Evidence from Rcts on Optimal Acupuncture Treatment for Knee Osteoarthritis – An Exploratory Review

Dry Needling in Overhead Athletes with Myofascial Shoulder Pain: A Systematic Review

The treatment of myofascial pain in athletes requires a set of rehabilitation techniques that aim to be effective quickly. In this context, dry needling (DNY) has shown interesting results due to its ability to reduce pain in the short term. Thus, the aim of this study was to investigate the role of DNY in managing myofascial shoulder pain in overhead athletes. PubMed, Scopus and Web of Science were screened up to March 2024, to identify studies that met the following inclusion criteria: overhead athletes with shoulder pain with a DNY approach for myofascial trigger points (MTrPs), RCT, case-control study, feasibility study as the study design. Exclusion criteria were studies that did not include athletes, studies that did not focus on the treatment of MTrPs with DNY, other reviews, no full-text availability and papers written in a language other than English. Out of 399 articles, 165 were excluded as duplicates. Of the 234 articles screened, only 6 articles met the inclusion criteria. A total of 6 studies were included in the systematic review. Initial results showed that DNY improved pain rapidly and in the short term; however, there is still no consensus on the minimum number and the interval between treatments. Major findings reported a rapid potential decrease in perceived pain, shoulder disability and an increase in muscle strength; in this scenario, DNY might be a valid solution in a sports rehabilitation setting.

Economic evaluation of acupuncture as an adjunctive treatment with usual care for mild-to-moderate knee osteoarthritis: A Markov model-based analysis

Background

Collaborative care (CC), in which acupuncture is combined with usual care (UC), improves clinical outcomes and increases costs in knee osteoarthritis (KOA). We evaluated the economic feasibility of CC for Korean female patients with mild-to-moderate KOA by using a cost-effectiveness approach.

Methods

Two alternatives for KOA (1. UC as a comparator; and 2. CC as an intervention) were defined based on clinical guidelines, official Korean statistics, and expert validation. Each alternative was simulated in a Markov model every 6 months for 10 years. Estimates of costs, utilities, and transition probabilities were obtained from official statistics and previous studies. The effectiveness of CC was synthesized from randomized controlled trials. A base-case analysis of a limited societal perspective, univariate sensitivity analysis, and probability sensitivity analysis were performed. An annual discount rate of 4.5% and threshold of 20,000 United States dollar per Quality-adjusted life year (USD/QALY) were applied.

Results

Every incremental cost-effectiveness ratio (ICER) of CC calculated from the analyses was sub-threshold. In the base-case analysis, with a limited societal perspective, the ICER was 11,085 USD/QALY. The ICERs from the univariate sensitivity analyses were -2,577-16,748 USD/QALY. The average ICER in the probability sensitivity analysis was 12,412 USD/QALY. When the threshold surpassed 8,000 USD/QALY, the cost-effectiveness of CC exceeded 50%. The probability was 70.27% when the threshold was 20,000 USD/QALY.

Conclusions

CC for Korean female patients with mild-to-moderate KOA was generally cost-effective. Considering the limitations of the evidence, we propose a re-evaluation using further clinical studies in the future.

Dry needling strategies for musculoskeletal conditions: Do the number of needles and needle retention time matter? A narrative literature review

Acupuncture and dry needling are both minimally invasive procedures that use thin, filiform needles without injectate for the management of a variety of neuromusculoskeletal pain conditions. While the theoretical constructs underlying the use of acupuncture and dry needling are unique, both appear to have the ability to elicit biochemical, biomechanical, endocrinological and neurovascular changes associated with reductions in pain and disability. However, optimal treatment dosage has yet to be determined, and there is a lack of consistency in the literature on the number of needles that should be inserted and the needle retention time. Therefore, the purpose of this narrative review is to further explore the importance of these two variables. While trigger point dry needling advocates single needle insertions via repetitive, quick in-and-out pistoning, most acupuncture and dry needling clinical trials have incorporated multiple needles for five to 40 min. Notably and to date, using a single needle to repeatedly prick trigger points one at a time with fast-in and fast-out pistoning maneuvers has not yet been shown to produce significant and clinically meaningful long term improvements in pain and disability in a wide array of musculoskeletal conditions. Insertion of multiple needles for typically 20-30 min durations has been shown to produce larger treatment effect sizes and longer-lasting outcomes than brief, single-needle strategies. Moreover, the number of needles and needle retention time are two variables associated with treatment dosage and must be carefully matched with specific musculoskeletal conditions and the patient's goals.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

