Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Efficacy of acupuncture for lifestyle risk factors for stroke: A systematic review

  • David Sibbritt ,

    Roles Conceptualization, Funding acquisition, Methodology, Writing – review & editing

    David.Sibbritt@uts.edu.au

    Affiliation Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia

  • Wenbo Peng,

    Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

    Affiliation Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia

  • Romy Lauche,

    Roles Data curation, Formal analysis, Writing – review & editing

    Affiliation Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia

  • Caleb Ferguson,

    Roles Data curation, Writing – review & editing

    Affiliation Nursing Research Centre, Western Sydney University & Western Sydney Local Health District, Blacktown Clinical & Research School, Blacktown Hospital, Sydney, New South Wales, Australia

  • Jane Frawley,

    Roles Data curation

    Affiliation Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia

  • Jon Adams

    Roles Conceptualization, Funding acquisition, Writing – review & editing

    Affiliation Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia

Efficacy of acupuncture for lifestyle risk factors for stroke: A systematic review

  • David Sibbritt, 
  • Wenbo Peng, 
  • Romy Lauche, 
  • Caleb Ferguson, 
  • Jane Frawley, 
  • Jon Adams
PLOS
x

Abstract

Background

Modifications to lifestyle risk factors for stroke may help prevent stroke events. This systematic review aimed to identify and summarise the evidence of acupuncture interventions for those people with lifestyle risk factors for stroke, including alcohol-dependence, smoking-dependence, hypertension, and obesity.

Methods

MEDLINE, CINAHL/EBSCO, SCOPUS, and Cochrane Database were searched from January 1996 to December 2016. Only randomised controlled trials (RCTs) with empirical research findings were included. PRISMA guidelines were followed and risk of bias was assessed via the Cochrane Collaboration risk of bias assessment tool. The systematic review reported in this paper has been registered on the PROSPERO (#CRD42017060490).

Results

A total of 59 RCTs (5,650 participants) examining the use of acupuncture in treating lifestyle risk factors for stroke met the inclusion criteria. The seven RCTs focusing on alcohol-dependence showed substantial heterogeneity regarding intervention details. No evidence from meta-analysis has been found regarding post-intervention or long-term effect on blood pressure control for acupuncture compared to sham intervention. Relative to sham acupuncture, individuals receiving auricular acupressure for smoking-dependence reported lower numbers of consumed cigarettes per day (two RCTs, mean difference (MD) = -2.75 cigarettes/day; 95% confidence interval (CI) = -5.33, -0.17; p = 0.04). Compared to sham acupuncture those receiving acupuncture for obesity reported lower waist circumference (five RCTs, MD = -2.79 cm; 95% CI: -4.13, -1.46; p<0.001). Overall, only few trials were considered of low risk of bias for smoking-dependence and obesity, and as such none of the significant effects in favour of acupuncture interventions were robust against potential selection, performance, and detection bias.

Conclusions

This review found no convincing evidence for effects of acupuncture interventions for improving lifestyle risk factors for stroke.

Introduction

Stroke is a major health issue with a significant burden upon quality of life and disability [1]. The control of stroke risk factors plays a vital role in reducing the risk of new or subsequent strokes of all types [2]. Three types of risk factors have been identified for stroke, including non-modifiable risk factors, medical risk factors, and lifestyle risk factors [2,3]. Lifestyle risk factors for stroke—hypertension, high cholesterol, smoking-dependence, alcohol-dependence, obesity, poor diet/physical inactivity—approximately accounted for 80% of the global risk of stroke [3]. Therefore, lifestyle risk factors for stroke are an ideal target for stroke prevention in comparison with other risk factors [4]. A growing stroke burden throughout the world suggests contemporary stroke prevention strategies for modifiable lifestyle risk factors may be insufficient and new effective approaches are needed [5]. However, the evidence for modification of lifestyle risk factors which are recommended by clinical guidelines for stroke management are not satisfactory [5,6].

Acupuncture is a traditional Chinese therapeutic intervention characterised by the insertion of fine metallic needles through the skin at specific sites (acupoints), with body and ears being the most common locations of acupoints [7]. Needles may be stimulated manually or by applying electric current [8]. There are various types of acupuncture treatments, such as needle acupuncture, electroacupuncture, acupressure, laser therapy, and transcutaneous electric acupoint stimulation (TEAS) [9]. Acupuncture has long been used for chronic diseases including musculoskeletal pain and hypertension [7]. The biological effects of acupuncture treatments, such as local inflammatory responses, anti-analgesia effects, and increase of opioid peptides, play an important role in the therapeutic effects of such therapy [10]. Nevertheless, the challenges inherent in designing and implementing rigorous acupuncture research may limit the understanding of the effectiveness of acupuncture, such as those relating to acupuncturists’ use of distinct syndrome classifications identified among people with the same condition and use of different skills when selecting and manipulating acupoints [11].

Using acupuncture to manage each lifestyle risk factor for stroke has attracted substantial and growing research interest over many decades. Previous reviews reported promising results of acupuncture use in controlling hypertension-associated symptoms [12], attaining weight loss [13], and reducing nicotine withdrawal symptoms [9]. In addition, WHO has indicated the effect of acupuncture for alcohol-dependence, in particular auricular acupuncture [14]. Nonetheless, a comprehensive systematic review assessing the effect of all forms of acupuncture for all identified lifestyle risk factors for stroke has not been conducted. As such, the aim of this paper is to identify and summarise the contemporary evidence of acupuncture interventions for lifestyle risk factors for stroke.

Methods

The systematic review reported in this paper has been registered with PROSPERO (International prospective register of systematic reviews, #CRD42017060490).

