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Archive for the ‘Research’ Category

Despite the physiological discrepancy, no condition is closer to my heart than knee pain. I found Eastern medicine by shredding the cartilage of my knee. I had surgery to repair the damage, but the physical therapy didn’t work out so well, and within a few weeks my knee was the size of a basketball. Months of crutching about led to yet more months wielding a cane. Add in the strain to my low back and hip muscles from the compensation, and at 25 I was rocking out the full old-timer, complete with cloudy disposition and an impressive ratio of grumps per day. After half a year of this, I found myself relocated to San Diego from Connecticut. It didn’t take long for me to find tai chi, which enabled the miracle of miracles by unlocking my body’s innate healing ability that modern physiological science had been unable to reach.

Two years of tai chi later, I found myself in school for acupuncture & Eastern herbs. At this point my knee had regained full functionality (it actually worked a bit better than before the surgery), but I still had some shooting, stabbing pain when especially active. Then there was the meteorologist that had moved into my knee, alerting me to barometric changes with dull aches. Long mornings in the cold ocean waiting for waves got that meteorologist humming, too. It was the perfect home experiment!

Every night after school I pulled out my books and notes and set to work on my knee. I wasn’t very skilled in the beginning, in fact I was rather dreadful. But I stuck with it, and gradually my needle technique grew less painful. However, my knee started to feel better right away. By the second semester, I hardly needed any needles in my knee at all.

I like to say that I specialize in anything interesting, but my first project was my knee, and as such, the aspect of Eastern medicine with which I am most familiar, is knee pain. It is then with great delight that I can share this study on osteoarthritis of the knee from the People’s Hospital of Peking University in Beijing.

The points used in the study on all 73 participants are almost exactly the same ones that I used on my knee. Of the 49 people who completed the four week study, all had improvement in their knees, and that improvement was sustained after the four week followup visit. There was no control arm. The study assumes acupuncture works, and is testing a particular protocol. Admittedly, a study in which every participant improves is a bit suspect, which is a reason why some meta-analysis studies regard acupuncture’s success as inconclusive. [Commence digression] However, the studies then go on to conclude that acupuncture doesn’t work, which is as intellectually irresponsible as designing a study that allows for 100% improvement. The world of acupuncture research and research on acupuncture is still in its fledgling stages, and these are the growing pains–ones that acupuncture can treat! [Digression concluded]

I still use the bulk of these points for my knee pain treatments, but I change up the other points to customize the treatment to the individual. A scientific study by nature has to use the same points from person to person, but our bodies are all different, and as such, the pain of the knee and surrounding structures changes from person to person. Acupuncture works best when it is customized, but it can still work when homogenized. The knee is especially suited to homogenization of treatment, given that the reason for the problem is essentially the same from person to person, and the location of pain changes only slightly. The source of knee pain is almost always within the knee and surrounding muscles, so needling the points around the knee works very well. Something like carpal tunnel syndrome on the other hand can stem from the neck, shoulder, and elbow, so it is more difficult to design a standardized treatment that effectively treats it equally in all cases.

Furthermore, from a point function perspective, two of the points used in the study are very commonly used by acupuncturists to improve metabolism and boost energy. Though the source for knee pain is usually within the knee joint, poor posture of the whole body and sloppy ergonomics will put more strain on the knee to exacerbate the pain. With this increase in energy, it is easier to maintain proper posture and gait. Another of the knee points used in the study is used by many acupuncturists for almost every condition involving tendons, which are a major component of any joint. These dual purposes reflect the local and systemic nature of acupuncture points. All points will benefit local problems, i.e. the point in the middle of the wrist crease benefits carpal tunnel syndrome. Then there are the systemic actions of the points, wonderfully illustrated in this study using brain imaging. In essence, acupuncture points stimulate parts of the brain that are associated with many of the problems the points are traditionally purported to treat. The People’s Hospital of Peking University study uses points that are local (on the knee) which also positively affect health of the body in a way that supports recovery from osteoarthritis of the knee. This is a study of a treatment strategy that is incredibly simple and elegant. It is no wonder that it garnered positive results.

