Acu/Moxa for distal sensory peripheral neuropathy in HIV: a randomized control pilot study

Feasibility of therapeutic Chinese massage (tui na) for peripheral neuropathy among people with human immunodeficiency virus: findings of a pilot randomized controlled trial

Background

Peripheral neuropathy (PN) is prevalent in people with human immunodeficiency virus (PHIV) with no Food and Drug Administration-approved treatment. Therapeutic Chinese massage (TCM) is a promising noninvasive and non-harmful intervention for HIV-related PN. However, relevant research is lacking. The purpose of this study is to evaluate the feasibility of TCM for HIV-related PN.

Method

We conducted a pilot, single-centered, two-arm, double-blinded, randomized controlled trial. Twenty eligible PHIV were recruited primarily from the AIDS Foundation Houston, Inc. in Texas and were randomly assigned into two groups. Ten participants in the intervention group received three weekly 25-min TCM sessions by a certified TCM therapist. The remaining ten control group participants received the same therapist's three weekly 25-min placebo massage sessions on their lower extremities. The outcome was the feasibility of this study as measured by recruitment and completion rates, participant safety, and treatment adherence and compliance, as well as the effect size of the intervention.

Results

The study population comprised 20 PHIV (mean age 55.23). This study showed high feasibility as measured by a high rate of recruitment, a 100% rate of completion, and zero serious adverse events. As we inquired 21 respondents for eligibility for the study, all except one had HIV-related PN. All respondents were willing to participate in the study and adhered to the group assignment after they enrolled in the study. The participants' baseline pain was at a medium to a high level (6.30 [2.15] out of 10).

Conclusion

Chinese massage is a feasible intervention in PHIV. Future relevant randomized controlled trials are expected.

Clinical trial registration

https://clinicaltrials.gov/, NCT05379140.

Acupuncture for Management of Endodontic Emergencies: a Review

Root canal treatment (RCT) employed for painful endodontic conditions like apical periodontitis and irreversible pulpitis is associated with a high incidence of postoperative pain. Pharmacological management for this purpose is effective, but not entirely free from side effects and in some cases may fail to provide adequate relief. Furthermore, concerns have been raised regarding the transmission of coronavirus disease-2019 (COVID-19) as a result of the aerosols generated and prolonged chair side time required for RCT. Acupuncture is a traditional Chinese therapy commonly employed as an alternative for the treatment of pain. And what's more, the use of acupuncture has been recently reported as treatment for the management of endodontic pain as well as on the anesthetic success in patients with irreversible pulpitis. This review aims to evaluate the current evidence for acupuncture in endodontics and its potential role in emergency pain relief and management for patients. To combat this, a thorough search for literature within the field was performed in five electronic databases. Retrieved studies were screened according to the pre-defined eligibility criteria. After both an electronic and manual search, five studies were selected for review. These studies reported the beneficial effects of acupuncture in reducing the failure of nerve block in patients with irreversible pulpitis and in controlling both intraoperative and postoperative pain following RCT. In addition, it was also reported to reduce anxiety surrounding the dental procedure and minimized the intake of analgesics after the endodontic procedure, which can result in some unwanted side effects. However, more in depth clinical research is required before any recommendation regarding the application of acupuncture in endodontic patients can be made.

Tui Na for painful peripheral neuropathy in people with human immunodeficiency virus: A randomized, double-blind, placebo-controlled trial protocol

Background

Peripheral neuropathy (PN), including numbness, loss of sensation, paresthesia, a burning sensation, and stabbing pain in extremities, is a common complication in people with human immunodeficiency virus (PHIV). Medications commonly used to treat HIV-related PN are not effective and lead to many side effects. HIV-related PN symptoms may be alleviated or treated with a series of therapeutic Chinese foot massages (TCFM), which are non-invasive and relatively safe. However, relevant studies are lacking.

Study design

This proposed trial is a prospective, two-arm, parallel, double-blinded, randomized controlled trial.

Aim

This proposed trial aims to assess the effectiveness of TCFM on HIV-related PN in people with HIV (PHIV).

Outcomes

The primary outcomes, measured at baseline, end of TCFM/placebo, and twelve weeks after, include (1), lower extremity pain, (2) lower extremity functioning, and (3) health-related quality of life. The secondary outcomes, measured throughout the trial process, include (1) recruitment and completion rate (No. of referred, No. of eligible, No. of enrolled, No. of withdrawals, trial recruitment rate, and trial completion rate), (2) participants' safety (No. and severity of adverse events), (3) treatment adherence (average time of each message session, No. of completed sessions, and No. of missed sessions), and (4) compliance (No. of participants completing the trial following the initial group assignment).

