The response-time relationship and covariate effects of acupuncture for chronic pain: A systematic review and model-based longitudinal meta-analysis

Acupuncture for migraine: A systematic review and meta-regression of randomized controlled trials

OBJECTIVES

This meta-analysis aimed to explore the relationship between the dose of acupuncture sessions, acupuncture frequency, and acupuncture duration and its effects on migraine.

METHODS

Eight databases were searched for randomized controlled trials (RCTs) evaluating the efficacy of penetrating manual acupuncture for migraine published in English and Chinese from inception to June 20, 2024. The robust-error meta-regression (REMR) approach and non-linear meta-regression with restricted cubic spline (RCS) were used to investigate the dose-response association between acupuncture sessions, acupuncture frequency, and acupuncture duration and the frequency of migraine attacks. The potential nonlinear relationships was tested by restricting the regression coefficient to zero and a P value＜0.1. The statistical analysis was conducted using Stata 17.0. The risk of bias was independently assessed by two reviewers using the Cochrane tool. The reporting quality for acupuncture procedures was evaluated by STRICTA criteria.

RESULTS

Thirty-two RCTs involving 1562 participants were included, and the results showed a J-shaped dose-response association between acupuncture sessions, acupuncture frequency, and acupuncture duration and migraine attack frequency. After 16 acupuncture sessions, the change in the frequency of migraine attacks was 3.95 (95 %CI: 3.13 to 4.77). Three sessions of acupuncture a week resulted in a significant decrease in the frequency of migraine attacks, reaching 4.04 (95 % CI: 2.49 to 5.58). After two months of acupuncture, the frequency of migraine attacks decreased significantly, showing a difference of 4.05 (95 % CI: 3.61 to 4.49). Subsequently, the improvement trend gradually flattened, yielding diminishing benefits to patients. The risk of bias showed that seven studies were rated as "low risk", two were rated as "high risk", and the others were rated as "unclear risk". The reporting quality of RCTs of acupuncture for migraine remain suboptimal.

CONCLUSIONS

A non-linear dose-response relationship was found between acupuncture sessions, acupuncture frequency, and acupuncture duration and migraine attack frequency. The results of our study recommend 16 sessions of acupuncture with a frequency of 3 sessions/week and a treatment duration of 1.5 to 2 months.

REGISTRATION NUMBER

This meta-analysis has been registered on PROSPERO (CRD42023400493).

Gender Differences in Amplitude of Low-Frequency Fluctuation Alterations in Healthy Volunteers by Acupuncture on Left "LI 15": A Resting-State fMRI Study

Objectives: This study is aimed at evaluating gender differences in neural activity change response to the acupuncture on left Jianyu (LI 15) in healthy volunteers. Methods: Forty healthy volunteers (20 males and 20 females) received 20-min acupuncture on left LI 15 and underwent functional magnetic resonance imaging (fMRI) scans before and after acupuncture. Amplitude of low-frequency fluctuations (ALFF) in the 0.01-0.08 Hz range were determined for both scans. Paired t-tests were performed on ALFF between two scans separately for the male and female groups to identify neural changes related to acupuncture. Results: After acupuncture, males showed significantly increased ALFF in the left cerebellum and right angular gyrus but decreased ALFF in the left precentral gyrus, left inferior occipital gyrus, and right fusiform gyrus. However, the ALFF change in females is almost negligible. Conclusions: Brain functional activity in response to acupuncture on left LI 15 is noticeably different between males and females. This is preliminary evidence that gender may be an important factor for optimal clinically personalized acupuncture therapy for poststroke shoulder pain in the future.

Recent advances in acupuncture for pain relief

Introduction

Acupuncture therapy has achieved global expansion and shown promise for health promotion and treatment of acute/chronic pain.

Objectives

To present an update on the existing evidence base for research and clinical practice supporting acupuncture analgesia.

Methods

This Clinical Update elaborates on the 2023 International Association for the Study of Pain Global Year for Integrative Pain Care "Factsheet Acupuncture for Pain Relief" and reviews best evidence and practice.

Results

Acupuncture is supported by a large research evidence base and growing utilization. Mechanisms of acupuncture analgesia include local physiological response at the needling site, suppression of nociceptive signaling at spinal and supraspinal levels, and peripheral/central release of endogenous opioids and other biochemical mediators. Acupuncture also produces pain relief by modulating specific brain networks, integral for sensory, affective, and cognitive processing, as demonstrated by neuroimaging research. Importantly, acupuncture does not just manage pain symptoms but may target the sources that drive pain, such as inflammation, partially by modulating autonomic pathways. Contextual factors are important for acupuncture analgesia, which is a complex multifaceted intervention. In clinical practice, historical records and many providers believe that acupuncture efficacy depends on specific acupoints used, the technique of needle placement and stimulation, and the person who delivers the procedure. Clinical research has supported the safety and effectiveness of acupuncture for various pain disorders, including acupuncture as a complementary/integrative therapy with other pain interventions.

