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Research Headache

February 22nd, 2012 4 comments

Greetings all! I know it’s been a while since I’ve blogged, so here we go – merry christmas, happy hanukah, happy new year, happy chinese new year happy valentine’s day yada yada been there done that.

What I wish to write about to day is a sharing of a personal experience with some research I’m involved with in the Philippine General Hospital, teaching hospital of the University of the Philippines College of Medicine.

Yes, skeptics, there IS research being done in reputable state universities.  Then again the skeptics have already ignored the research done at the University of Vermont and the University of  Munich (click the links!) so why won’t they ignore this one?

Anyway, the research is supposed to be a cross-sectional study comparing the preventive effects of acupuncture versus propranolol in the treatment of migraine.  What I would like to comment on is the initial procedure that the residents wanted to do.

Initially, the idea of the other researchers was to pick a set of points and use that same set of points on EVERY PATIENT.  Following the principles of traditional chinese medicine, I said that that shouldn’t be the case.  I understand that their objective was to standardize the treatment.  I pointed out that chinese medicine emphasizes the root cause of the headache/migraine and address those causes.  The points to be used depend on those factors, as well as the location and nature of the pain.

wei shengchu 60 displays acupuncture needles in hi 2172839354 300x200 Research Headache

This is NOT how to treat headache using acupuncture.

In the end, what the protocol we submitted (which was subsequently approved by the appropriate committees) was that we would come up with a POOL of points to choose from.  Other factors would be there would only be ONE acupuncturist to diagnose, select from the pool and insert/manipulate the needles.  That will try to eliminate skill variation in practitioners.

When that study gets published, you guys will be the first to know about it!

 

P.S. – Gotta love this study

http://www.healthcmi.com/index.php/acupuncturist-news-online/495-acupunctureceusbrainstrokerepair

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Accidentally Misquoted – And Clarifications from Dr. Eddie Concepcion

September 16th, 2011 No comments

Dr. Eddie Concepcion is one of the best acupuncturists in the Philippines.  I know, because for the past five years or so, I have had a chance to witness him in action firsthand as one of his colleagues at Oasis Acupuncture Clinic.  He’s a mild mannered yet stunningly engaging clinician who shuns the spotlight.  Sometimes I compare im to the Lakeside Recluse Li Shizhen; the difference being that Doc Eddie’s “lake” is his hobby of photography.

Somewhat like J.D. Salinger, Doc Eddie doesn’t usually give interviews to the media.  Again, I should know, because he usually would send me to do it for him.  Lately, however, he had consented to being interviewed by the Philippine Daily Inquirer (link).   We should be happy, right?

Apparently not.

I remember talking to Doc Eddie the other day and he starts off by saying “I was misquoted!”  I then got a chance to look at the article and I found myself saying to myself, “uh oh, I can see why Doc Eddie is peeved…”  I could instantly see that there were phrases and sentences that I know no educated acupuncturist would use or at the very least, were obviously taken out of context.

Here is a link to the article: http://lifestyle.inquirer.net/13691/healing-through-flowing.  I leave it to the reader to browse through it.

Understanding that most probably there were misunderstandings (boy, that’s redundant), Doc Eddie wrote a letter to the editor of the Inquirer, with the intention of clarifying statements that might unintentionally give readers the wrong ideas. With Doc Eddie’s permission I am posting the contents of that letter here:

Dear editor,
     Thank you for featuring me on your lifestyle issue (September 13, 2011: Healing through flowing).  Many of my patients and colleagues enjoyed the well-written article on Traditional Chinese Medicine and its great lay-out.  And, I enjoyed it, too.  However, I have to clarify a point which I think is very important.  On the fourth paragraph from last,  it stated that TCM is not a cure.   Perhaps, I may not have uttered it clearly but I think I said that it is not a cure-all. Because once harmony and balance is restored, we say that the patient is cured. It is not palliative since patients note the permanent effects TCM provides for conditions like migraine, trigeminal neuralgia, stroke and insomnia.  Yes, it has limits.
 But in many instances, it greatly complements Western Medicine in complicated conditions like cancer,  auto-immune disorders and a number of psychiatric disorders. Worldwide, premier hospitals offer acupuncture in physical rehabilitation for stroke and trauma, for the control of side effects in patients undergoing cancer chemotherapy and even as an adjunct in the treatment of nicotine, drug addiction and alcoholism.
I do hope I am able to help in your advocacy in promoting wellness. And, let me thank you again for the opportunity to explain a field of medicine that has helped me serve our countrymen.
  More power to you and your team.
Truly yours,
Edilberto M. Concepcion, MD
Thanks to Doc Eddie for giving me a topic to blog about again hahahaha.
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Defining Placebo: the Saint Jude Thaddeus of Medical Terminology

