Is acupuncture effective in treating chronic pain after spinal cord injury?

Mechanical diagnosis and therapy in musculoskeletal pain of individuals with spinal cord injury

CONTEXT/OBJECTIVE

Musculoskeletal pain (MSKP) has high prevalence in individuals with spinal cord injury (SCI). Mechanical Diagnosis and Therapy (MDT) is a method focused on identifying the pain source in the musculoskeletal system and presents good results in pain relief in people without neurological impairment. However, no studies have investigated the use of MDT in SCI population. The objective was to evaluate the applicability and outcomes of MDT treatment in pain relief and independence improvement in daily activities of individuals with SCI presenting MSKP.

DESIGN

Single-arm trial.

SETTING

Rehabilitation Hospital.

PARTICIPANTS

Twenty-four individuals with SCI who presented MSKP.

INTERVENTION

MDT-certified physical therapist conducted assessments and treatments of pain according to the MDT approach.

OUTCOMES MEASURES

Numeric rating scale (NRS) was used to measure pain and Pain Disability Index (PDI) and Patient-Specific Functional Scale (PSFS) to evaluate daily activities.

RESULTS

Significant median decreases were found for NRS (from 7 to 2) and PDI (from 27 to 8) after MDT, whereas PSFS score presented a significant mean increase (from 3.2-7.7). The average decrease in pain after MDT treatment was 70.9% (5.36 on the NRS).

CONCLUSION

MDT can reduce pain and enhance independence in daily activities in individuals with SCI and MSKP.

The effect of neuropathic pain treatments on pain interference following spinal cord injury: A systematic review

CONTEXT

Neuropathic pain is a common and debilitating condition following SCI. While treatments for neuropathic pain intensity have been reviewed, the impact on pain interference has not been summarized.

OBJECTIVE

To systematically review the effect of neuropathic pain interventions on pain interference in individuals with spinal cord injury.

METHODS

This systematic review included randomized controlled trials and quasi-experimental (non-randomized) studies which assessed the impact of an intervention on pain interference in individuals with spinal cord injury and neuropathic pain. Articles were identified by searching MEDLINE (1996 to April 11, 2022), EMBASE (1996 to April 11, 2022), PsycInfo (1987 to April, week 2, 2022). Studies were assessed for methodologic quality using a modified GRADE approach and were given quality of evidence (QOE) scores on a 4-point scale ranging from very low to high.

RESULTS

Twenty studies met the inclusion criteria. These studies fell into the following categories: anticonvulsants (n = 2), antidepressants (n = 1), analgesics (n = 1), antispasmodics (n = 1), acupuncture (n = 2), transcranial direct current stimulation (n = 1), active cranial electrotherapy stimulation (n = 2), transcutaneous electrical nerve stimulation (n = 2), repetitive transcranial magnetic stimulation (n = 1), functional electrical stimulation (n = 1), meditation and imagery (n = 1), self-hypnosis and biofeedback (n = 1), and interdisciplinary pain programs (n = 4).

CONCLUSION

When considering studies of moderate to high quality, pregabalin, gabapentin, intrathecal baclofen, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation (in 1 of 2 studies) were shown to have beneficial effects on pain interference. However, due to the low number of high-quality studies further research is required to confirm the efficacy of these interventions prior to recommending their use to reduce pain interference.

Scalp Acupuncture on the Immediate and Prolonged Motor Recovery in Spinal Cord Injury: a Case Report

Spinal cord injury (SCI) is one of the main causes of lifelong motor impairment and is associated with important secondary complications. Thus, multifaceted treatments are needed for early functional recovery. Currently, in cases of SCI, surgery, stem cell treatment, medication, and physical therapy are used to repair and restore neuronal activity. Additionally, encouraging results have been reported on the use of acupuncture to modulate neuronal plasticity. Here, we present an SCI case involving a burst fracture at the L3 level, which was treated for 21 days using scalp acupuncture with residential physical therapy. Activation of the motor area was observed after the 1st day of treatment, with the patient completely regaining power and range of motion in the knees, Additionally, over 21 days, the patient exhibited markedly improved motor recovery and functional outcomes, which had not been observed over the previous six months. This report highlights the importance of complementing scalp acupuncture with intensive physical therapy for better motor recovery.

