Acupuncture in the Management of Pain of Musculoskeletal and Neurologic Origin

Comprehensive consideration of multiple determinants from evidence to recommendations in guidelines for most traditional Chinese medicine was suboptimal: a systematic review

BACKGROUND

The overall comprehensive consideration of the factors influencing the recommendations in the traditional Chinese medicine (TCM) guidelines remains poorly studied. This study systematically evaluate the factors influencing recommendations formation in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) clinical practice guidelines (CPGs) and TCM CPGs.

METHODS

This was a methodological review in which we searched six databases and multiple related websites. The GRADE CPGs were identified as the guidelines developed by the GRADE Working Group or the two Co-Chairs. For the TCM CPGs, we randomly selected guidelines that were published by the TCM or integrative medicine academic societies from China mainland (published by the TCM or integrative medicine academic societies of China mainland). Two reviewers independently screened and extracted data. We included CPGs published in 2018-2022. We extracted information on the influencing factors of evidence to recommendation and conducted the analyses using descriptive statistics and calculated the proportion of relevant items by IBM SPSS Statistics and Microsoft Excel to compare the differences between the GRADE CPGs and the TCM CPGs.

RESULTS

Forty-five GRADE CPGs (including 912 recommendations) and 88 TCM CPGs (including 2452 recommendations) were included. TCM recommendations mainly considered the four key determinants of desirable anticipated effects, undesirable anticipated effects, balance between desirable and undesirable effects, certainty of evidence, with less than 20% of other dimensions. And TCM CPGs presented more strong recommendations (for or against) and inappropriate discordant recommendations than GRADE CPGs. GRADE CPGs were more comprehensive considered about the factors affecting the recommendations, and considered more than 70% of all factors in the evidence to recommendation.

CONCLUSIONS

The TCM CPGs lack a comprehensive consideration of multiple influencing determinants from evidence to recommendations. In the future, the correct application of the GRADE approaches should be emphasized.

Characteristics and quality of clinical practice guidelines addressing acupuncture interventions: a systematic survey of 133 guidelines and 433 acupuncture recommendations

OBJECTIVE

To systematically summarise acupuncture-related Clinical Practice Guidelines (CPGs)'s clinical and methodological characteristics and critically appraise their methodology quality.

DESIGN

We summarised the characteristics of the guidelines and recommendations and evaluated their methodological quality using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument.

DATA SOURCES

Nine databases were searched from 1 January 2010 to 20 September 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included the latest version of acupuncture CPGs, which must have used at least one systematic review addressing the benefits and harms of alternative care options to inform acupuncture recommendations.

DATA EXTRACTION AND SYNTHESIS

Reviewers, working in pairs, independently screened and extracted data. When there are statistical differences among types of CPGs, we reported the data by type in the text, but when not, we reported the overall data.

RESULTS

Of the 133 eligible guidelines, musculoskeletal and connective tissue diseases proved the most commonly addressed therapeutic areas. According to the AGREE II instrument, the CPG was moderate quality in the domain of clarity of scope and purpose, clarity of presentation, the rigour of development, stakeholder involvement and low quality in editorial independence, and applicability. The study identified 433 acupuncture-related recommendations; 380 recommended the use of acupuncture, 28 recommended against the use of acupuncture and 25 considered acupuncture but did not make recommendations. Of the 303 recommendations that used Grading of Recommendations Assessment, Development and Evaluation to determine the strength of recommendations, 152 were weak recommendations, 131 were strong recommendations, of which 104 were supported by low or very low certainty evidence (discordant recommendations).

CONCLUSION

In the past 10 years, a large number of CPGs addressing acupuncture interventions exist. Although these guidelines may be as or more rigorous than many others, considerable room for improvement remains.

The intersection between integrative medicine and neuropathic pain: A case report

INTRODUCTION

Neuropathic pain is a debilitating condition caused by lesion or disease of the somatosensory nervous system. Integrative modalities such as yoga, acupuncture, and massage are evidenced therapies for pain management. Additionally, medical cannabis and cannabinoids are emerging therapies for treatment of neuropathic pain (4,28). The authors of this study report a case of chronic neuropathic pain treated with integrative interventions.

