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The acupuncture treatment for postmenopausal hot
flushes (Acuflash) study: traditional Chinese
medicine diagnoses and acupuncture points used,
and their relation to the treatment response
Einar Kristian Borud,
1
Terje Alræk,
1
Adrian White,
3
Sameline Grimsgaard
1,2
1
The National Research Center
in Alternative and
Complementary Medicine,
University of Tromsø,
N-9037 Tromsø, Norway;
2
Clinical Research Center,
University Hospital of North
Norway, N-9038 Tromsø,
Norway;
3
Department of
General Practice and Primary
Care, Peninsula Medical School,
Universities of Exeter and
Plymouth, UK
Correspondence to:
Einar Kristian Borud, The
National Research Center in
Complementary and Alternative
Medicine, University of Tromsø,
N-9037 Tromsø, Norway;
einar.borud@uit.no
ABSTRACT
Introduction: The multicentre, pragmatic, randomised
controlled Acuflash study evaluated the effect of
traditional Chinese medicine (TCM) acupuncture on
postmenopausal vasomotor symptoms and health-related
quality of life. It concluded that use of acupuncture in
addition to self-care can contribute to a clinically relevant
reduction of hot flushes and increased health-related
quality of life. This article reports on the TCM syndrome
diagnoses and acupuncture points used and their relation
to the treatment response, and on treatment reactions
and adverse events.
Methods: The acupuncture group (n = 134) received 10
acupuncture treatment sessions and advice on self-care;
the control group (n = 133) received advice on self-care
only. The study acupuncturists met the current member-
ship criteria of the Norwegian Acupuncture Society, and
had at least 3 years’ experience of practising TCM
acupuncture. They were free to diagnose and select
acupuncture points for each participant, after initial
discussion.
Results: Fifty per cent of the participants in the
acupuncture group were diagnosed with Kidney Yin Xu as
their primary TCM syndrome diagnosis. No statistically
significant differences were demonstrated between the
syndrome groups regarding the distribution of responders
and non-responders, nor regarding the change in health-
related quality of life scores. A core of common
acupuncture points (SP6, HT6, KI7, KI6, CV4, LU7, LI4,
and LR3) were used in all the syndromes, and in addition
multiple idiosyncratic points. Core point selection and
frequency of use did not differ between responders and
non-responders. No serious adverse events were
reported.
Conclusion: Factors other than the TCM syndrome
diagnoses and the point selection may be of importance
regarding the outcome of the treatment.
Acupuncture is one of the most frequently used
complementary therapies in Norway. In two
recent surveys, 28% reported lifetime use, and
10.8% reported use within the previous year.
12
In
the 2002 National Health Interview Survey in the
USA, 4.1% reported lifetime use and 1.1% reported
use of acupuncture within the preceding year.
3
The
theoretical framework, understanding and practice
of acupuncture vary considerably. Traditional
Chinese medicine (TCM) acupuncture is based on
the traditional Chinese medical theories,
4
whereas
‘‘Western medical’’ acupuncture draws on the
principles of established medical physiology.
5
Although TCM is one of the oldest healing systems
in the world, it is a fully institutionalised part of
Chinese healthcare, accounting for 10–20% of
healthcare in China in 2006.
6
Acupuncture is
considered safe in the hands of competent practi-
tioners.
78
A National Institutes of Health Consensus
Development Panel on Acupuncture has recom-
mended that future research should place an
emphasis on ‘‘studies that examine acupuncture
as used in clinical practice and that respect the
theoretical basis for acupuncture therapy’’.
9
Acupuncture researchers have suggested the use
of a pragmatic trial design to answer practical
questions.
10
In the Acuflash study we aimed to
estimate the effectiveness of ‘‘real life’’ acupunc-
ture treatment on postmenopausal hot flush
frequency and intensity and health-related quality
of life as measured by the Women’s Health
Questionnaire (WHQ).
11
Hot flush frequency
decreased by 5.8/24 h in the acupuncture group
(n = 134) and 3.7/24 h in the control group
(n = 133), a difference of 2.1 (p,0.001). Hot flush
intensity decreased by 3.2 units (1–10 visual
analogue scale) in the acupuncture group and 1.8
units in the control group, a difference of 1.4
(p,0.001). The acupuncture group experienced
statistically and clinically significant improvements
in the vasomotor (p,0.001), sleep (p = 0.002) and
somatic symptoms (p = 0.011) dimensions of the
WHQ, compared with the control group.
12
Previous research has suggested that, among
patients with recurrent cystitis, those with TCM
diagnosis of Kidney fare better than patients with
other diagnoses.
13
The objective of this paper is to
report on the TCM syndrome diagnoses and the
acupuncture points used in the Acuflash study. We
report on secondary research questions: do TCM
diagnoses predict the overall treatment response,
and are patients with different diagnoses likely to
experience a differential response in their symp-
toms?We also report on the relation between the
acupuncture points used and the treatment
response, on other treatment interventions used
by the acupuncturists, and on treatment reactions
and adverse events.
METHODS
The study was a multicentre (Tromsø, Bergen and
Oslo), pragmatic, randomised controlled trial
(RCT) with two parallel arms, conducted in
2006/2007. It was approved by the Norwegian
Original paper
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Data Inspectorate, the Norwegian Biobank Registry and the
Regional Committee for Medical Research Ethics.
11
Altogether 267 women were included in the study. Mean
(SD) age at inclusion was 53.8 (4.4) years, and mean (SD) age at
menopause was 48.9 (3.7) years. For further sample character-
istics, see table 1. The participants were stratified by centre and
thereafter block randomised (random block size of four, six or
eight) to receive additional acupuncture or not receive addi-
tional acupuncture. Block randomisation (organising study
participants into blocks and randomising within each block)
was used to ensure close balance of the numbers in each group
at any time during the trial.
