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14/01/2012 / Pedanto

Palliative Acupressure

It’s Happened Again!

Once again I am faced with a day of palliative care teaching. Woe is me!

Yes, palliative care is nice (well the care providers are at least), and I’ve seen some great work from palliative care teams. Hospices somehow manage not to be as depressing as they should be – which is surely a testament to the skills of the those running them. I might even consider a career as a palliative care physician were it not for the following reasons:

  1.  The slightly odd view on evidence they hold
  2.  I have a serious problem being even slightly sensitive (I bet you hadn’t even noticed!)

Learning is Fun

So here we are sat in a group of about twenty students, a doctor, and a nurse. We are excited to receive teaching on anti-emetics (sickeningly fun!) and the Liverpool Integrated Care Pathway (why did they put in the word integrated? It just reminds me of Prince Charles’ forays into medicine!). – and yet another link on that subject 

The discussion begins with a little bit on the physiological basis of vomiting. Fairly useful for those of us who work things out from first principles (I have serious issues remembering anything in any other way – probably not the best attribute in that kind of person who needs to remember all that medical stuff…what are they called again?). Then we move onto anti-emetics. First it’s non-pharmacological approaches.

Pain and Pressure

We are invited to jam our thumbnails into a spot between the tendons on the underside of our wrists. Manipulation of this specific acupressure point is apparently good for decreasing nausea and vomiting. Strangely it made me feel a bit sick – perhaps it’s a little homeopathic with its law of similars.

Back to the learning – “What is acupressure?” I hear you cry.

Recap and Reflect

Remember what I said about acupuncture?

“Meridians and all that stuff. Here’s a quick explanation about Qi and Meridians: a long long time ago in China autopsies weren’t allowed. Therefore anatomy had to be invented. Some very fanciful people made up magic life force and channels they pass through. Then like my toilet after a kebab, that shit stuck.

Apparently sterile needles are used – I personally wouldn’t trust the autoclave of someone who thinks that shoving pins into you will help anything.” – addendum: I have never seen a picture of an acupuncturist using gloves.

She looks very cheery for someone who’s just been given Hepatitis B

.

Acupressure’s like that; but without needles. This gives it some serious advantages:

  1. It will not cause serious infections due to the lack of understanding of germ theory and aseptic technique by practitioners.
  2. It should really cost less.
  3. It appears to be even more magical than acupuncture (Healing Hands is a fairly advanced spell as far as I’m aware….then again I never level up Restoration).

Once again I’m very aware that my medical degree has not had much emphasis on the minor things like science, reason or how the world actually works. In fact for a science-based degree there appears to have been very little assessment of whether something is believeable. The following phrases are seemingly unknown by the majority of Newcastle graduates: confirmation bias, cognitive dissonance, the file draw effect. Instead we are taught to unerringly elicit and respect patients’ “Ideas Concerns and Expectations” without any capacity to challenge them if they are either repulsive or stupid, as apparently the most vital part of making a patient better is their fondness for you – for more information see here.

Tangential Tangents Aside

Anyhooo to the matter at hand. Where does one look for answers to life’s big questions? How about this guy:

Nothing gets me going like some good Data

.

Acupuncture for nausea and vomiting in palliative patients. Let’s find some literature. Here’s a Cochrane review, once again not my favourite type of literature as, to quote Mark Crislip, “If you make a huge pile of cow pats don’t be surprised when it doesn’t metamorphosise into gold“. But hell, I can use some cognitive dissonance to make this whole thing fit my viewpoint – which it does! God bless confirmation bias! (see what I did there – apparently call-backs work really well in stand-up… which now I think about it this is almost nothing like… shit!)

To quote:

Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting

Ezzo J, Richardson MA, Vickers A, Allen C, Dibble S, Issell BF, Lao L, Pearl M, Ramirez G, Roscoe JA, Shen J, Shivnan JC, Streitberger K, Treish I, Zhang G
Published Online: 
March 16, 2011 (THIS SHIT IS UP TO DATE!)

This review looked at whether stimulating acupuncture points could reduce nausea and vomiting caused by chemotherapy. Acupuncture points can be stimulated (Does this imply that they exist?!) by acupuncture applied with electricity (electroacupuncture), acupuncture without electricity (manual acupuncture), acupressure (pressing on the points usually with fingertip), or electrical stimulation on the skin surface such as wristwatch-like devices. Electroacupuncture reduced first-day vomiting, but manual acupuncture did not. Acupressure reduced first-day nausea, but was not effective on later days. Acupressure showed no benefit for vomiting. Electrical stimulation on the skin showed no benefit. All trials also gave anti-vomiting drugs, but the drugs used in the electroacupuncture trials were not the most modern drugs, so it is not known if electroacupuncture adds anything to modern drugs. Trials of electroacupuncture with modern drugs are needed.

And furthermore:

Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients, though studies did not involve placebo control.

Interpreting Cow Muck

Wait a second though – doesn’t that mean that acupressure has a benefit for these patients?

Not really. Firstly, without a placebo we can’t see how it might have compared to giving them  “Thewlisco Unicorn Kisses – the purest snake oil money can buy”. In fact, all it shows us is that if you tell a patient something will decrease their nausea, it appears that it might – as long as you do it in advance. A suitable placebo for a trail could be a random point being pressed which had not previously been linked to nausea and vomiting, whilst the patient was told it would help their symptoms – it’s amazing it wasn’t used, but then that might have confounded the magical world view of many CAM practitioners.

So when we were informed that “this reduces nausea”, to quote Ben Goldacre “I think you’ll find it’s a bit more complicated than that”. (officially the sexiest catchphrase ever)

The Message

Once again, what’s my point? Should palliative care teams get rid of their placebos? Probably not, they really have nothing to lose (well apart from paying for the services of wizards). If it makes a dying patient feel a little better then damn the evidence.

Once again my problem is with Newcastle University Medical School. I’ve recently been fobbed off by them on a rather important matter, so perhaps some of my less than amorous feelings are creeping in here. It seems like our training has been geared towards creating 350 incredulous GPs who are really good at hugging patients, but who come out of higher education as scientifically illiterate useless drones who might have a heart attack when attempting to open a copy of the New England Journal of Medicine. Even worse there will be some amongst us who are willing to propagate bullshit because they lack the inclination to be critical and pedantic.

On one final note: you are taught to be open and honest with patients. You are taught to ask about their ideas, concerns and expectations. You are asked to understand their health beliefs. You are asked to respect these (I will respect their right to hold them, but not their specific beliefs). You are told that a placebo is useful. Does anyone else feel uncomfortable directly lying to patients? Isn’t that in some way bad?!

Here’s your funnies:

Don’t be a twat

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3 Comments

Leave a Comment
  1. Fabian Gatto / Jan 16 2012 16:14

    Hello
    I really appreciate your shared information. I was searching for some information regarding acupuncture and other alternative medicial information.

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    check out my site http://www.acupunctureinc.nEt

  2. Pedanto / Jan 16 2012 23:05

    I doubt that the above comment was written by anyone who has actually read that blog as it’d be an odd place to advertise. Thought I’d approve it just to amuse myself thought

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