Suzuki Masao, et al.. Japanese Acupuncture and Moxibustion, 2009; Vol.5(1): 1-11

Takagi award-winning paper

Effect of Acupuncture Treatment in Patients with Bronchial Asthma
SUZUKI Masao1), NAMURA Kenji2), EGAWA Masato3), YANO Tadashi1)1) Department of Health Acupuncture and Moxibustion, Meiji University of Oriental Medicine
2) Department of Respiratory Internal Medicine
3) Department of Geriatric Acupuncture and Moxibustion, Meiji University of Oriental Medicine
Abstract[AIM] Acupuncture has traditionally been used in Japan in the treatment of bronchial asthma and is being increasingly applied. Although there are many published studies on acupuncture and asthma, few meet the scientific criteria necessary to prove the effectiveness of acupuncture. This study, therefore, presents the clinical results of acupuncture treatment for adult bronchial asthma.
[Design] Single-subject research design (N-of-1 method).
[Setting] Department of Internal Medicine, Acupuncture and Moxibustion Center, Meiji University of Oriental
Medicine, Japan.
[Participants] Six patients of both genders (mean age, 49.0 years) with moderate to severe persistent bronchialasthma.
[Intervention] Six patients received 10 sessions of acupuncture treatment (one time per week for 10 weeks). The
basic combination of meridian points for the treatment of the patients were LU 1 (Zhongfu), LU 5(Chize), LU 9(Taiyan), CV 4 (Guanyuan), CV 12 (Zhongwan), BL 13 (Feishu), BL 20 (Pishu), and BL 23 (Shenshu).
[Measurements] Primary outcome was the symptom of asthma at the end of the 10 treatment periods. Secondary
outcomes were Visual Analogue Scale of dyspnea (DVAS), respiratory function, Peak Expiratory Flow Rate(PEFR), blood, the use of asthma drugs. The effect of the intervention on eosinophils in blood was assessed.
[Main results] Late effects of asthma patients showed significantly better results, compared with base line on outcome measures after the 10 weeks. In this study, symptoms of asthma and dyspnea VAS in patients with asthma
were significantly improved by acupuncture.
[Conclusion] This study indicated that acupuncture was effective for asthma symptoms and respiratory function.
Key words: Bronchial asthma, Acupuncture, Lung function, Steroid, Single case study
Ⅰ．Introduction
Bronchial asthma is a condition characterized by increasing airway hypersensitivity and reversible obstruction of bronchial airways due to various stimulations. Its
main symptoms are episodic wheezing or dyspnea. In
patients with severe symptoms of asthma, their daily
lives and social lives are disturbed. Airway obstruction
is induced by inflammation of airways such as spasms inbronchial smooth muscle, airway edema, or increases inairway secretion and it is thought to be a chronic inflammatory disorder of airways1). For the treatment ofasthma, inhaled and oral corticosteroids are administered,
which are generally accepted to be the most effective
therapeutic drugs for bronchial asthma. There are, however, some patients with bronchial asthma who do notrespond to corticosteroids2).
Acupuncture is a traditional medicine that has been

Corresponding author Suzuki Masao
Department of Clinical Acupuncture and Moxibustion, Meiji University of Oriental Medicine
Hiyoshi-cho, Nantan City Kyoto, Japane-mail:masuzuki@meiji-u.ac.jp

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applied to respiratory diseases for a long time and has
recently been used for chronic bronchitis and emphysema as well as bronchial asthma3). In particular, somecases of acupuncture treatment for bronchial asthma
have been reported, and Fung et al.4) reported that acupuncture treatment was effective in preventing exerciseinduced asthma. In a systematic review performed byMartin et al.5), however, no obvious evidence was shown
because there were differences in the methods of acupuncture treatment between each report. There is no
consistent observation on the effect of acupuncture
treatment for bronchial asthma.
We, therefore, provided acupuncture treatment in conjunction with medication for patients with bronchialasthma who could not fully control it by inhaled or oralcorticosteroids and evaluated the effect of acupuncture
treatment for symptoms of asthma and respiratory functions using a single-subject research design (N-of 1,
single case study).

