PCAR7115E: Manuscript: Charlyn Moellers

CAM Therapies for Symptoms Management of Asthma and COPD:

Acupuncture & Acupressure for Symptoms Management of Asthma and COPD

Abstract

Asthma and COPD are two distinct chronic diseases which have in common limitations in

airflow and ultimate remodeling of the airways if not well controlled. The mechanisms

behind the sequela of each disease have different pathways but inflammation of the

airways causes irreparable damage to the airways or parenchyma of the lungs, based on

specific phenotypes. The allopathic healthcare system currently has no modality that

can effectively stop the progression of persistent asthma or COPD other than long-term

oxygen therapy for a select group of patients who are chronically hypoxic. Systemic

effects to pulmonary disease add to the severity, disabling effects and exacerbations of

COPD ultimately causing tissue destruction and limited tolerance for exertion. Dyspnea

is the primary effect, especially in COPD which is responsible for limiting a patient’s daily

activity level and leads to deconditioning. There are many studies which support the use

of acupuncture to treat asthma exacerbation as a useful modality for symptom relief.

Acupressure has also been trialed as a treatment to relieve dyspnea in the COPD

population. The uses of complementary and alternative medicine therapies such as

acupuncture and acupressure have possible applications to augment allopathic care.

There is a great need for quality pilot studies to be developed to study the effects that

acupuncture and acupressure can have on the health and well being of the COPD and

asthmatic patient.
Introduction

Asthma

Asthma presents as a flow limited disease characterized by a hypersensitivity of the

trachea and bronchi to various stimuli and is manifested by widespread narrowing of the

airways that change in severity either in response to treatment or spontaneously1.

Though considered a chronic inflammatory disorder, the immunohistopathic features of

neutrophils, lymphocytes, mast cell activation, and epithelial cell injury are thought to

be phenotype specific. The phenotypic patterns of the inflammation have different but

sometimes overlapping aspects (intermittent vs. persistent or acute vs. chronic) which

manifest as bronchospasm2. If not successfully controlled, asthma can progress to

moderate and persistent classifications of the disease and eventually lead to airway

remodeling. Once structural changes occurs (hypertrophy of mucus glands and

hyperplasia of the airway smooth muscle) there may be a loss of lung function and the

patient may not respond to standard treatments2. These changes in and around the

airway are different than the airway changes of COPD, however, with passage of time

the features of the airways in the two conditions may converge3. A stepwise approach

to symptom management is recommended based on classification of the severity of the

patient’s disease to maintain control of asthma with the least amount of medication and

hence minimal risk of side effects, with the ultimate goal of the patient being symptom

free.

WHO estimates that there are 300 million people currently suffering from asthma

throughout the world with it being the most common chronic disease among children.

The NIH Record reports 17 million asthmatics in the US with asthma prevalence,
morbidity and mortality increasing with a greater disparity among lower socioeconomic

groups despite the fact that there is now more known about asthma than any time in

history4. Asthma diagnosis has increased markedly since 1980, but, hospital

admissions for asthma have decreased significantly and have remained stable since

1990s, however, asthma deaths (as a proportion of asthma patients) have not declined

during the same period5. The reasons for this is unclear but it is noted that there are

fewer advances in the treatment of fatal asthma as have been made in the moderate to

persistent types of asthma.

COPD

Chronic Obstructive Pulmonary Disease (COPD) is a term used to describe a

cardiopulmonary and systemic syndrome related to varying long term, incurable

diseases (cystic fibrosis, chronic bronchitis, persistent asthma with airways remodeling,

Bronchiectasis, and emphysema) of the airways and other lung structures that

ultimately lead to irreversible airflow limitation as evidenced by spirometry testing of the

patient's flow rates.

The primary risk factor in COPD is smoking, followed by particulate and gaseous

pollution, occupational exposure to dusts and fumes, recurrent infection, and aging

which causes natural degenerative changes in the lung parenchyma1 that may begin as

early as the fifth or sixth decade and eventually resemble emphysematous changes.

