Effect of Needling at Selected Acupuncture Points (GB39, BL17, LR13) on Hemoglobin Levels in Anemia: a Randomized Placebo Controlled Study

K. Gayathri Devi; A. Mooventhan; N. Mangaiarkarasi; N. Manavalan

doi:10.51507/j.jams.2023.16.6.263

Articles Service

View[3495]
Download[806]
Crossref [0]
SCOPUS [0]

Brief Report

Split Viewer

Effect of Needling at Selected Acupuncture Points (GB39, BL17, LR13) on Hemoglobin Levels in Anemia: a Randomized Placebo Controlled Study

K. Gayathri Devi¹, A. Mooventhan^1,2,*, N. Mangaiarkarasi¹, N. Manavalan³

¹Department of Acupuncture and Energy Medicine, Government Yoga and Naturopathy Medical College, Chennai, Tamilnadu, India
²Department of Research, Government Yoga and Naturopathy Medical College, Chennai, Tamilnadu, India
³Department of Naturopathy, Government Yoga and Naturopathy Medical College, Chennai, Tamilnadu, India

Correspondence to:

A. Mooventhan
Departments of Research and Acupuncture and Energy Medicine, Government Yoga and Naturopathy Medical College, Chennai, Tamilnadu, India
E-mail dr.mooventhan@gmail.com

Received: April 20, 2023; Revised: June 27, 2023; Accepted: December 1, 2023

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

J Acupunct Meridian Stud 2023; 16(6): 263-267

Published December 31, 2023 https://doi.org/10.51507/j.jams.2023.16.6.263

Abstract

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONFLICT OF INTEREST
References

Iron deficiency anemia (IDA) is an important public health issue in India. This study was performed to determine the impact of acupuncture at the GB39, BL17, and LR13 points on hemoglobin levels, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and red cell distribution width (RDW) in people with IDA. One hundred women with IDA were randomly allocated to the acupuncture group (AG) or placebo control group (PCG). For 30 minutes per day, daily for 2 weeks, the AG received acupuncture at GB39, BL17, and LR13, while the PCG received needling at non-acupuncture points. Outcomes were assessed before and after the intervention. We found a significant increase (p < 0.001) in hemoglobin level (AG 10.39-11.38 g/dl, effect size 0.785; PCG 10.58-10.40 g/dl, effect size 0.191), MCH (AG 25.69-27.50 fl, effect size 0.418; PCG 27.43-27.23 fl, effect size 0.058), and RDW (AG 15.12-16.41 fl, effect size 0.626; PCG 14.91-14.94 fl, effect size 0.017) in the AG compared to the PCG. Results suggest that needling at the GB39, BL17, and LR13 acupuncture points is more effective in treating people with IDA than needling at non-acupuncture points.

Keywords

Acupuncture, Anemia, Blood, CAM

INTRODUCTION

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONFLICT OF INTEREST
References

A reduction in total hemoglobin or red blood cells (hemoglobin < 12 g/dl) is considered to constitute anemia [1]. Nutritional anemia, particularly iron deficiency anemia (IDA), is an important public health issue in India, and the high prevalence of anemia among adolescent girls causes an annual 1.8% loss of gross domestic product [2]. Deficient iron intake or absorption, increased iron need, menstruation, and infections are the main reasons for IDA in adolescent girls [3]. Traditional Chinese Medicine (TCM) places anemia in the “blood deficiency” category. The causes of blood deficiency are considered to include depletion of spleen Qi; weak spleen Qi leads to poor assimilation and supply of nutrients to the body. Literature suggests that acupuncture, an important traditional complementary and alternative medical practice that sees worldwide application [4], promotes oral iron therapy by improving iron absorption [5]. Gallbladder (GB)39 (Xuanzhong) is the influential acupuncture point for the treatment of bone marrow, which is responsible for erythropoiesis. Since TCM considers that the energy of a corresponding tissue or organ is concentrated at an influential point, acupuncture at GB39 is thought to help improve bone marrow function. Urinary bladder (BL)17 (Geshu) is the influential point for blood and thus expected to be useful in correcting blood deficiency. Deficiency in spleen Qi can result in anemia, and liver (LR)13 (Zhangmen), the Mu-front point for the spleen, can be used to address this [5-7]. Although these sources suggest that GB39, BL17, and LR13 are useful for the treatment of IDA [8], no studies so far have reported their effect on hemoglobin levels in patients with IDA. We therefore performed this study to determine the effect of acupuncture at GB39, BL17, and LR13 on hemoglobin levels, mean corpuscular volume (MCV) (average red blood cell volume), mean corpuscular hemoglobin (MCH) (concentration of hemoglobin in a particular volume of packed red blood cells) and red cell distribution width (RDW) (variation in red cell distribution) in people with IDA.

