Acupuncture combines the Latin *acus* (needle) and *punctum* (a prick) [1]. From the historical record of Huangdi Neijin (the Yellow Emperor's Classic), acupuncture has been used in China as a therapeutic tool for at least 2000 years [2]. In ancient China, soldiers noted, after being wounded by arrows, that their pain often eased for quite a while [3]. Therefore, a cause-andeffect relationship was assumed between the arrow wound and the unexpected diminution of pain. However, acupuncture has been little known in the Western world until 1970s after U.S. President Nixon's historic visit to China in 1972 [4]. Following the initial excitement engen‐ dered by the press reports [5], acupuncture becomes one of the most popular treatments in alternative medicine (Figure 1), and accounts for more than 10 million treatments given annually in the United States [6]. Much interest was further engendered by tales by subsequent visitors to China who witnessed surgical operations being successfully performed on con‐ scious patients under acupunctural anesthesia [7-15]. Scientific studies using modern technol‐ ogy on acupuncture actually began in China in the late 1950s with further progress being made since the discovery of endogenous opioids in 1975 [2,16]. Much more advances have been made in more recent years in further understanding of the basic mechanisms underlying this millennium old medical treatment and its various clinical applications in the 21st century. This

Electro-acupuncture at "Fenglong" (ST 40) has some therapeutic effect on decreasing the content of total cholesterol and low-density-lipoprotein cholesterol in hyperlipidemic rats and improving the gene expression of ATP-binding cassette transporter A1, peroxisome prolifer‐ ator-activated receptor alpha, liver X receptor alpha and retinoid X receptor-alpha mRNA, so

and reproduction in any medium, provided the original work is properly cited.

© 2013 Cheng; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

Tsung O. Cheng

**1. Introduction**

http://dx.doi.org/10.5772/55252

**2. Hypercholesterolemia**

#### **Chapter 12**

### **Acupuncture in Cardiology**

Tsung O. Cheng

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55252

#### **1. Introduction**

Acupuncture combines the Latin *acus* (needle) and *punctum* (a prick) [1]. From the historical record of Huangdi Neijin (the Yellow Emperor's Classic), acupuncture has been used in China as a therapeutic tool for at least 2000 years [2]. In ancient China, soldiers noted, after being wounded by arrows, that their pain often eased for quite a while [3]. Therefore, a cause-andeffect relationship was assumed between the arrow wound and the unexpected diminution of pain. However, acupuncture has been little known in the Western world until 1970s after U.S. President Nixon's historic visit to China in 1972 [4]. Following the initial excitement engen‐ dered by the press reports [5], acupuncture becomes one of the most popular treatments in alternative medicine (Figure 1), and accounts for more than 10 million treatments given annually in the United States [6]. Much interest was further engendered by tales by subsequent visitors to China who witnessed surgical operations being successfully performed on con‐ scious patients under acupunctural anesthesia [7-15]. Scientific studies using modern technol‐ ogy on acupuncture actually began in China in the late 1950s with further progress being made since the discovery of endogenous opioids in 1975 [2,16]. Much more advances have been made in more recent years in further understanding of the basic mechanisms underlying this millennium old medical treatment and its various clinical applications in the 21st century. This chapter reviews the current role of acupuncture in cardiology.

#### **2. Hypercholesterolemia**

Electro-acupuncture at "Fenglong" (ST 40) has some therapeutic effect on decreasing the content of total cholesterol and low-density-lipoprotein cholesterol in hyperlipidemic rats and improving the gene expression of ATP-binding cassette transporter A1, peroxisome prolifer‐ ator-activated receptor alpha, liver X receptor alpha and retinoid X receptor-alpha mRNA, so

© 2013 Cheng; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

arrhythmias [35]. Acupuncture has also been successfully employed to terminate nausea and

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 257

Acupuncture has been employed to treat both experimental [38-40] and clinical arrhythmias. The latter included ventricular extrasystoles [41,42], sinus bradycardia [43], atrial fibrillation [44,45], decreased heart rate variability [46,47,48,49,50] and sudden death [51]. In the treatment of paroxysmal atrial fibrillation and atrial flutter, acupuncture at Neiguan, Shenmen, and Danzhong is more effective than intravenous amiodarone (conversion rate: 85% vs 67%, p<0.01; conversion time:39.6+/-13.7 min vs 50.1+/-14.8 min, p<0.01)[52]. Acupuncture at Neiguan, Shenmen and Xinshu also can prevent recurrences of atrial fibrillation after cardioversion in patients with persistent atrial fibrillation [53]. The advantage of acupuncture in treating atrial fibrillation is obvious, because it does not have any of the untoward effect of pharmacotherapy or ablation. Atrial fibrillation is the most common cardiac arrhythmia, and anxiety plays a significant role in either its initiation or its perpetuation [54]. Because acupuncture is very effective in treating anxiety, this therapeutic modality warrants further investigation as a

A recently published systematic review of randomized controlled trials failed to provide conclusive evidence in support of acupuncture treatment for cardiac arrhythmias [55]. Furthermore, electro-acupuncture may interfere with demand pacemakers [56], although one recent case report from Greece indicated its safety [57]. Electo-acupuncture may also trigger inappropriate ICD discharges [58,59]. Therefore, extreme caution should be employed when electro-acupuncture is prescribed for patients with pacemakers and/or ICDs, and each patient

In a Chinese echocardiographic study of patients with congestive heart failure due to dilated cardiomyopathy under maintenance doses of conventional drugs, including digitalis, diuretics and potassium supplements, acupuncture resulted in an increase in stroke volume [60]. Because patients with heart failure have increased sympathetic activity and acupuncture produces release of endogenous opioids in the central nervous system which would inhibit central sympathetic outflow, sympathetic activation during acute mental stress was markedly attenuated [61] or virtually eliminated [62] after acupuncture. This may explain why ear acupuncture has been used in treating chronic heart failure, because one of the acupuncture points stimulated by the needle in the ear corresponds to the closest position of the vagus nerve to the cutaneous surface (vide infra), and electrical vagus nerve stimulation has been advocated

Acupuncture may become an additional therapeutic strategy to improve the exercise tolerance of patients with chronic heart failure, potentially by improving skeletal muscle function [64].

vomiting [36] and intractable hiccup [37] complicating acute myocardial infarction.

**4. Cardiac arrhythmias**

promising therapeutic option.

**5. Congestive heart failure**

should be considered individually with great care.

for patients with advanced heart failure [63].

**Figure 1.** A) An acupuncture manikin showing the location of the various acupoints along the meridians; (B) a com‐ plete set of acupuncture needles.

as to promote reverse cholesterol transport [17]. Furthermore, real-time PCR and western blot indicate that electroacupuncture at ST 40 induces the expression of nNOS and Mt1, two genes involved in NO signal transduction [18]. Acupuncture treatment for hypercholesterolemia thus involves the modulation of several biological pathways and provides a physiological link between NO signal transduction and the cholesterol-lowering effect of acupuncture [18].

#### **3. Coronary artery disease**

The effectiveness of acupuncture in treatment of angina has been well documented [19-21]. Its antianginal effect has been shown to be secondary to an antiischemic effect, which in turn is due to a decrease in heart rate and blood pressure and reduction in left ventricular afterload [22], a reduction in myocardial oxygen consumption, and a redistribution of coronary blood flow [23], myocardial release of β-endorphin [24], coronary vasodilatation [25], and increase in coronary collateral circulation [26]. Acupoint pressing has been shown to alleviate angina faster (2.45 +/- 1.67 min) than sublingual nitroglycerin (2.89 +/- 2.64 min) [27]. Transmyocardial acupuncture has also been used as a novel approach to myocardial revascularization [28,29], although its rationale has been questioned [30].

Acupuncture has been successfully used to improve microcirculation and left ventricular function in acute myocardial infarction [31-33]. Animal studies demonstrated that electroacupuncture could decrease the ST-segment elevation in ECG and reduce the infarct size following coronary ligation [34], although a recent study on rats failed to show a cardiopro‐ tective effect of electroacupuncture in terms of reduction of either infarct size or ventricular arrhythmias [35]. Acupuncture has also been successfully employed to terminate nausea and vomiting [36] and intractable hiccup [37] complicating acute myocardial infarction.

### **4. Cardiac arrhythmias**

Acupuncture has been employed to treat both experimental [38-40] and clinical arrhythmias. The latter included ventricular extrasystoles [41,42], sinus bradycardia [43], atrial fibrillation [44,45], decreased heart rate variability [46,47,48,49,50] and sudden death [51]. In the treatment of paroxysmal atrial fibrillation and atrial flutter, acupuncture at Neiguan, Shenmen, and Danzhong is more effective than intravenous amiodarone (conversion rate: 85% vs 67%, p<0.01; conversion time:39.6+/-13.7 min vs 50.1+/-14.8 min, p<0.01)[52]. Acupuncture at Neiguan, Shenmen and Xinshu also can prevent recurrences of atrial fibrillation after cardioversion in patients with persistent atrial fibrillation [53]. The advantage of acupuncture in treating atrial fibrillation is obvious, because it does not have any of the untoward effect of pharmacotherapy or ablation. Atrial fibrillation is the most common cardiac arrhythmia, and anxiety plays a significant role in either its initiation or its perpetuation [54]. Because acupuncture is very effective in treating anxiety, this therapeutic modality warrants further investigation as a promising therapeutic option.

A recently published systematic review of randomized controlled trials failed to provide conclusive evidence in support of acupuncture treatment for cardiac arrhythmias [55]. Furthermore, electro-acupuncture may interfere with demand pacemakers [56], although one recent case report from Greece indicated its safety [57]. Electo-acupuncture may also trigger inappropriate ICD discharges [58,59]. Therefore, extreme caution should be employed when electro-acupuncture is prescribed for patients with pacemakers and/or ICDs, and each patient should be considered individually with great care.

#### **5. Congestive heart failure**

as to promote reverse cholesterol transport [17]. Furthermore, real-time PCR and western blot indicate that electroacupuncture at ST 40 induces the expression of nNOS and Mt1, two genes involved in NO signal transduction [18]. Acupuncture treatment for hypercholesterolemia thus involves the modulation of several biological pathways and provides a physiological link between NO signal transduction and the cholesterol-lowering effect of acupuncture [18].

(A) (B)

**Figure 1.** A) An acupuncture manikin showing the location of the various acupoints along the meridians; (B) a com‐

The effectiveness of acupuncture in treatment of angina has been well documented [19-21]. Its antianginal effect has been shown to be secondary to an antiischemic effect, which in turn is due to a decrease in heart rate and blood pressure and reduction in left ventricular afterload [22], a reduction in myocardial oxygen consumption, and a redistribution of coronary blood flow [23], myocardial release of β-endorphin [24], coronary vasodilatation [25], and increase in coronary collateral circulation [26]. Acupoint pressing has been shown to alleviate angina faster (2.45 +/- 1.67 min) than sublingual nitroglycerin (2.89 +/- 2.64 min) [27]. Transmyocardial acupuncture has also been used as a novel approach to myocardial revascularization [28,29],

Acupuncture has been successfully used to improve microcirculation and left ventricular function in acute myocardial infarction [31-33]. Animal studies demonstrated that electroacupuncture could decrease the ST-segment elevation in ECG and reduce the infarct size following coronary ligation [34], although a recent study on rats failed to show a cardiopro‐ tective effect of electroacupuncture in terms of reduction of either infarct size or ventricular

**3. Coronary artery disease**

plete set of acupuncture needles.

256 Acupuncture in Modern Medicine

although its rationale has been questioned [30].

In a Chinese echocardiographic study of patients with congestive heart failure due to dilated cardiomyopathy under maintenance doses of conventional drugs, including digitalis, diuretics and potassium supplements, acupuncture resulted in an increase in stroke volume [60]. Because patients with heart failure have increased sympathetic activity and acupuncture produces release of endogenous opioids in the central nervous system which would inhibit central sympathetic outflow, sympathetic activation during acute mental stress was markedly attenuated [61] or virtually eliminated [62] after acupuncture. This may explain why ear acupuncture has been used in treating chronic heart failure, because one of the acupuncture points stimulated by the needle in the ear corresponds to the closest position of the vagus nerve to the cutaneous surface (vide infra), and electrical vagus nerve stimulation has been advocated for patients with advanced heart failure [63].

Acupuncture may become an additional therapeutic strategy to improve the exercise tolerance of patients with chronic heart failure, potentially by improving skeletal muscle function [64]. The German researchers from the University Hospital of Heidelberg found a remarkable increase in 6-minute walk distance, improvement in ventilatory efficiency and post-exercise recovery, and increase in heart rate variability, despite a lack of improvement of the cardiac ejection fraction and peak oxygen uptake [64]. They recommended that further research be carried out to understand the beneficial mechanisms of acupuncture – in particular, its effects on neurohormonal balance and production of inflammatory cytokines [64].

In patients with chronic heart failure, acupuncture may reduce digitoxicity by regulating intracellular Ca++, improving the function of Ca++-ATPase in the sarcoplasmic reticulum, and increasing the calcium sensitivity of cardiac troponin [65]. These considerations may provide a novel clue for attenuating the toxicity of digitalis preparations given to patients with chronic heart failure.

#### **6. Hypertension**

Experimental studies have shown that acupuncture inhibits the reflex-induced hypertension by modulating the activity of cardiovascular parasympathetic neurons in the rostral ventro‐ lateral medulla [66]. Activation of neurons in the arcuate nucleus of the hypothalamus, ventrolateral periaqueductal gray in the midbrain, and medullary nucleus raphé pallidus in the medulla by acupuncture can inhibit the activity of premotor sympathetic neurons in the rostral ventrolateral medulla. Glutamate, acetylcholine, opioids, gamma-aminobutyric acid, nociceptin, serotonin, nitric oxide and endocannabinoids in the brain all appear to participate in the antihypertensive response of acupuncture (Figure 2)[66]. Other possible mechanisms include decreases in plasma renin [67, 68], plasma neuropeptide Y [69], aldosterone [70] and angiotensin II activity [71,72]; increased excretion of sodium [73,74]; changes in plasma norepinephrine [75], serotonin [75] and endorphin levels [76,77]; and lowering of blood viscosity [75,78].

However, the Stop Hypertension with the Acupuncture Research Program (SHARP) pilot trial concluded that acupuncture provided no greater benefit than invasive sham acupuncture in controlling moderate hypertension [79]. Further research is obviously required to determine whether acupuncture can enhance clinical management of hypertension if used in combination with antihypertensive agents, over longer periods, or among specific subgroups of patients.

