM trials warrant more thoughtful modelling and more sophisticated models of statistical analysis since their design has all the challenges encountered in trials of drugs, devices, and surgical procedures in WM. Solutions are offered to some but many issues are unresolved.
Stat Med. 2011 Feb 22. doi: 10.1002/sim.4034.
Issues of design and statistical analysis in controlled clinical acupuncture trials: An analysis of English-language reports from Western journals. Shuai P, Zhou XH, Lao L, Li X. Department of Health Statistics, West China School of Public Health, Sichuan University, Chengdu, People's Republic of China.
Investigation of main methods of design and statistical analysis in controlled CTs for acupuncture published in the West between 2003-2009 and, based on the analysis, recommendations that address methodological issues and challenges in clinical acupuncture research. PubMed was searched for acupuncture RCTs published in Western journals in English between 2003 and 2009 using keyword acupuncture. 108 qualified reports of acupuncture trials including >30 symptoms/conditions were identified, analysed, and grouped into efficacy (explanatory), effectiveness (pragmatically beneficial), and other (unspecified). All were RCT. In spite of significant improvement in the quality of acupuncture RCTs in the last 30 years the reports show methodological issues and shortcomings in design and analysis and the quality of the efficacy studies was not superior to that of the other types of studies. There were for example unclear patient criteria and inadequate practitioner eligibility, inadequate randomisation, and blinding, deficiencies in the selection of controls, and improper outcome measurements; insufficient sample sizes and power calculations, inadequate handling of missing data and multiple comparisons, and inefficient methods for dealing with repeated measure and cluster data, baseline value adjustment, and confounding issues. Acupuncture RCTs can be improved and more rigorous research methods should be carefully considered.
These conclusions are not unexpected, as there seems to be a general consensus within the TCM acupuncture & moxibustion profession that RCT designs are not wholly compatible with the aim of achieving best assessment of the modality acupuncture & moxibustion. Teams have performed systematic reviews and meta analyses only to have to report that the RCT papers analysed fell short of providing adequacy of data, and use this criticism to conclude that such inadequacy invalidates the many tens or hundreds of RCTs analysed; would a better conclusion not be that RCT was unsuitable for thoroughly investigating the modality therefore either RCT studies should be ignored, or should become part of a wider collection of range and study type from which to derive an understanding of value, effectiveness and safety of the intervention assessed? The following systematic review and meta-analysis of only RCTs of moxibustion achieved what might to some professionals be an unsatisfactory conclusion, that there can be no firm conclusion; had other types of study been analysed to answer some of the outstanding questions unanswered by the selected RCTs, a firmer conclusion might have been possible. The exclusion of all RCTs which fail to meet strict criteria set by the authors is analogous to a detective refusing to consider as “shooter” of a victim any suspect, of several thousand known to have handled a similar weapon near the scene of the crime at the time of the shooting, who did not have expert ability with a gun of the type sought and finding this excludes all but a few dozen people, despite the fact that any of the thousands of guns and potential shooters had the capability to effect the crime.
Clin Rheumatol. 2011 Feb 18.
Moxibustion for rheumatic conditions: a systematic review and meta-analysis. Choi TY, Kim TH, Kang JW, Lee MS, Ernst E. Korea Institute of Oriental Medicine, Daejeon, 305-811, South Korea. Abstract
Moxibustion, an acupuncture-like intervention, is increasingly used in the management of rheumatic conditions. The aim of this review is to summarize and critically evaluate the trials testing effectiveness of moxibustion for major rheumatic conditions. Fourteen databases were searched from their inception through May 2010, without language restriction. RCTs were included if moxibustion was used as the sole treatment or as a part of a combination therapy with conventional drugs for rheumatic conditions. Cochrane criteria were used to assess the risk of bias. A total of 14 RCTs met inclusion criteria and all were of low methodological quality. The meta-analysis of the 8 RCTs suggested favourable effects of moxibustion on the response rate compared with conventional drug therapy with high heterogeneity. A subgroup analysis showed significant effects of moxibustion on the RR compared with drug therapy in patients with knee osteoarthritis, whereas it failed to do so in rheumatoid arthritis. The results of meta-analysis of the 6 RCTs suggested favourable effects of moxibustion plus drug therapy on the response rate compared with conventional drug therapy alone with high heterogeneity. This systematic review fails to provide conclusive evidence for the effectiveness of moxibustion compared with drug therapy in rheumatic conditions; the number of RCTs included in review and their methodological quality were low such that these limitations make it difficult to draw firm conclusions.
