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Rewiring the primary somatosensory cortex in carpal tunnel syndrome with acupuncture
Abstract
Carpal tunnel syndrome is the most common entrapment neuropathy, affecting the median nerve at the wrist. Acupuncture is a minimally-invasive and conservative therapeutic option, and while rooted in a complex practice ritual, acupuncture overlaps significantly with many conventional peripherally-focused neuromodulatory therapies. However, the neurophysiological mechanisms by which acupuncture impacts accepted subjective/psychological and objective/physiological outcomes are not well understood. Eligible patients (n = 80, 65 female, age: 49.3 ± 8.6 years) were enrolled and randomized into three intervention arms: (i) verum electro-acupuncture 'local' to the more affected hand; (ii) verum electro-acupuncture at 'distal' body sites, near the ankle contralesional to the more affected hand; and (iii) local sham electro-acupuncture using non-penetrating placebo needles. Acupuncture therapy was provided for 16 sessions over 8 weeks. Boston Carpal Tunnel Syndrome Questionnaire assessed pain and paraesthesia symptoms at baseline, following therapy and at 3-month follow-up. Nerve conduction studies assessing median nerve sensory latency and brain imaging data were acquired at baseline and following therapy. Functional magnetic resonance imaging assessed somatotopy in the primary somatosensory cortex using vibrotactile stimulation over three digits (2, 3 and 5). While all three acupuncture interventions reduced symptom severity, verum (local and distal) acupuncture was superior to sham in producing improvements in neurophysiological outcomes, both local to the wrist (i.e. median sensory nerve conduction latency) and in the brain (i.e. digit 2/3 cortical separation distance). Moreover, greater improvement in second/third interdigit cortical separation distance following verum acupuncture predicted sustained improvements in symptom severity at 3-month follow-up. We further explored potential differential mechanisms of local versus distal acupuncture using diffusion tensor imaging of white matter microstructure adjacent to the primary somatosensory cortex. Compared to healthy adults (n = 34, 28 female, 49.7 ± 9.9 years old), patients with carpal tunnel syndrome demonstrated increased fractional anisotropy in several regions and, for these regions we found that improvement in median nerve latency was associated with reduction of fractional anisotropy near (i) contralesional hand area following verum, but not sham, acupuncture; (ii) ipsilesional hand area following local, but not distal or sham, acupuncture; and (iii) ipsilesional leg area following distal, but not local or sham, acupuncture. As these primary somatosensory cortex subregions are distinctly targeted by local versus distal acupuncture electrostimulation, acupuncture at local versus distal sites may improve median nerve function at the wrist by somatotopically distinct neuroplasticity in the primary somatosensory cortex following therapy. Our study further suggests that improvements in primary somatosensory cortex somatotopy can predict long-term clinical outcomes for carpal tunnel syndrome.
... After removing 550 duplicates, we excluded 880 irrelevant records based on their title and abstract. The full text of 56 remaining records was then evaluated, and 16 eligible studies (Kumnerddee and Kaewtong, 2010;Jin and Lang, 2011;Li, 2011;Yang et al., 2011;Yao et al., 2012;Ramin, 2013;Xiang et al., 2014;Hadianfard et al., 2015;Chung et al., 2016;Maeda et al., 2017;Ural and Özturk, 2017;Xie et al., 2018;Tezel et al., 2019;Bahrami-Taghanaki et al., 2020;Xiong, 2020;Huang and Lin, 2022) were included in the final analysis. A list of excluded records with reasons is provided in Supplementary material 2. The PRISMA flow chart presents the selection procedure (Figure 1). ...
... A list of excluded records with reasons is provided in Supplementary material 2. The PRISMA flow chart presents the selection procedure (Figure 1). Of the included studies, eight were conducted in China (Jin and Lang, 2011;Li, 2011;Yang et al., 2011;Xiang et al., 2014;Chung et al., 2016;Xie et al., 2018;Xiong, 2020;Huang and Lin, 2022), two in the USA (Yao et al., 2012;Maeda et al., 2017), three in Iran (Ramin, 2013;Hadianfard et al., 2015;Bahrami-Taghanaki et al., 2020), two in Turkey (Ural and Özturk, 2017;Tezel et al., 2019), and one in Thailand (Kumnerddee and Kaewtong, 2010). The sample size of the studies ranged from 27 to 181, with a total of 1,025 participants. ...
... During the randomization process, 11 studies specified the randomization method (Kumnerddee and Kaewtong, 2010;Yang et al., 2011;Yao et al., 2012;Xiang et al., 2014;Hadianfard et al., 2015;Chung et al., 2016;Maeda et al., 2017;Ural and Özturk, 2017;Xie et al., 2018;Tezel et al., 2019;Bahrami-Taghanaki et al., 2020). Two studies (Yang et al., 2011;Chung et al., 2016) implemented appropriate methods to conceal the allocation sequence. ...
Background
The evidence for the effectiveness of acupuncture for patients with carpal tunnel syndrome (CTS) is insufficient. Therefore, this systematic review and meta-analysis aimed to evaluate the effectiveness of acupuncture on CTS through a comprehensive literature search.
Methods
English and Chinese databases were searched from their inceptions until 27 October 2022 to collect randomized controlled trials (RCTs) that investigated the effect of acupuncture on CTS. Two reviewers independently selected studies that met the eligibility criteria, extracted the required data, assessed the risk of bias using version 2 of the Cochrane risk-of-bias tool for randomized trials (ROB 2), and evaluated the quality of reporting for acupuncture interventions using the Revised Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA). The primary outcomes were symptom severity and functional status, while secondary outcomes included pain intensity, responder rate, and electrophysiological parameters. Review Manager software (version 5.4.1) was used for data analysis. The certainty of the evidence was rated with GRADEpro (version 3.6) software.
Results
We included 16 RCTs with a total of 1,025 subjects. The overall risk of bias was rated as low in one RCT, some concerns in 14, and high in one. Compared with night splints, acupuncture alone was more effective in relieving pain, but there were no differences in symptom severity and functional status. Acupuncture alone had no advantage over medicine in improving symptom severity and electrophysiological parameters. As an adjunctive treatment, acupuncture might benefit CTS in terms of symptom severity, functional status, pain intensity, and electrophysiological parameters, and it was superior to medicine in improving the above outcomes. Few acupuncture-related adverse events were reported. The above evidence had a low or very low degree of certainty.
Conclusion
Acupuncture as an adjunctive treatment may be effective for patients with CTS. Additionally, more rigorous studies with objective outcomes are needed to investigate the effect of acupuncture in contrast with sham acupuncture or other active treatments.
Systematic review registration
https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=329925, identifier CRD42022329925.
... In the brain, gray matter plasticity in primary somatosensory (S1) and motor (M1) areas has been associated with altered median nerve conduction (1) and sensations of pain and paresthesia (2). CTS patients also show altered white matter integrity within S1 (3). Functional neuroimaging has revealed altered S1 somatotopy, including reduced separation between cortical representations of the second (D2) and third (D3) digits of the hand (4,5). ...
... While severe median nerve compression in CTS is often treated surgically, conservative management with non-surgical and non-pharmacological interventions also has therapeutic benefit (6). Acupuncture, particularly electro-acupuncture (EA), a hybrid of traditional and modern neuromodulation techniques (7), was shown to improve maladaptive neuroplasticity, as well as median nerve conduction and CTS symptom severity (3). A study of evoked brain fMRI response found that EA at the hand/wrist produced contralateral S1 activation in the hand/wrist representation area which was linked with both median nerve latency (8) and post-stimulation reduction in CTS pain and paresthesia (9). ...
... The acupuncture therapy protocol has been previously described (3). Briefly, sixteen treatments were delivered over an 8-week period in a tapered schedule (three times, two times, and then once per week). ...
Carpal Tunnel Syndrome (CTS) is a median nerve entrapment neuropathy that alters primary somatosensory cortex (S1) organization. While electro-acupuncture (EA), a form of peripheral neuromodulation, has been shown to improve clinical and neurophysiological CTS outcomes, the role of EA-evoked brain response during therapy (within and beyond S1) for improved outcomes is unknown. We investigated S1-associated whole brain fMRI connectivity during both a resting and sustained EA stimulation state in age-matched healthy controls (N = 28) and CTS patients (N = 64), at baseline and after 8 weeks of acupuncture therapy (local, distal, or sham EA). Compared to healthy controls, CTS patients at baseline showed decreased resting state functional connectivity between S1 and thalamic pulvinar nucleus. Increases in S1/pulvinar connectivity strength following verum EA therapy (combined local and distal) were correlated with improvements in median nerve velocity (r = 0.38, p = 0.035). During sustained local EA, compared to healthy controls, CTS patients demonstrated increased functional connectivity between S1 and anterior hippocampus (aHipp). Following 8 weeks of local EA therapy, S1/aHipp connectivity significantly decreased and greater decrease was associated with improvement in patients' functional status (r = 0.64, p = 0.01) and increased median nerve velocity (r = −0.62, p = 0.013). Thus, connectivity between S1 and other brain areas is also disrupted in CTS patients and may be improved following EA therapy. Furthermore, stimulus-evoked fMRI connectivity adds therapy-specific, mechanistic insight to more common resting state connectivity approaches. Specifically, local EA modulates S1 connectivity to sensory and affective processing regions, linked to patient function and median nerve health.
... All participants reported their experience ("Deqi") with acupuncture stimulation. Deqi featured aching, pressure, heaviness, fullness, and numbness among other feelings (23)(24)(25)(26)(27)(28)(29). The acupuncturist used 0.40 × 40-mm sterile silver acupuncture needles (Guizhou, China) with the EA technique. ...
... Before conducting the gPPI analysis, we used a component-based noise correction method to remove artifacts from the fMRI data. To investigate how EA stimuli alter brain functional architecture at the ROI (Supplementary Figure 1) and large-scale network levels (static ICA results), we used gPPI analysis according to Lee Masson et al. (23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39). The regression model used in the gPPI analysis was as follows: Y = X 1 × β + X 2 × βG + error, where Y = time-series BOLD response of the seed, X 1 = the hemodynamic response function (HRF) convolved gPPI terms (i.e., time-series BOLD response of the seed × the psychological regressor as dictated by onset and duration of EA stimulus), β = the strength of FC (i.e., the beta estimates of gPPI terms), X 2 = X 1 × HRF convolved psychological regressor × covariates of no interest (age, Edu, and sex regressors), and βG = the beta estimates of the HRF-convolved time-series BOLD response of the seeds. ...
Introduction
Post-stroke aphasia (PSA) is a language disorder caused by left hemisphere stroke. Electroacupuncture (EA) is a minimally invasive therapeutic option for PSA treatment. Tongli (HT5) and Xuanzhong (GB39), two important language-associated acupoints, are frequently used in the rehabilitation of patients with PSA. Preliminary evidence indicated functional activation in distributed cortical areas upon HT5 and GB39 stimulation. However, research on the modulation of dynamic and static functional connectivity (FC) in the brain by EA in PSA is lacking.
Method
This study aimed to investigate the PSA-related effects of EA stimulation at HT5 and GB39 on neural processing. Thirty-five participants were recruited, including 19 patients with PSA and 16 healthy controls (HCs). The BOLD signal was analyzed by static independent component analysis, generalized psychophysiological interactions, and dynamic independent component analysis, considering variables such as age, sex, and years of education.
Results
The results revealed that PSA showed activated clusters in the left putamen, left postcentral gyrus (PostCG), and left angular gyrus in the salience network (SN) compared to the HC group. The interaction effect on temporal properties of networks showed higher variability of SN (F = 2.23, positive false discovery rate [pFDR] = 0.017). The interaction effect on static FC showed increased functional coupling between the right calcarine and right lingual gyrus (F = 3.16, pFDR = 0.043). For the dynamic FC, at the region level, the interaction effect showed lower variability and higher frequencies of circuit 3, with the strongest connections between the supramarginal gyrus and posterior cingulum (F = 5.42, pFDR = 0.03), middle cingulum and PostCG (F = 5.27, pFDR = 0.036), and triangle inferior frontal and lingual gyrus (F = 5.57, pFDR = 0.026). At the network level, the interaction effect showed higher variability in occipital network–language network (LN) and cerebellar network (CN) coupling, with stronger connections between the LN and CN (F = 4.29, pFDR = 0.042). Dynamic FC values between the triangle inferior frontal and lingual gyri were anticorrelated with transcribing, describing, and dictating scores in the Chinese Rehabilitation Research Center for Chinese Standard Aphasia Examination.
Discussion
These findings suggest that EA stimulation may improve language function, as it significantly modulated the nodes of regions/networks involved in the LN, SN, CN, occipital cortex, somatosensory regions, and cerebral limbic system.
... The choice of effective acupuncture points should be based on neuroanatomical and segmental principles, as the acupuncture-induced change in pain threshold is mainly mediated by segmental inhibition [5,6]. This is further supported by preclinical studies investigating the biological mechanism of acupuncture analgesia proposing different pain modulating neuronal systems on the spinal and central nervous level as a key mechanism of action [7,8]. Somatosensory pathways involved in the gate control theory and the descending pain suppression pathway mediate immediate analgesic effects if the stimulated acupuncture point and the region of pain share the same spinal segment [8]. ...
... Somatosensory pathways involved in the gate control theory and the descending pain suppression pathway mediate immediate analgesic effects if the stimulated acupuncture point and the region of pain share the same spinal segment [8]. Long-lasting analgesic effects, on the other hand, involve neuronal reorganization in the primary somatosensory cortex mediated by the stimulation of either local or distal points neuroanatomically corresponding with the affected area [7]. Therefore, the choice of effective acupuncture points strictly remains on neuroanatomical principles and exact identification of the pain-affected spinal segments in order to induce analgesia. ...
Introduction
Acupuncture is a promising treatment for visceral cancer pain, but to date, evidence for immediate effects on neuropathic pain is limited.
Case presentation
This report presents a case of immediate pain relief by single-needle acupuncture on opioid-refractory neuropathic breakthrough pain in a 78-year-old female breast cancer patient with cervical bone metastases. Acupuncture was applied at a single point neuroanatomically correlating to the pain affected spinal segment.
Discussion
Immediately after acupuncture, the patient reported a complete pain relief lasting for one day. In the following days, neuropathic breakthrough pain was better manageable with reduced dosages of opioids. Acupuncture is possibly effective in providing immediate and safe pain relief in neuropathic cancer pain through neuromodulating effects on the spinal and central nervous level. Randomized controlled studies with individualized acupuncture point protocols are needed to establish efficacy and safety.
... These studies can be divided into two types: those that compare acupuncture to treatment or lack of treatment (pragmatic trials) and those that compare acupuncture to placebo (efficacy trials) [40]. In addition, some studies seek to characterize the mechanism underlying the apparent effects of acupuncture [41,42]. Moreover, an extensive body of theoretical literature attempts to outline probable models that explain acupuncture's effectiveness [43]. ...
