The effect of acupuncture on the symptoms of knee osteoarthritis--an open randomised controlled study

Effects of acupuncture on the signs and symptoms of people with rheumatic diseases: A scoping review

INTRODUCTION

Rheumatic diseases constitute a wide range of chronic diseases that mainly affect the musculoskeletal system. They are characterized by inflammatory and degenerative processes that affect synovial joints, bones, muscles, and connective tissues. In addition, many rheumatological diseases have an autoimmune nature. This diversity of conditions results in a wide range of symptoms and degrees of severity, with a significant impact on patients' quality of life, compromising their daily activities and leading to a decline in mental health, including depressive symptoms and feelings of inadequacy.

OBJECTIVE

To map the scientific evidence in the literature on the effects of acupuncture on the signs and symptoms of people with rheumatic diseases.

METHODS

This is a scoping review, formulated according to the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist.

RESULTS

After the identification, screening and eligibility process, 18 studies were included in this review. All were published between 2002 and 2023; 33.33 % were published in China; and 50 % correspond to clinical trials. The most frequently cited diseases were: acute osteoarthritis or acute knee osteoarthritis (27.77 %); fibromyalgia (27.77 %); and rheumatoid arthritis (27.77 %). The effects of acupuncture on the signs and symptoms of people with rheumatic diseases are pain relief, improved quality of life, improved joint function, increased range of motion, anti-inflammation, reduced fatigue, decreased depression and anxiety symptoms, reduced medication use, immune system regulation, and increased finger mobility.

CONCLUSIONS

Acupuncture has beneficial effects on the signs and symptoms of people with rheumatic diseases, constituting a modality which can be easily and quickly applied by any healthcare professional, as long as they are properly trained.

Combination Treatment with Thread-Embedding Acupuncture and Electroacupuncture for Knee Osteoarthritis Patients with Postoperative Pain: A Randomized Controlled Feasibility Study

Purpose

This study aimed to evaluate the effectiveness and safety of combination treatment with thread-embedding acupuncture (TEA) and electroacupuncture (EA) in patients with persistent knee pain after arthroscopic surgery, autologous chondrocyte implantation, or autologous osteochondral transplantation.

Patients and Methods

Twelve patients with knee osteoarthritis (KOA) who experienced postoperative pain were randomized to either the treatment group (TG) or control group (CG) in a 1:1 ratio. The TG received TEA once a week for four sessions and EA twice a week for eight sessions while continuing usual care, defined as standard conventional treatments. The CG received only usual care for four weeks. The primary outcome was the visual analogue scale (VAS) score at week 4 compared with the baseline. The secondary outcomes were the VAS scores at weeks 2, 6, and 8, the Korean version of the Western Ontario and McMaster Universities Osteoarthritis Index (K-WOMAC), the EuroQol 5-Dimension 5-Level (EQ-5D-5L), and rescue medication consumption at weeks 2, 4, 6, and 8. Adverse events were assessed at each visit.

Results

The TG showed significant improvement in the VAS scores at weeks 4, 6, and 8 compared with the CG (week 4: -24.5; p = 0.0106, week 6: -19.667; p = 0.0228, week 8: -28.667; p = 0.0036). In the TG, significant differences were observed in K-WOMAC total scores at weeks 2, 4, 6, and 8 (week 2: 17.167; p = 0.0083, week 4: 23; p = 0.0018, week 6: 29.833; p = 0.0009, week 8: 30.5; p = 0.0006); however, there were no differences between the two groups. The two groups had no significant differences in the EQ-5D-5L and rescue medication consumption. No adverse events were observed in either groups during the study period.

Conclusion

This feasibility study suggests that adding combination treatment with TEA and EA to usual care might relieve pain in patients with KOA. Large-scale clinical trials are needed to confirm the long-term effects of combination treatment.

Effectiveness and Safety of Polydioxanone Thread Embedding Acupuncture Compared with Acupuncture Treatment for Knee Osteoarthritis: a Protocol for a Pilot, Assessor-Blinded, Randomized Controlled Trial

Importance

Knee osteoarthritis (OA) is a common degenerative joint disease in aging populations. Knee OA is difficult to cure and requires ongoing management. Thread embedding acupuncture (TEA) is a popular Korean medical treatment for knee OA. However, clinical evidence of its effectiveness and safety is insufficient.

Objective

This study aims to evaluate the effectiveness and safety of TEA compared with acupuncture for knee OA.

Design, Setting, and Population

A two-group, two-arm, parallel, single-center, randomized, controlled, and assessor-blinded pilot trial will be conducted. A total of sixty patients aged between 40 and 85 years old will be recruited.

Exposures

The TEA group will receive four sessions of TEA treatment over 4 weeks. The acupuncture group will receive eight sessions of acupuncture treatment over 4 weeks. A follow-up assessment will be conducted in week 8 for both groups.

Main Outcomes and Measures

Assessments will be performed at baseline, 2 weeks, 4 weeks, and 8 weeks. The primary outcome will be the mean change in the visual analog scale between the two groups at 4 weeks. The secondary outcomes will be the mean change in the Korean Western Ontario and McMaster Universities Osteoarthritis Index, knee range of motion, EuroQol 5-Dimension, patient global impression of change, and dosage of rescue medication. Statistical analysis will be conducted and the level of significance will be achieved in each variables.

Results

The results will be published in a peer-reviewed journal.

Conclusions and Relevance

This study provides a rationale for the effectiveness and safety of TEA for knee OA by comparing TEA treatment with acupuncture.

Evidence of Commonly Used Integrative Approaches with Pharmacotherapy for Chronic Pain Management

This review examines the integration of traditional pharmacological methods with alternative and complementary therapies in chronic pain management. It delves into neurostimulation techniques, highlighting their clinical outcomes and biological bases. Acupuncture's role in modulating pain pathways is explored, illustrating its balance of tradition and clinical application. The paper also covers the pain-relieving potential of herbal medicine, emphasizing natural products' significance in pain relief. Additionally, it discusses the psychological and rehabilitative dimensions of pain through psychosocial therapy and counseling. The conclusion underscores the importance of a multidisciplinary approach, integrating diverse therapies into conventional pain management to effectively treat chronic pain. This synthesis highlights the synergistic potential of combining traditional and innovative therapeutic modalities, offering a comprehensive guide for healthcare professionals in enhancing pain management practices.

The effectiveness of acupuncture as an adjunctive therapy to oral pharmacological medication in patient with knee osteoarthritis: A systematic review and meta-analysis

BACKGROUND

We aimed to find out whether the combined treatment of acupuncture and oral medication is more effective than sole oral medication in reducing pain and improving knee function at the end of treatment and after short-term period (4-6 weeks after treatment). Second, if it is effective, we investigated whether the effect surpasses the minimal clinically important difference.

METHODS

Articles published between January 1, 1992, and August 31, 2022, were searched in PubMed, Cochrane, and Embase. The PICO (population, intervention, comparison, and outcome) of this study are as follows: Population: knee osteoarthritis patients; Intervention: acupuncture (non-sham acupuncture) + oral medication (analgesic or non-steroidal anti-inflammatory drugs); Comparison: oral medication (analgesic or non-steroidal anti-inflammatory drugs); Outcome: visual analog scale (VAS) or Western Ontario and McMaster University (WOMAC) osteoarthritis index.

RESULTS

The combined treatment of oral medication and adjuvant acupuncture showed statistically significant improvement in VAS and WOMAC scores at the end of acupuncture treatment and short-term follow-up time (between 4 and 6 weeks after acupuncture). In addition, the degree of improvement of VAS and WOMAC index showed effects beyond minimal clinically important differences compared to pretreatment at both the end of acupuncture treatment and the short-term follow-up of acupuncture treatment.

CONCLUSION

The existing evidence suggests that adjuvant acupuncture may play a role in the treatment of knee osteoarthritis. However, physicians should be aware of adverse effects such as hematoma in adjuvant acupuncture treatment.

Efficacy of Acupuncture-Related Therapy in the Treatment of Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Knee osteoarthritis (KOA) is prevalent in middle-aged and elderly people. This condition negatively affects the quality of life of patients. Although non-steroidal anti-inflammatory drugs (NSAIDs) are often used to relieve symptoms associated with KOA, it is associated with many side effects. Acupuncture and moxibustion therapies have been applied in the treatment of KOA. However, the efficacy of various acupuncture and moxibustion treatments has not been compared.

