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Research Reviews
This section is designed to give a synopsis of some of the latest research published in Medline listed journals over the last year or so.
It will concentrate on controlled trials and systematic reviews, but will also include other papers that may be of interest to the
readership. Some papers will be reviewed in more detail than others. If summaries and comments are based on an abstract only, this
will be indicated. The main reviewer in this section is Mike Cummings, London. Other reviewers are indicated after the relevant review.

SR

Methodological differences in clinical trials of non- non-pharmacological treatments and 60 (54.5%)

pharmacological and pharmacological treatments assessed pharmacological treatments. Reports of
non-pharmacological treatments had a lower global
Boutron I, Tubach F, Giraudeau B, Ravaud P. quality score than did reports of pharmacological
Methodological differences in clinical trials treatments as measured by the Jadad scale (mean
evaluating nonpharmacological and pharmacological [SD] score, 1.4 [1.3] vs 3.0 [1.3]) and the Delphi list
treatments of hip and knee osteoarthritis. JAMA (mean [SD] score, 5.2 [1.5] vs 7.5 [1.1]). Lack of
2003;290(8):1062-70. reporting adequate random sequence generation and
Summary intention-to-treat analyses were found in both non-
Randomised controlled trials have been developed pharmacological and pharmacological articles. Non-
essentially in the context of pharmacological pharmacological treatments were less often
treatments (ie, oral drugs; intra-articular injection; compared with a placebo than were pharmacological
and topical, intramuscular, and intravenous treatments (28.0% of articles vs 71.7%). Compared
treatments), but assessment of the effectiveness of with pharmacological articles, non-pharmacological
non-pharmacological treatments (ie, surgery, articles less often described blinding of patients
arthroscopy, joint lavage, rehabilitation, (26.0% vs 96.7%), care providers (6.0% vs 81.7%),
acupuncture, and education) presents specific and outcome assessors (68.0% vs 98.3%). Care
issues. The objective of this review was to compare providers’ skill levels could influence treatment
the quality of articles of non-pharmacological effect in 84.0% of non-pharmacological articles vs
and pharmacological treatments of hip and knee 23.3% of pharmacological articles. The authors
osteoarthritis, and to identify specific methodological concluded that in their analysis of reports of hip and
issues related to assessment of non-pharmacological knee osteoarthritis therapy, non-pharmacological
treatments. MEDLINE and the Cochrane Central articles scored lower than pharmacological articles in
Register of Controlled Trials was searched for terms of quality. Assessments of non-
articles of randomised controlled trials published pharmacological treatments must take into
between January 1, 1992, and February 28, 2002, in consideration additional methodological issues.
28 general medical and specialty journals with high Comment
impact factors and assessing non-pharmacological This is an interesting paper, and is surprisingly
and pharmacological treatments in patients with hip readable for a systematic review. It draws attention,
or knee osteoarthritis. The quality of the methods on a wide stage (JAMA), to the methodological
reported in the selected articles was assessed by two difficulties of performing and assessing trials of
independent reviewers using the Jadad scale, the physical interventions. The authors suggest that tools
Delphi list, and guidelines found in the Users' Guides used to measure quality, such as the Jadad scale and
to the Medical Literature. Investigators also used a the Delphi list, are probably not appropriate for
checklist of items developed by the authors to assessing the quality of non-pharmacological trials.
analyze study characteristics. A total of 110 articles But they do stress that the quality of the latter should
were included in the analysis; 50 (45.5%) assessed be improved.