... This, in turn, may modulate the response of the amygdala (and hippocampus, see below), such that PTSD patients who underwent tDCS after (but not during) extinction of fear memory exhibited a decreased response to the negative stimulus during recall. This suggests the existence of a small period of time after extinction learning when memory is malleable, such that tDCS applied during this window may augment consolidation of extinction memory [42]. During these studies, neuromodulation was detached from real traumatic memory retrieval. ...
Posttraumatic stress disorder (PTSD) poses an ongoing challenge to society, to health systems, and to the trauma victims themselves. Today PTSD is often considered an incurable chronic problem that lacks effective treatment. While PTSD is closely related to memory, it also affects many physiological systems. PTSD is usually treated with medications and psychotherapy with moderate success, leaving a substantial proportion of patients with enduring distress and disability. Therefore, a search for better treatment options is vital. In this paper, we propose a model in which a conversation-based technique is integrated with bodily manipulation through acupuncture. This approach first emerged in clinical experience showing intriguing results from treating PTSD patients using acupuncture as a main strategy. Its theoretical foundations derive from the clinic and rely on contemporary neuroscience’s understanding of memory consolidation and reconsolidation processes. Research shows that acupuncture can have potentially positive effects at three levels: (a) achieving a balance between sympathetic and parasympathetic neural activity; (b) reducing activation in the limbic system, hence inducing a calming effect; (c) reshaping the functional connectivity map within important and relevant cortical regions that encompass the default-mode network. We suggest that coupling traumatic memory retrieval leading to reconsolidation, combined with acupuncture, offers considerable potential for positive clinical improvement in patients with PTSD. This may explain the positive results of the described case studies and can pave the path for future advances in research and treatment in this field.
... [109][110][111][112][113][114][115] Human neuroimaging studies have demonstrated that acupuncture can reverse maladaptive neuroplasticity in the brain. 116 While current research is exploring how acupuncture works to engage such changes, more than 100 functional magnetic resonance imaging (fMRI) studies evaluating evoked brain response to real vs sham acupuncture needling have now been published. 3336 engage somatosensory (ie touch) processing brain areas such as the thalamus and secondary somatosensory cortex, acupuncture needling more readily deactivates affect/emotion processing areas such as the amygdala. ...
The term “acupuncture” commonly refers to a non-pharmacologic therapy that is increasingly employed by diverse segments of the population for a wide variety of complaints including pain, insomnia, anxiety, depression, frozen shoulder, and other issues. The term is also used as a short-hand for the wider medical system from which the placement of needles into the skin for therapeutic benefit and related techniques evolved. Thus “acupuncture” refers both to the therapeutic technique and the therapeutic system of Acupuncture and Herbal Medicine (AHM). The other modalities included within AHM include a wide variety of physical and mechanical manipulations, herbal medicines, dietary recommendations, and lifestyle modifications. Clinically, acupuncture is increasingly offered in a variety of conventional medical settings such as hospitals, medical school clinics, veterans’ healthcare centers, oncology facilities, and rehabilitation centers, and its safety profile is excellent overall. Barriers to further incorporation of acupuncture into biomedical sites include insurance coverage of acupuncture, education of conventional medical practitioners and other stakeholders about the utility, efficacy, and evidence base of acupuncture. Acupuncturists in the United States are skilled practitioners who are highly educated in the complex therapeutic system from which acupuncture arose and in the technical aspects of its utility as a treatment modality. The training, certification, licensure, and regulation of acupuncturists is similar to that of conventional providers such has physician’s assistants, advanced practice nurses, and medical and osteopathic doctors. While clinical use and acceptance of acupuncture continues to grow, there is to date no definitive composite document explaining the utility of acupuncture in various healthcare settings, the current understanding of how acupuncture works, and the training, professional regulation, and certification of acupuncture practitioners. This article will address these topics and strive to create a reference for practitioners, administrators, legislators, insurance providers, patients and their families, and other stakeholders.
... In humans, postherpetic neuralgia was associated with S1 plasticity, shown as functional reorganization in magnetic resonance imaging, implicated in both evoked and spontaneous pain intensities (Li et al., 2022). Successful treatment of carpal tunnel syndrome using acupuncture was linked to the rewiring of the S1 (Maeda et al., 2017). ...
Aging is generally associated with declining somatosensory function, which seems at odds with the high prevalence of chronic pain in older people. This discrepancy is partly related to the high prevalence of degenerative diseases such as osteoarthritis in older people. However, whether aging alters pain processing in the primary somatosensory cortex (S1), and if so, whether it promotes pain chronification is largely unknown. Herein, we report that older mice displayed prolonged nociceptive behavior following nerve injury when compared with mature adult mice. The expression of peroxisome proliferator‐activated receptor‐gamma coactivator‐1α (PGC‐1α) in S1 was decreased in older mice, whereas PGC‐1α haploinsufficiency promoted prolonged nociceptive behavior after nerve injury. Both aging and PGC‐1α haploinsufficiency led to abnormal S1 neural dynamics, revealed by intravital two‐photon calcium imaging. Manipulating S1 neural dynamics affected nociceptive behavior after nerve injury: chemogenetic inhibition of S1 interneurons aggravated nociceptive behavior in naive mice; chemogenetic activation of S1 interneurons alleviated nociceptive behavior in older mice. More interestingly, adeno‐associated virus‐mediated expression of PGC‐1α in S1 interneurons ameliorated aging‐associated chronification of nociceptive behavior as well as aging‐related S1 neural dynamic changes. Taken together, our results showed that aging‐associated decrease of PGC‐1α promotes pain chronification, which might be harnessed to alleviate the burden of chronic pain in older individuals.
... A meta-analysis in 2017 showed that acupuncture is an effective and safe treatment for chronic pain [12]. Besides pain control, several trials suggest that acupuncture also has a positive influence on nerve function with an improvement of nerve conduction [13][14][15][16][17][18]. ...
BACKGROUND
Diabetic peripheral neuropathy (DPN) is a common complication of diabetes mellitus and can lead to serious complications. Therapeutic strategies for pain control are available but there are few approaches that influence neurological deficits such as numbness.
AIM
To investigate the effectiveness of acupuncture on improving neurological deficits in patients suffering from type 2 DPN.
METHODS
The acupuncture in DPN (ACUDPN) study was a two-armed, randomized, controlled, parallel group, open, multicenter clinical trial. Patients were randomized in a 1:1 ratio into two groups: The acupuncture group received 12 acupuncture treatments over 8 wk, and the control group was on a waiting list during the first 16 wk, before it received the same treatment as the other group. Both groups received routine care. Outcome parameters were evaluated after 8, 16 and 24 wk and included neurological scores, such as an 11-point numeric rating scale (NRS) 11 for hypesthesia, neuropathic pain symptom inventory (NPSI), neuropathy deficit score (NDS), neuropathy symptom score (NSS); nerve conduction studies (NCS) were assessed with a handheld point-of-care device.
RESULTS
Sixty-two participants were included. The NRS for numbness showed a difference of 2.3 (P < 0.001) in favor of the acupuncture group, the effect persisted until week 16 with a difference of 2.2 (P < 0.001) between groups and 1.8 points at week 24 compared to baseline. The NPSI was improved in the acupuncture group by 12.6 points (P < 0.001) at week 8, the NSS score at week 8 with a difference of 1.3 (P < 0.001); the NDS and the TNSc score improved for the acupuncture group in week 8, with a difference of 2.0 points (P < 0.001) compared to the control group. Effects were persistent in week 16 with a difference of 1.8 points (P < 0.05). The NCS showed no meaningful changes. In both groups only minor side effects were reported.
CONCLUSION
Study results suggest that acupuncture may be beneficial in type 2 diabetic DPN and seems to lead to a reduction in neurological deficits. No serious adverse events were recorded and the adherence to treatment was high. Confirmatory randomized sham-controlled clinical studies with adequate patient numbers are needed to confirm the results.
... 79 Clinical trials suggest that EA's mechanism for carpal tunnel syndrome potentially involves reshaping the white matter microstructure in the primary somatosensory cortex, concurrently enhancing functional connectivity between the primary somatosensory area and regions associated with emotional processing. 80,81 For chronic pain conditions such as fibromyalgia, EA can regulate primary somatosensory function linked with insular neurochemistry, thereby alleviating pain severity. 82 In summary, the limbic system may be the key area where acupuncture works. ...
Purpose
Electroacupuncture is widely used to pain management. A bibliometric analysis was conducted to identify the hotspots and trends in research on electroacupuncture for pain.
Methods
We retrieved studies published from 1994–2022 on the topic of pain relief by electroacupuncture from the Web of Science Core Collection database. We comprehensively analysed the data with VOSviewer, CiteSpace, and bibliometrix. Seven aspects of the data were analysed separately: annual publication outputs, countries, institutions, authors, journals, keywords and references.
Results
A total of 2030 papers were analysed, and the number of worldwide publications continuously increased over the period of interest. The most productive country and institution in this field were China and KyungHee University. Evidence-Based Complementary and Alternative Medicine was the most productive journal, and Pain was the most co-cited journal. Han Jisheng, Fang Jianqiao, and Lao Lixing were the most representative authors. Based on keywords and references, three active areas of research on EA for pain were mechanisms, randomized controlled trials, and perioperative applications. Three emerging trends were functional magnetic resonance imaging (fMRI), systematic reviews, and knee osteoarthritis.
Conclusion
This study comprehensively analysed the research published over the past 28 years on electroacupuncture for pain treatment, using bibliometrics and science mapping analysis. This work presents the current status and landscape of the field and may serve as a valuable resource for researchers. Chronic pain, fMRI-based mechanistic research, and the perioperative application of electroacupuncture are among the likely foci of future research in this area.
... The fMRI study showed that insertion of the acupuncture needle at acupoint ST 36 significantly affected the proprioceptive brain activation by decreasing blood oxygenation level-dependent signal intensity in basal ganglia, limbic system, and cerebellum , and EA could reduce chronic pain, so it can be used to treat the paresthesia brought on by PNI persisted (Lu et al., 2021). Current research showed that acupuncture at local versus distal sites may improve median nerve function at the wrist by somatotopically distinct neuroplasticity in the primary somatosensory cortex following therapy (Maeda et al., 2017). Some studies found that after sciatic nerve injury, local synaptic activity increased in the ipsilateral somatosensory cortex and decreased in the contralateral somatosensory cortex (Zuo et al., 2010;Nugent et al., 2015), and the plasticity changes following PNI were situated in homologous regions of the ipsilateral hemisphere in addition to the contralateral hemisphere (Fornander et al., 2016). ...
Peripheral nerve injury (PNI) is a structural event with harmful consequences worldwide. Due to the limited intrinsic regenerative capacity of the peripheral nerve in adults, neural restoration after PNI is difficult. Neurological remodeling has a crucial effect on the repair of the form and function during the regeneration of the peripheral nerve after the peripheral nerve is injured. Several studies have demonstrated that acupuncture is effective for PNI-induced neurologic deficits, and the potential mechanisms responsible for its effects involve the nervous system remodeling in the process of nerve repair. Moreover, acupuncture promotes neural regeneration and axon sprouting by activating related neurotrophins retrograde transport, such as nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), glial cell-derived neurotrophic factor (GDNF), N-cadherin, and MicroRNAs. Peripheral nerve injury enhances the perceptual response of the central nervous system to pain, causing central sensitization and accelerating neuronal cell apoptosis. Together with this, the remodeling of synaptic transmission function would worsen pain discomfort. Neuroimaging studies have shown remodeling changes in both gray and white matter after peripheral nerve injury. Acupuncture not only reverses the poor remodeling of the nervous system but also stimulates the release of neurotrophic substances such as nerve growth factors in the nervous system to ameliorate pain and promote the regeneration and repair of nerve fibers. In conclusion, the neurological remodeling at the peripheral and central levels in the process of acupuncture treatment accelerates nerve regeneration and repair. These findings provide novel insights enabling the clinical application of acupuncture in the treatment of PNI.
... placebo, which had an unpredictable impact on brain activity. This confirms that BCI is a targeted intervention, that patients can be taught to change activity in specific regions and frequencies, and that targeted brain changes predict symptom improvement.Other studies have demonstrated similar results, in which active treatment and placebo had similar outcomes but different mechanisms.23 Mechanistically, the association between EEG power and symptom report has been demonstrated.[24][25][26] ...
Background
Chemotherapy‐induced peripheral neuropathy (CIPN) includes negative sensations that remain a major chronic problem for cancer survivors. Previous research demonstrated that neurofeedback (a closed‐loop brain–computer interface [BCI]) was effective at treating CIPN versus a waitlist control (WLC). The authors' a priori hypothesis was that BCI would be superior to placebo feedback (placebo control [PLC]) and to WLC in alleviating CIPN and that changes in brain activity would predict symptom report.
Methods
Randomization to one of three conditions occurred between November 2014 and November 2018. Breast cancer survivors no longer in treatment were assessed at baseline, at the end of 20 treatment sessions, and 1 month later. Auditory and visual rewards were given over 20 sessions based on each patient's ability to modify their own electroencephalographic signals. The Pain Quality Assessment Scale (PQAS) at the end of treatment was the primary outcome, and changes in electroencephalographic signals and 1‐month data also were examined.
Results
The BCI and PLC groups reported significant symptom reduction. The BCI group demonstrated larger effect size differences from the WLC group than the PLC group (mean change score: BCI vs. WLC, −2.60 vs. 0.38; 95% confidence interval, −3.67, −1.46 [p = .000; effect size, 1.07]; PLC, −2.26; 95% confidence interval, −3.33, −1.19 [p = .001 vs. WLC; effect size, 0.9]). At 1 month, symptoms continued to improve only for the BCI group. Targeted brain changes at the end of treatment predicted symptoms at 1 month for the BCI group only.
Conclusions
BCI is a promising treatment for CIPN and may have a longer lasting effect than placebo (nonspecific BCI), which is an important consideration for long‐term symptom relief. Although scientifically interesting, the ability to separate real from placebo treatment may not be as important as understanding the placebo effects differently from effects of the intervention.
Plain Language Summary
Chemotherapy‐induced nerve pain (neuropathy) can be disabling for cancer survivors; however, the way symptoms are felt depends on how the brain interprets the signals from nerves in the body.
We determined that the perception of neuropathy can be changed by working directly with the brain.
Survivors in our trial played 20 sessions of a type of video game that was designed to change the way the brain processed sensation and movement.
In this, our second trial, we again observed significant improvement in symptoms that lasted after the treatment was complete.
