Effects of the 8 Constitution Acupuncture on CD4 Counts in Patients with HIV
PETER YOON, Ph.D , L.Ac / KYUNG KYU CHOI, Ph.D OMD, L.Ac., / KARP-SOON RHEEM, Ph.D.
Research Center, South Baylo University,
1126 N. Brookhurst St. Anaheim, CA 92801
Background: While acupuncture is commonly used in HIV for symptom relief or improving QOL, little is known about acupuncture trial to improve CD4 counts in patients with HIV. Objectives: To assess whether constitutionally individualized acupuncture trials increased CD4 counts in patients with HIV. Design: A quasi-experimental case control design. Subjects: Convenience sample of 10 HIV-positive adults. Method: Experimental group received individualized acupuncture trials which were tailored to the individual participant's constitution to promote immune function and health. Controlled- needling group received treatments with points identified as clinically irrelevant in treating the conditions under investigation. Subjects were treated twice a week for three weeks to six months. After treatment peripheral bloods of subjects were analyzed at the authorized institution to find the CD4 variation. Results: Individualized acupuncture trials showed a statistically significant increase in CD4+ counts (p=0.05). Conclusions: This preliminary finding suggests that the constitutionally individualized acupuncture trials may significantly increase CD4 counts in patient with HIV in larger scale, controlled studies.
Acupuncture treatment has been used by many people with HIV and AIDS in the United States as a complementary treatment to Western medicine. Acupuncture is commonly used in HIV for pain relief. Most of study articles are related with anecdotal because of its difficulty due to the trouble with creating an adequate placebo. So, there is scarcity of well-done clinical trials despite popularity of use.
Standardized Acupuncture and Individualized Acupuncture:
Shlay JC, et al12carried out an experimental study to evaluate whether a standardized acupuncture regimen, amitriptyline, or both together was more effective than placebo for 250 HIV positive people with peripheral neuropathy. Noneof the treatment groups was significantly better than placebo. Meanwhile, Philips,KD, et al13performed case series design in 21 HIV poadults with peripheral neuropathy. Ten group sessions of individualized acupuncture were administered over five weeks and completed pre-and post-treatment evaluation of pain and other symptoms. It was found that significant improvement in subjective pain and symptom with 50% reduction in summary score.
Chang, B.H,14et al studied the combined effect of relaxation response and acupuncture on quality of life in patients with HIV. All participants received individualized acupuncture treatment prescribed by their acupuncturists. Intervention group showed trends of greater improvements than the control group(p=0.07)
Philips,KD, et al15performed pre-test, post-test design in 21 HIV-infected adults aged 29-50 with reported sleep disturbance. Sleep activity and quality were measured before and after a 5-week. After 10-treatment individualized acupuncture intervention was assigned, it was shown that significant improvement in sleep activity and quality was obtained.
Beal,MW.16et al studied the effect of acupuncture trials on symptom relief in HIV-positive adults. The acupuncture trials used mostly included individualized acupuncture treatments such as with points chosen to address the individual participant's bothersome symptom, with a fixed protocol of 4 points that can be thought of as constitutionally supportivederived from traditional Chinese medicine, with the points which was chosen by the acupuncturists after an assessment of the patient that includes a history, observation of characteristics such as facial color, abdominal and meridian palpation, and pulse diagnoses. This aspect of the treatment is based on 5- phase theory, the points being derived from Japanese25, and with the four point combinations which consisted of LU-9 and SP-3 for people diagnosed with lung imbalance, SP-3 and PC-7 for the people diagnosed with spleen imbalance, LV-8 and KI-10 for people diagnosed with liver imbalance, and KI-7 and LU-8 for people diagnosed with kidney imbalance.
Kim,YS, et al,17who reviewed a total of 124 studies which were published in Korean journals from 1983 to 2001, stated : 'From the above clinical studies, it is possible to summarize the originality of Korean acupuncture by describing both of its characteristic approaches-individualized and practical. Firstly, a number of clinical studies in Korea have shown the benefits of individualized acupuncture treatment, such as Saam, Taegeuk or Eight constitution acupuncture18"21. Patel et al22noted that individualized treatments significantly favored acupuncture, whereas formulaic approaches, in which all the patients received the same treatment, showed no significant difference.'
