Jimi Windmills
Epidemiology
Asthma is characterised by airway
hypersensitivity to a variety of stimuli leading to chronic airway
inflammation and obstruction. It is considered to be partially
reversible, with treatment or by spontaneous resolution (Tortora and
Derrickson 2009: 913). Asthma affects 3-5% of the US population and
300 million worldwide, with a steadily increasing prevalence,
particularly in westernised countries. Asthma is more common in
children, especially boys. However, after puberty, it more commonly
affects females (Tortora and Derrickson 2009: 913; Boon et al. 2006:
670).
Aetiology and Pathogenesis
The Aetiology of asthma is complicated, and
involves various environmental and genetic determinants (Boon et al,
2006: 670). People with asthma often react to triggering stimuli in
concentrations too low to cause problems for people without asthma.
Common triggers include allergens such as pollen, moulds, dust mites,
and aspirin. Asthma attacks can also be provoked by exercise,
emotional upset and breathing cold air or cigarette smoke. The
resulting airway obstruction in the early (acute) phase response is
due to smooth muscle spasms in the smaller bronchi and bronchioles,
and may be contributed to by increased mucous secretion, oedema of
the mucosa of the airways, or damage to the epithelium of the airway
(Tortora and Derrickson 2009: 913). In the late phase (chronic)
response we generally see inflammation, oedema, fibrosis, and
necrosis of bronchial epithelial cells. These responses are mediated
by leukotrienes, prostoglandins, thromboxane, platelet-activating
factor, and histamine (Tortora and Derrickson 2009: 913).
Symptoms include coughing, wheezing,
difficult breathing, fatigue, moist skin, chest tightness,
tachycardia, and anxiety. In severe chronic cases, remodelling of the
airway can occur, which may progress further to fibrosis of the wall
of the airway, fixed narrowing of the airway, and a reduced response
to inhaled medication (Boom et al, 2006: 671).
Diagnosis and Treatment
Asthma is diagnosed on the basis of a
comparable clinical history, and demonstrated airflow obstruction.
Diurnal (measured first thing in the morning and before bed)
variation of more than 20% in peak expiratory flow (PEF) is
diagnostic of asthma, and the degree of variability is an indication
of the severity of the condition (Boon et al. 2006: 673). Treatment
of asthma most commonly utilises inhaled B2-adrenoceptor
agonists, and corticosteroids
Treatment of asthma in western medicine
generally follows an established, five-tier system, where treatment
becomes more intense until the condition stabilises, and then is
gradually reduced, as the patients symptoms become less severe, and
less frequent.
Acute attacks are treated with inhaled
B2-adrenoceptor
agonists (albuterol) which help relax the smooth muscles in the
bronchioles and dilate the airways. Long-term treatment of asthma
attempts to suppress the underlying inflammation. Anti-inflammatory
drugs are used most often, especially inhaled corticosteroids
(glucocorticoids), cromolyn sodium, and leukotriene blockers.
Patient education and avoidance of
aggravating factors play a key part of the management of asthma.
Patients should be advised not to smoke, and encouraged to identify
other triggers, and remove them from the home environment (Boon et al
2006: 675-6).
TCM Background Asthma
Asthma, in Traditional Chinese Medicine
(TCM), is called Xiao Chuan. Xiao
refers to patterns of rapid
shallow breathing, with wheezing, while Chuan
refers to breathing which is
laboured, through the mouth, with elevated shoulders and flared
nostrils, breathing is so difficult that patients are unable to
breath when lying flat (Wu and Fischer 2009: 28). According to Wu and
Fischer, it is often difficult in practise to differentiate which
pattern is predominant during an acute asthma attack, so the patterns
of Xiao Zheng (Wheezing)
and Chuan Zheng
(Breathlessness) are often considered together (2009: 28).
Aetiology and Pathogenesis
The aetiology of asthma, according to Wu
and Fischer include the six external influences, disruption of the
seven emotions, improper diet and eating habits, stress and
over-strain and extended illness where the physical condition is
frail. However, it is noted that in Xiao
conditions, the primary factor
is chronic phlegm in the lung, with external pathogens and internal
disharmony playing a lesser, although still important role (2009:
28).