Conclusion

Although the quality of supportive evidence is heterogeneous, acupuncture's potential cost-effectiveness and low risk profile under standardized techniques suggest consideration as a neuromodulatory and practical nonpharmacological pain therapy.

Exploration of quantitative-effectiveness association between acupuncture temporal parameters and stable chronic obstructive pulmonary disease: A systematic review and dose-response meta-analysis of randomized controlled trials

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is a globally common chronic respiratory disease with a high morbidity and mortality rate. Acupuncture has been proven effective for COPD. A dose-response meta-analysis was conducted to assess the correlation between the acupuncture temporal parameters(session, frequency, and duration) and its effectiveness in patients with stable COPD.

METHODS

Acupuncture randomized controlled trials on COPD were searched in eight databases from their inception to June 2023. The "doses" were defined as the acupuncture session, frequency, and duration. The outcomes mainly included Forced Expiratory Volume in one-second rate (FEV1%) and Six-minute Walking Distance (6MWD). The assessment of bias risk and literature quality were conducted independently using the Cochrane risk of bias tool and the Standards for reporting interventions in clinical trials of acupuncture. The dose-response relationship was modeled using robust error element regression, and meta-analysis was operated by R 4.3.1 and Stata 15.0. The protocol was registered in PROSPERO with the registration number CRD42023401406.

RESULT

Out of 1669 records, 17 RCTs with 1165 participants were finally included in the meta-analysis. There was notable heterogeneity among the studies, but sensitivity analysis demonstrated good robustness. The findings revealed a significant improvement in the following outcomes for stable COPD patients in the acupuncture group: FEV1% (MD=3.50, 95%CI: 2.05-4.95), 6MWD (MD=47.39, 95%CI: 29.29-65.50), St. George's respiratory questionnaire (SGRQ; MD=-8.25, 95%CI: -11.38 to -5.12); COPD assessment test (CAT; MD=-2.91, 95%CI: -3.99 to -1.83). The relationship between the acupuncture session, duration, and FEV1%, 6MWD followed a "Λ" curve pattern, while the relationship between acupuncture frequency and FEV1%, 6MWD exhibited logarithmic growth. Firstly, After 12 acupuncture sessions, FEV1% and 6MWD increased by 7.06% (95%CI: 4.56-9.55) and 36.28 m (95%CI: 20.37-52.20), respectively. The peak improvement in FEV1% and 6MWD was observed after 18 acupuncture sessions (MD=7.89, 95% CI: 5.33-10.45) and 45 sessions (MD=125.43, 95% CI: 72.80-178.07) each. Additionally, weekly acupuncture resulted in a 4.14% improvement in FEV1% (95% CI: 2.55-5.72) and a 42.49 m increase in 6MWD (95%CI: 17.16-67.81). Notably, the maximum effects on FEV1% and 6MWD improvement were achieved with different acupuncture frequencies, specifically three times a week (MD=6.00, 95% CI: 5.34-6.66) and once a day(MD=112.41, 95% CI: 77.27-147.56), respectively. Furthermore, after a 28-day duration of acupuncture treatment, FEV1% increased by 4.74% (95% CI: 3.73-5.75) and 6MWD increased by 47.34 m (95%CI: 22.01-72.67). During 60 days of acupuncture treatment, the FEV1% and 6MWD improvement reached their highest levels at 8.76% (95% CI: 7.05-10.47) and 88.06 m (95% CI: 45.96-130.16), respectively.

CONCLUSION

Acupuncture was effective in improving FEV1%, 6MWD, SGRQ, and CAT in patients with stable COPD. There was a dose-response relationship between the time parameters of acupuncture (session, frequency, and duration) and the efficacy of COPD treatment (FEV1% and 6MWD). The minimal clinically important difference could be achieved after 12 acupuncture sessions. Acupuncture with a medium-frequency (2-3 times per week) over 60 days may result in the greatest improvement in FEV1%, while higher-frequency acupuncture (5-7 times per week) for 2 months may lead to the maximum improvements in 6MWD. It indicated that the optimal acupuncture duration for different indicators remains consistent, while the optimal frequencies may differ. To confirm these results, it is necessary to conduct multicenter, large-scale randomized controlled trials.

