Acupuncture for osteoarthritis of the knee: a systematic review

Durable Effects of Acupuncture for Knee Osteoarthritis: A Systematic Review and Meta-analysis

PURPOSE OF REVIEW

Knee osteoarthritis (KOA) is a degenerative joint disease which can result in chronic pain and disability. The current interventions available for KOA often fail to provide long-lasting effects, highlighting the need for new treatment options that can offer durable benefits. Previous studies have suggested the efficacy of acupuncture for knee osteoarthritis (KOA) with its durability remaining uncertain. In this review, we aimed to investigate the durability of the efficacy after completion of treatment.

RECENT FINDINGS

We performed thorough searches of PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials from inception to November 4, 2023. The outcomes were assessed at all available time points after completion of treatment. Primary outcomes were changes from baseline in pain and function measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function subscales. Secondary outcomes included response rate, overall pain, the WOMAC stiffness subscale, total WOMAC index, and physical and mental health components of 12/36-item Short-Form Health Survey. A total of 10 randomized controlled trials (RCTs) involving 3221 participants were included. Pooled estimates suggested that acupuncture may offer potential improvements in function and overall pain for 4.5 months post-treatment versus sham acupuncture (SA). Acupuncture may provide durable clinically important pain relief and functional improvement up to 5 months post-treatment versus usual care, and up to 6 months post-treatment versus diclofenac. For acupuncture versus no treatment, one trial with large sample size indicated that improvements in pain and function persisted for 3 months post-treatment, while the other trial reported that significant pain reduction and functional improvement were only observed at the end of the treatment, not at 9 months post-treatment. However, acupuncture as adjunct to exercise-based physical therapy (EPT) showed no superiority to SA as an adjunct to EPT or EPT alone up to 11.25 months after completion of treatment. Acupuncture may provide pain alleviation and functional improvements in KOA patients for 3 to 6 months after completion of treatment with a good safety profile.

Treatment of rheumatic musculoskeletal disorders

Non-medicinal therapies with water, salts, exercise, massage, supportive devices, and electricity have been used for centuries and continue to be of benefit for some people with musculoskeletal disorders. Historical texts refer to the two electuaries mithridatium and theriaca as early therapeutic attempts of man to provide relief of musculoskeletal symptoms and attempt disease cures. For over 200 years, morphine-derived products have been used for musculoskeletal pain. The development of acetyl salicylic acid was a major breakthrough in joint pain management. This was followed by the introduction of nonsteroidal anti-inflammatory agents, paracetamol, and the use of corticosteroids. The gold-based compounds were the initial disease-modifying drugs and have been followed by the highly successful biologics agents. The basic objectives of musculoskeletal pain management include: reduction or elimination of joint pain; improvement or restoration of joint function and mobility; improvement of muscle strength to protect cartilage, ligaments, and joint capsule; prevention and reduction of damage to joint cartilage and supporting structures.

Approach to Assess Adequacy of Acupuncture in Randomized Controlled Trials: A Systematic Review

OBJECTIVE

To summarize and identify the available instruments/methods assessing the adequacy of acupuncture in randomized controlled trials (RCTs) for proposing a new improved instrument.

METHODS

A systematic literature search was carried out in 7 electronic databases from inception until 21st November 2022. Any study evaluating the adequacy or quality of acupuncture, specifying specific acupuncture treatment-related factors as criteria of subgroup analysis, or developing an instrument/tool to assess the adequacy or quality of acupuncture in an RCT was included. Basic information, characteristics and contents of acupuncture adequacy assessment were presented as frequencies and percentages.

RESULTS

Forty studies were included in this systematic review. Thirty-five studies (87.50%) were systematic reviews, none of which used formal methods to develop the assessment instruments/methods of acupuncture adequacy; of 5 methodological studies, only 1 study used a relatively formal method. Thirty-two studies (82.05%) assessed the components of acupuncture, while 7 (17.95%) assessed the overall quality of acupuncture. An independent assessment instrument/method was used to assess acupuncture adequacy in 29 studies (74.35%), whereas as one part of a methodological quality assessment scale in 10 (25.65%). Only 9 (23.00%) studies used the assessment results for subgroup analysis, sensitivity analysis or the criteria for inclusion in the meta-analysis.

CONCLUSION

Assessment contents for adequacy or quality of acupuncture in RCTs hadn't still reached consensus and no widely used assessment tools appeared. The methodology of available assessment instruments/scales is far from formal and rigorous. A new instrument/tool assessing adequacy of acupuncture should be developed using a formal method.

Comparative effectiveness of acupuncture in sham-controlled trials for knee osteoarthritis: A systematic review and network meta-analysis

Objectives

Although many trials have assessed the effect of acupuncture on knee osteoarthritis (KOA), its efficacy remains controversial. Sham acupuncture techniques are regarded as representative control interventions in acupuncture trials and sometimes incorporate the use of sham devices (base units) to support a non-penetrating needle. To achieve successful blinding, these trials also use acupuncture base units in the verum acupuncture group. Base units are not used in real-world clinical settings. We aimed to assess the effect sizes of verum and sham acupuncture for KOA in sham-controlled trials with or without base units.

Methods

A total of 10 electronic databases for randomized controlled trials (RCTs) comparing the efficacy of verum manual acupuncture and sham acupuncture for the treatment of KOA were searched for articles published before April 12, 2022. The primary outcome was pain intensity, and the secondary outcomes included physical function. The first assessment after the end of treatment was chosen for analysis. Effect sizes are reported as standardized mean differences (SMDs) with 95% confidence intervals (95% CIs). The risk of bias was assessed using the Cochrane risk of bias tool, and publication bias was evaluated using a funnel plot and Egger's test. The quality of evidence for estimates was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

Results

Fifteen RCTs were included. There was generally a low risk of bias except for the difficulty in blinding acupuncture therapists (performance bias). Compared to verum acupuncture in sham-controlled trials using base units, verum acupuncture in sham-controlled trials without base units was more effective for improving pain (SMD -0.56, 95% CI -1.09 to -0.03) and function (SMD -0.73, 95% CI -1.36 to -0.10) in KOA. The quality of evidence for network estimates was moderate to low due to the risk of bias and imprecision.

