IBS – the condition
Irritable Bowel Syndrome (IBS) is one of a group of conditions referred to as functional gastrointestinal disorders. These result from a change in the way the brain sends signals to the nerves supplying the digestive organs (gut-brain interaction). The condition results in a change to bowel habits, causing abdominal pain and cramping, bloating, and gives feelings of general discomfort. It can occur in some form in about 15-20% of adults, and as such is the most common bowel disorder seen by GPs. IBS is often treated with medication which helps alleviate symptoms. Typically, drugs aim to reduce feelings of cramp (antispasmodics), depression (antidepressants), constipation (activators to increase bowel secretions) or diarrhoea (antibiotics). However, many of these drugs carry risks such as cardiovascular events and have been shown to have only modest effects when compared to placebo (Manheimer 2012). In addition, as symptoms typically recur (some days better, some worse) medication may be needed long term to manage the condition.
The exact cause of IBS is not known, but it has been linked to diet, stress, family history, and oversensitivity of the nerves controlling the bowel. Medical investigations include blood tests to rule out coeliac disease (inflammation of the small bowel as an adverse reaction to gluten), and a stool sample to check for infections or inflammation. If either of these tests is positive, an endoscopy may be performed where a thin flexible tube with a small camera attached (endoscope) is inserted into the body. The area examined determines the name of the procedure. With bowel related disorders, sigmoidoscopy (testing the lower part of the bowel) or colonoscopy (testing the whole bowel) may be performed through the back passage into the bowel to test tissue (Biopsy).
How might acupuncture help?
IBS is thought in part to be an intestinal stress response. We have three main types of nerves. Sensory nerves are for feeling (touch, vibration, itch, pain), and motor nerves for movement (muscles, spasm, tremor). These two form parts of the central and peripheral nervous systems (CNS). In addition, we have other nerves for controlling the body’s internal environment (saliva, swallowing and digestion, sweating), which form the autonomic nervous system (ANS), and has two divisions – sympathetic (to speed things up) and parasympathetic (to slow things down). A subdivision of the autonomic nervous system is the enteric nervous system (ENS) which consists of a meshwork of tiny nerves wrapped around the food pipe (oesophagus), stomach and intestines. Importantly, this system can act independently to the others. Incredibly it consists of over 500 million neurons (nerve cells) or five times the number in the spinal cord. Essentially the ENS has two main functions, absorption and secretion (submucosal plexus) and intestinal movement or motility (myenteric plexus). Changes to the way these nerves fire is thought to be important in IBS.
IBS is thought in part to be an intestinal stress response.
What does acupuncture treatment involve?
A protocol for the acupuncture of IBS was developed by Reynolds et al (2008) who looked at the most common points generally used for treatment of this condition by acupuncturists (table 1). Points are generally needled on both sides of the body (bilateral) and the points are stimulated until a pleasant aching sensation (DeQi) is felt. The needles are typically about 2-3cms long but only inserted to a depth of about 2-5mm and are usually left in for about 20 minutes. Sometimes the needles are gently warmed with a heat lamp, or traditionally using moxa cones attached to the needle.
Table 1
Acupuncture points commonly used in IBS treatment
(data from Reynolds 2008)
Acupuncture needles are sterile fine filaments much smaller than an injection needle which most people are familiar with. They are flexible and inserted quickly using a special plastic guide tube meaning that many people do not actually feel them puncture the skin. Once in, the needle is gently stimulated by hand to give a pleasant relaxing ache which often spreads outwards. When all the needles are in, you simply relax (you will be lying down) for about 20-30 minutes. When the needles are removed you will feel warm and relaxed, and sometimes slightly sleepy that evening.
Acupuncture effects on the Autonomic Nervous System
The autonomic nervous system mentioned above (ANS) is responsible for the unconscious control of bodily functions such as digestion, respiration, and circulation. The ANS supplies the internal organs and has two main divisions, Sympathetic and Parasympathetic. In general terms the sympathetic system speeds up metabolic processes (fight or flight) while the parasympathetic slows them down (rest and digest), and these effects are brought about via chemical messengers (neurotransmitters).
