Acupuncture for Psychological Disorders Caused by Chronic Pain: A Review and Future Directions

Accumulating evidence supports an association between chronic pain and psychological disorders, a connection that seems to be bidirectional. Treating both the pain and psychological conditions together is essential for effective treatment outcomes. Acupuncture is a somatosensory-guided mind-body therapy that can tackle the multidimensional nature of pain with fewer or no serious adverse effects. In this review, we discuss the use of acupuncture in some conditions with a high incidence of psychological disorders caused by chronic pain: headache, musculoskeletal pain, low back pain, and cancer pain, focusing on the effect and potential mechanisms of acupuncture. Overall clinical studies indicated that acupuncture might effectively contribute to management of psychological disorders caused by chronic pain. Mechanistic studies showed that acupuncture significantly alleviated such psychological disorders by regulating the activity of amygdala and insula, and regulating functional connectivity of insular and limbic regions/medial prefrontal cortex in humans and the corresponding animal models. In addition, 5-HT in the dorsal raphe nucleus, opioid receptors in the cingulate cortex, and plasma met-enkephalin are involved in acupuncture relief of pain and psychological symptoms. Substantial evidences from animal and human research support a beneficial effect of acupuncture in psychological disorders caused by chronic pain.

Efficacy of Intensive Acupuncture Versus Sham Acupuncture in Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of intensive acupuncture (3 times weekly for 8 weeks) versus sham acupuncture for knee osteoarthritis (OA).

METHODS

In this multicenter, randomized, sham-controlled trial, patients with knee OA were randomly assigned to receive electroacupuncture (EA), manual acupuncture (MA), or sham acupuncture (SA) 3 times weekly for 8 weeks. Participants, outcome assessors, and statisticians were blinded with regard to treatment group assignment. The primary outcome measure was response rate, which is the proportion of participants who simultaneously achieved minimal clinically important improvement in pain and function by week 8. The primary analysis was conducted using a Z test for proportions in the modified intent-to-treat population, which included all randomized participants who had ≥1 post-baseline measurement.

RESULTS

Of the 480 participants recruited in the trial, 442 were evaluated for efficacy. The response rates at week 8 were 60.3% (91 of 151), 58.6% (85 of 145), and 47.3% (69 of 146) in the EA, MA, and SA groups, respectively. The between-group differences were 13.0% (97.5% confidence interval [97.5% CI] 0.2%, 25.9%; P = 0.0234) for EA versus SA and 11.3% (97.5% CI -1.6%, 24.4%; P = 0.0507) for MA versus SA. The response rates in the EA and MA groups were both significantly higher than those in the SA group at weeks 16 and 26.

CONCLUSION

Among patients with knee OA, intensive EA resulted in less pain and better function at week 8, compared with SA, and these effects persisted though week 26. Intensive MA had no benefit for knee OA at week 8, although it showed benefits during follow-up.

[Effect of acupuncture on knee injury and osteoarthritis outcome score in patients with knee osteoarthritis]

OBJECTIVE

To verify the clinical effect of acupuncture on knee osteoarthritis (KOA).

METHODS

Forty-two patients with KOA were randomly divided into an acupuncture group (21 cases, 1 case dropped off) and a sham acupuncture group (21 cases, 1 case dropped off). The patients in the acupuncture group were treated with routine acupuncture at 5-6 local acupoints [Dubi (ST 35), Neixiyan (EX-LE 4), Heding (EX-LE 2), Yinlingquan (SP 9), Xuehai (SP 10), Zusanli (ST 36), etc.] and 3-4 distal acupoints [Fengshi (GB 31), Waiqiu (GB 36), Xuanzhong (GB 39), Zulinqi (GB 41), etc.]. The patients in the sham acupuncture group were treated with shallow needling technique at non-acupoint. The needles were retained for 30 min in both groups. All the treatment was given three times a week for 8 weeks. Knee injury and osteoarthritis outcome score (KOOS) were recorded before and after treatment and 18-week follow-up.

RESULTS

Compared before treatment, the scores of 5 dimensions of KOOS [pain, symptoms (except pain), daily activities, sports and entertainment, and quality of life] were increased after treatment and during follow-up in the two groups (P<0.05), and the scores of pain and daily activities in the acupuncture group were higher than those in the sham acupuncture group (P<0.05).

CONCLUSION

Acupuncture can reduce the pain symptoms and improve daily activities in patients with KOA.

The Management of Sciatica by Acupuncture: An Expert Consensus Using the Improved Delphi Survey

Objective

Acupuncture therapy is an effective non-drug therapy for sciatica, but it has not yet formed an effective treatment strategy and recommendations. Our objective was to establish an expert consensus on acupuncture treatment of sciatica for clinical guidance based on the improved Delphi survey.

Methods

A group of 80 clinical specialists was invited to participate in two rounds of semi-open clinical issue investigation. At the same time, the PubMed, Embase, and Cochrane Library databases were searched for systematic reviews on acupuncture treatment of sciatica, and the quality of evidence was evaluated. Then the three-round Delphi survey was undertaken with 30 experts based on the clinical issue investigation and systematic reviews.

Results

In round 1 of the Delphi survey, the experts evaluated 17 items identified from the results of the clinical investigation and literature review. The criterion for achieving consensus was a threshold of 80% agreement. After the three-round Delphi survey, 16 items (94.12%) achieved consensus, including 5 domains: the principle of acupuncture treatment for sciatica; the “dose” of acupuncture; the clinical effects of acupuncture; the adverse effects, and others.

Conclusion

This Delphi survey achieved an expert consensus on key items in the management of sciatica for acupuncture, which provides the current opinions in China. We trust that these treatment recommendations may facilitate their implementation in the future.

Acupuncture for persistent atrial fibrillation after catheter ablation: study protocol for a pilot randomized controlled trial

Background

Atrial fibrillation (AF) is a common arrhythmia, which is closely related to cardiovascular morbidity and mortality. Although acupuncture is used in the treatment of AF, the evidence is insufficient. The objective of this pilot trial is to evaluate the feasibility, preliminary efficacy, and safety of acupuncture in reducing AF burden for persistent AF after catheter ablation (CA).

Methods and design

This will be a multi-center, 3-arm, pilot randomized controlled trial in China. Sixty patients in total will be randomly assigned to the specific acupoints group, the non-specific acupoints group, or the non-acupoints group in a 1:1:1 ratio. The whole study period is 6 months, including a 3-month treatment period and a 3-month follow-up period. All patients will receive 18 sessions of acupuncture over 12 weeks after CA and appropriate post-ablation routine treatment. The primary outcome is AF burden at 6 months after CA measured by electrocardiography patch that can carry out a 7-day continuous ambulatory electrocardiographic monitoring. The secondary outcomes include AF burden at 3  months after CA, recurrence of AF, quality of life, etc. The adverse events will also be recorded.

Discussion

This pilot study will contribute to evaluating the feasibility, preliminary efficacy, and safety of acupuncture in reducing AF burden for persistent AF after CA. The results will be used for the sample size calculation of a subsequent large-scale trial.

Trial registration

Chinese Clinical Trial Registry ChiCTR2000030576. Registered on 7 March 2020.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s13063-020-04967-y.

Efficacy of acupuncture for sciatica: study protocol for a randomized controlled pilot trial

BACKGROUND

Acupuncture is widely used for pain diseases while evidence of its efficacy for sciatica is insufficient. We aim to explore the feasibility and efficacy of acupuncture with different acupoint selecting strategies for sciatica induced by lumbar disc herniation.

METHODS

This is a multicenter, three-arm, patient-assessor-blinded randomized controlled pilot trial. Ninety patients will be assigned randomly into 3 groups including disease-affected meridians (DAM) group, non-affected meridians (NAM) group, and sham acupuncture (SA) group in a 1:1:1 ratio. The trial involves a 4-week treatment along with follow-up for 22 weeks. The primary outcome is the change of leg pain intensity measured by the visual analogue scale (VAS) from baseline to week 4 after randomization. Secondary outcomes include functional status, back pain intensity, and quality of life. Adverse events will also be recorded.

DISCUSSION

The results will inspire the optimal acupuncture strategy for sciatica and help establish a better design as well as power calculation for a full-scale study.

TRIAL REGISTRATION

ChiCTR2000030680 (Chinese Clinical Trial Registry, http://www.chictr.org.cn , registered on 9 March 2020).

