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Evidence-Based Applications of Veterinary Medical Acupuncture

Western Veterinary Conference 2006
Narda G. Robinson, DO, DVM, DABMA, FAAMA
Colorado State University College of Veterinary Medicine and Biomedical Sciences
Fort Collins, CO, USA

 

Objective:

Present information regarding the evidential basis of acupuncture.

General Key Points:

  • Evidence exists regarding the applications and effectiveness of acupuncture.
  • While most studies have been performed on humans or experimental animals, a handful of papers on veterinary patients have been published.

Overview of the Issue

In 1997, the National Institutes of Health issued a consensus statement of acupuncture, reflecting the assessment by a nonadvocate, non-Federal panel of experts of the medical knowledge available at the time. According to the Consensus Statement, “[P]romising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations, such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.”

Since 1997, hundreds more studies have been published on acupuncture. The outcomes of some of this research is presented below.

Additional Detail

One form of acupuncture, known as “PENS” (percutaneous electrical nerve stimulation) approaches pain treatment from a decidedly neuroanatomic perspective, treating the patient’s pain pattern along dermatomal, myotomal, and sclerotomal trajectories. PENS differs from electroacupuncture by having a certain needle placement, lead pattern, and electrical frequencies generated.1 Research on PENS has focused on headache2,3, diabetic neuropathic pain4, postherpetic neuralgia5, sciatica6, low back pain7,8, and pain secondary to bony metastasis9.

Other research on acupuncture for pain appears in the following table.

  • Low back pain: Acupuncture dry needling are useful for chronic low back pain.10-13
  • Knee osteoarthritis: Acupuncture improves pain and function in patients with knee osteoarthritis.14
  • Chronic visceral hyperalgesia: EA effectively treats visceral pain in rats subjected to colorectal distention, as an irritable bowel syndrome model15
  • Peri-operative analgesia: Acupuncture helped stabilize pulse rate and blood pressure during maxillofacial surgery.16
  • Lateral epicondyle pain: Acupuncture provides short-term relief for lateral epicondyle pain.17
  • Chronic orofacial pain: Acupuncture provides significant short term relief for patients with chronic orofacial pain.18
  • Migraine: Ear acupuncture can abort migraines.19,20

Acupuncture helps many conditions in addition to pain. See below for research regarding reproductive conditions.

  • Erectile Dysfunction: The use of acupuncture as a mono-therapeutic modality in ED, did not influence the profile of the stress and sex hormones, but did improve the quality of erection and restored the sexual activity with an overall effect of 39%.21
  • Labor induction: Acupuncture at points LI 4 and SP 6 supported cervical ripening at term and can shorten the time interval between the EDC and the actual time of delivery.22; Transcutaneous electrical stimulation at acupuncture points caused a significant increase in frequency and strength of uterine contractions in women.23
  • Labor pain management: Acupuncture may provide adjunctive pain relief during labor.24
  • Pain control during oocyte retrieval: EA without pre-medication provides pain relief during oocyte retrieval.25

A 2004 review article on the therapeutic roles of acupuncture in functional gastrointestinal disorders compiled several studies, and came up with the following list:26

  • Dysphagia–TENS helped reduce lower esophageal sphincter (LES) resting pressure, improved esophageal peristalsis and LES relaxation, and increased plasma vasoactive intestinal peptide (VIP)–an inhibitory neurotransmitter responsible for LES relaxation.
  • Non-cardiac chest pain–TENS effectively treated visceral heart pain in severe angina pectoris, as well as chest pain from esophageal origin.
  • Nausea and vomiting–Several randomized-controlled trials have provided evidence that acupuncture treats nausea and vomiting in various conditions, including post-operative, chemotherapy, pregnancy, and motion sickness. Animal models using ferrets and dogs show similar benefits; the effect appears to be mediated through the vagus nerve.
  • Gastric acidity–EA helps reduce acid secretion in both humans and animals.
  • Functional dyspepsia–Acupuncture effectively reduces dyspeptic symptoms, especially epigastric pain.
  • Antroduodenal dysmotility–acupuncture increases antroduodenal motility in cases of hypomotility, and may inhibit it in cases of hypermotility.
  • Gastric emptying–acupuncture accelerates gastric emptying in a canine model.
  • Gastric dysrhythmia–acupuncture reduces arrhythmia and increases normal gastric slow waves.
  • Post-operative ileus–three RCTs suggest that acupuncture increases GI motility in patients after abdominal surgeries, as evidenced by shortened time to first bowel sound, flatus passage, and excretion.
  • Irritable bowel syndrome–acupuncture improves rectal sensation; lowered sensory threshold to rectal distention is a hallmark of IBS.
  • Constipation–acupuncture helps children with constipation.