> of ruptured aneurysms in subarachnoid hemorrhage [84]. In a recent publication from Shanghai [85], the authors reviewed the progress of researches on the mechanism of acupunc‐ ture underlying improvement of acute cerebral hemorrhage from experimental studies and research methods. The effects of acupuncture mainly involve (1) lessening inflammatory reactions, (2) reducing impairment of free radicals and excitatory amino acids on cerebral neurons, (3) balancing release of vascular bioactive substances to increase regional cerebral blood flow, and (4) promoting repair and regeneration of the neural tissue. In regard to the research methods, many new biological techniques such as biological molecular approaches, neuro-cellular chemical methods, reverse transcription-polymerase chain reaction (RT-PCR) or quantitative real-time PCR, situ hybridization, western blotting, and electron microscopy

> **Figure 2.** Neuroendocrine modulation of blood pressure by acupuncture. Abbreviations: GABA, γ-aminobutyric acid; 5HT, 5-hydroxytryptamine or serotonin; NO, nitric oxide; IML, intermediolateral column of the spinal cord. From Ref

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 259

66, courtesy W. Zhou.

#### **7. Stroke**

Stroke should be considered as a coronary artery disease risk equivalent [80]. Acupuncture has useful applications in both the acute and chronic phases of a stroke. In ischemic stroke, acupuncture increases local cerebral blood flow as determined by single photon emission computed tomography [81] and near-infrared spectroscopy [82]. In rats with ischemic stroke, acupuncture has been shown to promote angiogenesis [83]. Acupuncture at Baihui and Fengchi is more effective than nimopidine in relieving cerebral vasospasm after embolization

The German researchers from the University Hospital of Heidelberg found a remarkable increase in 6-minute walk distance, improvement in ventilatory efficiency and post-exercise recovery, and increase in heart rate variability, despite a lack of improvement of the cardiac ejection fraction and peak oxygen uptake [64]. They recommended that further research be carried out to understand the beneficial mechanisms of acupuncture – in particular, its effects

In patients with chronic heart failure, acupuncture may reduce digitoxicity by regulating intracellular Ca++, improving the function of Ca++-ATPase in the sarcoplasmic reticulum, and increasing the calcium sensitivity of cardiac troponin [65]. These considerations may provide a novel clue for attenuating the toxicity of digitalis preparations given to patients with chronic

Experimental studies have shown that acupuncture inhibits the reflex-induced hypertension by modulating the activity of cardiovascular parasympathetic neurons in the rostral ventro‐ lateral medulla [66]. Activation of neurons in the arcuate nucleus of the hypothalamus, ventrolateral periaqueductal gray in the midbrain, and medullary nucleus raphé pallidus in the medulla by acupuncture can inhibit the activity of premotor sympathetic neurons in the rostral ventrolateral medulla. Glutamate, acetylcholine, opioids, gamma-aminobutyric acid, nociceptin, serotonin, nitric oxide and endocannabinoids in the brain all appear to participate in the antihypertensive response of acupuncture (Figure 2)[66]. Other possible mechanisms include decreases in plasma renin [67, 68], plasma neuropeptide Y [69], aldosterone [70] and angiotensin II activity [71,72]; increased excretion of sodium [73,74]; changes in plasma norepinephrine [75], serotonin [75] and endorphin levels [76,77]; and lowering of blood

However, the Stop Hypertension with the Acupuncture Research Program (SHARP) pilot trial concluded that acupuncture provided no greater benefit than invasive sham acupuncture in controlling moderate hypertension [79]. Further research is obviously required to determine whether acupuncture can enhance clinical management of hypertension if used in combination with antihypertensive agents, over longer periods, or among specific subgroups of patients.

Stroke should be considered as a coronary artery disease risk equivalent [80]. Acupuncture has useful applications in both the acute and chronic phases of a stroke. In ischemic stroke, acupuncture increases local cerebral blood flow as determined by single photon emission computed tomography [81] and near-infrared spectroscopy [82]. In rats with ischemic stroke, acupuncture has been shown to promote angiogenesis [83]. Acupuncture at Baihui and Fengchi is more effective than nimopidine in relieving cerebral vasospasm after embolization

on neurohormonal balance and production of inflammatory cytokines [64].

heart failure.

**6. Hypertension**

258 Acupuncture in Modern Medicine

viscosity [75,78].

**7. Stroke**

**Figure 2.** Neuroendocrine modulation of blood pressure by acupuncture. Abbreviations: GABA, γ-aminobutyric acid; 5HT, 5-hydroxytryptamine or serotonin; NO, nitric oxide; IML, intermediolateral column of the spinal cord. From Ref 66, courtesy W. Zhou.

of ruptured aneurysms in subarachnoid hemorrhage [84]. In a recent publication from Shanghai [85], the authors reviewed the progress of researches on the mechanism of acupunc‐ ture underlying improvement of acute cerebral hemorrhage from experimental studies and research methods. The effects of acupuncture mainly involve (1) lessening inflammatory reactions, (2) reducing impairment of free radicals and excitatory amino acids on cerebral neurons, (3) balancing release of vascular bioactive substances to increase regional cerebral blood flow, and (4) promoting repair and regeneration of the neural tissue. In regard to the research methods, many new biological techniques such as biological molecular approaches, neuro-cellular chemical methods, reverse transcription-polymerase chain reaction (RT-PCR) or quantitative real-time PCR, situ hybridization, western blotting, and electron microscopy have been extensively applied to researches on the underlying mechanisms of acupuncture therapy for cerebral infarction. In addition, the authors also pointed out that, in spite of achieving some greater progresses in experimental studies, most of the results basically reflect static, isolated and regional changes rather than dynamic and whole body changes. For these reasons, the authors recommended more in vivo research techniques and noninvasive research methods in the investigation of the underlying mechanisms of acupuncture therapy for acute cerebral ischemia [85].

**9. Diabetes**

ogy quality of the studies [114].

infection in diabetic patients [123].

**10. Obesity**

Diabetes is associated with a marked increase in the risk of coronary artery disease, so much so that patients with diabetes shuld be treated as if they have existing coronary artery disease [106,107,108,109]. As a matter of fact, diabetes should be considered as a coronary artery disease equivalent [95,110]. The prevalence of diabetes is rising [108]. The main reasons for the rising prevalence of diabetes are smoking and obesity, which are certainly true for China [111,112]. A recent study from the University of North Carolina School of Global Public Health, using data from the China Health and Nutrition Survey, the longest ongoing study of its kind in China, reported that Chinese teenagers have a rate of diabetes nearly four to five times greater than their counterparts in the United States (1.9% vs 0.5% for boys and 0.4% for girls) [113]. Although acupuncture has been advocated for treatment of obesity (vide infra), a recent review of the literature questioned its validity owing to small sample size and low methodol‐

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 261

On the other hand, acupuncture has been found to be effective in the management of patients with diabetes, by causing the release of endogenous opioid peptides such as β-endorphin from adrenal gland and thereby enhancing insulin secretion [115]. A recent literature review showed acupuncture to be effective in lowering blood glucose in both humans and rats [115]. Ear acupuncture in 45 diabetics in Peking University of Shenzhen Hospital, Shenzhen, Guangdong Province, China resulted in significant improvement in fasting plasma glucose, blood glucose load after 2-hour 75 gm oral glucose tolerance test and glycosylated hemoglobin [116]. Two recent studies from Beijing, China on patients with impaired glucose tolerance reported similar improvement in these parameters following electro-acupuncture, thus confirming its effec‐ tiveness in the prevention and treatment of diabetes at the early stage [117,118]. Another study from Nanjing, China reported acupuncture to be effective in lowering fasting blood leptin level, which may contribute to its clinical effect in improving diabetes [119]. Electro-acupunc‐ ture has also been used successfully for the treatment of diabetic peripheral neuropathy in rats [120] as well as in patients [121], although the quality of reports about randomized controlled trials is moderate to low [122]. Finally, acupuncture has been used in treating urinary tract

Obesity is another risk factor for coronary artery disease, hypertension, chronic heart failure, stroke and diabetes [124]. It is increasing in prevalence worldwide, especially in developing countries like China [95,125,126]. Two recent systematic reviews, one published in 2009 [127] and the other in 2012 [114], both suggested that acupuncture is an effective treatment for obesity, with fewer adverse effects of the various dieting plans and Western anti-obesity drugs. A recent study in obese rats showed that electro-acupuncture led to a reduction of body weight, decrease in the plasma leptin levels, and an increase in leptin receptor expression in the hypothalamus, suggesting that regulating the expression of leptin and the leptin receptor

Acupuncture has also been used successfully for post-stroke motor rehabilitation [86], behavioral recovery [87], aphasia [88], dysphasia [89], dysphagia [90], cognition disorders [91], depression [92], and urinary incontinence and urinary tract infection [93].

#### **8. Smoking cessation**

Cigarette smoking is prevalent in China; 67% of men [94] and 40% of male physicians [95] are smokers. It is a major cause of death in China and a principal cause of coronary heart disease in China [96]. In addition, secondhand smoke exposure (52% of nonsmokers in China are exposed to tobacco smoke for at least 15 minutes daily for >1 day per week [97]) was responsible for increased mortality due to coronary heart disease, ischemic stroke, lung cancer and chronic obstructive pulmonary disease in a recently published 17-year cohort study in China [98]. Another recently completed Chinese population study, the Kailuan community study, showed smoking cessation to be one of the seven key components of an essential population-wide strategy to reduce cardiovascular disease [99]. Although a 2012-15 blueprint on chronic disease prevention and control released by the Chinese Ministry of Health on May 21, 2012 set goals of reducing the adult smoking rate to below 25% among other goals [100], I have serious doubts as to how successful the Chinese Health Ministry's effort will be [101]. Nevertheless, any effective measure in curtailing cigarette smoking should be actively and urgently pursued.

Acupuncture has been found in a recently published review of smoking cessation intervention studies in China to yield a much higher abstinence rate than pharmacotherapy or counseling [102]. This observation was confirmed by two recently published meta-analyses of randomized controlled trials [103,104]. It has been postulated that, by increasing the levels of endorphin, enkephalin, epinephrine, norepinephrine, serotonin, and dopamine in the central nervous system and plasma, acupuncture provides the smoker with a deterioration in the taste of smoking, a decrease in the desire of smoking, and the obstruction of psychological symptoms resulting from smoking cessation [105]. The latest theory is that one of the acupuncture points stimulated by the acupuncture needle in the ear corresponds to the closest position of the vagus nerve to the cutaneous surface. Therefore, by stimulating this point, the acupuncturist blocks the outflow of withdrawal symptoms coming from the parasympathetic nervous system through the vagus nerve. However, more studies are needed to determine whether acupunc‐ ture is as efficacious as, or even more so than, pharmacotherapies.

#### **9. Diabetes**

have been extensively applied to researches on the underlying mechanisms of acupuncture therapy for cerebral infarction. In addition, the authors also pointed out that, in spite of achieving some greater progresses in experimental studies, most of the results basically reflect static, isolated and regional changes rather than dynamic and whole body changes. For these reasons, the authors recommended more in vivo research techniques and noninvasive research methods in the investigation of the underlying mechanisms of acupuncture therapy for acute

Acupuncture has also been used successfully for post-stroke motor rehabilitation [86], behavioral recovery [87], aphasia [88], dysphasia [89], dysphagia [90], cognition disorders [91],

Cigarette smoking is prevalent in China; 67% of men [94] and 40% of male physicians [95] are smokers. It is a major cause of death in China and a principal cause of coronary heart disease in China [96]. In addition, secondhand smoke exposure (52% of nonsmokers in China are exposed to tobacco smoke for at least 15 minutes daily for >1 day per week [97]) was responsible for increased mortality due to coronary heart disease, ischemic stroke, lung cancer and chronic obstructive pulmonary disease in a recently published 17-year cohort study in China [98]. Another recently completed Chinese population study, the Kailuan community study, showed smoking cessation to be one of the seven key components of an essential population-wide strategy to reduce cardiovascular disease [99]. Although a 2012-15 blueprint on chronic disease prevention and control released by the Chinese Ministry of Health on May 21, 2012 set goals of reducing the adult smoking rate to below 25% among other goals [100], I have serious doubts as to how successful the Chinese Health Ministry's effort will be [101]. Nevertheless, any effective measure in curtailing cigarette smoking should be actively and urgently pursued.

Acupuncture has been found in a recently published review of smoking cessation intervention studies in China to yield a much higher abstinence rate than pharmacotherapy or counseling [102]. This observation was confirmed by two recently published meta-analyses of randomized controlled trials [103,104]. It has been postulated that, by increasing the levels of endorphin, enkephalin, epinephrine, norepinephrine, serotonin, and dopamine in the central nervous system and plasma, acupuncture provides the smoker with a deterioration in the taste of smoking, a decrease in the desire of smoking, and the obstruction of psychological symptoms resulting from smoking cessation [105]. The latest theory is that one of the acupuncture points stimulated by the acupuncture needle in the ear corresponds to the closest position of the vagus nerve to the cutaneous surface. Therefore, by stimulating this point, the acupuncturist blocks the outflow of withdrawal symptoms coming from the parasympathetic nervous system through the vagus nerve. However, more studies are needed to determine whether acupunc‐

ture is as efficacious as, or even more so than, pharmacotherapies.

depression [92], and urinary incontinence and urinary tract infection [93].

cerebral ischemia [85].

260 Acupuncture in Modern Medicine

**8. Smoking cessation**

Diabetes is associated with a marked increase in the risk of coronary artery disease, so much so that patients with diabetes shuld be treated as if they have existing coronary artery disease [106,107,108,109]. As a matter of fact, diabetes should be considered as a coronary artery disease equivalent [95,110]. The prevalence of diabetes is rising [108]. The main reasons for the rising prevalence of diabetes are smoking and obesity, which are certainly true for China [111,112]. A recent study from the University of North Carolina School of Global Public Health, using data from the China Health and Nutrition Survey, the longest ongoing study of its kind in China, reported that Chinese teenagers have a rate of diabetes nearly four to five times greater than their counterparts in the United States (1.9% vs 0.5% for boys and 0.4% for girls) [113]. Although acupuncture has been advocated for treatment of obesity (vide infra), a recent review of the literature questioned its validity owing to small sample size and low methodol‐ ogy quality of the studies [114].

