[Acupuncture in orthopedics]. / Akupunktur in der Orthopädie.

Large randomized controlled trials have shown the effectiveness of acupuncture in comparison to various control treatments for low back pain, osteoarthrosis, shoulder pain, tension type headache, and migraine. For most of these diseases the cost-effectiveness of acupuncture has been proven. A few smaller controlled trials exist for tennis elbow and osteoarthrosis of the hip. The use of acupuncture for other locomotive disorders is based on textbook literature and expert opinion. Current data show that acupuncture is a relatively safe method. Internationally several guidelines for chronic low back pain have integrated acupuncture. In Germany acupuncture has been reimbursed by the state insurance system for chronic low back pain and osteoarthritis since 2007 and the estimated costs are between EUR 300-700 million annually. Acupuncture is offered by at least 12,000 medical doctors and acupuncture is mostly used for locomotive disorders.

Differences in Chinese diagnoses for migraine and tension-type headache: an analysis of the German acupuncture trials (GERAC) for headache.

A growing number of clinical trials are testing Chinese acupuncture in the management of headache disorders. Little is known, however, about the relationship between International Headache Society diagnostic criteria and traditional Chinese medicine (TCM) diagnosis in primary headache disorders. We conducted a secondary analysis of the data of the prospective, controlled, blinded German acupuncture trials for migraine and tension-type headache. Data were collected from 1042 headache patients, of whom 633 were diagnosed with migraine and 409 with tension-type headache. We found that the diagnoses of migraine and tension-type headache were mirrored by different patterns of TCM diagnoses, with the patterns Liver Yang Rising, Liver Fire Rising, and Phlegm appearing to be best suited to differentiating between migraine and tension-type headache. Although not unexpected, given that the diagnosis of primary headache disorders in both diagnostic systems is based largely on the nature and quality of patient-reported symptoms, this finding suggests that migraine and tension-type headache are associated with different patterns of TCM diagnosis.

[Above elbow amputation due to acupuncture treatment?]. / Armamputation als Folge einer Akupunkturbehandlung?

Opinions of acupuncture experts should always be sought in any lawsuit or claim for compensation involving sequelae of acupuncture treatment. Overall,--in the hands of experienced acupuncturists--acupuncture is very safe but not without minor adverse events. However, serious adverse events are extremely rare, especially the risk of a serious vascular lesion. In contrast, inflammatory bowel disease is an independent and disease specific risk factor for thromboembolism, especially if the disease is highly active.

Long-term improvement in pain coping for cLBP and gonarthrosis patients following body needle acupuncture: a prospective cohort study.

BACKGROUND: Little is known about potential long-term effects of body acupuncture. The aim of the study was to determine such long-term effects 3 and 6 months after the end of a course of acupuncture treatment for chronic low-back pain (cLBP) or chronic pain caused by gonarthrosis. METHODS: Prospective cohort study with patients who had received 10 sessions of needle body acupuncture within a maximum of 10 weeks. Data source was our survey of all patients receiving acupuncture treatment in Germany. A total of 1096 eligible patients with cLBP or gonarthrosis pain were identified (68.1% female) and invited by letter to participate in the study. Ultimately 249 patients remained, with no loss of representativeness. Two telephone interviews were conducted 3 and 6 months after the last acupuncture session using standardized questionnaires, available as electronic case report forms. The primary target criteria were self-assessment of pain tolerability prior to the start of acupuncture and after the end of treatment, and pain intensity (GCPS) over time. Secondary target criteria were changes to functional impairment (HFAQ for cLBP, WOMAC for gonarthrosis), quality of life (SF12), depression (CES-D) and patient global assessment of treatment effectiveness (PGA). For the indication cLBP, pain-related fear avoidance beliefs (FABQ) were also queried. RESULTS: Pain tolerability before acupuncture was reported as being significantly worse than pain tolerability at the time of the two post-acupuncture interviews. The scores for all post-acupuncture questionnaires showed no significant changes over time, with the exception of treatment effectiveness for gonarthrosis. Mean scores for each of the questionnaires at the 3 and 6 month follow-up interviews were as follows: cLBP: Pain tolerability (pre: 6.8, post: 3.4 / 3.4), pain intensity (41.8 / 42.6), PGA (2.4 / 2.6), SF12 physical (35.8 / 35.8), SF12 mental (45.3 / 46.9), CES-D (14.9 / 14.9), HFAQ (67.2 / 67.1), FABQ total (2.9 / 2.9). GONARTHROSIS: Pain tolerability (pre: 6.9, post: 3.6 / 3.9), pain intensity (42.9 / 42.8), PGA (2.6 / 2.9), SF12 physical (32.2 / 31.3), SF12 mental (45.0 / 46.2), CES-D (15.6 / 14.7), WOMAC total (34.6 / 34.0). CONCLUSIONS: Pain tolerability was significantly improved after acupuncture and remained so up to 6 months after treatment. The mean scores of almost all questionnaires did not change significantly between 3 and 6 months. We therefore conclude that acupuncture had a long-term effect on important aspects of cognitive and emotional pain coping.