The table below includes additional studies on gastrointestinal effects.

  • Effects of acupuncture on intestinal motility: The frequency of intestinal motility stimulated by ST 36 increased during acupuncture stimulation and after stimulation. The frequency of intestinal motility stimulated by BL 27 decreased during the acupuncture and after stimulation.27; Acupuncture at ST 36 induced dual effects, either stimulatory or inhibitory, on gastric motility. The stimulatory effects are mediated in part via vagal efferent and opioid pathways.28; Electroacupuncture (EA) at ST 36 promoted gastric myoelectric activity, which was regulated by the vagus.29
  • Treatment of liver damage: Acupuncture at ST 36 and LR 3 did not prevent acute liver injury but may be effective in treating liver injury induced by carbon tetrachloride in rats.30
  • Gastric acid secretion: Acupuncture performed led to significant reduction in gastric acid secretion.31
  • Acupuncture for GI endoscopy: Acupuncture produced effects similar to conventional premedication.32

Acupuncture can influence cardiopulmonary function as shown in the following table.

  • Safety and efficacy in respiratory problems: “Current published evidence reveals no reason to withhold acupuncture as a safe and potentially effective treatment in patients with bronchial asthma and chronic obstructive lung disease.”33
  • Postextubation laryngospasm: Acupuncture with bloodletting at LU 11 may prevent and treat laryngospasm occurring after tracheal extubation in children.34
  • Modification of cardiovascular function in dogs by acupuncture: Acupuncture at Jen Chung (GV 26) in dogs under halothane anesthesia produces sympathomimetic-like effects on the cardiovascular system. This response can be inhibited by pretreatment with propranolol and to a lesser extent with phentolamine. Severe hypotension and cardiac arrest produced by hypoxia in dogs under halothane anesthesia can be reversed by acupuncture ST 9, a sympathomimetic-like effect. Acupuncture at ST 36 results in a parasympathomimetic-like effect on the cardiovascular system which can be inhibited by atropine. A parasympatholytic-like effect resembling that produced by atropine can be obtained in dogs with sinus arrhythmia by acupuncture at LI 5.35
  • Reversal by acupuncture of cardiovascular depression induced with morphine during halothane anaesthesia in dogs: The depressant effect of morphine on cardiac output, heart rate and mean arterial pressure in dogs under halothane anaesthesia appeared to be reversed by acupuncture by electrocautery at Jen Chung (GV 26).36
  • Cardiovascular beneficial effects of electroacupuncture at PC 6 acupoint in anesthetized open-chest dog: Mean arterial pressure, end-diastolic volume, heart rate, stroke volume, cardiac output, and end-systolic pressure gradually decreased by 5 to 10% over 1.5 h without PC 6 EA. PC 6 EA at 40 Hz, however, increased these cardiovascular variables by 10 to 15%, especially end-systolic elastance (Ees) by 40% (p<0.05) over 15 to 60 min. After PC 6 EA was stopped at 1 h, these facilitated cardiovascular variables decreased below the pre-EA level.37
  • Pressor effect of electroacupuncture on hemorrhagic hypotension: PC 6 EA inhibited a hemorrhage-induced increase in plasma catecholamines. This study demonstrated a scientific basis for the therapeutic efficacy of acupuncture in the treatment of hemorrhagic hypotension and shock.38
  • Cardiovascular and endocrine effects of acupuncture in hypertensive patients: Acupuncture decreased blood pressure in hypertensive patients at least in part from a decrease in renin secretion.39
  • Decreased heart rate by acupuncture stimulation in humans via facilitation of cardiac vagal activity and suppression of cardiac sympathetic nerve: Acupuncture at PC 4 decreased heart rate as a result of a reciprocal coordination of an increase in cardiac vagal activity and a decrease in cardiac sympathetic activity.40
  • Reversal of reflex-induced myocardial ischemia by median nerve stimulation: a feline model of electroacupuncture: PC 6 stimulation (over the median nerve) diminished regional myocardial ischemia triggered by a sympathetically mediated increase in cardiac oxygen demand.41
  • Acupuncture in angina pectoris: Both genuine and sham acupuncture have a specific effect on some angina pectoris patients in addition to the effect of pharmacological therapy.42
  • Acupuncture inhibits sympathetic activation during mental stress in advanced heart failure patients: Acute acupuncture attenuates sympathoexcitation during mental stress in advanced HF patients.43