Comparison of the Effectiveness of Six and Two Acupuncture Point Regimens in Osteoarthritis of the Knee: A Randomised Trial

Background

Although substantial data have supported the effectiveness of acupuncture for treating knee osteoarthritis (OA), the number of points used has varied. The objective of this study was to compare the effectiveness of six and two acupuncture points in the treatment of knee OA.

Methods

A randomised trial of knee OA patients was conducted. Patients were randomly allocated into two groups of 35. The “six point group” received treatment at six acupuncture points, ST35, EX-LE4 ( Neixiyan), ST36, SP9, SP10 and ST34, while the “two point group” received treatment at just the first pair of points, ST35 and EX-LE4. Both groups received twice weekly electroacupuncture on 10 occasions. Electrical stimulation was carried out at low-frequency of 3 Hz to all points, with the intensity as high as tolerable. Both groups were allowed to take a 200 mg celecoxib capsule per day for intolerable pain. Patients were assessed at baseline, week 5, week 9 and week 13, using a Thai language version of the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Global assessment of change after 10 treatments was also recorded.

Results

Acupuncture at both six and two acupuncture points was associated with significant improvement. Mean total WOMAC score at weeks 5 and 13 of patients in both groups showed no significant difference statistically (p = 0.75 and p = 0.51). Moreover, the number of celecoxib capsules taken, global assessment of global change and body weight change of both groups also showed no statistical difference.

Conclusion

This evidence suggests that electroacupuncture to two local points may be sufficient to treat knee OA, but in view of some limitations to this study further research is necessary before this can be stated conclusively.

Optimizing acupuncture treatment for dry eye syndrome: a systematic review

BACKGROUND

In a former meta-analysis review, acupuncture was considered a potentially effective treatment for dry eye syndrome (DES), but there were heterogeneities among the outcomes. We updated the meta-analysis and conducted subgroup analysis to reduce the heterogeneity and suggest the most effective acupuncture method based on clinical trials.

METHODS

We searched for randomized controlled trials (RCTs) in 10 databases (MEDLINE, EMBASE, CENTAL, AMED, SCOPUS, CNKI, Wangfang database, Oriental Medicine Advanced Searching Integrated System (OASIS), Koreamed, J-stage) and searched by hand to compare the effects of acupuncture and artificial tears (AT). We also conducted subgroup analysis by (1) method of intervention (acupuncture only or acupuncture plus AT), (2) intervention frequency (less than 3 times a week or more than 3 times a week), (3) period of treatment (less than 4 weeks or more than 4 weeks), and (4) acupoints (BL1, BL2, ST1, ST2, TE23, Ex-HN5). The Bucher method was used for subgroup comparisons.

RESULTS

Nineteen studies with 1126 patients were included. Significant improvements on the Schirmer test (weighted mean difference[WMD], 2.14; 95% confidence interval[CI], 0.93 to 3.34; p = 0.0005) and break up time (BUT) (WMD, 0.98; 95% CI, 0.79 to 1.18; p < 0.00001) were reported. In the subgroup analysis, acupuncture plus AT treatment had a weaker effect in BUT but a stronger effect on the Schirmer test and a better overall effect than acupuncture alone. For treatment duration, treatment longer than 1 month was more effective than shorter treatment. With regard to treatment frequency, treatment less than three times a week was more effective than more frequent treatment. In the acupoint analysis, acupuncture treatment including the BL2 and ST1 acupoints was less effective than treatment that did not include them. None of those factors reduced the heterogeneity.

CONCLUSIONS

Acupuncture was more effective than AT in treating DES but showed high heterogeneity. Intervention differences did not influence the heterogeneity.

Dry needling: a literature review with implications for clinical practice guidelines

BACKGROUND

Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an 'intramuscular' procedure involving the isolated treatment of 'myofascial trigger points' (MTrPs).

