Research

Conclusion

Reviews

Pilkington K. Anxiety, depression and acupuncture: A review of the clinical research. Auton Neurosci. 2010 Oct 28;157(1-2):91-5.

Updated the 2007 anxiety review and located 3 further Chinese trials for generalised anxiety disorder. These found acupuncture to be similarly effective to drugs, but had small sample sizes. Overall the review concluded that the trials are too heterogeneous and of insufficiently high quality to be able draw firm conclusions. There is promising evidence for acute, short-term anxiety but the relevance of this to chronic anxiety conditions is unknown.

Samuels N et al. Acupuncture for psychiatric illness: a literature review. Behav Med 2008; 34: 55-64.

A literature review of acupuncture for psychiatric illness, which presents research that found acupuncture to increase central nervous system hormones, including ACTH, beta-endorphins, serotonin, and noradrenaline. It concludes that acupuncture can have positive effects on depression and anxiety.

Pilkington K et al. Acupuncture for anxiety and anxiety disorders - A systematic literature review. Acupuncture in Medicine 2007; 25: 1-10.

A systematic review (search to July 2004) including 12 controlled trials that evaluated the evidence for the efficacy of acupuncture in the treatment of anxiety and anxiety disorders. Ten of the trials were randomised, four focused on acupuncture in generalised anxiety disorder or anxiety neurosis, and six focused on anxiety in the perioperative period. No studies were located on the use of acupuncture specifically for panic disorder, phobias or obsessive compulsive disorder. The reviewers concluded that there are positive findings for acupuncture in the treatment of generalised anxiety disorder or anxiety neurosis but that there was insufficient evidence for firm conclusions, and that there was some limited evidence in favour of ear acupuncture for perioperative anxiety.

Clinical studies

Fogarty S, Harris D, Zaslawski C, McAinch AJ, Stojanovska L Acupuncture as an adjunct therapy in the treatment of eating disorders: a randomised cross-over pilot study. Complement Ther Med. 2010 Dec;18(6):233-40

A randomised cross-over study of acupuncture as adjunctive therapy for eating disorders. Nine women (5 with Anorexia, 4 with Bulimia) recruited from a multi-disciplinary outpatient eating disorder centre, which provided the standard treatment in the trial phase of the cross-over, aged (mean and SD) 23.7 (9.6) years, participated in the study. As well as improvements in the Eating Disorder Quality of Life scale there was also evidence of decreases in anxiety (both State and Trait as measured by the State Trait Anxiety Intervention)

Wu P, Liu S. Clinical observation on post-stroke anxiety neurosis treated by acupuncture. J Tradit Chin Med 2008; 28: 186-8.

A randomised controlled trial assessing the effect of acupuncture on post-stroke anxiety neurosis, in which 34 patients received acupuncture treatment supplemented by electroacupuncture and 33 patients had oral alprazolam. Anxiety symptoms (measured using the Hamilton Anxiety scale [HAMA]) were relieved in 82.35% of patients given acupuncture, with no difference as compared with the alprazolam group. The researchers concluded that acupuncture is a safe, effective and important method for treating post-stroke anxiety neurosis.

Yuan Q. Li J.-N. Liu B. Wu Z.-F. Jin R. Effect of Jin-3-needling therapy on plasma corticosteroid, adrenocorticotropic hormone and platelet 5-HT levels in patients with generalized anxiety disorder. Chinese Journal of Integrative Medicine.2007; 13 (4):  264-268.

A 6-week randomised controlled trial that compared acupuncture with anti-anxiety drugs and with acupuncture and drugs combined, in 86 patients with generalised anxiety disorder. Both clinical and biochemical effects were measured before and after treatment. Anxiety levels on the clinical global impression scale were similar in the three groups, though favoured acupuncture in the efficacy component. The platelet concentration of serotonin and plasma ACTH fell significantly but similarly in all groups, while corticosterone levels did not change. The reviewers concluded that acupuncture had a similar anti-anxiety effect to routine Western medicine but with less unwanted effects, and that this effect may be realised through regulating serotonin and ACTH.

Hollifield M et al. Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial. J Nerv Ment Dis 2007; 195: 504-13.

A randomised controlled trial assessing acupuncture for post-traumatic stress disorder, in which 73 participants were allocated to acupuncture treatment, group cognitive-behavioural therapy (CBT) or a waiting-list control group. Acupuncture resulted in an improvement in symptoms similar in magnitude to those with group CBT, and both treatment groups improved more than the waiting-list control group (p < 0.01). Symptom reductions were maintained at 3-month follow-up for both interventions. The researchers concluded that acupuncture may be an effective and acceptable nonexposure treatment option for post traumatic stress disorder.

Mora B et al. Auricular acupressure as a treatment for anxiety before extracorporeal shock wave lithotripsy in the elderly. J Urol 2007; 178: 160-4.

A randomised controlled trial of ear acupuncture for anxiety in 100 older patients with renal calculi about to undergo extracorporeal shock wave lithotripsy. Patients were randomised to ear acupuncture or a sham group and given treatment on the way to hospital. Anxiety was measured using a visual analog scale. The acupuncture group had significantly decreased anxiety scores on arrival at hospital, as well as a lower anticipation of pain scores than the sham treated group (p=0.001). After the lithotripsy, the ear acupuncture group also had less anxiety than the sham group (p=0.001). The researchers concluded that the older patients who received ear acupressure while being transported to the hospital were less anxious, anticipated less pain and were more optimistic about the treatment outcome than the sham group, and claimed that ear acupuncture is an effective treatment for anxiety.

Karst M et al. Auricular acupuncture for dental anxiety: A randomized controlled trial. Anesthesia and Analgesia 2007; 104: 295-300.

A randomised controlled trial comparing ear acupuncture with intranasal midazolam, placebo acupuncture, and no treatment for reducing dental anxiety in 67 patients having dental extractions Anxiety was assessed before the interventions, at 30 min, and after the dental extraction. Physiological variables were assessed continuously. With the no treatment group as control, the auricular acupuncture group, and the midazolam group were significantly less anxious at 30 min compared with patients in the placebo acupuncture group (P = 0.012 and <0.001, respectively). In addition, patient compliance assessed by the dentist was significantly improved if auricular acupuncture or application of intranasal midazolam had been performed (P = 0.032 and 0.049, respectively). The researchers concluded that ear acupuncture and intranasal midazolam were similarly effective for the treatment of dental anxiety.

Wang S-M et al. Acupuncture as an adjunct for sedation during lithotripsy. J Alt Comp Med 2007; 13: 241-6.

A randomised controlled trial comparing preprocedural ear acupuncture plus intraprocedural electroacupuncture with sham acupuncture as adjuncts for the preprocedural anxiety and pain management in 56 adult patients undergoing lithotripsy procedures. Patients in the acupuncture group were less anxious before the procedure than those in the sham group (p = 0.029), used less alfentanil (p = 0.040) and reported lower pain scores (p = 0.014). The researchers concluded that a combination of ear and body acupuncture can be used as an adjunct treatment to decrease preprocedural anxiety and intraprocedural analgesia in patients undergoing lithotripsy.

Gibson D et al. Effects of acupuncture as a treatment for hyperventilation syndrome: A pilot, randomized crossover trial. J Alt Comp Med 2007; 13: 39-46.

A single-blind randomised controlled trial that compared 4 weeks of acupuncture and breathing retraining in 10 patients with hyperventilation syndrome to reduce anxiety. The patients were randomised in to two groups, both of which received both treatments with a washout period of 1 week. Acupuncture reduced anxiety (using the HADA measure) more than breathing retraining (p = 0.02) and, in those who received acupuncture first, there was a reduction in anxiety levels that persisted through the washout period, suggesting that there may have been some carryover effect from this treatment. The researchers concluded that acupuncture may be beneficial in the management of hyperventilation syndrome in terms of reducing anxiety levels and symptom severity.

Courbasson CM. et al .Acupuncture treatment for women with concurrent substance use and anxiety/depression: an effective alternative therapy? Family & Community Health.2007;30(2):112-2

Auricular acupuncture was added to a 21-day outpatient structured psychoeducational treatment program for women with concurrent substance use problems, anxiety, and depression. The women (n=185) reported reduced physiological cravings for substances and felt significantly less depressed and less anxious than those in a control group (n=101). It was found that auricular acupuncture, as an adjunct therapy to a comprehensive psychoeducational treatment program for women with addictions, shows promise in being an effective, more viable treatment alternative to anxiolytics.

Gioia L et al. Sedative effect of acupuncture during cataract surgery. Prospective randomized double-blind study. Journal of Cataract and Refractive Surgery 2006; 32: 1951-4.

