Acupuncture for Xerostomia (Dry Mouth) in Cancer Patients

Much of the literature I've seen on acupuncture for xerostomia has been on treating the xerostomia once is develops. This sounds like a practical way to prevent, namely give acupuncture at the time of the radiation.

Cancer. 2011 Nov 9. doi: 10.1002/cncr.26550.
Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma.
Meng Z, Garcia MK, Hu C, Chiang J, Chambers M, Rosenthal DI, Peng H, Zhang Y, Zhao Q, Zhao G, Liu L, Spelman A, Palmer JL, Wei Q, Cohen L.


Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
Abstract
BACKGROUND:

Xerostomia (dry mouth) after head/neck radiation is a common problem among cancer patients, and available treatments are of little benefit. The objective of this trial was to determine whether acupuncture can prevent xerostomia among head/neck patients undergoing radiotherapy.
METHODS:

A randomized, controlled trial among patients with nasopharyngeal carcinoma was conducted comparing acupuncture to standard care. Participants were treated at Fudan University Shanghai Cancer Center, Shanghai, China. Forty patients were randomized to acupuncture treatment and 46 to standard care. Patients were treated 3×/wk on the same days they received radiotherapy. Subjective measures included the Xerostomia Questionnaire and MD Anderson Symptom Inventory-Head and Neck (MDASI-HN). Objective measures were unstimulated and stimulated whole salivary flow rates. Patients were followed for 6 months after the end of radiotherapy.
RESULTS:

Xerostomia Questionnaire scores for acupuncture were statistically significantly lower than for controls starting in week 3 through the 6 months (P = .003 at week3, all other P < .0001), with clinically significant differences as follows: week 11, relative risk (RR) 0.63 (95% confidence interval [CI], 0.45-0.87); 6 months, RR 0.38 (95% CI, 0.19-0.76). Similar findings were seen for MDASI-HN scores. Group differences emerged as early as 3 weeks into treatment for saliva (unstimulated whole salivary flow rate, P = .0004), with greater saliva flow in the acupuncture group at week 7 (unstimulated whole salivary flow rate, P < .0001; stimulated whole salivary flow rate, P = .002) and 11 (unstimulated whole salivary flow rate, P < .02; stimulated whole salivary flow rate, P < .03) and at 6 months (stimulated whole salivary flow rate, P < .003).

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Dr. Peng Li's Presentation Summarizing 50 years of Acupuncture Research

Dr. Li covered quite a bit of ground as you can imagine during his talk at ISAMS. I'll just feature a few highlights over the next few blog posts.
This slide is taken from Goldman's work entitled "Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture."
Dr. Li then goes on to describe the different protocols for choosing acupuncture points
1. Ashi point- local acupoints for Pain treatment
local release of chemicals, e.g. adenosine (A1 receptor).
convergent input to nearby spinal segment.
2.Acupoints related to Spinal segments
convergent inputs from internal organs and somatic n.
Gate control theory
3. Distant acupoints- supra-spinal integration
Selection of Acupoints

Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture.

Improvement of menopausal symptoms with acupuncture not reflected in changes to heart rate variability

This undercuts one of my theories that if someone's autonomics, heart rate variability (HRV) are improved with acupuncture then they are more likely to see improvement in their symptoms. In this study, the patients improved in 11 out of 12 of their symptoms from menopause, but their HRV did not change.

(To read further about acupuncture, HRV, and my practice please click here.)

Improvement of menopausal symptoms with acupuncture not reflected in changes to heart rate variability.

Wright CL, Aickin M.

School of Nursing Portland Campus, 3455 SW US Veterans Road, SN-ORD, Portland, OR 97239, USA; cwright80@hotmail.com.
Acupunct Med. 2011 Mar;29(1):32-9.
Abstract

Hypothesis Studies indicate that menopausal symptoms are relieved by acupuncture. Additional studies have suggested that acupuncture may affect heart rate variability (HRV). This paper reports a pilot study that investigated whether menopausal symptoms responded to acupuncture, and if changes in the spectral analysis of HRV, either suppression of low frequency or augmentation of high frequency bands, corresponded with symptom report. Methods/interventions 12 healthy menopausal subjects were enrolled in this feasibility study. At baseline, subjects were experiencing moderately distressing menopausal symptoms, scoring at least 22 of a possible 44 points on the Menopausal Rating Scale. 10 traditional Chinese medicine-based, protocol acupuncture treatments were administered over a 4 week period, three times a week for 2 weeks, followed by twice a week for 2 weeks. Outcome measures Menopausal Rating Scale questionnaire, 11 menopausal symptoms were evaluated on a zero to four severity scale via self-administered daily checklist for 4 weeks. Dynamic measures of HRV (autoregressive model) were captured before, during and after acupuncture at each session. Spectral analysis of the heart rate was used to compute power in the low frequency and high frequency bands, and their ratio. RESULTS: All subjects complied fully with the protocol without any reported adverse events. While all 11 symptoms showed significant improvement, and one HRV measure changed, on average over the study period, there was essentially no support for a relationship between HRV, menopausal symptom report and acupuncture intervention.

