Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: Evidence for a mechanotransduction-based mechanism

Proteomics analysis of deep fascia in acute compartment syndrome

Acute compartment syndrome (ACS) is a syndrome in which local circulation is affected due to increased pressure within the compartment. We previously found in patients with calf fractures, the pressure of fascial compartment could be sharply reduced upon the appearance of tension blisters. Deep fascia, as the important structure for compartment, might play key role in this process. Therefore, the aim of the present study was to examine the differences in gene profile in deep fascia tissue in fracture patients of the calf with or without tension blisters, and to explore the role of fascia in pressure improvement in ACS. Patients with lower leg fracture were enrolled and divided into control group (CON group, n = 10) without tension blister, and tension blister group (TB group, n = 10). Deep fascia tissues were collected and LC-MS/MS label-free quantitative proteomics were performed. Genes involved in fascia structure and fibroblast function were further validated by Western blot. The differentially expressed proteins were found to be mainly enriched in pathways related to protein synthesis and processing, stress fiber assembly, cell-substrate adhesion, leukocyte mediated cytotoxicity, and cellular response to stress. Compared with the CON group, the expression of Peroxidasin homolog (PXDN), which promotes the function of fibroblasts, and Leukocyte differentiation antigen 74 (CD74), which enhances the proliferation of fibroblasts, were significantly upregulated (p all <0.05), while the expression of Matrix metalloproteinase-9 (MMP9), which is involved in collagen hydrolysis, and Neutrophil elastase (ELANE), which is involved in elastin hydrolysis, were significantly reduced in the TB group (p all <0.05), indicating fascia tissue underwent microenvironment reconstruction during ACS. In summary, the ACS accompanied by blisters is associated with the enhanced function and proliferation of fibroblasts and reduced hydrolysis of collagen and elastin. The adaptive alterations in the stiffness and elasticity of the deep fascia might be crucial for pressure release of ACS.

Treating Lateral Epicondylopathy With Dry Needling and Exercise: A Case Series

CONTEXT

Lateral epicondylopathy (LE) is a common overuse injury affecting elbow, wrist, and hand function. It is characterized by weakness and pain in the muscles and tendons of the forearm responsible for the extension of your wrist and fingers. Trigger point dry needling is a technique reported to be beneficial in managing pain and dysfunction after LE diagnosis. LE is also commonly treated with conservative treatment, such as joint and soft tissue mobilization, self-care home programs, and anti-inflammatory use. We explored a different dry needling approach consisting of in situ dry needling with electric stimulation combined with targeted therapeutic exercise to treat LE in 3 cases.

CASE PRESENTATION

Three patients were referred for dry needling once a week for 6 weeks and home-based exercise therapy for LE. They were clinically evaluated using grip strength, a visual analog scale to assess pain, and Patient-Rated Tennis Elbow Evaluation Test scores. These were measured at 4 time points (weeks 0, 2, 4, and 6).

MANAGEMENT AND OUTCOMES

The dry needling intervention incorporated 8 locations in the upper-extremity with 2 electric stimulation channels. The patients had reduced pain as measured by a visual analog scale, increased function as measured by the Patient-Rated Tennis Elbow Evaluation Test, and increased grip strength over 6 weeks.

CONCLUSIONS

This case series illustrates the use of dry needling and a home exercise program to provide a favorable outcome in a patient with LE. Patients had an 80% to 100% reduction in pain and similar improvements in function that were significantly beyond the minimum clinically important difference. This dry needling approach is a safe and effective treatment of LE in the short term.

Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial

BACKGROUND CONTEXT

Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS.

PURPOSE

This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS.

STUDY DESIGN/SETTING

Randomized, single-blinded, multi-center, parallel-group clinical trial.

PATIENT SAMPLE

One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period.

OUTCOME MEASURES

The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months.

METHODS

Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63).

RESULTS

At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group.

CONCLUSION

Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.

TRPA1 Ion Channel Mediates the Analgesic Effects of Acupuncture at the ST36 Acupoint in Mice Suffering from Arthritis

Purpose

Acupuncture (ACU) has been demonstrated to alleviate inflammatory pain. Mechanoreceptors are present in acupuncture points. When acupuncture exerts mechanical force, these ion channels open and convert the mechanical signals into biochemical signals. TRPA1 (T ransient receptor potential ankyrin 1) is capable of sensing various physical and chemical stimuli and serves as a sensor for inflammation and pain. This protein is expressed in immune cells and contributes to local defense mechanisms during early tissue damage and inflammation. In this study, we investigated the role of TRPA1 in acupuncture analgesia.

Patients and Methods

We injected complete Freund's adjuvant (CFA) into the mouse plantars to establish a hyperalgesia model. Immunohistochemistry and immunofluorescence analyses were performed to determine the effect of acupuncture on the TRPA1 expression in the Zusanli (ST36). We used TRPA1-/- mouse and pharmacological methods to antagonize TRPA1 to observe the effect on acupuncture analgesia. On this basis, collagenase was used to destroy collagen fibers at ST36 to observe the effect on TRPA1.

Results

We found that the ACU group vs the CFA group, the number of TRPA1-positive mast cells, macrophages, and fibroblasts at the ST36 increased significantly. In CFA- inflammatory pain models, the TRPA1-/- ACU vs TRPA1+/+ ACU groups, the paw withdrawal latency (PWL) and paw withdrawal threshold (PWT) downregulated significantly. In the ACU + high-, ACU + medium-, ACU + low-dose HC-030031 vs ACU groups, the PWL and PWT were downregulated, and in carrageenan-induced inflammatory pain models were consistent with these results. We further found the ACU + collagenase vs ACU groups, the numbers of TRPA1-positive mast cells, macrophages, and fibroblasts at the ST36 were downregulated.

Conclusion

These findings together imply that TRPA1 plays a significant role in the analgesic effects produced via acupuncture at the ST36. This provides new evidence for acupuncture treatment of painful diseases.

Treatment of primary restless legs syndrome with Fu's subcutaneous needling: A case report

RATIONALE

Fu's subcutaneous needling (FSN) is a novel acupuncture technique developed based on traditional needling principles that aims to alleviate diseases by improving local muscle conditions and blood supply. FSN have been widely used for the treatment of various diseases. Restless legs syndrome (RLS) is a common central nervous system disorder characterized by intense discomfort in the legs, particularly at night, leading to an urge to move the legs for relief. In this study, we report a case in which FSN was used to treat primary RLS.

PATIENT CONCERNS

A 67-year-old patient complained of nocturnal discomfort in the right leg for over 4 months, the symptoms occurred 2-3 times, with uncontrollable movement impulses in the right leg during the onset, accompanied by a burning sensation, lasting about 2 h, accompanied by anxiety and insomnia. Imaging examinations revealed no spinal stenosis or history of kidney disease, rheumatic disease, diabetes, or Parkinson's disease.

DIAGNOSES

The patient was diagnosed with primary RLS, and the International Restless Legs Syndrome Study Group rating scale (IRLS) score was 26.

INTERVENTIONS

FSN was successfully performed three times per week on different days. No adverse and unanticipated events while the treatment. The total treatment course lasted for six weeks.

OUTCOMES

After the treatment, the patient reported that the recent onset interval was approximately 10 days, each time lasting approximately 15 min. The patient's IRLS score was 5, After a follow-up of 2 months following the end of treatment, the patient reported that the incidence of RLS was approximately one episode within two weeks,each lasting approximately 10 min.

