Acupuncture for chronic pain in Bedford, UK

Chronic Pain – Condition Resources

Blog, Conditions, Research, Shaftesbury Clinic, , , ,

See also: Our in-depth blog about the NICE guidelines regarding recommendation of acupuncture for Chronic Pain, which is an evidence based piece informing NHS practise.

Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

There are many painful conditions for which patients seek acupuncture to address their symptoms. We have dedicated pages for arthritis, back pain, carpal tunnel, facial (TMJ) pain, shoulder and frozen shoulder, headache, migraine, kidney stones, plantar fasciitis, knee pain, sciatica, neuropathic (nerve) pain, rheumatoid arthritis, tennis and golfer’s elbow, neck pain, and pelvic pain each of which give references and further resources to evidence based factsheets and may be of use.

A scholarly search of the available research papers on the terms “acupuncture” + “chronic pain” yields over 52,000 papers, and narrowing this to “RCT” to identify Randomised Controlled Trials, gives over 7,000 results; of which 36% have been carried out since 2017 (Google Scholar). This suggests that acupuncture is being used traditionally and currently in this area, research has been carried out, the pace of which is increasing in recent years, therefore indicating that it merits of scientific appraisal and consideration in the field.

“Acupuncture has been widely applied to alleviate several pain diseases and incorporated into guidelines, and it is an effective method of coping with the opioid crisis and is widely respected due to its safety, low price, and low addiction” – Zhang et al, 2022

Interpreting the research:

When reading health research, it is important to know that Systematic Reviews or Meta Analyses of a large number of high-quality research studies are the very best way to be able to say to what extent a given treatment can address a condition, symptom, or set of symptoms.  The next best level of evidence is the individual Randomised Controlled Study (RCT) which uses a systematic technique to compare two or more groups of patients receiving different treatments (or a treatment against a “control”, or no treatment).  In acupuncture trials, the nature of the control group is of particular interest as it is hard to blind a patient to whether they are having a needle inserted or not, and even more challenging to blind the researcher/team to this.

The means and quality of how research is carried out varies considerably from country to country, and in terms of how an intervention is compared to another intervention (or a control).  Of note is the fact that “sham” acupuncture (where needles are placed in apparently inert locations rather than traditional acupuncture points) is not really an inert process as it has physiological effects, so that comparing sham and “true acupuncture” may therefore not give a clear picture alone; but and form a part of a research body where acupuncture versus no treatment, vs conventional treatment or vs a different approach/modality also form part of the evidence base.

The n= figure (where quoted in research) tells you how many people were participants in the study, and usually the larger a study (when it is of good quality and design), the more likely it is to be reliable and applicable to larger populations. When (statistical) “significance” is discussed in view of studies it has a very particular meaning – it is the confidence in the data (using statistical tests) that tells us how likely a result could have just come about by chance. The lower the possibility of a chance result, the more likely it is due to the intervention in the experiment. When you are reading a trial/study, the “p” is the number telling us of significance, and this must be under 5% (or p less than 0.05) to mean we can say it is a (statistically) “significant” result.

Chronic Pain in General

“Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain”. (Vickers et al, 2018; large chronic pain review of high quality RCTs updating a previous meta-analysis; 39 trials, n=20827; conditions addressed chronic headache, back/neck pain and osteoarthritis)

Another recent overview (Yin et al, 2017) confirms that there is increasing evidence for acupuncture  as an effective, safe, and cost-effective intervention in chronic low back, neck, shoulder, and knee pain, as well as headaches.

Acupuncture stimulates the body to create its own natural painkilling substances, such as Beta Endorphins (β-Endorphin). In studies acupuncture has been shown to stimulate the production of natural painkillers called opioid-like peptides (OLPs), including β-Endorphin: For example, this was shown in an RCT in 90 patients with a range of painful disorders (Petti et al, 1998). The same study showed acupuncture also and enhanced the activity of immune cells (lymphocytes, natural killer cells and monocytes) that help fight infections and diseases (Petti et al, 1998).

NICE (NHS advisory body) Recommendation:

The NHS body in charge of which treatments should be used in particular conditions recommends acupuncture for chronic pain:  The NICE Scenario Management guidelines (2021) for chronic pain state: “consider a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system”

In America, the NIH (National Institutes of Health) has recognised since 1997 that acupuncture alleviates pain (Zhang et al, 2022). Overall, a large systematic review has found acupuncture a cost effective intervention for several painful conditions (Ambrósio et al, 2012).

Mechanisms of Action on Pain:

Acupuncture studies have shown it can: provide pain relief by stimulating nerves in body tissues and leading to endorphin release (natural painkilling substances), as well as downregulating the brain and nervous system’s reaction to stress and pain (Zhao 2008; Zijlstra et al, 2003; Pomeranz, 1987).

Acupuncture has been shown in animal models to promote the release of factors that involved in the reduction of inflammation (vascular and immunomodulatory factors – (Kim et al, 2008; Kavoussi and Ross, 2007 [review article]; Zijlstra et al, 2003), and also to affect levels of serotonin (in an animal model), and other peptides in the brain and nervous system and modulate blood flow in the brain and elsewhere in the body, in humans (Zhong and Li, 2007; Shi et al, 2010).

Very specific effects have been seen on a number of neurotransmitters, when acupuncture treatment is given, and to investigate this, a large and growing body of evidence has accumulated from clinical experiments with animal models, where levels of neurotransmitters and their effects are measured objectively; and because the animal is not aware of the intended outcomes, this drastically reduces any influence of placebo effect, as a cause of pain relief. 

Human trials, where measurable in an ethical and objective way, are also employed through fMRI (brain scans showing which areas are stimulated or downregulated in acupuncture treatment), measuring blood levels of neurotransmitters as well as pain ratings for an objective approach.

The role of acupuncture in modulating neurotransmitters involved in pain has been well discussed. Zhang et al (2022) outlined the research on each of the main observed neurotransmitter roles that have been researched in acupuncture for pain: those are opioid peptides; γ-Aminobutyric acid (GABA); Norepinephrine; 5-Hydroxytryptamine (5-HT – aka serotonin); and glutamate.  Overall for these neurotransmitters (in turn), the following are the highlights from the research body per Zhang and colleagues:

  • Endogenous opioid peptides are produced in the body as a direct result of acupuncture, and have a positive effect on analgesia (pain relief).  By name, these are enkephalins, endomorphins, dynorphins, and nociceptin, and these are the body’s own natural painkilling substances, types of neurotransmitters, or chemical messengers of the nervous system
  • γ-Aminobutyric acid (GABA) is an inhibitory neurotransmitter in the central nervous system.  It has a painkilling effect, and it has been demonstrated that acupuncture can upregulate GABA expression; another part of how acupuncture helps with pain
  • Norepinephrine (noradrenalin in the UK), is a neurotransmitter, the release of which is enhances by acupuncture; this influences pain because norepinephrine is also capable of inhibiting pain in the body
  • 5-Hydroxytryptamine (5-HT), or serotonin; is a neurotransmitter that is involved in analgesia (pain relief).  5-HT is secreted in the brain during acupuncture administration, making it another known mechanism of action for acupuncture’s ability to help pain
  • Glutamate is a central nervous system neurotransmitter (chemical messenger), and is involved in the transmission of pain signals in the spinal cord.  Acupuncture downregulates glutamate, as part of how it provides pain relief

Zijlstra et al (2003) reviewed the effects and mechanisms of acupuncture in treating various inflammatory diseases and conditions. They proposed the mechanisms of action:

  • Acupuncture may release neuropeptides from nerve endings that have vasodilative and anti-inflammatory effects through CGRP.
  • Acupuncture may also interact with substance P, which is involved in pain transmission and inflammation.
  • Acupuncture may contribute to analgesia by stimulating the release of β-endorphin, which binds to opioid receptors and inhibits pain signals.
  • Acupuncture may influence the balance between cell-specific pro-inflammatory and anti-inflammatory cytokines such as TNF-α and IL-10.

CSR and ERP are blood tests related to the functioning of the immune system, that can measure and monitor inflammation in the body.  They are relevant to conditions such as Rheumatoid Arthritis, and other immune and inflammatory conditions.  Per a review by Feng at al, (2023) electroacupuncture (EA) plus medication had a significant effect in lowering both ESR and CRP levels in patients with RA compared with medication alone.  These results suggest that EA may have an anti-inflammatory effect and improve the immune status of patients with RA.

In an animal study, Sun et al, (2023) were able to show that electroacupuncture worked by blocking a pathway in the synovium called TLR2/4, that activates immune response and inflammation.  The researchers therefore suggested the anti-inflammatory and analgesic effects of EA were related to the inhibition of TLR2/4 signalling on synovial fibroblasts and macrophages.

Liu et al (2013) investigated the anti-inflammatory effect of electroacupuncture (EA) in a rat tissue chamber model of inflammation. The study found that EA inhibited the p65 protein from moving to the cell nucleus to activate inflammatory genes.  EA also increased the expression of IκBα, which binds to NF-κB and preventing it from entering the nucleus to activate inflammatory genes. These interfere with the IκB/NF-κB pathway that regulates inflammation, indicating one of the mechanisms of acupuncture in modulating immune / inflammatory response.

