The Journal of Family Practice

An estimated 39.4 million US adults suffer from persistent pain,¹ and the National Institutes of Health indicate that pain affects more Americans than diabetes, heart disease, and cancer combined.²

As physicians, we know that conventional options to manage chronic pain leave much to be desired and that more evidence-based treatment options are sorely needed. Patients know this, too, and turn to complementary therapies for pain more than for any other diagnosis.³

Case in point: The use of acupuncture is growing. Its use in the United States tripled between 1997 and 2007.⁴ In addition, the research base for acupuncture is rapidly expanding. From 1991 to 2009, nearly 4000 acupuncture research studies were published, with studies on pain accounting for 41% of the acupuncture literature.⁴

But acupuncture is not without controversy. This is due to a lack of a universally accepted biologic mechanism, theories of use and efficacy based in an alternative medical system (traditional Chinese medicine [TCM]), and conflicting views of the evidence.

This article will help make sense of this growing body of knowledge by summarizing the latest evidence and addressing 7 common questions about acupuncture for pain conditions. Applying this information will give you the confidence to counsel patients appropriately and decide if acupuncture fits within their pain management plan.

1. What is acupuncture and how does it work?

Acupuncture, which has a 2000-year history of use, involves inserting needles at various points throughout the body to promote healing and improve function. Although acupuncture represents one piece of TCM (which is a holistic system that also includes herbal medicine, nutrition, meditation, and movement), it is often offered as an independent therapy.

Acupuncture point locations are determined either by using an underlying theoretical framework, such as TCM, or by using anatomic structures, such as muscular trigger points. Providers today often employ a hybrid approach when delivering acupuncture treatment. That is, practitioners may choose point locations based on TCM, but they may combine the practice with local treatments that are based on current knowledge of anatomy. For example, a patient presenting with low back pain may be treated utilizing traditional points located near the ankle and knee, and also by needling active trigger points in the quadratus lumborum muscle.

The mechanism of action. One of the reasons for the continuing controversy surrounding acupuncture is the lack of a clear understanding of its underlying mechanism of action. For centuries the “how” of acupuncture has been explained in poetic terms such as yin, yang, and qi. Only in the past half-century have we begun investigating the potential biologic mechanisms responsible for the physiologic effects seen with acupuncture treatment.

While research has uncovered several interesting theories, how these mechanisms interact to produce therapeutic effects is still unclear. However, looking at various components of the nervous system helps to provide some insight.

Consider the nervous system. One way to conceptualize the mechanisms of acupuncture is to consider the various levels of the nervous system and how each level is affected. In the central nervous system, needling an acupuncture point stimulates the natural endorphin system, altering the pain sensation.⁵ This effect is reversible with naloxone in animal models, indicating that blocking the endorphin system interferes with the analgesic benefits of acupuncture.⁵

Serotonergic systems are also involved centrally. Functional magnetic resonance imaging studies have shown that needling specific acupuncture points modulates areas of the brain.

In the spinal cord, the gate control theory is believed to play a role. (The gate control theory puts forth that nonpainful input closes the “gates” to painful input, which prevents pain sensations from traveling to the central nervous system.) Modulation of sensory input occurs at the level of the dorsal horn of the spinal cord during an acupuncture treatment, which can affect the physiologic pain response.⁶ Opioid receptors are also affected at the spinal cord level.⁷

Acupuncture use in the United States tripled between 1997 and 2007.

Lastly, multiple chemicals released peripherally, including interleukins, substance P, and adenosine, appear to contribute to acupuncture’s analgesia.⁶ We know this because a local anesthetic injected around a peripheral nerve at an acupoint blocks the analgesic effect of acupuncture.⁸ Taken together, acupuncture treatment produces physiologic changes in the brain, spinal cord, and at the periphery, making it a truly unique therapeutic modality.

2. Is acupuncture an effective treatment for pain?

Yes, but before we look at the individual studies, it is important to mention some of the shortcomings of the research to date. First, acupuncture trials lack a standard sham control intervention. Some sham treatments involve skin penetration, while others do not. This has led to controversy regarding whether the sham interventions themselves are physiologically active, thus lessening the magnitude of effect for acupuncture. This is a point of contention in the acupuncture literature and a factor to consider when deciding if results have clinical significance.

In addition, the acupuncturist providing treatment in a trial is typically unblinded. This is also true of trials measuring other physical modalities, but it contributes to the debate surrounding the magnitude of placebo response in acupuncture studies.

Finally, many randomized trials involving acupuncture have had low methodologic quality. Fortunately, there are now several high-quality systematic reviews that have attempted to filter out the lower-quality research and provide a better representation of the evidence (TABLE^9-14). A discussion of them follows.

General chronic pain. A 2012 meta-analysis¹⁵ evaluated the effectiveness of acupuncture for the treatment of chronic pain with one of 4 etiologies: nonspecific back or neck pain, chronic headache, osteoarthritis, and shoulder pain. This analysis attempted to control for the high variability of study quality in the acupuncture literature by including only studies of high methodologic character. The final analysis included 29 randomized controlled trials (N=17,922). The authors concluded that acupuncture was superior to both no acupuncture and sham (placebo) acupuncture for all pain conditions in the study. The average effect size was 0.5 standard deviations on a 10-point scale. The authors considered this to be clinically relevant, although the magnitude of benefit was modest.¹⁵

Low back pain. A 2017 systematic review by Chou et al⁹ evaluated 32 trials (N=5931) reviewing acupuncture for the treatment of chronic low back pain. This review found acupuncture was associated with lower pain intensity and improved function in the short term when compared with no treatment. And while acupuncture was associated with lower pain intensity when compared with a sham control, there was no difference in function between the 2 groups. Of note, 3 of the included trials compared acupuncture to standard medications used in the treatment of low back pain and found acupuncture to be superior in terms of both pain reduction and improved function.⁹

Trials that compared acupuncture to another active therapy have found that it often has fewer adverse effects.

The authors of a 2008 systematic review that evaluated 23 trials (N=6359)¹⁰ similarly concluded that there is moderate evidence for the use of acupuncture (compared to no treatment) for the treatment of nonspecific low back pain, but did not find evidence that acupuncture was superior to sham controls.¹⁰ The 2017 American College of Physicians clinical practice guidelines support the use of acupuncture for the treatment of chronic low back pain.¹⁶

In addition to helping with chronic low back pain, acupuncture is also showing promise as a treatment for acute spinal pain. A 2013 systematic review (11 trials, N=1139) showed that acupuncture may be more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) in treating acute low back pain and may cause fewer adverse effects.¹⁷

Headache pain. Evidence favoring acupuncture in the management of headache has been fairly consistent over the past decade. An updated Cochrane review on the prevention of migraine headaches was published in 2016.¹¹ Acupuncture was compared with no treatment in 4 trials (n=2199). The authors found moderate quality evidence that acupuncture reduces headache frequency (number needed to treat=4). Acupuncture achieved at least 50% headache reduction in 41% vs 17% in the groups that received no acupuncture. When compared with sham control groups (10 trials, n=1534), acupuncture demonstrated a small but statistically significant improvement in headache frequency. Three trials (n=744) compared acupuncture to medication prophylaxis for migraine headaches and found acupuncture had similar effectiveness with fewer adverse effects.¹¹

Osteoarthritis (OA). Most studies have focused on OA of the knee, and, thus far, have generated conflicting results. A Cochrane review in 2010 included 4 trials (n=884) that had a wait list control and 9 trials (n=1835) that compared acupuncture to a sham control.¹² When compared to a wait list control, acupuncture resulted in statistically significant and clinically relevant improvement in pain and function. However, when compared to sham treatment for OA, the review showed statistically significant improvement in pain and function for acupuncture that was unlikely to be clinically relevant.¹²

A more recent meta-analysis in 2016 evaluated 10 trials (N=2007) investigating acupuncture in the treatment of knee OA.¹³ The authors found acupuncture improved both pain and functional outcome measures when compared with either no treatment or a sham control.

Fibromyalgia. Systematic reviews in 2007 (5 trials, N=316)¹⁸ and 2010 (7 trials, N=385)¹⁹ showed that acupuncture did provide short-term pain relief in patients with fibromyalgia, but that the effect was not sustained at follow-up.These reviews were limited by a high risk of bias, which was noted in the studies. The authors of both reviews concluded that acupuncture could not be recommended for the treatment of fibromyalgia.

A more recent Cochrane review published in 2013 (9 trials, N=395) offered low- to moderate-level evidence of benefit for acupuncture compared with no treatment at one month follow-up.¹⁴ Of note, there was also evidence of benefit in improved sleep and global well-being, in addition to pain and stiffness measures in this review. The overall magnitude of benefit was small, but clinically significant. Acupuncture also has evidence of benefit in the treatment of conditions commonly seen in conjunction with fibromyalgia, including headaches and low back pain as described earlier.

3. What does a typical acupuncture treatment entail?

In a typical treatment, anywhere from about 5 to 20 needles are inserted into the body. Common areas of needling include the arms and legs, especially below the elbows and knees. Other frequently used areas are the scalp, ears, and structures related to the painful condition.

The needles used are very thin (typically smaller than a 30-gauge needle) and do not have a beveled tip like phlebotomy needles do. Most patients have minimal pain as the needles are inserted. During the treatment, the needles may be left alone or they may be heated or stimulated electrically. An average treatment lasts 30 to 40 minutes; many patients find the sessions relaxing.

4. Are there any adverse effects or complications of treatment?

Acupuncture is generally considered a safe therapy, with most patients experiencing no adverse effects at all. Minor adverse effects can include post-treatment fatigue, minor bruising, or vasovagal reactions from the insertion of the needles. Serious complications, such as pneumothorax, are possible, but are considered rare.²⁰ A 2004 study estimated the incidence of severe complications to be .05 per 10,000 acupuncture treatments.²¹

Infections are also possible, but most reported cases were due to practitioners reusing needles.²² The standard of care in the United States is to use only sterilized, single-use needles. With this practice, infections due to acupuncture are thought to be rare.

Of note, trials that compare acupuncture to another active therapy often find that acupuncture has fewer adverse effects. This has been the case when acupuncture was compared to NSAIDs for low back pain and to topiramate for headaches.^17,23

5. How does acupuncture fit into a patient’s treatment?

The simple answer is that it is often most effectively used as part of a comprehensive management plan for chronic pain.

As our understanding of the complexity of chronic pain deepens, our therapeutic armamentarium for the management of chronic pain needs to broaden. This was summed up well in a 2016 article on the multimodal management of chronic pain when the authors stated, “Many targets need more than one arrow.”²⁴ Effective management of chronic pain involves addressing psychosocial and lifestyle factors in a patient-centered way and finding a combination of treatments that most effectively leads to improved coping and function.

It’s important to note that like medications and injections, acupuncture is a passive therapy. Although there is evidence for efficacy of improved pain with acupuncture in certain conditions, it should be combined with treatments that actively engage patients, such as exercise, behavioral treatments, development of coping skills, sleep hygiene, and educational strategies.

6. To whom do I refer patients for acupuncture treatment?

In the United States, licensed acupuncturists and physicians most commonly perform acupuncture. There are more than 50 schools that train licensed acupuncturists in the United States, and it usually takes 3 years to meet the requirements.²⁵

Physicians are often trained through continuing medical education (CME) programs that take several months to complete. These programs often combine live lectures, distance learning, and hands-on training and are typically sponsored by a university. Most require 300 hours of CME to complete. Licensure varies by state, but in many states, having an MD or DO degree automatically allows physicians to practice acupuncture. (See “Online resources,” above for links to Web sites that can be useful in finding qualified acupuncturists in your area.)

7. Is acupuncture covered by insurance?

Patients can expect to pay $75 to $150 for an acupuncture session.

