By treating those patients within 48 hours after migraine attack, acupuncture can prevent mild migraine from exacerbating to full blown one. This phenomenon confirms the idea that adequate trial design influences the trial result. In conclusion, acupuncture is an effective tool to eliminate headache pain during attack and has short-term analgesic effect [ ]. However, for lingering disorders like migraine, prevention is way more important than treatment for acute flare up.
Acupuncture has been found to be more effective than Flunarize [ ] and topiramate [ ] for migraine prophylaxis. Indeed, one month after ending treatments, the difference between real and sham acupuncture on pain reduction and numbers of attack became insignificant [ ]. Further well-designed trials are needed to elucidate the prophylactic effect of acupuncture on chronic migraine.
There is no consensus as to whether acupuncture is superior to sham acupuncture for treating tension-type headache TTH [ ]. Very few good quality trials have been conducted and their conclusions are conflicting. Different researchers can conclude even the same data differently. For instance, the result of one trial that implied no difference between real acupuncture and superficial acupuncture at non-acupoit without De Qi was conducted in [ ]. These reviews concluded that acupuncture was an effective strategy for treating TTH but they also pointed out the most difficult issue of acupuncture research is the placebo effect.
Like migraine studies, some researches have concluded that acupuncture is a placebo [ , ]. Since the placebo effect of acupuncture analgesia is difficult to retort in headache trials, researchers have tried to evade this effect by investigating the existence of any additional phenomenon of acupuncture.
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In other words, both groups felt the same degree of pain but acupuncture group had higher pain threshold. The explanation for this discrepancy between perception of pain and pain threshold is based on the strong placebo effect of real acupuncture. During the treatments, real acupuncture and sham acupuncture can reduce the perception of pain, in part mediated by placebo effect. It is especially the case because TTH is related to emotional stressor and both treatments can offer participants a relieved experience.
But if this placebo effect is stronger enough in both treatments, then the specific effect decreased pain threshold of real acupuncture will be masked by placebo due to sampling and statistic limitation. This again reinforces our precaution that subjective parameters pain severity should be assessed along with objective ones pain threshold. Applying this conclusion to the migraine research, it is easily to speculate that there are certain specific therapeutic effects of real acupuncture causing objective changes in the patients with migraine, as the change of the pressure pain threshold in patients with TTH treated by real acupuncture.
Indeed current trial suggested real acupuncture changes heart rate variability HRV despite there are no significant difference in pain severity between placebo and real acupuncture [ ]. In conclusion, acupuncture is effective in treating chronic headache. Because chronic headache may have psychogenic symptom component, the benefit of acupuncture might be partly contributed to the placebo effect of acupuncture; however, acupuncture dose elicit specific therapeutic effects that sham acupuncture dose not produce.
Future trials should focus on develop objective assessment tools. Low back pain LBP may be the most popular pain condition for acupuncture trials. Although LBP is a self-limiting disease [ ], it is a major cause of medical expenses, absenteeism and disablement [ ]. Acupuncture is one of the most common complementary therapies for LBP.
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Early RCTs showed that acupuncture is superior to no treatment [ - ] in the pain scores, the dosages of pain pills, the limitation of activity and total hours of pain per. However, these early trials possess many serious flaws, such as poor description of statistical analysis and study protocol including point selection, duration, interval, stimulation type and so on , small patient numbers, and unclear outcome measurements.
As in chronic headache, these kinds of problems perplex most early clinical trials [ ].
In these early clinical trials, we can also notice that the validity of a trial is correlated with the results. More valid the trials are, more likely the negative results are shown [ ].
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Therefore, again, it had been speculated that acupuncture is placebo effect [ ]. However, current meta-analysis showed encouraging result of acupuncture treatment for patient with chronic LBP. Immediately after treatments, patients received acupuncture significantly had better reduction in pain intensity than placebo group [ ]. However, long-term benefit cannot be observed in this meta-analysis. Interestingly, compared with minimal acupuncture, individualized point selection in acupuncture treatment elicited better result in pain reduction [ ]; whereas fixed point brought out non-superior pain reduction [ ].
In both studies, acupuncture was used as a supplement to standard treatments. The phenomenon that acupuncture at individualized acupoints was more effective than minimal acupuncture but equal result of acupuncture at fixed point and minimal acupuncture implies the importance of strong non-specific and placebo effect of minimal acupuncture and fixed point strategy. Chronic LBP is not a specific diagnosis; it may consist of different disorders in different trials. If adequate acupuncture treatment cannot be given, non-specific and placebo effect then head up. However, the following example will ascertain again the importance of objective assessment tool.
