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This final issue of Acupuncture in Medicine for 2016 opens with two original papers focusing on the concept of neurophysiological acupuncture “dose”. Practitioners of Western medical acupuncture will probably already be familiar with the contemporary viewpoint that acupuncture needling stimulates the nervous system1 and that the degree of stimulation is a function of: (1) the number of needles inserted; (2) the needle retention time; and (3) the degree of needle manipulation, from nil (minimal acupuncture) through manual stimulation with variable frequency (manual acupuncture),2 to electrical stimulation (electroacupuncture). Thus, a dose-response is considered to exist between acupuncture interventions and clinical outcomes. In 2008, former Editor-in-Chief Adrian White, together with a panel of leading acupuncture researchers, highlighted the lack of research into what constitutes an adequate dose of acupuncture, and the risk of potentially unreliable conclusions if adequacy of dose is not given due consideration.3
Firstly, Armour and Smith present the findings of their narrative review of 11 randomised controlled trials of acupuncture for primary dysmenorrhoea (painful periods in the absence of any specific pelvic pathology, such as endometriosis).4 To be included, trials had to have ≥2 acupuncture treatment arms that differed with respect to ≥1 acupuncture dose components. They also considered the adequacy of treatment in cumulative terms (number and frequency of sessions over a treatment courses) and additionally examined for the potential impact of timing relative to menstruation, a unique consideration for this cyclical condition. Interestingly, in terms of dose, less appeared to be more when treating during the menses (suggesting heightened sensitivity to needling), whilst a greater number of needles appeared superior when treating during the premenstrual phase. Although their findings were contradictory, they highlight the importance of considering neurophysiological dose in future research.
Secondly, Lin et al take a closer look at the impact of varying acupuncture dose at the cerebral level using functional magnetic resonance imaging (fMRI) of the default mode network (DMN) of the brain in 58 healthy volunteers during needling at LI4, which is known to induce significant cerebral activation on fMRI.5 Relative to a single needle inserted at LI4, the authors examined the impact of: (1) manual stimulation of that one needle; and (2) insertion of two additional needles, 1.5cm proximal/distal to LI4. An additional comparator group receiving transcutaneous electrical nerve stimulation (at LI4) was also included as a non-penetrating control. Differential effects of the various interventions on the DMN were observed; a greater number of needles was associated with the strongest modulatory effect, suggesting an additive (or even synergistic) effect of multiple insertions.
Elsewhere in the issue, you will find a series of novel basic science reports examining mechanistic aspects of acupuncture in rat models of asthma, heroin addiction, Alzheimer's disease, local anaesthetic toxicity and migraine. These papers are followed by an interesting case series by Liang and Tian, who provided the inspiration for this month's cover image. Nine patients with chronic central serous chorioretinopathy were treated with 12 sessions of acupuncture at the extra point Erjian and evaluated subjectively by symptomatic review and visual acuity, and objectively by fluorescein angiography and optical coherence tomography. The results, albeit vulnerable to various types of bias due to study design, were encouraging and should pave the way for a controlled study of acupuncture for this ophthalmological condition. Finally, More et al report on the success of their acupuncture education program, in which 53 primary care providers were trained over a 3-year period in Florianópolis, Brazil. Positive lessons can be learnt from their approach, judging by the significant impacts seen on the number of acupuncture treatments provided in primary care and blossoming collaborations with local acupuncture specialists.
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