Mechanisms of acupuncture analgesia for clinical and experimental pain

Short-term effectiveness of dry needling on pain and ankle range of motion in athletes with medial tibial stress syndrome- a randomized control trial

INTRODUCTION

Medial tibial stress syndrome (MTSS) is also called soleus syndrome because the resultant periostitis is localized to the medial insertion of the soleus muscle. This study explores the effectiveness of dry needling (DN) targeting soleus myofascial trigger points (MTrPs) in managing MTSS.

AIM

To assess the impact of DN on pain reduction and ankle range of motion (ROM) improvement in athletes with MTSS.

STUDY DESIGN

This randomized controlled trial (RCT) included 50 university-level athletes. (DN group = 25; control group = 25).

METHOD

Outcome variables, pain, and ankle dorsiflexion ROM were measured using the Numeric Pain Rating Scale (NPRS) and universal goniometer, respectively. The trial used statistical analyses like Wilcoxon rank test for within-group comparisons and Mann-Whitney U test for between-group comparisons. The trial was registered with the Clinical Trials Registry of India; CTRI/2023/10/058837.

RESULT

There were 24 Females (Age = 21.4 ± 2.06) & 26 Males (Age = 20.5 ± 2.35). DN significantly reduced pain in the intervention group from NPRS 7 ± 1.30 to 2 ± 0.87 (p < 0.001), but in the control group, the pain increased from NPRS 7 ± 0.99 to 7 ± 1.05 (p = 0.009). There was no improvement in ankle ROM.

CONCLUSION

DN effectively alleviated MTSS-associated pain in the short-term but was not effective in improving ankle ROM.

Acupuncture for pain and pain-related disability in deep infiltrating endometriosis

Objectives

To evaluate the efficacy of acupuncture in relieving symptoms (dysmenorrhea, dyspareunia, pelvic pain and dyschezia) intensity, improving functional disability, reducing the number of days per months of dysmenorrhea, the frequency and the efficacy of analgesic use in deep infiltrating endometriosis (DIE). The safety profile was also evaluated.

Methods

The study sample was 34 patients with DIE; for 2 months (T-2, T-1) the women recorded diary notes on the numbers of days of menstruation, the presence, intensity, and disability related to dysmenorrhea, dyspareunia, pelvic pain, and dyschezia. They then received a total of 15 acupuncture treatments over 6 months (T1-T6; once a week for 12 weeks, then once a month for 3 months).

Results

Dysmenorrhea intensity was decreased during treatment. A decrease of at least 50% in number of days of dysmenorrhea, and a decrease in moderate-to-severe disability starting from T1 to T6 was recorded for 58.6% of patients. Dyspareunia intensity steadily decreased starting at T2; the percentage of women with moderate-to-severe disability declined from 73.3% at T-2, to 36.9% at T3, T4, and T5. A decrease in pelvic pain score was noted starting at T1; the percentage of disability decreased from 83.3% at T-2 to 33.3% at T3 and T6. The intensity of dyschezia decreased from T-2 to T3 and T4 and then increased slightly. Analgesic drug use was lower during treatment and its efficacy appeared to be greater.

Conclusions

The limitations notwithstanding our study-findings show that acupuncture was safe and effective in reducing pain intensity and symptoms-related disability. Larger-scale studies are needed to compare acupuncture and pharmacotherapy for endometriosis-related pain.

Overview of the Effect of Complementary Medicine on Treating or Mitigating the Risk of Endometriosis

OBJECTIVE

 Endometriosis is a hormone-dependent chronic inflammatory disease with symptoms such as pelvic pain, which affect the physical, emotional, and social health of women in reproductive age. The current overview article aims to explore the effect of complementary medicine on the treatment or in mitigating the risk of endometriosis.

METHODS

 This is an overview article done in Iran. Two separate researchers systematically searched 3 databases (Medline, Scopus, and Cochrane Central Register Trials) until September 2020. The methodological quality of each study was assessed using the assessment of multiple systematic reviews (AMSTAR) tool.

RESULTS

 The results of two reviews suggested that physical activity, tobacco smoking, diet, coffee and caffeine intake had no effect on mitigating the risk of endometriosis or improving its treatment, but acupuncture successfully reduced pain and related marker (serum CA-125) levels.

CONCLUSION

 As endometriosis is an annoying disease with many complications and is hard to diagnose and treat, related studies in complementary medicine can help patients with endometriosis. Based on the relevant literature review, among the complementary medicine available for the treatment or to mitigate the risk of endometriosis, only acupuncture seems to alleviate the pain of endometriosis.

Dry needling trigger points around knee and hip joints improves function in patients with mild to moderate knee osteoarthritis

INTRODUCTION

Dry needling may be an effective method to alleviate pain and improve range of motion. Controversial results have been found in previous studies using dry needling in knee problems. So, the aim of current study is to exert dry needling technique on unilateral muscles around the hip and knee joints and evaluate its effects on knee osteoarthritic patients.

