Wednesday, May 20, 2015

Effects of acupuncture on pain and inflammation in pediatric appendicitis

A paper [full text here] from The Journal of Alternative and Complementary Medicine says that "acupuncture may be a feasible and effective treatment modality for decreasing subjective pain and inflammation" in pediatric patients with appendicitis.

They studied six adolescents with appendicitis and administered acupuncture for pain control prior to surgery. Pain was assessed using three analog scales, and inflammation was measured using serial white blood cell (WBC) counts and C-reactive protein levels (CRP). CRP is a nonspecific indicator of inflammation in the body.

Figure 2 from the paper summarizes the results.

You can see that after 20 minutes of acupuncture, all three pain scores and WBCs declined. However, CRP continued to rise. Conspicuously absent from the figure and the text of the paper are any statistical analyses. This is due to the lack of a significant difference in any of these values because of the limited number of subjects studied.

The authors were undeterred and concluded "Although CRP as a general marker of inflammation stayed roughly the same on sequential blood draws, the median WBC showed a modest and noticeable drop. The implication of this finding is that the effectiveness of acupuncture may have a biophysiological basis." Look at the figure and decide for yourself if the WBC drop is really more noticeable than the CRP rise.

While the authors did mention some limitations of the study including the lack of statistics, they didn't discuss impediments to using acupuncture in patients who present to an emergency department. Whether patients were given antibiotics before or during the acupuncture session was not stated.

Even if the technique actually works [which is certainly not proven by this paper], how practical would it be to have an acupuncturist on call? Would she take in-house call? If not, how long would it take for her to get to the hospital? Would insurance pay for acupuncture? Would the acupuncturist be subject to work hours limitations?

The authors are not proposing acupuncture as a definitive treatment for appendicitis. So what is the clinical value of reducing inflammation? An even better way to reduce inflammation [and pain] is to remove the diseased appendix.

I know how difficult it is to publish papers and continue to do all the clinical and administrative work of an academic physician. As I have said on several occasions, many of my published papers were simply not very good.

But acupuncture to decrease inflammation in appendicitis patients? I doubt you'll be seeing an on-call acupuncturist any time soon.


NeuroTrumpet said...

Your commentary on this "study" is far too kind.

jflatulippe said...

It think the problem with this paper is its goal. Had they limited themselves to pain control and with proper analysis of their results they could have made a point for an alternative approach to pain management. As is nothing can be concluded, but "There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy" Hamlet, therefore I think that we should keep an open mind and wait for a good study that this topic deserves

Skeptical Scalpel said...

Neuro, I was afraid it was too harsh.

jf, good point but there is still the issue of having a readily available acupuncturist. The study used a convenience sample of patients and it took several months to enroll 6 patients.

artiger said...

In an effort to advance the study goals, I volunteer to allow the acupuncturist to take my call. Perhaps bowel obstructions, GI bleeds, and acute cholecystitis would benefit too. Maybe even trauma. The sky is the limit.

Anonymous said...

Anonymous Europe: This is just plain crazy....and just how inflammated were these appendices...? I can somehow hardly picture a gangrenous, perforated appendicitis reduced by acupuncture... Besides, were not some articles recently going around that acupuncture is actually useless?

Skeptical Scalpel said...

Artiger, sorry it only works for appendicitis.

Anon Europe, I agree with everything you said.

Libby said...

It isn't useless if the subjective pain is reported by the patient as reduced. If the patient states the pain has reduced they will become more relaxed and therefore reduce their screaming and decrease need for narcotics. A win-win for neighbouring patients/families, the staff & surgeon right?
I've used acupuncture and it really does work, but then I've never used it for pre or post surgical pain. Hopefully I'll never have that opportunity.
I agree with the on-call acupuncturist situation, unless there is someone like mine, who is trained in western medicine (in China). My physiotherapist is also trained in acupuncture so there are people who gain more than one skill set. I'm betting that adding acupuncture training to an already heavy learning load to medical training won't-or shouldn't-happen. If a pain specialist wants to, then that would be a separate training.

Skeptical Scalpel said...

Libby, thank you for commenting. Appendicitis patients typically are not screamers. They tend to lie quietly. In fact, children often don't look sick at all, which occasionally fools an inexperienced doctor. Small doses of standard pain meds control their pain in nearly every case.

frankbill said...

As a non medical person My question is what parent is going to make there child wait to see if acupuncture is going to lesson the pain? One thing is certain if appendices burst while waiting to see if acupuncture works child is going to get much worse.

frankbill said...

I had Appendicitis at age of 61 this was in Dec of 2008 in reading my notes I was having less pain by time I got to ED then I was having at home. This was without taking any thing for pain. At least for me if they had tried acupuncture then how could one tell if the acupuncture worked or there was less pain just with the passing of time.

Skeptical Scalpel said...

Frank, thanks for chiming in. Good points. As you point out, there were no controls in the study so the passage of time could have impacted the levels of pain.

Libby said...

Interesting about the pain levels in appendicitis. As a volunteer in ED I occasionally have people in great pain & parents very sure their child/loved one sure that the appendix is about to burst (even if the location of pain is not in the usual appendicitis location).
Acupuncture can relieve pain quite quickly but I admit, I wouldn't want to wait for someone to come to the hospital to relieve the pain...unless the drugs didn't work. So for me it would be drugs first then needles. My acupuncturist says it works best with acute pain but most people come in well after it starts. Again, I wouldn't stop by her office on my way to the hospital...unless I was sure what the issue was and knew I had time. Maybe send someone ahead to stand in the triage line for me!

Skeptical Scalpel said...

Or call an acupuncturist before you leave home.

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