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Acupuncture for the Management of Irritable Bowel Syndrome

From Alternative Medicine Alert ' August 2003

By David L. Diehl, MD, FACP
Acupuncture is a complementary and alternative medicine (CAM) modality that has undergone progressive acceptance by both patients and Western medical practitioners. Its major clinical application in the United States is for musculoskeletal conditions such as low-back pain, myofascial pain, headache, sciatica, and other similar conditions. Positive effects of acupuncture for digestive disorders have been known in Chinese medicine for centuries, but adoption of acupuncture for these conditions in Western medicine has lagged behind musculoskeletal indications. This may be due in part to a lack of convincing randomized data showing the efficacy of acupuncture for gastrointestinal (GI) conditions.

The functional digestive disorders, of which irritable bowel syndrome (IBS) is one of the most common, are a group of disorders of surprisingly high prevalence, whose adequate treatment continues to elude modern medicine. The functional disorders present a rich potential area of application for any CAM therapy. In patients attending GI clinics, those with IBS are most likely to see CAM practitioners.(1)

Mechanism of Action
There is a plethora of information regarding the physiological basis of acupuncture effects on the digestive system. Extensive research using animal models, as well as data from human subjects, has shed light on how acupoint stimulation leads to changes in gastric acid secretion, GI motility, and hormone and neuropeptide metabolism. Regional or systemic autonomic nervous system changes also may contribute to these effects. A recent review examined the physiologic effects of acupuncture on the digestive tract.(2)

IBS is a multifactorial condition; contributions from diet, psychosocial factors, and underlying physiology all come together to shape an individual's experience of pain or discomfort. Furthermore, any clinician with experience caring for patients with IBS knows that "there is IBS and there is IBS." The heterogeneity of the diagnosis of IBS conspires to make clinical studies of this condition hard to do, and hard to interpret.

Common Usage
As relates to the GI tract, acupuncture is best known and most extensively studied for its effects on nausea. In a number of carefully designed and conducted trials, acupuncture has been shown to be useful for anti-emesis. Beyond the treatment of nausea, there is a paucity of controlled trials of acupuncture for any GI condition, although there is a long and distinguished history of acupuncture for GI symptoms in the Chinese medical literature dating back more than 2,000 years.

Special Considerations Concerning Acupuncture Research
Acupuncture research, in comparison to pharmaceutical research, necessitates some special considerations. First, what is a proper control group to use? "Sham needling" (an invasive but "non-therapeutic" procedure such as shallow needling at non-acupuncture points) often is held to be the best, but also may dilute some of the effect of acupuncture due to non-specific effects of the minimal needling. "Placebo needling" involves non-penetrating simulation of needle placement (for example, taping a needle to the skin while the patient looks away). This obviously would require a subject na�ve to previous acupuncture treatment. Blinding of the subjects and the investigators also is of great importance. Double blinding requires the use of a blinded evaluator who is not aware of allocation of the patient to the real or sham/placebo group.

There is much debate about which approach to point selection should be used for acupuncture studies as well. Some studies employ a "one-size-fits-all" approach, with all treated patients randomized to the active arm getting the same assortment of needles (which may range from one to 20 needles) applied to the same points. Other investigators insist that the treatment must be tailored to the individual patient and the presentation at that particular visit. Thus, the treatment may change from visit to visit. Some practitioners favor treatments three times a week (and occasionally more), while others may try to require visits no more frequently than once a week. Different schools of acupuncture theory and practice can alter specific point selection markedly, and this can lead to disagreement over the selection of the most efficacious treatment.

Finally, it must be understood that acupuncture is only a single part of an integrated health care treatment system that traditionally includes dietary manipulation, herbal medicine, massage (Tui Na), exercise modalities (such as Tai Qi), and breathing/meditation practice (Qi Gong). Evaluating acupuncture in isolation may lead to results that would be different than when several of these modalities are combined.

Clinical Studies
There have been very few prospective randomized trials of acupuncture for IBS. All the studies that have been conducted have methodological failings, ranging from moderate to severe.

Lowe et al published (in abstract form) the results of a prospective randomized trial of real vs. sham acupuncture in a sample of 50 patients with IBS.(3) Treatments were given at nine points (specific acupoints were not specified in the abstract) twice weekly for four weeks. There was follow-up at four weeks and also at three months. The primary outcome was individual patient-determined treatment success rate; secondary outcome measures included McGill Pain Score and the IBS-36 (a validated IBS-specific quality-of-life tool).

