Acupuncture for neuropathic pain in adults

Research trends of acupuncture therapy for painful peripheral nervous system diseases from 2004 to 2023: a bibliometric and meta-analysis

Background

Peripheral nervous system diseases (PNSD) have represented a major global health burden, leading to significant economic impacts and diminished productivity. This bibliometric analysis was performed to summarize the current research trends and hotspots over the past two decades, aiming to provide a comprehensive perspective for future research.

Methods

All data were sourced from the Web of Science Core Collection (WoSCC) on March 1, 2024, for publications between January 1, 2004, and December 31, 2023. Data visualization and analyses, including descriptive statistics, co-occurrence mapping, and cluster analysis, were performed using CiteSpace (Version 6.1.R6) and Excel 2021.

Results

Our search yielded 678 references, with the annual publication count demonstrating an increasing trend over the past 20 years. The most productive country and institution were China and Kyung Hee University, respectively. Fang Jianqiao, was the most prolific author with the highest publications. Among journals, "Pain," was the most frequently cited, while the top-cited reference was a randomized controlled pilot trial by Lu Weidong in 2020. "Acupuncture" emerged as the keyword with the highest frequency. The meta-analysis indicated that acupuncture was more effective than standard care for pain associated with Diabetic Peripheral Neuropathy [MD = -2.03, 95% CI (-2.86, -1.21), 2 RCTs, 102 participants, p < 0.0001].

Conclusion

Our bibliometric review revealed key insights into the focal areas of PNSD research, underscoring the urgent need for continued and targeted high-quality investigations.

Exploration of the quantitative-effectiveness association between acupuncture temporal parameters and chemotherapy-induced peripheral neuropathy in cancer patients: a dose-response meta-analysis of randomized controlled trials

Background

Chemotherapy-induced peripheral neuropathy (CIPN) is one of the commonly reported symptoms impacting cancer survivors. This study evaluated and compared the effectiveness of acupuncture treatments for CIPN.

Methods

We searched six databases from their inception to August 2024 to identify eligible randomized controlled trials (RCTs). Primary outcome were pain scores. Secondary outcomes were quality of life including FACT/GOG-Ntx and EORTC QLQ-C30. The robust error meta-regression (REMR) method was used to evaluate the dose-response relationship across treatment parameters, including number of sessions, frequency, and duration.

Results

In total, 11 RCTs featuring 740 participants were included. The meta-analysis demonstrated that the primary analysis achieved a significant reduction in pain scores, with a standardized mean difference of [SMD= -1.23, 95% CI = (-2.22, -0.24); P < 0.01; I² = 95%], improvement quality of life including FACT/GOG-Ntx [SMD = 0.95, 95% CI = (0.02, 1.88); P < 0.01; I² = 93%] and EORTC QLQ-C30 [SMD = 0.36, 95% CI = (0.03, 0.68); P = 0.14; I² = 46%]. The nonlinear dose-response analysis suggests that pain improvement achieves the MCID at 16 treatment sessions, over 8 weeks, with a frequency of twice per week. Furthermore, analysis of the treatment duration chart shows that acupuncture maintains therapeutic effects during the follow-up period. Sensitivity analysis confirmed the robustness of these findings.

Conclusion

Acupuncture demonstrates significant potential in managing CIPN, particularly through individualized treatment regimens. The identified time-dose-response relationship suggests that tailoring acupuncture frequency and duration can to optimize pain relief in CIPN patients. Future high-quality studies and large-scale multicenter clinical trials are needed to validate these findings.

Electroacupuncture Alleviates Neuropathic Pain and Negative Emotion in Mice by Regulating Gut Microbiota

Background

Neuropathic pain (NP) is a prevalent chronic condition frequently accompanied by adverse emotional states. Previous research has demonstrated the clinical efficacy of electroacupuncture (EA) in mitigating neuropathic pain and its associated mood disorders. Recent studies have underscored a correlation between gut microbiota and both NP and negative emotional states. Nevertheless, the relationship between the modulation of gut microbiota by EA and the amelioration of NP remains inadequately understood.

Methods

Mice were randomly assigned to one of the three groups: the Control (Con) group, the EA group, and the Chronic Constrictive Injury (CCI) group (n = 12 each). Starting from the 8th day post-CCI induction, the EA group underwent EA treatment once every two days, for a total of 20 sessions. To investigate the impact of gut microbiota on CCI mice, we employed a variety of methods, including various behavioral tests and 16S ribosomal DNA (rDNA) sequencing.

Results

The results indicated that EA significantly ameliorated mechanical allodynia and emotional dysfunction induced by CCI in mice. Analysis through 16S rDNA sequencing revealed that the gut microbiota of NP model mice exhibited a marked increase in diversity. However, EA could partially reverse changes in the diversity of gut microbiota. The abundance of Alloprevotella, A2, Roseburia, Muribaculum, Ruminiclostridium, and Rikenella was increased, and the abundance levels of Bacteroides were decreased at the genus level in CCI mice. Following EA treatment, the relative abundance of Alistipes, A2, Roseburia, and Rikenella was decreased, whereas the relative abundance of Alloprevotella and Parabacteroides was increased in EA group when compared with the CCI group.

Conclusion

These findings suggested that EA exerted a significant therapeutic effect on NP, potentially through modulation of the gut microbiota.

Research progress in neuropathic pain after spinal cord injury: a bibliometric study from 2013 to 2024

Background

The incidence of neuropathic pain (NP) after spinal cord injury (SCI) is quite high. This pain is clinically challenging to treat and has an debilitating effect on patients. In recent years, NP is a popular topic of research and a number of relevant articles have been published in academic journals. The purpose of this article is to analyze the global research trend of NP after SCI using bibliometric methods.

Methods

The literature was screened from 2013 to 2024 based on the Web of Science core collection (WOSCC). These publications, including annual publications, journals, authors, references, and keywords via CiteSpace, were analyzed in order to help understand the current research direction and hotspots in this field.

Results

A total of 2022 publications were included in the analysis. The results showed that an overall upward trend in the number of publications in the study period. The top five productive journals are Spinal Cord, Journal of Neurotrauma, Pain, Experimental Neurology, and Journal of Spinal Cord Medicine, the journals related to spinal cord or pain. The top five most productive scholars are Armin Curt, Michael G. Fehlings, Wu Junfang, John L. K. Kramer, and Farinaz Nasirinezhad. Keyword bursts showed that signaling pathway, neuroinflammation, neuralgia, spinal cord stimulation, inhibition, and depression have become new research hotspots in the field of NP after SCI.

Conclusion

This study provides a basis for the study of pain after SCI. It summarizes past research on NP following SCI and offers valuable reference data for further exploration of research trends and issues of focus in this field.

Current perspectives and trends in acupuncture for sleep disorders: a bibliometric analysis

Background

Limitations of conventional treatment methods for sleep disorders have driven the use and development of complementary and alternative therapies such as acupuncture. However, despite the surge in related studies, there is still a lack of visual analysis and detailed elaboration regarding the current status, international collaborations, and research hotspots of acupuncture for sleep disorders.

Methods

We conducted a bibliometric analysis of publications on acupuncture for sleep disorders using the Web of Science Core Collection database from 2004 to 2023. We utilized the R package "bibliometrix" to count publications and citations, VOSviewer to create an inter-institutional referencing network, and CiteSpace to identify references and keywords with the highest citation bursts. Additionally, we employed a bibliometric online analysis platform designed for analyzing national partnerships.

Results

A total of 432 pertinent papers were retrieved, with China being the most prolific contributor, accounting for 61.6% of the publications, followed by the United States and South Korea. Despite China's high output, its average article citation rate and proportion of international collaborations were notably lower than those of the United States. Key research institutions such as the University of Hong Kong, Shanghai University of Traditional Chinese Medicine, Memorial Sloan Kettering Cancer Center, and Guangzhou University of Chinese Medicine have played significant roles in this field. Among authors, Ka-Fai Chung from the University of Hong Kong stood out as the most productive. In terms of journals, MEDICINE was the most active, while SLEEP was considered the most authoritative. The clinical effects of acupuncture for insomnia have garnered significant attention in recent years, with electroacupuncture emerging as the prevailing technique for addressing sleep disorders.