On the other hand, acupuncture has been found to be effective in the management of patients with diabetes, by causing the release of endogenous opioid peptides such as β-endorphin from adrenal gland and thereby enhancing insulin secretion [115]. A recent literature review showed acupuncture to be effective in lowering blood glucose in both humans and rats [115]. Ear acupuncture in 45 diabetics in Peking University of Shenzhen Hospital, Shenzhen, Guangdong Province, China resulted in significant improvement in fasting plasma glucose, blood glucose load after 2-hour 75 gm oral glucose tolerance test and glycosylated hemoglobin [116]. Two recent studies from Beijing, China on patients with impaired glucose tolerance reported similar improvement in these parameters following electro-acupuncture, thus confirming its effec‐ tiveness in the prevention and treatment of diabetes at the early stage [117,118]. Another study from Nanjing, China reported acupuncture to be effective in lowering fasting blood leptin level, which may contribute to its clinical effect in improving diabetes [119]. Electro-acupunc‐ ture has also been used successfully for the treatment of diabetic peripheral neuropathy in rats [120] as well as in patients [121], although the quality of reports about randomized controlled trials is moderate to low [122]. Finally, acupuncture has been used in treating urinary tract infection in diabetic patients [123].

#### **10. Obesity**

Obesity is another risk factor for coronary artery disease, hypertension, chronic heart failure, stroke and diabetes [124]. It is increasing in prevalence worldwide, especially in developing countries like China [95,125,126]. Two recent systematic reviews, one published in 2009 [127] and the other in 2012 [114], both suggested that acupuncture is an effective treatment for obesity, with fewer adverse effects of the various dieting plans and Western anti-obesity drugs. A recent study in obese rats showed that electro-acupuncture led to a reduction of body weight, decrease in the plasma leptin levels, and an increase in leptin receptor expression in the hypothalamus, suggesting that regulating the expression of leptin and the leptin receptor might be one of the molecular mechanisms underlying the reduction of body weight in dietinduced obese rats by electro-acupuncture treatment [128]. Another human study reported in 2010 found that laser acupuncture exerted a therapeutic effect on simple obesity by reducing both body weight and body mass index [129]. However, the amount of evidence is not fully convincing, because of the small sample size and poor methodological quality of all the reported trials to date.

#### **11. Acupunctural anesthesia for cardiac surgery**

The most amazing application of acupuncture is acupunctural anesthesia. Skeptics who deny that acupunctural anesthesia can work have suggested that acupuncture is nothing more than an effective use of hypnosis or autosuggestion. I was also a skeptic until I witnessed with my own eyes several operative procedures performed on conscious patients under acupunctural anesthesia including those with acquired valvular and congenital heart diseases (Figures 3 and 4). Being a native-born Chinese, I was able to communicate directly with the patients, without going through any interpreters, who may either inadvertently or deliberately omit or distort any actual expressions from the patients, to find out what discomfort they might experience during the procedures. Of course, I was not the only physician who was impressed by cardiac surgery under acupunctural anesthesia. Other well-known surgeons around the world, such as DeBakey from the United States [130], Hollinger et al from Germany [131], and Caracausi from Italy [132] were too.

Acupuncture also has a cardioprotective effect as a pretreatment on patients undergoing heart valve replacement. Cardiac ischemia-reperfusion injury after cardiopulmonary bypass often contributes to postoperative morbidity and mortality in patients undergoing heart valve replacement. A randomized controlled trial, which was reported from Xi'an, China in 2010, showed that electro-acupuncture pretreatment significantly reduced overall serum troponin I release at 6 hours, 12 hours and 24 hours after aortic cross-clamping removal [133]. Mean‐ while, electroacupuncture pretreatment also reduced the inotrope score at 12 hours, 24 hours, and 48 hours after the intensive care unit arrival and shortened intensive care unit stay time (p<0.05)[133]. The cardioprotective effect of transcutaneous electric acupoint stimulation was further confirmed recently in the pediatric cardiac patients with congenital heart disease [134].

After its initial enthusiasm in China in the 1970s, in the subequent years acupunctural anesthesia for open heart surgery gradually became less and less frequently used throughout China, because of its limitations and disadvantages [3,135]. Fortunately, with recent modifi‐ cation of the technique by combining acupuncture with conscious sedation, Zhou et al [135] were able to demonstrate its effectiveness again. This modification, which will be discussed bodes well for the future of acupunctural anesthesia for cardiac surgery, not only because of its sound physiological principles, simplicity in clinical application, significant benefit to the patient and favorable cost effectiveness, but also for its positive impact on healthcare cost.

**12. Adverse effects and complications**

(A)

(B)

(C)

Although acupuncture is extremely safe, adverse effects and sometimes serious complications have been reported. These include infective endocarditis [136,137,138], pericardial effusion

**Figure 3.** A man undergoing a closed transventricular mitral commissurotomy under acupunctural anesthesia in a hospital in Shanghai. (A) Patient fully awake and comfortable; (B) Patient smiling during the procedure; (C) Patient

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 263

eating oranges during the operation. All photographs taken by the author during his 1972 visit to China.

**Figure 3.** A man undergoing a closed transventricular mitral commissurotomy under acupunctural anesthesia in a hospital in Shanghai. (A) Patient fully awake and comfortable; (B) Patient smiling during the procedure; (C) Patient eating oranges during the operation. All photographs taken by the author during his 1972 visit to China.

#### **12. Adverse effects and complications**

might be one of the molecular mechanisms underlying the reduction of body weight in dietinduced obese rats by electro-acupuncture treatment [128]. Another human study reported in 2010 found that laser acupuncture exerted a therapeutic effect on simple obesity by reducing both body weight and body mass index [129]. However, the amount of evidence is not fully convincing, because of the small sample size and poor methodological quality of all the

The most amazing application of acupuncture is acupunctural anesthesia. Skeptics who deny that acupunctural anesthesia can work have suggested that acupuncture is nothing more than an effective use of hypnosis or autosuggestion. I was also a skeptic until I witnessed with my own eyes several operative procedures performed on conscious patients under acupunctural anesthesia including those with acquired valvular and congenital heart diseases (Figures 3 and 4). Being a native-born Chinese, I was able to communicate directly with the patients, without going through any interpreters, who may either inadvertently or deliberately omit or distort any actual expressions from the patients, to find out what discomfort they might experience during the procedures. Of course, I was not the only physician who was impressed by cardiac surgery under acupunctural anesthesia. Other well-known surgeons around the world, such as DeBakey from the United States [130], Hollinger et al from Germany [131], and Caracausi

Acupuncture also has a cardioprotective effect as a pretreatment on patients undergoing heart valve replacement. Cardiac ischemia-reperfusion injury after cardiopulmonary bypass often contributes to postoperative morbidity and mortality in patients undergoing heart valve replacement. A randomized controlled trial, which was reported from Xi'an, China in 2010, showed that electro-acupuncture pretreatment significantly reduced overall serum troponin I release at 6 hours, 12 hours and 24 hours after aortic cross-clamping removal [133]. Mean‐ while, electroacupuncture pretreatment also reduced the inotrope score at 12 hours, 24 hours, and 48 hours after the intensive care unit arrival and shortened intensive care unit stay time (p<0.05)[133]. The cardioprotective effect of transcutaneous electric acupoint stimulation was further confirmed recently in the pediatric cardiac patients with congenital heart disease [134].

After its initial enthusiasm in China in the 1970s, in the subequent years acupunctural anesthesia for open heart surgery gradually became less and less frequently used throughout China, because of its limitations and disadvantages [3,135]. Fortunately, with recent modifi‐ cation of the technique by combining acupuncture with conscious sedation, Zhou et al [135] were able to demonstrate its effectiveness again. This modification, which will be discussed bodes well for the future of acupunctural anesthesia for cardiac surgery, not only because of its sound physiological principles, simplicity in clinical application, significant benefit to the patient and favorable cost effectiveness, but also for its positive impact on healthcare cost.

reported trials to date.

262 Acupuncture in Modern Medicine

from Italy [132] were too.

**11. Acupunctural anesthesia for cardiac surgery**

Although acupuncture is extremely safe, adverse effects and sometimes serious complications have been reported. These include infective endocarditis [136,137,138], pericardial effusion

traditional Chinese medicine, of which acupuncture is an essential component, has a definite place in the management of various subacute and chronic cardiovascular disorders and risk factors. However, a recent systematic review showed that, in acute low back pain, acupuncture appears to be actually more effective than drugs for symptomatic improvement [154]. There‐ fore, more registered high-quality clinical trials need to be continued worldwide on this 2,000+-

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 265

Department of Medicine, The George Washington University, Washington, D.C., USA

[1] Haubrich WS: Medical Meanings. A Glossary of Word Origins. Philadelphia: Ameri‐

[2] Han JS: Physiologic and neurochemical basis of acupuncture anesthesia. In: The In‐ ternational Textbook of Cardiology (Cheng TO, ed) New York/Oxford: Pergamon

[3] Cheng TO: Acupuncture anesthesia for open heart surgery: Past, present and future.

[5] Cheng TO: The evolution of cardiology in China. In: Cardiothoracic Surgery in Chi‐ na. Past, Present and Future (Wan S, Yim APC, eds). Hong Kong: The Chinese Uni‐

[6] Cheng TO: Acupuncture in cardiology. InCirculation.net February 7, 2007. http://

[9] Cheng TO: A view of modern Chinese medicine. Observations by a Shanghai-born physician during his recent visit after 22 years of absence. Ann Intern med

www.incirculation.net/24174\_84428.aspx Accessed February 7, 2007.

year-old ancient Chinese therapy [155].

Address all correspondence to<EMAIL_ADDRESS>
can College of Physicians 1997:4.

Press 1987:1124-1132.

Int J Cardiol 2011; 150:1-3.

versity Press, 2007: 204-305.

1973;78:285-290.

[4] Cheng TO: Changes in China. N Engl J Med 1972; 287:259.

[7] Cheng TO: Acupuncture anesthesia. Science 1973; 179:521.

[8] Cheng TO: Medicine in China. J Am Geriatr Soc 1973; 21:289-313.

**Author details**

Tsung O. Cheng

**References**

**Figure 4.** A child fully awake and comfortable while undergoing open heart surgical closure of a ventricular septal defect under acupunctural anesthesia. Photograph taken by the author during his 1972 visit to China.

[139], cardiac tamponade [138,140], pneumothorax [141] and AIDS [138,142]. However, infective endocarditis and AIDS are not due to acupuncture per se, but to the unsterile technique that was employed during acupuncture. Hundreds of thousands of acupuncturists worldwide perform millions of acupuncture procedures per year [143]. Considering the small number of reported complications in the literature, acupuncture is very safe indeed [143,144,145,146,147]. As a matter of fact, the recent report of the successful use of electroacupuncture for treatment of arthritis in a patient with a total artificial heart is further testimonial to its safety [148].

#### **13. Conclusion**

Acupuncture has a definite place in cardiology. When performed by trained acupuncturists, it is safe, effective, cost-effective, and widely available. As more research evidence for acu‐ puncture efficacy, including the application of functional magnetic resonance imaging technique in recent years [149], becomes available, it will be possible to increase physician knowledge and change attitudes towards acupuncture [150,151], as it was so predicted by the NIH Consensus Development Panel on Acupuncture convened a decade and a half ago [152]. When incorporated into conventional health care as an integrated approach, the future of this ancient Chinese therapeutic modality is bright. As a matter of fact, acupuncture should prove to be an attractive alternative to Western medicine in the current era of cost containment in healthcare [153]. Although Western medicine may be preferred in the management of some acute cardiac conditions, such as acute myocardial infarction or malignant arrhythmias, traditional Chinese medicine, of which acupuncture is an essential component, has a definite place in the management of various subacute and chronic cardiovascular disorders and risk factors. However, a recent systematic review showed that, in acute low back pain, acupuncture appears to be actually more effective than drugs for symptomatic improvement [154]. There‐ fore, more registered high-quality clinical trials need to be continued worldwide on this 2,000+ year-old ancient Chinese therapy [155].

### **Author details**

Tsung O. Cheng

Address all correspondence to<EMAIL_ADDRESS>
Department of Medicine, The George Washington University, Washington, D.C., USA

#### **References**

[139], cardiac tamponade [138,140], pneumothorax [141] and AIDS [138,142]. However, infective endocarditis and AIDS are not due to acupuncture per se, but to the unsterile technique that was employed during acupuncture. Hundreds of thousands of acupuncturists worldwide perform millions of acupuncture procedures per year [143]. Considering the small number of reported complications in the literature, acupuncture is very safe indeed [143,144,145,146,147]. As a matter of fact, the recent report of the successful use of electroacupuncture for treatment of arthritis in a patient with a total artificial heart is further

**Figure 4.** A child fully awake and comfortable while undergoing open heart surgical closure of a ventricular septal

defect under acupunctural anesthesia. Photograph taken by the author during his 1972 visit to China.

Acupuncture has a definite place in cardiology. When performed by trained acupuncturists, it is safe, effective, cost-effective, and widely available. As more research evidence for acu‐ puncture efficacy, including the application of functional magnetic resonance imaging technique in recent years [149], becomes available, it will be possible to increase physician knowledge and change attitudes towards acupuncture [150,151], as it was so predicted by the NIH Consensus Development Panel on Acupuncture convened a decade and a half ago [152]. When incorporated into conventional health care as an integrated approach, the future of this ancient Chinese therapeutic modality is bright. As a matter of fact, acupuncture should prove to be an attractive alternative to Western medicine in the current era of cost containment in healthcare [153]. Although Western medicine may be preferred in the management of some acute cardiac conditions, such as acute myocardial infarction or malignant arrhythmias,

testimonial to its safety [148].

**13. Conclusion**

264 Acupuncture in Modern Medicine

[10] Cheng TO: Future development of Chinese medical journals. Ann Intern Med 1973; 79:897-898.