OBJECTIVES

To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions.

MAJOR FINDINGS

According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. 'sensitive loci' or 'nociceptors') when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners.

CONCLUSIONS

Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as 'pistoning' or 'sparrow pecking'; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical 'acupuncture' literature that have used the very same 'dry needles' to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just 'TrPs'.

Integrating acupuncture with exercise-based physical therapy for knee osteoarthritis: a randomized controlled trial

BACKGROUND

Knee osteoarthritis is a chronic disease associated with significant morbidity and economic cost. The efficacy of acupuncture in addition to traditional physical therapy has received little study.

OBJECTIVE

The objective of this study was to compare the efficacy and safety of integrating a standardized true acupuncture protocol versus nonpenetrating acupuncture into exercise-based physical therapy (EPT).

METHODS

This was a randomized, double-blind, controlled trial at 3 physical therapy centers in Philadelphia, PA. We studied 214 patients (66% African Americans) with at least 6 months of chronic knee pain and x-ray-confirmed Kellgren scores of 2 or 3. Patients received 12 sessions of acupuncture directly following EPT over 6 to 12 weeks. Acupuncture was performed at the same 9 points dictated by the traditional Chinese "Bi" syndrome approach to knee pain, using either standard needles or Streitberger non-skin-puncturing needles. The primary outcome was the proportion of patients with at least a 36% improvement in Western Ontario and McMaster Universities Osteoarthritis Index score at 12 weeks.

RESULTS

Both treatment groups showed improvement from combined therapy with no difference between true (31.6%) and nonpenetrating acupuncture (30.3%) in Western Ontario and McMaster Universities Osteoarthritis Index response rate (P = 0.5) or report of minor adverse events. A multivariable logistic regression prediction model identified an association between a positive expectation of relief from acupuncture and reported improvement. No differences were noted by race, sex, or age.

CONCLUSIONS

Puncturing acupuncture needles did not perform any better than nonpuncturing needles integrated with EPT. Whether EPT, acupuncture, or other factors accounted for any improvement noted in both groups could not be determined in this study. Expectation for relief was a predictor of reported benefit.

Complementary and alternative medicine in osteoarthritis

The intent of this focused clinical review is to assess the current literature on a variety of complementary and alternative medicine treatments for osteoarthritis. This review assesses acupuncture techniques, moxibustion, transcutaneous electrical nerve stimulation, low-level laser therapy, and massage. These treatment methods are growing in popularity among the general public. It is important that providers become aware of the existing literature regarding the efficacy of these alternative methods for the treatment of osteoarthritis to adequately respond to the inquiries of our patients.

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

OBJECTIVES

To assess two aspects of the external validity of acupuncture research for osteoarthritis knee pain and determine the common acupoints and treatment parameters used.

METHODS

The external validity of 16 randomised controlled trials (RCTs) was investigated using a scale consisting of two aspects: reporting and performance. The reporting aspect included acupuncturist's background, study location, treatment detailed, patient characteristics, positive trial results, adverse effects and between-group statistical differences, whereas treatment appropriateness, appropriate controls and outcomes were classified as the performance aspect. Acupuncture treatment in RCTs was compared with common practice according to the literature sources and survey of acupuncturists working in different parts of Thailand.

RESULTS

The levels of external validity for the reporting and performance aspects were in the range of 31.3% to 100%. Statistic values such as mean difference and confidence interval were reported by the minority of trials (43.8%). Patient satisfaction and quality of life were seldom used (31.3%). There were minor differences between research and practice in terms of the points used (25.0%), number of treatment sessions (6.3%) and frequency (12.5%). The most frequently used points were ST34, ST35, ST36, SP6, SP9, SP10, GB34, Xiyan and ah shi points, and the commonly used treatment parameters were 20 minutes, 10-15 sessions and two treatments weekly.

CONCLUSIONS

Reporting of the external validity of acupuncture RCTs for knee pain was notably inadequate in terms of trial setting, treatment provider and statistical reporting. The majority of studies involved appropriate controls and outcomes and applied acupuncture treatments in line with practice.

