Angina: acupuncture may be successful adjunctive treatment

anginaAcupuncture is effective in alleviating angina when combined with traditional antianginal treatment, according to study results published in JAMA Internal Medicine.

“The current aim of pharmacologic management of [chronic stable angina] is to prevent myocardial ischemia episodes, control symptoms, improve quality of life, and prevent cardiovascular events,” Ling Zhao, PhD, of the Acupuncture and Tuina School at the Chengdu University of Traditional Chinese Medicine in Sichuan, China, and colleagues wrote. “Because of limited medical resources and lack of obvious improvement to angina with percutaneous coronary intervention, Chinese clinicians choose traditional Chinese medicine and acupuncture in addition to antianginal treatment for [chronic stable angina].

“Acupuncture has been used as nonpharmacologic treatment for several decades, especially to relieve symptoms of myocardial ischemia, improve cardiac function, and prevent recurrence,” they continued.

To access acupuncture in the treatment of angina, researchers conducted a 20-week randomized clinical trial at five difference clinical centers in China between Oct. 10, 2012, and Sept. 19, 2015. Patients with angina were randomly assigned to receive acupuncture on acupoints in the disease-affected meridian, the non-affected meridian, sham acupuncture, or were place in a waitlist group that did not receive acupuncture. All participants received recommended antianginal therapies.

For patients assigned to receive acupuncture during the study period, treatment was given three times each week for 4 weeks.

All patients enrolled in the study were asked to keep a diary to record angina attacks. Diary entries were used to evaluate changes in angina attacks from the baseline to week 16.

Researchers included 398 patients with a mean age of 62.6 years in the intention-to-treat analysis. The frequency of angina attacks varied greatly across the four treatment groups. Greater reductions in mean angina attacks occurred in those who received acupuncture at acupoints in the disease-affected meridian compared with those in the nonaffected meridian group (difference = 4.07; 95% CI, 2.43-5.71), the sham acupuncture group (difference = 5.18; 95% CI, 3.54-6.81) and the wait list group (difference = 5.63; 95% CI, 3.99-7.27).

In addition to fewer angina attacks, those in the disease-affected meridian group had improved scores on measures that tested the severity of angina, including physical activity and rescue medication use. They also had better regulation of anxiety and depression after treatment compared with those who received sham or no acupuncture.

“Acupuncture was safely administered in patients with mild to moderate [chronic stable angina],” Zhao and colleagues wrote. “Compared with the [nonaffected meridian, sham acupuncture, and waitlist] groups, adjunctive acupuncture on the [disease-affected meridian] showed superior benefits in [chronic stable angina] treatment within 16 weeks. Acupuncture should be considered as one option for adjunctive treatment in alleviating angina.”– by Erin Michael at Healio 7/29/19

Click here to download PDF publication JAMA: jamainternal_zhao_2019_oi_190051

Acupuncture Outperforms Drugs for Anxiety

from Health CMi May 2019 

Acupuncture calms anxiety. Xuzhou Guangci Hospital psychiatric department researchers conducted a clinical trial comparing acupuncture and moxibustion for the treatment of anxiety disorders with gamma oryzanol plus alprazolam (a benzodiazepine medication). Acupuncture combined with moxibustion produced a 93.75% total effective rate and alprazolam plus gamma oryzanol produced a 75% total effective rate. Based on the data, the research team notes that acupuncture is safe and effective for the treatment of anxiety.

A total of 64 patients with a clinical diagnosis of anxiety disorder were recruited for the study and were randomly assigned to the acupuncture plus moxibustion group or the drug control group using randomization. The acupuncture plus moxibustion group was comprised of 14 male and 18 female patients, ages 20–70 years (mean age 50.5 years), with a duration of anxiety between 1–4 years (mean duration 2.2 years). Of these patients, 22 were classified as having mild anxiety while 10 were classified as having severe anxiety.

The drug control group was comprised of 15 male and 17 female patients, ages 25–75 years (mean age 50.8 years), with a duration of anxiety between 2–6 years (mean duration 2.3 years). Of these patients, 26 were classified as having mild anxiety, while 6 were classified as having severe anxiety. There were no statistically significant differences in baseline characteristics between the two groups (p>0.05).

Inclusion criteria for the study including the age range of 20–75 years and giving informed consent to participate. Exclusion criteria were other medical conditions and comorbidities, use of related therapies which may influence the study’s outcomes, psychological or pathological conditions that may affect judgement and observation, concurrent heart, liver, or kidney dysfunction, factors affecting drug metabolism, other psychological disorders, and other critical or advanced conditions. Pregnant and lactating women were also excluded from the study. Withdrawal criteria included failure to comply with the prescribed interventions, incomplete data, serious adverse reactions or complications, and the use of medications that may interfere with the study’s outcome measures.

Biomedical diagnostic criteria included symptoms such as depression, clinically significant excessive doubt or suspicion, anxiety, worry, timidity, and irritability. TCM (Traditional Chinese Medicine) diagnostic criteria included symptoms such as depression, chest or hypochondriac distension, shortness of breath, frequent sighing, and amenorrhea. Tongue and pulse diagnosis included a thin-white tongue coating and a wiry (bowstring) pulse.

Patient Care
Patients assigned to the drug control group were treated with alprazolam (a benzodiazepine) and gamma oryzanol. The dosages of these medications were 0.4 mg and 20 mg respectively, both taken three times a day. Patients assigned to the acupuncture plus moxibustion group were treated with acupuncture and moxibustion but did not receive alprazolam and gamma oryzanol. Acupuncture was administered at the following acupoints:

  • Baihui (GV20)
  • Shenting (GV24)
  • Anmian (NHN54)
  • Neiguan (PC6)
  • Sanyinjiao (SP6)

The acupoints were selected according to the TCM principles of stimulating the brain and nervous system, promoting restful sleep, regulating spleen and kidney function, and supplementing essence (jing), qi, and spirit (shen).

