MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

pain

The aim of this study was to investigate whether there is a difference in outcome between participants with high compared to low pain self-efficacy (PSE) receiving manual therapy, acupuncture, and electrotherapy.

Participants were stratified into high or low baseline (i) PSE, (ii) shoulder pain and disability index (SPADI), and (iii) did or did not receive the treatment. Whether the effect of treatment differs for people with high compared to low PSE was assessed using the 95% confidence interval of the difference of difference (DoD) at a 5% significance level (p < 0.05).

Treatment was labelled using 3 categories, 2 of which were subcategories of the first

  • “Any passive treatment” – any form of manual therapy and/or acupuncture and/or electrotherapy.
  • “Any manual therapy” – shoulder or spine joint mobilisations, deep transverse frictions, capsular stretches, trigger point therapy, muscle facilitation, or other techniques listed by the treating physiotherapist.
  • “Spinal/shoulder joint mobilisation” – for example, Maitland, Kaltenborn or Mulligan techniques.

To be categorised, treatment must have been delivered by the physiotherapist at least once and may have been delivered in conjunction with other treatments.

Six-month SPADI scores were consistently lower (less pain and disability) for those who did not receive passive treatments compared to those who did (statistically significant less pain and disability in 7 of 24 models). However, DoD was statistically insignificant.

The authors concluded that PSE did not moderate the relationship between treatment and outcome. However, participants who received passive treatment experienced equal or more pain and disability at 6 months compared to those who did not. Results are subject to confounding by indication but do indicate the need for further appropriately designed research.

This analysis suggests that manual therapy, electrotherapy, or acupuncture in addition to advice and exercise offered no improvement in pain or disability at six months, irrespective of PSE. Some patients who receive these treatments experienced more pain and disability at six months compared to those who do not.

I am not aware of compelling evidence that either of these treatments, all of which are often recommended, are effective for shoulder pain, and the results of this new study certainly do not suggest they are. However, as the design of the study was not primarily for this research question, these findings are, of course, merely tentative and need to be investigated further.

This systematic review aimed to investigate the effectiveness of cupping therapy on low back pain (LBP). Medline, Embase, Scopus and WANFANG databases were searched for relevant cupping RCTs on low back pain articles up to 2023. A complementary search was manually made on 27 September for update screening. Full-text English and Chinese articles on all ethnic adults with LBP of cupping management were included. Studies looking at acute low back pain only were excluded. Two independent reviewers screened and extracted data, with any disagreement resolved through consensus by a third reviewer. The methodological quality of the included studies was evaluated independently by two reviewers using an adapted tool. Change-from-baseline outcomes were treated as continuous variables and calculated according to the Cochrane Handbook. Data were extracted and pooled into the meta-analysis by Review Manager software (version 5.4, Nordic Cochrane Centre).

Eleven trials involving 921 participants were included. Five studies were assessed as being at low risk of bias, and six studies were of acceptable quality. The findings reveal:

