7. Acupuncture For Chronic Musculoskeletal Pain

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7. Acupuncture For Chronic Musculoskeletal Pain

 

 

CATEGORY:Alternative Medicines 300 Courses

COURSE NUMBER: 07

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DECLARATION …………………………………………………………………………………………………………………………………..II
ACKNOWLEDGMENT……………………………………………………………………………………………………………………… III
TABLE OF CONTENTS ……………………………………………………………………………………………………………………….V
LIST OF TABLES………………………………………………………………………………………………………………………………. XI
LIST OF FIGURES……………………………………………………………………………………………………………………………XVI
LIST OF PUBLICATIONS ………………………………………………………………………………………………………………..XXI
PUBLICATIONS……………………………………………………………………………………………………………………………. XXI
MANUSCRIPTS UNDER REVIEW OR READY FOR SUBMISSION ………………………………………………………………. XXI
CONFERENCE ABSTRACTS…………………………………………………………………………………………………………….. XXI
LIST OF ABBREVIATIONS …………………………………………………………………………………………………………..XXIII
SUMMARY……………………………………………………………………………………………………………………………………………1
CHAPTER 1 : INTRODUCTION……………………………………………………………………………………………………………5
CHRONIC MUSCULOSKELETAL PAIN……………………………………………………………………………………………………. 5
MSK AND ACUPUNCTURE…………………………………………………………………………………………………………………. 6
NEEDLE PLACEMENT AND ACUPUNCTURE …………………………………………………………………………………………… 9
ENDOGENOUS PAIN CONTROLS AND ACUPUNCTURE ……………………………………………………………………………. 10
PSYCHOPHYSICS AND ENDOGENOUS PAIN CONTROLS ………………………………………………………………………….. 11
AIM OF PHD PROJECT …………………………………………………………………………………………………………………….. 12
OUTLINE OF THE THESIS …………………………………………………………………………………………………………………. 12
CHAPTER 2 : LITERATURE REVIEW ON PSYCHOPHYSICAL ASSESSMENTS IN PAIN
RESEARCH AND ACUPUNCTURE FOR PAIN MANAGEMENT……………………………………………………….16
PSYCHOPHYSICAL ASSESSMENTS AND THEIR APPLICATION IN ASSESSING ENDOGENOUS PAIN CONTROL……… 16
Quantitative sensory tests…………………………………………………………………………………………………………… 16
Methods for QST……………………………………………………………………………………………………………………….. 20
Psychophysical subgroups and treatment response ……………………………………………………………………….. 37
Summary………………………………………………………………………………………………………………………………….. 38
ACUPUNCTURE……………………………………………………………………………………………………………………………… 39
Manual acupuncture………………………………………………………………………………………………………………….. 39
Acupuncture for MSK and individual variations……………………………………………………………………………. 42
Mechanism of acupuncture analgesia ………………………………………………………………………………………….. 45
A SUMMARY OF KNOWLEDGE GAPS ………………………………………………………………………………………………….. 51
AIM AND OBJECTIVES OF THIS PROJECT …………………………………………………………………………………………….. 54
CHAPTER 3 : LOCAL AND DISTANT ACUPUNCTURE POINT STIMULATION FOR
MUSCULOSKELETAL PAIN- A SYSTEMATIC REVIEW………………………………………………………………….55
INTRODUCTION……………………………………………………………………………………………………………………………… 55
METHODS …………………………………………………………………………………………………………………………………….. 57
Selection Criteria………………………………………………………………………………………………………………………. 57
Search methods…………………………………………………………………………………………………………………………. 58
Study selection ………………………………………………………………………………………………………………………….. 60
Data extraction and data analysis……………………………………………………………………………………………….. 62
RESULTS………………………………………………………………………………………………………………………………………. 64
Included studies………………………………………………………………………………………………………………………… 64
Adequacy of acupuncture and Confidence of treatment ………………………………………………………………….. 68
Acupuncture point Treatments…………………………………………………………………………………………………….. 73
Assessment of risk of bias…………………………………………………………………………………………………………… 78
Adverse events………………………………………………………………………………………………………………………….. 81
Effect of intervention …………………………………………………………………………………………………………………. 81
Local or distant point stimulation vs controls and Subgroup analysis of local vs distant point stimulation83