... Acupuncture is a multi-dimensional intervention. Needle stimulation, the essential component of the acupuncture procedure, is known to induce different types of somatosensory afferent activation and consequent modulatory effects on the brain (Chae et al., 2013;Maeda et al., 2017;Kim et al., 2020), as well as responses in other systems, including the immune and endocrine systems (Wei and Hsieh, 2020;Liu et al., 2021;Oh and Kim, 2021). Concurrently, in clinical settings, the needling procedure is necessarily accompanied by additional and supplementary procedures (e.g., preparations of needle insertion), which may potentially lead to various therapeutic contexts. ...
Introduction
Acupuncture is a clinical intervention consisting of multiple stimulus components, including somatosensory stimulation and manipulation of therapeutic context. Existing findings in neuroscience consolidated cognitive modulation to somatosensory afferent process, which could differ from placebo mechanism in brain. Here, we aimed to identify intrinsic process of brain interactions induced by compound stimulus of acupuncture treatment.
Methods
To separately and comprehensively investigate somatosensory afferent and cognitive/affective processes in brain, we implemented a novel experimental protocol of contextual manipulation with somatosensory stimulation (real acupuncture: REAL) and only contextual manipulation (phantom acupuncture: PHNT) for fMRI scan, and conducted independent component (IC)-wise assessment with the concatenated fMRI data.
Results
By our double (experimentally and analytically) dissociation, two ICs (CA1: executive control, CA2: goal-directed sensory process) for cognitive/affective modulation (associated with both REAL and PHNT) and other two ICs (SA1: interoceptive attention and motor-reaction, SA2: somatosensory representation) for somatosensory afference (associated with only REAL) were identified. Moreover, coupling between SA1 and SA2 was associated with a decreased heart rate during stimulation, whereas CA1 was associated with a delayed heart rate decrease post-stimulation. Furthermore, partial correlation network for these components demonstrated a bi-directional interaction between CA1 and SA1/SA2, suggesting the cognitive modulation to somatosensory process. The expectation for the treatment negatively affected CA1 but positively affected SA1 in REAL, whereas the expectation positively affected CA1 in PHNT.
Discussion
These specific cognitive-somatosensory interaction in REAL were differed from vicarious sensation mechanism in PHNT; and might be associated with a characteristic of acupuncture, which induces voluntary attention for interoception. Our findings on brain interactions in acupuncture treatment elucidated the underlying brain mechanisms for compound stimulus of somatosensory afferent and therapeutic contextual manipulation, which might be a specific response to acupuncture.
... Acupuncture contributes to angiogenesis and granulation and promotes tissue regeneration of wounds in mice (19). Other studies have reported adjustment of the primary somatosensory cortex by acupuncture (20), improvement of colitis by electroacupuncture (EA) treatment of sensitive skin points and acupuncture points (21), and an insomnia treatment effect of acupuncture (22). In addition, the combination of EA and laser acupuncture (LA) with modern science and technology as well as with traditional acupuncture is used as an acupoint treatment method. ...
Introduction
Allodynia, which can be induced by paclitaxel administration, is the presence of pain as a result of a stimulus that does not usually provoke pain. Many studies have investigated the analgesic efficacy of acupuncture, including laser acupuncture (LA) and electroacupuncture (EA). Although pain-related diseases are relatively common, few studies have analyzed the analgesic effects and mechanisms of LA combined with EA. The purpose of this study was to investigate the therapeutic effect and mechanism of manual acupuncture (MA), EA, LA, and combined therapy (LA + EA) in a paclitaxel-induced allodynia rat model.
Methods
A total of 56 rats were classified into eight groups: a normal (Nor, n = 7), a control (Con, n = 7), an MA (n = 7), an EA (n = 7), a 650-nm LA (650LA, n = 7), an 830-nm LA (830LA, n = 7), a 650-nm LA combined with EA (650LA + EA, n = 7), and an 830-nm LA combined with EA group (830LA + EA, n = 7). Allodynia was induced by intraperitoneal injection of 2 mg/kg of paclitaxel every other day for a total of four times except the Nor group. Acupuncture treatments were conducted at the points of Jungwan (CV12) and Joksamni (ST36) once every other day for 6 min, for a total of nine times. Withdrawal response reaction times and force intensity of the foot were measured before the start of the experiment, after the 4th paclitaxel administration (day 8), and after the 9th and last treatment (day 15). On the 16th day, mRNA and protein expression in the spinal nerves was assessed, and a metabolome analysis of the animals’ feces was performed.
Results and discussion
Our analyses show that 650LA + EA treatment resulted in an upregulation of protein expression related to pain relief and nerve regeneration, whereas 830LA + EA treatment led to significant changes in metabolomes. This study demonstrates that a combination treatment of EA and LA can suppress allodynia and promote upregulation of protein expression related to nerve regeneration and is effective in changing the intestinal microbiome. Further large-scale research is required to assess the exact mechanism underlying the therapeutic effect of this combination treatment in pain-related diseases.
... The "abdominal tank" theory suggests the coordination and unity of the abdomen and pelvic floor (40) and that treatment should not address only a single muscle or symptom. EA enhances pelvic floor innervation and muscle support (47), thereby improving pelvic floor muscle strength. ...
Background
Electro-acupuncture (EA) has promising effects on diastasis rectus abdominis (DRA), defined as a separation of the two muscle bellies of rectus abdominis. To study, there is scant knowledge or scarce high-quality evidence.
Objective
We aimed to evaluate the long-term efficacy and safety of EA in treating DRA during postpartum. It was assumed that the improvement of DRA was more obvious in the EA group than in the control group.
Design
Randomized, controlled, blinded trial (Clinical Trial Registration: ChiCTR2100041891).
Setting
Hangzhou Hospital of Traditional Chinese Medicine in China.
Participants
Females aged 20–45 years without a past medical history of pathological rectus abdominal dissection were recruited from DRA inclusion criteria from 42 days to 1 year postpartum.
Intervention
110 participants were randomly assigned in a 1:1 ratio to a control group with no EA intervention (n = 55), and EA group (n = 55). The EA group received ten sessions of EA combined with physical exercise or only physical exercise for 2 weeks with a 26-week follow-up.
Measurements
Outcomes were assessed at baseline, week 2, and week 26. The primary outcome was the change of the inter recti distance (IRD) and electromyographic evaluation of the pelvic floor. Secondary outcomes included elasticity of linea alba (LA), paraumbilical subcutaneous adipose tissue (SAT) measurement, body mass index (BMI), percentage body fat (F%), dyspepsia symptoms, menstrual symptoms, quality of life (QoL), pain performance of patients with lower back pain, postnatal depression symptoms (PDS), postpartum self-image, and DRA-related symptom assessment including urine leakage, frequency, and urgency, constipation, sexual dysfunction, and chronic pelvic pain.
Results
A total of 110 maternal (55 in each group) were recruited. The mean difference in IRD from baseline to week 2 and week 26 in all states of the two groups were reduced compared with those before treatment, with statistical significance (P < 0.05). The mean of IRD at the horizontal line of the umbilicus in the end-expiratory state was smaller in the EA group than in the control group, but the difference was not statistically significant (P > 0.05) at week 2. The mean of IRD at the horizontal line of the umbilicus in head-up and flexed knee state was smaller in the EA group than in the control group, and the difference was statistically significant (P < 0.05) at week 26. Five (9.1%) and thirteen (23.64%) adverse events were reported in EA and control groups, respectively. No serious adverse events were reported.
Limitation
The frequency intensity of EA parameters was selected between 4 and 6 because of individual tolerance differences.
Conclusion
EA is an effective approach to improve IRD, electromyographic evaluation of the pelvic floor, BMI, the elasticity of LA, paraumbilical SAT, and symptoms of DRA, with durable effects at 26 weeks.
Primary funding source
The Construction Fund of Medical Key Disciplines of Hangzhou (Project Number: OO20200097), Hangzhou Medical and Health Science and Technology Project No. A20200483, and Zhejiang Traditional Chinese Medicine Science and Technology Plan Project (Project Number: 2021ZQ065).
Clinical trial registration
http://www.chictr.org.cn/index.aspx, identifier: ChiCTR2100041891.
... Similarly, in CTS, a previous study suggested that sensory afferent interruption induces a decline in synaptic activity in S1 (Lu et al., 2017). In contrast, another study also indicated that cortical plasticity expands from the S1-hand area to the S1-leg and S1-face areas (Maeda et al., 2017). Functional cortical remapping occurred in distinctly defined subregions of ipsilateral S1 after CTS. ...
Background
Interhemispheric and intrahemispheric long-range synchronization and information communication are crucial features of functional integration between the bilateral hemispheres. Previous studies have demonstrated that disrupted functional connectivity (FC) exists in the bilateral hemispheres of patients with carpal tunnel syndrome (CTS), but they did not clearly clarify the phenomenon of central dysfunctional connectivity. This study aimed to further investigate the potential mechanism of the weakened connectivity of primary somatosensory cortex (S1) based on a precise template.
Methods
Patients with CTS ( n = 53) and healthy control subjects (HCs) ( n = 23) participated and underwent resting-state functional magnetic resonance imaging (rs-fMRI) scanning. We used FC to investigate the statistical dependency of the whole brain, effective connectivity (EC) to analyze time-dependent effects, and voxel-mirrored homotopic connectivity (VMHC) to examine the coordination of FC, all of which were adopted to explore the change in interhemispheric and intrahemispheric S1.
Results
Compared to the healthy controls, we significantly found a decreased strength of the two connectivities in the interhemispheric S1 hand , and the results of EC and VMHC were basically consistent with FC in the CTS. The EC revealed that the information output from the dominant hemisphere to the contralateral hemisphere was weakened.
Conclusion
This study found that maladjusted connections between and within the bilateral S1 revealed by these methods are present in patients with CTS. The dominant hemisphere with deafferentation weakens its effect on the contralateral hemisphere. The disturbance in the bilateral S1 provides reliable evidence to understand the neuropathophysiological mechanisms of decreased functional integration in the brains of patients with CTS.
... Research using tactile perceptions can provide insight to somatosensory processing and can also inform brain function more broadly. This approach has been used to advance our knowledge of several disorders including developmental disorders such as autism [1] and attention deficit hyperactivity disorder (ADHD) [2], neurological conditions such as concussion, [3][4][5][6][7][8][9][10][11][12] psychiatric disorders such as obsessive compulsive disorder [13] and chronic pain [14]. While somatosensory processing itself may be altered in these conditions, these studies have also provided insight into cortical inhibition more broadly. ...
Remote testing has become a desireable option as it helps reduce participant burden, can be more convenient and enables longitudinal data collection to track symptom recovery. Recently, advances in testing have enabled researchers to test somatosensory processing and brain function. Using tactile testing modalities such as vibrotactile stimulation to the fingertips can provide information about cortical inhibition, for example, without the need for invasive testing procedures. In the current manuscript, we present our initial experience for ‘at home’ tactile testing. We demonstrate 1) it is possible to develop an ‘at home’ testing battery with multiple tasks that is comparable to ‘in lab’ testing; and 2) it is feasible to collect this data remotely and repeatedly to monitor longitudinal changes. Participants included pediatric concussion patients and orthopedic injury (OI) controls, 8-18 years of age at time of participation, and were recruited ~10 days after injury. Testing was conducted on a 2-digit vibrotactile stimulator hand-held device and was based on previously used protocols. Stimulation was delivered to the left index and middle finger. Data quality of tasks was visually inspected to ensure data followed a pattern of converging values of thresholds over time. A total of 19 participants were recruited in this study; 11 concussion and 8 OI. Participants in the concussion group were 12.8 ± 2.2 years old (36.4% female) and participants in the OI group were 11.6 ± 2.5 years old (57.1% female) at the time of injury. Results from paired sample t-tests comparing task performance did not detect significant differences between the data collected from the home session and at the lab visit for the concussion group. Our results demonstrate that vibrotactile sensory testing can provide a non-invasive, objective measure of central nervous system functioning without relying on subjective questionnaires. This work demonstates it is possible to perform this testing remotely. Our data with children and adolescents demonstrates they are capable of completing these tasks at home; we therefore expect this at home testing protocol could easily be administered in other populations.
... In recent years, using neuroimaging techniques, our group (Shen et al., 2019; and other groups (Tu et al., 2009;Liu et al., 2018;Chen et al., 2019) have confirmed that PDM is associated with significant changes in the central nervous system's anatomy, metabolism, and resting-state function. Although the exact mechanisms of the analgesic e ects of acupuncture are not known, studies have postulated that acupuncture can alleviate pain by modulating brain regions and networks associated with pain processing Maeda et al., 2017). Neuroimaging research has demonstrated that chronic pain may be associated with alterations in multiple brain networks, such as the default mode network (DMN), sensorimotor network (SMN), salience network (SN), and descending modulation pathways (DPMS) (Kucyi and Davis, 2015;Kucyi and Davis, 2017). ...
Primary dysmenorrhea (PDM) is a common complaint in women throughout the menstrual years. Acupuncture has been shown to be effective in dysmenorrhea; however, there are large interindividual differences in patients' responses to acupuncture treatment. Fifty-four patients with PDM were recruited and randomized into real or sham acupuncture treatment groups (over the course of three menstrual cycles). Pain-related functional connectivity (FC) matrices were constructed at baseline and post-treatment period. The different neural mechanisms altered by real and sham acupuncture were detected with multivariate analysis of variance. Multivariate pattern analysis (MVPA) based on a machine learning approach was used to explore whether the different FC patterns predicted the acupuncture treatment response in the PDM patients. The results showed that real but not sham acupuncture significantly relieved pain severity in PDM patients. Real and sham acupuncture displayed differences in FC alterations between the descending pain modulatory system (DPMS) and sensorimotor network (SMN), the salience network (SN) and SMN, and the SN and default mode network (DMN). Furthermore, MVPA found that these FC patterns at baseline could predict the acupuncture treatment response in PDM patients. The present study verified differentially altered brain mechanisms underlying real and sham acupuncture in PDM patients and supported the use of neuroimaging biomarkers for individual-based precise acupuncture treatment in patients with PDM.
Background Compression neuropathy, such as carpal tunnel syndrome (CTS), results in changed afferent nerve signaling, which may result in changes in somatosensory brain areas. The purpose of this study was to assess cerebral changes following unilateral CTS and to assess short-term and long-term cerebral effects of guided plasticity treatment using ipsilateral cutaneous forearm deafferentation.
Methods Twenty-four patients with mild-to-moderate unilateral CTS were randomized to treatment with anesthetic cream (EMLA) or placebo. Patient-rated outcomes were assessed using Boston CTS questionnaire and disability of arm, shoulder, and hand questionnaire (QuickDASH). Patients were assessed for tactile discrimination and dexterity. Cortical activation during sensory stimulation was evaluated with functional magnetic resonance imaging at 3T. Assessments were performed at baseline, 90 minutes, and 8 weeks after treatment.
