The status and future of acupuncture mechanism research

Acupuncture for Erectile Dysfunction: A Systematic Review

Background. Acupuncture is increasingly used to treat patients with erectile dysfunction (ED), and our systematic review aimed to evaluate the current evidence for the efficacy and safety of acupuncture in treating ED. Methods. An electronic search was conducted in eight databases to identify randomized controlled trials (RCTs) of acupuncture for treating erectile dysfunction that were published in English and Chinese. The Cochrane Risk of Bias tool was used to assess the risk of bias. Results. Three RCTs with a total of 183 participants met the inclusion criteria. One trial showed the beneficial effects of acupuncture compared with sham acupuncture while the others did not. One trial suggested that acupuncture combined with psychological therapy was superior to psychological therapy alone. However, the overall methodological and reporting quality of the studies was low. The safety of acupuncture for ED was unclear because there were too few reports on this topic. Conclusion. The available evidence supporting that acupuncture alone improves ED was insufficient and the available studies failed to show the specific therapeutic effect of acupuncture. Future well-designed and rigorous RCTs with a large sample size are required. This trial is registered with CRD42014013575.

Electroacupuncture for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

Electroacupuncture (EA) is an extension technique of acupuncture based on traditional acupuncture combined with modern electrotherapy. Here, we conducted a systematic review specifically to assess the effectiveness and safety of EA for acute ischemic stroke. Eight databases were searched for randomized-controlled clinical trials (RCTs) of EA for acute ischemic stroke published from inception to June 2013. Ultimately, 67 studies claimed to be RCTs. Eighteen studies with 1411 individuals were selected for the analyses, which got [Formula: see text] “yes” in the domains of Cochrane risk of bias tool. The meta-analysis showed a significant effect of EA for improving Barthel Index ([Formula: see text]), Fugl–Meyer Assessment ([Formula: see text]), National Institutes of Health Stroke Scale ([Formula: see text]) and Revised Scandinavian Stroke Scale ([Formula: see text]) compared with western conventional treatments (WCTs). In an analysis of the total clinical efficacy rate, there was a significant difference between EA and WCTs ([Formula: see text]). Adverse effects were monitored in 6 studies, and were well tolerated in all stroke patients. According to the GRADE approach, the quality of evidence was mostly high or moderate. In conclusion, this systematic review revealed the evidence in support of the use of EA for acute ischemic stroke, although further larger sample-size and rigorously designed RCTs are required.

Acupuncture for postoperative pain following total knee arthroplasty: a systematic review protocol

INTRODUCTION

Total knee arthroplasty (TKA) is a common surgical method in orthopaedics; however, pain management after TKA remains a significant challenge. This review provides a comprehensive evaluation of the effects of acupuncture for postoperative pain after TKA.

METHODS AND ANALYSIS

The following 10 databases will be searched until August 2015: MEDLINE, EMBASE, CENTRAL, AMED, CINAHL, three Chinese databases (the China National Knowledge Infrastructure Database, the Chongqing VIP Chinese Science and Technology Periodical Database, and Wanfang Database) and five Korean databases (the Korean Medical Database, the Korean Studies Information Service System, the National Discovery for Science Leaders, the Database Periodical Information Academic, and the Oriental Medicine Advanced Searching Integrated System). All eligible randomised controlled trials related to the use of acupuncture for postoperative pain after TKA will be included. Assessment of risk of bias will be performed with the Cochrane risk-of-bias method. Mean differences or standardised mean differences will be calculated with 95% CIs for continuous data; the risk ratio will be used with 95% CIs for dichotomous data.

DISSEMINATION

This systematic review will be presented in a peer-reviewed journal. The result of this review will also be disseminated at a relevant conference presentation.

TRIAL REGISTRATION NUMBER

PROSPERO 2015: CRD42015020924.

Biolite: A Patented Ultra-Low-Level Laser-Therapy Device for Treating Musculoskeletal Pain and Associated Impairments

After an excursus on state-of-the-art knowledge for low-level laser therapy (LLLT), Biolite, a patented ultra-low-level laser therapy device used to treat musculoskeletal pain and associated impairments, is presented. The application protocols include short stimulation of sequences of acupuncture points. The observed effects seem, however, to be far from those that might be expected after acupuncture. The primary effect seems more likely to be an extracellular soft-tissue matrix reaction. The development of the technique, the studies performed, and the evidence collected over > 10 years suggest that specifically modulated laser light can interact with human tissues at light fluences well under those previously considered as being capable of having any effect. Musculoskeletal pain very often becomes an autonomous dysfunction that is independent of the original injury and that can be effectively treated using specific peripheral acupuncture-like stimulation. Because such acupuncture is capable of reducing motor control "interferences" from noxious stimuli, it can improve motor control performance, thereby reducing the risk of falls in the elderly individuals. The proposal of acupuncture-derived protocols to be applied by Western physiotherapists using an ultra-low-level laser therapy device is a further "bridge" between two different, and sometimes very different, clinical worlds to better serve our patients.

Neuroimaging and Neuromonitoring Effects of Electro and Manual Acupuncture on the Central Nervous System: A Literature Review and Analysis

The aim of this review is to provide an overview of the different effects of manual and electroacupuncture on the central nervous system in studies with different neuroimaging interventions. The Database PubMed was searched from 1/1/2000 to 1/6/2014 with restriction to human studies in English language. Data collection for functional magnetic resonance (fMRI) studies was restricted to the period from 1/1/2010 to 1/6/2014 due to a recently published review which included all published randomized and nonrandomized controlled clinical studies as well as observational studies with control groups, no blinding required. Only studies comparing manual or electroacupuncture with sham acupuncture were eligible. All participants were healthy adult men and women. A majority of 25 studies compared manual versus sham, a minority of 7 trials compared electro versus sham and only 1 study compared electro versus manual acupuncture. In 29 out of 33 studies verum acupuncture results were found to present either more or different modulation effects on neurological components measured by neuroimaging and neuromonitoring methods than sham acupuncture. Only four studies reported no effects of verum in comparison to sham acupuncture. Evaluation of the very heterogeneous results shows evidence that verum acupuncture elicits more modulation effects on neurological components than sham acupuncture.