ETHICS AND DISSEMINATION

Ethical approval is not required for literature-based studies. The results will be published in peer-reviewed journals or conferences.

Dose-response relationship between acupuncture time parameters and the effects on chronic non-specific low back pain: a systematic review and Bayesian model-based network meta-analysis protocol

INTRODUCTION

Low back pain (LBP) is a major global public health problem and the majority (nearly 90%) of patients with LBP suffer from non-specific LBP (NSLBP). Acupuncture has been widely used for relieving pain and is recommended as a first-line treatment in LBP guidelines. However, the guidelines do not recommend a specific acupuncture temporal dosage. A Bayesian model-based network meta-analysis (MBNMA) will be conducted to optimise the dosages of time parameters (session, frequency and duration).

METHODS AND ANALYSIS

The following databases will be searched from their inception until 1 July 2023: MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science, Cumulative Index to Nursing & Allied Health Literature (CINAHL), alternative health research database (Alt HealthWatch), China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database for Chinese Technical Periodicals, ClinicalTrials.gov, the WHO's International Clinical Trial and Chinese Clinical Registry. RCTs assessing the effects of acupuncture on chronic NSLBP will be selected. The primary outcome measure will be the improvement in pain intensity at different acupuncture time points. The MBNMA will be performed using R V.4.2.1 with related R packages. Risk of Bias V.2.0 and Confidence in Network Meta-Analysis will be used to assess the evidence quality.

ETHICS AND DISSEMINATION

Ethical approval is not required for literature-based studies. The results will be published in peer-reviewed journals or conferences.

PROSPERO REGISTRATION NUMBER

CRD42022336056.

Electroacupuncture alleviates pain after total knee arthroplasty through regulating neuroplasticity: A resting-state functional magnetic resonance imaging study

INTRODUCTION

We aimed to evaluate the efficacy of electroacupuncture in relieving acute pain after total knee arthroplasty (TKA) and related mechanism.

METHODS

In this randomized, single-blind, and sham-acupuncture controlled study. Forty patients with postoperative acute pain were recruited and randomly divided electroacupuncture group (n = 20) and sham-acupuncture group (n = 20) from November 2020 to October 2021. All patients received electroacupuncture or sham-acupuncture for 5 days after TKA. Their brain regions were scanned with resting-state functional magnetic resonance imaging before and after intervention. Pain was scaled. Another 40 matched healthy controls underwent scanning once. The amplitude of low-frequency fluctuation (ALFF) values was compared. Pearson's correlation analysis was utilized to explore the correlation of ALFF with clinical variables in patients after intervention.

RESULTS

Compared with the HCs, patients with acute pain following TKA had significantly decreased ALFF value in right middle frontal gyrus, right supplementary motor area, bilateral precuneus, right calcarine fissure and surrounding cortex, and left triangular part of inferior frontal gyrus (false discovery rate corrected p < .05). Patients had higher ALFF value in bilateral precuneus, right cuneus, right angular gyrus, bilateral middle occipital gyrus, and left middle temporal gyrus after electroacupuncture (AlphaSim corrected p < .01). Correlation analysis revealed that the change (postoperative day 7 to postoperative day 3) of ALFF in bilateral precuneus were negatively correlated with the change of NRS scores (r = -0.706; p = .002; 95% CI = -0.890 to -0.323) in EA group.

CONCLUSIONS

The functional activities of related brain regions decreased in patients with acute pain after TKA. The enhancement of the functional activity of precuneus may be the neurobiological mechanism of electroacupuncture in treating pain following TKA.

Acupuncture in chronic aspecific low back pain: a Bayesian network meta-analysis

Background

This Bayesian network meta-analysis investigated the available randomized control trials (RCTs) to point out which acupuncture protocol is the most effective for chronic aspecific low back pain (LBP). Efficacy was measured in terms of pain (Visual Analogic Scale, VAS) and disability (Roland Morris Disability Questionnaire, RMQ), Transcutaneous Electrical Nerve Stimulation (TENS).

Methods

PubMed, Google scholar, Embase, and Scopus were accessed in March 2022. All the RCTs comparing two or more acupuncture modalities for aspecific chronic LBP were accessed. Only studies which investigated the efficacy of acupuncture on patients with symptoms lasting a minimum of 1.5 months, or with at least three episodes in the previous 12 months, were considered eligible. The Review Manager Software (The Nordic Cochrane Collaboration, Copenhagen) was used for the methodological quality assessment. The STATA Software/MP, Version 14.1 (StataCorporation, College Station, Texas, USA), was used for the statistical analyses. The NMA was performed through the STATA routine for Bayesian hierarchical random-effects model analysis.

