NICE recommends acupuncture for chronic primary pain April 2021

NICE guidelines for chronic primary pain

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care in England.

NICE guidelines are evidence-based recommendations for health and care in England.

They set out the care and services suitable for most people with a specific condition or need, and people in particular circumstances or settings.

The guidelines help health and social care professionals to: prevent ill health, promote and protect good health, improve the quality of care and services, adapt and provide health and social care services.

Chronic pain is often difficult to treat and can have a significant impact on individuals and their families and carers. Chronic pain may affect between 30% and 50% of the population. Chronic primary pain is the pain with no clear underlying condition or impact of pain is out of proportion to any observable injury or disease.

NICE recommends acupuncture for chronic primary pain April 2021

Acupuncture for chronic primary pain

1.2.5Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:

is delivered in a community setting and

is delivered by a band 7 (equivalent or lower) healthcare professional with appropriate training and

is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries) or

is delivered by another healthcare professional with appropriate training and/or in another setting for equivalent or lower cost.

Why the committee made the recommendation

Many studies (27 in total) showed that acupuncture reduced pain and improved quality of life in the short term (up to 3 months) compared with usual care or sham acupuncture. There was not enough evidence to determine longer-term benefits. The committee acknowledged the difficulty in blinding for sham procedures, but agreed that the benefit compared with a sham procedure indicated a specific treatment effect of acupuncture. There was a wide variation among the studies in the type and intensity of the intervention used, and the studies were from many different countries. The committee agreed that the type of acupuncture or dry needling should depend on the individual needs of the person with pain.

Two economic evaluations (1 in the UK) showed that acupuncture offered a good balance of benefits and costs for people with chronic neck pain. However, both studies had limitations; a notable limitation being that the costs of acupuncture seemed low. Threshold analysis based on these studies indicated the maximum number of hours of a band 6 and 7 healthcare professional's time that would make the intervention cost effective.

An original economic model was developed for this guideline, which compared acupuncture with no acupuncture. The model used data from studies with usual care comparisons, not comparisons with sham acupuncture, because the committee agreed that a usual care comparison in an economic model better reflects the real world benefit of the intervention. The model showed that acupuncture was likely to be cost effective. The committee considered the results to be robust, and agreed that the studies used in the model were representative of the whole evidence review. Acupuncture remained cost effective when the assumed benefits and costs were varied (sensitivity analysis).

Overall, the committee agreed that there was a large evidence base showing acupuncture to be clinically effective in the short term (3 months); the original economic modelling also showed it is likely to be cost effective. However, they were uncertain whether the beneficial effects would be sustained long term and were aware of the high resource impact of implementation. Taking these factors into account, the committee made a recommendation to consider acupuncture or dry needling for chronic primary pain, caveated by the factors likely to make the intervention cost effective. These were: only if delivered in the community, and with a maximum of 5 treatment hours (based on the average resource use in the trials in the model and on the threshold analysis), and from a band 7 (equivalent cost or lower) healthcare professional (based on the threshold analysis). It was agreed there may be different ways of delivering the service that enable acupuncture to be delivered for the same costs, which would equally be appropriate. The committee agreed that discontinuing before this total amount of course time would be an option if the person finds that the first few sessions are not effective.

No evidence was found to inform a recommendation for repeat courses of acupuncture. The committee agreed that further research would help to inform future practice (see the recommendation for research on repeat courses of acupuncture for chronic primary pain).

References

https://www.nice.org.uk/guidance/ng193/chapter/Recommendations#acupuncture-for-chronic-primary-pain

 

Massage Therapy adds on acupuncture.

Massage therapy is used to help manage a health condition or enhance wellness. It involves manipulating the soft tissues of the body. Massage has been practiced in most cultures, both Eastern and Western, throughout human history, and was one of the earliest tools that people used to try to relieve pain.

There are many techniques in massage therapy. The most common form of massage therapy in Western countries is called Swedish or classical massage; Other styles include sports massage, clinical massage. Massage traditions derived from Eastern cultures, such as Shiatsu and Tuina.

Adding acupuncture to your massage therapy can achieve better effects or acupuncture is a good replacement of massage therapy, if you can’t get massage treatment.

References

https://www.nccih.nih.gov/health/massage-therapy-what-you-need-to-know

How many new coronavirus variants are circulating at the moment?

New variants of a virus are expected to occur over time, because viruses frequently change through mutation. Sometimes new variants emerge and disappear. Other times, new variants emerge and persist. There is no exception of coronavirus. Multiple variants of the virus that causes COVID-19 have been found globally during this pandemic.

Scientists monitor changes in the virus, including changes to the spikes on the surface of the virus to understand how changes to the virus might affect how it spreads and what happens to people who are infected with it.

