Acupuncture Therapy in a Group Setting for Chronic Pain

Acupuncture may play a key role in anti-depression through various mechanisms in depression

Depression has emerged as a significant global health concern, exerting a profound impact on individuals, as evidenced by its high prevalence and associated suicide rates. Considering its pervasive nature, the absence of optimal treatment modalities remains a challenge. Acupuncture has garnered substantial clinical and experimental validation for its efficacy in addressing diverse forms of depression, including postpartum, post-stroke, and adolescent depression. This article endeavors to elucidate the distinctive attributes and underlying mechanisms of acupuncture in the contemporary treatment of depression. Research has demonstrated that acupuncture exerts diverse physiological effects in animal models of depression, encompassing modulation of the brain, serum, and brain-gut axis. These effects are attributed to various mechanisms, including anti-inflammatory and anti-oxidative actions, promotion of neuronal plasticity, neuroprotection, neurotrophic effects, modulation of neurotransmitters, regulation of endocrine and immune functions, and modulation of cell signal pathways. Currently, the therapeutic mechanism of acupuncture involves the engagement of multiple targets, pathways, and bidirectional regulation. Hence, acupuncture emerges as a promising alternative medical modality, exhibiting substantial research prospects and meriting comprehensive worth further study and dissemination.

The cumulative analgesic effect of repeated electroacupuncture is modulated by Adora3 in the SCDH of mice with neuropathic pain

BACKGROUND

Existing remedial approaches for relieving neuropathic pain (NPP) are challenging and open the way for alternative therapeutic measures such as electroacupuncture (EA). The mechanism underlying the antinociceptive effects of repeated EA sessions, particularly concerning the regulation of the Adora3 receptor and its associated enzymes, has remained elusive.

METHODS

This study used a mouse model of spared nerve injury (SNI) to explore the cumulative analgesic effects of repeated EA at ST36 (Zusanli) and its impact on Adora3 regulation in the spinal cord dorsal horn (SCDH). Forty-eight male mice underwent SNI surgery for induction of neuropathic pain and were randomly assigned to the SNI, SNI + 2EA, SNI + 4EA, and SNI + 7EA groups. Spinal cord (L4-L6) was sampled for immunofluorescence, adenosine (ADO) detection and for molecular investigations following repeated EA treatment.

RESULTS

Following spared nerve injury (SNI), there was a significant decrease in mechanical withdrawal thresholds (PWTs) and thermal nociceptive withdrawal latency (TWL) in the ipsilateral hind paw on the third day post-surgery, while the contralateral hind paw PWTs showed no significant changes. On subsequent EA treatments, the SNI + EA groups led to a significant increase in pain thresholds (p < 0.05). Repeated EA sessions in SNI mice upregulated Adenosine A3 (Adora3) and cluster of differentiation-73 (CD73) expression while downregulating adenosine deaminase (ADA) and enhancing neuronal instigation in the SCDH. Colocalization analysis of Neun-treated cells revealed increased Adora3 expression, particularly in the SNI + 7EA group.

CONCLUSIONS

In conclusion, cumulative electroacupuncture treatment reduced neuropathic pain by regulating Adora3 and CD73 expression, inhibiting ADA and most likely increasing neuronal activation in the SCDH. This study offers a promising therapeutic option for managing neuropathic pain, paving the way for further research.

A scoping review of mechanisms of auricular acupuncture for treatment of pain

OBJECTIVES

Auricular acupuncture (AA) is becoming increasingly common in primary care clinics, emergency departments and peri-operatively for pain relief. Over the last decade, since the last comprehensive reviews were published, the literature has expanded. In this scoping review, we seek to document the efficacy of AA in treating both acute and chronic pain, describe the mechanism of action of AA in treating pain, and discuss how AA has been integrated into Western medicine to date.

METHODS

The authors performed a MEDLINE search inclusive of articles from 1966 to June 2023 including articles written in English identifying literature. We included human studies when more than 3 patients were included. Three hundred and fourteen unique articles were identified and 152 were selected by title screen. After abstract review, 117 were chosen for full-text review. Following full-text review, 33 articles were excluded and 21 added from references, totaling 105 articles included in our scoping review.

RESULTS

AA reduces pain severity in patients with both acute and chronic pain. The best studies in the acute settings have occurred in the peri-operative setting where sham AA is employed, multiple sessions of AA are given, and medication dosing is carefully monitored. In these cases, AA reduced pain and post-operative medications. In patients with chronic pain, multiple sessions of AA resulted not only in pain relief but also in improvements in function and disability. Literature suggests that AA works through multiple mechanisms with the most compelling data coupled to the autonomic nervous system and neuroendocrine system. Curriculums designed to teach AA and aid in implementation have been published.

CONCLUSION

AA is an accessible, effective means of pain relief. AA is relatively straightforward to learn, and protocols and curriculums exist to teach healthcare professionals this valuable skill. Overcoming implementation barriers, including patient education, are essential next steps.