Ⅱ．SUBJECTS AND METHODS
1. Subjects
Subjects were six patients (two males and four females, mean age 49.0 ± 18.0 years) from asthma patientstreated as outpatients in the Department of Internal Medicine, Meiji University of Oriental Medicine Hospitaland the Acupuncture and Moxibustion Center, Meiji
University of Oriental Medicine during the period from
August of 1997 to January of 2002, whose symptoms
could not be fully controlled by orally administered orinhaled corticosteroids in conjunction with standard
treatment such as orally administered theophylline andinhaled or orally administered β2-agonists.
According to the classification of severity of asthma
symptoms6), five cases were classified as severe persistent asthma (Step 4) and one case as moderate persistentasthma (Step 3). In the respiratory function tests (performed during the periods without attacks), VC was 2.7± 0.7 L, %VC was 97.0 ± 33.6%, FVC was 2.4 ± 0.4
L, FEV1 was 1.7 ± 0.4 L, FEV1% was 72.0 ± 10.8%,

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・

V 25 was 0.5 ± 0.2 L/S, peak flow values (PEFR) (onrising) was 235.0 ± 62.2 L/MIN, and PEFR (at bedtime) was 298.0 ± 89.7 L/min. Characteristics and classification of severity of asthma symptoms and respiratory
functions before acupuncture treatment of the six patients are shown in Table 1 (1-1, 1-2), 2.
Before performing this study, the six patients were informed of the purpose of the study and the research protocol, and we obtained their consent in written form.
This clinical study was performed with the approval of
the Ethics Committee of Meiji University of Oriental
Medicine.
2. Methods of acupuncture treatment
1) Setting the acupuncture treatment period (Table 3)
In order to evaluate the effect of the treatment, we set
two periods according to a single-subject research design(N-of 1, single case study)7). One was Period A in which
acupuncture treatment was performed in conjunction
with standard medication and the other was Period B in
which acupuncture treatment was not performed but
standard medication was performed. Only Period A wasrepeated. The acupuncture treatment was performed
once a week. In Period A, ten acupuncture treatments
were provided. In Period B, only medication was provided for the same number of treatment days as those of

Period A. When remarkable exacerbations of asthma
were observed in a patient and he/she wished to receive
acupuncture treatment during Period B, the next Period
A was started at that point.
2) Choice of meridian points and methods of treatment
Meridian points for the treatment of patients in thepresent study were those shown to be effective for patients with bronchial asthma and those that were shown
to be effective in various reports5,8,9). The basic combination of meridian points for the treatment were
Taiyan (LU 9), Chize (LU 5), Zhonghu (LU 1),
Zhongwan (CV 12), Guanyuan (CV 4), Feishu (BL 13),
Pishu (BL 20) and Shenshu (BL 23). Depth of insertion
was about 10 mm to 30 mm at all meridian points, which
depended on body habitus of the patients. At Taiyan,
from the peripheral cite to the central cite, transverse
insertion was performed, and at other meridian points,
perpendicular insertion was performed. For acupuncture
stimulation, manual twisting after insertion was performed for about ten seconds and the needles retained
for ten minutes after patients recognized needle sensation (de qi). When patients suffered from anorexia, insomnia, generalized fatigue or lumbago, those weretreated as well. For those treatments, disposable stainlessneedles (Seirin Corp.), 40 mm in length and 0.16 to 0.20