Direct comparison of local versus distant point stimulation ……………………………………………………………. 87
Local or distant versus combination of both …………………………………………………………………………………. 87
DISCUSSION………………………………………………………………………………………………………………………………….. 88
Summary of the results ………………………………………………………………………………………………………………. 88
Limitations and strengths …………………………………………………………………………………………………………… 88
Interpretation of the results………………………………………………………………………………………………………… 89
Conclusion……………………………………………………………………………………………………………………………….. 92
UPDATE……………………………………………………………………………………………………………………………………….. 93
Description of studies………………………………………………………………………………………………………………… 93
Adequacy and confidence of treatment…………………………………………………………………………………………. 95
Risk of bias assessment………………………………………………………………………………………………………………. 97
Effect of intervention …………………………………………………………………………………………………………………. 99
Conclusion……………………………………………………………………………………………………………………………… 104
CHAPTER 4 : DETECTING AND PROFILING SUBGROUPS OF PATIENTS WITH PAINFUL KNEE
OSTEOARTHRITIS – SYSTEMATIC REVIEW OF PSYCHOPHYSICAL STUDIES…………………………105
INTRODUCTION……………………………………………………………………………………………………………………………. 105
METHODS …………………………………………………………………………………………………………………………………… 107
Study identification and selection………………………………………………………………………………………………. 107
Data extraction and processing…………………………………………………………………………………………………. 109
Assessment of risk bias…………………………………………………………………………………………………………….. 109
RESULTS…………………………………………………………………………………………………………………………………….. 110
Description of studies………………………………………………………………………………………………………………. 110
Subgroup data ………………………………………………………………………………………………………………………… 116
Correlation data ……………………………………………………………………………………………………………………… 119
Risk of bias assessment…………………………………………………………………………………………………………….. 121
DISCUSSION………………………………………………………………………………………………………………………………… 122
Summary of results ………………………………………………………………………………………………………………….. 122
PPT and TS of pain at and away from the osteoarthritic knee ……………………………………………………….. 123
CPM………………………………………………………………………………………………………………………………………. 125
Risk of bias assessment…………………………………………………………………………………………………………….. 126
Implications for research and treatment …………………………………………………………………………………….. 126
Limitations……………………………………………………………………………………………………………………………… 127
Conclusion……………………………………………………………………………………………………………………………… 127
CHAPTER 5 : METHODOLOGIES OF EXPERIMENTAL STUDIES………………………………………………..128
INTRODUCTION……………………………………………………………………………………………………………………………. 128
ETHICS APPROVAL……………………………………………………………………………………………………………………….. 131
RECRUITMENT OF PARTICIPANTS……………………………………………………………………………………………………. 132
SELECTION CRITERIA……………………………………………………………………………………………………………………. 133
Healthy participants (Zheng et al., 2014)……………………………………………………………………………………. 134
Chronic non-specific low back pain participants (Koes et al., 2006, Chou et al., 2007, Deyo et al., 2014)
……………………………………………………………………………………………………………………………………………… 135
Knee osteoarthritis participants (Altman et al., 1986) ………………………………………………………………….. 136
DESIGN AND GENERAL PROCEDURE………………………………………………………………………………………………… 137
OUTCOME MEASURES …………………………………………………………………………………………………………………… 142
QST procedures………………………………………………………………………………………………………………………. 142
Psychological factors ………………………………………………………………………………………………………………. 152
Quality of life and functionality…………………………………………………………………………………………………. 154
Measurements of the outputs of the autonomic nervous system ……………………………………………………… 155
Skin temperature……………………………………………………………………………………………………………………… 156
Pain and medication diary………………………………………………………………………………………………………… 156
Adverse events………………………………………………………………………………………………………………………… 157
Summary of outcome measures used ………………………………………………………………………………………….. 157
INTERVENTIONS…………………………………………………………………………………………………………………………… 158
Vibration………………………………………………………………………………………………………………………………… 158
Acupuncture……………………………………………………………………………………………………………………………. 159
RANDOMISATION AND BLINDING PROCEDURE ………………………………………………………………………………….. 161
SAMPLE SIZE……………………………………………………………………………………………………………………………….. 162
DATA ANALYSIS ………………………………………………………………………………………………………………………….. 163

