ACUPUNCTURE AND SENSORINEURAL LOSS: A REVIEW
HEARING
Harvey A. Taub Veterans Administration Hospital, Syracuse, New York
Recent reports concerning the use of acupuncture as a possible treatment for sensorineural hearing impairment were reviewed and evaluated. It was concluded that acupuncture has no effect upon the hearing ability of individuals with sensorineural losses. Further, it was suggested that subjective feelings of improvement represent a placebo effect resulting from the application of a treatment that patients believe might work and not from acupuncture itself.
Although acupuncture is an ancient mode of treatment in China, it is only since the beginning of the 1970s that Americans gained any knowledge of this technique. Unfortunately, the initial information was not acquired through scientific literature but through personal observations and eyewitness accounts of various American physicians who returned from visits to China. In these accounts the two most dramatic uses of acupuncture were for anesthesia and for treatment of sensorineural hearing impairments. This latter application was of critical importance since at the present time there is no known treatment for individuals suffering from sensorineural hearing losses. T h e major impetus for the use of acupuncture in the United States as a treatment for sensorineural hearing impairments came in 1971 as a result of the personal visit to China by Samuel Rosen, a well-known otolaryngologist. His description of the use of acupuncture was disseminated to the general public through various news media as well as national magazines. Shortly thereafter, the public began being informed through television and newspapers of successful treatments and even cures by the new acupuncture clinics that had been established in Washington, D.C. These clinics claimed a high success rate with estimates of 40-80% of the patients having what has been described as "significant improvements" (Wensel, 1973). On the other hand, aside from eyewitness reports and anecdotal accounts emanating from the new acupuncture clinics, there were no research data to enable audiologists and otologists to evaluate the efficacy of the treatments. These data are now available as a result of publications in 1974 from numerous laboratories and clinics, and the general consensus of these papers is that acupuncture does not significantly improve the hearing ability of patients with sensorineural losses. 427
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DATA
Most accounts of the development of acupuncture for use with sensorineural hearing impairments state that it is a relatively new application that began about 1968 (Acupuncture Letter, 1974; Kao et al., 1973; Rosen, 1974). However, a report from the Eleventh People's Hospital in Shanghai (1959) suggests that research with this form of treatment began as early as 1956. This report from the Chinese Medical Journal described treatments where needles were inserted and left, without twirling or manipulating, for 30 minutes. Treatments were given every other day for a minimum of 30 days. The findings indicated that 87.5% of the patients (105 out of 120) showed improvement and that generally the effects first appeared within 10 treatments. While these findings might be considered encouraging, no standard hearing tests were used. T h e criteria for improvement included a change from inability to ability to hear a bell ringing and a subjective change in the clarity of ordinary conversation. Similar subjective criteria were used for determining marked improvement. Thus, it is difficult to draw conclusions on the basis of the findings of this paper. Bonica (1974) and Fairbanks, Wallenberg, and Webb (1974) also suggest that this lack of audiometric data is a crticism that may even be applied to much of the later findings and case reports that emanated from China. T h e first evaluations of acupuncture to appear in the American literature were published in 1973 and early 1974 in the new acupuncture journals, The American Journal of Chinese Medicine and The American Journal of Acupuncture, and provided additional positive evidence in favor of the use of this new form of treatment. However, all of these reports were preliminary studies with small numbers of patients (Kao et al., 1973; Kaslow and Lowenschuss, 1974; Peng, 1973). Further, the papers by Kaslow and Lowenschuss (1974) and Peng (1973) did not utilize pre- and posttreatment audiometric tests as the criteria for changes in hearing. Kaslow and Lowenschuss (1974) reported improvements for eight patients who had received acupuncture using electrical stimulation instead of needles, but they did not pretest the patients with standard hearing tests to determine the type and extent of loss. Similarly, their criteria for improvements were not scientifically vigorous and consisted of subjective reports and the ability to hear the ticking of a stopwatch. Peng (1973) reported improvements for eight out of 10 patients after most received only one to five treatments, but again the main criterion was the subjective reports of the patients. Peng did report that all patients received pretreatment audiograms and that a few received posttreatment audiograms. However the pre- and posttreatment data were presented for only one patient, and as noted by Fairbanks et al. (1974) these two audiograms were not directly comparable since one used the standards from the American Standards Association (ASA) while the second used the 1964 International Standards Organization (ISO) standards. T h e study by Kao et al. (1973) provides the best evidence in favor of the use of acupuncture and at the same time provides the background and basis for
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TAUB- Acupuncture 429
