Acupuncture for the Treatment of Tinnitus

Acupuncture for the Treatment of Tinnitus

Tinnitus, the perception of noise or ringing in the ears, is a prevalent problem in the United States, affecting approximately 45 million Americans each year.^1,2 Though tinnitus is not considered a disease on its own, it is a significant symptom stemming from some kind of underlying condition.³ Root causes of tinnitus range from age-related hearing loss to ear injury or circulatory disorder.¹ Further, tinnitus can appear in those with structural lesions or those with conditions such as Meniere’s disease and multiple sclerosis.³ Pulsatile and non-pulsatile tinnitus are two ways to classify the problem, though many subtypes are frequently identified in the literature (somatic, neurological, objective, subjective). Pulsatile tinnitus involves the sensation of a rhythmic sound that resembles a heartbeat, swooshing or whooshing not externally sourced.^4,5 This form of tinnitus is often caused by sounds such as personal pulse, vascular problems or changes in the ear canal.⁵ By comparison, non-pulsatile tinnitus is attributed to problems with the nerves involved with hearing and may be experienced in one or both ears.⁵ This form of tinnitus is oftentimes described as originating inside the head.⁵

Determining the cause of tinnitus, regardless of type, is of key importance in the terms of treatment. Clearly, if the underlying problem can be addressed and rectified or improved, the associated symptoms may be alleviated or improved as well. However, finding effective treatments for tinnitus have been challenging to date.³

Acupuncture, originating in ancient China, has been used for thousands of years to treat a variety of conditions. Due to its efficacious outcomes in treating multiple maladies, it seems appropriate to examine its usefulness when applied to those suffering from tinnitus. Research surrounding this topic is abundant, yet simultaneously inconsistent with many studies demonstrating efficacy and some  presenting its lack of usefulness.

In a review of 40 research studies, the efficacy of acupuncture as a treatment for tinnitus was examined.⁶ Eight different types of acupuncture were analyzed, some of which were tested in conjunction with additional interventions such as supplementary medicine.⁶  A total of 3657 subjects were included across the 40 studies.⁶ Researchers concluded that all eight methods of acupuncture were effective in the treatment of neurological tinnitus (tinnitus caused by disease such as Meniere's disease).⁶ 

Similarly, a  2019 study was performed to determine the usefulness of acupuncture as a treatment choice for patients suffering from tinnitus.⁷ One hundred seven tinnitus patients were examined over the course of 17-24 acupuncture treatments.⁷ Researchers concluded that patients experienced improvement in their tinnitus condition following the course of treatment.⁷

A clinical observation study was performed to determine the difference in outcome between acupuncture combined with the intake of an herbal formula compared with the intake of the same herbal formula alone.⁸ Sixty patients were randomized into two groups - a combined therapy group and an herbal formula only group and treatment was administered according to a specific regimen for a total of six weeks.⁸ Tinnitus severity score and tinnitus handicap inventory were used to determine clinical effects of the treatments over the course of the study.⁸ Results showed an efficacy rate of 93.3% in the combined therapy group when compared to the 67.9% efficacy rate in the herbal formula only group.⁸ Researchers concluded that acupuncture used in conjunction with an herbal formula provided improvement for tinnitus patients.⁸

 A randomized clinical trial of 50 participants tested the effectiveness of acupuncture on tinnitus when compared to no treatment.⁹ Subjects were divided into equal groups and were evaluated for five weeks.⁹ Results showed a statistically significant effect between groups, leading researchers to conclude the efficacy of acupuncture to reduce tinnitus intensity and improve the quality of life of the tinnitus patients.⁹

In a  systematic review of literature, tinnitus and the effect of acupuncture as a treatment modality was studied.¹⁰ Six randomized controlled studies were examined and results showed positive effect in two unblinded studies and no significant effect in four blinded studies.¹⁰ Researchers concluded: “The belief that acupuncture is a specifically effective treatment for chronic tinnitus is not based on the evidence of rigorous randomized controlled trials. Further research on this subject seems to be warranted but should be conducted according to the highest methodological standards.”¹⁰

