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Role of laser acupuncture in chronic respiratory diseases
Egyptian Journal of Chest Diseases and Tuberculosis (2014) 63, 1065–1070
H O S T E D BY
The Egyptian Society of Chest Diseases and Tuberculosis
Egyptian Journal of Chest Diseases and Tuberculosis www.elsevier.com/locate/ejcdt www.sciencedirect.com
ORIGINAL ARTICLE
Role of laser acupuncture in chronic respiratory diseases Amany R. Mohamed a, Marwa M. Shaban a b
b,*
Department of Physical Therapy, Critical Care, Cairo University Hospitals, Egypt Chest Department, Faculty of Medicine, Cairo University, Egypt
Received 2 June 2014; accepted 17 June 2014 Available online 15 July 2014
KEYWORDS Chronic respiratory diseases; Laser acupuncture therapy
Abstract Background: Use of laser makes efficient acupuncture application without the use of stainless steel needles. Irradiation with laser of acupuncture points can produce effects of diminishing inflammation, relieving pain, enhancing metabolism, improving tissue regeneration and immunity. Objectives: To discuss its efficacy as non-pharmacological intervention that may provide a valuable adjunctive or alternative treatment for chronic respiratory diseases. Subjects and methods: Indications were 31 patients suffering from chronic respiratory illness (asthma, COPD, bronchiectasis and ILD). They were subdivided into a control group that received conservative treatment with medication and a study group that received a 10 day course of LLL in addition to medication. All patients were subjected to full history taking, Plain Chest X-ray and HRCT chest. Parameters assessed before and after 10 days: BMI, flow/volume loop and treadmill 6MWT. Main results: There was no statistically significant difference in the mean value of age, BMI and sex difference between both groups. Also there was no statistically significant difference regarding baseline spirometric data and 6 MWD between both groups. There was a statistically significant improvement in FVC, FEV1, FEF 25–75% and 6 MWD after 10 days of laser when compared with baseline data within the study group, while within the control group there was a statistically
Abbreviations: COPD, chronic obstructive pulmonary disease; ILD, interstitial lung disease; HRCT, high resolution computed tomography; BMI, body mass index; 6 MWD, 6-min walk distance; FVC, forced vital capacity; FEV1, forced expiratory volume in first second; FEF 25–75%, forced expiratory flow at 25–75% of FVC; TCM, traditional Chinese medicine; ATP, adenosine triphosphate; LLL, low level laser; LPS, lipopolysaccharide; TNF-alpha, tumor necrosis factor-alpha; FGF-2, fibroblast growth factor-2; IGF-1, insulin-like growth factor 1; ATS, American Thoracic Society; PDGF, plateletderived growth factor * Corresponding author. Mobile: +20 01223718672. E-mail address: [email protected] (M.M. Shaban). Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis. http://dx.doi.org/10.1016/j.ejcdt.2014.06.012 0422-7638 ª 2014 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. All rights reserved.
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A.R. Mohamed, M.M. Shaban significant improvement in FVC, FEV1 and 6 MWD after 10 days of medical treatment when compared with baseline data. By comparing both groups, there was more significant improvement in FEV1 and 6 MWD after 10 days of laser when compared to the control group. Conclusion: A ten-day course of LLL may be a useful adjunct to standard medical care for chronic respiratory diseases, though this requires corroboration with larger studies. ª 2014 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. All rights reserved.
Introduction Acupuncture is an integral part of a 4000-year-old philosophy of medicine that is known as traditional Chinese medicine (TCM). Acupuncture is a therapy that involves the stimulation of defined points on the body with the use of needles for therapeutic and preventive purposes. Other methods of stimulation of acupuncture points include pressure (acupressure), electric and more recently the use of laser [1]. The basic idea underlying acupuncture therapy is that disorders related to the flow of ‘Qi’, thought to be the energetic life force moving through the body along a network of channels or pathways called meridians in the concept of TCM, can be prevented or treated by stimulating the relevant points on the body surface. By and large, these channels or pathways are modulated in such a way as to stimulate, when there is a deficiency or lack of energy, or reduce, when excess energy is present [1]. Laser therapy has biostimulative and tissue regenerative properties as well as antimicrobial, anti-inflammatory and analgesic effects [2]. Studies on its effects in respiratory disease have shown improvement in both gas exchange and pulmonary function, as well as enhanced immunity and other health benefits [2]. There are several extraordinary effects that have been observed with therapeutic lasers, and phototherapy makes laser therapy unique among the various healing modalities available today. Photobiomodulation produces changes in oxidation/reduction status of the mitochondria which leads to dramatic increases in ATP synthesis. Activation of the sodium/potassium pump alters the cell membrane permeability to calcium [3,4]. Phototherapy has been shown to effect cellular activity in the following ways: stimulates cell growth, increases cell metabolism, improves cell regeneration, invokes an antiinflammatory response, promotes edema reduction, reduces fibrous tissue formation, stimulates nerve function, reduces the production of substance P, stimulates long term production of nitric oxide, decreases the formation of bradykinin, histamine, and acetylcholine and stimulates the production of endorphins [4]. One of the basic properties of low level laser (LLL) seems to be the ability to inhibit inflammation at the level of innate immune activation. Representative studies showed that LLL was capable of suppressing inflammatory genes and/or pathology after the administration of lipopolysaccharide (LPS) as a stimulator of monocytes and bronchial cells, in vitro, and leukocyte infiltration in vivo. Inflammation induced by other stimulators such as zymosan, carrageenan, and TNF-alpha was also inhibited by LLL. Growth factor stimulating activity of LLL was demonstrated in both in vitro and in vivo
experiments in which augmentation of FGF-2, PDGF and IGF-1 was observed. Endogenous production of these growth factors may be useful in regeneration based on activation of endogenous pulmonary stem cells [5]. Bronchial asthma is a major health problem characterized by a chronic inflammatory disorder of the airways, in which many cells and cellular elements play a role [1]. COPD is a major global health problem predicted to rank as the third greatest cause of mortality by the end of the next decade, it is a slowly progressive and poorly reversible inflammatory disease characterized by the functional abnormality of airway obstruction, which includes emphysema, chronic bronchitis, and small airways disease [6]. Inhibition of the inflammatory response may represent an important therapeutic strategy for COPD [6]. As a consequence, therapeutic intervention in chronic respiratory diseases would require addressing the issues of inflammation and regeneration. The present study aimed to develop a possible rationale for how LLL may be useful as a non-pharmacological intervention that may provide a valuable adjunctive or alternative treatment for chronic respiratory diseases. Subjects and materials Thirty-one patients suffer from chronic respiratory illness, of both sexes (12 females and 19 males), their age ranged between 19 and 70 years. All subjects were recruited from the outpatient chest clinic of the Kasr Alainy hospital. Patients with other chronic diseases that may contribute to exercise limitation; such as: cardiac, renal and liver diseases were excluded. Malignancies and those with Lack of motivation and Nonadherence were also excluded. No symptoms of respiratory infection were seen for 4 weeks before the study. They were sub-divided into the control group (n = 15) and the study group (n = 16) The control group included patients that received conservative treatment with medication only while the study group included patients that received a tenday course of low level laser therapy, in addition to conservative treatment with medication. All patients were subjected to: Full history taking including medical history and clinical examination, Plain Chest X-ray (P-A view) and HRCT chest. In the study group, patients were subjected to low level laser therapy using (Phyaction CL) with output of 5–20 mW, wavelength of 905 nm and frequency of 5000 Hz. laser probe placed in intercostal space corresponding to the site of lesion both anteriorly and posteriorly on chest wall and arm as: Standardized laser acupuncture application with 7 points (LU-1, LU-2, CU-17, BL-13, BL-17, LU-5, LU-7). Each acupuncture point was stimulated for 1 min with total number of applications: daily for 10 days [7].
