Hypertension 2018

In March 1999 the Chinese Cochrane Centre opened in Chengdu. Now that it has been established for some time, we are starting to see reviews on acupuncture that include the Chinese literature. I remember reviewing one on neuropathic pain for Cochrane,[1] but this one on hypertension was a surprise when it popped up on PubMed at the end of November 2018.[2]

To get a feel of the difference between these reviews it is instructional to read the paragraph in the background section entitled: ‘How the intervention might work’. The one I reviewed from 2017 reads as follows:

The overwhelming data from basic science support the idea that acupuncture mediates its clinically relevant effects via nerves, usually, but not exclusively, in deep somatic tissue (Dhond 2008; Kim 2008; Zhang 2005). EA stimulates all fibre types, since all nerve impulses work through alterations in membrane potentials mediated via voltage‐gated channels. MA mediates a mechanical stimulus, and therefore will only stimulate mechanosensitive nerve endings (Toda 2002; Zhao 2008). Release of adenosine via both techniques may mediate a local inhibition of nociceptive fibres (Goldman 2010). Some evidence suggests that in the central nervous system acupuncture may produce an analgesic effect by the deactivation of limbic areas (Hui 2010; Shi 2015). Alternatively, descending inhibitory modulation may also be regulated by acupuncture to enable the modulation of pain (Takeshige 1992).
Ju 2017 [1]

That sounds a bit like something I might have written myself ;-).

The more recent one on hypertension reads thus:

The mechanism whereby acupuncture can lower BP is unclear. Acupuncture use is based on the TCM concept that diseases are due to disharmony in the body and there are channels (or ‘meridians’) of energy flow (called ‘qi’) within the body that can regulate the disharmony (Kalish 2004). When selected places (also called acupoints) on the meridians or collaterals are stimulated, diseases caused by dysregulation can be treated (Kaptchuk 2002). Mechanistic studies have demonstrated that acupuncture can normalize decreased parasympathetic nerve activity (Huang 2005), which is thought to result in increased excretion of sodium; reduced plasma renin, aldosterone, and angiotensin II activity; and changes in plasma norepinephrine, serotonin, and endorphin levels (Kalish 2004). For the management of chronic conditions, acupuncture can be practically administered monthly or at most weekly. Therefore, for it to be effective, it would need to reverse the elevated BP permanently or have a sustained effect for one week or more. A short‐term effect on BP for hours or even one to three days would not be sufficient to make it a practical therapy.
Yang 2018 [2]

You can imagine that I am moved to write a comment on this…

John Longhurst sadly died prematurely with his wife when their light aircraft lost power and crashed in February this year. He was responsible for some of the best physiological research on cardiovascular reflexes and electroacupuncture. If you were to read his chapter in the second edition of the textbook Medical Acupuncture – A Western Scientific Approach,[3] and then read the paragraph above on how ‘the intervention’ might work in hypertension, you would be flabbergasted, I give you my guarantee. I can only assume that the expert peer reviewers of this review came from a traditional acupuncture background – hardly useful from the perspective of a Cochrane review ie the cutting edge of modern evidence-based medicine.

The paragraph fails to mention the data on modulation of sympathetic tone, which is likely to be much more important than parasympathetic activity since it exerts direct control on peripheral resistance and thence blood pressure. The authors then go on to state that weekly treatment is the maximum possible frequency for chronic conditions, and therefore acupuncture must show an effect for at least 7 days. This is lunacy if one considers the basic science evidence. In the laboratory, acupuncture has never shown direct effects on physiological parameters for longer than 72 hours. Consequently, I teach my patients to self-administer EA every 3 days for maintenance of chronic inflammatory conditions. I have not taught patients for management of hypertension, and this may require treatment even more frequently.

The authors conclusions in the hypertension review are shocking, and most unlike Cochrane’s usual equanimity:

At present, there is no evidence for the sustained BP lowering effect of acupuncture that is required for the management of chronically elevated BP. The short‐term effects of acupuncture are uncertain due to the very low quality of evidence. The larger effect shown in non‐sham acupuncture controlled trials most likely reflects bias and is not a true effect. Future RCTs must use sham acupuncture controls and assess whether there is a BP lowering effect of acupuncture that lasts at least seven days.
Yang 2018 [2]

I am particularly surprised by the use of ‘most likely’. Personally I do not think the data supports more than a ‘may’. But hang on a minute, let’s have a think about this. Bias from a lack of blinding is particularly relevant to subjective outcomes, but we are talking about blood pressure here, and the patients are not all yogis… Well, let’s face it, if they were yogis, they probably would not need treatment for hypertension. But my point is that if it is all mind over matter in terms of blood pressure control, and hypertension can be controlled with placebos, why poison ourselves? The efficacy over placebo debate here is ridiculous, we need to compare effectiveness and harms of different interventions.

RCTs must use sham controls! Why? So the patients cannot bias the result by seeing the needles as opposed to the colourful pills? Who cares? Surely we should design large pragmatic studies to see whether or not acupuncture (preferably self-applied 2 to 3 times a week) can compete with modern drugs – it is certainly unlikely to compete with antihypertensive drugs in terms of NNH– number needed to harm.[4]

References

1. Ju ZY, Wang K, Cui HS, et al.Acupuncture for neuropathic pain in adults. Cochrane Database Syst Rev2017;12:CD012057. doi:10.1002/14651858.CD012057.pub2

2. Yang J, Chen J, Yang M, et al.Acupuncture for hypertension. Cochrane Database Syst Rev 2018;11:CD008821. doi:10.1002/14651858.CD008821.pub2

3. Longhurst JC. Acupuncture in cardiovascular medicine. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture – A Western Scientific Approach. London: Elsevier 2016. 394–421.