According to Anshen Shi, asthma is
considered to be a disease of latent phlegm in the lung, which is
triggered by an external pathogenic influence (Shi 2003: 336). The
primary aetiology of asthma in this view is phlegm. This phlegm is
the result of the bodies inability to properly distribute and process
fluids in an appropriate manner.
[Phlegm]
results from failure of the lungs to distribute and disseminate
fluids adequately, or from failure of the spleen to transform and
transport fluids, or from failure of the kidneys to steam and
transform fluids. Phlegm forms, accumulates and lies in the lung;
latent phlegm can be stirred by weather changes (exterior wind
carrying allergens), improper diet, emotional stress, and exertion
(Shi 2003: 336).
This latent phlegm obstructs the airways,
and impairs the lungs dispersing and descending of lung qi, which
causes wheezing, breathlessness, chest congestion and a productive
cough.
Patterns of Asthma
There seems to be a general consensus on
the patterns of asthma. Most authors split the patterns into excess
type, and deficient type asthma. Excess patterns of asthma are
usually invasion of wind-cold/heat, and accumulation of
phlegm/phlegm-heat in the lung. Deficient patterns are most often
vacuity of the lung, and vacuity of the kidney.
A notable exception to the two excess and
two deficient pattern trend comes from Cheng, who lists four
deficient patterns; Asthma combined with lung qi deficiency, asthma
combined with spleen qi deficiency, asthma combined with kidney
deficiency, and asthma combined with heart qi and yang deficiency.
Shi, unique amongst all other authors,
treats the conditions of Xiao and
Chuan separately.
Xiao Zheng (wheezing) has excess
and deficient patterns, which Shi correlates with acute attack and
remission phase asthma. In the acute phase, he gives us cold pattern
and heat pattern, and in the remission phase, he lists lung
deficiency, spleen deficiency, and kidney deficiency (Shi 2003: 21).
Shi lists five excess patterns of Chuan
Zheng (breathlessness); Wind
cold invading the lung, turbid phlegm accumulation in the lung,
phlegm-heat accumulation in the lung, stagnant qi obstructing the
lung, and exterior cold with lung heat. The deficient patterns are
lung deficiency and kidney deficiency (Shi 3002: 27). See appendix 1
for a full table of patterns.
Critical Analysis
In this section, after a brief report of
the setting and methods of each study, I will critique aspects of
each clinical trial against the consort check list and STRICTA
guidelines, and score the study on the JADAD scale.
Databases and Journals
Search terms employed to identify relevant
studies; Acupuncture, Asthma, Randomised Controlled Trial (RCT), Xiao
Chuan, Childhood, Paediatric, Breathlessness, and Wheezing.
The following databases were searched; The
Cochrane Library, PubMed/Medline, ScienceDirect, EBSCOhost, and
Google Scholar.
This resulted in 24 articles of interest
from 1996 - 2012, relating to the topic of asthma and acupuncture.
Some of these were systematic reviews or meta analysis, some related
to laser acupuncture, and some considered other modalities alongside
acupuncture.
Paper 1.
Joos S, Schott C, Zho H, Daniel V, Martin E
2000. 'Immunomodulatory Effects of Acupuncture in the Treatment of
Allergic Asthma: A Randomized Controlled Study', The
Journal of Alternative and Complementary Medicine, vol.
6, no. 6, pp. 519-525.
Objectives and Methods
The authors stated objective was to
investigate the immunological effects of Chinese acupuncture on
patients with allergic asthma.
Setting
Department of Anaesthetics of the
University of Heidelberg
Recruitment and Inclusion /Exclusion
Patients were recruited from two
pulmonologic practises and via newspaper advertisements. Patients
were included with mild to moderately severe bronchial allergic
asthma, with at least one positive reaction to a prick test,
perennial symptoms and regular use of anti-asthmatic medication.
Other inclusion criteria was a disease duration of minimum 1 year and
maximum of 20 years.
Patients were excluded if they had any
other serious disease, or were undergoing any other type of therapy,
including psychotherapy. Patients were also excluded if they were
using oral steroids in doses larger than 7.5mg of Prednisone a day.
Power calculation
There was no power calculation performed to
determine the number needed to treat. There was no other rationale
reported as to how the number of participants needed was determined.