Role of laser acupuncture in respiratory diseases of laser acupuncture in chronic respiratory diseases Parameters assessed before and after 10 days BMI or Quetelet index: it is defined as the individual’s body mass divided by the square of their height – with the value universally being given in units of kg/m2 [8]. Pulmonary function test: (flow/volume loop): using body plethysmography with highly transparent box; Sensor-medics V max series, 2130 Spirometer, V6200 Autobox, 6200DL. Spirometry indices are reported comparing the individual’s value along with the predicted values [9]. The forced vital capacity (FVC), the forced expiratory volume in the first second (FEV1), the ratio of FEV1 to FVC and the average of forced expiratory flow at 25–75% of forced vital capacity (FEF 25– 75%) were measured. When asthma is strongly suspected the response to bronchodilator aerosol is measured (Bronchodilator challenge test), reversible airway obstruction characterized by an increase in FEV1 that is both greater than 200 ml (absolute change) and 12% (% change) above the pre-bronchodilator FEV1 is characteristic of asthma [10]. Treadmill six-min walk test: using Electrical treadmill (Schiller Quinton 4000). Use of a treadmill to determine the 6 MWD allows constant monitoring during the exercise. Standardized instructions and encouragement similar to those for the corridor walk were given, according to ATS guidelines [11]. Patients were instructed to walk ‘‘as far as possible’’ during the time-that is, as fast as possible. They were told that they could slow down or even stop if necessary. There was no warming up before test. The initial treadmill speed was zero, and the test began when the treadmill was activated and the patient started walking. The patient controlled the treadmill speed during the test and could stop to rest at any time, as in the hallway test. Before, during, or after treadmill walk test, the walk testing was discontinued if the patient had thoracic pain, intolerable dyspnea, cramps, dizziness, staggering, diaphoresis, and pallor [11]. Statistical analysis Data were statistically described in terms of mean ± standard deviation (±SD), median and range. Comparison between the study groups was done using Student’s t-test for independent samples. Within group comparison was done using paired ttest. P values less than 0.05 were considered statistically significant. All statistical calculations were done using computer program SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 15 for Microsoft Windows. Results The present study included 31patients, they were selected from the outpatient chest clinic, Kasr Alainy hospital. They were further sub-divided into the control group (n = 15) and the study group (n = 16). The control group included patients that received conservative treatment with medication only while the study group included patients that received a ten-day course of LLL, in addition to conservative treatment with medication. The indications of those who suffer from chronic respiratory illness are as shown in (Fig. 1). In the present study, there was no statistically significant difference between the control group and the study group in
14 12 10 8 6 4 2 0
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Control Group Study Group Total parcipants
Chronic respiratory diseases among the participants.
Figure 1
50 45 40 35 30 25 20 15 10 5 0
age BMI
Control Group Figure 2
Study Group
Characteristics of the participants.
18 16 14 12 10 8 6 4 2 0
female male total
Control Group Study Group Figure 3
Sex characteristics of the participants.
the mean value of age and BMI with P-values 0.75 and 0.55, respectively as shown (Fig. 2), also there was no statistically significant difference in sex between the two groups with Pvalue 0.88 as shown in (Fig. 3). Regarding Baseline spirometric data and 6 MWD of both groups, it was shown that there was no statistically significant difference between the control and study group as shown in (Table 1). There was a statistical significant improvement in mean ± SD of FVC, FEV1, FEF 25–75% and 6 MWD after 10 days of laser therapy when compared with baseline data within the study group as shown (Table 2), while within the control group there was a statistical significant improvement
1068 Table 1
A.R. Mohamed, M.M. Shaban Baseline spirometric data and 6 MWD for the participants.
Baseline data
Control group (n = 15)
Study group (n = 16)
Total participants (n = 31)
P-Value
Statistical significance
FVC% (mean ± SD) FEV1% (mean ± SD) FEV1/FVC% (mean ± SD) FEF 25–75% (mean ± SD) 6 MWD (in meters) (mean ± SD)
58.13 ± 19.00 43.00 ± 19.86 59.40 ± 18.38 26.47 ± 24.38 32.67 ± 10.33
59.69 ± 14.29 49.50 ± 15.74 68.24 ± 15.23 33.56 ± 22.45 30.94 ± 11.52
58.94 ± 16.47 46.35 ± 17.86 63.96 ± 17.14 30.13 ± 23.29 31.77 ± 10.81
0.79 0.32 0.155 0.406 0.66
Not Not Not Not Not
significant significant significant significant significant
P-Value < 0.05 statistically significant.
Table 2
BMI, spirometric data and 6 MWD for the study group baseline and after 10 days of laser therapy.
