Effect of continued electroacupuncture on induction of interleukin-2 production of spleen lymphocytes from the injured rats

Can peri-surgical electroacupuncture relieve immunity suppression? A pilot study in dogs

General anesthesia and surgical stress can suppress the immunological response by acting both directly on the immune system and indirectly on the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Disturbance of the immune system during the perioperative period can lead to complications such as wound-healing disorders and infections up to sepsis. Effectiveness of acupuncture in regulating the immune function by increasing leukocyte numbers and inhibiting inflammatory response has been proven. This study aimed to explore the impact of electroacupuncture (EAP) on the dynamic balance of the immune system and immune cell populations in dogs undergoing surgery. Twelve healthy bitches scheduled for elective ovariectomy were divided into two groups according to whether (EAP, n=6) or not (CTR, n=6) a peri-operative electroacupuncture treatment was performed. Levels of leukocytes (neutrophils, monocytes, T- and B-cells) and immunoglobulins M (IgM) and A (IgA) were measured in blood samples collected before (T0), 1 h (T1) and 2.5 h (T2) after anesthesia induction. Leukocytes count decreased from T0 to T1 in both groups and restored within 1.5 h in EAP group whereas remained significantly lower in CTR group (P<0.02). In particular, neutrophils and monocytes increased in dogs receiving EAP (P<0.01) while T-cells decreased in CTR group (P<0.04) at T2. B-cells and cytotoxic T-cells decreased in EAP dogs (P<0.04) at T2. No differences in helper T-cells, IgM and IgA levels were recorded between groups and over time. Our results suggest a modulatory effect of EAP on the immune system which is early expressed on neutrophils, monocytes and T-cells.

Effects of perioperative transcutaneous electrical acupoint stimulation on monocytic HLA-DR expression in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass: study protocol for a double-blind randomized controlled trial

BACKGROUND

Cardiac surgery involving cardiopulmonary bypass (CPB) is known to be associated with a transient postoperative immunosuppression. When severe and persistent, this immune dysfunction predisposes patients to infectious complications, which contributes to a prolonged stay in the intensive care unit (ICU), and even mortality. Effective prevention and treatment methods are still lacking. Recent studies revealed that acupuncture-related techniques, such as electroacupuncture and transcutaneous electrical acupoint stimulation (TEAS), are able to produce effective cardioprotection and immunomodulation in adult and pediatric patients undergoing cardiac surgery with CPB, which leads to enhanced recovery. However, whether perioperative application of TEAS, a non-invasive technique, is able to improve immunosuppression of the patients with post-cardiosurgical conditions is unknown. Thus, as a preliminary study, the main objective is to evaluate the effects of TEAS on the postoperative expression of monocytic human leukocyte antigen (-D related) (mHLA-DR), a standardized "global" biomarker of injury or sepsis-associated immunosuppression, in patients receiving on-pump coronary artery bypass grafting (CABG).

METHODS

This study is a single-center clinical trial. The 88 patients scheduled to receive CABG under CPB will be randomized into two groups: the group receiving TEAS, and the group receiving transcutaneous acupoint pseudo-electric stimulation (Sham TEAS). Expression of mHLA-DR serves as a primary endpoint, and other laboratory parameters (e.g., interleukin [IL]-6, IL-10) and clinical outcomes (e.g., postoperative infectious complications, ICU stay time, and mortality) as the secondary endpoints. In addition, immune indicators, such as high mobility group box 1 protein and regulatory T cells will also be measured.

DISCUSSION

The current study is a preliminary monocentric clinical trial with a non-clinical primary endpoint, expression of mHLA-DR, aiming at determining whether perioperative application of TEAS has a potential to reverse CABG-associated immunosuppression. Although the immediate clinical impact of this study is limited, its results would inform further large-sample clinical trials using relevant patient-centered clinical outcomes as primary endpoints.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02933996. Registered on 13 October 2016.

[Effect of electro-acupuncture at Zusanli acupoint on postoperative T cell immune function in rats]

OBJECTIVE

To study the effect of electro- acupuncture at Zusanli acupoint in regulating perioperative cell immune functions in rats.