The study demonstrates how despite many RCTs being excluded by the selection criteria the few remaining repeat the message that moxibustion is more effective than conventional drug therapy for rheumatic conditions yet the conclusion reached is that no firm conclusions can be drawn due to low methodological quality of the RCTs, and as is so often seen in systematic reviews of the literature no further attempt is made to add value to the intimation inherent in the data that moxibustion is most effective and the authors leave that suspicion that moxibustion is a better option than conventional drugs in rheumatism. The addition of non RCT trials, experimental or clinical, to this amalgam might improve the situation; for example by adding experimental studies in animals and/or humans one can demonstrate probable physiological mechanisms underpinning the effectiveness of moxibustion in rheumatics, thereby increasing the probability that the benefits suspected from moxibustion in the main study are correct. This kind of scientific investigation, combining an amalgam of studies that build the case for or against a modality, is analogous to what happen in a court of law where various types of evidence are admitted from which the case for prosecution or defense builds; that may include witness evidence, material direct or indirect, circumstantial and expert witness evidence. The point being that at end of submission a more informed decision can be made, whereas in the RCTs for moxibustion review one is given only one design, that fails to reach a firm verdict, and the people are left with a limited view which could have been enhanced with the correct application of additional scientific evidence. For example, one might have additionally considered:-
Zhen Ci Yan Jiu. 2010 Jun;35(3):198-203.
Involvement of the hypothalamus-pituitary-adrenal axis in moxibustion-induced changes of NF-kappaB signalling in the synovial tissue in rheumatic arthritic rats. Gao J, Liu XG, Huang DJ, Tang Y, Zhou HY, Yin HY, Chen T. Department of Acu-moxibustion, Chengdu University of Chinese Medicine, Chengdu 610075, China.
The effect of moxibustion of B23 and S36 on synovial nuclear factor (NF)-kappaB p65 expression, and plasma ACTH and serum cortisol (CS) contents in rheumatic arthritis (RA) rats with adrenalectomy (ADX) was tested to study the underlying mechanism in ameliorating RA. 50 male SD rats were equally randomly divided into control, model, moxibustion, ADX and false ADX groups according to SPSS-aided random digits table. RA was established by injecting 0.1 mL Freund's complete adjuvant into the right paw. ADX operation was performed on the 6th after successful establishment of RA. Moxibustion was applied at B23 and S36 from the 7th day, 5 cones per session, once daily for 18 days. Then plasma ACTH and serum CS contents, for which the blood was collected during night, were detected by ELISA; NF-kappaB p 65 immunoactivity in synovial tissue was detected by immunohistochemistry. In comparison with control group the foot swelling of model, moxibustion, ADX, and false ADX groups increased significantly. Compared with model group the swelling degree of moxibustion and false ADX groups were decreased remarkably after treatment. No significant difference was found between ADX and model groups in foot volume. Compared with control group, plasma ACTH content in RA model group decreased obviously, while serum CS level and NF-kappaB p 65 immunoactivity increased apparently in model group. Compared with model group, serum CS contents in moxibustion, ADX and false ADX groups and synovial NF-kappaB p 65 immunoactivity in moxibustion and false ADX groups reduced considerably. No significant difference was found between ADX and model groups in synovial NF-kappaB p 65 immunoactivity. Therefore moxibustion can reduce inflammation reactions in RA rats in association with its effects in upregulating plasma ACTH, downregulaing serum CS level and synovial NF-kappaB p 65 immunoactivity, and the intact hypothalamus-pituitary-adrenal axis (HPAA).
Zhen Ci Yan Jiu. 2007 Apr;32(2):75-82.
[Influence of moxibustion on JAK-STAT signal transduction pathways of synovial cells in rheumatoid arthritis rabbits]. Yang X, Li JS, Yang SQ, Zhang XX, Zhang TS, Zhou HY, Liu XG. Chengdu University of Chinese Medicine, Chengdu 610075, China.
