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Controlled Trial on Point Specificity of Acupuncture in the Treatment of Lateral Epicondylitis (Tennis Elbow)
Abstract
Purpose: Aim of this study was to evaluate short and middle term effects of acupuncture in the treatment of lateral epicondylitis under consideration of point specificity. Methods: 50 patients with lateral epicondylitis were alternately allocated to verum (five classical acupuncture points) or sham acupuncture (five non-classical points with similar depth of insertion and stimulation). The blinded patients received three treatments within ten days. Outcome measures included pressure pain threshold (PPT), pain-free grip strength (GS) and impairment caused by pain (IP). Assessments were performed by an independent (blinded) examiner before, immediately after the first treatment, immediately after the third treatment and 14 days after the third treatment. Results: Immediately after a single treatment patients were improved in both groups, however, 14 days after the third treatments acupuncture was significantly superior to sham acupuncture in all outcome measures. In GS the verum group showed an improvement of 43% compared to 14% in the sham group immediately after the third treatment. 14 days after treatment there was a mean decrease in impairment caused by pain (IP) of 59% in the verum group compared to 24% in the sham group. Similar results were obtained for PPT, but baseline values differed between groups. No adverse effects of acupuncture were reported. Conclusion: The results suggest that acupuncture may have point-specific effects and seems to be effective in the treatment of lateral epicondylitis in primary care, if the objective is to obtain pain relief and to improve function.
... Two studies about acupuncture of LE are ongoing. Finally, four studies [20][21][22][23] were included and two ongoing trials [26,27] were described in this systematic review. ...
... Characteristics of the methods, participants, intervention, and outcome measures of all included studies and ongoing studies were shown in Tables 1 and 2 separately. Among the four included studies, there were two conducted in China [22,23], and two were conducted in Germany [20,21]. In total, there were 309 patients who participated in the included studies, among which there were 155 patients in the acupuncture group and 154 patients in the controlled group. ...
... All studies included both men and women. Two trials [20,21] compared acupuncture with sham acupuncture, one trial [22] compared electroacupuncture plus moxibustion with material insulation with blockage therapy, and one trial [23] compared electroacupuncture plus blockage therapy with blockage therapy. In these trials, frequency of acupuncture was at least 20 min per treatment and 3 treatments. ...
Objective
. This systematic review aimed to assess the effectiveness and safety of acupuncture for lateral epicondylitis (LE).
Methods
. Seven databases and the WHO International Clinical Trials Registry Platform Search Portal were searched to identify relevant studies. The data were extracted and assessed by two independent authors, and Review Manager Software (V.5.3) was used for data synthesis with effect estimate presented as standard mean difference (SMD) and mean difference (MD) with a 95% confidence interval. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess the level of evidence.
Results
. Four RCTs with 309 participants were included with poor methodological quality. Participants who received acupuncture and acupuncture plus moxibustion with material insulation were likely to have an improvement in elbow functional status and/or myodynamia. The overall quality rated by GRADE was from very low to low. Two studies reported that the needle pain would be the main reason for the dropout.
Conclusion
. For the small number of included studies with poor methodological quality, no firm conclusion can be drawn regarding the effect of acupuncture of elbow functional status and myodynamia for LE. This trial is registered with
CRD42015016199
.
... The assessment of the PPT was widely used (35 out of 42, 83.3%) in order to evaluate the effectiveness of acupuncture in reducing hyperalgesia in pain disorders. Most common conditions under investigation were myofascial pain, associated with the occurrence of MTrPs (8 out 35, 22.9%) [33,38,41,48,50,63,70,83], fibromyalgia (7 out of 35, 20%) [37,44,45,72,81,82,87], chronic neck and back pain (5 out of 35, 14.3%) [22,46,49,74,77], temporomandibular disorder (5 out of 35, 14.3%) [40,43,68,79,91], and experimentally induced delayed-onset muscle soreness (DOMS; 4 out of 35, 11.4%) [27,47,51,78]. PPT was also used as an outcome measure for the treatment effect of acupuncture in tension type headache [52,93], osteoarthritis of the knee [86], abdominal scar pain [62], plantar fasciitis [96], and syringomyelia [64]. ...
... Ten of the 35 patient studies (28.6%) evaluated the immediate effect of one single acupuncture treatment. Nine of these reported the PPT to be significantly elevated [33,40,41,43,51,64,78,79,83], and one study found no significant PPT increase [50]. Among the 26 studies (74.3%) that assessed the effectiveness of an acupuncture series, 18 (69.2%) ...
