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Acupuncture Treatment in Elderly People with Sarcopenia: Effects on the Strength and Inflammatory Mediators

Acupuncture Treatment in Elderly People with Sarcopenia: Effects on the Strength and Inflammatory... Hindawi Journal of Aging Research Volume 2019, Article ID 8483576, 8 pages https://doi.org/10.1155/2019/8483576 Clinical Study Acupuncture Treatment in Elderly People with Sarcopenia: Effects on the Strength and Inflammatory Mediators 1 2 Gisele Soares Mendes Damasceno , Tha´ıs Helena Machado Marçal Teixeira, 3 1 4 Vinicius Carolino de Souza, Tiago Sousa Neiva, Karina Prudente Pereira, 1 1 Maria de Fa ´ tima Teles Landim, Gislane Ferreira de Melo, 3 3 Juliana de Faria Fracon e Romão, Ota ´ vio Tole ˆdo No ´ brega , and Gustavo de Azevedo Carvalho Universidade Cato ´lica de Bras´ılia, Bras´ılia, Brazil Fundação de Ensino e Pesquisa em Ciˆencias da Sau ´de, Bras´ılia, Brazil Universidade de Bras´ılia, Bras´ılia, Brazil Secretaria de Estado de Sau ´de do Distrito Federal, Bras´ılia, Brazil Correspondence should be addressed to Gisele Soares Mendes Damasceno; gsmendes.fisio@gmail.com Received 10 July 2018; Revised 9 November 2018; Accepted 27 November 2018; Published 27 January 2019 Academic Editor: Giulia Accardi Copyright © 2019 Gisele Soares Mendes Damasceno et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Sarcopenia is defined as the progressive loss of skeletal muscle mass, associated with aging. A multidisciplinary approach has been increasingly prioritized in elderly care. A technique that has been widely used by the seniors is acupuncture. Objectives. To analyse the effects of acupuncture in muscle strength and in inflammatory markers of older people with sarcopenia. Methods. *e sample was composed by 53 elderly people, aged over 60 years. Inclusion criteria were as follows: male and female seniors, sedentary and who were not under acupuncture treatment during the survey period. Assessment of body composition, handgrip strength, and functional test and IL-6, IL-10, and TNF-α cytokines analyses were performed. After verification of the physical examination, the subjects were divided into two groups (sarcopenic and nonsarcopenic). *e first group was then randomized (by drawing lot) to be further divided into two subgroups: G1, composed of sarcopenic elderly people who received acupuncture intervention, and G2, composed of sarcopenic elderly people who did not receive intervention. *e nonsarcopenic elderly people composed the group 3 (G3) and did not receive acupuncture intervention. ANOVA Split Plot was performed for intergroup comparison. For intragroup evaluation, ANOVA was conducted for repeated measures. For the delta values, ANCOVA was performed with the pretest as covariant. A p< 0.05 significance level was adopted. Results. 26 older people concluded the collections. *ere was no statistically significant difference between the G1 group and the other ones regarding the assessed variables (muscle mass, muscle strength, functionality, and inflammatory markers). Conclusion. *e results allow us to infer that it is possible that the conducted intervention protocol has not produced any significant effects in the studied population. UTN number: RBR-8df2h4. energy expenditure, causing serious impacts on the health of 1. Introduction the elderly. Sarcopenia is defined as the progressive loss of skeletal With aging, the muscle regeneration process becomes deficient, as the production of endogenous stem cells be- muscle mass, associated with aging, with reduction of the number and size of muscle fibers, and with parallel decrease comes ineffective, and functional muscle replacement by in muscular strength and endurance [1–3]. It may lead to adipose and fibrous tissue occurs. Moreover, there is a re- falls, decreased functional-physical capacity, and increased duction in the capacity of muscle reinnervation and loss of 2 Journal of Aging Research alpha motor neurons of the spinal cord, causing de- seniors were found in this community. *e recruitment of generation of axons and reduction in the motor unit re- participants was carried out by telephone contact with the cruitment [4]. aforementioned elderly people. In this contact, they were Sarcopenia establishes its symptoms especially in invited to participate in the study and in a lecture, scheduled physically inactive individuals, but it is also seen in in- in advance, that was offered to every invited person, with the dividuals who remain physically active throughout their objective of explaining the study. lives, causing a diversity of functional alterations found in Inclusion criteria were as follows: male and female se- these elderly persons. A sedentary lifestyle plays an im- niors, sedentary and who were not under acupuncture portant role in the functional losses associated with aging. treatment during the survey period. Individuals who were Individuals who do not exercise for most of their lives afraid of needles, with mobility problems that prevented present bigger risks of having a deficit in joint mobility, in them to attend the data collection and processing location, maintenance or increase in muscle mass, and in static and and who presented difficulties of understanding the treat- dynamic balance in old age [5]. ment and the applied tests were excluded from this study. For the treatment of sarcopenia, it is recommended the Subjects who presented diseases that affect muscle mass and practice of physical exercises, particularly those for muscle strength, such as sequelae from cerebral vascular accident, strengthening [2, 5, 6], associated with dietary intervention, multiple sclerosis, muscular dystrophy, Parkinson’s disease, with protein intake [3, 7–9]. When necessary, pharmaco- among others, were also excluded. logical intervention is made via hormone replacement ther- *is project was approved by the Research Ethics apy, with testosterone, estrogen, and growth hormone [10]. Committee of the Universidade Catolica ´ de Brasilia. *e Increasingly, the multidisciplinary care approach for the elderly people who voluntarily accepted to participate in the elderly has been prioritized due to their diverse demands and project signed the freely given informed consent form and needed care to maintain a good quality of life. A technique were told to return in a scheduled time of a specific day for that has been widely used by the seniors is acupuncture [11]. the performance of the procedures that are described below. *is millenary practice of Oriental medicine can help treat various diseases. In addition to being recognized and en- couraged by the World Health Organization as a supple- 2.2. Physical Examination: Muscle Mass, Muscle Strength, and mentary therapy, it consists of a low-cost technique, with no Functionality. All data collection procedures were performed significant side effects and with proven efficacy in treating in the Community Hall of Granja do Torto, Distrito Federal, several clinical conditions [12]. in the