Lixing Lao

Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee: A Randomized, Controlled Trial

Context Previous studies of acupuncture for osteoarthritis have had conflicting results. This may have occurred because most studies have included small samples, a limited number of treatment sessions, or other limitations. Contribution This randomized, controlled trial compared 24 acupuncture sessions over 26 weeks with sham acupuncture or arthritis education in 570 patients with osteoarthritis of the knee. Acupuncture led to greater improvements in function but not pain after 8 weeks and in both pain and function after 26 weeks. No adverse effects were associated with acupuncture. Cautions Many participants dropped out of the study, so readers should interpret the findings at 26 weeks with caution. The Editors Osteoarthritis is the most common form of arthritis and is a major cause of morbidity, limitation of activity, and health care utilization, especially in elderly patients (1, 2). Pain and functional limitation are the primary clinical manifestations of osteoarthritis of the knee. Current recommendations for managing osteoarthritis, including guidelines published by the American College of Rheumatology (3) and European League of Associations of Rheumatology (4), focus on relieving pain and stiffness and maintaining or improving physical function as important goals of therapy. No curative therapies exist for osteoarthritis; thus, both pharmacologic and nonpharmacologic management focus on controlling pain and reducing functional limitation (5). Nonpharmacologic therapy, which includes patient education, social support, physical and occupational therapy, aerobic and resistive exercises, and weight loss, is the cornerstone of a multidisciplinary approach to osteoarthritis patient management (3). Pharmacologic therapies include nonopioid analgesics (such as acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs) (including cyclooxygenase-2 [COX-2] enzyme selective inhibitors), topical analgesics (capsaicin cream), opioid analgesics, and intra-articular steroid and hyaluronate injections. Often, these agents are used in combination for additive analgesic efficacy (6). Pharmacologic management of osteoarthritis is often ineffective, and agents such as NSAIDs may cause unwanted and dangerous side effects (7, 8). Complementary and alternative medicine is another approach to treating osteoarthritis (9-12), particularly in Asian societies (13). Many U.S. patients with osteoarthritis also use complementary and alternative medical therapies (14). A systematic review of acupuncture and knee osteoarthritis (15) identified 7 small randomized, controlled trials published in English. Within the methodologic limitations of the studies, the evidence suggested that acupuncture seemed to alleviate knee pain and function compared with sham acupuncture controls, although 2 trials comparing acupuncture with an active, nonpharmacologic treatment (physical therapy) did not indicate such an effect (16, 17). Before conducting our large-scale trial, we completed both a pilot study (18) and a randomized, single-blind trial (19) of the effect of acupuncture on osteoarthritis of the knee. Participants in the uncontrolled pilot study (n= 12) showed statistically significant improvement in both self-reported pain and physical function, as well as performance measures of physical function after 8 weeks of acupuncture treatment and at 12-week follow-up as compared with their baseline (18). In our larger randomized, single-blind trial (n= 73), which examined the benefit of acupuncture added to standard management with NSAIDs, the acupuncture treatment group experienced statistically significant improvements in self-reported pain and disability scores compared with a standard-care control group as late as 4 weeks after the end of treatment (19). However, this effect diminished within 18 weeks (26 weeks after the beginning of the trial) after the final acupuncture treatment. Together, however, the previously conducted trials (both our preliminary studies [18, 19] and those referenced in the systematic review [15]) have 3 methodologic limitations: lack of credible controls for the placebo effect, inadequate assessment of long-term treatment benefits, and insufficient sample sizes. We tested the hypothesis that an 8-week intensive acupuncture treatment regimen, followed by an 18-week tapering regimen, reduces pain and improves function among patients with knee osteoarthritis as compared with both sham acupuncture and education control groups. Methods Patient Recruitment We recruited patients for this multisite, placebo-controlled trial from March 2000 through December 2003, primarily through print and radio advertisements. The 3 sites were the Integrative Medicine Clinic of the University of Maryland School of Medicine, Baltimore, Maryland; the Innovative Medical Research Center (a private research firm), Towson, Maryland; and the Hospital for Special Surgery, New York City, New York. The