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accupuncture

Discussion in 'Pain Medicine' started by C Fiber, Aug 8, 2006.

  1. C Fiber

    C Fiber Member
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    Anyone doing accupuncture out there? How do you bill for it? What kind of certification do you need?
     
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  3. wonthurtabit1

    wonthurtabit1 Member
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    I wish I was doing more acupuncture. Harvard has a great 9 month course which gives you a certificate of medical acupuncture. There are also other courses, such as the Helms course out of UCLA which many docs have taken. I hope one day to integrate it into my practice in a more meaningful way. I know that I just scratched the surface (or poked the surface) of a medical tradition w/ records going back 5000 plus years.

    However, none of these courses compare to what acupuncture students learn in 4 years. Remember what it took for us to become doctors? Also, acupuncture is just the tip of the iceberg.... the easy part... to truly become an effective practitioner of eastern medicine one should know herbs. There are a host of books out there on neuroanatomical acupuncture. They give you a dx and a few points, and you point and shoot. IMHO this is a joke. Perhaps it works for acute, mild cases. It certainly does not encourage the practitioner to understand 5 element theory or lifestyle modification for health and disease.

    If I am not mistaken, an MD does not even need a certification to practice, your MD is enough. Now if you have a nanogram of an ethical conscience you might want to get training or do more than read a paint-by-numbers book.

    You have hit a rant topic for me. I think most MDs should not be practicing acupuncture bc they aren't competant. How ethnocentric to think you can pick it up in a few weekends? I thought about going back to acupuncture school, but had to eventually make a living.

    Also, in so many of these acupuncture trials where the results are unimpressive, who was performing the acupuncture? If they were MDs, for the most part, I would question the study.

    How to bill? I don't know. I do know that a lot of MDs are simply raking in the bucks w/ cash practices. I won't even comment further on that!!!
     
  4. octrode

    octrode Junior Member
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    couldn't agree more about the ethnocentricity!
     
  5. chinochulo

    chinochulo Member
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    If you open up a boutique shop in some swanky area of town, say Beverly Hills, Scottsdale, or Upper East Side, I am sure people will pay top cash dollar.

    To make money doing acupuncture, I think you would likely need to set aside an afternoon or a day a week. Logistically, it is difficult to mix in any interventional pain procedures at the same time. Once you have enough patients, you have to rotate yourself between three rooms, kinda like an orthopod rotating between knee arthroscopies in three rooms.

    Also, since there are different styles of acupuncture, it depends whether you practice the Chinese or Japanese method, for example. In Chinese style, you would likely insert the needle in a pre-determined acupuncture point based on patient's complaints, whereas in Japanese style, you need to manipulate the needle at the acupuncture point to gauge response to your treatment. More time consuming, unless you've been practicing it for years.
     
  6. paz5559

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    Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S, Irnich D, Walther HU, Melchart D, Willich SN. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med. 2006 Feb 27;166(4):450-7. PMID: 16505266

    Institute of Social Medicine, Epidemiology, and Health Economics, Charite, University Medical Center, Berlin, Germany. [email protected]

    BACKGROUND: Acupuncture is widely used by patients with low back pain, although its effectiveness is unclear. We investigated the efficacy of acupuncture compared with minimal acupuncture and with no acupuncture in patients with chronic low back pain. METHODS: Patients were randomized to treatment with acupuncture, minimal acupuncture (superficial needling at nonacupuncture points), or a waiting list control. Acupuncture and minimal acupuncture were administered by specialized acupuncture physicians in 30 outpatient centers, and consisted of 12 sessions per patient over 8 weeks. Patients completed standardized questionnaires at baseline and at 8, 26, and 52 weeks after randomization. The primary outcome variable was the change in low back pain intensity from baseline to the end of week 8, as determined on a visual analog scale (range, 0-100 mm). RESULTS: A total of 298 patients (67.8% female; mean +/- SD age, 59 +/- 9 years) were included. Between baseline and week 8, pain intensity decreased by a mean +/- SD of 28.7 +/- 30.3 mm in the acupuncture group, 23.6 +/- 31.0 mm in the minimal acupuncture group, and 6.9 +/- 22.0 mm in the waiting list group. The difference for the acupuncture vs minimal acupuncture group was 5.1 mm (95% confidence interval, -3.7 to 13.9 mm; P = .26), and the difference for the acupuncture vs waiting list group was 21.7 mm (95% confidence interval, 13.9-30.0 mm; P<.001). Also, at 26 (P=.96) and 52 (P=.61) weeks, pain did not differ significantly between the acupuncture and the minimal acupuncture groups. CONCLUSION: Acupuncture was more effective in improving pain than no acupuncture treatment in patients with chronic low back pain, whereas there were no significant differences between acupuncture and minimal acupuncture.


    Leibing E, Leonhardt U, Koster G, Goerlitz A, Rosenfeldt JA, Hilgers R, Ramadori G. Acupuncture treatment of chronic low-back pain -- a randomized, blinded, placebo-controlled trial with 9-month follow-up.
    Pain. 2002 Mar;96(1-2):189-96. PMID: 11932074

    There is some evidence for the efficacy of acupuncture in chronic low-back pain (LBP), but it remains unclear whether acupuncture is superior to placebo. In a randomized, blinded, placebo-controlled trial, we evaluated the effect of traditional acupuncture in chronic LBP. A total of 131 consecutive out-patients of the Department of Orthopaedics, University Goettingen, Germany, (age=48.1 years, 58.5% female, duration of pain: 9.6 years) with non-radiating LBP for at least 6 months and a normal neurological examination were randomized to one of three groups over 12 weeks. Each group received active physiotherapy over 12 weeks. The control group (n=46) received no further treatment, the acupuncture group (n=40) received 20 sessions of traditional acupuncture and the sham-acupuncture group (n=45) 20 sessions of minimal acupuncture.Changes from baseline to the end of treatment and to 9-month follow-up were assessed in pain intensity and in pain disability, and secondary in psychological distress and in spine flexion, compared by intervention groups.Acupuncture was superior to the control condition (physiotherapy) regarding pain intensity (P=0.000), pain disability (P=0.000), and psychological distress (P=0.020) at the end of treatment. Compared to sham-acupuncture, acupuncture reduced psychological distress (P=0.040) only. At 9-month follow-up, the superiority of acupuncture compared to the control condition became less and acupuncture was not different to sham-acupuncture.We found a significant improvement by traditional acupuncture in chronic LBP compared to routine care (physiotherapy) but not compared to sham-acupuncture. The trial demonstrated a placebo effect of traditional acupuncture in chronic LBP.


    Take home message - acupuncture is no better than sham, but is better than nothing (ie there is a placebo effect assoc c needle insertion)
     
  7. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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    This has already been covered...



    Plus I'll add something. First off, I love the Germans for doing so much research. They are really leading the way by pumping out study after study. That being said, there is are some major differences between how the German MDs do acupuncture and how we learn it in the US. I haven't seen these specific studies, but the usual problems [not going to use the word error] with the German studies are:

    1. The treatment protocol differs from what would be done in the US, sometimes to a small degree, sometimes to a major degree - my responses have ranged from "hmm, I wonder why they added that point" to "what the hell is the protocol for?".

    2. The "sham" treatment is sometimes not really a sham treatment at all. This can vary from a great sham treatment (I can't see any possible treatment effects) to a great musculo-skeletal / Trigger Point treatment (hardly a sham treatment). Without looking at the specific, it is impossible to tell the difference, but this has been happening quite a bit.

