***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Many Japanese reports of acupuncture and moxibustion for chronic pain are not listed in medical data bases such as Medline . Therefore , they are not easily accessible to research ers outside of Japan . To complement existing review s of acupuncture and moxibustion for chronic pain and to provide more detailed discussion and analysis , we did a literature search using ‘ Igaku Chuo Zasshi We d ’ ( Japana Centra Revuo Medicina ) and ‘ Citation Information by National Institute of Information ’ covering the period 1978–2006 . Original articles and case reports of acupuncture and moxibustion treatment of chronic pain were included . Animal studies , surveys , and news articles were excluded . Two independent review ers extracted data from located articles in a pre-defined structured way , and assessed the likelihood of causality in each case . We located 57 papers written in Japanese ( 20 full papers , 37 case reports ) . Conditions examined were headache ( 12 trials ) , chronic low back pain ( 9 trials ) , rheumatoid arthritis ( 8 trials ) , temporom and ibular dysfunction ( 8 trials ) , katakori ( 8 trials ) and others ( 12 trials ) . While 23 were described as clinical control trials ( CCTs ) , 11 employed a quasi-r and om method . Applying the 5-point Jadad quality assessment scoring system , the mean score was 1.5 ± 1.3 ( SD ) . Eleven ( 52 % ) of the CCTs were conducted to determine a more effective procedure for acupuncture ; these compared a certain type of acupuncture with another type of acupuncture or specific additional points . In particular , the trigger point acupuncture was widely used to treat chronic low back pain in Japan . Many reports of chronic pain treatment by acupuncture and moxibustion are listed in Japanese data bases . From the data , we conclude that there is limited evidence that acupuncture is more effective than no treatment , and inconclusive evidence that trigger point acupuncture is more effective than placebo , sham acupuncture or st and ard care BACKGROUND Fibromyalgia is a chronic pain syndrome associated with sleep disorders , fatigue and psychological symptoms . Combinations therapies , such as electrotherapy and therapeutic exercises have been used in the clinical practice . AIM To assess the efficacy of high-frequency transcutaneous electrical nerve stimulation ( TENS ) as an adjuvant therapy to aerobic and stretching exercises , for the treatment of fibromyalgia . DESIGN Controlled clinical trial . SETTING Unit of rehabilitation of a public hospital . POPULATION Twenty-eight women aged 52.4±7.5 years , with fibromyalgia . METHODS A visual analogue scale measured pain intensity ; tender points pain threshold , by dolorimetry ; and quality of life , by the Fibromyalgia Impact Question naire . All subjects participated in an eight-week program consisting of aerobic exercises , followed by static stretching of muscle chains . In TENS group , high-frequency ( 150 Hz ) was applied on bilateral tender points of trapezium and supraspinatus . RESULTS TENS group had a greater pain reduction ( mean change score=-2.0±2.9 cm ) compared to Without TENS group ( -0.7±3.7 cm ) . There was a difference between mean change scores of each group for pain threshold ( right trapezium : 0.2±1 kg/cm² in TENS group and -0.2±1.2 kg/cm² in Without TENS group ) . In the evaluation of clinical ly important changes , patients receiving TENS had relevant improvement of pain , work performance , fatigue , stiffness , anxiety and depression compared to those not receiving TENS . CONCLUSION It has suggested that high-frequency TENS as an adjuvant therapy is effective in relieving pain , anxiety , fatigue , stiffness , and in improving ability to work of patients with fibromyalgia . CLINICAL REHABILITATION IMPACT High-frequency TENS may be used as a short-term complementary treatment of fibromyalgia OBJECTIVE To test the hypothesis that acupuncture improves symptoms of fibromyalgia .  PATIENTS AND METHODS We conducted a prospect i ve , partially blinded , controlled , r and omized clinical trial of patients receiving true acupuncture  compared with a control group of patients who received simulated acupuncture . All patients met American College of Rheumatology criteria for fibromyalgia and had tried conservative symptomatic treatments other than acupuncture .  We measured symptoms with the Fibromyalgia Impact Question naire ( FIQ ) and the Multidimensional Pain Inventory at baseline , immediately after treatment , and at 1 month and 7 months after treatment . The trial was conducted from May 28 , 2002 , to August 18 , 2003 . RESULTS Fifty patients participated in the study : 25 in the acupuncture group and 25 in the control group .  