Overview of Treatment Guidelines and Clinical Practical Guidelines That Recommend the Use of Acupuncture: A Bibliometric Analysis

Provider Identified Access Barriers to Delivering Acupuncture to Persons with Traumatic Brain Injury and Chronic Pain: A Cross-Sectional Self-Report Survey

Objective: Traumatic brain injury (TBI) clinical practice guidelines for pain management and rehabilitation support the use of nonpharmacologic complementary and integrative health (CIH) modalities, such as acupuncture for remediating pain. Barriers to delivering CIH modalities, such as acupuncture warrant examination. The objective of this study is to explore provider perspectives on challenges to accessing acupuncture treatment for chronic pain in persons with TBI and describe differences across health care settings. Setting: Civilian, Veterans Affairs (VA), and Department of Defense health care systems. Participants: Health care providers (n = 145) were recruited from November 2022 to March 2023 via email through professional organizations and health care systems. Design: Descriptive cross-sectional self-report online survey. Main Measures: A survey assessed barriers using a 5-point Likert scale (always a barrier to never a barrier) using the Levesque Access to Care framework. Results: Of the 137 participants who provided information on setting, 86 (63%) worked in civilian health care; 47 (34%) worked in the Department of VA; and 4 (2.6%) in the Department of Defense (8 were missing data). Overall, providers endorsed all ten items as being barriers to accessing acupuncture treatment. However, these barriers were more statistically more frequently reported for civilian providers compared with VA providers for six of the 10 items, including lack of caregiver support (p < 0.0001); own knowledge and understanding of the treatment (p = 0.0025); health care setting culture discourages the treatment (p = 0.0181); lack of qualified providers (p = 0.0467); insurance does not cover (p < 0.0001), and patient cannot afford (p < 0.0001). VA provider respondents were more likely to answer all six items, as "Rarely/Never a Barrier," while providers in a civilian setting were more likely to respond "Always/Frequently" or "Sometimes" a barrier. Conclusion: Results reflect the cultural, organizational, and structural differences that make acupuncture more accessible within the VA. understanding barriers to delivering care is critical to inform implementation strategy mapping efforts, to tailor strategies that are aimed to increase access and engagement with acupuncture treatment in civilian health care settings.

Exploring the Analgesic Effect of Acupuncture on Knee Osteoarthritis Based on MLT/cAMP/PKA/CREB Signaling Pathway

Background

Acupuncture is an effective treatment for knee osteoarthritis (KOA), reducing pain and improving function. While melatonin (MLT) has notable pain relief benefits, the analgesic mechanism of acupuncture in KOA and its relationship with melatonin are still unknown. This study aims to explore this mechanism.

Methods

In this work, the KOA rabbit model was constructed using the traditional Hulth method, and the therapeutic effect was assessed by the Lequesne MG score and Pain assessment by hot plate test. The pathological alterations of cartilage tissue were observed using hematoxylin and eosin (H&E) staining, Safranin O-fast green and MASSON staining to observe the pathological changes in cartilage tissue, and the efficacy was evaluated according to the principles of Mankin score and Osteoarthritis Research Society International (OARSI) score. Meanwhile, MLT in serum, cyclic adenosine monophosphate (cAMP) in cartilage, and matrix metalloproteinase-3 (MMP-3) in joint fluid were detected by enzyme-linked immunosorbent assay. In addition, the expression of aromatic L-amino acid N-acetyltransferase (AANAT), melatonin receptor 1 (MT1) and 2 (MT2) mRNAs in cartilage was determined by real-time quantitative reverse transcription-polymerase chain reaction, and the levels of proteins related to PKA/CREB signaling pathway were detected by Western blotting.

Results

Based on the results of Lequesne MG score and Pain assessment by hot plate test experimental data, the treatment group presented significant improvements in knee pain and overall function relative to OA (Osteoarthritis) group. Besides, according to results of histologic staining, Mankin and OARSI scores, articular cartilage degeneration of treatment group remarkably improved. In addition, acupuncture significantly reduced the expression of the inflammatory factor MMP-3 in knee joint fluid and significantly increased the levels of MLT, AANAT, MT1, MT2, cAMP, PKA and CREB.

Conclusion

By regulating sympathetic excitability, acupuncture may activate the MLT/cAMP/PKA/CREB signaling pathway, decrease inflammatory factor expression and slow down degradation of articular cartilage, resulting in the relief of knee pain.

Effectiveness and safety of acupuncture for melasma: A meta-analysis of randomized controlled trials

BACKGROUND

Treating melasma remains challenging. We conducted a meta-analysis to assess the effectiveness and safety of acupuncture as a treatment option.

METHODS

We searched three English and four Chinese databases up to January 2, 2024. The primary outcome was the total effective rate, while secondary outcomes included skin lesion area and color scores, total lesion score, and adverse effects. Study quality was assessed using the risk of bias tool, and data were analyzed with Review Manager 5.4. The GRADE approach evaluated evidence certainty.

RESULTS

This study included 22 studies with 1644 participants. Findings indicate that acupuncture significantly outperforms Western medicine and other treatments (risk ratio [RR] = 1.21, 95 % confidence interval [CI] (1.18, 1.30), P < 0.00001, I² = 34 %). Acupuncture effectively reduces the area of skin lesions (mean difference [MD] = -0.35, 95 % CI (-0.52, -0.19), P < 0.0001, I² = 93 %), lightens color (MD = -0.45, 95 % CI (-0.58, -0.31), P < 0.00001, I² = 89 %), and lowers the total score of skin lesions (MD = -1.00, 95 % CI (-1.29, -0.70), P < 0.00001, I² = 79 %). Adverse reactions were infrequent with acupuncture. The most common needling sites were in the facial lesion area, noted in 17 studies. Sanyinjiao (SP6) was the most frequently used acupoint (n = 8), followed by Hegu (LI4) (n = 7) and Xuehai (SP10) (n = 7). Other commonly used acupoints included Tianshu (ST25), Zusanli (ST36), Taichong (LR3), and Zhongwan (RN12). All secondary outcomes, except for the primary outcome, were rated as very low quality.

CONCLUSION

This review confirms that acupuncture therapy effectively reduces the area and color of melasma lesions and lowers lesion scores. Acupuncture therapy appears to be a safe and effective treatment option for melasma; however, results should be interpreted cautiously due to potential publication and regional biases.

REGISTRATION

CRD42024503394.

Unraveling the neuroprotective potential of scalp electroacupuncture in ischemic stroke: A key role for electrical stimulation

This study aims to explore the neuroprotective effects of scalp Electroacupuncture (EA) on ischemic stroke, with a specific focus on the role of electrical stimulation (ES). Employing a rat model of middle cerebral artery occlusion (MCAO), we used methods such as Triphenyl tetrazolium chloride staining, micro-CT scanning, Enzyme linked immunosorbent assay (ELISA), and immunofluorescence to assess the impacts of EA. We further conducted RNA-seq analysis and in vitro experiments with organotypic brain slices and cerebral organoids to explore the underlying mechanisms. Our research revealed that EA notably reduced cerebral infarct volume and improved regional cerebral blood flow in rats following MCAO. Micro-CT imaging showed improved vascular integrity in EA-treated groups. Histological analyses, including HE staining, indicated reduced brain tissue damage. ELISA demonstrated a decrease in pro-inflammatory cytokines TNF-α, IL-1β, and IL-6, suggesting improved blood-brain barrier function. Immunofluorescence and Western blot analyses revealed that EA treatment significantly inhibited microglial and astrocytic overactivation. RNA-seq analysis of brain tissues highlighted a downregulation of immune pathways and inflammatory responses, confirming the neuroprotective role of EA. This was further corroborated by in vitro experiments using organotypic brain slices and cerebral organoids, which showcased the efficacy of electrical stimulation in reducing neuroinflammation and protecting neuronal cells. The study highlights the potential of scalp EA, particularly its ES component, in treating ischemic stroke. It provides new insights into the mechanisms of EA, emphasizing its efficacy in neuroprotection and modulation of neuroinflammation, and suggests avenues for optimized treatment strategies in stroke therapy.