4. Sheppard JP, Stevens S, Stevens R, et al. Benefits and Harms of Antihypertensive Treatment in Low-Risk Patients With Mild Hypertension. JAMA Intern Med 2018;178:1626–34. doi:10.1001/jamainternmed.2018.4684

Periosteal techniques 1963-2018

In July 2018 I gave a workshop on Western medical acupuncture theory and techniques to a group of Chinese Medicine doctors in Lanzhou New District. The workshop lasted a little over 4 days, and the participants did not seem to be familiar with periosteal needling.

I was aware that in other parts of China the use of mini-scalpel acupuncture or acupotomy was used, although I don’t think it is very widely used in practice. The needles are more like tiny chisels than scalpels in appearance, and they are sometimes targeted at soft tissue attachments to bone, but this is not at all like the periosteal needling with filiform acupuncture needles described by Felix Mann.[1–3]

As Western practitioners we often assume that in China acupuncture universally involves very strong needling techniques, but my translator, a doctor trained in integrative medicine (effectively a variety of Chinese medicine), gave me a different impression. She was relatively sensitive to needling herself, so I chose her to demonstrate the technique on me under my guidance. She had never needled onto periosteum before, as you can see from the video…

Felix Mann writes in 2000 that periosteal acupuncture was one of the most important inventions of his medical career.[2] He first started using the technique around 1963, and chose to call it periosteal acupuncture rather than bone acupuncture or osteopuncture because periosteum has a rich innervation and bone does not. So the name reflects the idea that acupuncture is primarily a form of nerve stimulation.

Periosteal acupuncture was one of the most important inventions of my medical career.
Felix Mann [2]

He suggests there is little point in leaving the needles in place, rotating them or stimulating them electrically. He preferred pecking like a woodpecker and immediate removal. Rotation appeared to do nothing on the periosteum in comparison to pecking, and electrical stimulation only appears to excite the more superficial tissues. The latter would be consistent with an insulating effect from embedding the tip of the needle within periosteum. With this in mind I was amused to read the slightly misleading title of a recent trial, which included the phrase ‘periosteal electrical dry needling’.[4] Clinical experience suggests that it is not possible to stimulate periosteum electrically via an acupuncture needle based on the entirely different sensations produced both in terms of the nature and perceived depth of the stimulus by pecking versus electrical stimulation of a needle on periosteum. But this has not stopped trials being performed by a group in the US that claim to do it.[5,6]

They describe:

Periosteal stimulation therapy (PST) is a technique that delivers high-frequency electrical stimulation to periosteum using acupuncture needles.

They continue to explain:

It has been hypothesized that PST exerts its effect primarily by stimulating sympathetic fibers in proximity to the periosteum…

Sympathetic nerve fibres are way too narrow and slowly conducting to sustain a frequency of 100Hz, and as far as I am aware, they exist in cancellous bone rather than periosteum. It’s Interesting that the references supporting the theory of PST are mostly to Felix Mann’s publications, and he did not advise using electrical stimulation.

Sympathetic nerve fibres are way too narrow and slowly conducting to sustain a frequency of 100 Hz

The research on manual periosteal needling is limited, but it seems to support the idea that effects are similar to those of standard manual acupuncture.[7,8]

References

1. Mann F. Reinventing Acupuncture: A New Concept of Ancient Medicine. 1st ed. Oxford: Butterworth Heinemann 1992.

2. Mann F. Reinventing Acupuncture: A New Concept of Ancient Medicine. 2nd ed. Oxford: Butterworth Heinemann 2000.

3. Campbell A. Acupuncture without points. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture – A Western Scientific Approach. London: Elsevier 2016. 125–32.

4. Dunning J, Butts R, Young I, et al.Periosteal Electrical Dry Needling as an Adjunct to Exercise and Manual Therapy for Knee Osteoarthritis: A Multi-Center Randomized Clinical Trial. Clin J Pain Published Online First: 28 May 2018. doi:10.1097/AJP.0000000000000634

5. Weiner DK, Moore CG, Morone NE, et al. Efficacy of periosteal stimulation for chronic pain associated with advanced knee osteoarthritis: a randomized, controlled clinical trial. Clin Ther 2013;35:1703–20.e5. doi:10.1016/j.clinthera.2013.09.025

6. Weiner DK, Rudy TE, Morone N, et al.Efficacy of Periosteal Stimulation Therapy for the Treatment of Osteoarthritis-Associated Chronic Knee Pain: An Initial Controlled Clinical Trial. J Am Geriatr Soc 2007;55:1541–7. doi:10.1111/j.1532-5415.2007.01314.x

7. Hansson Y, Carlsson C, Olsson E. Intramuscular and periosteal acupuncture for anxiety and sleep quality in patients with chronic musculoskeletal pain–an evaluator blind, controlled study. Acupunct Med 2007;25:148–57.

8. Hansson Y, Carlsson C, Olsson E. Intramuscular and periosteal acupuncture in patients suffering from chronic musculoskeletal pain – a controlled trial. Acupunct Med 2008;26:214–23.

Declaration of interests MC

A Tale of two Fridays

The following story was reported to me by a colleague from general practice. The details are altered somewhat to preserve anonymity, including the name of the teller, but regular readers will recognise some characteristic use of language and style.

Safe angulation for needling quadratus lumborum near lower lateral attachment to the iliac crest.

Dear Mike

This is a little story that illustrates the problems people have with acupuncture, or at least with what it means, or the perception of acupuncture.

One Friday some weeks ago, as part of routine primary care, I saw woman in her 30’s with unexplained left sided loin pain. She had suffered from an episode of pyelonephritis and subsequently developed persisting loin pain. Technically ‘chronic pain’, lasting for more than three months etc. She had undergone ultrasound scans, blood tests and two colleagues saw her. One had tried manual medicine within the osteopathic paradigm. “It aggravated it, and it stayed” she said, and she was frustrated and a bit scared. I examined and looked at the results and thought it could be myofascial pain, possibly secondary to the pyelonephritis following Maria Adele Giamberardino’s heuristics. I said that I could offer acupuncture, but first I would suggest stretching etc, all directed towards quadratus lumborum. I sensed apprehensiveness, and did not want to needle into apprehensiveness and preconceptions. She said that her husband was sceptical and he considered that acupuncture was mumbo jumbo.

