The status and future of acupuncture clinical research

Mitochondria as the Essence of Yang Qi in the Human Body

The concept of Yang Qi in Traditional Chinese Medicine (TCM) has many similarities with mitochondria in modern medicine. Both are indispensable to human beings and closely related to life and death. This article discusses the similarities in various aspects between mitochondria and Yang Qi, including body temperature, aging, newborns, circadian rhythm, immunity, and meridian. It is well-known that Yang Qi is vital for human health. Interestingly, decreased mitochondrial function is thought to be key to the development of various diseases. Here, we further explain diseases induced by Yang Qi deficiency, such as cancer, chronic fatigue syndrome, sleep disorder, senile dementia, and metabolic diseases, from the perspective of mitochondrial function. We aim to establish similarities and connections between two important concepts, and hope our essay can stimulate further discussion and investigation on unifying important concepts in western medicine and alternative medicine, especially TCM, and provide unique holistic insights into understanding human health.

Skin Temperature of Acupoints in Health and Disease: A Systematic Review

Introduction: Despite substantial progress made in the field of acupuncture research, the existence and specificity of acupoints remain controversial. In recent years, the concept of acupoint sensitization has emerged as a theoretical framework for understanding acupoints as dynamic functional entities that are sensitized in pathological conditions. Based on this premise, some have claimed that specific acupoints are thermally distinct between healthy and clinical populations, but no systematic review has been conducted to synthesize and evaluate the quality of studies supporting such claims. In this review, we provide a summary and quality assessment of the existing literature addressing the question of whether changes in skin temperature at specific acupoints are indicative of pathological conditions. Methods: A systematic literature search was performed in PubMed, EMBASE, and AltHealthWatch (EBSCO Host), by combining variations of search terms relevant to acupoints and temperature. The search was limited to the English language, and publication dates ranged from database inception to December 2020. Two authors independently screened all resulting abstracts and subsequently read full-text articles for eligibility. Information on study design, sample, acupoints, parameters of skin temperature assessments, and main findings were extracted from included studies. Quality of the thermal sensing methodology was evaluated using a thermal assessment checklist, adapted from the Thermographic Imaging in Sports and Exercise Medicine (TISEM) consensus checklist, and a modified Newcastle-Ottawa Scale (NOS) for case-control studies. Results: The search strategy yielded a total of 1771 studies, of which 10 articles met the eligibility criteria. Eight studies compared skin temperature at acupoints in healthy versus clinical populations, and two studies assessed within-subject changes in temperature of acupoints in relation to changes in health status. There were seven clinical conditions examined in the included studies: chronic bronchial asthma, chronic hepatitis, hyperplasia of mammary glands, infertility, intracranial hypertension, obesity, and primary dysmenorrhea. There were numerous methodological quality issues related to skin temperature measurements. Eight studies with case-control designs reported significant differences between healthy and clinical populations in temperature at certain acupoints. Two studies with pre-post designs reported that changes in health-disease status could be associated with changes in temperature at specific acupoints. Conclusion: A review of the available literature suggests that certain acupoints may be thermally distinct between healthy and unhealthy states. However, given the methodological limitations and heterogeneity across included studies, no definitive conclusion could be drawn as to whether changes in skin temperature at specific acupoints are indicative of pathological conditions.

Laser acupuncture versus oral glucose administration for pain prevention in term neonates: an observer-blinded non-inferiority randomized controlled clinical trial

BACKGROUND

Neonates undergoing intensive care are routinely submitted to minor painful procedures such as heel lances. Pharmacological treatment is limited in neonatal care and not recommended for minor painful interventions. Hence, non-pharmacological acute pain management is an important subject. Acupuncture could be a new strategy for neonatal pain prevention. Accordingly, the aim of the present study was to investigate whether laser acupuncture is non-inferior to oral sweet solutions in pain prevention.

METHODS

In total, 96 healthy term neonates were randomly assigned to receive either laser acupuncture with 10 mW at LI4 bilaterally (AG, acupuncture group) or 30% oral glucose solution (GG, glucose group) before heel lance for metabolic screening. The primary outcome was the difference in premature infant pain profile (PIPP) score between groups in a non-inferiority concept. Secondary outcomes were changes in heart rate and crying time.

RESULTS

Median (interquartile range) PIPP scores were comparable in the AG and GG (12 (10-14) vs 12 (9-14), p = 0.981). Nevertheless, the 95% confidence interval (CI) of location shift exceeded the predefined margin for non-inferiority of 1 (95% CI: -1.000006 to 1.000059). Heart rate was found to be significantly lower after intervention (p = 0.048) and after heel lance (p = 0.015) in the AG versus GG. There was no difference in crying time between groups (p = 0.890).

CONCLUSION

Laser acupuncture was not shown to be non-inferior to an oral glucose solution, possibly due to the higher than expected variability in PIPP scores within the studied groups. Future neonatal laser acupuncture studies for pain prevention with higher sample sizes are therefore warranted.

Role of the Medial Preoptic Area in Electroacupuncture Treatment of Reproductive Dysfunction in Ovariectomised Rats

Objective

To investigate the role of the medial preoptic area (MPOA) of the hypothalamus in electroacupuncture (EA) treatment of reproductive dysfunction in ovariectomised (OVX) rats and to examine the underlying mechanisms of action.