Because acupuncture works by stimulating nerve fibers, it can help restore neurologic function for a number of conditions, as shown in the following table.

  • Stroke in humans: Acupuncture focally increased CBF in stroke patients especially in the hypoperfused zone surrounding the ischemic lesion, and in the ipsilateral or contralateral sensorimotor area.44; Humans suffering from stroke are more likely to remain independent and in their own homes one year following their stroke if they have received acupuncture.45
  • Parkinson’s Disease in humans: Post-acupuncture improvement in the sleep and rest category (p=0.03) but no improvement in the categories of ambulation, mobility, body and movement, social interaction, communication, alertness behavior, emotional behavior, eating, work, home management, or recreation and pastimes. No adverse effects reported.46
  • Spinal cord injuries in humans: The use of concomitant auricular and electrical acupuncture therapies, when implemented early in acute spinal cord injury, can contribute to significant neurologic and functional recoveries.47
  • Wobbler syndrome in dogs: Some improvement noted in dogs with wobbler syndrome. No adverse effects observed with acupuncture. The use of this technique is proposed for large-scale clinical trials.”48
  • Peripheral nerve injury: Acupuncture facilitates recovery of peripheral nerves, including the median nerve49,50 and radial nerve51.
  • Epilepsy: Ear-point stimulation can potentially effectively treat epilepsy.52

Neuromodulation of sacral and other peripheral nerve function helps improve voiding dysfunction, as shown below.

  • Bladder activity: Acupuncture stimulation to the sacral segment affects both the bladder activity and sleep-arousal system.53
  • Neurogenic bladder in spinal cord injuries (SCI): Acupuncture may be beneficial in the management of neurogenic bladder of SCI, and the earlier the patient received electro-acupuncture therapy, the sooner the bladder balanced.54
  • Incontinence:  The study included 15 elderly women who were treated with manual acupuncture 12 times; almost all outcome measurements were significantly improved even at follow-up 3 months after the last treatment.55
  • Detrusor hyperreflexia incontinence: Acupuncture may represent another valuable therapeutic alternative to the treatment of urinary incontinence caused by detrusor hyperreflexia.56
  • Detrusor instability: 77% of patients with idiopathic detrusor instability were symptomatically cured.57
  • Urinary tract infection: Acupuncture may be a worthwhile alternative in the prevention of recurring lower UTI in women.58,59
  • Recurrent cystitis: The long-term outcome of acupuncture at the SP 6 point for women with frequency, urgency and dysuria was positive, but that the effect was temporary and repeated acupuncture was necessary to maintain beneficial effects.60
  • Renal colic: Acupuncture may be a good alternative for the treatment of renal colic.61
  • Nocturnal enuresis in children: Acupuncture can be useful for childhood nocturnal enuresis when combined with other treatment, including other forms of acupuncture.62

Certain skin conditions respond to acupuncture, as shown below.