LESSONS

FSN significantly improved leg discomfort and desire for leg movement in patients with RLS. FSN may exert its therapeutic effects by influencing connective and muscular tissues, thereby improving the condition of the central nervous system and the local blood supply in the legs. However, due to the limitation of a single clinical observation case, a randomized clinical trial with a sufficient follow-up time is needed.

The Top 100 Cited Articles on Acupuncture in the Last 20 Years: A Bibliometric Analysis

BACKGROUND

Acupuncture has gained increasing international attention in recent decades. The act of incorporating acupuncture treatment into the routine treatment of COVID-19 in China drove us to review the 100 most influential articles of the last 20 years to learn about the current status and trends of acupuncture.

METHOD

Articles related to acupuncture from January 1, 2001, to July 4, 2022, were searched in the Clarivate Analytics Web of Science Core Collection database. The top 100 most cited publications were selected, and information was extracted. Software such as VOSviewer, GraphPad Prism, Scimago Graphica, and CiteSpace were used to visualize and analyze the extracted data.

RESULT

The 100 most cited articles were identified, with an average of 218 citations (range: 131-625). The majority of the top 100 articles were from the USA (n = 53). The institution that published the most highly cited papers was Harvard University (n = 16). The most influential team was Klaus Linde's group. Pain was the top-ranked journal in terms of the number of publications. The largest clusters for co-occurrence keyword analysis focused on acupuncture and electroacupuncture analgesia and brain imaging responses to acupuncture stimulation via functional MRI. The two highest strength burst keywords were "randomized controlled trials" and "osteoarthritis," with "randomized controlled trials" being a consistent burst keyword from 2011 to the present.

CONCLUSION

This study provides insight into articles of historical significance in the field of acupuncture through bibliometric analysis. These data should provide clinicians and researchers with insight into future directions related to acupuncture.

Hintergrund

Die Akupunktur hat in den vergangenen Jahrzehnten zunehmend die internationale Aufmerksamkeit auf sich gezogen. Die Einbeziehung der Akupunktur in die Routinebehandlung von COVID-19 in China hat uns dazu veranlasst, die 100 einflussreichsten Artikel der letzten 20 Jahre zu überprüfen, um etwas über den aktuellen Stand und die Trends in der Akupunktur zu erfahren.

Methode

Artikel mit Bezug zu Akupunktur vom 1. Januar 2001 bis 4. Juli 2022 wurden in der Clarivate Analytics Web of Science Core Collection Datenbank gesucht. Die 100 am häufigsten zitierten Veröffentlichungen wurden ausgewählt und die Informationen wurden extrahiert. Visualisierung und Analyse der extrahierten Daten erfolgten mithilfe der Software VOSviewer, GraphPad Prism, Scimago Graphica und CiteSpace.

Ergebnis

Es wurden die 100 am häufigsten zitierten Artikel ermittelt mit durchschnittlich 218 Zitierungen (Spanne: 131 bis 625). Der Großteil der 100 meistzitierten Artikel stammte aus den Vereinigten Staaten (n = 53). Die Institution, die die meisten zitierten Artikel veröffentlichte, war die Harvard-Universität (n = 16). Das einflussreichste Team war die Gruppe von Klaus Linde. Was die Zahl der Veröffentlichungen betrifft, war Pain die am häufigsten zitierte Zeitschrift. Bei der Analyse der Koinzidenz von Schlüsselwörtern lag der Fokus der größten Cluster auf Akupunktur-und Elektroakupunktur-Analgesie sowie auf den Reaktionen auf Akupunkturstimulation in den bildgebenden Untersuchungen des Gehirns mittels funktioneller MRT. Die beiden stärksten Burst-Schlüsselwörter waren “randomisierte kontrollierte Studien” und “Osteoarthritis,” wobei “randomisierte kontrollierte Studien” von 2011 bis heute durchgängig ein Burst-Schlüsselwort ist.

Schlussfolgerung

Diese Studie bietet einen Einblick in historisch bedeutsame Artikel auf dem Gebiet der Akupunktur mittels bibliometrischer analyse. Diese Daten sollen Klinikern und Forschern einen Einblick in zukünftige Richtungen im Zusammenhang mit Akupunktur geben.

Novel Orthobiologic Preparation and Regenerative Rehabilitation of a Complex Shoulder Injury in a Competitive Adolescent Female Athlete

Background

Platelet-rich plasma (PRP) and prolotherapy have resulted in promising outcomes in patients with various types of shoulder injuries. However, there is a lack of preliminary evidence supporting preparation of PRP production, timely application of these therapies and regenerative rehabilitation protocols. The purpose of this case report is to describe the distinct method including orthobiologic preparation, tissue-specific treatment and regenerative rehabilitation of an athlete with a complex shoulder injury.

Case Presentation

A 15y/o competitive female wrestler with a complex shoulder injury presented to the clinic after unsuccessful conservative rehabilitation. Unique methods were incorporated to optimize PRP production, specific tissue healing and regenerative rehabilitation. Multiple injuries required different orthobiologic interventions at different time frames, in order to promote optimal healing and stability of the shoulder.

Outcomes

The described interventions resulted in successful outcomes including pain, disability, full return to sport, and regenerative tissue healing confirmed with diagnostic imaging.

Level of Evidence

5.

Suggesting a mechanism for acupuncture as a global percutaneous needle fasciotomy that respects tensegrity principles for treating fibromyalgia

Acupuncture is a minimally invasive therapeutic method that uses small caliber needles while inserting them through the skin into various areas of the body. Some empirical studies find evidence to support the use of acupuncture as a treatment for certain medical conditions, however, this peculiar practice is widely considered as the domain of alternative and non-evidence-based medicine. Several mechanisms have been suggested in an attempt to explain the therapeutic action of acupuncture, but the way in which acupuncture alleviates chronic non-cancer pain or psychosomatic and psychiatric disorders is not fully understood. A recent study suggested a theoretical model (coined "Fascial Armoring") with a cellular pathway to help explain the pathogenesis of myofascial pain/fibromyalgia syndrome and functional psychosomatic syndromes. It proposes that these syndromes are a spectrum of a single medical entity that involves myofibroblasts with contractile activity in fascia and aberrant extracellular matrix (ECM) remodeling, which may lead to widespread mechanical tension and compression. This can help explain diverse psycho-somatic manifestations of fibromyalgia-like syndromes. Fascia is a continuous interconnected tissue network that extends throughout the body and has qualities of bio-tensegrity. Previous studies show that a mechanical action by needling induces soft tissue changes and lowers the shear modulus and stiffness in myofascial tissue. This hypothesis and theory paper offers a new mechanism for acupuncture therapy as a global percutaneous needle fasciotomy that respects tensegrity principles (tensegrity-based needling), in light of the theoretical model of "Fascial Armoring." The translation of this model to other medical conditions carries potential to advance therapies. These days opioid overuse and over-prescription are ubiquitous, as well as chronic pain and suffering.

Changes of local microenvironment and systemic immunity after acupuncture stimulation during inflammation: A literature review of animal studies

An increasing number of studies have demonstrated the underlying mechanisms by which acupuncture therapy mediates both local and systemic immunomodulation. However, the connection between alterations in the local microenvironment and the resulting change in systemic immunity remains unclear. In this review, we focus on cell-specific changes in local immune responses following acupuncture stimulation and their link to systemic immune modulation. We have gathered the most recent evidence for chemo- and mechano-reactive changes in endothelial cells, neutrophils, macrophages, and mast cells in response to acupuncture. Local signaling is then related to the activation of systemic neuro-immunity including the cholinergic, adrenal, and splenic nervous systems and pain-related neuromodulation. This review aims to serve as a reference for further research in this field.

