Acupuncture and electro-acupuncture for people diagnosed with subacromial pain syndrome: A multicentre randomized trial

Effects of acupuncture on shoulder impingement syndrome: A systematic review and meta-analysis

BACKGROUND

Shoulder impingement syndrome (SIS) is a common condition that causes chronic shoulder pain. The effectiveness of acupuncture in treating chronic shoulder pain has been documented in previous studies; however, existing systematic reviews and meta-analyses have often excluded Chinese databases and combined different types of acupuncture interventions, such as electroacupuncture, warm acupuncture, pharmacopuncture, and acupotomy. Thus, this study specifically examines the exclusive impact of manual acupuncture on SIS.

METHODS

Several databases, including PubMed, Cochrane Central, Embase, 1 Chinese database (China National Knowledge Infrastructure), and 5 Korean databases (ScienceON, Oriental Medicine Advanced Searching Integrated System, KoreaMed, Korean Studies Information Service System, and KMBASE), were systematically searched for relevant studies. The quality of the included studies was evaluated using the Cochrane Assessment Tool for Risk of Bias Version 2. Data collected from the selected studies were synthesized for meta-analysis. The primary outcome was a pain scale score, and the secondary outcomes were shoulder function and disability.

RESULTS

This study included 5 randomized controlled trials. The primary outcome assessment revealed significantly reduced pain (standardized mean difference [SMD] = -0.50, 95% confidence interval [CI] = -0.74 to -0.27) and improvements in shoulder function and disability (SMD = -0.57, 95% CI = -0.96 to -0.19). A subgroup analysis based on treatment duration indicated that short-term acupuncture treatment (≤4 weeks) exhibited a high level of confidence with low heterogeneity (SMD = -0.37, 95% CI = -0.73 to -0.02).

CONCLUSION

Manual acupuncture is effective for relieving pain and improving shoulder function and disability in patients with SIS. However, further research is necessary to validate these findings owing to the limited number of patients and heterogeneity among the studies reviewed.

Percutaneous tendon dry needling and thrust manipulation as an adjunct to multimodal physical therapy in patients with lateral elbow tendinopathy: A multicenter randomized clinical trial

OBJECTIVE

The purpose of this study was to assess the effects of adding electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization, and ultrasound in patients with lateral elbow tendinopathy.

DESIGN

Randomized, single-blinded, multicenter, parallel-group trial.

SETTING

Thirteen outpatient physical therapy clinics in nine different US states.

PARTICIPANTS

One hundred and forty-three participants (n = 143) with lateral elbow tendinopathy were randomized.

INTERVENTION

Cervical spine manipulation, extremity manipulation, and percutaneous tendon electrical dry needling plus multimodal physical therapy (n = 73) or multimodal physical therapy (n = 70) alone.

MAIN MEASURES

The primary outcome was elbow pain intensity and disability as measured by the Patient-Rated Tennis Elbow Evaluation at baseline, 1 week, 4 weeks, and 3 months. Secondary outcomes included the Numeric Pain Rating Scale, Tennis Elbow Functional Scale, Global Rating of Change, and medication intake.

RESULTS

The 2 × 4 analysis of covariance demonstrated that individuals with lateral elbow tendinopathy receiving electrical dry needling and thrust manipulation plus multimodal physical therapy experienced significantly greater improvements in disability (Patient-Rated Tennis Elbow Evaluation: F = 19.675; P < 0.001), elbow pain intensity (Numeric Pain Rating Scale: F = 22.769; P < 0.001), and function (Tennis Elbow Function Scale: F = 13.269; P < 0.001) than those receiving multimodal physical therapy alone at 3 months. The between-group effect size was large for pain and disability (Patient-Rated Tennis Elbow Evaluation: standardized mean difference = 1.13; 95% confidence interval: 0.78, 1.48) in favor of the electrical dry needling and thrust manipulation group.

CONCLUSIONS

The inclusion of percutaneous tendon electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization and ultrasound was more effective than multimodal physical therapy alone in individuals with lateral elbow tendinopathy.Trial Registration: www.clinicaltrials.gov NCT03167710 May 30, 2017.