Acupuncture Improves White Matter Perfusion and Integrity in Rat Model of Vascular Dementia: An MRI-Based Imaging Study

White matter lesions induced by chronic cerebral hypoperfusion are associated with cognitive impairment in vascular dementia (VaD). Previous studies have shown that acupuncture can ameliorate the cognitive deficits of individuals with VaD. However, the neuroimaging mechanisms of acupuncture on white matter perfusion and integrity remain elusive. In this study, the VaD model was induced by bilateral common carotid arteries occlusion (BCCAO) in rats. Novel object recognition task and Morris water maze were performed to evaluate short-term memory and spatial learning and memory. Arterial spin labeling and diffusion tensor imaging (DTI) were used to measure the cerebral blood flow (CBF) and the white matter integrity. Pathological examinations detected the myelin loss and concomitant neuroinflammation. The results demonstrate that BCCAO rats with reduced CBF exhibited worse performance and altered DTI parameters, including decreased fractional anisotropy, increased radial diffusivity, and axial diffusivity in white matter regions. Acupuncture ameliorated cognitive impairment, increased CBF, and protected the myelin sheath integrity but not the axons of BCCAO rats. These protective effects of acupuncture on white matter were significantly correlated with improved CBF. Pathological examination confirmed that the loss of myelin basic protein and microglial accumulation associated IL-1β and IL-6 production were attenuated by acupuncture treatment. Our findings suggest that acupuncture protects cognitive function of BCCAO rats by improving white matter perfusion and integrity.

Neurological and psychological mechanisms of the specific and nonspecific effects of acupuncture on knee osteoarthritis: study protocol for a randomized, controlled, crossover trial

Background

Acupuncture, as one of the promising non-pharmacological interventions, has been proved to be beneficial for patients. However, the magnitude of acupuncture’s specific and nonspecific effects, as well as their neurological and psychological determinants, remains unclear. Therefore, this study is designed to examine the acupuncture efficacy, investigate whether the brain mechanisms between the specific and nonspecific effects of acupuncture are different, and to evaluate how psychological factors affect the acupuncture effects.

Methods

This is a randomized, controlled, crossover clinical trial. A total of 60 patients with knee osteoarthritis will receive 4 weeks of acupuncture treatment and 4 weeks of sham acupuncture treatment in a random order separated by a washout period of 2 weeks. The changes in clinical characteristics based on pain-related scales will be assessed to investigate the clinical efficacy of acupuncture. Resting state functional magnetic resonance imaging (fMRI) scans will be used to identify the brain activity changes related to the specific and nonspecific effects of acupuncture. The questionnaires of psychological factors will be used to evaluate patients’ psychological properties. Correlation and mediation analyses will be conducted among psychological factors, brain activity changes, and symptoms improvement to explore the neurological and psychological correlates of the acupuncture effects.

Discussion

This study will concentrate on distinguishing and clarifying the specific and nonspecific effects of acupuncture. The results of this study may contribute to rationally optimize the acupuncture therapies by flexible application of the specific and nonspecific effects of acupuncture.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900025807. Registered on 9 September 2019

Supplementary information

The online version contains supplementary material available at 10.1186/s13063-020-04908-9.

Acupuncture Therapy for Cognitive Impairment: A Delphi Expert Consensus Survey

Background

Current research evidence challenges clinical decision-making when acupuncture is taken into consideration in the treatment of cognitive impairment (CI). Aiming to provide some viable recommendations for acupuncture practitioners in dealing with actual clinic issues, an expert consensus study was conducted.

Methods

A clinical question investigation among 47 acupuncturists yielded 24 initial items. Subsequently, systematic reviews on acupuncture for CI were searched within three online databases. A panel of 30 authoritative experts were requested to respond with agreement, neutrality, or disagreement for each item. Consensus establishment was defined as the percentage of agreement on a given item >80%.

Results

Following a 2-round Delphi survey, there were 21 items reaching consensus and three items resulting in no consensus; of which 10 items reached 90∼100% agreement, and 80∼90% expert agreement was achieved for 11 items. These items could be roughly categorized into six domains: (1) therapeutic effects of acupuncture, (2) therapeutic principles, (3) acupoint selection and combination, (4) acupuncture parameters, (5) considerable combined therapies, and (6) possible adverse events.

Conclusion

Without ready-made guidelines, this expert consensus may be conducive to guide acupuncturists in implementing clinical acupuncture practice for CI. Moreover, given the lack of high-quality research evidence and plenty of unresolved clinical issues in this field, it is of necessity to carry out more studies to better clarify the treatment algorithm.

[Effect of electroacupuncture at "Zusanli" (ST 36) and its matching point at abdomen on intestinal motility in mice with postoperative ileus]

OBJECTIVE

To investigate the effect of electroacupuncture (EA) at different acupoint combination on intestinal motility and expression of inflammatory factors IL-6 and TNF-α in intestinal muscle layer in mice with postoperative ileus (POI), so as to provide reference of acupoint combination of clinical EA intervention for POI.

METHODS

A total of 78 SPF-grade male C57BL/6 mice aged 8-12 weeks were randomly divided into a sham operation group, a model group, a ST 36+ non-acupoint group, a ST 36+ ST 25 group, a ST 36+ CV 4 group and a ST 36+ CV 12 group, 13 mice in each group. The model of POI was established by intestinal manipulation. The mice in each acupuncture group were intervened with HANS-200A acupoint nerve stimulator within 3 hours after modeling, continuous wave, frequency of 10 Hz, intensity of 1 mA, for 20 min. The EA was given once. 22.5 h after model establishment, 7 mice in each group were intragastrically administered with fluorescein isothiocyanate-conjugated (FITC-dextran). 1.5 h after intragastric administration, intestinal motility was evaluated. 24 h after modeling, the expression of IL-6 and TNF-α mRNA in intestinal muscle layer was detected by real-time fluorescence quantitative PCR and spleen index was calculated.

RESULTS

Compared with the sham operation group, the intestinal motility 24 h after modeling in the model group was significantly decreased (P<0.01), and the expression of IL-6 and TNF-α mRNA in intestinal muscle layer was increased (P<0.01). Compared with the model group, the intestinal motility 24 h after modeling in the ST 36+ non-acupoint group and the ST 36+ ST 25 group was increased (P<0.01), and the expression of IL-6 and TNF-α mRNA in intestinal muscle layer was decreased (P<0.01, P<0.05), and the expression of TNF-α mRNA in intestinal muscle layer in the ST 36+ CV 4 group was also decreased (P<0.05), but there was no significant difference in the ST 36+ CV 12 group and the ST 36+ CV 4 group (P>0.05). There was no significant difference in spleen index among the groups (P>0.05).

CONCLUSION

EA at "Zusanli" (ST 36) or "Zusanli" (ST 36) combined with "Tianshu" (ST 25) can improve intestinal motility in mice with POI, and the mechanism may be related to the improvement of local inflammatory reaction. In addition, abdominal acupoints should be selected carefully.

Magnetic resonance imaging study of safe needling depth and angulation for acupuncture at BL40

OBJECTIVES

The objectives of this study were to identify the mean safe needling depth and angle at BL40 between subjects, taking into account variables including sex and body mass index (BMI).

METHODS

One hundred and twenty-four participants who had undergone magnetic resonance imaging (MRI) examination of the knee region for clinical indications were included in this study. BL40 needling sites were localized by World Health Organization (WHO) standards and were measured by MRI. As much as 70% of the value of AN (from the needle insertion point to the popliteal artery) was considered to represent the safe depth, and angle alpha between the BL40 straight line and the AN line was regarded as the safe angle.

RESULTS

Overall, mean safe depth regardless of BMI and sex was 18.51 ± 3.56 mm (95% confidence interval (CI), 17.88%-19.14%). Mean safe depth was 17.24 ± 3.14 mm in the low and normal BMI group, 18.76 ± 2.90 mm in the overweight group, and 22.01 ± 3.71 mm in the obese group. Thirteen patients (10.5%) had internal deviation of angle alpha (95% CI, 5.6%-15.3%), while 111 patients (89.5%) had external deviation (95% CI, 84.7%-94.4%). The mean internal and external deviations of angle alpha were 8.78° ± 2.92° (95% CI, 7.01°-10.55°) and 9.75° ± 3.46° (95% CI, 9.10°-10.41°), respectively.

CONCLUSION

We would suggest that, when using a straight needle insertion at BL40, it is safe to advance a 25-mm needle approximately 12.5 mm, and 17.5 mm should be safe for patients with BMI greater than 28 kg/m². Practitioners should decrease the depth of penetration when treating patients of low body weight or height.

Magnetic resonance imaging study of safe needling depth and angulation for acupuncture at BL40

OBJECTIVES

The objectives of this study were to identify the mean safe needling depth and angle at BL40 between subjects, taking into account variables including sex and body mass index (BMI).

METHODS

One hundred and twenty-four participants who had undergone magnetic resonance imaging (MRI) examination of the knee region for clinical indications were included in this study. BL40 needling sites were localized by World Health Organization (WHO) standards and were measured by MRI. As much as 70% of the value of AN (from the needle insertion point to the popliteal artery) was considered to represent the safe depth, and angle alpha between the BL40 straight line and the AN line was regarded as the safe angle.

