Acupuncture: review and analysis of controlled clinical trials changes are demonstrable by X-ray. In these cases, acupuncture may bring about a permanent cure Controlled studies on common diseases and conditions in this category have been reported by different authors, with favourable results for acupuncture treatments compared with standard therapy, delayed-treatment controls, control needling, mock TENS, or other sham acupuncture techniques The conditions concerned include cervical spondylitis or neck pain due to other causes(33-37), periarthritis of the shoulder(38, 39)fibromyalgia(40), fasciitis (41), epicondylitis(tennis elbow)(42-44), low back pain(45-49), sciatica(50-53), osteoarthritis with knee pain(54-56), and radicular and pseudoradicular pain syndromes(57). In some reports, comparison was made between standard care and acupuncture as an adjunct to standard care. The conclusion from one such randomized controlled trial was that acupuncture is an effective and judicious adjunct to conventional care for patients with osteoarthritis of the knee(58) Rheumatoid arthritis is a systemic disease with extra-articular manifestations in most patients. In this disease, dysfunction of the immune system plays a major role, which explains the extra-articular and articular features. Acupuncture is beneficial in the treatment of rheumatoid arthritis(4-6). While acupuncture may not improve the damage that has been done to the joints, successful pain relief has been verified in the majority of controlled studies(58). The action of acupuncture on inflammation and the dysfunctional immune system is also beneficial (5, 59) 2.1.3 Gout In a randomized controlled trial, blood-pricking acupuncture was compared with conventional medication(allopurinol). The acupuncture group showed greater improvement than the allopurinol group. In addition, a similar reduction of uric acid levels in the blood and urine of both groups was noted(60). Plum-blossom application to the se, sing plum-blossom needles), together with cupping(the which are then depressurized), has been recommended for treating gouty arthritis(61) 2.1.4 Biliary and renal colic Acupuncture is suitable for treating acute pain, provided the relief of pain will not mask the correct diagnosis, for which other treatments may be needed Biliary and renal colic are two conditions for which acupuncture can be used not only as an analgesic but also as an antispasmodic. In controlled studies on biliary olic(62-64)and renal colic(7, 65, 66), acupuncture appears to have advantages over conventional drug treatments(such as intramuscular injection of atropine, pethidine, anisodamine(a Chinese medicine structurally related to atropine, olated from Anisodus tanguticus), bucinnazine(also known as bucinperazine)or a metamizole-camylofin combination). It provides a better analgesic effect in a shorter time, without side-effects. In addition, acupuncture is effective for relieving abdominal colic, whether it occurs in acute gastroenteritis or is due to gastrointestinal spasm(67)
Acupuncture: review and analysis of controlled clinical trials changes are demonstrable by X-ray. In these cases, acupuncture may bring about a permanent cure. Controlled studies on common diseases and conditions in this category have been reported by different authors, with favourable results for acupuncture treatments compared with standard therapy, delayed-treatment controls, control needling, mock TENS, or other sham acupuncture techniques. The conditions concerned include cervical spondylitis or neck pain due to other causes (33–37), periarthritis of the shoulder (38, 39) fibromyalgia (40), fasciitis (41), epicondylitis (tennis elbow) (42–44), low back pain (45–49), sciatica (50–53), osteoarthritis with knee pain (54–56), and radicular and pseudoradicular pain syndromes (57). In some reports, comparison was made between standard care and acupuncture as an adjunct to standard care. The conclusion from one such randomized controlled trial was that acupuncture is an effective and judicious adjunct to conventional care for patients with osteoarthritis of the knee (58). Rheumatoid arthritis is a systemic disease with extra-articular manifestations in most patients. In this disease, dysfunction of the immune system plays a major role, which explains the extra-articular and articular features. Acupuncture is beneficial in the treatment of rheumatoid arthritis (4–6). While acupuncture may not improve the damage that has been done to the joints, successful pain relief has been verified in the majority of controlled studies (58). The action of acupuncture on inflammation and the dysfunctional immune system is also beneficial (5, 59). 2.1.3 Gout In a randomized controlled trial, blood-pricking acupuncture was compared with conventional medication (allopurinol). The acupuncture group showed greater improvement than the allopurinol group. In addition, a similar reduction of uric acid levels in the blood and urine of both groups was noted (60). Plum-blossom needling (acupuncture using plum-blossom needles), together with cupping (the application to the skin of cups which are then depressurized), has been recommended for treating gouty arthritis (61). 