Conclusion

These findings suggest that verum acupuncture in different types of sham-controlled trials has different effect sizes for KOA. Because base units are not used in clinical settings, the results of verum acupuncture in sham-controlled trials with base units need to be interpreted carefully.

Systematic review registration

https://www.researchregistry.com/browse-the-registry#registryofsystematicreviewsmeta-analyses/registryofsystematicreviewsmeta-analysesdetails/6269f962606c5e001fd8790c/, identifier reviewregistry1351.

Use of complementary and alternative medicine by patients with hypermobile Ehlers-Danlos Syndrome: A qualitative study

Background

Patients with hypermobile Ehlers-Danlos Syndrome (hEDS) often make use of complementary and alternative medical (CAM) techniques to manage their chronic pain and other symptoms. Nevertheless, how they use CAM, which techniques they favor, and how CAM use affects their allopathic care remain unclear. The purpose of this qualitative study was to understand patients' personal experiences with CAM and its role in their symptom management.

Materials and methods

Thirty individuals living with hEDS completed a brief online survey related to their CAM use. Thereafter, in-depth interviews were conducted with 24 of the survey respondents, qualitatively investigating their experiences with CAM. Data were analyzed using thematic analysis.

Results

Participants described massage therapy (N = 21), medical cannabis (N = 12), and mindfulness (N = 13) as some of the most useful CAM modalities for managing symptoms related to hEDS, but they expressed a general interest in pursuing any treatment that could potentially reduce their chronic pain. They suggested an overall trust in CAM modalities and practitioners and ascribed greater empathy to CAM practitioners than to conventional medical providers. However, they also described a critical skepticism of CAM (and conventional) therapies and recounted instances of injury from such treatments.

Conclusion

Participants made extensive use of CAM therapies. They described both critical benefits as well as harms from the use of these non-conventional modalities. These results underscore the importance of clinicians maintaining communicative and compassionate relationships with their patients, and of an openness to the discussion and use of CAM treatments.

Effects of Acupuncture on Postoperative Pain After Total Knee Replacement: Systematic Literature Review and Meta-Analysis

OBJECTIVE

To identify the analgesic effectiveness of acupuncture after total knee replacement by systematic review.

METHODS

A search of randomized controlled trials was conducted in five English medical electronic databases and five Chinese databases. Two reviewers independently searched in five English medical electronic databases and five Chinese databases. Two reviewers independently retrieved related studies, assessed the methodological quality, and extracted data with a standardized data form. Meta-analyses were performed with all-time-points meta-analysis.

RESULTS

A total of seven studies with 891 participants were included. The meta-analysis results indicated that acupuncture had a statistically significant influence on pain relief (standardized mean difference = -0.705, 95% CI -1.027 to -0.382, P = 0.000). The subgroup analysis results showed that acupuncture's effects on analgesia had a statistically significant influence (standardized mean difference= -0.567, 95% CI -0.865 to -0.269, P = 0.000). The main acupuncture points that produced an analgesic effect when they were used after total knee replacement included the Xuehai, Liangqiu, Dubi, Neixiyan, Yanglingquan, and Zusanli points. Electroacupuncture frequency ranged between 2 and 100 Hz.

CONCLUSIONS

As an adjunct modality, the use of acupuncture is associated with reduced pain and use of analgesic medications in postoperative patients. In particular, ear acupuncture 1 day before surgery could reduce analgesia .

Association Between Acupuncture and Knee Surgery for Osteoarthritis: A Korean, Nationwide, Matched, Retrospective Cohort Study

Objectives: The present study was undertaken to investigate the relationship between acupuncture therapy and surgery rate. Design: Matched, retrospective cohort study. Materials and Methods: From nationwide health insurance data (2002-2013 cohort data published by the National Health Insurance Service of Korea), patients with new cases of knee osteoarthritis that occurred between January 1, 2004 and December 31, 2010 were analyzed. Patients were divided into an acupuncture group (AG) and a control group (CG), based on records of acupuncture therapy. Propensity scores were calculated by using gender, age, income level, and Charlson comorbidity index (CCI), with the groups matched at a ratio of 1:3 (AG:CG). The final analysis period was 2 years after the first acupuncture therapy for AG and 2 years after initial diagnosis for CG; surgery rates were compared between the two groups. Stratified analyses were performed based on age, gender, and income level; sensitivity analyses were performed based on the frequency and duration of acupuncture therapy. Results: Propensity score-matched AG and CG included 8,605 and 25,815 subjects, respectively. Post-matching surgery rates were 0.26 and 0.93% in AG and CG, respectively. For all age groups, AG showed a lower surgery rate than CG. In the analysis based on gender, the female group showed a significantly lower hazard ratio of 0.225. In analysis based on income level, the results of the entire group were significant, with the lower income group showing the lowest hazard ratio. In sensitivity analyses, AG tended to show a lower surgery rate than CG. Conclusions: The present study demonstrated that acupuncture therapy is associated with a low rate of surgery for knee osteoarthritis. Additional studies are needed to support this conclusion.

Acupuncture for knee osteoarthritis with sensitized acupoints: results from a pilot, feasibility randomized controlled trial

Background

Although previous clinical studies suggest possible benefits of acupuncture for knee osteoarthritis (KOA), the value of acupuncture at sensitized points is uncertain. We aimed to preliminarily assess the feasibility of performing a definitive randomized controlled trial to explore the effectiveness of acupuncture for KOA with highly sensitized acupoints.

Methods

In this randomized, single-blind, parallel, pilot trial, 36 participants with KOA were randomly assigned to receive acupuncture at highly sensitized acupoints (high-sensitization group) or at low/non-sensitized points (low/non-sensitization group) by a computer-generated random sequence. Both groups received three treatment sessions per week for four consecutive weeks (12 sessions in total). Assessments were performed at screening and at 4, 8, 12, and 16 weeks after randomization. Primary feasibility outcomes were patient recruitment, retention rate, and adherence to group treatment. Secondary outcomes included the change of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score from baseline to 16 weeks, the change of Short Form (SF)-12 health survey score, and safety outcomes.

