Hay Fever Prophylaxis using Single PointAcupuncture: a Pilot Study

The results of rhis study \r'/erc ptesented at the tsMAS Sping Scientific Meeting held at Cheltenham in May 1994

SummaryTo determine whether single poitlt, Liver ?(Taichone), acuputlcture is effective lor hay ieverprctphylaris in a dedicated lleneral practice clinicsetting, 3A pati-.nts sulferinB fron htng-standing,noderate to severe bay fever were endonised 10acupuncture or conventional therapy. Three, tenminute acupuncture treatnents were given atweekly intetvals during April | 993.Four of the filieen acuputicturc patients had

canplctc rcnission of symptoms conpared withnonc from thc control group. The rest af theacupuncture group ltad a variablc rcsponse, but asntall, signilicant imprcvemenl in ov-.nll syrjplonlscore was clentonstrated, a-s wa-s a shorlening oltluration oi hay fever symptonts. The an of the hayiever season lor sont,. patients \Nas lal,.t lhanexpected, which nay have resulted in rerlucedelfectivity oi the act4tunctur,., tllus trealment maybe better safting at the be]in]in!: of May ta coverthe peak of synptoms in early June.

The results of this pilat study have shawn thatsingle point (Liver 3),lcupuncture given for hayfcver prophylaxis in a clinic setting was etrecuve,safe, easily reproducible, acceptablc andinexpenslve (lhe malerial cosl ol the l teatment wasl-.ss thaD 50p per p.llienl). The sludy neritsrepeaunS on a tatSer scate.

Key wordsAcupuncture, General pracliae,

lnttoductionHay fever is a common ailment affectinS up to 29%of the population f/,2). Those badly aff l icted sleeppoorly, f ind diff iculty concentrating at work, feelgcncral ly low and are often unable to go outdoors insumnrer. The peak prevalence of hay tever isbelh,een the ages of I6 and 24 years fj), thus oftcnaliecting young people during thc cri t ical fcwmonths ol their l ives when they arc sit t ing importantexaminations. Vuwman ei a/ 44) showed that schoolchildren sulfering from hay iever had Jowereducational performance despite, or possibly due to,adequate symptom conlrol wilh "not1 sedalitlg" anti-histamines.

Nar 1991Vo! t2 No.2

Conventional medicine offers no acceptableprophylaxis for hay fever 15 91. On the other handacupuncture is widely rsed to trcat hay fever bothfor prophylaxis and ior acutc syrnptoms, but as yetno sysLernatic study has been published in theEnglish l i teralure to demonstrate effectjvenessTradit ional Chinese acupuncture involves each

patient beinS treated wilh an individual prescript ionof points at the onsel of their hay {ever symptoms.This requires considerable knowledge of lradit ionalacLrpuncture, is t ime consuminS, especial ly aspatients'syrnptoms start at dif ferent t imes, and maynot be widely acceptable, as some ralhef uncomfort-able facial nccdling points are often involved.The air.s of this study were two fold:

a.To estabJish a safe, effective, widely acceptableand easily reproducible method of hay feverprophylaxis using singlc point acupuncture.

b.To examine the feasibi l i ty of treating patients indedicated cl inics, run rather l ike imrnunisationcl inics, to r.aximise eff iciency and to make itpr-rssible to offer the service in Beneral practice.

The main problems anticipated in designinS thestudy were:a, Prejudice and worries about acupuncture.b. Simplifying the acupuncture enough to be

reproduced by any doctor or nurse and yet beeffective in the majority of patients.

c. _fi..in8

the treatment to be cornpleted before thestart of the hay fever season, as this was unpre-dictabJe and varied betw€en patients.

MethodThe stLrdy was a control led randomised tf ial ofacupuncture at a single pair ot points (Livef 3)against conventional treatment. Al l patients werere8istered with a { ive-partner, semi rural practice.Those included were aged l8 40 years. They hadhad moderate to severe hay lever symptomsrequir ing double or tr iple drug therapy for two ormore months of the year for at least threeconsecutive years.