institutional review boards of the 3 sites approved the study. We determined the sample size (n= 570) by a power analysis based on our randomized pilot study (19), adjusted by the estimated decrease in effect size resulting from the inclusion of a sham acupuncture group designed to control for placebo effects. Patients met the following inclusion criteria: age 50 years or older, a diagnosis of osteoarthritis of the knee, radiographic evidence of at least 1 osteophyte at the tibiofemoral joint (KellgrenLawrence grade 2), moderate or greater clinically significant knee pain on most days during the past month, and willingness to be randomly assigned. Exclusion criteria were the presence of serious medical conditions that precluded participation in study, bleeding disorders that might contraindicate acupuncture, intra-articular corticosteroid or hyaluronate injections (as well as any knee surgeries or concomitant use of topical capsaicin cream) during the past 6 months, previous experience with acupuncture, or any planned events (including total knee replacement) that would interfere with participation in the study during the following 26 weeks. After a brief telephone screening, patients were scheduled to visit 1 of the 3 participating sites to sign an informed consent statement and undergo a brief rheumatologic examination (including radiographic examination of affected knees) by a physician or a nurse practitioner. Because the education course was a group activity, patients were recruited until a cohort of 12 to 21 patients was formed, at which point each cohort at each site was randomly assigned to 1 of 3 groups by a computer-generated process using randomly selected blocks of 3, 6, and 9. We assured allocation concealment by using disguised letter codes that were generated and sent to the site coordinators by a central statistical core. We used this procedure to ensure that approximately equal numbers of participants were in each treatment group across the course of the study, to ensure that each cohort would have participants assigned to all 3 treatment groups, and to make the breaking of the group assignment process more difficult. The research assistants who collected assessments from participants, the participants themselves (in the true acupuncture and sham acupuncture groups), and the statistician were blinded to group assignment. Assessments were conducted at baseline and 4, 8, 14, and 26 weeks after randomization. Study Interventions We developed and modified the acupuncture treatment and sham control protocols from previously reported and validated procedures (18-21). During the trial, 7 acupuncturists were used: 3 at the Integrative Medicine Clinic, 3 at the Innovative Medical Research Center, and 1 at the Hospital for Special Surgery. In general, acupuncturists were assigned to the same participants throughout the 26-week treatment schedule, except for vacation conflicts and staff turnover, and provided approximately the same proportions of true versus sham procedures. All acupuncturists were state-licensed and had at least 2 years of clinical experience. The studys principal acupuncturist trained and supervised the acupuncturists in performing true or sham procedures and avoiding interactions that could inadvertently communicate group assignment. True Acupuncture The true acupuncture (experimental) group underwent 26 weeks of gradually tapering treatment according to the following schedule: 8 weeks of 2 treatments per week followed by 2 weeks of 1 treatment per week, 4 weeks of 1 treatment every other week, and 12 weeks of 1 treatment per month. We based the acupuncture point selections on Traditional Chinese Medicine meridian theory to treat knee joint pain, known as the Bi syndrome. These points consisted of 5 local points (Yanglinquan [gall bladder meridian point 34], Yinlinquan [spleen meridian point 9], Zhusanli [stomach meridian point 36], Dubi [stomach meridian point 35], and extra point Xiyan) and 4 distal points (Kunlun [urinarybladder, meridian point 60], Xuanzhong [gall bladder meridian point 39], Sanyinjiao [spleen meridian point 6], and Taixi [kidney meridian point 3]) on meridians that traverse the area of pain (22, 23). The same points were treated for each affected leg. If both knees were affected, 9 needles were inserted in each leg. (The outcome measures were not specifically targeted to whether the patient had osteoarthritis in 1 or both knees, and we observed no differential effects on the basis of the number of knees treated.) The acupuncturists inserted 1.5-inch (for local points) and 1-inch (for distal points) 32-gauge (0.25-mm diameter) acupuncture needles to a conventional depth of approximately 0.3 to 1.0 inch, depending on point location. All participants in the treatment group achieved the De-Qi sensation, a local sensation of heaviness, numbness, soreness, or paresthesia that accompanies the insertion and manipulation of needles during acupuncture, at these 9 points. Acupuncturists applied electrical stimulati