morning, in an illuminated and ventilated office booked In a study in which the maximum dynamic and explosive for that evaluation. Initially, the level of physical activity was strength, anaerobic endurance, and speed in young high- evaluated via the short version of the International Physical performance sprinters before and after acupuncture were Activity Questionnaire, IPAQ, validated for the Brazilian analysed, significant and clinical improvements in the max- population [15]. Only seniors classified as sedentary or ir- imum dynamic strength and in the explosive strength were regularly active were selected. All participants were told not to observed, with the conclusion that acupuncture improved the exercise during the survey period. *ereafter, anthropometric physical performance of the studied population [13]. data were collected, consisting of an assessment of body mass Furthermore, Chae et al. investigated the immuno- (digital scale, Filizola ) and of height (wall stadiometer, modulatory effects of acupuncture through its action on CardioMed ), with the assessment of the body composition circulating levels of different cytokines in mice and they of each participant, performed by a tetrapolar bioimpedance discovered that acupuncture can cause significant decrease test (Biodynamics 310). Each participant was previously in serum levels of interleukin 6 (IL-6) and tumor necrosis instructed not to eat big meals up to four hours before the factor alpha (TNF-α). It is necessary to investigate whether examination, to avoid caffeine and alcohol consumption in these changes can also be found in elderly people and to the 24 hours before it, and to wear light clothing during the deepen knowledge in this area, with the aim of reducing the procedure. deleterious effects of aging, such as sarcopenia and immu- For analysis of functional capacity, the TUG test was nosenescence [14]. performed. Before the timed test, the patient executed it once Considering the impacts caused by sarcopenia on the as training. *e performance was assessed in seconds. *e functional-physical capacity of elderly people and the need timing started after the word “go,” while the individual was for alternatives that reduce organic and functional losses, the still seated and ended as soon as the subject sat down again. objective of this study was to analyze the effects of acu- Physical assistance was not allowed during the test [16]. puncture on muscle strength and on inflammatory markers *en the handgrip strength was measured using a of elderly people with sarcopenia. calibrated dynamometer (Jamar ). *e dynamometer was adjusted in the second position, considered to be more efficient for strength tests. *ree alternated measures be- 2. Materials and Methods tween the limbs were conducted, with one-minute rest 2.1. Subjects. A quantitative experimental blind longitudinal between measurings. *e values of the three measurings study was conducted. *e sample was initially composed by were recorded, and the highest one was considered [17, 18]. 53 elderly people, aged over 60 years. In a previous survey All data collection procedures mentioned before were conducted in the “Granja do Torto, Distrito Federal,” 149 performed by a sole evaluator, physiotherapist with more Journal of Aging Research 3 than five years of experience and trained to apply those tests, no intervention and were informed by telephone of the dates unlike the principal investigator during all the survey, who for data collection. Individuals who have missed two or more test days were excluded from the study. was not aware of which group each participant was part of, what characterized the study as a blind one. 2.5. Statistical Analysis. Collected data were inputted in an 2.3. Laboratory Tests: Inflammatory Mediators. Serum Excel 2010 (for Windows) spreadsheet and processed in the samples of each individual were collected and processed for Statistical Package for the Social Sciences (SPSS) 20.0 the analysis of inflammatory mediators by a trained labo- software. ANOVA Split Plot was performed for inter- ratory technician, blinded to the physical examination. *e group comparison. For intragroup evaluation, ANOVA samples were stored in a freezer at−80 C for later dosage and was conducted for repeated measures. For the delta values, analysis of IL6, IL10, and TNF-α cytokines by means of an ANCOVA was performed with the pretest as covariant. A immunoenzymatic assay (enzyme-linked immunosorbent p< 0.05 significance level was adopted. assay), specific to each mediator. *e dosages were held in duplicate, using a commercial kit (BioLengend ). Data were 3. Results analysed in the Immunogerontology Laboratory of the Universidade Catolica ´ de Bras´ılia (UCB). *e study began with 53 participants; however, only 26 concluded the collection, due to sample loss. G1 (n � 11) presented an average age of 72± 7.9 years, lean mass weight of 2.4. Intervention. After verification of the physical exami- 38.9± 6.7 kg, and body fat percentage of 33.4± 6.1%. G2 nation, the subjects were divided into two groups (sarcopenic (n � 4) presented an average age of 63.5± 3.3 years, lean mass and nonsarcopenic), according to the recommendations of weight of 38.1± 6.3 kg, and body fat percentage of 40.0± 7.0%. the European Working Group on Sarcopenia in Older People G3 (n � 12) presented an average age of 67.4± 7.7, lean mass (EWGSOP). *is group suggests as “sarcopenic” individuals weight of 49.5± 8.7 kg, and body fat percentage of 36.4± 6.9%. who present decrease of at least two out of three assessed *e groups showed normal distribution. parameters: muscle mass, muscle strength, and functionality. In the evaluation of lean body mass (Figure 1), G1 and *e cuoff points used in this study were as follows [19]: G2 presented significantly lower values than G3 in all 2 2 BIA: men: 8.87 kg/m ; women: 6.42 kg/m evaluated moments (p � 0.002). *e groups presented no significant changes during the study period, with levels of Handgrip: men: <30 kg; women: <20 kg lean body mass remaining stable (p � 0.348). G1 presented TUG: >0.8 M/S similar behavior to the other groups who received no *e first group was then randomized (by drawing lot) to intervention. be further divided into two subgroups: G1, composed of Figure 2 shows the body fat percentage. Even though the sarcopenic elderly people who received acupuncture in- values of the three groups are above the recommended tervention, and G2, composed of sarcopenic elderly people levels, G1 had the lowest values, when compared to the other who did not receive intervention. *e nonsarcopenic elderly groups, with significant difference in comparison to G2 people composed group 3 (G3) and did not receive acu- (p � 0.027) at Pre and Post 1 moments. However, the acupuncture intervention was not capable of promoting puncture intervention (data from this group will be used as a normal development parameter for the sample analysed in important changes in the body fat levels of G1 (p � 0.358). this study). All the subjects were