Results

Patient recruitment of 36 patients took 2 months, achieving the recruitment target. Retention rates were similar between the treatment groups, 14 (77.8%) patients in the high-sensitization group completed the 16-week follow-up and compared to 14 (77.8%) patients in low/non-sensitization group, but the result was lower than expected. All patients received at least ten treatment sessions in total. The WOMAC total score and the pain, stiffness, and physical function score in the high-sensitization group were lower or very close to those in the control group at each assessment point. Similar results were observed on quality of life. No adverse events occurred.

Conclusion

This trial has presented preliminary data on the feasibility of conducting a large trial to test the effectiveness of acupuncture at sensitized points in KOA patients.

Trial registration

ClinicalTrials.gov, NCT03008668. Registered on 26 December 2016—retrospectively registered.

Transcutaneous electrical nerve stimulation, acupuncture, and spinal cord stimulation on neuropathic, inflammatory and, non-inflammatory pain in rat models

Background

Transcutaneous electrical nerve stimulation (TENS), manual acupuncture (MA), and spinal cord stimulation (SCS) are used to treat a variety of pain conditions. These non-pharmacological treatments are often thought to work through similar mechanisms, and thus should have similar effects for different types of pain. However, it is unclear if each of these treatments work equally well on each type of pain condition. The purpose of this study was to compared the effects of TENS, MA, and SCS on neuropathic, inflammatory, and non-inflammatory pain models.

Methods

TENS 60 Hz, 200 μs, 90% motor threshold (MT), SCS was applied at 60 Hz, an intensity of 90% MT, and a 0.25 ms pulse width. MA was performed by inserting a stainless-steel needle to a depth of about 4-5 mm at the Sanyinjiao (SP6) and Zusanli (ST36) acupoints on a spared nerve injury (SNI), knee joint inflammation (3% carrageenan), and non-inflammatory muscle pain (intramuscular pH 4.0 injections) in rats. Mechanical withdrawal thresholds of the paw, muscle, and/or joint were assessed before and after induction of the pain model, and daily before and after treatment.

Results

The reduced withdrawal thresholds were significantly reversed by application of either TENS or SCS (P < 0.05). MA, on the other hand, increased the withdrawal threshold in animals with SNI and joint inflammation, but not chronic muscle pain.

Conclusions

TENS and SCS produce similar effects in neuropathic, inflammatory and non-inflammatory muscle pain models while MA is only effective in inflammatory and neuropathic pain models.

Osteoarthritis: Pathology, Diagnosis, and Treatment Options

Osteoarthritis (OA) is a worldwide endemic and debilitating disease. Previously thought to simply be damaged from "wear and tear," OA is now understood to be a complex interaction of local and systemic factors. This article reviews the pathology, symptoms, diagnosis, and various conservative, surgical, and novel treatments of OA.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

Periosteal Electrical Dry Needling as an Adjunct to Exercise and Manual Therapy for Knee Osteoarthritis: A Multicenter Randomized Clinical Trial

Objectives:

To compare the effects of adding electrical dry needling into a manual therapy (MT) and exercise program on pain, stiffness, function, and disability in individuals with painful knee osteoarthritis (OA).

Materials and Methods:

In total, 242 participants (n=242) with painful knee OA were randomized to receive 6 weeks of electrical dry needling, MT, and exercise (n=121) or MT and exercise (n=121). The primary outcome was related-disability as assessed by the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index at 3 months.

Results:

Individuals receiving the combination of electrical dry needling, MT, and exercise experienced significantly greater improvements in related-disability (WOMAC: F=35.504; P<0.001) than those receiving MT and exercise alone at 6 weeks and 3 months. Patients receiving electrical dry needling were 1.7 times more likely to have completely stopped taking medication for their pain at 3 months than individuals receiving MT and exercise (OR, 1.6; 95% confidence interval, 1.24-2.01; P=0.001). On the basis of the cutoff score of ≥5 on the global rating of change, significantly (χ²=14.887; P<0.001) more patients (n=91, 75%) within the dry needling group achieved a successful outcome compared with the MT and exercise group (n=22, 18%) at 3 months. Effect sizes were large (standardized mean differences >0.82) for all outcome measures in favor of the electrical dry needling group at 3 months.

Discussion:

The inclusion of electrical dry needling into a MT and exercise program was more effective for improving pain, function, and related-disability than the application of MT and exercise alone in individuals with painful knee OA.

Level of Evidence:

Level 1b—therapy. Prospectively registered February 10, 2015 on www.clinicaltrials.gov (NCT02373631).

Correlation between acupuncture dose and effectiveness in the treatment of knee osteoarthritis: a systematic review

BACKGROUND

Acupuncture is a widely used treatment for knee osteoarthritis, but evidence of its effectiveness from randomised controlled trials (RCTs) is contradictory.

OBJECTIVE

To systematically review RCTs to determine whether the effect of acupuncture is dose dependent for symptom management in knee osteoarthritis.

METHODS

Seven English/Chinese databases were searched through January 2017. Study quality was assessed using the Cochrane Collaboration tool. Slavin's qualitative best-evidence synthesis approach was used to provide methodological rigour. Included RCTs were separated into three categories according to the dose of acupuncture treatment: high dosage (HD), medium dosage (MD) and low dosage (LD). Correlation between dose and effect of treatment was analysed.

RESULTS

Eight RCTs with a total of 2106 subjects met the eligibility criteria. Numbers of studies using the various doses of acupuncture were 1 for LD, 1 for MD and 6 for HD, respectively. Compared with LD and MD acupuncture treatments, strong evidence showed that there was a positive correlation between HD acupuncture treatment and positive outcomes.

CONCLUSION

The effect of acupuncture may be associated with dose of acupuncture, with a higher dosage related to better treatment outcomes in terms of relief of pain and dysfunction in patients with knee osteoarthritis.

Acupuncture and Vitamin D for the Management of Aromatase Inhibitor-Induced Arthralgia

PURPOSE OF REVIEW

Aromatase inhibitor-induced arthralgia (AIA) is a very common syndrome which significantly affects breast cancer survivors' quality of life, and it often leads to non-compliance with aromatase inhibitor (AI) therapy. However, the treatment of AIA remains a clinical challenge. Here, we will review the current data for acupuncture and vitamin D in the management of AIA.

