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Acupuncture evidence

Discussion in 'General Issues and Discussion Forum' started by ggm2011, Feb 2, 2012.

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  1. ggm2011

    ggm2011 Member


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    Hi help needed, trying to set up acupuncture in NHS department in short time frame but as well as setting up patient forms and getting department policy on track. The Boss has just came back asking for more literature on acupuncture on foot conditions, especially Plantar Fasciitis. Anybody help me here. Thank you very much in advance.

    Graeme
     
  2. MischaK

    MischaK Active Member

    Hi Graeme you have probably already looked at these but here is some literature I found this morning with a quick search on CINAHL, I have not read these myself so I am unsure of the quality of research or if they will be useful to you,

    Are you proposing to use "traditional acupuncture" or "dry needling" ?




    Bailey, S. (2009). Acupuncture management of a case with chronic heel pain. Podiatry Now, 12(7),


    Cotchett, M. P., Landorf, K. B., Munteanu, S. E., & Raspovic, A. M. (2011). Consensus for dry needling for plantar heel pain (plantar fasciitis): a modified Delphi study. Acupuncture In Medicine, 29(3), 193-202. doi:10.1136/aim.2010.003145


    Reaves, W. (2011). Plantar fasciitis: the acupuncture treatment of heel pain. Journal Of Chinese Medicine, (96), 22-25.


    Santha, C. (2010). Acupuncture treatment for bilateral heel pain caused by plantar fascitis. Journal Of The Acupuncture Association Of Chartered Physiotherapists, 67-74.


    Smith, S. (2009). Acupuncture in the treatment of tarsal tunnel syndrome. Journal Of Chinese Medicine, (89), 19-25



    Mischa
     
  3. ggm2011

    ggm2011 Member

    Mischa thank you very much your a star!
     
  4. MischaK

    MischaK Active Member

    No problem :D
     
  5. Admin2

    Admin2 Administrator Staff Member

  6. Shane Toohey

    Shane Toohey Active Member

    Hi Graeme,

    For overall background on the science behind acupuncture see if you can get a copy of the book:

    An Introduction to Western Medical Acupuncture
    A White, M Cummings, J Filshie, Churchill Livingston, 2008

    It seems you are not alone having to re-invent the wheel.

    There are so many podiatrists using acupuncture techniques, including dry needling, in the UK but no collective interest group. Therefor every time someone wants to start using the techniques in a trust they end up doing what you are doing. There would be a great benefit in having such a collective formed.

    What also would be of use in the UK would be for the SCP which provides Acupuncture Certification to Poidatrists for completing prescribed courses to provide a short position statement to the effect that holders of the certificate have the competency to use acupuncture in their treatments and the capacity to make the professional judgement about when the therapy is apropriate.
    That is: that acupuncture is within the scope of practice of the certified podiatrist.

    When I was last in the UK at the Harrogate SCP Conference I spoke with a podiatric surgeon who said that he was using acupuncture techniques quite regularly in private practice but had been advised that he could not use it in his part-time visits to his NHS trust because the "physiotherapists had an acupuncture clinic and anyone who needed acupuncture should be sent there."
    Can you tell me that physiotherapists have the medical competency to treat for example skin condtions in neuropathic and vascularly compromised patients? Can you also tell me that a podiatric surgeon is not competent to insert an acupuncture needle and know when it is apropriate and not apropriate to do so?

    I think that podiatrists are too meek about the medical competency that they have achieved. This situation is mimicked? in Australia.


    Cheers
    Shane
     
  7. ggm2011

    ggm2011 Member

    Agree whole heartily with that Shane
    Big thank you
    Graeme :drinks
     
  8. kirsty-white

    kirsty-white Welcome New Poster

    Hello,

    I'm new to podiatry arena. This is my first post :) I am still a student podiatrist although this is my last year. Just want to be a little more involved in discussions surrounding podiatry.

    I was looking at a bmj article and found it quite useful:

    http://aim.bmj.com/content/16/2/66.abstract

    Hope it is of use

    Regards

    Kirsty
     
  9. PodAc doc

    PodAc doc Active Member

    Hi Graeme
    A very timely request! I am just completing a systematic review on the use of acupuncture for heel pain - hoping to have ready for submission within days. I would be happy to discuss this with you.
    Best wishes
    Richard
     
  10. PodAc doc

    PodAc doc Active Member

    Hi Shane
    I couldn't agree more, about reinventing the wheel.
    You may be interested to see a statement the SCP provided with regards to my course, in an email dated 08/08/08.