Regulation of internal organs (viscera) comes about mainly via two pathways. Changes in emotions may result in an indirect alteration in heart rate, blood flow or organ secretion, while impulses from receptors located within the organs themselves cause direct alteration via reflex changes in the organ. Stimulation of acupuncture points has been shown to produce several neurotransmitters which change (modulate) activity via the spinal cord and brain (Stenner-Victorin 2016). Looking at scientific studies, experiments on anaesthetized rats’ have shown that acupuncture like stimulation of the abdominal region calms down (inhibits) gastric motility and tone, while stimulation of the limb points can quicken (excite) motility.
Indirect effects of acupuncture on IBS targets stress and emotional responses, which can occur through signals from the autonomic nervous system. Acupuncture at a point on the hand (LI-4) has been shown to reduce heart rate (beats per minute) and smooth the heartbeat (Heart rate variability) through a sympathetic effect. In addition, using this point with one in the shin (SP-6) showed a more marked effect with real acupuncture compared to a sham treatment (Kim et al 2011).
Acupuncture point selection
Acupuncture points may be selected in the same body area as the affected organ to target direct reflex activity of the organ itself. Sympathetic nerves connecting to the GI tract are found in the thoracic to upper lumbar regions (T5-L2), while parasympathetic nerves are from the brain stem (Vagus nerve) and the sacral region for the lower colon (S2-4). Acupuncture points on the back (Bladder channel) or the abdomen (Stomach or Conception vessel), at the level of pain may be used.
Additionally, points may be selected to target stress responses, anxiety and depression for an indirect on IBS. Acupuncture has been used extensively in the treatment of depression and shown to be associated with short to medium term benefits to the same degree as counselling (MacPherson et al 2013). The general IBS treatment protocol used in several studies is shown in table 1, and this is modified (points added or not used) depending on how the patient presents.
Research on acupuncture in the treatment of IBS
Patients often report anecdotally that acupuncture helps alleviate some of their IBS symptoms. Using research to assess these effects, several studies have been performed. A Cochrane review (Manheimer et al 2012) looked at 17 randomized controlled trails (RCTs) which drew on the experience of over 1800 patients. Some studies compared real acupuncture to sham acupuncture, while others compared acupuncture to antispasmodic drugs commonly used in IBS treatment. Acupuncture offered greater benefits that the drugs, but when compared to sham, real acupuncture did not offer greater benefit. This may question the suitability of the sham or suggest that the effect of acupuncture was more psychological (mind effect) than physiological (structural change).
Studies since this Cochrane review have shown different results. A pragmatic RCT (one which is conducted in actual treatment rather than in a laboratory setting) looked at 233 patients and showed a significant difference favouring the acupuncture group over usual care (drugs or advice), with the acupuncture group being 18% better and the effect persisting at 6 and then 12 months following treatment (MacPherson et al 2012). In a later follow up at 24 months, there were no statistically significant differences between acupuncture and usual care (MacPherson et al 2017) suggesting that acupuncture treatment needs to continue. Additionally, these authors suggested that as the effects where largely maintained from 3 months through to 24 months “the apparent benefits of acupuncture represent more than a simple placebo response. Longer-term effects are likely to be associated with the underlying physiological mechanisms of action”
the apparent benefits of acupuncture represent more than a simple placebo response. Longer-term effects are likely to be associated with the underlying physiological mechanisms of action
References
Kim, E., Cho, J., Jung W., et al (2011) Effect of Acupuncture on Heart Rate Variability in Primary Dysmenorrheic Women. American Journal of Chinese Medicine 39(2):243-9
MacPherson H, Richmond S, Bland M, et al. (2013) Acupuncture and counselling for depression in primary care: a randomised controlled trial. PLoS Med 10:e1001518.
MacPherson, H. Tilbrook, H., Agbedjro, D et al (2017) Acupuncture for irritable bowel syndrome: 2-year follow-up of a randomised controlled trial. Acupuncture in Medicine. 35: 17-23
Manheimer E, Cheng K, Wieland LS, et al (2012) Acupuncture for irritable bowel syndrome.
Reynolds JA, Bland JM, MacPherson H: (2008). Acupuncture for irritable bowel syndrome an exploratory randomised controlled trial. Acupuncture in Medicine. 26:8–16.
Stener-Victorin, E (2016) Acupuncture and the autonomic nervous system. In, Filshie, J et al Medical Acupuncture (second edition). Elsevier, London.
Patients – for acupuncture treatment at our Congleton clinic phone us on 01260 290564