METHOD

For this double-blind randomized clinical trial, 40 female patients with mild to moderate knee osteoarthritis (aged 45-70 years old) were recruited. They entered the study if they had any trigger points around the hip or knee joints of the examined side and randomized into two groups. Pain, sensitivity of trigger points, balance and function measured by visual analogue scale, algometer, Y-balance test, timed up and go, self-paced walk tests beside KOOS questionnaire respectively before and after intervention. The intervention group received 3 sessions of dry needling on marked trigger points while the sham group received sham treatment consisting of only the plastic cover of a needle. Both groups reexamined 2 weeks after primary evaluation.

RESULTS

Comparing results before and after implementing dry needling revealed significant improvements in all measured variables in treatment group whereas, pain and timed up and go increased and peak pain pressure decreased in sham group. Between group comparison revealed significant differences in all variables.

CONCLUSION

Using 3 sessions of dry needling can increase functional activity, sensitivity and balance and decrease pain in patients with knee osteoarthritis in short term.

A Novel Research Technology to Explore the Mystery of Traditional Chinese Medicine: Optogenetics

Traditional Chinese medicine (TCM) is gaining increasing popularity worldwide for the function of health promotion and adjuvant therapy. However, the world's understanding of TCM is far from enough, which seriously limits the modernization and internationalization of TCM. Therefore, modern and efficient analytical methods are urgently needed to understand the mechanism of TCM. Optogenetics is one of the most prevalent technologies in the 21st century and has been used to explore life science, especially neuroscience. It already has had great influences in the study of neural circuits and animal models of mental diseases and was named “Method of the Year” by the Nature Methods journal in 2010. Increased interests occurred in the applications of optogenetics to explore a myriad of medical and mental health disorders. However, it has not so far been noticed by TCM researchers. We elaborated on an idea that introducing this technique into the field of TCM research to improve diagnosis, treatments, and evaluating the therapeutic effects. In this review, we made a systematic prospect in the theory, feasibility, and application of TCM optogenetics. We mainly focused on applying optogenetic methodologies to make a more comprehensive understanding of TCM.

Comparison between dry needling plus manual therapy with manual therapy alone on pain and function in overhead athletes with scapular dyskinesia: A randomized clinical trial

Muscles' trigger points can induce scapular dyskinesia (SD) which interferes with overhead athletes' professional training. We aimed to evaluate effects of dry needling (DN) alone and plus manual therapy (MT) on pain and function of overhead athletes with SD. 40 overhead athletes (15 male, 25 female) aged 18-45 with at least 3 points Numeric Rating Scale (NRS) pain intensity during training were recruited and randomly allocated to the treatment group: MT followed by DN on trigger points of Subscapularis, Pectoralis minor, Serratus anterior, upper and lower Trapezius muscles; or the control group: MT alone. The effect of shoulder trigger points DN plus MT with MT alone on pain, function, Pain Pressure Threshold (PPT) and SD in athletes with SD were compared. Both the examiner and the therapist were blinded to group assignment. Both groups were analyzed. Pain, disability and SD were improved in treatment group (P < .05). On the other hand, when only MT was applied, despite reduction in pain and disability (P < .001), scapular slide only improved in hands on waist position. Comparing the differences between groups showed a substantial reduction in pain (P < .001) and disability (P = .02) with significant improvement in scapular dyskinesia in treatment group (P = .02). Moreover, PPT significantly increased in the control group (P = .004). No adverse effects reported by the participants during this study. DN is an easy and applicable method that can synergistically reduce pain, disability and dyskinesia when it is combined with manual techniques to treat shoulder dysfunctions.

Role of Acupuncture in the Management of Severe Acquired Brain Injuries (sABIs)

Acupuncture therapy has been used to treat several disorders in Asian countries and its use is increasing in Western countries as well. Current literature assessed the safety and efficacy of acupuncture in the acute management and rehabilitation of patients with neurologic disorders. In this paper, the role of acupuncture in the treatment of acute severe acquired brain injuries is described, acting on neuroinflammation, intracranial oedema, oxidative stress, and neuronal regeneration. Moreover, beneficial effects of acupuncture on subacute phase and chronic outcomes have been reported in controlling the imbalance of IGF-1 hormone and in decreasing spasticity, pain, and the incidence of neurovegetative crisis. Moreover, acupuncture may have a positive action on the arousal recovery. Further work is needed to understand the effects of specific acupoints on the brain. Allegedly concurrent neurophysiological measurements (e.g., EEG) may help in studying acupuncture-related changes in central nervous system activity and determining its potential as an add-on rehabilitative treatment for patients with consciousness disorders.