Efficacy and Safety of Acupuncture for Restless Legs Syndrome in Patients with End-Stage Renal Disease: A Randomized-Controlled Trial at Hospital-Based Hemodialysis Center

Background: Restless legs syndrome (RLS) is frequent in patients with hemodialysis (HD) and occurs predominantly in its most severe forms. The study was conducted to evaluate the efficacy and safety of acupuncture for RLS in patients with end-stage renal disease (ESRD) at hospital-based HD center. Methods: This single-blind, randomized controlled trial was performed on patients with HD and RLS who were randomly assigned to the experimental group and control group. Data were collected using the International Restless Legs Syndrome Rating Scale (IRLSRS), Insomnia Severity Index (ISI), and heart rate variability (HRV) records at baseline, after the therapeutic course (12 times/4 weeks), and 1-week follow-up. Result: A total of 47 patients were evaluated with IRLSRS score from 11 to 30 in this study. There were 41 patients enrolled in the study based on inclusion/exclusion criteria and allocated randomly into two groups. A total of 35 participants completed the trial, including 18 subjects in the experimental group and 17 subjects in the control group. The comparison of IRLSRS and ISI showed a significant reduction between two groups after acupuncture treatment (p = 0.002, p = 0.003). The ISI after 1-week follow-up also revealed significant decrease (p = 0.003). This HRV results showed that high frequency (HF%) increased significantly (p = 0.021) and low frequency (LF%) decreased significantly in the acupuncture group (p = 0.021). The generalized estimating equation showed that the IRLSRS improved by 2.902 points (p < 0.001) in the acupuncture group compared with the control group and by 1.340 points (p = 0.003) after 1-week follow-up. There were no adverse effects observed during HD in this study. Discussion: The authors conclude that acupuncture could effectively improve the symptoms of RLS significantly. The results from this study provide clinical evidence on the efficacy and safety of acupuncture to treat the patients with RLS at the HD center.

Knowledge Mapping and Global Trends in the Field of the Objective Structured Clinical Examination: Bibliometric and Visual Analysis (2004-2023)

BACKGROUND

The Objective Structured Clinical Examination (OSCE) is a pivotal tool for assessing health care professionals and plays an integral role in medical education.

OBJECTIVE

This study aims to map the bibliometric landscape of OSCE research, highlighting trends and key influencers.

METHODS

A comprehensive literature search was conducted for materials related to OSCE from January 2004 to December 2023, using the Web of Science Core Collection database. Bibliometric analysis and visualization were performed with VOSviewer and CiteSpace software tools.

RESULTS

Our analysis indicates a consistent increase in OSCE-related publications over the study period, with a notable surge after 2019, culminating in a peak of activity in 2021. The United States emerged as a significant contributor, responsible for 30.86% (1626/5268) of total publications and amassing 44,051 citations. Coauthorship network analysis highlighted robust collaborations, particularly between the United States and the United Kingdom. Leading journals in this domain-BMC Medical Education, Medical Education, Academic Medicine, and Medical Teacher-featured the highest volume of papers, while The Lancet garnered substantial citations, reflecting its high impact factor (to be verified for accuracy). Prominent authors in the field include Sondra Zabar, Debra Pugh, Timothy J Wood, and Susan Humphrey-Murto, with Ronaldo M Harden, Brian D Hodges, and George E Miller being the most cited. The analysis of key research terms revealed a focus on "education," "performance," "competence," and "skills," indicating these are central themes in OSCE research.

CONCLUSIONS

The study underscores a dynamic expansion in OSCE research and international collaboration, spotlighting influential countries, institutions, authors, and journals. These elements are instrumental in steering the evolution of medical education assessment practices and suggest a trajectory for future research endeavors. Future work should consider the implications of these findings for medical education and the potential areas for further investigation, particularly in underrepresented regions or emerging competencies in health care training.

Delphi study for developing a checklist of adverse events associated with acupotomy

BACKGROUND

Acupotomy, a more invasive procedure than acupuncture, involves the use of a thicker needle with an integrated knife at the tip, necessitating safety research. We aimed to define relevant adverse events (AEs) and create a standardized form of the ACUPOtomy-related AEs CHECKlist (ACUPOCHECK).

METHODS

Before conducting the Delphi process, a systematic review and pilot prospective study were conducted to gather information on previously reported AEs. Using these data, pilot versions of the ACUPOCHECK and Delphi questionnaires were developed. The Delphi questionnaire involved selecting types of AE for inclusion, establishing separate criteria for acupotomy-related AEs, and achieving a consensus on AE assessment. Thirteen Korean doctors with experience in acupotomy or AE research were recruited to participate in each Delphi round. Consensus was considered to have been reached if the critical value for the content validity ratio met or exceeded 0.538.

RESULTS

The final ACUPOCHECK was developed using four rounds of the Delphi method and one face-to-face consensus meeting. It included 12 local AEs (pain, hemorrhage, bruise, hematoma, edema, pruritus, rash, infection, nerve damage, dysesthesia, movement impairment, and pneumothorax) and 14 systemic AEs (disease aggravation, needle fatigue, sleepiness, procedural nausea, procedural vomiting, procedural headache, procedural dizziness, sweating, procedural shock, syncope, dyspnea, procedural pain, sleep disorder, and postprocedural infection). Separate criteria were established for pain, hemorrhage and bruising: pain was defined as pain that occurrs during daily activities and persists for longer than 72 h, hemorrhage as bleeding that continues for ≥ 3 min despite pressure application, and bruising as having a bruise with a diameter of ≥ 3 cm. Open-ended descriptions were allowed for AEs not covered by the checklist, and severity and causality were assessed using the Common Terminology Criteria for Adverse Events and modified World Health Organization-Uppsala Monitoring Center criteria.

CONCLUSION

ACUPOCHECK provides a standardization framework that can help research on traditional practices as well as new tools and techniques that are more invasive and may cause more severe AEs. Subsequent studies will use ACUPOCHECK to develop rational safety guidelines for acupotomy techniques. Please cite this article as: Jun H, Lee H, Yoon SH, Kwon CY, Jeon D, Lee JH, Leem J. Delphi study for developing a checklist of adverse events associated with acupotomy. J Integr Med. 2024; 22(5): 579-587.

A review of the WHO strategy on traditional, complementary, and integrative medicine from the perspective of academic consortia for integrative medicine and health

Despite important progress in modern medicine, widely regarded as an indispensable foundation of healthcare in all highly advanced nations and regions, not all patients respond well to available treatments in biomedicine alone. Additionally, there are concerns about side effects of many medications and interventions, the unsustainable cost of healthcare and the low resolution of chronic non-communicable diseases and mental disorders whose incidence has risen in the last decades. Besides, the chronic stress and burnout of many healthcare professionals impairs the therapeutic relationship. These circumstances call for a change in the current paradigm and practices of biomedicine healthcare. Most of the world population (80%) uses some form of traditional, complementary, and integrative medicine (T&CM), usually alongside biomedicine. Patients seem equally satisfied with biomedicine and T&CM, but in the field of T&CM there are also many challenges, such as unsupported claims for safety and/or efficacy, contamination of herbal medicines and problems with regulation and quality standards. As biomedicine and T&CM seem to have different strengths and weaknesses, integration of both approaches may be beneficial. Indeed, WHO has repeatedly called upon member states to work on the integration of T&CM into healthcare systems. Integrative medicine (IM) is an approach that offers a paradigm for doing so. It combines the best of both worlds (biomedicine and T&CM), based on evidence for efficacy and safety, adopting a holistic personalized approach, focused on health. In the last decades academic health centers are increasingly supportive of IM, as evidenced by the foundation of national academic consortia for integrative medicine in Brazil (2017), the Netherlands (2018), and Germany (2024) besides the pioneering American consortium (1998). However, the integration process is slow and sometimes met with criticism and even hostility. The WHO T&CM strategies (2002-2005 and 2014-2023) have provided incipient guidance on the integration process, but several challenges are yet to be addressed. This policy review proposes several possible solutions, including the establishment of a global matrix of academic consortia for IM, to update and extend the WHO T&CM strategy, that is currently under review.

Reporting quality of acupuncture overviews: A methodological investigation based on the PRIOR statement

OBJECTIVE

Acupuncture overviews are increasing rapidly; however, their reporting quality is yet unclear. We aimed to investigate the reporting quality of relevant overviews according to the preferred reporting items for overviews of reviews (PRIOR) statement.

METHODS

We systematically searched PubMed from inception to August 16, 2022 for overviews on acupuncture therapies. Reporting quality of included overviews was evaluated using the PRIOR statement, and the results were cross-checked. Multiple linear regression analysis was used to assess the predictors of the reporting completeness. GraphPad 9.4 was utilized to generate an evidence map, Excel 2019 was used to extract and manage data, and R 4.2.3 was used for data analysis.

RESULTS

A total of 49 overviews published from 2006 to 2022 were included, of which China ranked first with 38 overviews. The most frequently searched database was PubMed/ Medline (n = 48, 98%), and commonly used methodological quality assessment tool was AMSTAR-2 (n = 14, 29%). The overarching themes centered on acupuncture for obstetrics, gynecology, reproductive diseases, as well as depression, anxiety, and insomnia. Reporting quality needs to be improved involving the definition of systematic reviews (SRs), overlap of primary studies and SRs, methods for managing discrepant data across SRs, risk of bias in primary studies, heterogeneity, and sensitivity analysis of synthesized results, reporting bias assessment, and registration and protocol. Moreover, publication in recent years and receiving funding support were significantly associated with higher overall reporting quality score (P < 0.05).

