ALLERGOL. ET IMMUNOPATHOL., 1998;26(6):263-271
ORIGINAL ARTICLES
Acupuncture in the treatment of asthma: a critical review*
P. A. Davis, C. Chang, R. M. Hackman, J. S. Stern andM. E. Gershwin
SUMMARY
Background: Increasingly, patients are turning to treatments and drugs that are considered "alternative" or "complementary" as part of their healthcare. In response, the National Institutes of Health (NIH) established an Office of Alternative Medicine (OAM) in 1992 to facilitate identification and evaluation of alternative and complementary therapies. Acupuncture, a therapy that has been used to treat disease in China for approximately 2,500 years, has attracted considerable attention. NIH in a consensus statement derived from a Fall of 1997 consensus conference to assess acupuncture has indicated that acupuncture was useful in pain control and maybe a useful adjunct treatment for the management of asthma. Further, the US Food and Drug Administration has removed acupuncture from the "experimental medical devices" category.
Methods: We have extensively searched the literature for reports addressing the use of acupuncture in asthma treatment. We sought these using the National Library of Medicine, the Office of Alternative Medicine''s database as well as other databases both English language based as well as other languages that catalog literature pertaining to alternative and complementary therapies. We then reviewed these reports and weighed the validity of the conclusions reached in the reports based on assessment of study design, number of subjetcs studied, duration of studies, types and number of controls, and statistical analyses used.
Results: Data presently in the literature do not provide sufficient support for a useful role for acupuncture in asthma management.
Conclusions: Further properly designed clinical studies examining the use of acupuncture in asthma are extremely important and urgently needed.
Key words: Asthma. Acupuncture. Alternative medicine. Clinical trials.
Allergol et Immunopathol 1998;26:263-71.
*Work was performed at the University of California.
Davis Center for Complementary/Alternative Medicine (CAM)
Research in Asthma. Allergy and Immunology. Meyer Hall.
One Shields Avenue. Davis. CA 95616 USA.
INTRODUCTION
...screw your courage to the sticking-place, and we''ll not fail
Lady Macbeth
This review examines the data reported in the literature regarding the use of and utility of acupuncture in the treatment of asthma. Increasingly, people are turning to treatments and drugs that are labeled "alternative" as part of their healthcare practices. In response to these trends, the United States government through the National Institutes of Health established an Office of Alternative Medicine (OAM) in 1992 to facilitate the process of identifying and evaluating alternative therapies. The goal of this effort is to identify those particular practices and approaches that are employed either elsewhere in the world or outside the umbrella of western healthcare that have the potential to significantly improve health and well-being, and subject them to a rigorous, scientifically sound research and evaluation program to establish either the futility or utility and efficacy of these nonconventional approaches. As part of this, the OAM provided funding for specific centers were where expertise existed to investigate CAM practices in use for the management and or treatment of a variety of diseases. Our center, established in 1996 was instituted to examine and evaluate CAM practices in the treatment of asthma, allergy and immunology.
ACUPUNCTURE
Acupuncture is an integral part of a 4,000 years old philosophy of medicine that is known as traditional Chinese medicine (TCM). A central tenet of this medical tradition is that health represents a balancing of energies within us, that when the human body is kept in a harmonious balance, health and well being are naturally maintained. Interestingly, given the current increasing importance of health maintenance as a healthcare approach in the United States, classical Chinese medicine texts treat as superior the physician who prevents disease, and regard the physician who merely treats disease as inferior, thus emphasizing the central role of health maintenance in traditional Chinese medicine.
The energy that is held to flow throughout the body or "Qi" (the energetic life force) provides the human body with life and vitality. Energetic imbalances, in the form of symptomatic disease, occur when the body''s natural energy homeostasis is disrupted. Qi is thought to move through the body in channels or pathways. When this flow is altered or blocked, disease results. The goal of acupuncture, along with herbal treatments and other adjunct medical therapies is to modulate these channels in such a way as to stimulate, when there is a deficiency or lack of energy, or reduce, when excess energy is present. Blood, body fluids, and temperature can alter the body''s natural state of health and these are all part of Qi, as are external forces that must be in harmony with a person''s body and mind.