Total fibromyalgia symptoms , as measured by the FIQ , were significantly improved in the acupuncture group compared with the control group during the study period ( P = .01 ) . The largest difference in mean FIQ total scores was observed at 1 month ( 42.2 vs 34.8 in the control and acupuncture groups , respectively ; P = .007 ) . Fatigue and anxiety were the most significantly improved symptoms during the follow-up period . However , activity and physical function levels did not change . Acupuncture was well tolerated , with minimal adverse effects . CONCLUSION This study paradigm allows for controlled and blinded clinical trials of acupuncture . We found that acupuncture significantly improved symptoms of fibromyalgia . Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety Summary Pain and fatigue during movement , but not at rest , are reduced by a onetime 30‐m treatment with active transcutaneous electrical nerve stimulation ( TENS ) in individuals with fibromyalgia . Abstract Because transcutaneous electrical nerve stimulation ( TENS ) works by reducing central excitability and activating central inhibition pathways , we tested the hypothesis that TENS would reduce pain and fatigue and improve function and hyperalgesia in people with fibromyalgia who have enhanced central excitability and reduced inhibition . The current study used a double‐blinded r and omized , placebo‐controlled cross‐over design to test the effects of a single treatment of TENS with people with fibromyalgia . Three treatments were assessed in r and om order : active TENS , placebo TENS and no TENS . The following measures were assessed before and after each TENS treatment : pain and fatigue at rest and in movement ; pressure pain thresholds , 6‐m walk test , range of motion ; 5‐time sit‐to‐st and test , and single‐leg stance . Conditioned pain modulation was completed at the end of testing . There was a significant decrease in pain and fatigue with movement for active TENS compared to placebo and no TENS . Pressure pain thresholds increased at the site of TENS ( spine ) and outside the site of TENS ( leg ) when compared to placebo TENS or no TENS . During active TENS  , conditioned pain modulation was significantly stronger compared to placebo TENS and no TENS . No changes in functional tasks were observed with TENS . Thus , the current study suggests TENS has short‐term efficacy in relieving symptoms of fibromyalgia while the stimulator is active . Future clinical trials should examine the effects of repeated daily delivery of TENS , similar to the way in which TENS is used clinical ly on pain , fatigue , function , and quality of life in individuals with fibromyalgia OBJECTIVE --To determine the efficacy of electroacupuncture in patients with fibromyalgia , a syndrome of unknown origin causing diffuse musculoskeletal pain . DESIGN --Three weeks ' r and omised study with blinded patients and evaluating physician . SETTING --University divisions of physical medicine and rehabilitation and rheumatology , Geneva . PATIENTS --70 patients ( 54 women ) referred to the division for fibromyalgia as defined by the American College of Rheumatology . INTERVENTIONS -- Patients were r and omised to electroacupuncture ( n = 36 ) or a sham procedure ( n = 34 ) by means of an electronic numbers generator . MAIN OUTCOME MEASURES --Pain threshold , number of analgesic tablets used , regional pain score , pain recorded on visual analogue scale , sleep quality , morning stiffness , and patient 's and evaluating physician 's appreciation . RESULTS --Seven of the eight outcome parameters showed a significant improvement in the active treatment group whereas none were improved in the sham treatment group . Differences between the groups were significant for five of the eight outcome measures after treatment . CONCLUSIONS --Electroacupuncture is effective in relieving symptoms of fibromyalgia . Its potential in long term management should now be studied Fibromyalgia is characterized by a range of symptoms that include muscle pain , fatigue and sleep disorders . Transcutaneous electrical nerve stimulation ( TENS ) is an established method for pain relief . The purpose of the study was to evaluate the effectiveness and safety of the use of two simultaneously new TENS devices for fibromyalgia pain . After Ethics approval and informed consent , 39 patients were prospect ively divided into three groups to evaluate TENS device , applied simultaneously in each patient : ( 1 ) at the lower back ( perpendicular to the vertebrae canal , at the level of the 5th lumbar vertebrae ) and ( 2 ) central ly above and below the space between the C7 and T1 spinous processes . The devices were applied for 20 min at 12-h interval