The "Japanese Orthopaedic Association (JOA) Clinical Practice Guidelines on the Management of Low Back Pain 2019, 2nd Edition" was published in May, 2019. We found multiple issues of serious misinformation on acupuncture; these included, but are not limited to inappropriate conclusions due to errors in literature selection, data extraction and data input. Accordingly we point out each error and provide the correct information.
1. A published paper of meta-analysis of randomized controlled trials (RCTs) on Japanese acupuncture for low back pain in Japanese patients is ignored.
2. Regarding acupuncture for acute low back pain, some RCT data has been incorrectly inputted and analyzed. The wrong numbers have been mistakenly inserted into the analysis software (plus instead of minus) leading to the opposite and incorrect conclusion that acupuncture is not superior to the control group. Furthermore, in a meta-analysis on the effect of acupuncture on functional disorder, data on pain are incorrectly inputted and analyzed.
3. The Guidelines' meta-analysis on acupuncture for chronic low back pain included five RCT papers. The papers included acupuncture (1 article), auricular point acupressure (2 articles), laser acupuncture (1 article) and acupressure backrest (1 article). Only one article in the meta-analysis used needle-inserting acupuncture, therefore, this is not a meta-analysis on acupuncture. There are also many errors in data input. Moreover, there is mislabeling of the forest plot figures: Figure 7 is incorrectly labelled "pain", but actually shows data on "functional disorder" (Figure 8), and vice versa.
4. A published paper of meta-analysis on the cost-effectiveness of acupuncture is ignored. Additionally, although a paper of "meta-analysis on the health economic effects of yoga" is cited, the health economic effects of yoga are not actually addressed or mentioned in that paper.
Although the Guidelines state they have fully complied with "Minds Manual for Guideline Development 2014" (Minds: Medical Information Network Distribution Service, Japan Council for Quality Health Care), they did not set up a systematic review team, and do not state whether or not they organized an external review committee. Such circumstances may have contributed to the serious errors in the Guidelines. Because we have also recognized many errors regarding other therapies addressed in the Guidelines, we fear that the present Guidelines may destroy the credibility of the entire clinical practice guidelines published in Japan. We strongly hope that a corrected and revised version is published as soon as possible.
The physical condition of athletes should be adequately assessed to ensure better performance. Because athletes are often challenged with the limits of strength and energy during training, orthopedic problems and poor physical condition, such as sports injuries, are unavoidable. Furthermore, in female athletes, the effects of hormonal changes and symptoms associated with the menstrual cycle cannot be estimated. The author experienced sports-related gynecological disorders in her active years. From participation in the 2004 Athens Olympic Games (athletics, women's hammer throw) up to 2012, the year of retirement, the author experienced repeated acute low back pain and struggle for daily training and conditioning. Moreover, women experienced endometriosis (ovary chocolate cysts) and anemia due to menorrhagia. Strong menstrual pain halted training activities. Premenstrual syndrome caused poor physical condition because of premenstrual edema and body stiffness. Because of the low mood at the time of resection for bilateral chocolate cysts in 2009, acupuncture was used as a part of conditioning. This was considered as "liver blood deficiency" in oriental medicine, from the perspective of the circulatory system. It increased awareness regarding physical fatigue, condemned the practice of forced training in poor conditions, contributed as a coping mechanism and prevented injury. Health problems progressing to organic dysmenorrhea may be completely prevented through an early diagnosis and treatment without residual pain. Menstrual problems can be treated with suitable hormonal therapies. Female athletes are recommended to undergo regular medical examinations by a gynecologist. Hormonal therapy combined with symptomatic treatment is preferable to appropriately treat pain associated with menstruation; training should be planned considering menstrual cycle occurrence. It is advisable to find personalized conditioning methods, such as acupuncture, in conjunction with medicine.
[Introduction] During the 10-year period between 2006 to 2016, the number of acupuncture-moxibustion clinics has increased by 59%. There have been some nationwide surveys on the business conditions of massage-acupuncture-moxibustion clinics, but there have been no studies focusing on acupuncture-moxibustion clinics. It is necessary to investigate their actual business conditions as part of the basic data required for considering the future of such clinics. In this paper, we focus and report on the business conditions of the clinics from our nationwide survey data base.
[Method] A survey was conducted on a total of 20,000 massage-acupuncture-moxibustion clinics in Japan extracted with a stratified random sampling, including 15,000 private management clinics, 2,000 corporate clinics and 3,000 house call service suppliers. The survey was mailed out in October 2016.
Replies from active acupuncture-moxibustion licensees were extracted and the questionnaires on the following items were analyzed; the number of patients, treatment fees, annual income, business type, and licenses. The calculated values are expressed as real values, percentiles, median values, and interquartile range.