PARTICIPANT WITHDRAWAL CRITERIA AND PARTICIPANT WITHDRAWAL PROCEDURES…………………………… 164
MANAGEMENT OF RISKS AND ADVERSE EVENTS……………………………………………………………………………….. 164
QST……………………………………………………………………………………………………………………………………….. 164
Acupuncture treatment …………………………………………………………………………………………………………….. 165
Personal information……………………………………………………………………………………………………………….. 165
CHAPTER 6 : VIBRATION IN HEALTHY HUMANS (SEG STUDY) ………………………………………………..166
INTRODUCTION……………………………………………………………………………………………………………………………. 166
DESIGN AND PROCEDURE ……………………………………………………………………………………………………………… 168
Design……………………………………………………………………………………………………………………………………. 168
Outcome measures…………………………………………………………………………………………………………………… 169
Vibration………………………………………………………………………………………………………………………………… 171
DATA ANALYSIS ………………………………………………………………………………………………………………………….. 172
RESULTS…………………………………………………………………………………………………………………………………….. 173
Baseline characteristics……………………………………………………………………………………………………………. 173
PPT, SUPRA and PIN changes after vibration ……………………………………………………………………………. 174
Rating to vibration…………………………………………………………………………………………………………………… 178
Effect of vibration in PA and PNA……………………………………………………………………………………………… 181
DISCUSSION………………………………………………………………………………………………………………………………… 184
Summary of results ………………………………………………………………………………………………………………….. 184
Vibration parameters……………………………………………………………………………………………………………….. 184
Vibration may induce hyperalgesia ……………………………………………………………………………………………. 188
Vibration response in PA and PNA ……………………………………………………………………………………………. 188
Strengths and Limitations…………………………………………………………………………………………………………. 189
Conclusion……………………………………………………………………………………………………………………………… 189
CHAPTER 7 : RESPONSE TO ACUPUNCTURE IN PAIN ADAPTIVE AND PAIN NON-ADAPTIVE
HEALTHY HUMANS (PAIN ADAPTABILITY AND ACUPUNCTURE ANALGESIA STUDY) …………190
INTRODUCTION……………………………………………………………………………………………………………………………. 190
DESIGN AND PROCEDURE ……………………………………………………………………………………………………………… 192
Acupuncture……………………………………………………………………………………………………………………………. 194
Outcome measures…………………………………………………………………………………………………………………… 196
Blinding and assessment of expectancy and blinding……………………………………………………………………. 196
Data analysis………………………………………………………………………………………………………………………….. 197
RESULTS…………………………………………………………………………………………………………………………………….. 197
Baseline data ………………………………………………………………………………………………………………………….. 197
Needling sensation perceived by PA and PNA groups………………………………………………………………….. 200
PPT changes after real and sham acupuncture between PA and PNA…………………………………………….. 202
Changes in ratings to SUPRA or PIN after real and sham acupuncture between PA and PNA groups .. 204
Expectation of acupuncture and Blinding …………………………………………………………………………………… 206
Internal consistency and session effect……………………………………………………………………………………….. 207
DISCUSSION………………………………………………………………………………………………………………………………… 208
Summary of results ………………………………………………………………………………………………………………….. 208
Strengths of the study: controlling of confounding factors…………………………………………………………….. 208
The debate over real and sham acupuncture……………………………………………………………………………….. 209
Acupuncture analgesia, sham acupuncture and the status of the nervous system……………………………… 210
Spatial distribution of acupuncture analgesia……………………………………………………………………………… 211
Limitations……………………………………………………………………………………………………………………………… 212
Implications of this study………………………………………………………………………………………………………….. 213
Conclusions ……………………………………………………………………………………………………………………………. 213
CHAPTER 8 : PAIN ADAPTABILITY IN INDIVIDUALS WITH CHRONIC MUSCULOSKELETAL
PAIN (PAIN ADAPTABILITY AND MSK STUDY) ……………………………………………………………………………214
INTRODUCTION……………………………………………………………………………………………………………………………. 214
METHODS …………………………………………………………………………………………………………………………………… 217
Design and procedure ……………………………………………………………………………………………………………… 217
Test sites ………………………………………………………………………………………………………………………………… 218
Outcome measures…………………………………………………………………………………………………………………… 219
Data analysis………………………………………………………………………………………………………………………….. 220
RESULTS…………………………………………………………………………………………………………………………………….. 221

