In an article in 2007 (10), Dr Narda Robinson (reference 40) cited an old paper that I published originally in 1981. I wish to comment on her conclusions, which I believe to be incorrect.

Paraphrasing the GBI section in Dr. Robinson's article, ... GBI involves the implantation of small pieces of gold wire ("beads") around the hip of a heavily sedated animal … implantation usually is done at acupoints GB29, GB30, and BL54, which lie near the hip joint … In contrast to the safe and effective techniques of dry needling and electroacupuncture, GBI is an ineffective and possibly harmful technique that warrants serious re-evaluation … accordingly, Dr. Robinson agrees with (my) statement that one “must surely question the scientific and medical competence of practitioners who employ this dangerous method 40”. Reference 40 was to an old article of mine (12). I updated that article in 1998 (12).

My original article referred to the dangerous practice of implanting cut-off acupuncture needles in the tissues. Such implants can be dangerous if they migrate, or are accidentally driven by trauma, to vital structures, such as the brain or spinal cord. In my opinion, that procedure (implanting cut-off acupuncture needles) constitutes malpractice; no acupuncture society that I know condones it. My updated article (12) said specifically:

Notes added September 1998: This article was written in 1981, before implantation of 1 mm diameter gold beads, or 2 mm lengths of 1 mm diameter 24 carat gold wire, became commonplace in veterinary acupuncture. This technique is used widely to treat hip dysplasia, chronic arthropathy and other chronic diseases in animals, especially dogs. The implants are inserted, under general anaesthesia, into acupoints near, or related to, the affected joint, organ, or area. Personal communications with veterinarians who have used the technique suggest that the clinical results are excellent and that migration of the implants from the original sites of insertion is minimal. However, great care must be taken to avoid insertion of those implants in, or near, joint capsules. In very rare cases, such implants may accidentally enter the joint-space and exaggerate the pain and stiffness. Should that happen, the offending implant(s) must be removed surgically.”

In a more recent article (11), Dr Robinson infers that veterinarians who use GBI are guilty of malpractice. She concluded: “Gold bead therapy offers no proven benefit over regular acupuncture and poses substantial potential for injury. The fact that implantation is regarded as malpractice in human medicine should come as a wake-up call to the veterinary profession.”

In my opinion, both of those conclusions are incorrect. As discussed below, many clinicians find GBI to be both safe and clinically effective in many conditions in humans and animals. See examples of the implants.

The implants can be 1-2mm spherical gold-plated beads (Fig 1), or 2-3mm pieces of gold wire, cut across to have basically blunt ends (Fig 2 and 3). In practice, GBI migration in tissues is minimal (16) and poses a very small risk of migration into joint capsules or other vital structures (Fig 4).Sharp cut-off needles are much more likely to move (or be moved by outside trauma) in tissues than gold mini-cylinders or spherical beads.

Indications for GBI in humanshttp://www.gold-implant-clinic.com/egoldimp.htm and 7, 8) include patients who need pain relief but cannot be treated successfully by other means. Specific indications include chronic pain, for example, arthritis of the neck, lumbar region, hip, knee, hand or ankle joint. They also include patients with active trigger points in scar tissue, resulting from disc prolapse operations or those with disc prolapse who cannot be operated due to the location of the prolapse.

GBI does not interfere with MRI: Dr Robinson suggests that GBI may pose serious problems to MRI. However, Ben Yakir (1) and at least 2 published papers (13, 14) report that GBI interferes little, if at all, with MRI. This contrasts with well documented MRI interference due to the injection of gold salts.

Clinical efficacy of GBI:Gold implants are used widely in human dentistry, surgery and medicine (2). Ben-Yakir (1) summarised the scientific basis of GBI. In a personal communication to me (October 2008), he stated that more than 30000 humans in Europe have had GBI recently to treat chronic diseases. The gold implants are circa 2mm long, cut from 24 carat gold wire 1mm in diameter.

A double-blind trial in canine hip dysplasia compared the clinical benefit of GBI with that of a single needling of points near the hip (4). There was no significant difference in clinical outcomes to GBI versus needling of points near the hip but both groups of dogs showed marked clinical improvement.

That result is not unexpected because many acupuncture research papers show that minimal stimulation in the same nerve segments as “verum acupoints” can elicit physiological and / or clinical effects similar to those elicited by “verum acupuncture”. Indeed, the clinical efficacy of low-level laser therapy (LLLT) at relevant acupoints in many human and animal conditions confirms that minimal stimuli (imperceptible in the case of LLLT) can activate marked clinical responses.

