Clinical study comparing acupuncture, physiotherapy, injection, and oral anti-inflammatory therapy in shoulder-cuff lesions

Acupuncture for Atraumatic Shoulder Conditions: Protocol for a Systematic Review and Meta-Analysis

Introduction

Shoulder pain is one of the most common musculoskeletal disorders among adults and is caused by a variety of shoulder conditions. The popularity of different acupuncture methods in the nonsurgical treatment of shoulder pain has recently increased. However, evidence regarding the efficacy of acupuncture for shoulder pain is inconsistent, and there is a lack of supporting evidence regarding the overall efficacy of different acupuncture methods for shoulder pain.

Methods and Analysis

A systematic review will be conducted to assess the effectiveness of a wide range of acupuncture techniques for atraumatic shoulder conditions. The PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Ovid MEDLINE, Chinese Biomedical Literature, Chinese National Knowledge Infrastructure, Wanfang, and Chongqing VIP databases will be searched to identify eligible studies. Studies will be selected according to preset inclusion and exclusion criteria and relevant data will be extracted from the final included studies. The heterogeneity, risk of bias, publication bias and evidence quality of the studies will be assessed, and a subgroup analysis and sensitivity analysis will be performed.

Systematic Review Registration

PROSPERO registration number CRD42021249625.

Acupuncture and the Cardiovascular System: A Scientific Challenge

In acupuncture research two main issues have to be addressed. One is whether the needle has a biological effect of its own. The other is whether acupuncture is of help to patients in their daily lives. With reference to this, acupuncture is a complex form of treatment in which the needles modulate physiological mechanisms of the body and the doctor supports the patient to achieve a life-style that assists with this.

To evaluate the biological effects of needling, a randomised, controlled trial group of 49 patients with angina pectoris had acupuncture while cardiological, neurophysiological and psychological observations were made in a mutually independent manner. Needling was found to improve the working capacity of the heart. In addition, acupuncture was found to activate cardiovascular autoregulatory mechanisms in 24 healthy persons.

To evaluate the effect of acupuncture in daily life, a controlled trial group of 69 patients with severe angina pectoris were followed for 2 years after treatment. The incidence of cardiac death or myocardial infarction was 7%, compared to 15–21% for the control group of published results concerning invasive treatments. Due to clinical improvement, surgery was postponed in 61% of the patients. The annual number of in-hospital days was reduced by 90%, leading to a US$ 12,000 saving for each patient.

Protocol: Testing the Relevance of Acupuncture Theory in the Treatment of Myofascial Pain in the Upper Trapezius Muscle

A protocol for a prospective single-blind parallel four-arm randomized placebo-controlled trial with repeated measures was designed to test the effects of various acupuncture methods compared with sham. Eighty self-selected participants with myofascial pain in the upper trapezius muscle were randomized into four groups. Group 1 received acupuncture to a myofascial trigger point (MTrP) in the upper trapezius. Group 2 received acupuncture to the MTrP in addition to relevant distal points. Group 3 received acupuncture to the relevant distal points only. Group 4 received a sham treatment to both the MTrP and distal points using a deactivated acupuncture laser device. Treatment was applied four times within 2 weeks with outcomes measured throughout the trial and at 2 weeks and 4 weeks posttreatment. Outcome measurements were a 100-mm visual analog pain scale, SF-36, pressure pain threshold, Neck Disability Index, the Upper Extremity Functional Index, lateral flexion in the neck, McGill Pain Questionnaire, Massachusetts General Hospital Acupuncture Sensation Scale, Working Alliance Inventory (short form), and the Credibility Expectance Questionnaire. Two-way analysis of variance (ANOVA) with repeated measures were used to assess the differences between groups.

Acupuncture for chronic pain: individual patient data meta-analysis

BACKGROUND

Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.

METHODS

We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17 922 patients analyzed.

RESULTS

In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias.

CONCLUSIONS

Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.

Acupuncture for shoulder pain

BACKGROUND

There are many commonly employed forms of treatment for shoulder disorders. This review of acupuncture is one in a series of reviews of varying interventions for shoulder disorders including adhesive capsulitis (frozen shoulder), rotator cuff disease and osteoarthritis. Acupuncture to treat musculoskeletal pain is being used increasingly to confer an analgesic effect and to date its use in shoulder disorder has not been evaluated in a systematic review.

OBJECTIVES

To determine the efficacy and safety of acupuncture in the treatment of adults with shoulder pain.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL were searched from inception to December 2003, and reference lists from relevant trials were reviewed.

