April 11, 2024 • 54 mins
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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Episode Transcript
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Introducer (00:02):
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:23):
d rjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes only.
Talk to your doctor beforemaking any medical decisions,
changes, etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
drjournalclub.
com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclub.
com.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
I just saw your name.
You're killing me, dude.
Dr. Adam Sadowski (01:17):
Okay, all right.
Dr. Joshua Goldenberg (01:18):
These names are getting more and more
inappropriate.
Okay, Dr.
Sadowski, despite what yourname tag says, little river side
thing here.
How are you doing today?
Dr. Adam Sadowski (01:31):
I'm doing great.
How are you?
Dr. Joshua Goldenberg (01:32):
Just fine , thank you very much.
So today we're talking aboutendometriosis.
We had a listener request for apaper on endometriosis and
integrative medicine and I founda nice little paper published
recently.
I was kind of surprised abouthow nice um on acupuncture, and
(01:54):
then it was like oh man, I don'tthink we've ever done an
acupuncture review at all.
I don't think, or endometriosisor endometriosis that's.
Dr. Adam Sadowski (02:04):
Yeah.
Dr. Joshua Goldenberg (02:04):
So it's a double whammy.
We definitely need to do thisand, yeah, and I don't know much
about acupuncture at all, letalone acupuncture research, so
it's a little bit of contentexpertise that we might rely on
our listeners to call in andcorrect us with.
But yeah, so I feel like wehave some good information to go
on.
Do you have any startingcomments before we jump into the
(02:27):
paper?
Dr. Adam Sadowski (02:28):
I have no starting comments, nope.
Dr. Joshua Goldenberg (02:31):
Okay, so we'll put the link in the show
notes.
So this is a review articleAcupuncture for Endometriosis by
Gies et al G-I-E-S-E Just cameout last year in 2023.
And it's a systematic reviewand meta-analysis looking at
acupuncture and endometriosis,so for the treatment therein.
(02:53):
And so I figure, yeah, let's,why don't we go through the
methods first and then we cankind of talk about the results
and basically go page by page?
I think just kind of make ourway through here.
So what's the first thing younoticed looking at the paper and
basically go page by page?
I think just kind of make ourway through here.
Sure, so what's the first thingyou noticed looking at the
paper?
What are your first impressions?
Dr. Adam Sadowski (03:12):
Well, the first thing I noticed was that
when looking at the abstract,they put in the study
registration Prospero ID, whichis usually a good sign, yeah, I
agree.
So right off the bat I knewthat we're going to get into
something pretty good here.
Um and I I typically don't readintroductions, this one was
really nice and short, which Iactually enjoyed.
Dr. Joshua Goldenberg (03:33):
They got oh, you actually read the
introduction this time.
That is impressive.
Dr. Adam Sadowski (03:38):
Unlike you, I'm not an endometriosis expert,
and so I was actually kind ofinterested to see what they had
to say.
Dr. Joshua Goldenberg (03:47):
Yep, yep, yep.
Dr. Adam Sadowski (03:51):
And it was only like three paragraphs long
and very short paragraphs.
So I did like the fact thatthey kept it nice and short and
really to the point andhighlighted that the aims of the
paper was to determine theeffects of acupuncture on
endometriosis-related pain andhealth-related quality of life.
And something that I reallyliked is that they focused this
(04:13):
paper with sort of another aimof contributing to the
evidence-based guidelines forendometriosis.
So it wasn't just oh, let's seewhat this research is.
There was a lot of intentbehind it, which you know.
You would think that you wouldalways want research to have
good intent behind it, butoftentimes you kind of just see
(04:36):
these studies that are just kindof being done just because they
can, whereas with this onethere 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 ofacupuncture, but can this
influence guidelines for themanagement of endometriosis?
(04:56):
So can this have overarchingimpact for this condition?
Dr. Joshua Goldenberg (05:03):
Yeah, I think you're spot on on that.
Reading between the lines, Ithink they have a guideline
development in place now, likeit'll probably come out next
year, I would imagine.
And the most brilliant way ofdoing that, according to like
all the recent guidelines onthis for grade, is first you do
a systematic review ofmeta-analysis and then that
information informs yourguideline panel on doing grade
(05:27):
guidelines and you can tell justby the quality of how they set
this up that they're just reallyfollowing, I think, grade by
the book.
So, yeah, I was super impressedwith all that as well and I
agree, I think so.
I am not an endometriosis expertand so I also read the
introduction and I agree.
I think it gave a good initialsense.
You know, one of the surprisingthings to me is like they were
(05:49):
saying that once you use MRI tohelp make that diagnosis,
something like one in five womenhave endometriosis.
Like that was shocking to me.
I didn't realize it was quitethat high of prevalence.
I knew it was common.
I have lots of patients thathave it in clinic but I had
(06:10):
absolutely no idea it was thatcommon.
So super, super commoncondition can have debilitating
effects on quality of life andall sorts of stuff and the
medication apparently is notgreat.
The satisfaction around surgeryis not great either.
So there's this appetite, ifyou will, for you know,
integrative and complementaryapproaches or other approaches
and that sort of set up therationale.
I thought, pretty well, now, asfar as you know, and they're
(06:33):
acupuncturists, right?
So I think one or two of theauthors are acupuncturists and
so that's their background,that's what they're looking for.
Now I don't understand theacupuncture side of all this,
but it looked like they werepretty inclusive of different
acupuncture styles.
So, whether it was five elementor traditional or what have you
(06:55):
.
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 thinkit's freely available online and
let us know if you have anyconcerns.
But from our read, it lookedpretty good from a methods
perspective.
So okay, cool.
(07:15):
Anything else to add before wejump into methods?
Dr. Adam Sadowski (07:22):
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 oflike how well they break it down
, how easy it reads in the factthat it's just, it's just very
linear.
In as you're reading you'relike, oh, this makes sense.
Okay, this, this makes sense.
You're not like having to flipthrough pages back and forth and
(07:43):
like try to figure out what'sgoing on.
It was very, it was like ifyou're a student doing a
systematic review and metaanalysis, this would be a really
good paper to reference or tolike help guide you through the
process.
Dr. Joshua Goldenberg (07:56):
So, dear listener, you might mark this,
mark this on your calendars.
I think this is the only timeI've this is, by the way, in
case you didn't, is adam gushingabout a paper, and that's one
of the few times I've seen himgushing about paper.
In fact, as we were reading itand prepping and doing our
quote-unquote green room, whichis text back and forth in
preparation, it was justhilarious because, like, as you
(08:17):
go, section by section, I wouldget these like and did you see
this?
Like exclamation point, and didyou see that?
And look what they did here?
That's hilarious.
So, yeah, no, I had similarfeels.
It looked like I was tellingyou my little, soon to be three
year old, she'll.
She'll be like you know, if youdo something good, good by her,
she'll be like oh, you make myheart happy and which is
(08:39):
adorable.
But that's what I felt, like.
It made my little methods hearthappy to read through this and
I agree, the Prospero orProspero registration was like
the first indication that, yes,this is good.
Oh, that reminds me.
So we've talked about qualityand systematic reviews before
and we've talked about using theAmstar 2 tool to evaluate that,
(09:00):
and I think I'm going to startteaching that.
So next month at Sonoran I'mgoing to put together a lecture
on how clinicians can use theMSTAR-2.
But I was like, ah, that'spretty onerous.
But they have, of the I don'tknow 20 domains to look at.
Seven of them they considercritical domains, like if you
get one of those wrong, thestudy is critically flawed, you
(09:21):
can basically throw it out.
So I'm going to start callingthese the seven deadly sins, and
I think that's how I'm going toteach.
It is to have people look forthese seven things whenever
they're looking at a systematicreview.
And so the number one thing isthat the protocol was registered
before commencement of thereview.
Like, first of all, you have tohave it freaking registered and
(09:41):
you have to register before youstart the review.
And not only is it registeredin Prospero, which is where it
should be registered, and youhave to register before you
start the review, and not onlyis it registered in Prospero,
which is where it should beregistered.
They actually have a sentencethat specifically says that they
didn't change anything in theregistration after they started
the study.
So normally, if you do need tomake methods changes as you go,
you just have to justify it anddo a timestamp, but rarely do
(10:02):
you see that they actuallyexplicitly tell you if any
changes were made.
So yeah, made my heart happy,good, good, good.
They described the issues inPICOS, which is wonderful.
It's just randomized controltrials, so we're starting with.
High-level evidence only wouldbe includable in here and, yeah,
(10:24):
go ahead.
Dr. Adam Sadowski (10:26):
They did make the comment that crossover
randomized control trials werealso allowed to be in, but they
only took the first period ofthat crossover.
So this way they didn't diluteany effects from a carryover
period.
So for those who aren't aware,with a crossover randomized
control trial you would startoff like one group would get the
(10:47):
intervention and one groupwould be in the control group
and then at some point theywould flip and in a good
crossover randomized controltrial that blinding would be
maintained throughout.
So you don't know when you'regetting intervention and when
you would be getting placebo.
And another good crossoverrandomized trial would also have
(11:13):
basically like a washout periodwhere when you're switching
from intervention to placebo,theoretically the carryover from
any sort of treatment effectsis not being carried over into
that transition.
Dr. Joshua Goldenberg (11:30):
Yeah, exactly.
Yeah, so that's a commonworkaround for these complicated
trials is to just take thefirst half of it essentially and
view it like a regularrandomized controlled trial for
the purposes of themeta-analysis.
So that was totally kosher, Ithink, a good point pointing
that out.
As far as the different typesof intervention, yeah, this was
(11:52):
mostly over my head, but theysaid that they included
traditional Chinese, fiveelement Japanese or biomedical,
sometimes called Western.
So that would be relevant tothe listener, just if you're
trying to find, okay, like greatthis, you know, here's the
results, but which type ofacupuncture should I pursue?
Dr. Adam Sadowski (12:13):
Which I think is really important too, that
they classified it because youknow, instead of just saying
acupuncture, it really varies,there's different types of
acupuncture.
So the fact that they didhighlight that and tried to
analyze it by type ofacupuncture, I think is actually
really important.
Dr. Joshua Goldenberg (12:29):
Yeah.
So this is the thing I hear alot from acupuncturists, where
they get really frustrated withthe research in their field
because they're like well, theresearchers clearly didn't know
what they're talking about, theycombine this with that, or they
didn't even do it right, orthat's not even acupuncture, and
(12:51):
so I think, to their credit.
I mean, amongst integrativemedicine, in fields, I feel like
acupuncture has more highquality research than almost any
other field.
They're just like light yearsahead of the rest of us and
they've developed these strictcriteria, checklists, reporting,
checklists to be transparentabout how these studies are done
and how they're classified.
And do we have integrity?
What was it called?
(13:12):
Content validity?
Basically like if you went toan 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, veryimpressed so far.
Dr. Adam Sadowski (13:24):
I think too this is why, like, it's
necessary to have contentexperts within, research, even
if they're not like primaryauthors, having them as part of
kind of like how a lot of papersin the BMJ will require public
say into, like what is actuallyclinically important or like
(13:48):
what would be an importantpatient reported outcome it's
not just a bunch of cliniciansdoing the research, but having
some content experts in there toyou know, to make sure that
what is being studied isactually important.
Dr. Joshua Goldenberg (14:01):
Yeah, absolutely so.
As far as we can tell, notbeing acupuncture experts
ourselves, this looks prettylegit both from an internal and
external validity perspective,meaning the methods look good
and it seems to have externalvalidity from an acupuncture
perspective.
But again, acupuncturists,please feel free to call in and
yell at us, but there is onething.
(14:23):
So I have only one issue withthis entire paper, which is in
the next section, as we movethrough the methods here.
