Presentation Outline
1. Overview of Acupuncture
History, Theory, and Practice
2. Trends in Usage and Integration
3. State of Clinical Research
4. State of Mechanistic Research
5. NESA’s NIH Research
Center
6. Questions and Discussion
History and Background
Acupuncture is one branch of a much larger, 3000- 4000
year old East Asian Medicine (EAM) system. Other
components include:
• Herbal medicine
• Manual Therapies (Massage, Cupping)
• Physical and Meditative Exercise (e.g. Tai Chi)
• Moxibustion
• Diet and Lifestyle
Key Phases in History of Acupuncture
• Early history of acupuncture still sketchy
• Earliest acupuncture texts attributed to Yellow Emperor who lived
between 2697-2596 B.C. Written version dated to 200 B.C.
• Acupuncture brought to the west in 17th
Century by Jesuit missionaries
• Nixon’s visit to China in 1971
(James Reston, NY Times)
“I’ve seen the past, and it works”
• NESA founded in 1975, first acupuncture
college in the U.S.; 2004 first NIH DCRC
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Acupuncture in the United States
• Increasing in popularity
• Between 4-10% Americans have tried
acupuncture; 2.1 million (1.1%) used it in 20021
• Number of Licensed Acupuncturists tripled
between 1992-2000, and expected to quadruple
by 20152
• Conditions3 commonly used in clinics: Pain relief,
psychological well being, stroke rehab., nausea,
headaches, addictions, & gynecology (infertility)
1. Barnes PM. 2004 Adv Data No. 343: 1-20; Acu Today 2004
2. Cooper et al 1998; JAMA
3. Cassidy CM 1998 J. Alt Comp Med; Xu 2001; S Med J
Acupuncture in the United States
• Among CAM modalities, acupuncture 2nd highest
in credibility and #’s referrals by physicians1
• Acupuncture increasingly becoming integrated
with conventional medicine
• Recent study reported 8 of 13 Harvard-affiliated
hospitals provide acupuncture2
--Pain Service, Oncology, Women’s Health, HIV
Clinic (8 ambulatory, 1 inpatient)
• NESA Clinics (n=12: e.g. Mt Auburn, Dimock,
Roxbury, BMC, Winchester, Malden)
1.
2.
Astin JA. Archives Intermal Medicine 1998; 158: 2303-2310
Highfield ES. Compl Ther in Med 2003; 11(3):177-83.
Acupuncture Theory/Philosophy
• Based on a holistic/ecological concept of
nature
• Everything in nature is inter-dependent and
mutually interactive: “The web that has no
weaver” (T. Kaptchuk)
• Nothing can be understood with out its
reference to the whole
• Physical symptoms, emotional state, beliefs,
social and environmental factors all interconnected
• Emphasis on treating the whole person
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Principle of Yin and Yang
• Central to EAM is dialectical concept of YinYang (Tai Chi)
• Both in nature and in human body, dynamic
and cyclic interplay of complementary forces
• Yin – more material, condensing (e.g. shade,
water winter, cool, body, stillness )
• Yang – more immaterial, expanding (sun, fire,
summer, warm, mind, movement)
• Health - constant state of dynamic balance
Yin/Yang Signs & Symptoms
Yin
Yang
Fatigue, drowsiness
Restlessness, throws off
covers
Flushed complexion
Likes cold
Constipation
Noisy, loud mouthed
Facial pallor
Desires heat
Diarrhea/ watery stools
Likes quiet, no desire to
talk
Copious clear urine
Dark, scanty urine
Principle of Five Elements
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Principles
Qi
• “Vital Energy”
• Permeates all things
• Travels through meridian
• Can be stagnant, depleted, collapsed,
rebellious
The Practice of Acupuncture
• Acupuncture: family of procedures involving
stimulation of anatomical points on the body
• Needles, electricity, heat, manual pressure,
laser, sound, magnets
• 365 acupuncture points
• 14 major meridians
• Styles – Chinese, Japanese, Korean,
British, French, American, ear,
scalp, hand
Practice: Diagnosis and Tx
• Evaluation – 4 Inquiries (Listen, touch, look, smell)
• Diagnostic classes: no1:1 mapping with biomedicine
(e.g. Hypertension; liver fire, kidney def., phlem)
• Treatments individualized (acupoints, stimulation,
frequency)
• ~1 hour session, seen 1-2x week
• Total number of sessions variable
• Needles inserted and left for 10-30 mins
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But, does it ‘work’?