I said my offer is there, no pressure, less work is good for me. She said “Come on, then”. I needled her in side lying as we teach on the course. Just one needle towards the lumbar transverse process, it could have been lateral part of erector spinae or quadratus lumborum, I am not so sure, but I am confident that the needle tip hit the target, the appropriate place. She confirmed that it was the pain she was experiencing. I stretched the muscle afterwards and whilst I was tidying up and typing the notes, she was wiggling her hip, searching for ‘her pain’, and the pain had disappeared. She asked how long will it last? I replied I don’t know, ideally forever, but what in life is ideal? Sceptical optimism, sceptical hope – I said please phone me on Monday. She never did.

…the pain had disappeared.

Friday afternoon one week later. I called a patient in. My heart sank: she had a tripod multifunction-cane, was tattooed all-over, smelled of nicotine, hopelessness and fed-up-ness, and took ages to make it to my door. The way from the waiting room to my room is a parcour with a flight of stairs up and a flight of stairs down. The Inca trail. A functional assessment strip. With a firm handshake plus the parcour I have a good understanding of the frailty score. She was frail. Her opener was “Do you do acupuncture?” Nobody in this town knows that I do acupuncture. I am a normal GP and use needling as part of my routine services but I do not attract sufferers of all countries to unite in my consultation room.

I do not attract sufferers of all countries to unite in my consultation room.

“Who told you?” I asked.

“A woman I know, she was so much better after your acupuncture.”

“Does her name start with…?”

“Yes”

The friends and family test! She recommended me.

She recommended acupuncture for pain that does not go away!

And here is where the parallel stops.

The ‘fed-up’ lady had a long medication list, was tearful and disabled. She came to get treatment for her coccydynia. I decided to do as little damage as possible and needled two points at gluteus maximus insertion at sacrum as anchor points for hope and a different conversation. Whilst she was lying down I asked her to tell me about her life. She told me about her multiple blood clots, the pulmonary embolus, that she nearly died, that she had three kids and three grandchildren, that she was a fighter, but that now she felt like giving up, that her tattoos were an idea of wanting change, like a makeover, she told me that she grieved for what she had lost and that she struggled with breathlessness and pain.

Whilst she was lying down I asked her to tell me about her life.

For pain clinic purposes she ticked all the criteria of multimorbidity, polypharmacy, depression etc and at a point pain started creeping in and settling somewhere in her body.

I know that acupuncture rarely works to get these emergent demons out.

Needling works extremely well for isolated myofascial pain, as it did for her neighbour, but not in isolation for multi-morbidity, hopelessness and all forms of demons.

In a way these two women seemed to have the same limited way of understanding acupuncture, just like the helicopter view looking at classification terms in systematic reviews.

Does acupuncture work for chronic pain/loin pain?

The answer is that it depends on the context and the label itself: ‘acupuncture for chronic pain/loin pain’ is probably too simplistic a question to answer.

Declaration of interests MC

Needling and spasticity

Inspired by Sánchez-Mila Acupunct Med 2018 [1]

I have been curious about the potential effect of acupuncture needling in muscles with high tone since witnessing the rapid relief of lumbar muscle spasm following insertion of acupuncture needles whilst serving as a medical officer in the British military.

Subsequently I have tried the technique (combined with immediate passive stretch) with success in localised contractures, and for restoring upper limb joint range in hemiplegic stroke. It takes multiple sessions in these latter cases, and I guess that makes it hard to compete with botulinum toxin injection, although the latter does have some limitations (eg cost, excess weakness, allergic reactions).

I have tried both direct dry needling into the muscles exhibiting high tone as well as electroacupuncture (EA) to either high tone agonist or weaker antagonist muscles. The latter seems to be the most convenient and palatable approach in my practice. So I was interested to see that recent systematic reviews now tentatively support the use of EA in post-stroke spasticity [2,3].

This paper uses the more direct approach of dry needling into the affected muscles. They choose a very specific subgroup of stroke patients with their first episode of unilateral hemiplegia and spasticity resulting in an equinovarus foot – that is a foot forced into dorsiflexion and inversion by tibialis posterior and triceps surae (soleus and gastrocnemius). The intervention involved multimodal rehabilitation (Bobath concept) with or without the addition of a single session of dry needling to the affected tibialis posterior under ultrasound (US) guidance. The outcomes were functional scales (Ashworth and Fugl-Meyer) plus computerised dynamic posturography – something rather like the Nintendo wii fit balance board.

Ultrasound-guided dry needling of tibialis posterior – Figure 1 from Sánchez-Mila *Acupunct Med* 2018 [1]

The needling involved relatively gentle movement of the needle (4-5mm lift and thrust at 1Hz) for 25-30 seconds within tibialis anterior. US guidance was used to ensure accurate positioning and presumably to avoid penetration of the posterior tibial artery that lies between soleus and tibialis posterior. A 0.3x50mm needle was used, and whilst it is not easy to see such a fine needle on US, it is easy to see movement of fascial planes as they are indented, and therefore be reasonably confident of the needle position.

26 patients were randomised, and the single session of needling for half a minute resulted in a significant improvement in spasticity and balance. Further research will be needed, but this does seem to support the idea we have had for some years that physical rehabilitation can be improved by adding needling.