Results Functional magnetic resonance imaging showed that sensory stimulation of the hand with CTS resulted in significantly less cortical activation in the primary somatosensory cortex (S1) than stimulation of the healthy hand. Treatment with cutaneous forearm deafferentation on the side with CTS resulted in increased cortical activation in S1 both after the initial treatment and following 8 weeks of treatment. In addition, QuickDASH and tactile discrimination showed improvement in the EMLA group over time.
Conclusions Stimulation of median nerve-innervated fingers in patients with unilateral CTS results in smaller-than-normal activation in the contralateral S1. Cutaneous forearm anesthesia on the side with CTS results in larger activation in S1, suggesting recruitment of more neurons, and a slight improvement in sensory function.
Although Systematic Reviews and Meta-Analyses (PRISMA) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Acupuncture (PRISMA-A) checklists had been in use for several years, compliance rate was still not optimistic. We investigated the quality of reporting for meta-analyses of acupuncture published in PubMed. We compared the compliance rate for the quality of reporting following the publication of both the PRISMA and PRISMA-A recommendations. We searched PubMed for articles published between January 1st, 2020 and December 31st, 2022, after Endnote X9 document management software and manual screening, 180 meta-analyses of acupuncture were selected as samples. The PRISMA, and PRISMA-A checklists were used to evaluate the quality of the literature. Data were collected using a standard form. Pearson χ ² test and/or Fisher exact test were used to assess differences in reporting among groups. Logistic regression is used to calculate OR and its 95% CI. The total reported compliance rate of all items in the PRISMA list was 61.3%, and the reported compliance rate of the items with a compliance rate of <50% accounted for 35.71% of the total items. The total reported coincidence rate of all items in the PRISMA-A was 56.9%, and the reported coincidence rate of the items with a reported coincidence rate of <50% accounted for 31.25% of all the items. The compliance rate of the published research to PRISMA or PRISMA-A has no statistical difference between the Journal Citation Reports partition (Quarter1–Quarter2) and Journal Citation Reports partition (Quarter3–Qurater4) ( P > .05). Regardless of the level of journals published, have obvious deficiencies in the details of the study, the reference basis for the design of the study, the analysis method, the degree of strictness, the scientific nature, and other aspects. We must strengthen education on the standardization of research reports.
Introduction
Acupuncture therapy has achieved global expansion and shown promise for health promotion and treatment of acute/chronic pain.
Objectives
To present an update on the existing evidence base for research and clinical practice supporting acupuncture analgesia.
Methods
This Clinical Update elaborates on the 2023 International Association for the Study of Pain Global Year for Integrative Pain Care “Factsheet Acupuncture for Pain Relief” and reviews best evidence and practice.
Results
Acupuncture is supported by a large research evidence base and growing utilization. Mechanisms of acupuncture analgesia include local physiological response at the needling site, suppression of nociceptive signaling at spinal and supraspinal levels, and peripheral/central release of endogenous opioids and other biochemical mediators. Acupuncture also produces pain relief by modulating specific brain networks, integral for sensory, affective, and cognitive processing, as demonstrated by neuroimaging research. Importantly, acupuncture does not just manage pain symptoms but may target the sources that drive pain, such as inflammation, partially by modulating autonomic pathways. Contextual factors are important for acupuncture analgesia, which is a complex multifaceted intervention. In clinical practice, historical records and many providers believe that acupuncture efficacy depends on specific acupoints used, the technique of needle placement and stimulation, and the person who delivers the procedure. Clinical research has supported the safety and effectiveness of acupuncture for various pain disorders, including acupuncture as a complementary/integrative therapy with other pain interventions.
Conclusion
Although the quality of supportive evidence is heterogeneous, acupuncture's potential cost-effectiveness and low risk profile under standardized techniques suggest consideration as a neuromodulatory and practical nonpharmacological pain therapy.
Acupuncture techniques, including acupuncture needling and moxibustion, are the basic skills of acupuncture clinical treatment. It plays a vital role in acupuncture science. It is the bridge between TCM foundation theory and clinical practice. Acupuncture needling and moxibustion are both external therapies. Acupuncture needling is the technique of using different needles to stimulate certain areas with different kinds of needling techniques to regulate body functions and treat disorders by stimulating channel Qi. Moxibustion, often abbreviated as ‘moxa’, uses wormwood or other materials to warm the body surface to achieve therapeutic effects. There are a great number of acupuncture needling and moxa techniques. Each of them has different needling, stimulation methods, intensities, and stimulation areas. Every acupuncture technique in clinical application has unique operational steps and implementation processes. The correct application is related not only to its safety and therapeutic effect but also to the level of curative effect. The learning and application of acupuncture techniques is a long-term practice and process. In clinical practice, it is an important part of acupuncture treatment to select different acupuncture techniques according to the characteristics of the disorders and other related factors to perform different operations. Thus, acupuncturists are required to meet the basic requirements of proficiency and flexible applications for both theoretical study and skill training.
Die Therapie mithilfe dünner Nadeln beruht auf 3000 Jahren Erfahrung. Sie wurde in China entwickelt und erfreut sich in Europa immer größerer Beliebtheit. Ihr werden stark schmerzlindernde Qualitäten zugeschrieben.
TCM methods can be used successfully to treat carpal tunnel syndrome and to alleviate accompanying symptoms. However, the length of time a conservative therapy can be continued and when, or whether, surgical intervention needs to be considered depend on the experience of the individual TCM practitioner and the patient’s neurological condition.
Akupunktur, die Therapie mithilfe feinster Nadeln, beruht auf 3000 Jahren Erfahrung. Sie wurde in China entwickelt und erfreut sich in Europa immer größerer Beliebtheit. Ihr werden stark schmerzlindernde Qualitäten zugeschrieben.
In 2021, the Clinical Practice Guidelines (CPG) for the Management of Chronic Pain was published, and included a section on acupuncture treatment for integrated medicine and chronic headaches. The purpose of this symposium was to discuss the current understanding of the evidence for acupuncture treatment for chronic pain and the expansion of guidelines. As a working group member of the CPG, Dr. Namba Toshimune introduced the process of including acupuncture in the CPG and discussed not only each field of specialty but also the outlook for developing unique CPG for acupuncture. Dr. Kubo presented the status of basic research on acupuncture treatment for pain in recent years, introduced about the effects of acupuncture stimulation on adenosine, orexin, and oxytocin in mice and rats, as well as the specific reactions of acupuncture points to acupuncture stimulation, and emphasized the importance of basic research to establish the effectiveness of acupuncture for chronic pain. Dr. Udo Yukihiro provided a detailed review of clinical research on acupuncture treatment for chronic pain, reporting on the current status of acupuncture treatment methods, stimulation sites, and stimulation methods. Minakawa described the current situation where systematic education for acupuncturists has not been sufficiently implemented and discussed their own acupuncture treatments for patients with chronic pain. We hope that the contents of this symposium will be helpful in clinical practice, research, and education.
This systematic review with a meta-analysis aimed to identify the altered brain structure and function in carpal tunnel syndrome (CTS) by summarizing the literature about magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), and magnetoencephalography (MEG) outcomes compared to healthy controls (HC). CTS is the most common nerve entrapment in the arm associated with altered peripheral and central nociceptive system. PRISMA guidelines were used to report the outcomes. Six databases were searched for relevant literature (Web of Science, Scopus, PubMed, Sage, EBSCO host, and Cochrane). Eligible studies comparing MRI, fMRI, and MEG findings in people with CTS (present for at least 2 months) and HC through the following parameters: (1) interdigit cortical separation distance, (2) white and grey matter changes, (3) peak latency of M20 wave and recovery function of N20 from the somatosensory cortex (SI), and (4) surface area of activated digit cortical representation. The results from different studies were pooled and a meta-analysis was done. From 17 included, there was a significant reduction of interdigit cortical separation distance of index-middle and index-little fingers in the CTS (SMD = − 0.869, 95% CI (− 1.325, − 0.413), p-value = 0.000) and (SMD = − 0.79, 95% CI (− 1.217, − 0.364), p-value = 0.000), respectively. Middle-little fingers interdigit separation showed no difference (SMD = − 0.2, 95% CI (− 0.903, 1.309), p-value = 0.718). There is evidence supporting the altered brain structure and function in CTS as evidenced by reduction of interdigit cortical separation distance, and excessive blurring and disinhibition of SI, with low resting state functional connectivity. Thus, centrally directed therapeutic approaches might complement peripheral treatments.
Introduction: Electro-acupuncture, an innovative adaptation of traditional acupuncture,
combines electrical stimulation with acupuncture needles to enhance therapeutic effects. While
acupuncture is widely used, its biological mechanisms remain incompletely understood. Recent
research has explored the neurophysiological aspects of acupuncture, particularly through functional
magnetic resonance imaging (fMRI) to investigate its effects on brain activity. Methods: In
this systematic review, we conducted an extensive search for randomized clinical trials examining
electro-acupuncture effects measured by fMRI. We employed strict eligibility criteria, quality assessment,
and data extraction. Results: Five studies met our inclusion criteria and were analyzed. The
selected studies investigated electro-acupuncture in various medical conditions, including carpal
tunnel syndrome, fibromyalgia, Crohn’s disease, irritable bowel syndrome, and obesity. Notably,
electro-acupuncture was found to modulate brain activity and connectivity in regions associated with
pain perception, emotional regulation, and cognitive processing. These findings align with the holistic
approach of traditional Chinese medicine, emphasizing the interconnectedness of body and mind.
Discussion: In carpal tunnel syndrome, electro-acupuncture at both local and distal sites showed
neurophysiological improvements, suggesting distinct neuroplasticity mechanisms. In fibromyalgia,
somatosensory electro-acupuncture correlated with reduced pain severity, enhanced brain connectivity,
and increased gamma-aminobutyric acid levels. For Crohn’s disease, electro-acupuncture
influenced the homeostatic afferent processing network, potentially mitigating gut inflammation.
Electro-acupuncture for irritable bowel syndrome led to decreased activity in the anterior cingulate
cortex, offering pain relief, while electro-acupuncture for obesity impacted brain regions associated
with dietary inhibition and emotional regulation. Conclusion: This systematic review provides
evidence that electro-acupuncture can positively impact a range of medical conditions, possibly by
modulating brain activity and connectivity. While the quality of the reviewed studies is generally
good, further research with larger sample sizes and longer-term assessments is needed to better
understand the mechanisms and optimize electro-acupuncture protocols for specific health conditions.
The limited number of studies in this review emphasizes the need for broader investigations in this
promising field. The research protocol was registered in PROSPERO (CRD42023465866).
Objectives. This study aimed to examine the effects of a short opponens splint and hand exercise program on pain, hand functionality, daily activities, and work efficacy in computer engineers with wrist pain. Methods. Forty-five engineers were randomized into three groups: group 1 (n = 15) utilized both splints and exercises, group 2 (n = 15) engaged in exercises only and group 3 (n = 15) received no treatment, across 8 weeks, thrice weekly. Only exercises were applied to group 2 (n = 15). No treatment was applied for group 3 (n = 15). The progress of subjects was controlled periodically each week. Outcome measurements including the Jamar hand dynamometer, pinchmeter, nine-hole peg test (9-NHPT), visual analog scale, Boston carpal tunnel syndrome questionnaire and Michigan hand outcome questionnaire (MHQ) were evaluated pre and post treatment during the study period. Results. Comparing the outcome measurements of the three groups showed a statistically significant difference between them except for the 9-NHPT and MHQ pain and esthetics (p < 0.05). According to post-hoc tests, groups 1 and 2 had more significant differences than group 3. Also, there was no statistically significant difference in any parameter between group 1 and group 2 (p > 0.017). Conclusion. Non-restrictive minimal orthosis or exercise programs are advisable for individuals with wrist pain.
Resumo
Objetivo A osteoartrite (OA) de quadril causa dor e perda da funcionalidade. O tratamento cirúrgico é a procedimento de escolha nos casos graves, mas as comorbidades clínicas, a idade e a longa lista de espera podem comprometer a qualidade de vida. Este estudo teve como objetivo descrever os resultados da acupuntura no controle da dor e melhora da funcionalidade em indivíduos com OA de quadril.
Método Doze pacientes com OA de quadril grave foram tratados com dez sessões semanais de um protocolo padronizado de pontos de acupuntura. A intensidade da dor foi avaliada pela Escala Visual Analógica de Dor (EVA) e a qualidade de vida pelo Índice WOMAC.
Resultados A intensidade da dor (EVA) reduziu de 75,8 ± 18,8mm para 20,0 ± 22,6mm após 10 sessões de acupuntura e 48,3 ± 26,6mm no período de seguimento (ANOVA F = 7,99; p < 0,001). Os valores do Índice WOMAC reduziram de 74,7 ± 12,7 para 45,7 ± 22,1 e 54,6 ± 22,9 nos mesmos momentos.
Conclusão A acupuntura é uma estratégia de reabilitação conservadora eficaz para reduzir a dor e melhorar a qualidade de vida em indivíduos com OA de quadril grave.
Evidence-based treatments for chronic low back pain (cLBP) typically work well in only a fraction of patients, and at present there is little guidance regarding what treatment should be used in which patients. Our central hypothesis is that an interventional response phenotyping study can identify individuals with different underlying mechanisms for their pain who thus respond differentially to evidence-based treatments for cLBP. Thus, we will conduct a randomized controlled Sequential, Multiple Assessment, Randomized Trial (SMART) design study in cLBP with the following three aims. Aim 1: Perform an interventional response phenotyping study in a cohort of cLBP patients (n = 400), who will receive a sequence of interventions known to be effective in cLBP. For 4 weeks, all cLBP participants will receive a web-based pain self-management program as part of a run-in period, then individuals who report no or minimal improvement will be randomized to: a) mindfulness-based stress reduction, b) physical therapy and exercise, c) acupressure self-management, and d) duloxetine. After 8 weeks, individuals who remain symptomatic will be re-randomized to a different treatment for an additional 8 weeks. Using those data, we will identify the subsets of participants that respond to each treatment. In Aim 2, we will show that currently available, clinically derived measures, can predict differential responsiveness to the treatments. In Aim 3, a subset of participants will receive deeper phenotyping (n = 160), to identify new experimental measures that predict differential responsiveness to the treatments, as well as to infer mechanisms of action. Deep phenotyping will include functional neuroimaging, quantitative sensory testing, measures of inflammation, and measures of autonomic tone.
Carpal tunnel syndrome is the most common entrapment neuropathy, affecting quality of life for many people. Although it is a well recognised condition, new insights into epidemiology, diagnosis, and treatment have emerged in the past 6 years. The availability of disease-modifying treatments for rare systemic disorders associated with carpal tunnel syndrome (eg, amyloidosis) should alert clinicians to these diagnostic possibilities. Besides clinical evaluation and electrophysiology, the role of ultrasonography as a diagnostic tool has been confirmed and new ultrasound techniques have been applied, the clinical use and feasibility of which require further investigation. Surgical and non-surgical interventions are beneficial for the treatment of carpal tunnel syndrome and several treatment options are now available, giving clinicians the possibility to choose the best approach for every patient. New diagnostic and therapeutic techniques require further validation.
