CIPN 2020 plus FFP & FWB

Stimulated by Bao et al 2020,[1] and a few others.

Image from the pre-digital era.
This is yours truly after a dip in the Gulf of Mexico, somewhere close to Fort Walton Beach (FWB) in January 1990. I imagine my peripheries were a bit tingly for a few minutes. Thus with one old image I am linking the two different items in this blog. For those of you (ie most reading this) who did not know me age 27, yes, I did have hair on my head once, but it didn’t last much longer after this photo was taken… 😦

This is the first three armed RCT of acupuncture on chemotherapy-induced peripheral neuropathy (CIPN), and the first to use sham acupuncture as well as a usual care control. The lead author is an oncologist, integrative medicine physician and medical acupuncturist from The Memorial Sloan Kettering Cancer Center (MSKCC) in New York. You can see Dr Ting Bao in a short video here describing the integrative medicine service at MSKCC.

CIPN – chemotherapy-induced peripheral neuropathy

It is a relatively small trial (n=75) and is described as a pilot study. Ten sessions of acupuncture were performed over 8 weeks, with 2 sessions per week for the first 2 weeks. Eight bilateral limb points were used (LI4, PC6, SI3, LR3, GB42, ST40, Bafeng 2, Bafeng 3) with 2 pairs being stimulated with low frequency electroacupuncture (EA) – a pair in each foot (LR3–GB42). The ear points Shenmen, Point Zero and a third point with low electrical resistance were also needled bilaterally with 0.16x15mm needles. The needles used for the body points were 0.25mm diameter and 30 or 40mm in length.

The sham technique involved using an empty guide tube to tap on the skin just away from 4 bilateral acupuncture points (LI4, LI11, TE5, ST40), and then a needle was applied to the skin surface with adhesive tape. The patients’ eyes were covered with pads in both groups during the treatment. From a physiological perspective, I am quite happy with this method, and it does not have the problem of potentially diminishing the effect in the real acupuncture group when real needles have to be placed through sham devices (see the blog: Trust Me, I’m an acupuncture expert… and Do sham acupuncture devices impede real acupuncture?).

The third arm was a usual care group.

The population recruited had received chemotherapy for solid tumours at least 3 months prior to enrolment and were suffering from moderate to severe CIPN. They were stratified according to the most bothersome CIPN symptom (tingling vs numbness vs pain) and severity (moderate 4–6 vs severe 7–10 on NRS – numerical rating scale 0–10).

At 8 weeks the acupuncture group had a significantly greater reduction in symptom scores than the usual care group, and the effect was maintained at 12 weeks.

The difference between real and sham will be used to power a definitive RCT, since this pilot was much too small to hope to show a difference over sham.

So, it was a nice little pilot study, and I hope that the definitive RCT that leads on from this will manage to reproduce similar results and give a definitive answer to the efficacy question for the first time.

What a the FFP in the blog title? No, it is not about fresh frozen plasma, but fighting family physicians!

FFP – fighting family physicians

As I was looking through the recent publications on PubMed, I saw that there were papers with acupuncture in the title in both the American Family Physician and the Canadian Family Physician journals. I thought I would have a look and see what the fuss was about.

The authors in Can Fam Physician were from Eglin Air Force Base in Florida, the location of my father’s last posting as a Ministry of Defence scientist on liaison to the US Air Force. I remember visiting my parents in Fort Walton Beach (FWB) early in January 1990. The white sand beaches stretched for miles and were empty, so I decided to take a dip.

The paper from the military family doctors at Eglin was a short piece outlining an evidence-based answer to the question: Is acupuncture effective in improving pain relief for low back pain? Their evidence-based answer was: Acupuncture is an effective treatment for relief from low back pain…[2]

So, it was quite a contrast to see the correspondence in Am Fam Physician within the same few days.

Evidence Lacking That Acupuncture Is More Effective Than Placebo

Harriet A Hall MD [3]

Acupuncture Not Supported By Strong Scientific Evidence

Joel R Kann MD [4]

These letters were in response to a paper and accompanying editorial published in Am Fam Physician in July 2019.[5,6] These are well balanced and articulated articles, and certainly not over-enthusiastic about the merits of acupuncture.

The letters in response cite the usual data-light papers and a well-recognised mantra of the sceptic brigade that acupuncture is …no more than a theatrical placebo.

…acupuncture is now becoming part of mainstream family medicine in the US and the sceptics are becoming the alternative minority

My impression is that acupuncture is now becoming part of mainstream family medicine in the US and the sceptics are becoming the alternative minority. Now we just need to catch up in the UK.

Talking of catching things…

Talking of catching things, all our in-person events are, of course, now on hold for a few months. We are rescheduling many, but I am planning to convert some to online events, rather like the Blog webinar for BMAS members. We will be sending out updates regularly, so look out for details in The Sharp End and some rather innovative solutions during this period of in-person social distancing.

Be safe…

References

1         Bao T, Patil S, Chen C, et al. Effect of Acupuncture vs Sham Procedure on Chemotherapy-Induced Peripheral Neuropathy Symptoms: A Randomized Clinical Trial. JAMA Netw open 2020;3:e200681. doi:10.1001/jamanetworkopen.2020.0681

2         Fuentes RC, Organ B, Creech J, et al. Acupuncture for low back pain. Can Fam Physician | Le Médecin Fam Can 2020;66:186–7.

3         Hall HA. Evidence Lacking That Acupuncture Is More Effective Than Placebo. Am Fam Physician 2020;101:325–6.

4         Kann JR. Acupuncture Not Supported By Strong Scientific Evidence. Am Fam Physician 2020;101:326–8.

5         Kelly RB, Willis J. Acupuncture for Pain. Am Fam Physician 2019;100:89–96.

6         Ledford CJW, Crawford PF. Integrating Medical Acupuncture into Family Medicine Practice. Am Fam Physician 2019;100:76–8.


Declaration of interests MC