Effects of acupuncture on pain and function in patients with subacromial impingement syndrome: A randomized sham-controlled trial

Background

Subacromial impingement syndrome (SIS) is the most common cause of shoulder pain. Acupuncture is a traditional medicine that is effective on pain. This study aimed to evaluate the effect of acupuncture treatment on pain, function, range of motion (ROM) and quality of life compared to sham acupuncture in patients diagnosed with SIS.

Methods

A randomized, prospective, double-blinded, sham-controlled trial was conducted. In acupuncture group 40 participants received acupuncture treatment plus exercise therapy while in control group 40 participants received sham acupuncture plus exercise therapy. Primary outcomes included pain-rest, activity and night pain. Secondary outcomes included function [Shoulder Pain and Disability Index (SPADI) and The Disabilities of the Arm, Shoulder and Hand Score (Quick DASH)], ROM, and quality of life [The Western Ontario Rotator Cuff Index (WORC)] in patients with SIS.

Results

Both groups had significant improvements for pain-rest, activity night pain scores, SPADI, Quick DASH and WORC after treatment and at the first month follow-up. Significant improvements were recorded in the acupuncture group for all ROM after treatment and at the first month follow-up while in control group only in passive internal rotation. Acupuncture group had better improvements for Quick DASH, WORC and all ROM parameters after the treatment, as well as for all parameters except pain-night and passive flexion at the first month follow-up.

Conclusion

This study suggest that acupuncture treatment is a safe, effective and non-invasive treatment option in patients with SIS.

Trial registration

The study protocol is registered at clinicaltrials.gov (NCT05794633).

Effects of Adding Four Sessions of Ultrasound-Guided Percutaneous Electrical Nerve Stimulation to an Exercise Program in Patients with Shoulder Pain: A Randomized Controlled Trial

Objective: Percutaneous electrical nerve stimulation (PENS) appears to be effective for the treatment of musculoskeletal pain. The aim of this trial was to investigate the effects on disability and pain, as well as on the psychological aspects of adding PENS into an exercise program in patients with subacromial pain syndrome. Methods: A randomized, parallel-group clinical trial was conducted. Sixty patients with subacromial pain were allocated into exercise alone (n = 20), exercise plus PENS (n = 20), or exercise plus placebo PENS (n = 20) groups. Patients in all groups performed an exercise program twice daily for 3 weeks. Patients allocated to the PENS group also received four sessions of ultrasound-guided PENS targeting the axillar and suprascapular nerves. Patients allocated to the exercise plus placebo PENS received a sham PENS application. The primary outcome was related disability (Disabilities of the Arm, Shoulder, and Hand, DASH). Secondary outcomes included mean pain, anxiety levels, depressive symptoms, and sleep quality. They were assessed at baseline, one week after, and one and three months after. An analysis was performed using intention-to-treat with mixed-models ANCOVAs. Results: The results revealed no between-group differences for most outcomes (related disability: F = 0.292, p = 0.748, n2p = 0.011; anxiety: F = 0.780, p = 0.463, n2p = 0.027; depressive symptoms: F = 0.559, p = 0.575, n2p = 0.02; or sleep quality: F = 0.294, p = 0.747, n2p = 0.01); both groups experienced similar changes throughout the course of this study. Patients receiving exercise plus PENS exhibited greater improvement in shoulder pain at one month than those in the exercise (Δ -1.2, 95%CI -2.3 to -0.1) or the placebo (Δ -1.3, 95%CI -2.5 to -0.1) groups. Conclusions: The inclusion of four sessions of ultrasound-guided PENS targeting the axillar and suprascapular nerves into an exercise program did not result in better outcomes in our sample of patients with subacromial pain syndrome at one and three months after treatment.

Shoulder specific exercise therapy is effective in reducing chronic shoulder pain: A network meta-analysis

BACKGROUND

Exercise therapy (ET) is frequently an early treatment of choice when managing shoulder pain, yet evidence on its efficacy to expedite recovery is inconsistent. Moreover, the value of adding adjunct therapies (i.e. injections, manual therapy, electrotherapy) to ET is currently unclear. This study combined both direct and indirect evidence across studies on the effectiveness of ET with/without adjunct therapies compared to usual medical care for adults with chronic shoulder pain.

