Embark on a journey through integrative medicine with hosts Dr. Joshua Goldenberg and Dr. Adam Sadowski as they explore acupuncture's potential in treating endometriosis. Delve into recent research and meta-analysis, navigating acupuncture's efficacy and its impact on endometriosis-related pain. Join the enlightening conversation and connect with the hosts on social media at drjournalclub.com to drive evidence-based discussions forward.
https://pubmed.ncbi.nlm.nih.gov/38033648/
Giese N, Kwon KK, Armour M. Acupuncture for endometriosis: A systematic review and meta-analysis. Integr Med Res. 2023 Dec;12(4):101003. doi: 10.1016/j.imr.2023.101003. Epub 2023 Oct 28. PMID: 38033648; PMCID: PMC10682677.
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Embark on a journey through integrative medicine with hosts Dr. Joshua Goldenberg and Dr. Adam Sadowski as they explore acupuncture's potential in treating endometriosis. Delve into recent research and meta-analysis, navigating acupuncture's efficacy and its impact on endometriosis-related pain. Join the enlightening conversation and connect with the hosts on social media at drjournalclub.com to drive evidence-based discussions forward.
https://pubmed.ncbi.nlm.nih.gov/38033648/
Giese N, Kwon KK, Armour M. Acupuncture for endometriosis: A systematic review and meta-analysis. Integr Med Res. 2023 Dec;12(4):101003. doi: 10.1016/j.imr.2023.101003. Epub 2023 Oct 28. PMID: 38033648; PMCID: PMC10682677.
Learn more and become a member at www.DrJournalClub.com
Check out our complete offerings of NANCEAC-approved Continuing Education Courses.
Welcome to the Dr Journal Club podcast, the show that goes under the hood of evidence-based integrative medicine. We review recent research articles, interview evidence-based medicine thought leaders and discuss the challenges and opportunities of integrating evidence-based and integrative medicine. Continue your learning after the show at www. d rjournalclub. com.
Dr. Joshua Goldenberg:Please bear in mind that this is for educational and entertainment purposes only. Talk to your doctor before making any medical decisions, changes, etc. Everything we're talking about that's to teach you guys stuff and have fun. We are not your doctors. Also, we would love to answer your specific questions on drjournalclub. com. You can post questions and comments for specific videos, but go ahead and email us directly at josh at drjournalclub. com. That's josh at drjournalclub. com. Send us your listener questions and we will discuss it on our pod. I just saw your name. You're killing me, dude.
Dr. Adam Sadowski:Okay, all right.
Dr. Joshua Goldenberg:These names are getting more and more inappropriate. Okay, Dr. Sadowski, despite what your name tag says, little river side thing here. How are you doing today?
Dr. Adam Sadowski:I'm doing great. How are you?
Dr. Joshua Goldenberg:Just fine, thank you very much. So today we're talking about endometriosis. We had a listener request for a paper on endometriosis and integrative medicine and I found a nice little paper published recently. I was kind of surprised about how nice um on acupuncture, and then it was like oh man, I don't think we've ever done an acupuncture review at all. I don't think, or endometriosis or endometriosis that's.
Dr. Adam Sadowski:Yeah.
Dr. Joshua Goldenberg:So it's a double whammy. We definitely need to do this and, yeah, and I don't know much about acupuncture at all, let alone acupuncture research, so it's a little bit of content expertise that we might rely on our listeners to call in and correct us with. But yeah, so I feel like we have some good information to go on. Do you have any starting comments before we jump into the paper?
Dr. Adam Sadowski:I have no starting comments, nope.
Dr. Joshua Goldenberg:Okay, so we'll put the link in the show notes. So this is a review article Acupuncture for Endometriosis by Gies et al G-I-E-S-E Just came out last year in 2023. And it's a systematic review and meta-analysis looking at acupuncture and endometriosis, so for the treatment therein. And so I figure, yeah, let's, why don't we go through the methods first and then we can kind of talk about the results and basically go page by page? I think just kind of make our way through here. So what's the first thing you noticed looking at the paper and basically go page by page? I think just kind of make our way through here. Sure, so what's the first thing you noticed looking at the paper? What are your first impressions?
Dr. Adam Sadowski:Well, the first thing I noticed was that when looking at the abstract, they put in the study registration Prospero ID, which is usually a good sign, yeah, I agree. So right off the bat I knew that we're going to get into something pretty good here. Um and I I typically don't read introductions, this one was really nice and short, which I actually enjoyed.
Dr. Joshua Goldenberg:They got oh, you actually read the introduction this time. That is impressive.
Dr. Adam Sadowski:Unlike you, I'm not an endometriosis expert, and so I was actually kind of interested to see what they had to say.
Dr. Joshua Goldenberg:Yep, yep, yep.
Dr. Adam Sadowski:And it was only like three paragraphs long and very short paragraphs. So I did like the fact that they kept it nice and short and really to the point and highlighted that the aims of the paper was to determine the effects of acupuncture on endometriosis-related pain and health-related quality of life. And something that I really liked is that they focused this paper with sort of another aim of contributing to the evidence-based guidelines for endometriosis. So it wasn't just oh, let's see what this research is. There was a lot of intent behind it, which you know. You would think that you would always want research to have good intent behind it, but oftentimes you kind of just see these studies that are just kind of being done just because they can, whereas with this one there seems to be like a lot of intentionality behind it. So not only is there evidence, or what is the evidence with regards to the efficacy of acupuncture, but can this influence guidelines for the management of endometriosis? So can this have overarching impact for this condition?