There was no significant difference between patients' perceptions of improvement (using 0-100% scale) in the two groups. Interestingly, both real and sham groups did show marked improvement compared to baseline in the McGill Pain Score as well as in the quality-of-life measurement. The authors concluded that acupuncture has no method-specific therapeutic benefit, but that participation in a trial can positively influence these measures.

Because this study was published only in abstract form, it is hard to assess certain specifics about methodology such as blinding. In addition, the study appears to be underpowered to detect an effect of real acupuncture.

Fireman et al performed a double-blind controlled study in a group of 25 patients.(4) Patients received two 30-minute sessions of real or control acupuncture, and then three weeks later were crossed over to receive the other treatment. The acupuncture treatment group was needled only at a single point, Large Intestine-4 (Li-4). Visual analog scales (VAS) were used to quantify response to either real or placebo needling. The authors found significant improvement in symptoms of alternating diarrhea and constipation, and overall feeling of well-being after the first needling session, but the change was not significant after the second session. There was no short- or long-term follow-up in this study.

This study contains a number of methodologic flaws and does not employ a sound research protocol for examining the effect of acupuncture on patients with IBS. First, only one point was used, and for only two sessions. It also is not clear whether the VAS was administered either immediately after the needling or at a later time. Despite the title of this study, it is not a reasonable evaluation of acupuncture treatment for IBS.

Chan et al performed a pilot study in which seven patients with IBS were offered a four-week course of acupuncture.(5) The patients filled out IBS symptom diaries on a daily basis for 28 days. The study used the same points on all patients. In all, eight acupoints were used, all stimulated bilaterally (for a total of 16 needles), and the needles were retained for only 3-5 seconds each. The authors found improvement in general sense of well-being and bloating, but no change in abdominal discomfort and bowel frequency. The obvious drawbacks to this study are small sample size, the absence of a control group and blinding, short follow-up, and the rather unusual needling technique involving "cookbook" selection of points and extremely short needle retention times.

In a description of a non-randomized clinical experience with IBS patients refractory to usual western therapy, Diehl et al offered acupuncture to a group of patients with functional dyspepsia (n = 14) and IBS (n = 10).(6) Initially, acupuncture was given weekly, and the interval between treatments was lengthened if possible. Outcomes were determined using patient and physician assessment of improvement and a quality-of-life survey. Length of follow-up was 2-14 months. In the 10-patient IBS group, three had a good response (almost complete or complete resolution of symptoms), six patients had a partial response (some improvement in symptoms or fewer recurrences of symptoms), while one patient had no response. The majority of patients experienced improvement in their symptoms, but ongoing therapy appeared to be necessary (at intervals of approximately 2-3 weeks) to maintain clinical improvement.

Adverse Effects
Acupuncture is a remarkably safe medical procedure. A long list of potential complications has been noted,(7) with transmission of viral infection and pneumothorax being among the most severe. Fainting, or so-called needle-shock, is perhaps the most common adverse effect, and can be seen in up to 2% of subjects. In two large recent studies of the safety of acupuncture, a total of 66,000 treatments by physicians or physiotherapists(8) or traditional acupuncturists(9) were evaluated prospectively. No fatalities were noted; significant adverse effects were seen in approximately 0.1% of patients in both studies. These results indicate that acupuncture is a very safe form of therapy.

Contraindications and Precautions
In some situations, IBS is a diagnosis of exclusion. Patients with atypical presentations, shorter duration of symptoms, or alarm symptoms of weight loss, rectal bleeding, or abnormal blood tests or GI radiology should be fully evaluated before the diagnosis of IBS can be made with certainty. In this way, a more serious underlying process will not be missed while CAM therapy is pursued.

Conclusion
At present, there are insufficient data to demonstrate that acupuncture is effective in the treatment of IBS, and the few studies that are available for review have significant methodological shortcomings.

Recommendation
While we await funding for and completion of better-designed studies, there is little risk associated with acupuncture treatment for IBS, and individual patients may derive a benefit from this intervention.