A double-blind randomised controlled trial comparing no acupuncture, true acupuncture and sham acupuncture (both given 20 minutes before surgery) for reducing anxiety in 25 patients having cataract surgery under local anaesthesia. Preoperative anxiety levels were lower with true acupuncture than with no acupuncture (P = 0.001) or sham acupuncture (P = 0.037). Postoperative anxiety levels were lower with true acupuncture than with no acupuncture (P = 0.003). The reviewers concluded that acupuncture was effective in reducing anxiety related to cataract surgery under topical anaesthesia.

Physiological studies

Hui KK et al. Acupuncture, the limbic system, and the anticorrelated networks of the brain. Auton Neurosci. 2010 Oct 28;157(1-2):81-90.

Studies have shown that acupuncture stimulation, when associated with sensations comprising deqi, evokes deactivation of a limbic-paralimbic-neocortical network, as well as activation of somatosensory brain regions. These networks closely match the default mode network and the anti-correlated task-positive network. The effect of acupuncture on the brain is integrated at multiple levels, down to the brainstem and cerebellum and appears to go beyond either simple placebo or somatosensory needling effects. Needling needs to be done carefully, as very strong or painful sensations can attenuate or even reverse the desired effects. Their results suggest that acupuncture mobilizes the functionally anti-correlated networks of the brain to mediate its actions, and that the effect is dependent on the psychophysical response. They discuss potential clinical application to disease states including chronic pain, major depression, schizophrenia, autism, and Alzheimer's disease.

Kim H  et al. The effects of acupuncture stimulation at PC6 (Neiguan) on chronic mild stress-induced biochemical and behavioral responses. Neuroscience Letters. 2009; 460 (1) (pp 56-60)

The effects of acupuncture on the behavioral responses induced by chronic mild stress (CMS) were evaluated in rats by using a maze and a sucrose intake test. C-fos expression in the brain was examined by immunohistochemistry. Acupuncture stimulation at point P6 (3 min) (but not at point SJ5) reversed stress-induced behavioural changes and significantly attenuated c-fos  expression in the hypothalamus, suggesting that acupuncture has a therapeutic effect on chronic stress-related diseases such as depression and anxiety

Lee B et al. Effects of acupuncture on chronic corticosterone-induced depression-like behavior and expression of neuropeptide Y in the rats. Neuroscience Letters 2009; 453: 151-6.

In animal studies, acupuncture has been found to significantly reduce anxiety-like behaviour, and increase brain levels of neuropeptide Y, which appears to correlate with reported anxiety.

Zhou Q et al. The effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the CNS of rats with chronic emotional stress-induced anxiety. Int J Clin Acupunct 2008 ;17: 79-84.

A study of the regulatory effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the central nervous system of rats with chronic emotional stress-induced anxiety. The levels of serotonin, noradrenaline and dopamine fell significantly, while GABA levels were significantly higher in the rats given acupuncture (P<0.05, or P<0.0). The researchers concluded that the anti-anxiety effect of electro-acupuncture may relate to its regulation of the imbalance of neurotransmitters.

Arranz L et al. Effect of acupuncture treatment on the immune function impairment found in anxious women. American Journal of Chinese Medicine.  2007;35(1):35-51

34 women with anxiety received 10 acupuncture treatments over a year, until complete remission. 20 healthy, non-anxious women formed the controls. Impaired immune functions in anxious women (chemotaxis, phagocytosis, lymphoproliferation and NK activity) were significantly improved by acupuncture, coming to the values of the healthy controls. The effects peaked 72 hours after a session and lasted up to a month after the course finished.

In an earlier paper (Arranz et al, 2007) the authors had reported  that acupuncture reversed the lowering of IL-2 levels and elevating of TNF-alpha and cortisol seen in anxious women. Therefore, these may be some of the parameters by which acupuncture could exert its therapeutic action on anxiety.

Research

Conclusion

Reviews

Ernst E, Lee MS, Choi TY Acupuncture for Depression? A Systematic Review of Systematic Reviews. Eval Health Prof. 2010 Dec 7. [Epub ahead of print]

A critical evaluation of eight systematic reviews (71 primary studies). Five had positive conclusions (all from China) and three did not. Given the perceived unreliability of Chinese studies they concluded that the effectiveness of acupuncture for depression remains unproven and that it may act largely as a placebo

Schroer S, Adamson J. Acupuncture for Depression: A Critique of the Evidence Base. CNS Neurosci Ther. 2010 Nov 21[Epub ahead of print]

This review identified a number of limitations in existing studies of acupuncture for depression. (i) Patients: often no rationale for patient selection procedures. Concerns about the generalisability of study populations. (ii) Intervention: poor quality acupuncture, not generalisable to routine clinical practice (iii) Comparisons: concerns about therapeutically inappropriate sham acupuncture. (iv) Outcomes: short-term, narrow range. Other methods may be better suited to evaluating acupuncture care. Uncertainty remains about the value of acupuncture care, as routinely practiced in the West, and this has not been resolved by trials to date.

Zhang Z.-J et al. The effectiveness and safety of acupuncture therapy in depressive disorders: Systematic review and meta-analysis. Journal of Affective Disorders. 2010;124 (1-2) (pp 9-21)

Systematic review with meta-analysis of acupuncture for various depressive conditions, particularly major depressive disorder (MDD) and post-stroke depression (PSD). Twenty higher quality RCTs of MDD (n = 1998) and 15 of PSD (n = 1680) were included. The efficacy of acupuncture alone for MDD was comparable to antidepressants, but not different from sham acupuncture. Acupuncture plus antidepressants did not yield better outcomes than antidepressants alone. For PSD, acupuncture was superior to antidepressants and waitlist controls in both response and symptom severity. Acupuncture-related adverse events were significantly lower than with antidepressants. Conclusions: Acupuncture therapy is safe and effective in treating MDD and PSD and could be considered an alternative option for the two disorders.

Smith C.A. et al. Acupuncture for depression. Cochrane database of systematic reviews (Online). (1) (pp CD004046), 2010.

30 randomised trials (2,812 participants) from Western and Chinese databases were meta-analysed. Acupuncture showed no consistent benefit over a wait list or sham acupuncture control. Most trials compared acupuncture with medication and found no effect between groups; two showed an additive benefit over and above drugs alone. For a subgroup with post-stroke depression acupuncture was superior to SSRIs (RR 1.66, 95%CI 1.03, 2.68. Conclusion: there is insufficient evidence to recommend the use of acupuncture for people with depression. The results are limited by the high risk of bias in the majority of trials

Wang H, Qi H, Wang BS, Cui YY, Zhu L, Rong ZX, Chen HZ. Is acupuncture beneficial in depression: A meta-analysis of 8 randomized controlled trials? J Affect Disord. 2008 Dec;111(2-3):125-34.

Meta-analysis which looked at the most recent clinical studies of acupuncture in the treatment of depression. It analysed the pooled results of eight small randomized controlled trials, comprising a total of 477 subjects and concluded; 'acupuncture was an effective treatment that could significantly reduce the severity of disease in the patients with depression'.

Leo RJ, Ligot JS Jr. A systematic review of randomized controlled trials of acupuncture in the treatment of depression. J Affect Disord. 2007 Jan;97(1-3):13-22.

Systematic review and meta analysis of acupuncture as a treatment of depression, which analysed the pooled results of nine small randomised controlled trials. Found that; 'acupuncture modalities were as effective as antidepressants employed for treatment of depression'.

Clinical studies

Manber R et al. Acupuncture for depression during pregnancy: a randomized controlled trial. Obstetrics and Gynecology. 2010; 115(3):511-520.

Randomized controlled study of acupuncture for depression during pregnancy, involving 150 women. Eight weeks of acupuncture at points specifically chosen to treat depression was significantly more effective than either non-specific acupuncture or the average of both control groups (the 2^nd was massage). The response rates were 63% for specific acupuncture, 37.5% sham acupuncture and 50% massage. They concluded that a short acupuncture protocol demonstrated symptom reduction and a response rate comparable to those of standard depression treatments, and hence could be a viable treatment option.