[25] Kurono Y, Egawa M, Yano T, Shimoo K: The effect of acupuncture on the coronary arteries as evaluated by coronary angiography: a preliminary report. Am J Chin Med

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 267

[26] Meng JB, Zhu GY, Fu WX, Song LM: Effect of acupuncture on the coronary collateral circulation of dogs suffering from experimental myocardial infarction. Zhen Ci Yan

[27] Wang YM, Wang QY, Zhang J, Guo YL: Comparative study on acupoint pressing and medication for angina pectoris due to coronary heart disease. Zhongguo Zhen

[28] Sen PK, Udwadia TE, Kinare SG, Parulkar GB: Transmyocardial acupuncture: a new approach to myocardial revascularization. J Thorac Cardiovasc Surg 1965;

[29] Sen PK, Daulatram J, Kinare SG, Udwadia TE, Parulkar MS: Further studies in multi‐ ple transmyocardial acupuncture as a method of myocardial revascularization. Sur‐

[30] Pifarre R, Jasuja ML, Lynch RD, Neville WE: Myocardial revascularization by trans‐ myocardial acupuncture. A physiologic impossibility. J Thorac Cardiovasc Surg

[31] Zhu BJ, Bi L, Liang SY, Pang L, Wang SL, Liu JF, Jiang AP, Li CJ, Ye ZJ, Yang: Effect of acupuncture on left ventricular function, microcirculation, blood rheology and cy‐ clic nucleotides in patients with acute myocardial infarction. J Tradit Chin Med 1989;

[32] Zhu BJ, Liang SY: Effects of acupuncture on microcirculation of acute myocardial in‐

[33] Li CJ, Bi LG, Zhu BJ, Qi MZ, Zhao CX, Xu YF, Yao ZL, Lu ZS, Sun SM, Dong H, et al: Effects of acupuncture on left ventricular function, microcirculation, cAMP and cGMP of acute myocardial infarction patients. J Tradit Chin Med 1986; 6:157-161. [34] Meng J: The effects of acupuncture in treatment of coronary heart diseases. J Tradit

[35] Dow J, Painovich J, Hale SL, Tien-A-Looi S, Longhurst JC, Kloner RA: Absence of ac‐ tions of commonly used Chinese herbal medicines and electroacupuncture on myo‐

[36] Dent HE, Dewhurst NG, Mills SY, Willoughby M: Continuous PC6 wristband acu‐ pressure for relief of nausea and vomiting associated with acute myocardial infarc‐ tion: a partially randomised, placebo-controlled trial. Complement Ther Med 2003;

cardial infarct size. J Cardiovasc Pharmacol Ther 2012;17:403-411.

farction patients. Zhen Ci Yan Jiu 1988;13:267-271.

2002; 30:387-396.

Jiu 1986; 11(3):196-197.

Jiu 2011; 31:595-8.

gery 1968; 64:861-870.

Chin Med 2004;24:16-19.

1969; 58:424-431.

9:63-68.

11:72-77.

50:181-189.

[25] Kurono Y, Egawa M, Yano T, Shimoo K: The effect of acupuncture on the coronary arteries as evaluated by coronary angiography: a preliminary report. Am J Chin Med 2002; 30:387-396.

[10] Cheng TO: Future development of Chinese medical journals. Ann Intern Med 1973;

[12] Cheng TO: Cardiovascular diseases. In: China Medicine As We Saw It (Quinn JR, ed). Bethesda, Maryland: US Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, DHEW Publication No. (NIH) 75-684.

[13] Cheng TO: Cardiology in the People's Republic of China. In: New Horizons in Cardi ovascular Practice (Russek HI, ed). Baltimore: University Park Press, 1975:1-27.

[14] Cheng TO: Acupuncture anesthesia for open heart surgery. Am J Cardiol 1975;

[15] Cheng TO: Stamps in cardiology. Acupuncture anaesthesia for open heart surgery.

[17] Zhang HX, Wang Q, Huang H, Yue W, Qin PF: Effect of electroacupuncture at "Fenglong" (ST 40) on rats with hyperlipidemia and its mechanism. Zhongguo Zhen

[18] Li L, Tan GH, Zhang YZ: Modulated expression of genes associated with NO signal transduction contributes to the cholesterol-lowering effect of electro-acupuncture. Bi‐

[21] Bueno EA, Mamtani R, Frishman WH: Alternative approaches to the medical man‐ agement of angina pectoris: acupuncture, electric nerve stimulation, and spinal cord

[22] Diao LH, Yang ZB, Zhou GX, Chen Y, Fan LY, Zhang YY, Liu H, Liu ST: Observation on therapeutic effects of electroacupuncture at Neiguan (PC 6) on silent myocardial

[23] Mannheimer C, Eliasson T, Augustinsson L-E, Blomstrand C, Emanuelsson H, Lars‐ son S, Norrsell H, Hjalmarsson A: Electrical stimulation versus coronary artery by‐ pass surgery in severe angina pectoris. The ESBY study. Circulation 1998;

[24] Eliasson T, Mannheimer C, Waagstein F, Andersson B, Bergh C-H, Augustinsson L-E, Hedner T, Larson G: Myocardial turnover of endogenous opioids and calcitoningene-related peptide in the human heart and the effects of spinal cord stimulation on

pacing-induced angina pectoris. Cardiology 1998; 89:170-177.

[16] Han JS: Acupuncture and endorphins. Neurosci Letters 2004; 361:258-261.

[19] Cheng TO: Acupuncture treatment for angina. Cardiology 1998; 90:152.

[20] Cheng TO: Acupuncture for relief of angina. Circulation 1998; 98:2357-2358.

otechnol Lett 2012 Mar 16 [Epub ahead of print]

stimulation. Heart Disease 2001; 3:236-241.

ischemia. Zhongguo Zhen Jiu 2011; 31:591-4.

[11] Cheng TO: China's "barefoot doctors". Prism (AMA) 1973; 1:16-18.

79:897-898.

266 Acupuncture in Modern Medicine

1974:261-288.

Heart 2000; 83:256.

Jiu 2012; 32:241-5.

97:1157-1163.

36:411.

[37] Liu FC, Chen CA, Yang SS, Lin SH: Acupuncture therapy rapidly terminates intracta‐ ble hiccups complicating acute myocardial infarction. South Med J 2005; 98:385-387.

iability in anesthetized rats. Evid Based Complement Alternat Med 2012;2012:817378.

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 269

[51] Tang ZL, Song XG, Zhou YP: A preliminary study on the prevention and cure of sud‐ den death caused by coronary heart disease by acupuncture. Zhen Ci Yan Jiu 1985;

[52] Xu HK, Zhang YF: Comparison between therapeutic effects of acupuncture and in‐ travenous injection of amiodarone in the treatment of paroxysmal atrial fibrillation

[53] Lomuscio A, Belletti S, Battezzati PM, Lombardi F: Efficacy of acupuncture in pre‐ venting atrial fibrillation recurrences after electrical cardioversion. J Cardiovasc Elec‐

[54] Pozuelo L: Fine-tuning a heart-brain connection. Anxiety in atrial fibrillation. Circ

[55] Kim TH, Choi TY, Lee MS, Ernst E: Acupuncture treatment for cardiac arrhythmias: A systematic review of randomized controlled trials. Int J Cardiol 2011; 149:263-5.

[56] Fujiwara H, Taniguchi K, Takeuchi J, Ikezono E: The influence of low frequency acu‐

[57] Vasilakos DG, Fyntanidou BP: Electroacupuncture on a patient with pacemaker: a

[58] Vlay SC: Electromagnetic interference and ICD discharge related to chiropractic

[59] Lau EW, Birnie DH, Lemery R, Tang AS, Green MS: Acupuncture triggering inap‐

[60] Huang DJ, Cheng DT, Das SK, Pitt, B: Effect of acupuncture on left ventricular size and function assessed by echocardiography in patients with stable dilated cardiomy‐

[61] Middlekauff HR, Hui K, Yu JL, Hamilton MA, Fonarow GC, Moriguchi J, Maclellan WR, Hage A: Acupuncture inhibits sympathetic activation during mental stress in

[62] Middlekauff HR: Acupuncture in the treatment of heart failure. Cardiol Rev 2004;

[63] Sabbah HN: Electrical vagus nerve stimulation for the treatment of chronic heart fail‐

[64] Kristen AV, Schuhmacher B, Strych K, Lossnitzer D, Friederich HC, Hilbel T, Haass M, Katus HA, Schneider A, Streitberger KM, Backs J: Acupuncture improves exercise

and atrial flutter. Zhongguo Zhen Jiu 2007; 27:96-8.

puncture on a demand pacemaker. Chest 1980; 78:96-97.

case report. Acupunct Med 2011; 29(2):152-3.

propriate ICD shocks. Europace 2005; 7:85-86.

opathy. J Tradit Chin Med 1985; 5:243-245.

12(3):171-3.

treatment. Pacing Clin Electrophysiol 1998; 21:2009.

advanced heart failure patients. J Card Fail 2002; 8:399-406.

ure. Cleveland Clin J Med 2011; 78 (Suppl 1):S24-S29.

Epub 2012 Feb 21.

10:148-151,147.

trophysiol 2011; 22(3):241-7.

Heart Fail 2012; 5:307-8.

iability in anesthetized rats. Evid Based Complement Alternat Med 2012;2012:817378. Epub 2012 Feb 21.

[51] Tang ZL, Song XG, Zhou YP: A preliminary study on the prevention and cure of sud‐ den death caused by coronary heart disease by acupuncture. Zhen Ci Yan Jiu 1985; 10:148-151,147.

[37] Liu FC, Chen CA, Yang SS, Lin SH: Acupuncture therapy rapidly terminates intracta‐ ble hiccups complicating acute myocardial infarction. South Med J 2005; 98:385-387.

[38] Xia Y, Guo XQ, Zhang AZ, Cao XD, Li P: Inhibitory effect of analogous electro-acu‐ puncture on experimental arrhythmia. Acupunct Electrother Res 1985; 10:13-34. [39] Fan W, Wu N, Fang C: Effect of acupuncture on ischemic ventricular tachyarrhyth‐ mia in experimental electrophysiology study. Zhonghua Xin Xue Guan Bing Za Zhi

[40] Zhang Y, Guo Y, Wang X, Shi L, Miao W, Xu T, Zhang C: Influence of changing Ca++ concentration in neiguan (PC6) on the effect of acupuncture treating experimental ar‐

[41] Liptak V, Habeler G, Egger J: Influence of acupuncture and electroacupuncture on

[42] Zhang J, Xu W: Frequent ventricular extrasystoles treated by needling neiguan (PC6) plus oral administration of mexiletine – a report of 30 cases. J Tradit Chin Med 2004;

[43] Gao ZW, Yu XY, Shen AX, Bao LE, Lin XC, Qiu JH, Wang ZL, Hu ZG, Zhang SH: Acupuncture treatment of 54 cases of sinus bradycardia. J Tradit Chin Med 1987;

[45] Lombardi F, Belletti S, Battezzati PM, Lomuscio A: Acupuncture for paroxysmal and persistent atrial fibrillation: An effective non-pharmacological tool? World J Cardiol

[46] Shi X, Wang ZP, Liu KX: Effect of acupuncture on heart rate variability in coronary heart disease patients. Zhongguo Zhong Xi Yi Jie He Za Zhi 1995; 15:536-538.

[47] Litscher G, Cheng G, Cheng W, Wang L, Niu Q, Feng X, Gaischek I, Kuang H: Sino-European transcontinental basic and clinical high-tech acupuncture studies-part 2: acute stimulation effects on heart rate and its variability in patients with insomnia.

[48] Litscher G, Cheng G, Wang L, Cheng W, Su H, Niu Q, Zou T, Wang Y, Feng X, Gai‐ schek I, Sheng Z, Kuang H: Biomedical teleacupuncture between China and Austria using heart rate variability-Part 2: Patients with depression. Evid Based Complement

[49] Anderson B, Nielsen A, McKee D, Jeffres A, Kligler B: Acupuncture and heart rate variability: a systems level approach to understanding mechanism. Explore (NY)

[50] Gao XY, Liu K, Zhu B, Litscher G: Sino-European transcontinental basic and clinical high-tech acupuncture studies-part 1: auricular acupuncture increases heart rate var‐

Evid Based Complement Alternat Med 2012;2012:916085. Epub 2012 Mar 4.

Alternat Med 2012;2012:145904. Epub 2012 Apr 17.

heart rate and extrasystoles. Wien Med Wochenschr 1980; 130:668-670.

[44] Berman RH: Acupuncture for cardioversion. Ann Intern Med 1973; 79:285.

rhythmia of rabbits. Zhen Ci Yan Jiu 1995; 20:63-67.

1987; 15:285-288, 311.

24:40-41.

268 Acupuncture in Modern Medicine

7:185-187.

2012; 4(3):60-5.

2012; 8(2):99-106.

tolerance of patients with heart failure: a placebo-controlled pilot study. Heart 2010; 96:1396-400.

sion with the Acupuncture Research Program (SHARP): results of a randomized con‐

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 271

[80] Lackland DT, Elkind MSV, D'Agostino R Sr, Dhamoon MS, Goff DC Jr, Higashida RT, McClure LA, Nitchell PH, Sacco RL, Sila CA, Smith SC Jr, Tanne D, Tirschwell DL, Touzé E, Wechsler LR, on behalf of the American Heart Association Stroke Council, Council on Epidemiology and Prevention, Council on Cardiovascular Radi‐ ology and Intervention, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Quality of Care and Outcomes Research: Inclusion of stroke in cardiovascular risk prediction instruments: A statement for healthcare professionals From the American Heart Association/American Stroke Association.

[81] Zhou HF, Wang J, Cao TJ, Ju QB, Huang CY, Feng Y, Li YM, Li XN, Qu F, Dou WB: Effects of eye acupuncture on SPECT-determined cerebral blood flow in patients

[82] Li H, Hou ZW, Bai YL, Gu SZ: Comparative study on curative effects of stroke treat‐

[83] Du Y, Shi L, Li J, Xiong J, Li B, Fan X: Angiogenesis and improved cerebral blood flow in the ischemic boundary area were detected after electroacupuncture treatment

[84] Jiang YZ, Li C, Xu JY, Lu YZ, Xu R, Han B, Lu WH: Observation of clinical efficacy of acupuncture for cerebral vasospasm after embolization of ruptured aneurysms.

[85] Wang F, Wang HQ, Dong GR: Progress of researches on mechanism of acupuncture therapy underlying improvement of acute cerebral hemorrhage. Zhen Ci Yan Jiu

[86] Fu QH, Pei J, Jia Q, Song Y, Gu YH, You XX: Acupuncture treatment programs for post-stroke motor rehabilitation in community hospitals: study protocol of a multi‐ center, randomized, controlled trial. Zhong Xi Yi Jie He Xue Bao 2012; 10(5):516-24.

[87] Lu T, Luo Y, Sun H, Qin W, Li Y: Electroacupuncture improves behavioral recovery and increases SCF/c-kit expression in a rat model of focal cerebral ischemia/reperfu‐

[88] Li G, Yang ES: An fMRI study of acupuncture-induced brain activation of aphasia

[89] Zheng H, Zhu SW, Yang F, Huang XM, Wang Z, Cui FF, Zhang DB: Efficacy observa‐ tion of Thoroughfare Vessel theory in acupuncture for post-stroke dysphasia. Zhong‐

[90] Sun XR, Fan GQ, Dai XZ: Primary optimization of acupuncture program for dyspha‐

ed with acupuncture by NIRS. Zhongguo Zhen Jiu 2011; 31:998-1002.

with cerebral infarction. Zhongguo Zhen Jiu 2011; 31:391-4.

to rats with ischemic stroke. Neurol Res 2011; 33;101-7.

sion. Neurol Sci 2012 Apr 13 [Epub ahead of print].

stroke patients. Complement Ther Med 2011; 19 Suppl 1:S49-59.

gia after cerebral infarction. Zhongguo Zhen Jiu 2011; 31:879-82.

