Methodological investigations for a multisite trial of auricular acupuncture for cocaine addiction: a study of active and control auricular zones

Are Auricular Maps Reliable for Chronic Musculoskeletal Pain Disorders?: A Double-Blind Evaluation

Aim

To examine the proposed somatotopic relation between the regions in which patients report musculoskeletal pain and tender points located on the external ears according to a map based on commonly used auricular acupuncture maps.

Methods

Twenty-five patients (16 women) from a chronic pain clinic were included. Patients were asked, before examination of the external ears, if they had past or present musculoskeletal pain in any of 11 body regions. An ear map, collapsed into 11 zones representing the musculoskeletal system, was used. The ear examiner was blinded to the patients’ pain conditions, medical history and ongoing treatment. Patients communicated with the examiner only to express if tenderness was present in the external ear on palpation using a spring-loaded pressure stylus commonly used for auricular acupuncture. The degree of tenderness was registered on a 5-point scale and dichotomised (no tenderness or tenderness). Agreements between the patients’ painful body regions and tenderness in the external ear zones were presented as percentage, kappa values, sensitivity and specificity.

Results

The 25 patients reported 116 past or present musculoskeletal pain regions and had 110 tender ear zones. No statistically significant agreements were found between the painful body regions and the corresponding tender ear zones.

Conclusions

Our results did not show agreements between patients’ reported musculoskeletal pain regions and tender zones in the external ears assessed according to commonly used maps in auricular acupuncture using a pressure stylus. However, very tender points occur on the external ear in a population with chronic musculoskeletal pain.

The History, Mechanism, and Clinical Application of Auricular Therapy in Traditional Chinese Medicine

Auricular therapy includes acupuncture, electroacupuncture, acupressure, lasering, cauterization, moxibustion, and bloodletting in the auricle. For 2500 years, people have employed auricular therapy for treating diseases, but the methods have been limited to bloodletting and cauterization. Only after 1957, the international scientific community became aware that the map of the ear resembles an inverted fetus, its introduction has led to auricular acupuncture (AA) becoming a more systemic approach, and, following the identification and standardization of more precise points, AA has been employed in clinical applications. The mechanisms of AA are considered to have a close relationship with the autonomic nervous system, the neuroendocrine system, neuroimmunological factors, neuroinflammation, and neural reflex, as well as antioxidation. Auricular therapy has been applied, for example, for pain relief, for the treatment of epilepsy, anxiety, and obesity, and for improving sleep quality. However, the mechanisms and evidence for auricular therapy warrant further study.

Altered Impedance of Ear Acupuncture Point MT2 in Breast Cancer Patients: A Preliminary Observation

Skin impedance at acupuncture points (APs) has been used as a diagnostic aid for more than 50 years. In this study, we have a diagnostic tool (JXT-2008) to measure the skin impedance of ear APs of 30 breast cancer patients and the corresponding skin impedance of ear APs of 30 healthy humans, and then we compared these changes in ear AP impedance in breast cancer patients and healthy individuals.

Is commercially available point finder accurate and reliable in detecting active auricular acupuncture points?

OBJECTIVES

This study was done to determine the specificity and sensitivity of a commercial Pointer Plus (Point finder) in detecting a region of low skin resistance on the ear.

DESIGN

This was a prospective blinded study.

SETTING/LOCATION

The study was done at the Yale New Haven Hospital, New Haven, CT.

SUBJECTS

The subjects were men and women who work at Yale New Haven Hospital.

INTERVENTIONS

There were no interventions.

OUTCOME MEASURES

Correlations were made between self-reported musculoskeletal pain and the detection of low skin resistance on the ear.

RESULTS

The positive predictive value for Pointer Plus detecting low skin resistance correlating to the neck region of French auricular map is 0.76 (76%). The positive predictive value for Pointer Plus to detect low skin resistance area correlating to the low back region of French auricular map is 0.25. The positive predictive value for Pointer Plus in detecting any low in skin resistance on the external auricles in patients who complained of more than two musculoskeletal pains is 0.29.

