Placebo Devices as Effective Control Methods in Acupuncture Clinical Trials: A Systematic Review

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

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

Acupuncture for hot flashes in hormone receptor-positive breast cancer: A pooled analysis of individual patient data from parallel randomized trials

BACKGROUND

Hot flashes are a common side effect of endocrine therapy (ET) that contribute to poor quality of life and decreased treatment adherence.

METHODS

Patients with breast cancer wo were receiving ET and experiencing hot flashes were enrolled through three parallel, randomized trials conducted in the United States, China, and South Korea. Participants were randomized to either immediate acupuncture (IA) or delayed acupuncture control (DAC). IA participants received 20 acupuncture sessions over 10 weeks, whereas DAC participants received usual care, then crossed over to acupuncture with a reduced intensity. The primary end point was a change in score on the endocrine symptom subscale of the Functional Assessment of Cancer Therapy (FACT)-Endocrine Symptoms between baseline and week 10. Secondary end points included the hot flash score and the FACT-Breast score. A planned pooled analysis of individual patient data was performed using longitudinal mixed models.

RESULTS

In total, 158 women with stage 0-III breast cancer were randomized (United States, n = 78; China, n = 40; South Korea, n = 40). At week 10, IA participants reported statistically significant improvements in the endocrine symptom subscale score (mean change ± standard error: 5.1 ± 0.9 vs. 0.2 ± 1.0; p = .0003), the hot flash score (-5.3 ± 0.9 vs. -1.4 ± 0.9; p < .003), and the FACT-Breast total score (8.0 ± 1.6 vs. -0.01 ± 1.6; p = .0005) compared with DAC participants. The effect of the acupuncture intervention differed by site (p = .005).

CONCLUSIONS

Acupuncture led to statistically and clinically meaningful improvements in hot flashes, endocrine symptoms, and breast cancer-specific quality of life in women undergoing ET for breast cancer in the United States, China, and South Korea.

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

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

Evaluating the effect of acupuncture on symptoms of diabetic peripheral neuropathy (DPN) among individuals with diabetic neuropathy: A single-blind, randomized trial study

Purpose

This study aimed to investigate the impact of acupuncture on Diabetic peripheral neuropathy (DPN) symptoms among individuals with diabetic neuropathy.

Methods

In a single-blind, randomized trial conducted between 2019 and 2020, 60 patients diagnosed with diabetic neuropathy were enrolled. These participants were randomly assigned to either the intervention or control group. The intervention group received real acupuncture alongside routine treatment once a week for seven sessions, each lasting 20 min. Meanwhile, the control group received sham acupuncture as an adjunct to their routine treatment, following the same schedule. To evaluate treatment efficacy, the study assessed primary outcomes, such as pain intensity measured using the Visual Analogue Scale (VAS). Secondary outcomes included evaluating fatigue severity and diabetic peripheral neuropathy (DPN) side effects, measured using the multidimensional fatigue inventory (MFI-20) and a standard questionnaire after each session.

Results

No statistically significant differences in pain and fatigue scores were observed between the two groups throughout all visits, even after adjusting for baseline characteristics, age, sex, type of diabetes, discopathy, and carpal tunnel syndrome parameters (P > 0.05). The findings did not provide strong evidence supporting a significant effect of real acupuncture compared to sham acupuncture on pain and fatigue values (P = 0.267 and 0.634, respectively). However, the 95% confidence interval for pain scores (-0.35, 1.28) was inconclusive, encompassing effect sizes favoring sham acupuncture.

Conclusion

Findings suggest that using acupuncture as an adjunctive therapy alongside routine treatment may not lead to a significant reduction in the symptoms of peripheral neuropathy and fatigue severity among individuals with diabetic neuropathy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01314-1.

Is Electroacupuncture Contraindicated for Preventing and Treating Chemotherapy-Induced Peripheral Neuropathy?

Background

Chemotherapy-induced peripheral neuropathy (CIPN) is a common side-effect of several drugs used to combat cancer. Thus, researchers have sought better treatments for and prevention of CIPN, such as electroacupuncture (EA). Some trials show EA worsens or prolongs CIPN pain and recommend against further studies on this. This narrative review explores EA for preventing or treating CIPN, comparing positive and negative outcomes.

Methods

PubMed, ScienceDirect, and Google Scholar were searched for electroacupuncture, CIPN, and peripheral neuropathy. A snowballing method was used to find systematic reviews and studies in systematic reviews.

Results

Seven English-language trials were found on using EA for preventing or treating CIPN. In 3 prevention studies, 1 had significant benefits, 1 had modest benefits, and 1 had worse pain in an EA group at follow-up, compared to sham controls. In 4 treatment studies, 2 had significant benefits, 1 had no difference from 3 controls, and 1 had sham control was superior to verum EA.

Conclusions

Most of the studies were limited by small sample sizes, and some studies used EA protocols and treatment doses (frequency and total number of sessions) that were potentially suboptimal. The quantity and quality of the studies are insufficient to draw firm conclusions on effectiveness and safety. More studies must test optimal EA protocols and treatment dosages. It is inappropriate to say that EA is not recommended for CIPN prevention or treatment, because there is no robust evidence to justify this. Generally, research has found benefits and no harms.

Acupuncture for brain diseases: Conception, application, and exploration

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

Use of complementary and alternative medicine in children affected by oncologic, neurologic and liver diseases: a narrative review

Complementary and alternative medicine (CAM) consist of a broad group of restorative resources often linked to existing local cultures and established health care systems and are also increasingly used in children with some serious illnesses. In this narrative review, we examine the epidemiology of the use, efficacy, and safety of complementary and alternative medicine in pediatric oncology, neurology, and hepatology. We searched for relevant articles published in Pubmed evaluating CAM use and its efficacy in safety in children affected by oncologic, neurologic and liver diseases. CAM is used to improve the success of conventional therapies, but also to alleviate the pain, discomfort, and suffering resulting from the diseases and their treatment, which are often associated with a significant burden of adverse effects. CAM use must be evaluated in children with neurological, oncological and liver diseases.

Pregnancy Benefit of Acupuncture on in vitro Fertilization: A Systematic Review and Meta-Analysis

BACKGROUND

Currently, more and more infertility couples are opting for combined acupuncture to improve success rate of in vitro fertilization (IVF). However, evidence from acupuncture for improving IVF pregnancy outcomes remains a matter of debate.

OBJECTIVE

To quantitatively summarized the evidence of the efficacy of acupuncture among women undergoing IVF by means of systematic review and meta-analysis.

METHODS

Four English (PubMed, Web of Science, EMBASE, and Cochrane Register of Controlled Clinical Trials) and Four Chinese databases (Wanfang Databases, Chinese National Knowledge Infrastructure, Chinese Science and Technology Periodical Database, and SinoMed) were searched from database inception until July 2, 2023. Randomized controlled trials (RCTs) that evaluated the acupuncture's effects for women undergoing IVF were included. The subgroup analysis was conducted with respect to the age of participants, different acupuncture types, type of control, acupuncture timing, geographical origin of the study, whether or not repeated IVF failure, and acupuncture sessions. Sensitivity analyses were predefifined to explore the robustness of results. The primary outcomes were clinical pregnancy rate (CPR) and live birth rate (LBR), and the secondary outcomes were ongoing pregnancy rate and miscarriage rate. Random effects model with I2 statistics were used to quantify heterogeneity. Publication bias was estimated by funnel plots and Egger's tests.

RESULTS

A total of 58 eligible RCTs representing 10,968 women undergoing IVF for pregnant success were identifified. Pooled CPR and LBR showed a signifificant difference between acupuncture and control groups [69 comparisons, relative risk (RR) 1.19, 95% confifidence intervals (CI) 1.12 to 1.25, I2=0], extremely low evidence; 23 comparisons, RR 1.11, 95%CI 1.02 to 1.21, I2=14.6, low evidence, respectively). Only transcutaneous electrical acupoint stimulation showed a positive effect on both CPR (16 comparisons, RR 1.17, 95%CI 1.06 to 1.29; I2=0, moderate evidence) and LBR (9 comparisons, RR 1.20, 95%CI 1.04 to 1.37; I2=8.5, extremely low evidence). Heterogeneity across studies was found and no studies were graded as high-quality evidence.

CONCLUSION

Results showed that the convincing evidence levels on the associations between acupuncture and IVF pregnant outcomes were relatively low, and the varied methodological design and heterogeneity might inflfluence the fifindings. (Registration No. PROSPERO CRD42021232430).

