human
***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: BACKGROUND To our knowledge , verum acupuncture has never been directly compared with sham acupuncture and guideline -based conventional therapy in patients with chronic low back pain . METHODS A patient- and observer-blinded r and omized controlled trial conducted in Germany involving 340 outpatient practice s , including 1162 patients aged 18 to 86 years ( mean + /- SD age , 50 + /- 15 years ) with a history of chronic low back pain for a mean of 8 years . Patients underwent ten 30-minute sessions , generally 2 sessions per week , of verum acupuncture ( n = 387 ) according to principles of traditional Chinese medicine ; sham acupuncture ( n = 387 ) consisting of superficial needling at nonacupuncture points ; or conventional therapy , a combination of drugs , physical therapy , and exercise ( n = 388 ) . Five additional sessions were offered to patients who had a partial response to treatment ( 10%-50 % reduction in pain intensity ) . Primary outcome was response after 6 months , defined as 33 % improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale question naire or 12 % improvement or better on the back-specific Hanover Functional Ability Question naire . Patients who were unblinded or had recourse to other than permitted concomitant therapies during follow-up were classified as nonresponders regardless of symptom improvement . RESULTS At 6 months , response rate was 47.6 % in the verum acupuncture group , 44.2 % in the sham acupuncture group , and 27.4 % in the conventional therapy group . Differences among groups were as follows : verum vs sham , 3.4 % ( 95 % confidence interval , -3.7 % to 10.3 % ; P = .39 ) ; verum vs conventional therapy , 20.2 % ( 95 % confidence interval , 13.4 % to 26.7 % ; P < .001 ) ; and sham vs conventional therapy , 16.8 % ( 95 % confidence interval , 10.1 % to 23.4 % ; P < .001 . CONCLUSIONS Low back pain improved after acupuncture treatment for at least 6 months . Effectiveness of acupuncture , either verum or sham , was almost twice that of conventional therapy To evaluate the efficacy of Chinese medicine ( CM ) acupuncture for  chronic neck pain ( CNP ) , a single blind , controlled , crossover , clinical trial was undertaken . Twenty-nine volunteers with CNP were r and omly recruited into two groups . Both groups received two phases of treatment with a washout period between the two phases . Group A ( 14 volunteers ) received CM acupuncture in the first phase and sham acupuncture in the second , while Group B ( 15 volunteers ) received sham in the first and real in the second . CM acupuncture was individualized and consisted of nine sessions on both local and distal points . Manual twisting of the needle was applied on all points plus strong electrical stimulation of distal points in CM acupuncture . Sham acupoints ( lateral to the real ) and sham ( weak ) electrical stimulation was used in the control group . Comparison of subjective and objective measures between the two groups was made at different periods , including baseline , after each phase of treatment , after washout , and after the 16th week follow-up . The subjective measures included pain intensity , duration per day , analgesic medication count , visual analogue scales ( VAS ) and neck disability index ( NDI ) . The objective measures consisted of neck range of motion ( ROM ) and pain threshold ( PT ) . Both the real and sham treatments significantly reduced subjective pain , without significant differences between groups for most subjective measures . Objective measures showed no significant change for either group before and after each period or by inter-groups analysis . A minimum 16-week effect of both real and sham acupuncture was found for subjective measures in the follow-up periods . Further study is recommended with an increased sample size , a longer washout period , and a longer baseline period We evaluated the efficacy of acupuncture as a useful adjuvant treatment in the management of rheumatoid arthritis ( RA ) . A pilot , r and omized , double-blind , and controlled clinical trial was conducted . Forty RA patients with active disease despite stable therapy for at least the preceding 1 month were r and omized to receive a st and ard protocol of acupuncture ( AC ) or superficial acupuncture at non-acupuncture points ( controlAC ) for 9 weeks . The primary outcome was