Research Database –
International Updates

Acupuncture

Issue 92

ELORRIAGA and colleagues, Department of Anaesthesia, McMaster University, Hamilton, Ontario, Canada, aelorriaga@sympatico.ca, have reviewed (16 references) the reporting of clinical details in trials of acupuncture for the treatment of migraine/headaches and nausea/vomiting.
Background: The aim of this study was to investigate the degree of reporting of clinical details in 30 randomized controlled trials on acupuncture for the treatment of migraine-headaches (11 trials) and nausea/vomiting (19 trials). In addition, the quality of randomization and the degree of reporting of information about the main outcome measures was to be assessed.
Methods: A checklist of 50 clinical details selected on the basis of a
previous study was used to evaluate the degree of reporting of information about patients, practitioners, diagnoses, and acupuncture treatments. The likelihood of bias in the randomization process was assessed using a previously validated scale. Information about the validity and clinical significance of main outcome measures was rated as fully,
partially, or not reported.
Results: In this sample of acupuncture trials, an average of 38.7% of important clinical details per trial were reported by researchers, the lowest being 26.4% for the migraine/headache group. Studies with better quality of randomization were not more likely to report more clinical details. Only five studies provided information about reliability and validity of the main outcome measures, and only four studies, all from the migraine/headache group, discussed the clinical significance of the outcome measures used.
Conclusions: The reporting of important clinical information in these studies was inadequate. Often the researchers did not discuss the reliability, validity and clinical relevance of the outcome measures used, thus rendering potential readers unable to assess the usefulness of the trials from a clinical point of view.
Elorriaga CA, Hanna SE, Fargas BA. Reporting of clinical details in randomized/controlled trials of acupuncture for the treatment of migraine/headaches and nausea/vomiting. The Journal of Alternative and Complementary Medicine 9 (1): 151-159, Feb 2003.

GRABOWSKA et al., Faculty of Health and Human Sciences, Thames Valley University, 32-38 Uxbridge Road, London W5 2BS, UK, christine.grabowska@tvu.ac.uk, have described the provision of acupuncture in a university health centre.
Methods: A retrospective audit was carried out for a year at a university-based acupuncture clinic. Two acupuncturists saw a total of 69 clients. Most had no experience of complementary or alternative medicine previously.
Results: Three quarters of clients were women; a third were less than 29 years old; two thirds were less than 40 years old; two thirds were Caucasians; a third smoked; and three quarters consumed some alcohol. Of those who attended follow up, 43 (80%) reported feeling better, 10 the same and one worse. No side effects were reported by 50 (73%) clients. Four reported minor side effects such as bruising and drowsiness.
Conclusions: The process of carrying out the audit gave the practitioners an opportunity to reflect on their clinical practice and improve service delivery.
Grabowska C, Squire C, MacRae E, Robinson N. Provision of acupuncture in a university health centre – a clinical audit. Complementary Therapies in Nursing and Midwifery 9 (1): 14-19, Feb 2003.

SAMUELS, Shoresh Medical Center, Jerusalem, Israel, reviews (34 references) clinical efficacy of acupuncture for nausea.
Abstract: Nausea results from stimulation of the Chemoreceptor Trigger Zone (CTZ) and the Vomiting Centre in the brain. Conventional medical therapy is not always effective and can have severe adverse effects. Acupuncture is a treatment where thin needles are inserted into the skin at points on energy channels (meridians) established thousands of years ago. The anti-emetic effects of acupuncture are apparently due to an increase in beta-endorphin and ACTH secreted from the pituitary gland, which subsequently inhibits both CTZ and Vomiting Centre. Concomitantly there is a decrease in acid secretion from the stomach, and a repression of gastric arrhythmias. Clinical research has found acupuncture to be an effective treatment for nausea, whether this be morning sickness in pregnant women, motion sickness in travellers, postoperative nausea, or chemotherapy-induced nausea n cancer patients.
Samuels N. Acupuncture for nausea: how does it work? Harefuah 142 (4): 297-300, 316, Apr 2003.

Issue 91

LACEY and co-workers,West Chester University, Sturzebecker Health Sciences Center, PA 19383, USA, have reviewed (81 references) the use of acupuncture for the treatment of obesity.
Abstract: The usefulness of acupuncture in obesity management has not been fully evaluated. This review describes the underlying principles of acupoint stimulation with an emphasis on auricular acupuncture, the method most often used for weight reduction. It is difficult to select suitable placebo methods. Studies available in the literature are usually of short duration (less than 3 months) and designed using non-standard treatment protocols. Further careful study of acupuncture as an adjunct in overweight management is advocated, and a research agenda is proposed.
Lacey JM, Tershakovec AM, Foster GD. Acupuncture for the treatment of obesity: a review of the evidence. International Journal of Obesity and Related Metabolic Disorders 27 (4): 419-427, Apr 2003.

NORHEIM and FOENNEBOE, National Research Centre for Alternative Medicine University of Tromsoe, Tromsoe, Norway, arne_norheim@hotmail.com, have conducted a survey of attitudes to the contribution of placebo in acupuncture.
Background: The aim of the study was to explore attitudes and beliefs about the placebo effect in acupuncture amongst doctors, patients, and acupuncturists.
Methods: Between February 1994 and June 1995, 4 anonymous
questionnaires were randomly distributed among 1135 doctors, 294 medical students, 432 acupuncturists and 653 members of the general public in Norway.
Results: 57% indicated the treatment effect seen in acupuncture as mainly a genuine acupuncture effect, 30% thought that half the effect comes from a placebo response, and 13% were of the opinion that the effect seen in acupuncture is mainly a placebo effect. Doctors and students expressed more sceptical views than others, and having had acupuncture treatment was significantly associated with a less sceptical view amongst all groups. Attitudes to the use of acupuncture for cancer patients are associated with attitudes to placebo for doctors and medical students, but not for the general public or acupuncturists.
Norheim AJ, Foenneboe V. Attitudes to the contribution of placebo in acupuncture – a survey. Complementary Therapies in Medicine 10 (4): 202-209, Dec 2002.