Sample size

An estimated 142 participants in total, or 71 participants in each arm, will be needed for this trial.

Trial status

This trial was registered at ClinicalTrials.gov of the National Institute of Health on Oct 26, 2022 (ClinicalTrials.gov Identifier: NCT05596123). The researchers expect to recruit participants starting in Feb. 2023 and ending in Feb 2025.

Pharmacologic and Non-Pharmacologic Treatments for Chronic Pain Used by Patients with Pain, HIV, and Depression

The objective of this study was to understand pain treatment utilization, perceived efficacy, and differences in utilization by gender, clinic site, chronicity of pain, pain severity, and depression severity among people living with HIV (PLWH), chronic pain, and elevated depression symptoms. Participants included 187 PLWH at three HIV clinics in the U.S. Overall, 85% of participants reported taking a pain medication. One quarter (25%) reported non-pharmacological professional treatments for pain (e.g., massage, physical therapy), 60% reported mind-body treatments, including exercise, meditation, and yoga, and 62% reported other non-pharmacological self-administered treatments (e.g., heat/cold). Most pain treatments were considered "slightly helpful" or "moderately helpful." Non-pharmacological self-administered treatments were more commonly used among women than men and among individuals with constant vs. intermittent pain. Further research is needed to evaluate the efficacy of the preferred analgesic modalities of PLWH.

Understanding the experiences and perception of people living with HIV on integrative traditional East Asian medicine management in Korea: an interview protocol for qualitative research

INTRODUCTION

Patients with HIV/AIDS have been able to experience the average life expectancy of the general population due to medical advancements. However, they face physical, emotional and social difficulties that worsen their quality of life. The pharmacological approach is often the first choice to address these issues, but it involves some limitations. Integrative traditional East Asian medicine (ITEAM) can compensate for the limitations of drugs and can be applied to treat physiological and psychiatric problems. In Korea, ITEAM interventions are easily accessible under the government insurance. However, the experiences, perceptions and barriers to the use of ITEAM in patients with HIV/AIDS are less studied. Therefore, we will interview them to explore their experiences and examine the strengths, limitations, barriers and improvements in the use of ITEAM.

METHODS AND ANALYSIS

This is a qualitative study using a phenomenological framework. We will conduct one-to-one interviews with 3-10 patients with HIV/AIDS who have been treated with ITEAM from March 2021 to January 2022. We will present semistructured open-ended questions and analyse them using experiential phenomenological research methods. The results will be reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies.

ETHICS AND DISSEMINATION

This research was approved by the Institutional Review Board of the National Medical Center (IRB number, NMC-2101-008). The results of this study will be disseminated through journal articles, newspapers and conference proceedings.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service: KCT0005855; Pre-results.

HIV-related Neuropathy: Pathophysiology, Treatment and Challenges

HIV-sensory neuropathy (HIV-SN) is a debilitating complication in HIV patients with or without anti-retroviral treatment (ART). Common symptoms of HIV-SN include pain, decreased sensation, paresthesias, and dysesthesias in a symmetric stocking-glove distribution. While HIV-1 protein such as gp120 is implicated in HIV-SN (e.g. impaired large-diameter fiber), ART itself was recently shown to contribute to HIV-SN in HIV patients and impair thin fiber. Multiple host mechanisms may play roles during the pathogenesis of HIV-SN, including neuron-glia interactions in the spinal dorsal horn (SDH), inflammation, mitochondrial dysfunction and endoplasmic reticulum stress. Concurrent infections, such as tuberculosis, also carry a higher likelihood of HIV-SN as well as environmental or genetic predisposition. Pro-inflammatory cytokines such as IL-1, IL2 receptor-alpha, and tumor necrosis factor (TNF) along with abnormal lactate levels have been identified as potential players within the complex pathophysiology of this condition. In this paper, we review the pathophysiology of HIV neuropathy, focusing on the various treatment options available or under investigation. Although several treatment options are available e.g., the capsaicin patch and spinal cord stimulation, symptomatic control of HIV-SN are often challenging. Alternative approaches such as self-hypnosis, resistance exercise, cannabinoids, and acupuncture have all shown promising results, but need further investigation.