Exploring the Mechanisms of Electroacupuncture-Induced Analgesia through RNA Sequencing of the Periaqueductal Gray

Electroacupuncture (EA) can relieve various pains. However, its mechanism in terms of the transcriptome is still not well-known. To explore the full profile of EA-induced molecular modification in the central nerve system, three twins of goats were selected for a match-paired experiment: EA stimulation (60 Hz, 30 min) and none-EA (control). Goats in the EA group showed an increased (p < 0.05) nociceptive threshold compared with the control goats. Experimental goats were sacrificed at 4 h of the experiment, and the periaqueductal grays were harvested for RNA sequencing. As a result, 2651 differentially expressed genes (1803 up-regulated and 848 down-regulated genes) were found and enriched in 30 Kyoto Encyclopedia of Genes and Genomes pathways and 149 gene ontology terms. EA-regulated five neuropeptide genes (proenkephalin, proopiomelanocortin, preprodynorphin, diazepam-binding inhibitor and proprotein convertase 1 inhibitor) were validated with quantitative PCR. Furthermore, up-regulated glutamate receptors, glutamate transporters, γ-aminobutyric acid (GABA) receptors, GABA transporters, synaptotagmins or mitogen-activated protein kinase (MAPK) genes might contribute to EA-induced analgesia through regulating the glutamatergic synapse, GABAergic synapse, MAPKs, ribosome or ubiquitin-proteasome pathways. Our findings reveal a full profile of molecular modification in response to EA and provide a solid experimental framework for exploring the mechanisms underlying EA-induced analgesia.

Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis

BACKGROUND

Endometriosis is a multifactorial, oestrogen-dependent, inflammatory, gynaecological condition that can result in long-lasting visceral pelvic pain and infertility. Acupuncture could be an effective treatment for endometriosis and may relieve pain. Our aim in the present study was to determine the effectiveness of acupuncture as a treatment for endometriosis-related pain.

METHODS

In December 2016, six databases were searched for randomised controlled trials that determined the effectiveness of acupuncture in the treatment of endometriosis-related pain. Ultimately, 10 studies involving 589 patients were included. The main outcomes assessed were variation in pain level, variation in peripheral blood CA-125 level, and clinical effective rate. All analyses were performed using comprehensive meta-analysis statistical software.

RESULTS

Of the 10 studies included, only one pilot study used a placebo control and assessed blinding; the rest used various controls (medications and herbs), which were impossible to blind. The sample sizes were small in all studies, ranging from 8 to 36 patients per arm. The mean difference (MD) in pain reduction (pre- minus post-interventional pain level-measured on a 0-10-point scale) between the acupuncture and control groups was 1.36 (95% confidence intervals [CI] = 1.01-1.72, P<0.0001). Acupuncture had a positive effect on peripheral blood CA-125 levels, as compared with the control groups (MD = 5.9, 95% CI = 1.56-10.25, P = 0.008). Similarly, the effect of acupuncture on clinical effective rate was positive, as compared with the control groups (odds ratio = 2.07; 95% CI = 1.24-3.44, P = 0.005).

CONCLUSIONS

Few randomised, blinded clinical trials have addressed the efficacy of acupuncture in treating endometriosis-related pain. Nonetheless, the current literature suggests that acupuncture reduces pain and serum CA-125 levels, regardless of the control intervention used. To confirm these findings, additional, blinded studies with proper controls and adequate sample sizes are needed.

Acupuncture-Induced Analgesia: A Neurobiological Basis in Purinergic Signaling

Chronic pain is a debilitating and rather common health problem. The present shortage in analgesic drugs with a favorable spectrum but without remarkable side effects furthered the search for alternative therapeutic manipulations. Increasing evidence from both basic and clinical research on acupuncture, a main alternative therapy of traditional Chinese medicine, suggests that chronic pain is sensitive to acupuncture procedures. Clarification of the underlying mechanisms is a challenge of great theoretical and practical significance. The seminal hypothesis of Geoffrey Burnstock and the astounding findings of Maiken Nedergaard on the involvement of purinergic signaling in the beneficial effects of acupuncture fertilized the field and led to an intensification of research on acupurines. In this review, we will summarize the state-of-the-art situation and try to forecast how the field is likely to develop in the future.

Acupuncture in shoulder pain and functional impairment after neck dissection: A prospective randomized pilot study

OBJECTIVES/HYPOTHESIS

The efficacy of conventional physiotherapy and antiinflammatory/analgesic drugs in the management of shoulder pain and functional disability following neck dissection is often disappointing. Acupuncture is a safe and well-tolerated method. We report the results regarding our pilot trial of acupuncture versus conventional care in the management of postoperative shoulder pain and dysfunction after neck dissection.

STUDY DESIGN

Pilot study.

METHODS

Patients at a tertiary university center with chronic pain or dysfunction attributed to neck dissection were randomly assigned to either weekly acupuncture or usual care (eg., physical therapy, analgesia, and/or antiinflammatory drugs) for 5 consecutive weeks. The Constant-Murley score, a composite measure of pain, function, and activities of daily living, was the primary outcome measure. As secondary end point, The Neck Dissection Impairment Index (NDII) was used to quantify site-specific, self-reported quality of life (QOL).