Conclusion

This bibliometric study effectively outlines the basic framework of knowledge surrounding acupuncture for sleep disorders over the past two decades, covering publications, countries, institutions, authors, and sources. It highlights promising clinical effects and underlying mechanisms of acupuncture, particularly for secondary insomnia and specific sleep disorders like restless legs syndrome. Moving forward, the focus and challenge for future research lie in the development of standardized study protocols and harmonization of efficacy assessment metrics.

Electroacupuncture inhibited carrageenan-induced pain aversion by activating GABAergic neurons in the ACC

Pain aversion is an avoidance response to painful stimuli. Previous research has indicated that the anterior cingulate cortex (ACC) is involved in pain aversion processing. However, as interneurons, the role of GABAergic neurons in the ACC (GABAACC neurons) in pain aversion is still unclear. Electroacupuncture (EA) has been shown to ameliorate pain aversion, but the mechanism is not clarified. The present study provided evidence that inhibition of GABAACC neurons contributed to pain aversion. EA alleviated pain aversion by activating GABAACC neurons in an intensity-dependent manner. Specifically, 0.3 mA EA stimulation showed better effects on pain aversion than 0.1 mA stimulation, which could be reversed by chemical genetic inhibition of GABAACC neurons. These results provide a novel mechanism by which EA alleviates pain aversion by reversing GABAACC neurons.

A comprehensive review of traditional Chinese medicine in treating neuropathic pain

Neuropathic pain (NP) is a common, intractable chronic pain caused by nerve dysfunction and primary lesion of the nervous system. The etiology and pathogenesis of NP have not yet been clarified, so there is a lack of precise and effective clinical treatments. In recent years, traditional Chinese medicine (TCM) has shown increasing advantages in alleviating NP. Our review aimed to define the therapeutic effect of TCM (including TCM prescriptions, TCM extracts and natural products from TCM) on NP and reveal the underlying mechanisms. Literature from 2018 to 2024 was collected from databases including Web of Science, PubMed, ScienceDirect, Google academic and CNKI databases. Herbal medicine, Traditional Chinese medicines (TCM), neuropathic pain, neuralgia and peripheral neuropathy were used as the search terms. The anti-NP activity of TCM is clarified to propose strategies for discovering active compounds against NP, and provide reference to screen anti-NP drugs from TCM. We concluded that TCM has the characteristics of multi-level, multi-component, multi-target and multi-pathway, which can alleviate NP through various pathways such as anti-inflammation, anti-oxidant, anti-apoptotic pathway, regulating autophagy, regulating intestinal flora, and influencing ion channels. Based on the experimental study and anti-NP mechanism of TCM, this paper can offer analytical evidence to support the effectiveness in treating NP. These references will be helpful to the research and development of innovative TCM with multiple levels and multiple targets. TCM can be an effective treatment for NP and can serve as a treasure house for new drug development.

Investigating the Effectiveness of Electroacupuncture for Diabetic Peripheral Neuropathy and Exploring the Feasibility of Infrared Thermography as an Efficacy Assessment Tool: Study Protocol for a Randomized Controlled Trial

Introduction

Diabetic peripheral neuropathy (DPN) affects patients' quality of life significantly. To date, selecting the appropriate treatment remains challenging. While electroacupuncture (EA) has shown promise as an effective adjunct therapy for DPN, and infrared thermography (IRT) has been considered as a potential predictor of treatment efficacy, the evidence for both remains inconclusive. As such, the objectives of this trial are twofold: to ascertain the efficacy of EA for DPN, and to explore the feasibility of IRT as an adjunctive objective tool for efficacy assessment.

Methods

The study was designed as a randomized, parallel, controlled trial. It spanned over 6 weeks of treatment and an additional 4 weeks of follow-up. 104 eligible participants will be stratified for severity of disease: mild with Toronto clinical scoring system(TCSS) score 6-8, moderate (TCSS score 9-11), and severe (TCSS score 12-19), and each level will be randomised in a 1:1 ratio into a EA group and waiting-list group. The waiting-list group received only the current conventional medication, while the EA group received an additional 12 EA sessions on top of the conventional medication. The primary outcome indicators is nerve conduction velocity (NCV), which will be tested at the baseline and week 6. Total clinical efficiency, TCSS, Clinical symptoms score of Traditional Chinese Medicine (TCM), Patient global impression of change(PGIC), Temperature of regions of interest (ROIs), and Physico chemical examination will be used as secondary outcome indicators. In addition, safety assessment will be determined based on adverse events during the trial.

Conclusion

The expected results of this study will determine whether EA improves efficacy in the treatment of DPN with an acceptable safety profile, and investigating variations in the efficacy of EA across different levels of DPN severity. Furthermore, it will explore the viability of IRT as an objective measure for evaluating treatment effectiveness for DPN.

Clinical Trial Registration

ClinicalTrials.gov identifier, NCT06054087.

Unraveling the Potential of Electroanalgesia: A Literature Review of Current Therapeutics

Neuropathic pain (NP), arising from dysfunction in the neurological system, poses a significant challenge in pain management due to its intricate origin and unpredictable response to conventional treatments. Electroanalgesia, a collection of techniques such as transcutaneous electric nerve stimulation (TENS), peripheral electrical nerve stimulation (PENS), spinal cord stimulation (SCS), deep brain stimulation (DBS), and electroacupuncture (EA), presents a potential alternative or complementary approach. This review brings together evidence from 56 studies to evaluate the effectiveness and safety of electroanalgesia in chronic NP. It discusses the mechanisms underlying NP, the indications for electroanalgesia, and the techniques utilized, emphasizing the diverse applications and potential benefits. However, despite its potential uses, electroanalgesia has its limitations, including variable effectiveness and potential adverse effects. Furthermore, the review recognizes the limitations of the methodology and the need for further research to refine treatment protocols and enhance the understanding of electroanalgesia's role in comprehensive pain management strategies.

An Integrated Care Approach to Improve Well-Being in Breast Cancer Patients

BACKGROUND

Breast cancer (BC) treatment has recently been revolutionized by the introduction of newer targeted agents, that helped tailoring therapies around the single patient. Along with increased survival rates, a careful evaluation of diet, lifestyle habits, physical activity, emotional and psychological experiences linked to the treatment journey, is now mandatory. However, a true proposal for an omnicomprehensive and "integrative" approach is still lacking in literature.

METHODS

A scientific board of internationally recognized specialists throughout different disciplines designed a shared proposal of holistic approach for BC patients.

RESULTS

A narrative review, containing information on BC treatment, endocrinological and diet aspects, physical activity, rehabilitation, integrative medicine, and digital narrative medicine, was developed.

CONCLUSIONS

In the context of a patient-centered care, BC treatment cannot be separated from a patient's long-term follow-up and care, and an organized interdisciplinary collaboration is the future in this disease's cure, to make sure that our patients will live longer and better.

TRIAL REGISTRATION

NCT05893368: New Model for Integrating Person-based Care (PbC) in the Treatment of Advanced HER2-negative Breast Cancer (PERGIQUAL). Registration date: 29th May 2023.

Bleeding Risk of Acupuncture for Patients with Hematological Malignancies Accompanying Thrombocytopenia: A Retrospective Chart Review

Introduction: In recent years, it has been reported that acupuncture is useful for alleviating the symptoms of patients with hematological malignancies, but the safety of acupuncture for such patients has not been established. This study evaluated the risk of bleeding from acupuncture in patients with hematological malignancies accompanying thrombocytopenia. Methods: The authors performed a retrospective investigation of the medical records of patients with hematological malignancies who received acupuncture during hospitalization at the hematology department of a single medical center in Japan. The bleeding risk at the acupuncture site was evaluated in the following four groups according to the platelet count measured on the day of acupuncture treatment: (1) <20 × 103/μL, (2) 20-49 × 103/μL, (3) 50-99 × 103/μL, and (4) 100 × 103/μL or more. Occurrence of grade 2 or higher bleeding according to the Common Terminology Criteria for Adverse Events, version 5.0, within 24 h from the acupuncture session or before the next session was defined as an event, and the risk of occurrence of bleeding was examined in each group. Results: Of 2423 acupuncture sessions conducted on 51 patients with hematological malignancies, 815 were included in the analysis. Ninety sessions were performed in the <20 × 103/μL platelet count group, 161 in the 20-49 × 103/μL group, 133 in the 50-99 × 103/μL group, and 431 in the 100 × 103/μL or more group. No bleeding event according to the authors' definition occurred in any of these groups. Conclusions: This study is the largest to date to assess the bleeding risk of acupuncture in patients with hematological malignancies accompanying thrombocytopenia. The authors considered that acupuncture could be safely performed without causing serious bleeding for patients with hematological malignancies accompanying thrombocytopenia.