Practitioners of TCM acupuncture
The 10 study acupuncturists were trained in TCM acupuncture;
nine were graduates from the ‘‘Akupunkturhøyskolen’’, a school
located in Oslo, offering a Bachelors degree in TCM acupunc-
ture. Hence, the TCM acupuncture approach tested was TCM
acupuncture as taught in Norway. They met the current
membership criteria of the Norwegian Acupuncture Society
(NAFO) (2500 h of training), and had at least 3 years’
experience of practising TCM acupuncture. They were sug-
gested as study acupuncturists by NAFO. Two acupuncturists
were teachers at the ‘‘Akupunkturhøyskolen’’. There were four
acupuncturists in Oslo, three in Bergen and three in Tromsø, all
practising in private clinics. Before the start of the study, all the
acupuncturists participated in a group meeting with the
researchers to discuss the expected TCM diagnoses and the
relevant acupuncture points.
Intervention
Both groups received a one-page leaflet with information about
self-care strategies to relieve menopausal symptoms. This
information included advice about sufficient sleep and rest,
reduction of physical and psychological stress, regular exercise,
healthy food and limited tobacco smoking and alcohol intake.
The participants in the acupuncture group had to receive 10
acupuncture sessions over 12 weeks. The minimum number of
Table 1 Baseline characteristics of the study participants in the Acuflash study
Characteristics Acupuncture group (n= 134) Self-care group (n= 133)
Mean (SD) age at randomisation, years 53.5 (4.4) 54.1 (3.7)
Mean (SD) age at menopause, years 49.3 (4.0) 48.6 (4.9)
Mean (SD) baseline hot flush frequency/24 h 12.0 (4.3) 13.1 (4.9)
Mean (SD) baseline hot flush intensity (0–10) 6.7 (2.0) 7.1 (1.7)
Mean (SD) self-reported weight, kg 71 (12) 70 (12)
Mean (SD) self-reported height, cm 167 (6) 168 (6)
Years of education, n (%)
(10 60 (44.8) 64 (48.1)
11–13 12 (9.0) 13 (9.8)
14–17 31 (23.1) 18 (13.5)
.17 31 (23.1) 36 (27.1)
Missing 0 2 (1.5)
Previous use of HRT, n (%) 71 (53.0) 61 (45.9)
Previous use of acupuncture, n (%) 86 (64.2) 85 (63.9)
Expect acupuncture relieves hot flushes, n (%)
Yes 80 (59.8) 68 (51.1)
No 0 (0) 0 (0)
Uncertain 53 (39.5) 61 (45.9)
Missing 1 (0.7) 4 (3.0)
Self-reported health, n (%)
Very bad 2 (1.5) 3 (2.3)
Bad 31 (23.1) 37 (27.8)
Good 78 (58.2) 74 (55.6)
Excellent 22 (16.4) 16 (12.3)
Missing 1 (0.7) 3 (2.3)
Sleep problems, n (%)
Never 32 (23.9) 33 (24.9)
1–3 nights per month 22 (16.4) 19 (14.3)
Once a week 14 (10.4) 12 (9.0)
.Once a week 66 (49.3) 66 (49.6)
Missing 0 3 (2.3)
Tobacco smoking, n (%)
Present 34 (25.4) 39 (29.3)
Past 67 (50) 53 (39.8)
Never 33 (24.6) 39 (29.3)
Missing 0 2 (1.5)
Teetotaller, n (%) 6 (4.5) 6 (4.5)
Mean (SD) baseline WHQ score
Vasomotor symptoms domain 0.98 (0.09) 0.98 (0.10)
Sleep problems domain 0.57 (0.33) 0.61 (0.32)
Somatic symptoms domain 0.48 (0.26) 0.55 (0.24)
HRT, hormone replacement therapy; WHQ, Women’s Health Questionnaire.
Original paper
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sessions accepted as ‘‘per protocol’’ was six. The acupuncturists
were asked to use diagnostic methods according to the
principles of TCM, and diagnose TCM syndromes associated
with the menopausal symptoms. Only the participants in the
acupuncture group were diagnosed. After the initial diagnosis,
each participant had to be treated with points selected
according to the syndrome diagnosis. The acupuncturists were
free to add individualised points to treat other symptoms
related to the menopause (ie, those included on the WHQ such
as depression, anxiety, insomnia), but not unrelated symptoms.
Point location was not standardised, but left to the acupunc-
turists to decide. They could use moxibustion (warmed needles)
if indicated. Herbal treatment was not allowed during the
study. De qi (a characteristic dull and numb sensation) had to be
obtained, and needle manipulation with even, reducing or re-
enforcing methods could be used.
Outcomes
The primary endpoint was change in mean hot flush frequency
and intensity per 24 h. Participants were defined as responders
if they gained a 50% or greater reduction in hot flush frequency.
Secondary endpoint was health-related quality of life, measured
by the WHQ.
14
The questionnaire consisted of 36 items covering
the following nine domains: depressed mood, somatic symp-
toms, anxiety/fears, vasomotor symptoms, sleep problems,
sexual behaviour, menstrual symptoms, memory/concentra-
tion, and attractiveness. Within each domain, an average score
between 0 and 1 was calculated, where 0 is an indicator of
‘‘good health status’’ and 1 is an indicator of ‘‘poor health
status’’.