MATERIALS AND METHODS

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONFLICT OF INTEREST
References

1. Study design

We used a randomized controlled study design. Participants were randomly allocated to the acupuncture group (AG) or placebo control group (PCG) based on computerized randomization at a ratio of 1:1. The AG received needling at the GB39, BL17, and LR13 acupuncture points, while the PCG received needling at non-acupuncture points. Both groups received needling for 30 minutes per day, once daily for 2 weeks. Outcomes were assessed before and after the intervention (Fig. 1).

Figure 1.Trial profile. GB39 = Gall bladder 39; BL17 = Bladder -17; LR13 = Liver 13.

2. Study setting

The study was conducted at Government Yoga and Naturopathy Medical College (GYNMC), Chennai, India. The institutional ethics committee of GYNMC approved the study protocol (Ref. No.: RES/IEC-GYNMC/2021/110).

3. Participants

A total of 100 female subjects aged 18-35 years participated in the study. Inclusion criteria were as follows: Female, aged 18-35 years, diagnosed with IDA, with a hemoglobin level < 12 g/dl, and willingness to sign the informed consent statement. Exclusion criteria were as follows: current use of nutritional supplements for IDA or regular medication for any chronic illness; currently menstruating, pregnant, or lactating; and any other systemic or psychological illness. All participants provided their written informed consent.

4. Intervention

1) Acupuncture group (AG)

The acupuncture points (GB39, BL17 and LR13) were selected based on suitability following TCM concepts, where GB39 is the influential point for bone marrow, BL17 is the influential point for blood, and LR13 is used to correct deficiency of the spleen Qi (a cause of anemia) [5-7]. A total of 6 needles were used per subject per session for bilateral needling at GB39 (0.5-cun depth, perpendicularly), BL17 (0.5-cun depth, transversely), and LR13 (0.5-cun depth, obliquely). The locations of the selected acupuncture points are provided in Table 1.

Table 1 . Details of the acupuncture points used in the study

Acupuncture point	Location	Needling
Gall blader (GB) 39 – Xuanzhong	3 cun proximal to the highest prominence of the lateral malleolus, on the anterior border of fibula	Vertically on the point
Urinary bladder (BL) 17- Geshu	1.5 cun lateral to the posterior midline, on the level of lower border of spinous process of the 7th thoracic vertebra (T7)	Transversely towards the spine.
Liver (LR) 13 - Zhangmen	Anterior and inferior to the free end of the 11th rib, approximately 1 cun superior to the umbilicus	Obliquely in a lateral direction

2) Placebo control group (PCG)

Participants received needling at the following non-acupuncture points: 1 cun proximal to the tip of the lateral malleolus, 2 cun lateral to the lower border of the T7 vertebra, and 2 cun below the free end of floating rib.

In both groups, the patients were informed about the procedure and sensations of needle insertion, and a response was sought. Manual stimulation was performed by the lifting and thrusting method at intervals of 10 minutes for the daily duration of 30 minutes. Needling was performed using 0.25 × 13-mm stainless steel sterile filiform needles. After needling, participants were given cotton balls to stem any bleeding.