RESULTS

Overall, mean safe depth regardless of BMI and sex was 18.51 ± 3.56 mm (95% confidence interval (CI), 17.88%-19.14%). Mean safe depth was 17.24 ± 3.14 mm in the low and normal BMI group, 18.76 ± 2.90 mm in the overweight group, and 22.01 ± 3.71 mm in the obese group. Thirteen patients (10.5%) had internal deviation of angle alpha (95% CI, 5.6%-15.3%), while 111 patients (89.5%) had external deviation (95% CI, 84.7%-94.4%). The mean internal and external deviations of angle alpha were 8.78° ± 2.92° (95% CI, 7.01°-10.55°) and 9.75° ± 3.46° (95% CI, 9.10°-10.41°), respectively.

CONCLUSION

We would suggest that, when using a straight needle insertion at BL40, it is safe to advance a 25-mm needle approximately 12.5 mm, and 17.5 mm should be safe for patients with BMI greater than 28 kg/m². Practitioners should decrease the depth of penetration when treating patients of low body weight or height.

[Cytomegalovirus detoxification and associated factors among preschool children in Yi'nan County]

Objective: To investigate cytomegalovirus detoxification and associated factors among preschool children in Yinan County, Shandong Province. Methods: Two kindergartens were selected from the county and township of Yinan respectively. A total of 250 children were investigated in October 2018. Case information was obtained through the child's guardian. Saliva samples of children and their mothers were collected for cytomegalovirus realtime-PCR detection.The status of CMV detoxification of children was explored and the associated factors were analyzed. Results: A total of 242 preschool children were investigated, and the detoxification rate of cytomegalovirus among them was 22.31% (54/242, 95%CI: 17.0%-27.6%). Logistic regression analysis showed that the rate of detoxification was higher in children whose mothers were cytomegalovirus detoxified (OR=12.39, 95%CI:1.73-88.65)and whose school was located in the county (OR=3.58, 95%CI:1.34-9.55). Conclusions: The detoxification rate of cytomegalovirus in preschool children is high, and there is mutual transmission between children and mothers. Women of childbearing age should pay attention to prevent congenital cytomegalovirus infection when they come into contact with children.

Standardizing therapeutic parameters of acupuncture in vascular dementia rats

INTRODUCTION

Despite acupuncture having been successfully used for the clinical treatment for vascular dementia in Asian countries for centuries, scientifically rigorous evidence is lacking for standardizing therapeutic parameters. To address this problem, it is necessary to examine the parameters of acupuncture using scientific methodology. The goal of this study is to investigate various therapeutic parameters, including manipulation, retention, and frequency of acupuncture, and their contribution to the efficacy of acupuncture in VD.

METHODS

We selected needle retention, treatment frequency, and needle rotation as the parameters. Acupuncture was performed on acupoints ST36 and GV20. Morris Water Maze was selected to assess the effect of acupuncture on cognitive function and Nissl staining indicated the hippocampal neuronal damage in VD rats.

RESULTS

Acupuncture stimulation resulted in a significant improvement in the spatial learning and memory deficit and reversed neuronal damage in the hippocampus. The approach of needle retention with 10 min, rotation for 30s every 5 min or daily treatment with acupuncture was more effective than nonretention, nonrotation, or alternative day treatment group.

CONCLUSION

This study demonstrated that needle retention, treatment frequency, and needle manipulation are important factors in improving the learning and memory as well as reducing the neuronal damage of the hippocampus in a rat VD model. These findings strongly suggest that the appropriate therapeutic parameters could significant influence the efficiency in animal experiments.

Effect of Electro-Acupuncture (EA) and Manual Acupuncture (MA) on Markers of Inflammation in Knee Osteoarthritis

Background

Inflammation plays a significant role in the pathogenesis of knee osteoarthritis (KOA). Although both electro-acupuncture (EA) and manual acupuncture (MA) are known to influence systemic inflammation, little is known about the potential changes in inflammation as a working mechanism of EA and MA in KOA.

Methods

Data from the Acupuncture for Knee Osteoarthritis Trial (ATKOA) were used. Serum concentrations of inflammatory factors (tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), IL-6, IL-8, IL-18, IL-4, IL-10, IL-13, IL-15, IL-17, monocyte chemotactic protein-1 (MCP-1), CC-chemokine ligand 5 (CCL5), and cartilage degradation biomarkers (matrix metalloproteinase-1 MMP-1, MMP-3, MMP-13 and cartilage oligomeric matrix protein COMP)) were measured at baseline and after 8 weeks of treatment. Clinical outcomes were valid and reliable self-reported pain and function measures for osteoarthritis using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and visual analogue scale (VAS) at baseline and post-treatment.

Results

Both 8-weeks EA and MA significantly reduced pro-inflammatory cytokines (TNFα, IL-1β), and cartilage degradation biomarkers (MMP-3, MMP-13) significantly increased the anti-inflammatory cytokine IL-13 compared with pre-treatment (p<0.05). Further, the reduction of TNF-α was more significant in EA when compared to MA (p=0.046). While there was no significant difference between groups in cytokines IL-1β (p=0.102), MMP-3 (p=0.113), MMP-13 (p=0.623) or IL-13 (p=0.935). Moreover, in both EA and MA, the effect of acupuncture on the VAS and WOMAC function scale after 8 weeks is clinically important, although no significant differences were found between groups.

Conclusion

Eight weeks of both EA and MA seem to provide improvement in pain relief and function among individuals with mild to moderate knee OA. This benefit is partly mediated by changes of major inflammatory factors TNF-α, IL-1β and IL-13.

Trial Registration

Controlled-Trials.com Identifier: NCT03274713.

[Reporting quality of RCTs of acupuncture for vascular dementia]

OBJECTIVE

To evaluate the reporting quality of randomized controlled trials (RCTs) of acupuncture for vascular dementia.

METHODS

The RCTs of acupuncture for vascular dementia were systematically retrieved from the Cochrane Library, PubMed, EMbase, CNKI, SinoMed, VIP and Wanfang databases from the date of establishment to October 31, 2018. The reporting quality of RCT was evaluated based on the internationally-recognized Consolidated Standards for Reporting of Trials (CONSORT) statement and Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA).

RESULTS

A total of 33 RCTs were included. According to the CONSORT statement, 12 items had a reporting rate of 0%, including important changes to methods after trial commencement, sample size, blind method, trial registry, etc.; 5 items had a reporting rate of below 10%, including trial design, type of randomization, random allocation sequence, randomization implementation and participant flow. The reporting rate was 36.36% for baseline data and 57.58% for randomization sequence generation. According to the STRICTA statement, the reporting rate was 21.21% for description of acupuncture depth, 60.61% for description of acupuncture response, 27.27% for description of additional intervention details and 0% for qualification of acupuncturists, respectively.

CONCLUSION

At present, the reporting quality of RCTs of acupuncture for vascular dementia is generally low. In the future, the RCTs of acupuncture for vascular dementia should be normatively reported according to the CONSORT statement and STRICTA statement.

The cerebral mechanism of the specific and nonspecific effects of acupuncture based on knee osteoarthritis: study protocol for a randomized controlled trial

Background

Research on the effect of acupuncture has been limited. Whether the effect of acupuncture is equivalent to placebo has been the focus of debate in this field. This study will explore the specific and non-specific effects of acupuncture for knee osteoarthritis (KOA) by functional magnetic resonance imaging (fMRI).

Methods and design

Ninety participants diagnosed with KOA will be randomly divided into the acupuncture group, sham acupuncture group, and waiting list group in a ratio of 1:1:1. Except for the waiting list group, the other participants will receive acupuncture or sham acupuncture three sessions per week for 4 weeks respectively. The primary outcome will be the response rate which is defined on an individual basis as at least a 2-point decrease in the numerical rating scale (NRS) of pain at the end of intervention period compared with the baseline. fMRI scans will be performed at baseline and the end of the intervention period to examine the response of various brain regions. The secondary outcomes will include the Western Ontario and McMaster Osteoarthritis Index (WOMAC), State-Trait Anxiety Scale-State Anxiety Subscale (STAI-S), and Stanford Expectations of Treatment Scale (SETS). Pearson’s correlation coefficient will be performed to investigate the changes in brain activity and clinical variables.

Discussion

The results of our study will help to evaluate the specific and nonspecific effects of acupuncture combined with clinical and brain function changes based on KOA.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900025799. Registered on 9 September 2019.

Transcutaneous electrical acupoint stimulation for stage 1 hypertension: protocol for a randomized controlled pilot trial

Background

Hypertension is a major pathogenic factor of cardiovascular diseases. Insufficient blood pressure control rate and sub-optimal medication adherence remain challenges for effective management of hypertension. Transcutaneous electrical acupoint stimulation (TEAS) has been used to treat various diseases, including hypertension, but the scientific evidence for its benefit remains insufficient. Therefore, we will perform a randomized, controlled clinical trial in patients with stage 1 hypertension to evaluate the effect of TEAS.