contacted again to be Handgrip strength values can be seen in Table 1. G2 had informed of their situation and of time and place for per- lower values than the other groups, with significant differ- formance of the next procedures. ence at Post 3 moment in comparison to G3 (p � 0.002). In G1 had 24 acupuncture sessions. Sessions were held spite of no statistical difference, G2 and G3 presented a three times a week, in-between days, in the morning, downward trend in the handgrip strength, while G1 pre- conducted by an acupuncturist physiotherapist with more sented more stable values in both limbs. than five years of experience. Disposable sterile needles with In the functionality assessment (Figure 3), G2 presented the size of 25 × 30 mm (Han sol) were used. Treatment was a slower TUG test time, but with no statistical significance. performed employing tonification acupoints, according to *is group showed an upward trend in time, while G1 and G3 presented similar behavior, with nonsignificant test time the recommendations of Luna and Fernandes Filho [13] and Maciocia ´ and Ming [20]. *e following points were used in reduction (p � 0.86). From the obtained values, the delta tonification: R3, BP3, BP6, VB34, F8, E36, and TA6. was calculated, with Pre moment as covariant, and there was All the seven points were bilaterally used. *e De Qi no significant difference. sensation (needle sensation) was obtained in all sessions. *e With respect to IL-6, all groups showed similar behavior participant remained lying with the needles in the points for and a statistical difference at Post 2 moment in comparison 20 minutes. to Pre moment noted (p � 0.05). Even with a slight drop in New bioimpendance, handgrip, and TUG tests, as well as the values, they were still higher than expected (2.08 pg/ml). blood collection, were performed after 12 sessions, 24 ses- Data can be seen in Table 2. sions, and 30 days after the end of the intervention, totaling IL-6 and TNF-α values usually present direct correlation. four collections throughout the survey. G2 and G3 received In this study, there was no relationship between the behavior 4 Journal of Aging Research Pre Post 1 Post 2 Post 3 Group 1 Group 2 Group 3 Figure 1: Lean body mass weight—groups G1, G2, and G3. Pre Post 1 Post 2 Post 3 Group 1 Group 2 Group 3 Figure 2: Body fat percentage—groups G1, G2, and G3. Signi­cant statistical dierence between G1 and G2. Table 1: Handgrip strength: left upper limb—G1, G2, and G3. LUL RUL G1 G2 G3 G1 G2 G3 Pre 26.00 ± 9.29 23.50 ± 3.11 31.33 ± 10.22 23.18 ± 7.64 23.75 ± 5.19 29.92 ± 8.52 Post 1 25.00 ± 9.44 22.75 ± 2.99 29.50 ± 9.19 21.73 ± 7.84 23.75 ± 4.65 28.42 ± 9.67 Post 2 24.40 ± 8.59 21.50 ± 4.51 28.75 ± 10.31 21.36 ± 6.07 23.75 ± 6.85 27.08 ± 9.71 ∗ ∗ Post 3 25.40 ± 8.54 20.25 ± 5.32 28.17 ± 9.49 22.00 ± 6.53 21.75 ± 7.04 27.50 ± 10.44 Signi­cant statistical dierence between G2 and G3. of IL-6 and TNF-α. e groups presented no statistical values than ideal (3.5 pg/ml). From the obtained values, the dierence between them or between the evaluated moments. delta was calculated, with Pre moment as covariant, and All groups presented lower values than ideal (4.12 pg/ml). there was no signi­cant dierence. IL-10 values showed a signi­cant drop in G2 at Post 3 moment in comparison to the baseline value (p ≤ 0.001), 4. Discussion indicating loss of anti-in…ammatory cytokines that provide protection against the oxidative eects of aging. G1 and G3 is study evaluated the eects of acupuncture in elderly presented a less-signi­cant decrease of IL-10 during the patients with sarcopenia. At the end of the treatment, the evaluated period. All groups concluded the study with lower protocol was not capable of promoting signi­cant changes in Journal of Aging Research 5 Pre Post 1 Post 2 Post 3 Group 1 Group 2 Group 3 Figure 3: TUG test time—G1, G2, and G3. Table 2: IL-6, TNF-α, and IL-10 levels found in G1, G2, and G3: It is possible that acupuncture bolsters physiological average and standard deviation. processes that are already bene­ted by physical exercises, as in the case of active individuals; however, in the case of Pre Post 1 Post 2 Post 3 individuals who already present an existing muscle loss and IL-6 who do not practice any physical activity, such as the elderly G1 3.75 ± 2.17 3.92 ± 3.33 2.31 ± 2.26 3.04 ± 1.76 people evaluated in this study, perhaps this mechanism is G2 5.66 ± 5.67 4.95 ± 3.07 2.74 ± 1.79 3.68 ± 0.51 not possible, or it requires a longer time to present results. G3 6.43 ± 4.90 5.48 ± 4.09 4.00 ± 2.85 5.16 ± 2.73 Acupuncture meridians pass through the body nour- TNF-α ishing and modulating muscle activity. Magnetic resonance G1 0.10 ± 0.20 0.07 ± 0.16 0.04 ± 0.13 0.07 ± 0.13 studies have shown that stimulation of acupuncture points G2 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 G3 0.03 ± 0.09 0.09 ± 0.31 0.03 ± 0.10 0.02 ± 0.05 stimulates or reduces activity in the brain areas corre- sponding to the motor command, activating type A ­bers IL-10 G1 2.82 ± 1.05 3.57 ± 0.80 2.63 ± 1.10 2.16 ± 1.20 immediately after needle stimulation. G2 2.34 ± 0.40 3.14 ± 0.95 2.07 ± 0.83 1.44 ± 0.59 No studies evaluating acupuncture stimulation for G3 3.74 ± 2.09 3.94 ± 1.58 3.40 ± 1.56 2.43 ± 1.42 muscle mass gain in the elderly were found. However, Signi­cant dierence found in IL-6 in groups at Post 2 moment in considering the function of the points used in the present comparison to Pre moment. Statistically signi­cant dierence of IL-10 study, it is suggested that the gain of muscle strength occurs values found in G2 at Post 3 moment in comparison to baseline value. due to increased blood irrigation, the promotion of elasticity of muscle ­bers, and improvement of muscular contractility. the group that received intervention in comparison to the More studies are needed to study the muscle function baseline values or in comparison to the control groups in any stimulated by acupuncture in the elderly. assessed variable. In the literature review, it was not possible In a study that analysed the eects of a workout program to detect any similar studies that employed acupuncture in in walking and functional mobility of seniors, the participants elderly people with the objective of gaining muscle mass or did circuit training exercises for six months with the objective strength. e studies that have this purpose usually are of improving body schema, muscle strength, balance, and walking. Walking speed and functional mobility were eval- conducted with athletes or young individuals, showing positive results [21, 22]. uated before and after the intervention. e workout program improved the functional performance of elderly people and Another study evaluated the eects of using acupuncture in local muscle endurance of upper limbs in weight training positively modi­ed the walking variables [24]. is study did not present results that are similar to the practitioners. e sample was composed by 40 individuals randomly divided into the Intervention Group and the ones observed in studies with resisted exercises. Even though Control Group. Arm …exion test was conducted in order to acupuncture is a technique that aims at promoting the quantify the local muscle endurance of the upper limbs in the energy rebalancing to the individual’s health establishment, participants, and acupuncture was applied at speci­c points it is a supplementary measure and it should not replace other with the objective of promoting a possible improvement in indicated treatments [11]. Probably acupuncture treatment their performance. At the end of the study, the individuals associated with other interventions, such as physical activ- ities and a balanced diet, deliver dierent results to the that were subjected to acupuncture had an increase in their performance, in comparison to the Control Group [23]. studied population. 