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RCTs

TENS wrist band device at PC6 appears to help differences between study and control groups. The
nausea and vomiting in pregnancy (n=230) time-averaged change in Rhodes Index total
experience of 6.48 for the study group was
Rosen T, de Veciana M, Miller HS, Stewart L, significantly better than the control value of 4.65
Rebarber A, Slotnick RN. A randomized (P=0.02). Study patients gained more weight than
controlled trial of nerve stimulation for relief of controls (2.9 versus 1.2lb, P=0.003). There were no
nausea and vomiting in pregnancy. Obstet statistically significant differences in medication
Gynecol 2003;102(1):129-35. use or urinary ketone measurements. The authors
Summary concluded that nerve stimulation therapy is
The objective of this study was to evaluate the effective in reducing nausea and vomiting and
effectiveness of low-level nerve stimulation promoting weight gain in symptomatic women in
therapy over the volar aspect of the wrist at PC6 to the first trimester of pregnancy.
treat nausea and vomiting in early pregnancy. Comment
Pregnant volunteers (n=230) with symptoms of This was a moderately large multicentre study using
mild to severe nausea and vomiting from 6 to 12 a wrist watch-like device called ReliefBand®.
weeks' gestation participated in a 21-day clinical Readers can view the device on its commercial
trial. Participants were randomly assigned to website: http://www.reliefband.com/. The device
receive a device for nerve stimulation therapy or provides a TENS stimulus to the area of PC6, and it
an otherwise identical but non-stimulating has five levels of intensity from 10 to 35mA. In view
placebo device. The primary outcome measure of the extensive and positive research into the effect
was self-recorded symptoms according to the of sensory stimuli applied to this area on nausea and
Rhodes Index of Nausea, Vomiting, and Retching vomiting, it seems reasonable to accept the positive
(Rhodes Index). Secondary outcome measures outcome of this study. However, it is important to
were medication use, weight gain, and the continue to be critical in this area.
presence of urinary ketones. Baseline The study received funding from the company that
characteristics were similar in both groups. A total makes the device. Observers assessing outcomes
of 187 women (81%) completed the trial. Pre- were not masked. Forty-three women (18.6%) did
treatment Rhodes Index scores for the entire not complete the study, and neither an intention to
population demonstrated no significant treat nor a sensitivity analysis was performed.

TENS wrist band device at PC6 performs less well of chemotherapy-induced nausea and vomiting
for the relief of chemotherapy-induced nausea and (NV), 739 patients were randomly assigned to
vomiting (n=739) either: 1) acupressure bands, 2) an acustimulation
band, or 3) a no band control condition. Patients in
Roscoe JA, Morrow GR, Hickok JT, Bushunow P, the acupressure condition experienced less nausea
Pierce HI, Flynn PJ et al. The efficacy of on the day of treatment compared to controls
acupressure and acustimulation wrist bands for (P<0.05). There were no significant differences in
the relief of chemotherapy-induced nausea and delayed nausea or vomiting among the three
vomiting. A University of Rochester Cancer treatment conditions. Additional analyses revealed
Center Community Clinical Oncology Program pronounced gender differences. Men in the
multicenter study. J Pain Symptom Manage acustimulation condition, but not the acupressure
2003;26(2):731-42. condition, had less NV compared to controls
Summary (P<0.05). No significant differences among the
As an adjunct to standard antiemetics for the relief three treatment conditions were observed in

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women, although the reduction in nausea on the day (chemotherapy), but this effect can be predicted
of treatment in the acupressure, compared to the no by patient expectation. The acustimulation wrist
band condition, closely approached statistical band was no different from the no treatment
significance (P=0.052). Expected efficacy of the control, except for women (n=645) on day three,
bands was related to outcomes for the acupressure when it was significantly worse! There was a
but not the acustimulation conditions. gender difference in treatment effects, and the
Comment acustimulation wrist band was significantly better
This was a very large (by acupuncture standards) than no treatment on day one and day four in men
multicentre study, which appears to have been (n=55), but this was a small sub-group, and the
independent of the original research group that result may simply be a type I error. Either that, or
developed the device, and the company that the wrist ‘gadget’ entertained the men and irritated
produces and sells it. The acustimulation wrist the women.
band device used in the study was the This is the biggest RCT to date of an
ReliefBand®, http://www.reliefband.com/. The acupuncture-like treatment. It suggests a useful
results are interesting. They suggest that there is effect can be achieved using simple acupressure,
an effect from wearing the simple acupressure but the strong suggestion is that this effect is
wrist band (Sea-Bands®) on the day of treatment related to expectation rather than stimulation.

