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This issue sees light at the end of the tunnel on the long debate over acupuncture's place in management of infertility and assisted reproduction. Shuai's positive study is discussed in an editorial by Carr that brings understanding, thought and expertise to a complex area. His conclusion is that the evidence strongly suggests an effect of segmental sensory stimulation, as long as it is given repeatedly certainly at both follicular phase and the embryo transfer stage.
Beyond the obvious fact that future studies should adopt this schedule, this story reinforces many lessons about acupuncture research. Designing clinical studies that produce meaningful results is very demanding in view of our current limited information on the various modes of stimulation and their various modes of action. Acupuncture research is still at an exploratory stage, so protocol-driven systematic reviews are unlikely to reveal the subtle effects; and blunt, non-penetrating needles – though theoretically ideal – are not suitable controls for at least some of acupuncture's effects. Additionally, the waste of research effort might have avoided by an approach using western science, championed by this journal.
The remaining original studies in this issue are attempts to provide the sort of basic information that is so desperately needed to guide future clinical research. Four studies measure the acute response to acupuncture. The first explored skin impedance in patients with cachexia. The others were in volunteers. Paley and Johnson were motivated by a search for the most rapid relief for cancer pain, clearly based on observed clinical need. They explored the ‘dose’ of acupuncture, comparing the analgesia produced by four and by two needles, in blinded volunteers. There were no differences in the pre-specified outcome – time taken to pain relief – but numbers achieving 33% reduction showed positive trends. The next two studies use objective measures: heart rate variability and cortical evoked potentials. In our last study in humans, Trevelyan et al report a rigorous Delphi consensus on treatment of phantom limb, probably the first on this indication, though somewhat retrospective in including traditional approaches.
There follows some interesting basic research on acupuncture's modes of action in tendinopathy. In a previous issue, Santos de Almeida and colleagues showed that EA improved the concentration and organisation of injured collagen, in vitro. Now they move on to show an effect on the ultrastructure of the fibrils. Also, Inoue and colleagues showed that EA given early after tendon injury increased cell count and corresponding tensile strength of the collagen at one week, though the difference from control was less marked after 10 days. A welcome insightful editorial by Speed on ‘tendinopathy’ highlights recent progress, particularly knowledge about the various structures that may be involved, and the variety of pathologies – a mixture of repair and degeneration now known, though still limited by lack of consensus. She recognises our studies as intriguing and stimulating, and makes the important observation that the animal models they used are not known to be directly relevant to clinical treatment in humans, again important consideration for future research.
In our educational section, Acar gives a fascinating description of the first medical textbook written in the Turkish language rather than Persian or Arabic, in the middle of the 15th century, by Sabuncuoğlu, and called Imperial Surgery. He describes clear references to acupuncture points and cauterisation, probably being introduced from China by Anatolians with Central Asian roots. The images are striking (see figure 1).
So, even after six centuries of thoughtful consideration on acupuncture, we still need to refine our thinking processes to gather the evidence necessary to decide how, and for what, acupuncture can be accepted into the mainstream of medicine.
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