The Emotion Regulation of Acupuncture in Chronic Low Back Pain: A Clinical Neuroimaging Protocol

Introduction

Acupuncture is effective for patients with chronic low back pain (CLBP), which can relieve pain intensity and regulate negative emotional states such as pain-related anxiety and depression. Previous studies mainly discuss the analgesic mechanism of acupuncture treatment of CLBP, but there are multiple dimensions to pain, including sensation, emotion and cognition. Therefore, this study aims to investigate the central mechanism of acupuncture for CLBP from the perspective of emotional regulation by functional magnetic resonance imaging (fMRI).

Methods and Analysis

A total of 72 patients with CLBP will be recruited in the study and randomly assigned to the verum acupuncture group or the sham acupuncture group. The trail will last for 18 weeks including a 2-week baseline, a 4-week treatment and a 12-week for follow-up period. The primary outcomes are the visual analog scale (VAS) and the Japanese Orthopaedic Association Scores (JOA) score. The secondary outcomes are the 12-item short form health survey (SF-12), the state trait anxiety inventory (STAI), the self-rating anxiety scale (SAS) and self-rating depression scale (SDS). The VAS, JOA, STAI SAS and SDS will be collected at baseline, week 2, week 4, and after follow-up. The SF-12 will be evaluated at baseline, week 2 and week 4. Functional magnetic resonance imaging (MRI) data will be collected at baseline and the end of treatment. Emotion-related brain regions will be chosen as regions of interest (ROIs). The gray matter volume (GMV), amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), functional connectivity (FC), and large-scale functional brain network based on these ROIs will be analyzed within and between the two groups.

Discussion

This study will verify the emotional regulation of acupuncture and explore the mechanism of acupuncture for emotion regulation in patients with CLBP.

Trial Registration Number

https://www.chictr.org.cn/showproj.html?proj=195486, identifier: ChiCTR2300070557.

Observation of the therapeutic effect of auricular bean pressing on early knee osteoarthritis pain: A randomized controlled trial

BACKGROUND

In the treatment of knee osteoarthritis (KOA), there is a need for the long-term use of therapeutic drugs that reduce joint pain and have fewer adverse effects.

OBJECTIVE

This study aimed to investigate the therapeutic effect of bean pressing on ear points on early KOA pain.

METHODS

One hundred patients with KOA recruited at the Wenzhou Hospital of Traditional Chinese Medicine between February 2019 and May 2022 were divided randomly into a treatment group (n= 50) and control group (n= 50). Patients in the treatment group received regular rehabilitation combined with auricular bean-pressing treatment, while patients in the control group only received conventional rehabilitation treatment. The measurement indicators - knee swelling, tenderness, range of motion sign score, C-reactive protein, and the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) indexes - were recorded before and after treatment.

RESULTS

On day 5 following the start of treatment, the visual analog scale (VAS) and WOMAC scores of the treatment group were significantly lower than those of the control group (P< 0.05), and the VAS and WOMAC scores in the treatment group after treatment were significantly lower than those before treatment (P< 0.05). At week 4 after the start of treatment, the dosage of nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment group was significantly lower than that in the control group (P < 0.05). No adverse events were observed during the treatment.

CONCLUSIONS

Auricular bean-pressing therapy had an analgesic effect and could also alleviate mild to moderate KOA swelling, joint stiffness, and other symptoms, effectively reducing the demand for NSAIDs and improving both knee function and quality of life. The results suggested that auricular bean-pressing therapy has promising prospects in the treatment of early KOA pain.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Settings for an Underserved Population: A Feasibility Pilot Study

Background

Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care.

Objective

To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings.

Methods

This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10 weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up.

Results

93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic.

Conclusions

Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants.

Exploring patient experiences and acceptability of group vs. individual acupuncture for Cancer-related pain: a qualitative study

Background

Individual acupuncture (AP) is a safe and effective treatment for cancer-related pain and other symptoms in cancer survivors. However, access to individual AP is limited, and costs can be prohibitive. Group AP could be a more cost-effective alternative as it is less expensive and non-inferior to individual AP for pain relief. Despite growing evidence in favour of group AP, patient acceptability and experience of group AP in cancer patients is relatively unknown. This exploratory study sought to compare patient experiences and acceptability of group versus individual AP in cancer patients.

Methods

Semi-structured, open-ended, in-depth interviews were conducted in a subset of 11 cancer patients enrolled in a randomized non-inferiority trial of group vs. individual AP for cancer pain. Participants for this study were recruited via purposive sampling, aiming for diversity in age, sex, education, employment, cancer types, and treatment arms. Data was analyzed using inductive thematic analysis.

Results

Two major themes were identified: a) overall experience of AP treatment b) value of AP. Participants across both treatment arms acknowledged improvement in pain, quality of sleep, mood and fatigue. Participants in the group AP arm reported a significant increase in perceived social support, while participants in the individual arm valued privacy and one-on-one interaction with the acupuncturist. Although some participants in the group arm had privacy-related concerns before the commencement of the program, these concerns waned after a few AP sessions. Participants across both the treatment arms reported cordial clinician-patient relationship with the acupuncturist. Willingness to pursue AP treatment in the future was comparable across both the treatment arms and was limited by out-of-pocket costs.