Multiple variants of the virus that causes COVID-19 are circulating globally:

In the UK a variant called B.1.1.7 with a large number of mutations was identified in the autumn of 2020. This variant spreads more easily and quickly than other variants. It has since been detected in many countries around the world.

In South Africa, another variant called B.1.351 emerged independently of B.1.1.7. Originally detected in early October 2020, B.1.351 shares some mutations with B.1.1.7.

In Brazil, a variant called P.1 emerged that was first identified in travelers from Brazil, who were tested during routine screening at an airport in Japan, in early January. This variant contains a set of additional mutations that may affect its ability to be recognized by antibodies.

These variants seem to spread more easily and quickly than other variants, which may lead to more cases of COVID-19.

The good news is that so far, studies suggest that antibodies generated through vaccination with currently authorized vaccines recognize these variants.

References

https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant.html

Coronavirus vaccine

In the UK, there are 2 types of COVID-19 vaccine The Pfizer-BioNTech vaccine and The Oxford vaccine to be used once they are approved. They both require 2 doses to provide the best protection. Both have been shown to be safe and effective in clinical trials. The NHS first offers these vaccines to those at highest risk of catching the disease and of suffering serious complications or dying from COVID-19 which includes older adults in care homes and frontline health and social care workers. When more vaccine becomes available, the vaccines will be offered to other people at risk as soon as possible.

The Pfizer-BioNTech vaccine was found to be safe and effective by the UK medicines regulator and has been approved for mass use in over-16s. Margaret Keenan who was turning 91 was the first person in the world to receive a dose. The Pfizer-BioNTech vaccine has manufacturing sites in Europe and the US. Initial vaccine doses for the UK are being produced at Pfizer's site in Puurs, Belgium.

The vaccine from Pfizer is made using genetic material RNA, a part of the virus's genetic code. This is injected into patients to activate patient’s immune cells. This technique never before developed on this scale - it has strict temperature requirements and needs to be stored at a very cold -70C to prevent it from degrading. This means it needs to be transported in a carefully controlled deep-freeze delivery chain.

The Oxford vaccine is a genetically modified common cold virus that used to infect chimpanzees. it can't trigger infection in humans because it has had a tiny bit of genetic material removed. A fragment of the genetic code for coronavirus is inserted into this gap. This forms the vaccine. The technical term is a viral vector vaccine. The Oxford vaccine has a crucial advantage - its vials can be stored and transported at normal fridge temperature.

Oxford-AstraZeneca vaccine approved for use in UK just before New Year 2021.

The first people will receive the Oxford University/AstraZeneca coronavirus vaccine on 4 January 2021 as the NHS rapidly expands COVID-19 vaccination programmes across the UK.

The NHS is the first health service in the world to deploy the life-saving jab, which has been authorised by the Medicines and Healthcare products Regulatory Agency (MHRA) after meeting strict standards of safety, quality and effectiveness. It is the only approved vaccine which can be stored at fridge temperatures.

Brian Pinker, 82-year-old has become the first person in the world to receive the Oxford-AstraZeneca vaccine since it was approved for use in the UK.

References
https://www.gov.uk/government/publications/covid-19-vaccination-why-you-are-being-asked-to-wait/why-you-have-to-wait-for-your-covid-19-vaccine
https://www.bbc.co.uk/news/health-55308216

https://www.gov.uk/government/news/first-people-to-receive-oxford-universityastrazeneca-covid-19-vaccine-today-4-january-2021

Acupuncture for subchorionic hematoma

Subchorionic hematoma or subchorionic hemorrhage is bleeding beneath the chorion membranes that enclose the embryo in the uterus due to partial detachment of the chorion membranes from the wall of the uterus. They are the most common cause of vaginal bleeding in 9-20 weeks pregnancy. Most women present with light vaginal bleeding, but some are asymptomatic with incidental ultrasound findings. The causes of subchorionic hematoma are not clear. The presence of a uterine malformation, a history of recurrent pregnancy loss, or pelvic infections are all possible risk factors to subchorionic hematoma. The symptoms of subchorionic hematoma are vaginal bleeding without abdominal pain; some patients may experience cramping. The increased pregnancy loss includes the volume of the bleeding, location and pregnancy weeks.

There was a paper that reported acupuncture for threatened miscarriage with subchorionic hematoma. They found that acupuncture combined with dextroprogesterone can improve the effective rate of patients with threatened abortion in early pregnancy complicated with subchorionic hematoma.

References
https://www.ncbi.nlm.nih.gov/books/NBK559017/
Jia-Man Wu et al Zhongguo Zhen Jiu 2019 Oct 12;39(10):1046-50.

