Acupuncture and bronchial asthma

Acupuncture in Patients with Allergic Asthma: A Randomized Pragmatic Trial

BACKGROUND

Although the available evidence is insufficient, acupuncture is used in patients suffering from chronic asthma. The aim of this pragmatic study was to investigate the effectiveness of acupuncture in addition to routine care in patients with allergic asthma compared to treatment with routine care alone.

METHODS

Patients with allergic asthma were included in a randomized controlled trial and randomized to receive up to 15 acupuncture sessions over 3 months or to a control group receiving routine care alone. Patients who did not consent to randomization received acupuncture treatment for the first 3 months and were followed as a cohort. All trial patients were allowed to receive routine care in addition to study treatment. The primary endpoint was the asthma quality of life questionnaire (AQLQ, range: 1-7) at 3 months. Secondary endpoints included general health related to quality of life (Short-Form-36, SF-36, range 0-100). Outcome parameters were assessed at baseline and at 3 and 6 months.

RESULTS

A total of 1,445 patients (mean age 43.8 [SD 13.5] years, 58.7% female) were randomized and included in the analysis (184 patients randomized to acupuncture and 173 to control, and 1,088 in the nonrandomized acupuncture group). In the randomized part, acupuncture was associated with an improvement in the AQLQ score compared to the control group (difference acupuncture vs. control group 0.7 [95% confidence interval (CI) 0.5-1.0]) as well as in the physical component scale and the mental component scale of the SF-36 (physical: 2.5 [1.0-4.0]; mental 4.0 [2.1-6.0]) after 3 months. Treatment success was maintained throughout 6 months. Patients not consenting to randomization showed similar improvements as the randomized acupuncture group.

CONCLUSIONS

In patients with allergic asthma, additional acupuncture treatment to routine care was associated with increased disease-specific and health-related quality of life compared to treatment with routine care alone.

The effectiveness of acupuncture compared to loratadine in patients allergic to house dust mites

Background. The aim of this work was to evaluate the clinical effectiveness of acupuncture and its impact on the immune system in comparison to loratadine in the treatment of persistent allergic rhinitis caused by house dust mites. Methods. In this study, 24 patients suffering from persistent allergic rhinitis induced by house dust mites were treated either with acupuncture (n = 15) or with loratadine (n = 9). The evaluation of the data was based on the subjective and the objective rhinoconjunctivitis symptom scores, specific and total IgE, and interleukins (IL-4, IL-10, and IFN- γ ) as markers for the activity of Th1 or Th2 cells. Results. The treatments with acupuncture as well as with loratadine were considered effective in the patients' subjective assessment, whereby the effect of the acupuncture tended to be assessed as more persistent after the end of treatment. A change in the specific or the total IgE was not detectable in either group. The interleukin profile showed the tendency of an increasing IL-10 value in the acupuncture group. The results of the study show that the effectiveness of acupuncture is comparable to that of loratadine. Conclusion. Acupuncture is a clinically effective form of therapy in the treatment of patients suffering from persistent allergic rhinitis. The results indicate the probability of an immunomodulatory effect.

Acupuncture in allergic rhinitis: A Mini-Review

Acupuncture is a therapy method known for millennia with apparently polygenetic roots. It is traditionally practiced in East Asian countries. During the recent fifty years, it has found wide applications in Europe as well. Today acupuncture is one of the most important parts of modern complementary medicine. Questions concerning the mechanism of action and efficacy of acupuncture, among others in the treatment of allergic rhinitis, still lead to many scientific discussions. This review summarizes the modern understanding of possible mechanisms of acupuncture as well as it presents the current state of clinical studies relating to the efficacy of acupuncture in the treatment of allergic rhinitis. Further investigations are necessary to confirm acupuncture as an effective therapy of allergic rhinitis.

Complementary/alternative medicines in allergic disease

Complementary/alternative medicines is a generic term that encompasses a variety of approaches, including homeopathy, acupuncture, phytotherapy and numerous holistic or behavioral techniques. Complementary/alternative medicines are widely used in a number of conditions, including asthma and rhinitis. The medical literature on complementary/alternative medicines is impressive, but there are few clinical studies conducted with an appropriate methodology, and their results are negative or conflicting. In general, the results are insufficient to provide recommendations for the use of complementary/alternative medicines in clinical practice. Regarding diagnostic techniques, none have demonstrated the capability of distinguishing between healthy and allergic subjects and none are able to identify sensitizations.

Self-administered acupressure reduces the symptoms that limit daily activities in bronchiectasis patients: pilot study findings

AIMS AND OBJECTIVES

To examine and compare the effects of acupressure on the perceived health-related quality of life of the participants with bronchiectasis.