Oh, so sorry, outcomes.
So they're looking at painoutcomes.
They're looking at quality oflife outcomes.
They're looking at adverseevents.
They're looking atendometriosis, specific
instruments.
(14:43):
So these are very good .
Dr. Adam Sadowski (14:48):
And the primary outcome was pain
severity, with the secondaryoutcome being adverse events and
health related quality of life,and just because we haven't
touched on it yet, the mainpatient population that they're
looking at is people ofreproductive age yes, With
pelvic pain or abnormal or,excuse me, pain with menses with
(15:10):
a confirmed diagnosis ofendometriosis that was either
confirmed through laparoscopy,ultrasound, MRI or
histopathology.
So people who you know they'redefinitively basically diagnosed
with endometriosis, not justsort of like, oh you might have
endometriosis and let's see ifthis helps, right.
Dr. Joshua Goldenberg (15:31):
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 theonly studies that they looked at
were in English or German, sothey excluded studies in other
languages.
Now that's particularly aconcern in acupuncture, because
(15:54):
a lot of acupuncture research isdone in Chinese.
Right, it comes out of China,it's done in Chinese, and so I
was pretty concerned about thereason it's German.
I think one of the authors'practices in Germany I googled
her is the acupuncturist inGermany, and so there's your
content expert.
But yeah, it was kind ofsurprising, and I think later,
when they actually, again totheir credit, are transparent
(16:16):
about their exclusions, I thinkalmost double the amount of
study.
Well, so that like they couldhave doubled the number of
studies if they also includedChinese articles, but anyway, so
I think that's the main issueis that they're missing possibly
half of the evidence base, butso anyway, so we only have these
English and German studies.
(16:36):
The search itself I thought wasexcellent.
It was well described.
They looked at multipledatabases.
Really importantly, they lookedat databases that are specific
to like integrative medicine.
So they looked at AMED, whichis a database on allied and
complementary medicine.
So a lot of times you'll havethese really lazy searches where
(16:57):
they do like PubMed and prettymuch that's it, and especially
if it's a content specific area,you want to make sure you're
checking those content specificdatabases.
So they did a really excellentsearch.
I was super thrilled with thatdetailed design fully provided
in the supplement, and then theydid their screening
independently and in duplicate,which is super important, and
(17:19):
they did their data extractionindependently in a duplicate,
which is also super superimportant.
Quality assessments of thestudies as well, risk of bias
and also specific checklists foracupuncture itself.
So things like NICMN, which Ididn't know beforehand, and then
STRICTA, which apparently areacupuncture, specific checklists
(17:43):
and guidelines for quality,which was seems important.
Dr. Adam Sadowski (17:46):
Yeah, so the NICMN scale is the National
Institute for ComplementaryMedicine Acupuncture Network and
it appears to be, you know,recommended to be used along
with the STRICTA checklist.
And the whole purpose of havingthose checklists in place is to
make sure that when we're doingacupuncture research we're
(18:08):
having a consistency in how it'sbasically being reported, to
make sure that we haveconsistency in the literature so
we can make a better sort ofconclusion or estimate or know
where things need to be altered.
Because if we can have astandardization to something
(18:29):
that many practitioners willalready say is sort of like a
heterogeneous type ofintervention to begin with, this
gives us some sort of astandard to work with and it's
not to say you can only usethese acupuncture points for
every single patient.
That's not what it's saying.
But what these guidelines aresaying is okay.
You know what is the reason forthe acupuncture?
(18:50):
How was the needling done?
What was the treatment regimen?
What were the other componentsof the regimen?
Was the person performing theacupuncture have some sort of
acupuncture background?
So, for example, was it like aphysical therapist doing dry
needling?
Is that consistent withacupuncture?
Or was it someone who has abackground in traditional
(19:13):
Chinese medicine or classicalChinese medicine or you know, an
acupuncture degree.
And then how did they havetheir comparison group, like
what was the outline of that?
So if we can have astandardization procedure, we
can make a better estimate anddraw better conclusions to with
regards to acupuncture as anintervention.
Dr. Joshua Goldenberg (19:36):
Yep, super well said and I think
we're the.
The editor community and thejournal community is moving
towards better reportingstandards, but it's still a lot
of concern out there.
Herbal medicine is the bigproblem, for example, but yeah,
so it's really important to bestandardized and how this stuff
is reported.
Dr. Adam Sadowski (19:56):
And I think that's just complementary and in
alternative medicine or,excuse me, complementary
integrative health.
Because you know, if you wereto say, like you and I have a
background as NDs, when I seeresearch that says naturopathy,
what the hell does that mean?
Because naturopathy is not anintervention.
In my opinion, it's a spectrumfrom which you are able to sort
(20:21):
of choose interventions, fromsomething that includes, like
you know, body work or bodymanipulation to even surgical
intervention.
So to say, you know, we studiednat body manipulation, to even
surgical intervention.
So to say, you know, we studiednaturopathy as an intervention.
You have to define that.
And so how are we going tostandardize what naturopathy is
from a research setting?
(20:42):
Are we looking at naturopathicherbal intervention or just
healthcare delivery from anaturopath, where that
naturopath ultimately decidedhow that patient or that
research subject got anintervention?
So, having something in placefor acupuncture, I actually
appreciated, and the fact thatthey're saying, hey, you should
(21:03):
combine this with this otherscale to get this holistic,
develop this holistic evidencebase for understanding the
intervention of acupuncture.
I thought that was cool andimportant.
Dr. Joshua Goldenberg (21:15):
Yeah, no, really good point.
I mean, I think with herbs youcan say like, okay, it's this
one plant that we're studyingand there's still a million
variables like when was itharvested, what kind of extract,
yada, yada, yada.
But to your point, like to say,acupuncture period is kind of
ridiculous and analogous tosaying, you know, naturopathy
period or medicine period, right, like what the hell does that
mean?
And so yeah.
(21:36):
So again, even more important,to be clear about these, these
different interventions, and Ithink they did a good job.
We'll get to it, but I thinkone of the tables, they did a
pretty good job of showing these, the different aspects of these
interventions.
So if you, you know, did wantto, if you're a provider and you
wanted to try these, you knowneedling techniques, you would
be able to see very clearlywhich ones were used, when they
(21:57):
got the effects that they didand what else.
Oh, and they use grade, ofcourse, which is our favorite,
which is the way of assessingthe overall confidence in the
evidence.
Dr. Adam Sadowski (22:07):
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 prismachecklist.
Did the research authors havethis checklist when developing
the acupuncture study?
And then the Nickman is kind oflike the grade of the
acupuncture.
(22:27):
So was there a checklist in howthey reported it or kind of
like a strobe guideline forobservational studies?
Where like, are they followingthis sort of criteria as to how
to report?
And then the NICMN sort ofquantifies the quality of that
reporting, where higher scoresindicate better quality better
(22:48):
quality, like reporting, or likebetter quality study, like more
trustworthy.
To my understanding it seemslike better quality in the
reporting, In the reportingwhich sort of indirectly then
translates to perhaps a betterquality study.
Dr. Joshua Goldenberg (23:03):
Yeah, and then, but to the quality piece,
like they did, they also didrisk 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 biasscale.
And then, right, then they usethese others to sort of describe
how well reported the otherstudies are.
Okay, cool, I think I'm withyou now.
Good, good, good, good.
And then they did ameta-analysis and used GRADE to
(23:26):
talk about the overall evidenceand we'll talk about the results
in a second.
And the way they usemeta-analysis is they looked at
mean difference.
So you know, if you're talkingabout a 10-point pain scale and
on average you could say, okay,they dropped two points of pain,
or something like that, thatwould be a mean difference.
If the way you're describingthe result is using different
(23:48):
instruments, it gets a littlebit more complicated.
You do things like standardizedmean difference or, in this
case, hedges g.
I don't know that we need toget into super detail on that,
but basically it's a way to tosay, okay, what is the overall
effect, even if these studiesuse different instruments?
Here, and then we have thesethresholds that we use to say if
(24:10):
that's a small, moderate orlarge effect, correct, okay,
cool.
Anything to add on that one?
Dr. Adam Sadowski (24:18):
No, but it seems like with Hedges G that we
are using that for smaller sizestudies, whereas other, like a
Cohen's D, you might see, isused for larger studies.
Dr. Joshua Goldenberg (24:30):
Right, exactly, and I think it's
technically, I think it's moreconservative and then also, but
you can think of it analogously,like if you're used to thinking
of Cohen d's thresholds, likepoint two is small, point five
is moderate and point eight is alarge effect.
I believe that is sort of ananalogous threshold, so you can
kind of think of it the same way, even if you haven't heard of
Hedge's g before, of ananalogous threshold.
(24:50):
So you can kind of think of itthe same way, even if you
haven't heard of Hedges' Gbefore.
Okay, cool, they did look atsubgroup analysis, or they
planned them anyway, fordifferent types of acupuncture,
so that absolutely makes sense.
The total number of treatmentsand the mode of stimulation, so
manual or electro acupuncture,so that all makes sense.
These would be reasonablesubgroups to look at a priori.
And, yeah, data amputation isboring but pretty
(25:12):
straightforward, yeah.
So overall I think I'm goodwith the methods.
I'm looking here at our sevendeadly sins and let's just see
if we can go through these.
Look, the thing is we don't dothis for money.
This is pro bono and, quitehonestly, the mothership kind of
ekes it out every month or so,right?
(25:33):
So we do this because we careabout this.
We think it's important, wethink that integrating
evidence-based medicine andintegrative medicine is
essential and there just aren'tother resources out there the
moment.
We find something that does itbetter, we'll probably drop it.
We're busy folks, but right nowthis is what's out there that
does it better.
We'll probably drop it.
We're busy folks, but right nowthis is what's out there.
Unfortunately, that's it, andso we're going to keep on
fighting that good fight.
(25:54):
And if you believe in that, ifyou believe in intellectual
honesty in the profession andintegrative medicine and being
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
becoming a member on Dr JournalClub.
If you're in need of continuingeducation credits, take our
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We have ethics courses,pharmacy courses, general
(26:15):
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Interact with us on socialmedia, listen to the podcast,
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These are all ways that you cansort of help support the cause.
Deadly sin number one Did theyregister the protocol?
Yes, they did.
Check Adequacy of theliterature search is sin number
two.
(26:35):
Yes, I thought that was anexcellent literature search.
Justification for excludingindividual studies they do give
I think that comes later.
They do give reasons for whichstudies they excluded.
Did they do risk of biasassessments?
Yes, check the appropriatenessof meta-analytic methods.
That looks good to me.
(26:56):
We just talked about that.
Did they consider risk of biaswhen interpreting results?
We'll see that they did.
That comes a little bit later.
And did they talk about thepossibility of publication bias?
So, this one, they did talkabout it.
They didn't assess because theydidn't have enough studies, and
we'll get there in a second.
I'm a little on the fence ofthis because I feel like they
missed half the data becausethey didn't look at published
(27:16):
Chinese studies.
But so I would say, maybe ahalf a deadly sin, but overall a
pretty good study.
Anything else you want to addabout methods or concerns or
anything like that?
Dr. Adam Sadowski (27:29):
No, and I get where you're coming from, but I
don't, I don't really thinkit's that big of a sin.
I I'd give it a pass okay, fairenough.
Dr. Joshua Goldenberg (27:39):
Um so all right, so we'll jump into the
results here.
Um to okay.
So they talked about how thestudies were excluded.
They found six final studies outof 1074 hits yeah, so, oh, okay
, hello, we talked about thislast time.
Yeah, remember when they hadlike all these databases and
they had like 74 hits and theywere like we did this extensive
(28:00):
search of like bs.