RESULTS

After randomization, 48 patients completed the study (23 and 25 patients on acupuncture and control arms, respectively). Constant-Murley scores improved more in the acupuncture group (gain difference between groups 13.6, P < 0.01), a statistically significant improvement in site-specific QOL was also recorded at NDII (gain difference between groups 11.5, P < 0.01).

CONCLUSION

Acupuncture is safe and effective; it should be introduced and offered to patients suffering from neck pain and dysfunction related to neck dissection.

LEVEL OF EVIDENCE

2b. Laryngoscope, 126:1790-1795, 2016.

The Use of Conservative and Alternative Therapy for Low Back Pain

Low back pain may have complex patho-physiological causes leading to chronicity that resists conventional managements. Complementary and alternative treatment options have, therefore, gained popularity. In this chapter, acupuncture, manual therapy, and natural healing for low back pain will be discussed. Special emphasis is given on the role of the individual in the control and prevention of low back pain.

Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder

BACKGROUND

Initial posttraumatic stress disorder (PTSD) care is often delayed and many with PTSD go untreated. Acupuncture appears to be a safe, potentially nonstigmatizing treatment that reduces symptoms of anxiety, depression, and chronic pain, but little is known about its effect on PTSD.

METHODS

Fifty-five service members meeting research diagnostic criteria for PTSD were randomized to usual PTSD care (UPC) plus eight 60-minute sessions of acupuncture conducted twice weekly or to UPC alone. Outcomes were assessed at baseline and 4, 8, and 12 weeks postrandomization. The primary study outcomes were difference in PTSD symptom improvement on the PTSD Checklist (PCL) and the Clinician-administered PTSD Scale (CAPS) from baseline to 12-week follow-up between the 2 treatment groups. Secondary outcomes were depression, pain severity, and mental and physical health functioning. Mixed model regression and t test analyses were applied to the data.

RESULTS

Mean improvement in PTSD severity was significantly greater among those receiving acupuncture than in those receiving UPC (PCLΔ=19.8±13.3 vs. 9.7±12.9, P<0.001; CAPSΔ=35.0±20.26 vs. 10.9±20.8, P<0.0001). Acupuncture was also associated with significantly greater improvements in depression, pain, and physical and mental health functioning. Pre-post effect-sizes for these outcomes were large and robust.

CONCLUSIONS

Acupuncture was effective for reducing PTSD symptoms. Limitations included small sample size and inability to parse specific treatment mechanisms. Larger multisite trials with longer follow-up, comparisons to standard PTSD treatments, and assessments of treatment acceptability are needed. Acupuncture is a novel therapeutic option that may help to improve population reach of PTSD treatment.

Electroacupuncture exerts an anti-inflammatory effect in a rat tissue chamber model of inflammation via suppression of NF-κB activation

OBJECTIVE

Electroacupuncture (EA) has beneficial effects in patients with various inflammatory diseases. However, the underlying mechanism remains unclear. As the kappa B inhibitor/nuclear factor-kappa B (IκB/NF-κB) pathway exerts a pivotal role in the mammalian immune response, we examined the involvement of the IκB/NF-κB pathway in EA-induced anti-inflammation.

METHODS

Ninety tissue chamber implanted rats were randomly divided into control (C), model (M) and EA (E) groups. Physiological saline and human recombinant interleukin-1β (hr IL-1β) were injected into the rats in groups C and M, respectively, and EA treatment was applied to the rats in group E after IL-1β injection. Nuclear staining of p65 (a subunit of NF-κB) was quantified in the exudate cells by immunohistochemical analysis and IκBα expression in the cytoplasm was quantified by western blot analysis.

RESULTS

Our results showed that, compared with group C, the percentage of cells with nuclear-localised p65 was increased in group M by 71.3%, 50.7% and 33.1% at 1, 5 and 24 h time points (p<0.01), respectively. This increase was fully inhibited in group E at 5 and 24 h time points (p<0.01). The expression of IκBα was stably enhanced in group M (p<0.05) during the test period. Compared with group M, greater expression of IκBα in group E was only observed at the 1 h time point (p<0.01).

CONCLUSIONS

Collectively, our data suggest that EA inhibits the nuclear translocation of p65 and increases the expression of IκBα, which leads to the suppression of NF-κB activation in a rat tissue chamber model of inflammation.

The meridian system and mechanism of acupuncture: a comparative review. Part 3: Mechanisms of acupuncture therapies

The human body is a hierarchical organism containing many levels of mutually interacting oscillatory systems. From the viewpoint of traditional Chinese medicine, health is a state of harmony emergent from the interactions of these systems and disease is a state of discord. Hence, human diseases are considered as disturbed functions rather than changed structures. Indeed, the change from normal to abnormal structure may be beneficent rather than maleficent. For example, when one kidney becomes twice the normal size following the destruction of the other kidney, it is good and not bad for us because we might be dead otherwise. Therefore, in Part 3 of this three-part series, emphasis is mainly laid on the acupuncture mechanisms of treating disturbed physiological functions rather than disordered structures. At first, the basic tenets of conventional neuroscience and cardiology are reevaluated so that clear understanding of how nervous and cardiovascular systems work together can be obtained. Then, the general principles of diagnosis and treatment in traditional Chinese medicine from the integrative perspective of complex dynamic systems are proposed. Finally, mechanisms of acupuncture therapies for treating 14 different categories of disorders will be elucidated via the magneto-electric inductive effects of the meridian system.

