Qi Spot

Let the good times roll.  Another study, as reported in various articles online, shows evidence that acupuncture works.  Ho hum, what’s new?

The difference is the method of evaluating the effect.  Instead of asking patients, hey does it hurt less?  They did Quantitative sensory testing.

What’s that?

The University of Chicago website defines quantitative sensory testing as:

Quantitative sensory testing (QST) is a method used to assess damage to the small nerve endings, which detect changes in temperature, and the large nerve endings, which detect vibration.

QST is used to diagnose and assess the severity of nerve damage, especially in the small nerve endings. It can also help determine if a neuropathy is responding to treatment. It is used to diagnose many different types of neuropathies, including peripheral neuropathies. It may also be used to identify where the nerves are damaged.

(It) ses a computer testing system to measure how the nerves involved react to vibration and changes in temperature. The test results are compared to a series of “normal” patients as well as to the patient’s unaffected side. (from http://peripheralneuropathycenter.uchicago.edu/

learnaboutpn/evaluation/quant/index.shtml or http://bit.ly/bb7gfC)

Quantitative Sensory Testing

Photo from http://www.neurology.upmc.edu/neuromuscular/patient_info/testing.html

Pretty objective, if you ask me.

So what does the article say?

Dr. Philip Lang and colleagues of the University of Munich used quantitative sensory testing to identify changes in pain sensitivity with acupuncture in 24 healthy volunteers.
After applying acupuncture to the leg, the researchers found that pain thresholds increased by up to 50 per cent. Effects were noted in both the treated leg and the untreated (contralateral) leg.

…It includes tests of both thermal perception (heat and cold), and mechanical perception (pressure applied to the skin).

The patterns of response provide diagnostic information in patients with nerve injury regarding the type of nerve involved, and possible treatments.

Okay, in real life this is how it goes.  Sometimes people have nerve damage.  This obviously leads to decrease in sensations.  A perfect example would be a diabetic with peripheral neuropathy.  Peripheral neuropathy means that the nerve damage occurs at the very ends of the body – fingers and toes.  This test serves to try to measure the nerve response to various external stimuli. In this case, temperature change and pressure, among others.

It is also quantitative, meaning it is measured with numbers.  No more “uh I think it hurts a bit less” here.  Stimulus is given and we see how the nerves respond.

In this case, the body’s threshold of pain is increased – meaning treatment is effective and that a patient can tolerate pain better.

The results pointed to two nerve fibres-the ‘A delta’ pain fibers and the ‘C’ pain fibers-as being specifically affected by acupuncture.

Confirms what Berman, Pomeranz and Stux have been saying for decades.

Although the effects were modest, the researchers believe they provide the basis for future studies in individuals with chronic pain, where the effects might be more dramatic.

Here’s the crazy part.  An objective mind sees it this way, while a skeptic will say the effects are negligible so why bother.  A skeptic will also point out that it’s “just” a pilot study. Excuse me while I go find a toilet to relieve my nausea in.

Oh, and remember how I said that acupuncture can be dependent on the practitioner?

An experienced acupuncturist performed all treatments, applied to acupuncture points commonly used in pain management.

No newbies here who might eff things up!  I’m sure this acupuncturist had good skeeeelz.

And finally,

The results provide a scientific background for the ancient practice of acupuncture, according to Dr. Dominik Irnich, the study’s leading author.

“Our results show that contralateral stimulation leads to a remarkable pain relief. This suggests that acupuncturists should needle contralaterally if the affected side is too painful or not accessible-for example, if the skin is injured or there is a dressing in place,” added Irnich.

Dr. Steven L. Shafer, Editor-in-Chief of Anesthesia & Analgesia and Professor of Anesthesiology at Columbia University, views the results as an important preliminary finding.

“Reproducible findings are the cornerstone of scientific inquiry. The authors have clearly described their methodology, and their findings. If other laboratories can reproduce these results in properly controlled studies, then this provides further support for the scientific basis of acupuncture. Additionally, the ability of quantitative sensory testing to identify specific types of nerves involved in pain transmission may help direct research into the mechanism of acupuncture analgesia,” commented Shafer.

The study has been published in the May issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

Note that the authors mention that contralateral needling works.  This is not a new discovery.  It fits perfectly with the Chinese theory of meridians and collaterals.  According to this, the meridians go up and down and are the big lines you see in point charts.  However, the collaterals also exist that connect one side to another.  While the existence of meridians may be doubted by some, the implication of this belief in meridians and collaterals indicates that what we are verifying scientifically now has been long known by the Chinese since ancient times.  May I also add, that the ancient Chinese put much weight in clinical experience.  They didn’t know how it was happening, but they saw what treatments work through trial and error.  I am glad that, thousands of years later, their hard work is paying off handsomely.

http://timesofindia.indiatimes.com/Life/Health-Fitness/Health/Acupuncture-the-best-bet-to-ease-pain/articleshow/5883083.cms

A problem with acupuncture is not so much the lack of research – there are kaboodles of it – but the way these researches are conducted.  A recent online conversation I had with a fellow Xavier high school alumnus made this obvious to me.  Here is a quote from an email I wrote which I think summarizes my thoughts on this.

