Abstract
Determining the efficacy of auricular acupuncture for reducing anxiety in patients withdrawing from psychoactive drugs
Black S, Carey E, Webber A, Neish N, Gilbert R. J Subst Abuse Treat. 2011;41(3)279–287.
A literature review conducted by the authors concluded that no previous study had investigated the efficacy of the National Acupuncture Detoxification Association (NADA) protocol for reducing anxiety in a substance-abuse treatment setting. This study was designed to test the hypothesis that the NADA protocol reduces anxiety associated with withdrawal from psychoactive drugs.
One hundred and one subjects, recruited from the Addiction Treatment Services, were randomized (via computer generated assignment) into 3 groups: an experimental group (n=32) who received auricular acupuncture (AA) according to the NADA protocol and two control groups, one using AA at sham points (n=38) and the other a treatment setting (relaxation) control group (n=31). Inclusion criteria were: (1) being at least 18 years of age; (2) self-reported primary presenting problem as one of the following: alcohol, cocaine, nicotine, cannabis, opioids, benzodiazepines, or amphetamines; (3) not having received acupuncture treatment within the past 3 months; (4) not currently receiving treated for an anxiety disorder; and (5) no history of coagulation or platelet disorders or currently taking medications that may promote bleeding. Three 45-minute sessions, over a period that did not exceed 2 weeks, were provided to subjects in each of the treatment groups. For each of the three treatment sessions, state anxiety, heart rate (HR), and blood pressure (BP) were measured immediately prior to and immediately following treatments (pretest–post-test design). Active treatment consisted of inserting needles at the five NADA protocol specified points: sympathetic, shen men, Lung, Liver, and Kidney. Needles were inserted to a depth of 1–3 mm and left in place for 45 minutes.
The primary outcome measure was the effect of treatment on subject state anxiety levels, measured (Spielberger State-Trait Anxiety Inventory [STAI] for adults to measure anxiety) immediately before and after each treatment session. Secondary outcome measures included changes in HR and BP, which were evaluated pre- and post-treatment. A total of 101 subjects completed at least one treatment session, 71 completed at least two sessions, and 49 completed three sessions. The mean age was 41.2 years (52 females; 49 males). Nicotine (32, 31.7%), alcohol (29, 28.7%), cocaine (17, 16.8%), and cannabis (11, 10.9%) use were the most commonly reported primary presenting problems.
There were significant differences in the baseline trait anxiety scores among the four major primary presenting problems (alcohol, cannabis, cocaine, or nicotine use; F=3.49, df=3, P=0.022), whereas other primary presenting problem differences did not reach significance. There was a significant decrease in the state anxiety scores of approximately 7.7 points (95% CI=5.2–10.2) after treatment (t=5.96, P<.001). However, there were no significant differences in the decrease in the pre– and post–state anxiety scores among the three treatment groups, all P≥0.21. There was a significant decrease in HR of approximately 4.0 beats per minute after treatment (t=3.27, P<0.001). However, there were no significant differences in the decrease by treatment among the three treatment groups, all P≥0.68. There was an insignificant decrease in systolic BP of approximately 1.9 mm Hg after treatment (t=1.78, P=0.077). There were no significant differences among the three groups; all p≥.07. There was an insignificant decrease in diastolic BP of approximately 1.0 mm Hg after treatment (t=0.078, P=0.44). There were no significant differences by treatment among the three groups; all P≥0.55.
Although a number of studies have demonstrated the clinical benefits of AA for treating substance abuse, a consensus of available studies has suggested that there is inconclusive evidence in support of AAs effectiveness as a stand-alone treatment or when given together with conventional treatment. In this study a significant effect of sham-point acupuncture on primary and secondary outcome measures were observed. These effects were not significantly different from those measured in the NADA protocol treatment group or in the control group. Although this study was powered to identify statistical significance a few limitations exist, such as the limited number of treatments (n=3)and the short duration of the study and follow-up. The lack of congruence between the clinical benefits and the research evidence pertaining to the NADA protocol makes it clear that further studies are needed to explore those mechanisms and clinical value.
Acupuncture for the treatment of major depressive disorder: a randomized controlled trial
Andreescu C, Glick RM, Emeremni CA, Houck PR, Mulsant BH. J Clin Psychiatry. 2011;72(8):1129–1135.