Current status and progress in research on dressing management for diabetic foot ulcer

Diabetic foot ulcer (DFU) is a major complication of diabetes and is associated with a high risk of lower limb amputation and mortality. During their lifetime, 19%-34% of patients with diabetes can develop DFU. It is estimated that 61% of DFU become infected and 15% of those with DFU require amputation. Furthermore, developing a DFU increases the risk of mortality by 50%-68% at 5 years, higher than some cancers. Current standard management of DFU includes surgical debridement, the use of topical dressings and wound decompression, vascular assessment, and glycemic control. Among these methods, local treatment with dressings builds a protective physical barrier, maintains a moist environment, and drains the exudate from DFU wounds. This review summarizes the development, pathophysiology, and healing mechanisms of DFU. The latest research progress and the main application of dressings in laboratory and clinical stage are also summarized. The dressings discussed in this review include traditional dressings (gauze, oil yarn, traditional Chinese medicine, and others), basic dressings (hydrogel, hydrocolloid, sponge, foam, film agents, and others), bacteriostatic dressings, composite dressings (collagen, nanomaterials, chitosan dressings, and others), bioactive dressings (scaffold dressings with stem cells, decellularized wound matrix, autologous platelet enrichment plasma, and others), and dressings that use modern technology (3D bioprinting, photothermal effects, bioelectric dressings, microneedle dressings, smart bandages, orthopedic prosthetics and regenerative medicine). The dressing management challenges and limitations are also summarized. The purpose of this review is to help readers understand the pathogenesis and healing mechanism of DFU, help physicians select dressings correctly, provide an updated overview of the potential of biomaterials and devices and their application in DFU management, and provide ideas for further exploration and development of dressings. Proper use of dressings can promote DFU healing, reduce the cost of treating DFU, and reduce patient pain.

Methodological Issues Relevant to Blinding in Physical Medicine and Rehabilitation Research

ABSTRACT

Blinding in research is important, and the field of physical medicine and rehabilitation poses special consideration owing to the patient populations and treatment methodologies used. Historically, blinding has been increasingly relevant to conducting good-quality research. The main reason to blind is to reduce bias. There are several strategies to blinding. At times, when blinding is not possible, alternatives to blinding include sham control and description of study and control groups. Illustrative examples of blinding used in physical medicine and rehabilitation research are described in this article, along with how to assess success and fidelity of blinding.

Cephalic version by moxibustion for breech presentation

BACKGROUND

Breech presentation at term can cause complications during birth and increase the chance of caesarean section. Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) at the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of changing breech presentation to cephalic presentation. This is an update of a review first published in 2005 and last published in 2012.

OBJECTIVES

To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (4 November 2021). We also searched MEDLINE, CINAHL, AMED, Embase and MIDIRS (inception to 3 November 2021), and the reference lists of retrieved studies.

SELECTION CRITERIA

The inclusion criteria were published and unpublished randomised or quasi-randomised controlled trials comparing moxibustion either alone or in combination with other techniques (e.g. acupuncture or postural techniques) with a control group (no moxibustion) or other methods (e.g. acupuncture, postural techniques) in women with a singleton breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined trial eligibility, assessed trial quality, and extracted data. Outcome measures were baby's presentation at birth, need for ECV, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events. We assessed the certainty of the evidence using the GRADE approach.   MAIN RESULTS: This updated review includes 13 studies (2181 women), of which six trials are new. Most studies used adequate methods for random sequence generation and allocation concealment. Blinding of participants and personnel is challenging with a manual therapy intervention; however, the use of objective outcomes meant that the lack of blinding was unlikely to affect the results. Most studies reported little or no loss to follow-up, and few trial protocols were available. One study that was terminated early was judged as high risk for other sources of bias. Meta-analysis showed that compared to usual care alone, the combination of moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth (7 trials, 1152 women; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.99, I2 = 38%; moderate-certainty evidence), but the evidence is very uncertain about the effect of moxibustion plus usual care on the need for ECV (4 trials, 692 women; RR 0.62, 95% CI 0.32 to 1.21, I2 = 78%; low-certainty evidence) because the CIs included both appreciable benefit and moderate harm. Adding moxibustion to usual care probably has little to no effect on the chance of caesarean section (6 trials, 1030 women; RR 0.94, 95% CI 0.83 to 1.05, I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effect of moxibustion plus usual care on the the chance of premature rupture of membranes (3 trials, 402 women; RR 1.31, 95% CI 0.17 to 10.21, I2 = 59%; low-certainty evidence) because there were very few data. Moxibustion plus usual care probably reduces the use of oxytocin (1 trial, 260 women; RR 0.28, 95% CI 0.13 to 0.60; moderate-certainty evidence). The evidence is very uncertain about the chance of cord blood pH less than 7.1 (1 trial, 212 women; RR 3.00, 95% CI 0.32 to 28.38; low-certainty evidence) because there were very few data. We are very uncertain whether the combination of moxibustion plus usual care increases the chance of adverse events (including nausea, unpleasant odour, abdominal pain and uterine contractions; intervention: 27/65, control: 0/57), as only one study presented data in a way that could be reanalysed (122 women; RR 48.33, 95% CI 3.01 to 774.86; very low-certainty evidence). When moxibustion plus usual care was compared with sham moxibustion plus usual care, we found that moxibustion probably reduces the chance of non-cephalic presentation at birth (1 trial, 272 women; RR 0.74, 95% CI 0.58 to 0.95; moderate-certainty evidence) and probably results in little to no effect on the rate of caesarean section (1 trial, 272 women; RR 0.84, 95% CI 0.68 to 1.04; moderate-certainty evidence). No study that compared moxibustion plus usual care with sham moxibustion plus usual care reported on the clinically important outcomes of need for ECV, premature rupture of membranes, use of oxytocin, and cord blood pH less than 7.1, and one trial that reported adverse events reported data for the whole sample. When moxibustion was combined with acupuncture and usual care, there was very little evidence about the effect of the combination on non-cephalic presentation at birth (1 trial, 226 women; RR 0.73, 95% CI 0.57 to 0.94) and at the end of treatment (2 trials, 254 women; RR 0.73, 95% CI 0.57 to 0.93), and on the need for ECV (1 trial, 14 women; RR 0.45, 95% CI 0.07 to 3.01). There was very little evidence about whether moxibustion plus acupuncture plus usual care reduced the chance of caesarean section (2 trials, 240 women; RR 0.80, 95% CI 0.65 to 0.99) or pre-eclampsia (1 trial, 14 women; RR 5.00, 95% CI 0.24 to 104.15). The certainty of the evidence for this comparison was not assessed.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth, but uncertain evidence about the need for ECV. Moderate-certainty evidence from one study shows that moxibustion plus usual care probably reduces the use of oxytocin before or during labour. However, moxibustion plus usual care probably results in little to no difference in the rate of caesarean section, and we are uncertain about its effects on the chance of premature rupture of membranes and cord blood pH less than 7.1.  Adverse events were inadequately reported in most trials.

ACURATE: A guide for reporting sham controls in trials using acupuncture

OBJECTIVE

To promote better reporting quality regarding sham acupuncture in clinical trials for a precise appraisal of the adequacy of the sham acupuncture procedure.

METHODS

A three-stage online Delphi survey was conducted to a group of experts. Items with higher than 80% consensus from the initial checklist were selected as the final candidates. Further discussion among the working group was convened to preclude potential redundancy among the items.

RESULTS

A total of 23 experts out of 35 (66%) responded to the Delphi process. The final checklist consists of 23 items in six categories: type of sham acupuncture, details of sham acupuncture manipulation, location of sham acupuncture, treatment regimen, practitioner, and protocol and settings.

CONCLUSION

This paper presents the Acupuncture Controls gUideline for Reporting humAn Trials and Experiments (ACURATE) checklist, an extension of The Consolidated Standards for Reporting of Trials (CONSORT) and to be used along with STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) when sham acupuncture needles are used in the study. This checklist focuses on a clear depiction of sham needling procedures to enhance replicability and enable a precise appraisal. We encourage researchers to use ACURATE in trials and reviews involving sham acupuncture to assist reporting sham acupuncture procedures and the related components.

Comparative effectiveness of acupuncture in sham-controlled trials for knee osteoarthritis: A systematic review and network meta-analysis

Objectives

Although many trials have assessed the effect of acupuncture on knee osteoarthritis (KOA), its efficacy remains controversial. Sham acupuncture techniques are regarded as representative control interventions in acupuncture trials and sometimes incorporate the use of sham devices (base units) to support a non-penetrating needle. To achieve successful blinding, these trials also use acupuncture base units in the verum acupuncture group. Base units are not used in real-world clinical settings. We aimed to assess the effect sizes of verum and sham acupuncture for KOA in sham-controlled trials with or without base units.