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mm in diameter, were used.
Ⅲ．EVALUATION METHODS
1. Symptoms of asthma
Patients recorded their asthma symptoms everyday inan asthma diary10) developed by the Bronchial Asthma
Severity Criteria Review Committee and their symptoms
for a week were scored (asthma score).
2. Dyspnea
Severity of dyspnea was evaluated by a 100 mm Visual Analogue Scale (VAS) of which the right end (100mm) indicates the worst dyspnea imaginable, while theleft end (0 mm) indicates no dyspnea, both at the beginning and at the end of the period A.
3. Respiratory functions
Vital capacity was measured with a spirograph before
Period A 1 began and when Period A 2 ended. Forced
expiratory
vital capacity, flow volume for a second and・
V 25 were measured by Flow Volume.
PEFR was also measured by peak flow meters(Vitalograph Ltd., Ireland). PEFR was measured at risetime and bedtime everyday. It was measured three times
at each rise time and bedtime, and the highest value wasrecorded in the asthma diary.
4. Administration doses of corticosteroids
Changes of administration doses of oral and inhaledcorticosteroids were evaluated four times before thebeginning and at the end of each Period A.
5. Statistical analysis
Data on asthma attack scores and VAS are expressed
as means ± standard errors, while PEFR was expressed
as mean ± standard deviation. Changes in the asthma
attack scores, VAS and PEFR were analyzed with one
factor ANOVA, which was followed by Fisher's PLSD
multiple comparisons if necessary. Differences wereconsidered statistically significant when the value wasless than 0.05.
Ⅳ．RESULTS
There were no withdrawals due to remarkable adverse
events or no interruption according to a doctor's judgment.

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1. Changes in asthma attacks (Fig.1)
Asthma scores before the start of Period A 1 were30.0 ± 8.1 and those at the end of the period were significantly improved to 4.7 ± 3.1 (p < 0.01). The values
before the start of Period A 2, however, significantly
increased to 21.6 ± 6.5 (p < 0.05). Asthma scores at theend of Period A 2 significantly improved to 1.5 ± 0.8 (p< 0.05). Conditions of asthma attacks significantly improved from 30.0 ± 8.1 before the start of Period A 1 to
1.5 ± 0.8 at the end of Period A 2 (p < 0.01).
2. Effect of acupuncture on dyspnea (Fig. 2)
Severity of dyspnea measured with VAS before thestart of Period A 1 was 55.7 ± 20.4 mm, which significantly improved to 19.7 ± 21.0 mm at the end of period
A 1 (p < 0.01). VAS values significantly improved from57.8 ± 25.7 mm before the start of Period A 2 to 15.5
± 11.5 mm at the end of Period A 2 (p < 0.01). The
values before the start of Period A 1 and at the end of
period A 2 significantly improved from 55.7 ± 20.4 to
15.5 ± 11.5 mm (p < 0.01).

3. Changes in PEFR on rising before and after theperiod of acupuncture treatment (Fig. 3-1)
Mean value of PEFR on rising significantly increased
from 235.0 ± 62.2 L/min before the start of Period A 1 to
325.8 ± 83.1 L/min at the end of Period A 1 (p < 0.05).
The mean value at the end of Period A 1 was 325.8 ±83.1 L/min and decreased to 244.2 ± 45.4 L/min before
the start of Period A 2 (p = 0.053). The mean value before the start of Period A 2 increased from 244.2 ± 45.4
to 323.3 ± 77.6 L/min at the end of Period A 2 (p =0.059). The mean value before the start of Period A 1
significantly increased from 235.0 ± 62.2 L/min to 323.3± 77.6 L/min at the end of Period A 2 (p < 0.05).
4. Changes in PEFR at bedtime before and after theperiod of acupuncture treatment (Fig. 3-2)
Mean value of PEFR at bedtime increased from 263.3± 62.5 L/min before the start of Period A 1 to 331.7 ±88.4 L/min at the end of period A 1. The mean value atthe end of Period A 1 was 331.7 ± 88.4 L/min and decreased to 273.3 ±78.1 L/min before the start of Period
A 2. The mean value before the start of Period A 2 increased from 273.3 ± 78.1 L/min to 326.7 ± 85.0 L/min6
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at the end of period A 2. The mean value before thestart of Period A 1 increased from 263.3 ± 62.5 L/min to326.7 ± 85.0 L/min at the end of Period A 2.
5. Respiratory function tests (Table 4-1)
In four cases (#2, #4, #5, and #6) out of six, respiratory function tests were performed before and after acupuncture treatment. Before the start of Period A 1 and at
the end of Period A 2, cases in which improvement of
more than 20% was seen in each respiratory function test
were one case out of four for VC, two cases out of four
for FVC, three cases． out of four for FEV 1 and three cases out of four for V 25.