Potential mechanisms of acupuncture for neuropathic pain based on somatosensory system

Neuropathic pain, caused by a lesion or disease of the somatosensory system, is common and distressing. In view of the high human and economic burden, more effective treatment strategies were urgently needed. Acupuncture has been increasingly used as an adjuvant or complementary therapy for neuropathic pain. Although the therapeutic effects of acupuncture have been demonstrated in various high-quality randomized controlled trials, there is significant heterogeneity in the underlying mechanisms. This review aimed to summarize the potential mechanisms of acupuncture on neuropathic pain based on the somatosensory system, and guided for future both foundational and clinical studies. Here, we argued that acupuncture may have the potential to inhibit neuronal activity caused by neuropathic pain, through reducing the activation of pain-related ion channels and suppressing glial cells (including microglia and astrocytes) to release inflammatory cytokines, chemokines, amongst others. Meanwhile, acupuncture as a non-pharmacologic treatment, may have potential to activate descending pain control system via increasing the level of spinal or brain 5-hydroxytryptamine (5-HT), norepinephrine (NE), and opioid peptides. And the types of endogenously opioid peptides was influenced by electroacupuncture-frequency. The cumulative evidence demonstrated that acupuncture provided an alternative or adjunctive therapy for neuropathic pain.

Pharmacological and non-pharmacological therapeutic interventions for the treatment of spinal cord injury-induced pain

Spinal cord injury (SCI) is a complex neurophysiological disorder, which can result in many long-term complications including changes in mobility, bowel and bladder function, cardiovascular function, and metabolism. In addition, most individuals with SCI experience some form of chronic pain, with one-third of these individuals rating their pain as severe and unrelenting. SCI-induced chronic pain is considered to be "high impact" and broadly affects a number of outcome measures, including daily activity, physical and cognitive function, mood, sleep, and overall quality of life. The majority of SCI pain patients suffer from pain that emanates from regions located below the level of injury. This pain is often rated as the most severe and the underlying mechanisms involve injury-induced plasticity along the entire neuraxis and within the peripheral nervous system. Unfortunately, current therapies for SCI-induced chronic pain lack universal efficacy. Pharmacological treatments, such as opioids, anticonvulsants, and antidepressants, have been shown to have limited success in promoting pain relief. In addition, these treatments are accompanied by many adverse events and safety issues that compound existing functional deficits in the spinally injured, such as gastrointestinal motility and respiration. Non-pharmacological treatments are safer alternatives that can be specifically tailored to the individual and used in tandem with pharmacological therapies if needed. This review describes existing non-pharmacological therapies that have been used to treat SCI-induced pain in both preclinical models and clinical populations. These include physical (i.e., exercise, acupuncture, and hyper- or hypothermia treatments), psychological (i.e., meditation and cognitive behavioral therapy), and dietary interventions (i.e., ketogenic and anti-inflammatory diet). Findings on the effectiveness of these interventions in reducing SCI-induced pain and improving quality of life are discussed. Overall, although studies suggest non-pharmacological treatments could be beneficial in reducing SCI-induced chronic pain, further research is needed. Additionally, because chronic pain, including SCI pain, is complex and has both emotional and physiological components, treatment should be multidisciplinary in nature and ideally tailored specifically to the patient.

The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury: 2021 update

STUDY DESIGN

Clinical practice guidelines.

OBJECTIVES

The objective was to update the 2016 version of the Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI).

SETTING

The guidelines are relevant for inpatient, outpatient and community SCI rehabilitation settings in Canada.

METHODS

The guidelines were updated in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations.

RESULTS

The working group identified and reviewed 46 additional relevant articles published since the last version of the guidelines. The panel agreed on 3 new screening and diagnosis recommendations and 8 new treatment recommendations. Two key changes to these treatment recommendations included the introduction of general treatment principles and a new treatment recommendation classification system. No new recommendations to model of care were made.

CONCLUSIONS

The CanPainSCI recommendations for the management of neuropathic pain after SCI should be used to inform practice.

Management of pain in individuals with spinal cord injury: Guideline of the German-Speaking Medical Society for Spinal Cord Injury

Introduction: Pain is a prominent complication in spinal cord injury (SCI). It can either occur as a direct or as an indirect consequence of SCI and it often heavily influences the quality of life of affected individuals. In SCI, nociceptive and neuropathic pain can equally emerge at the same time above or below the level of injury. Thus, classification and grading of pain is frequently difficult. Effective treatment of SCI-related pain in general and of neuropathic pain in particular is challenging. Current treatment options are sparse and their evidence is considered to be limited. Considering these aspects, a clinical practice guideline was developed as basis for an optimized, comprehensive and standardized pain management in SCI-related pain.

Methods: The German-Speaking Medical Society for Spinal Cord Injury (Deutschsprachige Medizinische Gesellschaft für Paraplegiologie – DMGP) developed a clinical practice guideline that received consensus from seven further German-speaking medical societies and one patient organization. The evidence base from clinical trials and meta-analyses was summarized and subjected to a structured consensus-process in accordance with the regulations of the Association of Scientific Medical Societies in Germany (AWMF) and the methodological requirements of the “German instrument for methodological guideline appraisal”.