Is acupuncture effective for the treatment of chronic pain? A systematic review

&NA; Pain is the major complaint of the estimated one million U.S. consumers who use acupuncture each year. Although acupuncture is widely available in chronic pain clinics, the effectiveness of acupuncture for chronic pain remains in question. Our aim was to assess the effectiveness of acupuncture as a treatment for chronic pain within the context of the methodological quality of the studies. MEDLINE (1966–99), two complementary medicine databases, 69 conference proceedings, and the bibliographies of other articles and reviews were searched. Trials were included if they were randomized, had populations with pain longer than three months, used needles rather than surface electrodes, and were in English. Data were extracted by two independent reviewers using a validated instrument. Inter‐rater disagreements were resolved by discussion. Fifty one studies met inclusion criteria. Clinical heterogeneity precluded statistical pooling. Results were positive in 21 studies, negative in 3 and neutral in 27. Three fourths of the studies received a low‐quality score and low‐quality trials were significantly associated with positive results (P=0.05). High‐quality studies clustered in designs using sham acupuncture as the control group, where the risk of false negative (type II) errors is high due to large sample size requirements. Six or more acupuncture treatments were significantly associated with positive outcomes (P=0.03) even after adjusting for study quality. We conclude there is limited evidence that acupuncture is more effective than no treatment for chronic pain; and inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care. However, we have found an important relationship between the methodology of the studies and their results that should guide future research.

Acupuncture and Dry-Needling for Low Back Pain : An Updated Systematic Review Within the Framework of the Cochrane Collaboration

Objectives. To assess the effects of acupuncture and dry-needling for the treatment of nonspecific low back pain. Background. Low back pain is usually a self-limiting condition that tends to improve spontaneously over time. However, for many people, back pain becomes a chronic or recurrent problem for which a large variety of therapeutic interventions are employed. Search strategy. We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003. Selection Criteria. Randomized controlled trials of acupuncture (that involved needling) or dry-needling for adults with nonspecific acute/subacute or chronic low back pain. Data Collection and Analysis. Two reviewers independently assessed methodologic quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analysis methods or levels of evidence when the data reported did not allow statistical pooling. Results. Thirty-five randomized clinical trials were included: 20 were published in English, 7 in Japanese, 5 in Chinese, and 1 each in Norwegian, Polish, and German. There were only 3 trials of acupuncture for acute low back pain. These studies did not justify firm conclusions because of their small sample sizes and low methodologic quality. For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and in short-term follow-up. There is also evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, the effects are onlysmall. Dry-needling appears to be a useful adjunct to other therapies for chronic low back pain. No clear recommendations could be made about the most effective acupuncture technique. Conclusions. The data do not allow firm conclusions regarding the effectiveness of acupuncture for acute low back pain. For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and “alternative” treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain. Because most of the studies were of lower methodologic quality, there is a clear need for higher quality trials in this area.