            An additional study demonstrated the ineffective nature of acupuncture on tinnitus patients.¹¹ The randomized, single-blind, placebo-controlled study followed 50 patients suffering from the condition and divided participants into a manual acupuncture group, an electrical acupuncture group and a placebo group.¹¹ Researchers studied frequency of tinnitus, tinnitus intensity, and reduction of life quality among patients over the course of the study.¹¹ Patients were evaluated before treatment, following six sessions of treatment and one month following the completion of treatment.¹¹ Results demonstrated no statistically significant effect of either form of acupuncture.¹¹ Despite the lack of statistically significant improvements, researchers noted relative advantages of electrical acupuncture when compared to the other two groups.¹¹

From the preponderance of the evidence, it appears that acupuncture holds a distinct amount of possibility in terms of an effective treatment modality for those suffering from tinnitus. There are several factors to acknowledge in regard to the studies reviewed, including small sample sizes and relatively brief treatment periods. However, it is important to note that though the evidence for the efficacy of acupuncture as a treatment option is perhaps not overwhelming, it does not include extensive risk. Therefore, it likely would be wise to consider acupuncture as a treatment option for those suffering from tinnitus, particularly if other therapies have not yielded results or have created negative side effects.

 References

1.Mayo Clinic. Tinnitus. Available at: https://www.mayoclinic.org/diseases-conditions/tinnitus/symptoms-causes/syc-20350156. Accessibility verified November 24, 2019.

2.American Tinnitus Association. Understanding the Facts: Demographics. Available at: https://www.ata.org/understanding-facts/demographics. Accessibility verified November 24, 2019.

3.Naderinabi B, Soltanipour S, Nemati S, Saberi A, Parastesh S. Acupuncture for chronic nonpulsatile tinnitus: A randomized clinical trial. Caspian J Intern Med. 2018;9(1):38–45. doi:10.22088/cjim.9.1.38

4.Department of Radiology and Biomedical Imaging. Pulsatile Tinnitus Clinic. Available at: https://radiology.ucsf.edu/pulsatile-tinnitus. Accessibility verified November 24, 2019.

5.My Health Alberta. Ringing in the ears (tinnitus). Available at: https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=tinit. Accessibility verified November 24, 2019.

6. Pang P, Shi Y, Xu H, et al. Acupuncture methods put to the test for a tinnitus study: A Bayesian analysis. Complementary Therapies in Medicine. 2019; 42:205-213.

7. Lin TY, Yang SW, Lee YS, et al. Analysis of Factors Influencing the Efficiency of Acupuncture in Tinnitus Patients. Evid Based Complement Alternat Med. 2019;2019:1318639. Published 2019 May 26. doi:10.1155/2019/1318639.

8. Chen S, Tan X, Fei L, Xiang X. Clinical observation on idiopathic tinnitus treated with acupuncture, buzhong yiqi tang and cizhu wan. Zhongguo Zhen Jiu. 2018;38(4):369-73. doi: 10.13703/j.0255-2930.2018.04.007.

9. Doi MY, Tano SS, Schultz AR, Borges R, Marchiori LL. Effectiveness of acupuncture therapy as treatment for tinnitus: a randomized controlled trial. Braz J Otorhinolaryngol. 2016;82(4):458-65. doi: 10.1016/j.bjorl.2016.04.002.

10. Park J, White AR, Ernst E. Efficacy of Acupuncture as a Treatment for Tinnitus: A Systematic Review. Arch Otolaryngol Head Neck Surg. 2000;126(4):489–492. doi:https://doi.org/10.1001/archotol.126.4.489.

11.Wang K, Bugge J, Bugge S. A randomised, placebo-controlled trial of manual and electrical acupuncture for the treatment of tinnitus. Complement Ther Med. 2010;18(6):249-55. doi: 10.1016/j.ctim.2010.09.005.

