Hay Fever Prophylaxis using Single Point Acupuncture: a Pilot Study

Hay Fever Prophylaxis using Single Point Acupuncture: a Pilot Study

The results of this study were presented at the BMAS Spring Scientific Meeting held at Cheltenham in May 1994

Summary

To determine whether Single point, Liver 3 (Taichong), acupuncture is effective for hay fever prophylaxis in a dedicated general practice clinic setting, 30 patients suffering from long-standing, moderate to severe hay fever were randomised to acupuncture or conventional therapy. Three, ten minute acupuncture treatments were given at weekly intervals during April 1993.

Four of the fifteen acupuncture patients had complete remission of symptoms compared with none from the control group. The rest of the acupuncture group had a variable response, but a small, significant improvement in overall symptom score was demonstrated, as was a shortening of duration of hay fever symptoms. The start of the hay fever season for some patients was later than expected, which may have resulted in reduced effectivity of the acupuncture, thus treatment may be better starting at the beginning of May to cover the peak of symptoms in early June.

The results of this pilot study have shown that single point (Liver 3) acupuncture given for hay fever prophylaxis in a clinic setting was effective, safe, easily reproducible, acceptable and inexpensive (the material cost of the treatment was less than 50p per patient). The study merits repeating on a larger scale.

Key words

Acupuncture, General practice, Hay fever prophylaxis.

Introduction

Hay fever is a common ailment affecting up to 29% of the population ( 1, 2). Those badly afflicted sleep poorly, find difficulty concentrating at work, feel generally low and are often unable to go outdoors in summer. The peak prevalence of hay fever is between the ages of 16 and 24 years ( 3), thus often affecting young people during the critical few months of their lives when they are sitting important examinations. Vuvvman et al ( 4) showed that school children suffering from hay fever had lower educational performance despite, or possibly due to, adequate symptom control with "non sedating" anti-histamines.

Conventional medicine offers no acceptable prophylaxis for hay lever ( 5-9). On the other hand acupuncture is widely used to treat hay fever both for prophylaxis and for acute symptoms, but as yet no systematic study has been published in the English literature to demonstrate effectiveness

Traditional Chinese acupuncture involves each patient being treated with an individual prescription of points at the onset of their hay fever symptoms. This requires considerable knowledge of traditional acupuncture, is time consuming, especially as patients' symptoms start at different times, and may not be widely acceptable, as some rather uncomfortable facial needling points are often involved.

The aims of this study were two fold:

a. To establish a safe, effective, widely acceptable and easily reproducible method of hay fever prophylaxis using single point acupuncture.

b. To examine the feasibility of treating patients in dedicated clinics, run rather like immunisation clinics, to maximise efficiency and to make it possible to offer the service in general practice.

The main problems anticipated in designing the study were:

a. Prejudice and worries about acupuncture.

b. Simplifying the acupuncture enough to be reproduced by any doctor or nurse and yet be effective in the majority of patients.

c. Timing the treatment to be completed before the start of the hay fever season, as this was unpredictable and varied between patients.

Method

The study was a controlled randomised trial of acupuncture at a single pair of points (Liver 3) against conventional treatment. All patients were registered with a five-partner, semi-rural practice. Those included were aged 18 - 40 years. They had moderate to severe hay fever symptoms requiring double or triple drug therapy for two or more months of the year for at least three consecutive years.

Names were taken from the 1992 prescription list, selecting those patients using two or more of the drugs: terfenadine (Triludan), astemizole (Hisminal), beclomethasone proprionate (Beconase), sodium cromoglycate (Opticrom).

Patients who had been prescribed the drugs by generic name were allocated to the control group. Those who had been prescribed the drugs by trade name were allocated to the acupuncture group. As eight different doctors had been involved in prescribing, it was felt mat this form of allocation was random and no bias had been introduced.

All patients were invited to participate by written invitation and screening questionnaire. A total of thirty patients was required. Those with chronic, vasomotor rhinitis, or who were pregnant, were excluded from the trial. Informed consent was obtained from all patients, who were warned about potential bruising and also drowsiness experienced by some after acupuncture. They were told this was an experimental form of acupuncture and given no expectation of success. The author visited all control patients personally to explain the purpose of the study, but they were not seen again during the trial. All participants were told to continue to use whatever conventional medication they wished or needed to control symptoms. An arbritary date of May 1st was taken for the start of the hay fever season, based on patients' past experience. Three acupuncture clinics were organised four weeks, three weeks and one week before. that date. Patients were seen at fifteen minute intervals and kept the same appointment time for all three sessions.