CASE PRESENTATION

The patient is a 71-year-old female with a past medical history of chronic neuropathic pain in her lower back and legs, degenerative arthritis, restless leg syndrome, carpal tunnel syndrome, and severe, chronic anxiety, presenting with worsening neuropathic pain. After over a decade of unsuccessful allopathic treatment, the patient sought out a more integrative approach to her pain management. A regimen of acupuncture, massage, gentle yoga, and medical cannabis was recommended. During the COVID-19 pandemic, she was unable to continue most of the integrative modalities and reported a significant increase in pain. The patient then joined a weekly Mind and Body program and began acupuncture treatments again, reporting a steady improvement in pain.

CONCLUSION

The patient's chronic neuropathic pain was effectively treated using an integrative approach, with a combination of acupuncture, massage, yoga, mind-body approaches, and medical cannabis. While this case originally presented similarly to other cases of chronic neuropathic pain, it is unique in that it demonstrates the importance of an individualized complex approach, highlighting the patient's driven engagement in integrative modalities and medical cannabis.

Efficacy of acupuncture versus sham acupuncture or waitlist control for patients with chronic plantar fasciitis: study protocol for a two-centre randomised controlled trial

INTRODUCTION

Plantar fasciitis (PF) is reported to be the most common cause of plantar heel pain. Acupuncture has been used for patients experiencing PF, but evidence of the efficacy of acupuncture on PF is limited. The primary objective of this trial is to compare combined acupuncture and sham acupuncture (SA) versus waitlist control for improving the level of pain experienced by patients suffering from chronic PF.

METHODS AND ANALYSIS

This will be a two-centre, parallel-group, sham and no-treatment controlled, assessor-blinded randomised trial. We will randomly allocate 120 participants with chronic PF to acupuncture, SA and waitlist control groups at a ratio of 2:1:1. Participants in the acupuncture and SA groups will receive a 30 min acupuncture or SA treatment for a total of 12 sessions over 4 weeks, with a 12-week follow-up. Participants in the waitlist control group will not undergo treatment for a period of 16 weeks but instead will have the option of 4 weeks (12 sessions) of acupuncture free of charge at the end of the follow-up period. The primary outcome will be the treatment response rate 4 weeks after randomisation, assessed as a minimum of 50% improvement in the worst pain intensity during the first steps in the morning compared with the baseline. All analyses will be performed with a two-sided p value of <0.05 considered significant following the intention-to-treat principle.

ETHICS AND DISSEMINATION

The study has been approved by the Ethical Committee of the Guang'anmen Hospital, China Academy of Chinese Medical Sciences (approval no. 2019-210-KY). The results will be disseminated through presentation at a peer-reviewed medical journal, the relevant conferences and scientific meetings.

TRIAL REGISTRATION

NCT04185259.

Comparison of electroacupuncture and manual acupuncture for patients with plantar heel pain syndrome: a randomized controlled trial

BACKGROUND

Plantar heel pain syndrome (PHPS), also known as plantar fasciitis, affects millions of people worldwide. Electroacupuncture (EA) and manual acupuncture (MA) are the two acupuncture modalities frequently used for PHPS in the clinical setting. However, which modality is more effective has yet to be determined.

OBJECTIVE

To examine whether EA is more effective than MA with regards to pain relief for patients with PHPS.

METHODS

Participants were randomly assigned (1:1) to receive 12 treatment sessions of EA or MA over 4 weeks with 24 weeks of follow-up. The primary outcome was the proportion of treatment responders, defined as patients with at least a 50% reduction from baseline in the worst pain intensity experienced during the first steps in the morning after a 4-week treatment, measured using a visual analogue scale (VAS, 0-100; higher scores signify worse pain). Analysis was by intention-to-treat.

RESULTS

Ninety-two patients with a clinical diagnosis of PHPS were enrolled from 29 July 2018 through 28 June 2019. Of the patients, 78 (85%) completed the treatment and follow-up. The primary outcome occurred in 54.8% (23/42) of the EA group compared to 50.0% (21/42) of the MA group after the 4-week treatment (difference -4.76, 95% confidence interval, -26.10 to 16.57, P = 0.662). There were no significant between-group differences for any secondary outcomes after 4 weeks of treatment and at 16 weeks and 28 weeks of follow-up. There were no serious treatment-related adverse events in either group.

CONCLUSION

Among patients with PHPS, EA did not have a better effect with respect to relieving pain intensity than MA at week 4, although both EA and MA appeared to have positive temporal effects, with decreased heel pain and improved plantar function.