In the discussion the author acknowledges that the study was most
likely underpowered to be able to demonstrate a broader improvement
in immune response.
Randomisation and Blinding
This study was a single blinded, randomised
controlled trial. Patients were stratified according to their age and
duration of disease. Randomisation was performed in groups of 6 to 10
patients using numbered envelopes.
Dropouts
There were no drop-outs in this study. All
patients completed the study, however there were two exclusions that
occurred along the way. One of the control patients was excluded
since she became pregnant during the study. One of the TCM treatment
group patients was excluded because of missing immunologic data.
Practitioner
Dr. H. Zho, an experienced acupuncturist
from China, who works in the Department of Anaesthetics at the
Heidelberg University, where the study was conducted.
Pattern Differentiation, Point Prescription, and Treatment
Dr. Zho performed a TCM differential
diagnosis, and a set of fixed points were used, these being; BL 13,
BL 17, LI 4 and LU 7. To these points Dr. Zho added others, based on
his diagnosis, including; LU 5, LU 6, ST 36, ST 40, KI 3, KI 7, SP
6, SP 9, CV 6, CV 12, and HT 7.
Needles used were Asia-Med brand needles
manufactured in Germany. All points were needled to a depth of 0.3 –
3cm, and de qi sensation was elicited from each point upon insertion
of the needles, and again before they were removed. Treatments were
conducted for 30 minutes, 12 times during the 4 weeks of the trial.
Control Group
This was not a placebo controlled trial,
the treatment group was compared to a control group who received
points that were selected by Dr. Zho, deemed to be non-specific to
the treatment of acupuncture. The control group, like the treatment
group received a fixed set of points; TE 3, TE 19, GB 8, and GB 34,
and additional points randomly chosen from the following set; BL 38,
BL 55, ST 4, ST 6, ST 32, TE 14, TE 25, and SI 5. These points were
needled superficially, less then 1cm depth, and given no stimulation.
Outcome Measurements and Results
The authors report a statistically
significant improvement in the general well being of the treatment
group over the control group. However, the most interesting results
of this study are the immunologic changes that were measured. In the
TCM treatment group CD3+
lymphocytes increased by 16%, and CD4+
cells by 14%. CD8+,
and CD25+
cells had non-significant increases. There were also significant
changes in cytokine levels, IL-6 and IL-10 concentrations decreased,
while IL-8 increased. The in
vitro lymphocyte proliferation
rate in the treatment group increased by 83%, and the eosinophil
count decreased by 25%. In the control group on only the CD4+
lymphocytes showed a change
(22% increase), and there were no significant changes to cytokine
concentrations or in vitro
lymphocyte proliferation rates. It was not reported that the data
collation and statistical analysis was performed by an external
competent blinded assessor.
Exit Questionnaire
There was no reported exit questionnaire to
determine the success of the blinding
Criticisms
Practitioner
The diagnosis and point prescription was
described as being made by an experienced practitioner, Dr H. Zho. We
are not actually provided with his credentials except that he is from
China, which is not necessarily an indication of skill or experience,
and that he works in the Anaesthetics department at the University of
Heidelberg, again not an indication of experience or skill as an
acupuncturist. All we have to go on, to determine his skill as an
acupuncturist, is that we are told he was able to perform a TCM
differential diagnosis, including tongue and pulse, which would
require at least some knowledge of TCM, and that his point
prescription seems reasonable as a treatment for asthma.
The actual treatment of patients was
performed by medical students, not Dr. Zho, and not acupuncture
students or qualified practitioners. These medical students had six
months training from Dr. Zho to 'achieve a comparable qualification'
(Joos et al. 2000: 521). I'm not exactly sure what is intended by
this statement. If it means that in six months, they had achieved a
comparable level of skill and TCM knowledge to their mentor, then
perhaps Dr. Zho was a “medical acupuncturist” who himself had had
just six months of training. Then again he may have been a 70 year
old master acupuncturist with 50 years of experience, and this is
just some obscure remark by the author. Without his qualifications
being reported we just do not know.
Treatment
We are to assume that all point locations
are standard locations. However this is troublesome, since it depends
upon whose standards you are treating in accordance with. The author
makes no mention of which standard they are basing their location on,
and in lieu of a reported standard, gives no anatomical description
of the locations of any points.
