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Effectiveness of Acupuncture for Treating Asthma
By Yoon Hang Kim, MD, MPH, and Jeanne Bowers, Dr. Kim is the director of Georgia Integrative Medicine in Atlanta, and Ms. Bowers is completing a master's degree in psychology at the University of West Georgia in Carrollton. They report no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
In the United States, asthma results in more than 1.5 million emergency room visits, approximately 500,000 hospitalizations, and more than 5,000 deaths annually. Approximately 15 million Americans have asthma, and the cost of conventional medical treatment for asthma is in excess of $6 billion annually.1
The pathophysiology of asthma is complex and involves at least the following components: 1) airway inflammation, 2) intermittent airflow obstruction, and 3) bronchial hyper-responsiveness. Inflammation in asthma may be acute, subacute, or chronic, and the presence of airway edema and mucus secretion contributes to airflow obstruction and bronchial reactivity. In addition, varying degrees of mononuclear cell and eosinophil infiltration, epithelial desquamation, smooth muscle hyperplasia, and airway remodeling occur. The primary focus of recent pharmaceutical advances in the treatment of asthma has thus been targeted at modulation of inflammation. Great strides have been made, but prevalence of the disease continues to grow, and concerns about complications from treatment still exist. As such, the search for effective therapies continues.
In the past two decades, acupuncture has grown in popularity in the United States. The report from a Consensus Development Conference on Acupuncture held at the National Institutes of Health (NIH) in 1997 stated that acupuncture is being "widely" practiced—by thousands of physicians, dentists, acupuncturists, and other practitioners—for relief or prevention of pain and for various other health conditions.2 According to the 2002 National Health Interview Survey—the largest and most comprehensive survey of complementary and alternative medicine (CAM) use by American adults to date—an estimated 8.2 million U.S. adults have used acupuncture, and an estimated 2.1 million U.S. adults had used acupuncture in the previous year.3
In 2003, a comprehensive review of acupuncture for pediatric asthma was published in this newsletter.4 The present article will provide an update of recent developments, specifically regarding the theoretical plausibility of the mechanism behind acupuncture for treatment of asthma, and new clinical trials that explore the potential effectiveness of acupuncture in this setting.
Mechanism of Acupuncture for Treating Asthma
The Chinese medical view of acupuncture is that it enhances the harmony of the bioenergy, or life force, called qi. Stimulation of acupuncture points is believed to activate the bioenergy and balance disharmony, resulting in resolution of symptoms. In addition to acupuncture points, there are energy channels (known as meridians) for each organ including lung energy. In traditional Chinese medicine, asthma is considered a complex illness involving deficiencies of kidney organ bioenergy governing vitality and lung bioenergy governing harmony.
Mechanisms relevant to the role of acupuncture for treatment of asthma appear to involve modulation of the inflammatory cascade.5 Jeong et al investigated the regulatory effect of cytokine production in asthma patients treated with Korean hand acupuncture.6 Interleukin-6 (IL-6) is a pro-inflammatory cytokine secreted by T cells and macrophages to stimulate immune response. Plasma levels of IL-6 were lowered after acupuncture treatment compared to pretreatment levels.
Another asthma study investigated the effect of acupuncture on immunoglobulins and reported decreased IgE levels (P < 0.01).7 In a murine model of ulcerative colitis, electroacupuncture was shown to down-regulate serum TNF-α, levels of which correlate well with severity of symptoms.8
Despite these data, more basic science research needs to be performed to elucidate the role of acupuncture in modulating inflammation.