TRIAL REGISTRATION NUMBER

ChiCTR1800016531 (Chinese Clinical Trial Registry).

The preemptive analgesia of pre-electroacupuncture in rats with formalin-induced acute inflammatory pain

Background

Electroacupuncture has been elicited to effectively alleviate the pain sensation. Preemptive analgesic effect of pre-electroacupuncture has also been suggested in recent studies, while the underlying analgesic mechanism of pre-electroacupuncture requires further investigation. This study aimed to explore the preemptive analgesia of pre-electroacupuncture in formalin-induced acute inflammatory pain model.

Methods

Forty rats were randomly divided into control, model, pre-electroacupuncture, and post-electroacupuncture group. Inflammatory pain model was induced via injecting 50 µl 5% formalin into the plantar surface of right hind paw, while the equal volume of saline injection in the control group. Rats in the pre-electroacupuncture group were treated with electroacupuncture at ipsilateral Zusanli (ST36) and Weizhong (BL40) acupoints (2 Hz, 1 mA) for 30 min before formalin injection, while received the same electroacupuncture treatment immediately after formalin injection in the post-electroacupuncture group. Flinching number and licking time were recorded during 60 min after formalin injection. Immunofluorescence and Western blot were used to detect the expression of ionized calcium binding adapter molecule 1 (Iba1) and c-fos in spinal cord. Moreover, enzyme-linked immunosorbent assay was applied to measure the secretion of IL-6, IFN-γ, IL-4, substance P, and calcitonin gene-related peptide in spinal cord.

Results

Paw flinching and licking were obviously induced by formalin injection. Iba1, c-fos, proinflammatory cytokines (IL-6 and IFN-γ), and pain neurotransmitters (substance P and calcitonin gene-related peptide) were dramatically increased in the L4-5 spinal cord after formalin injection, while anti-inflammatory cytokine IL-4 was decreased. Pre-electroacupuncture and post-electroacupuncture administration significantly attenuated formalin-induced nociceptive effects, spinal microglia and neurons activation, proinflammatory cytokines and pain neurotransmitters upregulation, and upregulated the anti-inflammatory cytokine. Furthermore, these effects of pre-electroacupuncture were more significant than that of post-electroacupuncture.

Conclusions

This study illustrates the potential therapeutic effect of pre-electroacupuncture against acute inflammatory pain and reveals the mechanism underlying pre-electroacupuncture mediated analgesia, thus providing a novel preemptive analgesic treatment.

Electroacupuncture versus manual acupuncture in the treatment of plantar heel pain syndrome: study protocol for an upcoming randomised controlled trial

INTRODUCTION

Plantar heel pain syndrome(PHPS) is a common cause of heel pain. It may worsen a patient's quality of life, and potentially lead to knee, hip or lower back problems. Previous studies have shown that electroacupuncture (EA) and manual acupuncture (MA) are effective treatments for relieving pain in patients with PHPS. However, little evidence supports the use of one intervention over the other.

METHODS AND ANALYSIS

A total of 92 patients diagnosed with PHPS will be recruited and randomly assigned to an EA group or an MA group at a ratio of 1:1. Patients in both groups will receive a 30 min acupuncture treatment (three times per week) for a total of 12 sessions over 4 weeks. The primary outcome will be the proportion of patients with at least 50% reduction from baseline in the worst pain intensity measured by visual analogue scale (0-100, higher scores signify worse pain) at first steps in the morning after 4-week treatment. The secondary outcomes will include change in worst pain intensity at first steps in the morning, change in mean pain intensity at first steps in the morning, change in worst pain intensity during the day, change in mean pain intensity during the day, change in the pressure pain threshold, change in ankle-dorsiflexion range of motion, change in Foot and Ankle Ability Measure total score and subscale scores, patients' global improvement assessment, patients' expectations for acupuncture and safety evaluation. We will perform all statistical analysis following the intention-to-treat principle.

ETHICS AND DISSEMINATION

The study has been approved by our ethics review board (Protocol Approval No. 2018-010-KY). The study findings will be disseminated through presentation at a high-impact medical journal, with online access. We also to plan to present it in select conferences and scientific meetings.

TRIAL REGISTRATION

ChiCTR-1800016531; Pre-results.

