Acupuncture and awareness

We have just published the results of a small experiment looking at acupuncture in people with chronic low back pain (see here). Now that is not a sentence I thought I would ever write, so there is some explaining to do. Acupuncture is a common treatment for back pain and one that has been well researched. The outcome of this research effort is pretty clear, acupuncture performs no better than placebo, which is what one might expect given the implausibility of traditional acupuncture and its incompatibility with well understood concepts within anatomy and physiology. However, a number of studies have shown that although true and sham acupuncture are no different, they are both better than usual care. While there are many explanations for this finding (some we discuss here), one favoured by advocates of acupuncture is that sham acupuncture is an active treatment and shares a mechanism of action with traditionally applied acupuncture.

Lots of ideas have been proposed; one mechanism that I think has some plausibility is that both true and sham acupuncture might help people with back pain by improving self-perception and awareness of the back. There is plenty of data supportive of the idea that self-perception is altered in chronic back pain and it might be that needling the painful area improves symptoms through a sensory discrimination like effect. One interesting thing about this proposal is that it can be easily tested. If this explanation is valid then the effects of acupuncture should be enhanced when the sensory discrimination like effects are enhanced.

We tested this idea using a randomised cross-over experiment. In both conditions we used the same number of needles, in the same points, inserted to the same depth and with an identical type and amount of needle manipulation. In the control condition, participants were asked to relax and not focus on the needles. In the experimental condition, participants responded to each needle manipulation by trying to localise the position of the needle that was being manipulated with reference to a picture of the back with the position of each needle marked. We measured pain on movement after each condition and found that people reported less pain after the experimental condition compared to the control condition.  This finding provides some support for the idea that people might derive benefit from acupuncture due to changes in self-perception, though there are other possible explanations.

It is a small experiment that only assessed pain on movement immediately after treatment, so is not the sort of data that should be strongly informing or changing clinical practice. It does build on the idea that impaired awareness and self perception could contribute to the clinical condition of chronic low back pain and offers some food for thought for those people using and researching acupuncture in the management of chronic pain. Foremost, it raises the issue that maybe needling should occur in areas of pain/altered perception rather than being based on the principles of TCM, in fact the results pose the question of whether penetrative needling is needed at all. Clearly there are a number of questions still to be answered.

About Ben

Benedict WandBen Wand is currently the coordinator of musculoskeletal studies for the Physiotherapy program at the University of Notre Dame Australia. He completed his original physiotherapy degree, as well as post graduate qualifications in sports science and manipulative physiotherapy in Sydney. He undertook his PhD at Brunel University in London on physiotherapy management of acute low back pain. His current research interests include the role of central nervous system dysfunction in chronic low back pain and physiotherapy management of chronic spinal pain.

References

Wand BM, Abbaszadeh S, Smith AJ, Catley MJ, & Moseley GL (2013). Acupuncture applied as a sensory discrimination training tool decreases movement-related pain in patients with chronic low back pain more than acupuncture alone: a randomised cross-over experiment. Br J Sports Med, 47 (17), 1085-9 PMID: 24021562

O’Connell NE, Wand BM, & Goldacre B (2009). Interpretive bias in acupuncture research?: A case study. Eval Health Prof, 32 (4), 393-409 PMID: 19942631

Comments

  1. Very encouraging story Jeisea,
    I believe one of the most experienced Yamamoto New Scalp Acupuncturists in Australia in Dr Emily Teo in Sydney if anyone else wanted to follow up this treatment – http://www.emilyteo.com.au/

  2. John Quintner says:

    The advice given by Sir Gilbert Blane [1749-1834] in his Elements of Medical Logick still seems to be appropriate:

    “There is nothing in which a young practitioner should be more on his guard, than being misled by the sweeping dogmas of schools, and the indiscriminate practices of sects, or of favourite practitioners.”

    Old practitioners might also take note!

  3. John Quintner says:

    Andrew, C Chan Gunn advocated the use of what he termed “intramuscular stimulation” to treat pain of presumed radiculopathic origin. I understand that his technique is still being taught.

    Having taken the opportunity in the 1990s to hear him talk in Sydney, I admit to being singularly unimpressed by his grandiose ideas. Others may have a better understanding of his rationale but it has always seemed to me to be unethical to inflict pain upon those who come to us seeking pain relief.

    Hopefully this form of treatment will soon be relegated to the dustbin containing an untold number of regimes of medical treatment that seemed at the time to be a good idea.

  4. John Ware says:

    Andrew,
    You are correct- I must have been dreaming that there was a sham condition. My apologies. Yes, a good follow up to this would include sham needling with and without awareness to the location of the input. I must have been thinking about a similar trial treating low back pain with real and sham acupuncture, which found no significant difference in pain reduction (http://www.ncbi.nlm.nih.gov/pubmed/22770838). There was also a trial comparing real and sham acupuncture for pain related to knee OA (http://onlinelibrary.wiley.com/doi/10.1002/acr.20225/abstract).