BACKGROUND

In an attempt to offer comfort, pain control and symptom management, nursing is becoming increasingly involved in offering complementary-alternative medicine as part of its caring-healing focus in comprehensive patient care. Acupressure is one such modality that is being increasingly used by both medical and nursing professionals. While acupressure has been reported to have beneficial effects in patients with respiratory disease, the benefits to bronchiectasis patients have remained uncertain.

DESIGN

A randomized, partially blinded study consisting of three groups.

METHODS

Thirty-five out-patients of both genders, aged 59.46 SD 11.52 years, who were suffering from bronchiectasis, were randomly split into one of three groups: standard care with supplemental acupressure for eight weeks (11 participants); standard care with supplemental sham acupressure for eight weeks (11 participants); and standard care alone (13 participants). Outcomes were determined by changes in daily sputum amounts, sputum self-assessment, six-minute walking distance, breathing difficulty (measured on the dyspnea visual analogue scale) and health-related quality of life (measured by the Saint George Respiratory Questionnaire).

RESULTS

The sputum self-assessment score improved over time for the sham acupressure participants (P = 0.03), when compared with the controls. For acupressure participants, the Saint George respiratory questionnaire activity component scores also improved over time, compared with controls (P = 0.01) after adjustment for covariates (treatment, time, age, sex and baseline values). Other variables did not differ between the standard care alone group and the other two groups.

CONCLUSIONS

Eight weeks of self-administered acupressure could be useful in reducing the effects of bronchiectasis on a patient's daily activities.

RELEVANCE TO CLINICAL PRACTICE

Acupressure may be regarded as a viable nursing intervention.

ARIA update: I--Systematic review of complementary and alternative medicine for rhinitis and asthma

Complementary-alternative medicines are extensively used in the treatment of allergic rhinitis and asthma, but evidence-based recommendations are lacking. To provide evidence-based recommendations, the literature was searched by using MedLine and the Cochrane Library to March 2005 (Key words: Asthma [OR] Rhinitis, [AND] Complementary [OR] Alternative Medicine, [OR] Herbal, [OR] Acupuncture, [OR] Homeopathy, [OR] Alternative Treatment). Randomized trials, preferably double-blind and published in English, were selected. The articles were evaluated by a panel of experts. Quality of reporting was assessed by using the scale validated by Jadad. The methodology of clinical trials with complementary-alternative medicine was frequently inadequate. Meta-analyses provided no clear evidence for the efficacy of acupuncture in rhinitis and asthma. Some positive results were described with homeopathy in good-quality trials in rhinitis, but a number of negative studies were also found. Therefore it is not possible to provide evidence-based recommendations for homeopathy in the treatment of allergic rhinitis, and further trials are needed. A limited number of studies of herbal remedies showed some efficacy in rhinitis and asthma, but the studies were too few to make recommendations. There are also unresolved safety concerns. Therapeutic efficacy of complementary-alternative treatments for rhinitis and asthma is not supported by currently available evidence.

The effects of a single acupuncture treatment in horses with severe recurrent airway obstruction

REASONS FOR PERFORMING STUDY

Acupuncture may be recommended for horses with 'heaves' because it is being increasingly applied to treat human asthma. Therefore, its efficacy was investigated in horses with this asthma-like disease.

OBJECTIVE

To evaluate the efficacy of a single acupuncture treatment for the relief of airway obstruction in heaves-affected horses.

METHODS

The efficacy of a single acupuncture treatment was tested in 10 heaves-affected horses, and the effect of removal from the dusty stall environment in 5 heaves-affected horses. Before treatment, horses were stabled to induce airway obstruction and, apart from trips to the laboratory for pulmonary function measurements, they remained stabled for the duration of each treatment. The severity of airway obstruction was quantified by measurement of lung function before treatment (baseline), and at 20, 60, 120 and 240 mins and 24 h after the following treatments administered in random order: halter restraint and patting, a single acupuncture treatment by an experienced acupuncturist, and a single acupuncture treatment using predetermined points (recipe) by a veterinarian with no acupuncture training. In a second study, horses were untreated and remained either in their stall or in a paddock for all measurements of lung function, after baseline readings were made.

RESULTS

In the first study, after all treatments, there was a temporal improvement in maximal change in pleural pressure, pulmonary resistance, dynamic compliance, respiratory rate, and tidal volume that lasted less than 24 h. There was no specific effect of acupuncture treatment. In the second study, removal from the dusty environment did not produce an improvement in lung function in the first 6 h. We conclude that most of the improvements in lung function observed in the study were due to handling.

