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: Objective : Considering the chronicity of osteoarthritis-associated pain , we aim ed to evaluate long-term outcome differences between patients who received immediate or delayed acupuncture in addition to usual care  , and to identify predictors for further acupuncture usage and a better long-term outcome . Material s and Methods : The Acupuncture in Routine Care study was an open-label r and omized pragmatic trial . As adjunct to  usual care  patients ( > 40 y , clinical and radiologic diagnosis of primary osteoarthritis of the knee or hip , pain duration > 6 mo ) received either immediate acupuncture in the first 3 months or delayed acupuncture in the subsequent 3 months . After 36 months 613 of 632 patients were available and asked to complete follow-up question naires . Primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) . Results : A total of 500 ( 82 % ) of the contacted patients completed question naires . After 36 months the WOMAC Index did not differ significantly between groups ( immediate acupuncture 36.53±26.19 vs. delayed acupuncture 38.24±25.54 ; P=0.420 ) .  Further acupuncture  treatment during the follow-up period was reported by 202 patients and predicted by previous successful acupuncture treatment at baseline ( odds ratio=2.5 ; 95 % confidence interval , 1.6 - 3.9 ) . Less osteoarthritis symptoms ( WOMAC Index ) after 36 months were predicted by being an acupuncture responder at 6 months ( P<0.001 ) , having higher school education ( P=0.005 ) , not wanting to use medications ( P=0.016 ) , and using additional therapies ( P⩽0.001 to P=0.025 ) . Discussion : No long-term outcome differences were found between patients who received immediate versus those who received delayed acupuncture  treatment . Education level and additional therapies were identified as predictors for a better long-term outcome Summary This multifactorial mixed‐ methods r and omized controlled trial quantified the specific and nonspecific factors of acupuncture , and found that the practitioner , not the treatment , has the strongest effect on outcome . Abstract The nonspecific effects of acupuncture are well documented ; we wished to quantify these factors in osteoarthritic ( OA ) pain , examining needling , the consultation , and the practitioner . In a prospect i ve r and omised , single‐blind , placebo‐controlled , multifactorial , mixed‐ methods trial , 221 patients with OA awaiting joint replacement surgery were recruited . Interventions were acupuncture , Streitberger placebo acupuncture , and mock electrical stimulation , each with empathic or nonempathic consultations . Interventions involved eight 30‐minute treatments over 4 weeks . The primary outcome was pain ( VAS ) at 1 week posttreatment . Face‐to‐face qualitative interviews were conducted ( purposive sample , 27 participants ) . Improvements occurred from baseline for all interventions with no significant differences between real and placebo acupuncture ( mean difference −2.7 mm , 95 % confidence intervals −9.0 to 3.6 ; P = .40 ) or mock stimulation ( −3.9 , −10.4 to 2.7 ; P = .25 ) . Empathic consultations did not affect pain ( 3.0 mm , −2.2 to 8.2 ; P = .26 ) but practitioner 3 achieved greater analgesia than practitioner 2 ( 10.9 , 3.9 to 18.0 ; P = .002 ) . Qualitative analysis indicated that patients ’ beliefs about treatment veracity and confidence in outcomes were reciprocally linked . The supportive nature of the trial attenuated differences between the different consultation styles . Improvements occurred from baseline , but acupuncture has no specific efficacy over either placebo . The individual practitioner and the patient ’s belief had a significant effect on outcome . The 2 placebos  were equally as effective and credible as acupuncture . Needle and nonneedle placebos are equivalent . An unknown characteristic of the treating practitioner predicts outcome , as does the patient ’s belief ( independently ) . Beliefs about treatment veracity shape how patients self‐report outcome , complicating and confounding study interpretation Introduction Our objective was to compare the effectiveness and safety of traditional Chinese moxibustion to that of sham moxibustion in patients with chronic knee osteoarthritis ( KOA ) pain . Methods We conducted a r and omized placebo-controlled trial involving 110 patients with KOA who met the inclusion criteria . These patients r and omly received either active moxibustion ( n = 55 ) or sham moxibustion control ( n = 55 ) at acupoints Dubi ( ST 35 ) , extra-point Neixiyan ( EX-LE 4 ) , and an Ashi ( tender ) point three times a week for 6 weeks . Effects were evaluated with Western Ontario and McMaster Universities ’ Osteoarthritis Index ( WOMAC VA 3.1 ) criteria at the end of the course of treatment and 3 , 12 , and 24 weeks after the initial treatment . Results The WOMAC pain scores showed greater improvement in the active treatment group than in control at weeks 3 ( P = 0.012 ) , 6 ( P < 0.001 ) , 12 ( P = 0.002 ) , and 24 ( P = 0.002 ) as did WOMAC physical function scores of the active treatment group at week 3 ( P = 0.002 ) , 6 ( P = 0.015 ) , and 12 ( P < 0.001 ) but not 24 ( P = 0.058 ) . Patients and practitioners were blinded successfully , and no significant adverse effects were found during the trial . Conclusions A 6-week course of moxibustion seems to