Acupuncture and the relaxation response for treating gastrointestinal symptoms in HIV patients on highly active antiretroviral therapy

OBJECTIVES

To examine the effect of acupuncture and the relaxation response (RR) for treating gastrointestinal (GI) symptoms in HIV patients who are using highly active antiretroviral therapy (HAART).

METHODS

The authors conducted a 4-arm 2×2 double-blind randomised controlled trial in an acupuncture clinic in the USA. Sham acupuncture and health education were used as the control conditions of real acupuncture and RR elicitation, respectively. Enrolled patients were randomised to real acupuncture+RR (AR), sham acupuncture+RR (SR), real acupuncture+health education (AE) or sham acupuncture+health education (SE) study arm. Participants listened to CDs with RR-eliciting instructions or health education while receiving acupuncture intervention. Interventions were provided twice weekly for 4 weeks and once weekly for another 4 weeks. Participants used daily diaries to record GI symptom severity ratings (0-10). The authors estimated the intervention effect as the changes in symptom rating per intervention session increase using a mixed-effects regression model.

RESULTS

A total of 130 people with HIV/AIDS who were on HAART and had persistent GI symptoms were enrolled and 115 started the study intervention. The AR group had greater intervention effects for loose stools symptoms than the other three groups (β=-0.149, -0.151 and -0.144, p value=0.013, 0.013 and 0.018 comparing AR to AE, SR and SE, respectively). The AR group also had significant intervention effects on reducing nausea symptoms when the intervention was given twice per week (β=-0.218, p=0.001).

CONCLUSIONS

Our trial provided preliminary data demonstrating the potential synergistic effects of acupuncture and RR for treating GI symptoms in HIV patients on HAART.

A randomized controlled trial of acupuncture for osteoarthritis of the knee: effects of patient-provider communication

OBJECTIVE

There is conflicting evidence on the efficacy of traditional Chinese acupuncture (TCA), and the role of placebo effects elicited by acupuncturists' behavior has not been elucidated. We conducted a 3-month randomized clinical trial in patients with knee osteoarthritis to compare the efficacy of TCA with sham acupuncture and to examine the effects of acupuncturists' communication styles.

METHODS

Acupuncturists were trained to interact in 1 of 2 communication styles: high or neutral expectations. Patients were randomized to 1 of 3 style groups, waiting list, high, or neutral, and nested within style, TCA or sham acupuncture twice a week over 6 weeks. Sham acupuncture was performed in nonmeridian points with shallow needles and minimal stimulation. Primary outcome measures were Joint-Specific Multidimensional Assessment of Pain (J-MAP), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and satisfaction scores.

RESULTS

Patients (n = 455) received treatment (TCA or sham) and 72 controls were included. No statistically significant differences were observed between TCA or sham acupuncture, but both groups had significant reductions in J-MAP (-1.1, -1.0, and -0.1, respectively; P < 0.001) and WOMAC pain (-13.7, -14, and -1.7, respectively; P < 0.001) compared with the waiting group. Statistically significant differences were observed in J-MAP pain reduction and satisfaction, favoring the high expectations group. In the TCA and sham groups, 52% and 43%, respectively, thought they had received TCA (κ = 0.05), suggesting successful blinding.

CONCLUSION

TCA was not superior to sham acupuncture. However, acupuncturists' styles had significant effects on pain reduction and satisfaction, suggesting that the analgesic benefits of acupuncture can be partially mediated through placebo effects related to the acupuncturist's behavior.

On the threshold - evaluation of variability in effects of acupuncture in a gender perspective

Variable results of pain alleviation in response to acupuncture have been reported, complicating its interpretation. Sources of variability are probably multi-factorial, including the contribution of gender related effects. Gender related variation in perceived pain has been discussed frequently, but documented effects of acupuncture referring to gender are sparse. Furthermore, factors such as operationalisation of the outcome variable and the statistical method for evaluation could also be sources of variability. When pain is regarded as subjective, the produced data should be treated as ordinal. The rank-based method by Svensson, taking the non-metric qualities of the ordinal data into account as well as the variability at the group and the individual level, is therefore an alternative. The present commentary aims to (1) evaluate changes in electrical sensory thresholds and electrical pain thresholds after low frequency electro-acupuncture separately in healthy women and men; (2) introduce and exemplify the method by Svensson in a user-friendly approach. To analyze the systematic patterns of change in thresholds, indicating evidence of treatment on a group level, the relative position (RP) and relative concentration (RC), were measured. The variation related to the individual, the relative rank variation (RV) was also measured. The results were divergent between women (n = 23) and men (n = 22), i.e. unchanged sensory threshold after acupuncture at the group level in women while changed in men. The assessed pain threshold after acupuncture on the other hand was changed towards higher levels in women and unchanged in men. The individual variation was apparent in both women and men but larger in women. For statistical analysis of the variability for both group and individual related effects, the rank-based method by Svensson could be used. The present study indicates that evaluation of sensory and pain threshold response should be analysed separately in women and men.

