Research Review By Dr. Ceara Higgins©

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Date Posted:

May 2017

Study Title:

Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities: A Systematic Review

Authors:

Cox J, Varatharajan S, Côté P.

Author's Affiliations:

Canadian Memorial Chiropractic College, Toronto, ON, Canada; University of Ontario Institute of Technology, Toronto & Oshawa, ON, Canada; The Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2016; 46(6): 409-430.

Background Information:

Extremity injuries are common, accounting for 22.3% (upper extremity strain/sprain injuries) and 19.5% (lower extremity strain/sprain injuries) of all lost-time claims made to the Ontario Workplace Safety and Insurance Board in 2013 (26). Acupuncture is commonly used to treat these types of injuries based on the proposed increase of endomorphin-1, beta endorphin, encephalin, and serotonin levels in the plasma and brain tissues, the analgesic and sedative effects, and the recovery in motor function often seen with acupuncture treatment (4). This systematic review aimed to determine the effectiveness and safety of acupuncture therapies for the management of upper and lower extremity musculoskeletal (MSK) disorders, providing an update on other similar systematic reviews published in the past.

Pertinent Results:

15 RCTs were reviewed for this systematic review: 10 were rated as having a low risk of bias and 5 had a higher risk of bias. Of these, 3 investigated the management of Carpal Tunnel Syndrome (CTS), 2 examined lateral epicondylitis, 4 investigated shoulder pain, 2 looked at knee pain, and one each looked at plantar fasciitis, Achilles tendinopathy, upper extremity pain, and piriformis syndrome. 11 of 15 utilized traditional needle acupuncture, 2 used electroacupuncture on meridian points, 1 used dry needling on myofascial trigger points, and 1 used acupressure on meridian points. Treatment durations varied from 3 to 8 weeks and number of treatments ranged from 8 to 36, with a variation in treatments per week of 1 to 7 (lots of variability here!). Needle retention (time left inserted) was between 20 and 30 minutes in 9 studies, 60 minutes in one study, and 1 to 2 days in one study.

Of the 5 studies with a high risk of bias, 4 showed inadequate or improperly described randomization methods, 5 did not have treatment allocation concealment, 4 did not blind outcome assessors, 4 were unclear on similarity or dissimilarity of baseline characteristics between treatment arms, 4 did not mention co-interventions, 4 had unknown validity and reliability of outcome measures, and 3 did not conduct an intention-to-treat analysis.

Evidence from articles with a low risk of bias:

Traditional Needle Acupuncture for CTS

Two studies were found. The first study (15) randomized patients to either 8 sessions of needle acupuncture over 4 weeks with use of a night splint, or 8 sessions of placebo non-penetrating needle acupuncture, a night splint, and vitamin B1 and B6 supplementation. Statistically significant differences were found in global symptoms score, distal motor latency, and sensory nerve conduction velocity favouring the needle acupuncture group post-intervention. Clinical significance, however, was unknown. The second study (28) compared 8 sessions of needle acupuncture over 4 weeks to a 4-week course of oral prednisone and found statistically significant differences favouring the needle acupuncture for clinical symptoms, distal motor latency, and distal sensory latency at 13 months. The acupuncture group was also less likely to report symptom recurrence or the need for other treatments and more likely to report a reduction in their clinical symptoms of more than 50% at both 7 and 13 months’ follow-up.

Electroacupuncture for Persistent CTS

A single RCT (16) suggested that 10 sessions of electroacupuncture over the course of 5 weeks showed statistically, but not clinically important differences in pain immediately post-intervention when compared to night wrist splinting. No statistically significant differences were seen between groups in symptom severity or function.

Traditional Needle Acupuncture for Persistent Nonspecific Upper Extremity Pain (Excluding Major Pathology)

A single RCT (7) compared 8 sessions of needle acupuncture performed over a 4-week period to placebo, non-penetrating needle acupuncture on the same schedule and found that the needle acupuncture group showed a small, statistically significant improvement in pain and symptoms severity, but no difference in function or grip strength.

Electroacupuncture for MSK disorders of the Shoulder

One RCT (8) randomized patients to either 7 sessions of electroacupuncture over 7 weeks, or 7 sessions of non-penetrating needle acupuncture without electrical current on the same schedule. The patients receiving electroacupuncture reported both statistically and clinically significant improvements in pain at 6-months post-intervention, as well as statistically significant improvements in disability, range of motion, and quality of life.