15 16
We selected the vasomotor symptoms, sleep
problems and somatic symptoms domains for the present
analysis because the participants in the acupuncture group
reported significant improvements in these domains compared
with the control group.
Statistical analysis
SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA) was used
for all statistical analyses. The subgroup analysis was per
protocol. Differences in change between groups were evaluated
with two-sample t tests and analysis of variance, and x
2
tests
were used for categorical variables. Two-sided p,0.05 was
considered statistically significant.
Data collection form
The data collection form prompted for each of nine specific
TCM syndrome diagnoses, as listed in table 3. The consensus of
the group meeting between acupuncturists and researchers
before the start of the study was to list the syndrome patterns
described by Maciocia as the main causes of menopausal
problems,
17
with the addition of Liver Qi Stagnation and
Stomach Heat. In addition, practitioners were free to diagnose
any other syndrome pattern, without any restrictions. They
were asked to record primary and secondary diagnoses at each
session. Characteristic symptoms and signs in the most
frequently used syndrome diagnoses are listed in table 2.
At each session, practitioners were asked to record acupunc-
ture points used, and indicate laterality of needling, needle
technique, whether de qi was obtained, and reasons for eventual
change of acupuncture points from the previous treatment
session. They were asked to record the use of moxa and use of
other interventions (massage, cupping, electro-acupuncture,
herbs or other). Finally, they had to record the prescription of
home-based self-treatment such as specific physical exercises, tai
chi, yoga, self-massage, relaxation exercises or other.
If the acupuncturist gave advice on facilitating and support-
ing lifestyle changes such as dietary advice (low dairy, avoid
wine and spirits, low wheat, stop/reduce coffee, ensure food is
warm and cooked) or non-dietary advice (more exercise, stop/
reduce smoking, more rest, protection from cold and damp,
general support and empowerment or other), this had to be
recorded.
The acupuncturists were asked to record treatment reactions
and adverse events. Treatment reactions were reactions which
could be positive indicators of treatment effect, but could be
experienced as adverse by acupuncture-naı¨ve participants.
Treatment reactions were communicated spontaneously by
the patient during or after treatment, or at the next visit
(recorded under the headings light-headedness, energised, tired,
relaxed, hungry, drowsy, other). Adverse events such as faint-
ing, forgotten needle, fit (convulsions), broken needle, skin
reactions, moxa burn, unacceptable bruising, pneumothorax,
unacceptable bleeding, infection, unacceptable pain at a point
from needling, unacceptable worsening of symptoms or other,
had to be recorded. These events were listed, and the
acupuncturists could tick the appropriate box.
In addition to the reporting carried out by the acupuncturist,
the women in the acupuncture group were asked in the
questionnaires they filled in at weeks 8 and 12 if they had
experienced any of the following treatment reactions during the
study: temporary worsening of hot flushes, dizziness, tiredness,
increased energy, more relaxed, hungrier.
RESULTS
Between February 2006 and March 2007, 535 women contacted
the study coordinators, and 267 met the inclusion criteria.
12
They were randomised to self-care plus acupuncture (n = 134)
or self-care only (n = 133). Altogether 19 women (7%) dropped
out: 16 in the control group and three in the acupuncture group.
A total of 131 participants in the acupuncture group were
included in the final analyses. The study groups were well
balanced with respect to background characteristics at baseline
(table 1).
At the first acupuncture treatment session, 127 participants
received an initial primary syndrome diagnosis and 106
participants received an initial secondary syndrome diagnosis
(table 3). During the treatment sessions, the primary syndrome
was revised once in 11 participants, and twice in one
participant. The secondary syndrome was revised once in 14
participants, twice in three, three times in three, and four times
in one participant. Fifty per cent of the participants were
diagnosed with Kidney Yin Xu as their primary syndrome
(table 3).
Among the secondary syndromes, Liver Qi stagnation was the
most prevalent diagnosis, with 19 per cent of the participants.
The distribution of responders/non-responders and change in
WHQ scores among primary syndromes are shown in tables 4
and 5. The distribution of responders and non-responders and
change in WHQ scores did not differ statistically between the
primary syndrome groups.
Altogether 131 participants received a total of 1285 treatment
sessions. Of these participants, 123 received 10 treatment
sessions, two received nine sessions, three received eight
sessions, one received seven sessions and two received three
sessions. The mean number of treatments per participant was
9.8, and the median number of points stimulated per treatment
session was 6.0 (SD 2.8, range 9). A total of 8599 acupuncture
Original paper
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point stimulations were performed during the study, and a total
of 104 different acupuncture points were used once or more.
The most commonly used acupuncture points are presented in
fig 1 and table 6.
In the acupuncture group, 67 participants were responders,
and 64 participants were non-responders. A total of 4217 point
stimulations were performed among responders, and 4382
among non-responders. The 10 most frequently used points
were identical among responders and non-responders (table 6),
and these 10 points constituted two-thirds of the total number
of point stimulations throughout the study. The distribution of
points used according to syndrome diagnosis is shown in table 7.
The eight most frequently used acupuncture points in total
were among the 13 most frequently used points in every
syndrome group.
Moxa was used in one treatment session during the study.
Cupping, electro-acupuncture and Chinese herbs were not used
at all. One of the 10 acupuncturists used massage in addition to
needling in altogether 191 treatment sessions. Due to a
significant number of missing values, we do not report on
acupuncture point laterality, needling technique, reasons for
eventual change of acupuncture points or if de qi was obtained.
The acupuncturists advised 13 participants to use massage as
a home-based self-treatment, six participants to use relaxation
techniques, and one was advised to use tai chi. They advised five
participants to use a low dairy diet, two to use a low wheat diet,
nine to ensure the food was warm and cooked, five to quit
tobacco smoking, 11 to take more exercise, nine to take more
rest, seven to avoid alcohol, and 15 to reduce coffee drinking.