It depends. Insurance coverage of acupuncture is highly variable and based on region and insurance type. Medicare and Medicaid plans do not pay for acupuncture. There are some private insurance plans that do. If covered, there may be limitations regarding diagnosis, number of visits, or provider. It is best for patients to call their insurance plan directly to inquire about coverage and any limitations. If paying out of pocket, patients can expect to pay $75 to $150 per treatment session.

CORRESPONDENCE
Russell Lemmon, DO, 1100 Delaplaine Court, Madison, WI 53715; [email protected].

An estimated 39.4 million US adults suffer from persistent pain,¹ and the National Institutes of Health indicate that pain affects more Americans than diabetes, heart disease, and cancer combined.²

As physicians, we know that conventional options to manage chronic pain leave much to be desired and that more evidence-based treatment options are sorely needed. Patients know this, too, and turn to complementary therapies for pain more than for any other diagnosis.³

Case in point: The use of acupuncture is growing. Its use in the United States tripled between 1997 and 2007.⁴ In addition, the research base for acupuncture is rapidly expanding. From 1991 to 2009, nearly 4000 acupuncture research studies were published, with studies on pain accounting for 41% of the acupuncture literature.⁴

But acupuncture is not without controversy. This is due to a lack of a universally accepted biologic mechanism, theories of use and efficacy based in an alternative medical system (traditional Chinese medicine [TCM]), and conflicting views of the evidence.

This article will help make sense of this growing body of knowledge by summarizing the latest evidence and addressing 7 common questions about acupuncture for pain conditions. Applying this information will give you the confidence to counsel patients appropriately and decide if acupuncture fits within their pain management plan.

1. What is acupuncture and how does it work?

Acupuncture, which has a 2000-year history of use, involves inserting needles at various points throughout the body to promote healing and improve function. Although acupuncture represents one piece of TCM (which is a holistic system that also includes herbal medicine, nutrition, meditation, and movement), it is often offered as an independent therapy.

Acupuncture point locations are determined either by using an underlying theoretical framework, such as TCM, or by using anatomic structures, such as muscular trigger points. Providers today often employ a hybrid approach when delivering acupuncture treatment. That is, practitioners may choose point locations based on TCM, but they may combine the practice with local treatments that are based on current knowledge of anatomy. For example, a patient presenting with low back pain may be treated utilizing traditional points located near the ankle and knee, and also by needling active trigger points in the quadratus lumborum muscle.

The mechanism of action. One of the reasons for the continuing controversy surrounding acupuncture is the lack of a clear understanding of its underlying mechanism of action. For centuries the “how” of acupuncture has been explained in poetic terms such as yin, yang, and qi. Only in the past half-century have we begun investigating the potential biologic mechanisms responsible for the physiologic effects seen with acupuncture treatment.

While research has uncovered several interesting theories, how these mechanisms interact to produce therapeutic effects is still unclear. However, looking at various components of the nervous system helps to provide some insight.

Consider the nervous system. One way to conceptualize the mechanisms of acupuncture is to consider the various levels of the nervous system and how each level is affected. In the central nervous system, needling an acupuncture point stimulates the natural endorphin system, altering the pain sensation.⁵ This effect is reversible with naloxone in animal models, indicating that blocking the endorphin system interferes with the analgesic benefits of acupuncture.⁵

Serotonergic systems are also involved centrally. Functional magnetic resonance imaging studies have shown that needling specific acupuncture points modulates areas of the brain.

In the spinal cord, the gate control theory is believed to play a role. (The gate control theory puts forth that nonpainful input closes the “gates” to painful input, which prevents pain sensations from traveling to the central nervous system.) Modulation of sensory input occurs at the level of the dorsal horn of the spinal cord during an acupuncture treatment, which can affect the physiologic pain response.⁶ Opioid receptors are also affected at the spinal cord level.⁷

Acupuncture use in the United States tripled between 1997 and 2007.

Lastly, multiple chemicals released peripherally, including interleukins, substance P, and adenosine, appear to contribute to acupuncture’s analgesia.⁶ We know this because a local anesthetic injected around a peripheral nerve at an acupoint blocks the analgesic effect of acupuncture.⁸ Taken together, acupuncture treatment produces physiologic changes in the brain, spinal cord, and at the periphery, making it a truly unique therapeutic modality.

2. Is acupuncture an effective treatment for pain?

Yes, but before we look at the individual studies, it is important to mention some of the shortcomings of the research to date. First, acupuncture trials lack a standard sham control intervention. Some sham treatments involve skin penetration, while others do not. This has led to controversy regarding whether the sham interventions themselves are physiologically active, thus lessening the magnitude of effect for acupuncture. This is a point of contention in the acupuncture literature and a factor to consider when deciding if results have clinical significance.

In addition, the acupuncturist providing treatment in a trial is typically unblinded. This is also true of trials measuring other physical modalities, but it contributes to the debate surrounding the magnitude of placebo response in acupuncture studies.

Finally, many randomized trials involving acupuncture have had low methodologic quality. Fortunately, there are now several high-quality systematic reviews that have attempted to filter out the lower-quality research and provide a better representation of the evidence (TABLE^9-14). A discussion of them follows.

General chronic pain. A 2012 meta-analysis¹⁵ evaluated the effectiveness of acupuncture for the treatment of chronic pain with one of 4 etiologies: nonspecific back or neck pain, chronic headache, osteoarthritis, and shoulder pain. This analysis attempted to control for the high variability of study quality in the acupuncture literature by including only studies of high methodologic character. The final analysis included 29 randomized controlled trials (N=17,922). The authors concluded that acupuncture was superior to both no acupuncture and sham (placebo) acupuncture for all pain conditions in the study. The average effect size was 0.5 standard deviations on a 10-point scale. The authors considered this to be clinically relevant, although the magnitude of benefit was modest.¹⁵

Low back pain. A 2017 systematic review by Chou et al⁹ evaluated 32 trials (N=5931) reviewing acupuncture for the treatment of chronic low back pain. This review found acupuncture was associated with lower pain intensity and improved function in the short term when compared with no treatment. And while acupuncture was associated with lower pain intensity when compared with a sham control, there was no difference in function between the 2 groups. Of note, 3 of the included trials compared acupuncture to standard medications used in the treatment of low back pain and found acupuncture to be superior in terms of both pain reduction and improved function.⁹

Trials that compared acupuncture to another active therapy have found that it often has fewer adverse effects.

The authors of a 2008 systematic review that evaluated 23 trials (N=6359)¹⁰ similarly concluded that there is moderate evidence for the use of acupuncture (compared to no treatment) for the treatment of nonspecific low back pain, but did not find evidence that acupuncture was superior to sham controls.¹⁰ The 2017 American College of Physicians clinical practice guidelines support the use of acupuncture for the treatment of chronic low back pain.¹⁶

In addition to helping with chronic low back pain, acupuncture is also showing promise as a treatment for acute spinal pain. A 2013 systematic review (11 trials, N=1139) showed that acupuncture may be more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) in treating acute low back pain and may cause fewer adverse effects.¹⁷

Headache pain. Evidence favoring acupuncture in the management of headache has been fairly consistent over the past decade. An updated Cochrane review on the prevention of migraine headaches was published in 2016.¹¹ Acupuncture was compared with no treatment in 4 trials (n=2199). The authors found moderate quality evidence that acupuncture reduces headache frequency (number needed to treat=4). Acupuncture achieved at least 50% headache reduction in 41% vs 17% in the groups that received no acupuncture. When compared with sham control groups (10 trials, n=1534), acupuncture demonstrated a small but statistically significant improvement in headache frequency. Three trials (n=744) compared acupuncture to medication prophylaxis for migraine headaches and found acupuncture had similar effectiveness with fewer adverse effects.¹¹

Osteoarthritis (OA). Most studies have focused on OA of the knee, and, thus far, have generated conflicting results. A Cochrane review in 2010 included 4 trials (n=884) that had a wait list control and 9 trials (n=1835) that compared acupuncture to a sham control.¹² When compared to a wait list control, acupuncture resulted in statistically significant and clinically relevant improvement in pain and function. However, when compared to sham treatment for OA, the review showed statistically significant improvement in pain and function for acupuncture that was unlikely to be clinically relevant.¹²

A more recent meta-analysis in 2016 evaluated 10 trials (N=2007) investigating acupuncture in the treatment of knee OA.¹³ The authors found acupuncture improved both pain and functional outcome measures when compared with either no treatment or a sham control.

Fibromyalgia. Systematic reviews in 2007 (5 trials, N=316)¹⁸ and 2010 (7 trials, N=385)¹⁹ showed that acupuncture did provide short-term pain relief in patients with fibromyalgia, but that the effect was not sustained at follow-up.These reviews were limited by a high risk of bias, which was noted in the studies. The authors of both reviews concluded that acupuncture could not be recommended for the treatment of fibromyalgia.

A more recent Cochrane review published in 2013 (9 trials, N=395) offered low- to moderate-level evidence of benefit for acupuncture compared with no treatment at one month follow-up.¹⁴ Of note, there was also evidence of benefit in improved sleep and global well-being, in addition to pain and stiffness measures in this review. The overall magnitude of benefit was small, but clinically significant. Acupuncture also has evidence of benefit in the treatment of conditions commonly seen in conjunction with fibromyalgia, including headaches and low back pain as described earlier.

3. What does a typical acupuncture treatment entail?

In a typical treatment, anywhere from about 5 to 20 needles are inserted into the body. Common areas of needling include the arms and legs, especially below the elbows and knees. Other frequently used areas are the scalp, ears, and structures related to the painful condition.

The needles used are very thin (typically smaller than a 30-gauge needle) and do not have a beveled tip like phlebotomy needles do. Most patients have minimal pain as the needles are inserted. During the treatment, the needles may be left alone or they may be heated or stimulated electrically. An average treatment lasts 30 to 40 minutes; many patients find the sessions relaxing.

4. Are there any adverse effects or complications of treatment?

Acupuncture is generally considered a safe therapy, with most patients experiencing no adverse effects at all. Minor adverse effects can include post-treatment fatigue, minor bruising, or vasovagal reactions from the insertion of the needles. Serious complications, such as pneumothorax, are possible, but are considered rare.²⁰ A 2004 study estimated the incidence of severe complications to be .05 per 10,000 acupuncture treatments.²¹

Infections are also possible, but most reported cases were due to practitioners reusing needles.²² The standard of care in the United States is to use only sterilized, single-use needles. With this practice, infections due to acupuncture are thought to be rare.

Of note, trials that compare acupuncture to another active therapy often find that acupuncture has fewer adverse effects. This has been the case when acupuncture was compared to NSAIDs for low back pain and to topiramate for headaches.^17,23

5. How does acupuncture fit into a patient’s treatment?

The simple answer is that it is often most effectively used as part of a comprehensive management plan for chronic pain.

As our understanding of the complexity of chronic pain deepens, our therapeutic armamentarium for the management of chronic pain needs to broaden. This was summed up well in a 2016 article on the multimodal management of chronic pain when the authors stated, “Many targets need more than one arrow.”²⁴ Effective management of chronic pain involves addressing psychosocial and lifestyle factors in a patient-centered way and finding a combination of treatments that most effectively leads to improved coping and function.

It’s important to note that like medications and injections, acupuncture is a passive therapy. Although there is evidence for efficacy of improved pain with acupuncture in certain conditions, it should be combined with treatments that actively engage patients, such as exercise, behavioral treatments, development of coping skills, sleep hygiene, and educational strategies.

6. To whom do I refer patients for acupuncture treatment?

In the United States, licensed acupuncturists and physicians most commonly perform acupuncture. There are more than 50 schools that train licensed acupuncturists in the United States, and it usually takes 3 years to meet the requirements.²⁵

Physicians are often trained through continuing medical education (CME) programs that take several months to complete. These programs often combine live lectures, distance learning, and hands-on training and are typically sponsored by a university. Most require 300 hours of CME to complete. Licensure varies by state, but in many states, having an MD or DO degree automatically allows physicians to practice acupuncture. (See “Online resources,” above for links to Web sites that can be useful in finding qualified acupuncturists in your area.)