Central neuropathic pain

Central neuropathic pain arises from a lesion or disease of the central somatosensory nervous system such as brain injury, spinal cord injury, stroke, multiple sclerosis or related neuroinflammatory conditions. The incidence of central neuropathic pain differs based on its underlying cause. Individuals with spinal cord injury are at the highest risk; however, central post-stroke pain is the most prevalent form of central neuropathic pain worldwide. The mechanisms that underlie central neuropathic pain are not fully understood, but the pathophysiology likely involves intricate interactions and maladaptive plasticity within spinal circuits and brain circuits associated with nociception and antinociception coupled with neuronal hyperexcitability. Modulation of neuronal activity, neuron-glia and neuro-immune interactions and targeting pain-related alterations in brain connectivity, represent potential therapeutic approaches. Current evidence-based pharmacological treatments include antidepressants and gabapentinoids as first-line options. Non-pharmacological pain management options include self-management strategies, exercise and neuromodulation. A comprehensive pain history and clinical examination form the foundation of central neuropathic pain classification, identification of potential risk factors and stratification of patients for clinical trials. Advanced neurophysiological and neuroimaging techniques hold promise to improve the understanding of mechanisms that underlie central neuropathic pain and as predictive biomarkers of treatment outcome.

Electroacupuncture Attenuates Neuropathic Pain in a Rat Model of Cervical Spondylotic Radiculopathy: Involvement of Spinal Cord Synaptic Plasticity

Purpose

Cervical spondylotic radiculopathy (CSR) is a common neurologic condition that causes chronic neck pain and motor functions, with neuropathic pain (NP) being the primary symptom. Although it has been established that electroacupuncture (EA) can yield an analgesic effect in clinics and synaptic plasticity plays a critical role in the development and maintenance of NP, the underlying mechanisms have not been fully elucidated. In this study, we explored the potential mechanisms underlying EA's effect on synaptic plasticity in CSR rat models.

Materials and Methods

The CSR rat model was established by spinal cord compression (SCC). Electroacupuncture stimulation was applied to LI4 (Hegu) and LR3 (Taichong) acupoints for 20 min once a day for 7 days. Pressure pain threshold (PPT) and mechanical pain threshold (MPT) were utilized to detect the pain response of rats. A gait score was used to evaluate the motor function of rats. Enzyme-linked immunosorbent assay (ELISA), Western blot (WB), immunohistochemistry (IHC), immunofluorescence (IF), and transmission electron microscopy (TEM) were performed to investigate the effects of EA.

Results

Our results showed that EA alleviated SCC-induced spontaneous pain and gait disturbance. ELISA showed that EA could decrease the concentration of pain mediators in the cervical nerve root. WB, IHC, and IF results showed that EA could downregulate the expression of synaptic proteins in spinal cord tissues and promote synaptic plasticity. TEM revealed that the EA could reverse the synaptic ultrastructural changes induced by CSR.

Conclusion

Our findings reveal that EA can inhibit SCC-induced NP by modulating the synaptic plasticity in the spinal cord and provide the foothold for the clinical treatment of CSR with EA.

Effects of repetitive transcranial magnetic stimulation combined with acupuncture on NLRP3 inflammasome and protease levels in patients with neuropathic pain

PURPOSE

This study aimed to investigate whether repetitive transcranial magnetic stimulation (rTMS) combined with acupuncture could alleviate pain in patients suffering from postherpetic neuralgia (PHN) by inhibiting NOD-like receptor 3 (NLRP3) inflammasome activation.

METHODS

Data of 92 PHN patients were retrospectively collected. The patients were grouped as control (nerve block), rTMS, and rTMS + acupuncture groups according to treatment methods. The visual analogue scale (VAS) score, as well as tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, NLRP3, and Caspase-1 levels of patients in each group prior and post-treatment were analyzed.

RESULTS

The rTMS + acupuncture group showed higher efficacy than the rTMS group and the control group, contributing to markedly lower VAS score, as well as TNF-α, IL-1β, IL-6, NLRP3 and Caspase-1 levels than the other two groups (P < 0.05).

CONCLUSION

rTMS plus acupuncture can reduce the inflammatory immune response and ease the pain in patients by inhibiting NLRP3 inflammasome and its resulting inflammatory factors, Caspase-1 and IL-1β.

Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews

BACKGROUND

Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013.

OBJECTIVES

To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS.

METHODS

We identified Cochrane reviews and non-Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria.  Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well-being, and participants' ratings of satisfaction or improvement with treatment.  MAIN RESULTS: We included six Cochrane and 13 non-Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non-Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non-Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high-certainty evidence for any comparison.  There was low-certainty evidence that bisphosphonates may reduce pain intensity post-intervention (standardised mean difference (SMD) -2.6, 95% confidence interval (CI) -1.8 to -3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate-certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181).  There was moderate-certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low-certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low-certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N-acetylcysteine, but no effect size was reported. There was low-certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low- and very low-certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids.

AUTHORS' CONCLUSIONS

Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high-certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high-quality trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult. Current non-Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence.

The core symptom in multiple myeloma patients undergoing chemotherapy: a network analysis

BACKGROUND

During chemotherapy for multiple myeloma, symptoms include those related to the disease, as well as adverse effects of the treatment. Few studies have explored the relationships between these symptoms. Network analysis could identify the core symptom in the symptom network.

OBJECTIVE

The aim of this study was to explore the core symptom in multiple myeloma patients undergoing chemotherapy.

METHODS

This was a cross-sectional study in which sequential sampling was used to recruit 177 participants from Hunan, China. Demographic and clinical characteristics were surveyed using a self-developed instrument. The symptoms of chemotherapy-treated multiple myeloma, including pain, fatigue, worry, nausea, and vomiting, were measured using a questionnaire with good reliability and validity. The mean ± SD, frequency, and percentages were used as descriptive statistics. Network analysis was used to estimate the correlation between symptoms.

RESULTS

The results showed that 70% of multiple myeloma patients using chemotherapy exhibited pain. In the network analysis, worrying was the dominant symptom, and the strongest relationship was between nausea and vomiting in chemotherapy-treated multiple myeloma patients' symptoms.

CONCLUSION

Worrying is the core symptom of multiple myeloma patients. Interventions could be most effective if there is a symptom management focus on worrying when providing care to chemotherapy-treated multiple myeloma patients. Nausea combined with vomiting could be better managed, which would decrease the cost of health care. Understanding the relationship between the symptoms of multiple myeloma patients undergoing chemotherapy is beneficial for precise symptom management.

IMPLICATIONS FOR PRACTICE

Nurses and health care teams should be a priority to intervene in the worrying for chemotherapy-treated multiple myeloma patients to maximize the effectiveness of an intervention. Except, nausea and vomiting should be managed together in a clinical setting.

Role of Integrative Health on Neuropathic Pain

PURPOSE OF REVIEW

Patients diagnosed with neuropathic pain experience continuous or intermittent spontaneous pain throughout their lives. Pharmacological treatments often provide limited relief; therefore, a multidisciplinary approach should be utilized to manage neuropathic pain. This review examines the current literature on integrative health modalities (anti-inflammatory diets, functional movement, acupuncture, meditation, and transcutaneous therapy) for treating patients with neuropathic pain.