Conclusion

Patient acceptability and experience of treatment in group AP was on par with individual AP. Group AP may further augment perceived social support among patients and privacy concerns, if any, subside after a few sessions.

Trial registration

ClinicalTrials.gov (NCT03641222). Registered 10 July 2018 - Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03600-6.

Inpatients with shoulder osteoarthritis who received integrative Korean medicine treatment: Long-term follow-up of an observation study

This study aimed to investigate the long-term clinical efficacy of and satisfaction with integrative Korean medicine (KM) treatment in patients with shoulder osteoarthritis (SOA). We conducted a prospective observational study of patients with SOA. Patients aged 19 years and older who underwent inpatient treatment for more than 1 week were eligible for enrollment in the study. The primary evaluation index was the numeric rating scale for shoulder pain. Sub-evaluation indices included the Shoulder Pain and Disability Index for shoulder function, EuroQol-5-dimension score for overall quality of life, and Patient Global Impression of Change. Outcome measures were assessed at admission, discharge, and follow-up. For the follow-up questionnaire survey, the following information was collected: current status, surgery after discharge, reasons for finding integrative KM treatment satisfactory/unsatisfactory, and quality of life after discharge. In total, 186 patients were enrolled in the primary analysis, and 103 patients completed the follow-up survey. The mean number of days of follow-up was 1019 ± 439. Compared with the baseline, the mean differences in the numeric rating scale and Shoulder Pain and Disability Index were 3.05 ± 0.34 and 36.06 ± 5.53, respectively. Regarding the Patient Global Impression of Change, 89 out of 103 (86.4%) patients chose "minimally improved" or better. Furthermore, the EuroQol-5-dimension score also increased, showing an improvement of health-related quality of life after treatment. Integrative KM treatment is a potential option for reducing pain severity and improving function and health-related quality of life in patients with SOA. Prospective randomized studies would support this finding for the next step.

Associação entre Temperamento e o Uso de Práticas da Medicina Alternativa e Complementar

Resumo Trata-se de um estudo brasileiro, transversal, mediado pela Internet com o objetivo de descrever como diferenças temperamentais associam-se ao uso de oito práticas de medicina alternativa e complementar (MAC): ioga, meditação, reiki, acupuntura, massagem, tai chi chuan, homeopatia e floral. A amostra foi composta por 22.415 indivíduos, sendo 69,5% mulheres, com idade média de 28,8 anos (DP = 9,1). As práticas mais utilizadas foram massagem e ioga e as variáveis sexo, idade, renda e diagnóstico psicopatológico ao longo da vida associaram-se a todas as práticas, exceto com tai chi chuan. Análise inferencial se baseou em modelo de regressão logística e os resultados foram calculados com base na razão de chances com intervalo de confiança de 95%. Observou-se que manifestações adaptativas de traços e de tipos psicológicos, associaram-se a maiores chances de praticar MAC. Resultados sugerem que perfis com maior regulação emocional tendem a utilizar mais frequentemente MAC e, possivelmente, obter benefícios.

Acupuncture for acute musculoskeletal pain management in the emergency department and continuity clinic: a protocol for an adaptive pragmatic randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain causes a significant burden on health and quality of life and may result from inadequate treatment of acute musculoskeletal pain. The emergency department (ED) represents a novel setting in which to test non-pharmacological interventions early in the pain trajectory to prevent the transition from acute to chronic pain. Acupuncture is increasingly recognised as a safe, affordable and effective treatment for pain and anxiety in the clinic setting, but it has yet to be established as a primary treatment option in the ED.

METHODS AND ANALYSIS

This pragmatic clinical trial uses a two-stage adaptive randomised design to determine the feasibility, acceptability and effectiveness of acupuncture initiated in the ED and continued in outpatient clinic for treating acute musculoskeletal pain. The objective of the first (treatment selection) stage is to determine the more effective style of ED-based acupuncture, auricular acupuncture or peripheral acupuncture, as compared with no acupuncture. All arms will receive usual care at the discretion of the ED provider blinded to treatment arm. The objective of the second (effectiveness confirmation) stage is to confirm the impact of the selected acupuncture arm on pain reduction. An interim analysis is planned at the end of stage 1 based on probability of being the best treatment, after which adaptations will be considered including dropping the less effective arm, sample size re-estimation and unequal treatment allocation ratio (eg, 1:2) for stage 2. Acupuncture treatments will be delivered by licensed acupuncturists in the ED and twice weekly for 1 month afterward in an outpatient clinic.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Duke University Health System Institutional Review Board. Informed consent will be obtained from all participants. Results will be disseminated through peer-review publications and public and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04290741.

Auricular acupressure for treating early stage of knee osteoarthritis: a randomized, sham-controlled prospective study

OBJECTIVE

We examined whether auricular acupressure (AA) at four specifically preselected AA points can alleviate knee pain and decrease non-steroidal anti-inflammatory drugs (NSAIDs) consumption and its adverse effects for osteoarthritis patients.