2.1.4 Biliary and renal colic Acupuncture is suitable for treating acute pain, provided the relief of pain will not mask the correct diagnosis, for which other treatments may be needed. Biliary and renal colic are two conditions for which acupuncture can be used not only as an analgesic but also as an antispasmodic. In controlled studies on biliary colic (62–64) and renal colic (7, 65, 66), acupuncture appears to have advantages over conventional drug treatments (such as intramuscular injection of atropine, pethidine, anisodamine (a Chinese medicine structurally related to atropine, isolated from Anisodus tanguticus), bucinnazine (also known as bucinperazine) or a metamizole–camylofin combination). It provides a better analgesic effect in a shorter time, without side-effects. In addition, acupuncture is effective for relieving abdominal colic, whether it occurs in acute gastroenteritis or is due to gastrointestinal spasm (67). 10
2. Review of clinical trial rer 2.1.5 Traumatic or postoperative pain For traumas such as sprains, acupuncture is not only useful for relieving pain without the risk of drug dependence, but may also hasten recovery by improving local circulation(68-70). Acupuncture analgesia to relieve postoperative pain is well recognized and has been confirmed in controlled studies(71-76). The first successful operation under acupuncture analgesia was a tonsillectomy. This was in fact, inspired by the success of acupuncture in relieving post-tonsillectomy pain. Post-tonsillectomy acupuncture was re-evaluated in a controlled study in 1990, which not only showed prompt alleviation of throat pain, but also reduction in salivation and promotion of healing in the operative wound (76) 2.1.6 Dentistry Acupuncture has been widely used in dentistry. There are reports of randomized controlled trials on the analgesic effect of acupuncture for postoperative pain from various dental procedures, including tooth extraction (77-78), pulp devitalization(79), and acute apical periodontitis( 80). According to a systematic review of papers on the use of acupuncture in dentistry published between 1966 and 1996, 11 out of 15 randomized appropriate statistics and sufficient follow-up showed standard acupuncture to be more effective than a placebo or sham acupuncture. It was therefore concluded that acupuncture should be considered a reasonable alternative or supplement to current dental practice as an analgesic( 81). Its use in the treatment of temporomandibular dysfunction was also supported in these studies 2. 1.7 Childbirth In childbirth, acupuncture analgesia is useful for relieving labour pain and can significantly reduce the duration of labour(82). In the case of weakened uterine contractions, acupuncture increases the activity of the uterus. Episiotomy and subsequent suturing of the perineum can also be carried out with acupuncture inf gesia. In addition, the avoidance of narcotics is advantageous for newborn anal 2.1. 8 Surgery Acupuncture analgesia has the following advantages in surgical operations. It is a very safe procedure compared with drug anaesthesia; no death has ever been reported from acupuncture analgesia. There is no adverse effect on physiological functions, whereas general anaesthesia often interferes with respiration and blood pressure, for example. There are fewer of the postoperative complications that sometimes occur after general anaesthesia, such as nausea, urinary retention, constipation, and respiratory infections. The patient remains conscious and able to talk with the medical team during the operation so that injury of the facial and recurrent laryngeal nerve can be avoided. However, remaining conscious may a disadvantage if the patient cannot tolerate the emotional stress of procedure
2. Review of clinical trial reports 2.1.5 Traumatic or postoperative pain For traumas such as sprains, acupuncture is not only useful for relieving pain without the risk of drug dependence, but may also hasten recovery by improving local circulation (68–70). Acupuncture analgesia to relieve postoperative pain is well recognized and has been confirmed in controlled studies (71–76). The first successful operation under acupuncture analgesia was a tonsillectomy. This was, in fact, inspired by the success of acupuncture in relieving post-tonsillectomy pain. Post-tonsillectomy acupuncture was re-evaluated in a controlled study in 1990, which not only showed prompt alleviation of throat pain, but also reduction in salivation and promotion of healing in the operative wound (76). 2.1.6 Dentistry Acupuncture has been widely used in dentistry. There are reports of randomized controlled trials on the analgesic effect of acupuncture for postoperative pain from various dental procedures, including tooth extraction (77–78), pulp devitalization (79), and acute apical periodontitis (80). According to a systematic review of papers on the use of acupuncture in dentistry published between 1966 and 1996, 11 out of 15 randomized controlled studies with blind controls, appropriate statistics and sufficient follow-up showed standard acupuncture to be more effective than a placebo or sham acupuncture. It was therefore concluded that acupuncture should be considered a reasonable alternative or supplement to current dental practice as an analgesic (81). Its use in the treatment of temporomandibular dysfunction was also supported in these studies. 