RECENT FINDINGS

The use of an anti-inflammatory diet, functional movement, acupuncture, meditation, and transcutaneous therapy in treating neuropathic pain has been investigated in prior literature with positive outcomes. However, there remains a large void in evidence-based knowledge and clinical applicability for these interventions. Overall, integrative health offers a cost-efficient and harmless way of creating a multidisciplinary approach to managing neuropathic pain. There are many complementary approaches to treating neuropathic pain as part of an integrative medicine approach. Research is needed to explore other herbs and spices not yet reported in the peer-review literature. Additionally, follow-on research is needed to understand the clinical applicability of the proposed interventions as well as the dose and timing of the interventions to predict response and duration.

Use of Acupuncture for Adult Health Conditions, 2013 to 2021: A Systematic Review

IMPORTANCE

Acupuncture is a popular treatment that has been advocated for dozens of adult health conditions and has a vast evidence base.

OBJECTIVE

To map the systematic reviews, conclusions, and certainty or quality of evidence for outcomes of acupuncture as a treatment for adult health conditions.

EVIDENCE REVIEW

Computerized search of PubMed and 4 other databases from 2013 to 2021. Systematic reviews of acupuncture (whole body, auricular, or electroacupuncture) for adult health conditions that formally rated the certainty, quality, or strength of evidence for conclusions. Studies of acupressure, fire acupuncture, laser acupuncture, or traditional Chinese medicine without mention of acupuncture were excluded. Health condition, number of included studies, type of acupuncture, type of comparison group, conclusions, and certainty or quality of evidence. Reviews with at least 1 conclusion rated as high-certainty evidence, reviews with at least 1 conclusion rated as moderate-certainty evidence, and reviews with all conclusions rated as low- or very low-certainty evidence; full list of all conclusions and certainty of evidence.

FINDINGS

A total of 434 systematic reviews of acupuncture for adult health conditions were found; of these, 127 reviews used a formal method to rate certainty or quality of evidence of their conclusions, and 82 reviews were mapped, covering 56 health conditions. Across these, there were 4 conclusions that were rated as high-certainty evidence, and 31 conclusions that were rated as moderate-certainty evidence. All remaining conclusions (>60) were rated as low- or very low-certainty evidence. Approximately 10% of conclusions rated as high or moderate-certainty were that acupuncture was no better than the comparator treatment, and approximately 75% of high- or moderate-certainty evidence conclusions were about acupuncture compared with a sham or no treatment.

CONCLUSIONS AND RELEVANCE

Despite a vast number of randomized trials, systematic reviews of acupuncture for adult health conditions have rated only a minority of conclusions as high- or moderate-certainty evidence, and most of these were about comparisons with sham treatment or had conclusions of no benefit of acupuncture. Conclusions with moderate or high-certainty evidence that acupuncture is superior to other active therapies were rare.

Acupuncture as Part of Multimodal Analgesia for Chronic Pain

Background

Chronic pain is a multifactorial condition that is afflicting populations worldwide causing an increasing economic, physical, mental, and emotional burden. Treatments range from medications to interventional procedures to complementary and alternative medicine (CAM), such as acupuncture. This review aims to discuss the use of acupuncture in the treatment of chronic pain, proposed mechanisms, indications, and efficacy for various chronic pain conditions.

Results

Evidence is varied on the efficacy and quality of data on the use of acupuncture in the treatment of chronic pain. Recent studies have demonstrated promising results in the support of acupuncture for the use in the treatment of cancer, neck, and back pain, functional dyspepsia, and various chronic abdominal pain syndromes.

Conclusion

Acupuncture, deemed well-tolerated and safe to use, has been increasingly studied and is regarded as effective in clinical practice, but its efficacy is limited by the lack of well-conducted, high-quality clinical trials, lower quality evidence, and conflicting study results. Additionally, the exact analgesic mechanism of acupuncture remains to be fully elucidated. Increasing evidence supports the role of acupuncture as therapy in the treatment of cancer, neck, and back pain and functional dyspepsia. Further rigorous studies are needed to fully assess the use of acupuncture in various chronic pain conditions, determine its indications, and optimal treatment schedule. Overall, future studies could benefit from better designed experimental studies, larger groups, and more objectives ways to measure pain reduction and symptom improvement.

Effects of Acupuncture on Neuropathic Pain Induced by Spinal Cord Injury: A Systematic Review and Meta-Analysis

Introduction

Neuropathic pain is a commonly seen symptom and one of the most intractable comorbidities following spinal cord injury (SCI). Acupuncture has been widely used for neuropathic pain after SCI in clinical settings. There is no systematic review or meta-analysis evaluating the efficacy of acupuncture in the treatment of SCI-induced neuropathic pain. Thus, this study aimed to conduct a systematic review and meta-analysis to assess the efficacy of acupuncture on SCI-induced neuropathic pain.

Methods

Seven databases were comprehensively searched, including PubMed, the Cochrane Library, the Web of Science, the China National Knowledge Infrastructure (CNKI), the Chinese Biomedical Literature Service System (SinoMed), the Wanfang Database, and the Chinese Scientific Journals Database (VIP) from their inception to 30 September 2021. Two independent reviewers evaluated the eligibility of the data retrieved based on the pre-established eligibility criteria and assessed the methodological quality of the included studies using the Cochrane Risk of Bias Tool. The outcome indexes in this study included the visual analogue scale, the numeric rating scale, the present pain intensity, and the pain region index. Sensitivity and subgroup analyses were also performed to specifically evaluate the intervention effects. In addition, publication bias was analyzed.

Results

Six randomized controlled trials (145 participants in the experimental groups and 141 participants in the control groups) were identified that evaluated the application of acupuncture for neuropathic pain after SCI and were included in this study. The results of our study revealed that acupuncture had a positive effect on the pain severity (standardized mean difference (SMD): -1.40, 95% confidence interval (CI): -2.23; -0.57), the present pain intensity (MD = -0.61, 95% CIs = -0.98; -0.23), and the pain region index (MD = -3.04, 95% CI = -3.98; -2.11). In addition, sensitivity analyses showed that these results were robust and stable. Subgroup analyses indicated that electroacupuncture (EA) had better effects on SCI-induced neuropathic pain. However, a publication bias was observed.

Conclusion

Available evidence appears to suggest that acupuncture may have a role in SCI-induced neuropathic pain management, but this remains to be determined.

Acupuncture and Moxibustion for Peripheral Neuropathic Pain: A Frequentist Network Meta-Analysis and Cost-Effectiveness Evaluation

Purpose

Acupuncture and moxibustion techniques have been increasingly used to treat peripheral neuropathic pain (PNP). However, there is a paucity of comparative information and cost-effectiveness assessment for techniques on PNP management. Patients and Methods. Randomized controlled trials studying the acupuncture or moxibustion treatments on PNP were identified from electronic databases. The quality of the included studies and the potential risk of bias was evaluated using the ROB 2.0 assessment tool. The primary outcome was at least 20% pain relief. The treatment effects were pooled through a frequentist-based network meta approach. Subsequently, the cost-effectiveness measured by incremental cost per additional responder (ICPR) was calculated.

Results

One three-arm trial and 15 two-arm trials comprising 1308 participants that satisfy the eligibility criteria were identified. Among the included studies, 12.5% were at low risk of bias, 68.75% had some concerns about the risk of bias, and 18.75% were at high risk of bias. The major sources of bias originated from the randomization processes of the studies. The patients were assigned to seven different acupuncture or moxibustion interventions and two pharmaceutical treatments. Except for acupoint injection, all the included acupuncture and moxibustion techniques showed superior improvements in PNP and were more cost-effective as compared to pharmaceutical treatments. Warm needling, fire needling, and moxibustion were the most effective treatments. Fire needling showed the lowest ICPR relative to the nonsteroidal anti-inflammatory drugs in the cost-effectiveness analysis of direct and indirect costs.

Conclusion

Acupuncture and moxibustion techniques are beneficial and cost-effective approaches for easing PNP and hence can be considered for PNP management.