Recruitment of MSK participants ………………………………………………………………………………………………. 221
CPT 2°C vs CPT 7°C in MSK participants …………………………………………………………………………………. 223
Characteristics of PA and PNA in MSK participants……………………………………………………………………. 230
Healthy vs MSK participants…………………………………………………………………………………………………….. 249
DISCUSSION………………………………………………………………………………………………………………………………… 260
Summary of results ………………………………………………………………………………………………………………….. 260
CPT at either 2°C and 7°C can be reliably used to identify PA and PNA………………………………………… 261
Characteristics of PA and PNA in MSK participants……………………………………………………………………. 262
Healthy vs MSK participants…………………………………………………………………………………………………….. 265
What determines PA and PNA…………………………………………………………………………………………………… 268
Significance of identifying PA and PNA……………………………………………………………………………………… 269
Limitations……………………………………………………………………………………………………………………………… 270
Conclusion and future directions……………………………………………………………………………………………….. 270
CHAPTER 9 : RELATIONSHIP BETWEEN LOCAL ACUPUNCTURE, PAIN ADAPTABILITY AND
CONDITIONED PAIN MODULATION (ACUPUNCTURE RESPONSE STUDY)……………………………….271
INTRODUCTION……………………………………………………………………………………………………………………………. 272
METHODS …………………………………………………………………………………………………………………………………… 274
Design and procedure ……………………………………………………………………………………………………………… 274
Acupuncture procedure ……………………………………………………………………………………………………………. 275
Outcome measures…………………………………………………………………………………………………………………… 276
Data analysis………………………………………………………………………………………………………………………….. 277
RESULTS…………………………………………………………………………………………………………………………………….. 278
Recruitment…………………………………………………………………………………………………………………………….. 278
Effect of local acupuncture……………………………………………………………………………………………………….. 281
Relationship between baseline characteristics and the change in clinical and experimental outcome
measures………………………………………………………………………………………………………………………………… 286
Pain adaptive vs pain non-adaptive……………………………………………………………………………………………. 297
Low back pain vs osteoarthritis…………………………………………………………………………………………………. 307
Acupuncture setting …………………………………………………………………………………………………………………. 308
DISCUSSION………………………………………………………………………………………………………………………………… 315
Summary of results ………………………………………………………………………………………………………………….. 315
Overall effect of local acupuncture on clinical pain……………………………………………………………………… 316
Characteristics of acupuncture responders…………………………………………………………………………………. 317
Possible mechanisms underlying local acupuncture point needling ……………………………………………….. 318
Local acupuncture and pain adaptability……………………………………………………………………………………. 320
Relationship between local acupuncture and CPM………………………………………………………………………. 321
Controlling of confounding factors ……………………………………………………………………………………………. 322
Limitations……………………………………………………………………………………………………………………………… 322
Conclusion……………………………………………………………………………………………………………………………… 323
CHAPTER 10 : GENERAL DISCUSSION ………………………………………………………………………………………….324
SUMMARY OF FINDINGS………………………………………………………………………………………………………………… 324
Objectives………………………………………………………………………………………………………………………………. 324
Interpretation………………………………………………………………………………………………………………………….. 329
STRENGTHS ………………………………………………………………………………………………………………………………… 332
LIMITATIONS ………………………………………………………………………………………………………………………………. 332
IMPLICATIONS FOR CLINICAL PRACTICE…………………………………………………………………………………………… 333
IMPLICATIONS FOR FUTURE STUDIES ………………………………………………………………………………………………. 334
Acupuncture analgesia: Needling site, pain adaptability and endogenous pain controls…………………… 334
Models of endogenous pain modulation ……………………………………………………………………………………… 335
REFERENCES:………………………………………………………………………………………………………………………………….336
APPENDIX 1 : SEARCH STRATEGY IN PUBMED …………………………………………………………………………..358
APPENDIX 2 : CHINESE SEARCH TERMS………………………………………………………………………………………359
APPENDIX 3 : SEARCH HISTORY IN PUBMED………………………………………………………………………………360
APPENDIX 4 : STUDIES IN THE SUBGROUP CATEGORY- ARENDT-NIELSEN 2010 (N=48)………..361
APPENDIX 5 : STUDIES IN THE SUBGROUP CATEGORY- ARENDT-NIELSEN 2014 (N=217)………362