CONCLUSIONS

The specificity and sensitivity of a commercial Pointer Plus (point finder) in detecting a region of low skin resistance on the ear being unreliable, depending on the correlating area based on a published auricular map. Additional assessments are needed to support the clinical practice.

Clinical Utility of Electrodermal Activity at Acupuncture Points: A Narrative Review

Objectives

To provide an in-depth analysis of seven well-reported studies that examined electrodermal activity (EDA) at acupuncture points with regard to three commonly held tenets of acupuncture: (1) EDA at pathology-related acupuncture points is distinguishable from non-pathology-related acupuncture points; (2) EDA at acupuncture points can assist in diagnosing and monitoring therapeutic progress; and (3) EDA at acupuncture points is able to identify substances that are either therapeutically beneficial or toxic to an individual.

Methods

Seven of 29 studies that scored >50% on their quality of reporting 54 essential technical and clinical details of EDA testing in human patients were identified from a previous literature review. Fourteen categories of data were extracted from these seven studies for further discussion.

Results

Two studies compared EDA at pathology-related auricular acupuncture points to non-pathology-related sites. Two studies correlated EDA measurements at sites other than auricular acupuncture points with the presence of specific medical conditions. The final three studies assessed changes in EDA at acupuncture points on the fingers and toes when different substances were placed in the electrical circuit with the patient.

Conclusions

This review highlights the heterogeneity of approaches to EDA assessments and the discrepancies between common clinical practice and the scientific evidence to support that practice. It also provides pilot data that suggest EDA testing at auricular acupuncture points may distinguish pathology-related acupuncture points from non-pathology-related points; decreased skin conductance correlates with tiredness or low energy; and EDA testing at the Jing-Well acupuncture points, on the tips of the fingers and toes, may assist in monitoring effectiveness of acupuncture treatment. The evidence does not support the use of VEGA testing for allergic status.

Electrodermal activity at acupoints: literature review and recommendations for reporting clinical trials

Electrodermal activity (EDA) at acupuncture points (acupoints) has been investigated for its utility as a diagnostic aid, a therapeutic monitoring tool, and a physiological outcome measure. The research methodologies reported in published trials, however, vary considerably and publications often lack sufficient details about electrical instrumentation, technical procedures, laboratory conditions, recorded measures, and control comparisons to permit a critical appraisal of the studies or to replicate promising findings. We developed a 10-category (54 subitems) Quality of Reporting scale based on technical issues associated with EDA measurements, publication requirements for reporting EDA in the psychophysiological literature, and recommendations from the CONSORT Statement for reporting clinical trials. Using our Quality of Reporting scale, we extracted data from 29 studies that evaluated EDA at acupoints in patients and generated weighted scores for each of the 10 categories of essential information. Only 9 of the 29 studies reviewed scored a mean of greater than 50% for reporting details of essential information. To rigorously build a program of research on EDA at acupoints we need to standardize research methodology and reporting protocols. We propose a checklist of recommended informational items to report in future clinical trials that record EDA at acupoints.

Investigation of specificity of auricular acupuncture points in regulation of autonomic function in anesthetized rats

Auricular acupuncture has been used for various autonomic disorders in clinical practice. It has been theorized that different auricular areas have distinct influence on autonomic functions. The present study aims to examine the effects of acupuncture stimulation at different auricular areas on cardiovascular and gastric responses. In male Sprague-Dawley rats anesthetized with pentobarbital sodium, five auricular areas, which were located at the apex of the helix (A(1)), the middle of the helix (A(2)), the tail of the helix (A(3)), the inferior concha (A(4)) and the middle of the antihelix (A(5)), had been selected for stimulation with manual acupuncture (MA) and different parameters of electroacupuncture (EA). A mild depressor response (6%-12% decrease from baseline) was evoked from A(1), A(3) and A(4) by MA and from all five areas by EA (100 Hz-1 mA). The biggest depressor response (-18.4+/-3.1 mmHg, p<0.001) was evoked from A(4). A small bradycardia was evoked by MA from A(4) and by EA at A(3), A(4) and A(5.) Increase in intragastric pressure (8-14 mmH(2)O) was evoked by MA from A(1), A(3) and A(4) and by EA at A(2.) These results show that similar patterns of cardiovascular and gastric responses could be evoked by stimulation of different areas of the auricle. The present results do not support the theory of a highly specific functional map in the ear. Rather, there is a similar pattern of autonomic changes in response to auricular acupuncture, with variable intensity depending on the area of stimulation.