At the 2009 ICMART Congress, Thessaloniki, several speakers commented that stimulation of “sham acupoints”, or of points near “verum acupoints”, is an invalid control in acupuncture research. I agree with that viewpoint and argue that future acupuncture research should compare the outcome to verum acupuncture with the outcome of a true negative control (no treatment) and / or a true positive control (for example state-of-the-art western medical or surgical treatment).

That said, a recent paper on GBI for hip dysplasia in dogs (6) concluded “The present study revealed that the pain-relieving effect of GBI observed in the blinded study continued throughout the two-year follow-up period.” This agrees with the clinical experience of many veterinarians, and recently some human therapists (9), who report useful clinical results in the weeks and months after implantation in a variety of chronic diseases.

In the 1970's, Drs Grady Young (deceased) and Terry Durkes were the first veterinarians to perform gold bead implants in dogs. Since then Dr. Durkes has treated thousands of dogs for a wide range of chronic and difficult conditions, including allergic dermatitis, arthritis, asthma, certain types of paralysis, faecal incontinence, hip dysplasia, intervertebral disc disease, long term injuries, lick granulomas, non-healing fractures, seizure activity - epilepsy, sensory neurodermatitis, spondylo-arthritis, traumatic nerve injury and urinary incontinence.

Recent papers showed that GBI in epileptic dogs significantly decreased seizure frequency and seizure severity (3) and significantly accelerated ulnar fracture healing in rats (15).

Veterinarians interested in further information on GBI may read "Permanent Acupuncture with Gold Bead Implants" at http://www.himmlisch.com/goldbeads.htm. Those not yet trained may consider taking the Basic Course in veterinary acupuncture (IVAS, 5).

I agree with Dr Robinson that further well-controlled studies of GBI are warranted. Meanwhile, if trained clinicians need to do so, I encourage them to use GBI for the indications listed above.

Personally, unless the client lives far away and finds repeat visits a serious inconvenience, I prefer to use simple acupuncture for most cases in which GBI may be applicable.

In summary, Dr Robinson’s citation of my 1981 reference to denigrate the scientific and medical competence of practitioners who use GBI is inappropriate and out of context. I do NOT regard GBI in the same light as implanting cut-off acupuncture needles in the tissues. GBI is a very safe procedure if performed by trained acupuncturists using surgical preparation and heavy sedation or short-acting general anaesthetic. It is useful to elicit long-term stimulation of acupoints in chronic diseases of humans or animals.

References

1. Ben-Yakir Sagiv (2008) GBI - the scientific basis. Proceedings of the International Veterinary Acupuncture Association (IVAS) Annual Congress, Keystone, CO, pp 193-194.
2. Demann ET, Stein PS, Haubenreich JE. (2005) Gold as an implant in medicine and dentistry. J Long Term Eff Med Implants. 15(6):687-98.
3. Goiz-Marquez G, Caballero S, Solis H, Rodriguez C & Sumano H. (2009) Electroencephalographic evaluation of gold wire implants inserted in acupuncture points in dogs with epileptic seizures. Res in Vet Sci, 86 (1), 152-161.
4. Hielm-Bjorkman A, Raekallio M, Kuusela E, Saarto E, Markkola A, Tulamo RM. (2001) Double-blind evaluation of implants of gold wire at acupuncture points in the dog as a treatment for osteoarthritis induced by hip dysplasia. Vet Rec 149(15):452-6.
5. IVAS (International Veterinary Acupuncture Society) Homepage. http://www.ivas.org/
6. Jaeger Gry T, Larsen Stig, Soli Nils and Moe Lars. (2007) Two years follow-up study of the pain-relieving effect of gold bead implantation in dogs with hip-joint arthritis. Acta Vet Scand. 2007; 49(1): 9.
7. Kjerkegaard Hans MD < gold.doc@mail.dk > Gold-Implantation: A New Method for Treating of Chronic Arthritic Pain, at: http://www.icmart.org/icmart04/abstract04.pdf and http://www.icmart.org/icmart05/abstract05.pdf
8. Kjerkegaard Hans MD: The Positive Effect of Gold Implantation in Chronic lumbar pain, at: http://tinyurl.com/lxosfa
9. Nejrup K, de Fine Olivarius N, Jacobsen JL, Siersma V. (2008 ) Randomised controlled trial of extraarticular gold bead implantation for treatment of knee osteoarthritis: a pilot study. Clin Rheumatol. May 24. [Epub ahead of print].
10. Robinson NG. (2007) Veterinary Acupuncture - An Ancient Tradition for Modern Times. Alternative & Complementary Therapies, Oct, pp 259-265; http://www.liebertonline.com/doi/abs/10.1089/act.2007.13506
11. Robinson NG. (2008) Gold Bead Implants – Medicine or Malpractice?: http://csuvets.colostate.edu/pain/Articlespdf/GoldBeadImplants.pdf
12. Rogers P. Serious complications of acupuncture-or acupuncture abuses? Am J Acupunct 1981:9; 347-351. Updated in 1998:http://med-vetacupuncture.org/english/articles/apabuse.html
13. Schrom T, Thelen A, Asbach P, Bauknecht HC. (2006) Effect of 7.0 Tesla MRI on upper eyelid implants. Ophthal Plast Reconstr Surg. Nov-Dec;22(6):480-482.
14. Thelen A, Bauknecht HC, Asbach P, Schrom T. (2006) Behavior of metal implants used in ENT surgery in 7 Tesla magnetic resonance imaging. Eur Arch Otorhinolaryngol. 263 (10):900-905.
15. Kim HY, Sohn BY, Seo UK, Lee H, Hahm DH, Shim I. (2009) An exploratory study of gold wire implantation at acupoints to accelerate ulnar fracture healing in rats. J Physiol Sci. 2009 May 2. [Epub ahead of print]. Dept of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, 77555-1069 USA. By causing long-term stimulation, gold wire implantation at acupoints is used empirically to prolong the effects of acupuncture. This study shows that subcutaneous gold wire implantation at acupoints has long-term effects on bone regeneration in the rat ulna bone defect model. PMID: 19412656 [PubMed - as supplied by publisher]
16. Miller JM, Rossi EA, Wiesmair M, Alexander DE & Gallo O. Stability of gold bead tissue markers. Journal of Vision, 6 (5), 616-624.

