The Research Roundup section will explore and review recently published articles on Acupuncture. These reviews will be in-depth and offer a critical analysis of the article as well as explain or elaborate on research topics, concepts, including how to critique articles.
A more patient-friendly version of each article review can also be found on the Rhoads to Health acupuncture website blog where I am a guest content contributor.
First up, sham acupuncture.
In 2011, the Society for Acupuncture Research (SAR) identified some paradoxes in acupuncture in a white paper. Of note, they addressed the findings of the non-inert effects of sham acupuncture as compared to real acupuncture (using the term verum, or true, acupuncture). Interesting. To fully understand if acupuncture has any effect on a clinical condition, it must be compared to something that doesn’t imitate or do anything even close to what acupuncture does. For research to be valid, one modality, like acupuncture, must be compared to an inert control. For example, pharmaceutical companies compare active drug pills to inert sugar pills (the control). The sugar pills are not supposed to have any effect and certainly not mimic anything like what the active drug pills are supposed to do. Do some of the study’s participants get better on the sugar pill? Yes. The placebo effect is a real thing and will be covered later. There are ways to remove these placebo responders from studies.
Research studies have shown that people get better with verum acupuncture, but they also get better with sham acupuncture, albeit not as well. Both of them outperform the controls. This has led to the misconception that it doesn’t matter where the needles are inserted. That point specificity is pointless (no pun intended). That’s the wrong way to think of it. Of course, it matters. The real problem here is the use of sham acupuncture as the control. It is commonly incorporated despite being poorly understood.
Sham is a sham.
Acupuncture clinical trials using sham acupuncture controls are “compromised methodologically” because they are not inert. They may not be as effective as real acupoints, but clearly something is happening. This is because the needling parameters are not clearly delineated. What, exactly, happens when an acupuncture needle is inserted at a verum acupoint vs. a sham acupoint? How do the components of needling (point location, depth of insertion, needle stimulation, needle size) affect outcomes? This has not been studied well at all. It appears that needle insertion activates neurologic pathways via the sympathetic nervous system, such as the spinothalamic tract, and that sham acupuncture might activate this pathway poorly and/or activate additional pathways such as the dorsal columns, providing activation of central mechanisms that then provide some beneficial activity such as pain inhibition. In other words, sham acupuncture has certain acupuncture-specific effects that cannot be controlled for. This is less than ideal and indicates that sham acupuncture shouldn’t be used as a control. Not until there is a truly inert way to perform acupuncture.
Sham needling practices have centered on non-penetrating needle/devices, superficial insertion, and off- meridian non-acupoints. None of these are inert. They will activate mechanoreceptors, invoking the gate theory of pain control, and fMRI has demonstrated similar central activation as verum acupuncture, including the periaqueductal gray, a critical area involved in descending pain inhibition.
So what do we do about this?
The SAR white paper and this 2008 article address some of these issues.
There is a need to increase the scientific assessment of the anatomy and physiology of both acupuncture points and their meridians. What are the specific effects of the needling parameters on therapeutic outcomes? What are the specific and non-specific effects of any proposed acupoint control considered? Finally, can we identify truly inert acupuncture-based controls?
Could this work? Phantom acupuncture.
Acupuncture and Headache – What does the research say?
Headaches are very common medical conditions that practitioners see in clinic. The two most common forms are migraine and tension-type, accounting for roughly 90% of all headaches managed in healthcare settings. They can be particularly severe and disabling, having a significant socioeconomic impact. In Traditional Chinese Medicine (TCM), acupuncture has been widely employed for treating headaches and in this edition of Research Roundup, we’re going to explore how effective acupuncture can be for migraines, arguably the more severe of the two. In fact, migraine headaches were ranked as the “sixth most prevalent out of 328 diseases” in the world according to the 2016 Global Burden of Disease Study.3
For those who suffer migraines or other headaches, any relief or decrease in the frequency (number of headaches in a particular timeframe), duration (how long the headache lasts), or severity (how painful or disabling the headache feels) is the goal of the acupuncturist. The severity of the pain (the headache) and any associated neurological symptoms, including the migraine aura, is incredibly disruptive to the individual and is “most burdensome in women between ages 15 and 49 years.”3 The long term goal is the elimination of the headache, but any relief is significant. The goal of acupuncture is not just to mask the pain or symptoms, but to get to the root of the problem.
In research, the highest quality of evidence comes from a Systematic Review, where multiple research studies are analyzed for their quality and their outcomes are summarized. In the way that they are analyzed, their combined data offers more consistent and reliable conclusions on how well the therapy works. The two research papers on acupuncture therapy for migraine headaches reviewed can be found here1 and here2. These systematic reviews examined a combined 43 research papers.
