Jacqueline Filshie

Defining an adequate dose of acupuncture using a neurophysiological approach – a narrative review of the literature

Many different styles of acupuncture practice exist, and lack of agreement on the optimal acupuncture treatment for any particular condition may mean that some patients do not receive the best treatment. This uncertainty also makes the negative results of sham controlled trials difficult to interpret. Unless we can be sure that both adequate acupuncture and an inactive sham were used in a particular trial, then that trial should not be interpreted as dismissing acupuncture for that condition. Acupuncture practice clearly involves much more than needling procedures, but there is a strong argument for elucidating the role of those needling procedure first. The components of acupuncture needling procedures have been described in the STRICTA document, but it is also clear that the patients perception of needling is relevant for the outcome of treatment. We therefore recommend the concept of ‘dose’ of acupuncture needling, which should include both the stimulus given to the patient, and certain aspects of the patients perceptions and response that are known to be linked to the subsequent therapeutic response. We propose the following definition of dose: the physical procedures applied in each session, using one or more needles, taking account of the patients resulting perception (sensory, affective and cognitive) and other responses (including motor). The dose may be affected by the state of the patient (eg nervous, immune and endocrine systems); different doses may be required for different conditions. The constituents of an adequate dose can be established initially by clinical opinion and subsequently by empirical evidence from experimental studies, which may be either clinical or basic research studies. Systematic reviews which do not consider the adequacy of the acupuncture treatment may have unreliable conclusions. Out of 47 recent systematic reviews, only six have applied some criteria for adequacy. Five used a rating system or conducted a subgroup analysis, and one excluded studies from the analysis altogether if they did not meet criteria for adequacy. Research into what constitutes an adequate dose of acupuncture has long been neglected and is now urgent. Clinical studies that compare the effects of different treatment protocols are probably the most reliable source of evidence, and may also demonstrate a dose-response relationship.

Acupuncture and self acupuncture for long term treatment of vasomotor symptoms in cancer patients - audit and treatment algorithm

Introduction Since hormone replacement therapy given for long periods is now recognised to produce serious side effects, patients with troublesome vasomotor symptoms are increasingly using non-hormonal treatment including acupuncture. Several randomised controlled trials have shown that acupuncture reduces menopausal symptoms in patients experiencing the normal climacteric. It may have this effect by raising serotonin levels which alter the temperature set point in the hypothalamus. Vasomotor symptoms can be extreme in breast cancer patients and patients with prostate cancer who are undergoing anticancer therapy. The safety of some herbal medicines and phytoestrogens has been questioned, as they could potentially interfere adversely with the bioavailability of tumouricidal drugs. A previous study reports short term benefit from acupuncture, and the aim of this report is to describe our approach to long term treatment. Acupuncture Approach After piloting several approaches, six weekly treatments were given initially at LI4, TE5, LR3 and SP6 and two upper sternal points, but avoiding any limb with existing lymphoedema or prone to developing it. If there were no contraindications, patients were given clear instructions on how to perform self acupuncture using either semi-permanent needles or conventional needling at SP6, weekly for up to six years, for long term maintenance. Audit Methods and Results A retrospective audit of electronic records was carried out by a doctor not involved in treatment. A total of 194 patients were treated, predominantly with breast and prostate cancer. One hundred and eighty two patients were female. The number of pre-treatment hot flushes per day was estimated by the patient: in the 159 cases providing adequate records, the mean was 16 flushes per day. Following treatment, 114 (79%) gained a 50% or greater reduction in hot flushes and 30 (21%) a less than 50% reduction. Treatment was abandoned in those who responded poorly or not at all. The duration of treatment varied from one month to over six years with a mean duration of nine months. Seventeen patients (9%) experienced minor side effects over the six year period, mostly minor rashes; one patient described leg swelling but this was likely to be due to a concurrent fracture. Conclusion Acupuncture including self acupuncture is associated with long term relief of vasomotor symptoms in cancer patients. Treatment is safe and costs appear to be low. An algorithm is presented to guide clinical use. We recommend the use of self acupuncture with needles at SP6 in preference to semi-permanent needles in the first instance, but poor responders use indwelling studs if they fail to respond adequately to self acupuncture with regular needles. Point location may be of less importance than the overall ‘dose’, and an appropriate minimum dose may be required to initiate the effect.