METHODS

Randomized controlled trials (RCTs) on the application of acupuncture and moxibustion in the treatment of KOA were searched in English databases and Chinese databases. Data were retrieved from establishment of the database to September 2020. Data analysis was performed using Stata14.0 and GeMTC 0.14.3 softwares.

RESULTS

A total of 40 RCTs involving 3215 patients with KOA were retrieved. Network meta-analysis revealed that the fire needle was superior to western medicine, electro-acupuncture, conventional acupuncture, warm needle and sham acupuncture; warm needle was better than conventional acupuncture and western medicine whereas electro-acupuncture was better than conventional acupuncture in improving pain scores in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Moreover, we found that fire needle and warm needle more effectively improved WOMAC stiffness scores than western medicine and sham moxibustion, whereas electro-acupuncture was superior to western medicine and sham moxibustion in improving WOMAC stiffness scores. Further analysis revealed that fire needle, warm needle and electro-acupuncture were more effective in improving WOMAC joint function scores than conventional acupuncture and western medicine. The fire needle was superior to conventional acupuncture and sham acupuncture, whereas electro-acupuncture was better than western medicine, conventional acupuncture and sham acupuncture in improving visual analogue scale scores.

CONCLUSION

This study shows that fire needle is superior to warm needle and electro-acupuncture, whereas warm needle and electro-acupuncture are better than conventional acupuncture, western medicine, sham moxibustion and sham acupuncture.

Effectiveness and safety of polydioxanone thread-embedding acupuncture (TEA) and electroacupuncture (EA) treatment for knee osteoarthritis (KOA) patients with postoperative pain: An assessor-blinded, randomized, controlled pilot trial

BACKGROUND

Degenerative knee osteoarthritis (KOA) shows an increase in morbidity with improvement in the living conditions and extended lifespans. Treatment for degenerative KOA has been gaining attention since it significantly affects the life of the elderly population and is also associated with increased expenses for medical services and high socioeconomic costs. Treatments for degenerative KOA include nondrug therapy, drug therapy, and surgical treatment. For cases that show little response to conservative treatment but have not involved severe deformation of the knee, procedures such as arthroscopic surgery, autologous chondrocyte implantation, or autologous osteochondral transplantation can be performed. However, effective treatment is required for patients experiencing sustained knee pain after surgery. Although studies confirming the therapeutic effects of acupuncture or thread-embedding acupuncture (TEA) treatment for degenerative KOA have been reported, clinical studies on a combination of TEA and electroacupuncture (EA) in patients complaining of knee pain after arthroscopic surgery, autologous chondrocyte implantation, or autologous osteochondral transplantation have not yet been reported. Therefore, this study aimed to evaluate the effectiveness and safety of this combination treatment in patients with persistent knee pain after arthroscopic surgery, autologous chondrocyte implantation, or autologous osteochondral transplantation.

METHODS/DESIGN

This study has been designed as a 2-group, parallel, single-center, randomized, controlled, assessor-blinded trial. Thirty-six patients with degenerative KOA who complained of pain even after arthroscopic surgery, autologous chondrocyte implantation, or autologous osteochondral transplantation will be randomized to either the (TEA + EA + Usual care) group or the (Usual care only) group in a 1:1 ratio. The patients in the (TEA + EA + Usual care) group will receive TEA treatment once a week for 4 weeks for a total of 4 sessions and EA twice a week for a total of 8 sessions while continuing usual care. The (Usual care only) group will only receive usual care for 4 weeks. To assess the efficacy of the TEA and EA combination treatment, the visual analogue scale, the Korean version of the Western Ontario and McMaster Universities Osteoarthritis Index, the EuroQol 5-Dimension 5-Level, and the doses of the rescue drug taken will be evaluated at baseline (1W) and weeks 2 (2W), 4 (4W), 6 (6W), and 8 (8W). The primary efficacy endpoint is the mean change in visual analogue scale at week 4 (4W) compared to baseline. Adverse events will be assessed at every visit.

DISCUSSION

This study will provide useful data for evaluating the clinical efficacy and safety of TEA and electroacupuncture combination treatment for improving pain and quality of life after surgery for degenerative KOA.

TRIAL REGISTRATION

Clinical Research Information Service of Republic of Korea (CRIS- KCT0004804), March 6, 2020.

Combined effect of laser acupuncture and electroacupuncture in knee osteoarthritis patients: A protocol for a randomized controlled trial

BACKGROUND

Knee osteoarthritis (KOA) is a common degenerative joint disorder that affects 250 million people globally. KOA can lead to disability and is often associated with cardiovascular disease, poor quality of life, and mortality. The most common treatment for KOA is non-steroidal anti-inflammatory drug administration. However, the analgesic effect is limited and often accompanied by multiple side effects. Hence, many KOA patients opt for complementary and alternative medicine. Acupuncture is one of the most popular complementary treatments with great analgesic effect and minimal side effect. Electroacupuncture (EA) and laser acupuncture (LA) have been known to reduce pain in KOA patients. However, to date, no study has assessed the benefits of combining these two therapies.

METHODS

Fifty participants diagnosed with KOA, aged 50 years or older, and with consistent knee pain for more than 3 months were recruited and randomly assigned to the treatment group (EA plus LA) or control group (EA plus sham LA without laser output). All subjects in the treatment group will undergo a combined EA and LA treatment thrice a week for 4 weeks. The acupuncture will be performed on GB33, GB34, SP9, SP10, and ST36 sites. The treatment group will receive acupuncture with a transcutaneous electrical nerve stimulator at GB33, GB34, SP9, and SP10 sites and with LA at EX-LE5, ST35, and BL40 sites. The subjects in the control group will undergo the same treatment modality as the treatment group, except these subjects will not be exposed to laser output. Outcome measurements will include visual analog scale, Western Ontario McMaster Universities Osteoarthritis Index, Knee injury and osteoarthritis outcome, body composition analysis, knee range of motion, quadriceps muscle stiffness, one-leg standing with eyes open test, and the 30-s chair stand test before and after 4 weeks of intervention.

OBJECTIVES

This protocol aims to investigate the combined effect of EA and LA in KOA patients.

A Guideline for Randomized Controlled Trials of Acupuncture

Guidelines for clinical trials of acupuncture are scarce, particularly in their guidance on choosing an adequate control in an acupuncture trial. This guideline was developed to address the research methodology for clinical research in acupuncture which contains the essential elements to be considered in the design, preparation and reporting of an acupuncture RCT. Particularly, investigators focused on the control design because of the unique feature of acupuncture. As one size does not fit all, one single design cannot answer all research questions. Therefore, we recommend that the clinical questions be answered in different stages of trials by choosing the appropriate control or comparator. This concept is adapted from classical drug trials developed by the Food and Drug Administration (FDA) of USA in which trials are staged in four phages in order to address different research questions. From the points listed above, this guideline offers the specific recommendations in an acupuncture RCT.

The Effectiveness of Acupuncture for Osteoarthritis of the Knee – a Systematic Review

Objective

To determine the effectiveness of acupuncture treatment for pain and function of patients with osteoarthritis of the knee.

Methods

A systematic review of randomised controlled trials was performed, including a meta-analysis which combined the results of trials that used adequate acupuncture treatment and used WOMAC scores to measure the effect. The internal validity (quality) and heterogeneity of studies were taken into account.

Results

Thirteen studies were available, of which eight, involving 2362 patients, could be combined. For both reduction of pain and improvement of function, acupuncture was significantly superior to sham acupuncture (P<0.05 for all comparisons) in both the short term and the long term. Compared with no additional intervention (usual care), acupuncture was again significantly superior for pain and function. The treatment effects were maintained after taking account of quality and heterogeneity in sensitivity analyses.

Conclusion

Acupuncture is an effective treatment for osteoarthritis of the knee. Its overall effect size is 0.8, and it can be considered instead of non-steroidal anti-inflammatory drugs for patients whose symptoms are not controlled by education, exercise, weight loss if appropriate and simple analgesics. Further research is necessary into the most efficient way of delivering acupuncture, and its longer term benefits.

A Blinded Randomised Trial of Acupuncture (Manual and Electroacupuncture) Compared with a Non-Penetrating Sham for the Symptoms of Osteoarthritis of the Knee

Objectives

To compare the effect of acupuncture (manual and electroacupuncture) with that of a non-penetrating sham (‘placebo’ needle) in patients with osteoarthritic knee pain and disability who are blind to the treatment allocation.

