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Original paper
Schroeder S, Meyer-Hamme G, Epplée S. Acupunct Med (2011). doi:10.1136/acupmed-2011-010034 1 of 4
ABSTRACT
Objectives Chemotherapy-induced peripheral
neuropathy (CIPN) can produce severe neurological
defi cits and neuropathic pain and is a potential
reason for terminating or suspending chemotherapy
treatments. Specifi c and effective curative
treatments are lacking.
Methods A pilot study was conducted to evaluate
the therapeutic effect of acupuncture on CIPN as
measured by changes in nerve conduction studies
(NCS) in six patients treated with acupuncture for
10 weeks in addition to best medical care and fi ve
control patients who received the best medical
care but no specifi c treatment for CIPN.
Results In fi ve of the six patients treated with
acupuncture, NCS improved after treatment. In the
control group, three of fi ve patients did not show any
difference in NCS, one patient improved and one
showed impaired NCS.
Conclusion The data suggest that acupuncture has
a positive effect on CIPN. The encouraging results of
this pilot study justify a randomised controlled trial of
acupuncture in CIPN on the basis of NCS.
INTRODUCTION
Chemotherapy-induced peripheral neuropa-
thy (CIPN) involves damage to the peripheral
nervous system and can produce severe neu-
ropathic pain or gait impairment and may be
a reason to terminate or suspend chemother-
apy treatments. Specifi c and effective curative
treatments are lacking. The major groups of
drugs that induce CIPN include the taxanes,
vinca alkaloids and platinum compounds. The
incidence of CIPN is high and can reach levels
of up to 92%.
1
Publications in English language journals on
acupuncture as a symptomatic treatment for
CIPN have been limited to only a few case
studies, all of which report an improvement
in symptoms.
2 3
A Chinese study described
acupuncture as more effective than cobama-
mide for the treatment of sensory symptoms
in paclitaxel-induced CIPN.
4
We conducted a pilot study in 2006 in 192
patients with peripheral neuropathy diag-
nosed on the basis of nerve conduction studies
(NCS). Patients were evaluated over a period
of 1 year, measured by NCS. The aim of this
Acupuncture for chemotherapy-induced peripheral
neuropathy (CIPN): a pilot study using neurography
Sven Schroeder
1,2,
, Gesa Meyer-Hamme
1
, Susanne Epplée
1
1
HanseMerkur Center for TCM
at the University Medical
Centre, Hamburg, Germany
2
Department of
Neurophysiology, Instituto de
Ciências Biomédicas, Abel
Salazar, University of Porto,
Porto, Portugal
Correspondence to
Sven Schroeder, HanseMerkur
Centre for TCM at the University
Medical Center, UKE-Campus,
House O55, Martinistrasse 52,
20246, Hamburg, Germany;
schroeder@tcm-am-uke.de
Received 22 May 2011
Accepted 11 October 2011
non-randomised non-blinded study was to
determine whether there is evidence of effec-
tive treatment of peripheral neuropathy (PN)
with acupuncture assessed by objective mea-
surements and whether further prospective
studies on the basis of the above criteria are
warranted. We have previously published
data on the treatment of PN of unknown aeti-
ology and diabetic neuropathy with acupunc-
ture, and found an improvement in NCS in
76% of patients after a treatment period of
10 weeks, one treatment per week.
5 6
In this
paper we report our results in patients with
CIPN.
METHODS
A total of 192 consecutive patients with PN of
the lower extremities were diagnosed by NCS
and treated in a neurologist’s outpatient clinic
for a period of 1 year. Patients with PN con-
fi rmed by neurological examination and NCS
were included in the study. Patients with alco-
hol abuse, drug usage, a history of diabetes,
toxic drugs (except a history of chemother-
apy) or infl ammatory disease documented as
underlying causes for PN were excluded from
the study. This was confi rmed by standard
screening.
5
Of this group, 11 patients had developed
symptoms of PN during the course of chemo-
therapy and were identifi ed as having CIPN.
Chemotherapy had been given for different
types of cancer (table 1).
Acupuncture treatment was offered to all
the patients with CIPN. Six patients agreed
to receive acupuncture treatment and fi ve
refused owing to personal inconvenience of
the appointments offered. These fi ve patients
(four men, one woman) of mean age 65 years
who received the best medical care but no spe-
cifi c treatment for PN thus served as a control
group. Six patients (three men, three women)
of mean age 64 years received the best medi-
cal care and additionally were treated with
acupuncture for PN of the lower extremities.
Patients in both groups did not receive any
other treatment for PN except stable doses
of carbamazepine or pregabalin during the
observation period. The characteristics of the
acupuncture and control groups are shown in
table 1.
Copyright 2011 by British Medical Journal Publishing Group.
