Traditional acupuncture in migraine: a controlled, randomized study

Placebo response in sham-acupuncture-controlled trials for migraine: A systematic review and meta-analysis

AIM

To understand the placebo response of acupuncture and its effect on migraine and optimize the design of future acupuncture clinical trials on migraine treatment.

METHODS

Randomized controlled trials with sham acupuncture as a control in migraine treatment were searched in four English databases from inception to September 1, 2022. The primary outcome was placebo response rate. Secondary outcomes were migraine symptoms, emotional condition, and quality of life. Factors associated with placebo response were also explored. Results were combined using risk difference (RD) or standardized mean difference (SMD) and 95% confidence interval (CI) with a random effects model.

RESULTS

The final analysis included 21 studies involving 1177 patients. The pooled response rate of sham acupuncture was 0.34 (RD, 95% CI 0.23-0.45, I2 89.8%). The results (SMD [95% CI]) showed significant improvements in migraine symptoms (pain intensity -0.56 [-0.73 to -0.38], and episode conditions -0.55 [-0.75 to -0.35]); emotional condition (anxiety scale -0.49 [-0.90 to -0.08] and depression scale -0.21 [-0.40 to -0.03]); and quality of life on the Migraine-Specific Quality-of-Life Questionnaire (restrictive 0.78 [0.61-0.95]; preventive 0.52 [0.35-0.68]; and emotional 0.45 [0.28-0.62]) and on the Medical Outcomes Study Short-Form (physical 0.48 [0.34-0.62] and mental 0.21 [0.02-0.41]). Only acupuncture treatment frequency had a significant impact on the placebo response rate (RD 0.49 vs. 0.14; p = 0.00).

CONCLUSIONS

The effect sizes for placebo response of sham acupuncture varied across migraine treatment trials. Further studies should routinely consider adjusting for a more complete set of treatment factors.

Bibliometric Analysis of 100 Most Highly Cited Publications on Acupuncture for Migraine

Background

Migraine is a serious global health concern that imposed a huge economic burden on social health care. Over the past few decades, the analgesic effects of acupuncture have been widely recognized, and there is a growing body of research on acupuncture for migraine. Citation analysis is a branch of bibliometrics that helps researchers analyze and identify historical or landmark studies within the scientific literature. Currently, there is no analysis of the 100 most highly cited publications on acupuncture for migraine.

Methods

The 100 most highly cited publications on acupuncture for migraine were screened using the Science Citation Index Expanded of the Web of Science Core Collection database. CiteSpace and VOSviewer programs were used for bibliometric analysis.

Results

A total of 493 publications on acupuncture for migraine were identified. 100 of the most highly cited publications on acupuncture for migraine were published from 1984-2020. These publications were cited 6142 times with an h-index of 44 and 84% were original articles. The highest frequency of citations was 416. A total of 335 authors were involved in the study with 37 lead authors. 212 institutions from 20 countries contributed to the 100 most highly cited publications. The most published studies came from the United States (n=36), followed by China (n=27) and Germany (n=26). The Technical University of Munich published the largest number of papers (n = 15). Top-cited publications mainly came from the Headache (n=13, citations=582). Neuroimaging is gradually emerging as a hot topic of research.

Conclusion

This is the first bibliometric analysis to offer a thorough list of the 100 most highly cited papers on acupuncture for migraine, demonstrating significant progress and emerging trends in this field to assist researchers in determining the direction for further research.

Therapeutic applications and potential mechanisms of acupuncture in migraine: A literature review and perspectives

Acupuncture is commonly used as a treatment for migraines. Animal studies have suggested that acupuncture can decrease neuropeptides, immune cells, and proinflammatory and excitatory neurotransmitters, which are associated with the pathogenesis of neuroinflammation. In addition, acupuncture participates in the development of peripheral and central sensitization through modulation of the release of neuronal-sensitization-related mediators (brain-derived neurotrophic factor, glutamate), endocannabinoid system, and serotonin system activation. Clinical studies have demonstrated that acupuncture may be a beneficial migraine treatment, particularly in decreasing pain intensity, duration, emotional comorbidity, and days of acute medication intake. However, specific clinical effectiveness has not been substantiated, and the mechanisms underlying its efficacy remain obscure. With the development of biomedical and neuroimaging techniques, the neural mechanism of acupuncture in migraine has gained increasing attention. Neuroimaging studies have indicated that acupuncture may alter the abnormal functional activity and connectivity of the descending pain modulatory system, default mode network, thalamus, frontal-parietal network, occipital-temporal network, and cerebellum. Acupuncture may reduce neuroinflammation, regulate peripheral and central sensitization, and normalize abnormal brain activity, thereby preventing pain signal transmission. To summarize the effects and neural mechanisms of acupuncture in migraine, we performed a systematic review of literature about migraine and acupuncture. We summarized the characteristics of current clinical studies, including the types of participants, study designs, and clinical outcomes. The published findings from basic neuroimaging studies support the hypothesis that acupuncture alters abnormal neuroplasticity and brain activity. The benefits of acupuncture require further investigation through basic and clinical studies.

Comparison of Acupuncture and Sham Acupuncture in Migraine Treatment: An Overview of Systematic Reviews

BACKGROUND

Acupuncture is widely used for treating migraine; however, evidence of its efficacy when compared with sham acupuncture is equivocal. This study aimed to compare the evaluate efficacy of acupuncture versus sham acupuncture in migraine treatment.

METHODS

We searched PubMed, the Cochrane Library, Web of Science, and EMBASE databases from their inception to April 25, 2021, for randomized controlled trials. The outcome measurement included response rate, migraine days, intensity, and frequency.

RESULTS

Twenty randomized controlled trials involving 2725 patients were included. Pooled data suggested that acupuncture was superior to sham acupuncture [mean difference (MD)=-0.52, 95% confidence interval (CI): -0.71 to -0.34, P<0.00001] in reducing the migraine frequency after treatment and follow-up (MD=-0.51, 95% CI: -0.70 to -0.32, P<0.00001). In reducing Visual Analog Scale, acupuncture was superior to sham acupuncture (MD=-0.72, 95% CI: -1.17 to -0.27, P=0.002) after treatment, and also superior to sham acupuncture (MD=-0.82, 95% CI: -1.31 to -0.33, P=0.001) on the follow-up. As for responder rate, acupuncture's efficacy was better than sham acupuncture (relative risk=1.28, 95% CI: 1.00-1.64, P=0.05). However, the reduction of migraine days in the acupuncture group was not significantly different from that in the sham acupuncture group after treatment (MD=-0.62; 95% CI: -1.31 to 0.08; P=0.08) and on the follow-up (MD=-0.68; 95% CI: -1.52 to 0.17; P=0.12).

CONCLUSIONS

Acupuncture appears to be an effective treatment modality for migraine. Compared with sham acupuncture, acupuncture had greater improvements in migraine frequency, Visual Analog Scale, and responder rate, but there was no statistically significant difference for the number of migraine days.

Pain, the uknown: epistemological issues and related clinical implications

Despite the huge development of pain management in the past decades, pain remains elusive and many patients still remain in the middle of the ford struggling between low drug efficacy and their overuse. A reason for pain elusiveness is its nature of subjective phenomenon, escaping the meshes of the objectivist, mechanist-reductionist net prevailing in medicine. Actually, pain is not only a symptom but an essential aspect of life, consciousness and contact with the world and its noetic and autonoetic components play a key role in the development of the concepts of pleasure-unpleasure and good-evil. The intensity and tolerability of pain and suffering also depends on what the pain means to the patient. The outstanding effects of placebo and nocebo, behavioral and non-pharmacological techniques warrant the need for a shift from the traditional positivist idea of patient as passive carrier of disease to the patient as active player of recovery and move toward a patient's centered approach exploiting individual resources for recovery. Among the mentioned techniques, hypnosis has proved to increase pain threshold up to the level of surgical analgesia, improve acute and chronic pain as well as coping and resilience, helping to decrease both drug overuse and the costs of pharmacological therapy. The wealth of available data suggest the need for a holistic approach, aiming to take care of the individual as an inseparable mind-body unit in its interplay with the environment, where patient's inner world, his/her experience and cognition are taken into due account as powerful resources for recovery through a phenomenological-existential approach.