An internal standard for verifying the accuracy of serious adverse event reporting: the example of an acupuncture study of 190,924 patients.

BACKGROUND: Reporting of all serious adverse events (SAEs) is a requirement for regulatory approval of a drug. Can equally rigorous reporting standards be expected in studies of non-drug treatments and how can underreporting, if any, be detected and proven? Using data from our large-scale prospective cohort study of acupuncture on outpatients, we examine the use of an internal standard, a principle taken from laboratory medicine, to quantify real event rates. METHODS: A total of 190,924 patients (68.6% women) seeking treatment for chronic pain (headache, low back pain, coxarthrosis or gonarthrosis) from 12,000 physicians in private practice in Germany were observed during a six-month period ending in May 2002. Most received ten sessions of body acupuncture. Mean treatment time was six weeks. All practitioners were certified in acupuncture and received written instructions on completing forms for basic patient data and SAE monitoring. They were also informed that payment by insurers would be made only upon return of the completed form. All SAEs occurring between start of the first acupuncture session and end of the last one were to be reported, whether causally related to the treatment or not. Multiple minor adverse events (AEs) per single patient were to be reported only once. As the internal standard we chose the expected number of deaths, based on the death rate for the German population, adjusted for age, sex distribution and mean observation time of our study patients. RESULTS: 45 SAEs and 14,404 AEs were reported (i.e. 2.4 SAEs and 754 AEs per 10,000 patients). The number of reported deaths (9) was only 5% of the statistically expected number (180). Applying the resulting correction factor of 20 to all reported SAEs, resulted in 900 expected SAEs (versus 45 reported) or 47 per 10,000 patients. CONCLUSIONS: Without verifying the accuracy of a measurement, results remain speculative. Our internal standard for the first time provides a means of verifying the accuracy of the reported SAE rate and correcting it to the statistically expected SAE rate.

[Chip fracture of the lateral tibial condyle--a roentgenologic sign of anterior cruciate ligament injury]. / Die chip fracture der lateralen Tibiakondyle--ein röntgenologisches Zeichen der vorderen Kreuzbandverletzung.

A case report serves as basis for describing the importance of the so-called chip fracture as the first roentgenological pointer to a rupture of the anterior cruciate ligament in a handball player. The paper discusses the biomechanical changes resulting from an ACL rupture and underlines the importance of early arthroscopic diagnosis or of arthroscopic surgery for regaining knee stability and for preventing secondary subsequent damage.

Acupuncture points are large fields: the fuzziness of acupuncture point localization by doctors in practice.

BACKGROUND: Acupuncture textbooks, schools, practitioners and clinical researchers designing randomized controlled trials on acupuncture all assume that acupuncture points are small and must be located precisely. METHOD: Seventy-one medical doctors with ≥200 h acupuncture training and ≥2 years of clinical experience independently identified 23 commonly used acupuncture points on a male volunteer, using sticky transparent films with an X/Y grid placed asymmetrically around acupuncture points. RESULTS: For each acupuncture point, the field covering 95% (68%) of all point locations varied from 2.7 (0.7) cm(2) for PC-6 up to 41.4 (10.2) cm(2) for ST-38. Commonly-used acupuncture points showed unexpectedly large variance in location: 95% (or 68%) areas were SP-6: 12.2 cm(2) (3.0 cm(2) ), ST-36: 20.7 cm(2) (5.1 cm(2) ), LI-15: 18.7 cm(2) (4.6 cm(2) ), BL-23: 22.4 cm(2) (5.6 cm(2) ) and BL-54: 22.5 cm(2) (5.6 cm(2) ). Points close to anatomical landmarks (forearm, ankle, poplitea; BL-60, BL-40, TW-5, PC-6) were located with less variance. Precision of point location was independent of length of acupuncture experience, kind of training or medical specialty. CONCLUSIONS: In respect to the high degree of variation in the localization of acupuncture points, we suggest that the term 'acupuncture field' is more appropriate than 'acupuncture points' to describe the clinical reality; for the design of sham-controlled acupuncture trials, we recommend a minimum distance of 6 cm between verum and sham points on face, hands and feet, and up to 12 cm for all other parts of the body.

