Orthopaedic and sports rehabilitation services are offered through a variety of outlets. More often than not they are multidisciplinary.  This fact is a testament to the complexity of the rehabilitation process. It takes an entire team of health care providers to restore a patient after a serious injury. The team may include an orthopaedic surgeon who runs tests, makes a diagnosis and a referral; a physical and/or occupational therapist; a chiropractor; and, lately, a massage therapist and an acupuncturist. While each team member brings his or her own expertise to the table, there can be a redundancy in their offerings, especially on the hands-on end of the treatment spectrum. For example, some acupuncturists may also be trained in Tui Na -– a form of Chinese manipulative therapy that combines therapeutic massage with joint mobilization, traction, and assisted stretching through PNF (proprioceptive neuromuscular facilitation). Many of these techniques fall squarely into the domain of physical therapy.

How should we leverage the skills of different members of the treatment team to assure speedy and safe recovery for our patients? How do we choose from the assortment of treatment modalities? And in what order should we implement them? Therapeutic exercises, which are an essential part of the rehabilitation process, may not be applicable immediately after surgery or injury. Pain and inflammation at that time may still be too acute to permit exercises. Therefore, pain-reducing techniques and anti-inflammatory measures are called for.

This is when and where electro-acupuncture, otherwise known as percutaneous electrical nerve stimulation (PENS), can be handy. PENS is a lesser-known sibling of TENS, which stands for a Transcutaneous Electrical Nerve Stimulation. The latter technique is usually performed by physical therapists, the former by acupuncturists. Both techniques are used to control pain. While we still need well-designed large-scale clinical studies to prove the efficacy of both modalities, some studies favor PENS over TENS in the treatment of pain. Look at the PENS for Low Back Pain randomized crossover study:

http://jama.ama-assn.org/content/281/9/818.full.pdf

I think that there are several advantages of using PENS over TENS to treat acute pain:

1. During PENS procedure at least two acupuncture needles penetrate skin. They deliver electrical stimulation directly to the targeted tissues under the skin, bypassing the skin’s electrical resistance. The skin’s electrical resistance can be as high as 450,000 Ohms when dry, less when wet. In contrast, electrical resistance of the internal body is much lower, typically measured at several hundreds of Ohms. TENS procedure is carried out with the external electrodes that are placed on the surface of skin. Electrical current always seeks a path of the least electrical resistance. With TENS, the electrical current spreads over the surface of skin but does not go underneath.
2. Acupuncture needles can be positioned with greater precision—in comparison with the surface electrodes—in the proximity of the treated anatomical structures. The electrical current flows trough the areas that are otherwise difficult to reach. For example, after a repair of the meniscus acupuncture needles can be inserted medially and laterally along the joint lines of the knee. The electrical current will flow from the one side of the knee to the other through the meniscus and the joint itself.
3. Although somewhat speculative:  in addition to a segmental analgesia, PENS may work systemically, through the pituitary hypothalamic system. http://www.ncbi.nlm.nih.gov/pubmed/9330669

PENS is an example of a useful non-redundant technique that brings acupuncture into the rehabilitation process.

In my last post about acupuncture research I argued that any ambiguity in study design will obscure output data.  While an inadequate control group or a sub-optimal acupuncture group are the most obvious culprits, the ultimate nemesis is our lack of consensus about the physiological framework of acupuncture, and hence of appropriate clinical techniques.  Fortunately, there is active ongoing research at the level of basic science and at the pragmatic clinical level to assist us in developing such consensus. Understandably, it will take time. We are lucky to have this time—that is if we keep delivering value to our patients.  But let’s not take it for granted: we can still be fired if we slack in our efforts to grow, to improve, and to adjust to changes.

Changes are happening everywhere in our field. Clinical tools for carrying out acupuncture procedures changed considerably in the last several decades. Above all, the disposable acupuncture needles today are much smaller than they used to be. Just look at the most popular needle gauges sold by medical suppliers — #34, #36, and higher. Shouldn’t we adapt our centuries-old clinical techniques to the current needle sizes?

For example, think about the Needle Moxa technique– a traditional Chinese form of heat therapy that involves the burning of mugwort, a spongy herb, on top of an acupuncture needle. The needle is supposed to serve as a conduit for heat transmission from the handle of the needle, where moxa punk is attached, toward its tip and into the treated area. Unfortunately, contrary to the commonly held belief, the heat does not reach the tip, at least not through the body of the needle. The diameter of the #34 gauge needle is too small to conduct heat effectively. As an experiment, take a standard 1.5inch needle and make the handle red-hot using a lighter—the tip will be barely warm.  It’s not a great return for all the efforts involved in securing moxa on the handle of the needle and shielding the skin underneath from the accidental falls of the hot moxa flakes!

