Long-term therapeutic effects of electro-acupuncture for chronic neck and shoulder pain--a double blind study

A randomized, single-blind, prospective trial of auricular 'battlefield' acupuncture for the reduction of postoperative tonsillectomy pain in adults

AIM

The purpose of this randomized, single-blind trial was to evaluate the efficacy of battlefield acupuncture in reducing postoperative pain and opioid consumption after adult tonsillectomy.

METHODS

Adult participants undergoing a tonsillectomy were randomized to either receive auricular 'battlefield' acupuncture or not. Groups were compared using the Wilcox rank sum test, Fisher's exact test and a generalized estimating equations model for post-discharge pain scores.

RESULTS

Statistically significant difference was not noted for morphine equivalent opioid use, nor was there any difference noted in the pain scores between the control group and treatment group.

CONCLUSION

Acupuncture is cheap, safe and effective in many settings. Peri-operative battlefield auricular acupuncture did not reduce postoperative pain or opioid consumption in this study.

WITHDRAWN: Acupuncture for neck disorders

BACKGROUND

Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied, as are perceptions of benefit. Acupuncture has been used as an alternative to more conventional treatment for musculoskeletal pain. This review summarises the most current scientific evidence on the effectiveness of acupuncture for acute, subacute and chronic neck pain. This update replaces our 2006 Cochrane review update on this topic.

OBJECTIVES

To determine the effects of acupuncture for adults with neck pain, with focus on pain relief, disability or functional measures, patient satisfaction and global perceived effect.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Manual, Alternative and Natural Therapy Index System (MANTIS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Index to Chiropractic Literature (ICL) from their beginning to August 2015. We searched reference lists, two trial registers and the acupuncture database Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) in China to 2005.

SELECTION CRITERIA

We included published trials that used random assignment to intervention groups, in full text or abstract form. We excluded quasi-randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

Two review authors made independent decisions for each step of the review: article inclusion, data abstraction and assessment of quality of trial methods. We assessed study quality by using the Cochrane Back Review Group 'Risk of bias' tool. We used consensus to resolve disagreements, and when clinical heterogeneity was absent, we combined studies by using random-effects meta-analysis models.

MAIN RESULTS

Of the 27 included studies, three represented individuals with whiplash-associated disorders (WADs) ranging from acute to chronic (205 participants), five explored chronic myofascial neck pain (186 participants), five chronic pain due to arthritic changes (542 participants), six chronic non-specific neck pain (4011 participants), two neck pain with radicular signs (43 participants) and six subacute or chronic mechanical neck pain (5111 participants).For mechanical neck pain, we found that acupuncture is beneficial at immediate-term follow-up compared with sham acupuncture for pain intensity; at short-term follow-up compared with sham or inactive treatment for pain intensity; at short-term follow-up compared with sham treatment for disability; and at short-term follow-up compared with wait-list control for pain intensity and neck disability improvement. Statistical pooling was appropriate for acupuncture compared with sham for short-term outcomes due to statistical homogeneity (P value = 0.83; I2 = 20%). Results of the meta-analysis favoured acupuncture (standardised mean difference (SMD) -0.23, 95% confidence interval (CI) -0.20 to -0.07; P value = 0.0006). This effect does not seem sustainable over the long term. Whether subsequent repeated sessions would be successful was not examined by investigators in our primary studies.Acupuncture appears to be a safe treatment modality, as adverse effects are minor. Reported adverse effects include increased pain, bruising, fainting, worsening of symptoms, local swelling and dizziness. These studies reported no life-threatening adverse effects and found that acupuncture treatments were cost-effective.Since the time of our previous review, the quality of RCTs has improved, and we have assessed many of them as having low risk of bias. However, few large trials have provided high-quality evidence.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up, and that those who received acupuncture report less pain and disability at short-term follow-up than those on a wait-list. Moderate-quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain at short-term follow-up.

Acupuncture for neck disorders

BACKGROUND

Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied, as are perceptions of benefit. Acupuncture has been used as an alternative to more conventional treatment for musculoskeletal pain. This review summarises the most current scientific evidence on the effectiveness of acupuncture for acute, subacute and chronic neck pain. This update replaces our 2006 Cochrane review update on this topic.

OBJECTIVES

To determine the effects of acupuncture for adults with neck pain, with focus on pain relief, disability or functional measures, patient satisfaction and global perceived effect.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Manual, Alternative and Natural Therapy Index System (MANTIS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Index to Chiropractic Literature (ICL) from their beginning to August 2015. We searched reference lists, two trial registers and the acupuncture database Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) in China to 2005.

