AN EXAMINATION OF CRITICAL ISSUES IN TRADITIONAL CHINESE ACUPUNCTURE RESEARCH BARRY WAYNE NESTER A DISSERTATION SUBMITTED IN TOTAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY SCHOOL OF HEALTH SCIENCES FACULTY OF HUMAN DEVELOPMENT ST. ALBANS, VICTORIA, AUSTRALIA VICTORIA UNIVERSITY OF TECHNOLOGY 1999 Copyright Barry Nester, 1999 All rights reserved. No part of this thesis may be reproduced, stored in a retrieval system, or transcribed in any form by any means electronic, photocopy, mechanical, recording, or other means, or translated mto any other language without prior written permission of the author. THESIS 615.892072 NES 30001005875176 Nester, Barry Wayne An examination of critical issues in traditional Chinese acupuncture researcl|. u TABLE OF CONTENTS page ABSTRACT xvi DECLARATION xvii PRELIMINARY NOTES ON TERMINOLOGY, FORMAT AND STYLE xviii-xx ACKNOWLEDGEMENTS xxi LIST OF TABLES xiv LIST OF FIGURES xv Chapter 1 INTRODUCTION 1 1.1 Background of the Study 1 1.1.1 Research: A path to Traditional Chinese Acupuncture (TCA) knowledge 1 1.2 The Aim of the Study 3 1.3 The Objectives of the Study 4 1.4 The Methodology of the Study 6 1.5 An Overview of the Structure and Format of the Dissertation 7 1.6 The Postmodern Context of the Study 11 1.7 The Importance of Significant Research Questions in the Field of TCA 15 1.7.1 The evaluation of the therapeutic effectiveness of TCA 16 1.8 The Significance of the Study 19 1.9 Limitations and Delimitations of the Study 22 1.9.1 Declaration of the author's position as researcher 22 1.10 The Determination of the Role of Traditional Chinese Acupuncture in Future Health Care Systems 25 1.10.1 The need to review health care in the Ught of the 'crisis' in Westem health care systems 26 1.10.2 The declining effectiveness of biomedicine 28 1.10.2.1 The economic consequences of biomedicine . 28 1.10.2.2 The effectiveness of biomedicine 28 1.10.2.3 Medical iatrogenesis 29 1.10.3 The challenge of the complementary therapies 30 m Chapter page DEFINING THE TERRAIN OF TRADITIONAL CHINESE ACUPUNCTURE PRACTICE AND RESEARCH 35 SECTION 1 The Nature and Practice of Traditional Chinese Acupuncture 35 2.1 The Nature of Traditional Chinese Medicine (TCM) 36 2.2 Cultural and Philosophical Influences on TCA 37 2.3 Core Concepts and Themes of TCM that Underpin TCA Practice 41 2.3.1 The TCM paradigm is broad and can tolerate diverse schools of thought and practice 41 2.3.2 Dao and the limits of knowledge 42 2.3.3 Ontology: The Chinese concept of qi (chi) 42 2.3.4 The concept of yin/yang 46 2.3.4.1 The interdependence of opposites 47 2.3.4.2 The interpenetration of opposites 48 2.3.4.3 The unity of opposites 48 2.3.5 No mind-body dualism in TCM 50 2.4 The Practice of Acupuncture 51 2.4.1 The acupuncture needling technique 51 2.4.2 The different forms of acupuncture 52 2.4.3 Traditional Chinese acupuncture therapy 54 2.4.4 TCA therapy is dynamic and not static 55 2.4.5 TCA therapy is more than the application o fthe acupuncture needling technique 56 2.4.6 The TCA practitioner-client encounter 57 SECTION 2 The Domain of Traditional Chinese Acupuncture Research 62 2.5 Appropriate Research Methods for TCA 62 2.6 The Purpose and Role of Basic Research, Applied Research, and Evaluation 65 2.6.1 The role of basic research in TCA 65 2.6.1.1 Types of basic research 66 2.6.1.1.1 Descriptive research 66 2.6.1.1.2 Exploratory research 67 2.6.2 Applied research and evaluation 67 