SMITH and CROWTHER, Department of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, SA, Australia, caroline.anne.smith@adelaide.edu.au, report on the placebo response in a trial of acupuncture for nausea and vomiting in early pregnancy.
Background: In order to assess the adequacy of a sham acupuncture control, its ‘credibility’ was explored in a study aimed at reducing nausea and vomiting in pregnant women.
Methods: 593 women with nausea or vomiting in early pregnancy were enrolled in this randomized placebo-controlled study. Participants completed the Rhodes Index of Nausea and Vomiting and the Credibility Rating Scale.
Results: The credibility of the acupuncture and sham acupuncture were not different. The change in nausea at the end of a week of study was 28% for the acupuncture procedure and 7% for the sham procedure. At the end of 3 weeks of study, there was a further small increase in effect: 32% for the acupuncture and 17% for the placebo treatment.
Conclusions: Sham acupuncture is a credible control and allows assessment of the size of the placebo response.
Smith C, Crowther C. The placebo response and effect of time in a trial of acupuncture to treat nausea and vomiting in early pregnancy. Complementary Therapies in Medicine 10 (4): 210-216, Dec 2002.

Comment: As can be seen by the above research studies, there is considerable activity across clinicians and academia to research the effects of acupuncture and to design methods that properly study these effects.

Issue 88

AHADIAN, Center for Pain and Palliative Medicine, University of California, San Diego, La Jolla 92093-0924, USA, fahadian@ucsd.edu, describes acupuncture in pain medicine as an integrated approach to the
management of refractory pain.
Abstract: The acupuncture nomenclature is gradually permeating
medical literature, and concomitantly the artificial barriers to integration of allopathic medicine and acupuncture are dissolving. Patients are increasingly looking to their physicians for help in integrating acupuncture in their health care, and pain physicians are accepting the challenge. As allopathic medicine, acupuncture is an intricate and detailed diagnostic and therapeutic system. For practising physicians, mastery of the skills necessary for the safe and affective treatment of many conditions is well within reach. Used in an integrated medical model, acupuncture is well suited to deal with many of the functional problems that allopathic medicine is not equipped to address. The result is patient and physician satisfaction.
Ahadian FM. Acupuncture in pain medicine: an integrated approach to the management of refractory pain. Current Pain and Headache Reports 6 (6): 444-451, Dec 2002.

CHANG and colleagues, The Institute of East-West Medicine, New York, NY 10021, USA, review (69 references) the role of acupuncture in the treatment of female infertility.
Background: The object of the review was to identify existing scientific rationale and clinical data in the use of acupuncture for infertility.
Methods: A Medline search was performed to find relevant articles.
Results: Studies have suggested that certain effects of acupuncture are mediated through endogenous opioids in the central nervous system, particularly beta-endorphin. Because these neuropeptides influence gonadotropin secretion, it seems logical to hypothesize that they may interfere with the female menstrual cycle.
Although studies of adequate design, sample size, and appropriate control on the effects of acupuncture on ovulation are lacking, there is one prospective randomized controlled study examining acupuncture in women undergoing IVF. Besides its central effect, the inhibitory effect of acupuncture on the sympathetic nervous system may increase blood flow to the uterus.
Conclusions: Although a definitive role for acupuncture in the treatment of female infertility is yet to be established, the effects both on the hypothalamic-pituitary-ovarian axis and on uterine blood supply warrant further study.
Chang R, Chung PH, Rosenwaks Z. Role of acupuncture in the treatment of female infertility. Fertility and Sterility 78 (6): 1149-1153, Dec 2002.

POURESMAIL and IBRAHIMZADEH, Shaheed Beheshti University of Medical Sciences and Health Services, Tehran, Iran, describe the effects of acupressure and ibuprofen on the severity of primary dysmenorrhoea.
Background: The aim of this randomized controlled trial was to compare the effects of acupressure using a new combination of acupoints, with Ibuprofen on the severity of primary dysmenorrhoea.
Methods: 216 female high school students aged 14–18 were randomly divided into three groups. One group received acupressure, the second group Ibuprofen, and the third group a sham acupressure treatment as placebo control.
Results: All three techniques produced a reduction in the severity of pain. Acupressure and Ibuprofen were similar to each other and significantly better than the sham procedure.
Conclusions: Acupressure, which produces no complications, is recommended as a better choice in the treatment of period pains.
Pouresmail Z, Ibrahimzadeh R. Effects of acupressure and Ibuprofen on the severity of primary dysmenorrhoea. Journal of Traditional Chinese Medicine 22 (3): 205-210, Sep 2002.

WONG and co-workers, Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China, present a clinical trial of acupuncture for patients with spinal cord injuries.
Background: The objective of the study was to establish whether electrical acupuncture through adhesive surface electrodes, together with auricular acupuncture, could improve the neurological or functional recovery of patients suffering from traumatic spinal cord injury.
Methods: A total of 100 patients with acute traumatic spinal cord injuries were recruited for this trial. They were randomly divided into acupuncture and control groups. The acupuncture group received electrical acupuncture via adhesive surface electrodes to the bilateral S13 and B62 points. In auricular acupuncture, four acupoints related to the spinal cord were stimulated at the helix, antihelix, and lower portion of the ear-back areas. Acupuncture therapy was initiated early in the emergency room setting or soon after surgical intervention. At the same time, patients were offered rehabilitation therapy. Patients in the control group received only rehabilitation therapy. Neurological and functional scores were assessed at admission, at hospital discharge, and at one year follow-up.
Results: There were significant improvements in neurological (sensory and motor) and functional scores both at hospital discharge and at one year follow-up in the acupuncture group compared to the control group. A greater percentage of patients in the acupuncture group recovered to a diminished degree of impairment.
Conclusions: The use of concomitant auricular and electrical acupuncture, when used early in acute spinal cord injury, can contribute to significant neurological and functional recovery.
Wong AMK, Leong CP, Su TY, Yu SW, Tsai WC, Chen CPC. Clinical trial of acupuncture for patients with spinal cord injuries. American Journal of Physical Medicine and Rehabilitation 82 (1): 21-27, Jan 2003.
Comments: The above studies demonstrates the extent of clinical research ongoing using acupuncture for a wide range of conditions.