The effectiveness and safety of acupuncture treatment on sciatica: A systematic review and meta-analysis

BACKGROUND

Sciatica results from primary or secondary damage to the sciatic nerve in the lumbar or gluteal region. The first option for sciatica is analgesics, but their therapeutic effect and safety in long-term use are questionable. On the other hand, acupuncture has recently been recognized as a complementary and alternative medicine (CAM) to conventional medicine, and studies on its effectiveness and safety have been actively conducted.

OBJECTIVE

To systematically compare acupuncture with analgesics in terms of effect, safety, and durability in the treatment of sciatica METHODS: This review was performed in accordance with Cochrane Handbook for Systematic Reviews of Interventions Version 6.2. Four databases were searched for this review: Wangfang, the Korean Traditional Knowledge Portal (KTKP), PubMed, and EBSCOhost. The primary outcome measures in the review were total effective rate (TER), visual analog scale (VAS) score and pain threshold, and the secondary ones were adverse effects (AEs) and relapse rates. Risk ratio (RR) for TER and mean difference (MD) for VAS score and pain threshold were used as statistics for the meta-analysis of effectiveness, along with associated 95 % confidence intervals (CIs) and P-values. AEs and relapse rates were used for the safety and durability of the interventions. Version 2 of the Cochrane risk-of-bias assessment tool for randomized trials (RoB 2) was used for the methodological quality of randomized controlled trials (RCTs) included in the review.

RESULTS

The synthesized TER of 28 RCTs involving 2707 participants was significantly higher in the acupuncture group compared to the analgesic group (RR [95 % CI] = 1.20 [1.16, 1.24], P < 0.001). The synthesized VAS score of 7 RCTs involving 589 participants was significantly reduced in the acupuncture group compared to the analgesic group (MD [95 % CI] = - 1.78 [- 2.44, - 1.12], P < 0.001). In 5 RCTs involving 311 participants, the synthesized pain threshold was significantly elevated in the acupuncture group compared to the analgesic group (MD [95 % CI] = 0.93 [0.64, 1.22], P < 0.001). Additionally, adverse effects (AEs) and relapse rates of RCTs in the review were lower in the acupuncture group compared to the analgesic group.

CONCLUSION

In this systematic review, acupuncture treatment was significantly effective and safe compared to analgesics in sciatica. In the future, studies with a rigorous study design are required to increase the validity of the effectiveness and safety of acupuncture treatment for sciatica.

The Effect of Fu’s Subcutaneous Needling Combined with Reperfusion Approach on Surface Electromyography Signals in Patients with Cervical Spondylosis and Neck Pain: A Clinical Trial Protocol

Background

Neck pain is one of the most common musculoskeletal diseases. Fu's subcutaneous needling therapy is a special acupuncture method that targets muscle trigger points. It has been proven to have a positive effect on the treatment of neck pain. The access to its curative effect may be related to the improvement of muscle and soft tissue condition. The purpose of this study is to evaluate the outcome of Fu's subcutaneous needling therapy for patients with neck pain by collecting changes in the sEMG of the patient's neck muscles and related data from evaluation scales and explore the feasibility and safety of Fu's subcutaneous needling therapy for neck pain.

Methods

72 patients meeting the inclusion criteria were randomly divided into FSN group and acupuncture group for corresponding treatment. FSN group was treated once every other day for 5 consecutive treatments; the acupuncture group was treated once a day for 10 consecutive treatments.

Result

Outcome indicators were measured at baseline, after the first treatment and the end of the treatment. Primary outcome indicators: average EMG (AEMG) and (mean power frequency) MPF of sternocleidomastoid muscle and superior trapezius muscle. Secondary outcome indicators: Mc Gill pain questionnaire (MPQ), neck disability index (NDI), and adverse reactions.

Conclusions

This study will explore the efficacy, safety, and possible mechanism of Fu's subcutaneous needling therapy for patients with neck pain, thus to provide more evidence support for clinical decision-making. This trial is registered with Chinese Clinical Trial Register Center (registration number ChiCTR2100043529).

Peptide Aggregation Induced Immunogenic Rupture (PAIIR)

Immunogenic cell death (ICD) arises when cells are under stress, and their membranes are damaged. They release damage-associated molecular patterns (DAMPs) that stimulate and drive the type and magnitude of the immune response. In the presence of an antigen, DAMPs ride the longevity and efficacy of antigen-specific immunity. Yet, no tool can induce the controlled ICD with predictable results. A peptide-based tool, [II], is designed that aggregates in the cell and causes cell membrane damage, generates ICD and DAMPs release on various cell types, and hence can act as an adjuvant. An influenza vaccine is prepared by combining [II] with influenza hemagglutinin (HA) subunit antigens. The results show that [II] induced significantly higher HA-specific immunoglobulin G1 (IgG1) and IgG2a antibodies than HA-only immunized mice, while the peptide itself did not elicit antibodies. This paper demonstrates the first peptide-aggregation induced immunogenic rupture (PAIIR) approach as a vaccine adjuvant. PAIIR is a promising adjuvant with a high potential to promote universal protection upon influenza HA vaccination.

Immediate Effect of Dry Needling on the Viscoelastic Properties of a Trigger Point on the Infraspinatus Muscle Measured with MyotonPRO

Purpose: This article investigates the immediate effects of a dry needling (DN) puncture on the viscoelastic properties (tone, stiffness, elasticity) of a trigger point (TP) in the infraspinatus muscle in non-traumatic chronic shoulder pain. Method: Forty-eight individuals with non-traumatic chronic shoulder pain were recruited. The presence of a TP in the infraspinatus muscle was confirmed by a standardized palpatory exam. The viscoelastic properties were measured with a MyotonPRO device at baseline (T1), immediately after DN (T2), and 30 minutes later (T3). A DN puncture was applied to the TP to obtain a local twitch response while performing the technique. Results: Analyses of variance showed significant decreases in tone ( p < 0.001) and stiffness ( p = 0.003) across time after the DN technique. Post hoc tests revealed a significant reduction in tone and stiffness from T1 to T2 ( p ≤ 0.004) and no significant changes from T2 to T3 ( p ≥ 0.10). At T3, only stiffness remained significantly lower compared to T1 ( p = 0.013). Conclusions: This study brings new insights on the immediate mechanical effect of DN on tone and stiffness of TPs. Whether these effects are associated with symptom improvement and long-term effects still needs to be verified.

Acupuncture and Dry Needling for Sports Performance and Recovery

ABSTRACT

Acupuncture and dry needling share many similarities in their proposed mechanisms of action and their sports medicine-related applications. Pain is the most common indication for these needling treatments, but there also are some limited studies on their use for ergogenic purposes. Needling can likely improve muscular strength and power, including increasing jump height, and it also can increase flexibility. In terms of sports recovery, acupuncture can not only be used for pain relief after injury, but also can help with routine recovery, such as in delayed onset muscle soreness. There are numerous case reports of acupuncture and dry needling being used to treat athletes for various diagnoses and conditions, however more high quality studies are needed in order to make more specific evidence-based recommendations. Given the high degree of safety and limited adverse events associated with needling treatments, it can likely be promoted in athletes.