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Further reading:

Demann ET, Stein PS, Haubenreich JE. (2005) Gold as an implant in medicine and dentistry. J Long Term Eff Med Implants. 15(6):687-98. Dept of Oral Health Science, Division of General Dentistry, College of Dentistry, University of Kentucky, Lexington, Kentucky 40536-0297, USA. The purpose of this collective review is to study the history, physical and chemical properties, application, and clinical consequences of gold implants in the dental and medical fields. Gold implants are used in various medical procedures, including reconstructive surgery of the middle ear, upper lid closure in facial nerve paresis-induced lagophthalmos, drug delivery microchips, antitumor treatment, treatment of rheumatoid arthritis, use on the surface of voice prostheses, and endovascular stents, with sound clinical results. However, in order to achieve better therapeutic benefits, clinical reports have documented that the surface of gold implants have been modified or encased in biocompatible alloplastic materials, or they have been replaced by cheaper and more biocompatible materials. Gold is also applied to a long list of dental prostheses, including inlays, onlays, crowns, bridges, periodontal splints, and post and cores. It has sufficient strength and corrosion resistance, and it is relatively biocompatible. In addition, gold dental prostheses have a long life cycle. However, esthetic concerns and cost make it a less desirable prosthesis today than in the past. PMID: 16393135 [PubMed - indexed for MEDLINE]

Jaeger Gry T, Larsen Stig, Soli Nils and Moe Lars. (2007) Two years follow-up study of the pain-relieving effect of gold bead implantation in dogs with hip-joint arthritis. Acta Vet Scand. 2007; 49(1): 9. gry.jaeger@veths.no 78 dogs with pain from hip dysplasia participated in a 6-month placebo-controlled, double-blinded clinical trial of gold bead implantation (GBI). In the present, non-blinded study, 73 of these dogs were followed for an additional 18 months to evaluate the long-term pain-relieving effect of GBI. The recently-published results of the six month period revealed that 30 / 36 dogs (83%) in the gold implantation group showed significant improvement (p = 0.02), included improved mobility and reduction in the signs of pain, compared to the placebo group (60% improvement). In the long-term 2-year follow-up study, 66 / 73 dogs had gold implantation and 7 dogs continued as a control group. The 32 dogs in the original placebo group had gold beads implanted and were followed for a further 18 months. A certified veterinary acupuncturist used the same procedure to insert the gold beads as in the blinded study, and the owners completed the same type of detailed questionnaires. As in the blinded study, one investigator was responsible for all the assessments of each dog. The present study revealed that the pain-relieving effect of GBI observed in the blinded study continued throughout the two-year follow-up period.

