The document summarizes a study comparing the effectiveness of triple acupuncture therapy versus carbamazepine treatment for primary trigeminal neuralgia. Sixty-four patients were randomly assigned to receive either triple acupuncture at trigger points or oral carbamazepine for one month. Results showed the acupuncture group had significantly higher pain relief rates and lower pain scores than the carbamazepine group at follow-up. Adverse effects were also less common with acupuncture. The study concludes that triple acupuncture may be a safer and more effective alternative to carbamazepine for trigeminal neuralgia.

1. Journal Club
Dr. Arun Panwar
I year MDS

2. Journal
 Name of the Journal: Current Medical Science
 Publisher: SpringerLink
 Section: Original Research
 Year of Publication: 2019
 Issue number: Aug;39(4)
 No of pages: 7
 Page no. 638 - 64
 Authors: Zhang YP, Wang Y, Xia WG, Song AQ
 Institutional Affiliation: Hubei Provincial Hospital of Integrated
Chinese and Western Medicine, Wuhan 430015, China

4. Background
 Trigeminal neuralgia (TN), most common clinical disease of
trigeminal nerve.
 Characterized by sudden onset, unilateral, transient and
recurrent electric shock-like pain.
 Happens unexpectedly and stops suddenly
 Multiple attacks often lead to depression, anxiety and fear.
 Recurrence rate is high leading to a serious impact on daily
and social life.

5.  Etiology: Neurovascular compression of the CN V at the root
entry zone is the most common cause.
 TN can be divided into primary and secondary types.
 Present Treatment modalities: Microvascular
decompression, Balloon compression, Continuous
Radiofrequency Thermocoagulation, Gammaknife radiosurgery.
 Medicines mainly including many antiepileptic drugs and
analgesic drugs such as carbamazepine, oxcarbazepine or
baclofen are used.

6. Acupuncture
 Acupuncture is generally used as an alternative therapeutic
treatment for chronic diseases and pain control.
 Triple puncture is one kind of acupuncture, which punctures
with one needle directly in a point and two by side.
 The main reason is that the multi-needle can enhance the
sense of prick and achieve a more remarkable effect than the
single needle

7. Aim:
 To study whether triple puncture is more effective and safer
than carbamazepine in relieving pain from TN.
 The study the total efficiency rate and VAS pain scores.
 To study the frequency of pain attack.

8. Materials and Method

9. Flow chart for patients screening in this
study

10. Clinical characteristics of the study patients

11. Inclusion Criteria:
 All the 64 patients were chosen at Department of Physical Medicine and
Rehabilitation, Hubei Provincial Hospital of Integrated Chinese and
Western Medicine from January 2016 to July 2018.
 The diagnostic criteria for TN were based on the principle of
International Classification of Headache Disorders (IHS)-III (2013).
 It was detailed as follows:
 Paroxysmal attacks of facial or frontal pain lasting a few seconds to less
than 2 min;
 Pain distributed along one or more divisions of the trigeminal nerve
 Sudden intense, sharp, superficial, stabbing, or burning pain;
 Precipitation of pain by daily activities such as chewing, coughing,
shaving, talking, facial washing or brushing teeth.

12. Exclusion Criteria:
 Secondary TN caused by tumors, intracranial lesions, multiple
sclerosis, or herpes zoster (excluded through clinical evaluation
and imaging examination)
 Patient with Coagulation disorder; mental disorders; pregnancy
or breast feeding mothers
 Unwilling patients

13. Randomization
 Eligible patients would be randomly assigned to treatment
group treated by triple puncture and control group given oral
carbamazepine by an independent administrator by a random
number table.

14. Ethical Clearance
 Study was approved by the local Ethics Committee of Hubei
Provincial Hospital of Integrated Chinese and Western
Medicine (China) (2015113), and all patients provided informed
consent before participation.

15. Acupuncture Treatment
 Acupoints given in the treatment group were based on expert’s
opinion.
 Acupoints were:
 For neuralgia of the 1st branch, Yuyao (EX-HN4) was selected.
Needle was inserted into the point 0.5 cm deep to reach the
bone surface of the orbital margin and induce a sensation of
electric transmission.
 For neuralgia of the 2nd branch, Sibai (ST 2) was selected.
Needle was inserted into the point via the infraorbital foramen
of an angle of 40°–50° posterolaterally upwards to a depth
limited within 1 cm, followed by appearance of the electric
shock sensation radiating to the upper lip and the upper teeth.

