Tuesday, 18 April 2017

Alternative medicine anyone? Acupuncture in MS

J Altern Complement Med. 2017 Apr 14. doi: 10.1089/acm.2016.0355. [Epub ahead of print]

Effects of Acupuncture on Gait of Patients with Multiple Sclerosis.

Criado MB, Santos MJ, Machado J, Gonçalves AM, Greten HJ.

Abstract


Multiple sclerosis is considered a complex and heterogeneous disease. Approximately 85% of patients with multiple sclerosis indicate impaired gait as one of the major limitations in their daily life. Acupuncture studies found a reduction of spasticity and improvement of fatigue and imbalance in patients with multiple sclerosis, but there is a lack of studies regarding gait. We designed a study of acupuncture treatment, according to the Heidelberg model of Traditional Chinese Medicine (TCM), to investigate if acupuncture can be a useful therapeutic strategy in patients with gait impairment in multiple sclerosis of relapsing-remitting type. The sample consisted of 20 individuals with diagnosis of multiple sclerosis of relapsing-remitting type. Gait impairment was evaluated by the 25-foot walk test. The results showed differences in time to walk 25 feet following true acupuncture. In contrast, there was no difference in time to walk 25 feet following sham acupuncture. When using true acupuncture, 95% of cases showed an improvement in 25-foot walk test, compared with 45% when sham acupuncture was done. Our study protocol provides evidence that acupuncture treatment can be an attractive option for patients with multiple sclerosis, with gait impairment.


Science and logic are my great escapes. Alternative medicine is the antithesis of this, a world stuck in the past. Much to my chagrin, alternative medical practitioners also display a certain arrogance in their practice, and have no desire to explain their practice beyond that of sensationalism and soothsaying! The difference between success and failure in this day and age, as the world faces seismic changes due to globalisation, is adaptation.

So, why am I bothering to post on this?

Simple really. If I had control over one thing in life, it would be to banish cynicism as an entitlement of the educated. I hope you'd agree when I say cynicism is unworthy of a liberal mind, and leads to passive aggression that triggers a rejoinder of equal malice.

The author, Maria Criado, in a paper which makes up her thesis has designed a cross-over, randomized control trial (i.e. has a sham arm and both arms either get the treatment or sham in different orders) of acupuncture in a small cohort (20) of relapsing-remitting MS subjects. She uses timed 25-foot walk (as well as tandem walking times over the same length), which is an objective measure of walking ability in MS.

With acupuncture she reports a 95% improvement in walking times compared to 45% in the sham group (placebo effect). I might add that this is better than that of fampridine (of course, fampridine has been tested in larger sample sizes than this). This doesn't require statistics, a change of >20% is considered to represent reliable change.

The Heidelberg model used in this study unifies traditional Chinese medicine with contemporary medical-scientific knowledge (for example, microcirculation, neural pathways etc). Acupuncture (see Figure 1) forms part of this. The conduits in acupuncture are the information pathways that connect the body (top/bottom, left/right, interior/exterior, and all of them together). When a tissue, or organ is imbalanced, information of the abnormality is passed through specific areas of the body, called reflex points (acupoint) or information zones. There are 324 acupoints, of which 323 have innervation of cranial and spinal nerves. The anatomic localization of the acupoints used in the study are shown in Figure 2. Sham acupuncture used points outside of the conduit points.

Figure 1: Mode of action of acupuncture (1: energetic; 2: neural; 3: humoural mechanisms).



Figure 2: Acupuncture points taken from the Heidelberg model.

These findings needs to be replicated in a much larger sample size. By demonstrating an improvement in an accepted measures of disability, acupuncture enters as a true contender in the MS therapeutics arena. Potential confounders, such as day-to-day variability in walking ability, impact of fatigue, pain symptoms and male:female differences also need to be considered in future studies. However, by undertaking a randomized controlled trial, Maria Criado demonstrates that it is possible to put alternative medicine through the same rigors as a conventional drug trial.

9 comments:

  1. I hope you'd agree when I say cynicism is unworthy of a liberal mind, and leads to passive aggression that triggers a rejoinder of equal malice.

    Wonderful and insightful comment! But so hard to have fresh innocent eyes every day.

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  2. No I don’t agree, quite the opposite: I don’t believe cynicism should be banished (from the educated or the… non-educated?). Without cynicism we, as people, would be even more prone to being controlled by others.

    We need cynicism. Where would we be without it? Would my parents have emigrated to a Western country (Aussie Aussie Aussie oi oi oi) a year before the war broke out in the former Yugoslavia? Would scepticism moved them to act quickly the same way cynicism did? I doubt it – before the war erupted in the former Yugoslavian countries, there was talk but few believed it would actually happen.