7. Is acupuncture covered by insurance?

Patients can expect to pay $75 to $150 for an acupuncture session.

It depends. Insurance coverage of acupuncture is highly variable and based on region and insurance type. Medicare and Medicaid plans do not pay for acupuncture. There are some private insurance plans that do. If covered, there may be limitations regarding diagnosis, number of visits, or provider. It is best for patients to call their insurance plan directly to inquire about coverage and any limitations. If paying out of pocket, patients can expect to pay $75 to $150 per treatment session.

CORRESPONDENCE
Russell Lemmon, DO, 1100 Delaplaine Court, Madison, WI 53715; [email protected].

An estimated 39.4 million US adults suffer from persistent pain,¹ and the National Institutes of Health indicate that pain affects more Americans than diabetes, heart disease, and cancer combined.²

As physicians, we know that conventional options to manage chronic pain leave much to be desired and that more evidence-based treatment options are sorely needed. Patients know this, too, and turn to complementary therapies for pain more than for any other diagnosis.³

Case in point: The use of acupuncture is growing. Its use in the United States tripled between 1997 and 2007.⁴ In addition, the research base for acupuncture is rapidly expanding. From 1991 to 2009, nearly 4000 acupuncture research studies were published, with studies on pain accounting for 41% of the acupuncture literature.⁴

But acupuncture is not without controversy. This is due to a lack of a universally accepted biologic mechanism, theories of use and efficacy based in an alternative medical system (traditional Chinese medicine [TCM]), and conflicting views of the evidence.

This article will help make sense of this growing body of knowledge by summarizing the latest evidence and addressing 7 common questions about acupuncture for pain conditions. Applying this information will give you the confidence to counsel patients appropriately and decide if acupuncture fits within their pain management plan.

1. What is acupuncture and how does it work?

Acupuncture, which has a 2000-year history of use, involves inserting needles at various points throughout the body to promote healing and improve function. Although acupuncture represents one piece of TCM (which is a holistic system that also includes herbal medicine, nutrition, meditation, and movement), it is often offered as an independent therapy.

Acupuncture point locations are determined either by using an underlying theoretical framework, such as TCM, or by using anatomic structures, such as muscular trigger points. Providers today often employ a hybrid approach when delivering acupuncture treatment. That is, practitioners may choose point locations based on TCM, but they may combine the practice with local treatments that are based on current knowledge of anatomy. For example, a patient presenting with low back pain may be treated utilizing traditional points located near the ankle and knee, and also by needling active trigger points in the quadratus lumborum muscle.

The mechanism of action. One of the reasons for the continuing controversy surrounding acupuncture is the lack of a clear understanding of its underlying mechanism of action. For centuries the “how” of acupuncture has been explained in poetic terms such as yin, yang, and qi. Only in the past half-century have we begun investigating the potential biologic mechanisms responsible for the physiologic effects seen with acupuncture treatment.

While research has uncovered several interesting theories, how these mechanisms interact to produce therapeutic effects is still unclear. However, looking at various components of the nervous system helps to provide some insight.

Consider the nervous system. One way to conceptualize the mechanisms of acupuncture is to consider the various levels of the nervous system and how each level is affected. In the central nervous system, needling an acupuncture point stimulates the natural endorphin system, altering the pain sensation.⁵ This effect is reversible with naloxone in animal models, indicating that blocking the endorphin system interferes with the analgesic benefits of acupuncture.⁵

Serotonergic systems are also involved centrally. Functional magnetic resonance imaging studies have shown that needling specific acupuncture points modulates areas of the brain.

In the spinal cord, the gate control theory is believed to play a role. (The gate control theory puts forth that nonpainful input closes the “gates” to painful input, which prevents pain sensations from traveling to the central nervous system.) Modulation of sensory input occurs at the level of the dorsal horn of the spinal cord during an acupuncture treatment, which can affect the physiologic pain response.⁶ Opioid receptors are also affected at the spinal cord level.⁷

Acupuncture use in the United States tripled between 1997 and 2007.

Lastly, multiple chemicals released peripherally, including interleukins, substance P, and adenosine, appear to contribute to acupuncture’s analgesia.⁶ We know this because a local anesthetic injected around a peripheral nerve at an acupoint blocks the analgesic effect of acupuncture.⁸ Taken together, acupuncture treatment produces physiologic changes in the brain, spinal cord, and at the periphery, making it a truly unique therapeutic modality.

2. Is acupuncture an effective treatment for pain?

Yes, but before we look at the individual studies, it is important to mention some of the shortcomings of the research to date. First, acupuncture trials lack a standard sham control intervention. Some sham treatments involve skin penetration, while others do not. This has led to controversy regarding whether the sham interventions themselves are physiologically active, thus lessening the magnitude of effect for acupuncture. This is a point of contention in the acupuncture literature and a factor to consider when deciding if results have clinical significance.

In addition, the acupuncturist providing treatment in a trial is typically unblinded. This is also true of trials measuring other physical modalities, but it contributes to the debate surrounding the magnitude of placebo response in acupuncture studies.

Finally, many randomized trials involving acupuncture have had low methodologic quality. Fortunately, there are now several high-quality systematic reviews that have attempted to filter out the lower-quality research and provide a better representation of the evidence (TABLE^9-14). A discussion of them follows.

General chronic pain. A 2012 meta-analysis¹⁵ evaluated the effectiveness of acupuncture for the treatment of chronic pain with one of 4 etiologies: nonspecific back or neck pain, chronic headache, osteoarthritis, and shoulder pain. This analysis attempted to control for the high variability of study quality in the acupuncture literature by including only studies of high methodologic character. The final analysis included 29 randomized controlled trials (N=17,922). The authors concluded that acupuncture was superior to both no acupuncture and sham (placebo) acupuncture for all pain conditions in the study. The average effect size was 0.5 standard deviations on a 10-point scale. The authors considered this to be clinically relevant, although the magnitude of benefit was modest.¹⁵

Low back pain. A 2017 systematic review by Chou et al⁹ evaluated 32 trials (N=5931) reviewing acupuncture for the treatment of chronic low back pain. This review found acupuncture was associated with lower pain intensity and improved function in the short term when compared with no treatment. And while acupuncture was associated with lower pain intensity when compared with a sham control, there was no difference in function between the 2 groups. Of note, 3 of the included trials compared acupuncture to standard medications used in the treatment of low back pain and found acupuncture to be superior in terms of both pain reduction and improved function.⁹

Trials that compared acupuncture to another active therapy have found that it often has fewer adverse effects.

The authors of a 2008 systematic review that evaluated 23 trials (N=6359)¹⁰ similarly concluded that there is moderate evidence for the use of acupuncture (compared to no treatment) for the treatment of nonspecific low back pain, but did not find evidence that acupuncture was superior to sham controls.¹⁰ The 2017 American College of Physicians clinical practice guidelines support the use of acupuncture for the treatment of chronic low back pain.¹⁶

In addition to helping with chronic low back pain, acupuncture is also showing promise as a treatment for acute spinal pain. A 2013 systematic review (11 trials, N=1139) showed that acupuncture may be more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) in treating acute low back pain and may cause fewer adverse effects.¹⁷

Headache pain. Evidence favoring acupuncture in the management of headache has been fairly consistent over the past decade. An updated Cochrane review on the prevention of migraine headaches was published in 2016.¹¹ Acupuncture was compared with no treatment in 4 trials (n=2199). The authors found moderate quality evidence that acupuncture reduces headache frequency (number needed to treat=4). Acupuncture achieved at least 50% headache reduction in 41% vs 17% in the groups that received no acupuncture. When compared with sham control groups (10 trials, n=1534), acupuncture demonstrated a small but statistically significant improvement in headache frequency. Three trials (n=744) compared acupuncture to medication prophylaxis for migraine headaches and found acupuncture had similar effectiveness with fewer adverse effects.¹¹

Osteoarthritis (OA). Most studies have focused on OA of the knee, and, thus far, have generated conflicting results. A Cochrane review in 2010 included 4 trials (n=884) that had a wait list control and 9 trials (n=1835) that compared acupuncture to a sham control.¹² When compared to a wait list control, acupuncture resulted in statistically significant and clinically relevant improvement in pain and function. However, when compared to sham treatment for OA, the review showed statistically significant improvement in pain and function for acupuncture that was unlikely to be clinically relevant.¹²

A more recent meta-analysis in 2016 evaluated 10 trials (N=2007) investigating acupuncture in the treatment of knee OA.¹³ The authors found acupuncture improved both pain and functional outcome measures when compared with either no treatment or a sham control.

Fibromyalgia. Systematic reviews in 2007 (5 trials, N=316)¹⁸ and 2010 (7 trials, N=385)¹⁹ showed that acupuncture did provide short-term pain relief in patients with fibromyalgia, but that the effect was not sustained at follow-up.These reviews were limited by a high risk of bias, which was noted in the studies. The authors of both reviews concluded that acupuncture could not be recommended for the treatment of fibromyalgia.

A more recent Cochrane review published in 2013 (9 trials, N=395) offered low- to moderate-level evidence of benefit for acupuncture compared with no treatment at one month follow-up.¹⁴ Of note, there was also evidence of benefit in improved sleep and global well-being, in addition to pain and stiffness measures in this review. The overall magnitude of benefit was small, but clinically significant. Acupuncture also has evidence of benefit in the treatment of conditions commonly seen in conjunction with fibromyalgia, including headaches and low back pain as described earlier.

3. What does a typical acupuncture treatment entail?

In a typical treatment, anywhere from about 5 to 20 needles are inserted into the body. Common areas of needling include the arms and legs, especially below the elbows and knees. Other frequently used areas are the scalp, ears, and structures related to the painful condition.

The needles used are very thin (typically smaller than a 30-gauge needle) and do not have a beveled tip like phlebotomy needles do. Most patients have minimal pain as the needles are inserted. During the treatment, the needles may be left alone or they may be heated or stimulated electrically. An average treatment lasts 30 to 40 minutes; many patients find the sessions relaxing.

4. Are there any adverse effects or complications of treatment?

Acupuncture is generally considered a safe therapy, with most patients experiencing no adverse effects at all. Minor adverse effects can include post-treatment fatigue, minor bruising, or vasovagal reactions from the insertion of the needles. Serious complications, such as pneumothorax, are possible, but are considered rare.²⁰ A 2004 study estimated the incidence of severe complications to be .05 per 10,000 acupuncture treatments.²¹

Infections are also possible, but most reported cases were due to practitioners reusing needles.²² The standard of care in the United States is to use only sterilized, single-use needles. With this practice, infections due to acupuncture are thought to be rare.

Of note, trials that compare acupuncture to another active therapy often find that acupuncture has fewer adverse effects. This has been the case when acupuncture was compared to NSAIDs for low back pain and to topiramate for headaches.^17,23

5. How does acupuncture fit into a patient’s treatment?

The simple answer is that it is often most effectively used as part of a comprehensive management plan for chronic pain.

As our understanding of the complexity of chronic pain deepens, our therapeutic armamentarium for the management of chronic pain needs to broaden. This was summed up well in a 2016 article on the multimodal management of chronic pain when the authors stated, “Many targets need more than one arrow.”²⁴ Effective management of chronic pain involves addressing psychosocial and lifestyle factors in a patient-centered way and finding a combination of treatments that most effectively leads to improved coping and function.

It’s important to note that like medications and injections, acupuncture is a passive therapy. Although there is evidence for efficacy of improved pain with acupuncture in certain conditions, it should be combined with treatments that actively engage patients, such as exercise, behavioral treatments, development of coping skills, sleep hygiene, and educational strategies.