The acupoint chosen was Taichong (Liver 3). This is found between the first and second metatarsal bones, 2 inches proximal to the web margin. Ultrafine (36 gauge) needles were inserted bilaterally to a depth of one centimetre and left for ten minutes. Patients were treated supine and no stimulation was used. Needling at this point is safe, easily reproducible, causes little discomfort and produces a relaxed and pleasant state. Taichong is a potent site for the treatment of many conditions and is felt to be non threatening to patients new to acupuncture. It has been used anecdotally for hay fever prevention (Mann, Paine, personal communication), usually in combination with other acupoints. By using a single point it was hoped that the treatment would be distilled to the most easily accessible, acceptable, reproducible form.

All participants filled out a pre-season questionnaire giving an overall score of symptoms for 1992, the amount of medication. normally used, and the anticipated duration of symptoms. Starting after the third acupuncture treatment, each participant kept a daily diary for the period April 19th and July 25th 1993, in which was recorded the amount of medication used: the number of drops, sprays and tablets of each type of drug. Also in the diary were 100mm visual analogue scales (VAS) to be completed daily to display the severity of symptoms. These were used to derive a patient symptom score. All patients were telephoned in May and June to make sure they were continuing their diaries. In September, each participant filled out a final questionnaire giving an overall symptom score for 1993, as well as a verbal assessment of whether the year was better, worse or the same as 1992. The pollen count was measured by the Oxford City Environmental Health Department using a Rotherham trap from May 10th until July 26th 1993.

Results

Forty-five invitations were sent. Thirty-six patients replied, of whom thirty-one were eligible for inclusion. Sixteen were allocated to the acupuncture group and fifteen to the control group. All returned completed diaries and questionnaires (Figure 1).

All but one patient (in the treatment group) considered that they suffered from moderate or severe hay fever. The two groups (Table 1) were well matched for age and smoking behaviour, but there was an excess of women in the control group (11 out of 15).

Although diaries were kept from 19th April until 25th July, a few patients had significant symptoms during August and one of the control patients did not even start symptoms until 26th July (Table 2). One control and one acupuncture patient used homoeopathic remedies, and one control patient used Intal. Six in each group (39% of all participants) felt that the cost of medication influenced which and how much medication they used. These patients tended to use only an oral antihistamine (incurring a single prescription charge) and tolerate poorer symptom control for as long as possible during the season. In the trial, six needles cost 48p, so the main cost of the acupuncture treatment was in medical time.

Acupuncture was well tolerated by all, with no side effects, although one patient experienced the profound drowsiness which affects some patients after acupuncture. Interestingly this patient also demonstrated the most dramatic improvement in overall symptom score, from 10 in 1992 to 1 in 1993.

Four patients experienced an excellent response to acupuncture (Table 3). They had all suffered from moderate or severe hay fever for more than five years. Their daily symptom scores were lower than any control subject and they required little or no medication. Of treated subjects, 56% felt they had a good, very good or excellent response to acupuncture.

The one control subject whose symptoms did not start until the end of July then had a particularly bad season. However her results are not recorded on the graphs, which therefore lowers the average symptom score of the control group.

One patient in the acupuncture group said in his verbal assessment that 1993 was the worse year, but gave it a better overall symptom score. The symptom scores of all other patients correlated with their overall verbal comparison of 1993 with 1992 (Table 5).

Discussion

The small number involved in the pilot study has limited the statistical interpretation of results. However many lessons have been learned. The initial concerns about patients' fear of acupuncture were not sustained, as 94% were willing to participate in further acupuncture studies.

The visual analogue scale was a very successful measurement of symptom control (Table 4). Patients found it easy to use, scoring was consistent for individual patients and reflected their differences in symptom severity. However this score is greatly influenced by the amount of medication used. Unfortunately there was no simple correlation between VAS scores and the reports of medication usage, varying even in individual patients at different times in the season. The cost of medication also affects the dose and type of drug used, and hence the effectiveness of symptom control. This factor had not been anticipated, but as both groups were equally affected, it was thought not to influence the results.

