SCIENCE OF ACUPUNCTURE

2011RM Clemmons, DVM, PhD, CVA, CVFTUniversity of Floridahttp://dog2doc.com/IVAS2011/

J Pain Symptom Manage. 2009 Apr;37(4):709-14. Epub 2008 Sep 11.

Acupuncture: what does the most reliable evidence tell us?

Many trials of acupuncture and numerous systematic reviews have recently become available. Their conclusions are far from uniform. In an attempt to find the most reliable type of evidence, this article provides an overview of Cochrane reviews of acupuncture. Such reviews were studied, their details extracted, and they were categorized as: reviews with a negative conclusion (no evidence that acupuncture is effective); reviews that were inconclusive; and reviews with a positive or tentatively positive conclusion. Thirty-two reviews were found, covering a wide range of conditions. Twenty-five of them failed to demonstrate the effectiveness of acupuncture. Five reviews arrived at positive or tentatively positive conclusions and two were inconclusive. The conditions that are most solidly backed up by evidence are chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. It is concluded that Cochrane reviews of acupuncture do not suggest that this treatment is effective for a wide range of conditions.

What does the literature say?

Total 16080 Human 12095 Animal 3007

Scientific (clinical trials, meta-analysis, randomized control trials)

Human 2605 Animal 52

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Acupuncture Cites on PubMed

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Num

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Cites by species Dog 218 Cat 235 Horse 66 Cow 38 Pig 35 Bird 12 Chicken 3 Rodent 1875 Human 12095

Feb-2010 to Feb-2011 Total 1027

Human 611 Animal 130

Scientific (Clinical trials, meta-analysis, random control trials)

Human 207 English 113 Chinese 89

Animal 2

Animal Scientific Articles

Saarto EE, Hielm-Björkman AK, Hette K, Kuusela EK, Brandão CV, Luna SP. Effect of a single acupuncture treatment on surgical wound healing in dogs: a randomized, single blinded, controlled pilot study. Acta Vet Scand. 2010 Oct 15;52:57.

METHODS: 29 dogs were submitted to soft tissue and/or orthopaedic surgeries. Five dogs had two surgical wounds each, so there were totally 34 wounds in the study. All owners received instructions for post operative care as well as antibiotic and pain treatment. The dogs were randomly assigned to treatment or control groups. Treated dogs received one dry needle acupuncture treatment right after surgery and the control group received no such treatment. A veterinary surgeon that was blinded to the treatment, evaluated the wounds at three and seven days after surgery in regard to oedema (scale 0-3), scabs (yes/no), exudate (yes/no), hematoma (yes/no), dermatitis (yes/no), and aspect of the wound (dry/humid).

RESULTS: There was no significant difference between the treatment and control groups in the variables evaluated three and seven days after surgery. However, oedema reduced significantly in the group treated with acupuncture at seven days compared to three days after surgery, possibly due the fact that there was more oedema in the treatment group at day three (although this difference was not significant between groups).

CONCLUSIONS: The use of a single acupuncture treatment right after surgery in dogs did not appear to have any beneficial effects in surgical wound healing.

Animal Scientific Articles

Joaquim JG, Luna SP, Brondani JT, Torelli SR, Rahal SC, de Paula Freitas F. Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits. J Am Vet Med Assoc. 2010 Jun 1;236(11):1225-9.

DESIGN: Retrospective case series and prospective clinical trial. ANIMALS: 40 dogs between 3 and 6 years old and weighing between 10 and 20 kg (22 and 44 lb) with long-standing (> 48 hours) clinical signs of severe neurologic disease attributable to thoracolumbar IVDD.

PROCEDURES: Thoracolumbar medullar injury was classified on the basis of neurologic signs by use of a scale ranging from 1 (least severe) to 5 (most severe). The DSX dogs (n = 10) were retrospectively selected from those that underwent DSX for the treatment of thoracolumbar IVDD. In addition, 19 dogs received EAP alone and 11 dogs underwent DSX followed by EAP (DSX + EAP). Outcome was considered a clinical success when a dog initially classified as grade 4 or 5 was classified as grade 1 or 2 within 6 months after the end of treatment.

RESULTS: The proportion of dogs with clinical success was significantly higher for dogs that underwent EAP (15/19) than for dogs that underwent DSX (4/10); the proportion of dogs with clinical success for dogs that underwent DSX + EAP was intermediate (8/11).

CONCLUSIONS AND CLINICAL RELEVANCE: EAP was more effective than DSX for recovery of ambulation and improvement in neurologic deficits in dogs with long-standing severe deficits attributable to thoracolumbar IVDD.