Miller JM, Rossi EA, Wiesmair M, Alexander DE & Gallo O. Stability of gold bead tissue markers. Journal of Vision, 6 (5), 616-624. Smith-Kettlewell Eye Research Institute, San Francisco, CA, USA. Significant soft tissue features in the orbit and elsewhere are not resolved by MRI or any other imaging method. We describe a new method that uses tiny (~0.1 mm diameter) gold beads as markers to visualize movements of such tissues with high spatial resolution (~100 ìm) and moderate temporal resolution (~100 ms). We describe bead fabrication, implantation, imaging, and image processing to extract three-dimensional bead coordinates. We then present results of an experiment to determine the stability of gold bead tissue markers (GBTMs) over time in normally moving orbital tissues. Most beads (76%) implanted in sclera, muscle, tendon, and connective tissue were highly stable over the 6-month measurement period. Beads that were judged unstable drifted only a few 100 ìm. Bead flows with gaze suggested that posterior Tenon's capsule moves with the globe, that the lateral rectus belly may sideslip, producing “bridle forces,” and that the posterior medial rectus pulley sling moves freely anteriorly and posteriorly, but hardly vertically, as required by the “coordinated active pulley” hypothesis. The GBTM method seems applicable to study such short time course phenomena as extraocular muscle (EOM) and connective tissue movement as a function of gaze and such long time course phenomena as myopic eye growth. Bead stability over time: Gold beads are remarkably stable with respect to extraocular tissues in which they are placed. Of the beads that appeared to drift significantly in half or more of the gazes we analyzed, none drifted more than two bead diameters. Even this is probably an overestimate of drift because it includes any habitual fixation differences that developed over the 6 months of the experiment, which were not correctable by bead group translation (see above). Comparing Figure 7A with Figure 7B, we saw that the least stabile beads were located in the posterior capsule or subcapsular space. To put this result in perspective, there were good reasons to expect beads to be unstable. Tissue growth processes might have expelled them from sclera or muscle, for example, into surrounding connective tissues or fat. Frequent, fast saccadic eye movements might have shaken beads loose from motile tissues, causing them to accumulate in calmer places. None of these effects seem to be large over a 6-month period. For full text, see: http://www.journalofvision.org/6/5/6/article.aspx

Nejrup K, de Fine Olivarius N, Jacobsen JL, Siersma V. (2008 ) Randomised controlled trial of extraarticular gold bead implantation for treatment of knee osteoarthritis: a pilot study. Clin Rheumatol. May 24. [Epub ahead of print]. General Practice, Holte, Denmark. The primary objective of this double-blind, randomised, controlled trial was to determine if implanting gold beads at five acupuncture points around the knee joint improves 1-year outcomes for patients with osteoarthritis (OA) of the knee. Participants were 43 adults aged 18-80 years with pain and stiffness from non-specific OA of the knee for over a year. The intervention was blinded implantation of gold beads at five acupuncture points around the affected knee through a hypodermic needle, or needle insertion alone. Primary outcome measures were knee pain, stiffness and function assessed by the patient at 0, 1, 3, 6, 9 and 12 months and knee score and knee function assessed by an orthopaedic surgeon at 0, 6 and 12 months. Within the first month, three patients dropped out. The remaining 21/19 patients in the intervention/control groups generally improved, but there was no statistically significant difference between the groups. The improvement was shown in the patients' self-assessment scores that decreased from randomisation until 1 year later (intervention/control group, medians): pain -1.92/-2.18 (P = 0.95, F test, general linear mixed model); stiffness -0.93/-0.43 (P = 0.11); function -7.23/-3.36 (P = 0.63). The surgeon's scores also generally improved, i.e. increased: knee score +16.4/+8.2 (P = 0.65); knee function +10.5/+5.8 (P=0.79). In the protocol-based subgroup analysis, the 15 intervention patients of the 32 patients who had a positive response to the initial conventional acupuncture had greater relative improvements in self-assessed outcomes. The treatment was well tolerated. This 1-year pilot study indicates that extraarticular gold bead implantation is a promising treatment modality for patients with OA of the knee. The new treatment should be tested in a larger trial including only patients who respond positively to initial conventional acupuncture. PMID: 18500437 [PubMed - as supplied by publisher]