METHODS AND FINDINGS

Using a network meta-analysis, randomized control trials comparing ET along with adjunct therapies were identified in MEDLINE, Embase, CINAHL, Sportdiscus, CENTRAL, Conference Proceedings Citation Index-Science, clinicaltrials.gov, and association websites. Outcomes included pain, range of motion (ROM), and health-related quality of life (HRQL) measures in adult patients with chronic shoulder pain. Data analysis used a Frequentist hierarchical model. CINeMA tool assessed the confidence in the results and Cochrane Risk of Bias tool assessed quality of studies. 54 studies primarily from Europe (40.38%) included 3,893 participants who were followed up to 52 weeks. Shoulder-specific ET (Mean difference (MD) = -2.1; 95% confidence interval (CI) = -3.5 to -0.7) or in combination with electro-physical agents (MD = -2.5; 95% CI = -4.2 to -0.7), injections (MD = -2.4; 95% CI = -3.9 to-1.04) or manual therapy (MD = -2.3; 95% CI = -3.7 to -0.8) decreased pain compared to usual medical care. Trends with ROM and HRQL scores were seen; however, only Manual Therapy (MD = -12.7 and 95% CI = -24.4 to -1.0) achieved meaningfully important changes. Sensitivity analysis excluding studies with high risk of bias showed similar results, with exception of injections that did not reach significance (MD = -1.3; 95% CI = -4.3 to 1.7).

CONCLUSION(S)

Shoulder-specific ET provided pain relief up to 52 weeks. Adjunct therapies to shoulder-specific ET added little value in reducing pain. The quality of evidence varied between moderate and very low.

Reproducibility of Exercise Interventions in Randomized Controlled Trials for the Treatment of Rotator Cuff-Related Shoulder Pain: A Systematic Review

OBJECTIVE

To determine the reproducibility of exercise therapy interventions in randomized controlled trials for rotator cuff-related shoulder pain (RCRSP).

DATA SOURCES

Data sources included Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and SPORTDiscus from studies published from database inception to April 23, 2022.

STUDY SELECTION

Randomized controlled trials studying the use of exercise therapy for RCRSP.

DATA EXTRACTION

Two reviewers extracted exercise reporting details from all studies using the Template for Intervention Description and Replication (TIDieR) and the modified Consensus on Exercise Reporting Template (CERT). The same 2 reviewers assessed risk of bias of all studies using Cochrane Risk of Bias Tool version 2.0.

DATA SYNTHESIS

For 104 studies meeting inclusion criteria, the average number of items reported on the TIDieR was 5.27 (SD 2.50, range 1-12 out of 12) and 5.09 (SD 4.01, range 0-16 out of 16) on the CERT. Improved reporting over time was seen on both the TIDieR and CERT dating back to 1993 and through April 23, 2022. When comparing groups of studies published before and after the TIDieR (2014) and CERT (2016) were established, a statistically significant increase in median scores was noted on the TIDieR (P=.02) but not the CERT (P=.31). Quality of exercise therapy reporting was highest in studies with "low risk" of bias, and lowest in studies with "high risk" of bias on the RoB-2.

CONCLUSION

Overall exercise reporting in trials for RCRSP is incomplete despite the development of the TIDieR and CERT checklists. This has implications for translating evidence into practice.

Researcher's Perspective on Musculoskeletal Conditions in Primary Care Physiotherapy Units through the International Classification of Functioning, Disability, and Health (ICF): A Scoping Review

(1) Background: Musculoskeletal disorders are the second cause of disability in the world. The International Classification of Functioning Disability and Health (ICF) is a tool for systematically describing functioning. Outcome measures for musculoskeletal disorders and functioning concepts embedded in them have not been described under the ICF paradigm. The objective of this scoping review was to identify ICF categories representing the researcher's perspective and to compare them with the ICF core set for post-acute musculoskeletal conditions. (2) Methods: This review was conducted as follows: (a) literature search using MEDLINE/PubMed, CINAHL, Web of Science, and Scopus databases; (b) study selection applying inclusion criteria (PICOS): musculoskeletal conditions in primary care, application of physiotherapy as a treatment, outcome measures related to functioning, and experimental or observational studies conducted in Western countries during the last 10 years; (c) extraction of relevant concepts; (d) linkage to the ICF; (e) frequency analysis; and (f) comparison with the ICF core set. (3) Results: From 540 studies identified, a total of 51 were included, and 108 outcome measures were extracted. In the ICF linking process, 147 ICF categories were identified. Analysis of data showed that 84.2% of the categories in the ICF core set for post-acute musculoskeletal conditions can be covered by the outcome measures analyzed. Sixty-eight relevant additional ICF categories were identified. (4) Conclusion: Outcome measures analyzed partially represent the ICF core set taken as a reference. The identification of additional categories calls into question the applicability of this core set in primary care physiotherapy units.

