Thought-provoking posts on science, health and beliefs

The blogosophere is pretty hot right now – some really interesting topics being discussed, enough to make me think again about my own biases.

The first one is the popular Science-Based Medicine blog that rarely fails to challenge those that prefer ‘belief’ over ‘evidence’ – do not proceed to this blog if you think homeopathy or reiki is ‘good for your health’, this blog does not mince words!  Three posts have particularly caught my eye recently – this one on some of the reasons people (even scientists!) find it hard to change tack when new evidence is found; this one on the misinterpretation of acupuncture trials; and this one on the role of adenosine in pain relief.

The first post really struck me as I look at my own bias towards nonbiomedical interventions – yes, even I can be tempted to ‘overlook’ studies that show equivocal findings for CBT-based approaches, or to focus on studies that show positive outcomes… I remember my initial concern about mirror therapy and graded motor imagery for CRPS – and while I still hold concerns that this treatment doesn’t seem to reduce pain and increase function in many people (notably the complex presentations we see at Pain Management Centre), I do think it holds promise for people with CRPS now that the evidence is gathering.  That’s science you see – revising what we accept in the face of accumulating evidence.

Movin’ Meat is the rather curious name of a blog written by an ER physician (and administrator, bless him).  This blog is often about    but this post is a repost and hilarious.  Do not read if you’re easily offended, but given that people with chronic pain DO have a sense of humour (how would you survive without it?!), this post on a Brand New Pain Scale hit my funny bone – read and enjoy!  After my experiences last year with tonsillectomy, I totally appreciate the need for a ‘beyond what I want to cope with’ number on a pain scale.   I’ve always thought that putting a number to my pain is a bit silly, wouldn’t it make more sense to start with ‘no pain’, move to ‘a bit of pain but it’s not bothering me’, go from there to ‘yup, this is pain and I’d like it to go no’ and finally ‘I’ve had enough, MAKE IT GO AWAY’.

And lucky last, but certainly not least, is BodyinMind blog and the rip-roaring debate going on there about exercise and back pain, and the most recent discussion about acupuncture and a critical review of some of the most recent papers on it in pain management.

If you’re a Facebook participant, head to the very informative and rational page Neuroscience and Pain Science for Manual Physical Therapists.  If you click on this link and you are not a member of Facebook, beware, you won’t be able to get in.  If you’re clicking on this at the Canterbury District Health Board, forget it, Facebook isn’t available.  Otherwise, click away and enjoy the discussions on a whole range of neuroscience and pain management topics.  Some fabulous people and over 2500 fans have joined this page and comment regularly – makes Facebook worth visiting just for this alone!

I hope you enjoy these links – let me know what your thoughts are!

More about acupuncture: press needles as a placebo
Slightly tangential to my normal topics, I located this article today on a placebo procedure that may work for acupuncture.
Many people will be aware that in acupuncture, it’s really difficult to truly conduct a double-blind trial where both the person receiving and the person giving the treatment are unaware of which is the ‘active’ treatment. In fact ongoing criticism of many studies such as those reviewed in Cochrane reviews (and the recent post I made of Ernst’s review of 32 Cochrane reviews) is that in giving the ‘placebo’ treatment, the comparison is not really between acupuncture and placebo acupuncture, but it is instead of acupuncture with ‘something else’, and in doing this, much of the ‘active’ component of acupuncture is lost.

This paper, written by researchers from Kyushu University; and Fukuoka University, is in two parts: Part One ‘to evaluate the applicability and efficacy of the press needles, 90 participants who had never been treated using acupuncture were randomly assigned to receive either the press needle (n=45) or a placebo (n=45)’. This part of the study determined whether participants thought the needles penetrated their skin, and whether the intervention was in any way effective. The participants all had chronic low back pain, and the findings showed that there was no significant difference concerning the perception of penetration, and for patients with LBP, the press needles reduced the subjective evaluation of LBP compared with the placebo (P<0.05).
Just to clarify the two interventions: press needles are a device that look like this (see below), while the placebo has just the needle removed, so it looks exactly the same.
press needle

Part Two looked at ‘the mechanism for the analgesic effect of the press needles on LBP.‘ Before the press needle was inserted, an anesthetic patch (lidocaine) was applied for 30 min to block the peripheral nerve fibres around the acupoint site. The two groups were compared where one group was treated with the press needles after local anesthesia, and a second group who were treated with the press needles without anaesthetic. The findings from this study showed that LBP was reduced significantly more in the press needle group than in the local anesthesia group (P<0.05), suggesting that one potential action is via the peripheral nerve fibres around the acupoint site.

Of course, those who practice acupuncture suggest that it’s not simply the action of the acupuncture at the site of insertion but also the context of the treatment (the ch’i and balancing yin/yang and unblocking the flow of ch’i) – suggesting that unless you’re a ‘real’ acupuncturist you can’t replicate the ‘real’ action of acupuncture with all the nonspecific effects of the consultation and so on. Hmmm, if the practitioner is blind to whether or not the press needle has a needle, and carries out all the rest of the consultation as normal, perhaps these arguments will no longer hold.