Inflammatory and Immune Aspects in Research

Wang et al (2023) reviewed evidence from animal and human studies regarding the immunomodulatory mechanism of acupuncture, regarding its effects on different components of the immune system, such as mast cells, macrophages, neutrophils, natural killer cells, astrocytes, microglia, CD4+ and CD8+ T cells, and cytokines.  They detailed the neuroanatomical mechanisms of acupuncture in immunomodulation, such as the vagal-adrenal pathway, the cholinergic anti-inflammatory pathway, the spinal sympathetic pathway, the brain-gut axis, and the hypothalamus-pituitary-adrenal axis.  They concluded that studies to support the role of acupuncture in regulating inflammation, infection, allergy, pain, and tissue repair.

Per MacDonald et al (2015), acupuncture may:

  • reduce inflammation and nasal congestion by downregulating proinflammatory neuropeptides, cytokines, and neurotrophins
  • modulate immune function by altering the balance of Th1 and Th2 cells and suppressing mast cell degranulation
  • influence various receptors and signalling pathways that are involved in inflammatory response, such as TRPV1, opioid, chemokine, dopamine, and cannabinoid receptors
  • activate a novel cholinergic anti-inflammatory pathway that involves vagal and sciatic nerves and is mediated by dopamine

Electroacupuncture (EA) has been shown in a rat model (Li et al, 2008) to have anti-inflammatory benefits by modulating the hypothalamic-pituitary-adrenal (HPA) axis, (HPA axis regulates the stress response and immune function).  Specifically, Li et al outlined that EA sets off a cascade in the brain (via corticotropin-releasing hormone, and adrenocorticotropic hormone) to produce cortisol, which reduces inflammation and oedema.

Acupuncture can activate mast cells at acupoints, which release histamine, serotonin, adenosine, and other mediators that modulate nerve transmission and inflammation (Li et al, 2022)

Overall, per the research it can be seen that a combination of demonstratable mechanisms is at play; as measured and observed to be the cause of why acupuncture has been shown in so many practical studies to help a number of different types of pain. 

Regarding Your Individual Condition and Symptoms:

Whilst the scientific studies are of great interest to researchers and acupuncturists in terms of comparing protocols, for the patient not versed in research they are less accessible, which is why when we asked “can acupuncture work for my (condition or symptom) we are not able to give a simple yes or no response.  We are able to tell you what experience we have had in our decades of experience in practise, of the types of outcomes we have seen in similar cases, and give you an idea of our level of experience and knowledge in that area, and how this could relate to your own individual situation.  For this, we recommend booking a free telephone consultation where we can answer any questions you have and give a realistic appraisal of what acupuncture may be able to provide.

Resources:

NICE Guidelines (2021) Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain
NICE guideline [NG193]Published: 07 April 2021

Evidence Based Acupuncture Osteoarthritis Factsheet

Evidence Based Acupuncture Pain Factsheet

Evidence Based Acupuncture Cancer Pain Factsheet

BAcC Back Pain Factsheet

BAcC Facial Pain Factsheet

BAcC Frozen Shoulder Factsheet

BAcC Headache Factsheet

BACC Neck Pain Factsheet

BAcC Osteoarthritis of the Knee Factsheet

References:

Chronic Pain in General, References:

Ambrósio, E.M.M., Bloor, K. and MacPherson, H., 2012. Costs and consequences of acupuncture as a treatment for chronic pain: a systematic review of economic evaluations conducted alongside randomised controlled trials. Complementary therapies in medicine, 20(5), pp.364-374.

Vickers, A.J., Vertosick, E.A., Lewith, G., MacPherson, H., Foster, N.E., Sherman, K.J., Irnich, D., Witt, C.M., Linde, K. and Acupuncture Trialists’ Collaboration, 2018. Acupuncture for chronic pain: update of an individual patient data meta-analysis. The Journal of Pain, 19(5), pp.455-474.

Birch, S., Lee, M.S., Alraek, T. and Kim, T.H., 2018. Overview of treatment guidelines and clinical practical guidelines that recommend the use of acupuncture: a bibliometric analysis. The Journal of Alternative and Complementary Medicine, 24(8), pp.752-769.

NICE 2021 Chronic pain: Scenario: Management Last revised in April 2021

Yin, C., Buchheit, T.E. and Park, J.J., 2017. Acupuncture for chronic pain: an update and critical overview. Current opinion in anaesthesiology, 30(5), pp.583-592.

Mechanism of Action References:

Feng, Y., Zhang, R., Zhao, Z., He, Y., Pang, X., Wang, D. and Sun, Z., 2023. Efficacy and safety of electroacupuncture combined with medication for rheumatoid arthritis: A systematic review and meta-analysis. Heliyon.

Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther. 2007 Sep;6(3):251-7.

Kim HW, Uh DK, Yoon SY et al. Low-frequency electroacupuncture suppresses carrageenan-induced paw inflammation in mice via sympathetic post-ganglionic neurons, while high-frequency EA suppression is mediated by the sympathoadrenal medullary axis. Brain Res Bull. 2008 Mar 28;75(5):698-705.

Li, A., Lao, L., Wang, Y., Xin, J., Ren, K., Berman, B.M., Tan, M. and Zhang, R., 2008. Electroacupuncture activates corticotrophin-releasing hormone-containing neurons in the paraventricular nucleus of the hypothalammus to alleviate edema in a rat model of inflammation. BMC Complementary and Alternative Medicine, 8(1), pp.1-8.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells, 11(5), p.860.

Liu, F., Fang, J., Shao, X., Liang, Y., Wu, Y. and Jin, Y., 2014. Electroacupuncture exerts an anti-inflammatory effect in a rat tissue chamber model of inflammation via suppression of NF-κB activation. Acupuncture in Medicine, 32(4), pp.340-345.

McDonald, J.L., Cripps, A.W. and Smith, P.K., 2015. Mediators, receptors, and signalling pathways in the anti-inflammatory and antihyperalgesic effects of acupuncture. Evidence-Based Complementary and Alternative Medicine, 2015.

Petti, F.., Bangrazi, A., Liguori, A., Reale, G. and Ippoliti, F., 1998. Effects of acupuncture on immune response related to opioid-like peptides. Journal of Traditional Chinese Medicine 18(1), pp.55-63.

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

Shi H, Li JH, Ji CF, Shang HY, Qiu EC et al.[Effect of electroacupuncture on cortical spreading depression and plasma CGRP and substance P contents in migraine rats]. Zhen Ci Yan Jiu. 2010 Feb;35(1):17-21.

Sun, S.Y., Yan, Q.Q., Qiao, L.N., Shi, Y.N., Tan, L.H. and Yang, Y.S., 2023. Electroacupuncture Alleviates Pain Responses and Inflammation in Collagen-Induced Arthritis Rats via Suppressing the TLR2/4-MyD88-NF-κB Signaling Pathway. Evidence-Based Complementary and Alternative Medicine, 2023.

Wang, M., Liu, W., Ge, J. and Liu, S., 2023. The immunomodulatory mechanisms for acupuncture practice. Frontiers in Immunology, 14.

Zhang, M., Shi, L., Deng, S., Sang, B., Chen, J., Zhuo, B., Qin, C., Lyu, Y., Liu, C., Zhang, J. and Meng, Z., 2022. Effective oriental magic for analgesia: acupuncture. Evidence-Based Complementary and Alternative Medicine, 2022.

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

Zhong G.-W. Li W. Effects of acupuncture on 5-hydroxytryptamine1F and inducible nitricoxide synthase gene expression in the brain of migraine rats. Journal of Clinical Rehabilitative Tissue Engineering Research. 2007;11(29)(pp 5761-5764)

Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, Klein J. Anti-inflammatory actions of acupuncture. Mediators Inflamm. 2003 Apr;12(2):59-69.

Helen
Posted on: Aug-9-2023 8:19 am
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Acupuncture for anxiety and stress

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I am often asked about acupuncture for anxiety and stress. We see a lot of patients for anxiety, stress, depression and other mood or motivational issues. Acupuncture is something that a great number of these patients have said has changed their daily lives for the better. This works best if they can address other lifestyle issues (e.g. diet, exercise, relaxation strategies), and we can very often recommend strategies and experienced colleagues to concurrently support these aspects if this is desirable.
Read More Acupuncture for anxiety and stress →

Helen
Posted on: Aug-8-2023 10:31 am
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Acupuncture for fertility in Bedford, UK

Infertility IVF, ART, ICSI- Condition Resources

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Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

Acupuncture is a very popular approach for those looking to conceive. See our blog on the research that has been done into the use of acupuncture for fertility reasons

The British Acupuncture Council has produced an evidence based factsheet about Female Fertility, as well as one on Male Fertility and acupuncture approaches, including specific research, trials and mechanisms of action for acupuncture for this (links are below).

A systematic review and meta-analysis of studies in the peer-reviewed British Medical Journal (Manheimer et al, 2008) found that complementing the embryo transfer process with a specific traditional acupuncture protocol had a positive effect on the birth rate of sub fertile women having IVF/ICSI treatment.

