Abstract
Stimulation of acupoint ST-34 acutely improves gait performance in geriatric patients during rehabilitation: a randomized controlled trial.
Hauer K, Wendt I, Schwenk M, Rohr C, Oster P, Greten J. Arch Phys Med Rehabil. 2011;92(1):7–14.
The objective of this study was to observe the acute effects of single acupoint stimulation based on Traditional Chinese Medicine criteria in frail, multimorbid patients during geriatric rehabilitation. Thirty-two patients were consecutively recruited during rehabilitation at a geriatric hospital. Inclusion criteria included adults ≥65 years of age, ability to walk 5 meters without support, no amputation of lower limbs, no leg casts or braces restricting mobility, full weight-bearing status, no use of vitamin K antagonists, and no cognitive impairment (based on a Mini-Mental Status [MMSE] score of >24). Patients were randomly assigned (by a person unrelated to the study) to either an intervention or control group, using an urn design for a clinical trial (an urn design involves using numbered containers). Measurements included descriptive parameters: age (years); functional status (activities of daily living); mobility status (independent outdoors versus indoors); geriatric depression scale score; fear of falling; MMSE; social status (dependent versus independent); comorbidity (number of diagnoses documented at discharge in patient charts); and pain (as shown on a visual analogue scale). These parameters were assessed by valid established tests. For objective assessment, used an electronic walkway (GAITRite-System) was used. Maximal gait speed was chosen as the primary study endpoint. Other temporal and spatial gait performances related to dynamic postural control and performance-based measures were used as secondary outcomes. The mean of 2 consecutive pre- and postinterventional trials was used in data analysis. Bilateral needling was performed on both the verum and control acupoints in the so-called Sparrow-Pecking technique, which, in essence, consists of 5 rapid skin penetrations within approximately 3 seconds within a line of 2 cun. For verum treatment, the acupuncture point ST 34 was used. Control treatment was performed at a nonspecific skin point. Statistical analysis was done, using an intention-to-treat analysis. Unpaired t-tests, Mann-Whitney U tests, and chi-quare tests were used for baseline comparisons as appropriate.
The 2 groups did not significantly differ with respect to baseline descriptive parameters and baseline gait parameters. The single stimulation of the acupoint ST 34 increased gait performance in all documented gait parameters, including maximal gait speed, except for the width of the base of support. Changes in gait speed averaged 0.056 m/s, representing a low but meaningful change in physical performance, particularly for frail older adults. However, the effect sizes achieved did not meet statistical significance. Results of this study concur with those of a previous study (JAMA 1997;278:1725–1727).
The current study indicates that a possible improvement was achieved; however, this study had several weaknesses. Only a single point (ST 34) was stimulated and 1-single application treatment was applied in a frail group of elderly subjects undergoing rehabilitation. Future studies will need to take these limitations into account by considering repeated interventions and longer follow-up periods.
Acupuncture for cancer pain in adults.
Paley CA, Johnson MI, Tashani OA, Bagnall AM. Cochrane Database Syst Rev. 2011;1:CD007753.
The objective of this review was to evaluate the efficacy of acupuncture for relief of cancer-related pain in adults. The review included all randomized controlled trials (RCTs) including those that were not blinded. Non-randomized trials, case reports, abstracts, and letters were excluded. All studies including adults (≥18 years of age) with cancer-related pain (related to the development of cancer and not to treatment or surgery) were considered. Subanalysis of data looking at cancer-induced bone pain (CIBP) was planned if the data allowed. Studies that evaluated any type of invasive acupuncture were included. These included studies using manual acupuncture, electroacupuncture, and auricular acupuncture. Both Western style and traditional Chinese acupuncture were included. Studies using comparisons of non-invasive techniques, such as laser acupuncture or acupressure, were excluded.
The primary outcome measure was patient-reported pain intensity using validated scales (e.g., visual analogue scales [VAS] or numerical rating scales) or verbal reporting. Secondary outcome measures included any of the following: (1) pain relief as measured by validated pain scales (e.g., VAS); (2) patient satisfaction; (3) quality of life; (4) analgesic consumption and changes in concurrent treatments; (5) hospital attendance/admission (including Hospice admission); and (6) adverse events (major or minor).