Traditional Needle Acupuncture for MSK Disorders of the Shoulder

Two studies were found with inconsistent information. The first study (19) compared verum acupuncture to sham, superficial, penetrating acupuncture at non-acupuncture points (an additional treatment group received 30 mg of diclofenac daily and 15 multimodal care sessions but had a large rate of loss to follow up. Due to this, the results from this arm were excluded). Both included groups received fifteen sessions, at a length of 20 minutes per treatment, with a schedule varying from 1 to 3 treatments per week. There were statistically significant improvements in pain intensity, shoulder mobility, and full elevation of the arm immediately post-intervention favouring the verum acupuncture group, with this group more likely to report a reduction in pain of more than 50% immediately post-intervention. However, the clinical significance was unclear. The second study (25) compared 3 weeks of acupuncture at a single acupuncture point along with multimodal physical therapy, to mock transcutaneous electrical nerve stimulation along with multimodal physical therapy. The acupuncture group showed statistically significant improvements in pain, disability, and patient self-reported improvement when compared to the other group. However, these differences were not clinically significant.

Dry Needling for Recent-Onset Plantar Fasciitis

One RCT (5) compared dry needling of myofascial trigger points to placebo needle acupuncture and showed statistically significant, but not clinically significant improvements in first-step pain and foot pain in the dry needling group immediately post-intervention and at 12 weeks.

Traditional Needle Acupuncture for Persistent Achilles Tendinopathy

A single RCT (29) showed statistically and clinically important differences in symptom severity in the group receiving needle acupuncture when compared to a group receiving eccentric exercises, both immediately post-intervention and at 16 weeks. At 24 weeks, these differences remained statistically significant, but not clinically significant.

Traditional Needle Acupuncture for Persistent Patellofemoral Pain Syndrome

One RCT (13) compared needle acupuncture to no treatment and discovered no clinically important differences in pain between groups at 5 months post-intervention. However, the results were unclear.

Evidence from articles with a high risk of bias:

Traditional Needle Acupuncture for Lateral Epicondylitis

A single RCT (9) compared 10 sessions of needle acupuncture to 10 sessions of superficial acupuncture. Post-intervention, the needle acupuncture group was more likely to report improvement, and showed statistically significant improvements in median pain threshold with gripping. As well, a smaller number of patients reported pain with the 3-kg lifting test. It is unclear how clinically significant these differences may be. As well, no between-group differences were seen at 3 and 12 months. A second RCT (11) compared 20 days of floating acupuncture (needle retained for 1-2 days and repeated 1 day after removal) to 20 days of conventional acupuncture. The floating acupuncture group was more likely to report recovery post-treatment.

Traditional Needle Acupuncture for Shoulder Impingement Syndrome

One RCT was found (14), which suggested no statistically significant differences in disability between groups treated with 5 weeks of acupuncture and home-based exercises or 5 weeks of ultrasound and home-based exercises over the 12-month follow-up period.

Acupressure for Persistent Knee Pain

A single RCT (24) treated seniors with either 4 weeks of acupressure and routine medical and nursing care or routine care alone. Statistically significant differences in pain and activities of daily living were seen favouring the acupressure group immediately post-intervention. No differences were seen between groups in depression and mobility.

Traditional Needle Acupuncture for Piriformis Syndrome

One RCT (27) randomized patients to 36 sessions of triple acupuncture or conventional acupuncture. The triple acupuncture group was more likely to report being cured or improved post-intervention. (REVIEWER’S NOTE: No description of triple acupuncture, aka. The Bai Hu Yao Tou maneuver was provided within the review).

No major adverse events were reported. However, nine studies reported minor adverse events including temporary bruising, ecchymosis, transient paresthesia, fainting, dizziness, dyspepsia, anxiety, and exacerbation of symptoms.

Clinical Application & Conclusions:

All evidence found in this review demonstrated small effect sizes with limited clinical significance. As well, the evidence was inconsistent across interventions and disorders.

The strongest evidence indicated that traditional needle acupuncture and electroacupuncture might both be useful for the treatment of CTS. Electroacupuncture may also be useful for the treatment of MSK disorders of the shoulder. Traditional needle acupuncture may also be helpful in the treatment of chronic Achilles tendinopathy.

Evidence is inconclusive for the use of traditional needle acupuncture in patients with persistent, nonspecific upper extremity pain, MSK disorders of the shoulder, or persistent patellofemoral pain syndrome. As well, dry needling may not benefit patients with recent-onset plantar fasciitis.

Studies with high levels of bias provided weak support for traditional needle acupuncture in the treatment of shoulder pain, lateral epicondylitis, and piriformis syndrome. However, it has been shown that RCTs with significant methodological limitations tend to overestimate treatment results (18), so these studies cannot be used to make recommendations for clinical treatment.

It is important to note that the varying results seen in this review can indicate that acupuncture’s effectiveness may be condition- and even patient-specific. As well, little is known about the optimal dosage for needle acupuncture, or the difference in effectiveness among different types of acupuncture. More research is needed to clarify these matters.