... Among the 26 studies (74.3%) that assessed the effectiveness of an acupuncture series, 18 (69.2%) showed a PPT increase after treatment [37,38,46,50,52,62,63,68,70,72,74,77,81,82,86,87,91,93] while six studies (23.1%) observed no effect of acupuncture on the PPT [22,27,[47][48][49]96]. The outcome of two studies was rated as unclear, because the analysis was performed by combining data of all groups [44,45]. ...
Background: The effect of acupuncture on sensory perception has never been systematically reviewed; although, studies on acupuncture mechanisms are frequently based on the idea that changes in sensory thresholds reflect its effect on the nervous system. Methods: Pubmed, EMBASE and Scopus were screened for studies investigating the effect of acupuncture on thermal or mechanical detection or pain thresholds in humans published in English or German. A meta-analysis of high quality studies was performed. Results: Out of 3007 identified articles 85 were included. Sixty five studies showed that acupuncture affects at least one sensory threshold. Most studies assessed the pressure pain threshold of which 80% reported an increase after acupuncture. Significant short-and long-term effects on the pressure pain threshold in pain patients were revealed by two meta-analyses including four and two high quality studies, respectively. In over 60% of studies, acupuncture reduced sensitivity to noxious thermal stimuli, but measuring methods might influence results. Few but consistent data indicate that acupuncture reduces pin-prick like pain but not mechanical detection. Results on thermal detection are heterogeneous. Sensory threshold changes were equally frequent reported after manual acupuncture as after electroacupuncture. Among 48 sham-controlled studies, 25 showed stronger effects on sensory thresholds through verum than through sham acupuncture, but in 9 studies significant threshold changes were also observed after sham acupuncture. Overall, there is a lack of high quality acupuncture studies applying comprehensive assessments of sensory perception.
... Lateral humeral epicondylitis (9) Lateral epicondylitis (10) Tennis elbow (11) 8 or 9-10 (12) Acupuncture (13) Acupuncture therapy (14) Acupoints (15) Body acupuncture (16) Scalp acupuncture (17) Electroacupuncture (18) Fire needle (19) Plum-blossom needle (20) Elongated needle (21) Intradermal needle (22) 12 or 13-21 (23) 7 and 11 and 22 ...
... e plots of the risk of bias and methodological quality of the included studies are shown and summarized in Figure 2. All of the included RCTs used randomization; however, only three studies were randomized by random number tables [13,17,20] with a low risk of bias. Another two studies were randomized by the registration order [16,19] and considered to have a high risk of bias. e details of allocation concealment were unclear in all included studies. ...
... e details of allocation concealment were unclear in all included studies. Four studies were reported with blinding [15][16][17][18]. Both evaluators and patients in the study were blinded in two RCTs [16,17], and the participants were blinded in two RCTs [15,18]. ...
Objective:
This study aimed at assessing the clinical effectiveness of acupuncture for lateral epicondylitis (LE).
Methods:
The following databases were systematically searched: China National Knowledge Infrastructure, Chinese Science and Technology Periodical Database, Wan Fang database, Chinese Biomedicine Literature, PubMed, EMBASE, and Cochrane Library from inception to May 2019. Randomized controlled trials (RCTs) meeting the inclusion criteria were included. RevMan 5.3 software was used to conduct meta-analyses. The study quality was evaluated with the Cochrane risk of bias.
Results:
Ten RCTs involving 796 individuals were included in this meta-analysis. Three studies reported randomized methods with a specific description. For the analyses of the clinical efficacy rate, acupuncture outperformed sham acupuncture (two RCTs, n = 130, P=0.15), medicine therapy (two RCTs, n = 124, P=0.02), and blocking therapy (four RCTs, n = 427, P=0.0001). For the analyses of the visual analog scale, acupuncture outperformed sham acupuncture (two RCTs, n = 92, P=0.18), medicine therapy (two RCTs, n = 144, P < 0.00001), and blocking therapy (two RCTs, n = 132, P=0.03). The subgroup analyses comparing acupuncture with sham acupuncture therapy revealed heterogeneities. The follow-up information and adverse reactions were not analyzed because of the insufficient number of studies.
Conclusions:
Acupuncture appears to be superior to drug or blocking therapy or sham acupuncture therapy for LE. However, considering the low quality of the available trials, further large-scale RCTs with a low risk of bias are needed in the future.
... All 19 included studies were full length journal reports. Of the 19 studies, 14 were published in Chinese and were conducted in China; four were published in English, three of which were conducted in Germany [15][16][17] and one was conducted in Canada [18]. The remaining study was conducted in Italy and published in Italian [19]. ...