6. Changes in eosinophil counts in the peripheral
blood (Table 4-2)
Hematological examinations were performed in fiveout of six patients before and after the period of acupuncture. There were three patients (#3, #5, and #6) who
showed more than a standard value of eosinophils (below 5%) before the start of Period A. However, at theend of Period A, cases 3, 5 and 6 showed decreases inthe eosinophil counts from 6.6% to 1.1%, 9.8% to 4.5%,
and 18.9% to 10.4%, respectively. In addition, for case 1,
there was a decrease from 0.8% to 0.3%, although thechange was observed within the normal limits.

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7. Changes in administration doses of inhaled andoral corticosteroids (Table 5)
Before the start and at the end of the Period A, thedoses of oral corticosteroids were reduced in three (#1,
#2, #3) out of four patients as were the doses of inhaledcorticosteroids in two (#2, #5) out of five patients.
Due to the deterioration of asthma attacks during Period B, doses of oral and inhaled corticosteroids needed to
be increased in three out of four cases (#1, #2, and #3)
and two (#2, #5) out of five patients, respectively.
Before the start of and at the end of the Period A, thedoses of oral corticosteroids were reduced in three (#1,
#2, and #4) out of four patients and the doses of inhaledcorticosteroids were reduced in three out of five patients(#1, #2, and #3)
8. Changes in severity of asthma (Table 5)
At the end of Period A, the severity of asthma symptoms were improved in six patients compared with that
before the start of Period A, as asthma attacks were ameliorated. However, due to deterioration of asthma attacks
in five patients during Period B, exacerbations of asthma
were observed before the start of Period A 2 in three outof five patients. At the end of Period A 2, severity was
improved in five patients compared with that before thestart of Period A 2. When compared with the state before
the start of Period A 1, improvement in the severity wasobserved in six patients at the end of Period A 2.

Ⅴ．DISCUSSION
1. Study design and clinical effectTo evaluate the effect of acupuncture treatment fromthe viewpoint of Evidence Based Medicine (EBM), it isdesirable to prove the effect of acupuncture treatment ina setting of a randomized controlled trial (RCT). There
are, however, difficulties in performing an RCT study
with control groups in practical and clinical settings,
since most patients want acupuncture treatment in actual
clinical acupuncture scenes. Accordingly, in the proof ofthe effect of acupuncture treatment, this study utilized asingle-subject research design (N-of-1), in which theclinical effect could be assessed without a control group.
In the single case study used here, it was thought that theclinical effect could be assessed by obtaining
reproducible data from a single patient who repeated two
periods alternately, Periods A and B.
With this single case study of six patients in an
improved state of asthma during Period A, five patients
who showed exacerbations of asthma when entering into
Period B showed improvement in asthma symptoms
when entering Period A 2 again. Moreover, all caseswith the administration of corticosteroids in the total
observation period showed improvement in asthma
symptoms when treated with acupuncture, indicatingthat this im provement was obtained due to the effect ofacupuncture treatment, and not to either the drug effects
or a self-remitting natural course. We considered, by

