Effect of Acupuncture on Chronic Pain with Depression: A Systematic Review

Lateral hypothalamic orexin neurons mediate electroacupuncture-induced anxiolytic effects in a rat model of post-traumatic stress disorder

The lateral hypothalamus' orexinergic system has been associated with anxiety-related behaviors, and electroacupuncture (EA) modifies orexin neurons to control the anti-anxiety process. However, in a rat model of post-traumatic stress disorder (PTSD), the important role of LH orexin neurons (OXNs) in the anxiolytic effects induced by EA has not been explored. In this study, rats underwent modified single prolonged stress (MSPS) for seven days before developing EA. The rats were then subjected to elevated plus maze (EPM) and open field (OFT) tests, and western blot and c-Fos/orexin double labeling investigations were carried out to determine the functional activation of LH orexinergic neurons. Compared to MSPS model rats, it has been demonstrated that EA stimulation enhanced the amount of time spent in the central zone (TSCZ) in OFT and the amount of time spent in the open arm (TSOA) in EPM in MSPS model rats (P < 0.01). After behavioral testing, MSPS model rats had decreased activated c-Fos positive OXNs. Still, EA in SPS rats increased that number and elevated orexin type 1 receptors (OXR1) protein expression in the LH. Furthermore, after administering SB334867 (an OXR1 antagonist) to MSPS model rats, the effects of EA therapy on anxiety-like behaviors (ALBs) were significantly diminished. Additionally, when low-dose orexin-A (LORXA) was administered intracerebroventricularly together with EA stimulation in MSPS rats, the anxiolytic effects of the stimulation were substantially enhanced (P < 0.05). The results of this study reveal the mechanisms by which acupuncture may reduce PTSD and advance our understanding of the function of LH orexin signaling in EA's anxiolytic effects.

Acupuncture as Part of Multimodal Analgesia for Chronic Pain

Background

Chronic pain is a multifactorial condition that is afflicting populations worldwide causing an increasing economic, physical, mental, and emotional burden. Treatments range from medications to interventional procedures to complementary and alternative medicine (CAM), such as acupuncture. This review aims to discuss the use of acupuncture in the treatment of chronic pain, proposed mechanisms, indications, and efficacy for various chronic pain conditions.

Results

Evidence is varied on the efficacy and quality of data on the use of acupuncture in the treatment of chronic pain. Recent studies have demonstrated promising results in the support of acupuncture for the use in the treatment of cancer, neck, and back pain, functional dyspepsia, and various chronic abdominal pain syndromes.

Conclusion

Acupuncture, deemed well-tolerated and safe to use, has been increasingly studied and is regarded as effective in clinical practice, but its efficacy is limited by the lack of well-conducted, high-quality clinical trials, lower quality evidence, and conflicting study results. Additionally, the exact analgesic mechanism of acupuncture remains to be fully elucidated. Increasing evidence supports the role of acupuncture as therapy in the treatment of cancer, neck, and back pain and functional dyspepsia. Further rigorous studies are needed to fully assess the use of acupuncture in various chronic pain conditions, determine its indications, and optimal treatment schedule. Overall, future studies could benefit from better designed experimental studies, larger groups, and more objectives ways to measure pain reduction and symptom improvement.

The Impact of Individualized Complementary and Integrative Health Interventions Provided in Clinical Settings on Quality of Life: A Systematic Review of Practice-Based Research

Background: The goal of this systematic review was to evaluate the impact of individualized complementary and integrative health (CIH) interventions on quality-of-life outcomes as collected in CIH outpatient clinics. Methods: A systematic review was conducted using PubMed, OVID, Cochrane, Web of Science, Scopus, and Embase through December 2020. Inclusion criteria were as follows: individualized CIH treatment, longitudinal effectiveness design, patient-reported outcomes, outpatient CIH clinic setting, participants aged ≥18 years, sample size of ≥25, and English full text. The study was listed in the PROSPERO database (CRD42020159193), and PRISMA guidelines were used. The variables extracted from articles focused on study details/demographics, CIH intervention characteristics, and outcome characteristics. Results: The literature search yielded 3316 records with 264 assessed for full-text review. Of these, 19 studies (including ∼14,002 patients) were specific to quality of life (or well-being) as a main outcome. Most studies included were multidisciplinary studies (n = 12), followed by acupuncture (n = 4), chiropractic (n = 3), and massage or reflexology (n = 1). The short-form group of questionnaires (SF-12, SF-36, SF-8) were the most used quality-of-life/well-being questionnaire, comprising 37% of studies (n = 7), and the Patient Reported Outcomes Measurement Information System (PROMIS) measures comprised 21% (n = 4). Both questionnaires are normed to U.S. population, allowing for comparison. The average improvement across the comparable SF and PROMIS measures for Physical Health was 6% (range 2%-20%) and for Mental Health was 5% (range 1%-11%), demonstrating clinical significance. Improvements in the observational studies are comparable to improvements reported from randomized controlled trials. Conclusions: Results from this systematic review indicate that CIH therapies largely have positive effects on health-related quality of life and well-being for various patient populations seen in CIH clinical settings. Direct comparisons across studies were limited due to the variability in study design and incomplete reporting in some of the publications. Suggestions for improving the design and reporting for future practice-based research are provided.

