Adverse events associated with acupuncture: three multicentre randomized controlled trials of 1968 cases in China

Practice recommendations for physiotherapists in Canada managing adverse events associated with acupuncture

In Canada, acupuncture is a regulated medical practice that involves inserting thin needles at specific points on the body to alleviate pain and other health conditions. Acupuncture is a controlled act in physiotherapy practice. Therefore, physiotherapists who incorporate acupuncture into their practice should have the necessary education and roster this controlled act with the regulatory college in their province. Although acupuncture can be helpful, potential complications can arise, ranging from minor bruising to life-threatening conditions such as pneumothorax and cardiac tamponade. This article provides information on the potential adverse effects of acupuncture and provides recommendations for physiotherapists regarding prevention and management of any incidents that may arise during treatment.

Heat and Acupuncture to Manage Osteoarthritis of the Knee (HARMOKnee): Protocol for an Effectiveness-Implementation Hybrid Randomized Controlled Trial

BACKGROUND

Knee osteoarthritis (KOA) is one of most prevalent and fastest-growing causes of pain, impaired mobility, and poor quality of life in the rapidly aging population worldwide. There is a lack of high-quality evidence on the efficacy of traditional Chinese medicine (TCM), particularly acupuncture, and a lack of KOA practice guidelines that are tailored to unique population demographics and tropical climates.

OBJECTIVE

Our HARMOKnee (Heat and Acupuncture to Manage Osteoarthritis of the Knee) trial aims to address these gaps by evaluating the short- and medium-term clinical and cost-effectiveness of acupuncture with heat therapy in addition to standard care, compared to standard care alone. Through a robust process and economic evaluation, we aim to inform evidence-based practice for patients with KOA to facilitate the large-scale implementation of a comprehensive and holistic model of care that harmonizes elements of Western medicine and TCM. We hypothesize that acupuncture with heat therapy as an adjunct to standard care is clinically more effective than standard care alone.

METHODS

A multicenter, pragmatic, parallel-arm, single-blinded, effectiveness-implementation hybrid randomized controlled trial will be conducted. We intend to recruit 100 patients with KOA randomized to either the control arm (standard care only) or intervention arm (acupuncture with heat therapy, in addition to standard care). The inclusion criteria are being a community ambulator and having primary KOA, excluding patients with secondary arthritis or previous knee replacements. The primary outcome measure is the Knee Osteoarthritis Outcome Score at 6 weeks. Secondary outcome measures include psychological, physical, quality of life, satisfaction, and global outcome measures at 6, 12, and 26 weeks. A mixed method approach through an embedded process evaluation will facilitate large-scale implementation. An economic evaluation will be performed to assess financial sustainability.

RESULTS

Patient enrollment has been ongoing since August 2022. The recruitment process is anticipated to conclude by July 2024, and the findings will be analyzed and publicized as they are obtained. As of November 6, 2023, our patient enrollment stands at 65 individuals.

CONCLUSIONS

The findings of our HARMOKnee study will contribute substantial evidence to the current body of literature regarding the effectiveness of acupuncture treatment for KOA. Additionally, we aim to facilitate the creation of standardized national guidelines for evidence-based practice that are specifically tailored to our unique population demographics. Furthermore, we seek to promote the adoption and integration of acupuncture and heat therapy into existing treatment models.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05507619; https://clinicaltrials.gov/study/NCT05507619.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54352.

Progress in treatment of facial neuritis by acupuncture combined with medicine from the perspective of modern medicine: A review

Facial neuritis is a common clinical disease with high incidence, also known as Bell palsy or idiopathic facial nerve paralysis, which is an acute onset of peripheral facial neuropathy. In modern medicine, there have been obstacles to the effective treatment of facial neuritis. At present, the clinical use of Western medicine treatment is also a summary of clinical experience, the reason is that the cause of facial neuritis is unknown. Facial neuritis belongs to the category of "facial paralysis" in traditional Chinese medicine. For thousands of years, Chinese medicine has accumulated a lot of relevant treatment experience in the process of diagnosis and treatment. At the same time, traditional Chinese medicine, acupuncture and the combination of acupuncture and medicine play an important role in the treatment of facial neuritis. This article discusses the treatment of facial neuritis with acupuncture combined with Chinese medicine, based on the research progress of modern medicine. In this review, we provide an overview of the effectiveness of acupuncture and medication combinations and facial neuritis with current studies investigating acupuncture and medication combinations in the treatment of facial neuritis.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Bibliometric Analysis of 100 Most Highly Cited Publications on Acupuncture for Migraine

Background

Migraine is a serious global health concern that imposed a huge economic burden on social health care. Over the past few decades, the analgesic effects of acupuncture have been widely recognized, and there is a growing body of research on acupuncture for migraine. Citation analysis is a branch of bibliometrics that helps researchers analyze and identify historical or landmark studies within the scientific literature. Currently, there is no analysis of the 100 most highly cited publications on acupuncture for migraine.

Methods

The 100 most highly cited publications on acupuncture for migraine were screened using the Science Citation Index Expanded of the Web of Science Core Collection database. CiteSpace and VOSviewer programs were used for bibliometric analysis.

Results

A total of 493 publications on acupuncture for migraine were identified. 100 of the most highly cited publications on acupuncture for migraine were published from 1984-2020. These publications were cited 6142 times with an h-index of 44 and 84% were original articles. The highest frequency of citations was 416. A total of 335 authors were involved in the study with 37 lead authors. 212 institutions from 20 countries contributed to the 100 most highly cited publications. The most published studies came from the United States (n=36), followed by China (n=27) and Germany (n=26). The Technical University of Munich published the largest number of papers (n = 15). Top-cited publications mainly came from the Headache (n=13, citations=582). Neuroimaging is gradually emerging as a hot topic of research.

Conclusion

This is the first bibliometric analysis to offer a thorough list of the 100 most highly cited papers on acupuncture for migraine, demonstrating significant progress and emerging trends in this field to assist researchers in determining the direction for further research.

Morphological and Chemical Analysis of Various Disposable Acupuncture Needles Used in South Korea

Objectives

The Korean Industrial Standard (KS) for sterile acupuncture needles was established in 2009 based on research on the quality control of acupuncture needles. We aimed to determine the quality of acupuncture needles available in South Korea in 2021 by examining their surface condition and chemical composition using field-emission scanning electron microscopy (FE-SEM) and energy-dispersive X-ray spectroscopy (EDS).

Methods

In South Korea, there are 23 brands of acupuncture needles, and we examined 10-15 needles from each brand, resulting in a total of 285 needles. The microstructures of the needles were assessed by SEM. Using SEM images, we evaluated the acupuncture needle tips for the following defects/aspects scratches, lumps, detached coating, bent tip, and tip sharpness. EDS was used to determine the chemical composition of the selected acupuncture needles.

Results

Overall, 88.4% of 285 needles were found to have at least one type of abnormality. The most frequently observed abnormalities were scratches and dents on the surface (68.1%), followed by detached coating (63.2%), and lumps (61.8%); blunt tips were observed in about 24% of them. Of 252 needles with at least one defect, 86.9% had two or more types of defects. The ratio of the number of needles with any defect to that of needles without any defect varied among brands, ranging from 50% to 100%. Regarding foreign materials, higher proportions of Si and O were observed on the needles, indicating incomplete or detached silicone coating.

Conclusion

The quality of acupuncture needles varied among brands, suggesting that further improvements can be made through various inspection methods.

Case series: acupuncture-related pneumothorax

Background

Acupuncture has become a more popular complementary and alternative medicine worldwide. As pneumothorax is a rare acupuncture-related adverse event (AE), it is thought to be under-recognized by acupuncturists and emergency physicians, and the public is often not aware of this potential AE resulting in delayed hospital presentation.

Methods

This is a case series of acupuncture-related pneumothoraces diagnosed in an emergency department (ED) in Singapore. Data was collected retrospectively from patients’ notes and prospectively from the patients over the phone.

Case presentations

Between 2017 and 2021, 4 out of 474 (0.84%) pneumothoraces were acupuncture related. Three of these patients consented to participate in this study. One patient developed bilateral pneumothoraces. All 3 patients claimed that they were not informed by the acupuncturists of potential serious AEs prior to acupuncture treatments and that they were not aware that such AE could occur. All 3 patients had reported their symptoms of chest pain and/or breathlessness to their acupuncturists post-treatment, but they were not advised to seek urgent medical attention. When the 3 patients had informed their acupuncturists about their diagnosis of pneumothorax, 2 of the acupuncturists did not seem to be aware of this acupuncture-related AE.