achievement of 20 % improvement according to the American College of Rheumatology ( ACR ) 20 criteria after five and ten treatment sessions and after 1 month of follow-up . Secondary measures included Disease Assessment Scale ( DAS ) , tender and swollen joint count , morning stiffness , Health Assessment Question naire ( HAQ ) , visual analogue scale ( VAS ) of pain , physician global assessment of activity disease , physician and patient global assessment of treatment , and inflammatory markers ( erythrocyte sedimentation rate and C-reactive protein ) . There was not significant difference between the groups regarding the number of patients that reached ACR20 at the end of the treatment ( p = 0.479 ) . However , after 1 month of follow-up , there was a trend in favor of the AC group , with p = 0,068 . Compared with the controlAC , the AC group also demonstrated significant improvement in the patient and physician global assessment of treatment and physician global assessment of disease activity , but there was no difference on other clinical and laboratorial measures . On the other h and , only the AC patients had within group improvement on the variables DAS , HAQ , morning stiffness , patient and physician global assessment of treatment , and physician global assessment of disease activity in comparison to baseline visit . Despite the improvement of some studied variables , there was no significant difference in the proportion of patients that reached ACR20 between the AC and controlAC groups . This negative result can be related to the small sample size , selection of patients , type of acupuncture protocol applied , and difficulties in establishing an innocuous and trustworthy placebo group to studies involving acupuncture Objectives To compare the effect of acupuncture ( manual and electroacupuncture ) with that of a non-penetrating sham ( ‘ placebo ’ needle ) in patients with osteoarthritic knee pain and disability who are blind to the treatment allocation . Methods Acupuncture naive patients with symptomatic and radiological evidence of osteoarthritis of the knee were r and omly allocated to a course of either acupuncture or non-penetrating sham acupuncture using a sheathed ‘ placebo ’ needle system . Acupuncture points for pain and stiffness were selected according to acupuncture theory for treating Bi syndrome . Both manual and electrical stimulation were used . Response was assessed using the WOMAC index for osteoarthritis of the knee , self reported pain scale , the EuroQol score and plasma β-endorphin . The effectiveness of blinding was assessed . Results There were 34 patients in each group . The primary end point was the change in WOMAC pain score after the course of treatment . Comparison between the two treatment groups found a significantly greater improvement with acupuncture ( mean difference 60 , 95 % CI 5 to 116 , P=0.035 ) than with sham . Within the acupuncture group there was a significant improvement in pain ( baseline 294 , mean change 95 , 95 % CI 60 to 130 , P<0.001 ) which was not seen by those who had sham acupuncture ( baseline 261 , mean change 35 , 95 % CI-10 to 80 , P=0.12 ) . Similar effects within group , but not between groups , were seen with the secondary end points of WOMAC stiffness , WOMAC function , and self reported pain . One month after treatment the between group pain difference had been lost ( mean difference 46 ; 95 % CI −9 to 100 , P=0.10 ) although the acupuncture group was still benefiting compared to baseline ( mean difference 59 ; 95 % CI 16 to 102 , P=0.009 ) . The EuroQol score , a generic measure of health related quality of life , was not altered by the treatments . A minority of patients correctly guessed their treatment group ( 41 % in the acupuncture group and 44 % in the control group ) . Plasma β-endorphin levels were not affected by either treatment . Conclusions Acupuncture gives symptomatic improvement for patients with osteoarthritis of the knee , and is significantly superior to non-penetrating sham acupuncture . The study did not confirm earlier reports of release of plasma β-endorphin during acupuncture ABSTRACT Neurobiological mechanisms invoking the release of endogenous opioids and depression of stress hormone release are believed to be the basis of acupuncture analgesia . This study compared plasma β‐endorphin and cortisol levels with self assessment scores of intensity of pain , before and after 10 days of electro‐acupuncture treatment in patients suffering from chronic pain as a result of osteoarthritis knees . Forty patients of either sex over 40 years with primary osteoarthritis knee were recruited into a single‐blinded , sham‐controlled study . For electro‐acupuncture group the points were selected according to the Traditional Chinese Medicine Meridian Theory . In the sham group needles were inserted at r and om points away from true acupoints and no current was passed . Both groups were treated for 10 days with one session every day lasting for 20–25 min . Pre‐ and post‐treatment Western Ontario and McMaster Universities ( WOMAC ) index of osteoarthritis knee and Visual Analogue Scale ( VAS ) for pain were recorded and blood sample s were taken for the measurement of plasma cortisol and β‐endorphin levels . Following electro‐acupuncture treatment there was a significant improvement in WOMAC index and VAS ( p = 0.001 ) , a significant rise in plasma β‐endorphin ( p = 0.001 ) , and a significant fall in plasma cortisol ( p = 0.016 ) . In conclusion electro‐acupuncture result ed in an improvement in pain , stiffness and disability . Of clinical importance is that an improvement in objective measures of pain and stress/pain associated biomarkers was shown above that of a sham treatment ; hence demonstrating acupuncture associated physiological changes beyond that of the placebo effects Clinicians cl aim that myofascial trigger points ( MTrPs ) are a primary cause of pain in whiplash injured patients . Pain from MTrPs is often treated by needling , with or without injection . We conducted a placebo controlled study to test the feasibility of a phase III r and omised controlled trial investigating the efficacy of MTrP needling in patients with whiplash associated pain . Forty-one patients referred for physiotherapy with a recent whiplash injury , were recruited . Patients were r and omised to receive st and ardised physiotherapy plus either acupuncture or a sham needle control . A trial was judged feasible if : i ) the majority of eligible patients were willing to participate ; ii ) the majority of patients had MTrPs ; iii ) at least 75 % of patients provided completed self- assessment data ; iv ) no serious adverse events were reported and v ) the end of treatment attrition rate was less than 20 % . 70 % of those patients eligible to participate volunteered to do so ; all participants had clinical ly identified MTrPs ; a 100 % completion rate was achieved for recorded self- assessment data ; no serious adverse events were reported as a result of either intervention ; and the end of treatment attrition rate was 17 % . A phase III study is both feasible and clinical ly relevant . This study is currently being planned BACKGROUND Acupuncture is widely used by patients with chronic pain although there is little evidence of its effectiveness . We investigated the efficacy of acupuncture compared with minimal acupuncture and with no acupuncture in patients with osteoarthritis of the knee . METHODS Patients with chronic osteoarthritis of the knee ( Kellgren grade < or = 2 ) were r and omly assigned to acupuncture ( n=150 ) , minimal acupuncture ( superficial needling at non-acupuncture points ; n=76 ) , or a waiting list control ( n=74 ) . Specialised physicians , in 28 outpatient centres , administered acupuncture and minimal acupuncture in 12 sessions over 8 weeks . Patients completed st and ard question naires at baseline and after 8 weeks , 26 weeks , and 52 weeks . The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis ( WOMAC ) index at the end of week 8 ( adjusted for baseline score ) . All main analyses were by intention to treat . RESULTS 294 patients were enrolled from March 6 , 2002 , to January 17 , 2003 ; eight patients were lost to follow-up after r and omisation , but were included in the final analysis . The mean baseline-adjusted WOMAC index at week 8 was 26.9 ( SE 1.4 ) in the acupuncture group , 35.8 ( 1.9 ) in the minimal acupuncture group , and 49.6 ( 2.0 ) in the waiting list group ( treatment difference acupuncture vs minimal acupuncture -8.8 , [ 95 % CI -13.5 to -4.2 ] , p=0.0002 ; acupuncture vs waiting list -22.7 [ -27.5 to -17.9 ] , p<0.0001 ) . After 52 weeks the difference between the acupuncture and minimal acupuncture groups was no longer significant ( p=0.08 ) . INTERPRETATION 
    Output:
    