Salvianolic acid B alleviates comorbid pain in depression induced by chronic restraint stress through inhibiting GABAergic neuron excitation via an ERK-CREB-BDNF axis-dependent mechanism

Pain comorbid with depression occurred frequently in clinical settings. This study aims to explore the molecular mechanism underlying antidepressant and analgetic effect of salvianolic acid B (SalB) in comorbid pain in depression induced by chronic restraint stress (CRS), which associates with GABAergic neuron activation in the amygdala and the ERK-CREB-BDNF signaling pathway. The differentially expressed genes related to comorbid pain in CRS-induced depression were screened through bioinformatics analysis. After CRS treatment for 3 weeks, depression-like behaviors were developed in GAD2-tdT mice. The retrograde tracer cholera toxin B subunit combined with retrograde tracer CTB-488 was injected into the parafascicular nucleus of thalamus to project GABAergic neurons to observe the labeling of neurons in the whole brain. After treatment with SalB and ERK-CREB-BDNF signaling pathway inhibitor, CRS mice showed a variety of depression-like behaviors, accompanied by enhanced activity of GABAergic neurons in the amygdala projecting to parafascicular nucleus of thalamus. BDNF underexpression occurred in the CRS mice. Overexpressed BDNF activated ERK-CREB-BDNF signaling pathway to alleviate comorbid pain in CRS-induced depression. After intraperitoneal injection of SalB, the depression-like behaviors and pain threshold in CRS mice were alleviated, the effects of which could be eliminated by ERK-CREB-BDNF signaling pathway antagonist. Collectively, SalB inhibits the excitation of GABAergic neurons in the amygdala and activates the ERK-CREB-BDNF signaling pathway through the parafascicular nucleus of thalamus, whereby alleviating comorbid pain in CRS-induced depression in mice.

Potential Mechanisms and Clinical Effectiveness of Acupuncture in Depression

Major depressive disorder is the most common mental disorder with significant economic burden and limited treatments. Acupuncture has emerged as a promising non-pharmacological treatment for reducing depressive symptoms. However, the potential mechanisms and clinical effectiveness of acupuncture are not fully understood. This review aimed to: (1) summarize the available evidence on the mechanisms and clinical effectiveness of acupuncture for depression, and then (2) compare with pharmacological interventions, guiding future studies. Studies with animal models of depression and patients have shown that acupuncture could increase hippocampal and network neuroplasticity and decrease brain inflammation, potentially to alleviating depressive disorders. Overall clinical studies indicated that acupuncture could relieve primary depression, particularly milder cases, and was helpful in the management of post-stroke depression, pain-related depression, and postpartum depression both as an isolated and adjunct treatment. It was emphasized that acupuncture combined with antidepressant pharmacological treatment not only enhanced the improvement of primary and secondary depressive symptoms but also reduced the side effects of the medical treatment, which is the main cause for high dropout rates with drug treatment. In summary, substantial evidence from animal and human researches supported the beneficial effect of acupuncture in depression. However, most clinical trials of acupuncture were small, and it is unclear whether their findings can be generalized, so more studies are needed.

Electroacupuncture Attenuates Neuropathic Pain and Comorbid Negative Behavior: The Involvement of the Dopamine System in the Amygdala

Neuropathic pain (NeuP) is an important clinical problem accompanying negative mood symptoms. Neuroinflammation in the amygdala is critically involved in NeuP, and the dopamine (DA) system acts as an important endogenous anti-inflammatory pathway. Electroacupuncture (EA) can improve the clinical outcomes in NeuP, but the underlying mechanisms have not been fully elucidated. This study was designed to assess the effectiveness of EA on pain and pain-related depressive-like and anxiety-like behaviors and explore the role of the DA system in the effects of EA. Male Sprague-Dawley rats were subjected to the chronic constrictive injury (CCI) model to induce NeuP. EA treatment was carried out for 30 min once every other day for 3 weeks. The results showed that CCI caused mechanical hyperalgesia and depressive and anxiety-like behaviors in rats and neuroinflammation in the amygdala, such as an increased protein level of TNFα and IL-1β and activation of astrocytes. EA treatment significantly improved mechanical allodynia and the emotional dysfunction induced by CCI. The effects of EA were accompanied by markedly decreased expression of TNFα, IL-1β, and glial fibrillary acid protein (GFAP) in the amygdala. Moreover, EA treatment reversed CCI-induced down-regulation of DA concentration, tyrosine hydroxylase (TH) expression, and DRD1 and DRD2 receptors. These results suggest that EA-ameliorated NeuP may possibly be associated with the DA system to inhibit the neuroinflammation in the amygdala.