Treatment of Lymphedema with Saam Acupuncture in Patients with Breast Cancer: A Pilot Study

Background: Lymphedema is a troublesome complication affecting quality of life (QoL) in many women after breast-cancer treatment. Recent studies have suggested that acupuncture can reduce symptoms of lymphedema in breast-cancer survivors. Objectives: This was a pilot study. It was designed to assess the feasibility and the safety of acupuncture with the Saam acupuncture method for treating lymphedema in Korean patients after surgical therapy for breast cancer. Materials and Methods: This was a prospective, single-arm, observational pilot study using before and after measurements. The study was conducted at the East-West Medical Center at the Daegu Catholic University Medical Center, in Daegu, Korea. The subjects were 9 patients with breast cancer who presented with lymphedema of the upper limb ipsilateral to surgery. Saam acupuncture was administered 3 times per week for 6 consecutive weeks, for 30±5 minutes at each session.The primary outcome measure was severity of lymphedema as assessed by stages of lymphedema, a visual analogue scale (VAS), and by circumferential measurements of the upper extremity. The secondary outcome measure was QoL, which was assessed by a self-administered questionnaire using the Short Form-36 questionnaire. Results: Acupuncture reduced severity of lymphedema significantly, as assessed by the VAS (P<0.001) as well as by circumferential measurements of the upper extremity. Four weeks after the final treatment, symptoms were not aggravated. SF-36 scores remained significant for health status at the end of treatment. Conclusions: The Saam acupuncture method appeared to provide reduction of lymphedema among women after they had undergone surgery for breast cancer. A randomized, controlled prospective study with a larger sample size is required to clarify the role of acupuncture for managing lymphedema in patients with breast cancer.

Partially Automated Method for Localizing Standardized Acupuncture Points on the Heads of Digital Human Models

Having modernized imaging tools for precise positioning of acupuncture points over the human body where the traditional therapeutic method is applied is essential. For that reason, we suggest a more systematic positioning method that uses X-ray computer tomographic images to precisely position acupoints. Digital Korean human data were obtained to construct three-dimensional head-skin and skull surface models of six individuals. Depending on the method used to pinpoint the positions of the acupoints, every acupoint was classified into one of three types: anatomical points, proportional points, and morphological points. A computational algorithm and procedure were developed for partial automation of the positioning. The anatomical points were selected by using the structural characteristics of the skin surface and skull. The proportional points were calculated from the positions of the anatomical points. The morphological points were also calculated by using some control points related to the connections between the source and the target models. All the acupoints on the heads of the six individual were displayed on three-dimensional computer graphical image models. This method may be helpful for developing more accurate experimental designs and for providing more quantitative volumetric methods for performing analyses in acupuncture-related research.

Meta-analysis of acupuncture therapy for the treatment of stable angina pectoris

Angina pectoris is a common symptom imperiling patients' life quality. The aim of this study is to evaluate the efficacy and safety of acupuncture for stable angina pectoris. Clinical randomized-controlled trials (RCTs) comparing the efficacy of acupuncture to conventional drugs in patients with stable angina pectoris were searched using the following database of PubMed, Medline, Wanfang and CNKI. Overall odds ratio (ORs) and weighted mean difference (MD) with their 95% confidence intervals (CI) were calculated by using fixed- or random-effect models depending on the heterogeneity of the included trials. Total 8 RCTs, including 640 angina pectoris cases with 372 patients received acupuncture therapy and 268 patients received conventional drugs, were included. Overall, our result showed that acupuncture significantly increased the clinical curative effects in the relief of angina symptoms (OR=2.89, 95% CI=1.87-4.47, P<0.00001) and improved the electrocardiography (OR=1.83, 95% CI=1.23-2.71, P=0.003), indicating that acupuncture therapy was superior to conventional drugs. Although there was no significant difference in overall effective rate relating reduction of nitroglycerin between two groups (OR=2.13, 95% CI=0.90-5.07, P=0.09), a significant reduction on nitroglycerin consumption in acupuncture group was found (MD=-0.44, 95% CI=-0.64, -0.24, P<0.0001). Furthermore, the time to onset of angina relief was longer for acupuncture therapy than for traditional medicines (MD=2.44, 95% CI=1.64-3.24, P<0.00001, min). No adverse effects associated with acupuncture therapy were found. Acupuncture may be an effective therapy for stable angina pectoris. More clinical trials are needed to systematically assess the role of acupuncture in angina pectoris.

Impact of whole systems traditional Chinese medicine on in-vitro fertilization outcomes

Patients undergoing IVF may receive either acupuncture or whole-systems traditional Chinese medicine (WS-TCM) as an adjuvant IVF treatment. WS-TCM is a complex intervention that can include acupuncture, Chinese herbal medicine, dietary, lifestyle recommendations. In this retrospective cohort study, 1231 IVF patient records were reviewed to assess the effect of adjuvant WS-TCM on IVF outcomes compared among three groups: IVF with no additional treatment; IVF and elective acupuncture on day of embryo transfer; or IVF and elective WS-TCM. The primary outcome was live birth. Of 1069 non-donor cycles, WS-TCM was associated with greater odds of live birth compared with IVF alone (adjusted odds ratio [AOR] 2.09; 95% confidence interval [CI] 1.36 to 3.21), or embryo transfer with acupuncture only (AOR 1.62; 95% CI 1.04 to 2.52). Of 162 donor cycles, WS-TCM was associated with increased live births compared with all groups (odds Ratio [OR] 3.72; 95% CI 1.05 to 13.24, unadjusted) or embryo transfer with acupuncture only (OR 4.09; 95% CI: 1.02 to 16.38, unadjusted). Overall, IVF with adjuvant WS-TCM was associated with greater odds of live birth in donor and non-donor cycles. These results should be taken cautiously as more rigorous research is needed.