Case study: Pilot testing of a local acupuncture intervention protocol for burn scars

BACKGROUND

Following burn injury and a prolonged duration of healing, scars may become hypertrophic, causing movement restriction, increased scar thickness, colour and pliability, and symptoms such as pain and itch. Acupuncture has emerged as a potentially beneficial treatment for neuroinflammation, which perpetuates the negative features of hypertrophic scars. The aim of this study was to pilot test an evidence-based methodology for applying and measuring the clinical effects of localised acupuncture for symptomatic scars, in a patient with a healed burn injury.

METHODS

A 71-year-old caucasian male presented with a hypertrophic scar that was painful and itchy after burn injury and subsequent skin grafting. He received acupuncture and massage treatment local to his scar as per the local (verum) group of the author's clinical trial under recruitment. Needles were inserted around the circumference of the skin grafted area and adjacent to areas of raised scar tissue within the grafted area and stimulated via bi-directional rotation. Outcome measures included a Numerical Rating Scale (NRS) for pain and itch, Patient and Observer Scar Assessment Scale (POSAS) self-assessment component and SF36 quality-of-life measure to capture any non-specific acupuncture effects.

CONCLUSION

Acupuncture applied locally around the scar was associated with short-term relief of symptoms and significantly reduced his subjective outcome measure scores relating to scar thickness, redness and pliability out to six months after injury. Some short-term increase in symptoms occurred on several occasions following treatment; however, treatment was well tolerated supporting the use of this protocol for a larger future clinical trial.

LAY SUMMARY

Following injury to the skin, scars can become raised, red and reduce movement. Other common symptoms may include pain and itch. Previous studies suggest acupuncture may help symptomatic scars, but more research is needed to confirm this with larger samples of patients.This case study tested the active treatment protocol for a clinical trial using acupuncture on symptomatic scars. A 71-year-old white man had a burn scar on his torso after a workplace accident. His treatment involved scar massage and local acupuncture. The acupuncture needles were inserted around the skin graft borders and thickened bands of scar tissue.Outcomes were measured using surveys recording symptoms, scar characteristics and quality of life. These were used to assess treatment effect and how well the protocol was tolerated. Over the course of treatment both pain and itch improvedThis case report showed that the treatment protocol was well tolerated, and that local acupuncture was associated with improved scar symptoms and physical characteristics up to six months after injury.

Acupressure in patients with seasonal allergic rhinitis: a randomized controlled exploratory trial

BACKGROUND

Acupuncture has shown beneficial effects for seasonal allergic rhinitis (SAR); however, it is time and cost intensive. We investigated feasibility and effects of self-administered body acupressure as a self-care technique that stimulates acupuncture points with manual pressure in SAR patients.

METHODS

We conducted a two-armed randomized controlled exploratory trial to compare effects of self-administered acupressure over 4 weeks at five acupuncture points plus rescue medication (RM) with cetirizine compared to RM alone in SAR patients. Among other outcome parameters, we assessed disease-related quality of life (Rhinitis Quality of Life Questionnaire [RQLQ]), overall SAR symptoms by a visual analogue scale (VAS) and a rescue medication score (RMS) after 4 and 8 weeks.

RESULTS

Forty-one SAR patients (mean age 38.5 ± 10.0 years, n = 21, 51.2% women) were randomized. Compared to RM alone (n = 21), acupressure plus RM (n = 20) was associated with relevant improvements after 4 weeks, shown by the difference between groups in adjusted means of RQLQ: - 0.9 points (95% CI - 1.6 to - 0.2; p = 0.011) and VAS overall SAR symptoms: - 21.6 mm (95% CI - 36.3 to - 6.8; p = 0.005). The RMS was lower in the acupressure group than in the control group: 1.9 points (95% CI - 3.8 to - 0.1; p = 0.120). Group differences decreased slightly until week 8. The acupressure was feasible and safe.

CONCLUSION

Results of this exploratory study indicate that self-applied acupressure is feasible, may improve disease-specific quality of life and reduce disease-related symptoms as well as anti-allergic medication intake in SAR patients. High-quality confirmatory studies including a sham-control group are needed in the future. Trial registration DRKS-ID: DRKS00014310. Date of registration in DRKS: 2018/04/24. Investigator sponsored/initiated trial (IST/IIT): yes. Ethics approval/approval of the ethics committee: Approved (leading) Ethics Committee No. EA1/033/18, Ethik-Kommission der Charité -Universitätsmedizin Berlin. URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014310.

Acupuncture for Pediatrics: An Educational Initiative

Objective

With the ongoing opioid crisis, the Centers for Disease Control and Prevention recommends nonpharmacologic therapies (e.g., acupuncture) for treating pain. Multiple agencies, such as the National Institutes of Health and World Health Organization, recognize acupuncture's effectiveness for treating pain, but acupuncture education for providers is scarce. A Workshop to Introduce Acupuncture for Pediatrics (AcuPeds-Workshop) was developed with support from American Academy of Pediatrics to educate providers. Additional funding was given by the Virginia Apgar Academy to evaluate the effects of attending this workshop.

Materials and Methods

This prospective study used Immediate and 1-Month Post-Workshop (PWS) surveys. The AcuPeds-Workshop components included: history; a literature review; videos of patients receiving acupuncture; and hands-on experience. The workshop was presented at numerous conferences. Attendee survey completion was voluntary.

Results

Of 327 attendees, the majority were female, non-Hispanic, and were physicians. At baseline, attendees had: heard of acupuncture, 96%; used it, 28%; and/or had a prior lecture, 13%. In the Immediate-PWS: 97% reported an increase in their knowledge and understanding of the indications for acupuncture; majority correctly addressed 3 clinical application scenarios and contraindications. With respect to attitude: 85% would use acupuncture for themselves and 88% would use it for patients. More than 80% rated the workshop components as useful or very useful. In the One-Month-PWS: majority addressed the same 3 clinical scenarios and contraindications correctly, and 11% considered referring patients for acupuncture.

Conclusions

Attendance at this AcuPeds-Workshop had a positive impact on attendees' knowledge, application of, and attitude about acupuncture. This workshop supports efforts to educate medical providers on this nonpharmacologic pain therapy.

Furnishing Wound Repair by the Subcutaneous Fascia

Mammals rapidly heal wounds through fibrous connective tissue build up and tissue contraction. Recent findings from mouse attribute wound healing to physical mobilization of a fibroelastic connective tissue layer that resides beneath the skin, termed subcutaneous fascia or superficial fascia, into sites of injury. Fascial mobilization assembles diverse cell types and matrix components needed for rapid wound repair. These observations suggest that the factors directly affecting fascial mobility are responsible for chronic skin wounds and excessive skin scarring. In this review, we discuss the link between the fascia's unique tissue anatomy, composition, biomechanical, and rheologic properties to its ability to mobilize its tissue assemblage. Fascia is thus at the forefront of tissue pathology and a better understanding of how it is mobilized may crystallize our view of wound healing alterations during aging, diabetes, and fibrous disease and create novel therapeutic strategies for wound repair.

Quantitative Evaluation of the Movement Distance of Deep Fascia and Change of Muscle Shape Related to Chain Response in Fascia Tissue of Lower Limb

By using ultrasonography, we measured the longitudinal movement distance of the deep fascia (LMDDF), change of the pennation angle (PA) and muscle thickness (MT) in both the tensor fasciae latae muscle (TFL) and the gluteus medius muscle (G-Med) during passive movement of the toes/ankle joints. 21 right lower limbs of 21 healthy males were evaluated in this study. We measured the LMDDF of the TFL and G-Med by measuring distance between the designated landmark on skin and the intersection of the major deep-fascia (D-fascia) and the fascial bundle. We also measured change of the PA and MT of both muscles. Additionally, we also measured the reliability of the measurement and the measurement error. The measurement was performed during three manual positions on the toes/ankle; manual holding of the toes and ankle joint in neutral, toes flexion and ankle plantar flexion/inversion position, toes extension and ankle extension/valgus position. The existence of muscle contraction of both the muscles during passive motion was monitored by active surface electrodes. This study confirmed mobility of the D-fascia in which the TFL's D-fascia moves and change of muscle shape in the distal direction during no muscle contraction due to passive movement. This fact suggests the possibility that passive tension on fascia tissue of the ankle extends to the proximal part of the limb, i.e., to the D-fascia of the TFL.