Methods/design

The study will be a two-arm parallel, randomized controlled trial. Sixty patients with stage 1 hypertension will be randomly assigned to the TEAS group and the control group in a 1:1 ratio. The participants in the TEAS group will receive non-invasive acupoint electrical stimulation for 30 min at four acupoints in the upper and lower extremities at home, 4 times weekly for 12 weeks for a total of 48 sessions. Participants in the control group will not receive any form of acupoint stimulation. All participants in both groups will receive lifestyle education on how to control high blood pressure, including diet, weight control, and exercise. The primary outcome measure will be the change of the mean systolic blood pressure from baseline to 12 weeks. Secondary outcomes include the change of mean diastolic blood pressure, quality of life, body mass index, and physical activity level.

Discussion

This pilot, randomized, controlled trial will explore the feasibility of TEAS. It will also provide potential clinical evidence for the efficacy and safety of TEAS in the treatment of patients with stage 1 hypertension. The results of this study will be published in peer-reviewed journals. Furthermore, this pilot trial as the precursor of a large scale randomized controlled trial will inform the sample size of the subsequent trial.

Trial registration

Chinese clinical trial registry, ChiCTR1900025042, Registered on 8 August 2019 (http://www.chictr.org.cn/showproj.aspx?proj=41496).

Effect of Acupuncture for Postprandial Distress Syndrome: A Randomized Clinical Trial

BACKGROUND

Postprandial distress syndrome (PDS) is the most common subtype of functional dyspepsia. Acupuncture is commonly used to treat PDS, but its effect is uncertain because of the poor quality of prior studies.

OBJECTIVE

To assess the efficacy of acupuncture versus sham acupuncture in patients with PDS.

DESIGN

Multicenter, 2-group, randomized clinical trial. (ISRCTN registry number: ISRCTN12511434).

SETTING

5 tertiary hospitals in China.

PARTICIPANTS

Chinese patients aged 18 to 65 years meeting Rome IV criteria for PDS.

INTERVENTION

12 sessions of acupuncture or sham acupuncture over 4 weeks.

MEASUREMENTS

The 2 primary outcomes were the response rate based on overall treatment effect and the elimination rate of all 3 cardinal symptoms: postprandial fullness, upper abdominal bloating, and early satiation after 4 weeks of treatment. Participants were followed until week 16.

RESULTS

Among the 278 randomly assigned participants, 228 (82%) completed outcome measurements at week 16. The estimated response rate from generalized linear mixed models at week 4 was 83.0% in the acupuncture group versus 51.6% in the sham acupuncture group (difference, 31.4 percentage points [95% CI, 20.3 to 42.5 percentage points]; P < 0.001). The estimated elimination rate of all 3 cardinal symptoms was 27.8% in the acupuncture group versus 17.3% in the sham acupuncture group (difference, 10.5 percentage points [CI, 0.08 to 20.9 percentage points]; P = 0.034). The efficacy of acupuncture was maintained during the 12-week posttreatment follow-up. There were no serious adverse events.

LIMITATION

Lack of objective outcomes and daily measurement, high dropout rate, and inability to blind acupuncturists.

CONCLUSION

Among patients with PDS, acupuncture resulted in increased response rate and elimination rate of all 3 cardinal symptoms compared with sham acupuncture, with sustained efficacy over 12 weeks in patients who received thrice-weekly acupuncture for 4 weeks.

PRIMARY FUNDING SOURCE

Beijing Municipal Science and Technology Commission.

[Effect of acupuncture on emotional disorder in patients with chronic pain: a Meta-analysis]

OBJECTIVE

To systematically review the effect of acupuncture on emotional disorder in the patients with migraine and knee osteoarthritis and its effect time limit.

METHODS

The randomized controlled trials of acupuncture for migraine or knee osteoarthritis were retrieved from the databases, starting from the time of establishment through to December, 2018, i.e. the Cochrane Library, PubMed, EMbase, CNKI, SinoMed, VIP and Wanfang. The bias risk assessment tool of Cochrane Review Manual 5.1.0 was adopted to evaluate the quality of trials in methodology. RevMan 5.3 software was used for the Meta-analysis.

RESULTS

A total of 12 articles were included, with 2450 cases. Regarding the immediate effect, the score of the emotional function subscale of migraine-specific quality-of-life questionnaire (MSQ) in the acupuncture group was higher than the control group (6.38[2.78,9.98], I ²=25%). In view of the emotional function subscale of the short-form of health survey (SF-36/SF-12), and the scores of the mental function and negative mode scale in Spain's index of quality of life (PQLC), there were no significant differences in the scores between the acupuncture group and the control group. In 3 months of treatment, the score of the emotional function subscale of MSQ in the acupuncture group was higher than the control group (9.66 [3.06,16.25], I ²=44%). The difference in the score of the mental health subscale of SF-36 and SF-12 was not significant between the acupuncture group and the control group. In 3 to 6 months of treatment, as well as in over 6 months of treatment, the score of every scale was not different statistically between the acupuncture group and the control group.

CONCLUSION

Acupuncture effectively maintains the healthy emotion in the patients with migraine and the effect is sustainable for 3 months after treatment. But the improvement of acupuncture is not remarkable in emotional disorder induced by knee osteoarthritis.

Acupuncture of different treatment frequency in postprandial distress syndrome: A pilot randomized clinical trial

BACKGROUND

The evidence for different frequencies of acupuncture treatment in postprandial distress syndrome (PDS) is insufficient. This study determined whether 3 sessions per week of acupuncture treatment are superior to 1 session per week for symptomatic outcomes in PDS.

METHODS

This 16-week randomized clinical pilot trial was conducted in an outpatient setting in China. Patients with PDS were randomly assigned to receive 3 sessions per week of acupuncture (group H) or 1 session per week of acupuncture (group L) for 4 weeks. The primary outcome was the complete elimination of core symptoms at week 4. Secondary outcomes included overall treatment efficacy, dyspepsia symptoms, quality of life, anxiety, and depression.

KEY RESULTS

Sixty patients were randomized of whom 53 (88.3%) completed this trial. The complete elimination rate of core symptoms was 26.7% (95% CI 12.3%-45.9%) in group H and 10.0% (95% CI 2.1%-26.5%) in group L at week 4 (P = .095). There was a significant difference between H and group L at weeks 8, 12, and 16 (P = .038, .02, and .02). All secondary outcomes were better in group H at all time points. No serious adverse events occurred in either groups.

CONCLUSIONS

This trial showed that acupuncture, at 3 sessions per week, tended to improve symptoms and the quality of life among patients with PDS as compared to once a week. Acupuncture treatment for 4 weeks was feasible and safe. A larger sample, multicenter, randomized controlled trial of acupuncture for PDS appears to be justified in the future.

The Hypotensive Role of Acupuncture in Hypertension: Clinical Study and Mechanistic Study

As a component of traditional Chinese medicine (TCM), acupuncture has the potential to lower blood pressure (BP) in patients with hypertension. Emerging evidence indicates that the acupuncture-induced inhibition of high BP occurs through the activation of the pathway in the afferent, central, and efferent pathways. An increasing number of studies have demonstrated that acupuncture not only activates distinct brain regions under conditions of hypertension caused by an imbalance between the sympathetic and parasympathetic systems but also modulates neurotransmitters in related brain regions to alleviate the autonomic response. The activity of these pathways can be assessed by injecting agonists or inhibitors or by performing neurotomy. This review focuses on the clinical and mechanistic studies of acupuncture in modulating BP, which might provide a neurobiological foundation for the effects of acupuncture. Although many mechanisms underlying the effects of acupuncture on cardiovascular function have been identified, further investigation is warranted.

Effects of electroacupuncture on the intestinal motility and local inflammation are modulated by acupoint selection and stimulation frequency in postoperative ileus mice

BACKGROUND

Electroacupuncture (EA) is widely used in various gastrointestinal diseases around the world, including POI. Here, we investigated different therapeutic effects of EA using lower limb and abdomen acupoints.

METHODS

Intestinal manipulation was performed in 88 mice, and eight mice underwent a sham operation. Forty mice were randomly divided into model group and four EA groups receiving stimulation at ST36 (2, 10, 30, 100 Hz). The most effective frequency was then used in the following experiments. Forty-eight mice were randomly divided into six groups receiving EA treatment at ST37, ST39, ST25, CV4, CV12, and a non-acupuncture point. Gastrointestinal motility and plasma TNF-α, IL-6 were evaluated in all mice. The local immune response and α-smooth muscle actin (α-SMA) expression were assessed by immunofluorescence, ELISA, and HE staining.