Dr. Joshua Goldenberg:Yeah, I think you're spot on on that. Reading between the lines, I think they have a guideline development in place now, like it'll probably come out next year, I would imagine. And the most brilliant way of doing that, according to like all the recent guidelines on this for grade, is first you do a systematic review of meta-analysis and then that information informs your guideline panel on doing grade guidelines and you can tell just by the quality of how they set this up that they're just really following, I think, grade by the book. So, yeah, I was super impressed with all that as well and I agree, I think so.
Dr. Joshua Goldenberg:I am not an endometriosis expert and so I also read the introduction and I agree. I think it gave a good initial sense. You know, one of the surprising things to me is like they were saying that once you use MRI to help make that diagnosis, something like one in five women have endometriosis. Like that was shocking to me. I didn't realize it was quite that high of prevalence. I knew it was common. I have lots of patients that have it in clinic but I had absolutely no idea it was that common. So super, super common condition can have debilitating effects on quality of life and all sorts of stuff and the medication apparently is not great. The satisfaction around surgery is not great either. So there's this appetite, if you will, for you know, integrative and complementary approaches or other approaches and that sort of set up the rationale.
Dr. Joshua Goldenberg:I thought, pretty well, now, as far as you know, and they're acupuncturists, right? So I think one or two of the authors are acupuncturists and so that's their background, that's what they're looking for. Now I don't understand the acupuncture side of all this, but it looked like they were pretty inclusive of different acupuncture styles. So, whether it was five element or traditional or what have you. So if you are an acupuncturist, an LAC, go read the paper. It's freely available online, and I think it's freely available online, and I think it's freely available online and let us know if you have any concerns. But from our read, it looked pretty good from a methods perspective. So okay, cool. Anything else to add before we jump into methods?
Dr. Adam Sadowski:No, but since we're going to kind of transition to methods, anyway, you can kind of tell a paper is going to be good, just kind of like how well they break it down, how easy it reads in the fact that it's just, it's just very linear. In as you're reading you're like, oh, this makes sense. Okay, this, this makes sense. You're not like having to flip through pages back and forth and like try to figure out what's going on. It was very, it was like if you're a student doing a systematic review and meta analysis, this would be a really good paper to reference or to like help guide you through the process.
Dr. Joshua Goldenberg:So, dear listener, you might mark this, mark this on your calendars. I think this is the only time I've this is, by the way, in case you didn't, is adam gushing about a paper, and that's one of the few times I've seen him gushing about paper. In fact, as we were reading it and prepping and doing our quote-unquote green room, which is text back and forth in preparation, it was just hilarious because, like, as you go, section by section, I would get these like and did you see this? Like exclamation point, and did you see that? And look what they did here? That's hilarious. So, yeah, no, I had similar feels. It looked like I was telling you my little, soon to be three year old, she'll. She'll be like you know, if you do something good, good by her, she'll be like oh, you make my heart happy and which is adorable. But that's what I felt, like. It made my little methods heart happy to read through this and I agree, the Prospero or Prospero registration was like the first indication that, yes, this is good. Oh, that reminds me.
Dr. Joshua Goldenberg:So we've talked about quality and systematic reviews before and we've talked about using the Amstar 2 tool to evaluate that, and I think I'm going to start teaching that. So next month at Sonoran I'm going to put together a lecture on how clinicians can use the MSTAR-2. But I was like, ah, that's pretty onerous. But they have, of the I don't know 20 domains to look at. Seven of them they consider critical domains, like if you get one of those wrong, the study is critically flawed, you can basically throw it out. So I'm going to start calling these the seven deadly sins, and I think that's how I'm going to teach. It is to have people look for these seven things whenever they're looking at a systematic review.
Dr. Joshua Goldenberg:And so the number one thing is that the protocol was registered before commencement of the review. Like, first of all, you have to have it freaking registered and you have to register before you start the review. And not only is it registered in Prospero, which is where it should be registered, and you have to register before you start the review, and not only is it registered in Prospero, which is where it should be registered. They actually have a sentence that specifically says that they didn't change anything in the registration after they started the study. So normally, if you do need to make methods changes as you go, you just have to justify it and do a timestamp, but rarely do you see that they actually explicitly tell you if any changes were made. So yeah, made my heart happy, good, good, good. They described the issues in PICOS, which is wonderful. It's just randomized control trials, so we're starting with. High-level evidence only would be includable in here and, yeah, go ahead.
Dr. Adam Sadowski:They did make the comment that crossover randomized control trials were also allowed to be in, but they only took the first period of that crossover. So this way they didn't dilute any effects from a carryover period. So for those who aren't aware, with a crossover randomized control trial you would start off like one group would get the intervention and one group would be in the control group and then at some point they would flip and in a good crossover randomized control trial that blinding would be maintained throughout. So you don't know when you're getting intervention and when you would be getting placebo. And another good crossover randomized trial would also have basically like a washout period where when you're switching from intervention to placebo, theoretically the carryover from any sort of treatment effects is not being carried over into that transition.
Dr. Joshua Goldenberg:Yeah, exactly. Yeah, so that's a common workaround for these complicated trials is to just take the first half of it essentially and view it like a regular randomized controlled trial for the purposes of the meta-analysis. So that was totally kosher, I think, a good point pointing that out. As far as the different types of intervention, yeah, this was mostly over my head, but they said that they included traditional Chinese, five element Japanese or biomedical, sometimes called Western. So that would be relevant to the listener, just if you're trying to find, okay, like great this, you know, here's the results, but which type of acupuncture should I pursue?
Dr. Adam Sadowski:Which I think is really important too, that they classified it because you know, instead of just saying acupuncture, it really varies, there's different types of acupuncture. So the fact that they did highlight that and tried to analyze it by type of acupuncture, I think is actually really important.