16.  For neuralgia of the 3rd branch, Xiaguan (ST 7) was selected.
Needle was inserted into the point posteriorly towards the medial
side for about 4 cm. A sensation like a electric shock radiating to
the mandible appeared.
 Quanliao as the main acupoint was pierced vertically by a
disposable sterilized filiform needles, 0.25 mm in diameter and 40
mm in length (HUANQIU China) after the routine disinfection, then
the needles were lifted and twisted to make the patient feel swelling
at electric shock which could be tolerated.
 Next two needles were pierced obliquely for 2–4 cm from the point
of about 1.5 cm on the left and right sides, with 45 degree angle.

17.  Yuyao (EX-HN4) - At the midpoint of the
eyebrow in a depression directly above the
pupil.
 Sibai (ST 2) - Below the pupil, in a depression
at the infraorbital foramen.
 Xiaguan (ST 7) - On the face, anterior to the
ear, in a depression between the zygomatic
arch and the mandibular notch, with mouth
closed.

18.  Quanliao (SI 18) - Directly below the outer canthus of the eye in
a depression on the lower border of the zygoma.

19.  The mild reinforcing-reducing method was adopted after “De
Qi’’, an acupuncture specific sensation, which can be described
as a feeling of soreness, numbness, swelling or heaviness.
 The needles were left in the acupoint for 40 min, manually
stimulated every 10 min by twirling to strengthen the sense with
the frequency of 80–100 times per min for 2 min.
 Yanglingquan and Fenglong acupoints were pierced vertically
for 3–4 cm, using reducing method with lifting and twisting after
‘‘De Qi’’.
 When needling Yanglingquan and Fenglong acupoints, the
patients would have the sense of Qi passing through.

20. Carbamazepine Treatment
 The patients in control group received treatment of oral
carbamazepine (Tegretol, Beijing Novartis Pharma Ltd, China)
for at least 1 month (300–600 mg per day).

21. Study Procedure
 All participants in this study were given a pain diary containing
a daily categorical verbal pain intensity scale (VPIS).
 A pain intensity scale with severe/ moderate/slight/no pain was
used.
 Visual analogue scale (VAS) pain scores 0–10 (where 0 means
no pain and 10 means the worst possible pain) were used.
 Each patient was asked to record his/her average 24 h pain
intensity using this scale in the evening.
 Number of bursts of pain and their strength were also noted
using an 11-point numeric rating scale.

22. Follow-up
 All patients were followed up for a period of three months
after the end of the treatment of the study.
 They were asked to note treatments sought for pTN during this
period and to judge treatment outcome.
 During the follow-up period, carbamazepine was given orally if
the patient suffered from unbearable pain. The dose and time
taken were recorded.

23. Adverse events
 Acupuncture was well tolerated in the treatment group.
 Only one felt fatigue, one developed dizziness and one
drowsiness.
 In control group, two subjects developed fatigue, one dizziness,
two drowsiness and two gastrointestinal reaction.

24. Statistical Analysis
 SPSS software 20.0 version was used.
 Total effective rate, VAS score, frequency of pain attack and
adverse events were analyzed using independent sample t-
tests at baseline to determine equality of the two groups.
 For qualitative data, Chi-squared test was done.

25. Result
Total Efficiency Rate
 The total efficiency rate of the two groups was 90.9% (treatment
group) and 75.9% (control group) respectively, and there were
significant between-group differences in the total effective rate.
VAS Score
 After treatment, the scores of VAS in the two groups were
significantly reduced as compared with those before treatment.
 Patients in treatment group had significantly greater reduction in
the score of VAS than that in control group at 4th week post-
treatment and 3rd month during the follow-up period.

26. Frequency of Pain Attack
 The frequency of pain attack was significantly lower in both
groups after treatment, and that in the treatment group was
significantly lower than that in control group.
Adverse Events
 The ratio of adverse events in the treatment and control groups
was 9.1% and 24.1% separately. There was significant
difference between the two groups.

28. Discussion
 Acupuncture is a highly safe procedure with few complications
reported.
 Currently, the drug choice for treatment of TN is
carbamazepine, which is considered the gold standard in
treatment for symptoms of TN.
 Carbamazepine has been shown to increase pain relief
compared with placebo, but also increases adverse effects,
such as drowsiness, dizziness and constipation.

29.  Both treatment are effective in relieving pain to variable
degrees. All patients had good alleviation of pain in comparison
to pre-enrollment values.
 VAS was comparable between groups during the follow-up
period, the benefit of acupuncture is better than carbamazepine
from the assessment values.
 In this study, results showed that triple puncture was associated
with a lower TN recurrence rate in 3 months after 4-week
treatment than carbamazepine.