Carpal tunnel syndrome is the most common entrapment neuropathy and is associated with altered brain function and structure. However, little is understood of the central mechanisms associated with its pain, symptom presentation, and treatment-related resolution. This longitudinal study evaluated carpal tunnel syndrome-related alterations in brain network communication and relationships to behavioural signs of central sensitization before and after carpal tunnel release surgery. We tested the hypothesis that carpal tunnel syndrome is associated with condition- and treatment-related plasticity in brain regions involved in somatosensation. We used quantitative sensory testing and clinical and pain questionnaires to assess sensory and pain function in 25 patients with carpal tunnel syndrome before (18 women, 7 men) and after (n = 16) surgery, and 25 sex- and age-matched healthy controls. We also acquired resting-state functional MRI to determine functional connectivity of two key nodes in the somatosensory system, the thalamus and primary somatosensory cortex. Seed-to-whole brain resting-state static functional connectivity analyses revealed abnormally low functional connectivity for the hand area of the primary somatosensory cortex with the contralateral somatosensory association cortex (supramarginal gyrus) before surgery (P < 0.01). After clinically effective surgery: (i) Primary somatosensory functional connectivity was normalized with the contralateral somatosensory association cortex and reduced with the dorsolateral prefrontal cortex (a region associated with cognitive and emotional modulation of pain) and primary visual areas (P < 0.001) from pre-op levels; and (ii) Functional connectivity of the thalamus with the primary somatosensory and motor cortices was attenuated from pre-op levels (P < 0.001) but did not correlate with temporal summation of pain (a behavioural measure of central sensitization) or clinical measures. This study is the first to reveal treatment-related neuroplasticity in resting-state functional connectivity of the somatosensory system in carpal tunnel syndrome. The findings of dysfunctional resting-state functional connectivity point to aberrant neural synchrony between the brain's representation of the hand with regions involved in processing and integrating tactile and nociceptive stimuli and proprioception in carpal tunnel syndrome. Aberrant neural communication between the primary somatosensory hand area and the dorsolateral prefrontal cortex could reflect increased attention to pain, paraesthesia, and altered sensation in the hand. Finally, reduced thalamocortical functional connectivity after surgery may reflect central plasticity in response to the resolution of abnormal sensory signals from the periphery. Our findings support the concept of underlying brain contributions to this peripheral neuropathy, specifically aberrant thalamocortical and corticocortical communication, and point to potential central therapeutic targets to complement peripheral treatments.
Aim
We carried out a systematic review and meta-analysis to evaluate the safety and efficacy of electroacupuncture for patients with carpal tunnel syndrome.
Methods
We searched PubMed, Embase, Cochrane Library, Scopus, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database up to May 2022 for relevant studies. Relevant studies were identified by using specific eligibility criteria and data were extracted.
Results
A total of 26 randomized controlled trials (RCTs) with 1,698 patients were included. Compared with routine treatment, electroacupuncture treatment had lower visual analog scale (VAS) score [mean difference = −0.79, 95% confidence interval (CI): −1.11 to −0.47, P < 0.00001], and the symptom severity scale and function status scale in electroacupuncture group were significantly lower than the control group ( P = 0.0001 and P = 0.006). Moreover, the electrophysiological parameters in the electroacupuncture group were better than the control group. The electroacupuncture group had higher total effective rate than the control group (odds ratio = 4.94, 95% CI: 3.44–7.08, P < 0.00001).
Conclusion
Our meta-analysis indicated that electroacupuncture had lower VAS score, higher total effective rate, a lower the scores of symptoms and function and electroacupuncture had better electrophysiological parameters. However, these findings needed to be verified further by multicenter, double-blind, and large-sample RCTs.
Objective
To examine whether appropriate statistical methods were used in acupuncture randomized controlled trials (RCTs).
Study Design and Setting
We searched PubMed to identify acupuncture RCTs with continuous outcome as primary outcome published in the core clinical journals and complementary and alternative medicine (CAM) journals between January 2010 to December 2019 (10 years). We compared statistical characteristics of included trials published in core clinical journals and CAM journals.
Results
We included 262 RCTs, including 46 published in core clinical journals and 216 in CAM journals. Of included RCTs, only 132 (50.4%) clearly predefined the primary outcome, 72 (27.5%) specified the use of ITT or modified ITT population for primary analysis. In the 167 trials reported missing participant data (MPD), 118 (70.7%) used suboptimal methods (e.g., complete case analysis) for dealing with MPD; 11 (6.6%) conducted sensitivity analysis regarding MPD. Among the 161 trials with repeated measures design, only 21 (13.0%) used advanced statistical models (e.g., mixed-effects models) for handling repeated-measure data in the primary analysis. In the 72 trials involving multiple acupuncturists, only four (5.6%) adjusted acupuncturist variable or considered the clustering by acupuncturist in analysis. Trials in core clinical journals were more likely to predefine primary outcome (78.3% vs. 44.4%, P＜0.001), use multiple imputations for handling MPD (40% vs. 1.5%, P＜0.001), and use statistically advanced methods for assessing treatment effect at a single time point (26.1% vs. 2%, P=0.001).
Conclusions
The use of statistical methods among acupuncture RCTs is far from satisfactory. Our findings highlighted the need for researchers to carefully use the optimal statistical methods, and for journal editors to strengthen the use of statistical methods.
Background
The study aimed to investigate how acupuncture modulates brain activities across multiple frequency bands to achieve therapeutic effects in PDM.
Methods
A total of 47 patients with PDM were randomly assigned to the verum acupuncture group and sham acupuncture group with three menstrual cycles of the acupuncture course. The fMRI scans, visual analog scale (VAS) scores, and other clinical evaluations were assessed at baseline and after three menstrual-cycles treatments. The global functional connectivity density (gFCD) analyses were performed between the pre-and post-acupuncture course of two groups at full-low frequency band, Slow-3 band, Slow-4 band, and Slow-5 band.
Results
After the acupuncture treatments, the patients with PDM in the verum acupuncture group showed significantly decreased VAS scores (p < 0.05). The frequency-dependent gFCD alternations were found in the verum acupuncture group, altered regions including DLPFC, somatosensory cortex, anterior cingulate cortex (ACC), middle cingulate cortex (MCC), precuneus, hippocampus, and insula. The sham acupuncture modulated regions including angular gyrus, inferior frontal gyrus, and hippocampus. The gFCD alternation in DLPFC at the Slow-5 band was negatively in the patients with PDM following verum acupuncture, and S2 at the Slow-4 band was positively correlated with VAS scores.
Conclusion
These findings supported that verum acupuncture could effectively modulate frequency-dependent gFCD in PDM by influencing abnormal DLPFC at Slow-5 band and hippocampus at the Slow-3 band. The outcome of this study may shed light on enhancing the potency of acupuncture in clinical practice.
Background
The aim of the study was to compare the clinical characteristics of diabetic carpal tunnel syndrome between patients with neuropathic pain (NeuP) and non-NeuP.Methods
We enrolled 276 patients with diabetic carpal tunnel syndrome. Pain symptoms were evaluated using a visual analog scale. Douleur Neuropathique 4, the Neuropathic Pain Symptoms Inventory questionnaire, and the body map were used to assess neuropathic symptoms. Baseline information, clinical manifestations, electrophysiological test results, and psychological status were compared between the neuropathic pain (NeuP) and non-NeuP to identify the risk factor for NeuP occurrence.ResultsResults showed that the degree of pain was more severe in NeuP patients than in nociceptive pain patients (p = 0.025). The frequencies of light touch and pinprick were more pronounced in the NeuP group than in the non-NeuP group (light touch: p = 0.001; pinprick: p = 0.004). There were 48 and 27 NeuP patients with extramedian and proximal spread, respectively, whereas in the non-NeuP group, there were 11 and 9 patients, respectively (p = 0.03). Electrophysiological results showed that patients in the NeuP group exhibited greater sensory nerve conduction velocity impairment compared with the non-NeuP group (p = 0.033). Pain Catastrophizing Scale total scores of the NeuP group were significantly higher than those of the non-NeuP group (p = 0.006).Conclusion
Of the 276 diabetic carpal tunnel syndrome patients studied, the majority had NeuP. Furthermore, light touch, electrophysiological test results, and psychological factors were found to be related to NeuP occurrence in patients with diabetic carpal tunnel syndrome.
Premature ejaculation (PE) is a frequently reported sexual dysfunction that has received considerable clinical attention in China. Being intrinsically related to cultural aspects, PE in the Chinese scientific environment is often treated using a combination of traditional Chinese medicine (TCM) techniques and a Western biomedical approach. In this perspective article, we highlight the most recent effects of the use of acupuncture, herbal medicine, and Fangzhongshu techniques, each alone and in combination with Western medicine, for delaying ejaculation; however, the efficacy of such therapies is not always supported by high-quality randomized control trials. To bridge the traditional holistic, individual-targeted perspective of TCM with Western biomedical approaches, we present the paradigm of the new Systems Sexology, derived from the well-known systems medicine, which may fill this gap by perfectly blending the most advanced technologies for an innovative, integrative, and interdisciplinary approach.
Carpal tunnel syndrome (CTS) is disease that gives burdens for many countries, with a few choices for the management such as drugs or surgery, each has side effects that decrease the quality of life. Acupuncture is proven to be an effective treatment for pain and can restore nerve functions, and laser acupuncture is one of the modalities. This study aims to assess the effectiveness of laser acupuncture with total sample of 3 patients (6 wrists) mostly with tingling sensations and the outcomes are Boston questionnaire (BCTQ), visual analogue scale (VAS), Tinel sign, Phalen sign, and parameters of nerve conduction study (NCS). Acupuncture points used here are PC6, PC7, EXUE9, and LI4. The results show a decrease in NCS grades for 3 wrists, all wrists have BCTQ score improvements, a decrease in VAS, but no significant improvement in Tinel and Phalen signs. It is concluded that laser acupuncture can be used as a treatment option for the management of carpal tunnel syndrome.
This study aimed to examine the clinical efficacy of electroacupuncture treatment for carpal tunnel syndrome by reviewing published randomized controlled trials. Among the 186 studies retrieved from 7 online databases (PubMed, Cochrane library, CNKI, NDSL, RISS, OASIS, KMbase) on October 29, 2021, 4 studies were selected according to the inclusion, exclusion criteria, and were evaluated using risk of bias. Control groups for electroacupuncture were wearing a splint at night, traditional acupuncture, and medication. Methods such as total effective, functional status scale, symptom severity scale, electromyography, tip pinch strength, visual analogue scale, numeric rating scale, and ultrasound were used to evaluate the therapeutic effect. Electroacupuncture was reported to have significant treatment results compared with the control group in methods such as total effectiveness, electromyography, and tip pinch strength. However, the quality of the studies (using risk of bias) does not allow reliable conclusions to be made. Many high quality (low risk of bias) randomized controlled trials are needed to examine the efficacy of electroacupuncture treatment for carpal tunnel syndrome.
Persistent stuttering is a prevalent neurodevelopmental speech disorder, which presents with involuntary speech blocks, sound and syllable repetitions, and sound prolongations. Affected individuals often struggle with negative feelings, elevated anxiety, and low self-esteem. Neuroimaging studies frequently link persistent stuttering with cortical alterations and dysfunctional cortico-basal ganglia-thalamocortical loops; dMRI data also point toward connectivity changes of the superior longitudinal fasciculus (SLF) and the frontal aslant tract (FAT). Both tracts are involved in speech and language functions, and the FAT also supports inhibitory control and conflict monitoring. Whether the two tracts are involved in therapy-associated improvements and how they relate to therapeutic outcomes is currently unknown. Here, we analyzed dMRI data of 22 patients who participated in a fluency-shaping program, 18 patients not participating in therapy, and 27 fluent control participants, measured 1 year apart. We used diffusion tractography to segment the SLF and FAT bilaterally and to quantify their microstructural properties before and after a fluency-shaping program. Participants learned to speak with soft articulation, pitch, and voicing during a 2-week on-site boot camp and computer-assisted biofeedback-based daily training for 1 year. Therapy had no impact on the microstructural properties of the two tracts. Yet, after therapy, stuttering severity correlated positively with left SLF fractional anisotropy, whereas relief from the social-emotional burden to stutter correlated negatively with right FAT fractional anisotropy. Thus, posttreatment, speech motor performance relates to the left dorsal stream, while the experience of the adverse impact of stuttering relates to the structure recently associated with conflict monitoring and action inhibition.
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Acupuncture is a medical treatment that has been widely practiced in China for over 3000 years, yet the neural mechanisms of acupuncture are not fully understood. We hypothesized that neurons and astrocytes act independently and synergistically under acupuncture stimulation. To investigate this, we used two-photon in vivo calcium recording to observe the effects of acupuncture stimulation at ST36 (Zusanli) in mice. Acupuncture stimulation in peripheral acupoints potentiated calcium signals of pyramidal neurons and astrocytes in the somatosensory cortex and resulted in late-onset calcium transients in astrocytes. Chemogenetic inhibition of neurons augmented the astrocytic activity. These findings suggest that acupuncture activates neuronal and astrocytic activity in the somatosensory cortex and provide evidence for the involvement of both neurons and astrocytes in acupuncture treatment.
Objective: This systematic review examined the effects of acupuncture on hand-and-wrist pain intensity, functional status, quality of life, and incidence of adverse effects in adults. Methods: Searches of 6 databases and previous reviews for randomized controlled trials (RCTs) were performed. Each outcome was analyzed for participant conditions, interventions, controls, and follow-up times determined a priori. Active controls were excluded. Follow-up periods were based on Cochrane 5.1.0 guidelines. The results were tabulated and described narratively. Results: In the 10 included RCTs (622 participants), 6 had a low risk of bias. For cryotherapy-induced pain, 1 trial showed significant pain reduction post treatment. For rheumatoid arthritis, 1 trial shown significant pain reduction and function improvements post treatment and short-term. For carpal tunnel syndrome, 1 trial showed significant pain reduction and functional improvements intermediate-term, while 3 trials suggested no significant difference. For tenosynovitis, 1 trial showed significant pain reduction and function improvements short-term. For poststroke impairments, 1 trial showed significant function improvements post treatment and at short-term, while another trial suggested no significant difference. No significant improvements were noted for trapezio-metacarpal joint osteoarthritis. In 2 trials, adverse effects occurred in patients with carpal tunnel syndrome; yet acupuncture appeared to be relatively safe. Conclusions: Acupuncture may be effective and safe for short-term pain reduction and functional improvement in hand-and-wrist conditions. Clinicians should interpret the results with caution due to small sample sizes and clinical heterogeneity. Future research is warranted.