So this is a more normal searchresult.
You would expect a thousandplus hits or whatever, and then
you whittle it down, so it itdidn't, it didn't look
suspicious, it looked perfect.
And so, of those 1000, theywent through and they found six
randomized control trials thatmet their inclusion criteria,
with 371 participants overall.
(28:22):
I'm curious how you want tohandle this.
I'm thinking we just jump tolike the tables or plots to talk
about results, or did you wantto go through it in in text form
?
Dr. Adam Sadowski (28:36):
I could just like quickly go through it.
What annoyed me about thispaper was that there was just a
lot of text when there reallydidn't need to be.
That's why I went to the tablesyeah, results section, and if
you read through it all, youcould have kind of gotten a
little misled.
Basically, from the 1074 hits,six studies, 371 total
(28:59):
participants, four of them wereyour typical randomized
controlled trial where you haveacupuncture versus a control
group.
One study used a crossoverdesign, but remember they only
used that initial part prior tothe groups actually crossing
over.
And then two studies were donein China, one in Australia, one
(29:19):
in the USA, one in Austria, onein Brazil.
The median age was 30, and allstudies used laparoscopy or
laparotomy to diagnoseendometriosis.
And then the acupuncture styles.
There were two traditionalChinese medicine style, one
Japanese style, one earacupuncture, and then two did
(29:42):
not specify the style ofacupuncture that was used.
What I actually reallyappreciated was that, when they
were looking at the studies,three studies used a fixed
treatment protocol.
So no matter who walked inthrough that door, if they had
the diagnosis, this was theacupuncture they were getting.
It was basically an algorithmyou get this, that's it.
(30:04):
One study used asemi-individualized treatment,
so I'm not really sure what thatmeant.
It looked like they had fixedpoints that were going to be
used, but then they had threepoints that could have or could
have not been used, depending onthe clinician that was
delivering the acupuncture, andthen one used an individualized
(30:25):
point.
However, it wasn't reallyindividualized because they had
an a priori determined algorithm, so not really individualized
in my opinion.
Dr. Joshua Goldenberg (30:36):
Quasi individualized Algorithmic, I
guess.
Dr. Adam Sadowski (30:40):
So AI acupuncture essentially uh for
for the acupuncturists out there.
On average they used 13 needles.
From a needle stimulationstandpoint, one study looked at
manual stimulation.
One person was hooked up to acar battery and electrically
stimulated this is a thing.
Dr. Joshua G (31:02):
Electroacupuncture is a thing, man one study.
Dr. Adam Sadowski (31:06):
They used no stimulation and then three did
not report on it from a needleplace but is stim?
Dr. Joshua Goldenberg (31:13):
is that, does that mean, is that chi or
is that different chi?
Well, like you know, whenyou're um, why do we do electric
stimulation?
No, like, there's like um she'slike the energy channels no, I
know, but.
But I'm like butchering this.
But there's like a thing thatyou get when you stimulate it
and you like bring about the chior something like it grabs at
(31:34):
it, or something like that.
There's a way to stimulate thatElectrocution.
No, all right, move on.
We clearly have no idea whatwe're talking about when it
comes to the actual intervention.
But oh, oh, yeah, look at this.
(31:56):
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 Ithink that's the, that's what
you're going for, that you likehit the, hit the site, right, I
believe, anyway.
Dr. Adam Sadowski (32:02):
So I'm not making that up, but I'm probably
butchering the pronunciationtwo studies left the needles in
place for 20 to 30 minutes, Twohad them in place for less than
20 minutes and then for twostudies.
They did not report on how longthe time was there for Cool.
Dr. Joshua Goldenberg (32:18):
And they go through all the different
points that we're used to.
So if you're an acupuncturistI'll tell you, like spleen six,
liver three, liver eight, so youcan go through and actually see
what was needled.
Dr. Adam Sadowski (32:29):
And then from the practitioner background,
for those who that like thepeople delivering the
acupuncture, three were licensedor registered acupuncturist, or
in one study there was a doctorof traditional Chinese medicine
.
One study includedphysiotherapists, and then
competency regarding acupuncturewas unclear.
Dr. Joshua Goldenberg (32:51):
Yeah, so this was cool too, because you
know, you never know who'simplementing the actual
intervention and sometimes it'speople that are like quickly
trained before the trial.
So again, explain again.
This goes to external validityor content validity.
Basically saying this is thesepeople actually knew what they
were doing they're well trained.
Dr. Adam Sadowski (33:12):
Yada, yada yada.
And then the last thing that Ithought was actually really cool
was when they looked at theNickman 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 inthe reporting.
The Nickman looks like it wasreported after 2016.
And they did find that prior to2016, those scores on average
(33:36):
were an 18.
And then after that, on averagewas a 21 and a half.
So basically, after theseguidelines were in place for how
to report acupuncture studies,they found that the quality of
reporting did in fact, improve.
Dr. Joshua Goldenberg (33:53):
So I think that was interesting and
cool.
Yeah, again, I think that afield of acupuncture, from a
research perspective, is likeagain, head and shoulders above
the rest of us, maybechiropractics after them, and I
feel like we're on the bottom.
But yeah, they do.
They do a really, really goodjob in standardizing and high
quality research.
So, okay, awesome, oh, and justjust a range of treatments.
(34:14):
So we're talking about, youknow, anywhere from five to 16
treatment sessions to get theeffects that we're talking about
here.
And they talked about differentcomparators.
I don't know that we need to.
Did you want to jump into thecomparators at all or Not?
Really, not really.
Yeah, I think that's totallyfine.
Talked about you.
Talked about quality, perfectrisk of bias.
Dr. Adam Sadowski (34:33):
Well, actually I rescind that.
I take that back because thethe type of intervention or the
type of comparator does seem tomatter.
When you're kind of looking atacupuncture research and those
who are sort of like very muchfor acupuncture and those who
are very much againstacupuncture or seem to be less
so inclined in sort of believingthe research that's out there,
(34:56):
the majority of the comparisonswere non-specific acupuncture
and I'm not entirely sure whatthat was defined as.
To my understanding was theykind of just like put random
needles into people.
So they weren't in likespecific, like gallbladder seven
or liver three points.
They were just kind of likeadjacent to it or maybe
(35:17):
somewhere like completely random.
One comparison was medicalwhich is a clever.
Dr. Joshua Goldenberg (35:23):
A clever thing, right, because it
controls for the whole ritual,the experience, the puncturing
of the skin, everything exceptfor actually needling these
channels.
Dr. Adam Sadowski (35:35):
Right, the theater, um yeah, it's very
clever and and you know, andthey they did kind of specify in
some of the studies, like thestudy from brazil, used
non-specific acupuncture wherethere was a stimulated therapy
with a needle insertion threecentimeters apart from the
original point, so likerelatively close to where it
(35:56):
would be, but actually not atthat point.
And then one nonspecificacupuncture was with no
correlation to endometriosis.
Another one was out without anysort of stimulation.
Another comparison was medicaladvice but no traditional
Chinese medicine, which I feellike is fair.
And then one was compared toChinese herbal medicine but no
(36:21):
acupuncture intervention.
It looks like yeah.
Dr. Joshua Goldenberg (36:23):
So to point, to put a finger on this a
little bit more.
So these are pretty strongcomparators, right, like these
would be, you would imagine.
These would have pretty strongeither active or placebo effects
, and so if you do see an effectin a study like that, which
we're going to see in a secondthey really did it's even more
(36:44):
impressive because the controlgroup, you would think, would
have pretty impressive placeboeffects.
So we're talking about thedifferential, the difference
between these, and the fact thatthat's as impressive as it ends
up being, I think, is even moreso.
It's not like it was aweightless control or they gave
them a little placebo pill.
These were pretty impressivecontrols, and so any difference
that you see above that, I think, is a pretty strong indication
(37:07):
of efficacy.
Dr. Adam Sadowski (37:09):
Yeah, agreed.
Dr. Joshua Goldenberg (37:10):
Okay, cool, so quickly.
Risk of bias so we had the sixstudies.
So one of the studies wasconsidered a low risk of bias,
two had some concerns and thenthree were high risk of bias.
So we'll see later.
That mixed bag, with only onelow risk of bias studied,
lowered the grade level overallfor some of the rankings and
we'll talk about that in a sec.
(37:30):
But overall the grade level forthe different outcomes ranged
from moderate to very low, andso moderate's pretty good.
Dr. Adam Sadowski (37:39):
However, moderate certainty of evidence
really only happened, I think,on one or two occasions.
The rest of the time it was lowto very low.
Dr. Joshua Goldenberg (37:48):
Yeah, and so we'll jump into that one
Agree.
And then they didn't do apublication 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 theydid.
But again I have concerns aboutyou know there are six.
(38:08):
You had, you found six studiesand five.
You found five studies inChinese.
Like you could have doubledyour data right there.
But anyway, I'll leave thatalone.
Mildson, according to Adam, allright.
So Pansferdi, blah, blah, blah,blah, blah, all right, so let's
jump into.
Should we jump into the actualresults?
Do you?
Should we let's's?
What do you?
What do you think?
Should we go to the summary offindings table?
(38:29):
How should we go through this?
Dr. Adam Sadowski (38:31):
I think the summary of a finding uh table is
sort of the best bet, becauseyou can get really lost uh in
the sauce with all the text.
Yeah, and really we have toremember that our primary
outcome was the effect ofacupuncture on on endometriosis
related pain.
Right, and within that therewere subdivisions of okay, is
(38:53):
this menstrual pain, is thisnon-specific endometriosis pain?
Is this pelvic pain?
And so they they in in thetable.
They did a good job of justoverall pain, menstrual pain and
then health related quality oflife.
Dr. Joshua Goldenberg (39:10):
Yeah, so this is beautiful.
So we're talking about tabletwo, if you're following along,
and this is this gorgeousness iscalled the summary of findings
table, which is recommended bygrade and by Cochran to present
information in a digestible way,and it's a beautiful, beautiful
thing.
So, yeah, we can probably geteverything else that we need to
talk about from this one table.
So overall pain when we'retalking about acupuncture
(39:34):
compared to nonspecificacupuncture for endometriosis.
So again, against a strongcontrol you would expect a
smaller effect, but we seeoverall pain hedges G of 1.5,
which again, that's double thethreshold of about double the
threshold of what we wouldconsider a large effect.
So a very large effect on painoverall and that's based on
(39:58):
three randomized control trials,over 200 participants with a
low grade level and that'sknocked down two levels because
of risk of bias.
So we talked about that before.
Only one study had a low riskof bias and then the
heterogeneity as well wasanother reason that they knocked
it down.
So it went down from high tomoderate and then down to low.
(40:18):
So it's low-level evidencebased on three randomized
controlled trials, but a verylarge effect size on overall
pain.
We see a similar thing withnon-specified pain using a mean
difference on a 10-point scale2.77 centimeters lower.
Two randomized controlledtrials, again low grade level.
(40:41):
So overall low grade evidencefrom randomized trials of a
pretty large clinicallymeaningful effect.
Dr. Adam Sadowski (40:48):
The way that you can kind of you know
clinically sort of make thatdiscussion with a patient is hey
, you know where do you rateyour pain on a scale of one to
10?
Oh, you're interested inacupuncture.
Okay, there's some shoddyevidence that suggests that you
know, we could lower, we couldimprove your pain.
Let's say, your pain levelright now is at a seven.
(41:11):
It may go down to a four withacupuncture.
You know, are you interested inpursuing that, yes or no?
Dr. Joshua Goldenberg (41:17):
Yeah, totally Exactly.
And then actually.
