Acupuncture is significantly more effective than donepezil in improving cognitive function in patients with mild to moderate Alzheimer's disease

Acupuncture has shown the much better improvement in cognitive function than donepezil in patients with mild to moderate form of Alzheimer’s disease in a 24-week clinical trial. The study was published in the journal of BMC Complementary and Alternative Medicine.

Alzheimer’s disease (AD) is characterized by memory impairment and personality changes and is the most common type of dementia. The conditions lead to a loss of personal independence which has wide range of impact on the individual, families and societies; as it is predicted that the prevalence of AD will rise exponentially in elderly people from 1% at age of 65 to approximately 40-50% by the age of 95. So far the medications used to treat AD include cholinesterase-inhibitors such as donepezil which offers only modest symptomatic relief, but produced significantly higher rates of adverse effects and discontinuation of treatment. So, alternative treatment for the condition is urgently needed. Acupuncture has been used to alleviate some symptoms of AD in China for a long time.

Recently a randomized, drug-controlled, parallel group clinical study was conducted to determine the efficacy and safety of acupuncture compared with donepezil in patients with mild to moderate AD. Eighty seven patients qualified to the study were randomly allocated into two groups: acupuncture group (AG, n=43) and drug group (donepezil, DG, n=44).

The primary outcome measures included (1) Alzheimer's Disease Assessment Scale-Cog (ADAS-cog). (2) Clinician Interview-Based Impression of Change plus caregiver input (CIBIC-Plus). The second outcome measures were (1) Activities of Daily Living Inventory (ADAS-ADL23). (2) The Neuropsychiatric Inventory–Questionnaire (NPI). Those measures were performed at the baseline, 12-week treatment period, and 12-week follow-up period respectively.

Basic acupuncture acupoints included RN17 (danzhong), RN12 (zhongwan), RN6 (qihai), ST36 (zusanli), SJ5 (waiguan) and SP10 (xuehai). Complementary acupoints: LR3 (taichong), GB39 (xuanzhong), ST40 (fenglong), BL17 (geshu), ST44 (neiting), ST25 (tianshu) and RN4 (guan yuan), could be selected as auxiliary acupoints according to patient’s symptoms and tongue manifestation. The needles were retained in situ for 30 min each time. Acupuncture treatment was given three times weekly for 12 weeks. The patients in the DG group received 5 mg/day of donepezil hydrochloride for the first 4 weeks and then, 10 mg/day for 8 weeks.

The results shown that acupuncture treatment statistically significantly improved cognitive function, global clinical status compared with donepezil according to the scores of ADAS-cog, CIBIC-Plus both at the end of 12-week treatment and 12-week follow-up period. However, there was no significant difference in the activities of daily living and behavioral symptoms based on the scores of ADCSADL23 and NPI between AG and DG groups. Further, In the AG group, 5 cases of insomnia, 4 cases of constipation, 6 elderly male cases with benign prostate hyperplasia and 2 cases of knee arthritis reported that their symptoms were clearly improved. However, patients in the DG group did not show any equivalent improvements.

During the trial, 4 patients (9.3%) in AG experienced punctuate hemorrhage after the needles were taken out, and 1patient (2.3%) had bruising. No serious adverse effects were reported and no patients withdrew from the AG. Seven patients (15.9%) in DG reported some adverse effects, including dizziness, nausea, loss of appetite, diarrhea, constipation; fatigue and agitation. 4 of 7 cases (9.09%) withdrew from the trial.

The study showed that acupuncture treatment could significantly improve cognitive function, global clinical status in patients with mild to moderate AD, compared with donepezil, with less adverse effects.

Reference

Jia Y, Zhang X, Yu J, Han J, Yu T, Shi J, Zhao L, Nie K., Acupuncture for patients with mild to moderate Alzheimer's disease: a randomized controlled trial. BMC Complement Altern Med. 2017 Dec 29;17(1):556.     https://www.ncbi.nlm.nih.gov/pubmed/29284465

Acupuncture significantly alleviated joint pain related to aromatase inhibitors among women with early-stage breast cancer

True acupuncture treatment showed a statistically significant reduction in joint pain at 6 weeks, compared with sham acupuncture or with waitlist control, among postmenopausal women with early-stage breast cancer and aromatase inhibitor–related arthralgias. The results of clinical study were recently published in the Journal of the American Medical Association.