Both reviews concluded that “acupuncture was is an effective and safe method for migraine”, and that “the acupuncture group had greater improvements in the frequency of migraine attacks, VAS score (for measuring pain), and treatment efficiency”. In other words, acupuncture was safe, reduced the pain, and the number of migraine headaches. A reduction in the duration of the headaches was only briefly mentioned, and this may reflect the need for further studies to fully clarify.
- Ou MQ, Fan WH, Sun FR, et al. A Systematic Review and Meta-analysis of the Therapeutic Effect of Acupuncture on Migraine. Front Neurol. 2020;11:596. Published 2020 Jun 30. doi:10.3389/fneur.2020.00596
- Li YX, Xiao XL, Zhong DL, et al. Effectiveness and Safety of Acupuncture for Migraine: An Overview of Systematic Reviews. Pain Res Manag. 2020;2020:3825617. Published 2020 Mar 23. doi:10.1155/2020/3825617
- GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390: 1211–59
Acupuncture and Hypertension – What does the research say?
In this edition of Research Roundup, we’ll examine how acupuncture can be used to lower hypertension, more commonly known as high blood pressure. Considering the impact of hypertension on heart disease and overall health, safe and effective therapies are warranted. Since some pharmacological agents have side effects, can acupuncture be used alone, or in combination with these agents, to modulate and reduce high blood pressure? The article examined today can be found here, and it summarizes some of the key research findings on how acupuncture treats this disease. Specifically, we’ll be focusing on ‘essential’ or primary hypertension, which really means that the cause is unknown.
According to the article, there are “numerous recommendations for controlling hypertension, including improving lifestyle, such as doing more exercise, keeping a balanced diet, and having pharmacological treatment”. Let’s see where acupuncture works to reduce hypertension. As a bonus for any acupuncturist who will read the article, it mentions specific acupoints for consideration!
Blood pressure regulation is complex. There are both neurological and neurochemical elements. It seems, according to the research, that acupuncture works on both. Some of this will get a little technical, only because the nervous system is highly interconnected and uses terminology that is confusing to everyone. Here we go. First, you need to know that blood pressure is controlled by the blood vessels and the heart and in turn, they are controlled by nerves. These nerves are grouped into two divisions, one that causes the blood vessels to constrict (a narrowing, also known as vasoconstriction) and the heart to pump harder, increasing blood pressure, and one that causes the heart to slow down; it has no direct effect on the blood vessels though. The first division is called the sympathetic nervous system and the second is called the parasympathetic. Reducing the sympathetic effect and/or increasing parasympathetic effect is the goal. According to the article, acupuncture decreases the sympathetic influence by controlling the source at both the spinal cord and thalamus (a brain structure referred to as the ‘rostral ventral lateral medulla’ and is a major source of sympathetic nervous system activity generation). It was also shown to increase parasympathetic influence, described in the article as an “increase in vagal activity”, citing the vagal nerve as the main control on decreasing the heart’s influence. That’s right – acupuncture influences both systems at the same time! Slowing the heart and relaxing the vasoconstriction (also known as vasodilation) and causing blood pressure to be lowered.
In addition to the nervous system, there are several neurochemicals that participate in hypertension, noting that the neurochemicals and the nervous system clearly work hand-in-hand. Two key findings were the reduction of norepinephrine and the reduction of renin (which is released from the kidneys and eventually triggers another neurochemical called angiotensin II) by acupuncture. Both of these, norepinephrine and the renin-angiotensin II pair, increase blood pressure directly at the blood vessels through vasoconstriction and were decreased by acupuncture.
Acupuncture is safe and can be used in conjunction with those taking blood pressure medications.
- Fan H, Yang JW, Wang LQ, et al. The Hypotensive Role of Acupuncture in Hypertension: Clinical Study and Mechanistic Study. Front Aging Neurosci. 2020;12:138. Published 2020 May 25. doi:10.3389/fnagi.2020.00138
Acupuncture and Infertility – What does the research say?
In this edition of Research Roundup, we’ll examine how acupuncture can be used to help achieve pregnancy, especially during IVF (in-vitro fertilization). Infertility is reported to affect up to 15% of all couples worldwide, and acupuncture has been used to improve the conditions necessary for ovulation and clinical pregnancy rates (CPR). While there are many causes and factors that have been offered for infertility, this edition of Research Roundup is focused on improving ovarian response in those women undergoing IVF. Does acupuncture promote successful ovulation and does it also enhance the success of the IVF protocol? The article chosen for this Research Roundup is a systematic review (we like these as they represent a high-level critique of the reviewed literature to answer these questions). The article can be found here.