Treatment was conducted with the patients in a supine position. Needles were inserted rapidly, accurately, and steadily to induce a heavy sensation in the surrounding area. Once a numb or aching sensation was achieved, the needles were removed. Needles at Baihui and Shenting were manipulated using a balanced reinforcing-reducing method. Needles at Neiguan were manipulated using a reinforcing method before applying moxa. Treatment was administered on alternate days and lasted a total of 30 minutes each time, with 15 days constituting a full course of patient care.

Outcomes
The primary outcome measure for the study was clinical efficacy. Each patient’s symptoms were rated according to TCM Syndrome Diagnosis and Efficacy Criteria. In patients showing >60% improvement in symptoms, treatment was classified as markedly effective. In patients showing 30–60% improvement, treatment was classified as effective. In patients showing <20% improvement or no change in symptoms, treatment was classified as ineffective. The markedly effective and effective scores were added together to give the total clinical efficacy rate.

After 15 days of treatment, the acupuncture plus moxibustion group had 20 markedly effective, 10 effective, and 2 ineffective cases, giving a total effective rate of 30/32 (93.75%). The drug control group had 10 markedly effective, 14 effective, and 8 ineffective cases, giving a total effective rate of 24/32 (75.00%). Although both groups showed improvements following treatment, the total effective rate was significantly higher in the acupuncture plus moxibustion group (p<0.05). In addition, adverse reactions were monitored throughout the study. No serious adverse reactions were recorded in either group, and no patients withdrew from the study.

The results of this randomized controlled trial indicate that acupuncture with moxibustion is a safe and effective treatment for anxiety, with the advantage of providing symptomatic relief within a relatively short period of time. This suggests that acupuncture plus moxibustion is a potentially useful adjunct to psychological therapy and other relevant interventions for anxiety.

1. Liu Jinpeng, Meng Li, Yu Xinqian, Wu Ming (2015) “Sedative Qingnao Acupuncture to Treat Anxiety Disorders Randomized Controlled Study” Journal of Practical Traditional Chinese internal Medicine Vol.29 (8) pp.152-153.

Acupuncture Reverses Chemotherapy Side Effects

in HealthCMi 

Acupuncture mitigates adverse effects resulting from chemotherapy. Chongqing Tumor Institute (Oncology Department of Traditional Chinese Medicine) researchers conducted a controlled clinical trial consisting of rectal cancer patients receiving chemotherapy. Acupuncture significantly reduced the severity of hand-foot syndrome, a known side effect of chemotherapy characterized by redness, swelling, tingling, numbness, itching, and pain of the palms and soles.

Acupuncture achieved a 70% total effective rate with a 16.67% complete cure rate and a 53.33% markedly effective rate for rectal cancer patients receiving chemotherapy utilizing capecitabine as part of the treatment regimen. [1] A total of 60 patients with rectal cancer were recruited for the study and were randomly assigned to receive treatment with acupuncture (n=30) or vitamin B6 (n=30).

The acupuncture group was comprised of 13 male and 17 female patients, ages 45–80 years (mean age 62.29), with a disease duration of 9–20 months (mean duration 16.4 months). The vitamin B6 group was comprised of 16 male and 14 female patients, ages 51–73 years (mean age 61.25), with a disease duration of 10–19 months (mean duration 15.8 months). The severity of the participants’ symptoms were graded using two scales, the Common Toxicity Criteria of the National Cancer Institute of Canada (CTC) and the Karnofsky Performance Scale (KPS). The CTC grades symptoms using a scale of 1–4, with higher scores indicating increased severity. The KPS is on a scale of 0–100, with higher scores indicating an increased ability to perform daily activities and lower scores indicating increased levels of disability.

For inclusion in the study, participants were required to have a CTC score of >1 and a KPS score of ≥60. Further criteria limited participants to ages 18–80 years, with an anticipated survival period of at least three months. Informed consent and ethical approval were required for all participants. Exclusion criteria included pregnancy, lactation, serious heart, liver, kidney, or brain dysfunction, psychiatric disorders, inability to cooperate with the study requirements, and refusal of acupuncture treatment.

 

Acupuncture
According to TCM (Traditional Chinese Medicine) principles, hand-foot syndrome is a type of bi syndrome involving obstruction of qi and blood circulation, deficiency of qi and blood, or dampness leading to a blockage of yang qi that is consequently unable to nourish the skin and muscles, thereby causing the symptoms of numbness and pain. Historically, the term “bi referred to the pathogenesis, or the symptoms as well as the name of the disease.” [2] Treatment principles were to tonify qi, promote blood circulation, promote yang qi, and remove stagnation. Patients allocated to the acupuncture group received treatment at the following acupoints:

  • Baihui (GV20)
  • Hegu (LI4)
  • Waiguan (TB5)
  • Zusanli (ST36)
  • Ashi points

For constitutionally weak patients, the following supplementary acupoints were added:

  • Taixi (KD3)
  • Sanyinjiao (SP6)
  • Yanglingquan (GB34)

Treatment was administered with patients in a supine position. Following standard disinfection, 0.35 × 40 mm filiform needles were inserted into each acupoint. Baihui was needled obliquely toward the occiput to elicit a distending sensation in the local area. Hegu and Waiguan were needled obliquely towards the palm, to a depth of 0.2–0.3 cun. The needle sensations were transmitted towards the palms.

Zusanli was needled perpendicularly using a reinforcing-reducing method. The needle was first rotated clockwise to elicit deqi, with sensations transmitted along the medial edge of the tibia toward the thigh. The needle was then rotated counter-clockwise, while applying finger pressure to the upper part of the acupoint with the aim of transmitting needle sensations back toward the toes.