Comparison of shoulder functions between assembly workers with and without subacromial pain syndrome

BACKGROUND: The occurrence of subacromial pain syndrome (SPS) is associated with the frequent handling and lifting of heavy loads and excessive repetitive work. Thus, assembly workers have a high prevalence of SPS. OBJECTIVE: The purpose of this study was to investigate differences in shoulder ROM, muscle strength, asymmetry ratio, function, productivity, and depression between workers with and without SPS. METHODS: Sixty-seven male workers (35 workers with SPS and 32 workers without SPS) participated in this study. Shoulder internal rotation (SIR), shoulder external rotation (SER), shoulder abduction (SAB), shoulder horizontal adduction ROM and SIR, SER, elbow flexion (EF), scapular depression and adduction, scapular protraction strength were measured. The asymmetry ratio was calculated using the asymmetry ratio formula; shoulder functions were measured using the shoulder pain and disability index (SPADI), disabilities of the arm, shoulder, and hand (DASH), and visual analogue scale (VAS); and Endicott work productivity scale (EWPS). RESULTS: The SPADI (p = 0.001), DASH (p = 0.001), and VAS (p = 0.001) values of workers with SPS were higher than those of workers without SPS. Also, workers with SPS had lower SIR (p = 0.001) and SAB (p = 0.002) ROM compared to workers without SPS. In addition, workers with SPS exhibited lower SIR (p = 0.012) strength than workers without SPS. Workers with SPS had higher asymmetry ratio in SIR (p = 0.015), SER (p = 0.005), and EF (p = 0.008) strength than workers without SPS. CONCLUSIONS: The SIR, SAB ROM, SIR strength, and the asymmetry ratio of SIR, SER, EF strengths could provide an important baseline comparison for the workers with SPS.

Physical Therapy Combined With Subacromial Cortisone Injection Is a First-Line Treatment Whereas Acromioplasty With Physical Therapy Is Best if Nonoperative Interventions Fail for the Management of Subacromial Impingement: A Systematic Review and Network Meta-Analysis

PURPOSE

To construct an algorithm to optimize clinical outcomes in subacromial impingement based on current, high-level evidence.

METHODS

A systematic review of all clinical trials on subacromial impingement published from 1999 to 2020 was performed. Demographic, clinical, range of motion (ROM), and patient-reported outcome measure (PROM) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model and treatments ranked via surface under the cumulative ranking curves with respect to 3 domains: pain, PROMs, and ROM.

RESULTS

A total of 35 studies comprising 3,643 shoulders (42% female, age 50 ± 5 years) were included. Arthroscopic decompression with acromioplasty ranked much greater than arthroscopic decompression alone for pain relief and PROM improvement, but the difference in absolute PROMs was not statistically significant. Corticosteroid injection (CSI) alone demonstrated inferior outcomes across all 3 domains (pain, PROMs, and ROM) with low cumulative rankings. Physical therapy (PT) with CSI demonstrated moderate-to-excellent clinical improvement across all 3 domains whereas PT alone demonstrated excellent ROM and low-moderate outcomes in pain and PROM domains. PT with nonsteroidal anti-inflammatory drugs or alternative therapies ranked highly for PROM outcomes and moderate for pain and ROM domains. Finally, platelet-rich plasma injections demonstrated moderate outcomes for pain, forward flexion, and abduction with very low-ranking outcomes for PROMs and external rotation.