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using the single-subject research design (N-of-1) in asingle case study, that it could evaluate the effect ofacupuncture treatment for asthma.
2. Clinical effects of acupuncture treatment
The patients with bronchial asthma studied here improved their asthma symptoms and VAS during Period
A (acupuncture treatment period). Moreover, there were
improvements in the airway obstruction in the assessment of FEV1 and PEFR, and improvements in bronchialasthma were observed not only from the subjective
symptoms but also from the findings of objective examinations.
As in the past, due to obstructive ventilation impairment caused by the constriction of bronchial smoothmuscle, bronchial asthma is characterized by decreases
・
in respiratory function tests, such as FEV 1, PEFR and V
25. Particularly, FEV1 reflects the airflowof the central
・
airway of the respiratory tract, while V 25 reflects the
airflow of the peripheral airway. From the data in thisstudy, improvements in the obstructive ventilation impairment was observed by acupuncture treatment inthree (#2, #5, #6) out of four patients in the assessable
respiratory
function test who showed increases in FEV1
・and V 25 at the end of Period A. Alternatively, in case
#4 who had a common cold since one day before the last
examination day and showed a slightly positive Creactive protein (CRP: < 0.5), respiratory function was
decreased due to upper respiratory inflammation.
Additionally, PEFR at rise time and bedtime in allcases was improved at the end of Period A. Because
PEFR indicates the maximal expiratory flow volume inreflection of airflow of the central airway, the value issignificantly lowered in patients with asthma symptoms.
Furthermore, PEFR values on rising being lower thanthat at bedtime suggest a possible asthma attack fromnight to morning time. All cases examined in this study
had an asthma attack at night and five of six cases
showed lower PEFR on rising compared with that at
bedtime (Table 1). However, with the continuous performance of acupuncture, the difference of the averagevalues of PEFR at rise time and bedtime was decreased
at every endpoint of Period A. The frequency of asthma
attacks at night was decreased in many cases. Moreover,the patients commented that the absence of nighttime
attacks led to sound sleep and physical relaxation. Thesefindings in respiration function, in which an asthma
attack was improved during Period A, indicated the ef-

fect of acupuncture. Alternatively, in Period B (period
without acupuncture), five of six cases showed deterioration of asthma attacks. Of five with deterioration, three(#1, #2, and #3) needed extra-outpatient visits other thanregular visits. In addition, more use of short-acting inhalation β2-agonists (bronchial dilatation drugs) was commented by all of these five patients. These results, inwhich a combined usage of this type of acupuncture(choice of meridian points, time of treatment) improved
asthma attacks but the 10 week course of acupuncture
allowing deterioration of asthma attacks, suggested that
acupuncture has an immediate, but little lasting, effecton asthma attacks. In the guideline at present 11), bronchial asthma is regarded as a disease that is not cured,
but controlled symptomatically over long periods of time.
As the guideline focuses mainly on drug therapy such as
inhaled corticosteroids, it may be desirable that acupuncture combined with drug therapy should be continued fora certain period of time even after achieving improvement or disappearance of asthma attacks. Further study
is, however, needed on how long acupuncture should becontinued.
The therapeutic mechanism of acupuncture to bronchial asthma has been speculated as a bronchial dilatation action through the autonomic nerve afferent pathway from a somatic visceral reflex stimulated by acupuncture, as well as relaxation of bronchial smooth muscle through the autonomic nervous system12). Sugiura etal.13) reported that bronchial asthma patients treated withacupuncture showed sedation and relaxation of constricted bronchial smooth muscle for one hour after acupuncture, which accompanied an improvement in respiratory resistance. Similarly, this study, in which reliefof・
dyspnea as well as improvements in FEV 1 and V 25
were experienced in patients, suggested a possibility that
acupuncture induced sedation and relaxation of thebronchial smooth muscle constriction state.
Bronchial asthma has been recognized as a chronic inflammatory disorder as research of the pathophysiologyof bronchial asthma advances. Particularly, it has been
proved that cytokine networks involving eosinophils at
the center induces release of cytotoxic eosinophilspecific granules to the airway that generate inflammation in the airway, leading to edema at the bronchial
mucosa or submucosa, increased production of mucus,
constriction of bronchial smooth muscle, and airway
obstruction. Therefore, airway inflammation through the