CONCLUSIONS

Assessed objectively, a single acupuncture treatment during an attack of heaves causes no more improvement in lung function than does handling the horse.

POTENTIAL RELEVANCE

Acupuncture should not replace conventional medical treatments for heaves.

An overview of two Cochrane systematic reviews of complementary treatments for chronic asthma: acupuncture and homeopathy

BACKGROUND

Acupuncture and homeopathy are commonly used complementary treatments for chronic asthma. This review summarizes two recently updated Cochrane systematic reviews that assess the safety and efficacy of homeopathy or acupuncture in individuals with chronic stable asthma.

INCLUSION CRITERIA

Only randomized-controlled trials were considered for inclusion. Statistical aggregation of the data was undertaken where possible.

SEARCH STRATEGY

Searches for both reviews were done with the assistance of the Cochrane Airways Group, and through electronic alerts.

RESULTS

ACUPUNCTURE: 11 studies with 324 participants met the inclusion criteria. Trial reporting was poor, and the trial quality was deemed inadequate to generalize the findings. There was variation in the type of active and sham acupunctures, the outcomes assessed and the time points measured. The points used in the sham arm of some studies are used for the treatment of asthma according to traditional Chinese medicine. Two studies used individualized treatment strategies, and one study used a combination strategy of formula acupuncture with the addition of individualized points. No statistically significant or clinically relevant effects were found for acupuncture compared with sham acupuncture. When data from two small studies were pooled, no difference in lung function was observed (post-treatment FEV1): standardized mean difference 0.12, 95% confidence interval 0.31 to 0.55).

CONCLUSION

ACUPUNCTURE: There is not enough evidence to recommend the use of acupuncture in the treatment of asthma. Further research needs to be undertaken, and this should take into account the different types of acupuncture practiced.

RESULTS

HOMEOPATHY: Six trials with a total of 556 people were included in the review. These trials were all placebo-controlled and double-blind, but were of variable quality. Standardized treatments in these trials are unlikely to represent common homeopathic practice where treatment tends to be individualized. The results of the studies are conflicting in terms of effects on lung function. There has been only a limited attempt to measure a "package of care" effect (i.e. the effect of the medication as well as the consultation, which is considered a vital part of individualized homeopathic practice).

CONCLUSION

HOMEOPATHY: There is not enough evidence to reliably assess the possible role of homeopathy in the treatment of asthma. Further studies could assess whether individuals respond to a "package of care" rather than the homeopathic intervention alone.

Acupuncture for chronic asthma

BACKGROUND

Acupuncture has traditionally been used to treat asthma in China and is used increasingly for this purpose internationally.

OBJECTIVES

The objective of this review was to assess the effects of acupuncture for the treatment of asthma or asthma-like symptoms.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register (searched August 2003), the Cochrane Complementary Medicine Field trials register, the Alternative Medicine Database (August 2003) and reference lists of articles. We also contacted trialists and researchers in the field of complementary and alternative medical research.

SELECTION CRITERIA

Randomised and possibly randomised trials using needle acupuncture or other forms of stimulation of acupuncture. Any form of control treatment was considered (no treatment in addition to conventional asthma treatment, sham or placebo interventions, active comparator interventions). Studies were included provided outcome was assessed at one week or more.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently assessed trial quality. A reviewer experienced in acupuncture assessed the adequacy of the active and sham acupunctures used in the studies. Study authors were contacted for missing information.

MAIN RESULTS

Eleven studies met the inclusion criteria with 324 participants. Trial reporting was poor and trial quality was deemed inadequate to generalise findings. There was variation in the type of active and sham acupunctures, the outcomes measured and time-points presented. The points used in the sham arm of some studies are used for the treatment of asthma according to traditional Chinese medicine. Two studies used individualised treatment strategies and one study used a combination strategy of formula acupuncture with the addition of individualised points. No statistically significant or clinically relevant effects were found for acupuncture compared to sham acupuncture. Data from two small studies were pooled for lung function (post-treatment FEV1): Standardised Mean Difference 0.12, 95% confidence interval -0.31 to 0.55).

REVIEWER'S CONCLUSIONS

There is not enough evidence to make recommendations about the value of acupuncture in asthma treatment. Further research needs to consider the complexities and different types of acupuncture.

Sham interventions in randomized clinical trials of acupuncture—a review

BACKGROUND AND OBJECTIVES

For non-drug interventions such as acupuncture, it is difficult to establish placebo or sham controls that are both inert and indistinguishable. We reviewed sham-controlled clinical trials of acupuncture to investigate (a) which types of sham interventions have been used in the past; (b) in what respects true and sham interventions differed; and (c) whether trials using different types of sham yielded different results.