Psychophysical and neurophysiological responses to acupuncture stimulation to incorporated rubber hand

From a neuroscientific perspective, the sensations induced by acupuncture are not only the product of the bottom-up modulation of simple needling at somatosensory receptors, but also of the reciprocal interaction of top-down modulation from the brain. The present study investigated whether acupuncture stimulation to incorporated body parts produces brain responses that are similar to the responses observed following acupuncture stimulation to the real hand. The present study included 17 participants who watched a rubber hand being synchronously stroked with their unseen left hand to induce incorporation of the rubber hand into their body. After the experimental modification of body ownership, acupuncture needle stimulation was applied to the LI4 acupoint on the incorporated rubber hand while brain activity was measured with functional magnetic resonance imaging (fMRI). When the rubber hand was fully incorporated with the real body, acupuncture stimulation to the rubber hand resulted in the experience of the DeQi sensation as well as brain activations in the dorsolateral prefrontal cortex (DLPFC), insula, secondary somatosensory cortex (SII), and medial temporal (MT) visual area. The insular activation was associated with the DeQi sensation from the rubber hand. The psychophysical and neurophysiological responses associated with acupuncture stimulation to the incorporated rubber hand were influenced by an enhanced bodily awareness of the hand, which was likely due to top-down modulation from the interoceptive system in the brain.

Different effects of transcutaneous electric nerve stimulation and electroacupuncture at ST36-ST37 on the cerebral cortex

BACKGROUND

The effects of transcutaneous electric nerve stimulation (TENS) and electroacupuncture (EA) on the cerebral cortex are largely unclear. The purpose of the present study was to investigate the effect of TENS and EA on the cerebral cortex by examining their effect on the median nerve-somatosensory evoked potentials (MN-SEPs).

METHODS

Twenty volunteers were studied. The cortical and cervical spinal potentials were recorded by median nerve stimulation at the left wrist. Sham TENS, 2 Hz TENS and 2 Hz EA were applied to both ST36 and ST37. MN-SEPs were recorded during sham TENS, 2 Hz TENS and 2 Hz EA, with at least 1 week interval for each subject. One-way analysis of variance was used to determine the differences in latency and amplitude of the MN-SEPs observed in the stimulation and post-stimulation periods compared with baseline. Scheffe's post hoc correction was employed to identify pairwise differences.

RESULTS

No differences in mean latency were found between the stimulation procedures during the stimulation and post-stimulation periods. 2 Hz EA but not sham TENS or 2 Hz TENS caused higher mean amplitudes in N20 and N30 during the stimulation and post-stimulation periods.

CONCLUSIONS

EA, but not TENS, induces changes in certain components of the signal.

Acupuncture may exert its therapeutic effect through microRNA-339/Sirt2/NFκB/FOXO1 axis

Recently, we have found that a number of microRNAs (miRNAs) and proteins are involved in the response to acupuncture therapy in hypertensive rats. Our bioinformatics study suggests an association between these miRNAs and proteins, which include miR-339 and sirtuin 2 (Sirt2). In this paper, we aimed to investigate whether Sirt2 was a direct target of miR-339 in neurons. In human SH-SY5Y cells, the luciferase assay implied that Sirt2 was likely a target of miRNA-339. Overexpression of miR-339 downregulated Sirt2 expression, while knockdown of miR-339 upregulated Sirt2 expression in human SH-SY5Y cells and rat PC12 cells. In addition, overexpression of miR-399 increased the acetylation of nuclear factor-κB (NF-κB) and forkhead box protein O1 (FOXO1) in SH-SY5Y cells, which are known targets of Sirt2. Our findings demonstrate that miR-339 regulates Sirt2 in human and rat neurons. Since Sirt2 plays a critical role in multiple important cellular functions, our data imply that acupuncture may act through epigenetic changes and subsequent action on their targets, such as miRNA-339/Sirt2/NF-κB/FOXO1 axis. Some physiological level changes of neurons after altering the miR-339 levels are needed to validate the suggested therapeutic role of miR-339/Sirt2/NF-κB/FOXO1 axis in response to acupuncture therapy in the future work.

Overview of the Relevant Literature on the Possible Role of Acupuncture in Treating Male Sexual Dysfunction

Objective

To systematically review scientific reports on the effectiveness of acupuncture to treat male sexual dysfunction.

Methods

The Medline database was searched for published clinical trials of acupuncture for erectile dysfunction (ED) and premature ejaculation (PE) with English abstracts. Risk of bias was assessed for randomised controlled trials (RCTs).

Results

Seven studies on two conditions of male sexual dysfunction met the inclusion criteria. Three out of four RCTs were patient-blinded, but all had a high risk of bias. Three suggested that acupuncture has a therapeutic effect as compared with sham acupuncture. Comparisons with paroxetine were inconsistent. Other uncontrolled studies and case series suggested satisfactory improvements of ED and PE after acupuncture.

Conclusions

Acupuncture appears to have promise for treating male sexual dysfunction, but in view of the small number of studies and their variable quality, doubts remain about its effectiveness. Further studies are justified.

Acupuncture for Pediatric Pain

Chronic pain is a growing problem in children, with prevalence as high as 30.8%. Acupuncture has been found to be useful in many chronic pain conditions, and may be of clinical value in a multidisciplinary treatment program. The basic principles of acupuncture are reviewed, as well as studies exploring basic mechanisms of acupuncture and clinical efficacy. Conditions commonly treated in the pediatric pain clinic, including headache, abdominal pain, fibromyalgia, juvenile arthritis, complex regional pain syndrome, cancer pain, as well as perioperative pain studies are reviewed and discussed. Areas in need of further research are identified, and procedural aspects of acupuncture practice and safety studies are reviewed. Acupuncture can be an effective adjuvant in the care of pediatric patients with painful conditions, both in a chronic and an acute setting. Further studies, including randomized controlled trials, as well as trials of comparative effectiveness are needed.

The meridian system and mechanism of acupuncture: a comparative review. Part 3: Mechanisms of acupuncture therapies

The human body is a hierarchical organism containing many levels of mutually interacting oscillatory systems. From the viewpoint of traditional Chinese medicine, health is a state of harmony emergent from the interactions of these systems and disease is a state of discord. Hence, human diseases are considered as disturbed functions rather than changed structures. Indeed, the change from normal to abnormal structure may be beneficent rather than maleficent. For example, when one kidney becomes twice the normal size following the destruction of the other kidney, it is good and not bad for us because we might be dead otherwise. Therefore, in Part 3 of this three-part series, emphasis is mainly laid on the acupuncture mechanisms of treating disturbed physiological functions rather than disordered structures. At first, the basic tenets of conventional neuroscience and cardiology are reevaluated so that clear understanding of how nervous and cardiovascular systems work together can be obtained. Then, the general principles of diagnosis and treatment in traditional Chinese medicine from the integrative perspective of complex dynamic systems are proposed. Finally, mechanisms of acupuncture therapies for treating 14 different categories of disorders will be elucidated via the magneto-electric inductive effects of the meridian system.

