Neural acupuncture unit: a new concept for interpreting effects and mechanisms of acupuncture

Does the outcome of acupuncture differ according to the location of sham needling points in acupuncture trials for migraine? A systematic review and network meta-analysis

Various acupuncture clinical trials have been conducted on migraine; however, the conclusions remain controversial especially when acupuncture was compared with sham acupuncture. Sham acupuncture is sometimes performed at the same acupuncture points used for verum acupuncture despite the evidence on acupuncture point specificity. Four databases were searched for sham acupuncture or waiting list-controlled acupuncture trials for migraine on December 25, 2023. Sham acupuncture was classified according to the needling points: sham acupuncture therapy at verum points (SATV) or at sham points (SATS). Network meta-analysis was performed based on the frequentist framework for headache pain intensity and response rate. A total of 18 studies involving 1936 participants were analyzed. Headache pain intensity and response rate were significantly improved in verum acupuncture compared with SATS. However, there was no significant difference between SATV and verum acupuncture. When comparing SATS and SATV, there was no significant difference in headache pain intensity and response rate; however, the results were in favor of SATV. The effect of the risk of bias on the certainty of evidence between verum and sham acupunctures was judged to be generally low. SATV should not be misused as a placebo control to evaluate the efficacy of acupuncture.

Evidence evaluation of acupuncture and its related therapies for female urinary incontinence: an overview and quality assessment of systematic reviews and meta-analyses

INTRODUCTION

Through methodological quality assessment, this paper summarized the report quality and evidence level of systematic reviews (SRs)/meta-analyses (MAs) of acupuncture and its related treatment of female urinary incontinence (UI).

EVIDENCE ACQUISITION

We conducted a comprehensive search in four internationally recognized databases (PubMed, Embase, Web of Science, Cochrane Library) for SRs/MAs pertaining to the treatment of female UI using acupuncture and its related therapies. We evaluated the methodological quality of the SRs/MAs using the "Assessing the Methodological Quality of Systematic Reviews 2" (AMSTAR-2) tool, assessed the quality of evidence using the "Grading of Recommendations, Assessment, Development, and Evaluation" (GRADE) system, and evaluated the reporting quality of the SRs/MAs using the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020" (PRISMA-2020) guidelines. This overview is registered with PROSPERO, CRD42024557600.

EVIDENCE SYNTHESIS

In the final selection of 7 SRs/MAs, a consistent finding of the superiority of acupuncture and related therapies in the treatment of female UI was observed. Methodological quality was classified according to AMSTAR-2, with three rated as "high," two as "moderate," and two as "low." The main sources of downgrading included the absence of funding sources, failure to provide a reasonable explanation for heterogeneity, and not reporting potential conflicts of interest. According to the GRADE system, the quality of evidence ranged from moderate to very low. The most common reason for downgrading the evidence quality was the repeated utilization of the same original randomized controlled trials. Some results were also downgraded due to inconsistency, imprecision, and potential publication bias. According to the PRISMA-2020 statement, most SR/MAs clearly presented their title information, and almost all of them correctly used meta-analysis methods. However, some of them lacked comprehensive analysis and discussion of bias risk and consistency of results and were deficient in terms of protocol registration and documentation.

CONCLUSIONS

Acupuncture and related therapies demonstrate superiority in terms of efficacy and safety for the treatment of female urinary incontinence (UI). The overall quality of the SRs/MAs seems to be satisfactory, particularly when compared to studies of acupuncture for the treatment of other conditions. However, attention should still be given to the proper use of methods and ensuring completeness in reporting.

Effects of time-dependent acupuncture on back muscle endurance in women with chronic nonspecific low back pain: A randomized crossover trial

BACKGROUND

Chronic nonspecific low back pain (CNLBP) is a leading cause of disability and remains a major burden for many public health systems. Acupuncture is a nonpharmacological treatment for CNLBP that can be effective in improving low back pain; nevertheless, its effect on improving back muscle endurance in patients with CNLBP and its duration of effect have not been studied.

OBJECTIVE

The goal of this study was to assess the impact of acupuncture on lower back muscle activity in CNLBP patients.

METHODS

This was a single-blind, randomized, crossover experimental study. Thirty female patients were randomized into Group A (15 patients) or Group B (15 patients). Patients in Group A were assigned to receive real acupuncture (RA) in the first phase and sham acupuncture (SA) in the second phase, while those in Group B received SA first and then RA, with a 1-week washout period between phases. Two-way repeated ANOVA was used to evaluate the effect of group and time on isokinetic parameters, Surface electromyography (sEMG) data, and blood data.

RESULTS

Significant interaction effects were identified between group * time on the isokinetic parameters of the lumbar extensor muscles, sEMG values of the erector spinae, blood lactate levels, and blood ammonia levels (all p< 0.05). Compared with those of the SA group, the isokinetic parameters of the lumbar extensor muscles, sEMG values of the erector spinae, blood lactate levels, and blood ammonia levels of the RA group were significantly different (all p< 0.05).

CONCLUSION

RA improves lumbar extensor endurance in patients with CNLBP and lasts approximately 9 minutes. RA can improve blood circulation to reduce blood lactic acid and blood ammonia produced during exercise.

Effectiveness of static, dynamic and combined dry needling techniques in the management of myofascial pain syndrome: A three-group study

Objectives

This study aims to evaluate and compare the therapeutic effectiveness of static dry needling (S-DN), dynamic dry needling (D-DN), and a combined technique (CT) for managing myofascial pain syndrome (MPS).

Patients and methods

Between January 1, 2023 and April 15, 2023, a total of 38 patients (9 males, 29 females; mean age: 40.5±12.7 years; range, 22 to 63 years) with MPS who experienced neck pain for less than six months and had at least one painful myofascial trigger point in the trapezius, rhomboids, or levator scapula muscle were included in the study. The patients were divided into three groups: D-DN, S-DN, and CT. Measurements included the Visual Analog Scale (VAS), range of motion (ROM), Neck Disability Index (NDI), and the European Quality of Life 5 Dimensions 3 Level Version (EQ5D3L). All measurements were made at baseline (T0), after the first treatment session (T1), after the final session (T2), and one-month post-treatment (T3).

Results

The group treated with S-DN showed less significant improvement in ROM scores compared to other treatment methods. Both the D-DN and S-DN groups showed decreased VAS scores at rest and during motion across all time points, compared to the CT group. The NDI scores decreased in all groups, while the EQ5D3L scores exhibited no variations between groups or across any time point irrespective of the treatment method employed.

Conclusion

Our study results suggest that all three methods are effective in treating MPS, with D-DN potentially being the preferred method over S-DN and CT due to its time efficiency.

Acupuncture: An Overview on Its Functions, Meridian Pathways and Molecular Mechanisms

Recent research has extensively explored the intricate mechanisms that underlie the effectiveness of acupuncture, highlighting the importance of stimulating acupoints, the role of acupuncture techniques in managing diseases, and the interaction between meridian pathways and molecular processes. Studies have underscored the crucial role of acupuncture in activating neurons, modulating the immune system, and influencing vascular activity, all of which contribute significantly to its therapeutic benefits across a wide range of symptoms and conditions. Utilization of imaging modalities enables the identification of changes in cerebral blood flow, brain function, and regional glucose metabolism following acupuncture sessions. The interstitial fluid circulation network within meridians adheres to specific laws that facilitate the transportation of materials. Acupuncture initiates the release of neurotransmitters, neuropeptides, and immune factors, impacting pain perception, inflammation, and physiological functions. It influences the complex neuro-endocrine-immune network by activating pathways involving the nervous system, the hypothalamic-pituitary-adrenal axis, and immune responses. Moreover, acupuncture induces molecular modifications such as phosphorylation, methylation, and histone modification, leading to key molecular changes that ultimately result in anti-inflammatory effects and the regulation of immune responses.

Adenosine triphosphate mediates the pain tolerance effect of manual acupuncture at Zusanli (ST36) in mice

OBJECTIVE

To investigate the mechanisms behind the effects of acupuncture in Traditional Chinese Medicine, we delved into the adenosine triphosphate/peripheral purinergic P2X receptor 3 (ATP/P2X3) receptor signaling system as an indicator of the body's energy state, commonly referred to as "Qi".

METHODS

The tail-flick test was utilized to explore the impact of acupuncture on pain tolerance threshold (PTT) in mice, while also assessing adenosine (ADO) levels and adenylate energy charge (EC) at Zusanli (ST36). The study further investigated the dose-dependent effects of acupuncture on PTT and ADO levels at Zusanli (ST36). To shed light on the underlying mechanisms of acupuncture's effects, the study examined the impact of ATP, a P2X3 receptor antagonist, and adenosine disodium on PTT following acupuncture administration.

RESULTS

Acupuncture at Zusanli (ST36) led to significant improvements in PTT in mice, with the most effective interventions being twirling for 2 min and needle retention for 28 min. These interventions also resulted in significant increases in ATP levels. The effects of acupuncture were further augmented by administration of different doses of ATP at Zusanli (ST36), and pretreatment with a P2X3 receptor antagonist decreased PTT. Adenylate EC peaked at 30 min after intraperitoneal injection of ATP, and pretreatment with various doses of i.p. ATP 30 min prior to acupuncture increased PTT in a dose-dependent manner. Additionally, pretreatment with an i.p. or intramuscular injection of adenosine disodium enhanced the effects of acupuncture.

