Acupuncture for Knee Osteoarthritis – a Randomised Trial Using a Novel Sham

Effect of Acupuncture on Blood Pressure and Metabolic Profile Among Patients With Essential Hypertension: Protocol of a Randomized Clinical Trial

Essential hypertension is a polygenic cardiovascular disease that is associated with maladaptive metabolic changes. Acupuncture as a non-pharmacologic intervention is used to lower blood pressure and improve metabolic dysfunction. However, such effects have not been clinically characterized. We will conduct a randomized clinical trial to evaluate the antihypertensive effect of acupuncture among patients with essential hypertension and determine the associated metabolic improvements. This study is a phase II, two-arm, randomized, sham-controlled trial (Trial registration: ChiCTR2100043737), in which biospecimens will be collected for metabolic profiling. A total of 64 patients with a clinical diagnosis of essential hypertension will be randomly assigned to either the acupuncture or the sham acupuncture group in a 1:1 ratio. All participants will receive 10 treatments over 4 weeks, with three sessions per week for the first 2 weeks and two sessions per week for the remaining weeks. The primary outcome is the change of the systolic and diastolic blood pressure measured by the 24-h ambulatory blood pressure monitoring from baseline to 4 weeks. Secondary outcomes include the circadian rhythm of blood pressure, sleep quality measured by the Insomnia Severity Index, cognitive function measured by the Montreal Cognitive Assessment, and others. Fasting blood serum and urine samples will be collected at baseline and 4 weeks for targeted and untargeted metabolomics analysis. We will use the mixed-effects model and other related bioinformatics approaches to analyze the clinical and metabolome data. This metabolomic-based trial will provide important clinical data regarding the efficacy of acupuncture for essential hypertension to better inform evidence-based care delivery for hypertension patients. Moreover, the findings will offer important insights into the mechanism of action of acupuncture for hypertension by revealing its effect on metabolism. The results of this study will be used to inform the design of a statistically powered, multicenter, randomized trial. We will publish the study findings in peer-reviewed journals. The ethical approval of this study has been reviewed and approved by the Sichuan Regional Ethics Review Committee on Traditional Chinese Medicine (ID: 2021KL-006). The outcomes of the trial will be disseminated through peer-reviewed publications.

Classic Chinese Acupuncture versus Different Types of Control Groups for the Treatment of Chronic Pain: Review of Randomized Controlled Trials (2000-2018)

OBJECTIVE

To review the effectiveness of classic Chinese acupuncture in the treatment of chronic pain by comparing treatment groups with different types of control groups in accordance with the newly published guidelines for systematic reviews.

METHODS

We searched EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials databases from 2000 to 2018. We included randomized controlled trials that included acupuncture as the sole treatment or as an adjunctive treatment for chronic pain. The outcome was pain intensity measured by the visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, 11-point numeric rating scale (NRS), and other tools. Two researchers conducted the study selection, data extraction, and quality assessment processes independently. Disagreements were solved by discussion and reanalysis of the data. The quality of all included studies was evaluated using the CBNG (the Cochrane Back and Neck Group) and the STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) checklists.

RESULTS

Sixty-one studies were fully analyzed and ranked based on the newest STRICTA and CBNG standards. We found good evidence that receiving acupuncture is better than not receiving treatment or being placed on a waiting list and reasonable evidence that it is better than conventional or usual care. Limited evidence was found regarding placebo treatments that involve the expectation of needling (real or fake).

CONCLUSION

Sham acupuncture may not be appropriate as a control intervention for assessing the effectiveness of acupuncture. Acupuncture effectiveness in controlling chronic pain is still limited due to the low quality of the studies published.

Metabolic profiling of dialysate at sensitized acupoints in knee osteoarthritis patients: A study protocol

BACKGROUND

Acupuncture therapy is frequently used to treat Knee Osteoarthritis (KOA) in clinic, and usually used local acupoints near the diseased knees as therapeutic targets. Some local acupoints appeared sensitization phenomenon which was called sensitized acupoints, which were regarded as important therapeutic targets to get better therapeutic effect on clinic. Therefore, it is necessary to explore the biological basis of acupoint sensitization. Meanwhile, there is a lack of an analysis of the metabolism for sensitized acupoints in KOA patients. Considering that acupuncture effect could be multi-targeted, omics (such as metabolomics) may be a useful method to reveal the relationship between sensitized acupoints and clinical efficacy of acupuncture.