Methods

Acupuncture naive patients with symptomatic and radiological evidence of osteoarthritis of the knee were randomly allocated to a course of either acupuncture or non-penetrating sham acupuncture using a sheathed ‘placebo’ needle system. Acupuncture points for pain and stiffness were selected according to acupuncture theory for treating Bi syndrome. Both manual and electrical stimulation were used. Response was assessed using the WOMAC index for osteoarthritis of the knee, self reported pain scale, the EuroQol score and plasma β-endorphin. The effectiveness of blinding was assessed.

Results

There were 34 patients in each group. The primary end point was the change in WOMAC pain score after the course of treatment. Comparison between the two treatment groups found a significantly greater improvement with acupuncture (mean difference 60, 95% CI 5 to 116, P=0.035) than with sham. Within the acupuncture group there was a significant improvement in pain (baseline 294, mean change 95, 95% CI 60 to 130, P<0.001) which was not seen by those who had sham acupuncture (baseline 261, mean change 35, 95% CI-10 to 80, P=0.12). Similar effects within group, but not between groups, were seen with the secondary end points of WOMAC stiffness, WOMAC function, and self reported pain. One month after treatment the between group pain difference had been lost (mean difference 46; 95% CI −9 to 100, P=0.10) although the acupuncture group was still benefiting compared to baseline (mean difference 59; 95% CI 16 to 102, P=0.009). The EuroQol score, a generic measure of health related quality of life, was not altered by the treatments. A minority of patients correctly guessed their treatment group (41% in the acupuncture group and 44% in the control group). Plasma β-endorphin levels were not affected by either treatment.

Conclusions

Acupuncture gives symptomatic improvement for patients with osteoarthritis of the knee, and is significantly superior to non-penetrating sham acupuncture. The study did not confirm earlier reports of release of plasma β-endorphin during acupuncture.

Controlling Practitioner–patient Relationships in Acupuncture Trials: A Systematic Review and Meta-Regression

Background

In trials, ‘therapist intensive’ complex interventions are typically delivered over time, during which a relationship between the practitioner and participant may develop. Such relationships are sometimes criticised as obscuring any ‘true’ treatment effect. Limiting interactions is one strategy that might be used to try to control for the effect of a therapeutic relationship.

Objectives

We conducted systematic review into the rationale, methods and effects of constraining relationships in controlled trials and cohort studies of acupuncture, including studies published before 2008 with an update citation search in 2010.

Methods

We searched six databases without keyword restrictions. Meta-analysis and meta-regression were used to explore the effect of relationship constraint on pain outcomes.

Results

Eighty-one of 785 (10.3%) trials reported constraining relationships. Most did not state the reason for constraint, describe the nature of the limitation, provide information on how the constrained relationship was monitored or note protocol adherence. Where a reason was reported, this was primarily to maintain participant blinding, rarely was it stated that the constraint was to control the therapeutic relationship. We found no evidence of an effect of constraint on pain outcomes (percentage heterogeneity explained, p=0.89). These results were robust to variation in trial quality and design.

Conclusions

Acupuncture trials appear to be constrained mostly to try to prevent participant unblinding to their allocated treatment, not to control the therapeutic relationship. The apparent lack of monitoring and negligible effects on pain outcomes of the included trials indicate the need for more high-quality randomised controlled trials investigating the effect of constraint.

Mechanisms of Action of Acupuncture for Chronic Pain Relief – Polymodal Receptors Are the Key Candidates

Therapeutic benefits of acupuncture for chronic pain patients have been clearly identified in recent clinical trials. Underlying mechanisms of acupuncture action mediated by endogenous opioids have been well demonstrated. The existence of pain inhibitory systems in the central nervous system has also been clarified and acupuncture seems to be a potent stimulus for activating the analgesic systems, although the pain mechanisms in acute and chronic states are essentially different. On the other hand, the exact nature of the acupuncture point still remains unclear. Here, we propose a key role of polymodal receptors (PMR) in acupuncture and moxibustion and offer a rational explanation of the acupuncture point as a sensitised PMR.

Moxibustion (burning of moxa) therapy has been shown by medical historians to predate the use of acupuncture, and the meridian theory developed in association with moxibustion treatment. A variety of sensory receptors are activated by acupuncture and/or moxibustion, but there are very few that can be excited by both stimuli. PMRs are one of the most promising candidates. The functional characteristics of PMRs correspond with those of acupuncture action in the periphery; and tender or trigger points, one of the primitive features of acupuncture points, are assumed to be the sites of sensitised PMRs. Diffuse noxious inhibitory control (DNIC) is proposed as a possible mechanism of immediate action of acupuncture, and inputs for the development of DNIC seem to be the PMRs.

In our experimental model, repeated eccentric contractions of muscle produced local tenderness at the palpable band and induced a typical referred pain pattern on application of pressure. Repeated indomethacin injections inhibited the production of the experimental trigger point.

These lines of evidence suggest that the acupuncture points are the sites where the PMRs are sensitised and that such conditions might be repeatedly produced by various biomechanical stressors, insufficient blood supply and metabolic products.

Comparison of the Effectiveness of Six and Two Acupuncture Point Regimens in Osteoarthritis of the Knee: A Randomised Trial

Background

Although substantial data have supported the effectiveness of acupuncture for treating knee osteoarthritis (OA), the number of points used has varied. The objective of this study was to compare the effectiveness of six and two acupuncture points in the treatment of knee OA.

Methods

A randomised trial of knee OA patients was conducted. Patients were randomly allocated into two groups of 35. The “six point group” received treatment at six acupuncture points, ST35, EX-LE4 ( Neixiyan), ST36, SP9, SP10 and ST34, while the “two point group” received treatment at just the first pair of points, ST35 and EX-LE4. Both groups received twice weekly electroacupuncture on 10 occasions. Electrical stimulation was carried out at low-frequency of 3 Hz to all points, with the intensity as high as tolerable. Both groups were allowed to take a 200 mg celecoxib capsule per day for intolerable pain. Patients were assessed at baseline, week 5, week 9 and week 13, using a Thai language version of the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Global assessment of change after 10 treatments was also recorded.

Results

Acupuncture at both six and two acupuncture points was associated with significant improvement. Mean total WOMAC score at weeks 5 and 13 of patients in both groups showed no significant difference statistically (p = 0.75 and p = 0.51). Moreover, the number of celecoxib capsules taken, global assessment of global change and body weight change of both groups also showed no statistical difference.

Conclusion

This evidence suggests that electroacupuncture to two local points may be sufficient to treat knee OA, but in view of some limitations to this study further research is necessary before this can be stated conclusively.

Trigger Point Acupuncture for Treatment of Knee Osteoarthritis – a Preliminary Rct for a Pragmatic Trial

Background

There is evidence for the efficacy of acupuncture treatment in knee osteoarthritis, but it remains unclear which acupuncture modes are most effective. We evaluated the effects of trigger point acupuncture on pain and quality of life in knee osteoarthritis patients, compared with acupuncture at standard points, and sham acupuncture.

Methods

Thirty patients (27 women, 3 men; aged 61–82 years) with non-radiating knee osteoarthritis pain for at least six months and normal neurological examination were randomised to one of three groups for the study period of 21 weeks. Each group received five acupuncture treatment sessions. The standard acupuncture point group ( n=10) received treatment at traditional acupuncture points for knee pain; the trigger point acupuncture group ( n=10) received treatment at trigger points; and the third group ( n=10) received sham acupuncture treatment at the trigger points. Outcome measures were pain intensity (visual analogue scale, VAS) and WOMAC index (Western Ontario and McMaster Universities Arthritis Index). The groups were compared by the area under the curve method.

Results

Five patients dropped out of the study because of lack of improvement, and one patient (in the trigger point acupuncture group) dropped out because of deterioration of symptoms; the remaining 24 patients were included in the analysis. After treatment, the trigger point acupuncture group reported less pain intensity on VAS than the standard acupuncture or sham treatment group, but both the trigger point acupuncture and standard acupuncture groups reported improvement of function of knee. There was a significant reduction in pain intensity between pre-treatment and five weeks after treatment for the trigger point acupuncture (P<0.01) and standard acupuncture groups (P<0.01) included in the analysis, but not for the sham treatment group. Group comparison using the area under the curves demonstrated a significant difference only between trigger point acupuncture and sham treatment groups analysed (P<0.025 for VAS, and P<0.031 for WOMAC).

Conclusion

These results suggest that trigger point acupuncture therapy may be more effective for osteoarthritis of the knee in some elderly patients than standard acupuncture therapy.