The objective of this randomized, parallel-group controlled trial was to determine whether a 2-point electro-acupuncture protocol (verum acupuncture) would be beneficial for treating mild or moderate major depressive disorder (MDD), compared to needling at non-channel scalp points with sham electro-stimulation (control acupuncture). Subjects who met the Diagnostic and Statistical Manual of Mental Disorders–IV * criteria for mild or moderate MDD and who presented with a Hamilton Depression Rating Scale (HDRS) of 14 or above were recruited via referral or advertisement. Subjects with severe depression; suicidal ideation; seizure disorder; or risk for seizures, psychosis, bipolar disorder, chronic MDD (2+ years), or treatment-resistant MDD; or history of substance abuse over the previous 6-months were excluded from the study. The study was conducted over 3 years at the University of Pennsylvania. All psychoactive medications were tapered prior to randomizations and all subjects remained off psychoactive medication over the duration of the study (12 sessions, with 2 sessions per week). The active group received acupuncture at 2 points (DU 20 and Yintang), electro-stimulated at 2 Hz for 30 minutes. The control group was needled at non-channel acupoints with sham electro-stimulation. The primary outcome measure was the absolute change in HDRS score. Data were collected at initial screening, baseline, weekly during the active phase, and at 2weeks post intervention. Secondary measures data collected at baseline and at 2 weeks post intervention were UKU Side-Effect Rating Scale (UKU), used to assess tolerability; and the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS-SF36), used to assess functional improvement.
Fifty-seven subjects were randomized into two groups: active intervention (n=28) and sham acupuncture (n=29). Subjects who completed at least one follow-up assessment were included in the data analysis. Four subjects in the control group had to be disqualified because there was an error by the acupuncturist who was stimulating the active points. The two groups did not differ at baseline in demographics, HDRS, and cognitive or functional status.
There was no difference in the absolute or relative decrease in HDRS scores between the two groups. A mixed-model analysis also failed to show any significant difference in the responses between the two groups. There was also no difference in the adverse effects (UKU) or functional status (MOS-SF36) between the two groups. Analysis of the anxiety subscale in HDRS showed a decrease in both groups but failed to show any statistical significance.
This study was not able to demonstrate a beneficial effect in the treatment of mild-to-moderate MDD using electro-acupuncture stimulation at the points used (Du 20 and Yintang). In fact, the decrease in HDRS score was higher in the control group than in the intervention group. Together with other similar studies, these results show that using a fixed protocol to apply acupuncture may not be appropriate unless prior experimental work has been conducted to substantiate the potential neurohormonal role of acupuncture stimulation at these specific points.
*Reference
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Arlington, VA: American Psychiatric Association, 1994.
Effect of acupuncture on nausea and/or vomiting during and after cesarean section in comparison with ondansetron
El-Deeb AM, Ahmady MS. J Anesth. 2011;25(5):698–703.
Four-hundred and fifty parturient patients (ages 25–35) who were admitted for elective cesarean section (CS) using spinal anesthesia were enrolled in this study. Subjects were excluded from this study if they had acupuncture treatment during the previous 6 months, nausea or vomiting during 24 hours preoperatively, diabetes, hypertension, cardiovascular disease, and any other serious systemic disease. Subjects were randomized (by sealed envelope) in three equal groups (150 parturient patients in each group) according to the antiemetic therapy used: the control group (1) received 2 mL of normal saline I.V. and sham points were stimulated bilaterally; (2) the ondansetron group received 4 mg of ondansetron I.V. 30 minutes before spinal anesthesia and sham points were stimulated bilaterally; and (3) the electro-acupuncture group received 2 mL of normal saline was IV and electrical stimulation of P 6 bilaterally for 30 minutes before spinal anesthesia. Electrical stimulation performed at the lowest comfortable efficient frequency felt by the patient.
Nausea and vomiting were evaluated and recorded every 10 minutes intraoperatively and at 2, 4, 6, 12, and 24 hours postoperatively by an independent anesthetist who was blinded to group assignment. Nausea was assessed using visual analogue score (VAS; 0, no nausea; 10, worst imaginable nausea). An antiemetic “rescue” drug (4 mg of ondansetron I.V.) was administered for severe nausea (nausea on the VAS at 4 or worse) or for vomiting within the study period. Data were also collected regarding time to first emetic event, duration of surgery, amount of ephedrine consumed, and complications. Patient satisfaction was evaluated and recorded based upon the whole-patient experience during the study period (satisfied or not).