Science by system (Highlights) GI 6

A meta-analysis of five RCTs showed favorable effects of moxibustion on the response rate compared to conventional drug therapy .

Heart 13 Acupuncture may become an additional therapeutic

strategy to improve the exercise tolerance of patients with CHF.

Blood Pressure 6 The present study showed that radial artery blood

flow volume decreased immediately during acupuncture at the LR-3 acupoint, but was increased at 180 seconds after acupuncture.

Science by system (Highlights) Brain 11 Hearing 1

Acupuncture and moxibustion therapy of excitation-focus transfer presents superior therapeutic effect on sudden deafness as compared with the routine western therapy.

Reproduction 15 Cancer 13

Science by system (Highlights) Pain 72

These data suggest that the presence and intensity of de qi has no effect on the pain relief obtained for patients with OA.

For this pathology (neck pain), the number of needles, 5 or 11, seems not to be an important variable in determining the therapeutic effect .

Significant improvements (p < 0.01) in painful symptoms and electromyographic activities of masseter muscles in maximal habitual occlusion after laser applications in TMJ.

Arthritis 15

Science by system (Highlights) Asthma 2

Acupuncture as an adjunct therapy to conventional medical care does not seem to affect pulmonary function in asthmatic patients. However, 12 sessions of acupuncture treatment during 4 weeks showed a favorable effect on the quality of life in adult asthmatic patients.

Stroke 14 Our meta-analyses of data from rigorous randomized

sham-controlled trials did not show a positive effect of acupuncture as a treatment for functional recovery after stroke.

Randomized clinical trials demonstrate that acupuncture may be effective in the treatment of post-stroke rehabilitation.

Science by system (Highlights) Stem Cells

Our results indicate that acupuncture for SCI can mobilize human CD133(+)34(-) cells.

Depression 9 Subjects in the experimental group (elderly in

nursing home) showed a statistically significant improvement in depressive mood status.

Acupuncture therapy is safe and effective in treating major depressive disorder (MDD) and post-stroke depression (PSD).

Science by system (Highlights) Nausea 9

Acupuncture (P6 or traditional) showed no significant benefit to women in pregnancy.

Study demonstrates that electroacustimulation (PC6) offers added protection against symptoms of postoperative nausea and vomiting.

Obesity 5 Analgesia 53

Animals (Scientific Studies) Analgesia

TCA was not superior to sham acupuncture. However, acupuncturists' styles had significant effects on pain reduction and satisfaction, suggesting that the analgesic benefits of acupuncture can be partially mediated through placebo effects related to the acupuncturist's behavior.

Significant reductions in pain, dysfunction, and xerostomia were observed in patients receiving acupuncture versus usual care for neck surgery.

Hauer K, Wendt I, Schwenk M, Rohr C, Oster P, Greten J. Stimulation of acupoint ST-34 acutely improves gait performance in geriatric patients during rehabilitation: A randomized controlled trial. Arch Phys Med Rehabil. 2011 Jan;92(1):7-14.

DESIGN: Multiple-blinded, randomized, controlled intervention trial. SETTING: Geriatric ward rehabilitation. PARTICIPANTS: 60 geriatric patients during rehabilitation. INTERVENTIONS: Both groups received a 1-time acupoint stimulation

according to randomization. Stimulation of a verum acupoint (verum treatment) according to principles of traditional Chinese medicine was compared with a technically identical needle application on a nonacupoint (control treatment) in the control group.

CONCLUSIONS: Study results showed that a 1-time administration of a specific acupoint stimulation regimen statistically significantly improved gait performance during geriatric ward rehabilitation.

Landgren K, Kvorning N, Hallström I. Acupuncture reduces crying in infants with infantile colic: a randomised, controlled, blind clinical study. Acupunct Med. 2010 Dec;28(4):174-9. Epub 2010 Oct 18.

OBJECTIVE: To investigate whether acupuncture reduces the duration and intensity of crying in infants with colic. Patients and methods 90 otherwise healthy infants, 2-8 weeks old, with infantile colic were randomised in this controlled blind study. 81 completed a structured programme consisting of six visits during 3 weeks to an acupuncture clinic in Sweden. Parents blinded to the allocation of their children met a blinded nurse. The infant was subsequently given to another nurse in a separate room, who handled all infants similarly except that infants allocated to receive acupuncture were given minimal, standardised acupuncture for 2 s in LI4.

CONCLUSIONS: Minimal acupuncture shortened the duration and reduced the intensity of crying in infants with colic.

Kong JC, Lee MS, Shin BC, Song YS, Ernst E. Acupuncture for functional recovery after stroke: a systematic review of sham-controlled randomized clinical trials. CMAJ. 2010 Nov 9;182(16):1723-9. Epub 2010 Sep 27.