Scientific Knowledge Graph of Acupuncture for Migraine: A Bibliometric Analysis from 2000 to 2019

OBJECTIVE

This study aims to explore the trend and knowledge mapping of acupuncture for migraine through bibliometrics.

METHODS

It retrieved the literature on acupuncture for migraine in the Web of Science database from 2000 to 2019, and then resorted to CiteSpace to conduct bibliometric analysis to attain the knowledge mapping.

RESULTS

The total number of publications each year has increased year by year, and the average annual growth rate from 2000 to 2009 was 15.57%, while from 2010 to 2019 was 6.35%, with a faster growth rate from 2000 to 2009. According to the cluster analysis of institutions, authors, cited references, and keywords, 10, 7, 12, and 10 categories were gained from 2000 to 2019. The most productive countries, institutions, and authors are the USA and China, Technical University of Munich and Beijing University of Chinese Medicine, Linde K and Liang FR from 2000 to 2019, whose frequency is 119/103, 28/24, and 28/24, respectively. However, the most important of them are Canada, Sichuan University, and Witt CM. Owing to their highest centrality, they are 0.86, 0.54, and 0.27 separately. Moreover, cited references that contributed to the most co-citations are Linde K (2005), yet, the most vital cited reference is Karst M (2001). Keywords such as migraine, acupuncture, headache, pain, and randomized controlled trial are the most frequently used. However, needle acupuncture is the crucial keyword. In the cluster analysis of institutions, authors, cited references, and keywords from 2000 to 2019, the largest cluster categories are #0 migraine prophylaxis, #1 randomized controlled trial, #0 episodic migraine, and #0 topiramate treatment. Then, randomized controlled trials of acupuncture prevention and treatment of migraine are the most important research content in this field.

CONCLUSION

Through the bibliometric analysis of the research on acupuncture for migraine in the Web of Science database in the past 20 years, the trends and the Knowledge Graph of the country, institution, author, cited reference, and the keyword are acquired, which have an important guiding significance for quickly and accurately positioning the key information in the field.

Differential Modulating Effect of Acupuncture in Patients With Migraine Without Aura: A Resting Functional Magnetic Resonance Study

Introduction: Migraine is a recurrent neurological disorder, the symptoms of which can be significantly relieved by acupuncture. However, the central mechanism via which acupuncture exerts its therapeutic effect in migraine is unclear. The aim of this study was to compare the differences in regional homogeneity (ReHo) between patients with migraine without aura (MwoA) and healthy controls (HCs) and to explore the immediate and cumulative therapeutic effect of acupuncture in patients with MwoA using resting-state functional magnetic resonance imaging (fMRI).

Methods: The study subjects were 40 patients with MwoA and 16 matched HCs. The patients with MwoA received acupuncture on 2 days per week for 6 weeks for a total of 12 sessions followed by 24 weeks of follow-up. The primary clinical efficacy outcomes were the number of days with migraine and the average severity of headache. Secondary outcomes were the Migraine-Specific Quality of Life Questionnaire, Self-Rating Anxiety Scale, and Self-Rating Depression Scale scores. In the migraine group, resting-state blood-oxygen-level-dependent fMRI scans were obtained at baseline and after the first and 12th acupuncture sessions to measure the ReHo value. In the HCs, only a baseline resting-state blood-oxygen-level-dependent fMRI scan was obtained.

Results: Compared with the control group, the migraine group had a significantly lower ReHo value in the cerebellum, which increased after the first acupuncture session. Long-term acupuncture significantly improved migraine symptoms and mood with a therapeutic effect that lasted for at least 6 months. After 12 acupuncture sessions, there were significant increase of cerebellum and angular gyrus in the migraine group.

Conclusion: These findings suggest that migraine is related to cerebellar dysfunction. Acupuncture can relieve the symptoms of migraine, improve dysfunction of cerebellum, and activate brain regions involved in modulation of pain and emotion The cumulative therapeutic effect of acupuncture is more extensive and significant than its immediate effect.

Spinal manipulation and perineural electrical dry needling in patients with cervicogenic headache: a multicenter randomized clinical trial

BACKGROUND CONTEXT

Spinal manipulation, spinal mobilization, and exercise are commonly used in individuals with cervicogenic headache (CH). Dry needling is being increasingly used in the management of CH. However, questions remain about the effectiveness of these therapies and how they compare to each other.

PURPOSE

The present study aims to compare the combined effects of spinal manipulation and dry needling with spinal mobilization and exercise on pain and disability in individuals with CH.

STUDY DESIGN/SETTING

Randomized, multicenter, parallel-group trial.

PATIENT SAMPLE

One hundred forty-two patients (n=142) with CH from 13 outpatient clinics in 10 different states were recruited over a 36-month period.

OUTCOME MEASURES

The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale. Secondary outcomes included headache frequency and duration, disability (Neck Disability Index), medication intake, and the Global Rating of Change (GROC). Follow-up assessments were taken at 1 week, 4 weeks, and 3 months.

METHODS

Patients were randomized to receive upper cervical and upper thoracic spinal manipulation plus electrical dry needling (n=74) or upper cervical and upper thoracic spinal mobilization and exercise (n=68). In addition, the mobilization group also received a program of craniocervical and peri-scapular resistance exercises; whereas, the spinal manipulation group also received up to eight sessions of perineural electrical dry needling. The treatment period for both groups was 4 weeks. The trial was prospectively registered at ClinicalTrials.gov (NCT02373605). Drs Dunning, Butts and Young are faculty within the AAMT Fellowship and teach postgraduate courses in spinal manipulation, spinal mobilization, dry needling, exercise and differential diagnosis. The other authors declare no conflicts of interest. None of the authors received any funding for this study.

RESULTS

The 2 × 4 analysis of covariance revealed that individuals with CH who received thrust spinal manipulation and electrical dry needling experienced significantly greater reductions in headache intensity (F=23.464; p<.001), headache frequency (F=13.407; p<.001), and disability (F=10.702; p<.001) than those who received nonthrust mobilization and exercise at a 3-month follow-up. Individuals in the spinal manipulation and electrical dry needling group also experienced shorter duration of headaches (p<.001) at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X²=54.840; p<.001) more patients (n=57, 77%) within the spinal manipulation and electrical dry needling group achieved a successful outcome compared to the mobilization and exercise group (n=10, 15%) at 3-month follow-up. Between-groups effect sizes were large (0.94<standardized mean score difference<1.25) in all outcomes in favor of the spinal manipulation and electrical dry needling group at 3 months. In addition, significantly (X²=29.889; p<.001) more patients in the spinal manipulation and electrical dry needling group (n=49, 66%) completely stopped taking medication for their pain compared to the spinal mobilization and exercise group (n=14, 21%) at 3 months.

CONCLUSION

Upper cervical and upper thoracic high-velocity low-amplitude thrust spinal manipulation and electrical dry needling were shown to be more effective than nonthrust mobilization and exercise in patients with CH, and the effects were maintained at 3 months.

Acupuncture vs. Pharmacological Prophylaxis of Migraine: A Systematic Review of Randomized Controlled Trials

Introduction: Migraine is a chronic paroxymal neurological disorder characterized by attacks of moderate to severe headache and reversible neurological and systemic symptoms. Treatment of migraine includes acute therapies, that aim to reduce the intensity of pain of each attack, and preventive therapies that should decrease the frequency of headache recurrence. The objective of this systematic review was to assess the efficacy and safety of acupuncture for the prophylaxis of episodic or chronic migraine in adult patients compared to pharmacological treatment.