  • High-quality evidence demonstrated cupping significantly improves pain at 2-8 weeks endpoint intervention (d=1.09, 95% CI: [0.35-1.83], p=0.004).
  • There was no continuous pain improvement observed at one month (d=0.11, 95% CI: [-1.02-1.23], p=0.85) and 3-6 months (d=0.39, 95% CI: [-0.09-0.87], p=0.11).
  • Dry cupping did not improve pain (d=1.06, 95% CI: [-0.34, 2.45], p=0.14) compared with wet cupping (d=1.5, 95% CI: [0.39-2.6], p=0.008) at the endpoint intervention.
  • There was no evidence indicating the association between pain reduction and different types of cupping (p=0.2).
  • Moderate- to low-quality evidence showed that cupping did not reduce chronic low back pain (d=0.74, 95% CI: [-0.67-2.15], p=0.30) and non-specific chronic low back pain (d=0.27, 95% CI: [-1.69-2.24], p=0.78) at the endpoint intervention.
  • Cupping on acupoints showed a significant improvement in pain (d=1.29, 95% CI: [0.63-1.94], p<0.01) compared with the lower back area (d=0.35, 95% CI: [-0.29-0.99], p=0.29).
  • A potential association between pain reduction and different cupping locations (p=0.05) was found.
  • Meta-analysis showed a significant effect on pain improvement compared to medication therapy (n=8; d=1.8 [95% CI: 1.22 – 2.39], p<0.001) and usual care (n=5; d=1.07 [95% CI: 0.21- 1.93], p=0.01).
  • Two studies demonstrated that cupping significantly mediated sensory and emotional pain immediately, after 24 hours, and 2 weeks post-intervention (d= 5.49, 95% CI [4.13-6.84], p<0.001).
  • Moderate evidence suggested that cupping improved disability at the 1-6 months follow-up (d=0.67, 95% CI: [0.06-1.28], p=0.03).
  • There was no immediate effect observed at the 2-8 weeks endpoint (d=0.40, 95% CI: [-0.51-1.30], p=0.39).
  • A high degree of heterogeneity was noted in the subgroup analysis (I2 >50%).

The authors concluded that high- to moderate-quality evidence indicates that cupping significantly improves pain and disability. The effectiveness of cupping for LBP varies based on treatment durations, cupping types, treatment locations, and LBP classifications. Cupping demonstrated a superior and sustained effect on pain reduction compared with medication and usual care. The notable heterogeneity among studies raises concerns about the certainty of these findings. Further research should be designed with a standardized cupping manipulation that specifies treatment sessions, frequency, cupping types, and treatment locations. The real therapeutic effects of cupping could be confirmed using a sham device or objective outcome measurements. Studies with at least six- to twelve-month follow-ups are needed to investigate the long-term efficacy of cupping in managing LBP.

Confused?

No need, it’s really quite simple: cupping can, according to this review, be shown to have some short-lasting effect, provided the study is flawed and does not control for placebo effects.

Surprised?

No need! There is hardly a form of so-called alternative medicine (SCAM) that does not have a similarly small effect of back pain, if tested in equally dodgy studies. This is particularly true for those treatments that can act as a theatrical placebo, e.g. acupuncture or chiropractic.

So, should a back pain sufferer try cupping?

If he/she insists, why not? But please don’t use wet cupping (which can do quite a bit of harm). Dry cupping (without injuring the skin) is arguably better (less risk, less expense, possibility of home treatment by your partner) than chiropractic, osteopathy, acupuncture, or many other SCAMs.

My conclusions – as mentioned many times previously – are as follows:

  1. Most SCAMs help a little with back pain (and similar conditions) because they can have a powerful placebo effect.
  2. Conventional medicine is also not convincingly effective for back pain.
  3. If you insist on SCAM, it is best to use one that is relatively harmless and inexpensive.

Diabetic peripheral neuropathy (DPN) is a common complication of diabetes mellitus and can lead to serious complications. Therapeutic strategies for pain control are available but there are few approaches that influence neurological deficits such as numbness.

This study investigated the effectiveness of acupuncture on improving neurological deficits in patients suffering from type 2 DPN.

The acupuncture in DPN (ACUDPN) study was a two-armed, randomized, controlled, parallel group, open, multicenter clinical trial. Patients were randomized in a 1:1 ratio into two groups: The acupuncture group received 12 acupuncture treatments over 8 wk, and the control group was on a waiting list during the first 16 wk, before it received the same treatment as the other group. Both groups received routine care.

Outcome parameters were evaluated after 8, 16 and 24 wk. They included:

  • neurological scores, such as an 11-point numeric rating scale (NRS) for hypesthesia,
  • neuropathic pain symptom inventory (NPSI),
  • neuropathy deficit score (NDS),
  • neuropathy symptom score (NSS);
  • nerve conduction studies (NCS) as assessed with a handheld point-of-care device.