CONCLUSION

Based on the PRIOR statement, this methodological study indicates that the reporting quality of the included acupuncture overviews is poor. In the future, authors of overviews are encouraged to use the PRIOR statement for standardized reporting. Furthermore, it is recommended that journal editors mandate the inclusion of this statement in authors' reports and require a complete PRIOR checklist.

Exploring the gap: attitudes, knowledge, and training needs in complementary and integrative medicine among healthcare professionals at German university hospitals

Introduction

The use of Complementary and Integrative Medicine (CIM) is very popular among the general population in Germany. However, international studies show that nurses, physicians, and other health care professionals (HCPs) at hospitals often do not feel sufficiently informed about different CIM approaches. Moreover, they do not feel trained enough to counsel their patients appropriately. In the German-speaking context, particularly within university hospitals, research on this subject is scarce. Therefore, the aim of this explorative study was to evaluate attitudes, subjective knowledge, and needs regarding CIM among HCPs with direct patient interaction across all four university hospitals in the federal state of Baden-Württemberg, Germany (Tübingen, Ulm, Freiburg, Heidelberg).

Methods

The multicenter, cross-sectional, anonymous full survey was conducted online using a self-developed, semi-structured, web-based questionnaire. Recruitment took place via all-inclusive e-mail distribution lists of all four university hospitals.

Results

A total of n = 2,026 participants (response rate varied by location from about 5 to 14%) fully answered the questionnaire. Nurses constituted the largest professional group (n = 1,196; 59%), followed by physicians (n = 567; 28%), physiotherapists (n = 54), psychologists (n = 48), midwives (n = 37), and other professions (n = 124). More than two-thirds (71%, n = 1,437) of the participants were female and 14% (n = 286) reported additional training in CIM. The overall attitude toward CIM (10-point Likert scale, 10 = "very favorable") was clearly positive (M ± SD: 7.43 ± 2.33), with notable differences between professional groups: midwives (9.05 ± 1.18), physiotherapists (8.44 ± 1.74), and nurses (8.08 ± 1.95) expressed the highest support, whereas physicians (5.80 ± 2.39) the lowest. 42% of the participants incorporated CIM in patient care (from 33% of physicians to 86% of midwives). Overall, relaxation therapy (n = 1,951; 96%), external applications (n = 1,911; 94%), massage (n = 1,836; 91%), and meditation/mindfulness (n = 1,812; 89%) were rated as useful or rather useful for patients. The average self-assessed knowledge level about CIM was moderate (M ± SD: 5.83 ± 2.03). Most of the participants found CIM training at university hospitals important and saw research about CIM as one of the tasks of university hospitals. The participants expressed the highest interest in education for acupuncture/acupressure, relaxation therapies, and manual medicine.

Discussion

This comprehensive survey of health care professionals (HCPs) at university hospitals in Germany reveals a clearly positive disposition toward CIM, aligning with findings from other hospital-based surveys and highlighting differences among professional groups. While most therapies deemed beneficial for patient care are supported by positive evidence, further research is required for others. Given the average self-reported knowledge of CIM, targeted education is essential to meet the needs of both HCPs and patients and to ensure the provision of evidence-based information on the risks and benefits of CIM.

Mobilizing endogenous neuroprotection: the mechanism of the protective effect of acupuncture on the brain after stroke

Given its high morbidity, disability, and mortality rates, ischemic stroke (IS) is a severe disease posing a substantial public health threat. Although early thrombolytic therapy is effective in IS treatment, the limited time frame for its administration presents a formidable challenge. Upon occurrence, IS triggers an ischemic cascade response, inducing the brain to generate endogenous protective mechanisms against excitotoxicity and inflammation, among other pathological processes. Stroke patients often experience limited recovery stages. As a result, activating their innate self-protective capacity [endogenous brain protection (EBP)] is essential for neurological function recovery. Acupuncture has exhibited clinical efficacy in cerebral ischemic stroke (CIS) treatment by promoting the human body's self-preservation and "Zheng Qi" (a term in traditional Chinese medicine (TCM) describing positive capabilities such as self-immunity, self-recovery, and disease prevention). According to research, acupuncture can modulate astrocyte activity, decrease oxidative stress (OS), and protect neurons by inhibiting excitotoxicity, inflammation, and apoptosis via activating endogenous protective mechanisms within the brain. Furthermore, acupuncture was found to modulate microglia transformation, thereby reducing inflammation and autoimmune responses, as well as promoting blood flow restoration by regulating the vasculature or the blood-brain barrier (BBB). However, the precise mechanism underlying these processes remains unclear. Consequently, this review aims to shed light on the potential acupuncture-induced endogenous neuroprotective mechanisms by critically examining experimental evidence on the preventive and therapeutic effects exerted by acupuncture on CIS. This review offers a theoretical foundation for acupuncture-based stroke treatment.

Global trends of acupuncture clinical research on analgesia from 2010 to 2023: a bibliometric and visualization analysis

Objective

Acupuncture, acknowledged as a potent non-pharmacological therapy, is frequently employed to alleviate pain. Despite its widespread use, there has been a lack of overarching bibliometric analysis of clinical research on acupuncture analgesia. We aimed to summarize current patterns, hotspots, and development trends in this field through bibliometric analysis.

Methods

This study evaluates academic publications retrieved from the Web of Science database (2010.01-2023.09) concerning acupuncture analgesia in clinical settings. All primary and secondary studies on humans were included. To track global developmental trends, we employed several software for analyzing annual publication volumes, countries/regions, institutions, authors, cited authors, journals, cited journals, references, and keywords and to draw collaborative networks and reference co-citation network maps.

Results

The final search encompassed 7,190 relevant studies, including 1,263 randomized controlled trials (RCTs) and 1,293 systematic reviews and meta-analyses. The results indicated a gradual increase in the number of annual publications on acupuncture analgesia in clinical practice. Among countries and institutions, China (2,139) and Chengdu University of Traditional Chinese Medicine (258) ranked first. Liang FR (89 articles) was the most prolific author, while MacPherson H (604) was the most cited author. MEDICINE (455) was the most productive journal, and Pain (2,473/0.20) ranked first in both the frequency and centrality of cited journals. Notably, the most frequently cited reference was a systematic review of individual patient data on acupuncture carried out for chronic pain that was published by Vickers Andrew J in 2012 (156). Burst analysis identified frontier research areas for 2010-2020, encompassing network meta-analysis, case reports, dry needling, lumbar disc herniation, cancer, post-herpetic neuralgia, insomnia, and bibliometric analysis.

Conclusion

This study outlines current trends and potential future research hotspots in clinical acupuncture analgesia over the past decade. Findings emphasize the necessity for enhanced international collaboration to improve research output and translation.

Heat and Acupuncture to Manage Osteoarthritis of the Knee (HARMOKnee): Protocol for an Effectiveness-Implementation Hybrid Randomized Controlled Trial

BACKGROUND

Knee osteoarthritis (KOA) is one of most prevalent and fastest-growing causes of pain, impaired mobility, and poor quality of life in the rapidly aging population worldwide. There is a lack of high-quality evidence on the efficacy of traditional Chinese medicine (TCM), particularly acupuncture, and a lack of KOA practice guidelines that are tailored to unique population demographics and tropical climates.

OBJECTIVE

Our HARMOKnee (Heat and Acupuncture to Manage Osteoarthritis of the Knee) trial aims to address these gaps by evaluating the short- and medium-term clinical and cost-effectiveness of acupuncture with heat therapy in addition to standard care, compared to standard care alone. Through a robust process and economic evaluation, we aim to inform evidence-based practice for patients with KOA to facilitate the large-scale implementation of a comprehensive and holistic model of care that harmonizes elements of Western medicine and TCM. We hypothesize that acupuncture with heat therapy as an adjunct to standard care is clinically more effective than standard care alone.

METHODS

A multicenter, pragmatic, parallel-arm, single-blinded, effectiveness-implementation hybrid randomized controlled trial will be conducted. We intend to recruit 100 patients with KOA randomized to either the control arm (standard care only) or intervention arm (acupuncture with heat therapy, in addition to standard care). The inclusion criteria are being a community ambulator and having primary KOA, excluding patients with secondary arthritis or previous knee replacements. The primary outcome measure is the Knee Osteoarthritis Outcome Score at 6 weeks. Secondary outcome measures include psychological, physical, quality of life, satisfaction, and global outcome measures at 6, 12, and 26 weeks. A mixed method approach through an embedded process evaluation will facilitate large-scale implementation. An economic evaluation will be performed to assess financial sustainability.

RESULTS

Patient enrollment has been ongoing since August 2022. The recruitment process is anticipated to conclude by July 2024, and the findings will be analyzed and publicized as they are obtained. As of November 6, 2023, our patient enrollment stands at 65 individuals.