RECENT FINDINGS

Acupuncture has been shown to improve AIA symptoms, but it has not consistently been proven to offer significantly more clinical benefit than sham acupuncture. Similarly, while some vitamin D trials have shown benefit, the studies have not consistently shown improvement in AIA symptoms. Neither acupuncture nor vitamin D can be touted as standard treatments for AIA. However, many patients do experience subjective improvement of their symptoms with these therapies. When other treatments, such as exercise and duloxetine, are not feasible or not effective, it is reasonable to offer a trial of acupuncture or vitamin D to patients who are suffering from AIA, as the potential harms are very few, and they do offer possible relief from AIA symptoms.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Acupuncture and Moxibustion as An Adjunctive Treatment for Osteoarthritis of the Knee - a Large Case Series

Background

In 1997, the first Pain Management Unit, which was set up as part of primary health care within the Andalusian Public Health System, offered acupuncture among other therapies. This observational study was conducted in preparation for a randomised controlled trial.

Methods

We conducted a descriptive study of patients who had been diagnosed with osteoarthritis of the knee. The patients received weekly acupuncture treatment, and related techniques, from November 1997 to November 2000. We recorded: socio-demographic data; measures of effectiveness, including intensity and frequency of pain; the daily dose of analgesic and anti-inflammatory medication; the degree of incapacity; and sleep disorders caused by pain in the knee.

Results

The 563 patients who presented were mainly female (88%) with an average age of 65 years (±10.7); the average age of the male patients was 67 years (±11.8). The condition in most patients (95%) was chronic: 54% had the condition for 5-10 years and a further 23% for more than 10 years. Of the total, 85 (15%) abandoned treatment and were excluded from the evaluation, while 75% of the remainder achieved a reduction in pain of 45% or more. This study is intended to form the basis for a subsequent controlled clinical trial of the effectiveness of acupuncture as a treatment for osteoarthritis of the knee.

Conclusion

The degree of pain relief experienced by patients from acupuncture justifies a more rigorous study.

The Clinical Effectiveness of Acupuncture for Pain Relief – you can be Certain of Uncertainty

Nowadays the volume of published research is so overwhelming that practitioners are turning to expert groups to interpret and summarise research for them. This paper critically reviews the processes used to establish one-sentence statements about the effectiveness of acupuncture for pain relief. Some one-sentence statements claim that acupuncture is not clinically effective because systematic reviews of clinical trials find similar amounts of pain relief between sham acupuncture and real acupuncture. However, these one-sentence statements fail to account for shortcomings in clinical trials such as inadequate doses and inappropriate acupuncture technique. Establishing the physiological intention of acupuncture and developing criteria to assess whether this has been achieved in trials will help to overcome some of these problems in future trials. In addition, shortcomings in systematic review methodology such as imprecise inclusion criteria, comparisons of heterogeneous study populations and imprecise definitions of acupuncture have resulted in discrepancies in vote counting of outcomes between review groups. Recognition of these issues has produced a shift in favour of acupuncture in recent systematic reviews and meta-analyses. It is hoped that this will be reflected in a reappraisal of some of the negative one-sentence statements about the effectiveness of acupuncture for pain relief.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Guidelines for Providing Acupuncture Treatment for Cancer Patients – a Peer-Reviewed Sample Policy Document

Clinical guidelines are statements that have been systematically developed and which aim to assist clinicians in making decisions about treatment for specific conditions, and promote best practice. They are linked to evidence and are meant to facilitate good medical practice. We are not aware of any guidelines for the safe practice of acupuncture in a conventional healthcare setting, yet they are necessary as acupuncture may be performed in a variety of settings and by a variety of healthcare professionals: doctors, nurses, physiotherapists, midwives, and non medically trained practitioners. These guidelines were developed for use in cancer patients, mainly for pain but also for some non-pain indications such as hot flushes. They are presented here as a template for other acupuncturists who are requested to provide policies for acupuncture treatment for cancer patients.

This article includes a general review of the evidence on mechanisms, effectiveness and safety of acupuncture that is intended to be used in conjunction with the guidelines; and the guidelines themselves. An appendix includes instructions for self acupuncture. The guidelines contain sections on roles and responsibilities, criteria for acupuncture practice, indications for acupuncture, contraindications and cautions, acupuncture treatment, and review and audit. These guidelines set basic, minimum standards of care, and need reassessment and ongoing validation as further data and evidence accumulate.

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

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

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

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Background

Evidence on the efficacy of acupuncture for reducing the pain and dysfunction of osteoarthritis is equivocal.

Objective

To determine whether acupuncture provides greater pain relief and improved function compared with sham acupuncture or education in patients with osteoarthritis of the knee.

Design

Randomised, controlled trial.

Setting

Two outpatient clinics (an integrative medicine facility and a rheumatology facility) located in academic teaching hospitals and one clinical trials facility.

Patients

570 patients with osteoarthritis of the knee (mean age [±SD], 65.5 ± 8.4 years).

Intervention

23 true acupuncture sessions over 26 weeks. Controls received 6 two-hour sessions over 12 weeks or 23 sham acupuncture sessions over 26 weeks.

Measurements

Primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at 8 and 26 weeks. Secondary outcomes were patient global assessment, 6-minute walk distance, and physical health scores of the 36-Item Short-Form Health Survey (SF-36).

Results

Participants in the true acupuncture group experienced greater improvement in WOMAC function scores than the sham acupuncture group at 8 weeks (mean difference, −2.9 [95% CI, −5.0 to −0.8]; P=0.01) but not in WOMAC pain score (mean difference, −0.5 [CI, −1.2 to 0.2]; P=0.18) or the patient global assessment (mean difference, 0.16 [CI, −0.02 to 0.34]; P> 0.2). At 26 weeks, the true acupuncture group experienced significantly greater improvement than the sham group in the WOMAC function score (mean difference, −2.5 [CI, −4.7 to −0.4]; P=0.01), WOMAC pain score (mean difference, −0.87 [CI, −1.58 to −0.16]; P=0.003), and patient global assessment (mean difference, 0.26 [CI, 0.07 to 0.45]; P=0.02).

Limitations

At 26 weeks, 43% of the participants in the education group and 25% in each of the true and sham acupuncture groups were not available for analysis.