Zhongguo Zhen Jiu 2012; 32:193-7.

guo Zhen Jiu 2011; 31:1067-70.

2011; 36(2):145-9.

trolled clinical trial. Hypertension 2006; 48:838-845.

Stroke 2012; 43:1998-2027.

sion with the Acupuncture Research Program (SHARP): results of a randomized con‐ trolled clinical trial. Hypertension 2006; 48:838-845.

tolerance of patients with heart failure: a placebo-controlled pilot study. Heart 2010;

[65] Ma SH, Gao JH, Wang YM, Zhang M, Ma YY, Hu JJ, Fu WX, Cui HF, Yu XC: Consid‐ erations about study on mechanisms of acupuncture underlying efficacy-enhance‐ ment and toxicity-attenuation of digitalis drugs for heart failure. Zhen Ci Yan Jiu

[66] Zhou W, Longhurst JC: Neuroendocrine mechanisms of acupuncture in the treat‐ ment of hypertension. Evid Based Complement Alternat Med 2012;878673. Epub

[67] Lee HS, Kim JY: Effects of acupuncture on blood pressure and plasma renin activity in two-kidney one clip Goldblatt hypertensive rats. Am J Chin Med 1994; 22:215-219.

[68] Chiu YJ, Chi A, Reid IA: Cardiovascular and endocrine effects of acupuncture in hy‐

[69] Zhang YL, Li CP, Peng M, Yang HS: Effect of acupuncture combined with medicine on neuropeptide Y in the patient of hypertension. Zhongguo Zhen Jiu 2005;

[70] Anshelevich IuV, Merson MA, Afanas'eva GA: Serum aldosterone level in patients with hypertension during treatment by acupuncture. Ter Arkh 1985; 57(10):42-45 [71] Shen S, Li J, Wang XM, Han JS: Angiotensin II release and anti-electroacupuncture

[72] Huang H, Liang S: Acupuncture at otoacupoint heart for treatment of vascular hy‐

[73] Yao T: Acupuncture and somatic nerve stimulation: mechanism underlying effects on cardiovascular and renal activities. Scan J Rehabil Med Suppl 1993; 29:7-18. [74] Lin MZ, Wei ZY: Effect of elctroacupuncture on the urine flow, sodium excretion and potassium excretion in the conscious dog. Zhen Ci Yan Jiu 1989; 143:365-369.

[75] Zhou Y, Wang Y, Fang Z, Xia C, Liu B, Chen Q, Zhang F: Influence of acupuncture on blood pressure, contents of NE, DA and 5-HT of SHR and the interrelation be‐ tween blood pressure and whole blood viscosity. Zhen Ci Yan Jiu 1995; 20:55-61. [76] Ulett GA, Han S, Han JS: Electroacupuncture: mechanisms and clinical application.

[78] Jin YX, Fu Q, Guo XQ: Effects of electroacupuncture of "zusanli" acupoint on high blood pressure and blood hyperviscosity in stress rats. J Tongji Med Univ 1992;

[79] Macklin EA, Wayne PM, Kalish LA, Valaskatgis P, Thompson J, Pian-Smith MMC, Zhang Q, Stevens S, Goertz C, Prineas RJ, Buczynski B, Zusman RM: Stop Hyperten‐

[77] Han JS: Acupuncture and endorphins. Neurosci Lett 2004; 361:258-261.

pertensive patients. Clin Exp Hypertens 1997; 19:1047-1063.

analgesia in spinal cord. Sheng Li Xue Bao 1996; 48:543-550.

pertension. J Tradit Chin Med 1992; 12:133-136.

Biol Psychiatry 1998; 44:129-138.

12:209-215.

96:1396-400.

270 Acupuncture in Modern Medicine

2011; 36(3):225-9.

2011 Dec 18.

25:155-157.

[91] Li W, Cheng YH, Yu XG: Observation on therapeutic effect of acupuncture combined with medicine on mild cognition disorders in patients with post-stroke. Zhongguo Zhen Jiu 2012; 32:3-7.

[106] Kannel WB, McGee DL: Diabetes and cardiovascular disease. The Framingham

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 273

[107] Haffner SM, Lehto S, Ronnemaa T, Pyörälä K, Laakso M: Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and

[108] Gregg EW, Cheng YJ, Saydah S, Cowie C, Garfield S, Geiss L, Barker L: Trends in death rates among U.S. adults with and without diabetes between 1997 and 2006: findings from the national health interview survey. Diabetes Care 2012; 35:1252-7.

[109] Benn M, Tybjærg-Hansen A, McCarthy MI, Jensen GB, Grande P, Nordestgaard BG: Nonfasting glucose, ischemic heart disease, and myocardial infarction. A Mendelian

[110] Hu DY, Pan CY, Yu JM, for the China Heart Survey Group: The relationship between coronary artery disease and abnormal glucose regulation in China: the China Heart

[112] Cheng TO: Diabetes epidemic in China and its economic impact. Int J Cardiol 2011;

[113] Yan S, Li J, Li S, Zhang B, Du S, Gordon-Larsen P, Adair L, Popkin B: The expanding burden of cardiometabolic risk in China: the China Health and Nutrition Survey.

[114] Sui Y, Zhao HL, Wong VCW, Brown N, Li XL, Kwan AKL, Hui HLW, Ziea ETC, Chan JCN: A systematic review on use of Chinese medicine and acupuncture for

[115] Peplow PV, Baxter GD: Electroacupuncture for control of blood glucose in diabetes:

[116] Ju YL, Chen ML, Wang L, Lan W, Chi X, Liu JX, Zhang HL: Effects of stimulating in the cavum concha on glucometabolism in patients with diabetes. Zhongguo Zhen Jiu

[117] Meng H, Zhai X, Hao JD, Wang HC: Intervention of electroacupuncture for patients

[118] Meng H, Hao JD, Wang HC, Zhao JY, Zhao CL, Zhai X: Effects of different frequen‐ cies of electroacupuncture on blood glucose level in impaired glucose tolerance pa‐

[119] Cai H, Zhao LJ, Zhao ZM, Guo JH, Yuan AH: Effect of acupuncture on serum leptin level in patients with type II diabetes mellitus. Zhen Ci Yan Jiu 2011; 36(4):288-91.

with impaired glucose tolerance. Zhongguo Zhen Jiu 2011; 31:971-3.

[111] Cheng TO: Smoking and diabetes in Chinese men. Postgrad Med J 2001; 77:551.

without prior myocardial infarction. N Engl J Med 1998; 339:229-34.

randomization study. J Am Coll Cardiol 2012; 59:2356-65.

study. JAMA 1979; 241:2035-2038.

Survey. Eur Heart J 2006; 27: 2573-79.

treatment of obesity. Obes Rev 2012; 13(5):409-30.

tients. Zhen Ci Yan Jiu 2011; 36(3):220-3.

literature review. J Acupunct Meridian Stud 2012; 5:1-10.

Obes Rev 2012;13:810-821

2012; 32:198-200.

149:1-3.

[106] Kannel WB, McGee DL: Diabetes and cardiovascular disease. The Framingham study. JAMA 1979; 241:2035-2038.

[91] Li W, Cheng YH, Yu XG: Observation on therapeutic effect of acupuncture combined with medicine on mild cognition disorders in patients with post-stroke. Zhongguo

[92] Zhang GC, Fu WB, Xu NG, Liu JH, Zhu XP, Liang ZH, Huang YF, Chen YF: Meta analysis of the curative effect of acupuncture on post-stroke depression. J Tradit Chin

[93] Chu JM, Bao YH, Zou C, Zhao HL, Gong Y, Wang CM: Randomized controlled clini‐ cal trials for electroacupuncture treatment of urinary incontinence in stroke patients.

[94] Cheng TO: The current state of cardiology in China. Int J Cardiol 2004; 96:425-439.

[95] Cheng TO: Cardiovascular health, risks and diseases in contemporary China. Int J

[96] Cheng TO: Prevention of cardiovascular disease in modern China: Utile or futile?

[97] Jiang Y, Elton-Marshall T, Fong GT, Li Q: Quitting smoking in China: findings from

[98] He Y, Jiang B, Li LS, Li LS, Ko L, Wu L. Sun DL, He SF, Liang BQ, Hu FB, Lam TH: Secondhand smoke exposure predicted chronic obstructive pulmonary disease and other tobacco related mortality in a 17-year cohort study in China. Chest 2012 May

[99] Wu S, Huang Z, Yang X, Zhou Y, Wang A, Chen L, Zhao H, Ruan C, Wu Y, Xin A, Li K, Jin C, Cai J: Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city. Circ Cardiovasc

[101] Cheng TO: Is China finally going to ban cigarette smoking? Int J Cardiol 2010;

[102] Kim SS, Chen W, Kolodziej M, Wang X, Wang VJ, Ziedonis D: A systematic review of smoking cessation intervention studies in China. Nicotine Tob Res 2012;14:891-

[103] Tahiri M, Mottillo S, Joseph L, Pilotee L, Eisenberg MJ: Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. Am J Med 2012;125:576-584

[104] Cheng HM, Chung YC, Chen HH, Chang YH, Yeh ML: Systematic review and metaanalysis of the effects of acupoint stimulation on smoking cessation. Am J Chin Med

[105] Cabioglu MT, Ergene N, Tan U: Smoking cessation after acupuncture treatment. Int J

[100] Anonymous: Chronic disease challenge. Beijing Review May 31, 2012; 55(22):5.

the ITC China survey. Tobacco Control 2010; 19(Suppl 2):i12-i17.

Zhen Jiu 2012; 32:3-7.

272 Acupuncture in Modern Medicine

Med 2012; 32:6-11.

Zhen Ci Yan Jiu 2011; 36(6):428-32.

CVD Prevention and Control 2009; 4:1-7.

Cardiol 2012; 154:233-242.

24. [Epub ahead of print]

145:1-2.

2012; 40(3):429-442.

Neurosci 2007; 117(5):571-8.

Qual Outcomes 2012; 5:487-493.

[120] Hwang HS, Yang EJ, Lee SM, Lee SC, Choi SM: Antiallodynic effects of electroacu‐ puncture combined with MK-801 treatment through the regulation of p35/p25 in ex‐ perimental diabetic neuropathy. Exp Neurobiol 2011; 20(3):144-52.

[133] Yang L, Yang J, Wang Q, Chen M, Lu Z, Chen S, Xiong L: Cardioprotective effects of electroacupuncture pretreatment on patients undergoing heart valve replacement

Acupuncture in Cardiology http://dx.doi.org/10.5772/55252 275

[134] Ni X, Xie Y, Wang Q, Zhong H, Chen M, Wang F, Xiong L: Cardioprotective effect of transcutaneous electric acupoint stimulation in the pediatric cardiac patients: a

[135] Zhou J, Chi H, Cheng TO, Chen TY, Wu YY, Zhou WX, Shen WD, Yuan L: Acupunc‐ ture anesthesia for open heart surgery in contemporary China. Int J Cardiol 2011;

[136] Cheng TO: Acupuncture needles as a cause of bacterial endocarditis. Br Med J 1983;

[137] Cheng TO: Subacute bacterial endocarditis following ear acupuncture. Int J Cardiol

[138] Cheng TO: Infective endocarditis, cardiac tamponade, and AIDS as serious complica‐

[139] Cheng TO: Pericardial effusion from self-inserted needle in the heart. Eur Heart J

[141] Andersen SA: Bilateral pneumothorax associated to acupuncture. Uqeskr Laeger

[142] Cheng TO: acupuncture and acquired immunodeficiency syndrome. Am J Med 1989;

[143] Ernst E, White A: Life-threatening adverse reactions after acupuncture? A systematic

[144] Ernst E, White AR: Prospective studies of the safety of acupuncture: a systematic re‐

[145] Melchart D, Weidenhammer W, Streng A, Reitmayr S, Hoppe A, Ernst E, Linde K: Prospective investigation of adverse effects of acupuncture in 97733 patients. Arch

[146] Endres HG, Molsberger A, Trampisch HJ: Adverse events in acupuncture: a prospec‐ tive survey of adverse events after acupuncture treatment of 190,000 chronic pain pa‐

[147] MacPherson H, Scullion T, Thomas K, Walters S: Patient reports of adverse events as‐ sociated with acupuncture: a large scale prospective survey. J Alternative Comple‐

tients. J Alternative Complementary Med 2004; 10:212.

[140] Cheng TO: Cardiac tamponade following acupuncture. Chest 2000; 118:1836-1837.

tions of acupuncture. Arch Intern Med 2004; 164:1464.

surgery: a randomized controlled trial. Ann Thorac Surg 2010; 89:781-6.

randomized controlled clinical trial. Paediatr Anaesth 2012;22:805-811.

150:12-16.

287:689.

1985; 8:97.

1991; 12:958.

2011; 173:2724-5.

review. Pain 1997; 71:123-126.

view. Am J Med 2001; 110:481-5.

Intern Med 2004; 164:104-105.

mentary Med 2004; 10:215.

87:489.

[133] Yang L, Yang J, Wang Q, Chen M, Lu Z, Chen S, Xiong L: Cardioprotective effects of electroacupuncture pretreatment on patients undergoing heart valve replacement surgery: a randomized controlled trial. Ann Thorac Surg 2010; 89:781-6.