Despite the well-proven efficacy of aromatase inhibitors (AIs), namely anastrozole, letrozole and exemestane for the treatment of hormone-sensitive breast cancer, some patients suffer from side effects or even stop treatment early due to undesirable toxicities. The most common side effects of AIs are hot flashes, vaginal dryness, musculoskeletal pain and headache etc.

Acupuncture is utilized to treat pain-related conditions including cancer related pain. However, the controversial reports indicated its effect is the same as the sham acupuncture.

This multicenter randomized blinded sham- and waitlist controlled clinical trial was conducted to evaluate the effect of acupuncture on joint pain related to aromatase inhibitors among women with early-stage breast cancer. Study participants were randomized 2:1:1 to the true acupuncture group, the sham acupuncture group, or the waitlist control group. Briefly, both true acupuncture and sham acupuncture consisted of twelve 30- to 45- minute sessions administered over a period of 6 weeks (2 per week) followed by 1 session per week for 6 weeks.

The results showed that the mean observed the Brief Pain Inventory Worst Pain (BPI-WP item, score range, 0-10; higher scores indicate greater pain) score was 2.05 points lower (reduced pain) at 6 weeks in the true acupuncture group, 1.07 points lower in the sham acupuncture group, and 0.99 points lower for the waitlist control group, with differences in adjusted 6-week mean BPI-WP scores between true acupuncture vs sham acupuncture of 0.92 points(95% CI,0.20-1.65; P = .01) and between true acupuncture vs waitlist control of 0.96 points (95% CI, 0.24-1.67; P = .01), in comparison with baseline. Patients randomized to the true acupuncture group had statistically significant improved symptom scores compared with those randomized to the sham acupuncture and waitlist control groups at 6 weeks according to BPI average pain, pain severity, and worst stiffness, and according to the modified assessment and quantification of chronic rheumatic affections of the hands (M-SACRAH), Western Ontario and McMaster Universities Arthritis Index (WOMAC) measures. Bruising was the most common adverse incident reported for those receiving true acupuncture or sham acupuncture. 

This is the first large multicenter trial to investigate the effect of acupuncture in treating AI-induced joint symptoms in breast cancer patients. The data clearly showed that true acupuncture statistically and significantly outperformed the sham acupuncture in joint pain relief of those patients.

Reference

DL. Hershman et al., Effect of Acupuncture vs Sham Acupuncture or Waitlist Control on Joint Pain Related to Aromatase Inhibitors Among Women With Early-Stage Breast Cancer A Randomized Clinical Trial. JAMA. 2018;320(2):167-176. doi:10.1001/jama.2018.8907.
https://www.ncbi.nlm.nih.gov/pubmed/29998338

Effect of scalp acupuncture on neurological disorders – a review study

Scalp acupuncture therapy has been used to treat many conditions in China since 5 BC. Scalp acupuncture needles are penetrated into the specific areas of the scalp or lines on the scalp, and it differs significantly from classic acupuncture in that it has its own theoretical basis and its acupoints are quite different from traditional acupoints. Modern scalp acupuncture was established on the base of traditional Chinese acupuncture, modern anatomy and physiology, by integrating traditional Chinese needling methods with western medical knowledge of representative areas of the cerebral cortex. This modern system of acupuncture was developed at a fast pace since 1970s, and scalp acupuncture acupoints were standardized in 1991 when the World Health Organization announced the International Standard Nomenclature for Scalp Acupuncture Points.

There are three basic features of scalp acupuncture that differentiate it from body acupuncture. Firstly, treatment zones (14 lines or zones) that have been mapped onto the scalp are associated with body functions and broad body regions, and are based on the ideas of different schools of scalp acupuncture. Secondly, scalp acupuncture is characterized by inserting needle into a thin layer of loose tissue beneath the scalp surface, at a low angle of about 15-30 degrees, with an insertion distance of about 1 cum (approximately one inch for adult). Thirdly, the needles in scalp acupuncture are subjected to rapid stimulation, which may be performed a variety of ways including twirling, pulling/thrusting and electro-stimulation.