February 15th, 2011 No comments

I have recently begun calling the placebo effect the Saint Jude Thaddeus of Medical Terminology.  This is not because placebo effects are miraculous – although they might sometimes seem to be – but because the placebo effect (or things even remotely connected to it) has gotten a bad rap for something it didn’t do. So what’s the connection to Saint Jude?  Note this excerpt from a traditional prayer:

…faithful servant and friend of  Jesus, the name of the traitor who delivered your beloved Master into the hands of the enemies has caused you to be forgotten by many, but the Church honors and invokes you universally as the patron of hopeless cases and of things despaired of…

stjude Defining Placebo: the Saint Jude Thaddeus of Medical Terminology So basically, Judas Thaddeus got a bad rap because of Judas Iscariot, so much so that there are now two ways of translating the name into English, Judas and Jude. So what does this have to do with placebo?  First we define placebo and placebo effect:

Placebo:
a. a substance having no pharmacological effect but given merely to satisfy a patient who supposes it to be a medicine.
b. a substance having no pharmacological effect butadministered as a control in testing experimentally or clinically the efficacy of a biologically active preparation.
Placebo effect:
a reaction to a placebo manifested by a lessening of symptoms or the production of anticipated side effects.
Hence, what is at play here: first, a true placebo must have NO BIOLOGICAL EFFECT.  You give it and there should be no physiologic change in the body.
Here are some beauts from the article:
In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which “showed that real acupuncture treatments were no more effective than sham acupuncture treatments.”
The authors then editorialized: “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.”
In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which “showed that real acupuncture treatments were no more effective than sham acupuncture treatments.” The authors then editorialized: “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.”
Okay, Mr Ho, the author, correctly states that the studies show that real acupuncture and sham acupuncture both have a better effect than no acupuncture.  The problem with this meta analysis is that the definitions of sham are not universal, as correctly pointed out by at least one commenter “japariesw”:
Dear writer (Mr. Ho), this controversy emerges from clinical trials comparing real and sham acupuncture. What you did not elaborate in your article is what is meant by ‘sham’ acupuncture? As acupuncture can be done not merely by piercing needles like in the photo, but also using laser, ultrasound, even with pressure or touch/ stroking the body surface. So, is the ‘sham’ acupuncture really sham? The modality of action is through neurophysicoendocrine pathway, by any modes of stimuli like stroking, piercing, etc. our body will react by showing the therapeutic effects like wellbeing, pain relieving, blood pressure downregulating (for hypertension, but not for normotensive)
So what the commenter is saying is that acupuncture is not just sticking needles in.  I’ve blogged on this topic extensively.  Also, sham still involves either putting needles in, albeit in false points, or stroking the skin.  Either way, neuro pathways are activated and thus, there is still a net physiologic effect.  Yet Mr. Ho says:
First, they admit that pooled clinical trials of the best sort show that real acupuncture does no better than sham acupuncture. This should mean that acupuncture does not work – full stop. But then they say that both sham and real acupuncture work as well as the other and thus is useful. Translation: Please use acupuncture as a placebo on your patients; just don’t let them know it is a placebo.
The authors trotted out the same conclusion after they reviewed an important German trial which also showed acupuncture to be merely a placebo.
Note how Mr. Ho  - loves to hammer the word home: Placebo placebo placebo! Yet there are some points of his that deserve critique.  He says that acupuncture is “no better” than sham.  That is not true.  I’ve seen those studies, they are slightly better than sham.  Second, he says that that “should mean acupuncture does not work” – that is skipping too many steps in the thinking process, and a perfect illustration of my article’s point.
Acupuncture no better than sham = acupuncture is placebo = it doesn’t work. This is their creed.
As long as a physiologic effect is seen, then by definition it cannot be a placebo.  Since there are physiologic effects (albeit different ones, which I mention in my above quoted blog posts) in both sham and real acupuncture, then even sham acupuncture is not a true placebo.
