Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis

Tension-Type Headache Management: A Systematic Review and Network Meta-analysis of Complementary and Alternative Medicine

INTRODUCTION

Tension-type headache (TTH) is common but challenging to manage due to limited effectiveness of conventional treatments. This study examines six complementary and alternative medicine (CAM) interventions through network meta-analysis to identify effective TTH management strategies.

METHODS

We searched PubMed, Embase, Web of Science, Cochrane Library, OVID, CNKI, Wanfang, VIP, and CBM databases for randomized controlled trials on CAM for TTH treatment. Headache frequency and intensity were the primary outcomes. Methodological quality was evaluated on the basis of the Cochrane risk of bias tool. We used R software to conduct this Bayesian network meta-analysis. We used mean difference (MD) with 95% credible intervals (CI) to calculate the continuous outcomes and analyzed the percentages of the surface under the cumulative ranking (SUCRA) curve.

RESULTS

In total, 32 randomized controlled trials (RCTs) with 2405 participants were analyzed. For reducing headache intensity, the network meta-analysis shows that acupuncture therapy combined with traditional Chinese medicine (AT_TCM), manual therapy (MT), psychological treatment (PT), and traditional Chinese medicine combined with acupuncture and manual therapy (TCM_AT_MT) are superior to Western medicine (WM). In the SUCRA curve, TCM_AT_MT is the best for reducing headache frequency (HF).

CONCLUSIONS

This review, assessed as low-quality evidence by GRADE, cautiously suggests potential benefits of PT over other CAM interventions for TTH and indicates TCM_AT_MT might better reduce HF. It proposes that combining CAM interventions could enhance outcomes. Due to the preliminary nature of these findings, further high-quality RCTs are essential to confirm these suggestions and provide clearer clinical guidance.

PROSPERO REGISTRATION NUMBER

CRD42021252073.

Electro-acupuncture modulated miR-214 expression to prevent chondrocyte apoptosis and reduce pain by targeting BAX and TRPV4 in osteoarthritis rats

Osteoarthritis (OA) is a highly prevalent joint disorder characterized by progressive degeneration of articular cartilage, subchondral bone remodeling, osteophyte formation, synovial inflammation, and meniscal damage. Although the etiology of OA is multifactorial, pro-inflammatory processes appear to play a key role in disease pathogenesis. Previous studies indicate that electroacupuncture (EA) exerts chondroprotective, anti-inflammatory, and analgesic effects in preclinical models of OA, but the mechanisms underlying these potential therapeutic benefits remain incompletely defined. This study aimed to investigate the effects of EA on OA development in a rat model, as well as to explore associated molecular mechanisms modulated by EA treatment. Forty rats were divided into OA, EA, antagomiR-214, and control groups. Following intra-articular injection of monosodium iodoacetate to induce OA, EA and antagomiR-214 groups received daily EA stimulation at acupoints around the knee joint for 21 days. Functional pain behaviors and chondrocyte apoptosis were assessed as outcome measures. The expression of microRNA-214 (miR-214) and its downstream targets involved in apoptosis and nociception, BAX and TRPV4, were examined. Results demonstrated that EA treatment upregulated miR-214 expression in OA knee cartilage. By suppressing pro-apoptotic BAX and pro-nociceptive TRPV4, this EA-induced miR-214 upregulation ameliorated articular pain and prevented chondrocyte apoptosis. These findings suggested that miR-214 plays a key role mediating EA's therapeutic effects in OA pathophysiology, and represents a promising OA treatment target for modulation by acupuncture.

Global trends and performances of infrared imaging technology studies on acupuncture: a bibliometric analysis

Objectives

To summarize development processes and research hotspots of infrared imaging technology research on acupuncture and to provide new insights for researchers in future studies.

Methods

Publications regarding infrared imaging technology in acupuncture from 2008 to 2023 were downloaded from the Web of Science Core Collection (WoSCC). VOSviewer 1.6.19, CiteSpace 6.2.R4, Scimago Graphica, and Microsoft Excel software were used for bibliometric analyses. The main analyses include collaboration analyses between countries, institutions, authors, and journals, as well as analyses on keywords and references.

Results

A total of 346 publications were retrieved from 2008 to 2023. The quantity of yearly publications increased steadily, with some fluctuations over the past 15 years. "Evidence-Based Complementary and Alternative Medicine" and "American Journal of Chinese Medicine" were the top-cited journals in frequency and centrality. China has the largest number of publications, with the Shanghai University of Traditional Chinese Medicine being the most prolific institution. Among authors, Litscher Gerhard from Austria (currently Swiss University of Traditional Chinese Medicine, Switzerland) in Europe, was the most published and most cited author. The article published by Rojas RF was the most discussed among the cited references. Common keywords included "Acupuncture," "Near infrared spectroscopy," and "Temperature," among others. Explore the relationship between acupoints and temperature through infrared thermography technology (IRT), evaluate pain objectively by functional near-infrared spectroscopy (fNIRS), and explore acupuncture for functional connectivity between brain regions were the hotspots and frontier trends in this field.

Conclusion

This study is the first to use bibliometric methods to explore the hotspots and cutting-edge issues in the application of infrared imaging technology in the field of acupuncture. It offers a fresh perspective on infrared imaging technology research on acupuncture and gives scholars useful data to determine the field's hotspots, present state of affairs, and frontier trends.

Firefighters' medical use and Korean Medicine experience in Korea: A qualitative study protocol

INTRODUCTION

Firefighters, compared to other occupational groups, are exposed more frequently in their working environment not only to physical issues, such as musculoskeletal disease, respiratory disease, and burns but also to mental health issues, such as PTSD and depression. Specifically, Korean firefighters experience significantly higher rates of work-related injuries compared to those in other countries. Recent statistics from the Korea National Fire Agency indicate a steady increase in the number of firefighting work-related injuries. However, there is a shortage of measures in place to address these issues. This study aims to investigate the health needs, overall healthcare usage, and unmet needs of firefighters in Korea. We also aim to investigate, through in-depth interviews, perceptions and hindering factors for integrative medicine approaches to fulfilling unmet needs.

METHOD

This study was conducted in accordance with the consolidated criteria for reporting qualitative research. Convenience and snowball sampling methods will be used to recruit firefighters to participate in the study, and interviews will be conducted using a semi-structured interview guide. The data will be analyzed in four stages using the qualitative analysis method of Krippendorff.

DISCUSSION

In this study, we examine the state of health issues and healthcare usage among Korean firefighters and investigate their perceptions of and needs for integrative medicine. In this way, we aim to explore how integrative medicine and Korean medicine approaches could improve and assist healthcare services for firefighters. Furthermore, our findings will provide policymakers and healthcare providers with the necessary basic information to develop integrative medicine systems suited to firefighters.

Current evidence for non-pharmaceutical, non-surgical treatments of canine osteoarthritis

Osteoarthritis is a progressive degenerative disease process that affects a significant proportion of the canine population, impacting these animals' quality of life. Currently, there is no cure and treatment consists of managing the clinical signs of pain and reduced mobility. There are many treatments for canine osteoarthritis and in this review we discuss the evidence base behind non-pharmaceutical, non-surgical treatments of this disease. These treatments include weight management, nutraceuticals, acupuncture, physiotherapies such as therapeutic exercise, hydrotherapy as well as other therapeutic modalities including photobiomodulation therapy, electromagnetic field therapy and others.