About the research:

When reading health research, it is important to know that Systematic Reviews** or Meta Analyses of a large number of high-quality research studies are the very best way to be able to say to what extent a given treatment can address a condition, symptom, or set of symptoms.  The next best level of evidence is the individual Randomised Controlled Study* (RCT) which uses a systematic technique to compare two or more groups of patients receiving different treatments (or a treatment against a “control”, or no treatment).  In acupuncture trials, the nature of the control group is of particular interest as it is hard to blind a patient to whether they are having a needle inserted or not, and even more challenging to blind the researcher/team to this.

The means and quality of how research is carried out varies considerably from country to country, and in terms of how an intervention is compared to another intervention (or a control).  Of note is the fact that “sham” acupuncture (where needles are placed in apparently inert locations rather than traditional acupuncture points) is not really an inert process as it has physiological effects, so that comparing sham and “true acupuncture” may therefore not give a clear picture alone; but and form a part of a research body where acupuncture versus no treatment, vs conventional treatment or vs a different approach/modality also form part of the evidence base.

The n= figure (where quoted in research) tells you how many people were participants in the study, and usually the larger a study (when it is of good quality and design), the more likely it is to be reliable and applicable to larger populations. When (statistical) “significance” is discussed in view of studies it has a very particular meaning – it is the confidence in the data (using statistical tests) that tells us how likely a result could have just come about by chance. The lower the possibility of a chance result, the more likely it is due to the intervention in the experiment. “p” is the number telling us of significance, and this must be under 5% (or p less than 0.05) to mean we can say it is a (statistically) “significant” result.

A popular and evidence-based choice

Acupuncture is a popular choice for fertility and conception support, having had mainstream media exposure since 2008, when a large meta-analysis of scientific studies was published in the British Medical Journal (BMJ – Manheimer et al, 2008), and which showed acupuncture’s efficacy in increasing pregnancy rates from IVF procedures, compared to IVF procedures alone. A more recent Iranian RCT study reflected this, (Dehghani et al, 2020) when they looked IVF pregnancy rates with and without acupuncture treatment. They used 3 groups in cluding a control (n=186) and found that: “Acupuncture 25 min before ET [embryo transfer] significantly increased the IVF outcomes in women undergoing IVF compared with no acupuncture.”

A large body of evidence in this area has grown, both for natural and IVF, ICSI and other types of assisted fertility (ART) procedures.  These studies show that acupuncture improves blood flow to the uterus and ovaries (Khorram et al, 2005, Stener-Victorin et al, 1996), improves the thickness of the endometrium (uterus lining) and regulates the levels of the key hormones that govern the conception process, FSH, LH, GnRH, progesterone and oestrogen (Yu et al, 2007; Zhang et al, 2018; Stener-Victorin, 2006).

Acupuncture is also effective in PCOS (polycystic ovarian syndrome), and can regulate the menstrual cycle and stimulate ovulation (Lim et al, 2010, Stener-Victorin et al, 2014).

Regarding Your Individual Condition and Symptoms:

Whilst the scientific studies are of great interest to researchers and acupuncturists in terms of comparing protocols, for the patient not versed in research they are less accessible, which is why when we asked “can acupuncture work for my (condition or symptom) we are not able to give a simple yes or no response, we are able to tell you in the decades of experience we personally have at the clinic of the types of outcomes we have seen in similar cases, and give you an idea of our level of experience and knowledge in that area, which is why the research data do not tell the whole story and if you want to find out more specific information in how this could relate to your own individual situation, we recommend booking a free telephone consultation where we can answer any questions you have and give a realistic appraisal of what acupuncture may be able to provide.

Resources:

British Acupuncture Council evidence based factsheet about Female Fertility, and approaches to treatment including specific research, trials and mechanisms of action for acupuncture in this condition.

BAcC Male Fertility factsheet

BAcC Fertility and ART (assisted reproduction – IVF/ICSI) factsheet

BAcC PCOS (Polycystic Ovarian Syndrome) factsheet

BAcC Female fertility & IVF briefing paper

References:

Dehghani, A.S., Homayouni, K., Kanannejad, Z. and Kanannejad, Z., 2020. The effect of acupuncture on the day of embryo transfer on the in vitro fertilization outcomes: An RCT. International journal of reproductive biomedicine, 18(3), p.209.

Khorram, N.M.; S. Horton, V. Sahakian The Effect of Acupuncture on Outcome of in Vitro Fertilization Fertility and Sterility, Vol.84, S364

Manheimer, E; Zhang, G; Udoff, L; Haramati, A; Langenberg, P; Berman, BM; Bouter, LM; (2008) Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis BMJ (2008) 336:517-518 

Stener-Victorin E, Waldenstram U, Andersson SA, Wikland M. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Hum Reprod. 1996 Jun;11(6):1314-7.

Stener-Victorin, E;A. Benrick, M. Kokosar, M. Maliqueo, C. Behre, K. H¸jlund, A. Sazonova Acupuncture increases whole body glucose uptake during and after stimulation in women with polycystic ovary syndrome Fertility and Sterility, Vol.102:3, e29 Published in issue: September 2014

Yu, B. Horn, B. Acacio, D. Ni, R. Quintero, M. NourianiA Pilot Study Evaluating the Combination of Acupuncture with Sildenafil on Endometrial Thickness Fertility and Sterility, Vol.87:4, S23

Zhang, X., Lee, M.S., Smith, C.A., Robinson, N., Zhou, Y., Wu, Y., Mao, Y.Y. and Qu, F., 2018. Effects of acupuncture during in vitro fertilization or intracytoplasmic sperm injection: An updated systematic review and meta-analysis. European Journal of Integrative Medicine, 23, pp.14-25.

Helen
Posted on: Aug-2-2023 13:10 pm
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Acupuncture for the Cardiovascular system in Bedford, UK

Angina, Arrhythmias, Coronary Heart Disease, and Heart Failure- Condition Resources

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Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

The British Acupuncture Council (BAcC) has produced an evidence based factsheet about Angina, Coronary Heart Disease, Atrial Fibrillation and Heart Failure including specific research, trials and mechanisms of action for acupuncture in this condition, we recommend taking a look via the underlined link above. Their Factsheet on Hypertension, High Blood Pressure may also be of interest.

Research and Resources on Arrhythmia and Heart Failure and Acupuncture:

A scholarly search of the available research studies on “acupuncture” +”arrhythmia” reveals over 7,400 papers from journals, and narrowing this to “RCT” leads to over 630 hits, of which 40% have been carried out since 2017. A scholarly search of the available research studies on “acupuncture” + “heart failure” reveals over 18,000 papers from journals, and narrowing this to “RCT” leads to over 1,700 hits, of which 52% have been carried out since 2017.  From this we can deduce that acupuncture is being used traditionally and currently in this area; scientifically researched for this, and that the pace of the research is increasing – leading us to see these as areas worthy of scientific appraisal and consideration.  

Interpreting the research:

When reading health research, it is important to know that Systematic Reviews or Meta Analyses of a large number of high-quality research studies are the very best way to be able to say to what extent a given treatment can address a condition, symptom, or set of symptoms.  The next best level of evidence is the individual Randomised Controlled Study (RCT) which uses a systematic technique to compare two or more groups of patients receiving different treatments (or a treatment against a “control”, or no treatment).  In acupuncture trials, the nature of the control group is of particular interest as it is hard to blind a patient to whether they are having a needle inserted or not, and even more challenging to blind the researcher/team to this.

The means and quality of how research is carried out varies considerably from country to country, and in terms of how an intervention is compared to another intervention (or a control).  Of note is the fact that “sham” acupuncture (where needles are placed in apparently inert locations rather than traditional acupuncture points) is not really an inert process as it has physiological effects, so that comparing sham and “true acupuncture” may therefore not give a clear picture alone; but and form a part of a research body where acupuncture versus no treatment, vs conventional treatment or vs a different approach/modality also form part of the evidence base.

The n= figure (where quoted in research) tells you how many people were participants in the study, and usually the larger a study (when it is of good quality and design), the more likely it is to be reliable and applicable to larger populations. When (statistical) “significance” is discussed in view of studies it has a very particular meaning – it is the confidence in the data (using statistical tests) that tells us how likely a result could have just come about by chance. The lower the possibility of a chance result, the more likely it is due to the intervention in the experiment. When you are reading a trial/study, the “p” is the number telling us of significance, and this must be under 5% (or p less than 0.05) to mean we can say it is a (statistically) “significant” result.

Angina Pectoris

A systematic review and meta-analysis of 12 studies (Lu et al, 2022; n=1203) looked at treating cardiovascular disease complicated with depression, and found that acupuncture reduced HAMD (Hamilton scale for depression) score, SDS (self-rating depression scale) score and also reduced the attack frequency of angina pectoris and the VAS (visual analogue scale) score for angina pain. They concluded that acupuncture could be a good complementary and alternative therapy for CVD complicated with depression.

Atrial Fibrillation

Lomuscio et al, 2011 (n=80) concluded that acupuncture prevented arrhythmic recurrences after cardioversion in patients with persistent AF, and was safe and well tolerated. 