Sixty-two participants were included. The NRS for numbness showed a difference of 2.3 (P < 0.001) in favor of the acupuncture group, the effect persisted until week 16 with a difference of 2.2 (P < 0.001) between groups and 1.8 points at week 24 compared to baseline. The NPSI was improved in the acupuncture group by 12.6 points (P < 0.001) at week 8, the NSS score at week 8 with a difference of 1.3 (P < 0.001); the NDS and the TNSc score improved for the acupuncture group in week 8, with a difference of 2.0 points (P < 0.001) compared to the control group. Effects were persistent in week 16 with a difference of 1.8 points (P < 0.05). The NCS showed no meaningful changes. In both groups only minor side effects were reported.

The authors concluded that acupuncture may be beneficial in type 2 diabetic DPN and seems to lead to a reduction in neurological deficits. No serious adverse events were recorded and the adherence to treatment was high. Confirmatory randomized sham-controlled clinical studies with adequate patient numbers are needed to confirm the results.

That “acupuncture may be beneficial” has been known before and presumably was the starting point of the present study. So, why conduct an open, under-powered trial with non-blind assessors and without defining a primary outcome measure?

Could the motivation be to add yet another false-positive study to the literature of acupuncture?

False-positive, you ask?

Yes, let me explain by having a look at the outcome measures:

  • NRS = a subjective endpoint.
  • NPSI = a subjective endpoint.
  • NDS = a subjective endpoint.
  • NSS = a subjective endpoint.
  • NCS = the only objective endpoint.

And what is remarkable about that?

  • Subjective endpoints are likely to respond to placebo effects.
  • Objective endpoints are not likely to respond to placebo effects.

In other words, what the authors of this study have, in fact, confirmed with their study is this:

acupuncture is a theatrical placebo!

Since the introduction of their new Education Standards in March 2023, the General Chiropractic Council (GCC) has been working with chiropractic education providers to support them in implementing the changes to their curricula. Recently, the GCC have stated this:

We expect students to be taught evidence-based practice: integrating individual clinical expertise, the best available evidence from current and credible clinical research, and the values and preferences of patients. Chiropractors are important members of a patient’s healthcare team, and interprofessional approaches enable the best outcomes. Programmes that meet these Standards will teach ethical, professional care and produce competent healthcare professionals who can serve the needs of patients.

These are indeed most encouraging words!

Basically, they are saying that chiropractic education will now have to be solidly based on the principles of evidence-based medicine (EBM) as well as sound medical ethics. Let me spell out what this really means. Chiropractic courses must teach that:

  • The current and credible clinical evidence suggesting that spinal manipulations, the hallmark intervention of chiropractors, are effective is weak for back pain and negative or absent for all other conditions.
  • The current and credible clinical evidence suggests that spinal manipulations, the hallmark intervention of chiropractors, can cause harm which in many instances is serious.
  • The current and credible clinical evidence thus suggests that the risk/benefit balance for spinal manipulations, the hallmark intervention of chiropractors, is not positive.
  • Medical ethics require that competent healthcare professionals inform their patients that spinal manipulations, the hallmark intervention of chiropractors, may not generate more good than harm which is the reason why they cannot employ these therapies.

So, the end of chiropractic in the UK is looming!

Unless, of course, the GCC’s words are not really meant to be translated into action. They could be just window dressing and politically correct bullshit. But that’ s really far too far fetched – after all they come from the GENERAL CHIROPRACTIC COUNCIL, known for its excellent track record, e.g.:

The WHO has just released guidelines for non-surgical management of chronic primary low back pain (CPLBP). The guideline considers 37 types of interventions across five intervention classes. With the guidelines, WHO recommends non-surgical interventions to help people experiencing CPLBP. These interventions include:

  • education programs that support knowledge and self-care strategies;
  • exercise programs;
  • some physical therapies, such as spinal manipulative therapy (SMT) and massage;
  • psychological therapies, such as cognitive behavioural therapy; and
  • medicines, such as non-steroidal anti-inflammatory medicines.