Issue 87

XUE and co-workers, The Chinese Medicine Unit, RMIT University, Bundoora, Victoria, Australia, charlie.xue@rmit.edu.au, investigated the effect of acupuncture on seasonal allergic rhinitis in a randomized controlled clinical trial.
Background: This two-phase crossover, single-blinded clinical trial was conducted with the aim of assessing the safety and efficacy of acupuncture in the treatment of seasonal allergic rhinitis (hayfever).
Methods: 30 patients were randomly assigned to two groups with 17 and 13 subjects respectively and treated with real or sham acupuncture three times a week for four weeks. The treatments were then crossed over for a further four weeks without a washout period. The acupuncture treatment was individualized. Patients were assessed before, during and after treatment. Outcome measures included subjective symptom scores, relief medication scores and adverse effects.
Results: 26 patients completed the trial. There was a significant improvement in symptom scores between the two treatments. No significant differences were found for relief medication, and no side effects were recorded in either group.
Conclusions: The results suggest that acupuncture is a safe and effective treatment for hayfever.
Xue CC, English R, Zhang JJ, Da Costa C, Li CG. Effect of acupuncture in the treatment of seasonal allergic rhinitis: a randomized controlled clinical trial. The American Journal of Chinese Medicine 30 (1): 1-11, 2002.

ZHU and POLUS, Betta Health Medical Center, Chinese Medicine Unit, Chadstone, Victoria, Australia, annzhu29@hotmail.com, conducted a controlled trial of acupuncture for chronic neck pain.
Background: In this single blind, controlled crossover study, the efficacy of traditional Chinese acupuncture as a treatment for chronic neck pain was evaluated.
Methods: 29 volunteers with chronic neck pain were randomly assigned to two groups. Both groups received two phases of treatment with a washout period between the two phases. Group A (14 patients) received acupuncture in the first phase and a sham treatment in the second phase. Group B (15 patients) received the sham treatment in the first phase and acupuncture in the second phase. Acupuncture was individualized and consisted of nine sessions on both local and distal points. Manual twisting of needles was performed on all points plus strong electrical stimulation on distal points. Sham acupoints (lateral to the real) and weak electrical stimulation were used in the control groups. Comparison of subjective and objective measures between the two groups was made at baseline, after each treatment phase, after washout, and after a 16-week follow up. Subjective measures included pain intensity, duration each day, analgesic medication count, and Neck Disability Index (NDI). Objective measures consisted of neck range of motion (ROM) and pain threshold.
Results: Both the real and sham treatments significantly reduced pain without significant difference between the two treatments according to the subjective measures. In the objective measures, there was no change from baseline in either group.
Conclusions: Further study is recommended with an increased sample size and longer baseline and washout periods.
ZhU XM, Polus B. A controlled trial on acupuncture for chronic neck pain. The American Journal of Chinese Medicine 30 (1): 13-28, 2002.

WHITE and colleagues, University of Southampton, Royal South Hants Hospital, Southampton, U.K., review (81 references) literature reviews of acupuncture for chronic neck pain to show pitfalls in conducting systematic reviews.
Background: The paper examines some of the problems specifically associated with conducting research into acupuncture and how this can lead to further problems in subsequent systematic reviews.
Methods: Studies for the treatment of chronic neck pain have been used as examples of how presented information can be misleading to an acupuncture-naïve reader.
Results and conclusions: Researchers must be sensitive to the demonstrated problems when compiling inclusion and exclusion criteria. The problems with scoring trials are discussed and further work to increase the scope of scoring mechanisms is recommended in order to produce more meaningful systematic reviews in the future.
White P, Lewith G, Berman B, Birch S. Reviews of acupuncture for chronic neck pain: pitfalls in conducting systematic reviews. Rheumatology 41 (11): 1224-1231, Nov 2002.

Comment: White and colleagues can take heart that researchers are battling with methodologies to properly assess the therapeutic efficacy of acupuncture for chronic neck pain and other conditions.

Issue 86

SZE and colleagues, Department of Medicine and Geriatrics, Shatin Hospital, N.T. Hong Kong, fkhsze@hotmail.com conducted a meta-analysis of randomized controlled trials of acupuncture in motor recovery after stroke.

Background: Acupuncture may be a promising treatment for post-stroke paralysis. This meta-analysis assesses the efficacy of acupuncture with and without stroke rehabilitation.

Methods: Randomized controlled trials comparing acupuncture to no acupuncture within 6 months of a stroke were identified by searching MEDLINE, CINAHL, EMBASE, Cochrane Library, and Chinese medical literature databases.

Results: 14 trials met the inclusion criteria. In trials that investigated acupuncture or no acupuncture in addition to stroke rehabilitation, no effects on change in motor impairment were found, and a small change in disability. Trials comparing real and sham acupuncture showed no effect. In trials with no additional stroke rehabilitation, there was a positive effect of acupuncture, but these studies were of a poor quality.

Conclusions: With stroke rehabilitation, acupuncture has no additional effect on motor recovery but has a small effect on disability. Without stroke rehabilitation, the effect of acupuncture remains uncertain.

Sze KFH, Wong E, Or KKH, Lau J, Woo J, et al. Does acupuncture improve motor recovery after stroke? A meta-analysis of rendomized controlled trials. Stroke 33 (11): 2604-2619, Nov 2002.