CONCLUSION

This research provides compelling evidence that ATP is involved in the regulation of PTT through acupuncture, revealing new avenues for achieving enhanced clinical outcomes.

Comment on Takakura et al. Acupuncture for Japanese Katakori (Chronic Neck Pain): A Randomized Placebo-Controlled Double-Blind Study. Medicina 2023, 59, 2141

We are writing because we have a number of concerns about the Takakura et al. [...].

Anatomical Exploration of the KI1 Acupoint: Implications for Medial and Lateral Plantar Nerve Stimulation

Background and Objectives: This study aims to identify the precise anatomical location and therapeutic mechanisms of the KI1 acupoint (Yongquan) in relation to foot muscles and nerves, known for treating neurological disorders and pain. Materials and Methods: Dissection of six cadavers at Chungnam National University College of Medicine examined KI1's relation to the foot's four-layer structure. Results: The KI1 acupoint was located in the superficial and deep layers of the plantar foot, adjacent to significant nerves like the medial and lateral plantar nerves. Differences in the acupoint's exact location between genders were noted, reflecting variances in foot morphology. KI1 acupuncture was found to stimulate the muscle spindles and nerve fibers essential for balance and bipedal locomotion. This stimulation may enhance sensory feedback, potentially improving cognitive functions and balance control. Conclusions: This anatomical insight into KI1 acupuncture underpins its potential in neurological therapies and pain management.

Can acupuncture increase microcirculation in peripheral artery disease and diabetic foot syndrome? - a pilot study

Background

Globally, diabetes mellitus (DM) and peripheral artery disease (PAD) have an increasing incidence and a high prevalence and are both associated with high morbidity and complication rates, e.g., as chronic non-healing peripheral ulcers. Impaired macro- and microcirculation and peripheral neuropathy lead to an increased risk of foot ulcers and infections. These complications are difficult to treat, have a high risk of becoming chronic and often lead to lower limb amputation. The aim of this planned study was to investigate the potential effects of acupuncture on improving microcirculation in patients with Diabetic Foot Syndrome (DFS) and PAD.

Materials and methods

In 18 patients with chronic non-healing peripheral ulcers and diagnosed DM or PAD, data on 8 microcirculatory parameters were collected simultaneously on intact skin close to the wound margin. Microcirculation was assessed using an O2C device combining laser Doppler shift and white light spectroscopy (LEA Medizintechnik GmbH, Giessen, Germany). Unilateral and bilateral acupuncture was performed on the connecting line between acupuncture points Stomach 14 and Stomach 15.

Results

After unilateral acupuncture (ipsilateral to the wound side), a statistically significant improvement in 7 out of 8 microcirculatory parameters was demonstrated compared to baseline measurements before acupuncture. After bilateral acupuncture, there was an additional improvement and statistical significance in all parameters in both DFS and PAD patients.

Discussion

These results show an improvement in the microcirculation and peripheral blood flow at the edges of the wound. As impaired micro- and macrocirculation is considered to be a critical prognostic factor for the healing of a peripheral lesion, the intervention could have a positive impact on the healing of (chronic) peripheral wounds.

Laser acupuncture to reduce temporomandibular disorder (TMD) symptoms: systematic review and meta-analysis

The application of low-level laser therapy (LLLT) to acupuncture points may produce effects similar to that of needle stimulation in patients with temporomandibular disorders (TMD). This systematic review was conducted according to the Cochrane Collaboration guidelines and aimed to address clinical questions using the following strategy: Patient/Problem, Intervention, Comparison, and Outcome (PICO). A comprehensive literature search was performed upto April 26, 2023, across nine electronic databases (BVS, PubMed, Scopus, Embase, Web of Science, ScienceDirect, Cochrane Library, Latin American and Caribbean Health Sciences Literature (LILACS), and Google Scholar) supplemented with gray literature. The risk of bias in randomized and nonrandomized clinical trials was assessed using two tools: risk-of-bias (RoB) 2 and Risk Of Bias In Non-randomised Studies-of Interventions (ROBINS-I). Meta-analysis involved the extraction of mean and standard deviation values for spontaneous pain and mouth opening levels. Seven studies were included in this review, all of which used LLLT. The applied wavelengths ranged from 690 to 810 nm without significant variations in light emission patterns. LLLT demonstrated a significant reduction in instantaneous pain levels (standard mean difference [SMD] = 3.85; 95% confidence interval [CI] = 2.09, 5.62; p < 0.003) and an improvement in instantaneous mouth opening ability (mean difference [SMD] = -7.15; 95% CI = -11.73, -2.58; p < 0.002), with low certainty of evidence. LLLT may alleviate symptoms in patients with TMD; however, caution should be exercised when interpreting the results because of protocol variations among studies and the limited number of studies included in the meta-analysis.

Immediate effects of superficial dry needling of the trigeminal nerve innervation field for participants with cervicogenic headache. A randomized controlled trial

BACKGROUND

Cervicogenic headache (CGH) is a common condition with a neuroanatomical basis involving the trigeminal nerve. Dry needling (DN) is a safe and effective treatment for CGH but most studies involve deep DN to cervical musculature.

OBJECTIVE

The aim of this study was to investigate immediate effects of superficial DN of the trigeminal nerve innervation field on numeric pain rating scale (NPRS), flexion-rotation test (FRT), cervical range of motion (AROM), and pain-pressure threshold (PPT) of right (R) and left (L) supraorbital (SO), and right (R) and left (L) greater occipital (GO) nerves in participants with CGH.

METHODS

A parallel controlled randomized design involving 30 participants with CGH received either superficial DN (N = 17) or sham DN (N = 13). Participants and outcome assessors were blind to group assignment. Wilcoxon signed rank analyzed within-group effects and Mann-Whitney U analyzed between-group.

RESULTS

Statistically significant between-group differences were observed for NPRS (P < .001) and AROM (P < .006) favoring DN and were clinically meaningful. Right and left Flexion rotation tests (FRT) outcomes were non-significant (P = .137) but clinically meaningful. No differences were observed for PPT over: R SO (P = .187); L SO (P = .052); R GO (P = .187); or L GO (P = .052). Between-group effect sizes across variables were moderate to large (0.53-1.4) but confidence intervals were wide.

CONCLUSION

Superficial DN targeting the innervation field of the trigeminal nerve improves clinical outcomes in patients with CGH. Only the immediate effects were analyzed and the sample size was small. Larger, longer-term assessments are needed comparing superficial DN of the trigeminal innervation field and other conservative interventions for CGH.

Different Outcomes According to Needling Point Location Used in Sham Acupuncture for Cancer-Related Pain: A Systematic Review and Network Meta-Analysis

Numerous acupuncture studies have been conducted on cancer-related pain; however, its efficacy compared to sham acupuncture remains controversial. We confirmed whether the outcome of acupuncture differs according to the needling points of sham acupuncture for cancer-related pain. We searched 10 databases on 23 May 2023 to screen acupuncture trials using sham acupuncture or waiting list as controls for cancer-related pain. Sham acupuncture was classified into two types, depending on whether the needling was applied at the same locations as verum acupuncture (SATV) or not (SATS). A network meta-analysis (NMA) was performed on the basis of a frequentist approach to assess pain severity. Eight studies (n = 574 participants) were included in the review, seven of which (n = 527 participants) were included in the NMA. The pain severity was not significantly different between SATV and verum acupuncture, but verum acupuncture significantly improved pain severity compared to SATS. The risk of bias affecting the comparisons between the verum and sham acupuncture was generally low. Previous acupuncture trials for cancer-related pain showed differing outcomes of sham and verum acupuncture, depending on the needling points of sham acupuncture. The application of SATV cannot be considered a true placebo, which leads to an underestimation of the efficacy of verum acupuncture.

Acupuncture for brain diseases: Conception, application, and exploration

The brain is probably the most complex organ in the human body. It has been the hot spot and direction of brain science research all over the world to deeply study the pathogenesis of various kinds of brain diseases and find effective treatment methods. Acupuncture is a nonpharmacological therapy of traditional Chinese medicine originating from ancient clinical practice. The research on the treatment of brain diseases by acupuncture has been constantly enriched and updated with the promotion of interdisciplinary research. In order to account for the current achievements in the field of acupuncture for brain diseases, this article reviews it in terms of conception, application, and exploration. Based on the literature review, we found that in the past decades, acupuncture has received widespread attention worldwide and many literatures have reported the clinical efficacy and underlying mechanisms of acupuncture in the treatment of brain diseases. Presently, the conception, application, and exploration of acupuncture in the treatment of brain diseases have evolved from empirical medicine to evidence-based medicine and precision medicine, and are experiencing a deeper understanding of the information about acupuncture regulating the brain function based on interdisciplinary research.

Harmonic effects of sham acupuncture at Tsu San Li (St-36) in the radial pulse wave

Background and aim

Acupuncture has been criticized as a theatrical placebo for the sham effect. Unfortunately, sham tests used in control groups in acupuncture studies have always ignored the underlying biophysical factors, including resonance involved in acupuncture points and meridians.

