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Randomised controlled trials
Myofascial neck pain
▸ Aranha MF, Müller CE, Gavião MB. Pain intensity and cervical range of motion in women with myofascial pain treated with acupuncture and electroacupuncture: a double-blinded, randomized clinical trial. Braz J Phys Ther. Published Online First: 28 Nov 2014. doi.org/10.1590/bjpt-rbf.2014.0066
Randomised controlled trial (RCT) comparing manual acupuncture (MA), electroacupuncture (EA) and sham, n=60.
Sixty women presenting with at least one myofascial trigger point (rigorously diagnosed clinically) at the upper trapezius and local or referred pain for more than 6 months were randomised into EA (2/100 Hz) or MA at GB20 and GB21 (bilaterally), LI4 and LR3 on the side of the pain, and two local tender points; or sham acupuncture 1 cm distal to these points. Eight sessions were scheduled and a follow-up was conducted after 28 days.
Pain was assessed by visual analogue scale (VAS) and cervical movements were assessed by a fleximeter.
There was reduction in general pain in the EA and MA groups, but the only significant difference between groups was that EA was superior to sham at 8 weeks but not at long follow-up (figure 1). EA was also superior to sham for increase in rotation in one direction only (p=0.049).
The study is limited by a 17% dropout rate. The report is unsatisfactory since the description of acupuncture does not define the amount of stimulation applied in MA or sham groups. This reviewer is not surprised at the amount of benefit achieved by quite strong stimulation provided by deep needling in the so-called ‘sham’ group.
Myofascial neck pain
▸ Wilke J, Vogt L, Niederer D, et al. Short-term effects of acupuncture and stretching on myofascial trigger point pain of the neck: a blinded, placebo-controlled RCT. Complement Ther Med 2014;22:835–41.
Small (n=19) crossover study: acupuncture, acupuncture plus stretch, and placebo laser.
Nineteen patients (11 women, 33±14 years) with myofascial neck pain in randomised order received the following treatments with 1 week washout between: acupuncture GB20, BL10, BL43, TE15, SI13 and GV14 as ‘near’ points and TE5, SI3 and GB34 (bilateral) as ‘far’ points, all with stimulation; the same acupuncture plus stretching; and placebo laser acupuncture with the inactive probe attached to the skin at the same points. Mechanical pain threshold (MPT) measured with a pressure algometer at the trigger point by a blinded assessor at up to 30 min after treatment was the main outcome.
Secondary outcomes were motion-related pain (VAS) and cervical range of movement (ROM) recorded by means of an ultrasonic 3D movement analysis system.
Both acupuncture and acupuncture plus stretching increased MPT post treatment by 5% and 11%, respectively (figure 2). Only acupuncture combined with stretching was superior to placebo (p<0.05). There were no significant differences between interventions at 15 and 30 min post treatment. Pain VAS did not differ between treatments at any measurement. Five minutes after application of acupuncture plus stretching, ROM was significantly increased in the frontal and transversal plane compared with placebo (p<0.05).
This small study could have been undertaken as part of a higher degree. The necessary sample size was estimated, and the resulting small sample required shows how much more efficient crossover studies are than parallel-arm studies. Given the small numbers, the results suggest that stretching immediately afterwards does add to the effect of needling myofascial trigger points, although lack of long-term follow-up limits the clinical relevance.
▸ Garcia-Vivas JM, Galaviz-Hernandez C, Becerril-Chavez F, et al. Acupoint catgut embedding therapy with moxibustion reduces the risk of diabetes in obese women. J Res Med Sci 2014;19:610–16.
RCT (n=99) with six groups.
Ninety-nine overweight women (body mass index (BMI) >25) were randomly assigned to six groups of treatment for 6 weeks: acupuncture with moxibustion; long needle acupuncture (up to depth of 10–12 cm in abdominal points) with moxibustion; electroacupuncture (EA) at 4 Hz; EA with moxibustion; embedded catgut with moxibustion; and sham non-penetrating acupuncture as control. Points used for needling were CV6, CV12, ST25, ST36 and SP6. Catgut was inserted through a hypodermic needle. Moxibustion was given at BL20 and BL23.
Obesity-related parameters including body weight, BMI, waist and hip circumferences, waist/hip ratio, biochemical parameters (triglycerides, cholesterol, glucose, insulin) and homeostasis model of assessment-insulin resistance (HOMA-IR) index were determined before and after each treatment for up to 6 weeks.