TARGINO et al., Division of Physical Medicine, Department of Orthopedics and Traumatology, University of Sao Paulo School of Medicine, Ave. Giovanni Gronchi, 1106 Sao Paulo, Brazil, ucklrsu@ucl.ac.uk, review (36 references) acupuncture treatment for pain in patients with fibromyalgia.

Background: Fibromyalgia is a chronic, painful musculoskeletal syndrome of unknown etiology. Several complementary therapies have been used in an attempt to decrease symptoms. This article presents a literature review of acupuncture trials for the condition.

Results: Application of traditional acupuncture results in positive rates on a Pain VAS, myalgic index, number of tender points, and improvement in quality of life as measured by the SF-36 questionnaire.

Targino RA, Imamura M, Kaziyama HHS, Souza LPM, Hsing WT, Imamura ST, et al. Pain treatment with acupuncture for patients with fibromyalgia. Current Pain and Headache Reports 6 (5): 379-383, Oct 2002.

Issue 85

FREEDMAN, Jonathan.Freedman@gp-e82060.nhs.uk, carried out an audit of 500 acupuncture patients in general practice.

Methods: An audit of 500 patients receiving acupuncture in a general practice. The clinic is run twice a week and funded by the practice. Short treatment courses are favoured but modulated according to patient need. The commonest conditions treated are neck pain, low back pain, shoulder problems, hayfever, knee osteoarthritis, and migraine.

Results and Conclusions: An overall improvement of 73% was obtained, with 61% classified as ‘significant’ or ‘cure’. The most worrying adverse effects encountered have been retained needles and forgotten patients, and this has led to appropriate changes in practice.

Freedman J. An audit of 500 acupuncture patients in general practice. Acupuncture in Medicine 20 (1): 30-34, Mar 2002.

GALLAGHER et al., Department of Psychology, University of Arizona, Tucson 85721—0068, USA, investigate the six-months relapse rate among women treated with acupuncture for depression.

Background: Conventional treatments for major depression, although reasonably effective, leave many patients without lasting relief. It is therefore desirable to explore alternative treatments that may provide more long-lasting improvement.

Methods: Randomized controlled double-blinded trial of eight weeks of acupuncture treatment of 38 women with depression. 26 women were interviewed at six months follow-up.

Results: 17 women had achieved full remission at the end of treatment; of these, 4 (24%) suffered a relapse within six months.

Conclusions: Compared to other empirically validated treatments for depression, acupuncture designed to address depression produces results that are comparable in terms of rates of response and relapse. The results suggest that a larger study of acupuncture in the acute and maintenance phase of major depression is warranted.

Gallagher SM, Allen JJ, Hitt SK, Schnyer RN, Manber R. Six-month depression relapse rates among women treated with acupuncture. Complementary Therapies in Medicine 9(4): 216-218, Dec 2001.

BIER and co-workers, I.B. Scientific, LLC, 1 Griffith Drive, Durham, NH 03824, USA, drbier@ibscientific.com, examined auricular acupuncture, education, and smoking cessation.

Background: The study evaluates the effect of auricular acupuncture alone and in combination with education on smoking cessation and cigarette consumption.

Methods: Randomized, sham-controlled prospective trial of 141 adults in a quasi-factorial design using acupuncture, sham acupuncture and education.

Results: All groups showed significant reduction in smoking, with the combined acupuncture – education group showing the greatest effect. The trend continued in follow-ups; however significant differences were not maintained. The amount smoked and number of years smoked negatively correlated with the treatment effect.

Conclusions: Acupuncture and education, alone and in combination, significantly reduce smoking; combined they show a greater effect.

Bier ID, Wilson J, Studt P, Shakleton M. Auricular acupuncture, education, and smoking cessation: a randomized, sham-controlled trial. American Journal of Public Health 92 (10): 1642-1647, Oct 2002.

Comment: As the above research suggests, there is a considerable amount of clinical work being carried out investigating the therapeutic efficacy of acupuncture for a range of conditions.

Issue 84

KAM and co-workers performed an audit of the effectiveness of acupuncture for musculoskeletal pain in primary health care.

Background: Musculoskeletal pain is very commonly encountered in general practice, yet little is known of the use of acupuncture for its treatment.

Methods: 116 patient records were examined. 92 patients met the diagnostic criteria for musculoskeletal pain. Information obtained included age, gender, diagnosis, duration of the problem, length of treatment, number of treatment sessions, duration of each treatment, number of needles used, level of benefit obtained, and recurrence of the pain.

Results: Overall, 69% of patients showed a good or excellent response to acupuncture treatment. There was a tendency for patients to experience greater relief the fewer needles the practitioner used. This could be a reflection of treating myofascial pain syndromes which are known to respond well to a single needle placed at the key trigger point.

Conclusions: The authors recommend acupuncture as a treatment option for patients who do not respond to the usual NSAID therapy.

Kam E, Eslick G, Campbell I. An audit of the effectiveness of acupuncture on musculoskeletal pain in primary health care. Acupuncture in Medicine 20 (1): 35-38, Mar 2002.

MACPHERSON and colleagues, hugh@ftcm.org.uk, have published the STRICTA recommendations, the STandards for Reporting Interventions in Controlled Trials of Acupuncture.

Background: Acupuncture treatments and control group interventions in controlled trials of acupuncture are not always precisely reported.

Results: An international group of experienced acupuncturists and researchers drafted the standards named STRICTA. The editors of several journals helped to redraft the recommendations in a second round. Participating journal editors are now requesting prospective authors to adhere to STRICTA when preparing manuscripts for publication. Other journals are invited to adopt these recommendations. The intended outcome is that interventions in controlled acupuncture trials should be more accurately reported and thus facilitate an improvement in appraisability and reproducibility of acupuncture trials.