Acupuncture and women's health: an overview of the role of acupuncture and its clinical management in women's reproductive health

BACKGROUND

Acupuncture and other modalities of Chinese/East Asian medicine have been used to treat women's health for many centuries. Gynecology specialties focus particularly on menstrual and reproductive disorders. Both the adoption of the use of acupuncture outside Asia, and the incorporation of scientific analysis in Asia have challenged biomedical conceptions of what can be achieved with this treatment method. The scale of research activity in relation to acupuncture and women's health has increased over the last 20 years.

OBJECTIVE

This review aims to explore the research evidence in relation to acupuncture use for women's reproductive disorders, focusing on both clinical findings and experimental research on acupuncture's mechanisms of action in relation to women's health.

METHODS

A narrative literature search was undertaken using searches of electronic databases and manual searches of journals and textbooks. The search included all literature published prior to June 2013. The literature was assessed as to the nature of the study it was reporting and findings synthesized into a commentary.

RESULTS

For acupuncture's mechanism of action the search resulted in 114 relevant documents; in relation to clinical reports on the use of acupuncture for women's health 204 documents were found and assessed.

CONCLUSION

There is preliminary data indicating acupuncture may improve menstrual health and coping for women experiencing delays falling pregnant. There is experimental data showing that acupuncture can influence female reproductive functioning, although the actual mechanisms involved are not yet clarified. Further well-conducted clinical research would benefit our understanding of the usefulness of acupuncture to women's health.

Acupuncture and standard emergency department care for pain and/or nausea and its impact on emergency care delivery: a feasibility study

OBJECTIVE

To evaluate the feasibility of delivering acupuncture in an emergency department (ED) to patients presenting with pain and/or nausea.

METHODS

A feasibility study (with historical controls) undertaken at the Northern Hospital ED in Melbourne, Australia, involving people presenting to ED triage with pain (VAS 0-10) and/or nausea (Morrow Index 1-6) between January and August 2010 (n=400). The acupuncture group comprised 200 patients who received usual medical care and acupuncture; the usual care group comprised 200 patients with retrospective data closely matched from ED electronic health records.

RESULTS

Refusal rate was 31%, with 'symptoms under control owing to medical treatment before acupuncture' the most prevalent reason for refusal (n=36); 52.5% of participants responded 'definitely yes' for their willingness to repeat acupuncture, and a further 31.8% responded 'probably yes'. Over half (57%) reported a satisfaction score of 10 for acupuncture treatment. Musculoskeletal conditions were the most common conditions treated n=117 (58.5%), followed by abdominal or flank pain n=49 (24.5%). Adverse events were rare (2%) and mild. Pain and nausea scores reduced from a mean±SD of 7.01±2.02 before acupuncture to 4.72±2.62 after acupuncture and from 2.6±2.19 to 1.42±1.86, respectively.

CONCLUSIONS

Acupuncture in the ED appears safe and acceptable for patients with pain and/or nausea. Results suggest combined care may provide effective pain and nausea relief in ED patients. Further high-quality, sufficiently powered randomised studies evaluating the cost-effectiveness and efficacy of the add-on effect of acupuncture are recommended.

A systematic review and meta-analysis of Baihui (GV20)-based scalp acupuncture in experimental ischemic stroke

Acupuncture for stroke has been used in China for over 2,000 years and nowadays is increasingly practiced elsewhere in the world. However, previous studies had conflicting findings on the results of acupuncture. Here, we conducted a systematic review and meta-analysis to assess the current evidence for the effect of Baihui (GV20)-based scalp acupuncture in animal models of focal cerebral ischemia. Six databases from the inception of each database up to June 2013 were electronically searched. Primary outcomes were infarct size and neurobehavioral outcome. Ultimately, 54 studies involving 1816 animals were identified describing procedures. Meta-analysis results showed that twelve studies reported significant effects of Baihui (GV20)-based scalp acupuncture for improving infarct volume compared with middle cerebral artery occlusion group (P < 0.01), and thirty-two studies reported significant effects of Baihui (GV20)-based scalp acupuncture for improving the neurological function score when compared with the control group (P < 0.01). In conclusion, Baihui (GV20)-based scalp acupuncture could improve infarct volume and neurological function score and exert potential neuroprotective role in experimental ischemic stroke.

Acupuncture

Worldwide, acupuncture is integral to everyday medical practice. In recent decades its practice has gained popularity in the United States. With increasing evidence of its clinical efficacy, acupuncture is now a widely practiced treatment modality in complementary and integrative medicine. According to the 2007 National Health Interview Survey, an estimated 3.1 million US adults and 150,000 children had acupuncture in the previous year. The National Health Interview Survey also estimated that between 2002 and 2007, acupuncture use among adults increased by approximately 1 million people. Patients want more information from their clinicians about the use of acupuncture and its safety and efficacy. Although many clinicians may recommend acupuncture, they often believe they are not sufficiently informed to discuss acupuncture with their patients. This article provides answers to the most frequently asked questions regarding acupuncture.

Traditional acupuncture triggers a local increase in adenosine in human subjects

Acupuncture is a form of Eastern medicine that has been practiced for centuries. Despite its long history and worldwide application, the biological mechanisms of acupuncture in relieving pain have been poorly defined. Recent studies in mice, however, demonstrate that acupuncture triggers increases in interstitial adenosine, which reduces the severity of chronic pain through adenosine A1 receptors, suggesting that adenosine-mediated antinociception contributes to the clinical benefits of acupuncture. We asked here whether acupuncture in human subjects is also linked to a local increase in interstitial adenosine concentration. We collected microdialysis samples of interstitial fluid before, during, and after delivering 30 minutes of conventional acupuncture in the Zusanli point in human subjects. The interstitial adenosine concentration increased significantly during acupuncture and remained elevated for 30 minutes after the acupuncture. Acupuncture-mediated adenosine release was not observed if acupuncture was not delivered in the Zusanli point or if the acupuncture needle was inserted, but not rotated. This study strengthens the role of adenosine in acupuncture-mediated antinociception by directly providing such evidence in humans.