We are told exactly which points were used
as fixed points in every patient in the TCM treatment groups point
prescription. However Dr. Zho's pattern specific points are not
thoroughly documented. The author states that Dr Zho prescribed
'flexible points, which were variable added in accordance to the
Chinese diagnosis (e.g., LU 5, LU6 […]' (2000: 521) etc. as I have
listed in the above section on treatment. This is terrible reporting,
in this statement, the only such listing of points in the study we
are given an “e.g.”, an
example of other points employed in the treatment. From this I can
only conclude that we have not been provided with an exhaustive list
of the points employed throughout the study. Neither were we given
any information about the needles used other than their brand, or
whether points were needled bilaterally or unilaterally.
This treatment would have benefited greatly
from a justification for the point selection, and a demonstration of
the historic usage of these specific points for asthma. In the
interests of consistent treatment within the groups, a fixed point
prescription would have lent greater cohesion to the study. Also,
reassessing a patient and changing a point prescription after a
course of treatment in a private acupuncture clinic, is a well
established and acceptable practise. However, doing so during the
course of a clinical trial is akin to running a pharmaceutical trial
and changing dosages or even switching medications entirely in the
middle of the trial based on how the patient is responding to the
treatment. In the end, we do not know which set of points are
responsible for the measured immunologic changes at the end of the
study.
Control Treatment
The authors acknowledge the fundamental
problem of using acupuncture of any kind as a control. They
themselves state;
'On
the one hand, the control procedure should be indistinguishable from
the real treatment, which means penetration of the skin is necessary
to produce pain sensation. On the other hand, the placebo has to be
physically inert otherwise it is called sham control [...]. However,
any needling or manipulation of the skin is believed to produce a
physiologic response. Keeping these much discussed considerations in
mind, it can be concluded that there is no acceptable placebo for
acupuncture research' (Joos et al. 2000: 524).
The
point selection for the control is interesting then, since all the
fixed points have some action that affects the areas of the chest
and/or throat. According to Deadman et al. the following points have
these actions;
- TE 3 – throat painful obstruction (2007: 394).
- TE 19 – indicated for fright, pain of the chest and lateral costal region, and dyspnoea (2007: 409).
- GB 8 – eliminates wind, and harmonises the diaphragm and stomach (2007: 427)
- GB – 34 – spreads liver qi and benefits the lateral costal region, treats all disorders of the lateral costal region, expels pathogens from the shaoyang [which runs over the lungs in the costal region and over the top of the lungs, on the upper back and shoulders] (2011: GB-34).
Now these might not be the first points you
would pick to treat asthma, but they obviously have a general, if not
a specific effect on the lungs and throat. Without looking at the
specific actions and indications of the variable points in the
control treatment, I would note that the channels on which they are
located (bladder, stomach, triple energiser [San Jiao] and small
intestine), all travel over the area of the lungs/throat.
Outcomes and Conclusions
This study is interesting in that, unlike
others studies, the effects of acupuncture as a treatment for asthma
are not measured by lung function, but rather by measuring
immunologic blood parameters. This is a stated goal of the study and
they certainly achieved some interesting results. I find it
interesting that while pulmonary function tests were performed at the
beginning of the study (FEV1 -
forced expiratory volume in 1
second), the only actual measurement of improvement in the patient’s
condition taken at the end of the study, is their subjectively
reported general wellbeing. On top of this, there is no explanation
of how general wellbeing was measured except that patients were asked
at the end of the study if they thought their general wellbeing had
improved, and the answers were recorded by their practitioners. This
seems very sloppy, as there is no baseline being measured at the
beginning of the study, and there is no particular scale, or specific
wellbeing questionnaire used to make any sort of accurate or
objective measurement. In this study, given the sloppy measurement
and reporting of wellbeing, and given that no pulmonary function
tests were taken after the course of treatment, I do not think that
the authors conclusion that acupuncture is an effective treatment for
patients with allergic asthma is at all valid. Rather, as the authors
have stated, acupuncture does seem to have a strong immunomodulatory
effect in patients suffering allergic asthma, but without pulmonary
function tests it is not a valid conclusion to say that this
correlates to an improvement in the severity of frequency of the
patient’s condition.