Personalized Physical Activity Programs for the Management of Knee Osteoarthritis in Individuals with Obesity: A Patient-Centered Approach

Physical activity (PA) plays a vital role in knee osteoarthritis (KOA) management. However, engaging individuals with KOA in regular exercise is challenging, especially when they are affected by obesity. The aim of the current review is to elucidate how to increase adherence to exercise in this population. When implementing a PA program with patients with KOA and obesity, a specific multi-step approach can be adopted. In phase I (the baseline assessment), the patients' eligibility for exercise is ascertained and a physical fitness assessment, sarcopenic obesity screening and quantification of the pain experienced are undertaken. Phase II adopts a patient-centered approach in implementing a PA program that combines an active lifestyle (>6000 steps/day) with land- or water-based exercise programs performed over eight to twelve weeks, with a frequency of three to five sessions per week, each lasting 60 min. In phase III, several strategies can be used to increase the patients' adherence to higher levels of PA, including the following: (i) personalizing PA goal-setting and real-time monitoring; (ii) enhancing physical fitness and the management of sarcopenic obesity; (iii) building a sustainable environment and a supportive social network for an active lifestyle; and (iv) reducing pain, which can ameliorate the clinical severity of KOA and help with weight management in this population.

Efficacy of acupuncture combined with active exercise training in improving pain and function of knee osteoarthritis individuals: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to investigate the clinical efficacy of acupuncture combined with active exercise training in improving pain and function of knee osteoarthritis (KOA) individuals.

DATA SOURCES

PubMed, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wan Fang Data, Technology Periodical Database and China Biology Medicine were searched from their inceptions to April 5, 2023.

REVIEW METHODS

We analyzed trials of acupuncture combined with active exercise training for KOA. The included studies were of high quality (Jadad ≥ 4) and RCTs. Study selection, data extraction, risk of bias and quality assessment were independently performed by two reviewers. We performed systematic analyses based on different outcome measures, including total efficiency rate, visual analogue scale (VAS), the Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC), the Lysholm Knee Scale (LKS) and range of motion (ROM). We used Review Manager 5.3 and Stata/MP 14.0 to analyze the data. And it was verified by trial sequence analysis (TSA). If I2 > 50% and p < 0.05, we performed sensitivity analysis and subgroup analysis to find the source of heterogeneity. Publication bias was studied by funnel plot and Egger's test was used to verify it.

RESULTS

Full 11 high-quality studies (Jadad ≥ 4) including 774 KOA individuals were included in this review for meta-analysis. The results showed that acupuncture combined with active exercise training (combined group) was superior to the acupuncture group in improving the total effective rate [RR = 1.13, 95%CI (1.05, 1.22), I2 = 0%, P = 0.70], reducing the pain level (VAS) [MD = - 0.74, 95%CI (- 1.04,  - 0.43), I2 = 68%, P < 0.05], improving knee joint function (WOMAC) [MD =  - 6.97, 95%CI (- 10.74, - 3.19), I2 = 76%, P < 0.05] and improving joint range of motion (ROM) [MD = 6.25, 95%CI (2.37, 10.04), I2 = 0%, P = 0.71]. Similarly, the combined group showed significant improvements in the total effective rate [RR = 1.31, 95% CI (1.18, 1.47), I2 = 48%, P = 0.10], pain (VAS) [MD = 1.42, 95% CI (- 1.85, - 1.00), I2 = 65%, P = 0.02] and knee function (WOMAC) [MD = 7.05, 95% CI (- 11.43, - 2.66), I2 = 86%, P < 0.05] compared with the non-acupuncture group.

CONCLUSION

The combined effect of all studies showed significant benefits of acupuncture combined with active exercise training in improving the total effective rate, reducing pain, promoting recovery of knee function and expanding range of motion. However, some evaluation indicators are highly subjective and need to be further confirmed by more objective and evidence-based high-quality RCTs in future.

SYSTEMATIC REVIEW REGISTRATION

[PROSPERO], identifier [No. CRD42023425823].

Effectiveness of acupuncture as adjunctive therapy in type 2 diabetic: Study protocol for a randomized controlled trial

INTRODUCTION

The incidence of type 2 diabetes mellitus is increasing worldwide. The literature suggests that acupuncture is a possible complementary therapy for type 2 diabetes mellitus. This study aims to determine the effectiveness of acupuncture as an adjunctive therapy on homeostasis model assessment-insulin resistance (HOMA-IR), and health-related quality of life (HRQoL) in patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

This randomized, double-blind, placebo controlled, and parallel design trial will be carried out in a public university teaching hospitals in Malaysia. Eligible type 2 diabetes mellitus subjects will be randomly assigned to receive either acupuncture (n = 30) or a placebo (n = 30). The intervention is carried out using press needle or press placebo on abdomen area (10 sessions of treatment). Both groups will continue with their routine diabetes care. Primary outcome of HOMA-IR will be measured at the time of recruitment (-week 0), and after completion of 10 sessions (week 7) of the treatment. Additionally, secondary outcome of HRQoL will be measured at the time of recruitment (-week 0), after completion of 5 sessions (week 3/4), and 10 sessions (week 7) of the treatment. Any adverse event will be recorded at every visit.

DISCUSSION

The findings of this study will provide important clinical evidence for the effect of acupuncture as adjunctive therapy on HOMA-IR, adiposity and HRQoL of type 2 diabetes mellitus.

TRIAL REGISTRATION NUMBER

NCT04829045.

Racial and Ethnic Variation in Complementary and Integrative Health Therapy Use Among US Veterans

Importance

White individuals are the greatest users of complementary and integrative health (CIH) therapies in the general population, but this might partially be due to differences in age, health condition, and location. Identifying the nuances in racial and ethnic differences in care is one important step to addressing them.

Objective

To evaluate racial and ethnic differences in Veterans Affairs (VA)-covered CIH therapy use in a more nuanced manner by examining the association of 5 demographic characteristics, health conditions, and medical facility locations with those differences.

Design, Setting, and Participants

Retrospective cross-sectional observational study of VA health care system users, using electronic health record and administrative data at all VA medical facilities and community-based clinics. Participants included veterans with nonmissing race and ethnicity data using VA-funded health care between October 2018 and September 2019. Data were analyzed from June 2022 to April 2023.

Main Outcome and Measure

Any use of VA-covered acupuncture, chiropractic care, massage therapy, yoga, or meditation/mindfulness.

Results

The sample consisted of 5 260 807 veterans with a mean (SD) age of 62.3 (16.4) years and was 91% male (4 788 267 veterans), 67% non-Hispanic White (3 547 140 veterans), 6% Hispanic (328 396 veterans), and 17% Black (903 699 veterans). Chiropractic care was the most used CIH therapy among non-Hispanic White veterans, Hispanic veterans, and veterans of other races and ethnicities, while acupuncture was the most commonly used therapy among Black veterans. When not accounting for the location of the VA medical facilities in which veterans used health care, Black veterans appeared more likely to use yoga and meditation than non-Hispanic White veterans and far less likely to use chiropractic care, while those of Hispanic or other race and ethnicity appeared more likely to use massage than non-Hispanic White veterans. However, those differences mostly disappeared once controlling for medical facility location, with few exceptions-after adjustment Black veterans were less likely than non-Hispanic White veterans to use yoga and more likely to use chiropractic care.

Conclusions and Relevance

This large-scale, cross-sectional study found racial and ethnic differences in use of 4 of 5 CIH therapies among VA health care system users when not considering their medical facility location. Given those differences mostly disappeared once medical facilities were accounted for, the results demonstrated the importance of considering facilities and residential locations when examining racial differences in CIH therapy use. Medical facilities could be a proxy for the racial and ethnic composition of their patients, CIH therapy availability, regional patient or clinician attitudes, or therapy availability.

The Opioid-Sparing Effect of Acupuncture After Abdominal Surgery: A Systematic Review and Meta-Analysis Protocol

Purpose

Routine overprescribing of postoperative opioid analgesics may induce side effects and correlate with chronic opioid use following surgery. This review aims to evaluate the effectiveness and safety of acupuncture for opioid-sparing effects in patients who underwent abdominal surgery.