Acupuncture for osteoarthritis of the knee: A systematic review

OBJECTIVE To evaluate trials of acupuncture for osteoarthritis (OA) of the knee, to assess the methodologic quality of the trials and determine whether low-quality trials are associated with positive outcomes, to document adverse effects, to identify patient or treatment characteristics associated with positive response, and to identify areas of future research. METHODS Eight databases and 62 conference abstract series were searched. Randomized or quasi-randomized trials of all languages were included and evaluated for methodologic quality using the Jadad scale. Outcomes were pain, function, global improvement, and imaging. Data could not be pooled; therefore, a best-evidence synthesis was performed to determine the strength of evidence by control group. The adequacy of the acupuncture procedure was assessed by 2 acupuncturists trained in treating OA and blinded to study results. RESULTS Seven trials representing 393 patients with knee OA were identified. For pain and function, there was limited evidence that acupuncture is more effective than being on a waiting list for treatment or having treatment as usual. For pain, there was strong evidence that real acupuncture is more effective than sham acupuncture; however, for function, there was inconclusive evidence that real acupuncture is more effective than sham acupuncture. There was insufficient evidence to determine whether the efficacy of acupuncture is similar to that of other treatments. CONCLUSION The existing evidence suggests that acupuncture may play a role in the treatment of knee OA. Future research should define an optimal acupuncture treatment, measure quality of life, and assess acupuncture combined with other modalities.