Methods

A total of 10 electronic databases for randomized controlled trials (RCTs) comparing the efficacy of verum manual acupuncture and sham acupuncture for the treatment of KOA were searched for articles published before April 12, 2022. The primary outcome was pain intensity, and the secondary outcomes included physical function. The first assessment after the end of treatment was chosen for analysis. Effect sizes are reported as standardized mean differences (SMDs) with 95% confidence intervals (95% CIs). The risk of bias was assessed using the Cochrane risk of bias tool, and publication bias was evaluated using a funnel plot and Egger's test. The quality of evidence for estimates was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

Results

Fifteen RCTs were included. There was generally a low risk of bias except for the difficulty in blinding acupuncture therapists (performance bias). Compared to verum acupuncture in sham-controlled trials using base units, verum acupuncture in sham-controlled trials without base units was more effective for improving pain (SMD -0.56, 95% CI -1.09 to -0.03) and function (SMD -0.73, 95% CI -1.36 to -0.10) in KOA. The quality of evidence for network estimates was moderate to low due to the risk of bias and imprecision.

Conclusion

These findings suggest that verum acupuncture in different types of sham-controlled trials has different effect sizes for KOA. Because base units are not used in clinical settings, the results of verum acupuncture in sham-controlled trials with base units need to be interpreted carefully.

Systematic review registration

https://www.researchregistry.com/browse-the-registry#registryofsystematicreviewsmeta-analyses/registryofsystematicreviewsmeta-analysesdetails/6269f962606c5e001fd8790c/, identifier reviewregistry1351.

Acupuncture for premature ventricular complexes without ischemic or structural heart diseases: A systematic review and meta-analysis of clinical and pre-clinical evidence

Background

With increasing evidence suggesting potential benefits, acupuncture is often applied to the treatment of premature ventricular complexes (PVCs), particularly in symptomatic patients who fail or are unsuitable for medications or refuse catheter ablation. However, the existing clinical evidence is inconsistent.

Objectives

This review aims to systematically evaluate the effectiveness and safety of acupuncture therapies for PVCs without ischemic or structural heart diseases, when it is compared with sham/placebo acupuncture or usual care, or used as an add-on therapy to routine care; and to summarize existing pre-clinical research evidence supporting the effects of acupuncture therapies for this clinical condition.

Methods

Four English-language databases, four Chinese-language databases and seven clinical registries were searched from their inceptions to May 21, 2021 and updated to November 01, 2022. Trials comparing acupuncture with sham acupuncture or evaluating the add-on effects of acupuncture were included. Primary outcomes are the number of premature ventricular beats (PVBs) and effective rate defined as "the proportion of participants with over 50% decrease in the number of PVBs from baseline to the end of treatment measured by 24-h Holter".

Results

A total of 479 records were identified with nine trials involving 847 participants included in this review. Meta-analysis on two sham-control trials with low risk of bias for all domains suggested that acupuncture could significantly reduce the number of PVBs (RR 3.83, 95% CI [2.19, 6.7], I ² = 0%). Moreover, the combination of acupuncture and standard treatment was superior to standard treatment alone in reducing the burden of PVBs (RR 1.21, 95% CI [1.08, 1.36], I ² = 0%). Though no treatment protocol consensus was announced, body acupuncture on point PC6, HT7, DU10, DU11, and ST36 with duration of needle retention ranging from 15 to 30 min for a 4-week treatment period is broadly used by the included trials. For experimental evidence, five studies explored the mechanisms of acupuncture for PVCs were eventually included into analysis and PC6 was the most frequently studied acupuncture point. Moreover, a reduction of electrical activity of sympathetic nerves in experimental animals undergoing electro-acupuncture was observed by four of these studies.

Conclusion

Sham-controlled RCT evidence with moderate-level certainty suggested that acupuncture could be a therapeutic option to reduce the burden of PVBs in patients without ischemic or structural heart diseases. Further clinical studies using validated and reliable outcome measurement instruments and bench research to unveil the mechanisms of acupuncture stimulation and point-specific effects for PVCs are needed.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=262132], identifier [CRD42021262132].

Advances in traditional Chinese medicine as adjuvant therapy for diabetic foot

Diabetes mellitus (DM) is a complex disease that often causes multiple systemic complications that have become a major international public health problem. Diabetic foot (DF) is one of the severe and frequent chronic complications of DM due to vascular lesions and neuropathy. DF ulcers (DFU) affect approximately 15% of people with DM and are the leading cause of death and disability. The prevalence and recurrence of DF are worrisome, and morbidity and mortality are also on the rise, which poses a substantial socioeconomic burden. Treating DF is difficult for clinicians and requires multidisciplinary cooperation, combining local and systemic therapy to reduce amputation and case-fatality rates. Traditional Chinese Medicine (TCM) has received extensive attention due to noticeable therapeutic effects and few adverse reactions. In recent years, research on DF treatment by TCM has been increasing, and further progress has been made. TCM includes oral medication, injectable preparations, and adjuvant therapy. This article reviews the relevant research on TCM-related adjuvant therapy for DF. We describe current progress in TCM in terms of external application, acupuncture, massage, acupoint injection, foot bath, fumigation, and moxibustion, as well as the mechanisms involved.

Acupuncture Treatment Modulate Regional Homogeneity of Dorsal Lateral Prefrontal Cortex in Patients with Amnesic Mild Cognitive Impairment

Background: Although acupuncture is widely used to improve cognitive and memory in the amnesic mild cognitive impairment (aMCI) patients with impressive effectiveness, its neural mechanism remains largely unclear. Objective: We aimed to explore functional magnetic resonance imaging (fMRI) mechanism of acupuncture for aMCI. Methods: A randomized, controlled, single-blind research was performed. A total of 46 aMCI patients were randomly assigned into verum and sham acupuncture group, who received a total of 24 times treatments (3 times/week, 8 weeks). Clinical evaluation and fMRI scanning were performed at baseline and after treatment for all aMCI patients. The interaction effects and inter-group effects of regional homogeneity (ReHo) were performed using mixed effect models, and the correlations between clinical improvement and neuroimaging changes before and after verum acupuncture treatment were analyzed using Pearson correlations. Results: As a result, interaction effects showed increased ReHo value in left dorsal lateral prefrontal cortex (DLPFC), increased functional connectivity between left DLPFC and left precuneus, and decreased functional connectivity between left DLPFC and left inferior temporal gyrus after verum acupuncture but inversely after sham acupuncture in the aMCI. Condition effects showed increased ReHo in right lingual gyrus, and bilateral post-central gyrus after verum and sham acupuncture in the aMCI. In addition, the changed Montreal Cognitive Assessment scores in verum acupuncture group were significantly correlated with changed ReHo values in left DLPFC. Conclusion: Together, our findings further confirmed that acupuncture could be used as a promising complementary therapy for aMCI by modulating function of left DLPFC to improve cognitive symptoms.

Performance, Detection, Contamination, Compliance, and Cointervention Biases in Rehabilitation Research: What Are They and How Can They Affect the Results of Randomized Controlled Trials? Basic Information for Junior Researchers and Clinicians

ABSTRACT

Bias is a systematic error that can cause distorted results leading to incorrect conclusions. Intervention bias (i.e., contamination bias, cointervention bias, compliance bias, and performance bias) and detection bias are the most common biases in rehabilitation research. A better understanding of these biases is essential at all stages of research to enhance the quality of evidence in rehabilitation trials. Therefore, this narrative review aims to provide insights to the readers, clinicians, and researchers about contamination, cointervention, compliance, performance, and detection biases and ways of recognizing and mitigating them. The literature selected for this review was obtained mainly by compiling the information from several reviews looking at biases in rehabilitation. In addition, separate searches by biases and looking at reference lists of selected studies as well as using Scopus forward citation for relevant references were used.This review provides several strategies to guard against the impact of bias on study results. Clinicians, researchers, and other stakeholders are encouraged to apply these recommendations when designing and conducting rehabilitation trials.

Effect of Sham Acupuncture on Chronic Pain: A Bayesian Network Meta-analysis

BACKGROUND

Along with increasing research on acupuncture for chronic pain, the validity of sham acupuncture (SA) has also been argued.

METHODS

Nine databases were searched for randomized controlled trials (RCTs) from the inception date to July 5, 2022. Using Markov Chain Monte Carlo methods, a Bayesian multiple treatment network meta-analysis (NMA) with random-effects model was conducted.