6 Journal of Aging Research namely, eight volunteers reported decreased joint and *ere is no consensus regarding the points used for strength and muscle mass gain [23]. In this study, the choice muscle pains, and two elderly patients who needed crutches or cane to walk discontinued the use of the devices in the first of acupoints was based on the literature, energetic function, indications, and location. A smaller number of points were ten sessions. Six participants reported improved perfor- used to avoid conflicts with the energetic function. *e mance of daily tasks, and all the members of G1 reported duration of sessions was 20 minutes, with the objective of sense of well-being with acupuncture, even after 30 days of tonifying the points. treatment interruption. *ese reports demonstrate that even *e used acupoints are in accordance with the objective though the results are not statistically significant, acu- of the study, since in the framework of sarcopenia, besides puncture was capable of promoting positive changes and improvement in the quality of life of the evaluated elderly Kidney Qi (energy) Deficiency (usual in aging), Spleen- Pancreas Yang deficiency also occurs. All the points were people. Future studies may assess whether a longer treat- ment in a larger sample is capable of promoting significant used aiming to tone one or more affected organs. IL-6 values observed in this study are noteworthy. Both results. *is study showed some limitations. *e sample size and groups of elderly people (the sarcopenic and the non- sarcopenic ones) presented high IL-6 values. Elevated IL-6 sample loss during the survey may have interfered in the values are strongly associated with increased mortality rate obtained results. At the end, the groups contained a very in elderly people [25]. *e adipocytes and macrophages are small sample, especially group 2, with only four participants, responsible for some of the IL-6 production, although the all female. *is can severely affect the results, as women have mechanisms of IL-6 induction by excess of adipose tissue are less muscle mass, higher fat percentage, and smaller pre- still unknown [26]. dictive values for the evaluated tests, when compared to men. *is is a possible cause for the results found, as the body fat percentage in the three evaluated groups were higher than Besides, considering that sarcopenia is a chronic con- dition that is established over the years, it is possible that the ideal. *ere was no significant difference in the fat per- centage between the evaluated groups; however, it is im- intervention period defined in this study may have been insufficient. *e clinical practice allows us to observe that portant to emphasize that despite the fact that the nonsarcopenic elderly people had an elevated fat percentage, chronic diseases require more time of acupuncture treat- their lean mass was also in a higher amount. ment to present effective results. Even though IL-6 and TNF-α values are positively *e standard treatment for sarcopenia advocates correlated in other studies [27–29], in this study, there was strengthening exercises and dietary interventions. Studies no correlation because despite the elevated IL-6 values in all have shown that resisted exercises programs for frail elderly the evaluated groups throughout the survey, TNF-α regis- people start showing significant results, such as increased muscle strength and decreased risk of falling, between 8 and tered normal values in all the groups. As to the anti-inflammatory IL-10 cytokine, there was no 24 weeks of treatment, conducted twice to three times a week [30–33]. Studies that evaluated the nutritional changes with difference between the evaluated groups, despite the fact that G3 had levels that were higher and within the expected or without protein supplementation in the diet of sarcopenic values. Balance between circulating concentration of pro- elderly people observed the behavior of muscle mass be- and anti-inflammatory cytokines is considered an important tween 10 and 18 weeks of intervention [34–36]. *ese studies means of controlling chronic inflammation, being subject to reinforce the hypothesis of this survey that the acupuncture regulation by genetic factors and lifestyle [30]. Considering treatment requires a longer period to present more signif- such information, it is possible that sarcopenic elderly icant results. people of this study are at high risk of developing other diseases, since the levels of pro- and anti-inflammatory 5. Conclusion cytokines are not in balance. *e stimulation with acupuncture modulates several *is study aimed at evaluating the effects of acupuncture in inflammatory markers both by suppressing its receptors elderly patients with sarcopenia, and the results allowed us to and by acting on the cholinergic anti-inflammatory infer that it is possible that the intervention protocol that was pathway that involves the expression of catecholamines. used has not shown significant effects in the evaluated No studies were found to evaluate the modulation of population, despite the remarkable results that were re- inflammatory markers in the elderly after stimulation with ported by the participants. It is recommended that further acupuncture. It is suggested that this modulation occurs studies with a significant sample be conducted, as well as a due to a homeostatic balance promoted by acupuncture, comparison of the effects of acupuncture with physical by reducing the synthesis of proinflammatory factors, activities and interventions on the diet of elderly people. and by increasing the production of anti-inflammatory factors. Further studies are needed to explore acupuncture Data Availability activity in inflammatory markers of elderly patients with sarcopenia. *e authors declare that these data are exploratory in Although it was not the objective of this study, it was nature and can be accessed through the description of the observed that the elderly people who were subjected to data in the article. *ere are no restrictions on access to acupuncture treatment reported subjective improvement, these data. Journal of Aging Research 7 [16] D. Podsiadlo and S. 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Acupuncture Treatment in Elderly People with Sarcopenia: Effects on the Strength and Inflammatory Mediators