Introduction
As the main manifestation of gallstone disease, biliary colic (BC) is an episodic attack that brings patients severe pain in the right upper abdominal quadrant. Although acupuncture has been documented with significance to lead to pain relief, the immediate analgesia of acupuncture for BC still needs to be verified, and the underlying mechanism has yet to be covered. Therefore, this trial aims first to verify the immediate pain-alleviation characteristic of acupuncture for BC, then to explore its influence on the peripheral sensitised acupoint and central brain activity.
Methods and analysis
This is a randomised controlled, paralleled clinical trial, with patients and outcome assessors blinded. Seventy-two patients with gallbladder stone disease presenting with BC will be randomised into a verum acupuncture group and the sham acupuncture group. Both groups will receive one session of immediate acupuncture treatment. Improvements in patients’ BC will be evaluated by the Numeric Rating Scale, and the pain threshold of acupoints will also be detected before and after treatment. During treatment, brain neural activity will be monitored with functional near-infrared spectroscopy (fNIRS), and the needle sensation will be rated. Clinical and fNIRS data will be analysed, respectively, to validate the acupuncture effect, and correlation analysis will be conducted to investigate the relationship between pain relief and peripheral–cerebral functional changes.
Ethics and dissemination
This trial has been approved by the institutional review boards and ethics committees of the First Teaching Hospital of Chengdu University of Traditional Chinese Medicine, with the ethical approval identifier 2019 KL-029, and the institutional review boards and ethics committees of the First People’s Hospital of Longquanyi District, with the ethical approval identifier AF-KY-2020071. The results of this trial will be disseminated through peer-reviewed publications and conference abstracts or posters.
Trial registration number
CTR2000034432.
Objective:
With the ongoing opioid crisis, the Centers for Disease Control and Prevention recommends nonpharmacologic therapies (e.g., acupuncture) for treating pain. Multiple agencies, such as the National Institutes of Health and World Health Organization, recognize acupuncture's effectiveness for treating pain, but acupuncture education for providers is scarce. A Workshop to Introduce Acupuncture for Pediatrics (AcuPeds-Workshop) was developed with support from American Academy of Pediatrics to educate providers. Additional funding was given by the Virginia Apgar Academy to evaluate the effects of attending this workshop.
Materials and methods:
This prospective study used Immediate and 1-Month Post-Workshop (PWS) surveys. The AcuPeds-Workshop components included: history; a literature review; videos of patients receiving acupuncture; and hands-on experience. The workshop was presented at numerous conferences. Attendee survey completion was voluntary.
Results:
Of 327 attendees, the majority were female, non-Hispanic, and were physicians. At baseline, attendees had: heard of acupuncture, 96%; used it, 28%; and/or had a prior lecture, 13%. In the Immediate-PWS: 97% reported an increase in their knowledge and understanding of the indications for acupuncture; majority correctly addressed 3 clinical application scenarios and contraindications. With respect to attitude: 85% would use acupuncture for themselves and 88% would use it for patients. More than 80% rated the workshop components as useful or very useful. In the One-Month-PWS: majority addressed the same 3 clinical scenarios and contraindications correctly, and 11% considered referring patients for acupuncture.
Conclusions:
Attendance at this AcuPeds-Workshop had a positive impact on attendees' knowledge, application of, and attitude about acupuncture. This workshop supports efforts to educate medical providers on this nonpharmacologic pain therapy.
This article summarises the existing scientific evidence for the effectiveness and physiological plausibility of acupuncture. Studies and meta-analyses have already furnished a body of evidence of the clinical effectiveness of some indications, for example for post-operative nausea and vomiting, for back pain, headaches, pain caused by osteoarthritis of the knee, shoulder pains as well as post-operative pain. The physiological effects of acupuncture and the underlying mechanisms are diverse. These include peripheral processes, spinal processes and supraspinous/cerebral mechanisms. The limitations of the results, the significance of the context and the course of acupuncture must be taken into account.
Myelinated axons with nodes of Ranvier are an evolutionary elaboration common to essentially all jawed vertebrates. Myelin made by Schwann cells in our peripheral nervous system and oligodendrocytes in our central nervous system has been long known to facilitate rapid energy efficient nerve impulse propagation. However, it is now also clear, particularly in the central nervous system, that myelin is not a simple static insulator but that it is dynamically regulated throughout development and life. New myelin sheaths can be made by newly differentiating oligodendrocytes, and mature myelin sheaths can be stimulated to grow again in the adult. Furthermore, numerous studies in models from fish to man indicate that neuronal activity can affect distinct stages of oligodendrocyte development and the process of myelination itself. This begs questions as to how these effects of activity are mediated at a cellular and molecular level and whether activity-driven adaptive myelination is a feature common to all myelinated axons, or indeed all oligodendrocytes, or is specific to cells or circuits with particular functions. Here we review the recent literature on this topic, elaborate on the key outstanding questions in the field, and look forward to future studies that incorporate investigations in systems from fish to man that will provide further insight into this fundamental aspect of nervous system plasticity.
This article is part of a Special Issue entitled SI: Myelin Evolution.
In the field of acupuncture research there is an implicit yet unexplored assumption that the evidence on manual and electrical stimulation techniques, derived from basic science studies, clinical trials, systematic reviews, and meta-analyses, is generally interchangeable. Such interchangeability would justify a bidirectional approach to acupuncture research, where basic science studies and clinical trials each inform the other. This article examines the validity of this fundamental assumption by critically reviewing the literature and comparing manual to electrical acupuncture in basic science studies, clinical trials, and meta-analyses. The evidence from this study does not support the assumption that these techniques are interchangeable. This article also identifies endemic methodologic limitations that have impaired progress in the field. For example, basic science studies have not matched the frequency and duration of manual needle stimulation to the frequency and duration of electrical stimulation. Further, most clinical trials purporting to compare the two types of stimulation have instead tested electroacupuncture as an adjunct to manual acupuncture. The current findings reveal fundamental gaps in the understanding of the mechanisms and relative effectiveness of manual versus electrical acupuncture. Finally, future research directions are suggested to better differentiate electrical from manual simulation, and implications for clinical practice are discussed.
The aim of this work was to evaluate the diagnostic performance of grey-scale, color Doppler, and dynamic ultrasound (US) for diagnosing carpal tunnel syndrome (CTS) using the medical diagnostic test called nerve conduction study (NCS) as the reference standard, and to correlate the increase in median nerve (MN) cross-sectional area (CSA) with severity of CTS. Fifty-one patients (95 wrists) with clinical symptoms of idiopathic CTS were recruited. The CSA and flattening ratio of the MN were measured at the distal radio-ulnar joint, pisiform, and hamate levels; bowing of the flexor retinaculum was determined at the hamate level. The hypervascularity of the MN was evaluated. The transverse sliding of the MN was observed dynamically and recorded as being either normal or restricted/absent. Another 15 healthy volunteers (30 wrists) were recruited as controls. Interoperator reliability was established for all criteria. CTS was confirmed in 75 wrists (75/95: 79 %; 14 minimal, 21 mild, 23 moderate, 17 severe). CSA at the pisiform level was found to be the most reliable and accurate grey-scale criterion to diagnose CTS (optimum threshold: 9.8 mm(2)). There was a good correlation between the severity of NCS and CSA (r = 0.78, p < 0.001). The sensitivity and specificity of color-Doppler and dynamic US in detecting CTS was 69, 95, 58, and 86 %, respectively. Combination of these subjective criteria with CSA increases the sensitivity to 98.3 %. US measurement of CSA provides additional information about the severity of MN involvement. Color-Doppler and dynamic US are useful supporting criteria that may expand the utility of US as a screening tool for CTS.
Carpal tunnel syndrome, a median nerve entrapment neuropathy, is characterized by sensorimotor deficits. Recent reports have shown that this syndrome is also characterized by functional and structural neuroplasticity in the primary somatosensory cortex of the brain. However, the linkage between this neuroplasticity and the functional deficits in carpal tunnel syndrome is unknown. Sixty-three subjects with carpal tunnel syndrome aged 20-60 years and 28 age- and sex-matched healthy control subjects were evaluated with event-related functional magnetic resonance imaging at 3 T while vibrotactile stimulation was delivered to median nerve innervated (second and third) and ulnar nerve innervated (fifth) digits. For each subject, the interdigit cortical separation distance for each digit's contralateral primary somatosensory cortex representation was assessed. We also evaluated fine motor skill performance using a previously validated psychomotor performance test (maximum voluntary contraction and visuomotor pinch/release testing) and tactile discrimination capacity using a four-finger forced choice response test. These biobehavioural and clinical metrics were evaluated and correlated with the second/third interdigit cortical separation distance. Compared with healthy control subjects, subjects with carpal tunnel syndrome demonstrated reduced second/third interdigit cortical separation distance (P < 0.05) in contralateral primary somatosensory cortex, corroborating our previous preliminary multi-modal neuroimaging findings. For psychomotor performance testing, subjects with carpal tunnel syndrome demonstrated reduced maximum voluntary contraction pinch strength (P < 0.01) and a reduced number of pinch/release cycles per second (P < 0.05). Additionally, for four-finger forced-choice testing, subjects with carpal tunnel syndrome demonstrated greater response time (P < 0.05), and reduced sensory discrimination accuracy (P < 0.001) for median nerve, but not ulnar nerve, innervated digits. Moreover, the second/third interdigit cortical separation distance was negatively correlated with paraesthesia severity (r = -0.31, P < 0.05), and number of pinch/release cycles (r = -0.31, P < 0.05), and positively correlated with the second and third digit sensory discrimination accuracy (r = 0.50, P < 0.05). Therefore, reduced second/third interdigit cortical separation distance in contralateral primary somatosensory cortex was associated with worse symptomatology (particularly paraesthesia), reduced fine motor skill performance, and worse sensory discrimination accuracy for median nerve innervated digits. In conclusion, primary somatosensory cortex neuroplasticity for median nerve innervated digits in carpal tunnel syndrome is indeed maladaptive and underlies the functional deficits seen in these patients.
Permutation methods can provide exact control of false positives and allow the use of non-standard statistics, making only weak assumptions about the data. With the availability of fast and inexpensive computing, their main limitation would be some lack of flexibility to work with arbitrary experimental designs. In this paper we report on results on approximate permutation methods that are more flexible with respect to the experimental design and nuisance variables, and conduct detailed simulations to identify the best method for settings that are typical for imaging research scenarios. We present a generic framework for permutation inference for complex general linear models (glms) when the errors are exchangeable and/or have a symmetric distribution, and show that, even in the presence of nuisance effects, these permutation inferences are powerful while providing excellent control of false positives in a wide range of common and relevant imaging research scenarios. We also demonstrate how the inference on glm parameters, originally intended for independent data, can be used in certain special but useful cases in which independence is violated. Detailed examples of common neuroimaging applications are provided, as well as a complete algorithm - the "randomise" algorithm - for permutation inference with the glm.
Carpal tunnel syndrome (CTS) is a common median nerve entrapment neuropathy characterized by pain, paresthesias, diminished peripheral nerve conduction velocity (NCV) and maladaptive functional brain neuroplasticity. We evaluated structural reorganization in brain gray (GM) and white (WM) matter and whether such plasticity is linked to altered median nerve function in CTS.
We performed NCV testing, T1-weighted structural MRI, and diffusion tensor imaging (DTI) in 28 CTS and 28 age-matched healthy controls (HC). Voxel-based morphometry (VBM) contrasted regional GM volume for CTS versus HC. Significant clusters were correlated with clinical metrics and served as seeds to define associated WM tracts using DTI data and probabilistic tractography. Within these WM tracts, fractional anisotropy (FA), axial (AD) and radial (RD) diffusivity were evaluated for group differences and correlations with clinical metrics.
For CTS subjects, GM volume was significantly reduced in contralesional S1 (hand-area), pulvinar and frontal pole. GM volume in contralesional S1 correlated with median NCV. NCV was also correlated with RD and was negatively correlated with FA within U-fiber cortico-cortical association tracts identified from the contralesional S1 VBM seed.
Our study identified clear morphometric changes in the CTS brain. This central morphometric change is likely secondary to peripheral nerve pathology and altered somatosensory afference. Enhanced axonal coherence and myelination within cortico-cortical tracts connecting primary somatosensory and motor areas may accompany peripheral nerve deafferentation. As structural plasticity was correlated with NCV and not symptomatology, the former may be a better determinant of appropriate clinical intervention for CTS, including surgery.
The autonomic nervous system (ANS) is of paramount importance for daily life. Its regulatory action on respiratory, cardiovascular, digestive, endocrine, and many other systems is controlled by a number of structures in the CNS. While the majority of these nuclei and cortices have been identified in animal models, neuroimaging studies have recently begun to shed light on central autonomic processing in humans. In this study, we used activation likelihood estimation to conduct a meta-analysis of human neuroimaging experiments evaluating central autonomic processing to localize (1) cortical and subcortical areas involved in autonomic processing, (2) potential subsystems for the sympathetic and parasympathetic divisions of the ANS, and (3) potential subsystems for specific ANS responses to different stimuli/tasks. Across all tasks, we identified a set of consistently activated brain regions, comprising left amygdala, right anterior and left posterior insula and midcingulate cortices that form the core of the central autonomic network. While sympathetic-associated regions predominate in executive- and salience-processing networks, parasympathetic regions predominate in the default mode network. Hence, central processing of autonomic function does not simply involve a monolithic network of brain regions, instead showing elements of task and division specificity.
Carpal tunnel syndrome (CTS) is the most preva lent form of peripheral neuropathy. The efficacy of acupuncture in management of mild to moderate CTS has been investigated in limited studies with controversial results. The aim of this study was to assess the short-term effects of acupuncture in treatment of mild to moderate carpal tunnel syndrome.
In a randomized controlled trial study, participants were randomly assigned to either control group which night splinting, vitamin B1, B6 and sham acupuncture for four weeks were administered, or intervention group that underwent acupuncture in 8 sessions over 4 weeks and night splinting. The clinical symptoms using global symptom score (GSS) and electrophysiological parameters were assessed at baseline and four weeks after the intervention.
Of 72 patients met the inclusion criteria, 64 patients actually completed the 4 week intervention and were evaluated for the outcome. There was a statistically significant difference in GSS between two arms of treatment after the intervention (p < 0.001) Using repeated measure ANOVA, the GSS in acupuncture group was significantly different after 4 weeks (p <0.001). Among electrophysiological parameters, nerve conduction velocity (NCV) was significantly different between two groups after 4 weeks (p = 0.02). Other parameters showed no statistically significant difference after intervention (p > 0.05).
Our findings indicated that the acupuncture can improve the overall subjective symptoms of carpal tunnel syndrome and could be adopted in comprehensive care programs of these patients.