A review of 560 Hickman catheter insertions

Indwelling, cuffed, tunnelled, central venous (Hickman) catheters are increasingly being used for venous access and the administration of chemotherapy for oncological patients. This paper reviews the technical problems associated with the percutaneous insertion of these catheters and the complications arising from their use. Five hundred and sixty catheters were inserted; 31.3% had complications at insertion, most commonly precipitation of an arrhythmia (13.9%). Arterial puncture occurred in 3.8% and pneumothorax in 1.6%. Catheters remained in place for a median period of 91 days. Forty percent of catheters were removed electively on completion of treatment; 30.2% required removal because of complications, which included sepsis, migration, thrombosis and blockage. Twenty percent of patients died with their catheter in place, 8.5% were still in situ and 1.6% were removed because of patient non compliance. Sepsis remains the commonest, long term complication, with staphylococcus epidermidis being the organism isolated most frequently. There were no catheter‐related deaths.

Guidelines for providing acupuncture treatment for cancer patients – a peer-reviewed sample policy document

Clinical guidelines are statements that have been systematically developed and which aim to assist clinicians in making decisions about treatment for specific conditions, and promote best practice. They are linked to evidence and are meant to facilitate good medical practice. We are not aware of any guidelines for the safe practice of acupuncture in a conventional healthcare setting, yet they are necessary as acupuncture may be performed in a variety of settings and by a variety of healthcare professionals: doctors, nurses, physiotherapists, midwives, and non medically trained practitioners. These guidelines were developed for use in cancer patients, mainly for pain but also for some non-pain indications such as hot flushes. They are presented here as a template for other acupuncturists who are requested to provide policies for acupuncture treatment for cancer patients. This article includes a general review of the evidence on mechanisms, effectiveness and safety of acupuncture that is intended to be used in conjunction with the guidelines; and the guidelines themselves. An appendix includes instructions for self acupuncture. The guidelines contain sections on roles and responsibilities, criteria for acupuncture practice, indications for acupuncture, contraindications and cautions, acupuncture treatment, and review and audit. These guidelines set basic, minimum standards of care, and need reassessment and ongoing validation as further data and evidence accumulate.

Safety aspects of acupuncture in palliative care

Acupuncture can mask symptoms of cancer and tumour progression. It is not safe to use such a therapy without full knowledge of the clinical stage of the disease, and the current status of orthodox therapy. Contraindications to acupuncture needling include an unstable spine, severe clotting disorder, neutropenia and lymphoedema. Whilst semi-permanent needles are used increasingly in symptom control and pain management they should not be used in patients with valvular heart disease or in vulnerable neutropenic patients. Acupuncture has an increasing role in support for pain and symptom management, but patients should not be advised to abandon conventional treatments in favour of complementary or alternative therapies alone, and should not have their hopes raised inappropriately, or have any guilt projected on to them for the cause of their cancer.

Unilateral computerised tomography guided coeliac plexus block: a technique for pain relief

Twelve patients have undergone unilateral coeliac plexus block using needle localisation by computed tomography and the technique is described. Computed tomography has the advantage that the needle route to the coeliac axis can be accurately planned, avoiding damage to other organs. In this study nine out of twelve patients had significant pain relief. Most success was achieved in patients with carcinoma of the pancreas.

Retroperitoneal fibrosis after multiple coeliac plexus blocks

Retroperitoneal fibrosis is described as a complication of multiple coeliac plexus blocks for chronic pancreatitis.