    3. The number of the patients in each treatment group is too small to see significant differences between the two groups.


    I'll try and get these articles so I can give you my slightly biased professional opinion.
     
  8. algosdoc

    algosdoc algosdoc
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    Strong work Paz...thanks
     
  9. paz5559

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    Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S, Irnich D, Walther HU, Melchart D, Willich SN. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med. 2006 Feb 27;166(4):450-7. PMID: 16505266

    METHODS
    PROTOCOL, DESIGN, AND RANDOMIZATION

    The Acupuncture Randomized Trial in Low Back Pain was a randomized, controlled, multicenter trial comparing acupuncture with minimal acupuncture and with a no acupuncture waiting list control. Minimal acupuncture served as a sham intervention; the additional no acupuncture waiting list control was included because minimal acupuncture may not be a physiologically inert placebo. In the acupuncture and minimal acupuncture groups, patients were blinded with regard to treatment. The Acupuncture Randomized Trial in Low Back Pain was part of a larger acupuncture project initiated by the German Federal Committee of Physicians and Health Insurers. The committee recommended that studies be conducted on the efficacy of acupuncture in the treatment of pain for 3 diseases, including chronic low back pain. The methods used in this trial and the results of the other 3 trials have been described in detail elsewhere. (Brinkhaus B, Becker-Witt C, Jena S, et al. Acupuncture Randomized Trials (ART) in patients with chronic low back pain and osteoarthritis of the knee: design and protocols. Forsch Komplementarmed Klass Naturheilkd. 2003;10:185-191. Linde K, Streng A, Jurgens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005;293:2118-2125. Witt C, Brinkhaus B, Jena S, et al. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet. 2005;366:136-143. Melchart D, Streng A, Hoppe A, et al. Acupuncture in patients with tension-type headache: a randomised trial. BMJ. 2005;331:376-382.)

    Patients were randomized in a 2:1:1 (acupuncture–minimal acupuncture–waiting list) ratio using a centralized telephone randomization procedure (a randomized list was generated using computer software [SAMPSIZE V2.0]). The study was performed according to common guidelines for clinical trials (Declaration of Helsinki, version Edinburgh 2000, International Conference on Harmonisation Good Clinical Practice, including certification by external audit). The protocol was approved by the local ethics review boards in all regions where the study was conducted. All study participants
    provided written informed consent.

    PARTICIPANTS
    Most participants were recruited through articles in local newspapers; a few patients spontaneously contacted trial centers. The inclusion criteria were as follows: clinical diagnosis of chronic low back pain with a disease duration of more than 6 months (further diagnostic results were not required), aged 40 to 75 years, average pain intensity of 40 or more on a 100-mm visual analog scale on the previous 7 days, only use of oral nonsteroidal anti-inflammatory drugs for pain treatment in the 4 weeks before treatment, and written consent. The main exclusion criteria were as follows: protrusion or prolapse of 1 or more intervertebral discs with concurrent neurological symptoms; radicular pain; prior vertebral column surgery; infectious spondylopathy; low back pain caused by inflammatory, malignant, or autoimmune disease; congenital deformation of the spine (except for slight lordosis or scoliosis); compression fracture caused by osteoporosis; spinal stenosis; spondylolysis or spondylolisthesis; patients with Chinese medicine diagnoses warranting treatment with moxibustion (determined by trial physicians); and any acupuncture treatment during the past 12 months.

    INTERVENTIONS
    The selection criteria of acupuncture physicians were as follows: at least 140 hours of acupuncture training (median, 350 hours), at least 3 years of experience (median, 10 years) in acupuncture treatment, and participation in the investigators’ meetings. The treatment strategies for acupuncture and minimal acupuncture were developed in a consensus process with acupuncture experts from 2 major German societies for medical acupuncture. The acupuncture and minimal acupuncture treatments consisted of 12 sessions of 30 minutes’ duration, each administered over 8 weeks (usually 2 sessions in each of the first 4 weeks, followed by 1 session per week in the remaining 4 weeks). Acupuncture treatment was semistandardized. All patients were treated with a selection of local and distant points, including (bilaterally) at least 4 local points from the following selection: bladder 20 to 34; bladder 50 to 54; gallbladder 30; governing vessel 3, 4, 5, and 6; and extraordinary points Huatojiaji and Shiqizhuixia. Also, physicians selected and needled bilaterally at least 2 distant points from the following sample: small intestine 3; bladder 40, 60, and 62; kidney 3 and 7; gallbladder 31, 34, and 41; liver 3; and governing vessel 14 and 20. In the event that patients were experiencing local or pseudoradicular sensation, at least 2 local points were acupunctured. In addition, other acupuncture points, including ear and trigger points, could be chosen individually. Sterile, disposable, 1-time needles had to be used; needle length and diameter were not predefined. Physicians were instructed to achieve de qi (an irradiating feeling), if possible. Needles were to be stimulated manually at least once during each session. The number, duration, and frequency of the sessions in the minimal acupuncture group were the same as for the acupuncture group. In each session, at least 6 of 10 predefined nonacupuncture points were needled bilaterally using a superficial insertion with fine needles (length, 20-40 mm). These points were not in the area of the lower back where the patients were experiencing pain. De qi and manual stimulation of the needles were avoided. All acupuncturists received a videotape, oral instruction, and a brochure showing detailed information onminimal acupuncture. Patients in the waiting list group did not receive acupuncture treatment for 8 weeks after randomization. After that period, they received 12 sessions of the acupuncture treatment previously described. Patients were allowed to treat chronic low back pain with oral nonsteroidal anti-inflammatory drugs, if required. The use of corticosteroids or pain-relieving drugs that act through the central nervous system was prohibited. Patients were informed about acupuncture and minimal acupuncture in the study as follows: “In this study, different types of acupuncture will be compared. One type is similar to the acupuncture treatment used in China. The other type does not follow these principles, but has also been associated with positive outcomes in clinical studies.”

    OUTCOME MEASUREMENT
    All patients completed a modified version of the pain questionnaire published by the German Society for the Study of Pain at baseline and after 8, 26, and 52 weeks. The pain questionnaire includes questions on sociodemographic characteristics, pain intensity (visual analog scale), back function (validated German questionnaire Funktionsfragebogen Hannover-Rucken),14 global assessment of treatment effects, and the following validated scales: (1) the German version of the Pain Disability Index,15 (2) a scale for assessing the emotional aspects of pain (Schmerzempfindungsskala),16 (3) a depression scale (Allgemeine Depressionsskala),17 and (4) the German version of the 36-Item Short-Form Quality of Life Questionnaire to assess health-related quality of life.18 The number of days with pain and taking pain medication was documented in a diary by the patients between baseline and week 8. The primary outcome variable was the change in low back pain intensity from baseline to the end of week 8 after randomization, as measured by a visual analog scale (range, 0-100 mm). The trial physicians documented medical history and examination results at baseline, study intervention in detail, and any serious adverse events. In addition, adverse effects were documented by patients at the end of week 8. To test blinding to treatment and assess the credibility of the respective treatment methods, patients complete a credibility questionnaire after the third acupuncture session. At the end of the study, patients were asked whether they thought they had received acupuncture following the principles of Chinese medicine or the other type of acupuncture.
     