The guidelines also outline 14 interventions that are not recommended for most people in most contexts. These interventions should not be routinely offered, as WHO evaluation of the available evidence indicate that potential harms likely outweigh the benefits. WHO advises against interventions such as:

  • lumbar braces, belts and/or supports;
  • some physical therapies, such as traction;
  • and some medicines, such as opioid pain killers, which can be associated with overdose and dependence.

As you probably guessed, I am particularly intrigued by the WHO’s positive recommendation for SMT. Here is what the guideline tells us about this specific topic:

Considering all adults, the guideline development group (GDG) judged overall net benefits [of spinal manipulation] across outcomes to range from trivial to moderate while, for older people the benefit was judged to be largely uncertain given the few trials and uncertainty of evidence in this group. Overall, harms were judged to be trivial to small for all adults and uncertain for older people due to lack of evidence.

The GDG commented that while rare, serious adverse events might occur with SMT, particularly in older people (e.g. fragility fracture in people with bone loss), and highlighted that appropriate training and clinical vigilance concerning potential harms are important. The GDG also acknowledged that rare serious adverse events were unlikely to be detected in trials. Some GDG members considered that the balance of benefits to harms favoured SMT due to small to moderate benefits while others felt the balance did not favour SMT, mainly due to the very low certainty evidence for some of the observed benefits.

The GDG judged the overall certainty of evidence to be very low for all adults, and very low for older people, consistent with the systematic review team’s assessment. The GDG judged that there was likely to be important uncertainty or variability among people with CPLBP with respect to their values and preferences, with GDG members noting that some people might prefer manual
therapies such as SMT, due to its “hands-on” nature, while others might not prefer such an approach.

Based on their experience and the evidence presented from the included trials which offered an average of eight treatment sessions, the GDG judged that SMT was likely to be associated with moderate costs, while acknowledging that such costs and the equity impacts from out-of-pocket costs would vary by setting.

The GDG noted that the cost-effectiveness of SMT might not be favourable when patients do not experience symptom improvements early in the treatment course. The GDG judged that in most settings, delivery of SMT would be feasible, although its acceptability was likely to vary across
health workers and people with CPLBP.

The GDG reached a consensus conditional recommendation in favour of SMT on the basis of small to moderate benefits for critical outcomes, predominantly pain and function, and the likelihood of rare adverse events.

The GDG concluded by consensus that the likely short-term benefits outweighed potential harms, and that delivery was feasible in most settings. The conditional nature of the recommendation was informed by variability in acceptability, possible moderate costs, and concerns that equity might be negatively impacted in a user-pays model of financing.

___________________________

This clearly is not a glowing endorsement or recommendation of SMT. Yet, in my view, it is still too positive. In particular, the assessment of harm is woefully deficient. Looking into the finer details, we find how the GDG assessed harms:

WHO commissioned quantitative systematic evidence syntheses of randomized controlled
trials (RCTs) to evaluate the benefits and harms (as reported in included trials) of each of the
prioritized interventions compared with no care (including trials where the effect of an
intervention could be isolated), placebo or usual care for each of the critical outcomes (refer to Table 2 for the PICO criteria for selecting evidence). Research designs other than RCTs
were not considered.

That explains a lot!

It is not possible to establish the harms of SMT (or any other therapy) on the basis of just a few RCTs, particularly because the RCTs in question often fail to report adverse events. I can be sure of this phenomenon because we investigated it via a systematic review:

Objective: To systematically review the reporting of adverse effects in clinical trials of chiropractic manipulation.

Data sources: Six databases were searched from 2000 to July 2011. Randomised clinical trials (RCTs) were considered, if they tested chiropractic manipulations against any control intervention in human patients suffering from any type of clinical condition. The selection of studies, data extraction, and validation were performed independently by two reviewers.

Results: Sixty RCTs had been published. Twenty-nine RCTs did not mention adverse effects at all. Sixteen RCTs reported that no adverse effects had occurred. Complete information on incidence, severity, duration, frequency and method of reporting of adverse effects was included in only one RCT. Conflicts of interests were not mentioned by the majority of authors.