Search strategy

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline, a systematic search of the literature was conducted using the MEDLINE, CINAHL/EBSCO, Scopus, and Cochrane Database of Systematic Reviews databases for studies published from January 1996 to December 2016. The lifestyle risk factors for stroke included in this systematic review are high blood pressure (hypertension & prehypertension), high cholesterol, obesity (overweight/obesity), smoking-dependence, alcohol-dependence, and physical inactivity. The literature search employed keyword and MeSH searches for terms relevant to ‘acupuncture’ and each lifestyle risk factor for stroke. Search terms used for each database are available in Table 1. Relevant randomised controlled trials (RCT) listed as references of published systematic review papers on selected lifestyle risk factors for stroke were also searched via Google Scholar by title, in order to include all relevant RCTs in this field.

Selection criteria

Types of studies.

Studies were eligible for inclusion if they met the following criteria: (1) RCTs focusing on the efficacy and safety of acupuncture for lifestyle risk factors for stroke; (2) conducted in humans; (3) published in a peer-reviewed English language journal with abstracts; (4) reported primary data findings. Exclusion criteria were (1) RCT protocols or observation of a RCT of this research area; (2) quasi-/pseudo-RCTs and cross-over RCTs (3) studies focusing on the efficacy and safety of acupuncture treatment(s) for stroke or post-stroke symptoms; (4) studies focusing on the efficacy and safety of acupuncture treatment(s) for the complications of stroke risk factors; and (5) conference abstracts.

Types of interventions.

There was no limitation on the forms of (traditional) acupuncture and the frequency and duration of the intervention. However, contemporary acupuncture such as trigger points and dry needling was not eligible for inclusion in this review.

Types of outcome measures.

Only anthropometric parameters and the widely used indicators of each lifestyle risk factor for stroke were included. The primary outcomes were a change in systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) for hypertension-focused RCTs; triglycerides, LDL/HDL cholesterol for hyperlipidemia/dyslipidemia-focused RCTs; body weight (BW), body mass index (BMI), waist circumference (WC) for obesity-focused RCTs; alcohol craving, completion rate of treatment, withdrawal symptoms for RCTs focusing on alcohol-dependence; withdrawal symptoms, daily cigarette consumption, abstinence rate for RCTs focusing on smoking-dependence; physical activity minutes/day and cardiorespiratory fitness for physical inactivity-focused RCTs.

Data extraction

Title and abstracts of all citations identified in the search were imported to Endnote (Version X8) and duplicates removed. These citations were independently reviewed for eligibility by two authors (WP and RL) and the full texts of ambiguous articles were retrieved if consensus was not reached. Any disagreements were assessed by a third author. We contacted authors regarding raw data of their RCTs where necessary for meta-analysis. Where we failed to obtain such raw data, the RCT had to be excluded in the meta-analysis. According to the RCT description in the articles included, raw data were extracted from post-intervention effect and/or follow-up (long-term) effect.

Data were extracted into a pre-determined table (Table 2) and checked for coverage and accuracy by two authors independently. Table 2 includes detailed information on sample size, inclusion criteria, participants’ characteristics, intervention groups, add-on strategy, results of outcome measures, and side-effects. Both statistically significant within-group and/or between-group effect of acupuncture interventions for each lifestyle risk factor for stroke were recorded if reported.

Data syntheses

Cochrane RevMan version 5.3 software was employed to conduct meta-analysis of the outcome measures and heterogeneity was determined using I2 statistic [15]. The meta-analysis included all studies where acupuncture was employed with or without co-interventions, provided that such intervention was given to all groups. However, meta-analyses were conducted only if at least two RCTs were available exploring a specific outcome of a risk factor. Acupuncture approaches shown in the meta-analysis include needle acupuncture (body, aural region, electroacupuncture), laser acupuncture, and acupressure. Analyses were performed separately for type of experimental interventions (acupuncture, acupressure, laser acupuncture, or the combination of acupuncture and acupressure) according to the RCT design. Random effects model (Mantel-Haenszel for dichotomous/categorical variables and inverse variance for continuous variables) was used to calculate mean differences (MD), standardized mean differences (SMD), or risk ratios (RR), and 95% confidence intervals (CI) were reported. Sensitivity analyses were used to test the robustness of statistically significant results for RCTs with low risk versus high risk of bias for the domains selection bias and performance/detection bias. Effects sizes of acupuncture compared to other interventions were shown in Table 3.

thumbnail
Table 3. Effect sizes of acupuncture in comparison to sham acupuncture or no treatment.

https://doi.org/10.1371/journal.pone.0206288.t003

Quality assessment

Two authors (DS and WP) independently assessed the risk of bias of all included studies using the Cochrane Risk of Bias Tool for selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), reporting bias (selective outcome reporting), and other bias (Table 4). Disagreements were assessed by a third author. It is worth noting that, due to methodological reasons and the uniqueness of acupuncture treatments, it is not feasible to blind the acupuncturist in acupuncture RCTs. Therefore, we adopted the domain of performance bias and only focused on adequate participant blinding.

thumbnail
Table 4. Risk of bias of the included studies using the Cochrane Risk of Bias Tool.

https://doi.org/10.1371/journal.pone.0206288.t004

Results

The key database searches identified 2,502 records with another six records from Google Scholar search, of which 299 duplicates were removed. After screening, the full texts of 305 papers were reviewed, of which a total of 62 full-text articles (reporting on 59 RCTs) were considered eligible and included in this systematic review. The PRISMA flowchart of literature search and article selection details has been shown in Fig 1.

There were 59 RCTs (5,650 participants) regarding the use of acupuncture interventions in treating lifestyle risk factors for stroke, of which 7 RCTs for alcohol-dependence (845 participants), 15 RCTs for smoking-dependence (1,960 participants), 12 RCTs for hypertension (927 participants), and 25 RCTs for obesity (1,918 participants). No publication reported on a trial examining the efficacy of acupuncture for the lifestyle risk factor for stroke of high cholesterol or physical inactivity as a primary outcome.

Alcohol-dependence

Seven RCTs [1622] focused on acupuncture treatments for alcohol-dependence using outcomes of alcohol craving (four RCTs), alcohol withdrawal symptoms (four RCTs), and drinking days (one RCT). Table 2 shows details of such RCTs’ characteristics and safety-related information. Most of the included studies defined alcohol-dependence according to the 3rd version (revised)/4th version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the 10th version of the International Statistical Classification of Diseases and Related Health Problems (ICD) [1621]. The sample size of RCTs focusing on alcohol-dependence ranged from 20 to 503 participants with only two studies recruiting more than 100 participants.