2.1.7 Childbirth In childbirth, acupuncture analgesia is useful for relieving labour pain and can significantly reduce the duration of labour (82). In the case of weakened uterine contractions, acupuncture increases the activity of the uterus. Episiotomy and subsequent suturing of the perineum can also be carried out with acupuncture analgesia. In addition, the avoidance of narcotics is advantageous for newborn infants. 2.1.8 Surgery Acupuncture analgesia has the following advantages in surgical operations. It is a very safe procedure compared with drug anaesthesia; no death has ever been reported from acupuncture analgesia. There is no adverse effect on physiological functions, whereas general anaesthesia often interferes with respiration and blood pressure, for example. There are fewer of the postoperative complications that sometimes occur after general anaesthesia, such as nausea, urinary retention, constipation, and respiratory infections. The patient remains conscious and able to talk with the medical team during the operation so that injury of the facial and recurrent laryngeal nerve can be avoided. However, remaining conscious may be a disadvantage if the patient cannot tolerate the emotional stress of the procedure. 11
Acupuncture: review and analysis of controlled clinical trials While the benefits of acupuncture analgesia are many, the disac dvantage es must also be considered The use of acupuncture is more time-consuming and in many cases may fail to bring about complete analgesia. It is often not suitable for abdominal surgery because suppression of visceral pain and muscle relaxation may be inadequate. It is not suitable in children because few children will tolerate the needling and keep still during major surgery. Also, the surgeon must be quick and deft, so that the operation can be finished before the patient develops tolerance to the needling In conclusion, acupuncture analgesia as an anaesthetic for surgical procedures is indicated in selected patients who show a good response to needling in the preoperative trial, particularly when they may be a poor surgical risk under conventional general anaesthesia. The use of adjuvant drugs to potentiate the effect of the acupuncture treatment is preferred. Acupuncture can also be used in combination with general anaesthesia to reduce the dosage of anaesthetic agents (83) 2.2 Infections Acupuncture has be een reporte d to be effective for treating acute bacillary dysentery(8-10). Its effect is comparable with that of conventional medicines such as furazolidone, but the use of acupuncture in the first line of defence against this disease is not practicable- daily performance of needling procedures is much more complicated than administering oral drug therapy. However, when no antidysenteric agent is available or the patient is allergic to antidysenteric agents, acupuncture may occasionally be used The results of research on the effects of acupuncture treatments that stimulate the immune system suggest that acupuncture may be of use in conjunction with other medical therapies for treating infections( 84) The effect of acupuncture on the immune system has been tested in hepatitis B virus carriers. In a comparative study, acupuncture-moxibustion is apparently superior to herbal medications in producing hepatitis B e core antibodies and reducing hepatitis B surface antigen(85). For epidemic haemorrhagic fever, compared with steroid and supportive treatments, moxibustion shortened the period of oliguria and promoted the reduction of kidney swelling(86) Acupuncture may be useful in treating pertussis(whooping cough), by relieving cough as well as promoting a cure(87) 2.3 Neurological disorders n the neurological field, headaches, migraines and neuralgia are the common painful conditions treated with acupuncture. Strokes and their sequelae are another major indication for acupuncture. Early treatment of paresis after stroke has proved highly effective Because improvement in the effects of stroke also occurs naturally, there has been some doubt about the contribution of acupuncture. In recent years, however, a number of controlled clinical evaluations have been undertaken in stroke
