The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain

In a pooled analysis of four randomized controlled trials of acupuncture in patients with migraine, tension-type headache, chronic low back pain, and osteoarthritis of the knee we investigated the influence of expectations on clinical outcome. The 864 patients included in the analysis received either 12 sessions of acupuncture or minimal (i.e. sham) acupuncture (superficial needling of non-acupuncture points) over an 8 week period. Patients were asked at baseline whether they considered acupuncture to be an effective therapy in general and what they personally expected from the treatment. After three acupuncture sessions patients were asked how confident they were that they would benefit from the treatment strategy they were receiving. Patients were classified as responders if the respective main outcome measure improved by at least fifty percent. Both univariate and multivariate analyses adjusted for potential confounders (such as condition, intervention group, age, sex, duration of complaints, etc.) consistently showed a significant influence of attitudes and expectations on outcome. After completion of treatment, the odds ratio for response between patients considering acupuncture an effective or highly effective therapy and patients who were more sceptical was 1.67 (95% confidence interval 1.20-2.32). For personal expectations and confidence after the third session, odds ratios were 2.03 (1.26-3.26) and 2.35 (1.68-3.30), respectively. Results from the 6-month follow-up were similar. In conclusion, in our trials a significant association was shown between better improvement and higher outcome expectations.     

Clinical evidence for acupuncture for adult asthma: Systematic review and meta-analysis of randomised sham/placebo-controlled trials

ObjectiveAcupuncture is a widely used asthma therapy, but the benefits remain uncertain. This study aimed to access the effectiveness of acupuncture for treatment of asthma in adults.MethodsFive English databases and four Chinese databases were searched from inception to November 2021. Randomised sham/placebo-controlled trials meeting inclusion criteria were included. Risk of bias was evaluated according to the Cochrane Review Handbook, and data analysis was performed in RevMan 5.4.1. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) profiler.ResultsSixteen randomised controlled trials (RCTs) were included in the meta-analysis. Results indicated that acupuncture was well-tolerated and could improve FEV1% compared with sham/placebo acupuncture [MD 6.11, 95% CI 0.54–11.68, I² = 93%, number of participants (n) = 603]. Acupuncture also improved Cai’s Asthma Quality of Life Questionnaire (AQLQ) (MD 7.26, 95% CI 5.02–9.50, I² = 0, n = 358), and reduced the asthma symptom score (SMD −2.73, 95% CI −3.59 to −1.87, I² = 65%, n = 120). One study showed acupuncture increased the Asthma Control Test (ACT) score (MD 2.00, 95% CI 0.90–3.10, n = 111), and decreased exacerbation frequency (MD −1.00, 95% CI −1.55 to −1.45, n = 111). Other lung function and medication use parameters were not statistically significant.ConclusionsAcupuncture versus sham/placebo control appeared to improve quality of life, FEV1%, symptoms, and asthma control, and reduced exacerbation frequency per year. Further studies with appropriate controls, more participants, and high-quality evidence are needed.     

针灸联合康复治疗汶川地震伤员截肢后幻肢痛疗效观察

目的探讨针灸联合康复对幻肢痛的治疗效果。方法将44例存在幻肢痛的5.12汶川地震伤员分为治疗组和对照组各22例,治疗组采用针灸联合康复方法综合治疗,对照组单纯采用康复方法治疗。以简明McGill疼痛问卷表（SF-MPQ）评分作为评价指标,观察两组治疗效果。结果治疗组总有效率为100%,对照组总有效率为81.9%,两组比较差异有显著性意义（P〈0.05）;两组治疗前后组内SF-MPQ评分比较,差异均有显著性意义（P〈0.01）;治疗后组间SF-MPQ评分比较,差异有显著性意义（P〈0.01）。结论针灸和康复治疗联合运用对幻肢痛有很好的疗效,远期疗效稳定。     

Self-reported somatosensory symptoms of neuropathic pain in fibromyalgia and chronic widespread pain correlate with tender point count and pressure-pain thresholds