Psychiatrists/nurses [17,20], acupuncturists [18,22], and oriental medical doctors [16] were reported as administering the acupuncture interventions. The modes of acupuncture delivered within the interventions included both specific and nonspecific/symptom-based auricular acupuncture (five studies), body acupuncture (one study), and combined auricular and body acupuncture (one study). Acupuncture treatment sessions ranged from 30-minutes to 45-minutes. Only one RCT employed needle stimulation technique for the acupuncture treatment of alcohol-dependence [17].

Non-significant differences between acupuncture and control groups for alcohol craving were reported in three RCTs [16,17,20], alcohol withdrawal symptoms in two RCTs [17,18], and drinking days in one RCT [20]. Statistically significant within-intervention group effects were reported for alcohol craving with specific auricular electroacupuncture [21] and alcohol withdrawal symptoms with combined use of auricular and body acupuncture [19], while statistically significant between-group effects were reported for alcohol withdrawal symptoms with symptom-based auricular acupuncture (VS specific auricular acupuncture) [22].

Risk of bias assessment indicated that three RCTs did not report information on random sequence generation, four RCTs failed to apply blinding to participants and personnel, one did not report adequate blinding of outcome assessors, and three failed to report complete outcome data (Table 4). Due to the great heterogeneity regarding intervention details and outcomes applied in the RCTs focusing on alcohol-dependence, no meta-analysis could be conducted.

Smoking-dependence

Fifteen RCTs [2338] focused on acupuncture treatments for smoking-dependence using outcomes of daily cigarette consumption (eight RCTs), smoking cessation rate (eight RCTs), smoking withdrawal symptoms (six RCTs), desire to smoke (two RCTs), cotinine concentrations (one RCT), and craving (one RCT). The details of such RCTs’ characteristics and safety-related information have been presented in Table 2. The majority of these RCTs defined smoking-dependence according to the number of cigarettes daily and/or smoking period [2330,3235,3738]. The sample size of the RCTs ranged from 29 to 477 participants, with six RCTs recruiting more than 100 participants.

Acupuncturists were reported to administer the acupuncture intervention in seven RCTs [23,24,26,3133,37], while physicians and researchers were reported to administer the acupuncture intervention in two RCTs [25,38] and one RCT [28], respectively. The modes of acupuncture delievered within the RCTs focusing on smoking-dependence included auricular acupuncture (four RCTs), auricular acupressure (three RCTs), body acupuncture (one RCT), TEAS (two RCTs), combined auricular acupuncture and auricular acupressure (two RCTs), combined auricular acupuncture, body acupuncture, and education (one RCT), combined auricular acupressure, body acupuncture, and psychological support (one RCT), and combined auricular acupuncture, body acupuncture, and auricular acupressure (one RCT). A total of 11 RCTs included acupuncture treatment follow-ups [2429,31,33,3638] and most ranged between 3 months to 9 months after the treatment. All electroacupuncture RCTs were conducted over 20-minutes (per session) with different stimulation frequency [2326,32,34].

Study results reported statistically significant within-intervention group effects for (a) daily cigarette consumption with combined body electroacupuncture, auricular acupuncture and auricular acupressure [23,24], auricular acupuncture [33], combined auricular electroacupuncture and acupressure [34], auricular acupressure [36], (b) desire to smoke with combined body electroacupuncture, auricular acupuncture and auricular acupressure [23,24], and (c) smoking withdrawal symptoms with auricular acupuncture [33]. Statistically significant between-group effects were reported for (a) smoking cessation rate with combined body electroacupuncture, auricular acupuncture and auricular acupressure (VS non-specific acupuncture) [23,24], combined auricular electroacupuncture and acupressure (VS sham acupuncture) [25], combined auricular acupuncture, body acupuncture, and education (VS sham acupuncture plus education) [31], (b) daily cigarette consumption with combined body electroacupuncture, auricular acupuncture and auricular acupressure [23,24], combined auricular acupuncture, body acupuncture, and education [31], (c) desire to smoke with combined body electroacupuncture, auricular acupuncture and auricular acupressure [23,24], TEAS (VS sham TEAS) [30], and (d) smoking withdrawal symptoms with body acupuncture (VS non-specific acupuncture) [35].

Compared to sham acupuncture, meta-analyses demonstrated individuals receiving auricular acupressure for smoking-dependence reported lower numbers of consumed cigarettes per day (two RCTs, MD = -2.75 cigarettes/day; 95%CI: -5.33, -0.17; p = 0.04; heterogeneity: I2 = 0%; Chi2 = 0.45; p = 0.50). However, none of the effect of these two RCTs was robust against selection bias and performance/detection bias. Meta-analysis did not show evidence for post-intervention effect of acupuncture interventions on smoking withdrawal symptoms compared to sham acupuncture (three RCTs, SMD = -0.95; 95%CI: -2.17, 0.26; p = 0.12). In addition, no evidence from meta-analysis has been found with regards to post-intervention effect on smoking cessation rate compared to sham controls, including acupuncture (three RCTs, RR = 1.11; 95% CI: 0.85, 1.46; p = 0.44), auricular acupressure (two RCTs, RR = 0.39; 95% CI: 0.08, 1.96; p = 0.26), and acupuncture plus auricular acupressure (two RCTs, RR = 2.51; 95% CI: 0.26, 24.24; p = 0.43). There was also no evidence for long-term effect on smoking cessation rate, including acupuncture (two RCTs, RR = 1.13; 95% CI: 0.40, 3.21; p = 0.82), auricular acupressure (two RCTs, RR = 2.43; 95% CI: 0.40, 14.66; p = 0.33), and acupuncture plus auricular acupressure (two RCTs, RR = 1.97; 95% CI: 0.67, 5.80; p = 0.22), when compared to sham controls (Table 3). Risk of bias assessment indicated 13 RCTs applied random sequence generation while nine RCTs did not allocate concealment appropriately. Seven RCTs failed to report information on blinding of outcome assessment. Ten RCTs did not provide complete outcome data (Table 4).

