Research Highlight: Asthma and Acupuncture

Research is essential to health care because it supports current methods of treatment and it can introduce new methods of treatment if research finds them to be statistically and clinically significant. However, most people have never learned how to properly read and interpret a study or what actually makes a good study. My aim will be to post studies, and to dissect them for you so that you can be informed! There are many studies that sound contradictory, or that may have negative findings which are based on unspecified information (e.g. the control group parameters are not defined, the paper may be poorly conducted/written, their isolation of variables is insufficient, etc).

So if you’re interested in learning about things, but not limited to, the naturopathic world, then keep an eye out for these posts (ideally they will be weekly), I will be featuring work of my colleagues which was written in a similar fashion as the following post. So enjoy! Never be afraid to ask questions and doubt the status quo!

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In a research class of mine, we were instructed to select a topic within the scope of practice of a naturopath and dissect a research article on it and then come to a conclusion based on supporting research whether this was an effective treatment. My topic, as is the title, was looking at specifically allergic-type asthma and the effectiveness of actual needling and the reduction of symptoms. I thought this information might be valuable to many, so I am posting what my conclusions are. I have looked at a very specific type of asthma and a specific type of treatment and intervention, so it is important to acknowledge that everyone is different, therefore you may or may not benefit from acupuncture if you have asthma despite what research says. We’re all individuals and it’s essential to try out different methods of treatment to see what works!

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Would acupuncture be an effective treatment for men and women above 16 years of age to reduce symptoms in those who have bronchial asthma?

P = Adults over the age of 16

 I = Real acupuncture with points actually used for asthma treatment in the clinical setting

C = Two control groups

1)   Sham acupuncture – insertion of needle around the acupuncture point, but not in an actual acupuncture point

2)   Control group – no needling

O = Reduction in amount and frequency of conventional medications used due to decreased attacks as well as improved respiratory functioning

It has been my experience that many different types of practitioners are using acupuncture, such as, but not limited to, naturopaths and chiropractors. The use of sterile needles prevents chances of infections and is a relatively non-invasive treatment for many differing physical and mental conditions, acute and chronic, severe and mild. According to the National Centre for Complementary and Alternative Medicine, very few complications have been encountered with acupuncture, but most will happen due to improper sterility of the needles as well as improper “delivery of treatment” which can result in infections and punctured organs (1). The needle sites should always be swabbed with alcohol before a needle is inserted to ensure safety (1).

The main current treatment for bronchial asthma is inhaled corticosteroids, and beta 2 sympathomimetics for rapid relief of acute attacks (2). While these are used wide-spread, they can result in long-term problems such as, but not limited to, tachycardia, thrush, osteoporosis, glaucoma, and suppression of adrenocortical functioning (2). This sheds light as to why it will be essential to find a safer and more effective way of treating asthma in Canadians.

Medications such as anti-inflammatory drugs are used long term and for acute asthmatic symptoms, short-term medications such as puffers containing “short-acting beta2-agonists” are used (3). However, inhaled corticosteroids have been shown to be the most effective for treating acute symptoms (4). These have been Environmental controls such as eliminating the allergens can also be used (3) but these may be difficult to completely eliminate, if for example, an individual has an allergy to grass but likes to spend time outdoors or spends time outside due to their jobs. However, despite the best efforts of conventional medications, asthma is still the main cause of absence from school, 3rd leading cause of job loss, 146,000 visits to the emergency room due to asthma attacks, $12 billion dollars in direct and indirect health care costs, which exceeded those costs of TB and AIDS/HIV combined (3). Perhaps to one person taking their puffer, their treatment is a success, when analyzing the socioeconomic impacts of asthma, perhaps the current methods of treatment aren’t as effective as one could hope.

The study in Question: Acupuncture and Bronchial Asthma: A Long-Term Randomized Study of the Effects of Real Versus Sham Acupuncture Compare to Controls in Patients with Bronchial Asthma

Systems Involved

Respiratory

Therapeutic modality used

Acupuncture

Authors

Grebski, E., Hinz, G., Medici, T.C., Wu, J., Wuthrich, B.