    To the the extent that myofascial trigger points exist as they have been defined in the literature, there is no mythology around needling. However, since the definition remains a moving target in terms of any established reliability, I think it’s safe to say that most patients are going to think “acupuncture”- whatever that means to them- when you insert a small needle into their painful region. I don’t think there’s any way around this, regardless of how hard you try to shape the narrative in a different way. In fact, I think that “biomedicalizing” the intervention by inventing some science-y sounding thing like a “myofascial trigger point” adds a whole other layer of mysticism to this intervention.

    I’m not sure that “semantics” is the proper term here. I think it’s important that we call things what they are, and the words we use to describe our interventions should reflect the current state of the science. For instance, fortunately you don’t hear many doctors going around saying that they perform “blood-letting” anymore. Although, there are rare conditions that require the removal of certain constituents of the blood (hemochromatosis comes to mind). An interesting side-bar to this is that blood-letting and acupuncture have a close historical relationship (http://www.doctorramey.com/veterinary-acupuncture-true-history/)

    Well, at least we’re rid of one of those.

  5. John Ware says:

    John,
    I’m similarly concerned about the American Physical Therapy Association’s endorsement of dry needling here in the U.S. Actions like these by our professional associations put those of us who promote a science-based approach to treating painful conditions in a tough spot. I’m seeing more referrals from physicians with specific instructions for dry needling. I don’t do it for the reasons I’ve expressed here, so I have to refer these patient out.

    I’m afraid that biomedicalism has a death grip on the rehabilitation professions despite evidence in a Cochrane Review from early in the decade that interventions directed towards psychosocial factors in patients with chronic LBP are effective (van Tulder et al, 2000).

  6. hi John Ware, reading above it says the needles pierced the skin? A follow up study where the “input” is no penetration with awareness vs no awareness penetration would help.
    Also dry needling doesn’t come with any mythology as far as i know it emerged from MD’s injecting cortisone into myofascial trigger point (palpable tender points on the body if you like) in the 1970’s. Subsequent scientific enquiry lead to the understanding that the needle not the substance was the “input” hence the use of acupuncture needles. Not sure where the science has now lead us.
    As for “myofascial release” speaking as a clinician its all semantics in the end and will leave it to the researchers to lead us into the light..

  7. John Quintner says:

    Just for the record, I am not suggesting that we toss out anything. But we do need at the very least to develop plausible scientific explanations to justify all interventions, including those that are pharmacological.

    It has long concerned me that the Australian Physiotherapy Association accredits courses in dry needling and, in so doing, endorses such treatment despite the lack of scientific evidence to support the practice. Some practitioners of prolotherapy appear to be running into similar problems of establishing scientific credibility.

    One elementary point is too often forgotten. We are not attempting to treat a “thing” called pain. Rather we are engaging with fellow human beings who have come to us for professional help because they are experiencing distress of an existential nature.

  8. Andrew,
    The results of Dr. Wand’s trial suggest that there may be a specific effect from applying sharp needles to the skin on the backs of patients with LBP when you draw their attention to the stimulus regardless of whether the needle pieces through the skin or not. The reason we need to throw out the word “acupuncture” is because it’s loaded with meaning that lacks any plausible explanatory model. It’s just kind of a made up thing based on lots of mythological ideas related to “Traditional Chinese Medicine” (TCM), for the most part. This is not to say that there isn’t something potentially therapeutic going on when you poke someone with a needle, it’s just not what acupuncturists (and dry needlers also for a different reason) claim is happening.

    I agree, by the way, that we need to throw out a whole lot of the mythology surrounding many manual therapies as well. We can start with “myofascial release”. 😉

  9. John Ware says:

    John,
    Well, as you’re well aware, it’s pretty hard to- as the existential phenomenologists say- “take the Coke out of the can”. Insofar as the treatment rituals around reflexology and CST create non-specific effects, just by indicating to the patient that one of these procedures is going to be performed already stacks the deck in the clinician’s favor. From there, I suspect it’s a matter of how well the method is sold that fleshes out the rest of the non-specific effects of the treatment.

    What I think the results of this study have done is piqued our interest in what *kind* of sensory-discriminative input we can draw the patient’s attention towards in order to shift their salience/threat-detecting apparatus away from a threat-state and towards “hmmm, well that doesn’t feel so bad” and then maybe allow some re-fining/re-establishing of those somatotopic maps followed by an adaptive motor response. And, of course, we need to do this without make up a bunch of nonsense out of whole cloth.

    I think the first order of business is to dump the mythology surrounding all these various methods- starting with the silly names that they’re known by and get on with the business of figuring out how or even whether applying certain S-D inputs is helpful for out patients.

  10. hey John surely that sensory input needs to come from somewhere so if we are going to toss out acupuncture et al we could lump a whole stack of the manual therapy tricks

  11. If acupuncture is purely a placebo why was there a difference between the groups when it appears the only variable here was “awareness”?

  12. John Quintner says:

    Ben, is it drawing too long a bow to claim that needling as practiced today is based upon the principles of TCM? Surely if such a connection exists it would be a very loose one.

    John, out of interest would you include such practices as reflexology and cranio-sacral therapy as other examples of FSDI or could they be thought of as examples of non-focal sensory-discriminative input?