  10. paz5559

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    Leibing E, Leonhardt U, Koster G, Goerlitz A, Rosenfeldt JA, Hilgers R, Ramadori G. Acupuncture treatment of chronic low-back pain -- a randomized, blinded, placebo-controlled trial with 9-month follow-up.
    Pain. 2002 Mar;96(1-2):189-96. PMID: 11932074

    2. Methods

    2.1. Study design
    The randomized, placebo-controlled, prospective study was conducted at the outpatient clinic of the Department of Orthopaedics, University Goettingen, Germany, from January 1996 to July 1998. It was performed according to the acupuncture guidelines of the World Health Organisation (World Health Organisation, 1995) and to the proposals of the National Institute of Health (Ramsay et al., 1998). It was approved by the local Ethics Committee. One hundred and fifty out-patients met the entry criteria (non-radiating pain for more than 6 months) and were assigned to one of the three treatment groups (traditional acupuncture, sham-acupuncture, control) using a computer-based randomization process. Treatment records were kept separately from assessment records, so that the physician was unaware of the affiliation of the patients. Patients were blinded regarding traditional and sham-acupuncture. The clinician performing the acupuncture (Dr Li) had to know the group affiliation. The patients were advised to continue existing medication but not to commence any new analgesic or treatment.

    2.2. Patient selection A consecutive sample of n ¼ 150 out-patients aged 18–65 years with non-radiating LBP for at least 6 months were included initially. Exclusion criteria were an abnormal neurological status, concomitant severe disease, psychiatric illness, current psychotherapy, pathological lumbosacral anterior-posterior and lateral X-rays (except for minor degenerative changes), rheumatic inflammatic disease, planned hospitalization, and refusal of participation. The 150 patients gave informed consent and were randomized. Nineteen patients had to be excluded after randomization, but prior to treatment. There were no significant differences between the groups (P ¼ 0:762, Fisher’s exact test, 3 £ 3 table) regarding the reason for exclusion. Six patients withdrew their given consent (AG:3; SG:1; CG:2), in 11 patients (AG:5; SG:4; CG:2) exclusion criteria (e.g. painlessness, hospitalization, severe disease) appeared prior to treatment, and two patients relocated (AG:2). Thus, the final study sample included 131 patients.

    2.3. Study procedures
    At baseline (T0, week 0), all patients underwent a complete evaluation including a medical history, a routine physical examination, a comprehensive physical examination of the lumbar spine, and a neurological investigation. The physical assessments including evaluation of spine flexion and the other outcome variables were performed by a blinded physician (Dr Rosenfeldt) at baseline (T0, week 0), at the end of treatment (T1, week 12), and 9 months after the end of treatment (T2, 9-month follow-up, week 52). The data documentation was done by a collaborator (M. Koehler) of the Department of Medical Statistics, Biometrical Study Center.

    2.4. Interventions
    All patients received standardized active physiotherapy of 26 sessions (each 30 min) over 12 weeks. It was performed by trained physiotherapists according to the Bruegger-concept (Bruegger, 1990), in which nociceptive somato-motoric blocking effects were seen as causal factors in pain syndromes. The aim was to remove a muscle imbalance through special training of proper posture and motion. The control group (CG) received active physiotherapy with no other treatment (routine care). The acupuncture
    group (AG) additionally received 20 sessions (each 30 min) of traditional and standardized acupuncture by an experienced Taiwanese physician (Dr Li) over 12 weeks. Dr Chien-Kang Li obtained his degrees at the University for Chinese Culture, Taipeh (Taiwan), and at the University of Goettingen, Germany. In the first 2 weeks of treatment, acupuncture was done five times a week, and in the next 10 weeks once a week. Acupuncture was performed as combined traditional body- and ear-acupuncture (Stux and Pomeranz, 1990). No additional intervention or conversation was done, except for a short explanation about the procedure. Patients were first treated supine for body-acupuncture, and then seated for ear-acupuncture. Twenty fixed body acupoints (nine bilateral, two single points) and six on the ear (alternately on one ear) were selected according to their function in traditional Chinese medicine (Stux and Pomeranz, 1990; World Health Organisation, 1993) and were needled in every patient (Table 1). We did not conduct a diagnostic procedure to determine individual acupoints. Depth of body needling depended on the location of the acupoints and upon the body build (min to max 10–30 mm). Needles were correctly inserted and manually stimulated at the body points until the ‘de qi’ sensation of heaviness and numbness was elicited, lasting 5–20 s. Body needles were left in situ for 30 min, ear needles were not stimulated and left in situ for 1 week. Wrapped one-way, stainless steel, sterilized needles, produced by Shenzou, Suzhan Hua Tuo, China were used. Body needles were 0.3 mm in thickness and 40 mm in length, ear needles 0.23 mm in thickness and of standardized size (small, medium). Ear needles were ring-shaped and fixed by plaster.

    The sham-acupuncture group (SG) received 20 sessions (each 30 min) of minimal acupuncture by the same physician (Dr Li) over 12 weeks. Sham-acupuncture was done following the standards of minimal acupuncture (Vincent and Lewith, 1995). Needles were inserted superficially, 10–20 mm distant to the verum-acupoints, outside the meridians, and were not stimulated (no ‘de qi’). Each acupuncture procedure (location of the acupoints and duration of needling) was documented to look for the
    compliance to the acupuncture protocol.

    2.5. Efficacy
    Primary outcome measures were pain intensity, quantified by a 10 cm visual analog scale (VAS-P, Scott and Huskisson, 1976) and pain disabilty, measured by the pain disability index (PDI, Tait et al., 1990). The total score consisting of seven areas of activity (min to max 0–70) measures the overall level of disability using numeric rating scales (0 ¼ no disability; 10 ¼ total disability). Secondary outcome measures were psychological distress and spine flexion. Psychological distress was measured by the hospital anxiety and depression scale (Zigmond and Snaith, 1983), a 14 item instrument for use in non-psychiatric medical patients. The total score (range 0–42) is a measure of psychological distress. Because there is a strong relationship between psychological distress and chronic pain, this is a relevant outcome parameter in the treatment of chronic pain patients (Craig, 1999). Spine flexion was measured by fingertip-to-floor distance (min 0 cm).

    2.6. Safety
    Safety was evaluated on the basis of the physical examinations and the patient-reported study events.
     
  11. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    My sense is that the analgesic properties of "the modalities" (acupuncture, manipulation, massage, etc) are grounded in the physiology of good 'ol fashioned counter-irritation.

    Moreover, their analgesic potency, as measured by VAS and other soft self-report outcomes, is approximately 1/3 of OTC NSAIDs. This may be a hurdle for designing clinical trials, but for clinical practice can be therapeutic when used under conditions that optimize other "non-specific" treatment effects (physician-patient rapport, expectany, natural history, and regression to the mean).



    N Engl J Med. 2001 May 24;344(21):1594-602.

    Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment.

    Hrobjartsson A, Gotzsche PC.

