Acupuncture

Acupuncture and MACE

Sun, 28 Jun 2020 12:29:19 +0000

Stimulated by Jung et al 2020.[1]

Image from Slashme on Wikipedia.
I wonder if the person or committee that came up with the acronym MACE had ever seen this image of the fruit of Myristica fragrans (nutmeg) split open to show the seed with the surrounding aril (also known as mace). I cannot help thinking it looks a bit like a ventricle.

It is somewhat ironic that last week I rather dismissed a paper on acupuncture in hypertension and the fMRI activation findings associated with certain points,[2] and just a few days later we publish this huge retrospective cohort study on acupuncture and MACE in hypertension.

MACE – Major Adverse Cardiovascular Events
HT – Hypertension

I don’t recall seeing the acronym MACE before, but I guess it is part of the terminology used within these huge healthcare databases. It will be higher up the tree of terms from those conditions we are more familiar with as clinicians: myocardial infarction (MI), stroke and death!

I have highlighted most of the large retrospective cohorts related to the use of acupuncture in this blog, and they can be found by selecting ‘Retrospective cohorts’ from the category list of this blog.

We have 5 or 6 from Taiwan, where they have most of the 23 million population on their National Health Insurance Research Database. There is one from the US on opioid prescription in back pain, one from Thailand on survival in stroke, and now this makes the third such study from Korea.

Korea has a population of 50 million, and they have a research database formed out of a random sample of 2% of the population, so the start point is one million individuals. Jung et al identified 59 370 patients taking anti-hypertensive drugs who had been diagnoses with HT between 2003 and 2006. Of these, 18 044 had received more than 2 sessions of acupuncture within a year of diagnosis. After propensity score matching the number in each group was 18 011, so presumably 33 patients having acupuncture could not be matched.

The MACE outcomes were those of interest, and then it was just a matter of observing the differences in these two large groups of similar patients. The term used is a hazard ration (HR), and if it is less than 1 that means the group of interest has fewer cases than the comparator (the matched cohort).

The analysis has been performed in a number of different ways. We have a crude (unadjusted) comparison, a multivariable analysis (adjusted for 5 key variables), the propensity score matched (PSM) analysis (this was the primary outcome of interest) and, wait for it, an inverse probability of treatment weighting analysis. That last one is a bit hard to conceptualise, but essentially, I think they calculated probability of MACE outcomes from the PSM and then used that to adjust the crude figures from the pre-PSM cohort of close to 60k patients.

Acupuncture use was associated with a reduced risk of MACE and all-cause mortality

As you might imagine, acupuncture use was associated with a reduced risk of MACE (HR 0.83), and all-cause mortality (HR 0.73). There was also a reduced risk of MI in the PSM, but not of stroke. Having said that, the mortality for all the different cardiovascular disease categories was lower in the acupuncture cohort (HR ~0.70).

More and more of these studies are demonstrating hitherto unexpected (at least by me) benefits associated with acupuncture treatment. I am starting to imagine a future where we all start having regular visits to our acupuncturist once we turn 40. I have always considered myself to be rather unresponsive to the effects of acupuncture, but the more of these large retrospective cohort studies I see, the more I consider booking in for some regular treatment.

References

1 Jung H, Yeo S, Lim S. Effects of acupuncture on cardiovascular risks in patients with hypertension: a Korean cohort study. Acupunct Med Published Online First: 20 June 2020. doi:10.1177/0964528420920290

2 Zhang J, Lyu T, Yang Y, et al. Acupuncture at LR3 and KI3 shows a control effect on essential hypertension and targeted action on cerebral regions related to blood pressure regulation: a resting state functional magnetic resonance imaging study. Acupunct Med Published Online First: 12 June 2020. doi:10.1177/0964528420920282

Declaration of interests MC

The amygdala and Rx of cLBP

Sat, 20 Jun 2020 15:17:10 +0000

Stimulated by Yu et al 2020,[1] and Zhang et al 2020.[2]

Image from Federico Beccari on Unsplash.

The key paper I am highlighting this week comes from the same imaging centre in Boston that gave us Rewiring the brain with acupuncture.[1] It was another paper that I nearly missed, but a subsequent paper in Acupuncture in Medicine led me to take a closer look.

The paper from Acupuncture in Medicine is considerably less sophisticated,[2] and raises more questions than it answers, but it allows us to make some contrasts in terms of methods. In this paper 31 patients with essential hypertension were randomised to receive one of two acupuncture protocols daily for 5 days per week in two consecutive weeks. Resting state fMRI was performed before and after the first session and then again at the end of the treatment course. The group that was intended to receive the proper treatment (Group A) had LR3 and KI3 needled bilaterally with a technique that would have been close to both the first metatarsal artery at LR3 and the posterior tibial artery at KI3. The other group had LR3 and a sham point needled (Group B). The sham point was 2cm medial to the midpoint of the Stomach meridian in the thigh. This would target rectus femoris or the muscle layer beneath it – vastus intermedius. Quite vigorous manual needling was performed 4 times over the 30-minute session in both groups.

…a failure to stratify for gender

The main drawback of this study was a failure to account for gender differences between the groups. We are presented with no baseline data apart from blood pressure (BP), and presumably this gender difference became apparent at peer review and was subsequently included as a limitation in the discussion. The authors report on within group changes in BP, but there is no comment on the 5.5mmHg difference in diastolic BP at baseline, and there were no between group differences. The latter could have been due to a lack of statistical power, but baseline imbalance due to a randomisation failure may have contributed. By randomisation failure here I really mean a failure to stratify for gender, and therefore the associated disparity in risk factors for hypertension between men and women in China.

The key focus of the study was on differences in resting state (rs) fMRI, but given the limitations described above, these have been somewhat over interpreted to my mind.

…several famous names from acupuncture research

Ok, so that paper has only deserved a mention to serve as a contrast to the one by Yu et al.[1] This group includes several famous names from acupuncture research, and it is clear to see from the methods the influence of perhaps the most well-known of those names.

The study involved 79 patients with chronic low back pain (cLBP) who were randomised to four groups. Before you cry out in concern at the potential loss of statistical power from dividing such a relatively small number in 4, it was effectively 2 groups that were subdivided into augmented and limited context manipulation. The acupuncture was a semi standardised manual acupuncture protocol that was applied 6 times over 4 weeks. The sham groups received non-penetrating needling with the Streitberger needle at 12 sham acupuncture points.

The augmented and limited context manipulations were similar to those used in Kapchuk et al,[3] and the clinical outcome was a scale for bothersomeness that was used by Cherkin et al in their famous cocktail stick trial.[4] As well as a clinical outcome, the main focus of the research was fancy imaging to investigate resting state functional connectivity (rsFC) in key areas of the brain, and look for correlations with the clinical outcomes. From prior research the VTA (ventral tegmental area) and the PAG (periaqueductal grey) were identified as key areas. Four additional regions of interest (ROIs) were nominated a priori based on their roles in pain modulation and reward. These were the ACC (anterior cingulate cortex), mPFC (medial prefrontal cortex), insula and amygdala

The change in bothersomeness was greater in the real acupuncture groups, and this just reached statistical significance. There was no difference between the augmented and limited context, indeed the mean change was numerically greater in the limited context groups.

Left amygdala rsFC with VTA
&
Left amygdala rsFC with PAG

The left amygdala was the ROI with rsFC increases with both the VTA and PAG when the real acupuncture group was compared with the sham group. So, the team used multiple regression analysis to examine the correlation between rsFC in these regions with the clinical changes in bothersomeness. They found that the increases in rsFC between the left amygdala and both the VTA and the PAG correlated with decreases in bothersomeness (this analysis was performed with data from all patients). They also found that pre-treatment rsFC between the left amygdala and the PAG correlated with changes in bothersomeness after treatment, so that the lower the rsFC before treatment, the bigger the change in bothersomeness clinically.

Well if you have managed to keep up with all the acronyms and correlations, you will see that we are now starting to build up a picture of functional changes in the brains of real patients that is consistent with our ideas concerning mechanisms of acupuncture from laboratory data built up over the past 50 years. This is quite exciting, and somewhat of a relief to find that what has been determined on the bench still holds true at the bedside.

what has been determined ‘on the bench’ still holds true ‘at the bedside’

I cannot say I am surprised that the augmented versus limited interactions revealed nothing of interest in this patient group, and I think that is one area of inquiry that needs refining for acupuncture. I suspect we need to include the subtle differences in non-verbal interaction between practitioners and their patients, although I am unsure how this can be best achieved.

References

1 Yu S, Ortiz A, Gollub RL, et al. Acupuncture Treatment Modulates the Connectivity of Key Regions of the Descending Pain Modulation and Reward Systems in Patients with Chronic Low Back Pain. J Clin Med 2020;9:1719. doi:10.3390/jcm9061719

3 Kaptchuk TJ, Kelley JM, Conboy LA, et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ 2008;336:999–1003. doi:10.1136/bmj.39524.439618.25

4 Cherkin DC, Sherman KJ, Avins AL, et al. A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain. Arch Intern Med 2009;169:858. doi:10.1001/archinternmed.2009.65

Declaration of interests MC

Atraumatic glenohumeral dislocation, IBS and other stories

Mon, 15 Jun 2020 09:32:47 +0000

Stimulated by Qin et al 2020,[1] and Pei et al 2020.[2]

Image modified from Figure 1 of Qin et al 2020.[1]

The first paper I am highlighting this week is an adverse event report attributed to acupuncture. It is quite unusual for two reasons. First, as the title states, the case presented with a shoulder dysfunction that turned out to be an atraumatic anterior dislocation. Second, following manual relocation of the humeral head, the x ray film image suggested persistent inferior subluxation, which subsequent MRI demonstrated to be a collection in the subdeltoid bursa. This collection proved to be an abscess that grew methicillin sensitive Staph aureus. Further questioning of the patient revealed a formerly undeclared history of acupuncture for cervical spondylosis around one month prior to presentation.