Neuroimaging data demonstrate that carpal tunnel syndrome, a peripheral neuropathy, is accompanied by maladaptive central neuroplasticity. To further investigate this phenomenon, we collected magnetoencephalography data from 12 patients with carpal tunnel syndrome and 12 healthy control subjects undergoing somatosensory stimulation of the median nerve-innervated Digits 2 and 3, as well as Digit 5, which is innervated by the ulnar nerve. Nerve conduction velocity and psychophysical data were acquired to determine whether standard clinical measures correlated with brain response. In subjects with carpal tunnel syndrome, but not healthy controls, sensory nerve conduction velocity for Digits 2 and 3 was slower than Digit 5. However, somatosensory M20 latencies for Digits 2 and 3 were significantly longer than those of Digit 5. The extent of the M20 delay for median nerve-innervated Digit 2 was positively correlated with decreasing nerve conduction velocity and increasing pain severity. Thus, slower peripheral nerve conduction in carpal tunnel syndrome corresponds to greater delays in the first somatosensory cortical response. Furthermore, spectral analysis demonstrated weaker post-stimulus beta event-related desynchronization and earlier and shorter event-related synchronization in subjects with carpal tunnel syndrome. The extent of the decreased event-related desynchronization for median nerve-innervated digits was positively correlated with paraesthesia severity. We propose that ongoing paraesthesias in median nerve-innervated digits render their corresponding sensorimotor cortical areas 'busy', thus reducing their capacity to process external stimulation. Finally, subjects with carpal tunnel syndrome demonstrated a smaller cortical source separation for Digits 2 and 3 compared with healthy controls. This supports our hypothesis that ongoing paraesthesias promote blurring of median nerve-innervated digit representations through Hebbian plasticity mechanisms. In summary, this study reveals significant correlation between the clinical severity of carpal tunnel syndrome and the latency of the early M20, as well as the strength of long latency beta oscillations. These temporal magnetoencephalography measures are novel markers of neuroplasticity in carpal tunnel syndrome and could be used to study central changes that may occur following clinical intervention.
Background:
The mechanisms of action underlying acupuncture, including acupuncture point specificity, are not well understood. In the previous decade, an increasing number of studies have applied fMRI to investigate brain response to acupuncture stimulation. Our aim was to provide a systematic overview of acupuncture fMRI research considering the following aspects: 1) differences between verum and sham acupuncture, 2) differences due to various methods of acupuncture manipulation, 3) differences between patients and healthy volunteers, 4) differences between different acupuncture points.
Methodology/principal findings:
We systematically searched English, Chinese, Korean and Japanese databases for literature published from the earliest available up until September 2009, without any language restrictions. We included all studies using fMRI to investigate the effect of acupuncture on the human brain (at least one group that received needle-based acupuncture). 779 papers were identified, 149 met the inclusion criteria for the descriptive analysis, and 34 were eligible for the meta-analyses. From a descriptive perspective, multiple studies reported that acupuncture modulates activity within specific brain areas, including somatosensory cortices, limbic system, basal ganglia, brain stem, and cerebellum. Meta-analyses for verum acupuncture stimuli confirmed brain activity within many of the regions mentioned above. Differences between verum and sham acupuncture were noted in brain response in middle cingulate, while some heterogeneity was noted for other regions depending on how such meta-analyses were performed, such as sensorimotor cortices, limbic regions, and cerebellum.
Conclusions:
Brain response to acupuncture stimuli encompasses a broad network of regions consistent with not just somatosensory, but also affective and cognitive processing. While the results were heterogeneous, from a descriptive perspective most studies suggest that acupuncture can modulate the activity within specific brain areas, and the evidence based on meta-analyses confirmed some of these results. More high quality studies with more transparent methodology are needed to improve the consistency amongst different studies.
Human brain imaging has identified structural changes in gray and white matter that occur with learning. However, ascribing imaging measures to underlying cellular and molecular events is challenging. Here we review human neuroimaging findings of structural plasticity and then discuss cellular and molecular level changes that could underlie observed imaging effects. Greater dialog between researchers in these different fields would help to facilitate cross-talk between cellular and systems level explanations of how learning sculpts brain structure.
In prospective experimental studies in patients with asthma, it is difficult to determine whether responses to placebo differ from the natural course of physiological changes that occur without any intervention. We compared the effects of a bronchodilator, two placebo interventions, and no intervention on outcomes in patients with asthma.
In a double-blind, crossover pilot study, we randomly assigned 46 patients with asthma to active treatment with an albuterol inhaler, a placebo inhaler, sham acupuncture, or no intervention. Using a block design, we administered one each of these four interventions in random order during four sequential visits (3 to 7 days apart); this procedure was repeated in two more blocks of visits (for a total of 12 visits by each patient). At each visit, spirometry was performed repeatedly over a period of 2 hours. Maximum forced expiratory volume in 1 second (FEV(1)) was measured, and patients' self-reported improvement ratings were recorded.
Among the 39 patients who completed the study, albuterol resulted in a 20% increase in FEV(1), as compared with approximately 7% with each of the other three interventions (P<0.001). However, patients' reports of improvement after the intervention did not differ significantly for the albuterol inhaler (50% improvement), placebo inhaler (45%), or sham acupuncture (46%), but the subjective improvement with all three of these interventions was significantly greater than that with the no-intervention control (21%) (P<0.001).
Although albuterol, but not the two placebo interventions, improved FEV(1) in these patients with asthma, albuterol provided no incremental benefit with respect to the self-reported outcomes. Placebo effects can be clinically meaningful and can rival the effects of active medication in patients with asthma. However, from a clinical-management and research-design perspective, patient self-reports can be unreliable. An assessment of untreated responses in asthma may be essential in evaluating patient-reported outcomes. (Funded by the National Center for Complementary and Alternative Medicine.).
Activity-induced structural remodeling of dendritic spines and glial cells was recently proposed as an important factor in neuroplasticity and suggested to accompany the induction of long-term potentiation (LTP). Although T1 and diffusion MRI have been used to study structural changes resulting from long-term training, the cellular basis of the findings obtained and their relationship to neuroplasticity are poorly understood.
Here we used diffusion tensor imaging (DTI) to examine the microstructural manifestations of neuroplasticity in rats that performed a spatial navigation task. We found that DTI can be used to define the selective localization of neuroplasticity induced by different tasks and that this process is age-dependent in cingulate cortex and corpus callosum and age-independent in the dentate gyrus.
We relate the observed DTI changes to the structural plasticity that occurs in astrocytes and discuss the potential of MRI for probing structural neuroplasticity and hence indirectly localizing LTP.
Unlabelled:
Acupuncture is a widely used symptomatic treatment for carpal tunnel syndrome (CTS). The objective of this systematic review was to evaluate the evidence of the effectiveness of acupuncture and acupuncture-like treatments for CTS. Systematic searches were conducted on 11 electronic databases without language restrictions. All randomized controlled trials (RCTs) of acupuncture as a treatment of CTS were included. Methodological quality was assessed using the Cochrane risk of bias tool. Six RCTs met our inclusion criteria. Their methodological quality was generally low. Two RCTs compared the effectiveness of acupuncture with a sham control. The others used active controls. A meta-analysis of acupuncture versus steroid block therapy favored acupuncture (2 studies, n = 144; risk ratio, 1.28; 95% CI, 1.08 to 1.52; P = .005; heterogeneity, I(2) = 10%) in terms of responder rate. Our systematic review and meta-analysis demonstrate that the evidence for acupuncture as a symptomatic therapy of CTS is encouraging but not convincing. The total number of included RCTs and their methodological quality were low. Further rigorous studies are required to establish whether acupuncture has therapeutic value for this indication.
Perspective:
This systematic review of RCTs focused on clinical trials testing the effectiveness of acupuncture for CTS. The existing evidence is not convincing enough to suggest that acupuncture is an effective therapy for CTS. Further RCTs should overcome the limitation of previous studies.
To investigate the efficacy of acupuncture compared with steroid treatment in patients with mild-to-moderate carpal tunnel syndrome (CTS) as measured by objective changes in nerve conduction studies (NCS) and subjective symptoms assessment in a randomized, controlled study.
A total of 77 consecutive and prospective CTS patients confirmed by NCS were enrolled in the study. Those who had fixed sensory complaint over the median nerve and thenar muscle atrophy were excluded. The CTS patients were randomly divided into 2 treatment arms: (1) 2 weeks of prednisolone 20 mg daily followed by 2 weeks of prednisolone 10 mg daily (n = 39), and (2) acupuncture administered in 8 sessions over 4 weeks (n = 38). A validated standard questionnaire as a subjective measurement was used to rate the 5 major symptoms (pain, numbness, paresthesia, weakness/clumsiness, and nocturnal awakening) on a scale from 0 (no symptoms) to 10 (very severe). The total score in each of the 5 categories was termed the global symptom score (GSS). Patients completed standard questionnaires at baseline and 2 and 4 weeks later. The changes in GSS were analyzed to evaluate the statistical significance. NCS were performed at baseline and repeated at the end of the study to assess improvement. All main analyses used intent-to-treat.
A total of 77 patients who fulfilled the criteria for mild-to-moderate CTS were recruited in the study. There were 38 in the acupuncture group and 39 in the steroid group. The evaluation of GSS showed that there was a high percentage of improvement in both groups at weeks 2 and 4 (P < 0.01), though statistical significance was not demonstrated between the 2 groups (P = 0.15). Of the 5 main symptoms scores (pain, numbness, paresthesia, weakness/clumsiness, nocturnal awakening), only 1, nocturnal awakening, showed a significant decrease in acupuncture compared with the steroid group at week 4 (P = 0.03). Patients with acupuncture treatment had a significant decrease in distal motor latency compared with the steroid group at week 4 (P = 0.012). Acupuncture was well tolerated with minimal adverse effects.
Short-term acupuncture treatment is as effective as short-term low-dose prednisolone for mild-to-moderate CTS. For those who do have an intolerance or contraindication for oral steroid or for those who do not opt for early surgery, acupuncture treatment provides an alternative choice.
Early-onset schizophrenia appears to be clinically more severe than the adult-onset form of the disease. In a previous study, we showed that anatomically related grey and white matter abnormalities found in adolescents patients were larger and more widespread than what had been reported in the literature on adult schizophrenia. Particularly, we found novel structural abnormalities in the primary sensorimotor and premotor systems. Here, we tested alternative hypotheses: either this striking sensorimotor-related pattern is an artefact due to a better sensitivity of the methods, or apparent greater structural abnormalities in the early-onset population are specifically associated with earlier disease onset. Then, if we were to find such characteristic structural pattern, we would test whether these anatomical abnormalities would remain static or, conversely, show dynamic changes in the still developing brain. To address these questions, we combined a cross-sectional study of brain structure for adolescent-onset patients (n = 25) and adult-onset patients (n = 35) and respective matched healthy subjects with a longitudinal study of adolescent-onset patients (n = 12, representative subset of the cross-sectional group) and matched healthy controls for >2 years. Looking at differences between adolescent and adult patients' grey matter volume and white matter microstructure abnormalities, we first confirmed the specificity (especially in motor-related areas) and the greater severity of structural abnormalities in the adolescent patients. Closer examination revealed, however, that such greater anomalies seemed to arise because adolescent patients fail to follow the same developmental time course as the healthy control group. Longitudinal analysis of a representative subset of the adolescent patient and matched healthy populations corroborated the delayed and altered maturation in both grey and white matters. Structural abnormalities specific to adolescent-onset schizophrenia in the sensori-motor cortices and corticospinal tract were less marked or even disappeared within the longitudinal period of observation, grey matter abnormalities in adolescent patients evolving towards the adult-onset pattern as defined by recent meta-analyses of adult schizophrenia. Combining cross-sectional adolescent and adult datasets with longitudinal adolescent dataset allowed us to find a unique, abnormal trajectory of grey matter maturation regardless of the age at onset of symptoms and of disease duration, with a lower and later peak than for healthy subjects. Taken together, these results suggest common aetiological mechanisms for adolescent- and adult-onset schizophrenia with an altered neurodevelopmental time course in the schizophrenic patients that is particularly salient in adolescence.
With the advent of diffusion tensor imaging (DTI), the study of plastic changes in white matter architecture due to long-term practice has attracted increasing interest. Professional musicians provide an ideal model for investigating white matter plasticity because of their early onset of extensive auditory and sensorimotor training. We performed fiber tractography and subsequent voxelwise analysis, region of interest (ROI) analysis, and detailed slicewise analysis of diffusion parameters in the corticospinal tract (CST) on 26 professional musicians and a control group of 13 participants. All analyses resulted in significantly lower fractional anisotropy (FA) values in both the left and the right CST in the musician group. Furthermore, a right-greater-than-left asymmetry of FA was observed regardless of group. In the musician group, diffusivity was negatively correlated with the onset of musical training in childhood. A subsequent median split into an early and a late onset musician group (median=7 years) revealed increased diffusivity in the CST of the early onset group as compared to both the late onset group and the controls. In conclusion, these DTI-based findings might indicate plastic changes in white matter architecture of the CST in professional musicians. Our results imply that training-induced changes in diffusion characteristics of the axonal membrane may lead to increased radial diffusivity as reflected in decreased FA values.
Carpal tunnel syndrome (CTS) is a cause of pain, numbness, and tingling in the hands and is an important cause of work disability. Although high prevalence rates of CTS in certain occupations have been reported, little is known about its prevalence in the general population.
To estimate the prevalence of CTS in a general population.
General health mail survey sent in February 1997, inquiring about symptoms of pain, numbness, and tingling in any part of the body, followed 2 months later by clinical examination and nerve conduction testing of responders reporting symptoms in the median nerve distribution in the hands, as well as of a sample of those not reporting these symptoms (controls).
A region in southern Sweden with a population of 170000.
A sex- and age-stratified sample of 3000 subjects (age range, 25-74 years) was randomly selected from the general population register and sent the survey, with a response rate of 83% (n = 2466; 46% men). Of the symptomatic responders, 81% underwent clinical examination.
Population prevalence rates, calculated as the number of symptomatic responders diagnosed on examination as having clinically certain CTS and/or electrophysiological median neuropathy divided by the total number of responders.
Of the 2466 responders, 354 reported pain, numbness, and/or tingling in the median nerve distribution in the hands (prevalence, 14.4%; 95% confidence interval [CI], 13.0%-15.8%). On clinical examination, 94 symptomatic subjects were diagnosed as having clinically certain CTS (prevalence, 3.8%; 95% CI, 3.1%-4.6%). Nerve conduction testing showed median neuropathy at the carpal tunnel in 120 symptomatic subjects (prevalence, 4.9%; 95% CI, 4.1%-5.8%). Sixty-six symptomatic subjects had clinically and electrophysiologically confirmed CTS (prevalence, 2.7%; 95% CI, 2.1%-3.4%). Of 125 control subjects clinically examined, electrophysiological median neuropathy was found in 23 (18.4%; 95% CI, 12.0%-26.3%).