Discussion

When pneumothorax manifests, there is a potential need for an invasive procedure and continuous monitoring as it may devolve into a life-threatening condition with cardiovascular compromise. Early medical recognition and attention are needed to ensure optimal patient outcomes. In the appropriate population cohort, a history of prior acupuncture treatments should be included as part of history-taking assessment in patients presenting with chest pain and/or breathlessness.

Conclusion

Emergency physicians should be vigilant of this potentially serious and life-threatening complication for anyone presenting with chest discomfort and/or breathlessness after recently undergoing acupuncture to ensure earlier diagnosis, management, and better patient outcome.

Effects of Electroacupuncture with Different Waveforms on Chronic Prostatitis/Chronic Pelvic Pain Syndromes: A Randomized Controlled Trial

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common disorder in adult men. Evidence has demonstrated that acupuncture is effective for treating CP/CPPS. Electroacupuncture (EA) is a combination of traditional acupuncture and electrical stimulation, and the waveform is one of the key factors influencing EA effects. Different waveforms contain different stimulating parameters, thus generating different effects. However, the effects of different waveforms of EA on CP/CPPS remain unclear and there is no recommended standard for the application of EA waveforms. At the same time, the waveform prescription of CP/CPPS is also different, so exploring the influence of different waveforms on CP/CPPS patients will also provide a certain treatment basis for clinical treatment. A total of 108 eligible patients were recruited from the Seventh People's Hospital affiliated to the Shanghai University of Traditional Chinese Medicine from March 18, 2021, to January 31, 2022, according to inclusion and exclusion criteria. All subjects were randomly divided into three groups (continuous wave 4 Hz, continuous wave 20 Hz, and extended wave 4/20 Hz) in a ratio of 1 : 1 : 1. Patients in all three groups were treated for the same duration of 20 minutes, with intervention twice a week for 4 weeks. The changes in chronic prostatitis index (NIH-CPSI), erectile function index 5 (IIEF-5), Hospital Anxiety and Depression Scale (HADS), and NIH-CPSI response rate in three groups were compared after the intervention, and the occurrence of adverse events in patients during treatment was observed. After 4 weeks of treatment, the CP/CPPS response rates were 66.7%, 62.5%, and 88.2% in the 4 Hz, 20 Hz, and 4/20 Hz groups, respectively. The reaction rate of CP / CPPS in 4 / 20 Hz group was higher than that in 4 Hz group and 20 Hz group. (P < 0.05). During treatment, the difference between NIH-CPSI scores between 4 Hz and 4/20 Hz was insignificant (P > 0.05). NIH-CPSI scores were lower in the 4/20 Hz group than in the 4 Hz and 20 Hz groups (P < 0.05). After treatment, there was no significant difference in the pain and discomfort subscales (P > 0.05) between the 4 Hz and 20 Hz groups and there were significantly lower pain and discomfort scores in the 4/20 Hz group (P < 0.05) compared to the 4 Hz and 20 Hz groups. There was no significant difference in the reduction of urination symptoms and quality of life among the three groups (P > 0.05). Compared with before treatment, IIEF-5 scores of the three groups were improved (P < 0.05). After treatment, there was no significant difference between the IIEF-5 scores in 4 Hz and 20 Hz (P > 0.05), while the IIEF-5 score in 4/20 Hz was significantly higher than that in 4 Hz and 20 Hz, and the change was significant (P < 0.05). The HADS scores decreased in all the three groups (P < 0.05), but there was no significant difference in HADS scores between the three groups (P > 0.05). Adverse events were mild and transient, and no serious adverse events occurred in each group. Both the expansive and continuous waveforms of EA can effectively alleviate symptoms such as prostatitis, erectile dysfunction, anxiety, and depression in patients with CP/CPPS. Expansion waves are superior to continuous waves in improving erectile function and pain symptoms in chronic prostatitis and can be used as a preferred waveform for the treatment of CP/CPPS. Trial Registration. This trial is registered with Chinese Clinical Trial Registry, ChiCTR2100044418.

Cerebral Blood Flow Velocity Modulation and Clinical Efficacy of Acupuncture for Posterior Circulation Infarction Vertigo: A Systematic Review and Meta-Analysis

Background

Vertigo is a cardinal symptom of posterior circulation infarction (POCI). Acupuncture is demonstrated to have a beneficial effect on posterior circulation infarction vertigo (PCIV). However, the mechanism of acupuncture therapy is not clarified. This study aims to assess the cerebral blood flow velocity modulation and clinical efficacy of acupuncture for PCIV patients.

Methods

We conducted this systematic review for clinical randomized controlled trials (RCTs) regarding acupuncture on PCIV. The study duration was from September 2020 to September 2021. We searched the PubMed, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Database, and VIP. The publication date was set from inception to August 31, 2020. Based on the inclusion and exclusion criteria, two researchers independently screened literature and extracted data including basic study information, intervention details, outcome details, and adverse events. Outcome measures included the blood flow velocities of vertebrobasilar arteries and the Clinical Effective Rate of posterior circulation infarction vertigo. Pooled data were presented as standardized mean differences (SMDs) and relative risks (RR), with 95% confidence intervals (CIs). The meta-analysis was conducted using Review Manager software version 5.3.0.

Results

A total of 20 eligible RCTs (1541 participants) were included in this review, which compared acupuncture therapy (1 RCT) or acupuncture combined with pharmaceutical therapy (19 RCTs) to pharmaceutical therapy in patients with posterior circulation infarction vertigo. 7 studies assessed the blood flow velocities of the basilar artery examined by Transcranial Doppler (TCD), 8 studies assessed the bilateral vertebral arteries, and 13 studies evaluated the Clinical Effective Rate of posterior circulation infarction vertigo. Meta-analysis results showed that blood flow velocities of the basilar artery (SMD = 0.58, 95% CI = 0.40–0.76; P < 0.05), left vertebral artery (SMD = 0.48, 95% CI = 0.22–0.73; P < 0.05), and right vertebral artery (SMD = 0.44, 95% CI = 0.19–0.69; P < 0.05) were significantly higher in the acupuncture group compared with the control group. Clinical Effective Rate (RR = 1.22, 95% CI = 1.15–1.29; P  =  0.792) was significantly better in the acupuncture group compared with the control group.

Conclusions

This study shows that acupuncture therapy is useful in improving the blood flow velocity of vertebrobasilar arteries and Clinical Effective Rate in patients with posterior circulation infarction vertigo. However, double-blind, sham-controlled trials with large sample sizes are required to support our conclusions.

Acupuncture and Moxibustion in the Treatment of Adult Diarrhea Irritable Bowel Syndrome: A Network Meta-analysis

Objective

This study was aimed at comparing the clinical efficacy of acupuncture and moxibustion on irritable bowel syndrome complicated with diarrhea (IBS-D) in adults and providing guidance for clinical treatment.

Methods

PubMed, The Cochrane Library, Embase, CBM, CNKI, and VIP and Wanfang databases were searched to obtain clinical randomized controlled trials (RCTs) on acupuncture and moxibustion in the treatment of IBS-D published from establishment of the database to August 5, 2021. Relevant data were extracted to assess the risk of bias in the included studies, and statistical software Stata 16.0 was used for meta-analysis.

Results

Twenty-one studies were eventually included in the network meta-analysis (NMA), including 1626 patients with IBS-D and 8 therapeutic measures. NMA showed that acupuncture [OR = 0.35, 95%CI (0.25, 0.49), P < 0.05], warming needle moxibustion [OR = 6.34, 95%CI (2.83, 14.21), P < 0.05], acupuncture+sandwiched moxibustion [OR = 12.83, 95%CI (4.49, 36.64), P < 0.05], acupuncture+heat-sensitive moxibustion [OR = 9.86, 95%CI (1.77, 55.00), P < 0.05] were more effective than pinaverium bromide in the treatment of IBS-D. Cumulative ranking probability (SUCRA) showed that the comprehensive efficacy of acupuncture and moxibustion (86.8%) and quality of life (QOL) (70.4%) was the best, while the comprehensive efficacy of pinaverium bromide (2.1%) and QOL (16.3%) was the worst. GV20, GV29, ST 25, ST37, ST36, SP6, LR3, and CV12 were used frequently.

Conclusion

Acupuncture+sandwiched moxibustion has the best effect on improving the efficacy and QOL of IBS-D patients. Limited by the number and quality of studies, we still need a large sample, multicenter, and high-quality clinical trials to confirm our findings.