As is usually with case reports that are written by the specialist team who deal with the adverse event, there is insufficient detail of the acupuncture to draw clear conclusions, or even clear attribution of cause. I guess it is conceivable that an acupuncture needle at LI15 could inoculate Staph aureus from the skin into the subdeltoid bursa. It is a short enough distance, being roughly 10 to 20mm in most shoulders, but Hoffman argues that the size and shape of an acupuncture needle is such that it is unlikely to inoculate sufficient numbers of bacteria (abscess derived Staph aureus) to cause infection in a healthy subject.[3]

We are told that the patient had acupuncture applied to her left shoulder for cervical spondylosis, but LI15 does not appear to be listed as a point that might be used for neck conditions.[4] LI14 is listed, but this point is too low for direct inoculation into the subdeltoid bursa. However, with such adverse event reports, we must assume the possibility of acupuncture being responsible unless we have a convincing alternative. Whilst I have presented arguments that raise questions regarding attribution, we must include this a possible adverse event for acupuncture and consider how we can reduce the risk.

And now for something completely different…

And now for something completely different – acupuncture for IBS (irritable bowel syndrome). This is a big pragmatic multi-centre clinical trial pitting 18 sessions of acupuncture over 6 weeks against guideline-based drug treatments – either an osmotic laxative or an antispasmodic depending on whether the patient was predominantly affected by constipation (IBS-C) or diarrhoea (IBS-D).[2] Over 500 patients were enrolled over a 3-year period at 7 centres in China. They were randomised 2:1 to receive either acupuncture or drug treatment.

The primary outcome was the IBS symptom severity score (IBS-SSS) at 6 weeks, but patients were also followed up at 18 weeks. The acupuncture group was better at both 6 and 18 weeks (p<0.001).

The authors performed a post-hoc calculation of responder rate (RR) based on a 50-point change in the IBS-SSS (0-500), and acupuncture was associated with a roughly 80% RR compared with roughly 50% for the drugs. They go on to argue that a previous study of acupuncture in IBS using a sham acupuncture control measured RR in the sham group at 31.2%,[5] so their 80% could not possibly be only a placebo response. The problem here is that the symptom score was different, and they used a slightly larger change to determine RR (reduction of 4 on a sum of Likert scales totalling 30). The RR in the real acupuncture group of the same trial was just 40.7%. Ten sessions of acupuncture were applied, compared with a non-point needling control, and the trial was conducted in an NHS hospital in Harrow.

In a more recent trial of acupuncture in IBS (n=97), the Streitberger needle was used as a sham, and proved to be as good as the real needling with RR of 53% real and 42% sham. In this trial 8 sessions were given over 4 weeks, and the RR was calculated on the basis of a reduction in symptom scores, but the exact method was different again.

‘other stories’

I will finish with the ‘other stories’ I refer to in the title. These are a couple of case reports submitted as letters to Acupuncture in Medicine.[6,7] Both involve the successful application of dry needling. One paper comes from Tehran and the other from Shanghai. Yes, dry needling in Shanghai!

The paper from Tehran describes the improvement in spasticity in an upper limb and associated changes in activation of motor areas on fMRI. It sounds as though the ‘dry needling’ was performed at LI4.

The paper from Shanghai concerned the successful treatment of previously intractable hiccups. This case is interesting because the symptom did not respond to either drugs or TCM acupuncture but did respond when dry needling was used. In this case the dry needling was performed at symmetrical points on the abdomen and back as well as the anterior scalene muscle bilaterally. The needles used were 0.35x75mm and were manipulated to achieve LTRs (local twitch responses) but were not rotated.

Unfortunately, the terminology of needling techniques does not always result in mechanistic clarity. In the first case report we have something more like acupuncture than needling of a trigger point (the original intention of dry needling), and in the second we have a description and images that suggest perfect symmetry in the location of trigger points, something likely to be closer to tenderness at acupuncture points than to genuine active myofascial trigger points.

References

1 Qin D, Zhao Z, Song J. Atraumatic glenohumeral dislocation associated with silent abscess formation following acupuncture. Acupunct Med Published Online First: 12 June 2020. doi:10.1177/0964528420920301

2 Pei L, Geng H, Guo J, et al. Effect of Acupuncture in Patients With Irritable Bowel Syndrome: A Randomized Controlled Trial. Mayo Clin Proc 2020;:1–13. doi:10.1016/j.mayocp.2020.01.042

3 Hoffman P. Skin Disinfection and Acupuncture. Acupunct Med 2001;19:112–6. doi:10.1136/aim.19.2.112

4 Deadman P, Al-Khafaji M, Baker P. A Manual of Acupuncture. 2nd ed. Journal of Chinese Medicine 2007.

5 Forbes A. Acupuncture for irritable bowel syndrome: A blinded placebo-controlled trial. World J Gastroenterol 2005;11:4040. doi:10.3748/wjg.v11.i26.4040

6 Mohammadpour F, Ali Oghabian M, Nakhostin Ansari N, et al. Effects of dry needling on post-stroke brain activity and muscle spasticity of the upper limb: a case report. Acupunct Med Published Online First: 12 June 2020. doi:10.1177/0964528420920294

7 Sun W, Pan D, Huang Q. Successful treatment of persistent hiccups with myofascial trigger point dry needling: a case report. Acupunct Med Published Online First: 12 June 2020. doi:10.1177/0964528420920296

Declaration of interests MC

Frequency of Rx in OAK

Mon, 08 Jun 2020 11:20:39 +0000

Stimulated by Lin et al 2020.[1]

Image from HVAC photoshoot 2012.[2]

This paper caught my eye for two reasons. First because the title implied the results might be useful for clinical practice, and second because it was an acupuncture trial published in the journal Pain, a journal that does not publish acupuncture trials very often.

It is not a huge trial (n=60), and technically it is not a positive trial, but it did show some differences between groups. Some will be surprised that they managed to show any difference between groups when both received electroacupuncture (EA) to local points for their OAK (OsteoArthritis of the Knee). That is what is quite unique about this paper, because there was a big difference between groups in terms of the frequency and total number of treatments applied.

EA was applied for 30 minutes to LR9–GB33 and two other points based on the location of pain, and the related meridian points. The extra points Xiyan were used, but I was pleased to see that the angulation and depth parameters made it possible that entry to the joint space may have been avoided – 30^o to 45^o or 90^o angulation and 10–30mm depth is quoted, but it is not clear which parameters applied to Xiyan. The rather pricey HANS-200A stimulator was used at the expected 2/100Hz, but the intensity was quoted as 0.1–1.0mA. This seems rather low, but it does depend on the pulse width settings, which are not stated in the paper, and I cannot find online…

Oh, wait, I have just received a message from a colleague in Brazil (Fabio Athayde). He tells me the pulse width for this device is 600µs at 2Hz and 200µs at 100Hz. 600µs is about three times wider than I tend to use, so at 1mA that might just reach a reasonable stimulus strength for OAK.

One group received weekly treatment (OSWA), and the other group were treated 3 times per week (TSWA), so by the end of the 8 weeks of treatment, whilst OSWA had received a quite reasonable 8 sessions, the TSWA group had notched up 24.

The main outcome was responder rate at 8 weeks, and a responder was determined by a reduction in numerical rating score (NRS) of pain by >=2. NRS and WOMAC were measured as secondary outcomes at 4, 8 and 16 weeks.

If you have read this far and haven’t looked at the results yet, what do you think? I have already given you a clue above when I said “technically… not positive”.

Well the responder rates were 64.7% (TSWA) versus 50.0% (OSWA) at 8 weeks (p=0.435). But there were rather larger differences at 4 and 16 weeks, which were both highly significant (p<0.001): 58.0% versus 13.3% (4 weeks) and 60.6% versus 14.7% (16 weeks).

These results are entirely believable…

These results are entirely believable and consistent with my experience of using EA in OAK. You do not generally see the maximum effect until 6 to 8 sessions, and the effect drops off after 4 to 6 weeks of no treatment. So, at 4 weeks of treatment, whilst OSWA is yet to reach peak effects, TSWA have already had 12 sessions. The aspect that I could not predict from my clinical experience was the extended length of action in the TSWA group. There seems to be minimal decline in the effect after 8 weeks of no treatment in the follow-up period, but this is after 24 sessions. In my clinical practice, I would spread out 24 sessions over nearly a year and a half and aim to have my patients pain free for the majority of the time.

I’m not sure why, but I thought I would check up on the main author. It is usually the last author, and or the corresponding author on a paper. The last author on this paper is Liu Cun-Zhi. Liu is also the family name of the current president of WFAS (World Federation of Acupuncture Societies), the same Liu responsible for some of the enormous clinical trials in recent years. The two authors do not appear to have published together as of the date of writing this, but they are both from Beijing, and have both published with colleagues from BUCM (Beijing University of Chinese Medicine).

I put Liu CZ [au] AND acup* into PubMed…

I put Liu CZ [au] AND acup* into PubMed and got 118 citations, 2 SRs and 24 RCTs. I looked down the SRs and RCTs; some were familiar, some even published in Acupuncture in Medicine,[3–5] but others did not spark any memory. It was interesting to browse the different designs and check the results against my expectations. There were a number of protocols,[6–10] and not all of them had subsequent publication of the results. I hunted around and found some results listed but unpublished in a couple of trials,[7,9] and no results in a couple more.[6,8] I am intrigued by those that remain unpublished, with no results listed despite them both being completed over 5 years ago. I am left to guess why, especially in an era when publishing negative trials of acupuncture tends to be easier and get you into higher profile journals.