One hundred and thirty-eight women were enrolled, but only 99 were included in the analysis; their mean age was 36 years. All but three were obese (BMI >30).
BMI was significantly reduced in response to all treatments (figure 3), but catgut embedding therapy combined with moxibustion was the only treatment that produced a significant reduction in body weight (3.1±0.2 kg, p<0.001), insulin (3.5±0.8 µU/mL, p<0.1) and HOMA-IR (1.4±0.2 units, p<0.01) in comparison with the sham group.
Two serious limitations on the interpretation of these results are the fact that the group sizes were small and there was a 38% dropout rate. The authors speculate that the better effect of catgut implantation may be due to continued stimulation. Interesting as the results clearly are, the title's claim that this treatment ‘reduces the risk of diabetes’ is clearly unjustified and excessive.
▸ Lee SW, Liong ML, Yuen KH, et al. Acupuncture and immune function in chronic prostatitis/chronic pelvic pain syndrome: a randomized, controlled study. Complement Ther Med 2014;22:965–9.
Incidental finding in RCT (n=12) of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
We investigated 12 patients with CP/CPPS participating in a prospective RCT comparing acupuncture with sham acupuncture for effects on cellular immunity. Acupuncture points were CV1, CV4, SP6 and SP9, without stimulation. Sham acupuncture was shallow needling 0.5 cm from those sites. Blood samples were taken before the first needling and after the last of 20 treatment sessions (week 10). Patients also completed questionnaires examining their CP/CPPS symptoms and mood status at the baseline and end of study visits.
At the end of the study eight of the 12 participants (67%) were classified as treatment responders, four participants each from the acupuncture and sham groups. Changes in some white blood cells are shown in figure 4. Only the difference in natural killer cell changes was significant. (p=0.03).
This should be regarded as an incidental finding of interest, but enough to stimulate further studies.
Cost-effectiveness for depression
▸ Spackman E, Richmond S, Sculpher M, et al. Cost-effectiveness analysis of acupuncture, counselling and usual care in treating patients with depression: the results of the ACUDep trial. PLoS ONE 2014 26;9:e113726.
Report of economic analysis of RCT (N=755).
The cost-effectiveness analyses are based on the acupuncture, counselling or usual care for depression (ACUDep) trial results. The analysis was of health service costs.
The analyses demonstrate a difference in mean quality-adjusted life years (QALYs) and suggest differences in mean costs, which are mainly due to the price of the interventions. Acupuncture and counselling both had higher mean QALYs than usual care (figure 5), but also higher costs. Acupuncture has an incremental cost-effectiveness ratio (ICER) of £4560 per additional QALY and is cost-effective, with a probability of 0.62 at a cost-effectiveness threshold of £20 000 per QALY. Compared with acupuncture, counselling is more effective and more costly with an ICER of £71 757 and a probability of being cost-effective of 0.36. For patients in whom acupuncture is inappropriate or unavailable, the incremental cost-effectiveness of counselling versus usual care was £7935 per additional QALY.
Without evidence that acupuncture is more effective than sham for treatment of depression, it is doubtful whether many commissioners will consider it. But this comparison is limited to two novel interventions and, as the authors comment, further research is needed to determine the most cost-effective treatment pathways for depressed patients when the full range of available interventions is considered.
▸ Lan L, Zeng F, Liu GJ, et al. Acupuncture for functional dyspepsia (review). Cochrane Database of Systematic Reviews 2014;10:CD008487.
Review of seven trials (n=542).
A range of databases was searched for RCTs of acupuncture for functional dyspepsia, diagnosed according to Rome II or ROME III criteria. Excluded were studies including patients with structural, systemic or metabolic disease as well as patients with severe mental health problems. Primary outcomes were improvement as measured by a range of scoring systems and freedom from recurrence for at least 6 months after finishing the acupuncture.
Seven RCTs were identified, two of which were unpublished. Six more studies had to be omitted from the analysis as they were of a different design or because the full text was unavailable. The most common causes for potential bias were lack of blinding of patients or personnel. No significant difference was found between acupuncture and cisapride and antiemetics, although there were fewer unwanted effects from acupuncture than from cisapride. Studies comparing acupuncture with sham found a small advantage for acupuncture, but those trials were thought to be of poor quality. The authors concluded that the evidence was too inconclusive to say whether acupuncture was effective.