the transition from the positive to the negative findings. In contrast to the previous reports, Kao et al. administered complete audiometric tests including pure-tone thresholds (air and bone), speech-reception thresholds (SRT), accuracy of speech discrimination, and tone decay. Audiograms were taken for five patients before the acupuncture treatments and then again after four and eight treatments. T h e findings suggested substantial changes in all measures for one patient with improvements in each ear being approximately 25 dB (our estimations) for the pure-tone average (500, 1000, and 2000 Hz), 15 dB for SRT, and 20% for speech discrimination. All four other patients had some positive changes during the course of treatment, but for three of them there were numerous inconsistencies across ears and tests with some suggesting improvements and others indicating little, no, or even a negative change. Speech discrimination scores showed the most improvements but also seemed to be the most variable of the tests. While some large improvements were demonstrated, Kao et al. noted that the findings were preliminary and that any conclusions must be limited because of the small number of patients treated and because this, like all preceding papers, did not control for or eliminate the possibility of psychological effects. T h e preliminary nature of these findings and the precautionary limitations were borne out by a second and more comprehensive study from the same clinic (Leung et al., 1974). In this report of 38 patients (17 female and 21 male, 69 ears) the authors obtained audiometric evaluations following the fourth, eighth, sixteenth, and twenty-fourth acupuncture treatment. Their findings suggested that while 22 patients (58%) reported subjective feeling of improvement, there was a considerable difference between these feelings and the changes on the audiogram. In general, the study by Leung et al. (1974) was the first to indicate differences between subjective and objective criteria and to indicate the possibility of negative findings. T h a t is, the previously noted studies suggested improvements mostly on the basis of subjective reports, while all of the following studies that used audiometric measures as the main criteria for improvements have suggested that acupuncture has no effect. Rintelmann et al. (1974) reported a detailed analysis of the audiometric tests on one male patient who reported some subjective improvements. They concluded that all variations were within normal limits and that eight treatments did not produce a measurable change in the patient's hearing levels. Fairbanks et al. (1974) gathered and compiled pre- and posttreatment audiograms from numerous audiologists and otolaryngologists in an effort to provide an independent evaluation of possible hearing changes in patients treated in the various acupuncture clinics in the Washington, D. C. area. Data were reported for a total of 66 patients (123 ears). T h e findings indicated that none of the patients had SRT or pure-tone average improvements greater than the minimum criteria of 10 dB. A few patients showed decrements larger than this minimum criterion. Speech discrimination was the most variable of the measures, and patients with improvements were offset by those with decrements in their scores. Fairbanks et al. (1974) concluded that, considering only audiometric data, there was no evidence to sug-
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gest that acupuncture could be used to cure sensorineural hearing impairments. A similar conclusion was drawn by Katinsky and Durrant (1974) after analyzing the audiometric tests of 82 ears of 41 patients (18 females and 23 males) who had received a minimum of 10 treatments for sensory deafness at the acupuncture centers in Washington, D. C. As in the Fairbanks et al. report, this evaluation indicates that most people showed no changes in the pre- and posttreatment audiograms, while those who exhibited improvements were more than offset by those who had decrements in hearing ability following treatments. Finally, Aber (1974) evaluated the audiograms of 30 children and adults who had been treated in various clinics in New York, New Jersey, and Washington, D. C., and again found no improvements following acupuncture. Thus, in total, these independent evaluations of approximately 140 patients treated at various clinics found that acupuncture produced no significant improvements in hearing levels. T h e studies of Eisenberg, Taub, and DiCarlo (1974) were designed as followups to Kao et al. (1973) and attempted to bridge the gap between the studies using subjective reports as the measure of change and those using only audiometric tests. T h e specific purpose was to attempt to separate out some of the psychological effects from the effects of the acupuncture treatments. A total of 25 patients (10 female and 15 male, 47 ears) participated in various phases of this project. In the pilot study, three out of four of the treated patients appeared to have improvements in both their subjective reports and audiometric tests. However, for two of these patients the improvements began after five control treatments that utilized needle areas not associated with sensory deafness. In the second study six experimental patients received eight treatments using acupuncture points most often recommended for the treatment of sensory deafness, while seven control patients were treated using areas not associated with deafness. Subjects were informed that some of them were receiving fake treatments although they were not informed which were the false treatments. Further, to evaluate practice effects three pretreatment tests were given to each patient. Finally, to reduce testing biases the audiologists were not informed of the specific treatments used