Safety of Acupuncture for Osteoarthritis of the Knee – a Review of Randomised Controlled Trials, Focusing on Specific Reactions to Acupuncture

In order to assess how many reported adverse reactions to acupuncture are truly associated with the physiological mechanisms of acupuncture, we performed a literature review of published RCTs of acupuncture for osteoarthritis of the knee. We searched for reports of RCTs using two data sources: PubMed and Japana Centra Revuo Medicina (Igaku Chuo Zasshi). Of the twelve RCTs located, seven included information on adverse events. No serious adverse events were reported. Joint swelling, local inflammation, haematoma and back pain occurred more frequently in the dummy electroacupuncture or minimal acupuncture group. We confirmed the possibility that many adverse reactions to acupuncture treatment reported in RCTs, at least for the knee OA, are non-specific, and that not all reported events should be attributed to the mechanism of action of acupuncture. It is likely this is also true for RCTs of acupuncture in other conditions, and for prospective surveys on adverse events of acupuncture.

Electroacupuncture Ameliorates Subchondral Bone Deterioration and Inhibits Cartilage Degeneration in Ovariectomised Rats

Objectives

To investigate the effects of electroacupuncture (EA) on subchondral bone mass and cartilage degeneration in an experimental animal model of osteoarthritis (OA) induced by ovariectomy (OVX).

Methods

Ninety 3-month-old female Sprague-Dawley rats were randomly divided into the following three groups (n = 30 each): sham operation without treatment (control group); OVX without treatment (OVX group);, and ovariectomy with EA treatment (EA group). Rats in the EA group received EA treatment from the day of OVX. Ten rats in each group were randomly killed at 4, 8 and 12 weeks after operation.

Results

EA reduced urine C-terminal cross-linking telopeptide of type I collagen from 4 weeks after OVX, reduced C-terminal cross-linking telopeptide of type II collagen and body weight from 8 weeks after OVX, and increased serum 17β-oestradiol from 4 weeks after OVX compared with the OVX group (all p<0.01). In the EA group, trabecular bone volume ratio, trabecular thickness and trabecular number increased, and trabecular separation were reduced at each time point compared with the OVX group (p<0.05, p<0.01, respectively). In the EA group, osteoprotegerin (OPG) expression was increased and receptor activator of nuclear factor kappa-B ligand (RANKL) expression was reduced at each time point compared with the OVX group (p<0.05, p<0.01, respectively). Mankin scores and mRNA expression of matrix metalloproteinase-13 (MMP-13) were lower in EA versus OVX groups at 12 weeks after OVX (both p<0.01).

Conclusion

The results suggest that EA inhibits subchondral bone loss by regulating RANK/RANKL/OPG signalling and protects articular cartilage by inhibiting MMP-13 in OVX rats.

Use of acupuncture in the management of pain

Nurses practising in almost any area of healthcare may encounter individuals who are considering acupuncture, particularly those caring for people who are experiencing chronic pain. Acupuncture is a complex intervention and in traditional practice is not simply the insertion of needles, as some people believe. This article provides a historical understanding of acupuncture, outlining some of the differences between styles of practice that may be relevant when selecting an acupuncturist. It also examines the issues that should be considered when assessing the evidence base for acupuncture.

Acupuncture for hip osteoarthritis

BACKGROUND

Hip osteoarthritis (OA) is a major cause of pain and functional limitation. Few hip OA treatments have been evaluated for safety and effectiveness. Acupuncture is a traditional Chinese medical therapy which aims to treat disease by inserting very thin needles at specific points on the body.

OBJECTIVES

To assess the benefits and harms of acupuncture in patients with hip OA.

SEARCH METHODS

We searched Cochrane CENTRAL, MEDLINE, and Embase all through March 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared acupuncture with sham acupuncture, another active treatment, or no specific treatment; and RCTs that evaluated acupuncture as an addition to another treatment. Major outcomes were pain and function at the short term (i.e. < 3 months after randomization) and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Six RCTs with 413 participants were included. Four RCTs included only people with OA of the hip, and two included a mix of people with OA of the hip and knee. All RCTs included primarily older participants, with a mean age range from 61 to 67 years, and a mean duration of hip OA pain from two to eight years. Approximately two-thirds of participants were women. Two RCTs compared acupuncture versus sham acupuncture; the other four RCTs were not blinded. All results were evaluated at short term (i.e. four to nine weeks after randomization).In the two RCTs that compared acupuncture to sham acupuncture, the sham acupuncture control interventions were judged believable, but each sham acupuncture intervention was also judged to have a risk of weak acupuncture-specific effects, due to placement of non-penetrating needles at the correct acupuncture points in one RCT, and the use of penetrating needles not inserted at the correct points in the other RCT. For these two sham-controlled RCTs, the risk of bias was low for all outcomes.The combined analysis of two sham-controlled RCTs gave moderate quality evidence of little or no effect in reduction in pain for acupuncture relative to sham acupuncture. Due to the small sample sizes in the studies, the confidence interval includes both the possibility of moderate benefit and the possibility of no effect of acupuncture (120 participants; Standardized Mean Difference (SMD) -0.13, (95% Confidence Interval (CI) -0.49 to 0.22); 2.1 points greater improvement with acupuncture compared to sham acupuncture on 100 point scale (i.e., absolute percent change -2.1% (95% CI -7.9% to 3.6%)); relative percent change -4.1% (95% CI -15.6% to 7.0%)). Estimates of effect were similar for function (120 participants; SMD -0.15, (95% CI -0.51 to 0.21)). No pooled estimate, representative of the two sham-controlled RCTs, could be calculated or reported for the quality of life outcome.The four other RCTs were unblinded comparative effectiveness RCTs, which compared (additional) acupuncture to four different active control treatments.There was low quality evidence that addition of acupuncture to the routine primary care that RCT participants were receiving from their physicians was associated with statistically significant and clinically relevant benefits, compared to the routine primary physician care alone, in pain (1 RCT; 137 participants; mean percent difference -22.9% (95% CI -29.2% to -16.6%); relative percent difference -46.5% (95% CI -59.3% to -33.7%)) and function (mean percent difference -19.0% (95% CI -24.41 to -13.59); relative percent difference -38.6% (95% CI -49.6% to -27.6%)). There was no statistically significant difference for mental quality of life and acupuncture showed a small, significant benefit for physical quality of life.The effects of acupuncture compared with either advice plus exercise or NSAIDs are uncertain.We are also uncertain whether acupuncture plus patient education improves pain, function, and quality of life, when compared to patient education alone.In general, the overall quality of the evidence for the four comparative effectiveness RCTs was low to very low, mainly due to the potential for biased reporting of patient-assessed outcomes due to lack of blinding and sparse data.Information on safety was reported in four RCTs. Two RCTs reported minor side effects of acupuncture, which were primarily minor bruising, bleeding, or pain at needle insertion sites. Four RCTs reported on adverse events, and none reported any serious adverse events attributed to acupuncture.

AUTHORS' CONCLUSIONS

Acupuncture probably has little or no effect in reducing pain or improving function relative to sham acupuncture in people with hip osteoarthritis. Due to the small sample size in the studies, the confidence intervals include both the possibility of moderate benefits and the possibility of no effect of acupuncture. One unblinded trial found that acupuncture as an addition to routine primary physician care was associated with benefits on pain and function. However, these reported benefits are likely due at least partially to RCT participants' greater expectations of benefit from acupuncture. Possible side effects associated with acupuncture treatment were minor.

The quality of reporting in randomized controlled trials of acupuncture for knee osteoarthritis: A cross-sectional survey

OBJECTIVE

To assess the reporting quality of acupuncture trials for knee osteoarthritis (KOA), and explore the factors associated with the reporting.

METHOD

Three English and four Chinese databases were searched from inception to December 2016 for randomized control trials testing effects of acupuncture for knee osteoarthritis. We used the standard CONSORT (2010 version), CONSORT Extension for Non-Pharmacological Treatments, and STRICTA for measuring the quality of reporting. Using pre-specified study characteristics, we undertook regression analyses to examine factors associated with the reporting quality.