6. To whom do I refer patients for acupuncture treatment?

In the United States, licensed acupuncturists and physicians most commonly perform acupuncture. There are more than 50 schools that train licensed acupuncturists in the United States, and it usually takes 3 years to meet the requirements.²⁵

Physicians are often trained through continuing medical education (CME) programs that take several months to complete. These programs often combine live lectures, distance learning, and hands-on training and are typically sponsored by a university. Most require 300 hours of CME to complete. Licensure varies by state, but in many states, having an MD or DO degree automatically allows physicians to practice acupuncture. (See “Online resources,” above for links to Web sites that can be useful in finding qualified acupuncturists in your area.)

7. Is acupuncture covered by insurance?

Patients can expect to pay $75 to $150 for an acupuncture session.

It depends. Insurance coverage of acupuncture is highly variable and based on region and insurance type. Medicare and Medicaid plans do not pay for acupuncture. There are some private insurance plans that do. If covered, there may be limitations regarding diagnosis, number of visits, or provider. It is best for patients to call their insurance plan directly to inquire about coverage and any limitations. If paying out of pocket, patients can expect to pay $75 to $150 per treatment session.

CORRESPONDENCE
Russell Lemmon, DO, 1100 Delaplaine Court, Madison, WI 53715; [email protected].

ABSTRACT

Purpose This study evaluated the effect of patient positioning on the diagnosis of hypertension in a clinic setting and the importance of following guidelines for measuring blood pressure (BP).

Methods In the trial part of this study, we recorded BP measurements by an aneroid sphygmomanometer with patients seated first on an examination table, a commonly observed practice, and second in the standard seated position as defined by the American Heart Association. Two measurements were obtained in each position for 204 patients, and we determined the difference between the average readings in the 2 positions. Factored into the comparison was an estimation of inherent variance of the device and observer achieved by repeated measurements on a healthy individual.

Results This investigation included an initial observational study of 25 regional primary care offices, the results of which showed frequent lack of adherence with accepted guidelines in patient positioning during BP measurement. The overall systolic and diastolic BPs were more than 2 mm Hg lower in the standard seated position compared with the examination table position (P<.001). Noncompliance with the position guideline resulted in misclassification of 15 patients (7.4%) as prehypertensive, when, in fact, they were normotensive. Misclassification of hypertension occurred in 12 patients (5.9%), when, in fact, they were normotensive. Logistic regression using relevant clinical factors did not identify those individuals who were misclassified.

Conclusion This study underscores the importance of patient positioning on BP determinations in order to accurately diagnose hypertension.

The high prevalence of hypertension and its burden of disease in the United States and worldwide are well known.¹ Hypertension is a major risk factor for coronary heart disease, congestive heart failure, ischemic and hemorrhagic stroke, chronic kidney disease, and peripheral arterial disease.² Among all risk factors, hypertension ranked first worldwide in disability-adjusted life-years.³ However, misclassification of an individual’s blood pressure (BP) as prehypertension or hypertension also confers significant health and financial burdens due to unnecessary medical encounters, testing, and treatment, and to increased cost of insurance coverage and out-of-pocket expenses. A correct assessment of BP in the outpatient setting depends on accurate measurement technique.

The diagnosis of hypertension is based on indirect measurement of BP using in-office, ambulatory, or home monitoring. Although office BP measurement is less than ideal, it is used most often to diagnose and monitor hypertension. Furthermore, most published trials of treatment recommendations are based on office BP measurements.⁴

Automated oscillometric and aneroid sphygmomanometers are common BP measurement devices. Proper technique is particularly important with the aneroid sphygmomanometer to obtain consistent and accurate results.⁵ Good training and an ability to hear the Korotkoff sounds are crucial.

Only 10 of 25 offices we visited in our area measured BP with patients properly seated in a chair. Most had their patients sit on the edge of the examination table.

Expert consensus groups such as the American Heart Association (AHA) publish recommendations for proper technique in reliably measuring BP,^6-8 and they emphasize the importance of patient positioning during BP measurement. The individual should be seated comfortably in a chair with both arms and back supported, legs uncrossed, and feet flat on the floor. We’ll refer to this as the “standard position.” Although the proper technique for measuring BP has been widely advocated, a recent literature review for the US Preventive Services Task Force concluded that surprisingly few studies are available on the diagnostic accuracy of office BP practices.⁹

One paper evaluated the effect of leg crossing on accuracy of BP measurement. No subjects were reclassified as hypertensive, but the study lacked statistical rigor.¹⁰ Another study found variable BP readings regardless of body position.¹¹

The purpose of our study was to compare BP measurement in 2 positions: the standard position described above, and the examination table position in which the patient is seated on the edge of the table with back, arms, and feet unsupported.

METHODS

We conducted our literature search across several scientific and medical literature databases, including PubMed, ScienceDirect, and CINAHL. Only English-language articles were reviewed.

We followed the BP measurement guidelines of the AHA. Prior to beginning the study, we provided instructions in proper BP measurement technique to the nurses who would obtain the data. The minimum sample size of patients needed to identify a difference of at least 2 mm Hg was 26, as estimated by power analysis. This was calculated using an alpha of .05 and a beta of .13.

The study population consisted of patients presenting consecutively to a teaching family medicine center. Adult patients, ages 18 and older, were informed about the study and invited to participate. Those who agreed were asked to read and sign an informed consent approved by a regional institutional review board for human subjects. We excluded patients who declined participation for any reason, who were in severe pain or distress that may have prevented them from completing the protocol, or who had limited mobility that could interfere with climbing onto the examination table. Patients considered for the study totaled 250, 28 of whom were ineligible. Another 18 patients declined participation, leaving 204 who completed the protocol.

Before testing began, we estimated the standard deviation of each aneroid sphygmomanometer and the assigned observer by repeatedly measuring the BP of a healthy normotensive individual sitting in the standard position. We obtained 46 measurements over 2 days to avoid subject and operator fatigue. Standard deviation for systolic BP was 3.6 mm Hg; for diastolic it was 3.8 mm Hg.

During testing, nurses recorded BP for each patient twice in the examination table position and twice in the standard position. They entered data into an Excel workbook for subsequent analysis. All examination rooms were equipped with newly purchased aneroid sphygmomanometers, and the appropriate cuff size was selected for each patient. Patients were instructed to remain quiet during the measurements. Patients sat first on the edge of the examination table. After a 5-minute rest, BP was measured twice in the same arm. Measurements were separated by 1 to 2 minutes. Patients then sat in the chair and rested another 2 minutes before BP was again measured twice in the same arm. The arms and back were supported in the chair and the stethoscope placed at heart level.

As per protocol, we obtained 4 BP readings on each patient and calculated the difference between the average systolic and diastolic BP values from the 2 positions. The standard error of the mean of this difference was determined using the equation, where Sd is the standard deviation of the aneroid sphygmomanometer and observer.¹² A one-sided, 95% confidence upper bound for the standard error of the difference is 1.65 × SEd. We compared patient-specific differences against this upper bound to identify significant systolic and diastolic BP changes due to positioning. If the patient’s BP difference exceeded the upper bound, it was attributed to the positional change and not to variation inherent to the sphygmomanometer and observer.

As an example, consider a patient whose average systolic BP readings from the examination-table and standard positions, respectively, were 128 mm Hg and 120 mm Hg. Assuming an SEd of 3.55 and an upper bound of 5.86, the observed 8 mm Hg difference in average systolic BPs would be considered significant. The amount of random variation from the sphygmomanometer and observer would not be expected to exceed 5.86 mm Hg.

In accordance with accepted standards, prehypertension was defined as a BP between 120-139/80-89 mm Hg, and hypertension was defined as a BP ≥140/90 mm Hg.⁴ BP below 120/80 mm Hg was considered normal. We calculated each patient’s average systolic and diastolic BP values in the 2 positions and thereby classified the individual as normotensive, prehypertensive, or hypertensive. We regarded as misclassified any patient whose BP showed significant lowering between the examination-table and standard positions resulting in a change of classification from prehypertensive or hypertensive to normotensive. For example, a patient with an examination-table position average reading of 126/85 mm Hg and a standard position average reading of 118/78 mm Hg would have been misclassified as prehypertensive.

We reviewed charts and gathered data, including subject age, sex, obesity (defined as a body mass index of ≥30 kg/m²), and history of diabetes, hypertension, or smoking. Other than age, all data were binary. We performed logistic regression analysis using the Excel Add-in Real Statistics Resource Pack software (Release 4.3)¹³ to determine if these factors could predict significant lowering of BP due to positional change.

Our associated observational study. We also conducted a separate observational study of 25 regional primary care offices to evaluate compliance with the AHA guidelines for measuring BP. The office nurses taking measurements were not informed of the study’s purpose to prevent deviation from their common practice.

In our study, 13.2% of patients classified as prehypertensive or hypertensive when they sat on the exam table were found to be normotensive when seated in the chair.

Data on 9 guideline criteria were collected to assess supervision of patients before and during measurements, including having the patient sit in a chair in quiet and comfortable surroundings with arms and back supported and feet on the ground. We also noted the type of BP measuring device used. Additionally, observers assessed the technique of the individuals using a manual device, including cuff placement and deflation rate. The observations were conducted during a clinic visit by a medical student knowledgeable in the AHA guidelines for measuring BP by automated oscillometric or aneroid sphygmomanometric devices. We conducted the study over a 2-week period in the second quarter of 2016.

RESULTS

Power analysis performed prior to the study showed that a minimum of 26 patients would be needed to predict a 2 mm Hg difference between BPs obtained in the 2 positions. Of the 204 patients used in the logistic regression analysis, 78 were men and 126 were women. Ages ranged from 18 to 101 years, yielding a mean of 54. One-hundred sixteen had previously received a diagnosis of hypertension, 39 had diabetes, 92 were obese, 22 were current smokers, and 68 were former smokers.

TABLE 1 shows the means and ranges of systolic and diastolic BP for both study positions. With this study population, mean BP recorded in the examination-table position decreased in the standard position by 2.1 and 2.2 mm Hg for systolic and diastolic BP, respectively (P<.001).

Significant BP lowering—as defined by a one-sided 95% confidence upper bound for the standard error of differences between study positions—was determined to be 5.86 and 6.22 mm Hg for systolic and diastolic pressures, respectively. Significant lowering of BP and misclassification due to positioning are summarized in TABLE 2. Significant lowering of mean systolic or diastolic BP with positional change from table to chair occurred in 62 subjects (30.4%). Misclassification of prehypertension occurred in 7.4% of subjects, and misclassification of hypertension occurred in 5.9%.

Logistic regression using patient age, sex, obesity, and history of diabetes, hypertension, and smoking as independent factors did not predict significant BP lowering with positional change.

Our observational study revealed that proper positioning in a chair was followed in only 10 of the 25 offices. In the remaining offices, patients were seated on the examination table. A 5-minute rest period before measuring BP was allowed in only 10 of the 25 offices. An automated oscillometric device was used in only 2 of the 25 offices.

DISCUSSION

In this study, 27 subjects (13.2%) were misclassified as prehypertensive or hypertensive as a result of deviating from the standard position in obtaining BP. Although the standard position is universally recommended, the guideline is not always followed in clinical practice.¹⁴

One study by Villegas et al found that 60% of physicians and nurses working in a major hospital were measuring BP inaccurately.¹⁵ In our initial observational study, 60% of primary care practices visited did not adhere to the recommended patient positioning. These medical offices are located in the community surrounding our facility and are operated by the same health care organization. The misclassification of prehypertension and hypertension observed in our prospective comparison of BP recordings in table and chair positions is, therefore, likely to occur to some degree at these practices, as well.