METHODS

Sixty-two patients (more than 40 years) with knee osteoarthritis of Kellgren-Lawrence grades of I or II upon radiographic classification were enrolled in this randomized, sham-controlled prospective study, and divided into two groups (AA group and control group). The AA group received true AA by embedding vaccaria seeds at four specific AA points (knee joint, shenmen, subcortex and sympathesis) ipsilateral to the knee osteoarthritis site, while the control group received four nonacupuncture points on the auricular helix. Visual analog scale (VAS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score, the number of patients who needed celecoxib pills and adverse effects were recorded.

RESULTS

VAS and WOMAC scores in the AA group were significantly lower than that in the control group (P < 0.05) at Days 3 and 7 postsugery. The VAS and WOMAC score were significantly decreased after the treatment in the AA group compared with that before the treatment (P < 0.05). The use of celebrex is significantly lower in the AA group than in the control group (P < 0.05), no major side effects were observed during the auricular acupressure treatment.

CONCLUSION

Auricular acupressure plays a role in analgesic effect and can effectively decrease NSAIDs requirements without causing adverse events for the treatment of human knee osteoarthritis.

Acupuncture intervention for acute pain in the Emergency Department trial: a consensus process

PURPOSE

This document describes the consensus process and intervention for a National Institutes of Health (NIH)-funded multi-site feasibility study utilizing acupuncture for ACUte paIn in The EmergencY Department (ACUITY). The acupuncture intervention is designed to be flexible and responsive to the most common Emergency Department (ED) scenarios, including trauma, acute pain of the low back, abdomen and/or musculoskeletal system, renal colic and headache.

BACKGROUND

Opioids remain a primary treatment for acute ED pain with attendant risk of adverse effects, addiction liability, diversion and death. Effective/safer options for acute pain are needed. Although acupuncture therapy has shown promise for acute pain in the ED alone or in conjunction with usual care, pragmatic trials are needed to obtain definitive and generalizable evidence.

METHODS

An Acupuncture Advisory Panel was convened that included nine acupuncture experts with 5-44 years of experience in practice and 2-16 years of experience in the acute pain care setting. A modified Delphi process was used with provision of a literature review, surveys of our panel members, three online discussions and email discussion as needed. The STandards for Reporting Interventions in Controlled Trials (STRICTA) checklist was used as a guide.

RESULTS

A responsive acupuncture intervention was agreed on for ACUITY. Session forms were fashioned in REDCap (Research Electronic Data Capture program to capture essential treatment data, assess fidelity and inform our design for a future pragmatic multi-site randomized controlled trial (RCT) of acupuncture in the ED, and for use by other future researchers.

CONCLUSION

Development of a responsive manualization intervention provides the appropriate framework for conducting a future, pragmatic, multi-site, definitive RCT of acupuncture in the ED.

TRIAL REGISTRATION NUMBER

NCT04880733 (ClinicalTrials.gov).

"The Pain Left, I Was Off and Running": A Qualitative Analysis of Group Acupuncture and Yoga Therapy for Chronic Pain in a Low-Income and Ethnically Diverse Population

Introduction: Chronic pain and the current opioid epidemic are pressing public health concerns, especially in low-income and ethnically diverse communities. Nonpharmacologic therapies that are safe, effective, and acceptable for the treatment of chronic pain conditions may provide a solution for addressing this issue. This qualitative analysis explores the experience of study participants who received combined acupuncture and yoga therapy (YT) to treat chronic pain delivered in a primary care setting. Methods: The group acupuncture with yoga therapy for chronic neck, low back, and osteoarthritic pain trial (GAPYOGA) assessed the feasibility and effectiveness of group acupuncture (GA) combined with YT in a low-income, racial, and ethnically diverse population. Individual in-depth interviews were conducted with a subset of patients in the trial. Nineteen participants were interviewed for qualitative analysis of their experience. Using the immersion and crystallization method, transcribed interviews were analyzed for themes meaningfully representing participant experience. Results: The combined GA and YT resulted in significant pain relief and transformative healing experiences. Three themes emerged from participant narratives: (1) transformative engagement with self in the healing process through pain relief, psychological well-being, and self-efficacy; (2) therapeutic relationship with acupuncture and yoga providers; and (3) fostering relationships with fellow participants in the group. Discussion: In this study of a low-income and ethnically diverse population, the combination of acupuncture and YT was found to alleviate pain, improve function, promote psychological well-being, and engage participants in self-care practices in a transformative healing process-resulting in physical and psychological benefits.

Modulation effect of acupuncture treatment on chronic neck and shoulder pain in female patients: Evidence from periaqueductal gray-based functional connectivity

Aims

Chronic neck and shoulder pain (CNSP) is a common neurological disorder, which females are more likely to suffer from. The periaqueductal gray (PAG) plays a key role in the descending modulation of pain. This study aimed to investigate altered PAG‐based functional connectivity (FC) in female patients with CNSP related to healthy controls (HCs) and the effect of acupuncture for female patients with CNSP using PAG‐based FC biomarkers.

Methods

PAG‐based FC value was calculated based on resting‐state functional images and then compared between patients with CNSP at pre‐acupuncture, post‐acupuncture, and HCs. Then, correlational analyses were performed to examine the relationships between increased PAG‐based FC strength and improved clinical parameters in patients after acupuncture treatment.