relieve pain effectively and improve function in patients with KOA for up to 18 weeks after the end of treatment . Moxibustion treatment appears to be safe , and the usefulness of the novel moxa device was vali date d . Trial registration Current controlled trial : IS RCT N68475405 . Registered 4 April 2014 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 Background Using an open r and omised controlled study , we examined the effectiveness of manual and electroacupuncture on symptom relief for patients with osteoarthritis of the knee . Methods Patients with symptomatic osteoarthritis of the knee were r and omised to one of three treatment groups . Group A had acupuncture alone , group B had acupuncture but continued on their symptomatic medication , and group C used their symptomatic medication for the first five weeks and then had a course of acupuncture added . Patients receiving acupuncture were treated twice weekly over five weeks . Needles were inserted ( with manual and electrical stimulation ) in acupuncture points for pain and stiffness , selected according to traditional acupuncture theory for treating Bi syndrome . Patients were assessed by a blinded observer before treatment , after five weeks ’ treatment and at one month follow up , using a visual analogue pain scale ( VAS ) and the Western Ontario McMaster ( WOMAC ) question naire for osteoarthritis of the knee . Results The 30 patients in our study were well matched for age , body mass index , disease duration , baseline VAS pain score and baseline WOMAC scores . Repeated measure analyses gave a highly significant improvement in pain ( VAS ) after the courses of acupuncture in groups A ( P=0.012 ) and B ( P=0.001 ) ; there was no change in group C until after the course of acupuncture , when the improvement was significant ( P=0.001 ) . Similarly significant changes were seen with the WOMAC pain and stiffness scores . These benefits were maintained during the one month after the course of acupuncture . Patients ’ rating of global assessment was higher than that of the acupuncturist . Conclusion We conclude that manual and electroacupuncture causes a significant improvement in the symptoms of osteoarthritis  of the knee , either on its own or as an adjunct therapy , with no loss of benefit after one month Clinical and experimental data indicate that most acupuncture clinical results are mediated by the central nervous system , but the specific effects of acupuncture on the human brain remain unclear . Even less is known about its effects on the cerebellum . This fMRI study demonstrated that manual acupuncture at ST 36 ( Stomach 36 , Zusanli ) , a main acupoint on the leg , modulated neural activity at multiple levels of the cerebro-cerebellar and limbic systems . The pattern of hemodynamic response depended on the psychophysical response to needle manipulation . Acupuncture stimulation typically elicited a composite of sensations termed deqi that is related to clinical efficacy according to traditional Chinese medicine . The limbic and paralimbic structures of cortical and subcortical regions in the telencephalon , diencephalon , brainstem and cerebellum demonstrated a concerted attenuation of signal intensity when the subjects experienced deqi . When deqi was mixed with sharp pain , the hemodynamic response was mixed , showing a predominance of signal increases instead . Tactile stimulation as control also elicited a predominance of signal increase in a subset of these regions . The study provides preliminary evidence for an integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 that correlates with the psychophysical response A prospect i ve , controlled clinical trial was undertaken to assess the relative efficacies of physiotherapy and electroacupuncture in the treatment of cervical spondylosis . The results suggested that , while both methods were effective , electroacupuncture produced an earlier symptomatic improvement with increased neck movement , especially in patients with mild degenerative changes of the cervical spine BACKGROUND Because of morbidity associated with painful knee osteoarthritis ( OA ) and commonly prescribed analgesics , patients often pursue complementary and alternative modalities ( eg , acupuncture ) . Clinical trials have demonstrated modest therapeutic efficacy of traditional Chinese acupuncture for knee OA pain , and patients with advanced disease have largely been excluded . We have previously demonstrated preliminary short-term tolerability and efficacy of periosteal stimulation therapy ( PST ) ( ie , electrical stimulation of the periosteum facilitated by acupuncture needles ) for older adults with advanced knee OA . OBJECTIVE This study evaluated the sustained efficacy of PST and boosters for treating chronic pain with advanced knee OA . METHODS One hundred ninety participants age > 50 years with Kellgren-Lawrence grade 3 or 4 knee OA and chronic pain were r and omized to ( 1 ) PST ( once a week for 10 weeks ) followed by PST boosters for 6 months ( once every 2 weeks 2 times , then once a month ) , ( 2 ) control PST ( ie , periosteal needles and brief electrical stimulation of control points ) once a week for 10 weeks , or ( 3 ) PST for 10 weeks followed by control PST boosters for 6 months . Change in the Western Ontario and McMaster Universities Osteoarthritis Index pain score immediately after the 10- 