METHODS

47 randomized controlled trials comparing true and sham acupuncture interventions for pain and a variety of other conditions were identified from systematic reviews and through a search in PubMed. Details of patients, interventions, sham interventions and outcomes were extracted in a standardized manner.

RESULTS

In two trials the sham intervention consisted of superficial needling of the true acupuncture points, four trials used true acupuncture points which were not indicated for the condition being treated, in 27 trials needles were inserted outside true acupuncture points, five trials used placebo needles and nine trials used pseudo-interventions such as switched off-laser acupuncture devices. True and sham interventions often differed in a variety of other variables, such as manipulation of needles, depth of insertion, achievement of an irradiating needling sensation (de-chi), etc. There was no clear association between the type of sham intervention used and the results of the trials.

CONCLUSION

Randomized trials investigating the specific effects of acupuncture have used a great variety of sham interventions as controls. Summarizing all the different sham interventions as "placebo" controls seems misleading and scientifically unacceptable.

Effect of acupuncture in the treatment of seasonal allergic rhinitis: a randomized controlled clinical trial

The clinical efficacy and safety of acupuncture in the treatment of Seasonal Allergic Rhinitis (SAR) was evaluated by employing a two-phase crossover single-blind clinical trial. Thirty subjects were randomly assigned to two groups with 17 and 13 subjects respectively and treated with real or sham acupuncture (three times per week) for four consecutive weeks and then a crossover for treatments for a further four weeks without a washout period. The administration of real acupuncture treatment was guided by a syndrome differentiation according to Chinese Medicine Theory. Subjects were assessed by various criteria before, during and after the treatments. Outcome measures included subjective symptom scores using a five-point scale (FPS), relief medication scores (RMS) and adverse effect records. Twenty-six (26) subjects completed the study. There was a significant improvement in FPS (nasal and non-nasal symptoms) between the two types of acupuncture treatments. No significant differences were shown in RMS between the real acupuncture treatment group and the sham acupuncture treatment group. No side effects were observed for both groups. The results indicate that acupuncture is an effective and safe alternative treatment for the management of SAR.

Acupuncture and bronchial asthma: a long-term randomized study of the effects of real versus sham acupuncture compared to controls in patients with bronchial asthma

BACKGROUND

Acupuncture has traditionally been used in China in the treatment of bronchial asthma and is being increasingly applied in Western countries. Although there are many published studies on acupuncture and asthma, few meet the scientific criteria necessary to prove the effectiveness of acupuncture.

OBJECTIVE

To examine the short- and long-term effects of real versus sham or no acupuncture in patients with bronchial asthma.

DESIGN

Randomized partially blinded study with three parallel groups.

SUBJECTS

Sixty-six (66) patients of both genders (mean age, 39 years) with mild-to-moderate persistent bronchial asthma.

INTERVENTIONS

After 2 weeks of run-in, the patients with asthma were randomized to receive either real (23 patients) or sham acupuncture (23 patients) or no acupuncture (20 patients). Two acupuncture periods (each 4 weeks) within the first 4 months were followed by a 6-month observation.

MEASUREMENTS

Primary outcome was the change of peak expiratory flow (PEF) variability at the end of the two treatment periods. Secondary outcomes were changes in forced expiratory volume in 1 second (FEV1), airway responsiveness, symptoms of asthma, the use of asthma drugs, and patients' well-being. Moreover, the effect of the intervention on eosinophils and eosinophil cationic protein (ECP) in blood and sputum was assessed.

RESULTS

PEF variability decreased in all groups. In a subgroup of patients whose asthma medication remained fairly unchanged, PEF variability decreased significantly after needling of real as well as sham points at month 4 and 5 compared to controls (p < or = 0.005). However, there was no difference in the decrease of PEF variability between patients who had the blinded treatment with real or sham acupuncture. Most of the other functional and clinical variables did not differ from those obtained in controls. Eosinophils and ECP in blood and sputum decreased in all groups, but the only significant differences were found in blood eosinophil count at 4 months between sham acupuncture and the control group (p < 0.05) and at 10 months between real and sham acupuncture (p < 0.05) suggesting a possible effect on eosinophilic inflammation.

CONCLUSIONS

In view of the fact that the effects after real and sham acupuncture compared to controls who had no needling at all were small, in all likelihood clinically irrelevant, our data do not seem to support the use of acupuncture in the management of pharmacologically well-treated patients with mild-to-moderate persistent asthma.