Widespread pain and pain hypersensitivity are the hallmark of fibromyalgia, a complex pain condition linked to central sensitization. In this study the painDETECT questionnaire (PDQ), validated to identify neuropathic pain and based on pain quality items, was applied in a cross-sectional sample of patients with chronic widespread pain (CWP). The aims of the study were to assess the patient-reported sensory neuropathic symptoms by PDQ and to correlate these with tender point (TP) count and pressure-pain thresholds. Eighty-one patients (75 F, 6 M) with CWP (ACR-criteria) filled in the PDQ. Manual TP examination was conducted according to ACR guidelines. Computerized cuff pressure algometry was used for the assessment of pressure-pain detection thresholds (PDT, unit: kPa) and pressure-pain tolerance thresholds (PTT, unit: kPa). Mean TP count was 14.32 (range: 2-18), mean PDQ score 22.75 (range: 5-37). Mean PDT was 8.8 kPa (range: 2-36) and mean PTT 30.9 kPa (range: 4-85). Deep-tissue hyperalgesia was the predominant somatosensory symptom reported in 83%, but other neuropathic symptoms were also frequent, e.g. burning 51% and prickling 47%. Statistically significant correlations were found between PDQ score and TP count: r = 0.35 (p < 0.01), and PDQ score and PDT: r = 0.45 (p < 0.01), and PTT: r = 0.43 (p < 0.01). The study indicates that pain in CWP has neuropathic features, and that the presence and number of tender points are associated with neuropathic pain symptoms. A high mean PDQ score was found to correlate with TP count and pressure-pain thresholds. The PDQ may become a useful tool assisting in the identification of central sensitization in patients with CWP and in the future diagnostic assessment fibromyalgia.     

针刺结合康复训练治疗脑卒中后肩痛的系统评价

目的：系统评价针刺结合康复训练治疗脑卒中后肩痛的有效性。方法计算机检索Cochrane图书馆、JBI循证护理数据库、PubMed、EMbase、CBM、万方和CNKI数据库,查找关于针刺结合康复训练治疗脑卒中后肩痛的相关研究文献,检索时限均从建库至2015年2月。由3位评价员按纳入与排除标准独立筛选文献、提取资料并评价质量后,采用RevMan 5．1软件进行Meta分析。结果共纳入13个RCT研究,869例患者。Meta分析结果显示：针刺结合康复训练治疗脑卒中后肩痛在减轻疼痛[95％ CI（0．92,2．09）,P＜0．00001]、改善上肢运动功能[95％ CI（1．16,11．60）,P＝0．02]和日常生活活动能力[95％ CI（3．00,19．49）,P＝0．007]方面优于单纯康复训练法,差异均有统计学意义。结论现有证据表明,针刺结合康复训练治疗脑卒中后肩痛较单纯康复训练方法更有效。鉴于纳入研究数量有限,上述结论尚需开展更多研究予以验证。     

The effect of chronic clinical pain on thermal and mechanical thresholds in sheep

Threshold responses were measured to a thermal skin test and a mechanical pressure test in two groups of conscious unrestrained sheep. The first group of sheep were healthy adult females and formed a control sample, the second group were also adult females, but were all suffering from a condition known as footrot. Footrot is a chronic infective lesion affecting usually one foot which appears to cause severe pain in its worst manifestation. These sheep were assessed for the severity of the lesion and degree of lameness and were divided into high and low severity subgroups. Footrot did not alter the threshold to the thermal test but the mechanical pressure threshold was significantly reduced in both footrot sub-groups compared to controls. A local anaesthetic block of the affected foot restored values to close to the control level. After treatment of the affected foot, the mechanical threshold in the low severity sub-group was returned to normal, but in the high severity sub-group it was still significantly reduced compared to the control animals. However, when retested 3 months later these values had returned to the normal control levels.     

The influence of non-specific low back pain on pressure pain thresholds and disability.

The purpose of this study was to investigate the pressure pain thresholds (PPTs) with respect to the Erector spinae and the hip muscles in 87 patients with subacute non-specific low back pain (LBP) and to evaluate the relationship between the PPTs and disability. In order to establish reference values, 64 healthy subjects were examined with respect to PPTs and used as a control group against the group of LBP patients. The mean PPT values of the Erector spinae and the hip at all examined points of the LBP group were significantly lower (p<0.001) in comparison to the PPT values of the healthy group. An exceptionally high difference (2.7 kg/cm2) was found at the L3 Erector spinae level. The correlation between having LBP or not in the whole group (n=151) and PPT, was highest at the L3 level of the Erector spinae (r=-0.710, p<0.001). When the group of patients with LBP was divided into two subgroups in terms of having an Oswestry disability index (ODI) lower than 40 ("moderate LBP disability") or an ODI higher than 40 ("severe LBP disability") it was surprising to notice that there was no significant difference between the PPTs of the Erector spinae and the hip musculature. This study has shown the possibility of the existence of muscular disorder in the lumbar part of the Erector spinae in patients with non-specific low back pain, but also reveals the strong inter-individual differences in muscular fibrosis sensitivity and pain behaviour related to gender.     