Also, I want to take a closer look at placebo.  By definition it doesn’t mean doing nothing, it means no physiologic effect yet the patient having a perceived OR REAL benefit.  Hence, if I wave my hands and nothing happens it’s not placebo.  If I dress well in clinic, with my dapper tie and crisp white white coat, speak with kind, reassuring words, and the patient already feels a bit better, that’s placebo.  Heck, there is a scene from the first season of Scrubs where the main female character flashes her breasts at a patient and the patient recovers.
And doctors do that all the time – use this placebo effect.  Why? Because a placebo effect is a placebo effect only if there is a perceived or real benefit – it is ERRONEOUS to say that placebo means no effect.
Yet placebo has become a buzzword for skeptics to attack acupuncture despite the fact that it cannot possibly apply to acupuncture.
Ho heaves on:
In any randomized and blinded clinical trial of any mode of treatment for any condition, the finding that the treatment is no better than a placebo always leads to one conclusion only: It is therapeutically useless. Acupuncture, it would seem, is exempted from this rule.
Again, this is true if sham acupuncture is a true placebo, meaning it has no physiologic effect.  Common sense shows that merely touching the skin creates physiologic responses.
The rest of the article by Ho elaborates on the skeptic’s next usual attack on acupuncture and chinese medicine: it is based on astrology and thus cannot work.
For someone with a Chinese surname, I find it appalling that Ho can have such a misconception about what Qi is:
In Chinese cosmology, all life is animated by a numinous force called qi, the flow of which mirrors the sun’s apparent “movement” during the year through the ecliptic. (The ecliptic is the imaginary plane of the earth’s orbit around the sun).
Qi flow does not mirror the sun’s movement.  Duh  See my immediately preceding article for explaining what Qi is.
Moreover, everything in the Chinese zodiac is mirrored on Earth and in Man. This was taught even in the earliest systematised TCM text, the Yellow Emperor’s Canon Of Medicine, thus: “Heaven is covered with constellations, Earth with waterways, and man with channels.”
If we translated channels as blood vessels, which is a possible interpretation, would Ho be so fast as to make a supernatural component?  The mythical author of the Canon was merely using words to help the reader grasp the concept.  Instead of focusing on “waterways” Ho focuses on “constellations”
This means that if there is qi flowing around in the imaginary closed loop of the zodiac, there is qi flowing correspondingly in the body’s closed loop of imaginary meridians as well.
These meridians run from head to toe to form a network interlinking 361 points on the skin. But why are there 361 points? Since the earth takes three minutes under 24 hours to rotate 360 degrees on its axis, the sun appears to revolve through 361 degrees on the ecliptic every 24 hours. Hence 361 points. This factoid alone is sufficient to nail down the acupuncture-astrology linkage.
Since qi flows around in a closed loop, needles can be inserted at one of these points far removed from your site of pain to rechannel qi. If done well, this supposedly can cure your spot of trouble.
Who said there are 361 points?  There are more than 400.  In the Yellow Emperor’s Canon, less than 200 are mentioned.  The point is that it evolved through time, not the product of some mathemagician. Therefore, for Mr. Ho to attempt to use acupuncture point number to try to create a numerology reference is out of date.  Also, no studious TCM practitioner will say that Qi flows in a “closed loop”.  Qi interacts with environment.
It’s arguably OXYGEN or breath.  Would we say oxygen flows in our body in a closed loop?
His last line: “So should doctors check the daily horoscopes of their patients?”
My answer: I certainly don’t.
Poor poor placebo effect, it’s gotten a bad rap.
Maybe we should ask St. Jude to help enlighten the minds who know not the Placebo effect and don’t bother to really learn about TCM before trying to debunk it.
References:
“placebo.” Dictionary.com Unabridged. Random House, Inc. 14 Feb. 2011. <Dictionary.com http://dictionary.reference.com/browse/placebo>
“placebo effect.” Dictionary.com Unabridged. Random House, Inc. 14 Feb. 2011.
Ho, Andy “Pinning down Acupuncture: It’s an Illusion” 13 Feb 2001 <http://www.thejakartaglobe.com/home/pinning-down-acupuncture-its-an-illusion/422438>
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Acupuncture In Pregnancy

October 8th, 2010 No comments

I was referred a patient, three months pregnant, for management of migraine, nausea and vomiting.  (Note to skeptics, the patient was referred by her neurologist, which proves that there is definitely a way for east and west to team up.)  One can imagine the thoughts that ran through my mind, “time to review the so-called forbidden points”.