Efficacy and Safety of Acupuncture Combined with Herbal Medicine in Treating Gouty Arthritis: Meta-Analysis of Randomized Controlled Trials

Background

Gouty arthritis is a common metabolic disease caused by long-term purine metabolism and elevated serum uric acid. In recent years, the incidence of gouty arthritis has been increasing year by year. As an effective method for treating gouty arthritis, acupuncture combined with herbal medicine has been widely used in clinical practice. However, the evidence for the treatment needs to be evaluated through systematic review and meta-analysis. Methods. The Cochrane Library, PubMed, Web of Science, EMBASE, China CBM database, Clinical Trials, CNKI, China Wanfang database, and VIP information database were searched from the establishment of each database to March 2021. Randomized controlled trials (RCTs) were included in the study, and the therapeutic effects of acupuncture combined with herbal medicine versus conventional therapy, or acupuncture combined with herbal medicine versus anti-inflammatory drugs, or acupuncture combined with herbal medicine versus acupuncture/herbal medicine alone were compared in the subjects with gouty arthritis. Two authors screened all references, assessed the risk of bias, and independently extracted the data. The binary outcome was summarized using 95% confidence intervals (CIs) and risk ratios (RRs). The overall quality of the evidence was assessed with hierarchy, and meta-analysis was performed with a random-effects model.

Results

A total of 14 randomized controlled trials (1,065 participants, 540 treatment groups, and 525 control groups) with treatment courses of 5 to 21 days were included. Acupuncture combined with herbal medicine and acupuncture was compared in three trials, acupuncture combined with herbal medicine and conventional therapy was compared in 14 of them, and acupuncture combined with herbal medicine and anti-inflammatory drugs was compared in 8 of them. The clinical efficacy (clinical symptoms, serological tests, and visual analogue scale (VAS) results) was significantly improved in the acupuncture combined with herbal medicine treatment group (P=0.0005, 95% CI 0.03 to 0.13; 687 participants; 8 trials), and the efficacy in reducing uric acid was also better (P < 0.00001; 95% CI −102.89, −68.37; 100 participants; 2 trials; evidence with moderate quality). The effect of acupuncture combined with herbal medicine was better than that of acupuncture alone (RR 1.22, 95%CI 1.06 to 1.41; 139 participants; 3 trials), the effect of acupuncture combined with herbal medicine was better than that of herbal medicine alone (RR 1.31 95%CI 1.08 to 1.57, 100 participants, 2 trials, evidence with moderate quality), and the effect of acupuncture combined with herbal medicine was better than that of colchicine (P = 0.02, RR 1.14 95%CI 1.02 to 1.27, 2 trials, evidence with moderate quality). The incidence of adverse events was considerably different between the two groups, and the acupuncture combined with herbal medicine group was significantly superior to the control group in terms of adverse events (P < 0.00001; 95% CI (0.08 to 0.32)).

Conclusions

The efficacy of acupuncture combined with herbal medicine was better than conventional drug therapy in treating gouty arthritis. The study results must be interpreted with caution due to the high or unclear risk of bias of the trials included in the study. PROSPERO registration number: CRD42020202544. INPLASY registration number: 202090006.

Acupuncture-related adverse events: systematic review and meta-analyses of prospective clinical studies

OBJECTIVE

Overview on risks of acupuncture-related adverse events (AEs).

DESIGN

Systematic review and meta-analyses of prospective studies.

DATA SOURCES

PubMed, Scopus and Embase from inception date to 15 September 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Prospective studies assessing AEs caused by needle acupuncture in humans as primary outcome published in English or German.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers selected articles, extracted the data and assessed study quality. Overall risks and risks for different AE categories were obtained from random effects meta-analyses.

MAIN OUTCOMES

Overall risk of minor AEs and serious adverse events (SAEs) per patients and per treatments.

RESULTS

A total of 7679 publications were identified. Twenty-two articles reporting on 21 studies were included. Meta-analyses suggest at least one AE occurring in 9.31% (95% CI 5.10% to 14.62%, 11 studies) of patients undergoing an acupuncture series and in 7.57% (95% CI 1.43% to 17.95%, 5 studies) of treatments. Summary risk estimates for SAEs were 1.01 (95% CI 0.23 to 2.33, 11 studies) per 10 000 patients and 7.98 (95% CI 1.39 to 20.00, 14 studies) per one million treatments, for AEs requiring treatment 1.14 (95% CI 0.00 to 7.37, 8 studies) per 1000 patients. Heterogeneity was substantial (I2 >80%). On average, 9.4 AEs occurred in 100 treatments. Half of the AEs were bleeding, pain or flare at the needle site that are argued to represent intended acupuncture reaction. AE definitions and assessments varied largely.

CONCLUSION

Acupuncture can be considered among the safer treatments in medicine. SAEs are rare, and the most common minor AEs are very mild. AEs requiring medical management are uncommon but necessitate medical competence to assure patient safety. Clinical and methodological heterogeneity call for standardised AE assessments tools, clear criteria for differentiating acupuncture-related AEs from therapeutically desired reactions, and identification of patient-related risk factors for AEs.

PROSPERO REGISTRATION NUMBER

CRD42020151930.

Feasibility and Effect of Electroacupuncture on Cognitive Function Domains in Patients with Mild Cognitive Impairment: A Pilot Exploratory Randomized Controlled Trial

Although Electroacupuncture (EA) has been reported to be potentially effective for cognitive disorders, there is limited information about which domains of cognitive function can be improved by EA treatment. Sixty patients with MCI were randomly assigned (1:1:1) to groups to receive 24 sessions over 12 weeks of EA, sham EA, or usual care. In the EA group, electric stimulation was applied at bilateral PC6 and HT7. Various cognitive tests included in the Seoul Neuropsychological Screening Battery II (SNSB-II) were performed at baseline and post-treatment to explore effects of EA on five cognitive domains: attention, language, visuospatial function, memory, and frontal/executive function. Among 60 randomized participants (63.7 ± 7.1 years, 89.7% females), 45 (75%) completed the study. Of the five cognitive function domains of SNSB-II, the T score of visuospatial function showed a tendency to be higher in the EA group than in the usual care group at post-treatment assessment (mean difference: 10.16 (95% CI, 1.14, 19.18), Cohen’s d = 0.72, p = 0.0283). According to the results of this pilot study, the estimated effect size of EA on the visuospatial function of MCI patients compared to usual care was medium. Large-scale clinical trials are needed to confirm effects of EA on cognitive functions.

Risks and Safety of Extended Auricular Therapy: A Review of Reviews and Case Reports of Adverse Events

OBJECTIVE

Auricular acupuncture (AA) and extended auricular therapy (AT) are a part of acupuncture practice shown to benefit patients with pain, anxiety, and other conditions, with cost-effective access enhanced when given in a group setting. Yet there are safety concerns and risks, perhaps unnecessary risks, that attend embedded, indwelling needles applied to the ear as a means of extended AT.

METHODS

Electronic searches were conducted in PubMed, MEDLINE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) for "auriculotherapy," "auricular acupuncture" or "auricular acupressure," "safety," "adverse events," "chondritis," and "perichondritis," with additional manual review of titles, links, and reference lists. Individual auricular therapy adverse event (AE) case reports were included, as well as systematic reviews and or meta-analyses if they evaluated AEs associated with AT.

RESULTS

Nineteen auricular AE case reports and nine safety reviews of or including auriculotherapy were included. Ten systematic reviews of AT with eight specific reviews of auricular acupressure (AP) were also included.

CONCLUSIONS

The primary AE risks is infection, perichondritis, and chondritis stemming from embedded or indwelling needles or potential inadvertent needlesticks from contaminated roaming sharps. Extended AP i.e., application of spheres, preferably seeds (natural, nontoxic botanical Vaccaria seeds) provides clinical benefit without the risks associated with embedded needles. More research is needed to establish if embedded needles at the ear are even necessary or have any advantage over in-session auricular acupuncture for immediate pain relief followed by ear acupressure.

Complementary and Alternative Medicine in Radiotherapy: A Comprehensive Review

Complementary and alternative medicine (CAM) approaches are widely used by patients throughout a broad range of medical fields and diseases, and often self-administered by patients without the involvement of physicians or other members of the health care team. CAM use is well documented in cancer and chronic illnesses, and emerging data in radiation oncology show CAM usage of 26% to 97% in radiation therapy patients. No information is, however, available on CAM usage in radiology and in the imaging procedure fields. This article reviews the fundamental principles and the experience with the wide spectrum of CAM in radiation oncology-a field that shares many parallels with radiology, such as prevalence of imaging, procedural requirements, and cooperation demanded from patients.CAM is defined as "approaches and practices that are typically not part of conventional medical care," and includes the use of mind- and body-based practices (eg, meditation, massage, acupuncture), natural products (eg, herbs, vitamins, minerals), and other interventions. Supplements are used frequently to alleviate side effects of therapy and promote overall well-being. Specifically, the mindfulness/meditation approaches of CAM are known to reduce anxiety and enhance physical and emotional wellbeing in patients with chronic diseases, such as cancer or neurologic diseases, through physiological, psychological, and perhaps placebo mechanisms. Such patients often require repetitive and invasive imaging examinations or procedures, such as for cancer treatment, cancer surveillance/follow-up, or monitoring of chronic diseases, for example, surveillance MRI in multiple sclerosis. Such parallels suggest that the vastly understudied area of CAMs deserve further investigation in both the radiation oncology and the imaging fields. Further research on CAM is needed to develop refined recommendations and national/and international guidelines on its use.