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Copyright © 2019 Gisele Soares Mendes Damasceno et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Journal of Aging Research Volume 2019, Article ID 8483576, 8 pages https://doi.org/10.1155/2019/8483576 Clinical Study Acupuncture Treatment in Elderly People with Sarcopenia: Effects on the Strength and Inflammatory Mediators 1 2 Gisele Soares Mendes Damasceno , Tha´ıs Helena Machado Marçal Teixeira, 3 1 4 Vinicius Carolino de Souza, Tiago Sousa Neiva, Karina Prudente Pereira, 1 1 Maria de Fa ´ tima Teles Landim, Gislane Ferreira de Melo, 3 3 Juliana de Faria Fracon e Romão, Ota ´ vio Tole ˆdo No ´ brega , and Gustavo de Azevedo Carvalho Universidade Cato ´lica de Bras´ılia, Bras´ılia, Brazil Fundação de Ensino e Pesquisa em Ciˆencias da Sau ´de, Bras´ılia, Brazil Universidade de Bras´ılia, Bras´ılia, Brazil Secretaria de Estado de Sau ´de do Distrito Federal, Bras´ılia, Brazil Correspondence should be addressed to Gisele Soares Mendes Damasceno; gsmendes.fisio@gmail.com Received 10 July 2018; Revised 9 November 2018; Accepted 27 November 2018; Published 27 January 2019 Academic Editor: Giulia Accardi Copyright © 2019 Gisele Soares Mendes Damasceno et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Sarcopenia is defined as the progressive loss of skeletal muscle mass, associated with aging. A multidisciplinary approach has been increasingly prioritized in elderly care. A technique that has been widely used by the seniors is acupuncture. Objectives. To analyse the effects of acupuncture in muscle strength and in inflammatory markers of older people with sarcopenia. Methods. *e sample was composed by 53 elderly people, aged over 60 years. Inclusion criteria were as follows: male and female seniors, sedentary and who were not under acupuncture treatment during the survey period. Assessment of body composition, handgrip strength, and functional test and IL-6, IL-10, and TNF-α cytokines analyses were performed. After verification of the physical examination, the subjects were divided into two groups (sarcopenic and nonsarcopenic). *e first group was then randomized (by drawing lot) to be further divided into two subgroups: G1, composed of sarcopenic elderly people who received acupuncture intervention, and G2, composed of sarcopenic elderly people who did not receive intervention. *e nonsarcopenic elderly people composed the group 3 (G3) and did not receive acupuncture intervention. ANOVA Split Plot was performed for intergroup comparison. For intragroup evaluation, ANOVA was conducted for repeated measures. For the delta values, ANCOVA was performed with the pretest as covariant. A p< 0.05 significance level was adopted. Results. 26 older people concluded the collections. *ere was no statistically significant difference between the G1 group and the other ones regarding the assessed variables (muscle mass, muscle strength, functionality, and inflammatory markers). Conclusion. *e results allow us to infer that it is possible that the conducted intervention protocol has not produced any significant effects in the studied population. UTN number: RBR-8df2h4. energy expenditure, causing serious impacts on the health of 1. Introduction the elderly. Sarcopenia is defined as the progressive loss of skeletal With aging, the muscle regeneration process becomes deficient, as the production of endogenous stem cells be- muscle mass, associated with aging, with reduction of the number and size of muscle fibers, and with parallel decrease comes ineffective, and functional muscle replacement by in muscular strength and endurance [1–3]. It may lead to adipose and fibrous tissue occurs. Moreover, there is a re- falls, decreased functional-physical capacity, and increased duction in the capacity of muscle reinnervation and loss of 2 Journal of Aging Research alpha motor neurons of the spinal cord, causing de- seniors were found in this community. *e recruitment of generation of axons and reduction in the motor unit re- participants was carried out by telephone contact with the cruitment [4]. aforementioned elderly people. In this contact, they were Sarcopenia establishes its symptoms especially in invited to participate in the study and in a lecture, scheduled physically inactive individuals, but it is also seen in in- in advance, that was offered to every invited person, with the dividuals who remain physically active throughout their objective of explaining the study. lives, causing a diversity of functional alterations found in Inclusion criteria were as follows: male and female se- these elderly persons. A sedentary lifestyle plays an im- niors, sedentary and who were not under acupuncture portant role in the functional losses associated with aging. treatment during the survey period. Individuals who were Individuals who do not exercise for most of their lives afraid of needles, with mobility problems that prevented present bigger risks of having a deficit in joint mobility, in them to attend the data collection and processing location, maintenance or increase in muscle mass, and in static and and who presented difficulties of understanding the treat- dynamic balance in old age [5]. ment and the applied tests were excluded from this study. For the treatment of sarcopenia, it is recommended the Subjects who presented diseases that affect muscle mass and practice of physical exercises, particularly those for muscle strength, such as sequelae from cerebral vascular accident, strengthening [2, 5, 6], associated with dietary intervention, multiple sclerosis, muscular dystrophy, Parkinson’s disease, with protein intake [3, 7–9]. When necessary, pharmaco- among others, were also excluded. logical intervention is made via hormone replacement ther- *is project was approved by the Research Ethics apy, with testosterone, estrogen, and growth hormone [10]. Committee of the Universidade Catolica ´ de Brasilia. *e Increasingly, the multidisciplinary care approach for the elderly people who voluntarily accepted to participate in the elderly has been prioritized due to their diverse demands and project signed the freely given informed consent form and needed care to maintain a good quality of life. A technique were told to return in a scheduled time of a specific day for that has been widely used by the seniors is acupuncture [11]. the performance of the procedures that are described below. *is millenary practice of Oriental medicine can help treat various diseases. In addition to being recognized and en- couraged by the World Health Organization as a supple- 2.2. Physical Examination: Muscle Mass, Muscle Strength, and mentary therapy, it consists of a low-cost technique, with no Functionality. All data collection procedures were performed significant side effects and with proven efficacy in treating in the Community Hall of Granja do Torto, Distrito Federal, several clinical conditions [12]. in the morning, in