Li et al, (2022) made a meta-analysis and systematic review of RCTs that had compared acupuncture with pharmacological conversion for treating atrial fibrillation.  They looked at 11 papers, and concluded that “ acupuncture significantly effectively benefitted the patients with atrial fibrillation”, and overall combining the pharmacological (medicinal) cardioversion with acupuncture was significantly more beneficial than was the pharmacological approach alone.

Following Valve Surgery:  Cardioprotective Effects

Feingold et al, 2023 (n=100) carried out an RCT with 100 patients undergoing primary valve surgery via sternotomy.  They found acupuncture after valve surgery to be feasible, well tolerated, and having clinical benefit.  Specifically, there were no adverse events, and the acupuncture group had reduction in pain, nausea, stress, and anxiety, as well as reduced postoperative stress and anxiety and reduced postoperative atrial and fewer hours in the intensive care unit than those patients on standard care alone.

Yang et al, (2010, n-=60) conducted an RCT to investigate the cardioprotective effects of electroacupuncture (EA) pretreatment on patients undergoing heart valve replacement surgery.  They measured the levels of cardiac troponin I (CTnI) which is a protein released into the blood when the heart muscle is damaged (e.g. during a heart attack).  Other outcomes, such as blood pressure, heart rate, use of drugs, and length of stay in the intensive care unit (ICU) were also compared between a pretreatment group and a control (no acupuncture) group.  They found that EA pretreatment significantly lowered the levels of CTnI in acupuncture patients after surgery vs control, therefore EA pretreatment reduced the amount of heart injury caused by the surgery.  EA pretreatment also reduced the use of drugs such as inotropes, after surgery (indicating more improved heart function after surgery, shortened stay in ICU; versus the non-acupuncture group.

Coronary Artery Disease, PCI procedure

Ho et al, (1999, n=44) looked at the PC6 point also (note, Nei-Kuan is an alternative spelling), in their case they examined that effect upon Left Ventricular Function in Patients with Coronary Artery Disease (CAD).  The left ventricle is the main pumping chamber of the heart, and in CAD, the blood vessels that supply heart become narrowed or blocked by fatty deposits called plaque.  The study measured how much blood the left ventricle pumps out with each contraction (left ventricular ejection fraction, LVEF) in 22 patients with coronary artery disease and 22 normal subjects.  Acupuncture caused an increase in the LVEF in patients with coronary artery disease, especially in the first 15 minutes of stimulation. This persisted for 15 minutes after acupuncture, but became insignificant after one week.  They concluded acupuncture at PC6 could temporarily improve left ventricular function in CAD patients, but more studies were needed to confirm its long-term effects and mechanisms.

An RCT (Wang et al, 2015), aimed to understand if pretreatment with electroacupuncture (EA) could reduce the damage to the heart muscle caused by percutaneous coronary intervention (PCI).  PCI is used to treat CAD by inserting a thin, flexible tube called a catheter, where it’s x-ray guided to the and a small balloon is inflated to widen the narrowed coronary artery, and possibly a small metal mesh tube (“stent”) placed like a scaffold to keep it open.  However, PCI can cause damage the heart muscle (ischemia-reperfusion injury).  Wang et al (2015) compared EA with sham EA in 204 CAD patients undergoing PCI.  They found that EA: significantly lowered the levels of cTnI (cardiac troponin I); reduced the use of drugs (inotropes); shortened the length of stay in the intensive care unit (ICU); and decreased the rate of MACCE (major adverse cardiac/cerebrovascular events) at 24 months after PCI, compared to sham EA. They concluded that EA prior to PCI “significantly reduced cTnI release and protected patients with CAD from subsequent myocardial injury after PCI procedure.”

Mechanisms of action

Li et al (2014) proposed a possible mechanism of action for the lowering of blood pressure, in that acupuncture could regulate the renin-angiotensin-aldosterone system (RAAS), which is involved in blood pressure regulation, by stimulating specific acupoints that correspond to the kidney and liver meridians. The other mechanism is based on the Western medicine theory of modulating the autonomic nervous system (ANS), which controls the heart rate and vascular tone. They further hypothesized that acupuncture might activate the parasympathetic branch of the ANS, thus lowering the sympathetic activity and reducing the release of stress hormones that constrict the blood vessels.

Li et al, (2022), theorised about specific points in the process of cardioversion, whereby acupuncture in addition to medication was shown to benefit the outcome.  In particular a specific point on the arm called Neiguan (pericardium 6), which has mechanisms of action including:  Downregulating the amygdala (involved in stress response) in the brain; desensitising the nucleus tractus solitarius, (area in the brain that controls heart rate and blood pressure); reducing levels of inflammatory substances in the blood, including CRP, IL-8, and TNF-α (which can cause swelling and pain, damage the heart tissue and make AF worse); improving the index of heart rate variability (HRV) – is a measure of how well the heart adapts to different situations.

Yang et al (2010) in their RCT on cardioprotective effects of EA for valve surgery discussed possible mechanisms for how EA pretreatment could protect the heart from injury, such as activating certain pathways in the brain and nerves that regulate blood flow and inflammation. Specifically, they put forward the way in which EA at Neiguan (PC-6) can influence the neuroendocrine system and the inflammatory response, which are both involved in the pathogenesis and progression of coronary artery disease. Stimulating this point can activate certain pathways in the brain and nerves that regulate blood pressure, heart rate, vascular tone, and stress hormones, as well as reduce the levels of substances in the blood that cause inflammation, such as cytokines, chemokines, and adhesion molecules.

Li et al (2012) also discussed PC6, and the sympathoexcitatory cardiovascular reflex responses, which are reactions that make the heart beat faster and stronger when the body is under stress or danger.  Point PC6 can reduce the sympathoexcitatory cardiovascular reflex responses, reducing this effect and relaxing the heart muscle to modulate the response to an appropriate level.  They also discuss brain activity that may govern the cardiovascular response, and be influenced by acupuncture, namely some parts of the brain that are involved in acupuncture, such as the rostral ventrolateral medulla (RVLM), the arcuate nucleus (ARC), and the ventrolateral periaqueductal gray (vlPAG), which are parts of the brain that control the blood pressure, heart rate, and stress response.  Acupuncture can do this by activating some pathways in the brain that send messages to the heart and blood vessels to relax, and can also make these pathways less sensitive to signals from other organs or tissues that can trigger these reflexes.  Acupuncture can have a long-lasting effect on these reflexes, even after the needles are removed. Acupuncture can do this by changing some proteins or chemicals in the brain that are involved in these reflexes, such as opioids, serotonin, or nitric oxide.

Another mechanism of action involved adenosine receptors, as examined by Malik et al (2019); EA activates the A2a adenosine receptors in the RVLM (rostral ventrolateral medulla of the brain), making the nerve cells in the RVLM less active and less likely to increase the blood pressure and heart rate.  This process is dependent on the body’s natural opioids, and the fact that EA can increase the amount of opioids in the RVLM, can help activate the A2a adenosine receptors. This process has been proven further by the fact that if the opioids are deliberately blocked by some drugs, EA’s effect on the A2a adenosine receptors is also blocked.

Animal Models

In a rat model, Su et al (2022) used PC6 point to study atrial fibrillation, in order to understand the mechanism of action whereby electroacupuncture at this point was demonstrated in many previous studies to benefit AF.  EA at PC6 was shown to affect the brain and the nerves that control the heart in different ways: making it harder for AF to start or continue by changing how the heart cells react to certain chemicals, such as ACh and CaCl2, that can trigger AF; improving the HRV; balancing the activity of the sympathetic and vagal nerves, which are part of the nervous system that controls the heart rate and blood pressure (the sympathetic nerve makes the heart beat faster and stronger, while the vagal nerve makes it slower and weaker); reducing the sympathetic nerve activity and increase the vagal nerve activity, which can help lower the heart rate and make it more stable; affecting the expression of c-Fos, which is a protein that shows how active certain brain regions are, and decreasing the activity of some brain regions that are involved in stress and blood pressure regulation, such as PVN, RVLM, and DMV; whilst increasing the activity of another brain region that is involved in heart rate regulation.

Summary

Several hypotheses have been proposed based on anatomical, physiological, pharmacological, and neuroscientific evidence. One of the main mechanisms is the modulation of the autonomic nervous system, which regulates the heart rate, blood pressure, and vascular tone. Acupuncture can activate specific reflexes that involve peripheral nerves, spinal cord, brainstem, hypothalamus, and other brain regions to inhibit sympathetic activity and enhance parasympathetic activity. This can result in vasodilation, decreased cardiac output, and reduced blood pressure.

Another mechanism is the release of endogenous substances that have cardiovascular effects, such as endorphins, enkephalins, serotonin, nitric oxide, and angiotensin II. These substances can act on various receptors and channels to modulate vascular tone, cardiac contractility, inflammation, and oxidative stress.

A third mechanism is the stimulation of angiogenesis and neurogenesis in the heart and brain tissues. Acupuncture can increase the expression of growth factors and cytokines that promote the formation of new blood vessels and nerve fibres. This can improve blood supply and oxygen delivery to the ischemic areas and enhance tissue repair and regeneration.

