Physiotherapy and Acupuncture

eightyfish

My girlfriend and fell injured her arm a few weeks ago. She has been going to a physio a couple of times a week since then. The actual clinic looks like a very professional place - no leaflets for homeopathy in the waiting room etc.

Last week, her physio was not there and the replacement physio decided to do some acupuncture as well as the normal physio stuff. She stuck pins in my girlfriend's neck in order to relieve the pain in her arm. (No immediate effect was felt)

So I'm asking is this a warning signal that she should be finding another physio because this one does not practice evidence-based treatment? Is there any evidence to back up the use of acupuncture to relieve pain in this way?

eightyfish

eightyfish wrote: »

My girlfriend and fell injured her arm a few weeks ago. She has been going to a physio a couple of times a week since then. The actual clinic looks like a very professional place - no leaflets for homeopathy in the waiting room etc.

Last week, her physio was not there and the replacement physio decided to do some acupuncture as well as the normal physio stuff. She stuck pins in my girlfriend's neck in order to relieve the pain in her arm. (No immediate effect was felt)

So I'm asking is this a warning signal that she should be finding another physio because this one does not practice evidence-based treatment? Is there any evidence to back up the use of acupuncture to relieve pain in this way?

Well placebos can help with pain for a certain amount of people.
But given what you're saying your girlfriend wasn't one of them.

But maybe he was doing the same kind of physio the other guy was doing?
Did she mention she had to do different exercises or anything?

I'd say have a word with the guy, it's possible that he only used acupuncture knowing well it's a placebo.

eightyfish

King Mob wrote: »

Well placebos can help with pain for a certain amount of people.
But given what you're saying your girlfriend wasn't one of them.

But maybe he was doing the same kind of physio the other guy was doing?
Did she mention she had to do different exercises or anything?

I'd say have a word with the guy, it's possible that he only used acupuncture knowing well it's a placebo.

Thanks for the reply. She was asked to do different types of exercises. The first physio told her to move her arm "within the pain barrier" while she second physio told her to move her arm even if it hurt. I think this may just be down to different styles of physiotherapy.

It was only the acupuncture thing that worried me. She (all women) said that it would help relieve the pain, nothing more than that. I'll ask my girlfriend to pry for more information next time.

tallaght01

I think acupuncture is very effective for some patients.

I think the explanation of how it works is balls, but it does seem to work.

bleg

I presume she gave consent for the acupuncture.

eightyfish

bleg wrote: »

I presume she gave consent for the acupuncture.

Yeah. In the "I'll give it a go" kind of way.

Improbable

I'd say if it was just a one off with this guy, then as long as the physio is helping overall, I wouldn't bother trying to start again with a different physio. Perhaps just have her say that she doesn't want any more acupuncture.

C0nc0rdance has just released a good video about acupuncture.

http://www.youtube.com/watch?v=pp5eiHUdwb4&feature=sub

jdivision

Acupuncture was shown to work clinically recently, I can attest it's had significantly more positive effects for me than physio - in the case of my back at one stage four months of physio three times a week had little impact and two sessions of acupuncture fixed the problem. It was after that I was convinced as before that I was a sceptic.

eightyfish

jdivision wrote: »

Acupuncture was shown to work clinically recently,

Hmm.

Although there is now good evidence that acupuncture can relieve pain,

I though there wasn't any evidence beyond placebo.

It seems that they acupunctured the mice feet - where the pain was. This physio was putting needles into her neck to relieve pain in the elbow. I need an explanation. Will ask the physio.

jdivision

jdivision wrote: »

Acupuncture was shown to work clinically recently,

Well that article is just crap frankly.

One of the longstanding mysteries surrounding acupuncture is why the technique only seems to alleviate pain if needles are inserted at specific points.

This has since been debunked by studies showing that putting needles in the wrong points is as effective if not more effective.
This is detailed in the video I posted above.

jdivision wrote: »

I can attest it's had significantly more positive effects for me than physio - in the case of my back at one stage four months of physio three times a week had little impact and two sessions of acupuncture fixed the problem.

You do realise that anecdotes are useless as evidence right?

For example take this one:
I tried acupuncture and it made my pain worse.
Now do you think this anecdote is evidence?

jdivision wrote: »

It was after that I was convinced as before that I was a sceptic.