[120] Hwang HS, Yang EJ, Lee SM, Lee SC, Choi SM: Antiallodynic effects of electroacu‐ puncture combined with MK-801 treatment through the regulation of p35/p25 in ex‐

[121] Jin Z, Zhang BF, Shang LX, Wang LN, Wang YL, Chen J, Jiang SS: Clinical observa‐ tion on diabetic peripheral neuropathy treated with electroacupuncture and acupoint

[122] Bo C, Xue Z, Yi G, Zelin C, Yang B, Zixu W, Yajun W: Assessing the quality of re‐ ports about randomized controlled trials of acupuncture treatment on diabetic pe‐

[123] Luo YX: Acupuncture for 62 cases of urinary infection of diabetes. Zhongguo Zhen

[124] Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D, Turner MB; American Heart Association Statistics Committee and Stroke Statistics Subcommittee: Heart disease and stroke statistics—2012 update: a report

[125] Xu H, Li Y, Liu A, Zhang Q, Hu X, Fang H, Li T, Guo H, Li Y, Xu G, Ma J, Du L, Ma G: Prevalence of the metabolic syndrome among children from six cities of China. BMC Public Health 2012; 12:13. http://www.biomedcentral.com/1471-2458/12/13

[127] Cho S-H, Lee J-S, Thabane L, Lee J: Acupuncture for obesity: a systematic review and

[128] Gong M, Wang X, Mao Z, Shao Q, Xiang X, Xu B: Effect of electroacupuncture on lep‐ tin resistance in rats with diet-induced obesity. Am J Chin Med 2012; 40:511-20. [129] Hu WL, Chang CH, Hung YC: Clinical observations on laser acupuncture in simple

[130] DeBakey ME: A Surgeon's Diary of a Visit to China. Phoenix, Arizona: Phoenix

[131] Hollinger I, Richter JA, Pongratz W, Baum M: Acupuncture anesthesia for open heart

[132] Caracausi SR: Electro-acupuncture in thoracic and cardiovascular surgery. Minerva

from the American Heart Association. Circulation 2012; 125:e2-e220.

[126] Cheng TO: Childhood obesity in modern China. Int J Cardiol 2012; 157:315-7.

perimental diabetic neuropathy. Exp Neurobiol 2011; 20(3):144-52.

injection. Zhongguo Zhen Jiu 2011; 31:613-6.

meta-analysis. Int J Obesity 2009; 33:183-196.

obesity therapy. Am J Chin Med 2010; 38(5):861-7.

surgery: a report of 800 cases. Am J Chin Med 1979; 7:77-90.

Newspapers, Inc. 1974:31-33.

Med 1979; 70:3857-3860.

Jiu 2011; 31:702.

274 Acupuncture in Modern Medicine

ripheral neuropathy. PLoS One 2012; 7(7):e38461.

[148] Gopalan R, Scott R, Arabia F, Chandrasekaran K: Electro-acupuncture therapy in a patient with a total artificial heart. Acupunct Med 2011; 29:302-3.

**Chapter 13**

**Acupuncture for Cancer Patients:**

Additional information is available at the end of the chapter

Acupuncture is a traditional Chinese medicine technique that involves inserting and manip‐ ulating filiform needles in predefined points on the skin (i.e., *acupuncture points*) to achieve therapeutic effect. Although studies have not been able to fully explain the mechanism of acupuncture, it has been proposed that acupuncture worked through its effect on neuro‐

Acupuncture points can be stimulated in various ways. With manual acupuncture, the fili‐ form acupuncture needle is inserted in an acupuncture point and manually rotated to stimu‐ late the point. With electroacupuncture, acupuncture points are stimulated by passing electrical current through inserted needles. Electrical current may also be passed through an electrode on the skin without inserting acupuncture needles, a technique called *noninvasive electrostimulation*. Acupressure is a form of modified acupuncture that replaces needles with physical pressure generated with either a finger or device such as an embedded stud in an

Acupuncture and acupuncture point stimulation have been widely used as a complementa‐ ry therapy to treat wide range of illnesses by many patients, especially cancer patients. Growing evidence suggests that acupuncture is beneficial for cancer pain, chemotherapy-in‐ duced nausea, vomiting, and may be beneficial for symptoms such as radiation therapy-in‐ duced xerostomia, fatigue, hot flashes, depression, anxiety, and insomnia. This chapter provides an overview of the role of acupuncture in alleviating cancer patients' symptoms,

and reproduction in any medium, provided the original work is properly cited.

© 2013 Wang and Bao; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Practice and Research**

Lizhen Wang and Ting Bao

http://dx.doi.org/10.5772/54005

transmitters and neurohormones. [1, 2]

with focus on the scientific evidence behind the practice.

**1. Introduction**

elastic wrist band.

**Chapter 13**

## **Acupuncture for Cancer Patients: Practice and Research**

Lizhen Wang and Ting Bao

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54005

### **1. Introduction**

[148] Gopalan R, Scott R, Arabia F, Chandrasekaran K: Electro-acupuncture therapy in a

[149] Zhong HZ, Chang JL, Zhu D, Gao Y: An overview of researches on underlying mech‐ anisms of acupuncture therapy by functional magnetic resonance imaging in recent 5

[150] Hewson MG, Copeland HL, Mascha E, Arrigain S, Topol E, Fox JE: Integrative medi‐ cine: implementation and evaluation of a professional development program using experiential learning and conceptual change teaching approaches. Patient Educ

[151] Park JJ, Beckman-Harned S, Cho G, Kim D, Kim H: The current acceptance, accessi‐ bility and recognition of Chinese and Ayurvedic medicine in the United States in the

public, governmental, and industrial sectors. Chin J Integr Med 2012; 18:405-8. [152] NIH Consensus Development Panel on Acupuncture. NIH Consensus Conference.

[153] 2007 national health interview survey. http://nccam.nih.gov/about/plans/2011/intro‐

[154] Lee JH. Choi TY, Lee MS, Lee H, Shin BC, Lee H: Acupuncture for acute low back

[155] Li ZJ, Liu ML, Wang JN, Liang FR: Method and current situations on acupuncture clinical trial registration in the world. Zhen Ci Yan Jiu 2012; 37:86, inside back cover.

patient with a total artificial heart. Acupunct Med 2011; 29:302-3.

years. Zhen Ci Yan Jiu 2012; 37(2):161-7.

Acupuncture. JAMA 1998; 280:1518-1524.

pain: a systematic review. Clin J Pain 2013;29:172-185.

Couns 2006; 62:5-12.

276 Acupuncture in Modern Medicine

duction.htm.

Acupuncture is a traditional Chinese medicine technique that involves inserting and manip‐ ulating filiform needles in predefined points on the skin (i.e., *acupuncture points*) to achieve therapeutic effect. Although studies have not been able to fully explain the mechanism of acupuncture, it has been proposed that acupuncture worked through its effect on neuro‐ transmitters and neurohormones. [1, 2]

Acupuncture points can be stimulated in various ways. With manual acupuncture, the fili‐ form acupuncture needle is inserted in an acupuncture point and manually rotated to stimu‐ late the point. With electroacupuncture, acupuncture points are stimulated by passing electrical current through inserted needles. Electrical current may also be passed through an electrode on the skin without inserting acupuncture needles, a technique called *noninvasive electrostimulation*. Acupressure is a form of modified acupuncture that replaces needles with physical pressure generated with either a finger or device such as an embedded stud in an elastic wrist band.

Acupuncture and acupuncture point stimulation have been widely used as a complementa‐ ry therapy to treat wide range of illnesses by many patients, especially cancer patients. Growing evidence suggests that acupuncture is beneficial for cancer pain, chemotherapy-in‐ duced nausea, vomiting, and may be beneficial for symptoms such as radiation therapy-in‐ duced xerostomia, fatigue, hot flashes, depression, anxiety, and insomnia. This chapter provides an overview of the role of acupuncture in alleviating cancer patients' symptoms, with focus on the scientific evidence behind the practice.

© 2013 Wang and Bao; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **2. Acupuncture to treat cancer pain**

Cancer pain is the most common and one of the most distressing and feared symptoms among cancer patients. It is estimated that up to two thirds of patients with metastatic can‐ cer suffered from cancer related pain.[3] More than 75% of hospitalized oncology patients experienced cancer related pain.[4-6] Due to its importance, pain is often referred to as the fifth vital sign of oncology patients. Cancer pain varies both by types of malignancy, and sites of cancer involvement.[7] The majority of cancer pain is caused by direct effect of can‐ cer as a result of visceral involvement, bony metastasis, soft tissue invasion, or infiltration to the nerve or nerve plexus.[8] Cancer treatments such as chemotherapy, radiation and sur‐ gery may also cause treatment-induced cancer pain.

proved pain control when compared to usual care alone. Lastly, Pfister et al's study showed that four weekly acupuncture treatments significantly reduced pain and improved function in cancer patients with chronic pain or dysfunction due to neck dissection than standard care alone.[24] However, with no sham therapy group in the last two studies, it is difficult to tease out the placebo effect, and leave the question that if the professionally trained acu‐ puncturists and massage therapists and real acupuncture needles are required in the inter‐

> **Treatment Duration**

Weekly for 4 weeks

**Evaluation Method**

inventory

medication quantification

rating scale

Constant-Murley score, a composite measure of pain, function, and activities of daily living

2 month VAS The acupuncture group had a

2 months WHO pain scale No difference among the three

1 month Brief pain

7 days VAS and

2 days Pain numeric

**Results**

Acupuncture for Cancer Patients: Practice and Research

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279

No difference between the two groups

Lower cumulative dose of patient controlled analgesic morphine used on postop day 2 in EA group (P < 0.05)

The treatment group has less pain P = 0.038

Constant-Murley scores improved more in the acupuncture group (adjusted difference between groups = 11.2; 95% CI, 3.0 to 19.3; P = .008).

significant decrease (P < 0.01) in pain intensity after 2 months (35% decrease) compared with the control groups

groups in long-term effective rate of analgesia, 81% in all groups.

vention remained unanswered.

Postthoracotomy pain

Postthoracotomy pain

pain and dysfunction in patients with cancer with a history of neck dissection

Peripheral or central neuropathic pain arising after cancer treatment

Stomach Cancer Pain

**Type of Pain Treatment**

Post-op pain Group 1:

**Groups**

Group 1: intradermal acupuncture; 2: sham acupuncture

Group1:electroac upuncture, 2: sham acupuncture

acupuncture and massage; 2: usual care

1.acupuncture (N=28) 2. usual care (N=30)

Group 1: auricular acupuncture; 2: sham control; 3: control

Group 1: acupuncture; 2:acupuncture point injection; 3: western analgesics

**Reference/ Sample size**

> Deng et al 2008[15] N=106

Wong et al 2006[16] N=27

Mehling et al 2007[17] N=45

Pfister et al 2010[24] N=58

Alimi et al 2003[19] N=90

Dang et al 1998[22] N=48

Cancer pain has traditionally been treated with opioids and interventional anesthetic or neu‐ rosurgical procedures. Despite maximal use of pain medications and application of inter‐ ventional procedures, a significant portion of cancer patients still suffer from pain. In addition, the undesired side effects of long term usage of opioid pain medication, particular‐ ly change of mental status, constipation, nausea, fear of dependence, could be an issue. As a result, cancer patients often seek help in complementary alternative medicine, including acupuncture in an attempt to control their pain.

Even though acupuncture has been widely used among oncology patients to control cancer pain, the role of acupuncture in controlling cancer pain has not been clearly established through well-designed clinical trials. Many clinical trials suffered from methodological flaws such as poor study design, small sample size and lack of statistical analysis.[11] As a result, two recent Cochrane systematic reviews of randomized controlled clinical trials on the role of acupuncture to treat cancer pain showed no strong evidence for the effectiveness of acupuncture in reducing cancer pain. Another Cochrane systematic review assessed the value of Transcutaneous Electrical Nerve Stimulation (TENS) in the management of cancerrelated pain in adults and remained inconclusive due to lack of suitable RCTs.[14]

On the other hand, a number of recent well-designed Randomized Controlled Trials (RCTs) have been conducted to study the role of acupuncture in treating cancer pain and are sum‐ marized in table 1.[15-23] Among them, four RCTs studied the efficacy of different types of acupuncture in controlling postoperative pain and presented mixed results. Deng et al's RCT on 106 cancer patients experiencing post-thoracotomy pain showed no statistical differ‐ ence between the real versus sham acupuncture groups in patient's pain scores measured by Brief Pain Inventory at the 30-, 60-, and 90 days follow-ups.[15] The efficacy of the unique intradermal needles used in this study was questionable. Wong et al's smaller RCT (N=27) showed a trend of lower Visual Analog Scale (VAS) pain scores in patients receiving electro‐ acupuncture when compared to patients receiving sham acupuncture on post-operative days 2 and 6; and a statistically significant lower cumulative dose of Patient Controlled An‐ algesia (PCA) on postop day 2 (p < 0.05).[16] This study was, however, limited by its small sample size. Mehling et al's RCT (N=93) compared acupuncture plus massage therapy with usual care in controlling postoperative pain, nausea, vomiting and depressive moods.[17] It showed that postop acupuncture and massage in addition to usual care significantly im‐ proved pain control when compared to usual care alone. Lastly, Pfister et al's study showed that four weekly acupuncture treatments significantly reduced pain and improved function in cancer patients with chronic pain or dysfunction due to neck dissection than standard care alone.[24] However, with no sham therapy group in the last two studies, it is difficult to tease out the placebo effect, and leave the question that if the professionally trained acu‐ puncturists and massage therapists and real acupuncture needles are required in the inter‐ vention remained unanswered.

**2. Acupuncture to treat cancer pain**

278 Acupuncture in Modern Medicine

gery may also cause treatment-induced cancer pain.

acupuncture in an attempt to control their pain.

Cancer pain is the most common and one of the most distressing and feared symptoms among cancer patients. It is estimated that up to two thirds of patients with metastatic can‐ cer suffered from cancer related pain.[3] More than 75% of hospitalized oncology patients experienced cancer related pain.[4-6] Due to its importance, pain is often referred to as the fifth vital sign of oncology patients. Cancer pain varies both by types of malignancy, and sites of cancer involvement.[7] The majority of cancer pain is caused by direct effect of can‐ cer as a result of visceral involvement, bony metastasis, soft tissue invasion, or infiltration to the nerve or nerve plexus.[8] Cancer treatments such as chemotherapy, radiation and sur‐

Cancer pain has traditionally been treated with opioids and interventional anesthetic or neu‐ rosurgical procedures. Despite maximal use of pain medications and application of inter‐ ventional procedures, a significant portion of cancer patients still suffer from pain. In addition, the undesired side effects of long term usage of opioid pain medication, particular‐ ly change of mental status, constipation, nausea, fear of dependence, could be an issue. As a result, cancer patients often seek help in complementary alternative medicine, including

Even though acupuncture has been widely used among oncology patients to control cancer pain, the role of acupuncture in controlling cancer pain has not been clearly established through well-designed clinical trials. Many clinical trials suffered from methodological flaws such as poor study design, small sample size and lack of statistical analysis.[11] As a result, two recent Cochrane systematic reviews of randomized controlled clinical trials on the role of acupuncture to treat cancer pain showed no strong evidence for the effectiveness of acupuncture in reducing cancer pain. Another Cochrane systematic review assessed the value of Transcutaneous Electrical Nerve Stimulation (TENS) in the management of cancer-

On the other hand, a number of recent well-designed Randomized Controlled Trials (RCTs) have been conducted to study the role of acupuncture in treating cancer pain and are sum‐ marized in table 1.[15-23] Among them, four RCTs studied the efficacy of different types of acupuncture in controlling postoperative pain and presented mixed results. Deng et al's RCT on 106 cancer patients experiencing post-thoracotomy pain showed no statistical differ‐ ence between the real versus sham acupuncture groups in patient's pain scores measured by Brief Pain Inventory at the 30-, 60-, and 90 days follow-ups.[15] The efficacy of the unique intradermal needles used in this study was questionable. Wong et al's smaller RCT (N=27) showed a trend of lower Visual Analog Scale (VAS) pain scores in patients receiving electro‐ acupuncture when compared to patients receiving sham acupuncture on post-operative days 2 and 6; and a statistically significant lower cumulative dose of Patient Controlled An‐ algesia (PCA) on postop day 2 (p < 0.05).[16] This study was, however, limited by its small sample size. Mehling et al's RCT (N=93) compared acupuncture plus massage therapy with usual care in controlling postoperative pain, nausea, vomiting and depressive moods.[17] It showed that postop acupuncture and massage in addition to usual care significantly im‐

related pain in adults and remained inconclusive due to lack of suitable RCTs.[14]

**2. Acupuncture to treat cancer therapy induced nausea and vomiting**

these patients.[29]

therapy are needed.

motherapy. [34]

ture in controlling this side effect.