Ashi points were selected according to the most painful areas on the hands and feet. These were needled perpendicularly to a depth of 0.1–0.2 cun. After the arrival of deqi, the needles were manipulated with a rapid, low-amplitude lifting and thrusting techniques for two minutes to elicit a strong distending sensation. The supplementary points, if used, were stimulated using an even technique with rapid, low-amplitude lifting and thrusting to elicit needle sensations in the local area. All needles were retained for 30 minutes and treatments were administered daily for two weeks.

Vitamin B6
Participants allocated to the vitamin B6 group were treated with 300mg of oral vitamin B6, taken daily for a total of two weeks.

Outcomes
Outcome measures included changes in CTC and KPS scores, and the QLQ-C30 (Quality of Life Questionnaire Core), a 30-item functional scale covering the areas of PF (physical function), RF (role function), CF (cognitive function), EF (emotional function), and SF (social function). Patients whose CTC scores were downgraded to grade 1 after treatment, with a disappearance of symptoms and a KPS score of ≥ 90 were classified as cured. For patients whose CTC scores were downgraded to ≥ grade 1, with an improvement in symptoms, and a KPS score of 80–89, the treatments were classified as effective. For patients showing no obvious improvements and had KPS scores of < 80, the treatments were classified as ineffective.

Mean pre-treatment KPS scores were 67.23 in the acupuncture group and 68.07 in the vitamin B6 group. Following treatment, these scores rose to 84.23 and 77.84 respectively. Although both groups showed improvements, positive patient outcomes were significantly greater in the acupuncture group (p<0.05). In the acupuncture group, there were 5 cured, 16 effective, and 9 ineffective cases, yielding a total effective rate of 70.0%. In the vitamin B6 group, there were 4 cured, 7 effective, and 19 ineffective cases, yielding a total effective rate of 36.7%.

Mean pre-treatment QLQ-C30 scores in the acupuncture group were 40.72, 44.53, 34.35, 39.23, and 33.19 in the areas of PF, RF, EF, CF, and SF respectively. In the vitamin B6 group, the equivalent pre-treatment scores were 41.13, 40.87, 33.89, 40.75, and 32.07. Following treatment, these scores fell to 7.13, 18.77, 4.89, 6.32, and 10.16 in the acupuncture group and 16.72, 20.77, 11.76, 18.17, and 12.88 in the vitamin B6 group. Both groups showed improvements across all areas, but positive outcomes were greater in the acupuncture group, with improvements in PF, EF, and CF being of statistical significance (p<0.05).

The results of this study indicate that acupuncture is an effective treatment for hand-foot syndrome, with the ability to alleviate symptoms and improve overall quality of life. The results demonstrate that an integrative model of patient care utilizing acupuncture as a treatment modality produces significantly less adverse effects associated with chemotherapy.

References:
1. Li Fangfei, Chen Hong, Li Guosen (2018) “Chemotherapy-induced hand-foot syndrome in rectal cancer treated with acupuncture” World Journal of Acupuncture-Moxibustion Vol.28 pp. 151-155.

2. Dai, J. H., Y. J. Shi, H. B. Yin, and H. Du. “The evolution of related names of Bi syndrome and the theory of etiology and pathogenesis.” Zhonghua yi shi za zhi (Beijing, China: 1980) 39, no. 4 (2009): 214-217.

Acupuncture Test Anxiety Relief Confirmed

March 27 2019 HealthCMiacupuncture-head

Acupuncture alleviates test anxiety. Changchun University of Traditional Chinese Medicine researchers conducted a clinical trial consisting of undergraduate students with test anxiety, a type of performance anxiety. The results demonstrate that acupuncture reduces pre-examination anxiety and reduces sleep disturbances. [1]

HAMA (Hamilton Anxiety Rating Scale) and PSQI (Pittsburgh Sleep Quality Index) scores significantly improved for student receiving acupuncture. A total of 58 students were randomly divided into three groups. One group received traditional acupuncture, another received scalp acupuncture, and a third group received no treatment.

Inclusion criteria for the clinical trial were a HAMA score of ≥ 15 and a PSQI score of ≥ 7. The symptoms were required to be induced by pre-examination stress and not related to systemic illnesses such as fever, cough, surgery, pain, or any other external factor. Students that had taken psychotropic or anti-anxiety medications in the previous two weeks or had complications including cardiovascular, lung, liver, kidney, or hemopoietic disorders were excluded from the trial. Students were required to give informed consent to participate and were not permitted to receive any additional treatments during the clinical trial period. Students assigned to the traditional acupuncture group received treatments at the following acupoints:

  • Sishencong (MHN1)
  • Shenmen (HT7)
  • Sanyinjiao (SP6)

Treatment was administered with each patient in a seated or supine position and 0.25 × 25 mm or 0.25 × 40 mm needles were utilized. Needles were manipulated for five minutes using an even technique and were retained for a total of 30 minutes. Students assigned to the scalp acupuncture group received treatments at the following acupoints:

  • Upper Middle Line Occiput (MS12)
  • Middle Line Vertex (MS5)
  • Middle Line Forehead (MS1)

Treatment was administered with each patient in a seated or supine position. Needles were inserted rapidly at a 10 or 15-degree angle to the scalp, to a depth of 1–1.5 cm. Needles were manipulated for five minutes using an even technique and were retained for a total of 30 minutes. For both acupuncture groups, treatment commenced four weeks prior to an examination and was conducted daily with five treatments making up one course of care. A total of four courses were administered, separated by a two-day break each time.

Outcomes
Primary outcome measures included HAMA and PSQI scores plus total effective rates. The HAMA is a scale comprised of 14 parameters, each rated from 0–4, with higher scores indicating increases in anxiety. Mean pre-treatment HAMA scores were 25.67 in the control group, 25.0 in the traditional acupuncture group, and 25.2 in the scalp acupuncture group.