Acupuncture: review and analysis of controlled clinical trials While the benefits of acupuncture analgesia are many, the disadvantages must also be considered. The use of acupuncture is more time-consuming and in many cases may fail to bring about complete analgesia. It is often not suitable for abdominal surgery because suppression of visceral pain and muscle relaxation may be inadequate. It is not suitable in children because few children will tolerate the needling and keep still during major surgery. Also, the surgeon must be quick and deft, so that the operation can be finished before the patient develops tolerance to the needling. In conclusion, acupuncture analgesia as an anaesthetic for surgical procedures is indicated in selected patients who show a good response to needling in the preoperative trial, particularly when they may be a poor surgical risk under conventional general anaesthesia. The use of adjuvant drugs to potentiate the effect of the acupuncture treatment is preferred. Acupuncture can also be used in combination with general anaesthesia to reduce the dosage of anaesthetic agents (83). 2.2 Infections Acupuncture has been reported to be effective for treating acute bacillary dysentery (8–10). Its effect is comparable with that of conventional medicines such as furazolidone, but the use of acupuncture in the first line of defence against this disease is not practicable—daily performance of needling procedures is much more complicated than administering oral drug therapy. However, when no antidysenteric agent is available or the patient is allergic to antidysenteric agents, acupuncture may occasionally be used. The results of research on the effects of acupuncture treatments that stimulate the immune system suggest that acupuncture may be of use in conjunction with other medical therapies for treating infections (84). The effect of acupuncture on the immune system has been tested in hepatitis B virus carriers. In a comparative study, acupuncture–moxibustion is apparently superior to herbal medications in producing hepatitis B e core antibodies and reducing hepatitis B surface antigen (85). For epidemic haemorrhagic fever, compared with steroid and supportive treatments, moxibustion shortened the period of oliguria and promoted the reduction of kidney swelling (86). Acupuncture may be useful in treating pertussis (whooping cough), by relieving cough as well as promoting a cure (87). 2.3 Neurological disorders In the neurological field, headaches, migraines and neuralgia are the common painful conditions treated with acupuncture. Strokes and their sequelae are another major indication for acupuncture. Early treatment of paresis after stroke has proved highly effective. Because improvement in the effects of stroke also occurs naturally, there has been some doubt about the contribution of acupuncture. In recent years, however, a number of controlled clinical evaluations have been undertaken in stroke 12
eview of clinical trial reports patients. For example, in randomized controlled studies, acupuncture treatment of hemiplegia due to cerebral infarction gave better results than conventional medication(88-93)and physiotherapy (94, 95). There were also beneficial effects when acupuncture was used as a complement to rehabilitation(96-98) In one study, patients with ischaemic cerebrovascular disease treated with acupuncture were compared with patients treated with conventional drugs Nerve function, as evaluated by electroencephalographic map and somatosensory evoked potential, showed a much more marked improvement i the patients treated with acupuncture(89). This has been further confirmed by experimental studies. In the laboratory a rat model of reversible middle cerebral artery occlusion was used. The somatosensory evoked potential recorded before and after the occlusion showed that electric acupuncture markedly promoted the recovery of the amplitude of the Pl-N1 wave (to 58.6% in the electric acupuncture group in contrast to 25. 5% in the control group after 7 days)(93). In ddition, recent clinical studies suggest that the effectiveness of acupuncture therapy can be further promoted by using temporal acupuncture(99, 100) Comparative studies have shown acupuncture treatments to be as effective for treating hemiplegia due to cerebral haemorrhage as for that due to cerebral infarction. Since early treatment with physiotherapy is unsatisfactory, it is advisable to use acupuncture as the primary treatment. Even in hemiplegia of ong duration, remarkable improvements can often be achieved. Hemiplegia due to other causes, such as brain surgery, can also be improved by acupuncture (101). Aphasia caused by acute cerebrovascular disorders can also be treated with acupuncture(10 Although acupuncture is effective for many painful conditions, there are only a few reports on post-herpetic neuralgia. Two of them were based on randomized clinical trials and provided completely opposite results(103, 104). Evaluation of cupuncture in the treatment of this painful condition therefore awaits further Peripheral nervous disorders are often treated with acupuncture. For example, good effects for Bell,s palsy have been reported in randomized controlled trials (105, 106). Facial spasm is another peripheral nervous disorder for which acupuncture treatment may be indicated For this condition it has been shown that wrist-ankle acupuncture is significantly better than traditional body acupuncture(107) Coma is a serious condition that can hardly be cured by acupuncture alone, but in a comparative study of two groups of patients with similar levels of coma, a significantly greater number of patients in the acupuncture group had a 50% or greater neurological recovery than those in the control group. This suggests that it is reasonable to incorporate acupuncture along with other therapeutic and supportive measures in the treatment of the comatose patient (108) Insomnia can also be treated successfully with acupuncture. In randomized control trials, both auricular acupressure and auricular acupuncture had a hypnotic effect(109, 110)