Effective Oriental Magic for Analgesia: Acupuncture

Pain is a kind of complex physiological and psychological symptom, which makes the person debilitated and uncomfortable. Some persistent pain is unbearable for the patients, reducing the quality of life and bringing considerable pressure to the individuals and society. Pain killers seem to be effective in analgesia for patients, but their safety and addiction are crucial issues. From the theory of traditional Chinese medicine (TCM), the blocked meridian is the main cause of pain, and effective acupuncture can play a positive analgesic effect. Acupuncture that can date back thousands of years is one of the ancient medical practices in China. Its safety and effectiveness are respected. Based on its superior safety and inferior side effects, it has been gradually recognized as a therapeutic intervention method for complementary medicine, which is also generally used to treat multiple pain diseases. It is shown by modern medical studies that neurotransmitters are the material basis for the acupuncture effect, and the effect of acupuncture analgesia is related to changes in neurotransmitters. However, the specific mechanism has not been elucidated. This review aims to comprehensively discuss the historical evolution of acupuncture analgesia, clinical research of acupuncture analgesia, comparison of acupuncture and drug therapy, the neurotransmitter mechanism of acupuncture analgesia, the effect of acupuncture manipulation on analgesia, and bibliometric analysis of acupuncture treatment for pain, to explore the superiority and related mechanism of acupuncture analgesia from different aspects, and to provide a more effective treatment for alleviating patients' pain.

Efficacy of acupuncture in the treatment of fibromyalgia

Purpose of Review

Fibromyalgia is a highly prevalent chronic pain syndrome that affects up to 4% of the population and causes significant morbidity and disability, with an increasing associated cost. Though many approaches for treatment have been tested, therapy regimens are still elusive, and efficacy is limited. This review summarizes the background of fibromyalgia and acupuncture and reviews the latest and seminal literature discussing the application of acupuncture in fibromyalgia.

Recent Findings

Fibromyalgia is hard to treat, owing both to its chronicity and poorly understood pathophysiology and etiology. Current treatments target symptoms primarily, and few attempt to address the source. Efficacious treatment requires long-term treatment by a multidisciplinary team. Though several treatments exist, they still fall short with a substantial number of patients. Acupuncture, a form of integrative medicine, has been a part of traditional Chinese medication for generations. Evidence shows that it effectively treats different kinds of pain conditions, including migraines and chronic musculoskeletal pain. Recent studies showed evidence to support its use in fibromyalgia. Clinical trials studying acupuncture in fibromyalgia have shown improvement in pain, quality of sleep, and quality of life, though the quality of evidence is mainly low to medium. Several studies were not able to provide evidence to support real over sham acupuncture. Weighing the overall evidence paints a picture of mixed results between equivocal results to positive. In analyzing these results, one must also consider publication bias supporting the dissemination of positive results.

Summary

An increasing number of studies support the utilization of acupuncture for the treatment of fibromyalgia. Though no head-to-head comparison was able to show the superiority of acupuncture to other therapies, mounting evidence supports its use as part of multimodal approaches to treatment with additive efficacy to traditional therapy. Further research will likely provide data on effective regimens and combination therapies.

Neoadjuvant Chemotherapy in Breast Cancer: An Advanced Personalized Multidisciplinary Prehabilitation Model (APMP-M) to Optimize Outcomes

Neoadjuvant chemotherapy is increasingly being employed in the management of breast cancer patients. Efforts and resources have been devoted over the years to the search for an optimal strategy that can improve outcomes in the neoadjuvant setting. Today, a multidisciplinary approach with the application of evidence-based medicine is considered the gold standard for the improvement of oncological results and patient satisfaction. However, several clinical complications and psychological issues due to various factors can arise during neoadjuvant therapy and undermine outcomes. To ensure that health care needs are adequately addressed, clinicians must consider that women with breast cancer have a high risk of developing "unmet needs" during treatment, and often require a clinical intervention or additional care resources to limit possible complications and psychological issues that can occur during neoadjuvant treatment. This work describes a multidisciplinary model developed at "Fondazione Policlinico Universitario Agostino Gemelli" (FPG) in Rome in an effort to optimize treatment, ease the application of evidence-based medicine, and improve patient quality of life in the neoadjuvant setting. In developing our model, our main goal was to adequately meet patient needs while preventing high levels of distress.

Effects of massage and acupuncture on the range of motion and daily living ability of patients with frozen shoulder complicated with cervical spondylosis

OBJECTIVE

This study was designed to study the effects of massage and acupuncture on patients with frozen shoulder complicated with cervical spondylosis through range of motion (ROM) and daily living ability.

METHODS

A total of 164 patients with frozen shoulder treated in our hospital from June 2016 to April 2019 were recruited and divided into a control group and an observation group. There were 100 cases in the observation group, all of whom were treated with massage combined with acupuncture. Another 64 cases were enrolled in the control group, all of whom were treated with acupuncture alone. The recovery of myodynamia, rating scale of the American Shoulder and Elbow Surgeons (ASES), score of American Spinal Injury Association (ASIA), ROM score, vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1), complication rate, total effective rate, and patient satisfaction were assessed.

RESULTS

After treatment, patients in the observation group had better recovery of myodynamia than the control group. They also had lower VAS scores, higher life function score and total ASES scores, higher ASIA scores, higher ROM scores, lower VCAM-1 and ICAM-1 expression, lower complication rate, higher total effective rate, and higher patient satisfaction.

CONCLUSION

Massage combined with acupuncture can better improve the ROM of joints and daily living ability of patients with frozen shoulder complicated with cervical spondylosis.

Efficacy of Dry Needling and Acupuncture in the Treatment of Neck Pain

CONTEXT

Neck pain is a common phenomenon and affects a large segment of the population. Chronic neck pain, lasting more than 3 months, likely occurs in 10% - 30% of patients with acute neck pain and affects up to 288 million cases globally, carrying a significant cost in terms of quality of life, disability, and healthcare dollars. Here we review neck pain background, acupuncture and the evidence that exist to support acupuncture use in chronic neck pain.

RESULTS

Neck pain not only affects quality of life directly, but also contributes to depression, job dissatisfaction and reduced productivity. Unfortunately, neck pain is strongly linked to office and computer work and is likely to continue increasing in prevalence. Traditional treatments, such as analgesics, physical therapy, exercise, and non-invasive therapy bring some relief, and invasive therapy is indicated if anatomical pathologies exist. Acupuncture is a form of integrative medicine, originally described and practiced in traditional Chinese medicine and now expanded to include methods including acupressure, dry needling, and others. Traditionally, it focused on restoring the patient's flow of Qi by puncturing specific points along the meridians. It has previously been shown to be effective in other forms of chronic pain and disability. Clinical trials studying acupuncture for neck pain have shown significant reduction in both pain and associated symptoms. These therapies are reviewed in this text.

CONCLUSIONS

Neck pain is a common and significant global problem. Acupuncture, dry needling, and cupping were all shown to be effective in alleviating pain both immediately after treatment, as well as provide long-lasting relief. These treatments are generally safe and inexpensive and should be considered as part of a multimodal approach for the treatment of neck pain. More head-to-head studies will provide better data to support a choice of a specific treatment over another.

Electroacupuncture Regularizes Gastric Contraction and Reduces Apoptosis of Interstitial Cells of Cajal in Diabetic Rats

Background/Aims

Gastric dysmotility is a frequent complication among patients with diabetes mellitus. Electroacupuncture (EA) has been empirically used to relieve gastrointestinal symptoms. The aims of this study were to investigate the effects of EA on gastric contraction and the mechanisms of interstitial cells of Cajal (ICC) involved.

Materials and Methods

Male Sprague–Dawley rats were randomized into the normal control, diabetes (DM), diabetic and sham EA (DM + SEA), diabetic and low-frequency EA (DM + LEA), and diabetic and high-frequency EA (DM + HEA) groups. Diabetic models were established and then treated with EA for 8 weeks. Body weight and blood glucose were recorded every 2 weeks. The spontaneous contractions of distal gastric strips were analyzed. Immunostaining and RT-PCR were used to test the apoptotic ICC, IGF-1/IGF-1R, and Nrf2/HO-1 pathways.

Results

The body weight in the DM + LEA and DM + HEA groups were increased compared with that of the DM group, though there was no effect on the blood glucose. The gastric contractions were obviously disordered in the DM group, but EA could regularize the contractions. The number of apoptotic ICC was dramatically increased in the DM group, but reduced with EA treatment. Meanwhile, the IGF-1/IGF-1R pathway was verified to be significantly altered in diabetic rats. The Nrf2/HO-1 pathway was not significantly increased in the DM group. EA with different frequencies efficiently improved the expression of IGF-1/IGF-1R signaling and activated the Nrf2/HO-1 pathway.