No effect of chinese acupuncture on isocapnic hyperventilation with cold air in asthmatics, measured with impulse oscillometry

The cost to society and the individual of treating asthma has been increasing in developed countries. This has given rise to studies of the efficacy of complementary treatments. The aim of this study was to evaluate the efficacy of traditional Chinese Acupuncture in patients with mild asthma. The method used for evaluation of efficacy was total airway resistance at 5Hz (R5) as measured by impulse oscillometry (IOS)--a forced oscillation technique, at baseline and after a bronchial challenge with voluntary isocapnic hyperventilation of cold air (IHCA). The study was a parallel group randomised placebo controlled trial with evaluator blinding. Twenty-seven asthmatics were recruited and 24 completed the study, 10 of them received acupuncture and 14 received a placebo treatment (mock-TENS). Treatment continued for 15 weeks, and efficacy was tested two weeks following the last treatment. Randomisation resulted in female over representation in the acupuncture group, but lung-function and bronchial responsiveness to IHCA were comparable in the two populations before the start of treatment (p>0.05 vs. p > 0.05). There were no statistically significant effects of the treatment before (p > 0.05) or after IHCA (p > 0.05) in either of the groups. The statistical power of the study to show a clinically relevant difference in bronchial responsiveness to IHCA after treatment was near 80%. We conclude that there were no significant effects of traditional Chinese Acupuncture on airway status in our patients with asthma.

Acupuncture

With the increasing availability of acupuncture in the United States, it is possible that patients will increasingly seek and use acupuncture for diverse indications. Research into acupuncture is still in its infancy, and much of the scientific evidence surrounding it is fragmentary and often contradictory. As is the case even in well-researched therapies, physicians often have to make decisions about patient care based on a mixture of available scientific evidence, anecdote, and patient preference. As investigations into this therapy continue, and patients, practitioners, and the medical system become more familiar with its integration into mainstream medical treatment settings [108], the role of acupuncture in the treatment of disease will become clearer.

Short-term acupuncture therapy is of no benefit in patients with moderate persistent asthma

STUDY OBJECTIVES

Acupuncture traditionally has been used to treat asthma. Nevertheless, only a few controlled studies have been performed to determine the efficacy of this treatment. Our study aimed to determine the efficacy of acupuncture in patients with moderate persistent asthma.

METHODS

Twenty-three patients with moderate persistent asthma who had been treated only with inhaled beta(2)-agonists were randomly assigned to receive four sessions of real acupuncture (RA) or sham acupuncture (SA) in a blinded manner. After a washout period of 3 weeks, the patients were crossed over. Monitoring included FEV(1), methacholine challenge, daily peak flow (PF) variability, and the keeping of an asthma diary.

RESULTS

Twenty of 23 patients completed the study. There was no significant change in FEV(1) following treatment. The mean (+/- SE) FEV(1) values before and after the RA were 73 +/- 4% and 73 +/- 3%, respectively (not significant [NS]). FEV(1) values before and after SA were 70 +/- 3% and 70 +/- 3%, respectively (NS). There was also no change in provocative methacholine concentration causing a 20% fall in FEV(1) (PC(20)) before and after treatment. The mean PC(20) values before and after RA were 0.92 +/- 0.42 mg/mL and 1.16 +/- 0.51 mg/mL, respectively (p = 0.71), while the PC(20) values before and after SA were 1.47 +/- 0.83 mg/mL and 1.11 +/- 0.79 mg/mL, respectively (p = 0.59). There was no change in the mean PF variability before and after the RA (1.6 +/- 3.1% and 1.8 +/- 2.3%, respectively [NS]). The PF variability before and after SA were 3.6 +/- 2.8% and 2.8 +/- 3.4%, respectively (NS). No significant difference was demonstrated for symptom scores or for the use of beta(2)-agonist inhalers (RA, 6.7 +/- 3.4; SA, 8.1 +/- 3.6; p = 0.58).

CONCLUSION

In patients with moderate persistent asthma, a short course of acupuncture treatment resulted in no change in lung functions, bronchial hyperreactivity, or patient symptoms.

Laser acupuncture in children and adolescents with exercise induced asthma

BACKGROUND

Laser acupuncture, a painless technique, is a widely used alternative treatment method for childhood asthma, although its efficacy has not been proved in controlled clinical studies.

METHODS

A double blind, placebo controlled, crossover study was performed to investigate the possible protective effect of a single laser acupuncture treatment on cold dry air hyperventilation induced bronchoconstriction in 44 children and adolescents of mean age 11.9 years (range 7.5-16.7) with exercise induced asthma. Laser acupuncture was performed on real and placebo points in random order on two consecutive days. Lung function was measured before laser acupuncture, immediately after laser acupuncture (just before cold dry air challenge (CACh)), and 3 and 15 minutes after CACh. CACh consisted of a 4 minute isocapnic hyperventilation of -10 degrees C absolute dry air.