Despite its relatively short history, scalp acupuncture has been now used to treat a wide range of conditions in many countries. Scalp acupuncture has been proven effective for the treatment of brain-related conditions such as cerebrovascular diseases and neurodegenerative disorders; but also for other conditions e.g. tinnitus and attention deficit hyperactive disorder.  In this review article, recent development of scalp acupuncture application on some neurological disorders were summarized.

The study found that scalp acupuncture provides an important complementary/alternative treatment approach for improving symptoms of many neurological disorders symptoms. By closely stimulating affected areas of the central nervous system, scalp acupuncture has showed advanced and more effective results compared to other acupuncture techniques. The studies also demonstrated that scalp acupuncture treatment is safer, more effective, and caused fewer side effects compared with conventional treatment such as medications in the respective conditions.

Although the studied cited above showed a certain effect of scalp acupuncture on stroke, PD and MS, the quality of studies were variable. Because many of the studies did not follow the Consolidated Standards of Reporting Trials (CONSORT) 2010 checklist and the revised Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) guidelines. For example, there were no sham acupuncture controls in majority studies. None of the included studies adopted assessor blinding.  STRICTA checklist items i.e. "depth of insertion," "description of participating acupuncturists" and “the optimal dosage for the scalp acupuncture treatment” were not mentioned. So following CONSORT and STRICTA recommendation are strongly recommended, and well-designed studies with rigorous methodologies are required to confirm the effectiveness of scalp acupuncture for neurological disorders.

Reference

BY Zeng, Scalp acupuncture treatment for neurological disorders. The Journal of Chinese Medicine and Acupuncture. 2018, Vol.25:1, 25-31.   https://www.atcm.co.uk/news-events/atcm-journals

Acupuncture improved gait impairment of patients with multiple sclerosis

Acupuncture treatment significantly improved gait impairment of patients with multiple sclerosis compared. It was reported in the Journal of Alternative and Complimentary Medicine.

Multiple sclerosis is a demyelinating neurological disorder, caused by the inflammatory reaction to dysfunction of immune system.  Multiple sclerosis affects the brain and spinal cord, causing a wide range of potential symptoms, including sensation, balance, vision and movement such as gait impairment. Acupuncture has been reported to effectively improve many symptoms of multiple sclerosis including fatigue, pain, depression and sleep interference.

Recently Dr. MB Criado and colleagues conducted a clinical study to investigate the effect of acupuncture on gait impairment of patients with multiple sclerosis. Twenty patients were recruited for the study and blindly and randomly allocated into true acupuncture and sham acupuncture treatment groups. In true acupuncture group acupoints ST34, BL40 and BL57 were selected and in sham acupuncture group points located 2 cun laterally to true acupoints. Leopard spot technique was applied in both true and sham groups. One month after first treatment, patients in both groups were swapped for the crossover study. Gait impairment was evaluated in all patients by the 25-foot walk test (T25WF) before and after the treatments.

The results found that there was no statistically significant difference with the 25-foot walk test at the base line between two groups. However, true acupuncture treatment significantly improved gait impairment judged by T25WF test compared with its baseline. Similarly, true acupuncture statistically and significantly improved gait compared with sham acupuncture which was not different from the baseline assessment. Patients in true acupuncture groups felt much better balanced movements.

The study showed acupuncture treatment can markedly improve gait impairment, in addition to other symptoms of multiple sclerosis.

Reference

Criado MB et al., Effects of Acupuncture on Gait of Patients with Multiple Sclerosis. J Altern Complement Med. 2017 Nov;23(11):852-857.   https://www.ncbi.nlm.nih.gov/pubmed/28410453

Treatment of scalp acupuncture for stroke

Stroke is the second most common cause of death preceded only by heart attacks and the major cause of disability in the western societies. Stroke occurs when the blood supply to part of the brain is cut off and is mainly caused by ischemic or hemorrhagic. Ischemic stroke is the most common subtype of stroke, accounting for about 80% of all strokes. Treatment of stroke depends on the type of stroke and which part of brain is affected. Conventional approaches include medication to prevent and dissolve the blood clots and reduce blood pressure, and surgery to remove blood clots, treat brain swelling and reduce the risk of further bleeding in case of hemorrhagic stroke. However, people who survived stroke are often left with long-term problems caused by injury to their brains. 