Xie YC. Li YH. [Observation on therapeutic effect of acupuncture at Zhongwan (CV 12) and Si-guan points combined with reinforcing-reducing manipulation of respiration for treatment of depression]. [Chinese] Zhongguo Zhenjiu.2009; 29(7):521-4

One hundred and twenty cases were randomly divided into an acupuncture group and a western medicine group (oral Fluoxetine, 20 mg per day). Treatments lasted for 8 weeks and the main outcomes were the Hamilton Depression Scale (HAMD) and the Treatment Emergent Symptom Scale (TESS) for adverse effects. Response rates were 95% for acupuncture and 92% for medication (no significant difference between them). Likewise HAMD scores improved substantially but similarly for both. There was a significant difference between two groups in TESS score (P < 0.01): almost no adverse reaction with acupuncture but nausea, anorexia, diarrhoea and other symptoms with medication. They concluded that acupuncture can significantly improve symptoms of depression patients with a similar therapeutic effect to Fluoxetine , but without the  adverse reactions.

Fu WB, Fan L, Zhu XP, He Q, Wang L, Zhuang LX, Liu YS, Tang CZ, Li YW, Meng CR, Zhang HL, Yan J. Acupuncture for treatment of depressive neurosis: a multi-center randomized controlled study. Zhongguo Zhen Jiu. 2008 Jan;28(1):3-6.

Multi-centre randomized controlled study of acupuncture for depression, involving 440 cases. Found the therapeutic effect of acupuncture on depression to be similar to or better than that of Prozac, with fewer side effects.

Zhang GJ, Shi ZY, Liu S, Gong SH, Liu JQ, Liu JS. Clinical observation on treatment of depression by electro-acupuncture combined with Paroxetine. Chin J Integr Med. 2007 Sep;13(3):228-30.

Randomized controlled trial involving 42 patients. Found that acupuncture combined with anti-depressant medication was more effective in treating depression than anti-depressants alone. Patients on the combined treatment also improved more quickly and experienced fewer side effects than those who only took medication.

Allen JJ et al. Acupuncture for depression: a randomized controlled trial. J Clin Psychiatry. 2006 Nov;67(11):1665-73.

Randomized controlled trial of acupuncture for major depression in 151 women. Eight weeks of depression-specific acupuncture led to a significantly greater reduction in depression than being on a waiting list but it was not superior to non-specific acupuncture. Concluded that the results do not support the efficacy of acupuncture as a monotherapy, though the manner of delivering blinded specific and non-specific acupuncture may limit the generalisability of the trial.

Röschke J, Wolf C, Müller MJ, Wagner P, Mann K, Grözinger M, Bech S. The benefit from whole body acupuncture in major depression. J Affect Disord. 2000 Jan-Mar;57(1-3):73-81.

Randomized controlled study of acupuncture used in conjunction with antidepressants to treat depression, involving 70 patients. Concluded that acupuncture plus antidepressants improved the course of depression more than medication alone.

Eich H, Agelink MW, Lehmann E, Lemmer W, Klieser E. Acupuncture in patients with minor depressive episodes and generalized anxiety. Results of an experimental study. Fortschr Neurol Psychiatr. 2000 Mar;68(3):137-44.

Randomized controlled trial of acupuncture treatment in 43 patients with minor depression. Results indicated that, compared with placebo treatment, acupuncture leads to a significant clinical improvement in depression as well as a marked reduction in anxiety symptoms.

Physiology studies (human and animal)

Hui KK et al. Acupuncture, the limbic system, and the anticorrelated networks of the brain. Auton Neurosci. 2010 Oct 28;157(1-2):81-90.

Studies have shown that acupuncture stimulation, when associated with sensations comprising deqi, evokes deactivation of a limbic-paralimbic-neocortical network, as well as activation of somatosensory brain regions. These networks closely match the default mode network and the anti-correlated task-positive network. The effect of acupuncture on the brain is integrated at multiple levels, down to the brainstem and cerebellum and appears to go beyond either simple placebo or somatosensory needling effects. Needling needs to be done carefully, as very strong or painful sensations can attenuate or even reverse the desired effects. Their results suggest that acupuncture mobilizes the functionally anti-correlated networks of the brain to mediate its actions, and that the effect is dependent on the psychophysical response. They discuss potential clinical application to disease states including chronic pain, major depression, schizophrenia, autism, and Alzheimer's disease.

Wang XJ, Wang LL.  [A mechanism of endogenous opioid peptides for rapid onset of acupuncture effect in treatment of depression.] Zhong Xi Yi Jie He Xue Bao. 2010 Nov 15;8(11):1014-1017.

Clinical and experimental studies show that the onset of effect of acupuncture on depression is more rapid than SSRI antidepressants. The onset time for both depression and various pains is a week or so, and the main pathway in both is through endogenous opioids.

Kim H  et al. The effects of acupuncture stimulation at PC6 (Neiguan) on chronic mild stress-induced biochemical and behavioral responses. Neuroscience Letters. 2009; 460 (1) (pp 56-60)

The effects of acupuncture on the behavioral responses induced by chronic mild stress (CMS) were evaluated in rats by using a maze and a sucrose intake test. C-fos expression in the brain was examined by immunohistochemistry. Acupuncture stimulation at point P6 (3 min) (but not at point SJ5) reversed stress-induced behavioural changes and significantly attenuated c-fos  expression in the hypothalamus, suggesting that acupuncture has a therapeutic effect on chronic stress-related diseases such as depression and anxiety.

Broyd SJ et al. Default-mode brain dysfunction in mental disorders: A systematic review. Neurosci Biobehav Rev. 2008 Sep 9.

Systematic review of the role of the default mode network in the pathophysiology of mental disorders including anxiety and depression.

Dhond RP, Yeh C, Park K, Kettner N, Napadow V. Acupuncture modulates resting state connectivity in default and sensorimotor brain networks. Pain. 2008 Jun;136(3):407-18.

Experimental fMRI study of brain activity before and after acupuncture. Found that verum acupuncture had a persistent effect on the connectivity of different brain areas during its resting-state. Acupuncture increased the extent of regions of the brain active at rest (the 'default mode network') to include areas involved with pain, emotion and memory.

Zhao ZQ, Neural mechanism underlying acupuncture analgesia. Prog Neurobiol. 2008 Aug;85(4):355-75.

Review of evidence for neural mechanisms underlying acupuncture analgesia and its ability to treat chronic pain.

Pohl A, Nordin C. Clinical and biochemical observations during treatment of depression with electroacupuncture: a pilot study. Hum Psychopharmacol. 2002 Oct;17(7):345-8.

Pilot study of electroacupuncture for major depression. Found a decrease of neuropeptide Y in plasma during treatment.

Sprott H, Franke S, Kluge H, Hein G. Pain treatment of fibromyalgia by acupuncture. Rheumatol Int 1998;18:35-36.

Experimental study of pain modulation by acupuncture in fibromyalgia patients. Found that acupuncture was associated with decreased subjective pain levels, as well as changes in concentration of pain modulating substances (serotonin and substance P) in serum.

Scott S, Scott WN. A biochemical hypothesis for the effectiveness of acupuncture in the treatment of substance abuse: acupuncture and the reward cascade. Am J Acupunct 1997;25:33-40.

Review exploring physiological basis of acupuncture in the treatment of addiction, in relation to endorphin mechanisms and the reward cascade.

Han JS. Electroacupuncture: An alternative to antidepressants for treating affective diseases? Intl J Neurosci 1986;29:79-92.

Review presenting evidence that acupuncture can accelerate synthesis and release of serotonin and noradrenline in the CNS.

Research

Conclusion

Randomised controlled trials

Wu Y et al. Effect of acupuncture-assisted anesthesia on stress response during laparoscopic cholecystectomy in aged patients. [Article in Chinese] Zhongguo Zhen Jiu 2011; 31: 155-7.

A randomised controlled trial that compared the difference between transcutaneous electrical acupoint stimulation (TEAS) assisted general anaesthesia and simple general anaesthesia on stress response during laparoscopic cholecystectomy in 40 older patients. The haemodynamic indices (i.e. mean arterial pressure, heart rate) had decreased in the general anaesthesia only group at 5 minutes compared to before anaesthesia and compared to the TEAS plus general anaesthesia group (p0.05), but they had all increased significantly in group general anaesthesia group. There were also significant differences between the two treatment groups in favour of TEAS at each time point (p<0.05, p 0 01 the researchers concluded that acupuncture-assisted anaesthesia helps to keep haemodynamics stable and reduce stress response during laparoscopic cholecystectomy in older patients strong

Huang W et al. An investigation into the effectiveness of traditional Chinese acupuncture (TCA) for chronic stress in adults: a randomised controlled pilot study. Complement Ther Clin Pract 2011; 17: 16-21.