Acupuncture as a Nonpharmacologic Treatment for Pain in a Pediatric Emergency Department

OBJECTIVES

With epidemic opioid deaths and abuse in the United States, government agencies recommend nonpharmacological treatments for pain. However nonopioid treatment options for moderate to severe pain in the pediatric emergency department (PED) are limited. Acupuncture has been shown to be effective for pain. The objective of this study was to evaluate the feasibility of using traditional acupuncture (TA) and battlefield acupuncture (BFA) in the treatment of pain in the PED.

METHODS

A pediatric cohort treated with acupuncture for pain in an urban PED was assessed. All subjects received TA or BFA as treatment, and pre/postacupuncture pain scores, feedback, and adverse events were assessed. The primary outcome was a change in pain score.

RESULTS

Twelve patients received BFA, and 13 received TA for these pain conditions: headaches, sciatica, paraphimosis, torticollis, joint pains (knee, shoulder, jaw), sprains (foot, wrist, thumb), dysmenorrhea, otitis externa, sickle cell, and muscle knot. The mean ± SD pain score change, 5.8 ± 2.5 (P < 0.05; 95% confidence interval, 4.9-7.0), was clinically and statistically significant. Over 90% of subjects reported significant improvement or resolution of pain; 96% were satisfied with pain relief and would receive acupuncture again. Two adverse events were noted: one patient reported dizziness, and another, a tinge of blood at 1 of 90 needled points.

CONCLUSIONS

This study suggests that acupuncture is a potential nonpharmacologic therapeutic option for acute pain management in the PED.

The Intersection of Dissemination Research and Acupuncture: Applications for Chronic Low Back Pain

Dissemination research is the study of distributing information and intervention materials to a specific clinical practice or public health audience. Acupuncture, a healthcare practice involving the stimulation of certain body points, often with thin needles, is considered an evidence-based treatment for low back pain (LBP), but is underutilized in the United States.

Body: We will use the example of acupuncture for LBP to identify opportunities to leverage dissemination research to increase utilization of acupuncture. Deficits in the awareness or knowledge of acupuncture may limit its adoption by patients and other stakeholders. Thus, we summarize methods to gather data on stakeholder awareness and knowledge of acupuncture for LBP, i.e., audience research. Engaging multiple stakeholder audiences (e.g., health system leaders, primary care providers, patients), is needed to generate knowledge on promising dissemination strategies for each audience. Audience segmentation is important for identifying population subgroups for whom adoption of acupuncture may require a more intensive or tailored dissemination strategy. To illustrate potential audience ‘segments’, our research discussion focused on developing dissemination strategies by age (i.e., older adults – those age 65 years or older, and younger adults – those under age 65 ). This decision was prompted by Medicare’s recent policy covering acupuncture for chronic LBP. We leverage current knowledge of barriers and facilitators of acupuncture use to discuss how further tailoring of dissemination strategies might optimize adoption of acupuncture in both groups of adults. Experimental study designs could then be used to compare the effectiveness of such strategies to increase awareness, knowledge, or adoption of acupuncture.

Conclusions: Conducting dissemination research may improve awareness and knowledge of acupuncture, and ultimately the adoption of acupuncture in biomedical settings. We anticipate that the concepts highlighted in this manuscript will also be helpful for those disseminating information about other complementary and integrative health approaches.

Dry needling strategies for musculoskeletal conditions: Do the number of needles and needle retention time matter? A narrative literature review

Acupuncture and dry needling are both minimally invasive procedures that use thin, filiform needles without injectate for the management of a variety of neuromusculoskeletal pain conditions. While the theoretical constructs underlying the use of acupuncture and dry needling are unique, both appear to have the ability to elicit biochemical, biomechanical, endocrinological and neurovascular changes associated with reductions in pain and disability. However, optimal treatment dosage has yet to be determined, and there is a lack of consistency in the literature on the number of needles that should be inserted and the needle retention time. Therefore, the purpose of this narrative review is to further explore the importance of these two variables. While trigger point dry needling advocates single needle insertions via repetitive, quick in-and-out pistoning, most acupuncture and dry needling clinical trials have incorporated multiple needles for five to 40 min. Notably and to date, using a single needle to repeatedly prick trigger points one at a time with fast-in and fast-out pistoning maneuvers has not yet been shown to produce significant and clinically meaningful long term improvements in pain and disability in a wide array of musculoskeletal conditions. Insertion of multiple needles for typically 20-30 min durations has been shown to produce larger treatment effect sizes and longer-lasting outcomes than brief, single-needle strategies. Moreover, the number of needles and needle retention time are two variables associated with treatment dosage and must be carefully matched with specific musculoskeletal conditions and the patient's goals.

Dry needling for scar treatment

OBJECTIVE

To review current scientific knowledge as to the efficacy of dry needling of scars on pain and other related symptoms and explore the possible physiological mechanisms of action.

METHODS

A narrative review of scientific literature published in English.

RESULTS

Two randomized controlled trials found that dry needling of scars (using the classic "surrounding the dragon" technique in one study and intradermal needling in a second study) was more effective than sham or control interventions with respect to scar appearance and pain. Two case reports have suggested that scar needling generates a rapid decrease in pain and improvement of mobility in scarred tissues. Another two case reports have reported positive effects of scar needling on the wound healing process. These findings are supported by an animal study examining the effect of needling on the wound healing process and the physiological mechanisms of action underlying the technique.

CONCLUSION

There is preliminary evidence that the "surrounding the dragon" needling technique is a beneficial treatment for patients suffering from scar pain and other scar-related symptoms and can facilitate wound healing and make this process less painful. Further high-quality studies should be conducted to verify/quantify the efficacy of this method, to better understand the underlying mechanisms of action underlying the effects of scar needling and to establish an effective intervention protocol.

Opposing Effects of Adenosine and Inosine in Human Subcutaneous Fibroblasts May Be Regulated by Third Party ADA Cell Providers

Human subcutaneous fibroblasts (HSCF) challenged with inflammatory mediators release huge amounts of ATP, which rapidly generates adenosine. Given the nucleoside’s putative relevance in wound healing, dermal fibrosis, and myofascial pain, we investigated the role of its precursor, AMP, and of its metabolite, inosine, in HSCF cells growth and collagen production. AMP (30 µM) was rapidly (t½ 3 ± 1 min) dephosphorylated into adenosine by CD73/ecto-5′-nucleotidase. Adenosine accumulation (t½ 158 ± 17 min) in the extracellular fluid reflected very low cellular adenosine deaminase (ADA) activity. HSCF stained positively against A_2A and A₃ receptors but were A₁ and A_2B negative. AMP and the A_2A receptor agonist, CGS21680C, increased collagen production without affecting cells growth. The A_2A receptor antagonist, SCH442416, prevented the effects of AMP and CGS21680C. Inosine and the A₃ receptor agonist, 2Cl-IB-MECA, decreased HSCF growth and collagen production in a MRS1191-sensitive manner, implicating the A₃ receptor in the anti-proliferative action of inosine. Incubation with ADA reproduced the inosine effect. In conclusion, adenosine originated from extracellular ATP hydrolysis favors normal collagen production by HSCF via A_2A receptors. Inhibition of unpredicted inosine formation by third party ADA cell providers (e.g., inflammatory cells) may be a novel therapeutic target to prevent inappropriate dermal remodeling via A₃ receptors activation.