5. Assessment

The primary outcome variable of this study was hemoglobin level, and the secondary outcome variables were MCV, MCH and RDW. The blood samples were collected in EDTA and plain vacutainers with 2-ml disposable syringes. Outcomes were assessed using a fully automated Beckman DxH800 Hematology analyzer before and after the intervention.

6. Sample size

A total of 100 female participants were included in the study. No preliminary sample size calculations were performed.

7. Randomization and blinding

Participants were randomly assigned to AG and PCG by computerized randomization (1:1 ratio). The sequentially numbered, opaque, sealed envelope (SNOSE) technique was used for allocation concealment. All participants were blinded to the needling at acupuncture or non-acupuncture points.

8. Data analysis

The Kolmogorov-Smirnov test was used to check results for normality. Baseline and demographic details of AG and PCG were compared by independent samples t-tests or Mann-Whitney U tests based on the data distribution. Since baseline demographic (height and weight) and outcome (MCV and MCH) variables differed significantly between groups, groups were compared using univariate analysis of covariance (ANACOVA) and post-hoc analysis with Bonferroni adjustment. SPSS v.16.0 was used for data analysis. Effect size was calculated using G*Power 3.1.9.4.

RESULTS

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONFLICT OF INTEREST
References

A total of 113 participants were recruited from a medical college hospital located in Chennai between January 2021 and May 2022. Of these, 13 participants were excluded as per the exclusion criteria. All remaining participants (n = 100) completed the study, and included their results were included in the statistical analysis. The baseline and demographic details for both groups are provided in Table 2. Results show that the AG displayed significant increases (p < 0.001 for all variables) over the PCG in hemoglobin level (AG 10.39-11.38 g/dl, effect size 0.785; PCG 10.58-10.40 g/dl, effect size 0.191), MCH (AG 25.69-27.50 fl, effect size 0.418; PCG 27.43-27.23 fl, effect size 0.058), and RDW (AG 15.12-16.41 fl, effect size 0.626; PCG 14.91-14.94 fl, effect size 0.017). Participants did not report adverse events during the study (Table 3).

Table 2 . Baseline and demographic details of the acupuncture group and placebo control group

Parameters	Acupuncture group (n = 50)	Placebo control group (n = 50)	p-value
Age (years)^†	20.92 ± 2.28	22.12 ± 3.51	0.164
Height (meter)^*	1.56 ± 0.05	1.58 ± 0.07	0.042
Weight (kilograms)^*	53.41 ± 9.13	57.24 ± 6.75	0.019
Body mass index (kg/m²)^*	21.93 ± 3.26	22.83 ± 2.37	0.120
Hemoglobin (mg/dl)^†	10.39 ± 1.22	10.58 ± 0.94	0.631
MCV (µm³)^†	78.38 ± 15.40	84.65 ± 8.17	0.027
MCH (pg)^*	25.69 ± 4.24	27.43 ± 3.49	0.027
RDW (%)^†	15.12 ± 2.04	15.12 ± 2.04	0.704

All values are mentioned in mean ± standard deviation.

MCV = mean corpuscular volume; MCH = mean corpuscular hemoglobin; RDW = red cell distribution width.

*Independent samples t-test; ^†Mann-Whitney U test.

Table 3 . Pre-test and post-test assessments of the acupuncture group and placebo control group

Parameter	Acupuncture group (n = 50)			Placebo control group (n = 50)			p-value
Parameter	Pre-test	Post-test	Effect size (Cohen’s D)	Pre-test	Post-test	Effect size (Cohen’s D)	p-value
Hb (mg/dl)	10.39 ± 1.22	11.38 ± 1.30	0.785	10.58 ± 0.94	10.40 ± 0.95	0.191	< 0.001^*
MCV (µm³)	78.38 ± 15.40	81.83 ± 10.38	0.254	84.65 ± 8.17	84.51 ± 8.17	0.017	0.369
MCH (pg)	25.69 ± 4.24	27.50 ± 4.41	0.418	27.43 ± 3.49	27.23 ± 3.45	0.058	< 0.001^*
RDW (%)	15.12 ± 2.04	16.41 ± 2.08	0.626	14.91 ± 1.74	14.94 ± 1.76	0.017	< 0.001^*

All values are mentioned in mean ± standard deviation.