This systematic review evaluated those with a poor ovarian response (POR), which predicts successful pregnancy outcomes. It is diagnosed by having met two of the following three conditions: 1. advanced maternal age (≥40 years); 2. a previous POR (≤3 oocytes after a conventional stimulation protocol); or 3. an abnormal ovarian reserve test (which evaluates the number of available follicles – follicles contain the eggs).
All forms of acupuncture (manual, ear, and electroacupuncture) were included with electroacupuncture being the main focus. The systematic review focused on evaluating randomized controlled trials only – this is good as it helps to weed out lower-quality research. In the article, there is a list of the acupuncture points used (Table 2 for those interested and note that Ren 4 and Spleen 6 were used in all studies). The controls (non-acupuncture) were conventional medical approaches. Unfortunately, sham acupuncture was included. See my previous comments on sham acupuncture here.
So what did they find? What would be the most important outcome in this scenario? Clinical pregnancy rates! Those rates were higher in those receiving electroacupuncture. This was attributed to having higher numbers of oocytes (eggs) retrieved and improved hormone environments.
Acupuncture is safe to use in conjunction with conventional IVF protocols. Dr. Rhoads can work with your primary care provider to help with pregnancy.
- Guven PG, Cayir Y, Borekci B. Effectiveness of acupuncture on pregnancy success rates for women undergoing in vitro fertilization: A randomized controlled trial. Taiwan J Obstet Gynecol. 2020 Mar;59(2):282-286. doi: 10.1016/j.tjog.2020.01.018. PMID: 32127151.
Acupuncture and Knee Pain from Arthritis– What does the research say?
In this edition of Research Roundup, we’ll examine how acupuncture can be used to decrease the pain and functional limitations found with the slow deterioration of the knee joint due to arthritis. While there are many different types of arthritis, this specifically refers to the most common one which is osteoarthritis [OA], sometimes referred to as degenerative joint disease [DJD]. Osteoarthritis can affect any joint in the body that contains articular or joint cartilage, and the knee is particularly affected. The hip joint is the second most common joint to suffer this disease. While the causes of osteoarthritis can be from several different factors, it is the symptoms that can be disabling for the patient. Deep, dull, and achy type of pain, especially at night or during times of rest that actually decreases with activity is a very typical presentation. Functional limitations such as joint stiffness and loss of full ranges of motion are very common. It is important to note that the disease is progressive and the goal of any therapy is to slow the disease. The article for this week examines the role that acupuncture can play in obtaining that goal and delaying any surgical joint replacement intervention.
While the disease is often thought of as bone disease, it is actually related to the articular cartilage. There are bony changes that are secondary as the disease progresses. This cartilage is a fascinating tissue as it actually requires movement to thrive metabolically. Too much, or more likely, too little movement, leads to the development of osteoarthritis as the cartilage cells fail.
The research articles examined the changes to the OA-damaged articular cartilage through the application of acupuncture, specifically electroacupuncture [EA]. The treatments were directed at decreasing the pain from the joint deterioration as pain causes one to use the joint even less. It also looked at making changes in the muscles surrounding the knee joint. The same pain also causes the muscles to be weaker from disuse, encouraging even more cartilage destruction. Please note that this particular article involves animal models of disease, with the results being extrapolated to humans [this is done all the time in research].
For the acupuncturists that are reading, the points selected were ST34, SP9, SP10, GB34, UB40, LV8, Neixiyan (EX-LE4), and Waixiyan (EX-LE5)). The frequency was set at 2/100 Hz at 2mA current. The treatment parameters were three 15-minute treatments per week for 4 weeks [12 total treatments].
The electroacupuncture was compared with a standard OA drug, celecoxib [Celebrex]. The results were interesting. The knee pain was “dramatically reduced” in both groups, and improved knee muscle size and function in the EA group, and a slightly better cartilage improvement in the drug group. This may be a factor related to the short timeframe of the study, with EA requiring additional treatments to exert its full effect. Both EA and celecoxib reduce inflammation, a significant part of the OA process, but they do it through different means [modulating nuclear factor-κB signaling vs. reducing prostaglandin (PG) synthesis, respectively].
- Shi, X., Yu, W., Wang, T., Battulga, O., Wang, C., Shu, Q., Yang, X., Liu, C., & Guo, C. (2020). Electroacupuncture alleviates cartilage degradation: Improvement in cartilage biomechanics via pain relief and potentiation of muscle function in a rabbit model of knee osteoarthritis. Biomedicine & Pharmacotherapy, 123, 109724. https://doi.org/10.1016/j.biopha.2019.109724