So let's talk about the, the,the few items that had moderate
level grade evidence to yourpoint, sure.
The few items that had moderatelevel grade evidence to your
point, sure.
So that is.
Menstrual pain specifically hada large effect size, very large
effect size, with moderatelevel grade evidence.
(41:37):
So that's pretty darn good.
It got ranked down once forimprecision, and that's because
this is just based on onerandomized controlled trial.
So that was the low risk ofbias study of about 100
participants.
So you have one randomizedcontrolled trial.
So that was the low risk ofbias study of about 100
participants.
So you have one randomizedcontrolled trial on 100 people
showing a very large effect onmenstrual pain.
Dr. Adam Sadowski (41:56):
However, that was at the end of the treatment
Right when we then look atfollow up, that moderate looks
like then became very low largereffect but yeah, but very low
quality evidence of much lessconfidence in that follow up
period.
Dr. Joshua Goldenberg (42:13):
So much more confidence to say you go,
you're, you're having menstrualpain, you go get acupuncture,
you finish it and you feelreally good and that is well
more and above beyond placeboeffects, based on the control
when they check in with you likeweeks or months later it's
unclear if you'll be better, butit seems like we have much more
(42:34):
confidence in that treatmenteffect right away type of thing.
Dr. Adam Sadowski (42:38):
And then also look at that sort of drop off
in number of participants.
You went from 106 to 42.
Dr. Joshua Goldenberg (42:44):
Yeah, so they basically like lost to fall
up 60% of those participants ofhigh, highly dubious data set.
I would probably just throwthat out.
That's a good point, eventhough it's a large effect.
I can't really put much faithin that at all, but you can put
decent faith in post treatmentresponse, which I think is
pretty good.
Okay, what else?
Anything else you want to focuson here?
(43:06):
Yeah, so again, follow-up notgreat where?
Dr. Adam Sadowski (43:08):
you have a clinically important outcome and
we have moderate certaintyevidence for a low magnitude of
(43:33):
effect.
The Hedge's G here was only0.19.
So let's round up to 0.2.
And the cutoff for 0.2 was 0.2for a small treatment effect and
that's probably more honest.
Yeah, If you just kind of thinkabout medicine in general, most
(43:53):
a lot of things work, but towhat degrees?
The magnitude of that treatmenteffect and it's it's typically
small.
Dr. Joshua Goldenberg (44:02):
Well, and also like you need to keep on
taking it for it to work.
So like that's the way I thinkabout it.
It's like if you're popping,you know aspirin for the pain
and it works while you're takingaspirin, but then you stop
taking aspirin and you check twoweeks later and the effect is
meaningless.
Like pretty close to being thisyear just at under the
threshold of minimal importantdifference.
That's not so crazy, it's.
(44:24):
It's analogous like you go getacupuncture.
You feel better Two weeks laterpost-acupuncture.
It doesn't.
It doesn't.
It doesn't look like the effectholds.
Let's put it that way.
I think it's a fair statementto say you're getting a pretty
large effect with decent levelevidence at the treatment once
you get the acupuncture.
But yeah, like weeks laterprobably not really going to
(44:44):
still work.
Is that fair?
Would you agree with that?
Dr. Adam Sadowski (44:48):
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 (44:56):
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 atthis.
So, but but flip, but this isflipped.
Oh, no, no, but this is uh.
Yeah, look at that.
This is interesting story.
Quality of life so, whereas wehave decent evidence for a large
effect on pain after thetreatment, like with with the
(45:18):
treatment we have very lowevidence 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 thereon the quality of life.
So I'm not sure what to make ofthat.
Dr. Adam Sadowski (45:34):
Well, perhaps that kind of makes sense,
because when you're looking athealth-related quality of life
at the end of a treatment, thatkind of seems like too acute of
a timeframe to see if it'sreally impacting your quality of
life.
But then if you measure againthat follow-up oh, let's say
several weeks later it's like,okay, well, how's your quality
(45:55):
of life?
It's like, oh, actually I mean,perhaps this is, this is
improved.
But then again you have tothink into account, like a
recall bias with that yeah, yeah, that's a really good point,
yeah, nice enough.
Dr. Joshua Goldenberg (46:06):
So sort of an interesting thing going on
there, although the effect waswas moderate, so decent, decent
effect on quality of life atfollow up.
And then the rest of theoutcomes are just very low level
evidence, just because we, youknow, there aren't a lot of
studies or there's just not alot of people, and so these are
for acupuncture compared to shamor acupuncture compared to
(46:29):
herbs or acupuncture compared tousual care.
So really the best evidence wehave is going to be compared to
nonspecific acupuncture, whichagain is even, in my opinion,
more impressive because again,those are harder comparators to
beat out.
I think that's all I wanted tosay on the overall effects.
Anything else you wanted to addon that one?
Dr. Adam Sadowski (46:50):
That was it.
Unfortunately, they weren'table to do any sort of subgroup
analyses, because each subgroupwas too small to provide any
sort of reliable conclusion.
I mean, overall, this was areally well done meta-analysis.
I think that the mainlimitations are just the fact
there's just too few studies.
Dr. Joshua Goldenberg (47:11):
They could have doubled it if they
looked at Chinese studies justsaying, Well, maybe we don't
know that.
Yeah, there were five Chinesestudies that were excluded just
because of language.
Dr. Adam Sadowski (47:24):
Oh, Okay.
Well, yeah, I mean rememberwhen it's like low quality of
evidence or when the grade isvery low.
Well, with grade very low, it'ssaying that future studies are
unlikely to impact the resultsof that.
Is that correct?
Dr. Joshua Goldenberg (47:39):
Grade very low or grade high.
Dr. Adam Sadowski (47:41):
Grade very low, or is it only high grade?
Dr. Joshua Goldenberg (47:47):
high grade.
So high grade.
There's like, yeah, there'snothing's going to happen.
You can do this big studytomorrow, the effect's not going
to change.
Uh, very low quality ofevidence.
They just say the results areuncertain.
Dr. Adam Sadowski (47:55):
Okay, like they just don't even say
anything, yeah the takeaway withthis is not that, like
acupuncture doesn't work, it'sjust 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 wassome moderate, there was
moderate uh grade uh, but a lotof this was was low to very low,
and so we just, we really justneed more studies.
Dr. Joshua Goldenberg (48:17):
Yeah, Um, or just read the.
Learn how to read Chinese Um.
But okay, now I'm fine, Um, butyeah, so to that point.
So high level evidence is likethis is the effect.
Moderate is this is probablythe 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 lookslike you can.
(48:39):
There's probably an effect anda large effect.
And then for most other stuffit's like yeah, maybe, maybe,
yes, maybe no, Hard to say,Maybe quality of life,
improvements to a moderate levelat follow up, stuff like that.
So to me this looks pretty good.
You know, one of the coolthings on the discussion they
talked about is cost.
I did want to bring that upreal quick.
Dr. Adam Sadowski (48:59):
So they're arguing yeah, Discussion section
what you read the discussionsection.
Dr. Joshua Goldenberg (49:08):
I did.
You read the discussion section.
I did.
I read the introduction and thediscussion.
Are you impressed?
Dr. Adam Sadowski (49:11):
Oh yeah, okay , I'm very impressed, you
skipped over.
Well, I would have had a smallstroke if you said that you also
read the discussion and theintroduction no, no, no I I
skipped straight to that andwanted to see what they said in
the conclusion, which I wasactually surprised by.
In the conclusion, I I was inagreement with them.
No spin, huh, no spin.
Dr. Joshua Goldenberg (49:31):
They didn't try to spin.
It's a good paper.
Yeah, it was a good goodauthors yeah Well, very, very
well-trained.
And you know, you always worryabout that Um, and myself
included like if you're theactual practitioner of a field,
like you have this intellectualand emotional bias and so you're
always worried about how thisstuff gets spun.
And yeah, they did.
They were very staid andconservative in their
(49:54):
conclusions.
They followed cochran guidanceon all that um in their
languaging and, yeah, super,super impressive.
Dr. Adam Sadowski (50:00):
would have happened if they were, if they
were funded by big needle?
Dr. Joshua Goldenberg (50:09):
I'm just like I'm just seeing like
packets of acupuncture pins nowwith like big needle on the like
the new branding thing or bigmoxibustion 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
(50:30):
say is, uh, they didn't do aneconomic analysis.
But one of the things theytalked about at the end is this
can be an expensive conditionbecause of all the surgeries and
medications and stuff like that.
Um, but that should becontrasted with the fact that
you know if acupuncture isn'tcovered, you have to go you, you
know, five to six times, 16times, like in these studies,
that may add up as well.
(50:51):
So you sort of have to likeweigh 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 toadd?
Dr Sadowski and again I willrefuse to read the name in front
(51:12):
of me on the screen Go ahead.
Dr. Adam Sadowski (51:15):
No, that's it .
Dr. Joshua Goldenberg (51:16):
Okay, all right.
Well, we hope you enjoyed it.
We have a whole slew oflistener requests.
Actually we have at least fivein the docket.
So thank you for that.
Keep them coming.
We will continue to reviewarticles and address concerns as
they came up.
Last week we talked about apaper Eric Urinell sent us, and
(51:37):
we've got a few patient requestpapers as well.
So we'll kind of go through allthis and try to get down the
docket.
Oh, and then a friend of thepod, dr Davis.
Dr Mark Davis sent us anotherrequest as well.
This is a contrast of twoconflicting resulted studies,
which I think would be aninteresting take I don't know
that we've ever done that beforeand sort of tease that apart.
Dr. Adam Sadowski (52:00):
Well, when we did our lovely homeopathy
series, oh yeah.
Dr. Joshua Goldenberg (52:06):
Oh yeah, so oh, you're going to hate me.
I'm like getting back into thewhole homeopathy series.
Oh yeah, oh, oh yeah, so oh,you're gonna hate me.
I'm like getting back into thewhole homeopathy research please
don't tell me this is anotherhomeopathy study.
I swear no, no, it's not.
No, I'm done, except that, likenow, I'm being like there's all
these active homeopathy studiesgoing on all of a sudden and
they're like josh, we need ameta-analyst and I'm like I
don't know Adam's going to killme, but we'll see how that goes.
(52:30):
All right, until next time.
Dear listener, thank you forputting up with us and we will
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Please do us a favor and letthem know about the podcast and,
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(52:52):
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It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Hey y'all this is Josh.
You know we talked about somereally interesting stuff today.
I think one of the things we'regoing to do that's relevant.
(53:13):
There is a course we have on DrJournal Club called the EBM
Boot Camp.
That's really meant forclinicians to sort of help them
understand how to criticallyevaluate the literature, etc.
Etc.
Some of the things that we'vebeen talking about today.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget to follow us onsocial and interact with us on
social media at DrJournalClub.
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(53:35):
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So please reach out to us.
We always love to talk to ourfans and our listeners.
If you have any specificquestions you'd like to ask us
about research, evidence, beinga clinician, et cetera, don't
hesitate to ask.
And then, of course, if youhave any topics that you'd like
us to cover on the pod, pleaselet us know as well.
Introducer (53:57):
Thank you for listening to the Doctor Journal
Club podcast, the show that goesunder the hood of
evidence-based integrativemedicine.
We review recent researcharticles, interview
evidence-based integrativemedicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visit www.
drjournalclub.
com to learn more.
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:23):
d rjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes only.
Talk to your doctor beforemaking any medical decisions,
changes, etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
drjournalclub.
com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclub.
com.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
I just saw your name.
You're killing me, dude.
Dr. Adam Sadowski (01:17):
Okay, all right.
Dr. Joshua Goldenberg (01:18):
These names are getting more and more
inappropriate.