Experimental procedure

In this study, the effects of sham acupuncture at Tsu San Li (St-36) were examined by analyzing noninvasive 30-sec. recordings of the radial arterial pulses for 3 groups of patients treated with different probes (blunt, sharp, and patch) on the superficial skin of the acupuncture point. The 3 groups were then treated with the sharp probe for 3 different periods (16, 30, and 50 s). Then we compared the harmonics of the radial arterial pulse after Fourier transformation before and after the treatment.

Results

Our results indicated that different probes have effects similar to needle insertion at Tsu San Li. Meanwhile, the harmonic effect of the sharp probe strengthened as time increased.

Conclusions

This study revealed that the meridian effect of sham testing from mechanical stimulation, even from simple touch, on an acupuncture point, should not be overlooked. Thus, even simple touch can be added to electrical or laser acupuncture.

Global research trends of sham acupuncture: A bibliometric analysis

OBJECTIVE

Sham acupuncture has been used as a control in acupuncture efficacy trials. However, questions have been raised about whether it is a physiologically inert placebo. We aimed to understand global research trends and provide guidance for future research by conducting a bibliometric analysis of sham acupuncture studies.

METHODS

Journal articles published to date related to sham acupuncture were retrieved from Web of Science on May 29, 2023. The publication year, country, keyword, author, and organization of the studies were analyzed using the available bibliometric information. Using VOSviewer software, the co-occurrence of keywords in sham acupuncture studies was visualized as a network map by cluster analysis and overlay analysis according to the publication year.

RESULTS

A total of 3428 studies were included in the analysis. Studies on sham acupuncture have been steadily increasing since 1991, with most of the studies conducted in China (1514 studies, 44.17%), followed by the United States (789 studies, 23.02%) and South Korea (277 studies, 8.08%). The keywords of sham acupuncture research were classified into four clusters: evidence synthesis, pain clinical research, mechanism research, and acupressure research. Keyword analysis according to the publication year showed that evidence synthesis on sham acupuncture was recently focused on psychiatric conditions including depression and insomnia through systematic reviews, and clinical and mechanism studies on sham acupuncture were mostly conducted relatively in the past.

CONCLUSION

This bibliometric analysis provides a comprehensive overview of the development and global trends of sham acupuncture research to date, suggesting directions for future research.

Acupuncture as multi-targeted therapy for the multifactorial disease obesity: a complex neuro-endocrine-immune interplay

The prevalence of obesity has reached pandemic dimensions. It is associated with multiple comorbidities and is becoming a clinical and public health threat. Obesity is a multifactorial disease with a complex pathophysiology and interplay of various systems. A strong interplay exists between the neuro-endocrine system, the immune system with systemic chronic low-grade inflammation, and microbiome dysbiosis that can lead to the development of obesity, which in turn can exacerbate each of these factors, hence creating a vicious cycle. The conventional treatment with lifestyle modifications such as diet, physical exercise, pharmacotherapy, and bariatric surgery does not always result in sufficient weight control thus paving the way for other strategies. As one such strategy, acupuncture is increasingly used worldwide to treat obesity. This narrative review outlines the evidence for this neuro-endocrine-immune interplay in the pathophysiology of obesity. Furthermore, the existing experimental and clinical evidence of acupuncture as a multi-targeted therapy for obesity is explained and future research perspectives are discussed.

The effects of acupuncture on depression by regulating BDNF-related balance via lateral habenular nucleus BDNF/TrkB/CREB signaling pathway in rats

Depression is a major mental disease worldwide, causing dysfunction of Lateral Habenular (LHb). As a non-invasive alternative, acupuncture (AP) has been widely used to treat depression in clinic, yet few basic studies have been focused on the effects and mechanism of acupuncture on synaptic plasticity in LHb. Therefore, this study aimed to explore the potential mechanism of the antidepressant effect of acupuncture. Male Sprague-Dawley (SD) rats were randomly divided into control, chronic unpredictable mild stress (CUMS), AP, fluoxetine (FLX), acupoint catgut embedding (ACE), sham-ACE groups (n = 9/group). Rats were given a 28-day treatment at the Shangxing (GV23) and Fengfu (GV16) acupoints with acupuncture, ACE, sham-ACE or fluoxetine (2.1 mg/kg). The results showed that AP, FLX and ACE suppressed the behavioral deficits, increased the level of the 5-hydroxytryptamine and FNDC5/IRISIN in serum, also reduced the expression of pro-BDNF impacted by CUMS. Both AP and FLX ameliorated the %area of IBA-1, GFAP, BrdU and DCX in the LHb and increased the expression of BDNF/TrkB/CREB, with non-significant difference between the two groups These findings suggest that AP therapy relieves depression-related manifestations in depressed rats, suggesting a potential mechanism via the BDNF/TrkB/CREB pathway in LHb.

Numerical Modeling and Simulation of Non-Invasive Acupuncture Therapy Utilizing Near-Infrared Light-Emitting Diode

Acupuncture is one of the most extensively used complementary and alternative medicine therapies worldwide. In this study, we explore the use of near-infrared light-emitting diodes (LEDs) to provide acupuncture-like physical stimulus to the skin tissue, but in a completely non-invasive way. A computational modeling framework has been developed to investigate the light-tissue interaction within a three-dimensional multi-layer model of skin tissue. Finite element-based analysis has been conducted, to obtain the spatiotemporal temperature distribution within the skin tissue, by solving Pennes' bioheat transfer equation, coupled with the Beer-Lambert law. The irradiation profile of the LED has been experimentally characterized and imposed in the numerical model. The experimental validation of the developed model has been conducted through comparing the numerical model predictions with those obtained experimentally on the agar phantom. The effects of the LED power, treatment duration, LED distance from the skin surface, and usage of multiple LEDs on the temperature distribution attained within the skin tissue have been systematically investigated, highlighting the safe operating power of the selected LEDs. The presented information about the spatiotemporal temperature distribution, and critical factors affecting it, would assist in better optimizing the desired thermal dosage, thereby enabling a safe and effective LED-based photothermal therapy.

Acupuncture for chemotherapy-associated insomnia in breast cancer patients: an assessor-participant blinded, randomized, sham-controlled trial

BACKGROUND

Insomnia is a highly prevalent symptom occurred during and post-chemotherapy. Acupuncture may have beneficial effects in the management of chemotherapy-associated insomnia. This study was conducted to determine the efficacy and safety of acupuncture in improving chemotherapy-associated insomnia in breast cancer patients.

METHODS

This assessor-participant blinded, randomized, sham-controlled trial was conducted from November 2019 to January 2022 (follow-up completed July 2022). Participants were referred by oncologists from two Hong Kong hospitals. Assessments and interventions were conducted at the outpatient clinic of School of Chinese Medicine, the University of Hong Kong. The 138 breast cancer patients with chemotherapy-associated insomnia were randomly assigned to receive either 15 sessions of active acupuncture regimen by combining needling into body acupoints and acupressure on auricular acupoints or sham acupuncture control (69 each) for 18 weeks, followed by 24 weeks of follow-up. The primary outcome was measured using Insomnia Severity Index (ISI). Secondary outcomes included the Pittsburgh Sleep Quality Index, Actiwatch and sleep diary for sleep parameters, depression and anxiety, fatigue and pain, and quality of life.

RESULTS

There were 87.7% (121/138) participants who completed the primary endpoint (week-6). The active acupuncture regimen was not superior to the sham control in reducing ISI score from baseline to 6 weeks (mean difference: - 0.4, 95% CI - 1.8-1.1; P = 0.609), but produced short-term treatment and long-term follow-up better outcomes in improving sleep onset latency, total sleep time, sleep efficiency, anxiety, depression, and quality of life. Participants of the active acupuncture group had a pronouncedly higher cessation rate of sleeping medications than the sham control (56.5% vs. 14.3%, P = 0.011). All treatment-related adverse events were mild. No participants discontinued treatments due to adverse events.

CONCLUSION

The active acupuncture regimen could be considered as an effective option for the management of chemotherapy-associated insomnia. It also could serve as a tapering approach to reduce and even replace the use of sleeping medications in breast cancer patients. Trial registration Clinicaltrials.gov : NCT04144309. Registered 30 October 2019.

Use of Rehabilitation Therapy in Palliative Care Patients

Palliative care is a unique area of veterinary medicine, where primary goals include maintaining quality of life, as opposed to treating with a curative intent. Using the disablement model and client partnership allows for the development of a function-targeted treatment plan individualized to patient and family needs. Rehabilitation modalities, especially when combined with adaptive pain management, are well-suited to palliative care because they can greatly enhance a patient's ability to achieve improved function and quality of life. These areas join in a concept called palliative rehabilitation which combines the unique needs of these patients and the tools accessible to the rehabilitation practitioner.

Transcutaneous electrical cranial-auricular acupoint stimulation versus escitalopram for mild-to-moderate depression: An assessor-blinded, randomized, non-inferiority trial

AIM

Transcutaneous electrical cranial-auricular acupoint stimulation (TECAS) is a novel non-invasive therapy that stimulates acupoints innervated by the trigeminal and auricular vagus nerves. An assessor-blinded, randomized, non-inferiority trial was designed to compare the efficacy of TECAS and escitalopram in mild-to-moderate major depressive disorder.