CONCLUSIONS

The findings of our HARMOKnee study will contribute substantial evidence to the current body of literature regarding the effectiveness of acupuncture treatment for KOA. Additionally, we aim to facilitate the creation of standardized national guidelines for evidence-based practice that are specifically tailored to our unique population demographics. Furthermore, we seek to promote the adoption and integration of acupuncture and heat therapy into existing treatment models.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05507619; https://clinicaltrials.gov/study/NCT05507619.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54352.

Characteristics and Challenges of Providing Acupuncture and Chinese Herbal Medicine in Oncology Treatment: Report of Survey Data and Experience of Five Unique Clinical Settings

Acupuncture is an integrative therapy with strong evidence to support its use in the oncology setting, yet barriers exist for implementation into conventional medical clinics. Though acupuncture is recommended in clinical practice guidelines for oncology, there is little data in the literature showing how acupuncture and other related therapies, including herbal medicine are successfully implemented in some oncology clinics, while others experience barriers to care. To characterize the current use of acupuncture (ACU) and herbal medicine (HM) in oncology clinics, we collected general demographic and usage data from 5 example clinics. In addition, to better understand the barriers faced by ACU and HM clinics in implementing acupuncture as a treatment modality, a survey was deployed to 2320 members of the Society for Integrative Oncology. This article examines the characteristics of oncology settings around the world, and shares data from the survey on the use of these therapies in the field of oncology. The primary barrier to acupuncture care, as reported by providers, was cost. With just under 70% of the oncologists reporting it as the most important obstacle. Additional barriers to implementation included concerns about competency and training, accessibility and safety of herbal medicine during treatment. Though acupuncture is being incorporated into more conventional oncology settings, organized strategies for implementation involving payers and policymakers is needed.

Peripheral Activation of Formyl Peptide Receptor 2/ALX by Electroacupuncture Alleviates Inflammatory Pain by Increasing Interleukin-10 Levels and Catalase Activity in Mice

In the context of the electroacupuncture (EA) neurobiological mechanisms, we have previously demonstrated the involvement of formyl peptide receptor 2 (FPR2/ALX) in the antihyperalgesic effect of EA. The present study investigated the involvement of peripheral FPR2/ALX in the antihyperalgesic effect of EA on inflammatory cytokines levels, oxidative stress markers and antioxidant enzymes in an animal model of persistent inflammatory pain. Male Swiss mice underwent intraplantar (i.pl.) injection with complete Freund's adjuvant (CFA). Mechanical hyperalgesia was assessed with von Frey monofilaments. Animals were treated with EA (2/10 Hz, ST36-SP6, 20 minutes) for 4 consecutive days. From the first to the fourth day after CFA injection, animals received i.pl. WRW4 (FPR2/ALX antagonist) or saline before EA. Levels of inflammatory cytokines (TNF, IL-6, IL-4 and IL-10), antioxidant enzymes (catalase and superoxide dismutase), oxidative stress markers (TBARS, protein carbonyl, nitrite/nitrate ratio), and myeloperoxidase activity were measured in paw tissue samples. As previously demonstrated, i.pl. injection of the FPR2/ALX antagonist prevented the antihyperalgesic effect induced by EA. Furthermore, animals treated with EA showed higher levels of IL-10 and catalase activity in the inflamed paw, and these effects were prevented by the antagonist WRW4. EA did not change levels of TNF and IL-6, SOD and MPO activity, and oxidative stress markers. Our work demonstrates that the antihyperalgesic effect of EA on CFA-induced inflammatory pain could be partially associated with higher IL-10 levels and catalase activity, and that these effects may be dependent, at least in part, on the activation of peripheral FPR2/ALX.

Factors influencing the quality of acupuncture clinical trials: a qualitative interview of stakeholders

OBJECTIVE

To investigate the influencing factors on the quality of acupuncture clinical trials from the stakeholders, and to provide references for improving the quality of acupuncture clinical trials.

METHODS

A qualitative study based on semi-structured interviews was performed. Experts, acupuncturists, editors, and patients were interviewed. The interview results were thematically analyzed from transcribed audio recordings.

RESULTS

A total of 38 stakeholders were interviewed, including 12 experts, 14 acupuncturists, 2 editors, and 10 patients. There were 25 tree nodes and 106 sub-nodes, with 1141 reference points. The key factors influencing the quality of acupuncture clinical trials could be divided into five core theme frameworks: a) trial design, b) trial conduction, c) research results reporting and publication, d) research evidence dissemination, and e) research evidence transformation and application.

CONCLUSIONS

The results reveal that to improve the quality of acupuncture trials, it should consider each step of trial design, trial conduction, research results reporting and publication, research evidence dissemination, and research evidence transformation and application. A guideline for quality control of the whole process of acupuncture clinical trials is needed.

Cross-Sectional Survey of Acupuncturists in the United States Who Prescribed Chinese Herbal Medicine for Patients with Symptoms Likely Related to COVID-19

Objective: The objective of this study was to examine the prescribing of Chinese herbal medicine (CHM) by licensed acupuncturists in the United States during the COVID-19 pandemic. Methods: A 28-question survey with nine branching questions was disseminated through collegial networks, paid advertisements, and a study website in April-July 2021. Participants indicated that they were licensed acupuncturists who treated more than five patients for symptoms likely related to COVID-19 to gain entry to the full survey. Surveys were undertaken electronically through the Research Electronic Data Capture (REDCap) system. Results: The survey was undertaken by 103 participants representing all US geographic regions and had an average of 17 years in practice. Sixty-five percent received or intended to receive the COVID-19 vaccine. Phone and videoconference were the predominant methods of patient contact; granules and pill forms of CHM were the most prescribed. A wide variety of information sources were used in devising patient treatments inclusive of anecdotal, observational, and scientific sources. Most patients were not receiving biomedical treatment. Ninety-seven percent of participants reported that they had no patients die of COVID-19, and the majority reported that <25% of their patients developed long hauler syndrome (post-acute sequelae SARS-CoV-2 infection). Conclusions: This study demonstrates that licensed acupuncturists were treating COVID-19 infected individuals in the United States during the early stages of the pandemic, and for many such patients this was the only therapeutic intervention they had access to from a licensed health care provider. Information disseminated from China through collegial networks, along with published sources including scientific studies, informed the approach to treatment. This study provides insight into an unusual circumstance in which clinicians needed to establish evidence-based approaches to the treatment of a new disease during a public health emergency.

Delivery of acupuncture in clinical trials: Research acupuncturists’ perspectives

Delivery of acupuncture in the setting of a clinical trial is a unique practice that diverges significantly from the delivery of acupuncture in a real-world clinical setting. Research acupuncturists, particularly those trained in traditional Chinese medicine (TCM), are often required to set aside valued precepts of traditional care, including diagnosing imbalances, individualizing treatment, and forging a therapeutic relationship with patients. TCM-trained acupuncturists express mixed feelings about participating in clinical trials. Many are eager to play a vital role in the advancement of acupuncture science and appreciate the need for strict protocol adherence to minimize bias. However, the acupuncturist(s) may also have concerns about clinical trial methodology, including but not limited to the delivery of a control condition, e.g., sham acupuncture. Investigators should anticipate certain questions and even a level of resistance to the requirements of research among acupuncturists and be prepared to address them. This manuscript presents a brief review of the subjective experience of the research acupuncturist within the available scientific literature as it pertains to the delivery of active and sham clinical research protocols. Our goals are to better understand the perspectives of acupuncturists who may participate in clinical research, so that their concerns may be addressed in study design and methodology. To that end, we suggest the creation of a novel training program specifically for clinical trial acupuncturists, intended for qualified TCM- and Western-trained practitioners, that would help to standardize the research acupuncturist's role and help to strengthen the design and execution of acupuncture studies.

Acupuncture combined with repeated transcranial magnetic stimulation for upper limb motor function after stroke: A systematic review and meta-analysis

BACKGROUND

Upper limb motor dysfunction after stroke is an important factor affecting patients' motor function and daily life. Acupuncture and repetitive transcranial magnetic stimulation are effective methods for stroke rehabilitation. However, a systematic and comprehensive overview of the combined efficacy of the two is lacking.

OBJECTIVE

Through a systematic review and meta-analysis of randomized controlled trials, this study aimed to assess the effectiveness of acupuncture combined with repetitive transcranial magnetic stimulation on upper extremity motor function in post-stroke patients.

METHODS

The relevant randomized controlled trials on acupuncture combined with repetitive transcranial magnetic stimulation in the treatment of upper limb motor disorders after stroke were searched in PubMed, Embase, Cochrane Library, Web of Science CNKI, VIP, Wanfang, and CBM databases. After screening clinical trials that met the inclusion criteria, data extraction was conducted independently by two investigators. Meta-analysis was performed using RevMan 5.4 software.