There is also a population with a genetic predisposition to COPD who have an alpha-1-

antitrypsin deficiency which leads to destruction of the elastic properties of the lungs and

cause emphysematous changes that are measureable in the third and fourth decade1.

The latest statistics in the US suggests that COPD is rising in morbidity and mortality
and projects it to be the third most common cause of death by 20206. Additionally,

WHO ranks COPD as the fourth leading cause of mortality in the world and projects a

30% increase in deaths due to COPD in the next 10 years without interventions to cut

risks7. COPD is treatable in the earlier stages, but by the time a patient becomes

symptomatic pulmonary function studies demonstrate moderate advancement of the

disease8. It has been demonstrated that patients with only mild stages of COPD have

significantly decreased work capacity and decreased gas exchange secondary to a loss of

pulmonary function and chronic deconditioning as evidenced by exercise testing9.

Exacerbations of COPD influence lung function negatively and promote clinical decline in

patients making prevention and management of exacerbation a high priority10.

Advancement in medicine and technology allow improved care of acute exacerbations of

COPD, but the healthcare system falls short of caring for the patient long term, other

than treating the symptoms. Despite its burden to healthcare resources COPD remains

a highly relevant health impact, yet is the most under-funded disease in relation to its

global burden5. Cardiopulmonary rehabilitation is underutilized for COPD, is poorly

funded, and as yet no effective program has been developed to sustain therapeutic

effects over time10, 11. Medications used to treat COPD have adverse and unwanted side

effects such as tremors, increased cardiac effects, nausea, vertigo, anxiety, fatigue,

thrush, GI irritation, CNS stimulation, and anorexia12, all of which may contribute to the

systemic effects of the disease.

Need for Evidenced based CAM Therapies in Management of Asthma and COPD

It has proven difficult to engage many patients in making life style changes for

successful management of chronic pulmonary disorders such as asthma and COPD for a
variety of reasons. Noncompliance to medication is a large percentage of the reason

due to undesirable side effects to medication, improper usage of medication inhalers,

cost of medications and limited access to healthcare are the cited basis13. It was found

that national and international clinical guidelines are often poorly disseminated due to

lack of understanding, patients under-reporting their symptoms make staging difficult,

or the guidelines were found to be difficult to follow in real life contexts13. A survey of

underserved people using CAM therapies and folk remedies without guidance to treat

their children’s asthma was correlated with negative prescription fill patterns14.

Dr Marjolein Gysels, an anthropologist, investigated patients’ personal experiences of

dyspnea and the social effects of COPD. Focusing on findings relating to patients with

COPD of her qualitative study using in-depth interviews with topic guides she gives some

insight to patients’ views of their illness and interactions with healthcare. The interviews

demonstrated that patients did not seek health services at the onset of symptoms, but

waited until they were in crisis. Furthermore the patients’ diagnoses did not lead to life-

style changes that would have improved their outcomes such as smoking cessation

because they did not have an adequate understanding of the label COPD. Dr Gysels

concluded that the ways in which diagnosis and prognosis are conceptualized and

discussed in medical interviews need to be better suited to patients with COPD. Gysels’

recommendation favors using a step wise approach within a frame directed to

surveillance of the patient and including a holistic and patient-centered approach to care

with the focus being on quality of life15.

There are CAM therapies which have been shown to be efficacious for treating asthma

and COPD; however none are listed in the national or international treatment guidelines

for either of the diseases’ publications at this time. A search of the literature yielded no
studies that are robust enough to make generalizations about complementary and

alternative therapies concerning COPD and asthma. Some small scale studies related to

acupuncture to treat asthma and acupressure to treat dyspnea warrants further

research.

Most studies involving acupuncture and pulmonary conditions were done with asthma

patients. As early as the 1977, trials were demonstrating significant improvement in

pulmonary function with acupuncture in the treatment of acute exacerbation of

asthma16, but a recent Cochrane review of 12 acupuncture studies (9 using the needling

technique, 3 using the laser technique) in 2008 have yet to produce adequate and

consistent outcomes to warrant large scale studies for the practice in persistent asthma.