METHODS

468 participants received two TECAS sessions per day at home (n = 233) or approximately 10-13 mg/day escitalopram (n = 235) for 8 weeks plus 4-week follow-up. The primary outcome was clinical response, defined as a baseline-to-endpoint ≥50% reduction in Montgomery-Åsberg Depression Rating Scale (MADRS) score. Secondary outcomes included remission rate, changes in the severity of depression, anxiety, sleep and life quality.

RESULTS

The response rate was 66.4% on TECAS and 63.2% on escitalopram with a 3.2% difference (95% confidence interval [CI], -5.9% to 12.9%) in intention-to-treat analysis, and 68.5% versus 66.2% with a 2.3% difference (95% CI, -6.9% to 11.4%) in per-protocol analysis. The lower limit of 95% CI of the differences fell within the prespecified non-inferiority margin of -10% (P ≤ 0.004 for non-inferiority). Most secondary outcomes did not differ between the two groups. TECAS-treated participants who experienced psychological trauma displayed a markedly greater response than those without traumatic experience (81.3% vs 62.1%, P = 0.013). TECAS caused much fewer adverse events than escitalopram.

CONCLUSIONS

TECAS was comparable to escitalopram in improving depression and related symptoms, with high acceptability, better safety profile, and particular efficacy in reducing trauma-associated depression. It could serve an effective portable therapy for mild-to-moderate depression.

Changes in Acupuncture-Induced Specific Acupoint Neurotransmitters are Possibly Related to Their Physiological Functions in Rats

This study investigated changes in neurotransmitters induced by the application of electroacupuncture (EA) at Zusanli (ST36) and Neiguan (PC6). A total of 30 rats were divided into five groups: sham, ST (EA at bilateral ST36 and ST37), ScT (ST plus previous neurectomy of the bilateral sciatic nerves), ScS (sham plus previous neurectomy of the bilateral sciatic nerve), and PC (EA at bilateral PC6 and PC7). The P2X2 receptor expression was stronger in the sham group than in the ST and PC groups (both p < 0.05) but similar between the sham and ScT groups (p > 0.05). Dopamine levels in the extracellular fluid surrounding the acupoints were higher in the PC group than in the sham and ST groups during the postacupuncture period (both p < 0.05). Glutamate levels in the extracellular fluid surrounding the acupoints were higher in the ST group than in the sham group during the acupuncture period (p < 0.05) and higher in the ST group than in the sham and PC groups during the postacupuncture period (both p < 0.05). Serum adrenaline and noradrenaline levels were higher in the PC group than in the sham, ST, and ScT groups (all p < 0.05). Glutamate levels in the CSF were higher in the ST group than in the sham, ScS, and PC groups (all p < 0.05). GABA levels in the CSF were higher in the ST group than in the sham, ScT, and PC groups (all p < 0.05). EA at ST36 and ST37 and PC6 and PC7 exerted an analgesic effect, EA at PC6 and PC7 can enhance heart function, and EA at ST36 and ST37 modulates the cerebral cortex. However, the study needs an evaluation of direct pain behavior, heart function, and brain function in the future.

Electroacupuncture-induced activation of GABAergic system alleviates airway inflammation in asthma model by suppressing TLR4/MyD88/NF-κB signaling pathway

BACKGROUND

Electroacupuncture (EA) has been shown to attenuate airway inflammation in asthmatic mice; however, the underlying mechanism is not fully understood. Studies have shown that EA can significantly increase the inhibitory neurotransmitter γ-aminobutyric acid (GABA) content in mice, and can also increase the expression level of GABA type A receptor (GABAAR). Furthermore, activating GABAAR may relieve inflammation in asthma by suppressing toll-like receptor 4 (TLR4)/myeloid differentiation factor 88 (MyD88)/nuclear factor-kappa B (NF-κB) signaling pathway. Therefore, this study aimed to investigate the role of GABAergic system and TLR4/MyD88/NF-κB signaling pathway in asthmatic mice treated with EA.

METHODS

A mouse model of asthma was established, and a series of methods including Western blot and histological staining assessment were employed to detect the level of GABA, and expressions of GABAAR and TLR4/MyD88/NF-κB in lung tissue. In addition, GABAAR antagonist was used to further validate the role and mechanism of GABAergic system in mediating the therapeutic effect of EA in asthma.

RESULTS

The mouse model of asthma was established successfully, and EA was verified to alleviate airway inflammation in asthmatic mice. The release of GABA and the expression of GABAAR were significantly increased in asthmatic mice treated with EA compared with untreated asthmatic mice ( P  < 0.01), and the TLR4/MyD88/NF-κB signaling pathway was down-regulated. Moreover, inhibition of GABAAR attenuated the beneficial effects of EA in asthma, including the regulation of airway resistance and inflammation, as well as the inhibitory effects on TLR4/MyD88/NF-κB signaling pathway.

CONCLUSION

Our findings suggest that GABAergic system may be involved in mediating the therapeutic effect of EA in asthma, possibly by suppressing the TLR4/MyD88/NF-κB signaling pathway.

Effect of low-level laser stimulation of acupuncture points in pediatric dentistry: a systematic review

The biomodulatory potential of low-level laser therapy (LLLT) has prompted investigations of different outcomes in health. One line of research is the stimulation of acupuncture points for the relief of different signs and symptoms related to the stomatognathic system. In dentistry, some studies in pediatric dentistry have demonstrated the benefit of LLLT therapies in the management of dental anxiety in children. This systematic review aimed to analyze previous clinical studies on the application of LLLT at acupoints among pediatric dental patients. This systematic review was conducted according to the Cochrane Collaboration guidelines and the population, intervention, comparison, and outcome strategy. A broad literature search up to June 17, 2022, was performed using four electronic databases (PubMed, Scopus, Embase, and Google Scholar). The risk of bias in randomized clinical trials was assessed using the RoB 2 tool. A total of four studies using LLLT for photobiomodulation were included (n = 4). The most common wavelengths used were in the infrared range (variation between 716 nm and 980 nm). There were little variations in the application time (14 s to 1 min) and exposure dose (1 to 5 joules). LLLT acted positively on different acupuncture points. LLLT provided various benefits and optimized dental practice by reducing the gag reflex during radiography and impression taking, preanesthetic pain, and symptoms of sleep bruxism in the pediatric dental population. Only one of the evaluated studies had a high risk of bias. The LLLT at acupuncture points is associated with positive results on sleep bruxism, preanesthetic pain, and gag reflex in pediatric dentistry. Future research studies should prioritize standardization of the study design and the methods of analysis.

The Role of Acupuncture in Treating a Patient with a Gambling Disorder

Background

Addiction is a chronic/relapsing disorder characterized by compulsive seeking and continuous involvement despite dangerous consequences. It causes long-term changes in the brain. Gambling disorder is a nonsubstance behavioral addiction. An important feature of gambling disorder is maladaptive gambling behavior that is persistent and repetitive, and interferes with patients' personal lives, families, and/or activities. Acupuncture is a nonpharmacologic therapeutic modality for managing addiction, with good results.

Case

A 32-year-old man with a gambling disorder was referred from a psychiatry department. The patient had a history of gambling since high school. He began to gamble in larger amounts in 2019. The patient got antiseizure, antidepressant, and antipsychotic medications, and cognitive behavioral therapy in the psychiatry department. Manual acupuncture therapy was performed at GV 20, Ex-HN 1, Ex-HN 3, PC 6, ST 40, and LR 3. Electroacupuncture was performed at LI 4, LI 11, ST 36, SP 6, and ST 25. Laser acupuncture was performed at NADA protocol bilateral ear points. The patient also received scalp acupuncture for extrapyramidal symptoms After this combination of acupuncture therapy for 8 sessions, with pharmacotherapy and psychotherapy, the patient's condition improved.

Conclusions

Acupuncture produces positive results in patient with gambling disorders. It helps regulate the reward system; stimulates release of neurotransmitters in the brain; produces neuroprotective effects; and activates certain brain areas to suppress impulsivity and craving and to balance emotions. Acupuncture is thought to be related to increased blood flow in the frontal lobe, thereby increasing nerve metabolism, as well as regulating dopamine in the basal ganglia. A combination of acupuncture, pharmacologic agents, and psychotherapy has a positive synergistic effect in patients with gambling disorder.

Perioperative Acupuncture Optimizes Surgical Outcomes: Theory, Clinical Practice and Future Perspectives

A growing body of evidence supports the use of perioperative acupuncture as part of an enhanced postsurgical recovery protocol. Data from both clinical trials and animal studies has shown that the integration of acupuncture into perioperative patient care leads to a reduction of perioperative complications such as preoperative anxiety, intraoperative hemodynamic instability, postoperative pain, postoperative cognitive dysfunction, and postoperative nausea and vomiting in surgical patients. Despite these favorable outcomes, perioperative acupuncture has yet to be widely adopted in current anesthesia practice. This review summarized data from clinical perioperative acupuncture studies and cites recent discoveries regarding the anatomical location and characteristics of acupoint(s), acupuncture stimulation techniques, and treatment practice protocols, as well as identified the areas of deficiency in perioperative acupuncture applications. To facilitate acupuncture integration in perioperative care practice, the authors propose to establish a perioperative acupuncture registry which can be used for data mining as well as a resource for studying the underlying mechanisms of acupuncture. Through this acupuncture registry, clinical guidelines and research protocols can be established, additional large/multi-center clinical and pragmatic trials can be easily performed to determine if the integration and expansion of perioperative acupuncture practice is cost-effective.