RESULTS

A total of 318 RCT reports were included. For the standard CONSORT, ten items were substantially under-reported (reported in less than 5% of RCTs), including specification of important changes to methods after trial commencement (0.6%), description of any changes to trial outcomes (0.0%), implementation of interim analyses and stopping guidelines (0.6%), statement about why the trial ended or was stopped (1.6%), statement about the registration status (4.4%), accessibility of full trial protocol (4.7%), implementation of randomization (4.7%), description of the similarity of interventions (3.5%), conduct of ancillary analyses (3.8%) and presentation of methods for additional analyses (4.4%). Four of the STRICTA items were under-reported (reported in less than 10% of RCTs), including description of acupuncture style (8.5%), presentation of extent to which treatment varied (1.3%), statement of practitioner background (7.2%) and rationale for the control (9.1%). For CONSORT Extension, the reporting was poor across all items (reported in less than 10% of trials). Trials including authors with expertise in epidemiology or statistics, published in English, or enrolling patients from multiple centers were more likely to have better reporting.

CONCLUSIONS

The reporting in RCTs of acupuncture for KOA was generally poor. To improve the reporting quality, journals should encourage strict adherence to the reporting guidelines.

Evaluation of the Effectiveness of Acupuncture in the Treatment of Knee Osteoarthritis: A Case Study

Background: Osteoarthritis is a widespread chronic disease seen as a continuum of clinical occurrences within several phases, which go from synovial inflammation and microscopic changes of bone and cartilage to painful destructive changes of all the joint structures. Being the most common joint disease, it is the leading cause of disability in working individuals above 50 years of age. In some cases, conventional treatments produce just a mild and brief pain reduction and have considerable side-effects. Contemporary Traditional Chinese Medicine (TCM) is a model of systems biology based on a logically accessible theoretical background. It integrates several therapeutic approaches, among them acupuncture, which has shown effective results in the treatment of knee and hip osteoarthritis, minimizing pain, improving functionality and consequently leading to a better quality of life. Methods: The present case study included two patients with clinical signs of osteoarthritis and diagnosis of medial pain, as defined by the Heidelberg Model of TCM. Over 6 weeks, those patients were treated with acupuncture, with a frequency of one session a week. The sessions lasted for thirty minutes and were based on the needling of 4 local acupoints. Before and after each session, pain and mobility assessments were performed. Results: The results were positive, with significant reduction of pain and increased knee joint flexion amplitude and mobility. Conclusion: Acupuncture was effective as an alternative or complementary treatment of knee osteoarthritis, with high levels of improvement within a modest intervention period.

Updated systematic review and meta-analysis of acupuncture for chronic knee pain

OBJECTIVE

To assess the effectiveness and safety of acupuncture for the treatment of chronic knee pain (CKP).

METHODS

We searched the MEDLINE, EMBASE, Cochrane CENTERAL, CINAHL and four Chinese medical databases from their inception to June 2017. We included randomised controlled trials of acupuncture as the sole treatment or as an adjunctive treatment for CKP. The primary outcome was pain intensity measured by visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale and 11-point numeric rating scale. Secondary outcome measurements included the 36-Item Short Form Health Survey and adverse events. The quality of all included studies was evaluated using the Cochrane risk-of-bias criteria and the STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) checklist.

RESULTS

Nineteen trials were included in this systematic review. Of these, data from 17 studies were available for analysis. Regarding the effectiveness of acupuncture alone or combined with other treatment, the results of the meta-analysis showed that acupuncture was associated with significantly reduced CKP at 12 weeks on WOMAC pain subscale (mean difference (MD) -1.12, 95% confidence interval (CI) -1.98 to -0.26, I²=62%, 3 trials, 608 participants) and VAS (MD -10.56, 95% CI -17.69 to -3.44, I²=0%, 2 trials, 145 patients). As for safety, no difference was found between the acupuncture and control groups (risk ratio 1.08, 95% CI 0.54 to 2.17, I²=29%).

CONCLUSION

From this systematic review, we conclude that acupuncture may be effective at relieving CKP 12 weeks after acupuncture administration, based on the current evidence and our protocol. However, given the heterogeneity and methodological limitations of the included trials, we are currently unable to draw any strong conclusions regarding the effectiveness of acupuncture for chronic knee pain. In addition, we found that acupuncture appears to have a satisfactory safety profile, although further studies with larger numbers of participants are needed to confirm the safety of this technique.

STRENGTHS

Systematic review without language restrictions.

LIMITATIONS

Only a few high-quality and consistent trials could be included in this review.

Electro-Acupuncture is Beneficial for Knee Osteoarthritis: The Evidence from Meta-Analysis of Randomized Controlled Trials

Knee osteoarthritis (KOA) is a common chronic degenerative disease of the elderly. Electro-acupuncture (EA) is considered as a beneficial treatment for KOA, but the conclusion is controversial. This systematic review compiled the evidence from 11 randomized controlled trials to objectively assess the effectiveness and safety of EA for KOA. Eight databases including PubMed, Cochrane Library, Clinic trials, Foreign Medical Literature Retrial Service (FMRS), Science Direct, China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), and Wanfang Data were extensively searched up to 5 July 2016. The outcomes included the evaluation of effectiveness, pain and physical function. Risk of bias was evaluated according to the Cochrane risk of bias tool. Eleven RCTs with 695 participants were included. Meta-analysis indicated that EA was more effective than pharmacological treatment (RR [Formula: see text] 1.14; 95% CI [Formula: see text] 1.01,1.28; [Formula: see text]) and manual acupuncture (RR [Formula: see text] 1.12; 95% CI [Formula: see text] 1.02,1.22; [Formula: see text]). Also, EA had a more significant effect in reducing the pain intensity (SMD [Formula: see text]; 95% CI [Formula: see text]; [Formula: see text]) and improving the physical function in the perspective of WOMAC (MD [Formula: see text]; 95% CI [Formula: see text], 5.56; [Formula: see text]) and LKSS (pharmacological treatment: MD [Formula: see text]; 95% CI [Formula: see text], 6.64; [Formula: see text]). Furthermore, these studies implied that EA should be performed for at least 4 weeks. Conclusively, the results indicate that EA is a great opportunity to remarkably alleviate the pain and improve the physical function of KOA patients with a low risk of adverse reaction. Therefore, more high quality RCTs with rigorous methods of design, measurement and evaluation are needed to confirm the long-term effects of EA for KOA.

Owner assessment of chronic pain intensity and results of gait analysis of dogs with hip dysplasia treated with acupuncture

OBJECTIVE To evaluate pain intensity and kinetic variables in dogs with hip dysplasia (HD) treated with acupuncture, carprofen, or a placebo. DESIGN Randomized, controlled clinical study. ANIMALS 54 HD-affected dogs and 16 healthy dogs. PROCEDURES Seven HD-affected dogs were removed from the study. Dogs with HD were treated in a blinded manner for 30 days with acupuncture (once weekly for 5 sessions; n = 15), carprofen (4.4 mg/kg [2.0 mg/lb], PO, q 24 h; n = 16), or placebo capsules containing lactose (1 mg/kg [0.45 mg/lb], PO, q 24 h; n = 16). Dogs were evaluated 2 weeks and immediately before (baseline) and 2, 4, and 6 weeks after the onset of treatment. Owners evaluated the dogs' pain intensity with 2 validated questionnaires and a visual analogue scale (VAS) for pain and evaluated degree of lameness with a VAS for locomotion. Kinetics of the hind limbs were also evaluated. Sixteen HD-free dogs were used to assess the evaluation protocol. RESULTS Owners' assessments revealed that outcomes of the 3 treatments did not differ significantly. The Canine Brief Pain Inventory and VAS pain intensity assessments were decreased from baseline at weeks 4 and 6, respectively, but only in acupuncture-treated dogs. The locomotion VAS values were decreased at week 4 in acupuncture-treated and carprofen-treated dogs. Kinetic evaluation findings did not differ among the groups or over time. CONCLUSIONS AND CLINICAL RELEVANCE Neither acupuncture nor carprofen was significantly different from placebo. Acupuncture and carprofen reduced the degree of subjectively evaluated lameness, and acupuncture was associated with a decrease in validated chronic pain scores.

Presence of caffeine reversibly interferes with efficacy of acupuncture-induced analgesia

Acupuncture is an alternative treatment for wide spectrum chronic pain. However, its validity remains controversial due to the disputed efficacy assessed in various clinical studies. Moreover, variability amongst individuals complicates the predictability of outcome, which impedes the integration of acupuncture into mainstream pain management programs. In light of our previous finding that the analgesic effect of acupuncture is mediated by adenosine A1 receptor activation at the acupuncture point, we here report that in acute and chronic animal pain models, oral intake of caffeine, a potent adenosine receptor antagonist, interferes with acupuncture analgesia, even at a low dose. Local administration of caffeine at the acupuncture point was sufficient to eliminate the analgesic effect, dismissing the systemic action of caffeine. Such interference was reversible, as caffeine withdrawal fully restored the efficacy of acupuncture by the next day, and long-term exposure to caffeine did not alter A1 receptor expression at the acupuncture point. Combined, these data indicate that a trace amount of caffeine can reversibly block the analgesic effects of acupuncture, and controlling caffeine consumption during acupuncture may improve pain management outcomes.