Dr. Diehl is Associate Clinical Professor, New York University School of Medicine, and Director of Gastro- intestinal Endoscopy, Bellevue Hospital Center, in New York, NY.

References
1. Smart HL, et al. Alternative medicine consultations and remedies in patients with the irritable bowel syndrome. Gut 1986;27:826-828.

2. Diehl DL. Acupuncture for gastrointestinal and hepatobiliary disorders. J Altern Complement Med 1999;5: 27-45.

3. Lowe C, et al. A placebo-controlled, double-blind trial of acupuncture in the treatment of irritable bowel syndrome (abstract #3168). Gastroenterology 2000;118: A617.

4. Fireman Z, et al. Acupuncture treatment for irritable bowel syndrome. A double-blind controlled study. Digestion 2001;64:100-103.

5. Chan J, et al. The role of acupuncture in the treatment of irritable bowel syndrome: A pilot study. Hepatogastroenterology 1997,44:1328-1330.

6. Diehl DL, et al. Acupuncture treatment for refractory function bowel diseases (abstract). Gastroenterology 1994;106:A488.

7. Lao L, et al. Is acupuncture safe? A systematic review of case reports. Altern Ther Health Med 2003;9:72-83.

8. White A, et al. Adverse events following acupuncture: Prospective survey of 32,000 consultations with doctors and physiotherapists. BMJ 2001;323:485-486.

9. MacPherson H, et al. The York acupuncture safety study: Prospective survey of 34,000 treatments by traditional acupuncturists. BMJ 2001;323:486-487.

Content (c) 2003 Thomson American Health Consultants, Inc.
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Heather is the Administrator of the IBS Message Boards. She is the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!

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Acupuncture Soothes Irritable Bowel Syndrome (IBS)

on 10 December 2014.

Acupuncture and moxibustion alleviate irritable bowel syndrome (IBS). Research confirms that acupuncture and moxibustion significantly reduce abdominal pain, diarrhea, and the ratio of abnormal stools. The research was conducted on patients with IBS-D, a type of irritable bowel syndrome characterized by insidious attacks of diarrhea. The total effective rate was 96.7% with many patients experiencing a complete recovery with no relapses. The positive patient outcomes for IBS-D patients suggest that additional research on IBS-C (constipation IBS) and IBS-A (alternating stool IBS) is warranted. Lower abdominal acupoints with four needles inserted.

Over 65% of patients in the study demonstrated "marked effect." The study's criteria for marked effect are: completely asymptomatic, normal frequency of bowel movements, normal stools, no relapse after three months. An additional 30% of patients experienced improvements. The criteria for "improvements" are significant reductions in symptoms and relapse within three months but only with mild symptom intensity.

As a standalone procedure, acupuncture demonstrated a 76.7% total effective rate including reductions in abdominal pain, diarrhea, and frequency of bowel movements. Acupuncture combined with moxibustion increased the total effective rate to 96.7%. The researchers note that "acupuncture combined with ginger and salt-partitioned moxibustion can obtain a remarkable effect for IBS-D. This integrative therapy is simple and convenient."

Biomedicine
The researchers note that the biomedical definition of IBS includes abdominal pain or discomfort with 2 out of 3 of the following symptoms: relief by defecation, changes in frequency of stools, changes in the form of stools (hard, loose, lumpy or watery). IBS may be further differentiated by greater than 3 bowel movements per day and urgent bowel movements. The symptoms occur for 12 weeks during a 12 month period but are not necessarily consecutive.

Traditional Chinese Medicine
The researchers note that IBS-D is differentiated into 3 patterns within Traditional Chinese Medicine (TCM) according to the Diagnosis and Treatment Protocol of Integrative Chinese and Western Medicine for Irritable Bowel Syndrome by Chen, et. al. Type 1 is liver qi stagnation with spleen deficiency. Symptoms may be triggered by emotional disturbances and include: diarrhea, abdominal pain, alleviation by defecation, and lower abdominal cramping. Secondary symptoms of type 1 IBS-D are: borborygmus, flatulence, mucus in stools, depression, sighing, irritability, poor appetite, and abdominal distention. Signs include a thin-white tongue coating and a wiry pulse.