Electroacupuncture at Zusanli Alleviates Sepsis by Regulating the TLR4-MyD88-NF-Kappa B Pathway and Diversity of Intestinal Flora

Background

Electroacupuncture (EA) at the Zusanli acupoint (ST36) has shown therapeutic potential for sepsis due to its ability to limit inflammation and to regulate gastrointestinal tract symptoms. However, the mechanisms contributing to the effects of EA at ST36 on sepsis and connections with the intestinal flora remain unclear. This study was designed to explore the effects of EA at ST36 on Toll-like receptor 4 signaling and the intestinal flora.

Methods

ICR mice were randomly divided into 4 groups: control group, model group, EA group, and sham EA group. EA at ST36 was performed at 2.5 mA and 2 to 100 Hz, and the 30 min of dense wave was achieved over 5 days. A sepsis model was built by intraperitoneal injection of lipopolysaccharide (LPS, 10 mg/mL). The levels of expression of interleukin-1β (IL-1β), IL-6, tumor necrosis factor-α (TNF-α), and IL-10 were detected by enzyme-linked immunosorbent assays, and lactate dehydrogenase (LDH) levels in serum were measured by biochemical tests. Expression levels of Bax, Bcl2, cleaved caspase-3, Toll-like receptor (TLR4), nuclear factor-kappa B (NF-κB), and myeloid differentiation factor 88 (MyD88) were assessed by the Western blotting. Terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) staining was used to evaluate apoptosis. The intestinal microecology was assessed via 16S rRNA gene sequencing.

Results

EA at ST36 reduced the expression of IL-1β, IL-6, and TNF-α and increased the expression of IL-10 to inhibit the inflammatory response. EA at ST36 also inhibited apoptosis, as measured by TUNEL staining, and decreased the Bax/Bcl2 ratio and levels of caspase-3 and cleaved caspase-3, as well as LDH release. Our results suggest that alleviation of sepsis may correlate with the downregulation of levels of TLR4, NF-κB, and MyD88. Importantly, EA at ST36 improved the diversity of the intestinal flora and increased the abundance of Firmicutes and Actinobacteria. Conclusion. EA at ST36 prevented sepsis from worsening by inhibiting inflammation and apoptosis, which correlated with the regulation of the TLR4/NF-κB/MyD88 signaling axis and modulation of the intestinal flora.

Evidence-Based Application of Acupuncture for Pain Management in Companion Animal Medicine

The use of veterinary acupuncture for pain relief is expanding among small animal practitioners. Although acupuncture was developed as part of the medical system in Ancient China, research into the scientific basis of its effects is expanding rapidly. Acupuncture is very effective for analgesia on a local, segmental, and suprasegmental level. Many forms of acupuncture can be used independently or as part of a balanced multi-modal approach for the control of acute and chronic pain. In the hands of a skilled practitioner, acupuncture can be a safe and effective modality for treating pain in companion animals. This article outlines the mechanisms of action of acupuncture, its related neurophysiology and provides examples from the literature demonstrating its effectiveness.

Sensory and autonomic innervation of the local tissues at traditional acupuncture point locations GB14, ST2 and ST6

OBJECTIVE

To visualize and compare the sensory and autonomic innervation of the local tissues at the sites of different traditional acupuncture points in the rat forehead and face by histochemical examination.

METHODS

GB14 (Yangbai), ST2 (Sibai) and ST6 (Jiache) were selected as the representative traditional acupuncture points in this study, and the local tissues at these sites were dissected in rats after perfusion followed by double or triple fluorescent histochemical staining. Here, calcitonin gene-related peptide (CGRP), tyrosine hydroxylase (TH) and vesicular acetylcholine transporter (VAChT) were used to label the sensory, sympathetic and parasympathetic nerve fibers, respectively.

RESULTS

The CGRP⁺ sensory, TH⁺ sympathetic and VAChT⁺ parasympathetic nerve fibers were simultaneously demonstrated in the local tissues at GB14, ST2 and ST6. Although the three kinds of nerve fibers ran in parallel or intermingled with each other, by the analysis from the view of three-dimensional reconstruction, it was clear that each of them distributed in an independent pattern to their corresponding target tissues including the blood vessels, hair follicles, arrector pili and subcutaneous muscles, as well as sebaceous glands.

CONCLUSION

Our study demonstrated the sensory and autonomic innervation of the local tissues at GB14, ST2 and ST6, providing neurochemical evidence indicating that the CGRP⁺ sensory, TH⁺ sympathetic and VAChT⁺ parasympathetic nerve fibers form a neural network at these point locations that may respond to acupuncture stimulation.

Transcutaneous Electrical Cranial-Auricular Acupoint Stimulation vs. Escitalopram for Patients With Mild-to-Moderate Depression (TECAS): Study Design for a Randomized Controlled, Non-inferiority Trial

Background

Previous studies in animals and humans indicated that transcutaneous vagus nerve stimulation (tVNS) and transcutaneous electrical acupoint stimulation (TEAS) on trigeminal nerve-innervated forehead acupoints can relief the symptoms of depression. However, due to the limited investigations on these two interventions, more research are needed to confirm their efficacy in depression. To improve the efficacy of the single treatment, we combined two treatments and created a novel non-invasive stimulation, transcutaneous electrical cranial-auricular acupoint stimulation (TECAS). To assess the efficacy and safety of TECAS, we compare it with a selective serotonin reuptake inhibitor (SSRI), escitalopram, for the treatment of depression.

Methods/Design

This is a multi-center, non-inferiority, randomized controlled trial that will involve 470 patients with mild to moderate depression. Patients will be randomly assigned to either the TECAS group or the escitalopram group in a 1:1 ratio. The TEAS group will receive two sessions of treatments per day for 8 consecutive weeks, and the escitalopram group will receive 8 weeks of oral escitalopram tablets prescribed by clinical psychiatrists as appropriate for their condition. The primary outcome is the clinical response as determined by Montgomery-Åsberg Depression Rating Scale (MADRS) scores at week 8, with -10% as the non-inferior margin. The secondary outcomes include the response rate determined by 17-item Hamilton Depression Rating Scale (HAMD-17), remission rate, changes from baseline in the scores on the MADRS, the HAMD-17, the Hamilton Anxiety Rating Scale (HAMA), the Pittsburgh Sleep Quality Index (PSQI), and the Short Form 36 Health Survey (SF-36).

Discussion

This will be the first randomized controlled trial to compare the efficacy of TECAS with escitalopram for depression. If effective, this novel intervention could have significant clinical and research implications for patients with depression.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT03909217].

Integrative Analysis of the Gut Microbiota and Metabolome in Obese Mice with Electroacupuncture by 16S rRNA Gene Sequencing and HPLC-MS-based Metabolic Profiling

Acupuncture has been used to treat numerous diseases such as obesity in China for thousands of years. Several mechanisms of acupuncture on obesity have been surveyed based on metabolomics, but the effects of acupuncture on the alterations in the gut flora are still unclear. In this study, an integrated approach based on 16S rRNA gene sequencing combined with high-performance liquid chromatography-mass spectrometry (HPLC-MS) metabolic profiling was conducted to investigate the effects of acupuncture on high-fat-diet-induced obesity through the regulation of the relative abundances of gut microbiota and their relationships with biomarker candidates. A total of 10 significantly altered bacterial genera and 11 metabolites were recognized, which recovered to normal levels after electroacupuncture treatment. The relative abundances of the bacterial families Muribaculaceae,Lachnospiraceae,Desulfovibrionaceae,Helicobacteraceae, Prevotellaceae,Ruminococcaceae,Rikenellaceae,Deferribacteraceae,Bacteroidaceae andTannerellaceaewere remarkedly changed among the three groups. Potential biomarkers, including LysoPC(0:0/16:0) ([Formula: see text]1),PC(0:0/18:0) ([Formula: see text]2),Cholic acid([Formula: see text]3),LysoPC(16:0) ([Formula: see text]4), 3[Formula: see text],6[Formula: see text],7[Formula: see text]-Trihydroxy-5[Formula: see text]-cholanoic acid([Formula: see text]5), 5beta-Cyprinolsulfate([Formula: see text]6),PC(18:0/0:0) ([Formula: see text]7), 1-Nitro-5-hydroxy-6-glutathionyl-5,6-dihydronaphthalene([Formula: see text]8),Glycocholic acid([Formula: see text]9),[Formula: see text]-Arginine([Formula: see text]10) andGulonic acid([Formula: see text]11), were involved in several metabolic pathways, such as the glycerophospholipid metabolism and primary bile acid biosynthesis. Interestingly, there was a strong correlation between the perturbed gut flora in Bilophila and Bifidobacterium and the altered intestinal metabolite of 3[Formula: see text],6[Formula: see text],7[Formula: see text]-Trihydroxy-5[Formula: see text]-cholanoic acid and Cholanoic acid and [Formula: see text]-Arginine. This finding suggested that the effects of electroacupuncture might change the proportions of Bilophila and Bifidobacterium by regulating the constituents of the functional metabolite of 3[Formula: see text],6[Formula: see text],7[Formula: see text]-Trihydroxy-5[Formula: see text]-cholanoic acid and Cholanoic acid and [Formula: see text]-Arginine. These results indicated that the effects of electroacupuncture focused on custom metabolic pathways as well as depend on the changes in the gut microbiota in obesity. These findings suggest that the 16S rRNA gene sequencing and HPLC-MS-based metabolomics approach can be applied to comprehensively assess the effects of traditional Chinese medicines.

