Acupuncture, legitimate or not

Andrew, I am impressed with your enthusiasm, and your principles. I hope practice doesn’t dampen them. The problem is that when you have a patient in pain in front of you, and you have not seen the condition before, you will not be saying to yourself, “There is no treatment that is evidence based, therefore I will not treat him”. You will think about what is causing the problem and how can you rectify it based on the knowledge you have gained in your education.
I have been in practice for 30 years, and when I started, I taught at the Ohio College of Podiatric Medicine, and we saw 40 runners a day. Back then, there were no real answers, mechanisms, or randomized clinical trials. All we had was experience that we rapidly developed. If a new condition came in, we would consider the mechanics, the structures that were getting affected, and how we could change it. How do you think the leaders in our profession came to be?
In a perfect world, there would be research that would prove things beyond a doubt. Since this is not a perfect world and I am in practice to help my patients that best way that I can, I do what I think will help my patients the most.
I have found that I am able to help patients using a modification of acupuncture principles, and I am trying to expand my knowledge of this. I am planning on doing research, and would like to ask what parameters would be accepted.
Since the limbic system affects the motor, hormonal, emotional and autonomic nervous systems, I was thinking of using changes in dorsiflexion of the ankle (for the motor effect); heart rate variability or blood pressure laying down, standing and sitting (for the autonomic effect); and an MMPI for the emotional component. I was wondering if you would find these tests acceptable.
By the way, I do not charge for my “acupuncture” treatment. There are insurance limitations on physical therapy where I practice, and I charge for these less effective therapies, as they are covered and to stay within practice standards. I do my “alternative” treatments to get my patients better as an add on.

Regards,
Stanley

 

Hi Stanley,

Importantly, I would like to say that while my posts have been perceived as disrespectful, that I have a great deal of respect for the depth of clinical experience and expertise that both yourself and Shane have clearly developed. Given the opportunity, a student such as myself would learn a great deal from you both regarding podiatric medicine in general, and the provision of effective treatments to patients.

Unfortunately, I am unqualified to give accurate advice on clinical research methodology – as I’m very much a learner in this area. The advice of a clinician with a PhD would probably be best. However, thankyou for inviting me to comment on your research ideas:

Personally, I view meridians and qi as essential components of acupuncture, without which the term acupuncture is misrepresented. However, as this is just my point of view, perhaps it would be best for us all to agree to disagree on this point, and move on as friends !

Maybe the next most important thing to test in podiatry would be this: if stimulation of traditional acupuncture points of the foot results in a consistently different physiological response when compared to stimulation of non-traditional acupuncture points of the foot.

The null hypothesis would be: Baseline = Trad points = Non-trad points

Maybe the trad acupuncture points could firstly be mapped with dermatomes / myotomes, to ensure that any difference found between the trad points and non-trad points is not due to neural sensory distribution.

There could be an intra-subject crossover design, with 3 conditions:

1. Baseline
2. Stimulation of all trad points of the foot (say there are 15 points – but I have no idea).
3. Stimulation of an equal proportion (15) of non-trad points of the foot.

Baseline data would be recorded (not sure, but this may need to occur first). Each subject would have stimulation of all trad points (probably one at a time), with the data recorded and grouped, followed by all non-trad points (one at a time) with the data recorded and grouped . Which group of points is tested first would need to occur according to a randomised order. The mean outcome values for each subject could be calculated for all trad points, and all non-trad points. That would be the data collection for one subject. Data for all conditions would have to occur at the same visit to avoid confounding variables.

An example of the data for 1 subject (and one outcome variable): The mean systolic BP in lying at baseline was 117 mmHg. The mean systolic BP in lying during stimulation of all trad points was 118 mmHg. The mean systolic BP in lying during stimulation of all non-trad points was 116 mmHg.

This would be the data for one participant only (n=1), the above would be repeated for probably a minimum of 30 participants. A power analysis might be possible if the variables being measured have been tested before. Otherwise you could have 30 participants and write it up as a pilot study.

An example of the data for 30 subjects after grouped comparison of the means by a paired t-test: The mean systolic BP in lying during stimulation of all trad points was significantly lower than the mean systolic BP in lying during stimulation of all non-trad points (p=0.005). Or another example: there were no significant differences between groups.

The only outcome variable that you have suggested that would probably be problematic with this study design would be the mini-mental state.

It may also be a good idea to blind the patient, a vertical surgical drape at knee level maybe.

I hope this of some value Stanley, as I currently have my training wheels on in this area !

Best wishes ,

Andrew

 

Andrew, in the spirit of fairness, why do you persist in locking acupuncture to qi? Why don’t you persist in locking allopathic medicine to evil humors? After all, allopathic medicine is much younger.

Andrew, I appreciate the input. The reason for the Lying/standing test of BP is to check for Ragland’s sign. When a person stands, their systolic bp should raise 8-10 points. If it stays the same or drops, this is the Ragland's sign and is related to supposedly adrenal fatigue. But as we know, a dysfunction of the sympathetic nervous system would give the same response.
Check this web page:
http://www.nymc.edu/fhp/centers/syncope/physiology_of_OI.htm
For the body to make this change in blood pressure, there would have to be an input from sensors in the body (arterial baroreceptors). If you remember, I referenced an article that showed that the acupuncture points go to the part of the brain that has to do with sensorimotor integration and motor control. I also told you that the output from the limbic lobe includes the autonomic nervous system. Taking blood pressure in the recumbent position would not show this complex reflex system and hence the effect of acupuncture. I do not know if Raglund’s sign would change, but I can do it just to see if it does.
As far as I see it, the first thing I have to find is a good parameter to test. Here is a problem that may or may not be. I find that there is an acupuncture problem with mild ankle dorsiflexion restrictions. If I do not have this finding, then I do not go primarily to the acupuncture system. Would you consider this a problem in the methodology?