RESULTS

Comparison of real acupuncture with placebo acupuncture showed no significant differences in the mean maximum CACh induced decrease in forced expiratory volume in 1 second (27.2 (18.2)% v 23.8 (16.2)%) and maximal expiratory flow at 25% remaining vital capacity (51.6 (20.8)% v 44.4 (22.3)%).

CONCLUSIONS

A single laser acupuncture treatment offers no protection against exercise induced bronchoconstriction in paediatric and adolescent patients.

Reflexology and bronchial asthma

Many asthma patients seek alternative or adjunctive therapies. One such modality is reflexology, whereby finger pressure is applied to certain parts of the body. The aim of the study was to examine the popular claim that reflexology treatment benefits bronchial asthma. Ten weeks of active or simulated (placebo) reflexology given by an experienced reflexologist, were compared in an otherwise blind, controlled trial of 20+20 outpatients with asthma. Objective lung function tests (peak flow morning and evening, and weekly spirometry at the clinic) did not change. Subjective scores (describing symptoms, beta2-inhalations and quality of life) and also bronchial sensitivity to histamine improved on both regimens, but no differences were found between groups receiving active or placebo reflexology. However, a trend in favour of reflexology became significant when a supplementary analysis of symptom diaries was carried out. It was accompanied by a significant pattern compatible with subconscious unblinding, in that patients tended to guess which treatment they had been receiving. No evidence was found that reflexology has a specific effect on asthma beyond placebo influence.

Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study

OBJECTIVE

According to Traditional Chinese Medicine (TCM) acupuncture is a suitable treatment for complex chronic diseases such as bronchial asthma. In a randomized, controlled study we investigated immunologic effects of Chinese acupuncture on patients with allergic asthma.

PATIENTS AND METHODS

The effects of acupuncture treatment given according to the principles of TCM (TCM group, n = 20) were compared with those of acupuncture treatment using points not specific for asthma (control group, n = 18). All patients were treated 12 times for 30 minutes over a time period of 4 weeks. Patients' general well-being and several peripheral blood parameters (eosinophils, lymphocyte subpopulations, cytokines, in vitro lymphocyte proliferation) were determined before and after acupuncture treatment.

RESULTS

In the TCM group, significantly more patients indicated an improvement in general well-being (79% in the TCM group versus 47% in the control group; p = 0.049) after acupuncture treatment. The following changes were found in the TCM group: within the lymphocyte subpopulations the CD3+ cells (p = 0.005) and CD4+ cells (p = 0.014) increased significantly. There were also significant changes in cytokine concentrations: interleukin (IL)-6 (p = 0.026) and IL-10 (p = 0.001) decreased whereas IL-8 (p = 0.050) rose significantly. Additionally, the in vitro lymphocyte proliferation rate increased significantly (p = 0.035) while the number of eosinophils decreased from 4.4% to 3.3% after acupuncture (p > 0.05). The control group, however, showed no significant changes apart from an increase in the CD4+ cells (p = 0.012).

CONCLUSION

The results imply that asthma patients benefit from acupuncture treatment given in addition to conventional therapy. Furthermore, acupuncture performed in accordance with the principles of TCM showed significant immune-modulating effects.

Integrity and research: introducing the concept of dual blindness. how blind are double-blind clinical trials in alternative medicine?

Double-blind methodology is used in clinical studies to control for potential external or nonspecific influences such as belief and expectation, as well as to maintain as much objectivity as possible on the part of the researchers. Despite not being feasible in all medical disciplines, as in the case of some modalities of complementary and alternative medicine, there are numerous studies that spuriously claim its use. Distinctions and standards therefore need to be set to avoid misleading information. We propose a new term in research methodology, dual-blind, to describe a methodological alternative in which the caregiver is not blind but the patient and an external evaluator/investigator are. The term double-blind should be used strictly to describe a methodology in which both the patient and the caregiver are blind. Making the distinction between these two terms will result in more reliable reports of clinical trials and will support integrity in research.

Alternative medicine for allergy and asthma

Orthodox medical approaches to asthma and allergic respiratory diseases are provided in guidelines developed by professional societies and national or state organizations that represent organized medicine. Alternative therapies may include such orthodox medical therapies as obsolescent formerly used agents, unusual but accepted agents, and agents that are in favor for orthodox therapy in other countries. However, the current growth of complementary and alternative medicine is based on the use of nonorthodox remedies that are becoming increasingly popular with patients and that should be familiar to physicians. Asthma and allergies are frequently treated with such remedies by patients, either as part of self-therapy or on the advice of a complementary and alternative medicine practitioner. The most popular alternative medical treatments are herbs (Western and Asiatic), acupuncture, various types of body manipulation, psychologic therapies, homeopathy, and unusual allergy therapies. There is little evidence in favor of most of these unorthodox treatments, although they are very often reported on favorably by patients. The published evidence that might support some alternative medical practices is reviewed so as to help physicians select alternatives that could appropriately be integrated into orthodox practice.