Evidence: Clinical Research
• 1997 NIH Consensus Statement
– > 500 Acupuncture trials, over half RCT’s
– “A List”: Very strong support of efficacy for:
dental pain, post-operative nausea, chemotherapy
related nausea
– “B List”: May be helpful for: addiction,headache,
fibromyalgia, stroke rehabilitation, osteoarthritis,
low back pain, asthma, carpal tunnel syndrome,
and menstrual cramps
– Clearly negative: tinnitus, smoking cessation
– Safe
– Significant methodological Issues
Methodological Issues
Problems common to all clinical trials
• e.g. Small sample size; randomization; statistical
analysis
Problems unique to acupuncture research
•
•
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•
•
Appropriate Control Groups
Patient and Practitioner Blinding
Individualized vs. Standardized Protocols
Dosage (Length/frequency of treatments; stimulation)
Experience and style of acupuncturists
Recent studies have overcome these problems
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Knee Osteoarthritis
(Berman et al 2004; Ann Intern Med)
Aim: Evaluate acupuncture as an adjunctive treatment
Design: Phase III trial based on 2 pilot studies
• RCT w/ 3 arms (n=570):
-active acupuncture (fixed protocol; manual + EA)
-sham acupuncture (taped guide tubes + decoys)
-education-attention control (12h meeting+mailings)
• Acupuncture/Sham Dosage: 23 Tx of 26 weeks
• Experienced, licensed practitioners
Primary Outcome: WOMAC Pain and Function
Knee Osteoarthritis
(Berman et al 2004; Ann Intern Med)
Results
• Sham Tx masked and credible
• After 26 weeks, in active acupuncture group:
- Pain reduced by 42% (vs. 33% and 19% in
sham and education; p=0.003)
-Function improved 40% (vs. 31% and 22% in
sham and education; p=0.01)
Conclusion: Acupuncture effective adjunct therapy for knee
osteoarthritis
-Methodologically sound, sham-controlled, trials possible
-Dosage and samples sizes important (8 vs. 26 wks)
Acupuncture for Chronic Stroke Symptoms
(Wayne et al 2006)
Background: Result of stroke studies to date mixed/limited;
methodological issues (dosage,standardized Tx, control);
all acute to sub-acute.
Aim: Evaluate acupuncture on upper extremity (UE) function
in long-term stroke survivors w/ persistent dysfunction
Design:
• Pilot RCT w/ 2 arms (n=33)
• Post-recovery stage (> 6 months; 0.8 to 24 y post-stroke)
• 20 Tx over 10 weeks in private office of senior practitioners
• active acupuncture (individualized protocol; manual + EA)
• sham acupuncture (sham needle device)
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Acupuncture for Chronic Stroke
Symptoms
(Wayne et al 2006)
Outcomes: UE motor function (FM), spasticity (Ashworth),
range of motion, mood (CES-D), and QOL (Nottingham);
Somatosensory function (fMRI) on subset (n=7)
Results:
• Treatment masking successful; < 50% guessed;
those who did guess were equally right/wrong.
• Relative to sham, active protocol-compliant subjects
had better outcomes w/r/t
-wrist spasticity (P<0.01)
-wrist and shoulder ROM (P<0.01)
-motor function (P=0.09)
Acupuncture and Chronic Stroke: fMRI data
(J. Schaechter et al 2007)
• n=7; BOLD fMRI
• Responses of motor and
somatosenory cortices to
sensorimotor testing before &
after 20 acu Tx
• Composite SMF change
score from clinical results
• Changes in ipsilesional SM
cortex parallel changes in
SMF after acupuncture
CONCLUSION
• Promising; additional
research warranted
Acupuncture for Chronic Headaches
(Vickers et al, BMJ 2004)
Aim: Determine effects of acupuncture on headache pain,
health status, and number sick days off in patients with
chronic headaches (predominantly migraine)
Design: -Pragmatic Trial (n=401) funded by NHS
-Patients randomized to acupuncture practitioners
(12 Tx over 3 months, no set protocol) or to usual care
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Acupuncture for Chronic Headaches
(Vickers et al. BMJ 2004)
Results: At 12 months, in the acupuncture group:
•Weekly headache scores reduced by 34% (vs. 16 in
control; P=0.0002)
• 22 fewer HA day/s per year
• 15% less medication
• 15% fewer days off sick
Cost effectiveness analysis (Wonderling et al 2004, BMJ)
• acupuncture for headaches favorable cost-benefit
profile
Adverse effects
Mechanistic Studies & Credibility
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Mechanistic Studies
Three important areas of studies
1. Neurohormonal
2. fMRI
3. Connective tissue
MEK AS=met-enkephalin; DYN AS=dynorphin A
Electroacupuncture at Low and High Frequencies
Releases Different CNS Opioids
Han et al (1991) Pain 47:295-298.
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Functional MRI
• Measures deoxyhemoglobin –
paramagnetic oxygen-depleted carrier
molecule
• Proxy for neuronal activity - increased
energy demand – increased blood flow
– changes in deoxyhgb
Visual (light) stimulation in comparison with
‘vision’-related acupoint (Bl 67) and non-acupoint
control
(Cho, Z. H. et al. (1998) Proc. Natl. Acad. Sci. USA 95, 2670-2673)
Cho, Z. H. et al. (1998) Proc. Natl. Acad. Sci. USA 95, 2670-2673
Copyright ©1998 by the National Academy of Sciences
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