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    Allergy season is upon us, and there was recently an article on Time.com reporting on a study about acupuncture and allergies.
    The conclusion of the study was that “Acupuncture led to statistically significant improvements in disease-specific quality of life and antihistamine use measures after 8 weeks of treatment compared with sham acupuncture and with [cetirizine (i.e. Zyrtec and Reactine)] alone, but the improvements may not be clinically significant.”
    Sham acupuncture is when needles are not placed in relevant points on the body. It is used as a control group in acupuncture studies. I am not alone in the acupuncture world to be itching for acupuncture studies that compare acupuncture point prescriptions against one another, for there are many different strategies to treat allergies, as opposed to compare real acupuncture against sham acupuncture.
    Real acupuncture in a clinical trial is not quality acupuncture by any stretch of the imagination. Acupuncture works the best when the points selected are customized to an individual. Acupuncture does not function like medication, which is exactly the same composition of chemicals for each patient. Acupuncture points that work well for one person may do nothing for another, and vice versa. An acupuncture study, in attempts to maintain the “gold standard” of blinded control studies, uses the exact same point prescription for every patient. Therefore, acupuncture will frequently produce clinically insignificant results when practiced in a study, because a study by intention does not practice clinical acupuncture.
    Acupuncture is an expensive way to treat allergies, so it is probably only an avenue of pursuit for those who do not respond to, do not wish to, or are unable to take medications. There are Eastern herbal formula designed to treat allergies, which work well in conjunction with acupuncture, which can cut down on the number of visits required and mitigate the cost.

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Acupuncture & Chronic Pain

“Acupuncture provides more relief from various types of chronic pain than does usual care and should be considered a valid therapeutic option, the authors of a meta-analysis concluded.”

A meta-analysis is when a group of researches read through many other studies and write up a research report that qualifies as its own study.

Much of the difficulty acupuncture has had with gaining recognition by the medical community stems from the difficulty in running a randomized controlled double-blind study. The biggest problem has been creating a control group. When we test a pill, we can use a placebo, but how do we pretend to put needles in the body? The solution is called “sham acupuncture,” which is when needles are just inserted into the skin and not the flesh beneath, or are inserted in a place of the body that is not one of the traditional acupuncture points. There are two problems with this.

An insertion into the skin is not the most common way to practice acupuncture, but an entire school of thought coming out of Japan dictates that it can be as or more effective to insert the needles just into the skin, than into the flesh beneath. I myself practice one of these styles, called Japanese Meridian Therapy. I often use it with patients who are very weak or sensitive to needles. Thus, a skin insertion is not sham at all.

Inserting a needle into a place that is not a “point” will often work better for a condition than a standard point. We call these “a-shi” points, which translates to “that’s it!” because they are tender to palpation.

This study mentions that despite these pitfalls, real acupuncture outperformed sham acupuncture, which has not always been the case, as I discuss in the migraine article.

The difficulty in doing a study has led previous authors to dismiss acupuncture’s efficacy, thereby creating an idea in the medical world that acupuncture does not work. Not all authors took this route, many suggested further studies were necessary. That a meta-analysis was undertaken and demonstrates that acupuncture can function like a proper study is wonderful for the advancement of Eastern medicine in the West.

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Inner Gate fMRI

http://www.ncbi.nlm.nih.gov/pubmed/22515798

I wouldn’t even make pretenses to being a neuroscientist by donning an Einstein wig and goggles, but I can generalize wildly at the distillations of actual neurobiologists with the best of them. This article is describing the areas of the brain that “light up” when subjects were needled at a specific acupuncture point, Nei Guan, which is also called Pericardium 6 (PC6), and translated into English as “Inner Gate.”