Acupuncture HRV results vary with point choice

I do have some problems with this study, even though it does address my two favorite topics, HRV(heart rate variability-a way to monitor stress response) and acupuncture. I strongly disagree with their opening statement that there is no evidence that acupuncture has effects on HRV. There have been studies too numerous to mention on this topic, and it begs the question of why they would study the issue if there was no evidence. I also wonder why they picked an acupuncture method that is not in current practice, i.e. a single "instantaneous" puncture. I would love to hear that single point, "instantaneous" puncture is just as effective as traditional "point combination," 20 minute sessions. That would be a boon to my practice and will await more studies with an open mind. All that said, I am buoyed by the thought that some points affect HRV more than others since that may give some keys to more effective acupuncture treatment.

To learn more about acupuncture, HRV, and my practice please click here.

Acupuncture to Danzhong but not to Zhongting increases the cardiac vagal component of heart rate variability.
Auton Neurosci. 2011 Jan 6.
Kurono Y, Minagawa M, Ishigami T, Yamada A, Kakamu T, Hayano J.

The Oriental Medical Center, Nagoya, Aichi, Japan.
Abstract

There is currently no convincing evidence that acupuncture has any specific effects on autonomic nervous function as assessed by heart rate variability (HRV). We examined whether the stimulation of neighboring acupunctural points, Danzhong (CV17) and Zhongting (CV16) on the anterior median line of the thorax, induced different effects on HRV. In 14 healthy males, epifascial acupunctural stimulation (single instantaneous needle stimulation on the fascial surface without producing De-Qi sensation) was performed at CV17 and CV16 on different days in a clinical study utilizing a cross-over design. We found that the stimulation of CV17, but not of CV16, decreased the heart rate (P=0.01, repeated measures ANOVA) and increased the power of the high-frequency component of the HRV, an index of cardiac vagal activity (P=0.01). The low-frequency to high-frequency ratio, an index of sympathetic activity showed no significant changes for either point. Our observations could not be explained as either nonspecific or psychological/placebo effects of needle stimulation. This study provides strong evidence for the presence of a specific acupunctural point that causes the modulation of cardiac autonomic function.

Neuro pathways involved in acupuncture decreasing Blood Pressure

This is a nice study that looks at the pathways involved in acupuncture's effect on blood pressure. I have had good results in my clinic in patients with hypertension as long as they are willing to follow through with their visits! Once their blood pressure has come down, monthly visits suffice usually with herbal supplementation.

To learn more about acupuncture, HRV, and my practice please click here.

Neural mechanism of electroacupuncture's hypotensive effects
Auton Neurosci. 2010 Oct 28;157(1-2):24-30. Epub 2010 May 5.
Neural mechanism of electroacupuncture's hypotensive effects. Li P, Longhurst JC
Department of Medicine, Susan-Samueli Center for Integrative Medicine, University of California, Irvine, California 92697, USA. pengli@uci.eduAbstract

EA at P 5-6 and S 36-37 using low current and low frequency may be able to reduce elevated blood pressure in a subset of patients (∼70%) with mild to moderate hypertension. The effect is slow in onset but is long-lasting. Experimental studies have shown that EA inhibition of cardiovascular sympathetic neurons that have been activated through visceral reflex stimulation is through activation of neurons in the arcuate nucleus of the hypothalamus, vlPAG in the midbrain and NRP in the medulla, which, in turn, inhibit the activity of premotor sympathetic neurons in the rVLM. The arcuate also provides direct projections to the rVLM that contain endorphins. Glutamate, acetylcholine, opioids, GABA, nociceptin, serotonin and endocannabinoids all appear to participate in the EA hypotensive response although their importance varies between nuclei. Thus, a number of mechanisms underlying the long-lasting effect of EA on cardiovascular function have been identified but clearly further investigation is warranted.