Both trials with results that remain hidden have similar designs. They both used 4 parallel arms in a 2×2 factorial design as follows:

Local acupuncture points plus distal acupuncture points
Local acupuncture points plus distal non-acupuncture points
Local non-acupuncture points plus distal acupuncture points
Local non-acupuncture points plus distal non-acupuncture points.

Given that this author seems to consistently publish results that are in line with what we might expect from a Western perspective, I will leave the reader to guess the implications of publishing the results of these two trials for someone who lives in Beijing.

References

1 Lin L-L, Tu J-F, Wang L-Q, et al. Acupuncture of different treatment frequency in knee osteoarthritis: a pilot randomised controlled trial. Pain Published Online First: 29 May 2020. doi:10.1097/j.pain.0000000000001940

2 Cummings M. The Development of Group Acupuncture for Chronic Knee Pain Was All about Providing Frequent Electroacupuncture. Acupunct Med 2012;30:363–4. doi:10.1136/acupmed-2012-010260

3 Sun N, Tu JF, Lin LL, et al. Correlation between acupuncture dose and effectiveness in the treatment of knee osteoarthritis: a systematic review. Acupunct Med 2019;37:261–7. doi:10.1136/acupmed-2017-011608

4 Sun N, Wang L-Q, Shao J-K, et al. An expert consensus to standardize acupuncture treatment for knee osteoarthritis. Acupunct Med Published Online First: 20 April 2020. doi:10.1177/0964528419900789

5 Wang T-Q, Li Y-T, Wang L-Q, et al. Electroacupuncture versus manual acupuncture for knee osteoarthritis: a randomized controlled pilot trial. Acupunct Med 2020;:096452841990078. doi:10.1177/0964528419900781

6 Shi G-X, Han L-L, Liu L-Y, et al. Acupuncture at local and distant points for tinnitus: study protocol for a randomized controlled trial. Trials 2012;13:224. doi:10.1186/1745-6215-13-224

7 Xue Z, Liu C-Z, Shi G-X, et al. Efficacy and safety of acupuncture for chronic dizziness: study protocol for a randomized controlled trial. Trials 2013;14:429. doi:10.1186/1745-6215-14-429

8 Fu Q-N, Shi G-X, Li Q-Q, et al. Acupuncture at local and distal points for chronic shoulder pain: study protocol for a randomized controlled trial. Trials 2014;15:130. doi:10.1186/1745-6215-15-130

9 Sun N, Shi G-X, Tu J-F, et al. Traditional Chinese acupuncture versus minimal acupuncture for mild-to-moderate knee osteoarthritis: a protocol for a randomised, controlled pilot trial. BMJ Open 2016;6:e013830. doi:10.1136/bmjopen-2016-013830

10 Lin L-L, Tu J-F, Shao J-K, et al. Acupuncture of different treatment frequency in knee osteoarthritis: a protocol for a pilot randomized clinical trial. Trials 2019;20:423. doi:10.1186/s13063-019-3528-8

Declaration of interests MC

Adrenaline Athletes and Acupuncture

Mon, 01 Jun 2020 13:47:28 +0000

Stimulated by Arriaga-Pizano et al 2020.[1]

Image by Cesar Marquez on Unsplash.

This paper was published online on 20^th May, and it took me a while before I had a closer look and discovered that it is really quite unique. It was a subsequent paper published a week later, a systematic review of acupuncture in low back pain (LBP),[2] that led me to considering devoting a blog to the topic.

…it packs quite a lot into a single paper

Having looked a bit closer at Arriaga-Pizano et al, I am quite excited to tell you why this is such a unique paper. It is relatively small (n=36 plus n=24) and focuses or rather healthy males (athletes), but it includes lots of different aspects: electroacupuncture (EA) vs sham; EA vs diclofenac; treatment of induced LBP; treatment of chronic LBP; release of catecholamines after EA; and assessment of the potential anti-inflammatory effect of those catecholamines released by EA. So, it packs quite a lot into a single paper.

We don’t get so many papers submitted from Mexico, and that made me peruse the author list. There I saw a name that is etched into my memory from 2014. The last author is the same Rafael Torres-Rosas that published on the effect of EA in a mouse model of septic shock with Luis Ulloa in Nature Medicine.[3] I subsequently invited Luis to speak at a BMAS meeting, and then bumped into Rafael presenting in Munich a few years later.

Nature Medicine

Just to remind you, this paper from Nat Med demonstrated that EA seemed to prevent mice dying of septic shock. In that set of experiments, dopamine appeared to be the key catecholamine, but in the current paper it is adrenaline aka epinephrine. Adrenaline is produced from noradrenaline (norepinephrine NE), which in turn is produced from dopamine, dihydroxyphenylalanine (aka levodopa), tyrosine and originally phenylalanine.

Arriaga-Pizano et al recruited 24 athletes with chronic LBP and randomised them to daily sessions of EA for 5 days, or 12 hourly diclofenac 100mg for the same time period. The athletes performed their normal training sessions each day, and their pain was evaluated using a visual analogue score (VAS).

Another group of athletes (n=36), who initially had no LBP, were randomised to three groups. One group (n=12) trained normally and were given 5 days of EA. They had blood samples taken at three time points to measure catecholamines. The remaining athletes (n=24) were subjected to a hard training regime designed to induce acute LBP. As soon as their LBP reached a moderate level the extra training was stopped and they either received EA or sham EA for 5 days. The sham was a superficial off-meridian technique with leads attached but no electrical stimulation applied.

And there’s more!

As well as measuring catecholamines in the blood of healthy, normally training athletes subjected to 5 days of EA, the research team took the same blood and cultured it in a standard medium or in lipopolysaccharide (LPS) for 3 hours before measuring tumour necrosis factor (TNF). They studied the effect of increasing doses of NE, epinephrine and dopamine in inhibiting production of leucocyte-derived TNF.

What did they find?

EA was better than sham in reducing acute LBP, EA was similar to diclofenac in reducing chronic LBP. EA resulted in increased blood levels of epinephrine, no increase in NE, and dopamine was not detected. NE and epinephrine were associated with a reduction in LPS-stimulated TNF in the athletes peripheral blood.

The bottom line is that EA may have both a pain relieving and anti-inflammatory effect in both acute (training-induced) and chronic LBP in athletes.

References

1 Arriaga-Pizano L, Gómez-Jiménez DC, Flores-Mejía LA, et al. Low back pain in athletes can be controlled with acupuncture by a catecholaminergic pathway: clinical trial. Acupunct Med Published Online First: 20 May 2020. doi:10.1177/0964528420912251

2 Li Y-X, Yuan S, Jiang J, et al. Systematic review and meta-analysis of effects of acupuncture on pain and function in non-specific low back pain. Acupunct Med Published Online First: 27 May 2020. doi:10.1136/acupmed-2017-011622

3 Torres-Rosas R, Yehia G, Peña G, et al. Dopamine mediates vagal modulation of the immune system by electroacupuncture. Nat Med 2014;20:291–5. doi:10.1038/nm.3479

Declaration of interests MC

|￣￣￣￣￣￣￣￣ | STOP KILLING BLACK PEOPLE | ＿＿＿＿＿＿＿＿| (\__/) || (•ㅅ•) || / 　づ

Sat, 30 May 2020 15:30:00 +0000

|￣￣￣￣￣￣￣￣ | STOP KILLING BLACK PEOPLE | ＿＿＿＿＿＿＿＿| (\__/) || (•ㅅ•) || / 　づ

You're killed police, you're told it's your fault. You're killed by covid-19, you're told it's your fault. You live in neighborhoods saturated with poverty, you're told it's your fault. Rarely are you told about the policy, about the history, about the li

Fri, 29 May 2020 18:50:26 +0000

You're killed police, you're told it's your fault. You're killed by covid-19, you're told it's your fault. You live in neighborhoods saturated with poverty, you're told it's your fault. Rarely are you told about the policy, about the history, about the literal knee on your neck.

Risk of mortality 2020

Sun, 24 May 2020 11:12:20 +0000

Stimulated by Lin et al 2020,[1] Park et al 2020,[2] and Khan et al 2019.[3]

Shifen Waterfalls, Shifen, Taiwan. Image by Vernon Raineil Cenzon on Unsplash, modified by MC in Lightroom.

What is the risk of mortality associated with acupuncture?

Well, it depends on the context of course, and I am using this title to draw together a few recent papers that I want to highlight. The main paper demonstrating a reduced risk of mortality associated with acupuncture, and the others highlighting adverse effects with the potential of mortality.

The first paper, published online on 20^th May in Acupuncture in Medicine, is another of the large retrospective observational studies from Taiwan. Lin et al found 17 121 subjects who had been hospitalised with hip fracture between 2000 and 2010. This number was reduced by exclusion of open and pathological fractures to 11 551. From this sample they identified 925 who had received at least one acupuncture treatment within a year of the hip fracture. Within this group there were 292 who had received at least 6 acupuncture treatments within 183 days of hip fracture. The details of this group were then used to match with a similar group that did not receive acupuncture. This was done by using the index dates (of surgery for hip fracture), index duration (time to 6^th session of acupuncture) and propensity score matching using age, gender, calendar year of operation, status of physical therapy and index duration. A 1:3 ratio was used so that the no acupuncture matched cohort had 3 times the number (n=876).

Various outcomes were observed and compared between the cohorts, and broadly these fell into the categories of mortality, readmission and reoperation.

a reduction in mortality by more than a half

The acupuncture cohort had a markedly reduced risk in all categories, and perhaps the most striking was a reduction in mortality by more than a half (hazard ratio 0.41). Readmissions and reoperations were reduced by just over a third (hazard ratio 0.64 and 0.62 respectively).