Acupuncture for chronic pain and depression in primary care: a programme of research

Background

There has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money.

Aim

Our aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression.

Methods and results

We synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective.

Conclusion

We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence.

Trial registration

Current Controlled Trials ISRCTN63787732.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Efficacy of focused low-intensity pulsed ultrasound therapy for the management of knee osteoarthritis: a randomized, double blind, placebo-controlled trial

The aim of this study was to investigate the effects of focused low-intensity pulsed ultrasound (FLIPUS) therapy on the functional and health status of patients with knee osteoarthritis (KOA). A total of 106 subjects with bilateral KOA were randomized sequentially into two groups. Group I received FLIPUS + diclofenac sodium, and group II received sham FLIPUS + diclofenac sodium. The therapeutic effects of the interventions were evaluated by measuring changes in VAS pain, the WOMAC scores, and the LI scores after 10 days of treatment as well as changes in LI and VAS at follow-up, 4 and 12 weeks later. In addition, changes in the range of motion, ambulation speed, and the SF-36 in each group were recorded after 10 days of treatment. Compared with those in group II, patients in group Ishowed significant improvements in VAS, WOMAC, LI, ambulation speed, and most items in the SF-36 after 10 days of treatment. In addition, patients in group I showed significant improvements in LI and VAS at follow-up. There were no FLIPUS-related adverse events during and after the interventions. In conclusion, FLIPUS is a safe and effective treatment modality for relieving pain and improving the functions and quality of life of patients with KOA.

Effects of Electroacupuncture for Knee Osteoarthritis: A Systematic Review and Meta-Analysis

Purpose. This study aims to verify the effects of electroacupuncture treatment on osteoarthritis of the knee. Methods. MEDLINE/PubMed, EMBASE, CENTRAL, AMED, CNKI, and five Korean databases were searched by predefined search strategies to screen eligible randomized controlled studies meeting established criteria. Any risk of bias in the included studies was assessed with the Cochrane Collaboration's tool. Meta-analysis was conducted using RevMan version 5.3 software. Results. Thirty-one randomized controlled studies of 3,187 participants were included in this systematic review. Meta-analysis was conducted with eight studies including a total of 1,220 participants. The electroacupuncture treatment group showed more significant improvement in pain due to knee osteoarthritis than the control group (SMD −1.86, 95% CI −2.33 to −1.39, I² 75%) and in total WOMAC score than the control group (SMD −1.34, CI 95% −1.85 to −0.83, I² 73%). Compared to the control group, the electroacupuncture treatment group showed more significant improvement on the quality of life scale. Conclusion. Electroacupuncture treatment can relieve the pain of osteoarthritis of the knees and improve comprehensive aspects of knee osteoarthritis and the quality of life of patients with knee osteoarthritis.

The Effects of Acupuncture on Chronic Knee Pain Due to Osteoarthritis: A Meta-Analysis

BACKGROUND

Acupuncture reportedly relieves chronic knee pain and improves physical function in patients diagnosed with osteoarthritis, but the duration of these effects is controversial. The aim of this study was to evaluate the temporal effects of acupuncture on chronic knee pain due to knee osteoarthritis by means of a meta-analysis.

METHODS

The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published through March 2015. Ten randomized controlled trials of acupuncture compared with sham acupuncture, usual care, or no intervention for chronic knee pain in patients with clinically diagnosed or radiographically confirmed knee osteoarthritis were included. All of the studies were available in English. Weighted mean differences (WMDs), 95% confidence intervals (CIs), publication bias, and heterogeneity were calculated.

RESULTS

The acupuncture groups showed superior pain improvement (p < 0.001; WMD = -1.24 [95% CI, -1.92 to -0.56]; I(2) > 50%) and physical function (p < 0.001; WMD = 4.61 [95% CI, 2.24 to 6.97]; I(2) > 50%) in the short term (up to 13 weeks). The acupuncture groups showed superior physical function (p = 0.016; WMD = 2.73 [95% CI, 0.51 to 4.94]; I(2) > 50%) but not superior pain improvement (p = 0.199; WMD = -0.55 [95% CI, -1.39 to 0.29]; I(2) > 50%) in the long term (up to 26 weeks). Subgroup analysis revealed that the acupuncture groups tended to have better outcomes compared with the controls. Significant publication bias was not detected (p > 0.05), but the heterogeneity of the studies was substantial.

CONCLUSIONS

This meta-analysis demonstrates that acupuncture can improve short and long-term physical function, but it appears to provide only short-term pain relief in patients with chronic knee pain due to osteoarthritis.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Effectiveness of Individualized Acupuncture Protocols in the Treatment of Gulf War Illness: A Pragmatic Randomized Clinical Trial

BACKGROUND

Gulf War Illness is a Complex Medical Illness characterized by multiple symptoms, including fatigue, sleep and mood disturbances, cognitive dysfunction, and musculoskeletal pain affecting veterans of the first Gulf War. No standard of care treatment exists.

METHODS

This pragmatic Randomized Clinical Trial tested the effects of individualized acupuncture treatments offered in extant acupuncture practices in the community; practitioners had at least 5 years of experience plus additional training provided by the study. Veterans with diagnosed symptoms of Gulf War Illness were randomized to either six months of biweekly acupuncture treatments (group 1, n = 52) or 2 months of waitlist followed by weekly acupuncture treatments (group 2, n = 52). Measurements were taken at baseline, 2, 4 and 6 months. The primary outcome is the SF-36 physical component scale score (SF-36P) and the secondary outcome is the McGill Pain scale.

RESULTS

Of the 104 subjects who underwent randomization, 85 completed the protocol (82%). A clinically and statistically significant average improvement of 9.4 points (p = 0.03) in the SF-36P was observed for group 1 at month 6 compared to group 2, adjusting for baseline pain. The secondary outcome of McGill pain index produced similar results; at 6 months, group 1 was estimated to experience a reduction of approximately 3.6 points (p = 0.04) compared to group 2.

CONCLUSIONS

Individualized acupuncture treatment of sufficient dose appears to offer significant relief of physical disability and pain for veterans with Gulf War Illness. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Gulf War Illness Research Program under Award No. W81XWH-09-2-0064. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01305811.

Electroacupuncture protects against articular cartilage erosion by inhibiting mitogen-activated protein kinases in a rat model of osteoarthritis

OBJECTIVE

The therapeutic effects of electroacupuncture (EA) on osteoarthritis (OA) are well documented; however, the precise mechanisms of action have not yet been fully elucidated. The present study aimed to investigate the effect of EA on cartilage in an experimental animal model of OA induced by anterior cruciate ligament transection (ACLT) and to examine for concomitant changes in the expression of mitogen-activated protein kinases (MAPKs) in the articular cartilage.

METHODS

Thirty-three-month-old male Sprague Dawley rats were randomly divided into the following three groups (n=10 each): sham operated group (Control group), ACLT without treatment (ACLT group), and ACLT with EA treatment (ACLT+EA group). One week after ACLT, rats in the ACLT+EA group received 12 weeks of EA treatment. Histological analysis and quantitative real-time PCR were used to investigate the effects of EA on cartilage morphology (quantified using modified Mankin scores) and expression of MAPKs (p38, c-Jun N-terminal kinase (c-Jun), and extracellular signal-regulated kinase (ERK)1), respectively.

RESULTS

ACLT produced coarse cartilage surfaces, fibrous degeneration, and fissuring, all of which were suppressed by EA treatment. Although Mankin scores in the ACLT+EA group were significantly higher compared to the Control group (p<0.01), they were significantly lower than the (untreated) ACLT group (p<0.01). The increase in mRNA expression of p38, c-Jun, ERK1, and matrix metalloproteinase (MMP)-13 observed in cartilage after ACLT was significantly inhibited by EA.

CONCLUSIONS

EA appears to prevent the degeneration of articular cartilage, at least partly through regulation of MMP-13 and inhibition of MAPKs in the cartilage of rats with ACLT-induced OA.