The meridian system and mechanism of acupuncture--a comparative review. Part 2: mechanism of acupuncture analgesia

In traditional Chinese medicine (TCM), pain is never merely a sign of discomfort. It is usually an integral part of a particular disease or physiological malfunction. Thus pain should not be treated in isolation since it will disappear as soon as its cause is identified and removed. Hence, in this Part 2 of a three-part series, initially, clinical pathologies in modern medicine and TCM are compared. Then, the pain pathophysiologies of these two schools of thought are reviewed. In addition, certain unique features of acupuncture effects that any valid mechanism must account for are outlined. Finally, various mechanisms of acupuncture analgesia are reviewed. One plausible mechanism based on the meridian system of Part 1, i.e., the chaotic wave theory of fractal continuum in terms of the neurovascular network, is also proposed. It contends that the injury current due to acupuncture at an acupoint will trigger electromagnetic inductive effects so that the impedances of correlated neurovascular bundles are drastically changed. Two consequent scenarios are possible. (1) If the impedance of the meridian hugely mismatches with that of the brain after acupuncture, then the traveling wave of pain signal will be largely reflected back and only partially transmitted to the brain, hence pain relief can be achieved. (2) If the impedance of the meridian entirely matches that of the pain source after acupuncture, then the pain source would appear to be nonexistent to the brain, hence analgesia can be achieved. The former mechanism can be used to explain the relief for chronic pain and the latter one for acute pain. It is believed that the proposed mechanisms via match or mismatch of the impedances can explain how the acupuncture works not only in the treatment of pain, but also in various other therapies of Part 3.

The meridian system and mechanism of acupuncture-a comparative review. Part 1: the meridian system

In traditional Chinese medicine (TCM), acupuncture has been used to heal various diseases and physiologic malfunctions in clinical practice for more than 2500 years. Due to its efficacy, acupuncture has been recommended by the World Health Organization in 1980 as an effective alternative therapy for 43 different disorders. Over the past few decades, various theories of the meridian system and mechanisms have been proposed to explain how acupuncture might work. Most of these mechanisms, however, cannot yet explain conclusively why acupuncture is efficacious in treating so many different diseases. A plausible mechanism has been unavailable until recently. This is the first of a three-part series that aims to provide a comparative review of the aforementioned topics. Part 1 reviews the current indications for acupuncture, basic concepts of TCM, and the essence of the meridian system. To establish a mathematically rigorous framework of TCM, the chaotic wave theory of fractal continuum is proposed. This theory is then applied to characterize the essence of the meridian system. Parts 2 and 3 will review the possible mechanisms of acupuncture analgesia and acupuncture therapies, respectively, based on biochemical, bioelectromagnetic, chaotic wave, and neurophysiologic approaches. It is sincerely hoped that this series of review articles can promote an understanding of the meridian system and acupuncture mechanisms to help patients in a logical and passionate way.

Specifying the nonspecific components of acupuncture analgesia

It is well known that acupuncture has pain-relieving effects, but the contribution of specific and especially nonspecific factors to acupuncture analgesia is less clear. One hundred one patients who developed pain of ≥ 3 on a visual analog scale (VAS, 0 to 10) after third molar surgery were randomized to receive active acupuncture, placebo acupuncture, or no treatment for 30 min with acupuncture needles with potential for double-blinding. Patients' perception of the treatment (active or placebo) and expected pain levels (VAS) were assessed before and halfway through the treatment. Looking at actual treatment allocation, there was no specific effect of active acupuncture (P=.240), but there was a large and significant nonspecific effect of placebo acupuncture (P<.001), which increased over time. Interestingly, however, looking at perceived treatment allocation, there was a significant effect of acupuncture (P<.001), indicating that patients who believed they received active acupuncture had significantly lower pain levels than those who believed they received placebo acupuncture. Expected pain levels accounted for significant and progressively larger amounts of the variance in pain ratings after both active and placebo acupuncture (up to 69.8%). This is the first study to show that under optimized blinding conditions, nonspecific factors such as patients' perception of and expectations toward treatment are central to the efficacy of acupuncture analgesia and that these factors may contribute to self-reinforcing effects in acupuncture treatment. To obtain an effect of acupuncture in clinical practice, it may therefore be important to incorporate and optimize these factors.