*8 constitution acupuncture has been largely used as one of most beneficial individualized-acupuncture in Korea as shown in papers: 1) ChangShik Yin, 'Korean acupuncture: the individualized and practical acupuncture.' Neurogical Research, 2007,Vol. 29, Supplemet 1, pp S10-S15, 2) YS Kim, The Practice of Korean Medicine: An Overview of Clinical Trials in Acupuncture' Evidence-based Complementary and
Alternative Medicine, 2005, Vol.2, No.3, pp 325-352. 3) Chae, SJ, et al, 'Comparison of the Improvement of Subjective Symptoms between Body Acupuncture Group and 8 Constitution Acupuncture Group', The Journal of Korean Acupuncture & Moxibustion Society, 2001,Vol 18, No. 3, pp 48-55. The theory behind the Eight constitution acupuncturemethod is that each person has a specific constitution, which determines the body's inherent strengths and weaknesses. Physiologic or pathologic characteristics of the patient assume a discernible pattern according to the constitution to which that person belongs. The needling method used in eight constitution acupuncture theory is basically a quick and superficial insertion of the needle, followed by an instant withdrawal. Insertion is repeated a designated number of times.
Acupuncture trials to increase CD4 counts in Patients without HIV:
There are a number of articles on the effects of acupuncture on various specific aspects of immune functioning, such as CD4 and CD8, NK cell, IL-2, humoral immunity and macrophage response. Some of these studies have been carried out in human patients with cancer and some in healthy and ill animals. Treatment administered to humans has involved acupuncture stimulation either to the ST-36 point or to a group of points including ST-36, whereas the analogous treatment has been to provide acupuncture treatment to the anterior tibialis muscle.
Ye F, Chen S, et al 19observed effects of electro acupuncture(EA) on CD4 and NK cell in patients of Chemotherapy. Before Chemotherapy(CM), CD4 was much lower than the normal range, after one months of CM with EA, no decline of all the indices including CD4 was found.
Wu B20investigated the role of acupuncture in the regulation of cellular immune function. When levels of CD3+, CD4+and CD8+ were checked after acupuncture treatments for patients with malignant tumors, the results showed that there were increased levels of CD3+, CD4+ percentage. The statistical significance was found to be remarkable.
Yamaguchi N, et al21examined effects of acupuncture on levels of CD+cell counts in people of 17 healthy volunteers. Peripheral blood was analyzed by using flow cytometry before and after acupuncture trials at the specific meridian points/75There was a statistically significant increase in the number of CD2+, CD4+ and CD8+ after acupuncture trials.
Acupuncture trials to increase the CD4 counts in Patients with HIV:
As far as the effect of acupuncture trials alone on regulating CD4 counts is concerned, only two reports are surveyed so far:
Jin-Lin Wang21reported in 1994 that 201 people with HIV/AIDS were treated by acupuncture, Chinese herbs, and western medicine into two groups: 1st group used acupuncture and Chinese herbs; 2nd group added Western medicine to their treatment regimen. The basic acupuncture points were: Li- 4, ST-36, Re-6, Ear-Spleen. Additional points were used as individually indicated. Sixty six % of the first group using acupuncture and herbs improved CD+ levels during the treatments. The effect of acupuncture only CD4 counts could not be discerned from that of Chinese herbs because both acupuncture and Chinese herbs affected to increase CD4 counts. However, additional acupuncture points which were individually used seemed to suggest need to positive application of the individualized acupuncture to patients with chronic illness.
In 2001, Henrickson 22reported the clinical outcomes of acupuncture and/or massage therapies in HIV-infected individuals who received HAART theraphies. Even though the effect of acupuncture-only on CD4 counts in HIV-infected patients was investigated, the result showed that acupuncture trials decreased the CD4 counts in patients with HIV.
As a result of literature survey, any study to improve CD4 counts by acupuncture alone in patients with HIV has not been found yet so far. It is expected that use of the individualized acupuncture may enhance immune function including increase in CD4 counts in patients with HIV.
The present paper is intended to improve CD4 counts by individualized acupuncture for patients with HIV.