Methods

62 female Sprague-Dawley rats (200–220 g) underwent bilateral ovariectomy (OVX). Three weeks later, 32 rats assigned to experiment 1 were randomly divided into four groups: two groups underwent MPOA lesioning (n=16) followed by EA at CV4, CV3, SP6 and bilateral Zigong (30 min per day) for 3 days (OVX+MPOA+EA group, n=8) or no treatment (OVX+MPOA group, n=8); and two groups underwent sham (S) surgery (n=16) followed by EA (OVX+SMPOA+EA group, n=8) or no treatment (OVX+SMPOA group, n=8). Plasma oestradiol and luteinising hormone (LH) were measured by radioimmunoassay and mature vaginal epithelial cells stained and quantified post-treatment. 30 rats assigned to experiment 2 were randomised to receive EA (OVX+EA group, n=15) or remain untreated (OVX group, n=15), following which push-pull perfusion in combination with high pressure liquid chromatography/electrochemical (HPLC-EC) detection was used to measure neurotransmitter release in the MPOA.

Results

EA significantly increased the percentage of mature vaginal epithelial cells and plasma oestradiol levels in sham MPOA-lesioned rats compared with MPOA-lesioned OVX rats (p<0.05). In sham MPOA-lesioned OVX rats, EA significantly decreased plasma LH levels compared with no treatment (p<0.01). HPLC-EC results showed that γ-aminobutyric acid (GABA) and β-endorphin levels in the MPAO were significantly increased in OVX rats following EA (p<0.01).

Conclusions

The present study suggests that the MPOA plays a crucial role in EA treatment of abnormal reproductive function in OVX rats.

On Dermatomes, Meridians and Points: Results of a Quasiexperimental Study

Background

Traditional Chinese medicine (TCM) meridians and points run vertically, reflecting their function in the Zhang-Fu system (meridian pattern). However, the trunk's spinal nerves show a traverse orientation, or a ‘horizontal pattern’.

Objective

The aim of the present work was to evaluate, via a cognitive quasiexperiment, whether the clinical indications of the points on the trunk are associated with their meridian function or with their innervation and visceral–somatic connection.

Methods

The points in each dermatome of the trunk were considered crosswise, regardless of their meridians. The clinical indications for each point were differentiated into two mutually exclusive categories: (a) vertical distribution effect (VDE) or ‘meridian pattern’, when indications were quite different regarding the indications for the other points on the dermatome; and (b) transverse distribution effects (TDE) or ‘horizontal pattern’, represented by mainly local or segmental indications except for Shu-Mu points. After observing that the proportions between both categories often exceeded 60% in pilot samples, 60% was adopted as the reference value.

Results

A total of 22 dermatomes accommodated 148 points with 809 indications, of which 189 indications (23.4%) exhibited VDE features, whereas 620 (76.6%) exhibited TDE features.

Conclusions

A TDE/VDE ratio of 3 : 1 implies that the clinical indications for the points of any dermatome on the torso are similar, regardless of their meridians, and suggests that most of the indications for trunk points involve a ‘horizontal pattern’ due to their neurobiological nature. These findings may help in understanding acupuncture's neurobiology and clarify some confusing results of clinical research, for example, excluding sham acupuncture as an inert intervention for future clinical trials.

Laser Acupuncture at Large Intestine 4 Compared with Oral Glucose Administration for Pain Prevention in Healthy Term Neonates Undergoing Routine Heel Lance: Study Protocol for an Observer-Blinded, Randomised Controlled Clinical Trial

Background

Nonpharmacological strategies have actually become more important in neonatal pain management during routinely applied minor painful procedures. However, commonly used nonpharmacological strategies are inferior to orally administered sweet solutions. Therefore, we will compare laser acupuncture, as a recent nonpharmacological method, with the standard care of oral glucose solution for pain prevention.

Methods

Ninety-five healthy term neonates will be allocated into one of two groups. Before routine heel lance for metabolic screening, one group will receive laser acupuncture at acupuncture point Large Intestine 4 (LI 4) bilaterally for 60 seconds per point (acupuncture group) and the other will receive the standard care with orally administered glucose solution (glucose group). The complete procedure of blood sampling will be recorded on video, excluding the intervention before heel lance. A paediatric nurse, blinded with respect to the allocation, will evaluate these video recordings and determine the Premature Infant Pain Profile (PIPP) for each neonate. Primary outcome will be the mean difference in PIPP scores between groups.

Discussion

This observer-blinded randomised controlled trial has been designed to explore potential advantages of laser acupuncture in the management of neonatal pain because more data are required to provide information about its efficacy and safety.

Trial Registration

This trial is registered with DRKS00010122.

Acupuncture and Kinesio Taping for the acute management of Bell's palsy: A case report

BACKGROUND

Bell's palsy is an idiopathic, acute peripheral palsy of the facial nerve that supplies the muscles of facial expression. Despite an expected 70% full recovery rate, up to 30% of patients are left with potentially disfiguring facial weakness, involuntary movements, or persistent lacrimation. The most frequently used treatment options are corticosteroids and antiviral drugs. However, accompanying clinical conditions, such as uncontrolled diabetes, hypertension, gastrointestinal disturbances, polypharmacy of geriatric patients, and significant sequelae ratios, indicate the need for safe and effective complementary therapies that would enhance the success of the conventional interventions.

CASE SUMMARY

A 26-year-old female presented with numbness and earache on the left side of the face; these symptoms had been ongoing for 8-10h. Physical examination revealed peripheral facial paralysis of House-Brackmann grade III and corticosteroid-valacyclovir treatment was initiated. On the same day, Kinesio Taping was applied to the affected nerve and muscle area with the aim of primarily neurofacilitation and edema-pain relief. On the fifth day, acupuncture treatment was started and was continued for 3 consecutive days. A physical therapy program was administered for the subsequent 10days. At the 3-week follow-up examination, Bell's palsy was determined as grade I, and the treatment was stopped.

