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      Effects of intensity of electroacupuncture on chronic pain in patients with knee osteoarthritis: a randomized controlled trial

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          Abstract

          Background

          Conditioned pain modulation (CPM) is impaired in people with chronic pain such as knee osteoarthritis (KOA). The purpose of this randomized, controlled clinical trial was to investigate whether strong electroacupuncture (EA) was more effective on chronic pain by strengthening the CPM function than weak EA or sham EA in patients with KOA.

          Methods

          In this multicenter, three-arm parallel, single-blind randomized controlled trial, 301 patients with KOA were randomly assigned. Patients were randomized into three groups based on EA current intensity: strong EA (> 2 mA), weak EA (< 0.5 mA), and sham EA (non-acupoint). Treatments consisted of five sessions per week, for 2 weeks. Primary outcome measures were visual analog scale (VAS), CPM function, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

          Results

          Three hundred one patients with KOA were randomly assigned, among which 271 (90.0%) completed the study (mean age 63.93 years old). One week of EA had a clinically important improvement in VAS and WOMAC but not in CPM function. After 2 weeks treatment, EA improved VAS, CPM, and WOMAC compared with baseline. Compared with sham EA, weak EA (3.8; 95% CI 3.45, 4.15; P < .01) and strong EA (13.54; 95% CI 13.23, 13.85; P < .01) were better in improving CPM function. Compared with weak EA, strong EA was better in enhancing CPM function (9.73; 95% CI 9.44, 10.02; P < .01), as well as in reducing VAS and total WOMAC score.

          Conclusion

          EA should be administered for at least 2 weeks to exert a clinically important effect on improving CPM function of KOA patients. Strong EA is better than weak or sham EA in alleviating pain intensity and inhibiting chronic pain.

          Trial registration

          This study was registered with the Chinese Clinical Trial Registry ( ChiCTR-ICR-14005411), registered on 31 October 2014.

          Electronic supplementary material

          The online version of this article (10.1186/s13075-019-1899-6) contains supplementary material, which is available to authorized users.

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          Most cited references33

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          The short-form McGill Pain Questionnaire.

          Ronald Melzack (1987)
          A short form of the McGill Pain Questionnaire (SF-MPQ) has been developed. The main component of the SF-MPQ consists of 15 descriptors (11 sensory; 4 affective) which are rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate or 3 = severe. Three pain scores are derived from the sum of the intensity rank values of the words chosen for sensory, affective and total descriptors. The SF-MPQ also includes the Present Pain Intensity (PPI) index of the standard MPQ and a visual analogue scale (VAS). The SF-MPQ scores obtained from patients in post-surgical and obstetrical wards and physiotherapy and dental departments were compared to the scores obtained with the standard MPQ. The correlations were consistently high and significant. The SF-MPQ was also shown to be sufficiently sensitive to demonstrate differences due to treatment at statistical levels comparable to those obtained with the standard form. The SF-MPQ shows promise as a useful tool in situations in which the standard MPQ takes too long to administer, yet qualitative information is desired and the PPI and VAS are inadequate.
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            Diffuse noxious inhibitory controls (DNIC). I. Effects on dorsal horn convergent neurones in the rat.

            Daniel Le Bars, Anthony H. Dickenson, Jean-Marie Besson (1979)
            (1) Sixty-eight convergent dorsal horn neurones have been recorded at the lumbar level in anaesthetized intact rats. All cells received prominent A alpha and C fibre afferents and correspondingly could be activated by high and low threshold stimuli applied to the peripheral excitatory receptive field. (2) The activity of 67/68 of these neurones was powerfully inhibited by noxious stimuli applied to various parts of the body. Since non-noxious stimuli were ineffective in this respect, the term "diffuse noxious inhibitory controls" (DNIC) is proposed. (3) DNIC could be evoked by noxious pinch applied to the tail, the contralateral hind paw, the forepaws, the ears and the muzzle; the most effective areas were the tail and muzzle. Noxious heat applied to and transcutaneous electrical stimulation of the tail were extemely effective in eliciting DNIC as was the intraperitoneal injection of bradykinin. (4) DNIC strongly depressed by 60-100% both the C fibre response following suprathreshold transcutaneous electrical stimulation and the responses to noxious radiant heat. (5) The spontaneous activity and the responses to low threshold afferents induced either by A alpha threshold electrical or natural stimulation were also powerfully inhibited. (6) In the majority of cases, long lasting post-effects directly related to the duration of conditioning painful stimulus were observed.
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              Prediction of chronic post-operative pain: pre-operative DNIC testing identifies patients at risk.