Data after 10 days of laser therapy
Study group (n = 16) Baseline
After 10 days
BMI kg/m2 (mean ± SD) FVC% (mean ± SD) FEV1% (mean ± SD) FEV1/FVC% (mean ± SD) FEF 25–75% (mean ± SD) 6 MWD in meters (mean ± SD)
26.52 ± 5.60 59.69 ± 14.29 49.50 ± 15.74 68.24 ± 15.23 33.56 ± 22.45 30.94 ± 11.52
26.82 ± 5.68 65.44 ± 18.38 55.25 ± 16.11 70.69 ± 15.29 38.88 ± 22.45 93.63 ± 29.96
P-Value
Statistical significance
0.089 0.015 0.009 0.180 0.003 0.000
Not significant Significant Significant Not significant Significant Significant
P-Value < 0.05 statistically significant.
Table 3
BMI, spirometric data and 6 MWD for the control group baseline and after 10 days of medical treatment.
Data after 10 days of medical treatment BMI kg/m2 (mean ± SD) FVC% (mean ± SD) FEV1% (mean ± SD) FEV1/FVC% (mean ± SD) FEF 25–75% (mean ± SD) 6 MWD in meters (mean ± SD)
Control group (n = 15) Baseline
After 10 days
27.80 ± 6.12 58.13 ± 19.00 43.00 ± 19.86 59.40 ± 18.38 26.47 ± 24.38 32.67 ± 10.33
27.67 ± 5.97 54.13 ± 18.79 39.60 ± 19.29 59.93 ± 16.01 26.07 ± 24.95 39.67 ± 13.29
P-Value
Statistical significance
0.334 0.033 0.013 0.833 0.754 0.001
Not significant Significant Significant Not significant Not significant Significant
P-Value < 0.05 statistically significant.
in mean ± SD of FVC, FEV1 and 6 MWD after 10 days of medical treatment when compared with its baseline data as shown in (Table 3). By comparing both groups after 10 days of treatment, there was more significant improvement in mean ± SD of FEV1and 6 MWD after 10 days of laser therapy when compared to the control group as shown in (Table 4). Discussion Laser therapy in general, is safe and can be often used where other physical modalities are contraindicated such as with pace-makers or metal implants [4]. Laser phototherapy can be of value in the mitigation and elimination of many painful conditions [4,12]. Laser phototherapy is easily applied to patients and has relatively short treatment times, depending on the power output of the device, the wavelengths used and the size of the area to be treated. There are no known permanent or serious side effects from laser therapy. [4,13]. The medical use of LLL irradiation has been occurring for decades, primarily in the area of tissue healing and inflammatory
conditions. Despite little mechanistic knowledge, the concept of a non-invasive, non-thermal intervention of laser acupuncture, the present study aimed to discuss its efficacy as a non-pharmacological intervention that may provide a valuable adjunctive or alternative treatment for chronic respiratory diseases. While the present study tried to find out the efficacy of LLL on measured pulmonary function parameters and 6 MWD for asthma, COPD, bronchiectasis and ILD, other studies showed its efficacy in other chest diseases. Amirov [14] divided 142 patients with pneumonia into two groups. The study group (96 patients) received laser therapy in combination with pharmaceuticals, while the control group (46 patients) was treated solely with drugs. A pronounced reduction in cell membrane permeability, a rise in concentrations of iron and chromium in the blood serum, and improvement of microcirculation were observed in those receiving laser treatment. Amirov [14] found, ‘‘These changes closely correlated with those in immunity, external respiration function and Concluded that Laser therapy is an effective method of pneumonia treatment and can be included in relevant combined schemes.’’ In another study, Lutai et al. [15] compared two groups of patients with pneumonia. The study group received laser
Role of laser acupuncture in respiratory diseases of laser acupuncture in chronic respiratory diseases Table 4
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BMI, spirometric data and 6 MWD for the participants after 10 days of treatment.
Data after 10 days of treatment
Control group (n = 15)
Study group (n = 16)
Total participants (n = 31)
P-Value
Statistical significance
BMI kg/m2 (mean ± SD) FVC% (mean ± SD) FEV1% (mean ± SD) FEV1/FVC% (mean ± SD) FEF 25–75% (mean ± SD) 6 MWD in meters (mean ± SD)
27.67 ± 5.97 54.13 ± 18.79 39.60 ± 19.29 59.93 ± 16.01 26.07 ± 24.95 39.67 ± 13.29
26.82 ± 5.68 65.44 ± 18.38 55.25 ± 16.11 70.69 ± 15.29 38.88 ± 22.45 93.63 ± 29.96
27.23 ± 5.74 59.97 ± 19.15 47.68 ± 19.14 65.49 ± 16.23 32.68 ± 24.18 67.52 ± 34.60
0.688 0.101 0.020 0.066 0.143 0.000
Not significant Not significant Significant Not significant Not significant Significant
P-Value < 0.05 statistically significant.