and were not permitted to retain copies of the audiometric tests for reference or comparison. T h e results indicated that three patients in each group thought they had some improvement in hearing, but audiograms taken after four and eight treatments showed no consistent changes. As in previous reports, speech discrimination scores were the most variable with differences between successive tests being as high as 22%. These differences were exhibited in both the pretests and posttests, thus suggesting that this and previous reports of variability resulted from measurement variability and not the acupuncture treatments. In addition, one patient had consistent improvements in one ear with all measures (10 dB for pure-tone average, 8 dB for SRT, and 18% for speech discrimination) during the pretests, thus suggesting that there may be changes due to practice even without acupuncture treatments. A third study by Eisenberg et al. (1974) provided eight real treatments to 14 patients (six former control patients and eight new volunteers) and obtained
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TAUB. Acupuncture 431
similar findings of positive subjective reports (10 out of 14) with no improvements in audiograms. Finally, a four-month follow-up study of the initial three pilot patients indicated that much of their subjective feelings of improvements diminished about two weeks after cessation of treatments, that audiometric scores had reverted back to the original pretreatment levels, and finally, that an additional eight treatments did not produce any consistent improvements in hearing ability. Considering all four studies together, Eisenberg et al. concluded that there were no consistent changes in the audiometric tests and that the changes that occurred could be attributed to normal test variability or practice effects. In one patient, the possibility of a functional or psychogenic component in the hearing loss existed. T h e last report to be presented in this section is that of Rosen (1974) who initially provided the main impetus for acupuncture when he discussed this mode of treatment enthusiastically in 1971. Rosen (1974) treated 30 children for a total of six months providing approximately 15 treatments per month. An additional 10 patients were assigned to a control condition that utilized the same needle points but without deep insertion. However, further analysis indicated all 40 children could be considered under treatment since the control condition actually constituted a real form of acupuncture used in China9 Puretone measurements were taken weekly while SRT and speech discrimination were measured monthly 9 As in Eisenberg et al. (1974) the audiologists were blind to the specific treatment groups and did not have access to the data from the previous hearing tests. T h e results of this study were clear in indicating that none of the measurements showed improvements of statistical or practical significance and that only two of the children exhibited any signs of consistent improvements in hearing levels. Although he called for more research, Rosen (1974, p. 350) concluded that, 9 . . it is a tragic mistake to take a child--or an a d u l t for t h a t m a t t e r - - f o r acupuncture t r e a t m e n t for neurosensory deafness to any of the so-called a c u p u n c t u r e centers. T h e r e has not been one case of i m p r o v e m e n t d e m o n s t r a t e d audiometrically, w h e n a child or any deaf p a t i e n t was tested before u n d e r g o i n g t r e a t m e n t and then afterwards, by any reputable otologist. T h e r e have only been unreliable and, perhaps, p l a n t e d testimonials. (p. 350)
T h e paper by Rosen (1974) also presents other information about the use of acupuncture in China. It appears that the estimates of cases with improvements have changed drastically from the original 80-90% (Eleventh People's Hospital, 1959; Peng, 1973) to only 8-11%. Further, this lower estimate is not based upon a short series of treatments as used in America, but is derived from treatments of one to four years in duration that are combined with auditory and speech training. However, Rosen does not present evidence, and there is no other published evidence to indicate that even these lower estimates are based upon standard audiometric measurements in well-controlled studies that separate the effect of acupuncture from those of motivation, auditory training, and speech therapy.
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DISCUSSION AND CONCLUSIONS One surprising result of the literature is the general agreement in the findings across the studies. T h a t is, all studies using subjective criteria indicated that patients believe their hearing has improved, while, except for the initial preliminary report of Kao et al. (1974), all studies using standard pre- and posttreatment audiometric tests indicate that there are no consistent, measurable differences in hearing as a result of the acupuncture treatments. These general findings are consistent across studies even though there was a wide variation in the number of acupuncture treatments provided, the number of needles used, the choice of areas for the needles, the depth of insertion of the needles, and the use of specific practices such as pulse diagnosis, twirling and electrical stimulation of needles, and moxibustion. In view of the consistent lack of positive findings with the standard audiometric measures, there are a number of alternate explanations that can be suggested to account for the verbal reports of improvements. First, it is possible that the verbal reports represent real improvements too small or too subtle to be measured by pure-tone or speech audiometric tests. This explanation does not appear to be a likely alternative since some of the recent negative findings were also based upon other tests including Bekesy audiometry, tympanometry, and measurement of the stapedial reflex (Katinsky and Durrant, 1974; Rintelmann et al., 1974; Rosen, 1974). A second alternative that was suggested by the Acupuncture Letter ("What Promise Does Acupuncture Hold for the Hard of Hearing?" 