JADAD
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Jadad
Calculation
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Score
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Was
the study randomised
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0/1
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1
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Was
the randomisation method appropriate
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0/1
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1
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Double
Blinded
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0/1
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0
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Blinding
described and appropriate
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0/1
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1
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Description
of withdrawals and dropouts
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0/1
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1
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Randomisation
described but inappropriate
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0/-1
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0
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Described
as double blind but blinding inappropriate
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0/-1
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0
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Total
Jadad Score
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4
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Paper 2.
Schween
S, Vogt L, Minakawa S, Eichmann D, Welle S, Stachow R, Banzer W 2011.
'Acupuncture in Children and Adolescents with Bronchial Asthma: A
Randomised Controlled Study', Complementary
Therapies in Medicine, vol. 19,
pp. 239-246.
Objectives and Methods
The
objective of this clinical trial was to collect data in the field of
paediatric pulmonology and acupuncture on the basis of a randomised
clinical trial. The study aimed to evaluate the immediate effects of
acupuncture as an adjunctive treatment in children and adolescents
with mild to severe bronchial asthma.
Setting
This study was set in an inpatient
rehabilitation centre, It does not report the location of the centre
nor does it report exactly what type of rehabilitation typically
occurs there. We can only assume that it is an inpatient
rehabilitation centre for those with chronic respiratory conditions.
Recruitment and Inclusion / Exclusion
The
inclusion criteria for the study was children between 12 and 17 years
of age with bronchial asthma who were currently being treated with
chronic use of inhaled corticosteroids. These patients were assigned
randomly to either the acupuncture or control group. Patients with
diseases which might have affected the development of asthma, for
example, obesity, were excluded. As was any patients who had been
assigned to the non-acupuncture group who expressed a desire to be
included in the acupuncture group.
Power Calculation
Power calculation was performed using
specific software, and taking into consideration previous research.
The total sample size needed was 47 in each group, a total of 94
patients. Taking into account a 30% dropout rate 130 patients were
recruited for the study.
Randomisation and Blinding
The study was randomised, but there is no
mention of the method of randomisation. There was no blinding
attempted in this study. Since there were only two groups, one who
underwent the normal rehabilitation programme, and the other who
participated in the same program, but also received acupuncture, it
was quite obvious who was, and who was not in the acupuncture group.
In their discussion, the authors point out the fundamental flaws in
placebo and sham acupuncture as control methods, and deliberately
avoided using them.
Dropouts
Full data was collected for 93 subjects, 46
in the acupuncture group, and 47 in the control group. There was an
overall dropout rate of 27%. Reasons reported for exiting the study
were life events, health issues and lack of personal motivation.
Practitioner
The authors report that the acupuncture was
performed by three acupuncturists, belonging to the German Medical
Acupuncture Association. These medical acupuncturists had many years
of experience in practical acupuncture.
Pattern Differentiation, Point
Prescription, and Treatment
Acupuncture treatment happened three times
per week for each participant in the acupuncture treatment group. The
treatment consisted of 3 fixed points; BL 13, CV 17, and LU 7, and
then a number of individual points between 2 and 6, that were
specific to the patients TCM diagnosis. Examples of these variable
points are ST 40, KI 6, LI 11, ST 41, and BL 42. de qi was attained
at each point, and needles were retained for 30 minutes. The needles
used were uncoated steel acupuncture needles, 0.18 x 13mm, and 0.3 x
30mm.
Control Group
The control group in this study, instead of
receiving acupuncture, attended a group discussion to clarify
questions on the topic of the study, to explain their role as
reference patients and to motivate them to continue in the study.
Outcome Measurements and Results
This study found comparable results between
both groups. There were no improvement differences between the groups
in lung function, provocation testing and quality of life scores. At
the end of the study, 50% of patients had reduced medication use but
there was no significant difference between the groups.
In the discussion the authors report that
there was a significant therapeutic effect of acupuncture in regard
to bronchial hyper-reactivity (PEF measurement), which indicates
better asthma control since it points to a reduction of inflammatory
cytokines, and processes in the bronchial mucosa. The authors also
report a significant decrease in anxiety sensation in the acupuncture
group.
