Acupuncture

Acupuncture is based on a complex theory of body functioning that is very different from the Western biologic approach. Briefly, it is believed that a free flow of energy or qi passes through 12 major pathways or meridians on the body. A balance of opposites also exists, known as yin and yang. Disease is believed to result from a disruption in the normal flow of this energy.

Treatment Method

Acupuncture involves the insertion of thin, solid, metallic needles into specific points on the meridians. It is believed that this alters the flow of energy and thereby produces improvement. Approximately 400 acupuncture points exist. Fortunately, not all these are used in a single session! Four to 12 points are typically used in a session.

For those wary of needles, methods other than needle insertion may be used to stimulate acupuncture points. The application of finger pressure to these points is known as acupressure or, in Japan, shiatsu. Small hot cups are placed on points with cupping, and electrically stimulated needles are used with electroacupuncture. Transcutaneous electrical nerve stimulation (TENS), a variant of electroacupuncture, sometimes is used. In moxibustion, smoldering fibers of an herb, Asian mugwort or "moxa," are placed on acupuncture points or are used to heat needles that are then placed in acupuncture points.

How could a needle stuck into the skin possibly provide pain relief and other medical benefits? Many answers to this question have been proposed. As noted, from a traditional Chinese medicine perspective, the insertion of needles is believed to alter the flow of energy in such a way that it produces therapeutic effects. From a Western scientific viewpoint, various possible mechanisms have been explored. One explanation for the pain-relieving effects of acupuncture is that it releases opioids, chemicals produced by the body that decrease pain. Other studies indicate that levels of another chemical, serotonin, are altered by acupuncture. Studies on the brain using magnetic resonance imaging (MRI) indicate that acupuncture may change the activity in specific pain-related brain regions. Acupuncture also may decrease stress or, in some situations, act as a placebo. In the end, it may be found that multiple processes are involved.

Studies in MS and Other Conditions

A large number of studies have evaluated the effectiveness of acupuncture. Unfortunately, many of these studies have been small and not well conducted. To attempt to understand the possible medical benefits of acupuncture, the National Institutes of Health (NIH) organized a 12-member panel in 1997 to review the studies on acupuncture (1). The panel concluded that there existed "clear evidence" for acupuncture's effectiveness in relieving nausea and vomiting associated with surgery, chemotherapy, and possibly pregnancy. Evidence for effectiveness also was found for pain after dental procedures and several other types of pain. The report concluded that "the data in support of acupuncture are as strong as those for many accepted Western medical therapies" and that acupuncture was a "reasonable option" for some conditions.

It is surprising how few studies have evaluated acupuncture in multiple sclerosis (MS). In 1974, a Canadian study of eight people with MS showed that a few had some mild and brief benefits (2). However, there did not appear to be long-lasting effects. In 1986, a very small study of two people with MS showed that multiple MS symptoms improved (3). A recent preliminary study indicates that acupuncture may improve MS-related bladder difficulties.

Interesting and contrary results have been obtained in small studies of the effects of acupuncture on MS-associated muscle stiffness, which is also known as spasticity. One study evaluated four people with MS—two of these people were wheelchair-bound and the other two were able to walk (4). Improvement in spasticity was seen in the two people who were able to walk but not in those who were wheelchair-bound. A 1986 study of 28 people with MS evaluated responses to stimulation at acupuncture sites (5). Interestingly, acupuncture sites were more sensitive in people with MS, and needle insertion provoked stiffness and muscle spasms. These findings may simply reflect a generalized MS-associated skin hypersensitivity or vulnerability to muscle stiffness.

Two large surveys have evaluated the effects of acupuncture on people with MS. At the Rocky Mountain Multiple Sclerosis Center, we conducted a web-based survey on acupuncture on our CAM website, www.ms-cam.org. The preliminary results have been reported (6) and may be viewed at the website. Among more than 1,000 respondents, about 20 percent had used acupuncture since they were diagnosed with MS. The symptoms that were reported to be improved most frequently were pain and anxiety— about two-thirds reported improvement with these symptoms. Other symptoms that were reported by 50 to 60 percent of people to be improved were fatigue, depression, muscle stiffness, numbness, and insomnia. Acupuncture was reported to be well-tolerated generally. About 4 percent noted worsening of a pre-existing MS symptom with acupuncture. About 4 percent also noted that acupuncture caused a new symptom—the most common new symptoms were dizziness, pain, and decreased balance.

Another survey evaluated acupuncture use in 217 people with MS in British Columbia (7). The preliminary results of this survey indicate that approximately two-thirds reported beneficial effects. Many symptoms were improved, including pain, spasticity, bowel and bladder difficulties, tingling, weakness, walking difficulties, incoordination, and sleep disorders. The few side effects that were reported were pain and soreness at the needle site and a worsening of some symptoms (fatigue, spasticity, dizziness, and walking unsteadiness).

Overall, the results of these surveys are promising. However, it must be kept in mind that these are self-assessment surveys, not formal clinical trials.