[Epidural injection therapy with local anaesthetics versus cortisone in the lumbar spine syndrome: a prospective study]. / Die epidurale Injektionsbehandlung mit Lokalanästhetikum versus Kortison beim chronischen lumbalen Nervenwurzelkompressionssyndrom: eine prospektive Studie.

AIM: The prospective randomised double-blind study analyses follow-up data of the therapeutic effects of cortisone versus local anaesthetics using an injection technique close to the nerve root in chronic lumbar spine syndrome. METHODS: 57 patients were included with an MRI-assured clinical diagnosis. The study was performed over a 6-month period to evaluate long-term effects. The level of disability (ODQ), the quantitative and qualitative sensations of pain were separately determined. The t-test was used for interval and relation variables, the chi (2) test for nominal variables and the Mann-Whitney-U-test for ordinal variables. RESULTS: Significant differences in favour of cortisone were not found for the measured parameters at any time. An improvement for all parameters was seen in both groups between the time t0 and the definite times t1 and t2. CONCLUSION: The advantage of a combined injection of local anaesthetics and cortisone versus a injection of local anaesthetics alone in epidural-peridural technique in the inpatient treatment of the chronic lumbar spine root compression syndrome could not be detected.

[German Acupuncture Trials (gerac) address problems of methodology associated with acupuncture studies]. / Zur Problematik von Akupunkturstudien am Beispiel der Methodik von gerac.

OBJECTIVE: Conflicting or ambivalent findings on the effectiveness of body acupuncture in pain treatment are often attributed to flaws in study methodology. The paper describes the methodology used for the German Acupuncture Trials (gerac), which demonstrates that it is possible to design acupuncture studies in accordance with the standards of good clinical practice. METHOD: Approximately 1000 chronic pain sufferers per indication (migraine, tension-type headache, low back pain (cLBP), or gonarthrosis) are randomly allocated to one of three treatment groups (verum acupuncture, sham acupuncture, or established conservative therapy). Patients are blind to the type of acupuncture. All patients receive ten sessions of treatment (two per week) with an option of adding five more treatments in cases of slight but insufficient improvement (number of headache days or von Korff pain score). Participating physicians are in private practice, representing a variety of specialties. All have completed at least a 140-hour training course in acupuncture. Mandatory and optional verum and sham points are predefined. The point selection is individualized according to the criteria of traditional Chinese medicine (TCM). Primary outcome measures are number of headache days per month, von Korff Graded Chronic Pain Scale or Hannover Functional Ability Questionnaire (cLBP), or WOMAC scores (gonarthrosis). Data are assessed by trained telephone interviewers not involved in treatment and blind to types of acupuncture. PRESENT STATUS: Over 500 participating physicians in ten urban areas of Germany. Patient recruitment for cLBP and gonarthrosis was completed in November 2003 and March 2004 respectively. Recruitment for chronic headaches will be completed in autumn 2004. CONCLUSIONS: The gerac trials prove that it is possible to design and carry out acupuncture studies in accordance to stringent standards of methodology and clinical practice. The results will form a basis for the assessment of acupuncture effectiveness in Germany and abroad.

The analgesic effect of acupuncture in chronic tennis elbow pain.

