Defining the quality of acupuncture: the case of acupuncture for cancer-related fatigue

BACKGROUND

The quality and dose of acupuncture used in a clinical trial affects the outcome, as with the quality and dose of any intervention. The dose of acupuncture treatment may be characterized by the frequency of treatment, needle type and depth, length of needle retention, point selection, and combination. The dose in trials of acupuncture has at times been described as low or inappropriate but is seldom assessed in systematic reviews of acupuncture trials. This article examines the research evaluating acupuncture for cancer-related fatigue to determine what characteristics of treatment may contribute to a quality acupuncture intervention.

METHODOLOGY

English and Chinese language databases were searched from inception to December 2013 for randomized controlled trials of acupuncture for the treatment of cancer-related fatigue. Assessment of the quality of the acupuncture intervention was undertaken using the domains and items from the NICMAN framework.

RESULTS

Seven studies with a total of 690 patients were included. Four of the studies were designed as feasibility or pilot studies, and the other 3 studies were described as "effectiveness" trials. The treatment paradigm for the active intervention was based on traditional Chinese medicine in all studies, yet few of the studies were explicit as to how the active intervention was justified within a traditional Chinese medicine paradigm. Acupuncture point prescriptions were developed by a small consensus panel or based on typical points and/or "clinical experience." No discussion of traditional Chinese medicine theory or literature review was reported in any studies. Acupuncture point location was adequately described in 4 of the 7 studies. Frequency of treatment was twice per week in 2 studies; all others were once per week. Two studies did not apply needle manipulation or stimulation, and no justification was given.

CONCLUSION

The 7 trials reviewed meet some criteria for a quality acupuncture intervention. However, frequently elements of the intervention were not addressed, and it is possible that the dosage trialed was suboptimal. Systematic reviews of acupuncture are likely to continue to be inconclusive while comparisons are conducted of heterogeneous interventions without providing.

Complementary therapies for acne vulgaris

BACKGROUND

Acne is a chronic skin disease characterised by inflamed spots and blackheads on the face, neck, back, and chest. Cysts and scarring can also occur, especially in more severe disease. People with acne often turn to complementary and alternative medicine (CAM), such as herbal medicine, acupuncture, and dietary modifications, because of their concerns about the adverse effects of conventional medicines. However, evidence for CAM therapies has not been systematically assessed.

OBJECTIVES

To assess the effects and safety of any complementary therapies in people with acne vulgaris.

SEARCH METHODS

We searched the following databases from inception up to 22 January 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2014,Issue 1), MEDLINE (from 1946), Embase (from 1974), PsycINFO (from 1806), AMED (from 1985), CINAHL (from 1981), Scopus (from 1966), and a number of other databases listed in the Methods section of the review. The Cochrane CAM Field Specialised Register was searched up to May 2014. We also searched five trials registers and checked the reference lists of articles for further references to relevant trials.

SELECTION CRITERIA

We included parallel-group randomised controlled trials (or the first phase data of randomised cross-over trials) of any kind of CAM, compared with no treatment, placebo, or other active therapies, in people with a diagnosis of acne vulgaris.

DATA COLLECTION AND ANALYSIS

Three authors collected data from each included trial and evaluated the methodological quality independently. They resolved disagreements by discussion and, as needed, arbitration by another author.