Meta-analysis: Acupuncture for osteoarthritis of the knee

Context Previous studies have come to inconsistent conclusions about the effectiveness of acupuncture for treating knee osteoarthritis. Contribution This meta-analysis of 9 trials showed that sham-controlled trials identified no clinically meaningful short-term benefits in pain or function with acupuncture for knee osteo-arthritis, although trials that did not use a sham control identified some benefits. Implications The use of different types of comparisons (sham acupuncture vs. interventions in which the participant knew whether they were receiving acupuncture) explains the variability in the conclusions of published trials about the effectiveness of acupuncture for treating knee osteo-arthritis. Placebo or expectation effects probably account for the observed benefits. The Editors Osteoarthritis is the leading cause of disability among older adults (1, 2). The joint most commonly affected by osteoarthritis is the knee (3, 4). The prevalence, disability, and associated costs of knee osteoarthritis are expected to steadily increase over the next 25 years because of aging in the population (5). Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are the most commonly used pharmacologic agents for treating knee osteoarthritis (6, 7). However, according to a recent systematic review (8), NSAIDs are only slightly better than placebo in providing short-term pain relief and their effects are probably too small to be meaningful to patients (8). Furthermore, many NSAIDs are associated with considerable side effects (9). Gastrointestinal bleeding, the most clinically substantial effect (10), causes approximately 2200 deaths and 12000 emergency hospital admissions each year in the United Kingdom alone (11) and is of particular concern to older patients (10). Acetaminophen may have a better toxicity profile than that of NSAIDs (6). However, a recent systematic review (12) suggests that acetaminophen is modestly less effective than NSAIDs and that the clinical significance of acetaminophen is questionable because it results in only a 5% greater improvement from baseline in pain than does placebo in the short term. The evidence for nonpharmacologic treatments for knee osteoarthritis is generally sparse and inconclusive (13). However, 2 effective nonpharmacologic treatments are exercise (14) and weight loss (15). Some patients with osteoarthritis, however, may have difficulty exercising or losing weight. The need for additional safe and effective treatments for osteoarthritis is clear. Acupuncture is a safe treatment that has a low risk for serious side effects (1619). Given its safety, whether acupuncture is effective for treating osteoarthritis of the knee is a highly relevant question. Our objective was to conduct a systematic review and meta-analysis of the effects of acupuncture for treating knee osteoarthritis. Methods Data Sources and Study Selection We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases to January 2007 to identify randomized, controlled trials (RCTs). We combined acupuncture-related terms with osteoarthritis-related terms and limited the search to RCTs (20). We considered older RCTs that were included in previous reviews of acupuncture for osteoarthritis (2124) for inclusion. Two authors independently selected articles and resolved disagreements by discussion. Our selection criteria were published RCTs of acupuncture in patients who had received a diagnosis of knee osteoarthritis. We considered the 2 outcomes of pain and function. We applied no language restrictions. We included only RCTs in which the acupuncture treatment involved the insertion of needles into traditional meridian points. The needles could be inserted into tender points in addition to the traditional meridian points and could be electrically stimulated. We excluded RCTs of dry needling or trigger-point therapy. We also excluded RCTs that compared only 2 different forms of active acupuncture. We prespecified that trials have at least 6 weeks of observation. This criterion has not been validated as a threshold for study inclusion. However, we thought that RCTs with observation periods less than 6 weeks may also have methodological shortcomings (25, 26) that may exaggerate their results of benefits (27, 28). Data Extraction and Quality Assessment Two authors independently extracted data and resolved disagreements by discussion. They extracted information pertaining to the quality of the methods, participants, interventions, and outcomes (including adverse effects). When a study reported more than 1 pain or function outcome measure, we gave preference to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function measures because the WOMAC is the most widely used and thoroughly validated instrument for assessing patients with knee osteoarthritis (2931). We contacted corresponding authors via e-mail and requested that they review the information we extracted from their studies, clarify any ambiguities, and supply missing information. We evaluated internal validity of the RCTs by using an 11-item scale developed by the Cochrane Back Review Group (32). We considered a score of 6 or more points to indicate high internal validity on the basis of data from ongoing research, in which 1 of the authors is involved. For the patient and outcomes assessor blinding items on the scale, we assigned sham-controlled trials 0.5 point rather than 1 point because we could not be certain that all shams were sufficiently credible in fully blinding patients to the treatment being evaluated. However, we assigned 1 point to sham-controlled trials that evaluated the credibility of the sham and found it to be indistinguishable from true acupuncture. Acupuncture Assessment No consensus exists on how best to assess treatment adequacy in acupuncture RCTs, and no methods have been validated (26). We used a method that involved assessing the adequacy of the following 4 aspects of the acupuncture treatment: choice of acupuncture points, number of sessions, needling technique, and experience of the acupuncturist. The adequacy of the sham intervention was also assessed by using an open-ended question. Two acupuncturists, who had previously used this adequacy assessment instrument for an earlier systematic review (33) on acupuncture, made these assessments. The acupuncturists assessed adequacy independently and achieved consensus by discussion. Assessments were based on only the description of the study population and the acupuncture procedure. The assessors were blinded to the results of the study and the publication. We asked the assessors to guess the identity of each study being assessed to test the success of the blinding. Data Synthesis and Analysis We placed RCTs into categories according to control groups, which were sham, usual care, and waiting list. We defined sham control as a sham intervention that was designed to be credible as the active treatment. We defined the usual care control as groups that received some additional standard care therapy that was not provided to the acupuncture group and waiting list control as groups that received no care while waiting for acupuncture. For our meta-analyses, we defined the short-term follow-up point as the measurement point closest to 8 weeks but no longer than 3 months after randomization. We defined the long-term outcome as the measurement point closest to 6 months but longer than 3 months after randomization. Because some RCTs used the visual analogue scale version of the WOMAC instrument and others used the Likert version, we used standardized mean differences as the principal measure of effect size so that the results of the RCTs could be combined. We calculated standardized mean differences (Hedge adjusted g) for all RCTs by using differences in improvements between groups divided by the SDs of improvements pooled from the 2 groups (34). For 3 RCTs (3537), we made some conservative assumptions to compute the standardized mean differences (Appendix Table 1). Appendix Table 1. Original Data from Included Studies and Assumptions Used to Derive the Meta-analysis Study Data* We used the DerSimonian and Laird (38) model, which is the random-effects model used in RevMan software, version 4.2 (Nordic Cochrane Centre, Copenhagen, Denmark) (39). This model estimates the average treatment effect by incorporating heterogeneity among clinically diverse trials with different, but related, treatment effects (40). When heterogeneity exists, the model (38) assigns smaller studies more weight than they would receive in a fixed-effects model (40). To evaluate statistical heterogeneity within our trial categories, we used I 2 tests on all outcomes included in our meta-analysis. We conducted sensitivity analyses for the short-term outcome of sham-controlled RCTs, restricting the analyses to RCTs assessed as adequate based on each item of the 11-item Cochrane scale (32) and the 4 aspects of the acupuncture treatment adequacy. We performed additional sensitivity analyses for funding source (industry vs. nonindustry) and follow-up length (3 months). We also evaluated whether the pooled effects of acupuncture met the threshold for minimal clinically important differences, defined as the smallest differences in scores that patients would perceive to be beneficial (29). The clinically relevant effects for knee osteoarthritis have been estimated to be standardized mean differences of 0.39 for WOMAC pain and 0.37 for WOMAC function (29). Role of the Funding Source The study was funded by the National Institutes of Health, National Center for Complementary and Alternative Medicine. The funding source had no role in the design, conduct, or reporting of the study or in the decision to submit the manuscript for publication. Results Study Characteristics We included 11 RCTs (3537, 4148) of 2821 patients with osteoarthritis (Figure 1). All studies but 1 (42) we