Journal

The Journal of Alternative and Complementary Medicine

Publication

2002, volume 8

Aim

To examine short- and long-term effects of real vs sham or no acupuncture in patients with bronchial asthma

Design

Randomized partially blind study with 3 parallel groups

Setting

Clinic (the article did not specify)

Participants:

Women and men ages 16-70 experiencing mild to moderate allergic bronchial asthma that have lasted less than 10 years and have required the use of daily conventional medications for acute and chronic instances.. Exclusion criteria included acupuncture treatment in the last 12 months for any clinical condition, immunotherapy for allergic asthma/rhinitis in the previous year, oral corticosteroids 8 weeks or more, inhalation of more than 1000 micrograms of beclomethasone daily or 800 micrograms of budesonide daily, blood clotting disorder, smoking more than 10 cigarettes a day, non-compliance regarding long-term research study, and no excess (shi)-type asthma.

Participants were randomized following a block design into one of the three intervention groups

Intervention(s):

1)   Acupuncture group: received acupuncture in 11 actual points used to treat asthma 20 minute sessions, twice weekly for eight weeks based on standard acupuncture formulas. The needles were inserted 13-40mm at a 45 or 90 degree angle. Needles manually manipulated every 5 minutes during each session. The points used were Dingchuan, Feishu, Yuji, Hegu, Quchi, Tazhui, Tsusanli, Zhangmen, San Yinjiao, Neiguan.

2)   Sham acupuncture: received needles in the vicinity of those 11 points, but not in an actual acupuncture point, 20 minute sessions, twice weekly for eight weeks. The needles were inserted to a maximum of 10mm at a 10 degree angle. Needles manually manipulated every 5 minutes during each session

3)   Control: no needling at all, but this group still came in to the same clinic as the other two groups

The figure to the right shows the specific acupuncture points, the real points are illustrated by dark solid points and the sham non-points are the white open points.

Main outcome measure(s):

The main outcome was determining the change in peak expiratory rate (PEF). Secondary outcomes included changes in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1), methacholine responsiveness, venous blood and sputum samples showing eosinophil count and eosinophil cationic protein (ECP) count, symptoms of asthma, use of asthma drugs.

Summary of key findings & results:

  • At 4 months, PEF variability decreased with real points (57% decrease) and sham points (53% decrease) more so than the control (6% increase)
  • At 5 months, PEF variability was
    – 61% – real points
    – 52% sham points
    – 4% control
  • At 10 months, there was not as significant change in PEF values, but the best value was seen in patients who received the        real acupuncture intervention (decrease PEF of 58%)
  • At months 4 and 5, Asthma attacks (day and night) decreased slightly in all three groups with statistically insignificant differences
  • At 10 months, real acupuncture showed 74% and sham acupuncture showed 67% decrease in asthma attacks.
  • Inhaled beta-agonists varied in all 3 groups slightly, but after 10 months the real acupuncture group showed the most distinct decrease in use.
  • Inhaled steroids increased slightly in real acupuncture and control, and decreased slightly in sham acupuncture.
    – None of the drug changes were statistically significant.
  • Score of well-being and physical activities were not significantly affected by real or sham acupuncture
  • Methacholine-induced airway responsiveness improved in all 3 groups, no statistically significant differences present
  • Serum and sputum eosinophils decreased in all 3 groups
    – Serum eosinophil decrease was greater in the real or sham acupuncture. At 4 months, the sham was statistically significant        relative to the control. At 10 months, there was a statistically significant difference between the real and sham acupuncture
    – Sputum eosinophil showed similar changes as those in serum but were not statistically significant.
    – Adverse reactions discussed along with statistical significance

No serious adverse effects occurred requiring premature cessation of the study. Minor side effects were seen in a few people who received the real acupuncture (specifically prolonged pain in the point where the needle was after it was withdrawn), but went away once intervention

Participant retention

Initially, 123 participants were recruited, 66 were eligible for the intervention and 57 were not: 41 of which did not fulfill all the study requirements, 11 could not make the time commitment, and 5 had other reasons (holiday, anemia, etc). The 66 eligible participants completed the study, but some fell out of the study at the 5 month part (1 due to a leg fracture, 1 who moved countries for a long time). 20 patients were selected for the control, and all 20 completed the study.

Quality of evidence

            Grade C. The study showed statistically significant negative evidence. The authors found that the data was clinically irrelevant and therefore did not support the use of as a means of treatment for individuals with mild-to-moderate bronchial asthma

Conflicts of interest

Whether conflict of interest was present or not, the authors did not state this specifically. The Swiss National Foundation, Lung Society of Canton Zurich, Eggenberger-Foundatation, and the Foundation for Scientific Research all funded the research. Depending on the acceptance of alternative medicine in Europe, the Lung Society may desire certain outcomes. For example, they would be biased towards negative results regarding acupuncture if alternative medicine was not well accepted because this would encourage the public to purchase conventional medications and seek contentional care. However, if the foundation was more interested in alternative medicine, they may not have wanted this study published because it had negative findings. Generally, from class discussions I have gathered that most funding companies do not like researchers to publish research which is not in their favour/best interest, so there may be some of this bias at play in terms of this publication.