The immediate analgesic effect of a single non-segmental acupuncture stimulation treatment on chronic tennis elbow pain was studied in a placebo-controlled single-blind trial completed by 48 patients. Before and after treatment, all patients were examined physically by an unbiased independent examiner. Eleven-point box scales were used [13] for pain measurement. Patients in the verum group were treated at non-segmental distal points (homolateral leg) for elbow pain following Chinese acupuncture rules, whereas patients in the placebo group were treated with placebo acupuncture avoiding penetration of the skin with an acupuncture needle. Overall reduction in the pain score was 55.8% (S = 2.95) in the verum group and 15% (S = 2.77) in the placebo group. After one treatment 19 out of 24 patients in the verum group (79.2%) reported pain relief of at least 50% (placebo group: six patients out of 24). The average duration of analgesia after one treatment was 20.2 h in the verum group (S = 21.54) and 1.4 h (S = 3.50) in the placebo group. The results are statistically significant (P < 0.01); they show that non-segmental verum acupuncture has an intrinsic analgesic effect in the clinical treatment of tennis elbow pain which exceeds that of placebo acupuncture.

[Acupuncture for pain in locomotive disorders. Critical analysis of clinical studies with respect to the quality of acupuncture in particular]. / Akupunktur bei Schmerzen des Bewegungsapparats. Kritische Analyse klinischer Studien unter besonderer Berücksichtigung der handwerklichen Qualität der Akupunktur.

88 clinical acupuncture studies concerning the treatment of locomotive disorders are compared. The studies are evaluated according to treatment quality and categorised into 6 categories. For the assessment of acupuncture treatment quality minimal criteria are defined: reporting the duration of one acupuncture treatment (at least 15 min.), reporting the frequency of acupuncture treatments (at least 10 sessions before cancelling the therapy), exact description of used acupuncture points. Without respect to biostatistical and therapeutical qualities, 75 of 88 studies (85.2%) showed positive results for the acupuncture treatment. None of the 16 studies, that met the minimal criteria we defined, could prove that acupuncture is non-effective. Only two of the 16 studies are controlled trials. Our results were compared with those of meta-analytical reviews, which discussed acupuncture studies solely on the basis of the biometrical aspects. In comparison to conventional orthopedic therapies, certain locomotive disorders are recommended for acupuncture therapy.

[The artist as a pain patient. An investigation on pain in the musculoskeletal system in musicians and their expectations regarding pain therapy.]. / Der Künstler als Schmerzpatient.

74 pop/rock/jazz musicians and 100 classical musicians were investigated by means of a specially designed questionnaire. Several social, musical, pain-, and health-related questions were asked. Pain of the musculoskeletal system was the main complaint of musicians in both group (75% classical; 64% rock-pop-jazz). Classical musicians suffer most from neck pain (35%) and the other group mostly from shoulder pain (30%). Specific instruments showed specific muscolosceletal pain patterns. 55% of the musicians in the classical field were treated by an orthopedic surgeon, whereas 43% of rock-pop-jazz musicians chose no therapy, although they suffered from pain. Only 32% of the classical musicians showed good compliance; 64% believe that medical therapy is not adjusted to the needs of musicians. 98% of the classical musicians and 89% of rock-pop-jazz musicians wish to have a doctor who is specially trained to deal with the needs of musicians.

[Chance coincidence of spondylolisthesis and osteoid osteoma of the spine--a case report]. / Zufllige Koinzidenz von Spondylolisthese und Osteoidosteom der Wirbelsäule--eine Fallbeschreibung.

Between 10 and 20% of all osteoid osteomas are located in the spine. Diagnosis is often hampered by atypical signs and symptoms and unclear X-rays. Striking (chance) X-ray findings in this case, a spondylolisthesis- can divert attention away from a correct diagnosis. Scintiscanning and computer tomography are essential for a correct diagnosis.

[Correlation of roentgen findings, intensity of pain and subjectively experienced impairment in gonarthrosis]. / Die Korrelation von Röntgenbefund, Schmerzintensität und subjektiv empfundener Beeinträchtigung bei der Gonarthrose.

At the Orthopedic Clinic of the Heinrich Heine University of Düsseldorf a clinical survey was carried out about patients with clinically obvious gonarthrosis. Wirth's rating was used to classify the x-ray state. The survey revealed the following correlations: Between the x-ray state according to Wirth and pain intensity measured by VAS scales exists a significant positive correlation (p < 0.001). Between the x-ray state according to Wirth and the individual clinical impairment measured by a modified LYSHOLM-SCORE exists a significant positive correlation (p < 0.001). The survey shows that the LYSHOLM-SCORE modified by Kloos does reveal the subjective impairment caused by gonarthrosis. The survey points out that on the one hand the subjective impairment at Wirth's x-ray state IV is higher than at state III, but that on the other hand the pain-score is higher at state III than at state IV.