After one week, HAMA scores in all groups reduced slightly to 23.28, 22.4, and 22.4 respectively. After two weeks, HAMA scores in the non-treatment control group remained relatively stable at 24.22, while scores in the traditional and scalp acupuncture groups fell further to 17.5 and 18.5 respectively. After four weeks, HAMA scores in the control group were 21.22, while the traditional and scalp acupuncture groups fell to 6.95 and 5.8 respectively. One week post-treatment, respective HAMA scores for the three groups were 11.78, 5.80, and 4.55. The results indicate that acupuncture is effective for the treatment of test anxiety.

The PSQI rates sleep quality and duration over nine parameters, each rated on a scale of 0–3, with higher scores indicating increases in sleep disturbances. Mean pre-treatment PSQI scores were 15.78 in the control group, 15.75 in the traditional acupuncture group, and 15.95 in the scalp acupuncture group. After one week, PSQI scores in the non-treatment control group remained at 15.78, while scores in the traditional and scalp acupuncture groups reduced to 13.75 and 12.95 respectively.

After two weeks, PSQI scores in the control group rose slightly to 15.95, while scores in the traditional and scalp acupuncture groups continued to fall to 11.15 and 8.95 respectively. After four weeks, PSQI scores in the control group were 16.5, while the acupuncture groups fell further to 8.05 and 5.95 respectively. One week post-treatment, respective PSQI scores for the three groups were 9.78, 6.25, and 4.7. The results indicate that acupuncture successfully benefits sleep for test anxiety patients.

Total effective rates for the three groups were calculated based on total reductions in HAMA and PSQI scores. At the end of the study, students with reductions in HAMA scores of ≥ 75% and PSQI scores of 0–5 points were classified as cured. For students with < 75% reductions in HAMA scores and PSQI scores of 6–10, the treatment was classified as markedly effective. For students with < 50% reductions in HAMA scores and PSQI scores of 11–15, the treatment was classified as effective. For students with < 25% reductions in HAMA scores and PSQI scores of 16–20, the treatment was classified as ineffective. The cured, markedly effective, and effective cases were added together to give the total effective rates for each group.

Regarding anxiety symptoms, the non-treatment control group had 8 cured, 4 markedly effective, 3 effective, and 3 ineffective cases, yielding a total effective rate of 83.33%. The traditional acupuncture group had 18 cured, 2 markedly effective, no effective, and no ineffective cases, yielding a total effective rate of 100%. Similarly, the scalp acupuncture group had 16 cured, 2 markedly effective, 1 effective, and no ineffective cases, yielding a total effective rate of 100%.

Regarding sleep disorders, the control group had no cured, no markedly effective, 2 effective, and 16 ineffective cases, yielding a total effective rate of 11.11%. The traditional acupuncture group had 14 cured, 4 markedly effective, 1 effective, and 1 ineffective case, yielding a total effective rate of 95%. The scalp acupuncture group had 16 cured, 2 markedly effective, 1 effective, and 1 ineffective case, yielding a total effective rate of 95%. The results of this study indicate that both traditional and scalp acupuncture offer effective relief for students suffering from anxiety and sleep disturbances due to pre-examination stress.

Reference:
Guo-juan Dong, Di Cao, Yue Dong, Jing Zhang, Fu-chun Wang (2018). “Scalp acupuncture for sleep disorder induced by pre-examination anxiety in undergraduates,” World Journal of Acupuncture-Moxibustion, vol. 28, pp. 156-160.

Acupuncture Knee Arthritis Cartilage Repair Discovery

Acupuncture stimulates knee osteoarthritis cartilage repair by regulating proteins TGF-β1 and IGF-1. Beijing University of Traditional Chinese medicine researchers determined that acupuncture accelerates articular cartilage repair in the osteoarthritic knee by inhibiting the overexpression of TGF-β1 and IGF-1. With multiple objective laboratory instruments measuring outcomes, the investigation also reveal that acupuncture smooths the surface of knee cartilage while regulating cell proliferation and differentiation. [1] Under the results section of this article, you will be able to read more about this groundbreaking discovery.