2. Review of clinical trial reports patients. For example, in randomized controlled studies, acupuncture treatment of hemiplegia due to cerebral infarction gave better results than conventional medication (88–93) and physiotherapy (94, 95). There were also beneficial effects when acupuncture was used as a complement to rehabilitation (96–98). In one study, patients with ischaemic cerebrovascular disease treated with acupuncture were compared with patients treated with conventional drugs. Nerve function, as evaluated by electroencephalographic map and somatosensory evoked potential, showed a much more marked improvement in the patients treated with acupuncture (89). This has been further confirmed by experimental studies. In the laboratory, a rat model of reversible middle cerebral artery occlusion was used. The somatosensory evoked potential recorded before and after the occlusion showed that electric acupuncture markedly promoted the recovery of the amplitude of the P1–N1 wave (to 58.6% in the electric acupuncture group in contrast to 25.5% in the control group after 7 days) (93). In addition, recent clinical studies suggest that the effectiveness of acupuncture therapy can be further promoted by using temporal acupuncture (99, 100). Comparative studies have shown acupuncture treatments to be as effective for treating hemiplegia due to cerebral haemorrhage as for that due to cerebral infarction. Since early treatment with physiotherapy is unsatisfactory, it is advisable to use acupuncture as the primary treatment. Even in hemiplegia of long duration, remarkable improvements can often be achieved. Hemiplegia due to other causes, such as brain surgery, can also be improved by acupuncture (101). Aphasia caused by acute cerebrovascular disorders can also be treated with acupuncture (102). Although acupuncture is effective for many painful conditions, there are only a few reports on post-herpetic neuralgia. Two of them were based on randomized clinical trials and provided completely opposite results (103, 104). Evaluation of acupuncture in the treatment of this painful condition therefore awaits further study. Peripheral nervous disorders are often treated with acupuncture. For example, good effects for Bell’s palsy have been reported in randomized controlled trials (105, 106). Facial spasm is another peripheral nervous disorder for which acupuncture treatment may be indicated. For this condition it has been shown that wrist–ankle acupuncture is significantly better than traditional body acupuncture (107). Coma is a serious condition that can hardly be cured by acupuncture alone, but in a comparative study of two groups of patients with similar levels of coma, a significantly greater number of patients in the acupuncture group had a 50% or greater neurological recovery than those in the control group. This suggests that it is reasonable to incorporate acupuncture along with other therapeutic and supportive measures in the treatment of the comatose patient (108). Insomnia can also be treated successfully with acupuncture. In randomized control trials, both auricular acupressure and auricular acupuncture had a hypnotic effect (109, 110). 13
Acupuncture: review and analysis of controlled clinical trials 2.4 Respiratory disorders Acupuncture is often used in treating respiratory disorders. Allergic rhinitis is one of the major indications. In controlled studies, it has been shown that acupuncture is more effective than antihistamine drugs in the treatment of allergic rhinitis (111-115). Acupunctures lack of side-effects is a distinct advantage in treating this condition; however, its protective effect against allergen-provoked rhinitis has not been verified (116) The acute symptoms of tonsillitis can be effectively relieved with acupuncture (117). Since there is no information about the incidence of complications secondary to tonsillitis treated with acupuncture, in clinical practice antibiotic herapy should still be considered the treatment of choice for acute tonsillitis. For sore throats from other causes, acupuncture treatment provides definite benefits, in contrast to a placebo and acupuncture refusal (118) Although there are conflicting results from controlled trials in treating bronchial asthma with acupuncture, the majority of the reports suggest that acupuncture is ffective(119-123) and that the effect is related to the points used (122). While bronchial asthma is not cured by acupuncture, it may be substantially relieved, at least for short periods of time. The success rates quoted in the literature are 60- 70%. Acupuncture has a limited role in treating acute asthmatic attacks since