an illuminated and ventilated office booked In a study in which the maximum dynamic and explosive for that evaluation. Initially, the level of physical activity was strength, anaerobic endurance, and speed in young high- evaluated via the short version of the International Physical performance sprinters before and after acupuncture were Activity Questionnaire, IPAQ, validated for the Brazilian analysed, significant and clinical improvements in the max- population [15]. Only seniors classified as sedentary or ir- imum dynamic strength and in the explosive strength were regularly active were selected. All participants were told not to observed, with the conclusion that acupuncture improved the exercise during the survey period. *ereafter, anthropometric physical performance of the studied population [13]. data were collected, consisting of an assessment of body mass Furthermore, Chae et al. investigated the immuno- (digital scale, Filizola ) and of height (wall stadiometer, modulatory effects of acupuncture through its action on CardioMed ), with the assessment of the body composition circulating levels of different cytokines in mice and they of each participant, performed by a tetrapolar bioimpedance discovered that acupuncture can cause significant decrease test (Biodynamics 310). Each participant was previously in serum levels of interleukin 6 (IL-6) and tumor necrosis instructed not to eat big meals up to four hours before the factor alpha (TNF-α). It is necessary to investigate whether examination, to avoid caffeine and alcohol consumption in these changes can also be found in elderly people and to the 24 hours before it, and to wear light clothing during the deepen knowledge in this area, with the aim of reducing the procedure. deleterious effects of aging, such as sarcopenia and immu- For analysis of functional capacity, the TUG test was nosenescence [14]. performed. Before the timed test, the patient executed it once Considering the impacts caused by sarcopenia on the as training. *e performance was assessed in seconds. *e functional-physical capacity of elderly people and the need timing started after the word “go,” while the individual was for alternatives that reduce organic and functional losses, the still seated and ended as soon as the subject sat down again. objective of this study was to analyze the effects of acu- Physical assistance was not allowed during the test [16]. puncture on muscle strength and on inflammatory markers *en the handgrip strength was measured using a of elderly people with sarcopenia. calibrated dynamometer (Jamar ). *e dynamometer was adjusted in the second position, considered to be more efficient for strength tests. *ree alternated measures be- 2. Materials and Methods tween the limbs were conducted, with one-minute rest 2.1. Subjects. A quantitative experimental blind longitudinal between measurings. *e values of the three measurings study was conducted. *e sample was initially composed by were recorded, and the highest one was considered [17, 18]. 53 elderly people, aged over 60 years. In a previous survey All data collection procedures mentioned before were conducted in the “Granja do Torto, Distrito Federal,” 149 performed by a sole evaluator, physiotherapist with more Journal of Aging Research 3 than five years of experience and trained to apply those tests, no intervention and were informed by telephone of the dates unlike the principal investigator during all the survey, who for data collection. Individuals who have missed two or more test days were excluded from the study. was not aware of which group each participant was part of, what characterized the study as a blind one. 2.5. Statistical Analysis. Collected data were inputted in an 2.3. Laboratory Tests: Inflammatory Mediators. Serum Excel 2010 (for Windows) spreadsheet and processed in the samples of each individual were collected and processed for Statistical Package for the Social Sciences (SPSS) 20.0 the analysis of inflammatory mediators by a trained labo- software. ANOVA Split Plot was performed for inter- ratory technician, blinded to the physical examination. *e group comparison. For intragroup evaluation, ANOVA samples were stored in a freezer at−80 C for later dosage and was conducted for repeated measures. For the delta values, analysis of IL6, IL10, and TNF-α cytokines by means of an ANCOVA was performed with the pretest as covariant. A immunoenzymatic assay (enzyme-linked immunosorbent p< 0.05 significance level was adopted. assay), specific to each mediator. *e dosages were held in duplicate, using a commercial kit (BioLengend ). Data were 3. Results analysed in the Immunogerontology Laboratory of the Universidade Catolica ´ de Bras´ılia (UCB). *e study began with 53 participants; however, only 26 concluded the collection, due to sample loss. G1 (n � 11) presented an average age of 72± 7.9 years, lean mass weight of 2.4. Intervention. After verification of the physical exami- 38.9± 6.7 kg, and body fat percentage of 33.4± 6.1%. G2 nation, the subjects were divided into two groups (sarcopenic (n � 4) presented an average age of 63.5± 3.3 years, lean mass and nonsarcopenic), according to the recommendations of weight of 38.1± 6.3 kg, and body fat percentage of 40.0± 7.0%. the European Working Group on Sarcopenia in Older People G3 (n � 12) presented an average age of 67.4± 7.7, lean mass (EWGSOP). *is group suggests as “sarcopenic” individuals weight of 49.5± 8.7 kg, and body fat percentage of 36.4± 6.9%. who present decrease of at least two out of three assessed *e groups showed normal distribution. parameters: muscle mass, muscle strength, and functionality. In the evaluation of lean body mass (Figure 1), G1 and *e cuoff points used in this study were as follows [19]: G2 presented significantly lower values than G3 in all 2 2 BIA: men: 8.87 kg/m ; women: 6.42 kg/m evaluated moments (p � 0.002). *e groups presented no significant changes during the study period, with levels of Handgrip: men: <30 kg; women: <20 kg lean body mass remaining stable (p � 0.348). G1 presented TUG: >0.8 M/S similar behavior to the other groups who received no *e first group was then randomized (by drawing lot) to intervention. be further divided into two subgroups: G1, composed of Figure 2 shows the body fat percentage. Even though the sarcopenic elderly people who received acupuncture in- values of the three groups are above the recommended tervention, and G2, composed of sarcopenic elderly people levels, G1 had the lowest values, when compared to the other who did not receive intervention. *e nonsarcopenic elderly groups, with significant difference in comparison to G2 people composed group 3 (G3) and did not receive acu- (p � 0.027) at Pre and Post 1 moments. However, the acupuncture intervention was not capable of promoting puncture intervention (data from this group will be used as a normal development parameter for the sample analysed in important changes in the body fat levels of G1 (p � 0.358). this study). All the subjects were contacted