There are still lots of questions of course. Do we need to needle tibialis posterior directly? A standard technique without US guidance would be easier in practice, so would more superficial needling be as effective? Tibialis posterior can be reached with a relatively deep insertion at around SP7 or SP8, without particular risk of hitting the posterior tibial artery. So this might be a possible approach when US is not available, and a handheld stimulator can be used to confirm the position in the muscle. Finally, I have found to my surprise (guided by a stroke patient with prior experience) that EA to antagonists can be just as good if not better (the patient felt it was better) than EA into the spastic muscles directly. With this in mind, perhaps we could achieve the same results with very much more convenience by my favourite approach of EA to ST36 and zongping?

…EA to ST36 and zongping 😉

References

Sánchez-Mila Z, Salom-Moreno J, Fernández-de-Las-Peñas C. Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. Acupunct Med 2018; acupmed-2017-011568. doi:10.1136/acupmed-2017-011568
Zhu Y, Yang Y, Li J. Does acupuncture help patients with spasticity? A narrative review. Ann Phys Rehabil Med Published Online First: 5 November 2018. doi:10.1016/j.rehab.2018.09.010
Cai Y, Zhang CS, Liu S, et al. Electroacupuncture for Poststroke Spasticity: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil 2017;98:2578–2589.e4. doi:10.1016/j.apmr.2017.03.023

Declaration of interests MC

e-19th century

Papers from the early 19th century

Inspired by Cloquet, Sarlandière, Pelletan, Carraro, and Pouillet, on Acupuncture. Edinburgh Med Surg J 1827;27:190–200.

On the 25^th October 2018 three rather unusual papers appeared on my PubMed search.[1–3] They were remarkable because they were nearly two centuries late! So I guess there is an ongoing process of digitising journal archives, and it happens that the word ‘acupuncture’ or ‘acupuncturation’ appeared in the titles of these old papers. I often use the search term ‘acup*’, where the asterisk is a wild card – meaning it can stand for any letter or combination of letters. Generally, that means I will get ‘acupuncture’ or ‘acupressure’… I never expected, in the modern era to get ‘acupuncturation’!

I was very pleased to find that the full text of these papers was hosted on PubMed Central (PMC), although they are reasonably big files since they are page images. The oldest of the three was published in 1827, and it is this paper to which the following extracts and comments are attributed.

The Edinburgh Medical and Surgical Journal was published in Edinburgh from 1805 to 1855, and was described as: …exhibiting a concise view of the latest and most important discoveries in medicine, surgery, and pharmacy.

EMSJ 1805

It was clearly a quite prestigious and conservative journal, as the opening paragraph of the earliest paper reveals:[1]

Those of our readers who have perused the essay of Mr Churchill on acupuncture and his papers in the London Medical Repository, and who are aware that investigations have been lately made on the same subject in various parts of the Continent, may be surprised that hitherto no notice has been taken of it in this Journal. Our reason has been, that the first accounts given of the virtues of the new remedy were so marvellous, and therefore seemed to savour so much of quackery, that, coming, as they did, from persons not of the highest authority, we could not but follow the general example, and decline giving implicit credit to their assertions.

The same paragraph goes on to describe the editors’ change of heart – dare I say u‑turn on the matter:

But these assertions have been re-echoed from almost every quarter of Europe; observations have been made on the subject at many continental schools of eminence; the several accounts given by unconnected writers agree very remarkably in every essential particular; the alleged facts have at length been put to the test of a full and minute train of experiments by one of the most scientific of the Parisian physicians, in a great public hospital, and under the eyes of its pupils; the results of these experiments, as published by his hospital assistants, harmonize exactly with the statements made by those who introduced the remedy into Europe; and under such circumstances we cannot any longer delay presenting a summary of the interesting information which has been accumulated in its favour.

So how about that then?

The acuphiles jump for joy…
(my neologism – ‘acupuncture lovers’)

But wait:

It must be confessed, however, that after all we cannot approach this singular topic without hesitation.

What now? I love the use of the term ‘singular’ here, meaning remarkable, which has fallen out of common use. It is the word I have noticed jumping out with great regularity from the text of Conan Doyle’s Sherlock Holmes, as reanimated by the wonderfully expressive voice of Stephen Fry.

It is true, that, in the hands of M. Cloquet, the remedial virtues of acupuncture have passed triumphantly through an ordeal, to which no remedy, whose claims were false, could be submitted without detection. But, at the same time, the utmost ingenuity of its favourers has been unable to discover, in a long course of minute inquires, any rational way of accounting for its effects; and, what is perhaps of more consequence, they have been unable to detect any physiological change or phenomenon co-ordinate with its operation. There is in short a total want of every sort of evidence in its favour as a remedy, except that most treacherous kind, the evidence of succession; and consequently, a philosophical mind, especially considering the diseases in which the greatest success has been obtained, will naturally feel inclined to attribute the cures which have been accomplished to the influence of the imagination, and to sentence acupuncture to banishment from regular practice, as being nothing else than a variety of animal magnetism.

…a total want of every sort of evidence in its favour as a remedy, except that most treacherous kind, the evidence of succession!

Could it be:

…nothing else than a variety of animal magnetism!

Well the piece goes on to say that the journal is not the place to discuss evidence, and proceeds to describe the experiences of the fellows who have written about the technique. It is interesting to note the common opinion of where the technique works best, or should I say, where it doesn’t!

It is applied to all manner of maladies; but those in which it is accounted most applicable and is in reality most successful, are evidently such as do not belong to the active inflammatory disorders.

The paper describes the fine needles used, the fact that they simply do not hurt at all to insert, and that they are often retained for only 5 to 6 minutes; but a chap called Cloquet describes having left them in for over an hour.

Sewing needles could be used apparently, but only after passing a thread through the eye so that the needle did not get lost inside the body. Longer needles are also described – three inches in length and one fortieth of an inch in diameter (the latter is just over 0.6mm, so not too fat).

Louis Berlioz, the father of the famous composer, is credited as having first written about its use in the contemporary practice of the time as a ‘memoire to the Parisian Society of Medicine’. Berlioz is also credited as being the first to use electrical stimulation of needles in the form of galvanism.