SELECTION CRITERIA

We included published trials that used random assignment to intervention groups, in full text or abstract form. We excluded quasi-randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

Two review authors made independent decisions for each step of the review: article inclusion, data abstraction and assessment of quality of trial methods. We assessed study quality by using the Cochrane Back Review Group 'Risk of bias' tool. We used consensus to resolve disagreements, and when clinical heterogeneity was absent, we combined studies by using random-effects meta-analysis models.

MAIN RESULTS

Of the 27 included studies, three represented individuals with whiplash-associated disorders (WADs) ranging from acute to chronic (205 participants), five explored chronic myofascial neck pain (186 participants), five chronic pain due to arthritic changes (542 participants), six chronic non-specific neck pain (4011 participants), two neck pain with radicular signs (43 participants) and six subacute or chronic mechanical neck pain (5111 participants).For mechanical neck pain, we found that acupuncture is beneficial at immediate-term follow-up compared with sham acupuncture for pain intensity; at short-term follow-up compared with sham or inactive treatment for pain intensity; at short-term follow-up compared with sham treatment for disability; and at short-term follow-up compared with wait-list control for pain intensity and neck disability improvement. Statistical pooling was appropriate for acupuncture compared with sham for short-term outcomes due to statistical homogeneity (P value = 0.83; I(2) = 20%). Results of the meta-analysis favoured acupuncture (standardised mean difference (SMD) -0.23, 95% confidence interval (CI) -0.20 to -0.07; P value = 0.0006). This effect does not seem sustainable over the long term. Whether subsequent repeated sessions would be successful was not examined by investigators in our primary studies.Acupuncture appears to be a safe treatment modality, as adverse effects are minor. Reported adverse effects include increased pain, bruising, fainting, worsening of symptoms, local swelling and dizziness. These studies reported no life-threatening adverse effects and found that acupuncture treatments were cost-effective.Since the time of our previous review, the quality of RCTs has improved, and we have assessed many of them as having low risk of bias. However, few large trials have provided high-quality evidence.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up, and that those who received acupuncture report less pain and disability at short-term follow-up than those on a wait-list. Moderate-quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain at short-term follow-up.

The outcome of control groups in clinical trials of conservative treatments for chronic mechanical neck pain: a systematic review

Background

Chronic neck pain is highly prevalent in Western societies, with about 15% of females and 10% of males suffering with it at any time. The course of untreated chronic neck pain patients in clinical trials has not been well-defined and the placebo effect has not been clarified.

Methods

A systematic review of RCT's of conservative treatments for chronic mechanical neck pain was conducted. Studies were excluded if they did not include a control group, if they involved subjects with whiplash injuries, a predominance of headache or arm pain associated with chronic neck pain and if only one treatment was reported. Only studies scoring 3–5 out of 5 on the Jadad Scale for quality were included in the final analysis. Data on change in pain scores of subjects in both placebo (PL) as well as no-treatment (NT) control groups were analyzed. Mean changes in pain scores as well as effect sizes were calculated, summarized and compared between these groups.

Results

Twenty (20) studies, 5 in the NT group and 15 in the PL group, with outcome intervals ranging from 1–52 weeks were included in the final analysis. The mean [95% CI] effect size of change in pain ratings in the no-treatment control studies at outcome points up to 10 weeks was 0.18 [-0.05, 0.41] and for outcomes from 12–52 weeks it was 0.4 [0.12, 0.68]. In the placebo control groups it was 0.50 [0.10, 0.90] at up to 10 weeks and 0.33. [-1.97, 2.66] at 12–24 weeks. None of the comparisons between the no-treatment and placebo groups were statistically significant.

Conclusion

It appears that the changes in pain scores in subjects with chronic neck pain not due to whiplash who are enrolled in no-treatment and placebo control groups were similarly small and not significantly different. As well, they do not appear to increase over longer-term follow-up.