Type 2 IBS-D is due to spleen and stomach deficiency. Diarrhea, especially after food intake, is a primary symptom along with loose stools, watery stools, mucus in stool, poor appetite, and abdominal distention after eating, gastric fullness and general digestive organ discomfort. Secondary symptoms include abdominal pain relieved by pressure, borborygmus, mental and physical fatigue, abdominal bloating, and reluctance to speak. Signs include a sallow complexion, a pale tongue with teethmarks, a white tongue coating, and a thready-weak pulse.

Type 3 IBS-D is due to spleen and kidney yang deficiency. Primary symptoms include early morning diarrhea, stools with undigested food, and abdominal pain with a cold sensation. Secondary symptoms include: coldness of the limbs, aching and weakness of the lower back and knees. Signs include a pale tongue with a greasy white coating and a deep-thready pulse.

Woman holding up copper handle acupuncture needles for display.

The study was conducted over a 4 year period. All participants in the study were screened for exclusion criteria. Patients with organic intestinal disorders were screened from participation using stool tests, fungal smear and colonoscopy.

Acupuncture
Acupuncture was applied to a set of primary and secondary points. Primary acupoints were:

Zhongwan (CV12)
Guanyuan (CV4)
Tianshu (ST25)
Zusanli (ST36)
Shangjuxu (ST37)
Pishu (BL20)
Dachangshu (BL25)

Secondary points were added for specific conditions:

Weishu (BL21) for weakness of the spleen and stomach
Ganshu (BL18), Xingjian (LR2) for liver qi stagnation with spleen deficiency
Shenshu (BL23) for yang deficiency of the spleen and kidney

The BL (bladder meridian of foot-taiyang) acupoints were needled with the patient in a prone position and the needles were removed upon the arrival of deqi. Next, patients assumed the supine position and the acupoints were inserted to 1 - 1.5 cun perpendicularly. Even reinforcing-reducing needle technique was applied using lifting and thrusting to achieve a deqi sensation of local soreness, distention, numbness, or a radiating sensation towards the abdomen. The needles were manipulated once every 10 minutes and were retained for a total of 30 minutes per session. In addition, the abdominal area was heated using a TDP heat lamp.

Moxibustion
Moxibustion was applied with patients in a supine position. A pillar of salt was poured onto acupoint Shenque (CV8). Next, ginger slices of 0.7 to 0.8 cm thickness and approximately 4 cm diameter were placed upon the salt pillar. Prior to placement, two toothpick sized holes were made through the ginger. Moxa cones of a 3 cm diameter and a 3 cm height were placed atop the ginger and were ignited. The moxa cone was replenished once during each session. Both acupuncture and moxibustion were performed once per day and 6 treatments made up one course of care. There was a 1 day interval between courses of care and all patients received 4 courses of care.

Additional Research
The results of the study indicate that combining acupuncture with moxibustion is significantly more effective for the treatment of IBS-D than acupuncture alone. Additional research confirms the efficacy of Traditional Chinese medicine. A meta-analysis published in the World Journal of Gastroenterology concludes, "Acupuncture exhibits clinically and statistically significant control of IBS symptoms." The study investigated all three types of IBS: diarrhea predominant (IBS-D), constipation predominant (IBS-C), and alternating (IBS-A). The researchers note "our meta-analysis of six randomized controlled trials suggests that acupuncture improves the symptoms of IBS, including abdominal pain and distention, sensation of incomplete defecation, times of defecation per day, and state of stool."

The researchers concluded that acupuncture is both safe and effective noting that, "No serious adverse events associated with acupuncture were reported in the articles." They aded that one study "showed that improvement in pain in IBS was positively associated with increased parasympathetic tone in the acupuncture group." This finding indicates that acupuncture regulates the parasympathetic nervous system.

One study in the meta-analysis was conducted at the University of York and was published in BMC Gastroenterology. This randomized controlled trial included 233 IBS patients who suffered from this condition for an average of 13 years. A total of 116 patients received acupuncture plus conventional care. This was compared with another group of 117 patients receiving only conventional medical care. The group receiving acupuncture plus conventional medical care demonstrated significantly superior clinical outcomes. The researchers concluded, "Acupuncture for irritable bowel syndrome provided an additional benefit over usual care alone. The magnitude of the effect was sustained over the longer term. Acupuncture should be considered as a treatment option to be offered in primary care alongside other evidenced based treatments."