CONCLUSIONS

Arthroscopic decompression with acromioplasty and PT demonstrated superior outcomes whereas CSI demonstrated poor outcomes in all 3 domains (pain, PROMs, and ROM). For patients with significant symptoms, the authors recommend PT with CSI as a first-line treatment, followed by acromioplasty and PT if conservative treatment fails. For patients with symptoms limited to 1 to 2 domains, the authors recommend a shared decision-making approach focusing on treatment rankings within domains pertinent to individual patient symptomatology.

LEVEL OF EVIDENCE

I, systematic review and network meta-analysis of Level I studies.

Investigating the effects of mobilization with movement and exercise on pain modulation processes in shoulder pain - a single cohort pilot study with short-term follow up

OBJECTIVE

To explore the association between manual therapy and exercise and pain modulation and clinical characteristics in people with musculoskeletal shoulder pain.

METHODS

This is a prospective, longitudinal, single cohort pilot study. People with shoulder pain for longer than 6 weeks underwent 4 weeks of glenohumeral mobilization with movement and shoulder exercises. Measures of pain modulation, shoulder pain, disability, range of motion and psychosocial factors were assessed at baseline and immediately after the 4-week period of treatment. Treatment effectiveness was assessed through parametric, non-parametric and multilevel modeling statistics.

RESULTS

Twenty-three individuals participatedwith no loss to follow-up. Significant and meaningful improvements in shoulder pain (NRS mean change 1.6/10, 95% CI 0.4 to 2.7), disability (SPADI mean change 20.5/100, 95% CI 13.1 to 27.9) and range of motion (mean change 33°, 95% CI 23 to 43°) were observed following treatment. Statistical but non-clinically meaningful changes were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55). Significant reductions were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55), however these were not considered clinically important. No association was found between clinical characteristics and sensory measures. No association was found between clinical characteristics and sensory measures.

CONCLUSION

Glenohumeral mobilization with movement and exercise did not improve pain modulation, despite improvements in pain, function and range of motion, in people with shoulder pain.

Effect Observation of Electro-Acupuncture Anesthesia Combined with General Anesthesia in Elderly Patients Undergoing Gastrointestinal Tumor Resection

Objective

To investigate the anesthetic effect of electro-acupuncture (EA) anesthesia combined with general anesthesia in elderly patients undergoing gastrointestinal tumor resection, and to analyze the effects of EA anesthesia on inflammatory factors, stress state and T lymphocyte subsets in elderly patients.

Methods

Total of 118 elderly patients who underwent gastrointestinal tumor resection in our hospital from June 2018 to March 2021 were selected and divided into the control group (59 cases) and the observation group (59 cases) according to the random number method. General anesthesia was adopted in the control group and EA anesthesia combined with general anesthesia was adopted in the observation group. The anesthesia effect, stress state, levels of inflammatory factors, T-lymphocyte subsets and adverse reactions were compared.

Results

The VAS score, agitation score and respiratory normalization time in the observation group were lower than those in the control group (p &lt; 0.05). After surgery, the levels of serum Cor, ET, NE and DA in the observation group were lower than those in the control group (p &lt; 0.05). At 24 h after surgery, the levels of serum TNF-α, IL-6 and IL-1β in the observation group were lower than those in the control group (p &lt; 0.05). At 24 h after surgery, the levels of CD3+, CD4+, and CD4+//CD8+ in the two groups were lower than those before surgery, and the levels of CD3+, CD4+, and CD4+//CD8+ in the observation group were higher than those in the control group (p &lt; 0.05). During the hospitalization, the total incidence rate of adverse reactions after anesthesia in the observation group was lower than that in the control group (p &lt; 0.05).

Conclusion

EA anesthesia combined with general anesthesia has good anesthesia effect when used for gastrointestinal tumor resection in the elderly. It can stabilize the internal environment of patients, alleviate postoperative stress response and inflammatory response, and regulate the body immune function. Moreover, it has high safety and can significantly reduce the occurrence of postoperative adverse reactions.

Use of Behavior Change Techniques Alongside Exercise in the Management of Rotator Cuff-Related Shoulder Pain: A Scoping Review

OBJECTIVES

The aims of this scoping review were to: (1) determine the frequency and types of behavior change techniques (BCTs) and education utilized in trials investigating exercise interventions for rotator cuff related shoulder pain (RCRSP); (2) subcategorize the BCTs and education found in the trials to summarize all behavior change approaches reported by trials; and (3) compare the frequency, types, and subcategories of BCTs and education utilized in the clinical guidelines for managing RCRSP between the trials.