No significant difference was noted among the three groups with respect to demographic characteristics, intraoperative ephedrine dose, gestational age, and duration of surgery. Nausea and vomiting occurred significantly less often in the active treatment groups (2 and 3) during the operation and for 6 hours postoperatively. There was no statistically significant difference among the groups in incidence of nausea and vomiting from 6 to 24 hours postoperatively. In addition, there was no statistically significant difference between groups 2 and 3 in incidence of nausea and vomiting intraoperatively and postoperatively. Antiemetic rescue was comparable in the active treatment groups (2 and 3) during the operation and postoperatively. Patient satisfaction with postoperative nausea and vomiting control was higher in the active treatment groups, compared with the control group (1).
Because the occurrence of nausea and vomiting after spinal anesthesia for cesarean delivery is mainly intraoperative, the timing of acupoint stimulation is important. Acupuncture should be performed before emetic stimulation by anesthesia and surgery. Preoperative electrical stimulation of P 6 does not interfere with operative maneuvers or postoperative rest and does not cause complications. In this study, there was a trend toward less nausea in the active groups. Although the incidence of intraoperative and early postoperative nausea or vomiting was less frequent in patients receiving electrical stimulation, there was no statistically significant difference in the incidence of late postoperative nausea or vomiting, compared with placebo. The results suggest that the use of acupoint stimulation is as effective as administering a single dose of ondansetron (4 mg), with a similar side-effects profile. These results are similar to the results from similar studies published earlier by McMillan C (1991) and Gan TJ (2004). †
†References
McMillan C, Dundee JW, Abram WP. Enhancement of the antiemetic action of ondansetron by transcutaneous electrical stimulation of the P6 antiemetic point, in patients having highly emetic cytotoxic drugs. Br J Cancer. 1991;64(5):971–972.
Gan TJ, Jiao KR, Zenn M, Georgiade G. A randomized controlled comparison of electro-acupoint stimulation or ondansetron versus placebo for the prevention of postoperative nausea and vomiting. Anesth Analg. 2004;99(4):1070–1075.
Acupuncture ameliorated skeletal muscle atrophy induced by hindlimb suspension in mice
Onda A, Jiao Q, Nagano Y, Akimoto T, Miyamoto T, Minamisawa S, Fukubayashi T. Biochem Biophys Res Commun. 2011 Jul 8;410(3):434–439.
The authors hypothesized that acupuncture is a promising, feasible, non-pharmacological strategy for preventing skeletal-muscle atrophy. The objective of this study was to test the hypothesis and to investigate the effect of acupuncture on skeletal-muscle atrophy induced by hindlimb suspension (HS) in mice and the expression levels of muscular-specific mRNAs involved in muscular protein degradation and synthesis.
HS consists of tail suspension from the cage ceiling. Mice were housed in independent plastic cages at 20°–23°C with a 12–12-hour light–dark cycle with free access to food and water ad libitum. Twenty-eight male mice were randomly assigned into four groups: (1) control; (2) untreated HS; (3) HS+manual acupuncture (MA); and (4) HS+MA+electrical stimulation (EA). There were 7 animals in each group. Mice in the MA and EA groups were anesthetized with Somnopentyl by intraperitoneal injection so that they would remain in a recumbent position during acupuncture treatment. Acupuncture was performed on the gastrocnemius muscle for 30 minutes every day for 2 weeks. The needle was inserted ∼ 5 mm into the muscle from the distal point of the gastrocnemius toward the vertex, parallel to the ground, to avoid damaging the soleus muscle. After the 2-week period of acupuncture treatment, all mice were sacrificed. Both soleus (slow-twitch) and gastrocnemius (fast-twitch) muscles were dissected from the hindlimb and analyzed.
After 2 weeks of HS, muscle mass and cross-sectional area (CSA) were significantly reduced in the soleus muscle (56% and 45% reductions, respectively), and were reduced, although not significantly, in the gastrocnemius muscle (20% and 21% reductions), indicating that HS induced muscle atrophy to a greater degree in the soleus than in the gastrocnemius muscle. HS-induced reduction in soleus-muscle mass was significantly less in the MA and EA groups (7% and 10% improvement in outcome, respectively), although this level of improvement was insufficient, as muscle mass was still lower in the MA and EA groups than in the control group. Furthermore, HS-induced reduction in the CSA of the soleus muscle was significantly lower in the EA group (18% improvement in outcome), although this level of improvement was insufficient, as CSA was still lower in the MA and EA groups than in the control group.