MacPherson H, White A, Cummings M, Jobst K, Rose K, Niemtzow R. Standards for reporting interventions in controlled trials of acupuncture: The STRICTA recommendations. Standards for Reporting Interventions in Controlled Trials of Acupuncture. Acupuncture in Medicine 20 (1): 22-25, Mar 2002.

Issue 83

ALRAEK and BAERHEIM, Department of Public Health and Primary Health Care, University of Bergen, Norway E: , terje.alrek@isf.uib.no, describe health changes experienced by women after acupuncture treatment for recurrent cystitis.

Background: The study aimed at exploring health changes reported by women after receiving prophylactic acupuncture for recurrent cystitis.

Methods: Qualitative study based on written free text on women’s own experience of changes in health after completion of traditional acupuncture treatment. Patients included in the study were women who had had three or more episodes of lower urinary tract infection in the previous 12 months. Data were analyzed using Giorgi’s phenomenological approach.

Results: Patients reported mainly improved pressure during micturition and more complete bladder emptying; more normal bowel movement and less abdominal discomfort; more energy, reduced stress-levels, and better sleep. A few reported feeling worse.

Conclusions: The symptoms described by the women in this study fit traditional Chinese medical theory for diagnosis of their vulnerability to cystitis. Qualitative methods have a role in complementary health research and may enrich our knowledge in other ways than conventional quantitative methods.

Alraek T, Baerheim A. ‘An empty and happy feeling in the bladder…’: health changes experienced by women after acupuncture for recurrent cystitis. Complementary Therapies in Medicine 9 (4): 219-223, Dec 2001.

CECCHERELLI et al., Observatory on Unconventional Medicine, Anesthesiological Unit of the Department of Pharmacology and Anesthesiology, University of Padova, Italy, E: istaneri@uxl.unipd.it, compared deep and superficial acupuncture in the treatment of lumbar myofascial pain.

Background: The purpose of the study was to compare the therapeutic effect of superficial and in-depth insertion of acupuncture needles in the treatment of patients with chronic low back pain.

Methods: A prospective, randomized double-blinded study was conducted in a Pain Service Unit. 42 patients with low back pain were divided into two equal groups. One group received needling at a depth of 2 mm, and the other group received needling deeply into the muscular tissue. Patients received 8 treatment sessions each. Pain intensity was measured using the McGill Pain Questionnaire before and after treatment and at 3 months follow-up.

Results: At the end of treatment there was no statistically significant difference between the two groups although pain reduction was slightly better in the group with deep needling. However at 3 months follow-up the difference between the two groups was statistically significant with the deeply needled group doing better.

Conclusions: Deep stimulation with acupuncture needles has a better analgesic effect than superficial needling.

Background: P6 acupuncture is known to be an effective preventive treatment for postoperative nausea and vomiting in adults. It is not clear whether the same is true in children.

Methods: Children undergoing anaesthesia and surgery were randomized to four groups: a) intravenous (IV) saline + bilateral P6 acupoint injection (50 children); b) IV droperidol + bilateral P6 sham acupoint injections (49 children); c) IV saline + bilateral sham point injections (43 children); d) IV saline + bilateral P6 sham acupuncture (45 children). Perioperative anaesthesia was standardized in all children. The incidence of postoperative nausea and vomiting was evaluated at 24 hours post surgery.

Conclusions: P6 acupoint injections are as effective as droperidol in controlling early postoperative nausea and vomiting in children.

Comment: The above published research provides an indication of the scale of research ongoing regarding the clinical efficacy of acupuncture for the treatment of a variety of conditions.

Issue 82

WHITE and coworkers, University of Exeter, Exeter, UK, a.r.white@ex.ac.uk, took part in the development of an information leaflet on acupuncture.

Background: Patients have the right to be fully informed of the likely risks of any treatment. Such information on acupuncture is available following publication of the results of two prospective surveys.

Methods: A standard Information Leaflet on acupuncture was developed by consensus between the three largest UK professional bodies.

Results: The Leaflet may be used as a form for written consent of patients. It is also intended to stimulate discussion of the risks associated with acupuncture.

Conclusion: An Information Leaflet on the risks of acupuncture fulfils a need of the profession as well as of patients.

White A et al. Informed consent for acupuncture – an information leaflet developed by consensus. Acupuncture in Medicine 19 (2): 123-9. Dec 2001.

Issue 81

MACPHERSON and colleagues, Foundation for Traditional Chinese Medicine, York, UK, hugh@ftcm.org.uk, conducted a survey of professional acupuncturists to obtain information on the type and frequency of adverse events and transient reactions reported following individual acupuncture treatment sessions.
Methods: The researchers contacted by post 1848 professional acupuncturists who were members of the British Acupuncture Council and practising in the UK. The acupuncturists were provided with standardized self-report forms to give to their patients, to be completed following a treatment, that detailed adverse events and transient reactions. Serious adverse events were defined as those requiring hospital admission, prolonging hospital stays, being permanently disabling or resulting in death. The researchers sought a sample size of at least 30,000 treatments, and a pilot study indicated that a 4-week period would be needed to obtain results from this number of treatments.
Results: 574 of the acupuncturists (31%) responded to the survey, reporting on adverse events and transient reactions associated with a total of 34,407 treatments. No serious adverse events were reported. There were reports of 43 significant ‘minor’ adverse events (rate 1.3 per 1000 treatments), which included: severe nausea and fainting (12), unexpected, severe and prolonged exacerbation of symptoms (7), prolonged and unacceptable pain and bruising (5) and psychological/emotional reactions (4). Three events could have been avoided: in two patients, acupuncture needles were left in by mistake; one patients suffered moxa burns to the skin due to practitioner error. Reports of local reactions included mild bruising (1.7%), pain (1.2%) and bleeding (0.4%). 10,920 mild transient reactions were recorded as occurring during 5136 treatments, accounting for 15% of all adverse events reported. Mild transient reactions most commonly reported after treatment were ‘feeling relaxed’ (11.9%) and ‘feeling energized’ (6.6%). After approximately 3% of treatments, patients reported an exacerbation of their symptoms.
Conclusion: This survey of more than 34,000 acupuncture treatments resulted in no reports of serious adverse events. The reported frequency of significant ‘minor’ adverse events was just over 0.1%. Local reactions were reported after less than 4% of treatments. Mild transient reactions, the most common of which were ‘feeling relaxed’ and ‘feeling energized’, occurred after 15% of treatments. Worsening of patients’ original symptoms was reported after about 3% of treatments. The authors of this report point out that, compared with adverse events reported due to medication routinely prescribed in primary care, these results indicate acupuncture to be a relatively safe treatment modality.
MacPherson H et al. A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists. Acupuncture in Medicine 19 (2): 93-102.