Conclusions

Acupuncture seems to provide improvement in function and pain relief as an adjunctive therapy for osteoarthritis of the knee when compared with credible sham acupuncture and education control groups.

Acupuncture treatment for knee osteoarthritis with sensitive points: protocol for a multicentre randomised controlled trial

INTRODUCTION

There is a lack of curative medical treatment for patients with knee osteoarthritis (KOA). Acupuncture represents an important alternative therapy. According to the theory of traditional Chinese medicine and preliminary clinical evidence, the patients' acupoints and tender points may become sensitised when the body suffers from a disease state; stimulation of such sensitive points could lead to a disease improvement. It is thus hypothesised that acupuncture at highly sensitised points on patients with KOA would achieve better treatment outcomes than acupuncture at low/non-sensitised points. Previously, we conducted a pilot trial to prove the feasibility of further investigation.

METHODS AND ANALYSIS

A three-arm, parallel, multicentre randomised controlled trial of 666 patients will be conducted at four hospitals of China. Eligible patients with KOA who consent to participate will be randomly assigned to a high-sensitisation group (patients receive acupuncture treatment at high-sensitive points), a low/non-sensitisation group (patients receive acupuncture treatment at low/non-sensitive points) or a waiting-list group (patients receive standard acupuncture treatment after the study is concluded) via a central randomisation system using 1:1:1 ratio. The primary outcome is the change of Western Ontario and McMaster Universities Osteoarthritis Index total score from baseline to 16 weeks. Outcome assessors and data analysts will be blinded and participants will be asked not to reveal their allocation to assessors. The outcome analyses will be performed both on the intention-to-treat and per-protocol population. The primary analyses will test if acupuncture at highly sensitised points would achieve statistically better treatment outcomes than acupuncture at low/non-sensitised points and no acupuncture (ie, waiting list), respectively. A small number of prespecified subgroup analyses will be conducted.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Bioethics Subcommittee of West China Hospital, Sichuan University: 2017 (Number 228). Results will be expected to be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03299439.

Overview of Treatment Guidelines and Clinical Practical Guidelines That Recommend the Use of Acupuncture: A Bibliometric Analysis

INTRODUCTION

As positive evidence emerges for the use of an intervention to treat a health problem, the intervention gradually becomes incorporated into treatment guidelines (TGs) or clinical practice guidelines (CPGs) that are related to that health problem. To assess whether this general hypothesis can apply to acupuncture, 96 health problems were identified for which positive conclusions in systematic reviews and meta-analyses regarding the effectiveness of acupuncture have been made and then searched for TGs or CPGs that have recommended the use of acupuncture.

METHODS

Through August 31, 2017, searches were performed in relevant medical databases and Google using "treatment guideline," "clinical practice guideline," and the names of the 96 medical conditions as search terms. A "snow-balling" search approach was adopted. All positive recommendations were added into the registry.

RESULTS

A total of 1311 publications were found that recommended using acupuncture published between 1991 and 2017. The number per year reached 50 in 2005 and 100 in 2009. In addition, 2189 positive recommendations were found for the use of acupuncture. Of these, 1486 were related to 107 pain indications and 703 were related to 97 nonpain indications. These recommendations were made by a wide range of groups, such as government health institutions, national guideline, and medical specialty groups. The recommendations came from around the world but were especially abundant in North America, Europe, and Australasia.

DISCUSSION AND CONCLUSION

Considerably more recommendations were found for the use of acupuncture than are known within the acupuncture or medical communities. A trend by year was also found; a rise in the number of positive statements about acupuncture was typically followed by a rise in the number of recommendations of acupuncture. Thus, the recommendations followed the emergent evidence for acupuncture. Better implementation plans need to be developed for the CPG/TG recommendations about acupuncture to be more effective/efficient.

Acupuncture for hip osteoarthritis

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Patient education strategies in cataract surgery: A systematic review

OBJECTIVE

To systematically review the comparative effectiveness of patient education strategies in cataract surgery.

METHODS

A comprehensive literature search of five electronic databases was conducted for randomized controlled trials (RCTs) studying the efficacy of educational interventions for cataract surgery patients. Peer-reviewed articles published in English were considered for inclusion without restriction limits on publication date. General study characteristics, measurement methodologies, and outcome measures were narratively synthesized. Quality appraisal was conducted using the Oxford quality rating system (for individual studies) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines (for bodies of evidence).

RESULTS

Sixteen RCTs were compiled for qualitative review. We identified 21 distinct patient outcomes, four (19%) with a multi-study evidence base: knowledge of cataracts/cataract surgery, knowledge of postoperative care, proficiency in postoperative care, and anxiety. Targeted interventions significantly increased educational efficacy in 11 (69%) studies, but there were consistent improvements only for patient understanding of cataracts/cataract surgery and postoperative care. Quality of evidence was poor for all outcomes examined in multiple studies, as well as for deciding to undergo cataract surgery (measured in one study). Cross-study examination revealed appreciable clinical and methodological heterogeneity.

CONCLUSIONS

Targeted interventions fostered patients' understanding of cataract surgery and postoperative care. Additional high-quality studies are needed to determine appropriate educational strategies that improve other clinical, performance, and humanistic outcomes.

Risk of bias and methodological issues in randomised controlled trials of acupuncture for knee osteoarthritis: a cross-sectional study

OBJECTIVE

To assess risk of bias and to investigate methodological issues concerning the design, conduct and analysis of randomised controlled trials (RCTs) testing acupuncture for knee osteoarthritis (KOA).

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials and four major Chinese databases were searched for RCTs that investigated the effect of acupuncture for KOA. The Cochrane tool was used to examine the risk of bias of eligible RCTs. Their methodological details were examined using a standardised and pilot-tested questionnaire of 48 items, together with the association between four predefined factors and important methodological quality indicators.