Auricular acupuncture for cancer pain (n=90) months for the eight patients who interrupted
treatment after one month. For three patients, no
Alimi D, Rubino C, Pichard-Leandri E, Fermand- data were available because they withdrew from
Brule S, Dubreuil-Lemaire ML, Hill C. Analgesic the study during the first month. Pain intensity
effect of auricular acupuncture for cancer pain: a decreased by 36% at two months from baseline in
randomized, blinded, controlled trial. J Clin Oncol the group receiving acupuncture; there was little
2003;21(22):4120-6. change for patients receiving placebo (2%). The
Summary difference between groups was statistically
During the last 30 years, auricular acupuncture significant. The observed reduction in pain
has been used as complementary treatment of intensity measured on the VAS represents a clear
cancer pain when analgesic drugs do not suffice. benefit from auricular acupuncture for these
The purpose of this study is to examine the cancer patients who are in pain, despite stable
efficacy of auricular acupuncture in decreasing analgesic treatment.
pain intensity in cancer patients. Ninety patients Comment
were randomly divided into three groups; one This is an interesting study for a number of
group received two courses of auricular reasons, but most notably because it is the first
acupuncture at points where an electrodermal RCT of any acupuncture technique in this
signal had been detected, and two placebo groups population – one that is notoriously difficult to
received either auricular acupuncture at points study in a rigorous fashion. There are one or two
with no electrodermal signal (placebo points) or methodological issues, such as the use of data
auricular seeds fixed at placebo points. Patients regarding withdrawals; however, on the whole the
had to be in pain, attaining a visual analogue score study appears to have been well conducted.
(VAS) of 30mm or more after having received The intervention involved the use of a
analgesic treatment adapted to both intensity and particular type of indwelling needle, described by
type of pain, for at least one month of therapy. the authors as ‘spear-headed implants’ of 3.4mm
Treatment efficacy was based on the absolute in length (Sedatelec). The portion of the ‘implant’
decrease in pain intensity measured two months that was actually embedded measured 1.2mm in
after randomisation using the VAS. The main length, and 0.7mm at its widest part. This type of
outcome was pain assessed at two months, with indwelling device typically falls out of the ear
the assessment at one month carried over to two after a few days. At this point it would constitute a

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potential hazard as a ‘contaminated sharp’. If this It is interesting to consider what the

technique is to be widely recommended there physiological difference might be between
needs to be some way of ensuring that any such inserting a needle (or needle-like device) into the
hazard is contained. skin of the pinna at a point of low skin impedance
In the real acupuncture group, points were compared with one of normal or average
selected using an electronic voltmeter. The reviewer impedance. Perhaps needling these areas creates a
is not familiar with the device used; however, it greater sensory stimulus. The authors found a
seems reasonable to assume from the description of reasonable correlation between the degree of
methods that points were selected based on having lowered impedance at these ear points and the
lowered skin impedance compared with their levels of pain on the VAS. However, this may
surroundings. Skin impedance is very difficult to simply reflect a general lowering of skin
measure reliably, and it is commendable that the impedance with increasing pain, which would be
authors used a device with a spring-loaded probe, expected as a stress response.
which reduces the inaccuracy related to operator So this is an interesting result, and the
applied pressure. The authors suggest that their technique is worthy of further study, but it cannot
method of point selection has been validated by be claimed that the positive result validates the
fMRI – the reviewer suspects that this is a theories regarding somatotopic representation of
somewhat ambitious claim. the body on the pinna.

Acupuncture for adductor spasmodic dysphonia Significant differences were found on all three
(n=10) subtests of the VHI, and the average total scores
pre-treatment and post-treatment differed by 17
Lee L, Daughton S, Scheer S, Stemple JC, points (considered significant according to VHI
Weinrich B, Miller-Seiler T et al. Use of standardization). Seven of 10 subjects reported
acupuncture for the treatment of adductor improvements in voice production, although
spasmodic dysphonia: a preliminary investigation. expert raters did not detect perceptual changes in
J Voice 2003;17(3):411-24. voice quality.
Summary Comment
Ten subjects with adductor spasmodic dysphonia Adductor spasmodic dysphonia, or spastic
participated in a study examining the effects of an dysphonia, is voice disorder thought to be a
acupuncture treatment protocol on their voice specific form of focal dystonia. It is a difficult
disorder. Treatment consisted of eight sessions, condition to treat, and the most popular current
and it was designed and performed by two treatment is injection of botulinum toxin into the
physicians certified in acupuncture. Voice thyroarytenoid muscles.
characteristics were evaluated pre-treatment and The reviewer has attempted to treat this
post-treatment using the CSL Motor Speech condition with acupuncture a handful of times
Profile (MSP), Unified Spasmodic Dysphonia (at the request of patients) with absolutely no
Rating Scale, and Voice Handicap Index (VHI). success. This small cohort study seems to bear out
Subjects also answered a post-treatment that impression of a lack of efficacy, since there
questionnaire regarding their experience. were no objective changes in voice quality
Significant pre-treatment and post-treatment following a reasonably comprehensive course of
differences occurred for some MSP measures. eight sessions of acupuncture.