    Department of Medical Philosophy and Clinical Theory, University of Copenhagen, Panum Institute, and the Nordic Cochrane Centre, Rigshospitalet, Denmark. [email protected]

    BACKGROUND: Placebo treatments have been reported to help patients with many diseases, but the quality of the evidence supporting this finding has not been rigorously evaluated. METHODS: We conducted a systematic review of clinical trials in which patients were randomly assigned to either placebo or no treatment. A placebo could be pharmacologic (e.g., a tablet), physical (e.g., a manipulation), or psychological (e.g., a conversation). RESULTS: We identified 130 trials that met our inclusion criteria. After the exclusion of 16 trials without relevant data on outcomes, there were 32 with binary outcomes (involving 3795 patients, with a median of 51 patients per trial) and 82 with continuous outcomes (involving 4730 patients, with a median of 27 patients per trial). As compared with no treatment, placebo had no significant effect on binary outcomes (pooled relative risk of an unwanted outcome with placebo, 0.95; 95 percent confidence interval, 0.88 to 1.02), regardless of whether these outcomes were subjective or objective. For the trials with continuous outcomes, placebo had a beneficial effect (pooled standardized mean difference in the value for an unwanted outcome between the placebo and untreated groups, -0.28; 95 percent confidence interval, -0.38 to -0.19), but the effect decreased with increasing sample size, indicating a possible bias related to the effects of small trials. The pooled standardized mean difference was significant for the trials with subjective outcomes (-0.36; 95 percent confidence interval, -0.47 to -0.25) but not for those with objective outcomes. In 27 trials involving the treatment of pain, placebo had a beneficial effect (-0.27; 95 percent confidence interval, -0.40 to -0.15). This corresponded to a reduction in the intensity of pain of 6.5 mm on a 100-mm visual-analogue scale. CONCLUSIONS: We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.


    J Clin Epidemiol 1991;44(6):613.

    Sensitivity of effect variables in rheumatoid arthritis: a meta-analysis of 130 placebo controlled NSAID trials.

    Gotzsche PC.

    Medical Department A, Rigshospitalet, Copenhagen, Denmark.

    In a meta-analysis of placebo controlled NSAID trials, the sensitivity of the effect variables was calculated as the correlation coefficient and as the difference between drug and placebo, divided by the placebo group standard deviation. The patient's global evaluation was the most sensitive variable overall. Pain was more sensitive than Ritchie's index. Several variables may be omitted from clinical trials, especially if two active drugs are being compared. For example, the best maximum estimate for the difference in ESR between NSAIDs and placebo was 1.0 mm/hr (95% confidence interval -1.5 to 3.4 mm/hr), and for joint size 0.44% (-1.0 to 1.9%), corresponding to a quarter of a millimeter for each of the 10 joints usually measured. It is suggested to record only the patient's global evaluation, pain, and morning stiffness.
     
  12. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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  13. Kwijibo

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    Why don't you pull up some of the literature on how effective alot of the stuff we do is...
     
  14. wonthurtabit1

    wonthurtabit1 Member
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    okay algos
    ya gotta weigh in here? what do you think of acupuncture? do you agree w/ paz's statement about the take home message?
     
  15. drrinoo

    drrinoo Rinoo Shah, MD
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    One cannot overlook the fact that acupuncture has crossed the threshold to be studied in the journals with the highest impact factors and most rigorous peer review process.

    There is no other interventional pain treatment or spinal surgery that has consistently met this threshold, as well as enroll the number of patients in these studies.

    Acupuncture is an interventional pain treatment that has been around for thousands of years, that has wide acceptance by millions, that has been used before oral analgesics were even available, that has technically evolved from large wooden spikes to 30 gauge needles, that has reintroduced Western civilization to the concept of 'counter-irritation', that has an incredible safety profile.....yet it cannot cross the most rigorous threshold of EBM (NEJM, Lancet, Arch of Int Medicine).

    If we live in a society that can only offer EBM pain procedures that cross this high threshold, we have no business practicing as pain physicians....since there is nothing we can offer our patients. It would be far more productive for all of us to get back to the labs and find real solutions....and perhaps find treatments our great grandchildren can offer their patients.
     
  16. gecko

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    Kudos to you, Dr. Shah for that last post.

    I'm busy studying for the PMR boards right now, but after that, I'll gather some acupuncture literature to add to this post.
     
  17. Ligament

    Ligament Interventional Pain Management
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    I TOTALLY agree with this sentiment. Also, if you can't read chinese I don't know if you can be an excellent chinese medicine practitioner. Do you know any great allopathic medical doctors that can't read english?

     
  18. paz5559

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    Uh, yah ... as Dr. Shah will tell you, there is terrific work being done all over asia (japan, korea, china, and the subcontnent) by non-english speakers. geez, talk about a myopic, xenophobic viewpoint!
     
  19. Ligament

    Ligament Interventional Pain Management
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    Note I said READ not speak. However, I have to admit this was not the best thought out comment I've made. Studying for the boards...

    I still don't see how one could be an outstanding chinese medicine physician if illiterate in chinese. The chinese medical literature is 5000 years old, and in chinese medicine, old is not obsolete like so much in allopathic medicine. Probably less than 0.1% of it has been translated from chinese.

     
  20. nolagas

    nolagas Member
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    Age is not evidence for efficacy. Constantly talking about how old this stuff is adds nothing. You don't have to study for 4 years or read chinese to randomly put needles in a person. And random placement is just as good as placement based on a persons mythical chi.
     
  21. wonthurtabit1

    wonthurtabit1 Member
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    I continue to be impressed at how so many on this forum can dismiss a medical practice that is over 5000 yrs old. I know time is not the only test of efficacy, but folks are dissing beliefs/practices held by 1 billion people. Isn't that a ethnocentric? dare I say racist? Also, perhaps the western based scientific method has biases that we don't even recognize. Witness how placebo or complex social interaction continues to baffle us? The scientific method depends on being able to control discrete variables. We can't measure or see or understand everything. Wasn't it Fritzof Capra who wrote about the observer effect in the Tao of Physics. The scientific method is not the holy grail for research. No question it has its strengths, but I protest when it is used to dismiss acupuncture as no better than sham.

    Are you folks saying that chi is nonsense and therefore so is tai chi, yoga, meditation, and so forth. What do we do w/ pesky things like emotions: anger? what is love? what is faith? are they real? Does prayer help people heal, what about remote prayer? There is so much we have to understand. Remember it was only very recently that words like psychoneuroimmunobiology entered our lexicon.

    Remember, as allopathic doctors we have been indoctrinated to see and understand the world in a particular way. One way, like one spoke to the center of the wheel. There are many equally valid and efficacious ways to understand and treat human illness and disease: chinese medicine, ayurveda, and many more. Why don't you pick up the classic book by the Yellow Emperor: the 5 elements or a book by Kiko Matsumoto?

    Doesn't anyone remember being told in medical school the following:
    "50% of what we are teaching you is wrong, the trouble is we don't know which 50%". In 20 yrs, we will laugh at some of the things we are doing now. We don't have the holy grail to pain medicine.

    I know, you want literature to support my points -- i gotta contact an old prof and see what he has to share, so stay tuned. And stay open-minded.
     
  22. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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    I apologize for dropping the ball on the studies. I had a critique of the first study that I typed up...then Safari had a browser error and I lost the entire post. I was going to go back and retype it later but then I started my accelerated BSN program - not very difficult, just mountains of hopefully relevant information.


    Anyway, the cliff-notes version of the first study:

    1. Median time of training of the medical acupuncturists was around 300 hours. Are you serious? I spent more time getting butchered by me fellow acupuncture students practicing needling technique before we even saw patients. It is absolutely ridiculous to think this much training makes a person competent, even if they are very gifted or intelligent. I will entertain the thought that a medical doctor could probably learn a strictly musculo-skeletal style of acupuncture in less time than your average acupuncturist, but it would take much longer than 300 hours.