Names were taken fronr the 1992 prescripl ion l ist,selecting those patients Lrsing two or more oi thedru€ls: ferferadire (hiludan), astemizole (Hisminal),beclam€thasone proprionate (Beconase), sadiumcromoglycatc (Opticron).

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Patients who had been prescribed the drugs bygeneric name were al located to the control group.Those who had been prescribed the drugs by tradename were al located to the acupuncture group. Aseight different doctors had been involved inprescribing, it was felt that this form of allocation wasrandom and no bias had been introduredAll patients were invited to participate by written

invitat ion and screening questionnaire. A total ofthifty patients was required. Those with chronic,vasomotor rhinitis, or who were pregnant, wereexcluded from the tr ial. Informed consent wasobtained from all patients, who were warned aboutpotential bruising and also drowsiness experiencedby some after acupuncture. They were told this wasan experimental form of acupuncture and given noexpectation of success. The author visited all controlpatients personally 10 explain the purpose of thestudy, but they were not seen aSain during the tr ial.All pafticipants were told to continue to usewhatever conventional medication they wished orneeded to control symptoms. An arbritary date ofMay ist was taken for the start of the hay teverseason, based on patients' past experience. Threeacupuncture cl inics were organised four weeks,three weeks and one week before that date. Patientswere seen at fifteen minute intervals and kept thesame appointment t ime for al l three sessions.The acupoint chosen was laichong (lyef 3). This is

foernd between the first and second metatarsal bones,2 inches proximal to the web margin. Ultrafine (36gauBe) needles were inserted bilaterally to a depth ofone centimetre and left for ten minutes. Patients weretreated supine and no stimulation was used. Needlingat this point is safe, easily reproducible, causes littlediscomfort and produces a relaxed and pleasant state.Taichong is a polent site for the treatment of manyconditions and is felt to be non threatening to patientsnew to acupuncture. lt has been used anecdotally forhay tever prevention (Mann, Paine, personal commu-nication), usually in combination with otheracupoints. By using a single point it was hoped thatthe treatment would be distilled to the most easilyaccessible, acceptable, reproducible form.All padicipants i i l led out a pre season questionnaire

giving an overal l score of symptoms for 1992, theamount of medication normally used, and theanticipated duration of symptoms. Starting after thethird acupuncture treatment, each participant kept adaily diary for the period Apri l l9th and july 25th1993, in which was recorded the amounr olmedication used: the number of drops, sprays andtablets of each type of drug. Also in the diary were100mm visual analogue scales (VAS) to becompleted daily to display the severity of symptoms.These were used to derive a patient symptom score.All patients were telephoned in May and June tomake sure they were continuing their diaries. InSeptember, each paft icipant f i l led out a f inal ques-t ionnaire giving an overal l symptom score for 1993,as well as a verbal assessment of whether the year

was bettet worse or the same as 1992. The pollencount was measured by the Oxford CityLnvi o1menldl Herl lh Depdlmenr u\inB aRotherham trap from May 1Oth unti l luly 26th 1993.

ResulfsForty live invitations were sent. Thirty-six patientsreplied, of whom thirty-one were el igible forinclusion. Sixteen were al located to the acupuncturegroup and fifteen to the control group. All returnedcompleted diaries and questionnaires fFlgur'e /).

Al l but one patient ( in the treatment group)considered that they suffered from moderate orsevere hay fever. The two groups flable 1) were wellrnatched for age and smoking behaviour, but therewas an excess of women in the control group (11out of l5).Although diaries were kept from 19th Apri l unti l

25th July, a {ew patients had signif icant symptomsduring August and one of the control patients didnot even staft symptoms Lrntil 26th luly (Table 2).One control and one acupuncture patient usedhomoeopathic remedies, and one control patientused /ntal Six jn each group (39'l" of all participants) feh that the cost of medjcation influencedwhich and how much medication they used. Thesepatients tended to use only an oral antihistamine(incurrinS a sinSle prescript ion charge) and toleratepoorer symptom control for as long as possibledurinS the season. In the tr ial, six needles cost 4Bp,so the main cost of the acupuncture treatment wasin medical i ime.

