Sex differences in comorbidities associated with Sjögren's disease.

Background: Little is known about the association of comorbidities with sex and age at diagnosis in Sjögren's disease. We tested the hypothesis that sex differences occur in comorbidities in patients with Sjögren's disease. Methods: Patients with Sjögren's disease were identified from 11/1974 to 7/2018 in the Mayo Clinic electronic medical record and assessed for 22 comorbidities according to sex and age at diagnosis. Results: Of the 13,849 patients identified with Sjögren's disease, 11,969 (86%) were women and 1,880 (14%) men, primarily white (88%) with a sex ratio of 6.4:1 women to men. The mean age at diagnosis was 57 years for women and 59.7 years for men, and 5.6% had a diagnosis of fibromyalgia at Sjögren's diagnosis. Men with Sjögren's disease were more likely than women to be a current or past smoker. The average time to diagnosis of comorbidities after diagnosis of Sjögren's disease was 2.6 years. The top comorbidities in patients with Sjögren's disease were fibromyalgia (25%), depression (21.2%) and pain (16.4%). Comorbidities that occurred more often in women were hypermobile syndromes (31:1), CREST (29:1), migraine (23:1), Ehlers-Danlos syndrome (EDS) (22:1), Raynaud's syndrome (15:1), SLE (13:1), systemic sclerosis (SSc) (13:1), and fibromyalgia (12:1). Women with Sjögren's disease were at increased risk of developing hypermobile syndromes (RR 7.27, CI 1.00-52.71, p = 0.05), EDS (RR 4.43, CI 1.08-18.14, p = 0.039), CREST (RR 4.24, CI 1.56-11.50, p = 0.005), migraine (RR 3.67, CI 2.39-5.62, p < 0.001), fibromyalgia (RR 2.26, CI 1.92-2.66, p < 0.001), Raynaud's syndrome (RR 2.29, CI 1.77-2.96, p < 0.001), SLE (RR 2.13, CI 1.64-2.76, p < 0.001), and SSc (RR 2.05 CI 1.44-2.92; p < 0.001). In contrast, men with Sjögren's were at increased risk for developing myocardial infarction (RR 0.44, CI 0.35-0.55, p < 0.001), atherosclerosis/CAD (RR 0.44, CI 0.39-0.49, p < 0.001), cardiomyopathy (RR 0.63, CI 0.46-0.86, p = 0.003), stroke (RR 0.66 CI 0.51-0.85, p = 0.001), and congestive heart failure (RR 0.70, CI 0.57-0.85, p < 0.001). Conclusions: The top comorbidities in Sjögren's disease were fibromyalgia, depression, and pain. Women with Sjögren's disease had a higher relative risk of developing fibromyalgia, depression, pain, migraine, hypermobile syndrome, EDS and other rheumatic autoimmune diseases. Men with Sjögren's disease had higher risk of developing cardiovascular diseases.

Pilot Study: Physical Examination Evidence of Acupuncture Principal Meridian Coupling.

Objective: This pilot study of acupuncture primary channel coupling examined the effect of anterior tibialis (AT) muscle activation (Stomach = ST channel distribution muscle) on ipsilateral anterior deltoid shoulder elevation strength (Large Intestine = LI channel distribution muscle). Design: Pilot study: prospective before and after trial, nonblinded. Materials and Methods: Twenty healthy adults ages 20-60 years without shoulder pathology were recruited from our institution. All subjects consented with the IRB-approved minimal risk protocol for this study. Average shoulder elevation break strength (kg) with arm elevated 90° from side was measured by dynamometer over 3 trials for each of 4 conditions: standing (baseline), standing with ipsilateral AT activation, seated with legs dangling ipsilateral AT activation, and seated with legs dangling ipsilateral gastrocsoleus (GS) activation. The main outcome measures were percentage decrement in shoulder elevation strength in AT and GS conditions compared with baseline. Paired t-test with a statistical significance alpha level of 0.05 was used for all statistical analyses. Results: A statistically and clinically significant 9.5%-12.5% (P < 0.001) decrease in shoulder elevation strength was found with ipsilateral AT activation whether in the standing or seated position. Reciprocal inhibition of the AT muscle through GS activation in the seated position produced markedly smaller 3%-4% decreases in shoulder elevation strength from baseline. Conclusions: This study provides quantitative physical examination evidence of LI-ST channel coupling, demonstrating a statistically (P < 0.001) and clinically significant decrement in shoulder elevation strength (9.5%-12.5%) with ipsilateral AT activation. These findings support the acupuncture concept of primary channel coupling, with results suggesting a neural basis for these results rather than from a fascial signaling mechanism.

