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Medicine involves a number of events and environments that are stressful, both for patients and (if you include qualifying examinations) for students. This issue presents some evidence that acupuncture seems to help a bit.
The intensive care unit is a stressful place, particularly to patients who are intubated. Zheng and colleagues report a sham-controlled trial which strongly suggests that acupuncture reduces the dose of sedative needed by these patients. However, our expert commentary by Farquhar-Smith highlights some limitations and suggests caution and more evidence in different patients and settings before it can be adopted.
The various procedures involved in in vitro fertilisation are known to be challenging, and so women will welcome our second sham-controlled trial in which Isoyama and colleagues show an effect of acupuncture on anxiety, though admittedly small groups.
Our next study involved students working up to their final examinations, a nervous period for anyone, the memory of which will resonate with readers. Dias and colleagues also randomised participants, but this time the control group had no acupuncture rather than sham acupuncture. The students benefitted, but we do not know precisely how. Rather ironically, one student stopped acupuncture because he found the needles stressful.
Many of the symptoms of anxiety involve the autonomic nervous system. One research group from Tsukuba, Japan, has previously shown that the pupil diameter narrows after acupuncture, due to increased parasympathetic stimulation. In the group's latest paper, Mori et al show that the effect can be observed even if the experiments are conducted in daylight instead of a dark room.
Still pursuing the topic of autonomic changes, Suzuki and colleagues show an effect in patients with chronic obstructive pulmonary disease that seems to involve the opposite change – parasympathetic inhibition or sympathetic stimulation. Another possible speculative mechanism could be direct effects on the respiratory muscles. In their case series of 26 patients, breathlessness assessed by Borg score improved after a course of acupuncture. The benefits were clinically relevant, and interestingly were more marked in patients with more severe disease.
Neurophysiological studies suggest that these different neuromodulatory effects of acupuncture can require different techniques of stimulation, so analysing precisely how practitioners manipulate the needle is important. Davis and colleagues present an innovative study using apparatus that directly measures the movement of the needle during stimulation.
So where should this stimulation be given? Acupuncture ‘points’ clearly exist on charts, but can we identify them in the body? It is probable that some effects like inactivating myofascial trigger points are best needled in ‘the right place’. For other effects, there is precious little evidence that ‘points’ have any specific distinguishing features, though the search goes on for features such as electrical phenomena. The literature on this is still inconclusive, as we saw in our December issue. Now two more papers are presented which are undoubtedly interesting and add new rigour. They describe technical advances using standardised multiple measurements. Kramer and colleagues use a fixed array of electrodes (figure 1) and Rezaei and colleagues use a special four-electrode device. Neither claims conclusive results, but both provide food for thought.
Inoue and colleagues take point-finding to a new level of precision by using x-ray imaging to locate the needles in their case series of patients with resistant back pain.
In our laboratory study section, Zhang and colleagues show that acupuncture enhances the effect of cucurmin in preventing the development of liver fibrosis.
Our shorter items show the usual fascinating diversity of acupuncture, but are united in suggesting that acupuncture may promote changes in tissue levels of various molecules: calcium in the tendons, cytokines in the fingers, and fat in the ageing skin.
But, first of all, turn the page and enjoy a cheerful tale of veterinary acupuncture from South America, told in charming images.
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