... Twelve studies [18][19][20][21][22][23][24][25][26][27][28][29] used the term lateral epicondylitis, whereas the term tennis elbow was used by four studies [30][31][32][33] to describe the condition. One study used both terms in its title, but in the text consistently used the term lateral epicondylitis [17]. One study used the term chronic epicondylitis [15] and the remaining study used the term chronic elbow pain [16]. ...
... One study [16] used non-invasive sham acupuncture at BL 13 on the back, in which subjects were stimulated with a pencil like probe and were shown an acupuncture needle. The other two studies [15,17] inserted real acupuncture needles a few centimeters away from traditional acupoints, their interconnecting lines (meridians) and painful pressure points. ...
Acupuncture and moxibustion have widely been used to treat lateral elbow pain (LEP). A comprehensive systematic review of randomized controlled trials (RCTs) including both English and Chinese databases was conducted to assess the efficacy of acupuncture and moxibustion in the treatment of LEP.
Revised STRICTA (2010) criteria were used to appraise the acupuncture procedures, the Cochrane risk of bias tool was used to assess the methodological quality of the studies. A total of 19 RCTs that compared acupuncture and/or moxibustion with sham acupuncture, another form of acupuncture, or conventional treatment were included.
All studies had at least one domain rated as high risk or uncertain risk of bias in the Cochrane risk of bias tool. Results from three RCTs of moderate quality showed that acupuncture was more effective than sham acupuncture. Results from 10 RCTs of mostly low quality showed that acupuncture or moxibustion was superior or equal to conventional treatment, such as local anesthetic injection, local steroid injection, non-steroidal anti- inflammatory drugs, or ultrasound. There were six low quality RCTs that compared acupuncture and moxibustion combined with manual acupuncture alone, and all showed that acupuncture and moxibustion combined was superior to manual acupuncture alone.
Moderate quality studies suggest that acupuncture is more effective than sham acupuncture. Interpretations of findings regarding acupuncture vs. conventional treatment, and acupuncture and moxibustion combined vs. manual acupuncture alone are limited by the methodological qualities of these studies. Future studies with improved methodological design are warranted to confirm the efficacy of acupuncture and moxibustion for LEP.
... The assessment of the PPT was widely used (35 out of 42, 83.3%) in order to evaluate the effectiveness of acupuncture in reducing hyperalgesia in pain disorders. Most common conditions under investigation were myofascial pain, associated with the occurrence of MTrPs (8 out 35, 22.9%) [33,38,41,48,50,63,70,83], fibromyalgia (7 out of 35, 20%) [37,44,45,72,81,82,87], chronic neck and back pain (5 out of 35, 14.3%) [22,46,49,74,77], temporomandibular disorder (5 out of 35, 14.3%) [40,43,68,79,91], and experimentally induced delayed-onset muscle soreness (DOMS; 4 out of 35, 11.4%) [27,47,51,78]. PPT was also used as an outcome measure for the treatment effect of acupuncture in tension type headache [52,93], osteoarthritis of the knee [86], abdominal scar pain [62], plantar fasciitis [96], and syringomyelia [64]. ...
... Ten of the 35 patient studies (28.6%) evaluated the immediate effect of one single acupuncture treatment. Nine of these reported the PPT to be significantly elevated [33,40,41,43,51,64,78,79,83], and one study found no significant PPT increase [50]. Among the 26 studies (74.3%) that assessed the effectiveness of an acupuncture series, 18 (69.2%) ...
... Among the 26 studies (74.3%) that assessed the effectiveness of an acupuncture series, 18 (69.2%) showed a PPT increase after treatment [37,38,46,50,52,62,63,68,70,72,74,77,81,82,86,87,91,93] while six studies (23.1%) observed no effect of acupuncture on the PPT [22,27,[47][48][49]96]. The outcome of two studies was rated as unclear, because the analysis was performed by combining data of all groups [44,45]. ...
The effect of acupuncture on sensory perception has never been systematically reviewed; although, studies on acupuncture mechanisms are frequently based on the idea that changes in sensory thresholds reflect its effect on the nervous system.
Pubmed, EMBASE and Scopus were screened for studies investigating the effect of acupuncture on thermal or mechanical detection or pain thresholds in humans published in English or German. A meta-analysis of high quality studies was performed.
Out of 3007 identified articles 85 were included. Sixty five studies showed that acupuncture affects at least one sensory threshold. Most studies assessed the pressure pain threshold of which 80% reported an increase after acupuncture. Significant short- and long-term effects on the pressure pain threshold in pain patients were revealed by two meta-analyses including four and two high quality studies, respectively. In over 60% of studies, acupuncture reduced sensitivity to noxious thermal stimuli, but measuring methods might influence results. Few but consistent data indicate that acupuncture reduces pin-prick like pain but not mechanical detection. Results on thermal detection are heterogeneous. Sensory threshold changes were equally frequent reported after manual acupuncture as after electroacupuncture. Among 48 sham-controlled studies, 25 showed stronger effects on sensory thresholds through verum than through sham acupuncture, but in 9 studies significant threshold changes were also observed after sham acupuncture. Overall, there is a lack of high quality acupuncture studies applying comprehensive assessments of sensory perception.