One participant was advised protection from cold and damp.
Eighty-four participants were not given any of these recom-
mendations.
Treatment reactions as reported by the acupuncturists and
self-reported by the participants are shown in table 8. The
acupuncturists reported one or more treatment reactions for 76
participants, and 120 participants self-reported one or more
treatment reactions.
The distribution of responders and non-responders and
change in health-related quality of life did not differ between
the groups that were reported to experience these treatment
reactions by the acupuncturists, and those that were not.
Regarding the self-reported treatment reactions, it was an equal
number of responders and non-responders within the groups
experiencing these symptoms. However, the mean reduction in
the WHQ vasomotor symptoms domain score from baseline to
week 12 was significantly larger in the groups that had felt more
relaxed and experienced increased energy, and the mean
reduction in the WHQ sleep domain score was significantly
larger in the group that had felt more relaxed (table 9). Change
in health-related quality of life did not differ between those
experiencing and not experiencing the other treatment reac-
tions.
No fainting, convulsions or bleeding were reported during the
treatment sessions. One skin reaction and one unacceptable
bruising were reported, as were five episodes of unacceptable
needling pain. Two episodes with a forgotten needle were
reported, but no broken needle, moxa burn, pneumothorax or
infections were reported.
DISCUSSION
In this study of acupuncture for menopausal hot flushes, seven
different primary TCM syndromes were diagnosed (table 3),
and 50 per cent of the participants in the study were diagnosed
with Kidney Yin Xu. Distribution of responders and non-
responders and change in health-related quality of life did not
differ between the TCM syndromes. The most frequently used
acupuncture points were identical among responders and non-
responders, and the eight most frequently used acupuncture
Table 2 Characteristic symptoms and signs in the most frequently used syndrome diagnoses in the Acuflash
study
Syndromes Symptoms and signs
KI Yin Xu empty heat Night sweating; hot flushes; restless; anxious; dry hair, skin, mouth; deep
weak pulse; tongue red without coating
KI Yang Xu empty cold Hot flushes but cold hands and feet; night sweating (early morning); tiredness;
low energy; depressed; deep pulse; tongue pale
KI Yin and KI Yang Xu Hot flushes but cold hands and feet; night sweating; frequent pale urination;
flushed around neck when talking; tongue pale or red
KI and LR Yin Xu with LR yang rising Hot flushes; irritability; dizziness; blurred vision; tongue red without coating
KI and HT not harmonised Hot flushes; palpitations; insomnia; mental restlessness; poor memory;
tongue red without coating, redder tip
Table 3 Primary and secondary traditional Chinese medicine
syndromes on initial diagnoses in the Acuflash study
Syndromes
n as primary
(%)
n as secondary
(%)
KI Yin Xu empty heat 67 (50) 17 (13)
KI Yang Xu empty cold 22 (16) 10 (7)
KI Yin and KI Yang Xu 11 (8) 8 (6)
KI and LR Yin Xu with LR yang rising 10 (8) 12 (9)
KI and HT not harmonised 14 (10) 18 (13)
Accumulation of phlegm and stagnation of Qi 1 (1) 12 (9)
LR Qi stagnation 0 (0) 25 (19)
Stomach heat 2 (2) 3 (2)
Stasis of blood 0 (0) 1 (1)
Missing 3 (2) 3 (2)
No syndrome 4 (3) 25 (19)
Total 134 (100) 134 (100)
Table 4 Distribution of responders and non-responders among primary
syndromes in the Acuflash study
Primary syndromes n Responder
Non-
responder
KI Yin Xu empty heat 67 33 34
KI Yang Xu empty cold 22 14 8
KI Yin and KI Yang Xu 11 5 6
KI and LR Yin Xu with LR yang rising 10 5 5
KI and HT not harmonised 14 6 8
Other syndromes 3 1 2
No primary syndrome 4 3 1
Total 131 67 64
Original paper
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points in total were among the 13 most frequently used points
among all TCM syndromes. No serious adverse events were
reported.
The primary goal for the TCM diagnostic process is to obtain
a TCM syndrome diagnosis. This is a procedural process that
may open up for constructive dialogue between the acupunc-
turist and the patient. It can introduce the patients for ways to
reflect and understand their own disease/imbalance.
The diagnostic syndromes in TCM are clusters of different
symptoms and signs. Symptom clusters were used to diagnose
most diseases in Western medicine before the twentieth
century, and Western medicine still uses symptom diagnoses
when the biological mechanisms are not well understood.
18
The
concept of symptom clusters has gained new interest in
Western medicine, and a symptom cluster has been defined as
a ‘‘stable group of two or more concurrent symptoms that are
related to each other and independent of other symptoms or
symptoms clusters’’.
19
The TCM diagnostic process divides
individuals diagnosed with one biomedical diagnosis into several
subgroups, each with a characteristic symptom cluster or
syndrome. This process may contribute to new insight, for
instance by identifying subgroups of individuals responding
particularly well to an intervention or treatment.
The TCM syndrome diagnosis, defined by symptoms and
signs, is guiding the treatment.
6
Fifty per cent of the
participants in the study were diagnosed with Kidney Yin Xu.
According to a widely used TCM textbook by Maciocia, a
Kidney deficiency is always at the root of menopausal
problems.
17
Zell et al found that ‘‘practitioners of TCM who
diagnose postmenopausal women with vasomotor symptoms
are likely to make a diagnosis that includes Kidney Yin
deficiency’’.