Results: This consensus-based guideline (S2k classification according to the AWMF guidance manual and rules) resulted in seven on-topic statements and 17 specific recommendations relevant to the classification, assessment and therapy of pain directly or indirectly caused by SCI. Recommended therapeutic approaches comprise pharmacological (e.g. nonsteroidal anti-inflammatory drugs or anticonvulsants) and non-pharmacological (e.g. physical activity or psychotherapeutic techniques) strategies for both nociceptive and neuropathic pain.

Discussion: Assessment of SCI-related pain is standardized and respective methods in terms of examination, classification and grading of pain are already in use and validated in German language. In contrast, valid, evidence-based and efficient therapeutic options are limited and ask for further clinical studies, ideally randomized controlled trials and meta-analyses.

A Comparative Study of Two Modalities in Pain Management of Patients Presenting with Chronic Brachial Neuralgia

Objectives: The study aims to assess, evaluate, and compare the efficacy of acupressure and hypnotherapy in the management of pain in patients presenting with chronic brachial neuralgia (CBN). Design: Randomized controlled trial. Settings/location: Department of Orthopaedic Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia. Subjects: Forty patients with CBN following traumatic brachial plexus injury from 2012 to 2017. Intervention: Therapy for a duration of 1 month in two groups; subjects in the hypnotherapy group received a weekly session of clinical hypnotherapy (total of four times) using a standardized protocol, while subjects in the acupressure group were guided by an acupuncturist during the initial session, received 2 month take home supply of acupressure patches, and were reviewed fortnightly. Outcome measures: The Visual Analog Scale, the Brief Pain Inventory, and the SF-36v2^® Health Survey were recorded at different time points; 1 month pretreatment (week 0), pretreatment (week 4), post-treatment (week 8), and 4 months post-treatment (week 20). Results: There was a statistically significant improvement in the average pain intensity from pretreatment to post-treatment score in both groups. The pain intensity increased 4 months later; however, the pain intensity was still significantly reduced in comparison with pretreatment scores. The study suggests that both treatment outcomes are effective in terms of alleviating pain and improving quality of life in subjects with CBN, to a different degree. Conclusion: Overall, both therapies were able to improve the pain intensity and quality of life significantly during the treatment period. Hypnotherapy was observed to have a better carryover effect compared to acupressure, especially in terms of improving quality of life and the mental component score.

Acupuncture for Central Pain Affecting the Ribcage following Traumatic Brain Injury and Rib Fractures – a Case Report

This case report describes the use of acupuncture in the management of chronic central pain in a 51 year old man following severe traumatic brain injury and multiple injuries including rib fractures. The patient reported rapid and significant improvements in pain and mood during a course of acupuncture treatment. Chronic pain following traumatic brain injury is a significant problem. Chronic pain after rib fractures is also commonly reported. Acupuncture is widely used in the management of pain but its use has been reported rarely in the traumatic brain injury literature. This case report suggests that acupuncture may be a useful option to consider in these patients. Outcome was assessed formally using a 0 10 verbal numerical rating scale for pain, and the Hospital Anxiety and Depression Scale (HADS) for psychological status before and after the course of treatment. These scales are widely used in clinical practice as well as in research involving patients with traumatic brain injury, although they have not been validated in this population. The changes in this patient's outcome scores were not consistent with the benefits he reported. Treatment of this patient highlighted the difficulties of using standardised self rating scales for patients with cognitive impairment. The report also discusses the effects of acupuncture on this patient's mood.

Spinal Cord Injury: How Could Acupuncture Help?

Spinal cord injury (SCI) is one of the most common causes of death and disability worldwide, and it can result in both permanent disability and serial complications in patients. Research shows that patients with SCI complications are often interested in acupuncture for symptomatic relief. Therefore, the issue of physicians advising their patients regarding the use of acupuncture to alleviate SCI complications becomes pertinent. We review and summarize two types of relevant publications: (1) literature concerning acupuncture for SCI and its complications and (2) underlying mechanisms of acupuncture therapy for SCI. Clinical trials and reviews have suggested that acupuncture effectively manages a range of post-SCI complications, including motor and sensory dysfunction, pain, neurogenic bowel and bladder, pressure ulcers, spasticity, and osteoporosis. The effect of acupuncture on post-SCI orthostatic hypotension and sexual dysfunction remains unclear. Decreased oxidative stress, inhibition of inflammation and neuronal apoptosis, regulation of the expression and activity of endogenous biological mediators, and increased regenerative stem cell production are the possible mechanisms of acupuncture therapy for SCI. Although many limitations have been reported in previous studies, given the evidence for the efficacy of acupuncture, we recommend that physicians should support the use of acupuncture therapy for SCI complications.

