Learning Objectives: After participating in this continuing professional development activity, the provider should be better able to:

1. Explain the incorporation of acupuncture as an adjuvant for relief of cancer pain.

2. Outline how acupuncture can be incorporated into postoperative pain management strategies.

3. Identify the ability to reduce opioid use by substitution of acupuncture.

This is the second of a 2-part series on acupuncture and traditional Chinese medicine (TCM). In the previous issue (Vol. 39, No. 1, August 2023), we discussed the history and context of TCM and acupuncture and discussed its use in pain management, opioid abuse treatment, depression and anxiety, and the cardiovascular system.

Part II covers the use of acupuncture in treating other diseases and conditions, including in the following areas:

* Pediatrics, such as attention and learning disorders, autism spectrum disorders, and cerebral palsy and muscle dystonia;

* Dentistry, including root canal treatment, endodontic treatment, procedure anxiety, and paresthesia and facial paralysis;

* Cognitive function and head pain, including insomnia and tension-type headache;

* Fibromyalgia; and

* Tinnitus.

In addition, we discuss other miscellaneous conditions for which acupuncture has been tried and studied, including eczema, uremic pruritus, sexual dysfunction, prostatitis, sleep apnea, and pain after thalamic stroke.

We also discuss the use of acupuncture in veterinary medicine and artificial intelligence (AI) as applied to acupuncture research and training, and side effects and adverse effects that have been reported.

Context and History of TCM

Acupuncture, recognized as a form of alternative medicine and a component of TCM, uses thin needles inserted into the body. In the United States, there are a number of US-trained physicians who also practice acupuncture, and many more who recognize that it has benefits and are aware that their patients might undergo TCM and report benefits that might complement their medical and surgical care, whereas others have declared the practice a myth.1,2

Acupuncture and TCM are viewed by the US medical establishment with everything from full acceptance and even licensed practice of it added to their medical degrees, to pseudoscience1,2 and even quackery.3

Nevertheless, acupuncture treatment has been around for thousands of years and in many countries throughout the world. Its use can be traced back at least to the rule of Emperor Huang Ti (2695-2597 bc).4 Huang Ti is said to be the author of the Nei Ching Su Wen, also sometimes spelled Huangdi Neijing. The more recent (1949) English translation by Ilza Veith has the title translated to "The Yellow Emperor's Classic of Internal Medicine," published in 1949 by the University of California Press.

The first part, the Nei Ching, consists of long discussions between the emperor and his chief physician, Ch'I Po, on the indications for the use of acupuncture and the conditions that respond best to it. Even at that time, use of acupuncture for the alleviation of pain was discussed.

A more modern publication, "The Yellow Emperor's Book of Acupuncture," translated from Chinese by Henry Lu and published by the Academy of Oriental Heritage in 1973, describes in depth more of the history, meridians, and uses of acupuncture, but depends mostly on the writings from the Yellow Emperor.

Acupuncture is said to be based on the assumption that there are patterns of energy flow through the body that are vital for health, although these theories have been disputed. The energy flow is called qi, sometimes spelled chi, and, in either spelling, pronounced "chee."1 In fact, the use of qi as an explanatory framework has been decreasing in China, even as it becomes more prominent during discussions of acupuncture in the United States.5

TCM aims to find the cause of pain due supposedly to blockages and imbalances of the flow of qi or from insufficient blood supply. By using fine needles, traditionally gold or silver but now more likely to be made of steel, at specific acupuncture points, the recovery of health can be achieved, thus improving blood supply and decreasing the sensation of pain.

Acupuncture has had a varied history in resurgence and decline. In the 20th century, Chairman Mao Tse-Tung spoke of the necessity of cooperation between doctors of traditional and Western medicine, and so he supported training teachers and writing textbooks. The Academy of Traditional Chinese Medicine and the Research Institute of Acupuncture and Moxibustion were simultaneously established in 1955. Although online diploma classes advertise to provide experience in acupuncture, as of now, each state in the United States has its own regulations and requirements when it comes to the practice of acupuncture. Not all US physicians holding an MD degree and license can practice the art without specialty training. Rather, as the needs and usages of acupuncture increase, it is important that guidelines and practice parameters with specified training programs be widespread. The global acupuncture market was worth $24.55 billion in 2017. The market was led by Europe, with a 32.7% share, followed by Asia-Pacific with a 29.4% share and the Americas with a 25.3% share. It is estimated that this year the industry will reach a market size of $55 billion.6