METHODS

Forty-two SD rats were divided into blank control group (n=6), model group (n=18), and electroacupuncture group (n=18). The rats in the latter two groups underwent thigh incision and femoral dissection under anesthesia; the rats in electro-acupuncture group received electro-acupuncture at bilateral Zusanli acupoint for 15 min before anesthesia and 1 h after the surgery. The rats in the model group and electro-acupuncture group were sacrificed at 6 h, 24 h, and 72 h after the operation and blood samples were taken from the ventricle for analyzing CD3, CD4, and CD8 T cell subpopulations and calculation of CD4/CD8 using flow cytometry. ELISA was used to detect the levels of interleukin-1 (IL-1) and IL-6.

RESULTS

The CD3 T cell subpopulation was significantly lower in the model group and electro-acupuncture group than in the blank group at 6 h and 24 h after the operation. At 72 h after the operation, CD3 subpopulation levels still remained low in the model group, but recovered the control level in electro-acupuncture group. At each time point of measurement, CD3 level was significantly lower in the model group than in the electro-acupuncture group. CD4 level in the model group was significantly lowered at 6 h and 24 h after the operation, and recovered the control level at 72 h. In the electro-acupuncture group, CD4 level was significantly lowered at 6 h after the operation, but recovered the control level at 24 h. At 24 h and 72 h, the levels of CD4 were significantly lower in the model group than in the electro-acupuncture group. CD8 level underwent no significant changes after the operation in either the model group or electro-acupuncture group. CD4/CD8 was significantly lowered at 24 h and 72 h after the operation in the model group but showed no significant variation in the electro-acupuncture group. Compared with that in the control group, IL-1 level was significantly lowered in both the model group and electroacupuncture group at 6 h, 24 h, and 72 h after the operation, and was significantly lower in the model group than in the electroacupuncture group at these time points. IL-6 level increased significantly in the model group and the electro- acupuncture group at 6 h and 24 h. at 72 h, IL-6 level was obviously lowered in the electro-acupuncture group but remained elevated in the model group.

CONCLUSIONS

Electro-acupuncture alleviates postoperative immune suppression and promotes recovery of the immune function in rats, suggesting a protective effect of electro-acupuncture at Zusanli acupoint on cellular immune function after surgery.

Alleviating Mechanical Allodynia and Modulating Cellular Immunity Contribute to Electroacupuncture's Dual Effect on Bone Cancer Pain

Hypothesis: Electroacupuncture (EA) has been used as an alternative analgesic therapy for hundreds of years, yet its analgesic potency and therapeutic advantage against bone cancer pain (BCP) in comparison with morphine remains unclear. This study aimed to investigate the effects of EA on mechanical allodynia and cellular immunity of BCP rats, and to further explore the potential mechanism. Methods: The BCP model was established by implanting Walker 256 mammary gland carcinoma cells into the left tibia of adult female Sprague-Dawley rats. EA (dilatational wave, 2/100 Hz, 0.5 mA–1mA–1.5 mA for 10 minutes each intensity) was applied bilaterally to Zusanli (ST 36) and Kunlun (BL 60) for 30 minutes. Both EA stimulation and morphine (10 mg/kg, intraperitoneally) was given once every other day. Naloxone (0.3 mg/kg, intraperitoneally) was injected at 30 minutes prior to EA. Mechanical allodynia were demonstrated by paw withdrawal thresholds (PWTs) which measured by dynamic plantar aesthesiometer. T cell proliferation, percentage of CD3⁺, CD4⁺ and CD8⁺ T lymphocytes in spleen as well as expression of interleukin-2 (IL-2) in plasma were detected by WST-8, flow cytometry, and enzyme-linked immunosorbent assay technique, respectively. Results: An intratibial inoculation of Walker 256 mammary gland carcinoma cells significantly decreased PWTs to mechanical stimuli. EA stimulation alleviated mechanical allodynia in BCP rats, and the analgesic potency of EA was weaker than that of morphine. In contrast to morphine, EA stimulation of BCP rats increased splenic concanavalin A (Con A)-induced T cell proliferation and plasma IL-2 content, as well as increased the percentages of splenic CD₃⁺CD₄⁺ and CD₃⁺CD₈⁺ T cell subsets. Moreover, both the analgesic effect and the partial immunomodulation of EA were suppressed by an intraperitoneal injection of naloxone. Conclusion: EA could significantly alleviate BCP-induced mechanical allodynia. Although the analgesic effect of EA was weaker than that of morphine, EA had an immunomodulation effect on cellular immunity. Both analgesic and immunomodulatory effect of EA might share the same mechanism via the opioid-mediated pathway, which needs further investigation.