So you're not skeptical at all now?
Is there nothing that could convince you that acupuncture doesn't work?

Ghostswimmer

Firstly, I declare no conflict of interest in any elements relating to acupuncture and/or physiotherapy.

Secondly, it is quite ridiculous to have such a hardened opinion regarding anything when evidence repeatedly given has not displayed reasons to be so definitive. Many research articles that are published that do not demonstrate clear differences over control are actually often interpreted by authors and clinical review panels as inconclusive.

There are several reviews demonstrating evidence that acupuncture is efficacious in some conditions and is not in others (Mayer article in Ann Rev Med., 2000. Attached). This is not unsurprising. In fact one wouldn’t use one drug to treat all conditions would they?

Furthermore, although the theories as to why acupuncture could work, as we currently observe due to TCM methods, may not make sense to us. However, that does not mean that the fundamental essence of treatment does not work. Studies have demonstrated that the points involved in acupuncture fundamentally alter neurological function (Fang et al., Neuroradiology, 2004. Attached). This means that whatever happens during acupuncture, it causes a biological response. It would be idiotic to disregard these types of studies completely. Regarding a possible mechanism of action, again this is not quite understood. Not that it is thrown out with the bathwater, just not understood. However, research is trying to focus more and more on potential biological mechanisms. As an example, attached is an article from Nature Neuroscience (Goldman et al.) from this month (July 2010). So this would be considered an opinion leading journal and given it has been published this month, it is the most recent evidence.

The American National Institute of Health (NIH) set up a panel to review the literature on acupuncture to determine clinical efficacy. To quote from their findings (NIH Consensus Conference. Acupuncture. JAMA. 1998;280:1518-24):

“There is clear evidence that needle acupuncture is efficacious for adult postoperative and chemotherapy nausea and vomiting and probably for nausea of pregnancy. Much of the research focuses on various pain problems. There is evidence of efficacy for postoperative dental pain. There are reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions. . . . However, there are also studies that do not find efficacy for acupuncture in pain. . . . Although many other conditions have received some attention. . . , the quality or quantity of the research evidence is not sufficient to provide firm evidence of efficacy at this time”

So, what I am saying is that to just purely disregard the treatment due to lack of research or a dogged opinion in light of evidence to the contrary is just incomprehensible. Although we do not know the full basis as to how acupuncture may or may not work, this is not a reason to just say it doesn’t work.

eightyfish

Ghostswimmer wrote: »

So, what I am saying is that to just purely disregard the treatment due to lack of research or a dogged opinion in light of evidence to the contrary is just incomprehensible. Although we do not know the full basis as to how acupuncture may or may not work, this is not a reason to just say it doesn’t work.

Just looking through the Abstract for the Mayer review, it's not that convincing:

The review covers the 14 medical conditions for which the
National Institutes of Health Acupuncture Consensus Development Panel (NIHCDP)
concluded that acupuncture either is effective (2 conditions) or may be useful (12
conditions). My conclusions partially support those of the NIHCDP. There is evidence
that acupuncture is effective for the treatment of postoperative and chemotherapyinduced
nausea and vomiting. Also, some data indicate that acupuncture may be useful
for headache, low back pain, alcohol dependence, and paralysis resulting from stroke
(4 of the 12 conditions for which the NIHCDP found that acupuncture may be useful).
For most of the remaining conditions, there is little evidence that acupuncture is either
effective or ineffective.

I have not read the papers beyond that yet. Wondering about pain here. I've just looked up some meta-analyses of studies specifically covering acupuncture and pain. This one from 2000 concludes

We conclude there is limited evidence that acupuncture is more effective than no treatment for chronic pain; and inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care. However, we have found an important relationship between the methodology of the studies and their results that should guide future research.

This one concludes

The quality of even the better studies proved to be mediocre. No study earned more than 62% of the maximum score. The results from the better studies ( 50% of the maximum score) are highly contradictory. The efficacy of acupuncture in the treatment of chronic pain remains doubtful.

This one concludes:

In conclusion, there is limited evidence deriving from one study that deep needling directly into myofascial trigger points has an overall treatment effect when compared with standardised care. Whilst the result of the meta-analysis of needling compared with placebo controls does not attain statistically significant, the overall direction could be compatible with a treatment effect of dry needling on myofascial trigger point pain. However, the limited sample size and poor quality of these studies highlights and supports the need for large scale, good quality placebo controlled trials in this area.