Okay, Dr.
Sadowski, despite what yourname tag says, little river side
thing here.
How are you doing today?
Dr. Adam Sadowski (01:31):
I'm doing great.
How are you?
Dr. Joshua Goldenberg (01:32):
Just fine , thank you very much.
So today we're talking aboutendometriosis.
We had a listener request for apaper on endometriosis and
integrative medicine and I founda nice little paper published
recently.
I was kind of surprised abouthow nice um on acupuncture, and
(01:54):
then it was like oh man, I don'tthink we've ever done an
acupuncture review at all.
I don't think, or endometriosisor endometriosis that's.
Dr. Adam Sadowski (02:04):
Yeah.
Dr. Joshua Goldenberg (02:04):
So it's a double whammy.
We definitely need to do thisand, yeah, and I don't know much
about acupuncture at all, letalone acupuncture research, so
it's a little bit of contentexpertise that we might rely on
our listeners to call in andcorrect us with.
But yeah, so I feel like wehave some good information to go
on.
Do you have any startingcomments before we jump into the
(02:27):
paper?
Dr. Adam Sadowski (02:28):
I have no starting comments, nope.
Dr. Joshua Goldenberg (02:31):
Okay, so we'll put the link in the show
notes.
So this is a review articleAcupuncture for Endometriosis by
Gies et al G-I-E-S-E Just cameout last year in 2023.
And it's a systematic reviewand meta-analysis looking at
acupuncture and endometriosis,so for the treatment therein.
(02:53):
And so I figure, yeah, let's,why don't we go through the
methods first and then we cankind of talk about the results
and basically go page by page?
I think just kind of make ourway through here.
So what's the first thing younoticed looking at the paper and
basically go page by page?
I think just kind of make ourway through here.
Sure, so what's the first thingyou noticed looking at the
paper?
What are your first impressions?
Dr. Adam Sadowski (03:12):
Well, the first thing I noticed was that
when looking at the abstract,they put in the study
registration Prospero ID, whichis usually a good sign, yeah, I
agree.
So right off the bat I knewthat we're going to get into
something pretty good here.
Um and I I typically don't readintroductions, this one was
really nice and short, which Iactually enjoyed.
Dr. Joshua Goldenberg (03:33):
They got oh, you actually read the
introduction this time.
That is impressive.
Dr. Adam Sadowski (03:38):
Unlike you, I'm not an endometriosis expert,
and so I was actually kind ofinterested to see what they had
to say.
Dr. Joshua Goldenberg (03:47):
Yep, yep, yep.
Dr. Adam Sadowski (03:51):
And it was only like three paragraphs long
and very short paragraphs.
So I did like the fact thatthey kept it nice and short and
really to the point andhighlighted that the aims of the
paper was to determine theeffects of acupuncture on
endometriosis-related pain andhealth-related quality of life.
And something that I reallyliked is that they focused this
(04:13):
paper with sort of another aimof contributing to the
evidence-based guidelines forendometriosis.
So it wasn't just oh, let's seewhat this research is.
There was a lot of intentbehind it, which you know.
You would think that you wouldalways want research to have
good intent behind it, butoftentimes you kind of just see
(04:36):
these studies that are just kindof being done just because they
can, whereas with this onethere 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 ofacupuncture, but can this
influence guidelines for themanagement of endometriosis?
(04:56):
So can this have overarchingimpact for this condition?
Dr. Joshua Goldenberg (05:03):
Yeah, I think you're spot on on that.
Reading between the lines, Ithink they have a guideline
development in place now, likeit'll probably come out next
year, I would imagine.
And the most brilliant way ofdoing that, according to like
all the recent guidelines onthis for grade, is first you do
a systematic review ofmeta-analysis and then that
information informs yourguideline panel on doing grade
(05:27):
guidelines and you can tell justby the quality of how they set
this up that they're just reallyfollowing, I think, grade by
the book.
So, yeah, I was super impressedwith all that as well and I
agree, I think so.
I am not an endometriosis expertand so I also read the
introduction and I agree.
I think it gave a good initialsense.
You know, one of the surprisingthings to me is like they were
(05:49):
saying that once you use MRI tohelp make that diagnosis,
something like one in five womenhave endometriosis.
Like that was shocking to me.
I didn't realize it was quitethat high of prevalence.
I knew it was common.
I have lots of patients thathave it in clinic but I had
(06:10):
absolutely no idea it was thatcommon.
So super, super commoncondition can have debilitating
effects on quality of life andall sorts of stuff and the
medication apparently is notgreat.
The satisfaction around surgeryis not great either.
So there's this appetite, ifyou will, for you know,
integrative and complementaryapproaches or other approaches
and that sort of set up therationale.
I thought, pretty well, now, asfar as you know, and they're
(06:33):
acupuncturists, right?
So I think one or two of theauthors are acupuncturists and
so that's their background,that's what they're looking for.
Now I don't understand theacupuncture side of all this,
but it looked like they werepretty inclusive of different
acupuncture styles.
So, whether it was five elementor traditional or what have you
(06:55):
.
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 thinkit's freely available online and
let us know if you have anyconcerns.
But from our read, it lookedpretty good from a methods
perspective.
So okay, cool.
(07:15):
Anything else to add before wejump into methods?
Dr. Adam Sadowski (07:22):
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 oflike how well they break it down
, how easy it reads in the factthat it's just, it's just very
linear.
In as you're reading you'relike, oh, this makes sense.
Okay, this, this makes sense.
You're not like having to flipthrough pages back and forth and
(07:43):
like try to figure out what'sgoing on.
It was very, it was like ifyou're a student doing a
systematic review and metaanalysis, this would be a really
good paper to reference or tolike help guide you through the
process.
Dr. Joshua Goldenberg (07:56):
So, dear listener, you might mark this,
mark this on your calendars.
I think this is the only timeI've this is, by the way, in
case you didn't, is adam gushingabout a paper, and that's one
of the few times I've seen himgushing about paper.
In fact, as we were reading itand prepping and doing our
quote-unquote green room, whichis text back and forth in
preparation, it was justhilarious because, like, as you
(08:17):
go, section by section, I wouldget these like and did you see
this?
Like exclamation point, and didyou see that?
And look what they did here?
That's hilarious.
So, yeah, no, I had similarfeels.
It looked like I was tellingyou my little, soon to be three
year old, she'll.
She'll be like you know, if youdo something good, good by her,
she'll be like oh, you make myheart happy and which is
(08:39):
adorable.
But that's what I felt, like.
It made my little methods hearthappy to read through this and
I agree, the Prospero orProspero registration was like
the first indication that, yes,this is good.
Oh, that reminds me.
So we've talked about qualityand systematic reviews before
and we've talked about using theAmstar 2 tool to evaluate that,
(09:00):
and I think I'm going to startteaching that.
So next month at Sonoran I'mgoing to put together a lecture
on how clinicians can use theMSTAR-2.
But I was like, ah, that'spretty onerous.
But they have, of the I don'tknow 20 domains to look at.
Seven of them they considercritical domains, like if you
get one of those wrong, thestudy is critically flawed, you
(09:21):
can basically throw it out.
So I'm going to start callingthese the seven deadly sins, and
I think that's how I'm going toteach.
It is to have people look forthese seven things whenever
they're looking at a systematicreview.
And so the number one thing isthat the protocol was registered
before commencement of thereview.
Like, first of all, you have tohave it freaking registered and
(09:41):
you have to register before youstart the review.
And not only is it registeredin Prospero, which is where it
should be registered, and youhave to register before you
start the review, and not onlyis it registered in Prospero,
which is where it should beregistered.
They actually have a sentencethat specifically says that they
didn't change anything in theregistration after they started
the study.
So normally, if you do need tomake methods changes as you go,
you just have to justify it anddo a timestamp, but rarely do
(10:02):
you see that they actuallyexplicitly tell you if any
changes were made.
So yeah, made my heart happy,good, good, good.
They described the issues inPICOS, which is wonderful.
It's just randomized controltrials, so we're starting with.
High-level evidence only wouldbe includable in here and, yeah,
(10:24):
go ahead.
Dr. Adam Sadowski (10:26):
They did make the comment that crossover
randomized control trials werealso allowed to be in, but they
only took the first period ofthat crossover.
So this way they didn't diluteany effects from a carryover
period.
So for those who aren't aware,with a crossover randomized
control trial you would startoff like one group would get the
(10:47):
intervention and one groupwould be in the control group
and then at some point theywould flip and in a good
crossover randomized controltrial that blinding would be
maintained throughout.
So you don't know when you'regetting intervention and when
you would be getting placebo.
And another good crossoverrandomized trial would also have
(11:13):
basically like a washout periodwhere when you're switching
from intervention to placebo,theoretically the carryover from
any sort of treatment effectsis not being carried over into
that transition.
Dr. Joshua Goldenberg (11:30):
Yeah, exactly.
Yeah, so that's a commonworkaround for these complicated
trials is to just take thefirst half of it essentially and
view it like a regularrandomized controlled trial for
the purposes of themeta-analysis.
So that was totally kosher, Ithink, a good point pointing
that out.
As far as the different typesof intervention, yeah, this was
(11:52):
mostly over my head, but theysaid that they included
traditional Chinese, fiveelement Japanese or biomedical,
sometimes called Western.
So that would be relevant tothe listener, just if you're
trying to find, okay, like greatthis, you know, here's the
results, but which type ofacupuncture should I pursue?
Dr. Adam Sadowski (12:13):
Which I think is really important too, that
they classified it because youknow, instead of just saying
acupuncture, it really varies,there's different types of
acupuncture.
So the fact that they didhighlight that and tried to
analyze it by type ofacupuncture, I think is actually
really important.
Dr. Joshua Goldenberg (12:29):
Yeah.
So this is the thing I hear alot from acupuncturists, where
they get really frustrated withthe research in their field
because they're like well, theresearchers clearly didn't know
what they're talking about, theycombine this with that, or they
didn't even do it right, orthat's not even acupuncture, and
(12:51):
so I think, to their credit.
I mean, amongst integrativemedicine, in fields, I feel like
acupuncture has more highquality research than almost any
other field.
They're just like light yearsahead of the rest of us and
they've developed these strictcriteria, checklists, reporting,
checklists to be transparentabout how these studies are done
and how they're classified.
And do we have integrity?
What was it called?
(13:12):
Content validity?
Basically like if you went toan 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, veryimpressed so far.
Dr. Adam Sadowski (13:24):
I think too this is why, like, it's
necessary to have contentexperts within, research, even
if they're not like primaryauthors, having them as part of
kind of like how a lot of papersin the BMJ will require public
say into, like what is actuallyclinically important or like
(13:48):
what would be an importantpatient reported outcome it's
not just a bunch of cliniciansdoing the research, but having
some content experts in there toyou know, to make sure that
what is being studied isactually important.
Dr. Joshua Goldenberg (14:01):
Yeah, absolutely so.
As far as we can tell, notbeing acupuncture experts
ourselves, this looks prettylegit both from an internal and
external validity perspective,meaning the methods look good
and it seems to have externalvalidity from an acupuncture
perspective.
But again, acupuncturists,please feel free to call in and
yell at us, but there is onething.
(14:23):
So I have only one issue withthis entire paper, which is in
the next section, as we movethrough the methods here.
Oh, so sorry, outcomes.
So they're looking at painoutcomes.
They're looking at quality oflife outcomes.
They're looking at adverseevents.
They're looking atendometriosis, specific
instruments.
(14:43):
So these are very good .