agent
***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: BACKGROUND To our knowledge , verum acupuncture has never been directly compared with sham acupuncture and guideline -based conventional therapy in patients with chronic low back pain . METHODS A patient- and observer-blinded r and omized controlled trial conducted in Germany involving 340 outpatient practice s , including 1162 patients aged 18 to 86 years ( mean + /- SD age , 50 + /- 15 years ) with a history of chronic low back pain for a mean of 8 years . Patients underwent ten 30-minute sessions , generally 2 sessions per week , of verum acupuncture ( n = 387 ) according to principles of traditional Chinese medicine ; sham acupuncture ( n = 387 ) consisting of superficial needling at nonacupuncture points ; or conventional therapy , a combination of drugs , physical therapy , and exercise ( n = 388 ) . Five additional sessions were offered to patients who had a partial response to treatment ( 10%-50 % reduction in pain intensity ) . Primary outcome was response after 6 months , defined as 33 % improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale question naire or 12 % improvement or better on the back-specific Hanover Functional Ability Question naire . Patients who were unblinded or had recourse to other than permitted concomitant therapies during follow-up were classified as nonresponders regardless of symptom improvement . RESULTS At 6 months , response rate was 47.6 % in the verum acupuncture group , 44.2 % in the sham acupuncture group , and 27.4 % in the conventional therapy group . Differences among groups were as follows : verum vs sham , 3.4 % ( 95 % confidence interval , -3.7 % to 10.3 % ; P = .39 ) ; verum vs conventional therapy , 20.2 % ( 95 % confidence interval , 13.4 % to 26.7 % ; P < .001 ) ; and sham vs conventional therapy , 16.8 % ( 95 % confidence interval , 10.1 % to 23.4 % ; P < .001 . CONCLUSIONS Low back pain improved after acupuncture treatment for at least 6 months . Effectiveness of acupuncture , either verum or sham , was almost twice that of conventional therapy To evaluate the efficacy of Chinese medicine ( CM ) acupuncture for  chronic neck pain ( CNP ) , a single blind , controlled , crossover , clinical trial was undertaken . Twenty-nine volunteers with CNP were r and omly recruited into two groups . Both groups received two phases of treatment with a washout period between the two phases . Group A ( 14 volunteers ) received CM acupuncture in the first phase and sham acupuncture in the second , while Group B ( 15 volunteers ) received sham in the first and real in the second . CM acupuncture was individualized and consisted of nine sessions on both local and distal points . Manual twisting of the needle was applied on all points plus strong electrical stimulation of distal points in CM acupuncture . Sham acupoints ( lateral to the real ) and sham ( weak ) electrical stimulation was used in the control group . Comparison of subjective and objective measures between the two groups was made at different periods , including baseline , after each phase of treatment , after washout , and after the 16th week follow-up . The subjective measures included pain intensity , duration per day , analgesic medication count , visual analogue scales ( VAS ) and neck disability index ( NDI ) . The objective measures consisted of neck range of motion ( ROM ) and pain threshold ( PT ) . Both the real and sham treatments significantly reduced subjective pain , without significant differences between groups for most subjective measures . Objective measures showed no significant change for either group before and after each period or by inter-groups analysis . A minimum 16-week effect of both real and sham acupuncture was found for subjective measures in the follow-up periods . Further study is recommended with an increased sample size , a longer washout period , and a longer baseline period We evaluated the efficacy of acupuncture as a useful adjuvant treatment in the management of rheumatoid arthritis ( RA ) . A pilot , r and omized , double-blind , and controlled clinical trial was conducted . Forty RA patients with active disease despite stable therapy for at least the preceding 1 month were r and omized to receive a st and ard protocol of acupuncture ( AC ) or superficial acupuncture at non-acupuncture points ( controlAC ) for 9 weeks . The primary outcome was