METHODS AND ANALYSIS

This study is a parallel design trial. Thirty KOA patients and 30 healthy volunteers will be recruited in this study. Mechanical pain threshold will be measured by Electron Von frey in order to confirm the highest sensitized acupoints. Then collect tissue fluid from the highest sensitized acupoints by micro dialysis technical, then apply electro-acupuncture method on the highest sensitized acupoints to treat KOA patients, after 20 sessions treatments, measure and collect again. Liquid chromatography-tandem mass spectrometry method will be used to analyze the metabonomics of dialysate.

RESULTS

This study will provide a high-quality evidence to reveal the local molecular mechanism of acupuncture sensitized acupoints for patient with KOA.

CONCLUSION

This study will provide up-date evidence of whether acupuncture sensitized acupoints have local molecular mechanism for KOA.

TRIAL REGISTRATION NUMBER

NCT03599180 (24 Jul. 2018).

Acutherapy for Knee Osteoarthritis Relief in the Elderly: A Systematic Review and Meta-Analysis

Purpose

This systematic review and meta-analysis was conducted to investigate the effects of various acutherapies on knee osteoarthritis (KOA) relief in the elderly.

Methods

Five databases were accessed from inception to July 2017 for searching randomized controlled trials (RCTs) on acutherapy for KOA relief in the elderly. Data were pooled after trial quality assessment for meta-analysis. Outcomes were the scores of knee pain, knee stiffness, and physical function accessed by Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index.

Results

17 RCTs including 4774 subjects were included. The results indicated that acutherapy significantly affected knee pain (standardized mean difference, i.e., SMD = - 0.73, [95% CI, -0.98 to -0.47], P <0.001), knee stiffness (SMD = -0.66, [95%CI, -0.85 to -0.47], P <0.001), and physical function (SMD = -1.56, [95%CI, -2.17 to -0.95], P<0.001) when compared with control condition without intervention of any acutherapy. Moreover, acutherapy was more effective than corresponding sham (placebo) intervention applied on nonacupoints (SMD = -0.16, [95% CI, -0.32 to -0.01], P = 0.04). However, no significant differences were found on treatment effects between acutherapy and sham acutherapy at the same acupoints (SMD= - 0.09, [95%CI, -0.40 to 0.21], P = 0.55).

Conclusions

Acutherapy was an effective approach for KOA relief in the elderly. The selection of acupoints position could be a crucial factor that influences the treatment efficacy of acutherapy.

The Evidence on Acupuncture for Knee Osteoarthritis – Editorial Summary on the Implications for Health Policy

Decisions on whether a health service should provide a particular treatment are based on the evidence on three questions: 1) whether the treatment can work, ie it is biologically active; 2) whether the treatment is safe and effective in daily practice; and 3) whether it is economically worthwhile. Evidence presented at the Kyoto conference shows that acupuncture for osteoarthritis of the knee has a biological effect, has a large clinical effect in practice, has negligible risk, and has a cost effectiveness which is well within the usual acceptable limit. On the present evidence, acupuncture is likely to offer an alternative to treatment with non-steroidal anti-inflammatory drugs (NSAIDs).

Efficacy Comparison of Five Different Acupuncture Methods on Pain, Stiffness, and Function in Osteoarthritis of the Knee: A Network Meta-Analysis

The principal objective of this present study was to compare the effects of different acupuncture methods on pain, stiffness, and physical function for osteoarthritis of the knee by the pairwise and network meta-analysis (NMA). A network meta-analysis of randomized controlled trials (RCTs) was searched from three English databases and one Chinese database until January 2018. A pairwise meta-analysis was performed with a random effects model. Then we carried out the NMA within a Bayesian framework. Mean difference (MD) and its 95% confidence interval (CI) were calculated by R 3.4.1, Stata 14.0, and RevMan 5.3 software to assess the relief of pain, the effectiveness for stiffness, and physical function recovery. Node-splitting method was used to calculate the inconsistency. Rank probabilities were assessed and clustered by the surface under the cumulative ranking curve (SUCRA). 16 trials mostly researched short-term effectiveness and showed that fire needle and electro-acupuncture were statistically significant to decrease WOMAC pain and physical function scores when compared with other treatments, but there was no significant difference in stiffness calculations. Our NMA demonstrated that acupuncture with heat pain or electrical stimulation might be suggested as the better choices in all acupuncture methods to osteoarthritis of the knee.