On the other hand, the small diameter of the needle gives it a relatively high electrical resistance. This makes it possible to use an acupuncture needle as an electrical heating device for point stimulation (Think about the filament in an incandescent light bulb). All it takes are two small electrical alligator clips, a basic portable power supply, and a #34 gauge, 1.5inch needle. One of two clips has to be attached to the shaft of the needle close to the tip. When a small electrical current passes through the body of the needle, there is a sufficient amount of heat being generated across the needle making it very hot. Caution: do not use it on your patients without proper training and do not burn yourself please!

The field of acupuncture in the US is still evolving. It will take it some time to catch up with the modern-day demands. We can facilitate the process by keeping our minds open and by embracing change.

Pick your answer below:

a. Both interventions work as placebos only

b. Both interventions are more than just placebos

c. I can’t answer definitively

This morning I came across Reuters’ coverage of yet another acupuncture study with peculiar results: http://www.reuters.com/article/2011/08/31/us-acupuncture-nobetter-idUSTRE77U63L20110831

The goal of this study was to establish whether acupuncture can be helpful in the treatment of the Polysystic Ovary Syndrome –- a hormone disorder characterized by irregular periods, acne, and insulin resistance, often associated with obesity — and to find out how it fares against the sham procedure. Women in both the true and the sham groups saw an improvement in hormones related to pregnancy and ovulation, and tended to have more periods after the study sessions than before. There was only a small difference between the two groups. ”Whether there’s actually some physiological benefit from a sham acupuncture treatment, I don’t know,” said study author Lisa Pastore, from the University of Virginia in Charlottesville. “It could be that the hope of getting better with acupuncture makes a difference”, — she told Reuters Health, “or that the benefit of simply slowing down, lying down in a quiet room” during either treatment was behind hormone and ovulation changes”.

It seems that Dr. Pastore went for c.

Most skeptics would jump on a.

But let’s give it further consideration before jumping to the conclusion. There is more to the question than meets the eye. The devil is in the details.

One thing that can be said with a good degree of certainty is that acupuncture is a complex intervention with many potential mechanisms of action. Sure, the placebo effect plays a huge role, as it does in many medical interventions. In fact, it might be even stronger in acupuncture due to its elaborate “ritualistic” component, Ted Kapchuk of Harvard Medical School argues.  http://www.annals.org/content/136/11/817

Even modern drugs that are vetted through rigorous double blind studies are not immune from doubts about their effectiveness due to placebo effect. Circa 2008, PLoS Medicine published a meta-analysis study on the SSRI’s drugs that are routinely used to treat depression. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582668/ Here is an excerpt by Prof. Irving Kirsch that conducted the study: “The results of our meta-analysis showed that people got better on medication, but they also got better on placebo, and the difference between the two was small. In fact, it was below the criterion for clinical significance established by the National Institute for Health and Clinical Excellence (NICE), which sets treatment guidelines for the National Health Service in the UK”.

Intriguingly, acupuncture seems to create both the placebo mediated effect on the brain and the more specific effect, according to a recent study that employed the fMRI technology: “Although controversy regarding appropriate control methodology (e.g. sham acupuncture) continues, data suggest that modulation of certain limbic brain networks may differentiate between specific and placebo components of acupuncture.”- Pain magazine, 2007. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913212

Last but not least: not all “sham” procedures are created equal. Way too often in acupuncture research, the so called “control” is not inert, and may have a therapeutic effect (beyond placebo) of its own. In Dr. Pastore’s research, fake needles were used to create an illusion of acupuncture without penetrating the skin. But these devices do stimulate mechanoreceptors, which are the sensory receptors that respond to mechanical pressure. So, was control good enough? Maybe… Maybe not… And here is another curve ball:  what we call “true” acupuncture in acupuncture research is often a sub-optimal version of acupuncture. In clinical practice there is more fine-tuning in the selection of the needling sites to account for the clinical diversity. So, if our labeling of “True” and “Sham” for the two treatment groups in the research does not adequately reflect reality, wouldn’t we get distorted data as output?

So, where do we stand? As far as the answer to the quiz, it is probably c. – insufficient data.

Here are a couple of thoughts / suggestions which may help to gain a better understanding of the subject:

1. Most acupuncture studies explore general effect on pain and/or on the functioning of the central nervous system. Yet in real life many patients turn to acupuncture for the “local” ailments such as tendinitis, bursitis, arthritis, and various strains and sprains. These are problems that are treated with Physical Therapy as well. Based on my anecdotal experience, I would not be surprised if acupuncture – either by itself or combined with electrical stimulation through the needles (percutaneous electrical stimulation) — worked better than conventional Physical Therapy for, say, Achilles tendinitis. We need good studies evaluating “local” effects of acupuncture.

1. In the study on electrical acupuncture for the postoperative pain, I used “active placebo” as control. Same set of points was stimulated either mechanically or electrically in two groups of post-surgical patients (patients were assigned randomly to these groups) with different short-term outcomes. http://www.painmanagementnursing.org/article/S1524-9042(09)00101-5/

Applying different types of stimulation to the same points can also be useful in teasing out the different physiological mechanisms at work.