[Results and Conclusion] The average number of patients per month: 98, average treatment fee: 3,000 yen, and average annual income: 3,240,000 yen were shown to be the standard features of the business conditions for acupuncture-moxibustion clinics in Japan.
The distribution of the aggregate values showed a large dispersion. Extreme bipolarization is shown in the annual income. It seemed to affect the low rate for receiving acupuncture-moxibustion treatments, and the unnecessary expenditure for judo therapies. More detailed analysis is required to clarify the actual business conditions of acupuncture-moxibustion clinics.
[Objective] For six consecutive years, we investigated 83 cases of the effect of acupuncture therapy on children with night terrors.
[Subjects and Methods] The number of subjects was 83 (38 boys and 45 girls, mean age: 2.2 ± 2.8 years old). Acupuncture therapy for infants was defined as pattern identification/syndrome differentiation and treatment. The acupuncture therapy used spoon needles and moxibustion; skin stimulation was applied to the acupuncture point. Infant needles in the Daishi style and moxibustion of the incense stick were used as a method to approach the hole. Therapeutic effect was judged by a self-written evaluation form certified by the Japan Society of Pediatric Acupuncture. One major item, "sleep disorder (broad sense of night terrors)," three minor items ('night terror' in a narrower sense), 'difficulty in falling asleep,' 'nocturnal awakening,' number of nocturnal awakenings at night, and satisfaction with acupuncture therapy in infants were investigated. Evaluations were made at the time of the first treatment and before the fifth treatment. In the statistical analysis, the change in the score of the evaluation slip and the number of partial awakenings were tested by the Wilcoxon signed-rank-sum test. The level of significance was set at 5%.
[Results] Significant improvement was observed in the score for the major item, minor items, and number of partial awakenings. The degree of satisfaction was 90.4%.
[Conclusion] It was suggested that acupuncture therapy in infants is effective for ameliorating symptoms of "sleep disorder."
[OBJECTIVE] In recent years, acupuncture treatment for cancer patients has spread worldwide. However, in Japan, there are few facilities where acupuncture and moxibustion treatment is being carried out in a hospital, and in introducing acupuncture treatment as part of palliative care is rare. In this study, we investigated the current situation at our hospital where acupuncturists are participating in the palliative care team of the hospital.
[PARTICIPANTS AND METHODS] Subjects were patients with cancer in our hospital who were hospitalized to receive the best supportive care for their condition and who had started acupuncture treatment between April 8, 2011 and November 13, 2017. The target patients were retrospectively investigated by medical records.
[RESULTS] Of the 75 patients, 72 (96%) were Performance Status 3 and 4. Thirty-seven (49%) had oxygen therapy. Fifty-five patients (73%) had pleural fluid or ascites during acupuncture and moxibustion treatment, and 50 patients (67%) had edema. In the treatment of acupuncture, Contact Needle Therapy was used to avoid the risk of infection and bleeding, and in the moxibustion treatment, scarring moxibustion was not used to avoid the risk of burns and infection. Fifty-nine patients (79%) had a positive opinion of the acupuncture treatment. Forty-five patients (66%) requested acupuncture within two days of their death. There were 3 adverse events, but all were mild and transient, .
[CONCLUSION] In the acupuncture treatment at our hospital for patients in the terminal stage of cancer, treatment was performed taking into consideration the risks to the patient, and there were no serious adverse events. There were many positive feedbacks from patients who received acupuncture, suggesting that acupuncture may be useful for alleviating symptoms at the end stage of cancer.
[Objective] To report reduction in frequency of headaches and use of medication and improvements in quality of daily life via C2 peripheral nerve field stimulation using electroacupuncture (EA-C2-PNfS) in a patient with migraines triggered by weather changes.
[Case] A woman in her 60s complaining of headache.
[Clinical History] Her headaches began to worsen in X-41 years. The OTC drug became ineffective from around X-15 years, and subject was diagnosed with migraine and overuse of headache medication by a neurosurgeon. Her headache was alleviated by the appropriate medications. She began a new job from August, X-1 year and headaches and over-medication increased in frequency. The acupuncture treatment was started in May, X year. The frequency of headaches was 8 times mo (month).
[Subjective Symptoms] Throbbing pain occurred mainly in the frontal and occipital regions, often accompanied by nausea, vomiting, and optic/auditory hyperesthesia. The main trigger was weather changes.
[Family History] Father, maternal grandmother and brothers have a history of headaches.
[Evaluation] Headache Diary (frequency of headache and medication), Headache Impact Test (HIT-6) (Quality of daily life).
[Treatment] EA-C2-PNfS was performed once a week. Interval of the treatment was adjusted depending on the patient's condition.
