Acupuntura Síndrome de Meniere

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Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2011, Article ID 429102,13pagesdoi:10.1093/ecam/nep047

Original ArticleExploring the EvidenceBase for Acupuncture in theTreatment ofMenieres SyndromeASystematic Review

Andrew F. Long,1 Mei Xing,2 KenMorgan,3 andAlisonBrettle4

1 School of Healthcare, University of Leeds, Leeds, LS2 9UT, UK2 School of Community Health Sciences and Social Care, University of Salford, Salford, UK3Acupuncturist, Bolton, UK4 School of Nursing, University of Salford, Salford, UK

Correspondence should be addressed to Andrew F. Long,[email protected]

Received 24 September 2008; Accepted 5 May 2009

Copyright 2011 Andrew F. Long et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Menieres syndrome is a long-term, progressive disease that damages the balance and hearing parts of the inner ear. To addressthe paucity of information on which evidence-based treatment decisions should be made, a systematic review of acupuncturefor Menieres syndrome was undertaken. The method used was a systematic review of English and Chinese literature, fromsix databases for randomized, non-randomized and observational studies. All studies were critically appraised and a narrativeapproach to data synthesis was adopted. Twenty-seven studies were included in this review (9 in English and 18 in Chineselanguages): three randomized controlled trials, three non-randomized controlled studies and four pre-test, post-test designs. Allbut one of the studies was conducted in China. The studies covered body acupuncture, ear acupuncture, scalp acupuncture, fluidacupuncture point injection and moxibustion. The studies were of varying quality. The weight of evidence, across all study types,is of beneficial effect from acupuncture, for those in an acute phase or those who have had Menieres syndrome for a number of

years. The review reinforces the importance of searching for studies from English and Chinese literature. The transferability ofthe findings from China to a Western context needs confirmation. Further research is also needed to clarify questions around theappropriate frequency and number of treatment/courses of acupuncture. The weight of evidence suggests a potential benefit ofacupuncture for persons with Menieres disease, including those in an acute phase and reinforces the importance of searching forpublished studies in the Chinese language.

1. Introduction

Menieres syndrome is a long-term, progressive disease that

damages the balance and hearing parts of the inner ear. Itis most common between the ages of 40 and 50 and rare inchildren and onset after the age of 60. Its incidence is about1 in 1000, equally distributed between men and women andwell documented in Caucasian, African-American and Asianraces [1]. The etiology and treatment of Menieres diseaseis not fully understood. In a literature-based, clinical reviewof the diagnosis and treatment of Menieres disease, Saeed[2] commented that currently, the treatment of Menieresdisease is empirical. As yet, no treatment has prospectivelymodified the clinical course of the condition and therebyprevented the progressive hearing loss. Indeed, Thorp et al.[3] in a critical review of studies of medical and surgical

approaches queried whether any evidence-based medicineexisted in the treatment of Menieres disease.

Conventional biomedical treatments include drugs, diet

and surgery. Drugs often form the first line of treatment.These include: diuretics (to reduce the amount of sodiumin the body); drugs to block symptoms of motion sickness,nausea and vomiting, and anxiety and vertigo; systemicor local corticosteroids to reduce inflammation within theinner ear and to stop any immune reactions; antibiotics; anddrugs to improve blood flow in the inner ear [4]. The mostcommonly recommended dietary treatment is a low sodiumdiet. Patients have sometimes been helped by limitingcertain components of their diet such as sugar, monosodiumglutamate, caffeine and alcohol [4]. Surgical treatment is thelast resort of conventional medicine for Menieres disease,the most controversial [2] and of greatest risk.
mailto:[email protected]:[email protected]


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2 Evidence-Based Complementary and Alternative Medicine

Table1: Inclusion and exclusion criteria.

Inclusion criteria:

Study on patients with a diagnosis of Menieres disease

All types of TCM acupuncture or moxibustion

Study using acupuncture or moxibustion in addition to otherTCM, for example, herbal medicine

Studies of any controlled type and case series if the sample sizewas10

Studies in the English or Chinese languages

Exclusion criteria:

Studies with a sample size of


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Evidence-Based Complementary and Alternative Medicine 3

Retrieval of hard copies of

potentially relevant citations

(n = 35)

Studies meeting inclusion criteria andcritically appraised

(n = 27)

Post-treatmentdesign

(n = 12)

Controlledstudies

(n = 6)

Case seriesreports

(n = 8)

Excluded studies(n = 8)

English language citations identified through

electronic databases of MEDLINE, Cochranecontrolled trials register, EMBASE, CINAHL,

AMED and hand-searching of E-CAM; Chinese

language citations identified through Chinese

Database of Science and Technology

Figure1: Flowchart literature search process.