Similar diagnostic misclassifications have been reported in other medical settings. In a published survey of 114 medical offices, McKay and coworkers noted frequent inconsistencies with published guidelines in measuring BP.¹⁶

Common clinical demographic data obtained during this study showed no association with the positional BP change. Increased muscle tension due to lack of body support while sitting on the edge of the examination table could be the cause of elevated BP for this subgroup of individuals. Measuring muscle tension of the arms and back while seated on an exam table and chair was beyond the scope of this study.

In clinical practice, different types of BP measuring devices are used. Calibration and quality control of these devices is often lacking.¹⁷ Before starting our study, we determined the statistical variance of the aneroid sphygmomanometers and found it to approximate the manufacturer’s precision specification. Guidelines recommend using the mean of 2 BP readings as representing the patient’s BP for a given clinic visit. Additional readings are recommended if there is more than a 5 mm Hg difference between the initial 2 readings.⁴

In our study, we used sampling statistics of the BP readings and clinical guideline BP ranges in making diagnostic determinations. The inability to identify those patients whose BP will be affected by positional change highlights the importance of following standard BP measurement guidelines for all patients.

Study limitations. Positional change in BP from examination table to chair lacks a comparison to BP changes in positioning from chair to table. If similar BP changes in the reverse sequence were to be observed, this would add support to the hypothesis that muscle tension of the unsupported body is a cause of BP elevation in certain individuals. We believe, however, that the sequence of BP measurements (from table to chair) did not have a significant impact because all patients were allowed to rest in each position before the BP was measured. The BP was therefore measured in a steady-state in both positions.

Increased muscle tension due to lack of body support while sitting on the edge of the examination table could be the cause of the elevated BP.

Additionally, BP measurement by aneroid sphygmomanometry is highly dependent on observer skill and hearing ability. Furthermore, a disproportionate number of BP measurements recorded in the study ended in zero, suggesting terminal digit bias by the observer. These sources of error may be avoided using an automated oscillometric measuring device.¹⁸ Automated devices also allow for repeated independent measurements that minimize the white-coat effect. However, there are also limitations to the accuracy of oscillometric equipment. This is especially true when recording BP in the elderly, a group whose stiff arterial walls may cause erroneous measurements.¹⁹

Guideline justification. Nonadherence to standard positioning when measuring BP leads to certain individuals being misclassified as prehypertensive or hypertensive. Misclassification in turn leads to unnecessary medical encounters, testing, and treatment. Misdiagnosis is also likely to increase the cost of an individual’s insurance coverage and out-of-pocket health care expenses.

CORRESPONDENCE
Roy N. Morcos, MD, St. Elizabeth Family Medicine Residency Program, 8423 Market Street, Suite 101, Boardman, Ohio 44512; [email protected].

ABSTRACT

Purpose This study evaluated the effect of patient positioning on the diagnosis of hypertension in a clinic setting and the importance of following guidelines for measuring blood pressure (BP).

Methods In the trial part of this study, we recorded BP measurements by an aneroid sphygmomanometer with patients seated first on an examination table, a commonly observed practice, and second in the standard seated position as defined by the American Heart Association. Two measurements were obtained in each position for 204 patients, and we determined the difference between the average readings in the 2 positions. Factored into the comparison was an estimation of inherent variance of the device and observer achieved by repeated measurements on a healthy individual.

Results This investigation included an initial observational study of 25 regional primary care offices, the results of which showed frequent lack of adherence with accepted guidelines in patient positioning during BP measurement. The overall systolic and diastolic BPs were more than 2 mm Hg lower in the standard seated position compared with the examination table position (P<.001). Noncompliance with the position guideline resulted in misclassification of 15 patients (7.4%) as prehypertensive, when, in fact, they were normotensive. Misclassification of hypertension occurred in 12 patients (5.9%), when, in fact, they were normotensive. Logistic regression using relevant clinical factors did not identify those individuals who were misclassified.

Conclusion This study underscores the importance of patient positioning on BP determinations in order to accurately diagnose hypertension.

The high prevalence of hypertension and its burden of disease in the United States and worldwide are well known.¹ Hypertension is a major risk factor for coronary heart disease, congestive heart failure, ischemic and hemorrhagic stroke, chronic kidney disease, and peripheral arterial disease.² Among all risk factors, hypertension ranked first worldwide in disability-adjusted life-years.³ However, misclassification of an individual’s blood pressure (BP) as prehypertension or hypertension also confers significant health and financial burdens due to unnecessary medical encounters, testing, and treatment, and to increased cost of insurance coverage and out-of-pocket expenses. A correct assessment of BP in the outpatient setting depends on accurate measurement technique.

The diagnosis of hypertension is based on indirect measurement of BP using in-office, ambulatory, or home monitoring. Although office BP measurement is less than ideal, it is used most often to diagnose and monitor hypertension. Furthermore, most published trials of treatment recommendations are based on office BP measurements.⁴

Automated oscillometric and aneroid sphygmomanometers are common BP measurement devices. Proper technique is particularly important with the aneroid sphygmomanometer to obtain consistent and accurate results.⁵ Good training and an ability to hear the Korotkoff sounds are crucial.

Only 10 of 25 offices we visited in our area measured BP with patients properly seated in a chair. Most had their patients sit on the edge of the examination table.

Expert consensus groups such as the American Heart Association (AHA) publish recommendations for proper technique in reliably measuring BP,^6-8 and they emphasize the importance of patient positioning during BP measurement. The individual should be seated comfortably in a chair with both arms and back supported, legs uncrossed, and feet flat on the floor. We’ll refer to this as the “standard position.” Although the proper technique for measuring BP has been widely advocated, a recent literature review for the US Preventive Services Task Force concluded that surprisingly few studies are available on the diagnostic accuracy of office BP practices.⁹

One paper evaluated the effect of leg crossing on accuracy of BP measurement. No subjects were reclassified as hypertensive, but the study lacked statistical rigor.¹⁰ Another study found variable BP readings regardless of body position.¹¹

The purpose of our study was to compare BP measurement in 2 positions: the standard position described above, and the examination table position in which the patient is seated on the edge of the table with back, arms, and feet unsupported.

METHODS

We conducted our literature search across several scientific and medical literature databases, including PubMed, ScienceDirect, and CINAHL. Only English-language articles were reviewed.

We followed the BP measurement guidelines of the AHA. Prior to beginning the study, we provided instructions in proper BP measurement technique to the nurses who would obtain the data. The minimum sample size of patients needed to identify a difference of at least 2 mm Hg was 26, as estimated by power analysis. This was calculated using an alpha of .05 and a beta of .13.

The study population consisted of patients presenting consecutively to a teaching family medicine center. Adult patients, ages 18 and older, were informed about the study and invited to participate. Those who agreed were asked to read and sign an informed consent approved by a regional institutional review board for human subjects. We excluded patients who declined participation for any reason, who were in severe pain or distress that may have prevented them from completing the protocol, or who had limited mobility that could interfere with climbing onto the examination table. Patients considered for the study totaled 250, 28 of whom were ineligible. Another 18 patients declined participation, leaving 204 who completed the protocol.

Before testing began, we estimated the standard deviation of each aneroid sphygmomanometer and the assigned observer by repeatedly measuring the BP of a healthy normotensive individual sitting in the standard position. We obtained 46 measurements over 2 days to avoid subject and operator fatigue. Standard deviation for systolic BP was 3.6 mm Hg; for diastolic it was 3.8 mm Hg.

During testing, nurses recorded BP for each patient twice in the examination table position and twice in the standard position. They entered data into an Excel workbook for subsequent analysis. All examination rooms were equipped with newly purchased aneroid sphygmomanometers, and the appropriate cuff size was selected for each patient. Patients were instructed to remain quiet during the measurements. Patients sat first on the edge of the examination table. After a 5-minute rest, BP was measured twice in the same arm. Measurements were separated by 1 to 2 minutes. Patients then sat in the chair and rested another 2 minutes before BP was again measured twice in the same arm. The arms and back were supported in the chair and the stethoscope placed at heart level.

As per protocol, we obtained 4 BP readings on each patient and calculated the difference between the average systolic and diastolic BP values from the 2 positions. The standard error of the mean of this difference was determined using the equation, where Sd is the standard deviation of the aneroid sphygmomanometer and observer.¹² A one-sided, 95% confidence upper bound for the standard error of the difference is 1.65 × SEd. We compared patient-specific differences against this upper bound to identify significant systolic and diastolic BP changes due to positioning. If the patient’s BP difference exceeded the upper bound, it was attributed to the positional change and not to variation inherent to the sphygmomanometer and observer.

As an example, consider a patient whose average systolic BP readings from the examination-table and standard positions, respectively, were 128 mm Hg and 120 mm Hg. Assuming an SEd of 3.55 and an upper bound of 5.86, the observed 8 mm Hg difference in average systolic BPs would be considered significant. The amount of random variation from the sphygmomanometer and observer would not be expected to exceed 5.86 mm Hg.

In accordance with accepted standards, prehypertension was defined as a BP between 120-139/80-89 mm Hg, and hypertension was defined as a BP ≥140/90 mm Hg.⁴ BP below 120/80 mm Hg was considered normal. We calculated each patient’s average systolic and diastolic BP values in the 2 positions and thereby classified the individual as normotensive, prehypertensive, or hypertensive. We regarded as misclassified any patient whose BP showed significant lowering between the examination-table and standard positions resulting in a change of classification from prehypertensive or hypertensive to normotensive. For example, a patient with an examination-table position average reading of 126/85 mm Hg and a standard position average reading of 118/78 mm Hg would have been misclassified as prehypertensive.

We reviewed charts and gathered data, including subject age, sex, obesity (defined as a body mass index of ≥30 kg/m²), and history of diabetes, hypertension, or smoking. Other than age, all data were binary. We performed logistic regression analysis using the Excel Add-in Real Statistics Resource Pack software (Release 4.3)¹³ to determine if these factors could predict significant lowering of BP due to positional change.

Our associated observational study. We also conducted a separate observational study of 25 regional primary care offices to evaluate compliance with the AHA guidelines for measuring BP. The office nurses taking measurements were not informed of the study’s purpose to prevent deviation from their common practice.

In our study, 13.2% of patients classified as prehypertensive or hypertensive when they sat on the exam table were found to be normotensive when seated in the chair.

Data on 9 guideline criteria were collected to assess supervision of patients before and during measurements, including having the patient sit in a chair in quiet and comfortable surroundings with arms and back supported and feet on the ground. We also noted the type of BP measuring device used. Additionally, observers assessed the technique of the individuals using a manual device, including cuff placement and deflation rate. The observations were conducted during a clinic visit by a medical student knowledgeable in the AHA guidelines for measuring BP by automated oscillometric or aneroid sphygmomanometric devices. We conducted the study over a 2-week period in the second quarter of 2016.

RESULTS

Power analysis performed prior to the study showed that a minimum of 26 patients would be needed to predict a 2 mm Hg difference between BPs obtained in the 2 positions. Of the 204 patients used in the logistic regression analysis, 78 were men and 126 were women. Ages ranged from 18 to 101 years, yielding a mean of 54. One-hundred sixteen had previously received a diagnosis of hypertension, 39 had diabetes, 92 were obese, 22 were current smokers, and 68 were former smokers.

TABLE 1 shows the means and ranges of systolic and diastolic BP for both study positions. With this study population, mean BP recorded in the examination-table position decreased in the standard position by 2.1 and 2.2 mm Hg for systolic and diastolic BP, respectively (P<.001).

Significant BP lowering—as defined by a one-sided 95% confidence upper bound for the standard error of differences between study positions—was determined to be 5.86 and 6.22 mm Hg for systolic and diastolic pressures, respectively. Significant lowering of BP and misclassification due to positioning are summarized in TABLE 2. Significant lowering of mean systolic or diastolic BP with positional change from table to chair occurred in 62 subjects (30.4%). Misclassification of prehypertension occurred in 7.4% of subjects, and misclassification of hypertension occurred in 5.9%.

