Stimulation of Lactation Using Acupuncture: A Case Study.

INTRODUCTION: Breastfeeding is a recognized preferred method of infant feeding; however, for many women, difficulties in breastfeeding result in termination before the recommended period of time. Acupuncture is suggested to be a promising option to treat lactation insufficiency and enhance the production of maternal milk. MAIN ISSUE: We have reported the case of a woman with lactation insufficiency due to Caesarean section and congenital unilateral invaginated nipple. Milk production started on the 3rd day following delivery. The newborn was not provided with any food or fluids other than mother's milk. At 5 days of life, the newborn required long feeding periods and lost 4% of his birth weight, with the participant reporting lactation insufficiency described by the perception of inadequate milk production. MANAGEMENT: Despite the implementation of conventional measures to improve lactation, the difficulties in breastfeeding persisted. Acupuncture was tried on Day 6 of life, and enhanced milk production was observed, which could be measured as the volume of residual milk extracted using the breast pump each time after the newborn achieved satiety. After acupuncture treatment there was an augmentation of maternal milk production from both breasts and successful lactation. CONCLUSION: This case study provides information that might be useful for prospective investigation of acupuncture's efficacy in women with lactation insufficiency.

Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial.

IMPORTANCE: A pharmacological approach to pain control after cesarean delivery is often insufficient on its own. Acupuncture is a promising method for mitigating postoperative pain and reducing postoperative opioid requirements. OBJECTIVE: To evaluate the efficacy and effectiveness of acupuncture as an adjunctive therapy for pain control after cesarean delivery, compared with a placebo intervention and standard care alone. DESIGN, SETTING, AND PARTICIPANTS: This single-center, placebo-controlled, patient- and assessor-blinded randomized clinical trial was conducted from January 13, 2015, to June 27, 2018, at a tertiary university hospital in Greifswald, Germany. Participants were women who were scheduled for elective cesarean delivery under spinal anesthesia and were randomized to either the acupuncture group (n = 60) or placebo group (n = 60). Another 60 consecutive patients who met the eligibility criteria and received the standard postoperative analgesia were selected to form a nonrandomized standard care group. The intention-to-treat analysis was performed from August 19, 2019, to September 13, 2019. INTERVENTIONS: In addition to standard pain treatment, each patient in the acupuncture group received auricular and body acupuncture with indwelling intradermal needles, whereas patients in the placebo group were treated with nonpenetrating placebo needles. MAIN OUTCOMES AND MEASURES: The primary outcome was pain intensity on movement, which was measured using an 11-item verbal rating scale. Secondary outcomes were analgesia-related adverse effects, analgesics consumption, time to mobilization and Foley catheter removal, quality of patient blinding to randomization, and patient satisfaction with treatment of pain. RESULTS: A total of 180 female patients (mean [SD] age, 31 [5] years) were included in the intention-to-treat analysis. The mean pain intensity on movement in the acupuncture group on the first postoperative day was lower than in the placebo group (4.7 [1.8] vs 6.0 [2.0] points; Cohen d, 0.73; 95% CI, 0.31-1.01; P = .001) and the standard care group (6.3 [1.3] points; Cohen d, 1.01; 95% CI, 0.63-1.40; P < .001). On the first postoperative day, 59 patients (98%) in the acupuncture group were fully mobilized vs 49 patients (83%) in the placebo group (relative risk [RR], 1.18; 95% CI, 1.06-1.33; P = .01) and 35 patients (58%) in the standard care group (RR, 1.69; 95% CI, 1.36-2.09; P < .001). The Foley catheter was removed in a total of 57 patients (93%) from the acupuncture group vs 43 patients (72%) from the placebo group (RR, 1.33; 95% CI, 1.12-1.57; P = .003) and 42 patients (70%) from the standard care group (RR, 1.37; 95% CI, 1.14-1.62; P = .002). Other parameters were comparable across the 3 study groups. CONCLUSIONS AND RELEVANCE: Results of this trial showed that acupuncture was safe and effective in reducing pain and accelerating mobilization of patients after cesarean delivery. With consideration for personnel and time expenditures, acupuncture can be recommended as routine, supplemental therapy for pain control in patients after elective cesarean delivery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02364167.