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EA increases anaesthetic gas requirements (n=46) Comment

This is the fourth trial to examine the effect of
Kvorning N, Christiansson C, Beskow A, Bratt O, acupuncture on anaesthetic gas requirement during
Akeson J. Acupuncture fails to reduce but a surgical skin incision or an equivalent
increases anaesthetic gas required to prevent experimental model. Two trials showed a reduction
movement in response to surgical incision. Acta of similar magnitude in anaesthetic gas
Anaesthesiol Scand 2003;47(7):818-22. requirements,1;2 and one showed no effect.3 This trial
Summary used EA in the upper and lower extremities, and the
Acupuncture is used for clinical pain relief but has skin incision was in the abdomen. Morioka et al
not been evaluated under clinical anaesthesia. This used EA in the lower leg, and the experimental
study was designed to compare movement in procedure – a high intensity intradermal electrical
response to surgical incision in anaesthetized stimulus, was applied to the thigh. In the two
patients subjected to electroacupuncture (EA) or ‘positive’ studies, the experimental procedure was
sham procedures. Our hypothesis was that EA similar to that in Morioka et al, but the therapeutic
stimulation would reduce the requirements for stimulus was applied to the head – on or near the
anaesthetic gas. Forty-six healthy women, pinna. This study used sevoflurane, and the others
scheduled for laparoscopic sterilisation at a used desflurane. There are other differences between
Swedish county hospital, were randomised to have the trials, and it seems as though we have some way
either the electroacupuncture (n=23) or a sham to go to comprehend the results of this work.
(n=23) procedure between the induction of One interesting result in this study was that
general anaesthesia and the start of surgery. The while the EA group were more likely to move
minimal alveolar concentration (MAC) of during the skin incision, their blood pressure did not
sevoflurane required to prevent neck or major rise, whereas in the sham group it did increase
limb movements in response to surgical incision significantly.
was determined in each group of patients. The
Reference List
MAC for sevoflurane was found to be higher in 1. Greif R, Laciny S, Mokhtarani M, Doufas AG,
the group given acupuncture than in the control Bakhshandeh M, Dorfer L et al. Transcutaneous electrical
group (2.1±0.3% vs. 1.8±0.4%; P=0.008). The stimulation of an auricular acupuncture point decreases
anesthetic requirement. Anesthesiology 2002;96(2):306-12.
authors concluded that EA given during general 2. Taguchi A, Sharma N, Ali SZ, Dave B, Sessler DI, Kurz A.
anaesthesia with sevoflurane failed to reduce but The effect of auricular acupuncture on anaesthesia with
instead increased the clinical need for anaesthetic desflurane. Anaesthesia 2002;57(12):1159-63.
3. Morioka N, Akca O, Doufas AG, Chernyak G, Sessler DI.
gas, possibly by reducing the anaesthetic effect of
Electro-acupuncture at the Zusanli, Yanglingquan, and
sevoflurane and/or by facilitating nociceptive Kunlun points does not reduce anesthetic requirement.
transmission and/or reflex activity. Anesth Analg 2002;95(1):98-102.