CONCLUSION

Acupuncture and Kinesio Taping, in conjunction with physical therapy modalities, are safe and promising complementary therapies for the acute management of Bell's palsy. However, further large scale and randomized controlled studies are necessary to assess whether these complementary interventions have significant additive or synergistic effect for complete recovery of patients with Bell's palsy.

Need for Registration and Reporting of Acupuncture Trials in Parkinson's Disease in Korea

Objective

Many people dealing with Parkinson’s disease (PD) turn to complementary and alternative medicine when searching for a cure or relief from symptoms. Acupuncture is widely used in the Korean PD population to alleviate symptoms and in hopes of curing the illness. However, acupuncture use for PD patients has only recently begun to be studied scientifically and is still considered an unproven treatment for PD. Therefore, there is an urgent need for acupuncture to be studied, validated and used for PD. Thus, our study’s aim is to examine how many acupuncture studies in PD are registered and reported in Korea.

Methods

The registries Clinicaltrials.gov and the Clinical Research Information Service (CRIS) and the search engine PubMed were searched to find relevant human clinical studies involving acupuncture therapy in PD patients. We examined the registration of trials, the posting and publication of results, and whether published articles were registered.

Results

In Clinicaltrials.gov, one completed trial was found with published results. In CRIS, one completed trial was found with published results. A total of 6 publications were found in our study: 2 articles were registered, but only 1 had the registered trial number listed in the article.

Conclusion

Acupuncture is popular among the PD population in Korea regardless of its unproven safety and efficacy. Despite the pressing need for clinical trials, the number of studies listed in the registries was small, and only a few publications were registered. More effort and rigor are needed to validate the efficacy and safety of acupuncture for PD.

Acupuncture point injection treatment of primary dysmenorrhoea: a randomised, double blind, controlled study

OBJECTIVE

To determine if injection of vitamin K3 in an acupuncture point is optimal for the treatment of primary dysmenorrhoea, when compared with 2 other injection treatments.

SETTING

A Menstrual Disorder Centre at a public hospital in Shanghai, China.

PARTICIPANTS

Chinese women aged 14-25 years with severe primary dysmenorrhoea for at least 6 months not relieved by any other treatment were recruited. Exclusion criteria were the use of oral contraceptives, intrauterine devices or anticoagulant drugs, pregnancy, history of abdominal surgery, participation in other therapies for pain and diagnosis of secondary dysmenorrhoea. Eighty patients with primary dysmenorrhoea, as defined on a 4-grade scale, completed the study. Two patients withdrew after randomisation.

INTERVENTIONS

A double-blind, double-dummy, randomised controlled trial compared vitamin K3 acupuncture point injection to saline acupuncture point injection and vitamin K3 deep muscle injection. Patients in each group received 3 injections at a single treatment visit.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the difference in subjective perception of pain as measured by an 11 unit Numeric Rating Scale (NRS). Secondary measurements were Cox Pain Intensity and Duration scales and the consumption of analgesic tablets before and after treatment and during 6 following cycles.

RESULTS

Patients in all 3 groups experienced pain relief from the injection treatments. Differences in NRS measured mean pain scores between the 2 active control groups were less than 1 unit (-0.71, CI -1.37 to -0.05) and not significant, but the differences in average scores between the treatment hypothesised to be optimal and both active control groups (1.11, CI 0.45 to 1.78) and (1.82, CI 1.45 to 2.49) were statistically significant in adjusted mixed-effects models. Menstrual distress and use of analgesics were diminished for 6 months post-treatment.

CONCLUSIONS

Acupuncture point injection of vitamin K3 relieves menstrual pain rapidly and is a useful treatment in an urban outpatient clinic.

TRIAL REGISTRATION NUMBER

NCT00104546; Results.

Reduced risk of stroke in patients with cardiac arrhythmia receiving traditional Chinese medicine: A nationwide matched retrospective cohort study

OBJECTIVE

Patients with cardiac arrhythmia were more likely to develop stroke than general population. The therapeutic effect of traditional Chinese medicine (TCM) on the risk of stroke in patients with cardiac arrhythmia was unknown. The aim of this study is to investigate the risk of stroke in patients with cardiac arrhythmia receiving TCM.

METHODS

From the one million cohort of the Taiwan's National Health Insurance Research Database, we identified cohort of cardiac arrhythmia included 2029 patients who received TCM treatment in 2000-2004. The matching methods with propensity score was used to select 2029 appropriate control cohort for comparison. Incident events of stroke were identified during the follow-up period at the end of 2010. Cox proportional hazard model was used to calculate adjusted hazard ratios and 95% confidence intervals of stroke associated with TCM treatment.

RESULTS

During the follow-up period, patients with cardiac arrhythmia who underwent TCM treatment (11.4 per 1000 person-years) had a lower incidence of new-onset stroke than those without TCM treatment (17.7 per 1000 person-years), with an HR of 0.62 (95% CI=0.50-0.78). The association between TCM treatment and decreased new-onset stroke was both significant in women and men. The young patients aged 45-54 years who received TCM had the lowest risk of stroke (HR=0.48, 95% CI=0.27-0.87).