A comprehensive search was undertaken and more trials were included than in an earlier review. I am missing trials comparing acupuncture with proton pump inhibitors or H2 antagonists, which nowadays are more often used for this purpose (I do not recall ever having prescribed cisapride). I would also disagree with the conclusion: if the trials do not show acupuncture to be better than medications and the trials comparing acupuncture with sham are of poor quality, then the evidence reviewed here simply does not support the use of acupuncture.
▸ Shen X, Xia J, Adams CE. Acupuncture for schizophrenia. Cochrane Database Syst Rev 2014;10:CD005475.
Review of 30 studies.
The usual methods were adopted for a Cochrane Review, with wide inclusion criteria.
All studies were at moderate risk of bias. When acupuncture plus standard antipsychotic treatment was compared with standard antipsychotic treatment alone, people were at less risk of being ‘not improved’ (n=244, 3 RCTs, medium-term risk ratio (RR) 0.40, CI 0.28 to 0.57, very low quality evidence). Mental state findings were mostly consistent with this finding (figure 6). Time in hospital also was less with additional acupuncture. There were fewer adverse effects in the acupuncture group.
When acupuncture was added to low-dose antipsychotics and this was compared with standard dose antipsychotic drugs, relapse was less in the experimental group (n=170, 1 RCT, long-term RR 0.57, CI 0.37 to 0.89, very low quality evidence).
One trial (n=88) found that participants given electroacupuncture were significantly less likely to experience a worsening in global state.
Evidence here is sparse and not generally reliable, but it suggests that acupuncture may have some antipsychotic effects in schizophrenia as measured on global and mental state, with few adverse effects.
▸ Yoe S, Choe I-H, van den Noort M, et al. Acupuncture on GB34 activates the precentral gyrus and prefrontal cortex in Parkinson's disease. BMC Complement Altern Med 2014;14:336.
This fMRI study investigated the effects on the brain produced by the stimulation of GB34 in healthy subjects and patients with Parkinson's disease (PD), comparing real needle insertion and sham non-penetrating acupuncture. Twenty-four volunteers were tested: 12 with PD in the ‘off’ condition 12 h after all anti-Parkinson drugs had been withheld and 12 healthy volunteers. All were familiar with acupuncture stimulation to control for the acupuncture experience.
Different patterns of brain activation were found in healthy participants compared with those with PD with both real and sham acupuncture. Healthy participants had almost all regions within the basal ganglia activated, unlike PD patients. In patients with PD, acupuncture activated the prefrontal cortex, precentral gyrus and putamen—areas that are known to be impaired in patients with PD (figure 7). Moreover, PD patients showed a significant improvement in motor function following GB34 stimulation.
Interestingly, the average stimulus intensities for real and sham acupuncture were not significantly different.
This study opens new doors to evaluating acupuncture treatment effects. Additionally, it emphasises the functional differences that can be found between healthy and ill patients. Further investigations of this type have the potential to clarify how acupuncture activates specific regions within the brain and can refine our ability to use acupuncture for healing and alleviating symptoms.
Rubber hand illusion and acupuncture response
▸ Chae Y, Lee I, Jung W, et al. Decreased peripheral and central responses to acupuncture stimulation following modification of body ownership. PLoS ONE 2014;9:e109849.
Crossover study of peripheral blood flow changes (n=28) and functional MRI (n=17) responses to acupuncture after experiencing rubber hand illusion (RHI).
Right-handed participants were subjected to RHI—stroking participant's hand with a brush while watching a rubber hand stroked likewise synchronously, which gives the illusion that the rubber hand is a part of the subject's body and is accompanied by a decrease in peripheral blood flow of the stroked hand, thought to be a result of ‘redistribution’ of blood flow into the ‘additional’ hand; asynchronous stroking is used as a control. Subjects were needled at LI4 before undergoing RHI, and the needles were stimulated manually following tactile stimulation. In the first experiment, skin perfusion was measured using a laser Doppler perfusion imager. In the second, functional MRI images were taken.
A significant difference in change of local blood flow following needling was observed between synchronous and asynchronous stroking (18.6±3.3% vs 9.3±2.8%; p<0.05; figure 8). In the functional MRI studies, significant differences in brain activation between synchronous and asynchronous stroking were observed in the right insula. The authors conclude that the effects of acupuncture can be modified by changes in perception of body ownership, although they acknowledge that the study lacked a non-needling control due to the difficulties in designing such a control.
This is an interesting experiment which illustrates the complexity of what happens in a human body when acupuncture is applied. There may also be clinical implications as body perception can be altered, for example, after stroke or brain haemorrhage. This summary has to be very brief and I would recommend that anyone interested should read the full article.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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