An alternative to sham?
For reasons I discussed in another post, research on whether acupuncture “works” is bedevilled by the difficullty of finding a control procedure that doesn’t actually do anything. A different approach to the testing of treatments is to use patients as their own controls. This is not often done but it remains a possibility. The idea is to study individuals with long-term symptoms and compare what happens when they are receiving treatment to when they are not. In a paper titled “Patients as their own controls in studies of therapeutic efficacy: Can we trust the results of non-randomized trials?”, Noel S. Weiss and Susan R. Heckbert (Journal of General Internal Medicine July 1988, Volume 3, Issue 4, pp 381–383) endorsed it.
This approach has the potential to provide a valid measure of efficacy if the condition being treated is chronic, if the effect of the therapy given prior to the first evaluation of patient status does not linger into the second period of the study, and if the means by which the evaluation of patient status is performed at the two points in time are comparable.
Case report
I want to describe a case of this kind. The patient is myself so I can’t claim any kind of objectivity, but I think the long period of observation makes it interesting. Anyway, for what it’s worth, here it is.
The symptoms
I don’t know the cause of this condition. Recurrent episodes of pain in my legs. They occur for no obvious reason at intervals of about four to six months. They can be on either side although I’ve never had them on both sides at once.
The pain begins mildly and intermittently in the front of the thigh. After a couple of days it becomes more severe and tends to move to the outer (lateral) side of the thigh and radiates down to the side of the knee. The distribution of the pain is suggestive of meralgia paraesthetica (a nerve entrapment disorder) but there is no change in sensation, which wojuld be expected. The pain isn’t continuous but comes and goes throughout the day in cycles lasting about 90 minutes. There is no back pain. No movements or muscle stretching make it either better or worse, although it is if anything better while I’m walking. It is bad enough to interfere with sleep. In intensity it reaches about 7 on a 10-point scale. It is relieved by paracetamol.
Response to acupuncture
Initially I sought for muscle trigger points in all the muscles in the region and found none, but anyway I needled the muscles (including tensor fasciae latae, which was suggested by two experienced colleagues). I needled locally in the painful areas. I tried general (central) needling at LR3 (interspace between first and second metatarsals). None of these made any difference.
In the end I pretty much gave up trying to treat the pain with acupuncture and simply waited for it to go away by itself, which it always did, though I was afraid that one day it wouldn’t. Then, during quite a bad episode, it occurred to me that the one acupuncture approach I hadn’t tried was periosteal (bone) needling. This is a technique I find to be effective for joint pain and also pain radiating from the neck or pelvis, but for some reason I hadn’t thought of it in my own case.
So I tried needling the hip bone (ilium). In anatomical terms this was about a thumb’s breadth below the iliac crest and three fingerbreadths behind the anterior superior iliac spine. (There is no need to be particularly fussy about exactly where periosteal acupuncture is done provided it’s anatomically safe.) To my considerable surprise the pain receded and disappeared over about ten minutes, exactly as it I’d taken paracetamol. I slept peacefully throughout the night and was still pain-free next morning. There was a slight recurrence the next evening; I repeated the treatment and the whole episode then ceased, much sooner than it was expected to do spontaneously.
Subsequently I’ve had further episodes, all of which have responded to periosteal needling. It seems to be best to carry this out at the earliest moment, as soon as I notice any symptoms. The problem has now remained under control for about three years.
Comment
The usual critics’ response to claims for acupuncture is that improvement is due to the placebo effect. I find this unlikely in my case. I’d tried numerous other acupuncture approaches previously without once getting any response and I certainly didn’t expect one this time, so I was genuinely surprised when it happened.
Incidentally, I don’t congratulate myself for having thought of this treatment. On the contrary, I should have thought of it a lot sooner.