The Cochrane Central Register of Controlled Trials and 5 other major databases were searched for eligible studies. Two reviewers, with a third reviewer acting as an arbiter, independently selected the studies to be considered in the review. Data extraction was conducted up to and including October 2010. A modified version of the validated Oxford 5-point Quality Scale was used to assess quality. Two reviewers completed the data extraction and scored each study, with a third reviewer acting as an arbiter when differences occurred between the 2 reviewers. An intention-to-treat (ITT) analysis was performed when data were continuous. When the number of missing values was significant, it was decided that it might be necessary to perform a sensitivity analysis to estimate the effect of the ITT analysis on the overall outcome. Studies with a high attrition rate (50% or more) were not be excluded from the review, because it was expected that there would be very few studies meeting the inclusion criteria.
The reviewers identified 253 references from the literature search. It was possible to exclude 226 initially based on the titles alone. An additional ten studies were excluded following abstract reviews, because the studies did not meet the inclusion criteria. Full study reports were obtained for the remaining 17 studies and an additional 13 studies were subsequently excluded, because further examination revealed that they were postoperative studies or did not have pain as a main outcome measure, or translation revealed that they did not meet the eligibility criteria of being an RCT. Three studies (with a total of 204 participants) met the inclusion criteria. An additional study was identified (Dang 1997), but because it contained data duplicated in a later report it was included as a secondary reference for an included study (Dang 1998). One study met the criteria for a high-quality study (4/5 point) (Alimi 2003). The two remaining studies (Chen 2008; Dang 1998) were of low methodological quality and received 2 points out of 5.*
The high-quality study found a significant decrease in pain intensity recorded on VAS at 1 month and at 2 months. Subjects in the true acupuncture group (auricular acupuncture) had significantly lower pain scores at 2 months than either the placebo acupuncture or ear seeds group (P<0.001). Chen 2008, reported that acupuncture was more effective (94.1%), compared with medication (87.5%; P<0.05). These results should be interpreted with caution, as the description and reporting of the study was unclear, and the method of analysis was debatable. Dang 1998 reported that a standard-therapy group experienced more effective immediate analgesia during the first 10 days of that trial than the intervention groups did, but, by the final 10 days, the effects were similar. There were no significant differences between the groups in either transient or long-term effects. The use of ordinal categories for pain relief without specifying parameters make additional comparisons of trial data meaningless. No studies investigating acupuncture for CIBP were identified, hence analysis was not done.
Acupuncture is widely used to treat cancer-related pain; however, the available evidence is suggestive but mostly of low quality. Additional well-designed studies are needed.
References for the studies cited in this review, in alphabetical order by first author, are as follows:
Acupuncture and related interventions for smoking cessation.
White AR, Rampes H, Liu JP, Stead LF, Campbell J. Cochrane Database Syst Rev. 2011;1:CD000009.
The goal of this review was to conduct a meta-analysis to evaluate the short- and long-term effects of acupuncture, acupressure, laser therapy, and electro-stimulation for smoking cessation. The primary objective was to evaluate whether acupuncture, acupressure, laser therapy and electro-stimulation: (1) are more effective than waiting list/no intervention for smoking cessation; (2) have a specific effect in smoking cessation beyond placebo effects; and (3) are more effective than other interventions used for smoking cessation. The secondary objective was to explore whether any particular acupuncture approach is more effective than any other.
Randomized controlled trials comparing acupuncture, acupressure, laser therapy, or electro-stimulation—with either no intervention, or a sham form of the intervention, or another intervention—for smoking cessation at any age were included. Studies using traditional and Western acupuncture approaches were considered separately. The outcome measure was complete abstinence from smoking.
Studies registered with the Cochrane Tobacco Addiction Group Specialized Register and major databases including Medical Acupuncture Research Foundation Acubriefs, the CISCOM database, and Chinese databases were searched. In addition, relevant references from published reviews, clinical trials, and conference abstracts were gathered for potential inclusion in the review.