So, this was mostly good news, but not entirely… the hazard ration for mortality was doubled for those patients with chronic obstructive pulmonary disease who received acupuncture. This nicely brings us on to the other papers I want to mention, as they are both concerning adverse events.

The first is a systematic review of cases and case series of adverse events related to electroacupuncture (EA). I take a keen interest in EA, as I use it so much in practice, and I have investigated,[4] and reported on safety aspects in the past.[5,6]

I was intrigued by the 3 reported deaths, and expected these to be cardiac in origin based on comments made by Adrian White in his review in 2004.[7] Adrian refers to 2 cardiac arrests related to EA in the neck, but these were described in a textbook with no particular detail. So, I was pleased to see more detail in this paper. More specifically the supplemental material includes details extracted from all the individual reports, many of which would not have been assessible to me before by virtue of the language.

three deaths in young women with schizophrenia

I was somewhat shocked to find that all three deaths described in this review were of relatively young women with a diagnosis of schizophrenia. One death was from cardiac injury and subsequent lung infection, and the other 2 from spinal cord injury.

Finally, we come on to a non-fatal adverse event report, but one that certainly has the potential to be fatal, particularly considering the geography. This case caught my eye because it was an unfamiliar journal to me, and because it was a haemopneumothorax, which is rather uncommon from acupuncture, this being only the third report in the English literature. Pneumothorax is the most common traumatic adverse event related to acupuncture, and I have highlighted it on the blog before. We now can estimate that the risk is around 1.75 per million treatments in at risk areas (See the previous blog: Post-acupuncture pneumothorax incidence). In this case the risk was attributed to needling at ST12, in the supraclavicular fossa at the midpoint of the clavicle. The report includes two chest x ray film images: the first demonstrating an apical left pneumothorax and a fluid level over the left lower lung field; and the second demonstrating an apical haematoma at the site of the original pneumothorax that developed after discharge. The latter required transfer from the rural area to a larger centre where evacuation was performed via video-assisted thoracic surgery.

References

1 Lin JC-F, Lin T-C, Cheng C, et al. Lower rates of mortality, readmission and reoperation in patients receiving acupuncture after hip fracture: a population-based analysis. Acupunct Med Published Online First: 20 May 2020. doi:10.1177/0964528420911664

2 Park JH, Lee J-H, Lee S, et al. Adverse events related to electroacupuncture: a systematic review of single case studies and case series. Acupunct Med Published Online First: 16 May 2020. doi:10.1177/0964528420920287

3 Khan AF, Soon D, Campbell I. Haemopneumothorax subsequent to acupuncture: a rural centre experience. ANZ J Surg 2019;:ans.15488. doi:10.1111/ans.15488

4 Thompson JW, Cummings M. Investigating the safety of electroacupuncture with a Picoscope. Acupunct Med 2008;26:133–9. doi:10.1136/aim.26.3.133

5 Cummings M. Safety aspects of electroacupuncture. Acupunct Med 2011;29:83–5. doi:10.1136/acupmed-2011-010035

6 Cummings M. Report of adverse event with electroacupuncture. Acupunct Med 2011;29:147–51. doi:10.1136/acupmed-2011-010020

7 White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33. doi:10.1136/aim.22.3.122

Declaration of interests MC

Update FedEx called and told me to take down this video and fired both of us Today .. I’m reposting this video because people like him doesn’t matter white or any race should never disrespect essential workers putting their lives in jeopardy especially wi

Wed, 20 May 2020 12:01:04 +0000

Update FedEx called and told me to take down this video and fired both of us Today .. I’m reposting this video because people like him doesn’t matter white or any race should never disrespect essential workers putting their lives in jeopardy especially with this covid-19 pic.twitter.com/Fw0S5gNRso

Functional dyspepsia 2020

Sun, 17 May 2020 12:30:14 +0000

Image by Paweł Czerwiński on Unsplash.

The main paper this week was an obvious choice as it is a big clinical trial published in a mainstream general medicine journal. Currently the paper has not surfaced on PubMed, although it is published online. I was tipped off by an email from the journal editor as I had been one of the reviewers.

Annals of Internal Medicine

I am pleased to say that we published the pilot study in Acupuncture in Medicine,[2] which lead up to this definitive multicentre clinical trial.[1] Note that we only published it in early February! I remember considering highlighting it at the time, but it didn’t make the cut. Well, it does now!

PDS – postprandial distress syndrome

The papers are on postprandial distress syndrome (PDS) the most common subclassification of functional dyspepsia (FD). The pilot study randomised 42 patients and the larger trial, just published, randomised 278. The populations both met the Rome IV criteria for PDS, and had normal gastroscopy findings within the previous year. Both used a parallel arm, sham controlled design, providing 12 sessions of acupuncture or sham over 4 weeks. The points were local to symptoms: CV17, CV12, CV6, ST25; in the limbs: ST36, SP4, PC6; and on the head: GV20. The larger trial also allowed the addition of an optional point guided by the TCM syndrome pattern: LR3, SP3 or ST44.

The sham was superficial needling at non-classical sites using the same needles but only inserting them 2-3mm, with no manipulation. It is always brave to use needling in the sham group, but the Chinese often manage to create enough of a difference. This could be because the standard manual needling is a lot stronger on average in China. One advantage of using gentle superficial needling in the sham group is the avoidance of having to use devices for non-penetrating needles in the real acupuncture group. These may degrade the real acupuncture effect.[3]

The response rate at the end of the 4 weeks treatment was 83.0% in the acupuncture group and 51.6% in the sham group. This difference was maintained after a further 3 months follow-up.[1]

Blinding was tested after the first and 6^th session, and there was no difference between the groups – 70 to 80% guessed they had real acupuncture in both real and sham groups at both time points.

On reviewing some large drug trials, a responder rate of 50% seems quite large, and whilst the outcomes are similar (a 7-point patient reported scale), they are not directly comparable.[4,5] It seems safer to simply look at the difference over placebo or sham in this situation as Yang et al do in their discussion – something I do not favour as it assumes sham is no different to a drug placebo.

On the subject of drugs in upper GI symptoms, it was a paper from 2007 that first made me take the potential role of acupuncture more seriously.[6] This paper took 30 patients with refractory heartburn, aka gastro-oesophageal reflux disease, GORD or GERD, depending on whether you prefer an ‘o’ at the start of your oesophagus or not. These patients had symptoms despite taking a standard dose of a PPI (proton pump inhibitor). They were randomised to double the dose or add acupuncture to the standard dose. The acupuncture group received 10 sessions over 4 weeks, and the protocol used standard points: CV17, CV12, ST36, SP9, LR3, PC6. The acupuncture group improved significantly, and the double-dose PPI group were really unchanged after 4 weeks.

Those of us who trained in the 80’s or earlier know what a huge impact cimetidine and ranitidine (H₂ receptor antagonists) had on rates of gastric surgery. Over my time as a medical student at Leeds I saw a transition of surgical techniques for ulcer disease ending with the highly selective vagotomy, and then they all disappeared, almost overnight, when cimetidine was introduced. The PPIs were simply the next stage in this drug revolution and were so rapidly effective that we even used them diagnostically in acute settings in the community. But like so many areas of modern healthcare, this short-term efficacy did not translate to a long-term solution for patients with GORD symptoms, and the commercial pressures from industry did nothing to help find a solution – they urged us to try the latest drug or to double the dose. It should have been obvious that this was not going to be a long-term solution, rather like drugs are not the solution to insulin resistance and type 2 diabetes.

The long-term solutions nearly always lie in lifestyle choices, and perhaps acupuncture is one way of transitioning from the passive treatment to the active engagement in personal health.

References

1 Yang J, Wang L, Zou X, et al. Effect of Acupuncture for Postprandial Distress Syndrome. Ann Int Med Published Online First: 2020. doi:10.7326/M19-2880

2 Tu J-F, Yang J-W, Wang L-Q, et al. Acupuncture for postprandial distress syndrome: a randomized controlled pilot trial. Acupunct Med Published Online First: 7 February 2020. doi:10.1177/0964528419900911

3 Kim T-H, Lee MS, Alraek T, et al. Acupuncture in sham device controlled trials may not be as effective as acupuncture in the real world: a preliminary network meta-analysis of studies of acupuncture for hot flashes in menopausal women. Acupunct Med 2019;:acupmed2018011671. doi:10.1136/acupmed-2018-011671

4 Van Zanten SV, Armstrong D, Chiba N, et al. Esomeprazole 40 mg once a day in patients with functional dyspepsia: The randomized, placebo-controlled ‘ENTER’ trial. Am J Gastroenterol 2006;101:2096–106. doi:10.1111/j.1572-0241.2006.00751.x

5 Vakil N, Laine L, Talley NJ, et al. Tegaserod treatment for dysmotility-like functional dyspepsia: Results of two randomized, controlled trials. Am J Gastroenterol 2008;103:1906–19. doi:10.1111/j.1572-0241.2008.01953.x

6 Dickman R, Schiff E, Holland A, et al. Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Aliment Pharmacol Ther 2007;26:1333–44. doi:10.1111/j.1365-2036.2007.03520.x

Declaration of interests MC

Metabolic effects 2020

Sun, 10 May 2020 14:30:46 +0000

Stimulated by Li et al 2020,[1] and Kim et al 2020.[2]

Image by Sharon Pittaway on Unsplash.

I was looking around for a story, and I thought I ought to check through the Online First papers from Acupuncture in Medicine. I’m sure you frequently do the same. Another paper from Lisa’s team (see last week’s blog) caught my eye. She had mentioned it on Women’s Health Day, but there was a lot of other data too, so I am again a bit late to get to this one. It was published just over a month ago, so that is some improvement from last week.