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Original paper
Schroeder S, Meyer-Hamme G, Epplée S. Acupunct Med (2011). doi:10.1136/acupmed-2011-0100342 of 4
Measurements of nerve conduction velocity (NCV)
were performed with a Neuropack-Sigma, MEB-9400,
EMG/NCV/EP-System (Nihon-Khoden, Tokyo, Japan).
The amplitudes of the motor and sensory responses were
measured to the fi rst negative peak. All studies of NCV
were done at room temperature (22–24°C). Skin tempera-
ture was measured at the sites of sensory nerve measure-
ments and values were analysed, adjusting for the effects
of temperature. Follow-up NCS data were collected after a
period of 6 months (±2 weeks) by examination of the sural
and tibial nerves in the same calf as in the initial assess-
ment. Standard orthodromic needle recording methods
were used for sural nerve assessment while standard sur-
face recording methods were used for tibial nerve record-
ings.
7 8
A change in NCV in the sural nerve of 2 m/s slower
or faster than the initial measurement was considered sig-
nifi cant. A change in the amplitude of the sensory nerve
action potential of more than 2 µV was defi ned as a signifi -
cant impairment or improvement in the sural nerve.
The patients were asked at the time of the second
NCS to tick one box to indicate whether their condition
had improved, worsened or remained unchanged.
Acupuncture treatment was based on a neurophysi-
ologcial approach to traditional Chinese medicine (TCM)
theory.
9
Point selection followed the training curriculum
at the TCM-Master Education at the Instituto de Ciências
Biomédicas Abel Salazar, University of Porto, Portugal.
The specifi c acupuncture protocols employed in this
study are described below, point location and depth of
insertion were as described in standard textbooks
10
and
disposable sterile steel needles of 0.30×30 mm were used
and left in place for 20 min to a depth of 10–30 mm. Each
patient received a standard 10-week treatment of the
ST34 (Liangqiu) as well as the fi ve extra points EX–LE12
(Qiduan) and the four extra points EX–LE8 (Bafeng). The
needles were inserted bilaterally. Twenty needles were
inserted per session. Needle stimulation techniques were
not used. We did not employ manipulation in order to
elicit a de qi sensation. Acupuncture was performed in
all cases by the same senior physician who had received
>1000 h of acupuncture training before participating in
the trial and had used acupuncture for 20 years. The six
patients in the acupuncture group were examined by NCS
2–21 months (mean 10.3) after chemotherapy. NCS was
performed before treatment and again 6 months later (ie,
3 months (±2 weeks) after the end of treatment).
The fi ve patients in the control group were examined
by NCS 1–14 months (mean 10.8) after chemotherapy and
routinely again at 6 months.
RESULTS
All six patients in the acupuncture group had hypoesthesia
in a stocking distribution; three had additional neuropathic
pain. There was no clinical motor involvement and no
motor involvement in NCS. NCS showed mixed damage of
the axon and the myelin sheath of the sensory sural nerve
in all six acupuncture-treated patients. All fi ve patients in
the control group had hypoesthesia in a stocking contri-
bution; three had additional neuropathic pain. There was
no clinical motor involvement and no motor involvement
in NCS. NCS revealed mixed damage to the axon and
myelin sheath of the sensitive sural nerve in two patients
in the control group while three had pure axonopathy. The
results of the NCS of the sural nerve as well as the subjec-
tive outcomes are shown in table 2. A comparison of the
mean values for the two groups is shown in table 3.
DISCUSSION
This pilot study shows improvement in NCS after acu-
puncture treatment in CIPN. The use of NCS as an
Table 1 Cancer types and chemotherapy of patients with
chemotherapy-induced peripheral neuropathy
Patient groups Chemotherapy
Acupunture group
Breast Docetaxel/doxorubicin/cyclophosphamide
Colon Oxaliplatin
Colon (sigmoid) Cisplatin
Bronchial Cisplatin
Lymphoma Rituximab/fl udarabin/cyclophosphamide
Lymphoma Rituximab/fl udarabin/cyclophosphamide
Control group
Breast Docetaxel/doxorubicin/cyclophosphamide
Colon (sigmoid) Oxaliplatin
Colon 5-fl uorouracil/oxaliplatin
Pleura mesothelioma Alimta/cisplatin
Lymphoma Rituximab/fl udarabin/cyclophosphamide
Table 2 Nerve conduction studies of the sural nerve and subjective outcome in acupuncture-treated and control groups
Acupuncture (10 treatments over 3 months) Control (no specifi c treatment)
Patient no NCV (m/s) Amplitude (µV)
Patients’
evaluation Patient no NCV (m/s) Amplitude (µV)
Patients’
evaluation
Initial After 6 months Initial After 6 months After 6 months Initial After 6 months Initial After 6 months After 6 months
1 0 30.6 0 0.8 Improvement 1 42 42 3.9 3.9 No change
200 00 No change 2 42 42 3.6 3.8 No change
3 36 45 0.2 1.7 Improvement 3 36 42 3.2 3.1 No change
4 0 42 0 1.2 Improvement 4 42 42 2.3 5 Improvement
5 0 42 0 2.2 Improvement 5 37 0 20 Impairment
6 34 45 1.5 2 Improvement
NCV, nerve conduction velocity.