The traditional Chinese medicine approach assesses the organic structure of the body, physiological functions, and pathological changes within the context of the dualistic, complementary relationship and ultimate unification of Yin and Yang. Five elements in traditional Chinese medical theory reflect the elements of Nature''s domain: wood, fire, earth, metal and water and appear to have a direct relationship with the body''s internal organs: liver/gallbladder, heart/small intestine, spleen/stomach, lungs/large intestine, and kidney/bladder. The five elements are utilized in assessing fundamental constitutional, diagnostic as well as treatment principles.
Genetics, diet, environment, climatic conditions as well as human emotions all have an affect on well being in Traditional Chinese medicine. A diagnosis is based on careful assessment of patient status including questions regarding chills, fever, perspiration, head and body, urine and stool, diet and appetite, chest and abdomen, eyes, ears, sleep, medical history, child-bearing and living habits, observations of the skin, color, tongue, hair, listening, smelling, and palpation (including pulse diagnosis).
A diagnosis as well as a treatment principle is determined prior to medical treatment. Hundreds of acupuncture points have been mapped throughout the body and dozens may be utilized in treatment.
TCM holds that acupuncture promotes the rebalancing of Ying and Yang energies and this is accomplished by needle insertion(s) at designated points that lie along meridiens that traverse the trunk and extremities. These meridiens and the association between the number and exact location of needle points used in relation to the diseases treated are the product of a long tradition of empirical practice of employing acupuncture to treat illnesses. According to the Standard International Acupuncture Nomenclature proposed by the World Health Organization, the meridian system in acupuncture consists of more tham 400 acupuncture points and 20 meridians connecting some of the points (1). Most acupuncture points and meridian points are the high electric conductance points on body surface and vice versa (2, 3). Some of the multiple needle points suggested as efficacious in asthma treatment and lung disease are presented in table I.
Table I Multiple needle points for asthma treatment |
| Lu 7, Ren 22, Ding Chuan, UB 13 |
| UB 13 + Lu 1 |
| UB 13 (Lung back-Shu) + Lu 9 (Lung Yuan-source point) |
| treatment of asthma due to Lung Qi deficiency |
| Lu-7 is combined with Ki-6 |
These anatomical meridiens and needling points appear to follow, as least partially, more western style anatomical markers such as blood vessels, peripheral nerves and lymph vessels. A modern, mechanistic explanation for the efficacy of acupuncture in the treatment of any condition has so far been elusive although relief of pain and nausea appear the most well-documented among the effects of acupuncture.
ASTHMA
Asthma is common lung disease characterized by reversible airway obstruction and airway inflammation (4), especially prevalent in children. Numerous epidemiological studies demonstrate increases in asthma mortality in developed countries (5-13). In the past two decades, asthma incidence and, more alarmingly, asthma related mortality in the United States has risen over 50% (14). The asthma associated mortality in the United States has risen from a nadir in 1977 of 0.16 to 0.42 deaths/100,000 in 1987 with deaths from asthma being highest among those over 65 years of age, compared to other age cohorts (14). Asthma imposes a significant economic burden as the over 12 million asthmatics in the United States experience well over 100 million patient days of restricted activity annually with costs of asthma care exceeding $4.6 billion a year (14).
Conventional asthma therapy is directed toward reducing inflammation and attenuating bronchial hyperreactivity. Unfortunately, many current conventional medicine asthma treatments achieve only a qualified success in asthma control. Further, despite ongoing, intense research efforts exploring the causes, mechanism and possible avenues of prevention, conventional medical asthma management relies on a limited number of drugs, as well as special techniques such as hyposensitization, and environmental adjustment. The lack of success for conventional asthma therapy has resulted in increasing numbers of patients seeking complementary medicine approaches to deal with their asthma (15).