Regards,

Stanley

 

Hi All,

From one forum to another: an intersting blog I read this morning on Science-based Medicine, pasted below:

http://www.sciencebasedmedicine.org/?p=252#more-252


A little backgroung on the author:

Into to the blog:

Context and history comment:

Efficacy comment:

Additional:

 

A very interesting and well written piece!

I especially liked:-

Regards
Robert

 

Yahoo! are reporting:
Needles, not technique, may be acupuncture key

Full story

 

This is a very interesting and somewhat polarizing debate. I do have my own views on acupuncture and the mechanism by which a causal effect is achieved through needling. I may invite some curt responses from those who believe in the meridians and acupuncture via needling, but here goes....

I personally feel that anyone who practices acupuncture or extols its virtues should read "The Body Electric: Electromagnetism and the Foundation of Life" by Robert O. Becker, MD. Dr. Becker was the physician sent to China during the Nixon administration to study Chinese Medicine, specifically acupuncture. His research into limb regeneration via electrical microcurrents is heralded as the definitive research that led to the advent of the implantable bone growth stimulators in use today. He was a tireless medical researcher whose efforts have produced incredible insights and progress into our understanding of how electrical currents produced in the body affect our physiology and healing.

What I gleaned from Dr. Becker's exhaustive studies of the electrical systems often mistaken as meridians or channels is that they do in fact exist, which is accepted as medical fact. What is not accepted as fact is that these routes that these impulses follow is some illusory ancient routes called the meridian system. I believe that that acupuncture was aware of them long before they were discovered and quantified by Western scientific researchers. I also believe that these impulses do not occur along some as yet unproven meridian system but occur along known nerve paths, lymphatic channels and within smooth muscles lining the intima of arterial vessels that are innervated in a known and quantifiable, predictable pattern. As is all physiology.

They are controlled by complex physical reactions too numerous to illustrate here, but they follow paths of innervation known to occur via embryologic growth and development into adulthood consistent with known anatomy and physiology. Complex chemical reactions produce electrical charges that fire the nerves to produce movement, beat the heart etc. These are internally mediated reactions reactions that are modulated by somatic and autonomic responses to stimuli. The question of external stimuli such as acupuncture affecting our physiology is real but I question the wisdom of the ancient beliefs of how this is achieved. I feel that Dr. Becker did as well. I also do not believe that one needs to pierce the skin with needles to achieve the effects that acupuncture produces.

As a chiropractor who uses a protocol called Cox Distraction technique on some low back sciatic patients, acupressure points along the sciatic nerve are inclusive of the protocol for patients with lumbar neuropathy. Without confounding this discussion with a lengthy explanation of the pressure sensitive structures below the skin that are effected and stimulated via touch and pressure and their effect on physiology, let me just say that I personally believe that acupressure (manual pressure) is as effective as acupuncture (via invasive needle) in achieving the desired analgesic effect. I have also found that focused manual pressure anywhere along the nerve path of sciatic distribution (not a meridian but a known pathway of communication) and not following the meridian system of lore does achieve the same effect as needle acupuncture in relieving low back mediated sciatic complaints.

Manual pressure directly and predictably affects the neuroepidermal junction (NEJ). The NEJ has been widely researched by myriad authors and been found consistently absent in regenerative capacity in limb loss. Likewise, scar tissue lacks a NEJ and the neural defect produces extensive collagen formation (that is not innervated or improperly associated with regard to function) to fill the defect. Stimulating the NEJ in peripheral nerve injury stimulates blastema formation, the initial step in regeneration and healing. As long as there is intact nerve function to the affected limb, stimulation the NEJ at the dermis will stimulate healing.

This is what I believe occurs with both needle and non-needle acupuncture. Simple stimulation of the NEJ to stimulate communication, growth and healing in damaged tissue. I truly believe that one day manual therapeutic methods will replace needle acupuncture and be validated by science as the primary treatment in peripheral neuropathy where there is an intact NEJ and sensory/motor component.

Placebo is a mechanism that affects outcomes in clinical trials and I agree there is a modicum of placebo effect inherent in any manual or minimally invasive healing method. I also believe that there is a definable and verifiable mechanism to every therapeutic methodology that our theories and research will eventually uncover that is simple, repeatable and explainable.

I also feel that Ian’s post is extremely important and relevant:

 

Hi David

Thanks for the post.

I suspect that accessing the self healing potential of the human soma and psyche is something we have hardly touched, equally, I suspect the synergising (have i just made that word up? ) of some complementary and allopathic medicine has been unfortunately hindered all to frequently by seeing them as diametrically opposed.

As well as training in Podiatry, over the years I have trained in various manners of what some prefer to consider as complementary techniques including varied reflexology approaches. I've also trained in using acupuncture points (no needles) in the treatment of emotional/psychological distress issues ( to very good effect). Certainly for resolution of many emotional / psychological distresses there needs to occur biochemical changes and it would seem that these are able to occur at the same time as the treatment is applied, so some rapid communication is going on.

If maintenance and / or restoring of human health is our goal then I am comfortable with using all the techniques I have trained in, regarding them as different ways of accessing the human psycho-soma's own potential for moving towards health.

How much is placebo? Don't know, but if we can learn to use placebo as a medical tool then maybe we can progress a lot more in some of our treatments.

Cheers
Ian

(away with the fairies again)

 

the Age is Reporting

and here is the link to the Cochrane Review