    "Our insurers are happy to cover techniques that are properly taught and verified by the Faculty and hence the Society, so long as they are in the treatment/management of foot related conditions (i.e. pathological conditions that either originate in the foot or occur there. So long as the practitioner is treating such a condition and can justify the treatment regime within his or her training then he or she is covered.
    An example would be anterior knee pain related to foot function - any treatment to improve the foot function will improve the knee pain and vice versa."
    Miss Debra B Browne
    CPD Officer

    Best wishes
    Richard
     
  11. Shane Toohey

    Shane Toohey Active Member

    Great Richard,
    So my interpretation of that is that once you have your certificate from SCP, the use of acupuncture techniques falls within the scope of practice for that podiatrist and they make their own individual professional opinion about when to use it just as they do with other modalities.
    In retrospect they could be asked to justify a particular treatment as always if there was an adverse event or other poor results occurred. However, they should not have to go and ask anyone for approval to use techniques within their scope of practice nor has any outside person the right to tell them what they can do or not do as it impinges on the professional judgement of the podiatrist.
    Cheers
     
  12. PodAc doc

    PodAc doc Active Member

    Yes, Shane, that would be my interpretation too.
    R
     
  13. Shane Toohey

    Shane Toohey Active Member

    Goodo Richard,

    Then who or which body in the uK could make such a statement that managers etc in the trusts would take notice of? Would a position statement to that effect from the SCP be useful? Considering that they have requirements for gaining their certificates then the certificates should have some authority attached to them.
    I'm not from the uK and am not a member of the SCP so the issue would be pursued best by a member I'd think. Meanwhile I am a stakeholder as a provider of an approved course and am willing to contact them to ask for their help with a problem that keeps being brought to my attention by participants in my workshops and others in general as well.
    I also mentioned the benefit that could be easily be achieved by the formation of an interest group, even simply an arena private group so that issues and interests can be shared more easily and get rid of the perception out there that each pod is on their own.

    Cheers again
    Shane
     
  14. PodAc doc

    PodAc doc Active Member

    Hi Shane
    Like you, I provide training in acupuncture for podiatrists, and am not a member of the SCP (I am a doctor, not a podiatrist). I have been asked a number of times to provide support for our alumni who have introduced acupuncture into their services. In private practice it is not an issue (although one practitioner did have to register her clinic as an acupuncture provider with the local council).
    In the NHS, my impression is that the issue is not insurance, but resources and evidence. The NHS is undergoing big changes at present and many services are under threat. Even the unit where I have been teaching for the past decade, and where acupuncture was very well established, has now been merged into a bigger entity and the future use of acupuncture there is uncertain.
    Managers need good arguments - such as demonstrable cost-effectiveness - to persuade them to approve something new and unusual. For this reason I have been concentrating recently on a systematic review of the use of acupuncture in heel pain, as part of a wider review. There is good quality evidence supporting the use of acupuncture - better quality than that which is available for other conventional interventions - watch this space.
    R
     
  15. Lilypad

    Lilypad Member

    It can be a useful addition to the physio etc. I've tried accupuncture on an wrist injury and it seemed to improve things. I have heard of some people recieving this on the NHS, whether this is true I'm not sure but I couldn't see any reason why not.
     
  16. Shane Toohey

    Shane Toohey Active Member

    Yes, thanks Lily(?), acupuncture is regularly used in the NHS. Unfortunately in some trusts podiatrists are being told they cannot use it.
    I have been using acupuncture as a podiatrist for 20 years and have had success using it to resolve conditions ranging from chronic neuropathic digital pain through to recalcitrant heel pain. It doesn't take long to find out if it (or rather your approach to using it) will help a particular presentation. What we need now are folk to do research and reviews as Richard has indicated above. I think an interest group would be very useful as well so that pods who are qualified will be able to combine resources for submissions. Cheers
    Shane
     
  17. ggm2011

    ggm2011 Member

    Hi Shane passed your contact details onto my NHS manager hopefully she will contact you. Thank You
     
  18. Interesting. How many good quality trials for the use of acupuncture in heel pain have you identified?
     
  19. From the abstract: 'Eighteen patients attending an orthopaedic outpatient clinic with a year or more's history of heel pain due to plantar fasciitis were studied. All had had conservative treatment of physiotherapy and shoe-support without significant pain relief before acupuncture was offered, and thus acted as their own controls for the purposes of the study."

    In what way did these patients act as their "own controls" in this study of acupuncture?:rolleyes: How is the history of previous treatment "a control" in a scientific study? A selection criteria I'll give ya' that, but a control? No. Nor any attempt at sham acupuncture. And if at first we don't succeed, we'll stick even more needles into you until you tell us its helped... true effect, placebo, or get me out of this room and stop them from sticking needles into me... this study answers none of these questions, nor a few others.
     
  20. PodAc doc

    PodAc doc Active Member

    The short answer is 5 RCTs, 2 of which score well against CONSORT, QI AND STRICTA criteria. The long answer is more interesting; as I said, watch this space - the review will be submitted soon.