Our findings indicate that acupuncture affects sensory perception. Results are most compelling for the pressure pain threshold, especially in pain conditions associated with tenderness. Sham acupuncture can also cause such effects. Future studies should incorporate comprehensive, standardized assessments of sensory profiles in order to fully characterize its effect on sensory perception and to explore the predictive value of sensory profiles for the effectiveness of acupuncture.
... 1,6 Therefore, interventions that may prevent or counteract the symptoms of DOMS and facilitate muscle regeneration following intense exercise are of great interest in athletic health care delivery. 3 Since recent research provides evidence for the efficacy of acupuncture on pain and dysfunction in various musculoskeletal and inflammatory disorders, [7][8][9] it is conceivable that acupuncture could also be a potential treatment option in DOMS. However, there is no consistent evidence to support this hypothesis. ...
This study was done to investigate the effects of a standardized acupuncture treatment on symptoms and muscle function in exercise-induced delayed-onset muscle soreness (DOMS).
A prospective, randomized, controlled, observer and subject-blinded trial was undertaken. Twenty-two (22) healthy subjects (22-30 years; 10 males and 12 females) were randomly assigned to three treatment groups: real acupuncture (deep needling at classic acupuncture points and tender points; n = 7), sham-acupuncture (superficial needling at nonacupuncture points; n = 8), and control (no needling; n = 7). DOMS of the nondominant elbow-flexors was experimentally induced through eccentric contractions until exhaustion. The outcome measures were pain perception (visual analogue scale; VAS; range: 0-10 cm), mechanical pain threshold (MPT; pressure algometer), and maximum isometric voluntary force (MIVF; force transducer). Treatment was applied immediately, 24 and 48 hours after DOMS induction. Measurements of MPT and MIVF were made prior to DOMS induction as well as before and after every treatment session. VAS data were acquired after DOMS induction as well as pre- and post-treatment. Final pain, MPT, and MIVF measurements were performed 72 hours after DOMS induction.
Following nonparametric testing, there were no significant differences between groups in outcome measures at baseline. After 72 hours, pain perception (VAS) was significantly lower in the acupuncture group compared to the sham acupuncture and control subjects. However, the mean MPT and MIVF scores were not significantly different between groups.
Although acupuncture seemed to have no effects on mechanical pain threshold and muscle function, it proved to reduce perceived pain arising from exercise-induced muscle soreness.
... 23,28,30,[42][43][44][45]56 As shown in Figure 1, a total of 14 trials were included in the analyses. 25,27,32,35,37,38,40,47,48,50,52,54,55,57 Study characteristics Ten (71%) trials analyzed the effects of acupuncture, and the remaining four (29%) the effects of electroacupuncture. The characteristics of the participants of the included studies are shown in Table 1. ...
... In a recent meta-analysis of the RCTs by Morley et al., acupuncture has shown to be efficient and successful in relieving pain (36). Although many studies comparing acupuncture with different therapeutic methods have shown the benefits of acupuncture, most of them suffer from a small sample size (37)(38)(39). ...
Lateral epicondylitis (LE) is one of the major causes of elbow pain. Despite being a self-limiting condition, its high incidence can cause a significant socioeconomic burden. Many treatment modalities have been proposed for the treatment, but the optimal strategy is still unknown. In this article, we discuss surgical and non-surgical strategies for the treatment of LE and address the research gaps.
... 23,28,30,[42][43][44][45]56 As shown in Figure 1, a total of 14 trials were included in the analyses. 25,27,32,35,37,38,40,47,48,50,52,54,55,57 Study characteristics Ten (71%) trials analyzed the effects of acupuncture, and the remaining four (29%) the effects of electroacupuncture. The characteristics of the participants of the included studies are shown in Table 1. ...
Objective
The aim of this study was to evaluate the effect of acupuncture/electroacupuncture, alone or combined with other interventions, on pain intensity, pain-related disability, and strength in lateral epicondylalgia (LE) of musculoskeletal origin.
Databases and data treatment
Electronic databases were searched for randomized clinical trials, where at least one group received acupuncture or electroacupuncture for LE of musculoskeletal origin. To be eligible, trials had to include humans and collect outcomes on pain intensity or pain-related disability in LE. Data were extracted by two reviewers. The risk of bias (RoB) of the trials was assessed using the Cochrane RoB tool, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the level of evidence was summarized using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) using random effects were calculated.