Efficacy Comparison of Different Acupuncture Treatments for Functional Dyspepsia: A Systematic Review with Network Meta-Analysis

Background

Acupuncture has been found to be an effective treatment for functional dyspepsia (FD). Currently, several types of acupuncture have been developed but it is not clear which type is suitable for FD. Currently, doctors often rely on experience to decide which form of acupuncture to apply. Herein, we employed network meta-analysis (NMA) to compare the effectiveness of various methods of acupuncture in the treatment of functional dyspepsia.

Methods

We searched for randomized controlled trials (RCTs) of acupuncture treatments for functional dyspepsia in seven databases; PubMed, the Cochrane Library, Embase, Wanfang database, China National Knowledge Infrastructure (CNKI) database, Chinese Science and Technique Journals (CQVIP), and Chinese Biomedical Database (CBM) from the date of database inception to October 10, 2019. Cochrane risk of bias tool was used to analyze the risk of bias of the included RCTs. Pairwise meta-analyses were performed with RevMan 5.3 and the network meta-analysis of the included RCTs was performed using the frequentist framework.

Results

A total of 35 studies involving 3301 patients and 10 interventions were eligible for this study. NMA results showed that five types of acupuncture (manual acupuncture, acupoint application, moxibustion, acupoint catgut embedding, and warm acupuncture alone) all were superior to prokinetics (itopride, mosapride, and domperidone) and sham acupuncture in terms of improving the symptoms of functional dyspepsia. Specifically, manual acupuncture and electroacupuncture were more effective in improving the MOS 36 Item Short-Form Health Survey (SF-36) compared to itopride and sham acupuncture, and electroacupuncture was the best among the three acupuncture therapies (acupuncture, electroacupuncture, and acupoint catgut embedding). Moxibustion and manual acupuncture were more effective in improving Nepean Dyspepsia Life Quality Index (NDLQI) compared to itopride, domperidone, and sham acupuncture; moxibustion ranks first among the three acupuncture therapies (acupuncture, electroacupuncture, moxibustion).

Conclusions

These results showed that manual acupuncture alone was the most effective therapy for FD. It should, therefore, be considered as an alternative treatment for FD patients who are unresponsive to prokinetics or intolerant to the adverse effects of prokinetics. We recommend further multiple centers and high-quality RCT studies to confirm the present findings.

Effectiveness and Safety of Acupuncture for Migraine: An Overview of Systematic Reviews

Background

Migraine is a common neurological disease, which burdens individuals and society all over the world. Acupuncture, an important method in Traditional Chinese Medicine, is widely used in clinical practice as a treatment for migraine. Several systematic reviews (SRs) have investigated the effectiveness and safety of acupuncture for migraine.

Objective

To summarize and critically assess the quality of relevant SRs and present an objective and comprehensive evidence on the effectiveness and safety of acupuncture for migraine. Data Sources. MEDLINE, Embase, Cochrane Library, PROSPERO database, Chinese National Knowledge Infrastructure (CNKI), Chinese Biological Medicine (CBM), China Science and Technology Journal (SCTJ), and WanFang database (WF) were searched from inception to December 2019 and grey literatures were manually searched. Selection Criteria. SRs which meet the criteria were independently selected by 2 reviewers according to a predetermined protocol. Data Extraction. Characteristics of included SRs were independently extracted by 2 reviewers following a predefined data extraction form. Review Appraisal. The methodological quality, risk of bias, and reporting quality of included SRs were assessed, respectively, by a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2, the Risk of Bias in Systematic reviews (ROBIS) tool, and the Preferred Reporting Item for Systematic Review and Meta-analysis-Acupuncture (PRISMA-A) statement. The quality of outcomes was evaluated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

Results

A total of 15 SRs were included. All the SRs were published between 2011–2019. Based on AMSTAR 2, 14 out of 15 SRs were rated critically low quality and 1 was rated low quality. According to ROBIS tool, 9 SRs (60%) were low risk of bias. With the PRISMA-A checklist, we found 11 out of 15 SRs were found adequately reported over 70%. With the GRADE tool, we found high quality of evidence indicated that the effective rate of acupuncture was superior to western medicine in treatment of migraine. Besides, acupuncture reduced more headache days and the times of using painkiller and was more effective in reducing the frequency and degree of headache than western medicine and sham acupuncture. Limitations. There might be some missing information. The accuracy of the conclusions may be decreased reduced since we were unable to synthesis all the evidence.

Conclusions

Based on high quality of evidence, we concluded that acupuncture may be an effective and safe therapy for migraine. However, the quality of SRs in acupuncture for migraine still needs more improvement.

Efficacy of electroacupuncture on acute abdomen emergency care: study protocol for a randomized controlled trial

BACKGROUND

Acute abdomen is a common disease in the emergency department (ED) and usually results in huge medical expenditure. To relieve abdominal pain effectively and reduce bed occupancy rate in emergency rooms, electroacupuncture is a practical method in the treatment of abdominal pain.

METHODS/DESIGN

Five hundred patients will be randomly and evenly divided into experimental and control groups. Both groups should have their basic information taken and their bilateral acupuncture points ( Hegu (LI 4), Neiguan (PC6), Zusanli (ST 36), Shangjuxu (ST37), Xiajuxu (ST39), Taichong (LR3), and Taibai (SP3)) will be intervened by electroacupuncture or vaccaria Seeds, in this clinical study. Electroacupuncture has been introduced to this experiment as an auxiliary technique. The experimental group will receive real electroacupuncture, but the control group will receive a placebo electroacupuncture in which transcutaneous electrical nerve stimulation will not be turned on. After the intervention, we will evaluate the difference in abdominal pain, the length of stay at the emergent observation ward, and the proportion of revisits with abdominal pain.

DISCUSSION

In Taiwan, medical expenditure is increasing annually because of the higher bed occupancy caused by acute abdominal pain in the hospital. We expect that the combined treatment of electroacupuncture and modern medical treatment will not only reduce bed occupancy and the length of ED stay but also effectively decrease the rate of readmission and revisits by 72 h. By means of electroacupuncture, the spiraling cost of health care can eventually be reduced.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03199495. Registered on 27 June 2017.

Cochrane reviews on acupuncture therapy for pain: A snapshot of the current evidence

Cochrane is an international non-profit organization established in 1993 to produce and disseminate high quality and unbiased systematic reviews of evidence on health care interventions. At the forefront of systematic review methodology, Cochrane is generally accepted to be among the most carefully prepared and rigorous sources of systematic review evidence. There are numerous Cochrane reviews on nonpharmacologic interventions for pain and multiple Cochrane reviews evaluating acupuncture therapy in pain conditions. But how complete and up to date are those reviews relative to other rigorous systematic reviews with meta-analyses of acupuncture therapy for pain published in the literature? In this 'snapshot' overview, we found 22 relevant Cochrane reviews, some concluding that acupuncture therapy is probably useful for treating specific pain conditions. However, many of the conditions for which acupuncture is most commonly used are either not represented in Cochrane reviews or the existing Cochrane reviews are seriously outdated and do not reflect current evidence. This creates confusion with the risks of adverse effects and addiction liability associated with pain medications, the prevalence of chronic pain, the ongoing opioid epidemic and the need for evidence-based options for pain as part of comprehensive pain care. Clinicians and patients want clarification on safe and effective options to treat pain. Issues involving reviewed trials' inadequate use of sham comparators, of acupuncture as a complex intervention with interactive components and a shift in research focus from efficacy trials to real-world pragmatic trials are discussed in relation to updating Cochrane reviews of acupuncture therapy for pain.

Comparing physicians' and patients' reporting on adverse reactions in randomized trials on acupuncture-a secondary data analysis

BACKGROUND

We aimed to compare patients' and physicians' safety reporting using data from large acupuncture trials (44,818 patients) and to determine associations between patient characteristics and reporting of adverse reactions.