FILSHIE, of the Royal Marsden Hospital, London, UK, jacqueline.filshie@btinternet.com, reviewed (19 references) the use and safety of acupuncture in patients with cancer.
Discussion: The author reports that the effects of acupuncture treatment can reduce symptoms due to cancer and progression of cancer, which may be dangerous if such underlying conditions are caused to go undetected and untreated. Therefore, acupuncturists should not treat a patient without having full knowledge of the patient’s medical history and current health status, and where cancer has already been diagnosed, the clinical status of the disease and any current conventional medical treatment that the patient is undergoing. Acupuncture needling treatment should not be given if the patient has an unstable spine, a severe blood clotting disorder, neutropenia (lowered blood levels of neutrophils, a type of white blood cell) or lymphoedema (local swelling due to blockage of lymphatic vessels). Semi-permanent needles, popularly used for controlling symptoms and relieving pain, are inadvisable for patients with valvular heart disease or in vulnerable neutropenic patients. Increasingly, acupuncture is gaining support for its benefits for managing chronic pain and other chronic symptoms. However, the author advises that patients should not be encouraged to abandon conventional medical treatments entirely, should not be given ‘false hopes’ of the success of complementary/alternative therapies, and should also not be encouraged to believe that they are responsible for the occurrence and progression of their cancer.
Filshie J. Safety aspects of acupuncture in palliative care. Acupuncture in Medicine 19 (2): 117-22. Dec 2001.

DONG and colleagues, Department of Obstetrics and Gynaecology, University Hospital of Geneva, Geneva, Switzerland, hong.g.dong@hcuge.ch, explored the effects of acupuncture on the quality of life, menopausal symptoms and reproductive hormone levels in menopausal women.
Methods: Subjects were 11 women experiencing common physical and psychological symptoms of the menopause. The women completed the Menopause Specific Quality of Life Questionnaire before an initial acupuncture session, after the last session (5 weeks later) and again 3 months after the last session. The investigators also measured blood levels of reproductive hormones (follicle-stimulating hormone [FSH], luteinizing hormone [LH], estradiol, progesterone and prolactin) before and after acupuncture treatment.
Results: Acupuncture treatment significantly reduced symptoms of hot flushes and other physical symptoms at the end of treatment, and these effects were still apparent 3 months later. No effects of acupuncture were detected on psychosocial or sexual symptoms or levels of reproductive hormones.
Conclusion: Acupuncture treatment was effective in relieving hot flushes and other physical symptoms of menopause in women, and the effects lasted for at least 3 months after the end of treatment. Acupuncture may therefore offer menopausal women a useful alternative to hormone replacement therapy. Further study involving a larger number of women is required to define more closely the possible use of acupuncture to manage menopausal symptoms.
Dong H et al. An exploratory pilot study of acupuncture on the quality of life and reproductive hormone secretion in menopausal women. The Journal of Alternative and Complementary Medicine 7 (6): 651-8. Dec 2001.

Comment: The above research studies demonstrate the safety, therapeutic versatility and efficacy of acupuncture in the treatment of a wide variety of conditions.

Issue 77

RABL and colleagues, Department of Obstetrics and Gynecology, University of Vienna, Austria, michaela.rabl@akh-wien.ac.at, evaluated the effectiveness of acupuncture given at term to pregnant women to help induce labour and thus reduce the need for post-term induction.
Methods: This was a prospective, randomized, controlled (no treatment) clinical trial of acupuncture in 45 pregnant women who had a confirmed ‘estimated date of confinement’ (EDC) and an uncomplicated, single-foetus pregnancy with the foetus in the ‘normal’ head-down position (cephalic presentation) at term. Subjects were excluded from the study if they had cervical dilation greater than 3 cm, were in active labour, had premature rupture of membranes, a previous Caesarian section, or if they or the foetus had any abnormality or medical condition. On their EDC, the women were randomly assigned to either the acupuncture (ACU; n=25) or the control group (CON; n=20). The ACU group received acupuncture at points Hegu (Large Intestine 4) and Sanyinjiao (Spleen 6) on both sides every second day after their respective EDC. All the subjects were examined every 2 days. Measurements taken included: cervical length (by vaginal ultrasound); foetal fibronectin test of cervical mucus; and cervical status according to the Bishop score. If subjects had not given birth by 10 days after their EDC, labour was induced by vaginal administration of prostaglandin tablets.
Results: In the ACU group, cervical length was significantly shorter on days 6 and 8 after the EDC in comparison with the CON group, the time period from the first positive foetal fibronectin test to delivery was shorter (2.3 days versus 4.2 days), and the time from EDC to delivery was shorter (mean = 5.0 days versus 7.9 days). Labour was induced in fewer women in the ACU group (n=5; 20%) than in the CON group (n=7; 35%), although the difference was not statistically significant. Oxytocin was used to augment labour in a smaller proportion of women in the ACU group (n=14; 56%) than in the CON group (n=13; 65%), although this difference was also not significant. There were no differences between groups in the overall duration of labour or in the durations of the first and second stages of labour.
Conclusion: Acupuncture applied bilaterally at points LI 4 and SP 6 in healthy pregnant women at term was able to encourage ripening of the cervix and reduce the time interval between the EDC and the actual time of delivery.
Rabl M et al. Acupuncture for cervical ripening and induction of labor at term – a randomized controlled trial. Wiener Klinische Wochenschrift 113 (23-24): 942-6. Dec 2001.