Publication Trends in Rehabilitative Effects of Acupuncture: A Visual Analysis of the Literature

Objectives

To conduct a comprehensive analysis of scientific outputs in 2011–2021 regarding the rehabilitative effects of acupuncture on diseases.

Methods

The study was conducted in the form of knowledge graph and data visualization, with data being drawn from the Web of Science Core Collection database.

Results

Articles and reviews were the dominant types; China, Guangzhou University of Chinese Medicine and Medicine ranked was the active country, institution, and journal, respectively, in terms of issued articles. Systematic reviews and the meta-analyses of stroke and pain were extensively carried out in the past decade, whose principal interventions were manual acupuncture, electroacupuncture, scalp acupuncture, and dry needling correspondingly at Baihui (DU20) and Zusanli (ST36). And most frequently utilized rehabilitation assessment criteria were the Fugl-Meyer Assessment Scale and the Barthel Index. More recently, motor function and chronic obstructive pulmonary disease have captured researchers' attention, which might be the futuristic frontier.

Conclusions

This article provided a relatively panoramic picture of the scientific outputs in acupuncture for disease rehabilitation, which may help readers embrace the heated topic and grasp the recent research focus on this field.

Understandings of acupuncture application and mechanisms

Acupuncture involves the stimulation of acupoints, which are located at specific sites of the human body, by insertion of fine metal needles, followed by manipulation. Acupuncture has been proven to be an effective treatment in pain relief. Available evidence showed that acupuncture alleviates acute pain in conditions such as postoperative pain, acute back pain, labour pain, primary dysmenorrhea, tension-type headaches and migraines. In addition, acupuncture relieves chronic pain, for example, low back pain (LBP), knee osteoarthritis (KOA), headache, shoulder pain, and neck pain. For other diseases like insomnia, drug addiction and stroke, more high-quality randomized control trials (RCTs) are needed to confirm the efficacy of acupuncture, although there are particular difficulties surrounding adequate blinding and control group designs. Recent biomedical technology unveils the mechanisms of acupuncture. Studies have found that adenosine triphosphate (ATP) and transient receptor potential vanilloid (TRPV) channels are involved in the stimulation of acupuncture at the acupoint area. In the central nervous system (CNS), neurotransmissions including opioids, serotonin, norepinephrine, orexin and endocannabinoid are modulated by acupuncture to induce analgesia. Moreover, acupuncture reduces cyclooxygenase-2 (COX-2) and prostaglandin E2 (PGE2) levels on the peripheral level by acting on the hypothalamic-pituitary-adrenal (HPA) axis, mediating peripheral opioid release. Acupuncture helps to treat insomnia by inhibiting sympathetic activity and down-regulating the HPA axis. Additionally, acupuncture reduces the effects of positive and negative reinforcements by modulating dopamine release in the nucleus accumbens. Recently, i-needles have been developed to allow for the analysis of metagenomics, meta-transcriptomics, and host-microbiome relationships following acupuncture, while skin implantable microsensors or needle-shaped microsensors are feasible for monitoring real-time microenvironmental changes in acupoints and even target organs. These studies may further accelerate the understanding of acupuncture's action mechanism.

Laser acupuncture for claudication symptoms in peripheral artery disease — Does it work? A randomized trial

Background: Peripheral artery disease (PAD) receives little attention despite its clinical consequences. Intermittent claudication is the most disturbing symptom of the disease resulting in marked limitations to functional walking performance. Treadmill walking exercise is the first-line non-pharmacological treatment in PAD; however, older patients may be unable to exercise because of the functional disability of the disease itself or deconditioning.

Objective: In an attempt to seek an alternative intervention, this study aimed to assess the effect of laser acupuncture on patient-reported claudication symptoms and walk performance in PAD.

Methods: Thirty male patients with PAD were assigned randomly to a control group ([Formula: see text], [Formula: see text] years old, [Formula: see text][Formula: see text]kg/m2) or a study group ([Formula: see text], [Formula: see text] years old, [Formula: see text][Formula: see text]kg/m2). Inclusion criteria were mild-to-moderate PAD, Fontaine stage II, unilateral or bilateral claudications, and older men. Exclusion criteria were asymptomatic PAD, resting pain, severe or critical limb ischemia, ischemic ulcers, and patients contraindicated for laser therapy. Both groups received pharmacological treatment, but only the study group received gallium aluminum arsenide (GaAlAs) laser therapy at nine acupuncture points, namely, Liver 2 (LV2), Stomach 41 (ST41), Urinary bladder 40 (UB40), UB60, UB61, Gall bladder 30 (GB30), GB34, GB38, and GB40 for 2 days/week and five consecutive weeks. A pen-type laser device was used at a wavelength of [Formula: see text][Formula: see text]nm, with a power output of [Formula: see text][Formula: see text]mW, a spot size of 0.08[Formula: see text]cm2, and an energy density of 2[Formula: see text]J/cm2, for 60[Formula: see text]s/point. The Edinburgh Claudication Questionnaire (ECQ) and the 6-min walk distance (6-MWD) were the endpoints of the study. The McNemar–Bowker Test and Generalized Estimating Equations Ordinal Logistic Regression Model were used for the within- and between-group statistical analyses of the categorical data of ECQ, respectively; and a mixed model MANOVA was used for the within- and between-group analyses of the 6-MWD data.

Results: There was a significant improvement in patients’ response to ECQ only in the study group compared to the baseline ([Formula: see text]) and the controls ([Formula: see text]) after the intervention. The 6-MWD increased significantly in the study group compared to the baseline ([Formula: see text][Formula: see text]m versus [Formula: see text][Formula: see text]m, [Formula: see text]).

Conclusion: The GaAlAs laser acupuncture applied at selected acupoints may be a promising intervention complementary to drug therapy that could help relieve claudication symptoms and improve physical functional performance in older men with PAD (Fontaine stage II). Trials were conducted under the Trial Registration No. PACTR201912698539774.

Plausible Mechanism of Sham Acupuncture Based on Biomarkers: A Systematic Review of Randomized Controlled Trials

Introduction

Sham acupuncture was developed to be used as an inert control intervention in clinical trials of acupuncture. However, controversies exist regarding the validity of sham acupuncture. In this systematic review (SR) of acupuncture trials, we assessed whether serum biomarkers showed significant differences after sham and verum acupuncture treatments.

Methods

Any acupuncture clinical trials that evaluated serum biomarker changes between sham acupuncture and verum acupuncture were included in this review. Relevant literature was searched in the PubMed database, EMBASE, and The Cochrane Central Register of Controlled Trials (CENTRAL) database from inception until June 2021. The Cochrane risk of bias was assessed. Summary effect estimates for each biomarker between groups were calculated with a random effect model.

Results

From 51 sham acupuncture trials, we found that there were no significant differences in most of the 36 serum biomarkers after sham acupuncture and verum acupuncture needling. Only VEGF, IG-E, TNF-a, NGF, GABA, NPY, and VIP serum levels were identified as being different between the groups. The overall risk of bias of the included studies and the limited numbers of studies for meta-analysis do not strongly support the results of this SR.

Conclusion

Sham acupuncture techniques might have similar effects on biomarkers as the so-called “real acupuncture” techniques, which indicates that sham acupuncture, as an inert intervention similar to a placebo drug, needs to be reconsidered.

Systematic Review PROSPERO Registration

identifier [CRD42021260889].

Acupuncture (superficial dry-needling) as a treatment for chronic postherpetic neuralgia - a randomized clinical trial

BACKGROUND

Postherpetic neuralgia is a painful condition where finding sufficient treatment poses a great challenge. Acupuncture is often used as an alternative treatment for these pains, yet no randomized trials, using a sham-placebo have been performed to confirm its effect. Our objective was to investigate the efficacy of acupuncture compared to sham-acupuncture when treating chronic postherpetic dermal pain.

METHODS

We performed a sham-controlled double-blinded randomized clinical trial (RCT) with two arms. The intervention group received superficial dry-needling, and the control group received sham acupuncture using blunted needles. Twenty-six patients received two treatments. They filled out questionnaires at baseline and 1 month after treatment: (1) average and maximum pain (Numeric Rating Scale), (2) neuropathic pain (Neuropathic Pain Scale Inventory) and (3) Quality of Life (QoL) (Short-form 36).

RESULTS

Thirteen patients were allocated to the intervention group and 15 to the control group. We did not detect any significant changes in levels of pain and neuropathic pain. One QoL parameter, regarding emotional problems, reached a level of statistical significance. The sham-blinding was successful. This is the first RCT on the effect of acupuncture (superficial dry-needling) on postherpetic neuralgia (PHN), using a sham procedure as control. We observed no significant changes or tendencies in the measured levels of pain. One QoL parameter had significant improvement in the intervention group compared to the control group.