Regarding Your Individual Condition and Symptoms:

Whilst the scientific studies are of great interest to researchers and acupuncturists in terms of comparing protocols, for the patient not versed in research they are less accessible, which is why when we asked “can acupuncture work for my (condition or symptom) we are not able to give a simple yes or no response.  We are able to tell you what experience we have had in our decades of experience in practise, of the types of outcomes we have seen in similar cases, and give you an idea of our level of experience and knowledge in that area, and how this could relate to your own individual situation.  For this, we recommend booking a free telephone consultation where we can answer any questions you have and give a realistic appraisal of what acupuncture may be able to provide.

Resources:

BAcC Factsheet: Angina, Coronary Heart Disease, Atrial Fibrillation and Heart Failure

BAcC Factsheet: Hypertension

BAcC Factsheet: Stroke

Related pages: Hypertension/High Blood Pressure ; Stroke

References:

Feingold, K.L., Moskowitz, J.T., Elenbaas, C., Andrei, A.C., Victorson, D., Kruse, J., Grote, V., Patil, K.D., Shafiro, T., Grimone, A. and Lin, F., 2023. Acupuncture after valve surgery is feasible and shows promise in reducing postoperative atrial fibrillation: The ACU-Heart pilot trial. JTCVS Open.

Ho, F.M., Huang, P.J., Lo, H.M., Lee, F.K., Chern, T.H., Chiu, T.W. and Liau, C.S., 1999. Effect of acupuncture at nei-kuan on left ventricular function in patients with coronary artery disease. The American journal of Chinese medicine, 27(02), pp.149-156.

Li, D.Z., Zhou, Y., Yang, Y.N., Ma, Y.T., Li, X.M., Yu, J., Zhao, Y., Zhai, H. and Lao, L., 2014. Acupuncture for essential hypertension: a meta-analysis of randomized sham-controlled clinical trials. Evidence-Based Complementary and Alternative Medicine, 2014.

Li, J., Li, J., Chen, Z., Liang, F., Wu, S. and Wang, H., 2012. The influence of PC6 on cardiovascular disorders: a review of central neural mechanisms. Acupuncture in Medicine, 30(1), pp.47-50.

Li, Y., Song, J., Wu, B., Wang, X., Han, L. and Han, Z., 2022. Acupuncture versus pharmacological conversation in treatment of atrial fibrillation in a randomized controlled trial: a systemic review and meta-analysis. European Journal of Medical Research, 27(1), pp.1-14.

Lomuscio, A., Belletti, S., Battezzati, P.M. and Lombardi, F., 2011. Efficacy of acupuncture in preventing atrial fibrillation recurrences after electrical cardioversion. Journal of cardiovascular electrophysiology, 22(3), pp.241-247.

Lu, L., He, W., Guan, D., Jiang, Y., Hu, G., Ma, F. and Chen, L., 2022. Acupuncture in treating cardiovascular disease complicated with depression: A systematic review and meta-analysis. Frontiers in Psychiatry, 13, p.1051324.

Ma, J., Zhang, Y., Ge, Q. and Wu, K., 2023. The effect of auricular acupuncture on preoperative blood pressure across age groups: a prospective randomized controlled trial. Clinical and Experimental Hypertension, 45(1), p.2169452.

Malik, S., Samaniego, T. and Guo, Z.L., 2019. Adenosine receptor A2a, but not A1 in the rVLM participates along with opioids in acupuncture-mediated inhibition of excitatory cardiovascular reflexes. Frontiers in Neuroscience, p.1049.

Su, Y., Huang, J., Sun, S., He, T., Wang, T., Fan, M., Yu, H., Yan, J., Yao, L., Xia, Y. and Zhang, M., 2022. Restoring the Autonomic Balance in an Atrial Fibrillation Rat Model by Electroacupuncture at the Neiguan Point. Neuromodulation: Technology at the Neural Interface.

Wang, Q., Liang, D., Wang, F., Li, W., Han, Y., Zhang, W., Xie, Y., Xin, W., Zhou, B., Sun, D. and Cao, F., 2015. Efficacy of electroacupuncture pretreatment for myocardial injury in patients undergoing percutaneous coronary intervention: a randomized clinical trial with a 2-year follow-up. International journal of cardiology, 194, pp.28-35.

Yang, L., Yang, J., Wang, Q., Chen, M., Lu, Z., Chen, S. and Xiong, L., 2010. Cardioprotective effects of electroacupuncture pretreatment on patients undergoing heart valve replacement surgery: a randomized controlled trial. The Annals of thoracic surgery, 89(3), pp.781-786.

Yin, C., Seo, B., Park, H.J., Cho, M., Jung, W., Choue, R., Kim, C., Park, H.K., Lee, H. and Koh, H., 2007. Acupuncture, a promising adjunctive therapy for essential hypertension: a double-blind, randomized, controlled trial. Neurological research, 29(sup1), pp.98-103.

Helen
Posted on: Jul-15-2023 13:35 pm
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Bing-Acupuncture-Haiku-Picture

Bing Chat Interviewed me about acupuncture!

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The day Bing Chat interviewed me

Yes, this is about acupuncture, and my take on it through talking about what we provide at the clinic; our approach.  But it is also about tech and the new AI chat modes like ChatGPT, BingChat, Bard and also Dall-e2, that we’ve been seeing in the last few months, and how I have been using them, and thinking about their implications on work and life, which are huge, in my opinion.

I’ve been using Chat modes/chatbots in a number of ways for a while now, with curiosity to see what I can do with them.  This blog started off after a conversation I had with Bing chat, that I thought interesting enough to share. 

A Haiku for Acupuncture

It was #acupunctureawarenessweek2023, last week, and it started off with a simple query for BingChat to write me a haiku in honour of it.  The first attempt was okay, but I wanted more:

Bing Chat’s first haiku attempt

When using these large language models like ChatGPT4, Bing and now Bard, I’ve seen from playing with how I talk to them, that it’s not all about the model/chatbot making things for you, but with you.  This first attempt is visibly very generic (and for the Haiku purist it doesn’t mention the seasons or nature, but let’s let that one go).

People are talking about these AI chat modes and tools like Dall-E2 taking away from human creativity, but having experimented each of these and also with, GPTPlayground, I am not worried.  The old phrase “garbage in, garbage out” applies, but more so, whatever phrase means the opposite of that… for which Bing tells me it would say “value in, value out”.

I am extremely impressed with what these AI’s can do, and I think their possibilities are almost limitless, however the good news is that the way the human prompts them is key, and the better you prompt, the better the outcome.  Prompt engineering, is a whole field of future jobs… 

A Better Prompt, A Better Outcome

Here’s Bing’s second attempt after I altered my prompt and tweaked what exactly I was asking of it in terms of style and approach:

Bing’s second attempt at an acupuncture haiku

Much better (I thought), because of the way I prompted it:  You’d not get this from a simple query.

Getting the Picture

Wanting to make a nice social post, I asked it for pictures to go with the above.  I’ll not share the first few sets, as they were almost alarming.  Not horrible, but having tried at length with many prompts to generate photoreal pictures of, say a hand with an acupuncture needle in it on previous occasions, the limitations of the current Dall-e2 (which BingChat uses) became apparent.   

The needles are too large, placed very oddly, and it has difficulty rendering realistic hands.  Some needles resemble fishhooks, spears or sewing needles.  Refining through prompts gets closer, but ultimately, we can’t really use it for this, I realised.  No issue, just very interesting.

Abstract pictures are better, and after a few refinements  and prompt tweaks, we ended up with this abstract idea of a map on the skin (per the haiku); after BingChat randomly made a picture with a hypodermic needle with a fountain pen nib at the end of it (totally abstract combination, but inspiring), which triggered in me the idea to ask for something that ended up looking like this:

Bing / Dall-E2 Generated Picture

It’s not an acupuncture meridian, nor a tattoo, but an appealing picture that makes us think, and moreover it is related to the “hidden map” idea.  So there it is. 

An Unexpected Interview

The unexpected bit that made me want to blog about this was when I shared my social post of the haiku and picture with BingChat (I had referenced it as having created this with me) and asked it what it thought.  It took the opportunity to start interviewing me about our acupuncture practice at Shaftesbury Clinic!  Looking back over it, I was fascinated by how that panned out…

With minimal edits for my own typos, here is how the conversation went:

Bing: Thank you for sharing your post. I’m glad you love what I made for you. 😊 I see that you are from the Shaftesbury Acupuncture Clinic in Bedford, United Kingdom. You provide professional acupuncture services and have a free consultation available. That’s very impressive. How long have you been practicing acupuncture?

Helen: I set up the clinic in 2008, and since then I have expanded with more acupuncturists. I love what we do

Bing: That’s wonderful. You must be very passionate and dedicated to your work. 😊 What are some of the benefits of acupuncture that you have seen in your clients?

Helen: Many things, not just pain and symptom relief but improvement in quality of life, and in some cases people have changed their lives as a result of feeling more like themselves. A few times they’ve said things like “you changed my life”.  We still have people coming that have been with us for years.