RESULTS

A total of 248 RCTs were eligible, of which 39 (15.7%) used computer-generated randomisation sequence. Of the 31 (12.5%) trials that stated the allocation concealment, only one used central randomisation. Twenty-five (10.1%) trials mentioned that their acupuncture procedures were standardised, but only 18 (7.3%) specified how the standardisation was achieved. The great majority of trials (n=233, 94%) stated that blinding was in place, but 204 (87.6%) did not clarify who was blinded. Only 27 (10.9%) trials specified the primary outcome, for which 7 used intention-to-treat analysis. Only 17 (6.9%) trials included details on sample size calculation; none preplanned an interim analysis and associated stopping rule. In total, 46 (18.5%) trials explicitly stated that loss to follow-up occurred, but only 6 (2.4%) provided some information to deal with the issue. No trials prespecified, conducted or reported any subgroup or adjusted analysis for the primary outcome.

CONCLUSION

The overall risk of bias was high among published RCTs testing acupuncture for KOA. Methodological limitations were present in many important aspects of design, conduct and analyses. These findings inform the development of evidence-based methodological guidance for future trials assessing the effect of acupuncture for KOA.

Efficacy and safety of electrical moxibustion for knee osteoarthritis: study protocol for a randomized controlled trial

Background

Knee osteoarthritis (KOA) is a significant health issue because it causes pain and functional limitation. Many studies have reported that moxibustion, a treatment in traditional Korean medicine, is effective in treating KOA. However, conventional moxibustion produces smoke, harmful gases, and odors that can adversely affect the eyes, skin, and throat. It is also difficult to control the intensity of stimulation in conventional moxibustion. An electrical moxibustion device was developed to circumvent these problems, but there are few studies of that device. We will evaluate the efficacy and safety of electrical moxibustion as a treatment for KOA, and compare it with traditional indirect moxibustion and usual care.

Methods

This is a multicenter, randomized, open, assessor-blinded, parallel-group clinical trial. A total of 138 eligible participants with KOA will be randomly allocated into three groups (electrical moxibustion, traditional indirect moxibustion, or usual care) with a 1:1:1 ratio. Participants in each moxibustion group will receive 12 sessions of moxibustion treatment at 6 acupoints (ST36, ST35, ST34, SP9, EX-LE4, SP10) plus up to 2 points of “ashi”, if needed, over a period of 6 weeks (2 sessions per week). A specifically designed device that provides thermal stimulation using electrical energy will be used for the electrical moxibustion group. Participants in the usual care group will receive usual treatment and self-care. The primary outcome measure is change in pain on a numerical rating scale (NRS) from week 1 to week 6. The secondary outcome measures are pain assessed on a visual analog scale (VAS), the Korean version of the Western Ontario and McMaster osteoarthritis index (K-WOMAC), patient global assessment (PGA), and the European quality of life five dimension five level scale (EQ-5D-5 L). Safety will be assessed by monitoring adverse events at each visit. Follow-up measurements will be performed at 12 weeks after baseline measurements.

Discussion

This trial will provide evidence on the efficacy and safety of electrical moxibustion as a treatment for KOA.

Trial registration

ClinicalTrials.gov, NCT03287570. Registered on 19 September 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2514-x) contains supplementary material, which is available to authorized users.

Animal Toxins as Therapeutic Tools to Treat Neurodegenerative Diseases

Neurodegenerative diseases affect millions of individuals worldwide. So far, no disease-modifying drug is available to treat patients, making the search for effective drugs an urgent need. Neurodegeneration is triggered by the activation of several cellular processes, including oxidative stress, mitochondrial impairment, neuroinflammation, aging, aggregate formation, glutamatergic excitotoxicity, and apoptosis. Therefore, many research groups aim to identify drugs that may inhibit one or more of these events leading to neuronal cell death. Venoms are fruitful natural sources of new molecules, which have been relentlessly enhanced by evolution through natural selection. Several studies indicate that venom components can exhibit selectivity and affinity for a wide variety of targets in mammalian systems. For instance, an expressive number of natural peptides identified in venoms from animals, such as snakes, scorpions, bees, and spiders, were shown to lessen inflammation, regulate glutamate release, modify neurotransmitter levels, block ion channel activation, decrease the number of protein aggregates, and increase the levels of neuroprotective factors. Thus, these venom components hold potential as therapeutic tools to slow or even halt neurodegeneration. However, there are many technological issues to overcome, as venom peptides are hard to obtain and characterize and the amount obtained from natural sources is insufficient to perform all the necessary experiments and tests. Fortunately, technological improvements regarding heterologous protein expression, as well as peptide chemical synthesis will help to provide enough quantities and allow chemical and pharmacological enhancements of these natural occurring compounds. Thus, the main focus of this review is to highlight the most promising studies evaluating animal toxins as therapeutic tools to treat a wide variety of neurodegenerative conditions, including Alzheimer’s disease, Parkinson’s disease, brain ischemia, glaucoma, amyotrophic lateral sclerosis, and multiple sclerosis.

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

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

Being Adaptive to Pain Enhances Sham Acupuncture Analgesia: A Crossover Healthy Human Study

We have reported a model that distinguishes pain adaptive individuals (PA) from those who are pain non-adaptive (PNA). The present randomised, cross-over, participant-assessor blinded study aimed to determine the impact of pain adaptability on individuals' response to real and sham acupuncture. Healthy volunteers (nine PA and 13 PNA) were randomly allocated to receive real and sham acupuncture on the left hand and forearm in two separate acupuncture sessions. Pressure pain thresholds (PPTs) were measured at bilateral forearms and right leg before, immediately after and 20 minutes after the end of acupuncture. Ratings to pinprick and suprathreshold PPT were also recorded. The two groups were comparable in their demographic and baseline data. Analgesia induced by real or sham acupuncture did not differ on any outcome measures. PA responded to acupuncture needling better than PNA, and to sham needling (20% increase in PPT) better than to real acupuncture (7.9%). Those differences were at 20 min after end of acupuncture in the areas distant to the needling sites. PNA reported little changes in PPT. Being adaptive to pain was associated with enhanced distant analgesia in response to sham acupuncture. Our finding might partly explain varied acupuncture analgesia in clinical practice and trials.

Arthropod toxins acting on neuronal potassium channels

Arthropod venoms are a rich mixture of biologically active compounds exerting different physiological actions across diverse phyla and affecting multiple organ systems including the central nervous system. Venom compounds can inhibit or activate ion channels, receptors and transporters with high specificity and affinity providing essential insights into ion channel function. In this review, we focus on arthropod toxins (scorpions, spiders, bees and centipedes) acting on neuronal potassium channels. A brief description of the K⁺ channels classification and structure is included and a compendium of neuronal K⁺ channels and the arthropod toxins that modify them have been listed. This article is part of the Special Issue entitled 'Venom-derived Peptides as Pharmacological Tools.'