therapy and drugs while the control group received only drugs. There was an earlier regression of clinical symptoms and a more rapid recovery of lung function in the group treated with laser therapy. The authors [15] concluded that, ‘‘non-drug treatment had an undeniably positive impact. In the absence of side effects of this method, infrared laser therapy can be recommended for rehabilitation of elderly patients with pneumonia.’’ Hacerova and Hubacek [16] studied the effect of laser acupuncture on acute sinusitis when compared to the control group on medical treatment. They found that laser irradiation causes a quicker withdrawal of inflammation and edema of the mucosa and thus brings restoration of drainage of sinus as well as normalization of mucociliary function and this strategy may be a great starting point for the treatment of other respiratory conditions. Puri and Arora [17] studied the bio-stimulatory effects of Gallium Arsenide Laser Irradiation at 890 nm as an adjunctive to anti-tuberculosis drugs in the treatment of pulmonary tuberculosis, one hundred thirty new sputum smear positive patients of pulmonary tuberculosis were included, they were randomly divided into two groups to receive either LLL or sham irradiation (control) concomitantly with anti-tuberculosis, Puri and Arora [17] concluded that there was a faster clearance of tubercle bacilli in the sputum of patients who were treated with LLL along with anti-tuberculosis treatment when compared to the control group and this improves the bacteriological cure and prevents secondary resistance. These findings provide evidence that LLL with Gallium Arsenide Irradiation may have bio-stimulatory effect as an adjuvant therapy for patients with tuberculosis. The present study showed that there was a more significant improvement in mean ± SD of FEV1 and 6 MWD after 10 days of laser therapy when compared to the control group. Although acupuncture treatment is commonly used in routine practice by qualified practitioners of traditional TCM in a variety of clinical settings and despite thousands of years of use, there is no robust evidence base to confirm its effectiveness in the treatment of asthma [18,19]. Evidence suggests that there is inconclusive evidence to indicate that short term (1–12 weeks) acupuncture treatment has a significant effect on the course of asthma when used in conjunction with drug maintenance treatment [7]. In contrast, Milojevic and Kuruc [20] treated 50 patients with bronchial asthma using laser acupuncture for 10 days, comparing changes with those of a control group of the same number of patients, differing only in that laser acupuncture was not given. Milojevic and Kuruc [20] found that ‘‘A tenday course of low-power laser stimulation of acupuncture
points in patients with bronchial asthma improves both the lung function and gas exchange parameters. Positive effects of laser treatment in patients with bronchial asthma are achieved in a short time and they last long, for several weeks, even months. Successive laser stimulation in asthmatics prolongs periods of remission and decreases the severity of asthmatic attacks. Similarly Ailioaie and Ailioaie [21] compared the effects of laser acupuncture and pharmaceutical drugs in asthma. The authors reported, ‘‘A noticeable improvement in the clinical, functional and immunological characteristics was observed in 83% of the patients in group with laser acupuncture treatment’’. Suzuki et al. [22] tried to determine whether a combination of traditional acupuncture treatment and conservative treatment for COPD improves dyspnea on exercise. The study included the acupuncture group (n = 15) that received acupuncture treatments once a week for 10 weeks and the control group (n = 15) that received conservative treatment with medication only. The authors [22] found that the acupuncture group had significantly better results on the Borg scale than the control group after 10 weeks. Also the 6-min walk distance and oxygen saturation improved significantly in the acupuncture group compared with the control group. In contrast, Bausewein et al. [23] looked at the effectiveness of non-pharmacological and non-invasive interventions to relieve breathlessness in participants suffering from the five most common conditions causing breathlessness in advanced disease. It included 47 randomized controlled and controlled clinical trials involving a total of 2532 participants described as suffering from breathlessness due to advanced stages of cancer, COPD, interstitial lung disease, chronic heart failure or motor neuron disease. Five of the trials were of acupuncture/ acupressure, which provided low strength evidence that acupuncture/acupressure is helpful. Most of the studies had been conducted in patients with COPD. Conclusion A ten-day course of low-power laser stimulation may be a useful adjunct to standard medical care for chronic respiratory diseases. Despite the availability, cost-effective efficacy and safety of LLL, the field is still in its infancy. As is obvious from the wide variety of LLL sources, frequencies, intensities used and no standard protocols exist. Further research is required to investigate the mechanism of the apparent effectiveness of laser acupuncture, which patients may be helped and which protocols are most effective.
1070 Conflict of interest None declared. References [1] S.C. Chang, The role of acupuncture in asthma, J. Chin. Med. Assoc. 70 (2007) 263–264. [2] D. Rindge, Laser acupuncture and respiratory disease, Acupuncture Today 6 (2) (2005). [3] T.I. Karu, Molecular mechanisms of therapeutic effects of low intensity laser radiation, Laser Life Sci. 2 (1988) 53. [4] W.J. Kneebone, Practical applications of low level laser therapy, Pract. Pain Manage. (2006), November/December. [5] F. Lin, S.F. Josephs, D.T. Alexandrescu, F. Ramos, V. Bogin, V. Gammill, C.A. Dasanu, et al, Lasers, stem cells and COPD, J. Transl. Med. 8 (2010) 16. [6] Z.H. Chen, H.P. Kim, S.W. Ryter, A.M. Choi, Identifying targets for COPD treatment through gene expression analyses, Int. J. Chron. Obstruct. Pulmon. Dis. 3 (3) (2008) 359–370. [7] R.W. McCarney, B. Brinkhaus, T.J. Lasserson, K. Linde, Acupuncture for chronic asthma, Cochrane Database Syst. Rev. (2003) (Issue 3). [8] G. Eknoyan, Adolphe Quetelet (1796–1874): the average man and indices of obesity, Nephrol. Dial. Transplant. 23 (1) (2007) 47–51. [9] R. Pellegrino, G. Viegi, R.V. Crapo, et al, Interpretative strategies for lung function tests, Eur. Respir. J. 26 (5) (2005) 948–968. [10] D. Shelledy, J.K. Stoller, An introduction to clinical diagnostic thinking, in: J.K. Stoller, E.D. Bakow, D.L. Longworth (Eds.), Critical Diagnostic Thinking in Respiratory Care – A Case Based Approach, WB Saunders, Philadelphia, 2002, pp. 11–38. [11] American Thoracic Society, ATS statement: guidelines for the six-minute walk test, Am. J. Respir. Crit. Care Med. 166 (1) (2002) 111–117. [12] J. Tuner, L. Hode, The Laser Therapy Handbook, Prima Books, Sweden, 2004, p. 170.