30.  Triple puncture is one of the acupuncture methods used to treat
local pain with multiple needles.
 Triple puncture not only strengthens the stimulation of the
needled acupoints and the effect of relieving pain, but also
enlarges the area of the acupuncture point and the scope of
treatment.
 Good therapeutic effects can be expected only when the
needling sensation is made to radiate to the painful area. This
therapy has been proved highly effective for TN.

31.  Past studies have suggested that the analgesic effect of
acupuncture is through increased activation of the serotonin
and endorphin neurotransmitters in the thalamus and brain
stem, which leads to decreased release of substance P in the
trigeminal nucleus.
 Another proposed mechanism is that the acupuncture needle,
acting as an electrode, might activate changes in the interstitial
fluid, leading to a rapid increase in the conductance of the
electrolyte medium along the fascial lamellar.

32.  From the data obtained, the two groups both showed an
outstanding recovery in improving symptoms during the
research period.
 Statistically remarkable improvements in the VAS score when
testing for differences within the groups compared with baseline
values was found.

33. Limitations of the study
 Treatment period and follow-up time should be longer, thus the
effect of treatment can be further objective.
 They did not evaluate hypoesthesia.
 They did not compare quality of life before and after the study
procedures.

34. Drawback
 Very little is known in medical literature about the effectiveness
and safety of triple acupuncture.
 The application of triple puncture for the treatment of TN is
limited by inadequate scientific and safety evidence.

35. Conclusion
 Triple puncture should be reconsidered as a useful treatment
option for Trigeminal Neuralgia, because it offers a high rate of
complete pain relief and has a long lasting effect without
serious complications.

36. Cross References 1

37.  METHODS: 36 patients of primary trigeminal neuralgia were randomly assigned into
an electroacupuncture and triple puncture group (group A) and a routine
electroacupuncture group (group B), 18 cases in each one. In the group A, the triple
puncture technique was used at the trigger points and stimulated with electricity. In
the group B, the regular needling technique was used at the trigger points, stimulated
with electricity.
 The treatment was given once every two days, the treatment for 10 days made one
session and two sessions were required. Separately, before treatment, at the end of
the first session of treatment and at the end of the second session, the score of
comprehensive symptoms, the score of visual analogue scale (VAS) and the clinical
efficacy were evaluated in the two groups.
 RESULTS: Compared with those before treatment, the comprehensive symptom
score and VAS score were all reduced after treatment in the two groups. The scores
were reduced much more apparently in the group A as compared with those in the
group B. The curative effective rate was 44.4% (8/18) in the group A, better than
27.8% (5/18) in the group B.
 CONCLUSIONS: The combined therapy of triple puncture and electroacupuncture at
trigger points achieves the better efficacy on primary trigeminal neuralgia as

38. Cross Reference 2

39.  METHODS: Sixty patients were randomized into a comprehensive therapy group
(30 cases) and a medication group (30 cases). This comprehensive therapy was
given once a day. In the medication group, CBZ was used for oral administration,
100 mg at the first time, twice a day, and 400 to 600 mg each day as the
maintenance dose. Separately, before and after treatment, in 2 and 6 months in
follow-up, pain rating index (PRI) were adopted.
 RESULTS: After treatment, the curative and markedly effective rate in the
comprehensive therapy group was 76.7%, which was better than 63.3% in the
medication group. The difference in PRI was not significant after treatment between
the two groups.
 In 2 and 6 months follow-up, PRI grade in the comprehensive therapy group was
superior to that of the medication group. The incidence of adverse reaction in the
comprehensive therapy group was 16.7%, which was lower than 30.0% in the
medication group.
 CONCLUSION: The comprehensive therapy of EA at acupoints combined with
spinal regulation method achieves the long-term efficacy on PTN as compared with
oral administration of CBZ in terms of the improvement of psychological condition,
analgesia and life quality. It is the safe, effective and stable therapy.

40. Critical Appraisal
 Title: Well depicted
 Alternate title could be: Triple acupuncture therapy for Primary
Trigeminal Neuralgia: A case control study
 Abstract: Not given
 Introduction: Well written
 Aims and Objectives are not mentioned separately in the study.
 Materials and methods: Clearly mentioned along with database
tables.
 Results: Depicted in narrative form as well as tabular form.
 Discussion: not done

41.  Limitations: Mentioned but not under a separate heading
 Conclusion: Not given. No Comments on future prospects.
 Conflicts of interests: Declared
 Fundings and Sponsorships: Not Revealed
 Contributions and Acknowlegements: Not mentioned.
 Reference: Organized using Vancouver style.
 Quality of evidence grade: Moderate
 Risk of bias: Low