              David Yarnitsky, Yonathan Crispel, Elon Eisenberg … (2008)
              Surgical and medical procedures, mainly those associated with nerve injuries, may lead to chronic persistent pain. Currently, one cannot predict which patients undergoing such procedures are 'at risk' to develop chronic pain. We hypothesized that the endogenous analgesia system is key to determining the pattern of handling noxious events, and therefore testing diffuse noxious inhibitory control (DNIC) will predict susceptibility to develop chronic post-thoracotomy pain (CPTP). Pre-operative psychophysical tests, including DNIC assessment (pain reduction during exposure to another noxious stimulus at remote body area), were conducted in 62 patients, who were followed 29.0+/-16.9 weeks after thoracotomy. Logistic regression revealed that pre-operatively assessed DNIC efficiency and acute post-operative pain intensity were two independent predictors for CPTP. Efficient DNIC predicted lower risk of CPTP, with OR 0.52 (0.33-0.77 95% CI, p=0.0024), i.e., a 10-point numerical pain scale (NPS) reduction halves the chance to develop chronic pain. Higher acute pain intensity indicated OR of 1.80 (1.28-2.77, p=0.0024) predicting nearly a double chance to develop chronic pain for each 10-point increase. The other psychophysical measures, pain thresholds and supra-threshold pain magnitudes, did not predict CPTP. For prediction of acute post-operative pain intensity, DNIC efficiency was not found significant. Effectiveness of the endogenous analgesia system obtained at a pain-free state, therefore, seems to reflect the individual's ability to tackle noxious events, identifying patients 'at risk' to develop post-intervention chronic pain. Applying this diagnostic approach before procedures that might generate pain may allow individually tailored pain prevention and management, which may substantially reduce suffering.
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                Author and article information

                Contributors
                Zheng-tao Lv: 630105736@qq.com
                Lin-lin Shen: 434454364@qq.com
                Bing Zhu: zhubing@mail.cintcm.ac.cn
                Zhao-qing Zhang: 2568584089@qq.com
                Chao-yang Ma: 376592187@qq.com
                Guo-fu Huang: hgfmkp@aliyun.com
                Jing Yin: 37590328@qq.com
                Ling-ling Yu: 527679774@qq.com
                Si-yi Yu: 546015526@qq.com
                Ming-qiao Ding: dingmingqiao@126.com
                Jing Li: lijingaza@gmai.com
                Xiao-cui Yuan: 876702537@qq.com
                Wei He: 2233058@qq.com
                Xiang-hong Jing: jxhtjb@263.net
                Man Li:
                ORCID: http://orcid.org/0000-0003-4041-0437
                liman73@mails.tjmu.edu.cn
                Journal
                Journal ID (nlm-ta): Arthritis Res Ther
                Journal ID (iso-abbrev): Arthritis Res. Ther
                Title: Arthritis Research & Therapy
                Publisher: BioMed Central (London )
                ISSN (Print): 1478-6354
                ISSN (Electronic): 1478-6362
                Publication date (Electronic): 14 May 2019
                Publication date PMC-release: 14 May 2019
                Publication date (Print): 2019
                Volume: 21
                Electronic Location Identifier: 120
                Affiliations
                [1 ]ISNI 0000 0004 0368 7223, GRID grid.33199.31, Department of Neurobiology, School of Basic Medicine, , Tongji Medical College of Huazhong University of Science and Technology, ; Wuhan, 430030 China
                [2 ]ISNI 0000 0004 1799 5032, GRID grid.412793.a, Department of Orthopedics, , Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, ; Wuhan, 430030 China
                [3 ]ISNI 0000 0004 0368 7223, GRID grid.33199.31, Combined Traditional Chinese and Western Medicine Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, ; Wuhan, 430030 China
                [4 ]ISNI 0000 0004 0632 3409, GRID grid.410318.f, Institute of Acupuncture and Moxibustion, , China Academy of Chinese Medical Sciences, ; Beijing, 100700 China
                [5 ]The Third Hospital of Wuhan, Wuhan, 430060 China
                [6 ]GRID grid.440160.7, Central Hospital of Wuhan, ; Wuhan, 430014 China
                [7 ]ISNI 0000 0001 0376 205X, GRID grid.411304.3, School of Acupuncture and Moxibustion, , Chengdu University of Traditional Chinese Medicine, ; Chengdu, 610075 China
                [8 ]GRID grid.452862.f, The Fifth Hospital of Wuhan, ; Wuhan, 430050 China
                [9 ]ISNI 0000 0004 0368 7223, GRID grid.33199.31, Union Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, ; Wuhan, 430022 China
                Author information
                http://orcid.org/0000-0003-4041-0437
                Article
                Publisher ID: 1899
                DOI: 10.1186/s13075-019-1899-6
                PMC ID: 6518678
                PubMed ID: 31088511
                SO-VID: 1cd4a983-fd91-47f1-8599-75d0ffb317bd
                Copyright © © The Author(s). 2019
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 16 July 2018
                Date accepted : 17 April 2019
                Funding
                Funded by: National Natural Science Foundation of China
                Award ID: 81473768
                Award Recipient :
                Funded by: Fundamental Research Funds for the Central Public Welfare Research Institutes
                Award ID: ZZKF08007
                Award Recipient :
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2019

                ScienceOpen disciplines: Orthopedics
                Keywords: electroacupuncture,knee osteoarthritis,diffuse noxious inhibitory control,randomized controlled trial,pain
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: electroacupuncture, knee osteoarthritis, diffuse noxious inhibitory control, randomized controlled trial, pain

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