A.R. Mohamed, M.M. Shaban [13] K. Sasaki, R.G. Calderhead, I. Chin, K. Inomata, To examine the adverse photochemical effects of extended dosage of laser therapy in vivo on the skin and subcutaneous tissue of the rat model, Laser Therapy 4 (2) (1992) 69–74. [14] N.B. Amirov, Parameters of membrane permeability, microcirculation, external respiration, and trace element levels in the drug-laser treatment of pneumonia, Ter Arkh 74 (3) (2002) 40–43. [15] A.V. Lutai, L.A. Egorova, E.A. Shutemova, Laser therapy of elderly patients with pneumonia, Vopr Kurortol Fizioter Lech Fiz Kult 3 (2001) 15–18. [16] M. Hacarova, J. Hubacek, Low Level Laser Therapy of Sinusitis, Laser Partner, 28.3.2002. [17] M.M. Puri, V.K. Arora, Role of gallium arsenide laser irradiation at 890 nm as an adjunctive to anti-tuberculosis drugs in the treatment of pulmonary tuberculosis, Indian J. Chest Dis. Allied Sci. 45 (2003) 19–23. [18] J. Martin, A.N.A. Donaldson, R. Villarroel, M.K.B. Parmar, E. Ernst, I.J. Higginson, Efficiency of acupuncture in asthma: systematic review and meta-analysis of published data from 11 randomized controlled trials, Eur. Respir. J. 20 (2002) 846–852. [19] R.W. McCarney, T.J. Lasserson, K. Linde, B. Brinkhaus, An overview of two Cochrane systematic reviews of complementary treatments for chronic asthma: acupuncture and homeopathy, Respir Med. 98 (2004) 687–696. [20] M. Milojevic, V. Kuruc, Low power laser biostimulation in the treatment of bronchial asthma, Med. Pregl. 56 (9–10) (2003) 413–418. [21] C. Ailioaie, L. Ailioaie, The treatment of bronchial asthma with LLLT in attack-free period in children, Ter Arkh 69 (12) (1997) 49–50. [22] M. Suzuki, K. Namura, Y. Ohno, H. Tanaka, M. Egawa, Y. Yokoyama, S. Akao, H. Fujiwara, T. Yano, The effect of acupuncture in the treatment of chronic obstructive pulmonary disease, J. Altern. Complement Med. 14 (9) (2008) 1097–1105. [23] C. Bausewein, S. Booth, M. Gysels, I.J. Higginson, Nonpharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases, Cochrane Database Syst. Rev. (2008) (Issue 2).
H O S T E D BY
The Egyptian Society of Chest Diseases and Tuberculosis
Egyptian Journal of Chest Diseases and Tuberculosis www.elsevier.com/locate/ejcdt www.sciencedirect.com
ORIGINAL ARTICLE
Role of laser acupuncture in chronic respiratory diseases Amany R. Mohamed a, Marwa M. Shaban a b
b,*
Department of Physical Therapy, Critical Care, Cairo University Hospitals, Egypt Chest Department, Faculty of Medicine, Cairo University, Egypt
Received 2 June 2014; accepted 17 June 2014 Available online 15 July 2014
KEYWORDS Chronic respiratory diseases; Laser acupuncture therapy
Abstract Background: Use of laser makes efficient acupuncture application without the use of stainless steel needles. Irradiation with laser of acupuncture points can produce effects of diminishing inflammation, relieving pain, enhancing metabolism, improving tissue regeneration and immunity. Objectives: To discuss its efficacy as non-pharmacological intervention that may provide a valuable adjunctive or alternative treatment for chronic respiratory diseases. Subjects and methods: Indications were 31 patients suffering from chronic respiratory illness (asthma, COPD, bronchiectasis and ILD). They were subdivided into a control group that received conservative treatment with medication and a study group that received a 10 day course of LLL in addition to medication. All patients were subjected to full history taking, Plain Chest X-ray and HRCT chest. Parameters assessed before and after 10 days: BMI, flow/volume loop and treadmill 6MWT. Main results: There was no statistically significant difference in the mean value of age, BMI and sex difference between both groups. Also there was no statistically significant difference regarding baseline spirometric data and 6 MWD between both groups. There was a statistically significant improvement in FVC, FEV1, FEF 25–75% and 6 MWD after 10 days of laser when compared with baseline data within the study group, while within the control group there was a statistically
Abbreviations: COPD, chronic obstructive pulmonary disease; ILD, interstitial lung disease; HRCT, high resolution computed tomography; BMI, body mass index; 6 MWD, 6-min walk distance; FVC, forced vital capacity; FEV1, forced expiratory volume in first second; FEF 25–75%, forced expiratory flow at 25–75% of FVC; TCM, traditional Chinese medicine; ATP, adenosine triphosphate; LLL, low level laser; LPS, lipopolysaccharide; TNF-alpha, tumor necrosis factor-alpha; FGF-2, fibroblast growth factor-2; IGF-1, insulin-like growth factor 1; ATS, American Thoracic Society; PDGF, plateletderived growth factor * Corresponding author. Mobile: +20 01223718672. E-mail address: [email protected] (M.M. Shaban). Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis. http://dx.doi.org/10.1016/j.ejcdt.2014.06.012 0422-7638 ª 2014 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. All rights reserved.
1066
A.R. Mohamed, M.M. Shaban significant improvement in FVC, FEV1 and 6 MWD after 10 days of medical treatment when compared with baseline data. By comparing both groups, there was more significant improvement in FEV1 and 6 MWD after 10 days of laser when compared to the control group. Conclusion: A ten-day course of LLL may be a useful adjunct to standard medical care for chronic respiratory diseases, though this requires corroboration with larger studies. ª 2014 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. All rights reserved.