Pharmacologic and Non-Pharmacologic Interventions for HIV-Neuropathy Pain. A Systematic Review and a Meta-Analysis

Background and Objectives: Among HIV infection symptoms, sensory neuropathy (HIV-SN) remains a main cause of suffering, with incidence varying from 13-50%. So far, numerous pharmacological and non-pharmacological treatments have been tested, although few evidence-based analgesic options are available. We conducted an up-to-date systematic review and meta-analysis of the literature in order to evaluate the efficacy and safety of pharmacologic and non-pharmacologic treatments for pain control, in patients with HIV neuropathy. Materials and Methods: We searched MEDLINE, EMBASE, Scopus/Elsevier, The Cochrane Central Register of Controlled Trials (CENTRAL), USA Clinical Trials registry, and The International Web of Science up to April 2019. All randomized controlled trials evaluating efficacy and safety of non-pharmacologic and pharmacologic therapies were included. Efficacy was defined as pain reduction during the study period. Safety was estimated from adverse events. A meta-analysis was performed whenever possible. Results: 27 randomized controlled trials (RCTs) were included for analysis (7 evaluating non pharmacologic interventions, 20 pharmacologic therapies). Non-pharmacologic studies (n = 742) involved seven different therapeutic modalities. Only Acupuncture/Moxibustion showed pain reduction over placebo, Gracely Pain Scale Mean (SD): Acu/Moxa 0.85 (0.12), placebo 1.10 (0.09), p = 0.05. Pharmacologic studies, involving 2516 patients revealed efficacy for capsaicin 8% over placebo (mean difference -8.04 [95% CI: -14.92 -1.15], smoked cannabis (where pooling data for meta-analysis was not possible) and recombinant Nerve Growth Factor. Conclusion: Despite various modalities for pain control in HIV-SN, strongest evidence exists for capsaicin 8% and smoked cannabis, although of low methodological quality. Among non-pharmacologic modalities, only Acu/Moxa gave a marginal beneficial effect in one study, possibly limited by inherent methodological flaws.

The Case for Local Needling in Successful Randomized Controlled Trials of Peripheral Neuropathy: A Follow-Up Systematic Review

Objectives: This work follows-up on a systematic review, published in 2017, of acupuncture for the treatment of mono- and polyneuropathy and associated symptoms. Previously reviewed trials of acupuncture for neuropathy primarily used acupuncture points in close proximity to underlying nerves. Further exploration of point selection for the treatment of each neuropathic condition is needed to assess the anatomical relationships between acupuncture points and peripheral nerves with respect to the treatment of neuropathy. Methods: The 13 randomized controlled trials included in the original review studied acupuncture for neuropathy caused by diabetes, Bell's palsy, carpal tunnel syndrome (CTS), human immunodeficiency virus (HIV), and idiopathic causes. The present review reexamines all acupuncture points used, focusing on specific neuropathic condition treated. Anatomical diagrams are presented to highlight acupuncture points underlying the nerves' anatomical relationships. Each selected acupuncture point is reviewed in detail, including its Traditional Chinese Medicine theory-based function, the point's indications for use, and the peripheral nerve most closely associated with it. Results: In Bell's palsy, the majority of selected acupuncture points were associated with the ipsilateral facial nerve. In CTS, the majority of the selected acupuncture points were closely associated with the median nerve and its branches. In polyneuropathy caused by diabetes, HIV, or idiopathic causes, most selected acupuncture points were in close proximity to peripheral nerves. Conclusions: All reviewed trials of acupuncture for neuropathy and neuropathic pain use acupuncture points that are closely associated with the peripheral nerves treated. Local needling is crucial for successful treatment of peripheral neuropathy.

2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Neuromuscular complications of HIV infection

With the introduction of combination antiretroviral therapy, human immunodeficiency virus (HIV)-infected individuals are living longer, and are commonly confronted with chronic neuromuscular complications. The spectrum of neuromuscular disorders in patients living with HIV infection is wide, and is caused by HIV per se and its products, particular antiretroviral drugs, or a combination of both. The purpose of this chapter is to review peripheral nervous system disorders in the setting of HIV infection, and to provide a general approach to diagnosis and management of these disorders. The early identification of these conditions may help with early intervention and management, allow prevention of morbidities associated with these disorders, and contribute to future research efforts in the field of HIV.