Hypertension

Twelve RCTs [3950] focused on acupuncture treatments for hypertension using outcomes of both SBP and DBP (12 RCTs), nighttime SBP and DBP (one RCT), daytime SBP and DBP (one RCT). See Table 2 for details of these RCTs’ characteristics and safety-related information. Most of these RCTs defined hypertension according to the [varied] upper and lower cut-off points of SBP and DBP levels with/without antihypertensive medication(s). The sample size of these RCTs ranged from 30 to 160 participants, and three of these studies recruited more than 100 participants.

Acupuncturists [39,46,48], physicians [44], Korean medicine practitioners [40], and naturopaths [49] administered acupuncture for hypertension. The modes of acupuncture delivered within the interventions included body acupuncture (eight RCTs), body acupressure (one RCT), combined body and auricular acupuncture (two RCTs), combined body acupuncture and music treatment (one RCT), and combined body acupuncture and exercise (one RCT). Four RCTs followed the effects of acupuncture interventions up to 12 months after treatment [39,43,45,48]. Seven RCTs using needle acupuncture employed stimulation techniques [39,40,4447,49].

Both statistically significant within-intervention group and between-group effects were reported in five RCTs for (a) SBP as well as DBP levels with body acupuncture (VS non-specific acupuncture) [48], combined body acupuncture and exercise (VS sham acupuncture plus exercise) [44], combined laser body acupuncture with/without music treatment (VS starch tablets) [47], body acupressure (VS sham acupuncture) [50], (b) nighttime DBP level with body acupuncture (VS sham acupuncture) [40]. In addition, study results reported statistically significant within-intervention group effects for (a) SBP as well as DBP levels with laser acupuncture [41], (b) SBP level with body electroacupuncture [42], (c) DBP level with combined body and auricular acupuncture [49], and statistically significant between-group effect for SBP level with body electroacupuncture (VS sham acupuncture) [43].

Meta-analyses did not show evidence for neither post-intervention nor long-term effect of acupuncture interventions on SBP control (two RCTs on acupuncture, MD = -0.54 mmHg; 95%CI: -10.69, 9.60; p = 0.92) and DBP control (two RCTs on acupuncture, MD = -1.38 mmHg; 95%CI: -4.06, 1.31; p = 0.32) compared to sham acupuncture (Table 3). Risk of bias assessment indicated only six hypertension-focused RCTs blinded participants and personnel appropriately and seven RCTs did not report information on blinding of outcome assessment (Table 4).

Obesity

A total of 25 RCTs [5177] focused on acupuncture treatments for obesity using outcomes of BMI (19 RCTs), BW (including weight loss) (18 RCTs), WC (11 RCTs), hip circumstance (four RCTs), eating suppression (two RCTs), waist-to-hip ratio (two RCTs), and fat mass (two RCTs). See Table 2 for details of the characteristics and safety-related information of these studies. Most of these RCTs defined obesity according to participants’ BMI with/without WC [5257,5977]. The sample size of these 25 RCTs ranged from 27 to 196 participants, and three of these studies recruited more than 100 participants.

Among the 11 obesity-focused RCTs that specified the personnel who administered acupuncture, acupuncturists were chosen in nine RCTs [52,55,58,59,6264,66,67]. The modes of acupuncture delivered within the interventions included auricular acupressure (six RCTs), auricular acupuncture (four RCTs), body acupuncture (four RCTs), Tapas acupressure or TEAS (two RCTs), combined auricular acupuncture and auricular acupressure (one RCT), combined auricular and body acupuncture with/without other intervention(s) (ie. moxibustion, exercise, diet) (three RCTs), auricular acupressure with TEAS or exercise (two RCTs), and body acupuncture with exercise, diet, or massage (three RCTs). Three obesity-focused RCTs followed the effect of acupuncture interventions, from 10-weeks to 12-months after the treatment [66,67,73]. All the electroacupuncture/TEAS studies focusing on BW employed different stimulation frequency with varied treatment durations [54,58,62,63,67,69,70,73,75,77].

Study results reported statistically significant within-intervention group effects for all BW, BMI, and WC with auricular acupressure (BW [60,61,6466,71]; BMI [56,60,61,6466,71]; WC [60,61,64,65]), combined auricular acupressure and TEAS [63], combined auricular acupressure and exercise [68], and body acupuncture [67,70]. Additionally, study results reported statistically significant within-intervention group effects for both BW and BMI with TEAS [62] and combined body acupuncture and massage [76]. Statistically significant between-group effects were reported for all BW, BMI, and WC with auricular acupressure (BW [61,61,65,71]; BMI [71]; WC [60,61,65]), auricular acupuncture (BW [51,72,73]; BMI [72,73]; WC [54,74]), and body acupuncture (BW [54]; BMI [54,74]; WC [54,74]). Combined body acupuncture and auricular acupuncture with/without exercise and diet has also shown statistically significant between-group effects for BW [53] and BMI [58], respectively.

Relative to sham acupuncture, meta-analyses only found those receiving acupuncture interventions for obesity reported lower waist circumference (five RCTs, MD = -2.79 cm; 95% CI: -4.13, -1.46; p<0.001; heterogeneity: I2 = 0%; Chi2 = 1.61; p = 0.81). However, after excluding RCTs with other than low risks of selection and performance/detection bias, none of the effect remained statistically significant. In comparison with no treatment intervention, meta-analyses did not show evidence for post-intervention effect of acupuncture interventions on BW (two RCTs on acupuncture, MD = -1.12 kg; 95%CI: -5.51, 3.27; p = 0.62; two RCTs on auricular acupressure, MD = -2.87 Kg; 95%CI: -6.47, 0.74; p = 0.12). Meta-analyses also did not show evidence for post-intervention effect of auricular acupressure interventions on BMI (two RCTs, MD = -0.41 kg/m2; 95%CI: -1.56, 0.73; p = 0.48) compared to no treatment (Table 3). Risk of bias assessment was unclear in numerous obesity-focused RCTs due to a lack of detail in the publications. Specifically, nine RCTs did not report random sequence generation and allocation concealment information. Twelve RCTs failed to report complete outcome data. Fifteen RCTs did not blind participants and personnel and 20 RCTs did not provide information on blinding of outcome assessment (Table 4).