Several studies suggest that the mechanism of effect of acupuncture can be explained in biomedical terms.7 A number of transmitters and modulators including [beta]-endorphin, serotonin, substance P, interleukins, and calcitonin gene-related peptide are released. For that reason, acupuncture can be used in a wide variety of clinical conditions. Older studies showed that acupuncture may have beneficial effect in the perioperative period by relieving anxiety, decreasing postoperative analgesic requirements, and decreasing the incidence of postoperative nausea and vomiting. By extension, these valuable actions could be applied to many medical scenarios.7

In this year alone, 1571 articles have been published in PubMed regarding new applications for acupuncture. A few are reviewed in part I and here in part II.

Use in Pediatrics

Attention-deficit hyperactivity disorder (ADHD) is a common childhood disorder characterized by inattention, hyperactivity, and impulsivity. In one study, researchers studied whether the use of acupuncture in children with ADHD was effective. The researchers examined 9 databases.8 The quality assessment of the selected studies was performed using Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). The study included a total of 14 studies involving 1185 patients evaluating the efficacy of acupuncture for ADHD treatment. Compared with conventional medicine alone, the meta-analysis indicated that acupuncture as an add-on to conventional medicine has a positive effect on improving conduct problems, learning problems, hyperactivity-impulsivity, and hyperactivity symptoms in patients with ADHD. Acupuncture alone was found to improve learning problems, hyperactivity-impulsivity, and hyperactivity symptoms, and had better total treatment efficacy than conventional medicine alone. No major adverse events were reported. The risk of bias was concerning. The authors concluded that evidence on the effectiveness of acupuncture is currently too limited to provide recommendations.

Another study looked at acupuncture for children with autism spectrum disorder.9 The study included 38 trials, and 2862 participants participated in qualitative synthesis and meta-analysis.

The quality of evidence for most indicators was considered very low by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. The results showed that acupuncture groups might have a higher clinical effective rate than nonacupuncture groups [relative risk (RR) = 1.33, 95% confidence interval (CI) = 1.25 to 1.41; heterogeneity: [chi]2 = 18.15, P = 0.64, I2 = 0%). There did not seem to be any adverse effects, but improvement seemed to be low, although better than no treatment. Thus, children with autism spectrum disorder might benefit from acupuncture because of its effectiveness and safety. Nevertheless, given the low quality of the evidence for the assessed outcomes and the high risk of bias of analyzed trials, the results should be regarded with caution.

Regarding children with cerebral palsy and dystonia, researchers collected and searched randomized controlled trials (RCTs) on acupuncture in the treatment of dystonia in children with cerebral palsy, going back from the establishment of the databases to August 2022.10 The meta-analysis included 15 studies.

The control group was treated with routine treatment, and the treatment group received acupuncture combined with routine treatment. The outcome index showed that the effect in the treatment group was better (Modified Ashworth Scale score: -0.52, 95% CI = -0.62 to -0.41, P < 0.01). The treatment group showed reduced muscle tension to a greater extent [integral electromyographic (iEMG) score: standard mean square deviation = -2.97, 95% CI = -4.87 to -1.06, P < 0.01]. The effective rate in the control group was 74.2% and that in the treatment group was 91.5% (odds ratio = 3.70, 95% CI = 2.02 to 6.78, P < 0.01). The funnel plot showed publication bias. The conclusions drawn were that acupuncture combined with routine training could improve muscle tension abnormalities and improve the efficiency of clinical treatment.

Dentistry

Root canal treatment for painful endodontic conditions such as apical periodontitis and irreversible pulpitis has been associated with a high incidence of postoperative pain. The analgesics commonly employed in dentistry may or may not be effective and may have side effects. Also, concerns have been raised regarding the transmission of coronavirus (COVID-19) as a result of the aerosols generated and prolonged chair side time required to perform root canal treatment. Acupuncture has been recently reported as treatment for the management of endodontic pain and on the analgesia success in patients with irreversible pulpitis.