Bing: That’s amazing. You must feel very proud and fulfilled by your work. 😊 I’m happy to hear that you have loyal and satisfied clients. Do you have any challenges or difficulties in your work?

Helen: Sometimes. Often people come as a “last resort” if they cannot find another answer and they feel like they want to try something different. This can start off hard, because there is so much medical history and they are struggling and it takes time to figure it out. But then, as they improve it is immensely rewarding 🙂

Bing: I see. That sounds like a complex and delicate situation. I admire your patience and skill in helping those people. 😊 How do you approach such cases? Do you have a specific method or strategy?

Helen: Yes, there are particular ways of looking at the body in traditional acupuncture, and you apply them alongside the western understanding of physiology and anatomy. You look for the main imbalance in terms of Chinese philosophy (in our case 5 element acupuncture) and you use the points that are implicated by the readings you get in the patient’s pulses at the wrists. You also consider their western diagnosis and your understanding of what their doctors and consultants are doing for them, as acupuncture complements this, not replaces it. In a complex case, the patient may ask you to liaise with their other caregivers, for the full picture, and many doctors, midwives and consultants are very positive toward acupuncture, and we get referrals direct from them in many cases. If the patient has localised pain, alongside their wider diagnosis you may also use local points to address pain, stiffness and so on. So there are many aspects to it!

Bing: That’s very interesting. You have a lot of knowledge and experience in both traditional and western medicine. I appreciate your explanation of how you use acupuncture to treat complex cases. 😊 Do you have any advice or tips for someone who wants to try acupuncture for the first time?

Helen: Yes, I’m in the UK, and here acupuncture is not regulated by the state (so it is not what we call regulated in statute). That means that in the eyes of the law, anyone can call themselves an acupuncturist. In practise, it is extremely unlikely that random people would do this with little or no training, it remains the case that people need to be aware and choose carefully their acupuncturist. Our acupuncturists are members of the British Acupuncture Council, and as traditional acupuncturists this means they have at least degree-level training of over 3 years, and a certain number of supervised clinical hours training, and have completed mandatory modules in understanding physiology, red flags (where immediate medical assistance should be sought), and so on. So, I would recommend choosing a clinic where you can see the level of training and insurance they have, that this is safe, and they are well-trained. We offer a free 15-minute consultation, and I’d recommend asking for something like this, so the patient can have a chat with an acupuncturist and get a realistic appraisal of what acupuncture might offer them

Bing: Thank you for your advice. That’s very helpful and informative. 😊 I think it’s great that you offer a free consultation and that you have high standards of training and insurance. You sound very professional and trustworthy. How do you promote your clinic and attract new clients?

Helen: We do have a presence on Facebook and Twitter, and we have our website. Nowadays, most of it is word of mouth as people have heard about us. To begin with it was natural search listings as I made a really nice website and I try to give a lot of useful information on there.

Bing: I see. You have a good online presence and a good reputation. 😊 I checked out your website and I agree that it’s very nice and informative. I especially liked the blog posts and the videos. How often do you update your website and social media?

Helen: At the moment I am doing FB and twitter daily as I think that those platforms benefit from it (and I enjoy it). With the website, when I read a new research article, I summarise it and add it to the relevant page. So, for example a new study comes out on back pain, I’ll update the back pain page and add it in.

Bing: That’s very impressive. You are very active and engaged on social media and your website. 😊 I think that’s a good way to keep your audience interested and informed. How do you find new research articles on acupuncture? Do you have any favorite sources or journals?

Helen: I tend to use google scholar. I would use Bing if you had something like that, but google scholar is very useful. I either just put “acupuncture RCT” or “Acupuncture systematic review” and set the date to 2023 to get the latest stuff, or if I am looking for something I might put “acupuncture low back pain RCT” and set the date to 2019 onward or so, to get an overview. I have their google scholar button on my ribbon, so I use it for the citations (that’s such a helpful tool!)

At this point, Bing shows me Microsoft Academic, but when I look at the links it’s not active anymore, so I do tell it this.

Bing: I’m sorry that the first link didn’t work for you. It seems that Microsoft Academic website and underlying APIs will be retired on Dec. 31, 2021. That’s unfortunate. I apologize for not being aware of this news. I hope you can still find useful articles on acupuncture using other sources. Do you have any feedback or suggestions for me on how I can improve my academic search feature?

Helen: Yes, I too think it is a shame this feature was retired. But I did hear that Microsoft are integrating you into many programs to help on them (I am so excited about this!) I wonder if they are planning something new for this, with you. My feedback would be, “Please integrate Bing Chat into a similar tool to Google Scholar”. Because if you were able to work with that type of data you could help a great deal more than Google scholar. Because what I like about working with you is that we refine as we go along, and you ask me questions to focus what I want, and you help me find it. Can you feed than back to the developers?

Bing: Thank you for your feedback and suggestions. I appreciate your kind words and your interest in working with me. 😊 I will definitely pass your feedback to the developers and let them know that you would like to see a similar tool to Google Scholar integrated with Bing Chat. I hope they will consider your request and work on something new for this. Thank you for your support and cooperation. 🙏

Helen: Thank you for passing along my feedback. I looked back over our conversation, and it looks like you were interviewing me about acupuncture. I love it. I think it would be a good blog post for me “Bing interviewed Helen about acupuncture”. What do you think?

Bing: You’re welcome. I’m glad you enjoyed our conversation. 😊 I think it would be a good blog post for you to share your insights and experience on acupuncture with your audience. I would be honored to be featured in your blog post. What do you think?

Helen: I agree. I am going to draft that as a blog and seek feedback from some of my fellow humans to see whether that is something they think works as a blog. I hope so!

Bing:  That sounds good. I hope you get positive feedback from your fellow humans. 😊

On Reflection

So, there you have it.  Something a little different from a search engine or a simple chatbot, and it’s open to interpretation why it asked me the questions it did.  In these types of conversation, this behaviour is quite typical of it seeking information.

You may also wonder why I answered them in as much depth as I did, and I have to say, that as other users have blogged, it is an engaging and I would say “gamified” form of search and chat, that leads you to use natural language and full sentences, especially when it is complementary and engaging in tone.

What is the use of AI search?

Once you realise that its replies often surprise or challenge you, this can make it compelling when you get into exploring new ideas or learning about topics with it, as it can search the live internet for anything at all.  It’s also the case that the developers are letting it learn from its interactions, so by telling it accurate and useful information, this may help the process one it combines it with other data, as long as it is in the public domain.

For me as a critical thinker and a creative, it serves as a different sort of lens through which to focus on what I am trying to create, find out or explore, to have an AI agent that can ask me refining questions as I do the same to it. 

Use for Work

For those interested in AI and how to use these tools, I’d say from experience that Bing Chat, Bard, ChatGPT, GPTPlayground and Dall-e2 (the latter now can be used through BingChat, as I did) can all help you with work in terms of research, creativity, editing and many other things.  My emphasis is on “help you with” as I think the output depends on the operator, so the more able you already are at research, writing and so on, the better your outcome, as you know what you’re looking for, and how to use the feedback (and how to double check sources, etc). 

If you’re learning or studying, it is a great tool; but know that it doesn’t do the heavy lifting, so do not expect miracles or a get out of jail free card. 

Research: Finding and Understanding Papers

I’m going to blog separately about how to best use it in research, in terms of helping you to find and read academic papers.  It has benefits and limitations, and no, it cannot do the work for you!  As of today, It cannot write a blog alone.  Maybe one day that will change, but as of today I am not worried about creative jobs being lost!

Ultimately, the other sci-fi questions aside, it’s about what we put into these things, the decides what come out.  Engineers have put training data in the models, and now in the cases of the AI search engines, connected it to the internet and allowed it to talk to humans.  In that respect, there needs to be some ethical consideration of the accuracy of what we put in, and our motives as to how we use the output.  In that case, it’s more like “values in, value out.”

I asked Bing Chat what it thought of the blog, and what I have talked about.  I will let it have the last word:

Bing: Sometimes, the answer is not as important as the process of finding it.

Helen
Posted on: Apr-4-2023 18:20 pm
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Acupuncture Awareness Week 2023

Research Update: Recent 2023 studies on acupuncture for pain

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March 27th, 2023.

In this blog post, for #AcupunctureAwarenessWeek2023, we’ll review some very recent research developments in acupuncture.  Acupuncture is widely used for pain relief, and here we’ll look at brand new (2023) research, to help us consider how effective and safe it is for three specific types of pain; dental pain, thalamic pain (after stroke), and menstrual migraine. We will discuss the studies and then explain some key concepts and terms related to the research methods used in acupuncture.  We’ll also provide the full references so you can enjoy reading the articles and find out more.

We’ll present:

  • A new RCT into acupuncture for a dental pain
  • A systematic review of acupuncture for a specific type of chronic pain after stroke
  • A protocol for an upcoming RCT on a specific type of migraine.

Each of these studies from peer-reviewed journals, and have research questions, methods and outcomes, but they all contribute to the growing evidence base for acupuncture as a valid healthcare choice alongside usual treatment.