MAIN RESULTS

We included 35 studies, with a total of 3227 participants. We evaluated the majority as having unclear risk of selection, attrition, reporting, detection, and other biases. Because of the clinical heterogeneity between trials and the incomplete data reporting, we could only include four trials in two meta-analyses, with two trials in each meta-analysis. The categories of CAM included herbal medicine, acupuncture, cupping therapy, diet, purified bee venom (PBV), and tea tree oil. A pharmaceutical company funded one trial; the other trials did not report their funding sources.Our main primary outcome was 'Improvement of clinical signs assessed through skin lesion counts', which we have reported as 'Change in inflammatory and non-inflammatory lesion counts', 'Change of total skin lesion counts', 'Skin lesion scores', and 'Change of acne severity score'. For 'Change in inflammatory and non-inflammatory lesion counts', we combined 2 studies that compared a low- with a high-glycaemic-load diet (LGLD, HGLD) at 12 weeks and found no clear evidence of a difference between the groups in change in non-inflammatory lesion counts (mean difference (MD) -3.89, 95% confidence interval (CI) -10.07 to 2.29, P = 0.10, 75 participants, 2 trials, low quality of evidence). However, although data from 1 of these 2 trials showed benefit of LGLD for reducing inflammatory lesions (MD -7.60, 95% CI -13.52 to -1.68, 43 participants, 1 trial) and total skin lesion counts (MD -8.10, 95% CI -14.89 to -1.31, 43 participants, 1 trial) for people with acne vulgaris, data regarding inflammatory and total lesion counts from the other study were incomplete and unusable in synthesis.Data from a single trial showed potential benefit of tea tree oil compared with placebo in improving total skin lesion counts (MD -7.53, 95% CI -10.40 to -4.66, 60 participants, 1 trial, low quality of evidence) and acne severity scores (MD -5.75, 95% CI -9.51 to -1.99, 60 participants, 1 trial). Another trial showed pollen bee venom to be better than control in reducing numbers of skin lesions (MD -1.17, 95% CI -2.06 to -0.28, 12 participants, 1 trial).Results from the other 31 trials showed inconsistent effects in terms of whether acupuncture, herbal medicine, or wet-cupping therapy were superior to controls in increasing remission or reducing skin lesions.Twenty-six of the 35 included studies reported adverse effects; they did not report any severe adverse events, but specific included trials reported mild adverse effects from herbal medicines, wet-cupping therapy, and tea tree oil gel.Thirty trials measured two of our secondary outcomes, which we combined and expressed as 'Number of participants with remission'. We were able to combine 2 studies (low quality of evidence), which compared Ziyin Qinggan Xiaocuo Granule and the antibiotic, minocycline (100 mg daily) (worst case = risk ratio (RR) 0.49, 95% CI 0.09 to 2.53, 2 trials, 206 participants at 4 weeks; best case = RR 2.82, 95% CI 0.82 to 9.06, 2 trials, 206 participants at 4 weeks), but there was no clear evidence of a difference between the groups.None of the included studies assessed 'Psychosocial function'.Two studies assessed 'Quality of life', and significant differences in favour of the complementary therapy were found in both of them on 'feelings of self-worth' (MD 1.51, 95% CI 0.88 to 2.14, P < 0.00001, 1 trial, 70 participants; MD 1.26, 95% CI 0.20 to 2.32, 1 trial, 46 participants) and emotional functionality (MD 2.20, 95% CI 1.75 to 2.65, P < 0.00001, 1 trial, 70 participants; MD 0.93, 95% CI 0.17 to 1.69, 1 trial, 46 participants).Because of limitations and concerns about the quality of the included studies, we could not draw a robust conclusion for consistency, size, and direction of outcome effects in this review.

AUTHORS' CONCLUSIONS

There is some low-quality evidence from single trials that LGLD, tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet-cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies. Methodological and reporting quality limitations in the included studies weakened any evidence. Future studies should be designed to ensure low risk of bias and meet current reporting standards for clinical trials.

The use of a novel bone allograft wash process to generate a biocompatible, mechanically stable and osteoinductive biological scaffold for use in bone tissue engineering

Fresh-frozen biological allograft remains the most effective substitute for the 'gold standard' autograft, sharing many of its osteogenic properties but, conversely, lacking viable osteogenic cells. Tissue engineering offers the opportunity to improve the osseointegration of this material through the addition of mesenchymal stem cells (MSCs). However, the presence of dead, immunogenic and potentially harmful bone marrow could hinder cell adhesion and differentiation, graft augmentation and incorporation, and wash procedures are therefore being utilized to remove the marrow, thereby improving the material's safety. To this end, we assessed the efficiency of a novel wash technique to produce a biocompatible, biological scaffold void of cellular material that was mechanically stable and had osteoinductive potential. The outcomes of our investigations demonstrated the efficient removal of marrow components (~99.6%), resulting in a biocompatible material with conserved biomechanical stability. Additionally, the scaffold was able to induce osteogenic differentiation of MSCs, with increases in osteogenic gene expression observed following extended culture. This study demonstrates the efficiency of the novel wash process and the potential of the resultant biological material to serve as a scaffold in bone allograft tissue engineering.

Treatment of women's reproductive health conditions by Australian and New Zealand acupuncturists

BACKGROUND

Acupuncture is used by nine percent of the Australian population; however, we know relatively little about the practice of acupuncture to treat women's reproductive health in Australia and New Zealand.

METHODS

This study surveyed acupuncturists to examine their practice with treating women's reproductive health complaints. A cross sectional survey of 3406 Australian and New Zealand acupuncturists was conducted. A self-completion questionnaire explored the areas of acupuncture treatment for gynaecological pregnancy and fertility complaints.