  • Canine otitis externa: Acupuncture significantly improved recovery time, pain control, and rate of resolution of secretions.63
  • Neurogenic pruritus: Acupuncture appeared to be effective in alleviating the distressing symptom of itching in patients presenting with neurogenic pruritus.64
  • Atopic dermatitis: Acupuncture eased the effects of withdrawal from steroids in patients with long-standing atopic dermatitis.65

Acupuncture affects immunity, and can influence blood composition, as shown below.

  • Connections between the immune system and the autonomic nervous system: Acupuncture tended to normalize the pattern of leukocytes.66
  • Enhancement of splenic interferon-gamma, interleukin-2, and NK cytotoxicity by S36 acupoint acupuncture in rats.: Electro-acupuncture stimulation of ST 36 acupoint enhanced splenic NK cytotoxicity and that IL-2 and IFN-gamma may function, at least in part, in the regulation of NK cell activity in this system.67
  • Effects on Sepsis: Acupuncture enhanced survival, re-established neutrophil migration, and reduced the number of bacteria in the focus of experimental infection in rats.68
  • Antioxidant status of erythrocytes: Acupuncture improved the antioxidant status of erythrocytes.69

Summary

The evidential basis of acupuncture is increasing in magnitude, making an evidence-based acupuncture practice viable.

References

1. Cummings M. Percutaneous electrical nerve stimulation–electroacupuncture by another name? A comparative review. Acupunct Med. 2001 Jun;19(1):32-5. Review.

2. honame EA, Craig WF, White PF. Use of percutaneous electrical nerve stimulation (PENS) for treating ECT-induced headaches. Headache. 1999 Jul-Aug;39(7):502-5.

3. Ahmed HE, White PF, Craig WF, Hamza MA, Ghoname ES, Gajraj NM. Use of percutaneous electrical nerve stimulation (PENS) in the short-term management of headache. Headache. 2000 Apr;40(4):311-5.

4. Hamza MA, White PF, Craig WF, Ghoname ES, Ahmed HE, Proctor TJ, Noe CE, Vakharia AS, Gajraj N. Percutaneous electrical nerve stimulation: a novel analgesic therapy for diabetic neuropathic pain. Diabetes Care. 2000 Mar;23(3):365-70.

5. Alper BS, Lewis PR. Does treatment of acute herpes zoster prevent or shorten postherpetic neuralgia? J Fam Pract. 2000 Mar;49(3):255-64. Review.

6. Ghoname EA, White PF, Ahmed HE, Hamza MA, Craig WF, Noe CE. Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica. Pain. 1999 Nov;83(2):193-9.

7. Ghoname ES, Craig WF, White PF, Ahmed HE, Hamza MA, Gajraj NM, Vakharia AS, Noe CE. The effect of stimulus frequency on the analgesic response to percutaneous electrical nerve stimulation in patients with chronic low back pain. Anesth Analg. 1999 Apr;88(4):841-6.

8. Ghoname EA, Craig WF, White PF, Ahmed HE, Hamza MA, Henderson BN, Gajraj NM, Huber PJ, Gatchel RJ. Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study. JAMA. 1999 Mar 3;281(9):818-23.

9. Ahmed HE, Craig WF, White PF, Huber P. Percutaneous electrical nerve stimulation (PENS): a complementary therapy for the management of pain secondary to bony metastasis. Clin J Pain. 1998 Dec;14(4):320-3.

10. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev. 2005; Jan 25:1:CD–1351.

11. Molsberger AF, Mau J, Pawalec DB, and Winkler J. Does acupuncture improve the orthopedic management of chronic low back pain–a randomized, blinded, controlled trial with 3 months follow up. Pain. 2002;99:579-587.

12. Manheimer E, White A, Berman B, Forvs K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005;142:651-663.

13. Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, and Berman B. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the Cochrane Collaboration. Spine. 2005;30:944-963.

14. Berman BM, Lao L, Langenberg P, Lee WI, Gilpin AMK, and Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee. A randomized, controlled trial. Annals of Internal Medicine. 2004;141:901-910.

