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In this issue
  1. David John Carr1,2
  1. 1Institute for Medical and Biomedical Education, St George's University of London, London, UK
  2. 2Royal London Hospital for Integrated Medicine, University College London Hospitals NHS Trust, London, UK
  1. Correspondence to Dr David John Carr, Institute of Medical and Biomedical Education, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK; davidcarr{at}

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This latest issue of Acupuncture in Medicine opens with two editorials. The first, by Philip Peplow from New Zealand, outlines our current understanding of how acupuncture, especially low frequency (2–15 Hz) electroacupuncture (EA), influences insulin signalling pathways in skeletal muscle and adipose tissue (figure 1, reproduced from Jung and Choi1). His commentary accompanies two novel animal experiments investigating the molecular mechanisms of action underlying the glucose-lowering effect of EA, which is now relatively well established following >30 clinical and preclinical studies in diabetic animals and humans. Liao et al have demonstrated that EA triggers the MAPK/ERK (mitogen-activated protein kinase; extracellular signal-related kinase) pathway through activation of insulin receptor substrate 1 (IRS1), meaning it may exert some of its effects through regulation of gene transcription. These effects appear separate from the Akt/PKB (protein kinase B) pathway, which is believed to mediate the principle metabolic effects of insulin including cellular uptake of glucose, facilitated by translocation of glucose transporter 4 from intracellular vesicles to the plasma membrane. Electrical stimulation may indeed be important here as MAPK and ERK are activated by muscle contraction and ERK phosphorylation has been demonstrated following EA but not MA (manual acupuncture) in a previous study in steroid-induced insulin-resistant rats.2 The second linked paper by Tzeng et al reveals that cell adhesion molecules may also be involved. Irrespective of the precise molecular mechanisms, the potential role of acupuncture in the management of insulin resistance is exciting, especially given its increasing prevalence worldwide. Although further research is required, the potential benefits are applicable not only to the management of diabetes mellitus (particularly type 2), but also other insulin resistant states including obesity, polycystic ovarian syndrome (in which EA is already known to enhance insulin sensitivity2) and gestational diabetes, in which insulin resistance is exacerbated by the production of various ‘anti-insulin’ hormones by the placenta during pregnancy.

Figure 1

A simplified overview of the insulin-signalling pathway, reproduced from Jung and Choi. When insulin binds to its receptor, insulin receptor substrate 1 (IRS1) is phosphorylated and activated. This triggers phosphatidylinositol 3-kinase (PI3K) to convert phosphatidylinositol 4,5-bisphosphate (PIP2) into phosphatidylinositol 3,4,5-trisphosphate (PIP3) within the plasma membrane of the cell. PIP3 is a second messenger that activates phosphoinositide-dependent protein kinase 1 (PDK1) and recruits Akt, also known as protein kinase B (PKB). Akt regulates a number of important metabolic processes, as shown (red up arrows indicate upregulation and down arrows indicate downregulation). Activation of IRS1 can also directly activate the Ras-mitogen-activated protein kinase (MAPK) pathway, via the Son of Sevenless (SOS) genes and MAPK kinase (MEK). The MAPK pathway activates transcription factors and genes that are involved in the regulation of cell growth.

Speaking of pregnancy, the second editorial by João Bosco Guerreiro da Silva from Brazil provides the inspiration for our October cover together with a contemporary overview of the evidence-based applications of acupuncture and related techniques in pregnancy. His commentary is linked to a review article by yours truly, which I hope will provide additional reassurance to our readers regarding the safety of acupuncture in pregnancy. Whilst recent systematic reviews in Acupuncture in Medicine and elsewhere have highlighted the safety of obstetric acupuncture in general, there arguably remains some controversy over so-called ‘forbidden points’, which formed the subject of a series of three debate articles in these pages back in 2011. In summary, there is absolutely no objective evidence of harm even when ‘forbidden’ points are needled (at any stage of pregnancy), and this must be weighed against the multiple potential benefits of antenatal acupuncture, which represents a safe, effective and drug-free treatment option for pain relief at a time when several classes of pharmacological analgesic are often restricted for fear of fetal renal impairment, premature closure of the ductus arteriosus and/or neonatal opiate withdrawal.

This issue's editor's choice article is a prospectively registered sham-controlled RCT of peri-operative EA as part of multimodal analgesia for inguinal hernia repair, from a group that recently presented their findings from a similar RCT among patients undergoing radical prostatectomy.3 Elsewhere you will find a systematic review of acupressure for anxiety and two studies of transcutaneous electrical nerve stimulation (TENS) for posturally-induced cardiovascular deconditioning in healthy human volunteers and experimental low back pain in rats, respectively. In addition, we have trials of MA for smoking cessation and EA for overactive bladder syndrome, and finally an animal study assessing the potential role of EA pretreatment in the prevention of fatigue, reflecting the variety you will no doubt have come to expect from Acupuncture in Medicine.


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  • Twitter Follow David John Carr at @IntegrativeMFM

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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