The Role of Oxidative Stress and Antioxidants in Liver Diseases

A complex antioxidant system has been developed in mammals to relieve oxidative stress. However, excessive reactive species derived from oxygen and nitrogen may still lead to oxidative damage to tissue and organs. Oxidative stress has been considered as a conjoint pathological mechanism, and it contributes to initiation and progression of liver injury. A lot of risk factors, including alcohol, drugs, environmental pollutants and irradiation, may induce oxidative stress in liver, which in turn results in severe liver diseases, such as alcoholic liver disease and non-alcoholic steatohepatitis. Application of antioxidants signifies a rational curative strategy to prevent and cure liver diseases involving oxidative stress. Although conclusions drawn from clinical studies remain uncertain, animal studies have revealed the promising in vivo therapeutic effect of antioxidants on liver diseases. Natural antioxidants contained in edible or medicinal plants often possess strong antioxidant and free radical scavenging abilities as well as anti-inflammatory action, which are also supposed to be the basis of other bioactivities and health benefits. In this review, PubMed was extensively searched for literature research. The keywords for searching oxidative stress were free radicals, reactive oxygen, nitrogen species, anti-oxidative therapy, Chinese medicines, natural products, antioxidants and liver diseases. The literature, including ours, with studies on oxidative stress and anti-oxidative therapy in liver diseases were the focus. Various factors that cause oxidative stress in liver and effects of antioxidants in the prevention and treatment of liver diseases were summarized, questioned, and discussed.

Paradoxes in Acupuncture Research: Strategies for Moving Forward

In November 2007, the Society for Acupuncture Research (SAR) held an international symposium to mark the 10th anniversary of the 1997 NIH Consensus Development Conference on Acupuncture. The symposium presentations revealed the considerable maturation of the field of acupuncture research, yet two provocative paradoxes emerged. First, a number of well-designed clinical trials have reported that true acupuncture is superior to usual care, but does not significantly outperform sham acupuncture, findings apparently at odds with traditional theories regarding acupuncture point specificity. Second, although many studies using animal and human experimental models have reported physiological effects that vary as a function of needling parameters (e.g., mode of stimulation) the extent to which these parameters influence therapeutic outcomes in clinical trials is unclear. This White Paper, collaboratively written by the SAR Board of Directors, identifies gaps in knowledge underlying the paradoxes and proposes strategies for their resolution through translational research. We recommend that acupuncture treatments should be studied (1) “top down” as multi-component “whole-system” interventions and (2) “bottom up” as mechanistic studies that focus on understanding how individual treatment components interact and translate into clinical and physiological outcomes. Such a strategy, incorporating considerations of efficacy, effectiveness and qualitative measures, will strengthen the evidence base for such complex interventions as acupuncture.

Spinal glial activation in a new rat model of bone cancer pain produced by prostate cancer cell inoculation of the tibia.