Methods: We included randomized-controlled trials published in western languages that compared any treatment involving needle insertion (with or without manual or electrical stimulation) at acupuncture points, pain points or trigger points, with any pharmacological prophylaxis in adult (≥18 years) with chronic or episodic migraine with or without aura according to the criteria of the International Headache Society.

Results: Nine randomized trials were included encompassing 1,484 patients. At the end of intervention we found a small reduction in favor of acupuncture for the number of days with migraine per month: (SMD: −0.37; 95% CI −1.64 to −0.11), and for response rate (RR: 1.46; 95% CI 1.16–1.84). We found a moderate effect in the reduction of pain intensity in favor of acupuncture (SMD: −0.36; 95% CI −0.60 to −0.13), and a large reduction in favor of acupuncture in both the dropout rate due to any reason (RR 0.39; 95% CI 0.18 to 0.84) and the dropout rate due to adverse event (RR 0.26; 95% CI 0.09 to 0.74). Quality of evidence was moderate for all these primary outcomes. Results at longest follow-up confirmed these effects.

Conclusions: Based on moderate certainty of evidence, we conclude that acupuncture is mildly more effective and much safer than medication for the prophylaxis of migraine.

Use of IMMPACT domains in clinical trials of acupuncture for chronic pain: A methodological survey

Acupuncture is one of the therapeutic resources used for the management of chronic pain. Variability in outcome measurements in randomized clinical trials of non-oncologic chronic pain (RCT-NOCP) generates inconsistencies in determining effects of treatments. The objective of this survey was to assess the adherence to the recommendations made by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) in the measurement of RCT-NOCP of acupuncture. This methodological research made a systematic search for eligible studies from different sources of information. Eligible studies included those with number of patients ≥100, who randomized and allocated patients with chronic non-oncologic pain to be treated with acupuncture or with "sham" acupuncture, or non-acupuncture. This research included the recommendations for IMMPACT in the measurement of RCT-NOCP: presence of outcomes pain, physical function, emotional state and improvement perception of patient, the source of the outcome information pain and the tools used to measure such domains. From a total of 1,386 studies, 24 were included in this survey. Eleven studies presented low risk of bias. Pain outcome was measured in 23 studies, physical function in 22 studies, emotional state in 14 studies and improvement perception of patient in one study. As for the pain outcome, the patient was the information source in 50% of the studies. The measurement tools recommended for IMMPACT were included in eight studies (35%) that evaluated pain, one study that evaluated the emotional state (7%), and one study that evaluated the improvement perception and satisfaction of patient. It was observed that studies which did not adhere to the recommendations had more favorable results for acupuncture in the outcome pain. This study concludes that randomized clinical trials that used acupuncture to manage chronic pain failed to adhere to IMMPACT recommendations. Clinical societies and IMMPACT do not share the same recommendations. This fact reflects in the diversity of outcomes and instruments adopted in the studies, making it difficult to compare the results.

Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine without aura: multicentre, randomised clinical trial

OBJECTIVE

To assess the efficacy of manual acupuncture as prophylactic treatment for acupuncture naive patients with episodic migraine without aura.

DESIGN

Multicentre, randomised, controlled clinical trial with blinded participants, outcome assessment, and statistician.

SETTING

Seven hospitals in China, 5 June 2016 to 15 November 2018.

PARTICIPANTS

150 acupuncture naive patients with episodic migraine without aura.

INTERVENTIONS

20 sessions of manual acupuncture at true acupuncture points plus usual care, 20 sessions of non-penetrating sham acupuncture at heterosegmental non-acupuncture points plus usual care, or usual care alone over 8 weeks.

MAIN OUTCOME MEASURES

Change in migraine days and migraine attacks per four weeks during weeks 1-20 after randomisation compared with baseline (four weeks before randomisation).

RESULTS

Among 150 randomised patients (mean age 36.5 (SD 11.4) years; 123 (82%) women), 147 were included in the full analysis set. Compared with sham acupuncture, manual acupuncture resulted in a significantly greater reduction in migraine days at weeks 13 to 20 and a significantly greater reduction in migraine attacks at weeks 17 to 20. The reduction in mean number of migraine days was 3.5 (SD 2.5) for manual versus 2.4 (3.4) for sham (adjusted difference -1.4, 95% confidence interval -2.4 to -0.3; P=0.005) at weeks 13 to 16 and 3.9 (3.0) for manual versus 2.2 (3.2) for sham (adjusted difference -2.1, -2.9 to -1.2; P<0.001) at weeks 17 to 20. At weeks 17 to 20, the reduction in mean number of attacks was 2.3 (1.7) for manual versus 1.6 (2.5) for sham (adjusted difference -1.0, -1.5 to -0.5; P<0.001). No severe adverse events were reported. No significant difference was seen in the proportion of patients perceiving needle penetration between manual acupuncture and sham acupuncture (79% v 75%; P=0.891).

CONCLUSIONS

Twenty sessions of manual acupuncture was superior to sham acupuncture and usual care for the prophylaxis of episodic migraine without aura. These results support the use of manual acupuncture in patients who are reluctant to use prophylactic drugs or when prophylactic drugs are ineffective, and it should be considered in future guidelines.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02765581.

Electro-acupuncture inhibits C-fiber-evoked WDR neuronal activity of the trigeminocervical complex: Neurophysiological hypothesis of a complementary therapy for acute migraine modeled rats

INTRODUCTION

Acupuncture has become a relevant complementary and alternative treatment for acute migraine; however, the neurophysiological mechanism (C-fibers) underlying this effect remains unclear. C-fibers play a crucial role for diffuse noxious inhibitory controls (DNIC) at wide dynamic range (WDR) neurons in the trigeminocervical complex (TCC) in migraine attacks, and we supposed that this may be the mechanism of acupuncture analgesia. This study aimed to examine the neurophysiology of acupuncture intervention in an acute migraine rat model.

METHODS

Inflammatory soup (IS) or saline was injected into the dura mater to establish a migraine and control model in rats. To explore the neurobiological mechanism of acupuncture for migraine, we implemented electro-acupuncture (EA), non-electric-stimulation acupuncture, and no-acupuncture in IS and saline injected rats, and recorded the single-cell extraneural neurophysiology of the atlas (C1) spinal dorsal horn neurons in the TCC.

RESULTS

Our research shows that electro-acupuncture at GB8 (Shuaigu), located in the periorbital region receptive field of the trigeminal nerve, may rapidly reduce the C-fiber evoked WDR neuronal discharges of the TCC within 60 s.

DISCUSSION

This study provides pioneering evidence of a potential neurobiological mechanism for the analgesic effect on migraine attacks achieved by electro-acupuncture intervention via DNIC. The data indicates that EA may become a crucial supplementary and alternative therapy for migraineurs that failed to respond to acute medications, e.g., fremanezumab, which achieves its analgesic effect via modulating Aσ-fibers, not C-fibers.

Prophylactic Electroacupuncture on the Upper Cervical Segments Decreases Neuronal Discharges of the Trigeminocervical Complex in Migraine-Affected Rats: An in vivo Extracellular Electrophysiological Experiment

Purpose

This rat experiment aims to demonstrate the efficacy of electrical acupuncture in preventing migraine attacks by stimulating the acupoint GB20.

Introduction

Migraine, which takes 2ed at level four causes of GBD’s disease hierarchy, becomes a public health issue. It is important for physicians to supplement their knowledge of its treatment and consider alternative methods of therapy, such as acupuncture. However, the neurobiological and pathophysiological mechanisms of this prophylactic effect were unclear. The trigeminocervical complex is thought to be an important relay station in migraine pathophysiology as the key nuclei of the trigeminovascular system and the brainstem descending pain modulation system.

Methods

There were six groups involved in this study: control, model, electroacupuncture, non-acupoint electroacupuncture, saline+electroacupuncture and saline+non-acupoint electroacupuncture. We injected saline or inflammatory soup into dura mater to induce control or migraine in the rats. The mechanical pain threshold and the single-cell extraneural neurophysiology of the C1 spinal dorsal horn neurons in the trigeminocervical complex were detected.