Kinking of the laryngeal mask airway in two children

One source of variation is ambiguous definition of the classes. It is not Elear from Mallampati’s description’ if inability to see the faucial pillars or masking of the uvula indicates class 111. Samsoon and Young require loss of fauces but allow the base of the uvula to be seen for this class. Samsoon-and Young2 created an additional class IV in which the soft palate is completely obscured, although the anterior border of the soft palate has no readily discernible landmark (in fact, they used an imaginary line joining the anterior edge of the fauces; personal communication). Their figure provides a helpful visual classification. Another very important source of variation is the response of the patient to the instructions. Many automatically say ‘Ah’ or simulate phonation, which falsely improves the view. Others arch the tongue which obscures the uvula. Two attempts are recommended to overcome these problems, but it is not easy to know if the assessment is made at a time when the patient’s response is appropriate. Mallampati’ suggests that difficult intubation is associated with grade 111 view of the larynx (failure to see beyond the epiglottis) and this is predicted by a class I11 view of the pharynx. In his original study only 55% of difficult laryngoscopies were correctly identified and in a more recent, larger study3 ( n = 666) the proportion was only 44%. Over half of the difficult patients were missed! Charters, Perera and Horton4 abandoned the test after their prediction that 22% (13/60) of their patients would be difficult when only one proved to be difficult. In our own experience 53% (66/122) were falsely predicted as difficult and all three patients in whom laryngoscopy was difficult were missed. A method for prediction of difficult intubation, previously described by one of us,’ was also used for comparison: all three difficult patients were identified with 17% false alarms. Head and neck mobility is not assessed by the test. However, limited movement, especially of the atlanto-occipita1 joint, is a common cause of difficult intubation.6 We maintain that the vital distinction between class I1 and I11 depends upon a wavering, ill-defined boundary that causes considerable observer variability. The identification of a class I11 patient may warn of an impending problem, although many false alarms will occur. A class IV obstetric patient, especially if associated with limited head and neck movement, will almost certainly be difficult to intubate and a junior should summon assistance (Samsoon and Young, unpublished prospective study). Difficulty with intubation is caused by many factors. It is a worry that many difficult patients will be missed, especially if head and neck mobility is not assessed.

Acupuncture for chronic pain: a review

Introduction Despite recent advances in the understanding and treatment of chronic pain many patients fail to achieve optimal control with conventional methods of analgesia, or do so only at the expense of unacceptable side effects. In many western pain clinics, acupuncture is now seen as complementary to more orthodox methods of pain relief. Advances in neuropharmacology and in neurophysiology over the past 25 years now show credible physiological mechanisms of action for acupuncture. A number of clinical trials have also been undertaken which begin to demonstrate the efficacy of acupuncture in a clinical setting. It is in this context that acupuncture for chronic pain is reviewed.

Acupuncture in palliative care

Acupuncture is being increasingly used for a multiplicity of symptoms in patients with cancer and those requiring palliative care. An evidence base has been accumulating over recent years for symptoms such as acute and chronic pain, nausea and vomiting, xerostomia, vasomotor symptoms, fatigue and dyspnoea. Many symptoms occur in patients with cancer long after their initial treatment, which usually consists of a combination of surgery, radiotherapy and chemotherapy. Today, 45% of patients worldwide survive at least 5 years beyond their initial diagnosis and cancer is increasingly regarded as a chronic disease. As treatments become more successful, patients face the additional challenges of dealing with both the physical and psychological sequelae of their condition.1 Yet, anticancer treatment remains an intense experience for many patients and causes numerous side effects. Acupuncture, being a non-drug treatment, provides at least a partial solution for the increasing proportion of patients who turn to complementary and alternative therapies for help with symptom control at variable times after their diagnosis. Acupuncture has been used in pain management in our large Oncology Hospital for over 30 years, initially treating only pain but gradually also used in the treatment of non-pain symptoms such as hot flushes, dyspnoea and radiation-induced bowel and bladder problems. A wide range of symptoms have been treated with …