Methods

Eleven databases in different languages, including English (Ovid MEDLINE, CENTRAL, EMBASE, CINAHL), Chinese, Korean, and Japanese, will be searched. Randomized controlled trials using acupuncture for postoperative pain control in adult patients undergoing abdominal surgery will be screened. All randomized controlled trials comparing acupuncture with no treatment, sham acupuncture, and conventional treatments will be included. The Cochrane risk of bias tool will be used to assess the risk of bias. The primary outcome will consist of a cumulative opioid consumption. Additionally, the number of cumulative opioid analgesic demands/requests, the time to initial opioid analgesic usage, postoperative pain, opioid-related side effects, and adverse events of acupuncture will be assessed. The mean differences or risk ratios with a 95% confidence interval will be calculated to estimate the pooled effect of acupuncture when it is possible to conduct a meta-analysis.

Results

This study could confirm the effect of opioid-sparing on acupuncture after abdominal surgery.

Conclusion

This study would evaluate the evidence on the effectiveness of acupuncture after abdominal surgery with a focus on opioid intake. It provides evidence to support decision-making on applying acupuncture for postoperative management.

Registration Number

CRD42022311155.

Approach to Assess Adequacy of Acupuncture in Randomized Controlled Trials: A Systematic Review

OBJECTIVE

To summarize and identify the available instruments/methods assessing the adequacy of acupuncture in randomized controlled trials (RCTs) for proposing a new improved instrument.

METHODS

A systematic literature search was carried out in 7 electronic databases from inception until 21st November 2022. Any study evaluating the adequacy or quality of acupuncture, specifying specific acupuncture treatment-related factors as criteria of subgroup analysis, or developing an instrument/tool to assess the adequacy or quality of acupuncture in an RCT was included. Basic information, characteristics and contents of acupuncture adequacy assessment were presented as frequencies and percentages.

RESULTS

Forty studies were included in this systematic review. Thirty-five studies (87.50%) were systematic reviews, none of which used formal methods to develop the assessment instruments/methods of acupuncture adequacy; of 5 methodological studies, only 1 study used a relatively formal method. Thirty-two studies (82.05%) assessed the components of acupuncture, while 7 (17.95%) assessed the overall quality of acupuncture. An independent assessment instrument/method was used to assess acupuncture adequacy in 29 studies (74.35%), whereas as one part of a methodological quality assessment scale in 10 (25.65%). Only 9 (23.00%) studies used the assessment results for subgroup analysis, sensitivity analysis or the criteria for inclusion in the meta-analysis.

CONCLUSION

Assessment contents for adequacy or quality of acupuncture in RCTs hadn't still reached consensus and no widely used assessment tools appeared. The methodology of available assessment instruments/scales is far from formal and rigorous. A new instrument/tool assessing adequacy of acupuncture should be developed using a formal method.

Acupoint Thread Embedding Combined With Wenshen Bugu Decoction for the Treatment of Aromatase Inhibitor-Associated Musculoskeletal Symptom Among Postmenopausal Breast Cancer Patients: Study Protocol of a Randomized Controlled Trial

BACKGROUND

Aromatase inhibitors (AIs) are recommended as the preferred therapy for postmenopausal women with hormone receptor-positive (HR+) breast cancer. As a result, aromatase inhibitor-associated musculoskeletal symptom (AIMSS) have become a major problem leading to therapy discontinuation and decreased quality of life in patients receiving adjuvant AIs treatment. Multiple therapies have been attempted, but have yielded limited clinical results. This study will be performed to determine whether acupoint thread embedding (ATE) combined with Wenshen Bugu Decoction can effectively treat AIMSS, so as to improve the AIs medication compliance of postmenopausal breast cancer patients.

METHODS

This study will utilize a randomized, 2 parallel groups controlled trial design. A total of 128 eligible postmenopausal breast cancer women with AIMSS will be randomized to receive a 12-week treatment with Wenshen Bugu Decoction alone (control group) or in combination with ATE (treatment group) in a 1:1 ratio. The primary outcome will be the 12 week Brief Pain Inventory Worst Pain (BPI-WP) score. The secondary outcome measures will include response rate, Brief Pain Inventory-Short Form (BFI-SF), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Functional Assessment of Cancer Therapy-Endocrine Symptom (FACT-ES), Functional Assessment of Cancer Therapy-Breast (FACT-B), bone marrow density (BMD), blood markers of bone metabolite, Morisky medication adherence scale-8 (MMAS-8), credibility and expectancy, and survival outcomes.

DISCUSSION

This trial may provide clinical evidence that ATE combined with Wenshen Bugu Decoction can be beneficial for treating AIMSS among postmenopausal breast cancer survivors. Our findings will be helpful to enhance the quality of life and reduce the occurrence of AIs withdrawal.

A bibliometric analysis of traditional Chinese non-pharmacological therapies in the treatment of knee osteoarthritis from 2012 to 2022

Objective

The benefits of traditional Chinese non-pharmacological therapies in the treatment of Knee osteoarthritis (KOA) are receiving increasing attention. Therefore, this study aims to systematically analyze the global research on the treatment of KOA by Chinese traditional non-pharmacological therapies using bibliometric analysis and present the results with a knowledge map form.

Methods

Literature related to traditional Chinese non-pharmacological therapies used in the treatment of KOA from 2012 to 2022 was searched from the Web of Science core database and PubMed database. CiteSpace, SCImago Graphica and VOSviewer were used to extract nations, institutions, journals, authors, references, keywords, as well as the most widely used acupoints, therapies and evaluation indexes.

Results

A total of 375 literature have been included. 32 countries around the world have participated in the research. China, the United States, and Europe were at the center of the global cooperation network. The most prolific institutions and authors were from China represented by Cun-zhi Liu and Jian-feng Tu of Beijing University of Chinese Medicine, the institution with the highest cited frequency was University of York, and "Osteoarthritis Cartilage" was the most frequently cited journal. The most frequently cited literature was "OARSI guidelines for the non-surgical management of knee, hip, and poly articular osteoarthritis." 22 kinds of Chinese non-pharmacological therapies were used to treat KOA, among which acupuncture was the most commonly used one, and ST36 (Zusanli) and WOMAC were the most commonly selected acupoint and evaluation index.

Conclusion

In the past decade, the value of Chinese non-pharmacological therapies in the treatment of KOA has received widespread attention. It was a common concern of global researchers to relieve the pain of KOA patients and restore the quality of life. Under the background that acupuncture accounts for a relatively high proportion, the next step may consider how to make the balanced development of a variety of Chinese non-pharmacological therapies. In addition, the problem of how to eliminate the placebo effect maybe the direction of future research.

Case report: Electroacupuncture for acute pain flare-up of knee osteoarthritis

Acute pain flare-up of knee osteoarthritis (KOA) is a common disease in orthopedics and is mainly treated with analgesic drugs. Patients usually refuse to take western medicines orally owing to gastrointestinal side effects or unsatisfactory treatment results. We report the case of a 69-year-old woman who had an acute pain flare-up of right KOA induced by long-distance walking. As the patient refused medication, we used electroacupuncture (EA) to relieve her symptoms. EA with a 2-Hz frequency and a 1–2-mA intensity had an analgesic effect on the acute pain flare-up of KOA. After 12 weeks of EA intervention, the bone marrow edema-like lesions (BMLs) improved significantly, as depicted on magnetic resonance imaging of the knee joint. However, more powerful evidence is needed to understand the mechanism of the EA technique that alleviates BMLs of KOA.

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.

What is the healthcare utilisation and out-of-pocket expenditure associated with osteoarthritis? A cross-sectional study

OBJECTIVE

To examine the use and out-of-pocket expenses resulting from consultations, products and practices across conventional, self-care, and complementary medicine (CM) treatments for osteoarthritis (OA) among Australian women.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey of 800 women from the 45 and Up Study who had reported a clinical diagnosis of OA.

OUTCOME MEASURES

Women's use of conventional, CM and self-prescribed treatments for OA and the associated out-of-pocket cost.