Rather alarming is the description of how there is no damage to tissues or organs, including the heart and lungs, followed immediately by a description of a fatality that seems to have resulted from the terror caused by the accidental disappearance of needles into the abdomen.

In regard to the accidents arising from acupuncture, it is only necessary to add, that in a few cases the operation has been followed by a tendency to fainting, and that in one instance, which occurred at the Hotel-Dieu of Paris, the accidental disappearance of the needles in the skin of the belly was followed by such extreme and uncontrollable terror, that the patient expired soon after.

After a long description of the effects observed in patients, this paper finishes with some conjecture over the mechanism. They include the possibility that it ‘operates through the mind’, but my favourite idea of theirs is that it acts by:

…rectifying an aberration of the nervous fluid.

References

Cloquet, Sarlandière, Pelletan, Carraro, and Pouillet, on Acupuncture. Edinburgh Med Surg J 1827;27:190–200.http://www.ncbi.nlm.nih.gov/pubmed/30330050 (accessed 25 Oct2018).
Renton J. Observations on Acupuncture. Edinburgh Med Surg J 1830;34:100–7.http://www.ncbi.nlm.nih.gov/pubmed/30330219 (accessed 25 Oct2018).
Banks JT. Observations on Acupuncturation. Edinburgh Med Surg J 1831;35:323–8.http://www.ncbi.nlm.nih.gov/pubmed/30329900 (accessed 25 Oct2018).

Declaration of interests MC

Another fatality

Inspired by Jian et al. Medicine 2018

Last Saturday (3^rd November 5, 2018) I was lecturing on the BMAS Foundation Course, and during the morning coffee break I received one of my regular email alerts from PubCrawler – an Irish website that searches (or crawls) PubMed (the US National Library of Medicine) leaving you free to go to the pub! It was somewhat ironic that I was about to give the Safety Brief for the course, when I received notification of this fatal case report – a death from bilateral tension pneumothorax in Shanghai, China.[1]

Reports of deaths from acupuncture are very rare, but there may be a degree of under-reporting, as can be inferred to some degree by this case. The last fatality reported was a curious one, possibly related to strong needling around the vagus nerve in the neck,[2] and prior to that there had been no reports for 10 years.[3]

…why emphasize this risk of which we should all be very aware?

So this is another report of pneumothorax – why emphasize this risk of which we should all be very aware? Well it was fatal, and most are not, but the remarkable features of this case relate to the postmortem diagnosis and the wonderful images provided by the authors.

A 52 year old man of apparently normal constitution received acupuncture and cupping treatment at an ‘illegal’ Chinese medicine clinic some 30 hours before being admitted to hospital with severe dyspnoea. He had been treated with 0.25x75mm needles to a variety of points on the dorsal and low back, some of which were clearly over the lung fields. It is not clear how deep the needles were inserted, but 30mm needles are long enough to reach the lung in some of the points used, so there is no question that the lungs were within easy reach of 75mm needles.

…there is no question that the lungs were within easy reach of 75mm needles.

It was not clear that he had acupuncture, so the early suspicion was of airway blockage. The patient collapsed 30 minutes after admission and cardiopulmonary resuscitation was attempted for an hour, although tension pneumothorax was clearly not suspected.

The body was frozen after death and then thawed before being subject to postmortem computed tomography (PMCT), some 207 hours after death. The CT images demonstrate dramatic collapse and compression of both lungs as well as severe compression in the upper mediastinum. The trachea appears to be only mildly deviated because of bilateral tension, so this important sign in unilateral tension pneumothorax would not have been apparent on resuscitation.

Jian 2018 Fig 1.png — PMCT findings in (A) the lung window, (B) the mediastinal window. Both lungs were collapsed and the density of both lungs was significantly elevated. Mediastinal compression and compression of heart and major vessels were also detected.

Jian 2018 Fig 2.png — Screen images of 3D reconstructions of lungs. Views in the coronal (A), axial (B) and sagittal (C) planes showed the collapsed lungs (purple) and gas in the pleural space (blue). 3D reconstructions (D) showed the collapsed lungs (red) and gas in pleural space (translucent).

Full body PMCT was a new concept to me, and in this case it was highly instructive. It lead the forensic examiners to perform a pneumothorax test – making a small opening into each side of the chest underwater to look for formation of bubbles. I spent a whole summer in the pathology department in Leeds, and assisted at many post mortems, but I had not seen nor heard of this test before, so clearly it is not routinely performed.

Jian 2018 Fig 4 — Results of bilateral pneumothorax test.

This is a very well described and wonderfully illustrated forensic case report, but most importantly it is a reminder to all of us who needle over the thorax to be vigilant in our techniques. The BMAS has published guidelines on safe needling over the thorax.

References

Jian J, Shao Y, Wan L, et al. Autopsy diagnosis of acupuncture-induced bilateral tension pneumothorax using whole-body postmortem computed tomography: A case report. Medicine (Baltimore) 2018;97:e13059. doi:10.1097/MD.0000000000013059
Watanabe M, Unuma K, Fujii Y, et al. An autopsy case of vagus nerve stimulation following acupuncture. Leg Med (Tokyo) 2015;17:120–2. doi:10.1016/j.legalmed.2014.11.001
Chang S-A, Kim Y-J, Sohn D-W, et al. Aortoduodenal fistula complicated by acupuncture. Int J Cardiol 2005;104:241–2. doi:10.1016/j.ijcard.2004.12.035

Declaration of interests MC

The one-needle wonder

A clinical vignette by Jens Foell (JF), edited by Mike Cummings (MC)

: Jens Foell

Bian Que is a prominent figure in the history of medicine. Allegedly he possessed x ray eyes and amazing healing properties. Legend says that he could cure people with one needle (eg getting an unconscious person back into action by needling Baihui – GV20). Performing the one-needle-wonder is every acupuncturist’s dream.