Physiological impact of nanoporous acupuncture needles: Laser Doppler perfusion imaging in healthy volunteers

BACKGROUND

Recently, porous acupuncture (PA), which is anodized to increase its surface area for higher stimulation intensity, was developed and showed significantly improved therapeutic effects with more comfort as compared with original acupuncture (OA) in vivo. However, the impact of PA on the change of local blood flow as well as its efficacy and acceptability has not yet been confirmed in a clinical trial. In a randomized, controlled crossover clinical trial, we investigated the effects of PA on the change in local blood flow using laser Doppler perfusion imaging and considered the sensation of pain intensity and discomfort severity using a visual analogue scale (VAS) to explore its physiological impact and the possibility of PA in clinical use.

METHODS

Twenty-one healthy participants were randomly treated with PA or OA on one side of Zusanli (ST36) and each participant served as his or her own control. Baseline local blood flow and galvanic skin response (GSR) were obtained for 5 min and acupuncture interventions were subsequently performed. Next, local blood flow and GSR were subsequently obtained for 10 min after insertion, 10 min after manipulation, and 5 min after the withdrawal of acupuncture. At the end of the experiment, participants were asked to indicate the sensation of pain intensity at each session of insertion, retention, manipulation, and withdrawal as well as the overall pain intensity and discomfort severity.

RESULTS

PA significantly increased the local blood flow as compared with OA and there was no significant difference in GSR between patients treated with PA versus OA in each phase of insertion and manipulation. No significant difference in pain intensity or discomfort severity was found during manipulation, retention, or withdrawal of acupuncture.

CONCLUSIONS

These results indicate that PA increases local blood flow, which can be closely related to the observed enhanced performance, without any associated discomfort or pain, suggesting its applicability in clinical practice.

Acupuncture induces adenosine in fibroblasts through energy metabolism and promotes proliferation by activating MAPK signaling pathway via adenosine3 receptor

Acupuncture has many advantages in the treatment of certain diseases as opposed to drug therapy. Besides, adenosine has been revealed to affect cellular progression including proliferation. Therefore, this study aimed at exploring the mechanism involving acupuncture stress and adenosine in fibroblast proliferation. The fibroblasts from fascia tissues of the acupoint area (Zusanli) were stimulated by different levels of stress, different concentrations of adenosine, and agonist or antagonist of A₃ receptor (A₃ R) to investigate the effect of stress stimulation, adenosine, and adenosine-A₃ R inhibition on fibroblasts. Then, the fibroblasts were treated with stress stimulation of 200 kPa or/and mitogen-activated protein kinase (MAPK) blocker. We revealed that stress stimulation and the binding of adenosine and A₃ R promoted fibroblast proliferation in the fascial tissue, increased the expression of immune-related factors, adenosine and A₃ R, and activated the MAPK signaling pathway. MAPK signaling pathway also directly affected the expression of adenosine, A₃ R, and immune-related factors. Stress stimulation and adenosine treatment upregulated A₃ R expression, and then activated the MAPK signaling pathway, which could in turn upregulate expression of adenosine, A₃ R and immune-related factors, and promote cell proliferation. Adenosine is shown to form a positive feedback loop with the MAPK signaling pathway. Collectively, stress stimulation in vitro induces the increase of adenosine in fibroblasts through the energy metabolism and activation of the MAPK signaling pathway through A₃ R, ultimately promoting fibroblast proliferation.

Evaluating the Effects of Acupuncture Using a Dental Pain Model in Healthy Subjects - A Randomized, Cross-Over Trial

Acupuncture is a complementary and nonpharmacological intervention that can be effective for the management of chronic pain in addition to or instead of medication. Various animal models for neuropathic pain, inflammatory pain, cancer-related pain, and visceral pain already exist in acupuncture research. We used a newly validated human pain model and examined whether acupuncture can influence experimentally induced dental pain. For this study, we compared the impact of manual acupuncture (real acupuncture), manual stimulation of a needle inserted at nonacupuncture points (sham acupuncture) and no acupuncture on experimentally induced dental pain in 35 healthy men who were randomized to different sequences of all 3 interventions in a within-subject design. BORG CR10 pain ratings and autonomic responses (electrodermal activity and heart rate variability) were investigated. An initial mixed model with repeated measures included preintervention pain ratings and the trial sequence as covariates. The results showed that acupuncture was effective in reducing pain intensity when compared to no acupuncture (β = -.708, P = .002), corresponding to a medium Cohen's d effect size of .56. The comparison to the sham acupuncture revealed no statistically significant difference. No differences in autonomic responses between real and sham acupuncture were found during the intervention procedures. PERSPECTIVE: This study established a dental pain model for acupuncture research and provided evidence that experimentally induced dental pain can be influenced by either real acupuncture or manual stimulation of needles at nonacupuncture points. The data do not support that acupoint specificity is a significant factor in reducing experimental pain.

Augmented Mechanical Forces of the Surface-Modified Nanoporous Acupuncture Needles Elicit Enhanced Analgesic Effects

Over the past several decades, clinical studies have shown significant analgesic effects of acupuncture. The efficacy of acupuncture treatment has improved with the recent development of nanoporous needles (PN), which are produced by modifying the needle surface using nanotechnology. Herein, we showed that PN at acupoint ST36 produces prolonged analgesic effects in an inflammatory pain model; the analgesic effects of PN acupuncture were sustained over 2 h, while those using a conventional needle (CN) lasted only 30 min. In addition, the PN showed greater therapeutic effects than CN after 10 acupuncture treatments once per day for 10 days. We explored how the porous surface of the PN contributes to changes in local tissue, which may in turn result in enhanced analgesic effects. We showed that the PN has greater rotational torque and pulling force than the CN, particularly at acupoints ST36 and LI11, situated on thick muscle layers. Additionally, in ex vivo experiments, the PN showed greater winding of subcutaneous connective tissues and muscle layers. Our results suggest that local mechanical forces are augmented by the PN and its nanoporous surface, contributing to the enhanced and prolonged analgesic effects of PN acupuncture.

Host-Microbiome Synergistic Control on Sphingolipid Metabolism by Mechanotransduction in Model Arthritis

Chronic inflammatory autoimmune disorders are systemic diseases with increasing incidence and still lack a cure. More recently, attention has been placed in understanding gastrointestinal (GI) dysbiosis and, although important progress has been made in this area, it is currently unclear to what extent microbiome manipulation can be used in the treatment of autoimmune disorders. Via the use of appropriate models, rheumatoid arthritis (RA), a well-known exemplar of such pathologies, can be exploited to shed light on the currently overlooked effects of existing therapies on the GI microbiome. In this direction, we here explore the crosstalk between the GI microbiome and the host immunity in model arthritis (collagen induced arthritis, CIA). By exploiting omics from samples of limited invasiveness (blood and stools), we assess the host-microbiome responses to standard therapy (methotrexate, MTX) combined with mechanical subcutaneous stimulation (MS) and to mechanical stimulation alone. When MS is involved, results reveal the sphingolipid metabolism as the trait d’union among known hallmarks of (model) RA, namely: Imbalance in the S1P-S1PR1 axis, expansion of Prevotella sp., and invariant Natural Killer T (iNKT)-penia, thus offering the base of a rationale to mechanically modulate this pathway as a therapeutic target in RA.