Auricular acupuncture for spinal cord injury related neuropathic pain: a pilot controlled clinical trial

OBJECTIVE

To obtain preliminary data on the effects of an auricular acupuncture protocol, Battlefield Acupuncture (BFA), on self-reported pain intensity in persons with chronic Spinal Cord Injury (SCI) and neuropathic pain.

DESIGN

Pilot randomized delayed entry single center crossover clinical trial at an outpatient rehabilitation and integrative medicine hospital center.

METHODS

Chronic (> one year post injury) ASIA impairment scale A through D individuals with SCI with injury level from C3 through T12 and below level neuropathic pain with at least five on the Numeric Rating Scale (NRS) were recruited. Twenty-four subjects were randomized to either an eight-week once weekly ten-needle BFA protocol (n = 13) or to a waiting list followed by the BFA protocol (n = 11).

OUTCOME MEASURES

The primary outcome measure was change in the pain severity NRS. Secondary outcome was the Global Impression of Change.

RESULTS

Demographically there were no significant differences between groups. Mean pain scores at baseline were higher in acupuncture than control subjects (7.75 ± 1.54 vs. 6.25 ± 1.04, P = 0.027). Although both groups reported significant reduction in pain during the trial period, the BFA group reported more pain reduction than the delayed entry group (average change in NRS at eight weeks -2.92 ± 2.11 vs. -1.13 ± 2.14, P = 0.065). There was a significant difference in groups when a group-by-time interaction in a mixed-effect repeated measures model (P = 0.014).

CONCLUSION

This pilot study has provided proof of concept that BFA has clinically meaningful effect on the modulation of SCI neuropathic pain.

Spinal cord injury-induced pain: mechanisms and treatments

Pain is a common consequence of a spinal cord injury (SCI) and has a major impact on quality of life through its impact on physical function, mood and participation in work, recreational and social activities. Several types of pain typically present following SCI with central neuropathic pain being a frequent and difficult to manage occurrence. Despite advances in our understanding of the mechanisms contributing to this type of pain and an increasing number of trials examining treatment efficacy, our ability to relieve neuropathic SCI pain is still very limited. Optimal management relies upon an integrated approach that uses a combination of pharmacological and nonpharmacological options.

The effect of virtual visual feedback on supernumerary phantom limb pain in a patient with high cervical cord injury: a single-case design study

We characterized the effect of virtual visual feedback (VVF) on supernumerary phantom limb pain (SPLP) in a patient with high cervical cord injury. The subject was a 22-year-old man diagnosed with complete spinal cord injury (level C2) approximately 5 years ago. We applied the ABA'B' single-case design and set phases B and B' as intervention phases for comparison. SPLP significantly improved in comparison of phase A with phase B and phase A with phase B'. We suggest that VVF reduces SPLP and the effect lasts after VVF.

Patients' perspectives on pain

Nociceptive and neuropathic pain (NP) are common consequences following spinal cord injury (SCI), with large impact on sleep, mood, work, and quality of life. NP affects 40% to 50% of individuals with SCI and is sometimes considered the major problem following SCI. Current treatment recommendations for SCI-NP primarily focus on pharmacological strategies suggesting the use of anticonvulsant and antidepressant drugs, followed by tramadol and opioid medications. Unfortunately, these are only partly successful in relieving pain. Qualitative studies report that individuals with SCI-related long-lasting pain seek alternatives to medication due to the limited efficacy, unwanted side effects, and perceived risk of dependency. They spend time and money searching for additional treatments. Many have learned coping strategies on their own, including various forms of warmth, relaxation, massage, stretching, distraction, and physical activity. Studies indicate that many individuals with SCI are dissatisfied with their pain management and with the information given to them about their pain, and they want to know more about causes and strategies to manage pain. They express a desire to improve communication with their physicians and learn about reliable alternative sources for obtaining information about their pain and pain management. The discrepancy between treatment algorithms and patient expectations is significant. Clinicians will benefit from hearing the patient´s voice.

Neuropathic pain post spinal cord injury part 1: systematic review of physical and behavioral treatment

BACKGROUND

Neuropathic pain has various physiologic and psychosocial aspects. Hence, there is a growing use of adjunct nonpharmacological therapy with traditional pharmacotherapy to reduce neuropathic pain post spinal cord injury (SCI).