Introducing a Standardized Acupuncture Protocol for Peripheral Neuropathy: A Case Series

Background: Peripheral neuropathy (PN) is defined as damage to the peripheral nervous system caused by a primary lesion or dysfunction. Multiple recent trials have suggested that acupuncture is beneficial for treating neuropathic pain. One challenge in acupuncture research is the lack of standardization of point selection, number of needles used, needle-retention time, needling depth, amount of needle manipulation, and use of moxibustion and electroacupuncture (EA). Objectives: This article presents a standardized acupuncture protocol for the treatment of PN that incorporates structural acupuncture principles based on proximity to peripheral nerves and on traditional approaches to the treatment of neuropathic pain. Materials and Methods: Ten consecutive patients diagnosed with large- or small-fiber neuropathy of various etiologies were treated with a standardized protocol, based on anatomical correlations of peripheral nerves and acupuncture points. Manual acupuncture was applied to left LR 4, LU 5; bilateral LI 11, KI 27, ST 36, GB 34, SP 6, SP 9, LI 4, TE 5, and BaFeng (except for the space between the first and second digits of the toes; LR 3 was used for that space). EA was applied to bilateral KI 3-1 and bilateral ST 41-LR 3. Patients underwent at least six acupuncture sessions, although the total number of sessions varied. Outcomes were measured using a visual analogue scale (VAS) and clinical signs and symptoms. Results: All 10 patients indicated improvement on the VAS and in clinical presentation. Conclusions: This standardized protocol appears to be effective for the treatment of neuropathy of various causes, including large- and small-fiber involvement. Further studies with larger sample sizes and randomized comparisons against sham acupuncture and other acupuncture regimens will be helpful to determine if this protocol could be established as a guideline for approaching peripheral neuropathy.

Acupuncture for the Treatment of Peripheral Neuropathy: A Systematic Review and Meta-Analysis

OBJECTIVES

Neuropathy and its associated pain pose great therapeutic challenges. While there has been a recent surge in acupuncture use and research, little remains known about its effects on nerve function. This review aims to assess the efficacy of acupuncture in the treatment of neuropathy of various etiologies.

METHODS

The Medline, AMED, Cochrane, Scopus, CINAHL, and clintrials.gov databases were systematically searched from inception to July 2015. Randomized controlled trials (RCTs) assessing acupuncture's efficacy for poly- and mononeuropathy were reviewed. Parallel and crossover RCTs focused on acupuncture's efficacy were reviewed and screened for eligibility. The Scale for Assessing Scientific Quality of Investigations in Complementary and Alternative Medicine was used to assess RCT quality. RCTs with score of >9 and active control treatments such as sham acupuncture or medical therapy were included.

RESULTS

Fifteen studies were included: 13 original RCTs, a long-term follow-up, and a re-analysis of a prior RCT. The selected RCTs studied acupuncture for neuropathy caused by diabetes, Bell's palsy, carpal tunnel syndrome, human immunodeficiency virus (HIV), and idiopathic conditions. Acupuncture regimens, control conditions, and outcome measures differed among studies, and various methodological issues were identified. Still, the majority of RCTs showed benefit for acupuncture over control in the treatment of diabetic neuropathy, Bell's palsy, and carpal tunnel syndrome. Acupuncture is probably effective in the treatment of HIV-related neuropathy, and there is insufficient evidence for its benefits in idiopathic neuropathy. Acupuncture appears to improve nerve conduction study parameters in both sensory and motor nerves. Meta-analyses were conducted on all diabetic neuropathy and Bell's palsy individual subject data (six RCTs; a total of 680 subjects) using a summary estimate random effects model, which showed combined odds ratio of 4.23 (95% confidence interval 2.3-7.8; p < 0.001) favoring acupuncture over control for neuropathic symptoms.

CONCLUSIONS

Acupuncture is beneficial in some peripheral neuropathies, but more rigorously designed studies using sham-acupuncture control are needed to characterize its effect and optimal use better.

Research on rehabilitation interventions for adults living with HIV: a scoping review

The aim of this paper is to use a scoping review to investigate the extent, range, and nature of research on rehabilitation interventions for adults living with HIV. Electronic databases (MEDLINE, EMBASE, CINAHL, AMED, and PsychINFO) and reference lists of the included articles were searched. Authors were emailed when possible for unavailable articles. A total of 897 titles and abstracts were retrieved. Thirty-three articles were included. There were 27 different rehabilitation interventions delivered by 18 professions. The studies were completed in four different countries. Most studies were published in 2008. A randomized-controlled trial was the most used method. The nature of the studies was analyzed according to the three-core concepts of the International Classification of Functioning, Disability and Health: 28 studies addressed impairments; six studies addressed activity limitations; and 14 studies addressed participation restrictions. This scoping study advances the knowledge of research on rehabilitation interventions for adults living with HIV. More research on rehabilitation interventions is needed in sub-Saharan Africa and other low-income and middle-income countries to ensure that these individuals are receiving the best possible care. There is a need for the HIV field to recognize the important contribution of rehabilitation toward the HIV care continuum.