Chinese medicine and the surgeon

The surgeon aims at a direct, complete removal of the pathology. In spite of the modern advancements of imaging facilities and precision instrumentations, unsatisfactory results and recurrences are not uncommon. This paper provides a general review of the four specific areas in surgery that would benefit from Chinese medicine. Extensive searches were made on four surgical areas based on available English language journals, viz. low-back pain, chronic ulcers, renal calculus, and enuresis in children, in the past 10 years. The quoted communications are mainly related to clinical evidences, while a smaller number of crucial laboratory reports are also included. Low-back pain, a most frequent orthopaedic problem, would benefit from acupuncture treatment. Chronic leg ulcers could achieve better results of healing using herbal supplements. Problems of renal stones, besides the conventional methods of removal, could be further supplemented with herbal drinks that aim at prevention of recurrences. Enuresis in children, an untreatable common condition, may respond well to acupuncture. Surgeons should keep an open mind. In case of difficulties, they could seriously consider options of traditional treatment.

Western medical acupuncture: a definition

Western medical acupuncture is a therapeutic modality involving the insertion of fine needles; it is an adaptation of Chinese acupuncture using current knowledge of anatomy, physiology and pathology, and the principles of evidence based medicine. While Western medical acupuncture has evolved from Chinese acupuncture, its practitioners no longer adhere to concepts such as Yin/Yang and circulation of qi, and regard acupuncture as part of conventional medicine rather than a complete "alternative medical system". It acts mainly by stimulating the nervous system, and its known modes of action include local antidromic axon reflexes, segmental and extrasegmental neuromodulation, and other central nervous system effects. Western medical acupuncture is principally used by conventional healthcare practitioners, most commonly in primary care. It is mainly used to treat musculoskeletal pain, including myofascial trigger point pain. It is also effective for postoperative pain and nausea. Practitioners of Western medical acupuncture tend to pay less attention than classical acupuncturists to choosing one point over another, though they generally choose classical points as the best places to stimulate the nervous system. The design and interpretation of clinical studies is constrained by lack of knowledge of the appropriate dosage of acupuncture, and the likelihood that any form of needling used as a usual control procedure in "placebo controlled" studies may be active. Western medical acupuncture justifies an unbiased evaluation of its role in a modern health service.

Clinical critical qualitative evaluation of the selected randomized controlled trials in current acupuncture researches for low back pain

BACKGROUND

Many randomized controlled trials (RCTs) and reviews concluded that acupuncture is not an effective treatment for low back pain (LBP) and there is no difference between real acupuncture and sham acupuncture in the treatment of LBP.

OBJECTIVE

This study aims to evaluate the most recently published RCTs and reviews from the clinical protocol, which is used by professional acupuncturists.

DATA SOURCES AND SYNTHESIS

English-language studies were identified through searches of The Cochrane Library, PubMed/MEDLINE and EMBASE, limited to those published between January 2007 and January 2010. Eighteen trials studying conditions related to LBP conditions treated by acupuncture or acupuncture as one of the co-interventions were eligible. STUDY APPRAISAL METHODS: A critical clinical qualitative evaluation is the core methodology of this study. The study design employs daily used clinical skills and knowledge with supplementary statistical concepts to evaluate the quality and reliability of the selected RCTs and reviews. Five evaluation criteria were established for the assessment of the selected RCTs and reviews. By implementing the evaluation criteria, which are similar to the inclusion and exclusion criteria used in RCTs, the weaknesses, limitations or errors of RCTs and reviews can be identified, despite the strength of internal validity produced by statistical calculations.

RESULTS

Various terms are used when describing LBP conditions. However, 16 RCTs or 88% of the trials did not establish a medical diagnosis. No trials had objective measurements as a clinical standard for assessing outcomes. Furthermore, significant variation existed due to the numerous treatment methods or therapists used in the RCTs included in the study. Various co-interventions were used in 10 or 55% of the trials, among them, 6 or 33% of the trials used non-steroidal anti-inflammatory drugs (NSAID) or analgesics. Due to the lack of diagnostic status, the accuracy of the external validity was put into question. No logistic regression models were used in any of the selected RCTs and reviews to resolve the degree of heterogeneity.

CONCLUSION

All selected RCTs either partially met the evaluation criteria or did not fulfill the evaluation criteria while being compared. The major problem existing in all RCTs was the lack of accurate medical diagnosis and a lack of objective measurements to judge the clinical outcomes, which in turn, created incorrect eligibility criteria, improper matches and inaccuracies in data recording before entry into statistical calculations. As a consequence of the subjective nature of measurements, conclusions of RCTs and RCT-based reviews were biased due to overgeneralized or cross-generalized estimations, which infer that alternative explanations cannot be excluded. In addition, the range of variables created in the treatment procedure was difficult to control or estimate, in turn, threatening the reliability of RCTs' estimations. For these reasons, creating appropriate diagnostic criteria before randomization and constructing a related objective outcome measurement, which are more relevant to clinical practice, should be considered in future RCTs and systematic review studies.