RESULTS

A total of 62 RCTs with 6806 patients and four kinds of treatments (real acupuncture (RA), non-acupuncture (NA), penetrative SA (PSA) and non-penetrative SA (NPSA)) were included. The results indicated that both NPSA and PSA were not superior to NA in improving chronic pain (NPSA: MD -4.77 [95% CI, -11.09 to 1.52]; PSA: MD, -4.96 [95% CI, -10.38 to 0.48]). After combining NPSA and PSA into the SA group, the weak trend of pain relief from SA was still not statistically significant (MD, -4.91 [95% CI, -9.93 to 0.05]). NPSA and PSA had similar effects (MD, 0.18 [95% CI, -5.45 to 5.81]). RA was significantly associated with pain relief, compared with NPSA and PSA (NPSA: MD, -12.03 [95% CI, -16.62 to -7.41]; PSA: MD, -11.85 [95% CI, -15.48 to -8.23]). The results were generally consistent regardless of pain phenotype, frequency, duration, acupuncture methods, analgesic intake, or detection bias.

CONCLUSION

These results suggested that acupuncture was significantly associated with reduced chronic pain. The two kinds of placebo acupuncture, NPSA and PSA, have similar effects. Both NPSA and PSA, with a weak but not significant effect, are appropriate to be inert placebo controls in RCTs for chronic pain.

Acupuncture Based on Regulating Autonomic Nerves for the Prevention of Migraine Without Aura: A Prospective, Double-Dummy, Randomized Controlled Clinical Trial

Background

Migraine without aura (MWoA) is a nervous system disease, which is closely related to autonomic nerves dysfunction. As a popular non-pharmacological alternative treatment for preventing migraine, it remains unclear whether the acupuncture can prevent MWoA. Thus, this trial aims to evaluate the preventive effect and safety of the acupuncture method of stimulating acupoints that regulate autonomic nerves in MWoA patients.

Methods

This is a single-center, prospective, double-dummy, randomized controlled clinical trial. A total of ninety-six patients with MWoA are randomly allocated to acupuncture combined with the placebo group and sham acupuncture combined with the medication group in a 1:1 ratio. All subjects will receive intervention for 8 weeks and follow-up assessments three times (one month, three months, and six months in follow-up visiting). The frequency of acupuncture in both groups is three times a week for eight weeks. The primary outcome will be evaluated using a visual analog scale (VAS) and the number of migraine attacks per four weeks. The secondary outcome measures will include the migraine-specific quality of life (MSQOL) scale and headache needs assessment survey (HANA) questionnaire scale.

Results

The acupoint selection of this clinical trial is based on the combination of traditional Chinese medicine theory with modern medicine, thereby evaluating the efficacy and safety of the acupuncture method of stimulating acupoints that regulate autonomic nerves in the prevention of MWoA. The results may provide evidence of the beneficial effects of acupuncture on the prevention of MWoA by regulating autonomic nerves dysfunction.

Trial Registration

ClinicalTrials.gov NCT04766762.

Reporting quality of sham needles used as controls in acupuncture trials: a methodological evaluation

OBJECTIVE

The description of controls is important in acupuncture clinical trials to interpret its effectiveness without fallacy. This paper aims to evaluate the reporting quality of acupuncture studies on the characteristics of sham needles.

STUDY DESIGN AND SETTING

Using a checklist developed from previously published reporting guidelines, the distribution of reported items and changes of reporting rates over time were investigated. Two-way ANOVA and linear regression were conducted.

RESULTS

Original articles of RCTs of any design involving sham needles as controls were eligible for assessment. 117 trials from three 2-year time periods between 2009 and 2018 were included. Seven items out of 25 were reported in more than 50% of the studies. While significant differences of reporting scores among categories were observed, there were no significant differences among time periods; no significant improvement was observed over time.

CONCLUSIONS

Low reporting qualities of sham needles used in acupuncture studies may influence how researchers understand the effectiveness of acupuncture. This study evaluated previous publications from 2009 to 2018 and found that reporting qualities on sham needles did not improve over time. Further studies are required to validate the items used in this study to endorse better reporting of controls in acupuncture trials.

Efficacy of Acupuncture on Quality of Life, Functional Performance, Dyspnea, and Pulmonary Function in Patients with Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Clinical Trial

Chronic obstructive pulmonary disease (COPD) is a respiratory disease characterized by the presence of chronic airflow obstruction. Previous studies have evaluated the effect of acupuncture treatment (AT) in patients with COPD. Nevertheless, these studies show a great deal of heterogeneity in treatment protocols, having sample sizes that are too small to estimate and clarify effect size and heterogeneity in patients’ baseline. The aim of this study is to evaluate the effectiveness of acupuncture on quality of life, functional performance, dyspnea, and pulmonary function in patients with COPD. As such, patients will go through the following three phases: Phase I–pretreatment: period of subject selection and inclusion in the protocol, with an interview and performance of exams and tests as follows: Mini-Cog, dual-energy X-ray absorptiometry, spirometry, the Patient-Generated Index, Saint George’s Respiratory Questionnaire, the six-minute walk test, the London Chest Activity of Daily Living, and the COPD Assessment Test. Phase II–8 weeks of treatment, with AT 3 times a week, with two parallel groups: Group I–with 50 subjects–AT according to the recommended technical standards; Group II–with 50 subjects–Control, without acupuncture. Phase III–Continuation of AT for 8 weeks, maintaining the subjects in the previously allocated groups and following the same methodology.

The Dose-Related Efficacy of Acupuncture on Endometrial Receptivity in Infertile Women: A Systematic Review and Meta-Analysis

Background

Progress has been achieved by using acupuncture widely for poor endometrial receptivity (PER). However, different acupuncture dosages may lead to controversy over efficacy.

Objective

To evaluate the evidence-based conclusions of dose-related acupuncture on infertile women with PER.

Method

References were retrieved from nine databases from inception to 26 February 2022. This meta-analysis included randomized controlled trials (RCTs) that investigated the dose-related efficacy of acupuncture for PER with outcomes of endometrium receptivity (ER) parameters by transvaginal sonography (TVS) and the subsequent pregnancy outcomes in three acupuncture-dose groups: the high-dosage group (three menstrual cycles), the moderate-dosage group (one menstrual cycle), and the low-dosage group (two or four days). Since there remained sufficient heterogeneity among the three subsets, we prespecified seven subgroup variables (four clinical and three methodological) to investigate the heterogeneities.

Results

A total of 14 RCTs (1,564 women) of moderate or low overall quality were included. The results were different when the dosage of acupuncture was restricted. For the moderate or high-dosage group, CPR and part of ER parameters were improved in the acupuncture group (i.e., CPR: OR = 2.00, 95% CI [1.24, 3.22], p = 0.004, I ² = 0% in one menstrual cycle; OR = 2.49, 95%CI [1.67, 3.72], p < 0.05, I ² = 0% in three menstrual cycles). However, for the low-dosage group, no statistical difference was observed in CPR (OR = 0.07, 95% CI [-0.10, 0.23], p = 0.44, I ² = 82%) and a part of the ER parameters. In subgroup analysis, four subgroup variables (the routine treatment, risk of performance bias, duration of acupuncture treatment, and the age of participants) could explain some of the heterogeneities across all trials.

Conclusion

The finding indicated that the trend of relatively more acupuncture dosage showed better effects for poor endometrial receptivity among PER women. It remains a potential heterogeneity in our studies. Further high-quality trials with a homogeneity trial design need to be conducted.

Electroacupuncture for treating cancer-related insomnia: a multicenter, assessor-blinded, randomized controlled, pilot clinical trial

Background

Insomnia is one of the most frequent symptoms in people with cancer. Electroacupuncture has been widely used in people with cancer or insomnia. We explored the feasibility and preliminary effectiveness of electroacupuncture for cancer-related insomnia.

Methods

People with cancer and insomnia disorder were randomly allocated to electroacupuncture, sham-electroacupuncture, or usual care groups. Participants received either 10 sessions of electroacupuncture at real acupoints, sham-electroacupuncture at non-acupoints, or usual care in each group for 4 weeks. We calculated the recruitment, adherence, and completion rates of participants. The Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), sleep diary and actigraphy-derived sleep parameters, Functional Assessment of Cancer Therapy-Fatigue (FACT-F), Montreal Cognitive Assessment (MoCA), and salivary levels of cortisol and melatonin were evaluated as outcome measures.

Results

Twenty-two participants were enrolled (8, 6, and 8 respectively in the electroacupuncture, sham-electroacupuncture, and usual care groups) and 20 participants completed the trials (8, 4, and 8 respectively). The recruitment, adherence, and completion rates were 78.57% (22/28), 95.45% (21/22), and 90.91% (20/22), respectively. Most of the participants had previously received conventional treatment for insomnia, but few had received Korean medicine treatment, without any demographic or clinical differences between groups. In the electroacupuncture group, there was a statistically significant reduction of 10.13 (mean) ± 8.15 (standard deviation) and 5 ± 3.70 points in mean ISI and PSQI scores at 4 weeks post-treatment (P = .0098 and .0066), compared with sham-electroacupuncture (2.06 ± 7.15 and 1.61 ± 4.34; P = .4796 and .3632) and usual care (3.25 ± 2.60 and 1.38 ± 2.13; P = .0096 and .1112). Although there was no significant difference in ISI score between groups at 4 weeks post-treatment, the electroacupuncture group continued to improve significantly at 4 weeks’ follow-up, showing borderline and significant differences compared to the sham-electroacupuncture and usual care (P = .0614 and .0015). The FACT-F scores in electroacupuncture group showed a significant improvement compared with the sham-electroacupuncture group (P = .0305). No electroacupuncture-related adverse events were reported.

