Acupuncture and transcutaneous stimulation analgesia in comparison with moderate-dose fentanyl anaesthesia in major surgery. Clinical efficacy and influence on recovery and morbidity

Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research

Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.

A protocol of systematic review and meta-analysis of acupuncture for drug resistant epilepsy

BACKGROUND

This study aims to appraise the effectiveness and safety of acupuncture for drug resistant epilepsy (DRE).

METHODS

We will search all potential randomized controlled trials (RCTs) of acupuncture for patients with DRE from their origin to March 1, 2020: MEDLINE, EMBASE, Cochrane Library, CINAHL, Scopus, WANGFANG, and Chinese Biomedical Literature Database. We will not apply any restrictions to the language and publication date. All RCTs investigating the effectiveness and safety of acupuncture for patients with DRE will be included. Study quality will be appraised by Cochrane risk of bias, and statistical analysis will be scrutinized by RevMan 5.3 software. Whenever possible, a narrative summary to describe study quality and content of the evidence will be performed.

RESULTS

This study will provide summarize high quality evidence and will utilize a variety of outcome measurements to verify effectiveness and safety of acupuncture for DRE.

CONCLUSION

The results of this study will seek to explore the effectiveness and safety of acupuncture for DRE.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020170517.

Some Problems Encountered in the Scientific Evaluation of Acupuncture Antiemesis

The production of a medical research paper is beset with problems from inception to publication. If the subject involves acupuncture, the problems can seem surprisingly great even for an established university research department.

Most acupuncture reports from China are anecdotal in nature and reviewing the Western literature shows that difficulty in definition of techniques has allowed invasive and non-invasive acupuncture to be used interchangeably, with consequent inaccuracy in the reported results. Because of the physical nature of the treatment, not all accepted criteria for clinical trials are achievable and ethical committees may therefore be reluctant to grant approval. Even publication has been made difficult by scepticism from peer reviewers, although a more enlightened attitude is now gaining ground.

If acupuncture is to become an accepted treatment, scientific evaluation by experienced research teams and perseverance in gaining publication for the results is vital.

Getting inside acupuncture trials--exploring intervention theory and rationale

Background

Acupuncture can be described as a complex intervention. In reports of clinical trials the mechanism of acupuncture (that is, the process by which change is effected) is often left unstated or not known. This is problematic in assisting understanding of how acupuncture might work and in drawing together evidence on the potential benefits of acupuncture. Our aim was to aid the identification of the assumed mechanisms underlying the acupuncture interventions in clinical trials by developing an analytical framework to differentiate two contrasting approaches to acupuncture (traditional acupuncture and Western medical acupuncture).

Methods

Based on the principles of realist review, an analytical framework to differentiate these two contrasting approaches was developed. In order to see how useful the framework was in uncovering the theoretical rationale, it was applied to a set of trials of acupuncture for fatigue and vasomotor symptoms, identified from a wider literature review of acupuncture and early stage breast cancer.

Results

When examined for the degree to which a study demonstrated adherence to a theoretical model, two of the fourteen selected studies could be considered TA, five MA, with the remaining seven not fitting into any recognisable model. When examined by symptom, five of the nine vasomotor studies, all from one group of researchers, are arguably in the MA category, and two a TA model; in contrast, none of the five fatigue studies could be classed as either MA or TA and all studies had a weak rationale for the chosen treatment for fatigue.

Conclusion

Our application of the framework to the selected studies suggests that it is a useful tool to help uncover the therapeutic rationale of acupuncture interventions in clinical trials, for distinguishing between TA and MA approaches and for exploring issues of model validity. English language acupuncture trials frequently fail to report enough detail relating to the intervention. We advocate using this framework to aid reporting, along with further testing and refinement of the framework.

Plasma adrenaline increases in anesthetized patients given electro-acupuncture before surgery

PURPOSE

In anesthetized patients, electro-acupuncture (EA) has been found to reduce sevoflurane-induced suppression of cranial and spinal motor responses to surgery without influencing the level of anesthesia. The underlying mechanisms are unclear. In the present study, blood samples were analyzed to evaluate if the increased clinical motor responses to surgery in patients subjected to EA under sevoflurane anesthesia are also reflected in higher plasma levels of catecholamines, adrenocorticotrophic hormone (ACTH), or cortisol.