30 Japanese Big-ear White rabbits were equally randomised into control, model and moxibustion groups. RA was established by Freund's Complete Adjuvant (FCA, 0.5 mL/kg) into the animal's bilateral joint cavities and moxibustion was applied to bilateral B23, 5 cones each time, once daily (except Sundays), for 3 weeks. The synovial tissue was analysed for the expression of signal molecules associated with JAK-STAT pathway with gene chip and bio information analytical techniques. Compared with normal control group the perimeters of both knee joints in model group increased significantly from the 3rd day to 21st day after injection of FCA; compared with model group the moxibustion group decreased considerably from the 6th day on. Compared with control group, JAK-STAT pathway-associated genes with up-regulated expression in model group were C/EBP beta, CBP, CRP, GATA3, IFNAR1, IFNAR2, IFNGR2, IL-10Rb, INDO, SH2B, STAT3, STAT6, JAK3 and GP130, and those with down-regulated expression were A2M, MIG and IL-2Rr, suggesting an abnormal activation of JAK-STAT pathway. In comparison with model group, the related gene up-regulated in moxibustion group in the expression was IL22R and those down-regulated were Cyclin D1, C/EBP beta, CRP, GATA3, IFNAR2, INDO, JAK2, JAK3, V-JUN, STAT3, STAT5, SH2B and OSM, showing that moxibustion had an inhibitory effect on AR-induced abnormal activation of some genes as C/EBP beta, GATA3, IFNAR2, INDO, etc so demonstrating that moxibustion can resist inflammation and eliminate swelling in RA rabbits, probably linking to its effect in inhibiting abnormal activation of JAK-STAT pathway in synovial cells.
Zhongguo Zhen Jiu. 2008 Oct;28(10):730-2.
Observation on therapeutic effect of the spreading moxibustion on rheumatoid arthritis. Xie XX, Lei QH. Department of Acupuncture and Physiotherapy, Gansu Hospital of Medicine and Health Care of Cadres, Lanzhou 730020, China
56 cases of RA were randomly divided into a spreading moxibustion group of 31 cases and an acupuncture group of 25 cases then the spreading moxa group were treated by moxibustion on the GV from GV 14 to GV 2; and bilateral corresponding Jiaji (EX-B 2) with drug powder composed of Qianghuo, Duhuo, Niuxi and fresh mashed ginger spread at the points The acupuncture group was needled at GV 14 and GV 12. They were treated for 50 days. The effective rate was 100.0% in the spreading moxibustion group and 84.0% in the acupuncture group showing that moxibustion has an significant therapeutic effect on rheumatoid arthritis.
Zhen Ci Yan Jiu. 1992;17(2):126-8, 132.
[Experimental study on the influence of acupuncture and moxibustion on interleukin-2 in patients with rheumatoid arthritis]. Xiao J, Liu X, Sun L, Ying S, Zhang Z, Li Q, Li H, Zhang Z, Jin B, Wang S. General Hospital of PLA, Beijing.
To observe the effects of the treatment of RA with acupuncture and moxibustion on IL-2, 41 patients were divided into warming needle and point injection groups at random, and 19 healthy subjects as control group. The results showed that the IL-2 levels in two RA groups before treatment were obviously lower than that in control group. After treatment the IL-2 level in control group was unchanged, but increased considerably in two RA groups. Generally, IL-2 is considered a very important signal for regulating immune response. The decrease of IL-2 in RA should be one of main causes of internal environment disorder and acupuncture & moxibustion as a stress stimulation exerted influence on the immunity through neuroendocrine system to improve IL-2 production.
By enhancing a systematic review with experimental and other studies, the intrinsic value of the review mightnot be lost of the "conclusion of no conclusion" but it might be upgraded with additional direct and circumstantial evidence as used in a court of law where various forms of evidence of varying value is admitted in the interest of finding the truth and the enduring public interest. Why should academics accept a lesser, equivocal, product when additional data types may add value? The statement that there were “limitations” which “make it difficult to draw firm conclusions” may be interpreted by media and the public as moxibustion cannot be considered “more effective than drugs”, yet that conclusion fails to reflect that the “meta-analysis of 8 RCTs suggested favourable effects of moxibustion on the response rate compared with conventional drug therapy…. with high heterogeneity” and that “ a subgroup analysis showed significant effects of moxibustion on the RR compared with drug therapy in patients with knee osteoarthritis, whereas it failed to do so in rheumatoid arthritis” and that “The results of meta-analysis of 6 RCTs suggested favourable effects of moxibustion plus drug therapy on the response rate compared with conventional drug therapy alone with high heterogeneity”. In effect 8 of 14 trials selected did “suggest favourable effects of moxibustion compared to drugs on response rate” and ”moxibustion plus drugs” fared better than drugs alone in 6 trials” which are significant statements despite the basis of only 14 studies of low methodology; the information, enhanced with the additional data as specified, can add value to inform the public on the potential inadequacy of drugs compared to moxibustion in rheumatic and osteoarthritic conditions.