CONCLUSION

In conclusion, acupuncture was not superior to treatment with sham acupuncture. Though individual patients may experience some pain relief from acupuncture, our results do not support the routine use of this type of acupuncture to treat PHN.

The Anti-Inflammatory Actions and Mechanisms of Acupuncture from Acupoint to Target Organs via Neuro-Immune Regulation

Inflammation plays a significant role in the occurrence and development of multiple diseases. This study comprehensively reviews and presents literature from the last five years, showing that acupuncture indeed exerts strong anti-inflammatory effects in multiple biological systems, namely, the immune, digestive, respiratory, nervous, locomotory, circulatory, endocrine, and genitourinary systems. It is well known that localized acupuncture-mediated anti-inflammatory effects involve the regulation of multiple populations and functions of immune cells, including macrophages, granulocytes, mast cells, and T cells. In acupuncture stimulation, macrophages transform from the M1 to the M2 phenotype and the negative TLR4 regulator PPARγ is activated to inhibit the intracellular TLR/MyD88 and NOD signaling pathways. The downstream IκBα/NF-κB and P38 MAPK pathways are subsequently inhibited by acupuncture, followed by suppressed production of inflammasome and proinflammatory mediators. Acupuncture also modulates the balance of helper T cell populations. Furthermore, it inhibits oxidative stress by enhancing SOD activity via the Nrf2/HO-1 pathway and eliminates the generation of oxygen free radicals, thereby preventing inflammatory cell infiltration. The anti-inflammatory effects of acupuncture on different biological systems are also specific to individual organ microenvironments. As part of its anti-inflammatory action, acupuncture deforms connective tissue and upregulates the secretion of various molecules in acupoints, further activating the NF-κB, MAPK, and ERK pathways in mast cells, fibroblasts, keratinocytes, and monocytes/macrophages. The somatic afferents present in acupuncture-activated acupoints also convey sensory signals to the spinal cord, brainstem, and hypothalamic neurons. Upon information integration in the brain, acupuncture further stimulates multiple neuro-immune pathways, including the cholinergic anti-inflammatory, vagus-adrenal medulla-dopamine, and sympathetic pathways, as well as the hypothalamus-pituitary-adrenal axis, ultimately acting immune cells via the release of crucial neurotransmitters and hormones. This review provides a scientific and reliable basis and viewpoints for the clinical application of acupuncture in various inflammatory conditions.

Adiponectin regulates electroacupuncture-produced analgesic effects in association with a crosstalk between the peripheral circulation and the spinal cord

Neurotransmitter-mediated acupuncture analgesia has been widely studied in nervous systems. It remains largely unclear if peripheral substances are involved the acupuncture analgesia. Adiponectin (APN), a circulating adipokine, shows analgesic effects. The study aimed to examine whether APN regulates analgesic effects of electroacupuncture (EA) in the complete Freund's adjuvant (CFA)-induced mouse model. APN wild type (WT) and knockout (KO) mouse were employed in the study. We found that EA attenuates the CFA-induced pain as demonstrated by the Hargreaves thermal test and the von Frey filament test. The deletion of APN significantly reduced the acupuncture analgesia in the CFA-treated APN KO mice while the intrathecal administration of APN mimicked the analgesic effects of EA. We further revealed that EA produced analgesic effects mainly via APN/AdipoR2-mediated AMPK pathway by the siRNA inhibitions of APN receptors (adipoR1/2) in the spinal cord. The immunofluorescence staining analysis showed that EA increased the APN accumulation in spinal cord through the blood circulation. In conclusion, the study indicates a novel mechanism that acupuncture produces analgesic effects at least partially via APN/AdipoR2-AMPK pathway in the spinal cord.

Case study: Pilot testing of a local acupuncture intervention protocol for burn scars

BACKGROUND

Following burn injury and a prolonged duration of healing, scars may become hypertrophic, causing movement restriction, increased scar thickness, colour and pliability, and symptoms such as pain and itch. Acupuncture has emerged as a potentially beneficial treatment for neuroinflammation, which perpetuates the negative features of hypertrophic scars. The aim of this study was to pilot test an evidence-based methodology for applying and measuring the clinical effects of localised acupuncture for symptomatic scars, in a patient with a healed burn injury.

METHODS

A 71-year-old caucasian male presented with a hypertrophic scar that was painful and itchy after burn injury and subsequent skin grafting. He received acupuncture and massage treatment local to his scar as per the local (verum) group of the author's clinical trial under recruitment. Needles were inserted around the circumference of the skin grafted area and adjacent to areas of raised scar tissue within the grafted area and stimulated via bi-directional rotation. Outcome measures included a Numerical Rating Scale (NRS) for pain and itch, Patient and Observer Scar Assessment Scale (POSAS) self-assessment component and SF36 quality-of-life measure to capture any non-specific acupuncture effects.

CONCLUSION

Acupuncture applied locally around the scar was associated with short-term relief of symptoms and significantly reduced his subjective outcome measure scores relating to scar thickness, redness and pliability out to six months after injury. Some short-term increase in symptoms occurred on several occasions following treatment; however, treatment was well tolerated supporting the use of this protocol for a larger future clinical trial.

LAY SUMMARY

Following injury to the skin, scars can become raised, red and reduce movement. Other common symptoms may include pain and itch. Previous studies suggest acupuncture may help symptomatic scars, but more research is needed to confirm this with larger samples of patients.This case study tested the active treatment protocol for a clinical trial using acupuncture on symptomatic scars. A 71-year-old white man had a burn scar on his torso after a workplace accident. His treatment involved scar massage and local acupuncture. The acupuncture needles were inserted around the skin graft borders and thickened bands of scar tissue.Outcomes were measured using surveys recording symptoms, scar characteristics and quality of life. These were used to assess treatment effect and how well the protocol was tolerated. Over the course of treatment both pain and itch improvedThis case report showed that the treatment protocol was well tolerated, and that local acupuncture was associated with improved scar symptoms and physical characteristics up to six months after injury.

Perspectives of patients on medical acupuncture in a primary care setting in Lebanon: a cross-sectional study

INTRODUCTION

There is paucity of data on the knowledge of acupuncture and its use among patients in Lebanon and the Arab countries.

OBJECTIVES

The primary objectives of this study were to determine the knowledge and attitude of patients in a primary care setting in Lebanon toward Western medical acupuncture and to determine factors that may affect their attitudes toward acupuncture use. The secondary objective was to compare the attitudes and knowledge of patients who had tried acupuncture with those who had not.

METHODS

This was a cross-sectional descriptive study about the perspectives of patients in a primary care setting in Lebanon on medical acupuncture.

RESULTS

A total of 212 surveys were completed (78.5% response rate). 24% of participants had not tried and were unwilling to try acupuncture (group 1), 63.5% of participants had not tried but indicated they would be willing to try acupuncture (group 2), and 12.5% of participants had previously tried acupuncture (group 3). Most participants in group 1 (55.6%) stated they would be unwilling to try acupuncture even if referred for it by a physician. Participants who had tried acupuncture (12.5%) had done so for pain conditions.

DISCUSSION

Group 3 scored higher on knowledge questions and had a more positive attitude toward the acupuncture procedure. Most patients who had tried it had done so to treat pain complaints.

CONCLUSION

Patients in groups 2 and 3 were more knowledgeable about acupuncture, had tried more complementary and alternative medicine (CAM) modalities, and were more likely to try acupuncture as an add-on or last resort treatment, compared to group 1.

The Temporal Dynamics of EEG Microstate Reveals the Neuromodulation Effect of Acupuncture With Deqi

The electroencephalography (EEG) microstate has recently emerged as a new whole-brain mapping tool for studying the temporal dynamics of the human brain. Meanwhile, the neuromodulation effect of external stimulation on the human brain is of increasing interest to neuroscientists. Acupuncture, which originated in ancient China, is recognized as an external neuromodulation method with therapeutic effects. Effective acupuncture could elicit the deqi effect, which is a combination of multiple sensations. However, whether the EEG microstate could be used to reveal the neuromodulation effect of acupuncture with deqi remains largely unclear. In this study, multichannel EEG data were recorded from 16 healthy subjects during acupuncture manipulation, as well as during pre- and post-manipulation tactile controls and pre- and post-acupuncture rest controls. As the basic acupuncture unit for regulating the central nervous system, the Hegu acupoint was used in this study, and each subject’s acupuncture deqi behavior scores were collected. To reveal the neuroimaging evidence of acupuncture with deqi, EEG microstate analysis was conducted to obtain the microstate maps and microstate parameters for different conditions. Furthermore, Pearson’s correlation was analyzed to investigate the correlation relationship between microstate parameters and deqi behavioral scores. Results showed that: (1) compared with tactile controls, acupuncture manipulation caused significantly increased deqi behavioral scores. (2) Acupuncture manipulation significantly increased the duration, occurrence, and contribution parameters of microstate C, whereas it decreased those parameters of microstate D. (3) Microstate C’s duration parameter showed a significantly positive correlation with acupuncture deqi behavior scores. (4) Acupuncture manipulation significantly increased the transition probabilities with microstate C as node, whereas it reduced the transition probabilities with microstate D as node. (5) Microstate B→C’s transition probability also showed a significantly positive correlation with acupuncture deqi behavior scores. Taken together, the temporal dynamic feature of EEG microstate could be used as objective neuroimaging evidence to reveal the neuromodulation effect of acupuncture with deqi.