Study Methods:

The researchers searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL. Reference lists of retrieved studies were also hand-searched for relevant studies. Study titles and abstracts were screened by pairs of independent reviewers based on the eligibility criteria outlined below. In cases where the titles and abstracts did not contain enough information to determine eligibility the full text was screened to make a final determination. In cases were the reviewers were unable to come to a consensus a third reviewer was consulted.

Inclusion Criteria:
  • Studies of adults or children with musculoskeletal disorders of the extremities. These included injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and supporting structures.
  • Studies utilizing acupuncture as an intervention. This included traditional, medical, modern, dry needling, moxibustion, electroacupuncture, laser acupuncture, microsystem acupuncture, and acupressure.
  • Studies comparing acupuncture to other interventions, placebo/sham interventions, or no intervention.
  • Studies utilizing one of the following outcome measures: 1) self-rated recovery; 2) functional recovery; 3) pain intensity; 4) health-related quality of life; 5) adverse events.
  • Studies published in English.
  • Studies published between January 1st, 1990 and January 16th, 2015.
  • Randomized controlled trials (RCTs) had to include at least 30 subjects per treatment arm, cohort-studies had to feature at least 100 subjects with MSK disorders, and case-control studies.
Exclusion Criteria:
  • Studies of extremity pain due to major structural pathology.
  • Guidelines, narrative reviews, letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, guideline statements.
  • Cross-sectional studies, case reports, case series, qualitative studies, non-systematic and systematic reviews, biomechanical studies, laboratory studies, studies not reporting on methodology.
  • Cadaveric or animal studies.
  • Studies solely of patients with grade III sprains or strains, arthritides, osteoarthritis, and severe injuries.
Internal study validity was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) criteria (10) to account for selection bias, information bias, and confounding and their impact on study results. Random pairs of independent reviewers also assessed the RCTs for: 1) clarity of the research; 2) randomization methods; 3) concealment of treatment allocation; 4) blinding of treatment and outcomes; 5) similarity of baseline characteristics between treatment arms; 6) co-intervention contamination 7) validity and reliability of outcome measures; 8) follow-up rates; 9) analysis according to intention-to-treat principles; and 10) comparability of results across study sites.

One reviewer extracted data from the articles with a second reviewer checking the extraction and results were separated according to condition treated and type of acupuncture utilized. Clinical importance of results was assessed using the following minimal clinically importance differences (MCIDs):
  • Between-group differences of 2/10 in the NRS (23).
  • Between-group differences of 14/100mm on the VAS for upper extremity injuries (23).
  • Between-group differences of 20/100mm on the VAS for patellofemoral pain syndrome (6).
  • Between-group differences of 19-100mm on the VAS for first-step plantar heel pain (17).
  • Between-group differences of 9/80 points on the Lower Extremity Functional Scale (2).
  • Between-group differences of 12/100 points on the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire (12).
  • Between-group differences of 13/100 for pain on the Foot Health Status Questionnaire (17).
  • 1/5 difference on the symptom severity subscale of the Carpal Tunnel Syndrome Questionnaire (21).
  • 10.2/100 difference on the Disabilities of the Arm, Shoulder, and Hand questionnaire (22).
  • 18/100 difference on the Shoulder Pain and Disability Index (3).
  • 6kg difference in grip strength using the JAMAR dynamometer (20).
  • 0.47 difference on the Boston Carpal Tunnel Syndrome Questionnaire functional capacity subscale (1).
  • 0.16 difference on the Boston Carpal Tunnel Syndrome Questionnaire symptom severity subscale (1).

Study Strengths / Weaknesses:

Strengths:
  • The search of 5 databases and independent review of the search strategy by two librarians helped ensure the completeness of the search.
  • The use of the SIGN criteria and established MCIDs helped to inform the scientific judgement of the reviewers.
  • Stratifying the results by type of acupuncture allowed us to understand the possible specific effects of these different treatment methods.
Weaknesses:
  • The search was limited to articles published in English from January 1, 1990 onward making it possible that pertinent studies may have been missed.
  • Critical appraisal of articles requires scientific judgement and can vary between or among reviewers. Using a standardized critical appraisal tool can help minimize this, however.
  • Due to clinical heterogeneity in the included studies, no meta-analysis was performed.
  • Although the reviewers attempted to account for possible bias, publication bias was not assessed.
  • The results of this review can only be generalized to MSK disorders of the extremities reported and the types of acupuncture used for each of these disorders.
  • The condition-specific MCIDs used may have been computed from populations that differ from those in the reviewed studies, which may not be entirely appropriate.