Pain perception during injection of local anesthesia in pedodontics.

OBJECTIVE: Few studies have examined pain levels for the injection of local anesthesia in children, though it is a routine technique in pediatric dentistry. The objective of the study was to evaluate the difference in the assessment of procedural pain by the child, parent, dental practitioner, and independent observers during injection of local anesthesia for dental treatment in pediatric dentistry. METHOD AND MATERIALS: In total, 27 male and 22 female children (5 to 17 years of age, mean ± SD 9.8 ± 4.0 years) received local anesthesia (LA) via infiltration or mandibular alveolar blocks according to a standard protocol. After the dental treatment, the children assessed the pain levels for the procedures on a visual analog scale (VAS), while their parents and the dental practitioner used a numeric rating scale (0 to 10). Independent observers also assessed pain via video tape for an evaluation after blinding. The heart rate was monitored continuously during the procedure. The Bland-Altman method was used to quantify the comparison between pain ratings. RESULTS: The assessed level of pain by dental practitioner, parent, and child during injection of LA differed clearly (child: 3.94 ± 2.71; parent: 3.31 ± 2.60; dental practitioner: 3.02 ± 1.98; video observer 1: 1.76 ± 2.56; video observer 2: 1.89 ± 2.55). In 42.9% of cases the dental practitioner's rating and the self--reported pain by the child during injection of LA differed by ≥ 2 on the numeric rating scale, which is clinically a highly different and relevant assessment. CONCLUSION: As pain perception in children during the injection of local anesthetic and its assessment varies considerably depending on the assessing person and the treated child, dental practitioners and researchers should be cautious in interpreting the patient's pain perception.

Auricular Acupuncture for Preoperative Anxiety-Protocol of Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: Preoperative anxiety causes profound psychological and physiological reactions that may lead to a worse postoperative recovery, higher intensity of acute and persistent postsurgical pain and impaired quality of life in the postoperative period. Previous randomized controlled trials (RCTs) suggest that auricular acupuncture (AA) is safe and effective in the treatment of preoperative anxiety; however there is a lack of systematic evidence on this topic. Therefore, this protocol was developed following the PRISMA guidelines to adequately evaluate the existing literature regarding the value of AA for the reduction in anxiety in patients in a preoperative setting, compared to other forms of acupuncture, pharmacological, or no control interventions and measured with questionnaires regarding anxiety and fear. Methods: The following databases will be searched: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, and Scopus Database. RCTs will be included if an abstract is available in English. Data collection and analysis will be conducted by two reviewers independently. Quality and risk assessment of included studies will be done using the Cochrane 5.1.0 handbook criteria and meta-analysis of effectiveness and symptom scores will be conducted using the statistical software RevMan V.5.3. Conclusions: This systematic review will evaluate the efficacy and safety of AA for preoperative anxiety. Since all data used in this systematic review and meta-analysis have been published, this review does not require ethical approval. The results may be published in a peer-reviewed journal or be presented in relevant conferences. Registration number: PROSPERO ID CRD42020.

Acupuncture for Relief of Gag Reflex in Patients Undergoing Transoesophageal Echocardiography-A Protocol for a Randomized Placebo-Controlled Trial.

Background: Gagging during transesophageal echocardiography examination (TEE) can be distressing and even dangerous for patients. The needling of acupuncture point CV24 was described to be effective in reducing the gag reflex during TEE in patients with ischemic stroke or transient ischemic attack. Methods: We describe a proposal for a prospective, randomized, patient, practitioner and assessor-blinded, single-center trial with two arms/groups; real acupuncture will be compared to placebo acupuncture. A total of 60 (30 per group) patients scheduled for elective TEE in order to exclude a cardiac embolic source, endocarditis or for valve failure evaluation will be recruited according to patients' selection criteria and receive either indwelling fixed intradermal needles at acupoints CV24 and bilateral PC6 or placebo needles at the same areas. Patients, the practitioners who will perform the TEE procedure, and the assessor of the outcome measures will be unaware of the group's (real or placebo) allocation. Results: The primary outcome is the intensity of gagging, measured using verbal rating scale (VRS-11) from 0 = no gagging to 10 = intolerable gagging. Secondary outcomes include the incidence of gagging, the use of rescue medication, patients' satisfaction with relief of unwanted side effects during TEE procedure, success of patients' blinding (patients' opinion to group allocation), heart rate and oxygen saturation measured by pulse oxymetry. Conclusions: To study the effects of acupuncture against gagging during TEE, we test the needling of acupoints CV24 and PC6 bilaterally. A placebo acupuncture is used for the control group. Trial registration number: NCT NCT0382142.