OBJECTIVE

The purpose of this study was to conduct a systematic review of published research on nonpharmacological treatment of neuropathic pain after SCI.

METHODS

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing nonpharmacological treatment of pain post SCI. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a treatment or intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention was being studied. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale.

RESULTS

The 16 articles selected for this review fell into 1 of 2 categories of nonpharmacological management of pain after SCI: physical and behavioral treatments. The pooled sample size of all studies included 433 participants. Of the 16 studies included, 7 were level 1, 3 were level 2, and 6 were level 4 studies.

CONCLUSIONS

Physical interventions demonstrated the strongest evidence based on quality of studies and numbers of RCTs in the nonpharmacological treatment of post-SCI pain. Of these interventions, transcranial electrical stimulation had the strongest evidence of reducing pain. Despite a growing body of literature, there is still a significant lack of research on the use of nonpharmacological therapies for SCI pain.

Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study

OBJECTIVE

The study sought to explore the possibility of using acupuncture and massage therapy for relieving neuropathic pain following spinal cord injury (SCI).

DESIGN

30 individuals with SCI and neuropathic pain were assigned to treatment of either massage or acupuncture, with 15 individuals in each group. Both groups received treatment twice weekly for 6 weeks. Treatments were evaluated at the end of treatment and 2 months later (follow-up).

RESULTS

Data were analysed on an intention-to-treat basis. Within the groups, ratings of present pain, general pain, pain unpleasantness and coping improved significantly at the end of treatment after acupuncture compared to baseline values, and following massage therapy ratings of pain interference on the Multidimensional Pain Inventory improved. At follow-up no significant improvements were seen. Between-group differences were seen regarding ratings of worst pain intensity at the end of treatment, and regarding pain unpleasantness and coping with pain at follow-up, both in favour of acupuncture. At the end of treatment, eight of the 15 individuals receiving acupuncture and nine receiving massage reported an improvement on the Patient Global Impression of Change Scale, and at follow-up six patients in the acupuncture group and one patient in the massage group still reported a favourable effect from the treatment. Few side effects were reported and neither dropout from the study did this due to adverse events.

CONCLUSION

Neuropathic pain following SCI is often only partially responsive to most interventions. Results from this study indicate, however, that both acupuncture and massage therapy may relieve SCI neuropathic pain. For this reason, larger randomised controlled trials are warranted for assessing the long-term effects of these treatments.

A longitudinal analysis of emotional impact, coping strategies and post-traumatic psychological growth following spinal cord injury: A 10-year review

OBJECTIVES

To review emotional impact, psychological growth and coping strategies in a sample of traumatic spinal cord injured people from 12 weeks post-injury to 10 years post-hospital discharge.

DESIGN

Longitudinal, multiple wave panel design.

METHODS

Eighty-seven people with traumatically acquired spinal cord injuries were assessed at 12 weeks post-injury and followed up 10 years later (43% of the original sample responded). The Beck Depression Inventory, the State Anxiety Inventory, the COPE Scale, the Functional Independence Measure and the Social Support Inventory were completed on both occasions.

RESULTS

Rates of anxiety and depression had changed little over the 10-year period. Two-thirds of the sample showed no signs or symptoms of depression. Coping strategies remained relatively stable over time, statistically significant regression models (coping strategies at week 12 post-injury) predicted one-third of the variance in depression at year 10. Rates of post-traumatic psychological growth were associated with higher levels of psychological distress.

CONCLUSIONS

These results suggest that many people living with spinal cord injury manage the consequences of their disability without significant levels of psychopathology. However, the coping strategies they employ remain critical in accounting for this adjustment. The relationship between post-traumatic growth and psychological well-being was found to be complex, raising many questions for future research.

Acupuncture's Effects in Treating the Sequelae of Acute and Chronic Spinal Cord Injuries: A Review of Allopathic and Traditional Chinese Medicine Literature

Each year, there are an estimated 12 000 individuals who sustain a spinal cord injury (SCI) in the United States. Improved understanding of the pathophysiology of SCI and its sequelae has over the past 50 years led to the development of medical treatments (especially urologic) that have enhanced short- and long-term survival from these injuries. The prevalence of individuals with SCI in this country is ~250 000 individuals; and beyond the incalculable personal consequences of these devastating neurologic injuries, substantial direct and indirect societal costs result from the sequelae of SCI including paralysis, sensory loss, chronic pain, decubiti and bladder and/or bowel incontinence. The purpose of this treatise is to review the allopathic and traditional Chinese medicine (TCM) literature available through MEDLINE, PubMed and eCAM search engines that discuss the potential uses of acupuncture to treat acute and chronic spinal cord injuries and their sequelae, and present the neurophysiologic mechanisms for acupuncture's beneficial effects. There is evidence that use of electroacupuncture in acute SCI may significantly improve long-term neurologic recovery from these injuries both in terms of motor, sensory and bowel/bladder function with essentially no risk. Acupuncture may even improve neurourologic function in individuals with chronic SCI, and help with management with chronic pain associated with these injuries.