Hb = hemoglobin; MCV = mean corpuscular volume; MCH = mean corpuscular hemoglobin; RDW = red cell distribution width.

*p-value < 0.001 in between group analysis using analysis of covariance (ANACOVA).

DISCUSSION

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONFLICT OF INTEREST
References

IDA is an important public health issue in India. When mild anemia is left untreated during adolescence, this may lead to severe anemia during pregnancy and parturition [2]. The present study was therefore performed to determine whether acupuncture treatment using suitable acupuncture points had measurable effects on hemoglobin levels, MCV, MCH, and RDW in people with IDA. A significant increase in hemoglobin level, MCH, and RDW was observed in the AG compared to the PCG, indicating that needling at the GB39, BL17, and LV13 acupuncture points was more effective in improving this metrics than needling at non-acupuncture points.

The World Health Organization defines anemia as blood hemoglobin values below 13 g/dl in men and 12 g/dl in women [1]. In the present study, the selected acupuncture points produced effects of a larger magnitude (mean difference, +0.8 g/dl; effect size, 0.861) in hemoglobin levels in the AG compared to the PCG. Within-group comparisons also confirmed that changes in hemoglobin were greater in the AG (mean difference, +0.99 g/dl; effect size, 0.785) than in the PCG (mean difference, –0.2 mg/dl; effect size, 0.191). Moreover, hemoglobin levels were returned to normal levels in 20 out of 50 participants in the AG (40%), while this did not occur at all in the PCG. This indicates that acupuncture might be useful in the management of IDA.

A study conducted by Joseph Sodipo showed that acupuncture resulted in increased hemoglobin levels and hematocrit value in sickle cell anemia [5]. Similarly, Xie et al. [9] found that in a randomized controlled oral iron therapy trial with sixty patients, a significant increase in iron absorption (reflected in iron status) and an increase in hemoglobin resulted in the acupuncture group compared to the control group. These previous findings on acupuncture and anemia support the present study results.

The possible mechanism for the effect of needling at acupuncture points on hemoglobin level, MCH, and RDW may be explained as follows. Acupuncture has a vasodilatory effect, as it increases microcirculation not only on the point stimulated but also in the related organ. By stimulating LV13, the MU-front point of the spleen, the activity of the spleen and the proper assimilation of food Qi is increased. In modern medicine, the spleen is known to not only play a role in the breakdown of red blood cells but also stores ~25-30% of the body’s red blood cell supply. Expulsion of red blood cells from the spleen therefore results in changes in blood hemoglobin level, MCH, and RDW. Stimulating LR13 further increases the Qi of the spleen and helps in the absorption of iron by maintaining proper digestion and activity of stomach Qi [10-12]. BL17 is the influential point for blood. In TCM, anemia is categorized as a blood deficiency syndrome, and BL17 is used to correct such deficiencies. A previous study suggested that BL17 stimulation removes blood stasis and nourishes blood cells, thus assisting in relieving many blood disorders. This point has a potential effect of increasing iron absorption by down-regulating leptin-hepcidin levels, which impede iron absorption. It also stimulates transferrin receptors, thereby increasing the absorption of iron in enteric cells. Improved absorption of iron results in changes in hemoglobin, MCH, MCV and RDW. Erythropoiesis occurs mainly in the bone marrow; inflammatory changes cause the release of cytokines that suppress erythropoiesis, stimulate hepcidin production in the liver, and negatively affect iron absorption and mobilization [9]. Needling of GB39, the influential point of bone marrow, stimulates the hypothalamic-pituitary-adrenal axis and helps to maintain cortisol levels, which in turn reduces pro-inflammatory cytokines and thereby reduces hepcidin levels. This regulates the absorption of iron as well as erythropoiesis [13]. While these reports suggest that each acupuncture point used in the present study is effective, our results might be due to the combined effect of LR13, BL17 and GB39. This is the first randomized placebo-controlled trial reporting the impact of three acupuncture points on IDA that reports no adverse events during the course of the study. The selected acupuncture points produced a larger magnitude of changes in hemoglobin levels in the AG than in the PCG. Throughout the trial period, participants were not aware of which group they were assigned to; however, they knew that they were receiving needling at certain points (acupoints or non-acupoints), which helped to reduce confounding factors such as psychological impact and needling effect.