Acupuncture Therapy in a Group Setting for Chronic Pain

Objective

This project was designed to test the feasibility and effectiveness of acupuncture therapy given in a group setting for chronic pain.

Design

Nonrandomized, repeated measures quasi-experimental trial.

Setting

Care was delivered in a primary care clinic waiting area after clinic hours.

Subjects

Included were primary care patients (≥18 years old) with chronic pain of the neck, back, shoulder, or osteoarthritis of any site of at least three months' duration.

Methods

Subjects received eight weekly acupuncture therapy sessions in a group setting. Acupuncture therapy included a combination of palpation, acupuncture needling, Tui na, Gua sha, and auricular treatment. Baseline pain levels were established in a two- to four-week run-in; assessment of the intervention impact on pain intensity, mood, and functional status were made at the end of the treatment period (eight weeks) and 16 weeks after completion of intervention (24 weeks).

Results

Of the total 113 participants recruited for the trial, 96 completed the 24-week protocol. We found a statistically and clinically significant decrease in pain severity, pain interference, and depression in our study population. There were no serious adverse events.

Conclusions

Acupuncture therapy offered in the group setting was effective in reducing pain severity, pain interference, and depression in patients with chronic neck, back, or shoulder pain or osteoarthritis. Benefit persisted through the 24-week measure despite no additional treatment. This finding has potentially important implications for improving access to effective acupuncture treatment for patients with limited financial resources.

The effectiveness of superficial versus deep dry needling or acupuncture for reducing pain and disability in individuals with spine-related painful conditions: a systematic review with meta-analysis

Objective: The purpose of this systematic review was to evaluate the effects of deep versus superficial dry needling or acupuncture on pain and disability for spine-related painful conditions. A secondary purpose was to account for the differences of needling location in relation to the painful area. Methods: This PROSPERO (#CRD42018106237) registered review found 691 titles through a multi-database search. Following a comprehensive search, 12 manuscripts were included in the systematic review and 10 in the meta-analysis. Standardized mean differences (SMD) with 95% confidence intervals were calculated for pain and disability. Results: The included studies demonstrated an unclear to high risk of bias recommending a cautious interpretation of the results. A consistent effect supporting deep needling over superficial with an SMD of 0.585 [0.335, 0.835], p < 0.001 from 10 articles for pain but a non-significant effect of 0.197 [-0.066, 0.461], p = 0.14 from 2 studies for disability. A temporal examination was similar for effects on pain with an SMD of 0.450 [0.104, 0.796] immediately, 0.711 [0.375, 1.048] short-term (1 to 11 weeks), and 0.470 [0.135, 0.805] for time-points ≥12 weeks. Regionally, there was a greater effect needling the area of pain locally (SMD = 0.754) compared to remotely (SMD = 0.501). Discussion: Statistically significant between-group differences were observed favoring deep needling over superficial. Both superficial and deep needling resulted in clinically meaningful changes in pain scores over time. However, differences between groups may not be clinically meaningful. More high-quality trials are needed to better estimate the effect size of deep versus superficial needling while controlling for location and depth of the lesion. Level of evidence: 1a.

A Randomized, Double-Blind, Sham-Controlled Study Assessing Electroacupuncture for the Management of Postoperative Pain after Percutaneous Nephrolithotomy

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is the gold standard procedure for large renal calculi but postoperative (PO) pain remains a concern. Modifications of the PCNL technique and intraoperative and PO strategies have been tested to reduce pain. PO pain control reducing risk of long-term pain medication and narcotic use is of considerable importance. Acupuncture is a common medical procedure shown to alleviate PO pain. Some benefits are that it is nonpharmacologic, easy to administer, and safe. The purpose of this study was to evaluate the effects of electroacupuncture (EA) on PO pain in patients undergoing PCNL.

MATERIALS AND METHODS

This was a randomized, double-blind, sham-controlled study. The study was Institutional Review Board approved and performed under standard ethical guidelines. Fifty-one patients undergoing PCNL by a single surgeon were randomized to one of the three groups: true EA (n = 17), sham EA (SEA, n = 17), and no acupuncture (control, n = 17). The EA and SEA were performed by a single licensed acupuncturist <1 hour before operation. PCNL was performed without the use of intraoperative nerve block(s) or local anesthetic. Pain scores (visual analog scale [VAS]), narcotic use (morphine equivalents), and side effects were recorded at set intervals postoperatively.

RESULTS

Mean VAS scores for flank and abdomen pain were lower at all time periods in the EA compared with the SEA and control groups. Mean cumulative opioid usage was lower in the EA group immediately postoperatively compared with both SEA and control groups. Two patients in the EA group did not require any PO narcotics. No differences between groups were found for PO nausea and vomiting. No adverse effects of EA or SEA were noted.

CONCLUSIONS

EA significantly reduced PO pain and narcotic usage without any adverse effects after PCNL. This promising treatment for managing PO pain warrants further investigation.

Efficacy of acupuncture in treating scars following tissue trauma

INTRODUCTION

Anecdotally, acupuncture is used in the treatment of scar tissue in order to improve scar quality and reduce symptoms of pain and pruritus. Unlike conditions such as lower back pain, knee osteoarthritis and migraines, there are no systematic reviews to confirm treatment efficacy. This systematic literature review aims to assess the current level of evidence for the use of acupuncture for treating abnormal scars such as hypertrophic or other symptomatic scars.

METHODS

A comprehensive database search was performed followed by reviewing reference lists, grey literature databases and Google Scholar. Study quality was assessed using the Oregon CONSORT STRICTA instrument (OCSI) for clinical trials and the Joanna Briggs Institute (JBI) checklist for case reports.

RESULTS

The search strategy discovered five case studies, one retrospective cohort study, one cohort study and three clinical trials that investigated the use of acupuncture for scars. Studies rated as low to moderate quality (26-50%) on the OCSI checklist due to lack of detailed reporting, use of non-validated outcome measures and heterogeneity of participant cohorts. Three case studies rated as moderate quality (5-6/8) and two as low quality (<2/8) on the JBI checklist.

DISCUSSION

All studies reported positive outcomes for the use of acupuncture for scar symptoms; however, treatment frequency, duration, number of treatments and points used varied between studies.

CONCLUSION

Acupuncture for the treatment of abnormal scars has a low level of evidence thus requiring further well-designed, controlled trials to be performed. Recommended treatment protocols for future studies have been provided.

A Hypothesis for the Anti-Inflammatory and Mechanotransduction Molecular Mechanisms Underlying Acupuncture Tendon Healing

A previous study demonstrated that acupuncture increases the synthesis and reorganisation of collagen molecules in rat tendons after injury. Clinical studies have shown that acupuncture improves pain and functional activity in patients with tendinopathy. However, the molecular mechanisms underlying these effects are unknown. Recent studies have shown that acupuncture can modulate both anti-inflammatory (AI) and mechanotransduction (MT) molecular pathways. Moreover, the modulation of these pathways can increase type I collagen synthesis, which is the main factor that influences tendon biomechanical properties. Our hypothesis is that acupuncture increases synthesis and subsequent reorganisation of type I collagen during tendon healing by concomitant modulation of the Toll-like receptor-nuclear factor-κB AI pathway, the mitogen-activated protein kinases pathway and the Rho/Rac-F-actin MT pathway. Increased collagen synthesis and reorganisation requires that at least one acupoint is anatomically connected with the site of the injury because of the local tenoblast MT mechanism. Confirmation of this hypothesis will increase the knowledge of acupuncture modulation of the previously mentioned molecular pathways, and such confirmation may also help to establish the relationships between the different types of acupuncture needle stimulation and the influence of acupuncture stimuli on pathway activity levels. In addition, the downstream therapeutic effects of acupuncture therapy may be established. This hypothesis can be verified in a rat tendon healing model, and subsequent clinical protocols for tendon healing can be developed and evaluated as standalone therapies or as a component of a combination therapy.

