Abstract
For this final column of 2021, the SAR board offers a few reflections on the year in research. We cite projects in the key areas of basic research, clinical trials, research methodology, and implementation science. We also include three emergent topics of COVID-19 illness, the opioid crisis, and diversity, equity, and inclusion (DEI). Not all of these involve acupuncture trials: some are reviews or initiatives we think likely to have important implications for research in the years to come.
We cannot claim to be comprehensive: indeed, our initial roundup was largely issues on which one or more of us were actively working. We would welcome correspondence regarding notable developments in acupuncture research this year that we have missed or misunderstood, and we appreciate important perspectives from Afua Bromley, 1 Chao and colleagues, 2 and Nielsen et al. 3
Basic Research
There has never been a satisfactory single-factor explanation of acupuncture's numerous context-dependent multisystem impacts. However, understanding of acupuncture's effect on pain perception advanced considerably this year in two ways. Mawla et al. 4 investigated the contribution of somatosensory afference in acupuncture efficacy in chronic pain patients, by comparing verum acupuncture with sham laser treatment that (unlike most sham acupuncture devices) has no somatosensory component. This neuroimaging study found that acupuncture's action on clinical pain in fibromyalgia is mediated by gamma aminobutyric acid-related plasticity in the insula cortex.
Meanwhile Ellingsen et al. 5 used a new functional magnetic resonance imaging technique, hyperscanning, to simultaneously evaluate brain activity in both a patient and an acupuncturist while the latter is delivering acupuncture for pain. They found that brain-to-brain synchrony in the temporoparietal junction was linked with better analgesia. The patient–acupuncturist relationship is understood as an important aspect of acupuncture therapy, whose mechanisms have heretofore been entirely unknown.
Both of these research programs have implications far beyond acupuncture itself. As noted by MacPherson et al., 6 biomedicine's understanding of pain and its repertoire of treatments have also drawn from acupuncture research. Noteworthy in this context is a major publication on “the emerging science of interoception,” by a team of scientists at multiple NIH centers. 7
The authors present the article as a “unified research framework” drawing together interoception's associated “neural and non-neural pathways, diseases and disorders, manipulations and interventions…research gaps and challenges.” A presentation at this year's SAR symposium emphasized the centrality of breath and body awareness to the theoretical systems underlying acupuncture and qigong, and presented preliminary data suggesting that acupuncture might directly impact validated outcome measures of interoceptive awareness. Somatosensory afference, patient–clinician relationship, and interoception are important factors that need further research as we explore acupuncture's mechanisms of action.
Clinical Research
Despite the multiple challenges of 2020–21, a few important trials were published, along with several notable reviews.
JAMA Oncology published the Personalized Electroacupuncture vs Auricular Acupuncture Comparative Effectiveness (PEACE) Trial, comparing two types of acupuncture with usual care only for 360 cancer survivors with chronic musculoskeletal pain. Patients were randomized to receive either electroacupuncture (EA), auricular acupuncture (AA) using the Battlefield Acupuncture Protocol, or usual care (UC). Relative to UC, both EA and AA had statistically significant and clinically meaningful reduction in pain severity, pain-related functional interference, and use of pain medications while improving mental and physical quality of life, which remained at 24 weeks.
However, AA was not as effective as EA and showed higher adverse events (mostly ear discomfort) and treatment discontinuation. 8 Another large trial was published in the Annals of Internal Medicine, comparing sham and verum acupuncture for chronic prostatitis and chronic pelvic pain. 9 Among 440 men, 60% of patients in the verum group showed clinically significant improvement after eight treatments, versus 36% given sham acupuncture. The effects persisted at 24 weeks—a notable finding in a condition with relatively few satisfactory treatment options.
Acupuncture safety was reviewed by a German–Chinese collaborative team. 10 With 21 prospective studies of adverse events identified, on average 9.4 events occurred per 100 treatments. However, half of these were either transitory pain, bleeding, or erythema at the needling site, which may not be considered as problematic. The proportion of events requiring treatment was 7.98 per 1 million treatments. Meanwhile a Cochrane review looked at acupuncture for chronic nonspecific back pain. 11 Of the 33 trials included, none is more recent than 2017 and none is rated “low risk of bias” for performance of the intervention, as none of the acupuncturists was blinded.
The review concludes that “Acupuncture was better than no treatment for pain relief and functional improvement immediately after treatment,” but that “[c]ompared with sham, acupuncture may not be more effective in reducing pain immediately after treatment…did not appear to improve back-specific function immediately after treatment, or may not enhance quality of life in the short term.” The paucity of new research and apparent lack of efficacy for this condition, despite widespread usage, likely reflect both the methodological difficulties with sham acupuncture and also the decision by National Center for Complementary and Alternative Medicine (now National Center for Complementary and Integrative Health) to restrict funding for trials including sham acupuncture controls.
