Vol. 18 •Issue 6 • Page 13
Taking a Stab at Asthma
Acupuncture May Relieve Allergy, Asthma Symptoms, But Proving It Works Is Difficult
Can the acupuncturist’s needle pierce asthma’s tough hide? Can this benign, non-toxic medical art dating to antiquity deflate asthma and allergy symptoms, sparing patients the side effects of steroids?
Most evidence is only anecdotal that acupuncture–gently sticking the body with tiny needles to correct what practitioners regard as disturbances in its flow of energy, or Qi–can ease airway constriction and inflammation.
But that hasn’t stopped the National Center for Complimentary and Alternative Medicine, part of the National Institutes of Health, to state that acupuncture “may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program.”
Others reject the idea. “Based on a small number of randomized, double-blind trials, acupuncture is not effective for the treatment of asthma or asthma-like symptoms,” states the Bandolier, an independent British journal, about evidence-based health care. “None of the studies produced statistically significant results for acupuncture for the main outcome measures of lung function.”
A new blinded, randomized clinical trial out of Hong Kong has renewed the debate, suggesting the 2,000-year-old Chinese therapy can help dry the noses of children with chronic rhinitis.
“Acupuncture does interact with the nervous system to ease the contraction in the lungs from an asthma attack,” said Subhuti Dharmananda, PhD, a practitioner of traditional Chinese medicine (TCM), including acupuncture.
“It is reasonable to think acupuncture can relax the bronchioles and alleviate asthmatic breathing. I’ve known asthma patients who visit acupuncturists and swear by them. They say they’ve reduced their medications.”
In America, he explained, patients get acupuncture once or twice a week, rarely more often than that. In those circumstances, it is hard to envision how that would affect asthma, he added. In China, it is practiced differently. Practitioners sign up patients for daily acupuncture, 10 days on, 10 off so there are 30 days of acupuncture in five weeks. “It’s conceivable you’ll have a number of biochemical and physiological changes,” added Dharmananda. “With daily acupuncture, the repeated impact on some neurotransmitters or other bio-chemicals would even alter the balance of T-cells or other factors.”
Proving all this in the court of scientific trials is the rub, admitted Dharmananda, director of the Institute for Traditional Medicine, Portland, Ore.
“Research done in China about acupuncture for various diseases generally reports positive results,” he noted. “But reasonable questions are raised as to how valid those studies are with their lack of control groups and other factors.”
Indeed, designing an adequately controlled clinical trial in the Western tradition seems to go against the very grain of the acupuncturist’s art.
First of all, trials require practitioners to adopt a uniform acupuncture treatment for all enrolled subjects. “Chinese doctors resist treating all patients the same,” he said. “They prefer that for any two patients, treatment would differ. So that works against the preference of a practitioner hired to provide acupuncture in a clinical trial. Delivering a one-size-fits-all therapy goes against their training and instincts and could hamper their abilities.”
Second, many practitioners would have trouble performing “sham” acupuncture, Dharmananda believes. “Acupuncture is a unique experience for the body,” he pointed out. “Many studies require practitioners to insert needles in non-acupuncture points, miss some points or try to do something else that doesn’t quite work in order to act as a control.”
People with mild asthma may achieve better results from acupuncture than more severe asthmatics, but funding and performing trials that yield convincing results could take years. “In the meantime,” he said, “people need relief.”
Hong Kong Study
These difficulties haven’t dissuaded researchers though.
Last year, Daniel Ng, MD, of Kwong Wah Hospital, Hong Kong, randomized 72 pediatric rhinitis patients into two groups for an eight-week trial: 35 patients received active acupuncture twice a week; the other 37 received sham acupuncture twice a week. This was a blinded study for both the assessing pediatricians and the patients.
Those in the active acupuncture group posted significantly lower daily rhinitis scores and more symptom-free days both during treatment and in follow-up, as reported in the journal Pediatrics.1 “The visual analog scale scores for immediate improvement after acupuncture were also significantly better for the active acupuncture group,” Ng et al. wrote.
There was no significant difference between the two groups in daily relief medication scores, blood eosinophil counts, serum IgE levels or nasal eosinophil counts, except for the IgE levels before and two months after acupuncture in the sham acupuncture group, they reported.
It’s “entirely possible” that acupuncture could lessen chronic nasal allergies, Dharmananda said, commenting on this study. “One possibility is by dilating the sinuses that are congested, changing the flow of fluids in the sinuses.