Is there a "proper" way to do acupuncture research?

Anyway here is the text:

(A) major misunderstanding (is) that the idea that acupuncture is like a pill – that can be single blinded (meaning that recipient doesn’t know that they’re getting the real thing or not) or double blinded (pill giver doesn’t know either.)  Obviously, using fake needles or sham treatments would necessitate that the “treatment” giver NOt be blinded.

However, the first difficulty comes in designing an adequate “sham”

First objection: sometimes inserting needles anywhere seem to stimulate an effect as well.

Second objection: even just pretending to insert needles seems to have an effect.  this is the “placebo” being indicated here.

The conclusion skeptics derive from these observations is thus: since inserting a needle into specific “points” doesn’t seem to be much different than inserting anywhere or simulating points without insertion, acupuncture is thus “useless”.

A closer examination of how acupuncture works biophysically (and yes, I do explain this to patients who ask) reveals that it works by simulation of the immune and nervous system.  Chris Kresser’s blog elaborates on this quite well.  Now is this the only way to stimulate the nervous and immune system? No.  Acupuncture evolved from touch/massage.  The question thus begged is, why not just touch?  My answer is that inserting needles saves time and effort.  Imagine if I had to stimulate ten points on a patient with my fingers?  By inserting needles to achieve the same stimulation, I can then leave the patient and attend to another one.

I'll bet Doctor Octopus would make a great masseuse...

So what is my proposal for an appropriate acupuncture “sham” procedure: it must involve NOT triggering the a-delta fibers.  A-delta fibers are the key to the “qi-sensation” or heavy feeling accompanying acupuncture (as opposed to sharp).  Research has shown that acupuncture analgesia is obliterated by blocking the transmission of a-delta fibers.  The best way to do that that i know of is through naloxone.  Hypothetically, a control group would have no treatment, another with conventional treatment, and two experimental groups – both with real acupuncture given by the SAME practitioner (more on this later) but with one blocked by naloxone.  The latter is the “sham”.  ”fake” needles that touch the skin also won’t work because the mere touching of the skin sets off similar reactions in the patient’s central nervous system, albeit to a lesser intensity as with acupuncture.

Now for the importance of the practitioner.  I once gave a lecture in a geriatrics convention and a participant commented to me that he used to practice acupuncture but his practice died out.  He then asked me “what are the points to use for migraine?”  I then said to myself, “kaya pala. (so that’s why…)” What does this incident tell us? Let me illustrate – it also explains to me why it is difficult to formulate studies for acupuncture.

It's not the size that counts. It's how you use it!

Acupuncture is not just inserting a needle and plugging it into a machine.  Acupuncture involves selecting points (although Chris Kresser disagrees with me there) , choosing how thick the needles are, determining how deep the insertion will be, and trying to control the sensations the patient feels through manipulation of the handle.  About manipulations, there are many which I shan’t specify now.  Suffice it to say that I have personally discovered that errors in any of the above will lead to treatment failure.  It is like surgery, the procedure itself is standard, but a lot also depends on how well the surgeon handles things.  i would normally not be so heretical as to compare something like acupuncture skills to the taxing physical and mental requirements required of a surgeon, but I hope the reader grasps my point (pun intended.)

Another problem is something I have been trying to get to with my earlier comments on different culture and world view.  Chinese medicine diagnoses things in a method somewhat different from western medicine.  I’m not just talking about differences in terminology.  I did touch on this with the example of dyspepsia.  I will try to elaborate more using headache, which is the disease condition that got me into acupuncture in the first place.

Point selection and manipulation in acupuncture depend on too many variables.  Ten people can have headaches.  One will have it in the front, another at the temples, another at the nape.  One will have headache associated with chronic sinusitis, another will have it due to migraines, yet another because he is a computer encoder always looking at CRT screens, another will have it after a flaring temper, yet another associated with menses.  Acupuncture treatment then, will seldom be the same for any two of these patients.

Hence, what would be my suggestion for a proper study?  In addition to the conditions above, we can also add something to make the patients even more homogenous (can never be totally homogenous though) – same race, same diet, same emotional pattern, same job, same associated factors for the headache.  Difficult yes, but necessary because of the nature of proper acupuncture point selection.

Clinical experience has shown that “cookbook” acupuncture, which means taking a western symptom “headache”, or “dysmenorrhea” CAN be effective, but I wouldn’t be surprised if it wouldn’t be AS effective.

What do you guys think?