Acupuncture facilitates neuromuscular and subjected to sham procedures. This study was
oculomotor responses to skin incision (n=45) designed to compare differences in movement,
dilatation of the pupils, divergence of the eye axes
Kvorning N, Christiansson C, Akeson J. Acupuncture and activity of auditory evoked potentials (AEPs)
facilitates neuromuscular and oculomotor responses between patients given EA and those not given EA
to skin incision with no influence on auditory under standardised sevoflurane anaesthesia.
evoked potentials under sevoflurane anaesthesia. Neuromuscular, oculomotor and AEP responses to
Acta Anaesthesiol Scand 2003;47(9):1073-8. skin incision were assessed with and without
Summary bilateral 2Hz EA in patients under steady-state
More sevoflurane was recently found to be required anaesthesia maintained with 1.8% of sevoflurane.
to prevent movement in response to surgical Forty-five healthy patients, scheduled for
incision in anaesthetised patients subjected to laparoscopic sterilisation, were randomised to
electroacupuncture (EA) compared with those receive EA (n=22) or sham (n=23) procedures between

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induction of anaesthesia and the start of surgery. probably not associated with interaction between
Middle latency AEP activity was recorded and EA and the depth of anaesthesia, as AEP activity
interpreted by the A-line ARX (autoregression with was similar in the two groups.
exogenous input) index (AAI). More patients Comment
receiving EA than those receiving sham were found This paper follows on from the last, and seems to
to respond to skin incision with movement of the indicate that there are real changes mediated by the
neck or limbs (77% vs. 43%; P=0.021), dilatation of EA. As yet the authors are at a loss to explain their
the pupils (77% vs. 39%; P=0.001) and divergence results, except to say that they appear to be consistent
of the eye axes (72% vs. 39%; P=0.023), whereas with an increased anaesthetic requirement in their
there was no difference in AAI response. The authors previous trial. Whilst this is all fascinating work in an
concluded that EA facilitates physiological responses explanatory sense, the reviewer cannot help thinking
to nociceptive stimulation under sevoflurane that, from a practical perspective, a small difference
anaesthesia. Differences in neuromuscular and in anaesthetic gas requirement is hardly as relevant to
oculomotor responses between acupuncture and the patient as something like post-operative pain,
sham patients under general anaesthesia are nausea and vomiting..

Acupuncture for chronic low back pain (n=60) alternative control groups.
Comment
Kerr DP, Walsh DM, Baxter D. Acupuncture in the The challenges to performing a rigorous acupuncture
management of chronic low back pain: a blinded trial in chronic low back pain are numerous. This
randomised controlled trial. Clin J Pain group addressed many of those challenges, but also
2003;19(6):364-70. made one of the most common mistakes - they failed
Summary to perform a power calculation before the trial. Using
The objective of this study was to assess the efficacy the pooled standard deviations from the trial, the
of acupuncture in the treatment of chronic low back authors performed sample size calculations (after the
pain. Sixty patients with chronic low back pain trial) based on achieving clinically meaningful
(symptoms for over six months) were recruited and differences, eg a drop in VAS for pain of 20 points.
randomly allocated to either acupuncture therapy or They calculated a sample size of 29 per group would
placebo transcutaneous electrical nerve stimulation have been required to detect a difference of 20 points
(TENS) groups. Patients were treated weekly for six in the VAS. To detect clinically meaningful
weeks, and blinded assessments were carried out differences in the other outcome parameters used, the
pre- and post-treatment using the McGill Pain sample size estimates ranged from 85 to 109 per
Questionnaire (MPQ) and visual analogue scales group. Vickers warns us, however, that sample size
(VAS) for pain, the Short-form 36 quality-of-life calculations based on standard deviations taken from
questionnaire, and a simple range of motion small studies tend to underestimate the required
measurement. A total of 46 patients completed the number of participants.1
trial and were followed up at six months. Analysis of Whilst 60 started the trial, only 46 completed it.
results using t tests showed that in both groups there The fall in VAS in the acupuncture group was 28.4,
were significant pre-post improvements for all as compared to 14.3 in the control. There were
scores, except for MPQ scores in the placebo-TENS similar trends in the other outcomes, so this looks
group. There was no significant difference between like a type II error (sample size too small to detect a
the two groups for any of the outcome measures at significant difference between groups), but of course
the end of treatment. Results from the six month the other possibility is that acupuncture was no better
follow-up would suggest that the response was than inactivated TENS.
better in the acupuncture group. The authors
Reference List
concluded that further research is necessary to fully
1. Vickers AJ. Underpowering in randomized trials
assess the efficacy of acupuncture in combating reporting a sample size calculation. J Clin Epidemiol
chronic low back pain using larger sample sizes or 2003;56(8):717-20.

