I am on my way back from Berlin after meeting Professor Benno Brinkhaus, a German pioneer of clinical acupuncture research, at the Charité. A window seat on an Intercity Express train, traveling at 250 kph, is one of my favorite places to work. And they serve such good coffee! Unfortunately, the journey will only take an hour and a half. But it looks as if I may be traveling this route more often in the future. Benno and I are planning some exciting collaborations in acupuncture basic research.
Talking to Benno I thought it might be a good idea to feature some of the important people in complementary medicine research working on somatosensory therapies with a series of interviews. Lucky for me, Benno agreed to be the first scientist featured by this series. The following interview was conducted on 28 July 2015.
For those of you, who do not know him, Prof. Brinkhaus is currently head of the Complementary and Integrative Medicine Research Unit and head of the Outpatient Clinic for Complementary and Integrative Medicine of the Institute for Social Medicine, Epidemiology, and Health Economics at the Charité – Universitätsmedizin in Berlin.
A new kind of medicine: Benno, cross your heart: If you have a headache: Needle or NSAID?
Prof. Brinkhaus: [chuckles] Both! It depends on the situation and in particular whether I have the have time to go and see an acupuncturist or to stick a needle myself.
You needle yourself?
What about your wife?
[chuckles] I have treated her several times. My wife is Catalan, you know? And southern Europeans seem to be a little bit more anxious compared to northern Europeans when it comes to needles… Nevertheless, I have had good success in treating her. Especially, when treating her in preparation of the birth of our children.
Well, I can assure you from my attempts to treat my own wife that this problem is not limited to southern Europeans…
I also started to treat my older children but have recently given up on that.
Because I think that it is better when the doctor is not a family member. As a specialist for internal medicine who also used to work in the ICU, I also feel that I may be a bit too relaxed, when it comes to ordinary diseases.
Can you tell our readers what kindled your interest in complementary medicine?
[chuckles] Oh, that is a long story. I studied medicine in Vienna and later in Düsseldorf. Towards the end of my studies, however, I was fed up with studying medicine. It completely lacked the creativity I was looking for and I also was not too happy with my ambitious fellow students. So I decided to finish my medicine studies and then continue with another discipline, for example architecture or arts.
But then I graduated and during my practical year I noticed that it is a completely different thing to study medicine than actually doing it. And I began to like it. However, I also felt that conventional medicine was not the only way I wanted to practice medicine as it was not very individualized and sometimes was not successful, particular in chronic diseases. So I thought it might help to get in contact with other medicine traditions. Searching for my first employment, I then found a unique position in Erlangen, where I could learn and practice internal medicine but at the same time be part of a complementary medicine department. At that time, Erlangen, was one of the very few places in Germany, where this was possible. Later, I decided to learn more about Chinese Medicine and took my first trip to China to learn the basics. I was fascinated by this kind of medicine, the way of thinking and the theory behind it. Back in Germany I started to study acupuncture in depth at the International Society for Chinese Medicine (SMS) in Munich, Germany.
Are there people that criticize your work?
Of course we always have colleagues that criticize our work. But I think this is o.k. as long as it happens in the scientific context. Now, after we have published in high-ranking journals, like Lancet, JAMA, and Annals of Internal Medicine, I think they acknowledge that we are doing good research and try to answer important questions.
Acupuncture is 60-80% placebo, homeopathy 90-100%
Let us continue with some more scientific questions: How much of acupuncture’s effect do you think is due to placebo effects?
[chuckles] I think our studies show that the unspecific effect is indeed quite large. It probably depends on the indication, on the patient, as well as on the doctor. If you have an empathic doctor and a patient with high expectations, the unspecific effect may amount to 60 or even 80 percent. But of course we have this serious problem that sham acupuncture is not a real placebo, it is just only a sham intervention and it probably leads to wrong estimates.
What about homeopathy? How many percent unspecific effect?
[chuckles] Oh, I think more than 90 percent. Probably 100 percent.
Do you apply acupuncture and homeopathy in your clinic?
