MEDICAL ACUPUNCTURE Volume 20, Number 1, 2008 Mary Ann Liebert, Inc. DOI: 10.1089/acu.2007.

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Original Paper

Acupuncture for the Treatment of Irritable Bowel Syndrome

Nelson P. Trujillo, MD

ABSTRACT Background: Irritable bowel syndrome (IBS) is a disorder characterized by lower abdominal pain or discomfort, diarrhea, constipation (or alternating diarrhea/constipation), gas, and bloating. Objective: To describe the treatment of IBS from the viewpoint of a gastroenterologist/acupuncturist. Design, Setting, and Patients: Over the past 5 years, 149 patients were diagnosed as having IBS following the Rome II criteria. An additional 35 patients presented with persistent (6 months) history of localized undiagnosed abdominal quadrant pain. The patients treated with acupuncture were selected on the basis of nonresponse to standard medical treatment. Interventions: Acupuncture Energetics method using an N-N1 circuit on the Yang MingTai Yin meridians. Occasionally, a Shao YangJue Jin circuit was used, especially if there was evidence of significant anxiety. Usually, microcurrent at 2 Hz was applied between 2 points, bilaterally. For the Balance Method, acupuncture points were needled only on 1 side, balancing Yin and Yang points. An example of a circuit would be SP 9, LR 8, TE 5, LI 4 on the right side, and PC 6, LU 7, ST 36, and GB 34 on the left side. The needles were inserted to 1.52.5 cun. De Qi was obtained on insertion. The needles were usually retained 3040 minutes. The patients were treated once a week. Main Outcome Measure: Response to treatment. Results: Overall, there was 80% improvement with acupuncture treatments in both groups of patients. The Acupuncture Energetics method and Balance Method were equally effective in the treatment of these patients. However, the Balance Method was applied more quickly to patients than the Acupuncture Energetics method. Conclusions: Acupuncture is an effective treatment for patients with IBS and patients with localized abdominal quadrant pain. Further studies are warranted to test the generalizability of these findings.
Key Words: Irritable Bowel Syndrome, IBS, Abdominal Pain, Acupuncture, Acupuncture Energetics Method, Balance Method

INTRODUCTION

METHODS
In 149 patients, a diagnosis of IBS was made according to Rome II criteria.2 An additional 35 patients presented with persistent (6 months) history of localized abdominal quadrant pain undiagnosed after physical examination and computed tomography with contrast of the abdomen and pelvis. IBS patients had undergone these diagnostic tests as well. Those treated with acupuncture were selected on the basis

(IBS) IS a disorder characterized by lower abdominal pain or discomfort, diarrhea, constipation (or alternating diarrhea/constipation), gas, and bloating.1 As a board-certified gastroenterologist and licensed acupuncturist, herein I review all the cases I have seen of IBS and persistent localized abdominal pain treated with acupuncture in the last 5 years.
RRITABLE BOWEL SYNDROME

George Washington University, Washington, DC.

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48 of nonresponse to standard medical treatment,3 which included dietary and lifestyle modifications, consumption of 3040 g/d of dietary fiber, probiotics, anticholinergics, low doses of amitriptyline (25 mg/d), and occasionally, pain medication. This group of nonresponders was then offered the opportunity to receive acupuncture for treatment of their IBS or localized abdominal quadrant pain. The patients had to commit to receive 3 weekly treatments before deciding whether treatments were beneficial. IBS patients with only constipation were excluded. A total of 184 patients fulfilled these criteria; 23 of these patients had been referred for acupuncture by another gastroenterologist. Of the 184 patients, 75 were excluded from consideration because they did not complete 3 treatments. Only 1 of the patients referred by the gastroenterologist had to be excluded. IBS patients numbered 94, and 15 patients were treated for abdominal quadrant pain. There were 78 women and 31 men; the median age was 53 years. The youngest patient treated was 11-years-old and the oldest was 91 years. The severity of symptoms was assessed using a Health Distress Index visual analog scale from 1 to 100: 125 was considered no improvement, 2550 was slight improvement, 5075 was significant improvement, and 75100 was considered improvement. I ascertained the patients condition 3 months after the conclusion of the acupuncture treatments for all improved patients (although a Health Distress Index was not done). Information on all but 2 is available. During the first 2 years of acupuncture practice, I used the Acupuncture Energetics method of acupuncture.4 For the remaining 3 years, the Balance Method was predominantly used.5 Occasionally, Kiko Matsumotos style of acupuncture was used.6 For the Acupuncture Energetics method, an N-N1 circuit was used on the Yang MingTai Yin meridians. Occasionally, a Shao YangJue Jin circuit was used, especially if there was evidence of significant anxiety. In this method of acupuncture, points were needled bilaterally.4 An example of a circuit would be SP 6, SP 9, LI 4, ST 36, and ST 40. Usually, microcurrent at 2 Hz was applied between 2 points, bilaterally, utilizing an Electrostimulator 8c Pro (Pantheon Research, CA). For the Balance Method, acupuncture points were needled only on 1 side, balancing Yin and Yang points. An example of a circuit would be SP 9, LR 8, TE 5, LI 4 on the right side, and PC 6, LU 7, ST 36, and GB 34 on the left side.5 The needles used were Spring Ten Handle 0.18 15, and 0.20 30 (Llhasa, OMS Inc, Weymouth, MA). They were inserted to 1.52.5 cun. De Qi was obtained on insertion. The needles were usually retained 3040 minutes. The patients were treated once a week.