SELECTION CRITERIA

Randomised and quasi-randomised trials, in all languages, of acupuncture compared to placebo or another intervention in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica, cervically referred pain and fracture.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted trial and outcome data. For continuous outcome measures where the standard deviations were not reported it was either calculated from the raw data or converted from the standard error of the mean. If neither of these was reported, authors were contacted. Where results were reported as median and range, the trial was not included in the meta-analysis, but presented in Additional Tables. Effect sizes were calculated and combined in a pooled analysis if the study end-points population and intervention were homogenous. Results are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where possible, combined in meta-analysis to indicate effect of acupuncture across all shoulder disorders.

MAIN RESULTS

Nine trials of varying methodological quality met the inclusion criteria. For all trials there was poor description of interventions. Varying placebos were used in the different trials. Two trials assessed short-term success (post intervention) of acupuncture for rotator cuff disease and could be combined in meta analysis. There was no significant difference in short-term improvement associated with acupuncture when compared to placebo, but due to small sample sizes this may be explained by Type II error. Acupuncture was of benefit over placebo in improving the Constant Murley Score (a measure of shoulder function) at four weeks (WMD 17.3 (7.79, 26.81)). However, by four months, the difference between the acupuncture and placebo groups, whilst still statistically significant, was no longer likely to be clinically significant (WMD 3.53 (0.74, 6.32)). The Constant Murley Score is graded out of 100, hence a change of 3.53 is unlikely to be of substantial benefit. The results of a small pilot study demonstrated some benefit of both traditional and ear acupuncture plus mobilization over mobilization alone. There was no difference in adverse events related to acupuncture when compared to placebo, however this was assessed by only one trial

AUTHORS' CONCLUSIONS

Due to a small number of clinical and methodologically diverse trials, little can be concluded from this review. There is little evidence to support or refute the use of acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function. There is a need for further well designed clinical trials.

Physiotherapy interventions for shoulder pain

BACKGROUND

The prevalence of shoulder disorders has been reported to range from seven to 36% of the population (Lundberg 1969) accounting for 1.2% of all General Practitioner encounters in Australia (Bridges Webb 1992). Substantial disability and significant morbidity can result from shoulder disorders. While many treatments have been employed in the treatment of shoulder disorders, few have been proven in randomised controlled trials. Physiotherapy is often the first line of management for shoulder pain and to date its efficacy has not been established. This review is one in a series of reviews of varying interventions for shoulder disorders, updated from an earlier Cochrane review of all interventions for shoulder disorder.

OBJECTIVES

To determine the efficacy of physiotherapy interventions for disorders resulting in pain, stiffness and/or disability of the shoulder.

SEARCH STRATEGY

MEDLINE, EMBASE, the Cochrane Clinical Trials Regiter and CINAHL were searched 1966 to June 2002. The Cochrane Musculoskeletal Review Group's search strategy was used and key words gained from previous reviews and all relevant articles were used as text terms in the search.

SELECTION CRITERIA

Each identified study was assessed for possible inclusion by two independent reviewers. The determinants for inclusion were that the trial be of an intervention generally delivered by a physiotherapist, that treatment allocation was randomised; and that the study population be suffering from a shoulder disorder, excluding trauma and systemic inflammatory diseases such as rheumatoid arthritis.

DATA COLLECTION AND ANALYSIS

The methodological quality of the included trials was assessed by two independent reviewers according to a list of predetermined criteria, which were based on the PEDro scale specifically designed for the assessment of validity of trials of physiotherapy interventions. Outcome data was extracted and entered into Revman 4.1. Means and standard deviations for continuous outcomes and number of events for binary outcomes were extracted where available from the published reports. All standard errors of the mean were converted to standard deviation. For trials where the required data was not reported or not able to be calculated, further details were requested from first authors. If no further details were provided, the trial was included in the review and fully described, but not included in the meta-analysis. Results were presented for each diagnostic sub group (rotator cuff disease, adhesive capsulitis, anterior instability etc) and, where possible, combined in meta-analysis to give a treatment effect across all trials.

MAIN RESULTS

Twenty six trials met inclusion criteria. Methodological quality was variable and trial populations were generally small (median sample size = 48, range 14 to 180). Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43) respectively). There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis. When compared to exercises, ultrasound is of no additional benefit over and above exercise alone. There is some evidence that for rotator cuff disease, corticosteroid injections are superior to physiotherapy and no evidence that physiotherapy alone is of benefit for Adhesive Capsulitis

REVIEWER'S CONCLUSIONS

The small sample sizes, variable methodological quality and heterogeneity in terms of population studied, physiotherapy intervention employed and length of follow up of randomised controlled trials of physiotherapy interventions results in little overall evidence to guide treatment. There is evidence to support the use of some interventions in specific and circumscribed cases. There is a need for trials of physiotherapy interventions for specific clinical conditions associated with shoulder pain, for shoulder pain where combinations of physiotherapy interventions, as well as, physiotherapy interventions as an adjunct to other, non physiotherapy interventions are compared. This is more reflective of current clinical practice. Trials should be adequately powered and address key methodological criteria such as allocation concealment and blinding of outcome assessor.