2,6.2.1 The evaluation of the effectiveness of TCA therapy 70 IV Chapter page 2 2.6.3 The improvement of TCA clinical practice and TCA teaching programs through 'action' research 71 2.7 The Flaws of Contemporary Acupuncture Clinical Research 72 2.8 Priorities for Traditional Chinese Acupuncture Research 75 2.9 TCA Research Questions and Issues 76 2.10 The Need for a Variety of Research Approaches and Designs to study TCA 78 2.11 TCA and Social Research Methods 79 2.11.1 Health care research is interactive 80 2.11.2 TCA research is reflexive 81 2.12 Desirable Characteristics of TCA Researchers 82 2.13 Desirable Characteristics of TCA Research 83 2.14 Summary 83 3 PHILOSOPHICAL AND SOCIOCULTURAL ASPECTS OF MEDICAL SYSTEMS 85 3.1 Introduction 85 3.2 Sociocultural Considerations of Medical Systems 87 3.3 Models of Health, Illness and Disease 88 3.4 The Different Discourses of Traditional Chinese Medicine and Biomedicine 91 3.5 Philosophical Underpinnings of Biomedicine 92 3.5.1 Mind-body dualism 92 3.6 Holism and Holistic Health Care 96 3.6.1 Assumptions of holism 96 3.7 A Holistic Definition of Health 98 3.8 The 'Systems' Perspective of Health Care 99 3.8.1 Characteristics of 'systems' theory 101 3.9 The Nature of the Human Being: Levels of being 107 3.9.1 Emergent properties 110 3.10 Perspectives of the Body 112 3.10.1 The nature of the human being in TCM and Biomedicine 113 3.10.2 The'lived body' 115 3.11 Healtii can be Something More Collective than Individual 118 3.12 Holistic Models of Health Care 119 3.12.1 The tenets of holistic forms of medicine 122 3.13 Traditional Chinese Acupuncture: An example of holistic and humanistic health care 122 3.14 Holons ('wholes' that are simultaneously 'parts') 125 3.15 Implications of the TCM Model of Health Care for Research 129 3.16 Summary 131 Chapter page 4 AETIOLOGICAL MODELS OF HEALTH, ILLNESS AND DISEASE 132 4.1 Oriental and Westem Understandings of the Causes of Illness and Disease 133 4.2 Disease Entities 134 4.3 The Concepts of Determinism and Causality in Healtii Care Research 136 4.3.1 In TCM it is not always possible to identify the 'causes' of illness and disease 138 4.4 Aetiological Models Used to Explain the Presence of Illness and Disease 140 4.4.1 Supematural/magical aetiological models 140 4.4.2 Naturalistic/systemic aetiological models 141 4.5 Aetiological Factors Involved in Health and Disease According to TCM 141 4.5.1 Imbalances of yin/yang 142 4.5.2 Disturbances of 5/je« 142 4.5.3 The quality of a person's zheng qi ('right' or antipathogenic qi) and resistance to pathogenic qi 143 4.5.4 The bu nei wai yin 143 4.6 Sociocultural Factors of Health and Disease 143 4.6.1 The role of beliefs in the production of health, illness and disease 145 4.6.2 Research that supports a sociocultural model of health and disease 145 4.7 Psychological Determinants in Health and Disease 146 4.7.1 Implications for TCA research 153 4.8 'Mind-body'and TCM Research 154 4.9 Summary 155 5 PARADIGMS OF RESEARCH 157 5.1 Paradigms of Research 157 5.2 Paradigms and the Postmodem Context 159 5.3 The Languages of Paradigms 161 5.4 Research Paradigms and TCA 163 5.4.1 Realism 164 5.4.2 Positivism 165 5.4.2.1 Objectivity and the avoidance of subjectivity 168 5.4.2.2 Criticisms of positivism 170 5.4.3 Postpositivism and neopositivism 173 5.4.4 The naturalistic paradigm 173 VI Chapter page 5 5.4.5 The humanistic paradigms 174 5.4.6 The interpretive paradigms 176 5.4.7 