Cost effectiveness

The authors discuss that the number of people seeking out alternative therapies has increased from 33.8 to 42.1% and that more people now visit alternative practitioners versus their GP. I believe that this indicates that there may be an increasing demand for patients as well as increased accessibility to acupuncture. However, there is still 58% of the population, which is not seeking acupuncture treatment, and thus it must be considered if cost might play a role in this. From past experience, acupuncture treatment isn’t very cheap. However, I believe that being able to adjust in quality of life changes, the cost effectiveness arises in things such as reduced sick days from work/school, savings in medication as well as fees for transport to/from doctor appointments, and potentially many other factors which surpass the basic savings seen in the exchange of money for treatment.

Strengths of the research

–       Study looked at the difference between real, sham and acupuncture points, to see if there is any bias due to needle insertion. A completely inert control group was also included in addition to the sham group

–       Follow ups were done up to 10 months post study and they did not exclude anyone after 10 months to ensure they could detect changes in need for asthma medication

 Limitations of the research

–       Sham points were in relatively close proximity to the real points, maybe this is why there was no huge statistical significance in real versus sham points

–       Needles for sham points were not inserted at the same angle. Because they had to adjust for insufficient approximation to normal distribution, a mean improvement of 15% was established to be clinically relevant. However, this may not be a truly accurate representation of clinical significance.

–       While standardized points were chosen, there is variability relative to patient height/robustness as well as the practitioner’s inability to put the needle in the absolute exact point each time in the subjects as well as between subjects for each visit. Humans are not able to be 100% accurate.

–       Main confounding factor was the inability to keep asthma medication intake constant across all patients. This means that it will be difficult to tell whether the effects were from the acupuncture or the medication

 

In an attempt to seek further knowledge about the effects of acupuncture and asthma, I would look for research where conventional medications were not used on a regular basis (except for intense acute attacks). I think this is essential to really understanding the impact that acupuncture can have on symptoms as well as the disorder. Initially, I wanted to suggest further research completely reliant on acupuncture as its sole treatment method, but I realize there might be a risk with removing conventional medications in acute instances. However, they may have been research done on this and it would be interesting to see what they found.

Ultimately, by reading this study, I do not feel confident that utilizing acupuncture for asthmatic patients would be a beneficial treatment. The results compared between 4 and 10 months indicates that acupuncture treatment was able to reduce serum and sputum eosinophils, decrease frequency of asthma attacks, and decrease inhaled beta-agonist use. Unfortunately, not much statistical significance is present in the results, and due to the reason listed above, it is difficult to determine whether acupuncture or the combination of acupuncture and conventional treatments were responsible for the results discovered. While acupuncture could be used supplementally with conventional methods, I do not feel confident that the patient would feel sufficient relief from their symptoms to minimize conventional treatments.

According to a study completed in Denmark which looked at the effects of acupuncture vs no intervention on asthmatic children aged 6 months to 6 years, symptoms decreased significantly and use of inhaled medications were reduced and daily use of steroids also dropped, which was significantly significant (5). Beta agonist use also dropped significantly, and overall this study concluded positive effects of acupuncture for asthma(5).

Another study I found looked at bronchodilator, two placebo interventions, and no intervention to see if sham acupuncture played an effect on asthma symptoms (6). The two placebos were a placebo inhaler and sham acupuncture. The “interventions” were carried out for 12 visits and spiromatry was assessed after each visit (6). Overall, the authors discovered that FEV1 was most improved with the bronchodilator, however patients did not report improvement significantly for either group, but were still higher than no intervention (6). While the study had its own limitations, the authors mention that using such a manner of placebo testing for disease (if appropriate) is just as valuable in the context of patient quality of life and patient self-reporting (6).

Another study, which focused more on cost-effectiveness of acupuncture for asthma, found that individuals who got acupuncture in addition to routine care reported a better quality of life that those who did not get acupuncture and acupuncture was also reported to be cost-effective (7).