Dr. Joshua Goldenberg:Yeah. So this is the thing I hear a lot from acupuncturists, where they get really frustrated with the research in their field because they're like well, the researchers clearly didn't know what they're talking about, they combine this with that, or they didn't even do it right, or that's not even acupuncture, and so I think, to their credit. I mean, amongst integrative medicine, in fields, I feel like acupuncture has more high quality research than almost any other field. They're just like light years ahead of the rest of us and they've developed these strict criteria, checklists, reporting, checklists to be transparent about how these studies are done and how they're classified. And do we have integrity? What was it called? Content validity? Basically like if you went to an acupuncturist and showed them this, they would say, oh yeah, that's definitely acupuncture and it's done well, etc. Etc. So again, just very, very impressed so far.
Dr. Adam Sadowski:I think too this is why, like, it's necessary to have content experts within, research, even if they're not like primary authors, having them as part of kind of like how a lot of papers in the BMJ will require public say into, like what is actually clinically important or like what would be an important patient reported outcome it's not just a bunch of clinicians doing the research, but having some content experts in there to you know, to make sure that what is being studied is actually important.
Dr. Joshua Goldenberg:Yeah, absolutely so. As far as we can tell, not being acupuncture experts ourselves, this looks pretty legit both from an internal and external validity perspective, meaning the methods look good and it seems to have external validity from an acupuncture perspective. But again, acupuncturists, please feel free to call in and yell at us, but there is one thing. So I have only one issue with this entire paper, which is in the next section, as we move through the methods here. Oh, so sorry, outcomes. So they're looking at pain outcomes. They're looking at quality of life outcomes. They're looking at adverse events. They're looking at endometriosis, specific instruments. So these are very good .
Dr. Adam Sadowski:And the primary outcome was pain severity, with the secondary outcome being adverse events and health related quality of life, and just because we haven't touched on it yet, the main patient population that they're looking at is people of reproductive age yes, With pelvic pain or abnormal or, excuse me, pain with menses with a confirmed diagnosis of endometriosis that was either confirmed through laparoscopy, ultrasound, MRI or histopathology. So people who you know they're definitively basically diagnosed with endometriosis, not just sort of like, oh you might have endometriosis and let's see if this helps, right.
Dr. Joshua Goldenberg:So we've got some imaging or surgery evidence and you've got pain, primarily, and let's see what acupuncture does. So they looked at the only. Again, the only issue is the only studies that they looked at were in English or German, so they excluded studies in other languages. Now that's particularly a concern in acupuncture, because a lot of acupuncture research is done in Chinese. Right, it comes out of China, it's done in Chinese, and so I was pretty concerned about the reason it's German. I think one of the authors' practices in Germany I googled her is the acupuncturist in Germany, and so there's your content expert. But yeah, it was kind of surprising, and I think later, when they actually, again to their credit, are transparent about their exclusions, I think almost double the amount of study. Well, so that like they could have doubled the number of studies if they also included Chinese articles, but anyway, so I think that's the main issue is that they're missing possibly half of the evidence base, but so anyway, so we only have these English and German studies.
Dr. Joshua Goldenberg:The search itself I thought was excellent. It was well described. They looked at multiple databases. Really importantly, they looked at databases that are specific to like integrative medicine. So they looked at AMED, which is a database on allied and complementary medicine. So a lot of times you'll have these really lazy searches where they do like PubMed and pretty much that's it, and especially if it's a content specific area, you want to make sure you're checking those content specific databases. So they did a really excellent search. I was super thrilled with that detailed design fully provided in the supplement, and then they did their screening independently and in duplicate, which is super important, and they did their data extraction independently in a duplicate, which is also super super important. Quality assessments of the studies as well, risk of bias and also specific checklists for acupuncture itself. So things like NICMN, which I didn't know beforehand, and then STRICTA, which apparently are acupuncture, specific checklists and guidelines for quality, which was seems important.
Dr. Adam Sadowski:Yeah, so the NICMN scale is the National Institute for Complementary Medicine Acupuncture Network and it appears to be, you know, recommended to be used along with the STRICTA checklist. And the whole purpose of having those checklists in place is to make sure that when we're doing acupuncture research we're having a consistency in how it's basically being reported, to make sure that we have consistency in the literature so we can make a better sort of conclusion or estimate or know where things need to be altered. Because if we can have a standardization to something that many practitioners will already say is sort of like a heterogeneous type of intervention to begin with, this gives us some sort of a standard to work with and it's not to say you can only use these acupuncture points for every single patient. That's not what it's saying. But what these guidelines are saying is okay.
Dr. Adam Sadowski:You know what is the reason for the acupuncture? How was the needling done? What was the treatment regimen? What were the other components of the regimen? Was the person performing the acupuncture have some sort of acupuncture background? So, for example, was it like a physical therapist doing dry needling? Is that consistent with acupuncture? Or was it someone who has a background in traditional Chinese medicine or classical Chinese medicine or you know, an acupuncture degree. And then how did they have their comparison group, like what was the outline of that? So if we can have a standardization procedure, we can make a better estimate and draw better conclusions to with regards to acupuncture as an intervention.
Dr. Joshua Goldenberg:Yep, super well said and I think we're the. The editor community and the journal community is moving towards better reporting standards, but it's still a lot of concern out there. Herbal medicine is the big problem, for example, but yeah, so it's really important to be standardized and how this stuff is reported.
Dr. Adam Sadowski:And I think that's just complementary and in alternative medicine or, excuse me, complementary integrative health. Because you know, if you were to say, like you and I have a background as NDs, when I see research that says naturopathy, what the hell does that mean? Because naturopathy is not an intervention. In my opinion, it's a spectrum from which you are able to sort of choose interventions, from something that includes, like you know, body work or body manipulation to even surgical intervention. So to say, you know, we studied nat body manipulation, to even surgical intervention. So to say, you know, we studied naturopathy as an intervention. You have to define that.