METHODS

Blood samples were obtained before anesthetic induction, soon after the study or control procedures had been completed under general anesthesia, and after 30 minutes of surgery under steady-state anesthesia with 1.8% of sevoflurane, in 45 healthy female patients, scheduled for sterilization by laparoscopy, randomized for bilateral 2 Hz-burst EA (study group; n = 22) or control (control group; n = 23) procedures.

RESULT

Plasma levels of adrenaline were found to approach the higher preanesthetic level after 30 minutes of surgery in patients given EA stimulation but to remain low in control patients (P < 0.05)-in agreement with the stronger clinical motor responses to skin incision in the EA group. Plasma levels of noradrenaline, ACTH, and cortisol did not change in or differ between the two groups.

CONCLUSION

The clinical facilitation of both cranial and spinal motor responses to surgery in patients given acupuncture under sevoflurane anesthesia is associated with increased plasma levels of adrenaline, possibly reflecting sympathetic activation.

Auricular electro-acupuncture as an additional perioperative analgesic method during oocyte aspiration in IVF treatment

BACKGROUND

The aim of this study was to compare the pain-relieving effect and the subjective well-being between auricular electro-acupuncture (EA) analgesia, auricular acupuncture (A) and conventional analgesia with remifentanil (CO).

METHODS

A total of 94 women undergoing IVF were randomized to auricular acupuncture with (EA, n = 32) or without (A, n = 32) continuous 1 Hz auricular stimulation (using a battery-powered miniaturized stimulator, P-Stim) or with adhesive tapes instead of needles and no electrical stimulation (control group, CO, n = 30) at the auricular acupuncture points 29, 55 and 57. All patients received patient-controlled analgesia (PCA) with remifentanil. Pain intensity and psychological well-being were assessed by means of visual analogue scales (VAS); tiredness, nausea and vomiting and analgesic drug consumption were documented.

RESULTS

Pain relief and subjective well-being were significantly greater in group EA during and after the procedure as compared with groups A and CO (P < 0.001). The patients were significantly more tired in group CO than in groups A and EA (P < 0.001). Consumption of the opioid remifentanil was significantly lower in group EA, comparable nausea (P < 0.001).

CONCLUSION

Auricular EA significantly reduces pain intensity and analgesic consumption of the opioid remifentanil during oocyte aspiration in IVF treatment.

Acupuncture facilitates neuromuscular and oculomotor responses to skin incision with no influence on auditory evoked potentials under sevoflurane anaesthesia

BACKGROUND

More sevoflurane was recently found to be required to prevent movement in response to surgical incision in anaesthetized patients subjected to electro-acupuncture (EA) than to sham procedures. The present study was designed to compare differences in movement, dilatation of the pupils, divergence of the eye axes and activity of auditory evoked potentials (AEPs) between patients given and those not given EA under standardized sevoflurane anaesthesia.

METHODS

Neuromuscular, oculomotor and AEP responses to skin incision were assessed with and without a bilateral 2-Hz burst EA in patients under steady-state anaesthesia maintained with 1.8% of sevoflurane. Forty-five healthy patients, scheduled for laparoscopic sterilization, were randomized for EA (n = 22) or sham (n = 23) procedures between induction of anaesthesia and start of surgery. Middle latency AEP activity was recorded and interpreted by the A-line ARX (autoregression with exogenous input) index (AAI).

RESULTS

More acupuncture than sham patients were found to respond to skin incision with movement of the neck or limbs (77% vs. 43%; P = 0.021), dilatation of the pupils (77% vs. 39%; P = 0.001) and divergence of the eye axes (72% vs. 39%; P = 0.023), whereas there was no difference in AAI response.

CONCLUSION

Electro-acupuncture facilitates physiological responses to nociceptive stimulation under sevoflurane anaesthesia. Differences in neuromuscular and oculomotor responses between acupuncture and sham patients under general anaesthesia are probably not associated with interaction between EA and the depth of anaesthesia, as AEP activity was similar in the two groups.

Acupuncture fails to reduce but increases anaesthetic gas required to prevent movement in response to surgical incision

BACKGROUND

Acupuncture is used for clinical pain relief but has not been evaluated under clinical anaesthesia. This study was designed to compare movement in response to surgical incision in anaesthetized patients subjected to electro-acupuncture (EA) or sham procedures. Our hypothesis was that EA stimulation would reduce the requirements for anaesthetic gas.