METHODS

Six pragmatic randomized trials with an additional non-randomized study arm that included those patients who refused randomization were evaluated. Patients received acupuncture treatment for osteoarthritis of the hip or knee, chronic neck pain, chronic low back pain, chronic headache, dysmenorrhea, or allergic rhinitis or asthma. Safety outcomes were evaluated by questionnaires from both the physicians and the patients. To determine level of agreement between physicians and patients on the prevalence of adverse reactions, Cohen's kappa was used. With multilevel models associations between patient characteristics and reporting of adverse reactions were assessed.

RESULTS

Patients reported on average three times more adverse reactions than the study physicians: for bleeding/haematoma, 6.7% of patients (n = 2458) vs. 0.6% of physicians (n = 255) and for pain, 1.7% of patients (n = 636) vs. 0.5% of physicians (n = 207). We found only minor agreements between patients and physicians (maximum Cohen's kappa: 0.50, 95% confidence interval [0.49;0.51] for depressive mood). Being a female and participation in the randomization were associated with higher odds of reporting an adverse reaction.

CONCLUSIONS

In our study, patients' and physicians' reports on adverse reactions of acupuncture differed substantially, possibly due to differences in patients' and physicians' questionnaires and definitions. For the assessment of safety, we strongly support the inclusion of patients' and physicians' reports while ensuring standardization of data collection and definitions.

Acupuncture for chronic neck pain with sensitive points: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Chronic neck pain is a challenging condition to treat in clinical practice and has a considerable impact on quality of life and disability. According to the theory of traditional Chinese medicine, acupoints and tender points may become sensitised when the body is in a diseased state. Stimulation of such sensitive points may lead to disease improvement and improved clinical efficacy. This study aims to evaluate the efficacy and safety of needling at sensitive acupoints in providing pain relief, improvement of cervical vertebral function and quality of life in patients with chronic neck pain.

METHODS AND ANALYSIS

This multicentre, randomised controlled, explanatory and parallel clinical trial will include 716 patients with chronic neck pain. Study participants will be randomly assigned in a 1:1:1:1 ratio to four treatment groups: the highly sensitive acupoints group, low/non-sensitive acupoints group, sham acupuncture group and waiting-list control group. The primary outcome will be the change in the visual analogue scale score for neck pain from baseline to 4 weeks. Secondary outcomes will be the Northwick Park Neck Pain Questionnaire and McGill pain questionnaire, 12-item Short-Form health survey, Neck Disability Index, changes in the pressure pain threshold, range of cervical motion, Self-Rating Anxiety Scale, Self-Rating Depression Scale and adverse events before treatment, post-treatment, and at 4, 8, 12, 16 and 20 weeks post-treatment. The intention-to-treat approach will be used in the statistical analysis. Group comparisons will be undertaken using χ2 tests for categorical characteristics, and analysis of variance for continuous variables to analyse whether acupuncture in the highly sensitive acupoints group achieves better treatment outcomes than in each of the other three groups.

ETHICS AND DISSEMINATION

Ethical approval of this study has been granted by the local Institutional Review Board (ID: 2017 KL-038). The outcomes of the trial will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ChiCTR1800016371; Pre-results.

Review article: treatment options for functional dyspepsia

BACKGROUND

Functional dyspepsia, consisting of epigastric pain syndrome and postprandial distress syndrome, is a prevalent functional gastrointestinal disorder. To date, only limited treatment options are available and conflicting results in terms of efficacy have been reported. Consequently, nonpharmacological treatment options are increasingly being explored for functional dyspepsia.

AIM

To provide an overview of current pharmacological and nonpharmacological treatment options for functional dyspepsia.

METHODS

A literature search was conducted on Pubmed and other sources to identify relevant studies.

RESULTS

Acid suppressive therapy reduced symptoms in 30%-70% of the patients, with higher benefit in epigastric pain syndrome and superior effectiveness for proton pump inhibitors compared to H₂ -antagonists. Prokinetic agents, primarily used to treat postprandial distress syndrome, showed variable efficiency: 59%-81% responder rate for dopamine receptor antagonists, 32%-91% for serotonin-4-receptor agonists and 31%-80% for muscarinic receptor antagonists. H Pylori eradication, recommended in infected patients, was effective in 24%-82%. Refractory symptoms are addressed with neuromodulators. However, their efficacy in functional dyspepsia remains incompletely elucidated, available data showing symptom reduction in 27%-71% of the patients. Regarding herbal agents, peppermint oil reduced symptoms in 66%-91%, rikkunshito in 29%-34% and iberogast in 20%-95%. Lastly, acupuncture, cognitive behavioural therapy and hypnotherapy may help to provide symptom control, but research on their efficacy remains sparse.

CONCLUSIONS

None of the available therapies is effective in the majority of patients without being associated with major side effects. Developing new treatment options is challenging due to the heterogeneity of functional dyspepsia, the lack of readily identified target mechanisms and the poor association between pathophysiological disturbances and symptoms.

The Effects of Acupuncture on Glutamatergic Neurotransmission in Depression, Anxiety, Schizophrenia, and Alzheimer's Disease: A Review of the Literature

Neuropsychiatric disorders, including depression, anxiety, schizophrenia, and Alzheimer's disease (AD), are diseases that are directly or indirectly associated with cerebral dysfunction and contribute significantly to disability in adult populations worldwide. Important limitations surround the currently available pharmacologic agents for neuropsychiatric disorders and, moreover, many patients fail to respond to these therapies. Acupuncture might be a complementary therapy for neuropsychiatry disorders. In this review, we investigate the current evidence for the treatment efficacy of acupuncture in depression, anxiety, schizophrenia, and AD. Secondly, we review recent advances in understanding of the dysregulated glutamate system underlying the pathophysiology of these disorders. Finally, we discuss the ways in which acupuncture treatment can potentially modulate glutamate receptors and excitatory amino acid transporters. We conclude that the treatment effects of acupuncture may be underpinned by its intervention in the dysregulated glutamate system. Further preclinical and clinical studies are needed to clarify the possible mechanisms of acupuncture in these neuropsychiatric disorders and to establish protocols for treatment guidelines.

Comparison of efficacy and safety between electroacupuncture at 'four sacral points' and conventional electroacupuncture for the treatment of urinary incontinence after stroke: study protocol for a randomised controlled trial

INTRODUCTION

Electroacupuncture at 'four sacral points', also known as electrical pudendal nerve stimulation therapy, combines the advantages of pudendal nerve neuromodulation and the technique of deep insertion of long acupuncture needles. It has been used to treat stress urinary incontinence, female urgency-frequency syndrome, idiopathic urgency urinary incontinence and neurological bladders in previous studies. Here, we describe the protocol for a randomised controlled trial for evaluation of the efficacy and safety of electroacupuncture at 'four sacral points' for the management of urinary incontinence after stroke.

METHODS AND ANALYSIS

This is an open-label randomised controlled trial with blinded assessments and analyses. A total of 140 eligible patients will be randomly allocated to two groups. The treatment group (n=70) will receive electroacupuncture at 'four sacral points' along with routine medical care, while the control group will receive conventional electroacupuncture along with routine medical care. Twenty treatment sessions will occur over a period of 4 weeks. The primary outcome measures will be the self-recorded findings in an incontinent episode diary at baseline and at 4 weeks after baseline. The secondary outcome measures will be the International Consultation on Incontinence Questionnaire Urinary Incontinence-Short Form (ICIQ-UI SF) score and the Barthel Activities of Daily Living Index (Barthel ADL Index) score at baseline and at 4 and 28 weeks after baseline.

ETHICS AND DISSEMINATION

This protocol has been approved by the Ethics Committee of the First Affiliated Hospital of Zhejiang Chinese Medical University (approval No. 2018-K-059-01). Written informed consent will be obtained from each participant. The results of the study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-17012847; Pre-result.

Acupuncture for neuropathic pain in adults

BACKGROUND

Neuropathic pain may be caused by nerve damage, and is often followed by changes to the central nervous system. Uncertainty remains regarding the effectiveness and safety of acupuncture treatments for neuropathic pain, despite a number of clinical trials being undertaken.

OBJECTIVES

To assess the analgesic efficacy and adverse events of acupuncture treatments for chronic neuropathic pain in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four Chinese databases, ClinicalTrials.gov and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 14 February 2017. We also cross checked the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with treatment duration of eight weeks or longer comparing acupuncture (either given alone or in combination with other therapies) with sham acupuncture, other active therapies, or treatment as usual, for neuropathic pain in adults. We searched for studies of acupuncture based on needle insertion and stimulation of somatic tissues for therapeutic purposes, and we excluded other methods of stimulating acupuncture points without needle insertion. We searched for studies of manual acupuncture, electroacupuncture or other acupuncture techniques used in clinical practice (such as warm needling, fire needling, etc).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were pain intensity and pain relief. The secondary outcomes were any pain-related outcome indicating some improvement, withdrawals, participants experiencing any adverse event, serious adverse events and quality of life. For dichotomous outcomes, we calculated risk ratio (RR) with 95% confidence intervals (CI), and for continuous outcomes we calculated the mean difference (MD) with 95% CI. We also calculated number needed to treat for an additional beneficial outcome (NNTB) where possible. We combined all data using a random-effects model and assessed the quality of evidence using GRADE to generate 'Summary of findings' tables.