The patients had been suffering from Menieres disease forvarious periods of time, ranging from 1 to 24 years. Thirteenof the studies included patients at an acute phase, within 110 days of an acute attack. Three studies [9,15,30] explicitlyfocused on the effects of acupuncture for acute symptomrelief. Sample sizes varied from 15 [11] to 286 [33], and 5had a sample size of less than 30 [18,19,25,26,30]. The six

controlled studies had total sample sizes ranging from 36 to189 in the acupuncture arm. Nine of the studies had 50 orfewer participants.

The majority of studies employed a graded outcomemeasurement approach, differentiating three to four categ-ories: cured, outstandingly effective, effective/improvedor not effective. Cured had the common meaning ofdizziness and other symptoms having disappeared or allsymptoms disappeared, able to return to work/resumenormal activities and no recurrence within a 1 or 2 yearperiod (depending on the studys follow-up time). Out-standingly effective had a similar meaning but with recur-rence of symptoms occasionally, by, for example, 6 months.

Effective/improved related to relief of symptoms. Partic-ular symptoms were often mentioned as part of the achievedoutcomes, in particular dizziness and vertigo.

3.2. Nature of Acupuncture. The studies covered five typesof acupuncture: body acupuncture; ear acupuncture; scalpacupuncture; fluid acupuncture point injection; and mox-

ibustion. All such types are classifiable as falling withinthe TCM style, ensuring the de-qi sensation. Half ofthe studies involved an individualized TCM prescriptionapproach to the treatment and half used a pre-set pre-scription, itself based on TCM principles and approachesto treating particular symptoms commonly experienced bypersons with Menieres disease, in particular, symptomsof dizziness, vertigo, nausea and vomiting. While none ofstudies mentioned the background of the acupuncturist,acupuncturists in China are all qualified medical doctors andat least 4 years training is required to work in a hospital.

No single, uniform number of courses or duration oftreatment within each course was apparent. In two controlled


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studies [10,14], once daily acupuncture was undertaken for10 days; in another [13], no indication of the number oftreatments or how often the treatment was given; in yetanother [30], patients continued with the treatment untilsymptom relief. Across the studies, a treatment once a dayfor a course of up to 10 sessions with the possibility of a

second (or more) course was common.

3.3. Quality of the Evidence. A number of weaknesses wereevident in the studies. First, as only six of the studieshad a comparison group and four others also includedpre-treatment measurement, any observed improved out-comes could have arisen because of other factors, includingsymptom remission. Secondly, only eight of the studieseither included audiometric testing [9,19,21] or recruitedMenieres disease patients according to established criteriafor Menieres [10,18,23,24,26]. Only two studies includedaudiometric testing as part of their outcome measurement[9,27]. Thirdly, most of the Chinese language studies did not

provide detail on the inclusion/exclusion criteria. Fourthly,very limited detail was provided on the choice of studyparticipants or setting of the studies. Fifthly, the lengthof follow-up (and thus final outcome measurement point)varied; eight studies had a follow-up time of 2 years and ninehad 1 year, while for seven no or little detail was provided.

3.4. Evidence of Effectiveness. The weight of evidence, acrossall study types, is one of the beneficial effects from fivetypes of acupuncturebody, ear or scalp acupuncture, fluidacupuncture point injection, or moxibustion (Table 2). Thethree randomized controlled trials [911] demonstrate astatistically significant benefit of body or scalp acupunc-

ture against Western medicine and vitamins, with a meandifference in the total effectiveness percentage of 14% infavor of acupuncture (P


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Table2:Continued.

Study,study

typeand

country

Treatment,samplesizea

ndfollow-uptime

Confirmeddiagnosis

andtimewith

Menièresdiseas

e

Appropriateness

oftreatment

Keyfindings

Summaryevaluativecomm

entsandoverall

quality

ScalpacupunctureplusherbalmedicineOnce

dailyacupuncturefor7days;simpleherbaltea

(tocontinueteafor1year)

MDacutestage

(hospitalized

followingacute

attack)

TCMindividualized

diagnosisand

treatment,with

herbalremedy

adjusted

Totaleffectivenessrate:97%

18%outstandingeffect

Strengthsinclude:clarityo

veroutcome

measurement,TCMdiagnosisandtreatment

andlengthoffollow-up.