again to be Handgrip strength values can be seen in Table 1. G2 had informed of their situation and of time and place for per- lower values than the other groups, with significant differ- formance of the next procedures. ence at Post 3 moment in comparison to G3 (p � 0.002). In G1 had 24 acupuncture sessions. Sessions were held spite of no statistical difference, G2 and G3 presented a three times a week, in-between days, in the morning, downward trend in the handgrip strength, while G1 pre- conducted by an acupuncturist physiotherapist with more sented more stable values in both limbs. than five years of experience. Disposable sterile needles with In the functionality assessment (Figure 3), G2 presented the size of 25 × 30 mm (Han sol) were used. Treatment was a slower TUG test time, but with no statistical significance. performed employing tonification acupoints, according to *is group showed an upward trend in time, while G1 and G3 presented similar behavior, with nonsignificant test time the recommendations of Luna and Fernandes Filho [13] and Maciocia ´ and Ming [20]. *e following points were used in reduction (p � 0.86). From the obtained values, the delta tonification: R3, BP3, BP6, VB34, F8, E36, and TA6. was calculated, with Pre moment as covariant, and there was All the seven points were bilaterally used. *e De Qi no significant difference. sensation (needle sensation) was obtained in all sessions. *e With respect to IL-6, all groups showed similar behavior participant remained lying with the needles in the points for and a statistical difference at Post 2 moment in comparison 20 minutes. to Pre moment noted (p � 0.05). Even with a slight drop in New bioimpendance, handgrip, and TUG tests, as well as the values, they were still higher than expected (2.08 pg/ml). blood collection, were performed after 12 sessions, 24 ses- Data can be seen in Table 2. sions, and 30 days after the end of the intervention, totaling IL-6 and TNF-α values usually present direct correlation. four collections throughout the survey. G2 and G3 received In this study, there was no relationship between the behavior 4 Journal of Aging Research Pre Post 1 Post 2 Post 3 Group 1 Group 2 Group 3 Figure 1: Lean body mass weight—groups G1, G2, and G3. Pre Post 1 Post 2 Post 3 Group 1 Group 2 Group 3 Figure 2: Body fat percentage—groups G1, G2, and G3. Signi­cant statistical dierence between G1 and G2. Table 1: Handgrip strength: left upper limb—G1, G2, and G3. LUL RUL G1 G2 G3 G1 G2 G3 Pre 26.00 ± 9.29 23.50 ± 3.11 31.33 ± 10.22 23.18 ± 7.64 23.75 ± 5.19 29.92 ± 8.52 Post 1 25.00 ± 9.44 22.75 ± 2.99 29.50 ± 9.19 21.73 ± 7.84 23.75 ± 4.65 28.42 ± 9.67 Post 2 24.40 ± 8.59 21.50 ± 4.51 28.75 ± 10.31 21.36 ± 6.07 23.75 ± 6.85 27.08 ± 9.71 ∗ ∗ Post 3 25.40 ± 8.54 20.25 ± 5.32 28.17 ± 9.49 22.00 ± 6.53 21.75 ± 7.04 27.50 ± 10.44 Signi­cant statistical dierence between G2 and G3. of IL-6 and TNF-α. e groups presented no statistical values than ideal (3.5 pg/ml). From the obtained values, the dierence between them or between the evaluated moments. delta was calculated, with Pre moment as covariant, and All groups presented lower values than ideal (4.12 pg/ml). there was no signi­cant dierence. IL-10 values showed a signi­cant drop in G2 at Post 3 moment in comparison to the baseline value (p ≤ 0.001), 4. Discussion indicating loss of anti-in…ammatory cytokines that provide protection against the oxidative eects of aging. G1 and G3 is study evaluated the eects of acupuncture in elderly presented a less-signi­cant decrease of IL-10 during the patients with sarcopenia. At the end of the treatment, the evaluated period. All groups concluded the study with lower protocol was not capable of promoting signi­cant changes in Journal of Aging Research 5 Pre Post 1 Post 2 Post 3 Group 1 Group 2 Group 3 Figure 3: TUG test time—G1, G2, and G3. Table 2: IL-6, TNF-α, and IL-10 levels found in G1, G2, and G3: It is possible that acupuncture bolsters physiological average and standard deviation. processes that are already bene­ted by physical exercises, as in the case of active individuals; however, in the case of Pre Post 1 Post 2 Post 3 individuals who already present an existing muscle loss and IL-6 who do not practice any physical activity, such as the elderly G1 3.75 ± 2.17 3.92 ± 3.33 2.31 ± 2.26 3.04 ± 1.76 people evaluated in this study, perhaps this mechanism is G2 5.66 ± 5.67 4.95 ± 3.07 2.74 ± 1.79 3.68 ± 0.51 not possible, or it requires a longer time to present results. G3 6.43 ± 4.90 5.48 ± 4.09 4.00 ± 2.85 5.16 ± 2.73 Acupuncture meridians pass through the body nour- TNF-α ishing and modulating muscle activity. Magnetic resonance G1 0.10 ± 0.20 0.07 ± 0.16 0.04 ± 0.13 0.07 ± 0.13 studies have shown that stimulation of acupuncture points G2 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 G3 0.03 ± 0.09 0.09 ± 0.31 0.03 ± 0.10 0.02 ± 0.05 stimulates or reduces activity in the brain areas corre- sponding to the motor command, activating type A ­bers IL-10 G1 2.82 ± 1.05 3.57 ± 0.80 2.63 ± 1.10 2.16 ± 1.20 immediately after needle stimulation. G2 2.34 ± 0.40 3.14 ± 0.95 2.07 ± 0.83 1.44 ± 0.59 No studies evaluating acupuncture stimulation for G3 3.74 ± 2.09 3.94 ± 1.58 3.40 ± 1.56 2.43 ± 1.42 muscle mass gain in the elderly were found. However, Signi­cant dierence found in IL-6 in groups at Post 2 moment in considering the function of the points used in the present comparison to Pre moment. Statistically signi­cant dierence of IL-10 study, it is suggested that the gain of muscle strength occurs values found in G2 at Post 3 moment in comparison to baseline value. due to increased blood irrigation, the promotion of elasticity of muscle ­bers, and improvement of muscular contractility. the group that received intervention in comparison to the More studies are needed to study the muscle function baseline values or in comparison to the control groups in any stimulated by acupuncture in the elderly. assessed variable. In the literature review, it was not possible In a study that analysed the eects of a workout program to detect any similar studies that employed acupuncture in in walking and functional mobility of seniors, the participants elderly people with the objective of gaining muscle mass or did circuit training exercises for six months with the objective strength. e studies that have this purpose usually are of improving body schema, muscle strength, balance, and walking. Walking speed and functional mobility were eval- conducted with athletes or young individuals, showing positive results [21, 22]. uated before and after the intervention. e workout program improved the functional performance of elderly people and Another study evaluated the eects of using acupuncture in local muscle endurance of upper limbs in weight training positively modi­ed the walking variables [24]. is study did not present results that are similar to the practitioners. e sample was composed by 40 individuals randomly divided into the Intervention Group and the ones observed in studies with resisted exercises. Even though Control Group. Arm …exion test was conducted in order to acupuncture is a technique that aims at promoting the quantify the local muscle endurance of the upper limbs in the energy rebalancing to the individual’s health establishment, participants, and acupuncture was applied at speci­c points it is a supplementary measure and it should not replace other with the objective of promoting a possible improvement in indicated treatments [11]. Probably acupuncture treatment their performance. At the end of the study, the individuals associated with other interventions, such as physical activ- ities and a balanced diet, deliver dierent results to the that were subjected to acupuncture had an increase in their performance, in comparison to the Control Group [23]. studied population. 