RESULTS

After the screening, 18 articles were included, with a total of 1083 subjects. The results of meta-analysis showed that combination therapy could effectively improve the patients' upper limb motor function (MD = 7.77, 95%CI [6.32, 9.22], P < 0.05), ability of daily living (MD = 8.53, 95%CI [6.28, 10.79], P < 0.05), and hemiplegic shoulder pain (MD = - 1.72, 95%CI [- 2.26, - 1.18], P < 0.05). Meanwhile, for neurophysiological indexes, combined treatment could significantly shorten the latency of motor evoked potential and central motor conduction time (MD = - 1.42, 95%CI [- 2.14, - 0.71], P < 0.05); (MD = - 0.47, 95%CI [- 0.66, - 0.29], P < 0.05), and also could increase the amplitude of motor evoked potential (SMD = 0.71, 95%CI [0.28, 1.14], P < 0.05).

CONCLUSION

According to the results of the meta-analysis, we can conclude that acupuncture combined with repeated transcranial magnetic stimulation can significantly improve the upper limb motor function and daily living ability of stroke patients.

Doctors' and Nurses' Attitudes of Acupuncture and Acupressure use in Perioperative Care: An Australian National Survey

BACKGROUND

Acupuncture and acupressure are not being systematically used in the management of postoperative nausea and vomiting and pain, despite being included in the guidelines.

AIM

To examine the beliefs, attitudes, and knowledge of Australian nurses/midwives and doctors toward the perioperative use of AA for the management of postoperative nausea and vomiting and pain; to explore the barriers and enablers influencing acupuncture and acupressure integration into hospital setting.

METHODS

A mixed-mode approach was undertaken for data collection. An online approach was used to recruit respondents from Australian College of Perioperative Nurses. Three hospitals from three different Australian states were selected via convenience sampling.

RESULTS

A total of 421 usable surveys were included in data analysis. The respondents comprised 14.3% doctors and 72.9% nurses/midwives. Overall, 69.4% were female, 85% were trained in Australia with 35% and 51.4% having knowledge or personal exposure to AA in general respectively. Over 60% of the respondents agreed AA should be routinely integrated into perioperative care, and over 80% would recommend AA to their patients if it was provided at their hospital, and, 75% would be willing to receive further education. The three main reported barriers included: perceived lack of scientific evidence (80.9%), unavailability of credentialed provider (77.2%) and lack of reimbursement (60.4%).

CONCLUSIONS

Positive attitudes are reported by Australian doctors and nurses toward AA. This is despite of low levels of knowledge or personal exposure to AA. Further studies are required to explore the implementation of barriers and address respondent calls for further education.

Quality assessment of Japanese clinical practice guidelines including recommendations for acupuncture

Background

The quality of clinical practice guidelines (CPGs) should be extensively evaluated. This study aimed to evaluate Japanese CPGs that include recommendations for acupuncture.

Methods

In a literature search, CPGs including recommendations for acupuncture published in Japan until October 2021 were sought. We assessed (1) whether the CPGs were developed in accordance with the Grading Recommendations Assessment, Development and Evaluation (GRADE) system, (2) the quality of the CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) II, and (3) whether the strength of the recommendations for acupuncture was consistent with each CPG's predefined procedure.

Results

Seventeen CPGs including 23 recommendations in total were identified and assessed. (1) Three CPGs were in accordance with the GRADE system. (2) The mean score of overall assessment using AGREE II was 4.5 on a 7-point Likert scale. The mean domain scores were 77% for domain 1 (scope and purpose), 54% for domain 2 (stakeholder involvement), 48% for domain 3 (rigor of development), 78% for domain 4 (clarity of presentation), 20% for domain 5 (applicability), and 51% for domain 6 (editorial independence). (3) The strength of the recommendations for acupuncture in two CPGs was judged to be underestimated. Some of the CPGs contained elementary problems that were not considered in AGREE II.

Conclusion

The methodological quality of Japanese CPGs including recommendations for acupuncture was not necessarily high. Since technical issues exist in each field of therapy, the respective experts should be involved in developing and reviewing CPGs to disseminate accurate health information.

Acupuncture as a post-stroke treatment option: A narrative review of clinical guideline recommendations

BACKGROUND

Acupuncture may be useful to treat the various clusters of symptoms occurring after a stroke. The use of evidence to underpin clinical practice and treatment guidelines (CPGs and TGs respectively) varies from country to country and may affect what recommendations are made by guideline developers.

PURPOSE

To examine the extent to which international clinical and treatment guidelines on post-stroke treatment mention the role of acupuncture and to identify what symptoms they recommend for its use.

METHOD

Scoping of national and international websites of CPGs and TGs r on the after care and rehabilitation of stroke patients provided by professional and government organisations was conducted. The presence/absence of recommendations and the underpinning evidence was appraised for the use of acupuncture for symptoms following stroke.

RESULTS

Of 84 CPGs and TGs on post stroke after-care identified from 27 countries between 2001 and 2021, 49 made statements about acupuncture. Positive recommendations on the use of acupuncture were identified for 15 symptom areas from 11 countries for: stroke rehabilitation, dysphagia, shoulder pain, motor recovery, walking, balance, spasticity, upper limb extremity impairment, post-stroke pain, central post stroke pain, cognitive disorder, depression, and sleep problems. Thirty-five CPGs (2001-2018) from 18 countries published over the same period were identified that made no mention of acupuncture and therefore no recommendations were made on its use.

CONCLUSIONS

Currently, evidence used by international guideline developers varies and this influences whether a positive or negative recommendation is made. Recommendations to use acupuncture should be based on the best available evidence which has been quality appraised.

Discussion on Collection of Clinical Questions in International Clinical Practice Guidelines of Acupuncture-Moxibustion

The clinical questions of acupuncture-moxibustion (Acup-Mox) guidelines are complicated, including not only the curative effect of Acup-Mox intervention measures, but also the operational elements of Acup-Mox. This paper aimed to put forward the idea and process of collecting clinical questions in developing international acupuncture clinical practice guidelines. The experience was collected and the idea of collecting clinical questions of Acup-Mox was formed through expert consultation and discussion in combination with expert opinions. Based on the characteristics of Acup-Mox discipline. This paper put forward the thinking of collecting elements of clinical questions following the intervention-population-outcome-control (I-P-O-C) inquiry process, according to the discipline of Acup-Mox. It was emphasized that in the process of collecting clinical questions, "treatable population" and "alleviable outcome indicators" for a specific Acup-Mox intervention with certain therapeutic effect should be focused on, so as to highlight the pertinence of clinical questions of Acup-Mox guidelines in terms of population and outcome elements.

Acupuncture Analgesia in Patients With Traumatic Rib Fractures: A Randomized-Controlled Trial

Pain management for traumatic rib fracture is important to prevent complications and reduce associated comorbidities. This trial investigated the analgesic efficacy of acupuncture on traumatic rib fracture. Patients with traumatic rib fracture were randomly assigned to traditional acupuncture (TA), laser acupuncture (LA) or sham laser acupuncture (SLA) groups in a 1:1:1 ratio. The intervention was performed on days 1 to 3 after treatment allocation. The acupoints included bilateral LI4 (Hegu), SJ6 (Zhigou), ST36 (Zusanli) and GB34 (Yanglingquan). The primary outcome was Numeric Rating Scale (NRS) scores for pain after the intervention. Secondary outcomes included sustained maximal inspiration (SMI) lung volume, stress responses, the use of analgesics, and associated complications. Data were analyzed via one-way analysis of variance (ANOVA) with Scheffé's post hoc testing or chi-squared testing. Of the 120 study participants, 109 completed all interventions and measurements. The primary outcomes, which indicated average pain intensity levels and pain while deep breathing, were both significantly lower in the TA and LA groups than in the SLA group after 2 treatments. No between-group differences were observed in SMI lung volume, stress response, analgesics use or associated complications. These findings suggest that TA and LA are safe and effective analgesic modalities for pain management for traumatic rib fracture.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT03822273].