An exploratory pragmatic randomised controlled trial that investigated the effectiveness of traditional Chinese acupuncture (TCA) using an individually targeted treatment protocol delivered by a traditionally trained Chinese acupuncturist. The trial examined the treatment of chronic stress as perceived by the 18 participants who all self-reported high stress levels. They were allocated to weekly TCA for 5 weeks; weekly attention only (practitioner present and participant supine) for 5 weeks or were in a waiting list control group. The Perceived Stress Scale 14 (PSS-14) and the Measure Yourself Medical Outcome Profile (MYMOP) were completed before and after treatment. After 5 weeks, the acupuncture group reported significant changes in MYMOP profile score and both MYMOP reported symptoms (p<0.05); the attention only group had significant changes in mymop profile score and one symptom p 0 05 waiting list showed no pss-14 scores decreased all 3 groups but difference between pre- post-treatment within did not reach significance addition there were self-reports of improvements with acupuncture for other health problems researchers concluded that lack clarity concerning definition stress makes it complex to investigate their study results suggest traditional chinese might be successful treating symptoms chronic

Kwong EY, Yiu EM. A preliminary study of the effect of acupuncture on emotional stress in female dysphonic speakers. J Voice. 2010; 24: 719-23.

A randomised placebo-controlled trial that investigated the effects of acupuncture (genuine vs. sham) on emotional stress in 18 people with phonotraumatic injuries. Cortisol levels were measured in samples of the participants' saliva. Samples were collected from each subject at 10 minutes pre-needling, immediately pre-needling, mid-needling, immediately post-needling, and 10 minutes post-needling time points. The findings suggested that the subjects' salivary cortisol concentrations did not reduce after acupuncture, and thus, acupuncture may not be able to reduce the emotional stress level in female dysphonic speakers.

Fassoulaki A et al. Pressure applied on the extra 1 acupuncture point reduces bispectral index values and stress in volunteers. Anesth Analg. 2003; 96: 885-90.

A crossover study that investigated the effect of pressure application on the acupuncture "extra 1" point in 25 healthy volunteers. Acupressure applied for 10 minutes on the extra 1 point significantly reduced bispectral index values and the verbal stress score when compared with acupressure applied on a control point.

Middlekauff HR et al. Acupuncture inhibits sympathetic activation during mental stress in advanced heart failure patients. J Card Fail 2002; 8: 399-406.

A study to assess whether acupuncture is sympatho-inhibitory in patients with 15 patients with heart failure, in whom muscle sympathetic nerve activity is increased. Heart failure patients with the greatest sympathetic activation have the poorest prognosis. The patients underwent acute mental stress testing before and during "real" acupuncture, non-acupoint acupuncture or no-needle acupuncture control. Muscle sympathetic nerve activity (MSNA) was recorded. Resting MSNA was not different before and after acupuncture.. During mental stress, sympathetic nerve activity increased significantly; this increase was eliminated following real acupuncture (p=0.03), but not after non-acupoint or no-needle acupuncture controls. The changes in blood pressure and heart rate during mental stress were not attenuated by real or control acupuncture. The researchers concluded that acute acupuncture might attenuate sympatho-excitation during mental stress in patients with advanced heart failure.

Uncontrolled studies

Pavao TS et al. Acupuncture is effective to attenuate stress and stimulate lymphocyte proliferation in the elderly. Neurosci Lett 2010; 484: 47-50.

A study that investigated the effects of acupuncture on stress-related psychological symptoms and cellular immunity in young adults and older subjects. Psychological variables (depression, anxiety and stress) were investigated by means of self-assessment inventories. Peripheral blood mononuclear cells were isolated and cultured in vitro to measure mitogen-induced T-cell proliferation as well as cellular sensitivity to dexamethasone. All data were assessed before and after the intervention. Acupuncture was able to significantly reduce depression (p<0.001), anxiety p 0 001 and stress scores the intervention also increased t-cell proliferation with greater intensity in older group no changes cellular sensitivity to dexamethasone were observed following acupuncture researchers concluded that was effective attenuating psychological distress as well increasing t- cell

Balk J et al. The relationship between perceived stress, acupuncture, and pregnancy rates among IVF patients: a pilot study. Complement Ther Clin Pract 2010; 16: 154-7.

An observational prospective cohort study that looked at the effect of acupuncture on perceived stress levels in 57 infertile women on the day of embryo transfer (ET), and assessed whether perceived stress levels at embryo transfer correlated with pregnancy rates. In all, 64.7% of the women who received acupuncture became pregnant compared with only 42.5% of those who did not have acupuncture. When stratified by donor recipient status, only non-donor recipients potentially had an improvement with acupuncture (35.5% without acupuncture vs. 55.6% with acupuncture). Those receiving acupuncture also had lower stress scores, both pre- and post-ET, compared to those who did not. Those who perceived that their stress levels decreased compared to baseline had higher pregnancy rates than those who did not, regardless of acupuncture status. The researchers concluded that acupuncture was associated with less stress both before and after embryo transfer, and that it possibly improved pregnancy rates.

Chan J, et al. An uncontrolled pilot study of HT7 for 'stress'. Acupunct Med 2002; 20: 74-7.

The acupuncture point Ht7 was needled in four weekly sessions using 17 volunteers recruited from staff in a hospice. 16 of them (94%) showed improved 'psychological stress' according to the Edinburgh Postnatal Depression Scale (EPDS),. The greatest fall in the EPDS scores was observed within the first two treatments and at the end of the study the average reduction was 44%,

Possible mechanisms of acupuncture

Kim H et al. The effects of acupuncture (PC6) on chronic mild stress-induced memory loss. Neurosci Lett. 2011; 488: 225-8.

An animal study that examined the effects of the PC6 acupuncture point on chronic mild stress-induced memory loss in rats. Memory storage and acetylcholinesterase (AchE) activity in the hippocampus were measured using a passive avoidance test (PAT) and AchE immunohistochemistry, respectively. In the PAT, the chronic mild stress group showed a markedly lower latency time than the control group (p<0.01 at 72 hours p 0 05 96 001 120 however acupuncture pc6 significantly recovered the impairment of memory exposure to chronic mild stress also decreased ache activity in hippocampus and stimulation produced an increase reactivity these results show that point is effective restoring stress-related biochemical behavioural impairments rats

Park HJ et al. Electroacupuncture to ST36 ameliorates behavioral and biochemical responses to restraint stress in rats. Neurol Res 2010; 32 Suppl 1: 111-5.

A study that looked at the effect of electroacupuncture on the behavioural and biochemical responses to restraint stress in rats. The stress increased the response of the anxiety-related behaviour, serum levels of corticosterone and the number of tyrosine hydroxylase-immunoreactive cells. The acupuncture group showed a significant decrease of anxiety-related behavioural response, and also had decreased serum corticosterone levels and tyrosine hydroxylase-immunoreactive expression The researchers concluded that the findings suggest that electroacupuncture might play a role in reducing the stress-related responses, which may be helpful for the treatment of stress-related disorders.

Hui KK et al. Acupuncture, the limbic system, and the anticorrelated networks of the brain. Auton Neurosci 2010; 157: 81-90.

Studies have shown that acupuncture stimulation, when associated with sensations comprising deqi, evokes deactivation of a limbic-paralimbic-neocortical network, as well as activation of somatosensory brain regions. These networks closely match the default mode network and the anti-correlated task-positive network. The effect of acupuncture on the brain is integrated at multiple levels, down to the brainstem and cerebellum and appears to go beyond either simple placebo or somatosensory needling effects. Needling needs to be done carefully, as very strong or painful sensations can attenuate or even reverse the desired effects. Their results suggest that acupuncture mobilizes the functionally anti-correlated networks of the brain to mediate its actions, and that the effect is dependent on the psychophysical response. They discuss potential clinical application to disease states including chronic pain, major depression, schizophrenia, autism, and Alzheimer's disease.

Hui K.K.-S. The salient characteristics of the central effects of acupuncture needling: limbic-paralimbic-neocortical network modulation. Human Brain Mapping 2009; 30: 1196-206.

A study assessed the results of fMRI on 10 healthy adults during manual acupuncture at 3 acupuncture points and a sham point on the dorsum of the foot. Although certain differences were seen between real and sham points, the hemodynamic and psychophysical responses were generally similar for all 4 points. Acupuncture produced extensive deactivation of the limbic-paralimbic-neocortical system. Clusters of deactivated regions were seen in the medial prefrontal cortex, the temporal lobe and the posterior medial cortex. The sensorimotor cortices, thalamus and occasional paralimbic structures such as the insula and anterior middle cingulate cortex showed activation. The researchers concluded that their results provided additional evidence that acupuncture modulates the limbic-paralimbic-neocortical network. They hypothesised that acupuncture may mediate its analgesic, anti-anxiety, and other therapeutic effects via this intrinsic neural circuit that plays a central role in the affective and cognitive dimensions of pain.