Dr. Adam Sadowski:And so how are we going to standardize what naturopathy is from a research setting? Are we looking at naturopathic herbal intervention or just healthcare delivery from a naturopath, where that naturopath ultimately decided how that patient or that research subject got an intervention? So, having something in place for acupuncture, I actually appreciated, and the fact that they're saying, hey, you should combine this with this other scale to get this holistic, develop this holistic evidence base for understanding the intervention of acupuncture. I thought that was cool and important.
Dr. Joshua Goldenberg:Yeah, no, really good point. I mean, I think with herbs you can say like, okay, it's this one plant that we're studying and there's still a million variables like when was it harvested, what kind of extract, yada, yada, yada. But to your point, like to say, acupuncture period is kind of ridiculous and analogous to saying, you know, naturopathy period or medicine period, right, like what the hell does that mean? And so yeah. So again, even more important, to be clear about these, these different interventions, and I think they did a good job. We'll get to it, but I think one of the tables, they did a pretty good job of showing these, the different aspects of these interventions. So if you, you know, did want to, if you're a provider and you wanted to try these, you know needling techniques, you would be able to see very clearly which ones were used, when they got the effects that they did and what else. Oh, and they use grade, of course, which is our favorite, which is the way of assessing the overall confidence in the evidence.
Dr. Adam Sadowski:One last thing I just wanted to kind of say about the. The Nickman in the stricta, yes, is you can kind of view the stricta as like a prisma checklist. Did the research authors have this checklist when developing the acupuncture study? And then the Nickman is kind of like the grade of the acupuncture. So was there a checklist in how they reported it or kind of like a strobe guideline for observational studies? Where like, are they following this sort of criteria as to how to report? And then the NICMN sort of quantifies the quality of that reporting, where higher scores indicate better quality better quality, like reporting, or like better quality study, like more trustworthy.
Dr. Adam Sadowski:To my understanding it seems like better quality in the reporting, In the reporting which sort of indirectly then translates to perhaps a better quality study.
Dr. Joshua Goldenberg:Yeah, and then, but to the quality piece, like they did, they also did risk of bias assessment. So the straight up, well, yeah, so that I guess the straight up risk of bias assessment. So the straight up, well, yeah, so I guess the straight up risk of bias. They did with the risk of bias scale. And then, right, then they use these others to sort of describe how well reported the other studies are. Okay, cool, I think I'm with you now. Good, good, good, good.
Dr. Joshua Goldenberg:And then they did a meta-analysis and used GRADE to talk about the overall evidence and we'll talk about the results in a second. And the way they use meta-analysis is they looked at mean difference. So you know, if you're talking about a 10-point pain scale and on average you could say, okay, they dropped two points of pain, or something like that, that would be a mean difference. If the way you're describing the result is using different instruments, it gets a little bit more complicated. You do things like standardized mean difference or, in this case, hedges g. I don't know that we need to get into super detail on that, but basically it's a way to to say, okay, what is the overall effect, even if these studies use different instruments? Here, and then we have these thresholds that we use to say if that's a small, moderate or large effect, correct, okay, cool. Anything to add on that one?
Dr. Adam Sadowski:No, but it seems like with Hedges G that we are using that for smaller size studies, whereas other, like a Cohen's D, you might see, is used for larger studies.
Dr. Joshua Goldenberg:Right, exactly, and I think it's technically, I think it's more conservative and then also, but you can think of it analogously, like if you're used to thinking of Cohen d's thresholds, like point two is small, point five is moderate and point eight is a large effect. I believe that is sort of an analogous threshold, so you can kind of think of it the same way, even if you haven't heard of Hedge's g before, of an analogous threshold. So you can kind of think of it the same way, even if you haven't heard of Hedges' G before. Okay, cool, they did look at subgroup analysis, or they planned them anyway, for different types of acupuncture, so that absolutely makes sense. The total number of treatments and the mode of stimulation, so manual or electro acupuncture, so that all makes sense. These would be reasonable subgroups to look at a priori. And, yeah, data amputation is boring but pretty straightforward, yeah. So overall I think I'm good with the methods. I'm looking here at our seven deadly sins and let's just see if we can go through these. Look, the thing is we don't do this for money. This is pro bono and, quite honestly, the mothership kind of ekes it out every month or so, right? So we do this because we care about this. We think it's important, we think that integrating evidence-based medicine and integrative medicine is essential and there just aren't other resources out there the moment. We find something that does it better, we'll probably drop it. We're busy folks, but right now this is what's out there that does it better. We'll probably drop it. We're busy folks, but right now this is what's out there. Unfortunately, that's it, and so we're going to keep on fighting that good fight. And if you believe in that, if you believe in intellectual honesty in the profession and integrative medicine and being an integrative provider and bringing that into the integrative space, please help us, and you can help us by becoming a member on Dr Journal Club. If you're in need of continuing education credits, take our NANSEAC approved courses. We have ethics courses, pharmacy courses, general courses. Interact with us on social media, listen to the podcast, rate our podcast, tell your friends. These are all ways that you can sort of help support the cause.
Dr. Joshua Goldenberg:Deadly sin number one Did they register the protocol? Yes, they did. Check Adequacy of the literature search is sin number two. Yes, I thought that was an excellent literature search. Justification for excluding individual studies they do give I think that comes later. They do give reasons for which studies they excluded. Did they do risk of bias assessments? Yes, check the appropriateness of meta-analytic methods. That looks good to me. We just talked about that. Did they consider risk of bias when interpreting results? We'll see that they did. That comes a little bit later. And did they talk about the possibility of publication bias? So, this one, they did talk about it. They didn't assess because they didn't have enough studies, and we'll get there in a second. I'm a little on the fence of this because I feel like they missed half the data because they didn't look at published Chinese studies. But so I would say, maybe a half a deadly sin, but overall a pretty good study. Anything else you want to add about methods or concerns or anything like that?