CONCLUSIONS

Receiving TCM treatment was associated with a lower risk of stroke in patients with cardiac arrhythmia. However, this study was limited by lack of information regarding lifestyles, biochemical profiles, the dose of herbal medicine, and acupuncture points used in treatments.

Noninvasive and alternative management of chronic low back pain (efficacy and outcomes)

OBJECTIVES

The goal of this article is to provide a thorough literature review of available noninvasive and alternative treatment options for chronic low back pain. In particular, the efficacy of each therapy is evaluated and pertinent outcomes are described.

MATERIALS AND METHODS

A comprehensive search for available literature was done through PubMed and Cochrane data base for topics discussed in this paper.

RESULTS

Relevant current and past references were reviewed and presented to reflect the efficacy of each therapy and related outcomes.

CONCLUSIONS

There are a wide variety of noninvasive and alternative therapies for the treatment of chronic low back pain. Those with the strongest evidence in the literature for good efficacy and outcomes include exercise therapy with supervised physical therapy, multidisciplinary biopsychosocial rehabilitation, and acupuncture. Therapies with fair evidence or moderately supported by literature include yoga, back schools, thermal modalities, acupressure, and cognitive-behavioral therapy. Those therapies with poor evidence or little to no literature support include manipulation, transcutaneous electrical nerve stimulation, low-level laser therapy, reflexology, biofeedback, progressive relaxation, hypnosis, and aromatherapy. Providers delivering care for patients with chronic low back pain must carefully evaluate these available treatment options related to their efficacy or lack thereof as well as relevant outcomes.

Real world research: a complementary method to establish the effectiveness of acupuncture

Background

Acupuncture has been widely used in the management of a variety of diseases for thousands of years, and many relevant randomized controlled trials have been published. In recent years, many randomized controlled trials have provided controversial or less-than-convincing evidence that supports the efficacy of acupuncture. The clinical effectiveness of acupuncture in Western countries remains controversial.

Discussion

Acupuncture is a complex intervention involving needling components, specific non-needling components, and generic components. Common problems that have contributed to the equivocal findings in acupuncture randomized controlled trials were imperfections regarding acupuncture treatment and inappropriate placebo/sham controls. In addition, some inherent limitations were also present in the design and implementation of current acupuncture randomized controlled trials such as weak external validity. The current designs of randomized controlled trials of acupuncture need to be further developed. In contrast to examining efficacy and adverse reaction in a “sterilized” environment in a narrowly defined population, real world research assesses the effectiveness and safety of an intervention in a much wider population in real world practice. For this reason, real world research might be a feasible and meaningful method for acupuncture assessment.

Summary

Randomized controlled trials are important in verifying the efficacy of acupuncture treatment, but the authors believe that real world research, if designed and conducted appropriately, can complement randomized controlled trials to establish the effectiveness of acupuncture. Furthermore, the integrative model that can incorporate randomized controlled trial and real world research which can complement each other and potentially provide more objective and persuasive evidence.

An outbreak of Mycobacterium tuberculosis infection associated with acupuncture in a private clinic of Zhejiang Province, China, 2012

BACKGROUND

Acupuncture carries the potential risk of transmission of pathogenic microorganisms from the environment to the patient, and from one patient to another. An outbreak of tuberculosis at a private clinic in eastern China was investigated to identify the source of infection, mode of transmission, and risk factors for infection.

METHODS

A probable case was one who had the onset of unexplained pain, swelling, or abscess in the area of invasive treatment between January 1, 2011 and February 23, 2012. A confirmed case was a probable case with positive laboratory test results for Mycobacterium tuberculosis. Patient history and the frequency of invasive treatment were compared between 56 probable and confirmed cases and 98 controls in a case-control study.

RESULTS

Fifty-six of 2561 patients (2.2%) who had visited the clinic developed tuberculosis. The odds ratio (OR) of M. tuberculosis infection increased with the frequency of clinic visits (Chi-square for trend=28.943, p=0.000). Multivariate analysis showed that the frequency of acupuncture (Chi-square=24.258, adjusted p-value=0.000) and sharing acupuncture needles (Chi-square=8.936, adjusted p-value=0.003) were risk factors for M. tuberculosis infection. Thirty-two pus sample and nine sputum sample cultures were M. tuberculosis-positive.

CONCLUSIONS

This outbreak was caused by acupuncture and was transmitted through sharing acupuncture needles contaminated with M. tuberculosis.

Comparative literature study between investigations in foreign Science Citation Index journals and Chinese core domestic journals in the treatment of low back pain with acupuncture

OBJECTIVE

To investigate the quality and methods of clinical research literature published in foreign Science Citation Index (SCI) journals studying the treatment of low back pain with acupuncture. To conduct a comparative study with clinical research literature published in Chinese core domestic journals, and to understand the prospects of current research trends of acupuncture clinical studies in Western countries and China.

METHODS

Studies on clinical acupuncture treatment of low back pain in English SCI journals and four Chinese core domestic journals dated from 2002 to 2012 were sourced and summarized for this study. Objective analysis and evaluation on the differences in subject and scope of study on low back pain by foreign and Chinese researchers were conducted.

RESULTS

Forty-seven English studies and 115 Chinese studies met our inclusion criteria. A keyword search revealed different kinds of low back pain related conditions in English and Chinese studies. The English studies were broad in scope, while the Chinese studies were more focused. There were also differences in the understanding and definition of concepts and study orientation.

CONCLUSION

More study should be undertaken to understand the contradictions that acupuncture faces in view of modern research to further advance the field.