Cheng CH et al. Endogenous Opiates in the Nucleus Tractus Solitarius Mediate Electroacupuncture-induced Sleep Activities in Rats. Evid Based Complement Alternat Med 2009; Sep 3.

An animal study that investigated the involvement of the nucleus tractus soliatarius opioidergic system in electroacupuncture-induced alterations in sleep, the findings of which suggested that mechanisms of  sleep enhancement may be mediated, in part, by cholinergic activation, stimulation of the opioidergic neurons to increase the concentrations of beta-endorphin and the involvement of the µ-opioid receptors.

Kim H et al. The effects of acupuncture stimulation at PC6 (Neiguan) on chronic mild stress-induced biochemical and behavioral responses. Neuroscience Letters. 2009; 460: 56-60.

The effects of acupuncture on the behavioural responses induced by chronic mild stress (CMS) were evaluated in rats by using a maze and a sucrose intake test. C-fos expression in the brain was examined by immunohistochemistry. Acupuncture stimulation at point P6 (3 min) (but not at point SJ5) reversed stress-induced behavioural changes and significantly attenuated c-fos expression in the hypothalamus, suggesting that acupuncture has a therapeutic effect on chronic stress-related diseases such as depression and anxiety.

Lee B et al. Effects of acupuncture on chronic corticosterone-induced depression-like behavior and expression of neuropeptide Y in the rats. Neuroscience Letters 2009; 453: 151-6.

In animal studies, acupuncture has been found to significantly reduce anxiety-like behaviour, and increase brain levels of neuropeptide Y, which appears to correlate with reported anxiety.

Komori M et al. Microcirculatory responses to acupuncture stimulation and phototherapy. Anesth Analg 2009; 108: 635-40.

Experimental study on rabbits in which acupuncture stimulation was directly observed to increase diameter and blood flow velocity of peripheral arterioles, enhancing local microcirculation.

Zhou Q et al. The effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the CNS of rats with chronic emotional stress-induced anxiety. Int J Clin Acupunct 2008; 17: 79-84.

A study of the regulatory effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the central nervous system of rats with chronic emotional stress-induced anxiety. The levels of serotonin, noradrenaline and dopamine fell significantly, while GABA levels were significantly higher in the rats given acupuncture (P<0.05, or p 0 the researchers concluded that anti-anxiety effect of electro-acupuncture may relate to its regulation imbalance neurotransmitters

Arranz L et al. Effect of acupuncture treatment on the immune function impairment found in anxious women. American Journal of Chinese Medicine.  2007;35(1):35-51

A study in which 34 women with anxiety received 10 acupuncture treatments over a year, until complete remission. Twenty healthy, non-anxious women formed the controls. Impaired immune functions in anxious women (chemotaxis, phagocytosis, lymphoproliferation and NK activity) were significantly improved by acupuncture, coming to the values of the healthy controls. The effects peaked 72 hours after a session and lasted up to a month after the course finished.

In an earlier paper, the authors had reported that acupuncture reversed the lowering of IL-2 levels and elevating of TNF-alpha and cortisol seen in anxious women. Therefore, these may be some of the parameters by which acupuncture could exert its therapeutic action on anxiety.

Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther 2007; 6: 251-7.

Review article that suggests the anti-inflammatory actions of traditional and electro-acupuncture are mediated by efferent vagus nerve activation and inflammatory macrophage deactivation.

Zijlstra FJ et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003; 12: 59-69.

An article that suggests a hypothesis for anti-inflammatory action of acupuncture: Insertion of acupuncture needles initially stimulates production of beta-endorphins, CGRP and substance P, leading to further stimulation of cytokines and NO. While high levels of CGRP have been shown to be pro-inflammatory, CGRP in low concentrations exerts potent anti-inflammatory actions. Therefore, a frequently applied 'low-dose' treatment of acupuncture could provoke a sustained release of CGRP with anti-inflammatory activity, without stimulation of pro-inflammatory cells.

Research

Conclusion

Heading

Cho SH et al. Acupuncture for pain relief in labour: a systematic review and meta-analysis. BJOG 2010;117(8):907-20.

A systematic review that critically evaluated the evidence on acupuncture for labour pain management. Ten randomised controlled trials involving 2,038 women receiving acupuncture alone, or as an adjunct to conventional analgesia, for pain relief in labour were included. Pain intensity on a 100-mm visual analogue scale and uptake of other analgesic methods were used as primary outcomes. VAS for pain intensity data were available in seven studies, and pooling of this data showed that acupuncture was not superior to minimal acupuncture at 1 hour and at 2 hours. Patients reported significantly reduced pain by 4% and 6% during electroacupuncture (EA) treatment at 15 and 30 minutes compared with placebo EA. Compared with no intervention, acupuncture reduced pain by 11% for the first 30 minutes. In trials where acupuncture was compared with conventional analgesia, women receiving acupuncture required less meperidine and other analgesic methods. No acupuncture-related adverse events were reported. Despite the results, the reviewers concluded that the evidence from randomised controlled trials does not support the use of acupuncture for controlling labour pain.

Lim CE et al. Effect of acupuncture on induction of labor. J Altern Complement Med 2009;15:1209-14.

A systematic review of the existing scientific evidence on the potential role of acupuncture for induction of labour during pregnancy. Ten studies were identified. The duration of labour as a result of acupuncture treatment ranged from 10 hours 20 minutes to 29.1 hours. All of the studies demonstrated labour induction by acupuncture treatment. However, because two (of the five) randomised controlled trials reported that there was no statistically significant effect of acupuncture, these results are more suggestive than definitive. The reviewers concluded that, although the definitive role of acupuncture in inducing labour is still yet to be established, the existing studies suggest that acupuncture may be beneficial in labour induction.

Vas J et al. Correction of nonvertex presentation with moxibustion: a systematic review and metaanalysis. Am J Obstet Gynecol 2009;201:241-59.

A systematic review including 6 randomised controlled trials and a total of 1,087 pregnant women that assessed moxibustion for breech presentation. The rate of cephalic version among the moxibustion group was 72.5% versus 53.2% in the control group (relative risk, 1.36; 95% CI 1.17-1.58). In terms of safety, no significant differences were found in the comparison of moxibustion with other techniques. The reviewers concluded that moxibustion at acupuncture point BL67 has been shown to produce a positive effect, whether used alone or in combination with acupuncture or postural measures, in comparison with observation or postural methods alone, for the correction of breech presentation.

Li X et al. Moxibustion and other acupuncture point stimulation methods to treat breech presentation: a systematic review of clinical trials. Chin Med 2009;4:4.

A systematic review that evaluated the efficacy and safety of moxibustion to treat breech presentation. Ten randomised controlled trials involving 2,090 women and 7 controlled clinical trials involving 1,409 women were included. Meta-analysis of randomised controlled trials showed significant differences between moxibustion and no treatment (RR 1.35, 95% CI 1.20 to 1.51; 3 RCTs), but not between moxibustion and knee-chest position. Moxibustion plus other therapeutic methods showed significant beneficial effects (RR 1.36, 95% CI 1.21 to 1.54; 2 RCTs). For nonrandomised controlled trials, moxibustion was more effective than no treatment (RR 1.29, 95% CI 1.17 to 1.42; 2 CCTs) but not more effective than the knee-chest position treatment. The reviewers concluded that moxibustion, acupuncture and laser acupoint stimulation tend to be effective in the correction of breech presentation.

van den Berg I et al. Effectiveness of acupuncture-type interventions versus expectant management to correct breech presentation: a systematic review.

Complement Ther Med 2008;16:92-100.

A systematic review of studies that assessed the effectiveness of acupuncture-type interventions (moxibustion, acupuncture, or electro-acupuncture) on acupuncture point BL 67 to correct breech presentation compared to expectant management. Six randomised controlled trials and three cohort studies fulfilled the inclusion criteria. In the former, the pooled proportion of breech presentations was 34% following treatment versus 66% in the control group (OR 0.25, 95% CI 0.11-0.58). The pooled proportion in the cohort studies was 15% versus 36% (OR 0.29, 95% CI 0.19-0.43). The reviewers concluded that their results suggest that acupuncture-type interventions on BL 67 are effective in correcting breech presentation compared to expectant  management.

van den Berg I e tal. Cost-effectiveness of breech version by acupuncture-type interventions on BL 67, including moxibustion, for women with a breech foetus at 33 weeks gestation: a modelling approach. Complement Ther Med 2010;18:67-77.