Regulatory Effects of Acupuncture on Emotional Disorders in Patients With Menstrual Migraine Without Aura: A Resting-State fMRI Study

Background: Menstrual migraine without aura (MMoA) refers to a specific type of migraine that is associated with the female ovarian cycle. It is particularly serious and has brought huge life pressure and mental burden to female patients. Acupuncture has been commonly used to prevent migraines and relieve concomitant emotional disorders; however, the physiological mechanism underlying this intervention remains unclear. This study aimed to use resting-state functional magnetic resonance imaging (rsfMRI) to investigate whether acupuncture can modulate brain function and if the potential influence on brain activity correlates with improving emotional symptoms in MMoA patients. Methods: Overall, 44 patients were randomly divided into a true acupuncture (TA) group and the sham acupuncture (SA) group. Patients underwent rsfMRI before and after 3-month treatment, the amplitude of low-frequency fuctuations (ALFF) and regional homogeneity (ReHo) in rsfMRI were calculated. Zung self-rating anxiety scale (SAS), Zung self-rating depression scale (SDS), frequency of migraine attacks, visual analog scale, and intensity of the migraine were used for evaluate the clinical effect. The clinical changes of variables were also used to further assess the correlation with brain activity in MMoA patients. Results: After acupuncture treatment, the emotional symptoms of both groups of patients improved, and the clinical symptoms of migraine were alleviated. The major finding of our study was that patients with MMoA showed lower ALFF value in the left anterior cingulate and the value was positively correlated with the decreases in the SAS and SDS scores. In the SA group, common brain regions responded both in ALFF and regional homogeneity values mainly in the insula, and no significant correlations were observed between brain regions and clinical variables. Conclusions: These results indicated that both two acupuncture treatments were helpful in treating migraine and could improve emotion symptoms. TA had a relatively better effect in reducing the frequency of migraine attack than SA. The two therapies have different modulation effects as TA regulates emotional disorders by modulating the frontal-limbic regions, and SA may modulate pain perception through the placebo effect on insula and by indirectly regulating emotional disorders. These findings provided evidence that acupuncture is a complementary and alternative therapy to relieve clinical symptoms in female patients with migraines and could help enhance clinical diagnosis and treatment. Clinical Trial Registration: [http://www.chictr.org.cn/index.aspx], identifier [ChiCTR-IOR-15006648. Registered 23 June 2015].

Electroacupuncture improves repeated social defeat stress-elicited social avoidance and anxiety-like behaviors by reducing Lipocalin-2 in the hippocampus

Background

Post-traumatic stress disorder (PTSD) is a trauma-related disorder that is associated with pro-inflammatory activation and neurobiological impairments in the brain and leads to a series of affective-like behaviors. Electroacupuncture (EA) has been proposed as a clinically useful therapy for several brain diseases. However, the potential role of EA treatment in PTSD and its molecular and cellular mechanisms has rarely been investigated.

Methods

We used an established preclinical social defeat stress mouse model to study whether EA treatment modulates PTSD-like symptoms and understand its underlying mechanisms. To this end, male C57BL/6 mice were subjected to repeated social defeat stress (RSDS) for 6 consecutive days to induce symptoms of PTSD and treated with EA at Baihui (GV 20) and Dazhui (GV 14) acupoints.

Results

The stimulation of EA, but not needle insertion at Baihui (GV 20) and Dazhui (GV 14) acupoints effectively improved PTSD-like behaviors such as, social avoidance and anxiety-like behaviors. However, EA stimulation at the bilateral Tianzong (SI11) acupoints did not affect the PTSD-like behaviors obtained by RSDS. EA stimulation also markedly inhibited astrocyte activation in both the dorsal and ventral hippocampi of RSDS-treated mice. Using next-generation sequencing analysis, our results showed that EA stimulation attenuated RSDS-enhanced lipocalin 2 expression in the hippocampus. Importantly, using double-staining immunofluorescence, we observed that the increased lipocalin 2 expression in astrocytes by RSDS was also reduced by EA stimulation. In addition, intracerebroventricular injection of mouse recombinant lipocalin 2 protein in the lateral ventricles provoked social avoidance, anxiety-like behaviors, and the activation of astrocytes in the hippocampus. Interestingly, the overexpression of lipocalin 2 in the brain also altered the expression of stress-related genes, including monoamine oxidase A, monoamine oxidase B, mineralocorticoid receptor, and glucocorticoid receptor in the hippocampus.

Conclusions

This study suggests that the treatment of EA at Baihui (GV 20) and Dazhui (GV 14) acupoints improves RSDS-induced social avoidance, anxiety-like behaviors, astrocyte activation, and lipocalin 2 expression. Furthermore, our findings also indicate that lipocalin 2 expression in the brain may be an important biomarker for the development of PTSD-related symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13041-021-00860-0.

Acupuncture With deqi Modulates the Hemodynamic Response and Functional Connectivity of the Prefrontal-Motor Cortical Network

As a world intangible cultural heritage, acupuncture is considered an essential modality of complementary and alternative therapy to Western medicine. Despite acupuncture’s long history and public acceptance, how the cortical network is modulated by acupuncture remains largely unclear. Moreover, as the basic acupuncture unit for regulating the central nervous system, how the cortical network is modulated during acupuncture at the Hegu acupoint is mostly unclear. Here, multi-channel functional near-infrared spectroscopy (fNIRS) data were recorded from twenty healthy subjects for acupuncture manipulation, pre- and post-manipulation tactile controls, and pre- and post-acupuncture rest controls. Results showed that: (1) acupuncture manipulation caused significantly increased acupuncture behavioral deqi performance compared with tactile controls. (2) The bilateral prefrontal cortex (PFC) and motor cortex were significantly inhibited during acupuncture manipulation than controls, which was evidenced by the decreased power of oxygenated hemoglobin (HbO) concentration. (3) The bilateral PFC’s hemodynamic responses showed a positive correlation trend with acupuncture behavioral performance. (4) The network connections with bilateral PFC as nodes showed significantly increased functional connectivity during acupuncture manipulation compared with controls. (5) Meanwhile, the network’s efficiency was improved by acupuncture manipulation, evidenced by the increased global efficiency and decreased shortest path length. Taken together, these results reveal that a cooperative PFC-Motor functional network could be modulated by acupuncture manipulation at the Hegu acupoint. This study provides neuroimaging evidence that explains acupuncture’s neuromodulation effects on the cortical network.

Comparison of Sensory and Motor Innervation Between the Acupoints LR3 and LR8 in the Rat With Regional Anatomy and Neural Tract Tracing

OBJECTIVE

This study aimed to investigate the sensory and motor innervation of "Taichong" (LR3) and "Ququan" (LR8) in the rat and provide an insight into the neural relationship between the different acupoints in the same meridian.

METHODS

The LR3 and LR8 were selected as the representative acupoints from the Liver Meridian and examined by using the techniques of regional anatomy and neural tract tracing in this study. For both acupoints, their local nerves were observed with regional anatomy, and their sensory and motor pathways were traced using neural tract tracing with single cholera toxin subunit B (CTB) and dual Alexa Fluor 594/488 conjugates with CTB (AF594/488-CTB).

RESULTS

Using the regional anatomy, the branches of the deep peroneal nerve and saphenous nerve were separately found under the LR3 and LR8. Using single CTB, the sensory neurons, transganglionic axon terminals, and motor neurons associated with both LR3 and LR8 were demonstrated on the dorsal root ganglia (DRG), spinal dorsal horn, Clarke's nucleus, gracile nucleus, and spinal ventral horn corresponding to their own spinal segments and target regions, respectively. Using dual AF594/488-CTB tracing, it was shown that the sensory and motor neurons associated with LR3 were separated from that of LR8.

CONCLUSION

This study demonstrates that LR3 and LR8 are innervated by different peripheral nerves, which originated from or terminated in their corresponding spinal segments and target regions independently through the sensory and motor pathways. These results provide an example for understanding the differential innervation between the different acupoints in the same meridian.

Historical perspectives on using sham acupuncture in acupuncture clinical trials

Background

Trials of acupuncture in the West began before textbooks about acupuncture were generally available. This placed trials at risk of possible faulty assumptions about the practice of acupuncture and adoption of problematic research assumptions and methods. Further, this lack of information has had an influence on the theories of developing a valid and reliable sham control treatment in clinical trials of acupuncture. This commentary explores these issues.

Methods

Literature review focussing on the time line of developments in the field, developments of sham interventions and use thereof and knowledge of physiological effects of needling.

Results

Early trials demonstrated a lack of knowledge about acupuncture. As the methodology of trials improved, new sham treatment methods were developed and adopted; however, the sham treatment methods were implemented without physiological studies exploring their potential physiological effects and without examining the broader practice of acupuncture internationally.

Conclusions

Mistaken assumptions about the practice of acupuncture reinforced by paucity of physiological investigations are factors that led to use of inappropriate sham interventions for acupuncture trials. These not only lead to confusing or misleading trial results, they, as far as we can see underestimate the effects of acupuncture leading to bias against acupuncture. There are significant problems with sham interventions and how they are applied in trials of acupuncture. Further research is needed to explore the effects of this both for future trials and for interpreting existing evidence.