1974) was that acupuncture may cause some direct change in the ability of patients to concentrate on sounds. However, this also does not appear to be a viable alternative since there is no physiological reason why acupuncture should have this effect and since any true increase in central nervous system efficiency should also be reflected by improvements in hearing test performance. T h e most viable explanation at the present time is that the reports of improvement represent a placebo effect similar to that seen with drugs. Patients who go for treatments are highly motivated to hear better and believe that acupuncture will help. Indeed, Study III of the research at the Syracuse VA Hospital (Eisenberg et al., 1974) attempted to study motivation and was considered a failure since it was difficult to recruit and maintain patients with low motivation. Those patients who completed the series of treatments in this study and reported improvements all believed that acupuncture could help even though they knew that previous findings were inconclusive. It is therefore suggested that improvements reported by patients represent an increased motivation and increased focusing of attention upon specific auditory stimuli that are at and just above threshold. Patients also may become more conscious of their affliction and begin to work harder at lipreading and other techniques that help make conversations "sound" clearer. Thus, no changes would be seen in the audiograms, while a patient might believe that hearing was improved. These feelings of improvements might be reinforced by the total aura of the treatment situation and by positive suggestions that might occur during administration. Further, even though they had no reference for judgment, numerous
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TAUB: Acupuncture 433
patients in o u r o w n studies r e p o r t e d t h a t they tested themselves by listening for certain sounds such as the ticking of a clock or a T V in the n e x t r o o m . T h i s possibility of searching for i m p r o v e m e n t s a n d of trying h a r d e r to h e a r certain sounds could also e x p l a i n w h y m a n y of the v e r b a l reports of i m p r o v e m e n t s were for b a c k g r o u n d - t y p e sounds such as dogs b a r k i n g , stairway noise, a n d vehicle traffic. T h e s e sounds are usually considered as noise or distractions a n d thus n o r m a l l y are not a t t e n d e d to even t h o u g h they m a y be above threshold. Finally, this n o t i o n could also e x p l a i n w h y i m p r o v e m e n t s are generally transient; t h a t is, patients c a n n o t m a i n t a i n a h i g h level of m o t i v a t i o n or c o n t i n u e testing themselves indefinitely a n d thus g r a d u a l l y revert back to p r e t r e a t m e n t habits. I n conclusion, o u r i n t e r p r e t a t i o n of the l i t e r a t u r e is t h a t a c u p u n c t u r e has no effect u p o n the h e a r i n g levels of individuals w i t h s e n s o r i n e u r a l losses. F u r t h e r , it is believed t h a t subjective feelings of i m p r o v e m e n t s r e p r e s e n t a placebo effect d u e to the a p p l i c a t i o n of a t r e a t m e n t t h a t patients believe m i g h t w o r k a n d not to a c u p u n c t u r e itself.
ACKNOWLEDGMENT Harvey Taub is also affiliated with the State University of New York Upstate Medical Center in Syracuse. Requests for reprints should be sent to him at Psychology Service, Veterans Administration Hospital, Irving Avenue and University Place, Syracuse, New York 13210.
REFERENCES ABER, W., Acupuncture. Archs Otolar., 100, 246-247 (1974). Acupuncture Letter, What promise does acupuncture hold for the hard of hearing? 1:8, 1-5 (1974). BONICA, J. J., Therapeutic acupuncture in the People's Republic of China: Implications for American medicine. J. Am. reed. Ass., 228, 1544-1554 (1974). EISENBERG, L., TAUB, H. A., and DICARLO, L. D., Acupuncture therapy of sensory deafness: Evaluation study. N.Y. St. J. Med., 74, 1942-1949 (1974). ELEVENTH PEOPLE'SHOSPITAL,SHANGHAICOLLEGEOF TRADITIONALCHINESEMEDICINE,SHANGHAI, Acupuncture in treatment of deaf-mutism. Chin. med. ]., 78, 12-14 (1959). FAIRBANKS,D. N. F., WALLENBERG,E. A., and W~B, B. M., Acupuncture for hearing loss. Archs Otolar., 99, 395-401 (1974). KAO, F. F., BAKER, R. H., LEUNG, S. J., SLIPPEN, M., AMPOLSAKDI,T., and LAPIDOT, A., Efficiency of acupuncture for the treatment of sensorineural deafness. Am. ]. Chin. Med., 1, 283-304 (1973). KASLOW,A. L., and LOWENSCHUSS,O., Hearing rehabilitation without needles. Am. ]. Acupuncture, 2, 23-29 (1974). KATINSKY,S., and DURRANT,J., Results of audiometric study of sensorineurally impaired subjects treated with acupuncture. Asha, 16, 411-414 (1974). LEUNG, S. J., BAKER,R., KAO, F. F., and LAPIDOT,A., Acupuncture treatment for sensory deafness. In Proceedings of the Second World Symposium on Acupuncture and Chinese Medicine. Am. J. Chin. Med., 2, 319-340 (1974). PENG, A., Acupuncture treatment for deafness: A preliminary report. Am. J. Chin. Med., l, 155-158 (1973). RINTELMANN, W. F., OYER, H. J., FOBORD,J. L., and FLOWERS,P. L., Acupuncture as a treatment for sensorineural hearing loss. Archs Otolar., 99, 300-303 (1974). ROSEN, L., Acupuncture and Chinese medical practices. Volta Rev., 76, 340-350 (1974). WENSEL, L., Introduction to acupuncture. Washington, D.C.: Washington Acupuncture Center (1973). Received February 5, 1975. Accepted March 19, 1975.