Discussion

This article reports the first systematic review of the effect of acupuncture interventions for lifestyle risk factors for stroke. A number of acupuncture techniques have been used for the management of these lifestyle risk factors and have yielded limited improvements in outcomes. No analysis can be conducted on RCTs focusing on alcohol-dependence and no evidence of the effect of acupuncture treatments on high blood pressure was shown based on meta-analysis. The meta-analysis showed individuals receiving auricular acupressure reported better outcomes in daily cigarette consumption than sham acupressure. Furthermore, acupuncture users have reported better outcomes in reducing waist circumference compared to sham acupuncture. No serious side effects occurred when using acupuncture on these four lifestyle risk factors. However, approximately half of the RCTs focusing on hypertension and obesity did not report safety information of acupuncture users. As such, acupuncture appears to be a relative safe treatment for the management of lifestyle risk factors for stroke.

Some evidence of the benefits of acupuncture and/or auricular acupressure was revealed for RCTs of lifestyle risk factors for stroke—smoking-dependence and obesity—in our review. However, a total of eight and 14 types of acupuncture-related interventions have been examined in RCTs focusing on smoking-dependence and obesity, respectively. The findings reported here highlighted the gaps in the evidence of clinical acupuncture use in the specific field of lifestyle risk factors for stroke and generally. Consistent with findings of prior systematic reviews [9,78], acupuncture involves a range of techniques. Both acupuncture-associated clinical trials and observational studies are required to determine methodology issues such as the use of acupuncture only, acupressure only, or the combination of acupuncture and acupressure, and the further choices of acupuncture like needle acupuncture, electroacupuncture and laser acupuncture. Therefore, future high-quality research is warranted to confirm our preliminary findings and provide robust effect estimates of acupuncture interventions for lifestyle risk factors for stroke.

In our review, approximately half of the RCTs focusing on smoking-dependence and obesity employed auricular acupressure alone or in combination with other acupuncture intervention(s). Acupressure is considered more practical (ease of application by patients themselves) with low cost, compared to other acupuncture treatments [79]. However, no consistent and convincing evidence has been found in this review on whether acupressure is effective for the management of overall lifestyle risk factors for stroke. As a result, there is insufficient evidence to conclude that the use of acupressure could improve the lifestyle risk factors for stroke and more studies are required.

Sham acupuncture is the most frequently employed comparison for acupuncture treatments in general [80] and among people with lifestyle risk factors for stroke which has been shown in our review. Although meta-analysis presented here reported statistically significant benefits of real acupuncture interventions regarding the management of the lifestyle risk factors of smoking-dependence and obesity than sham interventions, none of the effects of the RCTs included in the analyses was robust against potential selection, performance, and detection bias. In addition to the identified design challenges of acupuncture-associated RCTs regarding the choice of control group with the fact that sham acupuncture may also trigger physiological effect [81], future acupuncture-associated RCTs should avoid high risk of bias from lack of allocation concealment and missing outcome data, persuade original investigators to provide sufficient information on blinding of outcome ascertainment and if necessary, choose an appropriate comparable control intervention for clinical acupuncture research.

Some limitations of our systematic review are worth noting. The acupuncture interventions varied greatly across the RCTs of each lifestyle risk factor for stroke included in this review in terms of inclusion criteria of participants, acupuncture forms, acupoint selection, manipulation methods, and frequency/duration of the treatments. Also, this systematic review was restricted to RCTs published in English-language peer-reviewed journals. Furthermore, a proportion of included studies were not registered before they were published, we therefore cannot rule out the possibility of reporting or publication bias. The findings in this systematic review regarding the effect of acupuncture for lifestyle risk factors for stroke should be interpreted with caution. However, compared to previous Cochrane and systematic reviews [9,12,13,82], based on the risk of bias evaluation (Table 4), the methodological quality of RCTs on acupuncture treatments identified in our review has improved over recent years, including regards to random sequence generation application, the reporting of acupuncture treatments, and use of long-term follow-ups.

Conclusion

This review shows no convincing evidence regarding the effect of acupuncture, acupressure, laser acupuncture or their combination use for lifestyle risk factors for stroke. However, the translation of findings of this systematic review may contribute to the evidence-base of potential clinical practice guideline recommendations for stroke prevention.