RESULTS

Completed questionnaires were returned by 403 women (50.4%). Their average time since the first diagnosis of OA was 15.4 years, and self-rated severity of OA was 5.1 (out of 10) over the past 12 months. During the previous year, 67.0% of the women consulted a doctor, 39.2% consulted an allied health practitioner and 34.7% consulted a CM practitioner for their OA. Some women (19%) consulted with practitioner(s) from all three practitioner groups, 27% consulted with practitioner(s) from two of the three practitioner groups, while 6% consulted with a CM practitioner only. Women with a greater time since diagnosis had more consultations, as did women who rated their OA as more severe. Women's average combined out-of-pocket expenditure for OA-related healthcare consultations, prescription medications, products, and practices was $673 per annum. Extrapolated to all Australian women with OA, aged 50 years and over, the total out-of-pocket expenditure for this condition is estimated to be $873 million per annum.

CONCLUSIONS

Australian women with OA use a range of conventional and CM consultations, self-care, products and practices to manage their condition, incurring significant out-of-pocket expenses. Given the high individual and societal burden of OA, there is a need for further research into the concurrent use of different healthcare resources with a view to providing safe, cost-effective management of OA across the healthcare system and the wider community.

Is acupuncture effective for knee osteoarthritis? A protocol for a systematic review and meta-analysis

INTRODUCTION

Knee osteoarthritis (KOA) is one of the leading causes of disability. The effectiveness of acupuncture for treating KOA remains controversial. This protocol describes the method of a systematic review and meta-analysis evaluating the effectiveness and safety of acupuncture for treating KOA.

METHODS AND ANALYSIS

Four English databases (PubMed, Embase, Cochrane Library databases and Web of Science) and four Chinese databases (China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Database for Chinese Technical Periodicals, and Wanfang) will be searched from the database inception to 1 September 2021. All randomised controlled trials related to acupuncture for KOA will be included. Extracted data will include publication details, basic information, demographic data, intervention details and patient outcomes. The primary outcome will be pain intensity. Risk of bias will be assessed using the Cochrane Collaboration's tool for assessing risk of bias. Article selection, data extraction and risk of bias assessment will be performed in duplicate by two independent reviewers. If the meta-analysis is precluded, we will conduct a descriptive synthesis using a best-evidence synthesis approach. The strength of recommendations and quality of evidence will be assessed using the Grading of Recommendations Assessment Development and Evaluation working group methodology.

ETHICS AND DISSEMINATION

Ethics approval is not required because individual patient data are not included. This protocol was registered in the international Prospective Register of Systematic Reviews on 25 February 2021. The systematic review and meta-analysis will be submitted for publication in a peer-reviewed journal. The findings will also be disseminated through conference presentations.

TRIAL REGISTRATION NUMBER

CRD42021232177.

Current advances and novel research on minimal invasive techniques for musculoskeletal disorders

The present review summarized the current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Different invasive approaches were proposed in the physical therapy field for the management of musculoskeletal disorders, such as ultrasound-guided percutaneous needle electrolysis, dry needling, acupuncture and other invasive therapy techniques, discussing about their worldwide status, safety and interventional ultrasound imaging. Indeed, dry needling may be one of the most useful and studies invasive physical therapy applications in musculoskeletal disorders of different body regions, such as back, upper limb, shoulder, arm, hand, pelvis, lower limb, neck, head, or temporomandibular joint, and multiple soreness location disorders, such as fibromyalgia. In addition, the assessment and treatment by acupuncture or electro-acupuncture was considered and detailed for different conditions such as plantar fasciitis, osteoarthritis, spasticity, myofascial pain syndrome, osteoporosis and rheumatoid arthritis. As an increasing technique in physical therapy, the use of ultrasound-guided percutaneous needle electrolysis was discussed in injuries of the musculoskeletal system and entrapment neuropathies. Also, ultrasound-guided percutaneous neuromodulation was established as a rising technique combined with ultrasound evaluation of the peripheral nerve system with different clinical applications which need further studies to detail their effectiveness in different musculoskeletal conditions. Thus, invasive physical therapy may be considered as a promising approach with different novel applications in several musculoskeletal disorders and a rising use in the physiotherapy field.

Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot

Objective: To identify factors associated with implementing bundled group acupuncture and yoga therapy (YT) to treat underserved patients with chronic pain in community health center (CHC) settings. This is not an implementation science study, but rather an organized approach for identification of barriers and facilitators to implementing these therapies as a precursor to a future implementation science study. Design: This study was part of a single-arm feasibility trial, which aimed to test the feasibility of bundling GA and YT for chronic pain in CHCs. Treatment outcomes were measured before and after the 10-week intervention period. Implementation feasibility was assessed through weekly research team meetings, weekly yoga provider meetings, monthly acupuncture provider meetings, and weekly provider surveys. Settings: The study was conducted in New York City at two Montefiore Medical Group (MMG) sites in the Bronx, and one Institute for Family Health (IFH) site in Harlem. Subjects: Participants in the feasibility trial were recruited from IFH and MMG sites, and needed to have had lower back, neck, or osteoarthritis pain for >3 months. Implementation stakeholders included the research team, providers of acupuncture and YT, referring providers, and CHC staff. Results: Implementation of these therapies was assessed using the Consolidated Framework for Implementation Research. We identified issues associated with scheduling, treatment fidelity, communication, the three-way disciplinary interaction of acupuncture, yoga, and biomedicine, space adaptation, site-specific logistical and operational requirements, and patient-provider language barriers. Issues varied as to their frequency and resolution difficulty. Conclusions: This feasibility trial identified implementation issues and resolution strategies that could be further explored in future implementation studies. Clinical Trial Registration No.: NCT04296344.

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.

Global Trends and Performances of Magnetic Resonance Imaging Studies on Acupuncture: A Bibliometric Analysis

Objectives: To summarize development processes and research hotspots of MRI research on acupuncture and to provide new insights for researchers in future studies.

Methods: Publications regarding MRI on acupuncture from inception to 2020 were downloaded from the Web of Science Core Collection. VOSviewer 1.6.15 and CiteSpace V software were used for bibliometric analyses. The main analyses include collaboration analyses between countries/institutions/authors, co-occurrence analysis between keywords, as well as analyses on keyword bursts, citation references, and clusters of references.

Results: A total of 829 papers were obtained with a continually increased trend over time. The most productive country and institution in this field were the People's Republic of China (475) and KyungHee University (70), respectively. Evidence-based Complementary and Alternative Medicine (83) was the most productive journal, and Neuroimage (454) was the most co-cited journal. Dhond's et al. (2008) article (co-citation counts: 58) and Napadow's et al. (2005) article (centrality: 0.21) were the most representative and symbolic references, with the highest co-citation number and centrality, respectively. Jie Tian had the highest number of publications (35) and Kathleen K S Hui was the most influential author (280 co-citations). The four hot topics in MRI on acupuncture were acupuncture, fMRI, pain, and stimulation. The three frontier topics were connectivity, modulation, and fMRI. Based on the clustering of co-cited documents, chronic low back pain, sham electro-acupuncture treatment, and clinical research were the main research directions.

Conclusion: This study provides an in-depth perspective for MRI research on acupuncture and provides researchers with valuable information to determine the current status, hot spots, and frontier trends of MRI research on acupuncture.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Setting for an Underserved Population: Design and Rationale for a Feasibility Pilot

Chronic pain is prevalent in the United States, with impact on physical and psychological functioning as well as lost work productivity. Minority and lower socioeconomic populations have increased prevalence of chronic pain with less access to pain care, poorer outcomes, and higher risk of fatal opioid overdose. Acupuncture therapy is effective in treating chronic pain conditions including chronic low back pain, neck pain, shoulder pain, and knee pain from osteoarthritis. Acupuncture therapy, including group acupuncture, is feasible and effective, and specifically so for underserved and diverse populations at risk for health outcome disparities. Acupuncture therapy also encourages patient engagement and activation. As chronic pain improves, there is a natural progression to want and need to increase activity and movement recovery. Diverse movement approaches are important for improving range of motion, maintaining gains, strengthening, and promoting patient engagement and activation. Yoga therapy is an active therapy with proven benefit in musculoskeletal pain disorders and pain associated disability. The aim of this quasi-experimental pilot feasibility trial is to test the bundling of these 2 effective care options for chronic pain, to inform both the design for a larger randomized pragmatic effectiveness trial as well as implementation strategies across underserved settings.