Constructivism 177 5.4.8 Critical Social Theory 178 5.4.9 Phenomenological approaches to obtaining knowledge 180 5.4.9.1 Phenomenology and the language of consciousness 179 5.5 Research Paradigms and their Different Conceptions of the Human Being 182 5.6 The Relative Value of a Paradigm's Approach to Knowledge 183 5.6.1 The 'voices' of the various paradigms 183 5.7 Summary 184 6 WAYS-OF-KNOWING IN TRADITIONAL CHINESE ACUPUNCTURE 185 6.1 Chinese Philosophical Concepts of Knowledge 186 6.2 Modes of Thought in the Traditional Chinese Medicine 188 6.3 Thought Processes and Reasoning in TCA 189 6.3.1 Logistic reasoning 190 6.3.2 Inductive and deductive reasoning 191 6.3.3 Dialectical reasoning 192 6.4 Thought Processes Used in Clinical Reasoning 194 6.4.1 Pattem recognition 195 6.4.2 Hypothetico-deductive reasoning (HDR) 196 6.4.3 Systematic scanning 196 6.4.4 The role of introspection and intuition in clinical reasoning 198 6.5 Ways of Acquiring TCA Knowledge 199 6.5.1 Authority and tradition 199 6.5.2 The study of classical Chinese texts 200 6.5.3 Role-modelling 201 6.6 Types of Knowledge 202 6.6.1 Propositional knowledge 202 6.6.2 Non-propositional knowledge 203 6.6.2.1 Professional craft knowledge 203 6.6.3 Personal Knowledge 204 6.6.4 Knowledge from personal experience though 'trial and error' 205 6.6.4.1 Practical knowledge 207 6.7 Appropriation of Research Methods from other Disciplines 208 6,7.1 Clinical trials, naturalistic inquiry and qualitative research 209 6.8 Summary 209 Vll Chapter page THE EPISTEMOLOGICAL ORIENTATIONS OF TRADITIONAL CHINESE ACUPUNCTURE PRACTICE: IMPLICATIONS FOR RESEARCH 210 7.1 Research and the Health Professions 210 7.2 Epistemological Orientations to Practice 212 7.3 Reasons for the Neglect of the Epistemologies of Practice 213 7.4 Epistemological Orientations of Health Care Practice 213 7.4.1 The traditional epistemological orientation to practice 213 7.4.2 The disciplinal epistemological orientation to practice 216 7.4.3 Neopositivism 219 7.4.3.1 The fundamental body of knowledge of the neopositivistic orientation to practice 220 7.4.3.2 The applied body of knowledge of neopositivism 221 7.4.3.3 Professional practice of neopositivism 221 7.4.3.4 Advantages of the neopositivist orientation 222 7.4.3.5 Possible disadvantages of the neopositivist epistemological orientation to practice 222 7.4.4 The phenomenological epistemological orientation 224 7.4.4.1 Advantages and disadvantages of the phenomenological orientation 226 7.5 Summary: The Epistemological Orientations of TCA Practice and the Implications for Future Research 227 SCIENTIFIC INQUIRY AND TRADITIONAL CHINESE ACUPUNCTURE 230 8.1 TCA and Scientific Inquiry 231 8.2 Science and the Scientific Method 231 8.3 Implications of Quantum Physics and the Emerging New Sciences 234 8.3.1 Quantum physics 234 8.3.2 Chaos theory 236 8.4 Is TCM Scientific? 238 8.5 Typologies of Science 239 8.6 Truth and the Methods of Science 241 8.7 Philosophical Bases of Experimental and Clinical Research 242 8.8 The Role of Theory in TCM 242 8.9 Theory in TCA Practice and Research 244 8.10 Types of Quantitative Research Designs that can be used to examine TCA 248 VIU Chapter page 8 8.10.1 Correlational research 248 8.10.2 Experimental-type research 249 8.10.2.1 Prospective and retrospective research designs 252 8.10.2.2 Pragmatic randomised controlled trial (PRCT) 253 8.10.3 Quasi-experimental research 253 8.10.4 Single subject