External validity in randomised controlled trials of acupuncture for osteoarthritis knee pain

Effect of Moxibustion on the Intestinal Flora of Rats with Knee Osteoarthritis Induced by Monosodium Iodoacetate

In this study, a knee osteoarthritis (KOA) rat model induced by monosodium iodoacetate (MIA) was used to study the effect of moxibustion on improving knee cartilage damage and its effect on the intestinal flora. The experimental rats were divided into the normal group (N), model group (M), moxibustion treatment group (MS), and diclofenac sodium treatment group (DS). After 4 weeks, cartilage pathological damage in the knee joint was evaluated using hematoxylin-eosin and safranin O-fast green staining analysis. ELISAs and Western blots were used to detect the expression levels of IL-1β and TNF-α in the serum and cartilage, respectively. The total DNA of the fecal samples was extracted and subjected to high-throughput sequencing of the V3-V4 region of the 16S rRNA gene to analyze the changes in the intestinal flora. In the model group, the cartilage was obviously damaged, the expression levels of IL-1β and TNF-α in the serum and cartilage were increased, and the abundance and diversity of the intestinal flora were decreased. Moxibustion treatment significantly improved the cartilage damage and reduced the concentration of inflammatory factors in the serum and cartilage. The high-throughput sequencing results showed that compared to the model group, the moxibustion treatment regulated some specific species in the intestinal microorganisms rather than the α diversity. In conclusion, our findings suggest that moxibustion treatment may work through two aspects in rats. On one hand, it directly acts on knee cartilage to promote repair, and on the other hand, it regulates the composition of the intestinal flora and reduces the production of inflammatory factors.

Lack of association between acupoint sensitization and microcirculatory structural changes in a mouse model of knee osteoarthritis: A pilot study

As a stimulating point in acupuncture, acupoint has unique microcirculatory features, and its dynamics vary greatly depending on health status. Acupoint sensitization is defined as the transformation of an acupoint from a "silenced status" (healthy) to an "activated status" (disease). Our previous study demonstrated that acupoint sensitization is associated with an increase in the level of local blood perfusion. However, the structural changes in microcirculation during acupoint sensitization have yet to be elucidated because the high-resolution microcirculation imaging of acupoints has been difficult to obtain. In this study, the structural changes in microcirculation at the Zusanli (ST36), Yanglingquan (GB34) and nonacupoint sites on days 0, 7 and 21 were dynamically observed during acupoint sensitization in an experimental knee osteoarthritis mouse model by using optical-resolution photoacoustic microscopy. The results showed that no significant differences in microvessel density, the distribution of vessel diameters or vascular tortuosity were observed at the GB34, ST36 or nonacupoint sites among days 0, 7 and 21. We proposed that acupoint sensitization may not be associated with the structural changes in microcirculation and that the microcirculatory changes during acupoint sensitization are more likely to be functional. The functional characteristics of the sensitized acupoints warrant further investigation.

Interaction of energetic points, tendinomuscular meridian and 5 elements in the treatment of osteoarthritis of the knee in patients over 45 years old: a randomized controlled trial

INTRODUCTION

Acupuncture had a different approaches since its beginnings. Using traditional energetic points with an interaction of 5 elements and meridian theories with manual diagnosis of tender points has been proposed. This procedure can be an effective treatment in musculoskeletal disease but its development is short.

OBJECTIVES

To evaluate the efficacy of energetic points of tendinomuscular meridian in the treatment of pain, quality of life and function of the knee.

DESIGN

Randomized controlled trial, non standardized and double blind. Inclusions criteria were: being over 45 years, having had pain for more than 3 months, level II o greater in Kellgren-Lawrence and suffering morning stiffness. Exclusion criteria were artoplasty, corticosteroids and rehabilitation, arthropaties, autoinmune diseases and neuropathic pain.

RESULTS

Intervention group had significant improvement in average pain in the last 15 days at end of treatment (p<0.04) and quality of life at the end of follow-up (p<0.015). Other measurements no show significant differences between groups.

CONCLUSIONS

Energetic points of tendinomuscular meridian and the 5 elements related are equal or better than local acupuncture in the treatment of pain, quality of life and function in osteoarthritis of the knee. However, it is necessary to have more research with more tracing and poblation to improve the quality of the results.