Conclusions: Adverse effects are poorly reported in recent RCTs of chiropractic manipulations.

The GDG did not cite our review (or any other of our articles on the subject) but, as it was published in a very well-known journal, they must have been aware of it. I am afraid that this wilfull ignorance caused the WHO guideline to underestimate the level of harm of SMT. As there is no post-marketing surveillance system for SMT, a realistic assessment of the harm is far from easy and needs to include a carefully weighted summary of all the published reports (such as this one).

The GDG seems to have been aware of (some of) these problems, yet they ignored them and simply assumed (based on wishful thinking?) that the harms were small or trivial.

Why?

Even the most cursory look at the composition of the GDG, begs the question: could it be that the GDG was highjacked by chiropractors and other experts biased towards SMT?

The more I think of it, the more I feel that this might actually be the case. One committee even listed an expert, Scott Haldeman, as a ‘neurologist’ without disclosing that he foremost is a chiropractor who, for most of his professional life, has promoted SMT in one form or another.

Altogether, the WHO guideline is, in my view, a shameful example of pro-chiropractic bias and an unethical disservice to evidence-based medicine.

 

The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR), a painful condition caused by the compression or irritation of the nerves that supply the shoulders, arms and hands.

A multidisciplinary team autors searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were:

  1. randomized trials,
  2. had at least one conservative treatment arm,
  3. diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests.

Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach.

Of the 2561 records identified, 59 trials met the inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively.

There is very-low certainty evidence supporting the use of:

  • acupuncture,
  • prednisolone,
  • cervical manipulation,
  • low-level laser therapy

for pain and disability in the immediate to short-term, and

  • thoracic manipulation,
  • low-level laser therapy

for improvements in cervical range of motion in the immediate term.

There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion.

There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty.

The authors concluded that there is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

I agree!

Yet, to patients suffering from CR, this is hardly constructive advice. What should they do vis a vis such disappointing evidence?

They might speak to a orthopedic surgeon; but often there is no indication for an operation. What then?

Patients are bound to try some of the conservative options – but which one?

  • Acupuncture?
  • Prednisolone?
  • Cervical manipulation,?
  • Low-level laser therapy?

My advice is this: be patient – the vast majority of cases resolves spontaneously regardless of therapy – and, if you are desperate, try any of them except cervical manipulation which is burdened with the risk of serious complications and often makes things worse.

Certain aspects of yoga can be used as a non-pharmacological conservative therapeutic approach to the management of chronic low back pain (CLBP). This overview summarized and evaluated data from current systematic reviews (SRs) on the use of yoga for CLBP.

The researchers searched SRs on the use of yoga for CLBP in nine electronic databases from inception to September 2023. The methodological quality was evaluated using the Assessment of Multiple Systematic Review Scale-2 (AMSTAR-2). The reporting quality of the included SRs was evaluated using the Preferred Reporting Item for Systematic Review and Meta-Analysis-2020 (PRISMA-2020), and the quality of data was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Two independent researchers performed the screening, data extraction, and quality assessment process of SRs.

A total of 13 SRs were included. The results of the AMSTAR-2 indicated that the methodological quality of the included studies was relatively low. The PRISMA-2020 checklist evaluation results indicated that methodological limitations in reporting, especially regarding data processing and presentation, were the main weaknesses. The GRADE assessment indicated that 30 outcomes were rated moderate, 42 were rated low level, and 20 were rated very low level. Downgrading factors were mainly due to the limitations of the included studies.

The authors concluded that yoga appears to be an effective and safe non-pharmacological therapeutic modality for the Management of CLBP. Currently, it may exhibit better efficacy in improving pain and functional disability associated with CLBP. However, the methodological quality and quality of evidence for SRs/MAs in the included studies were generally low, and these results should be interpreted cautiously.

Sorry, but I beg to differ!

  • The safety of a therapy cannot be ascertained on the basis of such small sample sizes.
  • The effectiveness of yoga has not been demonstrated by these data.
  • All that has been shown with this review is that the quality of the research in this area is too poor for drawing conclusions.