RESULTS

ST36 stimulated with 10 or 30 Hz EA significantly increased the gastrointestinal motility and attenuated peripheral inflammation; however, ST36 stimulated with 2 or 100 Hz did not induce any effect. The therapeutic effects on motility and inflammation of 10 Hz EA in the ST36 group were similar in the ST36, ST37, ST39, or CV4 groups, but when applied to ST25, CV12 or non-acupoint had no significant differences. EA at ST36, ST37, ST39, or CV4 significantly inhibited local MPO activity, immune cells infiltration, and increased α-SMA.

CONCLUSIONS

EA at lower limb and abdomen acupoints with the same stimulation parameters had different therapeutic effects on postoperative dysmotility and inflammation. Furthermore, EA protected SMC to improve gastrointestinal transit by reducing local inflammation in the intestinal musculature in POI.

Effects of moxibustion on symptoms of mild cognitive impairment: protocol of a systematic review and meta-analysis

INTRODUCTION

Mild cognitive impairment (MCI) is considered the intermediate phase between normal age-related cognitive decline and dementia. Moxibustion has gained increased popularity for the management of MCI in China.This study aimed to evaluate the effects and safety of moxibustion on symptoms of MCI.

METHODS AND ANALYSIS

Four English databases and six Chinese databases will be searched from their inception to October 2019: Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, China National Knowledge Infrastructure, Chongqing VIP Chinese Science and Technology Periodical Database, Wanfang Database, SinoMed, China Doctoral Dissertations Full-text Database and the China Master's Theses Full-text Database. Only clinical randomised controlled trials and the first period in randomised cross-over trial related to moxibustion for MCI will be included. The primary outcomes include the improvement of cognitive function, as measured by validated assessment tools. The secondary outcomes include changes in the activity of daily living scale, effective rate and the incidences of adverse events. The selection of studies, data extraction and risk of bias assessment will be carried out by two independent reviewers. Review Manager V.5.3 software will be used for statistical analyses. Heterogeneity test, data synthesis and subgroup analysis will be performed if necessary. The risk of bias of included studies will be assessed by the Cochrane Handbook risk of bias tool. Evidence quality will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

Ethics approval is not required as no private information from individuals are collected. The results will be published in a peer-reviewed journal or disseminated in relevant conferences.

TRIAL REGISTRATION NUMBER

CRD42018112657.

An expert consensus to standardize acupuncture treatment for knee osteoarthritis

BACKGROUND

Acupuncture has been advocated for as a potentially effective therapy for patients with knee osteoarthritis (KOA) in systematic reviews and guidelines. However, there is still a lack of agreement on the optimal therapeutic protocol for acupuncture. This aim of this study was to develop an expert consensus regarding the therapeutic protocol of acupuncture to guide doctors in clinical practice.

METHODS

An initial list of items was based on an overview of research evidence from four databases and clinical problem investigation with a multidisciplinary panel. A two-step process was used to optimize the list, including semi-structured interviews with three acupuncture clinical experts and a three-round Delphi consensus survey with the voting panel. A nine-point Likert-type scale (1 = strongly disagree, 9 = strongly agree) was used to measure agreement.

RESULTS

In total, 52 professionals (response rate: 52%) confirmed their participation in the voting panel. The initial list including 28 items was evaluated. Following a three-round Delphi survey, a consensus was achieved including 37 items that can be broadly categorized into six domains: (1) main treatment principles, (2) acupuncture treatment, (3) dose of acupuncture intervention, (4) primary outcomes, (5) adverse events and (6) others.

CONCLUSION

This expert consensus could be used to guide doctors in clinical practice and help patients with KOA gain access to appropriate and coordinated acupuncture treatment.

[Challenges and enlightenments of SPARC program on acupuncture and moxibustion researches in China]

The advantages of western medical research were analyzed and the differences between skin nerve stimulation in western medicine and acupuncture-moxibustion in TCM were compared, so as to inspire the scientific researches of acupuncture and moxibustion in China. The related literature was searched and the research basis, content and achievements of the American stimulating peripheral activity to relief condition (SPARC) program were systematically summarized. From the perspectives of theoretical system, stimulation site, stimulation method and mechanism of action, the similarities and differences between skin nerve stimulation in western medicine and acupuncture-moxibustion in TCM were compared. Through comparative analysis, it is found that the systematic construction of SPARC "high-resolution neural circuit map" is essentially the upgraded version of the traditional distribution map of meridians and acupoints in China, which is similar to the research on origin of nervous system and stimulation site of acupuncture-moxibustion of TCM. Under the impact of "localization of traditional Chinese medicine" in other countries, learning from the international advanced research technology, gathering top-level talents, and encouraging openness and innovation will be the necessary pathway to improve the quality of acupuncture-moxibustion research and master the power of knowledge initiative.

Brain Functional Alternations of the Pain-related Emotional and Cognitive Regions in Patients with Chronic Shoulder Pain

Objective

Chronic shoulder pain (CSP) is a common health problem associated with shoulder dysfunction and persistent pain for many different reasons. However, the studies of pain-related functional brain regions in CSP have been poorly investigated. The main purpose of our study was to observe whether there are abnormal functional changes in brain regions in patients with CSP by using functional magnetic resonance imaging (fMRI).

Patients and Methods

We compared the differences of brain regions between 37 patients with CSP and 24 healthy controls (HC) using regional homogeneity (ReHo) method. The patients with chronic shoulder pain and healthy controls were matched for age and gender. Brain regions which had abnormal ReHo values were defined as seed region of interests. The approach of seed-based functional connectivity (FC) was further performed to analyze the connectivity between the seeds and whole brain regions. The relationship between abnormal regions and current clinical pain was also evaluated.

Results

Compared to healthy controls, the patients with CSP showed increased ReHo values in the left middle temporal gyrus and decreased ReHo values in right orbitofrontal cortex (OFC). The seed-based analyses demonstrated decreased connectivity between the right OFC and right rectus, superior frontal gyrus in patients with chronic shoulder pain. However, a correlation between ReHo values and clinical characteristics in CSP patients was not found.

Conclusion

The observed results indicate that there are abnormal ReHo values in brain regions of patients with CSP, especially in the OFC and middle temporal gyrus. Our findings demonstrate that the experience of CSP patients may be mainly associated with cognitive-affective pain processing, rather than nociception.

Acupuncture for postprandial distress syndrome: a randomized controlled pilot trial

BACKGROUND

Evidence for treating postprandial distress syndrome with acupuncture is limited.

AIM

We aimed to evaluate the feasibility of verum acupuncture versus sham acupuncture in patients with postprandial distress syndrome.

METHODS

A total of 42 eligible patients were randomly allocated to either verum acupuncture or sham acupuncture groups in a 1:1 ratio. Each patient received 12 sessions over 4 weeks. The primary outcome was the response rate based on the overall treatment effect (OTE) 4 weeks after randomization. Secondary outcomes included dyspepsia symptom severity and adverse events.

RESULTS

In each group, 19 patients (91.5%) completed the study. Thirteen patients receiving verum acupuncture and seven patients receiving sham acupuncture were classified as responders according to OTE (61.9% vs 33.3%; rate difference 28.6%; p = 0.06). Dyspepsia symptom severity at the end of treatment also differed significantly between verum acupuncture and sham acupuncture groups (5.9 units vs 3.7 units; between-group difference 2.2 (95% CI, 0.2-4.2); p = 0.04). No serious adverse events occurred.

CONCLUSION

Four weeks of acupuncture may represent a potential treatment for postprandial distress syndrome. The treatment protocol and outcome measures used in this trial were feasible. Since this was a pilot study, the efficacy of acupuncture still needs to be determined by a larger, adequately powered trial.

Electroacupuncture versus manual acupuncture for knee osteoarthritis: a randomized controlled pilot trial

OBJECTIVE

We aimed to explore the feasibility of evaluating the comparative effectiveness and safety of electroacupuncture (EA) relative to manual acupuncture (MA) for the treatment of knee osteoarthritis (KOA).

METHODS

A multicenter randomized controlled clinical trial was conducted in Beijing from September 2017 to January 2018. A total of 60 participants with KOA were randomly allocated to either EA (n = 30) or MA (n = 30) groups. Participants in the EA group were treated with EA at six to seven local traditional acupuncture points or ah shi points, and two to three distal points. Participants in the MA group had the same schedule as the EA group except that the electrical apparatus featured a working power indicator without actual current output, constituting a sham EA procedure, in order to blind participants. Both groups received 24 sessions over 8 weeks. The primary outcome was response rate, defined as a change of ⩾50% from baseline in the total scores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) after 8 weeks. Secondary outcomes included pain, stiffness, function, quality of life, and acupuncture-related adverse events (AEs) at 4 and 8 weeks.