I did see it when it came out, but it is an observational cohort study, and it didn’t tickle me intellectually until I saw this second, more recent paper with which to make a contrast.

Does acupuncture have metabolic effects?

They are both investigating the metabolic effects of acupuncture. One is a cohort of 80 women with polycystic ovarian syndrome and insulin resistance treated 3 times a week for 6 months, and the other is a sham controlled trial on 120 obese patients in whom metabolic parameters were measured before and after a 6-week course of biweekly acupuncture or sham.

I first became aware of the possibility of acupuncture having metabolic effects from Lisa’s research in women with PCOS. Initially this constituted improvements in hyperandrogenism,[3,4] and then the thing that surprised me the most was when effects on insulin resistance were demonstrated.[5–8] At this point it became clear to me that the metabolic influences required much more regular treatment than was practical in clinical practice, at least in the West.

This brings me back to the cohort who were treated 3 times per week for 6 months. Of course, this study was performed in China. I must have missed the protocol when it was published in 2015,[9] and clearly also the pilot study published the following year.[10]

78 treatment sessions in 6 months
that’s a lot of treatment!

In this cohort, after some 78 treatment sessions there was a highly significant drop in insulin resistance (as measured by HOMA-IR), which was maintained at 3 months follow-up. The HOMA-IR, which stands for Homeostatic Model Assessment of Insulin Resistance (insulin x glucose / 405) was still well into the abnormal range, which reflected a high fasting insulin in the presence of normal glucose.

Whilst checking for related papers, I stumbled across the next step. A protocol for an open-label comparison of acupuncture with metformin in obese women with PCOS.[11]

So, what of the other paper I am highlighting from Acupuncture in Medicine?[2]

…needles inserted 50-80mm ‘horizontally’

This trial was based in Korea and randomised 120 obese premenopausal women to either 12 sessions of acupuncture or sham. The acupuncture treatment involved manual acupuncture to 2 points in each limb, and 2 midline points on the abdomen, and electroacupuncture (EA) to long needles inserted 50-80mm ‘horizontally’ at ST25 and ST28. From this I assume these needles were in the subcutaneous fat layer. The sham group received treatment with non-penetrating needles at all the same points apart from the long needles. These were inserted in the same way, but placed 2cm lateral to the ‘real’ points, and the EA was inactive.

By contrast, Lisa’s protocols involve low frequency EA applied to muscle in the abdominal wall and legs.

Weight, BMI and waist circumference diminished significantly in both groups with no difference between the groups. There were differences between the groups in L-carnitine and some short and intermediate acylcarnitines, but these differences are not easy to interpret. Carnitine is a quaternary ammonium compound that transports long-chain fatty acids into mitochondria to be oxidised (‘burnt’), so it is certainly relevant, and I guess that increased values might indicate greater activity in fat metabolism in general. If this is the case, it did not result in a difference in weight loss, but that may be a reflection of the rather short time course of this study.

What can I take away from this dip into the world of metabolic effects of acupuncture?

A lot of treatment is needed, EA should probably be applied to muscles rather than fat, and sham controls should be avoided. Oh and don’t get me started on missing the point in the control group![12]

References

1 Li J, Wu W, Stener-Victorin E, et al. A prospective pilot study of the effect of acupuncture on insulin sensitivity in women with polycystic ovary syndrome and insulin resistance. Acupunct Med Published Online First: 4 April 2020. doi:10.1177/0964528420902144

2 Kim K-W, Shin W-C, Choi MS, et al. Effects of acupuncture on anthropometric and serum metabolic parameters in premenopausal overweight and obese women: a randomized, patient- and assessor-blind, sham-controlled clinical trial. Acupunct Med Published Online First: 17 April 2020. doi:10.1177/0964528420912259

3 Stener-Victorin E, Waldenstrom U, Tagnfors U, et al. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2000;79:180–8. doi:10.1034/j.1600-0412.2000.079003180.x

4 Jedel E, Labrie F, Odén A, et al. Impact of electro-acupuncture and physical exercise on hyperandrogenism and oligo/amenorrhea in women with polycystic ovary syndrome: a randomized controlled trial. Am J Physiol Metab 2011;300:E37–45. doi:10.1152/ajpendo.00495.2010

5 Stener-Victorin E, Baghaei F, Holm G, et al. Effects of acupuncture and exercise on insulin sensitivity, adipose tissue characteristics, and markers of coagulation and fibrinolysis in women with polycystic ovary syndrome: secondary analyses of a randomized controlled trial. Fertil Steril 2012;97:501–8. doi:10.1016/j.fertnstert.2011.11.010

6 Johansson J, Mannerås-Holm L, Shao R, et al. Electrical vs Manual Acupuncture Stimulation in a Rat Model of Polycystic Ovary Syndrome: Different Effects on Muscle and Fat Tissue Insulin Signaling. PLoS One 2013;8:e54357. doi:10.1371/journal.pone.0054357

7 Benrick A, Maliqueo M, Johansson J, et al. Enhanced insulin sensitivity and acute regulation of metabolic genes and signaling pathways after a single electrical or manual acupuncture session in female insulin-resistant rats. Acta Diabetol 2014;51:963–72. doi:10.1007/s00592-014-0645-4

8 Benrick A, Maliqueo M, Johansson J, et al. Erratum to: Enhanced insulin sensitivity and acute regulation of metabolic genes and signaling pathways after a single electrical or manual acupuncture session in female insulin-resistant rats [Acta Diabetologica, DOI 10.1007/s00592-014-0645-4]. Acta Diabetol 2015;52:219–20. doi:10.1007/s00592-014-0678-8

9 Zheng Y, Stener-Victorin E, Ng EHY, et al. How does acupuncture affect insulin sensitivity in women with polycystic ovary syndrome and insulin resistance? Study protocol of a prospective pilot study. BMJ Open 2015;5:e007757–e007757. doi:10.1136/bmjopen-2015-007757

10 Stener-Victorin E, Maliqueo M, Soligo M, et al. Changes in HbA 1c and circulating and adipose tissue androgen levels in overweight-obese women with polycystic ovary syndrome in response to electroacupuncture. Obes Sci Pract 2016;2:426–35. doi:10.1002/osp4.78

11 Stener-Victorin E, Zhang H, Li R, et al. Acupuncture or metformin to improve insulin resistance in women with polycystic ovary syndrome: Study protocol of a combined multinational cross sectional case-control study and a randomised controlled trial. BMJ Open 2019;9:1–10. doi:10.1136/bmjopen-2018-024733

12 Cummings M. Commentary: Controls for acupuncture – can we finally see the light? BMJ 2001;322:1578.

Declaration of interests MC

Transgenerational PCOS

Sun, 03 May 2020 13:03:04 +0000

Stimulated by Risal et al 2019.[1]

Yes, I am late to this party! Well, in my defence, there is no mention of ‘acup’ anywhere in the text of this paper, so it did not pop up in my searches back in December 2019 when it was published. By the way, ‘acup’ is a really useful set of letters if you want to search for any word related to acupuncture or acupressure, and you don’t get any false positives… there do not seem to be any words with this combination of letters that are not associated with the subject.

Last Wednesday was the BMAS Women’s Health Day. We have held this day every year since 2007, and it is led by Elisabet (Lisa) Stener-Victorin… a unique surname to search for in the literature as well by the way. Lisa has been a full professor at the Karolinska Institute in Stockholm for the last few years, having moved her lab from the University in Göteborg (Gothenburg in English). She is certainly one of the most prolific researchers within the acupuncture field in the West, and in terms of quality, she has only few peers globally. Unfortunately for us in the world of acupuncture, Lisa has developed a primary interest in polycystic ovarian syndrome, and hence she publishes some papers that do not appear on my searches, such as this one.

This paper just popped up on one of her slides in the section on PCOS, and I sat up and took notice. This was new research that I was not expecting to see – I attend these days every year, and I usually know all her new papers. She said she was pleased to get this one published, and briefly summarised the findings. It was not until later that I searched out the paper in Nature Medicine and saw that her research was highlighted on the front cover of the issue.

…the front cover of Nature Medicine

The paper includes research on women from Sweden (register-based cohort) and Chile (clinical case-controlled) with laboratory research on a PCOS model in mice. For the first time Lisa’s extended team have demonstrated that the effects of prenatal androgen exposure can result in PCOS-like features for three subsequent generations. They also found 4 genes with altered expression in the model that were abnormally expressed in the daughters of women with PCOS as well as in unrelated women with PCOS.

In case any of you are going to try to read this paper and want to skip to the colourful graphical display of results, F₁ refers to the first-generation female offspring of the mother that was exposed to androgens before pregnancy. F₂and F₃are the subsequent two generations. You can imagine that studying four generations is only really practical in a species that reproduces in a short timeframe, so Lisa had to move from rats to mice to achieve this.

Why study 4 generations?

Well, in the pregnant F₀sits both F₁in person as well as the germ cells forF₂, so only going to F₃ allows the study of a future generation that has not been directly exposed to the raised androgens.

This is an impressive piece of research, and Lisa is a good friend of the BMAS, but why am I highlighting this in a blog devoted to acupuncture research?

I’m coming directly to that now…

In the last 20 years Lisa and her colleagues have published at least 35 papers on acupuncture and PCOS. I will just mention a few of them here.