Symptoms of pain, numbness, and tingling in the hands are common in the general population. Based on our data, 1 in 5 symptomatic subjects would be expected to have CTS based on clinical examination and electrophysiologic testing.
Electroceutical devices that stimulate the peripheral nervous system come to the fore. Emily Waltz reports.
Paresthesia-and pain-dominant subgroups have been noted in carpal tunnel syndrome (CTS), a peripheral neuropathic disorder characterized by altered primary somatosensory/motor (S1/M1) physiology. We aimed to investigate whether brain morphometry dissociates these subgroups. CTS subjects were evaluated with nerve conduction studies, while symptom severity ratings were used to allocate subjects into paresthesia-dominant (CTS-paresthesia), pain-dominant (CTS-pain), and pain/paresthesia non-dominant (not included in further analysis) subgroups. Structural brain MRI data were acquired at 3T using a multi-echo MPRAGE T1-weighted pulse sequence, and gray matter cortical thickness was calculated across the entire brain using validated, automated methods. CTS-paresthesia subjects demonstrated reduced median sensory nerve conduction velocity (p=0.05) compared to CTS-pain. In addition, cortical thickness in pre- and post-central gyrus (S1/M1 hand area) contralateral to the more affected hand was significantly reduced in CTS-paresthesia compared to CTS-pain. Moreover, in CTS-paresthesia subjects, pre-central cortical thickness was negatively correlated with paresthesia severity (r(34)=-0.40, p=0.016) and positively correlated with median nerve sensory velocity (r(36)=0.51, p=0.001), but not with pain severity. Conversely, in CTS-pain subjects, contralesional S1 (r(9)=0.62, p=0.042) and M1 (r(9)=0.61, p=0.046) cortical thickness was correlated with pain severity, but not median nerve velocity or paresthesia severity. This double dissociation in somatotopically-specific S1/M1 areas suggests a neuroanatomical substrate for symptom-based CTS subgroups. Such fine-grained subgrouping of CTS may lead to improved personalized therapeutic approaches, based on superior characterization of the linkage between peripheral and central neuroplasticity.
At the Cleveland Clinic the diagnosis of carpal-tunnel syndrome has been made in 654 hands of 439 patients during the last seventeen years. The typical patient with this syndrome is a middle-aged housewife with numbness and tingling in the thumb and index, long, and ring fingers, which is worse at night and worse after excessive activity of the hands. The sensory disturbances, both objective and subjective, must be directly related to the sensory distribution of the median nerve distal to the wrist; but pain may be referred proximal to the wrist as high as the shoulder. There is usually a positive Tinel sign over the median nerve at the wrist, and the wrist-flexion test I described is also usually positive. About half of the patients also have some degree of thenar atrophy.
If steroid injections into the carpal tunnel give only transient relief, treatment should be by complete section of the transverse carpal ligament. This procedure will almost always relieve the patient's pain and numbness in the hand, and in many cases will also cure the paralysis of the thenar muscles, which may be present.
This issue provides a clinical overview of carpal tunnel syndrome, focusing on screening and prevention, diagnosis, and treatment. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.
Placebo effects are beneficial effects that are attributable to the brain-mind responses to the context in which a treatment is delivered rather than to the specific actions of the drug. They are mediated by diverse processes - including learning, expectations and social cognition - and can influence various clinical and physiological outcomes related to health. Emerging neuroscience evidence implicates multiple brain systems and neurochemical mediators, including opioids and dopamine. We present an empirical review of the brain systems that are involved in placebo effects, focusing on placebo analgesia, and a conceptual framework linking these findings to the mind-brain processes that mediate them. This framework suggests that the neuropsychological processes that mediate placebo effects may be crucial for a wide array of therapeutic approaches, including many drugs.
Context Carpal tunnel syndrome (CTS) is a cause of pain, numbness, and tingling
in the hands and is an important cause of work disability. Although high prevalence
rates of CTS in certain occupations have been reported, little is known about
its prevalence in the general population.Objective To estimate the prevalence of CTS in a general population.Design General health mail survey sent in February 1997, inquiring about symptoms
of pain, numbness, and tingling in any part of the body, followed 2 months
later by clinical examination and nerve conduction testing of responders reporting
symptoms in the median nerve distribution in the hands, as well as of a sample
of those not reporting these symptoms (controls).Setting A region in southern Sweden with a population of 170,000.Participants A sex- and age-stratified sample of 3000 subjects (age range, 25-74
years) was randomly selected from the general population register and sent
the survey, with a response rate of 83% (n=2466; 46% men). Of the symptomatic
responders, 81% underwent clinical examination.Main Outcome Measures Population prevalence rates, calculated as the number of symptomatic
responders diagnosed on examination as having clinically certain CTS and/or
electrophysiological median neuropathy divided by the total number of responders.
Results Of the 2466 responders, 354 reported pain, numbness, and/or tingling
in the median nerve distribution in the hands (prevalence, 14.4%; 95% confidence
interval [CI], 13.0%-15.8%). On clinical examination, 94 symptomatic subjects
were diagnosed as having clinically certain CTS (prevalence, 3.8%; 95% CI,
3.1%-4.6%). Nerve conduction testing showed median neuropathy at the carpal
tunnel in 120 symptomatic subjects (prevalence, 4.9%; 95% CI, 4.1%-5.8%).
Sixty-six symptomatic subjects had clinically and electrophysiologically confirmed
CTS (prevalence, 2.7%; 95% CI, 2.1%-3.4%). Of 125 control subjects clinically
examined, electrophysiological median neuropathy was found in 23 (18.4%; 95%
CI, 12.0%-26.3%).Conclusion Symptoms of pain, numbness, and tingling in the hands are common in
the general population. Based on our data, 1 in 5 symptomatic subjects would
be expected to have CTS based on clinical examination and electrophysiologic
testing.
Objective:
Fibromyalgia (FM) is a chronic functional pain syndrome characterized by widespread pain, significant pain catastrophizing, sympathovagal dysfunction, and amplified temporal summation for evoked pain. While several studies have demonstrated altered resting brain connectivity in FM, studies have not specifically probed the somatosensory system and its role in both somatic and nonsomatic FM symptoms. Our objective was to evaluate resting primary somatosensory cortex (S1) connectivity and to explore how sustained, evoked deep tissue pain modulates this connectivity.
Methods:
We acquired functional magnetic resonance imaging and electrocardiography data on FM patients and healthy controls during rest (the rest phase) and during sustained mechanical pressure-induced pain over the lower leg (the pain phase). Functional connectivity associated with different S1 subregions was calculated, while S1(leg) connectivity (representation of the leg in the primary somatosensory cortex) was contrasted between the rest phase and the pain phase and was correlated with clinically relevant measures in FM.
Results:
During the rest phase, FM patients showed decreased connectivity between multiple ipsilateral and cross-hemispheric S1 subregions, which was correlated with clinical pain severity. Compared to the rest phase, the pain phase produced increased S1(leg) connectivity to the bilateral anterior insula in FM patients, but not in healthy controls. Moreover, in FM patients, sustained pain-altered S1(leg) connectivity to the anterior insula was correlated with clinical/behavioral pain measures and autonomic responses.
Conclusion:
Our study demonstrates that both somatic and nonsomatic dysfunction in FM, including clinical pain, pain catastrophizing, autonomic dysfunction, and amplified temporal summation, are closely linked with the degree to which evoked deep tissue pain alters S1 connectivity to salience/affective pain-processing regions. Additionally, diminished connectivity between S1 subregions during the rest phase in FM may result from ongoing widespread clinical pain.
Most neuroimaging studies exploring brain response to different acupoints have been performed in healthy adults.
The aim of this study was to compare brain responses to acupuncture at local versus distal acupoints in patients with carpal tunnel syndrome (CTS), who have chronic pain, versus healthy controls (HC) and correlate these responses with median nerve function.
Brain response to electroacupuncture (EA; 2Hz) was evaluated with event-related functional MRI (fMRI) in patients with CTS (n=37) and age-matched HC (n=30). EA was applied at acupoints local (PC 7 to TW 5) and distal (SP 6 to LV 4) to the CTS lesions.
Brain response in both groups and acupoints included activation of the bilateral secondary somatosensory cortex (S2) and insula, and the contralesional primary somatosensory cortex (cS1). Deactivation was noted in ipsilesional primary somatosensory cortex (S1). A significant difference between local and distal acupoints was found in cS1 for HC, but not CTS. Furthermore, cS1 activation by EA at local acupoints was negatively correlated with median nerve peak sensory latency in HC, but was positively correlated in CTS. No correlation was found for EA at distal acupoints for either group.
Brain response to EA differs between CTS and HC and, for local acupoint stimulation, is associated with median nerve function, reflecting the peripheral nerve pathophysiology of CTS.
Magnetic resonance imaging (MRI) has greatly extended the exploration of neuroplasticity in behaving animals and humans. Imaging studies recently uncovered structural changes that occur in gray and white matter, mainly after long-term training. A recent diffusion tensor imaging (DTI) study showed that training in a car racing game for 2 h induces changes in the hippocampus and parahippocampal gyri. However, the effect of short-term training on the white matter microstructure is unknown. Here we investigated the influence of short learning tasks on structural plasticity in the white matter, and specifically in the fornix, in humans and rats. Human subjects performed a 2 h spatial learning task, and rats underwent training for 1 d in a Morris water maze. Between tasks, subjects were scanned with DTI, a diffusion MRI framework sensitive to tissue microstructure. Using tract-based spatial statistics, we found changes in diffusivity indices in both humans and rats. In both species, changes in diffusion in the fornix were correlated with diffusion changes in the hippocampus, as well as with behavioral measures of improvement in the learning tasks. These results, which provide the first indication of short-term white matter plasticity in the human brain, suggest that the adult brain white matter preserves dynamic characteristics and can be modified by short-term learning experiences. The extent of change in white matter was correlated with their extent in gray matter, suggesting that all components of the neural network are capable of rapid remodeling in response to cognitive experiences.
Objective.—
To provide clinicians, patients, and the general public with a responsible
assessment of the use and effectiveness of acupuncture to treat a variety
of conditions.Participants.—
A nonfederal, nonadvocate, 12-member panel representing the fields of
acupuncture, pain, psychology, psychiatry, physical medicine and rehabilitation,
drug abuse, family practice, internal medicine, health policy, epidemiology,
statistics, physiology, biophysics, and the representatives of the public.
In addition, 25 experts from these same fields presented data to the panel
and a conference audience of 1200. Presentations and discussions were divided
into 3 phases over 212 days: (1) presentations by investigators working in areas relevant
to the consensus questions during a 2-day public session; (2) questions and
statements from conference attendees during open discussion periods that were
part of the public session; and (3) closed deliberations by the panel during
the remainder of the second day and morning of the third. The conference was
organized and supported by the Office of Alternative Medicine and the Office
of Medical Applications of Research, National Institutes of Health, Bethesda,
Md.Evidence.—
The literature, produced from January 1970 to October 1997, was searched
through MEDLINE, Allied and Alternative Medicine, EMBASE, and MANTIS, as well
as through a hand search of 9 journals that were not indexed by the National
Library of Medicine. An extensive bibliography of 2302 references was provided
to the panel and the conference audience. Expert speakers prepared abstracts
of their own conference presentations with relevant citations from the literature.
Scientific evidence was given precedence over clinical anecdotal experience.Consensus Process.—
The panel, answering predefined questions, developed their conclusions
based on the scientific evidence presented in the open forum and scientific
literature. The panel composed a draft statement, which was read in its entirety
and circulated to the experts and the audience for comment. Thereafter, the
panel resolved conflicting recommendations and released a revised statement
at the end of the conference. The panel finalized the revisions within a few
weeks after the conference. The draft statement was made available on the
World Wide Web immediately following its release at the conference and was
updated with the panel's final revisions within a few weeks of the conference.
The statement is available at http://consensus.nih.gov.Conclusions.—
Acupuncture as a therapeutic intervention is widely practiced in the
United States. Although there have been many studies of its potential usefulness,
many of these studies provide equivocal results because of design, sample
size, and other factors. The issue is further complicated by inherent difficulties
in the use of appropriate controls, such as placebos and sham acupuncture
groups. However, promising results have emerged, for example, showing efficacy
of acupuncture in adult postoperative and chemotherapy nausea and vomiting
and in postoperative dental pain. There are other situations, such as addiction,
stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia,
myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and
asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable
alternative or be included in a comprehensive management program. Further
research is likely to uncover additional areas where acupuncture interventions
will be useful.
Imagine a day when electrical impulses are a mainstay of medical treatment. Your clinician will administer electroceuticals that target individual nerve fibres or specific brain circuits to treat an array of conditions. These will modulate the neural impulses that control the body, repair lost function and reinstate a healthy balance. They could coax insulin from islet cells, regulate food intake, and control inflammation. They may treat pressing major ailments such as hypertension, diabetes, obesity, heart failure, pulmonary and vascular disease. All this is within reach, we argue, if researchers from disparate disciplines in academia and industry work together. We herewith outline what needs to be done to bring about electroceuticals, and unveil a public-private research initiative and award that aim to catalyse the field.
To investigate the efficacy of acupuncture for the treatment of mild to moderate carpal tunnel syndrome (CTS).
Prospective, randomized, placebo-controlled, double-blinded study.
Single-center study.
Forty-one acupuncture-naïve adult subjects with mild to moderate CTS enrolled in the study. Thirty-four subjects completed the study.
Clinical diagnosis of CTS was supported by electrodiagnostic findings. Subjects were randomly assigned to either (1) acupuncture (n = 21) or (2) placebo acupuncture (n = 20) with use of Streitberger placebo acupuncture needles. Both groups received weekly sessions of acupuncture for 6 weeks. Wrist braces were provided to both groups to wear at night, and compliance was monitored.
The primary outcome measurement was subject-reported change in the Carpal Tunnel Self Assessment Questionnaire (CTSAQ) Symptom and Function scales immediately after and at 2 weeks and 3 months after the final treatment. The secondary outcomes included tip and key pinch strength and combined sensory index.
Compared with pretreatment baseline values, subjects in the acupuncture group had 0.58 improvement (P = .03) on the CTSAQ Symptom scale score at 3 months after the last treatment, whereas 0.81 improvement (P = .001) was noted in the placebo acupuncture group. No statistically significant difference was found between the groups treated with acupuncture and placebo acupuncture with respect to improvement in CTS symptoms, function, tip/key pinch, or combined sensory index.
To our knowledge, this study is the first randomized, placebo-controlled, double-blinded prospective study of traditional acupuncture for CTS. Both the treatment and placebo groups demonstrated improvements from baseline. Acupuncture was not shown to be superior to placebo acupuncture when used in conjunction with bracing for patients with mild to moderate CTS.