Conclusions

Electroacupuncture might be feasible for cancer-related insomnia, despite slow participant recruitment. Additional trials with adequately powered sample sizes and a substantial change to the recruitment procedure are needed.

Trial registration

Clinical Research Information Service, KCT0002162. Submitted 27 October 2016, Registered 2 December 2016 - Retrospectively registered (The first participant enrolment: 28 November 2016),

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03561-w.

Effectiveness of electro-press needle for menopause-associated hot flashes: Protocol of a randomized controlled trial

BACKGROUND

Hot flashes (HF) are a prevalent symptom associated with menopause affecting up to 85% of women aged 40 to 65 years. Previous studies indicated that acupuncture might relieve the symptom of HF significantly; however, its effectiveness has not been clarified quantitatively. Electro-press needles (EPN) is a novel acupuncture that combines a shallow tiny needle with an electrical transdermal stimulator. Either the needle or the electrical stimulator could function in the treatment. This study aims to evaluate the effectiveness of EPN in comparison with no intervention in relieving HF of perimenopausal and postmenopausal women.

METHODS/DESIGN

This study will be a 2-arm randomized waitlist controlled trial. According to the ratio of 1:1 and block randomization, a total of 122 patients with moderate or severe HF will be randomly allocated to either EPN group or waitlist control group. The EPN group will receive 3 sessions of EPN treatment each week in consecutive 6 weeks, 18 sessions in total. The waitlist control group will get no intervention over the first 6 weeks. All the patients will be followed up in the next 24 weeks. The primary outcome will be the percentage of the participants whose 24-hour mean HF is 50% less than the baseline at Week 6. Secondary outcomes will include HF score, HF frequency, HF severity, the Menopause Rating Scale and Menopause-Specific Quality of Life Questionnaire Score.

DISCUSSION

This study will evaluate the effectiveness and safety of EPN treatment to alleviate HF symptoms in perimenopausal and postmenopausal women, excluding self-healing factors. The limitations of the trial design are its single-center scope, lack of placebo control and impossible to blind the acupuncturists and patients.Trial registration: This clinical trial has been registered in Clinical Trial Registry (registration number: NCT04995107; date of registration: Aug 6, 2021).

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Systematic Review PROSPERO Registration

identifier [CRD42021260889].

Efficacy of acupuncture on cognitive function in poststroke depression: study protocol for a randomized, placebo-controlled trial

Introduction

Poststroke depression (PSD) is the most common mental complication after stroke and has a serious impact on functional outcomes and quality of life. Antidepressants are the first-line treatment for PSD, but many reported side effects remain. Clinical research has shown that acupuncture has a positive effect on PSD. This trial aims to study the efficacy and safety of acupuncture for PSD and to explore its effect on cognitive function. It is hypothesized that acupuncture treatment improves depressive symptoms, cognitive behavior, and negative emotion processing bias in PSD.

Methods

In this randomized, placebo-controlled, single-blinded trial, fifty-six people with PSD will be randomly allocated into the intervention (n=28) or control (n=28) groups. The intervention group will receive acupuncture treatment, and the control group will receive sham acupuncture treatment, in 20 sessions over 4 weeks. The primary outcome is the change from baseline in the Hamilton Depression Scale-17 (HAMD-17) scores at week 4. Secondary outcomes include the Wisconsin Card Sorting Test (WCST) and latency and amplitude of P1, N170, and P3 of the event-related potentials (ERPs) components to assess the changes in cognitive function and electroencephalography. Outcomes are assessed at baseline and post intervention.

Discussion

Acupuncture therapy could become an alternative treatment for PSD, and it is expected that this trial will provide reliable clinical evidence for the future use of acupuncture for the treatment of PSD.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900026948. Registered on 27 October 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06011-7.

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

BACKGROUND

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

METHODS

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

CONCLUSION

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

LAY SUMMARY

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

Acupuncture effects on in-vitro fertilization pregnancy outcomes: A meta-analysis

BACKGROUND

The effects of acupuncture on in-vitro fertilization outcomes remain controversial. This study aimed to perform a meta-analysis to assess the effectiveness of acupuncture as an adjuvant therapy to embryo transfer compared to sham-controls or no adjuvant therapy controls on improving pregnancy outcomes in women undergoing in-vitro fertilization.

METHODS

A systematic literature search up to January 2021 was performed and 29 studies included 6623 individuals undergoing in-vitro fertilization at the baseline of the study; 3091 of them were using acupuncture as an adjuvant therapy to embryo transfer, 1559 of them were using sham-controls, and 1441 of them were using no adjuvant therapy controls. They reported a comparison between the effectiveness of acupuncture as an adjuvant therapy to embryo transfer compared to sham-controls or no adjuvant therapy controls on improving pregnancy outcomes in women undergoing in-vitro fertilization. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated assessing the effectiveness of acupuncture as an adjuvant therapy to embryo transfer compared to sham-controls or no adjuvant therapy controls using the dichotomous method with a random or fixed-effect model.

RESULTS

Significantly higher outcomes with acupuncture were observed in biochemical pregnancy (OR, 1.98; 95% CI, 1.55-2.53, p < 0.001); clinical pregnancy (OR, 1.70; 95% CI, 1.46-1.98, p < 0.001); ongoing pregnancy (OR, 1.78; 95% CI, 1.41-2.26, p < 0.001); and live birth (OR, 1.58; 95% CI, 1.15-2.18, p = 0.005) compared to no adjuvant therapy controls. However, no significant difference were found between acupuncture and no adjuvant therapy controls in miscarriage (OR, 0.96; 95% CI, 0.48-1.92, p = 0.91). No significant difference was observed with acupuncture in biochemical pregnancy (OR, 1.16; 95% CI, 0.65-2.08, p = 0.62); clinical pregnancy (OR, 1.13; 95% CI, 0.83-1.54, p = 0.43); ongoing pregnancy (OR, 1.04; 95% CI, 0.66-1.62, p = 0.87); live birth (OR, 1.02; 95% CI, 0.73-1.42, p = 0.90), and miscarriage (OR, 1.16; 95% CI, 0.86-1.55, p = 0.34) compared to sham-controls.

CONCLUSIONS

Using acupuncture as an adjuvant therapy to embryo transfer may improve the biochemical pregnancy, clinical pregnancy, ongoing pregnancy, and live birth outcomes compared to no adjuvant therapy controls. However, no significant difference was found between acupuncture as an adjuvant therapy to embryo transfer and sham-controls in any of the measured outcomes. This relationship forces us to recommend the use of acupuncture as adjuvant therapy in women undergoing in-vitro fertilization and inquire further studies comparing acupuncture and sham-controls to reach the best procedure.

Kininogen-Nitric Oxide Signaling at Nearby Nonexcited Acupoints after Long-Term Stimulation

Acupuncture treatment is based on acupoint stimulation; however, the biological basis is not understood. We stimulated one acupoint with catgut embedding for 8 weeks and then used isobaric tags for relative and absolute quantitation to screen proteins with altered expression in adjacent acupoints of Sprague Dawley rats. We found that kininogen expression was significantly upregulated in the stimulated and the nonstimulated adjacent acupoints along the same meridian. The enhanced kininogen expression was meridian dependent and was most apparent among small vessels in the subcutaneous layer. Enhanced signals of nitric oxide synthases, cGMP-dependent protein kinase, and myosin light chain were also observed at the nonstimulated adjacent acupoints along the same meridian. These findings uncover biological changes at acupoints and suggest the critical role of the kininogen–nitric oxide signaling pathway in acupoint activation.

Comparing scientific worldviews between allopathic medical degree and East Asian medicine degree students utilizing the thinking about science survey instrument (TSSI)

BACKGROUND

Integrative medicine has become a new healthcare model due to the growing evidence base for complementary and integrative therapies. However, some question whether complementary and integrative therapies can truly be integrated with biomedicine due to differences in underlying paradigms and theoretical bases. This study aimed to explore differences in scientific worldviews between students studying East Asian medicine and those completing an allopathic medical degree using the validated Thinking about Science Survey Instrument (TSSI).