Summary of literature Survey for
CD4 Count Changes by Acupuncture Trials
Fig. Schematic Drawing of CD4 Changes vs Various Acupuncture trials
Retrospective Quasi-experimental Case Control Design
Fig. Schemiatic Drawing of Design for CD4 Changes vs Various Acupuncture Trial
The present study was conducted with a small convenience sample of HIV patients who were mostly transferred from western medical institutions. The primary purpose of the study was to access whether individualized acupuncture trials increased CD4 counts in people with HIV. Written informed consent was obtained prior to their participation. This study was conducted in compliance with the rules and regulations stipulated by the institutional review board, South Baylo University.
Subjects were grouped by the pulse diagnosis according to the eight constitution medicine which is known to be one of the most definite and popular constitution acupuncture methods23"28in Korea: At the first trial of pulse diagnosis to find sdbject's own constitution, the subject whose pulse was precisely clear to find its constitution was grouped into the experimental group while the subject whose pulse was too weak to read its constitution was grouped into the control-needling group. The experimental group received individualized acupuncture trials which were tailored to individual participant's constitution to promote immune function and health. The control-needling group received acupuncture treatments with points identified as clinically irrelevant in treating the conditions under investigation.
Ten participants were treated in this case-control study. Eight patients received experimental treatments and two participants received the controlled-needling treatment. Participants received acupuncture treatments twice each week for 3 weeks to six months. The needle is basically inserted superficially at l-2mm depth and removed quickly. Disposable acupuncture needles (30mm, 160um in diameter, Jesun Co. Ltd, Seoul, Korea) were inserted into the acupuncture points assigned by the protocol of 8 Constitution medicine acupuncture. Acupuncture treatment was singly performed with needles, which stayed in place for 5s and were stimulated to promote or restrict deki 29-32. In order to treat patients with HIV virus, all the patients with HIV received 3 formulas which were individually tailored to patient's constitution. Every patient received his own virus formula which was consisted of applications of the fundamental formula at 4 points 5 times, the bactericidal formula at 4 points 5 times and the psycho formula at 2 points once.
To evaluate the effect of acupuncture treatment, the CD4 count was since the CD4 count is generally accepted internationally as an indicator of condition of human immune system. We used the CD4 count as a surrogate marker. After average 3 month acupuncture trials, the peripheral blood of every patient was analyzed in the authorized institution to examine CD4 change. To compare the outcome CD4 count with intake CD4 counts or previous CD4 count data which were obtained when patients were treated with HAAT therapies without acupuncture trials.
All the statistical analyses were performed using the SPSS 11.0 statistical package. P=0.05 was used.
A great deal of useful information was obtained in this study. Eighty percents of participants showed increases in CD4 counts in positive rate as a result of individualized acupuncture trials which were holistically tailored to patient's own constitution physically as well as psychologically. Twenty percents of participants showed decreases in CD4 counts in negative rate as a result of controlled needling trials with the points identified as clinically irrelevant in treating the conditions under investigation. After confirming of drastic decrease in CD4 counts in control group, when new acupuncture trials exactly tailored to participant's own constitution were applied to subjects in control group in order to make the suppressed CD4 counts increase, CD4 counts were drastically increased as shown in Fig 3 and Fig 7. When acupuncture trials exactly tailored to participants were applied, one hundred percents of participants showed increase in CD4 counts in positive rate.
#1 : Pancreotonia Case
As shown in Fig.1,
-CD4 levels are increasedby 8CMAtrials.
-It is likely to imply that increase in CD4 counts are attributed to the boosting of CD4 activity due to the 8CM acupuncture trials.
-The 1stinvestigation of CD4 counts after13 days trials (3 Acu-trials=Jan 2, 08-Dec 20,07) shows no difference from intake CD4 counts. After 1st trials for 13 days the 1stinspection of CD4 shows nearly no difference from intake data of 343.
-After six months’continual trials, his CD4 count increased up to 421 which is 78 points higher than intake counts. Long term effect was big.
-The mean value of CD4 counts before 8CMA trials was 295 while after trials mean value was 379
# 2 : Pancreotonia Case
Fig. 2. Case of Pancreotonia Constitution
1st Visit : Dec 20, 2007, M. Age:39, Ht:5’8, Wt:140
Acupuncture Trials were administrated once a week.