Monitoring the Autonomic Nervous System and HRV in rats after Acupuncture

I often don't know what to make of these studies, but find them super interesting nonetheless, and somehow can't help but incorporate their findings into my practice for better or for worse. What I love about this study is that they actually saw a difference between electroacupuncture on Stomach 36 and Pericardium 6, both in pain reduction and autonomic response as measured by heart rate, LF(low frequency portion of HRV) and LF/HR (low frequency to high frequency ratio-a common measure of stress response.) They saw no reduction when using Liver 3 nor the sham, non-acupoint. I wish we had more studies like this, comparing one set of points and another. For one, it helps get away from the ever present placebo problem in research, and for two it might help inform our practice!!
The study model is 4 groups, sham point, Stomach 36, Pericardium 6, Liver 3, 9 rats in each group. They used alternating 2Hz/15Hz electro, (got to haul out my alternating device again...)
The abstract for the study follow. The emphases are mine. Poor rats...

(To read more about acupuncture, HRV, and my practice, please click here.

Zhen Ci Yan Jiu. 2010 Oct;35(5):335-41.
[Effects of electroacupuncture of different acupoints on changes of blood pressure and autonomic nerve system after colorectal distension in rats].

Chen SP, Gao YH, Yu XC, Liu JL.
Institute of Acu-moxibustion, China Academy of Chinese Medical Sciences, Beijing 100700, China.
Abstract

OBJECTIVE: To observe the influence of electroacupuncture (EA) of different acupoints on changes of mean arterial pressure (MAP), heart rate (HR) and heart rate variability (HRV) in colorectal distension (CRD) rats, so as to analyze the specificity of actions of acupoints in relieving visceral pain and regulating activities of the autonomic nerve system.

METHODS: Forty-five Wistar rats were randomized into control, Zusanli (ST 36), non-acupoint, Neiguan (PC 6) and Taichong (LR 3) groups (n = 9/group). Under anesthesia, CRD was given to the rats by using an aerostat for 5 min. EA (2 Hz/15 Hz, 2 mA) was applied to bilateral ST 36, non-acupoint (1.0 cm lateral to ST 36), PC 6 and LR 3 for 15 min, respectively. Electrocardiogram of the cervico-chest lead was recorded by using a bioelectric amplifier, and MAP recorded by using a pressure transducer and an amplifier. Low frequency and high frequency of HRV were analyzed by Chart 5.0.

RESULTS: Following CRD, the HR, MAP, LF and LF/HF levels increased significantly in all the 5 groups (P <> 0.05). Compared with the control group, 5 min and 15 min after EA ,and 10 min after ceasing EA, MAP values of ST 36 and PC 6 groups were decreased obviously (P < style="font-weight: bold;">The LF levels of both ST 36 and PC 6 groups at 5 min after EA, and those of ST 36, PC 6 and LR 3 at 15 min after EA were significantly lower than those of control group (P <> 0.05).

CONCLUSION: EA of ST 36 and PC 6 can suppress CRD-induced increase of MAP, HR and LF/HF, suggesting beneficial effects of EA in relieving visceral pain and mediating autonomic nerve system. The aforementioned effects of EA of LR 3 and non-acupoint are not obvious.

Moxibustion Activates Host Defense Against Herpes Simplex Virus in Mice

As time consuming as it is to use moxibustion in modern practice, it does seem to be the mainstay of enhancing immune function. I use it most often in patients with allergy and HIV. During my training the treatment rooms were full of moxa smoke. Here, at least in my practice, even using smokeless moxa, many notice and comment on the smell. This study reinforces my own biases, so of course I love it! ;)
Of note is that they used the moxa preventatively, before the virus was introduced. (Anecdotally this makes sense vis a vis my attempts to get patients in for treatment before the allergy season, and ongoing treatment to prevent illness in HIV positive patients.)
Also, of interest is that not only cytokine production but also natural killer cells.
The abstract follows, emphases are mine.

(To read more about acupuncture and my practice, please click here.)

Microbiol Immunol. 2010 Sep;54(9):551-7.
Moxibustion activates host defense against herpes simplex virus type I through augmentation of cytokine production.

Takayama Y, Itoi M, Hamahashi T, Tsukamoto N, Mori K, Morishita D, Wada K, Amagai T.