Research Methodology
The noninertness of sham acupuncture is a long-standing methodological challenge 12 that limits production of efficacy research without changing the evidentiary expectations of health care institutions and policy makers. The Mawla and Ellingsen articles mentioned may strengthen arguments for sham laser acupuncture as a control condition, as it is fully inert with respect to somatosensory afference. This raises the question of safety and efficacy of verum laser acupuncture, for which there is increasing, but by no means definitive, evidence. 13,14
Pragmatic and comparative effectiveness trials have increased in recent years, partly in relation to increased acceptance of the validated PRECIS-2 instrument 15 for balancing internal and external validity of study design. The instrument operationalizes the design choices that make studies more explanatory or more pragmatic. The shift toward comparative effectiveness research, as well as noninferiority designs such as the PEACE 8 and Acupuncture to Decrease Disparities in Outcomes of Pain Treatment 16 trials, may signal increased interest by funders in understanding the specific costs and clinical impacts of group and individual acupuncture systems, with an eye to scaling delivery for public health and reducing disparities.
Another methodological trend particularly important in pandemic times has been the use of smartphone apps to deliver self-administered acupressure and associated relaxation techniques. Interest in mobile health care applications has been on the rise generally, and in acupressure research since a 2018 trial of self-administered acupressure for menstrual pain. 17 Four such studies were published this year, addressing constipation, 18 ovarian cancer-related fatigue, 19 psychological distress, 20 and chronic musculoskeletal pain. 21
Implementation Research
Two articles were published this year that advanced the state of implementation science with regard to acupuncture and associated systems of care. Implementation research studies the introduction, scaling, sustainability, and impact of problem-solving approaches at the health care system level. 22
Ho et al. 23 described site-specific adaptations made to facilitate patient-centered and culturally competent delivery of acupuncture and pain counseling interventions among underserved speakers of Spanish, Cantonese, and English at multiple study sites. Miller et al. 24 documented findings of a 30-member stakeholder panel funded by the patient-centered outcomes research institute. The group discussed the current status of acupuncture implementation research and identified and described eight primary stakeholder groups important to acupuncture implementation—patients, policy makers, institutions, payers, researchers, associations, providers, and educators—providing a blueprint for future work in acupuncture implementation science.
COVID-19
Over the past year, a great deal of work has been done in China on the use of herbal medicine to reduce symptom burden and hospitalization rates. By one account, some 85% of Chinese COVID-19 patients received herbal therapy in the early days of the pandemic, many through a smartphone-based delivery service. 25 In the United States and Europe, many acupuncturists began conducting digital consultations. 26,27 It may be anticipated that next year will see publication of use of acupuncture for long COVID-19 and postvaccination symptoms: the syndromes share epidemiological and clinical characteristics of fibromyalgia, irritable bowel syndrome, and other inflammation-mediated multisystem syndromes, for which acupuncture therapy is often sought.
The pandemic also impacted academic conferences, including the SAR symposium that was conducted virtually in June of 2021. The reduction in travel time and cost appeared to shift the attendee population, with a much higher proportion of acupuncture students and practitioners than usual. The shift is notable in light of a 2021 Australian study suggesting that acupuncturists interviewed found clinical research only minimally relevant to their practice, mostly using online education to guide practice. 28 Clearly there is a need for both institutional and postgraduate educational outreach.
The Opioid Crisis
Drug overdose deaths spiked during the pandemic, rising significantly in nearly every state of the United States. 29,30 Addiction is increasingly treated as a form of self-medication for physical and emotional pain, 31 a connection that acupuncture research has long explored. 32 Basic research shows acupuncture modulating stress-related brain connectivity and neuroendocrine functions, 33,34 whereas clinical research suggests meaningful effects on depression with or instead of pharmacotherapy. 35 Acupuncture therapy is well understood to be effective for chronic pain; several projects this year explored its dissemination 36 and potential for pain management 37 and opioid sparing 38 –40 in public health through group visits and other approaches. 41,42
Diversity, Equity, and Inclusion
The murder of George Floyd in May 2020 brought about a long overdue tipping point for institutional acknowledgment of systemic racial injustice. In the field of acupuncture and East Asian Medicine, attacks on Asian Americans and Pacific Islanders added specific urgency to long-standing concerns about organizational nomenclature and DEI among practitioners and educators of acupuncture and associated disciplines.
Entities using the phrase “Acupuncture and Oriental Medicine” such as the Council of Colleges and the Accrediting Commission are transitioning to “Acupuncture and Herbal Medicine.” The National Commission for Certification in Acupuncture and Oriental Medicine (NCCAOM) has done much work on DEI, generating policy statements 43 and convening a task force with the American Society of Acupuncturists to generate substantive resources for cultural competency. SAR recognizes the deep need for such work, which begins with self-assessment and progresses through skills building and resource gathering as exemplified by the NCCAOM document.
Notable DEI-related research this year included Ho et al.'s implementation article already cited. A second article 44 from the Asian American Research Center on Health described development of an integrated East Asian Medicine/biomedical nutritional counseling program for Chinese Americans with type 2 diabetes. Both articles provide excellent models for genuine inclusion of diverse patient and researcher perspectives. Future study on diversity in acupuncture research will need to address the multiple social and economic barriers to specialized research training and the lack of access and financial barriers to usage.
Concluding Comments
Overall, in a chaotic year, a few centripetal forces can be identified. Interoception may emerge as an interesting new construct incorporating acupuncture's multiple theoretical and practical systems in a biomedically comprehensible whole-person framework. Personal and social sequelae of COVID-19 may stimulate interest in acupuncture as a nonpharmacologic approach to complex illness, as well as physical and emotional pain. And to address the needs of those most vulnerable, at any meaningful scale, culturally competent implementation research will be much needed.