A modelling study to estimate the effectiveness and costs of breech version with acupuncture-type interventions, including moxibustion, on BL67 compared to expectant management for women with a foetal breech presentation at 33 weeks gestation. The results suggested that such an intervention would reduce the number of breech presentations at term, thus reducing the number of caesarean sections, and so would be cost-effective compared to expectant management, including external cephalic version.

Ee CC et al. Acupuncture for pelvic and back pain in pregnancy: a systematic review. Am J Obstet Gynecol 2008;198:254-9.

A systematic review that looked at the effectiveness of acupuncture in treating pelvic and back pain in pregnancy. Two small trials on mixed pelvic/back pain and one large high-quality trial on pelvic pain met the inclusion criteria. Acupuncture, as an adjunct to standard treatment, was superior to standard treatment alone and physiotherapy in relieving mixed pelvic/back pain. Women with well-defined pelvic pain had greater relief of pain with a combination of acupuncture and standard treatment, compared to standard treatment alone or stabilizing exercises and standard treatment. Few and minor adverse events were reported. The reviewers concluded that limited evidence supports acupuncture use in treating pregnancy-related pelvic and back pain.

Smith CA et al. Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev 2006 Oct 18;(4):CD003521.

A systematic review that examined currently available evidence supporting the use of alternative and complementary therapies for pain management in labour. It included three trials of acupuncture involving 496 women. These showed a decreased need for pain relief. The reviewers concluded that acupuncture may be beneficial for the management of pain during labour, but the small number of women studied was a limitation.

Overview

Smith CA, Cochrane S. Does acupuncture have a place as an adjunct treatment during pregnancy? A review of randomized controlled trials and systematic reviews. Birth 2009 Sep;36(3):246-53.

A review that summarised the evidence examining the effectiveness of acupuncture during pregnancy and birthing. All placebo-controlled randomised trials of parallel design, and systematic reviews that evaluated the role of acupuncture during pregnancy and birthing were included. A critical appraisal of clinical trials and systematic reviews was undertaken. The summarised findings indicated that there is some evidence suggesting a benefit from acupuncture to treat nausea in pregnancy, and promising evidence for the effectiveness of acupuncture to manage back and pelvic pain, acupuncture-type interventions to induce change in breech presentation, and pain relief in labour. The reviewers concluded that evidence is beginning to consolidate that shows acupuncture may assist with the management of some complaints during pregnancy.  However, they sated that more evidence is needed to confirm this.

Randomised controlled trials

Pelvic and back pain

Wang SM et al. Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study. Am J Obstet Gynecol 2009;201:271.e1-9..

A randomised controlled trial that examined whether 1 week of continuous auricular acupuncture could reduce low back and posterior pelvic pain associated with pregnancy. 159 women were assigned to an acupuncture group, a sham acupuncture group, or a waiting list control group. All participants were monitored for 2 weeks. The changes from baseline to day 7 showed significant group differences in pain (F = 15; p<0.0001) and in the disability rating index score f="7;" p 0 0001 participants acupuncture group reported a greater reduction pain improvement of functional status compared with those sham control groups span style="text-decoration: underline;" data-mce-style="text-decoration: underline;">The researchers concluded that one week of continuous auricular acupuncture decreases the pain and disability experienced by women with pregnancy-related low back and posterior pelvic pain.

Elden H et al. Acupuncture as an adjunct to standard treatment for pelvic girdle pain in pregnant women: randomised double-blinded controlled trial comparing acupuncture with non-penetrating sham acupuncture. BJOG 2008;115:1655-68.

A randomised controlled trial that investigated whether acupuncture has a greater treatment effect than non-penetrating sham acupuncture in 115 women with pelvic girdle pain during pregnancy. Women were allocated to standard treatment plus acupuncture or to standard treatment plus non-penetrating sham acupuncture for 8 weeks. The main outcome measure was pain. After treatment, median pain decreased from 66 to 36 in the acupuncture group and from 69 to 41 in the non-penetrating sham group (p=0.493) as assessed on a VAS. Women in the acupuncture group were in regular work to a higher extent than women in the sham group (p=0.041). The acupuncture group had superior ability to perform daily activities measured with the disability rating index (44 vs. 55, P = 0.001). The researchers concluded that acupuncture had no significant effect on pain compared with non-penetrating sham acupuncture, but that there was some improvement in performing daily activities.

Mental health

Manber R et al. Acupuncture for depression during pregnancy: a randomized controlled trial. Obstet Gynecol 2010;115:511-20.

A randomised controlled trial that assessed the efficacy of acupuncture for depression during pregnancy in 150 pregnant women given acupuncture specific for depression or one of two active controls: control acupuncture or massage. Treatments lasted 8 weeks (12 sessions). The primary outcome was the Hamilton Rating Scale for Depression, at baseline and after 4 and 8 weeks of treatment. Women who received acupuncture specific for depression experienced a greater rate of decrease in symptom severity (p<0.05) compared with the combined controls="controls" cohen s d="0.46," 95 ci 0 01-0 77 or control acupuncture alone p 05 92 they also had significantly greater response rate 63 than 44 3 and 37 5 symptom reduction rates did not differ between span style="text-decoration: underline;" data-mce-style="text-decoration: underline;">The researchers concluded that acupuncture specific for depression reduces symptoms and increases response rate in similar amounts to those observed with standard depression treatments and could be a viable treatment option for depression during pregnancy.

da Silva JBG. Acupuncture for mild to moderate emotional complaints in pregnancy-a prospective, quasi-randomised, controlled study. Acupunct Med 2007;25:65-71.

A quasi-randomised controlled study that assessed the effects of acupuncture under real life conditions, in the treatment of emotional complaints during pregnancy in 51 women (conventionally-treated with counselling by their physicians and nurses). They were either treated or not by acupuncture. Both groups presented with emotional complaints such as anxiety, depression and irritability. They reported the severity of symptoms using a Numerical Rating Scale (NRS) from 0 to 10; and they rated how much the symptoms disturbed five aspects of their lives: mood, sleep, relationships, social activities, sexual life and joy of living. Over the study period, the NRS scores of intensity of emotional distress decreased by at least half in 60% of patients in the study group versus in 26% of those in the control group (P=0.013). The impact of the distress on three out of the five aspects of life was significantly less in the acupuncture group when compared with the control group (p<0.05). span="" style="text-decoration: underline;" data-mce-style="text-decoration: underline;">The researchers concluded that acupuncture seemed to be an efficacious means of reducing symptoms and improving the quality of life of women with emotional complaints during pregnancy.

Dyspepsia

da Silva JB et al. Acupuncture for dyspepsia in pregnancy: a prospective, randomised, controlled study. Acupunct Med 2009;27:50-3.

A randomised controlled trial under real-life conditions that assessed the effects of acupuncture on symptomatic dyspepsia during pregnancy and compared this with a group of patients undergoing conventional treatment alone. A total of 42 conventionally-treated pregnant women were treated, or not, by acupuncture. They reported the severity of symptoms and the disability these were causing in daily aspects of life such as sleeping and eating, using a numerical rating scale. The study also observed the use of medications. Significant improvements in symptoms were found in the acupuncture group. This group also used less medication and had a greater improvement in their disabilities when compared with the control group. The researchers concluded that acupuncture may alleviate dyspepsia during pregnancy.

Breech presentation

Guittier MJ et al. Moxibustion for breech version: a randomized controlled trial. Obstet Gynecol 2009;114:1034-40.

A randomised controlled trial that estimated the efficacy of moxibustion between 34 and 38 weeks of gestation to facilitate the cephalic version of fetuses in breech presentation and the acceptability of this method by women. BL 67 acupoint was stimulated by moxibustion daily for 2 weeks. The control group received expectant management care. A total of 212 women with breech presentation took part. The percentages of versions and of caesarean delivery were similar in the two groups. Acceptability of the intervention and women's perceptions of moxibustion were favourable. The researchers concluded that there was no beneficial effect of moxibustion to facilitate the cephalic version of fetuses in breech presentation. Despite this lack of proven effectiveness, women had positive opinions on the intervention.

Millereau M et al. Fetal version by acupuncture (moxibustion) versus control group [Article in French]. J Gynecol Obstet Biol Reprod 2009;38:481-7.

A study that assessed the efficacy of moxibustion in the 34th week of pregnancy to increase the rate of fetal reversal in 68 women with breech presentation. They were randomised to receive or not the treatment. The rate of fetal reversal was not statistically higher with moxibustion in primipara (7/19 vs. 6/19) or multipara (9/14 vs. 11/19) women. The researchers concluded that moxibustion did not modified the fetal reversal rate.