Conclusion

EA could improve gastric motility dysfunction and attenuate ICC apoptosis possibly through the regulation of IGF-1/IGF-1R and Nrf2/HO-1 pathways. EA may be a potential therapeutic method for diabetic gastric motility dysfunction.

Short-term effect of electroacupuncture on rehabilitation after arthroscopic triangular fibrocartilage complex repair: a randomised study

Background

Electroacupuncture (EA) alleviates chronic pain and acute postoperative pain after several surgical procedures. However, whether EA facilitates postoperative functional recovery after arthroscopic surgery has yet to be determined. This study investigated the short-term effect of EA on a rehabilitation course after arthroscopic triangular fibrocartilage complex (TFCC) repair.

Methods

Forty-two patients undergoing arthroscopic TFCC repair were randomised to an EA group (n = 19) or control group (n = 23). In the EA group, patients received EA treatment and standard active rehabilitation for 4 weeks. In the control group, patients received standard active rehabilitation for 4 weeks. At the end of the treatment and at the follow-up visit 4 weeks after the treatment, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, wrist range of motion (ROM), handgrip strength, and key pinch strength were collected and analysed.

Results

The EA group improved significantly than the control group in terms of DASH scores, all wrist motion arcs, and key pinch strength (P < 0.05) at the end of the 4-week treatment and the follow-up visit another 4 weeks later.

Conclusion

Patients treated with 4 weeks of EA after the arthroscopic TFCC repair had better wrist ROM and DASH scores than patients of control group

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02361-1.

Acupuncture in diabetic peripheral neuropathy-protocol for the randomized, multicenter ACUDPN trial

BACKGROUND

Acupuncture is used to treat patients with diabetic peripheral neuropathy; however, the evidence is unclear. We present the design and methodology of the ACUDPN (ACUpuncture in Diabetic Peripheral Neuropathy) trial, which investigates the effectiveness of acupuncture for the treatment of diabetic peripheral neuropathy (DPN) symptoms. The aim of this study is to investigate whether acupuncture is effective for the treatment of DPN symptoms.

METHODS

This study is a two-armed, randomized, controlled, parallel group, open-label, confirmatory, multicenter trial (8-week intervention period plus 16 weeks of follow-up). Physicians in outpatient units in Germany who specialize in acupuncture treatment will treat 110 diabetes type II patients with clinical symptoms of peripheral neuropathy in the feet and legs with signs of neuropathy according to nerve conduction testing. The patients will be randomized in a 1:1 ratio to one of the following two groups: (a) semi-standardized acupuncture plus routine care or (b) routine care alone. Acupuncture will consist of 12 treatments per patient over 8 weeks. The primary outcome will be the overall DPN-related complaints in the extremities after 8 weeks as measured by the Visual Analog Scale (VAS). Further outcome measures will include DPN-related pain, the Neuropathic Pain Symptom Inventory (NPSI), Diabetic Peripheral Neuropathic Pain Impact (DPNPI) scores, and nerve conduction parameters of the sural nerve at weeks 8, 16, and 24.

DISCUSSION

The results of this trial will be available in 2021 and will help clarify whether acupuncture can be considered effective for the treatment of DPN with regard to the subdimensions of the neuropathic clinical picture.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03755960 . Registered on 11 August 2018.

A Model of an Integrative Approach to Breast Cancer Patients

BACKGROUND

Breast cancer (BC) survivors have physical and psychological needs that require convincing responses by health care providers. The quality of life issue and clinical unmet needs are among the main reasons pushing a number of patients toward "natural" therapies that are often misleading and alternative to mainstream cancer care. Integrative Oncology (IO) tries to respond to many of those needs, by combining lifestyle counseling, body-mind activities, and complementary evidence-informed therapies with anticancer standard treatments.

METHODS

In our model at Fondazione Policlinico Gemelli (FPG), every woman diagnosed with a BC waiting for surgery or candidate to neoadjuvant chemotherapy undergoes a preliminary psycho-oncological distress evaluation and a brief lifestyle interview. Anthropometric measurements, body composition analysis, and individual levels of physical activity are recorded. Patients are given evidence based recommendations about the advisable diet and physical activity in a prehabilitation setting. A physician provides patients with information about integrative care plans to treat symptoms related to the disease or its treatments. Therapeutic approaches include acupuncture, mindfulness-based protocols, qigong, massage therapy, and classes of music/art therapy.

RESULTS

Between September 2018 and February 2020, the Center for Integrative Oncology at FPG has carried out 1249 lifestyle counseling sessions, 1780 acupuncture treatments, 1340 physiotherapy sessions, 3261 psycho-oncological consultations, 218 herbal medicine counseling sessions. Moreover, 90 BC patients completed the mindfulness based stress reduction (MBSR) protocol and 970 patients participated in qigong, art therapy, and music therapy classes.

CONCLUSIONS

Our integrative approach aims to achieve a person-centered medicine by improving symptoms management, adherence to oncological protocols, and eventually overall quality of life.

Effect of Electroacupuncture on Pain Perception and Pain-Related Affection: Dissociation or Interaction Based on the Anterior Cingulate Cortex and S1

Electroacupuncture (EA) can effectively modulate pain perception and pain-related negative affect; however, we do not know whether the effect of EA on sensation and affect is parallel, or dissociated, interactional. In this study, we observed the effects of the anterior cingulate cortex (ACC) lesion and the primary somatosensory cortex (S1) activation on pain perception, pain-related affection, and neural oscillation in S1. ACC lesions did not affect pain perception but relieved pain-paired aversion. S1 activation increased pain perception and anxious behavior. EA can mitigate pain perception regardless of whether there is an ACC lesion. Chronic pain may increase the delta and theta band oscillatory activity in the S1 brain region and decrease the oscillatory activity in the alpha, beta, and gamma bands. EA intervention may inhibit the oscillatory activity of the alpha and beta bands. These results suggest that EA may mitigate chronic pain by relieving pain perception and reducing pain-related affection through different mechanisms. This evidence builds upon findings from previous studies of chronic pain and EA treatment.

The quality of Cochrane systematic reviews of acupuncture: an overview

BACKGROUND

Many systematic reviews of clinical trials on acupuncture were performed within the Cochrane Collaboration, the evidence-based medicine (EBM) most recognized organization. Objective of the article was to systematically collect and identify systematic reviews of acupuncture published in the Cochrane Library and assess their quality from a methodological perspective.

METHODS

A comprehensive literature search was performed in the Cochrane Database of Systematic Reviews to identify the reviews of acupuncture conducted until June 2019. The methodological quality of the included reviews was assessed using the AMSTAR 2 checklist, an evaluation tool for systematic reviews.

RESULTS

Out of a total of 126 eligible reviews, 50 systematic reviews were included. According to the AMSTAR 2, 52% of Cochrane Systematic Reviews (CSRs) were of low quality, due to the presence of one or more weaknesses in at least one of the domains defined as critical for the methodological quality assessment. The less satisfied critical domain was inadequate investigation and discussion of publication bias. Declaration of potential sources of conflict of interest, and funding of the authors of the review and of the included studies were other important weaknesses.

CONCLUSIONS

The main methodological flaws in the included CSRs were related to topics of relatively new concern in the conduction of systematic reviews of the literature. However, both, lack of attention about retrieval of negative studies, and statements about conflict of interests are crucial point for the evaluation of therapeutic interventions according to EBM methodology.

Pain management in hidradenitis suppurativa and a proposed treatment algorithm

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Few HS-specific data exist to guide pharmacologic analgesia; however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning-type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This article incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacologic, and complementary and alternative treatment modalities.

Ocular Surface Pain: A Narrative Review

Ocular surface pain is a frequent cause of visits to an eye care provider and has a substantial impact on healthcare cost, yet a complete understanding of its causative factors and tools for diagnostic workup are notably missing in many eye clinics. The cornea has the densest sensory innervation in the human body and has the potential to be a powerful producer of pain. Pain can manifest as a result of a noxious stimulus or disruption in the ocular surface anatomy (nociceptive pain), or it can result from abnormalities in the ocular surface neurosensory apparatus itself (neuropathic pain). Novel advances in neurobiology have sought to differentiate the two entities, particularly to identify when chronic dry eye symptomatology is driven by neuropathic ocular pain. In this review, we seek to provide an overview of the prevalence, physiologic factors, and management of ocular surface pain complaints.