DEMOCRAPHIC DEIAITS O[ CONIROL ANDACUPUNCfURE GROUPS

Acupuncture ControlTota l 16 15Male 9 4

AEe RanSe 18 40 18 '40Mean Age 29.4 29.1Smoke6 (Active + Pa$ive) 4 (2+2) 4 (2+2)

TIMINC AND DURATION OF HAY FIVER SYMPfOMS

Na patient's synptoms werc counted until they hadrccoded a total VAS scote of at least 7cm over a week.

Acupuncture ConlrolSymptoms before I st May 25o/" 33./.Symptoms before lst iune 75o/a 66%Peak in 1st 2 weeks ot June 94% A7%Symptorns after 26th Jlly 25% 53%Able to predict naftofown hayrever season 25% 20yo

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PAftENI SUBIECTtVE ASSESSMTNT OFACUPUNCTURE EFFECT

No. of patientsExcel ent 4 (25.Of")Very good 2 \12.51")Cood 3 (18.8%)Fnir 4 l25.Aa/ . )No El lect I (18.8%)Worse 0

I imited the statist ical interprelal ion of results.However many lessons have been learned. Theinit ial concerns about patients'fear of acupuncturewere not sustained, as 9470 were wil l in8 topart icipate in further acupuncture stodiesThe visual analogue scale was a very successiul

measurement of symptom control flable 4). Patientsiound it easy to use, scorinS was consistent forindividual patients and reflected their di{ferences in

Acupuncture was well tolerated by all, with no sideeffects, although one patient experienced theprofoLrnd drowsiness which affects some patients afteracupuncture. Interestingly this patienl also demon-strated the most dramatic improvement in overallsymptom score, from 10 in 1992 to 1 in 1993.Four patients experienced an excellent response to

acupuncture (Table 3). Ihey had all suffered frommoderate or severe hay fever for more than fiveyears. Their dai ly symptom scores were lower thanany control subject and they required l i t t le or nomedication. Of treated subjects, 56% felt they had agood, very good or excellent response toacupuncture.The one control subject whose symptoms did not

start unti l Lhe end of July then had a part icularly badseason. Howevef her results are not recorded on theBraphs, which therefore lowers Lhe averagesymptom score of the control group.

One patient in the acupuncture group said in hisverbal assessment that 1993 was the worse year, butgave it a better overall symptom score. Thesymptom scores of al l other patients correlated withtheir overal l verbal comparison of 1993 with 1992(Table 5).

DiscussionThe small number involved in the pi lot study has

' 1 1 2 4 3 1 7 1 4 2 1 2 A 5 1 2 1 9April May June July

Weekbeginning

Key: . Acupun.ture ^ Conlbl

figure 1. Craphs shawing nedicatian needed ta cantrolsynptons, related ta weekly pollen count.

Mean number of anlihistamine tablets taken oer week

2 6 3 1 0 1 7 2 4 3 1 7 t 4 2 1 2 A 5Mean number oJ stercid nasa spays used p€r w€ek

1 9 2 6 3 1 0 l t 2 4 3 1 7 1 4 2 1 2 A 5 1 2 1 9Mean nlnberorsodium crcmoglycaledrcps used perweek

1 S 2 6 3 1 0 1 4 2 1 2 a 5 1 2 1 9

30 | Mean total w@kly analogue score

19 26 3 10 1T 24 31 7 14 21 2A

25

3 2 0

$gE

E

9 r z

€ ' oi i 3

0

n , ^P

0

! zooE 600€ sooo 400

& 3oo.e 2oa3 1oo

E

MEAN SYMPTOM SCORES FROM 100mmVISUAL ANATOCUE SCATT

A.upunclure Control' q q 2 c u l h a . 0 t a . - 4 6 4 - b' n q l

F , ' n r r F 4 . 6 5 ' | 8 '

lmprovenrcnt 2.36* 0.66'