BACKGROUND: Acupuncture is frequently advocated as an adjunct treatment during stroke rehabilitation. The aim of this review was to assess its effectiveness in this setting.

METHODS: We searched 25 databases and 12 major Korean traditional medicine journals from their inception to October 2009. We included randomized controlled trials, with no language restrictions, that compared the effects of acupuncture (with or without electrical stimulation) with sham acupuncture. We assessed the methodologic quality of the trials using the Cochrane risk-of-bias criteria and the PEDro (Physiotherapy Evidence Database) scale.

CONCLUSIONS: Our meta-analyses of data from rigorous randomized sham-controlled trials did not show a positive effect of acupuncture as a treatment for functional recovery after stroke.

Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, Donovan D, Katovic N, Reeder C, Eilers K. Acupuncture for hot flashes in patients with prostate cancer. Urology. 2010 Nov;76(5):1182-8. Epub 2010 May 21.

OBJECTIVES: To determine the effect of acupuncture on hot flash frequency and intensity, quality of life, and sleep quality in patients undergoing hormonal therapy for prostate cancer. Hot flashes are a common adverse effect of hormonal therapy for prostate cancer.

METHODS: Men who had a hot flash score > 4 who were receiving androgen deprivation therapy for prostate cancer underwent acupuncture with electrostimulation biweekly for 4 weeks, then weekly for 6 weeks, using a predefined treatment plan. The primary endpoint was a 50% reduction in the hot flash score after 4 weeks of therapy, calculated from the patients' daily hot flash diaries. The hot flash-related quality of life and sleep quality and biomarkers potentially related to hot flashes, including serotonin, calcitonin gene-related peptide, and urinary 5-hydroxyindoleacetic acid, were examined.

CONCLUSIONS: Multiple placebo-controlled trials have demonstrated a 25% response rate to placebo treatment for hot flashes. Of the 22 patients, 41% had responded by week 4 and 55% overall in the present pilot study, providing evidence of a potentially meaningful benefit.

Hübscher M, Vogt L, Ziebart T, Banzer W. Immediate effects of acupuncture on strength performance: a randomized, controlled crossover trial. Eur J Appl Physiol. 2010 Sep;110(2):353-8. Epub 2010 May 25.

The present study investigated the immediate efficacy of acupuncture compared to sham acupuncture and placebo laser acupuncture on strength performance. A total of 33 recreational athletes (25.2 +/- 2.8 years; 13 women) were randomized to receive acupuncture, sham acupuncture (needling at non-acupuncture points) and placebo laser acupuncture (deactivated laser device) in a double-blind crossover fashion with 1 week between trials. Assessment included bipedal drop jumps for maximum rebound height and quadriceps maximum isometric voluntary force (MIVF). Furthermore, surface electromyography (EMG) was used to measure the EMG activity of the rectus femoris muscle during a 30-s sustained MIVF of the knee extensors. Mean power frequency (MPF) analysis was applied to characterize muscular endurance. Measurements were performed at baseline and immediately after treatment by a blinded investigator. Repeated measures ANOVA and post hoc paired-sample t test with Bonferroni-Holm correction were used for statistical analysis.

CONCLUSIONS: Study shows that a single acupuncture treatment was efficacious for improving isometric quadriceps strength in recreational athletes.

Wu MX, Li XH, Lin MN, Jia XR, Mu R, Wan WR, Chen RH, Chen LH, Lin WQ, Huang CY, Zhang XR, Hong KD, Li L, Liu XX. Clinical study on the treatment of knee osteoarthritis of Shen-Sui insufficiency syndrome type by electroacupuncture. Chin J Integr Med. 2010 Aug;16(4):291-7. Epub 2010 Aug 10.

OBJECTIVE: To study the clinical effificacy of electroacupuncture (EA) on treating knee osteoarthritis (KOA) of Shen ()-Sui () insuffificiency (SSI) syndrome type.

METHODS: A total of 245 patients (279 knees) of KOA-SSI were randomly assigned to two groups by lottery: 141 knees in the treatment group and 138 knees in the control group. The treatment group was managed with EA at the dominant points of Neixiyan (Ex-LE4) and Waixiyan (Ex-LE5) as well as the conjugate points of Xuanzhong (GB39) and Taixi (KI3) for 30 min, once a day, with 15 days as one course; 2 courses were applied with a 5-day interval in between. The control group was treated with intra-articular injection of 2 mL hyaluronic acid into the affected joint every 7 days for 5 times in total. The clinical effects on the patients in different stages were observed, and their symptom scores of knee and contents of cytokines, including interleukin-1 (IL-1), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), prostaglandin E(2alpha) (PGE(2alpha)) and matrix metalloproteinases-3 (MMP-3), in the knee joint fluid were measured before and after treatment.

