Acupuncture alleviates MSK pain by the Memorial Sloan Kettering Cancer Center

 

Acupuncture is effective for the alleviation of musculoskeletal pain, headaches, shoulder pain, and arthritis related pain. Memorial Sloan Kettering Cancer Center (New York, NY) researchers conclude that the analgesic effects of acupuncture are superior to sham controls and the pain relief persists over time. The research team concludes that acupuncture is an effective treatment modality for chronic pain and referral to an acupuncturist is a reasonable treatment option. 

In a meta-analysis of 20,827 patients across 39 clinical trials, researchers determined that acupuncture’s pain relieving effects for patients with musculoskeletal pain, headaches, shoulder pain, and arthritis persist over time—with only a 15% decrease in treatment efficacy after one year. The sham controlled trials indicate an additional important factor. The researchers note that the effects of acupuncture cannot be explained by placebo effects.

A nuanced finding is that the analgesic effects of acupuncture are dose dependent. Increased numbers of acupuncture treatments produce superior patient outcomes with significant reductions in pain. The data also indicates that both manual acupuncture and electroacupuncture are equally effective.

 

Design Control
The sham control analysis highlights challenges in study design. Acupuncture’s analgesic effects were slightly better in studies using non-penetrating needle sham controls. This indicates that using penetrating needle sham acupuncture is active, producing relatively minor therapeutic benefits. This is consistent with the use of Ashi acupoints, indicating that using penetrating acupuncture needles near real acupuncture points is not an appropriate sham control.

Double-blinded and single-blinded study designs present challenges in research. One method used in acupuncture research is the application of Park sham devices. This apparatus administers both real filiform acupuncture needles and sham needles. The device securely holds either type of needle over the chosen acupoint. However, because it uses an insertion tube, the Park sham device cannot measure the effects of traditional free-hand needling.

The Park sham needle is used in single-blinded designs. This needle never penetrates the skin, its tip is blunt. When pressed, the needle retracts back up into the handle, giving the appearance of penetrating the skin. In actuality, the needle has telescoped upwardly into the handle.

Charing Cross Hospital (UK) researchers tested the effects of the Park sham needle in a small pilot study. They conclude “that the Park sham needle is an effective single-blind control.” Given the size of the study, the researchers indicate that a larger study is an appropriate follow-up to confirm the appropriateness of this needle.

Large sample sizes increase confidence and accuracy in outcome determinations. As a result, the research from the Memorial Sloan Kettering Cancer Center is important. A sample size of 20,827 patients across 39 studies is significant. The results were published in The Journal of Pain, the official journal of the American Pain Society.

 

Acceptance
Recent years have seen increased attention to acupuncture’s pain relieving effects. Based on modern research, the American College of Physicians now formally recommends acupuncture for the treatment of back pain. Published in the Annals of Internal Medicine, clinical guidelines were developed by the American College of Physicians to present recommendations.

Citing quality evidence in modern research, the American College of Physicians notes that nonpharmacologic treatment with acupuncture for the treatment of chronic low back pain is recommended. The official grade by the American College of Physicians is a “strong recommendation.” The recommendation was approved by the ACP Board of Regents and involves evidence based recommendations from doctors at the Penn Health System (Philadelphia, Pennsylvania), Minneapolis Veterans Affairs Medical Center (Minnesota), and the Yale School of Medicine (New Haven, Connecticut).

 

How Acupuncture Works
The clinical evidence in human trials is supported by objective data generated in laboratory research. University of California researchers have proven that electroacupuncture at acupoint ST36 (Zusanli) promotes enkephalin production, which dampens proinflammatory excitatory responses from the sympathetic nervous system. Electroacupuncture regulates preproenkephalin gene expression, a precursor substance that encodes proenkephalin, which then stimulates the production of enkephalin. The University of California research finds acupuncture’s ability to regulate preproenkephalin gene expression at least partially responsible for acupuncture’s ability to alleviate hypertension.