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Experimental Studies (humans)

Different modes of manual needling have different indicate that the mode of manual acupuncture
physiological effects (n=12) stimulation has a differential effect on the
perceived stimulation intensity, the cerebral
Backer M, Hammes MG, Valet M, Deppe M, activation and the cardiovascular reflex response.
Conrad B, Tolle TR et al. Different modes of Comment
manual acupuncture stimulation differentially In this report, needle rotation is described in terms
modulate cerebral blood flow velocity, arterial of both ‘frequency’ and ‘amplitude’. Low
blood pressure and heart rate in human subjects. frequency high amplitude (lf-ha) was 4-8 rotations
Neurosci Lett 2002;333(3):203-6. [amplitude] at 1-2Hz [frequency], and high
Summary frequency low amplitude (hf-la) was 0.5-2
The psychophysiological effect of different modes rotations at 4-8Hz. Hertz is the unit of frequency,
of manual acupuncture stimulation was and it is defined as one cycle per second. One
investigated in 12 healthy, right-handed, male cycle in terms of needle rotation is not defined,
subjects (mean age 29). The cerebral blood flow but presumably it is the process of rotating in one
velocity (CBFV) in both middle cerebral arteries, direction and then the other until the needle has
arterial blood pressure (BP), heart rate (HR) and returned to its start point. The amplitude would
the perceived intensity of the stimulation were then refer to the number of rotations in each
monitored while an acupuncture needle in the direction before the direction is changed. Low
right dorsal thenar muscle (LI4) was repetitively frequency high amplitude rotation might appear as
rotated with either high frequency (4-8Hz) and ‘long slow twirling’ of the needle, with the thumb
low amplitude (hf-la) or low frequency (1-2Hz) and finger moving slowly past each other, and
and high amplitude (lf-ha). Response patterns high frequency low amplitude as ‘short fast
induced by hf-la and 1f-ha stimulation differed twirling’. Anyway, the slow twirling was
significantly (P<0.05) as tested by Student's t test: significantly more painful than the fast twirling,
(1) 1f-ha stimulation was perceived as more and so it is hardly surprising that there were
intense and induced a more marked right physiological differences between the two manual
hemispheric CBFV increase; (2) while hf-la needling styles.
stimulation led to a slight decrease of BP and HR, This study adds to the evidence which suggests
lf-ha stimulation induced an initial pressor that, in relation to acupuncture, only high
response (increase of BP, decrease of HR) and a intensity stimuli have meaningful physiological
more marked long term decrease of BP. Data effects.

Atropine-induced gastric dysrhythmia is not electroacupuncture. Fifteen healthy male

normalised by electroacupuncture (n=15) volunteers were enrolled for this study. Each
subject was studied for three sessions
Chang CS, Chou JW, Wu CY, Chang YH, Ko CW, in a randomised sequence which included
Chen GH. Atropine-induced gastric dysrhythmia electroacupuncture on the Zusanli (ST36) points
is not normalized by electroacupuncture. Dig Dis with or without premedication with atropine and a
Sci 2002;47(11):2466-72. placebo stimulation on a non-acupoint. Cutaneous
Summary EGG was performed for 30 minutes at the
Acupuncture has been shown to improve the baseline, 30 minutes during acupuncture, and for
regularity of gastric myoelectric activity. The aim an additional 30 minutes after acupuncture. Serum
of this study was to evaluate whether atropine- gastrin, motilin, and human pancreatic
induced gastric dysrhythmia can be normalised by polypeptide (hPP) levels were also measured.

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When applying 2Hz of electrical stimulation on the electroacupuncture.