APPENDIX 6 : STUDIES IN THE SUBGROUP CATEGORY- CREAMER 1998 (N=58)……………………..363
APPENDIX 7 : STUDIES IN THE SUBGROUP CATEGORY- CRUZ-ALMEIDA 2013 (N=194)………….364
APPENDIX 8 : STUDIES IN THE SUBGROUP CATEGORY- EGSGAARD 2015 (N=212)………………….365
APPENDIX 9 : STUDIES IN THE SUBGROUP CATEGORY- FINAN 2013 (N=113)…………………………..366
APPENDIX 10 : STUDIES IN THE SUBGROUP CATEGORY- KING 2013 (209)……………………………….367
APPENDIX 11 : STUDIES IN THE SUBGROUP CATEGORY- SKOU 2014 (N=73) ……………………………369
APPENDIX 12 : ETHICS APPROVAL FOR THE SEG STUDY AND PAIN ADAPTABILITY AND
ACUPUNCTURE ANALGESIA STUDY …………………………………………………………………………………………….370
APPENDIX 13 : EXTERNAL ETHICS APPROVAL ENDORSED BY RMIT………………………………………373
APPENDIX 14 : ETHICS APPROVAL FOR THE PAIN ADAPTABILITY AND MSK STUDY AND
ACUPUNCTURE RESPONSE STUDY……………………………………………………………………………………………….374
APPENDIX 15 : PARTICIPANT INFORMATION AND CONSENT FORM FOR THE SEG STUDY
AND PAIN ADAPTABILITY AND ACUPUNCTURE ANALGESIA STUDY………………………………………375
APPENDIX 16 : PARTICIPANT INFORMATION AND CONSENT FORM FOR THE HEALTHY
PARTICIPANTS IN THE PAIN ADAPTABILITY AND MSK STUDY ……………………………………………….386
APPENDIX 17 : PARTICIPANT INFORMATION AND CONSENT FORM FOR THE MSK
PARTICIPANTS IN THE PAIN ADAPTABILITY AND MSK STUDY AND THE ACUPUNCTURE
RESPONSE STUDY……………………………………………………………………………………………………………………………392
APPENDIX 18 : SCREENING FORM FOR THE SEG STUDY AND PAIN ADAPTABILITY AND
ACUPUNCTURE ANALGESIA STUDY …………………………………………………………………………………………….398
APPENDIX 19 : SCREENING FORM FOR THE PAIN ADAPTABILITY AND MSK STUDY AND
ACUPUNCTURE RESPONSE STUDY……………………………………………………………………………………………….399
APPENDIX 20 : PAIN CATASTROPHIZING SCALE………………………………………………………………………..404
APPENDIX 21 : DEPRESSION ANXIETY AND STRESS SCALE, 21 ITEMS …………………………………….405
APPENDIX 22 : STATE TRAIT ANXIETY INVENTORY ………………………………………………………………….406
APPENDIX 23 : ACUPUNCTURE EXPECTANCY SCALE………………………………………………………………..407
APPENDIX 24 : SHORT FORM 36 ITEMS ………………………………………………………………………………………..408
APPENDIX 25 : MODIFIED ROLAND MORRIS QUESTIONNAIRE ………………………………………………..413
APPENDIX 26 : PITTSBURGH SLEEP QUALITY INDEX ………………………………………………………………..415
APPENDIX 27 : PAIN AND MEDICATION DIARY …………………………………………………………………………..419
APPENDIX 28 : ACUPUNCTURE PROTOCOL…………………………………………………………………………………446
APPENDIX 29 : MODES OF ADVERTISING AND NUMBER OF ENQUIRIES RECEIVED FROM
MSK AND HEALTHY INDIVIDUALS FOR THE PAIN ADAPTABILITY AND MSK STUDY…………..474
APPENDIX 30 : NUMBER OF ENQUIRIES AND MODE OF ADVERTISEMENT FOR MSK
PARTICIPANTS ………………………………………………………………………………………………………………………………..475
APPENDIX 31 BASELINE CHARACTERISTICS OF THE PA AND PNA IDENTIFIED AT 7°C
(MEAN ± SD)……………………………………………………………………………………………………………………………………..476
APPENDIX 32 : THERMAL SENSITIVITY OF THE PA AND PNA IDENTIFIED AT 7°C (MEAN ±
SD)……………………………………………………………………………………………………………………………………………………..477
APPENDIX 33 : PAIN AND MEDICATION DIARY OUTCOME MEASURES FOR LBP AND KNEE
OA PARTICIPANTS PRE AND POST ACUPUNCTURE TREATMENT (MEAN ± SD)……………………..478
APPENDIX 34 : CLINICAL CHARACTERISTICS OF LBP AND KNEE OA PARTICIPANTS PRE
AND POST THE ACUPUNCTURE TREATMENT (MEAN ± SD) ………………………………………………………479

APPENDIX 35 : PERCENTAGE PPT CHANGE AT THE KNEE, WRIST AND LOWER BACK
DURING CPTS IN LBP AND KNEE OA PARTICIPANTS PRE AND POST THE ACUPUNCTURE
TREATMENT (MEAN ± SD) ……………………………………………………………………………………………………………..480
APPENDIX 36 : CPT PAIN PARAMETERS OF LBP AND KNEE OA PARTICIPANTS DURING THE
CPTS PRE AND POST THE ACUPUNCTURE TREATMENT (MEAN ± SD) …………………………………….481
APPENDIX 37 : DURATION OF EACH SESSION FOR PA AND PNA (MEAN ± SD) ………………………..482
APPENDIX 38 : DURATION OF EACH TREATMENT FOR PA AND PNA (MEAN ± SD)…………………482
APPENDIX 39 : AVERAGE CLINICAL PAIN AFTER EACH SESSION OF ACUPUNCTURE FOR PA
AND PNA (MEAN ± SD) …………………………………………………………………………………………………………………….483

……………………………………………………………………………………………………………………………………………………………………………………………………………………

 

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