Effect of electro-acupuncture on the BDNF-TrkB pathway in the spinal cord of CCI rats

Microglia, which comprise a sensor for pathological events in the central nervous system, may be triggered by nerve injury and transformed from a quiescent state into an activated state; ionised calcium binding adaptor molecule 1 (Iba1) is a sensitive marker associated with activated microglia. Accumulated evidence suggests that spinal activated microglia and the brain-derived neurotrophic factor (BDNF)-tyrosine kinase receptor B (TrkB) signalling pathway play major roles in the production and development of neuropathic pain. Electro-acupuncture (EA) has a positive effect on relieving chronic neuropathic pain; however, the underlying mechanisms remain unclear. To determine the significance of EA in the treatment of neuropathic pain mediated by activated microglia and the BDNF-TrkB signalling pathway in the spinal cord, the mechanical withdrawal threshold (MWT) and thermal withdrawal latency (TWL) values were recorded to assess hyperalgesia and allodynia. In addition, the amount of activated microglia and BDNF were assessed via immunofluorescence. Iba1, BDNF and TrkB mRNA expression levels were examined using qPCR; the protein levels of BDNF, p-TrkB and TrkB in the spinal cord were analysed via western blotting. The present study demonstrated that EA treatment increased the MWT and TWL values. EA significantly inhibited the proportion of activated microglia and BDNF expression in the spinal cord after chronic constrictive injury (CCI). Furthermore, EA decreased the expression of BDNF and TrkB at both the mRNA and protein levels in the spinal cord of CCI rats. These findings suggest that the analgesic effect of EA may be achieved by inhibiting the activation of spinal microglia and subsequently blocking the BDNF-TrkB signalling pathway.

Acupuncture for anxiety

This review aims to examine the volume and quality of the evidence base which supports the use of acupuncture in the treatment of anxiety disorders. A literature review was conducted using Pubmed, Google scholar, AMED, BMJ, Embase, Psychinfo, Cochrane library, Ingenta connect, and Cinahl databases. Keywords were "anxiety,""anxious,""panic,""stress,""phobia," and "acupuncture" limited to year 2000 onwards and English language where available. The quality of research examining the use of acupuncture in the treatment of anxiety disorders is extremely variable. There is enormous variety regarding points used, number of points used in a session, duration of sessions, frequency of treatment and duration of treatment programme. While the generally poor methodological quality, combined with the wide range of outcome measures used, number and variety of points, frequency of sessions, and duration of treatment makes firm conclusions difficult. Against this, the volume of literature, consistency of statistically significant results, wide range of conditions treated and use of animal test subjects suggests very real, positive outcomes using a treatment method preferred by a population of individuals who tend to be resistant to conventional medicine.

Aging with spinal cord injury

The years after SCI may be associated with acceleration of the aging process because of diminished physiologic reserves and increased demands on functioning body systems. Clinicians with expertise in the treatment and prevention of SCI-specific secondary complications need to collaborate with gerontologists and primary care specialists and need to invest in the training of future physicians to ensure a continuum of accessible, cost-effective, and high-quality care that meets the changing needs of the SCI population. Managed care payers often do not adequately cover long-term disability needs to prevent secondary SCI-specific complications. In this era of increasing accountability, evidence-based clinical practice guidelines are needed to document scientific evidence and professional consensus to effectively diagnose, treat, and manage clinical conditions; to reduce unnecessary testing and procedures; and to improve patient outcomes. Longitudinal research is needed to minimize cohort effects that contribute to misinterpretation of cross-sectional findings as representative of long-term changes in health and functioning. However, longitudinal studies confound chronologic age, time since injury, and environmental change. Thus, time-sequential research, which controls for such confounding effects, is essential, as is research on the effects of gender,culture, and ethnicity. If we consider how much progress has been made over the past 50 years with respect to SCI mortality related to infectious disease, we can expect to achieve even greater progress against the effects of aging in the next 50 years. Recent developments in molecular biology regarding growth and neuro-trophic factors are bringing us closer to the goal of repairing the damaged spinal cord. The challenge remains for rehabilitation professionals to provide the most comprehensive and holistic approach to long-term follow-up, with an emphasis on health promotion and disease prevention, to postpone functional decline and enhance QOL.

Acupuncture and arthroscopic acromioplasty

BACKGROUND

Acupuncture alleviates acute and chronic shoulder pain. Yet it has not been determined whether acupuncture is useful following musculoskeletal surgery.