20
However, Scheid defines TCM as ‘‘that inter-
pretation of Chinese medical practice that is presented to us in
contemporary Chinese medical textbooks, emerging in the late
1950s’’.
21
Menopausal problems, as such, have not been
described in ancient Chinese medical texts, but a TCM
approach towards menopausal symptoms was ‘‘constructed’’
by textbook authors in the 1960s for use in textbooks suitable
for a Western audience.
21 22
According to Scheid, the TCM
understanding of menopausal symptoms, like TCM itself, is a
direct consequence of Chinese medical modernisation.
Practitioners in contemporary China have, in addition to the
above-mentioned modern textbooks, other sources of informa-
tion to draw on, such as direct access to the classical medical
texts and personal transmission of knowledge from teachers.
21
These sources are not readily available in the West, and may
suggest different syndrome patterns and point selection for the
treatment of menopausal symptoms.
21
Thus, the current
interpretation of menopausal symptoms as mainly a result of
Kidney deficiency is only one of several possible understandings,
and the correct TCM diagnoses for menopausal vasomotor
symptoms remain unclear. The TCM acupuncture practised in
our study was mostly based on theories and principles from the
above-mentioned textbooks from the 1960s and a more recent
interpretation by Maciocia.
17
The validity and reliability of the TCM diagnostic process has
been questioned, as has the inter-rater reliability.
23
A study
showed that TCM diagnosis and treatment recommendations
for specific patients with chronic low back pain vary widely
across practitioners,
24
as did a study assessing the variability in
the TCM diagnoses among patients with rheumatoid arthritis.
25
Therefore, the validity and reliability of the diagnostic process
in the present study may be low, resulting in ‘‘wrong’’ diagnoses
in some or many cases. In addition, as discussed earlier, the
correct TCM syndrome patterns for menopausal vasomotor
symptoms remain unclear. These facts may obviously affect the
study results, which must be interpreted with this in mind.
When stratifying the results on syndromes, we found the
highest proportion of responders among the participants
diagnosed with Kidney Yang Xu empty cold; 14 participants
were responders and eight non-responders. This is comparable
to what was found in a study of acupuncture for recurrent
cystitis by Alraek and Baerheim.
13
However, our study was not
powered to identify differences between the syndrome groups.
The differences regarding the ratio of responders to non-
responders or change in WHQ scores between the syndrome
groups were not statistically significant. Hence, being diagnosed
with a certain syndrome was of no prognostic value for patients
treated with acupuncture for menopausal complaints in this
study. The acupuncture points used in this syndrome group did
not differ from those used in the other syndrome groups, nor
did the points differ between responders and non-responders.
Table 5 Change in Women’s Health Questionnaire (WHQ) scores in the vasomotor symptoms, sleep
problems and somatic symptoms domains stratified on primary syndromes in the Acuflash study
Primary syndromes
Change in WHQ
vasomotor domain
Change in WHQ sleep
domain
Change in WHQ somatic
domain
KI Yin Xu empty heat (n= 67) 20.32 20.17 20.10
KI Yang Xu empty cold (n= 22) 20.15 20.20 20.14
KI Yin and KI Yang Xu (n = 11) 20.23 20.03 20.10
KI and LR Yin Xu with LR yang rising (n = 10) 20.20 20.23 20.31
KI and HT not harmonised (n = 14) 20.29 20.17 20.08
Figure 1 Most commonly used acupuncture points in the Acuflash
study*. *Usage as percentage of total number of treatments (n =1285).
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The participants in the control group were not diagnosed
according to TCM; hence we were not able to assess whether
certain TCM syndrome patterns were generally more responsive
regardless of whether acupuncture was provided.
The distribution of points used according to syndrome
diagnosis is shown in table 7. Although the acupuncturists
have applied different TCM diagnostic syndromes, eight ‘‘core’’
acupuncture points were used in all syndromes, with some
differences regarding frequency of use. A possible reason for the
application of eight ‘‘core’’ points in all syndromes may be that
the points were used for ‘‘symptomatic’’ treatment of hot
flushes, rather than addressing the TCM syndromes. However,
the acupuncturists were asked to select acupuncture points and
treat according to the syndrome diagnoses, and the majority of
‘‘core’’ points are described in a TCM textbook
17
as indicated for
KI Xu (Kidney deficiency) syndromes (SP6, KI3 – nourish the
Kidneys, KI7 – tonifies Kidney Yang, LU7 and KI6 – tonifies the
Kidneys, CV4 – tonifies Kidney Yang). Thus, a TCM syndrome
differentiation may not result in major differences regarding the
selection of acupuncture points when treating women with
postmenopausal vasomotor symptoms.