Exit Questionnaire
Since there was no blinding, there was no
exit questionnaire to determine its success. The patients were asked
four months after the study to rate their quality of life, and the
majority reported a continued improvement of the subjective quality
of life. The authors do not attribute this to acupuncture, as the
change was the same in both groups.
Criticisms
Practitioner
The authors of the study reported that the
'acupuncture was carried out by three acupuncture physicians with
many years continuous experience of practical acupuncture' (2011:
240), who were members of the 'German Medical Acupuncture
Association' (2011: 240). The authors fail to report the actual
qualifications of these “medical acupuncturists”.
My main contention here is the distinction
that is often present between a real
TCM acupuncturist, and these so
called “medical acupuncturists”. Citing a number of years of
experience of practical acupuncture means nothing. If I, having
attended a few weekend seminars on “medical acupuncture”, go off
and for the next 25 years stick needles in people I can say I have
many years experience of physically needling people and yet have
absolutely no understanding of TCM theory. The term the authors use
is practical acupuncture. This
is a far cry from being a true TCM acupuncturist who has completed a
degree or perhaps even post graduate studies in TCM, and has a
thorough understanding of complex TCM theory to back up their many
years of clinical and theoretical experience.
To be fair, the practitioners in this study
may well have been physicians who have also extensively studied TCM.
The problem here is that the authors failed to make this distinction
bringing the practitioners qualifications, and skill into question.
Treatment
The authors reporting of the acupuncture
intervention was actually very good, with a few exceptions that I
will cover first. The locations of the points were not specified as
belonging to any particular standard, nor were the anatomical
location described. This is a shortcoming that is shared with Joos et
al, and of most of the research that I read. Also in common with Joos
et al., is a failure to give a complete list of points that were
used. Again we are treated to an example of other points that were
used, leading to the conclusion that this is by no means a definitive
list.
To the authors credit, They included the
length and gauge of needles, as well as the angle and depth of
insertion. However, angle of insertion is only included for the fixed
points that were used. Additional points that made the list, were
given needle depth, as well as the indication for choosing each
point, e.g. 'mucous symptoms: St (stomach) 40; 10 – 15mm, kidney Qi
deficiency: Ki (kidney) 6; 2 – 3mm' (2011: 240).
Control Treatment
The control group was a simple
non-acupuncture treatment group.
Outcomes and Conclusions
This study in somewhat conflicting. On the
one hand they report that acupuncture was completely ineffective in
improving pulmonary function, based on a range of function tests, and
that it did not improve the patients reported quality of life, as
measured by an asthma specific quality of life questionnaire. On the
other hand, in the discussion, they tell us that acupuncture had an
immunomodulating effect which reduced inflammatory cytokines and
processes in the bronchial mucosa, and had a marked impact on asthma
related anxiety.
I find it somewhat perplexing to expect
patients who are dependant on anti-asthma medication and have a
history of chronic use of broncho-dilating inhaled corticosteroids,
to show significant improvement in pulmonary function in one month. I
find it even more difficult to understand the idea that if you take
away someone’s medication, upon which they have been dependant for
a long time and which specifically dilates the airways, for an entire
day, then make them run for 6 minutes as a provocation test, that you
would expect anything other than broncho-constriction to occur.
With these methods, it is hardly surprising
that no significant improvement of pulmonary function occurred in the
acupuncture group over the control group.
The author’s statement that acupuncture
had an effect on reducing inflammatory cytokines, and inflammatory
processes in the bronchial mucosa is completely unfounded based on
this study. While this statement agrees with previous studies such as
Joos et al., it is still not a valid conclusion of the study. No
inflammatory markers were measured in this study, therefore no
statement should be made about presumed changes in inflammatory
cytokine levels, leading to better control of asthma.
A nice outcome of this study is that in
measuring with a questionnaire, the patients change in anxiety
related to asthma, the authors have confirmed this finding from Joos
et al, who only had subjective patient reports as a measurement.
While the authors state that acupuncture provided no improvement to
quality of life for the patients in the treatment group, I would say
that reduced anxiety and fear related to asthma, is probably an
improvement.