The primary analysis included all studies in which acupuncture, acupressure, laser therapy, or electro-stimulation were given alone or as adjuncts to other interventions, as long as the other interventions were given to all groups. Data (when present in the report) were extracted for two time points: short-term effect (i.e., the first measure after the treatment, up to a maximum of 6 weeks from the quit date) and long term effect (i.e., the last time point used up to 1 year, but with a minimum of 6 months). All studies were included in the analysis, regardless of the risk of bias, given that this is uncertain for a high proportion of studies.
Thirty-three studies were identified: 5 studies used facial acupuncture; 11 studies used auricular acupuncture alone; 7 studies combined body and auricular acupuncture (2 used indwelling needles); and 1 study used facial, body, and indwelling auricular acupuncture in different groups. The risk of bias was judged to be unclear in many studies because of lack of detail given in the articles. Often, methods of randomization and allocation concealment could not be assessed, and baseline comparisons between groups were often not reported.
Results were analyzed based on type of control intervention. Short-term outcome studies (n=2) comparing acupuncture with waiting list/no intervention were statistically heterogeneous, while long-term studies (n=3) did not demonstrate a significant effect of acupuncture. Twelve studies that measured short-term outcome of acupuncture, compared with sham acupuncture, demonstrated an overall positive result (relative risk [RR] 1.18, 95% confidence interval [CI] 1.03–1.34), with moderate heterogeneity (I2=40%). Six studies with long-term outcomes did not show any relative effect of acupuncture, compared with sham (RR 1.05, 95% CI 0.82–1.35, with little evidence of heterogeneity (I2=20%). Acupuncture was less effective than nicotine-replacement therapy in both the short- and long-term with no heterogeneity. Acupuncture also showed no difference of effect, compared with counseling and psychological approaches (three studies) at either the short- or long-term study points.
Two studies compared acupressure with usual care or advice alone; in the short-term, their results showed considerable heterogeneity. One was a large definitive trial using four ear points and was positive in both short and long term, while the other small pilot study used one or two ear points, and showed no effect in the short-term, with no long-term outcome.
Overall, inconsistent evidence was noted with respect to whether acupuncture is effective for smoking cessation, compared with no intervention, in open studies. Acupuncture was considered to be less effective than nicotine-replacement therapy. No evidence was found that acupuncture is more (or less) effective than other active interventions used for smoking cessation. Overall there is not sufficient evidence to rule out an effect of acupuncture, acupressure, and laser stimulation on smoking cessation. The evidence does not point convincingly toward one approach being more effective than others.
Impact of electro-acupuncture and physical exercise on hyperandrogenism and oligo/amenorrhea in women with polycystic ovary syndrome: a randomized controlled trial.
Jedel E, Labrie F, Odén A, Holm G, et al. Am J Physiol Endocrinol Metab. 2011;300(1):E37–E45.
The objective of the study was to investigate if low-frequency electroacupuncture (EA) would decrease hyperandrogenism and reduce oligo/amenorrhea more effectively than physical exercise or no active intervention in women with polycystic ovary syndrome (PCOS). All sex steroids were measured by liquid chromatography–tandem mass spectrometry (LC-MS-MS) and gas chromatography–mass spectrometry (GC-MS) as recommended for clinical research.
Subjects (N=84) were recruited from the local community and the study was conducted at the Sahlgrenska University Hospital and at the Sahlgrenska Academy at the University of Göteborg. To be eligible, participants had to have ultrasound-verified polycystic ovaries with ≥12 follicles 2–9 mm and/or an ovarian volume of ≥10 mL in one or both ovaries, either oligo/amenorrhea (an intermenstrual interval >35 days and fewer than eight menstrual bleedings in the previous year; amenorrhea defined as absent menstrual bleeding or no menstrual bleeding in the previous 90 days), and/or clinical signs of hyperandrogenism (hirsutism or acne). Exclusion criteria were age ≥38 and any pharmacological treatment within 12 weeks or breastfeeding within 24 weeks of entering the study. Other exclusion criteria were cardiovascular disease, diabetes mellitus, and endocrine or neoplastic causes of hyperandrogenemia.