I really do look forward to further studies using this device, so we can progress toward a methodologically sound way to establish whether acupuncture has any effect apart from those ‘nonspecific’ components of the consultation. If it does – then we can have the discussion about whether this intervention can be included as part of ongoing self management, or whether it should be something completed before self management is commenced.

One thing I’m always reminded of in being a scientist: I may need to revisit my opinion on whether an approach should be supported or not, depending on the cumulative evidence available. Dogmatic beliefs simply don’t belong in health practice.

Miyazaki S, Hagihara A, Kanda R, Mukaino Y, & Nobutomo K (2009). Applicability of press needles to a double-blind trial: a randomized, double-blind, placebo-controlled trial. The Clinical journal of pain, 25 (5), 438-44 PMID: 19454879

Ernst, E. (2009). Acupuncture: What Does the Most Reliable Evidence Tell Us? Journal of Pain and Symptom Management, 37 (4), 709-714 DOI: 10.1016/j.jpainsymman.2008.04.009

Friday Funnies Return!

And you thought I’d abandoned y’all… Never fear, I can’t miss my weekend preparation, so here we go again!


I’m no fan of ergonomics for ‘preventing pain’, despite my couple of postgraduate papers in it! So when I found these couple of cartoons, I’m sorry I couldn’t stop myself…

ergonomic personality

I’ve been needling acupuncturists for a while now – perhaps after this I should stop?
acupn cartoon

OK, OK, I’m retreating NOW!
Have a great weekend!

It’s been a while… and review of acupuncture
Regular visitors to my blog will have wondered about the break in transmission – and I’m sorry, it’ll continue for another fortnight.

The past fortnight I’ve been recovering from having my tonsils removed – something that I am now convinced should happen when you’re young enough to think that jelly and icecream is a fabulous treat, and have quite a lot more ‘bounce-back’ than I had.  Not a pleasant experience, but hopefully one that will pay off in time.  This coming fortnight I’m going to Rotorua to the NZ Pain Society Annual Scientific Meeting.  It’ll be a busy time because I’m giving three papers and running the occupational therapy workshop – oh and a bit of sight-seeing as well, with any luck.  I was a kid last time I spent any longer than a night in Rotorua, and it’s a truly awe-inspiring place if you love geothermal activity and culture.

Despite the busyness, an article that caught my eye just yesterday is this one: Acupuncture: What Does the Most Reliable Evidence Tell Us? written by Edzard Ernst, it reviews several Cochrane reviews of acupuncture in an attempt to summarise the state of play in terms of evidence for acpuncture.  First a proviso – it is very difficult, if not impossible to use a double-blind methodology in acupuncture research, so it’s not an easy procedure to adequately investigate. At the same time, apologists for acupuncture are often unswayed by ‘evidence’ and prefer to rely on anecdote or opinion, so perhaps this is not as much of a problem as first thought (hmmph!). Suffice to say, at least one new guideline for low back pain endorses the use of acupuncture, so the jury is still out for some at least…

Anyway, in this paper, Ernst reviews 32 Cochrane reviews, twenty-five of them failed to demonstrate the effectiveness of acupuncture. Five reviews arrived at positive or tentatively positive conclusions and two were inconclusive. The conditions ranged from headache to nausea – and chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache were the only conditions in which evidence was found.

The reasons, however, for bringing this study to your attention are that Ernst spends some time discussing the limitations of Cochrane reviews – something which is worth debating, given the contradictory results for things like CBT for low back pain, and injection therapy for low back pain. Although Cochrane reviews represent a synthesis of evidence on a topic, the methodology is not fool-proof, and over time, it can be seen that reviews differn in their recommendations. I don’t think this is surprising because this is the nature of science – as evidence is gathered, I’m sure that some of the things I’ve felt strongly about will be found to lack support over time. Similarly, it won’t surprise me at all to find that almost all Cochrane reviews suggest further research is required, that few studies are methodologically strong, and that conclusions drawn are preliminary.

Ernst also discusses whether it is worthwhile continuing to carry out studies on the use of acupuncture – surely after some time, it’s useful to indicate when science simply doesn’t back a treatment (I keep thinking of homeopathy in this regard). Ernst suggests that perhaps acupuncture may not yet be at this point saying ‘Opinions may differ regarding whether further trials of acupuncture are warranted. In my view, we should clarify whether or not the clinical effects of acupuncture are specific or nonspecific. This means that we should consider conducting trials comparing real acupuncture with placebo acupuncture using the non-penetrating devices that recently became available. Such comparisons should be conducted in those clinical areas where the current evidence is most convincing.’

Unfortunately, proponents of acupuncture, like anyone who has invested time and money, and truly ‘believes’ in its usefulness, probably won’t be swayed by the findings in this review. And that, to me, is the saddest thing of all – because patients may persist with a treatment that has ‘non-specific’ effects only. At the same time, their belief that something outside of them is responsible for their recovery – and fail to develop confidence (a) in their own ability to cope with their pain and (b) that pain is tolerable, albeit unpleasant.