    The Tillu & Gupta paper you cite in your next posting is rather old and of course does not come up to today's standards. It was one of the first on this subject and is to be commended for breaking the ice, if nothing else. As far as I know, no-one is putting it forward as high quality evidence.

    It is very easy to do a selective search, find a weak paper then broadcast derogatory comments, but is that any more scientific than the paper in question?
    R
     
  21. Can you provide us with the references for the two that do score well? And the others too. Thanks.
    For the record, the article was originally posted up by another member of this forum. I didn't do any search, selective nor other for the paper in question. I have merely looked at the abstract provided by another member with a critical, scientific eye; rather than through the eyes of someone with a vested interest in the subject. I have then pointed out a flaw in it. It is very easy to do a selective search, ignore the flaws in the scientific methodology of a study and then erroneously broadcast it as evidence for something which you have a vested interest in too. But I don't think people generally get away with that here.

    I did do a quick search and find this review that I posted previously: http://www.bmj.com/content/338/bmj.a3115.full which after looking at 13 high quality trials (3025 patients) concluded:
    "A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."

    Talking of bias, what might your bias be Richard?
    Yeah, that'll be it.

    Now, lets take a look at the other studies on acupuncture and heel pain, since that one http://aim.bmj.com/content/16/2/66.abstract wasn't even a controlled trial; those references if you will...
     
  22. PodAc doc

    PodAc doc Active Member

    The review is my effort to make this info available, in a suitable form. As I said, watch this space - all will be revealed!
     
  23. All I wanted was the list of the 5 RCT's on acupuncture and heel pain so that we can draw our own opinions on their quality.
     
  24. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis
    Andrew J. Vickers, DPhil; Angel M. Cronin, MS; Alexandra C. Maschino, BS; George Lewith, MD; Hugh MacPherson, PhD; Nadine E. Foster, DPhil; Karen J. Sherman, PhD; Claudia M. Witt, MD; Klaus Linde, MD; for the Acupuncture Trialists' Collaboration
    Arch Intern Med. Published online September 10, 2012
     
  25. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    This study has got a lot of media coverage, but all is not as it seems:
    Full story
     
  26. Shane Toohey

    Shane Toohey Active Member

    Hi again Craig,

    Pardon me if I get out of my depth but I had a couple of ideas I wanted to express and so will take a chance and put tthem out.

    Steven Novell who you quoted also seems to be just expressing his opinions including an overall dismissal of meta-analysis which is a tool used almost routinely by Cochrane in coming to decisions about evidence base. So, I'd at least like to see a response to his opinions/critique.

    A constant problem with acupuncture trials is the use of "sham acupuncture' as the "placebo". This usually is conducted by placing needles in the 'wrong' place instead of the 'right' place. There is easily enough evidence to show that the insertion of an acupuncture needle registers within the differing levels of the neurological system and that there seems to be responses that would explain the claimed effects of acupuncture. Now, I'm just bringing this up to say that putting needles into the wrong place is only testing the specificity of the points used and is not at all a true placebo. Even when they use devices where needles are not inserted but the skin is pricked sufficiently for subjects to think they have been needled will also stimulate a response.

    We have similar problems with placebos in orthotic therapy studies and it seems that practical interventions do not easily fall into the gold standard 'drug testing' style of analysis. You academics will all know more about this than me. What has happened in orthotic research is that variables are reduced so that prescriptions are standardised. This standardisation doesn't really reflect what happens in clinical practice and will always statistically reduce the overall effectiveness of the intervention in a group. Similarly, with acupuncture, the same general diagnosis, eg OA of the knee would still have individual treated differently from each other in clinic.

    As you know, I use and teach acupuncture techniques and am now registered also as an acupuncturist. I find that clinically when I am using acupuncture techniques just as when I am using orthotic therapy I need to develop evidence for the progression of the use of the modality. This is a single case study in every case for me. This is how I practice. If I am not demonstrating that the problem is improving then I do not continue. Luckily, more than 30% respond or I'd be out of business, hey.

    Cheers
    Shane
     
  27. NewsBot

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    Articles:
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  28. PodAc doc

    PodAc doc Active Member

    Hi Graeme. You asked:
    Hi help needed, trying to set up acupuncture in NHS department in short time frame but as well as setting up patient forms and getting department policy on track. The Boss has just came back asking for more literature on acupuncture on foot conditions, especially Plantar Fasciitis. Anybody help me here. Thank you very much in advance.
    This is just to let you know that our systematic review is now in print:
    The effectiveness of acupuncture for plantar heel pain: a systematic review
    Richard James Clark and Maria Tighe
    Acupuncture in Medicine. 2012; 30:298-306.
    Best wishes
    Richard
     
  29. ggm2011

    ggm2011 Member

    Thank you Richard
     
  30. RunDNC

    RunDNC Member

    Another recent article that may be of some use

    Evaluation of dry needling in patients with chronic heel pain due to plantar fasciitis
    Bina Eftekhar-Sadata et al
    The Foot, Available online 29 November 2012, In Press, Corrected Proof
     
  31. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Press Release:
    How does acupuncture work? The science behind the therapy explored
     
  32. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
  33. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Press Release:
    Pro/Con Editorials Look at Evidence on Acupuncture for Symptom Relief
    http://www.anesthesia-analgesia.org/content/116/6/1356.full
     
  34. Lab Guy

    Lab Guy Well-Known Member

    I found this interesting.