experimental design (n=l trial or n of 1 trial) 254 8.10.5 Surveys 256 8.10.6 Epidemiology 257 8.10.7 Meta-analysis and systematic review 257 8.10.8 The limitations of quantitative research methods 258 8.11 Summary 259 9 APPROACHES TO THE MEASUREMENT OF HEALTH OUTCOMES IN TRADITIONAL CHINESE ACUPUNCTURE RESEARCH 260 9.1 Measuring Health Outcomes in TCA Research 260 9.2 The Measurement of Data in TCA Research 262 9.2.1 Assessment of data in the three realms of body, mind and spirit 263 9.3 Quality of Life (QOL) Measures 263 9.3.1 The reasons for considering 'health-related quality of life' 265 9.3.2 When should 'quality of life' not be measured? 268 9.4 The Purposes of Outcome Measurement in TCA Research 268 9.5 Definition of a TTierapeutic Outcome 268 9.6 The Distinction Between the Management of Chronic Illness and Disease and the Treatment of Acute Disease 269 9.6.1 Chronic disease and TCA therapy 270 9.6.2 Treatment of acute conditions by TCA 270 9.7 Deciding on which Domains and Parameters to Measure in TCA Research 271 9.8 Possible Domains and Parameters to Measure in Research to Establish TCA Efficacy 272 9.9 Research Instinments for TCA 274 9.9.1 'Weighted' and 'Unweighed' Parameters in 'Quality of Life' Instruments 274 9.9.2 Safety Parameters in TCA Efficacy Research 275 9.9.3 Parameters that measure both efficacy and safety 275 9.10 Research Instrument Validity and Reliability 275 9.10.1 Content, face & construct validity 276 9.11 Advantages of Creating an Original Instrument for a TCA Study 276 9.12 Disadvantages of Creating an Original Instinment for a TCA Study 277 IX Chapter page 9 9.13 Creating New Instruments by Modifying or Combining Sections of Other Research Instruments 277 9.14 Methods and Instruments for Measuring Outcomes in TCA 278 9.14.1 MOS 36-Item Short Form Health Survey (SF-36) 278 9.14.2 The World Health Organisation Quality of Life Group research instrument 279 9.14.3 The Patient Generated Index (PGI): A way of measuring quality of life 280 9.14.4 Measure Yourself Medical Outcome Profile (MYMOP) 281 9.15 Summary 282 10 THE EVALUATION OF THE EFHCACY OF TRADITIONAL CHINESE ACUPUNCTURE THERAPY 283 10.1 Evaluating the Efficacy of TCA Therapy: Some Preliminary Observations 284 10.2 The Randomised Conti-oUed Trial (RCT) 286 10.3 The Placebo Effect in Traditional Chinese Acupuncture Research 288 10.4 The Double-blind Randomised Controlled Trial 288 10.5 The Single-blind Randomised Conti-olled Trial 290 10.5.1 'Sham' acupuncture controls in TCA clinical research 291 10.5.2 Possible problems associated with the 'sham' acupuncture control 293 10.6 Are the Therapeutic Effects of the TCA Needling Technique and the Non-specific (placebo) Effects of Therapy Additive? 295 10.7 Problems of Adapting the Randomised Controlled Trial Methodology to Evaluate the Efficacy of TCA Therapy 296 10.8 Other Issues in the Evaluation of the Effectiveness of TCA 300 10.9 Overcoming Clinical Research Problems Associated with the Different Languages of TCM and Biomedicine 300 10.10 Which Diseases and Syndromes Should the TCA Profession and Researchers Consider for Research? 304 10.11 'Non-specific' (placebo) Factors in TCA Clinical Trials 305 10.12 The Mega-placebo Effect 306 10.13 The Importance of the Mind and Psychological Factors in Health and Disease 308 10.14 Understanding the Placebo Phenomenon 308 10.14.1 Placebo effects on illness and disease 309 10.14.2 Theories of placebo action 310