METHODS

122 medical students from Albert Einstein College of Medicine (Einstein) and 48 East Asian medicine students from the Pacific College of Health and Science (Pacific College) participated in this study. Participants completed the TSSI, a 60-item Likert-scale instrument that quantitatively measures the sociocultural resistance to, and support for science. Item and category means were compared between each group using an independent sample t-test.

RESULTS

Distinct differences were seen between the two groups of students with regard to age, gender distribution and prior education. Einstein students were generally supportive of science and Pacific College students were generally supportive of/positively neutral to science. Einstein students more strongly affirmed the relationship of science in relation to the categories of Epistemology, Public Health, Emotion and Aesthetics, the Economy, and Public Policy. Pacific College students more strongly affirmed the relationship between science and the category Race and Gender. There were no differences in the categories of Environment and Resource, Science for All, and Religion and Morality.

CONCLUSION

This study suggests that there are differences underlying the scientific worldviews of Einstein and Pacific College students, particularly with regard to Epistemology and Public Health. Such differences may be related to the different theoretical knowledge bases and ways of viewing health within the two disciplines. Despite demographic and educational differences between the two groups their overall scientific worldviews were similar with neither group expressing disparate views. This suggests that both groups may be receptive to the value of other paradigms. Providing courses that focus on different therapeutic approaches and paradigms during medical training may foster interprofessional understanding and collaborative practice between health professionals of different medical disciplines.

The Feasibility of Blinding Intraoperative Electro-Auricular Acupuncture Under Neuraxial Anesthesia

Objective: Demand for complementary medicine, in particular, acupuncture, has increased over the past few years but widespread acceptance has been limited, in part, by the lack of high-quality studies, including lack of blinding. Acupuncture studies traditionally have difficulty with blinding as sham acupuncture can have up to a 40%-50% analgesic effect. This study randomized patients between Acupuncture and No Acupuncture (standard of care) without using sham needles. The primary outcome was adequate blinding of electro-auricular acupuncture in the intraoperative setting with secondary outcomes of pain/nausea control. Materials and Methods: Forty patients undergoing anterior cruciate ligament reconstruction were enrolled. Subjects were randomly assigned to receive acupuncture (Enhanced Electro-Auricular Trauma Protocol) or No Acupuncture during their surgeries. All patients received spinal anesthesia and intravenous midazolam, ketamine, and propofol for sedation. 1000 mg of intravenous (IV) acetaminophen and up to 30 mg of IV ketorolac were given at closure. No opioids or peripheral nerve blocks were administered intraoperatively. Results: Bang's Blinding indices were 0.2 (95% confidence interval [CI]: -0.02, 0.42) in the Acupuncture group, and 0.11 (95% CI: -0.10, 0.31) in the No Acupuncture group on postoperative day 1. Both groups had adequate blinding. There were no differences in pain scores, nausea/vomiting incidence, opioid consumption 0-24 hours, or patient satisfaction. Five patients in the No Acupuncture group received rescue blocks, while no patients in the Acupuncture group needed a rescue block (Fisher's exact test: p = 0.047). Conclusions: This study proved the primary hypothesis that adequate blinding of intraoperative acupuncture can be performed when patients are under sedation and neuraxial anesthesia. This research is registered at ClinicalTrials.gov as Clinical Trial Registration #: NCT03711734.

Manual Acupuncture Plus Usual Care Versus Usual Care Alone in the Treatment of Endometriosis-Related Chronic Pelvic Pain: A Randomized Controlled Feasibility Study

Objective: To determine the acceptability and feasibility of acupuncture for the treatment of endometriosis-related chronic pelvic pain. Design: A prospective, randomized controlled feasibility study. Setting: Outpatient setting in Sydney, Australia. Subjects: Participants who were aged 18-45 years, had a confirmed laparoscopic diagnosis of endometriosis in the past 5 years, and had regular menstrual periods and mean pelvic pain scores ≥4/10. Interventions: Sixteen acupuncture treatments delivered by registered acupuncturists using a standardized point protocol over 8 weeks, twice per week plus usual care compared with usual care alone. Outcome measures: Primary outcome measures were feasibility, safety, and acceptability of the acupuncture intervention. Secondary outcomes were changes in self-reported pelvic pain scores, changes in quality of life as measured by the Endometriosis Health Profile (EHP-30), changes in descending pain modulation, and changes in systemic inflammation (plasma interleukin [IL-6] concentrations). Results: Twenty-nine participants were eligible to participate, with 19 participants completing the trial. There was unequal withdrawals between groups; the acupuncture group had a withdrawal rate of 14% compared with 53% in usual care. Adverse events were uncommon (6.7%) and generally mild. A 1.9 point decrease in median nonmenstrual pain scores and a 2.0 decrease in median menstrual pain scores between baseline and end of trial were observed in the acupuncture group only. Improvements in all domains of the EHP-30 were seen in the acupuncture group, with no changes seen in usual care. There was no difference between baseline and end of treatment in IL-6 concentrations for either group. Conclusions: Acupuncture was an acceptable, well-tolerated treatment and it may reduce pelvic pain and improve quality of life; however, usual care was not an acceptable control group. Trial Registration: anzctr.org.au: ACTRN12617000053325. Prospectively registered January 11, 2017.

IVF, acupuncture and mental health: a qualitative study of perceptions and experiences of women participating in a randomized controlled trial of acupuncture during IVF treatment

Infertility treatments such as in-vitro fertilization (IVF) are stressful and challenging to mental health and well-being. The use of alternative therapies adjunct to IVF treatment, such as acupuncture, is common and women hope to improve their chance of pregnancy and live birth. While many women engage in acupuncture adjunct to IVF in Australia, few qualitative studies of women's motivations and experiences have been conducted in this field. A qualitative study was nested within a randomized controlled trial of acupuncture during IVF treatment in order to explore women's perceptions of acupuncture, its effects in the context of IVF treatment, and how acupuncture is perceived in relation to the outcome of IVF. Fifty women randomized into both acupuncture and sham acupuncture groups were interviewed using a semi-structured format. In-depth interviews were transcribed, coded and categorized in a theoretical thematic analysis. Two primary themes emerged: 'psychological benefit' and 'perceived influence of acupuncture on fertility/medical outcome'. Regardless of randomization, women in both groups described similar psychological effects suggesting that a placebo effect was present. They were not convinced that acupuncture could enhance their treatment outcome through biomedical pathways. Rather, they perceived that acupuncture or sham acupuncture gave them a psychological advantage through increased relaxation, reduced psychological stress, and enhanced well-being and self-efficacy. In conclusion, there are significant features associated with a placebo effect in acupuncture that might be exploited to provide psychological benefit for women undertaking IVF.

Electroacupuncture for Poststroke Spasticity: Results of a Pilot Pragmatic Randomized Controlled Trial

CONTEXT

People with spasticity that occurred between 30 days and one year after stroke onset with a baseline Modified Ashworth Scale (MAS) ≥1.

OBJECTIVES

To determine the practicality of a pragmatic parallel-group open-labeled randomized controlled trial and to collect preliminary data of effectiveness and safety of electroacupuncture (EA) for poststroke spasticity.

METHODS

Eligible participants were randomly allocated to the intervention group (EA plus usual care) or the control group (usual care alone) at a 1:1 ratio with block sizes of six. Participants received EA three times a week for four weeks, then were followed up for another four weeks. Participants' retention and adherence in the trial were assessed to determine the practicality of trial design. Clinical outcome measures were the change scores of MAS, Fugl-Meyer Assessment of motor performance and Barthel Index, and adverse events.

RESULTS

Seventy-two people were screened for eligibility, and 30 of them were recruited and randomized. At the end, 25 participants followed the trial protocol and were included in our final data analyses using an intention-to-treat approach. No significant between-group difference was detected for the change scores of MAS, Fugl-Meyer Assessment, or Barthel Index at the end of treatment or end of follow-up. Eighteen participants reported 37 adverse events, but none of the participants was deemed related to EA.

CONCLUSION

It is feasible to conduct a full-scale trial to precisely evaluate the effectiveness and safety of EA for treating poststroke spasticity; however, longer treatment and follow-up phases should be considered in the full-scale trial.

Benefits of Adding Gluteal Dry Needling to a Four-Week Physical Exercise Program in a Chronic Low Back Pain Population. A Randomized Clinical Trial

OBJECTIVE

To determine if adding dry needling to a four-week exercise program has an additional benefit compared with adding sham dry needling to the same exercise program in subjects with chronic low back pain.

DESIGN

Randomized clinical trial.

SETTING

Physiotherapy and Pain Clinic of Alcala University.

SUBJECTS

Forty-six patients with chronic low back pain.