An investigation conducted by University of South Florida (Tampa) and Fujian University of Traditional Chinese Medicine (Fuzhou) researchers documents how acupuncture stops pain. The researchers note, “acupuncture exerts a remarkable analgesic effect on SCI [spinal cord injury] by also inhibiting production of microglial cells through attenuation of p38MAPK and ERK activation.” Microglia are nervous system cells that secrete proinflammatory and neurotoxic mediators. Acupuncture alleviates pain by attenuating this response.

 

Drug Free Intervention
One reason the acupuncture’s pain relieving effects are important is the opioid crisis. Stanford University researchers conclude that acupuncture reduces and delays the need for opioids after total knee replacement surgery. Over 4.7 million people in the United States have had knee replacement surgery. Conventional post-surgical treatment often includes prescription opioids. The drugs often provide pain relief for patients but are ineffective for some. Further, there is a growing concern that the extended use of prescription opioids leads to addiction, further exacerbating epidemic levels of opiate abuse. As a result, finding drug-free interventions that effectively relieve pain and decrease opiate use has become a public health imperative.

In the meta-analysis conducted at Stanford University (California), researchers analyzed the results of 2,391 patients over 39 randomized clinical trials comparing the efficacy of five of the most common drug-free interventions for decreasing pain and opiate use after knee replacement surgery: acupuncture, electrotherapy, cryotherapy, preoperative exercise, and continuous passive motion. Among them, only acupuncture and electrotherapy were associated with reduced and delayed opioid consumption.

 

 

References:
Vickers, Andrew J., Emily A. Vertosick, George Lewith, Hugh MacPherson, Nadine E. Foster, Karen J. Sherman, Dominik Irnich, Claudia M. Witt, and Klaus Linde. "Acupuncture for chronic pain: update of an individual patient data meta-analysis." The Journal of Pain (2017).

To, May, and Caroline Alexander. "The effects of Park sham needles: a pilot study." Journal of integrative medicine 13, no. 1 (2015): 20-24.

Qaseem, Amir, Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of PhysiciansNoninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of Internal Medicine (2017).

Cevic, C and Iseri, SO. The effect of acupuncture on high blood pressure of patients using antihypertensive drugs. Acupuncture & electro-therapeutics research 2013; 38(1-2).

Lin, Lili, Nikola Skakavac, Xiaoyang Lin, Dong Lin, Mia C. Borlongan, Cesar V. Borlongan, and Chuanhai Cao. "Acupuncture-induced analgesia: the role of microglial inhibition." Cell transplantation 25, no. 4 (2016): 621-628.

Maradit, H., Larson, D. R., Crowson, C. S., Kremers, W. K., Washington, R. E., Steiner, C. A., . . . Berry, D. J. (2015, September 02). Prevalence of Total Hip and Knee Replacement in the United States. Retrieved October 07, 2017, Stanford.

Breaking the cycle of injury by Michael Lord

Why rest as a strategy for injury prevention is the wrong approach.

My guess is that you've heard, or perhaps even thought to yourself, one of the following lines:

  • “I’m chronically injured and I don’t think my body is designed for this.”
  • “I’m going to take a long break after this race and let my body recover.”
  • “I think my body is wearing out because all this training is bad for it.”
  • “Running is bad for my knees and hips so I think I should stop.”
  • “I must be injury prone because I always seem to end up injured” 

If any of this is familiar to you, you’re not alone.

The holy grail of sports medicine and performance is injury prevention, yet it's hard to know if such a thing is even possible. There are countless variables, all of which interact with each other, that lead to injuries. To think we can control and purposefully manipulate these variables with any degree of certainty is an unlikely endeavor. Rather than taking the commonly utilized reductionist and narrow view to preventing injuries, such as specific exercises or stretches, the optimal path to reducing injury risk is to employ a more holistic view and focus on building global resilience. A resilient athlete is, under all circumstances, less likely to get injured than a non-resilient athlete.