15. Cui KM, Li WM, Gao X, Chung K, Chung JM, and Wu GC. Electro-acupuncture relieves chronic visceral hyperalgesia in rats. Neuroscience Letters. 2005;376:20-23.

16. Pohodneko-Chudakova IO. Acupuncture analgesia and its application in cranio-maxillofacial surgical procedures. Journal of Cranio-Maxillofacial Surgery. 2005;33:118-122.

17. Trinh KV, Phillips SD, Ho E, and Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology. 2004;43:1085-1090.

18. Goddard G. Short term pain reduction with acupuncture treatment for chronic orofacial pain patients. Med Sci Monit. 2005;11(2):CR71-CR74.

19. Romoli M, Allais G, Airola G, and Benedetto C. Ear acupuncture in the control of migraine pain: selecting the right acupoints by the “needle contact test”. Neurol Sci. 2005;26:S158-S161.

20. Linde K, Streng A, Jürgens S, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Hammes MG, Weidenhammer W, Willich SN, and Melchart D. Acupuncture for patients with migraine–a randomized controlled trial. JAMA. 2005;293(17)2118-2125.

21. Kho HG, Sweep CG, Chen X, Rabsztyn PR, Meuleman EJ. The use of acupuncture in the treatment of erectile dysfunction. Int J Impot Res. 1999 Feb;11(1):41-6.

22. Rabl M, Ahner R, Bitschnau M, Zeisler H, Husslein P. Acupuncture for cervical ripening and induction of labor at term–a randomized controlled trial. Wien Klin Wochenschr. 2001 Dec 17;113(23-24):942-6.

23. Dunn PA, Rogers D, Halford K. Transcutaneous electrical nerve stimulation at acupuncture points in the induction of uterine contractions. Obstet Gynecol. 1989 Feb;73(2):286-90.

24. Lee H and Ernst E. Acupuncture for labor pain management: a systematic review. American Journal of Obstetrics and Gynecology. 2004;191:1573-1579.

25. Stener-Victorin E. The pain-relieving effect of electro-acupuncture and conventional medical analgesic methods during oocyte retrieval: a systematic review of randomized controlled trials. Human Reproduction. 2005;20(2):339-349.

26. Ouyang H and Chen JDZ. Review article: therapeutic roles of acupuncture in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2004;20:831-841.

27. Choi M, Jung J, Seo M, Lee K, Nam T, Yang I, Yoon Y, Yoon J. Ultrasonographic observation of intestinal mobility of dogs after acupunctural stimulation on acupoints ST-36 and BL-27. J Vet Sci. 2001 Dec;2(3):221-6.

28. Tatewaki M, Harris M, Uemura K, Ueno T, Hoshino E, Shiotani A, Pappas TN, Takahashi T. Dual effects of acupuncture on gastric motility in conscious rats. Am J Physiol Regul Integr Comp Physiol. 2003 Oct;285(4):R862-72.

29. Liu JH, Yan J, Yi SX, Chang XR, Lin YP, Hu JM. Effects of electroacupuncture on gastric myoelectric activity and substance P in the dorsal vagal complex of rats. Neurosci Lett. 2004 Feb 12;356(2):99-102.

30. Liu HJ, Hsu SF, Hsieh CC, Ho TY, Hsieh CL, Tsai CC, Lin JG. The effectiveness of Tsu-San-Li (St-36) and Tai-Chung (Li-3) acupoints for treatment of acute liver damage in rats. Am J Chin Med. 2001;29(2):221-6.

31. Lux G, Hagel J, Backer P, Backer G, Vogl R, Ruppin H, Domschke S, Domschke W. Acupuncture inhibits vagal gastric acid secretion stimulated by sham feeding in healthy subjects. Gut. 1994 Aug;35(8):1026-9.

32. Lee H and Ernst E. Acupuncture for GI endoscopy: a systematic review. Gastrointestinal endoscopy. 2004;60(5):784-789.