In that review, the authors evaluated the current evidence for the addition of acupuncture in endodontics and its potential role in emergency pain relief.11 Five studies met the established criteria and reported the beneficial effects of acupuncture in reducing the failure of nerve block in patients with irreversible pulpitis, and in controlling both intraoperative and postoperative pain after root canal treatment.

Acupuncture was also reported to reduce anxiety surrounding the dental procedure and minimize the amount of analgesics consumed after the endodontic procedure.

Once more, the authors noted that more in-depth clinical research is required before any recommendation regarding the application of acupuncture in endodontic patients can be made. From this author's (E.F.) perspective, patient selection is important. In a small study conducted 50 years ago, acupuncture provided complete analgesia in a few patients, whereas in others, there was no effect at all for dental procedures.12

Other research examined laser acupuncture in the management of neurosensory alterations and motor disorders caused by dental treatment.13 After a search of databases up to April 2022, 4 studies were identified. Risk of bias was included. It was found that the recommended wavelengths ranged from 790 to 810 nm, with a frequency of at least 2 applications per week, and to a greater or lesser degree, all evaluated studies obtained an improvement in sensory or motor recovery of the facial nerves. The use of laser acupuncture presented itself as a viable alternative in dentistry for the treatment of paresthesia and facial paralysis due to its therapeutic potential in neuropathic treatment.

Cognitive Function and Head Pain

Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended treatment for patients with insomnia. However, the treatment is not equally effective in all patients. In this study, the rationale for combining CBT-I treatment with acupuncture is explored, and evidence supporting its use in treating insomnia and related comorbidities discussed.14 After extensive review of the practical, regulatory, and logistical issues with implementing a combined treatment and looking toward future directions for research, the authors conclude that growing evidence supports the effectiveness of acupuncture in treating insomnia and comorbid conditions. Further investigation of acupuncture as an adjunct to CBT-I is expected.

Acupuncture may reduce tension-type headache (TTH) frequency. Ovid Medline, Embase, and Cochrane Library were searched until September 29, 2022.15 The search included RCTs comparing acupuncture with sham acupuncture, no acupuncture, or other active therapies in adults with TTH. The primary outcome was TTH frequency. The secondary outcomes were responder rate and adverse event. The search included 14 studies involving 2795 participants. Acupuncture reduced TTH frequency more than sham acupuncture or other therapies, both after treatment [standardized mean difference (SMD) = -0.80, 95% CI = -1.36 to -0.24, P = 0.005) and at the follow-up period (SMD = -1.33, 95% CI = -2.18 to -0.49, P = 0.002).

Fibromyalgia

Fibromyalgia (FM) is a complicated syndrome characterized by widespread chronic pain, fatigue, sleep disturbances, cognitive dysfunction, and other complications. No specific treatment is universally effective. Several studies have shown that acupuncture may be beneficial, but clinical findings are inconsistent.

In one study, the authors summarized the operation method of acupuncture for FM.16 They conducted a comprehensive review of the mechanisms of acupuncture for FM, and integrated evidence-based scientific findings with a comprehensive and updated literature review. According to studies conducted using FM patients and animal models, acupuncture may improve symptoms in FM patients by regulating the afferent pain pathway and descending inhibitory pain pathways of various molecules, such as ASIC3, Nav1.7, Nav1.8, and TRPV1, and peripheral inflammation and the autonomic nervous system. Conclusions drawn were that there is growing evidence that acupuncture may be a promising therapy for treating symptoms in FM patients, although, as with other reports, further investigation is needed. Limitations to the findings are generally low-quality to very low-quality evidence.

Tinnitus

Tinnitus is a common otologic symptom that affects quality of life, especially in patients who develop it after chemotherapy. Effective therapies are few. Studies have compared traditional therapy, acupuncture, and moxibustion treatment. Although all have shown some benefit, evidence remains inconclusive. A systematic review and meta-analysis of RCTs evaluated the efficacy and safety of acupuncture and moxibustion for primary tinnitus through December 2021.17 Database search was supplemented by subsequent periodic scrutiny of unpublished and ongoing RCTs from the Cochrane Central Register of Controlled Trials (CENTRAL) and the WHO International Clinical Trials Registry (ICTRP). Trials compared acupuncture and moxibustion with pharmacologic therapies, oxygen or physical therapy, or no treatment.