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Original paper
Schroeder S, Meyer-Hamme G, Epplée S. Acupunct Med (2011). doi:10.1136/acupmed-2011-010034 3 of 4
objective parameter is promising for future acupunc-
ture studies, although the number of cases is limited.
Interestingly, an improvement in NCS after acupuncture
was shown in CIPN as well as in previous studies on PN
of undefi ned aetiology and diabetic neuropathy.
5 6
The
results are consistent with previously published case
studies on acupuncture treatment of CIPN.
4
Although PN has numerous causes including genetic,
toxic, metabolic, infectious, infl ammatory, ischaemic and
paraneoplastic disorders, the nerve can be destroyed in
a limited number of ways because the damage can only
occur at the level of the axon or the myelin sheaths.
11 12
Differentiating whether neuropathy is axonal, demyelinat-
ing or both is achieved by NCS.
11–14
It is generally accepted
that compromised nerve conduction in PN mainly depends
on structural changes of the myelin sheaths, while the
amplitude is correlated with the number of functional
axons.
7 8
Consequently, one may speculate that repeated
therapeutic interventions with acupuncture over a period
of 10 weeks improves the symptomatic state of PN and
also induces a normalisation of histological morphology.
It has been shown by Litscher et al
15
that acupuncture may
increase the blood fl ow in the limbs. Increased blood fl ow
to the vasa nervorum and dependent capillary beds sup-
plying the neurons
16
may contribute to nerve repair with
measurable improvement of axons or myelin sheaths.
Peripheral mechanisms possibly involved may include
other types of fi bres, such as the small unmyelinised or
thinly myelinised fi bres commonly believed to be unde-
tected by NCS.
In addition, the symptomatic effect of acupuncture may
refl ect morphological changes in the anatomy of periph-
eral nerves and also complex derangements of central and
peripheral regulation.
17 18
One hypothesis relates to the
enhancement of conduction by the dorsal column
19–21
or
higher centres.
22 23
CONCLUSION
The data suggest that acupuncture has a positive effect
on CIPN as measured by objective parameters (NCS).
The results are comparable to previous studies in dia-
betic neuropathy and PN of undefi ned aetiology. These
fi ndings are of special signifi cance since PN is otherwise
almost untreatable but seems to respond to treatment by
acupuncture. This pilot study shows encouraging results
for the application of acupuncture in CIPN, justifying a
randomised controlled trial.
Contributors SS designed data collection tools, monitored data collection for the
whole trial, wrote the statistical analysis plan, cleaned and analysed the data and
drafted and revised the paper. MH-G analysed the data and drafted and revised the
paper. ES monitored data collection and revised the draft paper.
Competing interests None
Patient consent Obtained
Ethics approval Ethical approval was obtained from the Ethik Kommission der
Hamburger Ärztekammer
Provenance and peer review Not commissioned; externally peer reviewed
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Table 3 Mean (SD) differences in nerve conduction studies of the sural nerve in acupuncture-treated and control groups
Acupuncture (10 treatments over 3 months) Control (no specifi c treatment)
Initial After 6 months Paired t test p Value Mean difference Initial After 6 months Paired t test p Value Mean difference
Mean NCV (m/s)
11.67 (18.09) 34.1 (17.54) t=3.0278 df=5 0.03 +22.43 (18.15) 39.8 (3.03) 33.6 (18.78) t=0.7962 df=4 NS −6.20 (17.41)
Mean amplitude (µV)
0.28 (0.60) 1.32 (0.83) t=3.2604 df=5 0.02 +1.03 (0.77) 3.0 (0.88) 3.16 (1.89) t=0.214 df=4 NS +0.06 (1.49)
Product of NCV
and amplitude
9.70 (20.44) 55.55 (37.66) t=3.4289 df=5 0.02 +45.85 (32.75) 120.29 (37.32) 132.72 (79.5) t=0.4163 df=4 NS +12.43 (66.78)
NCV, nerve conduction velocity.
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group.bmj.com on December 6, 2011 - Published by aim.bmj.comDownloaded from
doi: 10.1136/acupmed-2011-010034
published online December 5, 2011Acupunct Med
Sven Schroeder, Gesa Meyer-Hamme and Susanne Epplée
using neurography
peripheral neuropathy (CIPN): a pilot study
Acupuncture for chemotherapy-induced
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