Traditional Chinese medicine in patients with osteoarthritis of the knee

To evaluate whether the use of traditional Chinese medicine (TCM; 中醫 zhōng yī) influences symptoms or functional outcomes in patients with osteoarthritis (OA) of the knee (膝關節炎 xī guān jié yán).

A systematic review of randomized control trials was conducted. Searches for studies in PubMed that were performed between 1965 and August 2013, and retrieved studies were subjected to reference screening. The types of studies included in our review were 1) placebo-based or comparative studies; 2) open label, single-blinded or double-blinded studies; 3) studies evaluating the efficacy of TCM for treating OA of the knee; and 4) studies evaluating only TCM or combination preparations. Trials were conducted with participants over 18 years of age with knee pain and at least three of the following characteristics: 1) an age greater than 50 years; 2) morning stiffness lasting for fewer than 30 min; 3) a crackling or grating sensation; 4) bony tenderness of the knee; 5) bony enlargement of the knee; or 6) no detectable warmth of the joint to the touch. Studies were rated for risk of bias and graded for quality.

After screening, 104 studies that satisfied the eligibility requirements were identified, and only 18 randomized control trials were included in the quantitative and qualitative synthesis. Upon review, we found “moderate-quality” evidence of effects from acupuncture (針灸 zhēn jiǔ) on pain, which was measured using a visual analogue scale, and physical function, which was measured using qigong (氣功 qì gōng) with motion. “Low-quality” evidence was found regarding the effects of acupuncture on physical function, and no evidence was found regarding the effects of herbal medicine on pain or physical function. Herbal patches (藥布 yào bù) appeared to affect pain and physical and function, but these effects were not found to be significant.

The initial findings included in this review suggest that acupuncture is a promising intervention according to the primary outcome measure, pain, and qigong with motion is an effective method for treating physical function. However, according to the Grades of Recommendation, Assessment, Development, and Evaluation criteria, only moderate-quality evidence was found in these studies. Further rigorous studies are warranted to investigate the application of TCM in treating OA of knee.

On the hazard caused by the heat of acupuncture needles in warm needling (wēn zhēn)

Due to its simplicity and convenience, acupuncture has become popular as a complementary therapy. In this Chinese medicine, doctors have to find the traditional meridian acupuncture points before puncturing the needles into them. Moxibustion (艾灸 Ài Jiǔ) is also an important part of the acupuncture remedy. Treatment by acupuncture can be classified roughly into two types – direct moxibustion and indirect moxibustion. Warm-needling acupuncture (溫針灸 Wēn Zhēn Jiǔ) is classified under the method of indirect moxibustion. In the present study, 10 standard stainless steel acupuncture needles with 10 pieces of cylinder-shaped moxa cone (艾柱 Ài Zhù) as the heat source of warm needles were used. In order to prevent the practitioners from getting burns, it is necessary to study the temperature changes in some designated parts of the needles. Two sizes, 0.6 g and 1.0 g, of moxa cones were used for comparison of the measured temperatures. The needles are typically divided into two parts – the handle part and the needle body. In our experiment, the temperatures of WNA at different parts of the needles were measured. The larger the size of moxa cone is, the longer is the burning time. Based on the observations we suggest that when 0.6 g moxa is used, the physicians should better pick out the needles around 9 min after ignition; however, while using the 1 g moxa, it might be safer to pick out the needles around 13 min after ignition.

Immediate effects of electroacupuncture and manual acupuncture on pain, mobility and muscle strength in patients with knee osteoarthritis: a randomised controlled trial

OBJECTIVE

To compare the immediate effects of electroacupuncture and manual acupuncture on pain, mobility and muscle strength in patients with knee osteoarthritis.

METHODS

Sixty patients with knee osteoarthritis, with a pain intensity of ≥2 on the pain Numerical Rating Scale, were included. The patients were randomised into two groups: manual acupuncture and electroacupuncture. Pain intensity, degree of dysfunction (Timed Up and Go (TUG) test), maximal voluntary isometric contraction and pressure pain threshold were assessed before and after a single session of manual acupuncture or electroacupuncture treatments.

RESULTS

Both groups showed a significant reduction in pain intensity (p<0.001) and time to run the TUG test after the acupuncture treatment (p=0.005 for the manual acupuncture group and p=0.002 for the electroacupuncture group). There were no differences between the groups regarding pain intensity (p=0.25), TUG test (p=0.70), maximum voluntary isometric contraction (p=0.43) or pressure pain threshold (p=0.27).

CONCLUSIONS

This study found no difference between the immediate effects of a single session of manual acupuncture and electroacupuncture on pain, muscle strength and mobility in patients with knee osteoarthritis.

TRIAL REGISTRATION NUMBER

RBR-9TCN2X.

Patterns of traditional chinese medicine diagnosis in thermal laser acupuncture treatment of knee osteoarthritis

Knee osteoarthritis (OA) manifests with pain, joint stiffness, and limited function. In traditional Chinese medicine, knee OA is differentiated into three patterns: yang deficiency and cold coagulation, kidney deficiency, and blood stasis. The objective of this study was to determine whether yang deficiency cold coagulation patients respond better to thermal laser acupuncture treatment than do non-yang deficient patients. Fifty-two patients with OA were allocated to group A (yang deficient, n = 26) or B (non-yang deficient, n = 26). All patients received a 20-min thermal laser acupuncture treatment at acupoint Dubi (ST 35) three times a week for two weeks and twice a week for another four weeks. Outcome assessments were performed immediately after the first treatment, and at weeks 2, 6, and 10. Group A function scores were significantly better than those of Group B at weeks 2 (P = 0.049), 6 (P = 0.046), and 10 (P = 0.042), but no significant differences were found between the two groups in pain and stiffness scores at any time point. No significant adverse effect was observed. The combined 10.6 μm–650 nm laser treatment might be most beneficial to yang deficiency cold coagulation knee OA patients, particularly in improving function.

Effects of electro-acupuncture on oestrogen levels, body weight, articular cartilage histology and MMP-13 expression in ovariectomised rabbits

BACKGROUND

Electro-acupuncture (EA) treatment has been shown to decrease pain and improve the function of ovariectomised (OVX) rats with osteoarthritis (OA); however, the underlying mechanisms remain unclear.

OBJECT

We used OVX rabbits to replicate natural human menopausal processes and to evaluate whether EA could be used to prevent and treat postmenopausal OA.

METHODS

The rabbits were randomly divided into four groups of eight: a normal control group (NC), an OVX group, an ERT group (oestrogen replacement therapy after OVX) and an EA group (EA therapy after OVX). After the interventions, all of the animals were killed. Serum oestrogen levels and body weight were measured. The transcription of matrix metalloproteinase-13 (MMP-13) mRNA was detected using reverse transcriptase-PCR. Modified Mankin scores were used for histological assessment. Expression of MMP-13 in cartilage was determined by immunohistochemistry.

RESULTS

Both the EA group and the ERT group had increased serum oestrogen levels (p=0.028, p=0.037 respectively), as well as decreased expression of MMP-13 (p=0.000, p=0.000, respectively), relative to the OVX group. The body weight of the EA group was lower than that of the OVX group and the NC group (p=0.007), as well as the ERT group (p=0.010).

CONCLUSIONS

EA could be a new method for preventing and treating postmenopausal OA by producing endogenous sex hormones that inhibit the expression of MMP-13 and cause weight loss with no side effects and a relatively low cost.

Training Self-Administered Acupressure Exercise among Postmenopausal Women with Osteoarthritic Knee Pain: A Feasibility Study and Lessons Learned

Background. Osteoarthritis (OA) is more prevalent in women, particularly after menopausal age. Women are more likely to seek complementary and alternative medicine (CAM) approaches. We examined the feasibility of training self-administered acupressure exercise and assessed its impact on OA symptoms among women with knee OA. Methods. Thirty-six eligible postmenopausal women were randomly assigned in the acupressure exercise group (n = 15) or the control group (n = 21) for 12 weeks. Feasibility outcomes (e.g., compliance and adverse effects) and clinical outcomes (e.g., pain, stiffness, and physical function) were assessed. Data were collected at baseline, 6 weeks and 12 weeks. Both per-protocol and intention-to-treat analysis were employed. Results. The training materials were well received. The feedback from participants suggests that self-administered acupressure exercise is easy to learn and safe to perform at home, although no statistically significant results of the clinical outcome were observed. Our findings didn't reveal superiority or inferiority of acupressure compared with usual care. Conclusion. Acupressure exercise is feasible to be trained among postmenopausal women with knee osteoarthritis. Due to the limitations of this study such as small sample size and high attrition rate, acupressure's efficacy needs to be further explored in larger scale studies with more rigorous design.