6 Journal of Aging Research namely, eight volunteers reported decreased joint and *ere is no consensus regarding the points used for strength and muscle mass gain [23]. In this study, the choice muscle pains, and two elderly patients who needed crutches or cane to walk discontinued the use of the devices in the first of acupoints was based on the literature, energetic function, indications, and location. A smaller number of points were ten sessions. Six participants reported improved perfor- used to avoid conflicts with the energetic function. *e mance of daily tasks, and all the members of G1 reported duration of sessions was 20 minutes, with the objective of sense of well-being with acupuncture, even after 30 days of tonifying the points. treatment interruption. *ese reports demonstrate that even *e used acupoints are in accordance with the objective though the results are not statistically significant, acu- of the study, since in the framework of sarcopenia, besides puncture was capable of promoting positive changes and improvement in the quality of life of the evaluated elderly Kidney Qi (energy) Deficiency (usual in aging), Spleen- Pancreas Yang deficiency also occurs. All the points were people. Future studies may assess whether a longer treat- ment in a larger sample is capable of promoting significant used aiming to tone one or more affected organs. IL-6 values observed in this study are noteworthy. Both results. *is study showed some limitations. *e sample size and groups of elderly people (the sarcopenic and the non- sarcopenic ones) presented high IL-6 values. Elevated IL-6 sample loss during the survey may have interfered in the values are strongly associated with increased mortality rate obtained results. At the end, the groups contained a very in elderly people [25]. *e adipocytes and macrophages are small sample, especially group 2, with only four participants, responsible for some of the IL-6 production, although the all female. *is can severely affect the results, as women have mechanisms of IL-6 induction by excess of adipose tissue are less muscle mass, higher fat percentage, and smaller pre- still unknown [26]. dictive values for the evaluated tests, when compared to men. *is is a possible cause for the results found, as the body fat percentage in the three evaluated groups were higher than Besides, considering that sarcopenia is a chronic con- dition that is established over the years, it is possible that the ideal. *ere was no significant difference in the fat per- centage between the evaluated groups; however, it is im- intervention period defined in this study may have been insufficient. *e clinical practice allows us to observe that portant to emphasize that despite the fact that the nonsarcopenic elderly people had an elevated fat percentage, chronic diseases require more time of acupuncture treat- their lean mass was also in a higher amount. ment to present effective results. Even though IL-6 and TNF-α values are positively *e standard treatment for sarcopenia advocates correlated in other studies [27–29], in this study, there was strengthening exercises and dietary interventions. Studies no correlation because despite the elevated IL-6 values in all have shown that resisted exercises programs for frail elderly the evaluated groups throughout the survey, TNF-α regis- people start showing significant results, such as increased muscle strength and decreased risk of falling, between 8 and tered normal values in all the groups. As to the anti-inflammatory IL-10 cytokine, there was no 24 weeks of treatment, conducted twice to three times a week [30–33]. Studies that evaluated the nutritional changes with difference between the evaluated groups, despite the fact that G3 had levels that were higher and within the expected or without protein supplementation in the diet of sarcopenic values. Balance between circulating concentration of pro- elderly people observed the behavior of muscle mass be- and anti-inflammatory cytokines is considered an important tween 10 and 18 weeks of intervention [34–36]. *ese studies means of controlling chronic inflammation, being subject to reinforce the hypothesis of this survey that the acupuncture regulation by genetic factors and lifestyle [30]. Considering treatment requires a longer period to present more signif- such information, it is possible that sarcopenic elderly icant results. people of this study are at high risk of developing other diseases, since the levels of pro- and anti-inflammatory 5. Conclusion cytokines are not in balance. *e stimulation with acupuncture modulates several *is study aimed at evaluating the effects of acupuncture in inflammatory markers both by suppressing its receptors elderly patients with sarcopenia, and the results allowed us to and by acting on the cholinergic anti-inflammatory infer that it is possible that the intervention protocol that was pathway that involves the expression of catecholamines. used has not shown significant effects in the evaluated No studies were found to evaluate the modulation of population, despite the remarkable results that were re- inflammatory markers in the elderly after stimulation with ported by the participants. It is recommended that further acupuncture. It is suggested that this modulation occurs studies with a significant sample be conducted, as well as a due to a homeostatic balance promoted by acupuncture, comparison of the effects of acupuncture with physical by reducing the synthesis of proinflammatory factors, activities and interventions on the diet of elderly people. and by increasing the production of anti-inflammatory factors. Further studies are needed to explore acupuncture Data Availability activity in inflammatory markers of elderly patients with sarcopenia. *e authors declare that these data are exploratory in Although it was not the objective of this study, it was nature and can be accessed through the description of the observed that the elderly people who were subjected to data in the article. *ere are no restrictions on access to acupuncture treatment reported subjective improvement, these data. Journal of Aging Research 7 [16] D. Podsiadlo and S. 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