Association Between Acupuncture and Knee Surgery for Osteoarthritis: A Korean, Nationwide, Matched, Retrospective Cohort Study

Objectives: The present study was undertaken to investigate the relationship between acupuncture therapy and surgery rate. Design: Matched, retrospective cohort study. Materials and Methods: From nationwide health insurance data (2002-2013 cohort data published by the National Health Insurance Service of Korea), patients with new cases of knee osteoarthritis that occurred between January 1, 2004 and December 31, 2010 were analyzed. Patients were divided into an acupuncture group (AG) and a control group (CG), based on records of acupuncture therapy. Propensity scores were calculated by using gender, age, income level, and Charlson comorbidity index (CCI), with the groups matched at a ratio of 1:3 (AG:CG). The final analysis period was 2 years after the first acupuncture therapy for AG and 2 years after initial diagnosis for CG; surgery rates were compared between the two groups. Stratified analyses were performed based on age, gender, and income level; sensitivity analyses were performed based on the frequency and duration of acupuncture therapy. Results: Propensity score-matched AG and CG included 8,605 and 25,815 subjects, respectively. Post-matching surgery rates were 0.26 and 0.93% in AG and CG, respectively. For all age groups, AG showed a lower surgery rate than CG. In the analysis based on gender, the female group showed a significantly lower hazard ratio of 0.225. In analysis based on income level, the results of the entire group were significant, with the lower income group showing the lowest hazard ratio. In sensitivity analyses, AG tended to show a lower surgery rate than CG. Conclusions: The present study demonstrated that acupuncture therapy is associated with a low rate of surgery for knee osteoarthritis. Additional studies are needed to support this conclusion.

Acupuncture for knee osteoarthritis with sensitized acupoints: results from a pilot, feasibility randomized controlled trial

Background

Although previous clinical studies suggest possible benefits of acupuncture for knee osteoarthritis (KOA), the value of acupuncture at sensitized points is uncertain. We aimed to preliminarily assess the feasibility of performing a definitive randomized controlled trial to explore the effectiveness of acupuncture for KOA with highly sensitized acupoints.

Methods

In this randomized, single-blind, parallel, pilot trial, 36 participants with KOA were randomly assigned to receive acupuncture at highly sensitized acupoints (high-sensitization group) or at low/non-sensitized points (low/non-sensitization group) by a computer-generated random sequence. Both groups received three treatment sessions per week for four consecutive weeks (12 sessions in total). Assessments were performed at screening and at 4, 8, 12, and 16 weeks after randomization. Primary feasibility outcomes were patient recruitment, retention rate, and adherence to group treatment. Secondary outcomes included the change of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score from baseline to 16 weeks, the change of Short Form (SF)-12 health survey score, and safety outcomes.

Results

Patient recruitment of 36 patients took 2 months, achieving the recruitment target. Retention rates were similar between the treatment groups, 14 (77.8%) patients in the high-sensitization group completed the 16-week follow-up and compared to 14 (77.8%) patients in low/non-sensitization group, but the result was lower than expected. All patients received at least ten treatment sessions in total. The WOMAC total score and the pain, stiffness, and physical function score in the high-sensitization group were lower or very close to those in the control group at each assessment point. Similar results were observed on quality of life. No adverse events occurred.

Conclusion

This trial has presented preliminary data on the feasibility of conducting a large trial to test the effectiveness of acupuncture at sensitized points in KOA patients.

Trial registration

ClinicalTrials.gov, NCT03008668. Registered on 26 December 2016—retrospectively registered.

Guidelines for the diagnosis and treatment of osteoarthritis in China (2019 edition)

Osteoarthritis (OA) is a degenerative disease of middle-aged and elderly people, contributed a higher burden of disease in China and the world. In 2017, under the support of the Rheumatology and Immunology Expert Committee of the Cross-Strait Medical and Health Exchange Association. The objective was to develop an evidence-based diagnosis and treatment guideline for OA in China based on emerging new evidence. The guideline was registered at International Practice Guidelines Registry Platform (IPGRP-2018CN028). The grading of recommendations assessment, development and evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations, and the RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist was followed to report the guideline. The guideline provides recommendations for the OA diagnosis, disease risks monitoring and evaluate, treatment purpose and physical, medical and surgical interventions. This guideline is intended to serve as a tool for Chinese clinicians for the best decisions-making on diagnosis and treatment of OA.

Acupuncture Decreased the Risk of Coronary Heart Disease in Patients with Osteoarthritis in Taiwan: A Nationwide Matched Cohort Study

Objectives: Patients with osteoarthritis (OA) are more likely to develop coronary heart disease (CHD) than the general population. Acupuncture is commonly used in OA patients; however, the therapeutic effect of acupuncture on the risk of CHD in patients with OA and the association between OA patients and their risk to develop CHD in Taiwan are unknown. We investigated the risk of CHD according to acupuncture use in OA patients and compared it with the general population. Design: Records obtained from Taiwan's National Health Insurance Research Database identified 84,773 patients with OA, which were compared with 727,359 patients without OA diagnosis. Five thousand forty-six of those who met study inclusion criteria had 1:1 frequency matching and were categorized as OA-acupuncture cohort (n = 1682), OA nonacupuncture cohort (n = 1682), and non-OA cohort (n = 1682). Cox proportional hazards regression analysis determined the risk of CHD, which was defined as the study main outcome. Therapeutic effects of acupuncture and medical expenditure were also analyzed. Results: OA nonacupuncture cohort had 3.04 higher risk to develop CHD compared with OA-acupuncture cohort (95% confidence interval [CI], 2.54-3.63, p < 0.001) and non-OA cohort had 1.88 higher risk to develop CHD compared with OA-acupuncture cohort (95% CI, 1.52-2.32, p < 0.001). In subgroup analyses, OA patients treated with both acupuncture and oral steroids were at significantly lower risk of CHD compared with those who used neither (adjusted hazard ratio 0.34; 95% CI, 0.22-0.53), and OA patients treated with acupuncture had the lowest medical expenditure in a follow-up time of 6 months, and 3 and 5 years. Conclusion: This is the first large-scale investigation in Taiwan that shows the association between OA and CHD and the beneficial effects of acupuncture in OA patients, and their associated risk to develop CHD. Our results may provide valuable information for health policy decision making. Further randomized controlled trials are needed to confirm these observational findings.

Acupuncture and moxibustion for pain relief and quality of life improvement in patients with knee osteoarthritis: A protocol for systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis is to assess the efficacy of acupuncture and moxibustion in pain relief and quality of life improvement of knee osteoarthritis (KOA) patients.

METHODS

The following databases will be searched: MEDLINE, EMBASE, the Cochrane Library, Web of Science, Chinese Biomedical Literature Database, Chinese Nation Knowledge Infrastructure, Wanfang Database, the Chongqing VIP from inception to May 1, 2020. All randomized controlled trials (RCTs) used acupuncture or moxibustion to relieve pain and improve quality of life (QoL) among KOA patients will be included. Study selection, data extraction, quality assessment and assessment of risk bias will be performed by 2 reviewers independently. Data synthesis will be performed using Review Manager V5.3 software. A meta-analysis will be performed when there is sufficient available data.

PROSPERO REGISTRATION NUMBER

CRD42020169724.