On an ordinary evening in a minor injury unit in rural North Wales I came close to living this dream. A ‘doctor advice’ callback appeared on the screen: a paramedic visited a 76 year old woman who had called emergency services because she experienced acute intense left sided shoulder/arm pain. Nothing had helped. She could not drive a car, because she could not move the steering wheel. The ambulance crew had checked her vital signs. They were all in normal range. They performed an ECG, which did not show any signs of cardiac disease. They did not know what to do next, because the shoulder was just as painful as before despite the regular pain medication she had taken plus the intravenous paracetamol she has been given. They were stuck, and so was the patient. The patient had COPD, high blood pressure, hypothyroidism and carpal tunnel syndrome as long-term conditions. I recommended that she should be seen face to face in the unit.

When she arrived with her daughter she was clearly not well. The daughter was doing the talking for her. The patient was holding her breath and grimaced in pain. She described the pain as dull and throbbing and unbearable. I re-examined chest and neck; the cervical foraminal closure maneuver did not reproduce her pain, she could move her shoulder blade and I could passively move her arm in all directions. In the next step I carefully palpated her shoulder muscles. The muscles of the posterior armpit were quite tender to touch and finally I found a taut band with an active trigger point in what must have been the teres major muscle. Pressing on the painful spot reproduced the patient’s pain and palpating across the fibres of the muscle with a pincer grip elicited a twitch response.

Is unscheduled care the right place to perform acupuncture? Is dry needling or injection of trigger points with local anaesthetic standard practice in out of hours care? Certainly not. But what would be the alternative? The alternative would consist of escalating the drug regime in a frail elderly person with COPD by introducing stronger opioids or gabapentinoids or giving more nonsteroidal drugs with the added risk of injuries to kidney and stomach.

I explained the working diagnosis and the possible management options to the patient. She insisted that none of her medication had worked so far and going on like this is not an option. So I decided to offer acupuncture/dry needling. I used my purple middle-of-the-road standard needle, kept my controlling pincer grip on site and moved the needle around in the muscle bulk I held between my fingers. After removing the needle I asked the patient to relax her armpit muscles. I moved her arm around in several directions and gently stretched the muscle, followed by asking her again to relax the arm.

With an expression of astonishment she said she could move her arm again and that the pain has diminished substantially. She said it is still there, but bearable. I arranged with her that she should obtain a chest x ray film to make sure this was not the secondary feature of a potential primary malignancy (years of smoking!) and that I would contact her later to see how she was getting on after this non-pharmacological intervention for severe acute pain.

A week later I phoned the contact number to evaluate the intervention. It turned out the contact number belonged to the paramedic. The paramedic said that he had seen her in the village and that “acupuncture worked very well”. Eventually I obtained her home number and phoned her personally. She told me that indeed the intense shoulder pain had gone, that the chest x ray film was unremarkable and that she was getting physiotherapy for her carpal tunnel syndrome.

In retrospect I would not claim that this one-needle-intervention could be classified as a ‘wonder’ cure, but it certainly saved her from escalating the drug ladder or a hospital referral.

Generalising from this case there are several points to consider: acute myofascial pain can frequently be encountered in urgent-care-settings, but dry needling/acupuncture is not routinely part of the therapeutic culture in these settings. There is in my view an unmet need. Rather than in chronic pain settings skillful treatment of myofascial trigger points, identified by reproducing the patient’s pain pattern, can make a meaningful and immediate difference and keep the drug burden at bay.

Declaration of interests JF

Declaration of interests MC

Needle Migration in the neck

Comments by Michael Meinen (MM) and Mike Cummings (MC)

This blog was first published on 24th August 2018 on https://blogs.bmj.com/aim/

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.

JNRP-9-434-g001 — 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 perforations of anatomical structures are well documented as complications of acupuncture.[2] Indeed there are several cases of penetration of the brainstem with acupuncture needles.[3–7] This presentation highlights a few safety issues, and suggests an approach to dealing with such incidents in future..

The location of the needle suggests insertion in the midline at GV16 (Fengfu), which the patient must have performed by touch alone, at a slight upward angle. When patients are taught self-acupuncture, the danger of deep insertion should be discussed in detail, and perhaps self-needling without the ability to see what is being done should be discouraged in potentially dangerous areas such as this. At this point it is salient to remind readers of the BMAS needling policy in the neck.

Above C2 – angle the needle tip towards the palpable occipital bone.
Perpendicular insertion should be avoided.

Below C2 – angle the needle tip towards the cervical articular pillar
(the pars interarticularis and facet joints usually between C3 and C5).

On presentation, the needle (0.25x30mm) was 8mm below the surface of the skin, embedded in the muscles of the neck. The patient had been unsuccessful in his attempt to retrieve the needle. Ultrasound scanning failed to show the needle, and an initial surgical attempt to remove the needle in the emergency department was unsuccessful. The authors felt that manipulations by the patient and doctors had contributed to the needle migration. This suggests that, should a needle break and disappear into the patient’s soft tissue, that neither patient or practitioner should attempt to remove it, but that the patient should be referred, or self-refer, immediately to an emergency department. Again, this needs to be discussed when instructing a patient in self-acupuncture.

It seems that this location is particularly vulnerable to needle migration because of the thickness of muscle and the lack of resistance to needle progression when the tip reaches the spinal canal or brainstem. It seems sensible for the patient to relax the postural muscles of the neck by lying down with the head supported without any pressure on the needle site, while specialist investigation with x ray films and CT is awaited.