EDIT: I know there are more recent reviews also, this is just from a bit of searching this morning.

Ghostswimmer

Thanks Eightyfish for the response.

My point was really that if there is something happening, such as the neurological alterations and potential mechanistic discoveries (e.g. being the Nature article), that one shouldn't dismiss the potential biological benefit from the treatment.

Just being pernickety here, but you only ever seem to read the Abstract. Everything you have quoted comes from the abstract. These, as I'm sure you know, are not exactly reliable and you should analyse the results themselves and throw caution over any interpretation in the discussion. Basic science research really.

And all this research on Sciencedirect relates to pain. Albeit a major potential avenue for research for acupuncture use, there are other possible, less subjective, conditions that can be looked at. Pain is more difficult to quantify as an end-point. The well documented involvement of the role of subjective psychological influences on pain perception will cloud most research in this area. Traditional analgaesics work for most (even in that, one dose of a drug will work for one person and will not in another person), but neuropathic pain is treated by non-analgaesic sources (e.g. antiepileptics). This simply illustrates the complexity of this problem. And the chances are that most people looking for alternatives to pharmaceutical treatment will be the people looking for acupuncture etc.

So, perception of pain as a readout may not be the best for trial data. Some non-subjective endpoint is obviously best, albeit harder to obtain.

Anyway, just going back to my point, to throw out any potential for treatment on some specious beliefs is not good science, no matter how many youtube videos there are.

Ghostswimmer

eightyfish wrote: »

This physio was putting needles into her neck to relieve pain in the elbow. I need an explanation.

Sorry, meant to add, I suppose the elbow pain could be referred pain (from the C5/C6 cervical root irritation?) and that is why the person treated at the source. But it is always good to question why to any healthcare professional.

eightyfish

Ghostswimmer wrote: »

My point was really that if there is something happening, such as the neurological alterations and potential mechanistic discoveries (e.g. being the Nature article), that one shouldn't dismiss the potential biological benefit from the treatment.

Of course not, but I need to be convinced. I need strong evidence to make me believe that sticking needles in your neck will reduce the pain in your arm.

Just being pernickety here, but you only ever seem to read the Abstract. Everything you have quoted comes from the abstract.

Oh yeah - I acknowledged in my last post that I haven't read the papers yet. I'm in work, just reading overviews of the research to get an idea. I'll look into it more later. I think it does give you a good general overview, though, reading abstracts.

This simply illustrates the complexity of this problem. And the chances are that most people looking for alternatives to pharmaceutical treatment will be the people looking for acupuncture etc.

Aye - the effects of placebo are complex and well-documented. I'm looking for definite evidence that this method works to dull pain beyond any possible placebo or psychological effects. This is difficult to demonstrate, but it must be demonstrated if a so-called qualified medical-professional is going to use it on you when you pay them €80 in good faith. It is very easy to show by clinical trail that paracetamol and ibuprofen kill pain. Similar evidence must be presented for acupuncture for it to be taken seriously, IMO.

eightyfish

Ghostswimmer wrote: »

Sorry, meant to add, I suppose the elbow pain could be referred pain (from the C5/C6 cervical root irritation?) and that is why the person treated at the source. But it is always good to question why to any healthcare professional.

I don't know - maybe. She fell on her wrist and the lower bone of her arm slammed into her elbow joint. It was swollen for a couple of days and she couldn't move her arm. The restriction in movement and pain was so bad that the hospital initially though it was dislocation. She couldn't move her arm properly for a week and had to get a taxi into to work for two weeks. So it was a fairly bad injury without actually breaking bones.

Ghostswimmer

eightyfish wrote: »

Aye - the effects of placebo are complex and well-documented. I'm looking for definite evidence that this method works to dull pain beyond any possible placebo or psychological effects. This is difficult to demonstrate, but it must be demonstrated if a so-called qualified medical-professional is going to use it on you when you pay them €80 in good faith. It is very easy to show by clinical trail that paracetamol and ibuprofen kill pain. Similar evidence must be presented for acupuncture for it to be taken seriously, IMO.