The following review of reviews perhaps adds weight to this argument:-.
Zhong Xi Yi Jie He Xue Bao. 2010 Dec;8(12):1133-46.
Clinical critical qualitative evaluation of the selected randomised controlled trials in current acupuncture researches for low back pain. Miao EY. M. Modern Traditional Chinese Medical Clinic, Ringwood, Victoria 3134, Australia
Many RCTs and reviews conclude that acupuncture is not an effective treatment for low back pain (LBP) and there is no difference between real acupuncture and sham acupuncture in the treatment of LBP. This study aims to evaluate the most recently published RCTs and reviews from the clinical protocol, which is used by professional acupuncturists using English-language studies identified through searches of The Cochrane Library, PubMed/MEDLINE and EMBASE published between January 2007 and January 2010. 18 trials studying conditions related to LBP treated by acupuncture or acupuncture as one of the co-interventions were eligible for critical clinical qualitative evaluation as core methodology using daily used clinical skills and knowledge with supplementary statistical concepts to evaluate the quality and reliability of the selected RCTs and reviews. 5 evaluation criteria were established for assessment of selected RCTs and reviews, similar to the inclusion and exclusion criteria used in RCTs, so the weaknesses, limitations or errors of RCTs and reviews can be identified, despite the strength of internal validity produced by statistical calculations. Various terms are used to describe LBP conditions. 16 RCTs did not establish a medical diagnosis. No trials had objective measurements as a clinical standard for assessing outcomes. Significant variation existed due to the numerous treatment methods or therapists used in the RCTs included in the study. Various co-interventions were used in 10 or 55% of the trials, among them, 6 or 33% of the trials used NSAID or analgesics. Due to the lack of diagnostic status, the accuracy of the external validity was put into question. No logistic regression models were used in any of the selected RCTs and reviews to resolve the degree of heterogeneity. All selected RCTs either partially met the evaluation criteria or did not fulfil the evaluation criteria while being compared and the major problem existing in all RCTs was the lack of accurate medical diagnosis and lack of objective measurements to judge the clinical outcomes, which in turn, created incorrect eligibility criteria, improper matches and inaccuracies in data recording before entry into statistical calculations. As a consequence of subjective measurements, conclusions of RCTs and RCT-based reviews were biased due to over-generalized or cross-generalized estimations, which infer that alternative explanations cannot be excluded. In addition, the range of variables created in the treatment procedure was difficult to control or estimate, in turn, threatening the reliability of RCTs' estimations. For these reasons, creating appropriate diagnostic criteria before randomisation and constructing a related objective outcome measurement, which are more relevant to clinical practice, should be considered in future RCTs and systematic review studies.
Quality of Reviews and Reviewers
When an abstract contains what might appear to be a derogatory remark unevidenced in the abstract, as in the following example where the authors claim “All the positive reviews and most of the positive primary studies originated from China. There are reasons to believe that these reviews are less than reliable” it might best be clarified in the abstract as, unless one has access to the full review not often easily available to the public and media, it might influence the reader adversely against studies from China per se. The authors might best qualify the statement in abstract and full paper to avoid misleading the public and this is especially poignant as they state in their review of reviews that 5 of 8 reviews had positive conclusions, a position with important implications for public health which, if dismissed purely because the authors state “there are reasons to believe these reviews are less than reliable” without equitable reply from the scientists whose work has been so criticised, the public may become misinformed.
Eval Health Prof. 2010 Dec 7. Acupuncture for Depression? A Systematic Review of Systematic Reviews. Ernst E, Lee MS, Choi TY.