HYPOTHESIS

Compared to sham acupuncture, arthroscopic acromioplasty subjects who received real acupuncture would manifest significantly better recovery as demonstrated by: UCLA shoulder scale, improved range of motion, diminished pain, decreased need and duration of analgesic use, and enhanced patient satisfaction.

METHODS

Forty arthroscopic acromioplasty patients were randomized to real or sham acupuncture. UCLA shoulder scale scores, pain intensity, analgesic use, range of motion, and quality of life were monitored for four months. Data were analyzed with the general linear model ANOVA for repeated measures.

RESULTS

Thirty-five subjects completed the study. Real acupuncture subjects scored significantly better on UCLA shoulder scale (p<0.000); pain intensity (p<0.022); self-reported analgesic use (p<0.008); angles of abduction (p<0.046); and in six of eight health status questionnaire components.

CONCLUSIONS

Following arthroscopic acromioplasty, real acupuncture compared to sham acupuncture offered significantly greater improvement via: (1) lower pain level, (2) less analgesic use, (3) range of motion, and (4) patient satisfaction.

Treatments for chronic pain associated with spinal cord injuries: many are tried, few are helpful

OBJECTIVE

The objective was to investigate, in two community samples of people with spinal cord injuries, the frequency of use of different pain treatments and the perceived helpfulness of these treatments.

DESIGN AND SETTING

A postal survey was conducted in the community.

PARTICIPANTS

The participants were 471 persons aged 18 years or older who had spinal cord injuries and pain. There were 2 separate samples (n = 308 and n = 163).

OUTCOME MEASURES

The pain treatments used, the helpfulness of these treatments, and the Chronic Pain Grade questionnaire answers were assessed.

RESULTS

Respondents reported multiple pain treatments (range of 0-14 and median of 4 in sample 1; range of 0-16 and median of 4 in sample 2). The most commonly reported treatments were oral medications and physical therapy. Medication types most commonly reported were nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids. The treatments rated as most helpful were opioid medications, physical therapy, and diazepam therapy, and those rated as least helpful were spinal cord stimulation, counseling or psychotherapy, administration of acetaminophen, and administration of amitriptyline. Alternative treatments reported as most helpful were massage therapy and use of marijuana. Acupuncture was tried by many but was rated as only moderately helpful.

CONCLUSIONS

This survey of two large samples of community-dwelling individuals with spinal cord injury-related chronic pain indicates that multiple pain treatments are tried but only a few are rated as more than somewhat helpful. Furthermore, the treatments that are most commonly reported are not always those that are rated as most helpful. The findings point to a number of potentially fruitful directions for future research.

Acupuncture and Trager psychophysical integration in the treatment of wheelchair user's shoulder pain in individuals with spinal cord injury

OBJECTIVE

To determine the effectiveness of acupuncture and Trager Psychophysical Integration (a form of manual therapy) in decreasing chronic shoulder pain in wheelchair users with spinal cord injury (SCI).

DESIGN

A prospective clinical trial, with subjects randomized to acupuncture or Trager treatment condition. Subjects served as their own controls by including a 5-week pretreatment baseline period and a 5-week posttreatment follow-up period.

SETTING

Rehabilitation hospital research department.

PARTICIPANTS

Eighteen subjects with chronic SCI and chronic shoulder pain who used manual wheelchairs as their primary means of mobility.

INTERVENTION

Ten acupuncture or 10 Trager treatments over a 5-week period.

MAIN OUTCOME MEASURES

Changes in performance-corrected Wheelchair User's Shoulder Pain Index (PC-WUSPI) scores during baseline, treatment, and follow-up periods were assessed by using analysis of variance.

RESULTS

The mean PC-WUSPI score +/- standard deviation of the 18 subjects at entry was 48.9 +/- 24.6 (range, 8.0-94). No significant change in mean PC-WUSPI scores occurred during the pretreatment baseline period. Mean PC-WUSPI scores decreased significantly during the treatment period in both the acupuncture (53.4%; 23.3 points) and Trager (53.8%; 21.7 points) treatment groups. The reduced PC-WUSPI scores were maintained in both groups throughout the 5-week posttreatment follow-up period.

CONCLUSION

Acupuncture and Trager are both effective treatments for reducing chronic shoulder pain associated with functional activities in persons with SCI.