Dongand

Zhou[17]

China

n=

180

70%cured

Follow-up:1year

Upto10years

8%improved

Overallqualityjudgment:Good

MoxibustionatDu-20

Patientswith

clinicallyconfirmed

MD

TCMindividualized

diagnosiswithset

acupoint


Useofstandarddiagnosiscriteriaandoutcome

measurementcriteriaforM

D,appropriate

acupointwithTCMrationale.(Note:treatment

alsoincludedadviceondietandemotion)

Overallqualityjudgment:Good

SunandLi

[18]China

Twiceadayfor15days

75%cured

n=

20

Upto2years

25%outstandinglyimproved

Follow-up:1year

(Du-20)

Post-testdesign Electro-acupuncture,acupunctureand

moxibustion

MDpatientswh

ohad

auditoryvertigo

symptoms

Onesetpointfor

acupuncture,

anotherfor

moxibustion;

otherpoints

addedaccording

toTCMdiagnosis


Targetsonlycaseswithaud

itoryvertigo

syndrome.Detaileddescriptionofother

Menièressymptomsofcases;fullexplanation

ofpotentialroleofacupun

ctureintreating

Menières.

DaiandLiang

[19]

China

Onetreatmentdailyfor

up6days(30min

application)

70%cured

n=

23

18%excellent

Follow-up:1year

Upto17years

Acupuncture

MDqueryove

r

criteria

Individualized

treatment

followingTCM

principles


Strengthsinclude:appropr

iateTCMprinciples.

Butlackofdetailovertreatmentduration,

choiceofparticipantsanddiagnosticcriteria

forMD.

10sessionsfor1month

22%cured

Liu[20]Chinan=

51

Durationno

information

69%improved

Follow-up:2year

Overallqualityjudgment:Poor

MoxibustionatDu-20(over2hours),forupto

threesessions32

ConfirmedMD

(Otol.Dept)

Du-20isagood

experientialpoint

fordizziness.


100%symptom

relief(8

fromonesessio

n,10from

two,and14afterthree).

Strengthsinclude:MDcon

firmedby

OtolaryngologyDepartment,useofstandard

treatmentduration,useof

anappropriate

(Du-20)treatmentpointandlengthof

follow-up.

Chao[21]

China

n=

32

Notdiagnosed

accordingto

TCMtheory.

Weaknessesinclude:unclearsamplingcriteria,

solefocusononeMDsym

ptom(dizziness)

andlackofcontrolgroup.

Follow-up:2years

average9years

Note:

moxibustiononlyNorecurrenceafter2years.

Overallqualityjudgment:Fair


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Table2:Continued.

Study,study

typeand

country


ndfollow-uptime

Confirmeddiagnosis

andtimewith

Meni`eresdiseas

e

Appropriateness

oftreatment

Keyfindings


entsandoverall

quality

Electro-acupuncture

PatientswithMD

Treatment

accordingto

TCMpattern

diagnosis


Shortarticle;inconsequen

ce,limiteddetailson

methods,exceptonacupuncturetreatment.

Tian[22]

China

Twotothreecoursesof10sessionsdaily,with2

daysrestbetweencourse

(1020min

application)

FiftyhadMDfo

r15

years,22for>5years

50%markedimprovement

n=

72

24%improved


Follow-upperiod:1year

Treatmentmor

eeffectivein

casesofshorter

duration

AcupointinjectionatDu-20

PatientswithMD

accordingtobo

ok

ofcommondise

ases

Set,singlepoint

used,withTCM

rationale


Cleardiagnosticcriteriawithdetailed

treatmentprocedure.Butdurationof

follow-upisnotstatedand

lackofclarityover

outcomemeasurement(ca

usesofdizziness

disappeared).

Bo[23]China

Onceadayfor10days,1

daybreak,thenanother

courseoftreatment(330sessionsintotal)

75%cured

n=

88


Follow-up:notstated

Upto3years

23%improved

Wangand

Chen[24]

China

Acupuncturepointsinje

ctionwithDansheng

liquidononesideatonetimeplusscalp

acupuncture

PatientswithMD

Setprescription

butbasedon

goodTCM

treatment

principles


Combinedtraditionaland

scalpneedlingplus

pointsinjectionseemsapotentiallygood

treatmentmethod,andbasedonTCM

principles.WhilediagnosisisbasedonTCM

principles,treatmentisnotindividualized.