RESULTS

Questionnaires were completed by 377 acupuncturists. Ninety-six percent of practitioners reported treating women's reproductive health conditions within the previous year. All three areas of women's reproductive health were commonly treated with 96% treating gynaecological health, 91% treating pregnancy conditions, and 90% fertility conditions. The most commonly treated gynaecological conditions were premenstrual syndrome (90.1%, 95% CI 86.2-93.0), menopause (89.4%, 95% CI 85.4-92.4) and primary dysmenorrhea (89.1%, 95% CI 85.1-92.2). Participants reported treating general fertility not related to assisted reproduction (93%, 95% CI 89.4-95.5), treatment for a diagnosed fertility related conditions (85.8%, 95% CI 81.1-89.4), and to decrease infertility related stress (86%, 95% CI 81.5-89.7). The most common pregnancy related conditions treated were nausea (90.3%, 95% CI 86.3-93.3), back or pelvic pain (89.3%, 95% CI 85.1-92.4), and prebirth labour preparation (86.8%, 95% CI 82.3-90.3).

CONCLUSION

Treating women's reproductive health complaints was commonly reported among the groups of acupuncturists in Australia and New Zealand responding to this survey; however, our findings cannot be generalised to the wider acupuncture communities in these two countries.

Spatiotemporal expression patterns of doublesex and mab-3 related transcription factor 1 in the chicken developing gonads and Mullerian ducts

Sex of birds is genetically determined by the inheritance of sex chromosomes (ZZ for male and ZW for female), and the Z-linked gene named doublesex and mab-3 related transcription factor 1 (DMRT1) is a candidate sex-determining gene in avian species. However, the mechanisms underlying sex determination in birds are not yet understood, and the expression patterns of the DMRT1 protein in urogenital tissues have not been identified. In the current study, we used immunohistochemistry to investigate the detailed expression patterns of the DMRT1 protein in the urogenital systems (including Müllerian ducts) in male and female chicken embryos throughout embryonic development. Gonadal somatic cells in the male indifferent gonads showed stronger expressions of DMRT1 compared with those in the female indifferent gonads well before the presumptive period of the sex determination, and Sertoli cells forming testicular cords expressed DMRT1 in the testes after sex determination. Germ cells expressed DMRT1 equally in males and females after sex determination. The expression was continuous in males, but in females it gradually disappeared from the germ cells in the central part of the cortex of the left ovary toward both edges. The DMRT1 was also detected in the tubal ridge, which is a precursor of the Müllerian duct, and at the mesenchyme and outermost coelomic epithelium of the Müllerian duct in both sexes. Strong expression was observed in the males, but it was restricted to coelomic epithelium after the regression of the duct started. Thus, we observed the detailed spatiotemporal expression patterns of DMRT1 in the developing chicken urogenital systems throughout embryonic development, suggesting its various roles in the development of urogenital tissues in the chicken embryo.

Acupuncture and acupressure for pain management in labour and birth: a critical narrative review of current systematic review evidence

BACKGROUND

Reviews of maternity services highlight the need for a reduction of medical interventions for women with low risk pregnancies and births to prevent the potential cascade of interventions and their associated risks. Complementary medicines (CM) such as acupuncture and acupressure have claimed to be effective in reducing interventions in labour; however, systematic reviews of evidence to date are conflicting.

AIMS

To examine current evidence from systematic reviews on the topic of acupuncture and acupressure for pain management in labour and birth, and to evaluate the methodological and treatment frameworks applied to this evidence.

METHODS

A search limited to systematic reviews of the MEDLINE, CINAHL, PUBMED, EMBASE and Cochrane databases was performed in December 2013 using the keywords 'CAM', 'alternative medicine', 'complementary medicine', 'complementary therapies', 'traditional medicine', 'Chinese Medicine', 'Traditional Chinese Medicine', 'acupuncture', 'acupressure', cross-referenced with 'childbirth', 'birth', labo*r', and 'delivery'. The quality of the evidence is also evaluated in the context of study design.

RESULTS

The RCTs included in these systematic reviews differed in terms of study designs, research questions, treatment protocols and outcome measures, and yielded some conflicting results. It may be inappropriate to include these together in a systematic review, or pooled analysis, of acupuncture for labour with an expectation of an overall conclusion for efficacy. Trials of acupuncture and acupressure in labour show promise, but further studies are required.

CONCLUSION

The use of current systematic reviews of the evidence for acupuncture and acupressure for labour and birth may be misleading. Appropriate methods and outcome measures for investigation of acupuncture and acupressure treatment should more carefully reflect the research question being asked. The use of pragmatic trials designs with woman-centred outcomes may be appropriate for evaluating the effectiveness of these therapies.

Acupuncture and women's health: an overview of the role of acupuncture and its clinical management in women's reproductive health

BACKGROUND

Acupuncture and other modalities of Chinese/East Asian medicine have been used to treat women's health for many centuries. Gynecology specialties focus particularly on menstrual and reproductive disorders. Both the adoption of the use of acupuncture outside Asia, and the incorporation of scientific analysis in Asia have challenged biomedical conceptions of what can be achieved with this treatment method. The scale of research activity in relation to acupuncture and women's health has increased over the last 20 years.

