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We dress up our section of miscellaneous papers with the title: Education and Practice, but regular readers can see straight through that title, and will have come to expect erudition and variety that are epitomised by our three wonderful papers in this issue. They offer views on different aspects of the fascinating world of acupuncture, through three windows.
Straight ahead, through the square window, da Silva and colleagues describe how, over the years, they have developed the training of acupuncture for medical students in Brazil, probably the most advanced such training in the world outside China. They just get on using acupuncture, finding it safe and effective for patients including that difficult and needy group, those with chronic pain and multimorbidity. But through the window on the right, Foell's essay explores that claim: Is acupuncture the ‘longed-for magic formula’ for this increasingly recognised group? The glass in this window is misted up: he cannot see through. What is acupuncture's role, what is its place, how should it be integrated and what are the long-term outcomes? In the end, is it just good for jollying patients along—which may be valuable, but then how should we prevent dependence, how control demand? And thirdly, standing beside the window on the left field, in another classy essay, Campbell tweaks the curtain back a little to give us a glimpse of the future of acupuncture mechanisms. His thesis is that, since laboratory subjects may feel de qi in their arm when a needle is inserted into a rubber hand (‘their’ rubber hand), then these visual cues could be an important part of the mix of acupuncture mechanisms. Who can fail to be fascinated?
PULLING BACK THE CURTAIN
Our first clinical trial concerns the arthralgia of unknown mechanism that is associated with aromatase inhibitors, and which sadly does not respond to anti-inflammatory painkillers. Even more sadly, Oh and colleagues find that it looks as if the response to acupuncture is tiny, if any. However, Esmaeli and colleagues are more positive about the effects on sore throat postoperatively, which was halved after acupuncture—though no difference in need for medication. But critical appraisal leads to caution: the study, though large, was non-randomised. Lee and colleagues have put hard data on the importance of reducing patients’ fear of needling, showing a clear correlation between that fear and the sympathetic arousal.
Laboratory studies with MRI often provide a more optimistic outlook than clinical ones. Qhah-Smith and her colleagues show that laser stimulation does indeed produce a response in the brain—in the precuneus—which is different from the response to needling, not surprisingly. And Huang and colleagues demonstrate the response to acupuncture after stroke: the intact side is stimulated. Does that help the brain's recovery through compensatory changes?
And finally, please humour the editor in his mission on acupuncture research: we do not really know how best to give the acupuncture stimulus, and we do not really know how best to measure the effect. The data on acupuncture for drug dependence, albeit in this very exploratory analysis, seem to support the idea that the effect of acupuncture may, in the picturesque (and probably apocryphal) words of George Bush, be ‘seriously misunderestimated’.
Case histories and letters are varied and fascinating as always. Even a short letter can make a big difference to practice: Wong's letter shows that needling LI4 distally is safer than proximally, because of the course of the palmar metacarpal artery—shown in the figure 1. Above all, practice safely.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
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