Four systematic reviews of the use of acupuncture for treating asthma have been published. The first was performed by Kleijnen et al in 1991.9 The authors reviewed 13 trials, which were evaluated against 18 predefined methodological criteria and scored out of 100. Only eight studies scored above 50 and no paper scored above 72, leading the authors to conclude that no recommendations could be made due to the poor quality of the trials. A similar conclusion was reached in the review carried out by Linde et al in 2001 as a part of the Cochrane Collaboration.10 This review involved rigorous criteria; only seven of 21 studies met the inclusion criteria. Martin et al conducted another systematic review and meta-analysis of 11 RCTs, again finding insufficient sound data exist on which to make firm conclusions.11 Thus, all three of these reviews proposed that there was no conclusive evidence that acupuncture has a significant effect on the course of asthma; however, there was also no evidence that acupuncture is ineffective. Some of the problems pointed out by the three systematic reviews include heterogeneity of acupuncture techniques, outcome measures, and controls. The studies have also been small: The median sample size was 25 and the largest RCT had only 39 participants.
In 2004, the Cochrane Collaboration published an updated review of acupuncture for chronic asthma that included 11 studies meeting their inclusion criteria.12 These trials (n = 324) of variable quality found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, but the reviewers noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. The authors concluded that there was not enough evidence to make recommendations about the value of acupuncture in asthma treatment.
Randomized Control Trials Published after 2004
In 2005, Zhang et al randomly divided 90 asthma patients into two groups: an acupuncture treatment group and a control group receiving sham acupuncture.13 The study found that both groups showed an improvement in pulmonary functions, but differences between groups were not statistically significant.
Another study was performed by Cai et al in 2005 comparing two specific acupuncture points in 200 patients with acute exacerbations of asthma.14 Patients were randomly divided into two groups: one group treated at the acupuncture point Qingchuan and the other group treated at the acupuncture point Dingchuan. Although Dingchuan is a standard acupuncture point located on paraspinal muscles on the level of the T1 spinous process and is traditionally used to calm acute asthma, the point Qingchuan is not a described point and the authors did not reply to communication asking for the location of Qingchuan. The authors concluded that the total effective rate for the Qingchuan treatment group was 92% vs. 81% for the Dingchuan treatment group (P < 0.01). One limitation of this study is that it did not employ a sham acupuncture group, which measures non-specific effects of needling.
In 2006, Zhang conducted a clinical trial with 104 patients divided into two groups: a control group receiving usual conventional treatment for asthma and an acupuncture treatment group.15 After six months, the acupuncture treatment group reported a reduced incidence of asthmatic attacks (P < 0.05). Again, this study was limited at least by lack of a sham acupuncture control group, and the effects reported may have been due to non-specific effects of needling.
The above three publications were published in Chinese with English abstracts only. Requests to the principle investigator of each study for clarification of the study design and results have gone unanswered. Thus, no firm conclusions can be drawn from their stated results.
Stockert et al conducted a randomized controlled trial combining laser acupuncture and probiotics in school age children with asthma.16 The small study involved 17 children who were divided into laser acupuncture and probiotics vs. sham laser acupuncture and placebo. The study concluded that there was no significant effect from the combination therapy on quality of life, FEV1, or medication changes.
Mehl-Madrona et al explored the possibility of synergy between acupuncture and craniosacral therapy on clinical outcomes in adults with asthma.17 Results of this study suggest no synergy between the two modalities.
Despite addition of trials with larger numbers of participants coming from China, the state of evidence in clinical trials has not changed. The research trials still have weaknesses pointed out in the systematic review. However, there are some positive points in strengthening the biological plausibility of acupuncture for treating asthma through modulation of inflammation, the same way many asthma medications work.
In experienced hands acupuncture is a safe practice. In the United States, only sterile, single-use surgical grade stainless steel needles are permitted to be inserted into acupuncture points. The most common complaints involve local bleeding, transient pain during needle insertion, nausea, syncope, and mild disorientation.18,19 The treatment of asthma with acupuncture may result in pneumothorax as documented in early case studies,20 though this is a rare event, with but two reported cases in nearly a quarter of a million treatments.21
Despite some advances in understanding the biological plausibility of acupuncture's mechanism of action on the inflammatory cascade, the level of clinical research support is insufficient. An interesting trend is that acupuncture is being combined with other modalities. Treatment of chronic asthma with acupuncture to assess impact on quality of life and need for rescue medication would be a welcomed clinical trial.