A randomized controlled clinical trial of auricular acupuncture in smoking cessation

BACKGROUND

Tobacco smoking is responsible for human diseases of the lung, heart, circulatory system and various kinds of cancers, and is a serious public health problem worldwide. Acupuncture has been promoted as a treatment modality for smoking cessation. However, its efficacy still remains controversial.

METHODS

We conducted a prospective, randomized, controlled trial using auricular acupuncture for smoking cessation in 131 adults who wanted to stop smoking. Thirteen subjects withdrew from the study and 118 subjects were included in the final analyses (mean age, 53.7 +/- 16.8 years; 100 males, 18 females). The treatment group (n = 59) received auricular acupuncture in Shen Men, Sympathetic, Mouth and Lung points for 8 weeks. The control group (n = 59) received sham acupuncture in non-smoking-cessation-related auricular acupoints (Knee, Elbow, Shoulder and Eye points). The enrolled subjects were then followed monthly for 6 months after stopping the acupuncture treatment.

RESULTS

Between both groups before acupuncture treatment, there was no significant difference with regard to gender, mean age, education level, and mean values for the age at which smoking started, smoking duration, daily number of cigarettes smoked and nicotine dependent score. At the end of treatment, cigarette consumption had significantly decreased in both groups, but only the treatment group showed a significant decrease in the nicotine withdrawal symptom score. Smoking cessation rate showed no significant difference between the treatment group (27.1%) and the control group (20.3%) at the end of treatment. There was also no significant difference in the smoking cessation rate between the treatment group (16.6%) and the control group (12.1%) at the end of follow-up. There were no major side effects of auricular acupuncture in both groups.

CONCLUSION

Our results showed that auricular acupuncture did not have a better efficacy in smoking cessation compared to sham acupuncture. Combined acupuncture with behavior counseling or with nicotine replacement therapy should be used in further smoking cessation trials to enhance the success rate of smoking cessation.

Electrical skin impedance at acupuncture points

OBJECTIVES

To test whether electrical skin impedance at each of three acupuncture points (APs) is significantly lower than at nearby sites on the meridian (MP) and off the meridian (NP).

DESIGN

Two instruments - Prognos (MedPrevent GmbH, Waldershof, Germany), a constant-current (DC) device, and PT Probe (designed for this study), a 100-Hz sinusoidal-current (AC) device-were used to record electrical impedance at three APs (right Gallbladder 14, right Pericardium 8, and left Triple Energizer 1), and two control sites for each AP. Each AP, MP, and NP was measured four times in random order with each device.

SETTING

The study was conducted over a period of 4 days at the Oregon College of Oriental Medicine (OCOM).

SUBJECTS

Twenty (20) healthy adults (14 women and 6 men), all recruited from the OCOM student body and faculty, participated in the study.

RESULTS

The Prognos measurements had an intraclass correlation (ICC) = 0.84 and coefficient of variation (CV) = 0.43. The PT Probe had ICC = 0.81 and CV = 0.31. Impedance values at APs were not significantly less than at MPs or NPs. Impedance values at MPs were also not significantly less than NPs, although their individual p values were <0.05 in 4 of 6 cases. There was a significant trend of increasing impedance with repeated measurements with both the Prognos (p =0.003) and the PT Probe (p= 0.003).