To Use or Not Use Complementary and Alternative Medicine (CAM) in Psychiatric Care: Interviews with Clinical Decision-Makers in Sweden

Complementary and alternative medicine (CAM) is used as a complementary intervention in psychiatric healthcare. The reasons for using or not using CAM in psychiatric care in Sweden, and how such decisions are taken, are largely unknown. The aim was to investigate arguments for and against the use of CAM in Swedish psychiatric care, and how decisions are made. Interviews with 10 persons in decision-making positions in psychiatric health care were analysed thematically. The result shows diverging understandings of the evidence base for CAM. Arguments against CAM referred to scepticism, the importance of evidence-based practice and the obligation to follow national guidelines. Arguments in favour of CAM were that CAM was person-centred, safe, cost-effective, nursing interventions with positive effects, appreciated and demanded by patients, providing space for non-verbal communication and reflection, supporting the therapeutic alliance. Decision paths were described as top-down through a hierarchical structure, or bottom-up, driven by committed staff members. We discuss how detailed national guidelines should be to achieve equal and evidence-based care, while still allowing clinics to make local exceptions, adjusting the care according to clinical expertise and patients' preferences. Conclusion: Evidence-based, safe and cost-effective CAM methods may be relevant complementary interventions in psychiatric care, or as self-care, not to cure the psychiatric disease, but to reduce symptoms and promote sleep. With better knowledge of CAM, health professionals could guide patients through the jungle of CAM methods. Due to research problems on complex multicomponent interventions, high-quality pragmatic trials, including biomarkers, and qualitative studies are recommended.

The changing clinical landscape in acupuncture for women's health: a cross-sectional online survey in New Zealand and Australia

Background

Acupuncture is a popular treatment for women’s health. Several trials and meta-analysis have been published in recent years on key women’s health conditions but it is unclear if this has led to any changes in clinical practice or referrals from other health professionals. The aim of this survey was to explore if, how, and why, aspects of acupuncture practice have changed since our survey in 2013.

Method

An online cross-sectional survey of registered acupuncturists and Chinese Medicine practitioners in Australia and New Zealand. Questions covered the practitioner demographics and training, women’s health conditions commonly treated, modalities used, sources of information and continuing education (CE) (e.g. webinars), changes in clinical practice, and referral networks.

Results

One hundred and seventy registered practitioners responded to this survey, with 93% reporting treating women’s health in the last 12 months. The majority of respondents were from Australia (60%), held a bachelors level qualification (60%), and used a traditional Chinese medicine framework (86%). Most practitioners incorporated other modalities in addition to acupuncture. Most practitioners’ referral networks were predominantly based on word of mouth for menstrual, fertility and pregnancy related conditions, with referrals from medical practitioners being much less common. More than half (57%) reported having changed their women’s health practice in the past 12 months; just over a quarter of those who changed treatment (27%) reported it was due to research findings. The most commonly used sources of information/CE used to inform treatment were webinars and conferences, while peer-reviewed journal articles were the least commonly used source.

Conclusion

Acupuncture practitioners in Australia and New Zealand commonly treat women’s health conditions, but this is usually the result of women seeking them out, rather than being referred from a medical practitioner. The majority of practitioners did report changing their women’s health practice, but peer reviewed academic articles alone are not an ideal medium to convey this information since practitioners favour knowledge obtained from webinars and conferences. Academics and other clinician researchers should consider alternative means of disseminating knowledge beyond traditional academic publications and conferences, special interest groups may assist in this and also help improve research literacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03576-3.

Electroacupuncture ameliorates neuroinflammation in animal models

Background:

Neuroinflammation refers to a wide range of immune responses occurring in the brain or spinal cord. It is closely related to a variety of neurodegenerative diseases, for which it potentially represents a new direction for treatment. Electroacupuncture (EA) is one method of acupuncture treatment, which can be used as an adjuvant therapy for many diseases. This review focuses on molecular mechanisms of EA in the reduction of neuroinflammation, summarizes relevant basic research and outlines future directions for investigation.

Findings:

A growing body of basic research has shown that EA can ameliorate neuroinflammation centrally (in animal models of ischemic stroke, Alzheimer’s disease, traumatic brain injury, spinal cord injury, Parkinson’s disease and vascular dementia) and peripherally (e.g. after a surgical insult or injection of lipopolysaccharide) and that its effects involve different molecular mechanisms, including activation of the α7 nicotinic acetylcholine receptor signaling pathway and P2 type purinergic receptors, inhibition of nuclear factor κB, and mitigation of damage secondary to oxidative stress and NOD-like receptor protein 3 inflammasome activation.

Conclusions:

EA is capable of regulating multiple cell signal transduction pathways to alleviate neuroinflammation in animal models. Although the findings of animal studies are encouraging, further prospective clinical trials are needed to verify the efficacy of EA for the treatment of neuroinflammation.

Acupuncture-related treatments improve cognitive and physical functions in Alzheimer's disease: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine acupuncture-related treatments' effects and duration on improving cognitive function, physical function, and quality of life in patients with Alzheimer's disease.

DATA SOURCES

Eight electronic databases were searched for eligible randomized controlled trials from database inception to January 2021, including Medline, PubMed, EBSCO, Embase, Cochrane, Airiti Library, China National Knowledge Infrastructure, and China Journal Full-text Database.

REVIEW METHODS

A systematic review and meta-analysis were conducted on acupuncture types, cognitive function, activity of daily life, muscle strength and quality of life.

RESULTS

Sixty-six studies in total with 4191 participants, the overall risk of bias was classified 60% as low and 24% as high. Acupuncture-related treatments for cognitive function and self-care ability revealed a moderate effect size, with a significant difference in noninvasive and invasive remedies (p < 0.001). Cognitive function showed significant differences in 6, 8, 12, and 24 weeks while self-care ability in the latter two weeks (p < 0.001). Meta-regression analysis showed cognitive function increased by 0.05 points (p = 0.002) and self-care ability decreased by 0.02 points (p = 0.04) after weekly treatment. There was a significant difference in muscle strength (p = 0.0003).

CONCLUSION

Acupuncture-related treatments effectively improved cognitive function with the treatment lasted 6 weeks at least, but self-care ability started showing effects after 12 weeks of treatment. The improvement of muscle strength was also confirmed. Acupuncture-related treatments, particularly noninvasive ones, have few complications and high safety, perhaps providing patients and caregivers diversified choices and clinical care guidelines for reference.

Strengthening the quality of clinical trials of acupuncture: a guideline protocol

INTRODUCTION

Acupuncture has been accepted in many Western countries and clinical trials have been increasing recently. However, the problems of insufficient and low-quality evidence remain, and substantially hinder the development of acupuncture clinical trials. We therefore aim to develop a guideline to strengthen the quality of acupuncture clinical trials, in accordance with WHO handbook for guideline development and the Reporting Items for practice Guidelines in HealThcare. The guideline will help to improve the quality of acupuncture clinical trials.

METHODS AND ANALYSIS

We will search for studies on the quality of acupuncture clinical trials using PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang Data, China Science and Technology Journal Database, The Cochrane Library, the WHO and Health Technology Assessment websites, and other sources. We will also check reference lists and contact experts in the field. We will systematically evaluate the quality of acupuncture clinical trials, and extract and summarise the quality problems and countermeasures of such trials. We will also systematically review clinical trial quality control manuals and systems and formulate research questions on quality control in acupuncture clinical trials. Finally, we will develop the guideline and establish a comprehensive quality control system to ensure high quality acupuncture clinical trials. We will also evaluate the guideline and will update the guideline to reflect new scientific evidence.

ETHICS AND DISSEMINATION

Ethics committee approval and informed consent are not required for developing guideline because only published data will be used, however, we will interview the patients, the ethics committee approval has been got from West China Hospital of Sichuan Unversity (Number: 2021-1188). We will publish all manuscripts arising from this research and present the findings at conferences.

GUIDELINE REGISTRATION NUMBER

IPGRP-2021CN093.

Low methodological quality of systematic reviews on acupuncture: a cross-sectional study

BACKGROUND

While well-conducted systematic reviews (SRs) can provide the best evidence on the potential effectiveness of acupuncture, limitations on the methodological rigour of SRs may impact the trustworthiness of their conclusions. This cross-sectional study aimed to evaluate the methodological quality of a representative sample of SRs on acupuncture effectiveness.

METHODS

Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE were searched for SRs focusing on the treatment effect of manual acupuncture or electro-acupuncture published during January 2018 and March 2020. Eligible SRs must contain at least one meta-analysis and be published in English language. Two independent reviewers extracted the bibliographical characteristics of the included SRs with a pre-designed questionnaire and appraised the methodological quality of the studies with the validated AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2). The associations between bibliographical characteristics and methodological quality ratings were explored using Kruskal-Wallis rank tests and Spearman's rank correlation coefficients.

RESULTS

A total of 106 SRs were appraised. Only one (0.9%) SR was of high overall methodological quality, zero (0%) was of moderate-quality, six (5.7%) and 99 (93.4%) were of low-quality and critically low-quality respectively. Among appraised SRs, only ten (9.4%) provided an a priori protocol, four (3.8%) conducted a comprehensive literature search, five (4.7%) provided a list of excluded studies, and six (5.7%) performed meta-analysis appropriately. Cochrane SRs, updated SRs, and SRs that did not search non-English databases had relatively higher overall quality.