OBJECTIVE

This review aims to explore the research evidence in relation to acupuncture use for women's reproductive disorders, focusing on both clinical findings and experimental research on acupuncture's mechanisms of action in relation to women's health.

METHODS

A narrative literature search was undertaken using searches of electronic databases and manual searches of journals and textbooks. The search included all literature published prior to June 2013. The literature was assessed as to the nature of the study it was reporting and findings synthesized into a commentary.

RESULTS

For acupuncture's mechanism of action the search resulted in 114 relevant documents; in relation to clinical reports on the use of acupuncture for women's health 204 documents were found and assessed.

CONCLUSION

There is preliminary data indicating acupuncture may improve menstrual health and coping for women experiencing delays falling pregnant. There is experimental data showing that acupuncture can influence female reproductive functioning, although the actual mechanisms involved are not yet clarified. Further well-conducted clinical research would benefit our understanding of the usefulness of acupuncture to women's health.

The use of mini-CEX in UK foundation training six years following its introduction: lessons still to be learned and the benefit of formal teaching regarding its utility

BACKGROUND

The mini-clinical evaluation exercise (mini-CEX) is a widely used tool with a strong theoretical basis. It was introduced to UK foundation training in 2005.

AIMS

To assess current experiences, opinions and attitudes towards mini-CEX amongst foundation doctors, and explore what factors underpin these.

METHODS

Data were collected from foundation trainees via an on-line questionnaire.

RESULTS

Ninety-eight per cent of respondents had used mini-CEX during FY1, however, only 32% had ever received formal teaching regarding its use. In terms of understanding of the purpose of mini-CEX, only 30% of trainees commented on there being a formative aspect or requirement for feedback. The majority of trainees did not feel that mini-CEX was a useful part of their training. The main themes were the poor attitude and understanding of assessors and difficulties finding sufficient time. However, those who had received formal teaching as students regarding the use of mini-CEX were significantly more likely as postgraduates to find it beneficial (p = 0.031).

CONCLUSIONS

A more concerted effort to educate trainees and assessors regarding the correct use of mini-CEX will enhance its educational value. Increased education during undergraduate training regarding use of formative assessment may lead to more effective utilisation in the postgraduate setting.

The practice of acupuncture and moxibustion to promote cephalic version for women with a breech presentation: implications for clinical practice and research

OBJECTIVES

To examine what experienced acupuncture practitioners and researchers considered key aspects of treatment to promote cephalic version for women with a breech presentation, and to establish a treatment protocol through consensus to guide the self administration of moxa by pregnant women.

METHODS AND DESIGN

The Delphi method was used to seek the opinions of key informants. Sixteen English speaking international, Australian and New Zealand acupuncturists working in the area of pregnancy were invited to participate in the study. Participants were given a link to an online survey, and their views sought on treatment parameters guiding the treatment of breech presentation within a research setting.

RESULTS

Two rounds of the Delphi process were undertaken, 12 participants completed round one, and 10 completed round two. Eighty percent of participants agreed that moxa should commence between 34 and 35 weeks gestation. Ninety percent agreed to self administration of moxa by the woman, and use of smokeless and odourless sticks. Seventy percent agreed moxa should be applied for a minimum of 10 days, and be applied once a day for 30min. Monitoring safety was identified as an important outcome. Ninety percent agreed study clinical outcomes should assess side effects including burns, and maternal and foetal outcomes.

CONCLUSION

Findings from our study promote the clinical validity for a future research protocol, and highlight other areas for research to evaluate the role of acupuncture and moxibustion with normalising birth.

A survey describing the use of complementary therapies and medicines by women attending a family planning clinic

Background

Complementary medicines (CMs) are widely used by women. Although, women in Australia are frequent users of CM, few studies have examined their utilisation by women attending a family planning service. The aim of this study was to examine (i) the extent of and type of CM, (ii) women’s views about safety and efficacy, and (iii) the factors influencing women’s decision-making.

Methods

A cross-sectional survey using a convenience sample of 221women aged greater than 18 years attending a family planning (FP) service was undertaken over a two week period in Sydney, Australia. An anonymous self-administered questionnaire was designed to examine women’s current and previous use of CMs, their attitudes towards safety and effectiveness, the factors influencing their decision-making, and their disclosure of CM use to a FP health professional. Demographic questions were designed to describe the diversity of the participants. Logistic regression was used to examine the association between CM use and demographics.