The mistake of many rehab practitioners (i.e., PT, Chiro) is allowing athletes to become rehab junkies. Yet this is not due to a lack of expertise or skill in treating a specific injury. The mistake is made when too much focus is placed on the symptom or specific injury and the athlete is managed away from load and training for extended periods of time. This results in detraining and can be the beginning of a long cycle of symptom chasing. Soon the athlete develops a dependence on therapy and sees training as the bad guy. Unfortunately, the expertise of many practitioners almost blinds them to the bigger picture. Too much time and energy is spent promoting or relying on a specific treatment technique, exercise, or stretch; continually placing band-aids on each new problem. We need to shift this mindset and promote a journey towards independence and resilience. 

Consider my work with purplepatch, a group of professional and serious age-group triathletes. We have seen this cycle repetitively when onboarding new athletes, both in amateurs and professionals. We noticed that a major contributing factor to the chronic cycle of injury was not the training itself but the breaks athletes were taking away from training due to injury. The time away from training was robbing them of the thing which builds resilience — prolonged consistent training. To break this cycle, the first step is often to get them away from the treatment room and into the strength room. Combine this with changing habits (listed below), shifting the mindset away from what their limitations are, and getting them to move towards what they can do, and now we are having a different conversation. 

Why Do Athletes Get Stuck In A Chronic Cycle of Injury? 

Chronically injured athletes tend to fall into one of two buckets:

  1. Recurring injury to the same body part; or
  2. frequently collect new injuries.  

In both cases, risk factors tend to be a combination of internal to the athlete (e.g., aerobic capacity, biomechanics, strength, age, hormonal imbalances) and external (e.g., training program, sleep, nutrition). It shouldn’t be overlooked that external risk factors can lead to and magnify internal issues. 

 

The cycle of injury:

  

While it is undeniable that injuries will occur in athletes. They can be due to an unavoidable circumstance, such as an accident, or may come on gradually during the course of training. Whatever the initial trigger, the injury cycle ultimately ends up the same. 

This vicious cycle repeats, and before long the athlete hasn’t been training consistently for an extended period, this can be months or even years. There always seems to be an injury that takes them back to square one. The longer the athlete spends in this cycle the less resilient they are to training, leaving them vulnerable to sustaining another injury. 

Let’s use an analogy to crystalize the point. Imagine two bodies of water. One being a large reservoir many miles across, the other being a pond the size of a child’s swimming pool. If a boulder is thrown into the large reservoir the ripple will disrupt the water in one small section but ultimately the large volume of water will absorb and dissipate the ripples and not disrupt the whole reservoir. If the same size boulder is thrown into the smaller pond the effect will be vastly different, the ripples will disrupt the entire surface of the pond and it will take time for the water to settle.

A more resilient athlete can withstand different stressors such as a hard training day, a tight hip, stress from work, lack of sleep, etc. These are all examples of the boulder from our analogy. The resilient athlete has developed the resources to absorb these stressors without it causing a significant impact on the whole system. The non-resilient athlete cannot absorb the stressor without breaking down. 

Building Resilience

The conventional approach to dealing with the chronic cycle of injury is to take time off and “let your body heal,” but this is often the opposite of what you actually want to do.

When athletes view themselves as fragile and prone to injury they tend to shy away from load and training stress. By doing this they actually create a more fragile system. This stems from the misconception that athletes need to let their bodies rest and heal up because training is breaking them down. They think they are protecting themselves from an overuse injury by limiting their exposure to training. However, by doing less they are setting themselves up to be less resilient. This is not because the system itself is inherently weak, but rather because without training the system begins to loses the strength and resilience it had, becoming weaker. In other words, prolonged rest doesn’t create resilience, it works against it. 

 

More, Not Less

Paradoxically, developing a consistent platform of training more, not less, will protect you from injury. 