CAM AND ASTHMA
Current demographics, prevalence, and usage patterns of complementary and alternative medicine in the United States suggest that approximately 425 million visits to providers of CAM therapy were made in 1992 (16). Most people used CAM therapies as treatment for chronic rather than life-threatening medical conditions. Importantly, the costs associated with the use of CAM for treatment were approximately equal to those associated with non-reimbursed expenses incurred for all hospitalizations in the United States.
Data dealing specifically, with the use of alternative medicine treatments in the treatment of asthma is limited. We recently surveyed CAM professional healthcare providers regarding their use of CAM to treat asthma (17). We found that while physicians tended to utilize alternative/complementary medicine approaches more sparingly in the treatment of asthma than non-MD healthcare providers, both physician and nonphysician respondents did employ complementary/alternative medicine approaches in their treatment of asthma. Prominent among these alternative health modalities employed was acupuncture (table II).
| Table II | |||||
| Physicians | Non-physicians | Physician | Non-physician | ||
| Utility/usefulness | Utility/usefulness | ||||
| Ranking | Ranking | Percent | Percent | ||
| [1 (most) to 20 (least)] | [1 (most) to 20 (least)] | Using | Using | ||
| Acupuncture | 8 | 4 | 19 | 33 | |
Acupuncture was used by 33% of nonphysician respondents for the treatment of asthma. In addition, acupuncture was ranked by nonphysician respondents as overall the 4th most useful alternative medicine approach for treating asthma. Somewhat in contrast, only 14% of physician respondents indicated that they used acupuncture to treat asthma. Moreover their rating as to its utility was significantly lower as they ranked it only 8th overall in usefulness in asthma treatment. Our results (17) along with those of Eisenberg and coworkers (16) provide significant support to the contention that complementary medicine modalities occupy a larger role in the health care of US citizens than previously recognized.
CAM is frequently used for the treatment of pediatric conditions (18). Wolthers reported that 31% of patients seen at a pediatric outpatient clinic had received CAM treatment with the commonest complaints leading them to seek treatment being asthma/allergy (47%) (19). In 60% of the children treated with CAM, alternative treatment was sought in response to prompting from the family and friends. Spigelblatt and coworkers using a similar survey based approach reported a lower number of children were being treated with CAM in Canada (11%) (20). However the distribution of CAM treatment modalities used indicated that chiropractic, homeopathy, naturopathy, and acupuncture together accounted for 84%. Interestingly, children treated by CAM were different than average pediatric patients in that they were older than the nonCAM users, their mothers were better educated, and their parents also tended to use CAM. The usage of CAM with pediatric patients raises concerns not only regarding questions of efficacy and utility of CAM practices with respect to pediatric illness, but also whether differences exist between CAM effects on adults compared to children. The use of CAM among children raises significant research, medicolegal and ethical questions regarding informed consent, child welfare, etc.
ACUPUNCTURE AND ASTHMA-EVIDENCE OF EFFICACY?
The relatively widespread used of acupuncture for the treatment of asthma appears to be based on traditional use history and testimonial evidence rather than rigorous scientific documentation. Acupuncture in the treatment of asthma has been the subject of considerable interest with over 100 references being retrievable from the National Library of Medicine or the world wide web using as search terms asthma and acupuncture. Table III provides these references broken down by 5 year intervals illustrating the changing numbers of reports addressing issues related to acupuncture and asthma. The level of interest as evidenced by publications has risen and fallen since 1965 but in general has exhibited an increasing level of activity in acupuncture as related to asthma. However, while the numbers of publications have increased, the vast majority of these are either published in obscure or specialty journals and or represent anecdotal reports.