Introduction Acupuncture is an integral part of a 4000-year-old philosophy of medicine that is known as traditional Chinese medicine (TCM). Acupuncture is a therapy that involves the stimulation of defined points on the body with the use of needles for therapeutic and preventive purposes. Other methods of stimulation of acupuncture points include pressure (acupressure), electric and more recently the use of laser [1]. The basic idea underlying acupuncture therapy is that disorders related to the flow of ‘Qi’, thought to be the energetic life force moving through the body along a network of channels or pathways called meridians in the concept of TCM, can be prevented or treated by stimulating the relevant points on the body surface. By and large, these channels or pathways are modulated in such a way as to stimulate, when there is a deficiency or lack of energy, or reduce, when excess energy is present [1]. Laser therapy has biostimulative and tissue regenerative properties as well as antimicrobial, anti-inflammatory and analgesic effects [2]. Studies on its effects in respiratory disease have shown improvement in both gas exchange and pulmonary function, as well as enhanced immunity and other health benefits [2]. There are several extraordinary effects that have been observed with therapeutic lasers, and phototherapy makes laser therapy unique among the various healing modalities available today. Photobiomodulation produces changes in oxidation/reduction status of the mitochondria which leads to dramatic increases in ATP synthesis. Activation of the sodium/potassium pump alters the cell membrane permeability to calcium [3,4]. Phototherapy has been shown to effect cellular activity in the following ways: stimulates cell growth, increases cell metabolism, improves cell regeneration, invokes an antiinflammatory response, promotes edema reduction, reduces fibrous tissue formation, stimulates nerve function, reduces the production of substance P, stimulates long term production of nitric oxide, decreases the formation of bradykinin, histamine, and acetylcholine and stimulates the production of endorphins [4]. One of the basic properties of low level laser (LLL) seems to be the ability to inhibit inflammation at the level of innate immune activation. Representative studies showed that LLL was capable of suppressing inflammatory genes and/or pathology after the administration of lipopolysaccharide (LPS) as a stimulator of monocytes and bronchial cells, in vitro, and leukocyte infiltration in vivo. Inflammation induced by other stimulators such as zymosan, carrageenan, and TNF-alpha was also inhibited by LLL. Growth factor stimulating activity of LLL was demonstrated in both in vitro and in vivo
experiments in which augmentation of FGF-2, PDGF and IGF-1 was observed. Endogenous production of these growth factors may be useful in regeneration based on activation of endogenous pulmonary stem cells [5]. Bronchial asthma is a major health problem characterized by a chronic inflammatory disorder of the airways, in which many cells and cellular elements play a role [1]. COPD is a major global health problem predicted to rank as the third greatest cause of mortality by the end of the next decade, it is a slowly progressive and poorly reversible inflammatory disease characterized by the functional abnormality of airway obstruction, which includes emphysema, chronic bronchitis, and small airways disease [6]. Inhibition of the inflammatory response may represent an important therapeutic strategy for COPD [6]. As a consequence, therapeutic intervention in chronic respiratory diseases would require addressing the issues of inflammation and regeneration. The present study aimed to develop a possible rationale for how LLL may be useful as a non-pharmacological intervention that may provide a valuable adjunctive or alternative treatment for chronic respiratory diseases. Subjects and materials Thirty-one patients suffer from chronic respiratory illness, of both sexes (12 females and 19 males), their age ranged between 19 and 70 years. All subjects were recruited from the outpatient chest clinic of the Kasr Alainy hospital. Patients with other chronic diseases that may contribute to exercise limitation; such as: cardiac, renal and liver diseases were excluded. Malignancies and those with Lack of motivation and Nonadherence were also excluded. No symptoms of respiratory infection were seen for 4 weeks before the study. They were sub-divided into the control group (n = 15) and the study group (n = 16) The control group included patients that received conservative treatment with medication only while the study group included patients that received a tenday course of low level laser therapy, in addition to conservative treatment with medication. All patients were subjected to: Full history taking including medical history and clinical examination, Plain Chest X-ray (P-A view) and HRCT chest. In the study group, patients were subjected to low level laser therapy using (Phyaction CL) with output of 5–20 mW, wavelength of 905 nm and frequency of 5000 Hz. laser probe placed in intercostal space corresponding to the site of lesion both anteriorly and posteriorly on chest wall and arm as: Standardized laser acupuncture application with 7 points (LU-1, LU-2, CU-17, BL-13, BL-17, LU-5, LU-7). Each acupuncture point was stimulated for 1 min with total number of applications: daily for 10 days [7].
Role of laser acupuncture in respiratory diseases of laser acupuncture in chronic respiratory diseases Parameters assessed before and after 10 days BMI or Quetelet index: it is defined as the individual’s body mass divided by the square of their height – with the value universally being given in units of kg/m2 [8]. Pulmonary function test: (flow/volume loop): using body plethysmography with highly transparent box; Sensor-medics V max series, 2130 Spirometer, V6200 Autobox, 6200DL. Spirometry indices are reported comparing the individual’s value along with the predicted values [9]. The forced vital capacity (FVC), the forced expiratory volume in the first second (FEV1), the ratio of FEV1 to FVC and the average of forced expiratory flow at 25–75% of forced vital capacity (FEF 25– 75%) were measured. When asthma is strongly suspected the response to bronchodilator aerosol is measured (Bronchodilator challenge test), reversible airway obstruction characterized by an increase in FEV1 that is both greater than 200 ml (absolute change) and 12% (% change) above the pre-bronchodilator FEV1 is characteristic of asthma [10]. Treadmill six-min walk test: using Electrical treadmill (Schiller Quinton 4000). Use of a treadmill to determine the 6 MWD allows constant monitoring during the exercise. Standardized instructions and encouragement similar to those for the corridor walk were given, according to ATS guidelines [11]. Patients were instructed to walk ‘‘as far as possible’’ during the time-that is, as fast as possible. They were told that they could slow down or even stop if necessary. There was no warming up before test. The initial treadmill speed was zero, and the test began when the treadmill was activated and the patient started walking. The patient controlled the treadmill speed during the test and could stop to rest at any time, as in the hallway test. Before, during, or after treadmill walk test, the walk testing was discontinued if the patient had thoracic pain, intolerable dyspnea, cramps, dizziness, staggering, diaphoresis, and pallor [11]. Statistical analysis Data were statistically described in terms of mean ± standard deviation (±SD), median and range. Comparison between the study groups was done using Student’s t-test for independent samples. Within group comparison was done using paired ttest. P values less than 0.05 were considered statistically significant. All statistical calculations were done using computer program SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 15 for Microsoft Windows. Results The present study included 31patients, they were selected from the outpatient chest clinic, Kasr Alainy hospital. They were further sub-divided into the control group (n = 15) and the study group (n = 16). The control group included patients that received conservative treatment with medication only while the study group included patients that received a ten-day course of LLL, in addition to conservative treatment with medication. The indications of those who suffer from chronic respiratory illness are as shown in (Fig. 1). In the present study, there was no statistically significant difference between the control group and the study group in
14 12 10 8 6 4 2 0
1067
Control Group Study Group Total parcipants
Chronic respiratory diseases among the participants.
Figure 1
50 45 40 35 30 25 20 15 10 5 0
age BMI
Control Group Figure 2
Study Group
Characteristics of the participants.
18 16 14 12 10 8 6 4 2 0
female male total
Control Group Study Group Figure 3
Sex characteristics of the participants.
the mean value of age and BMI with P-values 0.75 and 0.55, respectively as shown (Fig. 2), also there was no statistically significant difference in sex between the two groups with Pvalue 0.88 as shown in (Fig. 3). Regarding Baseline spirometric data and 6 MWD of both groups, it was shown that there was no statistically significant difference between the control and study group as shown in (Table 1). There was a statistical significant improvement in mean ± SD of FVC, FEV1, FEF 25–75% and 6 MWD after 10 days of laser therapy when compared with baseline data within the study group as shown (Table 2), while within the control group there was a statistical significant improvement
1068 Table 1
A.R. Mohamed, M.M. Shaban Baseline spirometric data and 6 MWD for the participants.