Effect of Auriculotherapy on the Plasma Concentration of Biomarkers in Individuals with Knee Osteoarthritis

Knee osteoarthritis (KOA) is one of the most frequent noncommunicable diseases with pain associated symptoms and affects the musculoskeletal system. Various forms of treatment can be indicated, and nonpharmacological treatment is also an available option for the management of KOA individuals. For instance, auriculotherapy (AT) is one possible procedure associated with the Traditional Chinese Medicine for dealing with KOA. It is believed that the concentration of certain biomarkers could be altered in individuals with KOA after AT. The aim of this study was to evaluate the effect of AT on plasma concentration of biomarkers in KOA individuals. This intervention is a controlled trial. Twenty-one subjects were grouped in two groups and submitted to AT with the stimulation of the Shen Men, kidney, and knee points in the treatment group or different points in the control group, once a week for 5 weeks. Blood was collected before the beginning of protocols and a week after the last session. Kolmogorov-Smirnov and Wilcoxon tests were performed, and a p ≤ 0.05 was considered statistically significant. Hematological parameters did not show any significant variation between the control group and treated group. Concerning the biochemical parameters, a significant reduction of direct bilirubin (from 43.31 ± 22.10 to 21.21 ± 5.30 μmol/L, p = 0.003), aspartate aminotransferase (from 0.48 ± 0.16 to 0.38 ± 0.09 μKat/L, p = 0.010), and triglycerides (from 7.04 ± 2.90 to 5.45 ± 2.57 mmol/L, p = 0.008) in the treated group was obtained. In conclusion, the analysis of results suggests that AT might be a useful intervention for the management of KOA individuals.

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.

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.

Acupuncture and depth: future direction for acupuncture research

The research on acupuncture has increased steadily over the years and regular review and revision of the direction of future acupuncture research are necessary. This paper aims to review and explore the significance of acupuncture depth in modern acupuncture research. Searches conducted in Science Direct and China National Knowledge Infrastructure (CNKI) databases reflected a lack of focus on depth of acupuncture. We propose that the research trends of acupuncture should progress to the depth of insertion. It is suggested that future acupuncture research, especially randomized controlled trials (RCTs), should take into consideration the depth of insertion. Comparison between databases using different language of medium suggests the need for international collaboration of researchers from the same field. It is also crucial to inherit and innovate traditional medicine (TM) through modern technology. The use of bibliometric method is also suitable for development of TM research trends. Acupuncture and depth should be considered as one of the future directions of acupuncture research.

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.

Divergent neural processes specific to the acute and sustained phases of verum and SHAM acupuncture

PURPOSE

To discuss which brain region potentially functioned and switched between the immediate and delayed response of acupuncture.

MATERIALS AND METHODS

A nonrepeated event-related functional MRI (fMRI) design was used to investigate the spatial and temporal patterns of acupuncture effects induced by needling an acupoint ST36 (ACU) and a nonmeridian point (SHAM). The standard general linear model was used to detect the immediate neural responses of acupuncture. Graph theory analysis was used to characterize the functional integrated network of the acupuncture delayed effect.

RESULTS

Acupuncture induced significant signal changes in the limbic/paralimbic areas, neocortical regions, brainstem, and cerebellum for immediate effect both in ACU and SHAM. Some of these brain regions showed strong functional connectivity for a delayed effect in ACU. Conjunction analysis showed that the insula played a critical role during the overall process of ACU. No overlapping brain regions were found in SHAM.

CONCLUSION

The findings of this study suggested that the delayed effects may reflect a more significant characteristic underlying acupuncture. Given that the insula as a relay station switched between the immediate and delayed response, it suggested that divergent functional connectivity patterns may mediate the acupuncture-related effects for ACU and SHAM.