Effect of placebo acupuncture over no-treatment: A simple model incorporating the placebo and nocebo effects

Conventionally in controlled trials of drugs or modalities, the placebo and nocebo effects have been determined separately and understood to be the difference between the placebo and no-treatment groups. Recently, the effect of placebo acupuncture over no-treatment was found to be associated with the placebo and nocebo effects together. If these two effects are inseparable in acupuncture treatment, the conventional method of determining placebo and nocebo effects at the trial level will not reflect pure placebo or nocebo effects. Furthermore, if these effects are inseparable, observations about the efficacy of acupuncture will be biased when considering only the placebo effect. A simple mathematical model incorporating both the placebo and nocebo effects will be provided to see how the efficacy of acupuncture is affected.     

康复训练联合针灸预防宫颈癌术后尿潴留的效果观察

目的观察膀胱功能康复训练联合针灸治疗在预防宫颈癌术后尿潴留中的应用效果。方法选取60例宫颈癌行广泛子宫切除术患者,采用随机数字表法分为两组各30例。对照组进行膀胱功能康复训练,观察组在对照组基础上,术后第5天开始针灸治疗。比较两组患者术后尿潴留及尿路感染发生率、残余尿量、留置尿管时间。结果观察组尿潴留及尿路感染发生率分别为3.33%和0,明显低于对照组23.33%和13.33%,差异均有统计学意义(均P0.05);观察组残余尿量为(62.33±32.23)ml,明显少于对照组(93.33±29.28)ml,差异有统计学意义(P0.05);观察组留置尿管时间为(11.36±2.42)d,明显短于对照组(15.23±3.45)d,差异有统计学意义(P0.05)。结论膀胱功能康复训练联合针灸治疗能有效促进膀胱功能的恢复,促进患者恢复自主排尿,减少尿潴留的发生,缩短术后留置尿管时间,有利于患者的康复和提高术后生活质量。     

Specifying the nonspecific components of acupuncture analgesia

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

早期康复及针刺对急性脑卒中患者运动功能的影响

目的 观察早期康复和针刺治疗对急性脑卒中偏瘫患者运动功能的影响。方法 125例急性期脑卒中患者随机分为早期康复针刺治疗组（34组）,早期康复治疗组（39例）、单纯针刺治疗组（21例）、药物治疗对照组（31例）。应用Bobath疗法和针刺疗法治疗,以神经功能缺损评分（NFI）、简式Fugl-Meyer评分（FMA）、Barthel指数（MBI）、临床疗效和治疗效率作为观察疗效指标。结果 早期康复针刺组疗效明显优于单纯早期康复组、单纯早期针刺组和对照组。单纯早期康复组明显优于单纯早期针刺组和对照组,单纯早期针刺组明显优于对照组。结论 急性脑卒中早期介入康复治疗和针刺治疗,二种疗法相互结合应用,优于单一治疗,因此二者合用是促进脑卒中康复的有效方法。     

Reliability of cephalic thermal thresholds in healthy subjects

Reproducibility and normal variation of cephalic warm and cold detection thresholds were investigated in three healthy subject groups. The face, the mastoid process, and the hands were studied. No significant intra-observer test-retest difference ( n =20) was found. Good reliability (intra-class correlation coefficient [ICC]>0.4) was found for 13 of 14 measurements. A small significant inter-observer difference ( n =20) was found for cold thresholds. Good reliability (ICC>0.4) was observed for both cold and warm thresholds in most of the test locations (6 of 8). In general, the largest variability was found in the mastoid and frontal lateral regions. Thermal thresholds varied with investigation site in 56 controls (ANOVA, p <0.0005). No significant gender differences were found for cephalic warm and cold thresholds. Most cold thresholds (4 of 5) but also some warm thresholds (2 of 5) increased with age at the cephalic sites. Our results reveal the frontal medial, the maxillar medial, and lateral regions as the most reliable cephalic test locations. The mastoid region may also be useful for investigating the upper cervical small-fiber function.     

