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Dr. Varon and Dr. Fromm are Associate Professors of Medicine, Baylor College of Medicine, and Dr. Marik is Professor of Medicine, University of Pittsburgh Medical Center.
Correspondence to: Joseph Varon, MD, FCCP, 2219 Dorrington, Houston, TX 77030; e-mail: jvaron{at}roamer.net
Results of a 1998 survey indicate that 42% of adults in the United States consult alternative medical practitioners and spend an estimated $27 billion annually on alternative medical therapies.1 Alternative and complementary therapies are sought most frequently for chronic disabling conditions, including back pain, anxiety, depression, headaches, arthritis, HIV infection, and chronic allergic disorders, such as allergic rhinitis and asthma.1 2 The most common alternative therapies used in the United States include herbal medicine, chiropractic, megavitamins, homeopathy, spiritual healing, and acupuncture.1
Acupuncture is clearly one of the oldest and most widespread complementary techniques. The first documented history of acupuncture is ascribed to the legendary Yellow Emperor (Huang Di) in China [circa 2000 BC]. The first paragraph of the second part of his classic book Huang Di Nei Jing describes the desire of the benevolent emperor to relieve the suffering of his subjects afflicted with disease, shunning the poisons of medicine in favor of fine needles to harmonize the blood and Qi energy.3
To prevent the exploitation of those desperate to find a cure for their chronic and often incurable disease, it is important that alternative and complementary therapies undergo the same scientific scrutiny and regulation as traditional allopathic medical therapies. The randomized controlled trial (RCT) has become the "gold standard" in medicine by which to judge the effect of an intervention on patient outcome, because it provides the greatest justification for conclusion of causality, is subject to the least bias, and provides the most valid data on which to base all measures of the benefits and risk of particular therapies. For alternative therapies to become accepted by the medical community and become integrated into a patients’ treatment plan, it is essential that they be tested in an RCT. As most forms of alternative therapy require an individualized approach, an RCT can best be performed using a sham treatment arm, with both the patient and investigator being blinded to the treatment received. Using this approach, chiropractic manipulation has been shown to be as effective as sham chiropractic manipulation for the treatment of childhood asthma,4 while the benefit of homeopathy has been demonstrated for the treatment of asthma as well as allergic rhinitis and vertigo.5 6 7 In this issue of CHEST, Shapira and coworkers (see page 1396) conducted a randomized, double-blind, sham-controlled, crossover study of short-term acupuncture in patients with moderate persistent asthma. Each patient received four sessions of individualized acupuncture or sham acupuncture. In this carefully controlled and executed RCT, personalized short-term acupuncture therapy showed no benefit. Peak flow, bronchial reactivity as determined by methacholine challenge, asthma symptoms, and mediation usage were unaffected by acupuncture. The study population was well characterized and represented a homogeneous group of patients.
Previous studies8 9 10 11 12 of acupuncture have been published with conflicting results. In general, these studies are limited by the lack of a control group, inclusion of heterogeneous patients, nonindividualized treatment, lack of blinding, and the combination of acupuncture with other techniques. Tandon and Soh13 and Tashkin and coworkers14 performed double-blind, sham-controlled, crossover RCTs of acupuncture in patients with moderately severe asthma. In keeping with the findings of Shapira et al, both of these studies failed to demonstrate any benefit from acupuncture therapy. The article by Shapira et al is important because it provides the rigor of Western scientific method to an alternative medical therapy. The lack of efficacy places the benefit of acupuncture in patients with moderate asthma in serious doubt. Although previous data suggest an immediate effect in asthma, no long-term benefit has been demonstrated, and these studies are plagued by methodologic problems.8 11 12
Does this mean that we should discourage our asthmatic patients from being treated by acupuncture? Clearly, thousands of patients seek the care of acupuncturists for a variety of illnesses, including asthma. The population studied by Shapira et al is quite specific, and it is possible a real benefit exists in the treatment of acute asthma exacerbations. Further well-done trials are needed. Until then, we remain skeptical and cannot recommend acupuncture for the treatment of asthma.
References
This article has been cited by other articles:
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  O. Caspi, E. Schiff, J. Varon, R. E. Fromm Jr, P. E. Marik, and M. Y. Shapira Missing the (Acu) Point Chest, April 1, 2003; 123(4): 1312 - 1314. [Full Text] [PDF]
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