Acupuncture and in vitro fertilisation research: Current and future directions

Background

Acupuncture is a common adjuvant treatment to support patients undergoing in vitro fertilisation (IVF). However, the impact of acupuncture and the different roles it can play in IVF remain unclear.

Objective

In this paper, we present an overview and critique of the current evidence on acupuncture's impact on IVF-related stress, describe harms, and propose future directions for investigation.

Conclusion

Two to three acupuncture sessions performed on or around the day of embryo transfer are insufficient interventions to improve IVF birth outcomes but provide significant IVF-related stress reduction. Research investigating acupuncture to support IVF is heterogeneous and confounded by the lack of an appropriate comparator. However, evidence suggests several acupuncture sessions improve endometrial thickness, reduce stress, and improve patient satisfaction. Observational studies suggest more sessions are associated with increases in clinical pregnancy and live birth rates. An optimised acupuncture intervention with a reasonable comparator is necessary for future studies, with evidence-based guidance on technique and number of sessions. Acupuncture should not be rejected as an adjuvant therapy for IVF, but more studies are needed to clarify acupuncture's role in supporting IVF cycles.

The Elephant in the Room: The Need for Increased Integrative Therapies in Conventional Medical Settings

Pediatric integrative therapy programs are essential to the treatment and well-being of patients. Identifying an effective integrative therapy model within conventional pediatric medical settings, however, often proves difficult. Our goal in this article is to explore varied solutions to increase access and inclusion of integrative therapies in an effort to promote best practice and holistic care. The main methods applied in this article are vignettes that illustrate how the integrative therapies in a metropolitan academic hospital successfully treat the patient by complementing conventional medicine. This leads to comprehensive care. The central finding of the article proposes viable solutions to increase interdisciplinary collaboration both internally within the institution and externally. Integrative therapists detail how they were able to increase visibility and yield best practice through increased educational initiatives and interdisciplinary collaboration.

Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial

Study Design

Randomized, single-blinded, multi-center, parallel-group trial.

Objectives

To compare the effects of adding electrical dry needling into a program of manual therapy, exercise and ultrasound on pain, function and related-disability in individuals with plantar fasciitis (PF).

Background

The isolated application of electrical dry needling, manual therapy, exercise, and ultrasound has been found to be effective for PF. However, no previous study has investigated the combined effect of these interventions in this population.

Methods

One hundred and eleven participants (n = 111) with plantar fasciitis were randomized to receive electrical dry needling, manual therapy, exercise and ultrasound (n = 58) or manual therapy, exercise and ultrasound (n = 53). The primary outcome was first-step pain in the morning as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included resting foot pain (NPRS), pain during activity (NPRS), the Lower Extremity Functional Scale (LEFS), the Foot Functional Index (FFI), medication intake, and the Global Rating of Change (GROC). The treatment period was 4 weeks with follow-up assessments at 1 week, 4 weeks, and 3 months after the first treatment session. Both groups received 6 sessions of impairment-based manual therapy directed to the lower limb, self-stretching of the plantar fascia and the Achilles tendon, strengthening exercises for the intrinsic muscles of the foot, and therapeutic ultrasound. In addition, the dry needling group also received 6 sessions of electrical dry needling using a standardized 8-point protocol for 20 minutes. The primary aim was examined with a 2-way mixed-model analysis of covariance (ANCOVA) with treatment group as the between-subjects variable and time as the within-subjects variable after adjusting for baseline outcomes.

Results

The 2X4 ANCOVA revealed that individuals with PF who received electrical dry needling, manual therapy, exercise and ultrasound experienced significantly greater improvements in first-step morning pain (F = 22.021; P<0.001), resting foot pain (F = 23.931; P<0.001), pain during activity (F = 7.629; P = 0.007), LEFS (F = 13.081; P<0.001), FFI Pain Subscale (F = 13.547; P<0.001), FFI Disability Subscale (F = 8.746; P = 0.004), and FFI Total Score (F = 10.65; P<0.001) than those who received manual therapy, exercise and ultrasound at 3 months. No differences in FFI Activity Limitation Subscale (F = 2.687; P = 0.104) were observed. Significantly (X² = 9.512; P = 0.023) more patients in the electrical dry needling group completely stopped taking medication for their pain compared to the manual therapy, exercise and ultrasound group at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X² = 45.582; P<0.001) more patients within the electrical dry needling group (n = 45, 78%) achieved a successful outcome compared to the manual therapy, exercise and ultrasound group (n = 11, 21%). Effect sizes ranged from medium to large (0.53<SMD<0.85) at 3 months in favor of the electrical dry needling group.

Conclusion

The inclusion of electrical dry needling into a program of manual therapy, exercise and ultrasound was more effective for improving pain, function and related-disability than the application of manual therapy, exercise and ultrasound alone in individuals with PF at mid-term (3 months).

Level of evidence

Therapy, Level 1b.

Beyond the Laboratory, Into the Clinic: What Dogs with Disk Disease Have Taught Us About Photobiomodulation for Spinal Cord Injury

BACKGROUND

For spinal-cord-injured (SCI) patients, integrative medicine approaches such as photomedicine and acupuncture can renew hope and offer previously unrecognized ways to help regain function and improve quality of life.

OBJECTIVE

By understanding the mechanisms of action that these two modalities share, practitioners can better target specific attributes of spinal cord pathophysiology that are limiting recovery. Naturally occurring intervertebral disk disease (IVDD) in dogs affords unparalleled translational opportunities to develop treatment strategies involving photobiomodulation and acupuncture.

CONCLUSIONS

Insights derived through clinical trials of dogs with IVDD have the potential to raise the standard of care for both human and canine SCI patients.

The National Cancer Institute's Conference on Acupuncture for Symptom Management in Oncology: State of the Science, Evidence, and Research Gaps

The Division of Cancer Treatment and Diagnosis, Office of Cancer Complementary and Alternative Medicine, at the National Cancer Institute (NCI) held a symposium on "Acupuncture for Cancer Symptom Management" on June 16 and 17, 2016. Invited speakers included 19 scientists and scholars with expertise in acupuncture and cancer research from the United States, Europe, and China. The conference reviewed the NCI's grant funding on acupuncture, analyzed the needs of cancer patients, reviewed safety issues, and assessed both the current scientific evidence and research gaps of acupuncture in oncology care. Researchers and stakeholders presented and discussed basic mechanisms of acupuncture; clinical evidence for specific symptoms; and methodological challenges such as placebo effects, novel biostatistical methods, patient-reported outcomes, and comparative effectiveness research. This paper, resulting from the conference, summarizes both the current state of the science and clinical evidence of oncology acupuncture, identifies key scientific gaps, and makes recommendations for future research to increase understanding of both the mechanisms and effects of acupuncture for cancer symptom management.