Gooddetailontreatmentprocedures.

Acupuncturewithinjectiononceaday,with

scalpacupunctureevery

otherday,for10days.

5-daybreak,secondcourseoftreatment

Upto14years

62%cured

n=

50

30%outstandinglyimprovedOverallqualityjudgment:Fair

Follow-up:2years

Bodyacupuncture

PatientswithMD

Treatment

accordingto

TCMpattern

diagnosis


Studyreportisfromanabstract,translated

fromtheoriginalChinesepaper.Briefdetailon

methodsisprovided,with

extensivedetailon

needlingandTCMrationa

le.

Zhang[25]

China

Coursesof10sessionsw

itha2-dayrestbetween

(30minapplication)

72%cured

n=

18

Upto6years.

Follow-upperiod:2years

22%markedeff

ect



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Table2:Continued.

Study,study

typeand

country


ndfollow-uptime

Confirmeddiagnosis

andtimewith

Menièresdiseas

e

Appropriateness

oftreatment

Keyfindings


entsandoverall

quality

Acupuncture

MDqueryove

r

criteria

Treatment

followingTCM

principles,but

onlyfortheone

symptomof

dizziness


Strengthsinclude:treatmentbasedon

appropriateTCMprinciples.Butlackofdetail

overchoiceofparticipants

ordiagnostic

criteriaforMD,treatment

notindividualized,

nostandardcourseoftreatment,andunclear

lengthoffollow-up

SongandYi

[31]China

Onceadayuntilallsymptomsdisappear(mean

n=

5;range2to>10)

Upto15years

91%curedovershortterm

n=

152

8%improved


Follow-up:unclear

Acupuncture

PatientswithMDat

anacutestage

NoTCM

diagnosis

differentiationor

individualized

treatment


FollowingappropriateTCMprinciplesfor

treatingtwosymptoms(dizzinessand

vomiting)ofMD,butlimiteddetailandno

explicitfollow-upmention

ed.

Zhu[32]

China

n=

51

Upto6years

64%cured

Follow-up:notindicated



Acupuncture

PatientswithMD

Appropriate

acupunctureat

singlepoint.No

TCMpattern

differentiation


Thestudyreportsonalarg

egroupofpatients;

thetreatmentprovidedisanintegrated

treatmentforMD,butthereisalackofdetail

overthenumberofcoursesgiven.

Zhangand

Shang[33]

China

Onceadayfor3days(asonecourse)

57%cured

n=

286

Upto24years


Follow-up:1year


Bodyacupunctureandm

oxibustion

PatientswithMD

Treatment

accordingto

TCMpattern

diagnosis


Shortreportoncasestreatedoveranumberof

years.ArguesthatMenière

ssyndromebelongs

tothecategoryofdizzinessinTCM.

Strengthsincludeoneyear

follow-upandclear

rationalefortreatment.

Lu[34]

China

Onetreatmentperday(30minapplication);

214dailytreatmentsgiven(meanof7.4)

Twenty-twopatients

hadMD10years;

eightfor>10

87%cured

n=

30

13%effective

Follow-up:1year

30%symptom

freeafter1

year;47%re-occurrence

within6month

s


AcupunctureplusmoxibustionatDu-20

MDqueryove

r

criteria

TCMpattern

differentiation

andtreatment


Reportingoncasestreated

since1988forTCM

diagnosisofdizziness.

Wang[35]

China

Onceadayfor7daysas

onecourseoftreatment

n=

30

Upto10years

97%cured


Follow-up:2years

AsteriskindicatedstudieslocatedfromEnglishlanguagesearch.RCT:randomizedcontrolledtrial;CT:controlledtrial;MD:MenièresDisease;I:Intervention;C:Comparison/Control.


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disease would likely be biomedical, acupuncture may besought only when the condition becomes chronic. There arealso differences in education and training of, and access to,acupuncturists (traditional TCM trained practitioners orWestern acupuncture [41], thus the recognized importanceof reporting studies using the STRICTA framework [8].

This strongly suggests the need for a controlled trial ofacupuncture, for both persons in an acute phase and thosewho have had Menieres disease for a number of years.