p38 Mitogen-activated protein kinase is required for electroacupuncture restoration of CD4+/CD8+ homeostasis and cytokine expression in a rodent model of surgical trauma

Cumulative evidences addressed that electroacupuncture (EA) was favorably effective in the treatment of trauma stress-induced immunodeficiency and physical disorders. However, the salutary effects of EA under operation trauma conditions mediated via p38 MAPK remain unknown. Hence, our study aimed to further investigate the effects of EA on CD4(+)/CD8(+) homeostasis and cytokine expressions, and evaluate the p38 MAPK signaling regulatory mechanism of EA effects.

Acupuncture: Emerging evidence for its use as an analgesic (Review)

Acupuncture is an ancient Chinese technique, developed over >3,000 years, in which 'acupoints' are stimulated with the aim of treating various diseases. A number of previous studies have indicated that acupuncture may play a role in inducing analgesia. Acupuncture-induced analgesia has been hypothesized to act on various parts of the central nervous system, including the spinal cord, brain stem, cerebral ganglia and cerebral cortex. The mechanisms underlying the effects of acupuncture have been purported to include neurohumors and neurotransmitters, such as opioids and γ-aminobutyric acid, signaling pathways and the immune response, which are all involved in the induction of analgesia.

Electroacupuncture inhibits apoptosis of splenic lymphocytes in traumatized rats through modulation of the TNF-α/NF-κB signaling pathway

Surgical trauma leads to a severe deterioration of the immune system. Electroacupuncture (EA) may improve the immunodeficiency that occurs following surgery; however, the underlying signaling mechanisms require further study. In the present study, 40 rats were equally randomized into four groups: Control; Control + EA; Trauma; Trauma + EA. EA was applied at the 'Zusanli' (ST36) and 'Lanwei' (Extra37) acupoints, immediately following surgery. The splenic T cells were isolated from the rats 24 h after surgery. The apoptotic rate of the lymphocytes was measured by flow cytometric analysis, and western blotting was used to determine the protein expression levels of caspase-3, caspase-8, tumor necrosis factor (TNF)-α and TNF receptor 1 (TNFR1). The DNA binding activity of nuclear factor (NF)-κB was determined using Trans-AM® ELISA-based kits. The results of the present study showed that surgical trauma induced apoptosis of splenic lymphocytes, and significantly increased the protein expression levels of caspase-3 and caspase-8. This was accompanied by increased expression levels of TNF-α and TNFR1, and a marked reduction in the activity of NF-κB in splenic T cells. Administration of EA significantly decreased the expression levels of caspase-3, caspase-8, TNF-α and TNFR1, elevated the activity of NF-κB, and suppressed the apoptotic rate of the lymphocytes. The data suggests that EA may inhibit the apoptosis of splenic lymphocytes induced by surgical trauma, and ameliorate the postoperative immunosuppression. This may be mediated by the downregulation of TNF-α expression levels and upregulation of the activity of NF-κB.

Electroacupuncture alleviates intraoperative immunosuppression in patients undergoing supratentorial craniotomy

BACKGROUND

Clinical experience suggests that anaesthesia using a combination of acupuncture and drugs can reduce the dosage of anaesthetics required for craniotomy, decreasing both the disturbance in physiological functions during the operation and postoperative complications and improving the rate of recovery. The aim of the present study was to investigate the impact of electroacupuncture (EA) on the dynamic equilibrium of the immune system and immune cell populations during the pericraniotomy period.

METHODS

A total of 56 patients undergoing craniotomy were randomised into three groups: control (C, n=18), EA (A, n=19) and sham acupuncture (S, n=19) groups. Blood samples were collected before anaesthesia (T0) and 30 min, 2 h and 4 h after induction of anaesthesia (T1, T2 and T3, respectively,) to measure the levels of tumour necrosis factor α (TNFα), interleukin (IL)-8, IL-10, IgM, IgA, IgG and full blood count.