Supporting information

References

  1. 1. Cerniauskaite M, Quintas R, Koutsogeorgou E, Meucci P, Sattin D, Leonardi M, et al. Quality-of-life and disability in patients with stroke. Am J Phys Med Rehabil. 2012;91:S39–S47. pmid:22193309
  2. 2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Executive summary: heart disease and stroke statistics-2015 update. Circulation. 2015;131:434–441.
  3. 3. Stroke Foundation. Stroke risk factors. 2017. https://strokefoundation.org.au/About-Stroke/Preventing-stroke/Stroke-risk-factors.
  4. 4. Gorelick PB. Stroke prevention. An opportunity for efficient utilization of health care resources during the coming decade. Stroke. 1994;25:220–224. pmid:8266373
  5. 5. Feigin VL, Norrving B, George MG, Foltz JL, Roth GA, Mensah GA. Prevention of stroke: a strategic global imperative. Nat Rev Neurol. 2016;12:501–512. pmid:27448185
  6. 6. Gee ME, Bienek A, Campbell NR, Bancej CM, Robitaille C, Kaczorowski J, et al. Prevalence of, and barriers to, preventive lifestyle behaviors in hypertension (from a national survey of Canadians with hypertension). Am J Cardiol. 2012;109:570–575. pmid:22154320
  7. 7. National Center for Complementary and Integrative Health. Acupuncture: In depth. 2016. https://nccih.nih.gov/health/acupuncture/introduction.
  8. 8. Langevin HM, Schnyer R, MacPherson H, Davis R, Harris RE, Napadow V, et al. Manual and electrical needle stimulation in acupuncture research: pitfalls and challenges of heterogeneity. J Altern Complement Med. 2015;21:113–128. pmid:25710206
  9. 9. White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev. 2014;1:CD000009. pmid:24459016
  10. 10. National Center for Complementary and Integrative Health. Acupuncture research—areas of high and low programmatic priorities. 2015. https://nccih.nih.gov/grants/acupuncture/priorities.
  11. 11. Luo J, Xu H, Liu B. Real world research: a complementary method to establish the effectiveness of acupuncture. BMC Complement Altern Med. 2015;15:153. pmid:25997850
  12. 12. Lee H, Kim SY, Park J, Kim YJ, Lee H, Park HJ. Acupuncture for lowering blood pressure: systematic review and meta-analysis. Am J Hypertens. 2009;22:122–128. pmid:19008863
  13. 13. Belivani M, Dimitroula C, Katsiki N, Apostolopoulou M, Cummings M, Hatzitolios AI. Acupuncture in the treatment of obesity: a narrative review of the literature. Acupunct Med. 2013;31:88–97. pmid:23153472
  14. 14. Chmielnicki B. Evidence based acupuncture: WHO official position. 2016. https://www.evidencebasedacupuncture.org/who-official-position/.
  15. 15. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560. pmid:12958120
  16. 16. Lee JS, Kim SG, Jung TG, Jung WY, Kim SY. Effect of Zhubin (KI9) acupuncture in reducing alcohol craving in patients with alcohol dependence: a randomized placebo-controlled trial. Chin J Integr Med. 2015;21:307–311. pmid:25253549
  17. 17. Kunz S, Schulz M, Lewitzky M, Driessen M, Rau H. Ear acupuncture for alcohol withdrawal in comparison with aromatherapy: a randomized-controlled trial. Alcohol Clin Exp Res. 2007;31:436–442. pmid:17295728
  18. 18. Trümpler F, Oez S, Stähli P, Brenner HD, Jüni P. Acupuncture for alcohol withdrawal: a randomized controlled trial. Alcohol Alcohol. 2003;38:369–375. pmid:12814907
  19. 19. Karst M, Passie T, Friedrich S, Wiese B, Schneider U. Acupuncture in the treatment of alcohol withdrawal symptoms: a randomized, placebo-controlled inpatient study. Addict Biol. 2002;7:415–419. pmid:14578018
  20. 20. Sapir-Weise R, Berglund M, Frank A, Kristenson H. Acupuncture in alcoholism treatment: a randomized out-patient study. Alcohol Alcohol. 1999;34:629–635. pmid:10456592
  21. 21. Rampes H, Pereira S, Mortimer A, Knowles M. Does electroacupuncture reduce craving for alcohol? A randomized controlled study. Complement Ther Med. 1997;5:19–26.
  22. 22. Bullock ML, Kiresuk TJ, Sherman RE, Lenz SK, Culliton PD, Boucher TA, et al. A large randomized placebo controlled study of auricular acupuncture for alcohol dependence. J Subst Abuse Treat. 2002;22:71–77. pmid:11932132
  23. 23. He D, Berg JE, Hostmark AT. Effects of acupuncture on smoking cessation or reduction for motivated smokers. Prev Med. 1997;26:208–214. pmid:9085389
  24. 24. He D, Medbø J, Høstmark A. Effect of acupuncture on smoking cessation or reduction: an 8-month and 5-year follow-up study. Prev Med. 2001;33:364–372. pmid:11676576
  25. 25. Waite NR, Clough JB. A single-blind, placebo-controlled trial of a simple acupuncture treatment in the cessation of smoking. Br J Gen Pract. 1998;48:1487–1490. pmid:10024707
  26. 26. White AR, Resch KL, Ernst E. Randomized trial of acupuncture for nicotine withdrawal symptoms. Arch Intern Med. 1998;158:2251–2255. pmid:9818805
  27. 27. Georgiou AJ, Spencer CP, Davies GK, Stamp J. Electrical stimulation therapy in the treatment of cigarette smoking. J Subst Abuse. 1998;10:265–274. pmid:10689659
  28. 28. White AR, Moody RC, Campbell JL. Acupressure for smoking cessation–a pilot study. BMC Complement Altern Med. 2007;7:8. pmid:17359519
  29. 29. Cai Y, Zhao C, Wong Song U, Lei Z, Kean LS. Laser acupuncture for adolescent smokers-a randomized double-blind controlled trial. Am J Chin Med. 2000;28:443–449. pmid:11154059
  30. 30. Lambert C, Berlin I, Lee TL, Hee SW, Tan AS, Picard D, et al. A standardized transcutaneous electric acupoint stimulation for relieving tobacco urges in dependent smokers. Evid Based Complement Alternat Med. 2011;2011:195714. pmid:19073777