This study was aimed at evaluating the effectiveness of osteopathic visceral manipulation (OVM) combined with physical therapy in pain, depression, and functional impairment in patients with chronic mechanical low back pain (LBP).
A total of 118 patients with chronic mechanical LBP were assessed, and 86 who met the inclusion criteria were included in the randomized clinical trial (RCT). The patients were randomized to either:

  • Group 1 (n=43), who underwent physical therapy (5 days/week, for a total of 15 sessions) combined with OVM (2 days/week with three-day intervals),
  • or Group 2 (n=43), which underwent physical therapy (5 days/week, for a total of 15 sessions) combined with sham OVM (2 days/week with three-day intervals).

Both groups were assessed before and after treatment and at the fourth week post-treatment.

Seven patients were lost to follow-up, and the study was completed with 79 patients. Pain, depression, and functional impairment scores were all improved in both groups (p=0.001 for all). This improvement was sustained at week four after the end of treatment. However, improvement in the pain, depression, and functional impairment scores was significantly higher in Group 1 than in Group 2 (p=0.001 for all).

The authors concluded that the results suggest that OVM combined with physical therapy is useful to improve pain, depression, and functional impairment in patients with chronic mechanical low back pain. We believe that OVM techniques should be combined with other physical therapy modalities in this patient population.

OVM was invented by the French osteopath, Jean-Piere Barral. In the 1980s, he stated that through his clinical work with thousands of patients, he discovered that many health issues were caused by our inner organs being entrapped and immobile. According to its proponents, OVM is based on the specific placement of soft manual forces that encourage the normal mobility, tone and function of our inner organs and their surrounding tissues. In this way, the structural integrity of the entire body is allegedly restored.

I am not aware of good evidence to show that OVM is effective – and this, sadly, includes the study above.

In my view, the most plausible explanation for its findings have little to do with OVM itself: sham OVM was applied “by performing light pressure and touches with the palm of the hand on the selected points for OVM without the intention of treating the patient”. This means that most likely patients were able to tell OVM from sham OVM and thus de-blinded. In other words, their expectation of receiving an effective therapy (and not the OVM per se) determined the outcome.

 

NICE helps practitioners and commissioners get the best care to patients, fast, while ensuring value for the taxpayer. Internationally, NICE has a reputation for being reliable and trustworthy. But is that also true for its recommendations regarding the use of acupuncture? NICE currently recommends that patients consider acupuncture as a treatment option for the following conditions:

Confusingly, on a different site, NICE also recommends acupuncture for retinal migraine, a very specific type of migraine that affect normally just one eye with symptoms such as vision loss lasting up to one hour, a blind spot in the vision, headache, blurred vision and seeing flashing lights, zigzag patterns or coloured spots or lines, as well as feeling nauseous or being sick.

I think this perplexing situation merits a look at the evidence. Here I quote the conclusions of recent, good quality, and (where possible) independent reviews:

So, what do we make of this? I think that, on the basis of the evidence:

  • a positive recommendation for all types of chromic pain is not warranted;
  • a positive recommendation for the treatment of TTH is questionable;
  • a positive recommendation for migraine is questionable;
  • a positive recommendation for prostatitis is questionable;
  • a positive recommendation for hiccups is not warranted;
  • a positive recommendation for retinal migraine is not warranted.

But why did NICE issue positive recommendations despite weak or even non-existent evidence?

SEARCH ME!