Dr. Adam Sadowski:No, and I get where you're coming from, but I don't, I don't really think it's that big of a sin. I I'd give it a pass okay, fair enough.
Dr. Joshua Goldenberg:Um so all right, so we'll jump into the results here. Um to okay. So they talked about how the studies were excluded.
Dr. Joshua Goldenberg:They found six final studies out of 1074 hits yeah, so, oh, okay, hello, we talked about this last time. Yeah, remember when they had like all these databases and they had like 74 hits and they were like we did this extensive search of like bs. So this is a more normal search result. You would expect a thousand plus hits or whatever, and then you whittle it down, so it it didn't, it didn't look suspicious, it looked perfect. And so, of those 1000, they went through and they found six randomized control trials that met their inclusion criteria, with 371 participants overall. I'm curious how you want to handle this. I'm thinking we just jump to like the tables or plots to talk about results, or did you want to go through it in in text form?
Dr. Adam Sadowski:I could just like quickly go through it. What annoyed me about this paper was that there was just a lot of text when there really didn't need to be. That's why I went to the tables yeah, results section, and if you read through it all, you could have kind of gotten a little misled. Basically, from the 1074 hits, six studies, 371 total participants, four of them were your typical randomized controlled trial where you have acupuncture versus a control group. One study used a crossover design, but remember they only used that initial part prior to the groups actually crossing over. And then two studies were done in China, one in Australia, one in the USA, one in Austria, one in Brazil. The median age was 30, and all studies used laparoscopy or laparotomy to diagnose endometriosis. And then the acupuncture styles. There were two traditional Chinese medicine style, one Japanese style, one ear acupuncture, and then two did not specify the style of acupuncture that was used.
Dr. Adam Sadowski:What I actually really appreciated was that, when they were looking at the studies, three studies used a fixed treatment protocol. So no matter who walked in through that door, if they had the diagnosis, this was the acupuncture they were getting. It was basically an algorithm you get this, that's it. One study used a semi-individualized treatment, so I'm not really sure what that meant. It looked like they had fixed points that were going to be used, but then they had three points that could have or could have not been used, depending on the clinician that was delivering the acupuncture, and then one used an individualized point. However, it wasn't really individualized because they had an a priori determined algorithm, so not really individualized in my opinion.
Dr. Joshua Goldenberg:Quasi individualized Algorithmic, I guess.
Dr. Adam Sadowski:So AI acupuncture essentially uh for for the acupuncturists out there. On average they used 13 needles. From a needle stimulation standpoint, one study looked at manual stimulation. One person was hooked up to a car battery and electrically stimulated this is a thing.
Dr. Joshua Goldenberg:Electroacupuncture is a thing, man one study.
Dr. Adam Sadowski:They used no stimulation and then three did not report on it from a needle place but is stim?
Dr. Joshua Goldenberg:is that, does that mean, is that chi or is that different chi? Well, like you know, when you're um, why do we do electric stimulation? No, like, there's like um she's like the energy channels no, I know, but.
Dr. Joshua Goldenberg:But I'm like butchering this. But there's like a thing that you get when you stimulate it and you like bring about the chi or something like it grabs at it, or something like that. There's a way to stimulate that Electrocution. No, all right, move on. We clearly have no idea what we're talking about when it comes to the actual intervention. But oh, oh, yeah, look at this. Okay, I'm not making this up. They d, g, d, e, next word, q, I, d, g, um, and again, I'm probably butchering that, but I think that's the, that's what you're going for, that you like hit the, hit the site, right, I believe, anyway.
Dr. Adam Sadowski:So I'm not making that up, but I'm probably butchering the pronunciation two studies left the needles in place for 20 to 30 minutes, Two had them in place for less than 20 minutes and then for two studies. They did not report on how long the time was there for Cool.
Dr. Joshua Goldenberg:And they go through all the different points that we're used to. So if you're an acupuncturist I'll tell you, like spleen six, liver three, liver eight, so you can go through and actually see what was needled.
Dr. Adam Sadowski:And then from the practitioner background, for those who that like the people delivering the acupuncture, three were licensed or registered acupuncturist, or in one study there was a doctor of traditional Chinese medicine. One study included physiotherapists, and then competency regarding acupuncture was unclear.
Dr. Joshua Goldenberg:Yeah, so this was cool too, because you know, you never know who's implementing the actual intervention and sometimes it's people that are like quickly trained before the trial. So again, explain again. This goes to external validity or content validity. Basically saying this is these people actually knew what they were doing they're well trained.
Dr. Adam Sadowski:Yada, yada yada. And then the last thing that I thought was actually really cool was when they looked at the Nickman scores. They range from 13 to 22. And the score goes up to 23. And so the mean score was a 19. So so fairly high quality in the reporting. The Nickman looks like it was reported after 2016. And they did find that prior to 2016, those scores on average were an 18. And then after that, on average was a 21 and a half. So basically, after these guidelines were in place for how to report acupuncture studies, they found that the quality of reporting did in fact, improve.
Dr. Joshua Goldenberg:So I think that was interesting and cool.
Dr. Joshua Goldenberg:Yeah, again, I think that a field of acupuncture, from a research perspective, is like again, head and shoulders above the rest of us, maybe chiropractics after them, and I feel like we're on the bottom. But yeah, they do. They do a really, really good job in standardizing and high quality research. So, okay, awesome, oh, and just just a range of treatments. So we're talking about, you know, anywhere from five to 16 treatment sessions to get the effects that we're talking about here. And they talked about different comparators. I don't know that we need to. Did you want to jump into the comparators at all or Not? Really, not really. Yeah, I think that's totally fine. Talked about you. Talked about quality, perfect risk of bias.
