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When cooks make a pudding, they adds eggs to the other ingredients to make it richer and more tasty. But the balance has to be right: over-egging the pudding just spoils it. In the same way, the appeal of any scientific paper depends on having the right balance of all its ingredients – methods, data, conclusions and presentation in the journal. The editor is responsible for striking this balance, and when the balance is wrong the taste is ruined. Recently, an acupuncture paper with rather modest results was splashed on the journal cover and over-egged by a linked editorial, leading to some adverse publicity. The truth is that knowledge about acupuncture progresses rather incrementally, and true breakthroughs (eggs) are rare. It is our hope that we can be part of that careful, incremental progress, with just the right mix of ingredients.
It does seem that we are beginning to recognise the genuine eggs in the mixture that makes up acupuncture for palliative care, and in this issue we have four studies and a commentary by Filshie and Rubens. Cassileth and colleagues ran an exemplary pilot study, complete with stopping rules, in patients with lymphoedema and showed that it is worth going on to the full RCT. Lim and colleagues ran another pilot study of acupuncture for symptom control. They used nursing care in the comparison group, to control for the attention of the acupuncturist – which seems a bit impractical as they would be used in combination. Chang and Sommers report another study in patients covered by the ‘palliative’ umbrella, this time addressing the effects of relaxation and acupuncture on the side effects of highly active ante-retroviral therapy for HIV. The clever 2×2 design meant that the groups were too small to produce definitive answers. The fourth paper is an audit of acupuncture for patients with peripheral neuropathy from chemotherapy, by Donald and colleagues. Without doing any overegging, it seems fair to say that acupuncture shows promise in palliation.
Traumatic damage to the spinal cord is another life-long condition with symptoms that are not easy to manage conventionally. The study by Liu and colleagues raises the possibility that electroacupuncture (figure 1) might have longlasting effects on neurogenic urinary retention in about half of patients.
Back to puddings, and getting the recipe right. Two ingredients of a clinical trial that have to be right are the treatment and the control procedure. Cotchett and colleagues used a Delphi process to establish a treatment protocol for plantar fasciitis. And two papers and the commentary by Park and Bang struggle with that other tricky ingredient, placebo control. Takakura and his colleagues have now done several validation studies of his blunt needle that presses on the skin in a way that might blind the practitioner, as well as a new needle which stops short of the skin and so could be considered inert. Unsurprisingly perhaps, patients can readily identify the new one, and Park and Bang find the previous results less than convincing when they apply their ‘Blinding Index’. Tan and colleagues found that the Park sham needle was more likely to be identified in the arm than the leg. However, these studies used healthy volunteers, so do their results apply to clinical trials?
Usichenko and colleagues revisited the hypothesis that only points that are traditionally linked to hearing generate changes in the auditory cortex. But in the brainstem they found nothing, no response at all. And Mist and colleagues check the performance of the AcuGraph system for measuring acupuncture points.
Cowan discusses the mismatch between treatment and evidence of acupuncture for drug and alcohol dependence. Maybe the usual ‘disease model’ is not applicable, and qualitative research is needed to explore more appropriate interventions and outcomes.
Enjoy the mix.
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