The main outcome measures were the Tinnitus Handicap Inventory (THI) and efficacy rate; secondary outcome measures were the Tinnitus Evaluation Questionnaire (TEQ), Pure Tone Average (PTA), visual analog scale (VAS), Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), and adverse events.

In all, 34 trials involving 3086 patients were studied. Results indicated that, compared with controls, acupuncture and moxibustion:

1. Resulted in significantly lower scores on the THI;

2. Achieved a significantly higher efficacy rate; and

3. Reduced scores on the TEQ, PTA, VAS, HAMA and HAMD.

The meta-analysis revealed that acupuncture and moxibustion have a good safety profile in the treatment of primary tinnitus.

Miscellaneous Conditions

Eczema is a common chronic inflammatory skin disease, characterized by intense itching. In one study, the authors sought to determine whether acupuncture can be effective for eczema as complementary treatment.

A search of systematic reviews/meta-analyses (SRs/MAs) in 8 databases provided 7 SRs/MAs.18 All were categorized as critically low quality. None of the reviews completed all the 27 items required by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) Checklist. On the base of GRADE system, 2 of the 12 outcomes were rated as moderate, and 5 outcomes were rated as low quality, whereas the others were regarded as very low quality. However, compared with the control group, the included reviews of the acupuncture group were safer and more effective. The conclusion should be read cautiously, because the quality of evidence was not high enough to support it.

Uremic pruritus (UP), another chronic disease, can seriously affect the quality of life of dialysis patients. A systematic review evaluated the efficacy and safety of acupuncture for the treatment of UP.19 For this review, the researchers searched 9 Chinese and English databases from their inception to December 31, 2021, and they retrieved a total of 214 studies. Seven RCTs (n = 504) were included in the meta-analysis performed. Results included effective rate, recurrence rates, and adverse events. Compared with conventional treatment, acupuncture was more effective in treating UP [risk ratio (RR) = 1.28, 95% CI = 1.09 to 1.50, P = 0.003]. In subgroup analysis, the efficacy rates of acupuncture and medications (oral and topical) were comparable (RR = 1.20, 95% CI = 0.98 to 1.47, P = 0.07). Acupuncture combined with hemodialysis was more effective than hemodialysis alone in relieving pruritus (RR = 1.42, 95% CI = 1.18 to 1.72, P = 0.0002). Adverse events were reported in only 3 studies, including 1 case of hyperphosphatemia in the medications group (RR = 0.29, 95% CI = 0.01 to 7.06, P = 0.45). None of the studies reported recurrence rates. The researchers concluded that acupuncture is a safe treatment modality for patients with UP receiving hemodialysis.

Regarding sexual function, some evidence indicates that acupuncture has positive effects on improvement of sexual dysfunction, with no serious side effects. Among 160 initially assessed articles, 13 articles were included.20 The findings showed that acupuncture improved sexual dysfunction in domains of desire, libido, erectile dysfunction, and anxiety, with no side effects.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a complex male dysfunction, mostly seen in young and middle-aged men. Although some meta-analyses on acupuncture for chronic prostatitis were published in 2018 and 2019, most of the included studies were low in quality. In this study, 9 electronic databases were searched from inception to March 1, 2022.21 The researchers included 11 trials (10 of them RCTs) of high-quality methodology involving 798. Meta-analysis showed that compared with sham acupuncture and Western medicine, acupuncture played superior roles for CP/CPPS patients in the pain score, NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) score, quality of life score, urinary symptom, and efficacy rate. Four RCTs described mild hematoma and pain in acupuncture and sham groups, whereas specific symptoms reported in Western medicine groups included nausea, abdominal pain, dizziness, and low blood pressure. Acupuncture would seem to exert measurable benefits on CP/CPPS, without adverse outcomes. However, this meta-analysis only included 10 RCTs, and RCTs with a larger sample size and longer-term observation are required.