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.

Complementary and alternative medicine in osteoarthritis

The intent of this focused clinical review is to assess the current literature on a variety of complementary and alternative medicine treatments for osteoarthritis. This review assesses acupuncture techniques, moxibustion, transcutaneous electrical nerve stimulation, low-level laser therapy, and massage. These treatment methods are growing in popularity among the general public. It is important that providers become aware of the existing literature regarding the efficacy of these alternative methods for the treatment of osteoarthritis to adequately respond to the inquiries of our patients.

Immediate Effects of Acupuncture and Cryotherapy on Quadriceps Motoneuron Pool Excitability: Randomised Trial Using Anterior Knee Infusion Model

Objective

The authors asked the following research questions: will an anterior knee infusion model induce constant pain? will perceived pain alter motoneuron pool (MNP) excitability? and will treatments alter perceived pain and/or MNP excitability?

Methods

Thirty-six neurologically healthy volunteers participated in this randomised controlled laboratory study. To induce anterior knee pain (AKP), 5% hypertonic saline (0.12 ml/min with a total volume of 8.5 ml over 70 min) was injected into the infrapatellar fat pad of the dominant leg. One of four 30-min treatments was randomly assigned to each subject after pain was induced (acupuncture, cryotherapy, sham cryotherapy and no treatment). Five acupuncture needles (SP9, SP10, ST36, GB34 and an ah shi point) were inserted to a depth of 1 cm. Vastus medialis (VM) maximum Hoffmann reflexes normalised by maximum motor response were recorded from each subject at baseline, 20 min post-injection, 50 min post-injection and 70 min post-injection. To record pain perception, a visual analogue scale was used every 5 min after injection.

Results

An anterior knee infusion pain model increased perceived pain (p<0.0001). No change was found in VM MNP excitability among the four treatments (p<0.19) or at any of the time intervals (p<0.52). Cryotherapy reduced perceived pain compared with acupuncture (p=0.0003) and sham treatment (p=0.0002).

Conclusions

A pain model may be used in other neurophysiological intervention studies related to AKP. AKP alone may not directly alter quadriceps activation. None of the treatments altered VM MNP excitability. Cryotherapy reduced pain while a single session of acupuncture and sham treatments did not.

External validity in randomised controlled trials of acupuncture for osteoarthritis knee pain

OBJECTIVES

To assess two aspects of the external validity of acupuncture research for osteoarthritis knee pain and determine the common acupoints and treatment parameters used.

METHODS

The external validity of 16 randomised controlled trials (RCTs) was investigated using a scale consisting of two aspects: reporting and performance. The reporting aspect included acupuncturist's background, study location, treatment detailed, patient characteristics, positive trial results, adverse effects and between-group statistical differences, whereas treatment appropriateness, appropriate controls and outcomes were classified as the performance aspect. Acupuncture treatment in RCTs was compared with common practice according to the literature sources and survey of acupuncturists working in different parts of Thailand.

RESULTS

The levels of external validity for the reporting and performance aspects were in the range of 31.3% to 100%. Statistic values such as mean difference and confidence interval were reported by the minority of trials (43.8%). Patient satisfaction and quality of life were seldom used (31.3%). There were minor differences between research and practice in terms of the points used (25.0%), number of treatment sessions (6.3%) and frequency (12.5%). The most frequently used points were ST34, ST35, ST36, SP6, SP9, SP10, GB34, Xiyan and ah shi points, and the commonly used treatment parameters were 20 minutes, 10-15 sessions and two treatments weekly.

CONCLUSIONS

Reporting of the external validity of acupuncture RCTs for knee pain was notably inadequate in terms of trial setting, treatment provider and statistical reporting. The majority of studies involved appropriate controls and outcomes and applied acupuncture treatments in line with practice.

Complementary therapies for osteoarthritis: are they effective?

Increasing interest has focused on complementary management modalities, including tai chi, acupuncture, yoga, and massage therapy, as treatments for osteoarthritis (OA). This review article synthesizes evidence from randomized controlled trials (RCTs) and systematic reviews (SRs) that examined one or more of the above as treatments for OA. Medline, Pubmed, and Cinahl databases were searched to identify English-language articles using an RCT design or that conducted a SR of published studies and presented data on symptom or functional outcomes. Two authors independently abstracted relevant information (e.g., study sample, intervention characteristics, treatment effects, safety data). Retained articles (n = 29) included those that evaluated tai chi (8 RCTs, 2 SRs), acupuncture (11 RCTs, 4 SRs), yoga (2 RCTs), and massage therapy (2 RCTs). Available evidence indicates that tai chi, acupuncture, yoga, and massage therapy are safe for use by individuals with OA. Positive short-term (≤6 months) effects in the form of reduced pain and improved self-reported physical functioning were found for all 4 treatments. Limited information exists regarding the relative effectiveness of the therapies (e.g., yoga vs. tai chi vs. acupuncture), as well as treatment effects in persons with joint involvement besides the knee and in distinct patient subgroups (e.g., older vs. younger adults, persons with mild vs. moderate vs. advanced disease). Complementary therapies can reduce pain and improve function in adults with OA. Research is needed to evaluate long-term benefits of the treatments, as well as their relative effects among diverse patient subgroups.

The effectiveness of acupuncture in the treatment of Gulf War Illness

INTRODUCTION

It can be challenging to study complex and novel health states within the parameters of a RCT. This report describes the use of an unblinded Phase II Clinical Trial design to investigate the effectiveness of acupuncture in the treatment of Gulf War Illness (GWI). GWI is a complex illness found among veterans of the first Gulf War, and is characterized by multiple symptoms, including fatigue, sleep and mood disturbances, cognitive dysfunction, and musculoskeletal pain. No published trials of acupuncture for the treatment of GWI exist. This trial is designed to both answer questions of the effectiveness of acupuncture for our entire sample, as well as subgroups with of individual presentations of GWI.

MATERIALS AND METHODS

Our primary outcome is quality of life as measured by the SF-36. In an effort to better understand this complex disease and its treatment, our multi-level measurement plan examines psychosocial variables, fatigue, sleep quality, pain, and biomarkers of inflammation and immune status. All of the measurement instruments used in this trial show good validity and reliability.

RESULTS

This study is ongoing and clinical results are not available. We have achieved good feasibility of our recruitment, treatment, and data collection procedures.

CONCLUSIONS

Low constraint RCT designs are an appropriate choice when investigating conditions in which the causes and mechanisms of disease are poorly understood. This naturalistic RCT includes individualized protocols, a clinically supported length and dose of treatment, a wait list control arm, and the ethical benefit that all subjects receive treatment during the study.

Efeitos da craniopuntura de Yamamoto na osteoartrite de joelho: estudo de caso

O objetivo deste estudo foi verificar os efeitos da craniopuntura de Yamamoto na dor, na amplitude de movimento, qualidade de vida e funcionalidade de paciente com osteoartrite (OA) de joelho. Foi realizado um estudo de caso de uma paciente de 59 anos apresentando quadro de dor no joelho, redução funcional nos últimos três meses e radiografia constando o grau 3 de OA de joelhos. A avaliação foi feita antes e após o tratamento através da Escala Visual Analógica (EVA) para avaliação da dor, da qualidade de vida pelo questionário Western Ontario and McMaster Universities Osteoarthritis (WOMAC), da funcionalidade pelo Knee injury and Osteoarthritis Outcome Score (KOOS) e da amplitude de movimento do joelho pela goniometria. A craniopuntura foi realizada duas vezes por semana, com duração de 40 minutos cada, totalizando 10 sessões. A análise dos dados foi feita de forma descritiva. A variável utilizada foi o ganho relativo (GR) medido no pré e no pós-tratamento. A dor no joelho diminuiu (GR=100%), enquanto a amplitude de movimento aumentou em ambos os joelhos (GR=20%). Observou-se melhora na dor (GR=83%), na rigidez (GR=50%), na função (GR=80%) e no escore total da WOMAC (GR= 79%). Verificou-se, através da KOOS, melhora nos sintomas (GR=8%), na dor (GR=26%), nas atividades de vida diária (GR=21%) e na qualidade de vida (GR= 17%). Conclui-se que a craniopuntura foi efetiva no alívio da dor, na amplitude de movimento, qualidade de vida e funcionalidade de paciente com OA de joelho.