Chemotherapy-Induced Nausea and Vomiting (CINV) is one of the most common and feared treatment-related side effects among patients with cancer. As a result, nutritional sta‐ tus, quality of life, and treatment adherence may be severely compromised in patients.[28] Over the past 20 years, better understanding of the physiology of CINV and the subsequent development of modern pharmacologic antiemetic agents have substantially improved the control of CINV. However, study suggests that CINV remains a significant problem among

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281

CINV can either be acute, delayed, or anticipatory. Acute CINV occurs within 24 hours of chemotherapy, usually beginning within 2 to 4 hours and peaking in the first 4 to 6 hours. [30] Delayed CINV occurs from day 2 to 6 of chemotherapy.[30] Anticipatory CINV occurs before chemotherapy treatments in patients who have previously experienced significant CINV.[30] Most antiemetic research focuses on reducing acute and delayed CINV, with the understanding that this would result in better control of anticipatory CINV. Despite recent advances in pharmacologic antiemetic therapy, additional treatment for breakthrough CINV is needed. Several randomized controlled clinical trials suggested the efficacy of acupunc‐

A meta-analysis of 11 RCTs on 1247 cancer patients with CINV showed that the proportion of acute vomiting episodes was significantly lower in the acupuncture point stimulation group than the control group (22% vs. 31%, p=0.04). Those trials, however, did not show that acupuncture significantly alleviate acute chemotherapy-induced nausea or delayed CINV. [35,36] The clinical relevance of these results were limited by the fact that those clinical trials predated the use of aprepitant and that only 1 or 2 acupuncture points were stimulated dur‐ ing acupuncture treatment. More clinical trials to study the effect of acupuncture with addi‐ tional antiemetic acupuncture points in adjunct to modern pharmacologic antiemetic

In addition to acupuncture, acupressure has been demonstrated to effectively reduce CINV. In a single-arm prospective study on 100 metastatic solid tumor patients experiencing per‐ sistent CINV despite standard antiemetic agents, 68% of patients' emetic symptoms im‐ proved after being treated with acupressure at PC6 point.[33] A RCT on 160 breast cancer patients who experienced moderate nausea during previous chemotherapy cycles and were getting ready to begin their 2nd or 3rd cycle of chemotherapy showed that acupressure at PC6 through a wrist device significantly decreased the amount of delayed vomiting and the in‐ tensity of nausea over time when compared with placebo acupressure and usual care groups.[34] The authors concluded that acupressure was safe and effective for cancer pa‐ tients to manage delayed CINV and should be offered to breast cancer patients during che‐

There has been a number of RCTs studying the effect of acupuncture in reducing Radiation-Induced Nausea and Vomiting (RINV), and showed that even though there is no statistically significant difference between real and sham acupuncture, both treatments were significant‐

**Table 1.** Summary of Randomized Control Trials on Acupuncture for Cancer Pain Relief

There have been a number of clinical trials showing the effect of acupuncture in reduc‐ ing neuropathic pain in cancer patients. Among them, one clinical trial showed the effec‐ tiveness of auricular acupuncture in treating cancer treatment induced neuropathy.[19] This was a randomized, blinded, controlled trial conducted on 90 cancer patients with peripheral or central neuropathic pain arising after cancer treatment. The patients were randomized into one of three arms. One arm received real auricular acupuncture at real ear acupuncture points, which is defined as points where the electrodermal signal is be‐ ing detected. The other two arms were placebo arms. The second arm received real au‐ ricular acupuncture at the placebo points. The third arm received sham acupuncture through auricular seeds at the placebo points.[19] All patients received two courses of re‐ al or placebo auricular acupuncture in two months, one month apart. The needles were left in place until they fell out or were removed at a follow up appointment. Their pain intensity measured by VAS at the end of the second month was used to measure the treatment efficacy. This study showed that in the group that received real acupuncture, pain intensity decreased by 36% at the end of 2 months when compared with baseline, whereas it only decreased by 2% in the placebo groups (P < 0.0001).[19 A recent acu‐ puncture versus best medical care to treat peripheral neuropathy study showed that 76% patients in the acupuncture group had improvement in symptoms and nerve conduction studies whereas only 15% in the best medical care group did.[26] In addition, this study showed full correlation between the improvement in symptoms and nerve conduction studies.[26] Lastly, a recent randomized controlled clinical trial demonstrated that acu‐ puncture significantly reduced aromatase inhibitor-associated joint pain and stiffness than sham acupuncture.[27]

These studies suggest that acupuncture may be a valuable alternative modality within a comprehensive program of cancer pain management. With minimal side effects reported, acupuncture remains a viable option for patients suffering from cancer pain. Further re‐ search should focus on using rigorous scientific methodology and an effective protocol based on a sound, evidence-based rationale.

#### **2. Acupuncture to treat cancer therapy induced nausea and vomiting**

**Reference/ Sample size**

280 Acupuncture in Modern Medicine

He et al 1999[21] N=80

Crew et al 2010[27] N=38

**Type of Pain Treatment**

Post-operative pain in breast cancer patients

Aromatase inhibitorinduced joint muscle pain

than sham acupuncture.[27]

based on a sound, evidence-based rationale.

**Groups**

Group 1: acupuncture; 2: usual care

Group 1: acupuncture 2: sham acupuncture

**Table 1.** Summary of Randomized Control Trials on Acupuncture for Cancer Pain Relief

**Treatment Duration**

Post-op days 3, 5, 7 and day of discharge

> Twice per week for 6 weeks

There have been a number of clinical trials showing the effect of acupuncture in reduc‐ ing neuropathic pain in cancer patients. Among them, one clinical trial showed the effec‐ tiveness of auricular acupuncture in treating cancer treatment induced neuropathy.[19] This was a randomized, blinded, controlled trial conducted on 90 cancer patients with peripheral or central neuropathic pain arising after cancer treatment. The patients were randomized into one of three arms. One arm received real auricular acupuncture at real ear acupuncture points, which is defined as points where the electrodermal signal is be‐ ing detected. The other two arms were placebo arms. The second arm received real au‐ ricular acupuncture at the placebo points. The third arm received sham acupuncture through auricular seeds at the placebo points.[19] All patients received two courses of re‐ al or placebo auricular acupuncture in two months, one month apart. The needles were left in place until they fell out or were removed at a follow up appointment. Their pain intensity measured by VAS at the end of the second month was used to measure the treatment efficacy. This study showed that in the group that received real acupuncture, pain intensity decreased by 36% at the end of 2 months when compared with baseline, whereas it only decreased by 2% in the placebo groups (P < 0.0001).[19 A recent acu‐ puncture versus best medical care to treat peripheral neuropathy study showed that 76% patients in the acupuncture group had improvement in symptoms and nerve conduction studies whereas only 15% in the best medical care group did.[26] In addition, this study showed full correlation between the improvement in symptoms and nerve conduction studies.[26] Lastly, a recent randomized controlled clinical trial demonstrated that acu‐ puncture significantly reduced aromatase inhibitor-associated joint pain and stiffness

These studies suggest that acupuncture may be a valuable alternative modality within a comprehensive program of cancer pain management. With minimal side effects reported, acupuncture remains a viable option for patients suffering from cancer pain. Further re‐ search should focus on using rigorous scientific methodology and an effective protocol

**Evaluation Method**

VAS and range of movement

Brief Pain Inventory–Short Form (BPI-SF)

**Results**

The acupuncture group had an improved post-op pain (p≤0.01) and range of movement (p<0.001)

Significantly less pain (p=0.003) and pain-related interference (p=0.002) at week 6 in acupuncture arm than sham acupuncture arm

Chemotherapy-Induced Nausea and Vomiting (CINV) is one of the most common and feared treatment-related side effects among patients with cancer. As a result, nutritional sta‐ tus, quality of life, and treatment adherence may be severely compromised in patients.[28] Over the past 20 years, better understanding of the physiology of CINV and the subsequent development of modern pharmacologic antiemetic agents have substantially improved the control of CINV. However, study suggests that CINV remains a significant problem among these patients.[29]

CINV can either be acute, delayed, or anticipatory. Acute CINV occurs within 24 hours of chemotherapy, usually beginning within 2 to 4 hours and peaking in the first 4 to 6 hours. [30] Delayed CINV occurs from day 2 to 6 of chemotherapy.[30] Anticipatory CINV occurs before chemotherapy treatments in patients who have previously experienced significant CINV.[30] Most antiemetic research focuses on reducing acute and delayed CINV, with the understanding that this would result in better control of anticipatory CINV. Despite recent advances in pharmacologic antiemetic therapy, additional treatment for breakthrough CINV is needed. Several randomized controlled clinical trials suggested the efficacy of acupunc‐ ture in controlling this side effect.

A meta-analysis of 11 RCTs on 1247 cancer patients with CINV showed that the proportion of acute vomiting episodes was significantly lower in the acupuncture point stimulation group than the control group (22% vs. 31%, p=0.04). Those trials, however, did not show that acupuncture significantly alleviate acute chemotherapy-induced nausea or delayed CINV. [35,36] The clinical relevance of these results were limited by the fact that those clinical trials predated the use of aprepitant and that only 1 or 2 acupuncture points were stimulated dur‐ ing acupuncture treatment. More clinical trials to study the effect of acupuncture with addi‐ tional antiemetic acupuncture points in adjunct to modern pharmacologic antiemetic therapy are needed.

In addition to acupuncture, acupressure has been demonstrated to effectively reduce CINV. In a single-arm prospective study on 100 metastatic solid tumor patients experiencing per‐ sistent CINV despite standard antiemetic agents, 68% of patients' emetic symptoms im‐ proved after being treated with acupressure at PC6 point.[33] A RCT on 160 breast cancer patients who experienced moderate nausea during previous chemotherapy cycles and were getting ready to begin their 2nd or 3rd cycle of chemotherapy showed that acupressure at PC6 through a wrist device significantly decreased the amount of delayed vomiting and the in‐ tensity of nausea over time when compared with placebo acupressure and usual care groups.[34] The authors concluded that acupressure was safe and effective for cancer pa‐ tients to manage delayed CINV and should be offered to breast cancer patients during che‐ motherapy. [34]

There has been a number of RCTs studying the effect of acupuncture in reducing Radiation-Induced Nausea and Vomiting (RINV), and showed that even though there is no statistically significant difference between real and sham acupuncture, both treatments were significant‐ ly more effective than standard care alone in reducing the frequency and severity of RINV (table 2). Over 90% patients in both treatment groups believed that acupuncture has been effective against radiation-induced nausea.[35]

**Reference/ Sample size**

Molassiotis et al 200738 (N=47)

Johnston et al. 2011[68] (N=50)

Balk et al. 2009[69] (N=23)

Mao et al. 2009[39] (N=16)

**Treatment Groups Treatment Evaluation**

improve selfcare + weekly 50-minute acupuncture sessions

once to twice per week during the 6 week course of radiation therapy

12 treatments during the course of radiation therapy

1.acupuncture: six 20-min sessions over 2 week 2.acupressure: massage acupoints daily 3.sham acupressure: massage none acupoints daily

1. education integrated with acupuncture 2. usual care

1.real acupuncture 2.sham acupuncture

1. acupuncture: 12 treatments

**Table 3.** Summary of Pilot Studies on Acupuncture for Cancer Fatigue

**Method**

l Fatigue Inventory

Brief Fatigue Inventory (BFI)

Functional Assessment of Chronic Illness Therapy-Fatigue Subscale

The Lee Fatigue Scale (LFS), the Patient Global Impression of Change (PGIC).

Among these pilot studies, Molassiotis et al's pilot three-arm RCT was the most telling. In this trial, 47 cancer patients experiencing moderate to severe cancer fatigue were random‐ ized into three groups: acupuncture (n = 15), acupressure (n = 16), and sham acupressure (n = 16). Patients in the acupuncture group received six 20-minute acupuncture sessions over two weeks, whereas patients in the two acupressure groups were taught to massage real versus sham acupuncture points daily for two weeks. [38] The Multidimensional Fatigue In‐ ventory was used to assess their responses at baseline, week 2 and week 4 follow up. At the end of week two, general fatigue, physical fatigue, activity, and motivation significantly im‐ proved in the acupuncture and acupressure groups when compared to baseline.[38] At the end of week 2, fatigue level improved by 36% in the acupuncture group, 19% in the acupres‐ sure group and 0.6% in the control group. Moreover, the improvement maintained at the week 4 follow-up.[38] Acupuncture was found to be a more effective method than acupres‐ sure or sham acupressure. The authors concluded that acupuncture showed great potential

Two weeks Multidimensiona

**Results**

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Acupuncture for Cancer Patients: Practice and Research

Both acupuncture and acupressure significantly reduced cancer fatigue. Acupuncture was a more effective method than acupressure or sham acupressure.

A 2.38-point decline in fatigue as measured by the BFI when compared to usual care control (90% Confidence Interval from 0.586 to 5.014; p <0.10).

Both groups had improvement in fatigue, fatigue distress, quality of life and depression from baseline to week 10, but no statistically significant intergroup difference.

Average fatigue and energy domains of the LFS remained stable during and after RT, without any expected statistical decline owing to RT.