After randomization, each participant underwent a 12-week observation period followed by a baseline assessment, 16 weeks of intervention, and 16 weeks of follow-up. Women who met the inclusion criteria were randomly allocated in a 2:2:1 ratio to low-frequency EA, physical-exercise, or no-active-intervention groups. Computer-generated randomization within each stratum was conducted, using permuted blocks of five and was concealed until interventions were assigned. Low-frequency EA was given twice weekly for 2 weeks, once weekly for 6 weeks, and once every other week for 8 weeks, for a total of 14 treatments over 16 weeks, by a registered physical therapist. Acupuncture points and electrical stimulation were the same for all women in the low-frequency EA group: segmental acupuncture points located in the abdominal muscles with innervations corresponding to the ovaries (7); Conception Vessel (CV) 3; CV 6; Stomach (ST) 29; Spleen (SP) 6; and SP 9—all bilaterally. Needles were also placed in Extra-segmental acupuncture points alternating between muscles in the hand and/or lower arm; Large Intestine (LI) 4, or Pericardium (PC) 6, bilaterally. All needles were stimulated manually to produce De Qi once when inserted. CV 3, CV 6, ST 29, SP 6, and SP 9 were stimulated electrically with low-frequency EA of 2 Hz. The physical-exercise program consisted of 16 weeks of regular exercise, including brisk walking, cycling, or any other aerobic exercise at a self-selected pace described as “faster than normal walking” at a pace that could be sustained for at least 30 minutes at least 3 days per week. Women in the no-active-intervention group received oral information about the benefits of regular physical exercise.
Outcome measures taken at baseline, and at weeks 16 and 32, included anthropometric measurements, body–mass index (BMI; kg/m2), hyperandrogenism measured by Ferriman Gallwey (FG) scores, presence of acne, fasting blood samples for endocrine analyses, and physical fitness assessed with Åstrand's submaximal bicycle test. The primary outcome measure was changes in serum testosterone (T) between low-frequency EA and physical exercise at week 16. Secondary outcome measures were changes in serum T between low-frequency EA and physical exercise at week 32; changes in menstrual frequency, acne and hirsutism, endocrine blood analysis, BMI, and VO2max at weeks 16 and 32 between the two intervention groups.
Eighty-four women who met inclusion criteria were randomly allocated to one of the three study arms. There were 10 dropouts between allocation and baseline assessments, 15 between baseline and week 16, and 9 between weeks 16 and 32. The intention-to-treat (ITT) population comprised 74 participants who went through baseline assessments. The groups were comparable at baseline.
Compared to subjects who were randomized to physical activity, the low-frequency EA group had a statistically significant decrease between baseline and week 16 in serum T (P=0.038) and glucuronidated androgen metabolites ADT-G and 3G (P=0.030 and P=0.047, respectively). Menstrual frequency increased from 0.28 to 0.69 per month in the low-frequency EA group and was significantly higher than in the physical-exercise group at week 16 (P=0.018). Between baseline and week 32, acne score decreased in the low-frequency EA group, compared to the physical exercise group (P=0.006). There were no other differences between the low-frequency EA and the physical-exercise group at week 32.
Compared to the no-active-intervention group, the EA group had significant decreases, between baseline and week 16, in several serum endocrine levels. Menstrual frequency also improved more in the low-frequency EA group (P=0.001). Between baseline and week 32, menstrual frequency remained improved, and serum T, free T, and glucuronidated androgen metabolites (17 G) levels remained decreased and differed significantly from subjects in the no-active-intervention group. Similar changes were also noted at weeks 16 and 32 in the physical-exercise group, compared with the no-active-intervention group.
Both low-frequency EA and physical exercise were more effective than no active intervention for improving menstrual frequency and several of the measured sex steroids. Although both EA and physical activity decreased the level of circulating sex steroids, the effect on the specific sex steroids differed, suggesting that physical exercise and EA may act through different mechanisms. Both low-frequency EA and physical activity resulted in long-lasting improvements in monthly menstrual frequency. Repeated low-frequency EA was more effective than physical exercise for reducing serum sex steroids and acne, and at increasing menstrual frequency in women with PCOS. The present study highlights effects of alternative interventions for management of hyperandrogenism and oligo/amennorhea.