Report on the 10th Annual Symposium of Society for Acupuncture

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Conference Report

Report on the 10th Annual Symposium of Society
for Acupuncture Research (SAR)
- held at Harvard Graduate School of Education, Cambridge, Massachusetts,

November 15-16th 2003

Jongbae Park

Jongbae Park
research fellow
                          The SAR symposium has become a regular                    research can be totally objective and free of
Peninsula Medical
School, Universities of   feature of the acupuncture research calendar. It          subjectivity is not congruent with what we know
Exeter & Plymouth, UK     started with a small group of people who longed           from the philosophy and sociology of science.    for an open arena in which to discuss acupuncture         Evidence does not speak for itself and must be
                          research without any professional tensions or             judged for quality and likelihood of error.
                          barriers, and celebrated its tenth anniversary this       Interpretation is never completely independent of
                          year. It is a worthy aim to establish a successful        a scientist’s beliefs, preconceptions, or theoretical
                          society in this under-funded field, and I was             commitments.” The acupuncture community in
                          pleased to be able to attend this year’s symposium        the Western world has roots in a radical critique
                          and meet many acupuncture researchers. I have             of biomedicine, he said. Acupuncture researchers
                          summarised a selection of the presentations for           have a parallel responsibility to examine research
                          readers to share. Please note that further details of     critically and to perform the research, he concluded.
                          the symposium can be obtained from the society’s               Kathleen Hui presented functional MRI
                          website (                    images of 24 acupuncture-naïve healthy volunteers
                              The meeting started with an overview of the           after they had received manual acupuncture
                          symposium by Helen Langevin, one of the co-               stimulation to ST36 in the right leg, by rotating at
                          chairs. Ted Kaptchuk’s lunch time lecture, Should         the rate of 1Hz for two minutes. The same
                          acupuncture be researched or should we research           procedure was repeated once after a three minute
                          the research? was entertaining and enthusiastic.          interval. For control intervention, tactile stimulation
                          He raised some thought provoking questions                was performed over the acupoint. This report of an
                          about the value and meaning of placebo-                   fMRI study of acupuncture focusing on the
                          controlled randomised controlled trials (RCTs) in         cerebellum, which was said to be the first, found
                          acupuncture research. Research into external              that the images of volunteers who experienced de
                          generalisability and the question of whether the          qi, acupuncture-specific sensation, showed
                          results of RCTs have ecological validity raise            extensive reductions in the signal in the anterior
                          serious concerns about the uncritical acceptance          and posterior lobes of the vermis, medial and
                          of the RCT as the sole basis of accurate clinical         lateral hemispheres of the cerebellum, indicating
                          knowledge. He suggested that the ideal placebo-           that multiple regions related to nociception,
                          controlled RCT is the least subjective, fairest,          cognition, affect, balance, and sensorimotor
                          most explicit and standardised procedure ethically        functions were involved. In addition, a similar
                          possible for generating evidence of clinical              response with reductions in signal intensity was
                          efficacy, although it might have its own biases,          observed in the cerebral limbic and subcortical
                          distortions and systematic errors. Kaptchuk said it       network and in the brainstem. Interestingly, in the
                          may be that clinical truth is independent of the          occasional subjects who experienced sharp pain,
                          method of its production. He added: “The claim            signal increases predominated in the entire brain.
                          that medical research or any other scientific             She concluded by suggesting that the cerebellum

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                                                                                                               Conference Report