References

El-Wahsh S, Efendy J, Sheridan M. Migration of Self-Introduced Acupuncture Needle into the Brainstem. J Neurosci Rural Pract 2018;9:434–6. doi:10.4103/jnrp.jnrp_480_17
White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33. doi:10.1136/aim.22.3.122
Anderson DW, Datta M. The self-pith. AJNR Am J Neuroradiol 2007;28:714–5.
Choo DC, Yue G. Acute intracranial hemorrhage caused by acupuncture. Headache 2000;40:397–8.
Zhu Y, Xue Z, Xie D, et al. Medulla oblongata hemorrhage after acupuncture: A case report and review of literature. Interdiscip Neurosurg 2018;11:1–3. doi:10.1016/j.inat.2017.09.013
He W, Zhao X, Li Y, et al. Adverse events following acupuncture: a systematic review of the Chinese literature for the years 1956-2010. J Altern Complement Med 2012;18:892–901. doi:10.1089/acm.2011.0825
Miyamoto S, Ide T, Takemura N. Risks and causes of cervical cord and medulla oblongata injuries due to acupuncture. World Neurosurg 2010;73:735–41.pm:20934166

Declaration of interests MM

Declaration of interests MC

Aromatase inhibitors, joint pain and acupuncture

This blog was first published on 2nd August 2018 on https://blogs.bmj.com/aim/

Effect of Acupuncture on Joint Pain Related to Aromatase Inhibitors Among Women With Early-Stage Breast Cancer – Hershman et al JAMA 2018

woman

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.

elbow pain knee pain

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 weeks. The authors chose a clinically meaningful difference on this scale to be 2 points based on the analysis of 11 point Numerical Rating Scales (NRS) performed by Farrar et al.[2]

Farrar-Fig-2-1024x673

But is it a 2-point change from baseline that is clinically relevant, or a 2-point difference between groups. Well the individual patient only knows the change from their own baseline, and the proportion of that change attributed to natural history or expectation in the group mean differences of a trial is irrelevant to the individual.

In the analysis by Farrar et al,[2] the change of 2 points considered to be clinically relevant was measured from baseline. In the present study by Hershman et al,[1] at the primary end point (6 weeks) the mean BPI-WP score in the acupuncture group had dropped 2.05 from baseline, and the percentage of patients with a drop of 2 points or more was 58%. This seems to be clinically relevant to me, but the conclusion reads:

“…the observed improvement was of uncertain clinical importance.”

At all time points the difference between acupuncture and sham control was statistically significant, but the difference did not reach 2 points, and this probably explains their conclusion. At first I assumed it was the JAMA editors that insisted on this conclusion, having seen this done before in a high profile general medical journal.[3] But having checked the protocol of Hershman et al,[1] I see that the authors have made the error of taking Farrar et al’s 2-points’ difference from baseline as a between group difference instead:

Reduction in worst joint pain at 6 weeks between the true acupuncture compared to sham acupuncture and waitlist control groups: A difference of two points in the modified Brief Pain Inventory worst pain score (item #2) has been identified as a clinically meaningful difference.

[From 10.1 of the protocol in supplement 1 of Hershman et al][1]

So I think this must be an error on the part of the authors rather than the insistence of the JAMA editors, but I expect it made it easier to publish the paper in this particular journal, based on its history of accepting negative acupuncture papers.

Whether this particular paper is considered positive or not, the data from it will inform future reviews, and currently these appear to be positive.[4,5]

Before I sign off on this blog, I should comment on the sham control group. It was a superficial penetrating off-point sham, and it did not seem to perform better than waiting list at 6 weeks, with the difference between acupuncture and sham at 0.92 and the difference between acupuncture and waiting list at 0.96. The effect of sham seemed to grow though, since at the 24-week point the difference between acupuncture and sham was only 0.59, and the difference between acupuncture and waiting list was 1.23.

Another pattern to note is that the difference between acupuncture and sham appeared smallest and not statistically significant for the outcome of pain interference, which is probably the closest of the outcomes used to health-related quality of life (HRQoL). Readers of this blog will be familiar with the finding from previous ‘big data’,[6] and my blog on the same.

References

Hershman DL, Unger JM, Greenlee H, et al. Effect of Acupuncture vs Sham Acupuncture or Waitlist Control on Joint Pain Related to Aromatase Inhibitors Among Women With Early-Stage Breast Cancer: A Randomized Clinical Trial. JAMA 2018;320:167–76. doi:10.1001/jama.2018.8907
Farrar JT, Young JP, LaMoreaux L, et al. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149–58. doi:10.1016/S0304-3959(01)00349-9
Brinkhaus B, Ortiz M, Witt CM, et al. Acupuncture in Patients With Seasonal Allergic Rhinitis. Ann Intern Med 2013;158:225. doi:10.7326/0003-4819-158-4-201302190-00002
Chen L, Lin C-C, Huang T-W, et al. Effect of acupuncture on aromatase inhibitor-induced arthralgia in patients with breast cancer: A meta-analysis of randomized controlled trials. Breast 2017;33:132–8. doi:10.1016/j.breast.2017.03.015
Halsey EJ, Xing M, Stockley RC. Acupuncture for joint symptoms related to aromatase inhibitor therapy in postmenopausal women with early-stage breast cancer: a narrative review. Acupunct Med 2015;33:188–95. doi:10.1136/acupmed-2014-010735
Saramago P, Woods B, Weatherly H, et al. Methods for network meta-analysis of continuous outcomes using individual patient data: a case study in acupuncture for chronic pain. BMC Med Res Methodol 2016;16:131. doi:10.1186/s12874-016-0224-1

Declaration of interests MC

Acupuncture and IVF

– no clear effect on live birth rate

This blog was first published on 18th June 2018 on https://blogs.bmj.com/aim/

ivf-e830b00b29_180

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 35.4% with sham versus 29.2% with real), significantly favouring sham in all outcomes.[3] Following directly on from this the team decided, logically but rather surprisingly, to test sham versus sham: a single session of sham acupuncture after ET with sham before and after ET, as in the original protocol. This trial was presented in a meeting at The Hague in 2011, where it won a research prize (I was part of the awarding committee), and I remember discussing the topic with the first author of the paper – Emily So. There was no significant difference in pregnancy outcomes, but the two-session protocol conferred a significant benefit in terms of anxiolysis (details from the abstract submitted to the meeting, 2011).