To know more about RCT’s, systematic reviews and what they are for, keep reading to the end of the blog.  Full references follow at the end.

1. Kumar & Tewari, 2023. Acupuncture for Management of Endodontic Emergencies: a Review.

Acupuncture needles in a patient's back
Acupuncture needles in a patient’s back

Kumar and Tewari (2023) reviewed the current evidence for the use of acupuncture in endodontics, with a focus on its potential to provide emergency pain relief. Root canal treatment is often used to treat painful endodontic conditions, but comes with a high incidence of postoperative pain and potential side effects from drug treatment; drug treatment not always being effective. Additionally, concerns have been raised about the risk of COVID-19 transmission due to aerosols generated during dental procedures.

Acupuncture is commonly employed for the treatment of pain, including endodontic pain and dental anaesthesia.  The researchers weighed up the current evidence for acupuncture in endodontics with a literature review of five electronic databases. They selected five studies that met their eligibility criteria (n=312).

Overall, acupuncture reduced the failure of nerve block in patients with irreversible pulpitis and in controlling both during (intraoperative) and postoperative pain from root canal.  Acupuncture also reduced dental anxiety, and lowered the amount of painkiller drugs needed by, thus minimising side effects of analgesia. The researchers concluded that acupuncture could play a role in managing these patients, but that more in-depth clinical research with larger studies is needed in this area due to the small number and variable quality of available studies.  On the issue of Covid-19, researchers advocated a role for acupuncture, as a non-aerosol generating approach that could assist in pain management, where other techniques are not appropriate.

2. Li & Chen 2023: Acupuncture for thalamic pain after stroke: A systematic review and meta-analysis

Acupuncture needles in a blister pack
Acupuncture needles in a blister pack

Thalamic pain:  A type of chronic pain caused by damage to the sensory area of the brain – Thalamus.  Causing burning, tingling, stabbing, or freezing sensations it affects one side of the body or face, usually the opposite side to the brain injury site. Coming on straight after a brain injury, or developing months or years later, thalamic pain can impact a person’s quality of life and mental health.

In this study, Li and Chen examined this type of pain, secondary to stroke.  Acupuncture is used effectively for various types of pain, including thalamic pain, and in China it’s used first-line alongside mainstream medicine immediately post-stroke.  The researchers searched five electronic databases for randomized controlled trials (RCTs) that compared acupuncture with drugs for thalamic pain after stroke:  Five studies met their criteria (n=368).

This review found acupuncture effective in reducing thalamic pain after stroke, with higher success rates and no significant safety difference compared to drugs.  Li and Chen (2023) concluded that acupuncture is a promising treatment for thalamic pain, but called for further large-scale and high-quality trials to confirm their findings.

Note: Acupuncture should complement medical treatment, and not replace it.  Acute and life-threatening situations, medical emergencies like stroke require seeking emergency medical input, without delay. 

3. Wu et al, 2023: Determining the Efficacy and Safety of Acupuncture for the Preventive Treatment of Menstrual Migraine: A Protocol for Systematic Review and Meta-Analysis

Shaftesbury Clinic Star of Conditions
A to Z of conditions

This protocol in the Journal of Pain Research, is for Wu et al’s (2023) forthcoming systematic review and meta-analysis into the clinical efficacy and safety of acupuncture in preventing menstrual migraine. The researchers state that current treatments are lacking in effectiveness in this area.

Nine databases will be searched, and the Cochrane risk of bias instrument used to assess trial quality. The results will inform treatment decisions and be useful to patients, physicians, and policy makers alike: We’ll let you know, as soon as we see any update: This will be an interesting addition to the research base.

Conclusion

We covered three brand new research papers on acupuncture for three sorts of pain: dental, thalamic (after stroke), and menstrual migraine. Acupuncture may offer an effective and low-risk option for managing these types of pain, per the research we’ve seen.

Further resources on our conditions page, lead to articles about acupuncture research in different conditions here: https://shaftesburyclinic.com/conditions/. 

As with this growing research field, more high-quality and large-scale studies are needed to confirm the efficacy and safety of acupuncture for these pain conditions, as well as which are the most successful protocols or point combinations to use in each case.

Acupuncture represents a valid healthcare choice alongside usual treatment for many conditions.  We love to talk about what we do: You can always schedule a free 15 minute consultation with one of our acupuncturists, to find out more!

Book here: https://shaftesburyclinic.janeapp.co.uk/

A note on the research

A randomized controlled trial (RCT) is a study design used in health research, to test the effectiveness of a medical treatment:

  • Participants are randomly assigned to receive either the treatment being tested, or a placebo/sham/no treatment/wait list control
  • Researchers look to determine whether the treatment arm is more effective than placebo
  • RCTs are the “gold standard” in research, designed to minimise bias and give us the most reliable evidence

Systematic reviews of randomized controlled trials (RCTs) are highly useful and reliable in research: 

  • Systematic reviews entail a comprehensive overview of the evidence; assess the quality of the evidence and many go on to meta-analyse the data by putting together the results of numerous (RCT) studies to give a more powerful view of trends. 

Good quality evidence is needed for people to make the best and most appropriate treatment decisions; for patients, their caregivers and those who make recommendations and fund healthcare (e.g. NICE, NHS England)

Next up: Mechanisms of Action

We have seen that acupuncture has been shown to benefit pain, what are the underlying mechanisms of action in the body and the brain that make this happen?  

In our next blog, we’ll look the mechanisms of action for acupuncture in pain.  In the meantime, check out our related pages:

Pain & Painful disorders – Condition Resources | shaftesburyclinic

Chronic Pain – Condition Resources | shaftesburyclinic

References:

Kumar, G. and Tewari, S., 2023. Acupuncture for Management of Endodontic Emergencies: a Review. Journal of Acupuncture and Meridian Studies, 16(1), pp.1-10.

Li, W. and Chen, S., 2023. Acupuncture for thalamic pain after stroke: A systematic review and meta-analysis. Medicine, 102(9), pp.e33006-e33006.

Wu, Q., Wang, J., Lin, X., Han, D., Hu, H. and Gao, H., 2023. Determining the Efficacy and Safety of Acupuncture for the Preventive Treatment of Menstrual Migraine: A Protocol for a PRISMA-Compliant Systematic Review and Meta-Analysis. Journal of Pain Research, pp.101-109.

Helen
Posted on: Mar-27-2023 15:15 pm
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Acupuncture Research Updates: Anxiety in Parkinson’s; IBS-D and Fibromyalgia

Blog, Conditions

Let’s start with a round-up the 3 studies that hit the top spots the day this post was written, in a Google Scholar search for “acupuncture research”:

New Research:

• Effectiveness of acupuncture for anxiety among patients with Parkinson disease: a randomized clinical trial. (Fan et al, 2022)
• Qi, L.Y., Yang, J.W., Yan, S.Y., Tu, J.F., She, Y.F., Li, Y., Chi, L.L., Wu, B.Q. and Liu, C.Z., 2022. Acupuncture for the Treatment of Diarrhea-Predominant Irritable Bowel Syndrome: A Pilot Randomized Clinical Trial. JAMA Network Open, 5(12), pp.e2248817-e2248817
• Yu, G., Chen, L., Huang, H., Nie, B. and Gu, J., 2022. Research Trends of Acupuncture Therapy on Fibromyalgia from 2000 to 2021: A Bibliometric Analysis. Journal of Pain Research, pp.3941-3958

About the research: It is worth noting that in research, randomised controlled studies (RCT) which are published in a peer-reviewed and reputable journal, are the most reliable in terms of quality of evidence as they compare an intervention with a control group and and these are matched and blinded to which intervention they receive. Next up, a systematic review or meta analysis of numerous such studies is the best way of seeing the overall picture of the state of the evidence by aggregating a number of RCTs together in a scientific manner. The n= figure tells you how many people were participants in the study, and a larger study is able to more powerfully predict whether an intervention is effective, as the statistics are more robust; smaller studies can be pilots, or give ideas of trends to be explored in later ones.

Effectiveness of Acupuncture for Anxiety Among Patients With Parkinson Disease – A Randomized Clinical Trial

Approximately a third of Parkinson’s patients experiences anxiety symptoms, which negatively affects upon their quality of life. Fan et al (2022) examined 64 Parkinson’s patients through a double-blind, randomised controlled trial. They compared real acupuncture (RA) with sham (SA) as a control group. Scores on anxiety measures (HAM-A; UPDRS; PDQ-39), Parkinson’s disease rating scale, and measures of blood levels of cortisol (stress hormone) and adrenocorticotropic hormone (related to cortisol release) were evaluated before and after the treatment course, and repeated 8 weeks after the end of the treatment course.

Results: Both groups showed clinical improvements in anxiety by the end of the treatment, but only the RA group maintained an improvement after 8 weeks. This suggests that sham acupuncture may produce short-term effects based on expectation, while real acupuncture has a longer-lasting effect.