might play a coordinating role within the cerebral        temperature, skin conductance, and blood
network in mediating diverse acupuncture                  pressure were monitored during the sessions. The
modulatory actions. Several questions remained            results suggest that both electroacupuncture and
unanswered, including: whether information given          manual acupuncture reduced sensory and affective
to the volunteers prior to consent could have             ratings of pain stimuli, but the changes did not
affected their expectation; and, was the defining         reach statistical significance. No significant
acupuncture-specific sensation well enough                autonomic effects of the acupuncture treatments
differentiated from pain sensation?                       and interaction between responses to pain and
    Vitaly Napadow reported the difference in             treatment were found. Additionally, the study
fMRI between manual acupuncture and                       explored an acupuncture sensation scale based on
electroacupuncture. Fifteen acupuncture-naïve             a visual analogue scale of 10 descriptive words
healthy volunteers were studied after receiving           and reported finding three main factors - sharp
manual rotating at the rate of 1Hz or                     pain factor, heaviness factor and diffuse factor –
electroacupuncture stimulation at 2Hz and 100Hz           and that there was a significant correlation
to ST36 in the right leg for two minutes. The same        between analgesia and the ratings on numbness
procedure was repeated once after a three minute          and soreness.
interval. Tactile stimulation was performed over              Shin Lin reported on three recent collaborative
the acupoint as a control. Reductions in the signal       research studies conducted at the several
were found in limbic and paralimbic structures            laboratories under International Alliance for
including the amygdala, anterior hippocampus,             Mind/Body Signalling and Energy Research.
and the cortices of the subgenual and retrosplenial       The first was using the single square voltage
cingulate, ventromedical prefrontal cortex,               pulse method measuring electrical conductance
frontal and temporal poles. The anterior insula           before polarisation at 24 Jing-Well acupoints
and SII also demonstrated signal reductions.              (located at the edge of the base of finger nail)
Vitaly Napadow’s interpretation of the results            in a group of qigong practitioners after a
was that, overall, manual stimulation produced            session of qigong practice in comparison with
more widespread signal reductions than                    non-practitioners. It was found that the electrical
electroacupuncture, which produced more signal            conductance could increase by 50%, although the
increases, particularly at low frequency. It was          sample size was very small. In the second study,
thought-provoking to hear a novel proposal for            the heart rate variability of the qigong practitioners
analysing de qi, a psycho-physical sensation              during regulation of respiration showed a strong
which is acupuncture specific.                            low frequency peak corresponding to the deep
    Jian Kong presented the results of a sham             breathing cycles. During a deep meditative state
controlled, randomised controlled trial assessing         involving mind regulation, a high frequency peak
the different effects of electroacupuncture and           similar to that seen during deep sleep was
manual acupuncture on the psycho-physical and             observed, suggesting that qigong practice might
analgesic responses to noxious heat stimuli in 11         increase parasympathetic and decrease sympathetic
healthy volunteers. Volunteers pre-rated the              responses, with subsequent modulatory effect on
sensory intensity and unpleasantness of heat              the autonomic nervous system. In the third study,
stimulation (36Hz, 40-52º Celsius, four second            it was found - using laser Doppler flowmeter - that
duration) applied across the four extremities             the local blood flow in the hands quickly increased
during the first and second sessions of five. Only        when the qigong practitioners were asked to
those who demonstrated reliable ratings received          ‘send qi to the hands’ during mind regulation.
an identical series of noxious stimuli before and         A question may arise about publication bias as the
after one of the three modes of acupuncture               experiments can only be done on highly selected
(manual acupuncture, electroacupuncture, or               subjects.
sham acupuncture) in the order allocated by                   Richard      Hammerschlag         systematically
randomisation and performed at the LI4, ST36              reviewed all randomised controlled trials of
and SP6 on the right side. Heart rate, palm skin          acupuncture from 1997 to 2002 under the sub-

ACUPUNCTURE IN MEDICINE 2004;22(1):44-47.                                                                                    45
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Conference Report