Results

Before acupuncture treatment, compared to HCs, patients with CSNP showed altered PAG‐based FC with widely distributed brain regions, including the left medial superior frontal gyrus, bilateral posterior insula (pIns), and cingulate gyrus. After treatment, patients with CNSP exhibited specially improved PAG‐pIns FC compared to that before treatment, and no significant difference was observed in the increased PAG‐pIns FC strength between HCs and patients with CNSP after treatment. Furthermore, pain catastrophizing reduction was significantly correlated with the increased PAG‐pIns FC strength in patients after treatment.

Conclusion

The effect of acupuncture treatment may relate to the increased PAG‐pIns FC, which significantly correlated with pain catastrophizing reduction after treatment. These findings shed important mechanistic information on the role of therapeutic approaches in treating chronic neck and shoulder pain.

Pain and Opioid Use: Evidence for Integrating Acupuncture Into Treatment Planning

The epidemics of pain and opioid use pose unique challenges. Comprehensive approaches are required to address minds, bodies and spirits of individuals who live with pain and/or opioid use. The lack of an effective “quick fix” for either condition necessitates developing effective, innovative and multi-disciplinary avenues for treatment. This analytic article reviews epidemiological and demographic factors associated with pain and with opioid use and additional challenges posed by the Covid-19 epidemic. Several large-scale studies and meta-analyses have examined the role of acupuncture as a nonpharmacological approach to pain management as well as a component of comprehensive strategies to address opioid use disorder. We review and describe these in the context of safety, effectiveness, access and cost-related factors. With one in four U.S. hospitals as well as 88% of Veterans Health Administration facilities incorporating acupuncture, the feasibility of mobilizing and scaling up these treatment resources is being developed and demonstrated. We also identify potential facilitators and barriers to implementing acupuncture treatment. As part of a multi-disciplinary approach to pain management and/or opioid use disorder, we suggest that integrating acupuncture into treatment protocols may represent a viable strategy that is based on and consistent with public health principles.

Auricular Therapy for Treating Phantom Limb Pain Accompanied by Jumping Residual Limb: A Short Review and Case Study

Phantom limb pain (PLP) is a common complaint among patients after amputation, while jumping residual limb is a rare post-amputation complication, they rarely happen at the same time and both remain difficult to manage. At present, there is a paucity of literature on this topic, and no treatment has been proven effective for treating both of them. In the present brief report, we described a patient who developed severe PLP accompanied by jumping residual limb after below-the-knee amputation and she was treated by auricular therapy (AT) with satisfactory effect.

Acupuncture Intervention Protocol: Consensus Process for a Pragmatic Randomized Controlled Trial of Acupuncture for Management of Chronic Low Back Pain in Older Adults: An NIH HEAL Initiative Funded Project

OBJECTIVE

The aim of this article is to describe the consensus process used to develop an acupuncture intervention protocol for an NIH-funded pragmatic randomized controlled trial (PRCT) of acupuncture for the management of chronic low back (cLBP) in older adults (BackInAction).

BACKGROUND

CLBP is among leading causes of disability worldwide: almost 33% of US adults 65 and older experience LBP. Acupuncture is effective for cLBP but there is no specific data on older adults. The National Institutes for Health (NIH) funded a PRCT of acupuncture needling for this population. An essential trial milestone was development of a consensus intervention protocol.

METHODS

An Acupuncture Advisory Panel (AAP) was formed with nine members: two physician-acupuncturists, six licensed acupuncturists representing diverse work backgrounds, and an acupuncture researcher. We used a modified Delphi process that included provision of acupuncture trial data, survey data describing how each expert treats cLBP, three conference calls, and between-call email discussion.

RESULTS

Lively and professional discussions led to a consensus intervention protocol for the BackInAction trial that included steps/staging of care, recommendations for parameters of care session length, number of needle insertion sites, insertion depths, needle retention times, recommended types of needles, both local and distal areas of the body to be treated, acupuncture point options, auricular point options, self-care options, and minimum number of sessions considered ideal.

CONCLUSION

Using a modified Delphi process, an expert AAP created a consensus intervention protocol for the PRCT of acupuncture needling for cLBP in patients 65 and older.

Risks and Safety of Extended Auricular Therapy: A Review of Reviews and Case Reports of Adverse Events

OBJECTIVE

Auricular acupuncture (AA) and extended auricular therapy (AT) are a part of acupuncture practice shown to benefit patients with pain, anxiety, and other conditions, with cost-effective access enhanced when given in a group setting. Yet there are safety concerns and risks, perhaps unnecessary risks, that attend embedded, indwelling needles applied to the ear as a means of extended AT.

METHODS

Electronic searches were conducted in PubMed, MEDLINE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) for "auriculotherapy," "auricular acupuncture" or "auricular acupressure," "safety," "adverse events," "chondritis," and "perichondritis," with additional manual review of titles, links, and reference lists. Individual auricular therapy adverse event (AE) case reports were included, as well as systematic reviews and or meta-analyses if they evaluated AEs associated with AT.

RESULTS

Nineteen auricular AE case reports and nine safety reviews of or including auriculotherapy were included. Ten systematic reviews of AT with eight specific reviews of auricular acupressure (AP) were also included.