Results

Pre-electroacupuncture could significantly increase the mechanical pain threshold of the periorbital region receptive field of the trigeminal nerve and decrease the discharges of neurons in the trigeminocervical complex. Acupuncture also reversed the abnormal skin pain response of the periorbital region receptive field of the trigeminal nerve caused by low-intensity stimulation.

Discussion

We believe that our study makes a significant contribution to the literature because it is the first of its kind to use GB20 to provide relief from migraine attacks and mechanical cephalic cutaneous hypersensitivity by regulating the neuronal discharge from trigeminocervical complex.

The effect of physiotherapy and acupuncture on psychocognitive, somatic, quality of life, and disability characteristics in TTH patients

Introduction

Nonpharmacological therapies have been widely used to treat tension-type headache (TTH); however, limited evidence exists with regards to their effectiveness. Therefore, the aim of the present study was to examine the combined effect of acupuncture, stretching, and physiotherapy (myofascial release techniques and microwave diathermy) on psychocognitive, somatic, quality of life, and disability characteristics in such patients.

Subjects and methods

Patients with TTH (n=44) performed either acupuncture or stretching (control group, n=20) or acupuncture, stretching, and physiotherapy (experimental group, n=24) during a 4-week intervention period including 10 treatment sessions. They were tested for the Greek version of the Short-Form McGill Pain Questionnaire, the Greek version of the Migraine Disability Assessment Questionnaire, the Greek version of the Hospital Anxiety and Depression Scale, Short Form Health Survey 12 9 (SF-12), and Pain Catastrophizing Scale at baseline after the fifth and tenth sessions.

Results

All measures were improved throughout the first to tenth session (P<0.05), though no significant differences were observed between the two groups (P>0.05).

Conclusion

In summary, a significant beneficial role of acupuncture, stretching, and physiotherapy on cognitive, psychosomatic pain measures, disability index, quality of life, and catastrophizing in patients with TTH was observed.

Acupuncture as prophylaxis for chronic migraine: a protocol for a single-blinded, double-dummy randomised controlled trial

INTRODUCTION

Approximately 1.4%-2.2% of the global population suffers from chronic migraine. Acupuncture may serve as an alternative management for chronic migraine, where pharmacological prophylaxis is not suitable. However, the effects of acupuncture as migraine prophylaxis have not been confirmed. This study is designed as a single-blinded, double-dummy randomised controlled trial to evaluate the efficacy and safety of acupuncture compared with topiramate in patients with chronic migraine.

METHODS AND ANALYSIS

A total of 60 participants will be randomly assigned to two different groups. Participants will receive verum acupuncture and placebo medicine in the treatment group, while participants in the control group will be treated with sham acupuncture and real medicine (topiramate). All participants will receive a 12-week treatment and then be followed up for another 12 weeks. The primary outcome is the reduction of monthly headache days, and the secondary outcomes include the reduction of the number of days with acute headache medications, and changes of Migraine Disability Assessment, Migraine-Specific Quality of Life Questionnaire, Headache Impact Test, State-Trait Anxiety Inventory-trait, and Beck Depression Inventory-II scores from baseline to endpoints.

ETHICS AND DISSEMINATION

Ethical approval of this study was granted by the Research Ethical Committee of Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University (2017BL-045-01). Written informed consent will be obtained from all participants. Outcomes of the trial will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ISRCTN13563102; Pre-results.

Acupuncture in migraine prophylaxis in Czech patients: an open-label randomized controlled trial

BACKGROUND

Adjuvant acupuncture for the symptomatic treatment of migraine reduces the frequency of headaches and may be at least similarly effective to treatment with prophylactic drugs.

METHODS

This article describes an open-label randomized controlled clinical trial with two groups: the intervention group (n=42) and the waiting-list control group (n=44). This study occurred at the Czech-Chinese Center for Traditional Chinese Medicine at the University Hospital Hradec Kralove between October 2015 and April 2017.

RESULTS

After 12 weeks of acupuncture, the number of migraine days was reduced by 5.5 and 2.0 days in the acupuncture and the waiting-list control groups, respectively, with a statistically significant inter-group difference of 2.0 migraine days (95% CI: -4 to -1). A significantly greater reduction in the number of migraine days per 4 weeks was reached at the end of the 6-month follow-up period in the acupuncture vs. control groups (Δ -4.0; 95% CI: -6 to -2). A statistically significant difference was observed in the number of responders to treatment (response defined as at least a 50% reduction in average monthly migraine day frequency) in the acupuncture vs waiting-list control groups (50% vs 27%; p<0.05) at the end of the intervention. A significantly greater percentage of responders to treatment was noted in the intervention vs control groups at the 6-month follow-up (81% vs 36%; p<0.001).

CONCLUSION

Acupuncture can reduce symptoms and medication use, both short term and long term, as an adjuvant treatment in migraine prophylaxis in Czech patients.

Acupuncture modulates the abnormal brainstem activity in migraine without aura patients

Migraine is a common neurological disease with a high prevalence and unsatisfactory treatment options. The specific pathophysiological mechanisms of migraine remain unclear, which restricts the development of effective treatments for this prevalent disorder. The aims of this study were to 1) compare the spontaneous brain activity differences between Migraine without Aura (MwoA) patients and healthy controls (HCs), using amplitude of low-frequency fluctuations (ALFF) calculation method, and 2) explore how an effective treatment (verum acupuncture) could modulate the ALFF of MwoA patients. One hundred MwoA patients and forty-six matched HCs were recruited. Patients were randomized to four weeks' verum acupuncture, sham acupuncture, and waiting list groups. Patients had resting state BOLD-fMRI scan before and after treatment, while HCs only had resting state BOLD-fMRI scan at baseline. Headache intensity, headache frequency, self-rating anxiety and self-rating depression were used for clinical efficacy evaluation. Compared with HCs, MwoA patients showed increased ALFF in posterior insula and putamen/caudate, and reduced ALFF in rostral ventromedial medulla (RVM)/trigeminocervical complex (TCC). After longitudinal verum acupuncture treatment, the decreased ALFF of the RVM/TCC was normalized in migraine patients. Verum acupuncture and sham acupuncture have different modulation effects on ALFF of RVM/TCC in migraine patients. Our results suggest that impairment of the homeostasis of the trigeminovascular nociceptive pathway is involved in the neural pathophysiology of migraines. Effective treatments, such as verum acupuncture, could help to restore this imbalance.

On the Science of Consciousness: Epistemological Reflections and Clinical Implications

Consciousness has been one of the most important and tantalizing issues ever since the origin of philosophy and medicine. The concept of consciousness and the so-called "hard problem" (i.e., the mind-brain relationship) are highly complex topics that have yet to be elucidated, involving the realms of both science and philosophy with profound epistemological implications. In the lively debate on the foundations of the science of consciousness there are several potential biases of an essentially philosophical nature, such as those related to the paradigm and axioms adopted, and the ostensible logical contradiction between monism and dualism. Their origin dates back largely to Descartes' thinking and the birth of the new sciences as a compromise with the Inquisition, but they have been handed down through the Enlightenment and Positivism. A proper investigation of consciousness and the world of subjectivity demands a careful reflection on the paradigm of scientific medicine to identify possible flaws and overcome the limits of the mechanistic-reductionist approach.

Bioelectrodynamics: A New Patient Care Strategy for Nursing, Health, and Wellness

Bioelectrodynamics is an interdisciplinary subject that offers a pathway for nursing to develop a new patient care strategy in health care. The application of bioenergy to living organisms has the potential to advance medical science in the areas of prevention, cancer, wound care, pain, and many other chronic diseases.

Acupuncture for the prevention of episodic migraine

BACKGROUND

Acupuncture is often used for migraine prevention but its effectiveness is still controversial. We present an update of our Cochrane review from 2009.