MAIN RESULTS

We included six studies involving 462 participants with chronic peripheral neuropathic pain (442 completers (251 male), mean ages 52 to 63 years). The included studies recruited 403 participants from China and 59 from the UK. Most studies included a small sample size (fewer than 50 participants per treatment arm) and all studies were at high risk of bias for blinding of participants and personnel. Most studies had unclear risk of bias for sequence generation (four out of six studies), allocation concealment (five out of six) and selective reporting (all included studies). All studies investigated manual acupuncture, and we did not identify any study comparing acupuncture with treatment as usual, nor any study investigating other acupuncture techniques (such as electroacupuncture, warm needling, fire needling).One study compared acupuncture with sham acupuncture. We are uncertain if there is any difference between the two interventions on reducing pain intensity (n = 45; MD -0.4, 95% CI -1.83 to 1.03, very low-quality evidence), and neither group achieved 'no worse than mild pain' (visual analogue scale (VAS, 0-10) average score was 5.8 and 6.2 respectively in the acupuncture and sham acupuncture groups, where 0 = no pain). There was limited data on quality of life, which showed no clear difference between groups. Evidence was not available on pain relief, adverse events or other pre-defined secondary outcomes for this comparison.Three studies compared acupuncture alone versus other therapies (mecobalamin combined with nimodipine, and inositol). Acupuncture may reduce the risk of 'no clinical response' to pain than other therapies (n = 209; RR 0.25, 95% CI 0.12 to 0.51), however, evidence was not available for pain intensity, pain relief, adverse events or any of the other secondary outcomes.Two studies compared acupuncture combined with other active therapies (mecobalamin, and Xiaoke bitong capsule) versus other active therapies used alone. We found that the acupuncture combination group had a lower VAS score for pain intensity (n = 104; MD -1.02, 95% CI -1.09 to -0.95) and improved quality of life (n = 104; MD -2.19, 95% CI -2.39 to -1.99), than those receiving other therapy alone. However, the average VAS score of the acupuncture and control groups was 3.23 and 4.25 respectively, indicating neither group achieved 'no worse than mild pain'. Furthermore, this evidence was from a single study with high risk of bias and a very small sample size. There was no evidence on pain relief and we identified no clear differences between groups on other parameters, including 'no clinical response' to pain and withdrawals. There was no evidence on adverse events.The overall quality of evidence is very low due to study limitations (high risk of performance, detection, and attrition bias, and high risk of bias confounded by small study size) or imprecision. We have limited confidence in the effect estimate and the true effect is likely to be substantially different from the estimated effect.

AUTHORS' CONCLUSIONS

Due to the limited data available, there is insufficient evidence to support or refute the use of acupuncture for neuropathic pain in general, or for any specific neuropathic pain condition when compared with sham acupuncture or other active therapies. Five studies are still ongoing and seven studies are awaiting classification due to the unclear treatment duration, and the results of these studies may influence the current findings.

Mexican consensus on dyspepsia

Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H.pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement.

Safety of different acupuncture manipulations for posterior circulation ischemia with vertigo

Acupuncture at Fengchi (GB20) in the posterior neck improves vertigo. However, subarachnoid hemorrhage and spinal epidural hematoma have been reported to occur after acupuncture in the posterior neck. Therefore, in the present study, we assessed the safety of acupuncture at Fengchi. Laboratory tests and adverse event reports were used to evaluate the safety of different acupuncture manipulations for the treatment of posterior circulation ischemia with vertigo. A total of 136 patients were randomly assigned to four groups. Verum acupuncture was conducted with different needle insertion directions (contralateral paropia or prominentia laryngea) and different needle twisting frequencies (60 or 120 times/minute) at Fengchi and matching acupoints (for example, Zhongwan [CV12], Qihai [CV6], Zusanli [ST36], and Fenglong [ST40]). The patients received 14 treatments over 3–4 weeks. Routine blood analysis, hepatic and renal function tests, urine and feces tests and electrocardiography were performed before the first treatment session and after the final session. Adverse events were recorded after every session. Of the 136 patients, 120 completed the study. There were no significant differences between pretreatment and posttreatment test results in any of the groups. Only five patients suffered from minor adverse events (needling pain, slight hematoma and transient chest tightness). No serious adverse events were found. Our results indicate that a 14-session course of needling at Fengchi is relatively safe for treating posterior circulation ischemia with vertigo.

Use of acupuncture to alleviate side effects in radiation oncology: Current evidence and future directions

Several reports have shown that acupuncture is an effective method of complementary medicine; however, only a few of these reports have focused on oncological patients treated with radiation therapy. Most of these studies discuss a benefit of acupuncture for side-effect reduction; however, not all could demonstrate significant improvements. Thus, innovative trial designs are necessary to confirm that acupuncture can alleviate side effects related to radiation therapy. In the present manuscript, we perform a broad review and discuss pitfalls and limitations of acupuncture in parallel with standard radiation therapy, which lead the way to novel treatment concepts.

Effectiveness of electroacupuncture for polycystic ovary syndrome: study protocol for a randomized controlled trial

Background

Whether electroacupuncture is effective for patients with polycystic ovary syndrome is still inconclusive. Therefore, this study aims to evaluate the add-on effects of electroacupuncture to conventional drugs for the treatment of polycystic ovary syndrome.

Methods/design

This study is a two-center, open-labeled, randomized, controlled trial. A total of 116 eligible patients with polycystic ovary syndrome will be randomly allocated in a 1:1 ratio to the electroacupuncture plus clomiphene citrate group or to the clomiphene citrate group. Participants in the electroacupuncture plus clomiphene citrate group will receive electroacupuncture treatment in addition to clomiphene citrate capsules, whereas participants in the clomiphene citrate group will be prescribed clomiphene citrate capsules only. Electroacupuncture treatment will be performed from the fifth day of menstruation or withdrawal bleeding until the next menstruation, in three sessions per week for three menstrual cycles. The primary outcome is the ovulation rate. The secondary outcomes include the dominant follicle rate, mean number of dominant follicles, endometrial thickness, time point of ovulation, follicular size before ovulation, luteinizing hormone, estradiol level, and pregnancy rate. The measuring points for outcomes will be baseline and the completion of treatment. Any adverse events occurring during the trial process will be recorded. In addition, a quality-monitoring group independent from the research team will be set up to control the quality of the trial.

Discussion

The design and methodological rigor of this trial will allow for the collection of valuable data to evaluate the effectiveness of electroacupuncture for treating polycystic ovary syndrome. Therefore, this trial will contribute reliable evidence for use in clinical decision-making in acupuncture therapy of polycystic ovary syndrome as well as to future research in acupuncture for polycystic ovary syndrome.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-IOR-15007358, registered on 26 October 2015

Observations on the Prevalence, Characteristics, and Effects of Self-Treatment

Aims

When facing illness, a person may choose self-treatment as an alternative to hospital (and primary care)-based treatment. Despite its important role in health care, the study on self-treatment remains limited. The goal is to collectively report the observations in the literature on the prevalence, characteristics, and effects of self-treatment.

Methods

Databases (Medline/PubMed and Google Scholar) were searched. Articles were scrutinized for country of origin, sample size, recall period, prevalence, associated factors, etc.

Results

Published studies have reported that in some regions, the prevalence of self-treatment is high and varies across illness conditions and treatment approaches. Self-medication is the most popular self-treatment approach. Multiple regional, demographic, personal, cultural, and religious factors have been implicated in the pursuit of self-treatment. In addition, accessibility of health care also plays a role. In general, self-treatment has a positive clinical and financial effect. However, there have been concerns on abuse and possible negative effects.

Conclusion

This article reviews observations made in recent studies on several important aspects of self-treatment. Comprehensive and systematic study is still lacking. Interventions are needed to solve several problems associated with self-treatment.