CONCLUSIONS: EA could effectively alleviate the clinical symptoms in KOA patients of stage III, showing an effect superior to that of hyaluronic acid. EA also shows action in suppressing the secretion of IL-1, IL-6, TNF-alpha, PGE(2alpha) and MMP-3 in the knee fluid.

Pontarollo F, Rapacioli G, Bellavite P. Increase of electrodermal activity of heart meridian during physical exercise: the significance of electrical values in acupuncture and diagnostic importance. Complement Ther Clin Pract. 2010 Aug;16(3):149-53. Epub 2010 Feb 2.

Electric field measurements of skin potential and electrical currents are physiological indicators of electrodermal activity (EDA) and have been associated with a variety of sensory, cognitive and emotional stimuli. The aim of this study was to investigate the EDA at some hand acupoints before, during and after a physical exercise. EDA of eight points located at the corner of fingernails of hands was measured in 10 healthy young volunteers before, during and after a 14-min acute exercise in a bicycle ergometer. In pre-exercise resting state the parameters were stable and similar between the 8 different tested points.

CONCLUSIONS: During exercise a significant increase of current (from 1000-2000 to 4000-8000 nA) was observed, with the maximal values related to the point located on the ulnar side of the little finger, at the base of the nail, corresponding to the Shao chong (HT9) of heart meridian.

Pfab F, Huss-Marp J, Gatti A, Fuqin J, Athanasiadis GI, Irnich D, Raap U, Schober W, Behrendt H, Ring J, Darsow U. Influence of acupuncture on type I hypersensitivity itch and the wheal and flare response in adults with atopic eczema - a blinded, randomized, placebo-controlled, crossover trial. Allergy. 2010 Jul;65(7):903-10. Epub 2009 Dec 11.

BACKGROUND: Itch is a major symptom of allergic skin disease. Acupuncture has been shown to exhibit a significant effect on histamine-induced itch in healthy volunteers. We investigated the effect of acupuncture on type I hypersensitivity itch and skin reaction in a double-blind, randomized, placebo-controlled, crossover trial.

METHODS: An allergen stimulus (house dust mite or grass pollen skin prick) was applied to 30 patients with atopic eczema before (direct effect) and after (preventive effect) two experimental approaches or control observation: acupuncture at points Quchi and Xuehai [verum acupuncture (VA), dominant side], 'placebo-point' acupuncture (PA, dominant side), no acupuncture (NA). Itch intensity was recorded on a visual analogue scale. After 10 min, wheal and flare size and skin perfusion (via LASER-Doppler) were measured at the stimulus site, and the validated Eppendorf Itch Questionnaire (EIQ) was answered.

CONCLUSIONS: Acupuncture at the correct points showed a significant reduction in type I hypersensitivity itch in patients with atopic eczema.

Sherman KJ, Cherkin DC, Ichikawa L, Avins AL, Delaney K, Barlow WE, Khalsa PS, Deyo RA. Treatment expectations and preferences as predictors of outcome of acupuncture for chronic back pain. Spine (Phila Pa 1976). 2010 Jul 1;35(15):1471-7.

STUDY DESIGN: Preplanned secondary analysis of data from participants receiving acupuncture in a randomized clinical trial.

OBJECTIVE: To determine whether patients' expectations of and preferences for acupuncture predict short and long-term treatment outcomes for persons with chronic back pain.

SUMMARY OF BACKGROUND DATA: Although accumulating evidence suggests that patient expectations and treatment preferences may predict treatment outcomes, few studies have examined this relationship for acupuncture.

METHODS: Four hundred seventy-seven acupuncture-naïve participants with chronic low back pain who were randomized to 1 of 3 acupuncture or simulated acupuncture treatments were the focus of this analysis. Ten treatments were provided during a 7-week period, and participants were masked to treatment assignment. Before randomization, participants provided expectations regarding treatment success, impressions, and knowledge about acupuncture and treatment preferences. Outcomes of interest were functional status (Roland score) and symptom bothersomeness at 8 and 52 weeks postrandomization, obtained by telephone interviewers masked to treatment assignment.

CONCLUSIONS: Pretreatment expectations and preferences for acupuncture were not found predictive of treatment outcomes for patients with chronic back pain.

Wong CL, Lai KY, Tse HM. Effects of SP6 acupressure on pain and menstrual distress in young women with dysmenorrhea. Complement Ther Clin Pract. 2010 May;16(2):64-9. Epub 2009 Nov 14.