    This is why the years of experience is somewhat irrelevant. For one, we don't know how many patients they saw during that time - it could be a few acupuncture patients a week or fifty. It also doesn't say if these poorly trained medical acupuncturists were supervised by someone that was competent for their first few years.

    2. Actual treatment. This is one of hardest parts of an acupuncture study because it is a catch 22: if you don't individualize the treatment for the patient, then we can argue that you really aren't doing acupuncture in the traditional sense...but if you don't list the points that are used, then we can't judge the quality of the treatment protocol. This obviously can get quite ugly, and we normally have to just have "faith" that the treatment protocol is solid...but looking at the qualifications of the providers...sigh.

    I drew out all of the points listed and determined that, by using certain possible combinations of the points, some really solid treatments could have been done. But it was also possible to have some mediocre treatments, which would depend on the quality of the pratitioners. Once again, oops.

    Personally I would have used electro, which I tend to use on all lower back pain patients if they have a spinal injury, but they probably didn't want to through more noise into the study.

    3. Sham treatment. Unfortunately, the sham treatment was not described in enough detail to determine if it was truly a sham treatment or not. Some styles of acupuncture do shallow insertion without De qi, and apparently they can be quite successful (I've never done this style but I know people that do).

    4. Number of patients - since I'm going from memory, I don't recall if the number of patients was sufficient enough to see difference between the two [possibly flawed] treatment groups.

    5. Measurement of outcomes. If the treatments only lasted for eight weeks, why would an assessment of outcomes extend all the way out to 52 weeks? Is this a standard protocol for medical pain trials? Usually, acupuncture would be given for 4 - 8 weeks, with follow-up treatments every 4-6 weeks. This is much more effective than treating for 8 weeks, then having no more follow-ups.


    As I mentioned, this isn't fresh in my mind so I might have made some errors [which I'm sure will be pointed out]. I started to analyze the second study but I don't have the time right now. Perhaps somebody else would like to try.

    Oh, and as much as I have reservations about the onslaught of possibly flawed acupuncture research coming from Germany, I do intend on going over there in about 5 years and learning from some of the researchers...then I plan on doing a brewery tour across Europe.

    My fiance, who is also an acupuncturist, works with a man who recieved his acupuncture training in Germany. She hasn't had much of a chance to talk shop with him, but she has seen some of his charts, and is confused by the treatment protocols he uses. Hopefully in a few weeks I'll get the chance to talk with him and see if there is something I am missing.




    Edit - I do have to add that acupuncture is not 5000 years old. Chinese Herbal medicine is estimated to go back about 5000 years, but a conservative estimate of the age of acupuncture is about 2500 years. The reason for some of the confusion is that the first book of CM, called the Huang Di Nei Jing, is attributed to the legendary leader Huang Di and his chief doctor, Qi Bo [if I remember correctly], who supposedly was the leader of China 5K years ago. But it is doubtful that Huang Di ever existed, which is a common theme in Chinese literature - works that are written at one period in time are attributed back to a famous person in the past, or in this case, an immortal.

    A more reasonable estimate puts the writing of the Huang Di Nei Jing to about 200 BCE. Drawings on shells of people possibly doing acupuncture have been traced back to about 1000 BCE, but I forget the details.
     
  23. paz5559

    10+ Year Member

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    Ah yes, the old western vs eatern medicine gambit

    The problem is, you believe we need to stay open minded - I believe we ned to stay skeptical toward ALL treatments, Eastern,Western, Martian, or whatever, until they are proven more efficacious than placebo. Does that make me enthnocentric? Come on ...
     
  24. algosdoc

    algosdoc algosdoc
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    It is difficult to understand how so many believe in acupuncture when the western study evidence is so strongly demonstrative of placebo effect. Could it be that when an entire population is trained to believe in one system of medicine, that the placebo effect is overwhelmingly positive? Or if there is a ubiquitous belief system present in a population regarding the merits of a given therapy, then perhaps the outcomes are not placebo at all in that culture, but would be considered as part of a standard therapy, since the placebo effect is absorbed into the culture as a positive therapeutic intervention.
    Hmmmm.....
    Perhaps I had better go back to studying Chinese...
     
  25. wonthurtabit1

    wonthurtabit1 Member
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    Algos, you bring up a fascinating point. Acupuncture/herbs probably may work better on when done by Chinese or Japanese acupuncturists, in the same country on patients of the same the ethnicity.

    I appreciate Josh's input regarding the studies; as an MD w/ only 300 hrs of training I know that I know very little about acupuncture. He is probably in the best position to critique their study. Josh's point about the sham treatment is also interesting, if they did the same points, but not as deep that is the technique commonly taught in Japan and therefore may be just as effective as deeper needling to get a de-chi response.
     
  26. wonthurtabit1

    wonthurtabit1 Member
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    Algos, you bring up a fascinating point. Acupuncture/herbs probably may work better when done by Chinese or Japanese acupuncturists, in the same country on patients of the same the ethnicity.

    I appreciate Josh's input regarding the studies; as an MD w/ only 300 hrs of training I know that I know very little about acupuncture. He is probably in the best position to critique their study. Josh's point about the sham treatment is also interesting, if they did the same points, but not as deep that is the technique commonly taught in Japan and therefore may be just as effective as deeper needling to get a de-chi response.
     
  27. wonthurtabit1

    wonthurtabit1 Member
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    Dude, remember the journalist who went to China in the early 70's and watched patient's undergo major surgery w/ just acupuncture for anestheia. Do you want to try just taking a few little yellow pills (advil) before your next appy?
     
  28. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Poor choice or argument. It is not the needles, but the belief in their efficacy, that allowed for that type of surgery. No different than Voodoo- with an unwavering belief that if somebody of god-like status curses you to die, you do die.
     
  29. wonthurtabit1

    wonthurtabit1 Member
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    It was just friendly sparring w/ drusso.

    Steve, do you believe that the only reason acupuncture works at all, or in those surgical cases, is due to the belief of the patient in the acupuncturist? In other words acupuncture = voodoo?
     
  30. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I do not believe acupuncture works for chronic pain states. The science does not fit. Meridians were left out of my version of Netter, my anatomy lectures, my physiology course work, Robbins, Burne and Levy, etc.

    I do not believe acupuncture = Voodoo- that would be ethnically incorrect.

    I believe acupuncture has proven effective for CTX induced nausea.

    I see no harm in acupuncture if performed with sterile needles and by a competent practitioner. I feel the same way about trigger points. They both may serve the same purpose. I'll only do it if thepatient requests and they are told it is only a temporizing treatment lasting from hours to weeks. I believe the work of Travell and Simons is false science and is more a textbook based on a case series. RCT's will not convince me, but dissection and neurophyiologic correlations that provide a scientific basis for the treatment would certainly open my closed mind.

    All that being said- if a patient wants a procedure such as acupuncture, and I can provide that service without doing harm, and I can profit from that service, than I will offer that service.
     
  31. nolagas

    nolagas Member
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    None of your questions in any way resemble a rational argument.
    Your logical fallacies:
    5000 years old (Argumentum ad antiquitatem),
    beliefs/practices held by 1 billion people (Argumentum ad numerum),
    ethnocentric? dare I say racist?(Argumentum ad hominem)?