Additional References:

  1. Amirfeyz R, Pentlow A, Fotte J, et al. Assessing the clinical significance of change scores following carpal tunnel surgery. Int Orthop 2009; 33: 181-185.
  2. Binkley JM, Straford PW, Lott SA, et al. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther 1999; 79: 371-383.
  3. Breckenridge JD, McAuley JH. Shoulder Pain and Disability Index (SPADI). J Physiother 2011; 57: 197.
  4. Cabyoglu MT, Ergene N, Tan U. The mechanism of acupuncture and clinical applications. Int J BNeurosci 2006; 116: 115-125.
  5. Cotchett MP, Munteanu SE, Lantdorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther 2014; 94: 1083-1094.
  6. Crossley KM, Bennell KL, Cowan SM, et al. Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil 2004; 85: 815-822.
  7. Goldman RH, Stason WB, Park SK, et al. Acupuncture for treatment of persistent arm pain due to repetitive use: a randomized controlled clinical trial. Clin J Pain 2008; 24: 211-218.
  8. Guerra de Hoyos JA, Martin MC, Leon EB, et al. Randomized trial of long term effect of acupuncture for shoulder pain. Pain 2004; 112: 289-198.
  9. Haker E, Lundeberg T. Acupuncture treatment in epicondylalgia: a comparative study of two acupuncture techniques. Clin J Pain 1990; 6: 221-226.
  10. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323: 334-336.
  11. Huang Y, Fu ZH, Xia DB, et al. Introduction to floating acupuncture: clinical study on the treatment of lateral epicondylitis. Am J Acupunct 1998; 26: 27-31.
  12. Iverson JV, Bartels EM, Langberg H. The Victorian Institute of Sports Assessment – Achilles questionnaire (VISA_A) – a reliable tool for measuring Achilles tendinopathy. Int J Sports Phys Ther 2012; 7: 76-84.
  13. Jensen R, Gothesen O, Liseth K, et al. Acupuncture treatment of patellofemoral pain syndrome. J Altern Complement Med 1999; 5: 521-527.
  14. Johansson KM, Adolfsson LE, Foldevi MO. Effects of acupuncture versus ultrasound in patients with impingement syndrome: randomized clinical trial. Phys Ther 2005; 85: 490-501.
  15. Khosrawi S, Moghtaderi A, Haghighat S. Acupuncture in treatment of carpal tunnel Syndrome: a randomized controlled trial study. J Res Med Sci 2012; 17: 1-7.
  16. Kumnerddee W, Kaewtong A. Efficacy of acupuncture versus night splinting for carpal tunnel syndrome: a randomized clinical trial. J Med Assoc Thai 2010; 93: 1463-1469.
  17. Landorf KB, Radford JA, Hudson S. Minimal Important Difference (MID) of two commonly used outcome measures for foot problems. J Foot Ankle Res 2010; 3: 7.
  18. Moher D, Pham B, Jones A, et al. Does quality of reports of randomized trials affect estimates of intervention efficacy reported in meta-analyses? Lancet 1998; 352: 609-613.
  19. Molsberger AF, Schneider T, Gotthardt H, et al. German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) – a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment. Pain 1010; 151: 146-154.
  20. Nitschke JE, McMeeken JM, Burry HC, et al. When is a change a genuine change? A clinically meaningful interpretation of grip strength measurements in healthy and disabled women. J Hand Ther 1999; 12: 25-30.
  21. Ozyurekoglu T, McCabe SJ, Goldsmith LJ, et al. The minimal clinically important difference of the Carpal Tunnel Syndrome Symptoms Severity Scale. J Hand Surg Am 2006; 31: 733-738; discussion 739-740.
  22. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum 2009; 61: 623-632.
  23. Tashjian RZ, Deliach J, Porucznik CA, et al. Minimal clinically importance differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. J Shoulder Elbow Surg 2009; 18: 927-932.
  24. Tse M, Au J. The effects of acupressure in older adults with chronic knee pain; depression, pain, activities of daily living and mobility. J Pain Manag 2010; 3: 339-410.
  25. Vas J, Ortega C, Olmo V, et al. Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial. Rheumatology (Oxford) 2008; 47: 887-893.
  26. Workplace Safety and Insurance Board. By the Numbers: 2013 WSIB Statistical Report: Schedule 2. Toronto, Ontario, Canada: Workplace Safety and Insurance Board; 2014.
  27. Wu Q. Piriformis syndrome treated by triple puncture with the bai hu yao tou maneuver. J Tradit Chin Med 2003; 23: 197-198.
  28. Yang CP, Hsieh CL, Wang NH, et al. Acupuncture in patients with carpal tunnel syndrome: a randomized controlled trial. Clin J Pain 2009; 25: 327-333.
  29. Zhang BM, Zhong LW, Xu SW, et al. Acupuncture for chronic Achilles tendonopathy [sic]: a randomized controlled study. Chin J Integr Med 2013; 19: 900-904.