    Steven

    http://archinte.jamanetwork.com/article.aspx?articleid=1357513

    Abstract
    ABSTRACT | METHODS | RESULTS | COMMENT | ARTICLE INFORMATION | REFERENCES

    Background Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.
    Methods We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17 922 patients analyzed.
    Results In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias.
    Conclusions Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.
    Acupuncture is the insertion and stimulation of needles at specific points on the body to facilitate recovery of health. Although initially developed as part of traditional Chinese medicine, some contemporary acupuncturists, particularly those with medical qualifications, understand acupuncture in physiologic terms, without reference to premodern concepts.1
    An estimated 3 million American adults receive acupuncture treatment each year,2 and chronic pain is the most common presentation.3 Acupuncture is known to have physiologic effects relevant to analgesia,4,5 but there is no accepted mechanism by which it could have persisting effects on chronic pain. This lack of biological plausibility, and its provenance in theories lying outside of biomedicine, makes acupuncture a highly controversial therapy.
    A large number of randomized controlled trials (RCTs) of acupuncture for chronic pain have been conducted. Most have been of low methodologic quality, and, accordingly, meta-analyses based on these RCTs are of questionable interpretability and value.6 Herein, we present an individual patient data meta-analysis of RCTs of acupuncture for chronic pain, in which only high-quality RCTs were eligible for inclusion. Individual patient data meta-analysis are superior to the use of summary data in meta-analysis because they enhance data quality, enable different forms of outcome to be combined, and allow use of statistical techniques of increased precision.
     
  35. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Press Release:
    Study Finds Acupuncture Does Not Improve Chronic Knee Pain
    Acupuncture for Chronic Knee Pain.
    Rana S. Hinman, Paul McCrory, Marie Pirotta, Ian Relf, Andrew Forbes, Kay M. Crossley, Elizabeth Williamson, Mary Kyriakides, Kitty Novy, Ben R. Metcalf, Anthony Harris, Prasuna Reddy, Philip G. Conaghan, Kim L. Bennell.
    JAMA, 2014; 312 (13): 1313 DOI:
     
  36. Shane Toohey

    Shane Toohey Active Member

    Query, if you were on drug therapy for knee pain and took it for 12 weeks, would you have any benefit still showing 12 months later?
     
  37. Lab Guy

    Lab Guy Well-Known Member

    Results were recorded for short term (12 weeks) and long term (1 year).

    Steven
     
  38. Shane Toohey

    Shane Toohey Active Member

    Hi Steven,

    I may have misunderstood, but it seemed that treatment was for only 12 weeks

    I expect to reduce pain but not to cure and have folk on maintenance treatments after results have settled. Commonly, the results include improved functionality, for example not having to go sideways up stairs and more capacity to walk for greater distances. Also using medication for emergencies only (after unexpected aggravation from e.g. spring cleaning or painting up on ladders) instead of taking them daily. When treatment is having no effect then there is no point in continuing and we stop.
    I'm not sure how to look at the methodology of the study in detail.
    Very clearly sham acupuncture is not inert and needles will have an effect on the system when delivered at 'incorrect' locations. It does show a poor understanding of the mechanisms initiated by the needles.
    These studies are about the specificity of the points used.

    Laser can be really used in a placebo style with all the bells and whistles but nothing coming out. So clearly Laser can be used for this type of trial but it is not the same as needles.
    I am curious about the methodology. A lot of GP's only treat 'ashi' (tender) points. Can you give me a link so that I can have a look at it. I'm not paying 19GBP to have a look.

    Cheers
    Shane

    Cheers
    Shane
     
  39. PodAc doc

    PodAc doc Active Member

    Hi Shane,

    Yes, I too would like to see the full report - one wouldn't want to base a critique on the abstract alone. It does seem apparent, from what we have, that there are questions to be answered. Yes, the figures do suggest that the needling and laser treatment that was done, was no better than placebo (sham, ie. dummy laser). But the fact that they chose a 12-month OCM does, as you imply, suggest a lack of understanding of how acupuncture is commonly used. Again, the fact that they chose not to give details of the treatment in the Abstract suggests a lack of awareness of the diversity of practice. So, while we might agree that this group of physicians failed to get acupuncture to work for this group of patients, we might also caution against generalising this conclusion.
    Cheers
    Richard
     
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