Dr. Adam Sadowski (14:48):
And the primary outcome was pain
severity, with the secondaryoutcome being adverse events and
health related quality of life,and just because we haven't
touched on it yet, the mainpatient population that they're
looking at is people ofreproductive age yes, With
pelvic pain or abnormal or,excuse me, pain with menses with
(15:10):
a confirmed diagnosis ofendometriosis that was either
confirmed through laparoscopy,ultrasound, MRI or
histopathology.
So people who you know they'redefinitively basically diagnosed
with endometriosis, not justsort of like, oh you might have
endometriosis and let's see ifthis helps, right.
Dr. Joshua Goldenberg (15:31):
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 theonly studies that they looked at
were in English or German, sothey excluded studies in other
languages.
Now that's particularly aconcern in acupuncture, because
(15:54):
a lot of acupuncture research isdone in Chinese.
Right, it comes out of China,it's done in Chinese, and so I
was pretty concerned about thereason it's German.
I think one of the authors'practices in Germany I googled
her is the acupuncturist inGermany, and so there's your
content expert.
But yeah, it was kind ofsurprising, and I think later,
when they actually, again totheir credit, are transparent
(16:16):
about their exclusions, I thinkalmost double the amount of
study.
Well, so that like they couldhave doubled the number of
studies if they also includedChinese articles, but anyway, so
I think that's the main issueis that they're missing possibly
half of the evidence base, butso anyway, so we only have these
English and German studies.
(16:36):
The search itself I thought wasexcellent.
It was well described.
They looked at multipledatabases.
Really importantly, they lookedat databases that are specific
to like integrative medicine.
So they looked at AMED, whichis a database on allied and
complementary medicine.
So a lot of times you'll havethese really lazy searches where
(16:57):
they do like PubMed and prettymuch that's it, and especially
if it's a content specific area,you want to make sure you're
checking those content specificdatabases.
So they did a really excellentsearch.
I was super thrilled with thatdetailed design fully provided
in the supplement, and then theydid their screening
independently and in duplicate,which is super important, and
(17:19):
they did their data extractionindependently in a duplicate,
which is also super superimportant.
Quality assessments of thestudies as well, risk of bias
and also specific checklists foracupuncture itself.
So things like NICMN, which Ididn't know beforehand, and then
STRICTA, which apparently areacupuncture, specific checklists
(17:43):
and guidelines for quality,which was seems important.
Dr. Adam Sadowski (17:46):
Yeah, so the NICMN scale is the National
Institute for ComplementaryMedicine Acupuncture Network and
it appears to be, you know,recommended to be used along
with the STRICTA checklist.
And the whole purpose of havingthose checklists in place is to
make sure that when we're doingacupuncture research we're
(18:08):
having a consistency in how it'sbasically being reported, to
make sure that we haveconsistency in the literature so
we can make a better sort ofconclusion or estimate or know
where things need to be altered.
Because if we can have astandardization to something
(18:29):
that many practitioners willalready say is sort of like a
heterogeneous type ofintervention to begin with, this
gives us some sort of astandard to work with and it's
not to say you can only usethese acupuncture points for
every single patient.
That's not what it's saying.
But what these guidelines aresaying is okay.
You know what is the reason forthe acupuncture?
(18:50):
How was the needling done?
What was the treatment regimen?
What were the other componentsof the regimen?
Was the person performing theacupuncture have some sort of
acupuncture background?
So, for example, was it like aphysical therapist doing dry
needling?
Is that consistent withacupuncture?
Or was it someone who has abackground in traditional
(19:13):
Chinese medicine or classicalChinese medicine or you know, an
acupuncture degree.
And then how did they havetheir comparison group, like
what was the outline of that?
So if we can have astandardization procedure, we
can make a better estimate anddraw better conclusions to with
regards to acupuncture as anintervention.
Dr. Joshua Goldenberg (19:36):
Yep, super well said and I think
we're the.
The editor community and thejournal community is moving
towards better reportingstandards, but it's still a lot
of concern out there.
Herbal medicine is the bigproblem, for example, but yeah,
so it's really important to bestandardized and how this stuff
is reported.
Dr. Adam Sadowski (19:56):
And I think that's just complementary and in
alternative medicine or,excuse me, complementary
integrative health.
Because you know, if you wereto say, like you and I have a
background as NDs, when I seeresearch that says naturopathy,
what the hell does that mean?
Because naturopathy is not anintervention.
In my opinion, it's a spectrumfrom which you are able to sort
(20:21):
of choose interventions, fromsomething that includes, like
you know, body work or bodymanipulation to even surgical
intervention.
So to say, you know, we studiednat body manipulation, to even
surgical intervention.
So to say, you know, we studiednaturopathy as an intervention.
You have to define that.
And so how are we going tostandardize what naturopathy is
from a research setting?
(20:42):
Are we looking at naturopathicherbal intervention or just
healthcare delivery from anaturopath, where that
naturopath ultimately decidedhow that patient or that
research subject got anintervention?
So, having something in placefor acupuncture, I actually
appreciated, and the fact thatthey're saying, hey, you should
(21:03):
combine this with this otherscale to get this holistic,
develop this holistic evidencebase for understanding the
intervention of acupuncture.
I thought that was cool andimportant.
Dr. Joshua Goldenberg (21:15):
Yeah, no, really good point.
I mean, I think with herbs youcan say like, okay, it's this
one plant that we're studyingand there's still a million
variables like when was itharvested, what kind of extract,
yada, yada, yada.
But to your point, like to say,acupuncture period is kind of
ridiculous and analogous tosaying, you know, naturopathy
period or medicine period, right, like what the hell does that
mean?
And so yeah.
(21:36):
So again, even more important,to be clear about these, these
different interventions, and Ithink they did a good job.
We'll get to it, but I thinkone of the tables, they did a
pretty good job of showing these, the different aspects of these
interventions.
So if you, you know, did wantto, if you're a provider and you
wanted to try these, you knowneedling techniques, you would
be able to see very clearlywhich ones were used, when they
(21:57):
got the effects that they didand what else.
Oh, and they use grade, ofcourse, which is our favorite,
which is the way of assessingthe overall confidence in the
evidence.
Dr. Adam Sadowski (22:07):
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 prismachecklist.
Did the research authors havethis checklist when developing
the acupuncture study?
And then the Nickman is kind oflike the grade of the
acupuncture.
(22:27):
So was there a checklist in howthey reported it or kind of
like a strobe guideline forobservational studies?
Where like, are they followingthis sort of criteria as to how
to report?
And then the NICMN sort ofquantifies the quality of that
reporting, where higher scoresindicate better quality better
(22:48):
quality, like reporting, or likebetter quality study, like more
trustworthy.
To my understanding it seemslike better quality in the
reporting, In the reportingwhich sort of indirectly then
translates to perhaps a betterquality study.
Dr. Joshua Goldenberg (23:03):
Yeah, and then, but to the quality piece,
like they did, they also didrisk 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 biasscale.
And then, right, then they usethese others to sort of describe
how well reported the otherstudies are.
Okay, cool, I think I'm withyou now.
Good, good, good, good.
And then they did ameta-analysis and used GRADE to
(23:26):
talk about the overall evidenceand we'll talk about the results
in a second.
And the way they usemeta-analysis is they looked at
mean difference.
So you know, if you're talkingabout a 10-point pain scale and
on average you could say, okay,they dropped two points of pain,
or something like that, thatwould be a mean difference.
If the way you're describingthe result is using different
(23:48):
instruments, it gets a littlebit more complicated.
You do things like standardizedmean difference or, in this
case, hedges g.
I don't know that we need toget into super detail on that,
but basically it's a way to tosay, okay, what is the overall
effect, even if these studiesuse different instruments?
Here, and then we have thesethresholds that we use to say if
(24:10):
that's a small, moderate orlarge effect, correct, okay,
cool.
Anything to add on that one?
Dr. Adam Sadowski (24:18):
No, but it seems like with Hedges G that we
are using that for smaller sizestudies, whereas other, like a
Cohen's D, you might see, isused for larger studies.
Dr. Joshua Goldenberg (24:30):
Right, exactly, and I think it's
technically, I think it's moreconservative and then also, but
you can think of it analogously,like if you're used to thinking
of Cohen d's thresholds, likepoint two is small, point five
is moderate and point eight is alarge effect.
I believe that is sort of ananalogous threshold, so you can
kind of think of it the same way, even if you haven't heard of
Hedge's g before, of ananalogous threshold.
(24:50):
So you can kind of think of itthe same way, even if you
haven't heard of Hedges' Gbefore.
Okay, cool, they did look atsubgroup analysis, or they
planned them anyway, fordifferent types of acupuncture,
so that absolutely makes sense.
The total number of treatmentsand the mode of stimulation, so
manual or electro acupuncture,so that all makes sense.
These would be reasonablesubgroups to look at a priori.
And, yeah, data amputation isboring but pretty
(25:12):
straightforward, yeah.
So overall I think I'm goodwith the methods.
I'm looking here at our sevendeadly sins and let's just see
if we can go through these.
Look, the thing is we don't dothis for money.
This is pro bono and, quitehonestly, the mothership kind of
ekes it out every month or so,right?
(25:33):
So we do this because we careabout this.
We think it's important, wethink that integrating
evidence-based medicine andintegrative medicine is
essential and there just aren'tother resources out there the
moment.
We find something that does itbetter, we'll probably drop it.
We're busy folks, but right nowthis is what's out there that
does it better.
We'll probably drop it.
We're busy folks, but right nowthis is what's out there.
Unfortunately, that's it, andso we're going to keep on
fighting that good fight.
(25:54):
And if you believe in that, ifyou believe in intellectual
honesty in the profession andintegrative medicine and being
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
becoming a member on Dr JournalClub.
If you're in need of continuingeducation credits, take our
NANSEAC approved courses.
We have ethics courses,pharmacy courses, general
(26:15):
courses.
Interact with us on socialmedia, listen to the podcast,
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These are all ways that you cansort of help support the cause.
Deadly sin number one Did theyregister the protocol?
Yes, they did.
Check Adequacy of theliterature search is sin number
two.
(26:35):
Yes, I thought that was anexcellent literature search.
Justification for excludingindividual studies they do give
I think that comes later.
They do give reasons for whichstudies they excluded.
Did they do risk of biasassessments?
Yes, check the appropriatenessof meta-analytic methods.
That looks good to me.
(26:56):
We just talked about that.
Did they consider risk of biaswhen interpreting results?
We'll see that they did.
That comes a little bit later.
And did they talk about thepossibility of publication bias?
So, this one, they did talkabout it.
They didn't assess because theydidn't have enough studies, and
we'll get there in a second.
I'm a little on the fence ofthis because I feel like they
missed half the data becausethey didn't look at published
(27:16):
Chinese studies.
But so I would say, maybe ahalf a deadly sin, but overall a
pretty good study.
Anything else you want to addabout methods or concerns or
anything like that?
Dr. Adam Sadowski (27:29):
No, and I get where you're coming from, but I
don't, I don't really thinkit's that big of a sin.
I I'd give it a pass okay, fairenough.
Dr. Joshua Goldenberg (27:39):
Um so all right, so we'll jump into the
results here.
Um to okay.
So they talked about how thestudies were excluded.
They found six final studies outof 1074 hits yeah, so, oh, okay
, hello, we talked about thislast time.
Yeah, remember when they hadlike all these databases and
they had like 74 hits and theywere like we did this extensive
(28:00):
search of like bs.
So this is a more normal searchresult.
You would expect a thousandplus hits or whatever, and then
you whittle it down, so it itdidn't, it didn't look
suspicious, it looked perfect.
And so, of those 1000, theywent through and they found six
randomized control trials thatmet their inclusion criteria,
with 371 participants overall.
(28:22):
I'm curious how you want tohandle this.