Scalp acupuncture is a modern acupuncture technique in which needles are penetrated the specific area of the scalp or lines on the scalp, and differs significantly from classic acupuncture in that it has its own theoretical basis and its acupoints are quite different from traditional acupoints. Scalp acupuncture has integrated traditional Chinese needling methods with western medical knowledge of representative areas of the cerebral cortex. This modern system of acupuncture, although explored since 1930s, has really been developed since 1970s and standardized in 1991 when the World Health Organization announced the International Standard Nomenclature for Scalp Acupuncture Points (WHO, 1991).

Despite its relatively short history, scalp acupuncture has been used to treat a wide range of conditions in many countries. Scalp acupuncture has proven effective for the treatment of cerebrovascular diseases and neurodegenerative disorders (Hao et al., 2013; Li et al., 2014; Wang et al., 2009). Furthermore, a number of clinical trials have reported therapeutic effects of scalp acupuncture for the treatment of stroke (Chen et al., 2014; Lee et al., 2014). Here, recent research developments of scalp acupuncture treatment on stroke are summarized. 

Preclinical studies
Acupoint Baihui (GV20) is located on the highest point of the head and is an intersecting point of the Governing Vessel, Bladder, Gall Bladder, Triple Heater and Liver meridians. According theory of traditional Chinese medicine, acupuncture stimulation at Baihui can clear the mind, lift the spirits, tonify yang, strengthening the ascending function of spleen, eliminate interior wind and promote resuscitation. Indeed, Baihui acupoint has been used to effectively treat neurological disorders such as stroke in China for thousand years. 

A systematic review and meta-analysis to assess the current evidence for the effect of Baihui (GV20)-based scalp acupuncture in animal models of focal cerebral ischemia was conducted by Wang et al., (2014). Meta-analysis results showed that of 54 studies 12 reported significant effects of GV20-based scalp acupuncture for improving infarct volume compared with middle cerebral artery occlusion group, and 32 studies reported significant effects of GV20-based scalp acupuncture for improving the neurological function score when compared with the control group. It was concluded that GV20-based scalp acupuncture could improve infarct volume and neurological function score and exert potential neuroprotective role in experimental ischemic stroke.

Recently effect and mechanisms of scalp acupuncture on neurological dysfunction of intracerebral hemorrhage stroke rat model was investigated (Liu et al., 2017). Rat model of intracerebral hemorrhage (ICH) received scalp acupuncture at acupoint DU20 through GB7 on the lesion side, for 30 mins, twice a day, from day one of surgery for consecutive 7 days. A group of intracerebral hemorrhage model not receiving scalp acupuncture and a group of sham surgery and a group of naïve were used as controls. Behavioral tests included a composite neurological scale, corner turn test, forelimb placing test, wire hang task and beam walking were conducted at days 3 and 7, followed by biochemical studies, such as western blot analysis and histopathologic examine. The data showed that at day 3 after intracerebral hemorrhage, there was no significant difference of behavioral tests between scalp acupuncture group and ICH. However, at day 7 after surgery, there was a significant improvement of neurological deficits in scalp acupuncture treated group compared with ICH. Biochemical studies showed that brain content of tumour necrosis factor alpha and nuclear factor KappaB protein expression, inflammatory markers, was markedly decreased in scalp acupuncture group compared with ICH and sham groups.  The results demonstrated that improved behavioral effects by scalp acupuncture were associated with decreased markers of inflammation in rat model of intracerebral hemorrhage. 

Together, the studies above showed that scalp acupuncture improved neurological functions in both ischemic and hemorrhage models of stroke.