Pretty good and fair point.

ergo

I don't have time this minute to weigh knee deep into the argument re accupuncture etc but I just have this to say:

One of the best sports physios I know who currently works with a professional sports team in UK has a lot of time for accupuncture and does incorporate it into his practice

regarding evidence base, well there are a lot of things that are routinely accepted in medicine that have no serious evidence base

N8

eightyfish wrote: »

So I'm asking is this a warning signal that she should be finding another physio because this one does not practice evidence-based treatment?

classic - what evidence based therapies was the physio using prior to this maniac? Have you examined them before immediately deciding aainst acupuncture?

eightyfish

N8 wrote: »

classic - what evidence based therapies was the physio using prior to this maniac?

Good point, I don't know.

N8 wrote: »

Have you examined them before immediately deciding aainst acupuncture?

I didn't immediately decide anything. I asked a question on a health sciences forum:

Is there any evidence to back up the use of acupuncture to relieve pain in this way?

If you have anything to contribute, let me know.

eightyfish

ergo wrote: »

regarding evidence base, well there are a lot of things that are routinely accepted in medicine that have no serious evidence base

Well it depends - drugs etc, like painkillers, all have evidence to back them up. Sometimes it can be argued that big pharma distorts the evidence by ending trials early when they get good early results etc, but in the most part market drugs are on the market because they have been demonstrated to be effective and be safe. They have gone through clinical trials.

When it comes to physiotherapy, the methods must be more difficult to test. But it must be said that from common sense, the following statements different levels of evidence:

1. In order for your sprained elbow to heal, you should keep it in use during the day as the movement will help the healing process more than keeping it in a sling.
2. In order to help relieve the pain in your elbow, I'm going to stick some needles in your neck.

The more extraordinary the claim, the more extraordinary the evidence required.

N8

eightyfish wrote: »

I asked a question on a health sciences forum:

Is there any evidence to back up the use of acupuncture to relieve pain in this way?

If you have anything to contribute, let me know.

eightyfish wrote: »

So I'm asking is this a warning signal that she should be finding another physio because this one does not practice evidence-based treatment? Is there any evidence to back up the use of acupuncture to relieve pain in this way?

sorry I found myself automatically answering your first question first.

jdivision

King Mob wrote: »

Well that article is just crap frankly.?

because it doesn't agree with your point?

King Mob wrote: »

You do realise that anecdotes are useless as evidence right?

Of course, I can merely attest to what I experienced, ie physio was a lot more expensive and a lot less effective

King Mob wrote: »

So you're not skeptical at all now?
Is there nothing that could convince you that acupuncture doesn't work?

No, I've experienced the benefits. Given a choice between the two for the various ailments I've had I'd go with acupuncture every single time

jdivision

jdivision wrote: »

because it doesn't agree with your point?

No, because it's poorly researched.
Most science stories in the media are usually crap.

It overstates the evidence provided by the research.
And it makes a big deal about acupuncture points, which the studies I posted show are not needed for acupuncture to be effective (effective as a placebo).
One study showed that using needles that don't puncture the skin, let alone any nerve cluster, can be more effective than real acupuncture.

jdivision wrote: »

Of course, I can merely attest to what I experienced, ie physio was a lot more expensive and a lot less effective

Well in that case,since you think anecdotes are good evidence:
Physio was way more effective for me that acupuncture.

Does my anecdote trumps yours?

jdivision wrote: »

No, I've experienced the benefits. Given a choice between the two for the various ailments I've had I'd go with acupuncture every single time

So there's nothing that could change your mind?
Doesn't this make you the closed minded one?

Glenmore888

My husband is doing a *very* evidence based physio uni degree in Oz and they teach dry needling, which uses similar needles to acupuncture but without the Chinese medicine energy lines placement.

Sorry that I don't have references at hand, but I believe that there is a good evidence base for the use of dry needling in recent years in physio and it is common practice over here.

Glenmore888

Like I was saying, it is pretty well recognised in physiotherapy in Australia. The Australian Physiotherapy Association have had a special interest group since 1979.
http://www.physiotherapy.asn.au/index.php/groups/acupuncture-and-dry-needling

As for trials and evidence, I haven't done a search, but plenty of traditional accepted physiotherapy doesn't have a good evidence base behind it either. That's not to say that it doesn't work, just that large, well organised clinical trials have not been funded to examine the various techniques.

Follow the money, as they say in the Wire...

N8

bit off topic but acupuncture and obstetrics

http://www.reuters.com/article/idUSTRE63R6C020100429