Auricular acupuncture for treatment of preoperative anxiety in patients scheduled for ambulatory gynaecological surgery: a prospective controlled investigation with a non-randomised arm.

OBJECTIVE: Auricular acupuncture (AA) is a promising alternative treatment for situational anxiety. The aim of this pilot investigation was to test the acceptability and feasibility of AA as a treatment for preoperative anxiety (PA) in preparation for a subsequent randomised controlled trial. METHODS: AA was offered for treatment of PA to female patients who were scheduled for ambulatory gynaecological surgery. In patients who agreed, indwelling fixed needles were applied bilaterally at the points MA-IC1, MA-TF1, MA-SC, MA-AH7 and MA-T the day before surgery. Patients who declined AA but agreed to be examined constituted the control group (no intervention). State anxiety (primary outcome) was measured using the State-Trait-Anxiety Inventory (STAI) before AA (time I), the evening before surgery (time II) and immediately before surgery (time III). Anxiety was measured with a 100 mm visual analogue scale (VAS-100); heart rate, blood pressure and serum cortisol were also quantified. RESULTS: Data from 62 patients (32 with AA and 30 with no intervention) were analysed. Whereas preoperative anxiety was reduced after AA the evening before surgery (P<0.01), anxiety levels in the control group increased from the first to the last measurement (P<0.001). Secondary outcomes were comparable between the patients from both groups. CONCLUSIONS: AA was acceptable and feasible as a treatment for preoperative anxiety. The results were used for the sample size calculation of a subsequent randomised controlled clinical trial. TRIAL REGISTRATION NUMBER: NCT02656966; Results.

Effects of Electrical Transcutaneous Vagus Nerve Stimulation on the Perceived Intensity of Repetitive Painful Heat Stimuli: A Blinded Placebo- and Sham-Controlled Randomized Crossover Investigation.

BACKGROUND: Transcutaneous vagus nerve stimulation (TVNS) is a promising treatment for acute and chronic pain. However, experimental studies yielded controversial results. We examined if TVNS reduces the perceived intensity of repetitive painful heat stimulation and temporal summation of pain (TSP) in healthy volunteers in comparison with placebo and sham stimulation, as well as no intervention. METHODS: In 4 sessions, 90 heat pulse stimuli at individual pain tolerance temperature were applied to the ventral forearm of 49 healthy volunteers (25 women) using a Contact Heat Evoked Potential Stimulator thermode (Medoc, Ramat Yishai, Israel). Pain intensity was assessed with verbal ratings on a numeric pain scale (0-100) at every tenth heat pulse. After the first session in which pain intensities without intervention were evaluated, participants completed 3 sessions in a single-blinded randomized crossover manner: (1) sham stimulation applied at the earlobes, (2) placebo stimulation (inactive device), or (3) TVNS applied at the cymbas conchae. Primary data were analyzed using analysis of variance for repeated measures and t test for paired samples. RESULTS: Pain intensity decreased during all interventions as compared to no intervention (ηp = 0.22, P < .001; mean difference TVNS versus no intervention 9.5; 95% confidence interval [CI], 3.6-15.4; P < .001). Hypoalgesic effect of TVNS was better than that of placebo and sham in men before the onset of TSP (mean differences for TVNS versus placebo 6.2; 95% CI, 0.2-12.1; TVNS versus sham 6.2; 95% CI, 0.2-12.1; P < .05). In women, TSP response under TVNS was decreased if compared to no intervention (median difference, 7.5; 95% CI, 3.5-15.0; P = .003). CONCLUSIONS: TVNS, placebo, and sham stimulation exerted comparable effects under experimental heat pain stimulation. Only in male participants, TVNS was superior to sham and placebo conditions in the reduction of heat pain before the onset of TSP.