Acupuncture for chronic asthma

BACKGROUND

Acupuncture has traditionally been used to treat asthma in China and is used increasingly for this purpose internationally.

OBJECTIVES

The objective of this review was to assess the effects of acupuncture for the treatment of asthma or asthma-like symptoms.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register, the Cochrane Complementary Medicine Field trials register and reference lists of articles.

SELECTION CRITERIA

Randomised and possibly randomised trials using acupuncture to treat asthma and asthma-like symptoms. Acupuncture could involve the insertion of needles or other forms of stimulation of acupuncture points.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed by at least two reviewers independently. A reviewer experienced in acupuncture assessed the adequacy of the sham acupuncture. Study authors were contacted for missing information.

MAIN RESULTS

Seven trials involving 174 people were included. Trial quality varied and results were inconsistent. No statistically significant or clinically relevant effects were found for acupuncture compared to sham acupuncture. However the points used in the sham arm of some studies are used for the treatment of asthma according to traditional Chinese medicine. Only one study used individualised treatment strategies. Lung function could be compared statistically in only 3 trials. Peak expiratory flow rate showed a statistically insignificant increase of 8.4 litres/minute weighted mean difference (95% confidence interval -29.4 to 46.2) when acupuncture was compared to sham acupuncture.

REVIEWER'S CONCLUSIONS

There is not enough evidence to make recommendations about the value of acupuncture in asthma treatment. Further research needs to consider the complexities and different types of acupuncture.

A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma

BACKGROUND

Chiropractic spinal manipulation has been reported to be of benefit in nonmusculoskeletal conditions, including asthma.

METHODS

We conducted a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma. After a three-week base-line evaluation period, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation for four months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. The primary outcome measure was the change from base line in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. Except for the treating chiropractor and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to treatment assignment throughout the study.

RESULTS

Eighty children (38 in the active-treatment group and 42 in the simulated-treatment group) had outcome data that could be evaluated. There were small increases (7 to 12 liters per minute) in peak expiratory flow in the morning and the evening in both treatment groups, with no significant differences between the groups in the degree of change from base line (morning peak expiratory flow, P=0.49 at two months and P=0.82 at four months). Symptoms of asthma and use of 3-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups. There were no significant changes in spirometric measurements or airway responsiveness.

CONCLUSIONS

In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.

Acupuncture in treatment of stable asthma

Previous studies of acupuncture in asthma have reported conflicting results, some claiming benefit for some patients. We conducted a randomized, double-blind (patient and evaluator) study in 23 non-smoking asthmatics (10 M; 13 F) aged 43 +/- 15 years with forced expiratory volume in 1 s (FEV1) 59 +/- 16% pred. After initial assessment (respiratory function tests and Asthma Quality Life Questionnaire) patients were randomized to receive either 'real' or 'sham' acupuncture. The measurements were repeated within 1 h and after 2 weeks. Patients were recording peak expiratory flow rate (PEFR) throughout the period of the study. After 2 weeks patients who received 'real' treatment on the first visit received 'sham' treatment and vice versa. The measurements were again repeated within 1 h and after 2 weeks. There was no improvement in any aspects of respiratory function measured after either form of acupuncture. Despite this there was a significant improvement in AQLQ and parallel reduction in the usage of bronchodilators. We concluded that in some patients acupuncture could be useful in improving quality of life and reducing the need for using bronchodilators either by having a placebo effect or that the exact site of needle puncture on the chest is unimportant.

A critical analysis of acupuncture in pulmonary disease: efficacy and safety of the acupuncture needle