Yes. Both in our outpatient clinic, however, my specialities are naturopathy and acupuncture or Chinese medicine. I’m not a homeopathic doctor.
Don’t you see any problems in using treatments that you believe are largely based on the placebo-effect?
In our clinic, we usually combine multiple therapies, like acupuncture and osteopathy, with movement therapy and nutritional as well as life style advice. I think the most important goal is to stimulate change in our patients’ life style. Acupuncture is a great tool for this as the patients have to come back regularly to receive their treatment. So the sessions offer the opportunity to track the progress of such life style changes and make adjustments when necessary.
What do you consider your most important professional achievement so far?
I think the ART studies in pain diseases which we performed together with Claudia Witt, Klaus Linde and Dieter Melchart as well as the ACUSAR study in allergic rhinitis patients including the two pre-studies were ground-breaking. In ART we had four RCT trials, each with the same population number. We used the same design and methodology in all trials and for all indications. It was quite interesting to see that we got very different results for the sham (i.e. minimal acupuncture) groups. For example we saw a big response to the sham treatment in both headache groups (tension-type and migraine) but not in the osteoarthritis group. Of course, we were also able to show that acupuncture works in patients with allergic rhinitis, especially in seasonal allergic rhinitis. And it was very interesting that acupuncture showed long-time effects of more than 6 months and still reduced allergy symptoms in the following year.
Now let us talk about mechanisms for a moment. How do you think acupuncture and related techniques work?
This is one of the most important questions to answer these days. I believe that at present we only have some parts of a big puzzle. What we know is there seem to be different mechanisms of acupuncture for different diseases. In pain disorders acupuncture probably works by different mechanisms than e.g. in allergy or hypertension. We know that there are local effects that manifest themselves in the region close to the needle. Then there are effects on the spinal level and also in the brain. For the non-analgesic effects, acupuncture seems to modulate the activity of the autonomic nervous system as well as the immune system. Both effects are probably linked.
So the bottom line is that acupuncture works by neurally mediated mechanisms?
Yes, by the central and the autonomic nervous system, I think.
If you look ahead, what is your next most important goal?
I think it is quite difficult at the moment to get good projects funded. I surely would like to continue my work on acupuncture in atopic diseases, like seasonal allergic rhinitis placing a stronger emphasis on mechanisms. I would also very much like to work on acupuncture in stroke.
Acupuncture for serious diseases
That brings me to my next question: Do you think we should treat more serious diseases with acupuncture and related techniques?
Absolutely! As I said I would be happy to do a study on stroke patients if I had the funding. The problem is that you need to treat patients early and not start three or four weeks after the attack as many previous studies have. This of course means that you need one or better two acupuncturists at the stroke unit, which unfortunately is rather uncommon. I am also convinced that acupuncture would well complement emergency medicine, especially in the ambulance on the way to the hospital.
So apart from stroke, which other serious diseases should we treat with acupuncture?
Probably heart attacks. Of course only in addition to conventional therapy.
From your own experience, are there differences between somatosensory interventions in terms of what works best for a certain disease? For example, do you have patients where you only use cupping and others where you only use acupuncture?
I use more acupuncture than cupping or other interventions. This is because I have made very good experiences with acupuncture and consider it a stronger stimulus than e.g. cupping. Of course some patients do not tolerate needles or explicitly want to be cupped. But otherwise I prefer needles. However, we have also done two clinical studies with cupping for knee arthritis, where we compare cupping plus routine care to routine care only and got very good results. The results of a recent study, where we used a form of sham cupping for chronic low back pain, which means cupping with very little suction, are just being analyzed.
The medicine of the future
What is your vision for the future of integrative medicine?
My vision is that complementary medicine will transform conventional medicine into a modern form of medicine, let’s call it integrative medicine, which from my point of view is the medicine of the future. I hope that we will not be so dependent on pharmaceutical drugs any more and that patients will take more responsibility for their own lives including their health. If humans care more for themselves, maybe they will also care more for the society and the environment. In the end, medicine is not only about your own health but about the health of the social system and the health of the environment.
Benno, thank you very much for this interview and all the best for your future work!