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

Thinking about thinking…

For a long time I thought everyone thought about what they think about, how they think about it, and what their thinking concluded – now I know that some people never do this and live on simply following the rules (and probably having a fun and relaxed time of it!).  I, on the other hand, have always spent time at the end of the day thinking about my thoughts and what they mean and how I come up with them.  The technical term for this is ‘metacognition’, or ‘thinking about thinking’, and it’s a strategy that can be really useful in cognitive therapy as well as pain management – and even more useful in your professional work as a therapist.

I started writing this post after reading this from the Skeptical Methodologist… in it The Skeptical Methodologist points out that although ‘…the scientific method as we know it from the enlightenment is a sound way to find truth about our world, we must always remember that the evidence we produce from any one experiment is only as good as the assumptions that went into it.’

What this means, is that if we don’t include our assumptions in any experimental method, we won’t be able to seriously critique our findings – our findings may only hold true in certain circumstances.  This doesn’t detract from the truth of those findings in those circumstances, but it does mean that we can’t generalise without risking making errors.  For more about this, read Ben Goldman’s article on How Myths Are Made.

If we’re unaware of our assumptions we may never look at our findings in the light of them – and this error is one I’m especially concerned about when I see exclusive reliance on  ‘self reflection’ and peer review of practice.

After all, if we have learned our professional skills from others within the profession, and even our professional peers haven’t had a broad or general knowledge of other approaches to treatment (or even to science), then we’re unlikely to know the assumptions that we hold. Sometimes it takes an ‘outsider’ or an interaction with another model or approach to help us look at what we assume is a ‘given’.  This can be challenging and sometimes disheartening – but can aid us in generating new and different ways of viewing our practice.  Think of general systems theory which came originally from engineering and has now influenced almost all the sciences including biology, chemistry, physics, sociology, psychology and health care!

Wikipedia states that: ‘Metacognition refers to a level of thinking that involves active control over the process of thinking that is used in learning situations. Planning the way to approach a learning task, monitoring comprehension, and evaluating the progress towards the completion of a task: these are skills that are metacognitive in their nature. Similarly, maintaining motivation to see a task to completion is also a metacognitive skill. The ability to become aware of distracting stimuli – both internal and external – and sustain effort over time also involves metacognitive or executive functions.’

Metacognitive monitoring and metacognitive control of emotional states have been suggested as a way for people with mood disorders and other behavioural disorders to take control of their illness.  The suggestion is that the person monitors his/her emotional state, applies a label to it, compares it to what they would really like to feel, and then takes action to make the current emotional state become closer to the goal state.  Another approach is to become aware of the thoughts – label them, recognise the emotions – then choose what actions to take that will ensure what is important (eg a value) is done.  This is one of the underlying strategies of ACT.

So, what does metacognition look like?

For me, it means forever asking questions about ‘why’.  Why do I take notice of this and this and this?  Why does that strategy work here but not here?  It means I become aware of my thoughts – then I can check my beliefs, and the foundations of those beliefs, test them for helpfulness (and accuracy!).   I can match those thoughs against whether they are helping me achieve what I want in my life, and often whether they’re even accurate.

In pain management, it can mean helping patients identify their thoughts – and especially, their anxious worrying or ruminating.  Metacognitive theory suggests that this approach developes into ‘cognitive attentional syndrome’ where the thinking actually focuses attention on emotional content and distracts from active coping.   ‘This pattern consists of worry, rumination, fixation of attention on threat, and coping behaviours that the person believes are helpful but many of which backfire and keep emotional problems going.’ Treating these problems using metacognitive therapy involves ‘helping patients develop new ways of controlling their attention, new ways of relating to negative thoughts and beliefs, and by modifying metacognitive beliefs that give rise to unhelpful thinking patterns.’ Sound familiar?

In other words, if we can help people become aware of what they’re thinking and that it’s unhelpful and probably based on unaccurate beliefs (and distinct from who they are), and we’re able to engage them in activities that are much more interesting and involving, they’ll be able to reorient themselves into a life they want to live.

But before we start employing metacognitive therapy in pain management, how about spending about 10 minutes after doing an assessment or a treatment – and thinking about your thinking?  What goes through your mind while you’re working with that person?  What are your assumptions?  Check out whether you’re assuming things on the basis of gender, age, ethnicity, occupation, even diagnosis.  You might be surprised at what you find out.

Don’t forget, I post most days during the week, love coments (even when they don’t agree with me!) and will reply!  If you want to come back, just bookmark – or you can subscribe using the RSS feed link at the top of the page. Hope you have a good week!

Brain Maps!

Do you know your neuro-anatomy?


This site shows me just how lucky we are with the internet as a resource for seeing things that we couldn’t have dreamed about just five or so years ago. Head to Brain Maps for a look at detailed cross-sections and other images of the brains of homo-sapiens, rattus norvegicus, felis catus and more!!

And just when you thought that was enough, this site has even more resources for you to polish up your neurological knowledge.

Why would you want to learn all this? Well in the field of pain, we are essentially dealing with neuroanatomy in some form or another – and heaven knows I am no reductionist, but there is so much that our nervous system does that we don’t yet know about that I think if we’re working with people experiencing pain, then we really have to continually update our knowledge in order to integrate the findings from both gross anatomy and physiology and neuroanatomy and physiology. Oh, and don’t forget about psychology – and if you’ve a moment, and want to see what you can remember about methods? Go here and take this brief test. If you’re going to work in health, you’d better know about scientific method!