Although acupuncture is a widely used CAM therapy in the United States, the evidence in support of its use for asthma is inconclusive due to inadequate data. Until there is clear evidence for the benefit of acupuncture in treating asthma, acupuncture should play at most a complementary role to proven management therapies.
1. National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the diagnosis and management of asthma. NIH Publication No. 97-4051. Bethesda, MD: National Institutes of Health; 1997.
2. Culliton PD. Current utilization of acupuncture by United States patients. Abstract presented at: National Institutes of Health Consensus Development Conference on Acupuncture; 1997.
3. Barnes PM, et al. Complementary and alternative medicine use among adults: United States, 2002. CDC Advance Data Report #343. Atlanta, GA: Centers for Disease Control and Prevention; 2004.
4. Mark JD. Acupuncture and pediatric asthma. Altern Med Alert 2003;6:136-139.
5. Zijlstra FJ, et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003;12:21-27.
6. Jeong HJ, et al. Regulatory effect of cytokine production in asthma patients by SOOJI CHIM (Koryo Hand Acupuncture Therapy). Immunopharmacol Immunotoxicol 2002;24:265-274. Erratum in: Immunopharmacol Immunotoxicol 2003;25:129.
7. Guan Z, Zhang J. Effects of acupuncture on immuno-globulins in patients with asthma and rheumatoid arthritis. J Tradit Chin Med 1995;15:102-105.
8. Tian L, et al. Downregulation of electroacupuncture at ST36 on TNF-alpha in rats with ulcerative colitis. World J Gastroenterol 2003;9:1028-1033.
9. Kleijnen J, et al. Acupuncture and asthma: A review of controlled trials. Thorax 1991;46:799-802.
10. Linde K, et al. Acupuncture for the treatment of chronic asthma. (Cochrane Review) in the Cochrane Library, Issue 2, 2001 Oxford: Update Software Ltd.
11. Martin J, et al. Efficacy of acupuncture in asthma: Systematic review and meta-analysis of published data from 11 randomised controlled trials. Eur Respir J 2002;20:846-852. Comment in: Eur Respir J 2003;21:909.
12. McCarney RW, et al. Acupuncture for chronic asthma. Cochrane Database Syst Rev 2004;(1):CD000008.
13. Zhang ZL. Clinical observation on acupuncture for treatment of bronchial asthma at acute stage. Zhongguo Zhen Jiu 2005;25:158-160.
14. Cai ZH, et al. Multicenter controlled study on transient asthma-stopping action of acupuncture at "Qingchuan point." Zongguo Zhen Jiu 2005;25:383-386.
15. Zhang WP. Effects of acupuncture on clinical symptoms and pulmonary function in the patient of bronchial asthma. Zhongguo Zhen Jiu 2006;26:763-767.
16. Stockert K, et al. Laser acupuncture and probiotics in school age children with asthma: A randomized, placebo-controlled pilot study of therapy guided by principles of Traditional Chinese Medicine. Pediatr Allergy Immunol 2007;18:160-166. Erratum in: Pediatr Allergy Immunol 2007;18:272.
17. Mehl-Madrona L, et al. The impact of acupuncture and craniosacral therapy interventions on clinical outcome in adults with asthma. Explore 2007;3:28-36.
18. Peuker E, et al. Traumatic complications of acupuncture. Therapists need to know human anatomy. Arch Fam Med 1999;8:553-558.
19. White A, et al. Adverse events following acupuncture: Prospective survey of 32,000 consultations with doctors and physiotherapist. BMJ 2001;323:485-486.
20. Niggeman B, Gruber C. Side-effects of complementary and alternative medicine. Allergy 2003;58:707-716.
21. Ernst E, et al. Prospective studies of the safety of acupuncture: A systematic review. Am J Med 2001:110:481-485.