Dr. Adam Sadowski:Well, actually I rescind that. I take that back because the the type of intervention or the type of comparator does seem to matter. When you're kind of looking at acupuncture research and those who are sort of like very much for acupuncture and those who are very much against acupuncture or seem to be less so inclined in sort of believing the research that's out there, the majority of the comparisons were non-specific acupuncture and I'm not entirely sure what that was defined as. To my understanding was they kind of just like put random needles into people. So they weren't in like specific, like gallbladder seven or liver three points. They were just kind of like adjacent to it or maybe somewhere like completely random. One comparison was medical which is a clever.
Dr. Joshua Goldenberg:A clever thing, right, because it controls for the whole ritual, the experience, the puncturing of the skin, everything except for actually needling these channels.
Dr. Adam Sadowski:Right, the theater, um yeah, it's very clever and and you know, and they they did kind of specify in some of the studies, like the study from brazil, used non-specific acupuncture where there was a stimulated therapy with a needle insertion three centimeters apart from the original point, so like relatively close to where it would be, but actually not at that point. And then one nonspecific acupuncture was with no correlation to endometriosis. Another one was out without any sort of stimulation. Another comparison was medical advice but no traditional Chinese medicine, which I feel like is fair. And then one was compared to Chinese herbal medicine but no acupuncture intervention. It looks like yeah.
Dr. Joshua Goldenberg:So to point, to put a finger on this a little bit more. So these are pretty strong comparators, right, like these would be, you would imagine. These would have pretty strong either active or placebo effects, and so if you do see an effect in a study like that, which we're going to see in a second they really did it's even more impressive because the control group, you would think, would have pretty impressive placebo effects. So we're talking about the differential, the difference between these, and the fact that that's as impressive as it ends up being, I think, is even more so. It's not like it was a weightless control or they gave them a little placebo pill. These were pretty impressive controls, and so any difference that you see above that, I think, is a pretty strong indication of efficacy.
Dr. Adam Sadowski:Yeah, agreed.
Dr. Joshua Goldenberg:Okay, cool, so quickly. Risk of bias so we had the six studies. So one of the studies was considered a low risk of bias, two had some concerns and then three were high risk of bias. So we'll see later. That mixed bag, with only one low risk of bias studied, lowered the grade level overall for some of the rankings and we'll talk about that in a sec. But overall the grade level for the different outcomes ranged from moderate to very low, and so moderate's pretty good.
Dr. Adam Sadowski:However, moderate certainty of evidence really only happened, I think, on one or two occasions. The rest of the time it was low to very low.
Dr. Joshua Goldenberg:Yeah, and so we'll jump into that one Agree. And then they didn't do a publication bias assessment because they had too few studies. That's actually appropriate. The rule of thumb is 10. So if you have less than 10, it's an underpowered test to look for publication bias. So it's reasonable what they did. But again I have concerns about you know there are six. You had, you found six studies and five. You found five studies in Chinese. Like you could have doubled your data right there. But anyway, I'll leave that alone. Mildson, according to Adam, all right. So Pansferdi, blah, blah, blah, blah, blah, all right, so let's jump into. Should we jump into the actual results? Do you? Should we let's's? What do you? What do you think? Should we go to the summary of findings table? How should we go through this?
Dr. Adam Sadowski:I think the summary of a finding uh table is sort of the best bet, because you can get really lost uh in the sauce with all the text. Yeah, and really we have to remember that our primary outcome was the effect of acupuncture on on endometriosis related pain. Right, and within that there were subdivisions of okay, is this menstrual pain, is this non-specific endometriosis pain? Is this pelvic pain? And so they they in in the table. They did a good job of just overall pain, menstrual pain and then health related quality of life.
Dr. Joshua Goldenberg:Yeah, so this is beautiful. So we're talking about table two, if you're following along, and this is this gorgeousness is called the summary of findings table, which is recommended by grade and by Cochran to present information in a digestible way, and it's a beautiful, beautiful thing. So, yeah, we can probably get everything else that we need to talk about from this one table. So overall pain when we're talking about acupuncture compared to nonspecific acupuncture for endometriosis. So again, against a strong control you would expect a smaller effect, but we see overall pain hedges G of 1.5, which again, that's double the threshold of about double the threshold of what we would consider a large effect.
Dr. Joshua Goldenberg:So a very large effect on pain overall and that's based on three randomized control trials, over 200 participants with a low grade level and that's knocked down two levels because of risk of bias. So we talked about that before. Only one study had a low risk of bias and then the heterogeneity as well was another reason that they knocked it down. So it went down from high to moderate and then down to low. So it's low-level evidence based on three randomized controlled trials, but a very large effect size on overall pain. We see a similar thing with non-specified pain using a mean difference on a 10-point scale 2.77 centimeters lower. Two randomized controlled trials, again low grade level. So overall low grade evidence from randomized trials of a pretty large clinically meaningful effect.
Dr. Adam Sadowski:The way that you can kind of you know clinically sort of make that discussion with a patient is hey, you know where do you rate your pain on a scale of one to 10? Oh, you're interested in acupuncture. Okay, there's some shoddy evidence that suggests that you know, we could lower, we could improve your pain. Let's say, your pain level right now is at a seven. It may go down to a four with acupuncture. You know, are you interested in pursuing that, yes or no?