Guidelines for the diagnosis and treatment of neuroangiostrongyliasis: updated recommendations

A subcommittee of the Hawaii Governor's Joint Task Force on Rat Lungworm Disease developed preliminary guidelines for the diagnosis and treatment of neuroangiostrongyliasis (NAS) in 2018 (Guidelines, 2018). This paper reviews the main points of those guidelines and provides updates in areas where our understanding of the disease has increased. The diagnosis of NAS is described, including confirmation of infection by real-time polymerase chain reaction (RTi-PCR) to detect parasite DNA in the central nervous system (CNS). The treatment literature is reviewed with recommendations for the use of corticosteroids and the anthelminthic drug albendazole. Long-term sequelae of NAS are discussed and recommendations for future research are proposed.

Electroacupuncture-Related Metabolic Brain Connectivity in Neuropathic Pain due to Brachial Plexus Avulsion Injury in Rats

Objective: The present study aimed to investigate the analgesic effect of electroacupuncture (EA) in neuropathic pain due to brachial plexus avulsion injury (BPAI) and related changes in the metabolic brain connectivity. Methods: Neuropathic pain model due to BPAI was established in adult female Sprague-Dawley rats. EA stimulations (2/15 Hz, 30 min/day, 5-day intervention followed by 2-day rest in each session) were applied to the fifth-seventh cervical "Jiaji" acupoints on the noninjured side from 1st to 12th weeks following BPAI (EA group, n = 8). Three control groups included sham EA (nonelectrical acupuncture applied to 3 mm lateral to the real "Jiaji" acupoints), BPAI-only, and normal rats (no particular intervention; eight rats in each group). Thermal withdrawal latency (TWL) of the noninjured forepaw was regularly tested to evaluate the threshold of thermalgesia. Small animal [fluorine-18]-fluoro-2-deoxy-_D-glucose (¹⁸F-FDG) PET/CT scans of brain were conducted at the end of 4th, 12th, and 16th weeks to explore metabolic alterations of brain. Results: In the EA group, the TWL of the noninjured forepaw significantly decreased following BPAI and then increased following EA stimulation, compared with sham EA (P < 0.001). The metabolic brain connectivity among somatosensory cortex (SC), motor cortex (MC), caudate putamen (Cpu), and dorsolateral thalamus (DLT) in bilateral hemispheres decreased throughout the 16 weeks' observation in the BPAI-only group, compared with the normal rats (P < 0.05). In the EA group, the strength of connectivity among the above regions were found to be increased at the end of 4th week following BPAI modeling, decreased at 12th week, and then increased again at 16th week (P < 0.05). The changes in metabolic connectivity were uncharacteristic and dispersed in the sham EA group. Conclusion: The study revealed long-term and extensive changes of metabolic brain connectivity in EA-treated BPAI-induced neuropathic pain rats. Bilateral sensorimotor and pain-related brain regions were mainly involved in this process. It indicated that modulation of brain metabolic connectivity might be an important mechanism of analgesic effect in EA stimulation for the treatment of neuropathic pain.

Auricular neural stimulation as a new non-invasive treatment for opioid detoxification

The recent opioid crisis is one of the rising challenges in the history of modern health care. New and effective treatment modalities with less adverse effects to alleviate and manage this modern epidemic are critically needed. The FDA has recently approved two non-invasive electrical nerve stimulators for the adjunct treatment of symptoms of acute opioid withdrawal. These devices, placed behind the ear, stimulate certain cranial nerves with auricular projections. This neural stimulation reportedly generates a prompt effect in terms of alleviation of withdrawal symptoms resulting from acute discontinuation of opioid use. Current experimental evidence indicates that this type of non-invasive neural stimulation has excellent potential to supplement medication assisted treatment in opioid detoxification with lower side effects and increased adherence to treatment. Here, we review current findings supporting the use of non-invasive neural stimulation in detoxification from opioid use. We briefly outline the neurophysiology underlying this approach of auricular electrical neural stimulation and its role in enhancing medication assisted treatment in treating symptoms of opioid withdrawal. Considering the growing deleterious impact of addictive disorders on our society, further studies on this emerging treatment modality are warranted.

Brain Metabolism in Rats with Neuropathic Pain Induced by Brachial Plexus Avulsion Injury and Treated via Electroacupuncture

PURPOSE

Brain organisation is involved in the mechanism of neuropathic pain. Acupuncture is a common clinical practise in traditional Chinese medicine for the treatment of chronic pain. This study explored electroacupuncture's effects on brain metabolism following brachial plexus avulsion injury (BPAI)-induced pain.

METHODS

A total of 32 female rats were randomised into a normal group, model group, sham electroacupuncture group, and electroacupuncture group. A pain model was included via right BPAI. The electroacupuncture intervention at cervical "Jiaji" points (C5-7) was performed for 11 weeks. The mechanical withdrawal threshold of the non-injured (left) forepaw was measured at the baseline and on days 3, 7, 14, 21, 28, 56, 84, and 112 subsequent to BPAI. Positron emission tomography (PET) was applied to explore metabolic changes on days 28, 84, and 112.

RESULTS

After electroacupuncture, the mechanical withdrawal threshold of the left forepaws was significantly elevated and the effect persisted until 4 weeks after the intervention ceased (p<0.05 or p<0.001). In the sensorimotor-related brain regions, standardised uptake values in the bilateral somatosensory and motor cortices were observed in the electroacupuncture group. Metabolism particularly increased in the right somatosensory cortex. Metabolism changes also occurred in the pain-related brain regions and emotion- and cognition-related brain regions.

CONCLUSION

The present study demonstrated the beneficial effects of electroacupuncture for relieving BPAI-induced neuropathic pain in rats. Electroacupuncture intervention might inhibit maladaptive plasticity in brain areas governing multidimensional functions, especially in sensorimotor- and cognition-related cortices.

Acupuncture for Fibromyalgia: An Open-Label Pragmatic Study on Effects on Disease Severity, Neuropathic Pain Features, and Pain Catastrophizing

The treatment of fibromyalgia syndrome (FMS) is still far from being optimally coded, and pharmacological strategies are often unsatisfactory. Acupuncture plays a role among nonpharmacological intervention approaches; however, there is still no clarity as to when to integrate it into therapy. The objective of this study is to explore the role of acupuncture, in terms of efficacy on main disease severity measures and pain features, in patients with nonresponsive disease, defining nonresponsive FMS characterized by a revised Fibromyalgia Impact Questionnaire (FIQ-R) ≥39 and a Patient Health Questionnaire 15-item (PHQ15) ≥5 despite optimal drug therapy. Patients were treated with weekly sessions, for a total of eight acupuncture sessions. At the baseline and at the end of the treatment cycle, a comprehensive clinical evaluation was carried out to evaluate improvements in terms of disease severity and impact on neuropathic pain features (measured with the painDETECT questionnaire (PDQ)) and pain catastrophizing (measured with the Pain Catastrophizing Scale (PCS)). At the end of the eight-week treatment, patients experienced a significant improvement in all evaluated parameters (for FIQ-R, PDQ, and PHQ15 p < 0.0001, for PCS p=0.001). Of particular note is the effectiveness on manifestations that are difficult to treat such as neuropathic pain features and on negative psychological perceptions such as pain catastrophizing. It can be stated that acupuncture can be proposed also in phases of high severity of disease. Intervention with multimodal strategies, including acupuncture, could be of great benefit to patients.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

Acupuncture Improves Comorbid Cognitive Impairments Induced by Neuropathic Pain in Mice

Growing evidence indicates that neuropathic pain is frequently accompanied by cognitive impairments, which aggravate the quality of life of chronic pain patients. Here, we investigated whether acupuncture treatments can improve cognitive dysfunction as well as allodynia induced by neuropathic pain in mice. One week after the left partial sciatic nerve ligation (PSNL), acupuncture treatments on the acupoints GB30-GB34 (AP1), HT7-GV20 (AP2), or control points (CP) were performed for 4 weeks. Notably, the significant attenuations of mechanical allodynia and cognitive impairment were observed in the AP1 group, but not in PSNL, AP2, or CP groups. A random decision forest classifier based on the pain and cognitive functions displayed that the acupuncture group was clearly segregated from the other groups. We also demonstrated that acupuncture restored the reduced field excitatory post-synaptic potentials and was able to elevate the expression levels of glutamate receptors (NR2B and GluR1) in the hippocampus. Moreover, the expressions of Ca²⁺/calmodulin-dependent protein kinase II and synaptic proteins (pPSD-95 and pSyn-1) were enhanced by acupuncture treatment. These results suggest that acupuncture can enhance hippocampal long-term action through the regulation of the synaptic efficacy and that acupuncture may provide a viable option for managing both pain and cognitive functions associated with chronic neuropathic pain.