There was no difference between responders and non-
responders regarding the acupuncture points used or their
frequency of use. The point combination KI7–HT6 was
frequently used throughout the study, regardless of the
syndrome diagnosis. This point combination is described in
the literature as indicated for the treatment of menopausal
complaints, or more specifically to stop night sweating,
17
and
Table 6 Acupuncture points used in the Acuflash study
Responders* (n = 67) Non-responders* (n = 64)
Acupuncture
points
Number of
stimulations
Per cent of
total
Cumulative
per cent
Acupuncture
points
Number of
stimulations
Per cent of
total
Cumulative
per cent
SP6 424 10.1 10.1 SP6 390 8.9 8.9
HT6 419 9.9 20.0 KI6 368 8.4 17.3
KI7 416 9.9 29.9 KI7 359 8.2 25.5
KI6 291 6.9 36.8 HT6 336 7.7 33.2
CV4 262 6.2 43.0 CV4 313 7.1 40.3
LU7 260 6.2 49.1 LU7 293 6.7 47.0
LI4 199 4.7 53.9 LI4 227 5.2 52.2
LR3 196 4.6 58.5 LR3 219 5.0 57.2
ST36 177 4.2 62.7 KI3 193 4.4 61.6
KI3 173 4.1 66.8 ST36 171 3.9 65.5
GV20 115 2.7 69.5 GB34 119 2.7 68.2
LI11 109 2.6 72.1 PC6 96 2.2 70.4
PC6 106 2.5 74.6 GV20 95 2.2 72.5
CV12 94 2.2 76.9 CV12 85 1.9 74.5
SP4 91 2.2 79.0 LI11 79 1.8 76.3
LR8 78 1.8 80.9 LR8 64 1.5 77.7
GB34 73 1.7 82.6 SP4 62 1.4 79.2
68 other points{734 17.4 100.0 65 other points{913 20.8 100.0
Total 4217 4382
The eight most frequently stimulated acupuncture points in total are shown in bold.
*Responder: >50% reduction in hot flush frequency, non-responder: ,50% reduction of hot flush frequency.
{32 points were stimulated 59–10 times, 36 points were stimulated ,10 times.
{26 points were stimulated 59–10 times, 39 points were stimulated ,10 times.
Table 7 Acupuncture points used according to syndrome diagnosis in the Acuflash study*
KI Yin Xu empty heat (n = 69)
KI Yang Xu empty cold
(n = 22)
KI Yin and KI Yang Xu
(n = 11)
KI and LR Yin Xu with LR yang
rising (n = 10)
KI and HT not harmonised
(n = 14)
Acupuncture
points*
No of
stimulations{
Acupuncture
points
No of
stimulations
Acupuncture
points
No of
stimulations
Acupuncture
points
No of
stimulations
Acupuncture
points
No of
stimulations
SP6 6.3 SP6 7.1 KI7 6.5 CV4 6.0 CV4 7.8
KI7 5.7 KI7 6.5 HT6 5.4 LR8 5.0 KI6 7.6
HT6 5.5 HT6 6.4 SP6 5.2 HT6 4.7 KI7 7.1
KI6 5.1 KI6 5.0 LR3 3.5 KI7 4.0 SP6 7.1
CV4 4.3 LU7 4.6 CV4 3.4 LR3 3.9 LU7 6.9
LU7 4.1 LI4 2.6 KI3 3.3 KI6 3.8 HT6 6.6
KI3 3.7 CV4 2.4 LU7 3.3 LI11 3.8 CV15 4.1
LI4 3.6 ST36 2.3 KI6 3.0 SP4 3.8 LR3 3.8
ST36 3.3 PC6 2.1 CV12 1.8 LI4 3.5 LI4 3.7
LR3 3.3 LR3 2.0 GV20 1.7 GV20 3.4 GV20 2.3
GB34 1.9 SP4 1.8 LI4 1.6 PC6 3.1 KI3 1.9
LI11 1.5 KI3 1.7 ST36 1.6 LU7 3.0 SP4 1.9
CV12 1.3 CV12 1.5 KI10 1.5 SP6 2.9 HT7 1.9
66 other points 15.1 34 other points 13.3 32 other points 15.8 28 other points 24.5 32 other points 18.4
*The eight most frequently stimulated acupuncture points in total are shown in bold.
{Mean number of stimulations per participant.
Original paper
106 Acupunct Med 2009;27:101–108. doi:10.1136/aim.2009.000612
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may have been used as ‘‘symptomatic’’ treatment in this study.
The points selected and their frequency of use were almost
similar among responders and non-responders. Hence, when
treated with almost identical points, 50% of the participants in
this study were responders, and 50% were non-responders. A
more flexible approach, resulting in the selection of other
acupuncture points for the treatment of women in the non-
responder group, might have produced other results. Another
possible interpretation of these results may be that factors other
than the acupuncture point selection are of importance for the
outcome of the treatment.
The 10 most frequently used acupuncture points constituted
two-thirds of all point stimulations, and a total of 104 different
acupuncture points were used once or more. Hence, the
acupuncturists used a ‘‘core’’ of common acupuncture points
in all syndromes and in addition to these a wide selection of
idiosyncratic points. These findings correspond with the
findings by Napadow et al, studying the points used in two
acupuncture clinics in China.
26
When comparing the point
selection in this study with the points used in other studies
evaluating acupuncture for menopausal symptoms,
27–32
the only
point in common between all the studies was SP6. The
agreement between the eight most frequently stimulated points
in this study and the basic acupuncture points used in the
studies cited was moderate, and varied between two of nine
points,
28 31
and two of three
30
and four of six.
27
A TCM diagnostic syndrome differentiation, leading to an
appropriate selection of traditional acupuncture points, is
considered mandatory in the practice of TCM.
6
However, these
postulates have not been confirmed in clinical studies.
6
Cochrane reviews show that acupuncture is an effective
treatment for preventing headaches, but for migraine, studies
show similar results in groups receiving ‘‘true’’ acupuncture and
groups receiving ‘‘sham’’ acupuncture (‘‘interventions mimick-
ing ‘true’ acupuncture/‘true’ treatment, but deviating in at least
one aspect considered important by acupuncture theory, such as
skin penetration or correct point location’’).
33 34
Superficial
needling in non-acupuncture points (‘‘minimal acupuncture’’),
often used as a placebo control in RCTs of acupuncture, most
likely has physiological and clinical effects.
35
In the Acuflash
study, a ‘‘core’’ group of acupuncture points was used for all the
TCM diagnostic syndromes, rendering a clinically and statisti-
cally significant effect.