achievement of 20 % improvement according to the American College of Rheumatology ( ACR ) 20 criteria after five and ten treatment sessions and after 1 month of follow-up . Secondary measures included Disease Assessment Scale ( DAS ) , tender and swollen joint count , morning stiffness , Health Assessment Question naire ( HAQ ) , visual analogue scale ( VAS ) of pain , physician global assessment of activity disease , physician and patient global assessment of treatment , and inflammatory markers ( erythrocyte sedimentation rate and C-reactive protein ) . There was not significant difference between the groups regarding the number of patients that reached ACR20 at the end of the treatment ( p = 0.479 ) . However , after 1 month of follow-up , there was a trend in favor of the AC group , with p = 0,068 . Compared with the controlAC , the AC group also demonstrated significant improvement in the patient and physician global assessment of treatment and physician global assessment of disease activity , but there was no difference on other clinical and laboratorial measures . On the other h and , only the AC patients had within group improvement on the variables DAS , HAQ , morning stiffness , patient and physician global assessment of treatment , and physician global assessment of disease activity in comparison to baseline visit . Despite the improvement of some studied variables , there was no significant difference in the proportion of patients that reached ACR20 between the AC and controlAC groups . This negative result can be related to the small sample size , selection of patients , type of acupuncture protocol applied , and difficulties in establishing an innocuous and trustworthy placebo group to studies involving acupuncture Objectives To compare the effect of acupuncture ( manual and electroacupuncture ) with that of a non-penetrating sham ( ‘ placebo ’ needle ) in patients with osteoarthritic knee pain and disability who are blind to the treatment allocation . Methods Acupuncture naive patients with symptomatic and radiological evidence of osteoarthritis of the knee were r and omly allocated to a course of either acupuncture or non-penetrating sham acupuncture using a sheathed ‘ placebo ’ needle system . Acupuncture points for pain and stiffness were selected according to acupuncture theory for treating Bi syndrome . Both manual and electrical stimulation were used . Response was assessed using the WOMAC index for osteoarthritis of the knee , self reported pain scale , the EuroQol score and plasma β-endorphin . The effectiveness of blinding was assessed . Results There were 34 patients in each group . The primary end point was the change in WOMAC pain score after the course of treatment . Comparison between the two treatment groups found a significantly greater improvement with acupuncture ( mean difference 60 , 95 % CI 5 to 116 , P=0.035 ) than with sham . Within the acupuncture group there was a significant improvement in pain ( baseline 294 , mean change 95 , 95 % CI 60 to 130 , P<0.001 ) which was not seen by those who had sham acupuncture ( baseline 261 , mean change 35 , 95 % CI-10 to 80 , P=0.12 ) . Similar effects within group , but not between groups , were seen with the secondary end points of WOMAC stiffness , WOMAC function , and self reported pain . One month after treatment the between group pain difference had been lost ( mean difference 46 ; 95 % CI −9 to 100 , P=0.10 ) although the acupuncture group was still benefiting compared to baseline ( mean difference 59 ; 95 % CI 16 to 102 , P=0.009 ) . The EuroQol score , a generic measure of health related quality of life , was not altered by the treatments . A minority of patients correctly guessed their treatment group ( 41 % in the acupuncture group and 44 % in the control group ) . Plasma β-endorphin levels were not affected by either treatment . Conclusions Acupuncture gives symptomatic improvement for patients with osteoarthritis of the knee , and is significantly superior to non-penetrating sham acupuncture . The study did not confirm earlier reports of release of plasma β-endorphin during acupuncture ABSTRACT Neurobiological mechanisms invoking the release of endogenous opioids and depression of stress hormone release are believed to be the basis of acupuncture analgesia . This study compared plasma β‐endorphin and cortisol levels with self assessment scores of intensity of pain , before and after 10 days of electro‐acupuncture treatment in patients suffering from chronic pain as a result of osteoarthritis knees . Forty patients of either sex over 40 years with primary osteoarthritis knee were recruited into a single‐blinded , sham‐controlled study . For electro‐acupuncture group the points were selected according to the Traditional Chinese Medicine Meridian Theory . In the sham group needles were inserted at r and om points away from true acupoints and no current was passed . Both groups were treated for 10 days with one session every day lasting for 20–25 min . Pre‐ and post‐treatment Western Ontario and McMaster Universities ( WOMAC ) index of osteoarthritis knee and Visual Analogue Scale ( VAS ) for pain were recorded and blood sample s were taken for the measurement of plasma cortisol and β‐endorphin levels . Following electro‐acupuncture treatment there was a significant improvement in WOMAC index and VAS ( p = 0.001 ) , a significant rise in plasma β‐endorphin ( p = 0.001 ) , and a significant fall in plasma cortisol ( p = 0.016 ) . In conclusion electro‐acupuncture result ed in an improvement in pain , stiffness and disability . Of clinical importance is that an improvement in objective measures of pain and stress/pain associated biomarkers was shown above that of a sham treatment ; hence demonstrating acupuncture associated physiological changes beyond that of the placebo effects Clinicians cl aim that myofascial trigger points ( MTrPs ) are a primary cause of pain in whiplash injured patients . Pain from MTrPs is often treated by needling , with or without injection . We conducted a placebo controlled study to test the feasibility of a phase III r and omised controlled trial investigating the efficacy of MTrP needling in patients with whiplash associated pain . Forty-one patients referred for physiotherapy with a recent whiplash injury , were recruited . Patients were r and omised to receive st and ardised physiotherapy plus either acupuncture or a sham needle control . A trial was judged feasible if : i ) the majority of eligible patients were willing to participate ; ii ) the majority of patients had MTrPs ; iii ) at least 75 % of patients provided completed self- assessment data ; iv ) no serious adverse events were reported and v ) the end of treatment attrition rate was less than 20 % . 70 % of those patients eligible to participate volunteered to do so ; all participants had clinical ly identified MTrPs ; a 100 % completion rate was achieved for recorded self- assessment data ; no serious adverse events were reported as a result of either intervention ; and the end of treatment attrition rate was 17 % . A phase III study is both feasible and clinical ly relevant . This study is currently being planned BACKGROUND Acupuncture is widely used by patients with chronic pain although there is little evidence of its effectiveness . We investigated the efficacy of acupuncture compared with minimal acupuncture and with no acupuncture in patients with osteoarthritis of the knee . METHODS Patients with chronic osteoarthritis of the knee ( Kellgren grade < or = 2 ) were r and omly assigned to acupuncture ( n=150 ) , minimal acupuncture ( superficial needling at non-acupuncture points ; n=76 ) , or a waiting list control ( n=74 ) . Specialised physicians , in 28 outpatient centres , administered acupuncture and minimal acupuncture in 12 sessions over 8 weeks . Patients completed st and ard question naires at baseline and after 8 weeks , 26 weeks , and 52 weeks . The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis ( WOMAC ) index at the end of week 8 ( adjusted for baseline score ) . All main analyses were by intention to treat . RESULTS 294 patients were enrolled from March 6 , 2002 , to January 17 , 2003 ; eight patients were lost to follow-up after r and omisation , but were included in the final analysis . The mean baseline-adjusted WOMAC index at week 8 was 26.9 ( SE 1.4 ) in the acupuncture group , 35.8 ( 1.9 ) in the minimal acupuncture group , and 49.6 ( 2.0 ) in the waiting list group ( treatment difference acupuncture vs minimal acupuncture -8.8 , [ 95 % CI -13.5 to -4.2 ] , p=0.0002 ; acupuncture vs waiting list -22.7 [ -27.5 to -17.9 ] , p<0.0001 ) . After 52 weeks the difference between the acupuncture and minimal acupuncture groups was no longer significant ( p=0.08 ) . INTERPRETATION 
    Output:
    