V. CONCLUSION
Author Opinion
In review of the articles presented in this paper, it was observed that when acupuncture and moxibustion therapies are used in combination they are 30% more effective at treating patients suffering IBS than when each of those therapies are used individually. The combination of the two treatments showed consistent improvements through both objective and subjective outcome measurements. Furthermore, moxibustion treatment showed a 20% improvement over acupuncture when applied to ST25 based on DAI scores, QOL scores, and subjective pain assessments. These subjective improvements indicate changes in the comfort level of the subjects more than functional improvements which leads the author to believe that moxibustion therapy is best applied to treat the visceral hypersensitivity and visceral hyperalgesia aspects of IBS. Although moxibustion is historically used on distal acupoints, in the treatment of IBS, moxibustion therapy is best used on local points including, but not limited to, ST25.
Another local acupoint, REN12, was not a favored acupoint for IBS treatment in the reviewed articles however, its specific use with acupuncture resulted in a 25% decrease in symptoms of the upper gastrointestinal tract such as bloat, epigastric distention, and acid reflux. These upper gastrointestinal tract symptoms are indicators of the poor digestive functions that precede the lower gastrointestinal tract irritations which ultimately result in IBS. Practitioners can approach the treatment of IBS specifically using acupuncture on REN12 with a 25% improvement to the cause and prevention of IBS over patients not treated with REN12.
ST37 showed a 15% greater improvement over ST36 when applied to patients suffering IBS-D based on the Bristol Stool Scale however, this outcome measurement is not a reliable marker for chronic corrective care. Improvements in stool pattern are desirable for the patient however, the stool pattern may worsen for a period of time while the patient’s gastrointestinal irritation is actually decreasing as shown by immunohistochemistry assays. ST36 showed a 15% greater improvement regarding immunohistochemistry assays and analysis through electron microscopy. The benefit of ST37 is best observed during short term acute bowel irritation syndromes that have the symptom of diarrhea whereas ST36 has a greater overall benefit to chronic dysfunctions of the digestive tract.
Limitations in Acupuncture and Moxibustion Trials
AOM is based on a theoretical framework combined with clinical understanding, intake, and assessment while diagnosing each patient individually. Signs and symptoms give clues as to which pattern is presenting. Treatment options may vary greatly between practitioners as there is truly an art to the medicine. This fact makes AOM a challenge to study when based on Western Science parameters that focus on reproducibility in a single treatment, based on one dimensional lever systems. Individualization of treatment is a hallmark of AOM practices; however, individualization is not typically allowed in RCTs. Point selection was primarily based on Western Medical Acupuncture and AOM principles were not considered. AOM treatments usually involve lifestyle changes, dietary changes, spiritual practices, special exercises, nutritional therapies, gua sha, cupping, tui na, qi gong, herbal medicines, moxibustion, and/or acupuncture. 68% of acupuncturists treating IBS give lifestyle advice to their patients in addition to acupuncture (MacPherson, 2016). Although these practices each have therapeutic value by themselves, they are traditionally used together or in combinations to synergistically and cumulatively improve patient outcomes. In this project, only moxibustion and acupuncture were examined for efficacy in treating IBS treatment. Furthermore, IBS is a complicated disease pattern with multiple causative factors including physiological, psychological, and social contributions. There are inconsistencies in diagnosis in both Western Medical and AOM approaches. Lifestyle plays a major role in whether or not a patient improves however, not only was lifestyle medicine not used in the studies reviewed, it is impossible to control or evaluate lifestyle habits, related to pathology, in a study.
Up-to-date and current studies have limited sample sizes and lack relevant medical background information on subjects that may strongly influence trial outcomes. Measurements to gauge severity of the disease and improvements were heterogeneous leading to difficulties in analyzing statistical significance. Acupuncture and moxibustion therapies are considered to have cumulative effects; however, only one of the studies investigated, by MacPherson et al., discussed continuity programs or follow up care.
Future Studies
There are many controversies regarding the use of acupuncture or moxibustion in the treatment for IBS and very few studies that show their efficacy in combination. Manheimer and colleagues reported that none of their reviewed studies found statistically significant benefits of acupuncture compared to sham acupuncture (Anastasi, McMahon, & Kim, 2009) yet many other studies, clinical reports, and thousands of years of anecdotal success support the use of both acupuncture and moxibustion applied together in treatment. In order for these AOM practices to be accepted as evidence based medicine, there needs to be a return to patient-centered or individualized care. Practitioner skill set and artistic intuitive approaches are highly valued historically in AOM practices however, these qualities are entirely discounted in the modern scientific arena. Defensive medicine, or high liability care models, have unfortunately changed the terrain of academia and scientific research. Research requires funding which can only be justified by revenue generating practices which offset liabilities. Acupuncture and moxibustion both have low direct liability in patient care (risk to benefit ratio in favor); however, there is a high liability in deviating from standard of care.
Regarding the inclusion of animal studies, although the animal study outcomes do not represent the same level clinical evidence as human study outcomes, the animal studies were included for the purpose of supporting the recommendation for future human studies.
Final Thoughts
Current medical approaches to diseases of the gastrointestinal system are costly and often involve expensive drugs or surgeries that come with serious side effects. Approaches that are cost effective with low risk or low adverse effects would serve as valuable primary or adjunct treatments to conventional care. After reviewing current research, it is the author’s opinion that acupuncture and moxibustion therapies show increased treatment potential when combined together. In particular, ST37, ST25, and ST36 are the most beneficial acupuncture points in treating patients with IBS. Although the biomedical rationale for the acupoint selections was not discussed in the reviewed studies, there is support for use of these acupoints based on historical and traditional applications. ST36 is the He-Sea point of the stomach channel. The He-Sea acupoints are a subcategory of acupoints based on the five-shu division of acupoints within AOM theory. The He-Sea acupoints are known for their place on the acupuncture channels where the flow of qi goes deeper and affects the organs for which each channel is connected. In the case of ST36, the connected organ system is the stomach which directly affects functions of the gastrointestinal tract. ST36 is also grouped into the Sea of Water and Grain acupoints which are known for their influence on digestion. Historically, ST36 is used to harmonize the stomach, strengthen the spleen, and resolve dampness related to gastrointestinal tract functions. Peter Deadman, an AOM scholar, considers ST36 an essential acupoint in the treatment of any stomach fu disorder. ST37 is the lower He-Sea acupoint of the large intestine. Traditionally this point is used specifically to treat diarrhea and dysenteric disorders. It supports regulation of the spleen and stomach systems while clearing dampness which interferes with normal function. ST25 is the Front-Mu acupoint of the large intestine system. Front-Mu points are another category of acupoints that are located close to and associated with the organ being treated, in this case the large intestine. Front-Mu points are also known for their use diagnostically as they become sensitive when their related organ is in a state of dysfunction. These acupoints have been used for many thousands of years based on these theoretical assumptions and clinical reports however, supportive research describing the biomedical mechanisms of function is lacking. It is likely that the primary influence of acupuncture is neurological in effect. The response to the brain creates vasodilation to targeted tissues and organs which may involve local immune and anti-inflammatory responses. These concepts have yet to be verified scientifically.