Logistic regression using patient age, sex, obesity, and history of diabetes, hypertension, and smoking as independent factors did not predict significant BP lowering with positional change.

Our observational study revealed that proper positioning in a chair was followed in only 10 of the 25 offices. In the remaining offices, patients were seated on the examination table. A 5-minute rest period before measuring BP was allowed in only 10 of the 25 offices. An automated oscillometric device was used in only 2 of the 25 offices.

DISCUSSION

In this study, 27 subjects (13.2%) were misclassified as prehypertensive or hypertensive as a result of deviating from the standard position in obtaining BP. Although the standard position is universally recommended, the guideline is not always followed in clinical practice.¹⁴

One study by Villegas et al found that 60% of physicians and nurses working in a major hospital were measuring BP inaccurately.¹⁵ In our initial observational study, 60% of primary care practices visited did not adhere to the recommended patient positioning. These medical offices are located in the community surrounding our facility and are operated by the same health care organization. The misclassification of prehypertension and hypertension observed in our prospective comparison of BP recordings in table and chair positions is, therefore, likely to occur to some degree at these practices, as well.

Similar diagnostic misclassifications have been reported in other medical settings. In a published survey of 114 medical offices, McKay and coworkers noted frequent inconsistencies with published guidelines in measuring BP.¹⁶

Common clinical demographic data obtained during this study showed no association with the positional BP change. Increased muscle tension due to lack of body support while sitting on the edge of the examination table could be the cause of elevated BP for this subgroup of individuals. Measuring muscle tension of the arms and back while seated on an exam table and chair was beyond the scope of this study.

In clinical practice, different types of BP measuring devices are used. Calibration and quality control of these devices is often lacking.¹⁷ Before starting our study, we determined the statistical variance of the aneroid sphygmomanometers and found it to approximate the manufacturer’s precision specification. Guidelines recommend using the mean of 2 BP readings as representing the patient’s BP for a given clinic visit. Additional readings are recommended if there is more than a 5 mm Hg difference between the initial 2 readings.⁴

In our study, we used sampling statistics of the BP readings and clinical guideline BP ranges in making diagnostic determinations. The inability to identify those patients whose BP will be affected by positional change highlights the importance of following standard BP measurement guidelines for all patients.

Study limitations. Positional change in BP from examination table to chair lacks a comparison to BP changes in positioning from chair to table. If similar BP changes in the reverse sequence were to be observed, this would add support to the hypothesis that muscle tension of the unsupported body is a cause of BP elevation in certain individuals. We believe, however, that the sequence of BP measurements (from table to chair) did not have a significant impact because all patients were allowed to rest in each position before the BP was measured. The BP was therefore measured in a steady-state in both positions.

Increased muscle tension due to lack of body support while sitting on the edge of the examination table could be the cause of the elevated BP.

Additionally, BP measurement by aneroid sphygmomanometry is highly dependent on observer skill and hearing ability. Furthermore, a disproportionate number of BP measurements recorded in the study ended in zero, suggesting terminal digit bias by the observer. These sources of error may be avoided using an automated oscillometric measuring device.¹⁸ Automated devices also allow for repeated independent measurements that minimize the white-coat effect. However, there are also limitations to the accuracy of oscillometric equipment. This is especially true when recording BP in the elderly, a group whose stiff arterial walls may cause erroneous measurements.¹⁹

Guideline justification. Nonadherence to standard positioning when measuring BP leads to certain individuals being misclassified as prehypertensive or hypertensive. Misclassification in turn leads to unnecessary medical encounters, testing, and treatment. Misdiagnosis is also likely to increase the cost of an individual’s insurance coverage and out-of-pocket health care expenses.

CORRESPONDENCE
Roy N. Morcos, MD, St. Elizabeth Family Medicine Residency Program, 8423 Market Street, Suite 101, Boardman, Ohio 44512; [email protected].

ABSTRACT

Purpose This study evaluated the effect of patient positioning on the diagnosis of hypertension in a clinic setting and the importance of following guidelines for measuring blood pressure (BP).

Methods In the trial part of this study, we recorded BP measurements by an aneroid sphygmomanometer with patients seated first on an examination table, a commonly observed practice, and second in the standard seated position as defined by the American Heart Association. Two measurements were obtained in each position for 204 patients, and we determined the difference between the average readings in the 2 positions. Factored into the comparison was an estimation of inherent variance of the device and observer achieved by repeated measurements on a healthy individual.

Results This investigation included an initial observational study of 25 regional primary care offices, the results of which showed frequent lack of adherence with accepted guidelines in patient positioning during BP measurement. The overall systolic and diastolic BPs were more than 2 mm Hg lower in the standard seated position compared with the examination table position (P<.001). Noncompliance with the position guideline resulted in misclassification of 15 patients (7.4%) as prehypertensive, when, in fact, they were normotensive. Misclassification of hypertension occurred in 12 patients (5.9%), when, in fact, they were normotensive. Logistic regression using relevant clinical factors did not identify those individuals who were misclassified.

Conclusion This study underscores the importance of patient positioning on BP determinations in order to accurately diagnose hypertension.

The high prevalence of hypertension and its burden of disease in the United States and worldwide are well known.¹ Hypertension is a major risk factor for coronary heart disease, congestive heart failure, ischemic and hemorrhagic stroke, chronic kidney disease, and peripheral arterial disease.² Among all risk factors, hypertension ranked first worldwide in disability-adjusted life-years.³ However, misclassification of an individual’s blood pressure (BP) as prehypertension or hypertension also confers significant health and financial burdens due to unnecessary medical encounters, testing, and treatment, and to increased cost of insurance coverage and out-of-pocket expenses. A correct assessment of BP in the outpatient setting depends on accurate measurement technique.

The diagnosis of hypertension is based on indirect measurement of BP using in-office, ambulatory, or home monitoring. Although office BP measurement is less than ideal, it is used most often to diagnose and monitor hypertension. Furthermore, most published trials of treatment recommendations are based on office BP measurements.⁴

Automated oscillometric and aneroid sphygmomanometers are common BP measurement devices. Proper technique is particularly important with the aneroid sphygmomanometer to obtain consistent and accurate results.⁵ Good training and an ability to hear the Korotkoff sounds are crucial.

Only 10 of 25 offices we visited in our area measured BP with patients properly seated in a chair. Most had their patients sit on the edge of the examination table.

Expert consensus groups such as the American Heart Association (AHA) publish recommendations for proper technique in reliably measuring BP,^6-8 and they emphasize the importance of patient positioning during BP measurement. The individual should be seated comfortably in a chair with both arms and back supported, legs uncrossed, and feet flat on the floor. We’ll refer to this as the “standard position.” Although the proper technique for measuring BP has been widely advocated, a recent literature review for the US Preventive Services Task Force concluded that surprisingly few studies are available on the diagnostic accuracy of office BP practices.⁹

One paper evaluated the effect of leg crossing on accuracy of BP measurement. No subjects were reclassified as hypertensive, but the study lacked statistical rigor.¹⁰ Another study found variable BP readings regardless of body position.¹¹

The purpose of our study was to compare BP measurement in 2 positions: the standard position described above, and the examination table position in which the patient is seated on the edge of the table with back, arms, and feet unsupported.

METHODS

We conducted our literature search across several scientific and medical literature databases, including PubMed, ScienceDirect, and CINAHL. Only English-language articles were reviewed.

We followed the BP measurement guidelines of the AHA. Prior to beginning the study, we provided instructions in proper BP measurement technique to the nurses who would obtain the data. The minimum sample size of patients needed to identify a difference of at least 2 mm Hg was 26, as estimated by power analysis. This was calculated using an alpha of .05 and a beta of .13.

The study population consisted of patients presenting consecutively to a teaching family medicine center. Adult patients, ages 18 and older, were informed about the study and invited to participate. Those who agreed were asked to read and sign an informed consent approved by a regional institutional review board for human subjects. We excluded patients who declined participation for any reason, who were in severe pain or distress that may have prevented them from completing the protocol, or who had limited mobility that could interfere with climbing onto the examination table. Patients considered for the study totaled 250, 28 of whom were ineligible. Another 18 patients declined participation, leaving 204 who completed the protocol.

Before testing began, we estimated the standard deviation of each aneroid sphygmomanometer and the assigned observer by repeatedly measuring the BP of a healthy normotensive individual sitting in the standard position. We obtained 46 measurements over 2 days to avoid subject and operator fatigue. Standard deviation for systolic BP was 3.6 mm Hg; for diastolic it was 3.8 mm Hg.

During testing, nurses recorded BP for each patient twice in the examination table position and twice in the standard position. They entered data into an Excel workbook for subsequent analysis. All examination rooms were equipped with newly purchased aneroid sphygmomanometers, and the appropriate cuff size was selected for each patient. Patients were instructed to remain quiet during the measurements. Patients sat first on the edge of the examination table. After a 5-minute rest, BP was measured twice in the same arm. Measurements were separated by 1 to 2 minutes. Patients then sat in the chair and rested another 2 minutes before BP was again measured twice in the same arm. The arms and back were supported in the chair and the stethoscope placed at heart level.

As per protocol, we obtained 4 BP readings on each patient and calculated the difference between the average systolic and diastolic BP values from the 2 positions. The standard error of the mean of this difference was determined using the equation, where Sd is the standard deviation of the aneroid sphygmomanometer and observer.¹² A one-sided, 95% confidence upper bound for the standard error of the difference is 1.65 × SEd. We compared patient-specific differences against this upper bound to identify significant systolic and diastolic BP changes due to positioning. If the patient’s BP difference exceeded the upper bound, it was attributed to the positional change and not to variation inherent to the sphygmomanometer and observer.

As an example, consider a patient whose average systolic BP readings from the examination-table and standard positions, respectively, were 128 mm Hg and 120 mm Hg. Assuming an SEd of 3.55 and an upper bound of 5.86, the observed 8 mm Hg difference in average systolic BPs would be considered significant. The amount of random variation from the sphygmomanometer and observer would not be expected to exceed 5.86 mm Hg.

In accordance with accepted standards, prehypertension was defined as a BP between 120-139/80-89 mm Hg, and hypertension was defined as a BP ≥140/90 mm Hg.⁴ BP below 120/80 mm Hg was considered normal. We calculated each patient’s average systolic and diastolic BP values in the 2 positions and thereby classified the individual as normotensive, prehypertensive, or hypertensive. We regarded as misclassified any patient whose BP showed significant lowering between the examination-table and standard positions resulting in a change of classification from prehypertensive or hypertensive to normotensive. For example, a patient with an examination-table position average reading of 126/85 mm Hg and a standard position average reading of 118/78 mm Hg would have been misclassified as prehypertensive.

We reviewed charts and gathered data, including subject age, sex, obesity (defined as a body mass index of ≥30 kg/m²), and history of diabetes, hypertension, or smoking. Other than age, all data were binary. We performed logistic regression analysis using the Excel Add-in Real Statistics Resource Pack software (Release 4.3)¹³ to determine if these factors could predict significant lowering of BP due to positional change.

Our associated observational study. We also conducted a separate observational study of 25 regional primary care offices to evaluate compliance with the AHA guidelines for measuring BP. The office nurses taking measurements were not informed of the study’s purpose to prevent deviation from their common practice.

In our study, 13.2% of patients classified as prehypertensive or hypertensive when they sat on the exam table were found to be normotensive when seated in the chair.

Data on 9 guideline criteria were collected to assess supervision of patients before and during measurements, including having the patient sit in a chair in quiet and comfortable surroundings with arms and back supported and feet on the ground. We also noted the type of BP measuring device used. Additionally, observers assessed the technique of the individuals using a manual device, including cuff placement and deflation rate. The observations were conducted during a clinic visit by a medical student knowledgeable in the AHA guidelines for measuring BP by automated oscillometric or aneroid sphygmomanometric devices. We conducted the study over a 2-week period in the second quarter of 2016.