    There is a huge difference between Western and Eastern medicine. We can accept that not all Western treatments are evidence-based and replace them as evidence-based alternatives arise. Eastern medicine isn't changed even when proven to be non-efficacious or harmful because followers have an irrational faith in the practices despite evidence. I am not saying that all Eastern medical practices are wrong, but evidence has no role in the practice. All Western practices don't change quickly either, but they do change.

    Accupuncture can work but probably because of endorphins etc. + placebo-effect, not because of the flows of Chi. You don't have to spend >300 hours learning about Chi flows since Chi does not exist. You can place needles in random sites and it works just as well, no training required. All your training may help, but only by improving your delivery of the placebo effect by improving your ability to interact with the patients.

    The scientific method IS TOO the holy grail for research. You may happen upon correct treatments over time by chance as has been done in a variety of Eastern practices, but without the scientific method and a reality-based understanding (as much as is possible) of the treatments, you cannot refine them, standardize them, and remove harmful contaminants.

    I think that tai chi, yoga, meditation, faith, prayer, and so forth are probably helpful. They aren't helpful in an immaginary sense of tapping into energy flows or getting favors from someone who is magic. They are helpful by promoting relaxation, postitive outlook, etc.

    "There are many equally valid and efficacious ways to understand and treat human illness and disease: chinese medicine, ayurveda, and many more. "
    This is pc nonsense. Just because something hurts someones feelings does not automatically make it false. Not that it's good to be insulting, but come on. There is just no reason to believe what you say.

    "Doesn't anyone remember being told in medical school the following:
    50% of what we are teaching you is wrong, the trouble is we don't know which 50%".
    Yes, it's true and wonderful. We wouldn't advance at all if we were unwilling to change our views in the face of improving evidence. We'd be no better than traditional medicine, voodoo, or christian scientists.

    "And stay open-minded"
    I am open minded. Show me the evidence, and I'll make a reasoned judgement based on it. I'm a scientist.
     
  32. drrinoo

    drrinoo Rinoo Shah, MD
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    It is sad, that the failure of EBM to demonstrate efficacy of acupuncture, ie., efficacy sufficient to silence critics, is celebrated by those very same critics.

    This dovetails with a bigger philosophical consideration of EBM
    EBM works well when we have a thorough understanding of the pathophysiology and pathology of a disease process (good disease model and well defined interventions that capitalize on this understanding) and when we use concrete outcome measures...e.g. cardiology

    imagine if the early stents lacked efficacy...at that time they demonstrated two things....good outcomes (relevant to EBM), but a second more important thing....proof of concept....there was face validity (then and now) that impaired coronary blood flow due to obstruction/stenosis/etc was responsible for angina/MIs....imagine if the stents improved blood flow, but did not improve clinical outcomes...this would challenge this face validity

    In this hypothetical scenario, should we just celebrate, sit back the declare EBM to be the undefeated gladiator and go back home to celebrate...or should we say, wait a minute...this challenges some of our fundamental principles about cardiac pathophysiology...we must take a second look....

    We do not have a good working pathophysiological model of pain that is relevant to daily clinical practice.....you don't engage your patients in a dialogue about which neurobiological processes are relevant to their specific pain and you don't base routine clinical care on these concepts (e.g. Raja at Johns Hopkins used subcutaneous epinephrine to diagnose SMP...but no one does this on a practical level)....


    Rather, we go to the opposite extreme and use a working definition of pain that is all encompassing and completely vague...the IASP definition...this definition of pain is almost a sociological, rather than medical definition....

    and the closer a field of medicine is in its semblance to sociology and further from science....the less relevant EBM is...Correspondingly, evidenced -based sociology would use holistic, not concrete, outcome measures

    Cardiologists do not usually rely on holistic outcome measures to study efficacy...did my patient return to work, did my patient have an improved quality of life, or even post-procedure success with cardiac rehab...they rely on concrete outcome measures such as death, repeat hospitalization, serial labs...

    Can you imagine evidenced based sociology?...let us do an RCT on rehabilitating one group of prisoners versus a control group and have them return to society and follow their ability to return to work, to have an improved QOL, etc... who would permit such experimentation?

    Evidenced based politics.....Evidenced based decision making for choosing the right movie on a Friday night....evidenced based techniques cannot be broadly applied outside of medicine and similarly, cannot be applied to all fields of medicine

    Pain medicine, using the current IASP definition of pain, is a field of sociology...this is lost to most pain specialists...in fact, to circumvent the appearance of sounding pseudoscientic, pain specialists select only a portion of this definition when treating their patients....hence, the same pain problem can generate a variety of treatments that are based on a number of theories, depending on the practitioner....it is ironic, then that we criticize one another (psychologists vs. physical therapists vs. interventionalists vs. non-interventionalists vs. chiropracters vs. acupuncturists) when no single theory is sufficient to address chronic pain

    you will only see a cardiologist consulting a gastroenterologist, once they are confident the problem is not cardiac...not so in pain medicine...a chronic pain patient can see any practitioner or all practitioners in pain medicine and receive some sort of intervention, reflecting the diversity in our fields.

    With this type of diversity in theories, how can we even begin to assume understand what pain is...even the interventional pain/spine community uses pseudoscientific theories and they have no business calling other disciplines in pain medicine pseudoscientific...here is a sample of pseudoscientific concepts/statements and conundrums:

    the double diagnostic block paradigm...which, completely ignores the pharmacokinetics and pharmacodynamics of local anesthetics or the principle of central sensitization...and are not used to in the routine assessment of non-spinal diarthroidal synovial joints...among a number of flaws...

    'TFESIs are more site specific in terms of drug delivery to the pain generator, because of ventral epidural spread, as compared to interlaminar ESIs....[even if the pain generator is the DRG?]'

    A receiver operator characteristic curve for discography has only been recently generated, despite the widespread use of manometry

    selective nerve 'ROOT' (the latter is a pet peeve) blocks deliver local anesthetic DISTAL to the DRG and HNP, but they still can diagnose these proximal structures as pain generators?

    Why is it that interventional pain procedures marry a 'scientific' intervention--supposedly based on valid scientifc theories to 'holistic' outcome measures...return to work, QOL, etc...

    Rather we should eventually be doing what Clifford Woolf has proposed....define chronic pain states based on their specific neurobiological pathophysiology...and when this 'adverse' neurobiology improves....we can consider the intervention to be a success

    As far as placebo response and acupuncture...consider this... do you ever wonder why the IV that the nurse places and the anxiolytic conversation between the nurse and the patient ----'you are in great hands...he/she is an excellent doctor and all the patients do well'---does not result in a placebo response or could it?....after all, the nurse is placing a large bore needle in a randomly selected peripheral site...not unlike sham acupuncture?

    The placebo response is vastly complex and seemingly selective...acupuncture may rest on a placebo response...but why doesn't the IV and the conversation result in a durable placebo response

    As I've stated before, failure of pain procedures to cross the EBM threshold should force us to go back to the drawing board and rethink our theories of pain, rather than criticizing the technique and becoming self congratulatory

    Imagine the following scenario.....just be an optimist....if a patient has acute flare-up of their existing back pain....what if their spouse could place acupuncture needles in a location identified by their acupuncturist and avoid going to the ER....