Auricular Acupoints with Reduced Skin Resistance: Detection in Patients Scheduled for Hip Arthroplasty.

Objective: The detection of auricular acupuncture (AA) points by measuring electrical skin resistance (ESR) is often used in diagnostics and therapy; however, systematic investigations of ESR in AA points are rare. The aim of this study was to examine the frequency of detection of AA points with reduced ESR in patients scheduled for unilateral hip arthroplasty. Materials and Methods: Data were obtained from 2 prospective clinical trials, which studied the perioperative analgesic effects of AA in patients with unilateral degenerative hip osteoarthritis. Three AA points (MA-TF1, MA-AH4, and MA-IC1) were examined in these patients before arthroplasty surgery using a SVESA (Neuralstift SVESA 1070, SVESA, Muenchen, Germany) neural pen. The frequency of AA points detection on the ipsi- and contralateral sides of the affected hip joint was registered and analyzed with a χ2 test. Results: The data of 114 patients (60 females) were available for analysis. AA points with lower ESR were detected more frequently on the side ipsilateral to the affected joint rather than on the contralateral side: 81% versus 37% of patients (P < 0.0001). None of the AA points could be identified at all in 13% of patients with diabetes mellitus versus 3% of patients without diabetes mellitus (P = 0.07). Conclusions: AA points with low ESR were detected more frequently on the side ipsilateral to the underlying pathology. This finding is in agreement with neurophysiologic data. The therapeutic value of this finding should be clarified in future studies.

Acupuncture Reduces Pain and Autonomic Distress During Injection of Local Anesthetic in Children: A Pragmatic Crossover Investigation.

OBJECTIVES: Stimulation of acupoint LI4 has been shown to result in analgesic effects in patients experiencing acute pain. We aimed to study the effectiveness of LI4 stimulation for pain relief in children receiving an injection of a local anesthetic (LA). MATERIALS AND METHODS: Children scheduled for dental treatment using LA received bilateral acupuncture at LI4 using indwelling fixed needles. During the treatment, the parents of the patients stimulated the needles by massage. Two different treatment regimes were compared: a standardized LA injection given 5 minutes after acupuncture, and an LA injection without acupuncture. The order of treatment was randomized, with the 2 treatments performed in a crossover manner on different days. Pain intensity during LA injection, assessed by the patient with the Verbal Rating Scale or Faces Pain Scale (0 to 10), was used as the primary endpoint. Parent-assessed and dentist-assessed pain intensity and agitation, heart rate, and the patients' satisfaction with the therapy were also recorded. RESULTS: Data were obtained from 49 patients (22 female; mean age 10 y). Patients reported less pain when acupuncture was used: mean 2.3 (95% confidence interval, 1.5-3.1) versus 3.9 (95% confidence interval, 3.0-4.7); P<0.001. The patients' heart rate remained low throughout the dental treatment after LI4 stimulation, when compared with treatment without acupuncture (P<0.05). LI4 stimulation was safe and increased satisfaction levels in both the patients and their parents, when compared with LA injection alone (P<0.05). DISCUSSION: Stimulation of acupoint LI4 reduces pain and autonomic distress in children during LA injection in dental procedures.

Acupuncture for pain control after Caesarean section: a prospective observational pilot study.

OBJECTIVE: Options for pharmacological analgesia in patients who have undergone Caesarean section (CS) are often restricted. Acupuncture is a promising tool for treating postoperative pain. We aimed to study the feasibility and acceptability of acupuncture as an additional method of analgesia in CS patients in a prospective observational pilot investigation. METHODS: Twenty-two patients scheduled for elective CS under spinal anaesthesia were enrolled according to set inclusion criteria. Each patient received auricular and body acupuncture with 20 indwelling fixed needles according to previously validated protocols of acupuncture for postoperative analgesia. Pain intensity on an 11-point verbal rating scale (VRS-11, where 0=no pain and 10=maximal pain), analgesia-related side effects, time to mobilisation and Foley catheter removal after CS, and patients' compliance and satisfaction with treatment of pain on a 5-point VRS (VRS-5, where 1=excellent; 5=bad) were recorded. RESULTS: Twenty patients were included in the final analysis. One patient was disturbed by paraesthesia at the site of needling. All other patients tolerated acupuncture well. Pain intensity on movement on the first postoperative day was 4.3±2.4 (mean±SD; VRS-11) and decreased to 2.2±1.2 on the day of discharge. Patient satisfaction was 1.9±0.8 (mean±SD; VRS-5) and compliance (rated by their nurses) was 1.5±0.5 (mean±SD; VRS-5). CONCLUSIONS: Acupuncture for additional analgesia after CS was well accepted. The primary outcome measurement was feasible and allowed the sample size to be calculated for a future randomised controlled trial.