Baseline data
Control group (n = 15)
Study group (n = 16)
Total participants (n = 31)
P-Value
Statistical significance
FVC% (mean ± SD) FEV1% (mean ± SD) FEV1/FVC% (mean ± SD) FEF 25–75% (mean ± SD) 6 MWD (in meters) (mean ± SD)
58.13 ± 19.00 43.00 ± 19.86 59.40 ± 18.38 26.47 ± 24.38 32.67 ± 10.33
59.69 ± 14.29 49.50 ± 15.74 68.24 ± 15.23 33.56 ± 22.45 30.94 ± 11.52
58.94 ± 16.47 46.35 ± 17.86 63.96 ± 17.14 30.13 ± 23.29 31.77 ± 10.81
0.79 0.32 0.155 0.406 0.66
Not Not Not Not Not
significant significant significant significant significant
P-Value < 0.05 statistically significant.
Table 2
BMI, spirometric data and 6 MWD for the study group baseline and after 10 days of laser therapy.
Data after 10 days of laser therapy
Study group (n = 16) Baseline
After 10 days
BMI kg/m2 (mean ± SD) FVC% (mean ± SD) FEV1% (mean ± SD) FEV1/FVC% (mean ± SD) FEF 25–75% (mean ± SD) 6 MWD in meters (mean ± SD)
26.52 ± 5.60 59.69 ± 14.29 49.50 ± 15.74 68.24 ± 15.23 33.56 ± 22.45 30.94 ± 11.52
26.82 ± 5.68 65.44 ± 18.38 55.25 ± 16.11 70.69 ± 15.29 38.88 ± 22.45 93.63 ± 29.96
P-Value
Statistical significance
0.089 0.015 0.009 0.180 0.003 0.000
Not significant Significant Significant Not significant Significant Significant
P-Value < 0.05 statistically significant.
Table 3
BMI, spirometric data and 6 MWD for the control group baseline and after 10 days of medical treatment.
Data after 10 days of medical treatment BMI kg/m2 (mean ± SD) FVC% (mean ± SD) FEV1% (mean ± SD) FEV1/FVC% (mean ± SD) FEF 25–75% (mean ± SD) 6 MWD in meters (mean ± SD)
Control group (n = 15) Baseline
After 10 days
27.80 ± 6.12 58.13 ± 19.00 43.00 ± 19.86 59.40 ± 18.38 26.47 ± 24.38 32.67 ± 10.33
27.67 ± 5.97 54.13 ± 18.79 39.60 ± 19.29 59.93 ± 16.01 26.07 ± 24.95 39.67 ± 13.29
P-Value
Statistical significance
0.334 0.033 0.013 0.833 0.754 0.001
Not significant Significant Significant Not significant Not significant Significant
P-Value < 0.05 statistically significant.
in mean ± SD of FVC, FEV1 and 6 MWD after 10 days of medical treatment when compared with its baseline data as shown in (Table 3). By comparing both groups after 10 days of treatment, there was more significant improvement in mean ± SD of FEV1and 6 MWD after 10 days of laser therapy when compared to the control group as shown in (Table 4). Discussion Laser therapy in general, is safe and can be often used where other physical modalities are contraindicated such as with pace-makers or metal implants [4]. Laser phototherapy can be of value in the mitigation and elimination of many painful conditions [4,12]. Laser phototherapy is easily applied to patients and has relatively short treatment times, depending on the power output of the device, the wavelengths used and the size of the area to be treated. There are no known permanent or serious side effects from laser therapy. [4,13]. The medical use of LLL irradiation has been occurring for decades, primarily in the area of tissue healing and inflammatory
conditions. Despite little mechanistic knowledge, the concept of a non-invasive, non-thermal intervention of laser acupuncture, the present study aimed to discuss its efficacy as a non-pharmacological intervention that may provide a valuable adjunctive or alternative treatment for chronic respiratory diseases. While the present study tried to find out the efficacy of LLL on measured pulmonary function parameters and 6 MWD for asthma, COPD, bronchiectasis and ILD, other studies showed its efficacy in other chest diseases. Amirov [14] divided 142 patients with pneumonia into two groups. The study group (96 patients) received laser therapy in combination with pharmaceuticals, while the control group (46 patients) was treated solely with drugs. A pronounced reduction in cell membrane permeability, a rise in concentrations of iron and chromium in the blood serum, and improvement of microcirculation were observed in those receiving laser treatment. Amirov [14] found, ‘‘These changes closely correlated with those in immunity, external respiration function and Concluded that Laser therapy is an effective method of pneumonia treatment and can be included in relevant combined schemes.’’ In another study, Lutai et al. [15] compared two groups of patients with pneumonia. The study group received laser
Role of laser acupuncture in respiratory diseases of laser acupuncture in chronic respiratory diseases Table 4
1069
BMI, spirometric data and 6 MWD for the participants after 10 days of treatment.
Data after 10 days of treatment
Control group (n = 15)
Study group (n = 16)
Total participants (n = 31)
P-Value
Statistical significance
BMI kg/m2 (mean ± SD) FVC% (mean ± SD) FEV1% (mean ± SD) FEV1/FVC% (mean ± SD) FEF 25–75% (mean ± SD) 6 MWD in meters (mean ± SD)
27.67 ± 5.97 54.13 ± 18.79 39.60 ± 19.29 59.93 ± 16.01 26.07 ± 24.95 39.67 ± 13.29
26.82 ± 5.68 65.44 ± 18.38 55.25 ± 16.11 70.69 ± 15.29 38.88 ± 22.45 93.63 ± 29.96
27.23 ± 5.74 59.97 ± 19.15 47.68 ± 19.14 65.49 ± 16.23 32.68 ± 24.18 67.52 ± 34.60
0.688 0.101 0.020 0.066 0.143 0.000
Not significant Not significant Significant Not significant Not significant Significant
P-Value < 0.05 statistically significant.