CONCLUSIONS

The primary AE risks is infection, perichondritis, and chondritis stemming from embedded or indwelling needles or potential inadvertent needlesticks from contaminated roaming sharps. Extended AP i.e., application of spheres, preferably seeds (natural, nontoxic botanical Vaccaria seeds) provides clinical benefit without the risks associated with embedded needles. More research is needed to establish if embedded needles at the ear are even necessary or have any advantage over in-session auricular acupuncture for immediate pain relief followed by ear acupressure.

Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot

Objective: To identify factors associated with implementing bundled group acupuncture and yoga therapy (YT) to treat underserved patients with chronic pain in community health center (CHC) settings. This is not an implementation science study, but rather an organized approach for identification of barriers and facilitators to implementing these therapies as a precursor to a future implementation science study. Design: This study was part of a single-arm feasibility trial, which aimed to test the feasibility of bundling GA and YT for chronic pain in CHCs. Treatment outcomes were measured before and after the 10-week intervention period. Implementation feasibility was assessed through weekly research team meetings, weekly yoga provider meetings, monthly acupuncture provider meetings, and weekly provider surveys. Settings: The study was conducted in New York City at two Montefiore Medical Group (MMG) sites in the Bronx, and one Institute for Family Health (IFH) site in Harlem. Subjects: Participants in the feasibility trial were recruited from IFH and MMG sites, and needed to have had lower back, neck, or osteoarthritis pain for >3 months. Implementation stakeholders included the research team, providers of acupuncture and YT, referring providers, and CHC staff. Results: Implementation of these therapies was assessed using the Consolidated Framework for Implementation Research. We identified issues associated with scheduling, treatment fidelity, communication, the three-way disciplinary interaction of acupuncture, yoga, and biomedicine, space adaptation, site-specific logistical and operational requirements, and patient-provider language barriers. Issues varied as to their frequency and resolution difficulty. Conclusions: This feasibility trial identified implementation issues and resolution strategies that could be further explored in future implementation studies. Clinical Trial Registration No.: NCT04296344.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Setting for an Underserved Population: Design and Rationale for a Feasibility Pilot

Chronic pain is prevalent in the United States, with impact on physical and psychological functioning as well as lost work productivity. Minority and lower socioeconomic populations have increased prevalence of chronic pain with less access to pain care, poorer outcomes, and higher risk of fatal opioid overdose. Acupuncture therapy is effective in treating chronic pain conditions including chronic low back pain, neck pain, shoulder pain, and knee pain from osteoarthritis. Acupuncture therapy, including group acupuncture, is feasible and effective, and specifically so for underserved and diverse populations at risk for health outcome disparities. Acupuncture therapy also encourages patient engagement and activation. As chronic pain improves, there is a natural progression to want and need to increase activity and movement recovery. Diverse movement approaches are important for improving range of motion, maintaining gains, strengthening, and promoting patient engagement and activation. Yoga therapy is an active therapy with proven benefit in musculoskeletal pain disorders and pain associated disability. The aim of this quasi-experimental pilot feasibility trial is to test the bundling of these 2 effective care options for chronic pain, to inform both the design for a larger randomized pragmatic effectiveness trial as well as implementation strategies across underserved settings.

"It Gave Me Hope" Experiences of Diverse Safety Net Patients in a Group Acupuncture Intervention for Painful Diabetic Neuropathy

Purpose: To explore the experiences of living with painful diabetic neuropathy (PDN) and with a group acupuncture intervention in a sample of low-income, diverse patients.

Methods: We conducted a randomized clinical trial of a 12-week group acupuncture intervention for PDN. Data included validated measures of patient-reported outcomes, including pain and quality of life (QOL), as well as semistructured qualitative interviews about participants' experiences with PDN and the intervention. Interview transcripts were coded and analyzed using an inductive thematic framework.

Results: We recruited 40 participants from diverse racial/ethnic backgrounds from a public hospital and conducted in-depth qualitative interviews with a subset of 17 participants. Participants randomized to acupuncture experienced greater decreases in pain compared with usual care as well as improved QOL. In interviews, they described a myriad of socioeconomic and personal life stressors that compounded the significant suffering and disability brought on by PDN. Those who received acupuncture were able to decrease reliance on pain medication, improve their sleep and daily function, reduce stress, and engage more with their own self-care. They noted that the acupuncture intervention also gave them hope in the face of their chronic disease.

Conclusion: Acupuncture is a valuable adjunct treatment for low-income and marginalized populations with PDN. In addition to reducing pain and improving QOL, acupuncture may offer powerful benefits by increasing patient activation and hope.

Group versus Individual Acupuncture (AP) for Cancer Pain: A Randomized Noninferiority Trial

Background

A service delivery model using group acupuncture (AP) may be more cost-effective than individual AP in general, but there is little evidence to assess whether group AP is a comparable treatment in terms of efficacy to standard individual AP. The study aimed to compare the group to individual delivery of 6-week AP among cancer patients with pain.