OBJECTIVES: This study aims to evaluate the effects of Sanyinjiao (SP6) acupressure in reducing the pain level and menstrual distress resulting from dysmenorrhea.

METHODS: Forty participants with dysmenorrhea were assigned to either the acupressure group (n = 19) or the control group (n = 21). The acupressure group received 20 min of SP6 acupressure during the initial intervention session and was taught to perform the technique for them to do twice a day from the first to third days of their menstrual cycle, 3 months subsequent to the first session. In contrast, the control group was only told to rest. Outcomes were measured through (1) the Pain Visual Analogue Scale (PVAS), (2) the Short-Form McGill Pain Questionnaire (SF-MPQ), and (3) the Short-Form Menstrual Distress Questionnaire (SF-MDQ).

CONCLUSIONS: SP6 acupressure has an immediate pain-relieving effect for dysmenorrhea. Moreover, acupressure applied to the SP6 acupoint for 3 consecutive months was effective in relieving both the pain and menstrual distress level resulting from dysmenorrhea.

Cho SY, Jahng GH, Park SU, Jung WS, Moon SK, Park JM. fMRI study of effect on brain activity according to stimulation method at LI11, ST36: painful pressure and acupuncture stimulation of same acupoints. J Altern Complement Med. 2010 Apr;16(4):489-95.

OBJECTIVES: The objective of this study was to assess differences in brain responses between pressure and acupuncture stimulation at the same acupoint using functional magnetic resonance imaging (fMRI).

SUBJECTS: A total of 10 healthy right-handed volunteers were studied. DESIGN: fMRI was performed with two different paradigms; namely,

pressure and acupuncture stimulation at acupuncture points LI11 and ST36 on the left. fMRI data were analyzed using SPM2.

CONCLUSIONS: Brain signal activation patterns according to the stimulation methods and acupoints were observed to differ. Acupuncture stimulation activated more regions than pressure at the same acupoint. In particular, acupuncture stimulation activated the limbic system, such as the parahippocampal gyrus and anterior cingulate cortex.

Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Pain Pract. 2010 Mar-Apr;10(2):94-102. Epub 2010 Jan 8.

OBJECTIVES: There is controversy as to whether or not acupuncture is more effective than placebo. To help clarify this debate, we synthesized the evidence gathered from systematic reviews on the pooled data of high-quality randomized controlled trials comparing acupuncture to sham acupuncture for chronic pain.

METHOD: Systematic reviews of acupuncture for the most commonly occurring forms of chronic pain (back, knee, and head) published between 2003 and 2008 were sourced from Ovid databases: Medline, Allied and Complementary Medicine database, Cochrane Library and Web of Science during December 2008. Eight systematic reviews with meta-analyses of pooled data were eligible for inclusion. Data were extracted for short- and longer-term outcomes for the most commonly occurring forms of pain. Two independent reviewers assessed methodological quality.

CONCLUSIONS: The accumulating evidence from recent reviews suggests that acupuncture is more than a placebo for commonly occurring chronic pain conditions. If this conclusion is correct, then we ask the question: is it now time to shift research priorities away from asking placebo-related questions and shift toward asking more practical questions about whether the overall benefit is clinically meaningful and cost-effective?

Witt CM, Lüdtke R, Wegscheider K, Willich SN. E Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture? J Pain. 2010 May;11(5):431-5.

The aim of this paper was to quantify the influence of the physician's training and experience in the field of acupuncture on the outcome in patients with chronic pain. Patients visiting their physician because of chronic low back pain, headache, pain due to osteoarthritis of the knee or hip, or neck pain, were included in 4 multicenter, randomized, controlled studies. All patients received routine care; patients in the acupuncture groups received additional acupuncture treatment (on average 10 sessions). The data was pooled, and the 3-month change from baseline of the SF-36 bodily pain subscale as the main outcome defined. A total of 9,990 patients (mean age 49.6 +/- 13.6 years, 68% female) treated by 2,781 physicians (mean age 46.3 +/- 7 years, 37% female) were analyzed. The physicians had 7.3 +/- 5.2 (mean +/- sd) years of experience in acupuncture and their mean duration of formal acupuncture training had been 287 +/- 321 hours. The outcome was markedly improved in the acupuncture group.

CONCLUSIONS: We identified only 1 physician characteristic with a significant influence on the outcome: Internists performed better and orthopedists worse than the average physician. Neither the duration of training nor the duration of experience had any impact on the extent of the acupuncture effect.

Conclusion Science supports the

use of acupuncture for many conditions that affect man and animals.

We will have work to do to provide better evidence for where acupuncture can be applied best for the treatment and prevention of disease.