Acupuncture is often advocated as a treatment for depression, and several trials have tested its effectiveness. Their results are contradictory and even systematic reviews of these data do not arrive at uniform conclusions. The aim of this review is to critically evaluate all systematic reviews of the subject with a view of assisting clinical decisions. 13 electronic databases were searched to identify all relevant articles. Data of these systematic reviews and the primary studies they included were extracted independently by the two authors according to predefined criteria. 8 systematic reviews including 71 primary studies were found. 5 of the reviews arrived at positive conclusions and 3 did not. All the positive reviews and most of the positive primary studies originated from China. There are reasons to believe that these reviews are less than reliable. In conclusion, the effectiveness of acupuncture as a treatment of depression remains unproven and the authors' findings are consistent with acupuncture effects in depression being indistinguishable from placebo effects.
It may be obvious that reviewers of studies must not only have the required professional expertise and experience desirable for a subject under review, but that a review is carried out painstakingly to ensure that the authors’ work already published, therefore having been subjected to peer review and academic assessment, is treated with the utmost respect when admitted or rejected by systematic review and meta-analysis criteria. This requires time, patience and effort on behalf of a reviewer or review team. It may take days or weeks or even months depending on overall work load and other commitments for a reviewer to access and analyse what may be multiple databases to carefully select studies that meet a reviewers’ strict criteria for admission. In every case the ideal must be to analyse full papers, not abstracts, as the latter can easily mislead about quality and methodology of the study design, two major aspects that can make or break admission to the final collection reviewed. To achieve a reflection of the quality of studies published by the many centres of academic excellence one expects a Systematic Review and Meta Analysis to involve an enormous amount of time and effort from first design, tho' accessing databases, then obtaining original full papers where possible, collating, applying criteria to select suitable studies and reject unsuitable, analysing according to aim, obtaining results for statistical analysis, etc. and it was a surprise to find, when studying the contribution from the above team Ernst E et al, to the CAM bibliography and especially acupuncture & moxibustion, that The UKs first ever Professor of CAM Edzard Ernst and colleagues have authored an enormous number of academic trials in what might to some seem a relatively short period. For the approximately 6 month period August 2010 to early March 2011 from PubMed database Ernst E. and a team or alone has authored an impressive array of studies albeit that from such quantity amongst relatively few researchers one might reasonably question quality, and how many involve analysis of full papers, or whether majority abstracts were used and, if the latter, is it possible to criticise and exclude studies for low methodological quality if full papers were not carefully analysed - a task that may in some cases take weeks if only one or two authors are responsible, and where one might be a statistician and not a professional in the field investigated.
For “Ernst E” in PubMed 1451 studies were cited; some not Ernst E. Professor of CAM. For August 2010 to March 2011 51 publications were listed for Ernst E. with and without co-authors and a brief analysis showed 51 papers (using R for Review, S/R for Systematic Review):-
1. 3 were S/Rs or Rs of S/Rs authored by Ernst alone of Bach Flower remedies, Chiropractic, and herbals for rheumatism.
2. 5 were S/Rs or Rs of S/Rs authored by Ernst E. and Lee MS., of acupressure, acupuncture for rheumatism, acupuncture for TMJ, acupuncture for pain in Cochrane, massage for autism.
3. 10 were S/Rs or Rs of S/Rs authored by Ernst, Lee and others.
4. 16 were S/Rs and Rs of S/Rs authored by Ernst and others.
5. 2 were studies authored by Ernst only both for publication January 2011; One a study of acupuncture for shoulder pain, the other a study of spinal manipulation for headache.
6. There were also letters and replies opining on eg. acupuncture for low back pain, acupuncture “to die for”, if public use of CAMs is a criticism of mainstream medicine, homeopathy non-specific effects and good medicine, are acupuncture effects specific or non-specific, is anthroposophy a risk for measles vaccination, acupuncture for stroke, alternative medicine to alternative science.
This suggests an enormous work load to complete, for publication in a 6 month period, could the quality meet with the approval of professionals whose reputations may have been slighted by some of the conclusions; were the tasks that made this number of reviews and reviews of reviews possible in that period of time carried out the previous 6 months? A study of the previous 6 months found an equally large array of reviews and reviews of reviews had been completed and published by Ernst E. and others, almost as many completed systematic reviews and reviews of reviews as the last 6 months, and many co-authors being the same characters, such as Lee MS. Professor Ernst and his teams are certainly making an enormous contribution to the CAM literature, but might one reasonably ask of what quality?