PERSPECTIVE

This article presents further evidence of the role of adenosine in acupuncture-mediated antinociception by demonstrating that local adenosine concentrations increase in the acupoint in human subjects receiving traditional acupuncture.

The meridian system and mechanism of acupuncture-a comparative review. Part 1: the meridian system

In traditional Chinese medicine (TCM), acupuncture has been used to heal various diseases and physiologic malfunctions in clinical practice for more than 2500 years. Due to its efficacy, acupuncture has been recommended by the World Health Organization in 1980 as an effective alternative therapy for 43 different disorders. Over the past few decades, various theories of the meridian system and mechanisms have been proposed to explain how acupuncture might work. Most of these mechanisms, however, cannot yet explain conclusively why acupuncture is efficacious in treating so many different diseases. A plausible mechanism has been unavailable until recently. This is the first of a three-part series that aims to provide a comparative review of the aforementioned topics. Part 1 reviews the current indications for acupuncture, basic concepts of TCM, and the essence of the meridian system. To establish a mathematically rigorous framework of TCM, the chaotic wave theory of fractal continuum is proposed. This theory is then applied to characterize the essence of the meridian system. Parts 2 and 3 will review the possible mechanisms of acupuncture analgesia and acupuncture therapies, respectively, based on biochemical, bioelectromagnetic, chaotic wave, and neurophysiologic approaches. It is sincerely hoped that this series of review articles can promote an understanding of the meridian system and acupuncture mechanisms to help patients in a logical and passionate way.

Sympathetic Nervous System Responses to Acupuncture and Non-Penetrating Sham Acupuncture in Experimental Forearm Pain: A Single-Blind Randomised Descriptive Study

Objective

To quantify the sympathetic nervous system response to acupuncture and non-penetrating sham acupuncture in volunteers with pain.

Methods

A single-blind, randomised controlled study of 36 healthy adults with no recent participation in forearm strengthening or occupations involving repeated forceful wrist motion was carried out. A fatiguing wrist extension exercise protocol was completed to induce delayed onset muscle soreness. Group 1 received no treatment, group 2 a single session of acupuncture and group 3 a single session of sham acupuncture. Outcomes included skin conductance, skin temperature and perfusion measured for 20 min before treatment, during the 15 min treatment and for 10 min after treatment.

Results

The acupuncture group showed a significant increase from baseline in ipsilateral perfusion (135%) and bilateral skin conductance (144 and 146%) and a significant decrease from baseline in bilateral distal skin temperature (98%). The acupuncture and sham acupuncture groups showed decreased ipsilateral proximal skin temperature.

Conclusions

Acupuncture appears to activate the sympathetic nervous system, indicated by a bilateral increase in skin conductance and a bilateral decrease in distal skin temperature after needle insertion. The unilateral increase in perfusion near the needle site seen with acupuncture treatment may be due to local circulatory, rather than systemic, control.

Laser acupuncture for depression: a randomised double blind controlled trial using low intensity laser intervention

INTRODUCTION

Trials of acupuncture for the treatment of depression have produced mixed results. We examined the effectiveness of laser acupuncture compared with placebo acupuncture for the treatment of major depression.

METHODS

A randomised, double blinded, placebo controlled trial was conducted in Sydney, Australia. Participants aged 18-50 years with DSM-IV major depressive disorder were eligible to join the study. Forty-seven participants were randomised to receive laser acupuncture or placebo laser at acupoints LR14, CV14, LR8, HT7 and KI3. The intervention was administered twice a week for 4 weeks and once a week for another four weeks, for a total of 12 sessions. The primary outcome assessed the change in severity of depression using the Hamilton-Depression Rating Scale (HAM-D), and secondary outcomes assessed the change in severity of depression using the Quick Inventory for Depression-Self Reporting (QID-SR), the Quick Inventory for Depression-Clinician (QIDS-CL), with outcomes assessed at eight weeks. The treatment response (greater than 50% improvement in HAM-D) and remission (HAM-D<8) were analysed.

RESULTS

At eight weeks participants showed greater improvement in the active laser group on the primary and clinician-rated secondary outcome measures (HAM-D (mean 9.28 (SD 6.55) vs. mean 14.14 (SD 4.78 p<0.001); QIDS-CL (mean 8.12 (SD 6.61 versus 12.68 (mean SD 3.77)) p<0.001). The self-report QIDS-SR scores improved in both groups but did not differ significantly between the groups. In the active laser group, QIDS-SR scores remained significantly lower than baseline at 3 months follow-up. Response rates (active laser, placebo laser) on ITT (intention to treat) analyses were 72.0% and 18.2% (p<0.001), respectively. Remission rates on ITT analyses (active laser, placebo laser) were 56.0% and 4.5% (p<0.001). Transient fatigue was the only adverse effect reported.

LIMITATIONS

There was no follow-up for the placebo group at one and 3 months.

CONCLUSION

Laser acupuncture showed a clinically and statistically significant benefit with reducing symptoms of depression on objective measures.

Acupuncture for the treatment of hot flashes in patients with breast cancer receiving antiestrogen therapy: a pilot study in Korean women

OBJECTIVES

Antiestrogen therapy can cause vasomotor symptoms similar to those occurring during menopause, including hot flashes. Recent studies suggest that acupuncture is effective in reducing vasomotor symptoms in patients with breast cancer receiving tamoxifen. The purpose of this study was to assess the feasibility and safety of acupuncture for treatment of hot flashes in Korean patients with breast cancer receiving antiestrogen therapy.

DESIGN

This was a prospective single-arm observational study using before and after measurements.

SETTINGS/LOCATION

The study was located at the East-West Medical Center at Daegu Catholic University Medical Center, Daegu, Korea.

SUBJECTS

The subjects were 10 patients with breast cancer who were undergoing antiestrogen therapy with tamoxifen or anastrozole and who were suffering from hot flashes.

INTERVENTIONS

Acupuncture was administered 3 times a week for 4 consecutive weeks, for 20±5 minutes at each session.

OUTCOME MEASURES

The outcome measure was severity of hot flashes assessed by visual analogue scale (VAS) and total hot flash score.