Pelvic floor: Transverse perineal muscles

Transverse perineal muscles
There are two transverse perineal muscles, superficial and deep transverse perineal. They are part of the pelvic floor. Superficial transverse perineal muscle originates from tendinous fibers from the ischial tuberosity of the sitting bone, runs medially and ends at the perineal body the central tendinous point of the perinium with the bulbospongiosus muscle in front. Deep transverse perineal muscle originates from the ischium, runs medially, and ends at vagina and the perineal body posteriorly and blends with the opposite side muscle. They act to support the perineal body and pelvic floor.

WHO lists of acupuncture therapy tested

 The World Health Organisation lists a wide variety of diseases or disorders for which acupuncture therapy has been tested in controlled clinical trials. Here is the full list.

 

The diseases or disorders for which acupuncture therapy has been tested in controlled clinical trials reported in the recent literature can be classified into four categories as shown below.

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1. Diseases, symptoms or conditions for which acupuncture has been proved— through controlled trials—to be an effective treatment:

Adverse reactions to radiotherapy and/or chemotherapy

Allergic rhinitis (including hay fever)

Biliary colic

Depression (including depressive neurosis and depression following stroke)

Dysentery, acute bacillary

Dysmenorrhoea, primary

Epigastralgia, acute (in peptic ulcer, acute and chronic gastritis, and gastrospasm)

Facial pain (including craniomandibular disorders)

Headache

Hypertension, essential

Hypotension, primary

Induction of labour

Knee pain

Leukopenia

Low back pain

Malposition of fetus, correction of

Morning sickness

Nausea and vomiting

Neck pain

Pain in dentistry (including dental pain and temporomandibular dysfunction)

Periarthritis of shoulder

Postoperative pain

Renal colic

Rheumatoid arthritis,

Sciatica

Sprain

Stroke

Tennis elbow

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2. Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which further proof is needed:

Abdominal pain (in acute gastroenteritis or due to gastrointestinal spasm)

Acne vulgaris

Alcohol dependence and detoxification

Bell’s palsy

Bronchial asthma

Cancer pain

Cardiac neurosis

Cholecystitis, chronic, with acute exacerbation

Cholelithiasis

Competition stress syndrome

Craniocerebral injury, closed

Diabetes mellitus, non-insulin-dependent

Earache

Epidemic haemorrhagic fever

Epistaxis, simple (without generalized or local disease)

Eye pain due to subconjunctival injection

Female infertility

Facial spasm

Female urethral syndrome

Fibromyalgia and fasciitis

Gastrokinetic disturbance

Gouty arthritis

Hepatitis B virus carrier status

Herpes zoster (human (alpha) herpesvirus 3)

Hyperlipaemia

Hypo-ovarianism

Insomnia

Labour pain

Lactation, deficiency

Male sexual dysfunction, non-organic

Ménière disease

Neuralgia, post-herpetic

Neurodermatitis

Obesity

Opium, cocaine and heroin dependence

Osteoarthritis

Pain due to endoscopic examination

Pain in thromboangiitis obliterans

Polycystic ovary syndrome (Stein–Leventhal syndrome)

Postextubation in children

Postoperative convalescence

Premenstrual syndrome

Prostatitis, chronic

Pruritus

Radicular and pseudoradicular pain syndrome

Raynaud syndrome, primary

Recurrent lower urinary-tract infection

Reflex sympathetic dystrophy

Retention of urine, traumatic

Schizophrenia

Sialism, drug-induced

Sjögren syndrome

Sore throat (including tonsillitis)

Spine pain, acute

Stiff neck

Temporomandibular joint dysfunction

Tietze syndrome

Tobacco dependence

Tourette syndrome

Ulcerative colitis, chronic

Urolithiasis

Vascular dementia

Whooping cough (pertussis)

​

3. Diseases, symptoms or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which acupuncture is worth trying because treatment by conventional and other therapies is difficult:

Chloasma

Choroidopathy, central serous

Colour blindness

Deafness

Hypophrenia

Irritable colon syndrome

Neuropathic bladder in spinal cord injury

Pulmonary heart disease, chronic

Small airway obstruction

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4. Diseases, symptoms or conditions for which acupuncture may be tried provided the practitioner has special modern medical knowledge and adequate monitoring equipment:

Breathlessness in chronic obstructive pulmonary disease

Coma

Convulsions in infants

Coronary heart disease (angina pectoris)

Diarrhoea in infants and young children

Encephalitis, viral, in children, late stage

Paralysis, progressive bulbar and pseudobulbar

​

References

https://www.acupuncture.org.uk/public-content/public-traditional-acupuncture/4026-who-list-of-conditions.html

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