METHODS

Subjects were randomized to two groups: the dry needling group (N = 23) or sham dry needling group (N = 23). Both groups received a four-week exercise program and before the exercise started a session of dry needling or sham dry needling. Pain (visual analog scale), disability (Roland-Morris Questionnaire), and fear avoidance beliefs (Fear Avoidance Beliefs Questionnaire) were assessed at baseline, after treatment, and at three-month follow-up. Pressure pain thresholds (algometer) were measured at baseline, after the dry needling or the sham dry needling, and after treatment.

RESULTS

Both groups showed significant improvements for all variables. In the between-group comparison, the dry needling group improved significantly in pain at three-month follow-up and pressure pain thresholds at the end of treatment for all measures, and at three-month follow-up there was no improvement in gluteus medium.

CONCLUSIONS

In chronic low back patients, adding dry needling to a four-week exercise program has an additional benefit in pain and sensitivity compared with adding sham dry needling to the same exercise program.

Acupuncture as a Treatment Within Integrative Health for Palliative Care: A Brief Narrative Review of Evidence and Recommendations

Background: Acupuncture is one of the fastest developing evidence bases in Complementary Medicine and is one of the leading therapies included within integrative health care. This narrative review includes two separate parts: the first is about evaluation of the current evidence status in reviews on acupuncture and the second examines and gives examples of available recommendations on acupuncture in treatment guidelines from health care experts and public health organizations recommending acupuncture as a viable treatment in patients in palliative care. Methods: Electronic searches were performed in PubMed using the terms "acupuncture" + "palliative" and adding the term "safety" to find review articles documenting safety and evidence of effectiveness of acupuncture for treatment of symptoms in palliative care patients. Treatment guidelines that recommend use of acupuncture for symptom control in palliative care were found by searching through a database currently under construction by the lead author. Results: Acupuncture shows emerging evidence for 17 indications in palliative care. Examples were found and presented of publications recommending acupuncture for treatment of symptoms for patients in palliative care from Government, public health, oncology, and medical expert sources. The most publications are in oncology, but other conditions were found and a number were found in pediatric care. Conclusions: While the evidence for use of acupuncture to treat symptoms in palliative care patients is relatively weak, the evidence base is growing. Experts worldwide are also increasingly recommending acupuncture as a treatment for symptoms in palliative care. Since acupuncture is a safe, nonpharmacological treatment but with small, clinically significant effects, these recommended uses appear as pragmatic efforts to bridge the gap of treatment options available to this patient group.

Non-specific effects of acupuncture and sham acupuncture in clinical trials from the patient's perspective: a systematic review of qualitative evidence

BACKGROUND

Previous clinical trials have demonstrated that both acupuncture and sham acupuncture exert significant, non-specific effects on treatment outcomes when compared to no-treatment controls. A recently developed framework (mechanisms in orthodox and complementary and alternative medicine-MOCAM) suggests that the non-specific effects of acupuncture originate from multiple domains (e.g. patient characteristics, acupuncturist skill/technique, the patient-acupuncturist relationship, and the acupuncture environment). However, it remains to be determined precisely how these domains influence the non-specific effects of treatment among patients receiving acupuncture and sham acupuncture in clinical trials. Therefore, we conducted a systematic review to synthesize existing qualitative evidence on how trial participants randomized to acupuncture and sham acupuncture groups experience non-specific effects, regardless of the types of medical condition investigated.

METHODS

This systematic review included primary qualitative studies embedded in randomized controlled trials designed to investigate acupuncture or sham acupuncture interventions. Eligible studies published in English were derived from a search of five international databases. The methodological quality of included studies was evaluated using the Critical Appraisal Skills Programme (CASP) tool. Using a framework synthesis approach, the identified MOCAM framework was adapted based on the synthesis of the available qualitative evidence.

RESULTS

A total of 20 studies of high methodological quality were included. Our proposed model indicated that the effects of acupuncture may be increased by maintaining a professional status, applying a holistic treatment approach, practicing empathy, and providing patients with an appropriate explanation of the theory behind acupuncture and sham acupuncture. From the patient's perspective, the efficacy of treatment can be increased by following the lifestyle modification advice provided by acupuncturists, maintaining a positive attitude toward treatment efficacy, actively engaging with acupuncturists during consultation, and making behavioral changes based on experience gained during the trial.

CONCLUSION

The results of this study may provide a basis for improving and standardizing key components of non-specific effects in acupuncture treatment, and for improving the isolation of specific effects in future clinical trials involving acupuncture and sham acupuncture.

General Issues in Clinical Research of Acupuncture and In Vitro Fertilization

In vitro fertilization-embryo transfer (IVF-ET), a well-developed technology, provides the last possibility or hope for infertile women. However, the live birth rate per IVF cycle is still not satisfactory. Acupuncture is a frequently used adjunctive therapy drawing wide attention on improvement of IVF. Although so many randomized controlled trials have been evaluating the effect of acupuncture on IVF in the past 20 years, the exact efficacy of acupuncture on IVF is still controversy mainly because of no consensus on placebo control and acupuncture scheme. This paper focused on the general issues in clinical research of acupuncture and IVF and gave some suggestions for future directions.

Effect of acupuncture on hormone level in patients with gastrointestinal dysfunction after general anesthesia: A study protocol for a randomized controlled trial

BACKGROUND

Postoperative gastrointestinal dysfunction (PGD) refers to one of the common postoperative complications. Acupuncture can facilitate the recovery of PGD, whereas no therapeutic schedule of acupuncture has been internationally recognized for treating PGD. In the present study, a scientific trial protocol has been proposed to verify the feasibility of acupuncture in treating gastrointestinal dysfunction after laparoscopic cholecystectomy under general anesthesia. We conduct this protocol to investigate whether acupuncture recovery gastrointestinal dysfunction by influencing the expression of gastrointestinal hormone.

METHOD

The present study refers to a randomized, evaluator blinded, controlled, multi-center clinical trial; it was designed complying with the Consolidated Standards of Reporting Trials (CONSORT 2010) as well as the Standard for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA). The subjects will be taken from the inpatients having undergone laparoscopic surgery of Mianyang Affiliated Hospital of Chengdu University of traditional Chinese medicine, Mianyang Third Hospital and Mianyang Anzhou Hospital. Based on the random number yielded using SPSS 25.0 software, the qualified subjects will be randomly classified to the experimental group and the control group. Therapies will be performed 30 min once after operation, the experimental group will be treated with acupuncture, while the control group will receive intravenous injection of granisetron. The major outcome will be the time to first flatus, and the secondary outcomes will include the time to first defecation, abdominal pain, dosage of analgesia pump, abdominal distention, nausea, vomiting, gastrointestinal hormone, as well as mental state. The efficacy and safety of acupuncture will be also assessed following the principle of Good Clinical Practice (GCP).

DISCUSS

A standardized and scientific clinical trial is conducted to assess the efficacy and safety of acupuncture for gastrointestinal dysfunction after laparoscopic cholecystectomy under general anesthesia. The aim is to objectively evidence and improves the clinical practice of acupoint prescription, as an attempt to promote the clinical application of this technology.

Acupuncture in sham device controlled trials may not be as effective as acupuncture in the real world: a preliminary network meta-analysis of studies of acupuncture for hot flashes in menopausal women

BACKGROUND

Randomised controlled trials of acupuncture performed using sham interventions to control for the placebo effect have mostly used two types of sham techniques: techniques with minimal insertion of acupuncture needles with no additional stimulation (shallow needling control) and techniques with sham acupuncture devices that do not penetrate the skin (sham device control). To achieve successful blinding, sham device controlled acupuncture trials also use the acupuncture base unit in the verum acupuncture group, but in the shallow needling control trials this is not necessary for the verum acupuncture treatment.

OBJECTIVE

In this study, we analysed the estimated comparative effectiveness of these two verum acupuncture modalities in studies of acupuncture for menopausal hot flashes that used two types of sham control treatments.

METHODS

We conducted a network meta-analysis that included randomised controlled trials of acupuncture for hot flashes. Electronic databases, including Medline, Embase, Cochrane Library and AMED, were searched through March 2017. Data were extracted using a predefined data extraction tool by two independent reviewers. The risk of bias was assessed using the Cochrane risk of bias tool for randomised controlled trials. A five-node network meta-analysis was conducted based on the frequentist framework.

RESULTS

Eight studies were included in this review. From the network meta-analysis, we found that verum acupuncture in the shallow needling controlled trials was more effective than verum acupuncture in the sham device controlled trials (SMD -7.27, 95% CI-9.11 to -5.43). Significant heterogeneity and inconsistency were not observed among the included studies or the comparisons.

CONCLUSIONS

From this preliminary analysis, we found that different types of verum acupuncture may have different effect sizes with respect to the severity of menopausal hot flashes.