Effects of electroacupuncture therapy for Bell's palsy from acute stage: study protocol for a randomized controlled trial

Background

Although many patients with facial paralysis have obtained benefits or completely recovered after acupuncture or electroacupuncture therapy, it is still difficult to list intuitive evidence besides evaluation using neurological function scales and a few electrophysiologic data. Hence, the aim of this study is to use more intuitive and reliable detection techniques such as facial nerve magnetic resonance imaging (MRI), nerve electromyography, and F waves to observe changes in the anatomic morphology of facial nerves and nerve conduction before and after applying acupuncture or electroacupuncture, and to verify their effectiveness by combining neurological function scales.

Methods/Design

A total of 132 patients with Bell’s palsy (grades III and IV in the House-Brackmann [HB] Facial Nerve Grading System) will be randomly divided into electroacupuncture, manual acupuncture, non-acupuncture, and medicine control groups. All the patients will be given electroacupuncture treatment after the acute period, except for patients in the medicine control group. The acupuncture or electroacupuncture treatments will be performed every 2 days until the patients recover or withdraw from the study. The primary outcome is analysis based on facial nerve functional scales (HB scale and Sunnybrook facial grading system), and the secondary outcome is analysis based on MRI, nerve electromyography and F-wave detection. All the patients will undergo MRI within 3 days after Bell’s palsy onset for observation of the signal intensity and facial nerve swelling of the unaffected and affected sides. They will also undergo facial nerve electromyography and F-wave detection within 1 week after onset of Bell’s palsy. Nerve function will be evaluated using the HB scale and Sunnybrook facial grading system at each hospital visit for treatment until the end of the study. The MRI, nerve electromyography, and F-wave detection will be performed again at 1 month after the onset of Bell’s palsy.

Trial registration

Chinese Clinical Trials Register identifier: ChiCTR-IPR-14005730. Registered on 23 December 2014.

Risk Factors Associated with Adverse Events of Acupuncture: A Prospective Study

Objective

Mild adverse events (AEs) are common with acupuncture, but the risk factors remain unclear. A prospective study using a standardised AE assessment and acupuncture protocol was undertaken to address the question.

Methods

A 20-item AE report form investigated local and systemic AEs in 150 adults with insomnia randomised to receive traditional, minimal and non-invasive sham acupuncture. Sociodemographic, clinical and psychological variables at baseline and past history and perceived credibility of acupuncture were assessed.

Results

The incidence of any AEs per patient was 42.4% with traditional acupuncture, 40.7% with minimal acupuncture and 16.7% with non-invasive sham acupuncture. Traditional and minimal acupuncture were associated with a greater number of local AEs, while the presence of a chronic medical condition was predictive of fewer local and systemic AEs. Greater severity of insomnia, anxiety, depression, somatic symptoms and pain catastrophising thoughts were associated with lower risk, but most of the significant correlations disappeared after logistic regression. Divorce and widowhood were the only significant sociodemographic variables, while previous acupuncture treatment and perceived credibility of acupuncture were found to be unrelated. The risk of any AEs was higher in participants receiving traditional acupuncture (OR 4.26) and minimal acupuncture (OR 4.27) and in those without medical comorbidity (OR 3.39).

Conclusions

The prevalence of AEs was higher than usual, probably due to the low threshold in our definition of AEs and the systematic collection from the patients’ perspective. Baseline variables were largely unable to predict AEs associated with acupuncture. Further studies should explore the roles of practitioners, patients’ anxiety during treatment and patient–practitioner interactions.

Trial Registration Number

NCT01707706.

Two sets of acupoint combination of similar functions engage shared neural representation: a functional magnetic resonance imaging study

OBJECTIVE

To investigate whether the neural representations underlying alternating two acupoint combinations (ACs) are the same or not.

METHODS

In this functional magnetic resonance imaging study, two sets of analgesia ACs were utilized, including Waiguan (TE5) and Qiuxu (GB40) for Group A, and Neiguan (PC6) and Taichong (LR3) for Group B, which are the most commonly adopted in clinical treatment. Each group had 20 healthy subjects. An experimental design was proposed, which consisted of a pre-needling resting phase, a needling phase and a post-needling resting phase. This paradigm optimally mimics the clinical protocol as well as focuses on both the stimulation and the resting periods. The results were subjected to general linear model analysis, conjunction analysis and the functional connectivity analysis.

RESULTS

The rostral anterior cingulated cortex was engaged in the initiative period of the acupuncture effect in both groups, and it was chosen as the seed region for the functional connectivity analysis for the following resting period. The results showed that several shared brain regions were involved in both groups, in particular the insula, amygdala and hypothalamus. Moreover, significant differences were located at the posterior cingulated cortex as revealed by a two sample -test (P<0.05, corrected). Other regions showed no significant differences. This finding was further supported by the spatial correlation analysis that the two groups were significantly correlated (r =0.51, P<0.01).

CONCLUSION

This preliminary research helps us understand the neurophysiological mechanisms of acupuncture when following clinical guidelines on ACs, as well as provides an important opportunity to develop better treatment strategies for reducing, or even preventing pain.

Usage patterns and adverse experiences in traditional Korean medicine: results of a survey in South Korea

Background

Although traditional medicine (TM) in South Korea is included in the national health care system, it is considered complementary and alternative medicine (CAM), and not mainstream medicine. Therefore, the lack of statistical data regarding the usage and adverse experiences of traditional Korean medicine (TKM) makes difficult to understand the current status of TM. In this study, we aimed to report usage patterns and adverse experiences on TKM targeting consumers in South Korea.

Methods

A total of 2000 consumers participated in the survey on usage and adverse experiences in 2008. Among the 2,000 participants, 915 (45.8%) had taken herbal medicine or received traditional medicinal therapies; these individuals were further surveyed on the internet or in an interview.

Results

The usage rate was higher among women and among patients in their 30s. Of the total TKM usage, acupuncture accounted for 36.7%, and herbal medicine accounted for 13.4%. Regarding the frequency of use of TKM, 73.8% of patients reported using TM less than 5 times in 1 year. Of the 915 respondents, 8.2% of individuals had some type of adverse experience resulting from TKM. Adverse experiences were primarily caused by acupuncture and herbal medicines, and they primarily involved diseases of the digestive system and skin. The incidence of adverse experiences was less than 3.7% for acupuncture and 3.8% for herbal medicine. Overall, the incidence rate of adverse experiences for TKM for the entire population was 0.04 per 10,000 individuals.

Conclusions

The medical usage and occurrence of adverse events on TKM should be surveyed periodically, and the statistical trends should be analysed. The disparity between the survey results for traditional herbal medicines and medical practices, and those for the national pharmacovigilance system or academic reports of adverse experiences should be examined. The national pharmacovigilance system must be improved to compensate for the disparities. Policies and regulations are required to enhance the reporting of adverse experiences not only for herbal medicines but also for traditional medicinal therapies.

Acupuncture for patients with functional dyspepsia: study protocol of a randomised controlled trial

INTRODUCTION

Whether acupuncture is efficacious for patients with functional dyspepsia is still controversial. So we designed a randomised controlled trial to settle the problem.

METHODS AND ANALYSIS

We designed a multicentre, two-arm, sham-controlled clinical trial. 200 participants with functional dyspepsia will be randomly assigned to the true acupuncture (TA) group and sham acupuncture (SA) group in a 1:1 ratio. Participants in the TA group will receive acupuncture at points selected according to syndrome differentiation. Participants in the sham acupuncture group will receive penetrations at sham points. Participants in both groups will receive 20 sessions of electroacupuncture in 4 weeks, five times continuously with a 2 day rest in a week. The primary outcome is the proportion of patients reporting the absence of dyspeptic symptoms at 16 weeks after inclusion. The secondary outcome includes a Short-Form Leeds Dyspepsia Questionnaire, the Chinese version of the 36-Item Short Form Survey, the Chinese version of the Nepean dyspepsia index, etc.

ETHICS AND DISSEMINATION

The study protocol has been approved by the institutional review boards and ethics committees of the first affiliated hospital of Chengdu University of TCM, the first affiliated hospital of Hunan University of TCM and Chongqing Medical University, respectively (from April to August 2012). The results of this trial will be disseminated in a peer-reviewed journal and presented at international congresses.

TRIALS REGISTRATION

ClinicalTrials.gov NCT01671670.

Fear of acupuncture enhances sympathetic activation to acupuncture stimulation

BACKGROUND

Acupuncture treatment frequently evokes both pain and fear, causing patients to be hesitant about undergoing the procedure. This study investigated individual differences in autonomic response to acupuncture stimulation and its relationship to fear of the procedure.

METHODS

Twenty-seven participants filled out the acupuncture fear scale (AFS) questionnaire and underwent acupuncture stimulation at the LI4 acupuncture point. Autonomic responses were measured by recording the skin conductance response (SCR) throughout acupuncture stimulation. Pearson correlation analysis was performed between the self-reported AFS scores and changes in SCR.