1. Limitations

A limitation of this study might consist in the relatively small sample size. Further, we used a short study duration and no follow-up period. We also did not analyze iron absorption status or other biomarkers to determine the possible mechanisms underlying the observed effects. Further studies with a larger sample size, longer duration and more objective variables are therefore recommended for the better understanding of the effects and possible mechanisms of acupuncture in anemia treatment.

The conclusion of this study is needing at acupuncture points (GB39, BL17 and LR13) is more effective in treating anemia than needling at non-acupuncture points.

CONFLICT OF INTEREST

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONFLICT OF INTEREST
References

The authors declare no conflict of interest.

References

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONFLICT OF INTEREST
References

Johnson-Wimbley TD, Graham DY. Diagnosis and management of iron deficiency anemia in the 21st century. Therap Adv Gastroenterol 2011;4:177-84.
Kumari R, Bharti RK, Singh K, Sinha A, Kumar S, Saran A, et al. Prevalence of Iron deficiency and iron deficiency anaemia in adolescent girls in a tertiary care hospital. J Clin Diagn Res 2017;11:BC04-6. https://doi.org/10.7860/JCDR/2017/26163.10325
Ding L, Xu L, Jin Y, Wei Y, Pan Y, Sattar S, et al. Efficacy of SXN in the treatment of iron deficiency anemia: a phase IV clinical trial. Evid Based Complement Alternat Med 2019;2019:8796234. https://doi.org/10.1155/2019/8796234
Xiong W, He FF, You RY, Xiong J, Wang YM, Zhang C, et al. Acupuncture application in chronic kidney disease and its potential mechanisms. Am J Chin Med 2018;46:1169-85.
Sodipo J. Acupuncture and blood studies in sickle-cell anemia. Am J Chin Med 1993;21:85-9.
Jayasuriya A. Clinical Acupuncture. New Delhi: B. Jain Publishers, 2009.
Agrawal AL, Sharma GN. Advanced Acupuncture Therapy. New Delhi: CBS Publishers & Distributors, 2019.
Bainton DF, Finch CA. The diagnosis of iron deficiency anemia. Am J Med 1964;37:62-70.
Xie XC, Cao YQ, Gao Q, Wang C, Li M, Wei SG. Acupuncture improves intestinal absorption of iron in iron-deficient obese patients: a randomized controlled preliminary trial. Chin Med J (Engl) 2017;130:508-15.
Resano-Zuazu M. Acupuncture for anaemia and large intestine impaction associated with hind limb weakness in a horse: a case report. J Acupunct Meridian Stud 2020;13:187-90.
Salehi A, Marzban M, Imanieh MH. The evaluation of curative effect of acupuncture: a review of systematic and meta-analysis studies. J Evid Based Complementary Altern Med 2016;21:202-14. https://doi.org/10.1177/2156587215598422
Kapila V, Wehrle CJ, Tuma F. Physiology, spleen. Available at: https://pubmed.ncbi.nlm.nih.gov/30725992/[Date [Date accessed: July 31, 2023]
Lewith G, Vincent C. Evaluation of the clinical effects of acupuncture - a problem reassessed and a framework for future-research. Pain Forum 1995;4:29-39.