Knee osteoarthritis (KOA) often presents with pain, limited mobility, and a reduction in quality of life. Pathologically, it is characterized by changes in the articular cartilage, the subchondral bone, the intra-articular space, ligaments, and the articular capsule region. The researchers designed a laboratory experiment to determine the biochemical mechanisms by which acupuncture exerts its therapeutic actions. The randomized study of 30 experimental rabbits was divided into three arms: a control group (n=10), a knee osteoarthritis model group (n=10), and an acupuncture treatment group (n=10). For the KOA model group and treatment group, a KOA model was made by immobilization of the rabbit knee. Only the treatment group received warm needle acupuncture treatments. The control group did not receive any medical procedures or treatment for the duration of the study.
Results
The hospital researchers conclude, “In comparison with the control group, the expression levels of both TGF-beta1 [transforming growth factor beta 1] and IGF1 [insulin-like growth factor 1] were up-regulated in the KOA model group and then down-regulated after the warm-needling treatment.” They add that both microscopic and macroscopic improvements in the knee joint were observed. After the treatment, “the surface of knee cartilage became smoother.” Additionally, “less abnormal cell proliferations and clusters were found in the warm-needling group compared to those of the model group.” The research team determined that “acupuncture can inhibit the overexpression of TGF-beta1 and IGF-1 in the knee cartilage of rabbits with KOA, having a solid effect in improving pathological changes of knee cartilage.”
Acupuncture 
Acupuncture treatment commenced one week after the KOA model was established. Acupuncture was applied once per day, for a total of four weeks. Needle retention time per acupuncture session was 20 minutes. Manual needle stimulation was applied to elicit a deqi response for each needle. Additionally, moxa cuttings were attached to each needle handle and ignited for 20 minutes to warm the needles. The acupoints used in the study were the following:
  • EX-LE4 (Neixiyan, medial Xiyan)
  • EX-LE5 (Waixiyan, lateral Xiyan)
  • SP10 (Xuehai)
  • GB34 (Yanglingquan)
The researchers note that Traditional Chinese Medicine (TCM) principles were used to make the acupoint selection for the study. This acupoint prescription is widely used on human patients. In Traditional Chinese Medicine, KOA is in the scope of Gu Bi (translated as bone impediment) and Xi Tong (translated as knee pain). The stagnation of external pernicious influences (e.g., wind, cold, damp, heat, phlegm) in the local meridians (acupuncture channels and collaterals) is a primary cause of KOA.
The TCM treatment principle is to invigorate local blood circulation and disperse stagnation. Neixiyan, Waixiyan, Xuehai, and Yanglingquan are located at the knee region. Needling these acupoints accelerates local blood circulation. According to the Huangdi Neijing (The Yellow Emperor’s Classic of Medicine), “the knee is the house of the tendons.” Yanglingquan (GB34) is the gathering point of the tendons. Needling this acupoint treats tendon issues, including those related to the knee joint. In this study, moxibustion was also applied as a part of warm needling therapy. Moxibustion warms the local area and supplements acupuncture to promote blood circulation and disperse stagnation.
Laboratory Detection
The researchers note, “KOA is caused by an imbalance between knee cartilage degradation and repair, the process of which is closely related to TGF-beta1 and IGF-1.” [1] This is supported by another research investigation, in which Stephen et al. concluded that “TGF-beta1 and IGF-1 plays an important role in cartilage homeostasis.” [2]
TGF-beta1 is a secreted protein involved in osteoblast formation and bone remodeling. There is a positive correlation between the concentration of TGF-beta1 and the degree of cartilage damage. Fahlgren et al. note that “high concentrations of TGF-beta1 in synovial lavage fluid seemed indicative for the later development of more severe OA changes in contrast to lower concentrations.” [3] Couchourel et al. document that “Elevated TGFβ1 levels in OA osteoblasts are responsible, in part, for the abnormal ratio of COL1A1 to COL1A2 and for the abnormal production of mature type I collagen. This abnormal COL1A1-to-COL1A2 ratio generates a matrix that blunts mineralization in OA osteoblasts.” [4] Homeostasis is the key. Tsai et al. find that “at proper levels, TGF-β1 could prevent OA from progression.” [5]
IGF-1 is a mitogen (substance that stimulates mitosis) that plays a role in regulating the proliferation, differentiation and apoptosis of chondrocytes. Lan et al. note that at the early stages of knee OA, normal increase in concentrations of IGF-1 activates bone growth and repair. [6] However, they also document that overexpression of IGF-1 leads to osteophyte formation and disease deterioration. In a related research, Wei et al. conclude, “TGF-1 regulates development and homeostasis of articular cartilage, and only TGF-1 at proper levels can accelerate cartilage repair and prevent OA’s progression.” [7]
Based on the findings, the Beijing University of Traditional Chinese Medicine research team concludes that “the relation between TGF-beta1 and IGF-1 levels and articular cartilage repair is a normal distribution.” They add, “the key of knee OA treatment is to reduce the overexpression of the two regulatory factors.” Their findings demonstrate that acupuncture stimulates a homeostatic response on expression of these factors.
Summary
Laboratory data indicates that acupuncture is effective for the treatment of KOA. According to the research covered in this article, common protocols involve the application of acupoints EX-LE4 (Neixiyan), EX-LE5 (Waixiyan), SP10 (Xuehai), and GB34 (Yanglingquan). Patients interested in learning more about treatment are recommended to contact local licensed acupuncturists.
Primary Research
[1] Gao L, Chen M, Yue P, Zhang R, Xin SC. Effect of Warm-needle Moxibustion on Expression of Transfer Growth Factor-beta1 and Insulin like Growth Factor 1 in Knee Cartilage of Rabbits with Knee Osteoarthritis [J]. Acupuncture Research, 2015,40(3):229-232.
Notes
[1] Gao L, Chen M, Yue P, Zhang R, Xin SC. Effect of Warm-needle Moxibustion on Expression of Transfer Growth Factor-beta1 and Insulin like Growth Factor 1 in Knee Cartilage of Rabbits with Knee Osteoarthritis [J]. Acupuncture Research, 2015,40(3):229-232.
[2] Trippel S B. Growth Factor Inhibition Potential Role in the Etiopathogenesis of Osteoarthritis [M]. Philadelphia: Lippincott Williams & Wilkins, 2004:47-52.
[3] Fahlgren A, Andersson B, Messner K. TGF-beta1 as a prognostic factor in the process of early osteoarthrosis in the rabbit knee. Osteoarthritis Cartilage. 2001; 9:195–202. doi: 10.1053/joca.2000.0376.
[4] Couchourel D, Aubry I, Delalandre A, et al. Altered Mineralization of Human Osteoarthritic Osteoblasts Is Attributable to Abnormal Type I Collagen Production. Arthritis and rheumatism. 2009;60(5):1438-1450. doi:10.1002/art.24489.
[5] Tsai S-H, Sheu M-T, Liang Y-C, Cheng H-T, Fang S-S, Chen C-H. TGF-β inhibits IL-1β-activated PAR-2 expression through multiple pathways in human primary synovial cells. Journal of Biomedical Science. 2009;16(1):97. doi:10.1186/1423-0127-16-97.
[6] Lan X, Liu XM, Ge BF et al. Observation of Serum IGF-1 Concentration of Primary Osteoarthritis in Guinea Pigs [J]. Orthopedic Journal of China, 2000, 7(7):667-668.
[7] Wei YX, Wei Z, Liu P et al. Experimental Study on the Repair of Articular Cartilage Defects and Prevention on Osteoarthritis by Intra-articular Injection of IGF-1, TGF-β1 [J]. Chinese Journal of Clinical Healthcare, 2010, 13(3):274-277.