therapy and drugs while the control group received only drugs. There was an earlier regression of clinical symptoms and a more rapid recovery of lung function in the group treated with laser therapy. The authors [15] concluded that, ‘‘non-drug treatment had an undeniably positive impact. In the absence of side effects of this method, infrared laser therapy can be recommended for rehabilitation of elderly patients with pneumonia.’’ Hacerova and Hubacek [16] studied the effect of laser acupuncture on acute sinusitis when compared to the control group on medical treatment. They found that laser irradiation causes a quicker withdrawal of inflammation and edema of the mucosa and thus brings restoration of drainage of sinus as well as normalization of mucociliary function and this strategy may be a great starting point for the treatment of other respiratory conditions. Puri and Arora [17] studied the bio-stimulatory effects of Gallium Arsenide Laser Irradiation at 890 nm as an adjunctive to anti-tuberculosis drugs in the treatment of pulmonary tuberculosis, one hundred thirty new sputum smear positive patients of pulmonary tuberculosis were included, they were randomly divided into two groups to receive either LLL or sham irradiation (control) concomitantly with anti-tuberculosis, Puri and Arora [17] concluded that there was a faster clearance of tubercle bacilli in the sputum of patients who were treated with LLL along with anti-tuberculosis treatment when compared to the control group and this improves the bacteriological cure and prevents secondary resistance. These findings provide evidence that LLL with Gallium Arsenide Irradiation may have bio-stimulatory effect as an adjuvant therapy for patients with tuberculosis. The present study showed that there was a more significant improvement in mean ± SD of FEV1 and 6 MWD after 10 days of laser therapy when compared to the control group. Although acupuncture treatment is commonly used in routine practice by qualified practitioners of traditional TCM in a variety of clinical settings and despite thousands of years of use, there is no robust evidence base to confirm its effectiveness in the treatment of asthma [18,19]. Evidence suggests that there is inconclusive evidence to indicate that short term (1–12 weeks) acupuncture treatment has a significant effect on the course of asthma when used in conjunction with drug maintenance treatment [7]. In contrast, Milojevic and Kuruc [20] treated 50 patients with bronchial asthma using laser acupuncture for 10 days, comparing changes with those of a control group of the same number of patients, differing only in that laser acupuncture was not given. Milojevic and Kuruc [20] found that ‘‘A tenday course of low-power laser stimulation of acupuncture
points in patients with bronchial asthma improves both the lung function and gas exchange parameters. Positive effects of laser treatment in patients with bronchial asthma are achieved in a short time and they last long, for several weeks, even months. Successive laser stimulation in asthmatics prolongs periods of remission and decreases the severity of asthmatic attacks. Similarly Ailioaie and Ailioaie [21] compared the effects of laser acupuncture and pharmaceutical drugs in asthma. The authors reported, ‘‘A noticeable improvement in the clinical, functional and immunological characteristics was observed in 83% of the patients in group with laser acupuncture treatment’’. Suzuki et al. [22] tried to determine whether a combination of traditional acupuncture treatment and conservative treatment for COPD improves dyspnea on exercise. The study included the acupuncture group (n = 15) that received acupuncture treatments once a week for 10 weeks and the control group (n = 15) that received conservative treatment with medication only. The authors [22] found that the acupuncture group had significantly better results on the Borg scale than the control group after 10 weeks. Also the 6-min walk distance and oxygen saturation improved significantly in the acupuncture group compared with the control group. In contrast, Bausewein et al. [23] looked at the effectiveness of non-pharmacological and non-invasive interventions to relieve breathlessness in participants suffering from the five most common conditions causing breathlessness in advanced disease. It included 47 randomized controlled and controlled clinical trials involving a total of 2532 participants described as suffering from breathlessness due to advanced stages of cancer, COPD, interstitial lung disease, chronic heart failure or motor neuron disease. Five of the trials were of acupuncture/ acupressure, which provided low strength evidence that acupuncture/acupressure is helpful. Most of the studies had been conducted in patients with COPD. Conclusion A ten-day course of low-power laser stimulation may be a useful adjunct to standard medical care for chronic respiratory diseases. Despite the availability, cost-effective efficacy and safety of LLL, the field is still in its infancy. As is obvious from the wide variety of LLL sources, frequencies, intensities used and no standard protocols exist. Further research is required to investigate the mechanism of the apparent effectiveness of laser acupuncture, which patients may be helped and which protocols are most effective.
1070 Conflict of interest None declared. References [1] S.C. Chang, The role of acupuncture in asthma, J. Chin. Med. Assoc. 70 (2007) 263–264. [2] D. Rindge, Laser acupuncture and respiratory disease, Acupuncture Today 6 (2) (2005). [3] T.I. Karu, Molecular mechanisms of therapeutic effects of low intensity laser radiation, Laser Life Sci. 2 (1988) 53. [4] W.J. Kneebone, Practical applications of low level laser therapy, Pract. Pain Manage. (2006), November/December. [5] F. Lin, S.F. Josephs, D.T. Alexandrescu, F. Ramos, V. Bogin, V. Gammill, C.A. Dasanu, et al, Lasers, stem cells and COPD, J. Transl. Med. 8 (2010) 16. [6] Z.H. Chen, H.P. Kim, S.W. Ryter, A.M. Choi, Identifying targets for COPD treatment through gene expression analyses, Int. J. Chron. Obstruct. Pulmon. Dis. 3 (3) (2008) 359–370. [7] R.W. McCarney, B. Brinkhaus, T.J. Lasserson, K. Linde, Acupuncture for chronic asthma, Cochrane Database Syst. Rev. (2003) (Issue 3). [8] G. Eknoyan, Adolphe Quetelet (1796–1874): the average man and indices of obesity, Nephrol. Dial. Transplant. 23 (1) (2007) 47–51. [9] R. Pellegrino, G. Viegi, R.V. Crapo, et al, Interpretative strategies for lung function tests, Eur. Respir. J. 26 (5) (2005) 948–968. [10] D. Shelledy, J.K. Stoller, An introduction to clinical diagnostic thinking, in: J.K. Stoller, E.D. Bakow, D.L. Longworth (Eds.), Critical Diagnostic Thinking in Respiratory Care – A Case Based Approach, WB Saunders, Philadelphia, 2002, pp. 11–38. [11] American Thoracic Society, ATS statement: guidelines for the six-minute walk test, Am. J. Respir. Crit. Care Med. 166 (1) (2002) 111–117. [12] J. Tuner, L. Hode, The Laser Therapy Handbook, Prima Books, Sweden, 2004, p. 170.
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