Protein Needs in Compromised Populations Part II

HIV Patients

In a randomized, double-blind, multicenter trial of 59 HIV positive subjects, researchers studied the effect of high protein whey supplementation when compared to a matched isocaloric control supplement without added protein for patients with a history of weight loss (a typical and potentially dangerous factor for HIV positive patients).⁷ Following the 12-week study, researchers concluded that there was no observed difference in regard to increased energy intake or changes in weight/lean body mass.⁷ However, researchers stated that CD4 lymphocytes (white blood cells responsible for fighting bacteria, viruses and germs) did increase in the protein group, a potential benefit according to the authors.⁷ However, researchers also stated that gastrointestinal symptoms were more commonly reported in the high protein whey  group.⁷ It is important to note that this study was supported by the whey supplement company, drawing into question the validity of accurate findings.⁷

A 1999 three-arm randomized controlled trial of 536 HIV patients with CD4 counts below 200 looked at the impact of nutrients on the prevention of weight loss over a four-month period.⁸ Researchers  studied the implementation of three nutritional regimens to determine their effect on the prevention of weight loss in patients.⁸ Therapies consisted of a  500 kcal daily of caloric supplement with peptides and medium-chain triglycerides plus a multivitamin and mineral supplement, 500 kcal of a caloric supplement with whole protein and long-chain triglycerides plus a multivitamin and mineral supplement, and a multivitamin and mineral supplement only.⁸ At the conclusion of the four-month study, researchers concluded that no differences were observed (including the increased protein group), stating that caloric supplements did not provide a viable treatment modality for this population.⁸

In a 2003 study of 467 weight-stable HIV-infected men with CD4 counts lower than 200 were observed in regard to protein intake and body composition variables, including body cell mass (the depletion of which is a predictor of disease progression and death).⁹ Researchers concluded that increased protein intake was related to increased body cell mass, suggesting efficacy in the use of protein to boost health variables in HIV patients.⁹

Researchers in a 2006 study of children suffering from rapidly-progressing AIDS, examined the effect of  a whey protein supplement in regard to erythrocyte glutathione concentration, T lymphocyte counts and occurrence of additional infections.¹⁰ In the prospective double-blind clinical trial, 18 HIV-infected children undergoing antiretroviral therapy were followed for four months.¹⁰ The subjects were divided into three groups and given whey protein, maltodextrin or placebo, followed by an evaluation of erythrocyte glutathione concentration, T lymphocyte counts and occurrence of additional infections.¹⁰ Results demonstrated  that in the whey protein group, erythrocyte glutathione levels increased and co-infection occurrence decreased, while T lymphocytes remained unchanged when compared to the control group (placebo).¹⁰  Researchers concluded that the inclusion of a whey protein supplement was advisable for this population.¹⁰

Summary of Findings and Limitations

Though this brief review may appear to point to the overall benefits of increased protein intake and health-compromised people groups, it is important to note the existence of study limitations. Several of the studies reviewed involved very small sample sizes. Though this fact does not necessarily fully discount the findings, it does give reason to be cautious when evaluating the efficacy of information. Many of the studies reviewed also examined multiple factors combined with increased protein intake, making the definitive factor of efficacy more difficult to deduce. Further, as mentioned previously, one of the studies presented was funded by the maker of the protein supplement used in the study, thus giving reason to again be mindful of the bias potential. Length of the studies is also a factor to consider due to the fact that the relevance of data was not studied extensively in terms of long-term outcomes. Oftentimes interventions appear positive in the short-term but neutral or negative in the long-term. Further, though some benefit was shown in some of the presented studies, it is important to note that reduction in wound size or increased levels of CD4 levels for example, does not necessarily imply positive health outcomes for the individual overall. Symptom management, symptom reduction and more acceptable biomarkers do not always suggest optimal health, a point of key importance when evaluating treatment modalities.