The Safety of Laser Acupuncture: A Systematic Review.

Objective: Laser acupuncture has become increasingly attractive in clinical practice, especially for patients with needle phobias well as elderly people and children. However, literature concerning the safety of laser acupuncture has been limited. This systematic review synthesizes the current available literature on the safety of laser acupuncture. Methods: Ovid MEDLINE,® Epub Ahead of Print, In-Process & Other Non-Indexed Citations Daily, Ovid Embase, Scopus, and EBM Reviews-Cochrane Central Register of Controlled Trials databases were searched for available randomized controlled trials (RCTs) on laser acupuncture. Safety data were extracted from the included studies. Adverse events (AEs) data were extracted and assessed in terms of severity and causality. Results: Of 737 articles, 21 RCTs were included. The majority of these RCTs reported that laser acupuncture was safe, without AEs; 6 trials reported AEs (including tingling, pain flare-ups, and transient fatigue). All AEs were mild and resolved spontaneously within 24 hours. The causal relationship between AEs and laser acupuncture was felt to be "certain" in 4 studies, "probable" in 1 study, and "possible" in 1 study. AEs were collected and monitored by evaluation methods in 7 trials: 5 with AE questionnaires, 1 with a checklist, and 1 with oral reports. Conclusions: Laser acupuncture appears to be a safe therapy associated with few mild and transient AEs. However, given the heterogeneity of current studies, large, well-designed placebo-controlled RCTs with rigorous evaluation methods are needed to assess the safety of laser acupuncture more completely.

Laser Acupuncture: A Concise Review.

Background: Laser acupuncture (LA)-the use of nonthermal, low-intensity laser irradiation to stimulate acupuncture points-has become more common among acupuncture practitioners in recent years. LA is promoted as a safer pain-free alternative to traditional acupuncture, with minimal adverse effects and greater versatility. However, little is known about the mechanism of action of LA, laser characteristics, and effectiveness of LA therapy. Objective: This concise review of LA describes basic parameters and procedures, potential mechanisms of action, and the current evidence for its clinical efficacy. The article also highlights the need for more robust research on LA that can be translated into evidence-based clinical practices. Conclusions: LA has many features that make it an attractive option as a treatment modality, including minimal sensation; short duration of treatment; and minimal risks of infection, trauma, and bleeding complications. Future studies with high-quality methodologies, ample sample sizes, and consistent and reproducible laser parameters are critically needed to increase understanding and establish potential future clinical applications.

Neuroembryology of the Acupuncture Principal Meridians: Part 3. The Head and Neck.

Background: Accumulating evidence from anatomical, physiologic, and neuroimaging research shows that Classical acupuncture points stimulate nerve trunks or their branches in the head, trunk, and extremities. The first part of this series revealed that phenomenon in the extremities. Principal meridian distributions mirror those of major peripheral nerves there and Classical acupuncture points are proximate to peripheral nerves there. These relationships were shown to be consistent with the linear neuroembryologic development of the extremities. The second part of this series revealed that, in the trunk, a neuroanatomical basis for the Principal meridians exists consistent with lateral folding in early fetal neuroembryologic development. Objective: The aim of this Part is to provide anatomical data that corroborates a neuroanatomical basis for the Principal meridians in the head and neck, which is consistent with the longitudinal and lateral folding that occurs in early fetal neuroembryologic development. Methods: Adobe Photoshop software was used to apply Classical acupuncture points and Principal meridians as layers superimposed on neuroanatomic images of the head and neck, allowing demonstration of their anatomical relationships. Results: The Principal meridian distributions in the head and region can be conceptualized as connecting branches of the cranial and/or cervical spinal nerves. Conclusions: Anatomical data support the conceptualization of acupuncture Principal meridians in the head and neck as connecting branches of the cranial and/or cervical spinal nerves and are consistent with neuroembryologic development. Overall, the acupuncture Principal meridians can be conceptualized to have a neuroanatomical substrate that is corroborated by developmental neuroembryology.