De qi, a threshold of the stimulus intensity, elicits the specific response of acupoints and intrinsic change of human brain to acupuncture

Objectives.   De qi is the subjective constellation of sensations perceived by the acupuncturists and patients as described in several literatures, but the absence of quantitative evaluation methods in de qi restricts the use of acupuncture treatment widely in the world. In the present study, we tried to investigate the intrinsic property of de qi is and how evaluate it quantitatively. Methods. 30 healthy adult volunteers were determined to investigate intrinsic changes in the human body after acupuncture with de qi. Results. Acupuncture treatment with de qi apparently increased acupoint blood flow, tissue displacement, and the amplitude of myoelectricity after de qi on acupoints. Furthermore, acupuncture treatment induced fMRI signal increase/decrease in different brain regions although no significant change in electroencephalography. Interpretation. The intrinsic change of the subjects representing the specific response of acupoints and human brain to acupuncture indicated that de qi might be evaluated quantitatively by those above aspects, which facilitated the confirmation in validity and propagation of this treatment modality widely in the world.

Effects of pretreatment with a combination of melatonin and electroacupuncture in a rat model of transient focal cerebral ischemia

Both melatonin and electroacupuncture (EA) have been suggested to be effective treatments against stroke. However, it is unknown whether a combination of these two therapies could be beneficial against transient focal cerebral ischemia. The present study investigated the effects of pretreatment of a combination of melatonin and EA in a rat model of transient middle cerebral artery occlusion (MCAO). After pretreatment of melatonin plus EA (MEA), transient MCAO was induced for 90 minutes in male Sprague-Dawley (SD) rats. The neurological deficit score, brain infarct volume, cerebral edema ratio, neuronal inflammation, and apoptosis were evaluated 24 hours after transient MCAO. The expression of related inflammatory and apoptotic mediators in the brain was also investigated. The results showed that MEA improved neurological outcome, reduced brain infarct volume, and inhibited neuronal inflammation as well as apoptosis 24 hours after transient MCAO. The beneficial effects may derive from downregulation of proinflammatory and proapoptotic mediators and upregulation of antiapoptotic mediators. Thus, these results suggest a preventive effect of pretreatment of MEA on transient focal cerebral ischemia.

Standardized versus Individualized Acupuncture for Chronic Low Back Pain: A Randomized Controlled Trial

We aimed to compare the effectiveness of standardized and individualized acupuncture treatment in patients with chronic low back pain. A single-center randomized controlled single-blind trial was performed in a general medical practice in Germany run by a Chinese-born medical doctor trained in western and Chinese medicine. One hundred and fifty outpatients with chronic low back pain were randomly allocated to two groups (78 standardized and 72 individualized acupuncture). Patients received either standardized acupuncture or individualized acupuncture. Treatment encompassed between 10 and 15 treatments based on individual symptoms with two treatments per week. The main outcome measure was the area under the curve (AUC) summarizing eight weeks of daily rated pain severity measured with a visual analogue scale (0 mm = no pain, 100 mm = worst imaginable pain). No significant differences between groups were observed for the AUC (individualized acupuncture mean: 1768.7 (95% CI, 1460.4; 2077.1); standardized acupuncture 1482.9 (1177.2; 1788.7); group difference, 285.8 (-33.9; 605.5) P = 0.080). In this single-center trial, individualized acupuncture was not superior to standardized acupuncture for patients suffering from chronic pain. As a next step, a multicenter noninferiority study should be performed to investigate whether standardised acupuncture treatment for chronic low back pain might be applicable in a broader usual care setting. This trial is registered with ClinicalTrials.gov NCT00758017.

Teaching Acupuncture to Medical Students: The Experience of Rio Preto Medical School (Famerp), Brazil

Complementary and alternative medicine, and in particular acupuncture, has been practised and taught in recent years in many universities in the Western world. Here, we relate our experiences since 1997 in teaching acupuncture to medical students at Rio Preto Medical School (Faculty of Medicine of São José do Rio Preto (FAMERP)), Brazil. Classes are given in the third and fifth years. The main goals of understanding the mechanisms of action and being able to recognise patients who may benefit from treatment and referring them have been well achieved, scoring 3.6 and 4.1, respectively, on a scale of 1–5. Also using that scale, medical students believe that acupuncture is important in the curriculum (4.6), course time is not sufficient (2.7) and they would like more information (4.6). To overcome these concerns, many students join an undergraduate study group (Acupuncture League) where they have more time to learn. We also describe the presence of foreign medical students who, since 2000, have enrolled in a course of 150 h in an exchange programme.

Acupuncture for Treating Anxiety and Depression in Women: A Clinical Systematic Review

BACKGROUND

Anxiety and depression are high in prevalence, especially in the female population, whose incidence is approximately double that of the male population. In addition, these conditions are difficult to treat and have high relapse rates and medication side-effects. There is evidence to suggest that acupuncture may be an effective treatment modality.

OBJECTIVE

The aim of this review is to summarize the existing evidence on acupuncture as a therapy for anxiety and depression in women and to present a novel method for assessing acupuncture trial quality.

METHODS

Published randomized controlled trials were included, whereby acupuncture was compared with any control procedure in subjects with anxiety and/or depression. Two authors extracted data independently. A novel acupuncture trial quality-assessment tool was developed to analyze the literature quality.

RESULTS

Six articles used the desired inclusion and exclusion criteria. The quality of research varied heavily. Five studies were properly randomized. Three were double-blinded. Three used individualized acupuncture. Four studies were of at least reasonable quality. One was of marginal quality, and one was of poor quality. There was a significant difference between acupuncture and at least one control in all six trials.