What is the efficacy of physical therapeutics for treating neuropathic pain in spinal cord injury patients?

OBJECTIVE

Evaluate the place and level of proof of physical therapeutics for treating neuropathic pain in spinal cord injury (SCI) patients.

METHOD

Literature review from three databases: PubMed, Embase, Pascal. The following keywords were selected: chronic neuropathic pain/non-pharmacological treatment; transcutaneous electrical nerve stimulation, physiotherapy, acupuncture, physical therapy, transcranial magnetic stimulation, heat therapy, ice therapy, cold therapy, massage, ultrasound, alternative treatment, complementary treatment, occupational therapy. The articles were analyzed using the double-reading mode.

RESULTS

Three techniques emerge from the literature: magnetic or electrical transcranial stimulation, transcutaneous electrical nerve stimulation and acupuncture. Even though the first method is not easily accessible on a daily basis it is the one that yields the most promising results validated by Grade B studies. Healthcare professionals remain faithful to pain-relieving transcutaneous neurostimulation for both segmental neuropathic pain and below-level central neuropathic pain. Acupuncture is advocated by Canadian teams and could offer some interesting options; however, to this day, it does not have the methodological support and framework required to validate its efficacy. All other physical therapies are used in a random way. Only below-level massages are advocated by the patients themselves.

CONCLUSION

To this day, no study can validate the integration of physical therapy as part of the array of therapeutics used for treating neuropathic pain in SCI patients. In the future, it will require controlled and randomized therapeutic studies on homogenous groups of SCI patients, to control the various confusion factors.

The status and future of acupuncture clinical research

On November 8-9, 2007, the Society for Acupuncture Research (SAR) hosted an international conference to mark the tenth anniversary of the landmark National Institutes of Health Consensus Development Conference on Acupuncture. More than 300 acupuncture researchers, practitioners, students, funding agency personnel, and health policy analysts from 20 countries attended the SAR meeting held at the University of Maryland School of Medicine, Baltimore, MD. This paper summarizes important invited lectures in the area of clinical research. Specifically, included are: a review of the recently conducted German trials and observational studies on low-back pain (LBP), gonarthrosis, migraine, and tension-type headache (the Acupuncture Research Trials and the German Acupuncture Trials, plus observational studies); a systematic review of acupuncture treatment for knee osteoarthritis (OA); and an overview of acupuncture trials in neurologic conditions, LBP, women's health, psychiatric disorders, and functional bowel disorders. A summary of the use of acupuncture in cancer care is also provided. Researchers involved in the German trials concluded that acupuncture is effective for treating chronic pain, but the correct selection of acupuncture points seems to play a limited role; no conclusions could be drawn about the placebo aspect of acupuncture, due to the design of the studies. Overall, when compared to sham, acupuncture did not show a benefit in treating knee OA or LBP, but acupuncture was better than a wait-list control and standard of care, respectively. In women's health, acupuncture has been found to be beneficial for patients with premenstrual syndrome, dysmenorrhea, several pregnancy-related conditions, and nausea in females who have cancers. Evidence on moxibustion for breech presentation, induction of labor, and reduction of menopausal symptoms is still inconclusive. In mental health, evidence for acupuncture's efficacy in treating neurologic and functional bowel disorder is still inconclusive. For chronic cancer-related problems such as pain, acupuncture may work well in stand-alone clinics; however, for acute or treatment-related symptoms, integration of acupuncture care into a busy and complex clinical environment is unlikely, unless compelling evidence of a considerable patient benefit can be established.