33. Jobst KA. A critical analysis of acupuncture in pulmonary disease: efficacy and safety of the acupuncture needle. J Altern Complement Med. 1995 Jan;1(1):57-85.

34. Lee CK, Chien TJ, Hsu JC, Yang CY, Hsiao JM, Huang YR, Chang CL. The effect of acupuncture on the incidence of postextubation laryngospasm in children. Anaesthesia. 1998 Sep;53(9):917-20.

35. Lee DC, Lee MO, Clifford DH. Modification of cardiovascular function in dogs by acupuncture: a review. Am J Chin Med. 1976 WINTER;4(4):333-46.

36. Lee DC, Clifford DH, Lee MO, Nelson L. Reversal by acupuncture of cardiovascular depression induced with morphine during halothane anaesthesia in dogs. Can Anaesth Soc J. 1981 Mar;28(2):129-35.

37. Syuu Y, Matsubara H, Kiyooka T, Hosogi S, Mohri S, Araki J, Ohe T, Suga H. Cardiovascular beneficial effects of electroacupuncture at Neiguan (PC-6) acupoint in anesthetized open-chest dog. Jpn J Physiol. 2001 Apr;51(2):231-8.

38. Syuu Y, Matsubara H, Hosogi S, Suga H. Pressor effect of electroacupuncture on hemorrhagic hypotension. Am J Physiol Regul Integr Comp Physiol. 2003 Dec;285(6):R1446-52. Epub 2003 Jul 31.

39. Chiu YJ, Chi A, Reid IA. Cardiovascular and endocrine effects of acupuncture in hypertensive patients. Clin Exp Hypertens. 1997 Oct;19(7):1047-63.

40. Nishijo K, Mori H, Yosikawa K, Yazawa K. Decreased heart rate by acupuncture stimulation in humans via facilitation of cardiac vagal activity and suppression of cardiac sympathetic nerve. Neurosci Lett. 1997 May 23;227(3):165-8.

41. Li P, Pitsillides KF, Rendig SV, Pan HL, Longhurst JC. Reversal of reflex-induced myocardial ischemia by median nerve stimulation: a feline model of electroacupuncture. Circulation. 1998 Mar 31;97(12):1186-94.

42. Ballegaard S, Meyer CN, Trojaborg W. Acupuncture in angina pectoris: does acupuncture have a specific effect? J Intern Med. 1991 Apr;229(4):357-62.

43. Middlekauff HR, Hui K, Yu JL, Hamilton MA, Fonarow GC, Moriguchi J, Maclellan WR, Hage A. Acupuncture inhibits sympathetic activation during mental stress in advanced heart failure patients. J Card Fail. 2002 Dec;8(6):399-406.

44. Lee JD et al. The cerebrovascular response to traditional acupuncture after stroke. Neuroradiology. 2003;45:780-784.

45. Hopwood V and Lewith GT. Does acupuncture help stroke patients become more independent? J Alt Comp Med. 2005;11(1):175-177.

46. Shulman LM et al. Acupuncture therapy for the symptoms of Parkinson’s Disease. Movement Disorders. 2002;17(4):799-802.

47. Wong AM et al. Clinical trial of acupuncture for patients with spinal cord injuries. Am J Phys Med Rehabil.2003; 82(1):21-27.

48. Sumano H et al. Treatment of wobbler syndrome in dogs with electroacupuncture. Dtsch. Tierarztl. Wschr.2000;107:231-235.

49. Chen GS. The effect of acupuncture treatment on carpal tunnel syndrome. J Acupuncture. 1990;18:5-9.

50. Naeser MA, Kyung-Ae KH, Lieberman BE. Carpal tunnel syndrome pain treated with low-level laser and microamperes transcutaneous electrical nerve stimulation: A controlled study. Arch Phys Med Rehabil. 2002;83:978-988.

51. Millea PJ. Acupuncture treatment of compression neuropathy of the radial nerve: a single case report of “Saturday night palsy”. J Alt Comp Med. 2005;11(1):167-169.