  31. 31. Bier ID, Wilson J, Studt P, Shakleton M. Auricular acupuncture, education, and smoking cessation: a randomized, sham-controlled trial. Am J Public Health. 2002;92:1642–1647. pmid:12356614
  32. 32. Fritz DJ, Carney RM, Steinmeyer B, Ditson G, Hill N, Zee-Cheng J. The efficacy of auriculotherapy for smoking cessation: a randomized, placebo-controlled trial. J Am Board Fam Med. 2013;26:61–70. pmid:23288282
  33. 33. Wu TP, Chen FP, Liu JY, Lin MH, Hwang SJ. A randomized controlled clinical trial of auricular acupuncture in smoking cessation. J Chin Med Asso. 2007;70:331–338.
  34. 34. Yeh ML, Chang CY, Chu NF, Chen HH. A six-week acupoint stimulation intervention for quitting smoking. Am J Chin Med. 2009;37:829–836. pmid:19885943
  35. 35. Chae Y, Kang OS, Lee HJ, Kim SY, Lee H, Park HK, et al. Effect of acupuncture on selective attention for smoking-related visual cues in smokers. Neurol Res. 2010;32 Suppl 1:27–30.
  36. 36. Wing Y, Lee A, Wong E, Leung P, Zhang L, Pang ESY. Auricular acupressure for smoking cessation: a pilot randomized controlled trial. Med Acupunct. 2010;22:265–271.
  37. 37. Zhang AL, Di YM, Worsnop C, May BH, Da Costa C, Xue CC. Ear acupressure for smoking cessation: a randomised controlled trial. Evid Based Complement Alternat Med. 2013;2013:637073. pmid:24191168
  38. 38. Baccetti S, Monechi MV, Fre MD, Conti T, Faedda M, Panti P, et al. Smoking cessation with counselling and traditional Chinese medicine (TCM): a randomized controlled trial. Acupuncture and Related Therapies. 2015;3:48–54.
  39. 39. Macklin EA, Wayne PM, Kalish LA, Valaskatgis P, Thompson J, Pian-Smith MC, et al. Stop Hypertension with the Acupuncture Research Program (SHARP). Results of a randomized, controlled clinical trial. Hypertension. 2006;48:838–845. pmid:17015784
  40. 40. Kim HM, Cho SY, Park SU, Sohn IS, Jung WS, Moon SK, et al. Can acupuncture affect the circadian rhythm of blood pressure? A randomized, double-blind, controlled trial. J Altern Complement Med. 2012;18:918–923. pmid:22906144
  41. 41. Zhang J, Marquina N, Oxinos G, Sau A, Ng D. Effect of laser acupoint treatment on blood pressure and body weight—a pilot study. J Chiropr Med. 2008;7:134–139. pmid:19646375
  42. 42. Zhang J, Ng D, Sau A. Effects of electrical stimulation of acupuncture points on blood pressure. J Chiropr Med. 2009;8:9–14. pmid:19646381
  43. 43. Li P, Tjen-A-Looi SC, Cheng L, Liu D, Painovich J, Vinjamury S, et al. Long-lasting reduction of blood pressure by electroacupuncture in patients with hypertension: Randomized controlled trial. Med Acupunct. 2015;27:253–266. pmid:26392838
  44. 44. Yin C, Seo B, Park HJ, Cho M, Jung W, Choue R, et al. Acupuncture, a promising adjunctive therapy for essential hypertension: a double-blind, randomized, controlled trial. Neurol Res. 2007;29 Suppl 1:S98–S103.
  45. 45. Liu Y, Park JE, Shin KM, Lee M, Jung HJ, Kim AR, et al. Acupuncture lowers blood pressure in mild hypertension patients: a randomized, controlled, assessor-blinded pilot trial. Complement Ther Med. 2015;23:658–665. pmid:26365445
  46. 46. Chen H, Dai J, Zhang X, Wang K, Huang S, Cao Q, et al. Hypothalamus-related resting brain network underlying short-term acupuncture treatment in primary hypertension. Evid Based Complement Alternat Med. 2013;2013:808971. pmid:23781269
  47. 47. Zhan HR, Hong ZS, Chen YS, Hong HY, Weng ZB, Yang ZB, et al. Non-invasive treatment to grade 1 essential hypertension by percutaneous laser and electric pulse to acupoint with music: A randomized controlled trial. Chin J Integr Med. 2016;22:696–703. pmid:27614452
  48. 48. Flachskampf FA, Gallasch J, Gefeller O, Gan J, Mao J, Pfahlberg AB, et al. Randomized trial of acupuncture to lower blood pressure. Circulation. 2007;115:3121–3129. pmid:17548730
  49. 49. Sriloy M, Nair P, Pranav K, Sathyanath D. Immediate effect of manual acupuncture stimulation of four points versus slow breathing in declination of blood pressure in primary hypertension-A parallel randomized control trial. Acupuncture and Related Therapies. 2015;3:15–18.
  50. 50. Lin GH, Chang WC, Chen KJ, Tsai CC, Hu SY, Chen LL. Effectiveness of acupressure on the Taichong acupoint in lowering blood pressure in patients with hypertension: a randomized clinical trial. Evid Based Complement Alternat Med. 2016;2016:1549658. pmid:27803727
  51. 51. Richards D, Marley J. Stimulation of auricular acupuncture points in weight loss. Australian Family Physician. 1998;27 Suppl 2:S73–S77.
  52. 52. Mazzoni R, Mannucci E, Rizzello SM, Ricca V, Rotella CM. Failure of acupuncture in the treatment of obesity: a pilot study. Eat Weight Disord. 1999;4:198–202. pmid:10728182
  53. 53. Wei Q, Liu Z. Treatment of simple obesity with auricular acupuncture, body acupuncture and combination of auricular and body acupuncture. Chinese Journal of Clinical Rehabilitation. 2004;8:4357–4359.
  54. 54. Hsu CH, Hwang KC, Chao CL, Chang HH, Chou P. Electroacupuncture in obese women: a randomized, controlled pilot study. J Womens Health. 2005;14:434–440.
  55. 55. Elder C, Ritenbaugh C, Mist S, Aickin M, Schneider J, Zwickey H, et al. Randomized trial of two mind-body interventions for weight-loss maintenance. J Altern Complement Med. 2007;13:67–78. pmid:17309380
  56. 56. Hsieh CH. Auricular acupressure for weight reduction in obese Asian young adults: a randomized controlled trial. Med Acupunct. 2007;19:181–184.