Induction of labour

Asher GN et al. Acupuncture to initiate labor (Acumoms 2): a randomized, sham-controlled clinical trial. J Matern Fetal Neonatal Med 2009;22:843-8.

A randomised controlled trial that evaluated the efficacy of acupuncture for labour stimulation. Eighty nine nulliparous women at 38 weeks or greater were randomised to traditional Chinese medicine (TCM) acupuncture, sham acupuncture, or usual care only groups. Acupuncture points LI4, SP6, BL32, and BL54 were needled bilaterally. The primary outcome was time from enrolment to delivery. Secondary outcomes included rates of spontaneous labour and caesarean delivery. There were no statistically significant differences among groups for time from enrolment to delivery (p=0.20), rates of spontaneous labour (p=0.66), or rates of caesarean delivery (p=0.37). Rates of maternal and neonatal outcomes were not significantly different. The researchers concluded that TCM acupuncture was not effective in initiating spontaneous labour or reducing the rate of caesarean delivery compared with sham acupuncture or usual medical care.

Modlock J et al. Acupuncture for the induction of labour: a double-blind randomised controlled study. BJOG 2010;117:1255-61.

A double-blind randomised controlled trial that investigated whether acupuncture is effective for the induction of labour in post-term pregnancies. A total of 125 healthy women with uneventful pregnancies at gestational week 41(+6) were randomised to real acupuncture twice on the same day or sham acupuncture at the same points. The primary endpoint of labour or delivery was achieved in seven women (12%) in the acupuncture group and eight women (14%) in the control group (p=0.79). The researchers concluded that, under the treatment regimen investigated in this study, acupuncture for the induction of labour in post-term women at gestational age 41(+6) weeks may not be effective.

Liu J et al. The safety of electroacupuncture at Hegu (LI 4) plus oxytocin for hastening uterine contraction of puerperants--a randomized controlled clinical observation. J Tradit Chin Med 2008;28:163-7.

A randomised controlled trial that investigated the safety of electroacupuncture plus oxytocin for uterine contraction in 276 puerperants with difficult labour. The women were allocated to intravenous oxytocin, or electroacupuncture plus intravenous oxytocin. During labour, heart rate, respiratory frequency, blood pressure, fetal heart rate and the birth process, were all within the normal range in all of the women, with better effects in the acupuncture plus oxytocin group. The researchers concluded electroacupuncture plus intravenous oxytocin can intensify uterine contraction, shorten

the birth process to avoid probable systemic exhaustion consumption, and with no side effects in either puerperants and newborns.

Smith CA et al. Acupuncture to induce labor: a randomized controlled trial. Obstet Gynecol 2008;112:1067-74.

A randomised controlled trial that compared the clinical effectiveness of real acupuncture to with sham acupuncture to induce labour. A total of 364 women who were scheduled for a post-term induction with a singleton pregnancy and cephalic presentation were included. There was no difference in need for induction methods between groups: prostaglandin induction: relative risk (RR) 1.20, 95% CI 0.96-1.51; artificial rupture of membranes only: RR 0.93, 95% CI 0.72-1.20; oxytocin only: RR 0.89, 95% CI 0.60-1.32; artificial rupture of membranes plus oxytocin: RR 0.87, 95% CI 0.57-1.33; prostaglandins, artificial rupture of membranes, and oxytocin: RR 0.84, 95% CI 0.37-1.91. The median time from acupuncture to delivery was 68.6 hours compared with 65 for women in the control group. The researchers concluded that two sessions of manual acupuncture, using local and distal acupuncture points, administered 2 days before a scheduled induction of labour did not reduce the need for induction methods or the duration of labour for women with a post-term pregnancy.

Labour pain

Hjelmstedt A et al. Acupressure to reduce labor pain: a randomized controlled trial. Acta Obstet Gynecol Scand 2010;89:1453-9.

A randomised controlled trial that evaluated the effect of acupressure given during the active phase of labour on nulliparous women's ratings of labour pain. In all, 71 women were given acupressure at acupuncture point spleen 6 (SP6) on both legs during contractions over a 30-minute period (acupressure group), 71 women received light touch at SP6 on both legs during the same period of time (touch group) and 70 received standard care (standard care group). Labour pain intensity at different time intervals after treatment was compared with before treatment. A reduction of in-labour pain was found in the acupressure group and was most noticeable immediately after treatment (acupressure group vs. standard care group p < 0.001; acupressure group vs. touch group p < 0.001). The researchers concluded that acupressure seemed to reduce pain during the active phase of labour in nulliparous women giving birth, but that the treatment effect was small.

Ma SX et al. Effect of moxibustion at Sanyinjiao (SP 6) for uterine contraction pain in labor: a randomized controlled trial [Article in Chinese] Zhongguo Zhen Jiu 2010;30:623-6.

A randomised controlled trial to investigate the effect of moxibustion at Spleen 6 (SP 6) for uterine contraction pain in labour, and evaluate its safety. In all, 174 women with singleton pregnancies and cephalic presentation were allocated to a moxibustion group, a placebo-treated group and 'blank' group. Moxibustion was applied for 30 minutes when the cervix was 3cm dilated. The uterine contraction pain was assessed using a Visual Analogue Scale (VAS). The VAS scores in the treatment group were obviously decreased after 15 and 30 minutes of moxibustion (both p<0.05), but there were no obvious changes in vas scores placebo treated group and the blank decreased more with moxibustion than other two groups all p 0 05 after 30 minutes of effective rate labour analgesia was 69 5 vs 45 6 43 1 postpartum haemorrhage less apgar score newborn higher span style="text-decoration: underline;" data-mce-style="text-decoration: underline;">The researchers concluded that moxibustion at Spleen 6 can relieve uterine contraction pain, and is not associated with side effects in either the mother or infant.

Ma WZ et al. Clinical observation on the effect of electroacupuncture of Sanyinjiao (SP 6) on labor. [Article in Chinese] Zhen Ci Yan Jiu 2010;35:217-21.

A randomised controlled trial that observed the effect of electroacupuncture (EA) of Spleen 6 (SP 6) on labour in a total of 349 women compared with sham EA and control. The visual analogue scale (VAS) was used to assess the pain intensity before and after the interventions. The VAS score for childbirth pain intensity was significantly lower in EA group than in control group (p0.05). The duration of the active phase of the first stage of labour was significantly lower in EA group than in sham-EA group (p0.05). The researchers concluded that EA of Spleen 6 can relieve the pain intensity of labour and shorten the duration of the active period of first stage of labour, suggesting an improvement of the quality of delivery after EA.

Post-partum surgical repair pain

Kindberg S et al. Ear acupuncture or local anaesthetics as pain relief during postpartum surgical repair: a randomised controlled trial. BJOG 2009;116:569-76.

A randomised controlled trial that evaluated two methods of pain relief during postpartum surgical repair in regard to effectiveness, wound healing and patient evaluation.  A total of 207 primiparous women with a vaginal delivery at term who needed surgical repair of lacerations to the labia, vagina or perineum were allocated to receive ear acupuncture or local anaesthetics, Pain during surgical repair was more frequently reported by participants given ear acupuncture than those given a local anaesthetics (89% versus 54%, p<0.01). pain intensity was also reported as higher visual analogue scale score 3 5 vs 1 p 0 01 and the ear acupuncture group received more additional relief 53 versus 19 no difference observed in wound healing comparable proportions of participants dyspareunia at 6 months patient satisfaction with allocated pain-relief method lower 69 91 fewer women would recommend to a friend 74 The researchers concluded that ear acupuncture as used in this trial was less effective for pain relief compared with a local anesthetic, and patient satisfaction with allocated pain-relief method was lower in the ear acupuncture group.

Research on mechanisms for acupuncture in general

Hui KK et al. Acupuncture, the limbic system, and the anticorrelated networks of the brain. Auton Neurosci 2010; 157: 81-90.

A paper that discusses research showing that acupuncture mobilises the functionally anti-correlated networks of the brain to mediate its actions, and that the effect is dependent on the psychophysical response. The research used functional magnetic resonance imaging studies of healthy subjects to show that acupuncture stimulation evokes deactivation of a limbic-paralimbic-neocortical network, which encompasses the limbic system, as well as activation of somatosensory brain regions. It has also been shown that the effect of acupuncture on the brain is integrated at multiple levels, down to the brainstem and cerebellum.

Cheng KJ. Neuroanatomical basis of acupuncture treatment for some common illnesses. Acupunct Med 2009;27: 61-4.