Results
A total of 14 trials (10 acupuncture) were included. The meta-analysis found a moderate effect size of acupuncture (SMD = −0.66, 95% confidence interval (CI) = −1.22 to −0.10), but not electroacupuncture (SMD = −0.08, 95% CI = −0.99 to 0.83), in the reduction of elbow pain as compared to a comparative group. Acupuncture exhibited a significant moderate effect size (SMD = −0.51, 95% CI = −0.91 to −0.11) in the improvement of related-disability. Acupuncture (SMD = 0.36, 95% CI = 0.16 to 0.57), but not electroacupuncture (SMD = 0.34, 95% CI = −0.29 to 0.98), exhibited a significant but small effect size on strength. Most significant effects were in the short term. The RoB was low but the heterogeneity of trial results led to a downgrading of the GRADE evidence level.
Conclusion
Low-level evidence suggests positive effects of acupuncture, but not electroacupuncture, for pain, related-disability, and strength, in LE of musculoskeletal origin, in the short term.
... Within manual needling there are also many variations in the needling technique. Similarly, different outcome measures have been used to evaluate the efficacy of treatment for LEP, including pain, functional impairment, and grip strength [5,8,9]. In view of the need to establish an easy-to-replicate method of acupuncture treatment for LEP, it was decided to trial a simple manual needle manipulation technique that has been used by Fu-Chun Wang, one of the experts in our study group. ...
In planning for a large-scale multicenter trial to evaluate the effect of acupuncture for the treatment of lateral elbow pain, a pilot study was conducted. This was a prospective, investigator- and patient-blinded, nonrandomized, placebo controlled trial. Subjects were evaluated at baseline, before fourth, seventh, and ninth treatment, and at a two-week posttreatment follow-up. The treatment group received unilateral acupuncture at LI 10 and LI 11 at the affected side with manual needle manipulation; the control group received sham-laser acupuncture at the same acupoints. Measures included (i) disabilities of the arm, shoulder, and hand (DASH) questionnaire, (ii) pain-free grip strength (PFGS), and (iii) a visual analogue scale (VAS) for pain. Significant differences in DASH score, PFGS, and VAS between treatment and control group were found at the ninth treatment (
n
=
20
for each group,
P
<
0.05
). Only DASH showed significant differences compared to the control for all the measurement time points after treatment commenced and appears to be a sensitive and appropriate primary outcome measure for the future multisite trial. Results from this pilot study provided relevant information about treatment efficacy, credibility of control treatment, and sensitivity of different outcome measures for the planning of the future trial.
Abstract
Delayed onset muscle soreness (DOMS) is a common form of muscle soreness, experienced by individuals who perform unaccustomed exercise as a result of exercise induced muscle damage (EIMD) (Aminian-Far et al., 2011). Scientific studies have shown contradictory results on the effects of acupuncture on DOMS.
The aim of this study was to evaluate acupuncture effects on DOMS. For this preliminary study, 3 healthy participants, after completing a screening questionnaire and providing written informed consent, were randomly distributed into three groups (verum acupuncture group (VA), sham acupuncture group (SA) and a control group CG). Pressure pain threshold (PPT), vertical jump (VJ) and an isokinetic evaluation were performed before and after (immediately and after 24h) an EIMD protocol which subjects performing a five sets of 20 drop jumps from a height of 0,6m step, with a 10 seconds interval between jumps and 2 minutes rest period between sets.
The present protocol of EIMD showed success in inducing DOMS. When VA, SA and CG groups were compared, it was found that VA had better results in all outcome measures. However, SA group showed better results than CG, when PPT was compared.
As a conclusion, the results showed that acupuncture applied after an EIMD protocol, had a positive effect on PPT, VJ and Average Peak Torque.
[Bisset LM, Vicenzino B (2015) Physiotherapy management of lateral epicondylalgia.Journal of PhysiotherapyXX: XX-XX].
