Reflexões sobre as Indicações da Acupuntura

Em dezembro de 1979 a OMS publicou uma lista de indicações de Acupuntura na revista A Saúde do Mundo, descrita como “provisória”. A lista em questão inclui desde alguns dos problemas mais comumente encontrados na prática do terapeuta (como lombalgias, paralisia facial e cefaleias) até outras indicações que soam duvidosas (como miopia, retinose pigmentar, íleo paralítico e bexiga neurogênica).

A “Introdução” do documento Acupuncture: review and analysis of reports on controlled clinical trials de 2002 comenta sobre a maneira da produção da “lista provisória” de 1979:

…In recognition of the increasing worldwide interest in the subject, the World Health Organization (WHO) conducted a symposium on acupuncture in June 1979 in Beijing, China. Physicians practising acupuncture in different countries were invited to identify the conditions that might benefit from this therapy. The participants drew up a list of 43 suitable diseases. However, this list of indications was not based on formal clinical trials conducted in a rigorous scientific manner, and its credibility has been questioned.

Parece um método altamente informal e assistemático — e é. A citação do Chasing the dragon’s tail acrescenta detalhes a este processo de acréscimos ao conhecimento clínico ao longo do tempo:

The interesting questions about these case studies are more to do with methodology. The problems exist at three basic levels. First, at what level of use and experience should an observed clinical effect be incorporated into the body of clinica literature? That is, at what point can we say that moxa at CV-22 is good for asthma, or that gold and silver needles at the yang wei mai and yang qiao mai effectively treat trigeminal neuralgia? Second, how are such effects differentiated within the corpus of clinical literature and when is it acceptable for such observations to submit to experimental adaptation? That is, how do we determine when and how to use these treatments? Third, who is qualified to make such decisions and what is the appropriate methodology for making then? The last question is bound to be culturally and historically dependent. The way such findings may be interpreted in modern China or modern Japan will be quite different, depending on the theoretical perspectives of the interpreter.

Let us imagine that it is nearly four hundred years ago in China and I am a good friend of Yang Ji-Zhou, the author of Zhen Jiu Da Cheng. Because of this, he might have included these treatments in his text in 1601, despite the limited experience of my two cases. Today, almost four hundred years later, practitioners and students reading his text will place enormous trust in my results because they were included in this great and revered text, and because my friend’s reputation in later centuries is excellent. Is this a sufficient criteria for making general proclamations about the treatment os asthma and trigeminal neuralgia?

What if these treatments were to go through the mill of heuristic adaptation and later authors transmitted my results by saying only that CV-22 is good for asthma, or TB-5 is good for trigeminal neuralgia, without including the method I used (moxa) or the theory of extraordinary vessels? What if translators then simplified the terms with which I diagnosed these conditions? Would these points reliably produced the desired effects or would there be only a statistical percentage of patients who were helped?

These are particularly difficult questions because methodology is something remarkably lacking in traditional literature. Simplifying the accretion of therapeutic effects observed over the centuries into a list of functions is useful for the beginner. But who sifted through the literature? What standards and models did they apply to interpret it? What assumptions did the compilers and translators bring to their work?

(Citado de MANAKA, 1995.)

A lista de indicações da Acupuntura do documento de 2002 ampliou-se bastante em relação à de 1979 e certamente impressiona:

The diseases or disorders for which acupuncture therapy has been tested in controlled clinical trials reported in the recent literature can be classified into four categories as shown below.

1. Diseases, symptoms or conditions for which acupuncture has been proved — through controlled trials — to be an effective treatment:

  • Adverse reactions to radiotherapy and/or chemotherapy
  • Allergic rhinitis (including hay fever)
  • Biliary colic
  • Depression (including depressive neurosis and depression following stroke)
  • Dysentery, acute bacillary
  • Dysmenorrhoea, primary
  • Epigastralgia, acute (in peptic ulcer, acute and chronic gastritis, and gastrospasm)
  • Facial pain (including craniomandibular disorders)
  • Headache
  • Hypertension, essential
  • Hypotension, primary
  • Induction of labour
  • Knee pain
  • Leukopenia
  • Low back pain
  • Malposition of fetus, correction of
  • Morning sickness
  • Nausea and vomiting
  • Neck pain
  • Pain in dentistry (including dental pain and temporomandibular dysfunction)
  • Periarthritis of shoulder
  • Postoperative pain
  • Renal colic
  • Rheumatoid arthritis
  • Sciatica Sprain
  • Stroke
  • Tennis elbow

2. Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which further proof is needed:

  • Abdominal pain (in acute gastroenteritis or due to gastrointestinal spasm)
  • Acne vulgaris
  • Alcohol dependence and detoxification
  • Bell’s palsy
  • Bronchial asthma
  • Cancer pain
  • Cardiac neurosis
  • Cholecystitis, chronic, with acute exacerbation
  • Cholelithiasis
  • Competition stress syndrome
  • Craniocerebral injury, closed
  • Diabetes mellitus, non-insulin-dependent
  • Earache
  • Epidemic haemorrhagic fever
  • Epistaxis, simple (without generalized or local disease)
  • Eye pain due to subconjunctival injection
  • Female infertility
  • Facial spasm
  • Female urethral syndrome
  • Fibromyalgia and fasciitis
  • Gastrokinetic disturbance
  • Gouty arthritis
  • Hepatitis B virus carrier status
  • Herpes zoster (human (alpha) herpesvirus 3)
  • Hyperlipaemia
  • Hypo-ovarianism
  • Insomnia
  • Labour pain
  • Lactation, deficiency
  • Male sexual dysfunction, non-organic
  • Ménière disease
  • Neuralgia, post-herpetic
  • Neurodermatitis
  • Obesity
  • Opium, cocaine and heroin dependence
  • Osteoarthritis
  • Pain due to endoscopic examination
  • Pain in thromboangiitis obliterans
  • Polycystic ovary syndrome (Stein–Leventhal syndrome)
  • Postextubation in children
  • Postoperative convalescence
  • Premenstrual syndrome
  • Prostatitis, chronic
  • Pruritus
  • Radicular and pseudoradicular pain syndrome
  • Raynaud syndrome, primary
  • Recurrent lower urinary-tract infection
  • Reflex sympathetic dystrophy
  • Retention of urine, traumatic
  • Schizophrenia
  • Sialism, drug-induced
  • Sjögren syndrome
  • Sore throat (including tonsillitis)
  • Spine pain, acute
  • Stiff neck
  • Temporomandibular joint dysfunction
  • Tietze syndrome
  • Tobacco dependence
  • Tourette syndrome
  • Ulcerative colitis, chronic
  • Urolithiasis
  • Vascular dementia
  • Whooping cough (pertussis)

3. Diseases, symptoms or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which acupuncture is worth trying because treatment by conventional and other therapies is difficult:

  • Chloasma
  • Choroidopathy, central serous
  • Colour blindness
  • Deafness
  • Hypophrenia
  • Irritable colon syndrome
  • Neuropathic bladder in spinal cord injury
  • Pulmonary heart disease, chronic
  • Small airway obstruction

4. Diseases, symptoms or conditions for which acupuncture may be tried provided the practitioner has special modern medical knowledge and adequate monitoring equipment:

  • Breathlessness in chronic obstructive pulmonary disease
  • Coma
  • Convulsions in infants
  • Coronary heart disease (angina pectoris)
  • Diarrhoea in infants and young children
  • Encephalitis, viral, in children, late stage
  • Paralysis, progressive bulbar and pseudobulbar

Apesar de o documento Acupuncture: review and analysis of reports on controlled clinical trials citar uma longa lista de indicações “comprovadas” e outras “a comprovar”, uma pesquisa na Cochrane Library retorna 130 resultados não tão positivos assim. Há ainda o que esclarecer quanto à existência e à magnitude de efeito do tratamento.

Notas quanto aos (vários) vieses dos estudos chineses:

Data fabrication in China is an ‘open secret’. Acessado em julho de 2020.
Vickers, A.; Goyal, N.; Harland, R.; Rees, R. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials. 1998 Apr;19(2):159-66.

Bibliografia:

Birch, Stephen J.; Felt, Robert L. Entendendo a Acupuntura. 1a ed. trad. São Paulo: Roca, 2002.
Filshie, Jacqueline; White, Adrian; Cummings, Mike (eds.) Medical Acupuncture: A Western Scientific Approach. 2a ed. Elsevier, 2016.
Kaptchuk, Ted. The Web That Has No Weaver. 2a ed. McGraw-Hill, 2000.
Manaka, Y; Itaya, K; Birch, S. Chasing the dragon’s tail. Paradigm Publications, 1995. p. 11.
Acupuncture: review and analysis of reports on controlled clinical trials. World Health Organization, 2002.
Cochrane Library. Acessado em julho de 2020.

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