[Results] Though weather- related transient aggravations were occasionally observed, the frequencies of the headache and use of medication gradually decreased; The frequency of the headache was 8 times/mo at the start of the treatment, 6 times/mo after 12 weeks, 8 times/mo after 24 weeks, 3 times/mo after 36 weeks, once a mo after 48 weeks, 4 times mo after 54 weeks. The frequency of medication was 8 times/mo at the start of the treatment, 2 times/mo after 12 weeks, 6 times/mo after 24 weeks, 3 times mo after 36 weeks, once a mo after 48 weeks, 4 times/mo after 54 weeks. The score of HIT-6 also improved from 68 to 57. The treatment was concluded with patient satisfaction.
[Discussion] In this case, migraine triggered by weather changes was remarkably alleviated. Recently an activation of the spinal trigeminal nucleus was implicated in the pathology of weather-associated headaches. EA-C2-PNfS may inhibit the abnormal activity of spinal trigeminal nucleus.
[Objective] We report a patient with restless legs syndrome (RLS) associated with chronic cold sensation in her lower legs. Both symptoms were successfully treated with acupuncture and moxibustion.
[Patient] The patient was a 42-year-old female whose chief complaint was unpleasant abnormal sensation on the back of her lower legs that appeared when attempting to sleep. She had previously experienced the same sensation while she was pregnant, but it disappeared after childbirth. The unpleasant sensation appeared again in July, X year with no precipitating cause. The symptoms progressively worsened each day, eventually resulting in sleep disturbance. She was diagnosed as RLS in the department of neurology, but she did not want pharmacotherapy so she decided to start a treatment of acupuncture and moxibustion. She underwent the treatment once a week, with acupuncture in the triceps surae muscle of both lower legs, and an electronic moxibustion at acupoints BL57 and SP6 bilaterally. The International Restless Legs Syndrome Severity Rating Scale (IRLS) and the Numerical Rating Scale (NRS) were used for evaluation.
[Result] The IRLS score gradually decreased from 26 to 2 by the 7th treatment. The NRS score also decreased from 8 to 0. The patient's chronic cold sensation also improved with reduction in RLS symptoms.
[Discussion] Recently a dysfunction of the dorsoposterior hypothalamic dopaminergic A11 cell group has been implicated in the pathology of RLS. The dysfunction in this system induces an excessive sympathetic activity, which may cause microangiopathies resulting in the cold sensation.
[Conclusion] RLS and cold sensation are shared pathologies relating to the dopaminergic and the autonomic nervous system, and our report suggests that acupuncture and moxibustion treatment may have acted upon these systems to improve symptoms.
[Objective] Premature ventricular contraction (PVC) causes arrhythmia, and it most frequently occurs in healthy individuals. It has been recently reported that a combination of medical therapy and acupuncture has an effect on arrhythmia. Herein, we report on the use of acupuncture in a patient with PVC.
[Case] A 41-year-old male complained of arrhythmia and stiff shoulders. According to the Lown grading system, he was diagnosed with a grade 1 condition using Holter monitor in a hospital for internal diseases. Acupuncture was applied for decreasing the PVC count and discomfort in the chest region.
[Methods] Acupuncture was applied at points PC6, BL15, HT7, ST36, GV20, CV17, and KI3. Manipulation involved twirling the stemless needle (30 mm in length, 0.20 mm in diameter) at a low amplitude and high frequency, and the needle was then retained for 10 min. The treatment was applied twice a day for four weeks. Measurements were obtained using a visual analog scale, SF-36v2, and Holter monitor.
[Results] After four weeks of treatment, discomfort in the chest region decreased and quality of life improved. Additionally, the PVC count decreased after two weeks of treatment.
[Conclusion] Our findings suggest that acupuncture is effective for treatment of PVC.
The Japan-Korea Workshop on Acupuncture and EBM is an academic exchange between the Japan Society of Acupuncture and Moxibustion (JSAM) and the Korean Acupuncture and Moxibustion Medical Society (KAMMS). The theme of the 9th and 10th Workshop was clinical practice guidelines (CPG). Three Korean and two Japanese speakers presented in the 9th Workshop held at Osaka, and two in each country did in the 10th at Jecheon, Korea. Since Korea has already developed some Korean Medicine CPGs, the present state and protocols for improvement process were reported. On the other hand, Japan has not developed such CPGs on acupuncture. The Japanese speakers therefore presented results of a survey on Japanese CPGs that include “acupuncture-moxibustion” as a treatment option and quality assessment of those CPGs.
Although there are some differences on circumstances surrounding acupuncture practice between Japan and Korea, it was a good opportunity to obtain useful information for developing CPG on acupuncture in Japan and to discuss on this issue with Korean researchers preceding in this area. We reaffirmed the need for continued academic exchange between JSAM and KAAMS.