First came the effects of electroacupuncture (EA) on ovulation in PCOS.[2–5] Next we saw Lisa’s research veer towards the hormonal and metabolic profile, and how this might be mitigated with EA.[3,6–12] On the way, she even managed to demonstrate reduction in high muscle sympathetic nerve activity through both EA and exercise, and this was done via direct nerve recordings in women with PCOS.[13]

The bottom line here is that EA seems to ameliorate a number of the abnormal physiological, hormonal and metabolic parameters in PCOS, and or laboratory models, including alterations in genetic expression.[6,7,11,14–17]

It seems only a matter of time before we see the team investigate whether or not the effects of acupuncture in the prenatal period might mitigate these long-term transgenerational changes. If this proves to be the case there could be a lot of work for the acupuncturists of the future, unless the devices industry gets in first with an anti-PCOS bioelectric implant!

a word of caution…

But a word of caution before you all leap to treat pregnant women with PCOS! The team have already tried applying EA in pregnant rats exposed to excess testosterone, and the outcomes were worse rather than better. There were no adverse effects on the rats exposed to EA without testosterone, but the combination resulted in higher blood pressure and reduced placental function leading to decreased fetal growth.

So that was a small hiccup, but it is always good to have some negative or unexpected results. Afterall outside observers get a little suspicious if all your research is positive.

Let me finish on a positive note. I want to express my sincere thanks and appreciation for the pioneering work of Lisa and her extended team and colleagues and congratulate them for this ground-breaking research. They thoroughly deserve their front cover in Nature Medicine.

References

1 Risal S, Pei Y, Lu H, et al. Prenatal androgen exposure and transgenerational susceptibility to polycystic ovary syndrome. Nat Med 2019;25:1894–904. doi:10.1038/s41591-019-0666-1

2 Stener-Victorin E, Waldenstrom U, Tagnfors U, et al. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2000;79:180–8. doi:10.1034/j.1600-0412.2000.079003180.x

3 Jedel E, Labrie F, Odén A, et al. Impact of electro-acupuncture and physical exercise on hyperandrogenism and oligo/amenorrhea in women with polycystic ovary syndrome: a randomized controlled trial. Am J Physiol Metab 2011;300:E37–45. doi:10.1152/ajpendo.00495.2010

4 Johansson J, Redman L, Veldhuis PP, et al. Acupuncture for ovulation induction in polycystic ovary syndrome: a randomized controlled trial. Am J Physiol Metab 2013;304:E934–43. doi:10.1152/ajpendo.00039.2013

5 Wu X-K, Stener-Victorin E, Kuang H-Y, et al. Effect of Acupuncture and Clomiphene in Chinese Women With Polycystic Ovary Syndrome: A Randomized Clinical Trial. JAMA 2017;317:2502–14. doi:10.1001/jama.2017.7217

6 Mannerås L, Jonsdottir IH, Holmäng A, et al. Low-frequency electro-acupuncture and physical exercise improve metabolic disturbances and modulate gene expression in adipose tissue in rats with dihydrotestosterone-induced polycystic ovary syndrome. Endocrinology 2008;149:3559–68. doi:10.1210/en.2008-0053

7 Mannerås L, Cajander S, Lönn M, et al. Acupuncture and exercise restore adipose tissue expression of sympathetic markers and improve ovarian morphology in rats with dihydrotestosterone-induced PCOS. Am J Physiol Integr Comp Physiol 2009;296:R1124–31. doi:10.1152/ajpregu.90947.2008

8 Feng Y, Johansson J, Shao R, et al. Hypothalamic Neuroendocrine Functions in Rats with Dihydrotestosterone-Induced Polycystic Ovary Syndrome: Effects of Low-Frequency Electro-Acupuncture. PLoS One 2009;4:e6638. doi:10.1371/journal.pone.0006638

9 Johansson J, Feng Y, Shao R, et al. Intense electroacupuncture normalizes insulin sensitivity, increases muscle GLUT4 content, and improves lipid profile in a rat model of polycystic ovary syndrome. Am J Physiol Metab 2010;299:E551–9. doi:10.1152/ajpendo.00323.2010

10 Stener-Victorin E, Baghaei F, Holm G, et al. Effects of acupuncture and exercise on insulin sensitivity, adipose tissue characteristics, and markers of coagulation and fibrinolysis in women with polycystic ovary syndrome: secondary analyses of a randomized controlled trial. Fertil Steril 2012;97:501–8. doi:10.1016/j.fertnstert.2011.11.010

11 Maliqueo M, Benrick A, Alvi A, et al. Circulating gonadotropins and ovarian adiponectin system are modulated by acupuncture independently of sex steroid or β-adrenergic action in a female hyperandrogenic rat model of polycystic ovary syndrome. Mol Cell Endocrinol 2015;412:159–69. doi:10.1016/j.mce.2015.04.026

12 Stener-Victorin E, Maliqueo M, Soligo M, et al. Changes in HbA1c and circulating and adipose tissue androgen levels in overweight-obese women with polycystic ovary syndrome in response to electroacupuncture. Obes Sci Pract 2016;2:426–35. doi:10.1002/osp4.78

13 Stener-Victorin E, Jedel E, Janson PO, et al. Low-frequency electroacupuncture and physical exercise decrease high muscle sympathetic nerve activity in polycystic ovary syndrome. Am J Physiol Integr Comp Physiol 2009;297:R387–95. doi:10.1152/ajpregu.00197.2009

14 Manni L, Lundeberg T, Holmäng A, et al. Effect of electro-acupuncture on ovarian expression of alpha (1)- and beta (2)-adrenoceptors, and p75 neurotrophin receptors in rats with steroid-induced polycystic ovaries. Reprod Biol Endocrinol 2005;3:21. doi:10.1186/1477-7827-3-21

15 Johansson J, Mannerås-Holm L, Shao R, et al. Electrical vs Manual Acupuncture Stimulation in a Rat Model of Polycystic Ovary Syndrome: Different Effects on Muscle and Fat Tissue Insulin Signaling. PLoS One 2013;8:e54357. doi:10.1371/journal.pone.0054357

16 Kokosar M, Benrick A, Perfilyev A, et al. A Single Bout of Electroacupuncture Remodels Epigenetic and Transcriptional Changes in Adipose Tissue in Polycystic Ovary Syndrome. Sci Rep 2018;8:1878. doi:10.1038/s41598-017-17919-5

17 Benrick A, Pillon NJ, Nilsson E, et al. Electroacupuncture Mimics Exercise-Induced Changes in Skeletal Muscle Gene Expression in Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2020;105:1–15. doi:10.1210/clinem/dgaa165

Declaration of interests MC

Sign the petition! #Cancelstudentdebt to stimulate the economy in response to the #Coronavirus crisis. https://sign.moveon.org/petitions/congress-cancel-student-debt-to-stimulate-the-economy …

Wed, 29 Apr 2020 23:42:50 +0000

Sign the petition! #Cancelstudentdebt to stimulate the economy in response to the #Coronavirus crisis. https://sign.moveon.org/petitions/congress-cancel-student-debt-to-stimulate-the-economy …

Round acupuncture 2020

Mon, 27 Apr 2020 20:56:34 +0000

Stimulated by Kim et al,[1] and Lu et al.[2]

No sooner than I have blogged about acupotomy for the first time (last week), than another novel related technique is reported. The first paper I am highlighting is a case report of the use of round acupuncture in carpal tunnel syndrome (CTS). The second paper is another trial of acupuncture in CIPN (chemotherapy–induced peripheral neuropathy). There is a link between the two I will relate concerning a case I have seen in clinic.

Round acupuncture

Round acupuncture utilises a needle that has similar dimensions to the acupotomy needle I described in the last blog. The difference is that the end is smooth and round, unlike the chisel shape of the acupotomy needle. In this case report, the needle dimensions were 0.80x80mm, so that is the same gauge as a green hypodermic needle.

The patient had surgical release for bilateral CTS 9 years prior. Symptoms recurred after excessive use of her right wrist, and these did not respond to steroid injection or two sessions of acupotomy. The subsequent use of ‘round acupuncture’ was successful.

The point of insertion of the needle was 5mm ‘outside’ of PC7. From the look of Figure 2 in the paper they mean the ulnar side of palmaris longus tendon. This is the usual site used for steroid injections to avoid direct needling of the median nerve and is also a site I used to treat my patient with EA (electroacupuncture).

An acupotomy needle was used to pierce the skin without anaesthetic, then the round needle was inserted in and out at different angles with the intention of loosening up the tissues beneath the transverse carpal ligament (TCL). The needle was inserted as far as the distal fibres of the TCL, at both its ulnar attachments to the hamate and pisiform and its radial attachments to the trapezium and scaphoid.

Kaplan’s cardinal line

The authors included Kaplan’s cardinal line (KCL) in their Figure 2. A line that is used as a landmark by roughly 50% of US hand surgeons surveyed in 2006.[3] That’s something else I have learnt as a result of reading this paper.

So, how does this link to a paper on CIPN?

Well my patient presented with severe burning pain in both hands that extended 5cm or more proximal to the wrist and came on some months following chemotherapy for breast cancer. It was thought to be CIPN, but curiously the feet were not affected. I did not even consider CTS until the nerve conduction studies showed severe compression and strongly recommended surgery. By that time, and to my surprise, her symptoms had almost completely subsided with weekly EA treatment. As she had had axillary node surgery on one side, and this was the least badly affected side, I performed EA across a pair of points PC6 and a point on the ulnar aspect of the palmaris longus tendon at the level of PC7 (exactly the same site as used for the round acupuncture). I also used pairs of needles at my favourite sites bilaterally: ST36–Zongping.

CTS has been mentioned here before (Rewiring the brain with acupuncture), and perhaps I would have seen the same effect from my distant EA, without any need for the fiddly local needling?

So, let’s move on the paper from the Dana-Faber Cancer Centre. I read up about this centre about a year ago just before I introduced the first author (Weidong Lu) at the 21^st ARRC Symposium. If you interested, the presentation can be viewed here, along with my painfully long introduction. I particularly recommend listening to the section from 19:15 to 20:00, when Weidong tells the audience that if they want to perform ‘Oncology Acupuncture’ (ie treat patients who are under the care of an oncologist), they need to learn the language of oncology… the language of Chinese medicine is not enough. My colleague Jacky Filshie would be very pleased to have heard that! She invented the use of acupuncture in palliative care decades before the term oncology acupuncture was coined.[4] They are not entirely the same, but the overlap is large.