Neuroanatomic and clinical correspondences: acupuncture and vagus nerve stimulation.

BACKGROUND: The use of surgically implanted electronic devices for vagus nerve stimulation (VNS) is expanding in contemporary allopathic medical practice as a treatment option for selected clinical conditions, such as epilepsy, depression, tremor, and pain conditions, that are unresponsive to standard pharmacologic interventions. Although VNS device surgeries are considered minimally invasive, they are costly and have surgical and device-related risks; they can also cause serious adverse effects from excessive vagus nerve stimulation. OBJECTIVES: For millennia, acupuncturists have treated those same clinical conditions by piquering acupoints that are located proximate to the sternocleidomastoid muscle site where the VNS device is implanted on the vagus nerve. The hypothesis of this study is that these acupuncture points produce clinical benefits through stimulation of the vagus nerve and/or its branches in the head and neck region. METHODS: By using reference anatomic and acupuncture texts, classical and extraordinary acupoints in the head and neck region were identified that are anatomically proximate to vagus nerve pathways there, where the VNS electrode is surgically implanted. The clinical indications of these acupuncture points, as described in the acupuncture reference texts, were examined for similarities to those of VNS. RESULTS: This analysis demonstrated marked correspondences of the indications for those lateral head and neck acupoints to the clinical effects (beneficial and adverse) documented for the VNS device in the medical literature. This clinical correspondence, in conjunction with the anatomic proximity of the acupoints to the vagus nerve in the lateral neck, strongly suggests that vagus nerve (and hence the autonomic nervous system) stimulation is fundamental in producing the clinical effects of the acupoints. CONCLUSION: By having anatomic access to the vagus nerve and parasympathetic chain that permits electrical stimulation of those nerves in clinical practice, acupuncture may offer a less costly and safer alternative to implanted VNS devices for treating medically refractory epilepsy, tremor, depression, and pain conditions.

Invited commentary on central hypersensitivity in patients with subacromial impingement syndrome.

Pain pressure threshold (PPT) measurement by handheld algometer has been validated as a tool to identify and quantitate myofascial pain sites in an individual. The average of 3 readings at a given muscle site is used, so the standard error of measurement of these devices must be considered when determining whether PPT differences between muscle sites represent true changes. This commentary discusses this issue.

Neurogenic bladder.

Congenital anomalies such as meningomyelocele and diseases/damage of the central, peripheral, or autonomic nervous systems may produce neurogenic bladder dysfunction, which untreated can result in progressive renal damage, adverse physical effects including decubiti and urinary tract infections, and psychological and social sequelae related to urinary incontinence. A comprehensive bladder-retraining program that incorporates appropriate education, training, medication, and surgical interventions can mitigate the adverse consequences of neurogenic bladder dysfunction and improve both quantity and quality of life. The goals of bladder retraining for neurogenic bladder dysfunction are prevention of urinary incontinence, urinary tract infections, detrusor overdistension, and progressive upper urinary tract damage due to chronic, excessive detrusor pressures. Understanding the physiology and pathophysiology of micturition is essential to select appropriate pharmacologic and surgical interventions to achieve these goals. Future perspectives on potential pharmacological, surgical, and regenerative medicine options for treating neurogenic bladder dysfunction are also presented.