[Eight-step method in clinical research of traditional Chinese medicine]

With the progress and development of science and technology, biomedical technology has been widely used in traditional Chinese medicine (TCM) research. However, TCM and Western medicine developed and came into being at different times and from different cultural backgrounds. Their targets are to study and explore the objective laws of human life activities from different angles and by different means. To study and evaluate TCM simply by the diagnosis and treatment standards of Western medicine cannot truly reflect the characteristics of TCM. Lots of clinical phenomena in the diagnosis and treatment in TCM cannot be revealed scientifically. It might be a significant pattern to combine the study of TCM with Western medicine, based on double-screening model of combining disease with syndrome types, following up evidence-based medical research steps, and making use of systematic review and data mining to analyze the inherent laws of TCM symptoms.

Spatiotemporal mapping the neural correlates of acupuncture with MEG

Acupuncture is an ancient Eastern healing modality with putative therapeutic applications. Unfortunately, little is known about the central mechanisms by which acupuncture may exert its effects. In this study, 16 [corrected] healthy subjects were evaluated with magnetoencephalography (MEG) to map the location and timing of brain activity during low-frequency electroacupuncture (EA) and mechanical, noninsertive, sham acupuncture (SA) given at acupoint PC-6. Both EA and SA evoked brain responses that localized to contralateral primary somatosensory (SI) cortex. However, initial responses for EA peaked slightly earlier than those for SA and were located inferiorly within SI. Average equivalent current dipole strength was stronger (particularly at latencies >60 ms) for SA. These spatiotemporal differences between activations elicited by EA and SA are likely attributable to stimulus modality (electrical versus mechanical) and differences in the underlying somatosensory fibers transmitting these signals. The present data confirm that acupuncture modulates activity within somatosensory cortex, providing support for previous studies that suggest that the therapeutic effects of acupuncture are linked to SI modulation. Thus, MEG provides excellent spatiotemporal characterization of the somatosensory component of acupuncture, and future studies can contrast derived brain response parameters in healthy controls with those found in a diseased state.

The benefit of nonpharmacologic therapy to treat symptomatic osteoarthritis

Osteoarthritis affects a large proportion of the population, especially the elderly, leading to pain and disability. To relieve pain, many patients are turning toward nonpharmacologic therapies. Conventional nonpharmacologic treatments such as weight loss and exercise are well accepted by the medical community, and some randomized controlled trials support the use of these treatments in patients with knee osteoarthritis. However, little information exists regarding the efficacy of these treatments for osteoarthritis at other sites. Less conventional treatments such as acupuncture and massage are emerging as promising options for osteoarthritis treatment, but the magnitude of benefit has varied between studies. More investigation is necessary to reach a conclusion regarding the efficacy of these treatments.

Lead encephalopathy due to traditional medicines

Traditional medicine use is common in developing countries and increasingly popular in the western world. Despite the popularity of traditional medicines, scientific research on safety and efficacy is limited. However documented fatalities and severe illness due to lead poisoning are increasingly recognized to be associated with traditional medicine use. As society becomes more globalized, it is imperative for pharmacists and health care providers to learn about the safety of traditional medical practices. The information presented educates and alerts pharmacists and health care providers about the potential of traditional medicines to cause lead encephalopathy. Case reports were located through systematic literature searches using MEDLINE, CINAHL, AMED, CISCOM, EMBASE and The Cochrane library from 1966 to the February 2007. Reference lists of identified articles and the authors' own files were also searched. Inclusion criteria were cases of human lead encephalopathy associated with traditional medical practices. There were no restrictions regarding the language of publication. Data were subsequently extracted and summarized in narrative and tabular form. We found 76 cases of lead encephalopathy potentially associated with traditional medicine. Ayurvedic medicines were associated with 5 cases (7%), Middle eastern traditional medicines with 66 cases (87%) and 5 cases (7%) with other traditional medicines. Of the 76 cases, 5% were in adults and 95% were in infants and young children. Of the 4 adult cases, at least one was left with residual neurological impairment. In infants and young children, among 72 cases 8 (11%) were fatal, and at least 15 (21%) had residual neurological deficits. Traditional medicine users should be screened for lead exposure and strongly encouraged to discontinue metal-containing remedies. Therefore, the United States Food and Drug Administration and corresponding agencies in other countries should require and enforce heavy metal testing for all imported traditional medicines and "dietary supplements".