Cochrane reviews on acupuncture therapy for pain: A snapshot of the current evidence

Cochrane is an international non-profit organization established in 1993 to produce and disseminate high quality and unbiased systematic reviews of evidence on health care interventions. At the forefront of systematic review methodology, Cochrane is generally accepted to be among the most carefully prepared and rigorous sources of systematic review evidence. There are numerous Cochrane reviews on nonpharmacologic interventions for pain and multiple Cochrane reviews evaluating acupuncture therapy in pain conditions. But how complete and up to date are those reviews relative to other rigorous systematic reviews with meta-analyses of acupuncture therapy for pain published in the literature? In this 'snapshot' overview, we found 22 relevant Cochrane reviews, some concluding that acupuncture therapy is probably useful for treating specific pain conditions. However, many of the conditions for which acupuncture is most commonly used are either not represented in Cochrane reviews or the existing Cochrane reviews are seriously outdated and do not reflect current evidence. This creates confusion with the risks of adverse effects and addiction liability associated with pain medications, the prevalence of chronic pain, the ongoing opioid epidemic and the need for evidence-based options for pain as part of comprehensive pain care. Clinicians and patients want clarification on safe and effective options to treat pain. Issues involving reviewed trials' inadequate use of sham comparators, of acupuncture as a complex intervention with interactive components and a shift in research focus from efficacy trials to real-world pragmatic trials are discussed in relation to updating Cochrane reviews of acupuncture therapy for pain.

What Is the Appropriate Acupuncture Treatment Schedule for Chronic Pain? Review and Analysis of Randomized Controlled Trials

Background

Acupuncture is widely used for the treatment of chronic pain. Different protocols of acupuncture practice exist and lack agreement on the optimal schedule of acupuncture treatment.

Objective

To review the appropriate acupuncture treatment schedule for chronic pain.

Methods

Embase, Pubmed, Cochrane Central Register of Controlled Trials, and reference lists were searched from 2009 to 2018 to identify randomized controlled trials of acupuncture for chronic pain conditions. We collected factors of treatment schedule (D, duration of each treatment session; N, number of treatment sessions; T, total duration of treatment in weeks) from each of the trials, and the linear regression analysis with real pain relief rate (both treatment and follow-up) was performed. Furthermore, we recommend the concept of “DOSE” and frequency (F) to evaluate the dose and frequency effect of acupuncture.

Results

Twenty-four trials with a total number of 3461 patients met the inclusion criteria. Of these, data from 23 studies were available for analysis. Firstly, the results showed that follow-up pain relief rate was decreased slightly with the increase of the duration of each session and DOSE (r=-0.3414 and r=-0.3246, respectively), but those two factors had no correlation with the pain relief rate after treatment. Secondly, it showed that either lower frequency with 2 sessions/week and higher frequency greater than 2 sessions/week or DOSE of 30 mins/week can achieve higher pain relief rate after treatment. Thirdly, we found the rate of pain relief remained at a high level greater than 20% up to 18 weeks after the treatment, and then it dropped sharply below 10% with the follow-up extended. A positive relationship was found between study score and pain relief both in treatment and follow-up (r=0.4654 and r=0.3046, respectively).

Conclusions

The effect of acupuncture varies greatly with the different schedules of acupuncture, so it is necessary to review and choose the appropriate schedule. Although the current work is based on a limited number of trials, the findings suggest that acupuncture has a dose and frequency effect presenting within a certain range, which would have considerable implications for the design and interpretation of clinical trials. More high-quality randomized controlled trials on acupuncture schedule research were needed for providing more definitive evidence.

Effects of Electroacupuncture on Pain Memory-Related Behaviors and Synchronous Neural Oscillations in the Rostral Anterior Cingulate Cortex in Freely Moving Rats

Our previous studies have confirmed that electroacupuncture (EA) can effectively intervene in pain memory, but the neural mechanism involved remains unclear. In this study, we observed the effects of EA in regulating pain memory-related behaviors and synchronous neural oscillations in the rostral anterior cingulate cortex (rACC). During nociceptive behavioral testing, pain memory induced a nonpain stimulus that spurred a neural oscillatory reaction similar to that caused by pain stimuli in the rACC. After EA, nonpain stimuli did not induce decreased neural oscillatory activity in the rACC until the presentation of pain stimuli. During aversive behavioral testing, EA, through the downregulation of theta power, inhibited the retrieval of aversive memory and relieved pain memory-induced aversive behaviors. These changes of oscillatory activity may be the hallmarks of EA therapy for pain memory.

Application of electroacupuncture for postoperative pain management after total knee arthroplasty: a study protocol for a single-blinded, randomised placebo-controlled trial

INTRODUCTION

The purpose of this study is to assess the efficacy of electroacupuncture (EA) to relieve pain and promote functional rehabilitation after total knee surgery.

METHODS AND ANALYSIS

We propose a single-blinded, randomised placebo-controlled trial to evaluate the efficacy of EA. Patients with osteoarthritis (aged 55-80 years) undergoing unilateral total knee arthroplasty (TKA) will be included in the trial. They will be randomised to receive either EA or sham-EA. A total of 110 patients will receive EA and sham-EA for 3 days after TKA. Postoperative pain will be measured using visual analogue score, and the need for an additional dose of opioid and analgesics will be recorded as the primary outcome. Secondary outcomes include knee function and swelling, postoperative anxiety, postoperative nausea and vomiting among other complications.

ETHICS AND DISSEMINATION

This study has been approved by the ethics committee, and subsequent modifications of the protocol will be reported and approved by it. Written informed consent will be obtained from all of the participants or their authorised agents.

TRIAL REGISTRATION NUMBER

ChiCTR1800016200; Pre-results.

Electroacupuncture enhances antioxidative signal pathway and attenuates neuropathic pain induced by chemotherapeutic paclitaxel

One of the significant limiting complications of paclitaxel is painful peripheral neuropathy during its therapy for several types of cancers. Our recent study showed that impairment of Nrf2-antioxidant response element (Nrf2-ARE) and upregulation of oxidative signals in the dorsal root ganglion (DRG) of rats with treatment of paclitaxel result in neuropathic pain. The purpose of this study was to examine the beneficial role played by electroacupuncture (EA) in modifying neuropathic pain evoked by paclitaxel via Nrf2-ARE and oxidative mechanisms. Behavioral test was performed to determine mechanical and thermal sensitivity in rats. Western Blot analysis and ELISA were used to examine expression of Nrf2-ARE and superoxide dismutases (SOD); and the levels of products of oxidative stress in the DRG. Our data showed that paclitaxel increased mechanical and thermal sensitivity and this was accompanied with impaired Nrf2-ARE and SOD in the DRG and amplified products of oxidative stress (i.e. 8-isoprostaglandin F2alpha and 8-hydroxy-2'-deoxyguanosine). EA treatment largely restored the levels of Nrf2-ARE/SOD and inhibited products of oxidative stress and thereby attenuated mechanical and thermal hypersensitivity induced by paclitaxel. In conclusion, we revealed specific signaling pathways leading to paclitaxel-evoked neuropathic pain, including impairment of Nrf2-ARE and heightened oxidative signals. We further provided evidence for the role of EA in alleviating paclitaxel-neuropathic pain via these molecular mediators.