Methods

The study design was a randomized noninferiority trial of the individual (gold standard treatment) vs. group AP for cancer pain. The primary outcome was pain interference and severity, measured through the Brief Pain Inventory (BPI). Secondary outcomes included measures of mood, sleep, fatigue, and social support. Changes in outcomes from pre- to postintervention were examined using linear mixed effects modeling and noninferiority was inferred using a noninferiority margin, a difference of change between the two arms and 95% CIs. Pain interference was tested with a noninferiority margin of 1 on the BPI, while pain severity and secondary outcomes were compared using conventional statistical methods.

Results

The trial included 74 participants randomly allocated to group (35) or individual (39) AP. The noninferiority hypothesis was supported for pain interference [Ө - 1, Δ 1.03, 95% CI: 0.15-2.20] and severity [Ө - 0.81, Δ 0.52, 95% CI:.33-1.38] as well as for mood [Ө - 7.52, Δ 9.86, 95% CI: 0.85-18.86], sleep [Ө - 1.65, Δ 2.60, 95% CI: 0.33-4.88], fatigue [Ө 8.54, Δ - 15.57, 95% CI: 25.60-5.54], and social support [Ө.26, Δ - 0.15, 95% CI:  - 0.42-0.13], meaning that group AP was not inferior to individual AP treatment. Both arms evidenced statistically significant improvements across all symptoms before and after the intervention. Effect sizes for the group vs. individual AP on outcomes of pain, sleep, mood, and social support ranged from small to very large and were consistently larger in the group condition. The total average cost-per-person for group AP ($221.25) was almost half that of individual AP ($420).

Conclusions

This is the first study to examine the noninferiority of group AP with the gold standard individual AP. Group AP was noninferior to individual AP for treating cancer pain and was superior in many health outcomes. Group AP is more cost-effective for alleviating cancer pain and should be considered for implementation trials.

Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care-a Randomized Trial

BACKGROUND

Acupuncture has been shown to be effective for the treatment of chronic musculoskeletal back, neck, and osteoarthritis pain. However, access to acupuncture treatment has been limited in medically underserved and low-income populations.

OBJECTIVE

Acupuncture therapy delivered in groups could reduce cost and expand access. We compared the effectiveness of group versus individual acupuncture for pain and function among ethnically diverse, low-income primary care patients with chronic musculoskeletal pain.

DESIGN

This was a randomized comparative effectiveness non-inferiority trial in 6 Bronx primary care community health centers. Participants with chronic (> 3 months) back, neck, or osteoarthritis pain were randomly assigned to individual or group acupuncture therapy for 12 weeks.

PARTICIPANTS

Seven hundred seventy-nine participants were randomized. Mean age was 54.8 years. 35.3% of participants identified as black and 56.9% identified as Latino. Seventy-six percent were Medicaid insured, 60% reported poor/fair health, and 37% were unable to work due to disability.

INTERVENTIONS

Participants received weekly acupuncture treatment in either group or individual setting for 12 weeks.

MAIN MEASURES

Primary outcome was pain interference on the Brief Pain Inventory at 12 weeks; secondary outcomes were pain severity (BPI), physical and mental well-being (PROMIS-10), and opiate use. Outcome measures were collected at baseline, 12 and 24 weeks.

KEY RESULTS

37.5% of individual arm and 30.3% in group had > 30% improvement in pain interference (d = 7.2%, 95% CI - 0.6%, 15.1%). Non-inferiority of group acupuncture was not demonstrated for the primary outcome assuming a margin of 10%. In the responder analysis of physical well-being, 63.1% of individual participants and 59.5% of group had clinically important improvement at 12 weeks (d = 3.6%, 95% CI - 4.2%, 11.4%).

CONCLUSIONS

Both individual and group acupuncture therapy delivered in primary care settings reduced chronic pain and improved physical function at 12 weeks; non-inferiority of group was not shown.

TRIAL REGISTRATION

Clinicaltrials.gov # NCT02456727.

A Randomized Clinical Trial of Group Acupuncture for Painful Diabetic Neuropathy Among Diverse Safety Net Patients

OBJECTIVE

Existing pharmacologic approaches for painful diabetic neuropathy (PDN) are limited in efficacy and have side effects. We examined the feasibility, acceptability, and effects of group acupuncture for PDN.

DESIGN AND SETTING

We randomized patients with PDN from a public safety net hospital to 1) usual care, 2) usual care plus 12 weeks of group acupuncture once weekly, or 3) usual care plus 12 weeks of group acupuncture twice weekly.

METHODS

The primary outcome was change in weekly pain intensity (daily 0-10 numerical rating scale [NRS] averaged over seven days) from baseline to week 12. We also assessed health-related quality of life and related symptoms at baseline and weeks 6, 12, and 18.

RESULTS

We enrolled 40 patients with PDN (baseline pain = 5.3). Among participants randomized to acupuncture, 92% attended at least one treatment (mean treatments = 10.1). We observed no significant differences between once- vs twice-weekly acupuncture and combined those groups for the main analyses. Compared with usual care, participants randomized to acupuncture experienced greater decreases in pain during the 12-week intervention period (between-group differences from baseline = -2.06, 95% confidence interval [CI] = -3.01 to -1.10), but benefits were not maintained after acupuncture ended (baseline to week 18 = -0.61, 95% CI = -1.46 to 0.24). Quality of life improved for acupuncture participants (baseline to week 12 difference = 11.79, 95% CI = 1.92 to 21.66), but group differences were not significant compared with usual care (25.58, 95% CI = -3.90 to 55.06).