METHODS

Forty-six healthy women, scheduled for laparoscopic sterilization at a Swedish county hospital, were randomized to have either the electro-acupuncture (n = 23) or sham (n = 23) procedure between the induction of general anaesthesia and the start of surgery. The minimal alveolar concentration (MAC) of sevoflurane required to prevent neck or major limb movements in response to surgical incision was determined in each group of patients.

RESULTS

The MAC for sevoflurane was found to be higher in the group given acupuncture than in the control group (2.1 +/- 0.3% vs. 1.8 +/- 0.4%; P = 0.008).

CONCLUSION

Electro-acupuncture given during general anaesthesia with sevoflurane failed to reduce but instead increased the clinical need for anaesthetic gas, possibly by reducing the anaesthetic effect of sevoflurane and/or by facilitating nociceptive transmission and/or reflex activity.

The effect of electroacupuncture as an adjunct on cyclophosphamide-induced emesis in ferrets

The effect of electroacupuncture (EA) on cyclophosphamide-induced emesis in ferrets was studied at acupuncture point Neiguan (P6) with various electrical stimulation parameters (5-100 Hz, 1.5-3 V, 5-20 min, n=6/group). The combination therapy of EA (100 Hz, 1.5 V and 10 min) with the lower doses of ondansetron (0.04 mg/kg), droperidol (0.25 mg/kg) and metoclopramide (2.24 mg/kg) significantly reduced the total number of emetic episodes by 52%, 36% and 73%, respectively, as well as the number of emetic episodes in the first phase as compared to the sham acupuncture control (P<.01). These EA/drug combinations also showed a significant effect in preventing emesis as compared to either EA or drug alone (P<.05). The present study suggests that acupuncture may be useful as an adjunctive therapy in the treatment of chemotherapy-induced emesis.

Effects of electroacupuncture on intraoperative and postoperative analgesic requirement

Acupuncture has been shown to be effective in experimental and clinical acute pain settings. This study aims to evaluate the effect of preoperative electroacupuncture (EA) on intraoperative and postoperative analgesic (alfentanil and morphine) requirement in patients scheduled for gynaecologic lower abdominal surgery. Ninety patients were randomly assigned to one of three groups: Group I (control group)--received placebo EA for 45 minutes before induction of general anaesthesia (GA); Group II--preoperative EA instituted 45 minutes before induction of GA; Group III--45 minutes of postoperative EA. The Bispectral Index monitor was used intraoperatively to monitor the hypnotic effect of anaesthetic drugs, and alfentanil was titrated to maintain the blood pressure and pulse rate within +/- 15% of basal values. Postoperative pain was managed by intravenous morphine via a patient-controlled analgesia (PCA) device. Patients in Group II (0.44 +/- .15microg/kg/min) received less alfentanil than those in Group III (0.58 +/- .22 microg/kg/min) (p = p.024), but not significantly less than those in Group I 10.51 +/- 0.21 microg/kg/min) (p = 0.472). Postoperative morphine consumption was numerically lower in Group II compared with the other groups; however, the difference was statistically significant only during the period of 6-12 hours between Group II [0.03 (0.05) mg/kg] and Group I [0.10 (0.11) mg/kg] (p = 0.015), and Group II and Group III [0.08 (0.10) mg/kg] (p = 0.010). The 24-hour cumulative morphine consumption for Group II (0.52 +/- .19mg/kg) was less than that for either Group I I0.68 +/- 38mg/kg) or Group III (0.58 +/- .27mg/kg), but the difference did not reach significance. In conclusion, preoperative EA leads to a reduced intraoperative alfentanil consumption, though this effect may not be specific, and has a morphine sparing effect during the early postoperative period.

Systematic review and meta-analysis of interventions for postoperative fatigue

BACKGROUND

Postoperative fatigue is common, even after uncomplicated operations. Various theories have been presented regarding its aetiology, each suggesting different possible interventions. The purpose of this review was to identify all studies that have assessed interventions for postoperative fatigue and to evaluate these interventions using meta-analytical techniques.