METHODS

Data sources included Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, Google Scholar and PubMed, which were searched from inception to June 2020. Trials assessing exercise interventions for RCRSP were included. Three authors independently determined eligibility and extracted data. The frequency and types of BCTs and education in the trials and clinical practice guidelines were reported and compared descriptively. Two authors assessed the content of the BCTs to develop subcategories.

RESULTS

Most trials reported including at least 1 type of BCT (89.2%), which was most commonly feedback and monitoring (78.5%). There were many different approaches to the BCTs and education; for example, feedback and monitoring was subcategorized into supervised exercise, exercise monitoring, and feedback through external aids, such as mirrors. Clinical guidelines recommend supervision, goal setting, activity modification, pain management recommendations, information about the condition, and exercise education.

CONCLUSION

Although over two-thirds of trials reported including a BCT alongside exercise interventions for RCRSP, the breadth of these interventions is limited (supervision is the only common one). Future trialists should consider using any type of BCT that may improve exercise adherence and outcomes.

IMPACT

The findings of this review have: (1) identified gaps in the literature; and (2) contributed to the design of future exercise interventions for RCRSP.

March 2021 Letters to the Editor-in-Chief

Letters to the Editor-in-Chief of JOSPT as follows: "Competing Interests and a Cloudy Clinical Interpretation" "A Vested Interest in the Outcome" J Orthop Sports Phys Ther 2021;51(3):151-153. doi:10.2519/jospt.2021.0201.

Spinal Manipulation and Electrical Dry Needling in Patients With Subacromial Pain Syndrome: A Multicenter Randomized Clinical Trial

OBJECTIVES

To compare the effects of spinal thrust manipulation and electrical dry needling (TMEDN group) to those of nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current (NTMEX group) on pain and disability in patients with subacromial pain syndrome (SAPS).

DESIGN

Randomized, single-blinded, multicenter parallel-group trial.

METHODS

Patients with SAPS were randomized into the TMEDN group (n = 73) or the NTMEX group (n = 72). Primary outcomes included the Shoulder Pain and Disability Index and the numeric pain-rating scale. Secondary outcomes included the global rating of change scale (GROC) and medication intake. The treatment period was 6 weeks, with follow-ups at 2 weeks, 4 weeks, and 3 months.

RESULTS

At 3 months, the TMEDN group experienced greater reductions in shoulder pain and disability (P<.001) compared to the NTMEX group. Effect sizes were large in favor of the TMEDN group. At 3 months, a greater proportion of patients within the TMEDN group achieved a successful outcome (GROC score of 5 or greater) and stopped taking medication (P<.001).

CONCLUSION

Cervicothoracic and upper-rib thrust manipulation combined with electrical dry needling resulted in greater reductions in pain, disability, and medication intake than nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current in patients with SAPS. The effects were maintained at 3 months. J Orthop Sports Phys Ther 2021;51(2):72-81. Epub 28 Aug 2020. doi:10.2519/jospt.2021.9785.

Seven Key Themes in Physical Therapy Advice for Patients Living With Subacromial Shoulder Pain: A Scoping Review

OBJECTIVE

To systematically scope the reported advice and education in physical therapy management of patients with subacromial shoulder pain, and to define key themes of the advice and education.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched MEDLINE, Scopus, Web of Science, and CINAHL, with publication dates from 2007 to September 2019.

STUDY SELECTION CRITERIA

We included quantitative and qualitative research that reported on physical therapy interventions for subacromial shoulder pain.

DATA SYNTHESIS

We performed a qualitative synthesis that identified items included in patient advice and education.

RESULTS

Of 89 original studies included, there were 61 randomized controlled trials; 5 prospective studies; 16 nonrandomized observational intervention studies or case series; and 7 surveys, audits of physical therapy patient records, and focus groups with physical therapists. We identified 7 key themes for advice and education: exercise intensity and pain response, activity modification advice, posture advice, pain self-management advice, pathoanatomical and diagnosis information, behavioral approaches, and pain biology advice.