CONCLUSIONS

Within the reliability limits of our study methods, none of the three APs tested has lower skin impedance than at either of the nearby control points. These results are not consistent with previous studies that detected lower skin impedance at APs than nearby sites. Further study is necessary to determine whether MPs have lower skin impedance than nearby NPs. Our study suggests caution is warranted when developing, using, and interpreting results from electrodermal screening devices. Further studies are needed to clarify the clinically important and controversial hypothesis that APs are sites of lower impedance.

Skin impedance measurements for acupuncture research: development of a continuous recording system

Skin impedance at acupuncture points (APs) has been used as a diagnostic/therapeutic aid for more than 50 years. Currently, researchers are evaluating the electrophysiologic properties of APs as a possible means of understanding acupuncture's mechanism. To comprehensively assess the diagnostic, therapeutic and mechanistic implications of acupuncture point skin impedance, a device capable of reliably recording impedances from 100 kΩ to 50 MΩ at multiple APs over extended time periods is needed. This article describes design considerations, development and testing of a single channel skin impedance system (hardware, control software and customized electrodes). The system was tested for accuracy against known resistors and capacitors. Two electrodes (the AMI and the ORI) were compared for reliability of recording over 30 min. Two APs (LU 9 and PC 6) and a nearby non-AP site were measured simultaneously in four individuals for 60 min. Our measurement system performed accurately (within 5%) against known resistors (580 kΩ–10 MΩ) and capacitors (10 nF–150 nF). Both the AMI electrode and the modified ORI electrode recorded skin impedance reliably on the volar surface of the forearm (r = 0.87 and r = 0.79, respectively). In four of four volunteers tested, skin impedance at LU 9 was less than at the nearby non-AP site. In three of four volunteers skin impedance was less at PC 6 than at the nearby non-AP site. We conclude that our system is a suitable device upon which we can develop a fully automated multi-channel device capable of recording skin impedance at multiple APs simultaneously over 24 h.

Acupuncture treatment for opiate addiction: A systematic review

A review of the efficacy of acupuncture as treatment for opiate addiction, covering 33 years of reported literature in western scientific journals, was systematically undertaken. Some abstracts from Chinese language journals were also briefly reviewed. Supportive evidence often came from non-controlled nonblinded methodologies. When well-designed clinical trials (randomized, controlled, single-blind methodologies) were used, there was no significant evidence for acupuncture being a more effective treatment than controls. Some of the current supportive evidence for efficacy came from Chinese journals that have not been translated into English yet.

The physiological basis of reflexology and its use as a potential diagnostic tool

Ill-health changes the anatomy and physiology of affected organs, some of which can be observed visually, elicited through physical examination or confirmed through biomedical analysis. Understanding how anatomical changes contribute to physiological signs and symptoms will help practitioners identify the pathology, appreciate its origin and development and justify prescribed interventions in a way which can be upheld by critical external scrutiny. Reflexology contributes to an holistic approach to care and has recently improved its credibility as a discipline which supports orthodox care. Several research publications have identified possible theories and principles for the mechanism of action of reflexology, but more research to explain its contribution in identifying ill-health and diseases, as well as appropriate treatment modalities, is needed. This paper explores the physiological basis of reflexology, some of the theories for the mechanism of action and its potential as a diagnostic tool.

Efficacy of acupuncture for cocaine dependence: a systematic review & meta-analysis

: BACKGROUND: Acupuncture is a commonly used treatment option for the treatment of addictions such as alcohol, nicotine and drug dependence. We systematically reviewed and meta-analyzed the randomized controlled trials of acupuncture for the treatment of cocaine addiction. METHODS: Two reviewers independently searched 10 databases. Unpublished studies were sought using Clinicaltrials.gov, the UK National Research Register and contacting content experts. Eligible studies enrolled patients with the diagnosis of cocaine dependence of any duration or severity randomly allocated to either acupuncture or sham or other control. We excluded studies of acupuncture methods and trials enrolling patients with polysubstance use or dependence. We abstracted data on study methodology and outcomes. We pooled the studies providing biochemical confirmation of cocaine abstinence. RESULTS: Nine studies enrolling 1747 participants met inclusion criteria; 7 provided details for biochemical confirmation of cocaine abstinence. On average, trials lost 50% of enrolled participants (range 0-63%). The pooled odds ratio estimating the effect of acupuncture on cocaine abstinence at the last reported time-point was 0.76 (95% CI, 0.45 to 1.27, P = 0.30, I2 = 30%, Heterogeneity P = 0.19). CONCLUSION: This systematic review and meta-analysis does not support the use of acupuncture for the treatment of cocaine dependence. However, most trials were hampered by large loss to follow up and the strength of the inference is consequently weakened.