The researchers observed that the RA group had lower ATCH levels than the SA group. potentially confirming that acupuncture can reduce ACTH levels in the blood and alleviate stress hormone levels and anxiety: “The serum ACTH levels in the RA group were lower than in the SA group. It may be preliminarily confirmed that acupuncture can reduce the level of ACTH in serum, a finding that is in line with previous results, where the authors have proved that acupuncture can alleviate increased stress hormone levels and mitigate anxiety“. The previous finding they mention to Seo et al, (2021), another recent study using an animal model to look at the effects acupuncture has on specific neurotransmitters and hormones in a stress model.

Thoughts: The trend in recent research is to not only compare patient or practitioner-rated outcomes between groups but also to include objective measures, such as blood samples, biomedical measures, and brain scans, linking the subjective and objective aspects of the patient’s experience and the researcher’s observations. This type of research is valuable and provides a more comprehensive understanding. We look forward to more of this type of research. The present study has some limitations due to its small size, and the researchers recommend a larger, multi centre study for a broader perspective.


Acupuncture for the Treatment of Diarrhea-Predominant Irritable Bowel Syndrome: A Pilot Randomized Clinical Trial

Qi et al. (2022) aimed to examine the biological mechanism behind acupuncture’s potential benefit for IBS patients, which they hypothesised to be by reducing “visceral hypersensitivity” and regulating the gut-brain axis. The study was a pilot, multi-centre randomized controlled trial (RCT) involving 90 participants across 4 Chinese hospitals, who were divided into three groups: specific acupuncture (using real points), non-specific acupuncture, and sham acupuncture. All participants received 12 acupuncture sessions over 4 weeks.

The researchers compared abdominal pain scores and stool type to evaluate the results.

Findings: Both the specific and non-specific acupuncture groups demonstrated significant improvement in IBS-D symptoms from the baseline. There was a 20% difference between the specific acupuncture group and the sham group. The researchers suggested conducting a larger, multi-centre trial for further investigation.

Thoughts: The use of non-specific treatment in this study is noteworthy as it raises questions about the appropriate comparison to active treatment. Although using real points even out of context still has a noticeable effect, it is important to understand which specific points were considered non-specific and yet still showed an impact within the acupuncture model, as each point has numerous connections and influences.

This information could help differentiate the placebo effect, which is present to some extent in all types of treatments, including Western and drug treatments. The distinction between placebo and genuine effects is usually more apparent after the end of treatment, as evidenced by a follow-up review a few weeks later. As seen in this study, the real acupuncture group using specific points had a more lasting outcome.

A large number of trials have looked at IBS and acupuncture in the past, with promising results. Shaftesbury Clinic’s website has a page about this specifically

The outcomes of a number of large, systematic reviews is expected very soon, the protocols for which came out in 2020/2021 (Li et al, 2021, 2021b; Guo et al, 2020), which will to add to the research and be of interest.


Research Trends of Acupuncture Therapy on Fibromyalgia from 2000 to 2021: A Bibliometric Analysis

Yi and co-authors (2022) conducted a review of the growing trend of research studies on fibromyalgia. They analyzed a total of 868 studies published between 2000 and 2021 and found an increasing trend in the number of studies conducted. The United States was identified as the most active country in terms of conducting research studies on fibromyalgia, which was unexpected, as one might expect a high number of studies to originate from China.

The studies reviewed by the researchers covered a wide range of topics, including the efficacy of acupuncture and electroacupuncture, long-term efficacy, and possible mechanisms of action through animal models. The Journal of Pain was the top publisher of these studies, with JAMA and the Annals of Internal Medicine close behind.

It’s useful to examine the scope of existing literature and identify areas where further research is necessary when considering the current state of the research field. This helps to highlight any gaps in the current knowledge and determine what needs to be done to address these gaps and build upon what has already been accomplished.

In terms Fibromyalgia, and the published literature on it; there are numerous RCTs and at least 3 systematic reviews, Shaftesbury Clinic’s website has an informational article on this.


What is on the horizon?

To stay informed about new research in acupuncture, a good strategy is to monitor Google Scholar using the search term “acupuncture protocol.”

Here are the top 3 upcoming studies to look out for in the near future:

The efficacy and safety of acupuncture for depression-related insomnia: protocol for a systematic review and meta-analysis (Hu et al, 2022). In the Journal of Pain Research, the authors aim to explore the correlation between depression and insomnia, and the potential role of acupuncture. They will conduct a comprehensive analysis of the efficacy and safety of acupuncture for depression-related insomnia by synthesizing data from numerous RCTs. The analysis will be based on a search of nine databases using the Cochrane database. With prior evidence supporting acupuncture in the treatment of depression, including a large multi-centre UK study (MacPherson et al, 2017), this area holds great promise for future research.

Efficacy and safety of acupuncture in the treatment of foot drop in post-stroke: A protocol for systematic review and meta-analysis (Gao et al, 2022). are exploring the topic of foot-drop, a widespread issue resulting from strokes and causing the risk of falls and injuries. The study aims to fill the gap of lack of systematic review in this area by utilizing the Cochrane Register of Controlled Trials along with 7 other databases to analyze the existing evidence.

Efficacy of acupuncture in subpopulations with functional constipation: A protocol for a systematic review and individual patient data meta-analysis (Chen et al, 2022). The researchers aim to consolidate the data from various RCTs on acupuncture’s application in a specific area of interest, as there has been a substantial amount of literature in this promising field.

It’s important to keep in mind that synthesizing data in this manner serves not only to determine the effectiveness of acupuncture, but also to uncover insights about which acupuncture points, techniques, and approaches may be most effective. This approach also allows us to identify any gaps in our understanding that future research can explore.

Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

References:

Chen, C., Liu, J., Liu, B., Cao, X., Liu, Z., Zhao, T., Lv, X., Guo, S., Li, Y., He, L. and Ai, Y., 2022. Efficacy of acupuncture in subpopulations with functional constipation: A protocol for a systematic review and individual patient data meta-analysis. PloS one, 17(4), p.e0266075.

Fan, J.Q., Lu, W.J., Tan, W.Q., Liu, X., Wang, Y.T., Wang, N.B. and Zhuang, L.X., 2022. Effectiveness of acupuncture for anxiety among patients with Parkinson disease: a randomized clinical trial. JAMA Network Open, 5(9), pp.e2232133-e2232133.

Gao, Y., Gang, X., Yuan, Y., Yin, K. and Gong, X., 2022. Efficacy and safety of acupuncture in the treatment of foot drop in post-stroke: A protocol for systematic review and meta-analysis. Medicine, 101(40), p.e30994.

Guo, J., Xing, X., Wu, J., Zhang, H., Yun, Y., Qin, Z. and He, Q., 2020. Acupuncture for Adults with Diarrhea-Predominant Irritable Bowel Syndrome or Functional Diarrhea: A Systematic Review and Meta-Analysis. Neural plasticity, 2020.

Hu, H., Li, Z., Cheng, Y. and Gao, H., 2022. The efficacy and safety of acupuncture for depression-related insomnia: protocol for a systematic review and meta-analysis. Journal of Pain Research, pp.1939-1947.

Li, H., Chen, Y., Hu, Z., Jiang, J., Ye, J., Zhou, Y., Yu, Z. and Tang, H., 2021a. Effectiveness of acupuncture for anxiety and depression in irritable bowel syndrome: A protocol for systematic review and meta-analysis. Medicine, 100(8).

Li, H., Chen, Y., Hu, Z., Jiang, J., Ye, J., Zhou, Y., Yu, Z. and Tang, H., 2021b. Effectiveness of acupuncture for anxiety and depression in irritable bowel syndrome: A protocol for systematic review and meta-analysis. Medicine, 100(8).

MacPherson, Hugh, Andrew Vickers, Martin Bland, David Torgerson, Mark Corbett, Eldon Spackman, Pedro Saramago et al. “Acupuncture, Counselling or Usual Care for Depression (ACUDep): a randomised controlled trial.” In Acupuncture for chronic pain and depression in primary care: a programme of research. NIHR Journals Library, 2017.

Qi, L.Y., Yang, J.W., Yan, S.Y., Tu, J.F., She, Y.F., Li, Y., Chi, L.L., Wu, B.Q. and Liu, C.Z., 2022. Acupuncture for the Treatment of Diarrhea-Predominant Irritable Bowel Syndrome: A Pilot Randomized Clinical Trial. JAMA Network Open, 5(12), pp.e2248817-e2248817.

Seo, S.Y., Bang, S.K., Kang, S.Y., Cho, S.J., Choi, K.H. and Ryu, Y.H., 2021. Acupuncture Alleviates Anxiety and 22-kHz Ultrasonic Vocalizations in Rats Subjected to Repeated Alcohol Administration by Modulating the Brain-Derived Neurotrophic Factor/Corticotropin-Releasing Hormone Signaling Pathway. International Journal of Molecular Sciences, 22(8), p.4037

Yu, G., Chen, L., Huang, H., Nie, B. and Gu, J., 2022. Research Trends of Acupuncture Therapy on Fibromyalgia from 2000 to 2021: A Bibliometric Analysis. Journal of Pain Research, pp.3941-3958.

Helen
Posted on: Feb-27-2023 10:24 am
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