Common sense dictates that the management of a pregnant patient, using whatever medical tradition, requires special care.  Certain drugs can’t be given, certain manipulations are discouraged, etc.  Acupuncture wise, there are points that are traditionally forbidden as strong stimulation on them would cause uterine contractions.  I shan’t mention them here for fear that the less-than-holy might use these points to induce artificial abortions.  Sorry but I don’t want to advocate that.

Anyhow it got me thinking.  The points are forbidden because strong stimulation might cause contractions.  What if no stimulation is done?  This is not an exact science because I have sometimes elicited strong qi sensations from patients despite having just inserting a needle.  To be safe, avoid using aforementioned points then.

The second reason that some points are forbidden during pregnancy is because of anatomic location.  Granted, specialists in acupuncture anesthesia for cesarean sections are used to putting in six inch needles in the abdomen, but the general population, even of highly trained acupuncturists, would rather not risk having needles anywhere near a fetus.

Another school of thought is this: use the non-anatomic (first category) forbidden points, but keep the stimulation down (as mentioned before) and keep the number of needles down.  In other words, it’s not the individual point stimulation, but the sum total of all stimulations that are important to prevent premature uterine contraction.

To be safe, I keep the number of needles down, and avoid the “forbidden” points as much as possible.

And the patient’s symptoms are much improved, btw.

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Mainstream Medical Journals say Acupuncture Works; Skeptics Irritated.

September 5th, 2010 1 comment

I’m a bit tired so I’ll just quote this article and comment on it:

Outrage over Acupuncture Evidence Attacks NIH (http://www.healthcmi.com/index.php/acupuncturist-news-online/291-outrageacupunctureproofnih)

Doctors from the University of Maryland School of Medicine, Baltimore and the University of Vermont College of Medicine, Burlington published a case vignette in the New England Journal of Medicine recommending acupuncture for the treatment of lower back pain. The article cites that patients with lower back pain account for over $90 billion in annual health care expenses in the US. The doctors conclude that acupuncture is an effective means for treating lower back pain based partly on a recent study of 6,359 patients published in Spine1. For the lower back pain patient in the case study presented, 10-12 acupuncture treatments over an 8 week period are recommended.

Hmmm, why do these names sound familiar?  Oh I recall!  I had cited the University of Maryland Medical Center for it’s excellent website resource on astragalus root (Huang qi) research.  (http://qi-spot.com/2009/10/20/astragalus-root-for-swine-flu/).   Apparently, those guys are quite open minded.

So anyway, what this means is that some doctors published their opinions that acupuncture should be recommended.  Fair enough.  Everyone’s entitled to an opinion, right?  If it’s wrong, let it be proven wrong through tact and reasoning.

NOT.

The pro-acu docs cite extensive evidence:

The doctors cite physiological phenomena that measure the effects of acupuncture. Local anesthesia at needle insertion sites block the the analgesic effects of acupuncture showing that acupuncture is dependent upon neural innervation2. Acupuncture has been proven to cause the release of endogenous opioids in brain-stem, subcortical, and limbic structures3,4. Acupuncture has also been proven to induce the secretion of adrenocorticotropic hormone and cortisol from the pituitary gland thereby creating a systemic anti-inflammatory response5. Functional MRI studies in humans reveal that acupuncture stimulates limbic and basal forebrain areas involved in pain processing6. PET scan MRIs (positron-emission tomography) show that acupuncture increases opioid binding potential in the brain for several days7. Acupuncture has also been proven to mechanically stimulate connective tissues8, release adenosine at the site of needle stimulation9, and increase local blood blow10. The doctors then cite clinical trials showing the efficaciousness of acupuncture in the treatment of thousands of patients10-15.

So what do some skeptics do?  Do they try to base their argument on refuting the evidence?