Auricular Acupuncture in the Treatment of Cocaine/Crack Abuse: A Review of the Efficacy, the Use of the National Acupuncture Detoxification Association Protocol, and the Selection of Sham Points

BACKGROUND

The United Kingdom has had a significant increase in addiction to and use of cocaine among 16-29-year olds from 6% in 1998 to 10% in 2000. In 2000, the United Kingdom had the highest recorded consumption of "recent use" cocaine in Europe, with 3.3% of young adults. Acupuncture is quick, inexpensive, and relatively safe, and may establish itself as an important addiction service in the future.

AIM

To select investigations that meet the inclusion criteria and critically appraise them in order to answer the question: "Is acupuncture effective in the treatment of cocaine addiction?" The focus shall then be directed toward the use of the National Acupuncture Detoxification Association (NADA) protocol as the intervention and the selection of sham points for the control group.

DATA SOURCES

The ARRC database was accessed from Trina Ward (M. Phil. student) at Thames Valley University. AMED, MEDLINE and Embase were also accessed along with "hand" searching methods at the British Library.

INCLUSION AND EXCLUSION CRITERIA

People addicted to either cocaine or crack cocaine as their main addiction, needle-acupuncture, single-double-blinded process, randomized subjects, a reference group incorporating a form of sham points.

EXCLUSION CRITERIA

use of moxibustion, laser acupuncture, transcutaneous electrical nerve stimulation (TENS) electroacupuncture or conditions that did not meet the inclusion criteria.

QUALITY ASSESSMENT

The criteria set by ter Riet, Kleijnen and Knipschild (in 1990); Hammerschlag and Morris (in 1990); Koes, Bouter and van der Heijden (in 1995), were modified into one set of criteria consisting of 27 different values.

RESULTS

Six randomized controlled trials (RCTs) met the inclusion criteria and were included in this review. All studies scored over 60 points indicating a relatively adequate methodology quality. The mean was 75 and the standard deviation was 6.80. A linear regression analysis did not yield a statistically significant association (n = 6, p = 0.11).

CONCLUSIONS

This review could not confirm that acupuncture was an effective treatment for cocaine abuse. The NADA protocol of five treatment points still offers the acupuncturist the best possible combination of acupuncture points based upon Traditional Chinese Medicine. Throughout all the clinical trials reviewed, no side-effects of acupuncture were noted. This paper calls for the full set of 5 treatment points as laid out by the NADA to be included as the treatment intervention. Points on the helix, other than the liver yang points, should be selected as sham points for the control group.

Reliability of the Prognos Electrodermal Device for Measurements of Electrical Skin Resistance at Acupuncture Points

OBJECTIVES

(1) To characterize and calibrate an electrodermal screening device, Prognos. (2) To replicate a previous test-retest reliability study of this device with measurements of electrical skin resistance (ESR) at 24 Jing-well acupuncture points (APs). (3) To determine measurement precision in three successively more exacting trial protocols on the same set of subjects.

SETTINGS

Oregon College of Oriental Medicine and Portland State University, Portland, OR.

INSTRUMENTS

The Prognos device was electrically characterized by a team of research engineers at the Biomedical Signal Processing Laboratory of Portland State University. They determined that Prognos measures the average direct-current (DC) resistance between a metallic wrist strap and an electrode probe tip. The probe tip is connected to a linear spring set to trigger with an optically generated signal at a deflection of 2.62 mm, which corresponds to an average applied force of 2.68 +/- 0.04 N (mean +/- standard deviation [SD], n = 6). They also determined that the device quantifies resistance by applying a 1.1 microA current for an average of 223 +/- 3 ms (n = 7). When calibrated against a series of known resistors, Prognos measures accurately in the range of 150 kOmega to 14.3 MOmega with an error of less than 0.4%.

