Medical Acupuncture on the wrong side of NICE

The last Cochrane review which considered the role of Medical Acupuncture (MA) in the treatment of Low Back Pain (LBP) was carried out by Furlan et al in 2005. In this review verum MA was shown to be efficacious (more effective than ‘sham’) in providing short term pain relief. A good result from research point of view.

The NICE guidelines for the treatment of LBP published in 2009 were partly based on the abovementioned review as well as the GERAC trial which showed MA (including ‘sham’) to be more than twice as effective as conventional treatment in the primary outcome measures. In the GERAC trial, verum MA was not shown to be significantly more effective than ‘sham’ needling however there was a small trend in favour of verum needling.

"Cardio-acupuncture" -  My introduction to this term was at the Autumn Scientific Meeting hosted by the British Medical Acupuncture Society at the Royal College of Physicians in London last month.

Dr. Fokke Jonkman, a cardiologist, gave a very interesting account as to how he uses medical acupuncture to complement his cardiology practice. Being more well versed with the role of acupuncture in pain management, most of what he had to say took me into less familiar territory in terms of my understanding of a wider application of acupuncture in medicine.

Broadly speaking, the cardiovascular system i.e the heart, lungs and the vessels which circulate blood around the body is controlled by the autonomic nervous system which in turn is divided into a sympathetic (excitatory) and parasympathetic (more inhibitory) portion.

An audit of treatments for fibromyalgia at the Royal London Hospital for Integrated Medicine - Esther Odetunde, Chartered Physiotherapist.

Esther is a specialist physiotherapist working at the Royal London Hospital for Integrated Medicine (RLHIM) known for the high number of patients she treats, the vast majority of whom must feel well looked after given her very high attendance rate. Esther treats a challenging group of patients, those diagnosed with fibromyalgia. She is part of a small team offering a programme of care for those suffering with this potentially debilitating chronic pain condition. The team is multidisciplinary in nature and also comprises a physician, psychologist, dietician and occupational therapist.

Referred patients with fibromyalgia enter a care pathway based on the Eular fibromyalgia treatment guidelines (2007) and are selected either for group or individualized treatment. The care pathway also determines which part of programme is most applicable for the patient. For example if depression is the main issue, the patient would receive a course of CBT, in the case reduced function, pain and mobility issues physiotherapy would be offered. Different types of treatment may be offered concurrently.

Now I’m talking about stripped down back to basics yoga, no candles and incense!

As a system of exercise which promotes flexibility, power and strength it’s terrific. Yoga places an emphasis on integrated and functional movement, moving with fluidity and grace.

Done correctly a nice balance can be achieved between strength and flexibility. Going too far in either direction can cause problems. This has been the downfall of the ‘core strengthening’ approach. If not done correctly or applied to the wrong body type, core strengthening can promote rigidity, tension and stiffness which can actually promote pain and injury rather than relieve it as would be the conventional wisdom.

My client was referred to me by his GP with a 6 month history of ‘rotator cuff’, vague yes, but a starting point perhaps.

Indeed he showed and arc of pain raising the shoulder into abduction. He had a positive Jobes empty can test, but as we know this type of test lacks validity and reliability. Nonetheless the test indicated that some shoulder structure or other did not like to be stressed in this way. But did Jobe's test reproduce my clients pain? - no, and neither did the other impingement tests which appeared positive. So was the possible impingement a secondary issue?

My client's shoulder was ‘stiff’ and generally restricted in all directions. His pain was more accurately reproduced when he actively raised his arm into about 90 degrees of abduction and then outwardly rotated at the shoulder. This reproduced ‘his pain’ which was located at the upper long head of biceps brachii region. The biceps muscle, possibly tendon is the problem? No, only mildly tender to palpate and the biceps provocations tests were negative. However when I applied a gentle anteroposterior glide to the head of the humerus his pain eased immediately and he was able to move without pain further into range.