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HEARING
Harvey A. Taub Veterans Administration Hospital, Syracuse, New York
Recent reports concerning the use of acupuncture as a possible treatment for sensorineural hearing impairment were reviewed and evaluated. It was concluded that acupuncture has no effect upon the hearing ability of individuals with sensorineural losses. Further, it was suggested that subjective feelings of improvement represent a placebo effect resulting from the application of a treatment that patients believe might work and not from acupuncture itself.
Although acupuncture is an ancient mode of treatment in China, it is only since the beginning of the 1970s that Americans gained any knowledge of this technique. Unfortunately, the initial information was not acquired through scientific literature but through personal observations and eyewitness accounts of various American physicians who returned from visits to China. In these accounts the two most dramatic uses of acupuncture were for anesthesia and for treatment of sensorineural hearing impairments. This latter application was of critical importance since at the present time there is no known treatment for individuals suffering from sensorineural hearing losses. T h e major impetus for the use of acupuncture in the United States as a treatment for sensorineural hearing impairments came in 1971 as a result of the personal visit to China by Samuel Rosen, a well-known otolaryngologist. His description of the use of acupuncture was disseminated to the general public through various news media as well as national magazines. Shortly thereafter, the public began being informed through television and newspapers of successful treatments and even cures by the new acupuncture clinics that had been established in Washington, D.C. These clinics claimed a high success rate with estimates of 40-80% of the patients having what has been described as "significant improvements" (Wensel, 1973). On the other hand, aside from eyewitness reports and anecdotal accounts emanating from the new acupuncture clinics, there were no research data to enable audiologists and otologists to evaluate the efficacy of the treatments. These data are now available as a result of publications in 1974 from numerous laboratories and clinics, and the general consensus of these papers is that acupuncture does not significantly improve the hearing ability of patients with sensorineural losses. 427
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PERSPECTIVE AND RESEARCH
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DATA
Most accounts of the development of acupuncture for use with sensorineural hearing impairments state that it is a relatively new application that began about 1968 (Acupuncture Letter, 1974; Kao et al., 1973; Rosen, 1974). However, a report from the Eleventh People's Hospital in Shanghai (1959) suggests that research with this form of treatment began as early as 1956. This report from the Chinese Medical Journal described treatments where needles were inserted and left, without twirling or manipulating, for 30 minutes. Treatments were given every other day for a minimum of 30 days. The findings indicated that 87.5% of the patients (105 out of 120) showed improvement and that generally the effects first appeared within 10 treatments. While these findings might be considered encouraging, no standard hearing tests were used. T h e criteria for improvement included a change from inability to ability to hear a bell ringing and a subjective change in the clarity of ordinary conversation. Similar subjective criteria were used for determining marked improvement. Thus, it is difficult to draw conclusions on the basis of the findings of this paper. Bonica (1974) and Fairbanks, Wallenberg, and Webb (1974) also suggest that this lack of audiometric data is a crticism that may even be applied to much of the later findings and case reports that emanated from China. T h e first evaluations of acupuncture to appear in the American literature were published in 1973 and early 1974 in the new acupuncture journals, The American Journal of Chinese Medicine and The American Journal of Acupuncture, and provided additional positive evidence in favor of the use of this new form of treatment. However, all of these reports were preliminary studies with small numbers of patients (Kao et al., 1973; Kaslow and Lowenschuss, 1974; Peng, 1973). Further, the papers by Kaslow and Lowenschuss (1974) and Peng (1973) did not utilize pre- and posttreatment audiometric tests as the criteria for changes in hearing. Kaslow and Lowenschuss (1974) reported improvements for eight patients who had received acupuncture using electrical stimulation instead of needles, but they did not pretest the patients with standard hearing tests to determine the type and extent of loss. Similarly, their criteria for improvements were not scientifically vigorous and consisted of subjective reports and the ability to hear the ticking of a stopwatch. Peng (1973) reported improvements for eight out of 10 patients after most received only one to five treatments, but again the main criterion was the subjective reports of the patients. Peng did report that all patients received pretreatment audiograms and that a few received posttreatment audiograms. However the pre- and posttreatment data were presented for only one patient, and as noted by Fairbanks et al. (1974) these two audiograms were not directly comparable since one used the standards from the American Standards Association (ASA) while the second used the 1964 International Standards Organization (ISO) standards. T h e study by Kao et al. (1973) provides the best evidence in favor of the use of acupuncture and at the same time provides the background and basis for
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TAUB- Acupuncture 429
