COVID-19

Stimulated by a pandemic!

I have been looking around for the big news in the world of acupuncture, and of course my attention is constantly being diverted to our current situation, which for most is unprecedented. I would have liked to have had more data to report from the experience in China, but so far that is limited.

I have started to receive questions from colleagues around the world asking advice on what they can do to help… with acupuncture techniques.

Acupuncture can help with many symptoms related to both acute and chronic diseases, and in some cases can potentially reverse certain pathophysiological changes. In acute illness with say an upper respiratory virus the impact on symptoms will be modest and short-lived during the active illness but may be more significant immediately following the acute phase and help clear persistent symptoms.

The influence of acupuncture can be seen in many situations as being homeostatic, and so we get an impression that the absolute size of the effect varies with the severity of the condition ie how far from the normal set point you start the treatment. This might explain why in 2014 we saw a report of an effect on mortality in a mouse model of septic shock from a rather brief electroacupuncture (EA) intervention.[1] This was the first time an EA intervention had a measurable outcome in terms of mortality! We are more used to tail-flick latencies and von Frei hairs from laboratory work, and symptom scores from clinical trials. So an effect on mortality was big news, and I invited the boss (Luis Ulloa) to speak at a BMAS Scientific Meeting in 2014. I learnt a lot of new stuff that day, or more precisely the evenings before and after.

The vagal anti-inflammatory reflex

This followed on from the interest in vagal nerve mediated anti-inflammatory effects,[2] and demonstrated a less invasive and indirect form of enhancing vagal tone, and thus the anti-inflammatory reflex. The effect of both direct and indirect vagal nerve stimulation (VNS) has been compared and combined in a rodent model of colonic inflammatory bowel disease.[3] Direct VNS seems marginally more potent, but it comes with a much bigger potential adverse event profile, since it involves dissection of the neck to isolate the vagus nerve, and application of an electrode to facilitate stimulation.

Indirect VNS is most often applied via EA to ST36 or tibialis anterior in rodent models, and whilst the majority of laboratory trials use EA, MA has also been shown to mediate measurable anti-inflammatory effects.[4] There is also a move to try implanted electrodes at the same peripheral site.[5]

VNS – vagal nerve stimulation

I guess the laboratory study that has the most contemporary interest is the effect of EA on inflammation and lung function in a chronic obstructive pulmonary disease (COPD) model.[6]

So much for rodent models, but what about real patients? Well there is some indication of the use of similar techniques, ie EA in the region of ST36, being reported in patients with sepsis,[7,8] and in combination with a broader TCM bundle approach.[9] The smaller two of these papers (n=60)[7] (n=82)[8] did not demonstrate a significant impact on mortality, but the larger one (n=331) did,[9] with a modest reduction in days on mechanical ventilation, days in intensive care (ICU) and a drop in 28-day mortality from 43.3% to 31.5%.

At the beginning of the week I was visualising myself running around ICU with an EA device, and rather like the mouse model of septic shock, I naïvely assumed everyone treated would survive from the first intervention. These latter figures seem more realistic, with a reduction in mortality of 1:4 or 25%. That is going to be difficult to notice in the busy environment of a contemporary ICU.

I have just heard from a colleague in China, who tells me that EA is not being used. There is a lot of resistance to the use of TCM by Western-trained doctors, but many patients are having a combination of Western medicine and Chinese herbs. Acupuncture is not used much for COVID-19 patients in her region, but they have had rather few cases (less than 100), so the mortality figures are too small to interpret.

So, as far as I can tell, nobody seems to have tried stimulating the vagal anti-inflammatory reflex in this patient group as yet.

References

1         Torres-Rosas R, Yehia G, Peña G, et al. Dopamine mediates vagal modulation of the immune system by electroacupuncture. Nat Med 2014;20:291–5. doi:10.1038/nm.3479

2         Tracey KJ. The inflammatory reflex. Nature 2002;420:853–9. doi:10.1038/nature01321

3         Jin H, Guo J, Liu J, et al. Anti-inflammatory effects and mechanisms of vagal nerve stimulation combined with electroacupuncture in a rodent model of TNBS-induced colitis. Am J Physiol Liver Physiol 2017;313:G192–202. doi:10.1152/ajpgi.00254.2016

4         Lim H-D, Kim M-H, Lee C-Y, et al. Anti-Inflammatory Effects of Acupuncture Stimulation via the Vagus Nerve. PLoS One 2016;11:e0151882. doi:10.1371/journal.pone.0151882

5         Jin H, Guo J, Liu J, et al. Autonomically mediated anti‐inflammatory effects of electrical stimulation at acupoints in a rodent model of colonic inflammation. Neurogastroenterol Motil 2019;31:e13615. doi:10.1111/nmo.13615

6         Zhang X-F, Xiang S-Y, Geng W-Y, et al. Electro-acupuncture regulates the cholinergic anti-inflammatory pathway in a rat model of chronic obstructive pulmonary disease. J Integr Med 2018;16:418–26. doi:10.1016/j.joim.2018.10.003

7         Yang G, Hu R, Deng A, et al. Effects of Electro-Acupuncture at Zusanli, Guanyuan for Sepsis Patients and Its Mechanism through Immune Regulation. Chin J Integr Med 2016;22:219–24. doi:10.1007/s11655-016-2462-9

8         Meng J, Jiao Y, Xu X, et al. Electro-acupuncture attenuates inflammatory responses and intraabdominal pressure in septic patients. Medicine (Baltimore) 2018;97:e0555. doi:10.1097/MD.0000000000010555

9         Wang Y, Zhang Y, Jiang R. Early traditional Chinese medicine bundle therapy for the prevention of sepsis acute gastrointestinal injury in elderly patients with severe sepsis. Sci Rep 2017;7:46015. doi:10.1038/srep46015

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Declaration of interests MC