Results

Sixty-seven percent of women surveyed were currently using CMs, and 83% reported use during the previous 12 months. Most respondents utilised CMs to maintain their general health or for prevention of ill health. Over 30% of women lacked information to make an informed response to questions examining their views about the safety of CMs. Forty-four percent of participants stated they discussed their use of CMs with their FP providers. The main reason why women did not mention CMs was they did not see the relevance to their consultation (43%). Lower rates of CM use were found for younger women (OR 0.24, 95% CI 0.09-0.61), and those not completing high school (OR 0.44, 95% 0.20-1.00).

Conclusion

The use of CM is very common among women attending an Australian FP clinic, however our findings may not be generalisable to all women. We identified a notable gap in women’s awareness of the potential for interactions between CM and prescribed medication. Our findings also emphasise the need for healthcare providers to initiate discussions with clients about their utilisation of CM.

Acupuncture for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. The use of complementary therapies is increasing and some women look to complementary therapies during pregnancy and childbirth to be used alongside conventional medical practice. Acupuncture involves the insertion of very fine needles into specific points of the body. The limited observational studies to date suggest acupuncture for induction of labour appears safe, has no known adverse effects to the fetus, and may be effective. However, the evidence regarding the clinical effectiveness of this technique is limited.

OBJECTIVES

To determine the effectiveness and safety of acupuncture for third trimester cervical ripening or induction of labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 November 2012), PubMed (1966 to 23 November 2012), Embase (1980 to 23 November 2012), Dissertation Abstracts (1861 to 23 November 2012), CINAHL (1982 to 23 November 2012), the WHO International Clinical Trials Registry Portal (ICTRP) (23 November 2012) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing acupuncture used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, evaluated methodological quality and extracted data.

MAIN RESULTS

The original review included three trials and seven trials were excluded. This updated review includes 14 trials, and excludes eight trials. Three trials previously excluded due to no clinically relevant outcomes are now included. Eight new trials were included, and four new trials were excluded. We included 14 trials with data reporting on 2220 women.Trials reported on three primary outcomes only caesarean section, serious neonatal morbidity and maternal mortality. No trial reported on vaginal delivery not achieved within 24 hours; and uterine hyperstimulation with fetal heart rate (FHR) changes. There was no difference in caesarean deliveries between acupuncture and the sham control (average risk ratio (RR) 0.95, 95% confidence interval (CI) 0.69 to 1.30, six trials, 654 women), and acupuncture versus usual care (average RR 0.69, 95% CI 0.40, 1.20, six trials, 361 women). There was no difference in neonatal seizures between acupuncture and the sham group (RR 1.01, 95% CI 0.06 to 16.04, one trial, 364 women).There was some evidence of a change in cervical maturation for women receiving acupuncture compared with the sham control, (mean difference (MD) 0.40. 95%CI 0.11 to 0.69, one trial, 125 women), and when compared with usual care (MD 1.30, 95% CI 0.11 to 2.49, one trial, 67 women). The length of labour was shorter in the usual care group compared with acupuncture (average standardised mean difference (SMD) 0.67, 95% CI 0.18 to 1.17, one trial 68 women). There were no other statistically significant differences between groups. Few studies reported on many clinically relevant outcomes. One trial was at a low risk of bias on all domains.

AUTHORS' CONCLUSIONS

Overall, there have been few studies assessing the role of acupuncture for induction of labour. Before implications for clinical practice can be made there is a need for well-designed randomised controlled trials to evaluate the role of acupuncture to induce labour and for trials to assess clinically meaningful outcomes.

The molecular genetics of ovarian differentiation in the avian model

In birds as in mammals, sex is determined at fertilization by the inheritance of sex chromosomes. However, sexual differentiation - development of a male or female phenotype - occurs during embryonic development. Sex differentiation requires the induction of sex-specific developmental pathways in the gonads, resulting in the formation of ovaries or testes. Birds utilize a different sex chromosome system to that of mammals, where females are the heterogametic sex (carrying Z and W chromosomes), while males are homogametic (carrying 2 Z chromosomes). Therefore, while some genes essential for testis and ovarian development are conserved, important differences also exist. Namely, the key mammalian male-determining factor SRY does not exist in birds, and another transcription factor, DMRT1, plays a central role in testis development. In contrast to our understanding of testis development, ovarian differentiation is less well-characterized. Given the presence of a female-specific chromosome, studies in chicken will provide insight into the induction and function of female-specific gonadal pathways. In this review, we discuss sexual differentiation in chicken embryos, with emphasis on ovarian development. We highlight genes that may play a conserved role in this process, and discuss how interaction between ovarian pathways may be regulated.