OBJECTIVES

To investigate whether acupuncture is a) more effective than no prophylactic treatment/routine care only; b) more effective than sham (placebo) acupuncture; and c) as effective as prophylactic treatment with drugs in reducing headache frequency in adults with episodic migraine.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL: 2016, issue 1); MEDLINE (via Ovid, 2008 to January 2016); Ovid EMBASE (2008 to January 2016); and Ovid AMED (1985 to January 2016). We checked PubMed for recent publications to April 2016. We searched the World Health Organization (WHO) Clinical Trials Registry Platform to February 2016 for ongoing and unpublished trials.

SELECTION CRITERIA

We included randomized trials at least eight weeks in duration that compared an acupuncture intervention with a no-acupuncture control (no prophylactic treatment or routine care only), a sham-acupuncture intervention, or prophylactic drug in participants with episodic migraine.

DATA COLLECTION AND ANALYSIS

Two reviewers checked eligibility; extracted information on participants, interventions, methods and results, and assessed risk of bias and quality of the acupuncture intervention. The primary outcome was migraine frequency (preferably migraine days, attacks or headache days if migraine days not measured/reported) after treatment and at follow-up. The secondary outcome was response (at least 50% frequency reduction). Safety outcomes were number of participants dropping out due to adverse effects and number of participants reporting at least one adverse effect. We calculated pooled effect size estimates using a fixed-effect model. We assessed the evidence using GRADE and created 'Summary of findings' tables.

MAIN RESULTS

Twenty-two trials including 4985 participants in total (median 71, range 30 to 1715) met our updated selection criteria. We excluded five previously included trials from this update because they included people who had had migraine for less than 12 months, and included five new trials. Five trials had a no-acupuncture control group (either treatment of attacks only or non-regulated routine care), 15 a sham-acupuncture control group, and five a comparator group receiving prophylactic drug treatment. In comparisons with no-acupuncture control groups and groups receiving prophylactic drug treatment, there was risk of performance and detection bias as blinding was not possible. Overall the quality of the evidence was moderate. Comparison with no acupunctureAcupuncture was associated with a moderate reduction of headache frequency over no acupuncture after treatment (four trials, 2199 participants; standardised mean difference (SMD) -0.56; 95% CI -0.65 to -0.48); findings were statistically heterogeneous (I² = 57%; moderate quality evidence). After treatment headache frequency at least halved in 41% of participants receiving acupuncture and 17% receiving no acupuncture (pooled risk ratio (RR) 2.40; 95% CI 2.08 to 2.76; 4 studies, 2519 participants) with a corresponding number needed to treat for an additional beneficial outcome (NNTB) of 4 (95% CI 3 to 6); there was no indication of statistical heterogeneity (I² = 7%; moderate quality evidence). The only trial with post-treatment follow-up found a small but significant benefit 12 months after randomisation (RR 2.16; 95% CI 1.35 to 3.45; NNT 7; 95% 4 to 25; 377 participants, low quality evidence). Comparison with sham acupunctureBoth after treatment (12 trials, 1646 participants) and at follow-up (10 trials, 1534 participants), acupuncture was associated with a small but statistically significant frequency reduction over sham (moderate quality evidence). The SMD was -0.18 (95% CI -0.28 to -0.08; I² = 47%) after treatment and -0.19 (95% CI -0.30 to -0.09; I² = 59%) at follow-up. After treatment headache frequency at least halved in 50% of participants receiving true acupuncture and 41% receiving sham acupuncture (pooled RR 1.23, 95% CI 1.11 to 1.36; I² = 48%; 14 trials, 1825 participants) and at follow-up in 53% and 42%, respectively (pooled RR 1.25, 95% CI 1.13 to 1.39; I² = 61%; 11 trials, 1683 participants; moderate quality evidence). The corresponding NNTBs are 11 (95% CI 7.00 to 20.00) and 10 (95% CI 6.00 to 18.00), respectively. The number of participants dropping out due to adverse effects (odds ratio (OR) 2.84; 95% CI 0.43 to 18.71; 7 trials, 931 participants; low quality evidence) and the number of participants reporting adverse effects (OR 1.15; 95% CI 0.85 to 1.56; 4 trials, 1414 participants; moderate quality evidence) did not differ significantly between acupuncture and sham groups. Comparison with prophylactic drug treatmentAcupuncture reduced migraine frequency significantly more than drug prophylaxis after treatment ( SMD -0.25; 95% CI -0.39 to -0.10; 3 trials, 739 participants), but the significance was not maintained at follow-up (SMD -0.13; 95% CI -0.28 to 0.01; 3 trials, 744 participants; moderate quality evidence). After three months headache frequency at least halved in 57% of participants receiving acupuncture and 46% receiving prophylactic drugs (pooled RR 1.24; 95% CI 1.08 to 1.44) and after six months in 59% and 54%, respectively (pooled RR 1.11; 95% CI 0.97 to 1.26; moderate quality evidence). Findings were consistent among trials with I² being 0% in all analyses. Trial participants receiving acupuncture were less likely to drop out due to adverse effects (OR 0.27; 95% CI 0.08 to 0.86; 4 trials, 451 participants) and to report adverse effects (OR 0.25; 95% CI 0.10 to 0.62; 5 trials 931 participants) than participants receiving prophylactic drugs (moderate quality evidence).

AUTHORS' CONCLUSIONS

The available evidence suggests that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches. Contrary to the previous findings, the updated evidence also suggests that there is an effect over sham, but this effect is small. The available trials also suggest that acupuncture may be at least similarly effective as treatment with prophylactic drugs. Acupuncture can be considered a treatment option for patients willing to undergo this treatment. As for other migraine treatments, long-term studies, more than one year in duration, are lacking.

Verum and sham acupuncture exert distinct cerebral activation in pain processing areas: a crossover fMRI investigation in healthy volunteers

Although acupuncture is effective for treating pain, its site-specificity is questioned. The aim was to compare the cerebral responses of needling applied to an acupuncture point to the needling of a sham point, using functional magnetic resonance imaging (fMRI). Twenty-one healthy male volunteers were enrolled. Manual stimulation of the acupuncture (ST44) and sham points on the dorsum of the left foot was applied during fMRI in a crossover manner. fMRI data analysis was performed contrasting the ST44 and the sham conditions. Stimulation intensity, subjective discrimination of the needling site and the incidence of "Qi" sensation were additionally recorded. Stimulation of ST44 acupoint, in comparison to the sham procedure, was associated with an increased fMRI-activation in the primary somatosensory, the inferior parietal and the prefrontal cortex and the posterior insula. Sham needling was associated with increased activation in the anterior cingulate cortex and the anterior insula. Verum acupuncture increased the activity of discriminative somatosensory and cognitive pain processing areas of the brain, whereas sham needling activated the areas responsible for affective processing of pain. This may explain favorable effects of verum acupuncture in clinical studies about treatment of chronic pain patients.

Verum versus sham manual acupuncture for migraine: a systematic review of randomised controlled trials

BACKGROUND

Manual acupuncture (MA) is commonly used as a treatment for migraine in China. However, its specific clinical effects have been challenged on the basis that some of its effects may relate to psychological or 'placebo' mechanisms.

OBJECTIVE

To identify the effectiveness of verum MA compared with sham acupuncture for the treatment of migraine.

METHODS

Eight electronic databases were searched for randomised controlled trials (RCTs) evaluating the effect of verum versus sham MA on migraine. The quality of included trials was assessed using the 'risk of bias' tool provided by the Cochrane Handbook for Systematic Review of Intervention. RevMan 5.2 software was used for data analysis.