    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: Objective : Considering the chronicity of osteoarthritis-associated pain , we aim ed to evaluate long-term outcome differences between patients who received immediate or delayed acupuncture in addition to usual care  , and to identify predictors for further acupuncture usage and a better long-term outcome . Material s and Methods : The Acupuncture in Routine Care study was an open-label r and omized pragmatic trial . As adjunct to  usual care  patients ( > 40 y , clinical and radiologic diagnosis of primary osteoarthritis of the knee or hip , pain duration > 6 mo ) received either immediate acupuncture in the first 3 months or delayed acupuncture in the subsequent 3 months . After 36 months 613 of 632 patients were available and asked to complete follow-up question naires . Primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) . Results : A total of 500 ( 82 % ) of the contacted patients completed question naires . After 36 months the WOMAC Index did not differ significantly between groups ( immediate acupuncture 36.53±26.19 vs. delayed acupuncture 38.24±25.54 ; P=0.420 ) .  Further acupuncture  treatment during the follow-up period was reported by 202 patients and predicted by previous successful acupuncture treatment at baseline ( odds ratio=2.5 ; 95 % confidence interval , 1.6 - 3.9 ) . Less osteoarthritis symptoms ( WOMAC Index ) after 36 months were predicted by being an acupuncture responder at 6 months ( P<0.001 ) , having higher school education ( P=0.005 ) , not wanting to use medications ( P=0.016 ) , and using additional therapies ( P⩽0.001 to P=0.025 ) . Discussion : No long-term outcome differences were found between patients who received immediate versus those who received delayed acupuncture  treatment . Education level and additional therapies were identified as predictors for a better long-term outcome Summary This multifactorial mixed‐ methods r and omized controlled trial quantified the specific and nonspecific factors of acupuncture , and found that the practitioner , not the treatment , has the strongest effect on outcome . Abstract The nonspecific effects of acupuncture are well documented ; we wished to quantify these factors in osteoarthritic ( OA ) pain , examining needling , the consultation , and the practitioner . In a prospect i ve r and omised , single‐blind , placebo‐controlled , multifactorial , mixed‐ methods trial , 221 patients with OA awaiting joint replacement surgery were recruited . Interventions were acupuncture , Streitberger placebo acupuncture , and mock electrical stimulation , each with empathic or nonempathic consultations . Interventions involved eight 30‐minute treatments over 4 weeks . The primary outcome was pain ( VAS ) at 1 week posttreatment . Face‐to‐face qualitative interviews were conducted ( purposive sample , 27 participants ) . Improvements occurred from baseline for all interventions with no significant differences between real and placebo acupuncture ( mean difference −2.7 mm , 95 % confidence intervals −9.0 to 3.6 ; P = .40 ) or mock stimulation ( −3.9 , −10.4 to 2.7 ; P = .25 ) . Empathic consultations did not affect pain ( 3.0 mm , −2.2 to 8.2 ; P = .26 ) but practitioner 3 achieved greater analgesia than practitioner 2 ( 10.9 , 3.9 to 18.0 ; P = .002 ) . Qualitative analysis indicated that patients ’ beliefs about treatment veracity and confidence in outcomes were reciprocally linked . The supportive nature of the trial attenuated differences between the different consultation styles . Improvements occurred from baseline , but acupuncture has no specific efficacy over either placebo . The individual practitioner and the patient ’s belief had a significant effect on outcome . The 2 placebos  were equally as effective and credible as acupuncture . Needle and nonneedle placebos are equivalent . An unknown characteristic of the treating practitioner predicts outcome , as does the patient ’s belief ( independently ) . Beliefs about treatment veracity shape how patients self‐report outcome , complicating and confounding study interpretation Introduction Our objective was to compare the effectiveness and safety of traditional Chinese moxibustion to that of sham moxibustion in patients with chronic knee osteoarthritis ( KOA ) pain . Methods We conducted a r and omized placebo-controlled trial involving 110 patients with KOA who met the inclusion criteria . These patients r and omly received either active moxibustion ( n = 55 ) or sham moxibustion control ( n = 55 ) at acupoints Dubi ( ST 35 ) , extra-point Neixiyan ( EX-LE 4 ) , and an Ashi ( tender ) point three times a week for 6 weeks . Effects were evaluated with Western Ontario and McMaster Universities ’ Osteoarthritis Index ( WOMAC VA 3.1 ) criteria at the end of the course of treatment and 3 , 12 , and 24 weeks after the initial treatment . Results The WOMAC pain scores showed greater improvement in the active treatment group than in control at weeks 3 ( P = 0.012 ) , 6 ( P < 0.001 ) , 12 ( P = 0.002 ) , and 24 ( P = 0.002 ) as did WOMAC physical function scores of the active treatment group at week 3 ( P = 0.002 ) , 6 ( P = 0.015 ) , and 12 ( P < 0.001 ) but not 24 ( P = 0.058 ) . Patients and practitioners were blinded successfully , and no significant adverse effects were found during the trial . Conclusions A 6-week course of moxibustion seems to relieve