 

 

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We have often discussed cupping on this blog, e.g.:

Yes, generally speaking I have been critical about cupping – not because I don’t like it (I even used the treatment as a young clinician many years ago) but because the evidence tells me to. I was glad to see that the authors of a recent article entitled “Utility of Cupping Therapy in Substance Use Disorder: A Novel Approach or a Bizarre Treatment?” offer even more outspoken words about the therapy. Here are their conclusions:

Established treatment modalities for substance use disorder and its withdrawal symptoms include pharmacotherapy and psychotherapy, but their utilization by the general population remains unsatisfactory. Taboos regarding mental health services and concerns about confidentiality are massive obstacles for patients seeking psychiatric help, and alternative forms of medicine may seem more approachable, even with the associated risks. As displayed in this case, cupping therapy is a traditional therapy with no role in treating polyaddiction and withdrawal symptoms, but it unnecessarily exposes individuals to really uncomfortable and often concealed complications such as bruising, and skin and blood infections, especially when carried out by untrained, incompetent individuals. While one can explore these options in addition to seeking professional mental health care, it is imperative to spread awareness about the roles, scientific soundness, and adverse effects of these alternative health practices. The health promotion and education sectors need reforms to educate the general population, especially the rural population in India, about the dangers of iatrogenesis caused by non-evidence-backed treatments. There needs to be an extensive advertisement of only the most effective and scientific treatment options provided by medical professionals, and the risks of overlooking them in favor of traditional cures propagated by unqualified individuals. With all the scientific advancements in the 21st century ranging from artificial intelligence in healthcare, and robotic surgeries, to extensive clinical trials for novel anti-cancer drugs, we cannot allow the propagation of ancient, scientifically unsound techniques that may cause more harm than benefit to patients.

Why, I am sure you ask yourself, are they so critical? The reason lies in the case they report in the same paper:

A 30-year-old man presented to the psychiatric outpatient department with complaints of nervousness, anxiety, a sense of impending doom, irritability, anger outbursts, headache, and reduced sleep and appetite for the last five days. The patient had a history of daily consumption of 5-10 mg of alprazolam tablets, 200-250 mg of codeine syrup, and about five packets of chewable tobacco over the last seven years; this was a pattern of polyaddiction to a benzodiazepine, opiate, and nicotine. The patient had no history of fever, confusion, or hallucinations. On eliciting the past history, the patient revealed that he went to an alternative medicine practitioner after his family persuaded him to seek help for his substance use disorder. After ceasing the consumption of all three substances for three days, he started developing the symptoms with which he presented to our hospital. He was hesitant to talk about his substance use disorder to medical professionals and concerned about confidentiality, and, hence, went to an alternative medicine practitioner whom he deemed approachable. There he was given wet cupping therapy on the head for four days, which involved the use of rubber pumps to create a suction inside the cups placed on his head. After three to five minutes, the cups were removed and small incisions were made on the cupping sites, following which a second suction caused the oozing out of blood from the incision sites on the scalp (Figure 1). But, this did not improve his symptoms, and hence, he stopped going there two days before coming to our tertiary care hospital.

Figure 1: Wet cupping therapy on the head with blood oozing from incision sites<

Figure 1: Wet cupping therapy on the head with blood oozing from incision sites<

On examination, the patient had a pulse rate of 76 beats per minute, blood pressure of 128/78 mm Hg, and respiratory rate of 22 per minute. He was well-oriented to time, place, and person. Systemic examination of the cardiovascular system was unremarkable. He denied any other substance use. The skin over his head had distinct cupping marks but no signs of infection or active bleeding, which are some common complications after cupping therapy (Figure 2). On assessment, the patient had a Clinical Opiate Withdrawal Scale (COWS) score of 13 and a Clinical Institute Withdrawal Assessment (CIWA) scale score of 26.

Figure 2: Cupping marks on the head`

Figure 2: Cupping marks on the head

Later, the patient was admitted to the psychiatric ward to manage the withdrawal symptoms, where we initiated pharmacotherapy. Tablet diazepam (20 mg/day), sodium valproate (800 mg/day), tramadol (200 mg/day), thiamine (300 mg/day), paracetamol (500 mg/day) and intravenous fluids were given to the patient. We counseled the patient regarding substance abuse, its harmful effects, and de-addiction. The patient’s symptoms started to improve, and we continued the treatment for four days and discharged him with a COWS score of 4 and a CIWA score of 2. We intended to reassess him after 14 days, but we lost him to follow-up.

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