Zusanli point, there was a significant increase in Comment
the percentage of normal frequency (2-4cpm) The reviewer was a little surprised to read the title
during acupuncture (baseline versus acupuncture, of this study, since Sato et al have already
82.09±12.37% versus 93.08±8.17%, P<0.01). established, through their well-conducted and
There was a significant decrease in the percentage reported research on rats, that an intact vagal
of bradygastria as well as tachygastria during 2Hz supply is required for the excitatory effect of
of electrical stimulation on the Zusanli point. acupuncture on gastric motility.1 Atropine blocks
Using intravenous atropine immediately before the actions of acetylcholine at its muscarinic
electroacupuncture, the percentage of normal receptors, and the latter are found in the smooth
frequency during acupuncture and post muscle of the gut and mediate the effect of vagal
acupuncture periods decreased significantly parasympathetic efferent nerves. The results of
(baselines versus acupuncture and post this study, therefore, are entirely concordant with
acupuncture, 83.86±13.79% versus 55.07±29.44% the work of Sato et al, and might even have been
and 56.76±33.44%, P<0.01). There was a predicted.
significant decrease in serum PP after intravenous
atropine. This observation indicated that atropine- Reference List
1. Sato A, Sato Y, Suzuki A, Uchida S. Neural mechanisms
induced gastric dysrhythmia might be mediated
of the reflex inhibition and excitation of gastric motility
partly via the vagal pathway. However, atropine- elicited by acupuncture-like stimulation in anesthetized
induced gastric dysrhythmia is not normalised by rats. Neurosci Res 1993;18(1):53-62.

Trapezius is more sensitive and more easily ‘wound- cutaneous and intramuscular pain thresholds were
up’ than tibialis anterior (n=16) measured at standard anatomical points in the
trapezius and anterior tibial regions. Temporal
Ashina S, Jensen R, Bendtsen L. Pain sensitivity summation was assessed by repetitive electrical
in pericranial and extracranial regions. stimulation. Pressure-pain thresholds (P=0.005)
Cephalalgia 2003;23(6):456-62. and intramuscular electrical pain thresholds
Summary (P=0.006) were significantly lower in trapezius
Chronic myofascial pain is very common in the than in anterior tibial muscle. Temporal
general population. The pain is most frequently summation was present in skin and muscle of both
located in the shoulder and neck regions, and regions (P<0.001). The degree of temporal
nociceptive input from these regions may play an summation was significantly higher in muscle
important role for tension-type headache. The than in skin in the trapezius region (P=0.02), but
mechanisms leading to the frequent occurrence of not in the anterior tibial region (P=0.47). The
muscle pain in the shoulder and neck regions are authors found that muscle pain sensitivity was
largely unknown. It is possible that the pain is higher in the trapezius than in the anterior tibial
caused by increased sensitivity of muscle muscle. They also demonstrated that temporal
nociceptors or by central sensitisation induced by summation could be induced in both muscle and
nociceptive input from muscle. The primary aim skin and, importantly, that temporal summation
of the present study was to compare muscle pain was significantly more pronounced in muscle than
sensitivity in the trapezius and anterior tibial in skin in the trapezius but not in the anterior tibial
muscles. The secondary aim was to investigate region. These data may help to explain why
whether temporal summation, a clinical correlate chronic muscle pain most frequently is located in
of wind-up, is more pronounced in muscle than in the shoulder and neck regions.
skin and, if so, whether such a difference is more Comment
pronounced in the trapezius than in the anterior Readers may not be very surprised by the title of
tibial region. Sixteen healthy subjects were this review; however, this is the first time that this
included. Pressure-pain thresholds and electrical sort of comparison has been made. There are very

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Research Reports

few research units that study muscle pain, despite sensitive muscle, nor why it is more prone to
how common, and how poorly treated, it appears temporal summation (‘wind-up’) than tibialis
to be. This group is particularly interested in the anterior. The authors suggest that it may be related
importance of muscle pain in relation to headache. to its postural role in supporting the head and
It is not clear why the trapezius is a more shoulders, and this certainly seems plausible.