METHODS

Randomized controlled trials of interventions, identified from a systematic search of relevant databases, were evaluated according to standardized criteria and categorized according to intervention modality. Data relating to the efficacy of each intervention at four different postoperative time-points were collated and data synthesis by meta-analysis was performed.

RESULTS

Analgesia is effective in reducing fatigue immediately after operation. Perioperative administration of human growth hormone reduces fatigue between 8 and 30 days after abdominal surgery. Weaker evidence was found to suggest an influence of glucocorticoid administration and of surgical technique on fatigue in the first week after operation. No evidence was found to support the theory that psychosocial or nutritional interventions affect the symptom.

CONCLUSION

While the results demonstrate that improved analgesia can attenuate immediate postoperative fatigue in most patient groups, further research is needed to determine whether the efficacy of human growth hormone and glucocorticoids extends beyond abdominal surgery. The paucity of research into cognitive-behavioural, sleep and activity-based interventions also needs to be addressed.

Acupuncture

With the increasing availability of acupuncture in the United States, it is possible that patients will increasingly seek and use acupuncture for diverse indications. Research into acupuncture is still in its infancy, and much of the scientific evidence surrounding it is fragmentary and often contradictory. As is the case even in well-researched therapies, physicians often have to make decisions about patient care based on a mixture of available scientific evidence, anecdote, and patient preference. As investigations into this therapy continue, and patients, practitioners, and the medical system become more familiar with its integration into mainstream medical treatment settings [108], the role of acupuncture in the treatment of disease will become clearer.

Anti-hyperalgesic effect of electroacupuncture in a model of post-incisional pain in rats

Electroacupuncture has been proposed to be a low cost and practical method that allows effective pain management with minimal collateral effects. In this study we have examined the effect of electroacupuncture against the hyperalgesia developed in a model of post-incisional pain in rats. A 1-cm longitudinal incision was made through the skin and fascia of the plantar region of the animal hind paw. Mechanical hyperalgesia in the incision was evaluated 135 min after the surgery with von Frey filaments. The tension threshold was reduced from 75 g (upper limit of the test) to 1.36 +/- 0.36 g (mean +/- SEM) in control rats. It is shown that a 15-min period of electroacupuncture applied 120 min after surgery to the Zusanli (ST36) and Sanyinjiao (SP6) points, but not to non-acupoints, produces a significant and long-lasting reduction of the mechanical hyperalgesia induced by the surgical incision of the plantar surface of the ipsilateral hind paw. The tension threshold was reduced from 75 to 27.6 +/- 4.2 g in animals soon after the end of electroacupuncture. The mechanical threshold in this group was about 64% less than in control. Electroacupuncture was ineffective in rats treated 10 min earlier with naloxone (1 mg/kg, ip), thus confirming the involvement of opioid mechanisms in the antinociceptive effects of such procedure. The results indicate that post-incisional pain is a useful model for studying the anti-hyperalgesic properties of electroacupuncture in laboratory animals.

A prospective randomized study of electro-acupuncture versus alfentanil as anaesthesia during oocyte aspiration in in-vitro fertilization

The aim of the present study was to evaluate the anaesthetic effect during oocyte aspiration of a paracervical block (PCB) in combination with either electro-acupuncture (EA) or intravenous alfentanil. In all, 150 women undergoing in-vitro fertilization (IVF) and embryo transfer were randomized to receive either EA plus PCB or alfentanil plus PCB. Visual analogue scales (VAS) were used to evaluate subjective experiences during oocyte aspiration, and IVF outcome parameters were recorded. No differences in pain directly related to oocyte aspiration, adequacy of anaesthesia during oocyte aspiration, abdominal pain, or degree of nausea were found between the two groups in the VAS ratings. Before oocyte aspiration, the level of stress was significantly higher in the EA group than in the alfentanil group (P < 0.05), and the EA group experienced discomfort for a significantly longer period during oocyte aspiration (P < 0. 01). Compared with the alfentanil group, the EA group had a significantly higher implantation rate (P < 0.05), pregnancy rate (P < 0.05), and take home baby rate (P < 0.05) per embryo transfer. In conclusion, EA has been shown to be as good an anaesthetic method as alfentanil during oocyte aspiration, and we suggest that EA may be a good alternative to conventional anaesthesia during oocyte aspiration.