Results

Data from 44 RCTs (8338 procedures) were retrieved. 56% of patients were women. The mean age of the patients was 48 ± 10.6 years. The mean BMI was 26.3 ± 2.2 kg/m². The individual group (95% confidence interval (CI) 2.02, 7.98) and the standard combined with TENS (95% CI 2.03, 7.97) demonstrated the highest improvement of the RMQ. The VAS score was lower in the standard combined with TENS group (95% CI 3.28, 4.56). Considering the standard acupuncture group, different studies used similar protocols and acupuncture points and the results could thus be compared. The equation for global linearity did not find any statistically significant inconsistency in any of the network comparison.

Conclusion

Verum acupuncture is more effective than sham treatment for the non-pharmacological management of LBP. Among the verum protocols, individualized acupuncture and standard acupuncture with TENS were the protocols that resulted in the highest improvement in pain and quality of life.

Level of Evidence

Level I, Bayesian network meta-analysis of RCTs.

Effective Oriental Magic for Analgesia: Acupuncture

Pain is a kind of complex physiological and psychological symptom, which makes the person debilitated and uncomfortable. Some persistent pain is unbearable for the patients, reducing the quality of life and bringing considerable pressure to the individuals and society. Pain killers seem to be effective in analgesia for patients, but their safety and addiction are crucial issues. From the theory of traditional Chinese medicine (TCM), the blocked meridian is the main cause of pain, and effective acupuncture can play a positive analgesic effect. Acupuncture that can date back thousands of years is one of the ancient medical practices in China. Its safety and effectiveness are respected. Based on its superior safety and inferior side effects, it has been gradually recognized as a therapeutic intervention method for complementary medicine, which is also generally used to treat multiple pain diseases. It is shown by modern medical studies that neurotransmitters are the material basis for the acupuncture effect, and the effect of acupuncture analgesia is related to changes in neurotransmitters. However, the specific mechanism has not been elucidated. This review aims to comprehensively discuss the historical evolution of acupuncture analgesia, clinical research of acupuncture analgesia, comparison of acupuncture and drug therapy, the neurotransmitter mechanism of acupuncture analgesia, the effect of acupuncture manipulation on analgesia, and bibliometric analysis of acupuncture treatment for pain, to explore the superiority and related mechanism of acupuncture analgesia from different aspects, and to provide a more effective treatment for alleviating patients' pain.

The Influence of Acupuncture Parameters on Efficacy and the Possible Use of Acupuncture in Combination with or as a Substitute for Drug Therapy in Patients with Ulcerative Colitis

Background. Ulcerative colitis (UC) is an inflammatory disease of the colonic mucosa, which is accompanied by chronic, idiopathic characteristics. Acupuncture may be an effective therapy for UC. Here we focused on manual acupuncture and electroacupuncture (MA/EA), two widely used and studied acupuncture interventions, to probe the effects of acupuncture parameters on clinical efficacy in patients with UC and the use of MA/EA alone or with other drugs to support their wider adoption in clinical practice. Methods. The PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure Database, and Wanfang databases were searched from inception to April 27, 2021. Randomized clinical trials (RCTs) published in Chinese or English were included, and subgroup analyses were performed according to acupuncture parameter, acupuncture type, and control medicine type. The risk of bias was assessed using the Cochrane Risk of Bias tool and modified Jadad scale, and Review Manager 5.4 and Stata 14.0 were used to perform a meta-analysis. Sources of heterogeneity were explored; sensitivity analysis was performed; and the GRADE methodology was used to assess the evidence level. Results. Sixteen studies (1454 individuals) were included. Retention of the needle [10–30 minutes (RR 1.18, 95% CI [1.11, 1.26], $P<0.01$ ; heterogeneity: χ2 = 6.25, df = 6 ( $P=0.40$ ), I2 = 4%)], the frequency of MA [once every other day (RR 1.21, 95% CI [1.08, 1.35], $P<0.01$ ; heterogeneity: χ2 = 0.80, df = 1 ( $P=0.37$ ), I2 = 0%)], and the length of treatment [8 weeks (RR 1.35, 95% CI [1.01, 1.81], $P=0.04$ )] improved clinical efficacy at the end of treatment compared with medications alone. MA (RR 1.18, 95% CI [1.11, 1.25], $P<0.01$ ; heterogeneity: χ2 = 6.19, df = 7 ( $P=0.52$ ), I2 = 0%) increased clinical efficacy compared with medications. Furthermore, MA plus medications (RR 1.26, 95% CI [1.13, 1.40], $P<0.01$ ; heterogeneity: χ2 = 0.95, df = 2 ( $P=0.62$ ), I2 = 0%) and EA plus medications (RR 1.36, 95% CI [1.13, 1.63], $P<0.01$ ; heterogeneity: χ2 = 0.13, df = 1 ( $P=0.72$ ), I2 = 0%) both dramatically improved clinical efficacy. The clinical efficacy of MA plus mesalazine or MA plus metronidazole and sulfasalazine was greater than with mesalazine or metronidazole and sulfasalazine alone. Similarly, EA plus sulfasalazine was more effective than sulfasalazine alone. MA/EA resulted in fewer adverse reactions than medical therapies. The use of MA plus medications significantly reduced Baron scores. GRADE evaluations indicated that the evidence strength was moderate to low but mostly low. Conclusions. Our study provides the latest evidence to allow us to speculate about the possible optimal MA parameters to treat patients with UC. The low number of adverse reactions and high efficacy make MA/EA a possible supplement to or replacement for traditional UC drugs. The variable parameter settings preferred by patients and acupuncturists may be an important factor limiting the wider clinical deployment of acupuncture as a potential UC therapy.