RESULTS

During treatment, severity of hot flashes was reduced by 70%-95% in all patients. Acupuncture significantly alleviated severity of hot flashes assessed by a visual analogue scale (F=30.261; p<0.001) as well as the total hot flash score (F=21.698; p=0.006). Four (4) weeks after the final treatment, symptoms were not aggravated.

CONCLUSIONS

Acupuncture appeared to provide effective relief from hot flashes among Korean women receiving antiestrogen therapy after surgery for breast cancer, and the effects lasted for at least 1 month after termination of treatment. A randomized controlled prospective study with a larger sample size is required to clarify the role of acupuncture in the management of hot flashes in Korean patients with breast cancer.

Patch clamp: a powerful technique for studying the mechanism of acupuncture

Cellular and molecular events can be investigated using electrophysiological techniques. In particular, the patch-clamp method provides detailed information. In addition, the patch-clamp technique has become a powerful method for investigating the mechanisms underlying the effects of acupuncture. In this paper, recent researches on how acupuncture might modulate electrophysiological responses in the central nervous system (CNS) and affect peripheral structures are reviewed.

Fluid flow along venous adventitia in rabbits: is it a potential drainage system complementary to vascular circulations?

Background

Our previous research and other studies with radiotracers showed evidence of a centripetal drainage pathway, separate from blood or lymphatic vessels, that can be visualized when a small amount of low molecular weight tracer is injected subcutaneously into a given region on skin of humans. In order to further characterize this interesting biological phenomenon, animal experiments are designed to elucidate histological and physiologic characteristics of these visualized pathways.

Methods

Multiple tracers are injected subcutaneously into an acupuncture point of KI3 to visualize centripetal pathways by magnetic resonance imaging or fluorescein photography in 85 healthy rabbits. The pathways are compared with venography and indirect lymphangiography. Fluid flow through the pathways is observed by methods of altering their hydrated state, hydrolyzing by different collagenases, and histology is elucidated by optical, fluorescein and electron microscopy.

Results

Histological and magnetic imaging examinations of these visualized pathways show they consist of perivenous loose connective tissues. As evidenced by examinations of tracers’ uptake, they appear to function as a draining pathway for free interstitial fluid. Fluorescein sodium from KI3 is found in the pathways of hind limbs and segments of the small intestines, partial pulmonary veins and results in pericardial effusion, suggesting systematical involvement of this perivenous pathway. The hydraulic conductivity of these pathways can be compromised by the collapse of their fiber-rich beds hydrolyzed by either of collagenase type I, III, IV or V.

Conclusions

The identification of pathways comprising perivenous loose connective tissues with a high hydraulic conductivity draining interstitial fluid in hind limbs of a mammal suggests a potential drainage system complementary to vascular circulations. These findings may provide new insights into a systematically distributed collagenous connective tissue with a circulatory function and their potential relevance to the nature of acupuncture meridians.

The effectiveness of acupuncture in the treatment of Gulf War Illness

INTRODUCTION

It can be challenging to study complex and novel health states within the parameters of a RCT. This report describes the use of an unblinded Phase II Clinical Trial design to investigate the effectiveness of acupuncture in the treatment of Gulf War Illness (GWI). GWI is a complex illness found among veterans of the first Gulf War, and is characterized by multiple symptoms, including fatigue, sleep and mood disturbances, cognitive dysfunction, and musculoskeletal pain. No published trials of acupuncture for the treatment of GWI exist. This trial is designed to both answer questions of the effectiveness of acupuncture for our entire sample, as well as subgroups with of individual presentations of GWI.

MATERIALS AND METHODS

Our primary outcome is quality of life as measured by the SF-36. In an effort to better understand this complex disease and its treatment, our multi-level measurement plan examines psychosocial variables, fatigue, sleep quality, pain, and biomarkers of inflammation and immune status. All of the measurement instruments used in this trial show good validity and reliability.

RESULTS

This study is ongoing and clinical results are not available. We have achieved good feasibility of our recruitment, treatment, and data collection procedures.

CONCLUSIONS

Low constraint RCT designs are an appropriate choice when investigating conditions in which the causes and mechanisms of disease are poorly understood. This naturalistic RCT includes individualized protocols, a clinically supported length and dose of treatment, a wait list control arm, and the ethical benefit that all subjects receive treatment during the study.

Acupuncture for treatment of autism spectrum disorders

Background. There has been lack of reviews of evidence on efficacy, methodology, and/or safety of acupuncture in autism spectrum disorders. This paper examines the emerging evidence of the effects of acupuncture in the treatment of autistic children. Method. A literature review was completed via Medline and three Chinese search engines. A total of 31 studies were evaluated for acupuncture methodology, study design, treatment effects, and tolerability. Results. The acupoints used, the duration of needling, the frequency of treatment, the choice of stimulation, and the course of the treatment were highly variable amongst the studies. Behavioral and/or developmental improvements were reported in all acupuncture treatment studies. All studies reported general tolerability. Weakness of experimental designs was discussed. Conclusions. Vigorously controlled double-blinded clinical trials are needed to evaluate the efficacy and safety of acupuncture in children with autism spectrum disorders.

Acupuncture for polycystic ovarian syndrome

BACKGROUND

Polycystic ovarian syndrome (PCOS) is characterised by the clinical signs of oligo-amenorrhoea (infrequent or very light menstruation), infertility (failure to conceive), and hirsutism (excessive hair growth). Whilst Aleem 1987 revealed the presence of beta-endorphin in the follicular fluid of both normal and polycystic ovaries, Petraglia 1987 demonstrated that the beta-endorphin levels in ovarian follicular fluid of otherwise healthy women who were undergoing ovulation were much higher than the levels measured in plasma. Given that acupuncture has an impact on beta-endorphin production, which may affect gonadotropin-releasing hormone (GnRH) secretion, it is postulated that acupuncture may have a role in ovulation induction and fertility.

OBJECTIVES

To assess the efficacy and safety of acupuncture treatment for women with polycystic ovarian syndrome (PCOS).