Department of Immunology and Microbiology, Meiji University of Integrative Medicine, Hiyoshi-cho, Nantan, Kyoto 629-0392, Japan.
Abstract

Moxibustion is a technique used in traditional oriental medicine, the aim of which is to cure and/or prevent illness by activating a person's ability for self-healing. In this study, we assessed how moxibustion would affect the immune system and whether it would augment protective immunity. Mice were treated with moxibustion at Zusanli (ST36) acupoints; we analyzed mortality and cytokine activity in sera after infection with herpes simplex virus type 1 (HSV-1), and cytokine gene expression in the skin and the spleen without a virus challenge. Our study demonstrates that pretreatment of BALB/c mice with moxibustion resulted in a marked increase in the survival rate after infection with lethal doses of HSV-1, and elevated serum levels of IL-1β and IFN-γ on days 1 and 6 post-infection with HSV-1. Semi-quantitative RT-PCR assay showed that moxibustion treatment augmented the expression of IL-1α, IL-1β, IL-6, universal-IFN-α, MIP-1α, and TNF-α mRNA in the skin, and IL-1α, IL-1β, IL-12p40, IL-15, u-IFN-α, MIP-1α, and TNF-α mRNA in the spleen. Moreover, moxibustion induces augmentation of natural killer cell activity. Collectively, our study demonstrates that moxibustion activates protective responses against HSV-1 infection through the activation of cytokine production including IFN, and of NK cells.

Rethinking the Scientific Method from the New Yorker

The Truth Wears Off

This article from the most recent New Yorker looks at something called "the decline" effect. It is a phenomenon where an established result in science, or "fact" becomes less demonstrable over time. They give examples of antipsychotic medications,certain cognition effects and stents (ahem.) They mention several possible reasons for this effect. Wishful thinking on the part of researchers, for example. They cite acupuncture studies from 1990 to 2000 where all of the results from Asia were positive, when only 50% from the U.S. and Europe were positive. (This was obvious to anyone paying attention to the acupuncture literature at this time. I still ignore most of the studies out of Asia, China in particular.) Another possible explanation was just random chance that lead to the initial results that could not be reproduced.
The problem is, of course, that studies are very expensive! It's easy enough to call for more studies, but much more difficult to actually procure the money to pay for adequate studies. It was fortunate for the acupuncture community that the Insurance Companies in Germany were willing to pay for large enough studies to establish acupuncture efficacy for knee, hip and back pain. They did not discuss the corruption of studies by the drug companies as referenced in a previous post.

(To read more about acupuncture and my practice, please click here.)

ABSTRACT: ANNALS OF SCIENCE about the decline effect. On September 18, 2007, a few dozen neuroscientists, psychiatrists, and drug-company executives gathered in a hotel conference room in Brussels to hear some startling news. It had to do with a class of drugs known as atypical or second-generation antipsychotics, which came on the market in the early nineties. The therapeutic power of the drugs appeared to be steadily falling. A recent study showed an effect that was less than half of that documented in the first trials, in the early nineties. Before the effectiveness of a drug can be confirmed, it must be tested again and again. The test of replicability, as it’s known, is the foundation of modern research. It’s a safeguard
for the creep of subjectivity. But now all sorts of well-established, multiply confirmed findings have started to look increasingly uncertain. It’s as if our facts are losing their truth. This phenomenon doesn’t yet have an official name, but it’s occurring across a wide range of fields, from psychology to ecology. When Jonathan Schooler was a graduate student at the University of Washington, he discovered a surprising phenomenon having to do with language and memory that he called verbal overshadowing. While Schooler was publishing his results in journals, he noticed that it was proving difficult to replicate his earlier findings. Mentions psychologist Joseph Banks Rhine, who conducted several experiments dealing with E.S.P. In 2004, Schooler embarked on an imitation of Rhine’s research in an attempt to test the decline effect. The most likely explanation for the decline is an obvious one: regression to the mean. Yet the effect’s ubiquity seems to violate the laws of statistics. Describes Anders Møller’s discovery of the theory of fluctuating asymmetry in sexual selection. Mentions Leigh Simmons and Theodore Sterling. Biologist Michael Jennions argues that the decline effect is largely a product of publication bias. Biologist Richard Palmer suspects that an equally significant issue is the selective reporting of results—that is, the subtle omissions and unconscious misperceptions, as researchers struggle to make sense of their results. Mentions John Ioannidis. In the late nineteen-nineties, neuroscientist John Crabbe investigated the impact of unknown chance events on the test of replicability. The disturbing implication of his study is that a lot of extraordinary scientific data is nothing but noise. This suggests that the decline effect is actually a decline of illusion. Many scientific theories continue to be considered true even after failing numerous experimental tests. The decline effect is troubling because it reminds us how difficult it is to prove anything.

Read more http://www.newyorker.com/reporting/2010/12/13/101213fa_fact_lehrer?printable=true#ixzz17XfGb9b7