Evidence-Based Complementary and Alternative Medicine
Volume 2018, Article ID 8596918
Clinical Efficacy of Acupuncture on Rheumatoid Arthritis and Associated Mechanisms: A Systemic Review
Pei-Chi Chou (1) and Heng-Yi Chu (2)
1 School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
2 Department of Rehabilitation, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Abstract
Objective. The objective of this review is to investigate the detailed existing scientific information about the clinical efficacy of acupuncture on rheumatoid arthritis (RA) conditions and to reveal the proposed mechanisms. Methods. We searched the PubMed, EMBASE, Cochrane, AMED (Allied and Complementary Medicine), NCCAM (The National Center for Complementary and Alternative Medicine), and CNKI (China National Knowledge Infrastructure) databases to identify relevant monographs and related references from 1974 to 2018. Chinese journals and theses/dissertations were hand searched. Results. 43 studies were recruited. Each research was analyzed for study design, subject characteristics, intervention, selected acupoints, assessment parameters, proposed mechanisms, and results/conclusions. Conclusions. In our review, we concluded that acupuncture alone or combined with other treatment modalities is beneficial to the clinical conditions of RA without adverse effects reported and can improve function and quality of life and is worth trying. Several important possible mechanisms were summarized including anti-inflammatory effect, antioxidative effect, and regulation of immune system function. However, there is still inconsistency regarding the clinical efficacy and lack of well-designed human/animal double-blinded RCTs. Future discussion for further agreement on taking traditional Chinese medicine (TCM) theory into consideration as much as possible is a top priority.
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https://www.hindawi.com/journals/ecam/2018/8596918/"According to traditional Chinese medicine (TCM) theory, RA is categorized under the 'Bi' or impediment disease, which means a group of diseases caused by the invasion of wind, cold, dampness, or heat pathogen on the meridians involving muscles, sinews, bones, and joints, manifested by local pain, soreness, heaviness, or hotness, and even articular swelling, stiffness, and deformities, also referring to arthralgia.
"Acupuncture has been regarded as an important part of TCM and has been used for thousands of years to treat various clinical disorders including 'Bi' or RA like conditions based on TCM theory. There has been a trend to use complementary and alternative medicine (CAM) as 30–60% of rheumatic patients used CAM [9]. In the United States, a small but significant linear increase in the use of acupuncture (from 1.4% in 2007 to 1.5% in 2012 of the US adults) was reported [10]."
"However, discrepancy exists between previously conducted investigations and reviews regarding clinical efficacy of acupuncture for RA [14, 15]. As early as in 1985, a literature analysis of the efficacy using acupuncture for RA was done by Bhatt-Sanders and no conclusion was drawn [16]. Ernst and Posadzki suggested that the evidence to support the effectiveness of CAM as a treatment option for RA has also been ambiguous [17]. On the other hand, Hughes concluded that acupuncture elicited a range of effects which contributed to improvements in RA patients’ quality of life [18].
"The actual mechanism by which acupuncture works also remains controversial. Among all the proposed mechanisms, anti-inflammatory effect has been the most often mentioned which was supposed to provide nonanalgesic effects via suppression of inflammatory response, improvement of blood flow, or relaxation of muscle tone, but they are still largely conjectural [19]. Others include regulating plasma adrenocorticotropic hormone, serum cortisol levels, activity of synovial nuclear factor kappa B (NF-?B), and the release of endorphins [20–22]."
"According to the TCM theory, patients who suffer from the same disease may present different TCM syndrome patterns that also correspond to different biological processes and are associated with different related biomarkers [75]. Lu et al. indicated that RA patients may be divided into cold and heat pattern and they have different molecular signature processes and react differently to certain treatment [76], so theoretically RA patients may be treated by acupuncture without unanimous acupoints according to their TCM syndrome differentiation. These facts have led to obstacles when trying to conduct contemporary researches which critics may face in terms of methodology. Double-blinded RCT is thought to be the most optimal study design to establish scientific evidence, but acupoints selection by TCM theory would experience difficulties which may be the reason of the existing discrepancies between studies of human subjects. In addition, it is also difficult to classify animals into appropriate TCM syndrome categories like human. Another question is the standard localization of acupoints in animals and the correlation and difference between different species."
"Some authors provided better clinical efficacy using different needling techniques including warm needling [26–28, 33, 41, 55, 63, 65], plus herb steaming [29], needle-sticking method [59], reinforcing-reducing/twirling-reinforcing needling [27], and moxibustion [57, 66]."
"We found an interesting fact that acupoint ST36 was used in almost every research and followed by GB34 and LI4. According to TCM theory, RA should fit the disease condition called 'Bi' or impediment disease, which means any disease pattern that results from blockage of the meridians occurring when wind, cold, and dampness invade the fleshy exterior and the joints, and that manifests in symptoms such as joint pain, sinew and bone pain, and heaviness or numbness of the limbs as stated in Elementary Questions (Su Wen, bi lun). Distinction is made between three pattern types, each of which corresponds to a prevalence of one of those three evils: wind impediment (or moving impediment) characterized by wandering pain and attributed to a prevalence of wind; cold impediment (or painful impediment) characterized by acute pain and attributed to a prevalence of cold; damp impediment (or fixed impediment) characterized by heaviness and attributed to a prevalence of dampness. A fourth type, heat impediment, arises when the three evils transform into heat. The basic philosophy of how all the acupoints were selected derived from the above theory."
"Anti-inflammatory effect has been the most well-known mechanism of how acupuncture works for RA as many studies in this review used inflammatory biomarkers for comparison such as ESR, CRP, RF, IL, NF-?B, and TNF-a. Most of the studies comparing these biomarkers indicated the anti-inflammatory effect of acupuncture [22–24, 26, 31, 32, 37–39, 41, 43, 44, 50–55, 58, 59, 66]."
"Another possible mechanisms could be attributed to the antioxidative effect (such as inducing the increased activities of SOD and catalase in the serum of RA, alleviating oxidative stress and inflammation, and improving antioxidant and energy metabolic status) [33, 34, 47] and triggered release of endorphins [25] and regulation of immune function as IgG, IgA, and IgM decreased, while IgE did not change evidently after acupuncture in 12 RA patients [23, 32, 64–66]."
"Acupuncture has its root in TCM and traditionally TCM has one distinguished character; that is, it does not completely seek the specific pathogen and pathological changes in a specific organ or individual, but it seeks the disturbances among the self-controlled systems by analyzing all symptoms and signs. The TCM intervention is based on the differentiation of symptoms to clarify what is wrong in the self-controlled system. TCM seeks the therapeutic mechanism from the integrity and balance, in each individual and between the individual and the environment. The therapeutics work by activating and improving system connection and enhancing human resistance. The mechanism in TCM is not like modern medicine that seeks the mechanism from cellular or molecular perspectives [80]. In light of this, to attend simultaneously to a well-designed RCT with every possible variable controlled and TCM theory is extremely difficult. Future agreement on this issue warrants extensive discussion."
"In our review, we concluded that acupuncture alone or combined with other treatment modalities is beneficial to the clinical conditions of RA without adverse effects reported and can improve function and quality of life and is worth trying. Several important possible mechanisms were summarized including anti-inflammatory effect, antioxidative effect, and regulation of immune system function. However, there is still inconsistency regarding the clinical efficacy and lack of well-designed human/animal double-blinded RCTs. Future discussion for further agreement on taking TCM theory into consideration as much as possible is a top priority."
Comment: if "there is still inconsistency regarding the clinical efficacy and lack of well-designed human/animal double-blinded RCTs," it is not possible to conclude that acupuncture is beneficial.