52. Shu J, Liu R-Y, Huang X-F. The effects of ear-point stimulation on the contents of somatostatin and amino acid neurotransmitters in brain of rat with experimental seizure. Acupuncture & Electrotherapeutics Res., Int. J. 2004;29: 43-51.

53. Tanaka Y, Koyama Y, Jodo E, Kayama Y, Kawauchi A, Ukimura O, Miki T. Effects of acupuncture to the sacral segment on the bladder activity and electroencephalogram. Psychiatry Clin Neurosci 2002 Jun;56(3):249-50.

54. Cheng PT, Wong MK, Chang PL. A therapeutic trial of acupuncture in neurogenic bladder of spinal cord injured patients–a preliminary report. Spinal Cord 1998 Jul;36(7):476-80.

55. Bergstrom K, Carlsson CP, Lindholm C, Widengren R. Improvement of urge- and mixed-type incontinence after acupuncture treatment among elderly women – a pilot study. J Auton Nerv Syst 2000 Mar 15;79(2-3):173-80.

56. Honjo H, Naya Y, Ukimura O, Kojima M, Miki T. Acupuncture on clinical symptoms and urodynamic measurements in spinal-cord-injured patients with detrusor hyperreflexia. Urol Int 2000;65(4):190-5.

57. Philp T, Shah PJ, Worth PH. Acupuncture in the treatment of bladder instability. Br J Urol 1988 Jun;61(6):490-3.

58. Aune A, Alraek T, LiHua H, Baerheim A. Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women. Scand J Prim Health Care 1998 Mar;16(1):37-9.

59. Alraek T et al. Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women. American Journal of Public Health. 2002;92:1609-1610.

60. Chang PL, Wu CJ, Huang MH. Long-term outcome of acupuncture in women with frequency, urgency and dysuria. Am J Chin Med 1993;21(3-4):231-6.

61. Lee YH, Lee WC, Chen MT, Huang JK, Chung C, Chang LS. Acupuncture in the treatment of renal colic. J Urol 1992 Jan;147(1):16-8.

62. Bower WF, Diao M, Tang JL, and Yeung CK. Acupuncture for nocturnal enuresis in children: a systematic review and exploration of rationale. Neurourology and urodynamics. 2005;24:267-272.

63. Sanchez-Araujo M, Puchi A. Acupuncture enhances the efficacy of antibiotics treatment for canine otitis crises. Acupunct Electrother Res. 1997;22(3-4):191-206.

64. Stellon A. Neurogenic pruritus: an unrecognised problem? A retrospective case series of treatment by acupuncture. Acupunct Med. 2002 Dec;20(4):186-90.

65. Fukuda M, Kawada N, Kawamura H, and Abo T. Chapter 15. Treatment for atopic dermatitis by acupuncture. In: Complementary and Alternative Approaches to Biomedicine. Cooper EL and Yamaguchi N (eds.). Kluwer Academic /Plenum Publishers, 2004. pp. 229-237.

66. Mori H, Nishijo K, Kawamura H, Abo T. Unique immunomodulation by electro-acupuncture in humans possibly via stimulation of the autonomic nervous system. Neurosci Lett. 2002 Mar 1;320(1-2):21-4.

67. Yu Y, Kasahara T, Sato T, Guo SY, Liu Y, Asano K, Hisamitsu T. Enhancement of splenic interferon-gamma, interleukin-2, and NK cytotoxicity by S36 acupoint acupuncture in F344 rats. Jpn J Physiol. 1997 Apr;47(2):173-8.

68. Scognamillo-Szabo MVR, Bechara GH, Ferreira SH, and Cunha FQ. Effect of various acupuncture treatment protocols upon sepsis in Wistar rats. Ann NY Acad Sci. 2004;1026:251-256.

69. Pogosyan AS, Venediktova NI, Kosenko EA, and Kaminskii YG. Antioxidant status of erythrocytes after acupuncture treatment. Bulletin of Experimental Biology and Medicine. 2004;138(7):33-36.

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