RESULTS

Ten trials with 997 participants were included. Most trials had high methodological quality and were at low risk of bias. Meta-analysis showed superior effects of verum MA over sham acupuncture on the total effective rate, reflected by a reduction in the 'not effective' rate (relative risk (RR) 0.24, 95% CI 0.15 to 0.38; p<0.0001, four trials) and a reduced recurrence rate (RR 0.47, 95% CI 0.28 to 0.81; p=0.006, two trials), but no significant differences in headache intensity, frequency or duration, accompanying symptoms and use of medication. No severe adverse events related to acupuncture occurred during treatment with either verum or sham MA.

CONCLUSIONS

Current clinical evidence suggests that verum acupuncture is superior to sham acupuncture in migraine, reflected by a higher total effective rate and decreased recurrence rate. Nevertheless, further large-scale RCTs with a rigorous design are required to confirm these findings in view of the relative paucity of eligible RCTs and small sample sizes of those included.

Evidence-Based Treatments for Adults with Migraine

Migraine, a significantly disabling condition, is treated with acute and preventive medications. However, some individuals are refractory to standard treatments. Although there is a host of alternative management options available, these are not always backed by strong evidence. In fact, most of the drugs used in migraine were initially designed for other purposes. Whilst effective, the benefits from these medications are modest, reflecting the need for newer and migraine-specific therapeutic agents. In recent years, we have witnessed the emergence of novel treatments, of which noninvasive neuromodulation appears to be the most attractive given its ease of use and excellent tolerability profile. This paper reviews the evidence behind the available treatments for migraine.

Clinically meaningful nocebo effect occurs in acupuncture treatment: a systematic review

OBJECTIVE

To investigate the nocebo effect using randomized acupuncture trials that include sham and no-treatment groups.

STUDY DESIGN AND SETTING

Electronic databases were searched to retrieve eligible trials from their inception until June 2013. Risk differences were then calculated using the acupuncture and sham groups to determine the treatment effect and the sham and no-treatment groups to determine the nocebo effect.

RESULTS

In total, 58 eligible trials were analyzed. On the basis of the rate of patients with any adverse event in 31 trials reporting available data, the treatment effect was 0.012 (95% confidence interval [CI]: 0.003, 0.021), with a number needed to harm (NNH) of 83 (95% CI: 48, 333). The nocebo effect was 0.049 (95% CI: 0.012, 0.086), with an NNH of 20 (95% CI: 12, 83). By contrast, the rate of dropouts due to adverse events in 39 trials reporting available data showed no differences for both effects. In addition, nearly 70% of the trials reported zero dropouts in the sham and no-treatment groups.

CONCLUSION

Our findings suggest that (1) the nocebo effect of acupuncture is clinically meaningful and (2) the rate of patients with any adverse event may be a more appropriate indicator of the nocebo effect.

Two sets of acupoint combination of similar functions engage shared neural representation: a functional magnetic resonance imaging study

OBJECTIVE

To investigate whether the neural representations underlying alternating two acupoint combinations (ACs) are the same or not.

METHODS

In this functional magnetic resonance imaging study, two sets of analgesia ACs were utilized, including Waiguan (TE5) and Qiuxu (GB40) for Group A, and Neiguan (PC6) and Taichong (LR3) for Group B, which are the most commonly adopted in clinical treatment. Each group had 20 healthy subjects. An experimental design was proposed, which consisted of a pre-needling resting phase, a needling phase and a post-needling resting phase. This paradigm optimally mimics the clinical protocol as well as focuses on both the stimulation and the resting periods. The results were subjected to general linear model analysis, conjunction analysis and the functional connectivity analysis.

RESULTS

The rostral anterior cingulated cortex was engaged in the initiative period of the acupuncture effect in both groups, and it was chosen as the seed region for the functional connectivity analysis for the following resting period. The results showed that several shared brain regions were involved in both groups, in particular the insula, amygdala and hypothalamus. Moreover, significant differences were located at the posterior cingulated cortex as revealed by a two sample -test (P<0.05, corrected). Other regions showed no significant differences. This finding was further supported by the spatial correlation analysis that the two groups were significantly correlated (r =0.51, P<0.01).

CONCLUSION

This preliminary research helps us understand the neurophysiological mechanisms of acupuncture when following clinical guidelines on ACs, as well as provides an important opportunity to develop better treatment strategies for reducing, or even preventing pain.

Efficacy of Yamamoto new scalp acupuncture versus Traditional Chinese acupuncture for migraine treatment

BACKGROUND

Traditional Chinese acupuncture (TCA) is an effective alternative treatment in migraine headache. The aim of this study was to compare the therapeutic effect of Yamamoto new scalp acupuncture (YNSA), a recently developed microcupuncture system, with TCA for the prophylaxis and treatment of migraine headache.

METHODS

In a randomized clinical trial, 80 patients with migraine headache were assigned to receive YNSA or TCA. A pain visual analogue scale (VAS) and migraine therapy assessment questionnaire (MTAQ) were completed before treatment, after 6 and 18 sections of treatment, and 1 month after completion of therapy.

RESULTS

All the recruited patients completed the study. Baseline characteristics were similar between the two groups. Frequency and severity of migraine attacks, nausea, the need for rescue treatment, and work absence rate decreased similarly in both groups. Recovery from headache and ability to continue daily activities 2 hours after medical treatment showed similar improvement in both groups (p>0.05).

CONCLUSION

Classic acupuncture and YNSA are similarly effective in the prophylaxis and treatment of migraine headache and may be considered as alternatives to pharmacotherapy.

Evaluating the prophylaxis and long-term effectiveness of acupuncture for migraine without aura: study protocol for a randomized controlled trial

BACKGROUND

The instant-treatment effect of acupuncture for patients with migraines has been corroborated in numerous studies. However, most diseases are chronic and tend to recur, so the long-term effect of acupuncture can verify the existence of sustained efficacy or the placebo effect. Evaluating the efficacy of acupuncture in the prophylaxis of migraine without aura (MWoA) in China is also important because such studies are lacking.

METHODS

This trial is a multicenter, prospective, pragmatic randomized controlled clinical trial. We will randomly allocate 249 participants to three groups of 83. Patients in the individualized acupoint group will be treated with individualized acupuncture point prescriptions. The non-acupoint control group will undergo insertion of acupuncture needles at four bilateral non-points in locations not corresponding to acupuncture points. The waiting-list control group will not undergo treatment but instead will receive 20 acupuncture treatments for free after a waiting period of 24 weeks. Participants in the individualized acupoint group and non-acupoint control group will receive 20 sessions over four weeks and then all participants will receive 20 weeks of follow-up.

DISCUSSION

The results of our trial will help to supply evidence for the long-term acupuncture effect for MWoA in a long follow-up period, and special attention will be paid to comparison with the placebo effect.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov (NCT01687660) on 18 September 2012.

Effects of acupuncture on Chinese medicine syndromes of vascular dementia

OBJECTIVE

To study the effects of acupuncture on Chinese medicine syndromes of vascular dementia (VaD).

METHODS

Sixty-three VaD patients were divided into three groups. Those willing to be randomized were randomly assigned to receive either acupuncture (random acupuncture group, 24 cases) or rehabilitation training (guided rehabilitation group, 24 cases) for 6 weeks. Those unwilling to be randomized also received acupuncture for 6 weeks (non-random acupuncture group, 19 cases). Patient syndromes and their severity were evaluated before treatment (baseline), at the end of treatment, and at 4-week follow-up after the completion of treatment using a CM scoring system (scale of differentiation of syndromes of vascular dementia, SDSVD). The SDSVD scores of the random and non-random acupuncture groups, and of all patients who received acupuncture (combined acupuncture group, 43 cases), were compared with those in the guided rehabilitation group.

RESULTS

In the random, non-random, and combined acupuncture groups, SDSVD scores were significantly reduced at the end of treatment and at follow-up than at baseline. In the guided rehabilitation group, SDSVD scores were similar to baseline scores at the end of treatment and at follow-up. However, there were no significant differences in SDSVD scores among the three groups or between the combined acupuncture group and the guided rehabilitation group at any time points. In the non-random and combined acupuncture groups, SDSVD scores were significantly reduced at the end of treatment than at baseline in patients with hyperactivity of Liver (Gan)-yang or phlegm obstruction of the orifices.