JADAD
|
Jadad
Calculation
|
|
Score
|
|
Was
the study randomised
|
0/1
|
1
|
|
Was
the randomisation method appropriate
|
0/1
|
0
|
|
Double
Blinded
|
0/1
|
0
|
|
Blinding
described and appropriate
|
0/1
|
1
|
|
Description
of withdrawals and dropouts
|
0/1
|
1
|
|
Randomisation
described but inappropriate
|
0/-1
|
0
|
|
Described
as double blind but blinding inappropriate
|
0/-1
|
0
|
|
Total
Jadad Score
|
|
3
|
General Remarks
There does not appear to be much in the way
of recent, well performed, research into the efficacy of acupuncture
as a treatment for asthma. Certainly the material reviewed here
leaves a lot to be desired in terms of quality methodology in the
clinical trial and the quality of the reporting. This especially
seems to be the case when it comes to reporting the treating
acupuncturists credentials, what point location standards were
utilised, using a fixed treatment protocol so as to provide a
specific set of points to which any significant change can be
attributed and when using a variable point prescription actually
providing an exhaustive list of every point that was needled during
the course of the study. Without these fundamental issues being
addressed it is my opinion that the research cannot be considered to
be thorough.
Criticisms aside, it is very encouraging to
see the results obtained by Joos et al, pointing to the
immunomodulating effects of acupuncture in patients with asthma. It
would be especially interesting to see more studies along similar
lines that aim to measure both immune markers and changes in
pulmonary function in patients with a new diagnosis of asthma who
have not yet started on conventional treatment. I would say the
future looks strong for research into acupuncture and asthma, and
hopefully the effect of acupuncture on immune responses.
Appendix 1
Patterns of asthma according to various
authors
Deficient patterns of asthma
|
|
Shi
|
Wu and
Fischer
|
Cheng
|
Patel
|
|
Lung Xu
|
Spontaneous
sweating, aversion to wind, slight wheezing sound in the throat,
induced by changes in weather. In the aura stage there will be
sneezing and nasal congestion with clear, watery discharge.
Shortness of breath, low voice, pale complexion, and clear white
sputum. Pale tongue with thin white coat, Weak and thready pulse.
|
Shortness
of breath, feeble voice, weak forceless coughing and wheezing,
spontaneous perspiration, sensitivity to draughts, expectoration
of thin runny phlegm. Tongue: pale. Pulse: weak
|
Pale
complexion, spontaneous sweating, aversion to cold, shortness of
breath, tiredness, sneezing, stuffy nose. Tongue: Pale with thin
white coat. Pulse: Thin fast and weak.
|
Short
and quick breathing, weak and low voice, hydrosis, weak pulse.
|
|
Spleen
Xu
|
Poor
appetite, epigastric and abdominal distension, loose stools and
wheezing elicited by excessive consumption of cold, raw, sweet,
and greasy food. Shortness of breath, low weak voice and fatigue.
Tongue with thin greasy or white moist coating. Pulse thready weak
and soft.
|
No
pattern
|
Pale
complexion, poor appetite associated with phlegm, lassitude, loose
stool, or diarrhoea. Tongue: Swollen, thick greasy coating. Pulse:
slow and slippery.
|
No
pattern
|
|
Kidney
Xu
|
Shortness
of breath, shallow rapid breathing aggravated by exertion, more
difficulty inhaling than exhaling, wheezing triggered by exertion
and fatigue, soreness and weakness of the lower back and knees.
Kidney
Yang Xu – cold intolerance, cold limbs , pale complexion and
spontaneous complexion. Swollen tongue with white coating, Deep
thready pulse.
Kidney
Yin Xu – Red cheeks, irritability, sensation of heat and night
sweating. Red tongue with scanty coating. Thready rapid pulse.
|
Persistent
wheezing aggravated by physical exertion, shallow inspiration,
shortness of breath, difficulty in maintaining regular rhythm of
respiration, fatigue, lassitude, physical cold, cold extremities
and greenish complexion, Tongue: Pale. Pulse: Deep, weak, and
thready.
|
Dark
complexion, shortness of breath and becoming quite severe after
activities, associated with heart palpitations, dizziness, ringing
ears, soreness, weakness, and cold lower back and knees. Tongue:
Pale with a thin white coat. Pulse: Thin and weak.
|
Dyspnoea
upon exertion, chilliness with cold extremities, deep thready
feeble pulse.
|
|
Heart
Qi and Yang Xu
|
No
pattern
|
No
pattern
|
Heart
palpitations, sweating, restlessness, green or purple colour on
the lips, nails and tongue. There may be a cold or freezing
sensation in the extremities. Tongue: Dark with a white coat.