Role of medullary GABA, opioids, and nociceptin in prolonged inhibition of cardiovascular sympathoexcitatory reflexes during electroacupuncture in cats

Electroacupuncture (EA) causes prolonged suppression of reflex elevations in blood pressure for 1-2 h in anesthetized preparations. A long-loop pathway involving the arcuate nucleus (ARC), ventrolateral periaqueductal gray, and rostral ventrolateral medulla (rVLM) is involved in sympathoinhibitory cardiovascular EA effects. However, the mechanisms and locations of the prolonged EA inhibition are unknown. We hypothesized that this effect is mediated through a long-loop pathway involving opioid, nociceptin, and gamma-aminobutyric acid (GABA) receptor activation in the rVLM. In anesthetized, ventilated cats application of bradykinin to the gallbladder every 10 min induced consistent reflex increases in blood pressure. Bilateral EA stimulation at the cardiovascular acupoints P5-6 overlying the median nerves reduced the reflex responses for at least 80 min. Bilateral blockade with kynurenic acid in the ARC 60 min after onset of EA inhibition reversed the cardiovascular response, suggesting a role for the ARC in the long-loop pathway during the prolonged inhibitory response. Unilateral microinjection with either an opioid or a GABA(A) antagonist in rVLM 50-60 min after the beginning of the EA response reversed EA inhibition of the cardiovascular excitatory reflex. Gabazine also reversed EA inhibition of cardiovascular premotor sympathetic rVLM neurons. Conversely, microinjection of a nociceptin/orphanin FQ peptide antagonist did not affect the prolonged inhibitory effect. Thus the ARC, an important component in the long-loop pathway in the EA cardiovascular response, is required for prolonged suppression of reflex cardiovascular excitatory responses by EA. Furthermore, in the rVLM, opioids and GABA, but not nociceptin, participate in the long-term EA-related inhibition of sympathoexcitatory cardiovascular responses.

Acupuncture for Chronic Shoulder Pain in Persons With Spinal Cord Injury: A Small-Scale Clinical Trial

OBJECTIVE

To determine the efficacy of acupuncture in the treatment of chronic musculoskeletal shoulder pain in subjects with spinal cord injury (SCI).

DESIGN

Randomized, double blind (participants, evaluator), placebo (invasive sham) controlled trial.

SETTING

Clinical research center.

PARTICIPANTS

Seventeen manual wheelchair-using subjects with chronic SCI and chronic musculoskeletal shoulder pain.

INTERVENTIONS

Participants were randomly assigned to receive 10 treatments of either acupuncture or invasive sham acupuncture (light needling of nonacupuncture points).

MAIN OUTCOME MEASURE

Changes in shoulder pain intensity were measured using the Wheelchair User's Shoulder Pain Index.

RESULTS

Shoulder pain decreased significantly over time in both the acupuncture and the sham acupuncture groups (P=.005), with decreases of 66% and 43%, respectively. There was no significant difference between the 2 groups (P=.364). There was, however, a medium effect size associated with the acupuncture treatment.

CONCLUSIONS

There appears to be an analgesic effect or a powerful placebo effect associated with both acupuncture and sham acupuncture. There was a medium treatment effect associated with the acupuncture, which suggests that it may be superior to sham acupuncture. This observation, along with the limited power, indicates that a larger, more definitive randomized controlled trial using a similar design is warranted.

Bayesian Estimation of Intervention Effect with Pre- and Post-Misclassified Binomial Data

We consider studies in which an enrolled subject tests positive on a fallible test. After an intervention, disease status is re-diagnosed with the same fallible instrument. Potential misclassification in the diagnostic test causes regression to the mean that biases inferences about the true intervention effect. The existing likelihood approach suffers in situations where either sensitivity or specificity is near 1. In such cases, common in many diagnostic tests, confidence interval coverage can often be below nominal for the likelihood approach. Another potential drawback of the maximum likelihood estimator (MLE) method is that it requires validation data to eliminate identification problems. We propose a Bayesian approach that offers improved performance in general, but substantially better performance than the MLE method in the realistic case of a highly accurate diagnostic test. We obtain this superior performance using no more information than that employed in the likelihood method. Our approach is also more flexible, doing without validation data if necessary, but accommodating multiple sources of information, if available, thereby systematically eliminating identification problems. We show via a simulation study that our Bayesian approach outperforms the MLE method, especially when the diagnostic test has high sensitivity, specificity, or both. We also consider a real data example for which the diagnostic test specificity is close to 1 (false positive probability close to 0).

Acupuncture stimulation of ST-36 (Zusanli) significantly mitigates acute lung injury in lipopolysaccharide-stimulated rats

BACKGROUND

We sought to investigate the potential therapeutic effects of acupuncture stimulation of ST-36 (Zusanli) on endotoxemia-induced acute lung injury in lipopolysaccharide (LPS)-stimulated rats.

METHODS

Sixty rats were randomized into six groups (n = 10): (i) lipopolysaccharide (LPS) control group, (ii) normal saline (N/S) control group, (iii) LPS plus ST-36 group, (iv) N/S plus ST-36 group, (v) LPS plus sham point (Sham) group, and (vi) N/S plus Sham group. Manual acupuncture stimulation of ST-36 (designated as 'ST-36') or a 'non-acupoint' (designated as 'Sham') was performed in lightly immobilized rats for 30 min. Then, LPS injection was employed to induce sepsis. Rats were killed at 6 h after LPS injection and lung injury, nitric oxide (NO) biosynthesis and inducible NO synthase (iNOS) expression were assayed.