Electric acupoint stimulation reduces cold pain - an interpreted by fMRI are notoriously hard to
fMRI study (n=8) interpret. The authors were very sensible to keep
the difference between groups to a single
Zhang WT, Jin Z, Huang J, Zhang L, Zeng YW, parameter. They performed the sham EAS at the
Luo F et al. Modulation of cold pain in human same site as real EAS, so the only parameter that
brain by electric acupoint stimulation: evidence was altered was the intensity of stimulus. EAS
from fMRI. Neuroreport 2003;14(12):1591-6. was applied to ST36 and SP6 on the left leg. The
Summary stimulation parameters were as follows: frequency
The purpose of this study is to investigate the 2Hz; square wave width 0.6ms; intensity adjusted
modulation of pain responses in the human brain to a maximal but comfortable level - range from 8
by electric acupoint stimulation (EAS). Eight to 16mA. The cold test stimulus was applied to the
healthy subjects were enrolled; each received real left hand (thenar eminence).
or mock EAS treatment in separate sessions. Cool Subjective effects on pain and distress were
(18°C) and cold (2°C) stimuli were delivered, significantly reduced during the real EAS - these
during which functional magnetic resonance were measured on an eleven point scale (0-10). The
imaging scans were performed, before and after areas relating to cold pain were identified by
treatment. Real EAS specifically increased the effectively subtracting the ‘cool’ (18°C) effects from
pain-specific activation in bilateral secondary those of the ‘cold’ (2°C) stimulus. The authors admit
somatosensory area, medial prefrontal cortex, and that the patterns they identified were not consistent
Brodmann area (BA) 32, while it decreased the with previous reports. EAS caused both activations
activation in contralateral primary somatosensory and deactivations in the areas identified, and the
area, BA7, and BA24. The authors suggest that authors suggest that this may be explained by
EAS may induce an analgesic effect via deactivations relating to pain transmission and
modulation of both the sensory and the emotional activations relating to descending modulation. This
aspect of pain processing. would be consistent with the finding that activations
Comment were more frequent on the side ipsilateral to the test
Studies of the acute effects of sensory stimulation stimulus; however, such interpretation of these
(ie acupuncture or acupuncture-like stimuli) patterns must be considered as speculative.

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Research Reports

Experimental Studies (animals)

Neural mechanism of acupuncture-induced gastric acupuncture-induced gastric relaxations are mediated

relaxations via a somatosympathetic reflex. Its afferent limb is
composed of abdominal cutaneous and muscle afferent
Tada H, Fujita M, Harris M, Tatewaki M, nerves. Its efferent limb is the gastric sympathetic nerve
Nakagawa K, Yamamura T et al. Neural and the reflex centre is within the medulla. VLM
mechanism of acupuncture-induced gastric neurons may play an important role in mediating this
relaxations in rats. Dig Dis Sci 2003;48(1):59-68. reflex.
Summary Comment
Acupuncture has been used to treat gastrointestinal This appears to be a well-conducted and reported
symptoms in China for more than 3000 years. However, paper that confirms the findings of Sato et al,1
the mechanism of the beneficial effects of acupuncture and extends our knowledge of the neural
remains unknown. Strain gauge transducers were mechanism of acupuncture in this area, at least in
implanted on the serosal surface of the stomach to terms of the acute effects. The work of Sato et al
record circular muscle contractions in thiobutabarbital- concluded that the reflex centre for the inhibitory
anesthetised rats. Acupuncture on the right lower somatovisceral effect was in the spinal cord,
abdomen caused a transient relaxation of the stomach. whereas this paper suggests that it is in the
Acupuncture-induced gastric relaxations were ventrolateral medulla; however, apart from this the
abolished by guanethidine, propranolol, splanchnic data are entirely consistent. Both groups are
ganglionectomy, spinal cord transection, and highly respected in the physiology arena.
spinomedullary transection. In contrast, N(G)-nitro-L-
arginine, phentolamine, truncal vagotomy, and Reference List
1. Sato A, Sato Y, Suzuki A, Uchida S. Neural mechanisms
pontomedullary transection had no effect. Acupuncture
of the reflex inhibition and excitation of gastric motility
increased the number of c-Fos immunopositive cells at elicited by acupuncture-like stimulation in anesthetized
the ventrolateral medulla (VLM). It is concluded that rats. Neurosci Res 1993;18(1):53-62.

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Auricular acupuncture for cancer pain (n=90)

Acupunct Med 2004 22: 50-51

doi: 10.1136/aim.22.1.50

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