SUBJECTS

Thirty-one (31) healthy volunteers, 17 females and 14 males, 23-63 years of age. RESULTS OF RELIABILITY TEST-RETEST: The mean reliability of a single measurement was; 0.758 for a standard measurement protocol of four sequential sweeps of 24 Jing-well (Ting) APs; 0.851 for four sequential sweeps after ink-marking the APs; and 0.961 for four rapid repeat measurements at each inked AP. Mean absolute values of ESR decreased between the standard and marked protocols, but not between the marked and rapid repeat protocols.

CONCLUSIONS

Prognos performs accurately, against known resistors over the reported range of ESR. The reliability in the standard protocol (r = 0.758) is comparable to the reliability of 0.721 demonstrated under similar conditions by other investigators. Marking APs, and performing measurements in a rapid sequence, increases reliability of ESR measurements. Increased reliability in the second and third protocols is associated with decreased mean ESR values which may be related to increased accuracy of Prognos probe placement and/or inking the APs.

Clinical Research on Acupuncture: Part 2. Controlled Clinical Trials, an Overview of Their Methods

There is almost universal agreement that the quality of clinical trials of acupuncture is poor. There is an urgent need to improve their quality. The author develops here a list of 45 criteria important in the design, implementation, and writing up of controlled clinical acupuncture trials. This list has been compiled after examining the quality assessment criteria used in meta-analyses and systematic reviews of acupuncture, general publications on clinical trial designs and methodological considerations specific to acupuncture trials. Each criterion is discussed with recommendations about use and implementation. Additionally, each criterion is discussed relative to their importance in three types of acupuncture trial, acupuncture versus sham acupuncture, acupuncture versus standard therapy and acupuncture versus no treatment or wait-list. It is hoped that this exploration and systematic presentation of the 45 criteria will contribute to improving the quality of clinical trials of acupuncture. Improved trial quality will lead to greater ease interpreting the results of trials, especially in systematic reviews.

Should cocaine-abusing, buprenorphine-maintained patients receive auricular acupuncture? Findings from an acute effects study

OBJECTIVE

Buprenophrine is a synthetic opioid with micro-agonist properties currently pending Food and Drug Administration (FDA) approval as a maintenance agent for treating heroin-addicted individuals. Unlike methadone, a widely used opioid maintenance agent, buprenorphine is a kappa-receptor antagonist. Research linking the effects of acupuncture to the release of dynorphin, the endogenous ligand for the kappa-receptor, raised the possibility that buprenorphine may block acupuncture's effects. In this study, we sought to gather preliminary data on this issue in order to guide the clinical care of cocaine-abusing, buprenorphine-maintained patients.

DESIGN

Between-group analysis comparing buprenorphine- and methadone-maintained patients on ratings of acute effects after a single session of auricular acupuncture.

SUBJECTS

Thirty-four (34) cocaine-abusing, opioid-dependent patients, eighteen (18) maintained on buprenorphine, and sixteen (16) maintained on methadone.

INTERVENTION

A single, 40-minute session of auricular acupuncture; four needles were inserted in each auricle.

OUTCOME MEASURES

Acute effect ratings in four domains: pain, de qi sensations, relaxation effects, subjective experiences.

RESULTS

There were no significant differences in acute-effects ratings between the two groups. Patients in both groups reported positive effects.

CONCLUSIONS

These preliminary findings are consistent with the interpretation that buprenorphine does not block auricular acupuncture, supporting the provisional recommendation that cocaine-abusing patients maintained on buprenorphine should not be excluded from receiving auricular acupuncture or from participating in clinical studies of this treatment modality. Further, controlled research on this issue, with clinical outcomes, is needed.