RESULTS

Power analysis performed prior to the study showed that a minimum of 26 patients would be needed to predict a 2 mm Hg difference between BPs obtained in the 2 positions. Of the 204 patients used in the logistic regression analysis, 78 were men and 126 were women. Ages ranged from 18 to 101 years, yielding a mean of 54. One-hundred sixteen had previously received a diagnosis of hypertension, 39 had diabetes, 92 were obese, 22 were current smokers, and 68 were former smokers.

TABLE 1 shows the means and ranges of systolic and diastolic BP for both study positions. With this study population, mean BP recorded in the examination-table position decreased in the standard position by 2.1 and 2.2 mm Hg for systolic and diastolic BP, respectively (P<.001).

Significant BP lowering—as defined by a one-sided 95% confidence upper bound for the standard error of differences between study positions—was determined to be 5.86 and 6.22 mm Hg for systolic and diastolic pressures, respectively. Significant lowering of BP and misclassification due to positioning are summarized in TABLE 2. Significant lowering of mean systolic or diastolic BP with positional change from table to chair occurred in 62 subjects (30.4%). Misclassification of prehypertension occurred in 7.4% of subjects, and misclassification of hypertension occurred in 5.9%.

Logistic regression using patient age, sex, obesity, and history of diabetes, hypertension, and smoking as independent factors did not predict significant BP lowering with positional change.

Our observational study revealed that proper positioning in a chair was followed in only 10 of the 25 offices. In the remaining offices, patients were seated on the examination table. A 5-minute rest period before measuring BP was allowed in only 10 of the 25 offices. An automated oscillometric device was used in only 2 of the 25 offices.

DISCUSSION

In this study, 27 subjects (13.2%) were misclassified as prehypertensive or hypertensive as a result of deviating from the standard position in obtaining BP. Although the standard position is universally recommended, the guideline is not always followed in clinical practice.¹⁴

One study by Villegas et al found that 60% of physicians and nurses working in a major hospital were measuring BP inaccurately.¹⁵ In our initial observational study, 60% of primary care practices visited did not adhere to the recommended patient positioning. These medical offices are located in the community surrounding our facility and are operated by the same health care organization. The misclassification of prehypertension and hypertension observed in our prospective comparison of BP recordings in table and chair positions is, therefore, likely to occur to some degree at these practices, as well.

Similar diagnostic misclassifications have been reported in other medical settings. In a published survey of 114 medical offices, McKay and coworkers noted frequent inconsistencies with published guidelines in measuring BP.¹⁶

Common clinical demographic data obtained during this study showed no association with the positional BP change. Increased muscle tension due to lack of body support while sitting on the edge of the examination table could be the cause of elevated BP for this subgroup of individuals. Measuring muscle tension of the arms and back while seated on an exam table and chair was beyond the scope of this study.

In clinical practice, different types of BP measuring devices are used. Calibration and quality control of these devices is often lacking.¹⁷ Before starting our study, we determined the statistical variance of the aneroid sphygmomanometers and found it to approximate the manufacturer’s precision specification. Guidelines recommend using the mean of 2 BP readings as representing the patient’s BP for a given clinic visit. Additional readings are recommended if there is more than a 5 mm Hg difference between the initial 2 readings.⁴

In our study, we used sampling statistics of the BP readings and clinical guideline BP ranges in making diagnostic determinations. The inability to identify those patients whose BP will be affected by positional change highlights the importance of following standard BP measurement guidelines for all patients.

Study limitations. Positional change in BP from examination table to chair lacks a comparison to BP changes in positioning from chair to table. If similar BP changes in the reverse sequence were to be observed, this would add support to the hypothesis that muscle tension of the unsupported body is a cause of BP elevation in certain individuals. We believe, however, that the sequence of BP measurements (from table to chair) did not have a significant impact because all patients were allowed to rest in each position before the BP was measured. The BP was therefore measured in a steady-state in both positions.

Increased muscle tension due to lack of body support while sitting on the edge of the examination table could be the cause of the elevated BP.

Additionally, BP measurement by aneroid sphygmomanometry is highly dependent on observer skill and hearing ability. Furthermore, a disproportionate number of BP measurements recorded in the study ended in zero, suggesting terminal digit bias by the observer. These sources of error may be avoided using an automated oscillometric measuring device.¹⁸ Automated devices also allow for repeated independent measurements that minimize the white-coat effect. However, there are also limitations to the accuracy of oscillometric equipment. This is especially true when recording BP in the elderly, a group whose stiff arterial walls may cause erroneous measurements.¹⁹

Guideline justification. Nonadherence to standard positioning when measuring BP leads to certain individuals being misclassified as prehypertensive or hypertensive. Misclassification in turn leads to unnecessary medical encounters, testing, and treatment. Misdiagnosis is also likely to increase the cost of an individual’s insurance coverage and out-of-pocket health care expenses.

CORRESPONDENCE
Roy N. Morcos, MD, St. Elizabeth Family Medicine Residency Program, 8423 Market Street, Suite 101, Boardman, Ohio 44512; [email protected].

Resources

1. US Preventive Services Task Force. Screening for ovarian cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:588-594.
2. Henderson JT, Webber EM, Sawaya GF. Screening for ovarian cancer: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;319:595-606.

Resources

1. US Preventive Services Task Force. Screening for ovarian cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:588-594.
2. Henderson JT, Webber EM, Sawaya GF. Screening for ovarian cancer: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;319:595-606.

Resources

1. US Preventive Services Task Force. Screening for ovarian cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:588-594.
2. Henderson JT, Webber EM, Sawaya GF. Screening for ovarian cancer: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;319:595-606.

Roehr, B., BMJ 359:j4727, October 19, 2017

The author, a biomedical journalist from Washington, DC, explains how a zero-tolerance policy to opioid prescribing will impede the delivery of care for patients with severe pain. He notes that he has used hydrocodone daily for nearly ten years for nerve damage due to knee replacement and spinal surgeries, and suggests that reports of the opioid epidemic “crisis” represent overblown rhetoric from persons with an interest in promoting a “war on drugs” agenda. In fact, research shows that while 38% of the US population used a prescription opioid in 2015, few of whom were being treated for cancer, only 0.8% were classified as drug abusers. The author considers himself dependent on hydrocodone in the same way that he is dependent on his blood pressure medication, and states that hydrocodone allows him to remain relatively pain-free and productive but without adverse effects. The dramatic rise in opioid-related deaths is fueled in part by fentanyl and other illicit street drugs. In fact, he contends that CDC mortality data are methodologically flawed because deaths due to street drugs including heroin are combined with deaths due to prescription opioids, while in fact prescription drug deaths have been decreasing over the past few years. Efforts to control the opioid supply with prescribing limits, prosecution of “pill mills,” and tamper-resistant formulations were all in place before the recent increases in opioid-related deaths. The author disputes the concept of opioids as gateway drugs, stating that the gateway theory has long been disproven, yet he acknowledges that patients who lose access to prescription opioids may turn to more accessible, black-market options such as street drugs containing fentanyl. He concludes that denial of opioids to everyone because some are abusers will mean that many patients with legitimate need will suffer unnecessarily. 4 references ([email protected] – no reprints)

Roehr, B., BMJ 359:j4727, October 19, 2017

The author, a biomedical journalist from Washington, DC, explains how a zero-tolerance policy to opioid prescribing will impede the delivery of care for patients with severe pain. He notes that he has used hydrocodone daily for nearly ten years for nerve damage due to knee replacement and spinal surgeries, and suggests that reports of the opioid epidemic “crisis” represent overblown rhetoric from persons with an interest in promoting a “war on drugs” agenda. In fact, research shows that while 38% of the US population used a prescription opioid in 2015, few of whom were being treated for cancer, only 0.8% were classified as drug abusers. The author considers himself dependent on hydrocodone in the same way that he is dependent on his blood pressure medication, and states that hydrocodone allows him to remain relatively pain-free and productive but without adverse effects. The dramatic rise in opioid-related deaths is fueled in part by fentanyl and other illicit street drugs. In fact, he contends that CDC mortality data are methodologically flawed because deaths due to street drugs including heroin are combined with deaths due to prescription opioids, while in fact prescription drug deaths have been decreasing over the past few years. Efforts to control the opioid supply with prescribing limits, prosecution of “pill mills,” and tamper-resistant formulations were all in place before the recent increases in opioid-related deaths. The author disputes the concept of opioids as gateway drugs, stating that the gateway theory has long been disproven, yet he acknowledges that patients who lose access to prescription opioids may turn to more accessible, black-market options such as street drugs containing fentanyl. He concludes that denial of opioids to everyone because some are abusers will mean that many patients with legitimate need will suffer unnecessarily. 4 references ([email protected] – no reprints)

Roehr, B., BMJ 359:j4727, October 19, 2017

The author, a biomedical journalist from Washington, DC, explains how a zero-tolerance policy to opioid prescribing will impede the delivery of care for patients with severe pain. He notes that he has used hydrocodone daily for nearly ten years for nerve damage due to knee replacement and spinal surgeries, and suggests that reports of the opioid epidemic “crisis” represent overblown rhetoric from persons with an interest in promoting a “war on drugs” agenda. In fact, research shows that while 38% of the US population used a prescription opioid in 2015, few of whom were being treated for cancer, only 0.8% were classified as drug abusers. The author considers himself dependent on hydrocodone in the same way that he is dependent on his blood pressure medication, and states that hydrocodone allows him to remain relatively pain-free and productive but without adverse effects. The dramatic rise in opioid-related deaths is fueled in part by fentanyl and other illicit street drugs. In fact, he contends that CDC mortality data are methodologically flawed because deaths due to street drugs including heroin are combined with deaths due to prescription opioids, while in fact prescription drug deaths have been decreasing over the past few years. Efforts to control the opioid supply with prescribing limits, prosecution of “pill mills,” and tamper-resistant formulations were all in place before the recent increases in opioid-related deaths. The author disputes the concept of opioids as gateway drugs, stating that the gateway theory has long been disproven, yet he acknowledges that patients who lose access to prescription opioids may turn to more accessible, black-market options such as street drugs containing fentanyl. He concludes that denial of opioids to everyone because some are abusers will mean that many patients with legitimate need will suffer unnecessarily. 4 references ([email protected] – no reprints)

Giant congenital nevus was diagnosed in this patient. Congenital melanocytic nevi (CMN) are pigmented lesions that are present at birth and created by the abnormal migration of neural crest cells during embryogenesis. Nevi are categorized by size as small (<1.5 cm), medium (1.5-20 cm), large (>20 cm), or giant (>40 cm).

Congenital nevi tend to start out flat, with uniform pigmentation, but can become more variegated in texture and color as normal growth and development continue. Giant congenital nevi, which are rare, are likely to thicken, darken, and enlarge as the patient grows. Some nevi may develop very coarse or dark hair. CMN can cover any part of the body and occur independent of skin color and other ethnic factors.

CMN may present in almost any location and may be brown, black, pink, or purple in color. Café au lait macules, blue-gray spots, nevus of Ota, nevus spilus, and vascular malformations are part of the differential diagnosis for CMN and have individual location and color characteristics that set them apart clinically.

Patients with CMN are at increased risk for neurocutaneous melanosis (NCM; a melanocyte proliferation in the central nervous system) and melanoma. Magnetic resonance imaging (MRI) is helpful to exclude NCM. Treatment options for patients with large and giant CMN include early curettage, local excision, dermabrasion, and laser therapy. (There is, however, considerable debate about the value of surgery.) The newborn in the case underwent an MRI and the results were normal. At 4 months of age, he hadn’t developed any neurologic symptoms. The child’s nevi continue to grow and he sees his family physician for routine well-child visits and a dermatologist annually to monitor the nevi.

‌

Adapted from: Karnes J, Griffin C. Large plaques on a baby boy. J Fam Pract. 2016;65:407-409.