Schrom T, Thelen A, Asbach P, Bauknecht HC. (2006) Effect of 7.0 Tesla MRI on upper eyelid implants. Ophthal Plast Reconstr Surg. Nov-Dec;22(6):480-482. Dept of Otorhinolaryngology, Charite-Universitaetsmedizin Berlin, Charite Campus Mitte, Berlin, Germany. thomas.schrom@gmx.de To ensure the MRI compatibility of various eyelid implants in high-field MRI, 3 eyelid weights made of pure gold (99.99%), pure platinum (99.95%), and a platinum (97%)/iridium (3%) alloy were examined in vitro. Temperature changes, position changes, and imaging artifacts of the different implants were determined in a small-bore 7.0 Tesla MRI system. The 7.0 Tesla MRI system demonstrated that none of the eyelid implants carried a risk of heating or dislocation; therefore, these implants are MRI compatible up to a magnetic field strength of 7.0 Tesla. PMID: 17117110 [PubMed - indexed for MEDLINE]

Thelen A, Bauknecht HC, Asbach P, Schrom T. (2006) Behavior of metal implants used in ENT surgery in 7 Tesla magnetic resonance imaging. Eur Arch Otorhinolaryngol. 263 (10):900-905. Dept of Otorhinolaryngology, Charite, Universitatsmedizin Berlin, Klinik fur Hals-, Nasen-, Ohrenheilkunde, Campus Mitte, Schumannstr. 20/21, 10117, Berlin, Germany. ariane.debelius@charite.de Magnetic resonance imaging (MRI) has become increasingly important as an imaging technique in cross-sectional imaging of head and neck diseases. To investigate whether MRI examinations can be performed without risk in patients with metal implants even at higher field strengths, we examined different materials in 7 Tesla MRI. Implants near sensory organs like the middle ear or eye are of particular interest here. Using the 7 Tesla research MRI for small animals, we tested implants made of various metals like titanium, gold, gold/platinum, platinum/iridium, gold- plated silver, PTFE and stainless steel for heating, translocation and rotation according to a standardised protocol. A fiber optic temperature probe measured the heating of the implant before, during and after MRI scanning. None of the implants showed significant heating. The gold-plated stainless steel ventilation tube was the only implant to markedly change its position already in the Petri dish. Of the remaining implants, a trachea support ring, a nose dilatator and the wire from the ventilation tubes moved during vibration of the Petri dish. With exception of two implants, all implants changed positions in the water bath. In the swim test, the gold implants showed the least movement of all the implants. In this study, the properties of the non-ferromagnetic implant materials differed in the 7 Tesla MRI. Stainless steel ventilation tubes, the trachea support ring and the nose dilatator were not suited for the 7 Tesla MRI system, because they changed their position during MRI. In the case of ventilation tubes with a steel wire, the wire should be removed before MRI to prevent injury to the external auditory canal. There was a tendency for the pure gold implants to move less in the 7 Tesla MRI than all other tested materials. General statements cannot be made about the MRI suitability of different implants. Every implant should be individually examined to confirm its definitive MRI compatibility. Particularly, middle ear implants warrant special attention here due to their closeness to the oval window. PMID: 16835741 [PubMed - indexed for MEDLINE]

Goiz-Marquez G, Caballero S, Solis H, Rodriguez C & Sumano H. Electroencephalographic evaluation of gold wire implants inserted in acupuncture points in dogs with epileptic seizures. Res in Vet Sci, 86 (1), Feb 2009, 152-161. Dept de Fisiologia y Farmacologia, Facultada de Medicina Veterinaria y Zootecnial, Universidad Nacional Autonoma de Mexico, Avenida Universidad No. 3000, Delegacion Coyoacan, Ciudad de Mexico, C.P. 04510, Mexico. The purpose of this study was to evaluate both, clinically and with electroencephalographic (EEG) recordings, the effect of gold wire implants in acupuncture points in dogs with uncontrolled idiopathic epileptic seizures. Fifteen dogs with such diagnosis were enrolled in the study. A first EEG recording was performed in all dogs under anaesthesia with xylazine (1 mg/kg) and propofol (6 mg/kg) before the treatment protocol, and a second EEG was performed 15 weeks later. Relative frequency power, intrahemispheric coherence available through EEG, number of seizures and seizure severity were compared before and after treatment using a Wilcoxon signed-rank test. There were no significant statistical differences before and after treatment in relative power or in intrahemispheric coherence in the EEG recording. However, there was a significant mean difference in seizure frequency and seizure severity between control and treatment periods. After treatment, nine of the 15 dogs (60%) had at least a 50% reduction in seizures frequency during the 15 weeks established as follow-up of this treatment.