1stIncrease Rate=(364-318)/77 = 0.60
2ndIncrease Rate=(393-364)/83 = 0.35
3rdIncrease Rate=(408-396)/100= 0.15
-The 1st investigation of CD4 counts after 4 trials ( 27 days after=Jan 17, 08-Dec 20,07) shows increase in CD4 counts which are about 50 points higher than intake CD4 counts. The 1sttrials for 27 days was big. The slow increase rate after 1stinspection is attributed to receiving only one trial a week.
# 3 : Pulmotonia Case
At the first trial of pulse diagnosis to find subject’s own right constitution, the subject whose pulse was too weak to read constitution was grouped into the control-needling group. In Fig.3, this subject received the controlled needling at the acupuncture points of which constitution were assumed to be Pancreotonia until second inspection of CD4 counts finished.
The 1st investigation of CD4 counts after two months’ trials shows a very slight change in CD4 counts. After confirming of drastic reduction in CD4 counts at the 2nd blood analysis, the new acupuncture trials matched with the right constitution of Pulmotonia were applied to the patient, resulting in remarkable increase in CD4 counts.
It is noteworthy that during the first trials, the patient said ‘ I feel so good whenever I receive 8CMA trials.’ After 2 month trials, the 1st inspection’s CD4 count of 519 was not so different from the previous number of 520.
So, same therapy was continued to find any more changes in CD4 until
2nd inspection. After finding a drastic reduction in CD4 counts, new trials corresponding to the right constitution of Pulmotonia were applied to make the decreased CD4 counts get recovered. As the result, the CD4 counts was remarkable increased as shown in Fig.3.
From the control needling, it was found that there is a better or the best acupoint to lead to the result of the best treatment.
There are many references which show the importance of right acupoint to increase more the CD4 counts.
# 4 : Hepatonia Case
First Visit: 02/07/08. He suffered from Hepatitis C.
The 1st inspection of CD4 counts after first trials for 22 days (from Feb 7 to Feb 29, 08) shows sharp increase in CD4 counts by 68 points from 252 to 320.
# 5 : Hepatonia Case
Fig.5. Hepatonia Constitution Case
1st Visit: April 29,2008, M, Age:60, Ht:5’8
First Visit: 04/29/08
His Constitution is Hepatonia
# 6 : Pancreotonia Case
Fig. 6. Pancreotoni Case
1st Visit: Mar 25,08, M. Age:48.
First Visit: 03/25/08
His Constitution is Pancreotonia
# 7 : Pancreotonia
Fig.7.Pancreotonia Constitution Case
1st Visit: Nov.20, 07, M, Age:46, Ht:6’2, Wt:230
At the first trial of pulse diagnosis to find subject’s own right constitution, the subject whose pulse was too weak to determine
its right constitution was grouped into the control-needling group33-34. In Fig.7, this subject received the controlled needling at acupuncture points that are clinically irrelevant in treating the
conditions under investigation. The controlled needling was applied at the acupuncture points of which constitution were assumed to be of Hepatonia until second inspection of CD4 counts finished. After 2nd inspection, the right acupuncture treatment matching with right constitution of Pancreotonia was carried out, resulting in sharply increase in CD4 counts up to the highest value
Ref.33 : Control study cases :
Placebo needled acupuncture
Sham (non) invasive acupuncture
Ref.34 : Control needling Group(Yale Univ Paper)
®Clinically irrelevant’ acu-points
# 8 : Hepatonia Case
Fig. 8 Hepatonia Case
1stVisit: Dec 12,07. M. Age:59, Ht:6’1.Wt:185
First visit: Dec 12, 07. He suffered from diabetes.
After receiving 8CMA treatment for over two months, the 1stblood analysis showed drastic increase in CD4 by nearly 100 points. The 2ndblood analysis also showed great increase by 82 points after getting one month’s 8CMA trials.
After having 2ndblood analysis, he stopped taking medication without any consultation with doctor.
With a relation to stopping medication, the CD4 count decreased at the 3rdblood analysis. At the same time, he broke important rules to maintain quality of life. As the result, the 4thblood analysis showed that he became a patient with AIDS of poor CD4 counts under 200.
On Oct 1, 2008, he restarted taking medication in healthy circumstance. After receiving three week’s acupuncture trials, the CD4 counts at the 5thblood analysis were remarkably increased from 187 to 594 by 407 points.
