20000 needles…

Inspired by Ronel et al Mil Med 2018.[1]

My first blog of 2019 and I have been struggling to find inspiration. That is what comes from setting yourself an arbitrary target rather than just waiting for something divine. The former is driven by the modern requirements of a social media presence, and the latter is my preferred option.

I considered acupuncture, anxiety and IVF,[2] as it came from the biggest ever study in the area – not the main slice of course. The main slice, published in JAMA,[3] was reviewed here previously as Acupuncture and IVF. The results were underwhelming, as might be expected from any sham-controlled trial of acupuncture. There are numerous p values in the paper, and only very few reach significance. It is not clear whether or not there was any correction for this multiple testing, although the authors did intend to investigate anxiety and quality of life outcomes at the protocol stage of the original study. Real penetrating acupuncture may have had a marginal benefit over Streitberger (non-penetrating) needle sham in terms of anxiety directly after treatment, but since the main results of the intervention showed no effect on live birth rate, we are unlikely to recommend doing it. In addition, as mentioned in the previous blog, there is a suggestion of harm from potential expulsion of the embryo, which rather invalidates any reduction in anxiety.

I also toyed with caffeine and acupuncture analgesia (AA).[4] This was a paper sliced from a primary study on brain imaging,[5] which itself was quite interesting. But it was rather small (n=27), and observing outcomes in healthy subjects with no pain, so its negative finding (of no correlation between caffeine intake and AA) cannot be promoted with any degree of certainty. The original study, published earlier in 2018 was more interesting, and showed that video-guided acupuncture imagery treatment (imagining you are having real acupuncture whilst watching a video of when you had it previously) was just as good as real acupuncture in raising pain thresholds and both were superior to their respective shams. There were some differences in brain imaging, but these are notoriously difficult to interpret with confidence.

So to 20000 needles… this is a play on the title of the novel by Jules Verne – Twenty Thousand Leagues Under The Sea, first published in 1870. It is a simple case report of the utility of trigger point needling in acute back pain, that just happened to be performed within the environment of a deployed military submarine.[1] The authors do not specify the depth of the craft at the time of treatment, but we can allow that being omitted for ‘operational reasons’ 😉

Photograph of Jules Verne by Félix Nadar

The case was published online earlier in 2018 but came to my attention again when letters of correspondence on the case were published online in December.[6,7] The journal is not open access, but I recognised the name of the last author, and so sent him an email. I first met him at a BMAS meeting in London in the 1990’s, and then again on one of Bob Gerwin’s workshops some 20 years later. He obliged willingly…

I was interested because the title of the letter on PubMed gave me the whiff of a sceptic, but I did not recognise the name of any of the authors. Basically the letter bleated that:

…the hypothesis of “myofascial pain arising from trigger points” has been comprehensively refuted


…we were also surprised to learn that primary care physicians in the military are using dry needling, itself a highly controversial practice.

The letter went on to assert that the patient probably recovered spontaneously rather than as a result of the needling, and finished with a nice quote from the original Jules Verne novel:

From a caprice of nature, not from the ignorance of man. Not a mistake has been made in the working. But we cannot prevent equilibrium from producing its effects. We may brave human laws, but we cannot resist natural ones.

Jules Verne

An interesting choice that leaves the reader searching for the relevance, beyond the convenience of the phrase ‘a caprice of nature’. Of course a case report cannot prove a causal association between the needling and the recovery, hence it could well be a caprice of nature.

The rather philosophical passage comes from Captain Nemo after the Nautilus had been struck and lifted by a rotating iceberg. They (icebergs) do that from time to time when their base is undermined by warmer water apparently, so the captain goes on to explain.

I imagine there might be a number of submariners with trigger points if their vessel was stuck and lifted up onto its side by the base of a rotating mountain of ice. Fortunately, in this case there was no ice involved. The letter added nothing to the literature or to the case, but the attempt at appearing clever by quoting from the novel whose title had been used in the original paper was sufficiently amusing to have me investigate the lead author, and it was not long before I found an association with one of the main detractors of the trigger point hypothesis, who loves to write letters on all manner of subjects, and his reference 8 from the Lancet seems the most appropriate here.[8] It was a very short letter.


1         Ronel D, Gabbay O, Esterson A, et al. Twenty Thousand Needles Under the Sea. Trigger Point Dry Needling Aboard an Israeli Navy Submarine: A Case Report. Mil Med 2018;183:e762–4. doi:10.1093/milmed/usy046

2         Smith CA, de Lacey S, Chapman M, et al. The effects of acupuncture on the secondary outcomes of anxiety, and quality of life for women undergoing IVF: a randomised controlled trial. Acta Obstet Gynecol Scand Published Online First: 28 December 2018. doi:10.1111/aogs.13528

3         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

4         Cao J, Tu Y, Lang C, et al. Daily Caffeine Consumption Does Not Influence Acupuncture Analgesia in Healthy Individuals: A Preliminary Study. Anesth Analg Published Online First: 24 December 2018. doi:10.1213/ANE.0000000000003989

5         Cao J, Tu Y, Orr SP, et al. Analgesic Effects Evoked by Real and Imagined Acupuncture: A Neuroimaging Study. Cereb Cortex Published Online First: 23 August 2018. doi:10.1093/cercor/bhy190

6         Weisman A, Yona T, Masharawi Y. An Act of Man or a Caprice of Nature? Mil Med Published Online First: 12 September 2018. doi:10.1093/milmed/usy236

7         Ronel D, Gabbay O, Esterson A, et al. Response to the Letter by Weisman et al on: Twenty Thousand Needles Under the Sea: Trigger Point Dry Needling Aboard an Israeli Navy Submarine. A Case Report. Mil Med Published Online First: 4 December 2018. doi:10.1093/milmed/usy238

8         Quintner J. The politics of masturbation. Lancet (London, England) 1995;345:454.

Declarations of interest MC