Effect of acute acupuncture treatment on exercise performance and postexercise recovery: a systematic review

BACKGROUND

Preliminary evidence suggests that acupuncture applied proximally during a single bout of exercise can enhance exercise performance and/or expedite postexercise recovery. The purpose of this investigation was to review trials, systematically and critically, that have investigated such hypotheses and delineate areas for future research.

METHOD

A systematic review using computerized databases was performed.

RESULTS

Four trials were found: Three involved within-subjects designs and one used a parallel group design. Few participants were enrolled (n=10-20). Fourteen acupuncture sites were used across the four trials: DU 20, LI 15, LI 13, PC 6, ST 36, SP 6, PC 5, LU 7, LI 4, GB 37, GB 39, GB 34, and LI 11, and LR 3. PC 6, and ST 36 were the most commonly used sites. Three trials evaluated the effect of acupuncture on exercise performance. One of these trials noted that electroacupuncture stimulation of either PC 5 and PC 6 or LU 7 and LI4 significantly increased peak power output, blood pressure, and rate pressure product (RPP) versus control. However, two trials documented no effect of acupuncture on exercise performance using point combinations of either DU 20, LI 15, LI 13, PC 6, ST 36, and SP 6 or DU 20, ST 36, GB 34, LI 11, LR 3. One trial evaluated the effect of acupuncture on postexercise recovery and found that heart rate, oxygen consumption, and blood lactate were significantly reduced secondary to acupuncturing of PC 6 and ST 36 versus control and placebo conditions at 30 or 60 minutes postexercise.

CONCLUSIONS

There is preliminary support for the use of acupuncture as a means to enhance exercise performance and postexercise recovery, but many limitations exist within this body of literature. Adequately powered, RCTs with thorough and standardized reporting of research methods (e.g., acupuncture and exercise interventions) and results are required to determine more adequately the effect of acupuncture methods on exercise performance and postexercise recovery. Future investigations should involve appropriate placebo methods and blinding of both participants and investigators.

Using a Delphi consensus process to develop an acupuncture treatment protocol by consensus for women undergoing Assisted Reproductive Technology (ART) treatment

Background

Assisted reproductive technologies (ART) are increasingly utilised for resolving difficulties conceiving. These technologies are expensive to both the public purse and the individual consumers. Acupuncture is widely used as an adjunct to ART with indications that it may assist reducing the time to conception and increasing live birth rates. Heterogeneity is high between treatment protocols.

The aim of this study was to examine what fertility acupuncturists consider key components of best practice acupuncture during an ART cycle, and to establish an acupuncture protocol by consensus.

Methods

Fifteen international acupuncturists with extensive experience treating women during ART interventions participated in 3 rounds of Delphi questionnaires. The first round focused on identifying the parameters of acupuncture treatment as adjunct to ART, the second round evaluated statements derived from the earlier round, and the third evaluated specific parameters for a proposed trial protocol. Consensus was defined as greater than 80% agreement.

Results

Significant agreement was achieved on the parameters of best practice acupuncture, including an acupuncture protocol suitable for future research. Study participants confirmed the importance of needling aspects relating to the dose of acupuncture, the therapeutic relationship, tailoring treatment to the individual, and the role of co-interventions. From two rounds of the Delphi a consensus was achieved on seven treatment parameters for the design of the acupuncture treatment to be used in a clinical trial of acupuncture as an adjunct to ART. The treatment protocol includes the use of the traditional Chinese medicine acupuncture, use of manual acupuncture, a first treatment administered between day 6–8 of the stimulated ART cycle which is individualised to the participant, two treatments will be administered on the day of embryo transfer, and will include points SP8, SP10, LR3, ST29, CV4, and post transfer include: GV20, KD3, ST36, SP6, and PC6. Auricular points Shenmen and Zigong will be used. Practitioner intent or yi will be addressed in the treatment protocol.

Conclusions

Despite a lack of homogeneity in the research and clinical literature on ART and acupuncture, a consensus amongst experts on key components of a best practice treatment protocol was possible. Such consensus offers guidance for further research.

Acupuncture to improve live birth rates for women undergoing in vitro fertilization: a protocol for a randomized controlled trial

BACKGROUND

IVF is a costly treatment option for women, their partners, and the public. Therefore new therapies that improve reproductive and health outcomes are highly desirable. There is a growing body of research evaluating the effect of acupuncture administered during IVF, and specifically on the day of embryo transfer (ET). Many trials are heterogeneous and results inconsistent. There remains insufficient evidence to determine if acupuncture can enhance live birth rates when used as an adjunct to IVF treatment.The study will determine the clinical effectiveness of acupuncture with improving the proportion of women undergoing IVF having live births. Other objectives include: determination of the cost effectiveness of IVF with acupuncture; and examination of the personal and social context of acupuncture in IVF patients, and examining the reasons why the acupuncture may or may not have worked.