CONCLUSIONS

With respect to six reviewed studies, there is high-level evidence to support the use of acupuncture for treating major depressive disorder in pregnancy.

Acupuncture and Chinese herbs as treatments for depression: an Australian pilot study

AIMS

Aims were to determine the effectiveness of acupuncture and Chinese herbs as treatments for depression, and to assess beliefs, attitudes and treatment experience.

METHOD

Participants received acupuncture or acupuncture and Chinese herbs combined for five weeks. Acupuncture was given for 30 min twice a week and herbs taken three times a day. A Beliefs and Attitudes questionnaire was administered at baseline and Treatment Experience questionnaire post treatment. Outcome measure was improvement in depressive symptoms at the end of treatment period.

RESULTS

Nineteen participants completed 5 weeks of treatment, 12 in the acupuncture group and 7 in the combined group. Treatment significantly improved depressive symptoms, however, there were no differences between groups. At baseline, participants were positive about the perceived effectiveness of treatment, and treatment experiences were positive.

CONCLUSIONS

Acupuncture was effective in reducing depressive symptoms. However, herbs did not have an additional treatment effect. Beliefs and attitudes were positive.

Acupuncture for anxiety

This review aims to examine the volume and quality of the evidence base which supports the use of acupuncture in the treatment of anxiety disorders. A literature review was conducted using Pubmed, Google scholar, AMED, BMJ, Embase, Psychinfo, Cochrane library, Ingenta connect, and Cinahl databases. Keywords were "anxiety,""anxious,""panic,""stress,""phobia," and "acupuncture" limited to year 2000 onwards and English language where available. The quality of research examining the use of acupuncture in the treatment of anxiety disorders is extremely variable. There is enormous variety regarding points used, number of points used in a session, duration of sessions, frequency of treatment and duration of treatment programme. While the generally poor methodological quality, combined with the wide range of outcome measures used, number and variety of points, frequency of sessions, and duration of treatment makes firm conclusions difficult. Against this, the volume of literature, consistency of statistically significant results, wide range of conditions treated and use of animal test subjects suggests very real, positive outcomes using a treatment method preferred by a population of individuals who tend to be resistant to conventional medicine.

Neural acupuncture unit: a new concept for interpreting effects and mechanisms of acupuncture

When an acupuncture needle is inserted into a designated point on the body and mechanical or electrical stimulation is delivered, various neural and neuroactive components are activated. The collection of the activated neural and neuroactive components distributed in the skin, muscle, and connective tissues surrounding the inserted needle is defined as a neural acupuncture unit (NAU). The traditionally defined acupoints represent an anatomical landmark system that indicates local sites where NAUs may contain relatively dense and concentrated neural and neuroactive components, upon which acupuncture stimulation would elicit a more efficient therapeutic response. The NAU-based local mechanisms of biochemical and biophysical reactions play an important role in acupuncture-induced analgesia. Different properties of NAUs are associated with different components of needling sensation. There exist several central pathways to convey NAU-induced acupuncture signals, Electroacupuncture (EA) frequency-specific neurochemical effects are related to different peripheral and central pathways transmitting afferent signals from different frequency of NAU stimulation. More widespread and intense neuroimaging responses of brain regions to acupuncture may be a consequence of more efficient NAU stimulation modes. The introduction of the conception of NAU provides a new theoretical approach to interpreting effects and mechanisms of acupuncture in modern biomedical knowledge framework.

Local thermal therapy effects on menopausal symptoms and bone mineral density

OBJECTIVES

The aim of this study was to evaluate the effects of local thermal therapy with far-infrared rays (FIR) on menopausal symptoms and bone mineral density (BMD) in postmenopausal women.

SUBJECTS AND METHODS

A prospective randomized, controlled trial was conducted in female volunteers from communities in Northern Taiwan. The intervention group (n=22) received local thermal therapy with the help of FIR from an FIR emitter, for approximately 20 minutes per day, twice a week, for 20 sessions. They received the therapy on their backs while lying in a supine position. The control group (n=21) received no treatment. The primary outcome was the change in the Perceived Perimenopausal Disturbances Scale, designed for the measurement of menopause-related symptoms (MRS) before and after completion of treatment in a 10-week period. Secondary outcome parameters included serum levels of estradiol (E2) with osteocalcin (OC), and calcaneal BMD by quantitative ultrasound.

RESULTS

After 10 weeks of intervention, MRS determined by the scale decreased in mean total scores and mean scores for vasomotor, musculoskeletal, urologic, reproductive, and psychologic domains (p<0.05), except for reproductive (sexuality-related) symptoms. In the control group, mean total scores and scores of each domain had no significant difference between baseline and follow-up examination after 10 weeks. There was no significant difference between the quantitative ultrasound parameters in the calcaneus, serum E2, and OC levels either at the baseline or in the changes from the baseline between the intervention and control groups of women (p>0.05).

CONCLUSIONS

Local thermal therapy with FIR results in a significant reduction of MRS in postmenopausal women. Serum E2, OC levels, and calcaneal BMD showed no significant changes between the two groups. These results suggest that FIR local thermal therapy may be a potential alternative for the management of postmenopausal symptoms.

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.

