Defining an Adequate Dose of Acupuncture Using a Neurophysiological Approach – a Narrative Review of the Literature

Abstract

Many different styles of acupuncture practice exist, and lack of agreement on the optimal acupuncture treatment for any particular condition may mean that some patients do not receive the best treatment. This uncertainty also makes the negative results of sham controlled trials difficult to interpret. Unless we can be sure that both adequate acupuncture and an inactive sham were used in a particular trial, then that trial should not be interpreted as dismissing acupuncture for that condition. Acupuncture practice clearly involves much more than needling procedures, but there is a strong argument for elucidating the role of those needling procedure first. The components of acupuncture needling procedures have been described in the STRICTA document, but it is also clear that the patient's perception of needling is relevant for the outcome of treatment. We therefore recommend the concept of ‘dose’ of acupuncture needling, which should include both the stimulus given to the patient, and certain aspects of the patient's perceptions and response that are known to be linked to the subsequent therapeutic response. We propose the following definition of dose: the physical procedures applied in each session, using one or more needles, taking account of the patient's resulting perception (sensory, affective and cognitive) and other responses (including motor). The dose may be affected by the state of the patient (eg nervous, immune and endocrine systems); different doses may be required for different conditions. The constituents of an adequate dose can be established initially by clinical opinion and subsequently by empirical evidence from experimental studies, which may be either clinical or basic research studies. Systematic reviews which do not consider the adequacy of the acupuncture treatment may have unreliable conclusions. Out of 47 recent systematic reviews, only six have applied some criteria for adequacy. Five used a rating system or conducted a subgroup analysis, and one excluded studies from the analysis altogether if they did not meet criteria for adequacy. Research into what constitutes an adequate dose of acupuncture has long been neglected and is now urgent. Clinical studies that compare the effects of different treatment protocols are probably the most reliable source of evidence, and may also demonstrate a dose-response relationship.

Low-frequency electroacupuncture and physical exercise decrease high muscle sympathetic nerve activity in polycystic ovary syndrome

“…Thus, the next step in a future study is to elucidate whether there is a different response on MSNA between different stimulation techniques e.g., manual acupuncture and low-frequency EA, and to find out optimal dose, e.g., number of needles, stimulation intensity, and frequency. Comparison with low-frequency EA and manual acupuncture, in which the needles are inserted and manually but not electrically stimulated, will be very important, in addition to an "attention control" without needles (77). When comparing different stimulation modalities, e.g., needle insertion with and without electrical stimulation, the microneurographic technique for evaluating efferent sympathetic outflow, may provide a powerful tool for studying underlying mechanisms of action.…”

The effects of old, new and emerging medicines on metabolic aberrations in PCOS

“…Clinical randomized control studies though are needed to confirm this potential effect. These studies will be challenging as they are difficult to design for many reasons such as differences in stimulating techniques, variety of sham procedures and acupuncture points used, number and duration of treatments used [White et al 2008]. Also one needs to overcome the particularly potent placebo effect in acupuncture studies [Linde et al 2010] and thus double-blind studies are almost impossible to perform or design [Florakis et al 2008].…”

Defining the Quality of Acupuncture

“…6 There are good reporting criteria for acupuncture trials, but criteria for assessing the quality of acupuncture interventions in clinical research or the representation of real-world practice of acupuncture within study designs are lacking. 4,7 The dose in trials of acupuncture has at times been described as low or inappropriate but is seldom assessed in systematic reviews of acupuncture trials. 8 This article examines the research evaluating acupuncture for cancer-related fatigue (CRF) to determine what characteristics of treatment may contribute to a quality acupuncture intervention.…”

“…These characteristics affect the effectiveness, efficacy, and cost of an acupuncture treatment. 4 Underpinning dosage are the many different traditions of acupuncture-Japanese, traditional Chinese medicine (TCM), Korean, and dry needling. The heterogeneity of acupuncture is a formidable challenge in a clinical trial setting.…”