12
However, we do not know whether
these acupuncture points were superior to treat menopausal
symptoms, nor if the acupuncture ‘‘dose’’ was optimal. The
contribution of all the idiosyncratic acupuncture points used a
few times during the study remains unknown. Needle location
may not be as relevant as generally thought.
There is no agreement on what is adequate acupuncture point
stimulation or ‘‘dose’’.
36
In a systematic review of acupuncture
for knee pain, adequate acupuncture was defined as ‘‘consisting
of at least six treatments, at least one per week, with at least
four points needled for each painful knee for at least
20 minutes, and either needle sensation (de qi) achieved in
manual acupuncture, or electrical stimulation of sufficient
intensity to produce more than minimal sensation’’.
37
The
acupuncture treatment in the present study satisfied these
requirements.
The participants who felt more relaxed after treatment
experienced a larger decrease in the WHQ vasomotor symptoms
and sleep problems domains, and the participants feeling more
energised experienced a larger decrease in the WHQ vasomotor
symptoms domain. Consequently, both feeling relaxed and
energised after acupuncture treatment is associated with a
positive response on acupuncture therapy for menopausal
symptoms. However, there were equal numbers of responders
and non-responders within the groups experiencing these
treatment reactions.
Acupuncture is described as a safe procedure, with few
adverse events occurring among trained practitioners.
73839
In
this study, five episodes with unacceptable pain during needle
insertion, one episode with unacceptable bruising, two episodes
with a forgotten needle and one skin reaction were reported.
Altogether nine events classified as side effects were reported,
and a total of 1285 treatments were performed during the
study. Hence, the frequency of adverse events per treatment
was less than one per cent, confirming that TCM acupuncture
is a safe procedure. No serious adverse events were reported.
Table 8 Number of participants in the acupuncture group (n = 134) experiencing treatment reactions as
reported by acupuncturists and self-reported by participants
Treatment
reactions
More
relaxed
More
energy
More
tired
More
hungry
Light-
headed{Drowsy{
Temporary
worsening of
hot flushes* Dizziness*
Reported by
acupuncturists
44 39 30 7 11 7 – –
Self-reported 86 76 53 24 – – 26 13
*The acupuncturists were not asked to report these treatment reactions.
{The participants were not asked to report these treatment reactions.
Table 9 Change in Women’s Health Questionnaire (WHQ) scores in groups reporting treatment reactions at
12 weeks
More relaxed* (n = 86) Increased energy* (n = 76)
WHQ
dimensions Yes No
Mean
difference p Value Yes No
Mean
difference p Value
Vasomotor
symptoms
20.36 (0.40) 20.13 (0.31) 20.23 0.004 20.35 (0.39) 20.20 (0.39) 20.15 0.045
Sleep
problems
20.21 (0.35) 20.05 (0.39) 20.16 0.033 20.18 (0.38) 20.15 (0.34) 20.03 0.64
*Values are mean change in WHQ score from baseline to 12 weeks (SD).
Original paper
Acupunct Med 2009;27:101–108. doi:10.1136/aim.2009.000612 107
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CONCLUSION
The Acuflash study showed that TCM acupuncture as practised
in Norway in addition to self-care can contribute to a clinically
relevant reduction of hot flushes. The results did not differ
between the TCM syndrome groups, and there were no major
differences in point selection and frequency of use between
responders and non-responders. Factors other than the TCM
syndrome diagnoses and the point selection may be of
importance regarding the outcome of the treatment.
Funding: This work was supported by The Research Council of Norway. The principal
investigator was funded by the University Hospital of North Norway.
Competing interests: Adrian White is employed by the British Medical Acupuncture
Society as journal editor. Other authors declare no competing interests.
Ethics approval: Approved by the Norwegian Data Inspectorate, the Norwegian
Biobank Registry and the Regional Committee for Medical Research Ethics.
Editorial handling: In view of the third author’s conflict of interest as editor of this
journal, all editorial handling and decisions about acceptance of this article were
carried out by Simon Hayhoe on behalf of the editorial board.
Provenance and peer review: Not commissioned; externally peer reviewed.
REFERENCES
1. Launso L, Bessesen T, Nilsen T, et al.Bruk av alternativ behandling i Norge. Tromsø:
NIFAB. http://www.nifab.no/content/download/15907/88616/file/
NIFAB%20NAFKAM%20rapport%20brukerundersøkelse.pdf. 2007 (accessed 23 Jan
2009).
2. Norwegian Acupuncture Society (NAFO). Befolkningsundersøkelse om akupunktur.
Oslo: NAFO, 2006.
3. Burke A, Upchurch DM, Dye C, et al. Acupuncture use in the United States:
findings from the National Health Interview Survey. J Altern Complement Med
2006;12:639–48.
4. Kaptchuk TJ. Acupuncture: Theory, efficacy, and practice. Ann Intern Med
2002;136:374–83.
5. Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application.
Biol Psychiatry 1998;44:129–38.
6. Tang JL, Liu BY, Ma KW. Traditional Chinese medicine. Lancet 2008;372:1938–40.
7. Vincent C. The safety of acupuncture. BMJ 2001;323:467–8.
8. Norheim AJ. Adverse effects of acupuncture: a study of the literature for the years
1981–1994. J Altern Complement Med 1996;2:291–7.
9. NIH Consensus Conference. Acupuncture. JAMA 1998;280:1518–24.
10. MacPherson H. Acupuncture research: Time to shift from theoretical to practical
questions. J Altern Complement Med 2006;12:837–9.