I'm thinking we just jump tolike the tables or plots to talk
about results, or did you wantto go through it in in text form
?
Dr. Adam Sadowski (28:36):
I could just like quickly go through it.
What annoyed me about thispaper was that there was just a
lot of text when there reallydidn't need to be.
That's why I went to the tablesyeah, results section, and if
you read through it all, youcould have kind of gotten a
little misled.
Basically, from the 1074 hits,six studies, 371 total
(28:59):
participants, four of them wereyour typical randomized
controlled trial where you haveacupuncture versus a control
group.
One study used a crossoverdesign, but remember they only
used that initial part prior tothe groups actually crossing
over.
And then two studies were donein China, one in Australia, one
(29:19):
in the USA, one in Austria, onein Brazil.
The median age was 30, and allstudies used laparoscopy or
laparotomy to diagnoseendometriosis.
And then the acupuncture styles.
There were two traditionalChinese medicine style, one
Japanese style, one earacupuncture, and then two did
(29:42):
not specify the style ofacupuncture that was used.
What I actually reallyappreciated was that, when they
were looking at the studies,three studies used a fixed
treatment protocol.
So no matter who walked inthrough that door, if they had
the diagnosis, this was theacupuncture they were getting.
It was basically an algorithmyou get this, that's it.
(30:04):
One study used asemi-individualized treatment,
so I'm not really sure what thatmeant.
It looked like they had fixedpoints that were going to be
used, but then they had threepoints that could have or could
have not been used, depending onthe clinician that was
delivering the acupuncture, andthen one used an individualized
(30:25):
point.
However, it wasn't reallyindividualized because they had
an a priori determined algorithm, so not really individualized
in my opinion.
Dr. Joshua Goldenberg (30:36):
Quasi individualized Algorithmic, I
guess.
Dr. Adam Sadowski (30:40):
So AI acupuncture essentially uh for
for the acupuncturists out there.
On average they used 13 needles.
From a needle stimulationstandpoint, one study looked at
manual stimulation.
One person was hooked up to acar battery and electrically
stimulated this is a thing.
Dr. Joshua G (31:02):
Electroacupuncture is a thing, man one study.
Dr. Adam Sadowski (31:06):
They used no stimulation and then three did
not report on it from a needleplace but is stim?
Dr. Joshua Goldenberg (31:13):
is that, does that mean, is that chi or
is that different chi?
Well, like you know, whenyou're um, why do we do electric
stimulation?
No, like, there's like um she'slike the energy channels no, I
know, but.
But I'm like butchering this.
But there's like a thing thatyou get when you stimulate it
and you like bring about the chior something like it grabs at
(31:34):
it, or something like that.
There's a way to stimulate thatElectrocution.
No, all right, move on.
We clearly have no idea whatwe're talking about when it
comes to the actual intervention.
But oh, oh, yeah, look at this.
(31:56):
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 Ithink that's the, that's what
you're going for, that you likehit the, hit the site, right, I
believe, anyway.
Dr. Adam Sadowski (32:02):
So I'm not making that up, but I'm probably
butchering the pronunciationtwo studies left the needles in
place for 20 to 30 minutes, Twohad them in place for less than
20 minutes and then for twostudies.
They did not report on how longthe time was there for Cool.
Dr. Joshua Goldenberg (32:18):
And they go through all the different
points that we're used to.
So if you're an acupuncturistI'll tell you, like spleen six,
liver three, liver eight, so youcan go through and actually see
what was needled.
Dr. Adam Sadowski (32:29):
And then from the practitioner background,
for those who that like thepeople delivering the
acupuncture, three were licensedor registered acupuncturist, or
in one study there was a doctorof traditional Chinese medicine
.
One study includedphysiotherapists, and then
competency regarding acupuncturewas unclear.
Dr. Joshua Goldenberg (32:51):
Yeah, so this was cool too, because you
know, you never know who'simplementing the actual
intervention and sometimes it'speople that are like quickly
trained before the trial.
So again, explain again.
This goes to external validityor content validity.
Basically saying this is thesepeople actually knew what they
were doing they're well trained.
Dr. Adam Sadowski (33:12):
Yada, yada yada.
And then the last thing that Ithought was actually really cool
was when they looked at theNickman 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 inthe reporting.
The Nickman looks like it wasreported after 2016.
And they did find that prior to2016, those scores on average
(33:36):
were an 18.
And then after that, on averagewas a 21 and a half.
So basically, after theseguidelines were in place for how
to report acupuncture studies,they found that the quality of
reporting did in fact, improve.
Dr. Joshua Goldenberg (33:53):
So I think that was interesting and
cool.
Yeah, again, I think that afield of acupuncture, from a
research perspective, is likeagain, head and shoulders above
the rest of us, maybechiropractics after them, and I
feel like we're on the bottom.
But yeah, they do.
They do a really, really goodjob in standardizing and high
quality research.
So, okay, awesome, oh, and justjust a range of treatments.
(34:14):
So we're talking about, youknow, anywhere from five to 16
treatment sessions to get theeffects that we're talking about
here.
And they talked about differentcomparators.
I don't know that we need to.
Did you want to jump into thecomparators at all or Not?
Really, not really.
Yeah, I think that's totallyfine.
Talked about you.
Talked about quality, perfectrisk of bias.
Dr. Adam Sadowski (34:33):
Well, actually I rescind that.
I take that back because thethe type of intervention or the
type of comparator does seem tomatter.
When you're kind of looking atacupuncture research and those
who are sort of like very muchfor acupuncture and those who
are very much againstacupuncture or seem to be less
so inclined in sort of believingthe research that's out there,
(34:56):
the majority of the comparisonswere non-specific acupuncture
and I'm not entirely sure whatthat was defined as.
To my understanding was theykind of just like put random
needles into people.
So they weren't in likespecific, like gallbladder seven
or liver three points.
They were just kind of likeadjacent to it or maybe
(35:17):
somewhere like completely random.
One comparison was medicalwhich is a clever.
Dr. Joshua Goldenberg (35:23):
A clever thing, right, because it
controls for the whole ritual,the experience, the puncturing
of the skin, everything exceptfor actually needling these
channels.
Dr. Adam Sadowski (35:35):
Right, the theater, um yeah, it's very
clever and and you know, andthey they did kind of specify in
some of the studies, like thestudy from brazil, used
non-specific acupuncture wherethere was a stimulated therapy
with a needle insertion threecentimeters apart from the
original point, so likerelatively close to where it
(35:56):
would be, but actually not atthat point.
And then one nonspecificacupuncture was with no
correlation to endometriosis.
Another one was out without anysort of stimulation.
Another comparison was medicaladvice but no traditional
Chinese medicine, which I feellike is fair.
And then one was compared toChinese herbal medicine but no
(36:21):
acupuncture intervention.
It looks like yeah.
Dr. Joshua Goldenberg (36:23):
So to point, to put a finger on this a
little bit more.
So these are pretty strongcomparators, right, like these
would be, you would imagine.
These would have pretty strongeither active or placebo effects
, and so if you do see an effectin a study like that, which
we're going to see in a secondthey really did it's even more
(36:44):
impressive because the controlgroup, you would think, would
have pretty impressive placeboeffects.
So we're talking about thedifferential, the difference
between these, and the fact thatthat's as impressive as it ends
up being, I think, is even moreso.
It's not like it was aweightless control or they gave
them a little placebo pill.
These were pretty impressivecontrols, and so any difference
that you see above that, I think, is a pretty strong indication
(37:07):
of efficacy.
Dr. Adam Sadowski (37:09):
Yeah, agreed.
Dr. Joshua Goldenberg (37:10):
Okay, cool, so quickly.
Risk of bias so we had the sixstudies.
So one of the studies wasconsidered a low risk of bias,
two had some concerns and thenthree were high risk of bias.
So we'll see later.
That mixed bag, with only onelow risk of bias studied,
lowered the grade level overallfor some of the rankings and
we'll talk about that in a sec.
(37:30):
But overall the grade level forthe different outcomes ranged
from moderate to very low, andso moderate's pretty good.
Dr. Adam Sadowski (37:39):
However, moderate certainty of evidence
really only happened, I think,on one or two occasions.
The rest of the time it was lowto very low.
Dr. Joshua Goldenberg (37:48):
Yeah, and so we'll jump into that one
Agree.
And then they didn't do apublication 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 theydid.
But again I have concerns aboutyou know there are six.
(38:08):
You had, you found six studiesand five.
You found five studies inChinese.
Like you could have doubledyour data right there.
But anyway, I'll leave thatalone.
Mildson, according to Adam, allright.
So Pansferdi, blah, blah, blah,blah, blah, all right, so let's
jump into.
Should we jump into the actualresults?
Do you?
Should we let's's?
What do you?
What do you think?
Should we go to the summary offindings table?
(38:29):
How should we go through this?
Dr. Adam Sadowski (38:31):
I think the summary of a finding uh table is
sort of the best bet, becauseyou can get really lost uh in
the sauce with all the text.
Yeah, and really we have toremember that our primary
outcome was the effect ofacupuncture on on endometriosis
related pain.
Right, and within that therewere subdivisions of okay, is
(38:53):
this menstrual pain, is thisnon-specific endometriosis pain?
Is this pelvic pain?
And so they they in in thetable.
They did a good job of justoverall pain, menstrual pain and
then health related quality oflife.
Dr. Joshua Goldenberg (39:10):
Yeah, so this is beautiful.
So we're talking about tabletwo, if you're following along,
and this is this gorgeousness iscalled the summary of findings
table, which is recommended bygrade and by Cochran to present
information in a digestible way,and it's a beautiful, beautiful
thing.
So, yeah, we can probably geteverything else that we need to
talk about from this one table.
So overall pain when we'retalking about acupuncture
(39:34):
compared to nonspecificacupuncture for endometriosis.
So again, against a strongcontrol you would expect a
smaller effect, but we seeoverall pain hedges G of 1.5,
which again, that's double thethreshold of about double the
threshold of what we wouldconsider a large effect.
So a very large effect on painoverall and that's based on
(39:58):
three randomized control trials,over 200 participants with a
low grade level and that'sknocked down two levels because
of risk of bias.
So we talked about that before.
Only one study had a low riskof bias and then the
heterogeneity as well wasanother reason that they knocked
it down.
So it went down from high tomoderate and then down to low.
(40:18):
So it's low-level evidencebased on three randomized
controlled trials, but a verylarge effect size on overall
pain.
We see a similar thing withnon-specified pain using a mean
difference on a 10-point scale2.77 centimeters lower.
Two randomized controlledtrials, again low grade level.
(40:41):
So overall low grade evidencefrom randomized trials of a
pretty large clinicallymeaningful effect.
Dr. Adam Sadowski (40:48):
The way that you can kind of you know
clinically sort of make thatdiscussion with a patient is hey
, you know where do you rateyour pain on a scale of one to
10?
Oh, you're interested inacupuncture.
Okay, there's some shoddyevidence that suggests that you
know, we could lower, we couldimprove your pain.
Let's say, your pain levelright now is at a seven.
(41:11):
It may go down to a four withacupuncture.
You know, are you interested inpursuing that, yes or no?
Dr. Joshua Goldenberg (41:17):
Yeah, totally Exactly.
And then actually.
So let's talk about the, the,the few items that had moderate
level grade evidence to yourpoint, sure.
The few items that had moderatelevel grade evidence to your
point, sure.
So that is.
Menstrual pain specifically hada large effect size, very large
effect size, with moderatelevel grade evidence.
(41:37):
So that's pretty darn good.
It got ranked down once forimprecision, and that's because
this is just based on onerandomized controlled trial.