Corticosteroid injections for shoulder pain

BACKGROUND

While many treatments, including corticosteroid injections in and around the shoulder, are advocated to be of benefit for shoulder pain, few are of proven efficacy. This review of corticosteroid injections for shoulder pain is one in a series of reviews of varying interventions for shoulder disorders.

OBJECTIVES

To determine the efficacy and safety of corticosteroid injections in the treatment of adults with shoulder pain.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, Central and Science Citation Index were searched up to and including June 2002.

SELECTION CRITERIA

Randomised and pseudo-randomised trials in all languages of corticosteroid injections compared to placebo or another intervention, or of varying types and dosages of steroid injection in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica and fracture.

DATA COLLECTION AND ANALYSIS

Trial inclusion and methodological quality was assessed by two independent reviewers according to predetermined criteria. Results are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where possible, combined in meta-analysis.

MAIN RESULTS

Twenty-six trials met inclusion criteria. The number, site and dosage of injections varied widely between studies. The number of participants per trial ranged from 20 to 114 (median 52 participants). Methodological quality was variable. For rotator cuff disease, subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no benefit of subacromial steroid injection over NSAID was demonstrated based upon the pooled results of three trials. For adhesive capsulitis, two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling of any of the trials. One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term (success at seven weeks RR=1.66 (1.21, 2.28).

REVIEWER'S CONCLUSIONS

Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. There is a need for further trials investigating the efficacy of corticosteroid injections for shoulder pain. Other important issues that remain to be clarified include whether the accuracy of needle placement, anatomical site, frequency, dose and type of corticosteroid influences efficacy.

Effect of transcutaneous electrical nerve stimulation for pain relief on patients undergoing hemorrhoidectomy: prospective, randomized, controlled trial

PURPOSE

Posthemorrhoidectomy pain control remains a challenging problem. Transcutaneous electrical nerve stimulation is known to be effective in the treatment of many diseases. Our aim was to investigate the effect of transcutaneous electrical nerve stimulation on pain relief in patients undergoing hemorrhoidectomy.

METHODS

Sixty patients with symptomatic hemorrhoids were randomly allocated into two groups, the acupoint group (n = 30) and the nonpoint control group (n = 30). Transcutaneous electrical nerve stimulation was applied to those patients who received hemorrhoidectomy, and patient-controlled analgesia was achieved by injection of morphine through ambulatory infusion pumps. The dependent measures in this study were pain score from 0 (no pain) to 10 (agonizing pain), analgesic doses administrated through patient-controlled analgesia, and postoperative complications.

RESULTS

The subjective pain scores evaluated 8, 12, 16, and 24 hours after hemorrhoidectomy in the control group and the acupoint group were 5.9 +/- 0.5 and 4.1 +/- 0.5, 5.7 +/- 0.5 and 3.5 +/- 0.4, 4.1 +/- 0.4 and 2.3 +/- 0.3, and 3.2 +/- 0.4 and 1.9 +/- 0.2, respectively (two-way analysis of variance; P < 0.05). There was a significant difference between treatment groups in morphine use, with 11.6 +/- 2.2 mg in the control group and 6.2 +/- 1.3 mg in the acupoint group (P < 0.05). The acupoint group tended to have less postoperative acute urinary retention (Fisher's exact probability test; P = 0.145) and less need for analgesics than the control group (P = 0.112, Fisher's exact test).

CONCLUSION

Transcutaneous electrical nerve stimulation is effective for pain relief in patients receiving hemorrhoidectomy. Its efficacy and safety could assist outpatient pain management after hemorrhoidectomy.

Acupuncture and chronic pain: a criteria-based meta-analysis

A literature search revealed 51 controlled clinical studies on the effectiveness of acupuncture in chronic pain. These studies were reviewed using a list of 18 predefined methodological criteria. A maximum of 100 points for study design could be earned in four main categories: (a) comparability of prognosis, (b) adequate intervention, (c) adequate effect measurement and (d) data presentation. The quality of even the better studies proved to be mediocre. No study earned more than 62% of the maximum score. The results from the better studies (greater than or equal to 50% of the maximum score) are highly contradictory. The efficacy of acupuncture in the treatment of chronic pain remains doubtful.

A placebo-controlled trial of steroid injections in the treatment of supraspinatus tendonitis

In this report of a double-blind placebo-controlled trial of steroid injections for supraspinatus tendonitis, there was no statistical difference in the improvement in pain score between the two groups at 2 and 8 weeks of follow-up or in analgesic consumption. This trial casts further doubt on the efficacy of such treatment in soft tissue lesions around the shoulder.