Seeking fertility

I love working with patients who are seeking help with fertility. Whether they are trying on their own for the first time or taking extra steps prescribed by their doctors (often IUI or IVF), acupuncture has the potential to help achieve conception. And there are few things more rewarding than helping couples realize their dream of having a child.

Happily, these days, when couples first begin considering what options exist for them, there is a good chance they have already heard something about acupuncture.

News coverage

Over the past few years, the news media have brought attention to the effectiveness of acupuncture. CBS, FOX, and BBC have each run stories about the successes of acupuncture and the results of fertility research programs. These stories highlight how the modern techniques of reproductive medicine can be enhanced by the ancient tradition of Chinese medicine. Enhancement isn’t the whole story, however, and acupuncture can be of value to anyone seeking assistance. These latter people aren’t so newsworthy, I guess.

More sources

WebMD and the American Pregnancy Association also have interesting information about fertility and acupuncture, and as I was browsing around the web for what fellow licensed practitioners are saying, I found this article in Acupuncture Magazine by Jennifer Dubowsky. My hat’s off to Jennifer for this article and her other insightful contributions on the subject of fertility.

Personal testimonies

There’s nothing like hearing from someone who has gone down the same road, and like many professionals’ web sites, mine has testimonials from some of my fertility patients. But what can be more compelling than seeing and listening to real people? Like on YouTube: |1|2|.

Final thoughts

So there’s a lot of information out there readily available for interested couples. It shouldn’t come as a surprise to anyone, I suppose, that the general health and well-being of a patient – something that is at the heart of Chinese medicine — would have a direct impact on a patient’s fertility. Conception is a lot more than sperm meets egg. The physiological and emotional environments in which this takes place will have a dramatic impact on how events unfold. “Nourish the soil before planting the seed.” And then keep nourishing the soil through the ensuing pregnancy and birth. Then it’s . . . slow drum roll in the background . . . parenthood. But that’s a whole ‘nother story.

“Aculand”

It’s often the case that immediately after an acupuncture treatment a patient will experience a kind of dreamy, euphoric state. When I was in school students and teachers would refer to the after-effects of acupuncture as “aculand.” It’s not something any acupuncturist is attempting to achieve, it just seems to be one of the side effects of treatment.

My guess is it’s responsible for the items I often find left behind in my office or treatment room – checkbooks, sunglasses, watches. And it’s certainly on my mind when I schedule subsequent appointments. I always write them down on an appointment card and make sure they end up in a purse or pocket.

A research study of short term reactions to acupuncture

So imagine my surprise when I came across a research report on this very subject (“Short term reactions to acupuncture – a cross-sectional survey of patient reports” in Acupuncture in Medicine (2005, 23(3): 112-120 [abstract]). The authors don’t use the term “aculand.” Maybe it’s a term that’s not going to make it into the research vocabulary.

It’s a UK study with a sample size of 9408 patients! They were asked about their reactions during or immediately after treatment by practitioners of their choice (a total of 638 different acupuncturists).

The results

Well, I have to say, I was surprised at the frequency of responses. An amazing 95% of the patients reported experiencing at least one short-term reaction. The most common reaction? 79% reported feeling “relaxed.” Next, 33% felt “energized.” (This is more than 100% already because patients could report more than one response. The average number of responses was 1.8.) Next, 24% reported feeling “tired or drowsy.”

There were some responses on the “negative” side of the ledger, too. Which doesn’t surprise me. Temporary discomfort can be a part of healing. Some people get worse before they get better. It is totally normal for symptoms occasionally to flare up before they resolve. It’s my experience that if symptoms do get worse, they usually will last 24-48 hours and then improve.

And sometimes a small amount of pain is not really a negative thing. It can be the sensation of de qi, an integral component of acupuncture that is receiving its own research attention.

There was a very low response level for persistent “aggravation of symptoms” (1.8%). Interestingly, only 13 patients (an incredibly low 0.14%) responded that they were unwilling to have acupuncture again because of these “negative” reactions.

My new perspective

First of all, thanks to Hugh MacPherson and Kate Thomas for having conducted and published this study. It’s important to bring objective information to the table when talking about patient reactions to acupuncture. I was aware of the existence of short-term reactions, and my patients sometimes refer to them in their testimonials, but this study alerts me to its nearly universal – and variable — nature.

I’ll be watching my patients a little more closely. And maybe reducing the content of my lost and found drawer.

Golfer’s yips

The case of the curious golf affliction – the “yips”

A lot of my patients come to me because of chronic pain. So it’s no surprise that I see a lot of athletes – bikers, runners, tennis players –seeking help in restoring their performance levels. However, nobody has come to me, yet, with the specific request that I help their golf game. I’ve helped some here and there, but it’s always been a secondary consequence of treatment.

Well, thanks to an article in the journal of the British Medical Acupuncture Society (BMAS), I’m now ready to be of more direct help. Seems there is a condition that uniquely attacks golfers – the oddly named “yips.” It’s not really painful. Unless you’re a golfer. Adding about five strokes per round can hurt a lot.

Little did I know that this condition has been the subject of intense research (cf. A Multidisciplinary Study of the ‘Yips’ Phenomenon in Golf, Sports Medicine, 2000, 30(6) 423-437, and The ‘Yips’ in Golf, Sports Medicine, 2003, 33(1) 13-31). And now, thanks to BMAS (and their generous presentation of many articles through their website), a role for acupuncture is revealed: Acupuncture for Treatment of the Yips, a Case Report, by Palle Rosted (Acupuncture in Medicine, 2005, 23(4): 188-189).