**Table 2.** Summary of Randomized Control Trials on Acupuncture for the Relief of radiation induced nausea and vomiting

These studies suggest that acupuncture and acupressure are effective in reducing cancer treatment-induced nausea and vomiting in cancer patients. Most studies were conducted on break through CINV after the patients failed conventional anti-emetic medication. Further research needs to be conducted to determine if the combination of antiemetics and P6 acu‐ point stimulation works better than each component alone. Indeed, an animal study showed that combination therapy of electroacupuncture (EA) at P6 acupoint with ondansetron, dro‐ peridol or metoclopramide prevented emesis more significantly than EA or any of the medi‐ cations alone.[37] These data suggested that EA and anti-emetic medication work synergistically.

#### **3. Acupuncture to treat cancer fatigue**

Fatigue is a common symptom in patients with cancer and a frequent side effect of chemo and radiation therapy, with no effective treatment exists. Several prospective pilot studies have suggested that acupuncture may benefit patients suffering from cancer fatigue (table 3). These studies were limited by their small sample size, but have provided encouraging information for further lare sample sized RCTs.

**Table 3.** Summary of Pilot Studies on Acupuncture for Cancer Fatigue

ly more effective than standard care alone in reducing the frequency and severity of RINV (table 2). Over 90% patients in both treatment groups believed that acupuncture has been

> **Primary end point**

% of patients with at least 1 emesis episode during radiation

Occurrence of nausea and emesis in each group was after a mean dose of 27 Gray.

**Results**

70% patients in the verum acupuncture group and 62% in the sham acupuncture group experienced nausea at least 1 emesis during radiation. No significant difference between two groups.

Verum group: 37% experienced nausea, 8% vomiting; Sham group: 37% experienced nausea, 7% vomiting; Standard care group: 65% experienced nausea, 15% vomiting.

**Duration**

two to three times per week during radiation

2-3 times per week during radiation

**Table 2.** Summary of Randomized Control Trials on Acupuncture for the Relief of radiation induced nausea and

These studies suggest that acupuncture and acupressure are effective in reducing cancer treatment-induced nausea and vomiting in cancer patients. Most studies were conducted on break through CINV after the patients failed conventional anti-emetic medication. Further research needs to be conducted to determine if the combination of antiemetics and P6 acu‐ point stimulation works better than each component alone. Indeed, an animal study showed that combination therapy of electroacupuncture (EA) at P6 acupoint with ondansetron, dro‐ peridol or metoclopramide prevented emesis more significantly than EA or any of the medi‐ cations alone.[37] These data suggested that EA and anti-emetic medication work

Fatigue is a common symptom in patients with cancer and a frequent side effect of chemo and radiation therapy, with no effective treatment exists. Several prospective pilot studies have suggested that acupuncture may benefit patients suffering from cancer fatigue (table 3). These studies were limited by their small sample size, but have provided encouraging

effective against radiation-induced nausea.[35]

1. verum acupuncture (penetrating and causing 'deqi' sensation) (n = 109) 2. sham acupuncture (use non-penetrating sham needles) (n = 106)

1.verum acupuncture (n=109; 99 provided data) 2. sham acupuncture (n=106; 101 provided data) 3. standard care alone (n=62; 62 provided data)

**3. Acupuncture to treat cancer fatigue**

information for further lare sample sized RCTs.

**Treatment Groups Treatment**

**Reference/ Sample size**

282 Acupuncture in Modern Medicine

Enblom et al 2012[35] N=215

Enblom et al 2011[36] N=262

vomiting

synergistically.

Among these pilot studies, Molassiotis et al's pilot three-arm RCT was the most telling. In this trial, 47 cancer patients experiencing moderate to severe cancer fatigue were random‐ ized into three groups: acupuncture (n = 15), acupressure (n = 16), and sham acupressure (n = 16). Patients in the acupuncture group received six 20-minute acupuncture sessions over two weeks, whereas patients in the two acupressure groups were taught to massage real versus sham acupuncture points daily for two weeks. [38] The Multidimensional Fatigue In‐ ventory was used to assess their responses at baseline, week 2 and week 4 follow up. At the end of week two, general fatigue, physical fatigue, activity, and motivation significantly im‐ proved in the acupuncture and acupressure groups when compared to baseline.[38] At the end of week 2, fatigue level improved by 36% in the acupuncture group, 19% in the acupres‐ sure group and 0.6% in the control group. Moreover, the improvement maintained at the week 4 follow-up.[38] Acupuncture was found to be a more effective method than acupres‐ sure or sham acupressure. The authors concluded that acupuncture showed great potential to manage cancer-related fatigue and should be tested further with larger sample size and multi-center RCT. [38]

**Reference/ Sample size**

Deng et al. 2007[40] (N=72)

Hervik et al. 2009[42] (N=59)

Frisk et al. 2008[43] (N=45)

Walker et al. 2010[44] (N=50)

**Treatment Groups Treatment**

1. real acupuncture 2. sham acupuncture

1. real acupuncture 2. sham acupuncture (SA)

1. electro-acupuncture (EA) 2.hormone therapy (HT)

> 1. acupuncture 2. venlafaxine

**Duration**

**Evaluation Method**

frequency

hot flashes at day and night, and Kupperman index.

4 weeks Hot flash

10 weeks Mean number of

24 months Number of hot

12 weeks Hot flashes

In 2008, Hervik et al reported another randomized, sham acupuncture-controlled trial on the effect of acupuncture in treating breast cancer patients suffering from hot flashes following at least 3 months tamoxifen.[42] Fifty-nine women were randomized to 15 sessions (5 weeks biweekly followed by 5 weeks weekly) real versus sham acupuncture. The authors meas‐ ured mean number of hot flashes at baseline, at the end of the treatment period, and 12 weeks after treatment to assess the treatment effect. They reported that at the end of the treatment period, mean number of daytime hot flashes reduced significantly from 9.5 to 4.7 (p=0.001) in the real acupuncture arm, and from 12.3 to 11.7 (p=0.382) in the sham acupunc‐ ture arm. At 12 weeks follow up, further reduction was observed in real acupuncture arm (from 4.7 to 3.2) but not in sham acupuncture arm (from 11.7 to 12.1). A similar pattern was observed in night-time hot flashes as the number of hot flashes reduced from 6 to 2.6 in the real acupuncture arm and from 7.2 to 5.4 in the sham acupuncture arm at the end of the

**Table 4.** Summary of Randomized Control Trials on Acupuncture for hot flashes in breast cancer patients

flashes per day

frequency and severity

**Results**

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Acupuncture for Cancer Patients: Practice and Research

True acupuncture was associated with 0.8 fewer hot flashes per day than sham at 6 weeks, but the difference did not reach statistical significance

During the treatment period mean number of hot flashes at day and night was significantly reduced by almost 60%, respectively from baseline in the acupuncture group, and was further reduced by 30% both at day and night during the next 12 weeks. Kupperman index was reduced by 44% from baseline to the end of the treatment period in the acupuncture group, and largely maintained 12 weeks after treatment ended.

In the EA group, the median number of hot flushes/24 h decreased from 9.6 at baseline to 4.3 at 12 weeks of treatment (p < 0.001). In the HT group, the median number of hot flushes/24 h decreased from 6.6 at baseline to 0.

> acupuncture was as effective as venlafaxine

In addition to treating cancer fatigue, pilot study has also suggested the effect of acu‐ puncture in preventing radiation-induced fatigue. A single-arm acupuncture trial con‐ ducted on 16 cancer patients undergoing radiation showed that 12 acupuncture treatment during radiation resulted in a stable average fatigue score during radiation therapy and 87% patients reported either stable or improved fatigue during radiation. [39] These findings invite further research to study the role of acupuncture in preventing the development of cancer fatigue.

These pilot clinical trials encourages further large sample sized randomized controlled trials to evaluate the effect of acupuncture on treating and preventing fatigue in cancer patients.

#### **4. Acupuncture to treat hot flashes in cancer patients**

Vasomotor symptoms (hot flashes, night sweats) are common complaints among breast can‐ cer survivors. These symptoms are usually the result of breast cancer related treatment such as chemotherapy-induced menopause or estrogen deprivation therapy. Management of hot flashes among breast cancer survivors is challenging as the most effective treatment, hor‐ mone replacement therapy, is associated with increased risk of breast cancer recurrence and development of new breast cancer. Acupuncture shows promise as a therapeutic approach for hot flashed with minimal side effects. The role of acupuncture in reducing hot flashes in women with breast cancer has been studied in a number of well-designed RCTs (table 4).

In 2007, Deng et al reported results from a randomized, sham-controlled trial on the effect of acupuncture in treating breast cancer patients who experienced three or more hot flashes per day.[40] Seventy-two women were randomized to 8 sessions (4 weeks biweekly) real versus sham acupuncture. The primary end point was hot flash frequency at week 6. Pa‐ tients randomized to the sham acupuncture arm were crossed over to receive real acupunc‐ ture at week 7 and were evaluated 6 weeks later. All patients were also evaluated at 6 months. The investigators reported that the mean number of hot flashes per day at week 6 changed from 8.7 to 6.2 in the real acupuncture arm, and from 10.0 to 7.6 in the sham acu‐ puncture arm. The difference between real and sham acupuncture arm was not statistically significant (p = 0.3). When patients in the sham acupuncture arm were crossed over to re‐ ceive real acupuncture, their hot flash frequency further reduced from 7.6 to 5.8. The reduc‐ tion in hot flashes in all patients persisted during the 6 months follow up (real acupuncture arm down to 6.1 per day and sham acupuncture arm to 6.8 per day). The authors concluded that acupuncture reduced hot flash frequency as it was reduced significantly in both treat‐ ment arms, even though there was no statistically significant difference between real versus sham acupuncture.[40] Importantly, only fourteen minor adverse events, such as mild bleeding and bruising that did not require medical intervention were reported from the 560 acupuncture sessions.[40] Similar results were demonstrated in other RCT studying the ef‐ fect of acupuncture to treat hot flashes in perimenopausal women.[41]

to manage cancer-related fatigue and should be tested further with larger sample size and

In addition to treating cancer fatigue, pilot study has also suggested the effect of acu‐ puncture in preventing radiation-induced fatigue. A single-arm acupuncture trial con‐ ducted on 16 cancer patients undergoing radiation showed that 12 acupuncture treatment during radiation resulted in a stable average fatigue score during radiation therapy and 87% patients reported either stable or improved fatigue during radiation. [39] These findings invite further research to study the role of acupuncture in preventing

These pilot clinical trials encourages further large sample sized randomized controlled trials to evaluate the effect of acupuncture on treating and preventing fatigue in cancer patients.

Vasomotor symptoms (hot flashes, night sweats) are common complaints among breast can‐ cer survivors. These symptoms are usually the result of breast cancer related treatment such as chemotherapy-induced menopause or estrogen deprivation therapy. Management of hot flashes among breast cancer survivors is challenging as the most effective treatment, hor‐ mone replacement therapy, is associated with increased risk of breast cancer recurrence and development of new breast cancer. Acupuncture shows promise as a therapeutic approach for hot flashed with minimal side effects. The role of acupuncture in reducing hot flashes in women with breast cancer has been studied in a number of well-designed RCTs (table 4).

In 2007, Deng et al reported results from a randomized, sham-controlled trial on the effect of acupuncture in treating breast cancer patients who experienced three or more hot flashes per day.[40] Seventy-two women were randomized to 8 sessions (4 weeks biweekly) real versus sham acupuncture. The primary end point was hot flash frequency at week 6. Pa‐ tients randomized to the sham acupuncture arm were crossed over to receive real acupunc‐ ture at week 7 and were evaluated 6 weeks later. All patients were also evaluated at 6 months. The investigators reported that the mean number of hot flashes per day at week 6 changed from 8.7 to 6.2 in the real acupuncture arm, and from 10.0 to 7.6 in the sham acu‐ puncture arm. The difference between real and sham acupuncture arm was not statistically significant (p = 0.3). When patients in the sham acupuncture arm were crossed over to re‐ ceive real acupuncture, their hot flash frequency further reduced from 7.6 to 5.8. The reduc‐ tion in hot flashes in all patients persisted during the 6 months follow up (real acupuncture arm down to 6.1 per day and sham acupuncture arm to 6.8 per day). The authors concluded that acupuncture reduced hot flash frequency as it was reduced significantly in both treat‐ ment arms, even though there was no statistically significant difference between real versus sham acupuncture.[40] Importantly, only fourteen minor adverse events, such as mild bleeding and bruising that did not require medical intervention were reported from the 560 acupuncture sessions.[40] Similar results were demonstrated in other RCT studying the ef‐

**4. Acupuncture to treat hot flashes in cancer patients**

fect of acupuncture to treat hot flashes in perimenopausal women.[41]

multi-center RCT. [38]

284 Acupuncture in Modern Medicine

the development of cancer fatigue.

**Table 4.** Summary of Randomized Control Trials on Acupuncture for hot flashes in breast cancer patients

In 2008, Hervik et al reported another randomized, sham acupuncture-controlled trial on the effect of acupuncture in treating breast cancer patients suffering from hot flashes following at least 3 months tamoxifen.[42] Fifty-nine women were randomized to 15 sessions (5 weeks biweekly followed by 5 weeks weekly) real versus sham acupuncture. The authors meas‐ ured mean number of hot flashes at baseline, at the end of the treatment period, and 12 weeks after treatment to assess the treatment effect. They reported that at the end of the treatment period, mean number of daytime hot flashes reduced significantly from 9.5 to 4.7 (p=0.001) in the real acupuncture arm, and from 12.3 to 11.7 (p=0.382) in the sham acupunc‐ ture arm. At 12 weeks follow up, further reduction was observed in real acupuncture arm (from 4.7 to 3.2) but not in sham acupuncture arm (from 11.7 to 12.1). A similar pattern was observed in night-time hot flashes as the number of hot flashes reduced from 6 to 2.6 in the real acupuncture arm and from 7.2 to 5.4 in the sham acupuncture arm at the end of the treatment period, with further reduction in the real acupuncture arm (from 2.6 to 1.7) but not sham acupuncture arm (from 5.4 to 6.1) at the 12 weeks follow up. The difference be‐ tween the real and sham acupuncture arms was statistically significant (p <0.001). The au‐ thors concluded that acupuncture provided effective relief from hot flashes in breast cancer patients suffering from hot flashes while taking tamoxifen.[42] The evidence generated from these two trials suggests that acupuncture effectively decreases hot flashes frequency, al‐ though it is not clear whether it is superior to sham acupuncture.

**5. Acupuncture to treat and prevent xerostomia**

care were reported in a smaller sample sized RCT.[57]

ture control.[54]

research is needed.[58]