Unveiling the United States Acupuncture Workforce

Acupuncture was first legalized in Maryland in 1973. By the end of 2009, regulatory legislation had passed in all but six states. The growth of acupuncture is most commonly measured by its well-documented demand as a treatment modality and the rapid increase in the number of licensees. Much less documented is a puzzling stagnation in work opportunities and income. As many as half of all licensees, on graduation and licensure, may be unable to support themselves by working in their chosen profession. However, unlike other well-established complementary and alternative health professions, such as chiropractic and massage, acupuncture is conspicuously absent from the Bureau of Labor and Statistics occupations manual, with only a handful of secondary and incomplete studies available, which together provide an inexact picture of the workforce. In this article, the authors review seven reports that provide limited information including hours worked, income, and practice type. Although data from these published articles are not standard, it can be reasonably concluded from the available information that, over the past decade, 50% of the licensed acupuncture (LAc) workforce is working less than 30 hr weekly; 50% are earning less than $50,000 on average; and the number of LAcs working independently in practice, either in their own office or sharing one, has increased from approximately 75% to 90%. Suggestions are presented for conducting a much needed comprehensive analysis of the acupuncture workforce.

Mainstreaming Acupuncture: Barriers and Solutions

There is a place for the acupuncture profession within primary care. Nationwide, community clinics that serve the population of under- and uninsured persons are facing a tremendous shortage of primary care practitioners. Marginalized health care professions, that is, acupuncture, chiropractic, and naturopathy, are being drawn into a primary care role. An unanticipated workforce opportunity exists to fill the caregiver gap in community clinics. This transition can be quickly realized in states such as California where statutory code states that acupuncture is to be regulated and controlled as a primary care profession, but the requisite training has yet to be provided. Specific clinical experience in primary care settings would help overcome long-standing barriers that have resulted in the marginalization of the profession, high under- and unemployment among acupuncturists, and result in greater access to acupuncture treatment. A 1-year primary care training program for licensed acupuncturists (LAcs), which features clinical and didactic training, akin to what a physician assistant receives, would prepare acupuncturists to work in mainstream medicine. With appropriate training and biomedical collaboration skills, the participation of acupuncturists in mainstream medical settings can be accomplished with support from the acupuncture profession and mainstream medicine.

OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009

OBJECTIVE

To update evidence for available therapies in the treatment of hip and knee osteoarthritis (OA) and to examine whether research evidence has changed from 31 January 2006 to 31 January 2009.

METHODS

A systematic literature search was undertaken using MEDLINE, EMBASE, CINAHL, AMED, Science Citation Index and the Cochrane Library. The quality of studies was assessed. Effect sizes (ESs) and numbers needed to treat were calculated for efficacy. Relative risks, hazard ratios (HRs) or odds ratios were estimated for side effects. Publication bias and heterogeneity were examined. Sensitivity analysis was undertaken to compare the evidence pooled in different years and different qualities. Cumulative meta-analysis was used to examine the stability of evidence.