CONCLUSIONS

Group acupuncture is feasible and acceptable among linguistically and racially diverse safety net patients. Findings suggest clinically relevant reduction in pain from PDN and quality of life improvements associated with acupuncture, with no differences based on frequency.

Cochrane reviews on acupuncture therapy for pain: A snapshot of the current evidence

Cochrane is an international non-profit organization established in 1993 to produce and disseminate high quality and unbiased systematic reviews of evidence on health care interventions. At the forefront of systematic review methodology, Cochrane is generally accepted to be among the most carefully prepared and rigorous sources of systematic review evidence. There are numerous Cochrane reviews on nonpharmacologic interventions for pain and multiple Cochrane reviews evaluating acupuncture therapy in pain conditions. But how complete and up to date are those reviews relative to other rigorous systematic reviews with meta-analyses of acupuncture therapy for pain published in the literature? In this 'snapshot' overview, we found 22 relevant Cochrane reviews, some concluding that acupuncture therapy is probably useful for treating specific pain conditions. However, many of the conditions for which acupuncture is most commonly used are either not represented in Cochrane reviews or the existing Cochrane reviews are seriously outdated and do not reflect current evidence. This creates confusion with the risks of adverse effects and addiction liability associated with pain medications, the prevalence of chronic pain, the ongoing opioid epidemic and the need for evidence-based options for pain as part of comprehensive pain care. Clinicians and patients want clarification on safe and effective options to treat pain. Issues involving reviewed trials' inadequate use of sham comparators, of acupuncture as a complex intervention with interactive components and a shift in research focus from efficacy trials to real-world pragmatic trials are discussed in relation to updating Cochrane reviews of acupuncture therapy for pain.

Comparing physicians' and patients' reporting on adverse reactions in randomized trials on acupuncture-a secondary data analysis

BACKGROUND

We aimed to compare patients' and physicians' safety reporting using data from large acupuncture trials (44,818 patients) and to determine associations between patient characteristics and reporting of adverse reactions.

METHODS

Six pragmatic randomized trials with an additional non-randomized study arm that included those patients who refused randomization were evaluated. Patients received acupuncture treatment for osteoarthritis of the hip or knee, chronic neck pain, chronic low back pain, chronic headache, dysmenorrhea, or allergic rhinitis or asthma. Safety outcomes were evaluated by questionnaires from both the physicians and the patients. To determine level of agreement between physicians and patients on the prevalence of adverse reactions, Cohen's kappa was used. With multilevel models associations between patient characteristics and reporting of adverse reactions were assessed.

RESULTS

Patients reported on average three times more adverse reactions than the study physicians: for bleeding/haematoma, 6.7% of patients (n = 2458) vs. 0.6% of physicians (n = 255) and for pain, 1.7% of patients (n = 636) vs. 0.5% of physicians (n = 207). We found only minor agreements between patients and physicians (maximum Cohen's kappa: 0.50, 95% confidence interval [0.49;0.51] for depressive mood). Being a female and participation in the randomization were associated with higher odds of reporting an adverse reaction.

CONCLUSIONS

In our study, patients' and physicians' reports on adverse reactions of acupuncture differed substantially, possibly due to differences in patients' and physicians' questionnaires and definitions. For the assessment of safety, we strongly support the inclusion of patients' and physicians' reports while ensuring standardization of data collection and definitions.

Developing and employing a 'responsive manualization' in the 'Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment' comparative effectiveness study

OBJECTIVE

The aim of this article is to describe the process used to develop an acupuncture therapy manual for a large effectiveness trial comparing individual care against group care for chronic pain in an underserved population. The design needed to not only ensure research consistency and replicability but also be 'responsive' to real world heterogeneous and evolving presentations in challenging physical settings.

BACKGROUND

Chronic pain is prevalent in the United States. While acupuncture is effective for chronic pain, minority, ethnically diverse and lower socioeconomic populations have limited access. Group acupuncture is proposed as a lower cost option to facilitate access in safety net settings, but research on the effectiveness of group versus individual acupuncture is lacking.

METHODS

We engaged a modified Delphi process with expert practitioners from diverse backgrounds who were experienced in individual and group practice. All contributions were recorded and collated for second- and third-round consensus discussions that included contributions by the trial's research acupuncturists.

RESULTS

A 'responsive manual' flow chart was created with suggested sequencing that included interviews concurrent with palpation, Tui na, Gua sha, acupuncture needling, ear treatment, basic recommendations and options for departure with rationale. The manual was implemented by six research acupuncturists in five primary care settings in the Bronx, New York, with weekly team meetings to discuss manual use. There were no serious adverse events (AE) and few minor AE reported in this trial.

CONCLUSION

A 'responsive manual' can be structured and implemented that is not only consistent and replicable but also flexible to accommodate the real-world clinical needs of practitioners and patients in challenging physical settings.