Verum and sham acupuncture exert distinct cerebral activation in pain processing areas: a crossover fMRI investigation in healthy volunteers.

Although acupuncture is effective for treating pain, its site-specificity is questioned. The aim was to compare the cerebral responses of needling applied to an acupuncture point to the needling of a sham point, using functional magnetic resonance imaging (fMRI). Twenty-one healthy male volunteers were enrolled. Manual stimulation of the acupuncture (ST44) and sham points on the dorsum of the left foot was applied during fMRI in a crossover manner. fMRI data analysis was performed contrasting the ST44 and the sham conditions. Stimulation intensity, subjective discrimination of the needling site and the incidence of "Qi" sensation were additionally recorded. Stimulation of ST44 acupoint, in comparison to the sham procedure, was associated with an increased fMRI-activation in the primary somatosensory, the inferior parietal and the prefrontal cortex and the posterior insula. Sham needling was associated with increased activation in the anterior cingulate cortex and the anterior insula. Verum acupuncture increased the activity of discriminative somatosensory and cognitive pain processing areas of the brain, whereas sham needling activated the areas responsible for affective processing of pain. This may explain favorable effects of verum acupuncture in clinical studies about treatment of chronic pain patients.

Vagal sensory evoked potentials disappear under the neuromuscular block - an experimental study.

BACKGROUND: Transcutaneous vagal nerve stimulation is a promising treatment modality in patients suffering mood disorders and chronic pain, however, the mechanisms are still to be elucidated. A recently developed technique of EEG responses to electrical stimulation of the inner side of the tragus suggests that these responses are far field potentials, generated in the vagal system - Vagal Sensory Evoked Potentials (VSEP). OBJECTIVE: To reproduce the VSEP technique free from myogenic artifacts. METHODS: Fourteen ASA I-II patients scheduled for elective surgery in standardized Total Intravenous Anesthesia (TIVA) were enrolled. Transcutaneous electrical stimulation was applied to the inner side of the right tragus. Averaged EEG responses were recorded from the electrode positions C4-F4 and T4-O2 before and after induction of TIVA, during the maximal effect of the non-depolarizing muscle relaxing agent, cis-atracurium (C-AR) and after recovery from C-AR under TIVA. RESULTS: Typical response curves with P1, N1 and P2 peaks could be reproduced in all patients before and after anesthesia induction. The response curves disappeared during the C-AR action and re-appeared after recovery from C-AR under TIVA. CONCLUSION: The disappearance of the scalp responses to electrical tragus stimulation under the neuromuscular block suggests a muscular origin of these potentials.

Acupuncture does not influence brainstem auditory evoked potentials: a volunteer crossover study.

BACKGROUND: Although acupuncture is effective for treating several conditions, its site specificity is questionable. OBJECTIVE: To investigate whether acupuncture influences the brainstem auditory evoked potentials (BAEP). METHODS: 10 healthy volunteers were enrolled according to inclusion criteria. One of four acupuncture points-TE3, GB43 (both auditory system-specific, according to traditional Chinese medicine) and non-specific acupuncture points HT7 and ST44-was needled during each session. Each volunteer received four sessions of acupuncture, with a 1-week interval between the sessions. RESULTS: Peak latencies and amplitudes of the BAEP were registered before and during each session of acupuncture. Pain intensity and the incidence of paraesthesia (Qi sensation) during acupuncture were also registered. The peak latencies and amplitudes of the BAEP registered during acupuncture had not changed from the baseline levels. Needling of acupoint HT7 was most painful and induced the maximal incidence of Qi sensation. CONCLUSIONS: Findings suggest that monitoring the BAEP is not a suitable technique for studying the immediate effects of acupuncture.