“In yoga, they have discovered that if you apply pressure under an armpit in some way, it will clear the sinus on the other side. Left armpit, right sinus. I have done this. Mucus flow can change if you keep doing it. Whether you get rid of the basic allergic reaction, I don’t know.”
A pointed 2002 study published in Chest by Shapira et al., however, seemingly burst acupuncture’s balloon.
Researchers recruited 23 patients with moderate persistent asthma who had received beta2 agonists and randomly assigned them to receive four sessions of real or sham acupuncture in a blinded manner. After a washout period of three weeks, the patients were crossed over.
These investigators found that acupuncture made no difference in FEV1 reaction to methacholine challenge, daily peak flow (PF) variability or other symptoms.2
A rebuttal criticizing the study’s methodology soon appeared in the pages of Chest.3 Echoing Dharmananda’s reservations about conducting Western research on an Eastern medical art, authors of the rebuttal article identified what they called three “potential critical flaws” in the study’s design and data analysis.
First, they complained the study used only one acupuncturist to evaluate, diagnose and treat all subjects. One can’t draw generalized conclusions based on the outcomes from “any single surgeon or therapist,” they wrote.
Second, acupuncture treatment in the trial was uniform rather than tailored to each individual’s underlying pathophysiology, as required by TCM.
And third, asthma as a Western clinical entity does not exist in TCM. What clinicians here call asthma is marked within TCM by the presence of more than five syndromes. To achieve homogeneity among trial subjects, Shapira et al. should have used a double selection process, first selecting a specific conventional diagnosis, then a specific complimentary and alternative medicine (CAM) diagnosis from among the multiple possibilities.
Not content to sit back and wait, asthma patients are investigating acupuncture and other forms of CAM on their own.
William Silvers, MD, of Allergy Asthma Colorado in Englewood, Colo., surveyed 113 of his asthma/allergy patients in 1998 and another 103 last year about CAM. He presented his findings at the 2004 meeting of the American College of Allergy, Asthma, and Immunology.
Both times, the percentage of Silvers’ respondents interested in discussing CAM held steady at around 67 percent. But the percentage of those who had actually sought out a CAM provider rose from 4 percent in 1998 to 10 percent last year, a finding Silvers called “striking.”
The favored therapy also changed between the two survey points. In 1998, it was vitamin/mineral therapy; in 2004, it was acupuncture.
Based on these results, caregivers should consider an integrative approach, Silvers told Reuters Health. Allow asthma patients to try various alternative options but follow and scrutinize their outcomes “within a conventional medical framework.”
Acupuncture offers an attractive alternative to that segment of the patient population which does not believe in using drugs or fears their side effects, observed Dharmananda, who called today’s arsenal of steroids “not ideal” but needed until safer drugs come along.
“Having acupuncture available, which it now is in 36 states, helps these people and people with very mild asthma,” he said. “For those who suffer side effects, acupuncture gives them something else to try.”
Obviously, steroids work to a certain extent, “but chronic use of steroids has increased tremendously as asthma incidence increases,” he added. “Now very large numbers of people rely on drugs through the years, children included.”
Dharmananda does not advocate choosing between acupuncture and steroids. Instead, like silvers, he advises a mixture of options for patients interested in exploring CAM.
“If your patients express interest in CAM therapies, become familiar with at least one CAM practitioner in your community to whom you would feel comfortable referring,” he said.
“Say to the patient, ‘There is limited evidence that it works, but this fellow is a good practitioner and you can try it with him.’ That way, you can get someone to the service and have confidence they will be treated well.”
Do your research though; quackery is prevalent. “Training here is not up to high quality,” he said. “People in the field are easily swayed to methods other than standard Chinese medicine. Some have acupuncture but all kinds of other things besides.”
And, he said, know of some good literature, refer patients to it so they can make up their own minds. You may not have to refer patients very far. According to Dharmananda, some hospitals now have acupuncturists on site.
1. Ng D, Chow P, Ming S, et al. A double-blind, randomized, placebo-controlled trial of acupuncture for the treatment of childhood persistent allergic rhinitis. Pediatrics (2004;114:1242-47).
2. Shapira M, Berkman N, Ben-David G, et al. Short-term acupuncture therapy is of no benefit in patients with moderate persistent asthma. Chest (2002;121:1396-1400).
3. Caspi O, Schiff E. Missing the (acu) point. Chest (2003;123:1312-14).
You can reach Michael Gibbons at [email protected].