Being conducted in Germany [ ] with considerable large numbers of volunteers and a firm methodological design, this research had been a strong cons of beneficial effect of acupuncture. The researchers aimed to determine whether acupuncture has a better therapeutic effect for chronic LBP than the minimal acupuncture sham and no treatment.
After a long period of follow-up 8, 26 and 52 weeks and with multiple measurements of outcomes VAS; SF, Item Short-Form Quality of Life Questionnaire; SES, Schmerzempfindungsskala questionnaire for assessing the emotional aspects of pain ; ADS, Allgemeine Depressionsskala depression scale , they concluded that acupuncture is better than no treatment but not better than sham acupuncture in pain relief.
Only slightly improvement compared with sham acupuncture in functional outcome SF and times of limited function in the acupuncture group was observed between baseline and follow-up periods. However, read it details, a significant pain relief of acupuncture treatment will be found if according to the need of medication in their discussion portion. Acupuncture group need less medication and has better functional outcomes than sham one. Dose that turn out to be strong pros of beneficial acupuncture effect? Another interesting question is how long the acupuncture analgesia can last.
According to a 2-years follow-up study, acupuncture can induce an analgesic effect in chronic LPB patients for at least 2 years [ ]. This observation included a total of patients treated by practitioners.
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It was shown that both functional outcomes and pain severity improved. In addition, the study also suggested that acupuncture could prevent LBP change to a chronic state. In conclusion, acupuncture is a valid strategy for chronic LBP treatment. It can reduce the severity of and improve the functional outcomes in patients.
Acupuncture seems to be a specific treatment rather than a placebo, although some authors do not agree. Combination of acupuncture and conventional interventions is a better choice for patient with chronic LBP. The major discomforts associated with OAK are pain and dysfunction of movement. Early pilot study revealed that acupuncture relieved pain and improved function in patients with OAK [ ].
First, they used plastic guidance tubes to mask their procedure.
With the plastic tubes covering the true acupoints on the skin, the participants, who had never undergo prior acupuncture therapy, were not able to tell whether or not the needles were being inserted. In the acupuncture group, the needles were inserted with De Qi sensation ; in the sham group, the needles were not inserted. In addition to acupuncture at the acupoints that are commonly used for relieving knee pain, the researchers also needled at distal sham points on the abdomen that did not correspond to knee pain.
The sham points were also covered by plastic guidance tubes. In the acupuncture group, the needles were not inserted into the sham points, whereas in the sham group, the needles were inserted into. Therefore, in the acupuncture group, the patients received real needling at the true acupoints and sham needling at the sham points; in the sham group, the patients received sham needling at the true acupoints and real needling at the sham points.
In this crossover way, they can investigate effects of both placebo true acupoints without needling and non-specific physiologic effects to needle insertion sham acupoints with needling at the same time. The study comprised a total of patients randomized into 3 groups, true acupuncture, sham acupuncture and education. Treatment was tapered over 26 months 2 treatments every week for 8 weeks; 1 treatment every week for 2 weeks; 1 treatment every 2 weeks for 4 weeks; and 1 treatment per month for 12 weeks. After a long period of follow-up 26 weeks post-baseline period , there are still and participants available in the acupuncture and sham groups, respectively.
Most of the participants in both true and sham acupuncture groups reported that they had received true acupuncture. This suggested that this sham treatment is a credible blinding procedure and this sham acupuncture might elicit a similar degree of placebo effect as true acupuncture. Those who were received true acupuncture experienced better pain and functional outcomes; however, a significant difference in pain relief between the groups was not observed until 14 weeks.
This implies that true acupuncture improves short-term and long-term functional outcomes, whereas the analgesia effect takes longer time to be elicited. Other studies also suggested similar results that acupuncture is a benefit to the patients with OAK; however these studies showed that acupuncture can also elicited a short-term analgesia effect [ , ]. These conflicting results might be due to the different placebo procedures or different treatment protocols. In conclusion, although few reported discouraging results [ , ], most of the trials published so far have shown preferable result of real acupuncture, especially in short-term pain and functional outcomes [ ].
It is worth noting that, unlike acupuncture for chronic LBP, there is a general consensus among most studies that acupuncture is an effective treatment for OAK. Furthermore, its effectiveness both in pain relief and functional improvement seems not caused by the placebo or non-specific effects. This difference in effectiveness between these two diseases LBP and OAK might be due to the characteristics of the diseases. LBP is a heterogeneous syndrome comprising various disorders; it is an ambiguous and indistinct term.
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