Elevated estrogen receptor expression in hypothalamic preoptic area decreased by electroacupuncture in ovariectomized rats

In the present study, effects of electroacupuncture (EA) on estrogen receptor alpha (ERα) and beta (ERβ) mRNA and protein expression in the hypothalamus of ovariectomized (OVX) rats were detected by quantitative real-time reverse transcription PCR (qRT-PCR) and western blot analysis. Gonadotropin-releasing hormone (GnRH) release and GnRH mRNA level in hypothalamic preoptic area (POA) were evaluated by push-pull perfusion and qRT-PCR. Our results showed that elevated mRNA and protein expression of ERα and ERβ in hypothalamus were restrained following EA treatment in OVX rats. EA treatment also inhibited GnRH release and GnRH mRNA levels in OVX rats. These results provide novel evidence that EA treatment down regulates the expression of hypothalamic estrogen receptors (ERs), thus restores the response of GnRH neurons to estrogen depression, and partially resets the negative feedback of estrogen to hypothalamus-pituitary-ovary axis (HPOA) in OVX rats, which may be a critical mechanism for EA on female reproductive disorders.

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.

Effects of Sanyinjiao (SP6) with electroacupuncture on labour pain in women during labour

OBJECTIVE

To evaluate the effects of Sanyinjiao (SP6) with electroacupuncture on labour pain in women during the labour process.

METHODS

A total of 350 women in labour from three centres were randomly divided into the electroacupuncture group (acupuncture group), the sham electroacupuncture group (sham group) and the control group. Women in labour in the electroacupuncture group received the electroacupuncture on the point Sanyinjiao (SP6). The analgesic effect was self-rated by women in labour, using visual analogue scale (VAS). The duration and paralysis time of uterine contraction, uterine contraction regularity, degree of cervical extension, presentation of foetal descent, the condition of intra-partum haemorrhage and postpartum haemorrhage, labour manner, lochia, involution of uterus, milk secretion, neonate Apgar Score and neonate body height and weight were also measured. All data were analysed with Statistical Package for Social Sciences (SPSS) 12.0.

RESULTS

Labour pain scores from women in the acupuncture group were less than in the control group at needle retaining at 30min, 2 and 4h after needle withdrawal. Other evaluated indices did not show significant differences among the three groups. No adverse events were observed during the labour process.

CONCLUSION

SP6 with electroacupuncture could be an effective way for decreasing labour pain.

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.

Effects of moxibustion on dynorphin and endomorphin in rats with chronic visceral hyperalgesia

AIM: To observe the analgesic effects of moxibustion in rats with chronic visceral hyperalgesia and its influence on the concentration of dynorphin (Dyn) and endomorphin (EM) in spinal cord.

METHODS: The rat model of chronic visceral hyperalgesia was established by colorectal distention (CRD). In moxibustion (MX) group, moxibustion was applied once daily for 7 d; in sham moxibustion (SM) group, moxibustion was given to the same acupoints but with the non-smoldered end of the moxa stick. Model control (MC) group and normal control group were also studied. The scoring system of abdominal withdrawal reflex was used to evaluate visceral pain for behavioral assessment. Enzyme linked immunosorbent assay was performed to determine the concentrations of Dyn and EM in spinal cord.

RESULTS: Moxibustion significantly decreased visceral pain to CRD in this rat model, and no significant difference was detected between the SM group and the MC group. In MX group, moxibustion also increased the concentrations of Dyn and EM in spinal cord, and no significant difference was found between the SM group and the MC group.

CONCLUSION: Moxibustion therapy can significantly enhance the pain threshold of rats with chronic visceral hyperalgesia, and the effect may be closely related to the increased concentration of Dyn and EM in spinal cord.

Treatment of the adverse effects from acupuncture and their economic impact: a prospective study in 73,406 patients with low back or neck pain

The aim was to investigate the frequency of adverse effects due to acupuncture treatment, the need for treatment and the costs in patients with chronic low back or neck pain. This prospective observational study included patients who received acupuncture for chronic low back pain or chronic neck pain. After treatment all patients documented adverse events associated with acupuncture (defined as adverse effects) and provided details e.g. on treatment. Cost data was provided by the health insurance companies. We used a societal perspective including direct health care costs related to the acupuncture and the indirect costs caused through lost workdays. From 73,406 patients, 5440 patients (7.4% [95% CI 7.2%; 7.6%] reported experiencing at least one adverse effect and 1422 patients (1.9% [1.8%; 2.0%]) required treatment. The subsequent treatments reported were either self-treatment (1.2% [1.09%; 1.25%]), treatment with medication and/or by a physician (0.6% [0.57%; 0.68%]), or treatment in a hospital (0.03% [0.02%; 0.04%]). Patients reporting adverse effects that required treatment had higher costs compared to patients without adverse effects (at 3months €1265 [1179; 1351] vs. €1140 [1128; 1153] and at 12months € 3534 [3256; 3812] vs. € 3249 [3209; 3289]. The difference was caused through the expense of visiting physicians and higher indirect costs (difference at 3months: €125 [38; 211], p=0.005 and at 12months: €285 [4; 566], p=0.047). Adverse effects from acupuncture occur in about 7% of patients and were mainly treated by themselves. When these effects needed treatment by a health professional additional expenses were the consequence.

Acupuncture in Reproductive Medicine

Acupuncture is increasingly being used in reproductive medicine. This review summarizes the evidence of acupuncture in pain relief for oocyte retrieval, improving pregnancy outcomes of in vitro fertilization treatment, management of ovulation disorders, male subfertility, primary dysmenorrhea, endometriosis and menopausal symptoms. However, most of the studies are nonrandomized uncontrolled trials, case reports or case series. For randomized controlled trials, the sample size is underpowered and blinding of assessors is lacking. Different acupuncture protocols and controls are used. These heterogeneities make it difficult to compare studies and draw any firm conclusions. Further studies should also evaluate the cost-effectiveness of acupuncture and investigate the underlying mechanism of acupuncture treatment.