Any such study needs to be appropriately designed. Asthere is no definitive, demonstrated bio-medical curativeapproach for Menieres disease, choice of comparison groupis not straightforward. A placebo design would seem bothinappropriate and ethically problematic, as it is highlyimprobable that potential study participants will not betaking some medication or other approach to enable themto cope. While arguing for the need for greater and morerigorous evidence, Thorp et al. [3] make a similar commentin the context of conventional medicine. In Europe, anappropriate comparison might be drug treatment. In China,an appropriate contrast might be a (Western) drug approachor different forms of TCM approaches (e.g., types ofacupuncture and/or herbal medicine). Indeed, the formerform of comparison (acupuncture versus a drug or herbalapproach) was used in four of the included controlledstudies[912], and the latter (different forms of acupunctureor Chinese herbal medicine) in two others [13, 14]. It isimportant to note that choice of comparison group shouldbe culturally determined.

Whatever choice is made, it is important that fullmethodological details are provided in the research report,utilizing the STRICTA recommendations [8] both as a guideto reporting but also study design. The review suggests thepotential of exploring treatment once a day for a courseof up to 10 sessions with the possibility of a second (ormore) course. Such research should measure both the short-and longer-term symptom effect, based upon patient reportsof symptom benefit and (time before any) recurrence andextent of severity/symptom relief at any recurrence, generalhealth and well-being effects and a potential greater resolveto cope with the illness.

There are some limitations to this review. First, the Chi-nese literature search accessed only one database and limitedhand searching. More studies might be generated from awider search. Secondly, it is notable that the studies fromChina report positive effects of acupuncture. This may be due

to publication bias, [42] or be a true effect, demonstratingthat frequent and a large number of treatment sessions,evident in the Chinese studies, leads to better outcomes [37].In this regard it is interesting to note one of the findings froma systematic review of clinical trials on acupuncture in theJapanese literature[43]; studies undertaken pre-1990 tendedto focus on the appropriate choice of acupuncture technique,whereas post-1990 the focus tended to be on evaluationof acupuncture efficacy. This finding has some resonancewithin the Chinese literature in this review, especially withinthe case-series studies and their presentation and the depthof explanation about technique. Thirdly, inclusion of non-randomized and uncontrolled studies in the review could

be argued to be problematic [44]. Such studies were usedhere as a means to support, or otherwise, findings frommore powerful studies. In addition, such studies providedadditional information on the maintenance of beneficialeffects. Fourthly, in a recent report relating specifically toCochrane systematic reviews of TCM, where only 5 of the

28 described RCTs could be authenticated as RCTs, Wu et al.[45] argue for the need for review authorsto verify with studyauthors for claims that their RCTs were in fact randomized.This was not undertaken in this study. Fifthly, no attemptis made to draw together any of the TCM explanationsindicated in the included papers about the mechanismsthat might underpin acupuncture effecting the symptoms ofMenieres disease or other factors which may be associatedwith such symptoms.

5. Conclusion

The aim of this systematic review was to locate andcritically appraise evidence for acupuncture as a treatmentfor Menieres disease, drawing from both English andChinese language literature. Despite the range in the qualityof the located evidence, the overall conclusion is of thepotential benefit of acupuncture for persons with Menieresdisease, including those in an acute phase. The review alsodemonstrates the importance of searching for studies in theChinese language for such a therapy as acupuncture, givenits lengthy historical tradition within Chinese medicine. Asall but one of the studies took place within China, furtherresearch is needed in a Western health care context and toexamine the frequency and number of treatment or coursesof acupuncture.

Appendix

SearchStrategy forMEDLINEvia OVID interface

(1) meniere$.mp.

(2) (endolymphatic adj hydrops).mp.

(3) exp Endolymphatic Hydrops/

(4) exp Meniere Disease/

(5) 1 or 2 or 3 or 4

(6) exp Acupuncture Therapy/

(7) (acupuncture or electro? acupuncture or auricu-lotherapy or (auricular adj needles) or (needling adjtherapy) or (electric adj needling)).mp.

(8) exp Medicine, Chinese Traditional/

(9) 6 or 7 or 8

(10) 9 and 5

Key:

mp =title, original title, abstract, name of substance word,subject heading word

exp =explode subject heading


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/ =subject heading (MESH) search

$ =truncation symbol

? =wildcard symbol

adj =adjacent to

FundingResearch Development Fund of the University of Salford.

Acknowledgements

The authors gratefully acknowledge the comments of TonyBennett, as expert patient.

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http://oto2.wustl.edu/men/mntreat.htmhttp://oto2.wustl.edu/men/mntreat.htmhttp://oto2.wustl.edu/men/mntreat.htmhttp://oto2.wustl.edu/men/mntreat.htmhttp://oto2.wustl.edu/men/mntreat.htm


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