FINK and colleagues, Department of Physical Medicine and Rehabilitation, Hannover Medical School, Hannover, Germany, m.g.fink@gmx.de, tested the viability of a placebo needle designed for use as a ‘control’ treatment in acupuncture research.
Background: To assess the credibility of the placebo needle, the researchers carried out a randomized, double-blind, placebo-controlled clinical trial, comparing authentic acupuncture treatment with treatment using the placebo needle, and questioned the participants of the study on the credibility of the treatment they received in terms of whether they believed it to be ‘real’ or ‘placebo’ acupuncture. Subjects and evaluators of the study results were ‘blinded’ with regard to which subjects received which treatment.
Methods: Subjects were 68 patients aged 4814 years who fulfilled the criteria of the International Headache Society for tension-type headache. Subjects were assigned to receive either authentic acupuncture (traditional needle placement and manipulation) (ACU group) or needle insertion using the experimental placebo device (PBO group). Following their first treatment, each patient completed a questionnaire on credibility with regard to their treatment. After 3 or 4 treatments, patients were questioned about the feeling of needle insertion and ‘deqi’.
Results: The patients reported equal credibility ratings for the authentic acupuncture and the placebo treatments. All patients in the ACU group and all but 4 in the PBO group recognized needle insertion. However, 84% of ACU patients compared with only 34% of PBO patients reported ‘deqi’.
Conclusion: The prototype placebo needle used in this study had high credibility among subjects who received treatment with it. However, it was concluded that careful training is needed to achieve comparable prick sensations with authentic acupuncture versus the placebo device. The placebo response using placebo needles also deserves evaluation.
Fink M et al. Credibility of a newly designed placebo needle for clinical trials in acupuncture research. Forschende Komplementaermedizin und Klassische Naturheilkunde 8 (6): 368-72. Dec 2001.

Issue 75

SZE and colleagues, Department of Medicine, Shatin Hospital, Hong Kong, fkhsze@hotmail.com, carried out a prospective, randomized, controlled clinical trial to examine whether acupuncture might provide additional benefits over standard post-stroke motor rehabilitation.
Background: Following a stroke, many patients remain severely disabled despite conventional rehabilitation.
Methods: The study was conducted at a stroke rehabilitation unit in Hong Kong and included 106 Chinese patients with moderate-to-severe functional impairment at 3 to 15 days after a stroke. They were stratified into moderate and severe groups before randomization. Patients were then assigned to either 1) standard modalities of treatment (control group), which included physiotherapy, occupational and speech therapy, and skilled medical and nursing care, or 2) standard modalities of treatment plus traditional Chinese manual acupuncture (intervention group), which involved a mean of 35 acupuncture sessions on 10 main acupoints over 10 weeks. Outcome measures, performed by blinded assessors at weeks 0, 5 and 10, included Fugl-Meyer assessment, Barthel Index and Functional Independence Measure, respectively.
Results: Patients in the 2 groups were comparable at baseline with regard to all important prognostic characteristics. No statistically significant differences were found between the 2 treatment groups on any of the outcomes measured at week 10 or on outcome changes over time.
Conclusion: Traditional Chinese manual acupuncture on the body, as conducted in this study, had no additional benefit over standard post-stroke motor rehabilitation.
Sze FKH et al. Does acupuncture have additional value to standard poststroke motor rehabilitation? Stroke 33 (1): 186-94. Jan 2002.

Issue73

WASHIO and colleagues, Department of Preventive Medicine, Graduate School of Medical Sciences, Kyushu University, Japan evaluated the effects of acupuncture therapy on low back pain and/or knee pain in elderly patients.
Methods: In this cross-sectional study, 75 elderly patients (mean age 79 years) with low back pain and/or knee pain visited an acupuncture and physical therapy unit in a geriatric hospital during April 1999.
Results: 60 of the 75 patients reported diminished pain following their therapy. Of these 60 patients, 55.5% were treated with acupuncture. Of the remaining 15 patients (who did not report diminished pain), only 26.7% were treated with acupuncture (p=0.05 for the difference in proportions). This observation suggested that acupuncture therapy may be able to relieve low back pain and/or knee pain in elderly patients. However, 46% of the patients who received acupuncture therapy also received other types of physical therapy.
Conclusion: Further studies are needed to clarify the effects of acupuncture therapy on low back pain and/or knee pain.
Washio M et al. Effects of acupuncture therapy on low back pain and/or knee pain in elderly patients. Nippon Ronen Igakkai Zasshi 38 (4): 523-7. Jul 2001.