Global Acceptance
Given the recent study of acupuncture combined with moxibustion and the meta-analysis published in the World Journal of Gastroenterology, it is reasonable to implement acupuncture in primary healthcare settings for the treatment of IBS. Dietetics ingredients for remedies. The are other sources supporting the use of acupuncture. The Mayo Clinic website notes, "Researchers have found that acupuncture may help improve symptoms for people with IBS." The IBS fact sheet from Johns Hopkins Medicine online notes, "Several small studies suggest acupuncture provides significant relief from chronic pain. In IBS patients, there are reports that acupuncture can relax muscle spasms and improve bowel function." IBS affects approximately 10 - 15% of the population. Scientifically based research now demonstrates that acupuncture may help patients with IBS.

The Healthcare Medicine Institute (HealthCMi) offers continuing education courses on the treatment IBS and digestive disorders. Online acupuncture CEU courses are valid for NCCAOM� PDA (national Diplomate), California Acupuncture Board, Florida Board of Acupuncture, Texas CAE, CTCMA, CAAA, Massachusetts acupuncture continuing education credit and more. In addition to acupuncture and herbal medicine courses on digestive concerns, the course Chinese Medicine Dietetic Remedies covers the treatment of IBS with dietetic treatments. A special steamed bun (Ba Zhen Gao) that helps patients with IBS, diarrhea, chronic dysentery, and colitis is presented. The recipe contained in the course material is:

"Powder Shan Yao (the main ingredient), Fu Ling, Dang Shen, Yi Yi Ren, Qian Shi, Bai Bian Dou and Lian Zi. Mix the powder with rice or wheat flour and add water to make a dough. Optionally, add powdered Dang Shen and Fu Ling. Sugar may be added for flavor. Make a steamed bun, bread or pastry. Originally, this steamed bun was served to children suffering from malnutrition."

An additional congee recipe is also presented in the dietetics course material. The Shan Yao Lian Zi Zhu recipe presented in the course materials is as follows:

"Zhu, translated as congee, is nutritious and well tolerated by children. Make a powder with Shan Yao (Chinese yam), Lian Zi, Qian Shi, Bai Bian Dou and Yi Yi Ren. Combine the powder with rice (Geng Mi), oatmeal or wheat to make a congee. Optionally, add Dang Shen, Fu Ling or both."

Browse healthcmi.com to learn more about the IBS online course materials. At HealthCMi, we are dedicated to research and education to promote greater health and understanding.

References:
Liu, Xiao-xia. "Moxibustion on Shenque (CV 8) improves effect of acupuncture for diarrhea-predominant irritable bowel syndrome." Journal of Acupuncture and Tuina Science 12, no. 6 (2014): 362-365.

Thompson WG, Longstreth GF, Drossman DA, Heaton KW,Irvine EJ, Müller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut, 1999, 45 (Suppl 2): Ⅱ43-47.

Chen ZS, Zhang WD, Wei BH. Diagnosis and treatmentprotocol of integrative Chinese and Western medicine forirritable bowel syndrome (IBS). Shijie Huaren Xiaohua Zazhi,2004, 12(11): 2704-2706.

Chen CY, Wang Y. Clinical effect of Trimebutine in treatment of irritable bowel syndrome. Zhongguo Xinyao Yu Linchuang Zazhi, 2003, 22(4): 199.

Voland C, Serre CM, Delmas P, Cl�zardin P. Plateletosteosarcoma cell interaction is mediated through a specific fibrinogen-binding sequence located within the N-terminal domain of thrombospondin 1. J Bone Miner Res, 2000, 15(2): 361-368.

Chao, Guan-Qun, and Shuo Zhang. "Effectiveness of acupuncture to treat irritable bowel syndrome: A meta-analysis." World Journal of Gastroenterology 20, 7 (2014): 1871-1877.

MacPherson H, et. al. Acupuncture for irritable bowel syndrome: primary care based pragmatic randomised controlled trial. BMC Gastroenterology 2012; 12: 150.
- See more at: http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1405-acupuncture-soothes-irritable-bowel-syndrome-ibs#sthash.EIE2ESNr.dpuf

http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1405-acupuncture-soothes-irritable-bowel-syndrome-ibs

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Heather is the Administrator of the IBS Message Boards. She is the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!

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