CONCLUSIONS

Acupuncture reduced the severity of VaD. The improvement was the greatest in patients undergoing their treatment of choice. Treatments in this study were more effective for excess syndromes, such as Liver-yang hyperactivity or phlegm obstruction of the orifices than deficiency syndromes, such as Kidney (Shen)-essence deficiency.

A review of acupoint specificity research in china: status quo and prospects

The theory of acupoint specificity is the basis for elucidating the actions of acupoints as employed in clinical practice. Acupoint specificity has become a focus of attention in international research efforts by scholars in the areas of acupuncture and moxibustion. In 2006, the Chinese Ministry of Science approved and initiated the National Basic Research Program (973 Program), one area of which was entitled Basic Research on Acupoint Specificity Based on Clinical Efficacy. Using such approaches as data mining, evidence-based medicine, clinical epidemiology, neuroimaging, molecular biology, neurophysiology, and metabolomics, fruitful research has been conducted in the form of literature research, clinical assessments, and biological studies. Acupoint specificity has been proved to exist, and it features meridian-propagated, relative, persistent, and conditional effects. Preliminarily investigations have been made into the biological basis for acupoint specificity.

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.

[Adequate application of quantitative and qualitative statistic analytic methods in acupuncture clinical trials]

Recently, proper use of the statistical methods in traditional Chinese medicine (TCM) randomized controlled trials (RCTs) has received increased attention. Statistical inference based on hypothesis testing is the foundation of clinical trials and evidence-based medicine. In this article, the authors described the methodological differences between literature published in Chinese and Western journals in the design and analysis of acupuncture RCTs and the application of basic statistical principles. In China, qualitative analysis method has been widely used in acupuncture and TCM clinical trials, while the between-group quantitative analysis methods on clinical symptom scores are commonly used in the West. The evidence for and against these analytical differences were discussed based on the data of RCTs assessing acupuncture for pain relief. The authors concluded that although both methods have their unique advantages, quantitative analysis should be used as the primary analysis while qualitative analysis can be a secondary criterion for analysis. The purpose of this paper is to inspire further discussion of such special issues in clinical research design and thus contribute to the increased scientific rigor of TCM research.

Randomized controlled trial comparing acupuncture with placebo acupuncture for the treatment of carpal tunnel syndrome

OBJECTIVE

To investigate the efficacy of acupuncture for the treatment of mild to moderate carpal tunnel syndrome (CTS).

DESIGN

Prospective, randomized, placebo-controlled, double-blinded study.

SETTING

Single-center study.

PARTICIPANTS

Forty-one acupuncture-naïve adult subjects with mild to moderate CTS enrolled in the study. Thirty-four subjects completed the study.

METHODS

Clinical diagnosis of CTS was supported by electrodiagnostic findings. Subjects were randomly assigned to either (1) acupuncture (n = 21) or (2) placebo acupuncture (n = 20) with use of Streitberger placebo acupuncture needles. Both groups received weekly sessions of acupuncture for 6 weeks. Wrist braces were provided to both groups to wear at night, and compliance was monitored.

MAIN OUTCOME MEASUREMENTS

The primary outcome measurement was subject-reported change in the Carpal Tunnel Self Assessment Questionnaire (CTSAQ) Symptom and Function scales immediately after and at 2 weeks and 3 months after the final treatment. The secondary outcomes included tip and key pinch strength and combined sensory index.

RESULTS

Compared with pretreatment baseline values, subjects in the acupuncture group had 0.58 improvement (P = .03) on the CTSAQ Symptom scale score at 3 months after the last treatment, whereas 0.81 improvement (P = .001) was noted in the placebo acupuncture group. No statistically significant difference was found between the groups treated with acupuncture and placebo acupuncture with respect to improvement in CTS symptoms, function, tip/key pinch, or combined sensory index.

CONCLUSIONS

To our knowledge, this study is the first randomized, placebo-controlled, double-blinded prospective study of traditional acupuncture for CTS. Both the treatment and placebo groups demonstrated improvements from baseline. Acupuncture was not shown to be superior to placebo acupuncture when used in conjunction with bracing for patients with mild to moderate CTS.

Acupuncture for migraine prophylaxis: a randomized controlled trial

BACKGROUND

Acupuncture is commonly used to treat migraine. We assessed the efficacy of acupuncture at migraine-specific acupuncture points compared with other acupuncture points and sham acupuncture.

METHODS

We performed a multicentre, single-blind randomized controlled trial. In total, 480 patients with migraine were randomly assigned to one of four groups (Shaoyang-specific acupuncture, Shaoyang-nonspecific acupuncture, Yangming-specific acupuncture or sham acupuncture [control]). All groups received 20 treatments, which included electrical stimulation, over a period of four weeks. The primary outcome was the number of days with a migraine experienced during weeks 5-8 after randomization. Our secondary outcomes included the frequency of migraine attack, migraine intensity and migraine-specific quality of life.

RESULTS

Compared with patients in the control group, patients in the acupuncture groups reported fewer days with a migraine during weeks 5-8, however the differences between treatments were not significant (p > 0.05). There was a significant reduction in the number of days with a migraine during weeks 13-16 in all acupuncture groups compared with control (Shaoyang-specific acupuncture v. control: difference -1.06 [95% confidence interval (CI) -1.77 to -0.5], p = 0.003; Shaoyang-nonspecific acupuncture v. control: difference -1.22 [95% CI -1.92 to -0.52], p < 0.001; Yangming-specific acupuncture v. control: difference -0.91 [95% CI -1.61 to -0.21], p = 0.011). We found that there was a significant, but not clinically relevant, benefit for almost all secondary outcomes in the three acupuncture groups compared with the control group. We found no relevant differences between the three acupuncture groups.

INTERPRETATION

Acupuncture tested appeared to have a clinically minor effect on migraine prophylaxis compared with sham acupuncture.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00599586.

Acupuncture in primary headache treatment

Acupuncture has a long tradition of use for the treatment of many pain conditions, including headache. Its effectiveness has been studied mainly for primary headaches, particularly for migraine and tension-type headache (TTH). Traditional Chinese Medicine (TCM) has two diagnostic frameworks for headaches: meridian diagnoses, based on the location of the pain and on the meridians (or channels) that pass through it; syndrome diagnoses, dependent on external or internal factors and on the characteristics of the pain. The four meridians involved in headache are Shaoyang (TE-GB channels, on the temporal sides of the head); Taiyang (SI-BL channels, occiput); Yangming (LI-ST channels, forehead) and Jueyin (PC-LR channels, vertex). The syndromes may be due to excess or deficit. Very generally, the excess syndromes correspond in the majority of cases to migraine and the deficit syndromes to TTH. Acupuncture is a complex intervention, which is also characterized by a close interaction between patient and therapist. The complicated system of TCM classification of headaches has frequently generated great diversity among the various therapeutic approaches used in the different studies on acupuncture in headache treatment. Despite these differences, the recent Cochrane systematic reviews on acupuncture in migraine and in TTH suggest that acupuncture is an effective and valuable option for patients suffering from migraine or frequent TTH. Moreover, acupuncture seems to be a cost-effective treatment.

Three-armed trials including placebo and no-treatment groups may be subject to publication bias: systematic review

Background

It has been argued that placebos may not have important clinical impacts in general. However, there is increasing evidence of a publication bias among trials published in journals. Therefore, we explored the potential for publication bias in randomized trials with active treatment, placebo, and no-treatment groups.

Methods

Three-armed randomized trials of acupuncture, acupoint stimulation, and transcutaneous electrical stimulation were obtained from electronic databases. Effect sizes between treatment and placebo groups were calculated for treatment effect, and effect sizes between placebo and no-treatment groups were calculated for placebo effect. All data were then analyzed for publication bias.

