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literature
ABSTRACTS
OF CURRENT LITERATURE
Compiled by Russell J.Erickson
1999
ACUPUNCTURE LITERATURE REVIEW
PART 1 - PAIN
1.
Ahmed HE, Craig WF, White PF, et a]. Percutaneous electrical nerve stimulation:
an alternative to antiviral drugs for acute herpes zoster. Anesth
Analg. 1998;87:9 11 914.
One of a series of papers out now or coming
regarding the use of "acupuncture-like" needling with electrical stimulation.
The Fort Worth study group enrolled 50 acute patients in a well-randomized,
single-blinded study with 9-month follow-up. The control group was given
famciclovir, and the study group received percutaneous electrical nerve
stimulation 3 times weekly for 2 weeks, which involved needles above
and below the segment involved at 4 places -- along the spine, anterior
and posterior axilla, and anterior near the midline, with electrical
input alternating negative and positive from 4 to 100 Hz. The treated
group had statistically valid more rapid resolution of lesions, lower
visual analog scale (VAS) pain scores, improvement of sleep, and most
important, less postherpes neuralgic pain at 6 months (but not at 9
months, with 2 patients still in pain vs 3 controls).
2.
Ghoname EA, Craig WF, White PF, et al. Percutaneous electrical nerve
stimulation for low back pain: a randomized crossover study. JAMA.
1999;281:818-823.
In a randomized, single-blinded, sham-controlled
study, 60 persons with degenerative disk disease were treated with percutaneous
electrical nerve stimulation (PENS), sham-PENS, transcutaneous electrical
nerve stimulation, and exercise therapy 3 times weekly for 3 weeks.
PENS decreased the VAS pain level from 5,7 to 3,4, significantly more
than the other therapies, and 91% of patients noted it as the preferred
therapy. Level of activity and quality of sleep were statistically better
for patients receiving PENS. Daily analgesic decrease was superior.
Comment: A longer-term follow-up study
is proposed. This study, to maintain simplicity, involved only electrical
stimulation at 4 Hz, unlike these authors' usual practice of varying
hertz levels to reach the best effect. In another paper, the PENS researchers
noted that the addition of 15/30 Hz treatments gave greater benefit.
It is also important, when using this PENS approach to chronic pain,
that a 30-minute or greater period of stimulation was found superior
to 15. (Ghoname EA, Craig WF, et al. The effect of the duration of electrical
nerve stimulation on the analgesic response. Anesth Analg. In
press.)
3.
Ahmed HE, Craig WF, White PE, Huber P. Percutaneous electrical nerve
stimulation (PENS): a complementary therapy for the management of pain
secondary to bony metastasis. Clin J Pain. 1998;14:320-323.
Three patients with advanced cancer were treated
with PENS, and 2 responded with notable decrease in VAS pain scale scores
and need for medication. Rather complex montages of needles were used,
with periosteal stimulation.
4.
Ernst E. Complementary treatments for back
pain-the facts. FACT. 1999;4(l):3-5.
Dr Ernst summarizes
a meta-analysis examining acupuncture for
low back pain. (Ernst E, White AR. Acupuncture
for low back pain: a meta-analysis of randomized
controlled trials. Arch Intern Med.
1998; 158:235-241.) Six experienced acupuncturists
evaluated the adequacy of treatment in 12
studies, 9 of which could be included in a
meta-analysis. The odds ratio of improvement
with acupuncture was 2.30 vs 1.37 for sham-acupuncture.
They could conclude that acupuncture was superior
to various control interventions, but statistical
evidence of superiority to sham was uncertain.
Comment: Again,
we face the problem of DNIC (diffuse noxious
inhibitory control of pain) created by random
needling. Many studies have shown that random
needling creates a physiologic response, whether
one wishes to call it a superior placebo or
admit to an ability of any needling to shift
the electromagnetic spectrum and neuromodulators.
Therefore, when sham is used for comparison
with classic acupuncture, larger numbers are
required for a valid comparison.
5.
David J, Modi S, Aluko AA, Robertshaw C, Farebrother I Acupuncture or
physiotherapy for neck pain? similar success rates. Br J Rheumatol.
1998;37:1118-1122. Taken from: FACT. 1999;4(l):13-14.
A randomized, controlled study involving 70
patients with neck pain of more than 6 weeks' duration compared acupuncture
therapy with standard mobilization physical therapy, both given for
6 weeks. Pain VAS scores at 6 weeks and 6 months were not significantly
different for the 2 groups, although physiotherapy showed a favored
trend. Patients with higher baseline neck pain questionnaire scores
appeared to do better with acupuncture.
Comment: The reviewer, A.R. White, notes
that a nontreated control should be in order to test the natural progress
with time and that if treatment is indicated, the cost-effectiveness
might direct which of the 2 studied therapies is preferred.
PART
11 - MISCELLANEOUS
1.
O'Duffy G. Acupuncture as an adjunct to chemotherapy: a preventative
approach. NZ J Acupuncture. 1998; 1625.