Table III Astham and acupuncture literature | ||
| Year | Number | Citations |
| 1965-1970 | 3 | 2, 29-32 |
| 1971-1975 | 4 | 33-36 |
| 1976-1980 | 22 | 13, 23, 37-60 |
| 1981-1985 | 35 | 61-99 |
| 1986-1990 | 60 | 6-12, 19, 100-146 |
| 1991-1995 | 42 | 1, 3, 5, 14, 16, 18, 20-22, 24, 25, 28, 147-181 |
| 1996-1997 | 4 | 4, 15, 26, 27, 182-185 |
Acupuncture and asthma has also been the subject of several reviews. Most prominent among them was the 1991 review by Kleijnen and coworkers who after an exhaustive literature search found and reviewed 13 papers that sought to assess the efficacy of acupuncture in the treatment of pacients with asthma (21). They utilized a predetermined scoring system to assess the trials methodology with respect to appropriateness and size of the study population, standardization and documentation of intervention and the adequacy of the measurement of effects or lack there of upon treatment. Their conclusion was that "claims that acupuncture is effective are not based on the results of well performed clinical trials".
In a companion editorial to the article by Kleijnen et al, Lane and Lane reviewed a range of complementary/alternative medicine practices used in asthma. They also noted that the research study database for asthma and acupuncture was lacking but did suggest that some of the results seemed to be more than epiphenomena. They concluded that there may likely be beneficial effects of acupuncture on asthma and that further study was warranted (22). They also commented on the problems engendered in assessing acupuncture effects when the technique is either poorly described or is done by alternative methodology such as laser acupuncture (see for example (23), for which it is not at all established that this treatment method is to be considered "true" acupuncture).
The potential benefit of acupuncture on asthma was raised in a review article on acupuncture by Joshi (24). He concedes that the bases of this judgment may be tenuous due to the enormous variability of techniques and methodologies used.
Several other recent articles have attempted to examine acupuncture and asthma. However, they did so using either very subjective and or poorly described survey methodology. For example, Zwölfer et al report that 70% of their asthma patients showed a significant improvement upon acupuncture treatment. Unfortunately, this conclusion was based on only 17 subjects and efficacy assessed by survey responses to questions such as "Did our therapy help you?" (25).
During a recent international meeting (ICMART''97) International Medical Acupuncture Symposium Nicosia, Cyprus, 26-29 March 1997) a paper by Russian investigators Philippov, Philippova, and Shuvaen was presented on asthma and acupuncture. They reported the results of treating 61 people with either "infectious - and - allergic bronchial asthma in acute condition, including 36 patients with light course of the disease and 35 patients with the disease of medium severity". The authors report that "improvement was noted in 57 patients (93.4%) and manifested itself by ceasing attacks of asphyxia in all the patients with light course of the disease and in 31 patients (88.6%) with the disease of medium severity". While difficulties in assessing this report may arise from language barriers, assessment of the results runs up against the fact that, as also commented on by Kleijenen et al, methods in Russian papers "were always disappointingly poor" (21).
Finally, a 1997 assessment of the role of acupuncture in the treatment of asthma was done under the aegis of the Cochrane Collaboration (26). They found a lack of rigorous, well done clinical studies examining acupuncture and asthma. The authors also expressed the same degree of frustration regarding the absence of quality data with which to work to accurately assess acupunture''s role in asthma treatment. They concluded that "It is not yet possible to make any recommendations to patients, their physicians or acupuncturists about the practice of acupuncture in the treatment of asthma on the basis of the data currently reported. Given the increasing use of acupuncture by the public, there is an urgent need for quality research which should take into account the complex nature of acupuncture as a treatment modality".