the transition from the positive to the negative findings. In contrast to the previous reports, Kao et al. administered complete audiometric tests including pure-tone thresholds (air and bone), speech-reception thresholds (SRT), accuracy of speech discrimination, and tone decay. Audiograms were taken for five patients before the acupuncture treatments and then again after four and eight treatments. T h e findings suggested substantial changes in all measures for one patient with improvements in each ear being approximately 25 dB (our estimations) for the pure-tone average (500, 1000, and 2000 Hz), 15 dB for SRT, and 20% for speech discrimination. All four other patients had some positive changes during the course of treatment, but for three of them there were numerous inconsistencies across ears and tests with some suggesting improvements and others indicating little, no, or even a negative change. Speech discrimination scores showed the most improvements but also seemed to be the most variable of the tests. While some large improvements were demonstrated, Kao et al. noted that the findings were preliminary and that any conclusions must be limited because of the small number of patients treated and because this, like all preceding papers, did not control for or eliminate the possibility of psychological effects. T h e preliminary nature of these findings and the precautionary limitations were borne out by a second and more comprehensive study from the same clinic (Leung et al., 1974). In this report of 38 patients (17 female and 21 male, 69 ears) the authors obtained audiometric evaluations following the fourth, eighth, sixteenth, and twenty-fourth acupuncture treatment. Their findings suggested that while 22 patients (58%) reported subjective feeling of improvement, there was a considerable difference between these feelings and the changes on the audiogram. In general, the study by Leung et al. (1974) was the first to indicate differences between subjective and objective criteria and to indicate the possibility of negative findings. T h a t is, the previously noted studies suggested improvements mostly on the basis of subjective reports, while all of the following studies that used audiometric measures as the main criteria for improvements have suggested that acupuncture has no effect. Rintelmann et al. (1974) reported a detailed analysis of the audiometric tests on one male patient who reported some subjective improvements. They concluded that all variations were within normal limits and that eight treatments did not produce a measurable change in the patient's hearing levels. Fairbanks et al. (1974) gathered and compiled pre- and posttreatment audiograms from numerous audiologists and otolaryngologists in an effort to provide an independent evaluation of possible hearing changes in patients treated in the various acupuncture clinics in the Washington, D. C. area. Data were reported for a total of 66 patients (123 ears). T h e findings indicated that none of the patients had SRT or pure-tone average improvements greater than the minimum criteria of 10 dB. A few patients showed decrements larger than this minimum criterion. Speech discrimination was the most variable of the measures, and patients with improvements were offset by those with decrements in their scores. Fairbanks et al. (1974) concluded that, considering only audiometric data, there was no evidence to sug-
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gest that acupuncture could be used to cure sensorineural hearing impairments. A similar conclusion was drawn by Katinsky and Durrant (1974) after analyzing the audiometric tests of 82 ears of 41 patients (18 females and 23 males) who had received a minimum of 10 treatments for sensory deafness at the acupuncture centers in Washington, D. C. As in the Fairbanks et al. report, this evaluation indicates that most people showed no changes in the pre- and posttreatment audiograms, while those who exhibited improvements were more than offset by those who had decrements in hearing ability following treatments. Finally, Aber (1974) evaluated the audiograms of 30 children and adults who had been treated in various clinics in New York, New Jersey, and Washington, D. C., and again found no improvements following acupuncture. Thus, in total, these independent evaluations of approximately 140 patients treated at various clinics found that acupuncture produced no significant improvements in hearing levels. T h e studies of Eisenberg, Taub, and DiCarlo (1974) were designed as followups to Kao et al. (1973) and attempted to bridge the gap between the studies using subjective reports as the measure of change and those using only audiometric tests. T h e specific purpose was to attempt to separate out some of the psychological effects from the effects of the acupuncture treatments. A total of 25 patients (10 female and 15 male, 47 ears) participated in various phases of this project. In the pilot study, three out of four of the treated patients appeared to have improvements in both their subjective reports and audiometric tests. However, for two of these patients the improvements began after five control treatments that utilized needle areas not associated with sensory deafness. In the second study six experimental patients received eight treatments using acupuncture points most often recommended for the treatment of sensory deafness, while seven control patients were treated using areas not associated with deafness. Subjects were informed that some of them were receiving fake treatments although they were not informed which were the false treatments. Further, to evaluate practice effects three pretreatment tests were given to each patient. Finally, to reduce testing biases the audiologists were not informed of the specific treatments used and were not