    Finally, as health savings accounts become more popular, as patients become more responsible for their health care costs....allopathic physicians will have to face their day of reckoning.....even if we scream 'no better than placebo'...the patient will seek out the cheapest cost relative to placebo and they will shout back 'placebo=neurobiological correction'....

    they will seek out acupuncture....they already are....and the more you criticize your patient's judicious use of acupuncture, the more likely you are to lose your patient
     
  33. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Have you been reading a copy of:

    The Myth of Chronic Pain


    Benjamin L. Crue, Durango, CO, 2001, 1,359 pages, $94.00 (2 vols, hard cover), ISBN 0-9748575-0-5. Order from Maria’s Bookshop, 960 Main Avenue, Durango, CO 81301.


    A very good book on why we fail so often as interventionalists.
     
  34. Spine Specialist

    Spine Specialist Passion for Spine
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    I'm :confused: now.

    Is it acu or accupuncture?
     
  35. algosdoc

    algosdoc algosdoc
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    Perhaps I should hire a drop dead gorgeous nurse to start the IV in the guys and a hunk to start IVs in the ladies....then whatever I would do procedurally would probably be irrelevant.
     
  36. nolagas

    nolagas Member
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    You could tell them that the fluids have some unidentified mystical ingredient that will cure the pain. Then you'd get some effect even without changing anything. Problem is, lying to patients to get a placebo effect is considered unethical to medical doctors though it's standard pratice for holistic conmen.
     
  37. algosdoc

    algosdoc algosdoc
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    Ok then, forget the patients, at least I will be able to derive some visual candy from the situation.
     
  38. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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    That might explain why my positive patient outcome stats tend to be much higher than what I read about in research studies.



    Nothing wrong with showing off the arms if you have them.
     
  39. algosdoc

    algosdoc algosdoc
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    Well, I don't have them.....bummer. So there go my research nights now that I will have to start pumping iron in the gym...
     
  40. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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    So you're going to join a gym with the intention of getting great arms in order to help facilitate better outcomes with your patients?



    Sounds like a tax write-off to me.



    Of course I'm not an accountant.



    Oh, and upon further discussion with my fiance, it appears a great set of buttocks might be the key to getting those high positive outcomes. I recommend squats and dumbbell lunges. Or you could read research articles while on the elliptical.
     
  41. drrinoo

    drrinoo Rinoo Shah, MD
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    leap of faith...but if you extend the concept of acupuncture, i.e., electroacupuncture.....it is interesting what one can do....

    we already know about sacral nerve root stim in SCI urological problems and fecal incontinence....and now percutaneous lead placement into the motor point of a nerve can improve tissue health...

    when I was in Beijing, about 9 years ago....they were using electroacupuncture for SCI (at that time, I didn't know what to think of it)...now, it seems as if they were ahead of their time

    what is paradoxical is that if this was attributed to placebo, why only a local response? i..e, in the sacral distibution and for that matter in an area that is insensate....I have always been puzzled why placebo is so selective.

    e.g. a patient walks in and complains of back and neck pain...and they think it is connected....you engage in a rudimentary discussion of spinal anatomy and spinal interventions (9th grade level of discussion, since this is the avg educational level in America), ie.., the patient does not have an enhanced understanding of their spinal pain...yet when you do an intervention, the placebo is selective to the low back and not to the neck....

    in other words, the placebo response is 'smarter' than the patient....it 'knows' to produce a local response, despite the patient's understanding to the contrary...

    Archives of PM and R
    Volume 87, Issue 4, Pages 585-591 (April 2006)

    23 of 36


    ABSTRACT

    FULL TEXT

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    Long-Term Prevention of Pressure Ulcers in High-Risk Patients: A Single Case Study of the Use of Gluteal Neuromuscular Electric Stimulation
    Presented in part to the American Spinal Injuries Association and International Medical Society of Paraplegia, May 3-6, 2002, Vancouver, BC, Canada.
    Kath M. Bogie, DPhilac, Xiaofeng Wang, MSb, Ronald J. Triolo, PhDac

    Abstract
    Bogie KM, Wang X, Triolo RJ. Long-term prevention of pressure ulcers in high-risk patients: a single case study of the use of gluteal neuromuscular electric stimulation.

    Objective
    To evaluate the efficacy of gluteal neuromuscular electric stimulation (NMES) using implanted percutaneous electrodes to improve regional tissue health and decrease the risk of pressure ulcer development.

    Design
    Case study of long-term use of gluteal NMES.

    Setting
    Community.

    Participant
    A patient with a C4-level American Spinal Injury Association grade A spinal cord injury, 22 years postinjury at study enrollment, and a clinical history of regular grade II and occasional IV ischial pressure ulcers.

    Intervention
    Gluteal NMES using an electric stimulation system comprising a combination of implanted percutaneous electrodes and an external stimulator (controller).

    Main Outcome Measures
    Objective measurements of tissue health comprising evaluation of gluteal muscle thickness, interface pressures, and regional blood flow. Subjective self-reported sitting tolerance.

    Results
    Increased gluteal muscle thickness and blood flow together with reduced regional interface pressures occurred. Weight-shifting because of alternating left and right gluteal NMES became more effective over time as the muscles strengthened. Sitting tolerance more than doubled.

    Conclusions
    A gluteal NMES system has been developed that provides both improved regional tissue health and dynamic weight shifting while seated in the wheelchair. In the current case, regular daily use had a positive impact on multiple indirect indicators of tissue health. Continued use was indicated as the positive effects were lost when stimulation was discontinued.

    Key Words: Decubitus ulcer, Electric stimulation, Rehabilitation, Spinal cord injuries
    a Department of Orthopaedics, Case Western Reserve University, Cleveland, OH

    b Department of Statistics, Case Western Reserve University, Cleveland, OH

    c Cleveland VA Medical Center, Cleveland, OH
     
  42. nolagas

    nolagas Member
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    A Randomized Clinical Trial of Acupuncture Compared with Sham Acupuncture in Fibromyalgia
    Nassim P. Assefi, MD; Karen J. Sherman, PhD; Clemma Jacobsen, MS; Jack Goldberg, PhD; Wayne R. Smith, PhD; and Dedra Buchwald, MD

    5 July 2005 | Volume 143 Issue 1 | Pages 10-19


    Background: Fibromyalgia is a common chronic pain condition for which patients frequently use acupuncture.

    Objective: To determine whether acupuncture relieves pain in fibromyalgia.

    Design: Randomized, sham-controlled trial in which participants, data collection staff, and data analysts were blinded to treatment group.

    Setting: Private acupuncture offices in the greater Seattle, Washington, metropolitan area.

    Patients: 100 adults with fibromyalgia.

    Intervention: Twice-weekly treatment for 12 weeks with an acupuncture program that was specifically designed to treat fibromyalgia, or 1 of 3 sham acupuncture treatments: acupuncture for an unrelated condition, needle insertion at nonacupoint locations, or noninsertive simulated acupuncture.

    Measurements: The primary outcome was subjective pain as measured by a 10-cm visual analogue scale ranging from 0 (no pain) to 10 (worst pain ever). Measurements were obtained at baseline; 1, 4, 8, and 12 weeks of treatment; and 3 and 6 months after completion of treatment. Participant blinding and adverse effects were ascertained by self-report. The primary outcomes were evaluated by pooling the 3 sham-control groups and comparing them with the group that received acupuncture to treat fibromyalgia.

    Results: The mean subjective pain rating among patients who received acupuncture for fibromyalgia did not differ from that in the pooled sham acupuncture group (mean between-group difference, 0.5 cm [95% CI, –0.3 cm to 1.2 cm]). Participant blinding was adequate throughout the trial, and no serious adverse effects were noted.