In a fourth study, acupuncture was found to have significant effects on serum eosinophils as well as increased T lymphocytes, but no changes in cortisol (8). The conclusion of the study was that acupuncture had an immunomodulating effect on cellular and mucosal immunity in patients with asthma and that this would be an effective treatment to include alongside conventional treatment (8).

Acupuncture can be an integral part of naturopathic care, and considering the amount of people in Canada alone suffering from asthma I think this would be an effective area of disease to focus upon. Asthma treatment in clinic is doable because a large component about patient treatment is based on their self-report of the symptoms and quality of life. Additionally, naturopaths can order a CBC and within this, eosinophil levels can be further analyzed.

I believe that there is not enough evidence right now to support acupuncture and asthma. While some positive results seem to be found, a lot of research is lacking statistically significant research. Additionally, I found researching this particular topic challenging and found it hard to find viable research specifically on asthma and acupuncture needling (not laser, however this topic did seem to be quite researched). For doctors to make effective decisions as to whether this would be good treatment, research specificity needs to be increased – for example, a study where no conventional treatment is used (if this is ethical) or where conventional treatment is only used in very acute situations. Also, there will be an acupuncture group, a sham acupuncture, and as well as a control that receives no acupuncture, and perhaps a group that also gets acupuncture but has a sham bronchodilator. I believe that the continuation of conventional medicine with this disorder makes result interpretation harder because of the confounding effects. Yet, it may be unethical to tell people not to take their medication – I do not have enough knowledge around that and would need to do further investigation.

Fortunately, there really weren’t any significant adverse effects recorded, and for this reason I think utilizing acupuncture as a supplemental treatment to conventional methods would not be harmful and may, in some patients, offer additional relief from symptoms.

 

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I hope you found this useful. What other research would you like me to explain or look into?

‘TIll next time,

RZ

 

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Article reference

Grebski, E., Hinz, G., Medici, T.C., Wu, J., Wuthrich, B.. Acupuncture and Bronchial Asthma: A Long-Term Randomized Study of the Effects of Real Versus Sham Acupuncture Compare to Controls in Patients with Bronchial Asthma. The Journal of Alternative and Complementary Medicine 2002; 8(6): 737-750.

Additional References

1. Acupuncture: An Introduction. National Centre for Complementary and Alternative Medicine. http://nccam.nih.gov/health/acupuncture/introduction.htm#risks (accessed 5 February 2014).

2. Fishman, L., Niebling, W.B., Ukena, D. Bronchial Asthma: Diagnosis and Long-Term Treatments in Adults. Deutsches Arzteblatt International 2008. 105(21): 385-394. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696883/ (accessed 6 February 2014).

3. Asthma Facts and Statistics. The Asthma Society of Canada, http://www.asthma.ca/corp/newsroom/pdf/asthmastats.pdf (accessed 2 February 2014).

4. Asthma Treatment and Options. The American College of Allergy, Asthma, and Immunology. http://www.acaai.org/allergist/asthma/asthma-treatment/pages/default.aspx (accessed 5 February 2014).

5. Bennicke, P., Gert, K. Acupuncture in Asthmatic Children: A Prospective, Randomized, Controlled Clinical Trial of Efficacy. 2013. 19(4). http://ezproxy.ccnm.edu:2501/ehost/detail?sid=49418b95-7d8f-4b0d-8adb-6db72ae6a7a4%40sessionmgr4003&vid=1&hid=4106&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=mnh&AN=23981368 (accessed 3 April 2014)

6. Boyd, I., Dutile, S., Israei, E., Kaptcuk, T., Kelley, J., Kirsch, I., Marigowda, G., Wechsler, M. Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma. The New England Journal of Medicine. 2011. 365 http://ezproxy.ccnm.edu:2100/doi/full/10.1056/NEJMoa1103319 (accessed 3 April 2014)

7. Brinkhaus, B., Reinhold, T., Willich, S., Witt, C. Acupuncture in Patients Suffering from Allergic Asthma: Is It Worth Additional Costs? The Journal of Alternative and Complementary Medicine. 2014. 20(3). http://ezproxy.ccnm.edu:2224/doi/full/10.1089/acm.2012.0719 (accessed 2 April 2014)

8. Chen, H., Ran, J., Wang, Y., Xu, Y., Yang, Y., Yin, L Considerations for Use of Acupuncture as Supplemental Therapy for Patients with Allergic Asthma. Clinical Reviews in Allergy & Immunology. 2013. 44(3). http://link.springer.com/article/10.1007%2Fs12016-012-8321-3 (accessed 3 April 2014)

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