+5iBn ificant differcnce p=0.o282Mann Whitney Two Sample TesL

VEREAL ASSESSMENT OF 1992 COMPARTD TO 1993

Acupuncture ControNumber PercentaBe Number PerceniaSe

Better 11 69% 7 47Y,S a m e 1 2 5 % 2 1 3 o / .W o r s e l 6 % 6 4 4 %

Orford City aveage weokly grass pol .n count

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s,vrlrplon) s-overiLy. Flowevef this score is greatlyini lrenced by l l)e .rnroLrrt oi medicirt ion used.[]f lorlunltelv there rvas no simp e correlationl)cl$/een VAS s.-or-os nnd the rei)orts of rnedicationLr\aBe, vnrying even in individual patrents .rtdif ierenl t imes in the senson. The cost of nrcdical ionnlso irf feri ts the dosc'and t,vpe of drug uscd, andllen.e the ei ie(t iveness of syml)tom contro. l_hislaclof l)ad noL been irnt icipated, bLrt as both gfoupswefe equn ly nfiectecl, i t was thoutht not 1.)i f i lLrer] ce the results.The correct t imini l of prophylaxis l l fovccl to bc a

major problerr, as pati. .nts fel l into thfcc Broups,ench $,i th different t inring fcquifcrncnls lor

;. Those n,hose symptonrs started in Apri bulpenked in eaf y Junc.

b.Thosc whosc s_vmploms slarLed al the efd ol Mnyand peakcd in c.1rly Junc.

c.A ferv lvhosc symptorns starlc. l in lale lul), .rndp.'aked in August. lnd Scptcmber.

Ofly onc in iouf palicnls coLr . l a..Lrralely pre.l ictthc staft oi thcir own hay iever se.:son. The yr lencount iol lorved raLher lh.r) predicted the sevefity ofhay levef symplo ls, but cl icl move in paral lel. ManvoI lhc palienls did not stnft siSnif ic.rnt symptonrsLrf l i l one nloflh : l lef the i lcupunctlrre, wh ch w.lsprobab ), too long for ihe efiect to last. Wait int unti lpni enls present nt the vcfy staft oi s\rmplorns rnavu,el l be the nrost. ' f f lcicnt way ol h-cating hay iever.Clinics nould need to run froi lr lhc cnd oi Apri lr . r l ' i | ' t i n l i r : u l | . n . 1 i . r i | l - r L ' 1 ^ 1

.rcupLrncture effcct. l_his rvould probably preempt orshorten the hav fcvcr scason rather lhar aaL as.r l f l reprophyl. lcLic. l-he mosL corlsistenl i inding \ ' \ ,as thirtpal ienls in lhe acupur]ctrrre group f inished thetr haylcvcr synrploms iI n shorter t ime than the controlSfou p.L)urinB Lhe enfly pi i f t of the season the author

Lre.r led a) fLrrther patients with indiv dual prcscripl iori (nru t ip e l)ointi acupL rcturc, comnrcncing juslnfter their svnrptoms h.1d sLlrtcd. AIler a singleLreirtment 4 pit ients fcspondcd dramali. . l ly,ne-.din8 no further medicatiof for thc rcst ol Lhe hayi-over season. One p.rt ient had a much bcticr scasonLhan the previoLrs year and onc rcporlcal a \,vorseseason. Th s rcsponsc (66'X, sLrc.ess) is more typic;r lof that cl i | l lcal l \r expecLed lrom acupunchrretreatmcnt of hay iever. Although lhis gro!p wasmuch smallcr, lhev appeared 1() lare rfuch betterthan ci lher lhe l /r,er I ncLrp!nctrrre group or thccontrol group, lvhich underl ines the urgent need tosl!dy this appfo,r( h undef contro led c,rndit ions.

fhe ei iect oi / l l 'er - l ncupuncture on thc 5{r 'X, oipalienL\ who felt they bL.nefited was rcmarkable,cofsideri |B how minim.rl the ac!puncturc hacl bccnand how long before the season it had bccf givcn.l:or lhe ,1 (25%) patients whosc symploms al bL]lvanished, this was a most rvclconrc and valuableresponse. Tha' matcfial cosls ol acLrpL|)aluretreirtment are nrinrnral, lhus lhe berrefi ls oi t f issimple t. 'chniqLrc afc gral i iying lo both patients and

dcJckrr, and are high _v cost cf lccl ivc.CottclusionLarge scale, s nrplc, ha_v ic!,cr prophylaxis usinSacupuncture is possiblc. Sing c point f l lver lJacupuncturc I vcf in a cl i f ic sel l ing bel{rre lhe st.rrtoihay ievcr sympLonrs [,as saie, easily reproducil ] le,acceptahle and ir]expeIsive. An impfovement insymptoms has bccn dcmonstraled, as h.rs nshortcning ol duration. l 'he su.cess rale of lrealmenlis l ikely lo hc inrproved by usinS ir( l ividunlpresaripl ion acupunalLrre afd l inring lrenLment tocoin.ide wilh lhe ons-.1 oi symploms.