At the end of the 2-week period of acupuncture treatment, significant increases in mRNA expression levels in the soleus were observed for both atrogin-1 (a 302% increase, compared to control group) and MuRF1 (a 247% increase, compared to control group). The HS-induced increase in atrogin-1 expression in the soleus muscle was significantly decreased in the MA and EA groups, while that of MuRF1 expression was significantly decreased in the EA group alone, although these levels of improvement were insufficient when compared with the control group.
When exploring protein-synthesis pathways of the soleus, the expression level of PI3K mRNA was significantly increased in the HS group, but was not reduced by MA or EA. However, although Akt1 mRNA expression was not significantly increased by HS, expression levels of the Akt1 mRNA group in the soleus muscle were significantly upregulated by MA, compared to the control group. HS tended to increase the expression of adenosine A1 receptor mRNA, although this increase did not reach statistical significance; EA, however, significantly increased this receptor's expression, compared to that seen in the control group. The expression levels of myostatin and SIRT1 mRNAs were significantly increased by HS but were not affected by acupuncture.
Results from this study indicate that acupuncture partially prevents skeletal-muscle atrophy caused by HS. Based on the downregulation of certain genes involved in muscle-specific degradation (MuRF-1), and upregulated the genes involved in protein synthesis (Akt1 and TRPV4), the authors presumed that acupuncture prevents protein degradation and supports muscle synthesis in atrophic skeletal muscles. This would suggest that acupuncture could be a supplementary means of preventing muscle atrophy. The present study also revealed that EA was more effective than MA for preventing muscle atrophy and reducing the HS-mediated induction of MuRF1 gene expression. These findings, if substantiated by clinical studies could have great value among elderly people, patients who require prolonged bedrest, patients who need rehabilitation after stroke, and patients who require prolonged use of cast (immobilization).
Acupuncture in the inpatient acute care setting: a pragmatic, randomized control trial.
Painovich J, Herman PM. Evid Based Complement Alternat Med. 2012;2012:309762.
Patients, who were admitted by a pool of 6 participating physicians, and who had acute myocardial infarctions (AMI), coronary artery bypass grafting (CABG), congestive heart failure (CHF), cerebral vascular accidents, asthma, chronic obstructive pulmonary disease, pneumonia, laminectomy, total hip replacements, and total knee replacements, were targeted. At 6 months, low admissions to the study required a revision of the diagnosis restriction and, thereafter, all patients from the study's physician groups were approached to participate. Subjects diagnosed with cognitive impairment, with a concurrent diagnosis of sepsis or skin infection were excluded from the study. Randomization was accomplished by using a two thirds/one third–biased coin randomization to ensure that there were sufficient numbers of enrolled patients. The primary outcome was LOS. Several self-reported measures of health and patient satisfaction (hospital anxiety and depression scale [HADS]; a single-item measure of general health [“In general, how would your rate your overall health?”], with a 5-point response range; and two items capturing patient satisfaction using a visual analogue scale of 0–10) were also used to function as secondary outcomes. All patients received usual care during their hospital visits. Patients who were offered acupuncture and accepted were given daily acupuncture treatments. Each treatment and treatment style was based on individual patient presentation, diagnosis, and chief complaints.
Four hundred and thirty-one subjects admitted for hospitalization were randomized into an active acupuncture group (n=288) and a control group (n=143). However, only 383 patients signed consent forms. Of these patients, 172 (69%) were offered and accepted acupuncture treatment, 75 were offered acupuncture and refused, and 122 were randomized to the control group. On average, patients offered acupuncture had a significantly (P=0.047) longer LOS than those not offered acupuncture—on average 0.8 (95% confidence interval: 0.01–1.5) days longer. However, the average expected LOS estimates for the acupuncture group, based on their all-patient refined diagnosis-related group (APR-DRG), groups were expected to be longer (4.7 versus 4.4 days), given their conditions. Noting this discrepancy, the authors recalculated the data based on the average actual-to-expected ratios of LOS and total costs. The average actual-to-expected LOS ratio for patients who were not offered acupuncture was 0.94 compared to 1.04 for those offered acupuncture. This difference was not statistically significant (P=0.108). No statistically significant differences were found between the two groups in terms of changes in anxiety, depression, general health status, and patient satisfaction. There were no statistically significant differences in LOS or costs by treatment group across the APR-DRG defined subgroups.
In this study, acupuncture had a high acceptance rate (69%) when offered to patients who were receiving acute care, treatments were well-tolerated, conflicts with scheduling were rare, and no adverse events were reported. A major limitation is the short expected LOS, which limited the ability to observe a meaningful difference in LOS. A better measure might have been, pain level or use of medications.