pain effectively and improve function in patients with KOA for up to 18 weeks after the end of treatment . Moxibustion treatment appears to be safe , and the usefulness of the novel moxa device was vali date d . Trial registration Current controlled trial : IS RCT N68475405 . Registered 4 April 2014 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 Background Using an open r and omised controlled study , we examined the effectiveness of manual and electroacupuncture on symptom relief for patients with osteoarthritis of the knee . Methods Patients with symptomatic osteoarthritis of the knee were r and omised to one of three treatment groups . Group A had acupuncture alone , group B had acupuncture but continued on their symptomatic medication , and group C used their symptomatic medication for the first five weeks and then had a course of acupuncture added . Patients receiving acupuncture were treated twice weekly over five weeks . Needles were inserted ( with manual and electrical stimulation ) in acupuncture points for pain and stiffness , selected according to traditional acupuncture theory for treating Bi syndrome . Patients were assessed by a blinded observer before treatment , after five weeks ’ treatment and at one month follow up , using a visual analogue pain scale ( VAS ) and the Western Ontario McMaster ( WOMAC ) question naire for osteoarthritis of the knee . Results The 30 patients in our study were well matched for age , body mass index , disease duration , baseline VAS pain score and baseline WOMAC scores . Repeated measure analyses gave a highly significant improvement in pain ( VAS ) after the courses of acupuncture in groups A ( P=0.012 ) and B ( P=0.001 ) ; there was no change in group C until after the course of acupuncture , when the improvement was significant ( P=0.001 ) . Similarly significant changes were seen with the WOMAC pain and stiffness scores . These benefits were maintained during the one month after the course of acupuncture . Patients ’ rating of global assessment was higher than that of the acupuncturist . Conclusion We conclude that manual and electroacupuncture causes a significant improvement in the symptoms of osteoarthritis  of the knee , either on its own or as an adjunct therapy , with no loss of benefit after one month Clinical and experimental data indicate that most acupuncture clinical results are mediated by the central nervous system , but the specific effects of acupuncture on the human brain remain unclear . Even less is known about its effects on the cerebellum . This fMRI study demonstrated that manual acupuncture at ST 36 ( Stomach 36 , Zusanli ) , a main acupoint on the leg , modulated neural activity at multiple levels of the cerebro-cerebellar and limbic systems . The pattern of hemodynamic response depended on the psychophysical response to needle manipulation . Acupuncture stimulation typically elicited a composite of sensations termed deqi that is related to clinical efficacy according to traditional Chinese medicine . The limbic and paralimbic structures of cortical and subcortical regions in the telencephalon , diencephalon , brainstem and cerebellum demonstrated a concerted attenuation of signal intensity when the subjects experienced deqi . When deqi was mixed with sharp pain , the hemodynamic response was mixed , showing a predominance of signal increases instead . Tactile stimulation as control also elicited a predominance of signal increase in a subset of these regions . The study provides preliminary evidence for an integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 that correlates with the psychophysical response A prospect i ve , controlled clinical trial was undertaken to assess the relative efficacies of physiotherapy and electroacupuncture in the treatment of cervical spondylosis . The results suggested that , while both methods were effective , electroacupuncture produced an earlier symptomatic improvement with increased neck movement , especially in patients with mild degenerative changes of the cervical spine BACKGROUND Because of morbidity associated with painful knee osteoarthritis ( OA ) and commonly prescribed analgesics , patients often pursue complementary and alternative modalities ( eg , acupuncture ) . Clinical trials have demonstrated modest therapeutic efficacy of traditional Chinese acupuncture for knee OA pain , and patients with advanced disease have largely been excluded . We have previously demonstrated preliminary short-term tolerability and efficacy of periosteal stimulation therapy ( PST ) ( ie , electrical stimulation of the periosteum facilitated by acupuncture needles ) for older adults with advanced knee OA . OBJECTIVE This study evaluated the sustained efficacy of PST and boosters for treating chronic pain with advanced knee OA . METHODS One hundred ninety participants age > 50 years with Kellgren-Lawrence grade 3 or 4 knee OA and chronic pain were r and omized to ( 1 ) PST ( once a week for 10 weeks ) followed by PST boosters for 6 months ( once every 2 weeks 2 times , then once a month ) , ( 2 ) control PST ( ie , periosteal needles and brief electrical stimulation of control points ) once a week for 10 weeks , or ( 3 ) PST for 10 weeks followed by control PST boosters for 6 months . Change in the Western Ontario and McMaster Universities Osteoarthritis Index pain score immediately after the 10- 
    Output:
    