This study describes the reliability of pragmatic combinations of acupuncture points for lateral epicondylalgia as prescribed by physiotherapists who were experts in acupuncture. Raters (n=14; 33 to 59 years) independently prescribed acupuncture points for 30 simulated human patients with lateral epicondylalgia who were surveyed via a printed questionnaire. The frequency and cooccurrence of acupuncture points prescribed for patients with lateral epicondylitis were assessed. Absolute agreement and Light's kappa (κLight) with 95%CI were used to quantify the interrater agreement. Raters prescribed 103 unique acupuncture points in different combinations with a median [min; max] of 5 [0; 11] acupuncture points. The most prescribed acupuncture point was LI-11 (297/420=71%), and the most common cooccurring acupuncture points were LI-11 and LI-4 (160/420=38%). The absolute agreement for prescribing the acupuncture points ranged from 70% (point GB-20) to 0% (points LI-10, SP-6, LI-11, GB-34, LI-12, and LI-4). Point LR-3 showed the highest interrater reliability for prescribing the acupuncture points (κLight=0.112, 95%CI=[0.055; 0.194]), whereas point LI-4 showed the lowest reliability (κLight=-0.003, 95%CI=[-0.024; 0.024]). These findings suggest that pragmatic prescriptions of acupuncture points for lateral epicondylalgia are unreliable among physiotherapists who are experts in acupuncture. Explicit, high-level evidence-based rules for prescribing and teaching combinations of acupuncture points for lateral epicondylalgia are warranted.
Background::
Numerous treatment options have been proposed for enthesopathy of the extensor carpi radialis brevis (eECRB).
Purpose::
To (1) compare the efficacy and safety of nonsurgical treatment options for eECRB described in randomized placebo-controlled trials at short-term, midterm, and long-term follow-up and (2) evaluate outcomes in patients receiving placebo.
Study design::
Systematic review and meta-analysis.
Methods::
Following PRISMA guidelines, 4 electronic databases were searched for randomized placebo-controlled trials for eECRB. Studies reporting visual analog scale (VAS) for pain scores and/or grip strength were included. Random- or fixed-effects meta-analysis was employed to compare treatments with at least 2 eligible studies using the standardized mean difference and odds ratio. The study protocol was registered at PROSPERO (ID: CRD42018075009).
Results::
Thirty-six randomized placebo-controlled trials, evaluating 11 different treatment modalities, with a total of 2746 patients were included. At short-term follow-up, only local corticosteroid injection improved pain; however, it was associated with pain worse than placebo at long-term follow-up. At midterm follow-up, laser therapy and local botulinum toxin injection improved pain. At long-term follow-up, extracorporeal shock wave therapy provided pain relief. With regard to grip strength, only laser therapy showed better outcomes in comparison with placebo. While there was no difference among various treatments in the odds ratio of an adverse event, they all increased adverse events compared with placebo. In placebo-receiving patients, a sharp increase in the percentage of patients reporting mild pain or less was observed from 2% at short-term follow-up to 92% at midterm follow-up.
Conclusion::
Most patients experienced pain resolution after receiving placebo within 4 weeks of follow-up. At best, all treatments provided only small pain relief while increasing the odds of adverse events. Therefore, if clinicians are inclined to provide a treatment for particular patients, they may consider a pain relief regimen for the first 4 weeks of symptom duration. Patient-specific factors should be considered when deciding on treatment or watchful waiting.
Studies assessing the point-specific effect of acupuncture or the characteristics of acupuncture points (APs) tend to yield inconclusive results. In order to identify a possible confounding factor, we aimed to examine the variability in AP localization by means of a survey.
Attendees of the 14th ICMART (International Council of Medical Acupuncture and Related Techniques) congress as well as DÄGfA (German Medical Society of Acupuncture) lecturers and students were asked to locate and mark the APs LI 10 and TH 5 on a research assistant's arm. Identified points were transferred into a coordinate system, and the respective bivariate distribution function was calculated. Additionally, participants filled out a questionnaire about their acupuncture education and experience, the acupuncture style and point localization techniques used most frequently, and their estimation of the size of an AP.
The areas of the ellipses, theoretically containing 95% of AP localizations, varied between 44.49 and 5.18 cm(2). The largest distance between 2 identified points was 8.45 cm for LI 10 and 5.3 cm for TH 5. Apart from being trained at the same school, no other factor could be identified that determined the variability in AP localization.
Our results indicate that congruity of AP localization among experienced acupuncturists might be low. Although there are some limitations to our results, this possible bias should be taken into account when conducting acupuncture trials and interpreting results of previous acupuncture studies.
A prior national survey documented the high prevalence and costs of alternative medicine use in the United States in 1990.
To document trends in alternative medicine use in the United States between 1990 and 1997.
Nationally representative random household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997, respectively.
A total of 1539 adults in 1991 and 2055 in 1997.
Prevalence, estimated costs, and disclosure of alternative therapies to physicians.
Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (P < or = .001). The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (P = .002). In both surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. There was no significant change in disclosure rates between the 2 survey years; 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0%) and 1997 (58.3%) (P=.36). Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services.
Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.