during 7 consecutive days . For the placebo group ( PG ) , the devices did not transmitted electrical stimulus . The single-TENS group ( STG ) ( n = 13 ) had one active and one placebo TENS . The DTG applied both active TENS devices at the low back and cervical areas . Diclofenac was used as rescue analgesic . The efficacy measures were pain relief , reduction in use of daily analgesic tablets , quality of sleep and fatigue . The evaluation within groups revealed that patients from DPG refereed no pain relief when compared to their previous VAS pain score ( 8 cm , p > 0.05 ) , while patients from the STG refereed improvement of 2.5 cm in the pain VAS ( previous 8.5 cm compared to 6 cm after treatment ) ( p < 0.05 ) , and the DPG refereed daily maintained reduction of 4 cm in the VAS pain ( previous 8.5–4.3 cm ) ( p < 0.02 ) . Concurrent daily consumption of analgesic tablets was reduced in both STG ( p < 0.05 ) and DTG ( p < 0.02 ) . Comparison among groups revealed that analgesia , as well as quality of sleep and disposition , was DTG > STG > PG ( p < 0.05 ) . Participants subjectively found the active device useful . While the application of a single active TENS improved pain relief in fibromyalgia pain , pain and fatigue were further improved when two active devices were simultaneously applied at the low back and cervical area , with no side effects Background Acupuncture is often used to treat fibromyalgia ( FM ) , but it remains unclear whether acupuncture is effective . This study aims to evaluate the effects of acupuncture on pain and quality of life ( QoL ) in FM patients . Methods Sixteen patients ( 13 women and 3 men aged 25 - 63 years ) suffering from FM were r and omised into two groups : group A ( n = 8) received five acupuncture treatments after the fifth week and group B received ten acupuncture treatments . Outcome measures used in this study were pain intensity ( visual analogue scale , VAS ) and the fibromyalgia impact question naire ( FIQ ) . Results After the fifth week , pain intensity ( U = 25.0 ; P = 0.022 ) in group B decreased and QoL ( U = 24.5 ; P = 0.026 ) improved compared to group A. Conclusion The present study suggests that acupuncture treatment is effective to relieve pain for FM patients in terms of QoL and FIQ This article introduces the approach of GRADE to rating  quality of evidence .  GRADE specifies four categories-high , moderate , low , and very low-that are applied to a body of evidence , not to individual studies . In the context of a systematic review , quality reflects our confidence that the estimates of the effect are correct . In the context of recommendations , quality reflects our confidence that the effect estimates are adequate to support a particular recommendation . R and omized trials begin as high- quality evidence , observational studies as low quality . " Quality " as used in GRADE means more than risk of bias and so may also be compromised by imprecision , inconsistency , indirectness of study results , and publication bias . In addition , several factors can increase our confidence in an estimate of effect . GRADE provides a systematic approach for considering and reporting each of these factors . GRADE separates the process of assessing quality of evidence from the process of making recommendations . Judgments about the strength of a recommendation depend on more than just the quality of evidence UNLABELLED Despite promising preliminary results in treating fibromyalgia ( FM ) pain , no neuromodulation technique has been adopted in clinical practice because of limited efficacy , low response rate , or poor tolerability . This phase II open-label trial aims to define a methodology for a clinical ly effective treatment of pain in FM by establishing treatment protocol s and screening procedures to maximize efficacy and response rate . High-definition transcranial direct current stimulation ( HD-tDCS ) provides targeted subthreshold brain stimulation , combining tolerability with specificity . We aim ed to establish the number of HD-tDCS sessions required to achieve a 50 % FM pain reduction , and to characterize the biometrics of the response , including brain network activation pain scores of contact heat-evoked potentials . We report a clinical ly significant benefit of a 50 % pain reduction in half ( n = 7 ) of the patients ( N = 14 ) , with responders and nonresponders alike benefiting from a cumulative 
    Output:
    
This meta- analysis indicates that there is low- quality evidence for the effectiveness of ES for pain relief in patients with FM .
However , moderate- quality evidence for the effectiveness of electroacupuncture ( EA ) , combined or not combined with other types of treatment , was found for pain relief .