Dr O'Duffy provides an analysis of her approach
to prevention of nausea and other adverse effects of chemotherapy with
acupuncture. She notes that modern, often very expensive medications
have more side effects and frequently prevent vomiting better than nausea
following chemotherapy. She uses balancing treatments and big tonic
points for 2 weeks prior to the onset of therapy, and looks especially
at the organ (Zang Fu) effects of the drugs to be used, giving a reactive
treatment 1 to 2 days prior to chemotherapy. She also finds acupuncture
effective in the postradiation fatigue period, which is frequent at
3 weeks and beyond. She provides 7 pages of points for each group of
drugs used in varied cancer treatments, with the main and ancillary
expected adverse effects of chemotherapy treatments.
2.
Chen B. Clinical observation of effects of acupuncture on cerebral thrombosis
and changes of microcirculation. World J Acupuncture Moxibustion.
1998;8:3 11.
Patients with cerebral thrombosis, with 34
of 70 having hemiplegia, and a variety of sequelae among the rest, were
treated with acupuncture. Points GB 20, GV 16, Ll 11, Ll 4, SP 10, ST
36, and LR 3 were used for a total 40-day course. Thirty-three percent
"were basically cured," and 44% improved significantly to basic self-care.
Nailfold and bulbar conjunctiva circulation were studied using special
instruments. After therapy, microcirculation showed clearer capillary
loops, more normal artery-vein ratios, significantly less erythrocyte
aggregation, and less local exudation, with increased blood flow rate.
The authors believe acupuncture dilates microcirculation, relieves spasms,
and relieves platelet and granulocyte aggregation to cause the clinical
improvement seen in stroke patients.
Comment: A control group is needed to
define the natural progression of microcirculation toward normal following
stroke. This is, however, only 1 of several articles from China I have
reviewed over the past 3 years on this subject, all indicating a strong
effect of acupuncture on microcirculation. This group uses a scattering
of "Helm's Big Points" for therapy, one of many approaches.
3.
Zhuang L, Li Y, Zheng L, Yang W. Clinical observation on combined treatment
of vascular dementia with acupuncture, moxibustion and Chinese medicinal
herbs. World J Acupuncture Moxibustion. 1998;8:7-11.
Thirty cases of vascular dementia (VD) were
selected by DSM III standards and a Dementia Severity Table of Zheng
and Hasegawa. All patients had ischemic signs confirmed by computed
tomography or magnetic resonance imaging. Ages ranged from 55-83 years.
Major points along GV were used, with Sishencong, KI 3, BL 23 and 18,
plus GB 39. Fu Yuan Tang (Decoction for recovery) herbs were added.
Two months of therapy was given, with a dementia severity improvement
from 13.5 to 19.7 (average). The ability for self-care increased significantly,
and a number of neurologic and psychologic symptoms reported decreased
notably. Two enzymes active in oxygen-free radical inhibition increased
to normal range from levels half normal prior to therapy, and a compound
caused by free radicals decreased. The authors believe this metabolic
pathway is I effector of acupuncture results.
Comment: So many articles come from
China indicating interesting and promising effects of acupuncture on
neurologic problems and senility; the paradigm seems to need a look
in the United States. A study here, however, would be prohibitive to
fund in view of the large number of sessions generally used. Funding
of a researcher who would like to spend 3 to 6 months in China might
be the only rational approach, but one requiring careful groundwork.
4.
Yang W, Li Y, ZImang L, Zheng L. Effect of acupuncture-moxibustion plus
Chinese medicinal herbs on plasma TX132,6-keto-PGFl alpha in patients
with vascular dementia. World J Acupuncture Moxibustion. 1.998;8:119.
PG12 is a vasodilator and platelet aggregation
inhibitor from vascular endothelial cells, which rapidly metabolizes
to 6-keto-PGF1alpha. TXA2 is a vasoconstrictor and platelet aggregator
synthesized in platelet mitochondria that converts to TXB2. Before acupuncture
treatment of dementia, TXB2 was elevated (303 vs 104 in normal controls)
and 6-keto-PGF1alpha was deficient (81 vs 128 in controls). In patients
with marked improvement from acupuncture treatment, both compounds moved
markedly toward normal levels, with less shift in those showing less
improvement and none in nonresponders.
Comment: An interesting study of a statistically
valid biochemical change occurring in dementia patients treated with
acupuncture, which demonstrates statistical validity. The study techniques
are well described.
5.
Zheng N, Wang Y, Wu J, Wang H, Ding Y. Acupuncture effects on inducible
nitric oxide synthase mRNA, iNOS product and heat shock protein in peritoneal
macrophages of the mouse. World J Acupuncture Moxibustion. 1998;8:35-38.