Risks

It is always important to examine the level of risk associated with any type of intervention, even if the added measure appears to be harmless. Though protein is a necessary nutrient, an increase of consumption does not come without risk. Consuming large amounts of protein carries with it a significant amount of risk such as increased risk of cancer, diabetes and overall mortality.¹¹ Eating a high protein diet also creates excessive strain on the kidneys, causing complications such as the formation of kidney stones and other kidney-related health issues.¹³ In addition, the inclusion of high protein supplements made from dairy products carries with it a considerable amount of risk due to the detrimental effects of dairy consumption. Higher mortality rates, cancer, fracture risk and heart disease can all be linked to the consumption of dairy, a fact that should give significant pause to the recommendation to increase the consumption of it, particularly in immune-compromised populations.^{,14, 15, 16}

Conclusions and Future Research Opportunities

As reviewed above, some evidence appears to exist in regard to increased protein intake. However, study limitations exist and multiple risks exist to the implementation of increased protein intake. Additional research into alternative methods of improvement that do not involve increased protein intake would be wise to conduct, in addition to a more extensive evaluation of the risk-benefit ratio of protein intervention and the detrimental effects of engaging in such measures.

References

7. Sattler FR, Rajicic N, Mulligan K, et al. Evaluation of high-protein supplementation in weight-stable HIV-positive subjects with a history of weight loss: a randomized, double-blind, multicenter trial. American Journal of Clinical Nutrition. 2008;88(5):1313–1321. doi:10.3945/ajcn.2006.23583

8. Gibert CL, Wheeler DA, Collins G, et al. Terry Beirn Community Programs for Clinical Research on AIDS: randomized, controlled trial of caloric supplements in HIV infection. Journal of Acquired Immune Deficiency Syndrome. 1999;22:253–259. 

9. Williams SB, Bartsch G, Muurahainen N, et al. Protein intake is positively associated with body cell mass in weight-stable HIV-infected men. Journal of Nutrition. 2003; 133(4): 1143-1146.

10. Moreno YF,  Sgarbieri VC, da Silva MN, Toro AADC, Vilela MMS. Features of whey protein concentrate supplementation in children with rapidly progressive HIV infection. Journal of Tropical Pediatrics. 2006; 52(1): 34–38.

11. Levine ME, Suarez JA, Brandhorst S, et al. Low protein intake is associated with a major reduction in IGF-1, cancer, and overall mortality in the 65 and younger but not older population. Cell Metabolism. 2014;19(3):407–417. 

12.  Fontana L, Klein S, O Holloszy J, Long-term low-protein, low-calorie diet and endurance exercise modulate metabolic factors associated with cancer risk. American Journal of Clinical Nutrition. 2006; 84(6):1456–1462.

13. Robertson W, Heyburn P, Peacock M, Hanes F, Swaminathan R. The effect of high animal protein intake on the risk of calcium stone-formation in the urinary tract. Clinical Science. 1979; 57(3):285-288.

14. Michaëlsson K, Wolk A, Langenskiöld S, et al. Milk intake and risk of mortality and fractures in women and men: cohort studies. British Medical Journal.  2014; 349 :6015.

15. Aune D, Rosenblatt DAN, Chan DSM, et al. Dairy products, calcium, and prostate cancer risk: a systematic review and meta-analysis of cohort studies. American Journal of Clinical Nutrition. 2015;101:87-117.  

             16. Chen M, Li Y, Sun Q, et al. Dairy fat and risk of cardiovascular disease in 3 cohorts of US adults.                 American Journal of Clinical Nutrition. 2016;104(5):1209–1217. 

Protein Needs in Compromised Populations Part I

There does not appear to be much debate when discussing the importance of nutrition on patients suffering from wounds and burns and likewise with people who are HIV positive. More specifically, increased intake of protein is often posed as the essential nutrient for such patients. However, as is always the case, it is of paramount importance to examine the scientific findings of such claims before making the assumption that the recommendations are sound. For the purposes of this paper, a brief review of the literature concerning the afore-mentioned populations in relation to protein intake will be presented.