SEARCH STRATEGY

Relevant studies were identified from the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE® In-Process and other non-indexed citations, Ovid MEDLINE® Daily and Ovid MEDLINE(R), EMBASE, PsycINFO, AMED, Chinese National Knowledge Infrastructure (CNKI) (including the Chinese journal full-text database (CJFD)), Chinese BioMedical Literature Database (CBM), VIP database for Chinese Technical Periodicals, China's important Conference Papers Database, and the China dissertation database.

SELECTION CRITERIA

Truly randomised controlled trials (RCTs) that studied the efficacy of acupuncture treatment for infertility in women with PCOS. We excluded quasi- or pseudo-RCTs.

DATA COLLECTION AND ANALYSIS

We aimed to extract data independently by three authors using a piloted data extraction form. Data on study characteristics including methods, participants, interventions, and outcomes would be extracted. Crossover trials were not included unless there were first-phase data provided. Non-randomised controlled studies have been excluded.

MAIN RESULTS

No truly randomised controlled trials of acupuncture for PCOS were found .

AUTHORS' CONCLUSIONS

The current conventional medical treatments for women with PCOS are prescription medications, surgery, and lifestyle changes. Associated problems with current western therapies are the cost, risk of multiple pregnancies, undesirable side effects, and inconsistent effectiveness. Non-randomised acupuncture studies in PCOS have suggested a low associated adverse events rate, no increased risk of multiple pregnancies, and that it is inexpensive. However, there no RCTs have been performed in this area thus far. Therefore, properly designed RCTs are required before a conclusive statement can be drawn to support the use of acupuncture in the management of PCOS.

Acupuncture ameliorated skeletal muscle atrophy induced by hindlimb suspension in mice

Preventing skeletal muscle atrophy is critical for maintaining quality of life, but it is often a challenging goal for the elderly and patients with severe conditions. We hypothesized that acupuncture in place of exercise training is an alternative non-pharmacological intervention that can help to prevent muscle atrophy. To elucidate the effects of acupuncture on skeletal muscle atrophy caused by hindlimb suspension (HS), we performed acupuncture on mice according to two different methods: acupuncture with electrical stimulation (EA: electroacupuncture) and without electrical stimulation (MA: manual acupuncture). A needle was retained in the gastrocnemius muscle for 30 min every day for 2 weeks in the EA and MA groups. In the EA group, 30 min of repetitive electrical stimulation (1 Hz, 1 ms pulse width, 6.5 mA intensity) was also applied. HS significantly reduced muscle mass and the cross-sectional area of the soleus muscles. This HS-induced reduction was significantly improved in the EA group, although the level of improvement remained insufficient when compared with the control group. We found that the mRNA expression levels of atrogin-1 and MuRF1, which play a principal role in muscle-specific degradation as E3 ubiquitin ligases, were significantly increased in the HS group compared to the control group. EA and MA reduced the HS-induced upregulation of atrogin-1 (p<0.01 in EA and MA) and MuRF1 (p<0.01 in EA) mRNAs. We also found that the expression levels of PI3K, Akt1, TRPV4, adenosine A1 receptor, myostatin, and SIRT1 mRNAs tended to be increased by HS. EA and MA further increased the HS-induced upregulation of Akt1 (p<0.05 in MA) and TRPV4 (p<0.05 in MA) mRNAs. We concluded that acupuncture partially prevented skeletal muscle atrophy. This effect might be due to an increase in protein synthesis and a decrease in protein degradation.

Evidence-based medicine in practice

Evidence-based medicine (EBM) has emerged as a dominant paradigm in healthcare, strongly influencing clinical decision-making, access to and funding for interventions. However, EBM has a number of limitations, which appear to have been under-represented in the literature. We explore the development and shortcomings of EBM, and consider a complementary role for practice-based evidence in guiding clinical decision-making. EBM is a valuable and important part of the medical landscape. However, a range of significant limitations makes over-reliance on this paradigm problematic. Appropriate recognition of practice-based evidence helps to bridge the gap between evidence and clinical practices.

Acupuncture in primary care

Acupuncture, an ancient traditional Chinese medical therapy, is used widely around the world. When practiced by a certified provider, it is safe and patients often find it calming and relaxing. Animal and human studies have found a physiologic basis for acupuncture needling in that it affects the complex central and peripheral neurohormonal network. Although it is unclear whether acupuncture is beneficial over sham/placebo acupuncture, acupuncture care yields clinically relevant short- and long-term benefits for low back pain, knee osteoarthritis, chronic neck pain, and headache. The integration of acupuncture into a primary care setting also appears to be cost-effective. The practice of acupuncture in primary care requires rigorous training, financial discipline, and good communication skills. When done correctly, acupuncture is beneficial for both patients and providers.

Stimulation of acupoint ST-34 acutely improves gait performance in geriatric patients during rehabilitation: A randomized controlled trial

OBJECTIVE

To determine whether a specific regimen of acupoint stimulation improved gait performance in geriatric patients.

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.

MAIN OUTCOME MEASURES

Descriptive parameters were documented by valid, established tests. Gait performance was objectively measured by an electronic walkway before needling and after needling.

RESULTS

All gait parameters showed statistically significant improvement after verum treatment compared with control treatment (velocity, cadence, stride length, cycle time, step time, single support, double support: P values all <.05) except for the base of support (P=.163). Effect sizes achieved by 1-time stimulation of an acupoint were low and ranged from .08 to .24. No severe adverse clinical events related to the intervention occurred.

CONCLUSIONS

Study results showed that a 1-time administration of a specific acupoint stimulation regimen statistically significantly improved gait performance during geriatric ward rehabilitation. If sustainability of effects can be documented, acupuncture may prove to be an inexpensive intervention that may mildly improve motor performance in frail geriatric patients.

Biophysical modulations of functional connectivity

Resting-state low frequency oscillations have been detected in many functional magnetic resonance imaging (MRI) studies and appear to be synchronized between functionally related areas. Converging evidence from MRI and other imaging modalities suggest that this activity has an intrinsic neuronal origin. Multiple consistent networks have been found in large populations, and have been shown to be stable over time. Further, these patterns of functional connectivity have been shown to be altered in healthy controls under various physiological challenges. This review will present the biophysical characterization of functional connectivity, and examine the effects of physical state manipulations (such as anesthesia, fatigue, and aging) in healthy controls.