HIV neuropathy

PURPOSE OF REVIEW

To present an overview of HIV-associated distal symmetric polyneuropathy (HIV-DSP) and other HIV-related peripheral neuropathies in the post-highly active retroviral therapy era.

RECENT FINDINGS

HIV-DSP has become the most common neurologic complication of HIV largely due to the prolonged survival of HIV-positive patients with the advent of highly active retroviral therapy. HIV-DSP can be attributed to the disease itself or to secondary effects of certain HAART agents, and often the two disease entities cannot be distinguished. HIV-DSP can lead to significant morbidity and interfere with daily activities. Diagnosis can be obtained from a detailed history and neurologic exam revealing absent ankle jerks and abnormal, vibratory perception or decreased pinprick or temperature. Supporting studies include nerve conduction studies and skin biopsy. Although there are no United States Food and Drug Administration-approved treatments for HIV-DSP, clinicians often use off-label medications, including antidepressants, anticonvulsants, topical agents and other analgesics.

SUMMARY

The prevalence of those affected by HIV-DSP will continue to grow with the aging population of HIV-infected individuals. Compared to the diabetic neuropathy drug trials, trials in both symptomatic and disease-modifying agents for HIV-DSP have had little success. Other forms of HIV-related peripheral neuropathies are discussed briefly, and include acute and chronic inflammatory demyelinating polyneuropathy, autonomic neuropathy, polyradiculopathy, mononeuropathies, mononeuritis multiplex, cranial neuropathies, and amyotrophic lateral sclerosis-like motor neuropathy.

Understanding the etiology and management of HIV-associated peripheral neuropathy

HIV may cause several forms of peripheral neuropathy, the most common of which is distal symmetric polyneuropathy (DSP) characterized by pain and sensory deficits in a stocking-glove distribution. The pathophysiology of DSP remains largely unknown but is thought to be related both to the neurotoxicity of HIV-through indirect immunomodulatory mechanisms-and to the neurotoxic effects of anti-retroviral therapies, most notably the dideoxynucleoside reverse transcription inhibitors or so-called d-drugs. Determining whether symptoms arise from the virus or the treatment poses a challenge to the clinician who must decide if a patient's HAART regimen should be altered. Treatment of symptoms related to HIV-DSP is a difficult task and there is no evidence that the traditional agents used in chronic neuropathic pain are efficacious in the HIV-DSP population. Indeed few pharmacologic agents have proven efficacy in HIV-DSP - these include cannabis and the capsaicin 8 % dermal patch. As such, alternative, non-pharmacologic therapies are being investigated. More research is needed to further elucidate the complex pathophysiology of HIV-DSP which may yield additional therapies for these patients.

HIV-related neuropathy: current perspectives

Distal symmetric polyneuropathy (DSP) related to human immunodeficiency virus (HIV) is one of the most common neurologic complications of HIV, possibly affecting as many as 50% of all individuals infected with HIV. Two potentially neurotoxic mechanisms have been proposed to play a crucial role in the pathogenesis of HIV DSP: neurotoxicity resulting from the virus and its products; as well as adverse neurotoxic effects of medications used in the treatment of HIV. Clinically, HIV DSP is characterized by a combination of signs and symptoms that include decreased deep tendon reflexes at the ankles and decreased sensation in the distal extremities as well as paresthesias, dysesthesias, and pain in a symmetric stocking-glove distribution. These symptoms are generally static or slowly progressive over time, and depending on the severity, may interfere significantly with the patient's daily activities. In addition to the clinical picture, nerve conduction studies and skin biopsies are often pursued to support the diagnosis of HIV DSP. Anticonvulsants, antidepressants, topical agents, and nonspecific analgesics may help relieve neuropathic pain. Specifically, gabapentin, lamotrigine, pregabalin, amitriptyline, duloxetine, and high-dose topical capsaicin patches have been used in research and clinical practice. Further research is needed to elucidate the pathogenesis of HIV DSP, thus facilitating the development of novel treatment strategies. This review discusses the epidemiology, pathophysiology, clinical findings, diagnosis, and management of DSP in the setting of HIV.