METHODS

We will conduct a randomized controlled trial of acupuncture compared to placebo acupuncture.Inclusion criteria include: women aged less than 43 years; undergoing a fresh IVF or ICSI cycle; and restricted to women with the potential for a lower live birth rate defined as two or more previous unsuccessful ETs; and unsuccessful clinical pregnancies of quality embryos deemed by the embryologist to have been suitable for freezing by standard criteria. Women will be randomized to acupuncture or placebo acupuncture. Treatment is administered on days 6 to 8 of the stimulated cycle and two treatments on the day of ET. A non-randomized cohort of women not using acupuncture will be recruited to the study. The primary study outcome is the proportion of women reporting a live birth. Secondary outcomes include the proportion of women reporting a clinical pregnancy miscarriage prior to 12 weeks, quality of life, and self-efficacy. The sample size of the study is 1,168 women, with the aim of detecting a 7% difference in live births between groups (P = 0.05, 80% power).

DISCUSSION

There remains a need for further research to add significant new knowledge to defining the exact role of certain acupuncture protocols in the management of infertility requiring IVF from a clinical and cost-effectiveness perspective.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry ACTRN12611000226909.

Cephalic version by moxibustion for breech presentation

BACKGROUND

Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) to the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of correcting breech presentation.

OBJECTIVES

To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality for breech presentation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (26 March 2012), MEDLINE (1966 to 1 August 2011), EMBASE (1980 to August 2011), CINAHL (1982 to 1 August 2011), MIDIRS (1982 to 1 August 2011) and AMED (1985 to 1 August 2011) and searched bibliographies of relevant papers.

SELECTION CRITERIA

The inclusion criteria were published and unpublished randomised controlled trials comparing moxibustion (either alone or in combination with acupuncture or postural techniques) with a control group (no moxibustion), or other methods (e.g. external cephalic version, acupuncture, postural techniques) in women with a singleton breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and trial quality and extracted data. The outcome measures were baby's presentation at birth, need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events.

MAIN RESULTS

Six new trials have been added to this updated review. One trial has been moved to studies awaiting classification while further data are being requested. This updated review now includes a total of eight trials (involving 1346 women). Meta-analyses were undertaken (where possible) for the main and secondary outcomes. Moxibustion was not found to reduce the number of non-cephalic presentations at birth compared with no treatment (P = 0.45). Moxibustion resulted in decreased use of oxytocin before or during labour for women who had vaginal deliveries compared with no treatment (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.13 to 0.60). Moxibustion was found to result in fewer non-cephalic presentations at birth compared with acupuncture (RR 0.25, 95% CI 0.09 to 0.72). When combined with acupuncture, moxibustion resulted in fewer non-cephalic presentations at birth (RR 0.73, 95% CI 0.57 to 0.94), and fewer births by caesarean section (RR 0.79, 95% CI 0.64 to 0.98) compared with no treatment. When combined with a postural technique, moxibustion was found to result in fewer non-cephalic presentations at birth compared with the postural technique alone (RR 0.26, 95% CI 0.12 to 0.56).

AUTHORS' CONCLUSIONS

This review found limited evidence to support the use of moxibustion for correcting breech presentation. There is some evidence to suggest that the use of moxibustion may reduce the need for oxytocin. When combined with acupuncture, moxibustion may result in fewer births by caesarean section; and when combined with postural management techniques may reduce the number of non-cephalic presentations at birth, however, there is a need for well-designed randomised controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety of the intervention.

Acupuncture as a therapeutic treatment option for threatened miscarriage

Background

Threatened miscarriage involves vaginal bleeding in a pregnancy that remains viable. This is a common early pregnancy complication with increased risk factors for early pregnancy loss, preterm premature rupture of membranes (PPROM), preterm delivery, low birth weight babies and maternal antepartum haemorrhage. Currently there are no recommended medical treatment options, rather women receive advice that centres on a 'wait and see' approach. For women with a history of unexplained recurrent miscarriage providing supportive care in a subsequent pregnancy improves live birthing outcomes, but the provision of supportive care to women experiencing threatened miscarriage has to date not been examined.

Discussion

While it is known that 50-70% of miscarriages occur due to chromosomal abnormalities, the potential for therapeutic intervention amongst the remaining percentage of women remains unknown. Complementary and alternative medicine (CAM) therapies have the potential to provide supportive care for women presenting with threatened miscarriage. Within fertility research, acupuncture demonstrates beneficial hormonal responses with decreased miscarriage rates, raising the possibility acupuncture may promote specific beneficial effects in early pregnancy. With the lack of current medical options for women presenting with threatened miscarriage it is timely to examine the possible treatment benefits of providing CAM therapies such as acupuncture.