This is a small study (n=40), but they use one of my favourite designs for acupuncture studies. It is like the ARC trials from the Modellvorhaben.[5] One group gets treated while the other group waits for their treatment, and the primary comparison is just before the second group get their delayed treatment. In this case the patients got 18 sessions of acupuncture over 8 weeks and the main outcome was at 8 weeks. The second group had no acupuncture over those 8 weeks but then received 9 sessions of acupuncture over the following 8 weeks.

The treatment involved EA to a pair of points in both arms and legs, as well as manual acupuncture at other points. It looks as though about 27 points were used in each treatment, but 10 of those were in the tips of all the toes.

The disparity in the number of sessions is intriguing, and I guess that this might have been an attempt to assess dose. The most interesting graph to look at is Figure 3.

This was a pilot study, and they gathered a lot of outcomes data. I expect we will see a much larger study underway in the near future, if it hasn’t already begun!

References

1 Kim J-R, Lee YK, Lee H-J, et al. Round Acupuncture for the Treatment of Recurrent Carpal Tunnel Syndrome. J Pharmacopuncture 2020;23:37–41. doi:10.3831/KPI.2020.23.006

2 Lu W, Giobbie‐Hurder A, Freedman RA, et al. Acupuncture for Chemotherapy‐Induced Peripheral Neuropathy in Breast Cancer Survivors: A Randomized Controlled Pilot Trial. Oncologist 2020;25:310–8. doi:10.1634/theoncologist.2019-0489

3 Vella JC, Hartigan BJ, Stern PJ. Kaplan’s Cardinal Line. J Hand Surg Am 2006;31:912–8. doi:10.1016/j.jhsa.2006.03.009

4 Filshie J, Penn K, Ashley S, et al. Acupuncture for the relief of cancer-related breathlessness. Palliat Med 1996;10:145–50. doi:10.1177/026921639601000209

5 Cummings M. Modellvorhaben Akupunktur–a summary of the ART, ARC and GERAC trials. Acupunct Med 2009;27:26–30. doi:10.1136/aim.2008.000281

Declaration of interests MC

Few people talk about this, but there is a great deal of racism in medicine, which affects patient care. If you listen to the conversations in the doctor’s lounge when patients are not there, you would be surprised about the racist comments many physician

Sun, 19 Apr 2020 23:55:08 +0000

Few people talk about this, but there is a great deal of racism in medicine, which affects patient care. If you listen to the conversations in the doctor’s lounge when patients are not there, you would be surprised about the racist comments many physicians make behind the scenes.

Hazard pay. Student loan forgiveness. Universal Healthcare. And a heftier tax on the 1%. Raised minimum wage (and more than $15/hr) https://twitter.com/DaraGeez/status/1250157413182902277 …

Wed, 15 Apr 2020 17:10:52 +0000

Hazard pay. Student loan forgiveness. Universal Healthcare. And a heftier tax on the 1%. Raised minimum wage (and more than $15/hr) https://twitter.com/DaraGeez/status/1250157413182902277 …

.@Senatemajldr, I urge you to #cancelstudentdebt in the next #coronavirus package. A #StudentDebtStimulus will help the 45 million people with student debt and stimulate the economy when it is needed most.

Tue, 14 Apr 2020 01:51:31 +0000

. @Senatemajldr, I urge you to #cancelstudentdebt in the next #coronavirus package. A #StudentDebtStimulus will help the 45 million people with student debt and stimulate the economy when it is needed most.

.@SpeakerPelosi, I urge you to #cancelstudentdebt in the next #coronavirus package. A #StudentDebtStimulus will help the 45 million people with student debt and stimulate the economy when it is needed most.

Tue, 14 Apr 2020 01:51:19 +0000

. @SpeakerPelosi, I urge you to #cancelstudentdebt in the next #coronavirus package. A #StudentDebtStimulus will help the 45 million people with student debt and stimulate the economy when it is needed most.

#naturalmedicine #mullein #tinctures #gordolobo #herbs #extracts #herbalmedicine #vodka #acupuncture #magicherbs #homemademedicine #remedioscaseros Making mullein tinctures pic.twitter.com/X3YJnggFh0

Sun, 12 Apr 2020 18:05:48 +0000

#naturalmedicine #mullein #tinctures #gordolobo #herbs #extracts #herbalmedicine #vodka #acupuncture #magicherbs #homemademedicine #remedioscaseros Making mullein tinctures pic.twitter.com/X3YJnggFh0

Healthcare is a human right. Healthcare is a human right. Healthcare is a human right.

Fri, 10 Apr 2020 15:12:38 +0000

Healthcare is a human right. Healthcare is a human right. Healthcare is a human right.

As much as it is available to you at this time, please keep in mind that nutrition plays a large part in general health. #QuarantineLife #Nutrition #Diet #holistichealth #selfcare #selfawareness #COVID19 #WeAreAllInThisTogether #ThursdayThoughts #Welln

Thu, 09 Apr 2020 18:05:16 +0000

As much as it is available to you at this time, please keep in mind that nutrition plays a large part in general health. #QuarantineLife #Nutrition #Diet #holistichealth #selfcare #selfawareness #COVID19 #WeAreAllInThisTogether #ThursdayThoughts #Wellness pic.twitter.com/3fL5iBmBrh

The assumption that everyone has a computer, printer, toner, & wifi ALL at the same time in their homes is classist AF

Tue, 07 Apr 2020 19:51:40 +0000

The assumption that everyone has a computer, printer, toner, & wifi ALL at the same time in their homes is classist AF

Undocumented farm workers are now carrying papers deeming them “essential workers” who are critical to our food supply. They are risking their lives to continue to help guarantee produce in our stores. We should grant all of them amnesty when this is done

Sat, 04 Apr 2020 17:49:33 +0000

Undocumented farm workers are now carrying papers deeming them “essential workers” who are critical to our food supply. They are risking their lives to continue to help guarantee produce in our stores. We should grant all of them amnesty when this is done.

IMPORTANT TWEET: If you made a student loan payment in March then you can get a refund from Navient if you call them and ask them for one. Please share this post.

Fri, 03 Apr 2020 22:29:45 +0000

IMPORTANT TWEET: If you made a student loan payment in March then you can get a refund from Navient if you call them and ask them for one. Please share this post.

Cancel all student debt..like now.

Fri, 03 Apr 2020 03:28:50 +0000

Cancel all student debt..like now.

“Persons with disabilities, with limited English skills, and older persons should not be put at the end of the line for health care during emergencies,” a federal civil rights official said, warning against discrimination in coronavirus treatment. https:/

Mon, 30 Mar 2020 06:37:47 +0000

“Persons with disabilities, with limited English skills, and older persons should not be put at the end of the line for health care during emergencies,” a federal civil rights official said, warning against discrimination in coronavirus treatment. https://nyti.ms/3aworhu

#Acupuntura #acupuncture #longdistancemedicine #holistichealth #Telemedicine via @lectrrpic.twitter.com/Ymd28RsAvj

Fri, 27 Mar 2020 23:19:16 +0000

#Acupuntura #acupuncture #longdistancemedicine #holistichealth #Telemedicine via @lectrr pic.twitter.com/Ymd28RsAvj

More than 45 million Americans struggle with $1.6 trillion in student debt. We must cancel all student loan payments for the duration of this emergency. Long-term, we must cancel all student debt and make public colleges, universities, and trade schools

Thu, 19 Mar 2020 20:45:13 +0000

More than 45 million Americans struggle with $1.6 trillion in student debt. We must cancel all student loan payments for the duration of this emergency. Long-term, we must cancel all student debt and make public colleges, universities, and trade schools tuition- and debt-free.

Via @ Tracey Byer #ImmuneSystem #vitalitytea #StayHealthy cannabis leaf can be replaced w sagepic.twitter.com/yLoxw3gI8Z

Tue, 17 Mar 2020 19:30:49 +0000

Via @ Tracey Byer #ImmuneSystem #vitalitytea #StayHealthy *cannabis leaf can be replaced w sage* pic.twitter.com/yLoxw3gI8Z

We are calling on Congress to immediately cancel student debt for everyday Americans during this uncertain and frightening time! Take action now: https://actionnetwork.org/letters/cancel-student-debt-stimulate-economy …

Tue, 17 Mar 2020 15:04:29 +0000

We are calling on Congress to immediately cancel student debt for everyday Americans during this uncertain and frightening time! Take action now: https://actionnetwork.org/letters/cancel-student-debt-stimulate-economy …

#massage #health #pr

Wed, 14 Feb 2018 11:48:44 +0000

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Spa Themed Gift Bask

Wed, 14 Feb 2018 11:41:46 +0000

Spa Themed Gift Basket idea Wine glasses, bottle of wine,lotion, candle, bath salts, manicure set,massager, beauty mask and chocolates #basketofcandles #massageideas

This seductive massa

Wed, 14 Feb 2018 11:41:00 +0000

This seductive massage blend will sparkle up any romantic night #romanticmassage

So a friend of mine

Wed, 14 Feb 2018 11:34:55 +0000

So a friend of mine at massage therapy school didn't have any idea about my past on television or career at all. Which is fine I like it that way. He's only 18 and was wondering what I "used to look like" when I was closer to his age. I showed him the picture on the left which was only six years ago. He said "what happened?" LOL well truthfully in the last six years I've been to hell and back. But honestly I'm not sure I look that different. Maybe I'm just delusional. Maybe I just don't really

