Hip and Trending Holistic Medicine

Comments by Michael Meinen and Mike Cummings Case report El-Wahsh S, Efendy J & Sheridan M. Migration of self-introduced acupuncture needle into the brainstem. J Neurosci Rural Pract 2018; 9(3): 434 – 436. Lateral cervical spine x ray film showing the 0.25x30mm needle within the muscle layer. Presentation An elderly man presented to an emergency department after an acupuncture needle (which he had inserted himself) had broken off in the attempt to withdraw it.[1] Exploration of the neck was unsuccessful, and the patient required a CT scan to locate the needle (ultrasound failed to locate it); four days after initial presentation, it had migrated cranially through the foramen magnum and pierced the dura mater with the tip resting in the brainstem. It had to be removed by open surgery, followed by a patch repair of the dura mater. The tip of the needle was angulated. The patient made a good recovery and was free of symptoms at follow-up after a month. Discussion Accidental pe...

Effect of Acupuncture on Joint Pain Related to Aromatase Inhibitors Among Women With Early-Stage Breast Cancer – Hershman et al JAMA 2018 A large rigorous and statistically positive trial published in a prestigious general medical journal,[1] and an increasingly familiar conclusion rings out – acupuncture is significantly better than sham, but the difference may not be of clinical significance. This was not the exact conclusion of Hershman et al, but the latter is similar to this common EBM (Evidence-Based Medicine) mantra, perhaps insisted upon by the JAMA editors. Hershman et al is the biggest trial of acupuncture for joint pain related to the use of aromatase inhibitors in women with breast cancer, and it randomised 226 women in a 2:1:1 split to verum (110), sham (59) or waitlist (57). The acupuncture protocols involved 18 sessions over 12 weeks, with 2 per week for the first 6 weeks. The primary outcome was the worst pain score on the Brief Pain Inventory (BPI-WP) at 6 wee...

– no clear effect on live birth rate Acupuncture has become very popular within the field of assisted reproduction, and particularly as an intervention within IVF (In-Vitro Fertilisation). In an editorial from 2015 in Acupuncture in Medicine , David Carr lists 12 meta-analyses on the subject in just 6 years, including a total of 34 RCTs.[1] There was no clear conclusion from the reviews – most outcomes showed no benefit for acupuncture, but some did. In general we see quite large benefits over control in open studies, and no effects in blinded sham control studies. It is worth noting that in one high quality double blind study (n=370), the sham acupuncture group had a significantly better outcome than the real acupuncture group (live birth rate 38.4% versus 29.7% respectively).[2] The research team from Hong Kong went on to test the same protocol (treatment before and after embryo transfer – ET) in frozen-thawed cycles (FET; n=226). The results were very similar (live birth rate 35...

– does sophisticated MRI data point us to optimal treatment? For some time, a group on the US east coast have been quietly scanning brains with functional magnetic resonance imaging (fMRI) and related techniques to examine the effects of acupuncture. They hit the headlines in rather a dramatic manner in 2017.[1,2] At the beginning of the fMRI story we saw some extraordinary claims concerning point specificity in acupuncture from a famous name in the development of fMRI, but these were later retracted.[3] I was relieved to see the retraction, as the claims did not seem mechanistically credible from a neurophysiological point of view. The authors retracted their paper because the results were not in line with the body of developing evidence that acupuncture with typical deep tissue sensation (I prefer this term, but it equates to de qi ) seems to cause a general deactivation of limbic structures,[4,5] rather than very specific and targeted functional activations. So why am I a year b...

– more data, new insights… In 2012, the first individual patient data meta-analysis (IPDM) in the field of acupuncture was published.[1] It was also one of the first in the field of pain research. It was a struggle to publish, principally (I guess) because the IPDM method was relatively new to journal editors, and because the general medical journals tend towards conservatism and orthodoxy, so positive research on unorthodox interventions probably have higher hurdles to clear prior to publication. The 2012 IPDM included data from 29 trials and 17 922 patients. The update has just been published, and it includes data from 39 trials and 20 827 patients.[2] It should be noted that trials were only included where allocation concealment was unambiguously determined to be adequate, so this is a data set built on what used to be called the highest quality trials. Trials were grouped into 3 clinical categories for analyses: osteoarthritis, chronic headache, non-specific musculoskeletal pa...

– perhaps via direct pudendal nerve stimulation Earlier in 2017 this paper popped up in JAMA.[1] It was from the same group that had published a huge multicentre trial of electroacupuncture (EA) for chronic severe functional constipation,[2] which was featured in a previous blog . This was a large sham controlled trial (n=504) although not as big as the previous one on constipation (n=1075). We have known for some time that EA can influence symptoms in overactive bladder, albeit under another name.[3] These are mainly urge symptoms, and a simiar mechanism that reduces pain perception might be postulated to explain the results. Urinary stress incontinence (SUI) seems entirely different, and so the results of this trial were rather unexpected (by me at least). I revisited the paper to examine the intervention in more detail and consider the anatomy involved. The active EA intervention involved just two points on each side (I love the simplicity!) – BL33 and BL35. 75mm needles were emp...

– it seems to work after an intensive course… About a year ago I was surprised to see a sham controlled RCT of electroacupuncture (EA) published in Annals of Internal Medicine.[1] I was surprised for several reasons: I review for Annals, and I had not seen the paper for review; it was on chronic severe functional constipation – a subject with few previous RCTs of acupuncture; it was positive; it was the biggest 2 arm RCT in the acupuncture literature to date. The treatment was relatively straightforward – EA to the rectus abdominis muscle bilaterally (ST25—SP14) and manual stimulation of a point in tibialis anterior bilaterally (ST37). The sham control involved shallow needling of points close by, but not on the meridians, avoidance of typical needling sensation ( de qi ) and sham EA (ie no electrical stimulus, but the power indicator and sound as if it were real EA). The frequency used varied from 10 to 50Hz and the intensity was between 0.1 and 1mA. The frequency covers the best ra...

…in women with polycystic ovarian syndrome (PCOS) Finally I have come to address this topic, some months following publication of an eagerly awaited (at least by me) large clinical trial.[1] I have been a colleague and friend of the second author (ES-V) since proofreading her PhD thesis over 20 years ago. In those days I focussed solely on muscle so any suggestion of acupuncture being used to influence visceral function or blood flow was a bit of a conceptual stretch for me. After all my needles were going directly into the target that I wanted to influence, and I was just about comfortable with the idea that the needle alone actually did something useful without the need for injecting a drug. So the idea that acupuncture or electroacupuncture could have any useful effect through indirect influences only really arose when I read Lisa’s thesis. Her early work stimulated interest in the use of acupuncture in fertility and augmented reproduction,[2,3] although the subsequent plume of cl...

This piece has also been stimulated by a publication in JAMA , this time evaluating the use of denervation of joints in spinal pain.[1] It is a set of three large (n=251, n=228, n=202), probably definitive, pragmatic trials that evaluate the use of radiofrequency denervation (RFD) as an addition to a 3 month standardised exercise programme. The design is such that the intervention was given the greatest possible opportunity to demonstrate an effect, that is both the specific effect of the intervention plus the context in which it is provided. This is rather similar to the Acupuncture in Routine Care (ARC) trials performed as part of the German Modellvorhaben Akupunktur;[2] all of which were markedly positive for acupuncture. The results seem clear – at no time point did the difference been intervention and control reach clinical significance in terms of pain intensity (the primary outcome); and in only one of 18 time points across the three trials did the difference reach statistical...