TRUJILLO no improvement. The Balance Method was used on 59 patients; of these, 11 showed no improvement, 3 had slight improvement, 3 had significant improvement, and 42 were improved. The remaining 2 patients were treated by the other method and reported improvement. Improvement in the IBS patients treated with the Acupuncture Energetics method was 79%; improvement in the IBS patients treated with the Balance Method was 81%. Of the 15 patients treated for abdominal pain, 10 were improved, 2 had slight improvement, and 3 were not improved. Three of the improved patients were treated with the Balance Method; the remainder by the Acupuncture Energetics Method. Overall, there was 80% improvement in both groups of patients. This improvement was maintained for at least 3 months for all patients (2 patients, 1 in each category, were lost to follow-up). The median number of treatments for the IBS patients who were not excluded was 7, and a similar number of treatments for those with localized abdominal quadrant pain. The Balance Method treatment used fewer needles and was faster to set up than the Acupuncture Energetics treatment. Usually, no electrostimulation was applied with the Balance Method acupuncture.

DISCUSSION
The large number of exclusions for noncompletion, despite the patients previously agreeing to 3 acupuncture treatments, is worthy of note. Anecdotally, primary reasons given for not completing the course of 3 treatments were no improvement after the first treatment, significant or complete improvement after the first treatment and therefore, not needing any more treatments, and other circumstances not related to the outcome of the treatment such as cost or a reaction to the experience. The discrepancy of the small numbers of exclusions in those patients specifically referred for acupuncture vs the large numbers in those in which acupuncture was offered as a last recourse of treatment is puzzling. Most of the patients included in this study had never received acupuncture treatments. Perhaps there was a perception problem as to what to expect of an acupuncture treatment. I do not advertise that I perform acupuncture. When I tell patients that I have no additional medical treatments to improve their condition and suggest that they undergo acupuncture treatment, many ask if I can recommend an acupuncturist. I am suggesting that the setting where the patient is and the reason for being there affect the patients perception and expectation of an acupuncture treatment. My patients expect medical treatment, and not acupuncture, from me. This, in turn, may affect their willingness to continue with the treatments. Unexpected results delineated the high percentage of responders in the treated patients. They are a highly selected group of patients. If I would add those patients who were

RESULTS
Of the 94 IBS patients, 33 were treated with the Acupuncture Energetics Method; of these, 26 improved and 7 showed

IRRITABLE BOWEL SYNDROME excluded to the total to perform an analysis, there would be a significant decrease in the percent of improvement. Despite this, these groups of patients with medical treatment failures and their response to acupuncture was impressive and encouraging. It has been suggested that favorable responses to acupuncture, both therapeutic and sham, are similar and may represent a placebo effect; however, they do occur.7 I did not have a control of sham acupuncture treatment in my patients. However, I did use 3 different methods of acupuncture and the results were similar. Although a recent Cochrane review was indecisive in whether acupuncture was more effective than sham acupuncture in the treatment of IBS,8 many investigators have reported improvement of IBS following treatment with acupuncture.9,10 I suggest that if both sham and regular acupuncture produce an improvement in patients who otherwise would remain sick, then the acupuncture treatment, whether sham or real, has had a favorable and beneficial therapeutic effect. My reasons for switching from Acupuncture Energetics to the Balance Method were based on the presumption that the treatment results would be similar and it would conserve my time. Certainly, I use fewer needles with the Balance Method and can set up the treatment in much less time; also, I usually do not use microcurrent in the Balance Method. This retrospective review confirms the therapeutic similarity of both methods in the treatment of IBS and abdominal quadrant pain.

49 treatment may affect the patients willingness to complete a course of treatment.

REFERENCES
1. Irritable bowel syndrome. http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/. Accessed April 1, 2007. 2. Rome II. http://www.romecriteria.org/rome12biblio.html. Accessed April 1, 2007. 3. Podovei M, Kuo B. Irritable bowel syndrome: a practical review. South Med J. 2006;99(11):12351242. 4. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, CA: Medical Acupuncture Publishers; 1997. 5. Tan R. Dr. Tans Strategy of Twelve Magical Points. San Diego, CA: Advanced Principles and Techniques in Acupuncture; 2002. 6. Matsumoto K, Euler D. Kiko Matsumotos Clinical Strategies. Natick, MA: Kiko Matsumoto International; 2002. 7. Schneider A, Enck P, Streitberger K, et al. Acupuncture treatment in irritable bowel syndrome. Gut. 2006;55:649654. 8. Lim B, Manheimer E, Lao L, et al. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2006;(4):CD005111. 9. Forbes A, Jackson S, Walter C, Quraishi S, Jacyna M, Pitcher M. Acupuncture for irritable bowel syndrome: a blinded placebo-controlled trial. World J Gastroenterol. 2005;11(26): 40404044. 10. Fireman Z, Segal A, Kopelman Y, Sternberg A, Carasso R. Acupuncture treatment for irritable bowel syndrome: a double blind controlled study. Digestion. 2001;64:100103.

CONCLUSIONS
Acupuncture is an effective treatment for patients with IBS and patients with localized abdominal quadrant pain. The Acupuncture Energetics method and Balance Method are equally effective in the treatment of these patients. It appears that knowledge and expectation of an acupuncture Address correspondence to: Nelson P. Trujillo, MD, LAc, FACG, FAAMA 2021 K Street NW, Suite T-110 Washington, DC 20006 E-mail: nelsontrujillo@metrogastro.com