RESULTS

Significant lung injury, pulmonary iNOS expression and systemic and pulmonary NO biosynthesis were noted in the LPS groups. Rats in the LPS plus Sham group had lung injury, pulmonary iNOS expression, systemic and pulmonary NO biosynthesis similar to those observed in the LPS group. However, the degree of lung injury, pulmonary iNOS expression and pulmonary NO biosynthesis, but not systemic NO biosynthesis, were significantly attenuated in the LPS plus ST-36 group as compared with those in both the LPS group and the LPS plus Sham group.

CONCLUSION

Acupuncture stimulation of ST-36 may be effective as a prophylaxis measure against sepsis. However, results from this study do not support the use of acupuncture for the treatment of sepsis.

Practical considerations in the assessment and treatment of pain in adults with physical disabilities

Adults aging with physical disabilities experience a variety of pain disorders that affect their functionality and QOL. It is important that clinicians caring for this population be knowledgeable about this common symptom and be able to perform a thorough history and physical examination. In addition, it is imperative to have a good working knowledge of the strengths and limitations of the treatments available.

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.

Estimation of the intervention effect in a non-randomized study with pre- and post-mismeasured binary responses

In non-randomized clinical studies, the regression phenomenon can confound interpretation of the effectiveness of an intervention. The regression effect arises due to daily variation and/or misclassification of the biologic marker used in selection as well as in the assessment of the intervention effect. We consider a scenario in which the selection criterion for a subject's participation in the study is such that he/she must have a positive diagnostic test at screening. The disease status is then reassessed at the end of intervention. Thus, two repeated measurements of a binary disease outcome are available, with only selected subjects having a second measurement upon follow-up. We propose methods for estimating the change in event probability resulting from implementing the intervention while adjusting for the misclassification that produces the regression effect. We extend this approach to estimation of both the placebo and intervention effects in placebo-controlled studies designed with a misclassified binary outcome. Analyses of two biomedical studies are used for illustration.

Non-pharmacological pain-relieving therapies in individuals with spinal cord injury: a patient perspective

OBJECTIVE

To assess the non-pharmacological treatments used and preferred by patients with spinal cord injury and pain.

DESIGN

A cross-sectional descriptive study.

INTERVENTIONS

One hundred and twenty three patients with spinal cord injury, matched for gender, age, level of lesion and completeness of injury were assessed in 1999 at the Spinalis SCI unit, Stockholm, Sweden and followed-up in a mailed survey 3 years later. In total, 82.1% of the questionnaires (n=101) were returned. Ninety of these patients still suffered pain and were thus included in the study.

MAIN OUTCOME MEASURES

Pain questionnaires, visual analogue scale (VAS), Hospital Anxiety and Depression Scale and Life Satisfaction instrument.

RESULTS

63.3% of the patients had tried non-pharmacological treatments, where acupuncture, massage and transcutaneous electrical nerve stimulation (TENS) were the most commonly tried. Predictive for having tried non-pharmacological treatment were high ratings of pain intensity, presence of aching pain, and cutting/stabbing pain.

CONCLUSION

Massage, and heat were the non-pharmacological treatments reported to result in the best pain alleviation. Results from our study suggest that we need to (re)evaluate the treatments offered to patients with spinal cord injury and pain and combine non-pharmacological and pharmacological treatments.

Design and analytic considerations for single-armed studies with misclassification of a repeated binary outcome

Due to logistics or prohibitive costs, clinical studies often rely upon a potentially misclassified binary outcome variable for assessing an intervention effect. We consider noncomparative single-armed studies that are sometimes necessary for ethical reasons, and we focus on the situation in which subjects are selected to receive the intervention contingent upon a positive screening test. Both initial misclassification at screening and a regression phenomenon impacting the error-prone follow-up outcome measure contribute to bias in the typical treatment effect estimate. We propose a study design involving the collection of internal validation data assuming the availability of a more demanding gold standard outcome measure. We pursue likelihood-based analysis and describe efficiency considerations relevant to two different treatment effect definitions. We identify four possible types of validation study observations, and discuss finding the optimal allocation into these four types in order to minimize the variance of the estimated treatment effect. The optimal allocation can be highly dependent upon whether a ratio or a difference measure is adopted to evaluate the intervention. The methods are illustrated numerically, and a real-life example motivating the proposed optimal design is provided.