Is acupuncture effective for knee osteoarthritis? A protocol for a systematic review and meta-analysis

INTRODUCTION

Knee osteoarthritis (KOA) is one of the leading causes of disability. The effectiveness of acupuncture for treating KOA remains controversial. This protocol describes the method of a systematic review and meta-analysis evaluating the effectiveness and safety of acupuncture for treating KOA.

METHODS AND ANALYSIS

Four English databases (PubMed, Embase, Cochrane Library databases and Web of Science) and four Chinese databases (China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Database for Chinese Technical Periodicals, and Wanfang) will be searched from the database inception to 1 September 2021. All randomised controlled trials related to acupuncture for KOA will be included. Extracted data will include publication details, basic information, demographic data, intervention details and patient outcomes. The primary outcome will be pain intensity. Risk of bias will be assessed using the Cochrane Collaboration's tool for assessing risk of bias. Article selection, data extraction and risk of bias assessment will be performed in duplicate by two independent reviewers. If the meta-analysis is precluded, we will conduct a descriptive synthesis using a best-evidence synthesis approach. The strength of recommendations and quality of evidence will be assessed using the Grading of Recommendations Assessment Development and Evaluation working group methodology.

ETHICS AND DISSEMINATION

Ethics approval is not required because individual patient data are not included. This protocol was registered in the international Prospective Register of Systematic Reviews on 25 February 2021. The systematic review and meta-analysis will be submitted for publication in a peer-reviewed journal. The findings will also be disseminated through conference presentations.

TRIAL REGISTRATION NUMBER

CRD42021232177.

Touching-bone acupuncture in the treatment of chronic pain: A protocol for an overview of systematic reviews and meta-analysis

BACKGROUND

Chronic pain is the most common disease in the world, which lead the patients to suffer the disability both physically and psychologically. The chronic pain can affects the patients to work, socialize, sleep and can lead to depressive illness, decreased motivation, and a reduction in physical activity. Acupuncture is a promising treatment for the chronic pain which has a long history of use in China. This protocol aims to assess the effectiveness and safety of touching periosteum acupuncture therapy on patients with chronic pain.

METHODS

Randomized controlled trial literatures which include touching periosteum acupuncture therapy for treating chronic pain will be searched from 8 electronic databases including China Biology Medicine disc, VIP database, WanFang database, China National Knowledge Infrastructure, PubMed, Cochrane Library, Excerpt Medical Database, and Web of Science. The language will be restricted to Chinese and English. The primary outcome is to measure the relief of the pain by Visual Analogue Scale. Two or 3 reviewers will conduct the study selection, data extraction and the evaluation of the risk of bias. RevMan software (V.5.3) will be used to perform the assessment of the risk of bias and data synthesis.

RESULTS

From this study, we will confirm the effectiveness of safety of in the treatment of chronic pain.

CONCLUSIONS

We will ascertain the effectiveness of safety of touching periosteum acupuncture therapy in the treatment of chronic pain, to provide evidence to guide touching periosteum acupuncture therapy for patients with chronic pain in the future.

ETHICS AND DISSEMINATION

Ethics approval will not be necessary, because the included publications in our study are all from published articles. This systematic review will be published in a peer-reviewed journal or conference report to provide a reference in this field.

TRIAL REGISTRATION

CRD42021243387.