Dr. Joshua Goldenberg:Yeah, totally Exactly. And then actually. So let's talk about the, the, the few items that had moderate level grade evidence to your point, sure. The few items that had moderate level grade evidence to your point, sure. So that is. Menstrual pain specifically had a large effect size, very large effect size, with moderate level grade evidence. So that's pretty darn good. It got ranked down once for imprecision, and that's because this is just based on one randomized controlled trial. So that was the low risk of bias study of about 100 participants. So you have one randomized controlled trial. So that was the low risk of bias study of about 100 participants. So you have one randomized controlled trial on 100 people showing a very large effect on menstrual pain.
Dr. Adam Sadowski:However, that was at the end of the treatment Right when we then look at follow up, that moderate looks like then became very low larger effect but yeah, but very low quality evidence of much less confidence in that follow up period.
Dr. Joshua Goldenberg:So much more confidence to say you go, you're, you're having menstrual pain, you go get acupuncture, you finish it and you feel really good and that is well more and above beyond placebo effects, based on the control when they check in with you like weeks or months later it's unclear if you'll be better, but it seems like we have much more confidence in that treatment effect right away type of thing.
Dr. Adam Sadowski:And then also look at that sort of drop off in number of participants. You went from 106 to 42.
Dr. Joshua Goldenberg:Yeah, so they basically like lost to fall up 60% of those participants of high, highly dubious data set. I would probably just throw that out. That's a good point, even though it's a large effect. I can't really put much faith in that at all, but you can put decent faith in post treatment response, which I think is pretty good. Okay, what else? Anything else you want to focus on here? Yeah, so again, follow-up not great where?
Dr. Adam Sadowski:you have a clinically important outcome and we have moderate certainty evidence for a low magnitude of effect. The Hedge's G here was only 0.19. So let's round up to 0.2. And the cutoff for 0.2 was 0.2 for a small treatment effect and that's probably more honest. Yeah, If you just kind of think about medicine in general, most a lot of things work, but to what degrees? The magnitude of that treatment effect and it's it's typically small.
Dr. Joshua Goldenberg:Well, and also like you need to keep on taking it for it to work. So like that's the way I think about it. It's like if you're popping, you know aspirin for the pain and it works while you're taking aspirin, but then you stop taking aspirin and you check two weeks later and the effect is meaningless. Like pretty close to being this year just at under the threshold of minimal important difference. That's not so crazy, it's. It's analogous like you go get acupuncture. You feel better Two weeks later post-acupuncture. It doesn't. It doesn't. It doesn't look like the effect holds. Let's put it that way. I think it's a fair statement to say you're getting a pretty large effect with decent level evidence at the treatment once you get the acupuncture. But yeah, like weeks later probably not really going to still work. Is that fair? Would you agree with that?
Dr. Adam Sadowski:Well, the interesting thing here is that this was measured at follow-up. Yeah, so that's my point. Oh, yeah, then yes, I agree, yeah, totally.
Dr. Joshua Goldenberg:Cool, and then let's see what else. Quality of life yeah, also. So look at this. But this is flipped. Oh, no, no, no, yeah, look at this. So, but but flip, but this is flipped. Oh, no, no, but this is uh. Yeah, look at that. This is interesting story. Quality of life so, whereas we have decent evidence for a large effect on pain after the treatment, like with with the treatment we have very low evidence that there's an impact on quality of life at treatment, but we have pretty decent evidence at follow-up. That's kind of an inverse there on the quality of life. So I'm not sure what to make of that.
Dr. Adam Sadowski:Well, perhaps that kind of makes sense, because when you're looking at health-related quality of life at the end of a treatment, that kind of seems like too acute of a timeframe to see if it's really impacting your quality of life. But then if you measure again that follow-up oh, let's say several weeks later it's like, okay, well, how's your quality of life? It's like, oh, actually I mean, perhaps this is, this is improved. But then again you have to think into account, like a recall bias with that yeah, yeah, that's a really good point, yeah, nice enough.
Dr. Joshua Goldenberg:So sort of an interesting thing going on there, although the effect was was moderate, so decent, decent effect on quality of life at follow up. And then the rest of the outcomes are just very low level evidence, just because we, you know, there aren't a lot of studies or there's just not a lot of people, and so these are for acupuncture compared to sham or acupuncture compared to herbs or acupuncture compared to usual care. So really the best evidence we have is going to be compared to nonspecific acupuncture, which again is even, in my opinion, more impressive because again, those are harder comparators to beat out. I think that's all I wanted to say on the overall effects. Anything else you wanted to add on that one?
Dr. Adam Sadowski:That was it. Unfortunately, they weren't able to do any sort of subgroup analyses, because each subgroup was too small to provide any sort of reliable conclusion. I mean, overall, this was a really well done meta-analysis. I think that the main limitations are just the fact there's just too few studies.
Dr. Joshua Goldenberg:They could have doubled it if they looked at Chinese studies just saying, Well, maybe we don't know that. Yeah, there were five Chinese studies that were excluded just because of language.
Dr. Adam Sadowski:Oh, Okay. Well, yeah, I mean remember when it's like low quality of evidence or when the grade is very low. Well, with grade very low, it's saying that future studies are unlikely to impact the results of that. Is that correct?
Dr. Joshua Goldenberg:Grade very low or grade high.
Dr. Adam Sadowski:Grade very low, or is it only high grade?
Dr. Joshua Goldenberg:high grade. So high grade. There's like, yeah, there's nothing's going to happen. You can do this big study tomorrow, the effect's not going to change. Uh, very low quality of evidence. They just say the results are uncertain.
Dr. Adam Sadowski:Okay, like they just don't even say anything, yeah the takeaway with this is not that, like acupuncture doesn't work, it's just it's still up in the air is kind of how I would view it, where, like yeah, with with with one sort of area, there was some moderate, there was moderate uh grade uh, but a lot of this was was low to very low, and so we just, we really just need more studies.