RESULTS

Of 60 participants randomized, 53 (88%) completed the study. Response rates were 43% for the EA group and 30% for the MA group by the intention-to-treat analysis. Although significant differences were observed in WOMAC pain, stiffness, and function scores within both groups, between-group differences at 8 weeks did not reach statistical significance (odds ratio = 1.75 (95% confidence interval = 0.593-5.162)). Rates of AEs were low and similarly distributed between groups.

CONCLUSION

Both EA and MA interventions in KOA were feasible and appeared safe. Whether or not EA may have a stronger impact on pain and function requires further evaluation through larger, adequately powered, randomized controlled trials.

TRIAL REGISTRATION NUMBER

NCT03274713.

Influence of Acupuncture on Autonomic Balance in Adult Tinnitus Patients: An Exploratory Study

Acupuncture is an alternative therapy for tinnitus in clinical practice. The mechanism by which acupuncture can alleviate tinnitus is still unknown. Autonomic nervous system was reported to be responsible for tinnitus. The aim of this study was to explore the effect of acupuncture on autonomic balance in adult tinnitus patients. Thirty patients were randomly assigned into either the deep acupuncture (DA) group or the shallow acupuncture (SA) group. Each patient received 6 acupuncture sessions (a-f phase) over three weeks. Measures of heart rate variability and Tinnitus Handicap Inventory (THI) were obtained at baseline and after the sixth acupuncture session in all patients. The results showed that the low frequency/high frequency (LF/HF) pattern was increased at b-f phase until the sixth acupuncture session when compared with that at the first acupuncture session in DA group. However, it continuously increased at b-f phase in SA group even at the sixth acupuncture session, which was not significantly different from that at the first acupuncture session. The decrease in THI in DA group was greater than that in SA group after 3-week treatment (P=0.043). Our preliminary study suggests three-week deep acupuncture can improve tinnitus symptoms in adult tinnitus patients, which may be related to the regulation of autonomic nervous system balance.

[Observation on therapeutic effect of acupuncture at "experienced ten acupoints" for postprandial distress syndrome]

OBJECTIVE

To observe the clinical effect of acupuncture at "experienced ten acupoints" for postprandial distress syndrome.

METHODS

A total of 62 patients with postprandial distress syndrome were randomly divided into an observation group (31 cases, 5 cases dropping off) and a control group (31 cases, 6 cases dropping off ). Acupuncture was applied at Baihui (GV 20), Zhongwan (CV 12), Qihai (CV 6), Tianshu (ST 25), Neiguan (PC 6), Zusanli (ST 36), Gongsun (SP 4), Danzhong (CV 17) in the observation group. In the control group, 6 non-acupoint points were intervened with shallow puncture. The treatment was given 20 min each time, once every other day, 3 times a week for a total of 4 weeks in the two groups. Symptom index of dyspepsia (SID) and Nepean dyspepsia index (NDI) scores were compared before and after treatment, and the efficacy was evaluated in the two groups.

RESULTS

The effective rate in the observation group was 76.9% (20/26), which was higher than 28.0% in the control group (7/25, P<0.01). After treatment, the SID and NDI scores in the two groups were lower than those before treatment (P<0.01, P<0.05), and the SID and NDI scores in the observation group were lower than those in the control group (P<0.01, P<0.05).

CONCLUSION

Acupuncture at "experienced ten acupoints" can significantly reduce the symptoms of dyspepsia and improve the quality of life in patients with postprandial distress syndrome.

Efficacy and neural mechanism of acupuncture treatment in older adults with subjective cognitive decline: study protocol for a randomised controlled clinical trial

INTRODUCTION

Subjective cognitive decline (SCD) refers to individuals' perceived decline in memory and/or other cognitive abilities relative to their previous level of performance, while objective neuropsychological deficits are not observed. SCD may represent a preclinical phase of Alzheimer's disease. At this very early stage of decline, intervention could slow the rate of incipient decline to prolong and preserve cognitive and functional abilities. However, there is no effective treatment recommended for individuals with SCD. Acupuncture, as a non-pharmacological intervention, has been widely employed for patients with cognitive disorders.

METHODS AND ANALYSIS

The proposed study is a randomised, assessor-blinded and placebo-controlled study that investigates the efficacy and mechanism of acupuncture in SCD. Sixty patients with SCD will be randomly allocated either into an acupuncture group or a sham acupuncture group. They will receive 24 sessions of real acupuncture treatment or identical treatment sessions using a placebo needle. Global cognitive changes based on a multidomain neuropsychological test battery will be evaluated to detect the clinical efficacy of acupuncture treatment at baseline and end of treatment. MRI scans will be used to explore acupuncture-related neuroplasticity changes. Correlation analyses will be performed to investigate the relationships between the changes in brain function and symptom improvement.

ETHICS AND DISSEMINATION

The trial was approved by the research ethics committee. The results of the study will be published in a peer-reviewed academic journal and will also be disseminated electronically through conference presentations.

TRIAL REGISTRATION NUMBER

NCT03444896.

[Researches status on time-effect of acupuncture]

OBJECTIVE

To summarize the research status and influencing factors of the time-effect of acupuncture and to explain and analyze the optimal effect timing of acupuncture, and provide reference for obtaining the best clinical therapeutic effect.

METHODS

Literature regarding the studies of the time-effect of acupuncture published from January 2000 to August 2018 was searched, concluded and analyzed in CNKI, WANFANG, VIP and PubMed databases.

RESULTS

A total of 43 papers were included. The time-effect relationship of acupuncture was studied from various aspects: immediate effect, post-effect and total time-effect. The influencing factors of time-effect of acupuncture included needle retention time, acupoint types, number of acupoints and frequency of acupuncture treatment.

CONCLUSION

Even though preliminary achievements have been made in the study of the time-effect of acupuncture, there are many limitations and deficiency. These studies are mostly isolated and unsystematic, and the observation time of needle retention time and post-effect is not long enough to observe the exact best induction period, half-life period and residual effect period of acupuncture.In the future, we should combine the existing research experience and achievements to formulate a more reasonable research plan and observe the entire period of acupuncture in a longitudinal direction.

Efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for knee osteoarthritis: statistical analysis plan for a randomized controlled trial

Background

Acupuncture is widely used for knee osteoarthritis (KOA), despite contradictory evidence. This study is designed to determine the efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for KOA.

Methods/design

This is a multi-center three-arm randomized controlled trial. It will enroll 480 participants with KOA in China. Participants will be randomly assigned 1:1:1 to receive 24 sessions of electro-acupuncture, manual acupuncture, or sham acupuncture over 8 weeks. The primary outcome is the response rate, which is the proportion of patients who achieve the minimal clinically important improvement in pain and function at 8 weeks. The primary outcome will be analyzed using the Z-test with the intention-to-treat set. Secondary outcomes include pain, function, global patient assessment, and quality of life. Full details of the statistical analysis plan for the primary and secondary outcomes will be described in this article. The statistical analysis plan was written and submitted without knowledge of the study data.

Discussion

The data will be analyzed according to this pre-specified statistical analysis plan to avoid data-driven analysis and to enhance the transparency of the trial. The aim of the trial is to provide high-quality evidence on the efficacy of acupuncture for KOA.

Trial registration

Clinicaltrials.gov, NCT03366363. Registered on 20 November 2017.

Acupuncture attenuates cognitive impairment, oxidative stress and NF-κB activation in cerebral multi-infarct rats

BACKGROUD

Patients with multiple infarct dementia (MID) have subtle deficits that commonly go unnoticed, and are at risk of developing Alzheimer's disease. Oxidative stress induced by ischaemic injury results in intracellular calcium accumulation and neuronal apoptosis, leading to cognitive impairment by triggering various cellular signal transduction pathways. Several studies have suggested that NF-κB in the presence of p53 has a pro-apoptotic function in various models, but the mechanism is unclear.

AIMS

The aim of this study was to investigate whether acupuncture could protect cognitive function against cerebral multi-infarction (CMi) induced oxidative stress by inhibiting the activation of NF-κB and its target gene p53.

METHODS

An animal model of CMi was established by injecting homologous blood emboli into the right internal carotid artery of male Wistar rats. After 2 weeks of acupuncture treatment, cognitive function was detected by novel object recognition. Electron spin resonance and Fluo-3 fuorescence imaging were used to test the generation of ROS and intracellular calcium accumulation, respectively. Expression of NF-κB and p53 was examined by Western blot analysis and immunofluorescence.

RESULTS

CMi induced spatial learning and memory impairment, overproduction of intracellular hydroxyl radicals, and elevations of Ca²⁺, which were ameliorated by verum acupuncture treatment. Acupuncture inhibited activation of NF-κB and its downstream target gene p53.