Clinical studies
Patients with ischemic stroke of subacute stage recovered better following combination of body acupuncture and scalp acupuncture treatment compared to conventional therapy. It is believed that subacute stage of stroke occurs between 1-6 months after onset of stroke. Better recovery in the subacute stage of stroke is crucial for patient’s long-term revival. Chen et al., (2014) carried out a randomized controlled clinical trial to assess the efficacy of combination of body acupuncture and scalp acupuncture in patients of subacute stroke. One hundred twenty-six patients were divided into acupuncture treatment group (n=61) and conventional treatment group (n=65). Acupuncture was given 5 times a week for total 8 weeks. The Fugl-Meyer scale and NIHSS scale and Barthel index were used to evaluate the motor functioning, balance, sensation, joint functioning and activity of daily living before and during and after acupuncture treatment and follow-up. Assessment after 4-week acupuncture showed a very good improvement compared to baseline judged by all parameters but did not show significant difference from conventional treatment group. At the end of 8-week acupuncture patients demonstrated markedly improvement in all assessments compared to baseline. Acupuncture showed a significant functional improvement compared to conventional group at the end of 8-week treatment and 3-month follow-up assessment (Chen et al., 2014). Authors conclude that combination of body acupuncture and scalp acupuncture achieved better clinical efficacy in stroke recovery compared to conventional treatment. 

Recently, the study of the influence of scalp acupuncture on levels of inflammation in patients with acute cerebral infarction (ACl) was conducted to investigate its mechanism underlying improvement of ACI (Wang et al., 2016). A total of 61 patients with ACI were randomly allocated to scalp acupuncture group (n = 31) and control (medication) group (n = 30). Scalp acupuncture stimulation of bilateral Dingnieqianxiexian (MS 6) and Dingniehouxiexian (MS 7) was performed daily plus medication for 7 days, while patients in control group were given medication only. Clinical neurological dysfunction scales such as NDS, 0-45 points for consciousness, gazing, facial palsy, speech, myodynamia, walking-ability were monitored at the baseline and at the end of scalp acupuncture. Serum levels of inflammation markers, such as high-sensitivity C-reactive protein (hs-CRP), TNF-α, IL-6, and IL-1β, were assessed at the baseline and 3 and 7-day after scalp acupuncture. At the end of 7-day scalp acupuncture, patients showed a significant improvement of the neurological deficits compared with the baseline scores, and there was marked improvement in neurological dysfunction compared with control group. The levels of all inflammation markers were significantly decreased at both 3 and 7-day scalp acupuncture compared with baseline levels. The levels of inflammation makers were significantly lower in scalp acupuncture compared with control group. There was a correlation between the improved neurological deficits scores and decreased serum inflammation markers (Wang et al., 2016).

Conclusion
The results from the brief review study showed that scalp acupuncture is effective in improving neurological deficits of patients with stroke, and it could be an important part of rehabilitation program for stroke recovery.

References
Chen LF et al., [Motor dysfunction in stroke of subacute stage treated with acupuncture: multi-central randomized controlled study]. Zhongguo Zhen Jiu. 2014 Apr;34(4):313-8.  
Hao JJ et al., Treatment of multiple sclerosis with chinese scalp acupuncture. Glob Adv Health Med. 2013, 2(1):8-13. 
Lee SJ, Shin BC, Lee MS, Han CH, Kim JI. Scalp STRICTA recommendations for stroke recovery: a systematic review and meta-analysis of randomized controlled trials. Eur J Integr Med. 2013;5:87–99.
Li SK, [Effects of scalp acupuncture combined with auricular point sticking on cognitive behavior ability in patients with vascular dementia]. Zhongguo Zhen Jiu. 2014 May;34(5):417-20.  
Liu H et al., Scalp acupuncture attenuates neurological deficits in a rat model of hemorrhagic stroke. Complementary Therapies in Medicine 32 (2017) 85–90. 
Wang JH et al., Effect of Scalp-acupuncture Treatment on Levels of Serum High-sensitivity C-reactive Protein, and Pro-inflammatory Cytokines in Patients with Acute Cerebral Infarction. Zhen Ci Yan Jiu. 2016 Feb;41(1):80-4.
Wang S et al., Study on the mechanism of electroacupuncture scalp point penetration therapy in action on apoptosis in the Parkinson's disease rat model. Zhongguo Zhen Jiu. 2009 Apr;29(4):309-13.  
Wang WW et al., A systematic review and meta-analysis of Baihui (GV20)-based scalp acupuncture in experimental ischemic stroke. Sci Rep. 2014 Feb 5;4:3981. doi: 10.1038/srep03981. 
WHO Scientific Group on International Acupuncture Nomenclature. A proposed standard international acupuncture nomenclature. Report of a WHO scientific group. Geneva: World Health Organization; 1991.   http://apps.who.int/iris/handle/10665/40001