From March 2018 Health CMi

Lumbar Spinal Stenosis

Background

Although the efficiency of conservative management for lumbar spinal stenosis (LSS) has been examined, different conservative management approaches have not been compared. We have performed the first comparative trial of three types of conservative management (medication with acetaminophen, exercise, and acupuncture) in Japanese patients with LSS.

Methods

Patients with L5 root radiculopathy associated with LSS who visited our hospital for surgical treatment were enrolled between December 2011 and January 2014. In this open-label study, patients were assigned to three treatment groups (medication, exercise, acupuncture) according to the visit time. The primary outcomes were Zurich claudication questionnaire (ZCQ) scores before and after 4 weeks of treatment. Least square mean analysis was used to assess the following dependent variables in the treatment groups: changes in symptom severity and physical function scores of the ZCQ and the ZCQ score of patient’s satisfaction after treatment.

Results

Thirty-eight, 40, and 41 patients were allocated to the medication, exercise, and acupuncture groups, respectively. No patient underwent surgical treatment during the study period. The symptom severity scores of the ZCQ improved significantly after treatment in the medication (p = 0.048), exercise (p = 0.003), and acupuncture (p = 0.04) groups. The physical function score improved significantly in the acupuncture group (p = 0.045) but not in the medication (p = 0.20) and exercise (p = 0.29) groups. The mean reduction in the ZCQ score for physical function was significantly greater for acupuncture than for exercise. The mean ZCQ score for treatment satisfaction was significantly greater for acupuncture than for medication.

Conclusions

Acupuncture was significantly more effective than physical exercise according to the physical function score of the ZCQ and than medication according to the satisfaction score. The present study provides new important information that will aid decision making in LSS treatment.

Citation: Oka, H., Matsudaira, K., Takano, Y., Kasuya, D., Niiya, M., Tonosu, J., … & Inanami, H. (2018). A comparative study of three conservative treatments in patients with lumbar spinal stenosis: lumbar spinal stenosis with acupuncture and physical therapy study (LAP study). BMC complementary and alternative medicine18(1), 19.

To download a copy, click here: s12906-018-2087-y

Fibromyalgia: New Research

Zhang, X. C., Chen, H., Xu, W. T., Song, Y. Y., Gu, Y. H., & Ni, G. X. (2019). Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. Journal of Pain Research, 12, 527-542.  Purpose: Fibromyalgia (FM) can cause chronic widespread pain and seriously affect the quality of patient lives. Acupuncture therapy is widely used for pain management. However, the effect of acupuncture on FM is still uncertain. The aim of this review was to determine the effect and safety of acupuncture therapy on the pain intensity and quality of life in patients with FM.

Materials and methods: We searched PubMed, the Cochrane Library, Embase, the China National Knowledge Infrastructure, the Chinese Science and Technology Periodical Database, and the Chinese Biomedical Literature Database to collect randomized controlled trials (RCTs) of acupuncture for FM published before May 2018. A meta-analysis was performed according to the Cochrane systematic review method by using RevMan 5.3 software, and GRADE was used to evaluate the quality of the evidence.

Results: We identified 12 RCTs that compared acupuncture therapy to sham acupuncture or conventional medication. Meta-analysis showed that acupuncture was significantly better than sham acupuncture for relieving pain (MD =-1.04, 95% CI [-1.70, -0.38], P=0.002, I2=78%) and improving the quality of life (MD =-13.39, 95% CI [-21.69, -5.10], P=0.002, I2=82%), with low- to moderate-quality evidence in the short term. At follow-up in the long term, the effect of acupuncture was also superior to that of sham acupuncture. No serious adverse events were found during acupuncture.

Conclusion: Acupuncture therapy is an effective and safe treatment for patients with FM, and this treatment can be recommended for the management of FM.

Pelvic Pain & Acupuncture

talking-about-pelvic-painBACKGROUND: Endometriosis is a multifactorial, oestrogen-dependent, inflammatory, gynaecological condition that can result in long-lasting visceral pelvic pain and infertility. Acupuncture could be an effective treatment for endometriosis and may relieve pain. Our aim in the present study was to determine the effectiveness of acupuncture as a treatment for endometriosis-related pain.

METHODS:  In December 2016, six databases were searched for randomised controlled trials that determined the effectiveness of acupuncture in the treatment of endometriosis-related pain. Ultimately, 10 studies involving 589 patients were included. The main outcomes assessed were variation in pain level, variation in peripheral blood CA-125 level, and clinical effective rate. All analyses were performed using comprehensive meta-analysis statistical software.

RESULTS:  Of the 10 studies included, only one pilot study used a placebo control and assessed blinding; the rest used various controls (medications and herbs), which were impossible to blind. The sample sizes were small in all studies, ranging from 8 to 36 patients per arm. The mean difference (MD) in pain reduction (pre- minus post-interventional pain level-measured on a 0-10-point scale) between the acupuncture and control groups was 1.36 (95% confidence intervals [CI] = 1.01-1.72, P<0.0001). Acupuncture had a positive effect on peripheral blood CA-125 levels, as compared with the control groups (MD = 5.9, 95% CI = 1.56-10.25, P = 0.008). Similarly, the effect of acupuncture on clinical effective rate was positive, as compared with the control groups (odds ratio = 2.07; 95% CI = 1.24-3.44, P = 0.005).