    Limitations: A prescription of acupuncture at fixed points may differ from acupuncture administered in clinical settings, in which therapy is individualized and often combined with herbal supplementation and other adjunctive measures. A usual-care comparison group was not studied.

    Conclusion: Acupuncture was no better than sham acupuncture at relieving pain in fibromyalgia.
     
  43. MissBehavior

    MissBehavior Junior Member
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    Just food for thought: If this were true, veterinary acupuncture would be completely ineffective, which is certainly not. Acupuncture can be an effective treatment for animals in reproductive disorders, pain management, stereotypic behaviors, etc. It seems that further research on animals would dispute arguments that acupuncture only works because of the placebo effect. An animal cannot believe or not believe in a treatment.
     
  44. algosdoc

    algosdoc algosdoc
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    I seem to remember a guy named Pavlov or something thereabout, that had these dogs. If he had conditioned the animals to salivate due to acupuncture rather than ringing a bell, then would the animal believe in the acupuncture treatment?
     
  45. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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    Context
    A substantial number of patients use acupuncture to treat
    the symptoms of fibromyalgia, but previous randomized
    trials of this intervention are inconclusive, in part because
    of control groups that did not permit adequate blinding of
    the patients.

    Contribution
    This study randomly assigned 100 patients with fibromyalgia
    to 12 weeks of either true acupuncture treatment or
    one of 3 types of sham acupuncture. No differences in
    pain were identified between acupuncture and sham acupuncture.

    Cautions
    The study had too few patients to detect small differences
    between the groups
    . Patients could use other fibromyalgia
    therapies, so this study evaluates acupuncture as adjunctive
    treatment.
    –The Editors


    If you are trying to determine if sham acupuncture is just as effective as "real" acupuncture, it would help if the research study had enough patients to tell the differences between the groups...since that is the point.

    This study is a step in the right direction. The practitioners were well trained so the "lack of training / experience" argument cannot be made. The point protocols look good, although the authors point out that many argue against using fixed-points prescriptions. I like the "unrelated condition" sham group and hope that it will pan out in the future as a means to blind the practitioner.

    A quick search of pubmed found a positive study, but like this one, it lacks the numbers in each group to see the difference in the two groups (plus I can only see the abstract):

    Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial.Martin DP, Sletten CD, Williams BA, Berger IH.
    Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA. [email protected]

    OBJECTIVE: To test the hypothesis that acupuncture improves symptoms of fibromyalgia. PATIENTS AND METHODS: We conducted a prospective, partially blinded, controlled, randomized clinical trial of patients receiving true acupuncture compared with a control group of patients who received simulated acupuncture. All patients met American College of Rheumatology criteria for fibromyalgia and had tried conservative symptomatic treatments other than acupuncture. We measured symptoms with the Fibromyalgia Impact Questionnaire (FIQ) and the Multidimensional Pain Inventory at baseline, immediately after treatment, and at 1 month and 7 months after treatment. The trial was conducted from May 28, 2002, to August 18, 2003. RESULTS: Fifty patients participated in the study: 25 in the acupuncture group and 25 in the control group. Total fibromyalgia symptoms, as measured by the FIQ, were significantly improved in the acupuncture group compared with the control group during the study period (P = .01). The largest difference in mean FIQ total scores was observed at 1 month (42.2 vs 34.8 in the control and acupuncture groups, respectively; P = .007). Fatigue and anxiety were the most significantly improved symptoms during the follow-up period. However, activity and physical function levels did not change. Acupuncture was well tolerated, with minimal adverse effects. CONCLUSION: This study paradigm allows for controlled and blinded clinical trials of acupuncture. We found that acupuncture significantly improved symptoms of fibromyalgia. Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety.
     
  46. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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    Pavlov using acupuncture before feeding the dogs so that they are conditioned to associated acupuncture with getting fed, and thus salivate...check.

    Pavlov using acupuncture to condition the dogs to walk without a limp instead of having poor mobility d/t pain...huh?


    Just in case the extra handling the dogs experience during an acupuncture treatment might have a positive outcome, many of vet acupuncture studies include a control group where the dogs get handled, loved, and kissed.
     
  47. nolagas

    nolagas Member
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    There are many many studies showing that acupuncture is basically equal to sham acupuncture. I just posted the first one that came up in my search. That isn't to say that acupuncture produces only placebo effect, just that it's a waste of time to study and become a 'licensed acupuncturist' when random needle placement works just as well as traditional placement.
     
  48. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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    But if you look at the vast majority of the studies that show no difference between sham and "real" acupuncture, they either fail to have enough patients in either group (so no comparison can actually be made) or the treatments are done by those with insufficient training...which only shows that if acupuncture is done by those with 300 hours of training, the results aren't any different than just random needle placement.:laugh:


    But if you post a study that has enough patients between the groups and is done by "real" acupuncturists, I'd love to see it.
     
  49. algosdoc

    algosdoc algosdoc
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    The burden of proof rests on those who are performing acupuncture. If there are insufficient numbers to prove or disprove efficacy, then we as scientists must adopt the attitude that the technique remains unproven, and therefore is not recommended. Acupuncturists have the patient load to demonstrate proof of their technique, not physicians. Homeopathy and a host of other techniques are in the same boat....insufficient studies to support what they do, yet those engaged in the alternative medicine treatments will not do the studies necessary. Slowly, the field of medicine is examining nutriceuticals, vitamins, minerals, etc., and are finding there are a few that work, but there are many that have been sold for millions in profit that have no effect at all.
    Alternative medicine techniques has as an advantage they are not dependent on insurance coverage...it is a cash basis business. Whether the clientele are unsophisticated with regard to proof is rarely a concern of those in the alternative medicine business.
    Fortunately, the NIH is taking a keen interest in these treatments and whether or not they are scams/sham treatments.
     
  50. Josh L.Ac.

    Josh L.Ac. MSA/LAc & BSN/RN --> AA-S
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    Actually I agree for the most part. While I strongly believe that what I do is not just d/t the placebo effect, I know that my modality is a strong "carrier" of it [edit - see Ted Kaptchuk's research on acupuncture placebo vs. pill placebo]. I also entertain the slight possiblity that acupuncture might only have non-specific and placebo effects. I doubt it, and I am not losing any sleep over it, but as a scientist I always have to be open to the possibility.


    As I was discussing this thread with my fiance (also an acupuncturist), I did realize something: the effects of my acupuncture treatments has improved with experience. If the effects of acupuncture are only due to non-specific and placebo effects, then my experience should not matter. My improved ability to properly diagnose should not matter. My improved ability to develop a tailored treatment protocol should not matter. My improved needling ability should not matter.

    But it does.


    Granted, as a person grows with experience, their confidence rises. This would in turn be transmitted to the patient, which could improve the possiblity of a postive placebo-based outcome.

    The question would be would this increased confidence / improved placebo really be sufficient enough to explain my improved patient outcomes. Personally, I doubt it.
     
  51. zenman

    zenman Senior Member
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    I know at least one medical anthropologist who would disagree with you...after a little wager with a senior anthropologist and his voodoo priest friend. The "event" was set up for a Monday night after the young anthropologist had gone back to the states. Mon night he was laughing as nothing happened. Thursday night, double over in extreme pain, he got a call from the senior guy saying that they couldn't do the ceremony Monday night but were doing it now..."How are you feeling" he asked, LOL! An ER visit showed nothing wrong.:scared:
     

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