AcknowledgmentsI shou ld l i ke l o t hank l he CP Pr in . i p i l s ; n r l s ta f l a tFafinEdon Heallh Cerrlre lor ireely .r1L}virrg the rseoi their patients and prenrises for the studv.Part icular thrnks go to Fiona Hunt for hcr hclpthroLrghout the stLrdy and especial iy in col lecti fg thed.rtn rnd preparing the nr.IrLrscript.

Lyn Williamson MA MRCP MRCCPl7 Coxwcll Ro,1d, Faringdan, Oxfotd SN7 7EB

I t cnr ing Dlv l . Cro inb c DL (19871 P,e\ . le , . re o l anl rma aDdh.], r..ver in tn$lnnd .f(l W,ler tsfn,Vr tledi,tl lL\t11,rl.2 9 1 : 1 7 9 E i

I t ic l r rds 5, Thof l r r i l Lr , loben! H, Hr t res L j 11992r l lo i tr r , fv peop e th i rk L l rey h i le h i ! ie le . , fd wir . t thev ( lor t i \ t i l Bt t i5 l ) l . \ in \ i l . t ( ;enen! f t ,1 . t i .e t : ]E la)

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5. Noon L ( l9 l l rPrcpi , \ ' lJ i lc i foc! r t io f a8ai in ha! tcvcr .

6. S{)lroel rl FrenS Fl. K !frer J e/ ,r/ rr .r.r l) Top cnt clocJr)rsl i e . o m p . f e d w i t h o r a l l r . | a d m i l ( e ' e . l e r i e , r d i , , e o ' l r r epfophf l i \ is and l rcntnrcnl o i se.oni / ' r i fo .of l !n . l i r i l islaunDl Dt All.ryt aDd Cli]il.tl lnntnbl.itr 92 tl pt 1):7l8 l

7. Nornr .n P5, Wir<efssdcr $ l L i .h tennein L 1 i9r2r i iasoi . l !m prc. ip t . ted polef c \ t r . r . ts n Lhe l feaLfr -pnl othnyi:r.!. l.nr n.l oi,\lletu.r rt)d (lhicai lnnunaia\v. a0: 31 11

I l ln i r )e E, K i re ' , R.Drsd. , le E, I largrcalc [ ( ]9901C.mpar ior o i thc c i iQ. \ , i . { l sde c i r . ,c ts of Jq!eo! \nefo id nas. l spra) 1b!d.nnr i . le) rod i e , !e, , l r je( r ionLhef .pv lPol l incx Rr n rhe r 'e i t ,Jre, rL o i serso rJ l r l lers i .rh no.o i t ! i . t i ! i t is . l .unal . i / \ l l . - t : ty and ( l inn ' .1hnnuDola\r. 85 ll):6lL tl

9 . Anci l R, T. , r r l !5r i Y, Kiburc Y, Carnpbe I R,snr lh lR(1990) l l . xk idr i /e , l i oublc. b ind. p a.ebo .onl ro l lcd t r ia l o i. se lec l !e 5 ip . \ \ , i le rnsc i rh ib lo f IAA l l { , l l ior thcJrelenlion oi teiso.rl J ergic rhinitis. /ournrl ortntcmati.Dal L1..1i.al Retplnlr. I 6 (2):7i 8a

THE ASSOC]ATAN OFBRIT]SH VETERINARYACUPUNCTURE invites

Enquiries please to:fhe President, Mr John Ni.ol orThe secrctary, Mrc )ill HewsonEast Park Cottage, Handcrcss Sussex RH17 6BD.

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