How large are the nonspecific effects of acupuncture? A meta-analysis of randomized controlled trials

BACKGROUND

While several recent large randomized trials found clinically relevant effects of acupuncture over no treatment or routine care, blinded trials comparing acupuncture to sham interventions often reported only minor or no differences. This raises the question whether (sham) acupuncture is associated with particularly potent nonspecific effects. We aimed to investigate the size of nonspecific effects associated with acupuncture interventions.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials and reference lists were searched up to April 2010 to identify randomized trials of acupuncture for any condition, including both sham and no acupuncture control groups. Data were extracted by one reviewer and verified by a second. Pooled standardized mean differences were calculated using a random effects model with the inverse variance method.

RESULTS

Thirty-seven trials with a total of 5754 patients met the inclusion criteria. The included studies varied strongly regarding patients, interventions, outcome measures, methodological quality and effect sizes reported. Among the 32 trials reporting a continuous outcome measure, the random effects standardized mean difference between sham acupuncture and no acupuncture groups was -0.45 (95% confidence interval, -0.57, -0.34; I2 = 54%; Egger's test for funnel plot asymmetry, P = 0.25). Trials with larger effects of sham over no acupuncture reported smaller effects of acupuncture over sham intervention than trials with smaller nonspecific effects (β = -0.39, P = 0.029).

CONCLUSIONS

Sham acupuncture interventions are often associated with moderately large nonspecific effects which could make it difficult to detect small additional specific effects. Compared to inert placebo interventions, effects associated with sham acupuncture might be larger, which would have considerable implications for the design and interpretation of clinical trials.

Paradoxes in acupuncture research: strategies for moving forward

In November 2007, the Society for Acupuncture Research (SAR) held an international symposium to mark the 10th anniversary of the 1997 NIH Consensus Development Conference on Acupuncture. The symposium presentations revealed the considerable maturation of the field of acupuncture research, yet two provocative paradoxes emerged. First, a number of well-designed clinical trials have reported that true acupuncture is superior to usual care, but does not significantly outperform sham acupuncture, findings apparently at odds with traditional theories regarding acupuncture point specificity. Second, although many studies using animal and human experimental models have reported physiological effects that vary as a function of needling parameters (e.g., mode of stimulation) the extent to which these parameters influence therapeutic outcomes in clinical trials is unclear. This White Paper, collaboratively written by the SAR Board of Directors, identifies gaps in knowledge underlying the paradoxes and proposes strategies for their resolution through translational research. We recommend that acupuncture treatments should be studied (1) “top down” as multi-component “whole-system” interventions and (2) “bottom up” as mechanistic studies that focus on understanding how individual treatment components interact and translate into clinical and physiological outcomes. Such a strategy, incorporating considerations of efficacy, effectiveness and qualitative measures, will strengthen the evidence base for such complex interventions as acupuncture.

Current evidence of acupuncture on polycystic ovarian syndrome

OBJECTIVE

This paper aims to provide a literature review on evaluating the efficacy of acupuncture therapy in the treatment of polycystic ovarian syndrome (PCOS) by reviewing clinical trials; randomised and non-randomised and observational studies on PCOS. The paper will also determine the possible mechanism of acupuncture treatment in PCOS, limitations of recruited studies and suggest further improvements in future studies.

DESIGN

A comprehensive literature search was conducted through the databases Medline, PubMed, EMBASE, Cochrane, AMED (Allied and Complementary Medicine), NCCAM (The National Centre for Complementary and Alternative Medicine) to identify relevant monographs.

RESULTS

Four studies were recruited. Several studies showed that acupuncture significantly increases beta-endorphin levels for periods up to 24 h and may have regulatory effect on FSH, LH and androgen. beta-endorphin increased levels secondary to acupuncture affects the hyperthalamic-pituitary-adrenal (HPA) axis through promoting the release of ACTH through stimulation of its precursor pro-opiomelanocortin synthesis.

INCLUSION CRITERIA

All available acupuncture studies on human subjects with PCOS from June 1970 to June 2009.

EXCLUSION CRITERIA

Studies not meeting the inclusion criteria, published in languages other than English or animal studies.

CONCLUSION

Acupuncture is a safe and effective treatment to PCOS as the adverse effects of pharmacologic interventions are not expected by women with PCOS. Acupuncture therapy may have a role in PCOS by: increasing of blood flow to the ovaries, reducing of ovarian volume and the number of ovarian cysts, controlling hyperglycaemia through increasing insulin sensitivity and decreasing blood glucose and insulin levels, reducing cortisol levels and assisting in weight loss and anorexia. However, well-designed, randomised controlled trials are needed to elucidate the true effect of acupuncture on PCOS.

Moxibustion for cancer care: a systematic review and meta-analysis

Background

Moxibustion is a traditional Chinese method that uses the heat generated by burning herbal preparations containing Artemisia vulgaris to stimulate acupuncture points. Considering moxibustion is closely related to acupuncture, it seems pertinent to evaluate the effectiveness of moxibustion as a treatment of symptoms of cancer. The objective of this review was to systematically assess the effectiveness of moxibustion for supportive cancer care.

Methods

We searched the literature using 11 databases from their inceptions to February 2010, without language restrictions. We included randomised clinical trials (RCTs) in which moxibustion was employed as an adjuvant treatment for conventional medicine in patients with any type of cancer. The selection of studies, data extraction, and validations were performed independently by two reviewers.

Results

Five RCTs compared the effects of moxibustion with conventional therapy. Four RCTs failed to show favourable effects of moxibustion for response rate compared with chemotherapy (n = 229, RR, 1.04, 95% CI 0.94 to 1.15, P = 0.43). Two RCTs assessed the occurrence of side effects of chemotherapy and showed favourable effects of moxibustion. A meta-analysis showed significant less frequency of nausea and vomiting from chemotherapy for moxibustion group (n = 80, RR, 0.38, 95% CIs 0.22 to 0.65, P = 0.0005, heterogeneity: χ² = 0.18, P = 0.67, I² = 0%).

Conclusion

The evidence is limited to suggest moxibustion is an effective supportive cancer care in nausea and vomiting. However, all studies have a high risk of bias so effectively there is not enough evidence to draw any conclusion. Further research is required to investigate whether there are specific benefits of moxibustion for supportive cancer care.