CONCLUSIONS

Methodological quality of SRs on acupuncture is unsatisfactory. Future reviewers should improve critical methodological aspects of publishing protocols, performing comprehensive search, providing a list of excluded studies with justifications for exclusion, and conducting appropriate meta-analyses. These recommendations can be implemented via enhancing the technical competency of reviewers in SR methodology through established education approaches as well as quality gatekeeping by journal editors and reviewers. Finally, for evidence users, skills in SR critical appraisal remain to be essential as relevant evidence may not be available in pre-appraised formats.

Incorporating Acupuncture Into American Healthcare: Initiating a Discussion on Implementation Science, the Status of the Field, and Stakeholder Considerations

INTRODUCTION

The field of implementation science is the study of methods that promote the uptake of evidence-based interventions into healthcare policy and practice. While acupuncture has gained significant traction in the American healthcare landscape, its journey has been somewhat haphazard and non-linear.

METHODS

In June 2019, a group of thirty diverse stakeholders was convened by the Society for Acupuncture Research with the support of a Patient Centered Outcomes Research Institute, Eugene Washington Engagement Award. This group of stakeholders represented a diverse mix of patients, providers, academicians, researchers, funders, allied health professionals, insurers, association leaders, certification experts, and military program developers. The collective engaged in discussion that explored acupuncture's status in healthcare, including reflections on its safety, effectiveness, best practices, and the actual implementation of acupuncture as seen from diverse stakeholder viewpoints.

OBJECTIVES

A primary goal was to consider how to utilize knowledge from the field of implementation science more systematically and intentionally to disseminate information about acupuncture and its research base, through application of methods known to implementation science. The group also considered novel challenges that acupuncture may present to known implementation processes.

FINDINGS

This article summarizes the initial findings of this in-person meeting of stakeholders and the ongoing discussion among the subject matter experts who authored this report. The goal of this report is to catalyze greater conversation about how the field of implementation science might intersect with practice, access, research, and policymaking pertaining to acupuncture. Core concepts of implementation science and its relationship to acupuncture are introduced, and the case for acupuncture as an Evidence Based Practice (EBP) is established. The status of the field and current environment of acupuncture is examined, and the perspectives of four stakeholder groups--patients, two types of professional practitioners, and researchers--are explored in more detail.

Insight into the characteristics of research published in traditional, complementary, alternative, and integrative medicine journals: a bibliometric analysis

BACKGROUND

Traditional, complementary, alternative and integrative medicine (TCAIM) can be described as diverse medical and healthcare interventions, practices, products, or disciplines that are not considered as part of conventional medicine. Inherent in its definition, TCAIMs are comprised of a wide variety of therapies with highly variable safety and effectiveness evidence profiles. Despite this, the use of many TCAIMs is highly prevalent among patients globally. The present study consists of a bibliometric analysis of TCAIM journals.

METHODS

A single search of all International Standard Serial Number (ISSNs) of all journals categorized as "complementary and alternative medicine" (code 2707) based on the All Science Journal Classification (ASJC) was run on Scopus on April 17, 2021. All publication types were included; no further search limits were applied. The following bibliometric data were collected: number of publications (in total and per year), authors and journals; open access status; journals publishing the highest volume of literature and their impact factors; language, countries, institutional affiliations, and funding sponsors of publications; most productive authors; and highest-cited publications. Trends associated with this subset of publications were identified and presented. Bibliometric indicators of production were calculated, and bibliometric networks were constructed and visualized using the software tool VOSviewer.

RESULTS

A total of 172,466 publications (42,331 open access), were published by 219,680 authors in 143 journals from 1938 to 2021. Since the 1940s, an upward trend with respect to the volume of publications can be observed, with a steep increase observed between the mid-2000s and mid-2010s. The journal that published the largest number of publications was the Journal of Natural Products (n = 15,144). The most productive countries included China (n = 45,860), the United States (n = 29,523), and Germany (n = 10,120); a number of the most common institutional affiliations and funding sponsors also originated from these three countries.

CONCLUSIONS

The number of publications collectively published in TCAIM journals follows an upward trend. Given a high prevalence of TCAIM use among patients, increased acceptance of TCAIM among conventional healthcare providers, and growing interest in the research of TCAIM, future work should continue to investigate and track changes in the publication characteristics of the emerging research on this topic.

Acupuncture as a Treatment Within Integrative Health for Palliative Care: A Brief Narrative Review of Evidence and Recommendations

Background: Acupuncture is one of the fastest developing evidence bases in Complementary Medicine and is one of the leading therapies included within integrative health care. This narrative review includes two separate parts: the first is about evaluation of the current evidence status in reviews on acupuncture and the second examines and gives examples of available recommendations on acupuncture in treatment guidelines from health care experts and public health organizations recommending acupuncture as a viable treatment in patients in palliative care. Methods: Electronic searches were performed in PubMed using the terms "acupuncture" + "palliative" and adding the term "safety" to find review articles documenting safety and evidence of effectiveness of acupuncture for treatment of symptoms in palliative care patients. Treatment guidelines that recommend use of acupuncture for symptom control in palliative care were found by searching through a database currently under construction by the lead author. Results: Acupuncture shows emerging evidence for 17 indications in palliative care. Examples were found and presented of publications recommending acupuncture for treatment of symptoms for patients in palliative care from Government, public health, oncology, and medical expert sources. The most publications are in oncology, but other conditions were found and a number were found in pediatric care. Conclusions: While the evidence for use of acupuncture to treat symptoms in palliative care patients is relatively weak, the evidence base is growing. Experts worldwide are also increasingly recommending acupuncture as a treatment for symptoms in palliative care. Since acupuncture is a safe, nonpharmacological treatment but with small, clinically significant effects, these recommended uses appear as pragmatic efforts to bridge the gap of treatment options available to this patient group.

Acupuncture improves postoperative symptoms of pigmented villonodular synovitis: A protocol for systematic review and meta analysis

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a benign proliferative disease of synovial joint, synovial sac and tendon sheath. PVNS is usually treated by surgery, but postoperative joint dysfunction and pain will be accompanied, which seriously affects the quality of life. The purpose of this review is to evaluate the effectiveness and safety of this intervention in patients with pain and dysfunction caused by postoperative symptoms of PVNS.

METHODS

We will search the EMBASE, the Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, the Chongqing VIP (VIP), the US National Institute of Health, the NIH clinical registry Clinical Trials, the ICTRP, and the Australian New Zealand Clinical Trials Registry and the Chinese clinical registry, from their inception to 1st July 2020. Randomized controlled trials that include patients with postoperative symptoms of pigmented villonodular synovitis receiving acupuncture therapy versus a control group will be included. The selection of studies, data extraction and risk of bias assessment will be conducted by 2 independent researchers. A third review author resolved disagreements. The dichotomous data will be presented as risk ratios with 95% confidence intervals (CIs) and the continuous data will be presented as weighted mean differences or standardized mean differences with 95% CIs. Evidence quality will be evaluated using the GRADE system.

RESULTS

The results will be disseminated through a peer-reviewed journal publication.

CONCLUSIONS

This systematic review will provide updated evidence of various types of acupuncture specifically focuses on its effectiveness and safety for patients' pain and dysfunction caused by post-operation of pigmented villonodular synovitis.

ETHICS AND DISSEMINATION

Ethical approval is not necessary as this review will not require data from individual patients. The results of this will be published through peer-reviewed journal articles or conference presentations.

REGISTRATION

Open Science Framework (OSF). 2020, July 7. 10.17605/OSF.IO/CZW9P.

Efficacy and safety of acupuncture combined with western medicine for anxiety: A systematic review protocol

BACKGROUND

As a common clinical mental disorder, the prevalence rate of anxiety disorder increased yearly, devastating both physical health and social-economic prospect. The most common treatment relied on the use of western medications which is yet to fulfill ideal performance. While acupuncture is adopted as a treatment for anxiety disorders, the combination treatment of acupuncture and western medicines becomes more acknowledged. Albeit a spike in related literatures, the curative effect and safety of the treatment are still in lack of evidence. Therefore, this systematic review and meta-analysis protocol is planned to evaluate the efficacy and safety of the combination treatment of acupuncture and western medications.

METHODS

Six English databases (PubMed, Web of science, Medline, EBASE, Springer Cochrane Library and WHO International Clinical Trials Registry Platform) and four Chinese databases (Wan fang Database, Chinese Scientific Journal Database, China National Knowledge Infrastructure Database (CNKI) and Chinese Biomedical Literature Database) will be searched normatively according to the rule of each database from the inception to June 1, 2020. Two reviewers will independently conduct article selection, data collection, and risk of bias evaluation. Any disagreement will be resolved by discussion with the third reviewer. Either the fixed-effects or random-effects model will be used for data synthesis based on the heterogeneity test. The change in the scores on the Hamilton Anxiety Scale (HANA) and the self-rating anxiety scale (SAS) will be used as the main outcome measure, quality of life scale (SF-36), changes of symptoms in TCM, hormone levels and clinical global impression (CGI) as the secondary outcome. treatment emergent symptom scale (TESS), general physical examination(temperature, pulse, respiration, blood pressure), Routine examination of blood, urine and stool, Electrocardiogram, Liver and kidney function examination as the security indexes. RevMan 5.3.5 will be used for meta-analysis.