The relevance of childhood developmental factors to the efficacy of acupuncture on the affective component of back pain

There is substantial evidence to support the use of acupuncture in the treatment of low back pain. The main predictors of chronic low back pain are non-medical and psychosocial. The understanding of how acupuncture can modulate the pain experience has recently been enhanced by the elucidation of the role of C fibre afferents on the limbic system. C fibre deactivation of the limbic system can only occur in the presence of intact corticosubcortical neuronal pathways. The normal development of these pathways is determined by social factors in the early years of life. The effect of acupuncture treatment for low back pain may be determined by successful relationships between the mother and child in the first 18 months of life.

Laser acupuncture for acute inflammatory, visceral and neuropathic pain relief: An experimental study in the laboratory rat

Laser acupuncture is defined as the stimulation of traditional acupuncture points with low-intensity, non-thermal laser irradiation. We explored the clinical efficacy of a very low level diode laser wavelength 670 nm (Biolite LP020, RGM, Genoa, Italy), used to stimulate acupoints ST36 Zu San Li and TH5 Waiguan, on well-established experimental models of acute and persistent pain in the rat, e.g. acute inflammatory pain, muscle pain, visceral pain and neuropathic pain. We report the anti-edema and anti-hyperalgesia effects of laser acupuncture in models of acute inflammatory pain, e.g. CFA-induced inflammation and myofascial pain. We also indicate that spontaneous pain and thermal hyperalgesia are reduced in a neuropathic pain model, e.g. axotomy. On the contrary, no effects due to laser-acupuncture were observed on discomfort indices in a model of visceral pain, e.g. cystitis due to cyclophosphamide. We thus provide evidences that acupoints stimulation using a very low intensity laser irradiation can control pain and edema in specific experimental conditions.

Disinhibitory involvement of the anterior cingulate cortex in the descending antinociceptive effect induced by electroacupuncture stimulation in rats

The present study was conducted to clarify the role of the anterior cingulate cortex (ACCX) in acupuncture analgesia. Experiments were performed on 35 female Wistar albino rats weighing about 300 g. Single unit recordings were made from ACCX neurons with a tungsten microelectrode. Descending ACCX neurons were identified by antidromic activation from electrical shocks applied to the ventral part of the ipsilateral PAG through a concentric needle electrode. Cathodal electroacupuncture stimulation of Ho-Ku (0.1 ms in duration, 45 Hz) for 15 min was done by inserting stainless steel needles bilaterally. An anodal silver-plate electrode (30 mm x 30 mm) was placed on the center of the abdomen. Naloxone (1.0 mg/kg, i.v.) was used to test whether changes of ACCX activities were induced by the endogenous opioid system. Data were collected from a total of 73 ACCX neurons. Forty-seven neurons had descending projection to the PAG, and the other 26 had no projections to the PAG. A majority of descending ACCX neurons were inhibited by electroacupuncture stimulation. By contrast, non-projection ACCX neurons were mainly unaffected by electroacupuncture. Naloxone did not reverse acupuncture effects on the changes of ACCX neuronal activities. Acupuncture stimulation had predominantly inhibitory effects on the activities of descending ACCX neurons. Since the functional connection between ACCX and PAG is inhibitory, electroacupuncture caused disinhibition of PAG neurons, whose activity is closely related to descending antinociception to the spinal cord. This disinhibitory effect elicited by acupuncture stimulation is thought to play a significant role in acupuncture analgesia.

Neural mechanism underlying acupuncture analgesia

Acupuncture has been accepted to effectively treat chronic pain by inserting needles into the specific "acupuncture points" (acupoints) on the patient's body. During the last decades, our understanding of how the brain processes acupuncture analgesia has undergone considerable development. Acupuncture analgesia is manifested only when the intricate feeling (soreness, numbness, heaviness and distension) of acupuncture in patients occurs following acupuncture manipulation. Manual acupuncture (MA) is the insertion of an acupuncture needle into acupoint followed by the twisting of the needle up and down by hand. In MA, all types of afferent fibers (Abeta, Adelta and C) are activated. In electrical acupuncture (EA), a stimulating current via the inserted needle is delivered to acupoints. Electrical current intense enough to excite Abeta- and part of Adelta-fibers can induce an analgesic effect. Acupuncture signals ascend mainly through the spinal ventrolateral funiculus to the brain. Many brain nuclei composing a complicated network are involved in processing acupuncture analgesia, including the nucleus raphe magnus (NRM), periaqueductal grey (PAG), locus coeruleus, arcuate nucleus (Arc), preoptic area, nucleus submedius, habenular nucleus, accumbens nucleus, caudate nucleus, septal area, amygdale, etc. Acupuncture analgesia is essentially a manifestation of integrative processes at different levels in the CNS between afferent impulses from pain regions and impulses from acupoints. In the last decade, profound studies on neural mechanisms underlying acupuncture analgesia predominately focus on cellular and molecular substrate and functional brain imaging and have developed rapidly. Diverse signal molecules contribute to mediating acupuncture analgesia, such as opioid peptides (mu-, delta- and kappa-receptors), glutamate (NMDA and AMPA/KA receptors), 5-hydroxytryptamine, and cholecystokinin octapeptide. Among these, the opioid peptides and their receptors in Arc-PAG-NRM-spinal dorsal horn pathway play a pivotal role in mediating acupuncture analgesia. The release of opioid peptides evoked by electroacupuncture is frequency-dependent. EA at 2 and 100Hz produces release of enkephalin and dynorphin in the spinal cord, respectively. CCK-8 antagonizes acupuncture analgesia. The individual differences of acupuncture analgesia are associated with inherited genetic factors and the density of CCK receptors. The brain regions associated with acupuncture analgesia identified in animal experiments were confirmed and further explored in the human brain by means of functional imaging. EA analgesia is likely associated with its counter-regulation to spinal glial activation. PTX-sesntive Gi/o protein- and MAP kinase-mediated signal pathways as well as the downstream events NF-kappaB, c-fos and c-jun play important roles in EA analgesia.

