Stimulated by Kim et al,[1] and Lu et al.[2]
No sooner than I have blogged about acupotomy for the first time (last week), than another novel related technique is reported. The first paper I am highlighting is a case report of the use of round acupuncture in carpal tunnel syndrome (CTS). The second paper is another trial of acupuncture in CIPN (chemotherapy–induced peripheral neuropathy). There is a link between the two I will relate concerning a case I have seen in clinic.
Round acupuncture
Round acupuncture utilises a needle that has similar dimensions to the acupotomy needle I described in the last blog. The difference is that the end is smooth and round, unlike the chisel shape of the acupotomy needle. In this case report, the needle dimensions were 0.80x80mm, so that is the same gauge as a green hypodermic needle.
The patient had surgical release for bilateral CTS 9 years prior. Symptoms recurred after excessive use of her right wrist, and these did not respond to steroid injection or two sessions of acupotomy. The subsequent use of ‘round acupuncture’ was successful.
The point of insertion of the needle was 5mm ‘outside’ of PC7. From the look of Figure 2 in the paper they mean the ulnar side of palmaris longus tendon. This is the usual site used for steroid injections to avoid direct needling of the median nerve and is also a site I used to treat my patient with EA (electroacupuncture).
An acupotomy needle was used to pierce the skin without anaesthetic, then the round needle was inserted in and out at different angles with the intention of loosening up the tissues beneath the transverse carpal ligament (TCL). The needle was inserted as far as the distal fibres of the TCL, at both its ulnar attachments to the hamate and pisiform and its radial attachments to the trapezium and scaphoid.
Kaplan’s cardinal line
The authors included Kaplan’s cardinal line (KCL) in their Figure 2. A line that is used as a landmark by roughly 50% of US hand surgeons surveyed in 2006.[3] That’s something else I have learnt as a result of reading this paper.
So, how does this link to a paper on CIPN?
Well my patient presented with severe burning pain in both hands that extended 5cm or more proximal to the wrist and came on some months following chemotherapy for breast cancer. It was thought to be CIPN, but curiously the feet were not affected. I did not even consider CTS until the nerve conduction studies showed severe compression and strongly recommended surgery. By that time, and to my surprise, her symptoms had almost completely subsided with weekly EA treatment. As she had had axillary node surgery on one side, and this was the least badly affected side, I performed EA across a pair of points PC6 and a point on the ulnar aspect of the palmaris longus tendon at the level of PC7 (exactly the same site as used for the round acupuncture). I also used pairs of needles at my favourite sites bilaterally: ST36–Zongping.
CTS has been mentioned here before (Rewiring the brain with acupuncture), and perhaps I would have seen the same effect from my distant EA, without any need for the fiddly local needling?
So, let’s move on to the paper from the Dana-Faber Cancer Centre. I read up about this centre about a year ago just before I introduced the first author (Weidong Lu) at the 21st ARRC Symposium. If you interested, the presentation can be viewed here, along with my painfully long introduction. I particularly recommend listening to the section from 19:15 to 20:00, when Weidong tells the audience that if they want to perform ‘Oncology Acupuncture’ (ie treat patients who are under the care of an oncologist), they need to learn the language of oncology… the language of Chinese medicine is not enough. My colleague Jacky Filshie would be very pleased to have heard that! She invented the use of acupuncture in palliative care decades before the term oncology acupuncture was coined.[4] They are not entirely the same, but the overlap is large.
This is a small study (n=40), but they use one of my favourite designs for acupuncture studies. It is like the ARC trials from the Modellvorhaben.[5] One group gets treated while the other group waits for their treatment, and the primary comparison is just before the second group get their delayed treatment. In this case the patients got 18 sessions of acupuncture over 8 weeks and the main outcome was at 8 weeks. The second group had no acupuncture over those 8 weeks but then received 9 sessions of acupuncture over the following 8 weeks.
The treatment involved EA to a pair of points in both arms and legs, as well as manual acupuncture at other points. It looks as though about 27 points were used in each treatment, but 10 of those were in the tips of all the toes.
The disparity in the number of sessions is intriguing, and I guess that this might have been an attempt to assess dose. The most interesting graph to look at is Figure 3.
This was a pilot study, and they gathered a lot of outcomes data. I expect we will see a much larger study underway in the near future, if it hasn’t already begun!
References
1 Kim J-R, Lee YK, Lee H-J, et al. Round Acupuncture for the Treatment of Recurrent Carpal Tunnel Syndrome. J Pharmacopuncture 2020;23:37–41. doi:10.3831/KPI.2020.23.006
2 Lu W, Giobbie-Hurder A, Freedman RA, et al. Acupuncture for Chemotherapy-Induced Peripheral Neuropathy in Breast Cancer Survivors: A Randomized Controlled Pilot Trial. Oncologist 2020;25:310–8. doi:10.1634/theoncologist.2019-0489
3 Vella JC, Hartigan BJ, Stern PJ. Kaplan’s Cardinal Line. J Hand Surg Am 2006;31:912–8. doi:10.1016/j.jhsa.2006.03.009
4 Filshie J, Penn K, Ashley S, et al. Acupuncture for the relief of cancer-related breathlessness. Palliat Med 1996;10:145–50. doi:10.1177/026921639601000209
5 Cummings M. Modellvorhaben Akupunktur–a summary of the ART, ARC and GERAC trials. Acupunct Med 2009;27:26–30. doi:10.1136/aim.2008.000281
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