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Welcome to our first issue of 2016, which opens with two RCTs. The first, by Arab et al, which is also this issue's editor's choice, examines the efficacy and effectiveness of acupressure at a single point (HT7) on sleep quality in renal patients on haemodialysis relative to sham acupressure (equivalent technique applied at a location 0.5 cm away) and no treatment, respectively. Scores on the Pittsburgh sleep quality index were significantly improved to some degree in both the acupressure groups relative to standard care, reflecting the generalised effects of treatment, however there was a notably larger size of effect in the verum group compared to the sham group, suggesting that targeting HT7 is advantageous. Having noted the closer proximity of the ulnar nerve at this location, the authors consider the possibility that a greater degree of somatosensory stimulation may result following application of pressure at HT7. This study adds to a growing literature in this subspecialist field and compliments previous controlled investigations of acupressure for sleep quality,1 fatigue2 and uraemic pruritis3 in patients on haemodialysis. Regular readers of Acupuncture in Medicine may also remember case reports describing the use of acupuncture for problems such as erectile dysfunction, gastroparesis and hypersexuality in such patients. Collectively, these reports suggest there is potential for the future integration of acupuncture and related techniques into nephrology, although further research is needed.
The second RCT, from Solberg and colleagues, is a pilot that demonstrates the feasibility of recruitment of women with stress and urge (mixed) urinary incontinence to receive traditional acupuncture as an alternative to pelvic floor exercises or remaining on a waiting list for medical and/or surgical treatment. Like many other studies with an untreated group, the loss to follow-up in the waiting list group was high and this needs to be taken into account in future definitive trials to ensure adequate statistical power. The acupuncture treatment protocol was varied but typically involved needling segmental to the bladder (T11 to L2 and S2 to S4 based on the sympathetic and parasympathetic innervation, respectively) ventrally (eg, CV3, CV4), distally (eg, SP6, KI3, LR3) and/or dorsally (eg, BL23, BL28, BL31–34). Sacral neuromodulation is widely accepted for the management of lower urinary tract symptoms and typically involves intermittent peripheral forms of stimulation like percutaneous tibial nerve stimulation (ie, EA at or close to SP6), with paraspinal sacral nerve stimulation using internalised devices being reserved for longer-term neuromodulation.4 However, in this issue, Katayama et al confirm using CT that a 50 mm needle inserted directly over the S2 or S3 foramina at a 60° angle comes into close contact with the sacral nerve roots and could be used to apply electrical stimulation through a relatively less invasive approach. From a safety perspective, they advise against deep needling over the S4 foramina as needles came into close proximity with the rectum (6 mm).
Other original research in this issue includes another pilot study, from Hesse et al, who demonstrate the acceptability of indwelling auricular needles as a method of pain relief in new mothers following elective Caesarean section. If proven effective after an adequately powered RCT, the anticipated ease of implementation and cost-effectiveness of this method would, in my opinion, make it particularly appealing to busy postnatal wards. Finally, we have preclinical studies in rat models of tendinopathy, inhibited gastric motility, neuropathic pain and traumatic brain injury, all of which provide novel mechanistic insights. I am particularly grateful to Almeida et al for providing the inspiration for this issue's cover image and extending their previous work investigating the processes underlying the beneficial effects of acupuncture on tendon healing.
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