The correct timing of prophylaxis proved to be a major problem, as patients fell into three groups, each with different timing requirements for treatment:

a. Those whose symptoms started in April but peaked in early June.

b. Those whose symptoms started at the end of May and peaked in early June.

c. A few whose symptoms started in late July and peaked in August and September.

Only one in four patients could accurately predict the start of their own hay fever season. The pollen count followed rather than predicted the severity of hay fever symptoms, but did move in parallel. Many of the patients did not start significant symptoms until one month after the acupuncture, which was probably too long for the effect to last. Waiting until patients present at the very start of symptoms may well be the most efficient way of treating hay fever. Clinics would need to run from the end of April until the beginning of June to ensure the maximum acupuncture effect. This would probably preempt or shorten the hay fever season rather than act as a true prophylactic. The most consistent finding was that patients in the acupuncture group finished their hay fever symptoms in a shorter time than the control group.

During the early part of the season the author treated 6 further patients with individual prescription (multiple point) acupuncture, commencing just after their symptoms had started. After a single treatment 4 patients responded dramatically, needing no further medication for the rest of the hay fever season. One patient had a much better season than the previous year and one reported a worse season. This response (66% success) is more typical of that clinically expected from acupuncture treatment of hay fever. Although this group was much smaller, they appeared to fare much better than either the Liver 3 acupuncture group or the control group, which underlines the urgent need to study this approach under controlled conditions.

The effect of Liver 3 acupuncture on the 56% of patients who felt they benefited was remarkable, considering how minimal the acupuncture had been and how long before the season it had been given. For the 4 (25%) patients whose symptoms all but vanished, this was a most welcome and valuable response. The material costs of acupuncture treatment are minimal, thus the benefits of this simple technique are gratifying to both patients and doctor, and are highly cost effective.

Conclusion

Large scale, simple, hay fever prophylaxis using acupuncture is possible. Single point (Liver 3) acupuncture given in a clinic setting before the start of hay fever symptoms was safe, easily reproducible, acceptable and inexpensive. An improvement in symptoms has been demonstrated, as has a shortening of duration. The success rate of treatment is likely to be improved by using individual prescription acupuncture and timing treatment to coincide with the onset of symptoms.

References
1. Fleming DM, Crombie DL (1987) Prevalence of asthma and hay fever in England and Wales. British Medical Journal. 294:279-83

2. Richards S, Thornhill D, Roberts H, Harries U (1992) How many people think they have hay fever and what they do about it. British Journal of General Practice. 42:284-6

3. (1986) Hay fever among London's Taxi Drivers (letter). Lancet: 1397

4. Vuuvman E, Van Veggel L, Uiterwijk M, Leutner D, O'Hanlon J (1993) Seasonal allergic rhinitis and antihistamine effects on children's learning. Annals of Allergy. 71 (2): 121

5. Noon L (1911) Prophylactic inoculation against hay fever. Lancet. 1572-3

6. Sohoel P, Freng B, Kramer J et al (1993) Topical levocabastine compared with orally administered terfenadine for the prophylaxis and treatment of seasonal rhinoconjunctivitis. Journal of Allergy and Clinical immunology. 92 (1 pt 1): 73-81

7. Norman PS, Winkenwerder W, Lichtenstein L (1972) Trials of alum-precipitated pollen extracts in the treatment of hay fever. Journal of Allergy and Clinical Immunology. 50:31-44

8. Juniper E, Kline P, Ramsdale E, Hargreave F (1990) Comparison of the efficacy and side effects of aqueous steroid nasal spray (budesonide) and allergen-injection therapy (Pollinex-R) in the treatment of seasonal allergic rhinoconjunctivitis. Journal of Allergy and Clinical Immunology, 85 (3): 606-11

9. Ancill R, Takahashi Y, Kibune Y, Campbell R, Smith JR (1990) Randomized double-blind, placebo-controlled trial of a selective 5-lipoxygenase. inhibitor (AA-861) for the prevention of seasonal allergic rhinitis. Journal of International Medical Research. 18 (2): 75-88

The British Medical Acupuncture Society.

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By Lyn Williamson

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