Results

For the treatment effect, small trials with fewer than 100 patients per arm showed more benefits than large trials with at least 100 patients per arm in acupuncture and acupoint stimulation. For the placebo effect, no differences were found between large and small trials. Further analyses showed that the treatment effect in acupuncture and acupoint stimulation may be subject to publication bias because study design and any known factors of heterogeneity were not associated with the small study effects. In the simulation, the magnitude of the placebo effect was smaller than that calculated after considering publication bias.

Conclusions

Randomized three-armed trials, which are necessary for estimating the placebo effect, may be subject to publication bias. If the magnitude of the placebo effect is assessed in an intervention, the potential for publication bias should be investigated using data related to the treatment effect.

Efficacy of acupuncture for migraine prophylaxis: a single-blinded, double-dummy, randomized controlled trial

Insufficient clinical trial data were available to prove the efficacy of acupuncture for migraine prophylaxis. A multicenter, double-dummy, single-blinded, randomized controlled clinical trial was conducted at the outpatient departments of acupuncture at 5 hospitals in China to evaluate the effectiveness of acupuncture. A total of 140 patients with migraine without aura were recruited and assigned randomly to 2 different groups: the acupuncture group treated with verum acupuncture plus placebo and the control group treated with sham acupuncture plus flunarizine. Treated by acupuncture 3 times per week and drugs every night, patients from both groups were evaluated at week 0 (baseline), week 4, and week 16. The primary outcome was measured by the proportion of responders (defined as the proportion of patients with a reduction of migraine days by at least 50%). The secondary outcome measures included the number of migraine days, visual analogue scale (VAS, 0 to 10 cm) for pain, as well as the physical and mental component summary scores of the 36-item short-form health survey (SF-36). The patients in the acupuncture group had better responder rates and fewer migraine days compared with the control group (P<.05), whereas there were no significant differences between the 2 groups in VAS scores and SF-36 physical and mental component summary scores (P>.05). The results suggested that acupuncture was more effective than flunarizine in decreasing days of migraine attacks, whereas no significantly differences were found between acupuncture and flunarizine in reduction of pain intensity and improvement of the quality of life.

Issues of design and statistical analysis in controlled clinical acupuncture trials: an analysis of English-language reports from Western journals

OBJECTIVE

To investigate major methods of design and statistical analysis in controlled clinical acupuncture trials published in the West during the past six years (2003-2009) and, based on this analysis, to provide recommendations that address methodological issues and challenges in clinical acupuncture research.

METHOD

PubMed was searched for acupuncture RCTs published in Western journals in English between 2003 and 2009. The keyword used was acupuncture.

RESULTS

One hundred and eight qualified reports of acupuncture trials that included more than 30 symptoms/conditions were identified, analyzed, and grouped into efficacy (explanatory), effectiveness (pragmatically beneficial), and other (unspecified) studies. All were randomized controlled clinical trials (RCTs). In spite of significant improvement in the quality of acupuncture RCTs in the last 30 years, these reports show that some methodological issues and shortcomings in design and analysis remain. Moreover, the quality of the efficacy studies was not superior to that of the other types of studies. Research design and reporting problems include unclear patient criteria and inadequate practitioner eligibility, inadequate randomization, and blinding, deficiencies in the selection of controls, and improper outcome measurements. The problems in statistical analysis included insufficient sample sizes and power calculations, inadequate handling of missing data and multiple comparisons, and inefficient methods for dealing with repeated measure and cluster data, baseline value adjustment, and confounding issues.

CONCLUSION

Despite recent advancements in acupuncture research, acupuncture RCTs can be improved, and more rigorous research methods should be carefully considered.

How large are the nonspecific effects of acupuncture? A meta-analysis of randomized controlled trials

BACKGROUND

While several recent large randomized trials found clinically relevant effects of acupuncture over no treatment or routine care, blinded trials comparing acupuncture to sham interventions often reported only minor or no differences. This raises the question whether (sham) acupuncture is associated with particularly potent nonspecific effects. We aimed to investigate the size of nonspecific effects associated with acupuncture interventions.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials and reference lists were searched up to April 2010 to identify randomized trials of acupuncture for any condition, including both sham and no acupuncture control groups. Data were extracted by one reviewer and verified by a second. Pooled standardized mean differences were calculated using a random effects model with the inverse variance method.

RESULTS

Thirty-seven trials with a total of 5754 patients met the inclusion criteria. The included studies varied strongly regarding patients, interventions, outcome measures, methodological quality and effect sizes reported. Among the 32 trials reporting a continuous outcome measure, the random effects standardized mean difference between sham acupuncture and no acupuncture groups was -0.45 (95% confidence interval, -0.57, -0.34; I2 = 54%; Egger's test for funnel plot asymmetry, P = 0.25). Trials with larger effects of sham over no acupuncture reported smaller effects of acupuncture over sham intervention than trials with smaller nonspecific effects (β = -0.39, P = 0.029).

CONCLUSIONS

Sham acupuncture interventions are often associated with moderately large nonspecific effects which could make it difficult to detect small additional specific effects. Compared to inert placebo interventions, effects associated with sham acupuncture might be larger, which would have considerable implications for the design and interpretation of clinical trials.

Response to Ayurvedic therapy in the treatment of migraine without aura

Migraine patients who do not respond to conventional therapy, develop unacceptable side-effects, or are reluctant to take medicines resort to complementary and alternative medicines (CAM). Globally, patients have been seeking various non-conventional modes of therapy for the management of their headaches. An Ayurvedic Treatment Protocol (AyTP) comprising five Ayurvedic medicines, namely Narikel Lavan, Sootshekhar Rasa, Sitopaladi Churna, Rason Vati and Godanti Mishran along with regulated diet and lifestyle modifications such as minimum 8 h sleep, 30-60 min morning or evening walk and abstention from smoking/drinking, was tried for migraine treatment. The duration of the therapy was 90 days. Out of 406 migraine patients who were offered this AyTP, 204 patients completed 90 days of treatment. Complete disappearance of headache and associated symptoms at completion of AyTP was observed in 72 (35.2%); mild episode of headache without need of any conventional medicines in 72 (35.2%); low intensity of pain along with conventional medicines in 50 (24.5%); no improvement in seven (3.4%) and worst pain was noted in three (1.4%) patients, respectively. In 144 (70.5%) of patients marked reduction of migraine frequency and pain intensity observed may be because of the AyTP. Though the uncontrolled open-label design of this study does not allow us to draw a definite conclusion, from this observational study we can make a preliminary assessment regarding the effectiveness of this ayurvedic treatment protocol.

Manage migraine with acupuncture: a review of acupuncture protocols in randomized controlled trials

The aim of this article is to present a standardized protocol of acupuncture for the management of migraine. A systematic review of available randomized controlled trials of acupuncture for migraineurs was conducted in the five following electronic databases: Cochrane Central Register of Controlled trials, MEDLINE, EMBASE, PsycINFO and CINAHL. Information of selected acupoints and treatment course was extracted from the included trials. Then we analyzed the treatment methods used in these trials, to identify any similarities of therapeutic approaches. Additionally, quality of all the included trials was assessed. At last, the extracted information of acupuncture protocols was analyzed, and the similarities of therapeutic approaches were summed up. Bilateral use of the following points is recommended: Fengchi (GB20), Taiyang (EX-HN5), etc. De-qi sensation is requested in acupuncture manipulating procedure, and manual stimulation is suggested. The optimal treatment frequency is twice a week with one week rest between the first 10 and the last 10 sessions. Additionally, the duration of one treatment session ought to be 30 minutes, while it is recommended to use about 20 needles in one session. The total duration of an acupuncture treatment should be at least 10 weeks. The protocol analyzed from trials with positive results is different from trials with negative in number of treatment sessions. Therefore in future trials, enough acupuncture treatment sessions should be fully considered.