Criteria for therapeutic efficacy and safety include significant amelioration of symptoms and, ideally, cure (i.e., patients' belief in effective improvement of symptoms and quality of life, durable impact on symptoms, verifiable subjective and objective changes); improved patient management (e.g., diminishing, or ceasing medication, physiotherapy, and other interventions); safety for patient and practitioner and an acceptable side effect profile; cost-effectiveness of the therapy in practice and to teach to others. There is evidence that in bronchial asthma, chronic bronchitis, and chronic disabling breathlessness the use of acupuncture fulfills these to varying degrees. It can facilitate reducing pharmacologic medication and is safe, suggesting that acupuncture as an adjuvant in the treatment of respiratory disease might be safer than prolonged pharmaceutical maintenance therapy alone. Its cost-effectiveness has yet to be adequately researched. Twenty-one papers in English were obtained and 16 were further evaluated; eight were double-blind, five single-blind, and three unblinded. The remaining five, and most of the Chinese literature, were excluded on account of their poor quality. Acupuncture was effective in four of eight of the double-blind, three of five single-blind, and three of three unblinded studies (i.e., 10 of 16 [62.5%] overall). A previously unreported confounding variable was identified and concerned the designation of sham points. Most sham points were believed to be inactive but, according to traditional Chinese principles, many are active in pulmonary disease. Reappraised accordingly, the unequivocally positive studies were summed with those in which "real" and "sham" acupuncture were not significantly different but in which the combined effect of all acupuncture (i.e., real + sham) on breathlessness was significantly different from baseline. This yielded 13 of 16 (81%) [corrected] studies in which acupuncture led to significant improvement. In most studies, current pharmacologic treatment had a greater effect than acupuncture alone. However, in the 11 studies in which it was evaluated, medication could be significantly reduced by acupuncture in 10 (91%). Twenty-three of the 320 patients in the 16 studies (7%) reported minimal side effects, none requiring intervention. Current published evidence reveals no reason to withhold acupuncture as a safe and potentially effective treatment in patients with bronchial asthma and chronic obstructive lung disease. Further, more appropriately designed studies are urgently required. This would be facilitated in the United States by licensing the acupuncture needle as a therapeutic agent and might lead to important new insights and therapeutic opportunities.

Exercise-induced asthma and anaphylaxis

With increased popularity in exercise, the number of individuals with exercise-induced asthma (EIA), or 'exercise-induced bronchospasm', has increased due to an increased awareness among physicians of the clinical symptoms associated with EIA. EIA affects approximately 75 to 95% of asthmatic patients. 40% of children with allergic rhinitis have EIA, whereas only 3 to 11% of nonasthmatics have EIA. Although athletes with asthma have been recognised for years, EIA in nonasthmatic individuals has gained recognition since the 1984 Olympics. Vague symptoms of recurring poor performance, fatigue despite adequate conditioning, or 'getting winded' during an athlete's usual workout may be the presenting complaints. Athletes may be more likely to attribute these symptoms to poor conditioning or an upper respiratory infection, and not seek immediate assistance. Younger athletes may complain of stomach ache or refuse to participate in strenuous play because of an inability to keep up with other children. Additionally, an awareness of exercise-induced anaphylaxis needs to be considered when discussing aspects of airway compromise following exercise; however, its presentation is more urgent than those with EIA. Although the pathophysiology of EIA is somewhat controversial, the most likely explanation is a combination of heat and water loss leading to mediator release. The different medications that have been used to treat EIA are based on theories regarding the bronchial hyperreactivity of EIA.

Acupuncture and asthma: a review of controlled trials

BACKGROUND

Published controlled trials of acupuncture in asthma have often contained a small number of subjects and the results are contradictory. Controlled trials have been reviewed to determine whether clearer conclusions could be obtained by assessing as many studies as possible according to methodological criteria.

METHODS

A literature search produced 13 trials on the efficacy of acupuncture in the treatment of patients with asthma. These studies were reviewed on the basis of 18 predefined methodological criteria. A maximum of 100 points for study design could be earned in three main categories: (a) adequate study population, (b) adequate intervention, and (c) adequate measurement of effects.

RESULTS

The quality of even the eight better studies (more than 50% of the maximum score) proved to be mediocre. No study earned more than 72% of the maximum score. The results from the better studies are highly contradictory.

CONCLUSIONS

Claims that acupuncture is effective in the treatment of asthma are not based on the results of well performed clinical trials.

Alternative and complementary medicine for asthma

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Comparison of real and placebo acupuncture in histamine-induced asthma. A double-blind crossover study

A double-blind crossover study of the effects of real and placebo acupuncture on bronchial reactivity to histamine was carried out on 16 patients with moderately severe asthma. Treatment with real or placebo acupuncture failed to modulate the bronchial hyperreactivity to histamine. These results suggest that a single treatment with acupuncture is unlikely to provide improvement in the management of acute bronchial asthma.

Problems in the evaluation of alternative medicine

Evaluation of alternative medicine poses paradigmatic as well as procedural difficulties. Difficulties faced by the scientific community in accepting the 'world view' of acupuncture and homeopathy are described, and possibilities for evaluating alternative medical paradigms are considered. A selection of randomized controlled trials are reviewed and weaknesses in protocol and method identified.