Pulse: Tiny, weak and irregular.
|
No
pattern
|
Excess patterns of asthma
|
|
Shi
|
Wu and
Fischer
|
Cheng
|
Patel
|
|
Wind-cold
invading the lung
|
Xiao
Zheng pattern – Rapid
breathing with wheezing sound in the throat, stifling sensation in
the chest and diaphragm, scanty sputum that is difficult to
expectorate, and wheezing aggravated by cold weather. Dull
complexion, no thirst, aversion to cold and cold limbs. Tongue
White moist coat. Pulse: wiry tight or floating tight.
Chuan
Zheng pattern – Audible
signing dyspnea with coughing and gasping, rapid breathing,
stifling sensation in the chest, and abundant thin white sputum.
Aversion to cold, fever, headache, absence of sweating and no
thirst. Tongue: Thin white slippery coating. Pulse: Floating and
tight
|
Fullness
and distress in the chest, and dyspnea that are associated with
wheezing sound in the throat, cough with thin sputum, headache,
frequent attacks during the cold seasons or caused by cold.
Tongue: Pale with moist or greasy coating. Pulse: Floating and
tight.
|
Cough
with thin sputum, shortness of breath. Usually there are
accompanying symptoms of fever, chills, anhydrosis, white coating
on tongue, superficial pulse.
|
|
|
Turbid
phlegm accumulation in the lung
|
Audible
sighing Dyspnea, stifling sensation in the chest, cough, copious
sticky white sputum that is difficult to expectorate. Poor
appetite, sticky sensation in the mouth, no thirst, nausea and
vomiting. Tongue: Thick white greasy coating. Pulse: Slippery
|
No
Pattern
|
No
Pattern
|
No
Pattern
|
|
Phlegm-heat
accumulation in the lung
|
Xiao
Zheng pattern - Heavy
breathing sound with high-pitched wheezing choking cough, and
thick sticky yellow sputum that is difficult to expectorate.
Anxiety, sweating, red face, thirst with desire to drink,
headache, fever and aversion to wind. Tongue: Red with yellow
greasy coating. Pulse: Slippery rapid or slippery wiry.
Chuan
Zheng pattern – Audible
sighing with dyspnea, heat sensation in the chest with distension
and pain, coughing up copious thick yellow sputum that might be
blood tinged. Thirst with desire to drink cold beverages,
irritability, red face, dry throat, dark urine, and constipation.
Tongue: Yellow greasy coating. Pulse: Slippery and rapid.
|
Short
rapid respiration, loud husky voice, wheezing, coughing,
oppression in the chest, expectoration of thick yellow phlegm,
fever, perspiration, thirst with preference for cool drinks,
constipation and dark urine. Tongue: yellow slimy coating. Pulse:
rapid and slippery.
|
Dyspnea
with wheezing, irritability, oppressed sensation in the chest,
gasping for breath, cough with yellowish thick sputum, red
complexion, fever, sweating, thirst, and onset closely associated
with the warmer seasons. Tongue: Red with yellow greasy coating.
Pulse: Slippery and rapid.
|
Rapid
and coarse breathing, stifling sensation in chest, thick purulent
sputum, thick yellowish coating on tongue, rapid rolling and
forceful pulse.
|
|
Stagnant
qi obstructing the lung
|
Sudden
attacks of breathlessness elicited by emotional stress, rapid
short breathing with a suffocating sensation or constriction in
the throat, chest oppression and pain. Insomnia, palpitations,
stuffiness and pain in the hypochondriac and chest regions.
Tongue: Thin white coating. Pulse: Wiry
|
|
|
No
Pattern
|
|
Exterior
cold with lung heat
|
Audible
sighing dyspnea, rapid breathing, chest distension or pain,
dilated nostrils, and stick yellow sputum that is difficult to
expectorate. Slight aversion to cold, fever with or without
sweating, thirst, irritability, and headache. Tongue:Thin white or
yellow coating. Pulse: Floating or slippery and rapid.
|
|
|
No
Pattern
|
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