This case shows that if any patient receives the right acupuncture trials matched with his own constitution, dramatic increase in CD4 count is possible by 8CMA trials even though CD4 counts are temporarily suppressed by stopping taking medicine in unhealthy circumstance.
This case also shows that
# 9 : Hepatonia Case
Fig.9: Hepatonia Constitution Case
1stVisit: 05-01-08, Male. Treated once a week.
He got treated once a week.
Before visiting SBU, for 18 months, maximum CD4 was 801, minimum CD4 was 553, and average value was 648. His intake CD4 level was 607.
After getting 8CMA trials, his CD4 counts increased up to 982. His average CD4 was 877 and didn’t get down below 806 which was higher than maximum 801 before visiting SBU.
After 1sttrials for 14 days (after receiving only 2 treatments of 8CMA), his CD4 value drastically jumped from 607 to 982, increasing by 375 points. The sharp increase may be attributed to the high initial CD4 count of above 600 which is seen in healthy adults
#10 : Pancreotonia Case
Fig.10. Pancreotonia case
1stVisit: Mar13,08, M. Age:48. Ht:5’8.Wt:150
First visit : 03/13/08
His Constitution is Pancreotonia.
He was treated from 03/13/08 to 06/26/08.
Needling of Superficial Pricking:
According to the functional magnetic resonance imaging of whole brain, when superficial pricking is applied, it has been demonstrated that superficial pricking revealed more signal intensity than minimal applied acupuncture.91 the present study, superficial pricking was applied to all the subjects without any exception.
The frequency and total number of treatment :
In order to treat HIV virus in our study, all the patients received trials of the virus formula which was individually tailored to patient's constitution. Every patient's own virus formula was consisted of applications of the fundamental formula at 4 points 5 times, the bactericidal formula at 4 points 5 times and the psycho formula at 2 points once. The practitioner repeated the virus formula 3 times for one session. The total number of needling trials at assigned acupuncture points was 126 at least for one session. Comparing with less than 20 needling trials in recent papers,100"104the total number of 126 needling trials by superficial pricking in this study is considered to be one of factors to increase CD4 counts because of providing extensive signal intensity to regulate the immune function. Certainly, it all seems like sticking a bunch of needles into the epidermis.
The Different Effects of Various Individualized-Acupuncture:
Zijlstra F.J, et al105stated that it would be difficult to make comparisons between different acupuncture techniques used in most studies because from traditional Chinese medicine, acupuncture should be considered and applied as an individually based therapy. Many variables individualized can influence outcomes of every therapy: It should be considered to select many variable such as acupuncture points, number of acupuncture points, number of treatment session, the type, depth, direction, and manipulation of the inserted needle, the needle retention time, etc. Our acupuncture trials seem to be more individualized than any conventional acupuncture because of using various variables such as needling at 9 acupuncture points, totally superficial pricking, less than 5 second retaining time and 126 times in promoting and restricting modes. However, it is noteworthy that our individualized acupuncture trials use the standardizedformulas based on the proven theory of 8 constitution medicine. These variables would provide more extensive signal into enhance the immune function than the conventional acupuncture.
Stress, CD4 Cell Count decline and Needling of Psycho Formula
In the book of psychiatric aspects of HIV/AIDS106, Fernandez, F et al stated that there is evidence that stress management is an efficacious method of immunologic reconstitution among HIV-infected men after introducing a study demonstrated that men receiving stress management had higher CD4(+),CD45RA(+), and CD29(+) cell counts over a 12-month period post
intervention.107Remor E, et al,108recently examined the effect of perceived stress on CD4 counts decline in 100 patients with HIV and demonstrated that the perceived stress significantly induced CD4+ cell count decline in patients with HIV. At the point of view in stress management in patients with HIV, it is important to note that our acupuncture trials used the psycho formula to control stress related CD4 counts decline in patients with HIV. The application of this psycho formula seems to influence the CD4 counts increased partially.