11. Borud EK, Alraek T, White A, et al. The effect of TCM acupuncture on hot flushes
among menopausal women (ACUFLASH) study: a study protocol of an ongoing multi-
centre randomised controlled clinical trial. BMC Complement Altern Med 2007;7:6.
12. Borud EK, Alraek T, White A, et al. The Acupuncture on Hot Flushes Among
Menopausal Women (ACUFLASH) study, a randomized controlled trial. Menopause
2009;16:484–93.
13. Alraek T, Baerheim A. The effect of prophylactic acupuncture treatment in women
with recurrent cystitis: kidney patients fare better. J Altern Complement Med
2003;9:651–8.
14. Borud EK, Martinussen M, Eggen AE, et al. The Women’s Health Questionnaire
(WHQ): a psychometric evaluation of the 36-item Norwegian version. Scand J Psychol
2009;50:183–9.
15. Hunter M. The Women’s Health Questionnaire (WHQ): The development,
standardization and application of a measure of mid-aged women’s emotional and
physical health. Qual Life Res 2000;9:733–8.
16. Hunter MS. The Women’s Health Questionnaire (WHQ): Frequently Asked Questions
(FAQ). Health Qual Life Outcomes 2003;1:41.
17. Maciocia G. Obstetrics & gynecology in Chinese medicine. 1 edn. Edinburgh: Churchill
Livingstone, 1998:741–62.
18. Aronowitz RA. When do symptoms become a disease? Ann Intern Med
2001;134:803–8.
19. Kim HJ, McGuire DB, Tulman L, et al. Symptom clusters: concept analysis and clinical
implications for cancer nursing. Cancer Nurs 2005;28:270–82.
20. Zell B, Hirata J, Marcus A, et al. Diagnosis of symptomatic postmenopausal women
by traditional Chinese medicine practitioners. Menopause 2000;7:129–34.
21. Scheid V. Traditional Chinese medicine—what are we investigating? The case of
menopause. Complement Ther Med 2007;15:54–68.
22. Chengdu College of Chinese Medicine (Chengdu Zhongyi Xueyuan), ed. Zhongyi
fukexue jiangyi [Lecture Notes for Chinese Medicine Gynaecology]. Shanghai:
Shanghai kexue jishu chubanshe, 1964.
23. Zhang GG, Bausell B, Lao L, et al. Assessing the consistency of traditional Chinese
medical diagnosis: an integrative approach. Altern Ther Health Med 2003;9:66–71.
24. Hogeboom CJ, Sherman KJ, Cherkin DC. Variation in diagnosis and treatment of
chronic low back pain by traditional Chinese medicine acupuncturists. Complement
Ther Med 2001;9:154–66.
25. Zhang GG, Lee WL, Lao L, et al. The variability of TCM pattern diagnosis and herbal
prescription on rheumatoid arthritis patients. Altern Ther Health Med 2004;10:58–63.
26. Napadow V, Liu J, Kaptchuk TJ. A systematic study of acupuncture practice:
acupoint usage in an outpatient setting in Beijing, China. Complement Ther Med
2004;12:209–16.
27. Avis NE, Legault C, Coeytaux RR, et al. A randomized, controlled pilot study of
acupuncture treatment for menopausal hot flashes. Menopause 2008;15:1070–8.
28. Cohen SM, Rousseau ME, Carey BL. Can acupuncture ease the symptoms of
menopause? Holist Nurs Pract 2003;17:295–9.
29. Dong H, Ludicke F, Comte I, et al. An exploratory pilot study of acupuncture on the
quality of life and reproductive hormone secretion in menopausal women. J Altern
Complement Med 2001;7:651–8.
30. Nir Y, Huang MI, Schnyer R, et al. Acupuncture for postmenopausal hot flashes.
Maturitas 2007;56:383–95.
31. Sandberg M, Wijma K, Wyon Y, et al. Effects of electro-acupuncture on psychological
distress in postmenopausal women. Complement Ther Med 2002;10:161–9.
32. Vincent A, Barton DL, Mandrekar JN, et al. Acupuncture for hot flashes: a
randomized, sham-controlled clinical study. Menopause 2007;14:45–52.
33. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache.
Cochrane Database Syst Rev 2009:CD007587.
34. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane
Database Syst Rev 2009:CD001218.
35. Lund I, Naslund J, Lundeberg T. Minimal acupuncture is not a valid placebo control in
randomised controlled trials of acupuncture: a physiologist’s perspective. Chin Med
2009;4:1.
36. White A, Cummings M, Barlas P, et al. Defining an adequate dose of acupuncture
using a neurophysiological approach—a narrative review of the literature. Acupunct
Med 2008;26:111–20.
37. White A, Foster NE, Cummings M, et al. Acupuncture treatment for chronic knee
pain: a systematic review. Rheumatology (Oxford) 2007;46:384–90.
38. MacPherson H, Thomas K, Walters S, et al. The York acupuncture safety study:
prospective survey of 34 000 treatments by traditional acupuncturists. BMJ
2001;323:486–7.
39. White A, Hayhoe S, Hart A, et al. Adverse events following acupuncture: prospective
survey of 32 000 consultations with doctors and physiotherapists. BMJ
2001;323:485–6.
Original paper
108 Acupunct Med 2009;27:101–108. doi:10.1136/aim.2009.000612
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doi: 10.1136/aim.2009.000612
2009 27: 101-108Acupunct Med
Einar Kristian Borud, Terje Alræk, Adrian White, et al.
and their relation to the treatment response
diagnoses and acupuncture points used,
study: traditional Chinese medicine
postmenopausal hot flushes (Acuflash)
The acupuncture treatment for
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