  57. 57. Yeh CH, Yeh SC. Effects of ear points' pressing on parameters related to obesity in non-obese healthy and obese volunteers. J Altern Complement Med. 2008;14:309–314. pmid:18377231
  58. 58. Nourshahi M, Ahmadizad S, Nikbakht H, Heidarnia MA, Ernst E. The effects of triple therapy (acupuncture, diet and exercise) on body weight: a randomized, clinical trial. Int J Obes. 2009;33:583–587.
  59. 59. Hsu CH, Wang CJ, Hwang KC, Lee TY, Chou P, Chang HH. The effect of auricular acupuncture in obese women: a randomized controlled trial. J Womens Health. 2009;18:813–818.
  60. 60. Hsieh CH. The effects of auricular acupressure on weight loss and serum lipid levels in overweight adolescents. Am J Chin Med. 2010;38:675–682. pmid:20626053
  61. 61. Hsieh CH, Su TJ, Fang YW, Chou PH. Effects of auricular acupressure on weight reduction and abdominal obesity in Asian young adults: a randomized controlled trial. Am J Chin Med. 2011;39:433–440. pmid:21598412
  62. 62. Rerksuppaphol L, Rerksuppaphol S. Efficacy of transcutaneous electrical acupoint stimulation compared to electroacupuncture at the main acupoints for weight reduction in obese Thai women. International Journal of Collaborative Research on Internal Medicine & Public Health. 2011;3:811–820.
  63. 63. Rerksuppaphol L. Efficacy of auricular acupressure combined with transcutaneous electrical acupoint stimulation for weight reduction in obese women. J Med Assoc Thai. 2012;95 Suppl 12:S32–S39.
  64. 64. Lien CY, Liao LL, Chou P, Hsu Ch. Effects of auricular stimulation on obese women: A randomized, controlled clinical trial. European Journal of Integrative Medicine. 2012;4:e45–e53.
  65. 65. Hsieh CH, Su TJ, Fang YW, Chou PH. Efficacy of two different materials used in auricular acupressure on weight reduction and abdominal obesity. Am J Chin Med. 2012;40:713–720. pmid:22809026
  66. 66. Darbandi M, Darbandi S, Mobarhan MG, Owji AA, Zhao B, Iraji K, et al. Effects of auricular acupressure combined with low-calorie diet on the leptin hormone in obese and overweight Iranian individuals. Acupunct Med. 2012;30:208–213. pmid:22729014
  67. 67. Abdi H, Zhao B, Darbandi M, Ghayour-Mobarhan M, Tavallaie S, Rahsepar AA, et al. The effects of body acupuncture on obesity: anthropometric parameters, lipid profile, and inflammatory and immunologic markers. Scientific World Journal. 2012;2012:603539. pmid:22649299
  68. 68. He W, Zhou Z, Li J, Wang L, Zhu B, Litscher G. Auricular acupressure plus exercise for treating primary obese women: A randomized controlled clinical trial. Med Acupunct. 2012;24:227–232.
  69. 69. Guo Y, Xing M, Sun W, Yuan X, Dai H, Ding H. Plasma nesfatin-1 level in obese patients after acupuncture: a randomised controlled trial. Acupunct Med. 2014;32:313–317. pmid:24813558
  70. 70. Wu J, Li Q, Chen L, Tian D. Clinical research on using acupuncture to treat female adult abdominal obesity with spleen deficiency and exuberant dampness. J Tradit Chin Med. 2014;34:274–278. pmid:24992753
  71. 71. Kim D, Ham OK, Kang C, Jun E. Effects of auricular acupressure using Sinapsis alba seeds on obesity and self-efficacy in female college students. J Altern Complement Med. 2014;20:258–264. pmid:24070326
  72. 72. Yeo S, Kim K, Lim S. Randomised clinical trial of five ear acupuncture points for the treatment of overweight people. Acupunct Med. 2014;32:132–138. pmid:24342715
  73. 73. Schukro RP, Heiserer C, Michalek-Sauberer A, Gleiss A, Sator-Katzenschlager S. The effects of auricular electroacupuncture on obesity in female patients-a prospective randomized placebo-controlled pilot study. Complement Ther Med. 2014;22:21–25. pmid:24559812
  74. 74. Darbandi M, Darbandi S, Owji AA, Mokarram P, Mobarhan MG, Fardaei M, et al. Auricular or body acupuncture: which one is more effective in reducing abdominal fat mass in Iranian men with obesity: a randomized clinical trial. J Diabetes Metab Disord. 2014;13:92. pmid:25505744
  75. 75. Yeh ML, Chu NF, Hsu MY, Hsu CC, Chuang YC. Acupoint stimulation on weight reduction for obesity: a randomized sham-controlled study. West J Nurs Res. 2015;37:1517–1530. pmid:25183702
  76. 76. He J, Zhang X, Qu Y, Huang H, Liu X, Du J, et al. Effect of combined manual acupuncture and massage on body weight and body mass index reduction in obese and overweight women: a randomized, short-term clinical trial. J Acupunct Meridian Stud. 2015;8:61–65. pmid:25952121
  77. 77. Jiao C, Zhu X, Zhang H, Du X. EMP acupoint stimulation conducive to increase the effect of weight reduction through aerobic exercise. Int J Clin Exp Med. 2015;8:11317–11321. pmid:26379942
  78. 78. Zhang CS, Yang AW, Zhang AL, May BH, Xue CC. Sham control methods used in ear-acupuncture/ear-acupressure randomized controlled trials: a systematic review. J Altern Complement Med. 2014;20:147–161. pmid:24138333
  79. 79. Au DW, Tsang HW, Ling PP, Leung CH, Ip PK, Cheung WM. Effects of acupressure on anxiety: a systematic review and meta-analysis. Acupunct Med. 2015;33:353–359. pmid:26002571
  80. 80. World Health Organization. Acupuncture: review and analysis of reports on controlled clinical trials. 2002. http://www.iama.edu/OtherArticles/acupuncture_WHO_full_report.pdf.
  81. 81. Lewith G. The treatment of tobacco addiction. Complement Ther Med. 1995;3:142–145.
  82. 82. Cho SH, Whang WW. Acupuncture for alcohol dependence: a systematic review. Alcohol Clin Exp Res. 2009;33:1305–1313. pmid:19413653