permitted to retain copies of the audiometric tests for reference or comparison. T h e results indicated that three patients in each group thought they had some improvement in hearing, but audiograms taken after four and eight treatments showed no consistent changes. As in previous reports, speech discrimination scores were the most variable with differences between successive tests being as high as 22%. These differences were exhibited in both the pretests and posttests, thus suggesting that this and previous reports of variability resulted from measurement variability and not the acupuncture treatments. In addition, one patient had consistent improvements in one ear with all measures (10 dB for pure-tone average, 8 dB for SRT, and 18% for speech discrimination) during the pretests, thus suggesting that there may be changes due to practice even without acupuncture treatments. A third study by Eisenberg et al. (1974) provided eight real treatments to 14 patients (six former control patients and eight new volunteers) and obtained
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TAUB. Acupuncture 431
similar findings of positive subjective reports (10 out of 14) with no improvements in audiograms. Finally, a four-month follow-up study of the initial three pilot patients indicated that much of their subjective feelings of improvements diminished about two weeks after cessation of treatments, that audiometric scores had reverted back to the original pretreatment levels, and finally, that an additional eight treatments did not produce any consistent improvements in hearing ability. Considering all four studies together, Eisenberg et al. concluded that there were no consistent changes in the audiometric tests and that the changes that occurred could be attributed to normal test variability or practice effects. In one patient, the possibility of a functional or psychogenic component in the hearing loss existed. T h e last report to be presented in this section is that of Rosen (1974) who initially provided the main impetus for acupuncture when he discussed this mode of treatment enthusiastically in 1971. Rosen (1974) treated 30 children for a total of six months providing approximately 15 treatments per month. An additional 10 patients were assigned to a control condition that utilized the same needle points but without deep insertion. However, further analysis indicated all 40 children could be considered under treatment since the control condition actually constituted a real form of acupuncture used in China9 Puretone measurements were taken weekly while SRT and speech discrimination were measured monthly 9 As in Eisenberg et al. (1974) the audiologists were blind to the specific treatment groups and did not have access to the data from the previous hearing tests. T h e results of this study were clear in indicating that none of the measurements showed improvements of statistical or practical significance and that only two of the children exhibited any signs of consistent improvements in hearing levels. Although he called for more research, Rosen (1974, p. 350) concluded that, 9 . . it is a tragic mistake to take a child--or an a d u l t for t h a t m a t t e r - - f o r acupuncture t r e a t m e n t for neurosensory deafness to any of the so-called a c u p u n c t u r e centers. T h e r e has not been one case of i m p r o v e m e n t d e m o n s t r a t e d audiometrically, w h e n a child or any deaf p a t i e n t was tested before u n d e r g o i n g t r e a t m e n t and then afterwards, by any reputable otologist. T h e r e have only been unreliable and, perhaps, p l a n t e d testimonials. (p. 350)
T h e paper by Rosen (1974) also presents other information about the use of acupuncture in China. It appears that the estimates of cases with improvements have changed drastically from the original 80-90% (Eleventh People's Hospital, 1959; Peng, 1973) to only 8-11%. Further, this lower estimate is not based upon a short series of treatments as used in America, but is derived from treatments of one to four years in duration that are combined with auditory and speech training. However, Rosen does not present evidence, and there is no other published evidence to indicate that even these lower estimates are based upon standard audiometric measurements in well-controlled studies that separate the effect of acupuncture from those of motivation, auditory training, and speech therapy.
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432
JOURNAL OF SPEECH AND HEARING DISORDERS
XL
427-433
1975
DISCUSSION AND CONCLUSIONS One surprising result of the literature is the general agreement in the findings across the studies. T h a t is, all studies using subjective criteria indicated that patients believe their hearing has improved, while, except for the initial preliminary report of Kao et al. (1974), all studies using standard pre- and posttreatment audiometric tests indicate that there are no consistent, measurable differences in hearing as a result of the acupuncture treatments. These general findings are consistent across studies even though there was a wide variation in the number of acupuncture treatments provided, the number of needles used, the choice of areas for the needles, the depth of insertion of the needles, and the use of specific practices such as pulse diagnosis, twirling and electrical stimulation of needles, and moxibustion. In view of the consistent lack of positive findings with the standard audiometric measures, there are a number of alternate explanations that can be suggested to account for the verbal reports of improvements. First, it is possible that the verbal reports represent real improvements too small or too subtle to be measured by pure-tone or speech audiometric tests. This explanation does not appear to be a likely alternative since some of the recent negative findings were also based upon other tests including Bekesy audiometry, tympanometry, and measurement of the stapedial reflex (Katinsky and Durrant, 1974; Rintelmann et al., 1974; Rosen, 1974). A second alternative that was suggested by the Acupuncture Letter ("What Promise Does Acupuncture Hold for the Hard of Hearing?" 