CONCLUSIONS: Few randomised, blinded clinical trials have addressed the efficacy of acupuncture in treating endometriosis-related pain. Nonetheless, the current literature suggests that acupuncture reduces pain and serum CA-125
 levels, regardless of the control intervention used. To confirm these findings, additional, blinded studies with proper controls and adequate sample sizes are needed.
Citation: Xu, Y., Zhao, W., Li, T., Zhao, Y., Bu, H., & Song, S. (2017). Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis. PloS one, 12(10), e0186616.

Low Back Pain

50116042 - acupuncturist is treating the woman's backImpact of acupuncture treatment on the lumbar surgery rate for low back pain in Korea: A nationwide matched retrospective cohort study

Introduction

Low back pain (LBP) is a globally prevalent disorder with high social significance. Invasive surgical procedures are increasingly being used to treat LBP despite a lack of solid evidence supporting their long-term benefits. This nationwide retrospective cohort study investigated the association between acupuncture treatment and lumbar surgery rate in patients with LBP.

Methods

Using the National Health Insurance Service Sample Cohort Database for 2002–2013, we identified newly diagnosed LBP patients in Korea between 2004 and 2010 and divided them into an acupuncture group and control group according to whether or not they received acupuncture. Propensity scores based on age, sex, income, and Charlson Comorbidity Index were matched between the two study groups. The lumbar surgery rate in the two years following the first visit (control group) or the first acupuncture session (acupuncture group) was calculated. In addition to the overall analysis, stratified analyses were also conducted in different age, sex, and income strata. Sensitivity analyses were further performed using varying definitions of acupuncture treatment.

Results

After matching, 130,089 subjects were included in each study group. The lumbar surgery rate was significantly lower in the acupuncture group than in the control group (hazard ratio [HR] 0.633, 95% confidence interval [CI] 0.576–0.696). Decrease in HR was consistently observed in the acupuncture group for all age strata, except for patients in their 20s (HR 1.031, 95% CI 0.804–1.323). HR for lumbar surgery tended to be further reduced in the older age groups upon acupuncture treatment, with no apparent sex-related differences. Lowered HR in the acupuncture group was continuously observed across all income groups; the higher income group showed a tendency of greater decrease. Sensitivity analyses showed that the number of acupuncture sessions had no major impact on the likelihood of lumbar surgery, but also that more intensive acupuncture treatment was associated with further reduction in lumbar surgery rates.

Conclusion

The present results found that administration of acupuncture treatment is associated with lower lumbar surgery rates for LBP patients in Korea. Prospective studies are warranted in the future to further investigate the effect of acupuncture treatment on lumbar surgery incidence.

To download the full PDF study click here.

Citation: Koh, W., Kang, K., Lee, Y. J., Kim, M. R., Shin, J. S., Lee, J., … & Ha, I. H. (2018). Impact of acupuncture treatment on the lumbar surgery rate for low back pain in Korea: A nationwide matched retrospective cohort study. PloS one13(6), e0199042.

Acupuncture and Carpal Tunnel Syndrome

wristFrom HealthCMi Aug 2018

Researchers find acupuncture effective for the treatment of carpal tunnel syndrome (CTS), a local entrapment neuropathy affecting the wrist and hand that causes pain, numbness, and dysfunction. The research team documents acupuncture’s beneficial influence on the morphology of the median nerve and improvement of clinical symptoms.

According to researchers conducting the investigation, “while previous studies investigated the effect of acupuncture on clinical symptoms and electromyographic studies, to the best of our knowledge, its effect on median nerve morphology was not investigated before.” [1] This study demonstrates that acupuncture influences morphology of the median nerve, which opens up a host of possible future studies that may build upon this foundation of knowledge.

Median nerve compression in the carpal tunnel region of the wrist results in pain, numbness, and tingling in the fingers or hand, as well as possible weakness and atrophy of the hand muscles innervated by the median nerve. [2] More prevalent among women, it is correlated with overuse, diabetes mellitus, rheumatoid arthritis, hypothyroidism, and pregnancy. [3]

Diagnostically and prognostically, musculoskeletal ultrasound imaging has been growing in popularity for monitoring this condition because of its ease and cost effectiveness. Musculoskeletal ultrasound shows the cross-sectional area (CSA) in the wrist level of the median nerve and this study documents correlations between median nerve cross-sectional areas and electrophysiological changes within the CTS affected limb.

A total of 27 female patients (45 limbs) with CTS were diagnosed with electromyographic tests for the purposes of this investigation. The patients were similar in age, BMI (body mass index), duration of disease, and severity of CTS. Exclusionary criteria were the following: radicular pain, polyneuropathy, radial or ulnar nerve diseases, severe CTS, trauma history, prior hand surgery.

In patients with bilateral CTS, both extremities were included in the same group. All patients were informed about the study and provided consent. They were randomly divided into two groups (acupuncture and control). The mean duration of the disease was 18.3 months and 19.3 months respectively. Both groups used night wrist splints for CTS for 4 weeks, while only the acupuncture group received acupuncture treatments. The following nine acupoints were selected for the study:

  • Daling (PC7)
  • Ximen (PC4)
  • Neiguan (PC6)
  • Laogong (PC8)
  • Qingling (HT2)
  • Shenmen (HT7)
  • Shaofu (HT8)
  • Taiyuan (LU9)
  • Quchi (LI11)

The median nerve cross-sectional area was measured at the proximal carpal tunnel with musculoskeletal ultrasound, with the scaphoid and pisiform bones used as bony landmarks for the proximal tunnel where the cross section was measured. [4] Needles of size 0.25 × 25 mm were inserted into the points and were retained for 25 minutes per acupuncture session. Treatments were conducted two or three days per week for four weeks, totaling ten sessions.