Despite this overwhelming evidence proving the mechanisms of action and efficaciousness of acupuncture, skeptics were outraged at the publication of an article supportive of acupuncture in the venerable New England Journal of Medicine. An article recently posted in the Forbes “science business” section stated that the article is “embarrassing” and that acupuncture “infiltrates” the University of Maryland Medical School. In the article, the author calls acupuncture “pseudoscience” and states that it is based on “magical thinking of non-existent life-force.” The skeptic author’s only proof of his theory is that one of the many studies cited in the article found that acupuncture was only 47.6% effective for the treatment of lower back pain and that sham acupuncture was 44.2% effective. Therefore, the author concludes that using “toothpicks” randomly on the human body will have the same pain relieving effects as acupuncture. What the author fails to mention in the Forbes attack article is that conventional western medicine therapy (a combination of drugs, physical therapy, and exercise) was only 27.4% effective in that very same study. Should we therefore abolish western medicine by MDs and call it pseudoscience? Acupuncturists have noted that the success of sham acupuncture noted in that particular study of 1,162 patients in Germany reveals that poorly placed acupuncture needles also derive benefit for the patient.

I have already blogged at length on the physiologic differences between sham and real acupuncture (http://qi-spot.com/2010/04/30/definite-proof-acupuncture-more-than-placebo/) and why it SEEMS that acupuncture is hard to validate using holy grail of western medicine studies – the double blind study (http://qi-spot.com/2010/03/30/how-to-research-acupuncture/).

What I also find interesting is the insistence of skeptics that acupuncture works by balancing Qi or something.  That is the lynchpin of their argument.  I can hear it now:

Skeptic: “They believe in some quasi mystical energy flow!  That means acupuncture MUST be quackery!”

Acupuncturist:  ”There are modern, scientifically proven phenomena that explains what we mean by qi flow.  The “needling sensation” is a result of stimulation of nerve fibers, and can be inhibited by certain drugs.  Qi can also be used to mean function, so when “qi” is deficient, one can say there may be decreased circulation to a certain area, or decreased organ function.  An excess of qi can mean a muscle is too tense… (cites more examples)”

Skeptic: (oblivious) “They believe in some quasi mystical energy flow!  That means acupuncture MUST be quackery!”

Acupuncturist:  ”Never mind.”

Seriously, I feel that way sometimes, talking to skeptics.  What’s the point?  You can treat pain in these people and they’ll assign all sorts of reasons EXCEPT the obvious – acupuncture works.

The use of the word “toothpick” also indicates a lack of even a basic awareness of how acupuncture is performed.  You don’t just “prick” people, you insert the needle and manipulate it.

Oh well…

And lastly, a list of references cited by the link I cited…

References

1. Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of acupuncture for low back pain: a systematic review. Spine 2008;33:E887-E900.

2. Wang SM, Kain ZN, White P. Acupuncture analgesia: I. The scientific basis. Anesth Analg 2008;106:602-10.

3. Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci 2003;26:17-22.

4. Pomeranz B. Scientific research into acupuncture for the relief of pain. J Altern Complement Med 1996;2:53-60.

5. Li A, Lao L, Wang Y, et al. Electroacupuncture activates corticotrophin-releasing hormone-containing neurons in the paraventricular nucleus of the hypothalamus to alleviate edema in a rat model of inflammation. BMC Complement Altern Med 2008;8:20.

6. Dhond RP, Kettner N, Napadow V. Neuroimaging acupuncture effects in the human brain. J Altern Complement Med 2007;13:603-16.

7. Harris RE, Zubieta JK, Scott DJ, Napa- dow V, Gracely RH, Clauw DJ. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opioid receptors (MORs). Neuroimage 2009;47:1077-85.

8. Langevin HM, Churchill DL, Wu J, et al. Evidence of connective tissue involvement in acupuncture. FASEB J 2002;16:872-4.

9. Goldman N, Chen M, Fujita T, et al. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nat Neurosci 2010 May 30 (Epub ahead of print).

10. Sandberg M, Lundeberg T, Lindberg LG, Gerdle B. Effects of acupuncture on skin and muscle blood flow in healthy subjects. Eur J Appl Physiol 2003;90:114-9.

11. Brinkhaus B, Witt CM, Jena S, et al. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 2006;166:450-7.

12. Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, paralel-group trial with 3 groups. Arch Intern Med 2007;167:1892-8. [Erratum, Arch In- tern Med 2007;167:2072.]

13. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch In- tern Med 2009;169:858-66.

14. Thomas KJ, MacPherson H, Thorpe L, et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ 2006; 333:623. 15. Witt CM, Jena S, Selim D, et al. Prag- matic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 2006;164:487-96.

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