"It Gave Me Hope" Experiences of Diverse Safety Net Patients in a Group Acupuncture Intervention for Painful Diabetic Neuropathy

Purpose: To explore the experiences of living with painful diabetic neuropathy (PDN) and with a group acupuncture intervention in a sample of low-income, diverse patients.

Methods: We conducted a randomized clinical trial of a 12-week group acupuncture intervention for PDN. Data included validated measures of patient-reported outcomes, including pain and quality of life (QOL), as well as semistructured qualitative interviews about participants' experiences with PDN and the intervention. Interview transcripts were coded and analyzed using an inductive thematic framework.

Results: We recruited 40 participants from diverse racial/ethnic backgrounds from a public hospital and conducted in-depth qualitative interviews with a subset of 17 participants. Participants randomized to acupuncture experienced greater decreases in pain compared with usual care as well as improved QOL. In interviews, they described a myriad of socioeconomic and personal life stressors that compounded the significant suffering and disability brought on by PDN. Those who received acupuncture were able to decrease reliance on pain medication, improve their sleep and daily function, reduce stress, and engage more with their own self-care. They noted that the acupuncture intervention also gave them hope in the face of their chronic disease.

Conclusion: Acupuncture is a valuable adjunct treatment for low-income and marginalized populations with PDN. In addition to reducing pain and improving QOL, acupuncture may offer powerful benefits by increasing patient activation and hope.

Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care-a Randomized Trial

BACKGROUND

Acupuncture has been shown to be effective for the treatment of chronic musculoskeletal back, neck, and osteoarthritis pain. However, access to acupuncture treatment has been limited in medically underserved and low-income populations.

OBJECTIVE

Acupuncture therapy delivered in groups could reduce cost and expand access. We compared the effectiveness of group versus individual acupuncture for pain and function among ethnically diverse, low-income primary care patients with chronic musculoskeletal pain.

DESIGN

This was a randomized comparative effectiveness non-inferiority trial in 6 Bronx primary care community health centers. Participants with chronic (> 3 months) back, neck, or osteoarthritis pain were randomly assigned to individual or group acupuncture therapy for 12 weeks.

PARTICIPANTS

Seven hundred seventy-nine participants were randomized. Mean age was 54.8 years. 35.3% of participants identified as black and 56.9% identified as Latino. Seventy-six percent were Medicaid insured, 60% reported poor/fair health, and 37% were unable to work due to disability.

INTERVENTIONS

Participants received weekly acupuncture treatment in either group or individual setting for 12 weeks.

MAIN MEASURES

Primary outcome was pain interference on the Brief Pain Inventory at 12 weeks; secondary outcomes were pain severity (BPI), physical and mental well-being (PROMIS-10), and opiate use. Outcome measures were collected at baseline, 12 and 24 weeks.

KEY RESULTS

37.5% of individual arm and 30.3% in group had > 30% improvement in pain interference (d = 7.2%, 95% CI - 0.6%, 15.1%). Non-inferiority of group acupuncture was not demonstrated for the primary outcome assuming a margin of 10%. In the responder analysis of physical well-being, 63.1% of individual participants and 59.5% of group had clinically important improvement at 12 weeks (d = 3.6%, 95% CI - 4.2%, 11.4%).

CONCLUSIONS

Both individual and group acupuncture therapy delivered in primary care settings reduced chronic pain and improved physical function at 12 weeks; non-inferiority of group was not shown.

TRIAL REGISTRATION

Clinicaltrials.gov # NCT02456727.

Osteoarthritis: Pathology, Diagnosis, and Treatment Options

Osteoarthritis (OA) is a worldwide endemic and debilitating disease. Previously thought to simply be damaged from "wear and tear," OA is now understood to be a complex interaction of local and systemic factors. This article reviews the pathology, symptoms, diagnosis, and various conservative, surgical, and novel treatments of OA.

Electroacupuncture versus manual acupuncture for knee osteoarthritis: a randomized controlled pilot trial

OBJECTIVE

We aimed to explore the feasibility of evaluating the comparative effectiveness and safety of electroacupuncture (EA) relative to manual acupuncture (MA) for the treatment of knee osteoarthritis (KOA).

METHODS

A multicenter randomized controlled clinical trial was conducted in Beijing from September 2017 to January 2018. A total of 60 participants with KOA were randomly allocated to either EA (n = 30) or MA (n = 30) groups. Participants in the EA group were treated with EA at six to seven local traditional acupuncture points or ah shi points, and two to three distal points. Participants in the MA group had the same schedule as the EA group except that the electrical apparatus featured a working power indicator without actual current output, constituting a sham EA procedure, in order to blind participants. Both groups received 24 sessions over 8 weeks. The primary outcome was response rate, defined as a change of ⩾50% from baseline in the total scores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) after 8 weeks. Secondary outcomes included pain, stiffness, function, quality of life, and acupuncture-related adverse events (AEs) at 4 and 8 weeks.

RESULTS

Of 60 participants randomized, 53 (88%) completed the study. Response rates were 43% for the EA group and 30% for the MA group by the intention-to-treat analysis. Although significant differences were observed in WOMAC pain, stiffness, and function scores within both groups, between-group differences at 8 weeks did not reach statistical significance (odds ratio = 1.75 (95% confidence interval = 0.593-5.162)). Rates of AEs were low and similarly distributed between groups.

CONCLUSION

Both EA and MA interventions in KOA were feasible and appeared safe. Whether or not EA may have a stronger impact on pain and function requires further evaluation through larger, adequately powered, randomized controlled trials.

TRIAL REGISTRATION NUMBER

NCT03274713.

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

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

Implementation of Electrical Auricular Acupuncture and Low Frequency Modulated Electric Current Therapy in Pain Management of Patients with Knee Osteoarthritis: A Randomized Pilot Trial

Background: Knee osteoarthritis is a major cause of knee pain. Conservative therapy resources are limited due to adverse effects. Therefore, alternative non-invasive therapy approaches to reduce pain medications are gaining importance. The current study analyses if electrical auricular acupuncture (EAA) or low frequency modulated electric current therapy (LFMECT) could support analgesic treatment. Methods: In a randomized pilot trial patients with painful knee OA were treated with EAA (group 1) or LFMECT (group 2) additional to standard pharmacological analgesic treatment. In total 19 female and 10 male patients with a mean age of 59.1 years (standard deviation ± 13.6) and a mean BMI of 28.9 kg/m² (± 5.2) were included. Patients were randomly assigned to one of the groups stratified for age, gender and BMI. Before starting of the active study period and collecting of the initial data on day 1, all patients received a pharmacological analgesic baseline therapy for one week. At the next study stage patients started their randomly assigned treatment protocol for 42 days and final follow-up was set on day 70. Patients recorded their pain intensity (numerical rating scale; NRS) using a standardized patient diary. The pain free walking time in min was recorded and range of motion was assessed. Results: Rescue medication intake was comparable between both groups on day 42 (p = 0.55) and day 70 (p = 0.35). After the active study period (day 42) pain scores decreased significantly in both groups (group 1 p = 0.02; group 2 p = 0.0006). At follow up median pain scores further decreased in group 1 (p = 0.0002) and remained at a low level in group 2 (p = 0.001). Level of pain decreased in about 50% in both groups and was comparable during the study period. Total mean range of motion (ROM) increased in both groups (group 1 p = 0.0003; group 2 p = 0.02). Group 1 had more improvement of mean total ROM compared to group 2 (p = 0.034). Pain-free walking time increased in both groups and was comparable between both groups (p = 0.31). Any adverse effects due to EAA or LFMECT were not observed. Conclusions: Data of the current study indicates that implementation of EAA or LFMECT seems to be beneficial to reduce knee pain and improve knee function in patients with knee osteoarthritis.