Interpretive bias in acupuncture research?: A case study

Acupuncture is one of the most widely used and broadly researched of the complementary and alternative therapies, but high-quality trials generally show no benefit over sham acupuncture. Many would view this result as evidence of ineffectiveness for this intervention. This discussion article focuses on the report of a large multicenter randomized controlled trial of acupuncture for chronic low-back pain (CLBP) in the lay and academic press, the ensuing discussion, and its impact on both clinical practice and service provision. The authors suggest that interpretive bias has affected reporting, leading to questionable conclusions and advocacy in favor of this form of care that may exceed the evidence. They also suggest that a lack of understanding of research into the placebo effect may have contributed to confusion in the interpretation of these trials.

Are acupoints specific for diseases? A systematic review of the randomized controlled trials with sham acupuncture controls

Background

The results of many clinical trials and experimental studies regarding acupoint specificity are contradictory. This review aims to investigate whether a difference in efficacy exists between ordinary acupuncture on specific acupoints and sham acupuncture controls on non-acupoints or on irrelevant acupoints.

Methods

Databases including Medline, Embase, AMED and Chinese Biomedical Database were searched to identify randomized controlled trials published between 1998 and 2009 that compared traditional body acupuncture on acupoints with sham acupuncture controls on irrelevant acupoints or non-acupoints with the same needling depth. The Cochrane Collaboration's tool for assessing risk of bias was employed to address the quality of the included trials.

Results

Twelve acupuncture clinical trials with sham acupuncture controls were identified and included in the review. The conditions treated varied. Half of the included trials had positive results on the primary outcomes and demonstrated acupoint specificity. However, among those six trials (total sample size: 985) with low risk of bias, five trials (sample size: 940) showed no statistically significant difference between proper and sham acupuncture treatments.

Conclusion

This review did not demonstrate the existence of acupoint specificity. Further clinical trials with larger sample sizes, optimal acupuncture treatment protocols and appropriate sham acupuncture controls are required to resolve this important issue.

The effect of acupuncture on oral microcirculation in healthy volunteers: an exploratory study

BACKGROUND

acupuncture is a therapeutic technique currently used in the treatment of many pathologies. The aim of this study is to evaluate the potential effect of acupuncture on "in vivo" variations in oral microcirculation in healthy subjects.

METHODS

an exploratory study was conducted on 40 healthy subjects: 20 cases (mean 55.90, SD 16.04) and 20 controls (mean 51, SD 11.91). Videocapillaroscopy was used to detect variations in oral microcirculation. This method permits an accurate and non-invasive in vivo study of the capillaries of the oral mucous. The site selected for this pilot study is the lower lip since it is the simplest to investigate and is more readily accessible. Assessments were carried out in three phases: t(0) before the application of the needles; t(1) one minute after the application; t(2) five minutes after the application; similar time points were used for the control group. Data were compared using the Mann-Whitney test.

RESULTS

the study showed characteristic changes in oral microcirculation induced by acupuncture. The tortuousness of capillary loops and in the diameter of the afferent loop changed significantly (p<0.05) over time in the acupuncture group but not in the controls.

CONCLUSIONS

the findings lend support to our expectation that acupuncture may generate significant variations in oral microcirculation in healthy adults. Further research is needed to confirm these findings and evaluate the therapeutic role of acupuncture in oral pathologies.

Brain encoding of acupuncture sensation--coupling on-line rating with fMRI

Acupuncture-induced sensations have historically been associated with clinical efficacy. These sensations are atypical, arising from sub-dermal receptors, and their neural encoding is not well known. In this fMRI study, subjects were stimulated at acupoint PC-6, while rating sensation with a custom-built, MR-compatible potentiometer. Separate runs included real (ACUP) and sham (SHAM) acupuncture, the latter characterized by non-insertive, cutaneous stimulation. FMRI data analysis was guided by the on-line rating timeseries, thereby localizing brain correlates of acupuncture sensation. Sensation ratings correlated with stimulation more (p<0.001) for SHAM (r=0.63) than for ACUP (r=0.32). ACUP induced stronger and more varied sensations with significant persistence into no-stimulation blocks, leading to more run-time spent rating low and moderate sensations compared to SHAM. ACUP sensation correlated with activation in regions associated with sensorimotor (SII, insula) and cognitive (dorsomedial prefrontal cortex (dmPFC)) processing, and deactivation in default-mode network (DMN) regions (posterior cingulate, precuneus). Compared to SHAM, ACUP yielded greater activity in both anterior and posterior dmPFC and dlPFC. In contrast, SHAM produced greater activation in sensorimotor (SI, SII, insula) and greater deactivation in DMN regions. Thus, brain encoding of ACUP sensation (more persistent and varied, leading to increased cognitive load) demonstrated greater activity in both cognitive/evaluative (posterior dmPFC) and emotional/interoceptive (anterior dmPFC) cortical regions. Increased cognitive load and dmPFC activity may be a salient component of acupuncture analgesia--sensations focus attention and accentuate bodily awareness, contributing to enhanced top-down modulation of any nociceptive afference and central pain networks. Hence, acupuncture may function as a somatosensory-guided mind-body therapy.