The results of our assessment of the science base for acupuncture and asthma, based on our review of the literature, differs little from those of Linde et al (26), Jobst (27), Kleijnen et al (21) and Joshi (24). We too are struck by and frustrated with the paucity of good, well designed and well done clinical studies addressing this important issue. It is particularly noteworthy, that the lack of any real data upon which to base assessments persists despite a 1991 review article by Kleijnen et al with its call for better studies to be done in this important area (21). Rigorous, well designed and controlled studies are particularly urgently required given the evidence that both adults and children are increasing their use of CAM practices to treat chronic conditions such as asthma. The totality of the data, in particular the wealth of the millenia old traditional use history suggests that acupuncture can have some beneficial effect on asthma. Whether this is indeed true or not awaits the results of well designed experiments, which should be given a high priority. The late Carl Sagan wrote the following in his book "The Demon Haunted World", which is just as apt for acupuncture as it for ethnopharmacology (28). "Quinine comes from an infusion of the bark of a particular tree from the Amazon rain forest. How did pre-modern people ever discover that a tea made from this tree, of all plants in the forest, would relieve the symptoms of malaria? They must have tried every tree and every plant- roots, stems, bark, leaves- tried chewing on them, mashing them, making an infusion. This constitutes a massive set of scientific experiments continuing over generations- experiments that moreover could not be duplicated today for reasons of medical ethics. Think of how many bark infusions from other trees must have been useless, or made the patient retch or even die. In such a case, the healer chalks these potential medicines off the list, and moves on to the next. The data of ethnopharmacology may not be systematically or even consciously acquired. By trial and error, though, and carefully remembering what worked, they get there - using the molecular riches in the plant kingdom to accumulate a pharmacopoeia that works. Absolutely essential, life saving information can be acquired from folk medicine and in on other way. We should be doing much more than we are to mine the treasures in such folk knowledge worldwide".
ACKNOWLEDGEMENTS
Supported by grant U24-AI37627 from National Institutes of Health, Office of Alternative Medicine, Bethesda, Maryland.
RESUMEN
Antecedentes: Con frecuencia creciente, los pacientes recurren a tratamientos y fármacos que se consideran "alternativos" o "complementarios" como parte del cuidado de su salud. En vista de ello, los Institutos Nacionales de Salud de los Estados Unidos establecieron una Oficina de Medicinas Alternativas (OAM) en 1992 para facilitar la identificación y evaluación de las terapias alternativas y complementarias. La acupuntura, una terapia que ha sido utilizada en China para el tratamiento de enfermedades desde hace unos 2.500 años, ha atraído bastante interés. Los INS, en una declaración elaborada en una conferencia de consenso para valorar la acupuntura, celebrada en otoño de 1997, han indicado que la acupuntura es útil para el control del dolor y puede ser un tratamiento complementario beneficioso para el tratamiento del asma. Por otro lado, la Administración de Alimentos y Fármacos de los EE.UU. ha eliminado la acupuntura de la categoría de "dispositivos médicos experimentales".
Métodos: Hemos hecho una búsqueda bibliográfica amplia de informes sobre el uso de la acupuntura en el tratamiento del asma. Efectuamos esta búsqueda utilizando las bases de datos de la Biblioteca Nacional de Medicina y de la Oficina de Medicinas Alternativas de los Estados Unidos, además de otras bases de datos, en inglés y otros idiomas, que recogen literatura relacionada con las terapias alternativas y complementarias. A continuación revisamos estos informes y sopesamos la validez de sus conclusiones en base a valoraciones del diseño del estudio, número de sujetos estudiados, la duración de los estudios, los tipos y el número de los controles, y los análisis estadísticos utilizados.
Resultados: Los datos actualmente aportados por la literatura no respaldan suficientemente el uso de la acupuntura en el tratamiento del asma.
Conclusiones: Es muy importante y urgentemente necesario realizar estudios clínicos de diseño adecuado para examinar el uso de la acupuntura en el asma.
Palabras clave: Asma. Acupuntura. Medicinas alternativas. Estudios clínicos.
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Correspondence:
M. Eric Gershwin, M.D.
The Jack and Donald Chia Professor of Medicine
Chief, Division of Rheumatology, Allergy
and Clinical Immunology
University of California at Davis
One Shields Avenue, TB 192
Davis, CA 95616-8660