RESULTS

There was no significant difference between the measurements in groups A and S during craniotomy. The levels of IgM and IgA decreased significantly in group C compared with groups A and S at T2 and T3 time points. The levels of total T cells and suppressor T cells in group C decreased significantly compared with groups A and S at T1 and T2, and the level of natural killer cells in group C decreased significantly compared with groups A and S at T1. No significant differences between groups were found in the levels of TNFα, IgG, IL-10, IL-8, leucocytes, neutrophils, monocytes, Th cells or B cells.

CONCLUSIONS

EA appears to reduce immunosuppression of both the humoral and cellular components during surgery.

Serum IgG, IgA, IgM, and IgE Levels after Electroacupuncture and Diet Therapy in Obese Women

We investigated the effect of acupuncture therapy on obese women's body weight and peripheral blood levels of serum immunoglobulin G ( IgG ), immunoglobulin A ( IgA ), immunoglobulin M ( IgM ), and immunoglobulin E ( IgE ). Sixty-three healthy women were assigned into 3 groups: placebo electroacupuncture ( n = 13; mean age, 40.5 ± 4.2 years; body mass index [BMI], 33.5 ± 4.2), diet restriction ( n = 23; mean age, 42.9 ± 4.0 years; BMI, 34.6 ± 2.9), and electroacupuncture ( n = 24; mean age, 40.1 ± 5.9 years; BMI, 33.9 ± 2.7). Electroacupuncture was applied to the Hunger and Shen Men ear points and to the LI 4, LI 11, St 36, St 44, and Ren 6 body points for 30 min once daily for 20 days. A restricted diet of 1400 kilocalories was given to participants in all 3 groups for 20 days. Weight was lost significantly in subjects in the electroacupuncture group compared to those in the diet restriction and placebo electroacupuncture groups ( p < 0.000, Tukey test). Modulations in serum IgG ( p < 0.001) were apparent in women treated with electroacupuncture compared with women treated with placebo electroacupuncture and restricted diet only. No significant changes were seen in serum IgA , IgM , and IgE levels among the 3 groups. Our results suggest that electroacupuncture can be effectively used to treat obesity. We also observed a modulating effect of serum IgG , which is associated with weight loss, in patients in the electroacupuncture group.

Acupuncture and Immunomodulation

Acupuncture is a well-known form of Asian medical treatment and it is used not only as an effective curative method but also to prevent illness and mai ntain health. It is used for the production of analgesic effect; stress related physical-mental disorders and homeostasis. Electroacupuncture (EA) stimulation, an application of electrical current on acupuncture needles, is one of the most popular types of this traditional therapy. In recent years, intensive studies have been carried out to explain the underlying mechanisms of the efficacy of acupuncture. An increase in the release of endogen opioid peptides is generally accepted to be a keystone pathway that affects the immune system after the acupuncture application. To understand the huge gap between specific skin point applications and immune responses, a vast number of accumulating data of experimental and clinical studies in the literature have been collected. This paper reviews the data to explain the updated mechanisms related to immune modulation via acupuncture therapy.

The effects of electroacupuncture on TH1/TH2 cytokine mRNA expression and mitogen-activated protein kinase signaling pathways in the splenic T cells of traumatized rats

BACKGROUND

Surgical trauma contributes to postoperative immune suppression, which is associated with an increased susceptibility to subsequent infections. Electroacupuncture (EA) can alleviate pain and exert immunoregulatory effects. However, the mechanism underlying the immnuomodulation effects of EA is not fully elucidated. Therefore, we investigated the effects of EA on T helper (Th)1/Th2 cytokine production and mRNA expression and evaluated the signaling regulatory mechanism of EA effects.

METHODS

Rats were divided into four groups (n = 24 each): control, trauma, trauma (T) + sham EA, and T + EA. EA was applied to Zusanli (ST36) and Lanwei (Extra37) acupoints at 20 min after surgery for 30 min, and then performed once a day on postoperative days 1-5. Splenic T cells were isolated and the production and mRNA expression of interleukin (IL)-2, interferon-gamma, IL-4, and IL-10 were assayed. The activation of mitogen-activated protein kinase and the DNA binding activity of nuclear factor (NF)-kappaB and activator protein (AP)-1 were examined.

