Acupuncture vs BFT in FI

Stimulated by Ng et al 2024.[1]

BFT – biofeedback therapy
FI – faecal incontinence
PFE – pelvic floor exercises
UCL – University College London
IF – impact factor
EA – electroacupuncture
FIQL – faecal incontinence quality of life questionnaire
SNS – sacral nerve stimulation

– key to acronyms

This is the largest RCT of acupuncture in FI to date (n=91), and only the third in total. Of the 2 prior RCTs, one was a sham controlled trial of laser acupuncture plus PFE (n=40) and the other was a paper from China comparing acupuncture with medication (n=40). I got this detail from a recent review that included these 2 RCTs and a further 3 single arm pilot studies.[2]

The present study comes from a group in Singapore, where acupuncture is widely available. Most of the authors on the paper appear to be colorectal surgeons, with just one acupuncture affiliation on the list. I found some of them online. The first author is a young consultant surgeon who has been publishing for about 2 years: Yvonne Ng. The boss (the last author) trained in medicine at UCL and qualified in 2001: Emile Tan. The second author is the acupuncturist. He trained in Singapore and Nanjing: Koon Yaw Tan. I wonder if he is related to the boss.

The paper is published in the journal Diseases of the Colon and Rectum (IF 3.2), which is the official journal of the American Society of Colon and Rectal Surgeons.

The study compared acupuncture with PFE plus BFT, the latter being the main conventional non-invasive treatment for FI.  It was applied over 3 sessions starting with PFE alone and adding BFT on the second or third session. Patients were instructed to perform PFE 3 times a day with 40 repetitions each time.

The acupuncture was performed 3 times a week for 10 weeks and each session lasted for 1 hour, which seems a long time until you read the list of points. The points used were as follows: BL31 to BL34; BL23, BL20, & BL25; GV20; CV6 & CV4; ST36, SP6, KI3, & LR3; LI4. That is 27 needles in total and two sides of the body, hence the 1-hour treatment time, I guess. We are told that EA, moxibustion, and a heat lamp were used.

Outcomes were FI episodes, the St Mark’s incontinence score, and the FIQL. A primary outcome was not explicitly stated, but the objective of the trial was to determine effectiveness, and FI episodes and the St Mark’s incontinence score were used as inclusion criteria (at least 2 episodes of FI per week or a St Mark’s incontinence score of at least 5). The St Mark’s incontinence score comes from St Mark’s Hospital at Northwick Park, which is labelled as the National Bowel Hospital.[3] On looking up the website I discovered that they also have a footprint at my local hospital in Ealing.

Whilst a primary outcome was not stated, I found a sentence in the paragraph labelled ‘Analysis Plans and Sample Size’, which referred to a primary endpoint as the difference in weekly FI episodes between groups.

Medial FI episodes per week dropped from 16 at baseline to 7.5 at 15 weeks in the BFT group and from 15 to 3 in the acupuncture group. This difference was very highly statistically significant (p<0.001). Interestingly, both groups hovered around 7 to 8 at 5 weeks and 10 weeks, with the acupuncture group always being slightly better. But over the 5 weeks of follow-up after the end of treatment, the median in the acupuncture group fell again.

The St Mark’s score also fell significantly in both groups with the acupuncture group being somewhat better. The difference was highly statistically significant (p<0.002).

Despite the acupuncture group being ahead in terms of effectiveness, there was absolutely no different between the groups in the FIQL domains (lifestyle, coping, depression, embarrassment), whilst all improved significantly over time.

The authors acknowledge that longer term outcomes are needed, and they comment that only SNS has demonstrated ‘long-term efficacy’. I followed their reference here, and found a paper looking at prospective research on SNS across 10 European centres.[4] There were no control groups in any of these trials; however, 50% of patients who retained implants in the long term (5 years) were fully continent. This represented just over 30% of those initially recruited for a trial of SNS.

We are told that you can get acupuncture for $15 per session in Singapore, so 30 sessions work out to just $450, which compares favourably to the cost of SNS – $18k for the device and $1.5k per annum for maintenance).

We (Acupuncture in Medicine) have published an experimental study of EA at ST36 and stem cell injection in an animal model of FI (surgical incision of both external and internal sphincters). The combination of both seemed to have better effects than either treatment alone.[5]

References

1          Ng YY, Tan KY, Yun Z, et al. Efficacy of Traditional Acupuncture Compared to Biofeedback Therapy in Fecal Incontinence: A Randomized Controlled Trial. Dis Colon Rectum. Published Online First: 2 July 2024. doi: 10.1097/DCR.0000000000003357

2          Sipaviciute A, Aukstikalnis T, Samalavicius NE, et al. The Role of Traditional Acupuncture in Patients with Fecal Incontinence-Mini-Review. Int J Environ Res Public Health. 2021;18:2112. doi: 10.3390/ijerph18042112

3          Vaizey CJ, Carapeti E, Cahill JA, et al. Prospective comparison of faecal incontinence grading systems. Gut. 1999;44:77–80. doi: 10.1136/gut.44.1.77

4          Altomare DF, Giuratrabocchetta S, Knowles CH, et al. Long-term outcomes of sacral nerve stimulation for faecal incontinence. Br J Surg. 2015;102:407–15. doi: 10.1002/bjs.9740

5          Li X, Guo X, Jin W, et al. Effects of electroacupuncture combined with stem cell transplantation on anal sphincter injury-induced faecal incontinence in a rat model. Acupunct Med. 2018;36:254–60. doi: 10.1136/acupmed-2016-011262

---

Declaration of interests MC