  13. John Ware says:

    Andrew,
    On the contrary, I think what this study suggests is that what has been *called* “acupuncture” may provide specific effects that are beneficial to patient’s with pesky pain problems for entirely different reasons than acupuncturists and, dare I include dry needlers, have been claiming for all these years.

    Personally, I think we should start over by dropping the term “acupuncture” altogether- too much baggage. And while we’re at it, since penetration into muscle probably isn’t worth the risk, we may as well chuck “dry needling” as well. Let’s just call it what it is “focal sensory-discriminative input” or FSDI, if you will. Please send any royalties to the accompanying email address. 😉

  14. This almost seems to kinda say that maybe acupuncture sorta sometimes might actually be doing something useful..??? Take this man down to the dungeons

  15. John Ware says:

    This is very interesting to those of us who have been wondering about the so-called “non-specific” effects of acupuncture and dry needling. I’ve always considered that the treatment ritual surrounding this particular intervention carried much of the non-specific effect “weight”, so to speak. However, I recently read a study led by Nadine Foster (http://www.ncbi.nlm.nih.gov/pubmed/19665403) where the role of patient expectation appeared to have a weak influence on reductions in pain. It makes sense that non-threatening sensory-discriminative input that improves awareness of the painful region might be the specific effect that we’ve been looking for, including from performing certain kinds of manual therapy.

  16. Ben. A few years ago I my opinion was that acupuncture was quackery, airy fairy god dam hippy crap. At the time I’d had had a migraine for 3 weeks when my rather eccentric Indian GP insisted he use Yamamoto New Scalp Acupuncture to stop the pain. I was refused explaining that I felt the needles would cause me harm and worsen symptoms of CRPS, fearing that the syndrome would develop in my head. The doctor absolutely insisted and against my better judgement (no placebo here) I let him place 3 needles in the my scalp. With 30 minutes the pain and other symptoms of migraine were gone. What was more significant was that the headache did not recur. My pattern was that headaches would return over and over before eventually stopping. Aspirin was the only thing that helped. Over a few years my GP stopped migraines 3 times, each with a single treatment of 3 needles.
    More remarkable and life changing for me was that he used YNSA to treat wrist tendonitis. He used 5 treatments of 21/2 weeks. This was the only other time I’d had this Acupuncture. At the time I had whole body CRPS with dysautonomia. I couldn’t pass a tilt table test due to extremely labile BP. I struggled to walk up stairs, hill etc due to shortness of breath due to cardiac symptoms. To my complete disbelief my CRPS symptoms had gone. I had remission. My BP was normal. I could exercise etc with no symptoms. My muscles etc were weak so I needed physical therapy but pain was gone. Unfortunately a few months later I had an accident where I rupture my anterior and posterior cruciate ligaments, and accident which caused significant pain. My CRPS returned including the cardiac stuff. I had therapy for 12 months before I asked my GP to try the YNSA again to see if it was just a coincidence last time. Again he did five treatments over 21/2 weeks. I’ve been in remission for over 4 years now.
    I had YNSA as a trial for one other thing. I had idiopathic secretory diarrhea after a n overseas trip. YNSA made no difference so was stopped after a few treatments. My GP died about a year ago. I know little about acupuncture but suspect all acupuncture is not the same. YNSA was devised by a Japanese physician to treat neuropathic conditions! stroke, Parkinson’s and MS. I encourage you to keep doing research in this area. The results I had were measurable in as much as medical tests proved my BP was no longer labile, I could exercise normally with no cardiac symptoms etc. It was not a case of my relating a change in symptoms. This was not a case God dam hippy crap. 🙂

  17. John Quintner says:

    Ben, your research into this area is indeed timely. One of the fads that is spreading fast through the shadowy underworld of alternative medicine is that known as Neural Prolotherapy (or “sugar-coating the nerves”).

    Unfortunately, this form of treatment was pioneered by a New Zealand medical practitioner, who is now teaching others to use his technique for a great variety of chronically painful conditions.

    He has presented his ideas to members at a scientific meeting of the Australasian Association of Musculoskeletal Medicine. Three articles were published under its auspices (see below). But I cannot see that any doubts have been raised by the membership (or by anyone else) as to the scientific validity of this form of treatment. Echoes of dry needling, perhaps?

    What I find more disturbing is that the proponent of this treatment has drawn upon research published by such notable people as Geoffrey Bove and Douglas Zochodne, both of whom have distanced themselves from the nonsensical hypothesis that underlies Neural Prolotherapy.

    Yes, there are a number of questions that remain to be answered.

    References:

    Lyftogt J. Subcutaneous prolotherapy treatment of refractory knee, shoulder and lateral elbow pain. Australasian Musculoskeletal Medicine November, 2007: 83-85.

    Lyftogt J. Prolotherapy for recalcitrant lumbago. Australasian Musculoskeletal Medicine May 2008: 18-20.

    Lyftogt J. Pain conundrums: which hypothesis? Australasian Musculoskeletal Medicine November 2008: 72-7