Results
The median nerve cross-sectional area was measured by using musculoskeletal ultrasound on the patients while seated and positioned similarly (elbow at 90 degree flexion with the forearm in supination position). Cross-sectional areas of size 9 mm or greater had previously been determined as a possible diagnostic measure for CTS. [5]

Pain severity, hand function, and musculoskeletal ultrasound measurements were taken before and after treatments. The visual analog scale (VAS: 0–10 cm) measured pain severity. The Duruoz Hand Index (DHI) and Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores were used to assess hand functions and disability. All electrophysiological tests were performed by using a Nihon Cohden Neuropack machine.

Compound muscle action potential (CMAP: normal >6.8 mV) measured the reaction of the abductor pollicis brevis muscle to stimulation at the wrist and elbow. Sensory nerve action potential (SNAP: normal >10 uV) measured the reaction of wrist stimulation to signals traveling in the opposite direction of normal signals in the nerve fiber (antidromic) of the second finger. Motor distal latency (normal <3.8 ms), sensory nerve conduction velocity (SNCV: normal >40.4 m/sec), and motor nerve conduction velocity (M-NCV: normal >49.4 m/sec) were also measured before and after treatment.

Acupuncture group positive outcomes proved significant. The median nerve cross-sectional area decreased from 11.6 to 10.6 mm, motor distal latency decreased from 4.3 to 4.1 ms, and SNAP increased from 16.7 to17.6 uV. Also in the acupuncture group, VAS decreased from 9 to 4.8, CMAP increased from 12.9 to 14.8 mV, DHI decreased from 47 to 37, Quick DASH decreased from 67.2 to 56.8, S-NCV increased from 31 to 33.2 m/sec, and motor nerve velocity increased from 57.4 to 59 m/sec.

The improvement within the acupuncture group when comparing baseline values with the results highlights the success of acupuncture in decreasing clinical symptoms of CTS. It also highlights its ability to transform median nerve morphology such that acupuncture can reduce the cross-sectional area. The results within the control group were not as significant as the acupuncture group, highlighting the efficacy of acupuncture in treating neuropathic disorders compared with night splint monotherapy.

The researchers cited several investigations showing acupuncture’s positive influence on CTS. Recent studies have used magnetic resonance imaging to show how acupuncture may alter brain activity and the limbic system of CTS patients. [6,7,8] Acupuncture produces anti-inflammatory effects in the median nerve within the carpal tunnel, as well as effects that can be compared to ibuprofen, night splints, and oral or injected steroids. [9,10,11]

Summary
Acupuncture generates beneficial morphological changes in the median nerve of patients with carpal tunnel syndrome and reduces or eliminates symptoms. Based on the scientific evidence, acupuncture is a reasonable treatment option. Consult with a local licensed acupuncturist to learn more.

References:
1 Ural, Fatma Gülçin, and Gökhan Tuna Öztürk. “The acupuncture effect on median nerve morphology in patients with carpal tunnel syndrome: an ultrasonographic study.” Evidence-Based Complementary and Alternative Medicine 2017 (2017).

2. S. Tanaka, D. K. Wild, P. J. Seligman, V. Behrens, L. Cameron, and V. Putz-Anderson, “The US [musculoskeletal ultrasound] prevalence of self-reported carpal tunnel syndrome: 1988 national health interview survey data,”American Journal of Public Health, vol. 84, no. 11, pp. 1846– 1848, 1994.

3. R. J. Spinner, J. W. Bachman, and P. C. Amadio, “The many faces of carpal tunnel syndrome,” Mayo Clinic Proceedings, vol. 64, no. 7, pp. 829–836, 1989.

4. Ural, Fatma Gülçin, and Gökhan Tuna Öztürk. “The acupuncture effect on median nerve morphology in patients with carpal tunnel syndrome: an ultrasonographic study.” Evidence-Based Complementary and Alternative Medicine 2017 (2017).

5. J. T. Mhoon, V. C. Juel, and L. D. Hobson-Webb, “Median nerve ultrasound as a screening tool in carpal tunnel syndrome: correlation of cross-sectional area measures with electrodiagnostic abnormality,” Muscle and Nerve, vol. 46, no. 6, pp. 871–878, 2012.

6. A. U. Asghar, G. Green, M. F. Lythgoe, G. Lewith, and H. MacPherson, “Acupuncture needling sensation: the neural correlates of deqi using fMRI,” Brain Research, vol. 1315, pp. 111–118, 2010.

7. V. Napadow, J. Liu, M. Li et al., “Somatosensory cortical plasticity in carpal tunnel syndrome treated by acupuncture,” Human Brain Mapping, vol. 28, no. 3, pp. 159–171, 2007.

8. V. Napadow, N. Kettner, J. Liu et al., “Hypothalamus and amygdala response to acupuncture stimuli in carpal tunnel syndrome,” Pain, vol. 130, no. 3, pp. 254–266, 2007.

9. M. Hadianfard, E. Bazrafshan, H. Momeninejad, and N. Jahani, “Efficacies of acupuncture and anti-inflammatory treatment for carpal tunnel syndrome,” Journal of Acupuncture and Meridian Studies, vol. 8, no. 5, pp. 229–235, 2015.

10. Ho, Chien-Yi, Hsiu-Chen Lin, Yu-Chen Lee, Li-Wei Chou, Ta-Wei Kuo, Heng-Wei Chang, Yueh-Sheng Chen, and Sui-Foon Lo. “Clinical effectiveness of acupuncture for carpal tunnel syndrome.” The American journal of Chinese medicine 42, no. 02 (2014): 303-314.

11. Yang, Chun-Pai, Nai-Hwei Wang, Tsai-Chung Li, Ching-Liang Hsieh, Hen-Hong Chang, Kai-Lin Hwang, Wang-Sheng Ko, and Ming-Hong Chang. “A randomized clinical trial of acupuncture versus oral steroids for carpal tunnel syndrome: a long-term follow-up.” The Journal of Pain 12, no. 2 (2011): 272-279.