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eosinophil-centered cytokine network plays an importantrole in causing the attack of bronchial asthma.
In this study, two courses of acupuncture treatment(during Period A and Period B) showed improvement inasthma attacks in patients and decreased eosinophil
counts in blood in four out of five cases, which could bemeasured (#1, #3, #5, and #6). We15) also provided acupuncture treatment for patients who have both bronchialasthma (severe persistent asthma) and chronic obstructive pulmonary disease (COPD), once a week for ten
weeks and observed that the acupuncture treatment improved asthma attacks and decreased eosinophil countsin blood and Eosinophil Cationic Protein (ECP), a cytotoxic protein induced by eoshinophils, as a result. Thesefindings indicate a possibility that one of therapeuticmechanisms of acupuncture treatment for patients withbronchial asthma may be involved in improving
eosinophilic inflammation. However, until this point,among clinical reports3,16) on acupuncture treatment forbronchial asthma, there are no reports that acupuncture
treatment decreased eoshinophils specifically. Because
there is no definitive evidence of the possibility that
acupuncture treatment may improve eosinophilic inflammation of airways even though the possibility has
been suggested, we consider that we will need to review
the effect of acupuncture treatment on this point,
3. Doses of corticosteroids
At present, according to NIHLBI Guidelines for the
Diagnosis
andManagementofAsthma17),
corticosteroids for bronchial asthma are described to be
the most effective anti-asthma drugs, and are extensively
used as an improvement drug for acute symptoms or
long-term prevention drug. Inhaled corticosteroids are
considered to be most effective for patients withpersistent asthma, from moderate persistent (step 2) tosevere persistent (step 4). Oral corticosteroids arerecommended when patients do not respond to inhaledcorticosteroids. There are, however, some patients withasthma who are controlled poorly with these steroids2).
For such patients, the dose of corticosteroids is increasedin accordance with a clinical guideline and the side
effects of these drugs may cause problems. Inhaledcorticosteroids have relatively few side effects comparedwith oral steroids because they are inhaled to airways
directly, but there are still some side effects10). In thisstudy, subjects were patients with asthma whose
symptoms were controlled poorly even after they wereadministered persistent inhaled and oral steroids or
bronchodilators. Acupuncture treatment for thesepatients who did not fully responded to certain doses ofsteroids, improved their asthma symptoms in all cases inthis study, which suggested that one course of (tensessions) acupuncture treatment has efficient effects on
improvement of asthma symptoms. Mitchell et al.19) also
performed a clinical examination on 31 patients withmild to moderate asthma, in which an acupuncture
treatment group and fake group were randomly assigned.
It was reported that after eight acupuncture treatments
for 12 weeks, asthma attacks and PEFR were improved
significantly and doses of inhaled steroids could bedecreased. This result was similar to our findings in thepresent study.
According to medication therapy response to severityin the Asthma Prevention and Management Guideline6),
when symptoms are not controlled by ongoing treatment,
another more strict treatment should be provided. In
Japan, we take a step-up approach in the treatment withcorticosteroids in which doses of steroids are increased
when defined doses of corticosteroids according togrades of severity offer little effect. As for the cases inthis study, patients had been administered normal dosesof corticosteroids without improvement in asthma
attacks and doses had to be increased. We provided
acupuncture treatment on these patients in combination
with medication and observed the disappearance ofasthma attacks in two out of six cases and improvement
in four out of six cases at the end of the second course ofacupuncture treatment. This made it possible for dosesof steroids to be reduced or cut (Table 5). It wassuggested that patients who have difficulties incontrolling asthma symptoms with only medication canbe controlled by acupuncture treatment in combination
with medication.
Acknowledgements
We are thankful to Dr. Naoto Ishizaki who made agreat contribution to this paper.
VI. CONCLUSION
1. Acupuncture treatment was provided for six patientswith bronchial asthma who were controlled poorly
even
with
standard
medication
includingcorticosteroids.

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2. In all cases, improvement or disappearance of asthma
symptoms was observed in accordance with length of
the acupuncture treatment
3. At the end of the acupuncture treatment, improvementof respiratory function and decrease in eosinophil
counts were observed along with improvement ofasthma symptoms. In four out of six cases, doses ofcorticosteroids could be reduced.
4. As a result of acupuncture treatment provided forpatients with bronchial asthma, who were controlled
poorly with medication, acupuncture treatment wasconsidered to be effective in improving asthma
attacks, subjective symptoms, and respiratory
function of the patients.
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