Hypertension 2018

The Chinese Cochrane Centre in Chengdu.

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