RESULTS

Sixty-four systematic reviews, 266 randomised controlled trials (RCTs) and 21 new economic evaluations (EEs) were published between 2006 and 2009. Of 51 treatment modalities, new data on efficacy have been published for more than half (26/39, 67%) of those for which research evidence was available in 2006. Among non-pharmacological therapies, ES for pain relief was unchanged for self-management, education, exercise and acupuncture. However, with new evidence the ES for pain relief for weight reduction reached statistical significance, increasing from 0.13 [95% confidence interval (CI) -0.12, 0.36] in 2006 to 0.20 (95% CI 0.00, 0.39) in 2009. By contrast, the ES for electromagnetic therapy which was large in 2006 (ES=0.77, 95% CI 0.36, 1.17) was no longer significant (ES=0.16, 95% CI -0.08, 0.39). Among pharmacological therapies, the cumulative evidence for the benefits and harms of oral and topical non-steroidal anti-inflammatory drugs, diacerhein and intra-articular (IA) corticosteroid was not greatly changed. The ES for pain relief with acetaminophen diminished numerically, but not significantly, from 0.21 (0.02, 0.41) to 0.14 (0.05, 0.22) and was no longer significant when analysis was restricted to high quality trials (ES=0.10, 95% CI -0.0, 0.23). New evidence for increased risks of hospitalisation due to perforation, peptic ulceration and bleeding with acetaminophen >3g/day have been published (HR=1.20, 95% CI 1.03, 1.40). ES for pain relief from IA hyaluronic acid, glucosamine sulphate, chondroitin sulphate and avocado soybean unsponifiables also diminished and there was greater heterogeneity of outcomes and more evidence of publication bias. Among surgical treatments further negative RCTs of lavage/debridement were published and the pooled results demonstrated that benefits from this modality of therapy were no greater than those obtained from placebo.

CONCLUSION

Publication of a large amount of new research evidence has resulted in changes in the calculated risk-benefit ratio for some treatments for OA. Regular updating of research evidence can help to guide best clinical practice.

The effect of acupuncture duration on analgesia and peripheral sensory thresholds

Background

Acupuncture provides a means of peripheral stimulation for pain relief. However, the detailed neuronal mechanisms by which acupuncture relieves pain are still poorly understood and information regarding optimal treatment settings is still inadequate. Previous studies with a short burst of unilateral electroacupuncture (EA) in the Tendinomuscular Meridians (TMM) treatment model for pain demonstrated a transient dermatomally correlated bilateral analgesic effect with corresponding peripheral modality-specific sensory threshold alterations. However, the impact of EA duration on the analgesic effect in this particular treatment model is unknown. To obtain mechanistically and clinically important information regarding EA analgesia, this current prospective cross-over study assesses the effects of EA duration on analgesia and thermal sensory thresholds in the TMM treatment model.

Methods

Baseline peripheral sensory thresholds were measured at pre-marked testing sites along the medial aspects (liver and spleen meridians) of bilateral lower extremities. A 5-second hot pain stimulation was delivered to the testing sites and the corresponding pain Visual Analog Scale (VAS) scores were recorded. Three different EA (5Hz) stimulation durations (5, 15 and 30 minutes) were randomly tested at least one week apart. At the last 10 seconds of each EA session, 5 seconds of subject specific HP stimulation was delivered to the testing sites. The corresponding pain and EA VAS scores of de qi sensation (tingling) during and after the EA were recorded. The measurements were repeated immediately, 30 and 60 minutes after the EA stimulation. A four-factor repeat measures ANOVA was used to assess the effect of stimulation duration, time, location (thigh vs. calf) and side (ipsilateral vs. contralateral) of EA on sensory thresholds and HP VAS scores.

Results

A significant (P < 0.01) main effect of time and location with warm, cold and hot pain thresholds at the four testing sites without any significant difference in duration effect was observed. Similar time and location effects were observed with HP VAS with the longer durations (15 and 30 minutes) of stimulation showed a slower onset, but a more sustainable bilateral analgesic benefit than the short stimulation duration (5 minutes). The 15-minute stimulation resulted in an earlier onset of analgesic effect than the 30-minute stimulation paradigm.

Conclusion

Longer durations of EA stimulation provide a more sustainable analgesic benefit to hot noxious stimulation than a shorter duration of stimulation. The increase of cold threshold with sustained warm threshold temperature elevation as observed in the longer durations of EA suggests that as the duration of EA lengthened, there is a gradual shifting from an initial predominantly spinally mediated analgesic effect to a supraspinally mediated modulatory mechanism of thermal pain. The 15-minute stimulation appeared to be the optimal setting for treating acute pain in the lower extremities.