The Role of Tactile Stimulation for Expectation, Perceived Treatment Assignment and the Placebo Effect in an Experimental Nausea Paradigm

Introduction

Tactile stimulation during a placebo treatment could enhance its credibility and thereby boost positive treatment expectations and the placebo effect. This experimental study aimed to investigate the interplay between tactile stimulation, expectation, and treatment credibility for the placebo effect in nausea.

Methods

Ninety healthy participants were exposed to a 20-min vection stimulus on two separate days and were randomly allocated to one of three groups on the second day after the baseline period: Placebo transcutaneous electrical nerve stimulation (TENS) with tactile stimulation (n = 30), placebo TENS without tactile stimulation (n = 30), or no intervention (n = 30). Placebo TENS was performed for 20 min at a dummy acupuncture point on both forearms. Expected and perceived nausea severity and further symptoms of motion sickness were assessed at baseline and during the evaluation period. At the end of the experiment, participants in the placebo groups guessed whether they had received active or placebo treatment.

Results

Expected nausea decreased significantly more in the placebo groups as compared to the no treatment control group (interaction day × group, F = 6.60, p = 0.003, partial η² = 0.20), with equal reductions in the two placebo groups (p = 1.0). Reduced expectation went along with a significant placebo effect on nausea (interaction day × group, F = 22.2, p < 0.001, partial η² = 0.35) with no difference between the two placebo groups (p = 1.0). Twenty-three out of 29 participants in the tactile placebo group (79%) but only 14 out of 30 participants (47%) in the non-tactile placebo group believed that they had received the active intervention (p = 0.015). Bang’s blinding index (BI) indicated random guessing in the non-tactile placebo group (BI = 0; 95% CI, −0.35 to 0.35) and non-random guessing in the direction of an “opposite guess” in the tactile placebo group (BI = −0.52; 95% CI, −0.81 to −0.22).

Conclusion

Tactile stimulation during placebo TENS did not further enhance positive treatment expectations and the placebo effect in nausea but increased the credibility of the intervention. Further trials should investigate the interaction between perceived treatment assignment, expectation, and the placebo effect during the course of a trial.

Acupuncture for the Treatment of Pain - A Mega-Placebo?

Several control conditions, such as penetrating sham acupuncture and non-penetrating placebo needles, have been used in clinical trials on acupuncture effects in chronic pain syndromes. All these control conditions are surprisingly effective with regard to their analgesic properties. These findings have fostered a discussion as to whether acupuncture is merely a placebo. Meta-analyses on the clinical effectiveness of placebo revealed that placebo interventions in general have minor, clinically important effects. Only in trials on pain and nausea, including acupuncture studies, did placebo effects vary from negligible to clinically important. At the same time, individual patient meta-analyses confirm that acupuncture is effective for the treatment of chronic pain, including small but statistically significant differences between acupuncture and sham acupuncture. All acupuncture control conditions induce de qi, a distinct stimulation associated with pain and needling which has been shown to be a nociceptive/pain stimulus. Acupuncture therefore probably activates the pain matrix in the brain in a bottom-up fashion via the spino-thalamic tract. Central nervous system effects of acupuncture can be modulated through expectations, which are believed to be a central component of the placebo response. However, further investigation is required to determine how strong the influence of placebo on the attenuation of activity in the pain matrix really is. A meta-analysis of individual participant functional magnetic imaging data reveals only weak effects of placebo on the activity of the pain network. The clinical acupuncture setting is comprised of a combination of a distinct neurophysiological stimulus, the needling stimulus/experience, and a complex treatment situation. A broader definition of placebo, such as that proposed by Howick (2017) acknowledges a role for expectation, treatment context, emotions, learning, and other contextual variables of a treatment situation. The inclusion of particular treatment feature as a definitional element permits a contextual definition of placebo, which in turn can be helpful in constructing future clinical trials on acupuncture.

Acupuncture for Post-stroke Shoulder-Hand Syndrome: A Systematic Review and Meta-Analysis

Background: Shoulder-hand syndrome (SHS) is prevalent in hemiplegic patients after stroke. Potential benefits of acupuncture were shown in recent clinical trials. This systematic review aimed to comprehensively evaluate the safety and efficacy of acupuncture for SHS in stroke patients.

Methods: Five English databases (PubMed, Embase, CINAHL, CENTRAL, and AMED) and four Chinese databases (CBM, CNKI, CQVIP, and Wanfang) were searched from their inceptions to January 2019. Randomized, controlled trials that evaluated the add-on effects of acupuncture to rehabilitation for post-stroke SHS were identified.

Results: Thirty-eight studies involving 3,184 participants fulfilled the eligible criteria and were included in the review. The overall meta-analysis showed that acupuncture combined with rehabilitation significantly improved motor function (upper-limb Fugl-Meyer Assessment (FMA): 34 studies, mean difference (MD) 8.01, 95% confidence interval (CI) [6.69,9.33]), and reduced pain (visual analog scale (VAS): 25 studies, MD −1.59, 95%CI [−1.86,−1.32]). It also improved activities of daily living (ADL) when compared with rehabilitation alone (ADL: 11 studies, MD 9.99, 95%CI [5.91,14.06]). However, the certainty of evidence of all these outcomes was assessed as “low.” Subgroup analyses of acupuncture stimulation types and treatment duration all showed significant add-on effects comparing with rehabilitation alone. The safety of acupuncture was unclear because there is a lack of detailed reporting of adverse events in most of the included studies.

Conclusions: Acupuncture therapy seems effective for motor function, pain relief and activities of daily living in stroke patients with mild SHS, when it is used in combination with rehabilitation. The low certainty of evidence downgrades our confidence in making recommendations to clinical practice.

Interdisciplinary Relationship Models for Complementary and Integrative Health: Perspectives of Chinese Medicine Practitioners in the United States

OBJECTIVES

The combination of biomedicine and traditional and complementary medicine (T&CM) is often referred to as integrative medicine. However, the degree to which the medical disciplines are integrated varies between medical settings, and it is believed by some to be impossible due to epistemological and paradigmatic differences. Clinicians' perspectives are important determinants of how different medical disciplines are used together. This study explores the perspectives of experienced Chinese medicine practitioners when asked about the most ethical model (opposition, integration, or pluralism) for the relationship between biomedicine and T&CM.

DESIGN

Thirty-one Chinese medicine practitioners, undertaking a doctoral upgrade program at the Pacific College of Oriental Medicine, participated in this study. Participants were asked to read a publication discussing three models (opposition, integration, and pluralism) for the relationship between biomedicine and T&CM and then discuss, via an online forum within Moodle learning management system, the most ethical model. An inductive content analysis of the forum posts was undertaken to identify common themes, followed by member checking.

RESULTS

The data were found to contain six major and six minor themes. There was a clear preference for pluralism. The Chinese medicine practitioners expressed reservations about the integrative model, and, above all, cared about the quality of patient care. Much dialogue occurred around issues related to a power imbalance within health care, and possible cooptation issues. Paradigmatic differences and a lack of compatibility between biomedical research models and the practice of Chinese medicine were seen as problematic to the validity of research findings. Interprofessional education was viewed as critical for the development of respect, shared patient care, and referrals between clinicians from different disciplines.

CONCLUSIONS

This study provides insight into the issues associated with combining biomedicine and T&CM that are perceived by Chinese medicine practitioners. Such insights are important for the development and management of clinical settings that provide complementary and integrative health care, especially as the provision of insurance coverage for T&CM increases.

Systematic Review of Acupuncture Placebo Devices with a Focus on the Credibility of Blinding of Healthy Participants And/Or Acupuncturists

Background

An ideal placebo design in clinical research should resemble the intervention under investigation to facilitate blinding, yet remain clinically inert. With regard to physical interventions such as acupuncture, a true placebo device has not been developed and validated. Since 1998, researchers have designed several placebo acupuncture devices (PADs). The three most widely used PADs are the Streitberger, the Park and the Takakura device.

Aim

This review focuses on evaluating studies of these devices, in the context of credibility of blinding (COB), assessment of penetrating pain or sensation, and de qi sensation.

Methods

Electronic database searches were conducted in four English and two Chinese databases from their inception until November 2016. All studies included in the review were conducted on healthy participants and compared verum manual acupuncture with any of the aforementioned PADs with respect to one or more of the above three outcomes related to blinding effect.

Results

The synthesised analyses of the 15 included studies showed that the Streitberger and Park placebo devices may not blind participants successfully when tested at a sensitive acupuncture point (LI4). In terms of penetrating sensation, there were significant differences between these two placebo devices and verum acupuncture when applied at this point. The Takakura device was the only PAD that had the potential to blind the acupuncturist. However, the blinding analyses of all outcome measures were inconsistent.

Conclusion

Overall, there were insufficient data to confirm the blinding effects of these skin-contact PADs as each device was associated with limitations that warrant further design improvements.

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.