Dr. Joshua Goldenberg:Yeah, Um, or just read the. Learn how to read Chinese Um. But okay, now I'm fine, Um, but yeah, so to that point. So high level evidence is like this is the effect. Moderate is this is probably the effect. Low is this may be the effect, and then very low is you can't even trust any of this. So for menstrual pain, it looks like you can. There's probably an effect and a large effect. And then for most other stuff it's like yeah, maybe, maybe, yes, maybe no, Hard to say, Maybe quality of life, improvements to a moderate level at follow up, stuff like that. So to me this looks pretty good. You know, one of the cool things on the discussion they talked about is cost. I did want to bring that up real quick.
Dr. Adam Sadowski:So they're arguing yeah, Discussion section what you read the discussion section.
Dr. Joshua Goldenberg:I did. You read the discussion section. I did. I read the introduction and the discussion. Are you impressed?
Dr. Adam Sadowski:Oh yeah, okay, I'm very impressed, you skipped over. Well, I would have had a small stroke if you said that you also read the discussion and the introduction no, no, no I I skipped straight to that and wanted to see what they said in the conclusion, which I was actually surprised by. In the conclusion, I I was in agreement with them. No spin, huh, no spin.
Dr. Joshua Goldenberg:They didn't try to spin. It's a good paper. Yeah, it was a good good authors yeah Well, very, very well-trained. And you know, you always worry about that Um, and myself included like if you're the actual practitioner of a field, like you have this intellectual and emotional bias and so you're always worried about how this stuff gets spun. And yeah, they did. They were very staid and conservative in their conclusions. They followed cochran guidance on all that um in their languaging and, yeah, super, super impressive.
Dr. Adam Sadowski:would have happened if they were, if they were funded by big needle?
Dr. Joshua Goldenberg:I'm just like I'm just seeing like packets of acupuncture pins now with like big needle on the like the new branding thing or big moxibustion big moxie, yeah, or big chi, that's, that's a, that's a good brand we should, we should trademark that okay um, okay, last thing I wanted to say is, uh, they didn't do an economic analysis.
Dr. Joshua Goldenberg:But one of the things they talked about at the end is this can be an expensive condition because of all the surgeries and medications and stuff like that. Um, but that should be contrasted with the fact that you know if acupuncture isn't covered, you have to go you, you know, five to six times, 16 times, like in these studies, that may add up as well. So you sort of have to like weigh the pros and cons of cost. But again, I think you know, especially if insurance is covering it and things like that, or it's reasonable cost, it seems like a decent thing. We're not giving medical advice, we're just talking about the effects of the study. Anything else you would like to add? Dr Sadowski and again I will refuse to read the name in front of me on the screen Go ahead.
Dr. Adam Sadowski:No, that's it.
Dr. Joshua Goldenberg:Okay, all right.
Dr. Joshua Goldenberg:Well, we hope you enjoyed it. We have a whole slew of listener requests. Actually we have at least five in the docket. So thank you for that. Keep them coming. We will continue to review articles and address concerns as they came up. Last week we talked about a paper Eric Urinell sent us, and we've got a few patient request papers as well. So we'll kind of go through all this and try to get down the docket. Oh, and then a friend of the pod, dr Davis. Dr Mark Davis sent us another request as well. This is a contrast of two conflicting resulted studies, which I think would be an interesting take I don't know that we've ever done that before and sort of tease that apart.
Dr. Adam Sadowski:Well, when we did our lovely homeopathy series, oh yeah.
Dr. Joshua Goldenberg:Oh yeah, so oh, you're going to hate me. I'm like getting back into the whole homeopathy series. Oh yeah, oh, oh yeah, so oh, you're gonna hate me. I'm like getting back into the whole homeopathy research please don't tell me this is another homeopathy study.
Dr. Joshua Goldenberg:I swear no, no, it's not. No, I'm done, except that, like now, I'm being like there's all these active homeopathy studies going on all of a sudden and they're like josh, we need a meta-analyst and I'm like I don't know Adam's going to kill me, but we'll see how that goes. All right, until next time. Dear listener, thank you for putting up with us and we will talk to you later. If you enjoy this podcast, chances are that one of your colleagues and friends probably would as well. Please do us a favor and let them know about the podcast and, if you have a little bit of extra time, even just a few seconds, if you could rate us and review us on Apple Podcast or any other distributor. It would be greatly appreciated. It would mean a lot to us and help get the word out to other people that would really enjoy our content.
Dr. Joshua Goldenberg:Hey y'all this is Josh. You know we talked about some really interesting stuff today. I think one of the things we're going to do that's relevant. There is a course we have on Dr Journal Club called the EBM Boot Camp. That's really meant for clinicians to sort of help them understand how to critically evaluate the literature, etc. Etc. Some of the things that we've been talking about today. Go ahead and check out the show notes link. We're going to link to it directly. I think it might be of interest. Don't forget to follow us on social and interact with us on social media at DrJournalClub. D r Journalclub on Twitter. We're on Facebook, we're on LinkedIn, et cetera, et cetera. So please reach out to us. We always love to talk to our fans and our listeners. If you have any specific questions you'd like to ask us about research, evidence, being a clinician, et cetera, don't hesitate to ask. And then, of course, if you have any topics that you'd like us to cover on the pod, please let us know as well.
Introducer:Thank you for listening to the Doctor Journal Club podcast, the show that goes under the hood of evidence-based integrative medicine. We review recent research articles, interview evidence-based integrative medicine. We review recent research articles, interview evidence-based medicine thought leaders and discuss the challenges and opportunities of integrating evidence-based and integrative medicine. Be sure to visit www. drjournalclub. com to learn more.