RESULTS

This study will provide high-quality evidence to assess the effectiveness and safety of acupuncture combined with western medicine for anxiety.

CONCLUSION

This systematic review will explore whether acupuncture combined with western medicine is an effective and safe intervention for anxiety.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and will be shared on social media platforms. This review will be disseminated in a peer-reviewed journal or conference presentation.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42020149746.

Acupuncture and manual therapy for rotator cuff tears: A protocol for systematic review and meta analysis

BACKGROUND

The tears of rotator cuff is caused by the tears or aseptic inflammation of tendon tissue such as subscapular muscle, supraspinatus muscle, infraspinatus muscle, teres minor muscle, and so on, which make up the rotator cuff. Managements of rotator cuff disease often include acupuncture and manual therapy, usually delivered together. The aim of this review is to assess the effectiveness and safety of such interventions in patients with pain and dysfunction caused by rotator cuff tears.

METHODS

We will search the EMBASE, the Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, Wanfang Database, the Chongqing VIP, the US National Institute of Health, the NIH clinical registry Clinical Trials, the International Clinical Trials Registry Platform, the Australian New Zealand Clinical Trials Registry and the Chinese clinical registry, from their inception to April 1, 2020. Randomized controlled trials that include patients with rotator cuff tears receiving acupuncture and manual therapy versus a control group will be included. The selection of studies, data extraction and risk of bias assessment will be conducted by 2 independent researchers. A third review author will resolve disagreements. The dichotomous data will be presented as risk ratios with 95% CIs and the continuous data will be presented as weighted mean differences or standardized mean differences with 95% CIs. Evidence quality will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation system.

DISCUSSION

This systematic review will provide updated evidence of various types of acupuncture and manual therapy specifically focuses on its effectiveness and safety for patients' pain and dysfunction caused by rotator cuff tears.

ETHICS AND DISSEMINATION

Ethical approval is not necessary as this review will not require data from individual patients. The results of this will be published through peer-reviewed journal articles or conference presentations.

REGISTRATION

Open Science Framework Preregistration. Registration number 10.17605/OSF.IO/M3NKV.

Acupuncture for symptomatic rotator cuff disease: Protocol for a systematic review and meta-analysis

BACKGROUND

Rotator cuff disease (RCD) consists of subacromial impingement syndrome, rotator cuff tendinopathy or tendinitis, partial or full rotator cuff tear, calcific tendinitis, and subacromial bursitis. Acupuncture has been suggested as a meaningful nonsurgical intervention for managing shoulder pain and dysfunction. However, previous reviews have not completely addressed the role of acupuncture in the management of RCDs. The objective of this systematic review is to evaluate the effectiveness and safety of acupuncture for managing symptoms in patients with RCD.

METHODS

We will search the following databases from their inception to November 30, 2019: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), Physiotherapy Evidence Database (PEDro), 3 Chinese databases (China Academic Journal Full-text Database (CAJ), China Doctoral Dissertations Full-text database and China Masters' Thesis Full-text Database), 6 Korean databases (Korean studies Information Service System (KISS), National Digital Science Library (NDSL), Research Information Sharing Service (RISS), Korean Medical Database (KMBASE), Korea Institute of Science and Technology Information (KISTI), Oriental Medicine Advanced Searching Integrated System (OASIS)), and 3 trial registries (ClinicalTrials.gov, International Standard Randomized Controlled Trials Number (ISRCTN) Registry, WHO International Clinical Trials Registry Platform (ICTRP)). We will include randomized controlled trials of acupuncture for RCD. There will be no restrictions related to setting or location. The primary outcome is pain intensity and shoulder dysfunction measured on validated scales within 12 weeks. Quality assessment will be performed using the Cochrane risk of bias tool. Dichotomous outcomes will be presented as risk ratios (RR), and continuous outcomes will be presented as weighted or standardized mean differences (SMD). Each outcome will be calculated with 95% confidence intervals.

DISCUSSION

The updated evidence that would be provided by this review will offer useful information for patients and practitioners, and also have implications for future studies and the development of clinical practice guidelines of RCD.Registration: Open Science Framework (OSF) Preregistration. 2019, December 5. osf.io/n2e6t.

Therapeutic Efficacy and the Impact of the "Dose" Effect of Acupuncture to Treat Sciatica: A Randomized Controlled Pilot Study

Purpose

To investigate the required sample size for and feasibility of a full-scale randomized controlled trial examining the impact of the “dose” effect of acupuncture in treating sciatica.

Patients and methods

Fifty-seven patients with sciatica, aged 35–70 years, were recruited and screened. Thirty-one participants were randomly assigned to receive “low-dose” manual acupuncture (MAL) (n= 15) or “high-dose” manual acupuncture (MAH) (n=16). The acupuncture treatment was administered twice weekly for 4 weeks. The primary outcome was the visual analog scale (VAS) score at baseline and after 4 weeks of acupuncture treatment. Secondary outcomes included the Roland Disability Questionnaire for Sciatica (RDQS), the Sciatica Bothersomeness Index (SBI), and the World Health Organization Quality of Life in the Brief Edition (WHOQOL-BREF) scores at baseline and after 4 weeks of acupuncture treatment.

Results

Thirty patients completed the study. For all patients, acupuncture achieved significant improvement in the VAS (5.48±2.0, p<0.001), RDQS (3.18±2.83, p=0.004), and SBI (2.85±3.23, p=0.008) scores, but not in the WHOQOL-BREF scores. In the between-group analysis, the assessed scales showed no significant differences between the MAL and MAH groups. However, based on the level of chronicity, the MAH group demonstrated greater improvement in the outcomes and a significant benefit in the physical subscale of the WHOQOL-BREF (p<0.05).

Conclusion

Results of this pilot study indicate that acupuncture is safe and may effectively relieve symptoms and disability in patients with non-acute sciatica. MAL was as effective as MAH in treating sciatica. A subsequent trial with a larger sample size (estimated at n=96) is required to confirm whether patients with a high level of chronicity would benefit from MAH treatment.

Trial registration

NCT03489681.

Evidence, safety and recommendations for when to use acupuncture for treating cancer related symptoms: a narrative review

Background

Recently research on acupuncture for cancer related symptoms has significantly increased. To what extent have medical professionals recommended to use acupuncture in light of that evidence?

Methods

Evidence of effectiveness and safety was found by searching Pubmed for reviews to identify for what conditions and general results. Publications that recommend acupuncture in oncology were searched in the database of an ongoing general search for publications that recommend acupuncture. This database was developed by searching google for publications that recommend the use of acupuncture with the terms ‘name of symptom’ and ‘clinical practice guideline’ or ‘treatment guideline’.

Results

Acupuncture is moderately or weakly effective for 19 symptoms in patients with cancer and cancer survivors. Acupuncture is a safe therapy in cancer care if administered by trained acupuncturists. Acupuncture is targeted to improve symptoms associated with the cancer and different cancer treatments, not to treat the cancer itself. More than 350 publications by clinical practice guideline groups and expert groups, including public health statements made by national and government agencies recommended the use of acupuncture for 61 cancer related symptoms many with positive evidence of effectiveness.

Conclusion

The strength of evidence is weak for many indications, however the evidence for many standard therapies is either not very strong or if stronger, the incidence of adverse events is more, which makes acupuncture a treatment option despite the weak evidence. We have found evidence that many oncologists around the world have started to incorporate acupuncture into the treatment of various cancer related symptoms.

Efficacy of acupuncture in rheumatic diseases with spine involvement: Systematic review

Rheumatic diseases involving the spine, mainly cervical and lumbar spine, are highly prevalent, and consume considerable health resources. Acupuncture is a medical procedure endorsed by the WHO, with a wide spectrum of medical applications. The aim of this study was to review the evidence on acupuncture efficacy in these diseases. A literature search was performed in MEDLINE, CENTRAL and EMBASE (May 2017): 535 citations. We included four global reviews(45 systematic reviews) and three Systematic Reviews(70 clinical trials). Acupuncture improved cervical pain and functionality both immediately and in the short term. It also proved effective in the treatment of acute and chronic low back pain as the first therapeutic line, compared with placebo, and as an adjunct to other conventional treatments. Acupuncture is a safe intervention. However, acupuncture efficacy in radiculopathies (cervical, lumbar), lumbar spinal stenosis and ankylosing spondylitis is still inconclusive. Well-designed studies with medium and long-term evaluation are required.