Laser Speckle Imaging of Sensitized Acupoints

Acupoints microcirculatory dynamics vary depending on the body's health status. However, the functional changes observed during acupoint sensitization, that is, the disease-induced change from a "silenced" to an "activated" status, remain elusive. In this study, the microcirculatory changes at acupoints during sensitization were characterized. Thirty SD rats were randomly divided into five groups: normal control group (N), sham osteoarthritis group (S), light osteoarthritis group (A), mild osteoarthritis group (B), and heavy osteoarthritis group (C). The obtained results showed that the blood perfusion levels at the acupoints Yanglingquan (GB34), Zusanli (ST36), and Heding (EX-LE2) in groups A, B, and C were higher than those in groups N and S on days 14, 21, and 28 (p < 0.01 or p < 0.05). A significant difference in the blood perfusion was also observed at the acupoint Weizhong (BL40) in groups B and C on days 21 and 28 (p < 0.01). In addition, remarkable differences in the level of blood perfusion at the GB34, ST36, and EX-LE2 acupoints were observed on day 28 (p < 0.01 or p < 0.05) among groups A, B, and C. No marked differences in blood perfusion levels were observed at the nonacupoint site among all groups. In conclusion, acupoint sensitization is associated with an increase in the level of local blood perfusion at specific acupoints, and this increase is positively correlated with the severity of the disease. The functional changes in microcirculation at acupoints during sensitization reflect the different physiological and pathological conditions imposed by the disease.

The quality of reporting in randomized controlled trials of acupuncture for knee osteoarthritis: A cross-sectional survey

OBJECTIVE

To assess the reporting quality of acupuncture trials for knee osteoarthritis (KOA), and explore the factors associated with the reporting.

METHOD

Three English and four Chinese databases were searched from inception to December 2016 for randomized control trials testing effects of acupuncture for knee osteoarthritis. We used the standard CONSORT (2010 version), CONSORT Extension for Non-Pharmacological Treatments, and STRICTA for measuring the quality of reporting. Using pre-specified study characteristics, we undertook regression analyses to examine factors associated with the reporting quality.

RESULTS

A total of 318 RCT reports were included. For the standard CONSORT, ten items were substantially under-reported (reported in less than 5% of RCTs), including specification of important changes to methods after trial commencement (0.6%), description of any changes to trial outcomes (0.0%), implementation of interim analyses and stopping guidelines (0.6%), statement about why the trial ended or was stopped (1.6%), statement about the registration status (4.4%), accessibility of full trial protocol (4.7%), implementation of randomization (4.7%), description of the similarity of interventions (3.5%), conduct of ancillary analyses (3.8%) and presentation of methods for additional analyses (4.4%). Four of the STRICTA items were under-reported (reported in less than 10% of RCTs), including description of acupuncture style (8.5%), presentation of extent to which treatment varied (1.3%), statement of practitioner background (7.2%) and rationale for the control (9.1%). For CONSORT Extension, the reporting was poor across all items (reported in less than 10% of trials). Trials including authors with expertise in epidemiology or statistics, published in English, or enrolling patients from multiple centers were more likely to have better reporting.

CONCLUSIONS

The reporting in RCTs of acupuncture for KOA was generally poor. To improve the reporting quality, journals should encourage strict adherence to the reporting guidelines.

Mast cells are important regulator of acupoint sensitization via the secretion of tryptase, 5-hydroxytryptamine, and histamine

Mast cells (MCs) play a crucial role in mediating the establishment of networks among the circulatory, nervous and immune system at acupoints. However, the changes which occur in MCs during acupoint sensitization, i.e. the dynamic transformation of an acupoint from a "silenced" to an "activated" status, remain uncharacterized. To investigate the morphological and functional changes of MCs as an aid to understanding the cellular mechanism underlying acupoint sensitization, a rat model of knee osteoarthritis (OA) was induced by an injection of mono-iodoacetate (MIA) on day 0. On day 14, toluidine blue and immunofluorescence staining were used to observe the recruitment and degranulation of MCs and the release of mast cell co-expressed mediators: tryptase, 5-hydroxytryptamine (5-HT) and histamine (HA) at the acupoints Yanglingquan (GB34), Heding (EX-LE2) and Weizhong (BL40). Results showed that the number of MCs as well as the percentages of degranulated and extensively degranulated MCs at the acupoints GB34 and EX-LE2 in the light (A), mild (B), heavy (C) osteoarthritis groups were larger than those in the normal control (N) and normal saline (NS) groups (p < 0.01). Comparisons among the A, B and C groups suggested that the number and the degranulation extent of the MCs at the acupoints GB34 and EX-LE2 were positively correlated with the severity of the disease. Some MCs in the A, B and C group showed the release of 5-HT, HA, and tryptase in degranulation at the acupoints GB34 and EX-LE2. Such changes in MCs were not observed at the acupoint BL40. In conclusion, this study confirmed that acupoint sensitization is associated with the increase in recruitment and degranulation levels of MCs on a acupoint-specific and disease severity-dependent manner. The release of tryptase, 5-HT, and HA during MC degranulation is likely to be one of the cellular mechanisms occurring during acupoint sensitization.

Risk of bias and methodological issues in randomised controlled trials of acupuncture for knee osteoarthritis: a cross-sectional study

OBJECTIVE

To assess risk of bias and to investigate methodological issues concerning the design, conduct and analysis of randomised controlled trials (RCTs) testing acupuncture for knee osteoarthritis (KOA).