The areas of the brain that “lit up” in this study were: the anterior cingulate cortex (ACC), occipital fusiform gyrus, posterior cingulate cortex, and precuneus (PCC/PCU). They are involved with awareness, emotions, sense of self, empathy, judgments of self as distinct from others, pain, blood pressure & heart rate, episodic memories, and “unconscious” memory retrieval and vetting.

In Eastern medicine, PC6 is predominantly used for nausea, chest disorders, and shen disorders. The shen is the Eastern version of the ego as self (not the division into superego, id, etc.). Its name, Inner Gate, implies access to the inner workings, or the vault, which corresponds nicely to the idea of judging the parameters of our self, as well as memory retrieval. The Pericardium channel is used to treat disorders of the heart, like blood pressure, as the Pericardium literally wraps the heart to protect it, and figuratively acts as the Heart’s envoy & ambassador to protect it from hostile forces.

It is also the point used to access what is called the yin linking vessel, which is an extraordinary meridian that links all of the yin channels in the body together and acts as an overflow-canal system, to redistribute excesses and deficiencies into a state of balance. The yin channels are all connected with a yin organ, which are viewed as a seat of an aspect of consciousness in traditional Eastern medicine. In this way, PC6 can affect all the aspects of the shen, and thereby influence any emotional state.

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Migraines

The following is a study demonstrating acupuncture’s efficacy on acute migraines:

http://www.ncbi.nlm.nih.gov/pubmed/22536889

Verum (real) acupuncture demonstrated greater improvement in the migraine than did sham (fake) acupuncture. Sham acupuncture is when the needles are just pressed against the skin, or inserted into points that have no basis for treating a
migraine using the Eastern diagnostic and treatment system. It is the preferred way of blinding subjects in the control arm of a study, for they think they are getting acupuncture, as they can feel the needle’s tip, but an acu-point of clinical relevance, as determined by the principles of Eastern medicine, is not stimulated.

The second article tests the prophylactic use of acupuncture to prevent migraines:

http://www.ncbi.nlm.nih.gov/pubmed/22019576

The number of days in a month with a migraine was halved with acupuncture, whereas the topiramate (originally an anticonvulsant, but frequently used for migraines) group saw 25-40% improvement. 6% of the acupuncture group had side effects, whereas 66% of the topiramate group experienced adverse effects. Side effects of acupuncture are usually short lived, and at worse are an exacerbation of the symptoms. Topiramate has many side effects, some of which are nasty.

Here is a less favorable review. http://www.ncbi.nlm.nih.gov/pubmed/22231691

It essentially suggests that all needles that were inserted had the same effect regardless of the intention of the point selection. Shao-yang, and Yang-ming are two of the six aspects of the yin-yang symbol, the skinny white part and the little white circle respectively. The body is divided up into the six divivsions of yin and yang, so the shao-yang points are on a certain part of the body, while the yang-ming points are on another. Points along the shao yang are used to treat the acute aspect of a migraine. Yang ming treatments aid in things where there is inflammation, or slightly excessive amounts of blood in the head. I am assuming the sham group was needles that were just touched to the skin, as the category of non-shao-yang specific acupuncture is the rest of acupuncture that isn’t shao-yang.

This case is interesting, in that it exhibits the strength of the placebo effect caused by the sensation of needles inserted into the body, into actual acu-points, as opposed to sham acupuncture. Stimulating the needles with electricity (a practice that isn’t uncommon nor standard) probably added to the placebo effect.

The conclusion of this study is not that acupuncture is mere placebo effect. Had the shao-yang treatment been used for the acute  migraine attack, as the first article was treating, the results would probably have been favorable. The third article was examining acupuncture’s prophylactic treatment of migraines, something we deem to fall under the chronic stage of disease. The ideal treatment for chronic migraines, or migraine prophylaxis, incorporates the jue-yin aspect of the body, which the article did not address. This is an example of the study being conducted without a sufficient understanding of Eastern medicine. Had they incorporated jue-yin treatments, it would very most likely have shown a more clinically relevant result.

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