CONCLUSION

These findings suggest that acupuncture could protect cognitive function against oxidative stress induced by CMi, which is partially associated with suppression of NF-κB-p53 activation.

Correction to: Efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for knee osteoarthritis: study protocol for a randomised controlled trial

After publication of the original article [1], the authors have notified us that the Trial registration number NCT03274713 should be replaced by NCT03366363 in the Abstract section of the paper.

Efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for knee osteoarthritis: study protocol for a randomised controlled trial

Background

Knee osteoarthritis (KOA) is one of the most common musculoskeletal disorders. Although the available evidence for its efficacy is inconclusive, acupuncture is used as an alternative therapy for KOA. The aim of this trial is to determine the efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for KOA.

Methods/design

This is a study protocol for a randomised, three-arm, multicentre, clinical trial. A total of 480 patients with KOA will be randomly assigned to the electro-acupuncture group, the manual acupuncture group or the sham acupuncture group in a 1:1:1 ratio. All patients will receive 24 sessions over 8 weeks. Participants will complete the trial by visiting the research centre at week 26 for a follow-up assessment. The primary outcome is the success rate: the proportion of patients achieving a minimal clinically important improvement, which is defined as ≥2 points on the numerical rating scale and ≥6 points on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score at week 8 compared with baseline. Secondary outcomes include the numerical rating scale, WOMAC score, global patient assessment and quality of life at weeks 4, 8, 16 and 26 after randomisation.

Discussion

This trial may provide high-quality evidence for the efficacy of acupuncture in the treatment of KOA. The results of this study will be published in peer-reviewed journals.

Trial registration

ClinicalTrials.gov, NCT03274713. Registered on 20 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3138-x) contains supplementary material, which is available to authorized users.

Effectiveness of acupuncture for vascular cognitive impairment no dementia: a randomized controlled trial

OBJECTIVE:

To evaluate the effectiveness of acupuncture in patients with vascular cognitive impairment no dementia (VCIND) in comparison with citicoline, an agent for cognitive disturbances associated with chronic cerebral disorders.

DESIGN:

A randomized controlled multicenter trial.

SETTING:

In three hospitals in Beijing, China.

SUBJECTS:

A total of 216 patients with VCIND were recruited.

INTERVENTIONS:

Patients with VCIND (mean age of 65.4 years) were randomized to receive acupuncture (two sessions per week) or oral citicoline (100 mg three times daily) over three months.

MAIN MEASURES:

The primary outcome was the change from baseline to three months in cognitive symptom, measured by Alzheimer's disease Assessment Scale, cognitive subscale (ADAS-cog). Secondary outcomes included changes from baseline to six months in ADAS-cog, executive function measured by the Clock Drawing Test (CDT), and functional disability measured by the Ability of Daily Living (ADL) scale at three and six months.

RESULTS:

At three months, the acupuncture group had a greater decrease in mean ADAS-cog score (-2.33 ± 0.31) than the citicoline group (-1.38 ± 0.34) with a mean difference of -0.95 (95% CI, -1.84 to -0.07, P = 0.035). The mean change from baseline to six months in ADAS-cog also significantly favored acupuncture treatments (acupuncture change -2.61 vs citicoline -1.25, difference: -1.36 points; 95% CI, -2.20 to -0.51; P = 0.002). There was no difference between the two groups on CDT and ADL scores at either time point.

CONCLUSION:

Compared with citicoline, acupuncture has comparable and even superior efficacy with improved cognitive and daily living performance as a complementary and alternative medicine treatment for VCIND.

Efficacy of acupuncture versus sham acupuncture for postprandial distress syndrome: study protocol for a randomized controlled trial

Background

Postprandial distress syndrome (PDS) has a considerable impact on quality of life. Our previous pilot trial suggested that acupuncture might be a potential treatment option for PDS. We will conduct this large trial to determine the efficacy of acupuncture versus sham acupuncture for PDS.

Methods/design

A total of 280 eligible patients who meet the Rome IV criteria for PDS will be randomly allocated to either the acupuncture group or the sham acupuncture group. Each patient will receive 12 sessions over four weeks. The primary outcomes will be the response rate of overall treatment effect (OTE) and the elimination rate of all three cardinal symptoms (postprandial fullness, upper abdominal bloating, and early satiation) at four weeks after randomization. Secondary outcomes will include assessments of the severity of dyspepsia symptoms and disease-specific quality of life at weeks 4, 8, and 16 after randomization. All patients who receive randomization will be included in the intent-to-treat analysis.

Discussion

The finding of this trial will provide high-quality evidence on the efficacy of acupuncture for treatment of PDS. Results of this research will be published in peer-reviewed journals.

Trial registration

ISRCTN Registry, ISRCTN12511434. Registered on 31 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3051-3) contains supplementary material, which is available to authorized users.

Abnormal Global Brain Functional Connectivity in Primary Insomnia Patients: A Resting-State Functional MRI Study

Background: Resting-state functional magnetic resonance imaging (fMRI) studies have uncovered the disruptions of functional brain networks in primary insomnia (PI) patients. However, the etiology and pathogenesis underlying this disorder remains ambiguous, and the insomnia related symptoms are influenced by a complex network organization in the brain. The purpose of this study was to explore the abnormal intrinsic functional hubs in PI patients using a voxel-wise degree centrality (DC) analysis and seed-based functional connectivity (FC) approach.

Methods: A total of 26 PI patients and 28 healthy controls were enrolled, and they underwent resting-state fMRI. Degree centrality was measured across the whole brain, and group differences in DC were compared. The peak points, which significantly altered DC between the two groups, were defined as the seed regions and were further used to calculate FC of the whole brain. Later, correlation analyses were performed between the changes in brain function and clinical features.

Results: Primary insomnia patients showed DC values lower than healthy controls in the left inferior frontal gyrus (IFG) and middle temporal gyrus (MTG) and showed a higher DC value in the right precuneus. The seed-based analyses demonstrated decreased FC between the left MTG and the left posterior cingulate cortex (PCC), and decreased FC was observed between the right precuneus and the right lateral occipital cortex. Reduced DC in the left IFG and decreased FC in the left PCC were positively correlated with the Pittsburgh sleep quality index and the insomnia severity index.

Conclusions: This study revealed that PI patients exhibited abnormal intrinsic functional hubs in the left IFG, MTG, and the right precuneus, as well as abnormal seed-based FC in these hubs. These results contribute to better understanding of how brain function influences the symptoms of PI.

Acupuncture as a multifunctional neuroprotective therapy ameliorates cognitive impairment in a rat model of vascular dementia: A quantitative iTRAQ proteomics study

AIMS

Acupuncture has been reported to affect vascular dementia through a variety of molecular mechanisms. An isobaric tag for relative and absolute quantification (iTRAQ) with high-resolution liquid chromatography-tandem mass spectrometry (LC-MS/MS) analyses makes it possible to attain a global profile of proteins. Hence, we used an iTRAQ-LC-MS/MS strategy to unravel the underlying mechanism of acupuncture.

METHODS

Wistar rats were subjected to vascular dementia with bilateral common carotid occlusion. Acupuncture was intervened for 2 weeks at 3 days after surgery. The Morris water maze was used to assess the cognitive function. Proteins were screened by quantitative proteomics and analyzed by bioinformatic analysis. Four differentially expressed proteins (DEPs) were validated by western blot. The reactive oxygen species (ROS) production, neuron cell loss, and long-term potentiation (LTP) were determined after western blot.

RESULTS

Acupuncture at proper acupoints significantly improved cognitive function. A total of 31 proteins were considered DEPs. Gene ontology (GO) analysis showed that most of the DEPs were related to oxidative stress, apoptosis, and synaptic function, which were regarded as the major cellular processes related to acupuncture effect. Western blot results confirm the credibility of iTRAQ results. Acupuncture could decrease ROS production, increase neural cell survival, and improve LTP, which verified the three major cellular processes.

CONCLUSION

Acupuncture may serve as a promising clinical candidate for the treatment of vascular dementia via regulating oxidative stress, apoptosis, or synaptic functions.

A new animal model for menopausal transition: combination of ovariectomy and empty bottle stimulation

Previous small animal models for menopausal transition are mainly performed to mimic the biochemical changes of patients with menopausal transition. The psychological symptoms in animal models are often overlooked. To mimic clinical situation, we developed a new mouse model of menopausal transition: the combination of bilateral ovariectomy (OVX) and empty bottle stimulation (EBS). After OVX and 21 days of EBS, behavioral test and pentobarbital-induced sleep test were carried out. Then all the animals were euthanized for further investigations. Compared with the control group, the combination of OVX and EBS group (OVX + EBS) showed higher bodyweight, lower organ index of uteri, and lower concentrations of serum estradiol. In addition, behavioral manifestations, sleep quality, and morphologic features in OVX + EBS group showed significant differences compared with the control group. OVX alone or EBS alone failed to include all the changes of OVX + EBS group. These findings indicate ovariectomy or EBS alone could not well mimic the symptoms of menopausal transition. The combination of bilateral ovariectomy and EBS offers an easy and repeatable method for building comprehensive menopausal transition model in mice.