Acupuncture for the postcholecystectomy syndrome: Protocol for a systematic review and meta-analysis

BACKGROUND

Postcholecystectomy syndrome (PCS) is a term used to describe the persistence of biliary colic or right upper quadrant abdominal pain with a variety of postoperative gastrointestinal symptoms. Acupuncture and related treatments have shown clinical effects for PCS in many studies. But the systematic reviews and meta-analyses for them are lacking. We aim to evaluate the efficacy and safety of acupuncture on the treatment of PCS.

METHODS

We will search 8 electronic databases, including the Web of Science, PubMed, Cochrane Library, Embase, and 4 Chinese databases (CBM, Wanfang, VIP, and CNKI databases), and additional sources (WHO ICTRP, ChiCTR, Clinical Trials, Grey Literature Database), for potentially eligible studies. Literature retrieval, screening, and data extraction will be conducted by 2 researchers independently. In case of disagreement, a 3rd party shall be consulted to assist judgment. We will use RevmanV.5.3 to perform a fixed effect meta-analysis on the data of clinical homogeneity studies, and evidence's level will be assessed through the method for GRADE.

RESULTS

This systematic review and meta-analysis will put a high-quality synthesis of the efficacy and safety of acupuncture treatment in PCS.

CONCLUSION

The conclusion of this systematic review will provide evidence to assess acupuncture therapy is an efficacy and safe intervention to treat and control PCS.

ETHICS AND DISSEMINATION

Since this article does not involve patients' private data, no ethical approval is required. The agreement will be disseminated by peer-reviewed journals or conference reports.

TRIAL REGISTRATION NUMBER

PROSPERO CRD4201929287.

[Carboxytherapy - an innovative trend in resort medicine]

Carboxytherapy (the treatment based on carbon dioxide injections) is a multipurpose and widely used medical technology. The use of CO₂ injections (intracutaneous, subcutaneous, and pneumopuncture) have substantially supplemented and increased the practical relevance of carboxytherapy as a method for the treatment of many diseases. Thanks to it physiological properties, CO₂ has antihypoxic, antioxidant, vasodilatory, anti-inflammatory, analgesic, and spasmolytic activities; moreover, it improves blood viscosity, stimulates neoangiogenesis, and regenerative processes. Carbon dioxide is a sort of biochemical 'peacemaker' in tissue oxygenation: when blood cells are exposed to high CO₂ concentrations (Bohr effect), the rate of gas exchange (CO₂ and O₂) increases. The human organism interprets carboxytherapy (local hypercapnia) as oxygen deficiency and responses to it by boosting not only the blood flow, but also the vascular endothelial growth factor which stimulates neoangiogenesis and in the long run improves blood supply and tissue trophism. The multiple mechanisms of action, polymodal efficacy, a tool kit with a wide range of detectors and various modes of treatment make carboxytherapy a popular medical technology all over the world, namely in cosmetology, dermatology, aesthetic medicine, angiology, orthopaedics, cardiology, neurology, pulmonology, gynaecology, urology, proctology, plastic and general surgery, and other areas. Carboxytherapy provides a perfect example of the off-label usage in medicine that made it one of the most extensively applied medical technology for the treatment of various diseases despite the lack of the preclinical data and scarce relevant information available in textbooks, reference books and booklets.

Traditional Chinese medicine therapy reduces the risk of total knee replacement in patients with knee osteoarthritis

Knee osteoarthritis is a degenerative disease occurring in elderly people worldwide. For severe knee osteoarthritis, total knee replacement is the final treatment option. Traditional Chinese medicine (TCM) is popular in Taiwan and has been shown to exert therapeutic effects on knee osteoarthritis. We investigated the long-term clinical effects of TCM for reducing the need for total knee replacement risk in patients with knee osteoarthritis.We used the National Health Insurance Research Database to conduct a retrospective study of patients with knee osteoarthritis between 1997 and 2003 in Taiwan. Data from the date of diagnosis of knee osteoarthritis to total knee replacement were assessed using the Cox regression proportional hazards model, and the Kaplan-Meier survival curve was used to determine the association between total knee replacement risk and TCM use.A total of 34,231 patients with knee osteoarthritis, who were diagnosed by orthopedic or rehabilitation physicians between 1997 and 2003 were included. Patients were categorized into 2 groups: 26,257 (76.7%) were TCM users and 7974 (23.3%) were TCM non-users. The mean follow-up period was 9.26 years. Multivariate regression demonstrated that using TCM may decrease the need for total knee replacement in patients with knee osteoarthritis (adjusted hazards ratio [aHR] = 0.69, 95% confidence interval [95% CI]: 0.64-0.77) compared with TCM non-users. A relationship between longer TCM use and reduced total knee replacement use was observed, especially in patients who used TCM for ≥120 days (aHR = 0.49, 95% CI: 0.42-0.56).The results of this study suggested that TCM is associated with a reduced risk of total knee replacement in patients with knee osteoarthritis, with enhanced benefits from longer durations of TCM use.

Synthesizing the Strength of the Evidence of Complementary and Integrative Health Therapies for Pain

Objective

Pain and opioid use are highly prevalent, leading for calls to include nonpharmacological options in pain management, including complementary and integrative health (CIH) therapies. More than 2,000 randomized controlled trials (RCTs) and many systematic reviews have been conducted on CIH therapies, making it difficult to easily understand what type of CIH therapy might be effective for what type of pain. Here we synthesize the strength of the evidence for four types of CIH therapies on pain: acupuncture, therapeutic massage, mindfulness techniques, and tai chi.

Design

We conducted searches of English-language systematic reviews and RCTs in 11 electronic databases and previously published reviews for each type of CIH. To synthesize that large body of literature, we then created an “evidence map,” or a visual display, of the literature size and broad estimates of effectiveness for pain.

Results

Many systematic reviews met our inclusion criteria: acupuncture (86), massage (38), mindfulness techniques (11), and tai chi (21). The evidence for acupuncture was strongest, and largest for headache and chronic pain. Mindfulness, massage, and tai chi have statistically significant positive effects on some types of pain. However, firm conclusions cannot be drawn for many types of pain due to methodological limitations or lack of RCTs.

Conclusions

There is sufficient strength of evidence for acupuncture for various types of pain. Individual studies indicate that tai chi, mindfulness, and massage may be promising for multiple types of chronic pain. Additional sufficiently powered RCTs are warranted to indicate tai chi, mindfulness, and massage for other types of pain.

Developing and employing a 'responsive manualization' in the 'Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment' comparative effectiveness study

OBJECTIVE

The aim of this article is to describe the process used to develop an acupuncture therapy manual for a large effectiveness trial comparing individual care against group care for chronic pain in an underserved population. The design needed to not only ensure research consistency and replicability but also be 'responsive' to real world heterogeneous and evolving presentations in challenging physical settings.

BACKGROUND

Chronic pain is prevalent in the United States. While acupuncture is effective for chronic pain, minority, ethnically diverse and lower socioeconomic populations have limited access. Group acupuncture is proposed as a lower cost option to facilitate access in safety net settings, but research on the effectiveness of group versus individual acupuncture is lacking.

METHODS

We engaged a modified Delphi process with expert practitioners from diverse backgrounds who were experienced in individual and group practice. All contributions were recorded and collated for second- and third-round consensus discussions that included contributions by the trial's research acupuncturists.

RESULTS

A 'responsive manual' flow chart was created with suggested sequencing that included interviews concurrent with palpation, Tui na, Gua sha, acupuncture needling, ear treatment, basic recommendations and options for departure with rationale. The manual was implemented by six research acupuncturists in five primary care settings in the Bronx, New York, with weekly team meetings to discuss manual use. There were no serious adverse events (AE) and few minor AE reported in this trial.

CONCLUSION

A 'responsive manual' can be structured and implemented that is not only consistent and replicable but also flexible to accommodate the real-world clinical needs of practitioners and patients in challenging physical settings.