RESULTS

After acupuncture stimulation, SCR significantly increased and there were greater individual differences in enhanced sympathetic activations to acupuncture stimulation. Changes in SCR correlated with scores for the painful sensation domain of the AFS.

CONCLUSIONS

Our results indicate that fear of acupuncture-induced pain is associated with physiological arousal when people receive acupuncture stimulation. Fear of pain is the dominant factor in acupuncture-related fear and it should be considered in practice and in research.

Development and validation of acupuncture fear scale

Objectives. Strong aversions to acupuncture have been an obstacle to understanding its intrinsic action of acupuncture. Thus, it is necessary to evaluate the nature and extent of fear of acupuncture treatment. Our study aims to develop and validate an instrument that evaluates a patient's fear of acupuncture treatment. Methods. We have developed an acupuncture fear scale, a 16-item instrument which assesses the acupuncture fear score and uses it to survey 275 participants in South Korea, thus testing the reliability and validity of the instrument. Results. Internal consistency was high (Cronbach's alpha = 0.935). Test-retest reliability (Spearman's rank correlation coefficient) among 33 participants out of 275 ranged from 0.565 to 0.797 (P < 0.001). Principal component analysis revealed two factors accounting for 68% of the variance, which are painful sensation and possible adverse events, respectively. The acupuncture fear scale was positively correlated with the total of fear of pain questionnaire-III (r = 0.423, P < 0.001). Conclusions. The acupuncture fear scale can be a valid and reliable instrument that can measure fear of acupuncture treatment. These results strongly suggest that it would be a clinically useful tool to assess fear of acupuncture in the acupuncture clinic setting and an important instrument to understand the complex social-behavioral component of acupuncture modality.

Acupuncture adverse events in China: a glimpse of historical and contextual aspects

The article by He and colleagues, "Adverse Events Following Acupuncture: A Systematic Review of the Chinese Literature for the Years 1956-2010" is an important and timely contribution. In this commentary, the article is reviewed and issues are highlighted about how to interpret and contextualize the results of their study. While their review has been well performed, certain areas have been identified where the results may be inaccurate due to problems in the reporting of original incidents. For example, potential problems were found in the reporting of the minor adverse event (AE) of fainting and the more serious AEs of pneumothorax and hepatitis. The article by He and colleagues highlights the issue that almost all AEs associated with acupuncture in the modern period are due to the administration of the therapy rather than the therapy itself. Future prospective studies can address some of the shortcomings identified in this review.

A review of acupoint specificity research in china: status quo and prospects

The theory of acupoint specificity is the basis for elucidating the actions of acupoints as employed in clinical practice. Acupoint specificity has become a focus of attention in international research efforts by scholars in the areas of acupuncture and moxibustion. In 2006, the Chinese Ministry of Science approved and initiated the National Basic Research Program (973 Program), one area of which was entitled Basic Research on Acupoint Specificity Based on Clinical Efficacy. Using such approaches as data mining, evidence-based medicine, clinical epidemiology, neuroimaging, molecular biology, neurophysiology, and metabolomics, fruitful research has been conducted in the form of literature research, clinical assessments, and biological studies. Acupoint specificity has been proved to exist, and it features meridian-propagated, relative, persistent, and conditional effects. Preliminarily investigations have been made into the biological basis for acupoint specificity.

Complementary and alternative medicine in children: an analysis of the recent literature

PURPOSE OF REVIEW

Although many publications have documented the use of complementary and alternative medicine (CAM) in children and adolescents, most have lacked the scientific rigor to establish clear benefits over so-called conventional medicine. We reviewed the literature published in the past year to identify the types of CAM most often studied in children, the variety of conditions to which these modalities are applied, and the methodologies used in the articles exploring the most prevalent CAM modalities.

RECENT FINDINGS

We identified 111 published articles on CAM use in children in 2011. The most common modalities were herbal/dietary supplements, acupuncture, massage, chiropractic, and homeopathy. The most commonly studied conditions were pain, headache, attention deficit hyperactivity disorder (ADHD), asthma, and colic. Although a majority of the articles consisted of reviews, case reports, and other nonhypothesis-driven methodologies, we did find that several were randomized controlled trials, meta-analyses, or systematic reviews. These methodologies, however, rarely accounted for the majority of publications on a particular therapy or condition.

SUMMARY

The use of CAM in children continues to occupy a niche area of interest for many providers and families, but only a minority of articles published in the past year utilized methods of sufficient rigor to provide a useful comparison to more conventional therapies.

Acupuncture for the treatment of dry eye: a multicenter randomised controlled trial with active comparison intervention (artificial teardrops)

PURPOSE

To evaluate the effects of acupuncture compared to a control group using artificial tears.

METHODS

SETTING & DESIGN

multicenter randomised controlled trial (three local research hospitals of South Korea).

STUDY POPULATION

150 patients with moderate to severe dry eye.

INTERVENTION

Participants were randomly allocated into four weeks of acupuncture treatment (bilateral BL2, GB14, TE 23, Ex1, ST1, GB20, LI4, LI11 and single GV23) or to the artificial tears group (sodium carboxymethylcellulose).

MAIN OUTCOME MEASURE(S)

The ocular surface disease index (OSDI), tear film break-up time (TFBUT), Schirmer Ι test, visual analogue scale (VAS) for self-assessment of ocular discomfort, general assessment (by both acupuncture practitioners and participants) and quality of life (QOL) through the Measure Yourself Medical Outcome Profile-2 (MYMOP-2).

RESULTS

There was no statistically significant difference between two groups for the improvement of dry eye symptoms as measured by OSDI (MD -16.11, 95% CI [-20.91, -11.32] with acupuncture and -15.37, 95% CI [-19.57, -11.16] with artificial tears; P = 0.419), VAS (acupuncture: -23.84 [-29.59, -18.09]; artificial tears: -22.2 [-27.24, -17.16], P = 0.530) or quality of life (acupuncture: -1.32 [-1.65, -0.99]; artificial tears: -0.96 [-1.32, -0.6], P = 0.42) immediately after treatment. However, compared with artificial tears group, the OSDI (acupuncture: -16.15 [-21.38, -10.92]; artificial tears: -10.76 [-15.25, -6.27], P = 0.030) and VAS (acupuncture: -23.88 [-30.9, -16.86]; artificial tears: -14.71 [-20.86, -8.55], P = 0.018) were significantly improved in the acupuncture group at 8 weeks after the end of acupuncture treatment. TFBUT measurements increased significantly in the acupuncture group after treatment.

CONCLUSIONS

Acupuncture may have benefits on the mid-term outcomes related to dry eye syndrome compared with artificial tears.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01105221.

Prednisolone and acupuncture in Bell's palsy: study protocol for a randomized, controlled trial

Background

There are a variety of treatment options for Bell's palsy. Evidence from randomized controlled trials indicates corticosteroids can be used as a proven therapy for Bell's palsy. Acupuncture is one of the most commonly used methods to treat Bell's palsy in China. Recent studies suggest that staging treatment is more suitable for Bell's palsy, according to different path-stages of this disease. The aim of this study is to compare the effects of prednisolone and staging acupuncture in the recovery of the affected facial nerve, and to verify whether prednisolone in combination with staging acupuncture is more effective than prednisolone alone for Bell's palsy in a large number of patients.

Methods/Design

In this article, we report the design and protocol of a large sample multi-center randomized controlled trial to treat Bell's palsy with prednisolone and/or acupuncture. In total, 1200 patients aged 18 to 75 years within 72 h of onset of acute, unilateral, peripheral facial palsy will be assessed. There are six treatment groups, with four treated according to different path-stages and two not. These patients are randomly assigned to be in one of the following six treatment groups, i.e. 1) placebo prednisolone group, 2) prednisolone group, 3) placebo prednisolone plus acute stage acupuncture group, 4) prednisolone plus acute stage acupuncture group, 5) placebo prednisolone plus resting stage acupuncture group, 6) prednisolone plus resting stage acupuncture group. The primary outcome is the time to complete recovery of facial function, assessed by Sunnybrook system and House-Brackmann scale. The secondary outcomes include the incidence of ipsilateral pain in the early stage of palsy (and the duration of this pain), the proportion of patients with severe pain, the occurrence of synkinesis, facial spasm or contracture, and the severity of residual facial symptoms during the study period.

Discussion

The result of this trial will assess the efficacy of using prednisolone and staging acupuncture to treat Bell's palsy, and to determine a best combination therapy with prednisolone and acupuncture for treating Bell's palsy.

Trial Registration

ClinicalTrials.gov: NCT01201642