The chronic rehabbers are typically stuck in this cycle because they are managed away from load and training. While this might be an appropriate strategy to manage the short-term acute injury, you must ultimately work to increase the load intelligently to develop a consistent platform of training stress. This is how athletes begin to develop resilience. This consistent platform of training is called high chronic workloads. Interestingly, a high chronic workload is protective against injury, as long as you reach a high chronic workload safely.

Ultimately, athletes need to shift their mindset and understand that training hard is not the culprit for chronic injuries. Referencing our earlier analogy, our goal is to develop the appropriate resources—the large reservoir—to withstand stress. This is accomplished through consistent training. When you are able to build up and maintain a high chronic workload, you can better tolerate a stressor to the system. 

Spikes In Workload Lead To Injury

Now, this isn’t giving you license to throw caution to the wind and burry yourself with huge training loads. It’s how you develop the high chronic workload that breaks the cycle of injury.

The important thing to realize is that part of the injury cycle is an inappropriate increase in workload, called spikes. While the goal is to obtain a high chronic workload, such a workload is achieved through consistency over a long period of time and avoids dramatic spikes as well as long breaks away from training. 

You want to develop a long and consistent training platform to gradually build upon. The goal is to follow a program that has appropriate progressions in workload and includes periods of lower stress. The periods of lower stress will magnify the benefits of the hard training days allowing your body to absorb the load. This is the training cycle you must embrace. “Load is the vehicle which drives athletes to, or from, injury,” says Tim Gabbett, an expert on injury prevention in athletes. Stress is relative and it is relative to your baseline; too much and you will overload the system, just right and you build resilience.

Practical Application of Habit Changes

The chasm between acute injury rehab and training becomes larger and larger as injured athletes are managed away from training loads. Here are some simple recommendations to increase your success when trying to break the cycle of chronic injury: 

Don’t wait for your body to feel 100%. While you may need to take time to recover from the most recent injury, don’t wait for your body to feel perfect. By waiting you are robbing your body of load (which creates resilience). You may be surprised how much better you’ll feel by finding a training load that is challenging yet safe. 

Don’t be beholden to the plan written on paper. Making micro adjustments to the training plan when needed is crucial to avoiding the need for a longer break away from training. Develop an internal physical awareness and be honest with how your body is responding to the training loads.

Communicate with your coach. It’s not a failure if the plan needs to be adjusted. 

Go hard on hard days and easy on easy days.  This is a foundation to any training plan but its importance cannot be over stated. A common mistake is missing on this simple habit and is often the road to injury.

Getting out of the treatment room and into the strength room. This teaches athletes that they are physically robust and capable all while improving their strength and resilience. Strength training is a pillar in all good training programs. Often this is as much mental as it is physical when breaking the chronic cycle of injury. 

Commit to supportive practices. Consistency with activation, restoration work (i.e., foam rolling), and strength training is key. These routines are designed to support the most important muscle groups and movements for optimal performance. They may seem simple but when done consistently they are powerful. 

Long Term Development

To break the cycle of injury an athlete’s mindset needs to shift towards the long-term development of chronic training loads. This will undoubtedly mean different things for different people. Some people may be in a short-term situation while others may be on a much longer journey. Unfortunately, if an athlete has been in a cycle of chronic injury, it means they will likely need to take a long-term approach to building high chronic training loads. 

To get to the point where an athlete is resilient and adaptable their habits have to evolve. To truly break the injury cycle athletes cannot just focus on rehabbing from one injury in isolation. That is like siloing off one limb or joint of the body and treating it like it exists in a vacuum and has no interaction with the whole system. This is not how the body functions. We need to expand the lens and look at the role training plays in recovering from an injury. Focusing on what an athlete CAN do, not focusing on what they CAN’T do. This process should take on two parallel journeys: rehabbing the specific injury while concurrently mapping back to performance training.