Giant congenital nevus was diagnosed in this patient. Congenital melanocytic nevi (CMN) are pigmented lesions that are present at birth and created by the abnormal migration of neural crest cells during embryogenesis. Nevi are categorized by size as small (<1.5 cm), medium (1.5-20 cm), large (>20 cm), or giant (>40 cm).

Congenital nevi tend to start out flat, with uniform pigmentation, but can become more variegated in texture and color as normal growth and development continue. Giant congenital nevi, which are rare, are likely to thicken, darken, and enlarge as the patient grows. Some nevi may develop very coarse or dark hair. CMN can cover any part of the body and occur independent of skin color and other ethnic factors.

CMN may present in almost any location and may be brown, black, pink, or purple in color. Café au lait macules, blue-gray spots, nevus of Ota, nevus spilus, and vascular malformations are part of the differential diagnosis for CMN and have individual location and color characteristics that set them apart clinically.

Patients with CMN are at increased risk for neurocutaneous melanosis (NCM; a melanocyte proliferation in the central nervous system) and melanoma. Magnetic resonance imaging (MRI) is helpful to exclude NCM. Treatment options for patients with large and giant CMN include early curettage, local excision, dermabrasion, and laser therapy. (There is, however, considerable debate about the value of surgery.) The newborn in the case underwent an MRI and the results were normal. At 4 months of age, he hadn’t developed any neurologic symptoms. The child’s nevi continue to grow and he sees his family physician for routine well-child visits and a dermatologist annually to monitor the nevi.

‌

Adapted from: Karnes J, Griffin C. Large plaques on a baby boy. J Fam Pract. 2016;65:407-409.

Giant congenital nevus was diagnosed in this patient. Congenital melanocytic nevi (CMN) are pigmented lesions that are present at birth and created by the abnormal migration of neural crest cells during embryogenesis. Nevi are categorized by size as small (<1.5 cm), medium (1.5-20 cm), large (>20 cm), or giant (>40 cm).

Congenital nevi tend to start out flat, with uniform pigmentation, but can become more variegated in texture and color as normal growth and development continue. Giant congenital nevi, which are rare, are likely to thicken, darken, and enlarge as the patient grows. Some nevi may develop very coarse or dark hair. CMN can cover any part of the body and occur independent of skin color and other ethnic factors.

CMN may present in almost any location and may be brown, black, pink, or purple in color. Café au lait macules, blue-gray spots, nevus of Ota, nevus spilus, and vascular malformations are part of the differential diagnosis for CMN and have individual location and color characteristics that set them apart clinically.

Patients with CMN are at increased risk for neurocutaneous melanosis (NCM; a melanocyte proliferation in the central nervous system) and melanoma. Magnetic resonance imaging (MRI) is helpful to exclude NCM. Treatment options for patients with large and giant CMN include early curettage, local excision, dermabrasion, and laser therapy. (There is, however, considerable debate about the value of surgery.) The newborn in the case underwent an MRI and the results were normal. At 4 months of age, he hadn’t developed any neurologic symptoms. The child’s nevi continue to grow and he sees his family physician for routine well-child visits and a dermatologist annually to monitor the nevi.

‌

Adapted from: Karnes J, Griffin C. Large plaques on a baby boy. J Fam Pract. 2016;65:407-409.

Rothstein, M.A., Am J Publ Health 107(8):1253, August 2017

The author, from the University of Louisville School of Medicine, comments on the unintended consequences of restricting opioid prescribing. Causes and outcomes of the opioid addiction epidemic are well documented, including aggressive marketing by pharmaceutical companies without full disclosure of risk and a four-fold increase in US opioid-related deaths between 1999 and 2014 alone. Countermeasures include prescription drug monitoring programs to restrict use, legal limits on pill numbers per prescription, opioid patient “contracts,” and drug testing to ensure compliance. For fear of medicolegal risk, many physicians have decided to stop prescribing opioids for patients with chronic pain, limiting use to postoperative pain, cancer pain and terminal illness. In some cases, patients with severe pain turn to illicit drugs as the only alternative, leading to diseases such as HIV and hepatitis, as well as more overdose deaths. Eliminating opioids entirely as an option for chronic pain shows a lack of compassion and violates both standards of care and medical ethics. Many patients with severe pain due to chronic conditions legitimately need potent analgesics such as opioids, especially during acute episodes, because over-the-counter analgesics are completely ineffective. Patients who became addicted after using a lawful prescription also cannot be abandoned but need proper management. Stakeholders at all levels must address the undertreatment of pain with research, education and policy changes to acknowledge both the problem of opioid abuse and the needs of patients with chronic pain. After all, policies “should not presume that all physicians are reckless prescribers or that all patients are deceitful drug seekers.” 7 references ([email protected] – no reprints)

Rothstein, M.A., Am J Publ Health 107(8):1253, August 2017

The author, from the University of Louisville School of Medicine, comments on the unintended consequences of restricting opioid prescribing. Causes and outcomes of the opioid addiction epidemic are well documented, including aggressive marketing by pharmaceutical companies without full disclosure of risk and a four-fold increase in US opioid-related deaths between 1999 and 2014 alone. Countermeasures include prescription drug monitoring programs to restrict use, legal limits on pill numbers per prescription, opioid patient “contracts,” and drug testing to ensure compliance. For fear of medicolegal risk, many physicians have decided to stop prescribing opioids for patients with chronic pain, limiting use to postoperative pain, cancer pain and terminal illness. In some cases, patients with severe pain turn to illicit drugs as the only alternative, leading to diseases such as HIV and hepatitis, as well as more overdose deaths. Eliminating opioids entirely as an option for chronic pain shows a lack of compassion and violates both standards of care and medical ethics. Many patients with severe pain due to chronic conditions legitimately need potent analgesics such as opioids, especially during acute episodes, because over-the-counter analgesics are completely ineffective. Patients who became addicted after using a lawful prescription also cannot be abandoned but need proper management. Stakeholders at all levels must address the undertreatment of pain with research, education and policy changes to acknowledge both the problem of opioid abuse and the needs of patients with chronic pain. After all, policies “should not presume that all physicians are reckless prescribers or that all patients are deceitful drug seekers.” 7 references ([email protected] – no reprints)

Rothstein, M.A., Am J Publ Health 107(8):1253, August 2017

The author, from the University of Louisville School of Medicine, comments on the unintended consequences of restricting opioid prescribing. Causes and outcomes of the opioid addiction epidemic are well documented, including aggressive marketing by pharmaceutical companies without full disclosure of risk and a four-fold increase in US opioid-related deaths between 1999 and 2014 alone. Countermeasures include prescription drug monitoring programs to restrict use, legal limits on pill numbers per prescription, opioid patient “contracts,” and drug testing to ensure compliance. For fear of medicolegal risk, many physicians have decided to stop prescribing opioids for patients with chronic pain, limiting use to postoperative pain, cancer pain and terminal illness. In some cases, patients with severe pain turn to illicit drugs as the only alternative, leading to diseases such as HIV and hepatitis, as well as more overdose deaths. Eliminating opioids entirely as an option for chronic pain shows a lack of compassion and violates both standards of care and medical ethics. Many patients with severe pain due to chronic conditions legitimately need potent analgesics such as opioids, especially during acute episodes, because over-the-counter analgesics are completely ineffective. Patients who became addicted after using a lawful prescription also cannot be abandoned but need proper management. Stakeholders at all levels must address the undertreatment of pain with research, education and policy changes to acknowledge both the problem of opioid abuse and the needs of patients with chronic pain. After all, policies “should not presume that all physicians are reckless prescribers or that all patients are deceitful drug seekers.” 7 references ([email protected] – no reprints)

The FP considered several possibilities as part of the differential diagnosis: compound nevus, Spitz nevus, dysplastic nevus, fibrous papule, angiokeratoma, and amelanotic melanoma. A shave biopsy identified the lesion as a Spitz nevus.

Spitz nevi are uncommon solitary pink to black colored dome-shaped papules that usually appear in the first 2 decades of life. They have features that are histologically similar to melanoma and some may, in fact, be Spitzoid melanomas. When a Spitz nevus is suspected, the lesion should be biopsied for histopathologic diagnosis. If the diagnosis is confirmed, the typical treatment is to perform a complete excision with clear margins.

In this case, the pathologist noted that the deep margin was positive and recommended a conservative re-excision. The patient was sent to a dermatologist who fully excised the lesion with no complications.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP considered several possibilities as part of the differential diagnosis: compound nevus, Spitz nevus, dysplastic nevus, fibrous papule, angiokeratoma, and amelanotic melanoma. A shave biopsy identified the lesion as a Spitz nevus.

Spitz nevi are uncommon solitary pink to black colored dome-shaped papules that usually appear in the first 2 decades of life. They have features that are histologically similar to melanoma and some may, in fact, be Spitzoid melanomas. When a Spitz nevus is suspected, the lesion should be biopsied for histopathologic diagnosis. If the diagnosis is confirmed, the typical treatment is to perform a complete excision with clear margins.

In this case, the pathologist noted that the deep margin was positive and recommended a conservative re-excision. The patient was sent to a dermatologist who fully excised the lesion with no complications.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP considered several possibilities as part of the differential diagnosis: compound nevus, Spitz nevus, dysplastic nevus, fibrous papule, angiokeratoma, and amelanotic melanoma. A shave biopsy identified the lesion as a Spitz nevus.

Spitz nevi are uncommon solitary pink to black colored dome-shaped papules that usually appear in the first 2 decades of life. They have features that are histologically similar to melanoma and some may, in fact, be Spitzoid melanomas. When a Spitz nevus is suspected, the lesion should be biopsied for histopathologic diagnosis. If the diagnosis is confirmed, the typical treatment is to perform a complete excision with clear margins.

In this case, the pathologist noted that the deep margin was positive and recommended a conservative re-excision. The patient was sent to a dermatologist who fully excised the lesion with no complications.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references ([email protected] – no reprints)

Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references ([email protected] – no reprints)

Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references ([email protected] – no reprints)

The FP recognized this to be a nevus spilus (speckled nevus).

He explained that this was a benign nevus and that no treatment was indicated—especially because the only effective treatment would be deep excision down to the subcutaneous fat layer (requiring a graft for closure). The patient probably wouldn’t like the cosmetic result and the risks of this surgery (pain, infection, graft not taking) are not acceptable for this condition. Also, the procedure would not be covered by insurance, as this would be considered cosmetic surgery.

The physician explained that in the unlikely event of significant changes in the nevus, she should seek further evaluation. The patient understood the reality of the situation and thanked the doctor for explaining the diagnosis to her. She was reassured that this was benign.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized this to be a nevus spilus (speckled nevus).

He explained that this was a benign nevus and that no treatment was indicated—especially because the only effective treatment would be deep excision down to the subcutaneous fat layer (requiring a graft for closure). The patient probably wouldn’t like the cosmetic result and the risks of this surgery (pain, infection, graft not taking) are not acceptable for this condition. Also, the procedure would not be covered by insurance, as this would be considered cosmetic surgery.

The physician explained that in the unlikely event of significant changes in the nevus, she should seek further evaluation. The patient understood the reality of the situation and thanked the doctor for explaining the diagnosis to her. She was reassured that this was benign.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized this to be a nevus spilus (speckled nevus).

He explained that this was a benign nevus and that no treatment was indicated—especially because the only effective treatment would be deep excision down to the subcutaneous fat layer (requiring a graft for closure). The patient probably wouldn’t like the cosmetic result and the risks of this surgery (pain, infection, graft not taking) are not acceptable for this condition. Also, the procedure would not be covered by insurance, as this would be considered cosmetic surgery.

The physician explained that in the unlikely event of significant changes in the nevus, she should seek further evaluation. The patient understood the reality of the situation and thanked the doctor for explaining the diagnosis to her. She was reassured that this was benign.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.