I’ll post intermittently over the next fortnight – in the meantime, if you’ve enjoyed this post, and want to read more – there’s a few archived posts on here, just use the search button to look for a topic, or the category search to the left, or just below it, the tag cloud. There’ll be something there to chew over!

Ernst, E. (2009). Acupuncture: What Does the Most Reliable Evidence Tell Us? Journal of Pain and Symptom Management, 37 (4), 709-714 DOI: 10.1016/j.jpainsymman.2008.04.009

Advances in the science of acupuncture

Acupuncture has been used in China for thousands of years – it’s one of the first ‘alternative’ treatments requested by patients experiencing persistent pain, and one that has been receiving increasing attention from the scientific community as neurobiological research progresses.

This paper by Wang, Kain & White provides an overview of the state of play for acupuncture and analgesia. As a result of this I’m taking another look at acupuncture as a potential modality for people with chronic pain – with a few proviso’s!!

What’s the evidence?
Traditional Chinese acupuncture is a philosophy that focuses more on prevention than treatment of illnesses. The ancient Chinese believed that Qi flows through a network of channels called meridians, which bring Qi from the internal organs to the skin surface. Along these meridians there are acupuncture points that can be stimulated to correct the imbalance and restore the body to normal health.

Western theories are primarily based on the presumption that acupuncture induces signals in afferent nerves that modulate spinal signal transmission and pain perception in the brain.

Over the last decade, advanced imaging technologies have been introduced, including positron emission tomography (PET), single-proton emission computer tomography (SPECT), and functional magnetic resonance imaging (fMRI). These imaging technologies have made it possible to noninvasively visualize the anatomic and functional effects of acupuncture stimulation in the human brain.

PET scanning found that only acupuncture stimulation at LI4 with De Qi sensation activated the hypothalamus – sham or needling in ‘incorrect’ positions didn’t.
In another study, during a PET scanning sequence Biella et al. found that acupuncture, but not sham treatment, activated the left anterior cingulum, superior frontal gyrus, bilateral cerebellum, and insula, as well as the right medial and inferior frontal gyri. These are the same areas activated by acute and chronic pain.

However, just in case you thought it was ‘simple’ – the anticipation and belief of a patient might also affect the level of therapeutic outcome. This has been specifically examined, and findings from Pariente et al. identified that both true and sham acupuncture activated the right dorsolateral prefrontal cortex, anterior cingulated cortex, and midbrain, however only true acupuncture caused a greater activation in insula ipsilateral to the site of stimulation.

SPECT and fMRI studies have also been conducted, with similar findings – only true acupuncture produced activation of specific areas of the cortex that are apparently involved in pain perception.

Physiological and imaging studies are providing insight into the neurophysiological mechanism of acupuncture analgesia. Recent data suggest that acupuncture triggers a sequence of events involving the release of endogenous opioid-like substances, including enkephalin, [beta]-endorphin, and endomorphin, that modulate pain signals processed along the pathway. Imaging studies demonstrate that the limbic system plays an important role in acupuncture-induced analgesia.

Now just because I can, I invite you to consider the place of placebo, or as Dan Moerman calls it ‘meaning response’.
Unless really good randomisation and double blinding (the patient and the assessor are ALL unaware of whether the procedure is ‘real’ or ‘placebo’) we will run into the effect of having treatment (of any kind) can have on an individual. And especially in the case of acupuncture where the practitioner can never be blinded to whether the procedure is ‘real’ or ‘sham’, inadvertent changes of nonverbal (and at times verbal) behaviour can and will be conveyed.

So…. a very fruitful area of study, methinks.

Oh and another concern I have with acupuncture, as I do for any procedure that involves another person rather than self management for a chronic health condition – acupuncture is usually done by someone to someone. The very process of attending a practitioner is a form of pain or illness behaviour. This action by definition means the person has:

  1. identified that they want help
  2. need to ask someone else to help them
  3. can’t manage by themselves

This means the person will inevitably relinquish a degree of self efficacy (confidence that they can manage their problem by themselves and out of their own efforts) to the actions of another person.

As someone who likes my independence, I’m not sure that I want that.

If you’re curious to learn more, trying searching under the term ‘acupuncture’ and ‘chronic pain’, and seeing what comes up. I visited Cochrane Collaboration and found a couple of older reviews of acupuncture, none of them particularly able to identify strong support for its use.
I also visited the Bandolier Oxford Pain Site, and searched under ‘acupuncture’ – again I couldn’t find much support, and most articles were out-dated.

My question is: if fMRI and other studies are demonstrating significant changes in blood flow etc, are they truly controlling for ‘meaning response’, ‘treatment effects’, inadvertent communication of expectations by the practitioner etc, or is this confounding these results?  And if it is a ‘meaning response’ – how can we integrate this into our practice?

Dan’s book, by the way, Meaning, Medicine and the Placebo Effect is a really GREAT read – with some good info on pain as well as health care and the sociology of ill health. Good stuff!

If you’ve enjoyed this post, want to know more, want to keep reading – don’t forget you can subscribe using the RSS feed – and do drop me a line! I love mail, and am very happy to reply (even if we don’t agree!!).