CONCLUSION

While advice focused predominantly on the local tissue pathology model, 10% of studies included information about pain neuroscience education, psychosocial factors, motor imagery, or behavior change. J Orthop Sports Phys Ther 2020;50(6):285-293. doi:10.2519/jospt.2020.9152.

Relative Effectiveness of Electroacupuncture and Biofeedback in the Treatment of Neck and Upper Back Myofascial Pain: A Randomized Clinical Trial

OBJECTIVE

To determine the differences between clinical effects of electroacupuncture and biofeedback therapy in addition to conventional treatment in patients with cervical myofascial pain syndrome (MPS).

DESIGN

Randomized clinical trial.

SETTING

Physical medicine and rehabilitation clinic of a university hospital.

PARTICIPANTS

Fifty patients (N=50) aged 25-55 years of both sexes with chronic neck pain diagnosed with MPS (characterized by trigger points within taut bands) were randomly assigned to 2 equal groups of 25 individuals.

INTERVENTIONS

The patients in electroacupuncture group were treated with standard acupuncture and concomitant electrical stimulation; those in biofeedback group received visual electromyography biofeedback therapy for muscle activity and relaxation. Both groups received the intervention 2 times a week for a total of 6 sessions. Basic exercise training and medicines were administered for all the patients.

MAIN OUTCOME MEASURES

Pain severity based on the visual analog scale (VAS), functional status using Neck Disability Index (NDI), cervical range of motion (ROM) using and inclinometer, and pressure pain threshold (PPT) using an algometer were evaluated before and at 3 and 12 weeks after the treatment. Primary outcome was defined as 20% reduction in the 3-month neck pain and dysfunction compared to baseline, assessed through the NDI.

RESULTS

Fifty patients (39 women, 11 men) with a mean age (years) ± SD of 39.0±5.5 and neck pain duration (weeks) of 6.0±2.2 were analyzed. All parameters, except for PPT of the lower trapezius and paravertebral muscles were improved significantly in both groups, while baseline values were controlled. The primary outcome was achieved more significantly in the acupuncture group than in the biofeedback group: 20 (80.0%) vs 10 (40.0%); rate ratio=2 with 95% confidence interval (CI), 1.19-3.36; number needed to treat (NNT)=2.5 with 95% CI, 1.54-6.58. Advantages of acupuncture over biofeedback were observed according to values obtained from the NDI, VAS, extension and left lateral-bending ROM, and PPT on the left upper trapezius after the last session of intervention until 3 months (P<.05).

CONCLUSIONS

Both electroacupuncture and biofeedback therapies were found to be effective in management of MPS when integrated with conventional treatment. However, intergroup differences showed priority of acupuncture in some parameters vs biofeedback. Thus, electroacupuncture seems to be a better complementary modality for treatment of MPS in the neck and upper back area.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

What Is the Appropriate Acupuncture Treatment Schedule for Chronic Pain? Review and Analysis of Randomized Controlled Trials

Background

Acupuncture is widely used for the treatment of chronic pain. Different protocols of acupuncture practice exist and lack agreement on the optimal schedule of acupuncture treatment.

Objective

To review the appropriate acupuncture treatment schedule for chronic pain.

Methods

Embase, Pubmed, Cochrane Central Register of Controlled Trials, and reference lists were searched from 2009 to 2018 to identify randomized controlled trials of acupuncture for chronic pain conditions. We collected factors of treatment schedule (D, duration of each treatment session; N, number of treatment sessions; T, total duration of treatment in weeks) from each of the trials, and the linear regression analysis with real pain relief rate (both treatment and follow-up) was performed. Furthermore, we recommend the concept of “DOSE” and frequency (F) to evaluate the dose and frequency effect of acupuncture.