Summary

Despite vaginal bleeding being a common complication of early pregnancy there is often reluctance from practitioners to discuss with women and medical personal how and why CAM may be beneficial. In this debate article, the physiological processes of early pregnancy together with the concept of providing supportive care and acupuncture are examined. The aim is to raise awareness and promote discussion as to the beneficial role CAM may have for women presenting with threatened miscarriage.

Massage, reflexology and other manual methods for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour, and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of manual healing methods including massage and reflexology for pain management in labour.

OBJECTIVES

To examine the effects of manual healing methods including massage and reflexology for pain management in labour on maternal and perinatal morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (1966 to 30 June 2011), CINAHL (1980 to 30 June 2011), the Australian and New Zealand Clinical Trial Registry (30 June 2011), Chinese Clinical Trial Register (30 June 2011), Current Controlled Trials (30 June 2011), ClinicalTrials.gov, (30 June 2011) ISRCTN Register (30 June 2011), National Centre for Complementary and Alternative Medicine (NCCAM) (30 June 2011) and the WHO International Clinical Trials Registry Platform (30 June 2011).

SELECTION CRITERIA

Randomised controlled trials comparing manual healing methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We attempted to contact study authors for additional information.

MAIN RESULTS

We included six trials, with data reporting on five trials and 326 women in the meta-analysis. We found trials for massage only. Less pain during labour was reported from massage compared with usual care during the first stage of labour (standardised mean difference (SMD) -0.82, 95% confidence interval (CI) -1.17 to -0.47), four trials, 225 women), and labour pain was reduced in one trial of massage compared with music (risk ratio (RR) 0.40, 95% CI 0.18 to 0.89, 101 women). One trial of massage compared with usual care found reduced anxiety during the first stage of labour (MD -16.27, 95% CI -27.03 to -5.51, 60 women). No trial was assessed as being at a low risk of bias for all quality domains.

AUTHORS' CONCLUSIONS

Massage may have a role in reducing pain, and improving women's emotional experience of labour. However, there is a need for further research.

Relaxation techniques for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of relaxation therapies for pain management in labour.

OBJECTIVES

To examine the effects of relaxation methods for pain management in labour on maternal and perinatal morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2010), The Cochrane Complementary Medicine Field's Trials Register (November 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4), MEDLINE (1966 to 30 November 2010), CINAHL (1980 to 30 November 2010), the Australian and New Zealand Clinical Trial Registry (30 November 2010), Chinese Clinical Trial Register (30 November 2010), Current Controlled Trials (30 November 2010), ClinicalTrials.gov, (30 November 2010) ISRCTN Register (30 November 2010), National Centre for Complementary and Alternative Medicine (NCCAM) (30 November 2010) and the WHO International Clinical Trials Registry Platform (30 November 2010).

SELECTION CRITERIA

Randomised controlled trials comparing relaxation methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and extracted data. Data were checked for accuracy. Two review authors independently assessed trial quality. We attempted to contact study authors for additional information.

MAIN RESULTS

We included 11 studies (1374 women) in the review. Relaxation was associated with a reduction in pain intensity during the latent phase (mean difference (MD) -1.25, 95% confidence interval (CI) -1.97 to -0.53, one trial, 40 women) and active phase of labour (MD -2.48, 95% CI -3.13 to 0.83, two trials, 74 women). There was evidence of improved outcomes from relaxation instruction with increased satisfaction with pain relief (risk ratio (RR) 8.00, 95% CI 1.10 to 58.19, one trial, 40 women) and lower assisted vaginal delivery (RR 0.07, 95% CI 0.01 to 0.50, two trials, 86 women). Yoga was associated with reduced pain (mean difference (MD) -6.12, 95% CI -11.77 to -0.47), one trial, 66 women), increased satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women), satisfaction with the childbirth experience (MD) 6.34, 95% CI 0.26 to 12.42, one trial, 66 women), and reduced length of labour when compared to usual care (MD -139.91, 95% CI -252.50 to -27.32, one trial, 66 women) and when compared with supine position (MD -191.34, 95% CI -243.72 to -138.96, one trial, 83 women). Trials evaluating music and audio analgesia found no difference between groups in the primary outcomes pain intensity, satisfaction with pain relief, and caesarean delivery. The risk of bias was unclear for the majority of trials.

AUTHORS' CONCLUSIONS

Relaxation and yoga may have a role with reducing pain, increasing satisfaction with pain relief and reducing the rate of assisted vaginal delivery. There was insufficient evidence for the role of music and audio-analgesia. However, there is a need for further research.