Hormesis defined

Hormesis is a term used by toxicologists to refer to a biphasic dose-response to an environmental agent characterized by a low dose stimulation or beneficial effect and a high dose inhibitory or toxic effect. In the fields of biology and medicine hormesis is defined as an adaptive response of cells and organisms to a moderate (usually intermittent) stress. Examples include ischemic preconditioning, exercise, dietary energy restriction and exposures to low doses of certain phytochemicals. Recent findings have elucidated the cellular signaling pathways and molecular mechanisms that mediate hormetic responses which typically involve enzymes such as kinases and deacetylases, and transcription factors such as Nrf-2 and NF-kappaB. As a result, cells increase their production of cytoprotective and restorative proteins including growth factors, phase 2 and antioxidant enzymes, and protein chaperones. A better understanding of hormesis mechanisms at the cellular and molecular levels is leading to and to novel approaches for the prevention and treatment of many different diseases.

Did ‘the Princess on the Pea— Suffer from Fibromyalgia Syndrome?

Fibromyalgia syndrome (FMS) is a chronic pain syndrome characterised by central sensitisation resulting in hypersentivity of the skin and deeper tissues as well as fatigue. Possibly the princess in Hans Christian Andersen's ‘The Princess and the Pea’ suffered from FMS since chronic sleep disturbances are typical in FMS. These sleep disturbances have been attributed to a dysfunction in the systems regulating sleep and wakefulness resulting in loss of deep sleep. In addition, many patients with FMS experience cognitive dysfunction, characterised by impaired concentration and short term memory consolidation, a complaint also commonly reported in other sleep disorders.

In recent reviews evaluating the efficacy of acupuncture in FMS it has been concluded that acupuncture has no specific effect. A prerequisite for this conclusion is that all the major symptoms in the syndrome have been assessed. However, previous studies have generally focused on the pain alleviating effect of acupuncture in FMS. We have observed that not only pain but also sleep and cognitive dysfunction may be ameliorated in response to acupuncture, suggesting that these variables should be taken into account when evaluating the effects of acupuncture in FMS. Furthermore, the results demonstrated great individual variability apart from the systematic effects related to the group, indicating that individually performed treatment strategies are required. Our suggestion is supported by experimental and clinical studies showing that acupuncture may affect in somnia and alertness, and that there may be neurophysiologic bases for these specific effects.

Low-frequency electroacupuncture suppresses zymosan-induced peripheral inflammation via activation of sympathetic post-ganglionic neurons

Electroacupuncture (EA) is used to treat a variety of inflammatory diseases; however, the neurophysiological mechanisms underlying EA's anti-inflammatory effect remain unclear. Accumulating evidence suggests that the sympathetic nervous system regulates immunologic and inflammatory responses and thus we hypothesized that this system could be involved in EA's anti-inflammatory effect (EA-AI). The goal of the present study was to evaluate whether the sympathetic nervous system plays a critical role in EA-AI using a mouse air pouch inflammation model. We found that bilateral low-frequency (1 Hz) EA applied to the Zusanli acupoint significantly suppressed the number of zymosan-induced leukocytes migrating into the air pouch. Furthermore, double-labeling immunohistochemical experiments showed that EA stimulation increased Fos expression in choline acetyltransferase (ChAT)-positive sympathetic pre-ganglionic neurons in the intermediolateral region of thoracic spinal cord segments. Chemical sympathetic denervation by intraperitoneal injection of 6-hydroxydopamine (which spares sympathetic adrenal medullary innervation) significantly inhibited EA-AI. In contrast, adrenalectomy did not alter EA-AI. Finally, systemic propranolol administration significantly inhibited EA's anti-inflammatory effect, suggesting that beta-adrenoceptors are involved. Collectively, these results suggest that EA produces an anti-inflammatory effect in this mouse air pouch model by activating the sympathetic nervous system leading to the release of catecholamines from post-ganglionic nerve terminals, which act on beta-adrenoceptors on immune cells to inhibit their migration.