1974) was that acupuncture may cause some direct change in the ability of patients to concentrate on sounds. However, this also does not appear to be a viable alternative since there is no physiological reason why acupuncture should have this effect and since any true increase in central nervous system efficiency should also be reflected by improvements in hearing test performance. T h e most viable explanation at the present time is that the reports of improvement represent a placebo effect similar to that seen with drugs. Patients who go for treatments are highly motivated to hear better and believe that acupuncture will help. Indeed, Study III of the research at the Syracuse VA Hospital (Eisenberg et al., 1974) attempted to study motivation and was considered a failure since it was difficult to recruit and maintain patients with low motivation. Those patients who completed the series of treatments in this study and reported improvements all believed that acupuncture could help even though they knew that previous findings were inconclusive. It is therefore suggested that improvements reported by patients represent an increased motivation and increased focusing of attention upon specific auditory stimuli that are at and just above threshold. Patients also may become more conscious of their affliction and begin to work harder at lipreading and other techniques that help make conversations "sound" clearer. Thus, no changes would be seen in the audiograms, while a patient might believe that hearing was improved. These feelings of improvements might be reinforced by the total aura of the treatment situation and by positive suggestions that might occur during administration. Further, even though they had no reference for judgment, numerous
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TAUB: Acupuncture 433
patients in o u r o w n studies r e p o r t e d t h a t they tested themselves by listening for certain sounds such as the ticking of a clock or a T V in the n e x t r o o m . T h i s possibility of searching for i m p r o v e m e n t s a n d of trying h a r d e r to h e a r certain sounds could also e x p l a i n w h y m a n y of the v e r b a l reports of i m p r o v e m e n t s were for b a c k g r o u n d - t y p e sounds such as dogs b a r k i n g , stairway noise, a n d vehicle traffic. T h e s e sounds are usually considered as noise or distractions a n d thus n o r m a l l y are not a t t e n d e d to even t h o u g h they m a y be above threshold. Finally, this n o t i o n could also e x p l a i n w h y i m p r o v e m e n t s are generally transient; t h a t is, patients c a n n o t m a i n t a i n a h i g h level of m o t i v a t i o n or c o n t i n u e testing themselves indefinitely a n d thus g r a d u a l l y revert back to p r e t r e a t m e n t habits. I n conclusion, o u r i n t e r p r e t a t i o n of the l i t e r a t u r e is t h a t a c u p u n c t u r e has no effect u p o n the h e a r i n g levels of individuals w i t h s e n s o r i n e u r a l losses. F u r t h e r , it is believed t h a t subjective feelings of i m p r o v e m e n t s r e p r e s e n t a placebo effect d u e to the a p p l i c a t i o n of a t r e a t m e n t t h a t patients believe m i g h t w o r k a n d not to a c u p u n c t u r e itself.
ACKNOWLEDGMENT Harvey Taub is also affiliated with the State University of New York Upstate Medical Center in Syracuse. Requests for reprints should be sent to him at Psychology Service, Veterans Administration Hospital, Irving Avenue and University Place, Syracuse, New York 13210.
REFERENCES ABER, W., Acupuncture. Archs Otolar., 100, 246-247 (1974). Acupuncture Letter, What promise does acupuncture hold for the hard of hearing? 1:8, 1-5 (1974). BONICA, J. J., Therapeutic acupuncture in the People's Republic of China: Implications for American medicine. J. Am. reed. Ass., 228, 1544-1554 (1974). EISENBERG, L., TAUB, H. A., and DICARLO, L. D., Acupuncture therapy of sensory deafness: Evaluation study. N.Y. St. J. Med., 74, 1942-1949 (1974). ELEVENTH PEOPLE'SHOSPITAL,SHANGHAICOLLEGEOF TRADITIONALCHINESEMEDICINE,SHANGHAI, Acupuncture in treatment of deaf-mutism. Chin. med. ]., 78, 12-14 (1959). FAIRBANKS,D. N. F., WALLENBERG,E. A., and W~B, B. M., Acupuncture for hearing loss. Archs Otolar., 99, 395-401 (1974). KAO, F. F., BAKER, R. H., LEUNG, S. J., SLIPPEN, M., AMPOLSAKDI,T., and LAPIDOT, A., Efficiency of acupuncture for the treatment of sensorineural deafness. Am. ]. Chin. Med., 1, 283-304 (1973). KASLOW,A. L., and LOWENSCHUSS,O., Hearing rehabilitation without needles. Am. ]. Acupuncture, 2, 23-29 (1974). KATINSKY,S., and DURRANT,J., Results of audiometric study of sensorineurally impaired subjects treated with acupuncture. Asha, 16, 411-414 (1974). LEUNG, S. J., BAKER,R., KAO, F. F., and LAPIDOT,A., Acupuncture treatment for sensory deafness. In Proceedings of the Second World Symposium on Acupuncture and Chinese Medicine. Am. J. Chin. Med., 2, 319-340 (1974). PENG, A., Acupuncture treatment for deafness: A preliminary report. Am. J. Chin. Med., l, 155-158 (1973). RINTELMANN, W. F., OYER, H. J., FOBORD,J. L., and FLOWERS,P. L., Acupuncture as a treatment for sensorineural hearing loss. Archs Otolar., 99, 300-303 (1974). ROSEN, L., Acupuncture and Chinese medical practices. Volta Rev., 76, 340-350 (1974). WENSEL, L., Introduction to acupuncture. Washington, D.C.: Washington Acupuncture Center (1973). Received February 5, 1975. Accepted March 19, 1975.
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