The effect of auricular acupuncture on fentanyl requirement during hip arthroplasty: a randomized controlled trial.

OBJECTIVES: Although auricular acupuncture (AA) is suggested to be effective in treatment of pain, it has not yet been used for intraoperative analgesia. Therefore, we studied whether the AA reduces intraoperative analgesic requirement during total hip arthroplasty (THA). METHODS: One hundred and twenty patients scheduled for THA were enrolled in this patient-anesthesiologist-blinded study. The patients were randomly assigned to receive needling of specific AA points or a sham procedure (needling of 3 nonacupoints on the ear helix) ipsilateral to the surgery site. Fixed indwelling AA needles were placed in the evening before THA and withdrawn on the day after surgery. The patients received general anesthesia with desflurane, which end-tidal concentration was kept within 3.5 volume % to 5.5 volume % to maintain the Bispectral Index within 40% to 55%. The anesthesiologists were asked to titrate fentanyl to keep the heart rate and blood pressure within 20% of baseline values. The primary outcome was fentanyl amount given during surgery. The secondary outcome measures were incidence of nausea and vomiting and time to first request of analgesics in the recovery room. The success of patients' and anesthesiologist blinding was also documented. RESULTS: The data of fentanyl requirement of 116 patients were available for the final analysis. Patients from AA group required 15% less fentanyl during surgery than the controls (4.6±1.1 µg/kg vs. 5.2±1.3 µg/kg; mean±SD; P=0.008). Demographic data and secondary outcome measures were comparable in both groups. DISCUSSION: Regarding the modest clinical effect, AA should be further investigated for its clinical usefulness for complementary analgesia during the surgery.

Goal-directed acupuncture in sports-placebo or doping?

The modern pentathlon (MP), sports discipline including fencing, swimming, steeplechase and a cross-country run, requires a rapid change of central nervous and peripheral neuromuscular activity from one sport to another in order to achieve the best possible results. We describe the case where a top MP athlete was supported by a program of acupoint stimulation, which was directed to relieve the symptoms, preventing him from effective performance. Although the fact of acupoint stimulation was associated with improvement of his results, other factors like training effect, placebo and nonspecific physiological effects and their mechanisms in sports are discussed in a literature review. The popularity of complementary and alternative medicine methods among the athletes raises the question of their potential misuse as a doping in competitive sports.

Acupuncture reveals no specific effect on primary auditory cortex: a functional magnetic resonance imaging study.

Although acupuncture is effective in the treatment of several clinical conditions, its specificity has been questioned. We studied the effects of needle stimulation applied to 'ear-specific' acupuncture point GB43 on activations in primary auditory cortex using functional magnetic resonance imaging in comparison with sham acupuncture. Twenty healthy volunteers participated in this cross-over investigation. Multi-subject analysis showed no significant activations in the gyrus of Heschl during stimulation of the GB43 point or a sham point. In single-subject analysis, activation within the primary auditory cortex was seen in two out of 20 volunteers. We found no evidence for specificity of acupuncture point GB43 in relation to primary auditory activation, previously suggested by two independent research groups.

Acupuncture of specific points influences cortical auditory evoked potentials--a volunteer crossover study.

Specificity of acupoints remains a crucial question in acupuncture research. The aim was to investigate whether acupuncture of specific points influences the Cortical Auditory Evoked Potentials (CAEP). Ten healthy volunteers were enrolled in this study according to inclusion criteria. One of 4 acupoints: TH3, GB43 (both claimed as specific for auditory system by Traditional Chinese Medicine) and non-specific points H7 and ST44, was stimulated during one session. Each volunteer received 4 sessions of acupuncture with an interval of 1 week between the sessions. The latencies and amplitudes of CAEP were registered before and after the acupuncture during each session. The mean peak latencies of P2 component decreased after stimulation of TH3 by 11 ms and GB43 by 14 ms whereas the peak latencies of N2 component increased after stimulation of TH3 by 9 ms and GB43 by 4 ms compared to baseline values (p<0.05). The stimulation of H7 and ST44 did not produce any changes. These findings confirm the specificity of acupuncture points TH3 and GB43 in relation to auditory system.