There were problems cited with methodology and trial reporting primarily due to the

complexities and different types of acupuncture that is practiced. It is suggested by this

team that more pilot data be acquired before proceeding to large scale studies4.

Literature in modern Chinese medicine texts relating acupuncture to persistent asthma,

(allergen induced asthma) defines it as a new treatment; the theory still in its

development. Persistent asthma is a relatively new condition and rare in China, with

incidences increasing in Chinese people who live in the West and adopt Western life-

styles17. Thus, these treatments are not part of the classic Chinese medicine texts, as

are treatments for other phenotypes.

Acupuncture is a component of traditional Chinese medicine (TCM) that was first

recorded in China more than 2500 years ago. The general principle of acupuncture is

based on the flow of energy (qi), through meridians of the body that is life sustaining

and essential for good health. Qi influences blood and body fluids. These three factors

form the only media of communication between the zang (solid) and fu (hollow) organs,
and their related tissues and organs18. If these energy channels get blocked or the

system(s) involved become imbalanced they become susceptible to breakdown or illness

ensues. East Asian medicine expresses imbalances as source-manifestation rather than

having causal effects19. In this context, asthma symptoms (breathlessness, wheezing)

may stem from different sources such as deficiency of the Lungs, Kidneys’ Defensive-Qi

Systems, Spleen-Qi Deficiency, Stagnant Liver-Qi, etc16. Research needs to be

supported to better understand this system and its biochemical and physiologic effects

to help design quality studies.

The NIH Consensus Development Panel on Acupuncture identified another problem with

the design of studies as being in the different approaches to diagnosis and treatment

used in American acupuncture which have origins in China, Japan, Korea and other

countries. There is a need to form a consensus about the acupoints to use in treatment

groups and sham groups. McCarney, et al. also suggested having a “no treatment”

group as well where only conventional therapy is used4. The pilot studies should also

be designed around the specific asthma phenotypes so outcomes can be accurately

evaluated for each group since a distinction has been made between the etiologies and

manifestations of the disease.

Of interest to the COPD cohort may be the use of acupressure to relieve dyspnea.

Dyspnea is the subjective feeling of breathlessness that a patient is aware and is

implicated as one of the most troubling aspects of patient comfort, exercise limitations,

and quality of life reported among COPD patients. Intractable breathlessness is the

most common and distressing symptom in advanced cardiopulmonary disease, affecting

70-80% of COPD patients19, and despite research and medical advances, dyspnea

remains one of the most difficult symptoms to manage clinically. Acupressure uses the
acupuncture principles of TCM and is used to restore vital energy in the body. It is a

noninvasive therapy that stimulates meridians by means of massage pressure applied by

the hands or fingers to regulate qi. The Journal of Alternative and Complementary

Medicine published a study about the effects of acupressure on depression related to

dyspnea. The study had some design flaws in that its participants were more than 80%

male. Studies show that depression is more prevalent in females. Thus bias may have

been shown in trying to prove its intended hypothesis, but what is of interest is the

evidence shown on the relief of dyspnea. The subjects accepted into the study were

relatively stable patients diagnosed with COPD, had no co-morbid conditions, were not

hospitalized within the past two months, and had not received pulmonary rehabilitation

during the previous 6 months. The treatment group received acupressure massage by

the practitioner using his fingers to regulate qi in acupoints related to the lungs, large

intestine, spleen, and bladder channels, and the controlling and governing vessels,

which are used to relieve dyspnea. “According to the experience of clinical

acupuncturists, the dyspnea found in COPD patients is related to depletion of fluids and

qi, Lung qi vacuity, and then qi failing to govern this, or insufficiency of the Kidney

origin, essence vacuity, insecurity of the root and then qi failing to insure

containment”22. Citing a study by Tang et al. which related depressive symptoms to

insufficiency of the kidney essence, the investigator theorized that by using these points

to treat dyspnea, depression should also be reduced.