The athlete needs to identify what the ultimate training volumes and intensities they are trying to get back to, understand where they currently are, and identify what limitations the injury of the moment poses. Then a program can be designed that safely ramps back towards their ultimate goals in a way which creates system resilience. This should take place while the athlete is recovering from their current injury. These two things should not be viewed as separate isolated journeys, but concurrent.

And herein lies the difference. If we only focus only on the injured tissue, the rest of the body isn’t getting any training stress. The result is detraining. This creates a more fragile system and ultimately leaves a rehabbing athlete vulnerable to another injury.  

We can’t ever promise to predict, let alone prevent, all injuries. What we can do, however, is look at what aspects mitigate the risks and develop a more resilient and adaptable system. Consistent training, not consistently taking time away from training, is the path to reducing injuries. 

Spinal manipulation

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back PainSystematic Review and Meta-analysis

Neil M. Paige, MD, MSHS1Isomi M. Miake-Lye, BA1,2Marika Suttorp Booth, MS3; et alJessica M. Beroes, BS1Aram S. Mardian, MD4Paul Dougherty, DC5Richard Branson, DC6Baron Tang, PT, DPT7Sally C. Morton, PhD8Paul G. Shekelle, MD, PhD1,3

Author Affiliations

JAMA. 2017;317(14):1451-1460. doi:10.1001/jama.2017.308

  • Key Points

 

Question  Is the use of spinal manipulative therapy in the management of acute (≤6 weeks) low back pain associated with improvements in pain or function?

Findings  In this systematic review and meta-analysis of 26 randomized clinical trials, spinal manipulative therapy was associated with statistically significant benefits in both pain and function, of on average modest magnitude, at up to 6 weeks. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported in more than half of patients in the large case series.

Meaning  Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function and with transient minor musculoskeletal harms.

Abstract

Importance  Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT.

Objective  To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain.

Data Sources  Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms. 

Data Extraction and Synthesis  Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Main Outcomes and Measures  Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks.

Findings  Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, −9.95 [95% CI, −15.6 to −4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, −0.39 [95% CI, −0.71 to −0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.

Conclusions and Relevance  Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

Message from the Institute of Osteopathy: Osteopaths to join with Allied Health Professions in NHS Transformation

iO representatives Maurice Cheng, Robin Lansman and Matthew Rogers meet with Suzanne Rastrick

The Institute of Osteopathy is delighted to announce that the iO will be working with Suzanne Rastrick, the Chief Allied Health Professions Officer of NHS England, to strengthen the engagement of osteopaths with other health professionals, in the transformation of service delivery to improve patient outcomes.

AHPs form the third largest workforce in the health and care system, and from 1 April 2017, osteopaths will join twelve other autonomous health professions that Suzanne Rastrick represents, whose roles are increasingly seen as key to transforming health care and wellbeing, and increasing capacity across the health and care system.  ‘AHPs into Action’ is the recently announced, crowd sourced strategy developed to unlock this potential, and osteopaths will now be playing their part in this initiative.

Suzanne Rastrick said ‘I am delighted to welcome osteopaths under my remit for Allied Health Professionals, and to the ‘AHPs into Action’ programme. I look forward to working with the Institute of Osteopathy and the community of osteopaths, we plan to demonstrate our continuing pledge to encourage innovation, multi-professional working, and patient centred care.  I look forward to working with the iO senior team, and welcome the opportunity to engage with the wider membership, to ensure osteopaths are recognised for the contribution they make to improving outcomes for patients, and increasing capacity across the health and care system.’

Maurice Cheng, Chief Executive of the Institute of Osteopathy said ‘This new relationship with the Chief Allied Health Professions Officer marks an important milestone for our profession. Over 30,000 people visit an osteopath in the UK every day, and the patient centred and whole person approach to health has always been at the core of osteopathic care.  There are already good examples of the excellent results that arise from osteopaths, GPs and surgeons working together: by building better collaborative working with other health professionals, we know we can raise the contribution that the profession can make to patient wellbeing, and play our part in the mandate for positive change in UK health.’ (Institute of Osteopathy)