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials and four major Chinese databases were searched for RCTs that investigated the effect of acupuncture for KOA. The Cochrane tool was used to examine the risk of bias of eligible RCTs. Their methodological details were examined using a standardised and pilot-tested questionnaire of 48 items, together with the association between four predefined factors and important methodological quality indicators.

RESULTS

A total of 248 RCTs were eligible, of which 39 (15.7%) used computer-generated randomisation sequence. Of the 31 (12.5%) trials that stated the allocation concealment, only one used central randomisation. Twenty-five (10.1%) trials mentioned that their acupuncture procedures were standardised, but only 18 (7.3%) specified how the standardisation was achieved. The great majority of trials (n=233, 94%) stated that blinding was in place, but 204 (87.6%) did not clarify who was blinded. Only 27 (10.9%) trials specified the primary outcome, for which 7 used intention-to-treat analysis. Only 17 (6.9%) trials included details on sample size calculation; none preplanned an interim analysis and associated stopping rule. In total, 46 (18.5%) trials explicitly stated that loss to follow-up occurred, but only 6 (2.4%) provided some information to deal with the issue. No trials prespecified, conducted or reported any subgroup or adjusted analysis for the primary outcome.

CONCLUSION

The overall risk of bias was high among published RCTs testing acupuncture for KOA. Methodological limitations were present in many important aspects of design, conduct and analyses. These findings inform the development of evidence-based methodological guidance for future trials assessing the effect of acupuncture for KOA.

Gender differences in the neural response to acupuncture: clinical implications

OBJECTIVE

To examine gender differences and similarities in the psychophysical and brain responses to acupuncture at GB34, a point that is frequently used to treat motor function issues in Traditional Chinese Medicine.

METHODS

Functional MRI (fMRI) was used to measure brain activation in response to acupuncture at GB34 (on the right) in 19 healthy participants (9 male, 10 female). De qi sensations were rated to measure their psychophysical responses.

RESULTS

Overall de qi scores did not differ by gender, although females reported greater intensity of aching (p=0.04). Acupuncture activated the hippocampus, thalamus, globus pallidus, caudate body, claustrum, cingulate gyrus, and culmen in males, and the middle and inferior frontal gyrus, precuneus, postcentral gyrus, inferior parietal lobule, superior temporal gyrus, caudate body, insula, fusiform gyrus, cingulate gyrus, amygdala, and parahippocampal gyrus in females. The middle/medial frontal gyrus, middle temporal gyrus, thalamus, globus pallidus, caudate body, uvula, and cerebellar tonsil were activated when data from all subjects were combined. Relative to males, females exhibited greater brain activation in the right-sided postcentral gyrus, precentral gyrus, precuneus, postcentral gyrus, inferior parietal lobule, declive, middle occipital gyrus and parahippocampal gyrus.

CONCLUSIONS

The neural effects of GB34 acupuncture might differ between males and females because different brain structures were modulated in response to acupuncture. This potential gender effect should be taken into account in future clinical research. We also revealed that the caudate body was activated by GB34 acupuncture in both males and females and may represent a major target of GB34 acupuncture.

TRIAL REGISTRATION NUMBER

KMC IRB 0861-06.

Assessment of the quality of reporting for treatment components in Cochrane reviews of acupuncture

OBJECTIVES

High-quality reporting of treatment details can aid replication of study results in real-world clinical practice. The Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) is a reporting guideline for key elements of acupuncture interventions in clinical trials. This study used STRICTA to investigate whether Cochrane reviews of acupuncture adequately report important treatment details.

DESIGN

Systematic review

METHODS

Cochrane reviews of acupuncture were identified from The Cochrane Library (issue 7, 2012). Randomised controlled trials (RCTs) included in the reviews and published after 2005 were obtained. Using STRICTA, we extracted acupuncture-related information from the Cochrane reviews and the RCTs. The characteristics of the included studies' table were the major source of intervention information from Cochrane reviews. Reporting quality of acupuncture interventions in Cochrane reviews was assessed and compared with the respective RCTs.

RESULTS

25 Cochrane reviews of acupuncture and 92 RCTs met the selection criteria. Cochrane reviews were 16% less likely to report the acupuncture-related items of STRICTA than RCTs (risk ratio 0.84, 95% CI 0.79 to 0.88, I(2)=8%). Information was significantly better reported for 10 of the 15 treatment-group items of STRICTA in RCTs than in Cochrane reviews (p<0.05), while four items did so without statistical significance. One item related to practitioner background was significantly better reported in Cochrane reviews.

CONCLUSIONS

Reporting quality of treatment details in Cochrane reviews of acupuncture was insufficient with regard to STRICTA, even though such information was readily reported in RCTs. The overall quality of reporting of the RCTs, while better than the reviews, was also often suboptimal. Use of STRICTA guideline during the review process is recommended to adequately report the key treatment components in Cochrane reviews of acupuncture. The potential impact of STRICTA to the replicability and utilisation of reviews in future research and practice needs to be investigated.