Objectives To compare the efficacy of acupuncture and conventional massage for the treatment of chronic neck pain. Design Prospective, randomised, placebo controlled trial. Setting Three outpatient departments in Germany. Participants 177 patients aged 18-85 years with chronic neck pain. Interventions Patients were randomly allocated to five treatments over three weeks with acupuncture (56), massage (60, or "sham" laser acupuncture (61). Main outcome measures Primary outcome measure: maximum pain related to motion (visual analogue scale) irrespective of direction of movement one week after treatment. Secondary outcome measures: range of motion (3D ultrasound real time motion analyser), pain related to movement in sic six directions (visual analogue scale), pressure pain threshold (pressure algometer), changes of spontaneous pain, motion related pain, global complaints (seven point scale), and quality of life (SF-36). Assessments were performed before, during,and one week and three months after treatment. Patients' beliefs in treatment were assessed. Results One week after five treatments the acupuncture group showed a significantly greater improvement in motion related pain compared with massage (difference 24.22 (95% confidence interval 16.5 to 31.9), P=0.005) but not compared with sham laser (17.28 (10.0 to 24.6), P=0.33). Differences between acupuncture and massage or sham laser were greater in the subgroup who had had pain for longer than five years (n=75) and in patients with myofascial pain syndrome (n=129). The acupuncture group had the best results in most secondary outcome measures. There were no differences in patients' beliefs in treatment. Conclusion Acupuncture is a effective short term treatment for patients with chronic neck pain, but there is only limited evidence for long term effects after five treatments.
The nociceptive flexion reflex (R111 reflex) and the concurrent subjective pain score elicited by right sural nerve stimulation at random intensities were studied in 10 healthy volunteers. A close relationship was found between the recruitment curves of the reflex and the pain score as a function of stimulus intensity. As a consequence, the threshold of the R111 reflex (Tr) and of pain sensation (Tp) were found to be almost identical (mean: 9.8 and 11.3 mA, respectively). Similarly, the threshold for obtaining a maximal reflex response (Tmr) was found to be very close to that for intolerable pain (Tlp): 33.5 and 35.1 mA, respectively.
These four parameters were studied before and during the immersion of the left hand into a heated thermoregulated waterbath at various temperatures (from 40 to 47.5° Q. While nonnociceptive temperatures (40 to 44° C) were without effect, higher conditioning temperatures induced an increase in the four thresholds. In addition, a highly significant linear relationship was observed between the increase in these thresholds and the intensity of the conditioning stimulus in the 44 to 47.5°C range.
These four parameters were also studied before and during three other nociceptive conditioning stimuli: immersion of the left hand into a 6°C waterbath, 10 watts muscular exercise of the left hand performed under ischaemia and a painful (5.5 kg/cm2) pinch applied on the nasal septum. These three conditioning situations induced a very significant increase of the four thresholds considered in this study with the greatest being observed during nociceptive cold applied to the left hand.
During all the conditioning situations, variations in Tr and Tp as well as in Tmr and Tip were found to be linearly related. This indicates a close relationship between the effects of the conditioning nociceptive stimuli on the reflex and the related pain sensation.
These results suggest that the modulation of pain by heterotopic nociceptive stimuli can be explained at least in part by a depression in the transmission of nociceptive messages at the spinal level. They are discussed with reference to the counterirritation phenomena and common features with 'diffuse noxious inhibitory controls' (DNIC) are underlined.
This paper reviews some of the recent randomised trials on acupuncture published in the literature, with particular reference to the definition of placebo (control), sham acupuncture and real acupuncture. Response rates of 30, 50 and 70% of placebo, sham and real acupuncture respectively, are suggested for the groups of patients studied. The statistical methodology necessary in the design of acupuncture trials, in order to detect differences of this order of magnitude, is discussed. If the postulated response rate had been envisaged at the onset of the trials here reviewed, then the majority of these trials have very low power at a conventional 5% level of significance. It is emphasised that one cannot necessarily conclude from trials which produce statistically non-significant results that acupuncture (when compared with placebo for example) is ineffective. The paper suggests that meaningful comparisons between alternative treatments may be made by using ‘pain free intervals’ with subsequent analysis using life table techniques. Tables are provided for determining appropriate patient numbers.
Die zunehmende Implementierung Evidenz-basierten Handelns erfordert für die Akupunkturforschung die erneute intensive Auseinandersetzung mit den anerkannten Prüfmethoden und Bewertungskriterien. Es besteht die Notwendigkeit, Standards für gewisse Fragestellungen der Akupunkturforschung zu entwickeln. Ziel der vorliegenden Arbeit ist die kritische Darstellung der Anforderungen, Möglichkeiten und Grenzen einzelner, häufig verwendeter, wissenschaftlicher Prüfmethoden für die Evaluation der Akupunktur. Im Mittelpunkt stehen dabei die randomisierte klinisch-kontrollierte Studie und die systematische Meta-Analyse.
