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By John D. Mark, MD
Asthma is a chronic inflammatory condition that affects more than 17 million Americans.1 The prevalence of asthma increased 75% between 1980 and 1994,2 and has increased 150% over the last 20 years.3 This increase has occurred in both sexes and in all ethnic groups, primarily in urban, predominately minority, populations.4 The pediatric group (especially children younger than age 5) has shown the largest increases with a prevalence of more than 5 million diagnoses.
Asthma is responsible for approximately 500,000 hospitalizations, more than 1,997,000 emergency room visits, and at least 5,000 deaths annually.5,6 Direct health care costs attributed to asthma in the United States total more than $8.1 billion annually; indirect costs represent another $4.6 billion for a total of $12.7 billion.7 Pharmaceuticals account for the largest direct asthma costs.8 Reduced productivity due to loss of school days represents the largest indirect cost related to asthma, approaching $1.5 billion.7 These statistics are all the more concerning because the understanding of asthma has improved, as has the availability of effective medications for its control.9
Like many chronic illnesses, the use of complementary and alternative therapies for asthma has been popular. Acupuncture is one type of alternative therapy that health care providers have used in the treatment of asthma, in conjunction with conventional medications. The National Institutes of Health Consensus Statement of 1997 listed acupuncture as an adjunct treatment or an acceptable alternative for asthma, but also said acupuncture should be included in a comprehensive management program.10
Acupuncture’s growing popularity is reflected in that it is now part of the complementary and alternative medicine (CAM) curricula offered as an elective in most medical schools, and the British Medical Association has approved acupuncture for general practice.11,12 There are more than 11,000 licensed acupuncturists in the United States and this number is increasing.13 Acupuncture is one of the CAM therapies most frequently recommended by physicians and is integral to many pain treatment programs (both pediatric and adult) throughout the United States. Although it is infrequently recommended for children, Kemper has shown that many children with chronic pain are willing to try acupuncture.14
History and Mechanism of Action
It is important to remember that acupuncture is part of a complex theoretical framework that provides conceptual and therapeutic direction.15 Although acupuncture may seem to be based in part on conventional perceptions (e.g., trigger points), the approach is based mainly in concepts of yin, yang, dampness, wind, fire, dryness, cold, and earth. Qi, the life energy that provides a rationale for explaining change and linking phenomena in traditional Chinese medicine, is gently manipulated to treat the disharmony that may be present.
China, Japan, and Korea have all developed their own distinct versions of acupuncture and apply other associated therapies, including massage, scarification (body marking), and cupping in conjunction with acupuncture. Lifestyle counseling on topics such as diet, exercise, and mental health also may be part of therapy. Even the encounter between patient and acupuncturist is felt to be important in the healing process. Biomedically trained acupuncturists use approaches that are based on a Western understanding of myofascial trigger points and the nervous system, and might use a fixed regimen for a patient’s symptoms independent of a traditional Chinese medicine diagnosis.
The exact mechanism of how acupuncture might help asthma is unclear. Theories have been proposed about the immune modulating effects of acupuncture and others have postulated that increased levels of circulating endorphins and corticotrophins are involved in treating this chronic inflammatory illness.16,17
Since the 1970s there have been more than 500 randomized controlled trials (RCTs) evaluating the efficacy of acupuncture. Some of these studies had placebo controls, some included conventional therapies, and some looked either at acute symptoms or chronic ongoing symptoms associated with various illnesses or pain. Unfortunately, many problems have been encountered with acupuncture RCTs, such as insufficient sample size, poorly defined illnesses, vague enrollment criteria, and even the type of acupuncture utilized.18 Many of these studies were investigating asthma and other pulmonary problems, and studies have looked both at chronic and acute treatment of asthma symptoms.
Martin et al attempted to circumvent the problem of small sample sizes by eliminating many studies in previous reviews and combining the results from all relevant randomized clinical trials that compared acupuncture at real and placebo points in asthma patients.19 They felt that this would be a more objective assessment of sources of conflicting results found in previous trials and might detect moderate treatment effects, which may have been missed in small studies.
Utilizing many of the same studies included in the Cochrane systematic review, Martin et al included nine of 11 trials in the analysis, whereas the Cochrane methodology limited its review to just three of seven trials. The Martin paper identified more than 200 reviewable trials, but only 12 satisfied the inclusion criteria. Only 11 were analyzed due to difficulty with translation.
The authors concluded that there appears to be no clear agreement on the best method of conducting controlled trials of acupuncture in asthma in "relation to the type of design, selected endpoints, and data analysis." All the trials were too small to detect a modest effect of the acupuncture. The shortcomings of the trials were small sample size, effects of prognostic variables, missing information, and the bias against acupuncture introduced by the use of placebo points. Thus, this meta-analysis did not find evidence for the efficacy of acupuncture in the treatment of patients with asthma. This paper, along with the previous reviews, recognized the need for a large randomized clinical trial to address the above limitations.