    I also disagree that cynicism leads to passive aggressiveness. I would say lack of resources and the need to be civil (for example, in workplace) often lead to passive aggressiveness, not cynicism

    As for alternative medicine: if only acupuncture really did lead to 95% improvement in walking speed (so many people would be better off). Is it cynicism or scepticism that makes me doubt Criado’s claims? As I haven’t read her article or her claims outside of what is reported here, I can only guess it’s cynicism that makes me question her claims: to be sceptical I would actually have to read what she wrote.

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    1. Scepticism is good, it prompts you to check things yourself; cynicism on the other hand is gainfully distrustful and believes the worst ;)

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    2. I agree in that cynicism implies an element of embitterment. But scepticism/cynicism - it's often in the eye of the beholder - is it not? If someone else fails to appreciate my reasons for being sceptical about something, they may label me as cyncial to better fit in with their own rhetoric, their own opinions, perceptions.

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    3. As the old saying goes, "A cynic is merely a disappointed romantic".

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    4. When one is bound by RIM, and doesn't even completed her education at age 68, being bitter might be an unspoken privilege. I simply don't have balance.

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  3. Interesting,

    I do know a few people who have tried acupuncture though with different symptomatic purposing.

    Neither saw these types of gains which, if reproducible and perhaps with some extra oversight given its more alternative medicine roots... Quite remarkable.

    Few things:

    Science is well aware of neuroplasticity and the ability of external CNS inputs to afford changes in the CNS. After all, we'd all be not much more than amoeba's if those inputs had no resultant actions in the CNS.

    Stroke patients who undergo Music Therapy and other therapies regain some level of function often.

    I know folks (including myself) who have used TENS carefully and over time appear to have had results. I take LDN, not a neurologist I've spoken to that can explain why it stopped my urinary incontinence but it did. If I come off it? Invest in Depends underwear. Why? Cuz' I go through em' like pee on a rope.

    Might it be that acupuncture, tens, neuro-lumen which I've spoke to several patients who have had experience with it really might do something?

    Why not? The brain as an organ is the most flexible in the body.

    IMHO these types of studies need more oversight and yes, larger cohorts. Oversight due to prospect results and/or skew factors of them.

    Walking speed for example is one of those measures in MS that always makes me go, "Really?"

    Some cant ambulate. Others have problems ambulating.

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    Replies
    1. As with any study, there are definite confounders to consider...Having said this, this deserves another look with a larger n size. The group studied needs to be as comparable as possible, which I don't believe they quite managed (the acupuncture group seems slightly worse in ambulation than the sham group at the start).

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  4. Me? Well, I assume (bad word) like anyone else variables exist.

    If I go to the store before my "25 ft test" and I am boppin' around Walmart with my shopping cart assist balance, brace and confidence assist... My fiance' without MS barely keep up with me. When I leave, I can still ambulate quite well.

    On the other hand. Take the shopping cart away, I need hold his arm and we move Sllloooowwwly. Thus if I am going to take a spill I can throw him underneath me. LOL.

    If I happen to use my Total Gym before the 25 ft. walk test, guess what? Going to be very different results than if I do not.

    Now lets say that the air conditioner in the car is broken and its a 90 degree day. Now my body begins to turn into a mass of conflicting impulses. Expose me to it long enough my physical fatigue can feel like I could stop a semi-truck from moving just by leaning against the front of it.

    Point being, depending on numerous variables my body while never feeling like its a good time to break-dance may well feel like its Jello that wants move only if someone has a brush to push it along the floor.

    I am not alone in this. I've met many MS flavored gelatin patients given variables. One comes to mind who cannot drive because under "stress" she experiences tremor. Albeit not debilitating, it does not work well with 3000 pounds of plasti-metal. Whens stressed she needs a walker. When not, she walks pretty well.

    Now!!!! One would think that given todays miraculous technology we might find other measures towards more granular accounting of disability? Maybe?

    Think about it? A well measured intervention with clinical Guitar Hero on an Xbox might yield more data.

    We have timed 9 peg hole tests... How about timed Yahtzee junior.

    Either way... same variables might be in play.

    My 25 ft walk test should be "Prior to your clinical visit:"

    1. No shopping.
    2. Stay cool.
    3. Do not exercise.
    4. Do not drink your morning energy nutribullet.
    5. Do not get angry or stressed.
    6. Start out for the appointment 20 minutes earlier than your thinking to avoid #5
    7. When waiting for your 20 minutes w/ the Neuro having arrived early make sure there is someone to talk to avoiding #5 once more.
    8. Dont tell her that she is going to be tested on the 25 foot walk in order to avoid #5.
    9. Make sure she had her LDN the night before or her one leg might operate like a broken macpherson strut on the car complete with leaking radiator fluid.

    For clinic:

    1. Make sure keep stress low.
    2. Make sure air conditioning works
    3. Keep a mop on hand in case I become an adverse event walking down the hallway.

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