A review that looked at acupuncture treatment for some common conditions. It is found that, in many cases, the acupuncture points traditionally used have a neuroanatomical significance from the viewpoint of biomedicine. From this, the reviewers hypothesize that plausible mechanisms of action include intramuscular stimulation for treating muscular pain and nerve stimulation for treating neuropathies.

Lee B et al. Effects of acupuncture on chronic corticosterone-induced depression-like behavior and expression of neuropeptide Y in the rats. Neuroscience Letters 2009; 453: 151-6.

In animal studies, acupuncture has been found to significantly reduce anxiety-like behaviour, and increase brain levels of neuropeptide Y, the brain levels of which appear to correlate with reported anxiety.

Samuels N et al. Acupuncture for psychiatric illness: a literature review. Behav Med 2008; 34: 55-64

A literature review of acupuncture for psychiatric illness, which presents research that found acupuncture to increase central nervous system hormones, including ACTH, beta-endorphins, serotonin, and noradrenaline. It concludes that acupuncture can have positive effects on depression and anxiety.

Zhou Q et al. The effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the CNS of rats with chronic emotional stress-induced anxiety. Int J Clin Acupunct 2008 ;17: 79-84.

A study of the regulatory effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the central nervous system of rats with chronic emotional stress-induced anxiety. The levels of serotonin, noradrenaline and dopamine fell significantly, while GABA levels were significantly higher in the rats given acupuncture (P<0.05, or p 0 the researchers concluded that anti-anxiety effect of electro-acupuncture may relate to its regulation imbalance neurotransmitters

Zhao ZQ.  Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008;  85: 355-75.

Review article that discusses the various peripheral and central nervous system components of acupuncture anaesthesia in detail.

Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther 2007;  6:  251-7.

A review that suggests the anti-inflammatory actions of traditional and electro-acupuncture are mediated by efferent vagus nerve activation and inflammatory macrophage deactivation.

Han JS. Acupuncture and endorphins. Neurosci Lett 2004; 361: 258-61.

A literature review of studies relating to the release of endorphins by acupuncture.

Zijlstra FJ et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003;12: 59-69.

A review that suggests a hypothesis for the anti-inflammatory action of acupuncture. Insertion of acupuncture needle initially stimulates production of beta-endorphins, calcitonin gene-related peptide (CGRP) and substance P, leading to further stimulation of cytokines and nitric oxide (NO). While high levels of CGRP have been shown to be pro-inflammatory, CGRP in low concentrations exerts potent anti-inflammatory actions. Therefore, a frequently applied 'low-dose' treatment of acupuncture could provoke a sustained release of CGRP with anti-inflammatory activity, without stimulation of pro-inflammatory cells.

Pomeranz B. Scientific basis of acupuncture. In: Stux G, Pomeranz B, eds. Acupuncture Textbook and Atlas. Heidelberg: Springer-Verlag; 1987:1-18.

Needle activation of A delta and C afferent nerve fibres in muscle sends signals to the spinal cord, where dynorphin and enkephalins are released. Afferent pathways continue to the midbrain, triggering excitatory and inhibitory mediators in spinal cord. Ensuing release of serotonin and norepinephrine onto the spinal cord leads to pain transmission being inhibited both pre- and postsynaptically in the spinothalamic tract. Finally, these signals reach the hypothalamus and pituitary, triggering release of adrenocorticotropic hormones and beta-endorphin.

Methodological considerations concerning acupuncture trials

Lundeberg T et al. Is Placebo Acupuncture What It is Intended to Be?  Evid Based Complement Alternat Med. 2009 Jun 12. [Epub ahead of print]

Discusses the concerns with sham acupuncture and recommends instead that the therapy be evaluated by comparisons with standard treatments.

Research

Conclusion

Randomised Controlled Trials

Xiao L et al. Clinical observation on effects of acupuncture at Dazhui (GV 14) for abating fever of common cold. Chinese acupuncture & moxibustion 2007; 27: 169-72.

A randomised controlled trial that explored the therapeutic effect of acupuncture for abating fever of common cold. Two hundred and sixty-one patients were assigned to electroacupuncture or a control group given antondine injection. The transient effect of abating fever within 24 h was observed. After treatment, the body temperature at all observation time points in the treatment group were lower than those in the control group (p<0.01). The effect-appearing time (1.42 hours) was shorter in the treatment group than in the control group (3.44 hours, p<0.01). The cure rate and the abating fever rate were better (27.8% and 75.9%) with electroacupuncture that with the control ( 10.9% and 55.5%) (p<0.01). The researchers concluded that electroacupuncture had a definite therapeutic effect on high fever due to the common cold, and that the treatment should be taken as early as possible.

Kawakita K et al. Preventive and curative effects of acupuncture on the common cold: a multicentre randomized controlled trial in Japan. Complementary Therapies in Medicine 2004 Dec; 12: 181-8.

A trial that determined the preventive and curative effects of manual acupuncture on the symptoms of the common cold. A total of 326 participants were randomly allocated to acupuncture and no-treatment control groups. Acupuncture treatments were performed four times during the 2-week experimental period with a 2-week follow-up period. A common cold diary was scored daily for 4 weeks, and a common cold questionnaire was scored before each acupuncture treatment and twice at weekly intervals. The diary score in the acupuncture group tended to decrease after treatment, but the difference between groups was not significant Statistically significantly fewer symptoms were reported in the questionnaire by the acupuncture group than control group (p=0.024). No severe adverse event was reported. The researchers concluded that the trial found a significantly positive effect of acupuncture, and that use of acupuncture for symptoms of the common cold should be considered.

Takeuchi H et al. The effects of nasal massage of the "yingxiang" acupuncture point on nasal airway resistance and sensation of nasal airflow in patients with nasal congestion associated with acute upper respiratory tract infection. American Journal of Rhinology 1999; 13: 77-9.

A randomised controlled trial that determined whether nasal massage of a specific acupuncture point in patients with nasal congestion had any effect on nasal airway resistance (NAR) measured by posterior rhinomanometry and sensation of nasal airflow measured on a visual analogue scale (VAS). Twenty patients were randomized into two groups; one group self massaged the acupuncture point for 30 seconds, while the other group acted as control group without nasal massage. NAR and VAS were measured at baseline, and at 2 and 10 minutes after massage. At the end of the study, patients were asked to score any change in their nasal congestion. There was no statistically significant difference between the two groups in percentage change in NAR or VAS from baseline at any time during the study, although the massage group showed trends toward decongestion and relief from congestion. At the end of the study, more patients in the massage group than the control group felt their nasal congestion was improved.

Research on mechanisms for acupuncture

Komori M et al. Microcirculatory responses to acupuncture stimulation and phototherapy. Anesth Analg 2009; 108: 635-40.

Experimental study on rabbits in which acupuncture stimulation was directly observed to increase diameter and blood flow velocity of peripheral arterioles, enhancing local microcirculation.

Kawakita K et al. Do Japanese style acupuncture and moxibustion reduce symptoms of the common cold? eCAM 2008; 5: 481-9.

A review of research into the effects of Japanese style acupuncture and moxibustion on the symptoms of the common cold. It reports that research has shown acupuncture to reduce common cold symptoms, and that acupuncture stimulation enhances natural killer cell activities and modulates the number and ratio of immune cell types.

Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther 2007;  6:  251-7.

Review article that suggests the anti-inflammatory actions of traditional and electro-acupuncture are mediated by efferent vagus nerve activation and inflammatory macrophage deactivation.

Zijlstra FJ et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003; 12: 59-69.

An article that suggests a hypothesis for anti-inflammatory action of acupuncture: Insertion of acupuncture needles initially stimulates production of beta-endorphins, CGRP and substance P, leading to further stimulation of cytokines and NO. While high levels of CGRP have been shown to be pro-inflammatory, CGRP in low concentrations exerts potent anti-inflammatory actions. Therefore, a frequently applied 'low-dose' treatment of acupuncture could provoke a sustained release of CGRP with anti-inflammatory activity, without stimulation of pro-inflammatory cells.

Pomeranz B. Scientific basis of acupuncture. In: Stux G, Pomeranz B, eds. Acupuncture Textbook and Atlas. Heidelberg: Springer-Verlag; 1987: 1-18.

Needle activation of A delta and C afferent nerve fibres in muscle sends signals to the spinal cord, where dynorphin and enkephalins are released. Afferent pathways continue to the midbrain, triggering excitatory and inhibitory mediators in spinal cord. Ensuing release of serotonin and norepinephrine onto the spinal cord leads to pain transmission being inhibited both pre- and postsynaptically in the spinothalamic tract. Finally, these signals reach the hypothalamus and pituitary, triggering release of adrenocorticotropic hormones and beta-endorphin.