Inspired by Oliveira et al 2021.[1]
TLE – temporal lobe epilepsy
key to acronyms
TLE-HS – temporal lobe epilepsy with hippocampal sclerosis
AEDs – antiepileptic drugs
CLS – Cantril ladder scale
QoL – quality of life
QOLIE-31 – quality of life in epilepsy (31 item scale)
aHR – adjusted hazard ratio
There are few controlled trials of acupuncture in epilepsy to be found on PubMed, so naturally I was curious about this recent one from Campinas in the state of São Paulo, Brazil.
It included 52 consecutive patients diagnosed with TLE-HS who were not listed for surgical treatment.
TLE-HS is the most common refractory focal epilepsy in the adult population, with 60% to 70% of patients resistant to AEDs.
Patients were seen every week for 10 consecutive weeks and half of them were randomly assigned to receiving acupuncture. Both groups completed a well-being scale (CLS) every week, as well as an assessment of the occurrence of seizures. A quality-of-life assessment using the QOLIE-31 was performed in the first and tenth weeks.
GB13 is a point traditionally indicated in epilepsy
The acupuncture was performed weekly for 20 minutes and consisted of manual needling at set protocol of points: yintang, GV20, GB13, LI4, LR3. GB13 is on the forehead, level with the outer cantus of the eye and just inside the anterior hairline. It is a point specifically used in epilepsy, although I can see no particular logic to this from a neurophysiological perspective.
The baseline data demonstrates a randomisation failure in that the acupuncture group by chance had a significantly longer duration of illness and earlier age of diagnosis. Fortunately, the seizure frequency in the year prior to the study was not different between the groups.
The seizure frequency over 4 weeks decreased markedly in both groups, which the authors say can be explained by the effect of ‘grouping seizures’, that is, I assume the tendency of seizures to occur in groups. This is a challenge for the RCT design and maintaining sufficient statistical power to avoid a type II statistical error (false negative result) when the outcome in a control group can change so dramatically without the underlying condition changing in terms of natural history.
Despite the dramatic reduction in seizure frequency in the control group, the group receiving acupuncture did achieve an even greater reduction, such that there was a significant difference measured between the groups.
QoL measures demonstrated a more marked improvement in the acupuncture group and the authors wondered whether the QoL change caused the reduced seizure frequency or vice versa, since episodes of stress are thought to be related to the occurrence of epileptic seizures,[2] hence improved QoL may work the opposite way. Equally, a reduction in seizure frequency may promote an enhanced QoL.
The only prior reports of a trial of acupuncture in epilepsy that are to be found on PubMed are from a group in Norway.[3,4] This was a small trial with less than 20 in each arm and an unfortunately high withdrawal rate. Treatment was performed 3 times a week by imported Chinese professors and they used a very similar protocol to that of the recent trial, but GB13 was not mentioned. One key difference was the use of penetrating sham acupuncture in the control group.
A Cochrane review from 2014 managed to find 17 trials with 1538 participants.[5] 15 of these trials were from Chinese journals and presumably not listed on PubMed or published in English. Inevitably the results are limited by heterogeneity and small trials with a high risk of bias.
In reviewing some of the literature in this area I was reminded of the role of vagal nerve stimulation in the treatment of intractable epilepsy, and this led me to be more optimistic of a possible mechanism of acupuncture. A number of hypotheses are reported that implicate the role of the thalamus and hippocampus.[6,7]
Stroke patients treated with acupuncture had a reduced risk of developing epilepsy – aHR 0.74
Finally, I was happy to come across one of the earliest of the large retrospective cohort studies from Taiwan, which had eluded my gaze until now.[8] Stroke patients treated with acupuncture (at least 12 sessions) had a reduced frequency of developing epilepsy (9.5 vs 11.5 per 1000 person years). The adjusted hazard ratio worked out at 0.74, which is roughly a 25% reduction.
References
1 Oliveira GA, Tedrus GMAS, Nucci LB. Acupuncture, seizure frequency, and quality of life in temporal lobe epilepsy. Epilepsy Behav 2021;122:108213. doi:10.1016/j.yebeh.2021.108213
2 Maguire J, Salpekar JA. Stress, seizures, and hypothalamic-pituitary-adrenal axis targets for the treatment of epilepsy. Epilepsy Behav 2013;26:352–62. doi:10.1016/j.yebeh.2012.09.040
3 Kloster R, Larsson PG, Lossius R, et al. The effect of acupuncture in chronic intractable epilepsy. Seizure 1999;8:170–4. doi:10.1053/seiz.1999.0278
4 Stavem K, Kloster R, Røssberg E, et al. Acupuncture in intractable epilepsy: lack of effect on health-related quality of life. Seizure 2000;9:422–6. doi:10.1053/seiz.2000.0436
5 Cheuk DKL, Wong V. Acupuncture for epilepsy. Cochrane Database Syst Rev 2014;:CD005062. doi:10.1002/14651858.CD005062.pub4
6 Chen S, Wang S, Rong P, et al. Acupuncture for refractory epilepsy: role of thalamus. Evid-Based Complement Altern Med ECAM 2014;2014:950631. doi:10.1155/2014/950631
7 Meng F-G, Kao CC, Zhang H, et al. Using electroacupuncture at acupoints to predict the efficacy of hippocampal high-frequency electrical stimulation in pharmacoresistant temporal lobe epilepsy patients. Med Hypotheses 2013;80:244–6. doi:10.1016/j.mehy.2012.11.039
8 Weng S-W, Liao C-C, Yeh C-C, et al. Risk of epilepsy in stroke patients receiving acupuncture treatment: a nationwide retrospective matched-cohort study. BMJ Open 2016;6:e010539. doi:10.1136/bmjopen-2015-010539
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