Acupuncture for shoulder pain

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effect of acupuncture treatment on chronic neck and shoulder pain in sedentary female workers: a 6-month and 3-year follow-up study

The study was carried out to examine whether acupuncture treatment can reduce chronic pain in the neck and shoulders and related headache, and also to examine whether possible effects are long-lasting. Therefore, 24 female office workers (47+/-9 years old, mean+/-SD) who had had neck and shoulder pain for 12+/-9 years were randomly assigned to a test group (TG) or a control group (CG). Acupuncture was applied 10 times during 3-4 weeks either at presumed anti-pain acupoints (TG) or at placebo-points (CG). A physician measured the pain threshold (PPT) in the neck and shoulder regions with algometry before the first treatment, and after the last one and six months after the treatments. Questionnaires on muscle pain and headache were answered at the same occasions and again 3 years after the last treatment. The intensity and frequency of pain fell more for TG than for CG (Pb < or = 0.04) during the treatment period. Three years after the treatments TG still reported less pain than before the treatments (Pw < 0.001) contrary to what CG did (Pb < 0.04) The degree of headache fell during the treatment period for both groups, but more for TG than for CG (Pb=0.02) Three years after the treatments the effect still lasted for TG (Pw < 0.01) while the degree of headache for CG was back to the pre-treatment level (Pb < 0.001) PPT of some muscles rose during the treatments for TG and remained higher 6 months after the treatments (Pw < 0.05) which contrasts the situation for CG. Adequate acupuncture treatment may reduce chronic pain in the neck and shoulders and related headache. The effect lasted for 3 years.

Acupuncture and arthroscopic acromioplasty

BACKGROUND

Acupuncture alleviates acute and chronic shoulder pain. Yet it has not been determined whether acupuncture is useful following musculoskeletal surgery.

HYPOTHESIS

Compared to sham acupuncture, arthroscopic acromioplasty subjects who received real acupuncture would manifest significantly better recovery as demonstrated by: UCLA shoulder scale, improved range of motion, diminished pain, decreased need and duration of analgesic use, and enhanced patient satisfaction.

METHODS

Forty arthroscopic acromioplasty patients were randomized to real or sham acupuncture. UCLA shoulder scale scores, pain intensity, analgesic use, range of motion, and quality of life were monitored for four months. Data were analyzed with the general linear model ANOVA for repeated measures.

RESULTS

Thirty-five subjects completed the study. Real acupuncture subjects scored significantly better on UCLA shoulder scale (p<0.000); pain intensity (p<0.022); self-reported analgesic use (p<0.008); angles of abduction (p<0.046); and in six of eight health status questionnaire components.

CONCLUSIONS

Following arthroscopic acromioplasty, real acupuncture compared to sham acupuncture offered significantly greater improvement via: (1) lower pain level, (2) less analgesic use, (3) range of motion, and (4) patient satisfaction.

A controlled trial on acupuncture for chronic neck pain

To evaluate the efficacy of Chinese medicine (CM) acupuncture for chronic neck pain (CNP), a single blind, controlled, crossover, clinical trial was undertaken. Twenty-nine volunteers with CNP were randomly recruited into two groups. Both groups received two phases of treatment with a washout period between the two phases. Group A (14 volunteers) received CM acupuncture in the first phase and sham acupuncture in the second, while Group B (15 volunteers) received sham in the first and real in the second. CM acupuncture was individualized and consisted of nine sessions on both local and distal points. Manual twisting of the needle was applied on all points plus strong electrical stimulation of distal points in CM acupuncture. Sham acupoints (lateral to the real) and sham (weak) electrical stimulation was used in the control group. Comparison of subjective and objective measures between the two groups was made at different periods, including baseline, after each phase of treatment, after washout, and after the 16th week follow-up. The subjective measures included pain intensity, duration per day, analgesic medication count, visual analogue scales (VAS) and neck disability index (NDI). The objective measures consisted of neck range of motion (ROM) and pain threshold (PT). Both the real and sham treatments significantly reduced subjective pain, without significant differences between groups for most subjective measures. Objective measures showed no significant change for either group before and after each period or by inter-groups analysis. A minimum 16-week effect of both real and sham acupuncture was found for subjective measures in the follow-up periods. Further study is recommended with an increased sample size, a longer washout period, and a longer baseline period.

A study of the use of acupuncture in physiotherapy

OBJECTIVES

This two-phase study was designed to establish the current use of acupuncture within physiotherapy and to determine the opinions of those who received acupuncture therapy.

DESIGN

Retrospective study and questionnaire survey.

PATIENTS

Patients who attended an outpatient physiotherapy department over a 2-year period (phase 1, retrospective study of clinical records; n = 599). Patients who had received acupuncture treatment from outpatient physiotherapy (phase 2, patient survey; n = 200).

MAIN OUTCOME MEASURE

Patient records and questionnaire.

RESULTS

The patients who attended for outpatient physiotherapy were categorized into three main groups: low back pain, cervical/thoracic spine problems and soft-tissue injuries of peripheral joints. Acupuncture appeared to be used as a secondary form of treatment for these conditions, where other modalities failed rather than being used for best effect. The response rate to the questionnaire was 78%, of whom 60% stated that they had experienced pain relief following their acupuncture therapy, and 31% were still experiencing pain relief. The majority had achieved sufficient relief to carry out daily activities at home (80%) and at work (57%). Ninety-four per cent of respondents were either 'satisfied' or 'very satisfied' with their treatment.