Motion style acupuncture therapy for shoulder pain: a randomized controlled trial

Background

Strategies for preventing the persistence of pain and disability beyond the acute phase in shoulder pain patients are critically needed. Conventional acupuncture therapy (CAT) or motion style acupuncture therapy (MSAT) alone results in relative improvements in painful conditions in shoulder pain patients; combined interventions may have more global effects. The aim of this study is to evaluate the efficacy and safety of MSAT vs CAT for shoulder pain.

Methods

A randomized controlled trial using a factorial design was conducted from January 2014 to December 2015. Patients with a primary complaint of one-sided shoulder pain participated at three study sites. Eligible individuals were randomly assigned to receive MSAT plus minimal CAT (mCAT), CAT plus minimal MSAT (mMSAT), MSAT plus CAT, or mMSAT plus mCAT for 6 weeks in a 1:1:1:1 ratio. The primary outcome was change in shoulder pain intensity (measured using visual analog scale). The secondary outcomes included change in function of the shoulder joint (Constant–Murley score) and the health-related quality of life (Short Form-36 Health Survey). Moreover, perceived credibility of acupuncture was measured using the Treatment Credibility Scale. The outcomes were assessed at baseline and at 6, 10, and 18 weeks after randomization. Analysis of covariance with the baseline score adjustment had been used to determine the primary end point. The between-group differences of MSAT vs mMSAT and CAT vs mCAT were estimated, respectively, after tests of interaction between the two-dimensional interventions. All main analyses followed the intention-to-treat principle.

Results

A total of 164 patients completed the study. MSAT was superior to mMSAT in alleviating pain intensity at 10 weeks (P=0.024), and it was maintained for 18 weeks (P=0.013). Statistically significant differences were found when comparing MSAT with mMSAT for improvement in shoulder function (6 weeks, P=0.01; 10 weeks, P=0.006; and 18 weeks, P=0.01), physical health (10 weeks, P=0.023 and 18 weeks, P=0.015), and mental health (18 weeks, P=0.05). No significant differences were found in CAT when compared with mCAT.

Conclusion

After 18 weeks of treatment, pain and joint functions are improved more with MSAT than with minimal motion style acupuncture or conventional acupuncture in patients with shoulder pain.

Acupuncture and Lifestyle Myopia in Primary School Children-Results from a Transcontinental Pilot Study Performed in Comparison to Moxibustion

Background: Lifestyle risks for myopia are well known and the disease has become a major global public health issue worldwide. There is a relation between reading, writing, and computer work and the development of myopia. Methods: Within this prospective pilot study in 44 patients aged between 6 and 12 years with myopia we compared possible treatment effects of acupuncture or moxibustion. The diopters of the right and left eye were evaluated before and after the two treatment methods. Results: Myopia was improved in 14 eyes of 13 patients (15.9%) within both complementary methods. Using acupuncture an improvement was observed in seven eyes from six patients out of 22 patients and a similar result (improvement in seven eyes from seven patients out of 22 patients) was noticed in the moxibustion group. The extent of improvement was better in the acupuncture group (p = 0.008 s., comparison before and after treatment); however, group analysis between acupuncture and moxibustion revealed no significant difference. Conclusions: Possible therapeutic aspects with the help of evidence-based complementary methods like acupuncture or moxibustion have not yet been investigated adequately in myopic patients. Our study showed that both acupuncture and moxibustion can improve myopia of young patients. Acupuncture seems to be more effective than moxibustion in treating myopia, however group analysis did not prove this trend. Therefore, further Big data studies are necessary to confirm or refute the preliminary results.

[Research Advances in Insomnia Disorder Based on Magnetic Resonance Imaging]

As the most common sleep disorder,insomnia decreases the quality of life and is the high risk for cardiovascular disease,neurological disease,and psychiatric disease. It has become a major public health problem. In recent years,magnetic resonance imaging technology has been widely used for research on the brain structure in patients with insomnia. This article summarizes recent research findings of the abnormal brain structure and the potential neural mechanism of insomnia,with an attempt to understand the mechanisms in abnormal brain regions and thus further identify the pathophysiology of insomnia.

Effectiveness and feasibility of acupuncture for knee osteoarthritis: a pilot randomized controlled trial

OBJECTIVE:

To evaluate the effectiveness of acupuncture for pain relief and function improvement in patients with knee osteoarthritis and to determine the feasibility of an eight-week acupuncture intervention.

DESIGN:

Pilot randomized controlled trial.

SETTING:

Three teaching hospitals in China.

SUBJECTS:

Patients with knee osteoarthritis (Kellgren grade II or III).

INTERVENTIONS:

Patients were randomly assigned to an eight-week (three sessions per week) intervention of either traditional Chinese acupuncture or sham acupuncture.

MAIN MEASURES:

The primary outcome was response rate-the proportion of patients achieving score ⩾36% decrease in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function at week 8 compared with baseline. Secondary outcomes included pain, function and quality of life.

RESULTS:

Of 42 patients randomized, 36 (85.7%) completed the study. There was no significant difference in response rate between the traditional Chinese acupuncture and control groups: 61.9% (13 of 21) versus 42.9% (9 of 21) achieved score ⩾36% decrease in WOMAC pain and function at week 8 ( P = 0.217). The sum of WOMAC pain and function scores at week 8 was 11.6 (9.1) in the traditional Chinese acupuncture group compared with 16.3 (10.9) in the control group ( P = 0.183). There was no significant difference between groups. Three adverse events were recorded and were classified as mild.

CONCLUSION:

It showed that three sessions per week acupuncture intervention of knee osteoarthritis was feasible and safe. No difference was observed between groups due to small sample size. Larger (sample size ⩾ 296) randomized controlled trials of this intervention appear justified.

Abnormal Functional Connectivity of Anterior Cingulate Cortex in Patients With Primary Insomnia: A Resting-State Functional Magnetic Resonance Imaging Study

Background: Recently, there have been many reports about abnormalities regarding structural and functional brain connectivity of the patients with primary insomnia. However, the alterations in functional interaction between the left and right cerebral hemispheres have not been well understood. The resting-state fMRI approach, which reveals spontaneous neural fluctuations in blood-oxygen-level-dependent signals, offers a method to quantify functional interactions between the hemispheres directly.

Methods: We compared interhemispheric functional connectivity (FC) between 26 patients with primary insomnia (48.85 ± 12.02 years) and 28 healthy controls (49.07 ± 11.81 years) using a voxel-mirrored homotopic connectivity (VMHC) method. The patients with primary insomnia and healthy controls were matched for age, gender, and education. Brain regions, which had significant differences in VMHC maps between the primary insomnia and healthy control groups, were defined as seed region of interests. A seed-based approach was further used to reveal significant differences of FC between the seeds and the whole contralateral hemisphere.

Results: The patients with primary insomnia showed higher VMHC than healthy controls in the anterior cingulate cortex (ACC) bilaterally. The seed-based analyses demonstrated increased FC between the left ACC and right thalamus (and the right ACC and left orbitofrontal cortex) in patients with primary insomnia, revealing abnormal connectivity between the two cerebral hemispheres. The VMHC values in the ACC were positively correlated with the time to fall asleep and Self-Rating Depression Scale scores (SDS).

Conclusions: The results demonstrate that there is abnormal interhemispheric resting-state FC in the brain regions of patients with primary insomnia, especially in the ACC. Our finding demonstrates valid evidence that the ACC is an area of interest in the neurobiology of primary insomnia.

Bee venom therapy: Potential mechanisms and therapeutic applications

Bee venom is a very complex mixture of natural products extracted from honey bee which contains various pharmaceutical properties such as peptides, enzymes, biologically active amines and nonpeptide components. The use of bee venom into the specific points is so called bee venom therapy, which is widely used as a complementary and alternative therapy for 3000 years. A growing number of evidence has demonstrated the anti-inflammation, the anti-apoptosis, the anti-fibrosis and the anti-arthrosclerosis effects of bee venom therapy. With these pharmaceutical characteristics, bee venom therapy has also been used as the therapeutic method in treating rheumatoid arthritis, amyotrophic lateral sclerosis, Parkinson's disease, Alzheimer's disease, liver fibrosis, atherosclerosis, pain and others. Although widely used, several cases still reported that bee venom therapy might cause some adverse effects, such as local itching or swelling. In this review, we summarize its potential mechanisms, therapeutic applications, and discuss its existing problems.