What are the “yips”?

Many amateur golfers, and more than a small number of professional ones, lose control of the muscles in their arms in such a way that they can’t smoothly move a putter to and fro. Their arms can cramp or sometimes make involuntary movements. Aggravating if you’re an amateur, a catastrophe if you’re a professional.

A continuum of causes

The subtitle of the 2003 article in Sports Medicine is “A Continuum Between a Focal Dystonia and Choking.” It turns out that the yips are a psychoneuromuscular impediment. Yikes. Multiple causes here. From a localized neuromuscular problem to a psychosocial one – choking in common parlance.

The article on treating with acupuncture

Why do I like this article so much? First, it’s based on a sample size of one. That’s right, one golfer. One 65 year old Brit with a handicap of 14. Who would ever take seriously a study of sample size one? Well, me. If you read my blog on sample sizes in research and practice you’ll know why. Suffice it to say here that in an encounter between caregiver and patient, the sample size is always one. What I learn about one golfer today can help one golfer tomorrow.

Second, because it encompasses what acupuncture and Chinese medicine in general are so good at. The yips are a symptom. And we don’t attack symptoms willy-nilly. What is the cause of this symptom? Discovering this will take both rational evaluation and intuitive diagnosing. It takes listening. Same for the treatment. Rationality and intuition. Science and art. From sample sizes of N=1031 and N=72 describing the phenomenon in the two Sports Medicine articles, one golfer (N=1) gets treated in such a manner that he overcomes an impediment. I love it.

The cure for the N=1 golfer

Whatever physical muscular problems are involved with the yips, they are exacerbated by performance anxiety. The patient of this study did not clearly present physical or anxiety-related symptoms, so Rosted chose a combination of points to address the condition. (The details: GV20, EX-HN-1 [Si Shen Cong: four points one cun from GV20], and TE5.) The symptoms were gone after one treatment (a total of five were given), and there were no relapses by the 24-month follow-up.

Final thoughts

Performance anxiety and repetitive motor skills are important in lots of people’s lives. Maybe this isn’t so unique to golfers, after all. So, OK, I’m ready. Bring on the golfers, musicians, and poker players and let’s see what kinds of psychoneuromuscular impediments we can resolve. One at a time.

We’re all N = 1

There is a ton of interesting acupuncture research being conducted these days, and there is no doubt that we all will benefit from this work, practitioners and patients alike. Our aims are the same – bringing about healing. As I’ve been thinking about the actual research itself, though, I’ve become aware of a kind of disconnect between medical researchers and the patients they recruit for their work. These researchers are most interested in “Does treatment/drug X have a measurable effect on symptom Y?” And as a matter of good research protocol, they have to remain as neutral as possible about the outcome. That is to say, they can’t bias their work by hoping for one result or another.

Double blind research protocol

More importantly, some sort of randomized trial has to be set up and a placebo chosen. In the case of acupuncture studies, some type of “sham acupuncture” is employed (either inserting needles at random points disregarding established meridians, or only pretending to insert needles). Controls such as these are needed to ascertain whether the main treatment variable is the one responsible for any positive effects that might ensue. And then, in an attempt to remove bias from the gathering of data, a double-blind situation is set up whereby neither the doctor nor the patient is aware of which group he/she is in. (A real hurdle, for obvious reasons – the acupuncturist knows what group the patient is in, but at least the recording of results can be performed by someone who is unaware of treatment group assignments.)

A conundrum – two different views of sample size

The medical researcher is interested in the statistical results of the test. Does the treatment group differ significantly from the placebo group(s)? Statistics are based on samples of patients, and the larger the sample, the better. Sample sizes are referred top as “N,” so a sample size of 100 patients would be N = 100. The patients, on the other hand, are interested in their own personal health. Each is a sample of one. Hence the N = 1 in the title of this blog. How does the perspective of N = 1 relate to the perspective of the N = 100? Here’s where it gets interesting.

Lots of studies have failed to establish a statistically significant difference between treatment and control groups. So the researchers must conclude that the treatment is not effective. But there may be many individual patients who experienced significant individual benefits! It’s just that the significant individual benefits in the treatment group did not exceed the benefits of the control group.

The researcher, in a sense, has to dismiss the treatment’s effectiveness as being no better than the placebo’s. But each patient that responded positively has to be delighted, right? Nobody ever claims that their symptoms were less severe or that their recovery was less real. From their perspective the treatment (even if it was the placebo, and I’ll have more to say about placebos in a later blog) was successful.

What this means to me as a practitioner

As I treat patients, I have to be aware of what research has revealed about the kind of medicine I practice, and it certainly informs my treatment options, but every patient I see is a sample size of one. And what that means is that I look for unique, individual avenues to explore, and these avenues are not constrained by statistical evidence. I find this liberating in a way because it allows me to be creative in my practice; but also because it reminds me that my goals and my patients’ are the same – healing. And it really doesn’t matter if the exact same treatment given to another patient would not have the same result.

Significant individual benefits are not dependent on statistical significance in a clinical setting. I’ll have to talk to my family doctor the next chance I get and see if she has come to this same conclusion.