Für die Akupunktur ist es möglich, einen Wirksamkeitsnachweis mittels anerkannter Messmethoden und Prüfverfahren zu erbringen. Um zu aussagekräftigen Ergebnissen zu kommen, müssen einige Anforderungen an klinische Akupunkturstudien gestellt werden. Diese Anforderungen können bei sorgfältiger Studienplanung erfüllt werden. Ein Studiendesign mit Randomisation sollte angestrebt werden. Häufig ist der Vergleich mit einem Placeboverfahren nur bedingt aussagekräftig. Auch aus diesem Grund ist der Vergleich mit Standardtherapieverfahren anzustreben.
Die systematische Meta-Analyse spielt eine entscheidende Rolle bei der Beurteilung der Wirksamkeit eines Therapieverfahren. Dabei müssen Meta-Analysen eine gute Methodik aufweisen und auf Besonderheiten der Akupunktur Rücksicht nehmen.
Die Verwirklichung der Grundidee der EBM in der Akupunktur stellt Anforderungen an klinische Forscher, Methodologen, Ärzte, Patienten und Kostenträger. Dies beinhaltet die Umsetzung der Vorgaben der Initiatoren, die Beachtung der Besonderheiten einzelner Therapieverfahren und die kritische Analyse der vorliegenden Daten, um die Erkenntnisse der EBM im Einzelfall für den Patienten optimal zu nutzen.
Assessments of oedema and decrease in hand strength are useful for patients with a hand lesion. This study examined the asymmetry of the arms and determined the estimates of the unknown prior to lesion values for hand volume, grip strengths assessed with a Jamar dynamometer (GS[J]) and a Collins dynamometer (GS[C]), and pinch strength with a Jamar pinch gauge (PS) in 100 healthy working people. Hand volume, GS(J), GS(C) and PS of the dominant hand were respectively 3.6 +/- 4.1%, 6.6 +/- 9.2%, 11.7 +/- 11.2%, and 8.0 +/- 13.2% higher than those of the non-dominant hand (p < 0.001). Very good estimates were obtained with the values of the contralateral arm for all the indices studied. The correlation coefficient equalled 0.95 for hand volume, 0.91 for GS(J), 0.83 for GS(C), and 0.72 for PS. These estimates allow us to evaluate the evolution of oedema and hand strengths in patients with hand injury, especially to determine whether they could return to work as they are mostly manual workers with demanding jobs.
The purpose of this study was to compare the pain-alleviating effect of classical acupuncture with superficial needle insertion in 82 patients suffering from lateral epicondylalgia. Sessions were 20 min long, two to three times weekly with 10 treatments in all. Five acupuncture points were treated: LI 10, 11, 12, Lu 5, and SJ 5. After 10 treatments significant differences were observed between the groups favoring the classical acupuncture technique in relation to subjective and objective outcome. No such differences could be observed at the follow-ups after 3 months and 1 year. This study showed that classical "deep" acupuncture is superior to superficial needle insertion in the short-term symptomatic treatment of lateral epicondylalgia, but not at 3- and 12-month follow-up.
Pressure threshold is the minimal pressure (force) which induces pain. The pressure threshold meter (PTM) is a force gauge with a rubber disc of 1 cm2 surface. The instrument has been proven to be useful in clinical practice for quantification of deep muscle tenderness. Trigger points, fibrositis, myalgic spots, activity of arthritis as well as assessment of sensitivity to pain can be diagnosed by PTM. This study therefore established standards for pressure threshold as well as the reproducibility and validity of measurement in 24 male and 26 female normal volunteers at 9 sites. Muscles frequently afflicted by trigger points were examined. The deltoid was chosen as a reference since it is rarely a site for trigger points. Comparison of corresponding muscles on opposite sides failed to demonstrate significant differences (except for 1 muscle in females). These identical results obtained over muscles of opposite sides proved the excellent reproducibility and validity of pressure threshold measurement. Results serve as a reference for clinical diagnosis of abnormal tenderness and for documentation of treatment results. The sensitivity of individual muscles varies. Therefore the results presented should be kept in mind when diagnosis of pathological tenderness by palpation is attempted.
Acupuncture therapy for patients suffering from tennis elbow has shown itself to be an excellent alternative to steroid injections. Twenty-one out of 34 patients who were treated with acupuncture became much better--completely free of pain. Many of them had previously been given one or more steroid injections without improvement. In a control group of 26 patients who received only steroid injections, 8 patients reported a corresponding improvement. The ancient Chinese technique adapted to Western conditions has, in the above cases, neither caused any side effects nor worsened the condition of any patient, and is well worth trying as therapy for this disabling complaint.