There have been numerous studies investigating the use of acupuncture in a variety of settings, including exercise-induced symptoms in children and adolescents, isocapnic hyperventilation of cold air, and the treatment of dyspnea. In a study using laser acupuncture, Gruber et al found that a single treatment (using real and placebo points in random order) offered no protection against exercise-induced bronchoconstriction in a group of 44 children and adolescents.20 Malmstrom et al investigated the effect of 15 weeks of acupuncture in 27 asthmatics using a parallel-group, randomized, placebo-controlled trial.21 They found no significant effects in lung function or bronchial hyperresponsiveness measured by cold air challenge.
Shapira et al attempted to overcome many of the shortcomings of previous acupuncture and asthma studies.22 They utilized a sham, controlled, crossover design to evaluate the influence of a short and intensive course of personalized acupuncture on patients with moderate persistent asthma. Although their study sample was small (only 20 of 23 finished the study), the design was sophisticated in that it measured pulmonary function, airway reactivity (methacholine challenge), and patient symptoms and medication use. The authors reported no benefit (not even a trend) from the short-term treatment with acupuncture (36 days) in this blinded, placebo-controlled study of patients with moderate persistent asthma. In an accompanying editorial,23 the study was regarded as an improvement over previous studies of acupuncture and asthma since it provided the rigor of "Western scientific method to an alternative medical therapy." It was concluded that this study placed the benefit of acupuncture in patients with moderate asthma in serious doubt.
However, even this carefully designed study contained methodological shortcomings, including the use of only one acupuncturist who was responsible for the diagnosis and acupuncture treatment of all asthma subjects. Another criticism was that even though personalized, the study design gave treatments on a fixed time schedule despite the differing underlying pathologies found by traditional Chinese medicine diagnosis. In addition, this study was not sufficiently powered to study asthma, which in traditional Chinese medicine may be part of at least five different syndromes.24
Acupuncture involves the insertion into the skin of solid needles from 15-50 mm in length (there are some non-needle types of acupuncture, but they will not be discussed here). Depth of insertion can be several millimeters (most often) to centimeters and the tip of the needle may overlie muscles, nerves, and pleura.
Adverse effects of acupuncture include bacterial and viral infection; and trauma of tissues and organs.25 Often acupuncturists will advise patients that the therapy itself may briefly exacerbate symptoms, especially upon initiation of treatment. As with any CAM therapy, concern arises when delayed diagnosis occurs of a condition that could be treated appropriately with conventional means.
In a recent survey study of more than 32,000 consultations for acupuncture, vague complaints were reported including nausea, vomiting, fainting, drowsiness, disorientation, lethargy, anxiety, euphoria, headache, and slurred speech (671 minor events per 10,000 consultations). Complications of bleeding and needling pain were the most commonly reported adverse events and all but one case resolved within one week.26 There were several earlier case reports of pneumothorax in the treatment of bronchial asthma with acupuncture, but this now seems rare with only two cases in nearly a quarter of a million treatments.27,28
Acupuncture in the treatment of asthma in both adults and pediatrics has gained popularity over the last decade. It is one of the most commonly prescribed and recommended forms of CAM. Although it is not commonly thought of as a pediatric CAM therapy, it is now being utilized in the majority of pediatric pain clinics in the United States. However, there is still a relative dearth of data supporting a significant role for acupuncture in the treatment of either chronic asthma or the acute symptoms associated with asthma.
Acupuncture studies are difficult to design due to the individualistic nature of acupuncture and traditional Chinese medicine in general. Hammerschlag also called into question designing research for comparing acupuncture to standard care.29 It may be more important to consider studies that assess whole systems of care rather than specific therapies or modalities.
Clearly, conventional asthma treatment using newer anti-inflammatory medications (controller medications) has helped asthma patients. However, even with these medications and National Asthma Guidelines,30 asthma prevalence and severity are increasing. Because acupuncture is now utilized more commonly in asthma treatment; more research for its efficacy is needed.
Acupuncture traditionally has been utilized in the care of patients with asthma symptoms. It appears that complications of acupuncture are rare and transient in nature.31 Studies involving acupuncture are becoming more sophisticated in trying to eliminate the methodological problems many of the previous asthma and acupuncture studies have encountered. Acupuncture cannot be recommended alone as a management therapy for asthma based on studies completed. However, as an adjunct to current therapies as outlined in the National Asthma Guidelines,30 acupuncture may be useful, and further studies are warranted.
Dr. Mark is Assistant Professor of Pediatrics, Pediatric Pulmonary and Integrative Medicine, Department of Pediatrics, University of Arizona, Tucson.
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