Acupuncture for Sleep Apnea

Brazilian researchers who reported some time ago that acupuncture treatment may offer significant help in managing moderate obstructive sleep apnea say that follow-up projects have offered further support of their original findings.

Responding to an e-mail inquiry, Dr. Anaflávia O. Freire, principal author of the original study, said the most dramatic finding in the new studies was that acupuncture treatment led to significant strengthening of the genioglossus, or tongue muscle. After treatment, patients’ tongues were three or four times stronger than those of patients in the control group. Tongue strength was measured by electromyography, a technique of metering electrical activity in the muscle at rest and then as it is contracted.

Presumably a stronger genioglossus reduces the likelihood of the sleeper’s tongue dropping back and blocking the airway. Acupuncture also appeared to reduce inflammation in the genioglossus, Freire said.

The article that led to the follow-up studies, “Treatment of Moderate Obstructive Sleep Apnea Syndrome with Acupuncture,” was published online by Sleep Medicine Oct. 4, 2006, and subsequently appeared in the print edition of the journal in issue 8 (2007).

Study first of its kind

In a project Freire said was the first of its kind, she and her fellow researchers found that 10 weeks of acupuncture treatment of patients with moderate OSA led to significant improvement that was not duplicated in either an untreated control group or a second group that received sham acupuncture treatment. The randomized pilot trial was carried out at the Public Hospital of the Universidade Federal de São Paulo. The 36 participants, all diagnosed with moderate OSA, were separated 12 each into the three groups.

Ten of the participants were dropped during the 10 weeks, one from the treated group, two from the sham group and the others from the untreated control group. From the 26 who remained, the investigators reported that the mean apnea-hypopnea index of the treated group diminished from 19.9 to 10.1 while it rose from 21.6 to 24.6 in the sham group and from 20.4 to 28.2 in the control group.

“Widely accepted PSG (polysomnography) criteria for treatment to be considered successful is a reduction in AHI to lower than 10, with a 50 percent reduction from the baseline condition,” the authors wrote. “In our study, 60 percent of the patients reached these goals, and another 20 percent reached only the 50 percent reduction in the AHI.”

In the light of these and other numbers, they added, “We have found preliminary evidence that acupuncture is effective in the treatment of OSAS. This work, however, must be replicated and the observation period after treatment should be extended in order to evaluate the duration of the improvement obtained and also to establish well defined treatment protocols.”

Researchers all M.D.s

Freire and her colleagues who administered the actual and sham acupuncture treatments are all medical doctors as well as trained practitioners of traditional Chinese acupuncture. Their article included detailed information on which acupuncture points were stimulated in the treatments. They also offered extensive hypothesizing, in Western physiological terms, about the neurological responses that might have been invoked by the treatments. Should acupuncture prove out as an effective treatment for sleep apnea, it could be enormously valuable in poor countries, the authors suggested. In Brazil, where the authors said the minimum wage is around $90 a month, $1,000 CPAP machines are beyond the economic reach of many OSA sufferers, they said, and beyond the capacity of the public health system to finance, especially for those whose diagnosis is moderate OSA rather than severe.

Joining Freire in authorship of the article were Gisele C. M. Sugai, Fernanda Silveira Chrispin, Sónia Maria Togeiro, Ysao Yamamura, Luiz Eugênio Mello, and Sérgio Tufik. Despite the physiological comments, the Freire article provoked a letter to the editor from Dr. Balaji Yegneswaran, then at Toronto Western Hospital, which appeared in Sleep Medicine 9 (2008). He said he saw nothing other than chance to account for the improvements after acupuncture treatments and declared: “Presently, there is no pathophysiological explanation for this result.” Noting that 26 OSA patients were not prescribed CPAP treatment for the duration of the study, he said ethical research demanded “a concrete hypothesis, sufficient sample size, use of standard treatment as a control, [and] an understanding of the nature of treatment as one expects from drug trials…

Brazilian findings are tantalizing but preliminary

“What if patients decide to quit CPAP treatment and replace it with 10 sessions of acupuncture just because this paper is published in Sleep Medicine?” he asked. In a response published simultaneously, Freire and coauthor Mello thanked Yegneswaran for his letter. They added: “We suggest that a more open attitude while still retaining a healthy skepticism allows anyone interested in understanding acupuncture to find over 11,000 published items in PubMed with many of them in high profile journals.”

They agreed that best practice would have been to treat the control group with PAP therapy while the study was under way, but said they lacked the resources. “We do not have even enough CPAP devices for immediately treating all of the severe OSA patients that arrive to our center,” they wrote. “Considering this, we should be more worried about the ethical concern that most of the patients are untreated because of the price of the CPAP device as well as the adhesion of the patients. To this end, investigating new and more affordable treatments for OSA is of fundamental importance.”

Acupuncture is key in Brazil’s health care

In her e-mail comments to Wake-up Call, Freire noted that acupuncture plays a prominent role in Brazilian health care and is now a recognized medical speciality. Western-style research on acupuncture is being conducted in the best Brazilian universities, she said.

Freire and all her coauthors of the original article except Chrispin and Yamamura have successfully placed a new article titled “Immediate Effect of Acupuncture on the Sleep Pattern of Patients with Obstructive Sleep Apnea,” which reports that the AHI of OSA patients showed significant reduction after only one acupuncture treatment rather than the 10 weekly treatments of the earlier study. The article, which also notes the addition of one more acupuncture point to the 10 employed in the original study, will appear in Acupuncture in Medicine, the journal of the British Medical Acupuncture Society.

Victoria Thon, Ph.D., a member of the ASAA board of directors, who monitors research on alternative and complementary treatments of sleep apnea, cautioned that no one being successfully treated with PAP therapy should take the Freire study findings as an invitation to give up PAP treatment for acupuncture.

“We often see OSA patients read about the ‘success’ of a preliminary study and then assume ‘success’ to erroneously mean that an alternative therapy will cure them of their OSA and they can stop using their PAP,” she wrote in an e-mailed comment. “But that is not the case.

“It is always best to remain hopeful and optimistic about novel therapies for OSA. But it jeopardizes the health of an OSA patient to dismiss CPAP therapy, which has been extensively studied and in use for 25 years, for a new alternative OSA therapy. It is especially dangerous to do so without evidence that an alternative therapy is effective through the use of an objective sleep study.”

From Wake-up Call, Spring 2010.