Acupuncture's Effects in Treating the Sequelae of Acute and Chronic Spinal Cord Injuries: A Review of Allopathic and Traditional Chinese Medicine Literature.

Each year, there are an estimated 12 000 individuals who sustain a spinal cord injury (SCI) in the United States. Improved understanding of the pathophysiology of SCI and its sequelae has over the past 50 years led to the development of medical treatments (especially urologic) that have enhanced short- and long-term survival from these injuries. The prevalence of individuals with SCI in this country is ~250 000 individuals; and beyond the incalculable personal consequences of these devastating neurologic injuries, substantial direct and indirect societal costs result from the sequelae of SCI including paralysis, sensory loss, chronic pain, decubiti and bladder and/or bowel incontinence. The purpose of this treatise is to review the allopathic and traditional Chinese medicine (TCM) literature available through MEDLINE, PubMed and eCAM search engines that discuss the potential uses of acupuncture to treat acute and chronic spinal cord injuries and their sequelae, and present the neurophysiologic mechanisms for acupuncture's beneficial effects. There is evidence that use of electroacupuncture in acute SCI may significantly improve long-term neurologic recovery from these injuries both in terms of motor, sensory and bowel/bladder function with essentially no risk. Acupuncture may even improve neurourologic function in individuals with chronic SCI, and help with management with chronic pain associated with these injuries.

The languages of healing: linked by a common thread.

Though separated by different millennia, languages, levels of scientific advancement, and views of human physiology, both prehistoric and modern cultures have expressed concepts of evaluating and treating human illness that have remarkable overlap with those of Traditional Chinese Medicine (TCM). These similarities suggest these healing traditions likely are expressing a common, fundamental aspect of human anatomy and/or physiology. Prehistoric, ancient Egyptian, TCM, Mayan, myofascial pain, and myofascial meridian concepts of health and healing are discussed. Anatomical, clinical, and physiologic evidence is presented that suggests neuroanatomy is likely the common thread that unites these ancient and modern healing concepts. These findings should lead to an increased understanding of the anatomical and physiologic substrates of the beneficial clinical effects of acupuncture in treating pain and visceral disorders. This, in turn, should lead to novel, safer treatment techniques that combine modern technologies with ancient clinical acumen.

Invited commentary on "Discrimination of real and sham acupuncture needles using the park sham device: a preliminary study".

Peter T. Dorsher, MS, MD, provides an interesting commentary on the findings of a study by Tan and colleagues that was highlighted in the December issue of the Archives as displaying potential deficiencies in a number of sham acupuncture devices. Dr. Dorsher's comments, while focused on acupuncture, are interesting in their own right. However, a little thought shows that his insights into the nature of an adequate placebo provide an improved understanding of the issues involved in the design and validation of control interventions in general.

Myofascial referred-pain data provide physiologic evidence of acupuncture meridians.

UNLABELLED: Recently published data suggest substantial anatomic, clinical, and physiologic (referred pain to meridian) overlap of myofascial trigger points and acupuncture points, particularly in the treatment of pain disorders. This qualitative study examines whether myofascial referred-pain data from the Trigger Point Manual can provide independent physiologic evidence of acupuncture meridians. Trigger point regions were subdivided from prior, validated trigger point region-classical acupuncture point correspondence results into subsets according to the 12 acupuncture Organs of their anatomically corresponding acupuncture points (Bladder, Gallbladder, Heart, Kidney, Large Intestine, Liver, Lung, Pericardium, Small Intestine, Spleen, Stomach, and Triple Energizer). The referred-pain patterns for each subset of trigger point regions were graphically applied to a virtual human model along with the subset's corresponding acupuncture Principal meridian. All 12 meridian distributions were compared qualitatively with the summed referred-pain distributions of their anatomically corresponding trigger point regions. For all 12 subsets of trigger point regions, their summed referred-pain patterns accurately predicted the distributions of their corresponding acupuncture meridians, particularly in the extremities. The myofascial referred-pain data from the Trigger Point Manual provides independent physiologic evidence of acupuncture meridians. Understanding these meridians may enhance treatment of both pain and non-pain conditions. PERSPECTIVE: This article demonstrates that myofascial referred-pain data provide independent physiologic evidence of acupuncture meridians. The acupuncture tradition provides pain practitioners with millennia of accumulated clinical experience treating pain (and visceral) disorders and offers the potential for novel pain treatment approaches and understanding of pain neurophysiology.