&NA; Studies suggest that astrocytes and microglia in the spinal cord are involved in the development of persistent pain induced by tissue inflammation and nerve injury. However, the role of glial cells in bone cancer pain is not well understood. The present study evaluated the spinal glial activation in a novel rat model of bone cancer pain produced by injecting AT‐3.1 prostate cancer cells into the unilateral tibia of male Copenhagen rats. The structural damage to the tibia was monitored by radiological analysis. The thermal hyperalgesia, mechanical hyperalgesia and allodynia, and spontaneous flinch were measured. The results showed that: (1) inoculation of prostate cancer cells, but not the vehicle Hanks solution, induced progressive bone destruction at the proximal epiphysis of the tibia from day 7–20 post inoculation; (2) the inoculation also induced progressive thermal hyperalgesia, mechanical hyperalgesia, mechanical allodynia, and spontaneous flinches; (3) astrocytes and microglia were significantly activated in the spinal cord ipsilateral to the cancer leg, characterized by enhanced immunostaining of both glial fibrillary acidic protein (GFAP, astrocyte marker) and OX‐42 (microglial marker); (4) IL‐1β was up‐regulated in the ipsilateral spinal cord, evidenced by an increase of IL‐1β immunostained astrocytes. These results demonstrate that injection of AT‐3.1 prostate cancer cells into the tibia produces progressive hyperalgesia and allodynia associated with the progression of tibia destruction, indicating the successful establishment of a novel male rat model of bone cancer pain. Further, bone cancer activates spinal glial cells, which may release IL‐1β and other cytokines and contribute to hyperalgesia.

Acupuncture-point stimulation for chemotherapy- induced nausea and vomiting

PURPOSE Assess the effectiveness of acupuncture-point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients. MATERIALS AND METHODS Randomized trials of acupuncture-point stimulation by needles, electrical stimulation, magnets, or acupressure were retrieved. Data were provided by investigators of the original trials and pooled using a fixed-effects model. RESULTS Eleven trials (N = 1,247) were pooled. Overall, acupuncture-point stimulation reduced the proportion of acute vomiting (relative risks [RR] = 0.82; 95% CI, 0.69 to 0.99; P = .04), but not the mean number of acute emetic episodes or acute or delayed nausea severity compared with controls. By modality, stimulation with needles reduced the proportion of acute vomiting (RR = 0.74; 95% CI, 0.58 to 0.94; P = .01), but not acute nausea severity. Electroacupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% CI, 0.60 to 0.97; P = .02), but manual acupuncture did not; delayed symptoms were not reported. Acupressure reduced mean acute nausea severity (standardized mean difference = -0.19; 95% CI, -0.38 to -0.01; P = .03) and most severe acute nausea, but not acute vomiting or delayed symptoms. Noninvasive electrostimulation showed no benefit for any outcome. All trials used concomitant pharmacologic antiemetics, and all, except electroacupuncture trials, used state-of-the-art antiemetics. CONCLUSION This review complements data on postoperative nausea and vomiting, suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies with state-of-the-art antiemetics as well as studies for refractory symptoms are needed to determine clinical relevance. Acupressure seems to reduce chemotherapy-induced acute nausea severity, though studies did not involve a placebo control. Noninvasive electrostimulation seems unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy.

Is Acupuncture Analgesia an Expectancy Effect? Preliminary Evidence Based on Participants’ Perceived Assignments in Two Placebo-Controlled Trials

This purpose of this article is to contrast the analgesic efficacy of acupuncture following dental surgery with the analgesic effects based on the expectation of benefit in two independently conducted placebo-controlled trials evaluating acupuncture as an adjunctive therapy for dental surgery. Both trials used pain following dental surgery as the outcome variable, and both included a blinding check to ascertain patients’ beliefs regarding which treatment they were receiving. Although no statistically significant analgesic effect was observed between the acupuncture and placebo groups, participants in both experiments who believed they received real acupuncture reported significantly less pain than patients who believed that they received a placebo. Patients’ beliefs regarding the receipt of acupuncture bore a stronger relationship to pain than any specific action possessed by acupuncture. These results also support the importance of both employing credible controls for the placebo effect in clinical trials and evaluating the credibility of those controls.