Results

Twenty-four trials with a total number of 3461 patients met the inclusion criteria. Of these, data from 23 studies were available for analysis. Firstly, the results showed that follow-up pain relief rate was decreased slightly with the increase of the duration of each session and DOSE (r=-0.3414 and r=-0.3246, respectively), but those two factors had no correlation with the pain relief rate after treatment. Secondly, it showed that either lower frequency with 2 sessions/week and higher frequency greater than 2 sessions/week or DOSE of 30 mins/week can achieve higher pain relief rate after treatment. Thirdly, we found the rate of pain relief remained at a high level greater than 20% up to 18 weeks after the treatment, and then it dropped sharply below 10% with the follow-up extended. A positive relationship was found between study score and pain relief both in treatment and follow-up (r=0.4654 and r=0.3046, respectively).

Conclusions

The effect of acupuncture varies greatly with the different schedules of acupuncture, so it is necessary to review and choose the appropriate schedule. Although the current work is based on a limited number of trials, the findings suggest that acupuncture has a dose and frequency effect presenting within a certain range, which would have considerable implications for the design and interpretation of clinical trials. More high-quality randomized controlled trials on acupuncture schedule research were needed for providing more definitive evidence.

Effects of Adding Interferential Therapy Electro-Massage to Usual Care after Surgery in Subacromial Pain Syndrome: A Randomized Clinical Trial

Subacromial pain syndrome (SAPS) is a prevalent condition that results in loss of function. Surgery is indicated when pain and functional limitations persist after conservative measures, with scarce evidence about the most-appropriate post-operative approach. Interferential therapy (IFT), as a supplement to other interventions, has shown to relieve musculoskeletal pain. The study aim was to investigate the effects of adding IFT electro-massage to usual care after surgery in adults with SAPS. A randomized, single-blinded, controlled trial was carried out. Fifty-six adults with SAPS, who underwent acromioplasty in the previous 12 weeks, were equally distributed into an IFT electro-massage group or a control group. All participants underwent a two-week intervention (three times per week). The control group received usual care (thermotherapy, therapeutic exercise, manual therapy, and ultrasound). For participants in the IFT electro-massage group, a 15-min IFT electro-massage was added to usual care in every session. Shoulder pain intensity was assessed with a 100-mm visual analogue scale. Secondary measures included upper limb functionality (Constant-Murley score), and pain-free passive range of movement. A blinded evaluator collected outcomes at baseline and after the last treatment session. The ANOVA revealed a significant group effect, for those who received IFT electro-massage, for improvements in pain intensity, upper limb function, and shoulder flexion, abduction, internal and external rotation (all, p < 0.01). There were no between-group differences for shoulder extension (p = 0.531) and adduction (p = 0.340). Adding IFT electro-massage to usual care, including manual therapy and exercises, revealed greater positive effects on pain, upper limb function, and mobility in adults with SAPS after acromioplasty.

Dry needling in addition to standard physical therapy treatment for sub-acromial pain syndrome: a randomized controlled trial protocol

BACKGROUND

Trigger point dry needling interventions are utilized by physical therapists to manage shoulder pain. Observational studies have shown positive short-term outcomes in patients with subacromial pain syndrome receiving trigger point dry needling. However, little research has been done to evaluate the long-term effectiveness of trigger point dry needling specifically as it compares to other commonly utilized interventions such as exercise and manual therapy. The purpose of this study is to assess the additive short and long-term effectiveness of trigger point dry needling to a standard physical therapy approach of manual therapy and exercise for patients with subacromial pain syndrome.

METHODS

This multicenter randomized trial with 3 arms was designed following the standard protocol items for randomized interventional trials. Results will be reported consistent with the consolidated standards of reporting trials guidelines. 130 participants will be randomized to receive standard PT interventions alone (manual therapy and exercise), standard PT and trigger point dry needling or standard PT and sham trigger point dry needling. The primary outcome measures will be the Shoulder Pain and Disability Index and Patient Reported Outcomes Measurement Information Systems (PROMIS-57) scores collected at baseline, 6-weeks, 6-months and one year. Healthcare utilization will be collected for 12 months following enrollment and groups analyzed for differences.

DISCUSSION

It is not known if trigger point dry needling provides long-term benefit for individuals with subacromial pain syndrome. This study will help determine if this intervention provides additive benefits over those observed with the commonly applied interventions of exercise and manual therapy.

TRIAL REGISTRATION

Identifier: NCT03442894 (https://clinicaltrials.gov/ct2/show/NCT03442894) on 22 February 2018.