Atraumatic glenohumeral dislocation, IBS and other stories

Stimulated by Qin et al 2020,[1] and Pei et al 2020.[2]

Image modified from Figure 1 of Qin et al 2020.[1]

The first paper I am highlighting this week is an adverse event report attributed to acupuncture. It is quite unusual for two reasons. First, as the title states, the case presented with a shoulder dysfunction that turned out to be an atraumatic anterior dislocation. Second, following manual relocation of the humeral head, the x ray film image suggested persistent inferior subluxation, which subsequent MRI demonstrated to be associated with a collection in the subdeltoid bursa. This collection proved to be an abscess that grew methicillin sensitive Staph aureus. Further questioning of the patient revealed a formerly undeclared history of acupuncture for cervical spondylosis around one month prior to presentation.

As is usual with case reports that are written by the specialist team who deal with the adverse event, there is insufficient detail of the acupuncture to draw clear conclusions, or even clear attribution of cause. I guess it is conceivable that an acupuncture needle at LI15 could inoculate Staph aureus from the skin into the subdeltoid bursa. It is a short enough distance, being roughly 10 to 20mm in most shoulders, but Hoffman argues that the size and shape of an acupuncture needle is such that it is unlikely to inoculate sufficient numbers of bacteria (abscess derived Staph aureus) to cause infection in a healthy subject.[3]

We are told that the patient had acupuncture applied to her left shoulder for cervical spondylosis, but LI15 does not appear to be listed as a point that might be used for neck conditions.[4] LI14 is listed, but this point is too low for direct inoculation into the subdeltoid bursa. However, with such adverse event reports, we must assume the possibility of acupuncture being responsible unless we have a convincing alternative. Whilst I have presented arguments that raise questions regarding attribution, we must include this a possible adverse event for acupuncture and consider how we can reduce the risk.

And now for something completely different…

And now for something completely different – acupuncture for IBS (irritable bowel syndrome). This is a big pragmatic multi-centre clinical trial pitting 18 sessions of acupuncture over 6 weeks against guideline-based drug treatments – either an osmotic laxative or an antispasmodic depending on whether the patient was predominantly affected by constipation (IBS-C) or diarrhoea (IBS-D).[2] Over 500 patients were enrolled over a 3-year period at 7 centres in China. They were randomised 2:1 to receive either acupuncture or drug treatment.

The primary outcome was the IBS symptom severity score (IBS-SSS) at 6 weeks, but patients were also followed up at 18 weeks. The acupuncture group was better at both 6 and 18 weeks (p<0.001).

The authors performed a post-hoc calculation of responder rate (RR) based on a 50-point change in the IBS-SSS (0-500), and acupuncture was associated with a roughly 80% RR compared with roughly 50% for the drugs. They go on to argue that a previous study of acupuncture in IBS using a sham acupuncture control measured RR in the sham group at 31.2%,[5] so their 80% could not possibly be only a placebo response. The problem here is that the symptom score was different, and they used a slightly larger change to determine RR (reduction of 4 on a sum of Likert scales totalling 30). The RR in the real acupuncture group of the same trial was just 40.7%. Ten sessions of acupuncture were applied, compared with a non-point needling control, and the trial was conducted in an NHS hospital in Harrow.

In a more recent trial of acupuncture in IBS (n=97), the Streitberger needle was used as a sham, and proved to be as good as the real needling with RR of 53% real and 42% sham. In this trial 8 sessions were given over 4 weeks, and the RR was calculated on the basis of a reduction in symptom scores, but the exact method was different again.

‘other stories’

I will finish with the ‘other stories’ I refer to in the title. These are a couple of case reports submitted as letters to Acupuncture in Medicine.[6,7] Both involve the successful application of dry needling. One paper comes from Tehran and the other from Shanghai. Yes, dry needling in Shanghai!

The paper from Tehran describes the improvement in spasticity in an upper limb and associated changes in activation of motor areas on fMRI. It sounds as though the ‘dry needling’ was performed at LI4.

The paper from Shanghai concerned the successful treatment of previously intractable hiccups. This case is interesting because the symptom did not respond to either drugs or TCM acupuncture but did respond when dry needling was used. In this case the dry needling was performed at symmetrical points on the abdomen and back as well as the anterior scalene muscle bilaterally. The needles used were 0.35x75mm and were manipulated to achieve LTRs (local twitch responses) but were not rotated.

Unfortunately, the terminology of needling techniques does not always result in mechanistic clarity. In the first case report we have something more like acupuncture than needling of a trigger point (the original intention of dry needling), and in the second we have a description and images that suggest perfect symmetry in the location of trigger points, something likely to be closer to tenderness at acupuncture points than to genuine active myofascial trigger points.

References

1         Qin D, Zhao Z, Song J. Atraumatic glenohumeral dislocation associated with silent abscess formation following acupuncture. Acupunct Med Published Online First: 12 June 2020. doi:10.1177/0964528420920301

2         Pei L, Geng H, Guo J, et al. Effect of Acupuncture in Patients With Irritable Bowel Syndrome: A Randomized Controlled Trial. Mayo Clin Proc 2020;:1–13. doi:10.1016/j.mayocp.2020.01.042

3         Hoffman P. Skin Disinfection and Acupuncture. Acupunct Med 2001;19:112–6. doi:10.1136/aim.19.2.112

4         Deadman P, Al-Khafaji M, Baker P. A Manual of Acupuncture. 2nd ed. Journal of Chinese Medicine 2007.

5         Forbes A. Acupuncture for irritable bowel syndrome: A blinded placebo-controlled trial. World J Gastroenterol 2005;11:4040. doi:10.3748/wjg.v11.i26.4040

6         Mohammadpour F, Ali Oghabian M, Nakhostin Ansari N, et al. Effects of dry needling on post-stroke brain activity and muscle spasticity of the upper limb: a case report. Acupunct Med Published Online First: 12 June 2020. doi:10.1177/0964528420920294

7         Sun W, Pan D, Huang Q. Successful treatment of persistent hiccups with myofascial trigger point dry needling: a case report. Acupunct Med Published Online First: 12 June 2020. doi:10.1177/0964528420920296


Declaration of interests MC

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