CD4 Counts Decline by Control Needling and Trials to increase CD4 Counts: At the first trial of pulse diagnosis to find subject's own constitution, the subject whose pulse is too weak to read its constitution was grouped into the control-needling group. In Fig.3 & 7, control needling was administrated at acupuncture points that were clinically irrelevant in treating the conditions under investigation. The controlled needling trials were given to subjects until 2nd inspection of CD4 changes. After confirming the reduction in CD4 counts by controlled needling, the right needling at the acupuncture points precisely tailored to patient's own constitutions was applied to subjects in order to make up the reduced CD4 counts to be recovered. New applications of the right constitution acupuncture trials resulted in drastic increases in CD4 counts as shown in Fig. 3 and 7.
Suppression of CD4 Counts by Right Constitution Acupuncture Trials :
As shown in Fig 3, Fig 7 and Fig 8, CD4 counts were suppressed due to needling at wrong points which were intentionally assigned, by not taking medicine or by getting more infected in HIV virus. However, after applications of patient's own constitution acupuncture trials, CD4 counts in patients of all three cases drastically increased. It is also important to note that the temporally suppressed CD4 counts may be rapidly recovered when right constitution's acupuncture trials are applied to the subject at any status of CD4 count decreased. To our limited knowledge, this is the first study to demonstrate a relationship between constitution acupuncture and CD4 cell counts increase. From this finding, more studies are suggested to find whether the constitutional acupuncture trials have some potential to regain the suppressed CD4 counts in short period.
The naive CD4 cell subset and the Memory CD4 cell Subset
Antoni,M.H et al109reviewed that with progression of HIV infection, there is a preferential decline among subsets of CD4 T cells; the Naive CD4 T-helper- inducer cell subset(CD4+CD45 RA+) declines more than the memory subset (CD4++), resulting in disruptions in the cellular immune repertoire for novel antigens that underline susceptibility to opportunistic pathogens 110and rising CD4+T cell counts following antiretroviral therapy are due primarily to the redistribution of memory CD+T cell, with "reconstitution" of Naive CD4+ T cell being delayed for several months.111In the present study, the reason why the temporally suppressed CD4 cells can be restored by the application of right constitution acupuncture trials may be analyzed in the light of viewing the above suggestion.
This paper uses an innovative methodology to evaluate clinical outcomes. Using a quasi-experimental retrospective case control design treatment,
Using nonparametric statistical analysis, it was found that the means of the treatment groups' differences in pre-and post-CD4 counts showed improvement when compared with the non-treatment control group's pre- and post-CD4 counts. Treatment subjects were then interviewed and asked to rate their experiences of the therapies; the subjective experience was very positive.
We appreciate the financial support of the Korean 8 constitution medicine association.
Shlay JC, Chaloner K, Max MB, et al (1998). Acupuncture and amitriptyline for related peripheral neuropathy. JAMA, 280: 1590-1595.
Phillips, KD, Skelton, WD, Hand, GA (2004). Effect of Acupuncture Administered in a Group Setting on Pain and Subjective Peripheral Neuropathy in Persons with Human Immunodeficiency Virus Disease. J Alt Comp Med, 10:3, 449-455.
Beal, MW & Nield-Anderson, L (2000). Acupuncture for symptom relief in HIV-positive adults: lessons learned from a pilot study. Altern Ther Health Med, 6(5):33-42.
Phillips, KD & Skelton, WD(2001). Effects of individualized acupuncture on sleep quality in HIV disease. J Assoc Nurses AIDS Care, 12(1):27-39.
Ye F, Chen S, Lie W (2002). Effects of electro-acupuncture on immune function after chemotheraphy in 28 cases. J Tradit Chin Med, 22(1):21-23.
Wu B (1995). Effects of acupuncture on the regulation of cell-mediated immunity in the patients with malignant tumors. Zhen Ci Yan Jiu. 20(3): 67-71.
Yamaguchi N, Takahashi T, Sakuma M, et al.(2007). Acupuncture Regulates Leukocyto Subpopulatios in human Peripheral Blood. Evidence Based Complement Alterat Med.4(4): 447-453.
Jin-Lin Wang (1994). Using Chines Herbs and Acupuncture to Treat HIV/AIDS: an Analysis of 201 Cases. Bejing Alive.
Henrickson M.(2001). Clinical outcomes and patient perceptions of acupuncture and/or massage therapies in HIV-infected individuals. AIDS care, 13(6) 743-748. Yong-Suk Kim, Hyungjoon Jun, et al p?005). The Practic
More than 70 papers will be added hereafter.