RESULTS

Paw withdrawal threshold and paw withdrawal latency were significantly increased in the T + EA group compared with the trauma group from postoperative day 1 (paw withdrawal threshold: 5.8 +/- 0.7 vs 3.0 +/- 0.7 g; paw withdrawal latency: 7.0 +/- 0.8 vs 4.5 +/- 0.5 s; P < 0.001) to day 5 (9.0 +/- 0.6 vs 5.5 +/- 0.6 g; 12.0 +/- 1.3 vs 7.0 +/- 0.8 s; P < 0.001). Th1 cytokine (IL-2 and interferon-gamma) production and mRNA expression in splenic T cells of traumatized rats were significantly decreased on postoperative day 3 (P < 0.001, trauma group versus control group), whereas Th2 cytokine (IL-4 and IL-10) production and mRNA expression were increased (P < 0.001). This was accompanied with a significant depression in the activity of extracellular-regulated protein kinase (ERK)1/2, p38, NF-kappaB, and AP-1 (P < 0.001, trauma group versus control group). EA administration increased Th1 cytokine protein and mRNA expression, suppressed Th2 cytokine protein and mRNA expression (P < 0.05, T + EA group versus trauma group), and increased the activity of ERK1/2, p38, NF-kappaB, and AP-1 (P < 0.001, T + EA group versus trauma group).

CONCLUSIONS

EA regulates a balance between Th1 and Th2 cytokines at protein and mRNA levels in splenic T cells, and, at least in part, involves the signaling pathways of ERK1/2, p38, NF-kappaB, and AP-1. The findings suggest that EA may improve immune suppression after surgical trauma.

Sympathetic nervous system mediates surgical trauma stress-induced splenocyte apoptosis in rats

Surgical trauma stress has been reported to induce immunosuppression. The mechanisms involved are still unclear. The present study was designed to assess the role of the sympathetic nervous system in regulating splenocyte apoptosis induced by surgical trauma stress. Our results showed that the rats that underwent surgical trauma stress exhibited a significant reduction in splenic cellularity, the loss of splenocytes was likely mediated by apoptosis, for a substantial increase in apoptosis was observed by using DNA gel electrophoresis and TUNEL assay. At the same time, an increase in Fas(CD95/Apo-1) protein expression in splenocytes was also observed. These effects were significantly abolished by either chemical sympathectomy or beta-adrenergic receptor antagonist propranolol. The data clearly revealed that the sympathetic nervous system especially beta-adrenergic receptors was involved in surgical trauma-induced immune alterations via a mechanism of apoptotic cell death.

Electro-acupuncture in relieving labor pain

To study the efficacy of electro-acupuncture for the relief of labor pain, and to build a better understanding of how electro-acupuncture might influence the neuroendocrine system, 36 primiparas were randomly divided into an electro-acupuncture group and a control group. Assessments of pain intensity and degree of relaxation during labor were analyzed. The differences between the electro-acupuncture group and the control group on the concentration of beta-endorphin (beta-EP) and 5-hydroxytryptamine (5-HT) in the peripheral blood were compared. The electro-acupuncture group was found to exhibit a lower pain intensity and a better degree of relaxation than the control group (p = 0.018; p = 0.031). There existed a significant difference in the concentration of beta-EP and 5-HT in the peripheral blood between the two groups at the end of the first stage (p = 0.037; p = 0.030). Electro-acupuncture was found to be an effective alternative or complementary therapy in the relief of pain during labor. The benefit of electro-acupuncture for relieving labor pain may be based on the mechanism of producing a synergism of the central nervous system (CNS) with a direct impact on the uterus through increasing the release of beta-EP and 5-HT into the peripheral blood.

Involvement of peripheral opioid mechanisms in electroacupuncture analgesia

The involvement of the peripheral opioid system in modulating inflammatory pain has been well documented. This study aimed to investigate the possibility of electroacupuncture (EA)-mediated peripheral opioid release. Rats were injected with complete Freund's adjuvant in one of the hind paws to induce localized inflammatory pain. The pain behavioral changes were measured by paw withdrawal latency (PWL) to a noxious thermal stimulus. At day 5 of inflammation, rats received a second injection of saline or opioid antagonists into the inflamed paw, followed by EA at 30 Hz, 2 mA, and 0.1 ms for 30 minutes. The EA was conducted at acupuncture point GB30. A control was used in which needles were inserted at GB30 but no electrical stimulation was applied. Rats receiving EA showed a significantly longer PWL as compared with the control from 30 minutes to three hours after EA treatment. Intraplantar but not intraperitoneal injection of naloxone methiodide, a peripherally acting opioid receptor antagonist, eliminated the analgesic effect at 30 minutes after EA treatment. Intraplantar injection of an antibody against beta-endorphin and a corticotropin-releasing factor antagonist also produced a reduction in PWL in rats receiving EA. These data strongly suggest that peripheral opioids are released by EA at the inflammatory site.