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

Background

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

Aim

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

Methods and results

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

Conclusion

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

Trial registration

Current Controlled Trials ISRCTN63787732.

Funding

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

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

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

Effect of transcutaneous electrical acupuncture point stimulation at different frequencies in a rat model of neuropathic pain

BACKGROUND

Acupuncture and related techniques are used worldwide to alleviate pain; however, their mechanisms of action are still not fully understood. In the present study, we investigated the effect of transcutaneous electrical acupuncture point stimulation (TEAS) at different frequencies in a chronic constriction injury (CCI) model of neuropathic pain in rats.

METHODS

CCI was induced by ligating the common sciatic nerve, which produced neuropathic pain. 18 male Sprague-Dawley rats with CCI were randomly divided into three groups (n=6 each) that remained untreated (CCI group) or received TEAS at high frequency (CCI+TEAS-H group) or TEAS at low frequency (CCI+TEAS-L group). Rats in the CCI+TEAS-H group received high frequency stimulation (6-9 mA, 100 Hz) at GB34/GV26/ST36; those in the CCI+TEAS-L group received low frequency stimulation (6-9 mA, 2 Hz) at the same points. Rats in the control group had the same electrodes applied but received no stimulation. All three groups were subjected to behavioural studies after treatment. Expression of μ opioid receptors (MORs) in the L3-L5 dorsal root ganglion (DRG) was determined by immunofluorescence staining and Western blotting after treatment.

RESULTS

Compared with the untreated CCI group, both mechanical allodynia and thermal hypergesia were significantly attenuated, and MOR expression in the DRG was significantly increased by low frequency TEAS treatment at GB34/GV26/ST36 (p<0.05). In contrast, no significant differences were observed between the CCI and CCI+TEAS-H groups.

CONCLUSIONS

The use of low frequency TEAS significantly mitigated neuropathic pain in this rat model, and its analgesic effect is likely mediated by upregulation of MOR expression in the DRG.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

A background to acupuncture and its use in chronic painful musculoskeletal conditions

This article gives a brief description of the origins of acupuncture and describes some of the underlying philosophy behind this treatment and attempts to place it in context of the traditional Chinese medicine genre within which acupuncture is set. The article then explains the difference between traditional and Western style acupuncture and explains how point selection is made. The use of acupuncture is steadily increasing for a variety of reasons, it is a very safe intervention particularly when compared to conventional treatment and its lack of serious side effects might in part account for some of its popularity. The science behind acupuncture is also explored in terms of its underlying mechanisms and includes pain gate, endogenous opioids, diffuse noxious inhibitory control, serotonin and bioelectricity as possible explanations. The efficacy of acupuncture for a range of chronic musculoskeletal conditions is then explored and it is concluded that acupuncture has a place in the treatment of chronic musculoskeletal pain and in particular osteo-arthritis (OA). Where degenerative conditions are involved, acupuncture clearly cannot provide a ‘cure’ but can provide symptomatic relief, often over a prolonged period.

Effects of acupuncture and sham acupuncture in addition to physiotherapy in patients undergoing bilateral total knee arthroplasty — a randomized controlled trial

Objective: To compare the acute effects of acupuncture with sham acupuncture on knee pain, range of motion and ambulation in patients with knee osteoarthritis undergoing bilateral total knee arthroplasty, when added to a standard postoperative physiotherapy programme.

Design: Prospective patient- and assessor-blinded randomized controlled trial.

Setting: Acute inpatient physiotherapy department.

Patients: Thirty patients (24 women and 6 men) undergoing bilateral total knee arthroplasty were included for final analysis in the study.

Interventions: Both groups received a standard postoperative physiotherapy programme. Each patient was also given either 10 sessions of acupuncture or sham acupuncture within two weeks.

Main outcome measures: The primary outcome measures were the levels of pain at rest and at maximum after exercise measured by the numeric pain rating scale. Other outcome measures included active and passive ranges of knee motion measured by standard goniometer, and ambulation measured by the timed up-and-go test.

Results: Thirty-six patients were recruited at the start of the study with 18 patients allocated to the acupuncture group and another 18 patients to the sham acupuncture group. On postoperative day 15, there were 30 patients with complete data; three patients in each group dropped out from the study. The mean differences (95% confidence interval (CI)) in overall averages of postoperative mean pain levels were 0.4 (—0.6 to 1.3) and —0.8 (—2.0 to 0.4) at rest and at maximum respectively. There were no significant differences in the active and passive ranges of knee motion and the time for the timed up-and-go test between the two groups.

Conclusion: There is no difference between the acute effects of acupuncture and sham acupuncture in addition to standard postoperative physiotherapy programme in patients with knee osteoarthritis undergoing bilateral total knee arthroplasty.

Acupuncture reversed hippocampal mitochondrial dysfunction in vascular dementia rats

Hippocampal mitochondrial dysfunction due to oxidative stress has been considered to play a major role in the pathogenesis of vascular dementia (VD). Previous studies suggested that acupuncture could improve cerebral hypoperfusion-induced cognitive impairments. However, whether hippocampal mitochondria are associated with this cognitive improvement remains unclear. In this study, an animal model of VD was established via bilateral common carotid arteries occlusion (BCCAO) to investigate the alterations of cognitive ability and hippocampal mitochondrial function. BCCAO rats showed impairments in hippocampal mitochondrial function, overproduction of reactive oxygen species (ROS) and learning and memory deficits. After two-week acupuncture treatment, BCCAO-induced spatial learning and memory impairments as shown in Morris water maze were ameliorated. Hippocampal mitochondrial respiratory complex enzymes (complex I, II, IV) activities and cytochrome c oxidase IV expression significantly increased, which might contribute to the reduction of hippocampal ROS generation. In addition, acupuncture significantly improve mitochondrial bioenergy parameters such as mitochondrial respiratory control rate and membrane potential not PDH A1 expression. Placebo-acupuncture did not produce similar therapeutic effects. These findings suggested that acupuncture reversed BCCAO-induced hippocampal mitochondrial dysfunction, which might contribute to its prevention on cognitive deficits.