Differentiation of pain ratings in combat-related posttraumatic stress disorder

Although posttraumatic stress disorder (PTSD) is associated with chronic pain, preliminary evidence suggests reduced experimental pain sensitivity in this disorder. The questions addressed in the present study were whether pain perception would also be reduced in PTSD patients who are not suffering from chronic pain symptoms, and whether a reduction in pain sensitivity would also be present in combat veterans who did not develop PTSD. For this, we determined thermal detection and pain thresholds in 10 male combat-related PTSD patients, 10 combat control subjects (no PTSD) and 10 healthy controls without combat experience. All subjects were pain free. First, we measured thermal sensory thresholds with ramped heat and cold stimuli using the method of limits. Ramped thermal sensory stimulation revealed no deficits for the detection of (non-noxious) f2.1thermal stimuli between groups. In contrast, heat and cold pain thresholds in both combat groups (PTSD and combat controls) were significantly increased compared to healthy controls. However, these stimuli could not distinguish between the two groups due to ceiling effects. When using longer-lasting heat stimulation at different temperatures (30 s duration; method of fixed stimuli), we found significantly lower frequency of pain reports in PTSD patients compared with both combat and healthy controls, as well as significantly lower pain ratings. Our results suggest an association of PTSD with reduced pain sensitivity, which could be related to PTSD-related (neuro-)psychological alterations or to a pre-existing risk factor for the disorder.     

康复训练、中药和针刺治疗脑卒中偏瘫的临床观察

目的 探讨康复训练，中药和针刺治疗脑卒中偏瘫的效果。方法 120例脑卒中偏瘫患者，随机分为康复组和对照组，2组各60例，前者采用康复训练，中药和针刺治疗，后者采用中药和针刺治疗。2组患者治疗前及治疗1个月后采用Brunnstrom偏瘫运动功能恢复的6期标准进行评价。结果 康复期疗前，疗后相比，对照组疗前，疗后相比，运动功能均有显著提高。2组治疗后相比，康复组有效率明显优于对照组，P＜0．01。结论 早期康复训练对脑卒中偏瘫患者的功能恢复具有重要意义。     

正中神经损伤后手部感觉功能的康复训练

目的 观察正中神经损伤后早期康复训练对手部感觉功能恢复的影响。方法 将70例正中神经损伤患者随机分为康复组及对照组，康复组于术后2周开始康复治疗，并在康复治疗前及治疗过程中，参照国际标准分别评定手的感觉等级及两点辨别觉，对照组仅行一般处理。经过1个疗程(6—8周)治疗后，进行第2次评定，以后每1个疗程评定1次，共4-5次。结果 康复组患者手的感觉功能优良率达88％，有效率达97％。结论 感觉康复训练能够促进正中神经损伤患者手的感觉功能恢复。     

穴位按摩联合早期功能锻炼对腰椎间盘突出症患者术后疼痛的影响

目的 探讨穴位按摩联合早期功能锻炼对腰椎间盘突出症患者术后疼痛的影响.方法 采取简单随机对照法将50例腰椎间盘突出症术后患者分成两组,对照组采用术后常规护理、心理指导、分散注意力、适时应用镇痛药的方法,试验组在对照组方法的基础上采用穴位按摩和早期功能锻炼对术后疼痛进行护理,每6h对所有入组患者进行疼痛评估1次.比较两组患者疼痛程度和应用止痛药物的差别.结果 术后0～6h,两组的疼痛指数差异无统计学意义(P＞0.05),而在术后6～48h,试验组的疼痛指数较对照组低,使用止痛药的级别和例数均较对照组低,差异有统计学意义(P＜0.05).结论 穴位按摩联合早期功能锻炼能有效减轻腰椎间盘突出症术后患者的疼痛,并可明显减少止痛药物的使用.     

The role of cutaneous mechanoreceptors in thermal sensation and pain.

The functional behavior of slowly adapting cutaneous mechanoreceptors under combined thermal-mechanical stimulation was investigated by single-unit recordings from the lumbar dorsal roots of the cat. Increased sensitivity to bimodal stimulation was observed in 24 of the 28 units studied, employing stimulus-response functional behavior as the basis for judgment. Low-threshold receptors generally did not exhibit increased spontaneous firing as accompaniment to heightened sensitivity, while such enhanced basal activity was usually observed in moderate-threshold units in addition to increased reactivity. Information theory calculations performed on these stimulus-response data revealed that 15 of the 24 "heat-sensitive" receptors were additionally characterized by an enhanced ability to transmit neural information under bimodal stimulation. These results were interpreted as supporting pattern theories of pain as opposed to the concept of receptor specificity. No contradiction was observed, however, between the present results and those of other investigators. The present conclusions derive from new criteria for thermal reactivity based upon innovative stimulus conditions.