An Hypothesis for CXCL1/CXCR2 Signaling Regulating Neutrophil-Derived Opioid Peptides Involved in Acupuncture for Inflammatory Pain

Increasing evidences demonstrate that acupuncture is effective in treating inflammatory pain. Recent studies have found that peripheral endogenous opioid peptides in the area of inflammation are involved in acupuncture-treating inflammatory pain. However, the source of endogenous opioid peptides in local area of inflammation and the mechanism of acupuncture regulating these opioid peptides remain unclear. Studies have demonstrated that neutrophils infiltrated in the inflamed tissue contain and release opioid peptides. Chemokine (C-X-C motif) ligand 1 (CXCL1) is one of the key neutrophil chemokines and can promote the blood neutrophil recruitment to the area of inflammation. In our previous experiments, we found that acupuncture could alleviate inflammatory pain and significantly increase the concentration of chemokine CXCL1 in the blood of rats with inflammatory pain. So we suppose that increased concentration of CXCL1 by acupuncture could activate the blood opioid-containing neutrophils via its main receptor chemokine receptor type 2 (CXCR2) and promote them recruit to the inflamed tissue to release opioid peptides, participating in the analgesic effect of acupuncture.

Acupuncture for Chronic Pain-Related Depression: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review was to summarize and evaluate the existing evidence on the effectiveness and safety of acupuncture in relieving chronic pain-related depression (CPRD).

Methods

We searched seven online databases to identify eligible randomized controlled trials (RCTs) of acupuncture for CPRD published before September 2020. We included studies that used acupuncture as the intervention group, with or without a control group, and the control group was treated with conventional drugs. Meta-analysis was performed using RevMan 5.3 software. For outcomes, assessments were performed using the Hamilton Depression Scale (HAMD), Visual Analogue Scale (VAS), and adverse events.

Results

Eight studies involving 636 participants were identified and included in the meta-analysis. The results showed that single acupuncture treatment and drug treatment have the same effect in improving the HAMD score (MD = -0.14, 95% CI = [-0.88, 0.59], P = 0.71) and alleviating the VAS score (MD = -0.42, 95% CI = [-1.10, -0.27], P = 0.23), but acupuncture treatment is safer (OR = 0.03, 95% CI = [0.01, 0.21], P = 0.0003). In addition, acupuncture combined with drugs (control group) is more beneficial than single-drug treatment in improving the HAMD score (MD = -2.95, 95% CI = [-3.55, -2.36], P < 0.00001) and alleviating the VAS score (MD = -1.06, 95% CI = [-1.65, -0.47], P = 0.0004).

Conclusion

Acupuncture is an effective and safe treatment for CPRD, and acupuncture combined with drug therapy is more effective than single-drug therapy. Nevertheless, the conclusions were limited due to the low quality and a small number of included studies.

Understanding Traditional Chinese Medicine Therapeutics: An Overview of the Basics and Clinical Applications

Traditional Chinese medicine (TCM) is a systematic healthcare system developed from clinical experience based on a scientific model of regulation. TCM relies on unique theories and practices to treat diseases and enhance health. These practices include Chinese herbal medicine and dietetics, acupuncture and moxibustion, and other non-medication therapies such as Chinese bodywork or manual therapy, known as "Tuina", and traditional biofeedback exercises, known as "Qigong" and "Taijiquan". The integration of TCM in Western health systems and research requires a rational communicable theory, scientific proof of efficacy and safety, and quality control measures. Understanding the structural concepts of the TCM language makes possible the parallelism to Western physiology, and the inherent rational use of the reflex therapeutic systems, anti-inflammatory mechanisms and mental training involved, for example, in acupuncture and "Qigong". The results of TCM clinical trials and fundamental research on its nature and mechanisms have encouraged the development and application of well-designed research strategies such as double blinding in acupucture to overcome limitations and resistances in integrating these practices into the existing biomedical paradigms of the West. This review aims to overview some TCM theoretical concepts and the evidence-based clinical application of TCM's leading practices to create an easy-to-consult and condensed source of information, available for the healthcare community, facilitating the understanding and communication between conventional health professionals and TCM practitioners and acupuncturists.