Acupuncture elicits neuroprotective effect by inhibiting NAPDH oxidase-mediated reactive oxygen species production in cerebral ischaemia

In the current study, we aimed to investigate whether NADPH oxidase, a major ROS-producing enzyme, was involved in the antioxidant effect of acupuncture on cognitive impairment after cerebral ischaemia. The cognitive function, infract size, neuron cell loss, level of superoxide anion and expression of NADPH oxidase subunit in hippocampus of two-vessel occlusion (2VO) rats were determined after 2-week acupuncture. Furthermore, the cognitive function and production of O2(-) were determined in the presence and absence of NADPH oxidase agonist (TBCA) and antagonist (Apocynin). The effect of acupuncture on cognitive function after cerebral ischaemia in gp91phox-KO mice was evaluated by Morris water maze. Acupuncture reduced infarct size, attenuated overproduction of O2(-), and reversed consequential cognitive impairment and neuron cell loss in 2VO rats. The elevations of gp91phox and p47phox after 2VO were significantly decreased after acupuncture treatment. However, no differences of gp91phox mRNA were found among any experimental groups. Furthermore, these beneficial effects were reversed by TBCA, whereas apocynin mimicked the effect of acupuncture by improving cognitive function and decreasing O2(-) generation. Acupuncture failed to improve the memory impairment in gp91phox KO mice. Full function of the NADPH oxidase enzyme plays an important role in neuroprotective effects against cognitive impairment via inhibition of NAPDH oxidase-mediated oxidative stress.

Applications of acupuncture in breast cancer survivors

An increasing number of breast cancer survivors have been using acupuncture to reduce side effects associated with cancer treatment, such as joint/muscle discomfort, hot flashes, lymphedema, fatigue, chemotherapy-induced peripheral neuropathy, anxiety and depression. Rigorous clinical research has begun to investigate the safety, efficacy of acupuncture in treating such conditions. Acupuncture has been shown to be a safe procedure with minimal side effects. Most studies showed that acupuncture is significantly better than no acupuncture in relieving such symptoms. The benefit of real acupuncture over sham acupuncture in treating such symptoms has not been fully established. Additional research is needed to determine the efficacy, mechanism and cost–effectiveness of acupuncture. Meanwhile, since acupuncture poses minimal risks and carries potentially significant benefits, this medical procedure remains a reasonable treatment option for breast cancer survivors to alleviate cancer treatment induced side effects.

Pharmacological Alternatives for the Treatment of Neurodegenerative Disorders: Wasp and Bee Venoms and Their Components as New Neuroactive Tools

Neurodegenerative diseases are relentlessly progressive, severely impacting affected patients, families and society as a whole. Increased life expectancy has made these diseases more common worldwide. Unfortunately, available drugs have insufficient therapeutic effects on many subtypes of these intractable diseases, and adverse effects hamper continued treatment. Wasp and bee venoms and their components are potential means of managing or reducing these effects and provide new alternatives for the control of neurodegenerative diseases. These venoms and their components are well-known and irrefutable sources of neuroprotectors or neuromodulators. In this respect, the present study reviews our current understanding of the mechanisms of action and future prospects regarding the use of new drugs derived from wasp and bee venom in the treatment of major neurodegenerative disorders, including Alzheimer’s Disease, Parkinson’s Disease, Epilepsy, Multiple Sclerosis and Amyotrophic Lateral Sclerosis.

Comparative study on the effects of bee venom pharmacopuncture according to the treatment method for knee osteoarthritis

Objectives:

The purpose of this study is to compare the effects of bee venom pharmacopuncture (BVP) therapy according to the methods used to treat knee osteoarthritis (OA): intra-acupoint combined with intra-articular injection, intra-acupoint injection, and intra-articular injection.

Methods:

A total of 69 patients were recruited by the Department of Acupuncture & Moxibustion at Dong- Eui Oriental University Hospital from February 1 to July 23, 2012. The patients were assigned to 3 groups: the first group with intra-acupoint combined with intraarticular BVP Injection (the experimental group), the 2nd group with intra-acupoint BVP injection (control groupⅠ), and the 3rd group with intra-articular BVP injection (control groupⅡ). The participants were assigned in the order in which they were recruited. Treatments were done twice a week, for a total of 9 times. The effectiveness was assessed by using the visual analouge scale (VAS) and the Korea Western Ontario and McMaster Universities Osteoarthritis Index (KWOMAC).

Results:

All three groups exhibited significant VAS and KWOMAC effects. Moreover, the 4 week follow-up after the final treatment showed a persistence of BVP effects. However, when the groups were compared, no statistically significant differences in VAS and KWOMAC were noted, but when improvement was considered, the results showed that intra-articular injection was more effective than intra-acupoint injection. Especially, intra-acupoint combined with intra-articular injection was the most effective among the three treatments.

Conclusions:

Combining intra-acupoint with intraarticular injection, depending on the patient's symptoms, may produce better results when conservatively treating knee OA.

Acupuncture for low back pain: an overview of systematic reviews

Objective. As evidence of the effectiveness of acupuncture for low back pain (LBP) is inconsistent, we aimed to critically appraise the evidence from relevant systematic reviews. Methods. Systematic reviews of randomized controlled trials (RCTs) concerning acupuncture and LBP were searched in seven databases. Internal validity and external validity of systematic reviews were assessed. Systematic reviews were categorized and high quality reviews assigned greater weightings. Conclusions were generated from a narrative synthesis of the outcomes of subgroup comparisons. Results. Sixteen systematic reviews were appraised. Overall, the methodological quality was low and external validity weak. For acute LBP, evidence that acupuncture has a more favorable effect than sham acupuncture in relieving pain was inconsistent; it had a similar effect on improving function. For chronic LBP, evidence consistently demonstrated that acupuncture provides short-term clinically relevant benefits for pain relief and functional improvement compared with no treatment or acupuncture plus another conventional intervention. Conclusion. Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP. More efforts are needed to improve both internal and external validity of systematic reviews and RCTs in this area.