                title: Pilot test of a CONSORT and STRICTA based         back pain patients who received acupuncture may
                quality of reporting instrument. A new instrument        have had a better outcome.
                called Oregon CONSORT STRICTA instrument                      Albrecht Molsberger reported the results of
                (OCSI) was developed to assess the quality of            German Research of Acupuncture for shoulder
                RCT, converting 27 items from both the CONSORT           pain (GRASP) recruiting 427 patients who had
                and STRICTA guidelines into a series of questions,       only one sided shoulder pain rating 50 or higher
                retaining the numbering scheme and the original          on a visual analogue scale. Treatment was given
                wording. Each question was to be scored on a             by 48 office-based orthopaedists who have
                three-point scale (Yes=2, Partial=1, No=0) or Not        attended 140 hours of training. Patients (age 25-
                Applicable (NA) based on the composite scoring           65) were allocated through randomisation into
                of its sub-questions. In order to identify relevant      either verum group (n=154) to receive 15
                RCTs, Medline (Nov 1997-Oct 2002), and the               treatments (period not stated), sham group to
                database of the Oregon College of Oriental               receive 15 treatments of non-specific needling,
                Medicine library were searched, along with the           minimal effective acupuncture, or conventional
                speaker’s own personal database. The predefined          conservative orthopaedic treatment (COT). The
                inclusion criterion was a full article published in      primary endpoint was numbers achieving pain
                English, testing a treatment with acupuncture            reduction of 50% or higher on VAS at three
                needles using manual or electrical stimulation. A        months post-treatment. Secondary endpoints were
                total of 105 articles were identified from 53            pain reduction of 50% or higher on VAS directly
                journals in 16 countries. Eight of them were             after the end of the treatment, and global
                randomly selected and five raters used OCSI to           assessments on a four-score scale directly after the
                assess their quality, later meeting to discuss their     end of the treatment. The results after three
                scores, clarify assumptions and reach consensus.         months were: verum 78%, sham 47%, and COT
                (Inter-rater reliability and validity data were not      43%. The difference between verum and sham or
                reported.) The remaining articles were then              COT was significant. Conclusively, acupuncture is
                randomly distributed for single-rater scoring. The       an important supplement in the management of
                full report is awaited and will be presented later.      chronic shoulder pain.
                     Hugh MacPherson presented the results of a               Rosa Schnyer presented a therapist-blind
                pragmatic randomised controlled trial testing            (organised in such a way that the treatment
                acupuncture for low back pain. The study                 provider was not aware of the group allocation)
                recruited 241 patients, who were identified by           and assessor-blind, randomised controlled trial of
                their general practitioners in York. Patients who        acupuncture as a treatment for major depression.
                joined the study were randomly allocated either to       The aim was to evaluate the effectiveness of
                the option of up to 10 individualised acupuncture        acupuncture as a treatment for major depression
                treatments or to a control group. Both groups            as compared to both non-specific acupuncture and
                continued to receive conventional primary care           to a waiting list control. Individuals aged 18-65
                from their general practitioner. The key outcome         meeting DSM-4 diagnostic criteria were recruited
                measure was the bodily pain subscale (range 0-           through an exclusion process. Treatments, which
                100 points) of the SF-36 at 12 and 24 months post        were individually tailored on the basis of their
                randomisation, where a difference of five points is      pattern configuration using treatment manual,
                considered to be clinically significant. Patients        were provided twice a week for the first four
                received an average of 8.6 treatments. There was         weeks and once per week for the following four
                no statistically significant difference at 12 months     weeks. As control groups, the non-specific group
                (95% CI [-0,6, 12.6]), but a marginally significant      received valid and credible acupuncture that did
                difference (95% CI [1.8, 16.2]) at 24 months in          not directly address depression, and the waiting
                favour of acupuncture. It was concluded that it is       list group had to wait before they received specific
                possible to conduct a large pragmatic RCT in a           treatment. The outcome was measured using the
                primary care setting, and that at longer term            Hamilton Rating Scale for Depression. There was
                follow-up (such as 24 months) the group of low           no statistical difference between the groups. The

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                                                                                                           Conference Report

findings of the presenter’s previous study, that          acupuncture. The primary outcome was VAS of
there was a greater improvement with specific             pain, the McGill Pain Questionnaire, and the
acupuncture than with non-specific, were not              physical functioning sub-scale of the SF-36.
confirmed by this bigger study.                           Secondary outcomes included fatigue, sleep, well
    Karen Sherman shared the results of a sham            being, and general functioning. Participant
controlled, subject-, assessor- and data analyst-         masking and adverse effects were ascertained by
blind, RCT of acupuncture for the treatment of            self-report. The results showed no significant
fibromyalgia. One hundred patients with                   differences between groups. Overall, nearly half
fibromyalgia recruited via multiple methods,              of all participants had clinically meaningful
including media, notices, and letters to support          improvements in pain, fatigue, sleep and general
groups, were allocated into one of the following          well-being, with no significant difference noted
four treatments twice weekly for 12 weeks:                between groups. Participants’ masking was
acupuncture specifically designed to treat                adequate throughout the trial and no serious
fibromyalgia; acupuncture for an unrelated                adverse effects were noted. It was concluded
condition; needle insertion at non-acupoint               that the specific effects of acupuncture did not
locations; or non-penetrating simulated                   improve the primary symptoms of fibromyalgia.

ACUPUNCTURE IN MEDICINE 2004;22(1):44-47.                                                                                47
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                                  Report on the 10th annual symposium of
                                  society for acupuncture research (SAR)
                                  Jongbae Park

                                  Acupunct Med 2004 22: 44-47
                                  doi: 10.1136/aim.22.1.44

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