Issue 71

MACPHERSON and colleagues, Foundation for Traditional Chinese Medicine, York YO24 4EY, Medical Care Research Unit, University of Sheffield, and Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK, hugh@ftcm.org.uk, investigated the type and frequency of adverse events (AEs) following acupuncture. Mild transient reactions associated with acupuncture, some of which may indicate a positive response to treatment, were also described.
Background: Recent reports have highlighted the importance of good evidence of safety of acupuncture. However, sound evidence on the risks associated with acupuncture is scarce.
Methods: The study involved a prospective postal audit of treatments undertaken by 1,848 professional acupuncturists, who were members of the British Acupuncture Council (BAC) and were practising in the UK, during a 4-week period in 2000. The acupuncturists were invited to record details of AEs and mild transient reactions after treatment using standardized self-report forms. They were asked to give details of any AEs they considered to be ‘significant’, including any event that was ‘unusual, novel, dangerous, significantly inconvenient or requiring further information’. Serious AEs were defined as events requiring hospital admission, leading to permanent disability or resulting in death. Practitioners also provided information on themselves, including age, sex, length of training and years of practice. A sample size of 30,000 treatments was sought in order to fulfil the desired power of the study to reveal a 95% probability that no serious event occurred in the treatments sample.
Results: 574 (31%) of the practitioners approached participated. The mean age of the practitioners was 44.8 years (range 23-79); 65% were female; and 62% had been practising acupuncture for more than 5 years. Other information on the practitioners was available from the BAC’s database. Participants were sufficiently representative of the population of practitioners for a re-weighting of the primary data to be unnecessary. Participants reported on 34,407 treatments.
No serious AEs were reported (95% confidence interval [CI], 0, 1.1 per 10,000 treatments). 43 minor AEs were reported (a rate of 1.3 [95% CI, 0.9, 1.7] per 1,000 treatments). The most common events were severe nausea, fainting and/or related symptoms (n=12). Three avoidable events were caused by practitioners’ errors: two patients had needles left in, and one patient had moxibustion burns to the skin. 10,920 mild transient reactions were reported among 5,136 treatments (15% of the total number of treatments). Local reactions at the site of needling included mild bruising (587 cases; 1.7%), pain (422 cases; 1.2%), and bleeding (126 cases; 0.4%). Aggravation of existing symptoms occurred after 966 treatments (2.8%), 830 (86%) of which were followed by an improvement, possibly indicating a positive ‘healing crisis’. The most common mild transient reactions were; ‘feeling relaxed’ (4,098 cases; 11.9%) and ‘feeling energized’ (2,267 cases; 6.6%), symptoms that often indicate an encouraging response to treatment.
Conclusion: This study reports data collected over a 4-week period by one in three members of the BAC. No serious AEs were reported after 34,407 acupuncture treatments, consistent with an underlying serious AE rate of between 0 and 1.1 per 10,000 treatments. The rate of minor AEs was between 0.9 and 1.7 per 1,000 treatments. The results provide important evidence on public health and safety. Professional acupuncturists deliver approximately 2 million treatments per year in the UK. Comparison of these AE rates for acupuncture with those for drugs routinely prescribed in primary care suggests that acupuncture is a relatively safe form of treatment. Further research measuring patients’ experience of AEs is merited.
MacPherson H et al. The York acupuncture study: a prospective survey of 34 000 treatments by traditional acupuncturists. British Medical Journal 323: 486-7. Sep 2001.
Comments: Just a reminder of some of the statistics regarding adverse effects of standard and drug treatment include one death per every1200 people taking NSAIDs for at least 2 months. Also, 40,000 people die every year in the UK due to medical mishaps – four times more deaths than from all other types of accident, with a further 280,000 people suffering from non-fatal drug-prescribing errors, overdoses and infections. Contrast this with the safety evidence of acupuncture – no serious adverse events following over 34,000 acupuncture treatment (see Editorial – Issue 50).

Issue 68

SHANG, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303-3033, USA, cshang9@yahoo.com, reviewed (90 references) evidence and theories on cellular growth control mechanisms and their possible relationship to acupuncture points.
Background: A theory published a decade ago, the Morphogenetic Singularity Theory, postulated that: cellular growth control systems present in the embryo (and preserved after embryogenesis) guide the development and maintenance of all physiological systems; the evolutionary origin of the growth control system probably preceded all other physiological systems and its genetic blueprint may have been the ‘template’ from which the later systems evolved; a growth control system originates from a network of ‘organizing centres’ containing under-differentiated cells; organising centres have high electrical conductance and a high density of [intercellular] gap junctions and represent ‘singular points’ in a ‘morphogen’ gradient [morphogen = an agent that directs cellular growth and differentiation] and bioelectric field. Bioelectric fields have been shown to interact with morphogens to guide growth control [i.e. cellular differentiation and the development and maintenance of physiological systems].
Discussion: Acupuncture points have high electrical conductance and a high density of gap junctions and, like cellular growth control systems, may originate from physiological organizing centres. This may explain the apparent non-specific activation of organizing centres by acupuncture in many reported research results. Recent reports from several ‘prospective blind trials’ of acupuncture support this theory in relation to the role of singularity and ‘separatrix’ in morphogenesis and to the unique bioelectric and structural characteristics of organizing centres.
Conclusions: The available evidence supporting the morphogenetic singularity theory has broad implications for biomedical science. ~
Shang C. Electrophysiology of growth control and acupuncture. Life Sciences 68 (12): 1333-42. Feb 2001.

KALAUOKALANI and colleagues, Department of Anesthesiology, Washington State University School of Medicine, St. Louis, MO 63110, USA, investigated the variability in diagnosis and treatment patterns of acupuncturists evaluating the same patient.
Background: The effectiveness of acupuncture and other alternative therapies in common conditions needs to be examined. To date, little attention has been paid to variability in acupuncturists’ assessment, diagnosis and treatment patterns.
Methods: 7 acupuncturists practising Traditional Chinese Medicine evaluated the same patient with chronic low back pain and provided data on their main assessment techniques, diagnoses and treatment recommendations.
Results: For 5 out of the 7 acupuncturists, diagnostic agreement was high. Treatment recommendations varied between 5 and 14 acupuncture points requiring between 7 and 26 needles (many points being recommended for bilateral treatment). Only 4 (14%) out of 28 points selected were prescribed by 2 or more acupuncturists. Most acupuncturists recommended various forms of adjuvant heat.
Discussion: Among 7 acupuncturists, diagnostic agreement was high for the same patient with chronic low back pain, but treatment recommendations varied considerably. Such variations need to be considered particularly with respect to study designs and interpretations.
Kalauokalani D et al. Acupuncture for chronic low back pain: diagnosis and treatment patterns among acupuncturists evaluating the same patient. Southern Medical Journal 94 (5): 486-92. May 2001.

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