Stimulated by Valentini et al 2024.[1]
PAD – peripheral artery disease
key to acronyms
DFS – diabetic foot syndrome
I guess it was microcirculation in the title that attracted my attention to this paper. The title asks the question ‘Can acupuncture increase microcirculation?’ Well, surely the answer to this is yes. It is self-evident, is it not, that the red flare we frequently see around needles is a direct result of increased blood in the skin. But then we do need to be careful about such assumptions and we do need to view everything with a critical eye and check the data.
In this case, the question did not stop at the word microcirculation – there is an important second half of the question ‘…in peripheral artery disease and diabetic foot syndrome?’ This makes the question much less odd since, up to now, whilst symptoms and walking distance can improve with needling in PAD, the diseased large vessels do not appear to change. So, it makes sense to ask whether or not there are physiologically measurable changes in small vessels.
In this single arm pilot study (essentially a prospective case series) all the patients (n=18) had non-healing peripheral ulcers associated with either PAD or DFS. Many acupuncturist readers will have heard stories about using acupuncture to heal ulcers of various sorts. I probably first heard about it from Jacky Filshie using her wide surrounding technique in radionecrotic ulcers.[2]
I didn’t know about it at the time, but in the late 80’s Thomas Lundeberg also published data on blood flow in skin flaps from electrical stimulation at the base of the flaps.[3]
Ted Redfearn described his use of ‘surrounding the dragon’ after major vascular surgery in the early 90’s.[4] Then a GP member of the BMAS who I met regularly told me about his experience and went on to publish a nice case report with images of the size of a varicose ulcer before treatment and the healed leg afterwards.[5]
The prolific Spanish researcher Jorge Vas published a protocol for a multicenter trial of acupuncture and dressings for venous leg ulcers in 2008,[6] but unfortunately, this was the only trial of his that he had to abandon due to inadequate recruitment.
Nice before and after images continued to feature in our journal using surrounding techniques.[7,8]
To date we have a lot of stories and not much hard data, so I was interested to see the use of a new non-invasive device that measured blood flow and other parameters at two depths in skin using a combination of laser doppler and oxygen saturation. The device performs micro-lightguide spectrophotometry (O2C), and it popped up in the literature in 2012, measuring skin blood flow in ischaemic limbs.[9] It was subsequently tested in patients with PAD before and after a course of exercise.[10] The patient’s walking improved but there were no changes on the measurements at rest. During exercise there were significant differences in oxygen saturation measured in the affected leg compared with the normal one in those patients who had unilateral PAD.
I was quite hopeful about the results of this pilot study of acupuncture, but surprised to find there was absolutely no surrounding of any dragons. Indeed, the lower limbs were not needled at all. Only one point was needled on the anterior thorax. It was described as being on the connecting line between ST14 and ST15, so I guess that means over the second rib on the mamillary line. The other odd thing was that they did not use acupuncture needles. They used insulin syringes with 31G (0.3mm diameter) 5mm long needles and a sparrow-pecking technique with no needle retention.
They performed the technique unilateral to the ulcer and then at the same point bilaterally with measurements at baseline and after each treatment. The measurements were taken from the edge of the ulcers, ie a long way from the needling site.
The majority of parameters improved significantly after unilateral needling and all parameters improved significantly compared with baseline after bilateral needling.
The paper performs comparisons between the techniques and between the clinical subgroups. Bilateral acupuncture appeared to be better in all measures; however, the sequence was always unilateral and then bilateral, so it is not possible to be sure whether this was simply a function of the repeated stimulus rather than the dose or the bilateral location of needling.
There were a couple of differences in flow changes between PAD and DFS, but these are very difficult to interpret. On scanning the authors’ discussion, I discovered a paper from late 2023 that I had considered highlighting.[11] It is quite a large trial (n=360) from Harbin in the northeast of China. It compared adding EA to standard care with standard care alone for diabetic patients with lower limb arteriosclerotic wounds. There were significant benefits of adding EA… I will try to remember why I did not highlight it, and report at the blog webinar on Wednesday.
References
1 Valentini J, Sigl M, Dunckel C, et al. Can acupuncture increase microcirculation in peripheral artery disease and diabetic foot syndrome? – a pilot study. Front Med. 2024;11:1371056.
2 Filshie J. The non-drug treatment of neuralgic and neuropathic pain of malignancy. Cancer Surv. 1988;7:161–93.
3 Lundeberg T, Kjartansson J, Samuelsson U. Effect of electrical nerve stimulation on healing of ischaemic skin flaps. Lancet. 1988;2:712–4.
4 Redfearn T. Surrounding the Dragon. Acupunct Med. 1992;10:73–4.
5 Mears T. Acupuncture for chronic venous ulceration. Acupunct Med. 2003;21:150–2.
6 Vas J, Modesto M, Mendez C, et al. Effectiveness of acupuncture, special dressings and simple, low-adherence dressings for healing venous leg ulcers in primary healthcare: study protocol for a cluster-randomized open-labeled trial. BMC Complement Altern Med. 2008;8:29.
7 Hunter J. Acupuncture for keloid scar. Acupunct Med. 2011;29:2.
8 Foell J. Acupuncture as add-on treatment in the management of a patient with ecthyma gangrenosum. Acupunct Med. 2012;30:60–2.
9 Jørgensen LP, Schroeder TV. Micro-lightguide spectrophotometry for tissue perfusion in ischemic limbs. J Vasc Surg. 2012;56:746–52.
10 Gyldenløve T, Jørgensen LP, Schroeder TV. Micro-Lightguide Spectrophotometry (O2C) for Lower Limb Perfusion: Effects of Exercise Walking in Claudicants. Int J Angiol Off Publ Int Coll Angiol Inc. 2019;28:161–6.
11 Sang P, Zhao J, Yang H. The efficacy of electroacupuncture in among early diabetic patients with lower limb arteriosclerotic wounds. Int Wound J. Published Online First: 13 December 2023. doi: 10.1111/iwj.14526
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