Mice were stimulated with paraffin oil intraperitoneally
and divided to electroacupuncture (EA) at ST 36 at 2 Hz, controls with
peritoneal macrophages cultured, and controls with no treatment. The
authors' prior studies found acupuncture enhanced cellular immunity,
tending to veer it toward normal levels. Heat shock protein increases
in macrophages under stress and is protective in situations such as
ischernia and pathogen exposure. Nitrous oxide acts as a neuroendocrine
transmitter and vessel relaxing factor, and can be formed as ONNO with
a potent product, which is bactericidal and tumoricidal. In this study,
macrophages were removed from the peritoneum by saline wash 48 hours
after paraffin application. An intricate biochemical testing of macrophages
(well described) tested for iNOS mRNA, iNOS and heat shock protein,
which showed values from mice treated with acupuncture at 4.2, 3.9,
and 6.0 levels, respectively, compared with lower levels of 2.6, 2.4,
1.2 for controls with cultured macrophages, and 1.6, 1.2, and 2.1 for
untreated controls. These results indicated, at least in part, that
acupuncture might enhance immunity through an effect elevating the nitrous
oxide and heat shock protein mechanisms.
Comment: Many studies have been done
the past few years on nitrous oxide and its amazingly complex effects
within the body. This study, apparently carefully done with immunohistology
and such intricate nuances as in situ hybridization beyond my ken, indicate
differences in macrophage response between controls and EA-treated mice
at a probability level less than .0 1 (t test). This provides
support for previously reviewed papers indicating postoperative patients
had a decidedly smaller decrease in immune cell levels when treated
with acupuncture at points such as ST 36. Though the concept will undoubtedly
meet resistance, acupuncture prior to and following surgery really requires
testing in this country.
6.
Greenfell A, Patel N, Robinson N. Ethnic differences in complementary
medicine use. Compl Ther Med. 1998;6:127-132. Taken from: FACT.
1999;4(l):9-10.
Three hundred patients from 3 chronic condition
clinics in England were interviewed, and 68% had used some complementary
("integrative") therapy in the previous year. Acupuncture was the most
used by white patients at 38%, while black and Asian patients prunarily
used herbs at 65% and 44%, respectively. The patients' physicians referred
to complementary practitioners, with 58% utilizing acupuncturists. Of
the general practitioners involved, 16% practiced acupuncture directly.
The reviewer (E. Ernst) notes the "extravagant" level of complementary
use was likely due to the chronic nature of the patients' disorders.
The uncontrolled use of medication (herbs) from other countries whose
content cannot be verified is a risk.
7.
Cardini F, Weixin H. Moxibustion for correction of breech presentation:
a randomized controlled trial. JAMA. 1998;280:1580-1584.
Primigravidas with breech presentation (by
ultrasound study) in the 33rd week were treated with moxibustion at
BL 67 for 7 days, with a second 7-day course if breech persisted. Fetal
movement was more active in those 130 so treated than in 130 controls
(P<.01). By the 35th week, 75% of moxibustiontreated fetuses were cephalic
in presentation vs 48% of controls; a statistically very valid difference.
Those treated twice daily, rather than once, achieved a higher rate
of conversion. At birth, 62% of controls were cephalic, less than the
continued 75% of moxibustion fetuses. The rate of cesarean delivery,
however, appeared equal in the 2 groups.
Comment: An earlier, similar study in
an acupuncture journal (previously reviewed) reported from Italy 2 or
3 years ago had similar results. The only worrisome finding was a high
incidence of nuchal cords, although they did not report increased neonatal
distress. Again, in that prior report, there was an astoundingly high
rate of cesarean deliveries in both treated and control mothers.
8.
Cheng PT, Wong MK, Chang PL. A therapeutic trial of acupuncture in neurogenic
bladder of spinal cord injured patients: a preliminary report. Spinal
Cord. 1998;36:476-480. Taken from: FACT. 1999;4(l):12-13.
Eighty spinal cord injury patients with bladder
malfunction underwent standard bladder training and medication. Thirty-two
were randomly assigned to acupuncture therapy using CV 3, CV 4, and
BL 32 at 2030 Hz for 4 to 5 sessions weekly "until bladders were balanced"
(easy urination, residual less than 100 mL, no infection). Control (70%)
and acupuncture patients (80%) who reached this state achieved this
in 57 and 85 days, respectively, with upper motor neuron loss and 55
and 83 with lower motor neuron damage. Results were faster if acupuncture
was begun early. The reviewer notes that the dropout rate was too high
(25 %) and nonhomogeneous groups were not stratified for severity. Results
are promising, but need more definitive confirmation.
AUTHOR
INFORMATION
Dr
Erickson is retired from private practice
in Berkeley, California. He is also retired
from Kaiser-Permanente Hospital in Richmond,
California, where he was Senior Consultant
and former Chief of Pediatrics. Dr Erickson
is Secretary of the Board of the Medical Acupuncture
Research Foundation (MARF).
Russell
J. Erickson, MD
10 Ridge place
Pleasant Hill, CA 94523
Phone: 925-229-0889 - Fax: 925-228-4976 -
Email:Russpat@netvista.net
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