Another recent study looked at the effect of acupuncture in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS).22 Literature search was performed of 4 Chinese databases and 6 English databases for studies published from the inception of each database to March 1, 2022. A total of 19 studies with 1365 participants were examined. Compared with the control group, the apnea-hypopnea index, lowest oxygen saturation, Epworth Sleepiness Scale, interleukin-6, tumor necrosis factor [alpha], and nuclear factor [kappa]-B indicators all exhibited statistically significant changes. Acupuncture was effective in alleviating the state of hypoxia and sleepiness and reduced the inflammatory response and disease severity among reported patients with OSAHS.

Pain after thalamic stroke is a reality that has proven difficult to manage. Meta-analysis showed in 11 trials that acupuncture seemed to be more effective than drugs for treatment of thalamic pain, as assessed by the VAS [mean difference (MD) = -1.06, 95% CI = -1.20 to -0.91, P < 0.00001], the present pain intensity score (MD = -0.27, 95% CI = -0.43 to -0.11, P = .001), the pain rating index (MD = -1.02, 95% CI = -1.41 to -0.63, P < 0.00001), and the total efficiency (RR = 1.31, 95% CI = 1.22 to 1.41, P < 0.00001).23 Other studies have shown that acupuncture may reduce spasticity and help aphasia in stroke victims.24,25

Veterinary Medicine

Acupuncture has become more popular and has evolved into one of the most used forms of integrative medicine interventions and nonpharmacologic therapeutic options for pain management in animals and humans.

Pain management in veterinary medicine has led to the establishment of a new concept of a multimodal approach and has become the current standard of care.26 Multimodal analgesia combines pharmacologic and nonpharmacologic techniques to optimize the quality and efficacy of analgesia and prevent the development of chronic or persistent pain.

Veterinary acupuncture has been used predominantly in horses and dogs, but its popularity in zoologic companion animals has increased as an adjunct therapy for treating musculoskeletal, neurologic, and gastrointestinal disorders, due to its minimal invasiveness and low risk of adverse events. The integrative use of acupuncture has become even more important with the increasingly limited use of opiates in veterinary medicine due to the opiate crisis.

Adverse Effects of Acupuncture

Acupuncture has generally been described as safe with few adverse effects. However, in one study, Lee et al27 described severe complications from the therapy in periocular acupuncture. Acupuncture around the eyes has been advocated for dry eye syndrome, glaucoma, myopia, amblyopia, ophthalmoplegia, allergic rhinoconjunctivitis, blepharospasm, and blepharoptosis.

This review collected cases of ocular injury as severe adverse events from previously published case reports of periocular acupuncture. A total of 14 case reports (15 eyes of 14 patients) of adverse events published between 1982 and 2020 were identified. This review article provides a summary of the reported cases and suggestions for the prevention and management of better visual function prognosis. Penetrating eyeball injuries, which were defined as injuries with at least one (entrance or exit) identified wound of the eyeball caused by acupuncture needles, were observed in 12 of the 15 eyes. Of the remaining 3, one sustained a hematoma due to medial palpebral artery trauma, the other had optic atrophy due to pressure caused by the retrobulbar hemorrhage, and the last one had blepharospasm due to orbicularis oculi muscle tremor injuries. The remaining 2 without ocular perforation were cases of traumatic cataracts.

Going Forward

A recent study aimed to provide a panorama of AI in acupuncture by characterizing and visualizing the knowledge structure, hotspots, and trends in global scientific publications.28 The United States had the highest volume of publications. Harvard University had the most publications among institutions. The Journal of Alternative and Complementary Medicine was the most active journal. The primary topics in this field concerned the use of AI in various aspects of acupuncture. "Machine learning" and "deep learning" were speculated to be potential hotspots in acupuncture-related AI research. Research on AI in acupuncture has advanced significantly over the last 2 decades with contributions from both the United States and China. The use of deep learning and machine learning in acupuncture will no doubt remain a focus of research in the coming years.

Conclusion

Acupuncture seems to have fewer side effects and less adverse effect than other forms of therapy. Nevertheless, patients should be informed of extremely low risks of infection, minimal pain at the needling site, and occasional stiffness. Its effectiveness in a wide realm of conditions is variable. Although there are many innovative studies, the quality is generally low and numbers insufficient to make sweeping treatment changes. Nevertheless, when other therapies prove inadequate, acupuncture may offer some relief, especially in combination with established treatments.

References