CONCLUSION

Further investigation is required to adequately assess the efficacy of acupuncture as a pain-relieving modality.

Physical medicine modalities for mechanical neck disorders

OBJECTIVES

Multiple physical medicine modalities are commonly included as part of therapeutic interventions for mechanical neck disorders (neck pain). The objective of this review was to assess the effects of physical medicine modalities for pain in adults with mechanical neck disorders.

SEARCH STRATEGY

We searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services and reference lists of the retrieved articles from 1985 to December 1993 and we contacted content experts.

SELECTION CRITERIA

Randomised trials and controlled trials of physical medicine modalities in adults with mechanical neck disorder.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain information or data that could not be found in the published reports.

MAIN RESULTS

Thirteen trials were included. The overall quality of the included trials was generally good. Two trials using electromagnetic therapy produced a significant reduction in pain (p <0.01) with three to four weeks of daily (eight hours per day) therapy sessions; and three using laser therapy did not differ significantly from a placebo (p=0.20) for six to 10 sessions of treatment. Not enough scientific testing exists to clearly determine the effectiveness of other therapies. This includes treatments such as exercise, traction, acupuncture, heat / cold applications, electrotherapies, cervical orthoses and chronic pain / cognitive behavioural rehabilitation strategies.

REVIEWER'S CONCLUSIONS

There is little information available from trials to support the use of physical medicine modalities for mechanical neck pain. There is some support for the use of electromagnetic therapy and against the use of laser therapy with respect to pain reduction.

Patient education for mechanical neck disorders

BACKGROUND

To track down the best estimate of efficacy of the various conservative management strategies for mechanical neck disorders, a four-part systematic review was prepared. Part four investigates the efficacy of patient education strategies as the therapeutic intervention.

OBJECTIVES

This review of patient education is one of four reviews of conservative management of mechanical neck disorders. The other reviews address manual, physical and drug therapies. The objective of this review was to assess the effects of patient education for pain in adults with mechanical neck disorders.

SEARCH STRATEGY

We searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services from 1985 to December 1993, reference lists of the retrieved articles and we contacted experts in the field.

SELECTION CRITERIA

Randomised trials or controlled clinical trials of patient educational strategies for adults with mechanical neck disorders.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain data that could not be found in the published reports.

MAIN RESULTS

Three trials were included. Their methodological quality varied from weak to strong. One trial did not find a significant reduction in pain using group instructional strategies (neck school) and exercise with or without psychological counselling compared to no treatment (standardised mean difference 0.07, 95% confidence interval -0.51 to 0.66, and -0.37, 95% confidence interval -0.95 to 0.22, respectively). Another trial did not find a significant reduction in pain using individualised patient education (advice), anti-inflammatories and analgesics compared with placebo (standardised mean difference 0.24, 95% confidence interval -0.58 to 1.07). The third trial found that advice which included demonstrated mobilization exercises, verbal and written instruction on posture correction, the use of a collar, heat sources, muscle relaxation and analgesics gave significant pain relief compared with general advice about mobilisation after a period of rest and use of analgesics at 4 weeks of treatment (standardised mean difference -0.62, 95% confidence interval -1.05 to -0.19) but at 6 weeks of treatment there was no longer any difference (s.m.d. -0.37, 95% confidence interval -0.8 to 0.05). The first two trials lacked statistical power and the third was methodologically weak.

REVIEWER'S CONCLUSIONS

Patient education utilising individualised or group instructional strategies has not been shown to be beneficial in reducing pain for mechanical neck disorders.

[Acupuncture for the treatment of pain-a prospective study.]

Acupuncture is increasingly being used in Western medicine. In the present study the effect of acupuncture treatment was examined in 60 patients with chronic pain. The long-term success after 6 months was evaluated in 45 patients. Calculated on the basis of an index of the frequency of pain, its duration and intensity, a global success rate of 64% was found directly after the therapy and of 69% 6 months later. Furthermore, we examined to what extent the success of the therapy was dependent on several variables. It appeared that the consumption of analgesics could be reduced significantly in patients in whom the treatment was successful. All patients had been treated before by several methods. Because of the small number of side-effects and the patients' high degree of acceptance as well as the success of the treatment, we consider acupuncture an effective method in the treatment of chronic pain.