[Acupuncture treatment for the relief of gonarthrosis pain-a controlled clinical trial.]. / Schmerztherapie mit Akupunktur bei Gonarthrose : Eine kontrollierte Studie zur analgetischen Wirkung der Akupunktur bei Gonarthrose.

The analgesic effect of acupuncture in chronic gonarthrosis pain was studied in a placebocontrolled trial completed by 97 patients. Each patient was treated twice a week, receiving 10 acupuncture treatments in all. Before and after tee course of treatment all patients were examined by an unbiased independent examiner and the overall pain score was measured over 10 days using VAS scales; functional parameters (resilience) were measured with a modified Lysholm questionnaire. Patients in the verum group (n=71) were treated according to generally accepted acupuncture treatment recommendations. Patients in the placebo group (n=26) were treated with sham acupuncture at non-acupuncture points on the homolateral leg. A follow-up examination was carried out after 3 months. After ten treatments the overall reduction in pain score was 47.5% in the verum group (follow-up 48.2%), and 26.1% in the placebo group (follow-up 26.1%). The results are statistically significant (P<0.05); they show that in gonarthrosis pain the analgesic effect of verum acupuncture exceeds that of placebo acupuncture. Measurement of the functional parameters according to the Lysholm score showed no significant change.

[Long-term studies of the reproducibility of evoked spinal potentials from chronically implanted recording electrodes in the rat]. / Langzeituntersuchungen zur Reproduzierbarkeit evozierter spinaler Potentiale von chronisch implantierten Ableitelektroden bei der Ratte.

Over a period of 4 weeks we examined the reliability of spinal cord nerve potentials in the thoracic-lumbar region after stimulation of the hindpaw in 10 rats. Recording electrodes were chronically implanted over a period of 4 weeks into the lower thoracic and upper lumbar lamina by using an operation microscope. The action potentials were recorded at the dorsal root entry zone after stimulating the hindpaw. By comparing the data of the recording sessions we found a high reliability of the spinal cord evoked response over a long period. The experimental model is appropriate for the assessment of neurophysiological changes in the long term. Additionally we examined some basic characteristics of the evoked spinal response in this area.

[Clinical deterioration following chemonucleolysis. Sequestration or neurotoxic complication?]. / Die klinische Verschlechterung nach Chemonukleolyse. Sequester oder neurotoxische Komplikation?

The clinical deterioration in a patient after chemonucleolysis with chymopapain is described in a case report. Experiments were carried out, to receive a proper understanding of possible diagnostic and therapeutic approaches. The paper discusses the pathophysiology of these complications from the view-points of morphology and function. In the important early differential diagnosis between sequestration and neurotoxic complication, magnetic resonance tomography and possibly also spinally evoked nerve potentials play an important role. If a sequester has formed, immediate surgery is imperative, whereas in neurotoxic complication high dosage level cortisone treatment must be performed.

[Pain and the spine. A review. 1. On the pathophysiology of radicular pain syndromes. Current concepts explaining pain in nerve entrapment syndromes]. / Schmerz und Wirbelsäule. Ubersichtsarbeit--Teil 1--Zur Pathophysiologie radikulärer Schmerzsyndrome. Aktuelle Konzepte zur Erklärung der Schmerzen bei Nervenentrapmentsyndromen.

The problems of nociception and the development of pain in radicular syndromes of the spine may be summarized as follows: 1. The anatomic complex nerve root/dorsal ganglion is a key structure in the pain physiology of disk prolapse and spinal stenosis. 2. Chronic compression of nerve tissue causes structural changes. 3. These structural changes are associated with a change in the electrical properties of the nerve root membrane. 4. The change in membrane properties in the nociceptive pathways of nerve roots is one of the preconditions for perception of pain. As the authors' remark indicate, a better understanding of the pathophysiology of pain will lead to a more differentiated therapeutic approach.