Immunity and β-Endorphin Concentrations in Hypothalamus and Plasma in Rats with Steroid-Induced Polycystic Ovaries: Effect of Low-Frequency Electroacupuncture1

The human endocrinological disorder polycystic ovary syndrome (PCOS) is a common cause of reproductive failure. Even though the cause of PCOS is unknown, hormone and immune disturbances as well as hyperactivity in the sympathetic nervous system are likely to be involved in the pathogenesis of the disease. The present study was undertaken to elucidate if rats with estradiol valerate (EV)-induced polycystic ovaries (PCO) have altered beta-endorphin concentrations in the hypothalamus and in plasma and if they have alterations in circulating immune cell populations and the activity. Repeated low-frequency (2 Hz) electroacupuncture (EA) treatments are known to modulate the release of beta-endorphin, immune responses, and the activity in the autonomic nervous system. We therefore also investigated the effect of EA treatments on the beta-endorphin and the immune systems. Low-frequency EA was given 12 times, 25 min each, over 30 days starting 2-3 days after i.m. injection of EV. The beta-endorphin concentrations in the hypothalamus and in plasma as well as the frequencies of CD4+ T cells and CD8+ T cells were significantly lower in EV-injected control rats as compared to oil-injected control rats. Repeated EA treatments in EV-injected rats significantly increased beta-endorphin concentrations in the hypothalamus. In conclusion, these findings show that both the beta-endorphinergic and the immune system are significantly impaired in rats with steroid-induced PCO and that repeated EA treatments can restore some of these disturbances.

Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects

Acupuncture, an ancient therapeutic technique, is emerging as an important modality of complementary medicine in the United States. The use and efficacy of acupuncture treatment are not yet widely accepted in Western scientific and medical communities. Demonstration of regionally specific, quantifiable acupuncture effects on relevant structures of the human brain would facilitate acceptance and integration of this therapeutic modality into the practice of modern medicine. Research with animal models of acupuncture indicates that many of the beneficial effects may be mediated at the subcortical level in the brain. We used functional magnetic resonance imaging (fMRI) to investigate the effects of acupuncture in normal subjects and to provide a foundation for future studies on mechanisms of acupuncture action in therapeutic interventions. Acupuncture needle manipulation was performed at Large Intestine 4 (LI 4, Hegu) on the hand in 13 subjects [Stux, 1997]. Needle manipulation on either hand produced prominent decreases of fMRI signals in the nucleus accumbens, amygdala, hippocampus, parahippocampus, hypothalamus, ventral tegmental area, anterior cingulate gyrus (BA 24), caudate, putamen, temporal pole, and insula in all 11 subjects who experienced acupuncture sensation. In marked contrast, signal increases were observed primarily in the somatosensory cortex. The two subjects who experienced pain instead of acupuncture sensation exhibited signal increases instead of decreases in the anterior cingulate gyrus (BA 24), caudate, putamen, anterior thalamus, and posterior insula. Superficial tactile stimulation to the same area elicited signal increases in the somatosensory cortex as expected, but no signal decreases in the deep structures. These preliminary results suggest that acupuncture needle manipulation modulates the activity of the limbic system and subcortical structures. We hypothesize that modulation of subcortical structures may be an important mechanism by which acupuncture exerts its complex multisystem effects.

Most frequently used alternative and complementary therapies and activities by participants in the AMCOA study

This literature review examines the current state of the scientific evidence published in peer-reviewed journals indexed in MedLine for the 10 most commonly noted alternative activities reported by the first 1,016 eligible participants in the Alternative Medical Care Outcomes in AIDS study. The most frequently used activities are aerobic exercise (64%), prayer (56%), massage (54%), needle acupuncture (48%), mediation (46%), support groups (42%), visualization and imagery (34%), breathing exercises (33%), spiritual activities (33%), and other exercise (33%). Despite frequency of usage, clinical research is not reported on MedLine to support the use of most of these activities for HIV/AIDS. The limitations of using MedLine as the sole source for this review are discussed.