Some studies have evaluated the effectiveness of acupuncture for symptoms that may occur with MS. In these studies, however, the underlying disease was not MS. Limited studies suggest beneficial effects of acupuncture for weakness in people with strokes. In studies of variable quality, it has been found that acupuncture may be effective for other symptoms that may occur with MS, including anxiety, depression, pain (including headache, facial pain, low back pain, and neck pain), dizziness, sleeping difficulties, and urinary difficulties.

An important issue for MS is whether acupuncture has an effect on the immune system. At this time, the impact of acupuncture on immune-system activity is not well understood. Although no studies have been done specifically in people with MS, acupuncture studies on immune-system activity have been done in people with various forms of cancer and rheumatoid arthritis. Acupuncture has been associated with stimulating, inhibiting, and having no effect on the immune system. Because of these mixed results, further studies are needed to clarify this area.

Given the probable benefits of acupuncture in other medical conditions, it would be reasonable to pursue detailed studies of its effects in MS. Rigorous studies of the effect of acupuncture on the course of the disease would be expensive and difficult. In contrast, it would be feasible to evaluate the effects of acupuncture on some MS-associated symptoms, including pain, spasticity, weakness, and urinary disorders. If acupuncture were found to be effective for symptoms, it could be a useful therapy. However, the treatment of chronic symptoms might need to be long-term, which may not be practical.

Side Effects

In general, acupuncture is a well-tolerated procedure, especially when done by a well-trained acupuncturist. The NIH panel that evaluated acupuncture stated: "the occurrence of adverse events ... has been documented to be extremely low"(1). The panel also concluded that acupuncture was "remarkably safe with fewer side effects than many well-established therapies." Mild side effects include bruising at acupuncture sites, needle pain, fatigue, and bleeding.

In one report, over a 20-year period, only 216 serious acupuncture-related complications were reported worldwide. Two other studies, each of which assessed about 30,000 acupuncture treatments, found no serious complications and approximately 40 minor side effects, such as nausea and fainting. Serious complications often are caused by poorly trained or negligent acupuncturists.

For people with MS, it is important to realize that acupuncture may produce drowsiness in up to one-third of people. This effect could conceivably be worse in people who have MS-associated fatigue or in those who take potentially sedating medication such as lioresal (Baclofen), tizanidine (Zanaflex), or diazepam (Valium).

Other rare risks are associated with acupuncture. Sterile disposable needles should be used to avoid hepatitis and AIDS. People with damaged or prosthetic heart valves should probably not be treated with acupuncture because of the risk of infection. People who take blood-thinning medication (warfarin or Coumadin) or who have bleeding disorders may occasionally experience bruising or, more rarely, bleeding complications.

Electroacupuncture may produce heart-rhythm abnormalities in people with a pacemaker, and the fumes from moxibustion may worsen breathing in people with asthma. Acupuncture to the chest should be done with caution or avoided to prevent lung or heart injury. These and other precautions of acupuncture are shown in Table 4.1.

Practical Information

Acupuncture usually is done once or twice weekly. Sessions typically last about 50 minutes and cost $60 to $200. The length of time required for a course of treatment varies. If a beneficial response occurs, it should usually be noted after six to ten sessions. The length of a complete course of treatment depends on the specific symptoms and the underlying disease process. A longer treatment course may be necessary for MS and other chronic diseases.

Approximately 10,000 licensed acupuncturists practice in the United States, 3,000 of whom have M.D. or D.O. training. Organizations that can be helpful in obtaining information about acupuncture and locating an acupuncturist include:

■ Acupuncture and Oriental Medicine Alliance (AOMA) , 6405 43rd Avenue Court. NW, Suite B, Gig Harbor WA 98335 (253-851-6896) (www.aomalliance.org)

TABLE 4.1. Precautions with Acupuncture Use

Avoid with: Blood-thinning medication (warfarin or

Coumadin) or bleeding disorder Damaged or prosthetic heart valves Pacemaker (electroacupuncture) Use caution with: Immune-suppressing drugs or conditions Pregnancy Metal allergy

Acupuncture sites in thorax (risk of lung or heart injury)

■ American Association of Acupuncture and Oriental Medicine, P.O. Box 162340, Sacramento CA 95816 (866-455-7999) (www.aaom.org)

■ National Certification Commission for Acupuncture and Oriental Medicine 11 Canal Center Plaza, Suite 300, Alexandria VA 22314 (703-548-9004) (www.nccaom.org)

■ A listing of physicians or osteopaths who have acupuncture training is available from the American Academy of Medical Acupuncture (800-521-2262) (www.medicalacupuncture.org)

Conclusion

Acupuncture usually is well tolerated, but rare adverse effects do occur. Variable results have been obtained in studies of MS and acupuncture. In small and preliminary studies, MS-associated symptoms that have responded to acupuncture include anxiety, depression, dizziness, pain (including headache, facial pain, low back pain, and neck pain), bladder difficulties, sleeping difficulties, and weakness.

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