Wound and Burn Healing

According to an article published in the British Journal of Nursing, author Linda Russell reported that protein deficiency poses many detriments to the healing process such as reduction in collagen formation.¹ Further, Russell commented that high exudate loss has the potential to deplete protein stores by 100 grams per day, thus indicating the need for heightened intake of protein.¹ It should be noted that in addition to increased protein intake, the author encouraged a comprehensive evaluation of nutrition overall, stating that a holistic approach to nutrient load is vital to wound healing.¹

A 2014 review of the literature looked at the necessity of nutrition, including the subset of protein, in relation to wound healing.² Researchers stated that increased  protein needs were noted as a result of protein loss due to large surface area of unhealed wounds, wound exudates, chronic wound sites, and losses in lean body mass.^{2, 3} Further, researchers stated that in order to experience wound healing, protein losses must be accounted for and replaced by increased intake of protein.² Once again, it is noteworthy to mention that the authors recommend a comprehensive overview of nutrition and possible supplementation of various sources to enhance wound healing, rather than solely relying upon increased protein intake.

In a 1993 study of 28 malnourished patients with truncal pressure ulcers, researchers examined the effect of protein on wound healing.³ Patients were divided into two groups, one receiving 24% protein (high intake) and the other receiving 14% protein (moderately high intake).³ Researchers observed a decrease in wound surface area in the higher protein group but not the moderate protein group.³ Higher caloric intake was also noted as a contributing factor to the reduction in wound surface area in the higher protein group.³ Though the researchers concluded that high protein diets may improve wound healing, it is important to point out the uniqueness of the population studied (malnourished nursing home patients) and not automatically apply the findings to the general population.

A 2009 review of the literature studied the connection between nutrition and wound healing and confirmed conclusions previously mentioned. Authors stated, based upon their review,  that protein is a vital component to wound and burn healing.⁴ Skin regrowth, according to the review, is dependent upon cell proliferation and protein synthesis, both of which require increased protein consumption.⁴ In addition, researchers concluded that rapid protein initiation was vital in preventing protein malnourishment in patients.⁴ Researchers not only recommended protein intake increase but also the inclusion of anabolic hormones to heighten the body’s response to protein⁴  Of key importance would be an additional review of the data concerning risks involved with this type of supplementation,  a suggestion not examined in the current article.

A literature review in the Indian Journal of Critical Care Medicine examined the importance of hydration and nutritional intake in relation to pressure ulcers.⁵ Researchers noted that though hydration is of key importance to the regeneration of skin, nutrition is equally imperative to the wound healing process.⁵ Protein, along with a multitude of other nutrients, was recommended  as essential to the process of wound healing, stating that protein was the most important macronutrient involved in the repair of tissues.⁵

In a 2014 Cochrane Review, researchers studied a variety of factors in regard to wound healing, including increased protein intake.⁶ Outcome results showed a lack of efficacy in regard to the incorporation of increased protein and wound healing.⁶ Furthermore, out of the fourteen studies reviewed, authors concluded that nutritional supplements overall showed no benefit to wound healing (with the questionable exception of arginine which showed possible but not convincing efficacy).⁶

References

1. Russell, L. The importance of patients' nutritional status in wound healing. British Journal               of Nursing. 2013; 10(1): 44-49.

2. Molnar JA, Underdown MJ, Clark WA. Nutrition and chronic wounds. Advanced Wound                  Care (New Rochelle). 2014;3(11):663–681.

3. Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary                 protein in healing pressure ulcers. Journal of the American Geriatric Society. 1993; 41(4):                   357-362.

4. Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty.                2009;9:e9.

5. Saghaleini SH, Dehghan K, Shadvar K, Sanaie S, Mahmoodpoor A, Ostadi Z. Pressure                    ulcer and nutrition. Indian Journal of Critical Care Medicine. 2018;22(4):283–289. 

6. Langer  G, Fink  A. Nutritional interventions for preventing and treating pressure ulcers.                  Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.:CD003216. 

DOI:  10.1002/14651858.CD003216.pub2.