Stimulated by Abanes et al 2019.[1]
This is a small feasibility study that came out last month. I saw it on my PubMed searches but could not access full text. It was a single arm (n=16) study, so I felt I was not missing too much by not seeing the full paper. Then last weekend in on the BMAS Foundation Course in Dublin I ran into the lovely Commander Jane Abanes from the US Navy. She kindly sent me the full text, and we had some time for discussion of the broader subject of acupuncture use in the US military. This was of great interest to me as it was only a chance experience in the British military that led me to become interested in the field of acupuncture in the first place.
I had great fun retelling of my experiences with another US Navy nurse who was stationed with me some 20 plus years ago at RAF St Mawgan. I remember presenting her with homemade medals on a regular basis when she offered us assistance. There was a small amount of very efficient work performed, and a lot of laughter to be heard, when the senior medical staff got together for diplomatic liaisons – they had built a big medical facility across the road from us and did not seem to have many patients!
Perceived Stress Score
PSS-14
Cohen et al 1983 [2]
Anyway, enough reminiscing and laughter, we are here to talk about perceived stress. Commander Jane (as I called her on the FC) recruited a group of stressed airmen from a very large airbase in Arizona. She measured their level of ‘stress’ with the PSS-14. This is the 14 item Perceived Stress Score.[2] They had to score 16 or more on the scale, which runs from 0 to a maximum of 56. I just tried it and scored 5, although I have had a very unusual few weeks of late and probably would otherwise have scored between 0 and 3. The range of scores at baseline in this cohort of service men and women was 16 to 32 with a median of 20.5. Commader Jane’s simple and moderately gentle acupuncture protocol called SSA (standardized stress acupuncture) was performed weekly for 4 weeks. It involved a standard set of points and needling procedures – GV20, Yintang, LI4 bilateral and LR3 bilateral. Fine Seirin needles were used (0.20x30mm for points in the head and 0.20x40mm for LI4 and LR3), and the limb points were manipulated to produce typical needling sensation from deep tissue (de qi).
Standardized Stress Acupuncture (SSA)
GV20, Yintang, LI4, LR3
Abanes et al 2019 [1]
There was a drop in PSS of 6.5 points after the treatment course, as well as significant improvements in 3 of the 8 subscales of the SF36 (energy/fatigue, social functioning, emotional wellbeing). The improvement in PSS was statistically significant for the group and reached a clinically relevant change in 63% (10/16).
There is no discussion of adverse events in the paper, so I image there were none (I will ask the Commander). If this is the case, then we need not be so worried about insisting that future trials use a sham control, and go for pragmatic comparisons. Indeed, I think it highly unlikely that this protocol would manage to demonstrate an effect over sham, because it is rather gentle, and I would expect a typical sham to be quite effective in this situation. If we were wanting to measure a physiological difference over sham, I would definitely plump for my favourite protocol aimed at maximising general effects – electroacupuncture (EA) to tibialis anterior (ST36–Zongping 2/15Hz 3-6mA).
Talking of my favourite protocols, I have just seen another paper out today from the US.[3] It is quite a nice review article about acupuncture for pain, with a figure illustrating EA for knee osteoarthritis. The protocol appears to be identical to that used in the group clinics at RLHIM since 2005,[4,5] with the exception of the points over the anterior joint line (Xiyan), which we do not recommend. I am pleased to see EA applied to muscle being promoted, but I must point out that no RCT has ever actually used this protocol. Vas and Mavrommatis got closest,[6,7] but they both used NSAIDs as a co-intervention. Berman did the opposite,[8] only applying EA to Xiyan, something I have never understood, and unfortunately holding down the combined data point for EA in meta-analysis ever since due to the relative size of the trial. Whenever I think about it my PSS goes up just a bit!
References
1 Abanes J, Hiers C, Rhoten B, et al. Feasibility and Acceptability of a Brief Acupuncture Intervention for Service Members with Perceived Stress. Mil Med 2019;00:7–10. doi:10.1093/milmed/usz132
2 Cohen S, Kamarck T, Mermelstein R. A Global Measure of Perceived Stress. J Health Soc Behav 1983;24:385. doi:10.2307/2136404
3 Kelly RB, Willis J. Acupuncture for Pain. Am Fam Physician 2019;100:89–96.
4 Berkovitz S, Cummings M, Perrin C, et al. High volume acupuncture clinic (HVAC) for chronic knee pain–audit of a possible model for delivery of acupuncture in the National Health Service. Acupunct Med 2008;26:46–50.
5 Cummings M. The development of group acupuncture for chronic knee pain was all about providing frequent electroacupuncture. Acupunct Med 2012;30:363–4. doi:10.1136/acupmed-2012-010260
6 Vas J, Mendez C, Perea-Milla E, et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ 2004;329:1216.
7 Mavrommatis CI, Argyra E, Vadalouka A, et al. Acupuncture as an adjunctive therapy to pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: a 3-armed, randomized, placebo-controlled trial. Pain 2012;153:1720–6. doi:10.1016/j.pain.2012.05.005
8 Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med 2004;141:901–10.
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