Acupuncture Therapy in a Group Setting for Chronic Pain

Objective

This project was designed to test the feasibility and effectiveness of acupuncture therapy given in a group setting for chronic pain.

Design

Nonrandomized, repeated measures quasi-experimental trial.

Setting

Care was delivered in a primary care clinic waiting area after clinic hours.

Subjects

Included were primary care patients (≥18 years old) with chronic pain of the neck, back, shoulder, or osteoarthritis of any site of at least three months' duration.

Methods

Subjects received eight weekly acupuncture therapy sessions in a group setting. Acupuncture therapy included a combination of palpation, acupuncture needling, Tui na, Gua sha, and auricular treatment. Baseline pain levels were established in a two- to four-week run-in; assessment of the intervention impact on pain intensity, mood, and functional status were made at the end of the treatment period (eight weeks) and 16 weeks after completion of intervention (24 weeks).

Results

Of the total 113 participants recruited for the trial, 96 completed the 24-week protocol. We found a statistically and clinically significant decrease in pain severity, pain interference, and depression in our study population. There were no serious adverse events.

Conclusions

Acupuncture therapy offered in the group setting was effective in reducing pain severity, pain interference, and depression in patients with chronic neck, back, or shoulder pain or osteoarthritis. Benefit persisted through the 24-week measure despite no additional treatment. This finding has potentially important implications for improving access to effective acupuncture treatment for patients with limited financial resources.

The low-frequency BOLD signal oscillation response in the insular associated to immediate analgesia of ankle acupuncture in patients with chronic low back pain

Purpose

The present study evaluated the modulation effect of a painless acupuncture technique, ankle acupuncture (AA), on resting-state functional change in patients with chronic low back pain (CLBP).

Patients and methods

Fourteen participants diagnosed with CLBP received AA and underwent one brain functional image scan after tactile stimulation and another one following the insertion of the needle. The needling sensations and clinical pain intensities were evaluated after the end of each functional image scan. The significance levels of Visual Analog Scales/Scores (VASs) before and after acupuncture were determined using paired t-test. The brain areas showing differences in the amplitude of low-frequency fluctuation (ALFF) and fractional ALFF (fALFF) between the two scans were identified. We also explored the relationship between mean ALFF values in brain areas identified and VAS scores based on Pearson correlation coefficient.

Results

A complete-case analysis was performed on 12 participants. Neither different needling sensations nor any local sensations during the two scans was found. The clinical findings indicated that the scores of VAS scores were significantly lower after AA intervention (P<0.001). Compared with those after tactile stimulation, ALFF decreased in the left insular and increased in the left precuneus and right precentral gyrus, and fALFF decreased in the left insular, during retaining of AA (corrected). Moreover, there was a positive correlation found between mean ALFF change in the left insular and that of VAS values (P<0.05).

Conclusion

The present study demonstrated the low-frequency BOLD signal oscillation response in the left insular in brain activity was associated with an immediate analgesia of AA in patients with CLBP, which provides new insights into intrinsic connections between low-frequency brain signals and analgesic effects of acupuncture.

The cerebral mechanism of acupuncture for treating knee osteoarthritis: study protocol for a randomized controlled trial

Background

Acupuncture is safe and effective for reducing the symptoms of knee osteoarthritis (KOA), but the underlying mechanisms of acupuncture for treating KOA are not fully understood.

Methods/design

In total, 108 participants diagnosed with KOA will be recruited. They will be blinded to group assignment and randomized to either verum acupuncture, sham acupuncture or waiting-list groups with 36 patients in each group. Each patient in the acupuncture group will receive five treatments per week for 2 weeks. This study will focus on detecting the cerebral functional connectivity changes elicited by acupuncture treatment. The Visual Analog Scale and the short form of the McGill Pain Questionnaire, the Western Ontario and McMaster Universities Osteoarthritis Index, the Attention Test Scale, the Pain Assessment of Sphygmomanometer and the 12-Item Short Form Health Survey will be used to evaluate the symptoms and quality of life improvement at the baseline and the end of treatment. The Self-rating Anxiety Scale and the Self-rating Depression Scale will be used at the baseline and the end of treatment to investigate the influence of emotional state on brain activity and clinical variable. To ensure the consistency of acupuncture manipulation, the deqi scale will be performed after each acupuncture treatment. During the procedure of outcome evaluation and data analysis, the evaluators and statisticians will be blinded to the group allocation. The repeated measures analysis of variance (3 groups × 2 time points ANOVA) will be employed to analyze numerical variables of the clinical and neuroimaging data generated in the study, then the t test will be used in the post-hoc analysis.

Discussion

The results of this randomized, sham- and waiting-list-controlled functional magnetic resonance imaging (fMRI) study will help to investigate the influence of verum acupuncture treatment on the brain activities of patients with KOA, which might provide evidence for the clinical application of verum acupuncture for KOA management.

Trial registration

Chinese Clinical Trial Registry, ID: ChiCT-IOR-17012364. Registered on 14 August 2017.

Prevalence and Factors Associated with the Use of Acupuncture and Chinese Medicine: Results of a Nationally Representative Survey of 17161 Australian Women

Background

Traditional Chinese Medicine has considerable public support in Australia and elsewhere around the world; the literature suggests Chinese medicine (CM) and acupuncture are particularly popular.

Aim

To examine factors associated with CM/acupuncture use among young/middle-aged Australian women.

Methods

This research formed part of the Australian Longitudinal Study on Women's Health (ALSWH), a population-based cohort study. Data were obtained from the ‘young’ (34–39 years; n=8010) and ‘middle-aged’ (62–67 years; n=9151) ALSWH cohorts, who completed survey 6 (in 2012) and survey 7 (in 2013), respectively. Outcome measures included use of CM and visits to an acupuncturist in the previous 12 months. Predictive factors included demographic characteristics, and measures of health status (diagnosed chronic medical conditions) and health service utilisation. Statistical analyses included bivariate χ2 tests, two proportions Z-tests and backward stepwise multiple logistic regression modelling.

Results

In total, 9.5% and 6.2% of women in the young and middle-aged cohorts, respectively, had consulted an acupuncturist, and 5.7% and 4.0%, respectively, had used CM. Young women with low iron levels and/or endometriosis were more likely to use CM and/or acupuncture. Middle-aged women with low iron levels and/or chronic fatigue syndrome (CFS) were more likely to use CM, while middle-aged women with arthritis and/or CFS were more likely to use acupuncture.

Conclusions

Women with chronic conditions (including arthritis, low iron, CFS and endometriosis) were associated with higher odds of CM/acupuncture use. There is a need for further research to examine the potential benefits of CM/acupuncture for these chronic illnesses.

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

METHODS

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

RESULTS

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

CONCLUSION

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

Use of acupuncture in the management of pain

Nurses practising in almost any area of healthcare may encounter individuals who are considering acupuncture, particularly those caring for people who are experiencing chronic pain. Acupuncture is a complex intervention and in traditional practice is not simply the insertion of needles, as some people believe. This article provides a historical understanding of acupuncture, outlining some of the differences between styles of practice that may be relevant when selecting an acupuncturist. It also examines the issues that should be considered when assessing the evidence base for acupuncture.

2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

Objective:

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

Methods:

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

Results:

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

Conclusion:

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

METHODS

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

RESULTS

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

CONCLUSION

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

[Nonpharmacological pain therapy for chronic pain]

The treatment of chronic pain should be a multimodal combination of pharmacological and nonpharmacological components. This article describes some of the nonpharmacological treatment options and their evidence (e.g. physical therapy, massage, manual therapy, electrotherapy, acupuncture and music therapy). The evidence for an empirically detected effectiveness of all these forms of therapy is not very high and often inconsistent. Nevertheless, this does not mean that these forms of treatment should not be used but that they should be selected on an individual basis to improve the well-being of patients by being adjusted to their needs.