So where am I going with this? Well it seems likely that acupuncture or sham acupuncture confer a context-related benefit in terms of supportive care mediating anxiolysis. But beyond this, it seems possible that real acupuncture has some potential disadvantages when performed around embryo transfer. In brief, strong somatic stimulation in the segments related to the uterus, or indeed outside those segments, may influence contractile behaviour of the uterus. This is mostly harmless of course, but increasing contractions after ET in an otherwise quiescent uterus may expel the embryo. Equally, contractions initiated by the instrumentation during ET may be suppressed by acupuncture, which might prevent expulsion of the embryo. It was on the latter basis that Paulus first used the technique around ET (personal communication, Irina Szmelskyj).[4] A panel of experts presenting at the BMAS Spring meeting in Newcastle (2015) concluded that acupuncture should be avoided around ET and implantation unless the woman had symptoms that might be ameliorated with acupuncture – abdominal cramps for example.

…it seems possible that real acupuncture has some potential disadvantages when performed around embryo transfer.

The paper that stimulated this blog was published in JAMA in May 2018.[5] I heard the results presented in a meeting in Berlin a year before, and discussed them with the lead author Caroline Smith. Essentially it is the largest sham controlled trial of acupuncture within IVF to date (n=824), and it failed to demonstrate any benefit of acupuncture over sham. The live birth rate was 18.3% in the acupuncture group versus 17.8% in the sham group. The clinical pregnancy rate was marginally higher in the acupuncture group at 25.7% versus 21.7%, but this was negatively offset by an increased rate of pregnancy loss.

Given what I said above about Emily So’s research, the results are not particularly surprising. The rates of live birth appear much lower, but that is likely related to the fact that nearly half of the women in Caroline Smith’s study had already failed 2 or more cycles of IVF, whereas the majority in Emily So’s research were on their first cycle.

I was particularly interested to see in the supplementary data of Caroline Smith’s huge multicentre trial that in two of the 15 sites there was a significant benefit of sham over real acupuncture, and at no site was there a significant benefit for real over sham. Data was pooled from 4 sites, leaving 12 comparisons in the forest plot (see figure below). Using 95% confidence intervals we would only expect a type I statistical error (a significant difference in the sample data when there is no real difference between the populations sampled) to occur 5% of the time ie 1:20. So 2 occurrences in 12 comparisons does not seem likely by chance alone. This adds some weight to my comments above regarding potential risks associated with the somatovisceral reflex effects of real acupuncture.

Smith-et-al-JAMA-2018-eFigure-2-1002x1024

Does acupuncture have a role in fertility or not? The majority of the clinical trial data comes from within IVF cycles, and more specifically either side of ET. I have always thought this was a long shot from a physiological point of view, since acupuncture generally requires a course of regular treatments to mediate measurable effects in clinically relevant outcomes. So I am pleased that this trial will probably place the last nail in the coffin for this very limited technique. But is there any role for acupuncture in fertility? Well we have also seen a very large negative trial from China on segmental electroacupuncture (EA) versus clomiphene for ovulation induction in PCOS: the subject of a previous blog. I still hold out some hope that we will find a useful place for the technique since Elisabet Stener-Victorin first opened the whole chapter in 1996 with her trial on the influence of segmental EA on uterine artery impedance.[6]

In terms of acupuncture research and practice I think the focus should be outside IVF.

Either for couples with unexplained infertility and no male factor (unless treatment is aimed at the man of course – that’s another topic entirely), or in the weeks and months prior to an IVF cycle. This phase, theoretically at least, has always held the greatest promise, but because of the trial by Paulus in 2002,[4] the research, in my opinion, went on a very loud and frantic wild goose chase.

Postscript

After posting this blog I decided to email the team to ask about the live birth rate in the third of Emily So’s studies – the one comparing sham with sham. I emailed the senior author Ernest Hung Yu Ng, and to my surprise he answered with a further abstract describing more unpublished research from his team. They had gone on to test sham acupuncture either side of ET in an open pragmatic trial against no additional acupuncture in 800 women undergoing IVF! Live birth rate was not included in the abstract, but the on-going pregnancy rate was 32.3% in the sham acupuncture group and 33.3% in the no acupuncture group.

This is very useful addition data that clearly now points to the fact that sham acupuncture around ET is not beneficial, and therefore implies that real acupuncture may sometimes confer risks when applied at ET. This does not apply to acupuncture performed at other times, and further encourages me to promote the testing of acupuncture performed in the lead up to IVF rather than during the process.

References

Carr D. Somatosensory stimulation and assisted reproduction. Acupunct Med 2015;33:2–6. doi:10.1136/acupmed-2014-010739
So EWS, Ng EHY, Wong YY, et al. A randomized double blind comparison of real and placebo acupuncture in IVF treatment. Hum Reprod 2009;24:341–8. doi:10.1093/humrep/den380
So EWS, Ng EHY, Wong YY, et al. Acupuncture for frozen-thawed embryo transfer cycles: a double-blind randomized controlled trial. Reprod Biomed Online 2010;20:814–21. doi:10.1016/j.rbmo.2010.02.024
Paulus WE, Zhang M, Strehler E, et al. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril 2002;77:721–4.
Smith CA, de Lacey S, Chapman M, et al. Effect of Acupuncture vs Sham Acupuncture on Live Births Among Women Undergoing In Vitro Fertilization: A Randomized Clinical Trial. JAMA 2018;319:1990–8. doi:10.1001/jama.2018.5336
Stener-Victorin E, Waldenström U, Andersson SA, et al. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Hum Reprod 1996;11:1314–7.

Declaration of interests MC