it is a weak bronchodilator, but it may serve as a prophylactic measure over the long erm. Controlled trials have shown that acupuncture brings about modest improvement in objective parameters, with significant subjective improvement (124). Prospective randomized single-blind studies of the effects of real and sham acupuncture on exercise-induced and metacholine-induced asthma revealed that real acupuncture provided better protection than did sham acupuncture(119), but it failed to modulate the bronchial hyperreactivity to histamine(125) Corticosteroid-dependent bronchial asthma may respond better to acupuncture treatment than other types: the required dosage of corticosteroids gradually decreases during the first weeks of acupuncture treatment(126). Acupuncture may also provide symptomatic improvement in the late stages of bronchial asthma, where there are complications of disabling breathlessness due to impaired lung function(127) 2.5 Digestive disorders Epigastric pain is a common symptom in diseases of the stomach, including peptic ulcer, acute and chronic gastritis, and gastric spasm. Acupuncture provides satisfactory relief of epigastric pain-significantly better than injections of anisodamine or morphine plus atropine, as shown in randomized controlled trials(128, 129). For gastrointestinal spasm, acupuncture is also superior to injections of atropine(130), and for gastrokinetic disturbances, the effectiveness of acupuncture is comparable with that of conventional medicine(domperidone Another common symptom of digestive disorders is nausea and vomiting. This can be due to a disordered function of the stomach but it is more often a symptom or sign of generalized disorders. Morning sickness, postoperative vomiting, and nausea and vomiting related to chemotherapy are frequently
Acupuncture: review and analysis of controlled clinical trials 2.4 Respiratory disorders Acupuncture is often used in treating respiratory disorders. Allergic rhinitis is one of the major indications. In controlled studies, it has been shown that acupuncture is more effective than antihistamine drugs in the treatment of allergic rhinitis (111–115). Acupuncture’s lack of side-effects is a distinct advantage in treating this condition; however, its protective effect against allergen-provoked rhinitis has not been verified (116). The acute symptoms of tonsillitis can be effectively relieved with acupuncture (117). Since there is no information about the incidence of complications secondary to tonsillitis treated with acupuncture, in clinical practice antibiotic therapy should still be considered the treatment of choice for acute tonsillitis. For sore throats from other causes, acupuncture treatment provides definite benefits, in contrast to a placebo and acupuncture refusal (118). Although there are conflicting results from controlled trials in treating bronchial asthma with acupuncture, the majority of the reports suggest that acupuncture is effective (119–123) and that the effect is related to the points used (122). While bronchial asthma is not cured by acupuncture, it may be substantially relieved, at least for short periods of time. The success rates quoted in the literature are 60– 70%. Acupuncture has a limited role in treating acute asthmatic attacks since it is a weak bronchodilator, but it may serve as a prophylactic measure over the long term. Controlled trials have shown that acupuncture brings about modest improvement in objective parameters, with significant subjective improvement (124). Prospective randomized single-blind studies of the effects of real and sham acupuncture on exercise-induced and metacholine-induced asthma revealed that real acupuncture provided better protection than did sham acupuncture (119), but it failed to modulate the bronchial hyperreactivity to histamine (125). Corticosteroid-dependent bronchial asthma may respond better to acupuncture treatment than other types: the required dosage of corticosteroids gradually decreases during the first weeks of acupuncture treatment (126). Acupuncture may also provide symptomatic improvement in the late stages of bronchial asthma, where there are complications of disabling breathlessness due to impaired lung function (127). 2.5 Digestive disorders Epigastric pain is a common symptom in diseases of the stomach, including peptic ulcer, acute and chronic gastritis, and gastric spasm. Acupuncture provides satisfactory relief of epigastric pain—significantly better than injections of anisodamine or morphine plus atropine, as shown in randomized controlled trials (128, 129). For gastrointestinal spasm, acupuncture is also superior to injections of atropine (130), and for gastrokinetic disturbances, the effectiveness of acupuncture is comparable with that of conventional medicine (domperidone) (131). Another common symptom of digestive disorders is nausea and vomiting. This can be due to a disordered function of the stomach, but it is more often a symptom or sign of generalized disorders. Morning sickness, postoperative vomiting, and nausea and vomiting related to chemotherapy are frequently 14