So that was the low risk ofbias study of about 100
participants.
So you have one randomizedcontrolled trial.
So that was the low risk ofbias study of about 100
participants.
So you have one randomizedcontrolled trial on 100 people
showing a very large effect onmenstrual pain.
Dr. Adam Sadowski (41:56):
However, that was at the end of the treatment
Right when we then look atfollow up, that moderate looks
like then became very low largereffect but yeah, but very low
quality evidence of much lessconfidence in that follow up
period.
Dr. Joshua Goldenberg (42:13):
So much more confidence to say you go,
you're, you're having menstrualpain, you go get acupuncture,
you finish it and you feelreally good and that is well
more and above beyond placeboeffects, based on the control
when they check in with you likeweeks or months later it's
unclear if you'll be better, butit seems like we have much more
(42:34):
confidence in that treatmenteffect right away type of thing.
Dr. Adam Sadowski (42:38):
And then also look at that sort of drop off
in number of participants.
You went from 106 to 42.
Dr. Joshua Goldenberg (42:44):
Yeah, so they basically like lost to fall
up 60% of those participants ofhigh, highly dubious data set.
I would probably just throwthat out.
That's a good point, eventhough it's a large effect.
I can't really put much faithin that at all, but you can put
decent faith in post treatmentresponse, which I think is
pretty good.
Okay, what else?
Anything else you want to focuson here?
(43:06):
Yeah, so again, follow-up notgreat where?
Dr. Adam Sadowski (43:08):
you have a clinically important outcome and
we have moderate certaintyevidence for a low magnitude of
(43:33):
effect.
The Hedge's G here was only0.19.
So let's round up to 0.2.
And the cutoff for 0.2 was 0.2for a small treatment effect and
that's probably more honest.
Yeah, If you just kind of thinkabout medicine in general, most
(43:53):
a lot of things work, but towhat degrees?
The magnitude of that treatmenteffect and it's it's typically
small.
Dr. Joshua Goldenberg (44:02):
Well, and also like you need to keep on
taking it for it to work.
So like that's the way I thinkabout it.
It's like if you're popping,you know aspirin for the pain
and it works while you're takingaspirin, but then you stop
taking aspirin and you check twoweeks later and the effect is
meaningless.
Like pretty close to being thisyear just at under the
threshold of minimal importantdifference.
That's not so crazy, it's.
(44:24):
It's analogous like you go getacupuncture.
You feel better Two weeks laterpost-acupuncture.
It doesn't.
It doesn't.
It doesn't look like the effectholds.
Let's put it that way.
I think it's a fair statementto say you're getting a pretty
large effect with decent levelevidence at the treatment once
you get the acupuncture.
But yeah, like weeks laterprobably not really going to
(44:44):
still work.
Is that fair?
Would you agree with that?
Dr. Adam Sadowski (44:48):
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 (44:56):
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 atthis.
So, but but flip, but this isflipped.
Oh, no, no, but this is uh.
Yeah, look at that.
This is interesting story.
Quality of life so, whereas wehave decent evidence for a large
effect on pain after thetreatment, like with with the
(45:18):
treatment we have very lowevidence 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 thereon the quality of life.
So I'm not sure what to make ofthat.
Dr. Adam Sadowski (45:34):
Well, perhaps that kind of makes sense,
because when you're looking athealth-related quality of life
at the end of a treatment, thatkind of seems like too acute of
a timeframe to see if it'sreally impacting your quality of
life.
But then if you measure againthat follow-up oh, let's say
several weeks later it's like,okay, well, how's your quality
(45:55):
of life?
It's like, oh, actually I mean,perhaps this is, this is
improved.
But then again you have tothink into account, like a
recall bias with that yeah, yeah, that's a really good point,
yeah, nice enough.
Dr. Joshua Goldenberg (46:06):
So sort of an interesting thing going on
there, although the effect waswas moderate, so decent, decent
effect on quality of life atfollow up.
And then the rest of theoutcomes are just very low level
evidence, just because we, youknow, there aren't a lot of
studies or there's just not alot of people, and so these are
for acupuncture compared to shamor acupuncture compared to
(46:29):
herbs or acupuncture compared tousual care.
So really the best evidence wehave is going to be compared to
nonspecific acupuncture, whichagain is even, in my opinion,
more impressive because again,those are harder comparators to
beat out.
I think that's all I wanted tosay on the overall effects.
Anything else you wanted to addon that one?
Dr. Adam Sadowski (46:50):
That was it.
Unfortunately, they weren'table to do any sort of subgroup
analyses, because each subgroupwas too small to provide any
sort of reliable conclusion.
I mean, overall, this was areally well done meta-analysis.
I think that the mainlimitations are just the fact
there's just too few studies.
Dr. Joshua Goldenberg (47:11):
They could have doubled it if they
looked at Chinese studies justsaying, Well, maybe we don't
know that.
Yeah, there were five Chinesestudies that were excluded just
because of language.
Dr. Adam Sadowski (47:24):
Oh, Okay.
Well, yeah, I mean rememberwhen it's like low quality of
evidence or when the grade isvery low.
Well, with grade very low, it'ssaying that future studies are
unlikely to impact the resultsof that.
Is that correct?
Dr. Joshua Goldenberg (47:39):
Grade very low or grade high.
Dr. Adam Sadowski (47:41):
Grade very low, or is it only high grade?
Dr. Joshua Goldenberg (47:47):
high grade.
So high grade.
There's like, yeah, there'snothing's going to happen.
You can do this big studytomorrow, the effect's not going
to change.
Uh, very low quality ofevidence.
They just say the results areuncertain.
Dr. Adam Sadowski (47:55):
Okay, like they just don't even say
anything, yeah the takeaway withthis is not that, like
acupuncture doesn't work, it'sjust 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 wassome moderate, there was
moderate uh grade uh, but a lotof this was was low to very low,
and so we just, we really justneed more studies.
Dr. Joshua Goldenberg (48:17):
Yeah, Um, or just read the.
Learn how to read Chinese Um.
But okay, now I'm fine, Um, butyeah, so to that point.
So high level evidence is likethis is the effect.
Moderate is this is probablythe 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 lookslike you can.
(48:39):
There's probably an effect anda large effect.
And then for most other stuffit's like yeah, maybe, maybe,
yes, maybe no, Hard to say,Maybe quality of life,
improvements to a moderate levelat follow up, stuff like that.
So to me this looks pretty good.
You know, one of the coolthings on the discussion they
talked about is cost.
I did want to bring that upreal quick.
Dr. Adam Sadowski (48:59):
So they're arguing yeah, Discussion section
what you read the discussionsection.
Dr. Joshua Goldenberg (49:08):
I did.
You read the discussion section.
I did.
I read the introduction and thediscussion.
Are you impressed?
Dr. Adam Sadowski (49:11):
Oh yeah, okay , I'm very impressed, you
skipped over.
Well, I would have had a smallstroke if you said that you also
read the discussion and theintroduction no, no, no I I
skipped straight to that andwanted to see what they said in
the conclusion, which I wasactually surprised by.
In the conclusion, I I was inagreement with them.
No spin, huh, no spin.
Dr. Joshua Goldenberg (49:31):
They didn't try to spin.
It's a good paper.
Yeah, it was a good goodauthors yeah Well, very, very
well-trained.
And you know, you always worryabout that Um, and myself
included like if you're theactual practitioner of a field,
like you have this intellectualand emotional bias and so you're
always worried about how thisstuff gets spun.
And yeah, they did.
They were very staid andconservative in their
(49:54):
conclusions.
They followed cochran guidanceon all that um in their
languaging and, yeah, super,super impressive.
Dr. Adam Sadowski (50:00):
would have happened if they were, if they
were funded by big needle?
Dr. Joshua Goldenberg (50:09):
I'm just like I'm just seeing like
packets of acupuncture pins nowwith like big needle on the like
the new branding thing or bigmoxibustion 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
(50:30):
say is, uh, they didn't do aneconomic analysis.
But one of the things theytalked about at the end is this
can be an expensive conditionbecause of all the surgeries and
medications and stuff like that.
Um, but that should becontrasted with the fact that
you know if acupuncture isn'tcovered, you have to go you, you
know, five to six times, 16times, like in these studies,
that may add up as well.
(50:51):
So you sort of have to likeweigh 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 toadd?
Dr Sadowski and again I willrefuse to read the name in front
(51:12):
of me on the screen Go ahead.
Dr. Adam Sadowski (51:15):
No, that's it .
Dr. Joshua Goldenberg (51:16):
Okay, all right.
Well, we hope you enjoyed it.
We have a whole slew oflistener requests.
Actually we have at least fivein the docket.
So thank you for that.
Keep them coming.
We will continue to reviewarticles and address concerns as
they came up.
Last week we talked about apaper Eric Urinell sent us, and
(51:37):
we've got a few patient requestpapers as well.
So we'll kind of go through allthis and try to get down the
docket.
Oh, and then a friend of thepod, dr Davis.
Dr Mark Davis sent us anotherrequest as well.
This is a contrast of twoconflicting resulted studies,
which I think would be aninteresting take I don't know
that we've ever done that beforeand sort of tease that apart.
Dr. Adam Sadowski (52:00):
Well, when we did our lovely homeopathy
series, oh yeah.
Dr. Joshua Goldenberg (52:06):
Oh yeah, so oh, you're going to hate me.
I'm like getting back into thewhole homeopathy series.
Oh yeah, oh, oh yeah, so oh,you're gonna hate me.
I'm like getting back into thewhole homeopathy research please
don't tell me this is anotherhomeopathy study.
I swear no, no, it's not.
No, I'm done, except that, likenow, I'm being like there's all
these active homeopathy studiesgoing on all of a sudden and
they're like josh, we need ameta-analyst and I'm like I
don't know Adam's going to killme, but we'll see how that goes.
(52:30):
All right, until next time.
Dear listener, thank you forputting up with us and we will
talk to you later.
If you enjoy this podcast,chances are that one of your
colleagues and friends probablywould as well.
Please do us a favor and letthem know about the podcast and,
if you have a little bit ofextra time, even just a few
(52:52):
seconds, if you could rate usand review us on Apple Podcast
or any other distributor.
It would be greatly appreciated.
It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Hey y'all this is Josh.
You know we talked about somereally interesting stuff today.
I think one of the things we'regoing to do that's relevant.
(53:13):
There is a course we have on DrJournal Club called the EBM
Boot Camp.
That's really meant forclinicians to sort of help them
understand how to criticallyevaluate the literature, etc.
Etc.
Some of the things that we'vebeen talking about today.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget to follow us onsocial and interact with us on
social media at DrJournalClub.
D r Journalclub on Twitter.
(53:35):
We're on Facebook, we're onLinkedIn, et cetera, et cetera.
So please reach out to us.
We always love to talk to ourfans and our listeners.
If you have any specificquestions you'd like to ask us
about research, evidence, beinga clinician, et cetera, don't
hesitate to ask.
And then, of course, if youhave any topics that you'd like
us to cover on the pod, pleaselet us know as well.
Introducer (53:57):
Thank you for listening to the Doctor Journal
Club podcast, the show that goesunder the hood of
evidence-based integrativemedicine.
We review recent researcharticles, interview
evidence-based integrativemedicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visit www.
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UConn basketball star Azzi Fudd brings her championship swag to iHeart Women’s Sports with Fudd Around and Find Out, a weekly podcast that takes fans along for the ride as Azzi spends her final year of college trying to reclaim the National Championship and prepare to be a first round WNBA draft pick. Ever wonder what it’s like to be a world-class athlete in the public spotlight while still managing schoolwork, friendships and family time? It’s time to Fudd Around and Find Out!
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
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