This was a double blind, randomized, block experimental design. The subjects and the

data collector were blinded. The data collector measured the Geriatric Depression Scale

(GDS) and a Dyspnea Visual Analogue Scale (DVAS) before and after the twenty

treatment program which extended over four weeks. Oxygen saturation, blood
pressure, heart rate, and respiration rate were measured before the program started

and again after the twentieth session.

Data analyses were coded and analyzed using the descriptive statistics, the paired

samples t test, and stepwise multiple linear regression was conducted on changes in

GDS with Changes in dyspnea. Of importance concerning dyspnea are that the DVAS

and physiological markers of systolic blood pressure, heart rate, respiration rate, and

oxygen saturation which were all significantly improved (p<0.001) in the true

acupuncture group.

After revising and repeating the trial, using different outcome measures Wu, et al

published a new study in Journal of Advanced Nursing exploring the effectiveness of

acupressure on dyspnea in patients with COPD to see if employing acupressure can

improve dyspnea in patients who live at home. After blocking for age, sex, pulmonary

function, smoking, and steroid use, 44 patients were randomly assigned either to a true

acupoints acupressure or a sham group.

Following an established protocol acupoints (GV 14), (CV 22), (B13), (B 23), and (L10)

were used for the treatment group to promote the balance of qi. Following an

established protocol for the sham group and utilizing different meridians and ganglionic

sections to prevent confounding, participants received acupoint therapy at points (Sp 5)

and (Sp 3) to promote intestinal movement and increase intestinal circulation. The

reliability and validity of acupressure protocol was determined by five experts in TCM

who independently rated (100% agreement had to be established) the appropriateness

of the selected acupoints and protocol for the two groups. Each group received five

sessions per week lasting 16 minutes per session for a four week period, totaling 20
sessions. All sessions were conducted in the participants’ homes. Measures employed

before acupressure was initiated and at the conclusion of the 20th session were the

Pulmonary Functional Status and Dyspnea Questionnaire-modified scale (PFSDQ-M) and

the Spielberger State Anxiety Scale. The 6-minute walking distance test was performed

before the first session and after the last. Physiological indicators of oxygen saturation

and respiratory rate were measured before and after every session.

Results demonstrated the median age was 73 years, 81.8% participants were men, 80%

were married, 86% had ceased smoking, none of the participants used oxygen during

the study, 54% had severe obstruction (expiratory flows <50% predicted), all

participants used bronchodilators, and all participants had been receiving therapy for

COPD for a mean of 7.91 years. There were no significant differences between the

demographics of the true acupoints group and sham acupoints group. Outcomes of the

study reveal significant differences in PFSDQ-M (fatigue and dyspnea) in the treatment

group compared to the sham group, confirming that acupressure using true pressure

points relieved anxiety and dyspnea. The six-minute walking distance measurements,

indicating an enhanced tolerance for activity and state anxiety scale scores also

demonstrated a significant difference in the true acupressure group over the sham

group, as well as oxygen saturation and respiratory rate.

Conclusion

Allopathic medicine has made great advancements in the treatment of asthma but there

is still a need in treating certain phenotypes of the disease to prevent the destruction

and remodeling of the airways and parenchyma that chronic inflammation will cause

until it converges into COPD features. COPD remains a highly relevant impact to
patients’ health and quality of life, and our healthcare economy. A step wise approach

to treatment should be developed using surveillance and integrating CAM therapies such

as acupuncture and acupressure into the allopathic care of the patient with asthma and

COPD to help alleviate the systemic effects the conditions cause. Treating the patients

holistically can help alleviate dyspnea, which in turn may enhance tolerance to exercise

and diminish muscle wasting, anxiety, and hopelessness. Acupressure has the potential

to be a self taught modality21 and also has implications in the relief of dyspnea. Studies

are needed to see if retractable dyspnea can also be treated with acupressure or

acupuncture in acute dyspnea and in palliative care. There is a great need to develop

pilot trials to successfully study the outcomes on the different phenotypes of both

diseases in relation to treatments from the TCM system and to understand its

biochemical and physiologic effects so that this CAM modality can successfully be

integrated into allopathic care.

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