My Dad wanted you gu

Wed, 14 Feb 2018 11:26:04 +0000

My Dad wanted you guys to know that he's doing massages today #funny #meme #LOL #humor #funnypics #dank #hilarious #like #tumblr #memesdaily #happy #funnymemes #smile #bushdid911 #haha #memes #lmao #photooftheday #fun #cringe #meme #laugh #cute #dankmemes #follow #lol #lmfao #love #autism #filthyfrank #trump #anime #comedy #edgy #massagefunny #massagememes

Natural Bamboo Paddl

Wed, 14 Feb 2018 11:21:01 +0000

Natural Bamboo Paddle Cushion Massage Hair Brush Ball-Tipped Wooden Bristles #massagetips

Create a divine dinn

Wed, 14 Feb 2018 11:20:26 +0000

Create a divine dinner for your sweetheart on your Anniversary... and we've got the recipes that are to-die-for! #romanticmassageideas

Essential oils for s

Wed, 14 Feb 2018 11:19:59 +0000

Essential oils for sex and intimacy - Essential oils have been used in the bedroom for thousands of years. Here's why - plus some tips for using them in yours. Marriage tips | Marriage advice | Essential oil blends #romanticmassageideas

Brilliant self massa

Wed, 14 Feb 2018 11:11:00 +0000

Brilliant self massage tip you can easily do at your desk. Good for tension, stiff neck and headache. #massageforheadaches #massagetips

As its nearly Valent

Wed, 14 Feb 2018 11:04:04 +0000

As its nearly Valentines why not spread the love - Here is another meme to share to promote your clinic. #BusyHive #Massage #MassageTherapist #MassageLife #TheseHandsCreate #Valentines #MassageMeme #SpreadTheLove #TwoInOneDay #massagememes

Essential Oils For M

Wed, 14 Feb 2018 11:01:43 +0000

Essential Oils For Marma Chikitsa (Marma Point Massage) Infographics - The Ayurveda Experience Blog #massageinfographic

El Paso, TX. Chiropr

Wed, 14 Feb 2018 11:00:02 +0000

El Paso, TX. Chiropractic and Massage: While each offer considerable benefits on their own, they often mesh well with each other to create a comprehensive treatment plan for many conditions or injuries. See how massage therapy and chiropractic care are a pain-fighting, mobility-enhancing dynamic duo. For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900 #massagebenefits

Romantic couples mas

Wed, 14 Feb 2018 10:57:09 +0000

Romantic couples massage for Valentine' Day Specials@Fifth ave Thai Spa 212 644 8239: Make this Valentine's Day a great memorable! Take ... #romanticmassage

Destress with these

Wed, 14 Feb 2018 10:56:53 +0000

Destress with these simple massages you can do at your desk #infographic #Stress #Health #Massages #Office #Workplace #massageinfographic

Air Cushion Hair Sal

Wed, 14 Feb 2018 10:56:46 +0000

Air Cushion Hair Salon Brush For Long Hair TG Hair Paddle Brush Soft Teeth Ideal For Hair Smooth Head Massage Brush In Ball Tip #massagetips

Do-It-Yourself Chine

Wed, 14 Feb 2018 10:48:50 +0000

Do-It-Yourself Chinese Medicine for Lower Back Pain Traditional Chinese Medicine (TCM), with its 2500 year old history, offers many lower back pain remedies – lower back stretches and strengthening exercises, massage techniques, acupuncture, herbal remedies, liniments, sticking plasters and others. #TraditionalChineseMedicine #acupuncturebackpain #AcupunctureforBackpain #backmassagetechniques #massageforbackpain

Chubster rubster mas

Wed, 14 Feb 2018 10:47:13 +0000

Chubster rubster massage time (v.redd.it) submitted by kulayeb to /r/catbellies 2 comments original - #Funny #Cats - Cute Kittens - LOL #Purrito Memes - #Pets in Clothes - Kitty Breeds - Sweet Animal Pictures #massagememes #massagefunny

Massaging Office Cha

Wed, 14 Feb 2018 10:44:44 +0000

Massaging Office Chairs - Home Office Furniture Ideas Check more at http://invisifile.com/massaging-office-chairs/ #massageideas

Marketing Massage is

Wed, 14 Feb 2018 10:38:28 +0000

Marketing Massage is a combination of knowing what it is that you do and what solution you provide for clients and letting them know about it. I am creating the biggest list of massage marketing tips for massage therapists to implement in starting and building their massage business. The thing about this list is that […] #massagetips

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Wed, 14 Feb 2018 10:36:51 +0000

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Acupuncture

Acupuncture and MACE

Stimulated by Jung et al 2020.[1]

References

The amygdala and Rx of cLBP

Stimulated by Yu et al 2020,[1] and Zhang et al 2020.[2]

References

Atraumatic glenohumeral dislocation, IBS and other stories

Stimulated by Qin et al 2020,[1] and Pei et al 2020.[2]

References

Frequency of Rx in OAK

Stimulated by Lin et al 2020.[1]

References

Adrenaline Athletes and Acupuncture

Stimulated by Arriaga-Pizano et al 2020.[1]

References

|￣￣￣￣￣￣￣￣ | STOP KILLING BLACK PEOPLE | ＿＿＿＿＿＿＿＿| (\__/) || (•ㅅ•) || / づ

You're killed police, you're told it's your fault. You're killed by covid-19, you're told it's your fault. You live in neighborhoods saturated with poverty, you're told it's your fault. Rarely are you told about the policy, about the history, about the li

Risk of mortality 2020

Stimulated by Lin et al 2020,[1] Park et al 2020,[2] and Khan et al 2019.[3]

References

Update FedEx called and told me to take down this video and fired both of us Today .. I’m reposting this video because people like him doesn’t matter white or any race should never disrespect essential workers putting their lives in jeopardy especially wi

Functional dyspepsia 2020

References

Metabolic effects 2020

Stimulated by Li et al 2020,[1] and Kim et al 2020.[2]

References

Transgenerational PCOS

Stimulated by Risal et al 2019.[1]

References

Sign the petition! #Cancelstudentdebt to stimulate the economy in response to the #Coronavirus crisis. https://sign.moveon.org/petitions/congress-cancel-student-debt-to-stimulate-the-economy …

Round acupuncture 2020

Stimulated by Kim et al,[1] and Lu et al.[2]

References

Few people talk about this, but there is a great deal of racism in medicine, which affects patient care. If you listen to the conversations in the doctor’s lounge when patients are not there, you would be surprised about the racist comments many physician

Hazard pay. Student loan forgiveness. Universal Healthcare. And a heftier tax on the 1%. Raised minimum wage (and more than $15/hr) https://twitter.com/DaraGeez/status/1250157413182902277 …

.@Senatemajldr, I urge you to #cancelstudentdebt in the next #coronavirus package. A #StudentDebtStimulus will help the 45 million people with student debt and stimulate the economy when it is needed most.

.@SpeakerPelosi, I urge you to #cancelstudentdebt in the next #coronavirus package. A #StudentDebtStimulus will help the 45 million people with student debt and stimulate the economy when it is needed most.

#naturalmedicine #mullein #tinctures #gordolobo #herbs #extracts #herbalmedicine #vodka #acupuncture #magicherbs #homemademedicine #remedioscaseros Making mullein tinctures pic.twitter.com/X3YJnggFh0

Healthcare is a human right. Healthcare is a human right. Healthcare is a human right.

As much as it is available to you at this time, please keep in mind that nutrition plays a large part in general health. #QuarantineLife #Nutrition #Diet #holistichealth #selfcare #selfawareness #COVID19 #WeAreAllInThisTogether #ThursdayThoughts #Welln

The assumption that everyone has a computer, printer, toner, & wifi ALL at the same time in their homes is classist AF

Undocumented farm workers are now carrying papers deeming them “essential workers” who are critical to our food supply. They are risking their lives to continue to help guarantee produce in our stores. We should grant all of them amnesty when this is done

IMPORTANT TWEET: If you made a student loan payment in March then you can get a refund from Navient if you call them and ask them for one. Please share this post.

Cancel all student debt..like now.

“Persons with disabilities, with limited English skills, and older persons should not be put at the end of the line for health care during emergencies,” a federal civil rights official said, warning against discrimination in coronavirus treatment. https:/

#Acupuntura #acupuncture #longdistancemedicine #holistichealth #Telemedicine via @lectrrpic.twitter.com/Ymd28RsAvj

More than 45 million Americans struggle with $1.6 trillion in student debt. We must cancel all student loan payments for the duration of this emergency. Long-term, we must cancel all student debt and make public colleges, universities, and trade schools

Via @ Tracey Byer #ImmuneSystem #vitalitytea #StayHealthy *cannabis leaf can be replaced w sage*pic.twitter.com/yLoxw3gI8Z

We are calling on Congress to immediately cancel student debt for everyday Americans during this uncertain and frightening time! Take action now: https://actionnetwork.org/letters/cancel-student-debt-stimulate-economy …

#massage #health #pr

Spa Themed Gift Bask

This seductive massa

So a friend of mine

My Dad wanted you gu

Natural Bamboo Paddl

Create a divine dinn

Essential oils for s

Brilliant self massa

As its nearly Valent

Essential Oils For M

El Paso, TX. Chiropr

Romantic couples mas

Destress with these

Air Cushion Hair Sal

Do-It-Yourself Chine

Chubster rubster mas

Massaging Office Cha

Marketing Massage is

stress relief reed d

|￣￣￣￣￣￣￣￣ | STOP KILLING BLACK PEOPLE | ＿＿＿＿＿＿＿＿| (\__/) || (•ㅅ•) || / 　づ

Via @ Tracey Byer #ImmuneSystem #vitalitytea #StayHealthy cannabis leaf can be replaced w sagepic.twitter.com/yLoxw3gI8Z