The 2001 STRICTA recommendations for reporting acupuncture research: a review with implications for improving controlled clinical trial design.

BACKGROUND: The Consolidated Standards of Reporting Trials (CONSORT) guidelines were developed in 1996 by researchers and journal editors to improve the quality of reporting of biomedical research by providing a standardized format for researchers to present information on randomized controlled clinical trials (RCTs). This improved data reporting allows readers to independently assess the quality and conclusions of these studies, and has been widely incorporated in contemporary research reports. In 2001, a supplemental set of criteria that specifically address the reporting of design and implementation issues for RCTs involving the use of acupuncture was introduced, termed the STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) recommendations.The CONSORT guidelines are stated to be part of a broader effort to improve the quality of research, as they can be used by researchers to optimize the design of future trials. Similarly, the STRICTA recommendations outline research reporting standards that are and should be considered when designing controlled clinical trials that involve the use of acupuncture. The CONSORT and STRICTA recommendations thus not only serve to improve research reporting, but also serve to provide guidance for optimizing the designs of future clinical trials. OBJECTIVES: This paper presents a review of the STRICTA recommendations for reporting the results of controlled trials utilizing acupuncture, discusses their potential limitations, and offers suggestions for additions/enhancements to those standards based on research issued subsequent to the issuance of the STRICTA recommendations in 2001.

Subcutaneous trigger point causing radiating postsurgical pain.

BACKGROUND: The immediate onset of severe postoperative pain, especially pain radiating distant from the incision site, is uncommon after dermatologic surgery. OBSERVATION: A 37-year-old woman undergoing excision of a nevus from the left side of her midback had an exquisitely tender spot along the incision lines. This tender spot was hard to anesthetize and was clinically visible, after excision of the nevus, as a fibrous bundle in the subcutaneous plane. She presented in the immediate postoperative period with referred (distant) pain extending down the ipsilateral arm that was caused by a thoracic subcutaneous trigger point. CONCLUSION: Surgeons and pain management specialists should be aware of this potential cause of immediate postoperative pain to prevent unnecessary medical or surgical interventions in the postoperative period.

Can classical acupuncture points and trigger points be compared in the treatment of pain disorders? Birch's analysis revisited.

BACKGROUND: A 1977 study by Melzack et al. reported 100% anatomic and 71% clinical pain correspondences of myofascial trigger points and classical acupuncture points in the treatment of pain disorders. A reanalysis of this study's data using different acupuncture resources by Birch a quarter century later concluded that correlating trigger points to classical acupuncture points was not conceptually possible and that the only class of acupuncture points that could were the a shi points. Moreover, Birch concluded that no more than 40% of the acupuncture points examined by Melzack et al. correlated clinically for the treatment of pain (correlation was more like 18%-19%). OBJECTIVE: To examine Birch's claims that myofascial trigger points cannot conceptually be compared to classical acupuncture points and that most (at least 60%) of the classical acupuncture points examined by the study of Melzack et al. are not recommended for treating pain conditions, negating their findings of a 71% clinical pain correspondence of trigger points and acupuncture points. METHODS: Acupuncture references and literature were reviewed to examine the validity of the Birch study findings. RESULTS: Acupuncture references support the conceptual comparison of trigger points to classical acupuncture points in the treatment of pain disorders, and their clinical correspondence in this regard is likely 95% or higher. CONCLUSIONS: Although separated by 2000 years temporally, the acupuncture and myofascial pain traditions have fundamental clinical similarities in the treatment of pain disorders. Myofascial pain data and research may help elucidate the mechanisms of acupuncture's effects.